MEDICINE/PSYCHIATRY SEMINAR SAI YAN AU LEE - FAN SUI.
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Transcript of MEDICINE/PSYCHIATRY SEMINAR SAI YAN AU LEE - FAN SUI.
MEDICINE/PSYCHIATRYSEMINAR
SAI YAN AU
LEE - FAN SUI
Presenting Complaint
70 year old lady
Suicidal attempt by overdose of Temazepam
Shortness of breath (SOB) on mild exertion
Weight loss (4 stones in 4 years)
History of Presenting Complaint
Sunday (16/02/03)Took 25 tablets of Temazepam (10mg)Suicidal attempt came at the spur of momentCouldn’t cope up with her SOB, “I just had it enough!”
Found out by her niece
Called for an ambulance
History of presenting complaint - SOB on mild
exertionSOB started about 3 to 4 years ago
Diagnosed with emphysema in 1999
Condition declined ever since.
Became worse 12 months ago
Now unable to cook and need assistance to go to toilet and showering
Only manage to make herself coffee
History of presenting complaint - SOB on mild
exertionNo home O2
Still smoking 8/day
No productive cough or chest infection
Spirometry in 1999 FVC – 1.44 (75% predicted) FEV1 – 0.73 (47% predicted)
FEV1/FVC – 0.51(31% predicted)
History of presenting complaint - SOB on mild
exertionCXR: (1999 and 2002)
Hyperinflated lungs No pleural, mediastinal or hilar pathology
Inhalers(currently): Atrovent used 4-5 times/day Bricanyl 6 times/day Seretide: forgot to use sometimes
Past Medical History
1978 – mini stroke
1997 – hypertension
1999 – adenocarcinoma of colon (anterior resection performed), followed by colonoscopy in 2001, no radio/chemotherapy
Medication history
Stelazine 5 mg bd
DAPA – TABS 2.5 mg mane
Asterix – 100 mg mane
Temazepam – 10mg
Atrovent
Seretide
Bricanyl
Allergy to Panadeine Forte
Systemic Review
Endocrinology, urinary genital, GI and musculoskeletal systems – no abnormalities noted
Clinical Examination
PR - 70, regularRR - 20, prolonged expirationNo cyanosisChest clear, reduced movement (2cm)Breath sound vesicularHyperinflated chestNormal JVP/ no peripheral oedemaCVS -dual heart sound, normal apex beatGI - not remarkable
Neurological Rest tremor (upper limb)Normal toneNormal coordinationNo Parkinsonian sign
Past Psychiatric History
1978First episode of schizophrenia
1979Second episode of schizophrenia
Family History
Father died when she was 17 y.oMother died of pneumonia when she was 7 y.oNo psychiatric history in the familyDid not have a close relationship with her parents as she stays with her grandmother1 sister in Launceston, a/w
Personal and Social History
A Methodist
Good health all the while
Good family environment
Good peer relationships
Works in take away shops and news agency until 28 years ago
Start smoking at 19 y.o, about half to one pack/day, reduced to 13/day 4 years ago, and currently still smoking 8/ dayTried nicotine patches once last year but failedRarely drink alcoholNo drugs or substance abuseHappily married to her husbandHusband – 71 y.o, healthy with some joint problems, performs all the houseworkNot very well off financially, could not afford to see GI specialist, have to wait till next year
Mental State Examination
Appearance BehaviourSpeechMood and affectThought formThought contentAbnormal perceptual experience
Cognitive functions – Mini Mental Test
Insight
Rapport
Mental State Examination
NORMAL
Mini Mental test – 30/30
Differential Diagnosis
Frustration of her breathing problems leading to suicide attempt
Depression 2° to schizophrenia ??
SUICIDE &
DELIBERATE SELF - HARM
Suicide
Act of harming oneself without coercion by others, with the intent of death
2 forms (poison or physical trauma)
Occurs in all countries and culture
Prevalence ~ 5 to 30 per 100,000 pop.
Suicide (aetiology)
Social causes3 main types:-
Egotistic suicide – individual lacks meaningful links with family & community
Anomic suicide – individual’s ties with society fragment at times of breakdown
Altruistic suicide – individual determined by social customs resulting from excessive integration
Suicide (aetiology)
Medical causes Mental disorders Depressive disorders Alcohol abuse Drug-dependency Personality disorder Schizophrenia Chronic illnesses others
Assessment of suicidal risk
General issues Willingness to make
tactful but direct enquiries about patient’s intention
To be alert to the general factors signifying an increased risk
Assessing risk Consider direct
statement of intention
Consider old age Previous suicide
attempt Depressive disorder hopelessness
Completing the history
Mental state examination
Management(1)
General issuesMake a treatment plan and try to
persuade patient accept itAdmission (increased suicidal risk) or
outpatient
Management(2)
Community Full assessment of
patient and key relatives and review of suicidal risk
Regular review
Full dosage of safe psychiatric Rx
Choose less toxic drugs
Small prescriptions Involve relatives in
care of tablets Arrange immediately
access to extra help
Management(3)
Hospital Safe ward environment Adequate well trained
staff, good working relationship
Clear policies for assessment, review and observation
On admission Assess risk Agree level of
observation Remove suicidal objects Discuss plans with
patient Agree policy for visitors
During admission Regular review of
risk and plans Clear plans for leave
Discharge Plan and agree in
advance Prescribe adequate
but non dangerous amount of drugs
Early follow up
Deliberate self harm
A behaviour in which a person deliberately causes self injury or ingests a drug in excessive dosage but is not actually trying to kill himself.
Common emergency and in – patient admissions
Deliberate self harm (aetiology)
Precipitating factors Stressful life
problems Separation Illness
Predisposing factors Marital problems Length of
unemployment Poor physical health Parental loss
Psychiatric problems
Assessment
General aims Immediate risk of
suicide Subsequent risk Any current medical or
social problem
Specific enquiries Patient’s intention when
he harmed himself
Does he intend to die at that moment?
Patient’s current problem
Is there any psychiatric disorder?
Patient ‘s resources
Management
In – patient Rx (serious patients)
Psychological and social
Drugs are seldom required
Emphysema/COPD
COPD:Chronic Bronchitis, Emphysema, and some chronic asthma
Definition: chronic, slowly progressive disorder characterised by airflow obstruction (FEV1<80% predicted FEV1/FVC<70%)
Emphysema/COPD
Emphysema: Pathological of permanent destructive enlargement of airspaces distal to the terminal bronchioles
Epidemiology
UK: death rate - 25000 / year
AetiologySmoking: direct correlation with number of cigarettes smoked. Persisting airway inflammation Oxidant/antioxidant, proteinase/antiproteinase in lungs.
Dust/air pollutionLow birth weight/bronchial hyper-responsiveness
1-antitrypsin deficiency
Stop smoking slow decline in FEV1 50-70ml / year to 30 ml / year
Pathophysiology
Centriacinar
Panacinar: rarer / giant bullae
Pulmonary vascular remodelling hypoxaemia pulmonary hypertension right heart failure
Classification and diagnosis
Severity Spirometry
(FEV1)
Symptoms
Mild 60-70% predicted Smoker’s cough+/- SOB on exertion
Moderate 40-59% predicted SOB on exertion +/- wheeze, cough +/- sputum
Severe <40% predicted SOB, wheeze, cough, swollen legs
Investigations: Pulmonary function test
Spirometry If asthmatic: reversibility to Salbutamol /
ipratropium bromine If response to oral prednisolone 30mg daily
for 2 weeks prescribe regular inhaled steroids (Steroid Reversibility Trial)
Investigations: PaO2
Severe: alveolar underventilation reduced PaO2, increased PaCO2
Investigations: CXR
Exclude other pathology
Moderate - severe : hypertranslucent lung filledLow, flat diaphragmProminent pulmonary artery shadowsBullae
Investigation: CT
Quantify extent of emphysema
Smoker induced: apical
1-antitrypsin deficiency: basal
Management:
Reduce bronchial irritation:Stop smoking
Treat respiratory infection
Management (cont.)
Bronchodilator/antiinflammatory 2 adrenoceptor agonist/anticholinergics
Regular use in moderate to severe COPD
Steroid Reversibly Trial
Check technique for using inhaler
Long term 2 agonist: little value in COPD
Management (cont.)
Exercise / Obesity, nutrition, depression
Long term domiciliary O2 therapy
Low concentration of O2 given > 15 hours / day
Reduce pulmonary hypertension prolong life
Criteria:
Complications
Infections
Rupture of subpleural bullae pneumothorax
Respiratory failure / cor pulmonale
Prognosis
Decline in FEV1 (associated with age)
No drug shown to effect outcome (except O2 therapy)
Pulmonary hypertension poor
Mean survival - acute exacerbation of COPD is 3 years
Summary - our patient
Cease smoking
Review the inhaler technique
Lung function test
CXR
Colon CA follow up