hbm,exam,final, post

7/29/2019 HBM,Exam,Final, Post

1/84

8:30-9:10 Final Exam Review9:10-9:20 Break

9:20-10:00 Trauma Survivor Interview10:00-10:10 Break10:10-11:00 Death & Dying


2/84

ICM SAC Meeting Minutes 10/25Issues:-some people have only interviewed once because they are in a larger group-some people are not doing write-ups every week

-as long as they do at least one eventually, its ok-some group leaders are focused on doing quick 10-minute interviews whereas others are not using timeconstraints

-leaders each have their own style so everyone teaches it differently, but the main point is to learnhow to talk to patients

-one down-side of CCHERS or FaMeS is that you dont get any exposure the BMC hospital

Suggestions for future years:-at the beginning of the course, emphasize to the class that not all groups will be led in the same way andeach group will have a different experience, and emphasize that the goal is just to get more comfortabletalking to patients-at the beginning of the course, tell students which types of patients the different programs (regular ICM,FaMeS, CCHERS) can expect to see-set up some opportunity outside of ICM class time when FaMeS and CCHERS students can see the BMChospital and interview a patient or two

-make an attending or 4th year student available for a couple hours per semester whenFaMeS/CCHERS students can sign up to do interviews in BMC hospital

Other points:-Would it be a good idea in future years to have one or two more lectures on how to interview, or is it better tobe on the wards every week after the first lecture?

-we decided that it is better to be on the wards more and not add additional lectures

-perhaps if there are no patients available one week, a group can have another session wherestudents interview other students who are given scripts, as we did in our first ICM lecture


3/84

HBM & ICM SAC Representives

Kyle CyrThiago Oliveira

Julie Bartolomeo

Louis Yu

Jessica BarbourNahiris Bahamon

PhotoNot

Available

Lonnie Kurlander Michael Sherman

Lauren Sigman Ben Tannenbaum

Thank you for all your work as class representatives


4/84

Mike CallahanRan the Videos, didthe posting on Bb-8,double checked the

TurningPoint slides,and trouble shot theentire audio and

video recordings forthis course

Rebecca HalleyEditing slides andexam questions andpostings for spelling

and grammar errors,continually remindinglecturers of deadlines

for exam questions,outlines, PowerPointslide sets, & lectures

Thank you both for all your great contributions to this course


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8:30-9:10 Final Exam Review9:10-9:20 Break

9:20-10:00 Trauma Survivor Interview10:00-10:10 Break10:10-11:00 Death & Dying


6/84

Interview with Gina RussoDoug Hughes, MD

Boston University School of Medicine


7/84

Final Exam Review


8/84

Practice Questions

All the embedded TurningPoint questionsin the lectures for this half of the coursehave been harvested and placed in asingle PowerPoint file that can be found inthe Course Documents section of Bb-8

Todays Review has 24 TP question slideswith a total of about 60 accompanyingexplanation slides today. We wont getthrough them all but they will be availableto you on Bb-8 after this review


9/84

Final

Will not cover:

Early Child Development

Medical Student Mental Health

Human Sexuality

Learning Theory

The last class is November 1st

Final Exam is on November 17th

I will be at the AAMC meeting Nov 4th to 7th, so ifyou need help with questions be aware that I will beout of town for a couple of days


10/84

Final

Mid-term 50% case & 50% factoid questions

Final 66% case & 34% factoid questions

Midterm: had to know categories of medications(antidepressants, stimulants, etc)

Final: will need to know categories and classes ofmedications: example would be antidepressants(category), SSRI, MAOIs, tricyclics (classes of

antidepressants) Only medication you need to know by name is

lithium


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Final is Partially Cumulative

Were the current material overlaps withprevious material

Elder Abuse (present in first & second half) Obesity overlaps with atypical depression

Eating Disorders can be confused with majordepression

Adolescence overlaps with early adulthood


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Final Examination in HBM

Thursday November 17this the exam it is 50 questions The exam will begin at 8:30am, Students need to be

in Hiebert by 8:15am The exam is 1 hour 5 minutes long When time called, it is over there is no allowance for

entering/transposing answers on to the bubble sheet,failure to end when time is called will result in zeropoints for the exam

By 12:00pm, or sooner, the answers will be posted on

our Bb-8 site Post-Exam review will be 3:00 to 4:00 in E720 (Evans) Challenges will be to the SAC Representatives at 4:00


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Rules for Exam Challenge Session

Cell phones and other electronic/recording devicesare not permitted, they must remain in your bagor in your pocket during this session. If you musttake a call or use your phone for any reason, stepout of the room to do so.

All bags must be left in the center of the room atthe table

Writing may only be done at the table, paper andwriting utensils will not be permitted as you review

the questions around the room No notes on the content of the questions may be

taken from the room. The only notes that may bewritten are for challenges, which must be left withDr. Hughes, Rebecca, or a SAC representative.


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Challenging Question Type:

1. Differentiating degree in an open-ended questions & the partial

cumulative aspect of the final exam2. Elements and applications fromdifferent lectures and chapters.

What is really being asked?3. Question that are a composite ofdifferent chapters/topics


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Care of Patients Who are

Homeless


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1. Challenging Question Type:

Differentiating Degree in anOpen-Ended Questions & the

Partial Cumulative Aspect ofthe Final Exam

Homelessness,

Chapter # 26Doctor-Patient Communication,Chapters # 24


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Set Clickers

Press Go or Ch

Press 2

Press 6

Press Go or Ch

Should get a green light that lights up for3 seconds, that means you are set.


18/84

Which is the best screen for homelessness?

Are

youh

omel.

..

W

here

doy

ou...

Sorry

fora

ski...

Doy

ouliveo

u...

Ifreq

uently

...

20% 20% 20%20%20%

Are you homeless?

Where do you stay? Sorry for asking, but where

do you spend your nights?

Do you live outdoors or in ashelter for at least 5 daysout of the year?

I frequently see people

who have no fixed place tostay and it often affectstheir health, where do youlive?


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Which is the best screen for homelessness?

Are you homeless?

Where do you stay? Sorry for asking, but where

do you spend your nights?

Do you live outdoors or in ashelter for at least 5 daysout of the year?

I frequently see people

who have no fixed place tostay and it often affectstheir health, where do youlive?

Direct Question

Very Open Question

Open & Awkward

Direct & Awkward

Open, maybe a littleleading


20/84

Screening for Homelessness

Settings where status would affect mgmt

ER

Inpatient setting

Outpatient clinics

How can we ask?

Are you homeless??

Where do you stay?I frequently see people who have no fixed

place to stay and it often affects their health

A 48 ld h ti h i h l d


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A 48-year-old cachectic man who is homeless andmentally ill presents in the emergency room coughing upblood. Chest films find advanced and metastatic lungcancer. The man is informed of his inoperable and

serious condition. Psychiatry is consulted as the manreports having no family or friends in the area. Thepatient only requests coffee and will not answer anyquestions. What is the most appropriate next step for the

psychiatrist ?:

for...

ses... ge

... an...

vet...

20% 20% 20%20%20%

A. Get coffee for the man

B. Let the nurses know of thepatients request

C. Try to engage the patient in adiscussion about death & dying

D. Assess the man for majordepression and suicidal

thoughtsE. Involve the cha lain service


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Clinical Encounters

Get the story

Recognition of link between social issues and health

Realistic care plans (consider limitations ofenvironment)

Patient-centered decision making Encourage ANY positive change

What can I do to make it 1 step easier for thepatient to comply?

Aggressive assistance with benefit/disability

applications Communication with case managers

Advocacy

Professionalism and respect


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Death and Dying &

Psychosomatic Medicine


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Depression in the elderly is commonlycharacterized by memory loss and cognitiveproblems, these symptoms can mimic and bemostly likely misdiagnosed as?

deme

ntia

aslee

pdiso

rd...

majo

rdep

ressi...

pseu

dode

pres

si...

alcoho

linto

xi...

20% 20% 20%20%20%

1. dementia

2. a sleep disorder

3. major depression

4. pseudodepression

5. alcohol intoxication


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Fadem, page 55

Psychopathology in the Elderly

Depression in the elderly iscommonly characterized by memoryloss and cognitive problems, thesesymptoms can mimic and be mostly

likely misdiagnosed as dementia.This misdiagnosed disorder, know aspseudodementia..


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Psychosomatic Medicine

Not all psychiatric presentation is psychiatric

CNS tumors

Endocrine dysfunction

Addison's

Cushing's

Thyroid

Seizure disorders Dementia


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2. Challenging Question Type:Elements and Applications fromdifferent lectures and Chapters.

What is really being asked?Ethics,Chapter # 26Psychosomatic Med,Chapter # 25

Death & Dying,Chapters # 4 & 26Major Depression,Chapters # 13Pain,

Chapter # 25


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A 75-year-old retired physicist who is suffering frommetastatic cancer is referred to a psychiatrist by theprimary care physician because the patient wants to die

and has requested assistance in suicide. On evaluation,the psychiatrist finds that the patients cognition is intact.The most appropriate next step for the psychiatrist is to:

Beasp

ersu

asiv

eas

...

Fin

doutw

heth

erther

...

Tellthe

referrin

gph

ys...

Tellthe

referrin

gph

ys...

25% 25%25%25%A. Be as persuasive as possible so that the

patient accepts the cancer treatment.B. Find out whether there are areas of suffering

that can be addressed by available palliativecare measures.

C. Tell the referring physician that the patientcan be given assistance in suicide becausethe patient is a competent adult.

D. Tell the referring physician that even thoughthe patients cognition appears intact, thepatient is probably incapacitated by virtue of

the unreasonable choice that is being made.


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A 75-year-old retired physicist who is suffering frommetastatic cancer is referred to a psychiatrist by theprimary care physician because the patient wants to die

and has requested assistance in suicide. On evaluation,the psychiatrist finds that the patients cognition is intact.The most appropriate next step for the psychiatrist is to:

A. Be as persuasive as possible so that the

patient accepts the cancer treatment.B. Find out whether there are areas of suffering

that can be addressed by available palliative

care measures. EUTHANASIAC. Tell the referring physician that the patient

can be given assistance in suicide becausethe patient is a competent adult.

D. Tell the referring physician that even thoughthe patients cognition appears intact, thepatient is probably incapacitated by virtue of

the unreasonable choice that is being made.

Ethics,Chapter # 26Psychosomatic Med,Chapter # 25Death & Dying,Chapters # 4 & 26Major Depression,Chapters # 13Pain,

Chapter # 25


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Assisted Suicide

Not always clear what is a suicide v an accident

Physicians may asked by their dying or suffering

patients to assist in their death. This is called euthanasia and is illegal in all

States except Oregon, Washington, & Montana

Death is defined as irreversible cessation of allfunctions of the entire brain, including thebrainstem, often certified by a flatelectroencephalogram (EEG)


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Major Depression


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3. Challenging Question Type:

Elements and Applications fromdifferent lectures and Chapters.

Question is a Composite ofDifferent Chapters/Topics

Psychosomatic Med,Chapter # 25

Death & Dying,Chapters # 4 & 26Major Depression,Chapters # 13


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A 69-year-old woman with an 39 year history ofmajor depression comes to the physician becauseshe is concerned about memory loss over the past 12

days. She has difficulty remembering appointmentsthat she has made, and on one occasion, she got lostgoing to the health club where she has been amember for years. Her lithium carbonate was

increase 3 weeks ago. On the mental statusexamination, she is oriented to person, place, andtime, but recalls only one of three objects at 5minutes. Select the most likely diagnosis.

A. alcohol abuseB. major depression

C. masked depression

D. medication toxicity

E. normal age-associated memory decline


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What is the diagnosis?

alcoh

olab

use

majo

rdep

ressi.

..

maske

ddep

ress..

.

medica

tiont

ox...

norm

alag

eass

...

20% 20% 20%20%20%1. alcohol abuse

2. major depression

3. masked depression4. medication toxicity

5. normal age

associated memorydecline


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increased 3 weeks ago. On the mental statusexamination, she is oriented to person, place, andtime, but recalls only one of three objects at 5minutes. Select the most likely diagnosis.

A. dementiaB. major depression





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DSM-IV: 5 or more of the symptoms &one or both of the top 2 symptoms

A. At least 5 symptoms forat least 2 weeks

B. Symptoms cause

significant distressand/or impairment

C. Symptoms not due todrugs, alcohol, or

medical illness.D. If bereavement, usually

symptoms must persistfor at least 2 months

SYMPTOMS

Depressed mood

Anhedonia

Weight loss, >5%

Sleep problems

Psychomotor < or >

Chronic fatigue Worthlessness

Poor concentration

Suicide thoughts


37/84



increase 3 weeks ago. On the mental statusexamination, she is oriented to person, place, andtime, but recalls only one of three objects at 5minutes. Select the most likely diagnosis.

A. alcohol abuseB. major depression




Death & Dying,

Chapters # 4 & 26Psychopathology in the Elderly, p 55Major Depression,Chapters # 13Substance-Induced Mood Disorder, p 206

F 7 th 65 ld t t d ith


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For 7 months, a 65-year-old man was treated withadjunctive chemotherapy after a successful operationfor carcinoma of the colon. One year ago he wastreated for a viral pneumonia. Over the past severalmonths, he has developed insomnia, fatigue, cryingspells, feelings of guilt, and anhedonia. At ages 40 and55, the patient was treated with an antidepressantand psychotherapy for a depressive illness. Which of

the following is the most likely cause of this patientsmood?

A. chemotherapyB. viral pneumonia

C. major depressionD. metastatic cancerE. normal adjustment


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Man with cancer & fatigue

chem

othe

rapy

viral

pneu

moni.

..

majo

rdep

ressi.

..

meta

static

can..

.

n

orma

ladju

stm...

20% 20% 20%20%20%1. chemotherapy

2. viral pneumonia

3.

major depression4. metastatic cancer

5. normal adjustment

Depression the 9th one


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SIGECAPS; 5 of 9 For 7 months, a 65-year-old man was treated with

chemotherapy after a successful operation for carcinoma of thecolon. One year ago he was treated for a viral pneumonia. Overthe past several months, he has developed insomnia, fatigue,crying spells, feelings of guilt, and anhedonia. At ages 40 and

55, the patient was treated with an antidepressant andpsychotherapy for a depressive illness. Which of the following isthe most likely cause of this patients mood?

A. methotrexate

B. viral pneumonia

C. major depression

D. metastatic cancer

E. normal adjustment

Depression, the 9 one

d d d d h


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A depressed patient committed suicide witha gun, which would most likely be found at

the lowest concentration on autopsy?

1 2 3 4

25% 25%25%25%

1. Serotonin

2. Protein

3. Norepinephrine

4. Glucose


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Alcohol Abuse and Dependence

Substance Abuse


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A 26 year old male decides it is time to

move out of his moms house and find anapartment of his own. He feels moreconnect now to his mom since makingthat decision and also appreciates her

more. In the last six months theirrelationship has become much lessconflictual. He is also dating a woman hemeet in Starbucks and that relationship isalso going well, he will usually double datewith ether his best friend or her sister. Hedrinks 4 to 5 beers a night on weekends.


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What describes his currentdevelopment stage best?

Early

adoles

ce...

Mid

-adoles

cent

Late

-adoles

cen.

..

Early

Adulth

oo...

MiddleA

dulth

o...

La

teAdulth

ood

17% 17% 17%17%17%17%

1. Early adolescent

2. Mid-adolescent

3. Late-adolescent

4. Early Adulthood

5. Middle Adulthood6. Late Adulthood


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Late Adolescence (18-20 years)

Move to more separation from parents

Relationship with parent begin totransform into more of an adult-adult aswell as parent-child relationship

More intimacy in relationships

Date in pairs (opposed to in groups)

End of adolescence is unclear


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Developmental Milestones of EarlyMiddle Age, 20 to 40

Expected

Schooling ends

Careers begin Marriage

Children

Not Unexpected

Extended schooling

Career changes Divorce, remaining

single, alternative lifestyles

Delay in child bearing,adoption


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The same man is now 35 years old, and

for the last 8 years he has beenconsuming 5 to 6 beers every eveningplus a whiskey or two on the weekends.

He has had two DUI and has gotten awarning at work for tardiness. He hasnever had a long term relationship butdates on and off, though recently he has

been dating a woman at work who is 12years older then he is.


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What is the best medical diagnosis here?

A

lcoho

labu

se

Problem

drinki.

..

Alcoh

oldep

end.

..

Normal

dev

elop.

..

Arrested

dev

el...

20% 20% 20%20%20%

1. Alcohol abuse

2. Problem drinking

3. Alcohol dependence

4. Normal development

5. Arrested development


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Alcohol Abuse (DSM-IV)

....made only in the absence ofdependence or history of dependence

One or more of the below:

Failure to fulfill major roleobligations

Use in hazardous situations

Legal problems

Use despite problems


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A 29-year-old man with a 9-year history of alcoholism successfullycompletes an inpatient drug rehabilitation program. He seeks adviceabout the most effective way to maintain sobriety after discharge.

Which of the following is the most accurate advice?

1 2 3 4 5

20% 20% 20%20%20%

1. Take disulfiram before participating in asocial situation in which he might expect toconsume alcohol

2. Take naltrexone before participating in a

social situation, because one drink willmake him nauseous

3. Do not try to totally abstain from alcoholconsumption, but rather limit consumptionto socially appropriate amounts becausethis will keep the urge to drink withintolerable limits

4. Have a definite number of drinks in mindbefore engaging in a social event involvingalcohol

5. Join a local chapter of alcoholics

anonymous


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A 47-year-old man is hospitalized with acutepancreatitis. His history reveals a history ofepisodic binge alcohol consumption. When the

physician meets with patient to discuss thecondition, the patient asks: Doctor, what caused

this? which of the following is the most

appropriate response to this question?1. I am not sure2. Dont you know?3. Probably your alcoholism.

4. Probably a consequence of alcoholconsumption.

5. We need to talk about where we go from herein your long-term care


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Correct response?

Nots

ure

Wha

tdoy

outh...

You

ralco

holis

...

Con

sequ

ence

of...

Whe

redo

weg

o...

20% 20% 20%20%20%1. Not sure

2. What do you think

3. Your alcoholism

4. Consequence ofalcohol drinking

5. Where do we gofrom here

A 47 ld i h i li d i h


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A 47-year-old man is hospitalized with acutepancreatitis. His history reveals a history ofepisodic binge alcohol consumption. When the

physician meets with patient to discuss thecondition, the patient asks: Doctor, what causedthis? which of the following is the most

appropriate response to this question?1. I am not sure2. Dont you know3. Probably your alcoholism.

4. Probably a consequence of alcoholconsumption.

5. We need to talk about where we go from herein your long-term care

A 28-year-old female patient is brought into your emergency room


54/84

8 yea o d e a e pat e t s b oug t to you e e ge cy ooafter she was involved in a minor car accident. A field sobriety test bythe police found her to be legally intoxicated. She admits she mighthave had too much alcohol to drink at her friends house, admits to

having had 2 other DUI charges (driving under the influence ofalcohol), and admits that she may need to be careful about herdrinking alcohol in the future. She denies she has any problem withalcohol and adamantly denies being an alcoholic. She states she hasan excellent work history and is a responsible member of thecommunity. What stage best characterizes this woman currently?

Actio

n

Main

tena

nce

Co

ntem

platio

n

Pre-

contem

plat

...

Determin

atio

n/...

20% 20% 20%20%20%

A. Action

B. Maintenance

C. Contemplation

D. Pre-contemplation

E. Determination/Preparation

A 28-year-old female patient is brought into your emergency room


55/84

y p g y g yafter she was involved in a minor car accident. A field sobriety test bythe police found her to be legally intoxicated. She admits she mighthave had too much alcohol to drink at her friends house, admits to

having had 2 other DUI charges (driving under the influence ofalcohol), and admits that she may need to be careful about herdrinking alcohol in the future. She denies she has any problem withalcohol and adamantly denies being an alcoholic. She states she hasan excellent work history and is a responsible member of thecommunity. What stage best characterizes this woman currently?

A. Action

B. Maintenance

C. ContemplationD. Pre-contemplation

E. Determination or

Preparation


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Mid-Life

For the Sandwich Generation


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For the Sandwich Generationwhich is correct?

They

arethe

e...

They

usually

h...

Their

adult

ch...

Their

ownp

are..

.

Des

cribe

speo

p...

20% 20% 20%20%20%1. They are the early adulthoodcohort

2. They usually have declining

health3. Their adult children remain

financially dependant longer

4. Their own parents are dyingsooner

5. Describes people who havegrown up on fast food


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Developmental Milestones of MiddleAdulthood, 40 to 65

Expected Career peaks Adult Children leave

home for college andcareers Caring for elderly parents Marriage Retirement

Relatively good health

Not Unexpected Unemployment Adult children dont leave

home

Parents may move in Divorce or widowed Retirement not possible

Major and minor illnessoccur


59/84

Fadem, page 45

Middle Adulthood: 40-65 The middle-aged person usually possesses

good healthand has more money,Despite its

financial benefits, middle age nowadays isassociated with unique social responsibilities.With their aging parents living longer but notnecessarily in better health, and their adult

children remaining financially dependent onthem for longer, people now in middle age, whohave responsibilities to both older and youngerrelatives, have been call the sandwichgeneration.

A 20 ld t ith hi t f d l d


60/84

A 20-year-old man presents with a history of delayeddevelopmental milestones, problems with impulse control, andan IQ of 65. He was in special education classes during his

schooling. Which of the following is most likely to be revealed bya complete assessment?

1 2 3 4 5

20% 20% 20%20%20%

1. Genetic or chromosomal

abnormalities2. Perinatal insults

3. Sociocultural deprivation

4. Maternal substance

abuse

5. Mild mental retardation


61/84

Culture and Illness

A patient who is completely deaf arrives with an


62/84

p p yinterpreter at the outpatient clinic for an evaluation ofdepressed mood. You wish to know about the patients

sleep quality. Of the following, which is the mostappropriate way to work with the interpreter and thepatient?

Askt

heinte

rprete

r,...

Looka

tthe

patie

nta..

Askthe

inter

prete

r,..

.

Loudly

enun

ciate,

...

Writeo

utHow

arey

..

20% 20% 20%20%20%A. Ask the interpreter, How is she

sleeping?

B. Look at the patient and ask, Howare you sleeping?

C. Ask the interpreter, Please ask her

how she is sleeping.

D. Loudly enunciate, How are yousleeping? to the patient.

E. Write out How are you sleeping?

and give the note to the patient.


63/84

Fadem, page 313

No matter what the ethnicity or culture, itis essential that the physician speak

directly to the patient.


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Sleep

A 38 y/o man complains that for the past 2 years he hasi d l th f th d th t


65/84

required several naps over the course of the day thathelp with his sleep attacks; he finds the naps quiterefreshing, but sees his doctor because lately, as he iswaking up, he feels momentarily paralyzed. What isthe most likely diagnosis?

catap

lexy

narco

lepsy

hypn

agogicha

l...

idiop

athichy

p...

adv

anceds

leep..

.

20% 20% 20%20%20%

Pg. 177, Q.88

1. cataplexy

2. narcolepsy

3. hypnagogichallucinations

4. idiopathichypersomnolence

5. advanced sleep wave

syndrome


66/84

Narcolepsy, Fadem page 116

Patients have sleep attacks during which theysuddenly fall asleep during the day

Have hypnagogic (upon falling asleep) orhypnopompic (upon awakening from sleep)

hallucinations Cataplexy which is transient loss of motor tone

associated with strong emotion (no loss ofconsciousness)

Sleep paralysis, inability to move the body for afew seconds after awakening

* Catalepsy is a condition of muscle rigidity and sudden, temporaryloss of consciousness and feeling, like epilepsy


67/84

Characteristics and Treatment of Dyssomnias

Sleep Disorder Signs, Symptoms, and Issues Treatments

Narcolepsy

Sleep

drunkness

Sleep attacks: Episodes ofsudden day time sleepiness that

occur daily for at least 3

months despite a normal

amount of sleep at night

Sleepiness is relieved by

daytime naps Cataplexy

Hypnagogic hallucinations

Sleep paralysis

REM sleep latency < 10 minutes

Difficulty awaking fully after

adequate sleep (confused)

Rare, associated with genetic

factors; must be differentiated

from substance abuse or OSD

Traditionally treated withCNS stimulant (e.g.,

amphetamine)

Modafinil (increases the

release of NE, DA, HA)

Methylphenidate

(increases the levels ofNE and DA in the brain

through reuptake

inhibition of MAT)

Planned, timed daytime

naps

Stimulant agents (e.g.,

methylphenidate)

A 26 y/o man with narcolepsy has episodes of brief


68/84

A 26 y/o man with narcolepsy has episodes of briefparalysis without any loss of consciousness or otherdeficits. These attacks are usually precipitated bylaughter or anger. What is this phenomenon known as?

Pg. 58, Q.87

Catale

psy

Cataple

xy

Hyp

erso

mnia

Hyp

nago

gicha

llucin.

..

Hyp

nopo

mpi

cha

lluci...

20% 20% 20%20%20%

1.

Catalepsy2. Cataplexy

3. Hypersomnia

4. Hypnagogic hallucinations5. Hypnopompic hallucinations


69/84

Characteristics and Treatment of Dyssomnias

Narcolepsy Sleep attacks: Episodes ofsudden day time sleepiness that

occur daily for at least 3

months despite a normal

amount of sleep at night

Sleepiness is relieved by

daytime naps Cataplexy

Hypnagogic hallucinations

Sleep paralysis

REM sleep latency < 10 minutes

Traditionally treated withCNS stimulant (e.g.,

amphetamine)

Modafinil (increases the

release of NE, DA, HA)

Methylphenidate

(increases the levels ofNE and DA in the brain

through reuptake

inhibition of MAT)

Planned, timed daytime

naps


70/84

This case pertains to the next two question slides

A mother brings her 7-year-old son to you becauseshe is worried about him. She tells you that he sitsup in bed in the middle of the night and screams.

She says he is inconsolable, but eventually falls backto sleep. She starts crying as she tells you shecannot sleep after these episodes and is exhaustedat work during the day.


71/84

Which of the following initial responses is most appropriate?

Ica

nsee

thi...

Iknow

your

e...

Ican

seey

o...

Tell

mew

hyy...

A

reyouw

orri.

..

20% 20% 20%20%20%

Pg. 13, Q.3

1. I can see this is veryupsetting for you.

2. I know youre upset, butthis problem will get better.

3. I can see youre upset, butyoure really overreacting.

4. Tell me why you cant fallback to sleep after your sondoes.

5. Are you worried that this isyour fault?


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Which of the following initial responses is most appropriate?

Ica

nsee

thi...

Iknow

your

e...

Ican

seey

o...

Tell

mew

hyy...

Ca

nyou

tell.

..

20% 20% 20%20%20%

Pg. 13, Q.3

1. I can see this is veryupsetting for you.

2. I know youre upset, butthis problem will get better.

3. I can see youre upset, butyoure really overreacting.

4. Tell me why you cant fallback to sleep after your sondoes.

5. Can you tell me what youare feeling right now


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Interview

Open-ended questions; non structuredinquiries, allow patient to bring up almost anyissue that might interest them or bother them.Down side is that they invite long responseswhich can take a lot of time

Example:

So, tell me, what brought you into the hospitaltoday? orHow are you feeling?


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Interview

Closed-ended or Direct questions;questions that can often be answered

with a yes or a no or a short response. Examples:

Point to where it hurts

Are you sleeping better or worse thanusual?

Will I be getting honors in this course,

wont I?


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This case pertains to the next two question slides

A mother brings her 7-year-old son to you becauseshe is worried about him. She tells you that he sitsup in bed in the middle of the night and screams.

She says he is inconsolable, but eventually falls backto sleep. She starts crying as she tells you shecannot sleep after these episodes and is exhaustedat work during the day.

During what stage of sleep do these


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During what stage of sleep do theseepisodes most likely occur?

Stag

e1

Stag

e2

Stag

es3-4

Ra

pideyem

ovem

en...

Any

stag

e

20% 20% 20%20%20%

Pg. 13, Q.4

1. Stage 1

2.

Stage 23. Stages 3-4

4. Rapid eye

movement (REM)stage

5. Any stage

Sleep Disorders


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Secondary

Movementdisorders

Sleep Disorders

Parasomnias

Insomnias

Hypersomnia

NarcolepsyBreathingdisorders

Nightfrights

Bedwetting(enuresis)

Nocturnaleating

disorder

REMbehaviordisorder

Chronic Transient Apneas Other Restlesslegs

syndrome

Periodiclimb

movement

disorder

Sleepterrors

Nightmares

Somnambulism/somniloquence

Circadian rhythm Psychophysiologic insomnia Sleep state misperception

Comorbid disease Pain Medications

Obstructive Central

Ondines

curse

Other sleep disorders Substance abuse Other

Idiopathic insomnia Poor sleep hygiene

Primary

American Sleep Disorders Association. The International Classification of Sleep Disorders, Revised:Diagnostic and Coding Manual. Rochester, Minn: American Sleep Disorders Association; 2000.

Dyssomnias

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition-Text revision (DSM-IV-TR)

Bruxism

Sleep Starts

Standard Criteria for Scoring Slow-wave or


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EEG: (Stage 3) 30 50% high amplitude (> 75V),(Stage 4) >50% high amplitude, slow frequency ( 2

cps); maximal in the frontal

EMG: Tonic activity, low level

EOG: None, picks up EEG

Delta sleep makes up about 25% of sleep time in young adults.

This stage is associated with unusual behavioral characteristicslike sleepwalking (somnambulism), enuresis, and night terrors

Standard Criteria for Scoring Slow wave or

Delta Sleep (Stages 3 and 4)


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Characteristics and Treatment of

Sleep Disorder Signs, Symptoms, and Issues Treatments

Nightmare

disorder

Sleep terror

(pavor

nocturnus

disorder)

Repetitive, frightening dreamsthat occur during REM sleep

and are recalled on nighttime

awakenings

Common from ages 3-7

Repetitive experiences of fright

in which a person screams in

fear but cannot be awakened

and has no memory of having adream

Occur during delta sleep

More common in boys; runs in

families; can be a precursor to

temporal lobe epilepsy

Desensitization behaviortherapy provides marked

improvement

Pharmacological agents

that suppress REM sleep

(e.g., tricyclic

antidepressants andbenzodiazepines)

Pharmacological agents

that suppress delta sleep

(e.g., benzodiazepines)

Parasomnias

Although a 75-year-old patient goes to bed each


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Although a 75 year old patient goes to bed eachnight at 11PM and wakes up at 7AM, he feels sleepyall day. His wife reports that he snores loudly and

sleeps fitfully. Which of the following is the mostlikely diagnosis?

1 2 3 4 5

20% 20% 20%20%20%

1. Narcolepsy

2. Sleep-wakeschedule disorder

3. Insomnia

4. Kleine-Levinsyndrome

5. Sleep apnea


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Pain

Which two neurotransmitters are implicated


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Which two neurotransmitters are implicatedin the experience of chronic pain?

Seroton

in&Do

pamine

Dop

amine

&Norepi...

Norepine

phrin

e&...

Glut

amate

&Serotonin

Glut

amate

&Dop

amine

20% 20% 20%20%20%

1. Serotonin & Dopamine

2. Dopamine & Norepinephrine3. Norepinephrine & Dopamine

4. Glutamate & Serotonin

5. Glutamate & Dopamine


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Fadem, page 421

Other Treatments for Chronic Pain

The neurotransmitters serotonin and glutamate

are implicated in the experience of pain.


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Questions?

Good Luck on the Examination