Test Answers on EMMA Holliday – psychiatry – Flashcards
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Prevalence in society of schizophrenia
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1%
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Risk of Twin for schizoprenia -- Risk of sibling --
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twin- 50% sibling- 10%
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Positive symptoms for schizophrenia
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too much dopamine in the mesolimbic tract
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Negative symptoms from where in the brain and why
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not enough dopamine in the mesocortical tract
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A patient has delusions hallucination and flattened affect for 3 weeks
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Brief psychotic disorder ( MORE THEN A WEEK AND LESS THEN A MONTH)
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A patient has delusions hallucination and flattened affect for > 1 mon and < 6 mons
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schizopreniform disorder
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Typical antipsychotics help what symptoms in schizophrenia
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they help the positive symptoms but have no effect on the progression
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When trying to determine the difference between schizoaffective disorder and depression with psychotic feautres how do you do it <
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What was present first with out the other... in schizoaffective they will have had psychosis with out any depressive symptoms
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A patient has had MDD for 3 years and reports hearing voices telling him he is worthless and to kill himself.
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MDD with Psychotic Features.Delusions are typically mood congruent.* Tx w/ Atypical antipsychotic + SSRI or ECT (esp in preggos)
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A patient has had persecutory delusions for the past 3 years ( has be diagnosised with schizoprenia before) . 6 months ago he started having sadness, guilt, insomnia, ?concentration, SI
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Schizoaffective Disorder.(delusions/hallucinations for >2wks in absence of mood ss)*Tx w/ Atypical antipsychotics + SSRI if depression and + Li if manic
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A man is convinced Miley Cyrus is in love with him but is otherwise functional.
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Delusional Disorder. *Erotomanic* type. *Non-bizzare*.Tx w/ therapeutic relationship + meds
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DOC for acute agitation or psychosis
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*IM* haloperidol. Quick onset of action Blocks ( antagonist) the d2 dopamine receptor
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Haloperidol affects on the nigrostriatal path and affects on the tubularinfundibulum
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Nigrostrial - causes EPS Tubularinfundubulum - Hyperprolactinemia
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Low potency antipsycotics: (*C*heating *T*hieves are low)
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Chlorpromazine and Thioridazine. Less EPS more anti-Ach —non-neurologic side effects (anticholinergic, antihistamine, and ?1-blockade effects).
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Side effects of Chlorpromazine
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Corneal deposits
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Side effects of Thioridazine
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reTinal deposits
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Side effects of haloperidol
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NMS, tardive dyskinesia.
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Neuroleptic malignant syndrome (NMS)—
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rigidity, myoglobinuria, autonomic instability, hyperpyrexia. Treatment: dantrolene, D2 agonists (e.g., bromocriptine).
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Mneumonic for Neuroleptic syndrom *FEVER *
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*F*ever *E*ncephalopathy *V*itals unstable *E*nzymes elevated *R*igidity of muscles
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High potency Antiphyscotics : (Try to Fly High)—
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: Trifluoperazine, Fluphenazine, Haloperidol —neurologic side effects (EPS symptoms).
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If patient has a history of medication non-adherence
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need to give an injection to ensure compliance- Fluphenazine or haldol aka decanoate forms ever 2-4wks.
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Purple grey metallic rash over sun-exposed areas and jaundice?
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Chlorpromazine
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Prolonged *QTc* and pigmentary retinopathy?
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Thioridazine - prolonged QTC- can lead to torsades
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Pt wakes up with eyes "stuck" looking up or head "stuck" turned to the side.
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*Acute Dystonia*. (<12hrs). Tx w/ benztropine or diphenhydramine
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Pt reports feeling like they *"always have to move".*
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Akathesia. (30-90 days). Tx w/ propranolol (1stline) or benzo
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Coarse resting tremor, masked facies, unsteady gait, bradykinesia what is it and what is the treatment
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Parkinsonism. (>6mo) Tx w/ benztropine/diphenhydramine, amantidine or bromocriptine. *NOT L-dopa!!*
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After 10 years on fluphenazine, tongue movements and grimacing.
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Tardive Dyskinesia. (>years)Tx by stopping antipsychotic and switching to and atypical or clozapine.
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W/in hours of a haloperidol injections, pthas ?CPK, T = 103F, rigidity, autonomic instability, and delirium
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Neuroleptic Malignant Syndrome. 1st-d/c the offending med. 2nd-cooling blankets and dantroline Na or bromocriptine (2ndline). Remember that metoclopramide, compazine and droperidol can cause.
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Weight neutral but prolongs the QTc?
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Ziprazodone.
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Weight neutral but increases akathesia?
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Aripiprazole.
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Atypical agent w/ highest risk for EPS and ?prolactin
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Risperidone. But comes in depo shot
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Most assoc w/ weight gain? (but #1 S/E is sedation.)
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Olazepine
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Causes orthostasis and cataracts?
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Quetiapine (alpha blocking properties)
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Good for tx-refractory schizophrenia?
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Clozapine
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Most Common S/E- Clozapine
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Sedation, weight gain, ?blood sugar and lipids
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Most Danagerous S/E- Clozapine
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Agranulocytosis, decreased seizure threshold.
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What do you monitor and for how long with clozapine
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CBC --> ANC q week for 6mo and x2wks for next 6mo. D/c if WBCs<3000 or ANC<1500
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What the most important 1st question to ask the patient
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Sucisidal ideation - because this is the most likely to kill the patient
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RF for Suicidal ideation
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#1 - prior attempt > 45 white male with a serious illness a detailed plan, no support decreased support use of ETOH and drugs
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polysomnogram for a depressed person
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Early REM latency and more frequent REM
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Hormone that is high in a patient with depression
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Coritsol, the dexamethsone supression test would be abnormal
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Medications that might cause Depression ?
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IFN, beta-blockers, ?methyldopa, L-dopa, OCPs, ETOH, cocaine /amph withdrawal, opiates.
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Medical diseases that might cause depression?
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HIV, Lyme, Hypothyroidism, Porphyria, Uremia, Cushings Dz, Liver disease, Huntington's, MS, Lupus, *L-MCA stroke*
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What is the number 1 class of drugs used for the txt of depression and what other disease can you treat with these drugs
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SSRI-Fluoxetine, paroxetine, sertraline, citalopram. Also used in OCD, Bulemia, anxiety or premature ejaculation
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SSRI toxicity
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Fewer than TCAs. GI distress, sexual dysfunction (anorgasmia and decreased libido). Serotonin syndrome with any drug that increases 5-HT (e.g., MAO inhibitors, SNRIs, TCAs)—hyperthermia, confusion, myoclonus, cardiovascular collapse, flushing, diarrhea, seizures. Treatment: cyproheptadine (5-HT2 receptor antagonist).
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With SSRI has the most Drug drug interactions
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paroxetine
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What SSRI do you not need to taper when stoping
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Fluoxetine
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Which SSRi has the fewest Drug drug interactions
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citalopram
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if a patient is taking an SSRI and stops it suddenly and experiences HA, N/V/D dizziness and fatigue when stopping suddenly
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SHT discontinuation syndrome: more common with sertraline and fluvoxam
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Myoclonic jerks, tachycardia, High BP, hyperreflexia, n/v/d
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5HT syndrom - If SSRI + MAOi
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IF you have a loss of erection/ ejaculation
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Switch to buproprione (dopamine and norepinephrine inhibitor )
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Contraindications of buproprone
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Alcoholics Epileptics bulimics all because increased rick of seizures.
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Erections lasting longer then 3 hours
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trazodone
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Anti-depressant for old skinny sad ladies
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MIRTAZEPINE - Sedating increases appetite
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What Anti-depressents NOT for hypertensives OR those taking st johns wart
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VENALFAXINE
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Pounding head, flushing, nausea, myoclonus after eating cheese, drinking red wine, taking decongestant or merperidine?
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Hypertensive crisis w/ MAOI. Tx w/ 5mg IV phentolamine
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kid ate some unidentified pills out of grandma's purse. Grandma has HTN, HLP, fibromyalgia, insomnia and peptic ulcer disease. He now has dry mouth, tachycardia, vomiting, urinary retention, and seizures-- EKG SHOWS - widened QRS and prolonged QT intervals - what did he eat
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tricyclic antidepressants
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Most common cause of death in a kid who ingested Tricyclic antidepressants
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Arrhythmia--> torsades, v-fib and death
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What is the Treatment for tricyclic overdose
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Treatment is sodium bicarbonate - helps metabolic acidosis and is cardio protective ---- but if early on give acitvated charcoal
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Patient who is eating more, gaining weight, sleeping more and has leaden paralysis in the morning.
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Atypical depression - these peple are hypersenstivie to rejection and can affect social functing treat with MAOi
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*1 month* After death of her child, a mother feels guilty cant sleep, concentrate, eat, or enjoy her interests.
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Uncomplicated Bereavement. No *suicidal ideation* (other than thoughts of wanting to be w/ loved one). No psychosis (other than hearing/seeing loved one) *Rarely tx w/ antidepressants for sxs
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*4 months* after the death of her chihuahua, a woman still feels guilty, can't sleep, concentrate, eat, or enjoy her interests.
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*Adjustment Disorder*. Sxs *w/in 3mo* of stressor out of proportion. Can't persist longer than 6mo. *Best treated w/ psychotherapy-( other one is avoidant personality disorder*
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Adjustment disorder
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emotional symptoms (anxiety, depression) causing impairment following an identifiable psychosocial stressor (e.g., divorce, illness) and lasting 6 months in presence of chronic stressor).
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Prevalence of Bipolar in the populaiton
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1%
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Prevalence in the identical twin broher
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90%
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75 y/o man with the frist manic phase
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- look for medical cause right frontal hemisphere stoke. -
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Generalized anxiety disorder
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Pattern of uncontrollable anxiety *for at least 6 months* that is unrelated to a specific person, situation, or event. Associated with sleep disturbance, fatigue, GI disturbance, and difficulty concentrating.
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GAD- treatment
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SSRIs, SNRIs, buspirone, cognitive behavioral therapy.
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schizophrenia how many symptoms do you need to have
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If bizarre delusions or hearing voices you only need 1 other wise you need 2 for greater then 6 months
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what is the incidence of manic in the population
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1%
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Risk for diagnosis of manic in a twin
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80-90%
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If these sxs of manic depression occured in a 75 year old patient for the *1st time*
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Look for a medical cause *right frontal hemisphere stroke*
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What medication need to be avoided in a patient with manic depression
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SSRI and TCA can trigger mania
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Medications to start in a manic depressive patient
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Haloperidol or clonazepam for acute *agitation ( if you cant interview them) or delusion*. Lithium or valproic acid or carbamazepine for maintenace
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A *Manic patient* taking Advil develops n/v/d coarse tremor, ataxia, confusion, slurred speech
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LIthium toxicity. *Precipatated by NSAIDs* Better pain (safe) med are aspirin or sulindac
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Lithium toxicity - EKG findings
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*T wave* flattening or inversion + *U inversions*
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Treatment For lithium toxicity
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Fluid resuscitiation emergent dialysis if levels > 4 kidney diz if under 4 then then just fluids
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Side effects for lithium toxicity
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Weight gain and acne, GI irritation and cramps
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MOA of lithium
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Suppresses inosital triphosphate
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What is the therapeutic window for lithium
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0.6- 1.2
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What is the medical monitoring levels for lithium
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Li levels q4-q8wks TFT s q6mo-- ( can cause hypothyroidism) Cr, UA, CBC, EKG
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Lithium Contraindications to use
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Severe Reanl diseas ( because no clearence ) NOt for preggers or breastfeeding
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why lithium not for preggos
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Ebstein abnormality
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Preferred treatment for bipolar in preggos
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BENZO
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Bipolar + elevated on LFT and hepatitis --also can cause n/v/d skin rash
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Valproate,
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Bipolar + steven johnsons syndrom
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Lamotrogene ( more classic ) can be cambazepeine
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Bipolar + agranulocytosis if ANC < 2000 if ANC <1000
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Carbamazepine - check CBC regularly if ANC < 2000 - watch closesly every week if ANC <1000- D/c med
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Bipolar + increase AFP in a 20 wk preggos
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Could be valproate or carbamazepine --> Neural tube defect Any one of reproductive age should take 4 g of folate daily
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most common complications of carbamezapine
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Rash Drug -drug interaction
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therapeutic levels Valproate
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6- 12
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theraputic levels carbamezapine
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60-12 ( move the decimals over)
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28 y/o female is brought in by EMS complaining of sob, palpitations and chest pain. She smokes 1 PPD and her only medication is OCPs. She had one of these attacks previously while grocery shopping. She shares with you that she is so afraid of having another one she rarely leaves her house . What is this ... whats the next step
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PAIN disorder + agora-phobia * first medical work up--EKG ( check for heart disease), drugs screen, tsh/t4, cardiac enzymes*
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What is the drug regeimen for panic disorder- short term, long drugs
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Alprazolam or clonazepam low dose PRN short term -- but SSRI are the preferred drug *BUT DO NOT *give benzos to drug addicts COPDers or restrictive lung disease
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Counter-indications to benzo's
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drug addicts, COPDers, or restrictive lung disease ( suppress the respertory drive)
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Panic disorder on benzo and then stopped taking the benzo now comes in *sxs of a temp 101, convulsions, confusion and hypertension*.
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Acute benzo withdrawal reaction Similar to DT tx w/ diaepam or cholardiazepoxides + haloperidol *if psycotic*
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pt presents with a deathly fear of flying that inhibits her from interveiwing at the program of her dreams What is the diagnosis and what are the two best treatments
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Diagnosis : specific phobia Best txt is CBT w/ flooding or exposure/extinction. Medication is benzo for situational use.
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Patient presents with a deathly fear of presenting a case at ground rounds because the surgeons will laugh at her Diagnosis treatment
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Social phobia Best txt is propranolol to stop the hyperarousal and then situational benzo
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Patient keeps to herself and doesnt talk to peers b/c she is afraid they will laugh at her
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Avoidant personality disorder Best txt is CBT
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A patient is having a diffculty falling asleep b/c she keeps thining about failing biochem. IN class she cant concentrate b/c she worries her boyfriend will leave her Symtpoms have lasted 6 months
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Generalized anxiety Disorder. Best txt is *BUSPIRONE* 5ht 1a partial agonist -But doesnt work fast therefore begin treatment with benzos
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18 you just started college his grades are declining because he spends 2-3 hours in the shower scrubbing because on days he doesnt he worries about contracting an illness
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diagnosis - obsessive compulsive disorder
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Comorbid condition wiht OCD
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High prevelance of vocal motor ticks ; 5-7% of OCD pt have full blown tourettes
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What is the treatment for Obessive compulsive disorder. First line Gold standard
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*First line- SSRI * *Gold standard - Clomipramine*
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25 y/o sexual assult survivor comes to you with a six week hisotry of of recurrent night mares of when she was raped at knifepoint she now avoids situations where unknown men are present and she had to quite her job. Diagnosis
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PTSH - reliving, hyperarousal and avoidance
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Treatment for PTSD - Treatment for the night mares specifically
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PTSD - SSRI- sertraline or paroxetine *Nightmares give the alpha blockers - prazosin*
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IF someone had hyperarousal, avoidance behaviours and re-living of an experiance present for *only 3 weeks* - in responce to a traumatic event like rape diagnosis :
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Diagnosis - acute stress reaction stop with in 1 month
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IF someone had hyperarousal, avoidance behaviours and re-living of an experiance present for only 3 weeks - in responce to a bad breakup diagnosis :
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*adjustment disorder* onset w/in 3 months and goes away by 6 months
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A women complains of pelvic pain during menses you review the chart adn it says that she has also sought help over the past 10 years for pain in her low back, neck arms and feets. tingling in the arms She also complains of sonstipation Diagnosis --- comorbid condition --- Best txt ---
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Diagnosis --- somatoform disorder comorbid condition --- depression/ anexity + personality disorder. Best txt --- frequent follow with 1 physcian
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What are the critea for somatization disorder
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NOt intentinally produced -- onset before age 30 4 pain symptosm 1 gi symptoms 1 sexual 1 pseudoneurological symptom
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33 y/o is brought ot the ER after having a seizure in the waiting room of her neurologist office. Her worried hisband describes the episode as lasting 20 min. consisiting of shaking with her eyes closed. WHAT TesTs
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Notice no urination or defication - conversion diseorder
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Conversion Disorder
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Not intentially produced -Not limitied to pain or sexual dysfucntion - view as a cry for help not always la belle indifference
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What test to confrim or deny a seizure is a pseudoseizure
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LOOK FOR HIGH PROLACTIN -- or NORMAL EEG
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A 54 y/o RN has a history of 2 mon of diarrhea and ab pain. He has been to 4 other hospitals w/ the same complaints -- Colonscopy reveals pigmentation in the wall of the colon
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- melanosis coloni - from laxtives - giving himself diarrhea - muchausen syndrome ( they make themselves sick )
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Munchausen syndrome
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more severe then simple factitious( these people complain of symptoms but dont do anything to create them) b/c they actually induce sxs and do it for primary gain
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A concerned mother presents with 15 mon baby who is having recurrent seizures. She requests an MRI, sleep deprived EEG with intercranial leads
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munchausen syndrom by proxy a form of child abuse - this is munchausen becuase the mother is giving the baby something to cause the seizures *next step alert the child protective agency*
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45 y/o unemplyed man is involved in a car accident. HE sues the drive stating he has nerve damage to his legs that keeps him from walking Video evidence shows him dancing at a club the night before
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MALIGERING --- Goes as a v- code---- Associated w/ antisocial personality disorder, they do it for secodnary gain
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18 y/o presents with no menstrual cycle for 3 mo. A PREGNACY TEST is negative but her BMI is 17. her teeth are eroded and she has calluses on her knuckles ( russels sign): What are the vital signs : CBC: Chemistry: TFT: Fasting lipid profile: Hormones :
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ANOREXIA puring type - Amenoia ( endocrine abnormality) , and low bmi - *VItal signs*: Hypotension, braycardia and hypothermia *CBC*: leukopenia *Chemistry*: high H3co, low cl, low K, *high carotene( may cause yellowing of the skin)*, high lfts and amylase *TFT*: nomral *Fasting lipid profile*: elevated *Hormones*: elevated cortisol, low estrogen, low LH/fsh
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Long term complications of anorexia
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osteoporosis - also lentigo- downey hair, possible parotitis
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Most common cause of death anorexia
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heart disease ( ARRTHYMIA), suicide #2
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Complication of anorexia
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needs intensive conseling, needs nutritions ( give tpn)
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Complications of TPN in anorexia
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Re-feeding syndrom = *low PO4*, low mg, low ca *caused by fluid retention*
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Sleep EEG FOR AWAKE what are the characteristics
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Beta (highest frequency, lowest amplitude
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Sleep EEG For stage 1
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theta - consists about 5% of sleep
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Sleep EEG for stage 2
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Deeper sleep; when bruxism occurs *Sleep spindles and K complexes* 45%
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Sleep EEG for stage 3
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*Delta (lowest frequency, highest amplitude)* 25% Stage 3 is the less then 50% theta waves and stage 4 is greater then 50% theta waves Deepest non-REM sleep (slow-wave sleep); when sleepwalking, night terrors, and bedwetting occur
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What drugs decrease stage 3/4 sleep 3
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Impramine,And Benzodiapazems and Alcohol also decrease stage 3 and 4 sleep * impramine used to decrease betwetting *
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EEG for rem sleep
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REM. 25% Skeletal muscle paralysis Loss of motor tone, increase brain O2 use, and variable pulse and blood pressure; when dreaming and penile/clitoral tumescence occur; may serve a memory processing function
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DEpression sleep eeg
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Decrease rem latency and increase REM %
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Sleep eeg in the elderly
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Decrease latency o rem and increase cycling often less
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Trouble falling asleep or staying asleep causes impairment in fxn ;1mo.
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Insomnia. Educate about *sleep heigyne 1st*, then try benzos (reduce sleep latency and incr SWS and REM). *Zolpidem, zaleplon, escopiclone are GABAa recp*
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As falling asleep, feel creepy-crawlies on legs, better when they get up and move
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Dyssomnia NOS. - (Restless leg syndrom and peroid leg movement syndrom) R/o medical causes 1st-->Fe-def anemia or chronic kidney dz. Neuropathy. Tx w/ ropinirole (pathological gambling) or pramipexole (Da-ag)
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Daytime sleepiness and depression in a big fat guy with a big neck.
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Obstructive Sleep Apnea. Goes on axis III, "breathing related sleep d/o" goes on axis I. Need polysomnogram to diagnose --> >10 hypopneic/apneas per hour. Need CPAP to reduce pulmonary HTN.
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Irresistible attacks of refreshing (REM) sleep. Upon intense emotion, they lose muscle tone or have hallucinations as waking or falling asleep.
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Narcolepsy. Tx w/ scheduled naps and Modafinil ( need cataxpecy or hynogognic or hypnopmonic hallucinations)
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30 y/o man and his wife present for couples counseling. He constantly accuses her of cheating. He's in a feud w/ the neighbor b/c he feels they are attacking his character when they say they like his flowerbeds.
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Paranoid PD Low dose anti-psychotics can help paranoid behavior.
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30 y/o man, never been married or have any close friends. Works as a night security guard and in his free time works on his model ships in his basement.
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Schizoid PDDistinguish from Avoidant b/c they don't WANT relationships
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30 y/o man, never been married or have any close friends because "people make him uncomfortable". He is unemployed because he spends his time reading books on how to communicate with animals so he can "be at one with nature".
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Schizotypal PD Distinguish from Schizoid by magical thinking/ interests. Distinguish from Schizophrenia by lack of delus/hallu
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25y/o man comes to court mandated counseling for beating his girlfriend. He was kicked out of high school for fighting ; just got out jail for stealing a car.
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Antisocial PD. 2/3 have substance abuse (mosr common co-morbid codition).
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His girlfriend has a hx of unstable relationships, has superficial cuts on both wrists, is impulsive in her spending and sexual practices.
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Borderline PD. Commonly defensive mechanism used splitting.
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26 y/o MS2 is asked to seek counseling. Her classmates complain that she dresses too provocatively to class. She recently tried to seduce a professor.
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Histrionic PD. Look for substance abue or eating d/o ( comorbid condition)
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A 22 y/o MS1 doesn't feel like he needs to come to any classes or labs because he "already has the brilliance to be a doctor.
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Narcissistic PD. Can be confused w/ hypomania b/c of grandiosity. Give individual thearpy
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30 y/o woman has no friends and avoids happy hours with her coworkers b/c she fears ridicule and rejection. She feels "no one would want to be friends with me".
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Avoidant PD. Can tx social phobia sxs w/ b-blocker or SSRI -- different from social phobia because it is more persasive
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30 y/o woman has jumped from one relationship to another because she "doesn't do well alone". She calls her friends and family >20x a day to get their input on her daily decisions.
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Dependent PD. Look for co-morbid depression and anxiety. SSR - treat co-morbid condition.
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25 y/o MS4 spends more time color coding her notes and textbook highlighting than actually studying. She makes lists and study schedules 3 times per day. People don't like to work with her because she is so "anal"
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Obsessive Compulsive PD. Different from OCD b/c the actions are *"ego-syntonic"- these people arent bothered by there compulsions !!! *
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78 y/o lady is brought in from her nursing home for altered mental status. She sleeps more during the day and becomes agitated at night-reporting seeing green men in the corner. She also complains of pain upon urination. First step in work up
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Delrium and the first step is a medical work up. - do UA and culture, also glc, na, blood culture, b12, RPR - Make sure to look at med list benadryl, opiates bzs.
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What is the biggest risk factor for delrium
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AGE !! then underlying dementia is the 2nd biggest
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Other Common causes of delrium
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Acute substance withdrawal. Look for it on the 2nd or rd post-op day in alcoholic
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What are the EEG changes of the Delrium
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Diffuse background slowing of the background rhythm - Slow waves *psychosis has a normal eeg*
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Treatment of Delrium
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Reduce excessive stimuli, calendar and clock to orient the patient STOP unecessary meds Give haloperidol if agitated
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A 78 y/o female presents with memory loss... •Aphasia, apraxia, gets lost while driving?
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Alzheimer's Dementia. MC type.On MMSE, prompting does not ?recall
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what is the pathology of MRI
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Diffuse brain atrophy, b-amyloid plaques or tau tangles. decrease ACH ( decrease basal nucleous of meyhert) * tangles correlate with the degreee of dementia*
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What are the genes associated to alzheimers dementia.
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Early onset: APP (Chr 21), presenilin-1 (Chr 14), presenilin-2 (Chr 1) Late onset: ApoE4 (Chr 19) ApoE2 (Chr 19) is protective.
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Treatment for alzheimers
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Rivastigmine, Donepezil, galantamine (diarrhea). Ach - esterase inhibitors - *Cause diarrhea* Memantine- NMDA antagonist - want to decrease excitability * non of these improve the memory only decrease rate of decline*
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A 78 y/o female presents with memory loss Becomes more sexually explicit, apathy.
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Frontotemporal Dementia. (Pick's Dz).
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Pathology of frontaltemporal pick diz
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Lobar atrophy, *intra neuronal silver staining inculsions*- spares the parietal lobe
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What is the treatment for fontaltemporal, aka pick diz.
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Olanzepine for severe disinhibition. ( stop the behavorial problems)
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A 78 y/o female presents with memory loss Fluctuation in consciousness, *visual hallucinations* and shuffling gait
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Lewybody dementia
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Lewy body dementia pathology
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Intra cytoplasmic Alpha-synuclein inclusions in neocortex ( lewy body)
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Lewy body dementia treatment -
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Give Ach-Ease inhibitors. *NOT L-dopa*. Avoid neuroleptics.- *no haliperdol or benzo's*
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A 78 y/o female presents with memory loss... Sudden, step-wise decrease in memory/cognitions What is it and what is the work up
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Vascular Dementia. - Work up is MRI and MRA
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A 78 y/o female presents with memory loss Loss of vibration sense, labile affect. Pupil that accommodates but doesn't react. What is it what is the test What is the treatment
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Tertiary Syphilis. *DX:* +RPR, VDRL. Do spinal tap to look for spirochetes.- ( if seen you have to iv pencillin) *Tx:* IV penicillin. If Pen-allergic, must desensitize.
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A 78 y/o female presents with memory loss Myoclonus, startle response, seizures. Recently had a corneal transplant. What is it? What is the pathology ? EEG findings ?
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Creutzfeldt Jakob. Pathology: Sponigorm encephalopathy EEG finidngs: * triphasic bursts*
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A 78 y/o female presents with memory loss Incontinence, gait disturbance/freqfalls, and rapidly developing Dx: Work up: TX:
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DX: Normal Pressure Hydrocephalus. Work up: CT/MRI shows hydrocephalus, spinal tap shows nl opening pressure Tx: Ventriculoperitoneal shunt improves cognitive fxn in 50-67% of pts
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A 50 y/o known alcoholic presents to the ER with tonic clonic seizures. BP 180/110, HR 118, T 100.1. How long since the last drink
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12-24hrs. (bimodal peak at 8 and 48hrs)
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A 50 y/o known alcoholic presents to the ER with tonic clonic seizures. BP 180/110, HR 118, T 100.1. *How long till he develops confusion, fluctuations in consciousness and the feeling of ants crawling on him?*
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~48-72hrs since last drink is when delirium tremens usually start.
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A 50 y/o known alcoholic presents to the ER with tonic clonic seizures. BP 180/110, HR 118, T 100.1. *His blood alcohol level is 225mg/mL. How long till its out of his system?*
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~9hrs, Alcohol is metabolized by zero order kinetics (same amt/unit time = 25mg/hr)
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A 50 y/o known alcoholic presents to the ER with tonic clonic seizures. BP 180/110, HR 118, T 100.1. *If his medications included propranolol, lactulose, and allopurinol, what would be the best sign to monitor for his withdrawals?*
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*Beta-blockers mask the signs* of autonomic hyperactivity, but you *can follow hyperreflexia* to dose the benzos during w/drawal.
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Best intial treatment for our patient with alcohol withdrawl
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Diazepam or chloridiazepoxide b/c they have 80 & 120 hr 1/2 lives respectively
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WHAT if the alcoholic has child class C ( cirrohosis )
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Lorazepam, oxazepam or tempazepam
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MOSt specific test for ETOH consumption in the past 10 days
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*Carbohydrate-deficient transferrin.* Less specific-*elevated GGT* and AST more than twice ALT.
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Our next patient comes in w/ confusion, ataxia, and you find opthalmopelgia: Dx?
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Wernicke Encephalopathy. Caused by thiamine deficiency *Give thiamine 1st, then glucose containing fluids*. REVERSIBLE
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Wernicke can progress to what and how can you tell
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Can progress to Korsakoff's syndrome *(irreversible damage to mamillary bodies, etc)*-apathy, anter/retrograde amnesia and confabulation. Can see MB atrophy on MRI
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A patient is brought into the ER in a non-responsive state. His BP is 100/60, HR is 50, RR is 6. He has multiple track marks on his arms. •Best first step? • Diagnosis ?
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Diagnosis - heroin Best intial step- intubate ( under 8 intubate always ABC) Then give IV or IM naloxone(full mu-opiate antagonist)
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A patient is brought into the ER in a non-responsive state. His BP is 100/60, HR is 50, RR is 6. He has multiple track marks on his arms.---> NOW You realize his pupils are dilated. Does that change your dx?
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No. The hypoxia 2/2 respiratory depression can cause hypoxia
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•What sxs to you expect as he starts to withdraw? heorin
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Juicey - goosebumps Joint and muscle pain, photophobia, goosebumps, diarrhea, tachycardia, HTN, GI cramps, dilated pupils, anxiety/depression
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Treatment for heorin for withdrawal symptoms
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depression Clonidine for autonomic sxs, ibuprofen for muscle cramps, loperimide for diarrhea.Methadone, buprenorphrine or Naltrexone can be used for long-term dependence.
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Pt presents with horizontal nystagmus, dilated pupils, ataxia and acute psychosis.
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Hallucinogen (PCP) intoxication. Can use haloperidol for acute psychosis
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Pt presents s/p MVC with injected conjunctiva, sedation and is asking for Doritos.
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Cannabis intoxication.
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Pt presents with Suicidal ideation, hypersomnia, depression and anergia
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Cocaine/Amphetamine withdrawal.
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Pt presents with dilated pupils, seizure, tachycardia and HTN. -Best 1st test
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*Cocaine/Amphetamine intoxication EKG 1st * then urine tox screen. Tx seizure w/ lorazepam
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Tx of HTN and tachycardia in a patient with cocaine/amphetamine intoxication
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Calcium channel blocker. *Beta-blockers are CONTRAINDICATED!*
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When is death considered permanent
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6 years - 11 years - considered concrete operational
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IQ of 40-55
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Moderate retardation
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Iq of 55 -70
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Mild retardation
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IQ of 25-40
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Severe retardation
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IQ of < 25
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Profound
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What is the average and standard deviation for IQ
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Average is 100 - std is 15
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where does mental retardation go in DSM 4
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Axis 2
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An 11 year old boy is evaluated for developmental delay, poor school and social performance. Formal IQ testing reveal his IQ to be 50. He has a macrocephaly, long face and macroorchidism: What is the most likely cause What is the gentic cause What are the co-morbid genetic conditions
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Fragile X X-linked dominal inheritance CGG repeats w/ anticipation Cx = Seizures, MVP, dilation of the aorta, tremors, ataxia, ADHD-like behavior. *MC cause of inherited MR.*
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A newborn baby has decreased tone, oblique palpebral fissures, a simian crease, big tongue, white spots on his iris Diagnosis what are the whitespots called
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Diagnosis: down syndrom white spots: brushfeild spots
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What can you tell his mother about his expected IQ? for down syndrome
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He will likely have mild-moderate MR. Speech, gross and fine motor skill delay
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Common medical complications down syndrom ? -heart: - GI: - Endocrine : - MSK: -Neuro: Cancer:
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-Heart?VSD, endocardial cushion defects -GI? Hirschsprung's, intestinal atresia, imperforate anus, annular pancreas -Endocrine? Hypothyroidism -Msk? Atlanto-axial instability- careful for intubation -Neuro? Incr risk of Alzheimer's by 30-35. (APP is on Chr21) -Cancer?10x increased risk of ALL
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Café-au-laitspots, seizures large head. Autosomal dominant
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Neurofibromatosis
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oarse facies, short stature, cloudy cornea. Autosomal recessive.
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Hurler Syndrome
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Broad, square face, short stature, self-injurious behavior. Deletion on Chr17
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Smith Magenis
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Hypotonia, hypogonadism, hyperphagia, skin picking, agression. Deletion on paternal Chr15.
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Prader-Willi
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Seizures, strabismus, sociable w/ episodic laughter. Deletion on maternal Chr15.
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Angelman
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Elfin-appearance, friendly, increased empathy and verbal reasoning ability. Deletion on Chr7.
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Williams
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ADHD-like sxs, microcephaly, smooth philtrum. Most common cause of mental retardation.
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Fetal Alcohol Syndrome
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Seizures, chorioretinitis, hearing impairments, periventricular calcifications, petechiae@ birth, hepatitis.
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Congenital CMV infection.
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Seizures, hearing impairments, cloudy cornea/retinitis, heart defects, low birth weight.
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Congenital Rubella Syndrome
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Abnormal muscle tone, unsteady gait, seizures, mental retardation or learning disability.
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Cerebral Palsy from birth asphyxia.
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IUGR, hypertonia, distinctive facies, limb malformation, self-injurious behavior, hyperactive.
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Cornelia de Lange
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Coloboma, heart defects, choanalatresia, growth retardation, GU anomalies, ear deformity and deafness. Chr8.
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CHARGE
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Autism spectrum sxs, heart disease, palate defects, hypopasticthymus, hypoCa. Chr22 deletion.
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DiGeorge
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Vomiting, seizures, lethargy, coma. Acidosis w/ stress, illness. Causes neurological damage.
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Maple Syrup Urine Disease
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Exclusively in girls, normal development for 6-8mo, then regression, handwringing, loss of speech and use of hands. X-linked dominant deletion of MECP2.
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Rett Syndrome
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Normal development until age 2 then major loss of verbal, social skills w/ autistic like behavior.
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Childhood Disintegrative Disorder
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Lack of mother-child eye contact, language delay/repetitive language, peroccupation w/ "parts of toys" before age 3.
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Autism
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Problems with social skills (usually recognized in preschool) w/ preserved verbal ability.
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Asperger
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A 7 year old boyis brought in by his parents. They report he must be told several times to complete his chores, they cannot get him to focus on completing his homework (he is easily distracted), and that he often loses his shoes, pencils, books, etc. Diagnosis next best step
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Normal age appropriate behavior !!!-- Diagnosis of ADHD- need misbehaviour in 2 settings Next best step : How does he do at school
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Risk facotris for ADHD
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Family history 77% heritability, LBW tobacco ETOH exposure
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Co morbid ocnditons with ADHD
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ODD/CD in 30 - 50%
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TREATMENT IN ADHD
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Methylphenidate (blocks only Da) - Nausea, decrease appetite, increase HR Adn BP stunted growth Amphetamine (blocks da and Ne)- same se Atomoxetine NE reuptake inhibitor non stimulant -
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A 14 year old boy is sent for court mandated counseling. He stole his neighbor's lawn mower and then set fire to his tool shed. He has a 5 year history of truancy from school and assaulted a 13 year old school mate.
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Conduct Disorder. Need sxs for 6mo.Comorbid substance abuse. May progress to anti-social personality disorder
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A 14 year old boy is brought in by his grandmother. For the past year, he has been getting in trouble at school for being argumentative and disrespectful to his teachers. He defies the rules she sets for the house and often deliberately annoys her.
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Oppositional Defiant Disorder. *Need sxs for 12mo.* Stops just short of breaking the lay or physically harming others.
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A 9 year old boy is sent to counseling at the recommendation of his teacher. She states that at least once a day he makes loud grunting noises and hand movements that are disruptive to the class Diagnosis
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For tics to qualify as Tourettes they must occur at *least once a day for 1 year w/o a tic-free period longer than 3mo*
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Comorbid conditions for tourettes ?
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Look for the compulsions of OCD
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Treatment for tourettes first line vs. most effective
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-First line? Clonidine 2/2 relatively benign S/E profile - Most Effective?- Haloperidol or pimozide-DA-receptor antagonists
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7 year old complains of frequent abdominal pain resulting in many missed school days. He never gets the pain on the weekends or in the summer.
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Separation Anxiety Disorder
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6 year old adopted child is brought in because she has not formed a relationship with her adoptive parents. She is inhibited and hyper vigilant.
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Reactive Attachment Disorder
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•An 18mo old baby has recently been regurgitating and re-chewing her food. She had previously been eating normally.
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Rumination Disorder. Check lead levels.
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6y/o stools in her clothes once every 2 weeks. Next best test? Tx?
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Next best test is to check for fecal retention treatment is behavioural modification that only rewards
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6 y/o that unrinates in her clothes once a day
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NExt best test? R/o UTI Treatment: alarm and pad
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