Demographics-young old-65-74 middle old-75-84



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-DAinhibit the contraction reflex to cause smooth movement

Movie—


4 Cardinal Sx—

1. Resting treemor—pathomneumonic for Parkinson’s

-subsides with purposeful movement

2. Akinesia—difficult initiating movement

-masked facies—reptilian stare—no blinking

3. rigidity—

-lead-pipe

-cog-wheel

4. Loss of postural reflexes—

-wont catch themselves when they get pushed over


Treatment—

-Education of pt and family

-Meds mainly work by increasing DA or decreasing Ach

1. Levodopa—

-BEST MED for Parkinson’s

-precursor of DA

-DA itself will not cross the BBB

-takes very high doses to get sx effects(because of peripheral conversion of L-DopaDA)SE’s of high doses—N/V, schizophrenia

-therefore give levodopa and carbidopa together

-carbidopa decreases the conversion of levodopa to DA peripherallymore levodopa gets to brainmore DA to brain

-this only works for 5years
2. COM-T Inhibitors—

-COM-T causes breakdown of levodopa peripherally to DA

-when we inhibit itless breakdownmore gets to brain and converts to DA
Carbidopa / Levodopa (Sinemet)—

-recommended only once there is a functional impairment (ADLs, etc)

-decline in effectiveness in as many as 50% of individuals after 2 years

-a naturally occurring precursos of DA

-given in combination with Carbidopa because of SE’s of higher doses
Surgical Tx—

-unilateral surgical thalotomy helpful for tremor

-placement of electrodes into thalamus helpful for tremor

-pallidotomy may be helpful

-implantation of adrenal or fetal tissue
Evaluation of a Tremor—

-rhythmic oscillation of a body part

Three Main Types—

1. Postural / Physiologic Tremors—

-too much caffeine, nervous, etc

-very fine tremors

-occur normally in everyone during movement and while holding a fixed position

-usually invisible to the naked eye

-drugs may accentuate it

-unaffected by propanolol and / or etoh

-Treatment—

-BBs


-short acting benzos

-usually don’t treat this

2. Intention Tremors—

-essential (familial)

-tremor that is most prominent when the part affected is being used and least noticeable when the part is at rest—opposite of Parkinson’s

-may be accentuated by tasks that require precision

-diminished by use of etoh

-no abnormalities on neuro exam

-Treatment—

-avoid stimulants

-BBs (start on propanolol 10mg tid then switch to langer acting form)

-primidone (Mysoline 25mg qhs and work up to 100mg qd divided into 2 or 3 doses)


3. Rest tremors—

-most commonly due to Parkinson’s disease

*Also see Flow sheet Handout—

Lower Respiratory Infections—

Acute Bronchitis—

-inflammation of the tracheobronchial tree typically from a viral infection

-presents with—

-cough


-thick, mucoid sputum

-anorexia

-malaise

-HA


-chest pain

-fever


-auscultation can reveal ronchi and wheezing

-secondary bacterial infection is common

-Dx—

-clinical



-Cxray—wont show much

-sputum gram stain—no use

-most common bacteria are

-H Flu


-S Pneumo

-M Cat


-Tx—

-rest


-fluids

-antipyretic-analgesics—APAP, Motrin

-cough suppressants—dextromethorphan

-antibiotics—debateable—age, etc

-healthy

-watch and wait

-Bactrim—good to start with

-Doxycycline

-sick

-Macrolides



-Augmentin

-Quniolones (Floxin)


COPD—

-chronic bronchitis—cough for at least 3 months q year for 2 years (3?)

-Dx—

-breath sounds diminished or absent



-ronchi—between rales and wheezing

-commonly can get CHF from an acute exacerbation of chronic bronchitis which may appear clinically different such as

-S4

-presence of pedal edema



-pleural effusion on Cxray

-Tx of COPD—

-Atrovent

-B2 agonists

-Theophylline

-Inhaled corticosteroids—bigger role in asthma

-acute, short term PO steroids

-long term prednisone

-O2
Pneumonia—

-Pathogens—

-S. Pneumo

-H flu—more smokers

-Legionella

-chlamydia

-moraxella—these last three more common in younger—atypical (walking) pneumonia

-Hospital-acquired pathogens—

-Klebsiella

-H flu


-S pneumo

-S aureus

-Dx—

-frequently non-specific hx



-PE—

-dull percussion

-increased fremitus

-bronchial breath sounds

-Cxray

-CBC


-Sputum culture

-Tx—


-hospitalized or not

-prevention-pneumovax


Influenza—

Tx—


-rest

-keep warm

-drink plenty of fluids

-rimantidine

-amantidine

-prevention—

-flu shot in early November—takes 2 weeks to increase the antibodies
UTI—

-stasis, etc

-urosepsis—

>50% sepsis in elderly

-RF—age, UTI

-Asymptomatic Bacteriuria—

-not associated with development of renal failure

-increased mortality

-most authorities recommend not to treat it

-if have associated pyuria—probably should treat (>5wbc)

-treat it with—

-bactrim


-macrodantin

-noroxin


-Presentation of UTIs in the elderly—

-may be typical with sx such as:

-altered mental status

-decreased level of functioning

-lethargy

-anorexia

-general malaise

-when testing you do want—UA with C&S, cath in women?

-Tx—

-antibiotics for 10d



-repeat UA within 2 weeks

-if recurrent UTIs or treatment failuresconsider further work-up and/or referral

Polymyalgia Rheumatica—

-dz of elderly

-almost always >50yo—usu 60-75

-more caucasian and female

-chronic if not tx properly

-Pathogenesis—

-idiopathic

-may be genetic and immunological

-Presentation—

-gradual onset (weeks to months); can be acute—less common

-bilateral pain and stiffness of:

-shoulder—classic

-neck

-hip


-thigh

-can be unilateral and progress to bilateral

-morning stiffness

-pain with movement

-low grade fever

-weight loss

-fatigue

-generalized—no focal tenderness

-Dx—

-clinical dx—but look for:



-bilateral pain for at least 1 month in any two of the following in association with morning stiffness:

-neck


-shoulder girdle

-hip girdle

-ESR >40

-age >50


-exclusion of other dxs

-marked clinical improvement in response to 1week of <15mg/d of prednisone

-Tx—

-prednisone—10-15mg/d at least for 1year



-may be tapered once ESR and sx decrease

-maintenance dose—prednisone 5-10mg for a year or longer (2-3)

-relapse common
Temporal Arteritis—

-idiopathic

-if miss10-20% will go blind in that eye

-Bx vessel

-infl of vasculatureinfiltrative lymphocytes in vessel wallssx result of the direct inflammation

-decreased size of vesseldecrease flowischemia

gyne cell arteritis—another name—

-Presentation—

-gradual onset

-HA—unilateral—piercing/throbbing

-low grade fever

-scalp tenderness

-fatigue

-malaise


-weight loss

-masseter claudication—50-55% specific

-visual loss

-Dx—


-keep high index of suspicion

-any three of the following

-age of onset >50

-new onset or new type HA

-temporal artery tenderness

-ESR >50 (can be up to 100—higher than PM)

-temporal artery bx showing evidence of characteristic changes

-rapid improvement in sx following steroids

-many other non-specific

-Tx—


-begin soon

-taper steroids—10%q2weeks to lowest possible maintenance dose

-do until sx and labs are nl

-put in steroids that day

-high suspicion

-don’t wait for the ESR to come backtreat now



-Follow-up—

-AAA
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