Geriatrics MCH-

Geri phone 8210

Orthopnea- Dr John likes to ask about number of pillows

Heart Sounds:
S3- dilated cardiomyopathy
S4- HOCM

Edema: Dr. John doesn't like the subjective edema scale that nurses use
1- feet below ankles
2- calf and below
3- thigh and below
4- sacrum
5- anisarca

PNEUMONIA DOESN'T WHEEZE

Wheezing- COPD, asthma
Crackles- like rice crispies- CHF, pleural effusion, fluid

Muscle Strength:
1-twitch
2- no gravity
3- gravity, no resistance
4- gravity, some resistance
5- gravity, full resistance

HCT is 3-3.5 x Hb

BUN/Cr Ratio:
>20- Prerenal- decreased renal blood flow, as in shock, hypotension- decreased GFR- CHF
<15- Renal- intrinsic renal disease- ATN, ischemia, toxins- decreased GFR, urine with casts
15-20- Postrenal- outflow obstruction, such as stones, BPH, neoplasia, congenital anomalies (BILAT)

Troponin- Most sensitive and specific- lasts 7 days- most important after first 7 hours, peaks at 12
CKMB- same time as Troponin- lasts 3 days- good for a second MI at the 4-5 day mark
Myoglobin- fastest but least specific

INR- warfarin- range 2-3, or 2.5-3.5 with mechanical valve

aPTT- heparin- 20-35 sec
DR JOHN LOVES PT!!! PT- 11-15 sec

OLD NOMENCLATURE:
SGOT is = AST
SGPT is = ALT

If AST:ALT is >2:1, suspect alcohol (AST>ALT)

If ALT>ALT, suspect NAFLD
To diagnose a UTI:
1- WBC 40-60
2- Bacteria- count
3- Leukocyte Esterase- MOST SENSITIVE
4- Nitrates- MOST SPECIFIC- gram negatives, like e. coli

Ejection Fraction: >40% diastolic failure, or normal

<40% systolic heart failure

3 Paragraphs for d/c summary:

Why were they here?
What did we do?
What will we do later?

2 Paragraphs for HPI:

Where they came from, and why they are here\

Fluid Rates: 40 mL/hr = 1 L per day- This is a COMMON TRAP on geri/inpatient rotations- if you
write for a bunch of fluid (80/hr or 120/hr or, god forbid, wide open) keep an eye on the TOTAL
volume you are giving the patient each day.

Dr John loves to ask inane questions like this:

5 mL per teaspoon
15 mL per tablespoon
30 mL per ounce

John Ferretti Murmur Scale- HE ONLY ACCEPTS THESE DESCRIPTORS:

Murmurs: I: Listen to hear, II: easily heard at bedside, III: bounding (between 2 and 4), IV: palpable
thrill, V: steth tilted partway off the chest, VI: steth completely off chest
-it is very rare to find a murmur that is grade IV. Dr. John will tell you he has NEVER heard a grade V
or VI

Diastolic Failure: concentric hypertrophy with decreased compliance and abnormal filling
ONE HALF OF CHF PATIENTS HAVE PRESERVED EJECTION FRACTION
-pulmonary venous pressure is increased

SIRS Criteria: SIRS IS A BIG PAYOUT DIAGNOSIS

-Temp >38.3 or <36 (100.7)
-HR >90
-Tachypnea >20
-acute mental status change (not for billing)
-WBC >12,000 (cytosis) or <4000 (penia)- normal but with >10% immature
-CRP>2 standard deviations above normal
-Hypotension
Inflammation: vasodilation, leukocyte accumulation, increased permeability

Oxygen- for survival benefit, must be on for 15 hours

-Dr John will ask you why a patient is on oxygen, if they have it at home, how much at home, if we are
planning to wean, etc. Remember that O2 lines are a trip and fall risk! Tethers are always bad!
CHADSII- Warfarin for AFIB
-CHF
-AGE >75
-DM
-HTN >140/90
-STROKE (worth 2)
0- none or ASN
1- moderate- ASN or warfarin
2+ moderate or high- warfarin

Zosyn= piperacillin+tazobactam
Unasyn= ampicillin+sulbactam

Hyperkalemia- Give calcium gluconate, insulin/glucose, kayexalate, dialysis- PLEASE remember that
kayexalate takes a long time. The calcium in CaGluconate is there to stabilize the myocardium. DO
NOT FREAK OUT ABOUT HYPERKALEMIA UNTIL YOU SEE EKG CHANGES. If a K result
comes back “too high to count” or something, draw it again. The sample is most likely hemolyzed

Lewy Body Dementia- NO NEUROLEPTICS (chlorpromazine, haldol, thioridazine) or antiemetics

Eyes- OU- both- uterque

OD- right
OS- left

Exemptions outside of per-diem payment for patient in the TCU/Manor (?Geriopolis): Cardiac Cath,
CT, MRI, Ambulatory Surgery in OR, EMS- what these 5 exemptions mean is that they are the only
things that insurance will pay for in addition to the Per-Diem rate for a long term care stay. This is why
we don't do portable chest x-rays in the TCU (or shouldn't)- the TCU won't get any more money for
that patient to pay for the chest x-ray. Send them through the ER!!

Daily fluid intake is 20-25% from food- Dr John loves questions like this!

Hb increases 1-1.5 per unit of PRBCs

-Also, never forget that a difference between 9.8 one day and 8.9 the next MAY NOT be clinically
significant as the range of lab error is about 1 point on the Hb.

Be cool, and don't transfuse anyone that is over 8 unless they have severe coronary disease or you are
effing positive they are bleeding from somewhere and you haven't been able to stop it yet.

The definition of alcoholism in the elderly >2 drinks per day

Penicillin allergic patients may cross-react with cephalosporins. MAY

Don't ever put rubs or gallops for a cardio exam- Dr John doesn't like these terms as they are too
ambiguous.

NEVER EVER EVER put RRR (regular rate and rhythm) - what is a regular rate? No such thing,
since rate is a number. Always “rate 78 bpm, rhythm is sinus” or “ rate is 120 bpm, rhythm is
irregularly irregular (afib)

Dr Johns definition of SENSITIVITY: The ability of a test to be positive in a patient that HAS the
disease

Dr Johns definition of SPECIFICITY: The ability of a test to be negative in a patient WITHOUT the
disease

Aortic Stenosis- -crescendo-decrescedo SEM after the leaflets stop- right second intercostal space-
radiates to carotids
-the BIG 3 for aortic stenosis -syncope, CHF, angina
-pulsus parvus et tardus- weak and late- delayed slow-rising carotid upstroke
-PULSUS BISFERIOUS- double-striking- at radial artery- aortic stenosis
-normal aortic valve diameter 3-4 cm
-symptomatic when the diameter of the aorta is less than 1 cm^2 OR velocity > 4 OR gradient >40
-life expectancy of 3-5 years if untreated
-mild >1.5 -moderate 1-1.5 -severe <1 all in cm^2

Indications for an IVC filter-

-acute thromboembolism with contraindication to anticoagulation (surgery, stroke, active bleed)
-failed ASN, plavix, or warfarin
-prophylaxis in spinal, neuro, or bariatric surgery

PROXIMAL DVT ARE WORSE THAN DISTAL!!

Aortic Regurgitation- left ventricular dilatation and hypertrophy, reduced systolic function and stroke
volume, increased PULSE PRESSURE
-Bounding, “Water Hammer” Pulse-
-murmur is diastolic, lower left sternal border- HAVE PT LEAN FORWARD

Vascular Dementia- multiple strokes- mild cognitive impairment, multiple infarcts, lateralization signs,
pts have BETTER RECALL THAN ALZHEIMER DEMENTIA

Alzheimer Dementia- most notable is memory loss- treat with Acetylcholinesterase inhibitors like
tacrine, rivastigmine, galantamine, donepezil
-also treat with NMDA antagonist- memantine (namenda)
-diffuse atrophy on imaging

Lewy Body Dementia- reduction in EXECUTIVE function- planning, analysis, abstract thinking
-SENSITIVE TO NEUROLEPTICS AND ANTIEMETICS- give no chlorpromazine, haldol,
thioridazone- they cause catatonia and further cognitive decline
-general loss of cholinergic neurons- buzzwords are Alpha synuclein and ubuiquitin
Frontotemporal Dementia- Dz of higher level processing- frontotemporal atrophy on imaging- also
called “Pick Disease”- remember palmomental reflex
Sliding hiatal hernia causes Cameron's Erosions- a source of chronic blood loss and anemia-
-treat with iron supplements plus PPI

If you suspect osteomyelitis, get a SED RATE but confirm with imaging.

Fever of Unknown Origin- 3 weeks or more, >101 degree fever on several occasions, > 1 week
diagnostic workup without solution
-1 week intensive outpatient workup or 3 days in hospital

Fluoroquinolone antibiotics are equally bioavailable if given PO or ORAL

Most common cause of post-op ileus = ELECTROLYTE ABNORMALITIES

From Dr. John Czarnecki:

-When ordering NS or 1/2 NS with K+, only add the potassium after 1st void in hospital to make sure
the patient has adequate urine OP and kidney function