HCOLL Flashcards
2 options for pharmacological management of cog ss of AD dementia
1st line: Acetylcholinesterase inhibitors (AChE-1) eg donepezil, rivastigmine, galantamine
2nd: NDMA antagonists eg memantanine
examples of cholinesterase inhibitors and use
donepezil, rivastigmine, galantamine
1st line dementia
what’s memantanine
NDMA antag for dementia 2nd line
when to use lorazepam or haloperidol for short term distress
lorazepam if PD or LBD
haloperidol
can use olanzapine
what is part of the multifactorial assessment for falls
Hx assess gait, balance, mobility, weakness OP risk perceived functional ability and fear visual cog and neuro exam urinary incontinence assessment home hazards assessment CVS Med review (on admission postural BP, CK if long lie, ECG)
Prevention of falls
strength and balance training
environmental assessment
med review esp psychotropics
Fall: if no orthostatic hypo, abnormal ECG/CVS exam what are following steps of IX
24hr cardiac monitor and echo
if normal do tilt tallow with carotid sinus massage
CI for carotid sinus massage
MI/TIA/Stroke <3m
prev adverse reac
relative: VF/VT or carotid bruits
NICE risk increasing conditions for falls
dementia, delirium, LUTS in men, stroke, urinary incontinence due to neuro or in a women
possible meds in falls
ca and vit D
Fludrocortisin if very low unexplained BP
what percentage of over 80s fall every year
50%
falls assessment includes (look up)
HX, Ex, GALS, postural BP, HS, neuro, eye sight. ?fracture liaison?
criteria for the clinical dx of parkinsons
bradykinesia AND
muscle rigidity OR
resting tremor (4-6Hz) OR
postural instability with no other cause
imaging for parkinsons
SPECT scanning: DAT scan shows reduced ligand binding indicating degeneration of nigrostriatal neurones.
First line tx parkinsons
levodopa (co-beneldopa and sinemet)
eg of dopamine agonists used in PD and side effects
rotigotine and eropinorole
neuropsychiatric side effects ig impulse control disorder or hallucinations
MOAB inhibitors used in PD
selegiline and rasagaline
multiple myeloma screen consists of
ESR
serum IgGs
protein electrophoresis
urinary Bence-Jones proteins
Bone profile consists of
Ca, Vit D, phosphate, alkaline phosphate, parathyroid hormone
secondary causes of osteoporosis
- primary hyperparathyroidism, thyrotoxicosis (high HT and PTH and calcium as increase turn over
- steroid use/cushings (leads to decrease ca ab and increase ca extortion so causes secondary hyperparathyroidism
- DM, CLD, CKD
- immobility
- anorexia/malab eg IBD, coeliac, ca deficiency, secondary hyperparathyroidism, chronic pancreatitis
- chronic inflam eg RA or neoplastic disease
- drugs: anticonvulsants, heparin, lithium, steroids, sex hormone ag eg goserelin, aromatase inhibition’s, SSRI, PPI, thiazolidinediones (for DM)
- marfan, osteogenesis imperfecta, tener syn
- myeloma and haemoglobinopathies
- hypogonadism, meno <40
define osteopenia
1-2.5 SD below average
bone profile of osteoporosis
osteoporosis shows normal calcium, phosphate, ALP
osteomalacia bone profile
decrease calcium, decrease phosphate, increase ALP
pagets DB
normal Ca and normal phosphate, decrease ALP
first line treatment for OP
Bisphosphonate eg Alendronate or risedronate
vit D and Ca if need
?HRT
how would you manage pt with less than -2.5 DEXA
mod lifestyle and FUP DEXA within 2 years
management person intermediate risk OP
DEXA if >-2.5 treat
2nd line drug treatments for OP
Zolendronic acid, Raloxifene, Terpiramate, Denosumab
treatment OP if renal impairment
Denosumab (monoclonal AB to RANK-L). 6 monthly subcut.
adverse effects of bisphosphonate
upper GI ss, osteonecrosis jaw, atypical fractures, dental
what is raloxifene
Selective oestrogen R modulator for OP. used: secondary prevention, early meno, vertebral. Caution VT and TE disease
when to use teriparatide for OP
Tx failure, severe OP (-4 BD or -3.5 and 2 fractures). caution if hypercaxlcaemia
what is likely diagnosis Painless temporary loss of vision – curtain descending over vision
management
amourosis fugax
ix bloods (ESR, FBC, clotting, lipids), fundoscopy, carotid a doppler
aspirin 300mg PO and possibly carotid endartectomy
causes amourosis fugax
atherosclerotic carotid a
embolic occlusion, GCA, SLE, mal HTN, hypercoagulability, post vitreous detachment, other ocular causes, neuro causes
Define TACS and PACS
3/3 = TACS
- Higher Dysfunction eg Dysphasia, decreased consciousness, Visuspatial Neglect, Asterognosis or Apraxia
- Homonimous Hemianopia
- Motor/Sensory Deficit or face/arm/leg (2/3)
PACS 2/3 these or higher dysfunction alone
classify stroke of a pt with U/L hemiparesis and or hemisensory loss (ie pure sensory or pure motor or both) OR ataxic hemiparesis (ipsilateral pyramidal hemiparesis and cerebellar ataxia)
LACS
POCS =
- Cranial Nerve Palsy AND Contralateral Motor/Sensory deficit
- Bilateral Motor OR Sensory Deficit
- Conjugate Eye Movement problems
- Cerebellar Dysfunction
- Isolated Homonymous Hemianopia
Mx TIA
ASPIRIN 300mg PO asap
if taking anticoags or bleeding disorder -> urgent CT
refer to specialist clinic <24hrs: carotid a doppler. may then do endarterectomy. or antithrombin therapy = clopidogrel and aspirin or aspirin and dipyridamone if not tolerating clopidogrel
indications for <1hr urgent CT post stroke
- ?acute stroke thrombolysis
- on anticoags
- any known bleeding disprder
- decreasing GCS
- severe headache at onsett
- papilloedema/stiff neck
- unexplained fluctuation SS
what % deaths are stroke in UK
11%
20-30% mortality
130000 affected per year
where does the blood go in SAH
Subarachnoid haemorrhage: Bleeding that occurs outside of the brain tissue, between the pia mater and arachnoid mater.
Examination post stroke
- General inspection
- GCS (15 fully conscious. 8 worried about airway)
- ABCDE
Stable: - Neuro (where lesion ie UMN/LMN). Remember gait and pronator drift.
- What’s involved ie speech, sensory, cerebellar, cranial nerves
NIH Stroke Scale (NIHSS)
- Screening tool to assess stroke; location; severity; who to thrombolyse
- Can also get patient to describe what’s happening in picture (higher cortical function)
- Walk, observe gait
Rest examination:
- CV
- Clues as to cause: murmurs, BP, HR, HF, SBE, dissection
- Resp: ?aspiration
- Complications: pneumonia, PE
Imaging:
- CT exclude bleed. If not a bleed, changes may take 12-24 hours to see (clot and tissue death). Bigger see effects faster than smaller one as more likely acute inflam changes.
- MRI later
ECG: AF/MI?
Bloods: FBC, UE, coag, BM, ESR, LFTs, cholesterol.
Can appear to have new stroke but actually just old SS coming back.
ESR: Giant cell arteritis. Send to ophthalmology.
TFTs: hyperthyroidism and AF closely linked
Examination post stroke
- General inspection
- GCS (15 fully conscious. 8 ?airway)
- ABCDE
Stable: - Neuro (where lesion ie UMN/LMN). Remember gait and pronator drift.
- What’s involved ie speech, sensory, cerebellar, cranial nerves
NIH Stroke Scale (NIHSS) - Walk, observe gait
Rest examination:
- CV
- Clues as to cause: murmurs, BP, HR, HF, SBE, dissection
- Resp: ?aspiration
- Complications: pneumonia, PE
Imaging:
- CT exclude bleed. If not a bleed, changes may take 12-24 hours to see (clot and tissue death). Bigger see effects faster than smaller one as more likely acute inflam changes.
- MRI later
ECG: AF/MI?
Bloods: FBC, UE, coag, BM, ESR, LFTs, cholesterol.
Can appear to have new stroke but actually just old SS coming back.
ESR: Giant cell arteritis. Send to ophthalmology.
TFTs: hyperthyroidism and AF closely linked
Acute stroke Mx
- FAST admit to specialist stroke unit
- ABCDE (o2 if hypoxic, BM 4-11)
- Hx and exam (NIHSS-stroke severity score)– - BAMFORD classification
- CT
- Within 4.5hrs-thrombolysis? alteplase 0.9mg/kg
- ECG (AF/LVH/ischaemic changes)
- Bloods (FBC, UE, LFTS, ESR, Glc, Lipids, CRP, TFT, G/S, clotting, vasculitis and thrombophilia screen)
- Direct admission to stroke unit
- Hydration and nutrition (swallow assessment)
- ?fundoscopy if SAH
- ?CXR if ?aspiration
- MRI with DWI if uncertain after CT
- Antiplatelets (if NOT a bleed): clopidogrel (or aspirin and dipyridamole). Aspirin 300mg PO once CT excluded bleed.
- Statins
- Antihypertensives
- Assess/investigate risks (Echo, CDs)
- VTE prophylaxis
- Positioning
- Early MDT assessment
- Refer to vascular surgery if carotid doppler shows stenosis >50%
- malignant MCA syn -> decompressive hemicraniotomy
- if on warfarin and IC bleed: give vit K and prothrombin complex concentrate (optaplex). if heparin give protamine sulphate.
- LP 12 hrs after haemorrhagic if CT clear
malignant MCA syn -> decompressive hemicraniotomy - surgical evaluation or CSF shunt if primary IC haemorrhage has caused hydrocephalus
- ASD -> paradoxical embolism and stroke, consider for shunt closure
what to include in management of IC haemorrhage if on anticoags
if on warfarin and IC bleed: give vit K and prothrombin complex concentrate (optaplex). if heparin give protamine sulphate.
indication for carotid endarterectomy
Refer to vascular surgery if carotid doppler shows stenosis >50%
surgical management of acute stroke
- malignant MCA syn -> decompressive hemicraniotomy
- surgical evaluation or CSF shunt if primary IC haemorrhage has caused hydrocephalus
- ASD -> paradoxical embolism and stroke, consider for shunt closure
when to do LP in stroke mx
LP 12 hrs post haemorrhage stroke if CT negative. xanthochromia confirms SAH
secondary prevention of ischaemic stroke
- Antiplatelets: aspirin 300mg PO 2/52 then clopidogrel 75mg PO life (dipyridamole 200mg PO BD if can’t tolerate)
- statin: atorvastatin 80mg PO after 2/52
- antiHTN: after 2/52 if >185/110, ss HTN or other RF
- anticoagulant if indicated eg DOAC/warfarin for AF, do chadvcasc.
- lifestyle
- metformin if need to keep BM 5-15
- mx comorbidities
- Can resume driving 4/52. don’t need to inform DVLA if satisfactory clinical improvement.
