general Flashcards
list possible physical causes of weight loss
thyroid disorders
diabetes
consideration of malignancy
gastro-intestinal disorders
what is the HEADSS assessment?
review of ‘systems’ for adolescents since they have few physical health problems, medical issues come from risky behaviours. ask about the context of a teens life…
Home Education Activities/Employment Drugs Suicidality Sex
what questions would help in a suspected eating disorder consultation
do you think you need to lose weight? have you ever made yourself sick, given yourself diarrhoea or taken diet pills? how do you feel in general? Hx of cough? altered bowel habits? urinary symptoms? sweats or excessive thirst? dizziness? ask about periods? do you think you have a problem with your eating?
what is the PHQ-9 modified for adolescents score used for?
the severity measure for depression - age 11-17.
what is lanugo hair?
fine soft hair. a symptom of deep starvation
what clinical signs might you see if a pt had bulimia nervosa?
signs of repeated vomiting such as discoloured teeth and Russells sign on the hands
there may be no obvious stigmata of the disease on examination and pt’s often have a normal BMI, is may not present with weight loss
what history would suggest anorexia nervosa?
deliberately losing weight, probably for a sustained period and restricting diet and over-exercising. physical changes such as fatigue and loss of periods
what would be the next appropriate investigation after suspicion of anorexia nervosa during history?
ECG and bloods
what are the potential dangerous effects of anorexia?
CV:
- mitral valve prolapse
- sudden death-arrhythmia
- bradycardia and hypotension
- refeeding syndrome
Haematological: - pancytopenia due to starvation - thrombocytopenia - decreased sedimentation rate (dampens down bone marrow)
pulmonary:
- respiratory failure
- spontaneous pneumothorax
- emphysema
- aspiration pneumonia
endocrine and metabolic:
- amenorrhoea
- infertility
- osteoperosis
- thyroid abnormalities
- hypercortisolaemia
- arrested growth
- neurogenic diabetes insipidus
- hypoglycaemia
neurological:
- cerebral atrophy
opthalmic and dermatological:
- starvation associated pruritus
- languo haor
- alopecia
- dry skin
- lagophthalmos
GIT:
- constipation
- re-feed pancreatitis
- acute gastric dilation
- delayed gastric emptying
- hepatitis
- dysphagia
what would be the next referral for someone with anorexia?
child and adolescent mental health service
what are some of the potential hazards of nasogastric feeding in a pt with AN?
misplaced tubes
re-feeding syndrome
electrolyte imbalance
constipation
what is the purpose of emesis?
a defence mechanism
list different emetic stimuli
- blood
- intestine
- neuronal input from GI tract, labyrinth and CNS
what are the 2 units that make up the central neural regulation system of vomiting? and where are they located?
- the vomiting centre
- collection of sensory, motor and control nuclei
- receives input from vagal and sympathetic afferent nerves
- responds to incoming signals to coordinate emesis - the chemoreceptor trigger zone
- sensitive to chemical stimuli
- main site of action of many emetic and antiemetic drugs (BBB relatively permeable)
- located in the medulla and pontine reticular formation
what area is concerned with the mediation of motion sickness? describe the stages of motion sickness
chemoreceptor trigger zone (CTZ)
signals from LABYRINTH (inner ear) -> VESTIBULAR NUCLI -> CTZ-> VOMITING CENTRE -> VOMIT
list the main neurotransmitters involved in passing on the messages, and in the emesis/ anti-emesis process
Ach Histamine 5-HT Dopamine Substance P
(receptors found in relevant areas)
demonstrate how the various pathways in the control of vomiting are linked
- higher cortical centres (pain, repulsive sights, smells and emotions)
- vagal afferents, [direct] (convey signals from gut from enterochromaffin cells)
- and the CTZ (main site for sensing emetic stimuli)
- -> feed into the vomiting centre (integrates incoming signals: coordinates emesis)
- vestibular nucliei (inout from the labyrinth)
- vagal afferents (convey signals from the gut to brainstem)
- -> feed into the CTZ (main site for sensing emetic stimuli) –> vomitting centre (integrate incoming signals: coordinates emesis)
list 5 different triggers of nausea/ vomitting
- stimulation of the sensory nerve endings in the stomach and duodenum
- stimulation of the vagal sensory endings in the pharynx
- drugs (Ca chemo, opioids, GA, digoxin)
- disturbances of the vestibular apparatus
- various stimuli of the sensory nn. of the heart and viscera
- others: migraine etc
describe the stages of vomiting
- nausea - feeling of wanting to vomit, associated with autonomic effects like salvation/pallor/sweating
- retching - strong involuntary effort to vomit with no actual vomiting
- vomiting - expulsion of gastric contents through the mouth
what type of vomiting do oesophageal varies and gastric ulcer cause?
hematemesis - vomiting fresh blood or altered (ground coffee looking, comes from further down GIT) blood
other than hematemesis, name two other types of vomiting. provide examples of underlying causes
- projectile vomiting - suggestive of gastric outer or upper GI obstruction
- early-morning - e.g. pregnancy, alcohol dependence, some metabolic conditions (uraemia)
what are the 2 factors that need to be considered when prescribing anti-emetics?
- cause of the vomiting must be known to prescribe. it is better to treat the cause of the vomiting if possible
- drug must be chosen based on where it acts, and the source of the stimuli
a pregnant women with hyperemesis gravidarum required management. what are some of the considerations when using anti0emetics in pregnancy?
benefit: risk ratio (mother and foetus)
try and avoid giving in 1st trimester
list 4 types of anti-emetic medications based on their mechanism of actions
- antimuscarinics (M1)
- antihistamine (H1)
- dopamine antagonists (D2)
- 5HT3 antagonists
antimuscarinic anti-emetics:
a) name the location of muscarinic receptors where these drugs will act
b) name an example
c) name a common presentation that the example in b) is usually used for
d) name 4 SEs
a) vestibular nuclei which receives impulses from the labyrinth
b) Hyoscine Hydrobromide (caution in epilepsy)
c) motion sickness (tablets or patches)
d) dry mouth, blurred vision, hot/flushed skin, bradycardia followed by tachycardia, palpitations and arrhythmias
antihistamine anti-emetics:
a) when is it useful?
b) list some SEs
c) list 3 examples
a) in numerous causes of N/V; including motion sickness and stomach irritants. if someone has a more generic type, something like this will be prescribed
b) drowsiness, anti-muscarinic effects
c) cinnarixine –>good for vestibular disorders and motion sickness rather than generic N/V, contraindications in porphyria, SEs: drowsiness, nausea, weight gain
cyclizine –> generic N/V, motion sickness, vestibular disorders, palliative care. contraindicated in severe liver disease. SEs = angle closure glaucoma, depression, drowsiness
promethazine –> N+V, motion sickness, labyrinthine disorder, good for severe morning sickness. contraindicated in under 2 y/o. SEs: drowsiness, anxiety, dry mouth
dopamine antagonists anti-emetics: list 3 examples
- phenothiazines e.g. chlorpromazine, prochlorperazine –> any cause, including more severe N/V associated with Ca, radiotherapy drugs. SEs: sedation, hypotension, extrapyramidal symptoms
- domperidone –> N+V associated with cytotoxic therapy; GI causes. caution if increased GI motility or cardiac disease. SEs: small increased risk of serious cardiac adverse effects, dry mouth
- metoclopramide –> N/V associated with migraine/ chemo/ radiotherapy and post-op. contraindicated post GI surgery, GI haemorrhage/ obstruction. SEs: movement disorders, fatigue, motor restlessness, spasmodic torticolis, stimulates prolactin release
5HT3 antagonists:
a) name the location of receptors where these drugs act
b) name and example
c) name a common presentation the example
d) list SEs
a) prime site of action is the CTZ
b) ondansetron (‘ansetron’)(contraindicated in congenital long QT syndrome)
c) N/V in pt’s receiving cytotoxic, radiation therapy and post op N/V
d) headache, GI upset (uncommon)
what are the 2 specific types of gut motility?
- propulsion (peristalsis)
2. mixing (combination of peristalisis and local contractive contractions)
describe the implications of chronic constipation
- impedes bowel
- proximal bowel attempt to clear stool via peristalsis waves -> can cause pain and dilation
- overflow may cause Dx of diarrhoea which if treated can have serious consequences
(*before prescribing laxatives, should ensure the problem is constipation, check the pt’s ‘norm’, try to reverse the cause)
discuss 4 types of laxatives and give an example
- Bulk-forming e.g. Ispaghula husk:
- provides increased volume and promotes peristalsis by distension
- indications = small hard stools, fibre cannot be increased in diet
- contraindications = colicky pain, reduced gut motility
- SEs = abdo distension, bronchospasm - stimulant laxative e.g. Senna:
- indications: require increased GI motility
- contraindications: abdo cramps, intestinal obstruction
- SEs: diarrhoea, electrolyte imbalance - softener laxative e.g. Docusate:
- indications: chronic constipation, allow penetration of intestinal fluid
- contraindications: intestinal obstruction
- SEs: abdo cramps, rash, nausea - osmotic laxative e.g. lactulose:
- indications: produce osmotic diarrhoea of low focal pH ( useful in hepatic encephalopathy as ammonia producing bacteria don’t like environment)
- contraindications: intestinal obstruction, galactosemic
- SEs: abdo pn, flatulence, N/V
acute diarrhoea = abrupt onset of 3 or more loose stools/ day and lasts no longer than 14days.
a) describe the problems associated with acute diarrhoea
b) name possible bacterial causes
a) increased GIT motility
decrease absorption of fluid
loss of electrolytes
b) campylobacter enteritis
shifellosis
samonellosis
Ecoli
what is the Tx for ACUTE diarrhoea?
- maintenance of fluid and electrolyte balance (oral rehydration prep)
- anti motility drugs e.g. Loperamide (Imodium). contraindicated in active UC, antibiotic associated colitis, abdomen distension. Yes = GI disorders, headache, nausea
- antispasmodics to reduce muscle tone e.g. Buscopan (hyoscine butyl bromide). contraindicated in tachycardia. SEs skin reactions, dyspnea
Chronic diarrhoea is an episode that last >14days.
what is the Tx?
anti motility agens –> loperamide
bulk forming drugs –> ispaghula hull
opioids if associated pain
define what its meant by complementary alternative medicine
no universally accepted definition.
NHS -> ‘complementary and alternative medicines (CAMs) are treatments that fall outside of mainstream healthcare’
outline the range of CAMs therapies
> alternative medical systems e.g. traditional Chinese medicine, homeopathy, naturopathy, indigenous healing systems
> mind-body interventions e.g. yoga, meditation, deep-breathing exercises, tai chi
> biologically based therapies e.g. herbal medications, vegetable juice therapy, bee venom therapy
> manipulative and body-based methods e.g. osteopathy, chiropractic, acupuncture
> energy therapies e.g. healing touch, magnet therapy, light therapy
Identify the potential indirect risks associated with complementary alternative medicine
- what is established and evidence based can be difficult
- some CAM modalities can be obtained without practice of practitioner e.g. acupuncture (could be perceived as health professional, and gives healthcare advise)
- medical pleuralism: adoption of more than one medical system to the use of both conventional and complementary and alternative medications (e.g. complexity of interactions with migrants that trust systems back home, which may use forms of CAM, and difficult it it goes against evidence-based advice and interacts with medications provided by the NHS)
Discuss the reasons why, and how, patients may use Complementary Alternative Medicines.
reasons:
- chronic long term conditions
- enhancing general sense of well being and overall wellness
- belief that it will be more effective than conventional Tx
- exhausted conventional options or there is no options
- conventional options associated with SEs/ risk (see CT as less natural and herbal is natural and therefore safe)
- feeling of more control
- bridge the gap between illness/disease and waiting time for appointment
- part of health system belief in home country
- longer time with practitioner compared to NHS
Identify the potential risks, direct and indirect, associated with specific complementary alternative medicine
- Homeopathy:
D - no risk of interactions with ‘high potency’ medications
ID - delay in receiving appropriate Tx
- homeopathic practitioners are more likely to have anti-vaccine views and give advice on this
- no legal regulations to set up clinic. media however, have to be made as described - Herbal medicine:
D- interaction with other drugs e.g. contraceptives, anti-depressives, anti-coagulants, anti-epilepsy agents etc
- adverse drug reactions (herbal practitioner can make mix to suit pt’s needs - no regulation)
- quality control (potency difference between batches)
ID - delay in receiving appropriate Tx
*regulated
3. chiropractic and osteopathy: D - adverse reaction (50%) - tearing of artery wall leading to stroke - injury to spinal cord - chiropractic X-rays ID - delay in receiving TX - practitioner attitudes * statutory regulation
4. acupuncture: D - infections - pneumathorax ID - delay in receiving Tx - attitudes of practitioners **local authority licensing
what are the ethical issues surrounding CAM?
does it work?
- nothing more than a placebo, is that a bad thing?
- do we need to know how a treatment works?
is it safe?
- regulation of practitioners/ substances
- direct vs indirect harm
how to balance pt choice against the first duty of a doctor: make the care of your pt’s your first concern
- pt autonomy
- informed choice
