Exam 3 Flashcards
What is the most common psychiatric disorder in the US?
Anxiety
Anxiety definition
Unpleasant state of physical & psychological arousal that interferes with effective psychosocial functioning
Most common presents at age _____; most commonly affects _____
Most commonly presents aged 20-45 years
Mostly women
What are the 3 types of anxiety and describe what you would see in those people
Affective—dread, foreboding, or panic, apprehension, fear, irritability, intolerance, frustration, overreaction; accompanied by autonomic hyperactivity
Behavioral—apathy, compulsion, rigidity, overreactions, preoccupation, repetitive actions
Somatic—loss of appetite, dry mouth, fatigue, diarrhea, sweating, chest pain, hyperventilation, vomiting, paresthesias
Depressed mood is what disorder?
Mood affective disorder
With depressed mood you can see:
Sadness and apathy
Fatigue, loss of appetite, change in sleep, insomnia, irritability, anger, anxiety, hyperactivity
Grief is triggered by:
It is a _____ and ____ response
Triggered by loss of things/persons of value to an individual
Emotional and Physiological response
What are the 5 stages of grief?
Denial
Anger
Bargaining
Depression
Acceptance
What are the 3 phases of grief?
Avoidance
Confrontation
Accommodation
Substance use disorder can cause?
SUBSTANCE USE DISORDER Can cause tolerance, habituation, & physical dependence
Intimate partner violence definition
Pattern of assaultive & coercive behaviors that may include inflicted physical injury, psychological abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation, threats
Intimate partner violence victims are typically:
Intimate partner violence perpetrators are typically:
Victim is typically a child, woman or elderly person
Perpetrator is typically a man, parent or other trusted adult or caregiver
Psychiatric Assessment pneumonic
Always (Appearance)
Send (speech)
Mail (Memory/mood)
Through (thoughts)
the Post (Perception)
Office (Orientation)
Substance use disorder should be a ____ screening
Substance use disorder should be a routine screening
2 possible Clinical Presentation of SUBSTANCE USE DISORDER
Patients who ask questions about their personal substance use
Recent negative consequences from long-standing substance use
Opioid Use Disorders can be from _____ or _____ drugs
Prescription or Illicit
Most common—hydrocodone, fentanyl, oxycodone, oxymorphone, morphine, methadone
Substances sold on street are most likely to be laced with other substances and effects on body can be more unpredictable
Complication of Opioid Use Disorders
HIV/AIDS, hepatitis B/C, tuberculosis, social/judicial issues, low birth weights
Opioid Use Disorders intoxication symptoms
Sudden change in behavior
Euphoria, Drowsiness, Confusion, Nausea, Slowed breathing, Constipation
Opioid Use Disorders withdrawal symptoms
Muscle & Bone pain, Sleep disturbances, Nausea, Diarrhea, Intense cravings
Nicotine dependence can come from
Cigarettes, cigars, chewing tobacco, pipes, snuff, Vaping
Nicotine dependence intoxication characteristics
Intoxication—no characteristics
Nicotine dependence withdrawal symptoms
Withdrawal—intense cravings, depressed mood, sleep problems, impaired concentration, anxiety, increased appetite, irritability
Alcohol-related disorder risk factors
Risk Factors—concurrent depression, anxiety, personality disorder, family hx of alcohol disorder, early age at drinking onset
Biochemical effect of Alcohol
CNS depressant
readily absorbed from stomach and small intestine → bloodstream → liver
Alcohol intoxication is greatest when:
Alcohol intoxication is manifest at:
greatest when BALs are increasing
manifested at the rate of which it is consumed
Alcohol withdrawal symptoms
irritability, tremulousness, insomnia; seizures, delirium tremens, death
BAL
0.05
0.1
0.2
0.3
>0.4
BAL 0.05
Disruption in:
Thinking
Judgment
Inhibition
BAL 0.1
Obvious intoxication
BAL 0.2
Depression of motor functioning & emotional/behavioral dysfunction
BAL 0.3
Stupor
Confusion
BAL >0.4
Coma
Alcohol treatment can be _____ or _____ setting
inpatient or outpatient setting
Pharmacologic treatment for alcohol withdrawal
Long-acting benzos—lorazepam, oxazepam, diazepam, chlordiazepoxide, carbamazepine
Antipsychotics—haloperidol (hallucinations, agitation)
Beta blockers, Clonidine, Phenytoin
Cannabis Disorders:
Euphoric effects of THC:
THC can create a mellow mood by:
impairs short term memory by:
Euphoric effects of THC can last for hours—distortions of time, sound, color, & taste; changes in ability to concentrate; dreamlike states
THC can create a mellow mood by increasing GABA activity
Impairs short-term memory by decreasing brain acetylcholine activity
High doses of THC can cause:
Smoked marijuana can improve:
High doses—red eye, mild tachycardia, orthostatic hypotension, increased appetite, dry mouth, disruptions in recall/memory/sensory-input
Smoked marijuana can improve appetite in persons with HIV/AIDS and reduce N/V in chemotherapy patients
Health risks of THC
50-70% more carcinogens than tobacco
Increased cough, asthma, respiratory infections
Increased incidence head and neck cancers
Circulatory changes—BP, arrhythmias, cerebellar infarction
Immune system dysfunction and fertility issues (erratic ovulation, decreased sperm count)
Exacerbation of panic attacks, anxiety, and depression
Hallucinogen-related disorders can be consumed:
examples of drugs include:
can cause:
Dissociative agents can be smokes, consumed orally, snorted, or injected
Examples include- PCP, angel dust, ketamine, salvia divinorum, LSD, mescaline, MDMA, ecstasy, psilocybin
Can cause - Falls & accidents, memory loss, cognitive deficits, hallucinations, nausea, altered perception
Inhalant - related disorders occur when -
can cause
Exposure to volatile hydrocarbons, gases, nitrities—laughing gas, poppers, snappers, whippets
Can cause neurocognitive problems, pulmonary/cardiac issues, sudden death, respiratory depression, aspiration
Sedative-Hypnotic/Anxiolytic-Related Disorders drugs
Can cause
Barbiturates
carbamates —muscle relaxers
benzodiazepine (Xanax, Ativan—short-acting: Klonopin, Valium—longer-acting)
Can cause CNS depressants—neurologic deficits in memory, coordination, autonomic depression & cognition, alcohol-like side effects
Stimulate - related disorders drugs
cocaine and amphetamine
Cocaine is a ____ ____
it works by:
CNS stimulant—blocks reuptake of dopamine thus increasing dopamine activity in several areas of the brain
Cocaine intoxication symptoms
Cocaine tolerance
Cocaine withdrawal
Fast onset of intoxication - increased self-esteem & perception, agitation, irritability, impaired judgement, impulsive sexual behavior, aggression, hyperactivity, mania, paranoid psychosis
Tolerance and need for increased dosages lead to convulsions, respiratory arrest, cardiac arrest; hypertension, angina, MI, CVA, pulmonary edema, respiratory depression, placental abruption, uterine rupture, PIH
Withdrawal - Irritability, depression, anxiety, insomnia, attention deficit
Amphetamines (Adderall and Meth)
Intoxication symptoms -
Side effects -
Intoxication - Elation, increased self-esteem, increased physical endurance, insensitivity to fatigue/feelings of invulnerability
Methamphetamine—half-life 11 hours
Side effects—hyperthermia, dehydration, anxiety, insomnia, disturbed mood, violent behavior, psychosis; dermatologic issues (skin sores, tooth decay, tooth loss)
Caffeine related disorders -
low doses -
high doses -
lethal doses -
Low Doses—300mg/day—insomnia, restlessness
High Doses–1000mg/—arrhythmias, psychomotor agitation
lethal doses - 5-10g/day—can cause death
Gambling disorder definition
Frequent, compulsive, uncontrolled or addictive gambling occurring habitually, intermittently, or in isolated episodes
Behavior not a substance—creates same brain stimulation as substances
Management for patients with substance or addictive behavior disorders
Motivational interviewing
Formal treatment, support recovery
Discuss various strategies
Follow-up/Referral for patients with substance or addictive behavior disorders
Access to information and support resources (education, treatment, support)
Monitor self-reported use, laboratory markers, & consequences; closely follow those in active treatment
Referral to specialist immediately when patient’s behavior represents a danger to self or others
Patient education for patients with substance or addictive behavior disorders
Education on effects of drugs, substances, behaviors, etc.
`DSM 5 criteria for diagnosis of substance use disorder
Substances taken in greater amount than intended
There is persistent desire or unsuccessful effort to cut down or control use
There is a craving for the substance
Repeated use leads to inability to perform role in the workplace or at school or home
Use continues despite negative consequences in social and interpersonal situations
Valued social or work-related roles are stopped because of use
Repeated substance use occurs in potentially dangerous situations
Substance use not deterred by medical or psychiatric complication
Tolerance develops: increasing amount is needed to obtain effects
Withdrawal syndrome occurs or patient takes substances to prevent withdrawal
Schizophrenia has a _____ onset
They typically hear:
behavioral symptoms :
acute or insidious onset
Hear internally generated voices not heard by others or believe other people are reading their minds, controlling their thoughts, or plotting to harm them
Fearful, withdrawn, reluctant to engage in treatment or nonadherent to treatment
To be diagnosed with Schizophrenia symptoms must:
Symptoms present for at least 6 months with 2+ positive or negative sx present for at least 1 month.
and cause social, employment, or self-care impairment
Schizophrenia clinical presentation:
first frank episode:
______ symptoms are common
____ symptom cluster
First frank episode usually 15-25yoa (men) and 25-35 (women)
Depressive symptoms are common
4 Symptom Clusters -
Positive-exaggeration of normal
Negative-absence or diminution of normal
Cognitive Impairments
Affective Disturbances
Positive symptoms
Hallucinations
Delusions
Disorganization
Movement disorders
Negative symptoms
Flat/blunted affect
Alogia (poverty of speech)
Asociality/anhedonia (lack of pleasure)
Apathy (lack of self-motivation)
Cognitive impairment
Poor executive function
Difficulty focusing
Verbal/visual learning/memory deficits
Verbal comprehension
Social cognition
Affective disorders
Blunted/flat affect
Poor self-esteem
Depression & anxiety
Increased risk of suicide
Management for patients with schizophrenia
tx for positive symptoms
tx for negative symptoms
Reduce or eliminate symptoms, maximize quality of life, improve function, promote/maintain recovery
Pharmacologic is mainstay of treatment for positive symptoms
Negative symptoms—cognitive behavior therapy, cognitive remediation therapy
Many patients have increased tendency to be non-compliant due to medication side effects
Clozapine—lowest risk of causing extrapyramidal symptoms—can cause low neutrophils (frequent CBC). Myocarditis potential adverse reaction and clozapine must be stopped at that point
Cognitive behavioral therapy
typical antipsychotic
Atypical antipsychotics
Typical Antipsychotics - Perphenazine, fluphenazine, trifluoperazine, haloperidol, thiothixene, loxapine, chlorpromazine
Atypical Antipsychotics - Clozapine, olanzapine, quetiapine, risperidone, aripiprazole, ziprasidone, paliperidone, iloperidone
Initiate medications at lower doses and gradually titrate; remission can be achieved in 3-4 months
Follow up/referral for patient with schizophrenia
Frequent evaluation of CBC, CMP, presence of cataracts when taking antipsychotics
4 side effects antipsychotic drugs can cause
Pseudo-parkinsonism - stopped posture, shuffling gait, tremors at rest
Akathisia - restless, trouble standing still
Acute dystonia - facial grimacing, involuntary upward eye movement, muscle spasms of tongue, face neck, and back (back muscle spasms cause trunk to arch forward)
Tardive dyskinesia - protrusion and rolling the tongue, involuntary movements of the body and extremities
Major depressive disorder definition
Substantial negative changes in mood, thinking and behavior.
Intense feelings of sadness, irritability, or apathy
Major depressive disorder risk factors
Age—adolescent or adult
Gender—female
Family History—hx of depression, suicide or suicide attempts, alcohol abuse, substance abuse
History—migraine headache, back pain, recent MI, PUD
Current Medical Condition—chronic disease, insomnia
Lifestyle—stress, poverty, <high school education, recent traumatic event, parent/caregiver of child with behavioral disorder, retired
How to diagnosis major depressive disorder
DSM-5—five (or more) symptoms have been present during the same 2-week period & represent a change from previous functioning; symptoms must be present nearly every day; at least one symptom must be:
Depressed mood
Anhedonia (loss of interest or pleasure)
DSM-5 Symptom Criteria
1. Depressed mood most of the day
2. Markedly diminished interest or pleasure in activities
3. Significant weight changes
4. Insomnia or Hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or inappropriate guilt
8. Diminished ability to think or concentrate, indecisiveness
9. Recurrent thoughts of death
Pharmacologic management to MDD
front-line tx
Moderate to severe tx with
Front-line Tx.—SSRIs, SNRIs, TCAs, bupropion
SEs: decreased sexual desire, decreased sexual response, headache, stomach upset, sedation, fatigue, nervousness
Medication limitations: seizure disorder, renal disease, liver disease
Contraindicated in bulimia—paroxetine, fluoxetine, fluvoxamine (liver)
Moderate to Severe Depression—Sertraline or Escitalopram
Non-pharmacologic tx for MDD
Nonpharmacologic
Interpersonal and cognitive behavior therapy
Support groups, Professional counseling
Establish a routine, increase activities, relaxation, massage, exercise, good nutrition
Follow up and referral for MDD
Regular monitoring of effectiveness of medications
Titrate every 1-2 weeks with in the first month of initiating therapy; satisfactory relief typically achieved in 4-6 weeks
Patient education for MDD
Report signs of increased agitation, irritability & suicidality
Danger symptoms—hallucination/delusions, severe urinary retention, fluctuation of BP, seizure, cardiac complications, suicidal thoughts, extreme self-care deficits
Clear understanding of side effects
Bipolar 1 definition
Bipolar 2 definition
cyclothymic disorder
Bipolar I—mania; at least one episode of mania, an episode of depression is not required for dx
Bipolar II—recurrent moods of hypomania & depression; both
Cyclothymic disorder—alternating cycles of hypomania & depressive episodes less severe than manic or MDDs
Management of bipolar
Pharmacological
non-pharm
Pharmacological
Mood-stabilizing medications, 2nd-generation antipsychotics, 1st-generation antipsychotics, adjunctive anxiolytics/antidepressants
Antidepressants can precipitate mania so should always be given in conjunction with a mood-stabilizer
BD 1—lithium, valproic acid, carbamazepine, oxcarbazepine
Acute mania—divalproex/valproic acid
Non-Pharm
Referral to psychiatrist, psychotherapy, cognitive behavioral therapy
Follow-Up/Referral:
Patient education for bipolar
Limit everyday stimulants (coffee, alcohol, OTC meds that contain)
Maintain regular sleep patterns and work schedules
Avoid unnecessary or illegal drugs
Mnemonic for diagnostic criteria for manic episodes
D - distractibility
I - indiscretions (excessive pleasure activities)
G - Grandiosity
F - Flight of ideas
A - Activity increase
S - Sleep deficits
T - Talkativeness
Definition of
Completed suicide:
Attempted suicide:
Aborted Suicide:
Suicidal ideation:
Parasiticidal behavior:
Completed Suicide—self-inflicted death
Attempted Suicide—potentially lethal acts that did not result in death
Aborted Suicide—potential suicidal behavior that was stopped before the action was completed
Suicidal Ideation—thoughts of causing self-demise
Parasuicidal Behavior—patients who injure themselves in nonlethal gestures but do not wish to die
If a patient presents with suicidal ideation make sure to ask them about -
Red flag presenting signs
plan
intent
availability of means
Hopelessness about the future, helplessness, lack of future-orientation
Management of suicidal patient
Assess level of risk (more specific & detailed the plan and the more available & lethal the method)
Reduce/eliminate imminent danger
Never leave a patient alone who is actively suicidal
Involve family members or SOs
What scoring system can you use to determine a persons degree of suicide risk?
S - sex
A - age
D - depression
P - previous attempt
E - ethanol consumption
R - rational thinking loss
S - social support loss
O - organization of a plan
N - no spouse
S - sickness
0-4 low risk
5-6 medium risk
7-10 high risk
Follow up and referral for suicidal patients
For non-acutely suicidal patients, follow-up within 24 hours of assessment. Acutely suicidal send to hospital.
24-hour crisis line
Do not exceed 1-week supply (no refills) of medications
Generalized anxiety disorder definition
Use screening questionnaire such as
excessive worry, over 6 months, about multiple concerns that are difficult to control
Cause by inadequate Norepinephrine, Serotonin, and/or GABAs
Use screening questionnaires—i.e. GAD-7, Beck Anxiety Inventory
3 primary symptoms of GAD
Motor Tension—shakiness, restlessness, insomnia, headaches
Autonomic hyperactivity—excessive sweating, various GI sx., palpitations, concentration problems, tachycardia, headaches, SOB
Cognitive Vigilance—irritability, quick-to-startle response
Criteria for diagnosing GAD
Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events or activities
Management for GAD
pharmacological -
non-pharm -
Pharmacological
SSRIs—first-line treatment (Escitalopram, Paroxetine, Sertraline)
SNRIs—acute treatment (Venlafaxine, Buspirone)
TCAs—when needing sedation (Imipramine)
Antipsychotic—trifluoperazine
Antihistamine—Hydroxyzine
Anti-seizure—Pregabalin
Nonpharmacological - Cognitive-behavioral therapy
Follow up/Referral for GAD
monthly appts may be necessary until patient establishes appropriate support
Develop plan with patient to include criteria for seeking emergency services when needed
Patient Education for GAD
Medication can take 4-6 or even 8 weeks to reach effectiveness
Do not mix medications with alcohol
GAD cannot be managed with medication alone, CBT and lifestyle modification, counseling
Education—symptom recognition, effective interpretation of physical symptoms, treatment modalities, decrease of stimulants, medication & counseling (together)
Panic disorder definition
recurrent, intense, short episodes of panic-level psychological & physical symptoms of anxiety
clinical presentation of panic disorder
Recurrent and unpredictable panic attacks—develop suddenly within 10 minutes; resolve within the hour
Fear of the next attack
Pharm
non-pharm
management of panic disorder
Pharmacological
SSRIs & SNRIs—first line treatment
TCAs, benzos, valproic acid, gabapentin; avoid extensive use of benzos
Nonpharmacological
Cognitive behavioral therapy, hypnosis, alternative (yoga, meditation)
DSM 5 criteria for diagnosing panic disorder
Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or discomfort that reaches a peak within minutes, and during which time 4 (or more) of the following are present:
1 - palpitations
2 - sweating
3 - trembling
4 - sense of SOB
5 - feeling of choking
6 - chest pain or discomfort
7 - nausea or abdominal discomfort
8 - feeling dizzy or light headed
9 - chills or heat sensation
10 - paresthesia (numbness or tingling sensation)
11) derealization (feeling of unreality) or depersonalization (being detached from oneself)
12 - fear of loosing control or going crazy
13 - fear of dying
Follow up/Referral for panic disorder
F/U on pharmacologic management every 1-2 weeks, then every 2-4 until therapeutic dosage is achieved
F/U with psychiatrist if fail to respond after 6-8 weeks of standard treatment
Patient education for panic disorder
Thorough understanding of disease process
Exercise, healthy nutrition, relaxation techniques
PTSD definition
Syndrome that develops after a person witnesses, participates in, or experiences direct exposure to actual or threatened trauma (death, threatened death, serious injury, sexual violence)
Experiences are overwhelming; persons re-experience the trauma in dreams and daily thoughts
Clinical presentation of PTSD
Reexperiencing the traumatic event or having intrusive thoughts/nightmares about the event—nightmares, flashbacks, sudden vivid memories
Avoidance symptoms
Negative thoughts/feelings that began/worsened after the trauma
Hyperarousal symptoms—unprovoked anger, jumpiness, “on guard”
pharm
non-pharm
management for PTSD
Pharmacological
SSRIs—paroxetine, sertraline
TCAs may be effective; anxiolytics for acute or short=term sx—Buspirone may reduce intrusive sx
Nonpharmacological
Safety assessment, history established, trauma-focused psychotherapy, cognitive behavioral therapies, narrative exposure therapy, written narrative exposure
DSM 5 algorithm for diagnosing PTSD
Traumatic event -
Trauma exposure -
Meets symptom criteria (new/worse afterward: intrusion, avoidance, hyperarousal
duration >1 month
distress/impairment
PTSD diagnosis
Sexual assault definition
Intentional touching of the victim’s genitals, anus, groin, or breasts
Voyeurism
Exposure to exhibitionism
Undesired exposure to pornography
Public display of images that were taken in a private context or when victim is unaware
pharmacological treatment for sexual assault
STI treatment tetanus booster, HIV counseling/testing/prophylaxis, Hep B, emergency contraception
OCD diagnostic criteria
Presence of obsessions, compulsions, or both—one category required for diagnosis
Obsessions vs compulsions
common examples
Obsessions—recurrent & persistent thoughts, urges, or images experienced as intrusive & unwanted
Compulsions—repetitive behaviors or mental acts an individual feels forced to perform due to either an obsession or strict rules of conduct—decrease anxiety from obsessions
common obsession - Aggressive impulses
Contamination (shaking hands with someone)
Need for order (distress w/disorder or asymmetry)
Religious (blasphemous thoughts, concerns)
Repeated doubts
Sexual imagery (recurrent pornographic images)
common compulsion
Checking (locks, alarms, appliances)
Cleaning (handwashing)
Hoarding (saving trash)
Mental acts (praying, counting, repeating words)
Ordering (reordering objects to achieve symmetry)
Reassurance-seeking
Repetitive actions
OCD
pharm
non-pharm
management
Pharmacological
SSRIs—generally, higher dosages and longer duration trials are necessary to treat OCD—escitalopram & citalopram are not recommended
Nonpharmacological
Cognitive behavioral therapy, group sessions,
body dysmorphia disorder definition
Pre-occupation with one or more perceived physical defects or flaws, often not visible or only slightly so to others
Body dysmorphic disorder clinical presentation
Rarely report symptoms due to feeling ashamed about themselves & their bodies
Depression, anxiety, request referral to dermatologists, plastic surgeons, orthodontists, maxillofacial surgeons
Frequently check mirrors, pick skin, or camouflage bodies; comorbid eating or substance use disorder
pharm and
non-pharm
management for body dysmorphic disorder
Management:
SSRIs—first line treatment—fluoxetine, citalopram, escitalopram, fluvoxamine, clomipramine—12-16 weeks trial
Cognitive behavioral therapy, cognitive restructuring, perceptual retraining
Educate patient and family about the disorder
Hoarding DSM 5 diagnostic criteria
Persistent difficulty disregarding or parting with items regardless of actual value
Results in accumulation of stuff that clutter that living areas and substantially compromise their intended use
Management for hoarding disorders
SSRIs—venlafaxine, paroxetine, cognitive behavioral therapy
Anorexia definition -
refusal to maintain a minimally normal body weight and an intense fear of gaining weight d/t to body image disturbance
Symptoms: amenorrhea, Constipation, Abdominal pain, Hypothermia, Lethargy, Anxious energy, Headaches
Bulimia definition
recurrent episodes of binge eating, followed by compensatory methods to prevent weight gain—self-induced vomiting, misuse of diuretics/laxatives/enemas, excessive exercising or fasting
Symptoms: irregular menses, abdominal pain, fatigue, peripheral edema, bloating, depression, acid reflux, sore throat
Binge-eating disorders
recurrent episodes of binge eating without the compensatory use of vomiting, laxatives, emetics or diuretics
Management of eating disorders
Inpatient—supervised meals, gradual increase in calories, activity; daily weight
Outpatient—Weekly weigh-ins progressing to monthly; gradual weight gain, cognitive behavioral therapy, family therapy
SSRIs—fluoxetine (only drug approved for BN), Vyvanse (BEN)
insomnia disorders are defined as
o Difficulty sleeping
Management of insomnia disorders
Cognitive behavioral therapy, sleep hygiene habits
Benzodiazepines—estazolam, flurazepam, quazepam, temazepam, triazolam; eszopiclone, zaleplon, zolpidem
Antihistamines—diphenhydramine
Antidepressants—trazodone, mirtazapine, doxepin
Antipsychotics—quetiapine, olanzapine
Patient education for insomnia
Discuss good sleep hygiene practices, possible sleep study is suspect sleep apnea
DSM 5 criteria for insomnia
dissatisfaction with sleep quality
clinically significant distress
minimum 3nights/ week
minimum 3 months
have adequate sleep opportunity`
Restless leg syndrome definition
symptoms
Neurologic, sensorimotor—uncomfortable sensations in legs—burning, tingling, crawling, itching
Uncontrolled desire to move legs, associated with sleep disturbance
Clinical Presentation
Symptoms at rest, often worse at night, uncontrollable urge to move legs, excessive daytime sleepiness, bed partner notices excessive movement during sleep, family history
Restless leg syndrome management
pharm
non-pharm
Sleep hygiene, baths, whirlpool, massage, exercise
Pramipexole, Ropinirole
types of abdominal pain
Visceral pain
parietal pain
colicky
burning pain
Most common abdominal complaint cause by mechanical, inflammatory and ischemic factors
Visceral pain—caused by distention or spasm of hollow viscus—generalized and dull
Parietal pain—sharp & well localized—caused by irritation of peritoneum
Colicky—comes and goes
Burning pain—caused by irritation of gastric mucosa by gastric contents
constipation def
most common cause
Difficult or infrequent defecation
Most common cause is lack of dietary fiber
Functional constipation
disordered motility
secondary constipation
Functional—diet low in fiber, sedentary lifestyle
Disordered motility—slowed transit time, megacolon or megarectum, IBS, diverticular disease, common in elderly
Secondary constipation—medications—opioids, analgesics, CCBs, antidepressants, antiparkinsonians, cough medicines, aluminum antacids; chronic laxative use, prolonged immobilization, colorectal cancer
Diarrhea definition
What do you want to focus on during exam?
Increase in frequency, volume, or fluid content of bowel movements over what is normal for the individual
Focus on patient history:
Frequency
Amount & fluidity
Color & characteristics—bloody, tarry, black, steatorrheic, mucus
Diet, Recent Travel, source of drinking water, medication use, med/surg history, sexual practices, social/family hx.
Where can people experience heartburn pain?
Dyspepsia definition: - associated symptoms
Heartburn—extreme pain, often radiating to the back, arms, or jaw
Dyspepsia—epigastric discomfit, postprandial fullness, early satiety, anorexia, belching, nausea, heartburn, vomiting, bloating, borborygmi, dysphagia, abdominal burning.
Jaundice definition
Will see what labs?
Yellow coloration of the skin, mucous membranes & sclera from accumulation of bilirubin in the blood
Elevated AST, ALT, bilirubin
Melena definition
Black, tarry stools that test positive for occult blood—most common cause is upper GI bleed
Dysphagia definition
Difficulty swallowing caused by mechanical obstruction or a functional problem that impairs motility
Gastroenteritis definition
Inflammation of the stomach and intestine that manifests as anorexia, nausea, vomiting, and diarrhea
Bacterial, Viral, Parasitic most common causes
Management of gastroenteritis
antimotility drugs such as:
Antimicrobials if:
Fluid and electrolyte management for patients presenting with diarrhea
Calories from boiled starches (potatoes, pasta, rice, wheat, oats) with salt during illness
Anti-motility drugs—pepto-bismol, Imodium, Lomotil—contraindicated in febrile dysentery
Antimicrobials if severe diarrhea with fever and leukocytes in stool—azithromycin (traveler’s diarrhea)
Patient education for gastroenteritis
Prevent spread of disease—good hand washing, safe disposal of waste, avoid daycare while sick
When traveling to high-risk area, only consume safe foods & beverages
Types of hepatitis and how they are typically contracted
Hepatitis A—contaminated food or water—fecal-oral route of transmission
Hepatitis B—transmission via direct contact with infected blood/blood products or by sexual contact
Hepatitis C—percutaneous exposure to blood & blood products
Hepatitis D—only persons with HepB are at risk for HepD—injection drug use—parenteral route
Hepatitis E—fecal-oral route, not as easily transmitted as A—fecally contaminated water
Hepatitis definition
chronic hepatitis
Acute viral—systemic infection predominantly affecting the liver
Chronic Hepatitis—elevated AST/ALT for more than 6 months; typically B & C
Prodromal phase presentation
Icteric phase presentation
Convalescent phase
Prodromal Phase Presentation - Anorexia, nausea, vomiting, malaise, URI, flu-like sx., myalgia, arthralgia, easy fatigability, fever
Icteric Phase - Jaundice, dark urine 5-10 days after initial sx.
Convalescent Phase - Increased sense of well-being, other symptoms subside and appetite returns
Management and referral of hepatitis
HepA & B vaccines
Supportive treatment—balanced nutrition with adequate calories and fluids
HCV—referral to hepatologist
HAV—usually do not require f/u
HBV—f/u 1 month and blood draw in 6 months
Referral to hepatologist for chronic hepatitis
Appendicitis definition
How is it diagnosed
Inflammation of the vermiform appendix caused by an obstruction and/or infection
Dx - CT abdomen
Most common cause of acute RLQ pain requiring surgical intervention
3 signs of acute appendicitis and how to test for them
Rovsing’s sign (a.k.a. indirect tenderness) is a right lower quadrant pain elicited by pressure applied on the left lower quadrant.
Psoas sign -Pain on passive extension of the right thigh. It is present when the inflamed appendix is retrocecal and overlying the right psoas muscle.
Obturator sign - is a clinical sign of acute appendicitis, it is defined as discomfort felt by the subject/patient on the slow internal movement of the hip joint, while the right knee is flexed. It indicates an inflamed pelvic appendix that is in contact with the obturator internus muscle
Appendicitis symptoms
pain in RLQ vague at first than localizing
low grade fever
constipation or diarrhea
n/v
Management of appendicitis
Follow up
Patient education
Surgery - Preop—correct fluid & electrolyte imbalances, bedrest, NPO, NG if indicated, stool softener if constipated
Give a 3rd gen cephalosporins (cefitraxone)
Follow-Up/Referral:
F/U with surgeon 5-7 days post-op
Patient Education:
Post-op instructions from surgeon; no heavy lifting for 2 weeks
what is GERD?
Primarily caused by?
Backward flow of stomach or duodenal contents into esophagus without retching or vomiting
Primary cause—inappropriate, spontaneous transient relaxation of lower esophageal sphincter (LES)
Precipitating Factors -
Reclining after eating
Eating a large meal
Restrictive clothing
Heavy lifting
Ingesting alcohol, chocolate, caffeine, fatty/spicy foods, nicotine
How is GERD diagnostic made?
If a patient fails therapy then?
Usually made from history
EGD after failed treatment
Initial management to GERD
Unresponsive management
Initial:
Weight loss, elevate head of bed 6-8 inches, avoid meals 2-3 hours before bedtime, avoid irritating foods
8 week trial PPI once daily—step-up to twice daily if only partial response
Unresponsive to 8 weeks of PPI:
If EGD shows erosion or Barrett’s esophagus—chronic PPI may be necessary
Follow up and referral for GERD
8 weeks after initiation of either PPI (omeprazole) or H2 (famotidine) therapy
Evaluate chronic PPIs every 6 months
Possible adverse effects of PPI—pneumonia, c-diff, osteoporosis, vit B12 deficiency
What is peptic ulcer disease?
Usually caused by?
Break in the surface mucosa of the stomach or duodenum
Occur when there is an imbalance between the protective factors o the mucosa and aggressive factors as acid & pepsin
Usually result of H. Pylori infection, medications (NSAIDs)
Gastric ulcers and Duodenal ulcers
Major difference between peptic ulcer disease and GERD
PUD has pain (dyspepsia) in epigastrium relieved by food or antacids
Management of PUD
how to treat H pylori
PPIs—omeprazole, rabeprazole, lansoprazole, esomeprazole, dexlansoprazole, pantoprazole
Duodenal ulcers—4 weeks; Gastric ulcers—8 weeks
H2RAs—avoid cimetidine due to affect on other medications (warfarin, theophylline, phenytoin)
Daily at bedtime or half regular dose twice daily for 8 weeks
H. Pylori infection
riple therapy: clarithromycin w/ amoxicillin or metronidazole and PPI BID x14 days
FU and PE for PUD
F/U in 4 weeks if treating H. Pylori
If non-HP, f/u unnecessary unless symptoms recur
PE
Stool can turn black if taking bismuth preps
Sucralfate cannot be taken with other medications as it will bind to them
What is a hemorrhoid
External
vs
internal
Mass of dilated and tortuous veins either internal or external
Primary cause believed to be straining during defecation, complicated by constipation, prolonged sitting, pregnancy, and anal infection
Objective
External: usually protrude on standing or with Valsalva
Internal: rectal bleeding (bright red streaks)
Abdominal hernia def
Protrusion of peritoneally lined sac through defect or weakened area in abdominal wall
Management and PE of hernias
Surgical referral
FU 3-7 days post op
Avoid heavy lifting for at least 4-6 weeks.
what is Irritable bowel syndrome and how is it diagnosed
Abdominal pain/discomfort and change in bowel habits
Two must be present:
Abdominal pain relieved by defecation
Change in frequency in stool
Change in the appearance of the stool
Women more than men, 3:1
Common dietary triggers—lactose, fructose, sorbitol, glutens
IBS symptoms
Abdominal pain
Altered bowel habits
Diarrhea & Constipation
Painless diarrhea
LLQ pain
Sharp/burning/cramping/
diffuse/dull
incomplete evacuation
Management of IBS
what type of diet
2 classes of meds
PE includes
First make accurate diagnosis and identify symptom pattern specific to each patient
Therapy is symptomatic
Slowly eliminate IBS triggering foods to attempt to isolate a food trigger
High fiber diet, at least eight 8-oz glasses of water/day, probiotics
Anti-diarrheal—loperamide, diphenoxylate
Antispasmodics—dicyclomine, hyoscyamine
Diet, stress management, good bowel habits
What is celiac disease and how is it diagnosed?
Gluten-sensitive enteropathy; celiac sprue; autoimmune disorder affecting small intestinal villous epithelium
Wheat, rye, barley
T-cell mediated
Serum testing anti-tTG IgA antibodies
Management is a strict gluten free diet
How does a bowel obstruction occur?
Classified based on _____ or ____ and _____ of _____
Early obstruction is:
Late obstruction is _____
Mechanical blockage or functional (paralytic ileus) disrupting motility
Acute onset causes—torsion, herniation, intussusception
Chronic causes—slow process, tumor growth, strictures
Classified partial or complete and location of lesion
Early obstruction—alkalosis due to non-absorbed hydrogen ions
Later obstruction—acidosis occurs due to alkaline pancreatic secretions & bile not being absorbed
Subjective and objective symptoms
Management
Sudden onset colicky pain with N/V
Pain with peristaltic waves
Initial diarrhea followed by constipation
BS high pitched & hyperactive
Management -
Immediate hospitalization with surgical referral
Most will require NG tube insertion
IV fluid rehydration, accurate I/O
Surgical repair if complete obstruction
What is diverticulitis vs diverticulosis
Diverticulitis - Inflammatory changes within the diverticular mucosa of the intestine
Diverticulosis - Asymptomatic, uninflamed outpouchings
Possible causes and
how it is diagnosed
Low fiber diet, high fat, high red meat, obesity, chronic constipation
Abdominal X-ray
CT abdomen
Colonoscopy
How is diverticular disease treated?
FU will require:
Patient education
Rest, clear liquid diet during acute phase; high fiber diet after
Abscess drain if necessary
Augmentin BID, Flagyl TID, Bactrim DS BID all for 7-10 days or until patient is afebrile for 3-5 days
Hyoscyamine, Dicyclomine, Buspirone—for pain
Possible hospitalization for acute presentation requiring hydration, analgesia, & bowel rest (NG)
Possible surgical management with resection
Follow-Up/Referral:
Will require follow up colonoscopy
Patient Education:
High fiber diet, avoid irritating foods (seeds, popcorn, hulls), constipation prevention, increase water intake
Inflammatory bowel disease 2 common conditions
Chronic immunological disease that manifests in intestinal inflammation
Exacerbations and remissions throughout a patient’s lifetime
Ulcerative Colitis—involves only mucosal surface of the colon—friability, erosions, bleeding
Crohn’s Disease—segmental or patchy transmural inflammation of the bowel wall of any portion of GI tract
Management of UC
Nutrition counseling: Avoid caffeine, raw fruits/vegetables and other foods high in fiber; can try lactose free
Avoid anti-diarrheals in the acute phase; mild to moderate diarrhea—lomotil, Imodium
Topical mesalamine, steroid enemas, oral 5-ASAs, typically require systemic flucocorticoids
Severe disease unresponsive to treatment will require surgical referral
Correct fluid/electrolyte imbalances (hypokalemia)
Management of Crohn’s disease
Sulfasalazine, glucocorticoids; treatment aimed at suppressing inflammatory process and symptom relief
Sulfasalazine interferes with folic acid absorption—must take supplement
Metronidazole, ciprofloxacin, ampicillin, tetracycline
Avoid anticholinergics and anti-diarrheals to decrease risk of toxic megacolon or ileus
Colorectal cancers
most important risk factor in developing
typically presents as
Majority of cases are both curable and preventable if detected early
Age is most important risk factor for developing colorectal cancer in US
Typically present as polyps
Cancer typically found incidentally during abdominal surgery or screening colonoscopy
First step in disease process -
average risk should begin coloscopy at
high risk
First step is staging of the disease—tissue of origin, origin of specimen, degree of tissue differentiation
Average Risk—Begin age 50 thru 75 (45 for African Americans)
high risk - Colonoscopy every 5 starting age 40 or 10 years younger than age at dx of youngest affected relative
what is cholecystitis - impacted ___ within _____
Subjective complaints
Acute inflammation of gallbladder was
Impacted calculus within cystic duct
Indigestion, N/V esp after consuming meal high in fat
Begins as colicky pain
Pain localized to RUQ
Objective sign of cholecystitis
murphy sign take a deep breath push on RUQ pain will be elicited
Management of cholecystitis
Avoid foods high in fat
Nonsurgical—oral dissolution solutions, lithotripsy
If remain symptomatic after non-surgical attempts and diet management, surgical intervention
What is acute pancreatitis
80% of the time it is caused by
Acute inflammation of the pancreas and surround tissues from release of pancreatic enzymes
80% caused by biliary tract disease or alcoholism
How to treat mild acute pancreatitis
How to treat severe acute pancreatitis
Mild—resolves spontaneously in a few days; fasting is necessary
Parenteral fluids, consider NG tube, Morphine for opioid pain relief; introduce clear liquids when patient is pain free, amylase/lipase have returned to normal and bowel sounds returned
Severe—typically require ICU for aggressive fluid resuscitation (up to 6-8L/day)
Daily labs (CBC, CMP, amylase/lipase, blood cx if fever, ABG); prolonged fasting—TPN may be necessary
What is chronic pancreatitis
What typically causes it?
Slow, progressive inflammation; irreversible fibrosis of the pancreas; destruction of exocrine & endocrine tissue
Alcoholism with high protein and high/low fat daily diet
Management and patient education for chronic pancreatitis
Prevent further pancreatic damage, manage pain, supplement exocrine & endocrine function
Abstinence from alcohol is imperative
Narcotics are usually necessary for pain control
Low-fat diet, oral pancreatic enzyme supplement, fat-soluble vitamins (A,D,E,K); Insulin (maintain glucose at higher than normal level to avoid hypoglycemia due to deficiency of glucagon secretion)
Goal of treatment is to control diarrhea and gain body weight
Caution against long-term narcotic use and risk for drug dependence
What is cirrhosis
Hepatocellular injury of entire liver from fibrosis, nodular regeneration, & distorted hepatic architecture.
Cirrhosis is permanent and irreversible
Many causes—chronic alcohol abuse & viral hepatitis leading causes
Objective findings of cirrhosis
enlarged firm liver palpable below R costal margin
jaundice
muscle wasting
spider angioma
encephalopathy
asterixis (liver flap)
Management of alcohol induced cirrhosis
Management of irreversible chronic cirrhosis
Alcohol-induced -
Absiinence is most effective treatment
Patients presenting with ascites who continue to drink drop 2 year survival rate to <25%
Increase protein intake to 1-1.5 g/kg per day (unless encephalopathy); vitamin/mineral supplementation (B12, folate, thiamine, magnesium, zinc)
irreversible
Liver transplant is treatment of choice
Patient education for cirrhosis
Daily weight, psychological well-being, educate on medications that cause hepatotoxicity (i.e. acetaminophen)
Avoid CNS depressants with encephalopathy
S/Sx of infection with ascites and risk for bacterial peritonitis
