Psych Flashcards
ECG take 2
What it represents
P wave = depolorisation of atrial muscle
PR interval = time for electricle impulse to spread from atria to ventricles (3-5 small squares)
QRS = depolorisation of the ventricles (<3 squares)
ST segment = period when ventricles are completely activated
T wave = repolorisation of ventricular muscle
U wave = repolorisation of pappilary muscles (abnormal if after flattened T wave)
Context
note BP/HR consciouness when taking ECG
RRPWQST
RATE: 300, 150, 100, 75, 60, 50 (small = 4ms and large = 200ms
RHYTHM: regular = equal distance between QRS complexes
P WAVES: P wave before every QRS = sinus (impulse from SAN to ventricles) - no P = abnormal rhythm. >1 P = heart block (abnormal coduction to the ventricles)
WIDTH: QRS >3 squares = slow ventricle conduction (abnormal conduction or eronously starting in ventricular tissue)
Q WAVE: if QRS starts with deep downward deflection could be old MI
Qtc should be <11 squares in men and 11.5 in women
ST segment: should be level with baseline. elevated = MI and depressed = MC Ischaemia
T wave: normally upside down in VR and V1 .. in other leads could be ischamie or ventricular hyertrohy
QT interval: varies with heart rate, prolonged with some drugs (>12 small squares)
Calibration: 1 square wide and two high . . .. . should be included on every record (25mm/s)
AXIS
serves to alert of other pathology eg PE/ conudction abnormality
Normal = +ve I and II
Left leaving = positive in I and Negative in II
Right reaching = -ve in 1 and +ve in 2
90 degrees from isoelectric lead, see if +ve at +90 or -90
RAD ax Right ventricluar hypertrophy (2ary pulmoary conditions causeing right heart strain)
LAD ax wtih conduction abnormalities
V leads
V1,V2 look at right ventricle
V3/V4 look at septum
V5/V6 look at left ventricle
V leads QRS - first septal depolorisation from left to right (intial R wave in V1/V2 but q wave in V5/V6) then ventricular depolorisation
RS trasition point represents the position of interventricular septum (normal V3/V4), right ventricle hypertrophy pushes to V4/V5/V6
Reporting ECG
Always:
- rhythm
- conduction intervals
- cardiac axis
- description of QRS complexes
- description of ST segments and T waves
eg:
- Simus rhythm, rate 50bpm
- normal PR interval (100ms)
- Normal QRS complex duration (120ms)
- Normal Cardiac Axis
- Normal QRS complexes
- Normal T waves (inverted in VR is normal)
Setup
attache electrodes to correct limbs
ensure ggod elecrical contact
check the calibrationand speed settings
make patient comfortable and relaxed
Psych History
*ask them to take through a typical day if they are a poor historian
PC and HPC
Open Question
Onset, duration, severity, course, intermittent or continuous, anything make it better or worse, have you experienced this before.
Depression screening Question:
During the last month have you felt low, depressed or hopeless? Have you had little interest or pleasure in doing things?
If either +ve f/u with SIGECAPS
Bipolar Screening Question
Have you ever experienced periods of feeling particularly high, energetic or euphoric?
if +ve f/u with DIGFASTER
Schizophrenia Screening Questions
“Have you ever heard voices speaking when there seems to be no-one around?”
“Do you ever feel that people are discussing you negatively?”
“Do you fear that people may be out to get you?”
“Have you ever felt that something or someone is able to put thoughts into your head?”
“Have you ever felt that something or someone can remove thoughts from your brain?”
“Have you ever felt that something or someone can hear your thoughts?”
“Have you noticed any sensations that seem odd or inexplicable?”
Past Psych Hx
Have you seen a psychiatrist for anything in the past? (hospitalised?)
Have you seen a doctor before for menthal health problems?
Have you experienced low mood in the past?
Premorbid Personality/Status
Past Medical History
esp ones associated with psychiatric illness eg hypothyroidism
Chronic illness = major risk factor for dpression
Drug History
How have you found taking the medication? Any side effects? Any missed doses?
Recreational use?
Social/Personal History
Pregnancy? How was growing up? Job? Education? Relationships? Sexual History?
smoking/drinking/ recreational drug use
Crime/Gambling
Housing and Finances
Social/relgious affiliations
Anyone else at home?
Do you have a support network around you?
How have you been looking after yourself?
Family Hx
Anyone in you family struggled with mental health problems in the past?
Family Tree
Other relationships
atmosphere at home
Insight/ICE
What do you think is causing these problems?
SIGECAPS
Sleep - how have you been sleeping?
Interests - what would you normally enjoy doing?
Guilt - How do you feel about yourself at the momment?
Energy - how have your energy levels been
Concentration - can you follow tv or read a book without being distracted?
Appetite - how was you appetite been recently?
Psychomotor
Suicide - When people feel down and depressed, they can feel that life is no longer worth living. Have you ever felt like this?
- have you ever harmed or thought about harming yourself?
Sometimes people fear leaving their children behind and have thoughts of taking their lives too? Have you experienced anything like this?
What things stop you wanting to end your life?
DIGFASTER
Distractability
Insomnia
Grandiosity
Flight of Ideas
Agitation/Activities
Sexual Exploits
Talkative
Elevated Mood
Racing thoughts
MCA and MHA
MCA
MCA is used to treat physical conditions
MHA only used to treat MH conditions
MCA may require DOLs if freedoms are being deprived
Types of section (MHA)
Section 2: 28 days for assessment (by 2 doctors but one must be MHA approved Section 3: 6 months for treatment (by 2 doctors but one must be MHA approved)
Section 4: 72 hours for emergency assessment (by 1 doctor, and an approved mental health practitioner or closest relative)
Section 5(2) 72 hour detainment for assessment of patient already in hospital. by doctor in charge pts care
Section 5(4) 6 hours detainment for assessment of patient already in hospital (by approved mental health murse)
Common law: may be used in the emergency department to keep patients from leaving and treating them
Psych Risk Assessment
Happy Snakes Never Explode During Violent Divorce
Self Harm
Some people think of harming themselves
Suicide
some people have thoughts of ending it all
Plans?
Preparation?
prtoective factors
Self neglect
have you been looking after yourself?
washing and cleaning?
Hoarding?
Risk of exploitation
Anyone else at home with you
who looks after the finances, looks after you?
Risk of deterioation (phsyical and mental)
Risk to others (volence)
RIsk to dependants
Do you have any children or anyone who looks after you?
General
Leaving here today what do you think you will do?
Risk of deliberate self harm and suicide (including discussion of risk factors relevant to the patient).
Risk of self neglect (including discussion of risk factors relevant to the patient).
Risk of being exploited by others (including discussion of risk factors relevant to the patient).
Risk of further deterioration of mental or physical health (including discussion of risk factors relevant to the patient).
Risk of aggression and violence to other people (including discussion of risk factors relevant to the patient).
Risk to children has been considered.
Risk to property and risk of driving has been considered.
Risk assessment is well structured.
Consider all important information from history and mental state informulating risk assessment, which is relevant to patient’s presentation and context.
Anxiety Disorders
Anxiety
Feeling + Physical
Individual experience
Bad experience so risk of mood disorders and to self medicate
Generalised Anxiery Disorder
At least 6 months
somatic sx ie impairs normal fxn
chronic problem so psychotherapy best
Panic Disorder
Presents like physical problem so r/o others
Benzos to abort attack
SSRIs can be used to decrease frequency
CBT can be used to get out of panic attack
agoraphobia = fear of leaving home alone
Phobias
Irrational or/and irrational fear
Flooding = medicate then rapid exposure to stimulus
Desensitisation = gradual exposure (floor by floor analagy
Social Phobia
non selective BB eg propanalol
Mood Disorders 1
General
exists on a spectrum
catatonia = that wazy felxibility
Mood disorder with psychotic features or vice versa?
Both Inhibit normal fxn
Major depressive Disorder
Clx dx but always assess SI
left SIGECAPS = typical and right is atypical
psychomotor retardation
Bipolar 1
specific tx pathway but remember as three presentations
word salad - no discernable pattern or structure
Mood stablisers:
1st line = lithium
2nd line = valporic acid
3rd line = carbamazepine or lamotrigine
Quetiapine = go to psychotic can give in any state
Bipolar 2
Must have MDE at some point (SSRI might push them into it?)
r/o catatonia and psychosis as either makes it automatically B2
Cyclopthymia
= milder B2
Dysthymia
Less severe chronic indolent MDD w/o episodes exceeding 2 months
Dementia Diagnosis
Memory Loss
Rule out the other types
Delirum: some sort of alternation/insult . . . fix this and they return to normal
Cognition
congition = higher fxn that seperates us from animals. . . . attending something important and ability to multitask
Test eg montreal congnitive assessment
MCI = cognitivly imparied by still able to function
Flow
r/o amnesia, delirum and MCI
then r/o reversible:
TSH = hypothyroidism
BMP= U&Es = creatinine and urea
LFTs = cirhosis
B12 = can present like dementia
RPR= syphilis
CT/MRI = subdural
Depression screen = pseudodementia
Dementia
Alzheimer’s
Chonic, insidious loss of memory: first short term, then long term, then think they are who they were 20y previously
Personality goes later
CT as rule out subdural but will show diffuse cortical atrophy
Picks
Frontotemporal dementia
Lewy-Body Dementia
Dementia predominant with parkinsonism
(parkinson’s dementia will have dementia sx present later)
MRI not needed to diagnosis but would show substantia nigra atrophy
Vascular dementia
Step wise worsening of symtpoms is key
(or could have dementia with vascular changes on top)
tx the stroke and support the dementia
Creutzfeldt–Jakob disease
mad cow disease from undercooked meat
However MC a sporadic mutation
classic = young dementia with myoclonus
diagnose with MRI
months to live
Normal Pressure Hydrocephalus
(but does have increased intracranial pressure?)
Wet = urinary incontinence
wobble = ataxic gait
werid = dementia
Key is sx improve with LP .. . . therefore put in VP shunt.
AMT
Age
42 west street
current year
patients home address
identify 2 jobs
Patient DOB
Year WW1 started
Current Monarch/ Prime minister
Count Backwards from 20
recall address
4-7 = congitive impairment
0-3 = severe cognitive impairment
amt-4
age
DOB
Place
Year
Delirium Causes
Pain
Infection - look for an tx > avoid catheterisation
Constipation
Hydration/Hypoxia: encourage po intake > check fluids > get advice if complex renal/cardiac picture
Check SATS
Medication/Mobility : encourage mobilisation soon after surgery
meds r/v esp polypharmacy (NICE medication optimisation)
Environment - lighting/talking/family/friends/ activities
Extra
promote sleep
address senses
Nutriition - eating + dentures etc
Short Cam
Delirium
RFs
>65
cognitiv impaired (assessif suspected or dementia)
curret hip fracture
severe illness (deteriation or risk of)
PC/indications
lcognifve function (reduced concentrations and responsiveness + confusion)
Perception (visual /auditory)
Physical function ( reduced mobility/movement, restless/agitation, reduced appetite, sleep disturbacnce)
socila behaviour ( reduced co-operation, change n mood /atitude, change in communication)
Prevention
familiar team/place
multicomponent intervention package
Diagnosis
Short CAM
Mx
Initial: effectiv ecommunication and reorientation (where they are, why, what you role is) - family helps
Distresseed people: if risk to self/others and non pharmacological is innappropriate/ineffective give short term haliperidol (< 1 wk) - start low and go slow
500 micrograms and adjust in increments 2-4 hrly (max 5mg/day)
Deppression Criteria
Sleep
Interests
Guilt/ Worthlessness
Energy/fatigue
Concentration
Confidence
Appetite (weight)/ also sexula appetite decreased
Psychomotor (agitation or retardation)
Suicidal Ideation
Mild
2 of the core sx (low mood, anhedonia, fatiguability)
and at least 2 others for 2 weeks
No sx to an intense degree
SOME difficulty with normal fxn (social/work/domestic)
Moderate
2 core sx + at least 3 extra (pref 4)
some likely to be intense but not neccessary
considerable difficulty to fxn normally
Severe
Somatic syndrome considered always present
all 3 core + 4 others
Normal fxn severely limited
no psychotic sx
Severe with psychotic symptoms
Usually of negative depressive content such as rotting flesh or assuming responsibility for negative delusions eg world ending
Extra
4 somatic sx for ‘somatic syndrome’ to be considered present
If > 1 episode then should be subcategorised under recurrent depressive disorder (eg recurrent depressive disorder, current depression mild)
Dementia: rely objectively on observed somatic symptoms, such as psychomotor retardation, loss of appetite and weight, and sleep disturbance.
GAD Criteria
A) 6 months of worry/anxiety about most things, most days
- can justify several weeks
B) At least 4 of: (including at least 1 from STAM)
Sweating
Trembling (shaking)
Accelerated HR (palpitations)
Mouth = dry
Sx think brain, chest, abdo, muscles, nerves
or think apprehension + motor tension + autonomic overactivity
A) A period of at least six months with prominent tension, worry, and feelings of apprehension, about everyday events and problems.
B) At least four symptoms out of the following list of items must be present, of which at least one from items (1) to (4).
Autonomic arousal symptoms
(1) Palpitations or pounding heart, or accelerated heart rate.
(2) Sweating.
(3) Trembling or shaking.
(4) Dry mouth (not due to medication or dehydration).
Symptoms concerning chest and abdomen
(5) Difficulty breathing.
(6) Feeling of choking.
(7) Chest pain or discomfort.
(8) Nausea or abdominal distress (e.g. churning in the stomach).
Symptoms concerning brain and mind
(9) Feeling dizzy, unsteady, faint or light-headed.
(10) Feelings that objects are unreal (derealization), or that one’s self is distant or “not really here” (depersonalization).
(11) Fear of losing control, going crazy, or passing out.
(12) Fear of dying.
General symptoms
(13) Hot flashes or cold chills.
(14) Numbness or tingling sensations.
Symptoms of tension
(15) Muscle tension or aches and pains.
(16) Restlessness and inability to relax.
(17) Feeling keyed up, or on edge, or of mental tension.
(18) A sensation of a lump in the throat or difficulty with swallowing.
Other non-specific symptoms
(19) Exaggerated response to minor surprises or being startled.
(20) Difficulty in concentrating or mind going blank, because of worrying or anxiety.
(21) Persistent irritability.
(22) Difficulty getting to sleep because of worrying.
Schizophrenia
At least 1 of:
THIB
Thoughts (inset/withdraw/broadcast)
Hallucinating Voices (running commentry/discussing pt/ from body part)
Influence/control/passivity delusional perception
Bizarre (impossible) or cultural inappropriate PERSISTANT delusion
OR at least 2 of
SHIN
Speech : iconherent/irrelevent (neologisms/breaks of thought)
Hallucinations (persistant of any modality)
Inaminate (ie catatonic behaviour)
Negative sx (apathy, paucity of speech, blunting or incongruity of affect)
QT interavl
Qtc should be <11 squares in men and 11.5 in women
Prolongation causes: electrolyte imbalance, cardiac ischaemia and medications
Medicaions:
ASDs
Antiarrythmics (flecainide, solatol, amiodarone)
TCAs
Antidepressents (eg citalopram and venlafaxine)
Intro
Time from the start of the Q wave to the end of the T wave
Represents time taken for ventricular depolarisation and repolarisation, effectively the period of ventricular systole from ventricular isovolumetric contraction to isovolumetric relaxation
Normal Values
QTc is prolonged if > 440ms (11squares) in men or > 460ms (11.5 squares) in women
QTc > 500 is associated with an increased risk of torsades de pointes
QTc is abnormally short if < 350ms
A useful rule of thumb is that a normal QT is less than half the preceding RR interval
Causes
Hypokalaemia
Hypomagnesaemia
Hypocalcaemia
Hypothermia
Myocardial ischemia
ROSC Post-cardiac arrest
Raised intracranial pressure
Congenital long QT syndrome
Medications/Drugs
Medications
Antipsychotics
Chlorpromazine
Haloperidol
Droperidol
Quetiapine
Olanzapine
Amisulpride
Thioridazine
Type IA antiarrhythmics
Quinidine
Procainamide
Disopyramide
Type IC antiarrhythmics
Flecainide
Encainide
Class III antiarrhythmics
Sotalol
Amiodarone
Tricyclic antidepressants
Amitriptyline
Doxepin
Imipramine
Nortriptyline
Desipramine
Other antidepressants
Mianserin
Citalopram
Escitalopram
Venlafaxine
Bupropion
Moclobemide
Antihistamines
Diphenhydramine
Astemizole
Loratidine
Terfanadine
Other
Chloroquine
Hydroxychloroquine
Quinine
Macrolides: Erythromycin; Clarithromycin
IQ
The IQ range for categories (according to ICD 10) is as follows:
Mild: 50-69
Moderate: 35-49
Severe: 20-34
Profound: below 20
Depressive Episode Mx
Mild
Initial mx
Sleep Hyegine advice: print form, regular exercise, no excesssing eating/drinking/smoking before bed
Active monitoring with follow up (eg 2 weeks) : provide info about depression
Low intensity psychosocial interventions
Individual guided self help based CBT (6-8 sessions)
Computerised CBT ( 9-12 weeks with pt review)
Group Based CBT (10-12 meetings with 8-10 participants)
Lower intensity psychosocial with chronic physical condition
Group physical activity Programme (2-3/week for 10-14 weeks)
Group Based Peer support programme (8-12 weeks)
The previous interventions also stand (6-8 sessions)
Antidepressants
If present for 2 years
if previous moderate or severe depression
if it complicates care of a physical health condition
Moderate (or inadequate response)
if not benefited from low intesity psychosocial intervention consider:
SSRI (r/v q 2-4 weeks for first 3 months)
or
High intesnity psychosocial intervention:
CBT - 16-20 sessions (2 a week at first)
IPT 16-20 sessions (2 a week at first)
can also consider councelling or psychodynamic psychotherapy
Severe or Moderate
Combine the above two
Mild/Moderate with Chronic Physical Condition
SSRI
or
High intensity psychosocial intervention (individual or group CBT)]
Severe with chronic Physical Condition
consider both
Response?
Yes: cont. and monitor for relapse
No: consider specialist referal
GAD Mx
Stepwise Approach
1. Education and Active Monitoring
Provide information on tx options available for GAD and self help resources
Ask to monitor sx and revisit
2. Low intensity psychosocial Interventions
Individual non facillitated self help ( CBT based written or electronic)
Individually guided self help (same as above but monitored)
Psychoeducational groups (CBT based with presentations and interaction)
3. High Intensity Psychosocial or Medication
Psychosocial:
CBT (12-15 weekly sessions)
Applied Relaxation (12-15 weekly sessions)
SSRI: try sertraline first
4. Try alternative
Therapy- then try SSRI
SSRI - try therapy or another SSRI
Agoraphobia
All three of:
a) Sx of anxity (not 2ary to delusions/obsessional thoughts)
b) anxiety restricted to 2 of: crowds, public spaces, travelling away from home and travelling along
c) avoidance of phobic situation must be prominant feature
can be diagnosed with or without panic disorder
All of the following criteria should be fulfilled for a definite diagnosis:
(a) the psychological or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms, such as delusions or obsessional thoughts;
(b) the anxiety must be restricted to (or occur mainly in) at least two of the following situations: crowds, public places, travelling away from home, and travelling alone; and
(c) avoidance of the phobic situation must be, or have been, a prominent feature.
Panic Disorder (+/- agoraphobia) Mx
Mild to moderate
Offer individual non facilitated self help (CBT based)
Individual facilitated self help
f/u q4-8wks
https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/talking-therapies-and-counselling/self-help-therapies/
Moderate or Severe
CBT
or
antidepressant ( if disorder is long standing or declined/unsucessful psychosocila intervention) (escitalopram, sertraline, citalopram, paroxetine and venlafaxine)
If tx unsuccssful refer to specialist
Panic Disorder Dx
Several severea attacks of autonomic anxiety within a month:
a) circumstances with no objective danger
b) no predictable situations or patterns
c) comparitivly free of symptoms between attacks
These are not explained by phobias . . . this would be a severe manifestation of a phobia
Police Detention
Section 136
Bleeped - check if AMPH is aware of situation
Take Handover From Police
(clear police leaving with MHLT)
R/V Paris Hx
Review Pt
Document and make mx plan
D/W consultant - make sure AMPH aware
Decide Plan (Home, informal admission, MHA)
LOOK UP THE GUIDANCE DOCUMENT
Rapid Tranq Summary
Step 1
De-escalate + Psychosocial treatment
Step 2
- Lorazepam 1–2mg (max 4mg/24hrs PO+IM)
- Promethazine 25–50mg (max 100mg/24hrs PO+IM)
- Haloperidol 5mg(max 20mg/24hrsPO only*)
repeat dose after 45-60 mins, consider step 3 and snr prescriber input if inadequate after 2 doses
Step 3
- Lorazepam** 1 – 2mg (max dose as step 2)
or
If lorazepam is unavailable: Midazolam** 7.5mg (max 15mg/24hrs)
or
- Promethazine 50mg (max dose as step 2)
or
- Haloperidol 5mg(max 12mg/24hrsIM only*). NB Should be the last drug considered
repeat does after 30-60 mins. urgent seniour input if inadequate after 2
Extra
have procyclidine on hand if haliperidol being prescribed
can prescribe haliperidol and promethazine together
Social Hx
Pregnancy? How was growing up? Job? Education? Relationships? Sexual History?
smoking/drinking/ recreational drug use
Crime/Gambling
Housing and Finances
Social/relgious affiliations
Anyone else at home?
Do you have a support network around you?
How have you been looking after yourself?
Bipolar etc
Hypomania
Persistent mild elevation of mood for at least several days
Mild DIGFASTER
mild disruption and decreased attention but not severe to the point of loss of work and social rejection
must be isolated with no previous mood disorder
rule out agitated depression, cyclothymia, mania, hyperthydroidism
Mania without psychotic symptoms
Above but more severe. Irritability is more likely. Grandiosity can be present but not delusional. Loss of social inhibitions. Likely severe limitations to normal functioning
Mania with psychotic symptoms
even more severe with delusional ideation, can be persecutory, grandious or of religious themes
more likely to neglect eating, cleaning, generally looking afrer self
delusions can be congruent or incongruent
can be mistaken for schitzophrenia esp if earlier hypomania is missed or speech becomes incompreshensible
Bipolar Affective disorder
manic episodes usually last 2wks to 4-5 months and depressive episodes tend to be longer
at least two mood episodes
written as : bipolar affective disorder current episode xxxx
Cyclothymia
multiple cycles of mood urelated to life events that do not meet criteria of depresssion/mania/bipolar affect disorder etc
PTSD Dx
Delayed and/or protracted response to a exceptionally threatening event
Guidelines
within 6 months of exceptional event (possible to justify longer though).
must have repetitive intrusive recollection or re-enactment of events in head
common to have emotional detachment and numbing
may have co-committent mental health disorders like depression
Symptoms Choice of meds
Side effects choice of meds
pain choice of meds
Changing meds
Serotonin Syndrome
Discontinuation Syndrome
Suicide Questions
Plans
Preparation
Protective Factors
Precipitating Factors
Perpetuationg Factors
Delusional Disorder
and
other persistent delusional state
Delusional disorder
A delusion persistent for three months
Depressive sx or depression dx may be present intermittently if delusion persists when not
no or only occasinoal auditory hallucinations
no hx of shitzophrenic sx
Other Persistent Delusional state
Delsions with peristent auditory or other hallucinations that do not meet diagnosis of schizophrenia
or persistent delusion < 3 months
Acute and Transient psychotic disorders
Acute onset 48hr - 2 weeks general
with or without acute stress (trauma, terroism, war)
no organic cause
not manic state
There are a few diagnosis here with more details .. . . can lead to more peristant states but generally more acute onset has a better outcome
Schizoaffective disorders
Definate schizophrenic symptoms and affective disorders present simultaneously
includes manic type, depressive type and mixed type
