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