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Y5 Management Fml > Sike > Flashcards

Sike Flashcards

1
Q

Depression Rx

A

Admit if risk is high
Bio- SSRI (explain spiel)
Psychological- CBT
Social - take part in more activities, hobbies, sleep hygiene. CRISIS NUMBER

leaflets + charities

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2
Q

What is the SSRI spiel

A

takes time to work
review in 1-2 weeks to check side effects
starting low and titrate up

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3
Q

How would you describe OCD

A

a condition where you have recurrent intrusive thoughts which often make you carry out compulsions/actions to neutralise these thoughts

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4
Q

OCD Rx

A

1st line: ERP (form of CBT):
is a therapy that encourages you to face your fears and let obsessive thoughts occur without ‘putting them right’ or ‘neutralising’ them with compulsions.

2nd line: SSRI (fluoxetine) - should continue for 12 months after remission

Leaflet, charities, social stuff (sleep hygiene, smoke/drink, job, relationships etc)

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5
Q

CBT spiel

A
  • talking therapy
  • will receive weekly/fortnightly therapy sessions
  • helps us identify and address any unhelpful thoughts and behaviours
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6
Q

PTSD Rx (same as acute stress disorder)

A

1st line: Trauma focused CBT
2nd line: EMDR

a comprehensive psychotherapy that helps you process and recover from past experiences that are affecting your mental health and wellbeing. It involves using side to side eye movements combined with talk therapy to address these thoughts and experiences

SSRI may be used as adjunct during the course of treatment but is not routinely used

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7
Q

Explain what PTSD is

A
  • PTSD is a condition that occurs after someone has gone through some major traumatic event
  • It is characterised by episodes where you feel like you’re vividly reliving the trauma as well as times when you may feel like you’re particularly anxious and on high alert
  • It can also affect your behaviour such that you avoid anything that may trigger you to feel all these emotions again
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8
Q

Generalised anxiety disorder Rx

A

1st line: self help and psychoeducational group
2nd line: SSRI (sertraline) AND/OR high intensity psychological intervention eg CBT
+/- propranolol (not in asthmatics)
NEVER give benzo as it is addictive

social: smoking cessation/caffeine/sleep hygiene, encourage reliance on supportive contacts etc

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9
Q

Delirium Rx

A
  • Admit: delirium fluctuates so even if they are lucid right now, they could deteriorate if they go home
  • Identify cause (infection/environment/pain/DRUGS steroids)
  • Treat cause
  • one staff member per shift, reorientation
  • adjust environment: lighting/pain. Avoid transferring patient frequently. Try keep the same carer with the pt
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10
Q

psych investigations pool U LEGIT?

A

Urine drug screen

Lipids/HbA1c/prolactin (before starting anti-psychotics)
Electrolyte - U&Es and ECG maybe
Glucose
Infection- urine dip, stool culture, CXR, HIV/syphilis screen (rachel mentioned always do this for patients presenting with psychosis/mania)
Thyroid - TFTs

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11
Q

baseline Ix before starting antipsychotics

A

 Weight
 Waist circumference
 Pulse and BP
 Fasting BM, HbA1c, lipid profile, prolactin
 Assessment of any movement disorders
 Assessment of nutritional status, diet and physical activity
 ECG (many drugs prolong QTc), need to redo if changing dose of drug
 Children should also have height measured every 6 months

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12
Q

schizophrenia Rx

A

Schizophrenia is:

  • a long term condition caused by imbalance of chemicals inside your brain
  • you may see, hear, feel or believe in things which may appear out of touch with reality

ACUTE PSYCHOSIS EPISODE:
if first episode - involve EIS (early intervention service team)

admit only if theres risk to self, others or from others. If can be managed at home, contact Crisis team who can treat the acute episode of crisis at home (least restrictive environment)

Bio psycho social
Bio:
1st line: atypical antipsychotic eg quetiapine
+ CBT should be offered to all pts + social + CLOSE monitoring of CVD risk factors (smoking/waist circumference/routine BP/glucose and HbA1c/lipids)

Psycho:
CBT for psychosis, psychoeducation, family therapy, art therapy

social:

  • allocated a care coordinator who can help with finances, housing, education, employment
  • offer exercise/dietician (eg if pt on OLANZAPINE)
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13
Q

SSRI in GAD

A

higher dose used compared to depression and take longer to work (6-8 weeks)

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14
Q

Anorexia/Bulimia Ix

A 
Examination, height and weight and BMI. 
Squat test (cannot stand up from squatting without help)
General examination to look for:
Dry skin 
Lanugo Hair 
Russel’s sign 
• Swelling of salivary glands 
• Tooth Erosion 
• Cold extremities
• Difficulty with squat test
Bedside:
obs 
Urine dip (starvation induced ketosis)
ECG (hypokalaemia, Bradycardia, orthostatic hypotension
cardiac arrhythmias)
SCOFF questionnaire

Bloods
TFTs,
FBC (anaemia),
LFTs (starvation induced transaminitis, albumin may be low).
U and Es (vomiting –> electrolyte imbalance).
phosphate and magnesium

Refer to marzipan guidelines, guideline produced to help doctors manage eating disorders

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15
Q

Anorexia Rx in children vs adults

A

Children: anorexia focused family therapy because what a child eats is largely influenced by family, ED-CBT is second line
The aim of the family therapy is to empower the parents and family so that they can overcome this challenge together with their child

Adults: ED CBT OR MANTRA (maudsley anorexia nervosa treatment for adults) OR SSCM (Specialist supportive clinical management)

Both:
manage depression - FLUOXETINE is good for eating disorders
dietician referral
BEAT charity (eating disorder charity)
Explain the long term risks of anorexia (osteoporosis, infertility, cardiac problems)

MDT team:
dietician, physio (if muscle weakness), eating disorders team

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16
Q

what are the long term effects of anorexia that you would explain to pt

A

osteoporosis, arrhythmias, anaemia, inferility

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17
Q

what should you keep in mind in addition to the standard psych history when taking an anorexia history

A

BINDS especially growth/development and social

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18
Q

Examinations and questionnaires for dementia in primary care

A 
Physical examination (look for resting tremor/cogwheel rigidity as seen in lewy body). 
Neuro exam (eg look for hemiparesis)
Cardio exam (HTN risk factors etc)

AMTS, MMSE

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19
Q

Ix for dementia

A

everything (to rule out organic causes)

Full blood count. 
Erythrocyte sedimentation rate (ESR). 
C-reactive protein (CRP). 
Urea and electrolytes. 
Calcium.
HbA1c. 
Liver function tests.
Thyroid function tests. 
Serum B12 and folate levels.
urine dip/CXR/ECG may also be indicated
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20
Q

Rx for dementia for primary care

A

referral to secondary care once ruled out organic causes and dementia is still suspected: memory clinic/ or community old age psychiatry

medication review to optimise physical help

Social:
Adaptation for patient -
- help from others: MDT involvement from social services/carers.
- help themselves: dozette box
- Environmental/Needs assessment by local council e.g. grab rails in bathroom, improve lighting in home to avoid risk of falls, avoid rugs/mats on the floor as they can cause confusion
- consider nominate a LPA for finances/decisions
- change gas hob to electric hob
Biological/Medical:
- AChE inhibitors may be useful for symptomatic relief
- DONT give antipsychotics (they block dopamine which makes lewy body dementia worse)
- Parkinsons medications may improve tremor but may worsen psychosis so avoid if possible too
- admiral nurses (dementia specialist nurses that provide support for the entire family)
- alzheimer’s society

Psychological
- reminiscence therapy: talking therapy that use props/sensory stimulation to spark memories. Used to treat severe memory loss/ dementia

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21
Q

Which type of dementia should you not give AChE inhibitors

A

vascular dementia - supportive management only

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22
Q

Outline the alcohol questionnaires and their uses

A

AUDIT (alcohol use disorders identification test) to identify an alcohol use problem

SADQ (severity of alcohol dependence questionnaire) for severity of dependence

Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar) for severity of withdrawal

APQ (alcohol problems questionnaire) for the nature and extent of the problems arising from alcohol misuse.

23
Q

Alcohol dependence primary care counselling components

A
  • Establish risks (driving, suicide)
  • Assess social issues and advise accordingly (SAFEGUARDING)
  • Establish goals (elimination or moderation. Elimination is often preferred)
  • Explain that symptoms of withdrawal (worst in the first 48 hours and should pass after 3-7 days)
  • Advise against stopping drinking abruptly
  • Explain referral to drugs and alcohol service and the process of assisted withdrawal (benzodiazepines, psychological treatment and relapse prevention
24
Q

Bio psycho social model for alcohol dependence management

A

Bio: Inpatient or community detox

  • mild cases can be managed in community in pt’s home (community)
  • In both community and inpatient management, a fixed dose REDUCING drug regimen is used: chlordiazepoxide or diazepam gradually reduce the dose over 7-10 days
  • after successful withdrawal, give acamprosate (anticraving) or naltrexone (opioid receptor antagonist)
  • counsel withdrawal is worse in the first 48 hrs and should improve afterwards
  • correct any organic issues eg give PABRINEX (IM injection)

Psycho- CBT, behavioural couples therapy
Social- DRIVING (cannot drive during treatment, DVLA needs to be informed), job centres , ALCOHOLICS ANONYMOUS

Follow up after withdrawal. Safety net to go to A and E if acute withdrawal symptoms

25
Q

When would pts need inpatient assisted alcohol withdrawal

A

high risk of seizures/delirium tremens

26
Q

Alcohol history HPC components

A

Features of dependence - compulsion, control, withdrawal symptoms, tolerance, primacy (main priority in life)

Impact on relationships, work, law (drink driving, arrested)

Complications of drinking: weight loss and poor diet, memory problems, mood.

27
Q

EUPD Rx

A

• Explain the diagnosis ( increased sensitivity to emotions and is likely to be linked to stressful life circumstances and experiences, could lead you to act in ways that may harm yourself)
• Explain that personality disorders are often undiagnosed (~10% may have a personality disorder, ~2% have EUPD)
• Explain dialectical behavioural therapy (helps you understand your thought processes and teaches you to not view things as black and white, teaches skills to cope with difficult emotions)
 DBT aims to introduce two important concepts:
• Validation: accepting that your emotions are acceptable
• Dialectics: showing you that things in life are rarely black or white, and helping you be open to ideas and opinions that contradict your own

  • Explain the use of therapeutic communities (meet other people with similar issues and support each other in recovering)
  • Crisis management: provide numbers for crisis resolution team, community mental health nurse, out-of-hours social worker, Samaritans
  • Support: mind.co.uk
28
Q

Acute mania Rx

A 
Admit
Biological (acute mania give atypical antipsychotic = aripriprazole/olanzapine, long term = lithium)

Psychological (CBT – identify relapse indicators, relapse prevention strategies), Social (family support, aiding return to work, deal with financial issues resulting from overspending)

We believe you’re experiencing something called mania – this is when a chemical change in your brain can lead to a very increased mood

This may not sound like a bad thing and I know you’ve told us that you feel great right now, but it can actually be very damaging in the long run

It can lead you to make risky decisions that you wouldn’t otherwise make and this can cause you serious harm (financial, physical, emotional)

We would like to keep you in the hospital to give you some treatment that can normalise the chemicals in your brain and help you think clearer

When you’re feeling back to normal, we can also discuss how we can help you get back to regular work and perhaps discuss any financial issues that you may have

If they refuse: assess capacity by checking whether they can understand, retain, weigh up and communicate the decision

29
Q

paracetamol overdose Ix

A

Bedside:

  • obs
  • mental state exam
  • abdominal examination (liver)
  • urine drug screen

Bloods:

  • FBC
  • LFTs
  • clotting
  • VBG for blood gas
  • serum paracetamol concentration 4 hrs after ingestion
  • if also aspirin/salicylate poisoning then screen for serum salicylate levels
30
Q

Paracetamol overdose Rx

A
  • admit (if not voluntary then consider section 2 under the MHA)
  • explain the implications: damage to liver, could be fatal, may need transplant
  • discuss need to do investigations/have carried out investigations to track liver damage and paracetamol levels. Plasma paracetamol levels are done at 4 hrs after ingestion and plotted. Give NAC if above treatment line
  • discuss long term management BIOPSYCHSOCIAL of depression/underlying mental health conditions
31
Q

what is important to ask in hx for paracetamol overdose

A
  • before, during and after
  • before: why
  • during how many pills when did they take it, did they take anything else other than paracetamol (sleeping tablets, alcohol, opioids)
  • after: how did people find u
  • screen for liver failure problems: abdo pain, nausea, jaundice
32
Q

Explain what anorexia is

A

3 components according to dsm V

  • body dysmorphia: may see themselves as overweight
  • food restriction
  • fear of gaining weight
33
Q

Bulimia Rx children vs adults:

A
  • refer in all cases
    Adults:
    1. First line:
    psycho: Bulimia nervosa focused self help for adults. If doesnt work then eating disorders focused CBT
    2. bio: fluoxetine for concomitant depression
    3. Social: BEAT, work, dietician

children:
- BN focused family therapy
social same as above

MDT team:
dietician, physio (if muscle weakness), eating disorders team

34
Q

components of bulimia

A

Recurrent episodes of binge eating.

Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.

The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months.

Self-evaluation is unduly influenced by body shape and weight.

Binging or purging does not occur exclusively during episodes of behavior that would be common in those with anorexia nervosa.

35
Q

depression in BPAD in primary care

A

you probably wont start antidepressants straight away in primary care. Refer to secondary care who may give olanzapine with fluoxetine. in primary care you probably could mention give CBT

 Difficult because antidepressants can cause a switch to mania
 To reduce this risk, antidepressants should only be given with a mood stabiliser or antipsychotic
• 1st line: fluoxetine + olanzapine/quetiapine
• 2nd line: lamotrigine
 Monitor closely for signs of mania and immediately stop antidepressants if signs are present
 Medication can be cautiously withdrawn if the patient is symptom-free for a sustained period

36
Q

what is cyclothymia

A

mini bipolar

37
Q

Cotard syndrome management

A

admit + maybe section + treat depression

38
Q

Benzodiazepine withdrawal Counselling

A

A-E approach
Bio psycho social
bio:
- Diazepam
- Oxazepam may be considered instead in patients with liver failure. Dose is gradually reduced overtime
Duration: may take 3 months to a year or more

psycho:
- CBT for underlying mental health issues/sleeping issues

Social:
- no driving if drowsy
- work
etc

39
Q

acute alcohol withdrawal management

A 
A-E approach
Check airway - if patient is drowsy then call anaesthetics etc to secure airway
Breathing- give oxygen
C- fluids, continuous cardiac monitor
D- GCS, glucose levels 
E- everything else, urinary drug screen

Drugs: (basically lorazepam + IV thiamine covers your ass for all of the following scenarios)

  • Standard acute withdrawal symptoms: benzodiazepine (e.g. lorazepam) or carbamazepine or Alternatively: clomethiazole (use with caution)
  • if Seizures/Delirium Tremens: oral lorazepam OR chlordiazepoxide
  • If symptoms persist: offer IV lorazepam or haloperidol

Nutrition:
IV thiamine

Psycho: CBT to address underlying ?depression etc / sleep problems

Social:

  • Offer advice on local support services (alcoholics anonymous, SMART recovery)
  • refer to drug and alcohols services for detox
40
Q

Opioid overdose Rx

A

A-E
airway - if drowsy, call anaesthetics
breathing - oxygen
cardiac - fluids, continuous cardiac monitoring
disability - GCS assessment, glucose levels
E: Naloxone + bio psycho social (STI screen? if opioids injected)

41
Q

benzodiazepine overdose Rx

A 
A-E
airway - if drowsy, call anaesthetics
breathing - oxygen
cardiac - fluids, continuous cardiac monitoring
disability - GCS assessment, glucose levels 
E:
Bio psycho social
drug = flumazenil
42
Q

Opioid withdrawal Rx

A

Explain that it would be worth getting tests done for blood-borne diseases and offer vaccinations

Explain the features of withdrawal (restlessness, anxiety, sweating, yawning, diarrhoea, abdominal cramps, nausea and vomiting, palpitations)

Manage expectations and explain timescale (begin within 24 hours, peaks after 2-3 days and should be significantly better by 1 week)

Explain detoxification regime (giving a substitute that should lessen the symptoms of withdrawal)
- 1st line is methadone (liquid) or buprenorphine (sublingual)
Explain that symptomatic treatments will be given to reduce nausea, diarrhoea and autonomic symptoms

Explain the role of psychological therapies in preventing relapse

Explain the role of the key worker

Support: Narcotic Anonymous, SMART Recovery

43
Q

discontinuation syndrome

A

electric shock in head
nausea and vertigo
feeling anxious

you get this when you stop taking antidepressants
More common with paroxetine and venlafaxine

44
Q

give example of depot

A

flupenthixol (a typical antipsychotic)

45
Q

psychosis presentation ddx

A

if first episode psychosis say:
‘ since this is first episode psychosis, i would like to further assess the patient before I make a diagnosis’ :shows youve been on the wards

schizoaffective if mood + psychosis
delusional disorder - delusions only and no hallucinations
drug induced psychosis (always include this as ddx)

note can also combine:
schizophrenia with depression/mania
depression with psychosis

46
Q

schizoaffective disorder vs combination problems eg schizophrenia with depression/mnania, depression with psychosis

A

timing: schizoaffective = mood and psychotic disorder TOGETHER (will be really obvious in exam)

if you have schzioprhenia for 7 months then get depression = schizophrenia with depression

47
Q

postpartum depression rx

A

biopsychosocial

always start psychological therapies (CBT) and social support then consider use sertraline (safe for breastfeeding)

48
Q

Postpartum psychosis Rx

A

emergency so senior support

olanzapine and quetiapine are used as they are quite safe in women just given birth

psycho/social - dont forget partner/family support

MBU

49
Q

BPAD in pregnancy what drugs are used

A

olanzapine is safe in pregnancy/postpartum (think of O as pregnant abdomen)

fluoxetine

Lithium is not totally contraindicated (ask senior advice/ultimately need to balance risk of relapse of mania vs risk of congenital defects)

crucially: AVOID sodium VALPROATE in ALL women of child bearing age (risk of teratogenicity)

50
Q

PACES questions for post natal depression/psychosis screen

A

do you have new feelings/thoughts which you have never had before which make you disturbed or anxious

do you feel able to look after your baby adequately

sometimes people feel like they are incompetent and cannot cope, or estranged from baby, does this happen to you, are these feelings persisent

sometimes people have unpleasant thoughts of harming their baby, has this happened to you

51
Q

when do you admit for eating disorders

A

Risk to self, others or from others
BMI<13
extremely rapid weight loss
physical complications (eg ECG changes due to electrolyte abnormalities)

52
Q

what is refeeding syndrome

A

eg might get this in anorexia station

  • rapid initiation of normal nutrition in a chronically malnourished patient can lead to rapid insulin release (previously suppressed). This may lead to increased displacement of Mg, PO4 and Potassium form extracellular into intracellular space. So serum levels of these 3 are reduced
  • symptoms include edema (multifactorial eg rhabdomyolysis causing kidney failure), tachycardia (torsade de pointes caused by low K+ or Mg2+) and SEIZURES
53
Q

refeeding syndrome Rx

A

daily monitoring of bloods

  • Po4, mg, k
  • thiamine levels monitoring

MDT: involve specialist dietician to introudce food gradually.

Y5 Management Fml (11 decks)

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