geriatrics
Elevated ferritin TIBC low or normal dx: Anemia of chronic disease vs iron deficiency = high RDW, TIBC and transferrin
A 66-year-old woman presents to her primary care provider with fatigue. She notes more joint pain over the past year. She has no signs of bleeding and eats a healthy diet. She has a medical history of type 2 diabetes mellitus and rheumatoid arthritis. Her complete blood count shows hemoglobin of 9 g/dL, mean corpuscular volume of 90 fL, and mean corpuscular hemoglobin of 30 pg. Reticulocyte index is < 2. C-reactive protein is 20 mg/L. An iron panel, methylmalonic acid panel, and peripheral smear are ordered. Based on the suspected diagnosis, what abnormality are you most likely to see on her laboratory results? AElevated ferritin BElevated methylmalonic acid CElevated transferrin saturation DSickle cells on peripheral smear
Amoxicillin-clavulanate plus azithromycin dx: adult w/ co-morbidity outpatient vs Doxycycline can be used as monotherapy in adults without comorbidities or risk factors for methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa, especially when there is high suspicion for atypical pathogens.
68-year-old woman with a medical history of hypertension, diabetes mellitus type 2, and chronic kidney disease treated with metformin and lisinopril presents to her primary care physician's office with a 4-day history of productive cough, shortness of breath, and fever. Her vital signs are a heart rate of 108 bpm, blood pressure of 142/86 mm Hg, respiratory rate of 18/minute, oxygen saturation of 98% on room air, and temperature of 100.6°F. Physical exam reveals a regular heart rate and rhythm, rales in the left lower lung with increased tactile fremitus, bronchophony, egophony, and increased work of breathing. The abdomen is soft and nontender to palpation in four quadrants. Chest X-ray is shown above. Which of the following is the most appropriate therapy? AAmoxicillin plus azithromycin BAmoxicillin-clavulanate plus azithromycin CCefuroxime DDoxycycline
Electrocardiogram steps taken to evaluate syncope 1) Obtain a comprehensive history 2)Perform a physical examination (which may include careful carotid sinus massage in older patients) 3)Review an ECG and any rhythm strips that may be obtained by emergency medicine clinicians attending the patient 4) Perform transthoracic echocardiogram (which is useful to evaluate for the presence and severity of structural heart disease if status is uncertain) after completing a comprehensive medical history, physical examination, and ECG
70-year-old woman presents after she suddenly passed out while cooking dinner. She has a history of hypothyroidism and hypertension. The patient's current medications are levothyroxine 25 mcg and amlodipine 10 mg. She reports her spouse was with her during the event and was able to catch her and assist her to the ground, so there is no history of head injury. The patient was unconscious for a few seconds, per the spouse's history, and when she regained consciousness, her cognition was normal without any signs of confusion or memory loss. Before the event, the patient recalls breaking out in a "cold sweat" and feeling like she was going to vomit. There were no obvious precipitating factors that she recalls, and this is the patient's first time experiencing an episode like this. Her vital signs are a temperature of 97.5°F, blood pressure of 101/66 mm Hg, heart rate of 76 bpm, respiration rate of 20/minute, and oxygen saturation of 100%. Her physical exam reveals lungs that are clear to auscultation bilaterally, and her heart exam presents with normal rate and rhythm. Cranial nerves are intact, and the patient does not present with any focal neurological deficits. Which is recommended as an initial test in the evaluation of the patient? AElectrocardiogram BElectrophysiologic testing CHead CT DTilt-table testing
The primary goal of treatment is to reduce the IOP, which is typically done with systemic medications (e.g., intravenous acetazolamide), topical medications (e.g., pilocarpine, timolol, apraclonidine), or a combination of the two. It is important to decrease IOP before moving forward with more definitive treatment options. dx: acute angle-closure glaucoma vision loss, blurred vision, halos around lights, nausea, and vomiting. Some common eye exam findings include eye erythema, a cloudy cornea, and a decrease in pupillary reactivity. The eye may also be hard to touch due to high IOP (often > 30 mm Hg), which is measured via tonometry.
77-year-old woman presents to the ED with severe right eye pain, headache, nausea, and vision loss. Her vital signs are temperature of 98.7°F, blood pressure of 124/70 mm Hg, heart rate of 90 bpm, respiration rate of 26/minute, and oxygen saturation of 96%. Ocular examination reveals a poorly reactive and dilated pupil, scleral erythema, and a cloudy cornea. Her right eye is also hard on palpation. What is the recommended initial management for the suspected condition? AIntravenous acetazolamide BIntravenous mannitol CIridotomy DTopical latanoprost
Grip strength assessment Functional Assessment of Older Drivers ---A whisper test is generally enough to evaluate general hearing capabilities. ---- to evaluate driving safety, the rapid pace walk test is recommended. This test involves having the patient walk 10 feet back and forth at their own pace first, then telling them to walk as fast as they can safely and measuring the time it takes them. ---- In general, visual acuity, visual field, and contrast sensitivity tests are the most important aspects of evaluating driving safety.
78-year-old man with a history of hypertension and hyperlipidemia presents for a physical examination, and a driving safety assessment is performed. A full driving history reveals he has had no history of prior collisions or traffic violations. His medication list consists of lisinopril 10 mg and atorvastatin 40 mg. Visual acuity, contrast sensitivity, and visual field assessments are performed and found to be within normal limits. A whisper test to evaluate gross hearing is also performed, and the patient passes it without issue. His Mini-Mental Status Exam suggests no cognitive impairment, and full range of motion of major joints is observed. Which of the following is another important aspect of the physical examination required to further assess the patient's ability to drive safely? AAudiology test BGrip strength assessment CHeel-to-toe test DRetinal examination
Bilateral proximal joint stiffness dx: Polymyalgia rheumatica vs Heliotrope rash (B) is an erythematous, purple rash on the periorbital skin (most often the upper eyelids) that is often accompanied by swelling of the eyelids. It is a pathognomonic finding in dermatomyositis. Proximal muscle weakness (C) can manifest as difficulty flexing or extending the neck, rising from a seated position, and shaving or combing the hair. Polymyalgia rheumatica may cause motor weakness, but pain is the predominant symptom. Proximal muscle weakness occurs more commonly in myopathies of various etiologies (e.g., dermatomyositis, polymyositis, inclusion body myositis, hypothyroidism) and in myasthenia gravis.
A 65-year-old man presents to the clinic with bilateral shoulder and hip pain for the past 2 weeks. He reports no recent trauma, fever, chills, or extremity paresthesias but states he has felt fatigued and generally unwell. He has a medical history of hypertension, for which he takes amlodipine, and hyperlipidemia, for which he takes atorvastatin. Vital signs include a BP of 135/84 mm Hg, HR of 80 bpm, RR of 20/min, T of 98.6°F, and SpO2 of 99% on room air. Physical exam findings include a regular heart rate and rhythm and lungs clear to auscultation. Laboratory studies include a C-reactive protein of 20 mg/L. Findings on shoulder radiographs are normal. He is started on prednisone and improves over the next week. Which of the following additional findings is most consistent with the suspected diagnosis? ABilateral proximal joint stiffness BHeliotrope rash CProximal muscle weakness DUlnar deviation
Prostate-specific antigen every 1-2 years The recommended screening method for patients with average risk who desire screening is to screen with a prostate-specific antigen every 1-2 years. The discussion to begin screening in these individuals occurs at 50 years of age. Screening should be offered up to 70 years of age but can be stopped earlier for patients who have a life expectancy < 10 years.'' vs Digital rectal examination annually (C) is not recommended for prostate cancer screening either as a standalone test or as an adjunct to prostate-specific antigen.
A 66-year-old man presents to the clinic for an annual wellness exam. He was reading about prostate cancer recently and asks you if he can be tested. He has a medical history of diabetes mellitus, for which he takes metformin and glipizide, and hypertension, for which he takes lisinopril. Vital signs include a BP of 130/86 mm Hg, HR of 94 bpm, RR of 20/min, T of 98.6°F, and SpO2 of 99% on room air. Exam findings include a regular heart rate and rhythm, lungs clear to auscultation, and a soft and nontender abdomen. According to the United States Preventive Services Task Force, which of the following is the recommended approach to prostate cancer screening for patients of this age who desire screening? ADigital rectal examination and prostate-specific antigen every 10 years BDigital rectal examination and prostate-specific antigen every 5 years CDigital rectal examination annually DProstate-specific antigen every 1-2 years
Annual low-dose chest CT is recommended for patients with a high risk for the development of lung cancer. Lung cancer is the most common cause of cancer-related deaths in adults. It is divided into two subgroups: small cell lung cancer and non-small cell lung cancer. high-risk criteria for the development of lung cancer include those aged 50-80 years who have at least a 20 pack-year smoking history and are either currently smoking or have quit within the past 15 years.
A 68-year-old man with a history of hypertension and a 20 pack-year smoking history with current tobacco use presents to his primary care provider for his annual exam. He does not have specific concerns today. Vital signs include a heart rate of 78 bpm, blood pressure of 130/78 mm Hg, respiratory rate of 20/minute, oxygen saturation of 99% on room air, and temperature of 98.6°F. Physical examination reveals regular heart rate and rhythm, without wheezing, rales, or rhonchi on lung auscultation. Which of the following is the most appropriate annual screening test for this patient? AChest X-ray BLow-dose chest CT CPulmonary function tests DSputum cytology
Deposits of alpha-synuclein protein in the brainstem, substantia nigra, and cerebral cortex dx: Dementia with Lewy bodies
A 68-year-old man with a history of hypertension and hyperlipidemia presents to his primary care provider for a routine examination with his spouse. His spouse states the patient has had increasing episodes of confusion and lethargy over the past few months and has at times been having difficulty paying attention to simple tasks and conversations. He has not been sleeping well and has episodes when he punches or kicks in his sleep. The spouse also says he will randomly engage in conversation with a friend when there is nobody there. You have begun to take a history when the patient quickly becomes distracted. He begins talking to a friend in the room, but there is no one else in the room. He takes losartan and atorvastatin daily. His blood pressure is 145/82 mm Hg, but vital signs are otherwise within normal limits. Upon exam, the patient has impaired judgment, but his memory is intact. You observe a slight tremor in both hands. What is the pathophysiology of this patient's most likely condition? ADeposits of alpha-synuclein protein in the brainstem, substantia nigra, and cerebral cortex BEnlarged ventricular size with normal cerebrospinal fluid pressure CNeuritic plaques and deposits of beta-amyloid protein DProgressive depletion of dopamine-producing neurons in the basal ganglia
Presbycusis = Age-related hearing loss progressive, symmetric, high-frequency hearing loss that occurs over years. It is the most common cause of sensorineural hearing loss. Risk factors for sensorineural hearing loss include family history, noise trauma (e.g., amplified music, jet planes), exposure to ototoxic substances (e.g., aminoglycosides, loop diuretics, NSAIDs, heavy metals), tobacco use, hypertension, and diabetes mellitus. Patients will present with gradual worsening voice discrimination, especially in crowded or loud places, and general decreased hearing. Patients may struggle to identify sounds on a whisper voice or finger rub test in the office weber sound is heard in both ears, the test is normal or demonstrates symmetric hearing loss. The Rinne test assesses air and bone conduction of sound. Normally, air conduction is longer than bone conduction.
A 68-year-old man with a medical history of hypertension, hyperlipidemia, and obesity presents to your office for a routine visit. His medications include lisinopril, aspirin, and atorvastatin. Vital signs include a heart rate of 78 bpm, blood pressure of 132/74 mm Hg, and body mass index of 32 kg/m2. He expresses to you that he has become more withdrawn and does not enjoy going to social events like he once did. Over the years, it has become progressively more difficult for him to differentiate voices in crowded spaces, making it difficult for him to engage with those around him. His two-item Patient Health Questionnaire score is 1. Your physical exam reveals patent external auditory canals with intact, clear tympanic membranes. You cover one ear at a time and whisper three words, but he reports not being able to differentiate the words on either side. The Weber test does not lateralize. The Rinne test shows longer air conduction than bone conduction in both ears. What is the suspected diagnosis? ACholesteatoma BMénière disease CPresbycusis DVestibular schwannoma
dx: sexual dysfunction Antihypertensive medications are frequently encountered in the older population and are likely to be a strong factor in sexual dysfunction. Patients using beta-blockers and diuretics are at a particularly elevated risk of sexual dysfunction. Other medications that influence sexual health in older adults include antiandrogens, antipsychotics, and antidepressants, particularly serotonin-selective receptor inhibitors.
A 68-year-old woman presents to the clinic with concerns over her low libido. She notes the onset to be several years ago. She has been married to her partner for over 40 years, and she reports feeling happy and safe in the relationship. She reports no symptoms of depression or anxiety. She has recently retired from her teaching position and is excited about her future travel plans. Her surgical history is significant for bilateral salpingectomy and cholecystectomy. Her medications include metoprolol, a daily multivitamin, hydrochlorothiazide, a daily aspirin, and the occasional acetaminophen. What aspect of the patient's history is most likely to contribute to her symptoms? AAntihypertensive use BFamily history of cardiovascular disease CRecent retirement DSurgical history
Follow-up at the next scheduled visit' Who to treat if asymptomatic 1) Pregnant patients 2) Urologic intervention: patients undergoing transurethral resection of the prostate and other urologic procedures in which mucosal bleeding is anticipated 3) Kidney transplant recipients: 1-3 months following transplant
A 68-year-old woman with a medical history of diabetes and hypertension treated with metformin, lisinopril, and low-dose aspirin presents to the clinic for her routine yearly checkup. She states she has no concerning symptoms and is mainly interested in reviewing her diet and medications during the visit. Vital signs today include a heart rate of 78 bpm, blood pressure of 136/78 mm Hg, respiratory rate of 20/minute, oxygen saturation of 98% on room air, and temperature of 98.6°F. As part of her yearly exam, a point-of-care dipstick urinalysis is performed, which is positive for leukocytes and nitrites. Physical examination reveals a soft, nontender abdomen, no suprapubic tenderness, and no costovertebral tenderness. The urine is sent for culture, and 3 days later, returns with a result of > 100,000 CFUs/ml of Escherichia coliisolated. When notified of the results, she again reports no urinary symptoms. Which of the following is the best next step in management? AFollow-up at the next scheduled visit BRefer to urology for further evaluation and treatment CTreat with ciprofloxacin 500 mg twice a day DTreat with nitrofurantoin 100 mg twice a day
Observation dx: CLL Treatment is recommended for patients with active disease, which is indicated by anemia, thrombocytopenia, massive splenomegaly, massive lymphadenopathy, constitutional symptoms, or rapidly progressive lymphocytosis. Various chemotherapy agents are used. The most common cause of death for patients with CLL is infection.
A 75-year-old man presents for follow-up after he was found to have leukocytosis with a prominent lymphocytosis on blood work that was performed at an annual exam. He reports generally feeling well and reports no fever, weight loss, or night sweats. He has a history of hyperlipidemia, for which he takes atorvastatin. Vital signs include a BP of 120/80 mm Hg, HR of 80 bpm, RR of 20/min, T of 98.6°F, and SpO2 of 99% on room air. Exam findings include nontender, firm, and mobile anterior cervical lymphadenopathy. He has a regular heart rate and rhythm, and his lungs are clear to auscultation. His white blood cell count is 16,000 cells/microL with an absolute B lymphocyte count of 12,000 cells/microL. Peripheral smear reveals morphologically mature-appearing small lymphocytes with smudge cells. Immunoglobulin light chain restriction on flow cytometry confirms clonality of the circulating lymphocytes. His hemoglobin count is 12.5 g/dL, and his platelet count is 220,000 platelets/microL. Which of the following is the recommended treatment? AAcalabrutinib BObservation CTherapeutic phlebotomy DVenetoclax plus obinutuzumab
Opioids Dyspnea is a subjective experience and may be described by patients as breathlessness, chest tightness, a feeling of suffocation, rapid breathing, increased effort of breathing, air hunger, rapid breathing, incomplete exhalation, or shortness of breath. It is one of the most common symptoms in the last 6 months of life for patients with terminal cancer. Treatment should focus on reducing the distress caused by dyspnea. . Supportive measures should be provided to all patients, including cool air from a window or fan blowing on the face, relaxation techniques, and modification of activity level and use of assistive devices such as a wheelchair. Opioids are effective in reducing dyspnea in patients who do not have adequate symptom relief from supportive measures. vs lookout next flash card
A 69-year-old patient presents to her hospice care clinician for evaluation of dyspnea. She reports chest tightness and a constant feeling of suffocation. She reports she has tried relaxation techniques and a fan blowing cool air on her face without improvement in her symptoms. She reports no fever, cough, or anxiety. Medical history includes stage IV ovarian cancer. Vital signs are notable for a temperature of 97.4°F, blood pressure of 144/86 mm Hg, heart rate of 92 beats/minute, respiratory rate of 20 breaths/minute, and oxygen saturation of 96% on room air. Physical exam reveals increased respiratory effort with use of accessory muscles and lungs clear to auscultation bilaterally. Her chest X-ray is shown above. Which of the following is the most appropriate next step in management? ABenzodiazepines BNoninvasive ventilation COpioids DSupplemental oxygen
20-valent pneumococcal conjugate vaccine dx: not nknown previous vaccination Suggested Recommendations for Pneumococcal Vaccination in Immunocompetent Adults ≥ 65 Years of Age in the USA--------> vs The PPSV23 (B) is not the recommended pneumococcal vaccine for older adults without prior pneumococcal vaccination, according to the Advisory Committee on Immunization Practices. However, the 15-valent PCV, followed 1 year later by the PPSV23, is an acceptable alternative if the 20-valent PCV is not available.
A 70-year-old woman presents to the clinic for a routine wellness examination. She reports that she wants to make sure she is updated on all vaccinations since she has a new grandchild being born this month and her sister was recently admitted to the hospital for an infection. She has a medical history of hypothyroidism, for which she takes levothyroxine, and overactive bladder, for which she takes mirabegron. Vital signs include a BP of 120/80 mm Hg, HR of 70 bpm, RR of 20/min, T of 98.9°F, and SpO2 of 97% on room air. Exam findings include a regular rate and rhythm, lungs clear to auscultation bilaterally, and no pretibial edema. You review her vaccination history and see that she had her last Tdap 8 years ago, the recombinant zoster vaccine 5 years ago and 4 years ago, and an influenza vaccine earlier this year. Which of the following vaccines is recommended for this patient? A20-valent pneumococcal conjugate vaccine B23-valent pneumococcal polysaccharide vaccine CTdap booster DThird dose of recombinant zoster vaccine
Antibiotic use dx: Clostridioides difficile infection.
A 70-year-old woman with a history of GERD on a proton pump inhibitor presents to her primary care provider with fever, abdominal pain, and several episodes of diarrhea for the past 3 days. She reports she was recently hospitalized and treated for a complex sinus infection with intravenous and, subsequently, oral antibiotics. Vital signs include a heart rate of 88 bpm, blood pressure of 120/82 mm Hg, respiratory rate of 20/minute, oxygen saturation of 99% on room air, and temperature of 101.2°F. Physical examination reveals a soft abdomen that is diffusely tender to palpation in all quadrants with hyperactive bowel sounds. Her lab results reveal a leukocytosis. Which of the following risk factors is the greatest contributor to her current condition? AAdvanced age BAntibiotic use CProton pump inhibitor use DRecent hospitalization
Stress cardiomyopathy (takotsubo) is most common in postmenopausal women who have experienced recent emotional stress (death of a loved one, natural disaster, new medical diagnosis) or physical illness (infection, surgery) that causes a catecholamine surge. Excess catecholamines damage the heart by causing microvascular spasm resulting in myocardial stunning and myocardial toxicity vs Vasospastic angina (D) is caused by spasm of coronary artery smooth muscle resulting in transient obstruction of blood flow. Symptoms include chest pain at rest, more commonly at night, which is relieved with the use of sublingual nitroglycerin.
A 70-year-old woman with a medical history of hypertension and hyperlipidemia treated with carvedilol and atorvastatin presents to the emergency department with substernal chest pain and shortness of breath that started with activity 2 hours ago and is not relieved with rest. She reports intermittent nausea and emotional stress related to the recent death of her spouse. Her vital signs are a heart rate of 105 bpm, blood pressure of 102/68 mm Hg, respiratory rate of 22/minute, oxygen saturation of 98% on room air, and temperature of 98.6°F. Physical exam reveals tachycardia and a regular rhythm with no murmurs, rubs, or gallops. There are no bibasilar crackles, and the abdomen is soft and nontender to palpation in four quadrants. Laboratory tests reveal a high-sensitivity troponin I of 150 ng/L. Chest X-ray shows mild interstitial pulmonary edema. ECG shows sinus tachycardia with ST elevation in leads V1, V2, and V3. Urgent coronary angiography reveals left ventricular apical ballooning and nonobstructive coronary artery disease. Which of the following is the most likely diagnosis? AMyocarditis BST elevation myocardial infarction CStress cardiomyopathy DVasospastic angina
Decreased renal plasma flow The effects of normal aging on the kidney include decreased renal plasma flow, increased baseline prostaglandin-induced vasodilation, decreased number of functioning glomeruli, decreased renal mass, replacement of normal parenchyma with fat and fibrotic tissue, decreased creatinine clearance, decreased hydroxylation of vitamin D, and impaired retention of water, solute, amino acids, and glucose. The glomerular filtration rate (GFR) does not change with age in one-third of the population. For the rest, there is usually a gradual decline in the GFR with age. By age 70, the number of functioning glomeruli is reduced by 50%, and the renal plasma blood flow is reduced by 40%. Because the renal blood flow is reduced, there is a compensatory increase in circulating prostaglandins, causing vasodilation within the kidney that helps maintain perfusion.
A 72-year-old man presents to the clinic with 2 days of decreased urine production and pedal edema. He takes simvastatin 20 mg for dyslipidemia, fluoxetine 20 mg for major depressive disorder, and recently began taking ibuprofen 800 mg three times daily for right knee pain. His vital signs are within normal limits, and his physical exam reveals 1+ pitting pedal edema bilaterally, no suprapubic tenderness, and no costovertebral tenderness. His urinalysis shows positive for granular casts, specific gravity 1.000, 1+ protein, 1+ hemoglobin, 1+ leukocytes, no nitrites, no urobilinogen, no bilirubin, and a pH of 5.0. Which of the following normal physiologic changes of aging is most likely responsible for his current diagnosis? ADecreased circulating white blood cell count BDecreased liver mass CDecreased renal plasma flow DProstate gland hyperplasia
Abnormal exercise stress test Mild aortic stenosis correlates to a valve area of 1.5-2.0 cm2. Moderate disease correlates to a valve area of 1.0-1.5 cm2, and the valve area in severe disease is < 1.0 cm2. A patient with asymptomatic aortic stenosis would be considered a candidate for aortic valve replacement if the aortic valve area were ≤ 0.6 cm2. vs A left ventricular ejection fraction of 55% (C) is within the normal range. Patients who have asymptomatic aortic stenosis and a normal ejection fraction may require aortic valve replacement if they do not pass an exercise stress test or have rapid disease progression. An aortic valve area of 3 cm2 (B) describes a normal aortic valve measurement.
A 74-year-old man presents to the clinic for his annual exam. He states he feels well. He currently takes lisinopril 10 mg daily for hypertension and simvastatin 10 mg nightly for dyslipidemia. His blood pressure is 130/82 mm Hg, his pulse is 80 beats/minute, and his respirations are 14/minute. His oxygen saturation is 98% on room air, and his nonfasting glucose is 124 mg/dL. Physical exam reveals a harsh systolic murmur that is loudest at the second intercostal space to the right of the sternum. ECG reveals increased amplitude in the R wave of aVL and the S wave in V3. A transesophageal echocardiogram reveals a maximum transaortic velocity of 4.2 m/s. Which of the following additional findings would be an indication for surgical intervention for this patient? AAbnormal exercise stress test BAortic valve area of 3 cm² CLeft ventricular ejection fraction of 55% DRadiation of cardiac murmur to the carotid arteries
Violent movements during sleep Rapid Eye Movement (REM) Sleep Behavior Disorder Etiology Disruption of neurocircuit in ventromedial medulla Interferes with inhibitory neurons' actions on spinal motor neurons Clinical Loss of skeletal muscle atonia during REM sleep Acting out dreams with vocalizations, complex behaviors, or both May result in injury to self or bed partnerMore prevalent in menOnset usually around 50s or 60s DiagnosisPolysomnography Treatment Safety precautions (place cushions around individual, remove dangerous objects) Clonazepam is first line Gabapentin or melatonin is second line
A 74-year-old woman presents for evaluation because her bed partner notes that the patient frequently calls out in her sleep. She has a history of Lewy body dementia and hypertension. Her vital signs are a temperature of 97.0°F, blood pressure of 123/80 mm Hg, heart rate of 89 bpm, respiration rate of 18/minute, and oxygen saturation of 100%. Physical exam reveals a slightly stooped posture, muscle rigidity, and minimal resting tremor of her hands bilaterally. Heart and lung exams are within normal limits, and the rest of the physical exam is unremarkable. Which of the following further describes common clinical manifestations in this suspected condition? ADifficulty falling asleep or staying asleep BFalling asleep abruptly during normal activity CRepeated episodes of paused breathing during sleep DViolent movements during sleep
Psyllium (Metamucil) Dietary and lifestyle modifications, including adequate fluid and fiber intake, regular exercise, and bulk-forming (fiber) laxatives (e.g., psyllium), are the first-line treatments for chronic constipation. Discontinuing medications causing or contributing to constipation should be considered whenever possible. Osmotic laxatives (e.g., polyethylene glycol 3350), which increase intestinal water retention, should be the next step in treatment if bulk-forming laxatives do not improve vs Manual disimpaction (C) and enemas are the treatment for fecal impaction, which may be associated with constipation in older adults. Patients with fecal impaction can present with abdominal pain or distension, anorexia, nausea and vomiting, or early satiety. Physical exam may show mild tachycardia, abdominal distention and diffuse tenderness, and a large amount of stool in the rectum vault on digital rectal exam.
A 74-year-old woman presents to the clinic with a sense of incomplete evacuation with bowel movements. She reports two bowel movements per week, and she has tried increasing her fluid and dietary fiber intake without improvement in her symptoms. She reports no rectal bleeding or change in her weight. Medical history includes diabetes treated with metformin and a left below-the-knee amputation due to peripheral vascular disease. She uses a wheelchair for ambulation. Her last colonoscopy was 2 years ago and resulted with normal findings. Vital signs are notable for a temperature of 98.4°F, blood pressure of 138/84 mm Hg, heart rate of 86 beats/minute, respiratory rate of 16 breaths/minute, and oxygen saturation of 95% on room air. Physical exam reveals the abdomen is soft, nontender, and nondistended, with normal bowel sounds present throughout. Rectal exam reveals normal rectal tone and a small amount of palpable hard stool. Which of the following treatments is the most appropriate next step? AAlvimopan BBisacodyl CManual disimpaction DPsyllium
Thyroid-stimulating hormone dx: malnutrition The initial evaluation of an older adult with weight loss should include serial weight measurements, dietary or appetite assessment, careful history and physical examination, and laboratory studies. Some important findings in the history that may indicate an underlying gastrointestinal malignancy include dysphagia, early satiety, and gastrointestinal bleeding (indicated by melena or hematochezia) or a lung malignancy in a patient with weight loss, cough, hemoptysis, and worsening shortness of breath. The recommended initial laboratory studies include complete blood count, chemistry panel, and a thyroid-stimulating hormone.
A 74-year-old woman presents to the clinic with involuntary weight loss over the past 3 months. She states that 3 months ago, she weighed 146 pounds and states she now weighs 128 pounds. She reports that she may be eating less frequently than normal but states she eats a normal amount for her at each meal. She reports no other new symptoms. She has a medical history of hypertension, for which she takes lisinopril, and hyperlipidemia, for which she takes rosuvastatin. She states she smoked cigarettes in her 20s and 30s but has not smoked since that time. Vital signs include a BP of 150/105 mm Hg, HR of 92 bpm, RR of 24/min, T of 98.6°F, and SpO2 of 95% on room air. Physical exam findings include a regular heart rate and rhythm, lungs clear to auscultation, and no abnormal lesions on oral exam. Her abdomen is soft and nontender. Her last colonoscopy was 9 years ago and showed no polyps or cancer at that time. Her hemoglobin is 13.0 g/dL. Which of the following tests is recommended as part of the initial evaluation of this patient? AColonoscopy BCT of the chest, abdomen, and pelvis CThyroid-stimulating hormone DUpper gastrointestinal endoscopy
Tdap is a vaccine administered intramuscularly that is recommended at 10-year intervals for adults. A similar vaccine with different dosages called DTaP is administered routinely during childhood. vs Zoster recombinant (D) is recommended to decrease the recipient's risk of developing herpes zoster and postherpetic neuralgia. It does not reduce the transmission of varicella. The zoster recombinant vaccine is recommended for immunocompetent adults who are ≥ 50 years of age.
A 75-year-old man presents to the clinic for an annual wellness examination. He reports no new medical concerns but does mention that his daughter is about to give birth to his first grandchild, and he and his spouse will be helping take care of the infant. He has a medical history of hypertension, hyperlipidemia, diabetes mellitus, and osteoarthritis and takes the following medications: amlodipine, atorvastatin, metformin, glipizide, and meloxicam. His vaccinations were last reviewed and updated at 65 years of age. Vital signs include a BP of 120/80 mm Hg, HR of 88 bpm, RR of 20/min, T of 98.9°F, and SpO2 of 95% on room air. Exam findings include a regular heart rate and rhythm, lungs clear to auscultation bilaterally, and a soft and nontender abdomen. Which of the following vaccinations is recommended to help protect the patient's new grandchild? AHaemophilus influenzae type B BHepatitis A CTdap DZoster recombinant
Decreased testosterone levels Which gonadotropic hormone is responsible for stimulating the Sertoli cells of the seminiferous tubules to engage in spermatogenesis? Answer: Follicle-stimulating hormone. vs Medication side effects (D) are a common cause of sexual dysfunction in older patients. Medications with such side effects include antihypertensives such as beta-blockers (e.g., carvedilol), diuretics, antiandrogens, antipsychotics, and antidepressants. The physical exam findings in this patient are not side effects of beta-blockers.
A 75-year-old man with a history of stable angina pectoris, diabetes mellitus, hypertension, and hypercholesterolemia presents to the clinic with concerns for his decreased sexual libido. He is no longer interested in sexual intercourse with his spouse and has difficulties maintaining an erection. He also reports fatigue, depression over the past 2 years, and a weight gain of 15 pounds over the past year. He takes aspirin, losartan, metformin, carvedilol, atorvastatin, and as-needed nitroglycerin. Vital signs reveal a blood pressure of 143/86 mm Hg, heart rate of 92 bpm, respiration rate of 16 breaths/minute, oxygen saturation of 97% on room air, and a temperature of 98.3°F. Exam is notable for decreased muscle mass and body hair, and the testes appear small. His abdominal exam is benign, and you do not note any lower extremity edema. What is the most likely etiology of this patient's low libido and sexual dysfunction? AAtherosclerosis of the peripheral vessels BDecreased testosterone levels CHyperglycemia and insulin resistance DMedication side effects
Encourage enrollment in a water aerobics class A comprehensive review of all medications, In addition, older patients should be screened for depression, gait changes, falls, hearing loss, urinary incontinence, and weight loss. The most important element to implement in the prevention of falls for these patients : is an exercise program. Patients should be encouraged to perform moderate-intensity aerobic exercise 150 minutes per week and 2 or more days of resistance training per week. Flexibility and balance exercises, such as yoga, are also helpful in preventing falls. Some patients may require physical therapy to achieve fall prevention, and others may need adaptation to their exercise regime to suit their physical limitations, such as water aerobics for patients with osteoarthritis of the knees. Referring the patient to neurology (C) may not be necessary, as the neurologic exam findings are normal
A 75-year-old woman presents to the clinic for a 6-month follow-up visit. She is taking losartan 100 mg daily for hypertension, metformin 500 mg twice daily for diabetes mellitus, and atorvastatin 20 mg daily for dyslipidemia. She has occasional pain in her knees and feels a little more unsteady on her feet lately. She also reports decreased memory. Her vital signs are within normal limits, and her physical exam reveals decreased muscle tone in her legs and arms, a slow but steady gait, and normal deep tendon reflexes bilaterally. Serum cholesterol, glucose, glycosylated hemoglobin, comprehensive metabolic panel, and complete blood count are within normal limits. Urinalysis findings are also normal. A Mini-Mental State Examination reveals mild cognitive impairment. Which of the following is the best next step to prevent disability in this patient? AEncourage enrollment in a water aerobics class BPrescribe donepezil 5 mg daily CRefer patient to neurology DTransition patient to a nursing home facility
Remove the indwelling catheter and collect a midstream sample for culture dx: Catheter-associated urinary tract infections (CAUTI) vs Aspirating urine from the collection port using sterile technique (A) is an acceptable method of culturing urine in a patient with an indwelling catheter that cannot be removed. However, this option has a higher risk of culturing bacteria in the biofilm or bacteria introduced from outside the catheter and not the bladder when compared to a midstream sample.
A 75-year-old woman with a history of diabetes mellitus and alcohol use disorder is admitted to the hospital with an acute hip fracture following a fall at her nursing home. She underwent an open reduction and internal fixation surgery 4 days ago, and an indwelling urinary catheter was placed without complications. Today, she developed altered mental status with fluctuating levels of attentiveness. The patient's speech appears disorganized, and she cannot provide an accurate history. Vital signs reveal a blood pressure of 141/86 mm Hg, heart rate of 92 bpm, 18/minute, temperature of 102.3°F, and oxygen saturation of 96% on room air. Upon exam, her mucous membranes are moist, skin turgor is normal, and capillary refill is < 2 seconds. Her breathing is unlabored and symmetric, with lungs clear to auscultation. The urine within the urinary catheter bag appears cloudy and is foul smelling. What is the best method of determining this patient's most likely diagnosis? AAspirate urine from the collection port using sterile technique BCollect a urine specimen from the collection bag CExamine the catheter bag for cloudy urine DRemove the indwelling catheter and collect a midstream sample for culture
Colonoscopy is the test of choice in patients with new-onset iron deficiency anemia without a known etiology to assess for possible colorectal cancer. can present with iron deficiency anemia, a change in bowel habits, and possibly blood in the stool, including both melena and hematochezia. routine colorectal cancer screening starting at 50 years old and continuing through 75 years old. Updated guidelines recommend starting screening as young as 45 years old in individuals at average risk.
A 76-year-old woman presents with fatigue, weakness, vague abdominal pain, and a 20-pound weight loss over the past 6 months. Vital signs include a heart rate of 90 bpm, blood pressure of 110/70 mm Hg, respiratory rate of 20/minute, oxygen saturation of 99% on room air, and temperature of 97.9°F. Physical examination reveals generalized pallor and cachexia. On exam, her abdomen is soft, nontender, and without masses. Lab work reveals a hemoglobin level of 7.2 g/dL, a serum ferritin level of 9 mg/mL, and a serum iron level of 30 mcg/dL. Which of the following is the most appropriate diagnostic study to evaluate the most likely underlying cause of her anemia? ABone marrow biopsy BColonoscopy CCT scan of the abdomen and pelvis DPelvic ultrasound
Aspirin and clopidogrel dx:Short-term dual antiplatelet therapy (DAPT) is recommended for patients with an acute ischemic stroke who do not have a known cardioembolic source (e.g., atrial fibrillation) at presentation and have one of the following criteria: minor ischemic stroke (defined by a National Institutes of Health Stroke Scale ≤ 5) or a stroke due to thrombosis from intracranial large artery atherosclerosis. vs Rivaroxaban (D) is a factor Xa inhibitor anticoagulant. Anticoagulation therapy is recommended for patients who have a cardioembolic stroke from conditions such as atrial fibrillation
A 77-year-old man presents to the emergency department after developing left face and arm numbness 6 hours ago. He states he also is having difficulty moving his left arm. The symptoms fluctuate some but have progressed since onset. He reports he had similar symptoms 2 weeks ago that resolved in under an hour, and he did not seek medical evaluation at that time. He has a medical history of hypertension, for which he takes amlodipine, and hyperlipidemia, for which he takes atorvastatin. Vital signs include a BP of 154/91 mm Hg, HR of 72 bpm, RR of 20/min, T of 98.6°F, and SpO2 of 97% on room air. Physical examination reveals left-sided facial droop, decreased sensation in the left arm, and left arm strength of 3 out of 5. He has no other neurological deficits on exam. His head CT scan is shown above. Transthoracic echocardiogram shows no signs of a thrombus or patent foramen ovale. CT angiogram shows evidence of severe stenosis of the right middle cerebral artery. Cardiac monitoring shows no signs of dysrhythmias. Which of the following is the recommended early antithrombotic therapy for secondary stroke prevention in this patient? AAspirin BAspirin and clopidogrel CClopidogrel DRivaroxaban
Erythropoiesis-stimulating agents , such as epoetin or darbepoetin dx: Anemia of chronic disease
A 77-year-old man with a history of hypertension, benign prostate hypertrophy, and stage IV chronic kidney disease presents for routine follow-up to evaluate his laboratory workup. His vital signs are a temperature of 97.1°F, blood pressure of 120/72 mm Hg, heart rate of 77 bpm, respiration rate of 18/minute, and oxygen saturation of 99%. He reports feeling more fatigue than usual and becomes winded more easily. His laboratory results include an estimated glomerular filtration rate of 25 mL/min/1.73, a hemoglobin level of 9.9 g/dL, a normal mean corpuscular volume, a ferritin level of 200 mg/mL, and a decreased reticulocyte count of 50 mg/dL. What is the preferred treatment for the patient's suspected diagnosis? ABlood transfusion BErythropoiesis-stimulating agents CFolic acid supplementation DIron supplementation
To assess the patient's functional status in his own home vs A home visit to assess for suspected elder abuse (C) is justified. However, there is no suspected elder abuse in this case because the patient lives alone.
A 78-year-old man who lives by himself presents to the clinic for a wellness check. He has no current health concerns to discuss and states he wants to return home as soon as possible because being out makes him nervous. He does not bring his medicine bottles but states he takes medications for hypertension, diabetes, generalized anxiety disorder, osteoarthritis, and benign prostatic hypertrophy. His vital signs are a blood pressure of 130/80 mm Hg, pulse of 60 beats/min, temperature of 98.5°F, respirations of 16/min, oxygen saturation of 98%, and body mass index of 19 kg/m2. His nonfasting glucose level is 140 mg/dL. Physical exam reveals multiple contusions to bilateral forearms and lower legs, a slow gait, decreased reaction time, and mild confusion. Which of the following is an appropriate indication for a home-based visit of this patient from the primary care provider? ATo accommodate the patient's agoraphobia BTo assess the patient's functional status in his own home CTo evaluate for suspected elder abuse DTo reconcile the patient's home and reported medications
Surgical evacuation of the hematoma dx: subdural hematoma Risk factors for the development of a subdural hematoma include the presence of cerebral atrophy, chronic alcohol use, advancing age, anticoagulation use, and prior head injury. Urgent hematoma evacuation is recommended for the treatment of large and symptomatic chronic SDHs with clot thickness > 10 mm or with a midline shift > 5 mm. Untreated symptomatic SDH can lead to brain herniation and even death due to increased intracranial pressure and further hematoma expansion. vs Reversal of anticoagulation (C) is often required for the treatment of subdural hematomas, particularly in severe cases that are at risk of hematoma expansion. In cases in which surgical evacuation is needed, reversal of anticoagulation is also warranted but does not come before surgical evacuation of the hematoma.
A 79-year-old man presents to the emergency department with progressive left-sided weakness, headache, and lethargy for the past 2 days. His medical history is significant for atrial fibrillation treated with warfarin. His family member notes he fell 3 weeks ago, hit his head, and experienced mild confusion following the fall. Vital signs include a heart rate of 95 bpm, blood pressure of 145/92 mm Hg, respiratory rate of 19/minute, oxygen saturation of 99% on room air, and temperature of 98.2°F. His neurologic examination reveals dysarthria and hemiparesis. A noncontrast CT of the brain is shown above. Lab results reveal an INR of 2.0. Which of the following is the most definitive intervention for the suspected diagnosis? ABlood pressure control with IV nicardipine BExternal ventricular drain placement CReversal of anticoagulation with IV vitamin K DSurgical evacuation of the hematoma
Dentures dx:Oral candidiasis is a fungal infection of the mouth caused by Candida albicans. When the infection is related to denture use, it can also be called denture stomatitis. Other risk factors include immunosuppressive conditions, inhaled corticosteroids, antibiotics, diabetes, and poor oral hygiene.
A 79-year-old woman with a medical history of hypertension, GERD, and osteoarthritis treated with captopril, omeprazole, and as-needed naproxen presents to the clinic reporting pain with eating and swallowing for the past 3 days. She has a 10 pack-year history of smoking. Vital signs today include a heart rate of 88 bpm, blood pressure of 140/86 mm Hg, respiratory rate of 22/minute, oxygen saturation of 96% on room air, and temperature of 98.6°F. Physical examination reveals erythema, tenderness, and mild inflammation of the mucosa under the base of her dentures. White plaques on an erythematous base are also noted on nearby oral mucosa. The plaques are easily scraped away when manipulated with a tongue depressor. Which of the following elements of the patient's history most likely contributed to her condition? ACaptopril BDentures CNaproxen DSmoking
Multidisciplinary care team
A 92-year-old man is hospitalized for myocardial infarction. A team consisting of a physician, pharmacist, nurse, respiratory therapist, and social worker has been providing most of his care. The pharmacist has managed drug interactions, the respiratory therapist has encouraged the use of incentive spirometry, and the nurse has helped him ambulate as able. What aspect of this patient's care is most important to improving the hospital course of an older adult? AAmbulation BIncentive spirometry CManagement of drug interactions DMultidisciplinary care team
Pureed foods , thickened liquids, or finely chopped solids mixed with gravies or sauces for moisture can help to reduce aspiration in patients with difficulty swallowing. Altering the consistency can facilitate easier swallowing of the food bolus and reduces the need for mechanical digestion in patients without teeth or dentures. vs Total parenteral nutrition (D) is nutritional support given intravenously to bypass the gastrointestinal tract. It may be used in a variety of situations in which a patient is unable to tolerate any enteral nutrition, such as prolonged sedation on ventilator support. It can be used on a temporary or permanent basis. Generally, if an individual is able to tolerate enteral nutrition, as in this case, it is the preferred mode of nutritional support. Thin liquids (C) increase aspiration risk, as they are more easily redirected to the bronchus, increasing the risk of aspiration.
A 93-year-old patient with a medical history of advanced dementia and active stage IV endometrial cancer is brought to your clinic by a family member for the sensation of food getting caught in her throat. This started several months ago but is now occurring more frequently every time she eats. She is not vomiting, coughing, or experiencing nausea or weight loss. On a physical exam, the patient appears frail, and her dentures are ill-fitting. Cranial nerves are intact. There is no palpable lymphadenopathy, and lung sounds are clear. Vital signs include a heart rate of 60 bpm, blood pressure of 106/74 mm Hg, respiratory rate of 16 breaths/min, oxygen saturation of 98%, temperature of 98.1°F, and weight of 64 kg. A barium swallow study is ordered to further assess this patient's symptoms. What dietary modification would be most appropriate for this patient? AGastrostomy tube BPureed foods CThin liquids DTotal parental nutrition
Recommend against further colon cancer screening routine colorectal cancer screening starting at 50 years old and continuing through 75 years old. Updated guidelines recommend starting screening as young as 45 years old in individuals at average risk. 76 to 85 years of age= Patients in this age group with multiple medical comorbidities or a life expectancy < 10 years, as observed in this patient, have reduced benefit of colorectal cancer screening, and screening may be discontinued
An 80-year-old man with a medical history of heart failure with ejection fraction < 35% on sacubitril-valsartan 97 mg/103 mg twice daily and chronic obstructive pulmonary disease on oxygen supplementation presents for his annual examination. He recently learned that his 70-year-old cousin was diagnosed with colon cancer. The patient's last screening colonoscopy was at age 75 and was benign. He reports no weight loss, melena, hematochezia, or changes to his stool appearance or habits. Vital signs include a heart rate of 55 bpm, blood pressure of 128/78 mm Hg, respiratory rate of 27 breaths/minute, oxygen saturation of 91%, temperature of 97.9°F, and weight of 82 kg. Abdominal examination is without masses, and no lymphadenopathy is appreciated. What is the most appropriate recommendation for colon cancer screening in this patient? APerform screening colonoscopy in 5 years BProvide a fecal-immunochemical DNA test now CRecommend against further colon cancer screening DRefer for capsule endoscopy now
History of intracranial neoplasm dx:Which is contraindication to receiving alteplase?---->image Ischemic Stroke Management Noncontrast head CT to rule out hemorrhage, shows loss of gray-white matter differentiation Fingerstick blood glucose to rule out hypoglycemia Alteplase (tPA) within 3 to 4.5 hours of Sx onset depending on exclusion criteria (e.g., history of ICH, SBP ≤ 185 mm Hg, DBP ≤ 110 mm Hg) Serial neuro exams, NIH stroke scale BP goal 24 hours post-tPA: < 180/105 mm Hg If no thrombolytics allow for permissive hypertension, treat BP > 220/120 mm Hg Statin, antiplatelet therapy, swallow evaluation DVT prophylaxis 24 hours post-tPA with LMWH if no hemorrhagic conversion
An 81-year-old man presents to the ED with slurred speech and unilateral right-sided weakness that started 1 hour ago. He has a history of diabetes, hypertension, and stage IV duodenal carcinoma with metastasis to the brain. His vital signs are a temperature of 97.1°F, blood pressure of 167/96 mm Hg, heart rate of 81 bpm, respiration rate of 28/minute, and oxygen saturation of 97%. His physical exam reveals impaired ability to smile on the right side of the face. There is also a notable decline in grip strength of his right hand. His lungs are clear to auscultation, and he has normal rate and rhythm on heart exam. A CT scan of the brain reveals an infarct in the middle cerebral artery. His glucose level reading is 150 mg/dL. Which of the following aspects of the patient's presentation is a contraindication to receiving alteplase? AAge ≥ 80 years BCurrent hyperglycemia CHistory of intracranial neoplasm DSystolic blood pressure ≥ 160 mm Hg
Bereavement dx: Excessive alcohol consumption (more than seven drinks per week or more than three drinks in 1 day) is common in older adults (adults > 65 years of age). Risk factors for excessive alcohol use in older adults include bereavement, depression, anxiety, pain, disability, and a prior history of excessive alcohol use. The American Geriatric Society guidelines recommend screening older adults by asking specific questions about the frequency and quantity of alcohol use. The CAGE questions should cut down ,annoyed , guilty, if they have ever taken a drink first thing in the morning (eye-opener) to steady their nerves or get rid of a hangover. Two affirmative responses are sensitive and specific for excessive alcohol use and dependence. What are the complications of excessive alcohol use in older adults? Answer: Increased frequency of falls, decreased cognition, and malnutrition.
An 81-year-old man presents to the clinic for an annual checkup. He reports no medical concerns today and states he has been taking his medications as prescribed. He has a history of hypertension and congestive heart failure and takes the following medications: lisinopril, metoprolol, and furosemide. During screening questions, he does report he has felt a need to cut down on alcohol consumption and states that he drinks four to five beers about three times per week. Exam findings include a regular heart rate and rhythm, lungs clear to auscultation, and a soft and nontender abdomen. Which of the following is a risk factor for the suspected condition? ABereavement BCigarette smoking CFemale sex DLow socioeconomic status
Oral fidaxomicin DX: Clostridioides difficile infection. The clinical manifestations include watery diarrhea, crampy lower abdominal pain, and malaise. Patients may develop a low-grade fever and abdominal distention in severe cases. The diagnosis is confirmed by microbiologic stool testing (nucleic acid amplification testing or enzyme immunoassays are often used) showing the presence of C.diff toxin. CT of the abdomen and pelvis is often obtained to evaluate abdominal pain prior to confirming the diagnosis of C. diff. Typical findings include colonic wall thickening, low-attenuation mural thickening, and pericolonic stranding. CT imaging can also assess for complications, such as bowel perforation and toxic megacolon.
An 81-year-old woman presents to the emergency department with abdominal pain and nonbloody, watery diarrhea for 2 days. She reports associated malaise but no vomiting. She states that she was seen by her primary care provider 2.5 weeks ago for mild cellulitis that was treated with cephalexin. She has not had similar symptoms previously. She has a medical history of hyperlipidemia, for which she takes atorvastatin, and hypothyroidism, for which she takes levothyroxine. Vital signs include a BP of 130/84 mm Hg, HR of 105 bpm, RR of 20/min, T of 99.2°F, and SpO2 of 97% on room air. Exam findings include moderate lower abdominal tenderness but no rebound tenderness or guarding. Laboratory findings include a white blood cell count of 19,000 cells/microL and a lactic acid of 2 mmol/L. Nucleic acid amplification testing of the stool confirms the suspected toxin- and spore-producing organism. CT shows colonic wall thickening and pericolonic stranding. What is the recommended antimicrobial regimen for the suspected diagnosis? AIntravenous piperacillin-tazobactam BIntravenous vancomycin COral fidaxomicin DOral metronidazole
CT of the head
An 82-year-old woman presents to the emergency department with a constant room-spinning sensation for the past 4 hours. She has an associated severe headache, diplopia, and nausea but reports no hearing changes or tinnitus. She reports that nothing makes the sensation better or worse and reports no focal numbness or weakness. She has a medical history of diabetes mellitus, for which she takes metformin and canagliflozin, and she smokes a pack of cigarettes per day. Vital signs include a BP of 154/91 mm Hg, HR of 72 bpm, RR of 20/min, T of 98.6°F, and SpO2 of 97% on room air. Physical examination reveals a vertical nystagmus that is not suppressed with visual fixation. She has no sensory or motor deficits but is unable to ambulate. Which of the following is the most appropriate next step for this patient? ACT of the head BMRI of the brain CTransthoracic echocardiogram DVideo nystagmography
Pulsus alternans dx:Left-sided heart failure describes left ventricular dysfunction with resultant pulmonary congestion, decreased cardiac output, or both. Pulsus alternans occurs in severe left ventricular dysfunction and describes a peripheral pulse that alternates evenly between weak and strong impulses. The patient in the above vignette has symptoms of purely left-sided heart failure, although many patients will present with both right- and left-sided heart failure, as left-sided heart failure is the most common cause of right-sided heart failure.
An 82-year-old woman presents to the emergency department with acute shortness of breath. She states the dyspnea is worse when she lies flat. She has hypertension and coronary artery disease, for which she takes carvedilol 3.125 mg twice daily, lisinopril 10 mg once daily, aspirin 81 mg once daily, and atorvastatin 40 mg nightly. Vital signs are a blood pressure of 110/90 mm Hg, pulse of 108 bpm, respirations of 20/min, temperature of 98.6°F, and oxygen saturation of 90%. Physical exam reveals an S3 gallop, a laterally displaced apical impulse, diaphoresis, pulmonary rales at bilateral lung bases, and cool extremities without edema. Which of the following additional clinical manifestations is consistent with this patient's most likely diagnosis? AAscites BHepatojugular reflux CPulsus alternans DSplenomegaly
Chlorthalidone dx; antihypertensive agents for adults over 55 years old Diuretics and calcium channel blockers Thiazide and thiazide-like diuretics increase vasodilation and reduce plasma volume, cardiac output, and systemic vascular resistance, causing a reduction in blood pressure. vs loop diuretics pose a greater risk of electrolyte imbalances due to excessive diuresis. and Overall, furosemide is a poor antihypertensive and is used in short durations in patients with fluid retention and kidney disease.
An 82-year-old woman presents to your clinic to establish care. Her medical history is complicated by hyperlipidemia and type 2 diabetes mellitus. Her medications include rosuvastatin and basal insulin. On physical exam, she is in no acute distress and has a normal mood and affect. On cardiovascular exam, she has a regular rate and rhythm; no murmurs, rubs, or gallops; clear and unlabored breathing; and no wheezing or crackles. Her blood pressure today is 172/80 mm Hg, heart rate is 68 bpm, respiratory rate is 24/min, oxygen saturation is 98% on room air, and temperature is 97.1°F. After counseling the patient on maintaining a heart-healthy diet and encouraging more exercise, which of the following clinical therapeutics should be considered as initial therapy? AChlorthalidone BFurosemide CLisinopril DMetoprolol
Accelerated skeletal muscle catabolism in the setting of inflammation dx: Cachexia is a disorder characterized by hypercatabolism of skeletal muscle. This often occurs in the setting of a chronic disease characterized by significant inflammation. It is most commonly seen in cancer patients but can also occur with chronic autoimmune disorders, chronic infections, or other chronic end-organ diseases. vs Mucositis secondary to chemotherapy preventing nutrient intake (C) is often seen in patients with cancer who are receiving intensive chemotherapy. While this would cause weight loss, it does not necessarily cause the same hypercatabolism of skeletal muscle seen in cachexia.
An 82-year-old woman with advanced pancreatic cancer presents to the office for her first palliative care appointment. She has noted that her appetite has decreased, but she forces herself to eat what she can. Despite this, she continues losing weight at a rapid pace. Vital signs during the visit include a heart rate of 110 bpm, blood pressure of 100/78 mm Hg, respiratory rate of 18 breaths/minute, oxygen saturation of 98% on room air, and temperature of 97.6°F. On exam, she has no adventitious breath sounds, tachycardia with regular rhythm, and no conjunctival pallor or jaundice, but she does have little muscle mass. Her blood work is notable for a creatinine level of 0.3 mg/dL. What is the underlying pathogenesis of her condition? AAccelerated skeletal muscle catabolism in the setting of inflammation BHypophosphatemia due to overeating in a previously starved patient CMucositis secondary to chemotherapy preventing nutrient intake DPoor perfusion to kidneys resulting in kidney failure
Serial weights dx: Older adults have a higher risk of malnutrition that continues to increase as they age due to multifactorial changes in nutritional needs, diminished organ system reserves, and weakened homeostatic controls. Malnutrition is defined as having two or more of the following: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation, and diminished functional status as measured by handgrip strength. vs The Nutritional Risk Screening 2002 and Mini Nutritional Assessment (B) is a generic tool to assess the risk of malnutrition in the hospital setting and determine who may benefit from nutritional therapy. It is not clinically helpful in the outpatient setting.
An 83-year-old woman with a history of cerebrovascular accident, congestive heart failure, hypertension, diabetes mellitus, and depression is brought into the clinic by her daughter for a routine checkup. Her daughter states the patient has been eating less than her normal amount. The patient has difficulty swallowing her food but reports no other concerns. The patient takes hydrochlorothiazide, amlodipine, metformin, and sertraline daily. Her spouse passed away a few years ago, and she lives on a fixed income. Upon exam, she has a blood pressure of 136/78 mm Hg, heart rate of 75 bpm, respiration rate of 14 breaths/min, and temperature of 97.9°F. Her height is 64 inches, and her weight is 113 pounds, which is 9 pounds less than her previous recorded weight 6 months ago. What is the preferred routine screening method for the most likely condition of this patient? ABMI BNutritional Risk Screening 2002 CSerial weights DSkinfold measurements
Nursing home is the preferred place for terminal care. in advanced dementia or Alzheimer disease treatment of Alzheimer disease, such as acetylcholinesterase inhibitors (e.g., donepezil, galantamine, rivastigmine) and N-methyl-D-aspartate receptor antagonists (e.g., memantine).However, one of the most important focuses in dementia management is access to palliative and planned care for dementia patients.
An 85-year-old woman with a history of memory impairment and cognitive decline currently lives at home with her spouse. Her spouse expresses to you that a few times over the past 3 months, she opened the front door in the middle of the night and wandered down their street. She also frequently soils her garments, refuses to eat at times, and often forgets where she is. She is also beginning to become combative and confused when her spouse provides care for her. Her spouse expresses that it is becoming increasingly more difficult to care for her, as arthritis limits their ability to help her to the bathroom and assist her with other activities of daily living. Her vital signs are temperature of 97.7°F, blood pressure of 133/79 mm Hg, heart rate of 70 bpm, respiration rate of 18/minute, and oxygen saturation of 97%. Her physical assessment reveals poor dentition, unwashed and unkempt hair, and clothes that are stained and smell of urine. Which of the following describes the most appropriate level of care for the patient? AAssisted living facility BHospitalization CNursing home DShort-term rehabilitation facility
Methocarbamol Beer criteria At what age should Beers criteria be implemented? Answer: 65 years of age. Methocarbamol is on the Beers criteria and is not recommended for use in older adults due to sedation and increased risk of fractures. Most muscle relaxants also cause anticholinergic side effects (e.g., memory impairment and blurred vision), which can be dangerous in this population as well. Although tools like the Beers criteria are helpful when prescribing and deprescribing for older adults, they should be used in conjunction with good clinical judgment and take patient-specific factors into account.
An 86-year-old patient presents to the clinic for an annual well visit. He reports no symptoms. His medical history includes anxiety treated with buspirone, allergic rhinitis treated with cetirizine, low back pain and muscle spasms treated with methocarbamol, and hypertension treated with telmisartan. Vital signs are notable for a temperature of 98.8°F, blood pressure of 136/84 mm Hg, heart rate of 78 beats/minute, respiratory rate of 16 breaths/minute, and oxygen saturation of 97% on room air. Physical exam reveals lungs clear to auscultation bilaterally, normal heart rate and rhythm, and extremities warm and dry without swelling. Which medication is inappropriate for use in this patient? ABuspirone BCetirizine CMethocarbamol DTelmisartan
Metastatic prostate cancer vs Burst fracture of L4 (A) appears on radiograph as a comminuted vertebral body with loss of vertebral height. Burst fractures occur in the setting of extreme axial force, such as a fall from a great height or a motor vehicle collision. Patients with burst fractures will have a history of trauma and will often have contusions. In contrast, patients with pathologic fractures will often have no history of trauma and no outward signs of a fall. Spondylolisthesis (D) describes slippage of one vertebra on another. This condition may be the cause of low back pain and can cause radicular signs and symptoms if severe. However, palpable inguinal lymph nodes would not be present. Plain X-rays of the lumbar spine in patients with metastatic prostate cancer might show compression fractures of the vertebrae or pathologic fractures.
An 88-year-old man presents to the clinic with low back pain that has been gradually worsening for several years and recently became severe. He takes metoprolol tartrate 25 mg twice daily for hypertension and tamsulosin 0.4 mg nightly for benign prostatic hypertrophy. Usually, he urinates five times each night. However, since yesterday, he has not been able to urinate or defecate. He reports weakness of his lower legs with new-onset difficulty ambulating. He states the pain in his back now radiates down both legs. His vital signs are within normal limits except for a blood pressure of 145/90 mm Hg. Physical exam reveals decreased sensation to his inner left thigh, decreased strength in his right and left legs, decreased range of motion of his hips, tenderness to palpation over his lower vertebrae and low back, and firm, enlarged inguinal lymph nodes on the left. An X-ray of the lumbar spine shows widespread sclerotic lesions in the vertebrae and a fracture of L4. Which of the following is the most likely diagnosis? ABurst fracture of L4 BMetastatic prostate cancer CMultiple myeloma DSpondylolisthesis
Decreased neurologic functioning inhibits the gag reflex, which leads to decreased swallowing and subsequent pooling of saliva This pooling of saliva causes raspy, gurgling, or rattling breath sounds that are sometimes described as the death rattle and occur close to death. While patients are often unconscious at this point or too weak to speak, they do not seem to be overly troubled by the secretions. Rather, the family members and loved ones are often concerned over this loud, disconcerting breathing. Often, the only intervention needed is to reassure those caring for the patient that this breathing pattern is a normal step in the dying process.
An 88-year-old woman on hospice for terminal pancreatic cancer begins to have raspy, gurgling breath sounds and increased drooling. The patient's spouse is concerned and calls the hospice nurse. The nurse checks the patient's vital signs, and they are unchanged from the last visit. The patient is not alert, not moaning, and not in any apparent distress. The nurse instructs the spouse to call in any family members who may wish to be present in the patient's final hours. Which of the following best describes the physiologic process causing these new symptoms? ADecreased neurologic functioning inhibits the gag reflex, which leads to decreased swallowing and subsequent pooling of saliva BMotor neuron dysfunction causes excess parasympathetic stimulation of the salivary glands COpiates used for pain management lead to decreased gastric emptying and increased salivation DReflux of stomach contents into the upper esophagus stimulates salivation
Opioid analgesia, particularly morphine, is the preferred form of pain management at the end of life. Patient comfortand dignity are the primary goals of end-of-life care,
An 89-year-old man has recently been diagnosed with stage IV lung cancer with metastasis to the lumbar spine that has resulted in multiple compression fractures. His prognosis is poor. He has an increased need for supplemental oxygen and reports persistent 10/10 back pain that is worse with any movement. He has decided to start hospice care at home. What would be the most appropriate option for pain management in this patient? AAcetaminophen 650 mg every 4 hours BGabapentin 600 mg every 8 hours CMorphine 2 mg every 2 hours DNaproxen 500 mg every 12 hours
Abnormalities of language
Based on the suspected diagnosis, which of the following clinical manifestations suggests involvement of the anterior cerebral circulation? AAbnormalities of language BImpaired consciousness without focal findings CMotor weakness without other deficits DVertigo
testosterone for hypogonadism patient
Due to the increased risk of prostate cancer, prostate-antigen levels should be measured every 6 months while a patient is taking testosterone. Testosterone may also increase the risk of benign prostatic hyperplasia, erythrocytosis, and cardiovascular disease. Testosterone supplements are not advised for asymptomatic patients with low testosterone.
Beers Criteria
Some Medications to Avoid in Older Adults According to Beers Criteria Alprazolam Hydroxyzine Amitriptyline Indomethacin Belladonna alkaloids Insulin, sliding scale Benztropine Ketorolac Chlordiazepoxide Lorazepam Clonazepam Meclizine Clozapine Methocarbamol Cyclobenzaprine Nifedipine, immediate release Cyproheptadine Oxybutynin Doxepin Phenobarbital Doxylamine Promethazine Diphenhydramine (oral) Trihexyphenidyl Glimepiride Zolpidem Glyburide
Stage 2
Physical examination reveals a shallow open wound over the left ischial tuberosity. It is 2 cm in diameter with a pink moist wound bed without tunneling. No adipose or deep tissue is visible. Which of the following is the correct stage of the patient's condition? AStage 1 BStage 2 CStage 3 DStage 4
By age 70, the number of functioning glomeruli is reduced by 50%, and the renal plasma blood flow is reduced by 40%. Because the renal blood flow is reduced, there is a compensatory increase in circulating prostaglandins, causing vasodilation within the kidney that helps maintain perfusion. When NSAIDs are administered to older adults, the drug-induced prostaglandin blockade can decrease renal perfusion and lead to acute kidney injury. The most common acute kidney injury caused by NSAID use is acute tubular necrosis. Findings in acute tubular necrosis include granular casts, anuria or oliguria, and uremia. Treatment is to discontinue the offending medication. NSAIDs should be used with extreme caution and at low doses in the older population. Other medications that are renally excreted should also be used with caution in older adults, including intravenous contrast and chemotherapeutic agents.
The effects of normal aging on the kidney include decreased renal plasma flow, increased baseline prostaglandin-induced vasodilation, decreased number of functioning glomeruli, decreased renal mass, replacement of normal parenchyma with fat and fibrotic tissue, decreased creatinine clearance, decreased hydroxylation of vitamin D, and impaired retention of water, solute, amino acids, and glucose. The glomerular filtration rate (GFR) does not change with age in one-third of the population. For the rest, there is usually a gradual decline in the GFR with age.
Genitourinary Syndrome of Menopause (Atrophic Vaginitis) Risk factors: natural or surgical menopause, antiestrogenic drugs Sx: dyspareunia, vulvar and vaginal dryness, bleeding, itching PE: pale, dry, shiny epithelium Caused by a decrease in estrogen Tx: lubricants, moisturizers, topical estrogen
Vaginal moisturizers and lubricants are the most appropriate recommendations for this patient with atrophic vaginitis. Vaginal estrogen (C) may be an appropriate next step for patients whose symptoms are refractory first-line treatment with vaginal moisturizers and lubricants.
Gastrostomy tubes (A) deliver nutrition enterally while bypassing the oropharynx and esophagus. They have not been shown to reduce the risk of aspiration pneumonia compared to oral feeding. They may be used in patients with prolonged and persistent dysphagia, head and neck cancer, esophageal cancer, pancreatic cancer, prolonged ileus, gastric dysmotility, or inoperable intestinal obstructions.
What is the most common site of aspiration pneumonia? Answer: Right lower lobe
Hospice Type of palliative care Typically < 6 months to live Avoid the use of life-prolonging treatments (but may be concurrently pursued) Limit ED and hospital visits Emotional and physical support Focus on quality of care Palliative care aims to help relieve pain for patients who are experiencing disease but is not focused on end-of-life care. The disease for a patient receiving palliative care may be chronic, but the prognosis may vary from curable to progressive. Hospice care is focused on patients with a limited prognosis, generally 6 months or less. The care hospice patients receive is palliative, but not all patients receiving palliative care are on hospice.
Which of the following aspects of the patient's condition would make him a candidate for hospice care? AComplex care requirementsYour Answer BDecline in function CFrequent hospital admissions DPrognosis of 6 months or less
Noninvasive ventilation (B) (e.g., face mask or nasal mask) can be helpful in patients with hypercapnia due to inadequate ventilation to manage acute, reversible respiratory failure when the patient does not want invasive mechanical ventilation. Its use is controversial because it may prolong life without improving quality of life. Benzodiazepines should not be used routinely for the treatment of dyspnea in patients who do not have anxiety. Supplemental oxygen (D) is helpful in managing dyspnea in patients who are hypoxic (oxygen saturation ≤ 88%), but it does not improve dyspnea in patients who are not hypoxic.
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