Oxford handbook summary Flashcards
Weight loss DDx
GIT: malabsorption, malnutrition, dieting
Chronic: hyperthyroidism, DM, HF, RD, COPD, degenerative neurological, TB/HIV
Malignancy
Psychiatric: depression, dementia, anorexia
BMI ranges
- Healthy: 18.5- 24.9
- Overweight: 25- 29.9
- Obese: 30- 39.9 (35- 39.9 – OBESITY II)
- Morbidly Obese: ≥40
Meds to stop smoking
• Nicotine replacement therapy: continue for 3months, gradually decrease over 2 weeks
o Contraindicated: post MI, stroke or TIA, arrhythmia
• Bupropion: 150mg od for 3 days, then 150mg bd for 7-9weeks- start 1 week before intended quit day
o Contraindicated: epilepsy, eating disorders, bipolar disorders
• Varenicline 0.5mg od for 3days, 0.5mg bd 4d, 1mg bd 11/52- started 1 week before intended quit day
Contraindicated: Caution in Psychiatric illness
Recommended levels of alcohol
Men <21 u/ weekly
Women <14 u/weekly
Alcohol assessment
FBC( MCV),
LFT( GGT, AST, bilirubin), USS shows fatty liver/ cirrhosis
Alcoholic management
o Community alcohol team, self-help organization
o Detoxification with chlordiazepoxide 1/52
Vitamin B supplements: mild 10-25mg/d; severe 200-300mg/d
Insomnia drugs
Benzodiazepines (temazepam), zolpidem,
zopiclone,
low dose TCA (amitriptyline) when severe, disabling or distress
SE: amnesia and daytime somnolence
Mental state examination
• Appearance and behavior: self- neglect, malnutrition, eye contact, movement, agitation, aggression
• Speech
• Mood
• Thinking: form, content, flow, possession
• Perception: illusions, hallucinations, pseudohallucinations
• Cognition
Insight on their illness, the effects and need for treatment
Cognitive behavior therapy
- Behavioral therapy: systematic desensitization + anxiety reducing measures
- Cognitive therapy: focus on thoughts and reasoning behind assumptions that lead to abnormal reactions
Patient learns to recognize negative thinking patterns- can teach them ways to challenge cognitive errors
Panic attack Sx
PANICS”
• Palpitations, paresthesias
• Abdominal distress
• Nausea
• Intense fear of dying or losing control, light-headedness
• Chest pain, chills, chocking, disconnetedness
• Sweating, shaking, SOB
panic attack tx
1. SSRI (paroxetine, citalopram): start at low dose and increase – review in 2,4, 6, 12 weeks. Continue for ≥6mo
OR
2. TCA (imipramine, clomipramine)
OR
3. Non-drug treatmentanxiety drug tx
SSRI (sertraline 50-150mg od)
Anxiety psychological Symptoms
Fearful anticipation Irritability, restlessness Sensitive to noise, poor concentrate Worrying thoughts, obsessions Insomnia, nightmares Depression, depersonalization, fear of losing control/ dying
Anxiety Physical symptoms
Dry mouth Headache, epigastric pain, tinnitus Tremor, tinnitus, parasthesiae, dizziness Difficulty swallowing Frequent loose motions/ flatulence Frequency/ urgency of micturition SOB, chest pain, palpitations Sexual dysfunction, menstrual problems
Somatization disorder
Starts <30 multiple organ system complaints 4 pain, 2 GI, 1 sexual, 1 pseudoneurological
Agrophobia:
onset 20-40years.
Crowds, being far from home, situtations where difficult to escape lead to panic attacks, fear of fainting, loss of control
SSRI, MAOI, TCA
PTSD
last >1 month and start anytime after event
• Intrusive recollections: thoughts, nightmares, flashbacks
• Avoidant behavior
• Increased arousal: anxiety, irritability, vigilance, insomnia and decreased concentration
• Numbing of emotions
Depression screening
Past month have you been bothered by feeling down, depressed or hopeless?
During last month, have you often been bothered by having little interest or pleasure in doing things?
Depression Biophychosocial Assessment (BPA)
- Current symptoms- nature, onset, duration, severity
- Phx depression or mood elevation
- Fhx of mental illness
- Relationship qualities, living conditions, social support, financial worries
- Alcohol/ substance use
- Suicidal ideation
- Treatment options and if any previous tx
Depression Sx
> 50% of time in past two weeks
SIG E CAPS
- Depressed mood
- Sleep disturbances
- Loss of interest- anhedonia
- Guilt or feeling of worthlessness
- Loss of energy
- Loss of concentration
- Appetite/ weight changes
- Psychomotor retardation or agitation
- Suicidal ideation
Suicide risk
SAD PERSONS
• Sex: male • Age: teenager or elderly • Depression • Previous attempt • Ethanol or drug use • Loss of rational thiknig • Sickness • Organized plan • No spouse – divorced/ widowed/ single Social support lacking
Depression Tx
SSRI SNRI TCA Mirtazapine Reboxetine MAOI
SSRI:
fluoxetine 20mg od, citalopram 20-40mg od, sertraline 50-150mg od
• First line, safer in overdose, more compliant
• SE: short term increased anxiety, GI symptoms- dyspepsia common. (+ PPI if >60- GI bleed risk)
• Elderly have risk of hyponateamia
• Fluoxetine: only tx for kids
SNRI:
venlafaxine 37.5mg bd, duloxetine 60mg od
• Avoid if uncontrolled HT, contraindicated in arrhythmia
TCA:
lofepramine 70mg od/ db/ tds, trazodone 150-300mg daily
• Titrate dose up
• SE: drowsiness, dry mouth, blurry vision, constipation, urinary retention, sweating, arrhythmia
• Caution in CVD, prostate hypertrophy, raised intraocular P (risk of acute glaucoma)
Mirtazapine 15-45 mg nocte
- Presynaptic a2- adrenoreceptor antagonist increase central noradrenergic and serotonergic NT
- SE: sedation initially and weight gain
Reboxetine 4-6mg bd
- Selective inhibitor of NA reuptake
* Not recommended in elderly
MAOIs: phenelzine 15mg tds
• Only initiated in specialist setting
• Diet specifid: only fresh food, avoid game, alcohol, foods with tyramine (Cheese, pickled herring, beans pods, merat, year, soya beans) cause high BP headache
Cant start other antidepressants until stopped for 2 week
Follow up for depression meds
- Every 1-2 weeks until stable assessing response, compliance, SE, suicide risk
- Continue for 4-6 weeks before saying treatment failed and another 2-4 if partial response
- Continue for at least 6monoth. 12 months if elderly/ GAD and 2 years if recurrent depression
BP
• If ≥140/90: measure again, if not on medications do ambulatory BP monitoring or home BPM
• If ≥180 systolic or ≥110 diastolic: start antihypertensives without waiting for ABPM/ HBPM
Refer same day if you suspect accelerated HT (± papilloedema ± retinal haemorrhage) or Pheochromocytoma
