OPIC: passmed Flashcards
You are working in the memory clinic and your next patient is an 85-year-old man who is accompanied by his wife. You take a collateral history from the patient’s wife which reveals that he has been becoming gradually more confused and forgetful over the past year. However, she mentions he can recall past events vividly. Last week, she states she found him wandering the streets only 2 minutes from his house, having forgotten where he was. His wife denies any sudden decline in his cognition or behaviour. She also denies any evidence of hallucinations. Given the most likely diagnosis, what part of the brain is affected?
Cortex and hippocampus
Alzheimer’s disease causes widespread cerebral atrophy mainly involving the cortex and hippocampus
A 79-year-old man with a known history of mixed type dementia (Alzheimer’s and vascular) is assessed in memory clinic as his family have noticed a further deterioration in his memory and cognition. His mini-mental state score is 12 and as such he is commenced on memantine.
Which of the following best describes the mechanism of action of memantine?
NMDA antagonist
A 92-year-old lady is being visited by the district nurses. She has developed a grade 2 pressure ulcer on her right buttock over which she is quite tender. On examination her temperature is 36.5ºC, there are no signs of cellulitis and there is no exudate. The area around the ulcer is erythematous but is not warm to touch.
Given her presentation what is the most appropriate management of this patient?
analgesia, wound dressing, nutritional assessment
dont routinely give abx unless signs of infection
A 64-year-old woman presents with her husband to the GP. Her husband describes how she has become more irritable and impulsive over the past year, buying expensive jewellery without telling him. He thinks she has developed more of a sweet tooth lately. During the consultation, the patient starts crying without warning. There is no previous psychiatric history. Her father developed a gambling addiction in later life.
What is the most likely diagnosis?
Frontotemporal dementia presents with social disinhibition and often has a family history
A 75-year-old lady is admitted in an acute confusional state secondary to a urinary tract infection. Despite antibiotic therapy, reassurance and environmental modification she remains agitated. You are considering prescribing haloperidol. Which one of the following conditions may be significantly worsened if haloperidol is prescribed?
All antipsychotics may worsen the symptoms of Parkinson’s disease and should be avoided if possible. A small dose of oral _lorazepam_ may be an alternative in such a situation.
The nursing staff are concerned as she has not yet been to bed yet and it is now 4 am. She is a falls risk due to frailty and is attempting to leave the ward. They have tried relevant nursing interventions but to no avail.
She is being treated for community-acquired pneumonia with IV co-amoxiclav and is on day 2 of treatment. Her vital signs are stable. There are no other symptoms to report.
There is no relevant past medical history of note but she does currently have an adult with incapacity act in place.
What is the most appropriate management of this patient?
oral haloperidol
An 85-year-old female presents with increasing forgetfulness. She is brought in by her daughter who notices that she has been forgetting things and has been getting lost. Her daughter now cooks for her. She has also been talking about a man in her garden, despite the fact she does not have a gardener. The daughter notices that these concerns were improving a few months ago, but has again gotten worse in the past 2 weeks. The patient reports poor sleep where she remembers her dreams vividly.
Her past medical history includes hypertension, hyperlipidaemia, and diabetes. She is on perindopril, rosuvastatin, and metformin. She has never smoked and drinks alcohol.
Which of the following is the most likely cause of her presentation?
Visual hallucinations with dementia = Lewy body dementia
A 74-year-old man had a bout of viral gastroenteritis 1 week ago with 3 days of vomiting and diarrhoea. These symptoms largely settled, but he has since had ongoing nausea. In the last few days, his vision has become more blurry and he has felt increasingly dizzy, resulting in several falls. His pulse is 54/min and irregular and his blood pressure is 119/68 mmHg. He has a history of ischaemic heart disease, hypertension, atrial fibrillation and type 2 diabetes. There have been no recent changes to his medications.
A.AmitriptylineB.ApixabanC.AtorvastatinD.BisoprololE.Co-careldopaF.CodeineG.DigoxinH.GliclazideI.IndapamideJ.Oxybutynin
Digoxin
This man has typical symptoms of digoxin toxicity. Digoxin has a narrow therapeutic index and toxicity can be potentiated by renal failure and hypokalaemia - his recent viral gastroenteritis may have been the trigger in this scenario.
Symptoms of acute digoxin toxicity include gastrointestinal disturbance (nausea, vomiting, abdominal pain), dizziness, confusion, blurry or yellow vision, and arrhythmias.
A.AmitriptylineB.ApixabanC.AtorvastatinD.BisoprololE.Co-careldopaF.CodeineG.DigoxinH.GliclazideI.IndapamideJ.Oxybutynin
Amitriptyline
This woman is likely to be suffering from the side-effects of an anticholinergic drug such as amitriptyline, including dry eyes, dry mouth, hypotension (often postural) and delirium. Amitriptyline is a commonly prescribed neuropathic painkiller.
Other side-effects include constipation, urinary retention, arrhythmias (including QT interval prolongation) and hypothermia.
While oxybutynin can also cause anticholinergic symptoms, it is used in the treatment of overactive bladder and urge incontinence rather than pain.
An 80-year-old man with advanced Alzheimer’s dementia has had a fall in the residential home. He also has a history of atrial fibrillation, type 2 diabetes, osteoarthritis, gout and hypertension. He normally walks with a zimmer frame, although the staff noticed that he had been limping more in the last 24 hours.
He is alert and apyrexial. His pulse is 85/min and blood pressure is 145/80 mmHg. His capillary blood glucose is 8.0 mmol/mol. On examination, he has a laceration to his right arm that is bleeding profusely. On inspection of his feet, he has a swollen red metatarsophalangeal joint of his left big toe.A.AmitriptylineB.ApixabanC.AtorvastatinD.BisoprololE.Co-careldopaF.CodeineG.DigoxinH.GliclazideI.IndapamideJ.Oxybutynin
Indapamide
Indapamide33%
This man has a likely diagnosis of gout. Indapamide and other thiazide diuretics can precipitate this condition, and strong consideration should be made with regards to stopping this drug in this patient.
While his profuse bleeding may be exacerbated by an anticoagulant such as apixaban, this is unlikely to have contributed to the fall itself. The normal blood glucose suggests that gliclazide is the unlikely culprit here.
You are a doctor on-call overnight. You are called by the nurse about an 82-year-old man on the orthopaedic geriatric ward has become increasingly confused following his total hip replacement 5 days ago.
He was complaining of considerable post-operative pain and has been given regular morphine which is managing his pain.
You go to see him and agree he is confused with an abbreviated mental test score (AMTS) of 4/10. He is unable to give you a history but consents to an examination. You assess his wound which is clean, chest is clear and abdomen soft, non-tender. Pupils are equal and reactive. The nurse reports he has been eating and drinking less.
Observations are all within normal range. Urine dip negative. Bloods taken yesterday morning demonstrated a long-standing slight normocytic anaemia and his inflammatory markers are coming down since the operation.
What is the most likely cause of his symptoms?
constipation
An elderly, frail woman is admitted to the ward following a fall at home. What is the most appropriate way to assess her risk of developing a pressure sore?
waterlow score
picks disease
frontotemporal dementia
Middle aged adult with insidious onset dementia and personality changes = Pick’s disease
A 72-year-old female is brought into the general practice by her worried husband.
She has been more forgetful over the past few months, on some days more than others, and seems to struggle to keep her focus on simple daily activities and conversations. Her husband is also worried as she occasionally states she is talking to their dog whilst apparently talking alone, although they have never had any pets.
She is otherwise well, eating and drinking as usual. Examination and routine blood tests are all unremarkable, and there is no reason to suspect delirium.
What is the most likely diagnosis?
Visual hallucinations with dementia = Lewy body dementia
An 86-year-old gentleman comes to see you with his daughter for a medication review. His memory has been declining recently and he was referred to memory clinic three months ago, where he was diagnosed with Alzheimer’s dementia.
His other medical history includes chronic back pain secondary to osteoporosis, ischaemic heart disease and atrial fibrillation.
Which one of the following medications should you consider stopping?
amitriptyline
aspirin
rivaroxaban
statin
alendronic acid
The STOPP-START Criteria (Gallagher et al., 2008) outlines medications that we should consider withdrawing in the elderly. One example of this is the use of tricyclic antidepressants in patients with dementia, due to the risk of worsening cognitive impairment.
