A,patient,who,is,82,years,old,is,brought,into,the,clinic.,His,wife,states,that,he,was,working,in,his,garden,to
day,and,became,disoriented,and,had,slurred,speech.,She,helped,him,back,into,the,house,,gave,him,cool,f
luids,,and,within,15,minutes,his,symptoms,resolved.,He,appears,in,his,usual,state,of,health,when,he,is,ex
amined.,He,states,that,although,he,was,scared,by,the,event,,he,feels,fine,now.,How,should,the,nurse,pra
ctitioner,proceed?,Prescribe,an,aspirin,daily.,Reexamine,him,tomorrow.,
Send,him,to,the,emergency,department.,Order,an,EKG.,
This,patient,likely,suffered,a,transient,ischemic,attack.,He,needs,urgent,evaluation,with,head,CT,and/or,
MRI,,ECG,,lab,work,(CBC,,PTT,,lytes,,creatinine,,glucose,,lipids,and,sedimentation,rate);,possible,magneti
c,resonance,angiography,,carotid,ultrasound,,and/or,transcranial,Doppler,ultrasonography.,He,is,at,incre
ased,risk,of,stroke,within,the,first,48,hours,after,an,event,like,this,one.,On,initial,evaluation,,the,most,imp
ortant,determination,to,be,made,is,whether,the,etiology,of,the,stroke,or,TIA,is,ischemic,or,hemorrhagic.,
After,this,determination,,treatment,can,begin.,
Unfortunately,,this,determination,cannot,be,made,in,the,clinic.,The,patient,needs,urgent,referral,to,a,cen
ter,where,this,evaluation,and,possible,treatment,can,be,performed.,
The,most,common,presenting,sign,of,Parkinson’s,disease,is:,
muscular,rigidity.,t
remor.,falling.,bra
dykinesia.,
Approximately,70%,of,patients,with,Parkinson’s,disease,have,tremor,as,the,presenting,symptom.,The,tre
mor,typically,involves,the,hand,but,can,involve,the,legs,,jaw,,lips,,tongue.,It,seldom,involves,the,head.,Mu
scular,rigidity,and,bradykinesia,are,two,less,common,presenting,signs.,
When,should,medications,be,initiated,in,a,patient,who,is,diagnosed,with,Parkinson’s,disease?,
As,soon,as,the,disease,is,diagnosed,
,
When,symptoms,interfere,with,life’s,activities,
,
When,nonpharmacologic,measures,have,been,exhausted,After,MRI,and,CT,have,r
uled,out,stroke,or,tumor,
, The,medications,used,to,treat,patients,who,have,Parkinson’s,disease,do,not,prevent,the,progression,of,t
he,disease.,Therefore,,it,is,not,necessary,to,start,medications,until,symptoms,interfere,with,the,patient's,
quality,of,life.,Levodopa,is,often,used,initially,at,the,lowest,dose,that,helps,a,patient,manage,symptoms.,I
t,can,be,titrated,upward,as,needed.,Orthostatic,hypotension,is,a,common,side,effect,of,levodopa,,so,blo
od,pressure,should,be,monitored,closely.,
A,72-year-
old,patient,with,history,of,polymyalgia,rheumatica,complains,of,new,onset,,unilateral,headache,and
,visual,changes.,Her,neurologic,exam,is,otherwise,normal.,Her,CT,results,are,WNL.,ESR,is,75,(Normal:
,0-29).,VS:,BP,140/82,,HR,67,,RR,18,,T,100.,What,is,the,most,likely,reason,for,her,symptoms?,
Transient,ischemic,attack,
Temporal,arteritis,
Meningitis,
CVA,
,
Polymyalgia,rheumatica,(PMR),is,a,chronic,inflammatory,condition,that,produces,morning,stiffness,in,the
,neck,,shoulders,,and,hips.,Its,peak,incidence,is,70-
80,years,old.,PMR,is,commonly,associated,with,temporal,arteritis,,also,known,as,giant,cell,arteritis.,Temp
oral,arteritis,is,a,chronic,vasculitis,of,the,medium,and,large,vessels.,Temporal,arteritis,is,characterized,by,
new,onset,unilateral,temporal,headache,,abrupt,onset,of,visual,disturbances,,elevated,sedimentation,rat
e,,jaw,claudication,,and,unexplained,fever.,This,is,best,diagnosed,by,temporal,artery,biopsy.,She,should,b
e,referred,to,neurology,for,evaluation,today.,
What,recommendation,should,be,made,to,an,older,adult,who,is,diagnosed,with,mild,dementia?,
Driving,will,probably,not,increase,your,risk,of,an,accident.,
,
The,healthcare,provider,should,recommend,that,the,patient,stop,driving,today.,
,
The,healthcare,provider,should,recommend,assessment,of,driving,to,determine,risk,of,an,accident.,
The,patient,may,continue,to,drive,as,long,as,he,feels,comfortable.,
,
Dementia,independently,increases,the,risk,of,motor,vehicle,accidents,if,the,patient,drives.,The,healthc
are,provider,should,discuss,this,with,the,patient,and,a,family,member,if,a,family,member,is,present,du
ring,the,older,adult’s,evaluation.,
Depending,on,the,degree,of,impairment,,the,healthcare,provider,could,recommend,stopping,driving,,or,
recommend,that,an,assessment,be,done.,The,assessment,is,usually,completed,by,either,an,occupational
,or,physical,therapist,or,someone,trained,to,assess,this.,
A,person,with,20/60,vision:,
,
is,legally,blind.,
,
will,have,difficulty,reading,a,newspaper.,
, ,
will,be,unable,to,see,the,big,“E”,on,the,eye,chart.,has,better,vision
,than,someone,with,20/80,vision.,
Using,the,Snellen,nomenclature,for,describing,visual,acuity,(example,20/80),,the,first,number,represen
ts,the,test,distance.,In,most,cases,this,is,20,feet.,The,second,number,represents,the,distance,at,which,t
he,average,eye,can,see,the,letters,on,a,specific,line,of,the,chart.,In,other,words,,the,examinee,can,see,a
t,20,feet,what,an,average,eye,(20/20),can,see,at,80,feet.,20/80,is,a,measure,of,distant,vision,,not,near,v
ision,such,as,reading,a,newspaper.,
The,big,“E”,represents,20/200,vision.,
20/200,is,considered,legally,blind,by,most,standards.,
,
A,patient,reports,a,history,of,transient,ischemic,attack,(TIA),6,months,ago.,His,daily,medications,are,lisinop
ril,,pravastatin,,and,metformin.,After,advising,him,to,quit,smoking,,what,intervention,is,most,important,in,
helping,to,prevent,stroke,in,him?,
Auscultation,of,carotid,arteries,at,each,visit,
Taking,low,dose,aspirin,daily,
Assessing,hemoglobin,A1C,every,3-6,months,
Encouraging,smoking,cessation,at,each,visit,
Antiplatelet,therapy,,usually,aspirin,,inhibits,the,enzyme,cyclooxygenase,and,reduces,thromboxane,A2,pr
oduction,,which,stimulates,platelet,aggregation.,Thus,,
risk,of,ischemic,stroke,is,reduced.,The,dosage,of,aspirin,needed,to,prevent,an,event,is,debatable.,Most,
studies,found,that,75-
150,mg,daily,was,as,effective,in,preventing,stroke,as,was,higher,doses.,Lower,doses,of,aspirin,are,assoc
iated,with,less,GI,toxicity,and,fewer,side,effects.,
A,75-year-
old,is,diagnosed,with,essential,tremor.,What,is,the,most,commonly,used,medication,to,treat,this?,
Carbidopa,
,
Long-acting,propanolol,
Phenobarbital,
Gabapentin,
Tremor,is,the,most,common,of,all,movement,disorders,and,essential,tremor,is,the,most,common,cause,o
f,all,tremors.,It,is,characterized,by,rhythmic,movement,of,a,body,part,,commonly,the,hands,or,head.,Bet
a,blockers,are,the,most,commonly,used,medication,class,to,treat,essential,tremor.,Propanolol,is,the,mos
t,commonly,used,medication,,but,other,beta,blocking,agents,are,used,as,well.,Both,gabapentin,and,phen
obarbital,are,used,,but,,not,nearly,as,often.,Carbidopa,is,used,in,patients,with,Parkinson’s,disease.,
day,and,became,disoriented,and,had,slurred,speech.,She,helped,him,back,into,the,house,,gave,him,cool,f
luids,,and,within,15,minutes,his,symptoms,resolved.,He,appears,in,his,usual,state,of,health,when,he,is,ex
amined.,He,states,that,although,he,was,scared,by,the,event,,he,feels,fine,now.,How,should,the,nurse,pra
ctitioner,proceed?,Prescribe,an,aspirin,daily.,Reexamine,him,tomorrow.,
Send,him,to,the,emergency,department.,Order,an,EKG.,
This,patient,likely,suffered,a,transient,ischemic,attack.,He,needs,urgent,evaluation,with,head,CT,and/or,
MRI,,ECG,,lab,work,(CBC,,PTT,,lytes,,creatinine,,glucose,,lipids,and,sedimentation,rate);,possible,magneti
c,resonance,angiography,,carotid,ultrasound,,and/or,transcranial,Doppler,ultrasonography.,He,is,at,incre
ased,risk,of,stroke,within,the,first,48,hours,after,an,event,like,this,one.,On,initial,evaluation,,the,most,imp
ortant,determination,to,be,made,is,whether,the,etiology,of,the,stroke,or,TIA,is,ischemic,or,hemorrhagic.,
After,this,determination,,treatment,can,begin.,
Unfortunately,,this,determination,cannot,be,made,in,the,clinic.,The,patient,needs,urgent,referral,to,a,cen
ter,where,this,evaluation,and,possible,treatment,can,be,performed.,
The,most,common,presenting,sign,of,Parkinson’s,disease,is:,
muscular,rigidity.,t
remor.,falling.,bra
dykinesia.,
Approximately,70%,of,patients,with,Parkinson’s,disease,have,tremor,as,the,presenting,symptom.,The,tre
mor,typically,involves,the,hand,but,can,involve,the,legs,,jaw,,lips,,tongue.,It,seldom,involves,the,head.,Mu
scular,rigidity,and,bradykinesia,are,two,less,common,presenting,signs.,
When,should,medications,be,initiated,in,a,patient,who,is,diagnosed,with,Parkinson’s,disease?,
As,soon,as,the,disease,is,diagnosed,
,
When,symptoms,interfere,with,life’s,activities,
,
When,nonpharmacologic,measures,have,been,exhausted,After,MRI,and,CT,have,r
uled,out,stroke,or,tumor,
, The,medications,used,to,treat,patients,who,have,Parkinson’s,disease,do,not,prevent,the,progression,of,t
he,disease.,Therefore,,it,is,not,necessary,to,start,medications,until,symptoms,interfere,with,the,patient's,
quality,of,life.,Levodopa,is,often,used,initially,at,the,lowest,dose,that,helps,a,patient,manage,symptoms.,I
t,can,be,titrated,upward,as,needed.,Orthostatic,hypotension,is,a,common,side,effect,of,levodopa,,so,blo
od,pressure,should,be,monitored,closely.,
A,72-year-
old,patient,with,history,of,polymyalgia,rheumatica,complains,of,new,onset,,unilateral,headache,and
,visual,changes.,Her,neurologic,exam,is,otherwise,normal.,Her,CT,results,are,WNL.,ESR,is,75,(Normal:
,0-29).,VS:,BP,140/82,,HR,67,,RR,18,,T,100.,What,is,the,most,likely,reason,for,her,symptoms?,
Transient,ischemic,attack,
Temporal,arteritis,
Meningitis,
CVA,
,
Polymyalgia,rheumatica,(PMR),is,a,chronic,inflammatory,condition,that,produces,morning,stiffness,in,the
,neck,,shoulders,,and,hips.,Its,peak,incidence,is,70-
80,years,old.,PMR,is,commonly,associated,with,temporal,arteritis,,also,known,as,giant,cell,arteritis.,Temp
oral,arteritis,is,a,chronic,vasculitis,of,the,medium,and,large,vessels.,Temporal,arteritis,is,characterized,by,
new,onset,unilateral,temporal,headache,,abrupt,onset,of,visual,disturbances,,elevated,sedimentation,rat
e,,jaw,claudication,,and,unexplained,fever.,This,is,best,diagnosed,by,temporal,artery,biopsy.,She,should,b
e,referred,to,neurology,for,evaluation,today.,
What,recommendation,should,be,made,to,an,older,adult,who,is,diagnosed,with,mild,dementia?,
Driving,will,probably,not,increase,your,risk,of,an,accident.,
,
The,healthcare,provider,should,recommend,that,the,patient,stop,driving,today.,
,
The,healthcare,provider,should,recommend,assessment,of,driving,to,determine,risk,of,an,accident.,
The,patient,may,continue,to,drive,as,long,as,he,feels,comfortable.,
,
Dementia,independently,increases,the,risk,of,motor,vehicle,accidents,if,the,patient,drives.,The,healthc
are,provider,should,discuss,this,with,the,patient,and,a,family,member,if,a,family,member,is,present,du
ring,the,older,adult’s,evaluation.,
Depending,on,the,degree,of,impairment,,the,healthcare,provider,could,recommend,stopping,driving,,or,
recommend,that,an,assessment,be,done.,The,assessment,is,usually,completed,by,either,an,occupational
,or,physical,therapist,or,someone,trained,to,assess,this.,
A,person,with,20/60,vision:,
,
is,legally,blind.,
,
will,have,difficulty,reading,a,newspaper.,
, ,
will,be,unable,to,see,the,big,“E”,on,the,eye,chart.,has,better,vision
,than,someone,with,20/80,vision.,
Using,the,Snellen,nomenclature,for,describing,visual,acuity,(example,20/80),,the,first,number,represen
ts,the,test,distance.,In,most,cases,this,is,20,feet.,The,second,number,represents,the,distance,at,which,t
he,average,eye,can,see,the,letters,on,a,specific,line,of,the,chart.,In,other,words,,the,examinee,can,see,a
t,20,feet,what,an,average,eye,(20/20),can,see,at,80,feet.,20/80,is,a,measure,of,distant,vision,,not,near,v
ision,such,as,reading,a,newspaper.,
The,big,“E”,represents,20/200,vision.,
20/200,is,considered,legally,blind,by,most,standards.,
,
A,patient,reports,a,history,of,transient,ischemic,attack,(TIA),6,months,ago.,His,daily,medications,are,lisinop
ril,,pravastatin,,and,metformin.,After,advising,him,to,quit,smoking,,what,intervention,is,most,important,in,
helping,to,prevent,stroke,in,him?,
Auscultation,of,carotid,arteries,at,each,visit,
Taking,low,dose,aspirin,daily,
Assessing,hemoglobin,A1C,every,3-6,months,
Encouraging,smoking,cessation,at,each,visit,
Antiplatelet,therapy,,usually,aspirin,,inhibits,the,enzyme,cyclooxygenase,and,reduces,thromboxane,A2,pr
oduction,,which,stimulates,platelet,aggregation.,Thus,,
risk,of,ischemic,stroke,is,reduced.,The,dosage,of,aspirin,needed,to,prevent,an,event,is,debatable.,Most,
studies,found,that,75-
150,mg,daily,was,as,effective,in,preventing,stroke,as,was,higher,doses.,Lower,doses,of,aspirin,are,assoc
iated,with,less,GI,toxicity,and,fewer,side,effects.,
A,75-year-
old,is,diagnosed,with,essential,tremor.,What,is,the,most,commonly,used,medication,to,treat,this?,
Carbidopa,
,
Long-acting,propanolol,
Phenobarbital,
Gabapentin,
Tremor,is,the,most,common,of,all,movement,disorders,and,essential,tremor,is,the,most,common,cause,o
f,all,tremors.,It,is,characterized,by,rhythmic,movement,of,a,body,part,,commonly,the,hands,or,head.,Bet
a,blockers,are,the,most,commonly,used,medication,class,to,treat,essential,tremor.,Propanolol,is,the,mos
t,commonly,used,medication,,but,other,beta,blocking,agents,are,used,as,well.,Both,gabapentin,and,phen
obarbital,are,used,,but,,not,nearly,as,often.,Carbidopa,is,used,in,patients,with,Parkinson’s,disease.,
