NPS Flashcards
Carrie Westcott (38 years old, female, married with children, bank employee) was diagnosed with bipolar disorder type I by a psychiatrist last year after she experienced two depressive episodes and a manic episode. Her husband brought her to the ED worried that she had become increasingly irritable, and stopped eating and drinking in the last 2 days.
lithium s/e:
- short term: gastrointestinal discomfort with nausea and diarrhoea, vertigo and muscle weakness
- long term: weight gain, fine tremor, fatigue, thirst, polyuria, cardiovascular and thyroid problems, leucocytosis, bluish discoloration/pain in fingers and toes, pseudotumor cerebri and rarely angioneurotic oedema
Non-pharm mx:
- De-escalation of acute episode
- Psychosocial strategies emphasising adherence to medication
- Education and support of patient, family and carers
- Interpersonal and social rhythm therapy
- Cognitive Behavioural Therapy (CBT)
- Addressing substance/alcohol abuse and medical illnesses
- MDT
- medicolegal considerations
Pharm:
- acute: antipsychotic +/- benzo
- long term: lithium (valproate secondline), but start now because slow acting
A 75-year-old man, Mr Robert Fisk, living independently with his wife, presents to ED distressed with acute onset shortness of breath which woke him from sleep. He has a history of previously well-controlled heart failure secondary to a dilated cardiomyopathy. Further questioning reveals symptoms consistent with paroxysmal nocturnal dyspnoea and 4-pillow orthopnoea over the previous two nights. He does not have a history of ischaemic heart disease. His only other health problem is osteoarthritis. Vital signs include a blood pressure of 130/80 and pulse rate of 108/minute in a regular rhythm. His other examination findings were consistent with acute pulmonary oedema.
Non-pharm mx
- PPO(ND)
- fluid and Na restriction - long term
Pharm
- N: initially sublingual, then IV
- D:
- don’t forget VTE prophylaxis
- cease PDE-5i, beta blockers, NSAIDs etc
15 year old male was brought in by his mother presenting with general “unwellness”, reduced energy, sleep disturbance, moodiness, fighting with peers and family, arguing, and needing prompting to complete school work.
2y later apprentice motor mechanic and his mother is fearful that he may lose his apprenticeship. He is binge drinking with mates most weeks. He denies using any other illicit substances. He often oversleeps in the morning and seems to have little interest in activities. He has had a few “sickies” from work and he is missing soccer training more often than not, he was previously devoted to his sport.
Non-pharm:
- CBT
- Psychoeducation and supportive counselling
- Drug & Alcohol counselling
- Nutrition
- Other complementary and lifestyle interventions
- psychiatrist referral not necessary rn
Pharm: if refractory
- fluoxetine: limited evidence for other SSRIs, none for TCAs
S/E
- stomach upset and loose bowel actions, headaches, agitation, loss of libido or impacts on sexual function, restlessness and sleeping or sedation problems. Weight gain or loss may result in the consideration of a change of medication.
- SS: changes to mental state (confusion, hypomania, agitation) and myoclonus/clonus, hyperreflexia, tremor and poor coordination.
Mrs Connie Anderson is 42 years old and was admitted this morning with increasing tiredness and breathlessness without chest pain over several weeks. She has had heavy periods but no history of acute bleeding. On admission Mrs Anderson was noted to be pale without signs of heart failure.
Results of blood tests were:
Microcytic hypochromic anaemia.
Haemoglobin (Hb) 60 g/L (NR: 115–165)
Serum iron 6 micromol/L (NR: 14–32)
Serum ferritin 3 micrograms/L (NR: 25–155)
Serum folate and B12 pending.
Non-pharm
- blood transfusion if necessary
- consider cause - improve diet, consider ceasing drugs that cause bleeding, increase metabolism (eg phenytoin for folate), antagonise effect (eg methotrexate for folate)….
Pharm
- supplementation
Drug interactions
- Fe: drugs that increase gastric pH eg antacids
Maria Pappas is a 62-year-old Greek lady with persistent degenerative arthritic pain mainly from known lumbar spine disease with osteoarthritis. An X-ray in 2002 showed significant spondylolisthesis of her lumbar spine and bilateral lumbar facet joint arthritis. She has other widespread osteoarthritic changes, especially in her temporomandibular joint and her hands. This interferes with one of her favourite social occupations; playing cards. All other medical conditions except for her persistent pain are well controlled. She suffers greatly from constant pain in the joints which is aggravated by motion, and she is finding it increasingly difficult to mobilise. For the last four years her osteoarthritic pain has been controlled with regular paracetamol (1 g, four times daily) and once daily dosing of celecoxib (200 mg, once daily) (both initiated by her GP). Maria presents today complaining that her back pain is quite severe even with regular use of paracetamol and celecoxib. Joint pain and stiffness begin to occur after long periods of inactivity, such as when sitting for long journeys or watching a two-hour television show. The pain is moderately severe even at rest or with very little movement. She asks if you can prescribe something ‘stronger’.
Her recent bone mineral density (BMD) score was -2.7 T-score units. A T-score of -2.5 or less (that is -2.6, -2.7, and so on) is indicative of osteoporosis. Again an X-ray is undertaken and excludes any fractures.
multi-modal, multidisplinary approach using both non-drug interventions and pharmacotherapy. Realistic goals need to be set and health professionals should engage patients in a conversation about their expectations in the light of these goals. A cure may not be likely but coping with less pain is realistic in this case.
Non-pharm
- Patient education about pain and its management
- Massage
- Heat and cold applications
- Exercise
- Cognitive behaviour therapy (CBT)
- Transcutaneous electrical nerve stimulation (TENS)
- Weight loss
- Physiotherapy
- Occupational therapy
Pharm
- paracetamol
- NSAID: low dose for minimal duration - avoid regular use
- opioids: consider potential risks before starting
- others eg neuropathic, TCA, ketamine etc
86-year old Polish woman, who has presented with exacerbation of chronic obstructive pulmonary disease and is now recovering well. You note that her pulse is irregular and the ECG confirms AF at a rate of 67 beats per minute. You review her previous admissions and note that going back to 2 years previously, she has always been in AF during her admissions, and the patient’s general practitioner (also Polish) confirms that she has had an irregular pulse when she has seen him as well. You make the diagnosis of rate controlled permanent non-valvular AF. You perform an echocardiogram which shows a large left atrium, but it is otherwise normal. You speak to your senior colleague who suggests that you consider stroke risk reduction.
Non-pharm options - specialist decision:
- Electrical cardioversion
- AV node ablation and pacemaker insertion
- Radiofrequency catheter ablation of arrhythmogenic foci in atria, usually found around pulmonary veins
- Surgical maze procedure
- Internal atrial defibrillators
- Obliteration of left atrial appendage.
Pharm
- aspirin for if CHADS2VASc 1 ONLY IF ANTI-COAG CONTRAINDICATED
- anticoag if 2 or more
- warfarin fine
- in community, risks of double anticoagulation greater than risks of not bridging warfarin
- NOACs need dose reduction in elderly and renal impairment
Ongoing
- regular Hb and INR monitoring
Mrs Roberta Fernando was treated for acute pulmonary oedema in ED. Now she has been admitted to the medical ward under your care.
Her usual medications include:
hydrochlorothiazide (25 mg daily)
perindopril arginine (2.5 mg daily)
atorvastatin (40 mg in the morning)
aspirin (100 mg daily)
On admission, her potassium is 4.2 mmol/L, creatinine 96 micromol/L. Your task now is to optimise the treatment of chronic heart failure.
There are 2 NPS modules on heart failure. The first focuses on acute heart failure and the treatment of pulmonary oedema. This second module examines the treatment of chronic heart failure.
Non-pharm
- look for and remove precipitating factors eg infections, ischaemia, arrhythmias, lack of compliance (diet, meds)=> vax, CVD risk optimisation, diagnosis and treatment of depression
- cease/avoid drugs that can precipitate heart failure: steroids, NSAIDs, verapamil
- salt and water restriction
- regular exercise
- daily weights
- smoking cessation
- remain active, DON’T REST UNNECESSARILY
Pharm
- CCF (carvedilol, perindopril, frusemide)
- can add spironolactone
- ARBs if ACEi not tolerated; dig if firstline drugs don’t work
Mrs Umaga has been brought in by ambulance because she has been getting more short of breath over the past 3-4 days, and her normally non-productive cough has worsened. She is coughing more frequently and she is bringing up yellow sputum.
On admission she was not breathless at rest but had mild central cyanosis. Heart rate was 96 (sinus rhythm). Jugular vein pressure was not elevated, she had widespread wheezing sounds but no basal crepitations. Temperature was 37.0˚C. Her partial pressure of carbon dioxide (paCO2) was 47 mmHg and partial pressure of oxygen (paO2) was 52 mmHg with oxygen saturation (SaO2) 85%, haemoglobin 142 g/L, creatinine 0.09 mmol/L, sodium 139 mmol/L, potassium 3.8 mmol/L, bicarbonate 20 mmol/L.
There was no evidence of consolidation or heart failure on her admission chest radiograph.
Her admission medications are: salbutamol 200 micrograms by metered-dose inhaler (MDI) as required, tiotropium 18 micrograms daily, diltiazem (controlled release) 240 mg once daily, hydrochlorothiazide 25 mg daily, and paracetamol as required.
Non-pharm - O2 - physio LONG TERM - pulm rehab: gradually increasing exercise - support smoking cessation - vax
Pharm
- SABA 2-6hrly, SAMA 6hrly (spacer reduces s/e, but nebulised fine)
- oral CS
- abx: amox/doxy
- nicotine for smoking cessation lol
Mr Grant is 77 years old and lives alone. He was admitted 24 hours ago with pneumonia which is being treated with antibiotics. He has responded well to the initial treatment and we won’t consider this aspect of the case further. You are rung at midnight by the ward nurse. She says that the patient is not sleeping, is confused, restless and very noisy.
On examination he is disorientated, inattentive, tremulous and appears to be having visual hallucinations. His pulse rate is 106 beats per minute and he is sweating with a temperature of 38.4 °C.
Admission notes refer to a past history of heavy drinking and smoking.
On admission his gamma glutamine transpeptidase (GGT) is 240 units/L (normal range 0–60) and his mean corpuscular volume (MCV) 107 fL (normal range 80–100). Serum creatinine level is 180 micromol/L electrolytes are normal.
Non pharm
- Move him to a quiet room and dim the lighting
- Initiate an alcohol withdrawal chart
- Give him IV fluids
Pharm
- thiamine
- diazepam - IV stat, then PO (secondline: antipsych ie haloperidol; thirdline: betablocker)
*olanzepine is not good antipsych here because long time to onset and long half life make it difficult to titrate the dose to effect
Mrs Pitt is 82 years old and was admitted at 10 pm with shortness of breath due to an exacerbation of her chronic heart failure. You are called to see her at 3 am because she is wide awake, disorientated, confused and trying to climb out of bed. She is disturbing other patients and requiring intensive nursing time.
You note that before coming to hospital she was on regular once daily treatment with digoxin 125 microgram, sertraline 50 mg, chlorthalidone 12.5 mg and an ACE inhibitor. One week prior to admission indapamide 2.5 mg daily was added to her regimen to treat shortness of breath with crackles in her lungs.
All the above medications are still charted and in the Emergency Department she was slightly cyanosed and still short of breath and given frusemide 120 mg. On admission, her serum sodium was 116 mmol/L, potassium 4.3 mmol/L and creatinine 250 micromol/L. Examination revealed a raised jugular vein pressure and loud widespread basal crackles. Her oxygen saturation is 85. Her temperature is 36.7 °C and her pulse is 76 beats per minute.
Non-pharm
- Transfer her to a quiet area
- Ask her daughter to sit with her mother
- Check whether she has a full bladder
- Giving oxygen?
- Restrict oral and IV fluids
Pharm
- haloperidol (need an antipsych that works fast and is rapidly metabolised to it doesn’t accumulate - so better for maintenance control)
- DON’T USE benzos - excess sedation and even resp failure in elderly patients
Mrs Amy Teague a 71 year old lady, diagnosed with type 2 diabetes 8 years ago, presents for a routine checkup with you.
Non-pharm
- Encourage weight loss
- healthy eating plan
- Recommend a reduction in consumption of alcohol
- Encourage smoking cessation
- Start intensive exercise
- Increase physical activity
- Monitor for complications of diabetes
Pharm
- metformin
- add another agent (usually sulfonylurea)
- add insulin (long acting) - target fasting BSL 6-8
- MDT: don’t forget podiatry and dental
S/E
- metformin: GI, lactic acidosis
- exenatide: GI, pancreatitis, renal failure
- SGLT2 inhibitor: dehydration, UTIs, genital infections
Mr Smith, a 56-year-old truck driver, is referred to you after his blood pressure (BP) was recorded at 165/105 mmHg at a work site health check. He is asymptomatic.
Mr Smith had been diagnosed with asthma a few years before, for which he uses a salbutamol metered-dose inhaler, obtained over the counter from his chemist. He continues to smoke 15 cigarettes/day. Much of his diet comprises ‘fast food’ purchased at the roadside during his 65-hour long working weeks. He drinks up to 6-8 cans of mid-strength beer/day and is centrally overweight (BMI 29 kg/m2) with a waist circumference of 100 cm.
Symptoms of secondary hypertension: haematuria/nocturia (renal disease), flushing/tremor/palpitations (phaeo), claudication (could be CoA), hx of pressor intake
Non-pharm
- weight reduction
- reduced salt
- increase fruit and veg, omega-3 fish oils
- reduced alcohol
- increase PA
Pharm
- Firstline are ACEi(/ARB), CCB, thiazide diuretic (if >65yo)
- start low
- add another agent if not well controlled; check other factors eg compliance, lifestyle factors, ?secondary cause
Aim
- 125/75 IF >1g proteinuria/day
Other consideration
- beta blockers: contrai in asthma; consider if past MI
- thiazide: increased risk new-onset DM
- ACEi: cough - dose realted
- alpha blocker: postural hypotension
Insomnia
Non-drug
- Sleep hygiene
- Sleep restriction: only go to bed however long you normally actually sleep before the time you wake up -> periodically reassess, gradually increasing time
- Stimulus control therapy
- Relaxation therapy
- Paradoxical intention
- CBT
Ric Burke is a 49-year-old IT consultant who has come to see you as he is concerned that he is at risk of a heart attack. Ric has type 2 diabetes, diagnosed two years ago, which is well controlled. He has a family history of type 2 diabetes and his father, a long-term smoker, died recently of a heart attack at age 73. There is no other significant family history.
Ric has 6 or 7 alcoholic drinks per week and smokes 10 cigarettes a day (he has tried to quit a number of times without success). Ric’s only exercise is his weekly social game of squash, and his lunch often consists of take-away meals. Ric takes extended release metformin 1000 mg in the evening and over-the-counter aspirin 100 mg in the morning. On examination his waist circumference is 100 cm, blood pressure 130/82 mmHg, resting pulse 75 beats per minute, with regular rhythm.
Ric’s total cholesterol is 6.3 mmol/L, HDL cholesterol 1.8 mmol/L, LDL cholesterol 3.9 mmol/L and triglycerides 1.4 mmol/L. HbA1C is 6.7%. Renal function, liver function tests and full blood count are all within normal ranges. Microalbuminuria is not detected.
Assess risk
- low <10%
Non-pharm
- SNAP
- weight reduction: waist circumference 94cm or less
Pharm
- statin
- then consider adding ezetimibe, cholestyramine (bile acid binding resin), fibrate (esp if TAG high)
Mrs Roberta Fernando was treated for acute pulmonary oedema in ED. Now she has been admitted to the medical ward under your care.
Her usual medications include:
hydrochlorothiazide (25 mg daily)
perindopril arginine (2.5 mg daily)
atorvastatin (40 mg in the morning)
aspirin (100 mg daily)
On admission, her potassium is 4.2 mmol/L, creatinine 96 micromol/L. Your task now is to optimise the treatment of chronic heart failure.
There are 2 NPS modules on heart failure. The first focuses on acute heart failure and the treatment of pulmonary oedema. This second module examines the treatment of chronic heart failure.
Non-pharm
- look for and remove precipitating factors eg infections, ischaemia, arrhythmias, lack of compliance (diet, meds)=> vax, CVD risk optimisation, diagnosis and treatment of depression
- cease/avoid drugs that can precipitate heart failure: steroids, NSAIDs, verapamil
- salt and water restriction
- regular exercise
- daily weights
- smoking cessation
- remain active, DON’T REST UNNECESSARILY
Pharm
- CCF (carvedilol, perindopril, frusemide)
- can add spironolactone
- ARBs if ACEi not tolerated; dig if firstline drugs don’t work
