Integrative Flashcards
List important factors in a falls history
How LOC? - feelings before, during, after Injuries sustained Pain Headache Long lie \+ collateral
List risk factors for falls
Previous fall Age >80 Female Visual impairment Medication (B-blockers, diuretics, opioids, insulin) Gait disorder (PD, cerebellar, OA) Poor footwear Polypharmacy Infection Environment (loose rugs, wet floor, poor light, walking aids, cluttered home)
Describe the examination you would undertake in someone with a fall
Temp. (infection) MMSE/confusion screen (delirium) Bruising Postural BP (lying/standing) Timed Up&Go Test Turn 180 test ECG (heart block) Vision test, fundoscopy Neurological exam, cranial nerve
Describe how to perform a lying/standing BP
Lie down for 5 mins Take BP Stand up for 1 min Take BP Continue standing for 3 mins Take BP
Positive if drop in systolic BP >20mmHg/drop in diastolic BP by 10mmHg with symptoms/systolic BP <90 when standing
List some investigations taken after a fall
Bloods - FBC, U&Es, LFTs, TFTs, B12, glucose) Urinalysis ABG ECG/ECHO CT head
List the management of falls
Referral to ED (injuries), AFU (medical cause of fall), OP falls clinic, community OT/PT, age concern
Falls assessment and bone health review - FRAX, DEXA, bisphosphonates
Medication review (e.g. NO TEARS, STOPP/START)
Describe the NO TEARS in a medication review
Need/indication Opinion of patient Tests Evidence/guideline change ADRs/side effects Risk reduction Simplification/dosset box
List red flag symptoms of stroke
Proceeded by a headache Progressive neurology Decreasing GCS Falls Systemic illness No vascular RFs
List important factors in a stroke history
Onset (morning?)
Progression of symptoms
Symptoms - NIH stroke scale, FAST
Associated features - raised ICP
What examination would you perform in a patient with a stroke?
Neurological examination
NIH stroke scale
List differentials for a stroke
SAH Bell's palsy Brain tumour Brain abscess Hemiplegic migraine
List risk factors for a stroke
CVS RFs (smoking, hypercholesterolaemia, hyperlipidaemia) AF Post partum PFO COCP use
What is a stroke?
Sudden onset of focal neurological deficit attributable to a vascular cause
Describe a stroke classification system
Bamford/Oxford Stroke Classification
TACS = all three of: unilateral weakness (+/- sensory deficit) of face, arm and leg + homonymous hemianopia + higher cortical dysfunction (dysplasia, visuospatial disorder)
PACS = two out of: unilateral weakness (+/-sensory deficit) of face, arm and leg + homonymous hemianopia + higher cerebral dysfunction
POCS = one of: cranial nerve palsy and contralateral motor/sensory deficit + bilateral motor/sensory deficit + conjugate eye movement disorder + cerebellar dysfunction + isolated homonymous hemianopia
LACS = one of: pure sensory stroke + pure motor stroke + sensori-motor stroke + ataxic hemiparesis
State the most likely cause of each different type of stroke
TACS = cardiac emboli - affects areas of brain supplies by both ACA + MCA PACS = large vessel disease - only part of anterior circulation is compromised POCS = cerebellar/brainstem - posterior circulation is compromised LACS = small vessel disease - no loss of higher cerebral functions
Describe the blood supply of the brain
ACA - anteromedial cerebrum (frontal, medial)
MCA - lateral cerebrum (frontal, lateral, parietal, temporal)
PCA - medial and lateral posterior cerebrum (occipital)
Describe the acute assessment of a stroke
Ix - CT head, clotting, U&Es, cholesterol
Mx - O2 if sats <94%, thrombosis, HTN management
State the management of a stroke that presents in <4.5h
Thrombolysis with alteplase
Aspirin 300mg
Describe the management of an acute stroke
Aspirin 300mg OD for 14 days Clopidogral 75mg Consider thrombolysis Maintain BP <130/80 Statin Transfer to stroke unit Advice smoking cessation
List complications of stroke
Seizures Stroke extension Disability +incontinence Recurrence Depression Cognitive decline Infections
Define the ABCD2 score and what is it used for
= to determine the risk of stroke in the days following a TIA Age >60: <60 = 0 >60 = 1 BP >140/90 <140/90 = 0 >140/90 = 1 Clinical features: No speech disturbance or unilateral weakness = 0 Speech disturbance with no unilateral weakness = 1 Unilateral weakness = 2 Duration of symptoms <10 mins = 0 10-59 mins = 1 >60 mins = 2 Diabetes No diabetes = 0 Diabetes = 1 0-3 = low, 4-5 = moderate, 6-7 = high
List important lifestyle changes to tell a patient following a stroke
No driving for 1mo
Smoking cessation
No LMWH
Describe the pathophysiology of Parkinson’s Disease
Low dopamine in substantia nigra in the basal ganglia (controls movement)
What is Parkinson’s Disease?
A degenerate, progressive disease affecting the basal ganglia
List the clinical features of Parkinson’s
Motor features:
Bradykinesia - facial immobility, difficulty initiating movement
Postural instability - festinating gait
Tremor - resting, pill rolling
Rigidity - cogwheel (upper)/leadpipe (lower)
Non motor features:
Depression
Sleep disturbance - restless legs, REM
Autonomic dysfunction - increased sweating, drooling, constipation
Falls
Describe the classical gait of a person with Parkinson’s
Stooping Slow to initiate walking Shortened stride Shuffling, festinating Decreased arm swing Pedestal turning
List investigations for Parkinson’s
Clinical diagnosis
Test for Wilson’s if <50
CT head or DaTSCAN if pyramidal/cerebellar, ?diagnosis
List management options for Parkinson’s
Levodopa (dopamine precursor) + carbidopa (decarboxylase inhibitor) Bromocriptine (dopamine agonist) Entacapone (COMT inhibitor) Selegilene (MAO-B inhibitor) Amantadine (antiviral) PT/OT/speech therapy SSRI
List ADRs for levodopa
Nausea Vomiting Confusion Chorea Ineffective
List differentials for Parkinson’s (other causes of Parkinsonism) and the symptoms they cause
Multiple systems atrophy - autonomic, ataxia, falls
Supranuclear palsy - balance/movement disorder, failure of vertical gaze
Lewy body dementia - nocturnal wandering, visual hallucinations
Drug induced parkinsonism - symmetrical, young, dopamine agonist/lithium/AED/metoclopramide
Vascular - sudden onset, LL>UL, MRI diagnosis
List the types of patients at risk of malnutrition
Elderly
Oncology
Intentional weight loss
Acute illness
List risk factors of refeeding syndrome
Very low BMI
Unintentional weight loss >10-15% body weight in 3-6 months, little/no nutritional intake >5-10 days, low electrolytes prior, alcohol/drug (insulin, chemo, antacids, diuretics) abuse
What is refeeding syndrome?
Low phosphate, magnesium, potassium
Thiamine deficiency
Sodium and water retention
Describe the management of refeeding syndrome
Baseline bloods Daily bloods Regular ECG Feed slowly Reflace fluid Pabrinex --> thiamine PO Vit. B12 Multivitamins
What is advanced care planning?
The process of conversation to discuss possible future situations and understand patient preferences e.g. preferred place of care/death, DNACPR, ADRT, power of attorney, anticipatory medication
Describe the pathophysiology of dying
Respiratory secretions
Decreased brain perfusion - drowsy, delirium
Decreased cardiac function - thready pulse, cool, mottled
Decreased renal perfusion - low urine output
Decreased metabolic rate - low oral intake, fatigue
Describe how to verify death
Unresponsive
No central pulse, heart sounds or respiratory effort for 2 mins
Pupils fixed and dilated
