PANCE Exam: Pediatrics/Geriatrics Review Questions & Answers

PEDIATRICS

Question: Describe some child development stages at the following ages: 1–2 months, 3–5 months, 6–8 months, 9–11 months, 1 year, and 18 months:
1–2 months: Holds head erect, drops toys, follows objects, becomes alert with voices
3–5 months: Reaches for objects and brings to mouth, grasps cube (ulnar first then thumb), laughs, turns from back to side
6–8 months: Reaches with one hand, imitates “bye bye” babbles, inhibited by the word no
9–11 months: Stands alone, imitates peek-a-boo, uses thumb and index to pick up object, follows one step command like “come here”
1 year: Walks independently, says mama and dada, gives toys on request, says one to two words
18 months: Throws ball, sits self on chair, says 4–20 words, feeds self

Question: What are the three possible schedules from which to choose when deciding the set of polio vaccines a child needs?

1. 2 doses of IPV followed by 2 doses of OPV
2. 4 doses of IPV
3. 4 doses of OPV

Question: A child is born to an HBsAg-negative mother. Which vaccine should the child receive?
Recombivax (2.5) or Engerix-B (10). The second dose should be given at least 1 month after the first, and the third dose at least 2 months later (but not before the age of 6 months).

Question: An unvaccinated 13-year-old adolescent comes to your office. Should he receive a hepatitis vaccine if there are no known carriers in his family?
Yes.

Recommended Immunization Schedule for Persons Aged 0 Through 6 Years—United States 2009 For those who fall behind or start late, see the catch-up schedule

This schedule indicates the recommended ages for routine administration of currently licensed vaccines, as of December 1, 2008, for children aged 0 through 6 years. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. Licensed combination vaccines may be used whenever any component of the combination is indicated and other components are not contraindicated and if approved by the Food and Drug Administration for that dose of the series. Providers should consult the relevant Advisory Committee on Immunization Practices statement for detailed recommendations, including high-risk conditions: http://www.cdc.gov/vaccines/pubs/acip-list.htm. Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS). Guidance about how to obtain and complete a VAERS form is available at http://www.vaers.hhs.gov or by telephone, 800-822-7967.

1. Hepatitis B vaccine (HepB). (Minimum age: birth)

At birth:
- Administer monovalent HepB to all newborns before hospital discharge.
- If mother is hepatitis? surface antigen (HBsAg)-positive, administer HepB and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth.
- If mother's HBsAg status is unknown, administer HepB within 12 hours of birth. Determine mother's HBsAg status as soon as possible and, if HBsAg-positive, administer HBIG (no later than age 1 week).

After the birth dose:

- The HepB series should be completed with either monovalent HepB or a combination vaccine containing HepB. The second dose should be administered at age 1 or 2 months. The final dose should be administered no earlier than age 24 weeks.

- Infants born to? BsAg-positive mothers should be tested for HBsAg and antibody to HBsAg (anti-HBs) after completion of at least 3 doses of the HepB series, at age 9 through 18 months (generally at the next well-child visit).

4-month dose:
- Administration of 4 doses of HepB to infants is permissible when combination vaccines containing HepB are administered after the birth dose.

Question: 2. Rotavirus vaccine (RV).(Minimum age: 6 weeks)

- Administer the first dose at age 6 through 14 weeks (maximum age:
   14 weeks 6 days). Vaccination should not be initiated for infants aged
   15 weeks or older (i.e., 15 weeks 0 days or older).

- Administer the final dose in the series by age 8 months 0 days.
- If Rotarix® is administered at ages 2 and 4 months, a dose at 6 months is not indicated.

3. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP).(Minimum age: 6 weeks)

- The fourth dose may be administered as early as age 12 months, provided
    at least 6 months have elapsed since the third dose.

- Administer the final dose in the series at age 4 through 6 years.

4. Haemophilus influenzae type b conjugate vaccine (Hib).(Minimum age: 6 weeks)

- If PRP-OMP (PedvaxHIB® or Comvax® [HepB-Hib]) is administered at ages
    2 and 4 months, a dose at age 6 months is not indicated.

- TriHiBit® (DTaP/Hib) should not be used for doses at ages 2,4, or 6 months
    but can be used as the final dose in children aged 12 months or older.

5. Pneumococcal vaccine.(Minimum age: 6 weeks for pneumococcal conjugate vaccine [PCV]; 2 years for pneumococcal polysaccharide vaccine [PPSV])

- PCV is recommended for all children aged younger than 5 years.
   Administer 1 dose of PCV to all healthy children aged 24 through 59 months who are not completely vaccinated for their age.

- Administer PPSV to children aged 2 years or older with certain underlying medical conditions (see MMWR
2000;49[No. RR-9]), including a cochlear implant.

6. Influenza vaccine. (Minimum age: 6 months for trivalent inactivated influenza vaccine [TIV]; 2 years for live, attenuated influenza vaccine [LAIV])

- Administer annually to children aged 6 months through 18 years.

- For healthy nonpregnant persons (i.e., those who do not have underlying medical conditions that predispose them to influenza complications) aged 2 through 49 years, either LAIV or TIV may be used.

- Children receiving TIV should receive 0.25 mL if aged 6 through 35 months or 0.5 mL if aged 3 years or older.
- Administer 2 doses (separated by at least 4 weeks) to children aged younger than 9 years who are receiving influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza season but only received 1 dose.

7. Measles, mumps, and rubella vaccine (MMR). (Minimum age: 12 months)

- Administer the second dose at age 4 through 6 years. However, the second dose may be administered before age 4, provided at least 28 days have elapsed since the first dose.

8. Varicella vaccine. (Minimum age: 12 months)

- Administer the second dose at age 4 through 6 years. However, the second dose may be administered before age 4, provided at least 3 months have elapsed since the first dose.

- For children aged 12 months through 12 years the minimum interval between doses is 3 months. However, if the second dose was administeredat least 28 days after the first dose, it can be accepted as valid.

9. Hepatitis A vaccine (HepA). (Minimum age: 12 months)

- Administer to all children aged 1 year (i.e., aged 12 through 23 months). Administer 2 doses at least 6 months apart.

- Children not fully vaccinated by age 2 years can be vaccinated at subsequent visits.

- HepA also is recommended for children older than 1 year who live in areas where vaccination programs target older children or who are at increased risk of infection. See MMWR2006;55(No. RR-7).

10. Meningococcal vaccine. (Minimum age: 2 years for meningococcal conjugate vaccine [MCV] and for meningococcal polysaccharide vaccine [MPSV])

- Administer MCV to children aged 2 through 10 years with terminal complement component deficiency, anatomic or functional asplenia, and certain other high-risk groups. See MMWR2005;54(No. RR-7).

- Persons who received MPSV 3 or more years previously and who remain at increased risk for meningococcal disease should be revaccinated with MCV.

The Recommended Immunization Schedules for Persons Aged 0 Through 18 Years are approved by the Advisory Committee on Immunization Practices (www.cdc.gov/vaccines/recs/acip), the American Academy of Pediatrics (http://www.aap.org), and the American Academy of Family Physicians (http://www.aafp.org). DEPARTMENT OF HEALTH AND HUMAN SERVICES · CENTERS FOR DISEASE CONTROL AND PREVENTION

Recommended Immunization Schedule for Persons Aged 7 Through 18 Years—United States - 2009 For those who fall behind or start late, see the schedule below and the catch-up schedule

This schedule indicates the recommended ages for routine administration of currently licensed vaccines, as of December 1, 2008, for children aged 7 through 18 years. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. Licensed combination vaccines may be used whenever any component of the combination is indicated and other components are not contraindicated and if approved by the Food and Drug Administration for that dose of the series. Providers should consult the relevant Advisory Committee on Immunization Practices statement for detailed recommendations, including high-risk conditions: http://www.cdc.gov/vaccines/pubs/acip-list.htm. Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS). Guidance about how to obtain and complete a VAERS form is available at http://www.vaers.hhs.gov or by telephone, 800-822-7967.

Question: 1. Tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap). (Minimum age: 10 years for BOOSTRIX® and 11 years for ADACEL®)

- Administer at age 11 or 12 years for those who have completed the recommended childhood DTP/DTaP vaccination series and have not received a tetanus and diphtheria toxoid (Td) booster dose.

- Persons aged 13 through 18 years who have not received Tdap should receive a dose.

- A 5-year Interval from the last Td dose is encouraged when Tdap is used as a booster dose; however, a shorter interval may be used if pertussis immunity is needed.

Question: 2. Human papillomavirus vaccine (HPV). (Minimum age: 9 years)

- Administer the first dose to females at age 11 or 12 years.

- Administer the second dose 2 months after the first dose and the third dose 6 months after the first dose (at least 24 weeks after the first dose).

- Administer the series to females at age 13 through 18 years if not previously vaccinated.

Question: 3. Meningococcal conjugate vaccine (MCV).

- Administer at age 11 or 12 years, or at age 13 through 18 years if not previously vaccinated.

- Administer to previously unvaccinated college freshmen living in a dormitory.

- MCV is recommended for children aged 2 through 10 years with terminal complement component deficiency, anatomic or functional asplenia, and certain other groups at high risk. See MMWR
2005;54(No. RR-7).

- Persons who received MPSV 5 or more years previously and remain at increased risk for meningococcal disease should be
revaccinaged with MCV.

Question: 4. Influenza vaccine.

- Administer annually to children aged 6 months through 18 years.

- For healthy nonpregnant persons (i.e., those who do not have underlying medical conditions that predispose them to influenza complications) aged 2 through 49 years, either LAIV or TIV may be used.

- Administer 2 doses (separated by at least 4 weeks) to children aged younger than 9 years who are receiving influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza season but only received 1 dose.

Question: 5. Pneumococcal polysaccharide vaccine (PPSV).

- Administer to children with certain underlying medical conditions (see MMWR
1997;46[No. RR-8]), including a cochlear implant.
A single revaccination should be administered to children with functional or anatomic asplenia or other immunocompromising
condition after 5 years.

Question: 6. Hepatitis A vaccine (HepA).

- Administer 2 doses at least 6 months apart.

- HepA is recommended for children older than 1 year who live in areas where vaccination programs target older children or who are at increased risk of infection. See MMWR
2006;55(No. RR-7).

Question: 7. Hepatitis B vaccine (HepB).

- Administer the 3-dose series to those not previously vaccinated.

- A 2-dose series (separated by at least 4 months) of adult formulation Recombivax HB® is licensed for children aged 11 through 15 years.

Question: 8. Inactivated poliovirus vaccine (IPV).
- For children who received an all-IPV or all-oral poliovirus (OPV) series, a fourth dose is not necessary if the third dose was administered at age 4 years or older.

- If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless of the child’s current age.

Question: 9. Measles, mumps, and rubella vaccine (MMR).

- If not previously vaccinated, administer 2 doses or the second dose for those who have received only 1 dose, with at least 28 days between doses.

Question: 10. Varicella vaccine.

- For persons aged 7 through 18 years without evidence of immunity (see MMWR
2007;56[No. RR-4]), administer 2 doses if not previously vaccinated or the second dose if they have received only 1 dose.

- For persons aged 7 through 12 years, the minimum interval between doses is 3 months. However, if the second dose was administered at least 28 days after the first dose, it can be accepted as valid.

- For persons aged 13 years and older, the minimum interval between doses is 28 days.

The Recommended Immunization Schedules for Persons Aged 0 Through 18 Years are approved by the Advisory Committee on Immunization Practices (www.cdc.gov/vaccines/recs/acip), the American Academy of Pediatrics (http://www.aap.org), and the American Academy of Family Physicians (http://www.aafp.org).
DEPARTMENT OF HEALTH AND HUMAN SERVICES - CENTERS FOR DISEASE CONTROL AND PREVENTION

When is the MMR vaccine given?
The first is given at 12–15 months of age and the second at 4–6 years. Children who have not yet received the second dose should not receive it after they are 11 or 12 years old.

Question: How common is vaccine-associated paralytic polio?
1/2.4 million cases.

Question: Which polio vaccine can induce secondary transmission of vaccine virus?
OPV.

Question: At what age do most children most commonly present with intestinal malrotation? Also, what are the common complications, signs, and symptoms?
Malrotation usually occurs in children younger than 12 months. Volvulus is a common complication. Signs and symptoms include vomiting, blood-streaked stools, and abdominal pain.

Question: What are two unique clinical findings of tetralogy of Fallot?
A boot-shaped heart on X-ray and exercise intolerance that is relieved by squatting. Treat shortness of breath by placing patient in the knee–chest position and administering morphine.

Question: What are the signs of left-sided heart failure in an infant?
Increased respiratory rate, shortness of breath, and sweating during feeding.

Question: What is the most common cause of CHF in the second week of life?
Coarctation of the aorta.

Question: What is the most common cause of pediatric bacteremia?
Streptococcal pneumonia.

Question: What two viral illnesses are prodromes for Reye syndrome?
Varicella (chicken pox) and influenzae B.

Question: What are the signs and symptoms of Reye syndrome?
Irritability, combativeness, lethargy, right upper quadrant tenderness, history of influenzae B or recent chicken pox, papilledema, hypoglycemia, and seizures. Laboratory results reveal hypoglycemia, an ammonia level 20 times greater than normal, and a normal bilirubin level.

Question: Describe the five stages of Reye syndrome:
Stage I: Vomiting, lethargy, and liver dysfunction
Stage II: Disorientation, combativeness, delirium, hyperventilation, increased deep tendon reflexes, liver dysfunction, hyperexcitable, tachypnea, fever, tachycardia, sweating, and pupillary dilatation
Stage III: Coma, decorticate rigidity, increased respiratory rate, and a mortality rate of 50%
Stage IV: Coma, decerebrate posturing, no ocular reflexes, loss of corneal reflexes, and liver damage
Stage V: Loss of deep tendon reflexes, seizures, flaccidity, respiratory arrest, and 95% mortality

What are the first, second, and third drugs of choice for the treatment of seizures in children?
Phenobarbital, phenytoin, and carbamazepine, respectively.

Question: What is the drug of choice for the treatment of a febrile seizure?
Phenobarbital.

Question: Why is diazepam (Valium) avoided in neonatal seizures?
It may cause hyperbilirubinemia by uncoupling the bilirubin–albumin complex.

Question: What is the most common cause of painless lower GI bleeding in an infant or child?
Meckel diverticulum.

Question: A 16-month-old child presents with bilious vomiting, a distended abdomen, and blood in the stool. Diagnosis?
Malrotation of the midgut.

Question: A child presents with periodic abdominal cramps, currant jelly stools, and a sausage-like tumor mass in the right lower quadrant. A contrast X-ray shows a coil spring sign. Diagnosis?
Intussusception.

Question: A child presents with bluish discoloration of the gingiva. Probable diagnosis?
Chronic lead poisoning. Expect the erythrocyte protoporphyrin level to be elevated with this condition.

Question: What is the current therapeutic regimen for treatment of meningitis in a neonate?
Ampicillin and cefotaxime. A combination of these two antibiotics should be used in infants up to 2 months of age to cover coliform, group B streptococci, Listeria, and Enterococcus. In children aged 2 months to 6 years, cefotaxime alone is indicated.

Question: What is the most common cause of abdominal pain in children?
Constipation.

Question: True/False: High fever in neonates with bacterial pneumonia usually follows a period of general fussiness and decreased feeding:
True.

Question: Conjunctivitis is an associated finding in about what percentage of neonates with chlamydial pneumonia?
About 50%.

Question: How many days after birth should newborns stop losing weight?
About 6 days.

True/False: A neonate stool color can be an important sign:
False. Unless blood is evident, stool color is insignificant.

Question: What is the difference between vomiting and regurgitation?
Very little once it’s on you! Vomiting is caused by forceful diaphragmatic and abdominal muscle contraction. Regurgitation occurs without effort.

Question: Is regurgitation dangerous in an otherwise thriving neonate?
No. However, it can be dangerous for newborns with failure to thrive or respiratory problems, and it may be associated with chronic aspiration.

Question: Projectile vomiting in the neonate is often associated with pyloric stenosis. When this is the case, such vomiting becomes a prominent sign at what age?
2–3 weeks.

Question: Infectious diarrhea is usually viral. What are the two most common agents?
Rotavirus and Norwalk agent.

Question: True/False: Bacterial and parasitic etiologies of diarrhea in the neonate are rare:
True.

Question: What are some entities in the differential diagnosis of bloody diarrhea in the neonate?
Necrotizing enterocolitis, bacterial enteritis, allergic reactions to milk, and iatrogenic causes secondary to antibiotics.

Question: What are some of the signs of sepsis to look for in babies with necrotizing enterocolitis?
Poor feeding, lethargy, fever, jaundice, abdominal distention, and poor color.

Question: What should be considered in the case of a neonate who has never passed stool?
Meconium ileus or plug, Hirschsprung disease, intestinal stenosis, or atresia.

Question: Anal stenosis, hypothyroidism, and Hirschsprung disease can all present with what clinical sign?
Constipation, which was not present at birth but began before the infant was 1 month old.

Question: What is normal systolic blood pressure in a newborn?
60 mm Hg.

Question: After the first month of life, what is the cause of meningitis and the number one cause of pneumonia in children?
Meningitis: H. influenzae.
Pneumonia: Streptococcus pneumoniae. H. influenzae is the second most common cause.

Discuss infantile spasms:
Onset is by 3–9 months of age. It typically lasts seconds, and may occur in single episodes or bursts. The EEG is often abnormal. Almost 85% of these patients will be mentally handicapped.

Question: How much does the average teenager grow during adolescence?
Teenagers generally increase their height by 15%–20% and double their weight.

Question: At what age do most people first have intercourse?
Males: 16.1 years. Females: 16.9 years.

Question: By what age do most children stop wetting their beds?
Age 4; 30% of 4 year olds and 10% of 6 year olds still wet their beds.

Question: What is the medical treatment for idiopathic enuresis?
Desmopressin nose drops or imipramine. Most cases eventually resolve spontaneously.

Question: A 6-year-old boy consistently wets his pants. You tell his mother to reward the child with treats and praise during dry periods because this will help reinforce the desired behavior. What is this type of conditioning?
Positive operant conditioning. The basic principles were defined by Pavlov:

Apnea (choanal stenosis)
Tall forehead
Renal/genital anomalies

Beckwith-Wiedemann syndrome
Neoplasm (Wilms tumor or hepatoblastoma)
Bloom syndrome
Skin erythema of face
Cat-eye syndrome
Ear anomalies
Fetal alcohol syndrome
Learning disorder
Fetal rubella syndrome (German measles clinical features)
Small for gestational age
Fragile X syndrome
Ears (enlarged)
Fetal varicella syndrome (clinical features)
Seizure
Pyelonephritis (clinical features in newborn)
Odorous urine

Trisomy 18
Ninety percent die within first year

Turner syndrome
Sexuality (delayed puberty)


GERIATRICS

Question: Describe changes in vital signs in elderly patients.
Blood pressure: Rise in systolic pressure due to arterial stiffening, and a widened pulse pressure. In some patients, orthostatic hypotension is seen.
Heart rate: Usually does not change elderly. Rhythms can change; most common is atrial arrhythmias (atrial fibrillation).
Respiratory rate: Usually remains unchanged.
Temperature: Patients more susceptible to hypothermia.

Question: What is the most common murmur heard in the elderly patient?
Systolic aortic murmur.

Question: What percentage of elderly in the United States are older than 80 years?
About 13%.

Question: Which gender and race has the highest life expectancy?
White women.

Question: What are the two most prevalent diseases in the elderly older than age 60?
Hypertension (60%–84%) and diabetes (18%–21%).

Question: What is the rate of cancer in patients older than age 65?
There is a 10-fold increase.

Question: What are the 3 leading causes of death in the elderly?
Heart disease (33%), cancer (22%), and cerebrovascular accident (8%).

Question: Name the 6 basic activities of daily living (ADLs).

1. Dressing
2. Bathing
3. Feeding
4. Toileting
5. Transferring
6. Ambulating

Question: Name the 7 instrumental activities of daily living (IADLs).

1. Money management
2. Medication administration
3. Using transportation
4. Using the telephone
5. Shopping
6. Housekeeping
7. Meal preparation

Question: At what age should all elderly start receiving an annual influenza vaccine?
65 years of age.

What percentage of the elderly are ambulatory?
90%.

Question: What percentage of the elderly live in nursing homes?
5%.

Question: What is the percentage of elderly older than 65 years who fall and older than 80 years who fall?
About 30% of those older than 65 years fall, and it is 50% when older than 80 years.

Question: Which sex is more likely to have urinary incontinence in the elderly years?
Women. However, as the age goes above 80 years, the percentage is equal.

Question: What is the most common form of incontinence in the elderly?
Urge incontinence. It is more common in women and is due to detrusor hyperreflexia or decreased sensory capabilities.

Question: What drugs are used to treat stress incontinence?
α-Adrenergic agonists and estrogen.

Question: Strokes, Parkinson disease, and Alzheimer disease are most commonly associated with which type of incontinence?
Urge incontinence.

Question: What are some reversible conditions that you should consider that are related to urinary incontinence?
Remember the mnemonic
DRIIIPP:

Delirium
Restricted mobility—illness, injury, gait
Infection
Inflammation—atrophic vaginitis
Impaction
Polyuria
Pharmaceuticals (diuretics, anticholinergics, α-antagonists)

Question: What is the rate of mortality in an elderly patient with a pressure ulcer (bedsore)?
The mortality increases fourfold.

Question: What percentage of women over the age of 80 has osteoporosis?
70%.

Question: What percentage of prostate cancer deaths occur over the age of 65?
92%.

What may result from the administration of an aminoglycoside or cephalosporin to an elderly patient who is dehydrated?
Acute renal failure secondary to tubulointerstitial injury. This may also occur if the above-mentioned drugs are given to an elderly patient on furosemide or with preexisting renal disease.

Question: What is the most common cause of hearing loss in the elderly?
Presbycusis. Other causes include neoplasms, noise exposure, ototoxic drugs, and otosclerosis.

Question: Presbycusis is a hearing loss at which end of the audible range?
The high end (4000–8000 Hz).

Question: Is the incidence of epidural and subdural hematomas higher or lower in elderly patients?
Epidural hematomas are less common and subdural hematomas are more common.

Question: What geriatric population is at greatest risk for esophageal cancer?
Elderly African Americans have a risk four times that of elderly Caucasian Americans. Other populations at risk include Chinese, Iranians, and South Africans.

Question: Who has a higher rupture rate in appendicitis, the very young or the very old?
The very old. The rupture rate for geriatric patients is 65%–90% with an associated mortality of 15%. The pediatric population has a rupture rate of 15%–50% and an associated mortality rate of 3%.

Question: What is sundown syndrome?
Hallucinations and delusions that occur at nighttime because of decreased sensory stimulation.

Question: What is the most common cause of large bowel obstruction in the elderly?
Fecal impaction. Other causes are stenosing diverticula, neoplasms, and volvulus colon. Adhesions are rarely a cause of obstruction in the large bowel.

Question: The most common causes of dysphagia in the elderly population include:
Hiatal hernia, reflux esophagitis, webs/rings, and cancer.

Question: An elderly patient with chronic COPD is most likely to contract what kind of pneumonia?
H. influenzae pneumonia. Ampicillin is the drug of choice. This population is at risk and should be vaccinated.

Question: Giant cell arteritis is a chronic inflammation of the large blood vessels. What arteries are most commonly involved?
The carotid and the cranial arteries. Blindness may result in 20% of afflicted patients. Treat with high dose corticosteroids. Those with a visual component must have an immediate ophthalmologic evaluation.

Question: What are the common neurologic signs and symptoms of giant cell arteritis?
Amaurosis fugax, deafness, depression, and paralysis. Amaurosis fugax is the most dangerous because it can lead to permanent monocular or binocular blindness.

What is the Trendelenburg test for varicose veins?
Raise the leg above the heart, and then quickly lower it. If the leg veins become distended immediately after this test, there is valvular incompetency.

Question: What is the most common cause of cataract development?
Old age. Cataracts occur congenitally, from medication or from trauma. Slit lamp examination may show absent red reflex and a gray clouding of the lens.

Question: What is the most common cause of blindness in the elderly?
Senile macular degeneration. Such patients experience a gradual loss of central vision. The macula appears hemorrhagic or pigmented. This is due to atrophic degeneration of the retinal vessels that results in leaking vessels, fibrosis, and scarring of the retina.

Question: What is the most common nontraumatic cause of dementia?
Alzheimer disease. At 65 years of age, 10% of the population has Alzheimer; by 85 years, 50% does. Multiinfarct dementia is the second most common cause of nontraumatic dementia.

Question: What is the first symptom of Alzheimer disease?
Progressive memory loss. This is followed by disorientation, personality changes, language difficulty, and other symptoms of dementia.

Question: What is the prognosis for patients with Alzheimer disease?
Alzheimer is an irreversible disease. Death occurs 5–10 years after presumptive diagnosis.

Question: Differentiate between dementia and delirium:

Dementia: Irreversible, impaired functioning secondary to changes and deficits in memory, spatial concepts, personality, cognition, language, motor and sensory skills, judgment, or behavior. There is no change in consciousness.

Delirium: A reversible, organic mental syndrome reflecting deficits in attention, organized thinking, orientation, speech, memory, and perception. Patients are frequently confused, anxious, excited, and have hallucinations. A change in consciousness may be evident.

Question: How frequently should a patient at high risk for pressure ulcers be repositioned?
Every 2 hours.

Question: What is the most common complication of a pressure ulcer?
Sepsis.

Question: What is the most common presenting symptom in Parkinson disease:
Tremor. The brain lesion is located in the substantia nigra.

Question: List, by order of initiation, drugs used for the treatment of Parkinson disease?
Start with amantadine (Symmetrel) and trihexyphenidyl (Artane); if this fails, use a combination of levodopa and carbidopa. Pergolide and bromocriptine can be used to treat episodes of immobility.

What is the drug of choice for treating depression in the elderly?
Nortriptyline.

Question: A 65-year-old African American has hypertension and gout. What medications should be prescribed?
Although diuretics are the most effective drugs for the treatment of hypertension in this race, the patient has gout, which will be exacerbated by the use of diuretics. ACE inhibitors or calcium channel blockers are better choices for this patient.

Question: What is the mortality rate for geriatric patients who have sustained a hip fracture?
25% will die in the first year following the fracture.

Question: What is the most common cause of community-acquired pneumonia in the elderly?
Streptococcus pneumoniae.

Question: How do you clinically differentiate between polymyalgia rheumatica and polymyositis?
In polymyositis, there is proximal muscle pain, weakness, and tenderness, and elevated muscle enzymes. In contrast, polymyalgia rheumatica presents with an elevated sedimentation rate (also seen in giant cell arteritis, which is associated with polymyalgia rheumatica).

Question: What are the two pathologic findings used to confirm the diagnosis of Alzheimer disease?
The quantity of neurofibrillary tangles and senile plaques. Other findings include neuronal loss and amyloid degeneration.

Question: What is the most common cause of UTIs in uncatheterized elderly patients?
E. coli.

Question: What is the most common cause of relapsing UTIs in elderly patients?
Chronic bacterial prostatitis, caused by E. coli, Proteus, Klebsiella pneumoniae, and enterococci.

Question: In the elderly, what is a common side effect of verapamil?
Constipation.

Question: What is the most common pathophysiologic cause of delirium?
Acetylcholine deficiency.

Question: Parkinson-like side effects are common with which class of drugs?
Neuroleptics. Parkinson-like side effects can develop with perphenazine, chlorpromazine, reserpine, haloperidol, metoclopramide, and the illicit meperidine analog MPTP.

Question: In the elderly, what is the most common cause of death resulting from community-acquired infections? Institutional? Nosocomial?
In the community and institutions, it is bacterial pneumonia; in hospitals, it is UTIs.

What is the most common cause of drug-induced hallucinations in the geriatric population?
Propranolol.

Question: Why is it unsafe to place a geriatric patient on digoxin and Lasix?
Hypokalemia and digoxin toxicity may result. If this is the best choice for management, careful monitoring of both electrolytes and digoxin levels will be needed.

Question: What percentage of patients with primary Alzheimer disease will present with secondary depression?
30%–35%.

Question: What is the most common cause of abdominal pain in the elderly?
Constipation.

Question: What is the most common risk factor for Alzheimer disease?
A family history of dementia.

Question: An elderly female presents with high blood pressure and a history of CHF. What is the antihypertensive drug of choice?
ACE inhibitors. They will reduce both preload and afterload.

Question: Patients with which type of apolipoprotein are more likely to acquire Alzheimer disease?
Type 4, apolipoprotein E.

Question: An elderly man presents with high blood pressure and a history of NIDDM. What is the antihypertensive drug of choice?
ACE inhibitors. They have renal protective properties.

Question: What is the major risk of tricyclic antidepressants in the elderly?
Orthostatic hypotension because this can lead to falls.

Question: An elderly African American man presents with high blood pressure and a history of angina. What is the antihypertensive drug of choice?
Calcium channel blockers.

Question: What are the most common sources of sepsis in the elderly?
Respiratory > urinary > intra-abdominal.

Question: Describe the common findings of benign essential tremors:
Tremulousness of speech and nodding of head. This is an action tremor that is usually familial and is often treated with atenolol, propranolol, diazepam, and alcohol.

What laboratory values increase with age?
BUN/Cr, sedimentation rate, thyroxine (T4), and calcium (in women).

Question: What laboratory values decrease with age?
Leukocyte count and creatinine phosphokinase.

Question: What is the incidence of morbidity and mortality in patients older than 60 years who present with syncope?
1 in 5 will suffer significant morbidity or mortality within 6 months.

Question: What percentage of septic elderly patients do not present with a fever?
25%.

Question: What drugs are most commonly associated with ADRS in the elderly?
Analgesics, cardiovascular, and psychotropic drugs.

Question: What are the common adverse drug interactions of cimetidine in the elderly?
Cimetidine inhibits the metabolism of phenytoin, Coumadin, and theophylline.

Question: What are the common adverse drug interactions of Coumadin?
Metabolism is inhibited by allopurinol, trimethoprim-sulfamethoxazole, metronidazole, and quinolones.

Question: What is the most common cause of acute abdominal pain in the elderly?
Acute cholecystitis. Approximately 50% of patients older than 65 years have gallstones.

Question: Describe the clinical features of appendicitis in the elderly:
Anorexia and vomiting are less common, and migration of the pain to the RLQ is absent in up to 60% of elderly patients. The elderly account for 50% of the deaths as a result of appendicitis. Half of elderly patients with appendicitis have normal white counts upon presentation.


REFERENCES
Crawford MH. Current Medical Diagnosis and Treatment—Cardiology. 3rd ed. New York, NY: McGraw-Hill; 2009.
Fauci AS, Braunwald E, Kasper DL, et al., eds. Harrison’s Principles of Internal Medicine, 17th ed. New York: McGraw-Hill; 2008. http://www.accessmedicine.com
Hay WW Jr, Levin M, Sondheimer JM, Deterding R. Current Medical Diagnosis and Treatment—Pediatrics. 13th ed. New York, NY: McGraw-Hill; 2009.
McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis and Treatment 2009. New York, NY: McGraw-Hill; 2009.