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Psychiatry > Introduction (Hx, Ex, Risk etc.) > Flashcards

Introduction (Hx, Ex, Risk etc.) Flashcards

1
Q

risk assessment structure

A

self: DSH, suicide, self-neglect, deterioration, exploitation
others: aggression/violence, dependence
other risk: driving, property, education/employment

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2
Q

MHA principles

A

3 parts: mental illness (not substances)? risk? appropriate care available?

3 professional: 2 doctors, one specially trained (SW, AMHP); consult NOK

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3
Q

MCA principles

A

2 stage test: illness affecting brain? affecting decisions (understand, retain, evaluate, communicate)?

assume capacity UPO; help as much as possible to get capacity; unwise is not incapable; best interests; least restrictive

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4
Q

differentials

A

psychiatric illnesses: think groups

dementia, delirium

physiological: thyroid, liver, anaemia, vitamin deficiency, renal failure, phaechromocytoma, calcium, porphyria

substance abuse:

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5
Q

common investigations

A

collateral history, GP notes
home visits

bloods: FBC, EUC, LFT, TFT, B12/folate, Ca, BM
UA, cultures
ECG, CXR, EEG
Neuroimaging

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6
Q

impact of disorders

A

BPS
diagnosis distress
stigma: dismissed, employment, public abuse, prejudiced health services, finance/insurance

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7
Q

factors influencing engagement, and Mx

A

insight and direct illness effects (delusions, avolition, cognition)
SE, low benefit, enjoy being unwell, dependence worries, stigma
substance abuse, chaotic lifestyle, complex regimes

identify reason and re-educate; capacity and insight
reduce SE, optimise dose, try alternatives, comorbidities
access: e.g. depot, supervised consumption, community support
motivational interviewing (motivation and ambivalence)

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8
Q

classification (ICD-10)

A

F0: organic
F1: psychoactive substances
F2: schizophrenia and delusional disorders (psychosis)
F3: mood disorders
F4: neurotic, stress-related, and somatoform disorders
F5: behavioural syndrome/MH with physiological/hormone dysfunction
F6: adult personality/behaviour disorders
F7: mental retardation
F8: psychological development
F9: CAMHS

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9
Q

psychological models

A

psychodynamic: feelings, identity, emotions; past influences

cognitive behaviour: thoughts, feelings, behaviours, attitudes; current erroneous thinking and maladaptaion

social: life events, maladjustment, stressors

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10
Q

General stats

A

25% life time risk of MH issues; 10% of kids

mortality: schiz 4.8, severe mood 4.9, mild mood 2.4, substances 18.0, personality 3;
male MH mortality 6.1, female 2.8; average 20y premature

direct cost £77b per year, 14% of NHS spend; not including indirect costs

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11
Q

Levels of care:

based on: risk, function, co-morbidity, environment/stressors, history, engagement

A

I: community; recovery maintenance; infrequent
II: primary care; ongoing low intensity community services; regular
III: primary care; high intesnity community services; frequent
IV: secondary care; MDT; intensive programmes
V: secondary care; residential treatment
VI: tertiary care; inpatient services

based on risk

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12
Q

specialist teams

A

crisis team: 24/7; ST Mx at home; prevent Ax; crisis houses
early intervention e.g. EIP: reduced DUP, intensive f/u
assertive outreach: intensive contact for engagement/risk
liaison: gen Hospital teams
mother and baby units: perinatal; avoid separation
eating disorders: community and inpatient (regional)
personality disorders: community and inpatient; high-security hospitals

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13
Q

common MH in primary care

A

87% present with insomnia, tension headaches, physical disease (1/3 are psych)
somatisation: very common; abdo, chest, back, headache; stress
substance abuse: supsicious drugs (DF118), new reg/unreg’d, alcohol abuse comorbidities
depression: very common, often missed (50% Dx 1st consult, 40% missed, 20% unDx for 6/12)
psychosis (4%): 25% OPd, 72% IP
neuroses (64%): 44% OPD, 18% IP

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14
Q

referral to secondary care indications

A 
treatment resistance
unclear diagnosis
specialist investigations: CT, EEG etc
intensive treatment (high risk): ECT, psychotherapy, megadose, some APDs, CMHT
patient request
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15
Q

BPS management:

A

history, MSE, exam, investigations, risk and capacity, level of care, follow-up

biological: medications, ECT, comorbidities, substance abuse
psychological: psychoeducation, self-help, counselling, CBT, PDT, group therapy, FIT etc
social: lifestyle changes, stressors; education/employment, finance, housing, relationships, carers, social inclusion/hobbies

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16
Q

History pointers

A

reason for referral: who? insight? expectations
HPC: time course/fluctuations; symptoms incl. impact; treatments/effect
PPH: incl. DSH, SI, Ax, MHA; pre-morbid history (self/others opinion too)
personal history: childhood (birth, school, abuse), adult (relations, support, work)
forensic history; current SH (incl. support)

signpost, explain reasoning, normalise Sx, screening Qs

17
Q

‘DOCTAR’

A 
duration
onset: acute/chronic
chronology: episodic, continuous, fluctuating
triggers and treatments
aggravating factors
relieving factors
18
Q

common presentations

A

confusion: dementia, delirium, other organic, pseudodementia
bizarre behaviour: mania, dementia, organic, OCD, ADHD
dangerous behaviour: functional or dysfunctional; risk taking
physical symptoms
interpersonal relationship difficulties
emotional distress, affects function

19
Q

MSE

A

appearance/behaviour: clothing, habitus, eye contact, expression, movement, social behaviour

mood: obj/subj; lability, congruence; mood and affect
speech: rate, volume, quality, fluency; flight/thought disorder
thought: form (flight, accel/decel, dissoc), content (delusion, overvalued, obsession, alientation)
cognition: alert, orientated, memory, concentration/attention, frontal lobe (MOCA)
perception: hallucination, illusion, pseudohallucination, depersonalisation, derealisation
insight: Awareness (ill?), Attribution (psych?), Acceptance (treatment?)

20
Q

immediate management

A

investigations: collateral history, notes/GP info, blood tests, ECG, neuroimaging
treatments: BPS; make safe

21
Q

explanations

A

I EAT PIE: epidemio, aetio, treatment, prognosis

I MAST DIE: indication, mechanism, adv., SE, treatment course, discontinue/alternatives

22
Q

specialisms

A

general adults: 18-65

children/adolescents 65yo

23
Q

factors affecting GP diagnosis

26-32% with diagnosable illness
only 23% feel ‘ill’ and attend; only 10% detected; 2.4% referred, 0.06% admitted

A

less likely to present: somatic, concurrent physical illness, mild/atypical Sx, male, young, unmarried, educated, taciturn, less insight
more likely: female, unemployed, life stressors
doctor: non-verbals, patient expectations/experience, longer consultations, empathy, listening skills, ID high risk groups

24
Q

Risk assessment - RF

A

self: history, PD, substances, unemployed, social class, violence, single
suicide (static): DSH, serious previous, PPH, substances, PD, childhood, FHx, male, old, single
suicide (dynamic): SI/intent, hopeless, psych Sx, substances, Ax and recent d/c, stress, poor problem-solving
suicide (future): access, poor f/u, poor Rx, future stressors
to others: violence, young male, social network, unemployed, psychotic, substances, Rx, MSE, situation/access, command, insight
deterioration: concordance
driving: severe anx/depp, mania/ psychosis (DVLA)

25
Q

Obs levels

A

I: highest; 1:1 arms length
II: high risk; 1:1 eyesight
III: 15m location; leave with responsible adult
IV: hourly location; can leave alone

26
Q

Rapid tranquillisation:

A

only if psychological Mx failed

PO first: lorazepam, APDs (onlanz, risp, halo)
encourage PO if refused
IM if PO failed: loraz, promethiazine, olanz (not if BZD), halo

Psychiatry (16 decks)

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