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sue



Points : 42144
Join date : 2013-12-26

PostSubject: AMC Clinical exam preparation   Sat Dec 28, 2013 1:25 pm

amc clinical exam

A 40 year old Mr. Ralph Deakin sees you in general practice with a complaint of depressed mood similar to previous episodes 12 and 15 years ago which were treated successfully with imipramine (Tofranil), a tricyclics antidepressant (TCA) but he would like to avoid it because he suffered from unpleasant side effects like dry mouth, dry eyes and constipation at the time.  

YOUR TASK IS TO:
• Take further history
• Discuss your diagnosis with the patient
• Advise the patient regarding the best medication for him



HOPC: A 40 year old Mr. Ralph Deakin sees you in general practice with a complaint of depressed mood similar to previous episodes 12 and 15 years ago which were treated successfully with imipramine (Tofranil), a tricylic antidepressant (TCA) but he would like to avoid it because he suffered from unpleasant side effects like dry mouth, dry eyes and constipation at the time and he wonders if there are other tonics or mediations available.

He recently lost his job as a real estate agent and his mood became quite depressed, he suffers from sleeping problems (insomnia), general loss of energy and motivation and he does not enjoy the things he used to enjoy like playing golf, going to the movies etc.

PHx. + FHx.: normal

SHx: married insurance broker, 2 children, stable family, non smoker, little alcohol, no recreational drugs, NKA/

EXAMINATION: mildy overweigth man (BMI 26) with normal vital signs and no pathological findings on physical examination/

DIAGNOSIS: MAJOR DEPRESSION, RECURRENT
Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown but probably involves heredity, changes in neurotransmitter levels, altered neuroendocrine function, and psychosocial factors. Diagnosis is based on history. Treatment usually consists of drugs, psychotherapy, or both and sometimes electroconvulsive therapy.
Major depression, recurrent: two or more episodes of major depression which manifests with at least five of the following nine symptoms, one being a depressed mood or loss of interests/pleasure, present most of the day nearly every day for a minimum of two consecutive weeks:
1. Depressed mood
2. Loss of interests/pleasure (ANHEDONIA)
3. Change in sleep (insomnia or hypersomnia)
4. Significante change in appetite or weight
5. Change in psychomotor activity (agitation or retardation)
6. Loss of energy or fatigue
7. Trouble concentrating or indesciveness
8. Thoughts or feelings of worthlessness or guilt
9. Thoughts about death or suicide
Conceptually these symptoms may be grouped as disturbances in:
• Emotions (depressed mood, loss of interests/pleasure)
• Ideation (worthlessness/guilt, death/suicide)
• Neurovegetative or somatic symptoms (sleep, appetite/weight, psychomotor, energy, concentration).







A mnemonic is helpful in remembering the criteria for major depression:
Seeing that Lack of ENERGY is common to most episodes, the mnemonic relates to “treating “ this symptom by ”prescribing energy capsules” as SIG: E(nergy) CAPS:
• S: sleep changes
• I: interest (decreased / anhedonia)
• G: guilt (excessive)
• E: energy (decreased)
• C: concentration (decreased)
• A: appetite changes
• P: psychomotor agitation or retardation
• S: suicidal ideation

MANAGEMENT:
Ralph should be offered the choice of a selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitors (SNRI) such as sertraline, paroxetine, citralopam, fluoxetine or venlafaxine
SSRI and SNRI antidepressants are sometimes preferred because they tend to start working more quickly, and they do not seem to cause a dry mouth, constipation or sedation, all of which are common with tricyclic antidepressants (TCA).
TCAs also have high risk of cardia arrhythmias in overdosage!!!
SSRI and SNRI antidepressants have different side effects, including stomach pains, nausea, vomiting and diarrhoea which usually occur early during treatment. Other common side effects include tremor, dizziness, increased perspiration and male and female sexual function (delayed ejaculation in men, decreased libido in women).

In addition one should consider psychotherapy or a combination of medication and psychotherapy or electroconvulsive therapy (ECT).

For the treatment of a recurrent episode of major depressions one has to take into consideration that the particular medication that achieved remission in past episodes is likely to achieve remission in subsequent episodes, often at the same dose but patient preference, often based on side effects, is important!!!
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