Psychiatric-Mental Health Flashcards
Suicide Risk Factors
- Older person who had recently lost a spouse (due to death or divorce)
- Plan involving gun or other lethal weapon
- Hx of attempted suicide and/or family hx of suicide
- Mental illness (depression, bipolar ds)
- Hx of sexual, emotional, and/or physical abuse
- Terminal illness, chronic illness, chronic pain
- Alcohol abuse, substance abuse
- Age 15-24 yrs or >60
- Significant loss (divorce, breakup w/ boyfriend/girlfriend, job loss, death of a loved one)
- Elderly males who recently lost a partner are at highest risk of suicide
Demographic subgroups
- American Indian and Alaska Native youth and middle-age persons have the highest rate of suicide
- African Americans have the lowest suicide rate
- Females make more attempts
- Males more likely to die by suicide
Acute Serotonin Syndrome (Serotonin Toxicity): Overview
- Occurs from high levels of serotonin accumulating in body d/t introduction of a new drug (drug interaction) and an ↑ in dose
- acute onset with rapid progression
- Hunter Toxicity Criteria Decision Rules/Criteria
Look for:
- dilated pupils (mydriasis)
- higher risk if combining 2 drugs that lboth both serotonin (e.g., SSRIs, MAOIs, TCAs, triptans, tryptophan)
If switching to another drug affecting serotonin, wait a minimum of 2 weeks
** Acute serotonin syndrome is a potentially life-threatening reaction → Refer to ED!
Acute Serotonin Syndrome (Serotonin Toxicity): Hunter Toxicity Criteria Decision Rules/Criteria
Pt must have taken a serotonergic agent and meet one of the following conditions:
- spontaneous clonus
- inducible clonus + agitation and diaphoresis
- ocular clonus + agitation or diaphoresis
- termor + hyperreflexcia
OR
- hypertonia + temperature >100.4º (38ºC) + ocular clonus or inducible clonus
Malignant Neuroleptic Syndrome: Overview
- Rare life-threatening idiopathic reaction from typical and atypical antipsychotics
- often seen w/ high-potency, first-gen antipsychotics (e.g., chlorpromazine, haloperidol)
- Mortality rate 10-20%
- can be seen in Parkinson’s disease (parkinsonism hyperpyrexia syndrome) d/t withdrawal of L-dopa or dopamine agonist therapy, dose reduction, or switching medications
- usually develops following initiation or a rapid ↑ in dose
S/Sx
- sudden onset of high fever
- muscular rigidity
- mental status changes
- dysautonomia (fluctuating BP)
- urinary incontinence
Look for hx of mental illness and prescription of antipsychotics
** Potentially life-threatening reaction → Refer to ED!
Psychiatric-Mental Health Evaluation
At-Risk Patients: The Baker Act
Allows 72 (3 days) of involuntary detention for evaluation and treatment of persons who are considered at very high risk for suicide and/or hurting others
Psychiatric-Mental Health Evaluation: Common Mental Health Questionnaires
- Beck Depression Inventory-II
- Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5)
- Folstein Mini-Mental State Exam (MMSE)
- Geriatric Depression Scale (GDS)
- Generalized Anxiety Disorder 7-Item (GAD 7) Scale
Psychiatric-Mental Health Evaluation: Common Mental Health Questionnaires - Best Depression Inventory-II
A multiple-choice self-report inventory for evaluating depression; based on the theory that negative cognitions about the self and world in general can cause depression
Psychiatric-Mental Health Evaluation: Common Mental Health Questionnaires - DSM-5
The diagnostic manual for mental and emotional disorders created and used by the APA
Psychiatric-Mental Health Evaluation: Common Mental Health Questionnaires - Folstein Mini-Mental State Exam (MMSE)
A questionnaire used to evaluate an individual for confusion and dementia (e.g., Alzheimer’s, stroke)
Testing tip: A question on the MMSE or MME will describe an action (such as asking a patient to spell world backward) and ask you to indicate the name of the tool that is being used
Psychiatric-Mental Health Evaluation: Common Mental Health Questionnaires - GDS
A 30-item (yes/no response) questionnaire. Shorter version contains 15 items; used to assess depression in the elderly; self-assessment format
Psychiatric-Mental Health Evaluation: Common Mental Health Questionnaires - GAD-7
A 7-item screening tool for helping to identify patients w/ anxiety
- valid and efficient tool (89% sensitivity and 82% specificity)
- The higher the score, the higher the anxiety level
Points for Levels of Anxiety:
Mild anxiety (5)
Moderate anxiety (10)
Severe anxiety (≥15)
Folstein Mini-Mental State Exam Components
Cognitive Skill → Action Required
* Orientation → What ist he date today? (current day, month, year); Location? (name of the city, county, state)
- Immediate Recall (Recall 3 objects) → Instruct patient that that you will be testing their memory; say 3 unrelated words (pencil, apple, ball); ask pt to repeat words
- Attention and Calculation (Counting backward, Backward spelling) → Say “starting at 100, count backward and keep subtracting 7”; say “spell the word world backward”
- Writing and Copying (Writing a Sentence; copying a figure) → Give person one black piece of paper and ask them to write a sentence; draw intersecting pentagons; as pt to copy the pentagons
- Scoring → Max score is 30 correctly done
Score of <19 indicates impairment
Psychotropic Drugs: Atypical Antipsychotics
1. Examples
2. Adverse Effects
3. Monitor what?
- Olanzapine (Zyprexa)
- Risperidone (Risperdal)
- Quetiapine (Seroquel)
- Olanzapine (Zyprexa)
- Obesity
- DM2
- Obesity
- All can cause weight gain
- Check BMI
- Check weight Q3 months
- All can cause weight gain
Psychotropic Drugs: Typical Antipsychotics!
1. Examples
2. Adverse Effects
3. Monitor what?
- Haloperidol (Haldol
- Chlorpromazine
- Haloperidol (Haldol
- Elevates lipids/triglycerides
- Extrapyramidal effects
- Tardive dyskinesia
- QT prolongation
- Sudden death
- Malignant neuroleptic syndrome (rare)
- Elevates lipids/triglycerides
- Labs → Fasting blood glucose and lipids
BBW!! → Frail elderly are at higher risk of death from antipsychotics
- Look for signs of extrapyramidal sx: dystonia, parkinsonism, akathisia (inability to stay still) tardive dyskinesia
Psychotropic Drugs: Anticonvulsants
1. Examples
2. Adverse Effects
3. Monitor what?
- Lamotrigine (Lamictal)
- Carbamazepine (Tegretol)
- Valproate (Depakote)
- Lamotrigine (Lamictal)
- Stevens-Johnson syndrome (Lamictal)
- Advise pt to report rashes (Stevens-Johnson)
- some anticonvulsants are also used as a mood stabilizers for bipolar ds
- Monitor serum carbamazepine concentration
- check serum valproic acid concentration
- Advise pt to report rashes (Stevens-Johnson)
Psychotropic Drugs: SSRIs! →
1. Examples
2. Adverse Effects
3. Monitor what?
- First-line treatment for?
- Common SSRIs
- Sertraline (Zoloft)
- Paroxetine (Paxil)
- Citalopram (Celexa)
- Escitalopram (Lexapro)
* SSRIs are also indicated for chronic anxiety disorders (social anxiety disorder, panic disorder)
- Sertraline (Zoloft)
- All SSRIs can cause sexual dysfunction
- Highest risk of erectile dysfunction (ED)
- elderly on multiple drugs, less risk of drug interactions
- All SSRIs can cause sexual dysfunction
- BBW!! → All SSRIs may cause suicidal ideation/plans (<24 yo)
- Do NOT discontinue Paxil abruptly; wean gradually
* Has a short half-life (compared w/ other SSRIs), and needs to be weaned; do NOT discontinue abruptly, will cause withdrawal sx
- BBW!! → All SSRIs may cause suicidal ideation/plans (<24 yo)
- Major depressoin, OCD
- GAD, panic ds, social anxiety ds
- Premenstrual dysphoric ds
- PTSD
- Major depressoin, OCD
- Fluoxetine (Prozac) → Longest half-life and first SSRI (useful for noncompliance)
- Paroxetine (Paxil) → shortest half-life
* Common SE: erectile dysfunction → * Bupropion is used off-label for antidepressant-induced sexual dysfunction caused by SSRIs
- Fluoxetine (Prozac) → Longest half-life and first SSRI (useful for noncompliance)
- Citalopram (Celexa) → Has fewer drug interactions compared w/ other SSRIs
- Other SSRIs: Sertraline (Zoloft), fluvoxamine (Luvox)
SSRIs
6. Side Effects
7. Contraindications
- Loss of libido, ED, anorexia, insomnia
- avoid w/ anorexic pts and undernourished elderly (depresses appetite more)
- Taper SSRIs over 2-4 weeks prior to discontinuation
- Loss of libido, ED, anorexia, insomnia
Paroxetine (Paxil): common SE: ED
- most likely to cause sx and may need to be discontinued for a period of 3-4 weeks or longer (slower wean)
Fluoxetine is least likely to cause discontinuation syndrome because of its long elimination half-life; can be tapered over 1-2 weeks
- Abrupt discontinuation may precipitate dysphoria, fatigue, chills, myalgias, headache, dizziness, gastrointestinal distress
- discontinuation syndrome occurs in 20-30%
- Avoid within 14 days of taking an MAOI (serotonin syndrome)
- Can induce mania w/ bipolar pts
- Avoid within 14 days of taking an MAOI (serotonin syndrome)
Psychotropic Drugs: Atypical Antidepressants
1. Examples
2. Adverse Effects
3. Monitor what?
- Bupropion (Wellbutrin)
- Bupropion (Zyban)
- Bupropion (Wellbutrin)
- Bupropion is used off-label for antidepressant-induced sexual dysfunction caused by SSRIs
- also used to treat major depression, seasonal affective disorder, and smoking cessation
- increases risk of seizures; avoid if pt at higher risk of seizures (during abrupt discontinuation of ethanol, benzodiazepines)
- Seizures
- Contraindicated w/ seizures ds, anorexia, or bulimia
- For smoking cessation
- Contraindicated w/ seizures ds, anorexia, or bulimia
Psychotropic Drugs: SNRIs
1. Examples
2. Adverse Effects
3. Monitor what?
4. Mechanism of Action
5. Indications
- Venlafaxine (Effexor)
- Duloxetine (Cymbalta)
- Desvenlafaxine (Pristiq)
- Venlafaxine (Effexor)
- Can precipitate acute narrow-angle glaucoma
- Bioavailability ↓ in 33% in smokers
- Can precipitate acute narrow-angle glaucoma
- Avoid w/ uncontrolled narrow-angle glaucoma
- Do not take 5 days before or 14 days after MAOI, linezolid, selegiline, IV methylene blue
- Avoid w/ uncontrolled narrow-angle glaucoma
- ↑ available serotonin and norepinephrine in brain
Duloxetine (Cymbalta) → can tx GAD, fibromyalgia, depression, and diabetic peripheral neuropathy; smoking ↓ bioavailability by 33%
* An SNRI used to for depression, chronic anxiety, and management of diabetic peripheral neuropathy
Psychotropic Drugs: TCAs
1. Examples
2. Adverse Effects
3. Monitor what?
4. Indications
5. Avoid in what?
- Amitriptyline (Elavil)
- Nortriptyline (Pamelor)
- Doxepin (Sinequan)
- imipramine (Tofranil)
- Amitriptyline (Elavil)
- Anticholinergic effects
- Category X
- Anticholinergic effects
- Do not combine w/ SSRIs, or MAOIs, as they will ↑ risk of serotonin syndrome
- NOT considered first-line tx for depression
- Other uses: Postherpetic neuralgia (chronic pain), urinary incontinence
- NOT considered first-line tx for depression
- Avoid if pt at high risk for suicide because they may hoard pills and overdose (suicide attempt)
- Overdose causes fatal cardiac (ventricular arrhythmia) and neuro effects (seizures)
** TCAs used for herpetic neuralgia, migraine headache prophylaxis (NOT acute treatment)
Psychotropic Drugs: Lithium
1. Examples
2. Adverse Effects
3. Monitor what?
- Lithium carbonate (Eskalith)
- Contrainidcated of sodium depletion, dehydration, significant renal or cardiovascular ds
- Used for bipolar ds
- “Ebstein’s anomaly” is a congenital heart defect caused by lithium
- Check serum trough level (12 hrs after last dose)
- Used for bipolar ds
Monoamine Oxidase Inhibitors (MAOIs)
1. Examples
2. Indications
3. Contraindications
4. What foods should you avoid?
- Phenelzine (Nardil)
- Tranylcypromine (Parnate)
- Phenelzine (Nardil)
- RArely used d/t serious food (high tyramine content) and drug interactions
- Do NOT combine w/ SSRIs, TCAs, monoamine oxidase B (MAO-B → selegiline [Eldepryl]), serotonin receptor agonists (e.g., sumatriptan [Imitrex], zolmitriptan [Zomig])
- RArely used d/t serious food (high tyramine content) and drug interactions
- Do NOT combine MAOI w/ SSRI or TCA
- Wait at least 2 weeks before initiating SSRI or TCA (high risk of serotonin syndrome)
- Do NOT combine MAOI w/ SSRI or TCA
- High-Tyramine Foods and MAOIs
- The combination can cause tyramine pressor response (elevates BP, risk of stroke)
- AVOID combining w/ fermented foods such as beer, Chianti wine, some aged cheeses, fava beans
- High-tyramine foods can also cause migraine headache in susceptible persons
Benzodiazepines (Tranquilizers)
1. Indications & Considerations
2. Examples
- ultra-short acting
- medium-acting
- long-acting
- anxiety ds, panic =ds, and insomnia
- Diazepam (Valium) is also used for severe alcohol withdrawal and seizures
- Do NOT abruptly discontinue d/t ↑ risk of seizures; wean slowly
- anxiety ds, panic =ds, and insomnia
- Ultra-short acting: Midazolam IV only (Versed); triazolam (Halcion)
- Medium-acting: Alprazolam (Xanax), lorazepam (Ativan)
- Long-acting: Diazepam (Valium), chlordiazepoxide (Librium), temazepam (Restoril), and clonazepam (Klonopin)
- Ultra-short acting: Midazolam IV only (Versed); triazolam (Halcion)
Major and Minor Depression
1. Definition/Etiology
2. Symptoms
- Aka unipolar depression (vs. bipolar depression)
- minor depression → milder form
- criteria of s/sx are same as major depression except there are fewer sx (at least 2 but <5).
- attributed to dysfunction of neurotransmitters serotonin and norepinephrine
- strong genetic component - Mood: depressed most of the time; may become tearful
- Anhedonia: diminished interest or pleasure in all or most activities
- Energy: fatigues or loss of energy
- Sleep: Insomnia or hypersomnia
- Guilt: feelings of worthlessness and inappropriate guilt
- Concentration: diminished concentration and difficulty making decisions
- Suicide: recurrent/obsessive thoughts of death and suicidal ideation
- Weight: weight loss (>5% of body weight) or weight gain
- Agitation: psychomotor agitation or retardation
- Mood: depressed most of the time; may become tearful
Major and Minor Depression
3. Immediate Goals
4. Differential Diagnoses
5. Screening Tools
- Assess for suicidal and/or homicidal Ideation or Plan
- If pt is considered to be a real and present threat of harm to self or others
- Refer to psychiatric hospital; pt must be driven by a family or friend
- If non available, call 911 for police; the police can “Baker Act” the patient - Rule our organic causes
- hypothyroidism
- anemia
- autoimmune ds
- vitamin B12 deficiency
- Rule our organic causes
- Beck Depression Inventory: Contains 21 Items
- Beck Depression Inventory for Primary Care (99% specificity): contains 7 items
- 2-Item Question → Ask the following 2 questions; if yes to either question (or both), positive finding:
* During the past month, have you felt down, depressed, or hopeless?
* During the past month, have you felt little interest or pleasure doing things?
- Beck Depression Inventory: Contains 21 Items
Major and Minor Depression
6. Labs
7. Treatment Plan
- CBC
- chemistry profile
- TSH
- folate
- vit B12
- UA
** Rule out organic causes; toxicology screen to r/o illicit drug use if a risk
- CBC
- R/O ds such as anemia, diabetes, hypothyroid (TSH/thyroid panel), chemistry panel (low K for ADdison’s disease) and vit B12 anemia
- Refer for psychotherapy; CBT can reduce sx (comparable to an antidepressant med) and is usually effective → if necessary, refer to psychiatrist or PMHNP; if psychotic → Refer to ED!
- Psychotherapy + antidepressants work better together than alone
- R/O ds such as anemia, diabetes, hypothyroid (TSH/thyroid panel), chemistry panel (low K for ADdison’s disease) and vit B12 anemia
- Pt starting to recover from depression may commit suicide (from ↑ in psychic energy); monitor closely!
- If potentially suicidal, be careful when refilling or prescribing certain meds that may be fatal if pt overdose (e.g., benzos, hypnotics, narcotics, amphetamines, TCAs); give smallest amount and lowest dose possible with close follow-up!
Major and Minor Depression
8. First-line Meds
9. Other antidepressants
10. FDA BBW!
- SSRIs
- Tell pts that antidepressants effect may take 4-8 weeks (up to 12 wks) to manifest
- also first line therapy for elderly pts because of fewer side effects
* Initiation of meds for elderly and pts diagnosed w/ renal or hepatic ds should begin at low dose and increased slowly and gradually as tolerate
* After initiation, follow up in 2 weeks to check for compliance and SE
* Continue SSRI therapy for at least 4-9 months after sx have resolved (usually on first episode); frequent relapse means pt may need lifetime treatment
- SSRIs
- TCAs (amitriptyline [Elavil], nortriptyline [Pamelor])
- Prefer bedtime dose d/t sedation
- other sues: postherpetic neuralgia, chronic pain, stress urinary incontinence
- Avoid w/ suicidal pts because they may hoard pills and take an overdose (causes fatal arrhythmias)
- TCAs (amitriptyline [Elavil], nortriptyline [Pamelor])
- ↑ risk of death in elderly (with dementia) on antipsychotic drugs such as haloperidol (Haldol) and chlorpromazine (Thorazine)
SSRIs: Special Considerations
1. FDA BBW in children, adolescents, & young adults
2. Elderly pts
3. Pts w/ sexual dysfunction caused by SSRI
4. Depressed pts who want to quit smoking
5. Depressed pt w/ peripheral neuropathy
6. Depressed pt w/ postherpetic neuralgia & chronic pain
7. Depressed pt w/ stress urinary incontinence
- ↑ risk of suicidal thinking and behavior in children, adolescents, sand young adults
- risk of suicidality is ↑ in young adults 18-24 yrs during initial treatment (first 1-2 months) - Consider using citalopram (Celexa) and escitalopram (Lexapro)
- fewer drug interactions than other SSRIs
- may prolong QT interval
- Consider using citalopram (Celexa) and escitalopram (Lexapro)
- Consider adding bupropion (Wellbutrin)
- another option is switch to an ANRI or atypical antidepressant
- Consider adding bupropion (Wellbutrin)
- Consider bupropion (Zyban)
- Can be combined w/ nicotine-avoidance products (e.g., patches, gum)
- Consider bupropion (Zyban)
- Consider duloxetine (Cymbalta)
- also indicated for neuropathic pain - Consider TCAs
- Consider TCAs
Antipsychotics: Adverse Effects
- pill rolling
- shuffling gait
- bradykinesia
► caused by chronic use of antipsychotics - Extrapyramidal symptoms (EPS):
- Akinesia
- Akathisia
- Bradykinesia
- Tardive dyskinesia
- can lead to ↑ risk of obesity, DM2, HLD, metabolic syndrome, and hypothyroidism
- Both classic and new generation have strong anticholinergic effects
Akinesia
inability to initiate movement
Akathisia
A strong inner feeling to move, unable to stay still
Bradykinesia
slowness in movement when initiating activities or actions that require successive steps such as buttoning a shirt
Tardive dyskinesia
Involuntary movements of the lips (smacking), tongue, face, trunk, and extremities (more common in schizophrenics)
Anticholinergics: Side Effects
Many drug classes have strong anticholinergic effects, including:
- antipsychotics
- TCAs
- decongestants
- antihistamines (e.g., pseudoephedrine)
- Use caution with BPS; urinary retention, narrow-angle glaucoma, and preexisting heart ds
Anticholinergics: Side Effects - SAD CUB (mnemonic to help remember anticholinergics side effects)
Sedation
Anorexia
Dry mouth
Confusion and constipation
Urinary retention
BPH
Minor and Major Depression: Complementary/Alternative Treatments
Include various herbs and supplements, guided imagery, and lifestyle measures such as exercise and yoga
*Be aware of herb-drug interactions
Minor and Major Depression: CAM - St. John’s Wort
1. Drug interaction
2. Adverse Effects/Notes
St. John’s wort (Hypericum perforatum)
- SSRIs (e.g., citalopram/Celexa, paroxetine/Paxil)
- Tricyclics (e.g., amitriptyline/Elavil, imipramine/Tofranil)
- MAOIs
- alprazolam (Xanax)
- protease inhibitors (indinavir), etc
- cyclosporine
- OC
- TCAs
- SSRIs (e.g., citalopram/Celexa, paroxetine/Paxil)
- ↓ digoxin effectiveness
- causes breakthrough bleeding that ↓ effectiveness of birth control pills
- serotonin syndrome
- ↓ digoxin effectiveness
- used for depression, menopausal sx, and other conditions
Minor and Major Depression: CAM - Amino acid supplements such as 5-HTP, L-tryptophan
1. Drug interaction
2. Adverse Effects/Notes
- SSRIs and MAOIs
- Dextromethorphan
- Triptans (e.g., Imitrex, Zomig)
- SSRIs and MAOIs
- Serotonin Syndrome
Minor and Major Depression: CAM - Omega-3 fatty acids (cold-water fish oil such as from salmon) + Folate and vitamin B6 (pyridoxine)
1. Drug interaction
2. Adverse Effects/Notes
- No major interactions
- high doses of omega-3 fish oil may ↑ risk of bleeding
- supplements are usually stopped ~1 week before surgery
- high doses of omega-3 fish oil may ↑ risk of bleeding
Minor and Major Depression: CAM - Exercise, yoga, massage, guided imagery, acupuncture, light therapy
1. Drug interaction
2. Adverse Effects/Notes
- Exercise is just as effective in treatment depression as some drugs
Minor and Major Depression: SIG-E-CAPS (mnemonic for remembering s/sx of depression)
Sleep
Interest
Guild
Energy
Concentration
Appetite
Psychomotor
Suicide
Minor and Major Depression: CAM - Kava-kava and/or valerian root
1. Drug interaction
2. Adverse Effects/Notes
used to tx anxiety and depression
- Do NOT mix w/
- benzos
- hypnotics
- CNS depressants
Alcoholism
1. Definition/Etiology
2. Legal Definition
3. Dietary Guidelines for Americans (Ethyl Alcohol or Ethanol)
- compulsive desire to drink alcohol despite personal, financial, and social consequences
- strong craving for alcohol
- unable to limit drinking
- with alcohol dependence, pt experiences cognitive, behavioral, and physiologic sx generated from persistent and chronic use
- Abrupt cessation causes withdrawal sx
- alcohol abuse occurs when maladaptive behavior pattern appears from repeated alcohol use
Exam Tips:
- Questions may ask about who is most likely (or least likely to become an alcoholic)
- ↑ BAL >0.08% is illegal for driving (blood alcohol or breathalyzer) in all US states
- Standard drink sizes, considered “one drink”
* Beer: 12 oz (~5% alcohol)
* Malt liquor: 8-9oz (~7% alcohol)
* Wine: 5 oz (~12% alcohol)
* Liquor/spirits: 1.5 oz or a “shot” of 80-proof gin, vodka, rum, whiskey, or tequila (~40% alcohol)
- ↑ BAL >0.08% is illegal for driving (blood alcohol or breathalyzer) in all US states
- Women: 1 drink per day
- Men: 2 drinks per day
- Binge drinking:
* pattern of alcohol consumption that brings BAL to ≥0.08% on one occasion (generally within 2 hours)
* Males ≥ 5 drinks in a single occasion
* Females ≥ 4 drinks in a single occasion
- Women: 1 drink per day
- Women metabolize alcohol (50%) more slowly than men; also more susceptible to alcohol-related liver damage
- Excessive alcohol consumption is the 3rd leading preventable cause of death in US
- The DSM-5 diagnosis of alcoholism is called “alcohol use disorder”
Alcoholism
5. People who should abstain from Alcohol
- pregnant women (or suspect pregnancy or breastfeeding)
- recovering alcoholics or people who cannot control amount they drink
- People w/ jobs requiring alertness and coordination (e.g., pilots, truck drivers)
- People taking meds that interacts w/ alcohol
Drugs that Interact w/ Alcohol (Ethanol) + Side/Adverse Effects
Benzodiazepines → Lorazepam (Ativan), clonazepam (Klonopin), alprazolam (Xanax), diazepam (Valium)
- Drowsiness, impaired motor control, dizziness, respiratory depression, overdose risk
Hypnotics → Zolpidem (Ambien, eszopiclone (Lunesta), temazepam (Restoril), doxylamine (Unisom)
- Drowsiness, dizziness, impaired motor control, memory issues
Opioids → Meperidine (Demerol), oxycodone (Percocet), hydrocodone (Vicodin)
- Drowsiness, impaired motor control, respiratory depression
Antidiabetics → Glipizide (Glucotrol), glyburide (DiaBeta), Glucophage (Metformin)
- Hypoglycemia, flushing, headache, vomiting, palpitations
Statins → Atorvastatin (Lipitor), simvastatin (Zocor)
- Liver damage
Herbs → Kava-kava, kratom
- ↑ sedation, liver damage
Antiseizures → Phenytoin (Dilantin), topiramate (Topamax), gabapentin (Neurontin)
- ↑ risk of seizures, drowsiness, unusual behavior
Muscle relaxants → Cyclobenzaprine (Flexeril), carosprodol (Soma)
- Drowsiness, ↑ risk of overdose, impaired motor control
Antipsychotics → Haloperidol (Haldol), olanzapine (Zyprexa), risperidone (Risperdal)
- Drowsiness, respiratory depression, impaired motor control, hypotension, seizures
Antihistamines → Diphenhydramine (Benadryl), loratadine (Claritin), cetirizine (Zyrtec)
- Drowsiness, dizziness, ↑ risk of overdose
Hypertensives → Verapamil (Calan), benazepril (Lotensin), losartan (Cozaar), hydrochlorothiazide, clonidine (Catapres), terazonsin (Hytrin), doxazosin (Cardura)
- Dizziness, drowsiness, fainting, hypotension, arrhythmia
Alcoholism
6. Lab Results
a. Gamma-Glutamul Transferase
b. AST/ALT Ratio (liver Transaminases)
c. MCV
d. Carbohydrate-Deficient Transferrin
a. - Lone elevation (w/ or w/out ALT and AST) is a possible sign of occult alcohol abuse
b. - Both AST and ALT are usually elevated (w/ or w/out elevated gamma-glutamyl transaminase [GGT])
- Ratio of 2:11 with AST/ALT (AST level is double the level of ALT) is associated w/ alcohol abuse (alcoholic hepatitis)
- ALT is more specific for the liver than AST; AST also found in liver, cardiac/skeletal muscle, kidneys, and lungs
c. RBCs may be larger size (MCV >100 fL) d/t folate deficiency resembling mild macrocytic anemia
- Platelets → chronic alcohol use affects production and function of platelets in body; alcoholism can cause thrombocytopenia; ↑ risk of bleeding (stroke)
- Triglycerides: alcohol affects synthesis of lipids in liver; effect is attributed to inhibition of lipoprotein lipase activity; very high levels of triglycerides can ↑ risk of acute pancreatitis
d. -Biomarker test for chronic alcohol abuse (2-3 weeks or longer); elevated level is highly suggestive of recent high alcohol consumption, esp if abnormal ALT and/or ST; can detect binge drinking or daily heavy drinking (≥4 drinks/day); can also detect relapse
- proved to be superior to GGT or MCV as indicator of chronic alcohol (ethanol) abuse and hepatitis caused by alcohol abuse (w/ ↑ AST and ALT)
** Lone GGT elevation can be a sign of occult alcohol abuse
** AST/ALT ratio of 2.0 or higher is more likely in alcoholism
** A male who drinks one glass of wine or one beer daily is NOT considered an alcoholic
Quick Screening Tests for Identification of Alcohol Abuse/Alcoholism: CAGE test
Positive finding of at leats 2/4 → highly suggestive of alcohol abuse:
C - Do you feel the need to CUT DOWN?
A - Are you ANNOYED when your spouse/friend comments about your drinking?
G - Do you feel GUILTY about your drinking?
E - Do you need to drink EARLY in the morning (an EYE-OPENER)?
Examples of some quote using CAGE:
C - “I would like to drink less on the weekends.” “I only drink a lot on weekends.”
A - “My wife nags me about my drinking.” “My best friend thinks I drink too much.”
G - “I feel bad that I don’t spend enough time with the kids because of my drinking.”
E - “I need a drink to feel better when I wake up in the morning.”
Quick Screening Tests for Identification of Alcohol Abuse/Alcoholism: T-ACE Test
Similar to CAGE test, except for the first question; last 3 questions are from the CAGE test
Positive finding of at least 2/4 is highly suggestive of alcohol abuse
T - Does it TAKE MORE THAN 3 DRINKS to make you feel high?
A - Have you ever been ANNOYED by people’s criticism of your drinking?
C - Are you trying to CUT DOWN on drinking?
E - How you ever used alcohol as an EYE-OPENER in the morning (having a drink when you wake up to treat a hangover)?
Quick Screening Tests for Identification of Alcohol Abuse/Alcoholism: Short Michigan Alcoholism Screening Test Questionnaire
13-item questionnaire that is a shorter version of the original Michigan Alcoholism Screening Test (MAST) Questionnaire (contains 24 items)
- Can be used in adults and adolescents
- a disadvantage is time required to take and score it.
Quick Screening Tests for Identification of Alcohol Abuse/Alcoholism: Alcohol Use Disorders Identification Test
- 10-question tool used in women, minorities, and adolescents
- Unlike other screening tests, AUDIT has proved to be accurate across all ethnic and gender groups
- one of the most accurate alcohol screen tests (92%)
Alcoholism
7. Treatment Plan (Meds vs Nonpharm)
- Benzodiazepines (Librium, Valium), antipsychotics if needed (e.g., Haldol)
- Vitamins:
- Thiamine 100 mg IV
- Folate 1 mg PO/IV daily
- Multivitamins w/ high-caloric diet
- Refer to AA (12-step program), a therapist, and/or recovery program
- Avoid prescribing a recovering alcoholic/addict drugs w/ abuse potential such as narcotics or any meds that contains alcohol (cough syrup)
Meds:
- Disulfiram (Antabuse) → Causes severe N/V, headache, other unpleasant effects
- Naltrexone (Vivitrol) → ↓ alcohol cravings
Alcoholism: AA
Alcoholic Anonymous
- one of the most successful methods for recovering alcoholics (founded by BIll Wilson and Dr. Robert Smith)
- Pt is paired w/ mentor (a recovered alcoholic); believes in a “higher power”
- Must follow a 12-step program and attend AA meetings (uses “chip” reward)
- Support group for family members and friends is called Al-Anon (Al-Anon Family Groups)
- Support group for teen children of alcoholics is all Alateen
Acute Delirium Tremens
Characterized by a sudden onset of confusion, delusions, transient auditory/tactile/visual hallucinations, tachycardia, hypertension, hand tremors, disturbed psychomotor behavior (picking at clothes), and grand mal seizures
- Considered a medical emergency → Refer to ED!
Korsakoff’s Syndrome
(Wernicke-Korsakoff Syndrome)
- Complications from chronic alcohol abuse
- neurologica ds w/ sx that include: hypotension, visual impairment, and coma
S/S
- mental confusion
- ataxia
- stupor
- coma
- hypotension
Tx: high-dose parenteral vitamins, esp thiamine (Vitamin B1)
Korsakoff’s Amnesic Syndrome
- type of amnesia caused by chronic thiamine deficiency d/t chronic alcohol abuse
- problems w/ acquiring/learning new information (antegrade amnesia) and retrieving older information (retrograde amnesia)
s/Sx
- confabulation
- disorientation
- attention deficits
- visual impairment
- chronic deficiency damages the brai permanently
Smoking Cessation: Options - Nicotine Gum
Tobacco use → most common cause of preventable death
- Discuss at every visit w/ smoker patients
Nicotine gum use
- follow “chew and park” pattern → chew gum slowly until nicotine taste appears, then “park” next to cheeks (buccal mucosa) until taste disappears
- repeat pattern several times and discard nicotine gum after 30 mins of use
Smoking Cessation: Options - Nicotine patches
- cannot smoke while on nicotine patches
- do not use w/ other nicotine products (e.g., gum, inhaler)
- pt can overdose on nicotine
- nicotine overdose can cause acute MI, HTN, and agitation in susceptible pts
- nicotine products can be used w/ bupropion (Zyban)
** Do NOT mix nicotine patches w/ nicotine gum. Do NOT smoke while on patches
Smoking Cessation: Options - Bupropion (Zyban)
- decreases cravings to smoke
- pt can still smoke while on bupropion
- can be combined w/ nicotine products
- individual eventually loses desire to smoke and finally quits
Contraindications:
- seizure disorders
- hx of anorexia/bulimia
- abrupt cessation of ethanol
- benzodiazepines
- antiseizure drugs
- severe stroke
- brain tumor
- Be careful w/ depressed pts → may increase risk of suicidal thoughts and behavior
Smoking Cessation: Options - Bupropion (Zyban)
- decreases cravings to smoke
- pt can still smoke while on bupropion
- can be combined w/ nicotine products
- individual eventually loses desire to smoke and finally quits
Contraindications:
- seizure disorders
- hx of anorexia/bulimia
- abrupt cessation of ethanol
- benzodiazepines
- antiseizure drugs
- severe stroke
- brain tumor
- Be careful w/ depressed pts → may increase risk of suicidal thoughts and behavior
Smoking Cessation: Options - Varenicline (Chantix)
- prescribe for ≥12 weeks
- even if not ready to quit, initiating drug will reduce cravings for tobacco use and facilitate quitting
- may be combined w/ nicotine patch (↑ risk of adverse effects)
- take a careful psychiatric hx and avoid prescribing to mentally unstable pts or those w/ hx of recent suicidal ideation
Adverse Effects:
- neuropsychiatric sx
- may impair the ability to drive or operate heavy machinery
- FAA prohibits pilots and air traffic controllers from taking the drug (FAA= Federal Aviation Administration)
Electronic Cigarettes (Vaping)
1. Definition/Etiology/Contents
2. Sx of possible lung damage (EVALI)
- AKA: E-cigarettes, e-cigs, vapes, vaping, vape pens, e-hookahs
- devices that heat a liquid into aerosol (vapor), which is inhaled by user
- liquid contains nicotine, flavoring, and other additives
- vitamin E acetate, used as a diluent, can cause serious lung damage → diagnosis is called e-cigarette, or vaping, product use-associated lung injury (EVALI)
- Tetrhydrocannabiol (THC) vapes are also associated w/ EVALI
- >2,800 causes of EVALI have been reported to CDC w/ 60 deaths
- Favored vapes (e.g., cotton candy, mint, grape) are very popular w/ teens
- newer vapes are smaller, easier to hide, and resemble USB flash drives
- in 2018, 1/5 high school students reported using e-cigarettes in the past month
- according to the CDC and FDA, e-cigarettes are not safe for youth, young adults, and pregnant women - difficulty breathing
- SOB
- chest pain
- mild-to-mod GI sx (vomiting, diarrhea)
- fevers
- fatigue
- difficulty breathing
- EVALI should be suspected in younger pts w/ hx of vaping (or other e-cigarettes products) w/ pneumonia-like sx, progressive dyspnea, and/or worsening hypoxemia
- some have a hx of asthma, which can become exacerbated w/ vaping
- EVALI should be suspected in younger pts w/ hx of vaping (or other e-cigarettes products) w/ pneumonia-like sx, progressive dyspnea, and/or worsening hypoxemia
Insomnia (Sleep Disorder)
1. Definition
2. Risk Factors
3. Etiology
- ideal amount of sleeP: 7-8 hours
- about 40-709 million Americans suffer from either transient (<1 week), short-term (1-3 months), or chronic (>3 months) insomnia
- can manifest as either difficulty falling asleep (sleep-onset insomnia) or falling asleep but waking up during the night or too early and being unable to go back to sleep
- can cause daytime drowsiness, fatigue, tension headache, irritability, and difficulty concentrating/focusing on tasks
*Clinical diagnosis
- self-medicating using alcohol to facilitate sleep may indicate a coexistent alcohol/drug-dependence problem
- abrupt cessation of these agents may cause increased insomnia and/or anxiety
- ideal amount of sleeP: 7-8 hours
- depression
- severe anxiety
- GERD
- female gender
- illicit drug use
- musculoskeletal illness
- pain
- chronic health problems
- shift work
- alcohol
- caffeine
- nicotine
- certain meds (e.g., SSRIs, cardiac, BP, and allergy meds, steroids, ACEi, ARBs)
- depression
- Circadian rhythm disorders
- psychic issues
- mental illness
- environmental factors
- certain meds
- jet lag
- noise
- idiopathic causes
- Circadian rhythm disorders
Medical conditions that can cause insomnia
- OSA
- RLS
- chronic fatigue syndrome
- bipolar disorder
- GERD
- Alzheimer’s disease
- Parkinson’s disease
- arthritis pain
- stroke
Insomnia Classification
1. Primary
2. Secondary
3. Tertiary
4. Short-term
5. Chronic
- 25%; not caused by disease, mental illness, or environmental factors
- caused by disease (physical, emotional, mental) or environmental factors
- duration of up to 3 nights
- AKA acute insomnia; duration of <3 months; caused by pain, stress, grief, or other factors; expected to resolve when stressor is gone or when pt has adjusted
- Presence of sx for at least 3 months, occurs at least 3 nights/week; can be primary or secondary insomnia
Insomnia
4. Treatment Plan (Nonpharm)
- FIRST LINE: sleep hygiene
- improve sleep hygiene (maintain regular sleeping time, nighttime ritual, avoid caffeine/tobacco/heavy meals before bedtime, get out of bed in 30 mins if not asleep, use bed only for sleep and sex)
- avoid using media w/ screens (smartphones, TV, computers) when in bed; the blue light can disrupt melatonin secretion by the pineal gland
- CBT for insomnia (CBT-I) is recommended for chronic insomnia in most pts; alone or in combination w/ meds
- Refer to sleep lab (polysomnography) ← GOLD STANDARD for sleep apnea
- after diagnosis → Refer to otolaryngologist
- FIRST LINE: sleep hygiene
Insomnia
5. Meds
6. Benzodiazepines/Hypnotics (short-acting, intermediate, long-acting)
7. Nonbenzodiazepine Hypnotics
- Diphenhydramine (Benadryl), OTC antihistamine; can cause exc ess sedation and confusion in the elderly
- most sedating antihistamine
- avoid w/ the elderly
- Diphenhydramine (Benadryl), OTC antihistamine; can cause exc ess sedation and confusion in the elderly
- See Psychotropic Drugs
- Some benzodiazepines are more sedating and are used a hypnotics, including triazolam (Halcion) and temazepam (Restoril)
Hypnotics and “sleeping pills” are ideally used for a short duration, but many insomniacs continue using sleeping pills daily to help w/ sleep. Physical dependence may develop w/ long-term use. If patient has been on benzodiazepine for a long time, do not discontinue abruptly (will ↑ risk of seizures); wean off slowly and gradually
- Short-acting (half-life <5 hrs): Alprazolam (Xanax), triazolam (Halcion), midazolam (Versed)
- Intermediate-acting (half life 5-24 hrs): Lorazepam (Ativan), temazepam (Restoril), clonazepam (Klonopin)
- Long-acting (half-life >24 hrs): Diazepam (Valium), chlordiazepoxide (Librium)
- These drugs have quick onset (0-15 mins). Do not take if unable to get 7-8 hours of sleep.
Adverse effects:
- agitation
- hallucinations
- nightmares
- suicidal ideation
- There has been cases in which person wakes up and does their normal routine (sleep-driving, eating, working) but is unable to recall incident
Ex:
- Zolpidem (Ambien) & eszopiclone (Lunesta) for sleep onset or inability to stay asleep
- Ramelteon (Rozerem)_ for sleep-onset insomnia (melatonin agonist)
- Temazepam (Restoril), lorazepam (Ativan) for sleep-onset insomnia and sleep maintenance insomnia
** Do not mix kava-kava and valerian root w/ benzodiazepines, hypnotics, or CNS depressants!
** Buspirone (BuSpar), a nonbenzodiazepine drug for chronic anxiety, is taken BID, NOT as an PRN like benzodizepines
Insomnia
8. Complementary/Alternative Treatments
- Avoid kava-kava or kava-containing supplements
* FDA Consumer Advisory issues; they are associated w/ liver injury (hepatitis, cirrhosis, fulminant liver failure)
- Valerian root (sedating, also used for anxiety)
- Melatonin (also for circadian rhythm ds such as shift work, jet lag)
- Chamomile tea
- Meditation, yoga, tai chi, acupuncture, regular exercise (avoid 4 hours before bedtime)
- Avoid kava-kava or kava-containing supplements
** Kava-kava and valerian root are natural supplements used for insomnia/anxiety. Do not mix kava-kava and valerian root w/ benzodiazepines, hypnotics, or CNS depressants!
Bipolar Disorder
1. Definition/Etiology
2. Clinical Presentation
3. Treatment/Meds
- characterized by mood instability, alternating cycles of mania and depression
- Peak incidence of onset is 20s (ranges from age 14-30 years)
- characterized by mood instability, alternating cycles of mania and depression
TWO types:
- Bipolar type 1
Bipolar type 2 (hypomania instead of mania)
- Bipolar pts are at higher risk of suicide (10-15% die by suicide)
- Manic sx:
- increased energy/activity’
- gradiosity
- less need for sleep
- disinhibition
- talkativeness
- euphoric mood
Depressive sx: similar to major depression
* at higher risk of suicide during the depressive phase of illness
*** LOOK FOR S/SX OF DEPRESSION AND SUICIDE WARNINGS!
- May have psychotic episodes (delusions, hallucinations)
- bipolar pts have higher rates of substance abuse (40-60%), and other comorbidities (ADHD, anxiety, OCD, eating disorders)
- Refer to psychiatrist or PMHNP for management
Meds:
- Lithium salts → Adversely affect kidney and thyroid gland
- anticonvulsants (divalproex [Depakote], lamotrigine [Lamictal])
- 2nd gen antipsychotics (risperidone [Risperdal], quetiapine [Seroquel], olanzapine [Zyprexa])
Schizophrenia
1. Definition/Etiology
2. Clinical Presentation
3. Treatment Plan
- Psychotic sx including delusions and paranoia (disorganized speech and behavior)
- Onset usually around the second decade; peak incidence is between 16-30 years - hallucinations are common (usually auditory) with loss of ego boundaries
- flat and restricted affect
- poor social skills
- executive function is very poor (ability to plan and organize day-to-day activities)
- hallucinations are common (usually auditory) with loss of ego boundaries
- Refer to psychiatrist or PMHNP for management
Schizophrenia
4. Medications + Safety Issues/Monitoring
- Use of typical antipsychotics ↑ risk of sudden death among elderly who are in long-term care
- Antipsychotics can prolong QT intervals and cause a fatal arrhythmia called torsade de pointes, including clozapine (Clozaril), thioridazine (Mellaril), ziprasidone (Geodon), haloperidol (Haldol), quetiapine (Seroquel)
- Use of typical antipsychotics ↑ risk of sudden death among elderly who are in long-term care
- Pregnancy testing (ALL medications)
- Lithium → serum creatinine, eGFR, TSH, chemistry profile, EKG; if cardiac RF
- Antipsyhoctics → A1C, lipid profile, EKG if cardiac RF
- Divalproex (Depakote) → CBC, CMP
Anorexia Nervosa
1. Definition/Etiology
2. Clinical Presentation
3. Treatment
4. Complications
- Onset is usually during adolescence
- Morality rate is 5%; death rate is 5-10x greater than gen population
- Definition: irrational preoccupation w/ an intense fear of gaining weight along w/ distorted perception of body shape and weight
- pt tend to secretive, perfectionistic, and self-absorbed
2.- severe restriction of food intake
- marked weight loss (BMI <18.5)
- lanugo (face, back, and shoulders)
- amenorrhea for ≥ 3 months
- if purging, loss of dental enamel may be present
- engages in severe food restriction or cycles of binge eating and purging (ex. laxatives, vomiting)
- excessive daily exercise is common
- Refer to eating disorders therapist or inpatient hospitalization in eating disorder unit
** Bupropion (Wellbutrin) is contraindicated for anorexic/bulimic pts; increases seizure threshold - osteopenia/osteoporosis d/t prolonged estrogen depletion (from amenorrhea) and low calcium intake; higher risk of stress fractures
- female athlete triad is seen in physically active slender females w/ amenorrhea, premature osteopenia/osteoporosis, and disordered eating
- Peripheral edema may occur (low albumin from low protein intake)
- Cardiac complications are the most common cause of death (e.g., arrhythmias, cardiomyo8pathy, atrophy of heart muscles, bradycardia); hypotension is common w/ BP <90/50 mmHg
- osteopenia/osteoporosis d/t prolonged estrogen depletion (from amenorrhea) and low calcium intake; higher risk of stress fractures
Posttraumatic Stress Disorder (PTSD)
1. Definition/Etiology
2. Clinical Presentation
3. Treatment
- & 2. Characterized by flashbacks, nightmares, intrusive thoughts, avoidance of reminders of trauma, sleep disturbance, and hypervigilance
- causes: combat/war, sexual assault (12%), MI, stroke, ICU stay (20%)
- comorbidity (e.g., depression, anxiety, antisocial disorder, and substance abuse) is higher in PTSD
Assessment tools: PTSD check list (PCL-5) → a 20-item self-report measure (for screening and for monitoring sx over time)
- FIRST LINE: trauma-focused psychotherapy (exposure therapy, CBT, or eye movement desensitization and rep9rocessing [EMDR])
- Meds can be used alone or w/ psychotherapy; SSRIs are the preferred drug class to treat PTSD
- FIRST LINE: trauma-focused psychotherapy (exposure therapy, CBT, or eye movement desensitization and rep9rocessing [EMDR])
Munchausen Syndrome
- AKA “factitious disorder imposed on self”
- pt falsifies sx of factitious ds (e.g., abdominal pain, chest pain, seizures) and/or injured self and seeks medical treatment, including multiple surgeries
- AKA “factitious disorder imposed on self”
- Munchausen by proxy → a related ds, refers to a parent using a child (and making the child sick) to obtain medical care
- Rare conditions (1%); difficult to diagnose
Female athlete traid
- amenorrhea
- low bone mass
- low BMI
Recognize how anorexic patients present
- lanugo
- peripheral edema
- amenorrhea
- BMI <18.5
Abuse: All Types
1. Definition/Etiology
2. Types
- abusive behaviors are multifactorial
- may include physical, emotional, and sexual abuse, and/or neglect, + economic abuse or material exploitation
- can happen at any age and during pregnancy (higher risk)
* State of pregnancy is also associated w/ higher incidence of abuse d/t jealousy over the pregnancy
- abusive behaviors are multifactorial
- Upon ED presentation, pattern of injuries is inconsistent w/ hx given
- elderly most likely to be abused are those >80 years and/or frail
- children w/ mental, physical, or other disabilities, and stepchildren are more likely to be abused
- Physical
- Sexual
- Emotional/psychological
- Neglect
- Physical
Exam Tip: There will always be a few questions on physical abuse; the questions may address physical abuse, child abuse, sexual abuse, and/or elder abuse
Abuser: a person who does not want the abused person out of sight or interviewed alone; typically answers all the questions for the pt and will exhibit “controlling” behaviors toward abused pt
- Common finding: delay in seeking medical tx for injury
- intimate partner violence (IPV) → intentional control or victimization performed by a person to another w/ whom the person has an intimate or spousal relationship
- MOST significant reason for missing diagnosis of IPV or other abuse is failure to ask
Abuse: All Types
3. Risk Factors that increase Likelihood of Abuse
- ↑ stress (partner/parent/caregiver)
- alcohol/drug abuse
- personal hx of abuse, positive family hx of abuse
- major loss (e..g, financial, job loss)
- social isolation
- pregnancy (domestic abuse)
- elderly abuse: frail elderly and those w/ dementia are more likely to be abused; about 2/3 of all elder abuse is perpetrated by family members (usually an adult child or a spouse); most abused elderly also suffer economic abuse
- only certain states have mandatory reporting of partner abuse; be mindful of institutional abuse of elderly, children, and the disabled
Abuse: All Types
4. Physical Exam
- another health provider (witness) should be in the same room during the exam
- interview victim without abuser in the same room
- collect visual evidence of trauma via Polaroid or digital camera to document all injuries; keep all evidence in a safe place; use a ruler to identify and document the size of the injuries; document direct “quotes” in pt’s hx
- use abuse assessment screening tool w/ a body map to document assessment findings
- look for spiral fractures (greenstick fracture) multiple healing fractures (esp in rib area), burn marks w/ pattern, welts, etc
- look for signs of neglect (e..g, dirty clothes, inappropriately dressed for weather)
- for partner abuse, focus on developing a plan for safety w/ pt when appropriate; give pt the phone number of a crisis center and/or safe place
- STD testing:
- Chlamydial and gonorrheal cultures ( must use cultures + Geen-Probe)
- HIV, hep B, syphilis, herpes type 2
- Genital, throat, and anal area culture and testing MUST be done
- Abuse pt is very fearful and quiet when with the “abuser”
Abuse: All Types
5. Treatment Plan
- Provide prophylactic treatment against several STDs (e/ parental consent for minors)
- teach pt lthe cycle of abuse; education pt regarding safety issues and having an escape plan ready for use
- healthcare professionals must report actual or suspected child abuse
- be aware of individual state guidelines on reporting suspicion of elderly abuse
- abuse of a disabled person MUST be reported to the Disabled Person Protective Commission; contact adult protective services or law enforcement agencies w/ concerns regarding self-neglect
- Provide prophylactic treatment against several STDs (e/ parental consent for minors)
- Abuse Cases: Interview together and then separately
Good Communication Concepts
- State things objectively; do NOT be judgmental → “You have bright-red stripes on your back” instead of “it looks as if you have been whipped on your back”
- Open-ended questions are preferred → “How can I help you?” instead of “what type of object was used to hurt your back?”
- Do NOT reassure patients (this stops the pt from talking more about their problems) → “We will make sure you get help” instead of “Don’t worry, everything will be fine.”
- Let the pt vent their feelings. Do NOT discourage pt from talking → “Please tell me why you feel so sad.”
- Validate feelings → “Yes, I understand your anger when someone hits you”
Exam Tip: * Any answer choice that reassures patients is usually WRONG
* Delaying an action (e.g., waiting until the pt feels better) is ALWAYS wrong
Motivational Interviewing
A counseling method used to help an individual resolve a state of indecision (ambivalence) into finding the internal motivation (motivational enhancement) to make positive and healthier behaviors
- Recent meta-analyses have shown that motivational interviewing is effective in ↓ drug and alcohol use in adolescents and adults
- method is used for substance abuse, smoking cessation, alcohol abuse, losing weight, reducing sexual risk behaviors, and other types of unhealth behaviors
Five Principles of Motivational Interviewing
- Express and listen w/ empathy about pt’s issues (through reflective listening)
- Understand the pt’s own motivations
- Avoid argument (or direct confrontation)
- Adjust to pt (rather than opposing the pt)
- Support self-efficacy (empower the pt)
* Alfred Bandura, a psychologist, defined self-efficacy as one’s belief in one’s ability to succeed in accomplishing a task
