CVS Risk Factors, Instrumentation, Pain Management & Psychiatric Disease Flashcards

Question

Describe the pathophysiology of Obstructive Sleep Apnoea?

Answer 1

**Sleep studies** Indicated in all patients with excessive daytime sleepiness and at least two of the following: 1. Loud snoring 2. Witnessed choking, gasping, or apnea during sleep 3. Diagnosis of hypertension Consider in patients with comorbidities (including complications of OSA) and risk factors for OSA. In-laboratory polysomnography is the gold standard for the diagnosis of sleep-related breathing disorders and can also help identify other sleep-related conditions (e.g., seizures).

Answer 2

1. Systemic hypertension 2. Hypoxia-induced cardiac arrhythmia (e.g., (atrial fibrillation, atrial flutter) 3. Pulmonary hypertension and cor pulmonale 4. Global respiratory insufficiency 5. Cardiac infarction, stroke, and sudden cardiac death (the risk of sudden death is high in infants and the elderly) 6. Polycythemia 7. Risk of accidents (e.g., car crashes, occupational accidents) due to microsleep 8. Increased risk of developing vascular dementia 9. Poor sleep leads to increased appetite and obesity.

Answer 3

**Approach to Treatment of OSA** - Treat all patients with diagnosed OSA. - First-line treatment: positive airway pressure (PAP) - Consider alternative treatment in patients who are unable to tolerate or decline PAP: 1. Oral appliances 2. Upper airway modifications 3. Positional therapy 4. Supportive care should include management of risk factors, e.g., weight loss and sleep hygiene.

Answer 4

mild to moderate depression

Answer 5

Bipolar Disorder with Mania

Answer 6

**Affect** = an objective impression of a person’s mood. How another person perceives you.

Answer 7

Caution putting those you suspect BPD on an antidepressant as you can cause a full blow manic episode.

Answer 8

= Antithesis of depression Mania usually always requires hospitalization whereas hypomania can often be managed at home

Answer 9

1. **Bipolar Type 1** with HYPER (extreme) mania. There may or may not be much depression. 2. **Bipolar Type 2** with HYPO (not extreme) mania but usually more significant depression. 3. **Rapid cycling** with cycling up and down more than 4 times per year, or even ultra-rapid cycling several times within a day. 4. **Mixed States** – Both manic and depressed at the same time. 5. **Cyclothymic Disorder** – “bipolar light” – Hypomania and mild depression

Answer 10

Sodium valproate + Lithium are both teratogenic so consider usage in young women. Lifestyle changes are super important in bipolar disorder.

Answer 11

Mainstay of drug treatment for anxiety = antidepressants

Answer 12

Positive = what you can see, negative = cant see.

Answer 13

**Causes of Psychotic Disorder - What we Know** Primary = no obvious trigger/ 'functional mental illness Secondary = organic 1. Delirium 2. Thyrotoxicosis 3. Medication 4. Drugs 5. Stroke 6. Brain injury Vulnerable brain + insult = psychosis

Answer 14

- You are born with way more neurons than you need, during childhood & adolescence & early adulthood, it reshapes (neuronal pruning). - Temporo-parietal – sensory - Frontal = social interaction, drive to do things.

Answer 15

Clozapine = the most potent antipsychotic but it’s not the most potent D2 blocker

Answer 16

- Clozapine > Olazepine/Amisulpride > Risperidone > Quetiapine - Antipsychotics are relatively inaffective for negative symptoms and cognitive impairment - Clozapine = the most effective drug by far but not first line given the dangerous side effects – must be monitored carefully (agranulocytosis), usually reserved for patients who don’t respond to the others.

Answer 17

Risk of relapse = high so long-term treatment is often necessary CBT = Cognitive Behavioural Therapy CRT = Cognitive remediation therapy (CRT), sometimes referred to as cognitive enhancement therapy or cognitive rehabilitation therapy, is a treatment method that helps individuals improve their memory, attention, organizational skills, and information processing.

Answer 18

Myelination of pathways Beginning of adolescence = commencement of puberty End of adolescence = complete ossification of the clavicle (anatomically) and socially – eg. End of university, marriage etc.

Answer 19

Intra-uterine insult – eg. Fetal alcohol syndrome

Answer 20

**Psychological Treatments** 1. Informal psychological help 2. Psychotherapies - Insight-directed psychotherapies - Cognitive behavioural therapies

Answer 21

**Psychotherapies** - Trained practitioner - Sanctioned by society to do it - Guided by some clearly articulated theory **Essentials** - Enable a person to satisfy her/his legitimate needs for affection, recognition, sense of mastery by helping him/her to correct the maladaptive attitudes, emotions, and behaviour which impede the attainment of such... - Seeks to improve social interactions, reduce distress whilst helping to accept that suffering is an inevitable aspect of life and to use this for personal growth. - Some have an evidence base, others not.

Answer 22

1. Housing 2. Employment 3. Relationships

Answer 23

**Social Psychiatry - Employment** - Unemployment is a risk factor for psychiatric illness and suicide - People with mental illness are overrepresented in unemployment figures - Many people with MI would like to work - Employment is a positive contributor to good mental health

Answer 24

Lithium is a psychiatric medication used primarily as a first-line therapy for bipolar disorder. It is also used in treatment-resistant depression to augment antidepressants. The specific mechanism by which lithium acts to stabilize mood is not definitively known, but it is thought to be due to inhibition of the phosphoinositol cascade. Common side effects include gastrointestinal distress (nausea, diarrhea), polyuria, polydipsia, and tremor. Lithium therapy has a very narrow therapeutic index; frequent monitoring is therefore required to prevent toxicity.

Answer 25

- 95% of lithium is excreted by the kidneys. - It is freely filtered at the glomerulus and mostly reabsorbed in the proximal convoluted tubule via sodium channels.

Answer 26

LITHIUM: “Lithium can cause Irregular Thyroxine levels (hypothyroidism or hyperthyroidism), Heart (Ebstein anomaly), nephrogenic diabetes Insipidus, and Uncontrolled Muscle movements (tremor).”

Answer 27

Toxicity occurs at serum levels > 1.5 mEq/L.

Answer 28

Alternative maintenance treatment options for bipolar disorder include: 1. Lamotrigine 2. Valproate 3. Carbamazepine. Valproate and antipsychotics (e.g., olanzepine, quetiapine) can be used for treatment of acute mania and hypomania.

Answer 29

Before prescribing lithium to women of child-bearing age, evaluate thyroid function, renal function, and human chorionic gonadotropin levels to rule out pregnancy.

Answer 30

**Teratogenic effects** It appears that the risk of teratogenic effects from lithium has been exaggerated in the past. However, there is a small risk and lithium is best avoided during pregnancy. Management during pregnancy should be collaborative and requires careful informed consideration of the risks.

Answer 31

1. Drainage of urine in Urinary retention 2. Urinary output monitoring 3. Taking a sterile urine sample 4. Supportive management of immobilized patients 5. Drug instillation (e.g., BCG instillation in bladder cancer) 6. Bladder irrigation with saline (e.g., in haematuria with clots)

Answer 32

**Transurethral catheterization**: a urologic procedure that involves insertion of a catheter through the urethra with placement in the bladder. - Generally the preferred method for acute bladder catheterization **Suprapubic catheterization:** a surgical procedure that involves insertion of a catheter through the abdominal wall with placement in the bladder. - Method of choice if transurethral catheterization is difficult (e.g., urethral stricture, large prostate) or contraindicated (e.g., suspected urethral trauma, recent urethral surgery, acute bacterial prostatitis) - Often preferred for chronic bladder catheterization

Answer 33

Materials (top left): Sterile: (a) stopper; (b) 10mL syringe; (c) swabs; (d) tweezers; (e) disposal tray; (f) urinary catheter; (g) lubricant with lidocaine; (h) perforated drape; (i) sterile gloves Non-sterile: (j) mucosal antiseptic; (k) distilled water; (l) collection bag Procedure: 1. The sterile drape is placed over the patient. Using one hand to open the labia and the other hand to hold the forceps and water/disinfectant soaked swab, the labia and urethral meatus are cleaned (using one swab per wipe). 2. The lubricant containing lidocaine is applied to the urethral meatus and into the urethra (not illustrated). The lubricant should be given a few minutes to provide adequate numbing of the urethra. The lubrication is then applied to the catheter tip and the catheter is advanced into the urethra until urine flows. 3. The catheter is advanced fully and 10mL of distilled water are injected into the balloon port of the catheter. 4. The catheter is connected to the collection bag and is then withdrawn slowly until the balloon catches and cannot be withdrawn any further.

Answer 34

1. New onset neurological symptoms 2. Infection over the site

Answer 35

Choose an insertion site at the 4th or 5th intercostal space , between the anterior and midaxillary lines.

Answer 36

**Percutaneous endoscopic gastrostomy** - May be performed endoscopically, surgically, or fluoroscopically **Indication**: nutrition support is anticipated for ∼ > 4 weeks

Answer 37

Commonly, PEG tubes are used to provide a route for enteral feeding, hydration, and medication administration in patients who are likely to have prolonged inadequate oral intake. Gastrostomy tubes are occasionally placed for decompression in the setting of prolonged ileus, dysmotility, or inoperable intestinal obstruction.

Answer 38

**Gastrostomy tube** (e.g., inserted via percutaneous endoscopic gastrostomy): a feeding tube that is inserted into the stomach through a small incision in the abdominal wall **Jejunostomy tube** A feeding tube that bypasses the stomach and duodenum Used if gastrostomy is contraindicated - eg. due to gastroparesis, chronic pancreatitis

Answer 39

Non-pharmacological pain management is the management of pain without medications. This method utilizes ways to alter thoughts and focus concentration to better manage and reduce pain. 1. Education and psychological conditioning 2. Hypnosis 3. Comfort therapy 4. Physical and occupational therapy 5. Psychosocial therapy/counseling 6. Neurostimulation

Answer 40

- The WHO analgesic ladder was a strategy the World Health Organization (WHO) proposed in 1986 to provide adequate pain relief for cancer patients. - This analgesic path is currently applied for managing cancer pain, acute and chronic non-cancer painful conditions due to a broader spectrum of diseases such as degenerative disorders, musculoskeletal diseases, neuropathic pain disorders, and other types of chronic pain. - The three main principles of the WHO analgesic ladder are: “By the clock, by the mouth, by the ladder”. - This three step approach is inexpensive and 80-90% effective when optimally utilized.

Answer 41

Patient Controlled Analgesia (PCA) is a method of pain relief that allows a patient to selfadminister small doses of analgesia as required, from a locked programmable pump. PCA is appropriate for patients’ who have acute pain which is likely to warrant repeated doses of parenteral opioid.

Answer 42

Opioid analgesics act on receptors in the CNS and GIT producing analgesia, respiratory depression, sedation and constipation. They act mainly at mu-opioid receptors in the CNS, reducing transmission of the pain impulse, and by modulating the descending inhibitory pathways from the brain. Cough suppression occurs in the medullary centre of the brain.

Answer 43

1. Concussions. 2. Encephalitis. 3. Meningitis. 4. Intestinal blockage. 5. Appendicitis. 6. Migraine headaches. 7. Brain tumors.

Answer 44

In many cases nil investigations may be appropriate. Basic biochemistry may include (as appropriate): * electrolytes and renal function * full blood count * pancreatic and liver enzymes * glucose. If small bowel obstruction is suspected, erect and supine abdominal radiographs should be considered. However, it should be remembered that these are neither sensitive nor specific. They can be normal in patients with partial/ subacute obstruction and acute gastroenteritis may cause a degree of small bowel dilation and some fluid levels.

Answer 45

The nauseated patient may be more comfortable in a Fowler's or semi-Fowler's position, but if vomiting or regurgitation occurs, or appears imminent, the patient should be placed in a reclined position with the head lower than the chest and abdomen; a partial or full Trendelenburg position is preferred. This will reduce the risk for aspiration. Also, the patient should be turned on their right side based on anatomical considerations. The right primary bronchus branches at a less acute angle from the trachea, and aspirated material is more likely to enter the right lung, at least initially. Turning the patient to the right side may spare the left lung from aspirant. While positioning the patient, initiate high volume suctioning using a tonsil or Yankauer tip. Avoid placing the suction tip too deeply into the oropharynx to avoid triggering more retching and pushing vomitus further into the airway.

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CVS Risk Factors, Instrumentation, Pain Management & Psychiatric Disease Flashcards

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