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Physical Diagnosis > Lecture 4 (Preg+old ppl), EXAM 3 > Flashcards

Lecture 4 (Preg+old ppl), EXAM 3 Flashcards

1
Q

Epidemiology

  • How many aged people over 65 in the US?
  • ~14% of population, accounts for how much of health care expenses?
  • Nearly 40% of hospitalized patients are who?
  • Percentage of visits made to primary care outpatient settings by who?
  • Elderly patients represent much of ED visits?
A
  • 47.8 Million aged over 65 in the United States - expected to double by 2060
  • ~14% of population, accounts for > 34% of health care expenses
  • Nearly 40% of hospitalized patients are elderly
  • Percentage of visits made to primary care outpatient settings by persons aged 65 or over is reaching majority
  • Elderly patients represent ~ 25% of all Emergency Department visits.

  • Bottom Line – you will treat elderly patients unless you enter the specialty of Pediatric Medicine
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2
Q

What is the difference btw adult H+P and geriatric assessment?

A
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3
Q

Obtaining History and Review of Symptoms:
* What do geriatric patients tend to do? What as providers need to do?
* How does acute illness present in geriatric patients?

A
  • Geriatric patients tend to underreport – ask direct questions, consult with family/caregivers
  • Acute illness present differently – less likely to have a fever with infections, less likely to report CP with MI
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4
Q

What are special areas of concer when assessing older adults (5)?

A
  • Functional impairments in activities of daily living and instrumental activities of daily living
  • Medication management
  • Smoking
  • Alcohol
  • Nutrition
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5
Q

First, what do you need to ask for older patients?

A

First, ask about how well the patient performs theactivities of daily living(ADLs), which consist of six basic self-care abilities
* bathing,
* Dressing
* Toileting
* Transferring
* Continence
* feeding.

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6
Q

OLD PEOPLE

After ADLs what do you need move onto and ask?

A

Then, move on to higher level functions, theinstrumental activities of daily living(IADLs)
* using the telephone
* Shopping
* preparing food
* housekeeping,
* Laundry
* Transportation
* taking medicine
* managing money.

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7
Q

Medication Management

  • Huge prevalence of adverse drug events lead to what?
  • Adults over 65 recieve approx. how much of all presciptions?
  • Almost 40% take what?
A
  • Huge prevalence of adverse drug events leading to hospitalization and poor patient outcomes
  • Adults over 65 receive approx. 30% of all prescriptions
  • Almost 40% take five or more prescription drugs daily
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8
Q

Medication Management:
* Older adults have more than 50% of all reported what? Why?

A
  • Older adults have more than 50% of all reported Adverse Drug Events causing hospital admission
  • Because of pharmacodynamic changes in the distribution, betabolism, and elimination of drugs place them at risk
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9
Q

OLD PPL

  • What is the BEERS list?
  • What is the single most common modifiable risk factor associated with falls?
A
  • BEERS list: list of medication that is not recommended for older people
  • MEDICATIONS ARE THE SINGLE MOST COMMON MODIFIABLE RISK FACTOR ASSOCIATED WITH FALLS
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10
Q

Alcohol in older people recommends what? Why?

A

Lower recommended drinking limits for those >65 due to physiologic changes that alter alcohol metabolism, frequent comorbid illness, and risk of drug interatctions

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11
Q

Older adults should have no more than how many drinks?
What are the stats on elderly and drinking?

A

Older adults should have no more tha 2 drinks on any one day or 7 drinks a week.

Adults over 65:
* 40% drink (liver is extra sensitive and gets Irritated)
* 4.5% are binge drinkers (increase fall risk)
* 2%-4% may have abuse or dependence
* >14% exceed recommended limits
* When health status taken into account, >53% have harmful or hazardous drinking

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12
Q

Screening all older adults for harmful alcohol use is especially important due to what? (2)

A
  • Adverse interactions with most medications
  • Exacerbation of comorbid illnesses, including cirrhosis, GI bleeding, GERD, Gout, HTN, DM, Insomnia, Gait disorders and depression
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13
Q

What do you need to watch out for in older peoples?

A

Watch for clues to excess ETOH consumption, especially in pts with recent bereavement or losses, pain, disability, depression, FH of ETOH disorders.

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14
Q

What are clues to alcohol use disorders in older adults?

A
  • Memory loss, cognitive impairment
  • Depression, anxiety
  • Neglect of hygiene, appearance
  • Poor appetite, nutritional deficits
  • Sleep disruption
  • Hypertension refractory to therapy
  • Blood sugar control problems
  • Seizures refractory to therapy
  • Impaired balance and gait including falls
  • Recurrent gastritis and esophagitis
  • Difficulty managing warfarin dosing
  • Use of other substances that may lead to addiction such as sedatives or opioid analgesics, illicit drugs, nicotine
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15
Q

Don’t forget that older adults use and have what?

A
  • Older adults use and abuse illicit drugs
  • Older adults will have newly diagnosed STDs
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16
Q

⭐️

Vital signs:
* How does BP change?
* Many older adults develop what?
* How does HR and rhythm change?
* How does RR and temp change?

A
  • Blood Pressure – aorta and large arteries stiffen and become atherosclerotic, systolic blood pressure rises.
  • Many older adults develop orthostatic (postural) hypertension
  • Heart Rate and Rhythm – declines in the pacemaker cells of the sinoatrial node and decreased maximal heart rate effects response to exercise and physiologic stress – increases rate of abnormal heart rhythms
  • Respiratory Rate and Temperature remain unchanged. But, changes in temperature regulation increases chance of hypothermia
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17
Q

What is most prominent with mental status of older people

A

Depression and Dementia most prominent

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18
Q
  • What is delirium?
  • What can exacerbate or mask dementia?
  • Hearing deficiencies casue what?
A
  • Delirium – “a temporary state of confusion” may be the first clue to infection, problems with medications, or impending dementia.
  • Decline in vision, hearing may either exacerbate or mask dementia
  • Hearing deficiencies isolate which is thought to escalate dementia
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19
Q

What are normal skin, nails and hair changes in older people?

A
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20
Q

Think about picture: what are changes (skin and hair) in older adults?

A
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21
Q

General Survey/Skin

Pay attention to what in older people?
What is frequently found?

A

Pay attention to posture, color/texture of skin, color of sclera, hearing, general affect.

Frequently found in elderly –
* poor posture, slumping, obvious spinal deformity
* dry skin, multiple skin lesions, thin skin

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22
Q

What are normal changes of HEENT in older people?

A
  • pupils become smaller, pupillary response slows, sclera may be slightly yellow or brown
  • a gray-white ring on surface of eye (Arcus Senilis)
  • hearing acuity decreases (presbycusis)
  • gums recede
  • nose becomes longer/larger
  • visual acuity decreases
  • lacrimal secretions decrease causing dry eyes
  • salivary secretions decrease, loss
  • loss of taste
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23
Q

What is normal in cardiovascular with older people?

A
  • PMI may be displaced do to kyphosis (makes palpation of PMI less reliable as indicator of cardiomegaly)
  • Signs of arterial insufficiency (hair loss, decreased pulses and bruits) are common.
  • Peripheral edema much more likely to be due to venous insufficiency, but if found, must evaluate for CHF
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24
Q

Older ppl CV

  • Always listen to neck for what?
  • What does a S3 or S4 suggest?
  • What is super common?
A
  • Neck – always listen for carotid bruits – indicates stenosis from atherosclerotic plaque
  • Heart Sounds – hearing an S3 strongly suggests failure/volume overload, you may hear an S4 in otherwise healthy geriatric patient but it indicates a decrease in ventricular compliance and impaired ventricular filling
  • Murmurs – Common to hear systolic aortic murmur – 1/3 over age 60 and 50% of those over 85.
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25
Q

Peripheral Vascular System

  • What is more common? What is not typical?
  • When having abdominal or back pain- what must be consider?
  • Temporal arteries may develop what?
A
  • Arterial and venous disorders are more common in older adults – however – loss of arterial pulsations is not typical and demands further evaluation
  • Abdominal or back pain – must consider abdominal aortic aneurysm
  • Temporal arteries may develop giant cell, or temporal, arteritis – leading to vision loss in 15% of patients (head ache and jaw pain frequently accompanies)
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26
Q

Pulmonary (older people):
* Rales may be due to what?
* Important to document what?
* What is a rale?

A
  • Rales may be due to age related changes in lung physiology and age- related pathophysiology, not pneumonia or pulmonary edema.
  • Important to document any sounds heard, or not heard, when the patient is well without evidence of disease.
  • Rale – also referred to as “crackles” – course breath sounds indicative of something impacting alveoli – may be fluid, bacteria – in elderly may be due to aging process of alveoli physiology
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27
Q

Abdominal Exam (older people):
* What might happen to liver span?
* Increased what?
* Kyphosis of spine may lead to what?
* What response may be blunted?
* Papate and percuss what? why?
* What can be palpable with constipation

A
  • Liver span may be decreased due to loss of cell volume.
  • Increased abdominal fat
  • Kyphosis of spine may lead to appearance of abdominal distention (Elderly patients may be unable to lay flat on an exam table)
  • Peritoneal signs/pain response may be blunted
  • Palpate and percuss bladder – check for urinary retention
  • Sigmoid colon may be palpable with constipation
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28
Q

Musculoskeletal Exam- OLDER PEOPLE

  • What is sarcopenia?
  • Loss of height d/t what?
  • _ of aging
  • Increase in what?
  • Limbs may appear what?
A
  • Sarcopenia – decline in muscle tissue due to aging process
  • Loss of height due to intervertebral discs becoming thinner and vertebral bodies shorten or collapse due to osteoporosis
  • Kyphosis of aging
  • Increase in anteroposterior diameter of chest
  • Limbs may appear disproportionately long
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29
Q

Nervous system of older ppl

  • What happens to motor reflexes?
  • Atrophy of interosseous muscles cause what?
  • How do you know it is a benign essential tremor of head, jaw, lips, hands?
  • What is diminished?
  • What reflexes may be diminsihed or absent?
  • Always observe waht?
A
  • Motor – slowed reflexes, diminished strength
  • Atrophy of interosseous muscles – backs of hands appear thin with underlying bone structure prominent
  • Benign essential tremor of head, jaw, lips, hands (disappear at rest)
  • Vibratory sense diminished – typical at feet and ankles
  • Ankle reflexes may be diminished or absent
  • Always observe gait
30
Q

What is a clinical peral of the nervous system in older people?

A
  • pearl – changes due to aging are symmetrical – if asymmetry exists in your physical exam of patient – look for alternate cause
31
Q

Male GU/Female Pelvis, Breast-> OLDER PEOPLE

  • What happens to prostate, penis size, testicles?
  • What becomes easier to palpate in women?
  • What decreases in size in women?
  • Pelvic exams may require what?
A
  • Enlarged prostate, penis size decreases, testicles drop lower in the scrotum
  • Abnormalities/masses become easier to palpate in breasts.
  • Decreased size of ovaries and uterus – may be unable to palpate.
  • Pelvic exams may require pediatric speculum due to thinning of vaginal walls.
32
Q

What are geriatric syndromes?

A
  • “multifactorial condition that involves the interaction between identifiable situation-specific stressors and underlying age-related risk factors, resulting n damage across multiple organ systems”
  • Strongly linked to functional decline
33
Q

What do you need to get for personal and family history?

A
34
Q

What do you need to ask for ROS in preg people?

A
  • Mood (preg depression+mental illness)
  • Stressors, sleep, appetite, energy.
  • GU/Reproductive - last menstrual period, vaginal discharge, pain, vaginal bleeding, dysuria
  • Skin – pruritic areas, rash, color/texture changes (preg normal or could be liver disease)
35
Q

What are common possitives in first, second and third trimester?

A
  • First trimester – frequent urination, lightheadedness, heartburn, constipation, veins become visible, tender breasts, pregnancy “glow” to skin, mood changes/lability, nausea/vomiting
  • Second trimester – may begin to have intolerance to heat, experience ”hot flashes”, back discomfort, breast tenderness, abdominal expansion, hair and nail changes, BP decrease
  • Third trimester – increased ligamentous laxity, increased curvature of lower spine, leg cramps, foot and ankle swelling, slight temperature increase, shortness of breath, ”colostrum” (yellow watery pre-milk) may leek from nipples.
36
Q

What do you need to monitor/track in preg?

A

Monitoring/Tracking Weight and Blood Pressure

37
Q

Pregnancy:
* How should you do BP?
* What is normal weight gain?
* Women underweight gain how much?
* Women overweight gain how much?

A
  • Obtain blood pressure with back and arm supported, seated position, legs uncrossed, do not allow to talk during measurement
  • Expected “normal” weight gain during pregnancy is 25-35 pounds
  • Women underweight at time of becoming pregnant will gain more
  • Women overweight at time of becoming pregnant will gain less
38
Q

What are skin changes in pregnant people?

A
  • Pigmentation may darken - areola, inner thighs, labia, neck
  • Striae gravidarum (stretch marks)
  • Pruritic urticarial papules and plaques
  • Pre-existing skin disorders may flair
  • Linea Nigra – dark line of skin from symphysis pubis to umbilicus due to hormonal changes (occurs in ~80% of pregnancies)
39
Q

What happens to respiratory system in preg people?

A
  • Increased tidal volume
  • Increased respiratory rate
40
Q

What happens to CV system in preg people?
* Output, BV, HR, heart sounds, valves, and murmurs

A
  • Increased output
  • Increased blood volume
  • Resting heart rate elevated
  • BP decrease
  • S3 is a normal finding in pregnancy
  • S4 may be present in ~15%
  • Mitral stenosis, aortic stenosis and tricuspid sounds are accentuated
  • Systolic Murmur may be heard late in pregnancy (typically resolves 1-3 weeks post delivery)
41
Q

GI system of preg people:
* Increase what?
* What happens due to hormonal changes
* Increase symptoms of what
* What decreases?
* Bowel mvt?

A
  • Increased reflux
  • Nausea & vomiting (due to hormonal changes)
  • Increased symptoms of heartburn
  • Decreased gastric motility
  • Constipation
42
Q

MSK System in preg people:
* What is exaggerated?
* Increased what?
* What happens to prepare for labor and birth?

A
  • Exaggerated lumbar lordosis
  • Increased ligamentous laxity
  • Pelvic ligaments relax to prepare for labor and birth.
43
Q

Abdominal Exam in preg people:
* What should patient do/ be laying in during exam?
* What happens as pregnancy advances?

A
  • The patient should have an empty bladder
  • The patient should be laying supine with pillow under her head
  • As pregnancy advances, it may be uncomfortable for patient to be totally flat – adjust position as necessary for comfort
44
Q

What should you observe and document in pregnant people?

A
  • Document shape of abdomen.
  • Document any scars
  • Striae gravidarum
  • Linea nigra
45
Q

Determining uterine size:
* What is the landmarks?
* What should your left hand be doing?
* Fundal height location is used for what? Explain?

A

Landmarks – symphysis pubis and the umbilicus

Use left hand to palpate the fundus, determining height of the fundus

Fundal height location used to estimate gestation –
* Just above symphysis pubis ~12 weeks
* Halfway between symphysis and umbilicus ~16 weeks
* At umbilicus ~22 weeks
* General rule – measurement in centimeters = gestational age

46
Q
  • What is the fundal height?
  • The fundus will feel like what?
  • What do we use to measure?
A
  • Fundal Height – the distance from the synthesis pubis to the fundus of the uterus
  • The fundus will feel like a hard ball under the skin.
  • Use flexible tape measure
47
Q

What do you need to palpate in preg person?

A
  • Palpate Liver, Spleen and Kidneys
  • Palpate four quadrants of abdomen forabnormal masses
48
Q

Palpation of Uterus:
* What position is most common?
* Palpate what?
* What type of palpation is done during pelvic exam?

A
  • Position – mid-line most common, may tilt to left or right.
  • Palpate the wall of uterus for any abnormality.
  • Palpate externally for shape (pear shape)
  • Internal/external palpation during pelvic exam
49
Q

How do the breasts change in first, second, third trimester?

A
  • First trimester – swelling of breasts, darker areola, small bumps within the areola
  • Second trimester – growth continues, minor leakage may occur
  • Third trimester – significant darkening, likely enlarged nipples, stretch marks may be present
50
Q

Preg

What is expected for the vagina/cervix, vaginal secretions, the cervix?

A
  • Vagina/Cervix – increased vascularity causes a blueish tint to the vaginal walls and cervix, this is termed “Chadwick” sign
  • Vaginal secretions may become thicker, white – termed “leukorrhea of pregnancy”
  • The cervix softens and turns cyanotic due to increased vascularity, edema and glandular hyperplasia.
51
Q

What is the hagar sign?

A

Hagar” sign – palpable softening of the cervical isthmus

52
Q

What is the chadwick sign?

A
53
Q

Health Promotion & Counseling in preg people

  • What do you need to do for nutrition?
  • What do patients need to be caution of?
  • Encourage what?
  • Abstain from what, limit what, clear all what?
  • 1/5 preg women experience what?
  • Identify what?
A
  • Nutrition – take a diet hx, review BMI, recommend prenatal vitamin
  • Caution re: eating processed meats, raw and undercooked seafood, eggs, smoked salmon, unpasteurized milk
  • Encourage exercise
  • Abstain from tobacco and ETOH, limit RX drugs to only necessary, clear all herbal and unregulated supplements through OB/GYN
  • 1/5 Pregnant women experience some form of partner abuse.
  • Identify breast changes expected in pregnancy and when they occur.
54
Q

A 42-year-old G2P1 arrives at clinic for a routine prenatal visit late in her third trimester. On exam, the physician notes a subtle murmur; on further auscultation, it becomes apparent that the murmur occurs during the diastolic phase. The patient has minimal complaints but does reveal that she has had swelling in her feet and shortness of breath. Because these symptoms have been only slightly more severe than during her last pregnancy, she assumed this was normal for pregnancy. Which of the following is true about her presentation?

  1. A leftward rotated apical impulse would confirm a diagnosis of heart failure in this patient.
  2. A diastolic murmur during pregnancy is known as a venous hum.
  3. Diastolic murmurs during pregnancy may be due to anemia.
  4. Cardiomyopathy is very rare during and after pregnancy due to protective effects of estrogen and progesterone; it does not need to be considered on this patient’s differential diagnosis
  5. A diastolic murmur during pregnancy is likely pathological and should always be investigated.
A

5) A diastolic murmur during pregnancy is likely pathological and should always be investigated.

55
Q

A 17-year-old G1P0 presents at a routine prenatal check. By last menstrual period (LMP), her gestational age at this visit is 36 weeks, 2 days. A first-trimester ultrasound confirmed her estimated delivery date. On exam, her fundus measures 31 centimeters. Ultrasound imaging might reveal which of the following anatomical findings that would explain this size?
1. Renal agenesis of the fetus resulting in intrauterine growth retardation
2. Twin pregnancy
3. Normal size, organs, and amniotic fluid for the gestational age
4. Extra amniotic fluid
5. Uterine leiomyomata that restrict fetal development

A
  1. Renal agenesis of the fetus resulting in intrauterine growth retardation
56
Q

A 26-year-old G0P0 is interested in becoming pregnant and presents for prepregnancy counseling. She was not vaccinated as a child and unsure if she wishes to be vaccinated now. She asks if she can change her mind during pregnancy and receive vaccinations during that time. What should she be told?
1. Hepatitis B, measles/mumps/rubella (MMR), and influenza vaccines are safe during pregnancy.
2. No vaccines are safe during pregnancy, and the risks of vaccination outweigh the benefits of immunity to infectious diseases.
3. If a pregnant woman does not show sufficient titers to rubella, measles/mumps/rubella (MMR) vaccination should be given postpartum to protect future pregnancies from the effects of congenital rubella.
4. Polio and influenza vaccinations are not safe during pregnancy and should never be utilized.
5. RhoGAM is a vaccine specific to pregnancy that should be given to all pregnant women

A

3) If a pregnant woman does not show sufficient titers to rubella, measles/mumps/rubella (MMR) vaccination should be given postpartum to protect future

57
Q

A 34-year-old G3P2 at 27 weeks’ gestation is referred to the clinic upon discharge from a correctional institution where she has been incarcerated for 25 days for a drug offense. She denies any further substance abuse, but her behavior is concerning for intoxication, and she smells of alcohol and cigarettes. The clinician inquires about her drug use with open-ended questions and counsels her that which of the following is true?

  1. Pregnant women are not routinely screened for hepatitis C, but this test should be added to the panel of prenatal blood tests for patients with a history of intravenous drug use.
  2. Women can safely drink one alcoholic drink per day without risk of fetal alcohol syndrome.
  3. Cigarettes are a rare cause of low birth weight in the growing fetus.
  4. If a pregnant patient does not intend to quit tobacco, she should not bother to cut down as there is no benefit to the pregnancy from decreased use without cessation.
  5. Tobacco is only associated with low birth weight; no other negative outcomes are known from cigarette use during pregnancy.
A
  1. Pregnant women are not routinely screened for hepatitis C, but this test should be added to the panel of prenatal blood tests for patients with a history of intravenous drug use.
58
Q

A woman presenting in the late second trimester of her third pregnancy reports that she is experiencing several abdominal symptoms that she attributes to pregnancy: nausea, vomiting, urinary frequency, discomfort in the lower abdomen, tenderness over the suprapubic area, and severe constipation. Which of the following is true regarding these pregnancy symptoms?
1. Iron supplementation, hormonal changes, slowed intestinal transit, physical pressure from the gravid uterus, and increased blood volume all contribute to abdominal symptoms in pregnant women.
2. Round ligament pain presents as a severe, spontaneous, sudden-onset abdominal pain that is not provoked or relieved by changing position and may be accompanied by vaginal bleeding.
3. Pregnant women may safely lose >5% of prepregnancy weight due to nausea and vomiting.
4. Urinary frequency and suprapubic discomfort in second and third trimesters of pregnancy is inevitably due to the fetus pushing on the maternal bladder; no evaluation is necessary.
5. The hormone human placental lactogen is responsible for constipation by slowing intestinal transit.

A
  1. Iron supplementation, hormonal changes, slowed intestinal transit, physical pressure from the gravid uterus, and increased blood volume all contribute to abdominal symptoms in pregnant women.
59
Q

A 42-year-old school teacher with a history of irregular periods who underwent successful intrauterine insemination (IUI) on January 25th presents to the clinic for care on March 19th. Her last menstrual period (LMP) was November 11th of the previous year. Which of the following is true about the gestational age of her pregnancy?

  1. It is determined by date of insemination plus 2 weeks.
  2. It is determined by the opinion of the specialist who completed the procedure.
  3. It is 18 weeks and 2 days.
  4. It is determined by her LMP.
  5. It is indeterminate due to the IUI procedure.
A
  1. It is determined by date of insemination plus 2 weeks.
60
Q

A 32-year-old patient with two prior pregnancies presents to clinic concerned that she may be pregnant after missing one cycle of her menses, which was previously very regular. A urine human chorionic gonadotropin (HCG) test is positive. Presuming a normal pregnancy, what can the physician expect to find on examination and ultrasound?
1. A uterine fundus that is palpable just below the umbilicus
2. An internal cervical os open to the width of a fingertip
3. A bluish hue of cervix known as the Chadwick sign
4. A cervix with a texture firmer than the nonpregnant cervix, known as the Hegar sign
5. Hyperexcitability of the facial nerve known as a Chvostek sign

A

3)A bluish hue of cervix known as the Chadwick sign

61
Q

A 31-year-old marathon runner presents for prenatal care with her first pregnancy. She is in her second trimester and is experiencing some fatigue and muscle aches. Her prepregnancy body mass index (BMI) was noted at 19.2. How should she be counseled on exercise and nutrition during pregnancy?
1. She should switch from running to weight-lifting (e.g., bench press) to maintain muscle mass while avoiding the stressors of running on the fetus.
2. She should avoid unpasteurized dairy products and delicatessen meats due to the risk of mycobacteria, shigellosis, and brucellosis.
3. She should gain at least 40 pounds during the pregnancy to account for being underweight at the time of conception.
4. Immersion in hot water is a safe and effective nonmedicinal way of coping with musculoskeletal complaints during pregnancy.
5. She should increase her calorie intake to 300 calories per day or more from her prepregnancy baseline

A

5)She should increase her calorie intake to 300 calories per day or more from her prepregnancy baseline

62
Q

A 22-year-old G1P0 presents for a routine prenatal visit at 32 weeks’ gestational age. Leopold maneuvers indicate that the fetus is in a transverse lie, with the fetal skull palpable at the woman’s left side. Fetal heart tones are heard at the uterine fundus with a baseline rate of 140 and beat-to-beat variability noted. Which of the following steps is appropriate to take at this time?
1. Order a stat cesarean section.
2. Perform an external version.
3. Plan for induction of labor at 36 weeks.
4. Admit the patient to labor and delivery for monitoring.
5. Schedule a return visit in ~2 weeks.

A
  1. Schedule a return visit in ~2 weeks.
63
Q

A 29-year-old G2P1 presents to the clinic after a positive home pregnancy test. She confides at the appointment that her male partner has become increasingly abusive lately and once struck her while she was holding her older child. How should she be counseled?
1. Reassure her that she is safe as very few pregnant women are hurt or murdered by their partners, who generally become less violent during the vulnerable period of pregnancy.
2. Demand that she leaves the partner immediately and threaten to withhold care if she does not comply.
3. Reassure her that no matter what she reveals, all information she discloses will be kept strictly confidential.
4. Ask open-ended questions, allow her to make decisions that she feels are best for herself given the circumstance, and provide immediate or long-term referrals to domestic violence resources.
5. Ask that she bring the partner to all appointments so that he can be included in decisions and thus feel less threatened and less likely to harm the patient again.

A

4) Ask open-ended questions, allow her to make decisions that she feels are best for herself given the circumstance, and provide immediate or long-term referrals to domestic violence resources.

64
Q

Concerning alcohol consumption in older adults, which of the following is true?

a) The CAGE screening for alcohol abuse retains the same sensitivity and specificity it
has for younger populations.
b) Alcohol alone does not cause cognitive impairment in older patients.
c) Symptoms and signs of alcohol abuse are more overt and easier to notice during
outpatient encounters in older patients than in younger patients.
d) Alcohol consumption is responsible for 10% of all hospitalizations in patients age >65
years.
e) The detection of alcohol abuse is higher in older patients than younger patients due
to more frequent ambulatory interactions with health care providers.

A

a) The CAGE screening for alcohol abuse retains the same sensitivity and specificity it

65
Q

An 80‐year‐old woman who lives alone at home presents with concerns about maintaining her independent living status. She continues to drive and care for herself and her pet dog but reports two falls over the past 4 months. During one fall, she struck her head, causing a bruise over the right eye. She attributes these episodes to environmental factors: Once she tripped over a rug,
and once she misjudged the depth of the curb while crossing the street. Which of the following would be the best approach to this patient?

a) Order a computed tomography (CT) scan of the head to rule out cerebellar pathology.
b) Advise her that falls are associated with aging and that no preventive measures have
proven effective.
c) Perform a comprehensive assessment of fall risk and plan preventive interventions.
d) Advise the patient to be more careful and attentive to her surroundings and provide
reassurance that two episodes is not a cause for concern.
e) Advise her that she may require a walker or a cane to provide better balance.

A

c) Perform a comprehensive assessment of fall risk and plan preventive interventions.

66
Q

Which of the following is true about hair in the aging adult?
a) Women may experience the development of sparse coarse facial hair in their mid‐50s.
b) Age‐related hair changes are the same for all individuals regardless of ethnicity or
race.
c) Age‐related hair loss in males is normal only after age 50 years.
d) Although hair loss occurs in both sexes, hair on the head, trunk, legs, and pubic hair
is invariably spared any age‐related changes.
e) Age‐related hair loss on the scalp is abnormal in women and should be evaluated to
rule out underlying pathology.

A

a) Women may experience the development of sparse coarse facial hair in their mid‐50s.

67
Q

A 75‐year‐old female in generally good health presents to a new primary care provider after she
recently moved to a new city. She takes no prescribed medications, but she has been told in the
past that her blood pressure was borderline elevated and might require treatment at some time
in the future. Which of the following findings during the physical examine is consistent with the
normal aging process and not a sign of cardiovascular disease?
a) An unchanged pulse pressure with equal increases in both systolic and diastolic
pressures
b) A widened pulse pressure with increased systolic pressure (up to 140) and decreased
diastolic pressure
c) A narrowed pulse pressure with increased systolic and diastolic components
d) An isolated increase in systolic blood pressure to >150 mm Hg
e) A drop in systolic pressure of 25 mm Hg when rising from a supine to standing
position

A

b) A widened pulse pressure with increased systolic pressure (up to 140) and decreased diastolic pressure

68
Q

Which of the following is true about the presentation of pain in the older adult?
a) Older patients are more likely to report pain symptoms than younger patients.
b) The prevalence of pain is greater in community‐dwelling older adults compared to those living in nursing homes.
c) Pain is often overtreated in the aging population due to overreporting and exaggeration of symptoms.
d) The majority of pain complaints in this population are due to cardiac or gastrointestinal (GI) syndromes.
e) The American Geriatrics Society (AGS) prefers the term “persistent pain” over the term “chronic pain.”

A

e) The American Geriatrics Society (AGS) prefers the term “persistent pain” over the term “chronic pain.”

69
Q

A 78‐year‐old woman presents to clinic with her two daughters, who are concerned about hercontinued ability to live independently. She has thus far been highly self‐reliant and is opposed to the idea of leaving of her home of 30 years. The clinician performs a complete history and physical exam (including mental status and memory testing) as well as orders laboratory tests before providing the patient and her family the finding that she has age‐appropriate changes that do not reflect any particular disease process. Which of the following findings is most consistent with the normal aging process and does not impair the ability to live alone?

a) Decreased level of thyroid hormone
b) Mild cognitive impairment
c) Decreased adipose‐to‐muscle ratio
d) Age‐related cognitive decline
e) Persistent urinary incontinence

A

d) Age‐related cognitive decline

70
Q

Medications carry both risks and benefits for older patients. Although the risks of polypharmacy
(the use of many medications at once) are very well known, many older patients take many
medications for a variety of conditions. Which of the following best describes medication prescribing and utilization in the older adult population?
a) Only half of all older patients take at least one drug daily.
b) Older patients rarely take or have adverse effects from sleep medications.
c) Individuals age >65 years account for 30% of all prescribed drugs.
d) Although older patients take more medications than younger adults, their rate of hospitalization for drug‐related adverse reactions is the same.
e) Medications prescribed for known indications are not considered to be a modifiable risk factor for adverse events.

A

c) Individuals age >65 years account for 30% of all prescribed drugs.

71
Q

Which of the following best describes the role of the health practitioner in caring for the aging American population?
a) Prepare all persons age ≥65 years for the eventuality that they will become frail.
b) Assure that all elders complete an annual physical examination.
c) Employ the same disease models used to treat younger patients with chronic disease.
d) Evaluate geriatric conditions in terms of functionality and quality of life rather than via traditional disease models.
e) Understand that the older population is generally homogenous with little variation in needs.

A

d) Evaluate geriatric conditions in terms of functionality and quality of life rather than

72
Q

A 66‐year‐old recently retired restaurant worker presents to his primary care provider with a oncern about hearing loss. He relates a history of difficulty distinguishing voices in crowded settings when significant background noise exists, which hastened his retirement. Which of the following is true about this patient’s experience with hearing and the aging process?

a) Any hearing impairment that causes functional decline warrants formal testing and evaluation.
b) Early age‐related hearing loss initially affects lower‐pitched sounds.
c) Decreased hearing acuity associated with aging is formally known as hypoacusis.
d) Age‐related declines in hearing does not begin until age ≥75 years.
e) His experience is consistent with the normal aging process.

A

a) Any hearing impairment that causes functional decline warrants formal testing and evaluation

Physical Diagnosis (17 decks)

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