osce stations Flashcards
explain clozapine to a patient :
- why they are on it
- answer any questions they may have
- mention important side effects and risks
A- helps to stop the transmission of messages in the brain which cause symptoms like psychosis
T- take it once daily as a tablet
H- take it in the morning . start low dose then up the dose.
do not miss more than 48hours as risk of myocarditis and low BP. If omit for 48 hours need to re-titrate up to maximum dose
L- longterm if it works
E- no sure
T-tests, need to have full bloods before starting including prolactin and blood lipids and ecg and weight
then once weekly for first 18 weeks
then once fortnightly for first year
then once monthly for the rest of time
I- side effects : MANY agitation, agranulocytosis, akathasia, antimuscarinic symptoms (hypersalivation, constipation), seizures,
C- contraindicated in alcoholic and toxic psychoses, bone marrow disorrders, coma , hx agranulocytisis severe cardiac disroders, uncontrolled epilepsy
CAUTION: agranulocytosis, toxic megacolon, neuroleptic malignant syndrome (fever, muscle rigidity,altered mental status and autonomic dysfunction)
S- supplementary advice : mind.co.uk
Take an alcohol history from this patient:
she is a 65 year old woman who has come to speak to the GP.
Patient hx: drinks 1 bottle of wine every night . Has a job but is in some trouble at work because she turned up late a few days in a row due to hangover. Broke up with her husband 5 years ago because of an affair on his side. Feels low in mood and hopeless and lonely. has stopped going to see her friends for the pub quiz on fridays because she is running out of money and would rather spend money on the wine as it is cheaper than the pub. doesn’t drink in the morning only in the evening. craves wine every evening and isn’t able to stop herself from drinking a whole bottle. hasn’t noticed any physiological symptoms yet apart from feeling quite rough in the mornings but this is becoming a norm.
has got annoyed when her sister called her out on the drinking and had an argument with her about that
knows she should cut down but feels she can’t
once got in trouble for drink driving
does not feel suicidal but sometimes wonders if life is worth living as she feels low and lonely a lot of the time
CAGE questionnaire F- first drink I-when did drinking increase? how has your drinking progressed? D-dependency symptoms - compulsion -loss of control -continuing despite harm -primacy -physiological withdrawal -tolerance increased? need 3 or more to be dependent.
P-What is her drinking pattern? eg talk me through what you drink in a typical day. what where when how much with who?
hpc: psychosis? mood?
pmh: any mental health issues? or medical problems resulting from alcohol misuse?eg weight loss, memory
have they tried to quit before
dh,
fh: any family alc problems?
sh: effect of alc on work and relationships, any problems with the law?
smoking or rec drugs?
don’t forget to ask about MOOD and RISK
and INSIGHT: do you want help with the alcohol?
QUESTIONS:
do you think she is alcohol dependent and why? yes as she has >3 of the dependency criteria
what investigations might you do ?
physical exam looking for malnourishment, signs of liver and heart disease incl af
bloods : fbc macrocytic anaemia, U&Es,CRP,LFTs, clotting, lipids, glucose, gamma gt vitamin levels esp thiamine
if acute state of intoxicaton measure blood alcohol
Acute alcohol withdrawal treatment?
consider if patient needs inpatient management
IV pabrinex or oral thiamine to prevent wernickes encephalopathy
chlordiazepoxide to treat tremor and agitation in delirium tremens
take a drug hx of a person who presented to A&E with heroin overdose
follow alcohol hx template
patient hx: started taking heroin 2 yrs ago when he became homeless because he fell out with his mum who kicked him out. he takes it to take the pain away
has passed out a few times from it and has lost a few days worth of memory. has lost significant amount of weight.
spends every day trying to get the money together to buy heroin and rarely buys food or spends money on shelter
has stolen from friends before to get money and has been in prison for this, in prison he went into opiate withdrawl which was terrible but was abstinent . then when released relapsed back
would like to stop using but only if things can get better for him
questions:
-what is the risk with opiate overdose?
resp depression and death
- what are the risks with opiate use?
- Hep B and C and HIV
- Endocarditis, necrotising fasciitis, septicaemia
- VTE
- social problems eg crime prostitution and homelessness
what are the symptoms of opiate overdose rhinorrhoea needle track marks pinpoint pupils drowsiness watering eyes yawning
how do you treat opiate overdose?
IV or IM Naloxone
how can you treat opiate addiction?
-patients are usually managed by specialist drug dependence clinics although some GPs with a specialist interest offer similar services
patients may be offered maintenance therapy or detoxification
NICE recommend methadone or buprenorphine as the first-line treatment in opioid detoxification
compliance is monitored using urinalysis
detoxification should normally last up to 4 weeks in an inpatient/residential setting and up to 12 weeks in the community
Take a hx from this neighbour who has brought your patient into hosp
found neighbour screaming complaining that rats were running around their bed
hasn’t seen him for a week
patient is confused and agitated and has been sick twice
patient has a tremor
hpc: you suspect he has a drinking problem as his recycling bin is always full of cans
but dont know him that well as he keeps to himself
pmh, dh, fh. dont know but ask about psych mania or depression
sh: lives alone and unemployed you think he has a daughter somewhere
ask about other hallucinations eg auditory or visual
ask about delusions: persecutory, reference, control- is anyone trying to control u , passivity: can anyone control your thoughts or feelings, grandiose, nilhilistic do you feel your organs are rotting
what is your differential?
- delerium tremens
- drug induced or alcohol induced psychosis
- depression with psychosis
- schizophrenia
questions:
- when does alcohol withdrawal start? peak is 6-12 hours ? what symtoms: sweating, pallor, tremor, tachycardia, anxiety,
-what is the peak time for seizures to occur as part of alcohol withdrawal?
36 hours
- what is the peak time for delerium tremens to occur ? 48-72 hours
symptoms : coarse tremor, visual or auditory hallucinations, tachycardia, confusion, fever
- how do you treat acute alcohol withdrawal?
Librium (Chlordiazepoxide) (A BDZ) and pabrinex (thiamine)
starting dose then sliding scale
explain laser photocoagulation to someone with diabetic eye disease
risks and benefits and cons
risks: pain
cons: constriction of VFs
benefits; Spares central vision and stops new vessel formation slowing disease progression
