Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2749_Библиотеки_им_академика_М_И_Перельмана
.pdf
l
https://t.me/med1917
What is the plan?
l
Do you have the means to carry it out?
l
What would cause you to carry out your plan or keep
you from carrying it out?
l
Have you ever attempted suicide in the past?
Initial Questions
The rst set of questions helps determine whether the
patient is at risk. Patients rarely volunteer thoughts of
suicide, so it is important to ask directly. There is no
evidence to suggest that asking about suicide precipitates suicidal thinking or acts.
Follow-Up Questions
The second set of questions helps you evaluate how
imminent the risk is. Patients at high risk for suicide
should be referred for psychiatric evaluation; those at
imminent risk should be admitted for evaluation and
treatment. Major risk factors for suicide include hopelessness, substance abuse, and prior suicide attempts.
How do I evaluate for a diagnosable psychological
disorder?
All positive screening tests for mental health disorders
require a full diagnostic follow-up interview using
standard diagnostic criteria, such as those from the
Diagnostic and Statistical Manual of Mental Disorders, ed 5, (DSM-5), to determine the presence or
absence of specic disorders. The manual describes
specic symptom criteria for mental disorders and
psychosocial problems. Although primary care providers often diagnose and treat patients with symptoms of depression and anxiety, serious impairment of
mental or emotional functioning, psychoses, bipolar
disorder, and substance abuse disorders require evaluation, diagnosis, and treatment by qualied mental
health specialists. Primary care is not a substitute for
psychiatric care. When a patient has been screened
and is suspected to be at high risk for a condition, the
primary care practitioner has a responsibility to refer
the patient to an appropriate resource. See the differential diagnosis table at the end of this chapter for the
diagnostic criteria for some common psychological
disorders.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
Physical examination can yield little additional data
that are of diagnostic value. No physical nding is
Chapter 4 • Affective Changes
39
specic for any psychological disorder. The physical
examination should be directed at identifying organicbased conditions that mimic psychological disorders.
Perform a comprehensive and thorough physical examination, if the patient has not had one since the
onset of symptoms. This chapter presumes that you
have performed the physical evaluation for specic
presenting symptoms as part of your process to rule
out a physiological cause.
Assess Vital Signs
When substance abuse is suspected, vital signs can
quickly conrm the presence of an organic condition
related to substance intoxication or withdrawal. Abnormal values for body temperature, blood pressure, heart
rate, or respiratory rate indicate a need for a thorough
evaluation.
Observe General Appearance
Look for signs of depression or substance abuse, such
as an unkempt personal appearance, unusual dress, and
general state of poor nutrition (skin condition and appearance of hair and nails). Observe the patient’s demeanor and appearance for signs of neglect or a facial
expression that might indicate depression. Observe for
such behaviors as nger tapping and pacing that indicate anxiety. Methamphetamine users will often have
self-induced facial lesions secondary to scratching.
Adolescents who are abusing substances sometimes
wear clothing or jewelry that displays drug-oriented
grafti.
Observe the infant or child’s engagement. Children
with autism may make few, if any attempts, to contact
socially with others, prefer to be alone, and ignore attempts to seek attention, affection, or a connection with
their surroundings.
Observe Mental Status
Perform a mental status examination. Assess general
behavior. Irritability can occur in patients with anxiety.
Note body posture, movement, and facial expressions.
Assess for suicidal or delusional thought content,
which can occur with substance abuse or psychotic
disorders. Determine affect for emotional range (broad
or restricted), intensity (blunted, at, or normal), stability, and congruence with the patient’s stated mood.
Evaluate the patient’s cognitive abilities, including
attention, concentration, and memory. A number of
assessment instruments are available, including the Mini
Mental State Examination (MMSE) (see Chapter 9,
Figure 9-1 for sample items from the MMSE).
40
https://t.me/med1917
Chapter 4 • Affective Changes
Note Speech and Thought Process
Speech tone, quality, and rate reect mental status. In
depression, the speech can be soft and monotonous
with little spontaneity. In mania, the speech can be
rapid, pressured, and loud, and the speech content consists of a ight of ideas.
Language delay that is not consistent with development should be noted. In some children with autism,
language begins to regress instead of increase in skill
level.
Examine the Eyes
Substance abusers can have eyes that are injected,
jaundiced, puffy, or glassy. Pupils may be dilated or
constricted. The patient may have droopy eyelids and a
sleepy appearance, or a xed stare. The patient may
have difculty controlling eye movements.
Examine the Ears, Nose, and Mouth
The ears should be examined. If language delay is suspected, hearing loss or deafness should be ruled out.
Substance abusers may have chronic rhinorrhea,
frequent nosebleeds, lesions in the nose or around the
nostrils, or a perforated nasal septum. The patient may
have dry lips, halitosis, or an odor of alcohol, marijuana, or tobacco.
Examine the Skin
Look for skin lesions that reect depression or anxiety,
such as neurogenic scratching, nail biting, and hair
pulling. Look for evidence of attempted self-injury or
suicide. Adolescents may show evidence of cutting
scars, or supercial cuts on areas of the body. Although
typically not suicide attempts, cutting serves as a coping mechanism for unrelieved feelings.
In substance abusers, the skin may be cold and
clammy, itching and burning, tight, swollen, or puffy.
The person may perspire excessively, have discolored
ngers, or injection marks along the veins. Tattoos or
burn marks, possibly done while under the inuence of
drugs or alcohol, can disguise injection marks. The patient may have injuries or bruises from falling or ghting.
Assess Balance and Gait
The patient who has a substance abuse problem may
have a slow gait or poor balance.
LABORATORY AND DIAGNOSTIC STUDIES
There are no laboratory tests to assist in the diagnosis
of most psychological conditions. Base the laboratory
and diagnostic studies on the presenting reports (see
specic chapters).
Commonly performed tests to help identify under-
lying conditions include the following:
Complete Blood Count With Indices
and Differential
The complete blood count (CBC) will provide information about the presence of infection or anemia.
Serum Electrolytes
Symptoms of depression can be exacerbated by hyponatremia, hypernatremia, hypercalcemia, and hyperphosphatemia.
Thyroid Function Tests
An elevated level of thyroid-stimulating hormone
(TSH) is related to chronic symptoms of depression. A
hyperthyroid state can be associated with anxiety.
Toxicology Screen and Blood Alcohol Level
Urine and blood screening tests can be used to determine alcohol or drug intoxication as a cause of psychological symptoms.
Serum B12 and Folate
Deciencies of vitamin B12 and folate are reversible
causes of dementia in older adults.
DIFFERENTIAL DIAGNOSIS
Normal Stress
Stress is the nonspecic response of the body to any
demand. The perception of a demand as stressful depends on the individual’s experience of how much demand for adaptation an event or situation requires.
Stressors can be acute or chronic. External stressors
include adverse physical conditions (such as pain) or
stressful psychological environments (such as poor
working conditions, abusive relationships, or major
life events). Internal stressors can be physical (such
as infections or inammation), or psychological (such
as worry). Daily hassles or situational factors inuence
the stress load, because minor annoyances that happen
daily can accumulate. Situational factors can exacerbate a depressive disorder in signicant ways. Symptoms of stress include mental, physical, and behavioral
symptoms. Common physical symptoms include responses of the autonomic nervous system and musculoskeletal system.
Chapter 4 • Affective Changes
https://t.me/med1917
41
Normal Grief
Grief is a subjective feeling precipitated by the loss of
someone or something important to the individual. Nor-
mal grief is a process of emotional upheaval, distress,
and eventual resolution. Individuals who are grieving
often experience both physical and psychological
symptoms, and can have difculty functioning. Grief
and depression share many of the same characteristics,
and normal grief can become clinical depression. An
individual with a history of depression is at risk of
becoming depressed in times of signicant loss. The
mood disturbance in depression is typically pervasive
and unrelenting. In normal grief, uctuations in mood
are common. Although the pain of grief is intense, the
individual is able to experience moments of less inten-
sity or even happiness.
Domestic/Partner Violence
Domestic/partner violence is a pattern of assaultive and
coercive behaviors that include physical, sexual, psy-
chological, and economic attacks by adults or adoles-
cents against their intimate partners. Individuals who
have experienced abuse could present with an injury that
is not consistent with the description of how the injury
occurred. The individual may be seen frequently for
undiagnosed psychosomatic concerns. This patient can
appear depressed or show evidence of suicide attempts.
Substance Use Disorders
Substance use disorders are divided into two groups:
substance abuse and substance dependence. The catego-
ries of substances included are alcohol, amphetamines,
cannabis, cocaine, hallucinogens, inhalants, opioids,
phencyclidines, sedatives, and hypnotics. Substance
abuse occurs when repeated use of alcohol or other
drugs leads to signicant impairment in functioning and
relationships, but does not include compulsive use, ad-
diction or withdrawal symptoms when stopping the
substance. Substance dependence includes a history of
substance abuse plus continued use despite related prob-
lems, an increase in substance tolerance, and withdrawal
symptoms if the substance use is stopped.
Autism Spectrum Disorder
Autism spectrum disorder is a difcult disorder to
diagnose because there are no laboratory tests and
the clinical signs can be subtle. Infants under the age
of 18 months are very difcult to diagnose. Noting a
lack of social interaction can be the rst sign. At
18 months of age the Modied Checklist for Autism
in Toddlers (M-CHAT-R/F) has been shown to be
useful in screening for autism spectrum disorders.
Box 4-8 describes the checklist. After age 3 years the
Autism Diagnostic Observation Schedule is more
useful. Generally children with autism spectrum disorder exhibit mild to severe decits in social interaction,
verbal and nonverbal communication, and have repetitive behaviors or interests. Box 4-9 describes a
screening checklist for toddlers.
Box 4-8
Modied Checklist of Autism in
Toddlers, Revised, With Follow-Up
(M-CHAT-R/F)
The M-CHAT-R/F is validated for screening toddlers between
16 and 30 months of age, to assess risk for autism spectrum disorders. The 20-item instrument can be scored in
less than 2 minutes. Designed to maximize sensitivity, the
false positive rate is high, so a structured follow-up interview is available. Children who score in the moderate risk
range (3 to 7 at-risk responses) need to be adminstered
the relevant Follow-Up items. Children whose Follow-Up
score is 2 or more, or whose initial M-CHAT-R score is 8 or
more should be referred for diagnostic evaluation and early
intervention. The instrument and scoring instructions are
available for download from www.mchatscreen.com.
From Robins D, Fein D, Barton M: Modified checklist for autism in
toddlers, 1999 to Modified Checklist for Autism in Toddlers, Revised,
with Follow-Up, 2009.
Box 4-9
The Five Key Items on the CHAT
Screen
ASK THE PARENT
1. Does your child ever pretend (e.g., to make a cup of tea
using a toy cup and teapot) or pretend with other things?
2. Does your child ever use an index finger to point, to indicate interest in something?
HEALTH PRACTITIONER OBSERVATION
1. Gain the child’s attention, then point across the room at
an interesting object and say “Oh look! There’s a (name
of toy)!” Watch the child’s face. Does the child look
across to see what you are pointing at?
2. Gain the child’s attention, then give child a toy cup and
teapot and say “Can you make me a cup of tea?” Does
the child pretend to pour out tea, drink it, etc.?
3. Say to the child “Where’s the light?” or “Show me the
light.” Does the child point with an index finger at
the light? To record “yes” on this item, the child must
have looked up at your face around the time of pointing.
Reprinted with permission from Baird G, Charman T, Cox A, et al:
Current topic: Screening and surveillance for autism and pervasive and
developmental disorders. Arch Dis 84:471, 2001.
CHAT, Checklist for autism in toddlers.
42
https://t.me/med1917
Chapter 4 • Affective Changes
Adjustment Disorders
There are several adjustment disorder diagnoses. All of
the disorders in this category relate to a signicantly
more difcult adjustment to a life situation than would
normally be expected, considering the circumstances.
The condition is acute if the disturbance lasts less than
6 months, and chronic if it lasts for 6 months or longer
in response to a chronic stressor or one that has enduring consequences.
The disorders in this category can present themselves quite differently. The key to diagnosis is to examine the issue that is causing the adjustment disorder
and to determine the primary symptoms associated
with the disorder (e.g., anxiety or depression).
Anxiety Disorders
There are several types of anxiety disorders and multiple diagnoses. An anxiety disorder should not be
confused with everyday stress and worry. Anxiety disorders are persistent conditions that require careful
diagnosis. Anxiety is a group of disorders characterized by a number of both mental and physical symptoms, with no apparent explanation. The primary
feature is abnormal or inappropriate anxiety. Apprehension, fear of losing control, fear of going “crazy,”
fear of impending danger or death, and uneasiness are
among the most common psychological symptoms.
Common physical symptoms include dizziness, lightheadedness, chest/abdominal pain, nausea, increased
heart rate, and diarrhea.
Generalized Anxiety Disorder
Chronic anxiety, also referred to as generalized anxiety
disorder, manifests as persistent worries, fears, and
negative thoughts lasting a minimum of 6 months.
Excessive worry over daily activities and a tendency
toward headache and nausea are seen. Typically, generalized anxiety disorder (GAD) develops over a period of time and is not noticed until it is signicant
enough to cause problems with functioning. Anxiety
is persistent, pervasive, and occurs in many different
settings.
Panic Disorder
Panic disorder is manifested by sudden attacks of fear
accompanied by symptoms that resemble a heart attack
(e.g., palpitations, chest pain, dizziness). Often the
symptoms develop rapidly and without an identiable
stressor. The individual could have had periods of high
anxiety in the past, or could have been involved in a
recent stressful situation; however, the underlying
cause is typically subtle. Panic attacks subside as abruptly
as they begin, typically lasting a few minutes, although
they can last several hours. The patient could have
thoughts of impending disaster, which can lead to repeated emergency medical presentations. The frequency
of these attacks can vary from several times a day to
only once or twice a year.
Social Phobia (Social Anxiety Disorder)
Symptoms include extreme anxiety and fear associated with social or performance situations in which
the patient is exposed to unfamiliar people or to scrutiny. The patient recognizes that the fear is excessive
or unreasonable, but avoids the social or performance
situations, or endures them with intense distress or
anxiety.
Mood Disorders
Mood disorders contain several categories, including
dysthymia, depression, and bipolar disorder.
The disorders in this category include those in
which the primary symptom is a disturbance in mood
with inappropriate, exaggerated, or a limited range of
affect. The feelings are extreme, pervasive, and unrelenting.
Dysthymia
The patient experiences feelings that are less intense
than major depression, but that still disrupt everyday
life. The patient experiences a depressed mood for
most of the day, for more days than not, for a minimum
of 2 years. During this time, there must be two or more
of the following symptoms: undereating or overeating,
sleep difculties, fatigue, low self-esteem, difculty
with concentration or decision making, and feelings of
hopelessness.
Major Depressive Disorder
The hallmark symptom of depression is either a depressed mood or a loss of interest or pleasure in usual
activities. Major depression can signicantly impair a
person’s ability to function in family, work, and social
situations. Patients with depression experience deep,
unshakeable sadness and diminished interest in nearly
all activities. Crying and feeling depressed or suicidal
occur frequently.
Bipolar Disorder
Bipolar disorder has two types. Bipolar I disorder requires the occurrence of at least one manic episode
even though other episodes, such as major depressive,
Chapter 4 • Affective Changes
https://t.me/med1917
43
hypomanic, or mixed, could have occurred. Bipolar II
disorder requires at least one hypomanic episode.
Mania is sometimes referred to as the other extreme of
depression. The patient experiences an elevated, expansive, or irritable mood with behaviors and symptoms that
reect a “high.” The symptoms are sufcient to interfere
with usual social activities and relationships with others.
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Psychological Disorders
In bipolar II disorder, there are periods of highs, as
described previously, often followed by periods of
depression. The high episodes are hypomanic rather
than manic. The symptoms are similar but are not severe enough to cause marked impairment in social or
occupational functioning and typically do not require
hospitalization to ensure the safety of the person.
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Normal
stress
Normal
grief
Domestic or
partner
violence
Substance
use
disorders*
Perceived stress related to external or
internal stressors, such as daily life
events or situations, psychological
environments, relationships
Can be acute or chronic
Can feel unable to cope or adapt
Can have mental, physical, and
behavioral symptoms
Loss of someone or something of
importance
Can have physical and psychological
symptoms
Mood fluctuations; feels depressed
Can have difficulty functioning
Reports physical, sexual, psychological,
emotional, or economic attacks from
family or partners
Could seek care frequently for
undiagnosed psychosomatic concerns
Could report suicide attempts
Reports recurrent substance use that
results in failure to fulfill major obli-
gations at work, school, or home and
substance-related legal problems
Use in situations that are physically
hazardous (e.g., driving while
intoxicated)
Continued use despite significant social
or interpersonal problems caused
or exacerbated by effects of the
substance
Report increased tolerance of and need
for increased amounts of substance
Report withdrawal symptoms
Report unsuccessful efforts to cut down
or control substance use
Could appear unkempt, with unusual
dress
Could have depressed demeanor
Facial expression (e.g., dejected, sad,
downcast)
Tearing, crying
Adolescents could show evidence of
cutting
May appear unkempt, with unusual
dress, general state of poor nutrition
Depressed demeanor
Facial expression (e.g., dejected, sad,
downcast)
Tearing, crying
Speech could be soft and monotonous
with little spontaneity
Adolescents can show evidence of cutting
Can have injuries inconsistent with
history
Adolescents can show evidence of
cutting
Skin can be cold and clammy, itching
and burning, tight, swollen, or puffy
Excess perspiration
Discolored fingers or injection marks
along the veins
Tattoos or burn marks, injuries or bruises
Methamphetamine users can have
self-induced facial lesions secondary
to scratching
Eyes can be injected, jaundiced, puffy,
or glassy
Pupils can be dilated or constricted
Eyelids can be droopy with sleepy
appearance or fixed stare
Can have difficulty controlling eye
movements
Can have chronic rhinorrhea, lesions in
the nose or around the nostrils, perfo-
rated nasal septum
Can have dry lips, halitosis, or an odor
of alcohol, marijuana, or tobacco
None
None
None
Toxicology screen
Blood alcohol level
Continued
44
https://t.me/med1917
Chapter 4 • Affective Changes
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Psychological Disorders—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Autism
spectrum
disorder*
Adjustment
disorder*
ANXIETY DISORDERS
Generalized
anxiety
disorder*
Panic
disorder*
Social
phobia
(social
anxiety
disorder)*
Lack of language developmental mile-
stones; could lose language skills;
social interaction lacking
The development of emotional or behav-
ioral symptoms in response to an identifiable stressor(s) occurring within 3 mo
of the onset of the stressor(s)
Distress that is in excess of what would be
expected from exposure to the stressor
Significant impairment in social or
occupational (academic) functioning
Excessive anxiety and worry for most
days of past 6 mo, about a number of
events or activities (such as work or
school performance)
Difficult to control the worry
Associated physical symptoms, such
as restlessness, edginess, fatigue, dif-
ficulty concentrating, irritability, sleep
disturbance, social, occupational, or
other areas of functioning
Recurrent unexpected panic attacks:
discrete period of intense fear or dis-
comfort with physical symptoms, such
as palpitations, pounding heart, or
accelerated heart rate, sweating, trem-
bling or shaking, sensations of short-
ness of breath or smothering, feeling
of choking, chest pain or discomfort,
nausea or abdominal distress, feeling
dizzy, unsteady, lightheaded, or faint,
paresthesias, chills or hot flushes
Report fear of losing control or going
crazy, fear of dying
Persistent concern about having
additional attacks
Marked and persistent fear of one or
more social or performance situations
Anxious about acting in a way that will
be humiliating or embarrassing
Report panic attack related to exposure
to the situation
Avoids the situation
Avoidance, anxiety, and distress interferes
significantly with the person’s normal
routine, occupational (academic)
functioning, or social activities or
relationships
Lack of eye contact, might not smile,
does not respond to name with
hearing intact
None Refer for psycho-
Behaviors such as finger tapping and
pacing that indicate anxiety
Restlessness, edginess, difficulty
concentrating
Adolescents could show evidence of
cutting
None except during attack Refer for psycho-
None Refer for psycho-
M-CHAT screening
at age 18 mo
CHAT screening for
toddlers
Refer for develop-
mental and cognitive evaluation
logical evaluation
Refer for psycho-
logical evaluation
logical evaluation
logical evaluation
Chapter 4 • Affective Changes
https://t.me/med1917
45
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Psychological Disorders—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
MOOD DISORDERS
Dysthymic
disorder*
Major
depressive
disorder*
Bipolar
disorder*
CBC, Complete blood cell count; CHAT, Checklist for autism in toddlers. M-CHAT, Modified checklist for autism in toddlers.
*For specific diagnostic criteria, see Diagnostic and statistical manual of mental disorders, ed. 5, Arlington, Va., 2013, American Psychiatric
Association.
Depressed mood for most of the day, for
more days than not, for at least 2 yr
Reports symptoms of depression such as
appetite and sleep disturbance, low
energy or fatigue, low self-esteem,
poor concentration or difficulty
making decisions, feelings of
hopelessness
Reports acute symptoms of depressed
mood most of the day, nearly every
day, or loss of interest or pleasure in
all or almost all activities of the day,
nearly every day
Experiences other symptoms most every
day such as appetite disturbance,
sleep disturbance, psychomotor agitation or retardation, fatigue or loss of
energy, feelings of worthlessness or
excessive or inappropriate guilt,
diminished ability to think or concentrate, recurrent thoughts of death or
suicide
History of at least one manic episode or
hypomanic episode
A distinct period of abnormally and
persistently elevated, expansive,
or irritable mood, lasting at least
1 wk
Accompanying symptoms of inflated
self-esteem or grandiosity, decreased
need for sleep, more talkative than
usual or pressure to keep talking,
insomnia or hypersomnia nearly
every day, psychomotor agitation or
retardation, flight of ideas or racing
thoughts, easy distractibility, increase
in goal-directed activity, excessive
involvement in pleasurable activities
that have a high potential for painful
consequences
Report history of one or more major
depressive episodes (see above)
Can appear unkempt, with unusual
dress; general state of poor nutrition
Depressed demeanor
Facial expression (e.g., dejected, sad,
downcast)
Tearing, crying
Speech can be soft and monotonous
with little spontaneity
Adolescents could show evidence of
cutting
Can appear unkempt, with unusual
dress; general state of poor nutrition
Depressed demeanor
Facial expression (e.g., dejected, sad,
downcast)
Tearing, crying
Speech can be soft and monotonous
with little spontaneity
Adolescents could show evidence of
cutting
In mania, the speech can be rapid,
pressured, and loud, and the speech
content consists of a flight of ideas
Refer for psycho-
logical evaluation
Serum electrolytes
CBC
Thyroid function
tests
Refer for psycho-
logical evaluation
Refer for psycho-
logical evaluation
46
https://t.me/med1917
Chapter 4 • Affective Changes
References and Readings
American Geriatrics Society 2012 Beers Criteria Update Expert
Panel: American Geriatrics Society updated Beers Criteria for
potentially inappropriate medication use in older adults, J Am
Geriatr Soc 60:616–631, 2012.
American Psychiatric Association: Diagnostic and statistical man-
ual of mental disorders, ed. 5, Arlington, Va., 2013, American
Psychiatric Association.
Baird G, Charman T, Cox A, et al: Current topic: Screening and sur-
veillance for autism and pervasive and developmental disorders, Arch
Dis Child 84:471, 2001.
Butler R, Carney S, Cipriani A, et al: Depressive disorders, Am Fam
Physician 73:1999, 2006.
Citrome L, Goldberg JF: The many faces of bipolar disorder: How to
tell them apart, Postgrad Med 117:15, 2005.
Dosreis S, Weiner CL, Johnson L, Newshaffer CJ: Autism spectrum
disorder screening and management practices among general
pediatric providers, J Dev Behav Pediatr 27:88, 2006.
Feldhaus KM, Koziol-McLain J, Amsbury HL: Accuracy of three
brief screening questions for detecting partner violence in the
emergency department, JAMA 277:1357, 1997.
Goolsby MJ, Grubbs L: Advanced assessment: interpreting ndings and for-
mulating differential diagnoses, ed. 2, Philadelphia, 2011, FA Davis.
House A, Stark D: Anxiety in medical patients, BMJ 325:207, 2002.
Johnson CP: Recognition of autism before age 2 years, Pediatr Rev
29:86, 2008.
Knight JR, Shrier L, Bravender T, et al: New brief screen for adoles-
cent substance abuse, Arch Pediatr Adolesc Med 153591, 1999.
Lieberman JA III: BATHE: An approach to the interview process in
the primary care setting, J Clin Psychiatry 58:3, 1997.
Mersy DJ: Recognition of alcohol and substance abuse, Am Fam
Physician 67:1529, 2003.
Snyderman D, Rovner BW: Mental status examination in primary
care: a review, Am Fam Physician 80:809, 2009.
Stein M: Attending to anxiety disorders in primary care, J Clin
Psychiatry 64:35, 2003.
Whooley MA, Avins AL, Miranda J, Browner WS: Case-nding
instruments for depression: Two questions are as good as many,
J Gen Intern Med 12:439, 1997.
Williams JW Jr, Noel PH, Cordes JA, et al: Rational clinical
examination. Is this patient clinically depressed? JAMA
287:1160, 2002.
Williams JW Jr, Steffens D: Update: Depression. In DL Simel, R
Drummond (eds.): The rational clinical examination: Evidence-
based clinical diagnosis, New York, 2009, McGraw Hill.
CHAPTER
https://t.me/med1917
5
menorrhea is a lack of menstruation that can be the
A
result of primary or secondary causes. Primary
amenorrhea is dened as the absence of menarche by age
16 years with normal pubertal growth and development,
the absence of menarche by age 14 years with lack of
normal pubertal growth and development, or the absence
of menarche 2 years after sexual maturation is complete.
Primary amenorrhea is a rare condition, with constitutional puberty delay the most common cause. One-third
of primary amenorrhea cases are genetic in nature, such
as Turner syndrome or abnormality of the X chromosome.
Secondary amenorrhea is dened as the absence of
menstruation for at least three cycles in women
with established normal menstruation, or 9 months in
females with previous oligomenorrhea (menstrual periods occurring at intervals of greater than 35 days, with
only four to nine periods in a year). The most common
causes of secondary amenorrhea are the physiological
events of pregnancy, lactation, and menopause.
The production of menstrual ow requires an intact
outow tract, a hormonally responsive uterus, and an
integrated hypothalamic-pituitary-ovarian (HPO) axis.
An important task in the diagnostic evaluation of amenorrhea is to identify the malfunctioning element. Begin
with investigation of etiological reasons for amenorrhea
and use that knowledge to determine the type of amenorrhea. In turn, the suspected cause guides diagnostic tests,
treatment, and referrals. This method of classication
directs you to evaluate constitutional causes, congenital
or chronic disorders, the lower genital tract, and then
dysfunction of any component of the HPO axis.
The normal menstrual cycle begins with the pulsatile
delivery of gonadotropin-releasing hormone (GnRH)
by the medial basal hypothalamus. In response, the
posterior pituitary releases luteinizing hormone (LH)
and follicle-stimulating hormone (FSH). These inuence the growth and development of a follicle and its
release of estradiol, which causes the uterine endometrium to proliferate and initiates the LH surge, which is
followed by ovulation and menstruation (Figure 5-1
and Table 5-1).
Amenorrhea
The hypothalamus is also affected by the central
nervous system (CNS) and the thyroid gland, factors
which can determine the amount of GnRH received by
the pituitary. Alterations in the pattern of GnRH pulsatile release decreases circulating LH and FSH levels;
the consequence is an anovulatory menstrual cycle and
amenorrhea.
About 66% of all amenorrheic women are hypoestrogenic because of either hypothalamic-pituitary hypofunction or end-organ failure. Determining whether
the patient is hypoestrogenic can expedite nding the
reason for her amenorrhea and setting the sequencing
of laboratory tests. The progesterone challenge test
(PCT) causes withdrawal bleeding if there is estrogen
production and an adequate outow tract. The functional status of the pituitary-ovarian unit is assessed by
measuring the gonadotropins (LH and FSH).
DIAGNOSTIC REASONING: FOCUSED
HISTORY
Is there a pregnancy?
Key Questions
l
Are you sexually active?
l
Are you using any birth control methods?
l
Are you trying to become pregnant?
Pregnancy
For any female with a uterus, it is important to rule out
pregnancy as the rst step in determining the cause of
amenorrhea. It is rare, but a young girl can become
pregnant before the onset of menses. Pregnancy should
be ruled out before the administration of androgenic
challenge tests. If the woman is pregnant and there is
accompanying bleeding, determination of whether the
pregnancy is uterine or ectopic is the next priority (see
Chapter 36). Be cognizant of domestic violence and
sexual abuse, with consequent unintended pregnancy.
Ask direct questions in private about being hit, pushed,
or slapped, or about having nonconsensual sex.
47
48
https://t.me/med1917
Chapter 5 • Amenorrhea
Pituitary
gland
Anterior
Hypothalamus
GnRH
Posterior
HYPOTHALAMICPITUITARY
CYCLE
Follicle-stimulating hormone (FSH)
Follicular phase
LH
FSH
Primary
follicle
Estrogen
Estrogen
Progesterone
Menstruation
Proliferative
phase
Luteinizing hormone (LH)
Luteal phase
Ovulation
Egg
Corpus luteumGraafian follicle
Progesterone Some
Secretory
phase
estrogen
Ischemic
phase
Pituitary
hormones
OVARIAN
CYCLE
Degenerating
corpus luteum
Ovarian
hormones
Menstruation
Functional
layer
Basal layer
Day
FIGURE 5-1 Interrelationships among cerebral hypothalamic, pituitary, ovarian, and uterine functions
throughout the menstrual cycle. (From Lowdermilk DL, Perry SE, Cashion MC, Alden K: Maternity &
women’s health care, ed. 10, St Louis, 2012, Mosby.)
Contraceptive Use
The type and use patterns of contraceptives are important in the search for the cause of amenorrhea.
Contraceptive failures can account for an unintended
pregnancy. Amenorrhea can occur after discontinuation of oral contraceptives. Measurement of serum
gonadotropins is affected by long-acting contraceptives, such as medroxyprogesterone acetate (DMPA)
1 5 10 281 5
14
(Depo-Provera), implants, or intrauterine devices
(IUDs) containing progestagens; these must be discontinued before testing.
Seeking Pregnancy
Knowing that the patient is seeking pregnancy, or if the
patient is pregnant, whether it is intended or unintended,
allows the interview to be structured appropriately.
ENDOMETRIAL
CYCLE
Соседние файлы в папке Библиотека им академика М.И. Перельмана