Potpourri Flashcards
Define Hypertension
BP >140/90
Define Isolated Systolic Hypertension
Systolic BP >140 & diastolic BP less than 90
Associated Conditions with HTN
MI CVA PVD CHF Renal failure
CV Disease Risks
Continuous & consistent HTN & independent of other risks
Each 20/10 mmHg rise doubles risk of CVD
Benefits of Lowering BP
Decreased risk of stroke, MI, & HF
Define Dementia
Cognitive impairment more common with HTN
Accurately Measuring BP
Cuff size
Correct inflation
Appropriate interval
Several readings
Possible Reasons for Secondary HTN
Sleep apnea Drug-induced Chronic kidney disease Primary aldosteronism Reno vascular disease Chronic steroid therapy or Cushing's syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease
CVD Risk Factors
HTN Cigarette smoking Dyslipidemia Obesity Physical inactivity DM Microalbuminuria or GFR less than 60 mL/min Age: 55+ for men, 65+ fro women Family Hx of premature CVD (men less than 55 or women less than 65)
Target Organ Damage
Heart: LVH, angina, prior MI, prior coronary revascularization, CHF CVA/TIA Renal disease PAD Retinopathy
Aggressive BP Management
Weight loss
Sodium restriction
Treatment with all classes of drugs except hydrazine & minoxidil
Laboratory Tests for BP Issues
EKG UA CMP Fasting lipid panel H/H TSH Microalbumin
Lifestyle Modification for HTN
Weight reduction Adopt DASH eating plan Dietary sodium reduction Physical activity Moderation of alcohol consumption
Medication Classes for HTN with Heart Failure
Thiazides Beta-blocker ACEI ARB Aldosterone antagonists
Medication Classes for HTN with Status Post MI
Beta-blockers
ACEI
Aldosterone antagonists
Medications for HTN with High CAD Risk
Thiazides
Beta-blockers
ACEI
CCBs
Medications for HTN with DM
Thiazides Beta-blockers ACEI ARB CCB
Medications for HTN with Chronic Renal Disease
ACEI
ARB
Medications for HTN with Recurrent Stroke Prevention
Thiazides
ACEI
What medication class is good for gout, history of hyponatremia, & osteopenia/osteoporosis?
Thiazides
What medication class is good for RAD or 2nd/3rd degree heart block, atrial tachycardia, migraines, thyrotoxicosis, essential tremor, or in the perioperative period?
Beta-blockers
What medication class is useful in Raynaud’s Syndrome?
CCBs
What medication class is useful in BPH?
Alpha blockers
What medication classes have a risk of pregnancy?
ACEI
ARBs
What medication classes are good for hyperkalemia?
Aldosterone antagonists
K-sparing diuretics
Define Orthostatic Hypotension
Drop in standing SBP >10 mmHg
When should you always check orthostatic BP?
When adjusting meds
Differential Diagnosis of Marked BP Elevations & Acute Target Organ Damage
Encephalopaty TIA/CVA Papilledema MI or unstable angina Pulmonary edema Life-threatening arterial bleeding or aortic dissection Renal failure
Define Hypertensive Emergency
Marked BP elevations & acute target organ damage
Define Hypertensive Urgency
Market BP elevation but NO acute target organ damage
Define Pseudohypertention
When BP readings may be falsely elevated in some elderly patients with very stiff, calcified arteries
Treatment of HTN Reduces Incidence of
MI
Stroke
HF
What should you evaluate for with HTN in the elderly?
Target organ damage
Other CV risk factors
What is the 3rd leading cause of death & disability in the developed world?
CVA
Complications of Strokes
Venous thromboembolism
MI during acute period
MI or CVA first?
Major Risk Factors
HTN Smoking Atrial fibrillation MI Hyperlipidemia DM CHF Acute ETOH abuse TIA with >70% occlusion of carotid arteries OCP + smoking Hypercoagulopathy High RBC count & hemoglobinopathy Age, gender, race, prior stroke, & heredity
2 Types of Stroke
Ischemic
Hemorrhagic
Define TIA
Brief episodes of focal neurological deficits lasting 2-3 minutes to at most a few hours but less than 24 hours with no residual deficits with complete functional recovery
TIA Warning Sign of What
Impending stroke
Define Completed Stroke
Acute, sustained functional neurological deficit lasting from days to permanent
Stroke Syndromes
Internal carotid artery (ICA) occlusion ACA occlusion MCA occlusion PCA occlusion Vertebrobasilar occlusion Lacunar infarct Spinal stroke
Anterior Circulation TIA’s & Stroke
Anterior or middle cerebral artery
Amaurosis fugax (monocular blindness)
Face-hand-arm-leg contralateral hemiparesis
Aphasia/dysarthria
MCA Occlusion
Contralateral hemiplegia in face-arm-hand
Dominant hemisphere = aphasia
Non-dominant right hemisphere = confusion, spatial disorientation, sensory & emotional neglect
ACA Occlusion
Sensorimotor deficit in contralateral foot & leg
Brocas or anterior conduction aphasia in dominant hemisphere
TIA’s rarely affect ACA distribution
Posterior Circulation TIA & Stroke
Vertigo Diplopia/dysconjugate gaze, ocular palsy homonymous hemianopsia Sensorimotor deficits Dyarthria Ataxia
Vertebro-Basilar Posterior Circulation Occlusion
VA-PICA syndrome Horner's syndrome PICA-AICA-SCA acute cerebellar infarction BA V-B junction Basilar apex PCA quadrantic or homonymmous hemianopsia PCA thalamus involvement
VA-PICA Syndrome
Headache
Ataxia
N/V
Ipsilateral paralysis in tongue & swallowing
Ipsilateral face & contralateral body
V-B Junction
Lower extremity paraplegia or tetraplegia Conjugate or dysconjugate gaze paralysis Constricted pupils Respiratory depression Coma
Basilar Apex
PCA junction results in hemiplegia-diplegia Pupillary & occulomotor paralysis Visual field defects Stupor Coma
PCA (proximal branches) Thalamus Involvement
Memory loss
Sensorimotor hemiplegias
Spinal Stroke
Prolonged hypotension
Intraspinal mass lesions
Define Lacunar Infarct
Small, deep infarcts caused by occlusion of the small arteries that penetrate deeper brain structures
Types of Hemorrhagic Stroke
Subarachnoid hemorrhage
Intracerebral hemorrhage
Presentation of Hemorrhagic Stroke
Headache
N/V
Decreased consciousness
Types of Intracerebral Hemorrhage
Hypertensive atherosclerotic hemorrhage Lobar hemorrhages Hemorrhage from vascular malformations Bleeding into brain tumors (uncommon) Blood dyscrasias or anticoagulants (uncommon) Inflammatory vasculopathies (uncommon)
Define Subarachnoid Hemorrhage
Rupture of an artery with bleeding onto the surface of the brain
Causes of Subarachnoid Hemorrhage
Aneurysm
AVM
Bleeding disorder due to anticoagulants
Describe Subarachnoid Hemorrhage
Worst headache ever Radiates to face & neck Phonophobia Photophobia Maximal intensity immediately after onset
Subarachnoid Hemorrhage Physical Signs
Nuchal rigidity Altered mental status Poor sign if with transient loss of consciousness (seizure, cardiac dysrhythmia) Papilledema May not have neurological defect
Define Intracerebral Hemorrhage
Rupture of an artery with bleeding into the brain parenchyma
1 Cause of Intracerebral Hemorrhage
Hypertension
Amyloid angiopathy
Differential Diagnosis of Stroke
Focal seizures Glaucoma Benign vertigo or Menieres disease Cardiac syncope or syncope from other causes Migraine HA Intracranial neoplasm Subdural hematoma Epidural hematoma Hyperglycemia Hypoglycemia Postcardiac arrest ischemia Drug overdose Meningitis, encephalitis Trauma Anoxic encephalopathy Hypertensive encephalopathy
Diagnosis of Stroke
ABCs H&P EKG, monitor, pulse oximetry Labs: CBC, electrolyte, glucose, ABG, PT/PTT, Urine drug screen, LP CT or MR head scan Echo, EEG Carotid duplex ultrasonogrpahy MRA or angiography
Management of Acute Stroke
Medical management
Surgical management
Prognosis
Medical Management
Prevention, lifestyle modification
Early recognition with rapid transport/pre-arrival notification
ABCs, O2, IV
Rapid evaluation for TPA
Thrombolytics
Only for ischemic stroke if given within 3 hours of onset of signs and symptoms Class I AHA recommendation
Contraindications Thrombolytics
BP >185/110 AMI Seizure Hemorrhage LP within 7 days Atrial puncture at incompressible site Surgery within 14 days Bleeding diathesis Within 3 months of head trauma Hx of intracranial hemorrhage Minor or rapidly improving stroke symptoms
Chronic Prophylactic Anticoagulation Indications
Acute anterior MI with mural thrombus formation
Chronic a-fib with CHF within 3 months, HTN, previous thromboembolism, LV dysfunction and/or enlarged left atrium, or chronic valvular disease
A-fib without any risk factors: ASA therapy
Chronic Management of Stroke
Multidisciplinary approach Psychiatric services PT/OT/speech-language VNS/home health attendant Skilled nursing facility Social services Family support groups
Perform Carotid Endarterectomy
Good general health
HTN controlled
Internal carotid stenosis 70-99%
Ipsilateral stroke or TIA within 3-6 months
Surgeon with morbidity/mortality less than 2%
Worse outcome if used to treat stroke
Maybe Carotid Endarterectomy
Multiple coexisting comorbid conditions HTN poorly controlled Internal carotid artery either completely or less less than 70% occluded No history of ipsilateral TIA or stroke Inexperienced surgeon
Define Parkinson’s Disease
Idiopathic slowly progressive degenerative CNS disorder characterized by tremor, muscular rigidity, bradykinesia
Physiology of Parkinson’s Disease
Striatal dopamine is deficient & dopaminergic neurons are lost in the substansia nigra
Diagnosis of Parkinson’s Disease
H&P
Clinically if 2/3 cardinal features
Cardinal Features
Tremor
Rigidity
Bradykinesia
Symptoms of Parkinson’s Disease
Stiffness & slowed movements Tremor or shaking at rest Difficulty getting out of chair or rolling in bed Frequent falls or tripping Difficulty walking Memory loss Speech changes Small handwriting Slowness in performing ADLs Sialorrhea
Physical Findings in Parkinson’s Disease
Muscle rigidity, cog wheeling type Bradykinesia Postural instability, stooped forward posture Decreased arm swinging in ambulatory activity Resting/tremor/pill-rolling tremor Masked facies Micrographia Dysarthria, hypokinetic, monotonous low volume Painful dystonia Dementia Depression Akathisia inability to sit still Seborrheic dermatitis face & scalp Autonomic dysfunction
Differential Diagnosis of Parkinson’s Disease
Progressive supranuclear palsy Multisystem atrophy Shy-drager syndrome Olivopontocerebellar atrophy Wilson disease Multiple strokes Subdural hematoma Normal pressure hydrocephalus Basal ganglion lesion Hypothyroidism & hyperparathyroidism Post encephalitis Creutzfeldt-Jacob disease
Treatment of Parkinson’s Disease
Carbidopa/levodopa Dopamine MAOIs type B Catechol-O-methyltransferase inhibitors Amantadine DBS Regular exercise
End of Life Issues for Parkinson’s Disease
Severely impaire & immobile At risk for aspiration Eating may become impossible Dementia Discuss end-of-life care issues early Advise patient to appoint a surrogate to make medical care decisions
Define Polymyalgia Rheumatica
Inflammatory condition which is characterized by severe bilateral pain & morning stiffness of the shoulder, neck, & pelvic girdle
Epidemiology of Polymyalgia Rheumatica
Increased incidence at higher latitudes
Women > Men (3:1)
Presentation of Polymyalgia Rheumatica
Bilateral, severe, persistent pain in the neck, shoulders, & pelvic girdle
Pain on active & passive movement of joints
Morning stiffness more than 1 hour & after periods of rest
Myositis
Lethargy
Weight loss
Depression
Fever
Joint effusions
+/- asymmetric peripheral arthritis, carpal tunnel syndrome, edema of hands, wrists, ankles, & feet
Important Differential Diagnosis of Polymyalgia Rheumatica
Systemic lupus erythematosus Polymyositis Bacterial endocarditis Paraneoplastic syndromes Amyloidosis
Labs for Polymyalgia Rheumatica
ESR: elevated CRP IL-6 levels: elevated CBC: anemia of chronic disease Rheumatoid & ANA: not elevated LFTs mildly elevated
Associated Diseases with Polymyalgia Rheumatica
Giant cell arteritis (GCA)
Management of Polymyalgia Rheumatica
Document symptoms & level of disability at diagnosis
Consider giant cell arteritis
Advise to seek treatment if symptoms of GCA
Monitor response to treatment via ESR & CRP
Manage residual physical or psychosocial disability
Consider other possible diagnoses
Drug therapy: prednisone, bisphosphonates, calcium & vitamin D
Referral to physiotherapist & OT
Symptoms of GCA
Headache
Jaw claudications
Visual disturbances
Prednisone & Polymyalgia Rheumatica
Some may produce dramatic response
Some may be able to come off treatment all together except exacerbations
Some may need to be on long term low dose steroids
Age-Related Macular Degeneration Impacts
Ability to drive
Increased rates of falls
Ability to live independently
Define Age-Related Macular Degeneration
Degenerative disease of the central portion of the retina (macula)
Results in loss of central vision
2 Classifications of Age-Related Macular Degeneration
Dry
Wet
Dry Age-Related Macular Degeneration
Ischemic
Retinal epithelial cell apoptosis
Activating inflammation
Wet Age-Related Macular Degeneration
Balance between substances that promote or inhibit blood vessel development
Vascular endothelial growth factor (VEGF)
Risk Factors for Age-Related Macular Degeneration
Age Smoking Genetics CVD Diet Cataract surgery Heavy alcohol use Caucasians
History of Age-Related Macular Degeneration
Rate of vision loss One or both eyes involved Loss near/far vision or both Associated symptoms Acute distortion of loss of central vision: may be wet
Ophthalmologic Evaluation of Dry Age-Related Macular Degeneration
Durban appears as bright yellow spots
Atrophy appears as areas of depigmentation
May be increased pigmentation
Ophthalmologic Evaluation of Wet Age-Related Macular Degeneration
Subretinal fluid and/or hemorrhage
Neovascularization: grayish-green discoloration
Often require fluorescein angiogram
Treatment of Dry Age-Related Macular Degeneration
None
Slow progression: vitamin C, E, beta carotene, zine & copper
Treatment of Wet Age-Related Macular Degeneration
VEGF inhibitors
Photocoagulation
Surgery
Tool for Detecting Age-Related Macular Degeneration
Amsler grid
Types of Glaucoma
Acute angle
Secondary
Congenital
Primary open-angle
Secondary Glaucoma Due to
Uveitis
Old trauma
Steroid therapy
What glaucoma is the most common?
Primary open-angle glaucoma
What is the leading cause of irreversible blindness in the world?
Glaucoma
Primary Open-Angle Glaucoma
Optic neuropathy: “cupping”
Peripheral visual field loss followed by central field loss
Must be screened for
Risk Factors for Primary Open-Angle Glaucoma
Elevated IOP
Increasing age with increase risk of blindness
African Americans 4-5 x risk
Family history
Screening for Primary Open-Angle Glaucoma
Specialist with special equipment
Can examine optic disc for cupping
Treatment of Primary Open-Angle Glaucoma
Topical & systemic medications
Laser therapy
Surgery
Types of Angle-Closure Glaucoma
Primary
Secondary
Primary Angle-Closure Glaucoma
Anatomically predisposed
No identifiable secondary cause
Secondary Angle-Closure Glaucoma
Responsible for closure of the anterior chamber angle
Ex: fibrovascular membrane, mass, or hemorrhage
Risk Factors for Angle-Closure Glaucoma
Family history Older than 40-50 Female Hyperopia (farsightedness) Pseudoexfoliation Race: Inuit & Asian populations
Symptoms of Pressure Rising Acutely in Angle-Closure Glaucoma
Decreased vision Halos around lights Headache Severe eye pain N/V
Signs of Angle-Closure Glaucoma
Conjunctival redness
Corneal edema or cloudiness
Shallow anterior chamber
Mid-dilated pupil that reacts poorly to light
Treatment of Angle-Closure Glaucoma
Ophthalmologic emergency
Immediate referral for further evaluation
What is the leading cause of blindness in the world?
Cataract
Risk Factors for Cataracts
Age Smoking Alcohol Sunlight exposure Metabolic syndrome DM Systemic corticosteroid use
Presentation of Cataracts
Painless, progressive process
Complain of problems with night driving, reading road signs or difficulty with fine print
Increase in nearsightedness
Physical Exam Findings in Cataracts
Lens opacity
Darkening of the red reflex, opacities, or obscuration of ocular funds detail
Treatment of Cataracts
Surgery
Pre-Op for Cataract Surgery
Controlled HTN
Maintain medication use
Complications of Cataract Surgery
Endophthalmitis
Retinal detachment
Common Etiologies of Presbycusis
Sensorineural
Bilateral
Beginning in the high frequency range
Risk Factors for Presbycusis
Lifetime exposure to noise Genetics Medications Older age DM Cerebrovascular disease Smoking HTN White
Presentation of Presbycusis
Complain of inability to hear/understand speech in crowded or noisy environment
Difficulty understanding consonants
Inability to hear high pitched voiced
Associated Symptoms of Presbycusis
Tinnitus
Hearing pulsatile noise in one ear (need MRA or MRI)
Differential Diagnosis of Presbycusis
Cerumen impaction
TIA
CVA
What can presbycusis lead to?
Isolation
Depression
Low self-esteeem
Hearing Amplification
Done through licensed audiologist
Do not restore hearing to normal
Need to be fit and programmed properly
Signs/Symptoms of Hypothyroidism
Fatigue Cold intolerance Weakness Lethargy Weight gain Constipation Myalgias, arthralgias Menstrual irregularities Hair loss Dry, course skin Hoarse voice Brittle nails Myxedema Delayed reflexes Slow reaction time Bradycardia
Define Subclinical Hypothyroidism
Normal T4
Elevated TSH
Define COPD
Slow progressive irreversible airway obstruction
Signs of COPD Exacerbations
Increased dyspnea
Infections
Respiratory failure
Risk Factors for COPD
Smoking Exposure to inhalants Alph-1 antitrypsin Asthma Age Genetics
Pathophysiology of COPD
Inflammation
Increased mucus
Decreased ciliary movement
Air flow obstruction
Pathophysiology of Chronic Bronchitis
Hypertrophy of the mucus cells
Increase in number of mucus cells
Inflammation leads to formation of more mucus
Why Acute Exacerbations in COPD
Infections
Environmental pollution
Unknown
Treatment of COPD
Oxygen Long term inhaled glucocorticoids SABAs (add on) Short acting anticholinergics (add on) Glucocorticosteroids (add on)
Complications of COPD
Cor pulmonale Pneumonia Pneumothorax Polycythemia Arrhythmias
Local Deposition Effects of Inhaled Glucocorticoids
Dyphonia
Thrush
Cough/throat irritation/reflex bronchoconstriction
Systemic SE of Inhaled Glucocorticoids
Consider pharmacokinetics
Osteoporosis
Adrenal suppression
Increase intra-ocular pressure/cataracts
Signs of Worsening COPD
Decrease in BMI
Decrease in FEV1
Increased dyspnea on exertion
Need for O2
End Stage COPD
Hospice Control pain Bedridden Support family Get living will from patient
Predisposing Conditions for Community Acquired Pneumonia
Smoking Alcohol consumption Pulmonary edema Malnutrition Administration of immunosuppressive agents Being 65+ COPD Previous episode of pneumonia
Pathogens of Community Acquired Pneumonia
H. flue
Chlamydia
Strep pneumo
Risk Factors for Drug Resistance
65+ years old Antibiotic therapy within last 3-6 months Alcoholism Medical comorbidities Immunosuppressive illness or therapy
Treatment of Uncomplicated Community Acquired Pneumonia
Azithromycin
Erythromycin
Clarithromycin
Treatment of Complicated Community Acquired Pneumonia (cormobidities or recent antibiotic use)
Respiratory fluoroquinolones
Amoxacillin-clavulanate (Augmentin)
Indications for Hospitalization of Community Acquired Pneumonia
CRB-65 Confusion Respiratory rate: >30 BP: less than 90 systolic or 60 diastolic Age: >65
Underlying Factors of Patients in Long Term Care Facilities with Pneumonia
COPD
Left heart failure
Aspiration
Parameters for Long Term Care Facility Residents for Treatment
Able to eat & drink Pulse: less than 100 Respiratory rate: less than 30 BP: >90 or decrease of less than 20 from baseline O2 sat: >92% or 90% if COPD
Common Causes of Pain in the Elderly
Osteoarthritis Other joint diseases Night time leg cramps Claudication Neuropathies: diabetics, herpetic, idiopathic Cancer
Why is pain underrated in the elderly?
Patients underreport
Health care providers hesitant to prescribe opiates
WHO Guidelines for Pain Management
Mild: non-opioid +/- adjuvant
Moderate: opioid +/- adjuvant
Severe: stronger opioid +/- adjuvant
Medications NOT to Use for Pain Management in the Elderly
Amitriptyline
Propoxyphene
SE of NSAIDs in the Elderly
Renal toxicity
GI
Cardiotoxicity: worsen CHF & HTN
Interacts with aspirin & warfarin
First Line Treatment of Pain in the Elderly
Tylenol
Arthritis strength Tylenol
Treatment of Neuropathic Pain in the Elderly
Gabapentin
Lyrica
Cymbalta
Opioids & the Elderly
Small doses spread apart
Talk heavily about SE including constipation & confusion
Adjuvant Therapies for Pain Management
Exercise: PT, OT, strengthening Physical methods: ice, heat, massage CBT Chiropractic therapy Acupuncture Relaxation & guided imagery Biofeedback
Define Osteoporosis
Disease characterized by low bone mass with micro architectural disruption & skeletal fragility
Risk Factors for Fractures
Advanced age Previous fracture Long-term glucocorticoid therapy Low body weight (less than 127 pounds) Family history of hip fracture Smoking Excess alcohol intake
Treatment for Fractures
Surgery Analgesics Calcitonin Vertebroplasty Kyphoplasty