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The main ideas from this information are: - Left side heart failure causes fluid to back up in the lungs, resulting in congestive heart failure and shortness of breath. - Patients with severe CHF may experience symptoms like coughing up pink frothy sputum, and sitting them up with CPAP can help alleviate the problem. - Proximal nocturnal dyspnea, characterized by sudden respiratory distress when reclining, is a common symptom of CHF. - Stroke is a leading cause of death, with ischemic and hemorrhagic strokes being the two types. - Metabolic risk factors for stroke include smoking, hypertension, and diabetes. - Atrial fibrillation is a major cause of ischemic strokes and can be treated with medication or ablation. - Age, race, and gender are uncontrollable risk factors for stroke. - Signs and symptoms of stroke include altered level of consciousness, numbness or paralysis on one side, slurred speech, visual disturbances, headache or dizziness, and caused by left side or vice versa. With left side heart failure, fluid backs up in the lungs. This is where we get that congestive heart failure. Pulmonary edema with shortness of breath. They're gonna have shortness of breath, especially when they lie down. These patients with severe CHF, when they lie down, they're gonna flash over. They're gonna be coughing up that pink frothy sputum. You sit them up, throw them on CPAP, and you'll fix the problem in two minutes. It'll be amazing. You'll go from night to day in two minutes when CPAP is sitting them up. You gotta get that fluid out of the lungs. PND, proximal not proximal nocturnal dyspnea, characterized by sudden attack of respiratory stress that wakes the person when he or she is reclining. This is why whenever you have a patient that you suspect cardiac issues, especially if you listen to lung sounds and you get crackles or wobbles or fluid, always ask them, how many pillows do you sleep with at night? If they say three or more, they have CHF. That's fluid, and they have to sleep sitting up. Or they might not even say that. They might say, I sleep with my recliner. I'm more comfortable in my recliner. If a patient is sitting in their recliner, they've got fluid. Patients will record coughing, feeling suffocated, and cold sweats, and you will notice the tachycardia. Stroke is the leading cause of death, one of the leading causes of death in older people. We talked about that, and there are the two types. There is the ischemic and hemorrhagic. Ischemic is the lack of blood flow by a blockage. It's just like a heart attack. Hemorrhagic is a rupturing of a blood vessel, and that's the one that is more fatal, right? Almost 90% of strokes are ischemic strokes, but only about 10% are hemorrhagic, but 90% of deaths from strokes are caused by hemorrhagic. So even though they're a small percentage, they're a huge portion of the deaths. So very serious. For metabolic risk factors, smoking. If you smoke, stop. If you don't smoke, don't stop. Don't use nicotine, don't vape. Hypertension. Again, that constant pounding against the iron walls changes the cellular makeup, and makes them more likely to become harder or build up plaques. Diabetes. With treatment, it gets like, it stops right there. What's that? Um, like the hypertension. Stroke? Yeah. You mean a stroke? The hypertension. What about it? Like it stops making it worse, because it makes the veins and the arteries thinner, right? Right, so if you have hypertension over time, it's gonna cause permanent damage. It's gonna change the cellular makeup of the blood vessel. Someone had a stroke already. Is there a possibility of getting it again? Yeah, yeah, very well if we get it again. People who have strokes generally end up on blood thinners to avoid that happening. If you have a stroke, you'll be on blood thinners. Maybe short time, maybe. If you're 80 years old, you have a stroke, you're gonna be on blood thinners. I met a woman that she had 15 strokes. 15? Something, right? That's what she said. She had like something in two. Wow. That she had some kind of other conditions, some kind of clotting abnormality or something. 15 strokes, that's huge. That's huge. Atrial fibrillation, that's one of the number one causes of ischemic strokes is that the pooling of blood in the upper right chamber, upper right portion of the right atria that ends up causing micro clots that travel through obesity and a sedentary lifestyle. Uncontrollable risk factors, age, it's a numbers game. How is atrial fibrillation, it looks like it's preventable. I mean, isn't that more kind of genetic or? Well, atrial fibrillation is preventable because we can treat it with medication and ablation. If you have AFib, you could treat it with medication like Cardizem or Digitalis and take blood thinners. Or you could have an ablation nun. An ablation stops it. So it is treatable if it's balanced. But the number one cause of ischemic strokes is diagnosed or undiagnosed atrial fibrillation. Some people have it and they don't notice it. Uncontrolled risk factors, age, again, it's a numbers game, it's a percentage game. The older you are, the more likely you are to have it. Race, African Americans, Hispanic, Mediterranean, more likely to have it because they generally have a higher blood pressure as well as more cholesterol in their systems. And then gender, men are five times more likely to have a stroke, but women are five times more likely to die from a stroke. Same with heart attacks because women don't recognize the symptoms like men do with babies. Sign of symptoms, acute altered level of consciousness. Maybe, maybe not, maybe it's not acute. Maybe it's just a minor, maybe they just, they forgot something or they misplaced something or they can't think of a word. Numbness, weakness, or paralysis on one side. Numbness or tingering, we call that asthesia. Weakness, we call that paresis. Paralysis, we call it paralysis. If it's on one side, it's hemi. So, hemi-asthesia, hemi-paresis, hemi-paralysis. Slurred speech or difficulty speaking. Slurred speech is dysarthria. Difficulty speaking, you could have that dysphasia, both the expressive and receptive. Visual disturbances, things like diplopia, which is double vision, blurred vision, seeing things upside down. Headache or dizziness, incontinence, seizures. And some of those are major, but some of it, it might be just I forgot what I had for lunch. I forgot where I was 10 minutes ago. I can't think of something. Hemorrhagic strokes are less common, but again, 90% of deaths are hemorrhagic. Hey, you made it! Signs you took it. Can a stroke cause a STEMI or an NSTEMI? Can it cause a heart attack? The cause of the stroke can cause a heart attack, yes, because it's a blockage, but it generally won't go from here to here. It would go from here to here. But yeah, if you're having a stroke, you could also have a heart attack. In theory, yes. Ischemic strokes occur when a blood clot blocks blood flow to a portion of the brain. And we know that the vast majority of those are correctible. Time and tissue, the quicker you get the patient to the hospital and the quicker they undergo treatment, whether it be tissue plasminogen activator or they have a mechanical thrombectomy, to clear it. Which UMass does. The treatment goal is to salvage as much surrounding tissue as possible. Time is tissue. If the symptoms occurred within the past few hours, the patient is a candidate for stroke center therapy. All hospitals in the area, except for Memorial, are stroke centers. If you suspect a brain bleed, they need to go to UMass. But if you're just suspecting a stroke, possibly ischemic, any hospital except Memorial can do it. They just have to have CAT scan capability with telemedicine and fibrinolytics. Because what happens is they go in, they get put in the CAT scan, they get assessed by the ER physician, and then they get dialed in to a neurologist at UMass or whatever their participating hospital is. And the neurologist does the assessment through telemedicine, through a camera. The ER physician at Webster will do all the assessments while the neurologist from UMass looks on. They'll review the CAT scan information, the radiological report, and they'll make a determination. Yep, they're good for fibrinolytics, or nope, I want them here because I need to do surgery. A TIA is a transient ischemic attack. It's not a mini-stroke, like they like to call it. It's more like angina for the heart. It's a stroke where the body cleared itself out. 40% of major occlusive strokes, live special occlusive strokes, were preceded by at least one bout of a TIA within the previous 12 months. Just like almost 40% of STEMIs, big, major heart attacks, were preceded by at least one bout of angina within the previous 12 months. So don't think of it as a mini-stroke. It is a full-blown stroke that the body was able to clear up the clot. That doesn't mean the clot didn't travel down further and block further on down. I see it, if I think it's a TIA, I don't even think the word TIA. If I go to assess a patient, and a patient is presented with signs of stroke, it's a stroke. I call it in as a stroke, I write it in as a stroke. If the symptoms go away, woohoo, awesome. It's still a stroke to me. Let the doctor, let the neurologist assess for the TIA. Nobody's ever gonna tell you, you're gonna bring in a patient with stroke-like symptoms. You call it in, and when you get there, the patient doesn't have symptoms. Nobody's ever gonna say, this is who it means, why'd you bring him in, he doesn't have any symptoms. That's not gonna happen. That's the way it happens in my bed. An ambulance brought him in? Yes, it took him an hour, never mind. His first stroke. And the hospital dismissed him? The neurosurgeon called my mom, who was fine to me, and she told him, I know my husband, he doesn't walk like that. He walks just fine, and I told her, no, go home. And she insisted, and Lou screamed at him. She said, okay, fine, I'll do a CAT scan. Oh, surprise, look it, it's a stroke! Yeah, and he had also something else in the blood. What was it, what hospital was this? It was in Israel. Oh. Well, Israel has top-flight medicine here. Yes, they did, and he apologized, and he's not a good doctor, that's surprising. It happens around here, too. It happens around here. That's why I said that, I'm like, I'm thinking I should use an ambulance. Yeah. Changes in the nervous system. Changes in thinking speed, memory, and posture stability are the most common symptoms. These are the major boosted strokes. You have the patient that just, they drop to the ground, they can't walk, or they can't see, and they can't communicate. Those are big strokes. Many of your strokes are not. They're just mild symptoms, mild changes. Like my friend, whose father just forgot what he had for lunch. So the brain decreases in weight and volume. Again, as we get older, our brain atrophies. By the time I'm 75 or 80 years old, my brain is, like right now, all of our brains take up about 80% of the space in our skull, right? By the time I'm 75, 80, it's only about 70 or 75%. I lose five to 10% of my brain volume by the time I'm 75, 80 years old. Now it just doesn't become hollow. That space is taken up by something. It's taken up by cerebral spinal cord. So your body will make more cerebral spinal cord to ensure that that stays sealed, right? It stays full. So which means that at my age, I fall, trip, and hit my head on the ground. I get up and make sure nobody's looking because I'm embarrassed and I walk away. But you get a 70 year old that falls and whacks their head, they're going right in for a cat scan because the brain has that chance to shift more and cause more vascular damage and possibly a head bleed than for me because they're older. That make sense? So remember, the brain atrophies. There's a five to 50% loss of neurons in older people. Your brain does replace neurons. It's not, I know people say, oh, what's a brain cell instead? Your brain does replace cells, but they don't replace it at the rate that you lose them. So over time, our brain does diminish. So you can stay active, read, study, games, and that stays it off. So does the brain get a lot smaller as age goes on, but what functions go first? Is it motor skills or what part of the brain? It's not one function. All functions degrade. Thinking, memory processing, your motor skills, everything degrades with age. It just happens. Some things, like let's say playing the guitar. If you play the guitar your entire life, you watch somebody 85 years old, they can still play the guitar, but they don't move as well, and that's it. The performance of most sensory organs declines with age. It's just a natural thing that happens to us. Visual changes. A visual acuity, depth perception, the ability to accommodate light, changes with age, and this is why many patients over the age of 80 will stop driving, right? Because like my mother will drive like between eight and three, eight in the morning and three in the afternoon. She will not venture out after four o'clock because she has poor visual perception at night. She can't take the bright lights coming at her. She can't see, so she won't drive if there's ever a chance of light, of headlights. Patients can develop what they call myopia and presbyopia. Myopia is nearsightedness. I have farsightedness. I have trouble seeing near. Then there's presbyopia, which I have difficulty, I can see near, I have difficulty seeing far. Some people have both. I have my glasses here. That cost me over $500. And it's not that they're designers. These glasses, and they have, they're transition lenses. Used to be the old bifocals and people had it. These are transitions, so the way they tell you is you point your nose at what you're looking at. So if I'm looking at you, I point my nose at you, right? So if I have to look far away, I put my head down because I can see better. If I put my head up, everything there is blurry, but up close, wow, I can read that. So that's how it works. I also got Cresol lenses, scratch resistant Cresol lenses. I'll use this one. But, they work great, let me tell you. Cataracts can also interfere with vision with a cataract. Something old people have. It's in the lens, right? It's the clouding of the lens, correct. The lens builds up this clouding. They can fix it. They can surgically peel back the cornea and they can scrape it, vacuum it out, and clean it, and then put it back. Sometimes they can even do corneal replacements. They can do corneal transplants. So they can fix that. People sometimes have multiple cataract surgeries. Kind of like having a cloudy headlight. Yeah, it's like a cloudy headlight in your eyes and it gets difficult to see. Sometimes patients can have decreased tear production and they end up with dry eyes, chronic dry eyes. Your eye Your eye is a globular shape and it's mostly moisture. It's mostly water, right? So when my eye dries out, it changes its shape. It contracts. And that causes blurred vision. Many forms of bad vision are hydration related. So one of the more common medications they give is restasis. You put the drops in your eyes and it's a special coating that causes your eyes to retain moisture. And it helps with vision because dry eyes can cause blurred vision. Patients can also develop a condition called macular degeneration. That's actually a breakdown of the inside lining and tissues of the eye. And you can also develop glaucoma. Glaucoma is increased intraocular pressure. So between increased intraocular pressure that can change the shape of the eye, expand it, swell it, and even damage the retina, macular degeneration, cataracts, and dry eyes, you can have a real problem as you get older with vision. Inability to differentiate colors. Color blindness is not an uncommon thing as we get older. Decreased night vision. This is why most people stop driving at night. Inability to see up close. That's the presbyopia. I can see far away. Um, no. What? Did I say... I said it backwards earlier, didn't I? I did. Inability to see up close is presbyopia. If I can see up close, but I can't see... but I can't see far away, that's myopia. Myopia is distance. Sorry. Presby is close, myopia. Sorry. So I had it backwards. So the inability to see up close is presbyopia. The inability to see far away is myopia. Other diseases, things like glaucoma, we talked about that intraocular pressure. The number one treatment for that is atropine. Atropine, just like the parasympathetic... the parasympatholytic atropine. You get those in eyebrows. Macular degeneration we talked about and retinal detachment. If you have chronic dry eye, macular degeneration, glaucoma, it can lead to retinal detachment. So what happens is, maybe you hit your head, maybe you wake up wrong, whatever, and all of a sudden you have a black spot. And no matter where you look, that black spot is always there. That's the damaged retina. And you said, your father had you fixed, which is frickin' amazing, because I never thought you could do that. That can happen from dry eyes? Not necessarily dry eyes, but from all of these it can. We just had a patient that rolled their car that they went to go get her, and she was ejected from the car, and she had retinal detachment, and the paramedics said it wasn't something they've experienced yet. So they were in shock when they went to provide care for her because they were like, what is going on? And hopefully, they were able to fix it. I hope. It wasn't quick. Yeah, it took a couple weeks. They injected air, and he had to lay on... That air pushes the retina back against the choroid, and hopefully it will heal. Well, they did, they had to, but once it was there, they had to release, they went in and were able to do some kind of... Imagine what they can do to it. Imagine what they can do to it. Change in nervous system hearing. Changes in the inner ear make hearing high-frequency sounds difficult. You ever have one of those elderly patients where they have the hearing aid, and it makes a high-pitched squealing sound, and everybody goes... They can't even hear that because they lose that high-pitched sound so they can hear the low pitch, not the high pitch. You can use this to the advantage. I've had many patients over, many partners over the years that have kind of high squeaky voices, and it's their turn to deal with the patient and say, Hello, sir, how are you? How can I help you today? What's going on? I can't hear you. What? What? And they have a fellow doctor, I come in and say, Hello, sir, how are you? Oh, fine, how are you? How does he hear you? I'm talking just as loud. They can hear the lower tones, not the higher tones. That's what the hearing aid does. The hearing aid enhances the higher tones, the higher frequencies. Problem with balance Problem with balance makes falls more likely and a couple of reasons. Those changes in the inner ear can affect hearing but can also affect your semicircular canals. Controlling balance. It might be important. I know. Take a break.