Psychosocial Mental Health Study Guide

PSYCHOSOCIAL MENTAL HEA Name Cause Signs/Symptoms Diagnostics • Secretive disease. Problems with erosion of lingual surface of upper teeth due to excessive exposure to gastric contents during vomiting. Hypokalemia caused by laxative and diuretic use is common. Pt is typically of average to slightly above average weight. Bulimia Nervosa • • • DSM V: Eating excessing amount of food in 2 hours Person feels lack of control over eating Recurrent compensatory behavior to prevent excessive weight gain such as vomiting, excessive exercise, laxative or diuretic abuse or fasting Occurs once per week for at least 3 months PTSD Combat/war, sexual assault, MI, stroke, ICU stay Flashbacks, nightmares, intrusive thoughts, avoidance of reminders of trauma, agoraphobia, sleep disturbance and hypervigilance, feelings of detachment Assessment tools such as PTSD checklist Anxiety Situational, Phobias, OCD, Generalized Panic disorder occurs more in women than men with agoraphobia GAD – excessive worry occurs on more days than not for 6 months Munchausen Syndrome Factitious disorder imposed on self. Patient falsifies symptoms and or injures self-seeking medical treatment. Treatments Cognitive behavior and pharmacological therapy. SSRIs – but NOT Wellbutrin First line treatment is SSRI such as paroxetine and sertraline. Therapeutic trial of 6-8 weeks to determine effectiveness. Mirtazapine for sleep. Cognitive behavioral therapy, Eye movement desensitization and reprocessing (EMDR). Benzos – limited duration, addiction concern behavioral treatment and SSRI to kick in and then wean off Benzo GAD – SSRI, SNRI, buspirone Panic disorder – SSRI, SNRI, TCA, BB, MAOI OCD – SSRI, SNRI, TCA Concerns Binge eating is lack of control over amou nt and type of food 2+ times per week for 6 months. Accompanied by distress, self-anger, shame and frustration because of purging. Pt is usually obese. Comorbidities such as depression, anxiety, antisocial disorder and substance abuse is higher Herbs: Kava-kava, valerian root and passion flower Munchausen syndrome by proxy (makes the child sick) TOBACCO CESSATION ➢ Nicotine gum use: Chew and park – chew gum slowly until nicotine taste appears and then park next to cheeks until the taste disappears. Repeat pattern several times and discard after 30 minutes of use ➢ Nicotine patches – do not use with other nicotine products. Nicotine overdose can cause acute MI, HTN, agitation. ➢ Bupropion (Zyban) decreases cravings to smoke. Patients can still smoke while on medication. Individually eventually loses desire to quit. Contraindications include seizures, anorexia/bulimia, abrupt cessation of alcohol, benzos, stroke and brain tumor. Can increase risk of suicide. ➢ Varenicline (Chantix) – 12 weeks. Advise to quit within 1-4 weeks. Avoid prescribing to mentally unstable or hx suicide. Pilots and air traffic controllers are not allowed to take medication. PSYCHOSOCIAL MENTAL HEA ABUSE ➢ Physical, emotional and sexual abuse, economic abuse, material exploitation o Can happen at any age (± risk with pregnancy) o Pattern of injury is inconsistent with story ➢ Factors that increase likelihood of abuse o Increased stress o Alcohol and drug abuse o Personal hx of abuse, family hx of abuse o Major loss o Social isolation o Pregnancy o Elderly (especially those who are frail with dementia) ➢ Physical Exam o Another health care provider should be in the room during exam o Interview with abuser and then without o Collect visual evidence, photos, use ruler. Document in direct quotes. o Look for spiral fx, multiple healing fx, burns, welts, etc. o Look for signs of neglect o Develop a safety plan with partner abuse o STD testing ➢ State things objectively, do not be judgmental ➢ Abuser is typically dominant in conversation ➢ BATHE o Background – how are things at home? Work? Anything changed? o Affect, anxiety – how do you feel about home life? Work?School? Life in general? o Trouble – What worries you the most? o Handling – how are you handling the problems? o Empathy – that sounds difficult ➢ SOAP o Support – Normalize but do not minimalize. What support do you have? o Objectivity – Watch your reactions to the story. o Acceptance – personal acceptance ▪ Acknowledge patient priorities o Present focus ▪ Focus on present, negotiate contract ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ DSM CRITERIA FOR SUBSTANCE ABUSE DISORDER Require 2 or more of the following within past 12 months Substance use in larger amounts over longer period than intended Desire to cut down or has tried unsuccessfully in the past Excessive time spent obtaining substance, using substanceor recovering from substance Craving or a strong desire to use Inability to maintain major roleobligations Continued substance use despite recurrent social orinterpersonal problems related to substance use Substance use in potentially hazardous positions Important social, occupational or recreational activities are given up or reduced due to substance use Tolerance o Needing more to get same effect o Diminished effect with same amount Withdrawal o Set of characteristic withdrawal symptoms o Same or other substances taken to avoid withdrawal RANDOM SUBSTANCE ABUSE FACTS Often have underlying mood disorder Young adults (18-25) are most likely to misuse RX meds Chronic used of marijuana can lead to COPD Alternative to methadone is buprenorphine plus naloxone Hyperthermia and racing heart is potentially life threatening with MDMA (ecstasy or Molly) RENAL KIDNEYS ➢ ➢ ➢ ➢ ➢ ➢ ➢ Body’s regulator of fluids Water is reabsorbed by antidiuretic hormone and aldosterone Excrete water-soluble waste (creatinine, urea, uric acid) Produce erythropoietin (stimulates bone marrow to produce more RBC), renin, bradykinin, prostaglandins and calcitriol/vitamin D3 Average UO is 1500 mL Oliguria < 400 mL day Right kidney sits lower than left due to liver displacement URINALYSIS ➢ Epithelial Cells – large amounts indicate contamination; a few are normal ➢ Leukocytes – normal WBCs in urine <10 o Leukocyte esterase o Pyuria (presence of leukocytes) in males is always abnormal ➢ Urine for Culture and Sensitivity o >100,000 ➢ Red Blood Cells o <5 is normal ➢ Protein o Indicates kidney damage o Urine dipstick detects albumin not microalbumin (Bence-Jones proteins) ➢ Nitrites o Indicative of infection ➢ Cast o Hyaline cast are normal o WBC cast may be seen with infection o RBC cast and proteinuria are diagnostic of glomerulonephritis KIDNEY FUNCTION ➢ Serum Creatinine – when renal function ³ creatinine ± Creatinine affected by age (less sensitive in elderly), gender (higher in males), ethnicity (high with African background), muscle mass Male 0.7 to 1.3 Female 0.6 to 1.1 ➢ Estimated Glomerular Filtration Rate (eGFR) eGFR 90 Stage 2 eGFR 60-89 Stage 3a eGFR 45-59 Stage 3b eGFR 30-44 Stage 4 eGFR 15-30 Stage 5 eGFR < 15 ➢ Blood Urea Nitrogen – elevation may be caused by acute renal failure, high-protein diet, hemolysis, CHF or drugs (waste product of protein from foods eaten, dehydration will also elevate BUN) ➢ BUN-to-Creatinine Ratio – evaluate dehydration, hypovolemia, acute renal failure KIDNEYS ➢ Prerenal azotemia – most common cause of acute renal failure, kidneys are hypoperfused – which leads to acute tubular necrosis. Caused by ³ circulating volume such as dehydration and acute blood loss; ³ CO such as heart failure; excessive sequestering of fluids as in burns ➢ Postrenal azotemia – obstruction to urine flow and is uncommon cause of renal failure. Such as glomerulonephritis CHRONIC KIDNEY DISEASE ➢ Common electrolyte disorders include hypernatremia, hypercalcemia and hyperkalemia ➢ Increase in creatinine from 1-2 indicates a 50% loss in renal function ➢ Creatinine clearance usually approximates eGFR ➢ Creatinine is best described as a product related to skeletal muscle metabolism ➢ Common causes include DM, recurrent pyelonephritis, polycystic kidney disease ➢ Persistent proteinuria is commonly found in early development of CKD ➢ ACEI can limit the progression of some renal disease by reducing efferent arteriolar resistance ➢ Objective findings in glomerulonephritis include edema, RBC cast and proteinuria ➢ Anemia: Normocytic, normochromic anemia with low retic count ➢ Erythropoiesis is recommended with CKD and Hgb < 10 ➢ Dialysis and transplant discussion at Stage 4 CKD ➢ Some meds that affect kidneys – Allopurinol, antibiotics, digoxin, lithium, gabapentin, H2 blockers, antiarrythmias RENAL Name Cause Pyelonephritis E. Coli, Klebsiella spp. Proteus mirabilis Signs/Symptoms Diagnostics High fever, chills, dysuria, frequency, and unilateral flank pain (described as deep ache) N/V May have had recent UTI CVA tenderness UA – large leukocytes, hematuria, WBC cast and proteinuria Urine C&S Un co mplicated may treat as outpatient Cipro BID x 7 days or Levaquin daily Rocephin 1 gra m + Aug mentin BID x 14 days Abrupt onset of oliguria, edema and weight gain (fluid retention). Complains of lethargy, nausea and loss of appetite. Rapid ³ in renal function ± creatinine ³ GFR Hydrate Acute renal failure Decreased blood flow to kidneys; damage to kidneys; urine blockage in kidney Bladder cancer Long term use with pioglitazone Painless hematuria (microscopic or gross). May appear at the end of voiding. Dysuria, frequency, nocturia (not related to UTI). Advanced disease may complain of lower abdominal or pelvic pain, perineal pain, low-back pain or bone pain. UA – microscopic hematuria is the primary findin g in 20 % of individuals with bladder CA Urine C&S Urine for cytology Hematuria Cancer, infection, renal calculi, coagulopathy, glomerular disease, hydronephrosis, polycystic kidneys, trauma, medications, BPH, exercise induced Gross hematuria if urine is pink, red, brown or blood clots are present. UA If infection: Urine C&S If malignancy: Urine for cytology Urinary Tract Infection (Cystitis) E. Coli, Klebsiella spp. Staph. Saprophyticus, Proteus mirabilis Frequency, burning, urgency, dysuria, hematuria, foul-smelling urine, nocturia, lower abd. /back pain – NO FEVER Risk factors: female, pregnancy, hx of UTI, DM, failure to void after sex, spermicide use, low fluid intake, poor hygiene, catheterization UA moderate to large leukocytes, +/- nitrites, few RBC (inflammation) C&S > 100,000 UTI never normal in male – R/O other causes. 3 or more UTI in 1 year in females – R/O other causes ***nitrates are normal in urine, nitrites can indicate infection Nephrolithiasis (Urolithiasis) Glomerulonephritis Majority made of calcium oxalate; Struvite stones are found in those with hx of kidney infection Inflammation of glomeruli in kidney. Occurs 1-2 Weeks s/p bacterial infection Treatments Severe colicky pain that comes in waves. Patient cannot sit still. Pain builds in intensity, lessens and disappears. Associated with N/V. May have gross or microscopic hematuria Stones in upper urethra or renal pelvis may cause flank pain and tenderness whereas stones in lower urethra may cause pain radiating to testicle or labia. Both can cause abdominal pain Pink or cola colored urine due to hematuria, foamy due to proteinuria, HTN, edema of face, hands, feet and abdomen, possible anemia UA ±Protein, RBCs, renal cast ±Creatinine and BUN CT scan or kidney sono Confirmatory diagnosis is with Kidney biopsy Preferred therapy for nonmuscularinvasive bladder cancer without evidence of metastasis is transurethral resection with intravesical chemotherapy. Despite successful initial therapy, local recurrence is common Un co mplicated: Bactrim DS BID x 3 days; (sulfa allergic/resistance) Nitrofurantoin (Macrobid) 100mg BID x 5 days Ciprofloxacin (Cipro) 250mg PO BID – no fluoroquinolones in pregnancy or <18yo Pyridium – leaves it orange (avoid in liver disease) Comp licated: Keflex, Cipro 500mg BID or Levaquin 750 daily for 7-10 days ***Nitrofurantoin contraindicated with renal insufficiency Concerns Risk factors: Elderly > 50; male (73 years), smoker, occupational exposure to textile dyes and heavy metals For men do prostate exam Only treat pregnant women with asymptomatic bacteriuria UTI in pregnant women and children <3 are more likely to progress to pyelonephritis Renal and bladder sono for UTI infants Toradol injection Increase fluids, strain urine Avoid high-oxalate foods: rhubarb, spinach, beets, chocolate, tea and meats Consider alpha blocker Refer urology Risk factors: family hx of stones, gout, bariatric surgery, high doses vitamin C Meds that cause kidneys stones: HCTZ, topiramate, indinavir Acute is often self-limiting. Manage underlying cause and protect kidneys – antihypertensives, antimicrobials, systemic corticosteroids and immune suppressants. Plasmapheresis, dialysis If left untreated, can lead to kidney failure, HTN, electrolyte disorders and nephrotic syndrome Risk factors include infection: bacterial endocarditis, immune disease: Goodpasture’s syndrome, SLE, or vasculitis: polyarteritis or Wegener’s granulomatosis WOMEN’S HEALTH RANDOM GU URINARY INCONTINENCE Normal healthy women of reproductive age ➢ Discharge – white, clear, flocculent (1/2 to 1 tsp daily) ➢ Normal pH – 3.8-4.2 Types Stress incontinence If test positive for STI then also recommend o Syphilis, HIV and Hep B testing Urge incontinence Friable cervix – brisk bleeding with cleaning with cotton swab o Increased chance to acquire STI Functional incontinence Normal findings on pelvic exam in older woman o Flattening of vaginal rugae o Scant white vaginal discharge o Should not be able to palpate ovary Overflow incontinence Mixed incontinence Definition Associated with lifting, laughing, sneezing, bending Frequent dribbling; due to blockage of flow Reports of strong sensation of needing to void. 3 hours or miss dose, use condoms o Micronor – 28 days of progestin. Start taking on day 1 of menstrual cycle ➢ New prescriptions o Can be started after ruling out pregnancy o 35 migraines without aura o CAD/CVA o Undiagnosed genital bleeding o Pregnant o Liver disease or tumor o Estrogen-dependent tumor o Thrombus/emboli – factor V Leiden o Smoker 35 or older Relative contraindications o Migraines 35+ o Smoker < 35 o Fracture/cast on lower extremity o Hypertension ORAL CONTRACEPTIVE PROBLEMS ➢ Unscheduled bleeding (spotting) ➢ Menstrual cramps o Mefenamic acid (Ponstel), Aleve, Advil, Anaprox ➢ Menorrhagia – heavy bleeding ➢ Missing pills o Missed 1 day – take 2 now and continue o Missed 2 days – take 2 pills for 2 days and finish pack (use condoms for current cycle) ➢ Drug interactions – anticonvulsants, antifungals, St. John’s wort, PCN, Tetracyclines, Rifampin ➢ Thromboembolic Warning signs: ACHES o Abdominal pain o Chest pain o Headaches o Eye problems (vision changes) o Severe leg pain ➢ ➢ ➢ ➢ ➢ ➢ ➢ OTHER METHODS IUD – risk for infection, perforation, heavy bleeding o ParaGard – copper-bearing; effective 10yrs o Mirena – levonorgestrel hormone; effective 5 yrs. little more effective than Paragard (Skyla) - smaller Depo-Provera (6% failure rate) – injections q3 month, start within 5 days of cycle. Recommend calcium with vitamin D and weight-bearing exercise. Avoid >2 years. Risk for osteopenia/porosis. Avoid if anorexic/bulimic. May delay return of fertility – do not use if wish to become pregnant in 12 months. Does not interact with Dilantin Diaphragm w/ gel (13% failure rate) – after insertion, the cervix should be smoothly covered. Leave in for 6-8h. Add spermicide w/ every act of intercourse. Cervical cap can be work for up to 72h - ±risk UTI and TSS Condoms (18% failure rate) NuvaRing (9% failure rate) leave inside for 3weeks Patch (9% failure rate)- risk of VTE Implants (<1% failure rate) – may take 1yr to ovulate after removal, weight gain. Norplant good for 5yr, Nexplanon 3yr EMERGENCY CONTRACEPTION ▪ ▪ ▪ ▪ ▪ ▪ ▪ r/o pregnancy effective up to 72h after unprotected sex most effect within first 24h inhibits ovulation, slows sperm and ovum transport Plan B – progesterone only (89% effective): take 1st dose now, 2nd dose 12h later. If vomits tablet within 1 hour – repeat dose Ulipristal – inhibits embryo transplantationapproved for up to 5 days after intercourse Return if no menses w/in 3 weeks WOMEN’S HEALTH Name Cause Signs/Symptoms Middle-age or older female with painless mass feels hard and irregular. Mass attached to skin and tissue (immobile) RUQ of breast most common location (tail of spence). Skin changes: dimpling, retraction, peau d’orange 55, early menstruation, nulliparous, obesity, late menopause, infertility, Ectopic pregnancy 6-8 weeks after LMP Sexually active, amenorrhoeic or light to scant bleeding, one sided lower abdominal/pelvic pain w/ cramping worsening when supine or with jarring. May refer to right shoulder, hx PID, tubal ligation, or previous ectopic Quantitative HCG – should double 24-72 hours Leadin g cause death 1st trimester of pregnancy Bilateral breast tenderness and lumps up to 2Weeks prior to menses, resolving w/ menses. No masses, skin chan ges, nipple discharge, or nodes on physical exam Fibrocystic disease Polycystic Ovarian Syndrome (PCOS) Osteoporosis Hormonal abnormality, infertility, excessive androgen production, insulin resistance Loss of bone density from estrogen def. Presents teenage years; hirsutism, acne, oligomenorrhea, amenorrhea, dark hair on face, cheek, beard areas, acanthosis nigricans, mood/mental health problems Rotterdam Criteria (2 of 3): Oligomen orrhea, hyperandrogenism and cystic ovaries 4.5 Candida Vaginitis Candida albicans yeast in vulva/vagina White curdy cottage cheese-like vaginal discharge c/o severe pruritus, swelling and redness. Wet smear – pseudohyphae and spores, budding yeast w/ large # WBC -azole antifungal, oral fluconazole (Diflucan), or vaginal miconazole (Monistat), Clotrimazole (Gyne-Lotrimin), Terconazole (Terazol-3) cream; If patient on antibiotic daily yogurt or lactobacillus pills; complicated case butoconazole Atrophic Vaginitis Estrogen deficiency Vaginal dryness, itching, pain w intercourse. less rugae, pale color, may bleed on physical exam Pap smear shows atrophic changes Elevated FSH/LH pH > 5.0 topical estrogen cream is symptomatic or recurrent UTI (oral estrogen as solo intervention is likely inadequate) Osphena (non-estrogen) Dysmenorrhea Excessive prostaglandins Most common GYN problem Primary – pain improving w/ menses, N/V, diarrhea, back pain, starts as teen & improves w/ age and NSAIDs Secondary – after 35yo, abnormal bleeding, non-midline pain worsens w/ time (most commonly as endometriosis) – pain with intercourse Diagnostics Good history, physical exam esp. pelvic, check STDs, fibroids, Treatments Metronidazole (Flagyl) BID x 7 days, Clindamycin cream, Not STD, no partner treatment needed Abstain from sex until treatment complete NSAIDs; if secondary treat cause; exercise, heat to area. Oral contraceptives Concerns Clue cell = mature squamous epithelial cell with numerous bacteria noted on cell borders ± Risk with HIV, those on antibiotics, diabetics Vaginal bleeding postmenopause – endometrial biopsy for CA Structural Post-menopausal bleedin g > 12 months since LMP – refer to OB GYN r/o cancer PALM-COEIN Abnormal Uterine Bleeding (AUB) Menopause Polyps > 30 years Adenomyosis > 30 Leiomyoma/Fibroids > 30 Malignancy/Hyperplasia >40 No naturally occurrin g menstrual period for 12 months Hot flashes, night sweats, symptoms typically occur the week before menses. Estrogen receptors are found in highest concentration in the vagina Non-Structural Coagulopathy any age Ovulatory Dysfunction any age Endometrial Disorder any age Iatrogenic Medications any age Not classified ± LH & FSH ³ testosterone ³ estradiol ³ progesterone Hormonal Therapy – contains ¼ or less amount estrogen as COC. May preserve bone density, but contributes to endometrial, breast cancer and CAD; use lowest dose possible, if hysterectomy – add progestin component is to minimize endometrial hyperplasia. Estradiol 1mg provides relief in 4 weeks vs. lo w dose 8-12 W eeks. Low dose is better tolerated Estrogen receptor modulator therapy: Evista – osteoporosis risk is reduced Other options: venlafaxine, sertraline, gabapentin, paroxetine Phytoestrogens include red clover, ginseng, black cohosh, yam, and soy products High dose vitamin E (800 IU) Perimenopause 40-45