medicine of older adult Flashcards
patient with Contralateral homonymous hemianopia with macular sparing and visual agnosia. pointing to wrong items in room. what vessel is affected?
posterior cerebral artery
PCA is a branch of the basilar artery but if basilar artery was affected itself, would cause ataxia, dysphagia, vertigo, nausea and vomiting due to a loss of blood supply to the cerebellum.
if pontine artery was affected -infarction of the brainstem and therefore can lead to paralysis and locked-in syndrome if the damage is extensive.commonly presents with reduced GCS, paralysis and bilateral pin point pupils!!. It would not result in homonymous hemianopia or visual agnosia.
Anterior inferior cerebellar artery - sudden-onset vertigo and vomiting, ipsilateral facial paralysis, and deafness.
Posterior inferior cerebellar artery is incorrect. These strokes can cause a lateral medullary syndrome with a collection of symptoms including contralateral truncal and extremity sensory deficits, ipsilateral facial sensory deficits, ataxia, vertigo, nystagmus, dysphagia and Horner’s syndrome. Homonymous hemianopia and visual agnosia are not typically seen in these patients. aka lateral medullary syndrome
lacunar infarct - These are strokes that lead to one of the following:
1. pure sensory impairment - complete one sided sensory loss
2. unilateral weakness, affecting face arm leg or all 3
3. ataxic hemiparesis.
Internal capsule infarcts can present with a purely motor stroke affecting one limb only.
Patient presents with reduced upper and lower limb sensation and power on right side. But lower extremity is affected more. What artery was most likely affected?
Left anterior cerebral artery!!!
middle cerebral artery = contralateral hemiparesis and sensory loss with the upper extremity being more affected than the lower, contralateral homonymous hemianopia, and aphasia.
Posterior cerebral artery - contralateral homonymous hemianopia with macular sparing. visual agnosia
2/5 strength in the left upper and lower limb and 5/5 strength in the right upper and lower limb, with normal sensation bilaterally. Her right eye is depressed and abducted with a wide pupil. Additionally, she has a consensual light reflex on the left pupil but lacks a direct reflex on the right
most likely diagnosis?
right branches of the posterior cerebral artery!!! (webers syndrome)!!! -> ipsilateral cn3 palsy (ptosis, pupil dilated) (NOT facial droop )and contralateral weakness upper and lower extremity
you need to know ACA, MCA, PCA, Webers syndrome, PICA, AICA, basilar artery, pontine artery
how do total anterior circulation infarcts TACI and partial anterior circulatory infarcts present?
how do posterior circulation infarcts present?
- unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
TACI = all 3 criteria
PACI = 2 criteria
POCI:
involves vertebrobasilar arteries
presents with 1 of the following:
1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia
Patient presenting with HF with reduced LVEF. Already on a beta blocker. Blood pressure 150/96. What medication should be added
Enalapril- Patients with heart failure with reduced LVEF should be given a beta blocker and an ACE inhibitor as first-line treatment.
Aldosterone antagonists are second line options. Eg spironolactone and eplerenone
if patients suffer significant upper gastrointestinal side effects from the use of alendronate eg for osteoporosis, what is the next line in management?
change alendronate to risedronate
name a drug used for parkinsons that has reduced effectiveness over time
levodopa
cabergoline is associated with pulmonary fibrosis
acute Heart Failure not responding to treatment eg IV furosemide. what do you consider next?
CPAP - used in patients with resp failure
A patient with advanced prostate cancer and bone metastases is offered intravenous zoledronic acid to assist with pain and the presence of bone fractures. Three days after the administration of the drug, the patient presents to the emergency department with body aches, muscle spasms, and tingling around his lips.
what will serum studies most likely show?
hypocalcemia
symptoms match up.
zolendronic acid reduces bone turnover.
hypocalcemia AND vitamin D deficiency should be corrected before giving bisphosphonates!!!
how do you diferentiate where an intracapsular hip fracture and an extracapsular hip fracture lies?
intracapsular (subcapital): from the edge of the femoral head to the insertion of the capsule of the hip joint
extracapsular: these can either be trochanteric or subtrochanteric (the lesser trochanter is the dividing line). they both start under the line connecting the greater trochanter to the lesser trochanter. and straight line underneath lesser trochanter marks subtrochanteric region
management of intracapsular hip fracture?
Undisplaced Fracture:
internal fixation, or hemiarthroplasty if unfit.
Displaced Fracture:
(total hip replacement or hemiarthroplasty). hemiarthroplasty if patients were previously very fit. have to be fit to do the total hip replacement
extracapsular hip fracture management?
stable intertrochanteric fractures: dynamic hip screw
if reverse oblique, transverse or subtrochanteric fractures: intramedullary device
patient hip accident An X-ray shows a subtrochanteric fracture of the left femur.
management?
intramedullary device
tamsulosin is what type of drug?/mechanism
alpha 1 ANTAGONIST
BPH
If men have a mixture of storage and voiding symptoms that persist after treatment with an alpha-blocker alone, eg tamsulosin then what do you add on?
what medication is indicated if the patient has a significantly enlarged prostate and is considered to be at high risk of progression?
Tolterodine - or another antimuscarinic (anticholinergic) drug such as darifenacin
significantly enlarged = 5 alpha reductase inhibitors eg finasteride
define malnutrition mathematically
unintentional weight loss greater than 10% in the last 3-6 months
eg patient of 100kg losing 10kg in last 6 months
81 yo woman, fall and fracture she takes 10mg prednisolone daily for polymyalgia rheumatica.
What other measures should be taken at this stage given her fracture?
alendronic acid!!!
Start alendronate in patients >= 75 years following a fragility fracture, without waiting for a DEXA scan. age range you are just presumed to have osteoporosis
If a patient is under the age of 75 years a DEXA scan should be arranged. These results can then be entered into a FRAX assessment
to determine the patients ongoing fracture risk.
how does amourosis fugax present?
which vessel does it affect?
IPSILATERAL Disease
painless black curtain coming down vertically into the field of vision in one eye.
retinal or ophthalmic artery
If clopidogrel is contraindicated or not tolerated for secondary stroke prevention - eg causing diarrhea.
management?
change to aspirin (+ dypiridamole!!)
clopidogrel is now FIRST line. aspirin 300 mg daily for 2 weeks then clopidogrel 75 mg daily long-term. A statin should also be offered if the patient is not already on statin therapy.
only use aspirin long term if clopidogrel contraindicated or not tolerated.
Carotid endarterectomy is recommend if the patient has suffered a stroke or TIA in the carotid territory and is not severely disabled
should only be considered if the stenosis > 50%
*note if stroke is as a result of atrial fibrillation, then you give aspirin short term and a doac long term eg apixaban
stroke occurred in the last 6 hours and is in the proximal anterior circulation. patient undergoes thrombolysis. what management should be considered next?
mechanical clot retrieval!! ie thrombectomy.
it is a large artery stroke same would apply for ACA
NICE recommends to offer thrombectomy and thrombolysis to people who have had an ischaemic stroke with CT evidence within 6 hours of symptom onset. Though this patient is outside of that 6 hour window, NICE also specifies that if the CT perfusion scan shows a limited infarct core (with the potential to salvage affected brain tissue), they should be offered thrombectomy between 6-24 hours after the event.
if hip fracture suspected despite negative hip xrays, first line investigation?
MRI hip
what is the analgesia of choice in a neck of femur fracture?
iliofascial nerve block
name an important side effect of bisphosphonates to warn patients about
heartburn - oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate)
others: hypocalcemia, atypical stress fractures, osteonecrosis of the jaw
finasteride for BPH may take how long to show its effects?
6 months
A 69-year-old woman is brought to the emergency department with sudden onset unsteadiness. On examination she is haemodynamically stable, has normal visual fields, no ophthalmoplegia but a nystagmus which is present at rest, loss of pinprick sensation over the right trigeminal distribution but no facial weakness or loss of light touch sensation over the face. She also has loss of pinprick sensation in the left arm and leg although she has 5/5 power in all limbs and preserved light touch sensation in all dermatomes.
This clinical syndrome is most likely due to a stroke affecting which of the following vascular territories?
right PICA / lateral medulary syndrome
A 78-year-old man is admitted to the stroke ward. You are asked to examine him. He denies any headache. You find he has normal motor function but has completely lost sensation on the right hand side of his body. There is no hemianopia or dysphasia. What type of stroke is this?
lacunar stroke
An 81-year-old man presents to the emergency department with sudden onset nausea and vomiting. He was walking in the park when he suddenly felt like the ‘world around him was spinning’ and he started vomiting.
On examination, he look unwell and disorientated. A cranial nerve examination reveals that he is unable to raise his eyebrows, smile or raise his eyelid on the right side. The sensation is also lost on the right side of his face. He also cannot hear from the right ear, which is a new symptom for him. An ataxic gate is noted.
Given the most likely diagnosis, where is the lesion?
right aica
Sudden onset vertigo and vomiting, ipsilateral facial paralysis and deafness - anterior inferior cerebellar artery
76 yo
fractured neck of femur
bone profile investigation done
most likely results?
Osteoporosis is commonly associated with normal blood test values (e.g. normal ALP, normal calcium, normal phosphate, normal PTH)
If a patient is deemed high-risk based on a QFracture OR FRAX score next step in management?
eg Qfracture score of 14%
Dexa scan!!
as the calculated 10-year fracture risk is 10% or higher
how should bisphosphonate meds be taken?
why?
empty stomach!! at least 30 minutes before breakfast (or another oral medication); the patient should stand or sit upright for at least 30 minutes after taking
to prevent eosophageal reaction
65 yo tscore -2.5 meaning
bone density is 2.5 standard deviations below that of average healthy YOUNG adult
describe the type of tremor seen in parkinsons
unilateral tremor improving with voluntary movements
recommended tool to assess for a stroke in acute setting eg emergency room?
ROSIER is an acronym for ‘Recognition Of Stroke In the Emergency Room’. It is the tool recommended by NICE to assess stroke symptoms in an acute setting.
aspirin should only begin in acute setting of stroke ie before thrombolysis or thrombectomy availability if what?
hemorrhagic stroke excluded
ropinirole fall into what group of anti parkinsons drugs known to cause impulse control disorders?
dopamine receptor AGONISTS - others include bromocriptine!!!, cabergoline!!, apomorphine!!
After a five year period for oral bisphosphonates (three years for IV zoledronate), treatment should be re-assessed for ongoing treatment, with an updated FRAX score and DEXA scan.
This guidance separates patients into high and low risk groups. To fall into the high risk group, one of the following must be true:
Age >75
Glucocorticoid therapy
Previous hip/vertebral fractures
Further fractures on treatment
High risk on FRAX scoring
T score <-2.5 after treatment
If any of the high risk criteria apply, treatment should be continued indefinitely, or until the criteria no longer apply. If they are in the low risk group however, treatment may be discontinued and re-assessed after two years, or if a further fracture occurs.
A 63-year-old man complains of dystonia, chorea, and athetosis (involuntary writhing movements). These symptoms have been worsening, and he notices it is worse a few hours after taking his medication. He is on medication for hypertension, parkinson’s, and depression.
What medication may have caused this?
what other side effects?
levodopa
postural hypotension
on an doff phemomenon
which antiparkinsons drug would be most likely to improve patients ability to perform activities of daily living (ADLs)?
levodopa
or co-careldopa as it is commonly prescribed
A 72-year-old man who is being treated for Parkinson’s disease is reviewed. Which one of the following features should prompt you to consider an alternative diagnosis?
diplopia -not common in Parkinson’s disease and may suggest an alternative cause of parkinsonism such as progressive supranuclear palsy
when should you weight bear after hip fracture?
full weight bearing immediately post op
A 69-year-old lady is brought to hospital by an ambulance crew with a suspected stroke. On review in the emergency department she is unable to speak although she is able to follow instructions which have been written down. She has no past medical history.
A blockage of which of the following cerebral arteries is most likely to be the cause of this woman’s symptoms?
LEFT middle cererbral artery not right
left hemisphere brain usually the dominant one that has wernickes and brocas area
A 72-year-old man is brought to the emergency department with 2 days of agitation. Last week he had norovirus and has been vomiting since. Yesterday, his vomiting was severe and he now cannot keep anything down. He has Parkinson’s disease and takes oral co-careldopa.
His temperature is 39.7ºC, his pulse is 115 bpm, and his blood pressure is 156/93 mmHg. He is diaphoretic and all four limbs are rigid with hyporeflexia.
what is used to prevent the most likley diagnosis?
transdermal dopamine agonist patch
Missed doses of dopaminergic medication can precipitate NMS, characterised by fever, altered consciousness, agitation, tremors, diaphoresis, muscle rigidity, and autonomic dysfunction (e.g., tachycardia and hypertension), as seen in this patient.
If a patient with Parkinson’s disease cannot take levodopa orally, they can be given a dopamine agonist patch as rescue medication to prevent acute dystonia
what patient factors are required to calculate a z score?
ge, gender and ethnic factors
what is the standard target time for thrombolysis and thrombectomy?
thrombolysis = 4.5 hrs
thrombectomy = 6 hours
An 80-year-old man with his wife presents to the emergency department. He states that he has been more forgetful over the past month by not being able to concentrate and continually leaving the fridge open. His wife expresses concerns at how he says that he has seen monkeys standing behind him on multiple occasions. Past medical history includes diagnosis of type 2 diabetes and hypertension over 15 years ago.
What is the most likely diagnosis?
lewy body dementia
due to hallucinations
which medication, when prescribed to patients with dementia are associated with severe increase in mortality?
antispychotics
Warfarin is an anticoagulant and vitamin K antagonist that can be used to treat a number of conditions, including DVT. However, the STOPP criteria states that it has no proven added benefit when given for longer than 6 months for uncomplicated DVT. As this patient had a DVT 2 years ago and there is no other indication for anticoagulation, this should be stopped. Furthermore, there is mention in the history of recurrent epistaxis and this has quite possibly been caused by warfarin therapy.
how to differentiate drug induced parkinsons and parkinsons?
parkinsons has assymetrical features
A 67-year-old male attends the Emergency department with sudden onset dizziness and vomiting, which has been present for the past 2 hours. He has a background of hypertension and hypercholesterolaemia for which he takes ramipril and simvastatin. Examination reveals vertical nystagmus and difficulty standing without support. What is the most appropriate next step in this patient’s management?
CT head.
symptoms point to a cerebellar stroke. CT will rule out hemorrhage -> then mri best to determine infarction.
vertical!!! nystagmus points towards a central cause of vertigo
BPPV has episodes lasting a few seconds to a minute not for 2 hours
patients with vestibular neuritis can stand without support
A 64-year-old woman presents to her general practitioner with dizziness. When she rolls over in bed in the morning, she experiences sudden onset dizziness associated with nausea, which spontaneously resolves after around 20 seconds if she keeps her head still. After these episodes, the patient feels light-headed and unbalanced for several hours. She has suffered recurrent otitis media in the past and her family history is significant for otosclerosis.
What is the most important immediate investigation?
dix hallpike maneuvere
history is classic for BBPV
name the classification system for neck of femur fractures
Garden
n 86-year-old woman with Parkinson’s disease presents to her neurologist. She is taking levodopa three times daily and complains of worsening symptoms in the lead-up to taking each dose. Her neurologist decreases her dose of levodopa and increases its frequency to five times daily.
What clinical sequelae of treatment is the neurologist attempting to mitigate?
end of dose wearing off phenomenon
An 87-year-old woman presents to her general practitioner for a medication review. She has a complex past medical history comprising diabetes, hypertension, osteoporosis and depression. She has been feeling weak and run down recently. The doctor decides to formally assess her frailty status, in order to address her needs in the best way possible.
Which one of the following tools should they use?
PRISMA-7
Frailty should be specifically assessed through the evaluation of gait speed, self-reported health status, or the PRISMA-7 questionnaire
not frax as patient has already been diagnoses with osteoporosis and you are asked for frailty specifically
An 89-year-old man presents to his general practitioner for a medication review. He has been complaining of a burning sensation in his chest just after eating. It does not improve with over-the-counter antacids and denies any red flag symptoms of cancer. You need to decide whether to prescribe him some proton pump inhibitors for his symptoms. He has a complex medical history, comprising mild dementia, depression, resected prostate cancer, chronic back pain and hypertension.
Which one of the following tools would help you in your decision?
START tool
there is also the STOPP tool
