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sukky

CHRONICH INSOMNIA

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hi guys any attempt?

Discuss how you would assess a 56yr old woman with osteoarhtritis and a past history of depression who now presents with chronich insomnia,she doesnt think her present problem is depression,how would u manage?

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suggested probe includes

information gathering from gp about the osteoarthritis and past psychiatry hx

detailed hx from patient about onset and duration of the insomia

any psychosocial stressors? any nightmares

chronich pain from the osteoarhtritis?is it well manage?

more information about mood,apetite  reduce need for sleep? increase energy or low energy

risk assesment ,suicidal idea as a result of the chronich insomnia

work hx

family psych hx

any bereavement

mse to asses mood,cognition and thought system

physical examination to check for physical problems in addition to the chronich osteoarthritis

diff diagnoses

mental illness or no mental illness

mental illness:

depression

bipolar dx presently manic

psychotic illness

malingering

factitious dx

somatisation dx

organic

chronich pain from the osteoarthritis

thyroid dysfn

investigation includes fbc,tft,u$es,xray of the affected joints

managent

bio pschosocial

pscho education

explain sleep hygeine

treat any underlying mental illness

ssri for depression

cbt for depression,ipt for interpersonal problems

psychosocial intervetion for any housing,financial and employment problems

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Few more differentials which could be considered

substance misuse- eg alcohol

CFS

side effects of medication

fibromyalgia

obstructive sleep apnoea- if obese

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yes sedan, cfs,osa , alc⊂ misuse are good differentials

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what about the issues here first

- establishing the underlying reason for her depression.

- risk assessment to her self and others, including family anf staf.

Management

I agree with the suggestion. but where in hospital or at home? and what level of support she will need.

and for the long term you said antidepressant, how are we going to monitor that? out-patient or CPN.

::)

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just afew thoughts too

why bipolar currently manic for CHRONIC insomnia- examiners might ask??

How about hypochondrasis, anxiety, meds she is on as cause or unrealistic expectations ofsleep

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just a possibility that the chronich insomnia is the reduce need for sleep which is a symptom of bipolar dx with manic or hypomanic,side effect of medication is another good diff,hypochondriacal patient will usually be preocupied with believe that they ve a specific illness and will be looking for investigations to confirm this illness.

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hi guys any attempt?

Discuss how you would assess a 56yr old woman with osteoarhtritis and a past history of depression who now presents with chronich insomnia,she doesnt think her present problem is depression,how would u manage?

why am i seeing this woman now?

who referred her to me?

background info from GP +past med&psych hx.

detailed hx and MSE of the pt.

depressed/elated mood?other biol/cognitive/somatic sxs of mood d/o?

any life events e.g bereavement/marital separation?

is insomnia initial,middle or late?any nightmares?

any psychotic sxs? scary visual hallucinations?any sleep-related delusions?

risk assessment-any suicidal ideas?risk of violence.

consent for extensive collateral hx.

current social circumstances+financial status.

any recent substance misuse/ETOH.

drug hx(prescribed meds).any benzos abuse?opiate misuse/other pain killers.

PMH-duration of OA.any comorbid physical illnesses?chronic pain?

DD:

Functional:

1.depression

2.persistent mood d/o e.g cyclothymia/dysthymia

3.pseudodementia

4.benzo dependence

5.no mental illness-chr. insomnia

Organic:

1.OSA

2.hyperthyroidism

3.cerebral mets

Others:

somatoform pain d/o,malingering,somatisation d/o,CFS.

invx:

FBC,u&e+crtn,tfts,lfts,ESR/CRP,B12/folate,VDRL,neuroimaging(ct/mri/eeg),psychometric testing,MMSE+cognitive assessment.

RX:

dictated by eventual DX if any!

along biopsychosocial lines.

anti depressants/mood stabilizer/neuroleptics/diazepam for detox/appropriate specialty referral.

CBT/IPT/Family tx/CAT/compliance tx.

social work involvement if needed.

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i think we have to prioritise our answers rather than say everything under the sun...including why the particular treatment would be useful...eg why family therapy in chrnoic insomnia...

otherwise it looks as if u have just one template for all the pmps...with no variation

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there are diffr types of examiners..some wld allow u rant on while some wld expand the supplied probes infinitely...cutting in frequently

..be prepared.

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i would agree with OMC.

be prepared to keep talking and some of them might just let you continue. some will interrupt anyway. don't stop yourself and let them ask you questions. that may be trouble. rather speak about everything you know and leave little time for them to ask the questions!

mine is not any different to what other have said but i will type it out anyway-----------

Source of referral and reason for referrring now- concerns??

Construct a possible differential diagnosis(is this woman mentally ill?)

Collect more information from- GP

   Past history.

   ?Careres

Complete history and Mental state from the patient + ?carer.

N,O,P(nature onset and progression) of symptom/s- INSOMNIA

associated features- to facilitate diagnosis.

In this patient, things to mainly ellicit without fail will be--

Precipitating events? - death, divorce job loss etc.

Mood - anxiety symptoms?

Delusions?- keeping vigil and not sleeping. other features of psychosis ellicit completely.

Risks- suicide/ harm to others.

Alcohol, smoking & drugs

MMSE

Medical History- Pain, other incurable illnesses??

Arrive at possible DDs.

1.Chronic Insomnia

2.Depression

3.cyclothymia/dysthymia  

4.Mixed anxiety and Depression

5.Somatoform disorders,? Chronic fatigue syndrome(remember the age)

6.Organic- Substance use

   Medical causes- Grave's disease, OA, Cancer pain etc

Investigations:

FBC, U&E, LFT, RFT, TFT, ESR, CRP- to rule out physical causes.

If needed Neuro imaging.

? cerebral infarcts,metastases etc.

Treatment

Based on the diagnosis.

talk about reatment of depression and anxiety.

BIO

PSYCHO APRROACHES

SOCIAL

both in short term and long term plans

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Chronic insomnia:

I would add to the differential: menopause symptoms if it was chronic and she presented at this or younger (around 50)age

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Hi Ali,

I am not sure abt menopause. first-it may cause insomnia but not chronic. Second it is rare and we are expected to tell only the most probable one.

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I prefer to mention Nonorganic insomnia rather than chronic insomnia according to ICD10

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I would like to see whether it is primary or secondary insomnia.

How did her GP treat her ?benzodiazpine most probably is used by Gps , for how long?

I would like to get some more information from her partner about her sleep pattern?does she snore, kick at night or becomes restless, or her breath stops and becomes irrigular.

any poor sleep hygiene? too much coffee at night, multiple naps during the day time.

beside her OA any other medical problems that keeps her awake or make her sleep interrupted eg CHF, poorly controlled DM.

is she on steroid for OA this can cause insomina.

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