Counselling stations Flashcards
statins
statins stop the liver from making cholesterol
cholesterol is one of the things that predispose to artery problems –> heart disease (angina, heart attacks), kidney diseaese and stroke
1 in every 50 people who take the medicine for 5 years will avoid a serious event
tablet
some it doesnt matter when as long as same time (atorvastatin), others must be in the evening (simvastatin) (because body makes most of cholesterol at night)
with or without food
lifelong
won’t notice an effect - work in the background continually (dont stop taking or else levels will go back in a few weeks)
TESTS
befoe starting = lipids, LFTs, renal function, HbA1c, cK, TFTs
review pt in 4w to see how getting on - should take this long for cholesterol to drop
liver tests 3m then 12m and check lipid levels
if at risk of diabetes - also monitor hba1c (statins can increase sugars)
check creatinine kinase if muscle pain
SE = GI, headache, muscle pains, sleep problems, epistaxis
uncommon SE = hair loss, sexual dysfunction, skin reactions
stop taking if yellow skin, severe muscle pain (could be sign of muscle breakdown)
CI = pregnancy, breastfeeding, avoid grapefruit juice, had allergic reaction to statin in past, liver problems, want to get pregnant, breastfeeding, st johns wort
nhs.uk statins, leaflet
extra = do not take extra one if forget to take
help w nausea - simple meals no rich and spicy food
try vaseline for nose bleeds
breech pregnancy
3 types - extended/frank, flexed/complete, footling/incomplete
risk factors - fibroids, polyhdraminosi, multiple pregnancy, previa
MANAGMENET
<36w may turn spontaneously
ECV - 50%
done at 36w nuli, 37w multi
can be painful
rates increase by tocolysis such as salbutamol (relax the uterus)
CI = when u doing c section, APH in last 7 days, abnormal CTG, ruptured membranes, multiple preg
can be tried again
complications = transient fetal heart abnormalities (go back to normal), persistent ones like fetal brady, placental abruption
chance of baby turning back after is v low- 2%
planned c section lower risk of perinatal death than planned vaginal - no signif maternal outcomes
however, most cases vaginal is still safe - CI in footling
other reasons vag CI = big baby, IUGR, prev c section, previa
vaginal should take place in hospital - ctg offered
explain that if paitent goes into labour to come to hospital urgently due to risk of cord prolapse
steroids
Action
o Will reduce inflammation and swelling
o Are man-made version of hormones normally produced by the adrenal glands which sit on top of the kidneys
Timeline/how to take it
o Tablet taken once a day - take in morning after breakfast - can help reflux (taking it in the morning mimics your body’s own release of steroids)
Effect - how long until
o Should start immediately - may take a few days to get to full effect
Tests
o Before starting - BP, weight, HbA1c, lipids, BMI, (UE risk of hypokalaemia)
o Eye examination every 6-12 months - glaucoma
o Osteoporosis assessments
o Measuring height in children
o Monitoring for signs of adrenal suppression
Important side effects o Hypertension o Diabetes o Osteoporosis o Increased risk of infection - avoid close contract with people with chickenpox o Peptic ulcers o Acne o Mood changes o Weight gain o Muscle pain o Skin thinning o Difficulty sleeping o Will start on a low dose of steroids first to reduce these
Complications and CI
o Warn patient not to take any NSAIDs
o Do not stop medication suddenly due to risk of Addisonian crisis
o Not usually recommended in pregnant - unless risks outweigh benefits
Safety-net and supplementary information
o Tell doctor if develop tummy pains or vomit any blood
o Will provide people on long-term steroids with a steroid card
keep out of sunlight in a cool dry place away from children
atypical antipsychotics
How do anti-psychotics work?
o Schizophrenia is caused by an over-activity of chemicals involved in transmission of messages in the brain - the main problem is that it causes is that it affects people’s ability to distinguish abnormal thoughts in their head from reality - sometimes this can mean having hallucinations, feeling very paranoid, losing interesting in things - does this ring true with you?
o Olanzapine works by blocking receptors in the brain that are involved in transmitting these messages
How is it caused
o It affects young people like yourself
o We don’t know what exactly causes it but is likely due to combination of genetics and the environment around us
o Some things make it worse or trigger it - such as significant stress or drugs - do either of these things apply to you?
Effect on life?
o Once treated, most people make a recovery -however, there may be times in life where symptoms come back - this is called a relapse
o People with schizophrenia are also at risk of other mental health problems like depression and suicide
o If you start to spot any signs of a relapse such as feeling fearful or having hallucinations you must tell somebody. Similarly if you start to feel low in mood or have any suicidal thoughts it is crucial to inform your doctor. You may need urgent assessment and treatment in these instances
o We would hope that with continued treatment this wouldn’t happen. Is everything clear so far? Can I go on to talk about the treatment?
General note on treatment
o There are things that you can do and things that I can do
o What you can do: keep a healthy lifestyle. Some of the medication have side effects on your health such as weight gain. It is important to exercise and eat a balanced diet to prevent any adverse effect from this. Avoid drugs and alcohol as these can make mental health disorders worse and trigger a relapse or depressive episode. You also have a responsibility to attend appointments with your doctor and take medication as prescribed
o What we can do: we will look after you joint with other services like the GP and community psychiatry team. The main way we treat schizophrenia is with a medicine called an antipsychotic. This can be given as an injection every so often, or as a tablet. We will monitor some blood tests every now and again. We can also use talking therapies, either on your own or with your family. We will also put you in touch with other services that can help with employment or financial matters as this can be a challenge with a new mental health diagnosis.
o As we have previously discussed you may need more urgent treatment for relapses such as with the crisis team or in hospital if very severe
How do you take the medication?
o Tablet daily, or injection every 1-4 weeks
o Start at a small dose and build up over a week or two - dose adjust depending on the person’s response
A lot of people take it at night because it can make you feel sleepy
Length of treatment?
o Long term - keeps symptoms from returning
o Tell doctor if wanting to get pregnant
Time before effective
o Days - weeks
Test
o Tests 3 monthly, then yearly - lipids, prolactin, LFTs, glucose, checking physical health
Side effects
o Anti-dopaminergic - tardive dyskinesia, tremor, movement disorders
Alpha adrenergic receptors - postural hypotension
Histamine - sedation
Serotonin receptors -metabolic SE - weight gain, glucose intolerance
o Anti-cholinergic - constipation, dry mouth
o Anti-histaminergic - weight gain, dizziness, drowsiness
o Anti-adrenergic - hypotension
Hyperprolactinaemia - low libido, sexual dysfunction, gynecomastia, galactorrhea
Reduced seizure threshold
Complications
o Neuroleptic malignant syndrome
o Agranulocytosis - rash, infection
Reputable site
o Rethink.org
saftey net - if you feel hot or stiff then seek help immedately
can make you blood cells that fight infection drop in levels so let us know if you feel unwell with a sore throat
SSRI counselling
Explore fears - are not addictive
How do they work?
o Antidepressants alter the balance of some of the chemicals in your brain called neurotransmitters
o SSRIs mainly affect a neurotransmitter called serotonin - an altered level of this is thought to play a part in the cause of depression
How to take it?
o Once daily as a tablet
o Stop 6 months after you start feeling better
When does it start to work?
o Delayed onset of effect - around 4 weeks
o Patients can feel worse before they feel better - increased risk of suicidal thoughts in early stages of treatment (particularly under 30). Ensure support; see again within 2 weeks or sooner if high risk
o ‘It’s important that you keep with it because this is suspected - we wouldn’t want you to stop the medication without speaking to us first’
Monitoring?
o None
Side effects
o GI upset, drowsiness, dry mouth, decreased sex drive, increased risk of bleeding (ask about use of NSAIDs and consider gastro-protection)
o Sertraline can make you feel more or less hungry than usual, so you may lose or gain weight when you start taking it - BNF says weight changes
Discontinuation symptoms
o GI upset, flu like symptoms, sleep disturbance, tingling
o More common in drugs with shorter half-life e.g. venlafaxine + paroxetine
o Should be reduced over a 4-week period - not necessary for fluoxetine though due to its long half-life of 2-4 days
Not working?
o If no response after 4 weeks, increase dose if well tolerated - or consider changing
Contraindications
o Mania
Cautions
o Serotonin syndrome - think triptans, tramadol, ecstasy
Pregnancy
o Weight up risks and benefits - ‘manufacturers advise avoid during pregnancy unless the potential benefit outweighs the risk’
o Use in first trimester gives small increase of congenital heart defects - background rate of approximately 1 in 100
o Use during third trimester can result in persistent pulmonary HTN of the new-born
o Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
o Not known to be harmful in breastfeeding - but again weigh up
Supplementary advice
o www.mind.org.uk
for sexual dyfunction
Reducing dose if achieved full remission
Drug holidays - intermittently miss one or two doses prior to planned sexual activity (not effective with fluoxetine due long half-life)
Phosphodiesterase inhibitor (such as sildenafil) for erectile dysfunction
combined pill - weight gain
things to ask before how much they weigh any migraines smoker any medical conditions or do they take any medication any allergies if <18 ask how old their bf is and if consensual ask about their cycle any previous surgery history of cancer unexplained bleeding high bp previous contraception and pregnancies
Action
o Inhibits ovulation
o Thickens cervical mucus to prevent sperm penetration
o Reduces endometrial receptivity to implantation
o 99% effective
Time
o Taken once a day
How to take
o Tablet
o Take for 21 days then have 7-day break
Length of treatment
o N/a
Effects before time
o If taken on first five days of period is effective straight away - after that then will need to take extra contraception for 7 days
Tests
o Review at 3 months to check blood pressure and BMI
PROS
o Periods become lighter, less painful and regular
o Some improvement in acne
o Decreased PMS symptoms
o Reduction in ovarian, endometrial and colorectal cancer
Important side effects o GI and headache o Breakthrough bleeding o Weight gain o Mood changes o Breast tenderness
Contraindications and complications
o Risk of MI and stroke - VTE risk is 2-3x background risk
o Increased risk of breast and cervical cancer
o CI = migraines with aura, smoking (<35 is a 2 so advantages still outweigh, >35 and >15 a day is a 4, smoke less is a 3), BMI >35, breastfeeding 0-6 weeks (if not breastfeeding then 3 weeks), current or past breast cancer
o Interactions - St John’s wort, some antibiotics
Supplementary advice
o Missed pill - 1 missed pill is ok just take 2 in same day. 2 missed pills or start a new pack 2 days late then take last pill now and use extra contraception for 7 days (if you missed 2 or more in first week and sex in previous 7 days then may need EC)
o If there are less than 7 pills in pack left then finish pack and miss out on break
lithium counselling
Action
o It is commonly prescribed as a mood stabiliser for mood disorders such as bipolar and recurrent depressive episodes that have not responded to anti-depressants
o It works by changing the way your brain processes signals to help stabilise your mood
Timeline
o Once a day
How to take
o Can be prescribed in tablet, capsule and liquid form. Swallow it with plenty of water. Patients are often encouraged to take it at night however this isn’t essential - the patient can choose when they take it but it should be at the same time every day
It is only said to be a night because blood tests need to be done during the day, 12 hours after a dose
o Doesn’t matter if eat with or without food
o Once or twice daily dose
Length of treatment
o Lifelong if it works - regular reviews by psychiatrist
o Risk relapsing if come of it
Effects - time until
o It can take several weeks or months to work (hope to see some affect in a few weeks)
Tests
At the start - BMI, UE, calcium, kidney tests, TFTs, FBC
o It can take several weeks to get the dose correct and to do this we need to take a blood sample every week at the beginning of the treatment
Will be weekly at first
o The lithium level must always be measured 12 hours after their previous dose. Once the lithium level is stable the frequency of blood tests will decrease to once a month, and finally once every 3 months for 1 year, then every 6 months
o In addition, the patient will require six-monthly thyroid function tests (because lithium can cause the thyroid to become under-reactive), urea and electrolytes (the kidneys are responsible for preventing lithium build up in the body therefore we need to make sure the kidneys are working effectively) and calcium monitoring
Important side effects?
o Lethargy, insipidus (diabetes), tremor, hypothyroidism, insides (GI), urine (increased), metallic taste
Complications and contraindications
o Lithium toxicity
GI - diarrhoea, vomiting
Neuromuscular - dizziness, ataxia, tremor
Others - restless, drowsiness
CI = some drugs can precipitate toxicity e.g. diuretics, acei
Supplementary advice o End with a leaflet o Bipolaruk.org.uk o What happens if they miss a dose? Inform them not to take a double dose and instead take their next one as normal
Mention that patients on lithium will receive a lithium record book
They should take this book to all of their appointments to help keep track of their blood test results. Encourage the patient to carry this book with them at all times in case of emergency, particularly if going on holiday
o If the patient is of childbearing age discuss risks with pregnancy - it is associated with increased heart defects and can pass through breastmilk so should be avoided in breastfeeding
Therefore patient should use a reliable form of contraception
Speak to psychiatrist before trying to get pregnant - may change medication or continue if risks are understood
Dont stop suddenly - we will reduce dose down gradually
HRT counselling
ACTION
menopause occurs when ovaries stop making eggs
HRT replaces some of the hormones that start to decline which causes menopause
progesterone protects the endometrium
symptoms include hot fluses, weaker bones, vaginal dryness, loss of libido, mood changes, sleep disturabcnes
it can also have a positive influence on other long-term health problems like reduces risk of osteoporosis and CV disease
also incdicated for women under 60 at risk of fractures or women with early menopause even if no symptoms
TIMELINE
once daily
HOW TO TAKE
most common way is a tablet but other forms include patches and gels or implants (patch might be good if lactose sensitivtiy as most contain lactose)
combined for uterus - either monthly then break, 2 monthly then break or continuous
of oestrogen only for hysterectomy ad do not require endometrial proection
LENGTH OF TREATMENT
trial withdrawal should be suggested when a woman is been asymptomatic for 1 – 2 years, or has been on HRT for >5 years
main issue is breast cancer risk of IHD risk increases if >10 years on it
EFFECTS - TIME UNITL
within weeks - maximal benefit in months
TESTS
o if subtotal – got to check there is no endometrial tissue left around cervical stump – so do 2 progesterone challenges – bleeding after this means positive and needs combined, no bleeding is negative, and means is ok for oestrogen only
- Blood pressure and weight
IMPORTANT SIDE EFFECTS
oestrogen = breast tenderness, leg cramps, bloating, nausea, headaches
progestogen = backache, depression
breakthrough bleeding
risk of clots (2-3x (however overall risk is still low) - but more if previous clot, smoker, obese, immobility - if increased risk then gel or patch)
small risk of stroke
combined = breast cancer - one extra case per 1000 a year and returns to normal after stopping
risks increase >65 years
PROS
reduction in frequency and severity of hot fulshes
improved mood
improved vaginal dryness and improve overal sexual function
can also imrpve urinary symptoms like increased frequency of passing urine
reduces osetoporosis risk
reduces incidence of coronary heart disease
combined reduces colorectal cancer risk
CONTRAINDICATIONS
past breast cancer, undiagnosed vaginal bleeding, endometrial hyperplasia, previous pe or dvt, untreated htn
ALTERNATIVES
conservative - weight loss, caffeine, light clothing
Phyto-oestrogens in certain foods and supplements are commonly used e.g. soy, nuts, wholegrains
MOOD - cbt or antidepressants
VASOMOTOR - ssri’s, clonidine, gabapentin
VAGINAL DRYNESS- lubricants, moisturisers
IRREGULAR BLEEDING - ius
oil of evening primrose for breast tenderness
SUPPLEMENTARY ADVICE
doesnt work as contraception
warfarin counselling
ACTION
thins the blood
does this by blocking vitamin k - this is a vitamin that the body uses to make a clot
TIMELINE
once daily, usually in the evening
HOW TO TAKE
tablet
LENGTH OF TREATMENT
depends on reason
EFFECTS - TIME BEFORE
2-3 days
start w lmwh if immediate effect is required
TESTS
start on 5mg then test INR day 5 and 8 then adjust accordingly
then regular INR checks - how regular depends on inr stability
IMPORTANT SIDE EFFECTS
bruis more easily
GI, headache, hair loss, rash
tell dr if unusual bleeding like bruises without a cause, dark stools, cuts take a long time to heal
CONTRAINDICATIONS
a lot of drug interactions inc steroids, NSAIDs, aspirin, only take half paracetamol dose
CI in pregnancy, haemorrhagic stroke
caution in patients at high risk of falls
avoid too much green veg, cranberry juice, grapefruit juice, alcohol binges
avoid contact sports
SUPPLEMENTARY ADVICE
give anticoagulatn book (yellow)
DOAC counselling
ACTION
TIMELINE
HOW TO TAKE
rivaroxaban must be taken with food
apixaban/edoxaban can be taken without
LENGTH OF TREATMENT
EFFECTS - TIME BEFORE
TESTS
UE
IMPORTANT SIDE EFFECTS
seek advise if bloody stools, blood urine, nose bleeds >5mins, spontaneous brusing, unusla headaches, cuts take long time to heal, involved in major trauma
rash, gi, headache, tired
CONTRAINDICATIONS
CI in pregnancy
avoid contact sports
avoid excess alcohol
SUPPLEMENTARY ADVICE
mustnt stop taking it and try not to forget because rapid fall in drug levels
if missed do not take a double dose
will be given an anticoagulant alert card - carry this with you
ADVANTAGES COMPARED TO WARFARIN
fixed dose, no monitoring for inr, favrouble major bleeding profile overall, lower incidence of intracerebral haemorrhage - but disadvatnages inc bad in renal dysfunction, no specific drug antidote except dabigatran
metformin counselling
ACTION
increases the sensitivity of cells to insulin
TIMELINE
once daily w breakfast - may be increased to twice or three times
HOW TO TAKE
with a meal at same time each day
LENGTH OF TREATMENT
lifelong
EFFECTS - TIME BEFORE
TESTS
UE before starting then annuals
IMPORTANT SIDE EFFECTS
gi, headache, altered taste, weight loss, b12 deficiecny
lactic acidosis
CONTRAINDICATIONS
renal impairement
must not be taken on the day of and 2 days after GA or X ray contrast media as this increases lactic acidosis risk
SUPPLEMENTARY ADVICE
POP counselling
ACTION
thickens mucus, reduces endometrial receptivity to implantation, inhibts ovulation
TIMELINE
HOW TO TAKE
LENGTH OF TREATMENT
EFFECTS - TIME BEFORE
- Taken during first 5 days of period, will work straight away
- If not, then need additional contraception for 2 days
TESTS
IMPORTANT SIDE EFFECTS
acne, breast tenderness, breast enlargement, change in sex drive, mood changes, headaches, n or v, cysts on ovaries (usually harmless and disappear on their own)
CONTRAINDICATIONS
past breast cancer
decompensated liver diseae
SUPPLEMENTARY ADVICE
missed pill - if >12 hours then take a pill asap but only 1 even if means taking 2 on one day - then will need contraception for 2 extra days
if you have unprotected sex from the time that you miss your pill until 2 days after you start taking it reliably again, you may need emergency contraception
levodopa counselinng - just bried notes
will help w rigidity and your slow movements
given w carbidopa
3-4 times a day w food to reduce the nausea
take for as long as it wors effectively
after 5 years most suffer from it working for a shorter time and an on-off effect (fluctuate between severe parkinsonism and repetitive involuntary movements)
SE = psychosis, n and v, postural hypotension, dyskinesias
CI in glaucoma
DS counselling
What is it
o It is the most common congenital abnormality - occurs in roughly 1 in 1000
o It occurs due to the presence of additional genetic material from chromosome 21
o Life-long condition with no cure, not inherited
o Can live independently - some may need additional help and care
Quality of life of baby
o Main cause of early mortality is congenital heart disease - but despite this, many people with DS live happy and fulfilling lives
o They will develop at their own pace
o Life expectancy is 58 in UK
Cause
o Meiotic non-disjunction of the maternal chromosome 21 (95%)
o Robertsonian translocation of unbalanced chromosomal material, usually between chromosome 14 and chromosome 21 (4%)
o Mosaicism
Risk factors
o Risk increases with age - over 40 risk is nearer to 1 in 80, 45 is 1 in 40
o Risk is higher if previous DS baby
How does it present o Low tone - may cause trouble with feeding o Increases reflexes o Characteristic facial features e.g. high arched palate, flat nasal bridge, short neck, epicanthic folds, large gap between toes o Short stature and obesity o Around 50% have congenital heart disease (most common forms are VSD, ASD, complete atrioventricular septal defect) o Developmental delay o Intellectual disability o Autism, ADHD o AD by 6th decade o Asthma is more common o Duodenal atresia, Hirschsprung’s o Diabetes
Screening
o Combined test - 8-14 weeks
Beta-hCG
PAPP-A
Nuchal translucency scanning - increased translucency is associated with DS
• Collection of fluid behind the fetal neck
o Quadruple test - if presents later in pregnancy - less reliable - 14-20 weeks
Beta-hCG
AFP
Inhibin A
Unconjugated estriol
o Is considered positive if risk is greater than 1 in 150 - and then these women are offered diagnostic testing
If positive, does not mean baby has DS, merely means that you fall into the risk category of patients for whom amniocentesis is offered
Diagnosis - dont have to do this
o Chorionic villus sampling - 11-14 weeks
2% risk of miscarriage, infection risk, may have to be repeated if didn’t work first time rarely causes injury to the baby
Takes a small sample of cells from the placenta which is the organ linking the mother’s blood supply with the unborn baby’s
Tests for other things to - Edward’s, Patau’s, sickle cell, thalassaemia, CF, muscular dystrophy - same with amniocentesis
The cells are removed via the abdomen with a needle (most common) or via the cervix with a tube or small forceps
Takes about 10 minutes
Described as uncomfortable rather than painful - may experience period like cramps afterwards
Results available within 3 working days
o Amniocentesis - 15 weeks
1% risk of miscarriage, infection risk, may have to be repeated if didn’t work before
The pregnancy will be at a more advanced stage so you will have less time to think about options
Long thin needle via abdomen guided by an US image
Takes a sample from the amniotic fluid
10 minutes
Period pain
3 working days
saftey netting after procedures - come back if severe abdo pain, contractions, watery loss from vag, fever, bleding
can go home day of - dont have to stay in hospital unless presence of complications
will be see in outpatients clinic in couple weeks time w results
When can I abort?
o Abortion act says it may be terminated after 24 weeks
o Should they wish to keep the baby there is a lot of support and counselling available
Post-natal investigations
o Echocardiography: to screen for congenital cardiovascular abnormalities
o Red reflex testing: to screen for congenital cataracts
o TFTs: to screen for congenital thyroid disease
o FBC: to screen for myeloproliferative disorders and polycythaemia
o Hearing assessment: to screen for congenital hearing issues
o Radiographic swallowing assessment: performed if feeding difficulties are present to screen for gastrointestinal abnormalities (e.g. duodenal atresia)
Management
o Tailed MDT approach
o Genetic counselling for subsequent children
Sensitising events
o Will need anti-D if Rh negative
hysterectomy counselling
Types o Total No cervix o Subtotal Still have cervix o Hysterectomy and salpingo-oophorectomy o Radial Uterus, ovaries, fatty tissue and lymph nodes are removed
Approaches
o Vaginal
o Laparoscopic
o Abdominal
Complications o Damage to bladder/ureter/bowel o Blood loss o VTE o Early menopause o Reaction to GA
Anaesthetic
o GA
o Regional - spinal or epidural (vaginal)
Scar
o Just above pubic hairline - about 10cm long
o Vertical scar is from belly button to pubic hairline
o If laparoscopic then port sites - often around umbilicus so won’t see
SEs
o Catheter - TWOC once can mobilise
o PV bleedings 1-2-week post-operation
Shower
o Can shower day of operation - pat scar dry and keep it clean
Recovery
o 6-8 weeks
Discharge criteria o Eating and drinking o Mobilising o Pain controlled by PO o Urine passed
