Bellâ€™s Palsy Reassurance about stroke Ã Patient will feel much better Ask questions which help diagnosis - Have you been unwell? - Were you alright the night before? - Find s/s: flu? - Do you have DM or high blood pressure? - Have you had it before? - No need to ask stoke questions Ã already diagnosed Explain pathogenesis Â· This is Bellâ€™s palsy, the nerve that supplies the face is paralyzed. Â· Itâ€™s self-limiting 75%, >90% recovery in 3-6 weeks Why it happens? Draw a diagram, cause is infection, autoimmune. Use the word â€˜might haveâ€™. Any treatment? If due to HZ, give Acyclovir Examine the ears to see blister. If patient comes in 3 days Ã Steroid may help General treatment - Diet, water - Take care of face by Â· Use glasses Â· Artificial tear Â· Ointment or ABO eye drop if infection occurs - Refer to PT Ã facial exercise advice - Analgesic for pain Questions in the real exam Do you think it is stroke? Why it happens? Will I have it forever? How can I do in front of others? Hepatitis C Breaking a bad news or reassurance - Is it alright if I go ahead? - Do you want someone to stay with you? Ask for risk factors - She was an IV user Ã IV drug might be the cause of hepatitis C Management General Â· Notify the authority and blood bank Â· Test the partners and children Specific Â· Refer to gastroenterogist Â· Anti-viral treatment Information sheet, support group Ask feed back from the patient: What do you understand? Review the test to partner Ã make an appointment Inform that â€˜Youâ€™re not able to donate bloodâ€™. Liver might become cirrhosis, cancer Ã regular blood test for LFT It is unlikely to transmit by sexual intercourse. Vertical transmission Ã if not sure, refer to O&G Herpes Zoster (Shingles) Questions to ask: - Immunosuppressive history? DM? - Are there any children at home? (child might get chickenpox) Treatment: Â· Acyclovir in 72 hours: 800 mg 5 times a day X 7 days Â· Calamine lotion or soothing lotion Â· Anti-histamine: ask for occupation, drowsy or non-drowsy drug Â· Steroid in really bad case but not proven Complication: Â· Post-herpatic neuralgia if last beyond 1 month Ã see you in 2 weeks if analgesic cannot control. Â· Herpes opthalmaticus Ã can cause corneal scar ADHD Whatâ€™s been bothering you? Howâ€™s his performance at school? Does it happen recently? Or on going? How is his grade and how was before? Notice any changes at school? Concentration span? What is his relation to school mates and teacher? How about family? What do you do? How many children? How much time you spend with your kids? Does he sleep? (never look tired) FH? How bad was it? Do you drink alcohol? Smoke? Recreational drugs? Does he behave like this at home? Is anything going on at home? DDX: ADHD Conduct disorder Anti-social personality Depression (if not eating well) Treatment: Â· Counseling Â· Child psychiatrist Â· Imipramine (stimulant) Mental State Examination (MSE) General appearance Mood: Objective Affect: Subjective Though: Delusion Ã Grandiosity Suicidal Perception: Hallucination Cognition Insight In psychiatric patient, have to exclude Â· Thyroid Â· Menopause Can say psychotic illness, instead of schizophrenia ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ PTSD & Depression Always think about thyrotoxicosis and other medical conditions Psychiatry: Good history Counseling Differential diagnosis PTSD (Post-traumatic stress disorder) Â· Nightmares: Had it happened before? When? Â· Flashbacks: - Do you think about that quite often? - Have you been to the place it happened? - Does anything remind you of that? (trigger) Precipitating factor Trigger Avoidance S/S associated with it: Panic attack Impact a. How does it effect your social life? b. Personal life? Work? c. Relationship? Coping: How are you coping? d. Coping skill: Drug & alcohol or social support (?) Medical problems e. Do you have medical problems esp. thyroid? f. What do you do? Have you had any mental/emotional problem? g. Is there any FH of emotional problem? Depression questions Â· How is your mood? Â· How is your energy? Â· How is your sleep? Â· How is your appetite? Some people, when they go through this experience, they start drinking or use elicit drugs. Have you been using them? Have you had any thoughts of ending your life? (harming yourself?) Do you have anyone to talk about it? Would you like to talk to someone? Find whether she need psychotherapy or urgent treatment. **Identify risk of harming herself or others** Do you have a feeling of worthlessness? Have you been feeling guilty? Can you enjoy what you used to? You really need treatment at this stage. If suicidal idea Ã admit & consult psychiatrist If you donâ€™t want, I have to use law. Be safe, non-judgment and low-tone voice Ask menstrual history to exclude thyroid.