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66 Cards in this Set
- Front
- Back
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Patient describes pain as burning, stabbing, and/or shooting. What type of pain is this?
A. Neuropathic B. Musculoskeletal C. Inflammatory D. Mechanical compression E. Mixed |
A. Neuropathic
Includes metabolic causes of pain, CNS conditions, MS, stroke, fibromyalgia |
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Before starting opioid medications what must be documneted?
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Ineffeciveness of nonopioid medications.
Also you must demonstrate that the benefits outweigh the risks. |
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Six A's for monitoring patients with chronic nonmalignant pain taking opioids:
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Analgesia
Affect (mood) Activities Adjuncts Adverse effects Aberrant behavior |
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Legal requirement for urine drug screens:
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Not legally required but HIGHLY recommended.
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How long can morphine be detected in the urine?
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1.0 to 1.5 days
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Patient takes coedine and tests positive for both codeine and morphine.
Are they abusing drugs? |
Not necessarily. Codeine is metabolized in part to morphine. Thus, it's possible they are being compliant
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Most common side effects of patients on opioids:
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Somnolence
Nausea Sedation Constipation |
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Patient on opioids is constipated. How long does it take for this side effect to resolve with continued usage?
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Usually doesn't resolve
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How long does it take for tolerance to build in a patient who is taking opioids and complains of sedation?
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10 days
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A written treatment plan for patient on opioids should include the following:
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Objectives to determine success
Any further diagnostic testings Addressing any psychosocial and physical function issues Adjustments of therapy to meet individual needs of patient Non-drug treatment |
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High risk patients who are on narcotics should have the following agreements in writing:
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Urine drug screens (frequency)
Written documentation on refill numbers and frequency Violations of agreement that result in d/c of medicaton |
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"Pleasure pathway" involved in addiction:
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Median Forebrain Bundle
Nucleus Accumbens Locus coeruleus Median gitudineal fasciculus |
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The 2005 Clinician's guide Helping Patients Who Drink Too Much recommends one single question for screening for alcoholism:
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How many times in the past year have you had more than 5 drinks in a day?
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According to the abbreviated Fagerstrom tobacco test, which question best predicts tobacco addiction?
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How soon after you wake up do you smoke your first cigarette
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When using liver transaminases to diagnose alcoholism, what are you looking for?
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AST>ALT
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When doing drug screens, is a patient vulnerable to criminal proscution if an illegal drug is found?
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No, because chain of custody is not usually established
However, they may be subjected to subpoenas of medical records, or if patient is applying for insurance |
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Brief interventions for patients who are at high high risk for addiction:
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Inform patient of your concerns regarding substance use
Encourage patient to state their point of view Assess readiness to change If pt is agreeable move towards d/c, help them plan appropriately If not agreeable, consider cutting down or keeping diary |
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Treatment modality for tobacco addiction with highest success rate:
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Inpatient counseling
Followed by intense outpatient counseling, Chantix, and Nicotine nasal spray |
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Treatments for alcohol addiction with highest success rate:
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AA
Also Naltrexone, CBT, Minnesota model |
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Treatments for narcotics addiction with the highest success rates:
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Methadone
Buprenorphine |
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Review: Patients withdrawaling from opiates may experience the following:
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Goosebumps, cramps, Myadriasis, rhinorrhea, myoclonic jerks
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Criteria for outpatient detoxification:
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Pt must be willing / able to do the following:
Commitment to abstain from using any other substances other than what Dr orders Have a responsible friend / family member who wil monitor for serious symptoms, encourage pt to keep appointments, discard any EtOH in pts home. Physician must be able to monitor patient on daily basis |
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Criteria for inpatient detox
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Can't meet criteria for outpatient (see other flashcard)
Risk of life-threatening withdrawal Hx of high tolerance, previous withdrawal seizures / delirium / psychosis Major comorbidities (stroke, liver disease, AIDS) |
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Two benefits of using receptor blocking therapy in treatment of addiction:
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1. Help overcome any adverse side effect caused by the drug being abused (ex, respiratory depression in heroin)
2. Can follow patients who agree to take medicine on a regular basis and patients can get on with their life Blocking agents are a good choice in people who have much to lose if they continue to us (ex: Physicians) |
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Side effects of methadone
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Similar to other narcotics:
Respiratory depression sleep apnea, prolonged QT interval, abdominal pain and constipation |
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Side effects of buprenorphine
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CNS sedation, respiratory depresssion, pain, insomnia, anxiety, nausea
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Timeframe needed to diagnose GAD
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6 months
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Percentage of patients presenting to the ER with chest pain meet criteria for panic disorder?
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17-25%
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Many patients with anxiety do not show up to the office to discuss their worries, instead they commonly present with these symptoms:
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Insomnia pain, fatigue
A clue may be that multiple treatments have failed in the past |
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Conditions that can mimic anxiety
(Lots) |
Hyperthyroidism
Menopause Cardiac arrhythmias Asthma Angina TIA EtOH withdrawal Med side effects Neurologic disorders Stuttering ADHD |
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Red flags in patient with anxiety disorder:
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Suicadility
Substance buse Sexual / physical abuse Bulimia / Anorexia Wt loss Focal weakness Hallucinations / Delusions Developmental Delay |
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Four strategies for approach to patient with suspected anxiety disorder
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Suggest anxiety as part of a differential diagnosis
Explain illness in ways that make sense to the patient Discuss course of illness and side effects of treatments Provide written resources |
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Discuss beta blockers for the use of social anxiety disorder
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Strength of evidence = "B"
They are better when the issue is performance anxiety versus true social anxiety |
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Treatment of choice for obsessive compulsive disorder
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Antidepressants: SSRI or TCA
CBT Sertraline in children |
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Has psychotherapy immediately after a traumatic event been shown to be effective in preventing PTSD
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No
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Two long term treatments for patients on short term benzos for anxiety:
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Buspirone
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Which antidepressant is most efficacious in a patient with panic disorder?
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Trick question! No one antidepressant has been shown to be better than others
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What does the evidence say about using CBT in social anxiety disorder?
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CBT improves distress and avoidant behavior, but no additional benefit when combined with antidepressants
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Is buspar useful in social anxiety disorder?
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No evidence to say it works better than placebo
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Studies show that CBT is effective in preventing a panic attack for how long?
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2 years
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Antibiotic that drammatically raises duloxetine levels
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Cipro
Note that Venlafaxine and Duloxetine boht raise TCA levels drammatically |
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This SNRI interacts with both clonidine and dizepam
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Mirtazepine
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These two medications used to treat depression can cause blurred vision
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SNRIs and Trazodone
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Predictors of early discontinuing of antidepressant medicine:
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Low education level
Lower family income Ethnicity Patients who receive psychotherapy are more likely to continue antidepressants |
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How does the onset of action of Mirtazepine compare with SSRIs?
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Faster onset of action
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Buproprion has fewer sexual side effects and appears to cause modest weight loss; however it was shown to have an increase in these two side effects:
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Insomnia and Headache
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Which two seratonin receptors are blocked by Mirtazepine?
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5-HT2A and 5-HT2C
Also blocks alpha-2 receptors |
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Patient has been on an antidepressant for 3 weeks and complains that it is not working. What do you do?
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Wait a little longer... An adequate trial of an antidepressant requires 4 to 12 weeks.
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Patient has been on an antidepressant for 9 weeks and complains that it is not working. What are your options?
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Although adequate trials should be 4-12 weeks long, you should consider switching to a different medication if you don't see response in 8 weeks.
You can try a different medication in the same class, or choose a different class, or augment current treatment with a second agent. |
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Review: Side effects of SSRIs
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Agitation
Insomnia GI problems Sexual dysfunction |
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Review: Side effects of TCAs
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Weight gain
Sedation Constipation Dry mouth Orthostatic hypotension Reflex tachycardia Side effects are less with secondary TCA (nortriptyline and desipramine) verses tertiary (imipramine, amitriptyline) |
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What health condition is a contraindication for using TCA:
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Heart disease
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Review: Symptoms of TCA overdose:
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Respiratory depression
QT prolongation Seizures Hallucinations Hypertension (can last up to 5 days) |
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Medical complaints in a primary care office that should clue the physician to think about depression as a DDx:
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Multiorgan system complaints
Emotional flatness Persistent sleep disturbance that is unrelated to stressors Frequent visits for unclear reasons Frequent ER visits for unexplained symptoms Patients with previous history of emotional breakdowns |
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Review
Factors that increase the risk of suicide in depressed patients: |
Increased age (>70 men / 60 women)
Gender (Men more often complete) Poor social support Lack of marital support / family Alcoholism / substance use History of prior attempts Specific plan Family history of successful suicide |
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Differences in gender regarding suicide risk:
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Women attempt suicide more frequently although men complete it more frequently
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Three criteria for when to initiate antidepressant medication:
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Symptoms present for more than 1 month
Symptoms interfere with functioning PHQ-9 score is >14 |
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According to the Sloan text what medication would you choose in a depressed patient with hypersomnia:
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SSRI
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According to the Sloan text, how long you should continue antidepressant medications in a newly diagnosed depressed patient
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9 to 12 months
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This type of therapy achieves the following:
Identify events or relationships that stimulate abnormal amounts of stress or grief Encourage discussion about the nature and origin of the stress reaction Move through strategies to resolve the stressful situation |
Interpersonal therapy
Often good for marital stress. |
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Indications for referral in a depressed patient:
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History of severe chronic symptoms
Unresponsiveness of treatment for bipolar disorder High risk of suicide |
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Pt is on antidepressant for 6 months. Comes to you for a follow up and says, "I'm doing better" What should you next ask about?
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Ask: What does "I'm doing better" mean?
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When it comes to adolescents and depression, they may not present with feelings of sadness, but instead present with feelings of
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Irritability
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A recent NIMH showed that this treatment combo is particularly good in adolescent patients:
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CBT in combo with fluoxetine
The NIMH trial also showed that teens do not have an increase risk of suicide |
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This antidepressant carries a black-box warning against prescribing to patients with liver disease:
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Nefazodone
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This complementary therapy often used for treatment of depression is contraindicated in patients taking SSRIs
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Hypercium
St. John's Wort |
