The answer to question 1 ANS: A
One instrument that holds promise for rapid screening in primary care is the Mini-Cog (Box 20.4); it takes 2 to 4 minutes to administer, has good sensitivity (76 to 99) and specificity (89 to 96), and has been validated in primary care (Harvan & Cotter 2006). A positive screen on the Mini-Cog requires a more thorough evaluation. The Montreal Cognitive Assessment (MoCA) is the most sensitive instrument for detecting mild cognitive impairment; the MoCA website contains detailed instructions and normative data for the test in 35 languages (
www.mocatest.org).
The answer to question 2 ANS: B
The approach to the physical examination of older adults will not differ greatly from standard examination techniques presented in this text. Some tests of functional ability are not routinely considered in the usual examination of the adult; those are presented in the various sections that follow. With older adults who are debilitated, it is important to focus the examination and reduce extraneous activities and distractions. Whenever possible, begin the examination with maneuvers that can be accomplished with the patient in his or her current position. For example, when the patient arrives to the examination seated in a wheelchair, check vital signs, heart rate, extremities, or anything else that can be done in the seated position first. If a patient's ability to transfer from the wheelchair is in question, observe the transfer before the patient becomes fatigued. The exertion of getting on the examination table could fatigue an individual enough to preclude optimal performance. Likewise, perform all supine or standing examinations together to preserve the patient's stamina. A reordering of the sequence of the examination should be done in a logical and thoughtful manner.
The answer to question 3 ANS: D
For the well elderly, the 10-Minute Screener for Geriatric Conditions is a useful tool for general practice (Bluestein & Rutledge 2006). This brief screening tool (Table 20.2) addresses vision, hearing, leg mobility, urinary incontinence, nutrition and weight loss, memory, depression, and physical disability. Using a combination of subjective and objective measures, the 10-Minute Screener covers all the basic ADL and IADL functions in a manner that fits well within the outpatient examination. A positive screen requires further evaluation, in some cases by a specialist or a geriatric specialist.
The answer to question 4 ANS: D
Trauma, hypertension, or coagulopathy contributes to the avulsion of the anchoring placental villi from the expanding lower uterine segment, which, in turn, leads to bleeding into the decidua basalis. This can push the placenta away from the uterus and cause further bleeding. Bleeding through the vagina, called overt or external bleeding, occurs 80 of the time, though sometimes the blood will pool behind the placenta, known as concealed or internal placental abruption. Women may present with vaginal bleeding, abdominal or back pain, abnormal or premature contractions, and fetal distress or death.
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