Psychiatry history Flashcards
How do you ask about drinking pattern in an alcohol history?
- can you tell me about your drinking?
- starting from first thing in the morning, talk me through what you drink in a typical day?
- what do you drink?
- how much?
- when do you start
- where?
- Do you drink alone? (alone)
- How has your drinking progressed? (progression)
What is the CAGE questionnaire?
- Have you ever felt you should cut down on your drinking?
- Do people annoy you by critisicing your drinking?
- Do you feel guilty about your drinking?
- Do you drink first thing in the morning? (need an eye opener?)
What are the features of alcohol dependence that should be asked in an alcohol Hx?
- Do you have to drink more to get the same effect you used to? (tolerance)
- what happens when you dont drink?
- do you get shakes or sweats when you don’t drink for a few days? (withdrawal)
- do you get any cravings or urges for alcohol? (compulsion)
- would you say drinking has become your main priority in life? (primacy)
- have you ever had any treatments for detox for alcohol? (previous treatment)
- What helped?
- what triggered your relapse?
What are the questions on ‘consequences’ of alcohol dependence that should be asked in an alcohol hx?
- has your drinking caused any problems in your life? (open)
- how has your drinking affected your working life?
- how are things financially for you at the moment?
- how has your drinking affected your relationships with family and friends?
- have you had any problems with the law?
- Do you ever drive after drinking?
What are the questions on alcohol ‘complications’ that should be asked in an alcohol Hx?
physical
- have you noticed any weight loss?
- how is your appetite?
- have you had any problems with your memory?
mental: depression, anxiety, psychosis, self-harm
- how has your mood been over the past few weeks?
- have you noticed any strange or unusual experiences?
- it seems as if things have been very difficult for you recently. Have things ever got so bad that you thought about harming yourself?
What PMH, DH, FH and SH should you ask in an alcohol hx?
PMH - do you suffer from any medical or psychiatric conditions?
any diabetes, liver disease and CVS?
DH - any meds? any allergies?
FH - anyone in your family had problems with alcohol? Do any conditions run in your family?
SH - smoke? any rec drugs?
How do you ask about ‘insight’ in an alcohol hx?
It seems alcohol has been a significant part of your life…
- do you think you have a drink problem?
- Do you want to stop or reduce your drinking?
- would you be interested in accepting help if offered to you?
What investigations should be done after an alcohol hx? (if suspected dependence)
- General physical examination
- assessing for malnourishment
- signs of liver and heart disease (both AF and alcoholic cardiomyopathy)
- bloods
- FBC (macrocytic anaemia)
- U&Es
- CRP
- LFTs
- clotting screen
- lipids
- glucose
- Gamma - GT
- vitamin levels (particularly thiamine)
- in acute state of intoxication also measure blood alcohol levels
- Further investigations depend on any related illness e.g. abdo USS, CT/MRI abdomen (liver disease) and echocardiography (for heart disease)
How do you manage alcohol dependence?
General measures:
- Advice about alcohol adverse effects
- vit supplements inc thiamine to prevent wernickes encephalopathy
- support and advice (inc listening ear at times)
- financial support where possible and indicated
Acute alcohol withdrawal:
- consider if inpatient management needed
- IV pabrinex or oral thiamine to prevent wernickes encephalopathy
- chlordiazepoxide (benzo) to treat temor and agitations in delirium tremens
Abstinence:
- social support - involve fam and friends in their care where possible
- support groups e.g. AA etc
- CBT
- Acaprosate - reduces cravings
- Naltrexone - reduces pleasurable effects of alcohol; particularly effective in binge drinkers
- disulfiram; causes unpleasant rxn if patient drinks alcohol including nausea, headache and palpitations
What are the key points of a forgetfulness history?
- HPC- natural Hx –> onset and prognosis
-
Cognition
- short term e.g. appointments and taking meds
- long term
- visuospatial
- language (words)
-
Changes
- behaviour
- personality
- rule out other psych issues
- depression
- anxiety
- psychosis
-
Organic causes
- weight loss
- fever
- night sweats
- parkinsonism
-
Risk assessment
- Dangerous events
- driving
- harm - self/others
- collateral- & safety net collateral
What are the symptoms of alzheimers disease as a DDx for forgetfulness?
- Progressive global impairment of cognitive function
- Short term meemory often affected first, followed by confusion –> irritability –> agression –> LT memory loss –> mood swings and incontinence
- AD is the most common form of dementia - >50% of cases
- risk factors: ++age, caucasian, female, vascular disease
What are the symptoms of vascular dementia as a DDx in forgetfulness history?
- Vasc Dementia:
- stepwise decline in cognitive functioning over months-years
- evidence of previous stroke with onset of dementia within 3 months of stroke
- CVS risk factors likely to be present
What are the symptoms of dementia with lewy bodies as a ddx for forgetfulness?
- Fluctuating confusion
- parkinsonian features
- tremor
- bradykinesia
- festinating gait
- ataxia (leading to falls)
- micrographia
- visual hallucinations
- intermittent loss of consciousness
- Short term memory is often preserved to a greater extent than in alzheimers- but visuospatial difficulties are more pronounced
What are the symptoms of frontotemporal dementia as a ddx in forgetfulness hx?
- Agression, inappropriate social behaviour, emotional blunting, incontinence and speech and language difficulties all tend to occur early
- often insidious
- earlier age of onsent than in Alzheimers Disease
What are the other causes (including organic) for DDx of forgetfulness?
- normal ageing process
- impairment of memory and intellect is common in the elderly, but does not always justify a diagnosis of dementia
- delirium
- acute confusional state common in the elderly, often due to infection/drugs (e.g. morphine)/alcohol
- depressive psuedodementia
- common in elderly; often present with memory impairment and difficulty in attention and concentration
- metabolic disturbances
- e.g. uraemia from renal or liver failure,
- hypothyroisdism,
- hypo-/hypercalcaemia,
- hypoglycaemia and
- vitamin B12 deficiency
- Brain tumour
- behavioural/personality changes, headaches, seizures and nausea and vomiting are common features
- usually a secondary tumour
- parkinsons disease
- parkinsonian features preceding symptoms of dementia by at least 1 year
