MD3 Flashcards
Pure sensory stroke is classically associated with a stroke in which area?
Thalamus
What is baclofen used for?
Spasms (generalised - systemic)
Bilateral strokes are highly suspicious for what stroke source?
Cardiogenic
What is mirabegron?
Sympathetic mimetic to decrease bladder release to help incontinence
What type of stroke causes hemineglect?
Right parietal
Cerebellar DANISH mnemonic?
Disdiadichokinesis
Ataxia
nystagmus
Intention tremor
Slurred speech
Hypotonia
Which area of the brain allows the the eyes to work together (a look left means one eye moving laterally and the other moving medially)
MLF
Why is foot drop dangerous in geriatrics?
Causes falls
Key differential to rule out in suspected delirium?
Stroke
List 4 components of a delirium workup.
- CXR
- bloods +/- cultures
- bladder scan
- urines
+/- CT brain for stroke
CUBBS
Chest, urines, bloods, bladder, stroke
Which quick bedside test could seperate delirium from depression/dementia?
4AT
Best way to test inattention for suspected delirium?
Count backwards from 20 or list the months of the year backwards.
What is antalgic gait?
Odd gait due to pain
All anti-psychotics impact which chemical pathway in the brain?
Dopamine paths. This is why you can use Parkinsons as a way to workout what antipsychotics might do to a patient. eg. low dopamine gives erratic movements as in Parkinsons, so giving dopamine blockers in psychosis may cause dyskinesia. Likewise, giving dopamine agonists for Parkinsons’s patients may cause psychosis.
What is olanzipine and what are the main side effects?
the ‘panacea’ of psychosis but has a horrible metabolic profile - weight gain, sedation, appetite increase.
Pubic rami fractures are strongly linked to which condition?
osteoporosis
List 4 common causes of falls in geriatric patients:
- hypotension
- hypoglycemia
- neuropathy
- CNS drugs
What are the 2 main complications of falls in the elderly?
Bleeds and fractures (think osteoporosis)
Management of delirium in geriatrics?
REALLY IMPORTANT to avoid pharmacological intervention unless absolutely necessary - try to change the environment and get family involved first.
List the bloods for a Geris screen.
FBE, CMP, UEC, CRP, LFT, B12, Folate, Vit D, TFT, glucose
It is important to include ______ in ROS for geriatric patients.
Urinary symptoms
How to screen for depression in geriatrics?
GDS score, any score above 5 should be investigated
Define mild cognitive impairment?
Cognitive decline WITHOUT loss of independence or function
Which 3 categories are used to ‘treat’ mild cognitive impairment?
- lifestyle - as with CVD risk factors
- medicolegal - appoint POA
- follow up in 12 months
‘missed appointments’ is medschool alarm bells for ____.
dementia
Management of early dementia?
- support via dementia australia
- confirm medico-legal done
- Report to vicroads
- Cholinesterase inhibitors
Which medications are used to slow the progression of dementia? What is the main side effect?
Cholinesterase inhibitors. GIT upset.
List some strategies to help patients with dementia.
- routine
- support of family
- carer support
- cleaners + meal prep
- good GP relationship
Mnemonic for features of delirium?
FISC
Fluctuating
Inattention
Short/Acute
Change in Cognition
What is the screening tool for delirium/
4AT test
Mnemonic for investigations to order for suspected delirium?
SCRUBS (or SCRUBB)
Stroke (CTB)
CXR
Rationalisation of meds
Urine - dipstick + MCS
Bloods
Scan/Bladder USS
How to manage delirium?
- supportive care
- address predisposing factors
- prevent complications
- do not restrain
- familar surroundings
- family present
What is the main diagnostic tool for dementia?
DSM-5
2 key histological findings for Alzheimers?
amyloid beta plaques and neurofibrillary tangles
How does vascular dementia differ from Alzheimers?
- cognition often degrades in stepwise manner with new infarcts
- memory can be spared
- focal neurology and slow info processing are more common than memory loss
Management of vascular dementia?
Same as for strokes/IHD
Compare the two broad types of Lewy Body disease.
Parkinson’s dementia
- Parkinsons present BEFORE dementia
Lewy Body Dementia
- parkinsonism develops AFTER dementia
- hallucinations
How does fronto-temporal dementia present?
Depends which of those lobes is targeted first.
Frontal - behavioural change/disinhibition
Temporal - primary progressive aphasia
USUALLY front-temporal dementia patients are younger
Which type of dementia are cholinesterase inhibitors ineffective in?
Front-temporal dementia
Why are CT brains readily given in geriatric patients and what do they rule out?
Radiation not an issue with few years of life left.
Rule out space occupying lesions and bleeds, most commonly chronic subdurals and meningiomas.
List 3 reasons MRIs might be difficult in an elderly patient.
- Difficulty lying still with reduced cognition
- Expensive
- Access
Which 3 areas of the CNS control micturition?
Micturition = urination
1. Pons
2. S2-4 for pudendal parasympathetic release
3. L roots for sympathetic
A right parietal stroke may cause ______.
Hemineglect
Which area of the brain allows the eyes to move in tandem?
milf
MLF - medial longitudinal fasiculus
Ischaemic strokes tend to improve for _____ weeks
6-8 then plateau
Foot drop and circumductive gait increase risk of ____ in older patients.
Falls
Which examination should be done first in potential delirium?
Neuro - rule out stroke
Name 3 systems that can cause asterixis.
Lung - CO2
Liver - Ammonia
Kidney - urea
‘Twitch and Itch’ are common long-term side effects of which group of medications?
opiods
Which two pathologies must be ruled out before diagnosing dementia?
Delirium and Depression
Which group of medications are contraindicated in delirium. List two exceptions to this rule.
BENZOS.
The two exceptions:
- alcohol withdrawal delirium
- Parkinson delirium wherein anti-psychotics cannot be given
One question to test for inattention in suspected delirium?
Count backwards from 20
All anti-psychotics act by blocking _____
the dopamine pathway
Side effect of olanzapine?
horrific metabolic profile - appetite up, weight gain, sedation
What are EPS of anti-psychotics?
Extra pyramidal side effects - eg. tardive dyskinesia. Erratic movements similar to Parkinsons due to long term antagonism of dopamine system (Parkinsons similar pathophysiology)
List 3 Diabetes related risk factors for falls in geriatric patients.
- Orthostatic hypotension due to autonomic dysfunction +/- BP lowering meds
- Hypoglycemia due to anti-hyperglycemics or low nutrition due to cognition
- Neuropathy - can’t feel limbs
List 3 major medication groups that contribute to falls.
- BP meds
- CNS meds (sedation)
- Anti Hyperglycemics
Does stroke cause syncope?
ONLY if its a huge brainstem stroke
Main 2 pathologies we are concerned about post fall?
- fractures (osteoporosis)
- bleeds (anti-coagulants)
Why do we tolerate elevated BSL (up to 15) in geriatric patients?
Better than the risk of hypoglycemia, geriatric patients may not experiecne side effects of hypos and therefore might not notice and totally tank.
Which cognition test is approved for non-English speakers?
RUDAS
Which cognition test is best for checking executive function?
MOCA
Ladder of laxatives?
Coloxyl+senna > movicol > lactulose > glyceryl suppository > +/- microlax > fleet enema
3 exams to conduct for suspected cauda equina?
Lower Neuro
Urinary continence/catheter/bladder fullness
DRE rectal tone
List 3 causes of SIADH and 3 causes of Diabetes Insipidus
SIADH
- lung cancer
- stroke
- head injuries
DI
- brain tumours + pituitary
- removal of brain tumours
- lithium
Mnemonic for geriatric giants?
CODFOD Meds
- cognition
- opioids (pain)
- dementia
- falls
- osteoporosis
- delirium
- meds - polypharmacy
Examinations to perform for a fall?
need to examine for CAUSES and OUTCOMES
- cardio for arrythmia
- cranial nerve for ICP
-back exam + sacral
- chest wall tenderness
- neck movement
- hip movements
2 pillars of Wernicke-Korsakoff syndrome?
- no memory laying
- ophthalmaplegia
Why is future dental work a worry for patients started on bisphosphonates?
Osteonecrosis of the jaw
Risk of missing a denosumab dose?
More fracture risk than ever before
Why is denosumab preferable in many patients to bisphosphonates?
- easier
- gentler on kidneys
Rules for taking bisphosphonates?
Must sit upright for 30 mins after taking it to avoid osephagitis and can have no food in tummy, can only take it with water
What is overflow diarrhea?
Liquids of colon escaping from rectum in constipated patient. Looks like diarrhea but is actually constipation, do AXR
3 top causes of peripheral neuropathy?
Diabetes
Hypothyroid
B12 deficiency
Why are neuropathic anti-convulsants a risk for geriatric patients?
They are sedating, falls risk.
What is clorvescent?
K+ tablet replacement
Compare the literal T10 spinal level to the T10 dermatome.
T10 level = xiphoid process
T10 dermatome = umbilicus
What is functional incontinence?
Incontinence not due to a pathology but due to an inability to get to the toilet.
Which cognition test is preferable for vascular dementia?
MOCA
Name the big 4 pall care end of life meds.
The 4 Ms:
- midazolam
- morphine (often ordine)
- Metaclopramide
- Mucus (glycopyrolate = atropine lite)
Describe the findings in neurogenic shock.
- impaired neuro impact prevents vasoconstriction leading to systemic vasodilation
- HR likely to be normal as not hypovolemic
- skin often flushed instead of pale like other kinds of shock
What are the 2 broad treatment groups for neuropathic pain?
Anti-convulsants (eg. pregabalin and gabapentin) and anti-depressants (eg. duloxetine and amitriptyline)
Having rib fractures leads to a risk of which other pathology?
Pneumonia - no deep breaths
Asthma attack mnemonic?
POSSUM
Pred/hydrocort (is faster)
Oxygen
SABA
SAMA - ipratropium
Uhhhhhdrenaline (adrenaline)
Magnesium Sulphate
What is the key physiological feature of an asthma attack?
Hyperexpansion, leads to tamponade or pneumothorax
Brand names for short acting morphine (liquid and pill) and for long acting morphine?
short - ordine (liquid)
short - sevredol (pill)
long - MS contin
What to give instead of metaclopramide in Parkinsons?
Donperidone
Mnemonic for Mental State Examination?
BAPTISM At Church
Behaviour
Appearance
Perception
Thoughts
Insight
Speech
Mood
Affect
Cognition
What 4 things to check to declare patient dead?
- response to voice
- pupils fixed and non-reactive
- pulses and heart sounds
- breath sounds
What time of the day are steroids most likely to cause agitation?
After midday when levels are meant to be dropping
Name one IV and one oral treatment for Reynauds.
- IV - iloprost infusion - prostacyclin for vasodilation
- Nifedipine (Ca+ blocker, think Amlodipine)
Mnemonic for DIC causes?
DICk MOPS
DIC - malignancy, OBG, pancreatitis, sepsis
Mnemonic for most important pancreatitis severity markers.
RANSONS CRITERIA - SILC
Sugar (glucose) up
Immune - WBC up
LDH up
Ca2+ down
Name a liver safe opioid.
There aren’t any. Some are better than others, consider hydromorphone.
Name 2 causes of non-megaloblastic macrocytic anaemia.
- hypothyroid
- alcohol
Pain from 60 degrees to 120 degrees in shoulder abduction is consistent with?
Shoulder impingement
What is a timed up and go?
Part of the Comprehensive Geriatric Assessment that asks a patient to stand, walk 3 metres then return to their seat and sit back down. Should only take 10 seconds.
Normochromic, Normocyctic anaemia is typical of which pathology?
Anaemia of chronic disease
Name the 3 pronged approach for osteoporosis.
- Medication (either denosumab or bisphosphonate)
- Vit D supplement
- Strength training
Name the key non-pharmacological management for falls risk.
FALLS AND BALANCE CLINIC
What is the key to managing venous insufficiency and what do you need to check before you take this path?
COMPRESSION.
Need to check for PVD before you do this or you’ll occlude weak arteries - do an ABPI.
3 pronged management for geriatric wounds?
- Compression
- Dressing
- Wound clinic
How does fear of falling contribute to falls risk?
Fear of falling –> reduced mobilisation –> deconditioning
Which 3 components are needed for balance control?
- CNS function (cerebellum)
- sensory input (sight and proprioception)
- effector response
List 3 management points for falls risk.
- EXERCISE
- medication review
- vit D supplement
- falls and balance clinic
Operate early and mobilise early are two key aspects of which pathology?
NOF
List two pathologies that may arise from long term PPI use.
- C.diff risk
- B12 deficiency
What is a prescribing cascade?
Assigning a new medication to deal with the sides effects of another medication - it keeps snowballing.
Why does venous insufficiency cause ulcers?
Fluid causes pressure build up which cuts off supply leading to hypoxia and tissue death.
What is ulcer ‘slough’?
Yellow coating of an ulcer that resembles puss but is not due to an infection - rather it is a product of dying inflammatory cells
What is the key management for a diabetic foot ulcer and which pathology should you be looking out for each time you review the foot?
Key management = taking pressure of ulcer - aided by podiatrist.
Keep an eye out for osteomyelitis.
Reactive arthritis, Rheumatoid arthritis and enteropathic spondyloarthropathies cause which eye related conditions?
reactive - conjunctivitis
RA - scleritis
Enteropathic - uveitis
Which body areas are most prone to pressure sores?
Bony prominences
How to definitively manage an arterial ulcer?
Need to restore flow. Eg. angioplasty
What is micturition?
Urination
If a patient has bilateral ischemic strokes, what should you suspect?
More proximal cause - eg. cardioembolic
Hemineglect is caused by strokes in which brain area?
Non-dominant parietal (right)
3 molecules/systems that can cause metabolic flap?
Urea - kidney
Ammonia - liver
CO2 - lung
Name two causes of delirium that would benefit from benzodiazepines over anti-psychotics.
Alcohol induced/withdrawal delirium and Lewy Body/Parkinsons delirium
Which test separates dementia and delirium?
4AT
What is an Antalgic gait?
Limp due to pain
What are the two key physio rehab components for post fall management?
Core strength and balance retraining
List 4 key precipitants of falls in geriatric patients.
- Orthostatic hypotension
- Hypoglycaemia
- Peripheral neuropathy
- Any CNS drugs
What are the two major post falls risks?
- Bleeds
- Fractures
Which vital sign can be a good indicator of aspiration?
o2 sats
Approximately what BSL would be tolerated in geri populations.
Under 15 is fine, don’t want to risk hypos causing falls
Which cognitive test is approved for foreign speaking translators?
RUDAS
List some falls prevention strategies.
- supervision/assist
- high visibility room
- walking aids
- proxy buzzer
- lower bed/crash mat
Mnemonic for geriatric giants?
CODFODmeds
Continence
Osteoporosis
Delirium
Falls
Opioids (pain)
dementia
Meds - polypharmacy
MOA of tiatropium and ipratropium?
Tiatropium - LAMA
ipratropium - SAMA
What is a physiological advantage of denosumab over bisphosphonates?
Avoids eGFR issues
Instructions for taking bisphosphonates?
To avoid osephagitis - sit up for 30 mins after taking it and take it with only water nothing else, before food
Fluctuating cognition is a key feature of ______ ?
Delirium
Which opioid is safe in CKD?
Fentanyl
What is the KICA test for?
Cognitive test for First Nations people
Top 3 causes of peripheral neuropathy?
Diabetes, B12 deficiency, hypothyroid (and alc is in there somewhere)
What is clorvescent?
Potassium tablet
Best cognitive test for executive dysfunction?
MOCA - great for vascular dementia
Two side effects common to chronic opioid use?
Opioid itch and opioid twitch
What are the big 4 end of life pall care medications? (Mnemonic)
The four M’s:
- midazolam
- morphine - often S/C
- metaclopramide
- mucolytics (glycopyrolate)
2 broad medication classes used for neuropathic pain?
Anticonvulsants and anti-depressants (duloxetine and amytriptiline)
Mnemonic for asthma treatment?
POSSUM
Pred (actually do hydrocortisone)
O2
SABA
SAMA
uhhhDrenaline (adrenaline)
Magnesium sulphate
Why is anxiety during an asthma attack a huge problem?
Anxiety increases RR, causing tachypnea and even further reducing length of expiratory phase. This adds to hyperexpansion of the lungs and can result in tamponade or pneumothorax
What kind of words are often used to describe neuropathic pain?
Electric type words like shock or zap
What is the alternative to metaclopramide given to Parkinson’s patients?
Donperidone
What is the typical breakthrough (PRN) dose given to patient?
1/6th of regular dose - same agent
What are the four components of verifying a patient has died?
- Response to voice/pain
- Pupil response
- Pulse/ heart sounds
- Breathing sounds (turn of O2 first)
Nifedipine and iloprost are used for which condition?
Reynauds.
Iloprost is a prostacylcin analogue
Nifedipine is a calcium channel blocker
Mnemonic for causes of DIC?
DIC(k) MOPS
DIC
Malignancy
OBG
Pancreatitis
Sepsis
Mnemonic for Ranson’s criteria?
SILC
Sugar (glucose up)
Immune cells (WBC up)
LDH up
Calcium down (think of all the calcium being used up by forming pancreatic calcifications evident in chronic pancreatitis)
2 causes of non-megaloblastic macrocytic anaemia?
Hypothyroid and alcoholism
Pain on 60 to 120 degrees of shoulder abduction is associated with which pathology?
Shoulder impingement
If you have mania, you are 100% experiencing which pathology (the only 100% specific finding in psych)
Bipolar
What is FEP?
First episode psychosis - doesn’t really count as schizophrenia yet
What are the four dopamine paths and how may anti-psychotics impact these paths?
- Mesolimbic pathway - responsible for positive symptoms (hallucinations, psychosis) - responds well to anti-psychotics
- Mesocortical pathway - responsible for negative symptoms (apathy, social withdrawal etc) - respond poorly to anti-psychotics
- Nigrostriatal (think substantia nigra, the Parkinson’s pathway) - blocking this path with anti-psychotics leads to extra-pyramidal side effects eg. tardive dyskinesia
- Tuberoinfundibular - pituitary dopamine path, blocking the dopamine in this path with anti-psychotics removed prolactin inhibition so you can get prolactin build up
How to differentiate Parkinson’s and extra pyramidal side effects on exam?
The pill rolling tremor: Parkinsons will cause a UNILATERAL pill rolling tremor whereas EPSE will cause bilateral effects
What are the main side effects of typical vs atypical anti-psychotics?
Typical - tardive dyskinesia
Atypical - metabolic syndrome
What class of anti-psychotics are aribiprazole and brexpiprazole?
Ari- 3rd Gen - partial dopamine agonist that outcompetes dopamine in body, blocking receptors. MAKES PTs RESTLESS
Brex - 4th Gen - same mechanism as above with less restless side effects.
Difference between schizophrenia vs schizoaffective?
Schizophrenia = just psychotic symptoms
Schizoaffective = psychosis and depressed mood symptoms
Depression with psychotic characteristics = big mood problems with precipitated psychotic symptoms
All on the same sort of spectrum
List some of clozapine’s key side effects.
- myocarditis
- seizures
- drooling
- neutropenia
Then the other classic atypical antipsychotic sides: constipation, weight gain, sedation etc.
Dangerous complication of rapid hyponatremia?
Cerebral edema
How might anti-psychotics impact the bladder?
Cause urge incontinence due to anti-cholinergic effects
If you give an anti-depressant to a depressed patient and they become manic, what is their underlying diagnosis?
Bipolar. All manic people have bipolar.
Are SSRIs/SNRIs given in bipolar?
No because they will the person into mania
What is Beck’s triad and what does it indicate?
Cardiac tamponade
- JVP up
- muffled heart sounds
- hypotension
Rose coloured rash is typical of which pathology?
Salmonella infection (typhoid)
What is sulfasalazine?
DMARD
Food poisoning after 3 hrs from an egg salad is likely due to?
Staph aureus - few organisms can cause food poisoning so quickly - consider staph, bacillus cereus and vibrio
What is cystic medial necrosis?
Large vessel genetic disease that causes aortic aneurysms and dissections
Convert oral morphine to subcut
Divide by 2 or 3 (sources say different things) - 30mg ordine becomes 10mg sub cut for example
Convert 10mg morphine to hydromorphone
2mg - it’s 5x stronger
What is Lambert Eaton syndrome and who gets it?
Like myasthenia but can be overcome by movement and less eye involvement. Attacks pre synaptic terminal. Happens in patients in lung cancer.
