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
