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

1.2.3.1. New position

1.2.3.2. His daughter's relationship

1.2.4. Fainting attack

1.2.4.1. Attacks for few seconds

1.2.4.2. Missed lunch

1.2.5. Became sweaty

1.2.5.1. Before fainting

1.2.6. FROM TRIGER TWO

1.2.6.1. 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

3.1.1.1. New position

3.1.1.2. 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

3.6.1.1. Sensing changes in BP

3.6.1.2. 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

6.1.1.1. Internal

6.1.1.1.1. Nutritional state

6.1.1.1.2. Weel-being

6.1.1.2. External

6.1.2. Symptoms

6.1.2.1. Physicla

6.1.2.1.1. Sleep Distrubance

6.1.2.1.2. Headache

6.1.2.2. Behavioral

6.1.2.2.1. Anxiety

6.1.2.2.2. Nervousness

6.1.2.2.3. induce the patient for unhealthy behaviors

6.1.2.3. Emotional

6.1.3. Correlations between CVS events and stress

6.1.3.1. Chronic stress

6.1.3.1.1. Patient starts to modfiy his lifestyle

6.1.3.1.2. Increase secretion in stress hormones

6.1.3.1.3. Induce inflammation & fibrosis

6.1.3.1.4. Psychological factors

6.1.3.2. Poor lifestyle

6.1.3.3. EARLY intervention is important

6.1.3.4. Polyvagalal theroy

6.1.3.4.1. Patient initially cope well

6.1.3.4.2. With increased stress,, patient cannot cope

6.1.4. Pathophysiology

6.1.4.1. Received by the brain as a threat

6.1.4.1.1. Adaptation

6.1.4.1.2. Behavioral responce

6.1.4.1.3. All systems are affected

6.1.4.2. Stress per se does not lead to CVS complications

6.1.4.3. Activation of HPA axis

6.1.4.3.1. Release catecholmines

6.1.4.3.2. Increase Cortisol secretions

6.1.4.4. PNS will work then SNS

6.1.4.4.1. rest and recreation response

6.1.4.5. Neurotransmitters

6.1.4.5.1. 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

6.2.2.1. Unkown

6.2.2.1.1. Makes it difficult to diagnose

6.2.2.2. Infection

6.2.2.2.1. EBV

6.2.2.3. Psychological

6.2.2.4. Immune system problems

6.2.2.5. Hormonal imbalances

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

6.2.4. Symptoms

6.2.4.1. Fatigue

6.2.4.1.1. They are ALWAYS fatigue

6.2.4.1.2. With exercise

6.2.4.1.3. With daily activities

6.2.4.1.4. Not revealed with sleep

6.2.4.2. Insmonia

6.2.4.2.1. Could explain forgetfulness

6.2.4.3. Forgetfullness

6.2.4.4. Difficulty in concentration

6.2.4.5. Enxplained sore throat

6.2.4.6. Some LN in the neck are enlarged

6.2.4.7. Mucle cramps

6.2.4.8. Pain in joints

6.2.4.8.1. 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

6.3.1.1. For SBP full by 20 mmHg

6.3.1.2. In DBP full by 10 mmHg

6.3.1.3. For SBP full by 20 mmHg

6.3.2. Symptoms

6.3.2.1. Dizziness

6.3.2.1.1. In pregnant women

6.3.2.1.2. Infection inner ear

6.3.2.2. Syncope

6.3.3. Mechanism

6.3.3.1. Heart

6.3.3.1.1. Medictions

6.3.3.1.2. Decrease blood supply to heart

6.3.3.2. Vessels

6.3.3.2.1. Dilatation

6.3.3.3. Volume

6.3.3.3.1. Dehydration

6.3.3.3.2. Blood loss

6.3.3.4. ANS

6.3.3.4.1. Vasovagal episodes

6.3.4. Medications

6.3.5. Syncope

6.3.5.1. Decrease perfusion to brain

6.3.5.2. Vasovagal syncope

6.3.5.2.1. 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

7.1.2.1. No papiltaion

7.1.2.2. Auora

7.1.2.3. dizziness

7.1.2.4. No SOB

7.1.2.5. No weakness

7.1.3. Poor appetite

7.1.3.1. 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

7.2.1.1. 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

7.3.1.1. No smoker

7.3.1.2. No alcohol

7.3.2. Occupational

7.3.2.1. 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

7.4.5.1. Well

7.5. Physical Examination

7.5.1. Vitals

7.5.1.1. Hg = 180

7.5.1.2. Wg = 86 kg

7.5.1.3. PR = 80

7.5.1.4. BP = 130 /85

7.5.1.5. T = 36.8 C

7.5.1.6. RR = 18/ min

7.5.1.7. No papable LN

7.5.2. Insepction

7.5.2.1. Looks depressed

7.5.3. CVS Examiantion

7.5.3.1. Precordium

7.5.3.1.1. Insepction

7.5.3.2. Apex beat = 5th MCL

7.5.4. Respiratory, GI, Hematological

7.5.4.1. ALL NORMA

7.6. Investiation

7.6.1. CBC

7.6.1.1. Normal

7.6.2. Serum Creatine

7.6.2.1. Normal

7.6.3. LFT

7.6.3.1. Norma

7.6.4. Thyroid

7.6.4.1. Normal

7.6.5. Electrolytes

7.6.5.1. Normal

7.6.6. CXR

7.6.6.1. Normal

7.6.7. MRI

7.6.7.1. 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

11.1.2.1. Retain the satisfaction

11.1.3. Reliefve the symptoms & the pain

11.1.4. Pharmacological

11.1.4.1. Only for the symptoms

11.1.4.2. Pain

11.1.4.2.1. Painkillers

11.1.4.2.2. Acupuncture

11.1.4.3. Sleep

11.1.4.3.1. Sleep pills

11.1.4.3.2. Timing sleep

11.1.4.3.3. Use bed only for sleep

11.1.4.3.4. Exercise 4 hours before sleep

11.1.4.4. No recommended for CFS per se

11.1.4.5. Cortisol

11.1.4.6. Immune therapy

11.1.4.6.1. Vaccination

11.1.4.7. Antidepressants

11.1.5. If the cause EBV

11.1.5.1. antivural

11.1.5.2. Acyclovir

11.1.6. Avoid caffiene

11.1.7. Non-pharmacological

11.1.7.1. CBT

11.1.7.1.1. Much better than GET

11.1.7.1.2. Also better outcomes than those with mediacl care only

11.1.7.1.3. Internet-based is better !!

11.1.7.2. Graded exercise therapy

11.1.7.2.1. RCT milshowed mild to moderate benefits

11.1.7.2.2. Start Light

11.1.7.2.3. Increase severity

11.1.7.3. Time Management

11.1.7.4. Supportive therapy

11.1.7.4.1. Difficult

11.1.8. Prognosis

11.1.8.1. Short term - poor

11.1.8.2. Long term - much better

11.2. Depression

11.2.1. Mood Disorders

11.2.1.1. MDE

11.2.1.1.1. 5 out of 9

11.2.1.1.2. One of 2 are required

11.2.1.1.3. For 2 weeka

11.2.1.2. Dysthemic

11.2.1.2.1. 2 years

11.2.1.2.2. Depresed mood

11.2.1.2.3. Low selfesteem

11.2.1.2.4. Hopelessness

11.2.2. Reactive

11.2.2.1. /brought in by external stressor

11.2.3. Clinical

11.2.3.1. "Endogenous"

11.2.4. Management

11.2.4.1. Tips

11.2.4.1.1. Patient has to learn about his/her depression

11.2.4.1.2. Has to know that treatment takes long time

11.2.4.1.3. Doen't have to rely on treatment only

11.2.4.1.4. Has to get involve in social life

11.2.4.1.5. During the time of the treatemnt,, he/she could be depressed in the beginning of the treatment

11.2.4.2. Look for secondary causes

11.2.4.2.1. Drugs

11.2.4.2.2. Medical conditions

11.2.4.2.3. Modify lifestyle

11.2.4.3. Psychotherapy

11.2.4.3.1. Cognitive therapy

11.2.4.3.2. Interpersonal therapy

11.2.4.3.3. 12-16 hours per week

11.2.4.3.4. Pcyhocodynamic

11.2.4.4. Antidepressants

11.2.4.4.1. 12 weeks after the psychotherapy

11.2.4.4.2. Great benefits in sever-to-moderate depression

11.2.4.4.3. Classes

11.2.4.4.4. Presciption

11.2.4.5. Herbal

11.2.4.5.1. St. Jones Worts

11.2.4.5.2. MOA

11.2.4.5.3. Side effects

11.2.4.5.4. Good benefits

11.2.4.6. Massage

11.2.4.7. Light therapy

11.2.4.7.1. Substitute for sun light

11.2.4.8. ECT

11.2.4.8.1. Curent pass through the brain

11.2.4.8.2. For severe conditions

11.2.4.8.3. 6-10 sessions,, patient should go for antidepressants

11.2.4.9. Special considerations

11.2.4.9.1. Follow-up

11.2.4.9.2. Clarify the possibility of addiction

11.2.4.9.3. Clarify side effects

11.2.4.10. Barriers to treatment

11.2.4.10.1. Social stigma

11.2.4.10.2. False belief about medications

11.2.4.10.3. Patients-erlated problem

11.2.4.10.4. Socially isolated

11.2.4.10.5. Patients don't relize they're depressed

11.2.4.10.6. Shortage of resources

11.2.4.10.7. Physicians

12. Step 11: Evaluation

12.1. 1. Resources

12.1.1. Uptodate

12.1.2. Helpguide.org

12.1.3. CDC

12.1.4. Medicinenet

12.1.5. Mayoclinic

12.1.6. Dr. Ahmed AlSaleh's Lecture