Block 33 Week 8 Flashcards
Criteria for an intellectual disability?
- an IQ of under 70 - measured w WAIS4
- loss of adaptive social functioning
- onset before the age of 18
- ALL OF WHICH NEED TO APPLY
ABAS-3 looks at?
- 3 domains looked at: conceptual, social, practical
what is not counted as an intellectual disability?
- specific learning difficulty e.g. dyslexia
- adult brain injury
- early onset dementia
- autism diagnosis alone
- cognitive and AFL impairment secondary to severe mental illness
- below average IQ
evidence of LDs?
- Sig developmental delay during childhood
- special education
- very limited to independent living skills
- no employment
epidemiology of LDs?
- 20 in 1000 ppl have some form of LD
mild LD affects?
1.5% of the population
features of mild ID?
Severe LD affects?
0.4%
mild LD?
- IQ of 50-70
- Language fair.
- Little sensory or motor deficits slight, reasonable level of independence
35-49 IQ?
- generally better receptive than expressive
language
Severe LD?
- 20-34
- increased sensory and motor deficits
- 50% will have epilepsy
Profound LD?
- <20
- Increased need and vulnerability.
- Developmental level about 12 months.
Who is involved in an MDT for LDs?
- Care Managers (Social Workers)
- Receptionists
- Psychologists
- Secretaries
- Speech & Language
- Physiotherapy
- Nursing
- Psychiatry
- Occupational Therapy
biological factors predisposing to mental illness?
- Genetic vulnerability
- Brain damage
- Infection
- Physical disability
- Sensory impairment
- Tumours
- Medication or Physical treatment
social factors which predispose a person with disabilities to mental illness?
- small circle of friends.
- limited opportunity for social outings.
- reduced employment opportunities.
- lack of finance.
- lack of support
- reduced access to transport.
- exploitation (sexual and financial)
- poor housing.
- family attitudes.
- lack of Choice
psychogical factors predisposing a person with disabilities to mental illness?
- Learning Experiences
- Personality
- Separation/Loss
- Coping Style
- Life Events
- Self Esteem
- Lack of assertiveness
- Feeling helpless
capacity is the ability to:
—Receive and retain relevant information
—Balance costs benefit.
—Communicate decision
adults w capacity can refuse treatment unless
the treatment is for mental disorder when treated under the mental health act
core principles of the MCA 2005?
1.Adults are assumed to have capacity. A lack of capacity has to be clearly demonstrated.
2. No-one should be treated as unable to make a decision unless all practicable steps to help them have been exhausted and shown not to work.
3. A person can make an unwise decision.
4. If it is decided that a person lacks capacity then any decision taken on their behalf must be in their best interests.
5. Any decision should show that the least restrictive option or intervention is achieved.
what is required in order for conset to be valid?
- Have Capacity
- Act under free will (not pressurised)
- Provided with enough information.
role of psychiatry?
- work as part of the community team
- diagnose and treat mental illness
- assess risk
- offer advice on medication
role of community nursing?
- advice and support on:
- Your mental health
- Your physical health e.g. health screening and promotion
- Epilepsy and seizures
role of social care nursing?
- assessment needs - talking to the person and their carers to decice what support they need
- making sure they get the support e.g. residental housing or respite or day services
speech and language therapy?
- looks at total communication
- communication books or aids w pictures or symbols
- looks at ppls eating drinking and swallowing skills
- looks at how much ppl understand
role pf physiotherapy?
- help w mobility/ exercise
- assist at wheelchair and orthotics clinics
- help w 24hr postural management
role of OT?
- Help w everyday tasks like:
- domestic activities
- help w finding: easier way of doing things
- help to learn new skills and be more independent
health inequalities faced by ppl w LDs?
- people w IDs enjoy less good health and are less likely to attend GP
- less likely to be invited for screening
- much more likely to die young
additional health needs for those with learning difficulties?
- 25% hearing or visual impairment, epilepsy
- 5x increased risk of sudden death in epilepsy
- upto 20% have mental health problems
risk of dementia w downs syndrome?
- dementia - 4-5x greater and early onset in down’s syndrome
lower rates of ? cancer with LDs?
ower rates of lung, prostate, urinary tract cancers
higher rates of ? cancer with LDs?
- higher rates of oesophageal, stomach and GB cancer and leukemia
what is inc with Downs syndrome?
- CHD - upto half w Down’s
- hypothyroisim - DS
? infection is prev in LDs?
H pylori
LD and schiz?
- lifetime risk of someone w a LD of schiz is 3x that of the general population
- depression 5x
increase risk of MH issues w LD in those w:
- more likely to be broke, live in poor housing, no job, no social network
- dependent on services and paid care providers
- infatilised
- protected from risk taking
- overmedicated
- co-morbities
schiz w LD?
- simpler symptoms
- often has an organic feel
- monitor for adverse drug reactions - might not be able to tell you that something is wrong
barriers to healthcare w LDs?
- not understanding letters
- phone system
- touch screen system
- not being able to read badges
- confusion between diff roles e.g. psychiatrist, nephrologist
- using big words
- talking to carers instead of them
improving care for those w LDs?
- transforming care partnerships
- community Tx reviews
- LD mortality review
- annual healchecks
- hospital passports/ flagging systems
community treatment reviewS?
- community treatment reviews - called when someone is admitted to hospital
- expert and senior member of commissioning group which try and find altns to hospital admission
LD mortality review?
- Learning disabilitity mortality review - anyone who dies w a LD is reported to this body, tasked w investigating the death to see if anything could ahve been done to prevent it
flagging system?
- hospital passports/ flagging systems - identifies key details abt the person so the team caring for them know how to support them
acute liason nurses?
to ensure they recieve the same outcome as other ppl
green light toolkit?
- green light toolkit - ensures ppl w LDs are not disadvantaged when they access MH services
reasonable adjustments for LDs?
- easy read letters
- longer appts
- awareness training
- flagging system
- quieter areas to wait, not having to wait
- visit to a department to look round prior to appt
MDT members in a community LD team?
- MDT: psychiatrist, psychology, nursing, OT. physio, AHP (social care)
- reasaonable adjustments made to meet the health needs of ppl w LDs
co-morbities w LD?
- ADHD is the most common co-morbidities
- anxiety, mood disorder, language disorder
What is diagnostic overshadowing?
- Diagnostic overshadowing occurs when a health professional makes the assumption that a person with learning disabilities’ behaviour is a part of their disability without exploring other factors such as biological determinants
- Attributing all other problems to the learning disability
when can diagnostic overshadowing occur?
- Diagnostic overshadowing can occur during an assessment, such as when a health professional interprets a person with a learning disability rubbing their heads as a behaviour linked to their learning disability and fails to investigate any possible underlying health cause
people with learning disabilities have worse health outcomes than the general population. These include:
- reduced access to and less likely to receive interventions for their obesity
- greater risk of death from avoidable causes
- low take up of national cancer screening programmes
- low uptake of vaccinations
- increased risk of death due to resp infection - one of the highest causes of amenable death
how can diagnostic overshadowing be avoided?
- don’t make assumptions
- always communicating with the patient directly
- Assess people’s health and wellbeing so that any changes in behaviour that may signify changes in condition or an illness are not attributed to their learning disability
- pay attention to non verbal communication e.g. body position, painm anx
- seek help from patient’s family/ carers to get to know the person better
how can psychiatric disorders present in LDs?
- response to frustration - impulsive, stubborn, aggressive
- passitivity, withdrawal, compliance
- poor frustration tolerance can cause aggression towards caregivers or self-injurious behaviour
- challenging behaviour may be a way of asking for somthing - to be stopped, or for attention e.g.
biological factors involved in the onset of MH in problems w LDs?
- pain or poor physical health -> impact on wellbeing
- side effects of medications
- Some genetic syndromes are associated with specific mental health problems (e.g. Prader Willi syndrome - OCD)
psychological factors involved in the onset of MH problems in ppl w LDs?
- increased risk of abuse and neglect
- bereavement
- lack of support - difficulty with relationships
- lack of access to resources
social factors involved in the onset of MH problems in people w LDs?
- poverty - inability to wotk
- isolation
- loneliness
- negative life events
- undiagnosed autism
impact on carers where a person has a complex MH need?
- stress and worry - about their future health
- anxiety
- loneliness - may feel like they don’t have time for other activtiies
- financial strain - loss of job
- anger and guilt
- depression - feeling low due to the challenges faced whilst looking after someone else
problems that ppl w sensory impairments can have accessing MH services?
- difficulty sitting in waiting rooms
- difficulty in engaging with different healthcare professionals
- new environment -> stress
- being unable to hear conversations or see facial expressions -> sig obstacles in accessing social support and connection
- reliance of telephone systems and GP touch screens
- visual impairment -> difficulty with written information
strategies for managing behavioural problems in those w LDs?
- Enable the child to express themselves.
- Help the person to do what they enjoy.
- Find coping strategies to reduce stress.
- Stay alert and try to anticipate problems.
- Create a firm support network of family, friends and professionals.
interventions for LDs?
- personalised inteventions based on functional assessment if behaviour
- assessment and modification of environmental behaviour that could trigger/ maintain the behaviour
when should AP be used for challenging behaviour?
- psychological or other inteventions don’t produce change
- the risk to the person or others is very severe (for example, because of violence, aggression or self-injury).
Interventions for a child under 12?
- parent training programmes for parents with a child under 12:
- focus on developing communication and social functioning
interventions for children aged 3-5?
- preschool classroom based interventions for children aged 3-5:
- curiculum design and development
- social and communication skills training for the children
- skills training in behavioural strategies
multi-agency approach for LDs?
- children’s social care, adult services and other agencies need to undertake a multi-agency assesment using the agreed assesment framework to determine if parents with LDs require support
types of organ rejection?
- within minutes to hours: B cells
- after this: T cell mediated
Assessing suicide risk?
*What taken/done
*How much
*When
*What with – alcohol/drugs
*Where
*Anyone present
- How/when obtained
*Did they tell anybody afterwards?
*Delay in seeking help?
*How came to hospital?
*How long thinking about?
*How often – how intrusive?
*Degree of planning?
*saving or purchasing in advance
*were they expecting to be found
concealment/timing
self harm assessment - prepatory acts?
- affairs – bills etc
- will
- pets
- turning off services
- visit to significant others beforehand
- note ??
other things to ask in a self harm assessment?
- past history of SH
- past psych history
- current psych history
DSH or failed suicide
self harm assessment - screening for social stresses?
*relationships
*housing
*employment
*debt
- criminal proceedings
section 2?
- Detain inpatient 72 hours – for assessment to be made with a view to an application for admission being made -
- mental disorder
- risks
- unwilling to remain informally
- Does not authorise treatment
- Start MHA assessment process
who can place a patient under a section 2?
*Doctor in charge of treatment or nominated deputy
*If no current psychiatric involvement - consultant medic/surgeon…
*If patient open to psych -medic or psychiatrist
RF for self harm?
- Socio-economic disadvantage.
- Socialisolation.
- Stressful life events, for example relationship difficulties,
- Bereavement by suicide.
- Mental health problems
- Chronic physical health problems.
- Alcohol and/or drug misuse.
- Involvement with the criminal justice system (with people in prison being at particular risk).
self harm rates peak in which age gr?
- 16 to 24 women
- 25 to 34-year-old men.
suicide rates peak in the ? age
- Suicide rates are highest in both men and women aged 45–49 years.
RF for suicide?
- Male
- Older
- Widowed/separated/single
- Living alone/social isolation
- Low income/unemployed
- Certain occupation (e.g. doctor, farmer)
- Family history of suicide
epidemiology of self harm and suicide?
- 1:10 young ppl
- F>M 1.5-2.2:1
- age
groups of people more likely to self harm?
- divorced people more likely to self harm
- adversity
- substance misuse
- childhood abuse
- gay and bisexual
suicide rates after self harming?
- 50X higher suicide rates within 5-10 yrs
- higher suicide rate in men and higher self harm rates for women
commonest form of self harm?
- overdose - 80%
- cutting
- RF for later cutting
management of Self harm?
- CBT or problem solving therapy that is spec tailored for self harming - ASAP
- dialectical behaviour therapy adapted for adolescents - DBT-A for young ppl and children
creating a safety plan for self harm?
- establish the means of self-harm
- recognise the triggers and warning signs of increased distress, further self-harm or a suicidal crisis
- identify individualised coping strategies, including problem solving any factors that may act as a barrier
- identify social contacts and social settings as a means of distraction from suicidal thoughts or escalating crisis
- identify family members or friends to provide support and/or help resolve the crisis
- include contact details for the mental health service, including out‑of‑hours services and emergency contact details
- keep the environment safe by working collaboratively to remove or restrict lethal means of suicide.
harm minimisation - self harm?
- distraction techniques or coping strategies
- approaches to self care
- wound hygiene and aftercare
- providing factual information on the potential complications of self-harm
- the impact of alcohol and recreational drugs on the urge to self-harm.
when should a person be referred to MH services (community mental health teams and liason psychiatry teams)?
- The person’s levels of concern or distress are rising, high or sustained.
- The frequency or degree of self-harm or suicidal intent is increasing.
- The person providing assessment in primary care is concerned.
- The person asks for further support from mental health services.
- Levels of distress in family members or carers of children, young people and adults are rising, high or sustained, despite attempts to help.
neural tube vs neural crest?
neural tube develops into the central nervous system while the neural crest develops into parts of the peripheral nervous system and endocrine cell
sepsis triggers release of?
Sepsis triggers the release of IL-1 causing vasodilation → hypotension
causes of paralytic ileus?
Hyperkalemia, acidosis and handling of the bowel during surgery are all causes of paralytic ileus
adhesions after a bowel surgery?
long term side effects than paralytic ileus
igA vs IgG?
IgA = breast milk
IgG = placenta
Organ rejection cells?
organ rejection within 6 months = B cells, after this its acute or chronic so its cytotixic T cells
what leads to bronchoconstriction>?
leukotriene
neural tube ->
retina
neonatal sepsis, vaginal delivery ->
group B streptoccocus
IgD ->
B cell activation
source of vit B?
The only source of vitamin B12 for humans is animal-based foods -> vegan diet can lead to macrocytic anemia
How does tetanus cause paralysis?
tetanus blocks release of GABA -> overexcitation of muscles -> muscle paralysis
long term metformin use is associated w?
vitamin B12 deficiency due to reduced vitamin B12 absorption
allopurinol inc risk of ? toxicity
azathioprine
which ab can prolong QT?
Macrolides like erythromycin may cause prolongation of the QT interval
what is the principle inhibitory NT of the SC?
Glycine is the principal inhibitory neurotransmitter of the spinal cord - GABA main inhib in the brain
Organophosphate poisoning?
Organophosphate poisoning occurs due to inhibition of acetylcholinesterase leading to upregulation of nicotinic and muscarinic cholinergic neurotransmission
meningitis causes in 0-3 months?
- group B strep - most common in neonates
- e coli
- listeria
meningitis causes in 3 months to 6 yrs?
- neisseria meningitidis
- strep pneu
- haemophilus influenza
6 - 60 years meningitis?
- neisseria meningitis
- strep pneumoniae
> 60 yrs meningitis?
- most common: strep pneumonia
- nesisseria meningitis
- listeria
nicrorandil side effects?
- lethargy
- flush
- hypotension
- dyspepsia
- chest pain
- anal ulceration
Bbs side effects?
- cold peripheries
- bronchospasm
- sleep disturbance
CCBs SE?
- ankle oedema
- constipation
- dyspepsia - relax lower OS
vitamin D inc plasma?
calcium and phosphate levels
when does paracetamol overdose occur?
Paracetamol overdose occurs when glutathione stores run-out leading to an increase in NAPQI - NAC replenishes glutathione stores
wernicke’s encephalopathy triad?
nystagmus, ophthalmoplegia and ataxia
Korsakoffs syndrome?
Korsakoff’s syndrome develops from Wernicke’s and presents as amnesia and confabulation.
Lab features suggestive ofPseudomonas aeruginosainclude:
- Gram-negative rod
- non-lactose fermenting
- oxidase positive
- commonly associated w wound infections post op
insulin binds to?
tyrosine kinase receptors
factors affecting wound healing
immunocompromised meningitis?
listeria
vitamin D deficiency?
- poor wound healing
- general malaise and capillary fragility causing bleeding from the gums.
- This is caused by defective synthesis of collagen.
phospholipids converted to arachdonic acid by?
phospholipase A2
Neural crest ->
parafollicular cells of the thyroid
RF for pulm HTN?
sleep apnoea, cocaine use, and previous pulmonary embolism (PE).
Management of PHTN?
- vasoactive agents likeprostacyclin (or PGI-2)are the first-line management option to promote vasodilation.
Use of ? during pregnancy is related to gray baby syndrome?
chloramphenicol
how does chloramphenicol work?
inhibits protein synthesis by acting on 50s ribosomal subunit
first order kinetics?
- majority of drugs exhibit’first-order’ elimination kinetics i.e. the rate of drug elimination is proportional to drug concentration
zero order kinetics?
- certain drugs exhibit zero-order kinetics where therate of excretion is constant despite changes in plasma concentration, this is due to saturation of the metabolic process
examples of 0 order drugs?
- phenytoin
- salicyclates
- heparin
- aspirin
which ab fix complement?
Only IgM and IgG immunoglobulins fix complement
IL-8 functions?
IL-8 - main functions include: neutrophil chemotaxis
INF-g?
Interferon-gamma is produced primarily by natural killer cells and T helper cells
calcitonin?
Calcitonin causes a decrease in plasma calcium and phosphate by inhibiting osteoclasts
PTH?
PTH increases plasma calcium but decreases phosphate levels
Severe benzodiazepine overdose is treated by
Severe benzodiazepine overdose is treated by flumazenil - high risk of seizures though
Which drug dereases iron abs?
omeprazole - inhibits stomach acid which promotes iron abs
warfarin and ? interact
valproate
rifampicin causes inc in ? clearance?
- Rifampicin causes inc clearance of the COCP
- leading to a reduction in its effectiveness
tetracyclines are teratogenic bc?
- They are teratogenic due to their ability to bind to calcium ions in developing bones and teeth - cause teeth discoloration
- They should not be taken with high calcium foods or drinks such as milk for this same reason.
tetracyclines can also cause?
tetracyclines can also increase the sensitivity of the skin, cause gastrointestinal disturbances and cause kidney impairment.
viral infections result in raised ? count?
Viral infections typically result in a raised lymphocyte count, fungal infections result in a raised eosinophil count and protozoan infections often result in a raised monocyte count.
summary of tetracyclines, aminoglycosides and macrolides?
tetracyclines and aminogycosides -> 30s ribosomes inhibition
macrolides -> 50s inhibition
quinolones mechanism?
Quinolones (e.g. ciprofloxacin) - inhibits DNA synthesis - topoisomerase inhibition
PE management?
Massive PE + hypotension - thrombolyse: alteplase
haemadynamically stable: DOAC
sarcoid features?
FABLE
Fevers
Arthralgia
Bilateral hilar lymphadenopathy
Lupus pernio
Erythema nodosum
SSRI monitoring?
ssri: monitor for hyponatreamia, urea+ electrolytes
sick day rules - stop DAAMN drugs?
Diuretics
ACEi
ARBs
Metformin
NSAIDs
Takotsubo cardiomyopathy?
- Takotsubo cardiomyopathy also known as ‘Broken heart syndrome
- apical balooning of LV - resembling octopus pot
management of broad complex tachys?
IV amiodarone is the first-line treatment for regular broad complex tachycardias without adverse features
factors associated w poor schiz prognosis?
- strong family history
- gradual onset
- low IQ
- prodromal phase of social withdrawal
- lack of obvious precipitant
SSRI use in the 3rd trimester?
SSRI use during third trimester - risk of persistent pulmonary hypertension of the newborn
how long should AD be continued after remission?
Antidepressants should be continued for at least 6 months after remission of symptoms to decrease risk of relapse
acute dystonia vs tardive dyskinesia?
acute dystonia: involves sustained muscle contractions leading to abnormal postures, not repetitive movements as seen in tardive dyskinesia.
tangentiality?
Tangentiality refers to wandering from a topic without returning to it
circumstantiality?
Circumstantialityis where patients give unnecessary and excessive detail before finally answering a question
flight of ideas vs tangentiality?
- patients jump from one topic to the next with discernible links between them
- in flight of ideas the question would’ve first been answered, then the patient would have jumped to the next topic - patient doesn’t answer ques in tangentiality
- In flight of ideas the speech would also be at a faster rate.
knights move thinking?
- unexpected and illogical and unexpected leaps from one idea to another.
- While this patient is leaping from one topic to another there are loose associations between each topic.
review one week after ? commencement
SSRI
Stages of alcohol withdrawal?
- symptoms: 6-12 hours
- seizures: 36 hours
- delirium tremens: 72 hours
SSRI discontinuation syndrome?
Dizziness, electric shock sensations and anxiety are symptoms of SSRI discontinuation syndrome
Most likely SSRI to cause QT prolongation?
Citalopram is the most likely SSRI to lead to QT prolongation and Torsades de pointes
long term lithium use can cayse?
hyperparathyroidism and resultant hypercalcaemia.
Factors suggesting diagnosis of depression over dementia?
- short history, rapid onset
- biological symptoms e.g. weight loss,sleep disturbance
- patient worried about poor memory
- reluctant to take tests, disappointed with results
- mini-mental test score: variable
- global memory loss (dementia characteristically causes recent memory loss)
conversion disorder?
Functional neurological disorder (conversion disorder) - typically involves loss of motor or sensory function
antimuscarinic side effects are more common w?
antimuscarinic side-effects are more common with imipramine than other types of tricyclic antidepressants - dry mouth and blurred vision
what is not a first rank symp of schiz?
visual hallucinations
acute dystonic reactions more common w ?
Acute dystonic reactions are more common with first-generation (or typical) antipsychotics such as haloperidol.
what are acute dystonic reactions?
Acute dystonic reactions includetorticollis, opisthotonus, dysarthria and oculogyric crises.
SSRI of choice in children and adolescents?
Fluoxetine
type 1 vs type 2 bipolar?
Type I bipolar is associated with mania and type 2 is associated with hypomania
Clozapine side effects?
- SCAM
- Seizures
- Constipation/clozapine-induced gastrointestinal hypomotility (CIGH)
- Agranulocytosis
- Myocarditis
Tx of delirium tremens?
Chlordiazepoxide or diazepam are used in the treatment of delirium tremens/alcohol withdrawal
most tolerable AP?
Aripiprazole has the most tolerable side effect profile of the atypical antispsychotics, particularly for prolactin elevation
Use of antipsychotics in the elderly causes inc risk of?
stroke and VT
lambert eaton syndrome?
- weakness that is worse in the legs.
- It can be differentiated from myasthenia gravis, which typically affects the face and arms earlier, and lambert eaton syndrome gets slightly better with muscle use, whereas myasthenia gravis is worsened by muscle use.
signs and symptoms of lung abcess?
characterised by swinging fevers, night sweats, pleuritic chest pain, dyspnoea, and cough
Tx of torsades?
IV magnesium sulfate
thiazide diuretics ->
hypokalaemia -> Flattened T waves
Young male smoker with symptoms similar to limb ischaemia - think?
Buerger’s disease
Aortic stenosis management?
AVR if symptomatic, otherwise cut-off is gradient of 40 mmHg
statins can’t be used in?
pregnancy
side effect of mesalazine?
Pancreatitis is significantly more common as a side-effect with mesalazine than sulfasalazine.
aminosalicylates are assoc w ?
agranulocytosis
dysphagia suggestive of achalasia?
Dysphagia equally to both solids and liquids from the outset is suggestive of achalasia
achalasia barium swallow?
A barium swallow which shows a grossly expanded oesophagus that tapers at the lower oesophageal sphincter (‘bird’s beak’ appearance)
oral contraceptive assoc w ?
drug induced cholestasis
crypt abcesses + rectal bleeding ->
points more towards UC than CD
CD associated w ?
gallstones
RF for gallstones?
SOLIDC
Sudden weight loss
OCP
Loss of bile salts
Increasing age
Diabetes
CD
SSRI and MAOI should not be?
SSRIs and MAOIs should never be combined as there is a risk of serotonin syndrome (also can’t be used w triptans)
tricyclic AD can cause?
urinary retetntion e.g. amitryptiline
what can cause upper zone lung fibrosis?
asbestos and methotrexate
what can cause lower zone fibrosis?
prev radiotherapy
inhaled beclomethasone can cause?
inhaled beclomethasone can cause oral candiassis - pred is not typically given in an inhaler, usually oral
tension pneumothorax?
- The patient will be hypotensive due to the expanding pleural space obstructing cardiac outflow. This does not occur in simple pneumothoraces.
- tracheal deviation away
Persistent productive cough +/- haemoptysis in a young person with a history of respiratory problems →
? bronchiectasis
restrictive pattern + normal gas transfer ->
obesity
All cases of pneumonia should have a repeat chest X-ray at
6 weeks after clinical resolution
Pneumothorax can occur following
high pressure non-invasive ventilation
Older patient, progressive exertional dyspnoea, dry cough, clubbing, non-smoker →
idiopathic pulmonary fibrosis
HF XR findings?
- Alveolar oedema (bat’s wings)
- KerleyBlines (interstitial oedema)
- Cardiomegaly
- Dilated prominent upper lobe vessels
- Effusion (pleural)
alzheimers dementia RF?
- age
- women
- Down’s syndrome.
- Vascular risk factors
gene linked to AD?
ApoE4
Pathology in alzheimers?
- Extracellular β amyloid plaques and
- intracellular tangles of hyperphosphorylated tau
AD clinical features?
- Gradual onset often with episodic memory –forgetting conversations, where put things, things that done, repeating questions
- Progressive decline and spreads to other aspects of cognition
4 As of alzheimers?
- Aphasia –expressing/understanding language
- Apraxia –carry out complex tasks
- Agnosia –recognising objects, people
- Amnesia
- Executive functions –planning and sequencing - when it spreads to frontal lobe
summary of 4 As in alzheimerS?
- apahasia
- apraxia
- agnosia
- amnesia
Vasc dementia?
- slightly more common in men
- vascular RF
2 common phenotypes of VD - stepwise progression?
- stepwise progression - new infarct -> progression, variable/focal deficits,
- speech, memory, executive function
- localised problems
2 common phenotypes of VD - marche a petit pas?
- marche a petit pas - small steps, bradyphrenia - think more slowly, executive function - planning judgement, emotional lability - change emotions quickly, urinary incontinence
LBD CF - 4 common features?
- fluctuating cognition
- complex visual hallucinations
- Parkinsonism (tremor, rigidity, bradykinesia)
- REM Sleep disorder (shout/move as act out dreams)
pathology of LBD?
- Lewy Bodies –eosinophilic inclusions in the neurones, build up of α-synuclein protein
- LB stain pink/red
FTD?
- 2% of dementia, younger people 45-65, men=women
- More genetic, 1/3 Autosomal Dominant, can now test for some genes
Pathology of FTD?
- Atrophy of frontal and anterior temporal lobes - wasting and knife edge pattern
- Some have “Pick bodies” with abnormal tau protein
- Others have an accumulation of different proteins e.g. TDP-43, FUS, UPS
CF of the behavioural variant of FTD?
- Disinhibition
- Apathy/inertia - don’t doo much w/o the executive functions
- Loss of sympathy/empathy
- Perseveration –stuck on repeated behaviours
- Hyperorality –just like sweet foods, things in mouth
- Loss of executive functions –planning, judgement
- need 3/6 for diagnosis of frontotemporal dementia
less common variants of FTD?
- Primary progressive aphasia
- progressive non fluent aphasia
- semantic dementia
rare causes of dementia?
- parkinsons disease
- huntingtons disease
- Creutzfeldt Jakob disease
- HIV assoc
huntingtons disease?
- Huntington’s Disease –autosomal dominant, dementia with chorea “dancing movements” in arms and legs
- often at a young age
Creutzfeldt Jakob disease?
prion disease causing a rapidly progressive Dementia
dementia subtypes summary table
what is methylphenidate?
dopamine and norepinephrine reuptake inhibitor
apiprazole?
D2 partial agonist
Atomoxetine?
selective NA reuptake inhibitor
suicide rate in major depression?
10-15%
depression causes inc?
coronary atherosclerosis later in life
what specifically supports diagnosis of acute schiz?
acute schizophrenia: delusional perceptions specifically support diagnosis
best Tx for phobias?
phobias -> best treatment: behavioural therapy like desenitisation
clock drawing test early impairment in?
clock drawing test more likely to be impaired at an early stage in small vessel vascular dementia
autism key features?
autism: pointing at things rarely even when he wants them - key feature of autism is impaired verbal and non-verbal communication.
hallucinations are diff to?
difficult to distinguish from a real perceptio
4 year old adopted girl frequently does the opposite of what her adoptive parents tell her to do and can be controlling in their company.She struggles to get on with her peers, but is usually charming to strangers, although can seem hyper alert to what is going on around her.
What is the most likely diagnosis?
reactive attachment disorder
assertive outreach team?
provide ongoing care upon discharge for MH condition
LT lithium use can lead to?
hyperparathyroidism and resultant hypercalcaemia
SS vs NMS?
Dilated pupils in serotonin syndrome, Hyperreflexia in serotonin syndrome (Hyporeflexia in NMS)
clozapine is good for?
clozapine is effective for negative symptoms when other AP have failed
first line in PTSD?
The first-line drug treatment for PTSD is venlafaxine or a selective serotonin reuptake inhibitor (SSRI) such as sertraline.
SSRI + ? -> bleeding risk
SSRI + NSAID = GI bleeding risk - give a PPI
Mirtazapine may be prescribed due to useful side effects like
sedation and inc appetite
