Considering Alternatives

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Considering Alternatives by Mind Map: Considering Alternatives

1. Step 1:

1.1. Difficult Words

1.2. Identifying Cue

1.2.1. 48 year old male

1.2.2. Driven by taxi to clinic

1.2.3. Recent history of stress New position His daughter's relationship

1.2.4. Fainting attack Attacks for few seconds Missed lunch

1.2.5. Became sweaty Before fainting

1.2.6. FROM TRIGER TWO Chronic Fatigue syndrome

2. Step 2: Problem Formulation

2.1. 48 year old male came to the clinic after becoming pale, sweaty, & passing out as a consequence of stressful event.

3. Step 3: Hypotheses Generation

3.1. Conduction problems

3.1.1. As a result of huge amount of stressful news & events New position Daughter's

3.1.2. Causes problem conduction issue

3.1.3. Loss of control --> led to postural hypotension

3.1.4. Affects CV risks

3.2. Stress attacks lead to transient arrhythmia

3.3. Depression

3.4. Activation of sympathetic nervous system

3.4.1. Missed beats

3.4.2. Sweating due to activation of SNS

3.4.3. Hyperglycemic then hypoglycemic state

3.5. When standing suddenly

3.5.1. Heart becomes tachycardia

3.6. Postural Hypotension

3.6.1. Baromechanical regulation of BP Sensing changes in BP Hypovolemia

3.6.2. Chemoreceptors for short term regulation

3.6.3. Not an old patient

3.7. Arrhythmia

3.7.1. Benign

3.7.2. Then become malignant

3.7.3. Can cause fainting!

3.8. Fainting due to hypoglycemia

3.8.1. No lunch

3.9. Hypoglycemia & activation of SNS simultaneously

3.10. Religious involvement

4. Step 4: Hypothesis Organization

4.1. Primary

4.1.1. Stress

4.1.2. Syncope

4.2. Secondary

4.2.1. Hypotension

4.2.2. Hypoglycemia

4.2.3. Arrhythmia

5. Step 5: Learning Objectives

5.1. 1. Pathophysiology of stress

5.1.1. How the patient present

5.1.2. Focus on CV events

5.2. 2. T explain the mechanism of postural hypotension & list the causes

5.3. 3. To know about the chronic fatigue syndrome

6. Step 6: Review

6.1. Stress

6.1.1. Two factors Internal Nutritional state Weel-being External

6.1.2. Symptoms Physicla Sleep Distrubance Headache Behavioral Anxiety Nervousness induce the patient for unhealthy behaviors Emotional

6.1.3. Correlations between CVS events and stress Chronic stress Patient starts to modfiy his lifestyle Increase secretion in stress hormones Induce inflammation & fibrosis Psychological factors Poor lifestyle EARLY intervention is important Polyvagalal theroy Patient initially cope well With increased stress,, patient cannot cope

6.1.4. Pathophysiology Received by the brain as a threat Adaptation Behavioral responce All systems are affected Stress per se does not lead to CVS complications Activation of HPA axis Release catecholmines Increase Cortisol secretions PNS will work then SNS rest and recreation response Neurotransmitters Regulate mood perception

6.2. 3. To know about the chronic fatigue syndrome

6.2.1. Fatigue with no explained medical condition duration ofat least 6 months

6.2.2. Causes Unkown Makes it difficult to diagnose Infection EBV Psychological Immune system problems Hormonal imbalances

6.2.3. 2/3 ofpatients with CFS have some psychiatric illness

6.2.4. Symptoms Fatigue They are ALWAYS fatigue With exercise With daily activities Not revealed with sleep Insmonia Could explain forgetfulness Forgetfullness Difficulty in concentration Enxplained sore throat Some LN in the neck are enlarged Mucle cramps Pain in joints No signs of inflammation

6.2.5. Other findings

6.3. 2. T explain the mechanism of postural hypotension & list the causes

6.3.1. Full in BOP upon standing For SBP full by 20 mmHg In DBP full by 10 mmHg For SBP full by 20 mmHg

6.3.2. Symptoms Dizziness In pregnant women Infection inner ear Syncope

6.3.3. Mechanism Heart Medictions Decrease blood supply to heart Vessels Dilatation Volume Dehydration Blood loss ANS Vasovagal episodes

6.3.4. Medications

6.3.5. Syncope Decrease perfusion to brain Vasovagal syncope Not need for the body to change it\s state

7. Step 7: Inquiry Plsn

7.1. Present History

7.1.1. No third party

7.1.2. Previous Episodes No papiltaion Auora dizziness No SOB No weakness

7.1.3. Poor appetite Lost 4 kg in last 4 months]

7.1.4. Dificulty in concenttration

7.1.5. Feels hopeless in helpless

7.1.6. Suicidality

7.1.7. No history of infection

7.2. Past Medical history

7.2.1. Episode 20 years ago Exam in the university

7.2.2. No history of cardiac disease

7.2.3. Rhiniti

7.2.4. No history of psychiatic disease

7.3. Social & occupational history

7.3.1. Socail No smoker No alcohol

7.3.2. Occupational Manage of compaany in the city

7.4. Family histroy

7.4.1. Parent s laive wnad weekl

7.4.2. Mohter hada similar episode

7.4.3. Father had depression

7.4.4. Sibnlings

7.4.5. One daughter Well

7.5. Physical Examination

7.5.1. Vitals Hg = 180 Wg = 86 kg PR = 80 BP = 130 /85 T = 36.8 C RR = 18/ min No papable LN

7.5.2. Insepction Looks depressed

7.5.3. CVS Examiantion Precordium Insepction Apex beat = 5th MCL

7.5.4. Respiratory, GI, Hematological ALL NORMA

7.6. Investiation

7.6.1. CBC Normal

7.6.2. Serum Creatine Normal

7.6.3. LFT Norma

7.6.4. Thyroid Normal

7.6.5. Electrolytes Normal

7.6.6. CXR Normal

7.6.7. MRI Normal

8. Step 8: Diagnostic Decision

8.1. CFS + Depression

8.2. Progressive tiredness over last 6 months

8.3. Family history of psychiatric ilness

9. Learning Objectives

9.1. 1- Management of CFS

9.1.1. Acute

9.1.2. On going

9.2. 2- Management of Depression

9.2.1. Criteria

9.2.2. Types

10. Step 9: Review

11. Step 10: Management

11.1. CFS

11.1.1. no cure

11.1.2. Goals Retain the satisfaction

11.1.3. Reliefve the symptoms & the pain

11.1.4. Pharmacological Only for the symptoms Pain Painkillers Acupuncture Sleep Sleep pills Timing sleep Use bed only for sleep Exercise 4 hours before sleep No recommended for CFS per se Cortisol Immune therapy Vaccination Antidepressants

11.1.5. If the cause EBV antivural Acyclovir

11.1.6. Avoid caffiene

11.1.7. Non-pharmacological CBT Much better than GET Also better outcomes than those with mediacl care only Internet-based is better !! Graded exercise therapy RCT milshowed mild to moderate benefits Start Light Increase severity Time Management Supportive therapy Difficult

11.1.8. Prognosis Short term - poor Long term - much better

11.2. Depression

11.2.1. Mood Disorders MDE 5 out of 9 One of 2 are required For 2 weeka Dysthemic 2 years Depresed mood Low selfesteem Hopelessness

11.2.2. Reactive /brought in by external stressor

11.2.3. Clinical "Endogenous"

11.2.4. Management Tips Patient has to learn about his/her depression Has to know that treatment takes long time Doen't have to rely on treatment only Has to get involve in social life During the time of the treatemnt,, he/she could be depressed in the beginning of the treatment Look for secondary causes Drugs Medical conditions Modify lifestyle Psychotherapy Cognitive therapy Interpersonal therapy 12-16 hours per week Pcyhocodynamic Antidepressants 12 weeks after the psychotherapy Great benefits in sever-to-moderate depression Classes Presciption Herbal St. Jones Worts MOA Side effects Good benefits Massage Light therapy Substitute for sun light ECT Curent pass through the brain For severe conditions 6-10 sessions,, patient should go for antidepressants Special considerations Follow-up Clarify the possibility of addiction Clarify side effects Barriers to treatment Social stigma False belief about medications Patients-erlated problem Socially isolated Patients don't relize they're depressed Shortage of resources Physicians

12. Step 11: Evaluation

12.1. 1. Resources

12.1.1. Uptodate


12.1.3. CDC

12.1.4. Medicinenet

12.1.5. Mayoclinic

12.1.6. Dr. Ahmed AlSaleh's Lecture