Constipation
Thyroid/Adrenal
Elder Patient

CHAPTER 25
CHAPTER 126
CHAPTER 181

20 November 2013
1. Which of the following is not
correct?
A. Most cases of thyrotoxicosis are due to

autoimmune disease.
B. Hypothyroidis...
2. Which of the following statements
regarding thyroid storm is correct?
A. Administration of iodinated contrast
material ...
3. A 24 year old female presents with an acute overdose of
her mother’s synthroid. She has a normal mental status
V/S : BP...
4. Which is the best ED screening test
for hypothyroidism ?
•
•
•
•

A. T3
B. T4
C. TSH
D. TBG (thyroid binding globulin)
5. When treating a patient with
diagnosed myxedema coma which is
not correct?
• A. Accucheck and airway management are
par...
6. A 65 year old female on chronic
steroids presents to the ED with
altered mental status and
hypotension, which is true?
...
7. A 4 year old female with congenital
adrenal hyperplasia presents to the
ED with altered mental status and
hypotension, ...
8. An 85 year old male presents with 7 days of
constipation and bloating. He does not have any pain,
which test should be ...
9. An 85 year old female presents to the
emergency department with acute
abdominal pain. Which is correct?
• A. Her chance...
10. The most common atypical
presentation of an acute MI in the
elderly is:
•
•
•
•

A. Dizziness
B. Shortness of breath
C...
1.Which of the following is not
correct?
A. Most cases of thyrotoxicosis are due to

autoimmune disease.
B. Hypothyroidism...
Meet your thyroid!
• Purpose
– To influence the metabolism of cells by
increasing their basal metabolic rate
– Other roles...
Hyperthyroidism
• Condition caused by overproduction and
increased circulation of thyroid hormone
Hypothalamic-Pituitary Thyroid Axis
Causes of TRH release
• Low T3 T4
• Exercise
• Stress
• Sleep
• Malnutrition
• Hypogly...
Thyroid Hormone
• Triiodothyronine (T3)
– Only 20% of circulating T3 was secreted
– 80% peripheral conversion from T4 (liv...
Beta Receptor Effect
• Beta agonist effect-dramatic increase in
response
– Increases the expression of Beta receptors
– In...
Spectrum of Hyperthyroid Disease

Sub-clinical

Thyrotoxicosis

Thyroid Storm
Causes of Hyperthyroidism
• Grave’s Disease
– Most common form of hyperthyroidism
– Antibodies formed to the TSH receptor
...
Causes of Hyperthyroidism
• Toxic Adenoma- hot nodule
• Thyroiditis
– Hashimoto’s
– Post-partum thyroiditis
• 5-10% of pre...
Thyrotoxicosis Sx’s
•
•
•
•
•

Constitutional
Hypermetabolic
CV
Psychiatric
Muscular/Neuro
– Proximal muscle groups
– Poor...
Cardinal Exam Findings
• V/S: Tachycardia (most common rhythm
disturbance), widened pulse pressure
• CV: Systolic flow mur...
Pemberton’s Sign
2. Which of the following statements
regarding thyroid storm is correct?
A. Administration of iodinated contrast
material ...
Thyroid Storm
• Definition
NB ! – Thyrotoxicosis with mental status changes
DDX for Thyroid Storm
•
•
•
•
•
•
•
•

Sepsis
Sympathomimetic ingestion
Heat Stroke
DT’s
MH
Neuroleptic malignant syndrome...
Can’t Miss
Precipitants of Thyroid Storm
•
•
•
•
•
•
•

STEMI
Sepsis
Stroke
Hypoglycemia/DKA
Mesenteric Ischemia
Toxemia
P...
Other important precipitants
• Iodinated contrast agents
• Drugs
–
–
–
–
–

Amiodarone
Lithium
Anesthetic agents
Pseudoeph...
Diagnosis
• Primary clinical
• Persistent tachycardia
• Lab testing in the ED
– Low TSH
– Free T3 Free T4 not necessary fo...
Thyroid-Directed Treatment
4 Goals
•
•
•
•

Identify and treat precipitant
Reduce thyroid hormone production
Prevent relea...
Treatment of Thyroid Storm
• Supportive
– Airway management
– Cooling (no ASA)
– Fluids
– Glucose and electrolyte controls...
Symptomatic Treatment
Beta blockade – blocks adrenergic effects
– Propanolol
• 60-80 mg po q 6-12 hours
• IV test dose 0.5...
Inhibition of Thyroid Hormone
Synthesis
• Propylthiouracil or methimazole
– Blocks synthesis
– PTU also blocks peripheral ...
Inhibition of thyroid hormone release
• Iodine
– SSKI 5 gtts PO/NGT/PR

• Lithium for Iodine allergic or best for:
– IV co...
Blocking peripheral conversion
• Corticosteroids
– Adrenal insufficiency can be seen in thyroid
storm because of increased...
3. A 24 year old female presents with an acute overdose of
her mother’s synthroid. She has a normal mental status
V/S : BP...
A 24 year old female presents with an acute overdose of
her mother’s synthroid. She has a normal mental status
V/S : BP 17...
Factitious Thyrotoxicosis
(Thyrotoxicosis Factitia)
•
•
•
•

Self-ingested hormone
Beta blockers
Cholestyramine to block G...
4. Which is the best ED screening test
for hypothyroidism ?
•
•
•
•

A. T3
B. T4
C. TSH
D. TBG (thyroid binding globulin)
Hypothyroidism
• Most common functional disorder of the
thyroid
• 5 times more common than Hyperthyroidism
• More common i...
Hypothyroidism
Pathophysiology
• Primary
– Intrinsic gland failure 95-99% of cases
– Previous treatment of hyperthyroidism...
Thyroid physiology in pregnancy
• Increased estrogen - increased TBG and
lowered T4 levels
• HCG and TSH have identical s...
Hypothyroidism
• Constitutional
• Hypometabolic
– Cold intolerance
– Weight gain, but increased appetite

• Proximal myopa...
Myxedema Coma
•
•
•
•
•
•

Elderly female in the winter
Hypothermia
Altered mental status
Hypotension
Bradycardia
Other cl...
Can’t Miss
Precipitants of Myxedema Coma
•
•
•
•
•

STEMI
Sepsis (especially pneumonia)
Stroke
Hypoglycemia/DKA
GI Bleed
When treating a patient with
diagnosed myxedema coma which is
not correct?
• A. Accucheck and airway management are
paramo...
Treatment of Myxedema
• Airway and supportive
– IV fluids
– Passive warming

• Seek out and treat underlying cause!
• Thyr...
Adrenal Insufficiency
Cortex: Cortisol

Medulla: Release
of EPI/ NE
Adrenal Gland
• Medulla
– Controlled by sympathetic NS
– Secretes epi and NE

• Cortex
– Secrete corticosteroids
• Glucoco...
6. A 65 year old female on chronic
steroids presents to the ED with
altered mental status and
hypotension, which is true?
...
7. A 4 year old female with congenital
adrenal hyperplasia presents to the
ED with altered mental status and
hypotension, ...
Adrenal Insufficiency
• Primary – More pronounced clinical symtoms
– Addison’s
– Failure of the adrenal gland to produce c...
Acute vs. Chronic
• Acute
– Most common cause is exogenous administration
of glucocorticoids which suppresses the HPA axis...
Clinical presentation
• General
– Weakness, fatigue

• GI:
– N/V
– Anorexia
– Abdominal pain/ cramps

• Dizziness
Labs in Adrenal Insufficiency
• K+
– Elevated in Primary (65%)
– Not elevated in secondary

• Glucose
– Primary- mild
– Se...
Adrenal Crisis
• Refractory hypotension is the hallmark of
Adrenal Crisis
– Sometimes the only clue

• Treatment
– Hydroco...
Elderly
• Problem of Polypharmacy
• Physiologic changes of aging
• Cardnial presentations not present
– Sepsis
– MI

• Abd...
9. An 85 year old female presents to the
emergency department with acute
abdominal pain. Which is correct?
• A. Her chance...
Physiology of aging
• CNS
– B/B barrier ---risk of meningitis
– Impaired thermoregulation
– Altered autonomic nervous syst...
Physiology of aging
• Pulmonary
– Decreased
•
•
•
•

Vital capacity
Compliance
Chemoreceptor response to hypoxia/hypercapn...
Psychosocial Issues
• ETOH dependence
• Depression
– Manifests as agitation or somatic complaints

• Sundown syndrome
– Se...
Pharmacy issues in elderly
• Polypharmacy
– Elders consume 30% of the drugs in the US
– Drug-drug interactions

• 12-30% o...
Inappropriate Medications
•
•
•
•
•

Narcotics (tylenol is best for pain)
NSAIDS
Muscle relaxers
Any sedative hypnotics
An...
Unique Clinical Aspects
• Hx
– Cognitive defects
– Sensory impairment
• Loss of high-frequency hearing

– Physical impairm...
Exam
• Tachycardia often absent
• Blunted response to infection
– 30% no fever
– Rectal temps

• When fever present, 89% h...
10. The most common atypical
presentation of an acute MI in the
elderly is:
•
•
•
•

A. Dizziness
B. Shortness of breath
C...
The most common atypical
presentation of an acute MI in the
elderly is:
•
•
•
•

A. Dizziness
B. Shortness of breath
C. Na...
Specific Conditions
• MI
–
–
–
–
–

Painless presentation increases with age
Acute onset of dyspnea
Syncope
Weakness/dizzi...
An 85 year old male presents with 7 days of
constipation and bloating. He does not have any pain,
which test should be don...
Constipation
US
ACES: Constipation / Thyroid-Adrenal / Elderly
ACES: Constipation / Thyroid-Adrenal / Elderly
ACES: Constipation / Thyroid-Adrenal / Elderly
Upcoming SlideShare
Loading in...5
×

ACES: Constipation / Thyroid-Adrenal / Elderly

430
-1

Published on

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
430
On Slideshare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
8
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

ACES: Constipation / Thyroid-Adrenal / Elderly

  1. 1. Constipation Thyroid/Adrenal Elder Patient CHAPTER 25 CHAPTER 126 CHAPTER 181 20 November 2013
  2. 2. 1. Which of the following is not correct? A. Most cases of thyrotoxicosis are due to autoimmune disease. B. Hypothyroidism is more common than hyperthyroidism. C. Thyrotoxicosis is less common in men. D. Mental status changes distinguish between hyperthyroidism and thyrotoxicosis. E. Both Amiodarone and Lithium can cause a drug-induced thyrotoxicosis.
  3. 3. 2. Which of the following statements regarding thyroid storm is correct? A. Administration of iodinated contrast material is a precipitating factor. B. An elevated thyroxine-stimulating hormone level is expected. C. Corticosteroid administration is contraindicated. D. Iodine should be given before propylthiouracil. E. Lithium is relatively contraindicated
  4. 4. 3. A 24 year old female presents with an acute overdose of her mother’s synthroid. She has a normal mental status V/S : BP 176/90, P-130 reg, Temp= 99.0 Which of the following does not have a role in her treatment? A. B. C. D. E. Testing for co-ingestions PTU Inderal Steroids Cholestyramine
  5. 5. 4. Which is the best ED screening test for hypothyroidism ? • • • • A. T3 B. T4 C. TSH D. TBG (thyroid binding globulin)
  6. 6. 5. When treating a patient with diagnosed myxedema coma which is not correct? • A. Accucheck and airway management are paramount. • B. Steroids may play a role in treatment • C. IV T4 should not be used in older patients. • D. IV T3 should not be used in older patients. • E. The precipitating event is important to identify and treat.
  7. 7. 6. A 65 year old female on chronic steroids presents to the ED with altered mental status and hypotension, which is true? • A. She is more likely to have a low sodium and a high potassium, and a low glucose. • B. She is more likely to have a low sodium and a normal potassium, and a low glucose. • C. She is more likely to have a low sodium, high potassium, and normal glucose.
  8. 8. 7. A 4 year old female with congenital adrenal hyperplasia presents to the ED with altered mental status and hypotension, which is true? • A. She is more likely to have a low sodium and a high potassium, and a low glucose. • B. She is more likely to have a low sodium and a normal potassium, and a low glucose. • C. She is more likely to have a low sodium, high potassium, and normal glucose.
  9. 9. 8. An 85 year old male presents with 7 days of constipation and bloating. He does not have any pain, which test should be done first to rule out an acute life threat? • • • • • A. Portable flat plate of the abdomen B. Portable 3-way of the abdomen C. Bedside ultrasound D. CT scan of the abdomen E. Rectal exam to rule out fecal impaction
  10. 10. 9. An 85 year old female presents to the emergency department with acute abdominal pain. Which is correct? • A. Her chance of having a surgical cause of her pain is 2 X that of a younger patient. • B. The most common cause in her age group is appendicitis. • C. An EKG is not necessary • D. The presence of a fever doesn’t help distinguish between infectious and noninfectious causes in the elderly.
  11. 11. 10. The most common atypical presentation of an acute MI in the elderly is: • • • • A. Dizziness B. Shortness of breath C. Nausea and vomiting D. Fatigue/weakness
  12. 12. 1.Which of the following is not correct? A. Most cases of thyrotoxicosis are due to autoimmune disease. B. Hypothyroidism is more common than hyperthyroidism. C. Thyrotoxicosis is less common in men. D. Mental status changes distinguish between hyperthyroidism and thyrotoxicosis. E. Both Amiodarone and Lithium can cause a drug-induced thyrotoxicosis.
  13. 13. Meet your thyroid! • Purpose – To influence the metabolism of cells by increasing their basal metabolic rate – Other roles: • Protein synthesis • Synergistic with other hormones ( i.e. Human growth hormone) • Cool fact: – ~100 days of thyroid hormone is stored in the thyroid
  14. 14. Hyperthyroidism • Condition caused by overproduction and increased circulation of thyroid hormone
  15. 15. Hypothalamic-Pituitary Thyroid Axis Causes of TRH release • Low T3 T4 • Exercise • Stress • Sleep • Malnutrition • Hypoglycemia
  16. 16. Thyroid Hormone • Triiodothyronine (T3) – Only 20% of circulating T3 was secreted – 80% peripheral conversion from T4 (liver and skeletal muscle) – T3 is the biologically active hormone NB ! • Thyroxine (T4) • 99% of thyroid hormone is protein bound – Most to Thyroid binding globulin (TBG) • Only Free T3 and T4 are clinically relevant
  17. 17. Beta Receptor Effect • Beta agonist effect-dramatic increase in response – Increases the expression of Beta receptors – Increase Sensitivity of receptors
  18. 18. Spectrum of Hyperthyroid Disease Sub-clinical Thyrotoxicosis Thyroid Storm
  19. 19. Causes of Hyperthyroidism • Grave’s Disease – Most common form of hyperthyroidism – Antibodies formed to the TSH receptor • Toxic Mutinodular Goiter – 2nd leading cause of hyperthyroidism – Multiple autonomously functioning nodules – Females age > 50 – Milder than Graves and more gradual in onset
  20. 20. Causes of Hyperthyroidism • Toxic Adenoma- hot nodule • Thyroiditis – Hashimoto’s – Post-partum thyroiditis • 5-10% of pregnant pts. • 6 wks- 6 months postpartum – – – – – NB ! Trauma Subacute (viral) Suppurative – septic, anterior neck pain Drug-induced- Amiodarone and Lithium Factitious
  21. 21. Thyrotoxicosis Sx’s • • • • • Constitutional Hypermetabolic CV Psychiatric Muscular/Neuro – Proximal muscle groups – Poor exercise intolerance – Thyrotoxic periodic paralysis • Ophthalmologic • Dermatologic (pretibal edema)
  22. 22. Cardinal Exam Findings • V/S: Tachycardia (most common rhythm disturbance), widened pulse pressure • CV: Systolic flow murmur, Afib, systolic rub • Ophthalmologic: lid lag, globe lag, proptosis • Neuro: Tremor, Proximal muscle weakness • Dermatologic: warm, moist skin brittle hair • Neck: thyroid enlargement • Ext: Pre-tibial edema
  23. 23. Pemberton’s Sign
  24. 24. 2. Which of the following statements regarding thyroid storm is correct? A. Administration of iodinated contrast material is a precipitating factor. B. An elevated thyroxine-stimulating hormone level is expected. C. Corticosteroid administration is contraindicated. D. Iodine should be given before propylthiouracil. E. Lithium is relatively contraindicated
  25. 25. Thyroid Storm • Definition NB ! – Thyrotoxicosis with mental status changes
  26. 26. DDX for Thyroid Storm • • • • • • • • Sepsis Sympathomimetic ingestion Heat Stroke DT’s MH Neuroleptic malignant syndrome Pheochromocytosis Withdrawl syndrome
  27. 27. Can’t Miss Precipitants of Thyroid Storm • • • • • • • STEMI Sepsis Stroke Hypoglycemia/DKA Mesenteric Ischemia Toxemia PE
  28. 28. Other important precipitants • Iodinated contrast agents • Drugs – – – – – Amiodarone Lithium Anesthetic agents Pseudoephedrine ASA • Post-partum • Blunt trauma/Vigorous palpation • Burns
  29. 29. Diagnosis • Primary clinical • Persistent tachycardia • Lab testing in the ED – Low TSH – Free T3 Free T4 not necessary for us
  30. 30. Thyroid-Directed Treatment 4 Goals • • • • Identify and treat precipitant Reduce thyroid hormone production Prevent release Block peripheral conversion
  31. 31. Treatment of Thyroid Storm • Supportive – Airway management – Cooling (no ASA) – Fluids – Glucose and electrolyte controls • Aggressive search for precipitating event
  32. 32. Symptomatic Treatment Beta blockade – blocks adrenergic effects – Propanolol • 60-80 mg po q 6-12 hours • IV test dose 0.5-1.0 mg slow IV then 1-2mg q 15 min until HR normal. • Added benefits of blocking peripheral conversion and of being non-selective (helps with tremor) – Esmolol – Metroprolol
  33. 33. Inhibition of Thyroid Hormone Synthesis • Propylthiouracil or methimazole – Blocks synthesis – PTU also blocks peripheral conversion PTU Dose= 600-1000mg loading dose – Then 300 mg q 6 hrs.
  34. 34. Inhibition of thyroid hormone release • Iodine – SSKI 5 gtts PO/NGT/PR • Lithium for Iodine allergic or best for: – IV contrast – Amiodarone • Steroids
  35. 35. Blocking peripheral conversion • Corticosteroids – Adrenal insufficiency can be seen in thyroid storm because of increased cortisol clearance – Hydrocortisone 100mg IV • Propranolol • PTU
  36. 36. 3. A 24 year old female presents with an acute overdose of her mother’s synthroid. She has a normal mental status V/S : BP 176/90, P-130 reg, Temp= 99.0 Which of the following does not have a role in her treatment? A. B. C. D. E. Testing for co-ingestions PTU Inderal Steroids Cholestyramine
  37. 37. A 24 year old female presents with an acute overdose of her mother’s synthroid. She has a normal mental status V/S : BP 176/90, P-130 reg, Temp= 99.0 Which of the following does not have a role in her treatment? A. B. C. D. E. Testing for co-ingestions PTU Inderal Steroids Cholestyramine
  38. 38. Factitious Thyrotoxicosis (Thyrotoxicosis Factitia) • • • • Self-ingested hormone Beta blockers Cholestyramine to block GI absorption No role for PTU
  39. 39. 4. Which is the best ED screening test for hypothyroidism ? • • • • A. T3 B. T4 C. TSH D. TBG (thyroid binding globulin)
  40. 40. Hypothyroidism • Most common functional disorder of the thyroid • 5 times more common than Hyperthyroidism • More common in women
  41. 41. Hypothyroidism Pathophysiology • Primary – Intrinsic gland failure 95-99% of cases – Previous treatment of hyperthyroidism • Central hypothyroidism – Euthyroid sick syndrome – Pituitary disease (adenoma, hemorrhage, infiltrative) – Hypothalamic disease
  42. 42. Thyroid physiology in pregnancy • Increased estrogen - increased TBG and lowered T4 levels • HCG and TSH have identical subunits – Initially an increase in T3 and T4, – Decreased TSH @ 8 wks
  43. 43. Hypothyroidism • Constitutional • Hypometabolic – Cold intolerance – Weight gain, but increased appetite • Proximal myopathy • Hung-up reflexes
  44. 44. Myxedema Coma • • • • • • Elderly female in the winter Hypothermia Altered mental status Hypotension Bradycardia Other clues: – Thyroid scar, myxedema facies (puffy eyelids, large tongue, etc)
  45. 45. Can’t Miss Precipitants of Myxedema Coma • • • • • STEMI Sepsis (especially pneumonia) Stroke Hypoglycemia/DKA GI Bleed
  46. 46. When treating a patient with diagnosed myxedema coma which is not correct? • A. Accucheck and airway management are paramount. • B. Steroids may play a role in treatment • C. IV T4 should not be used in older patients. • D. IV T3 should not be used in older patients. • E. The precipitating event is important to identify and treat.
  47. 47. Treatment of Myxedema • Airway and supportive – IV fluids – Passive warming • Seek out and treat underlying cause! • Thyroid hormone replacement – IV Synthroid- T4 (CV risk factors and elderly • 300-500 microgram bolus – IV Liothyronine-T3 (younger patient) • 10-20 microgram bolus • Hydrocortisone
  48. 48. Adrenal Insufficiency Cortex: Cortisol Medulla: Release of EPI/ NE
  49. 49. Adrenal Gland • Medulla – Controlled by sympathetic NS – Secretes epi and NE • Cortex – Secrete corticosteroids • Glucocorticoids-Cortisol (ACTH) • Mineralcorticoids (Renin-angiotensin system, ACTH) • Adrenal androgens (ACTH)
  50. 50. 6. A 65 year old female on chronic steroids presents to the ED with altered mental status and hypotension, which is true? • A. She is more likely to have a low sodium and a high potassium, and a low glucose. • B. She is more likely to have a low sodium and a normal potassium, and a low glucose. • C. She is more likely to have a low sodium, high potassium, and normal glucose.
  51. 51. 7. A 4 year old female with congenital adrenal hyperplasia presents to the ED with altered mental status and hypotension, which is true? • A. She is more likely to have a low sodium and a high potassium, and a low glucose. • B. She is more likely to have a low sodium and a normal potassium, and a low glucose. • C. She is more likely to have a low sodium, high potassium, and normal glucose.
  52. 52. Adrenal Insufficiency • Primary – More pronounced clinical symtoms – Addison’s – Failure of the adrenal gland to produce cortisol, adldosterone, or both – Intact HPA axis – Low cortisol, high ACTH (melanocyte stimulating hormone stimulated) – Elevated potassium in 65% • Secondary – Impaired stimulation of the adrenals – Disruption of normal secretion of ACTH or Corticotropin-releasing hormone by hypothalmus. – Low cortisol and low ACTH – Potassium normal
  53. 53. Acute vs. Chronic • Acute – Most common cause is exogenous administration of glucocorticoids which suppresses the HPA axis. – Can occur in lower doses but should be expected in 30mg/day over 3 weeks – Etomidate-transient – Other stressors: sepsis, infection, etc.
  54. 54. Clinical presentation • General – Weakness, fatigue • GI: – N/V – Anorexia – Abdominal pain/ cramps • Dizziness
  55. 55. Labs in Adrenal Insufficiency • K+ – Elevated in Primary (65%) – Not elevated in secondary • Glucose – Primary- mild – Secondary-more severe • Hyponatremia – Seen in both (90%)
  56. 56. Adrenal Crisis • Refractory hypotension is the hallmark of Adrenal Crisis – Sometimes the only clue • Treatment – Hydrocortisone 100 mg IV – Dexamethasone 4 mg IV • IV fluids • Correction of electrolyte/glucose abnormalities • Seek out and treat precipitating illness
  57. 57. Elderly • Problem of Polypharmacy • Physiologic changes of aging • Cardnial presentations not present – Sepsis – MI • Abdominal pain often surgical • Trauma patients have worse outcomes
  58. 58. 9. An 85 year old female presents to the emergency department with acute abdominal pain. Which is correct? • A. Her chance of having a surgical cause of her pain is 2 X that of a younger patient. • B. The most common cause in her age group is appendicitis. • C. An EKG is not necessary • D. The presence of a fever doesn’t help distinguish between infectious and noninfectious causes in the elderly.
  59. 59. Physiology of aging • CNS – B/B barrier ---risk of meningitis – Impaired thermoregulation – Altered autonomic nervous system • Sensory deprivation – Hearing, vision • CV – Decreased contractility and ability to increase HR – Poorer organ perfusion
  60. 60. Physiology of aging • Pulmonary – Decreased • • • • Vital capacity Compliance Chemoreceptor response to hypoxia/hypercapnea Ventilation drive • Renal – Less mass – Decreased drug elimination – Altered pharmokinetics • GI – Increased risk of gastric ulcer – Increased risk of perforation – Longer healing times
  61. 61. Psychosocial Issues • ETOH dependence • Depression – Manifests as agitation or somatic complaints • Sundown syndrome – Sensory deprivation
  62. 62. Pharmacy issues in elderly • Polypharmacy – Elders consume 30% of the drugs in the US – Drug-drug interactions • 12-30% of elderly admissions are due to adverse drug reactions • Altered pharmokinetics – – – – GI blood flow Renal clearance Decreased lean body mass Decreased hepatic flow
  63. 63. Inappropriate Medications • • • • • Narcotics (tylenol is best for pain) NSAIDS Muscle relaxers Any sedative hypnotics Antihistamines
  64. 64. Unique Clinical Aspects • Hx – Cognitive defects – Sensory impairment • Loss of high-frequency hearing – Physical impairments • Previous stroke
  65. 65. Exam • Tachycardia often absent • Blunted response to infection – 30% no fever – Rectal temps • When fever present, 89% have infectious cause- Pulmonary>Urinary> others
  66. 66. 10. The most common atypical presentation of an acute MI in the elderly is: • • • • A. Dizziness B. Shortness of breath C. Nausea and vomiting D. Fatigue/weakness
  67. 67. The most common atypical presentation of an acute MI in the elderly is: • • • • A. Dizziness B. Shortness of breath C. Nausea and vomiting D. Fatigue/weakness
  68. 68. Specific Conditions • MI – – – – – Painless presentation increases with age Acute onset of dyspnea Syncope Weakness/dizziness N/V • Abdominal pain – Badness!!! – Cholecystitis most common cause of an acute abdomen • Major Trauma – Higher morbidity and mortality
  69. 69. An 85 year old male presents with 7 days of constipation and bloating. He does not have any pain, which test should be done first to rule out an acute life threat? • • • • • A. Portable flat plate of the abdomen B. Portable 3-way of the abdomen C. Bedside ultrasound D. CT scan of the abdomen E. Rectal exam to rule out fecal impaction
  70. 70. Constipation US
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×