Page 313 - TNFlipTest

Toronto Notes 2019 Common Presenting Problems
• allergyskintesting
■ for patients with chronic rhinitis whose symptoms are not controlled by conservative and
pharmacological therapy
■ may identify allergens to include in immunotherapy treatment
• immunotherapy(allergyshots)
■ reserved for severe cases unresponsive to pharmacologic agents
■ consists of periodic (usually weekly) subcutaneous injections of custom prepared solutions of one or
more antigens to which the patient is allergic
Amenorrhea
• seeGynecology,GY7
Anxiety
• seePsychiatry,PS36
Epidemiology
• 25-30%ofpatientsinprimarycaresettingshavepsychiatricdisorders
• manyareundiagnosedoruntreated;hencetheneedforgoodscreening • highrateofcoexistenceofanxietydisordersanddepression
Screening
• screeningtoolssuchastheGeneralizedAnxietyDisorder7-item(GAD-7)tool • screeningquestions
■ Do you tend to be an anxious or nervous person?
■ Have you felt unusually worried about things recently? ■ Has this worrying affected your life? How?
Assessment
• associatedsymptoms
• riskfactors:pasthistoryofanxiety,stressfullifeevent,trauma,socialisolation,female,comorbid
Family Medicine FM15
psychiatric diagnosis (e.g. depression), family history of anxiety or depression
• assesssubstanceabuse,suicidalideation/self-harm
• todifferentiateanxietydisorders,considersymptomsandtheirduration
• usetheGAD-7tooltoassessandmonitorlevelsofanxiety
Symptoms of GAD
ANDICREST
Anxious, nervous, or worried No control over the worry Duration >6 mo
Irritability
Concentration impairment Restlessness
Energy decreased
Sleep impairment
Tension in muscles
Can Fam Physician 2005;51:1340-42
Differential Diagnosis of Anxiety Disorders
• Panic disorder
• GAD
• Social Anxiety Disorder (previously Social
Phobia)
• Agoraphobia
• Specific phobia
• Selective Mutism
• Separation Anxiety Disorder
• Other: GMC, AMC, mood disorder,
psychotic disorder, OCD, PTSD
Rule Out
• Cardiac (post MI, arrhythmias)
• Endocrine (hyperthyroidism, diabetes,
pheochromocytoma)
• Respiratory (asthma, COPD)
• Somatoformdisorders
• Psychotic disorders
• Mood disorders (depression, bipolar) • Personality disorder (OCPD)
• Drugs (amphetamines, thyroid
preparations, caffeine, OTC for colds/ decongestants, alcohol/benzodiazepine withdrawal)
In the form of panic with physical (autonomic) symptoms?
Do the panic attacks come ...
Symptoms of Anxiety
Are the symptoms predominantly ...
Secondary to a specific experienced trauma?
Recurrent anxious thoughts?
Excessive worry and apprehension about common concerns
<1 month?
ACUTE STRESS REACTION
Setting where it may be difficult to escape
>1 month?
PTSD
<6 months +stressor
ADJUSTMENT DISORDER
No
With a specific situation
Is patient avoiding situation?
Yes
Specific trigger (e.g. flying, spiders, blood, etc.)
SPECIFIC PHOBIA
“Out of the blue”
Patient afraid of another attack and its implications
PANIC DISORDER
Yes
>6 months
GAD
No
No
Are the thoughts intrusive, inappropriate and distressing?
Are they accompanied by a repetitive behaviour meant to neutralize the anxiety?
Yes
OCD
Excessive worry and apprehension about social situations?
Public setting where there might be negative evaluation
SOCIAL PHOBIA
PANIC DISORDER WITH AGORAPHOBIA
Figure 7. Differentiating anxiety disorders
Adapted from: Evans M, Bradwejn J, Dunn L. Anxiety Review Panel. Guidelines for the treatment of anxiety disorders in primary care. Toronto: Queen’s Printer of Ontario, 2000.41