Sgmex1

Front 1

Aging causes

Back 1

Oxidative Stress, Free radicals, cellular damage, slow cell manipulation, loss of tissue elasticity that affects most organs, loss of physiologic reserve (decreased kidney function), Atherosclerosis, Degnerative disorders, Psychologically people become very habitual

Front 2

Mortality

Back 2

Females 84
Males 83

Front 3

compression of morbidity

Back 3

Onset of morbid disease to death
- area between the curves contains 90% of the healthcare $

Front 4

Bullet

Back 4

Things that you do that result in a physical finding
"lungs are clear"

Front 5

Element

Back 5

historical finding- symptoms that you write down
"smoker, non-somoker, etc"

Front 6

medical decision making

Back 6

Includes assesment and plan- shows responsible decision making

Front 7

Pain QRST

Back 7

o Pain: PQRST
 Provocation, Quality, Region radiation, Severity, Temporal pattern

Front 8

o Chief complaint

Back 8

o Chief complaint

Front 9

o Medications

Back 9

o Medications: include dosage and frequency (how much and how often)

Front 10

o Allergies

Back 10

o Allergies: list the adverse effects to differentiate intolerance

Front 11

o Past/Family/Social

Back 11

o Past/Family/Social 3 elements
 Past Medical History
• Address the issues that they bring up with Physical findings, etc.

Front 12

o ROS

Back 12

o ROS- 10 systems with 3 elements each including negatives

Front 13

o Physical Exam

Back 13

o Physical Exam 9 systems with 3 bullets each
 Inspection Palpation Percussion Auscultation
 Combine eyes with ENT and mouth

Front 14

o Impressions

Back 14

o Impressions: Reflect the highest risk factors (HTN, Chest Pain)

Front 15

o Plan

Back 15

o Plan: reflect the highest risk/decision making (order x labs, order x test, admit, call x)

Front 16

o Do Not Say

Back 16

o Do Not Say “Unremarkable or None, WNL” Say unabtainable, blah blah

Front 17

o Directives

Back 17

o Directives: DNR report/religion

Front 18

Points in the Geriatric H/P

Back 18

Chief Complaint/Pain/PQRST
medications
Allergies
PMH
FMH
SH
ROS
Physical
Assessment
Plan

Front 19

Detrusor pressure

Back 19

60cm H2o

Front 20

Normal Bladder Volume

Back 20

400-500mL

Front 21

Residual Volume

Back 21

<200mL
>200= overflow incontinence

Front 22

Requirements of continence

Back 22

Cognitive function
Moblility and dexterity
Environment
Motivation

Front 23

Bladder parasympathetic innervation

Back 23

 Parasympathetic- Cholinergic- Bladder Contraction and urination: S2-4
• Anticholinergics for spastic bladder- Get dry mouth, etc, don’t want to give to Elderly

Front 24

Bladder sympathetic innervation

Back 24

 Sypmathetic- αAdrenergic- Bladder relaxation, sphincter contraction: T11-L2
• αAdrenergic blocker for obstruction- BPH

Front 25

Bladder Somatic innervation

Back 25

 Somatic- voluntary pelvic floor muscular contraction: Pudendal Nerve
• Kegels- start emptying bladder and stop intermittently

Front 26

hyperactive/hypersensitive bladder

Back 26

Failure to store
o Hyperactive bladder/Hypersensitive bladder: Detrusor Instability, Hypersensitive bladder
 UTI irritation in the lining will make detrusor contracts and you can’t help it.
 Detrusor instability- muscle decides to just go off on its own.

Front 27

Incompetent sphincter

Back 27

Failure to store
o Incompetent sphincter- Gal whose got 10 kids with a relaxed pelvis bends down to pick up a sack of groceries and coughs at the same time. Pudendal N is important here! Throw in that this same lady has been having burning sx when she urinates: UTI on top of it.

Front 28

Failure to store categories

Back 28

Hyperactive/Hypersensitive bladder
incompetent sphincter

Front 29

Failure to empty categories

Back 29

Underactive bladder/overactive sphincter
Obstruction

Front 30

Underactive bladder/overactive sphincter

Back 30

Failure to empty
o Underactive bladder/ Overactive Sphincter: Spinal Cord trauma or lesion

Front 31

Obstruction

Back 31

Failure to empty
o Obstruction: BPH is most common problem in older males. Male takes antihistamine and ends up in the ER begging for a catheter.

Front 32

Types of urinary incontinence

Back 32

Acute and Chronic

Front 33

Acute Urinary Incontinence

Back 33

o Acute- Transient or reversible factors are present
 Factors: (DRIP) Delirium; Restricted Mobility or Retention; Infection, inflammation, fecal impaction; (DKA) Polyurea, pharmaceuticals
• Pharmaceuticals- diuretics; pshycotropics; anti-cholinergics (OTC antihistamines), narcaotics and CCBs impair contractility

Front 34

Categories of chronic urinary incontinence

Back 34

Stress
Urge
Overflow
Functional

Front 35

Stress incontinence

Back 35

• Females: Poor anatomical support/ urethral dysfunction due to many factors
• Males: Sphincter damage from prostate surgery or radiation therapy
o Tx: (kegels, Bladder training), αAdrenergic drugs, estrogen, surgery

Front 36

Urge Incontinence

Back 36

 Urge: “gotta go … oops, too late”
• Local GU conditions that irritate the inside of the bladder: Stones, obstruction, Chronic infection, adjacent inflammation
o “Old lady with urgency, dysruia, frequency: has a few wbcs in the urine, culture shows no growth b/c she drinks cranberry juice- Bug won’t grow. Abx”
• CNS disorders: Stroke, dementia, parkinsonism, spinal cord lesions w/ impaired symp innervations
• Idiopathic: detrusor instability without underlying disorders
o Tx: Behavioral therapies (kegels, Bladder training), bladder relaxant anticholinergic drugs

Front 37

Overflow Incontinence

Back 37

 Overflow “gotta go … oops, too late but it’s a Growing problem, not a Going problem.”
• Anatomical Obstruction: BPH, urethral stricture, large cystocele
• Poor contractility: DM, Spinal cord injury with impaired Parasymp innervations
• Neurogenic: detrusor-sphincter dyssynergy
o The bladder doesn’t contract so you have a large residual and small expulsion volume. Pt will randomly just “dribble” urin.
o Tx: Surgery, Catheterization, Cholinergic Agonist, αAdrenergic antagonists

Front 38

Functional Incontinence

Back 38

 Functional
• Chronic impairments of Cognitive function, mobility, dexterity (can’t physically do it)
• Environmental Factors
• Psychological Factors
o Tx:, Garments, Pads, Catheters, Behavioral therapy: Scheduled toileting, Habit training, Prompted voiding

Front 39

o Pt develops urge incontinence with painless hematuria

Back 39

o Pt develops urge incontinence with painless hematuria: Think cancer- do cytology/culture and send to urologist.

Front 40

Chronic Catheterization Indications

Back 40

• Chronic Catheterizaiton indications: Significant irreversible urinary retention; Skin disorders; Patient comfort/preference, immobility
o Using intermittent reduces UTIs

Front 41

o 1. Gotta Go Gotta Go, oops it’s too late. Bladder culture neg, PVRV: 0

Back 41

Classic Urge Incontinence

Front 42

o 2. Gotta Go Gotta Go, oops it’s too late. Bladder culture neg, PVRV: 400cc

Back 42

Obstructive incontinence

Front 43

o 3. Sneezing/going up stairs, urinalysis normal, PVRV: 0.

Back 43

Stress incontinence

Front 44

o 4. Dribble all the time, urinalysis normal, PVRV 400cc, Digital Rectal BPH.

Back 44

Overflow incontinence

Front 45

o 5. Younger married lady with one kid, hope to have more, had to go a lot over the last 3 days, burns, 30wbc/hpf, PRV:0.

Back 45

UTI urge incontinence

Front 46

o 6. Carrying groceries and sneezing I dribble, recently increased frequency, burns when pee, PVRV: 0, 20wbc/hpf.

Back 46

UTI and Stress incontinence.

Front 47

Myopia

Back 47

Nearsighted

Front 48

Hyperopia

Back 48

Farsighted

Front 49

Astigmatism

Back 49

distorted vision

Front 50

Presbyopia

Back 50

inability to focus on near objects due to aging

Front 51

Accomodation

Back 51

• Accommodation- the lens “rounds up” by the contraction of ciliary muscles (loosening the zonules) while the pupil becomes smaller to see near objects (this is difficult conceptually)

Front 52

Convergene

Back 52

eyes move together so they both see close objects

Front 53

• Presbyopia-

Back 53

• Presbyopia- impaired accommodation- it’s a lens problem, they get old and hardened and the ciliary body can’t contract as well- difficulty focusing on near objects.
o Tx: Reading glasses or bifocals, it is acceptable to send them to walmart or the optometrist.

Front 54

Cataracts

Back 54

• Cataracts- “Dirty Glasses,” Makes driving at night especially difficult- “Christmas trees.”
o Increase w/age, DM, smoking, EtOH
o Tx: Phacoemulsion w/ intraocular lens implants
 Opacification w/ blurring post tx- YAG laser capsulotomy
• Darnit- looks like my cateracts came back

Front 55

Macular Degeneration

Back 55

• Macular Degeneration- m/c cause of blindness in the elderly
o Peripheral vision saved (excellent), central loss
 Predisposed: age, genetics, smoking, HTN, fair skin
o Dry- drusen (yellow products of metabolism) accumulate UNDER the macula
o Wet- Drusen + angiogenesisis and choroidal neovascularization (wet= new bvs), the worst
o Tx:
 Beta Carotene (CI in smokers), VitE, VitC, Zinc
 Laser phototherapy to tx the neovascularization (wet macular degeneration)
 Intra-vitreal VEGF injection

Front 56

Diabetic Retinopathy

Back 56

o Ischemia + neovascularization (tiny vessels in the cup) + microaneurysms + hemorrhage
o Annual Opth exam
o Control glucose and HTN

Front 57

Glaucoma

Back 57

• Glaucoma- 2nd m/c cause of blindness in elderly
o Central vision saved “tunnel vision”
 Increased incidence w/family history, AAs
o Optic nerve head damage ( may or may not have high intraocular pressure)
 Increased pressure is due to Aqueous drainage impairment
 Cup/disk is usually < 1:2
• Glaucoma- >1:2 (much greater)

Front 58

Open Angle Glaucoma/ Closed Angle

Back 58

o Open angle- drainage is slow, asymptomatic, slow subtle peripheral vision loss
 Tx: BB eyedrops
o Closed angle- drainage is blocked, acute and symptomatic,
 Sx: eye pain, headache, noticeable vision deterioration, nausea and vomiting
 May be provoked by Myadriatics, etc. recognize Sx.
 Emergency Tx required: iridectomy
o Tx: Beta-blocker eyedrops, increase drainage, decrease production (epi, pilocarpine, Pgs)

Front 59

Eye Compare and Contrast

Back 59

• Compare and Contrast
o Presbyopia- need cheaters- get around 40yo
o Cataracts- dirty glasses: Lens implant with following YAG
o Macular degeneration- most common cause of blindness in the elderly- central vision loss, preserved peripheral vision
o Glaucoma- can be acute or subtle, Generally tunnel vision, can cause vision loss.

Front 60

Low vision rehab

Back 60

• Low vision rehab
o Magnification, improved lighting, optical devices w/ training to use eccentric (off center) viewing, talking devices, Braille.

Front 61

Conductive hearing loss

Back 61

• Conductive Hearing loss
o Cerumenosis- thicker, drier, more adherent cerumen
o Middle ear pathology: tympanosclerosis, otosclerosis (fusion of the ossicles within the innerear)

Front 62

Sensorineural hearing loss

Back 62

• Sensorinerual hearing loss: Generally from past exposure but could be from drugs or physical damage
o Presbycusis- symmetrical and bilateral loss of High Frequency (no need to yell, just articulate)
o Phonemic regression- permanent loss of hearing at CNS due to lack of stimulation
 If a person gets a hearing aid, but their brain has forgotten high pitches, they won’t hear them even with the aid.

Front 63

Audiometry

Back 63

• Audiometry
o Conductive hearing loss: Air conduction needs to be louder than bone conduction to be heard
o Sensorineural: air and bone conduction loudness is the same
 Frequency change: High frequencies are heard less (like presbicussis)
o Consonant sounds are in the >1000hz range which is difficult for geriatric hearing (PBZT)

Front 64

Amplification

Back 64

• Amplification
o Cheap= worse than nothing (better to have nothing than a cheap-o)
o Digital (best and not covered by medicare)

Front 65

Cognitive impariment exam

Back 65

Examination:
• Critical questions in the newly confused patient: How long has this been going on, How abruptly did it start? Has the patient’s functional status changed? If the situation is progressing, how fast is it?

Front 66

Geriatric Delerium

Back 66

Geriatric Delirium- Tripping balls; Confusional state + altered consciousness and attention
• Signs/Sx
o Acute illnesss- Caused by direct physiological consequence of a general medical condition, drug withdrawal, or sundowner syndrome.
 Etiologies include metabolic, toxic, septic, hypoxemic, electrolyte imbalance, fever, glucose, etc.
o Excess Sympathetic activity (Tach, diaphoresis, tremor, mydriasis, HTN)
• Exam: Check vitals, SaO2 and/ or ABGs, CBC, CMP, UA, etc

Front 67

Geriatric dimentia types

Back 67

Vascular
Alzheimers
parkinsons
CJD
C Lewy bodies

Front 68

Vascular dimentia

Back 68

• Vascular dementia: Stroke, mini stroke, trauma, etc. Check Hx and look for focal neurological sign.
o Had DIA- memory drops, has another, memory drops again

Front 69

Alzheimers

Back 69

• Vascular dementia: Stroke, mini stroke, trauma, etc. Check Hx and look for focal neurological sign.
o Had DIA- memory drops, has another, memory drops again

Front 70

Geriatric Depression/Pseudodimentia

Back 70

• Signs, SX
o Depressed mood
o Diminished interest/pleasure in activities
o Wt/Sleep changes
o Psychomotor agitation or retardation w/loss of energy
o Indecisiveness, poor concentration, thoughts of suicide or death

Front 71

Depression: Very important Associated Diseases

Back 71

• Very Important Associated diseases: Cushings, HypOthyroidism (with other sequelae), Hyperparathyroidism, Hypogonadism, Addisons disease, Cerebral tmors, Viral infections, Stroke
o Pt with hair falling out, wearing sweats in the middle of the summer in the desert, complaining of a memory problem: Order TSH, Hypothyroidism.

Front 72

Mini Mental Status Exam

Back 72

• 30 is gold standard
o Draw parallellagram, >27 normal, <20 moderate, <17 severe
o Draw clock at 4:20

Front 73

Compare and Contrast Dimentia, Depression, Delerium

Back 73

 Dimentia- aggressive cognitive decline, often the pt forgets that he forgets
 Depression- vegetative sx, flat affect, vegetative sx, Get up and Go, got up and left.
 Delerium- tripped out, acute onset, hallucinations, delusions

Front 74

o 75yo widow gives a detailed account of her poor memory ever since the death of her husband 6 months ago.

Back 74

Pseudodimentia with depression

Front 75

o 70yo man’s wife who is complaining of his worsening memory over the past couple years and increased irritability and gets lost driving the car. He most likely has

Back 75

MOST likely Alzheimers

Front 76

o 76yo man’s wife complains that his memory had never been the same since his previous doctor gave him “rat poision” for several spells of confusion. Had TIAs with atrial fibrillation with irregularly irregularly heartrate.

Back 76

He most likely has MultiInfarct dementia

Front 77

o Depressed 80yo widow complains that her memory has worsened over the past 6mo. She has pedal edema, cold intolerance, easy bruisability, exercise intolerance

Back 77

Hypothyroidism depression

Front 78

o Healthy 70yo man drank a little more than usual at the club where he goes every night. He then fell and fractured his hip which was pinned 3 days ago. Nurse calls b/c he is agitated and claims that the CIA has bugged his hospital.

Back 78

This guy has delirium and sees snakes/etc.

Front 79

Consequences of falls

Back 79

• Mortality 60-70% consequence of injury d/t fall
• Morbidity: fracture (5-10%); soft tissue injury (30-40%); subdural hematoma; hypo/hyperthermia; undiscovered fall (rhabdomyolysis  renal failure); lost confidence; pt/family anxiety; expensive
• LOST INDEPENDENCE – Falls number 1 reason for lost independence Long Term Care

Front 80

Etiology of Falls

Back 80

Etiology of falls:
• 37% Accidents/environment
• The other 63% are medical issues:
o Weakness/balance; drop attack (sudden movement of head/neck)
o Dizziness/vertigo
o Orthostatic hypotension (drugs that cause that)
o Syncope
o Drugs: TCAs, anti-psychotics, benzos, diuretics, laxatives, diltiazem

Front 81

Pt with risk of falls

Back 81

• LE weakness increases risk by 400%
• Hx of falls risk
• Gait/mobility disorder
• Meds

Front 82

Sentinel Event

Back 82

Falling -

Front 83

Post fall evaluation

Back 83

• Vitals c orthostatic BP (should not see systolic BP drop >20mm)
• Px: sensory fxn; evidence of trauma, CV, musculoskeletal, neuro and gait evaluation

Front 84

Spastic hemiparesis

Back 84

People with hemiparesis often have difficulties maintaining their balance due to limb weaknesses leading to an inability to properly shift body weight. This makes performing everyday activities such as dressing, eating, grabbing objects, or using the bathroom more difficult. Hemiparesis with origin in the lower section of the brain creates a condition known as ataxia, a loss of both gross and fine motor skills, often manifesting as staggering and stumbling. Pure Motor Hemiparesis, a form of hemiparesis characterized by sided weakness in the leg, arm, and face, is the most commonly diagnosed form of hemiparesis.[1]

Front 85

Scissor gait

Back 85

This gait pattern[2] is reminiscent of a marionette. Hypertonia in the legs, hips and pelvis means these areas become flexed to various degrees, giving the appearance of crouching, while tight adductors produce extreme adduction, presented by knees and thighs hitting, or sometimes even crossing, in a scissors-like movement while the opposing muscles, the abductors, become comparatively weak from lack of use. Most common in patients with spastic cerebral palsy, usually diplegic and paraplegic varieties, the individual is often also forced to walk on tiptoe unless the plantarflexor muscles are released by an orthaepedic surgical procedure.

Front 86

Steppage Gait

Back 86

o Steppage (Lower motor neuron disease- Neuropathies)

Front 87

Ataxic Gait

Back 87

posterior column disease; cerebellar degeneration; peripheral neuropathy)
People with cerebellar ataxia may initially present with poor balance, which could be demonstrated as an inability to stand on one leg or perform tandem gait. As the condition progresses, walking is characterized by a widened base and high stepping, as well as staggering and lurching from side to side.[1] Turning is also problematic and could result in falls. As cerebellar ataxia becomes severe, great assistance and effort are needed in order to stand and walk.[

Front 88

Parkinson Gait

Back 88

Parkinsonian gait is characterized by small shuffling steps and a general slowness of movement (hypokinesia), or even the total loss of movement (akinesia) in the extreme cases.[2][3][4] Patients with PD demonstrate reduced stride length and walking speed during free ambulation while double support duration and cadence rate are increased.[5][6][7][8] The patient has difficulty starting, but also has difficulty stopping after starting. This is due to muscle hypertonicity.[9]

Front 89

Gait assistive devices

Back 89

o Assistive devices
 3-4 Wheel walkers (For: ataxia, hemiparesis, scissor gait)
 2 wheel walkers (For: Parkinson’s)
 Cane: (For: antalgic gait)
 Maladaptive device (ataxic gait)

Front 90

Understand the difference between IADLs and bADLs

Back 90

IADLS: SHAFT
shopping, housekeeping, accounting, food preparation/meds, telephone/transportation

BADLs: DEATH
Dressing, Eating, Ambulating, Toileting, Hygiene

Front 91

What is most likely to put you in the nursing home?

Back 91

o what’s likely to put you in the NH is falls, mobility disorders, falls, incontinence, anxiety, depression

Front 92

Photocoagulation

Back 92

tretment for wet diabetic macular degeneration
nota goodthing or wet macular degeneration in diabetics b/c you are sacrificing some vision when you do that but you are doing it to not have the vessels break but you lose some vision at the macula with this.

Front 93

Vasular dimentia: Review

Back 93

someone with atrial fib or some other reason, carotid stenosis, or whatever, multiple TIA, or just one good stroke.

Front 94

Depression: review

Back 94

 Depression- vegetative sx, happens to ppl that get alzheimers or another poor diagnosis.
• Sx: get up and go got up and left, I don’t know-mia, get up early go to bed late, can’t go back to sleep, flat affect, diminished libido

Front 95

Delerium vs dimentia

Back 95

Front 96

Age Vs Alzheimers

Back 96

Front 97

Dimentia vs depression

Back 97