BIOSOFT HELP FILES

1)      Premalatha – 6 yrs – epistaxis – anterior nares – nad, therefore bleeding posterior or sinus origins =>? red flag => onset after 55 yrs => any other ENT sx like tinnitus, ear ache without ear pathology, etc =>

2)      Menorrhagia

3)      Myopia – major symptom blurred distance vision, major sign reduced unaided distance visual acuity

4)      Use FBC as a cancer-detecting tool in the elderly, those with fatigue, low, any bleeding from any orifice,

5)      Some dangerous pediatric symptoms and signs – bulging fontanelle, extensor attacks, persistent vomiting, abnormal increase in head size, arrest or regression of motor development, altered behavior, abnormal eye movements, lack of visual following, poor feeding/failure to thrive, squint,

6)      Get the daily milk requirements from somewhere – in ml/kg/day

7)      Minimum Data Set for acute lower respiratory infection of children – ht, wt, temp, HR, RR, chest in drawing, alveolar rales, cyanosis, nose flaring, grunting, anorexia, wheezing, drowsiness, laryngeal stridor

8)      Common neonatal problems in a pediatric ward – pneumonia (34%), septicemia (12%), meningitis (13.5%), congenital heart disease (6%), congestive cardiac failure (3%), birth asphyxia (8%),  hypocalcemic seizures (3%), bronchiolitis (2%), acute gastroenteritis (2.5%), upper respiratory infection (2.5%), neonatal jaundice (3.5%), miscellaneous (14%)

9)      Some questions to assess the respiratory effort  in children – color changes, cyanosis, respiratory effort, apnea

10)    Careful auscultation of the nose, oropharynx, neck, and chest help locate the site of the stridor

11)    Classic signs of compartment syndrome are – pain out of proportion to the trauma and physical findings, exquisite pain on passive stretch of the muscles of the affected compartment (FitzSimmons and Wardrobe)

12)    Collect some info on necrotizing enterocolitis

13)    ALARMS - Anaemia, Loss of weight, Anorexia or early satiety, Recurrent persistent or poorly controlled symptoms, Mass or Melena, Swallowing difficulties.

14)    Primary survey-positive patients – collapse, shock (pulse < 50 or > 120, SBP < 90), rigid abdomen, heavy vaginal bleeding, complications of labor, airway obstruction (stridor, anaphylaxis, Hx of FB,), Respiratory rate < 10 or > 29, oxygen saturation < 93% on air with no p/h of COPD, altered level of consciousness (GCS < 12 acute deterioration ) (vital signs – pulse, blood pressure, respiratory rate, oxygen saturation, temperature, GCS, - AROPuGST – In primary care common causes of airway obstruction are inhaled FB, epiglottitis, quinsy, anaphylaxis/angioedema, croup, facial fractures ) – symptoms suggestive of primary survey positivity – fainting, postural dizziness, fast breathing, breathing difficulty, noisy breathing, stridor, wheeze, recessions, accessory muscle use, agitation, impending doom, weakness of body, sweating, cold body, pallor, confusion, unresponsiveness,

15)    How to elicit a history of mania – for bipolar disorders – “Have you ever had 4 continuous days when you were feeling so good, high, excited, or hyper, that other people thought you were not your normal self or you got into trouble” and “have you experienced 4 continuous days when you were so irritable that you found yourself shouting at people or starting fights or arguments ” – positive responses for these 2 questions require psychiatric referral

16)    Causes of symptoms – psychological conflicts being manifest as physical symptoms, communication of certain thoughts and feelings in physical symptoms that cannot be expressed verbally, reinforcement and social learning variables, underlying depression, anxiety or abuse, precipitation by a depressing psychological event,

17)    Queer turns – vertigo, seizures, syncope (sudden brief transient loss of consciousness and postural tone from which there is spontaneous recovery), drop attacks (no LOC but loss of  postural tone)

18)    Respiratory distress – CADORA – Cyanosis, Agitation, Dyspnea, Oxygen saturation < 93% in air, Recessions, Accessory muscle use, new additions – grunting, tachypnea, nasal flaring or alar flare,  (TAG)

19)    Early shock – tachycardia, tachypnea, skin mottling, CRD > 2 sec, Intermediate shock – tachycardia, tachypnea, hypotension, cold and pale skin, CRD > 4 secs, Severe shock – bradycardia, bradypnea, hypotension, cold and pale skin, CRD > 6 secs

20)    Ill-Looking Child Syndrome – LAIA-CHEM – Lethargy, Anorexia, Irritability, Apathy (lack of response), CRD > 2 secs, Hypotonia, Eye contact, Moaning

See under hearing loss

1. Wash your hands and don PPE if appropriate.

2. Check the identity of the patient with the ward/nursing staff, and ensure this matches the identity of the patient by checking their wristband.

3. Assess the patient’s response to verbal stimuli e.g. “Hello, Mr Smith, can you hear me?” (response to verbal stimuli is not part of the formal process but is good practice as a first approach to the patient)

4. For a minimum of five minutes, confirm the absence of:

Central pulse on palpation (carotid artery)
Heart sounds on auscultation
Respiratory sounds on auscultation
Signs of life (e.g. movement and respiratory effort)
The carotid pulse can be located between
[The carotid pulse can be located between the larynx and the anterior border of the sternocleidomastoid muscle.]

Asystole on continuous ECG monitoring
Absence of pulsatile flow using direct intra-arterial pressure monitoring
Absence of contractile activity using echocardiography
5. After five minutes of cardiorespiratory arrest, confirm:

a. Bilateral absence of pupillary reflexes using a pen torch (after death, the pupils become fixed and dilated)
b. Bilateral absence of corneal reflexes using a piece of cotton/paper
c. The absence of any motor response to supraorbital pressure

6. The time of death should be recorded as the time at which all these criteria have been confirmed.

DOCUMENTING DEATH CONFIRMATION
Identity confirmed as Grace Smith
DOB 11/06/90 PATIENT ID 555-452-332
The patient is in bed, eyes closed, with no signs of life or respiratory efforts
No palpable carotid pulse for 5 minutes
No heart or respiratory sounds for 5 minutes
Pupils fixed and dilated
No corneal reflex
No reponse to supraorbital pressure
Death confirmed

Age > 50 yrs, abdominal surgery, pelvic surgery, hip surgery, knee surgery, cancer, prolonged travel, major disease, pregnancy, puerperium, fracture, polycythaemia, thrombocytosis, oral contraceptives, antiphospholipid syndrome, nephrotic syndrome, Behcet’s syndrome, congenital coagulation deficits

1)      Mild Dehydration – anorexia, thirst, skin flushing, fatigue, dry eyes and crying with few tears or no tears, slightly dry mouth, irritable

2)      Moderate Dehydration - Sunken appearing eyes, Sluggish or lethargic, Skin feels dry and not springy, tachycardia, tachypnea, reduced sweating, reduced urination, rising body temperature, cramps,

3)      Signs of severe dehydration – Cramps, vomiting, confusion, wrinkled skin, tachycardia, tachypnea, no urine output in 6 hours  When skin is pinched between fingers, it fails to spring back to its original shape  Very lethargic or possibly unconscious

1)      Mild Dehydration - thirst, dry eyes and crying with few tears or no tears, slightly dry mouth, dark urine, fewer wet diapers than usual, less active than usual or irritable, capillary refill delay < 2 secs,  normal respiration, normal BP, normal skin and turgor, child alert, in summary, child is thirsty and reduced urine output

2)      Moderate Dehydration – anorexia, vomiting, Sunken appearing eyes, Sluggish or lethargic, Skin feels dry and not springy, capillary refill delay 2-4 secs, tachypnea, BP postural dop, skin turgor slow, lethargic,

3)      Signs of severe dehydration – food refusal, high temperature, sunken fontanelle (the soft spot on top of the head), capillary refill delay > 2 secs, tachypnea, BP drops, No urine output in 6 hours  When skin is pinched between fingers, it fails to spring back to its original shape and remain tented, Very lethargic or confused, tears absent

1)      Hypovolemic shock

2)      Sepsis syndrome

3)      Fits

1)      Hypovolemic shock

2)      Sepsis syndrome

3)      Any neurological symptom or sign – hypo or hypernatremic dehydration

4)      Loss of  hypertonic fluid, serum Na < 135 meq/L, signs and symptoms of dehydration proportionately more than the fluid loss - Hyponatremic dehydration

5)      Loss of hypotonic fluid, serum Na > 150 meq/L,  signs and symptoms of dehydration proportionately less than the fluid loss - Hypernatremic dehydration

Late-Life Cognitive Activity May Delay Dementia
Taking up reading, puzzles, and games even in one's 80s may provide cognitive protection
Abstract
Objective: To test the hypothesis that a higher level of cognitive activity predicts older age of dementia onset in Alzheimer's disease (AD) dementia.

Methods: As part of a longitudinal cohort study, 1,903 older persons without dementia at enrollment reported their frequency of participation in cognitively stimulating activities. They had annual clinical evaluations to diagnose dementia and AD, and the deceased underwent neuropathologic examination. In analyses, we assessed the relation of baseline cognitive activity to age at diagnosis of incident AD dementia and to postmortem markers of AD and other dementias.

Results: During a mean of 6.8 years of follow-up, 457 individuals were diagnosed with incident AD at a mean age of 88.6 (SD = 6.4; range: 64.1-106.5). In an extended accelerated failure time model, a higher level of baseline cognitive activity (mean 3.2, SD = 0.7) was associated with older age of AD dementia onset (estimate = 0.026; 95% confidence interval: 0.013. 0.039). Low cognitive activity (score = 2.1, 10th percentile) was associated with a mean onset age of 88.6 compared to a mean onset age of 93.6 associated with high cognitive activity (score = 4.0, 90th percentile). Results were comparable in subsequent analyses that adjusted for potentially confounding factors. In 695 participants who died and underwent a neuropathologic examination, cognitive activity was unrelated to postmortem markers of AD and other dementias.

Conclusion: A cognitively active lifestyle in old age may delay the onset of dementia in AD by as much as 5 years.
Cognitive Activity and Onset Age of Incident Alzheimer's Disease Dementia
Robert S. Wilson, Tianhao Wang, Lei Yu, Francine Grodstein, David A. Bennett, Patricia A. Boyle
Neurology Jul 2021, 10.1212/WNL.0000000000012388; DOI: 10.1212/WNL.0000000000012388

Introduction
Some individuals reach ages beyond 100 years and become centenarians with intact cognitive functions,1-5 which indicates that cognitive impairment is not inevitable at extreme ages. Cross-sectional and longitudinal studies in younger age groups (20-90 years) have shown that aging is accompanied by a maintenance in language, semantic knowledge, abstract reasoning, and visuospatial functions, whereas a vulnerability is observed in domains such as processing speed, executive functions, and episodic and working memory.6-11 It is still unclear to what extent individuals who maintain cognitive health until age 100 years escape or delay decline across different cognitive domains. Based on the 40% incidence of dementia at age 100 years, and assuming a continued increase beyond 100, it is to be expected that a decline in cognitive functions will be observable in this age group.12,13

In this study, we aim to identify trajectories of cognitive performance in different domains for cognitively healthy centenarians, and to explore associations with risk factors of cognitive decline, including neuropathology associated with Alzheimer disease (AD) and factors of cognitive reserve.14,15
Beker N, Ganz A, Hulsman M, et al. Association of Cognitive Function Trajectories in Centenarians With Postmortem Neuropathology, Physical Health, and Other Risk Factors for Cognitive Decline. JAMA Netw Open. 2021;4(1):e2031654. doi:10.1001/jamanetworkopen.2020.31654