PACES Psych+ Paeds Flashcards
What are some features of abnormal grief?
Extremely intense (disabling)
Lasting > 6 months
Delayed
What are some physical causes of depression?
Cushing’s syndrome
Hypothyroidism
Addison’s disease
Dementia
Head injury
Stroke
MS
What are the cognitive symptoms of depression?
Selective memory for negative events
Pathological guilt
Feeling of guilt about being a burden on others
Pessimism
What are the components of the Beck’s cognitive triad?
Negative views about the self (worthless)
Negative views about the world (helpless)
Negative views about the future (hopeless)
What is the investigations for Depression/grief?
PHQ9 to assess baseline level of depression
· Investigations for physical causes (not indicated for all scenarios): FBC (anaemia), TFTs, cortisol
What are thereversible causes of dementia?
Brain (subdural haematoma, space-occupying lesion, normal pressure hydrocephalus)
Endocrine (Addison’s disease, Cushing’s disease)
Vitamin deficiency (B12, folate, thiamine (Wernicke’s), niacin (pellagra))
Neurosyphilis
Describe the features of lewy body dementia?
DLB causes parkinsonism, hallucinations and syncope but short-term memory is less affected than in VD and AD
The ONSET can vary.
Describe the features of Vascular Dementia?
VD has a stepwise decline, DLB and AD has more of a gradual decline
There will also be associated VASCULAR Risk factors.
Describe the features of alzeheimers dementia?
This is a gradual decline and a slow onset.
This starts with poorer recollection of recent memories as opposed to older memories.
They will have problems finding words.
Problems recogninsing people and carrying out skilled tasks.
What are the risk factors of Vascular dementia?
cardiovascular disease
hypertension
high cholesterol
diabetes
What changes may you see on CT scan for Alzehimers, Vascular and Lewy body dementia?
AD - Gerealised atrophy
LBD - Mild atrophy
VD - Multiple lucencies
What congenital condition increases the risk of developing Alzehiemer Dementia?
Down’s syndrome
What is the biological management of AD?
2 drugs?
Optimize physical health
Depends of severity
Slow rate of cognitive decline using anti-dementia drugs
If score >10 on MMSE → acetylcholinesterase inhibitors e.g. donepizil, rivastigmine
If mod-severe AD, intolerant of above → memantine (N-methyl-D-aspartate receptor (NMDA-R) antagonist)
Structured group cognitive stimulation programmes (good for mild-moderate)
Treat any psych/behavioural symptoms of dementia e.g. anxiolytic drugs e.g. trazodone
What is the psychological therapy in AD?
NICE recommends aromatherapy, massage, animal assisted therapy
Reminiscence therapy - talking about the ‘old days’ enhances sense of belonging, confidence
Multisensory therapy - as dementia advances and speech is lost, easier to respond to music, touch
Cognitive stimulation therapy: memory training and relearning
What is the social therapy in AD?
Emotional support, educate about dementia
Train to manage common problems
Home visit
Addressing functional problems that result e.g. kitchen skills
Always carry ID, dossett boxes for meds, reality orientation: visible clocks, environment modifications
Day centres for daytime activities and social contact
Day hospitals enable daily psych care
Provide advice and support for carers
Advising on legal measures to prepare for loss of capacity
Power of attorney
Consider advance statement
Inform DVLA and insurer - not safe to drive
Recall the 10 questions in the AMTS?
How old are you?
What time is it? (to the nearest hour)
What Year is it?
Where are we?
I want you to remember this address: 42 West Register Street. Ask to recall later on in test.
Do you know who I am? Do you know who that is [point to nurse / family member]?
Do you know who the Prime Minister / President is?
What is your date of birth?
Can you tell me when the second world war ended / the first moon landing was / other memorable date ?
Can you count down from 20 to 1?
A score of 7-8 or less suggests cognitive impairment at the time of testing, although further and more formal tests are necessary to confirm a diagnosis of dementia, delirium or other causes of cognitive impairment.
What are the investigations that are required for a patient that has AD?
Neuro examination/ cranial nerve exam
MMSE
Good to have a collateral history
Run some blood tests, LFTs, WBC, Glu, Ca + U+Es etc
Could do a brain scan
REFER to memory clinic.
What does a low AMTS score with a lot of answers stating, I don’t know suggest?
Depression more than dementia.
What is the biological management of depression?
SSRI
Increase dose SSRI
SNRI
Augment with quetiapine
ECT
What is the Psychological management of depression?
psychological therapies such as individual CBT
psychoeducation about depression
follow up appointment at GP
IF SEVERE REFER TO CRISIS OR HOME TREATMENT TEAM.
What is the social management of depression?
very important in elderly popn
LEAFLET about MIND
Social services to arrange package of care
physio very important to get back mobility as soon as possible and stop functional decline during the recovery
Exercise once possible as treatment
What are the biological treatments of depression?
Sleep disturbance - sleeping more or less
Decreased/increased appetite
Loss of libido
Psychomotor retardation
Agitation
If started on SSRI what medication can never be combined otherwise it may precipitate Serotonin syndrome?
Monamin Oxidase inhibitors?
What are the most common organisms that cause UTIs in children?
E. coli
Klebsiella
Proteus
Name and describe a structural anomaly that increases a child’s risk of getting UTIs.
Vesicoureteric reflux – the ureters insert directly into the bladder meaning that they have a short intramural path such that a full bladder no longer closes of the ureters. This leads to reflux of urine up the ureters and, potentially, into the kidneys.
Posterior urethral valve – an obstructing membrane in the posterior male urethra that causes bladder outflow obstruction in male newborns
What is the treatment of serotonin syndrome?
Supportive: O2, fluids and Benzoz.
What is the management of an elderly that is suspected to be abused?
CONSULT SENIORS
It is important to ensure the patients safety and honour.
The wishes of a competent individual needs to be respected.
Possible options include:
temporary hospitalisation
obtaining a court protective order
placing the patient in a safe home in the community.
What are the investigations in regards to a suicide attempt?
Physical examination (get an idea of baseline state and rule out organic causes)
· PHQ9 and GAD7 – assess baseline
· Admit the patient if you think that they are at high risk of suicide
List 3 classes of anti depressants and give an example of each?
Selective seotonin receptor inhibitor SSRI – sertraline, citalopram, escitalopram, fluoxetine
Serotonin and Noradrenaline Receptor Inhibitor – duloxetine, venlafaxine
Noradrenaline and specific serotonergic antidepressants NaSSA – mirtazapine (tetracylcine antidepressant)
tricyclic antidepressant TCA – imipramine, amitriptyline
What are the investigations with a patient that is dependent on alcohol?
Physical Examination: establish baseline physical state (consider measuring weight)
· Bloods: FBC, LFT, B12, folate, U&E, clotting, glucose
· Urine drugs screen and breathalyser
· Rating Scales:
o AUDIT to identify use disorder
o SADQ to determine severity of dependence
o APQ to assess then nature of problems arising from alcohol
What is the general management of Alcohol dependence?
Carry out motivational interviewing and establish goal (encourage abstinence)
Refer to Drugs and Alcohol Service
Bio, psycho + Social management
Arrange an appointment for any time after you finish withdrawal
Safety Net: if symptoms become very severe, go to A&E
What is the Biological management of Alcohol dependence?
Assisted Withdrawal
o Community-based (inpatient management is not appropriate for this patient)
§ Drug and Alcohol Service
o Fixed-dose drug regimen (chlordiazepoxide or diazepam)
§ Titrate based on severity of alcohol dependence
§ Gradually reduce the dose over 7-10 days (give 2 days of medication at a time)
o After successful withdrawal, consider acamprosate or naltrexone (for 6 months) with individualised psychological intervention
o Thiamine supplementation
o Expectations: withdrawal symptoms are worst within the first 48 hours, and takes about 3-7 days after the last drink to completely disappear
What is the psychological management of Alcohol dependency?
o CBT, behavioural or social network and environment-based
o Focus on alcohol-related cognitions
§ Weekly 1-hour sessions for 12 weeks
o Refer to self-help resources and support groups (Alcoholics Anonymous, SMART Recovery
What is the social management of Alcohol dependence?
o Direct to the relevant services regarding legal and financial support (e.g. benefits)
o Direct to services that can help find a new job (e.g. job centres)
o Driving – DVLA will need to be informed about you receiving treatment (can’t drive during treatment)
If you suspect OCD, What sort of questions may you ask?
Screen for OCPD? Do you keep your room nice and tidy
What is the management of OCD?
You will refer to OCD clinic
CBT is first line
SSRI is second line
Clomipramine is third line
What are some key differences between an obsession and a delusional belief?
The thoughts are identified as your own
Thoughts are repetitive and intrusive
Evidence of resistance by the patient (at least in the early stages)
Signs of avoidance (e.g. leaving the room when her sister walks in)
What is autism?
Pervasive developmental disorder defined by abnormal or impaired development before age 3 years.
Abnormal functioning in: social interaction, communication and restricted/repetitive behaviour.
Affects 1-2% children.
If Charles was autistic, what behaviours might you expect to see around his age?
Clumsy walking, minimal babbling, avoid eye contact, no smiling, avoids hugs, plays alone and exhibits repetitive behaviour, doesn’t respond to name being called, disturbed sleep pattern
How would you investigate these?
Hearing and sight test, SALT assessment, Assess IQ, M-CHAT score (modified checklist for autism in toddlers)
How would you manage this in a GP setting?
Collateral history from rest of family/nursery teachers, advice family on sleep hygiene, methods of countering challenging behaviour, care plan approach with a key worker for family,
MDT approach:
Community paediatrician
Autism team/CAMHS
Clinical psychologist
Occupational therapist
SALT
School - special educational needs assessment from DoH
National Autistic Society
Why can’t he have it as 3 separate vaccines to not overload his system?
Given as 1 in 3 is just as safe, doesn’t ‘overload’ immune system and makes sure the baby goes through as little pain as possible
3 separate vaccines have no safety evidence
Only a tiny amount of your Charles’ immune system will be used to develop a response to this vaccine, the rest will be used to fight off the many bugs they come into contact with every day!
The vaccines work at different times so won’t be overloaded
6-10 days measles
2-3 weeks mumps
12-14 days rubella
I read that the MMR contains egg products, will it cause an allergic reaction?
Is grown on egg cells but contains no egg proteins so will not cause Charles to have an allergic reaction
NOTE: flu vaccine is grown on hens’ eggs and can trigger a reaction if individuals are allergic to eggs
You’re slightly concerned about his behaviour - does this sound like he’s developing autism? Will the MMR vaccine make it worse?
This vaccination is very safe and almost every baby born in the UK receives it
It is protect both your child and the community as a whole
These infections are typically picked up around school so it really is important that Charles gets vaccinated as soon as possible
There is NO evidence that the MMR vaccine is linked to autism. The paper that suggested this has been discredited and the doctor who published it is no longer allowed to work in the UK as a doctor
Causes no delay in development
What are the sympotoms and complications of Mumps?
MUMPS
Symptoms to look out for: orchitis (Charles could become infertile in the future), meningitis, pancreatitis, encephalitis, hearing loss, parotid lymphadenopathy
What are the sympotoms and complications of Measles?
MEASLES
Symptoms to look out for: 3C’s: cough, coryzal, conjunctivitis, Koplik spots, maculopapular rash, D&V
Complications: pneumonia, febrile convulsion, otitis media, encephalitis, subacute sclerosing panencephalitis
Subacute sclerosing panencephalitis - typically occurs 7 years after measles infection, persists in CNS to cause progressive dementia and death. High measles Ab in blood and CSF
What are the sympotoms and complications of Rubella?
RUBELLA
Red/pink pruritic rash spreading from ears → face → trunk → limbs, lymphadenopathy, fever, conjunctivitis, coryza, arthralgia
Congenital rubella syndrome (CRS) - cataracts, deafness, congenital heart disease, IUGR, organ damage
What does a DMSA scan do?
Detects renal scarring
