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