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ECG of Acute inferior myocardial infarction

ECG2

 

 

  • ST elevation in the inferior leads II, III and aVF
  • reciprocal ST depression in the anterior leads

 

Psychiatry Mcqs 2

1. Re: NICE guidelines on depression
  1. Mild depression antidepressants (ADs) are the first line treatment
  2. Dysthymia antidepressants are effective
  3. Antidepressants are recommended for moderate to severe depression
  4. In severe depression antidepressants or CBT is recommended
  5. Patient with one episode of depression with functional impairment should receive prophylaxis for 2 years
2. NICE guidelines on treatment resistant depression
  1. Combination of antidepressants are supported
  2. Augmentation with lithium is not useful
  3. ECT is recommended
  4. Augmentation with antipsychotic is recommended
3. Re: Treatment of depression
  1. People with depression are at increased risk of cardiovascular disease
  2. 2/3rd of patient who have a single episode of depression will go on to have another episode of depression
  3. Dose for prophylaxis – Adults should receive the same dose as used for acute treatment
  4. Lithium also has some efficacy in the prophylaxis of unipolar depression
  5. Patients with more than two episodes are recommended 2 years prophylactic treatment
4. Re: Treatment of depression
  1. Poor response at 2 weeks predicts no response in the future for that drug
  2. If there is poor tolerability switching between drug classes is a good option
  3. If there is non-response switching to another drug in the same class will not have any effect
  4. A single episode of depression has be treated for at least 6-9 months after full remission
  5. 50% of patients will relapse if treatment is discontinued on remission

5. True/False

  1. Relapse rates after ECT is lesser than after ADs
  2. In the elderly a lower dose of AD may be used in prophylaxis than what was used in acute treatment
  3. Each episode of depression increases the chances of having another episode
  4. Schizophrenia increases the possibility of having depression

Answers                                                                                                        

1. Re: NICE guidelines on depression
  1. Mild depression antidepressants (ADs) are the first line treatment – F, Not recommended, active monitoring, individual guided self help, CBT, exercise
  2. Dysthymia antidepressants are effective – T
  3. Antidepressants are recommended for moderate to severe depression – T, first line – SSRI
  4. In severe depression antidepressants or CBT is recommended – F, ADs and CBT is recommended
  5. Patient with one episode of depression with functional impairment should receive prophylaxis for 2 years – F, if the patient had 2 episodes 2 years are recommended
2. NICE guidelines on treatment resistant depression
  1. Combination of antidepressants are supported – T
  2. Augmentation with lithium is not useful – F, useful recommended
  3. ECT is recommended – T
  4. Augmentation with antipsychotic is recommended – T
3. Re: Treatment of depression
  1. People with depression are at increased risk of cardiovascular disease – T
  2. 2/3rd of patient who have a single episode of depression will go on to have another episode of depression – T
  3. Dose for prophylaxis – Adults should receive the same dose as used for acute treatment – T, in the elderly the dose may be reduced
  4. Lithium also has some efficacy in the prophylaxis of unipolar depression – T, but should not be used as a single agent. May be used in combination with a AD
  5. Patients with more than two episodes are recommended 2 years prophylactic treatment – T
4. Re: Treatment of depression
  1. Poor response at 2 weeks predicts no response in the future for that drug – T, Taylor et al, 2006, meta analysis
  2. If there is poor tolerability switching between drug classes is a good option – T, but not much evidence
  3. If there is non-response switching to another drug in the same class will not have any effect – F, some evidence
  4. A single episode of depression has be treated for at least 6-9 months after full remission – T
  5. 50% of patients will relapse if treatment is discontinued on remission – T, within 3-6 months

5. True/False

  1. Relapse rates after ECT is lesser than after ADs – F, Similar, thus need prophylaxis with ADs
  2. In the elderly a lower dose of AD may be used in prophylaxis than what was used in acute treatment – T, but not recommended for adults
  3. Each episode of depression increases the chances of having another episode – T, through kindling
  4. Schizophrenia increases the possibility of having depression – T, all non-affective illness increase possibility

Psychiatry Mcqs 1

1. True or False Re: APs in schizophrenia
  1. The response to APs vary greatly between individuals
  2. There is no first choice AP for all
  3. SGAs are not superior to FGAs
  4. When non-clozapine SGAs are compared to each other Olanzapine is superior
  5. Risperidone is superior to other SGAs except olnz. and cloz.
2. When compared with FGAs the following SGAs have proven more efficacious
  1. Olanzapine
  2. Ziprazidone
  3. Aripiprazole
  4. Risperidone
  5. Amisulpride
3. True or false Re: APs in schizophrenia
  1. Depot preparations are associated with better global outcome and reduction in the frequency of hospital admission
  2. GASS and LUNSERS are questionnaires used to detect drug side effects in pts. on APs
  3. Following Depot administration it would take close 6-12 week reach a steady plasma concentration
  4. AP polypharmacy can cause sudden death
4. True of False Re: Neuroleptic equivalent doses
  1. Closely follows the drugs efficacy
  2. Related the maximum dose that can be prescribed
  3. Related to chlorpromazine equivalents
  4. Based on dopamine studies
  5. Only has value in FGAs
5. True of False Re: Maximum licensed doses
  1. Chlorpromazine – 1000 mg/day
  2. Haloperidol – 30 mg/day
  3. Clozapine 900mg/day
  4. Olanzapine 20mg/day
  5. Risperidone – 24mg/day

Answers                                 

1. True or False Re: APs in schizophrenia
  1. The response to APs vary greatly between individuals – T
  2. There is no first choice AP for all – T, due to above reason
  3. SGAs are not superior to FGAs – T, After reviewing the CATIE and CUTLES studies the world psychiatric association made this statement
  4. When non-clozapine SGAs are compared to each other Olanzapine is superior – T, Leucht et al 2009 Meta analysis, head-to-head comparison of SGAs
  5. Risperidone is superior to other SGAs except olnz. and cloz. – T, Leucht et al 2009 Meta analysis, head-to-head comparison of SGAs
2. When compared with FGAs the following SGAs have proven more efficacious
  1. Olanzapine – T
  2. Ziprazidone – F
  3. Aripiprazole – F
  4. Risperidone – T
  5. Amisulpride – T
3. True or false Re: APs in schizophrenia
  1. Depot preparations are associated with better global outcome and reduction in the frequency of hospital admission – T, Schooler (2003)
  2. GASS and LUNSERS are questionnaires used to detect drug side effects in pts. on APs – T, Glasgow Antipsychotic Side-Effect Scale (GASS) And the Liverpool University Neuroleptic Side-Effect Ratings Scale (LUNSERS), can be a useful first step in this process.
  3. Following Depot administration it would take close 6-12 week reach a steady plasma concentration – T
  4. AP polypharmacy can cause sudden death – T
4. True of False Re: Neuroleptic equivalent doses
  1. Closely follows the drugs efficacy – F, not related
  2. Related the maximum dose that can be prescribed – F, not related
  3. Related to chlorpromazine equivalents – T
  4. Based on dopamine studies – T, also clinical experience and guess work
  5. Only has value in FGAs – ?T, not useful for SGA
5. True of False Re: Re: maximum licensed doses
  1. Chlorpromazine – 1000 mg/day – T
  2. Haloperidol – 30 mg/day – T
  3. Clozapine 900mg/day – T
  4. Olanzapine 20mg/day – T
  5. Risperidone – 24mg/day – F, 16mg/day

Tips for GP trainees working in psychiatry

Tips for GP trainees working in psychiatry

Many doctors approach psychiatry with a sense of trepidation and, occasionally, fear. The aim of this article is to give some concrete advice to help trainees to relax and enjoy this fascinating rotation. A spell in psychiatry has the potential to be one of the most useful rotations on the general practice training scheme. Much of psychiatry is now managed in the community and so will form a significant part of your work following qualification. As increasing pressure comes to bear on mental health trusts to cut costs and close inpatient beds this is only likely to increase. When people suffer mental health issues it is very often the GP who is their first port of call, and so a good working knowledge of the area, as well as insight into the mechanisms and frameworks of secondary care, is an asset. During the job, you will also have the opportunities and time to develop your communication skills, occasionally in crisis situations. Continue reading

Internal Med Residency 1

My 12 Best Tips on Psychiatric Diagnosis

Below are my 12 tips on how best to ensure accurate and safe diagnosis:

(1) The less severe the presentation, the more difficult it is to diagnose. There is no bright line demarcating the very heavily populated boundary between mental disorder and normality. Milder problems often resolve spontaneously with time and without need for diagnosis or treatment.

(2) When in doubt, it is safer and more accurate to underdiagnose. It’s easier to step up to a more severe diagnosis than to step down from it.

(3) Children and teenagers are especially hard to diagnose. They have a short track record, varying rates of maturation, may be using drugs, and are reactive to family and environmental stresses. The initial diagnosis is likely to be unstable and inappropriate.

(4) Mental illness is hard to diagnose in the elderly. Their psychiatric symptoms may be caused by medical and neurological illness and they are prone to drug side effects, interactions, and overdose.

(5) Take the time and make the effort. It takes time to make the right diagnosis—adequate time for each interview and often multiple interviews over time to see how things are evolving. Except for classic presentations, a quick diagnosis is usually the wrong diagnosis.

(6) Get all the information you can. No one source is ever complete. Triangulation of data from multiple information sources leads to a more reliable diagnosis.

(7) Consider previous diagnoses—but don’t blindly believe them. Based on their tenure, incorrect diagnoses tend to have a long half-life and unfortunate staying power. Always do your own careful evaluation of the patient’s entire longitudinal course.

(8) Constantly revisit the diagnosis. This is especially true when someone is not benefiting from a treatment that is based on it. Clinicians can get tunnel vision once they’ve fixed on a diagnosis, become too married to it, and are blinded to contradictory data.

(9) Hippocrates said that knowing the patient is just as important as knowing the disease. Don’t get so caught up in the details of the symptoms that you miss the context in which they occur.

(10) If you hear hoof-beats on Broadway, think horses, not zebras! When in doubt, go with the odds. Exotic diagnoses may be fun to think about—but you almost never see them. Stick with the bread and butter.

(11) Accurate diagnosis can bring great benefits; inaccurate diagnosis can bring disaster.

(12) Remember the other enduring dictum from Hippocrates: First, Do No Harm.

– See more at: http://www.psychiatrictimes.com/blogs/dsm-5/my-12-best-tips-psychiatric-diagnosis#sthash.euXPGPmL.dpuf

Clavicle

clavicle01

 

the clavicle or collarbone is a long bone that serves as a strut between the scapula and the sternum. It is the only long bone in the body that lies horizontally. It makes up part of the shoulder and the pectoral girdle, and is palpable in all people; in people who have less fat in this region, the location of the bone is clearly visible, as it creates a bulge in the skin. It receives its name from the Latinclavicula (“little key”) because the bone rotates along its axis like a key when the shoulder is abducted.

scapula3

Scapula

In anatomy, the scapula or shoulder blade, is the bone that connects the humerus(upper arm bone) with the clavicle (collar bone). Like their connected bones the scapulae are paired, with the scapula on the left side of the body being roughly a mirror image of the right scapula. In early Roman times, people thought the bone resembled a trowel, a small shovel. The shoulder blade is also called omo in Latin medical terminology.

The scapula forms the posterior (back) located part of the shoulder girdle. In humans, it is a flat bone, roughly triangular in shape, placed on a posterolateral aspect of the thoracic cage.

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