question

Schizophrenia: Time duration and Brain histological findings

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Chronic mental disorder with periods of psychosis, disturbed behavior and thought, and decline in functioning that lasts > 6 months. Associated with increase dopaminergic activity, decrease dendritic branching.

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Schizophrenia: Symptoms needed for diagnosis

answer

2 or more of the following (first 4 in this list are "positive symptoms"): ~Delusions ~Hallucinations—often auditory ~Disorganized speech (loose associations) ~Disorganized or catatonic behavior "Negative symptoms"—flat affect, social withdrawal, lack of motivation, lack of speech or thought

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Most common type of schizophrenia

answer

Paranoid type

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Most treatable type of schizophrenia

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Paranoid type

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Prevalence in society of schizophrenia

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1%

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Schizophrenia: ~Risk of MZ twin ~Risk of sibling

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twin = 50% sibling = 10%

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Positive symptoms for schizophrenia

answer

Increased dopamine in the mesolimbic tract

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Negative symptoms for schizophrenia

answer

Decreased dopamine in the mesocortical tract

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Diagnosis: Delusions hallucination and flattened affect for 3 weeks

answer

Brief psychotic disorder ( > 1 WEEK AND <1 MONTH)

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Diagnosis: Delusions hallucination and flattened affect for > 1 month and < 6 month

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Schizopreniform disorder

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Typical antipsychotics help what kinds of symptoms in schizophrenia

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Positive symptoms, but no effect on the progression

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Difference between schizoaffective disorder and depression with psychotic features?

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What was present first without the other, i.e. schizoaffective thave had psychosis without any depressive symptoms

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Diagnosis: 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

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Treatment for MDD with Psychotic Features?

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Atypical antipsychotic + SSRI or ECT (especially in pregnant patients)

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Diagnosis: Persecutory delusions for past 3 years (diagnosed with schizophrenia), 6 months ago he started having sadness, guilt, insomnia, ? concentration, SI

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Schizoaffective Disorder; delusions/hallucinations for > 2 weeks in absence of mood symptoms

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Treatment for Schizoaffective Disorder?

answer

Atypical antipsychotics + SSRI if depression + Li if manic

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A man is convinced Miley Cyrus is in love with him, but is otherwise functional

answer

Delusional Disorder, erotomanic type. *Non-bizzare*

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Treatment for Delusional Disorder?

answer

Therapeutic relationship + meds

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Treatment: Acute agitation OR psychosis

answer

*IM* haloperidol --Quick onset of action --D2 dopamine angtagonist

question

Haloperidol: Effects on nigrostriatal pathway and tubularinfundibulum?

answer

Nigrostrial = causes EPS Tubularinfundubulum = Hyperprolactinemia

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Low potency antipsychotics:

answer

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?

answer

Corneal deposits

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Side effects of Thioridazine?

answer

Retinal deposits

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Side effects of haloperidol?

answer

--NMS --Tardive dyskinesia

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Symptoms of Neuroleptic malignant syndrome (NMS)?

answer

Rigidity, myoglobinuria, autonomic instability, hyperpyrexia

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Treatment for NMS?

answer

Dantrolene, D2 agonists (e.g., bromocriptine) Stop offending med, cooling blankets, and Dantroline Na or Bromocriptine

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Neuroleptic syndrome:

answer

*FEVER* *F*ever *E*ncephalopathy *V*itals unstable *E*nzymes elevated *R*igidity of muscles

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High potency Antipsychotics:

answer

Trifluoperazine, Fluphenazine, Haloperidol —neurologic side effects (EPS symptoms)

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Treatment of psychotic patient with a history of medication non-adherence?

answer

Give injection/decanoate - Fluphenazine or Haldol every 2-4 weeks

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Side effect: Purple grey metallic rash over sun-exposed areas and jaundice?

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Chlorpromazine

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Side effect: Prolonged *QTc* and pigmentary retinopathy?

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Thioridazine --> can lead to torsades

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Diagnosis: Medicated, psychotic patient wakes up with eyes "stuck" looking up or head "stuck" turned to the side

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Acute Dystonia <12 hours of beginning medication

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Treatment for Acute Dystonia?

answer

Benztropine or diphenhydramine

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Diagnosis: Medicated, psychotic patient reports feeling like they "always have to move"

answer

Akathesia 30 - 90 days of beginning medication

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Treatment for Akathesia?

answer

Propranolol (1st line) or benzodiapene

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Diagnosis: Coarse resting tremor, masked facies, unsteady gait, bradykinesia

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Parkinsonism >6 months of beginning medication

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Treatment of Parkinsonism side effects?

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Treatment: Benztropine, diphenhydramine, amantidine or bromocriptine *NOT L-dopa!*

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Diagnosis: After 10 years on fluphenazine, tongue movements and grimacing

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Tardive Dyskinesia > Many years after starting antipsychotic

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Treatment of Tardive Dyskinesia?

answer

Stop antipsychotic and switching to and atypical or clozapine

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Diagnosis: Within hours of a haloperidol injections, ?CPK, T = 103F, rigidity, autonomic instability, and delirium

answer

Neuroleptic Malignant Syndrome Other causes: metoclopramide, compazine and droperidol

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Antipsychotic medication: Weight neutral but prolongs the QTc?

answer

Ziprazodone

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Antipsychotic medication: Weight neutral but increases akathesia?

answer

Aripiprazole

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Antipsychotic medication: Atypical agent with highest risk for EPS and ?prolactin?

answer

Risperidone, also in depo form

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Antipsychotic medication: Most associated with weight gain, BUT most common side effect is sedation?

answer

Olazepine

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Antipsychotic medication: Causes orthostasis and cataracts?

answer

Quetiapine --Alpha blocking properties

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Antipsychotic medication: Good for treatment-refractory schizophrenia?

answer

Clozapine

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Most common side effects of Clozapine?

answer

Sedation, weight gain, ?blood sugar and lipids

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Most dangerous side effects of Clozapine?

answer

Agranulocytosis Decreased seizure threshold

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What do you monitor with Clozapine?

answer

CBC --> ANC every week for 6 months and every 2 weeks for next 6 months Stop Clozapine if WBCs < 3000 or ANC < 1500

question

What the most important and first question to ask the depressed patient?

answer

Suicidal ideation, most likely to kill the patient

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Risk factors for suicidal ideation?

answer

#1 - Prior attempt >45 years old, white male, serious illness, detailed plan, no support, use of ETOH and drugs

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Polysomnogram for a depressed person?

answer

Early REM latency and more frequent REM

question

Increased hormone in depressed patient?

answer

Coritsol Dexamethsone supression test would be abnormal

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Medications that might cause depression?

answer

IFN, beta-blockers, ?-methyldopa, L-dopa, OCPs, ETOH, cocaine/amphetamine withdrawal, opiates

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Medical diseases that might cause depression?

answer

HIV, Lyme, Hypothyroidism, Porphyria, Uremia, Cushings Dz, Liver disease, Huntington's, MS, Lupus, *L-MCA stroke*

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First line drug for treatment of depression?

answer

SSRIs = Fluoxetine, paroxetine, sertraline, citalopram

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Other conditions treated with SSRIs?

answer

OCD, bulemia, anxiety, or premature ejaculation

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Side effects of SSRIs

answer

GI distress, sexual dysfunction (anorgasmia and decreased libido) Fewer than TCAs

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SSRI toxicity

answer

Serotonin syndrome with any drug that increases 5-HT (e.g., MAO inhibitors, SNRIs, TCAs

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Symptoms of Serotonin syndrome?

answer

Hyperthermia, confusion, myoclonus, cardiovascular collapse, flushing, diarrhea, seizures

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Treatment of Serotonin syndrome?

answer

Cyproheptadine (5-HT2 receptor antagonist)

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SSRI with most drug-drug interactions?

answer

Paroxetine

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SSRI that can be discontinued without a taper?

answer

Fluoxetine

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SSRI with fewest drug-drug interactions?

answer

Citalopram

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Suddenly stopping SSRI and experiences HA, N/V/D dizziness and fatigue

answer

5-HT discontinuation syndrome; more common with sertraline and fluvoxam

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Diagnosis: Myoclonic jerks, tachycardia, hypertension, hyperreflexia, n/v/d

answer

5-HT syndrome, particularly if the patient is taking both SSRI + MAOI

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Patient experiences loss of erection/ejaculation on SSRI?

answer

Switch to buproprione (dopamine and norepinephrine antagonist)

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Contraindications of buproprione?

answer

Due to increased rick of seizures: Alcoholics Epileptics Bulimics

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Drug: Erections lasting longer then 3 hours?

answer

Trazodone

question

Drug: Anti-depressant for old, skinny, sad ladies?

answer

Mirtazepine - Sedating, increases appetite

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Drug: Anti-depressent NOT for hypertensives?

answer

Venalfaxine

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Drug: Anti-depressent NOT for patients taking St John's Wart?

answer

Venalfaxine

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Diagnosis: Pounding head, flushing, nausea, myoclonus after eating cheese, drinking red wine, taking decongestant or merperidine?

answer

Hypertensive crisis with MAOI

question

Treatment for Hypertensive crisis with MAOI?

answer

5mg IV phentolamine

question

Pediatric patient ingested unidentified pills. He now has dry mouth, tachycardia, vomiting, urinary retention, and seizures. EKG demonstrates *widened QRS and prolonged QT intervals*. What medication did the child ingest?

answer

Tricyclic antidepressants

question

Most common cause of death in a kid who ingested TCAs?

answer

Arrhythmia --> torsades, v-fib, and death

question

What is the treatment for tricyclic antidepressant overdose?

answer

Sodium bicarbonate --Helps metabolic acidosis --Cardio protective

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Patient who is eating and sleeping more, gaining weight, and has leaden paralysis in the morning.

answer

Atypical depression --Hypersensitive to rejection, affecting social functioning

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Treatment for Atypical depression

answer

MAOI

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Diagnosis: One month following the death of her child, a mother feels guilty, can't sleep, concentrate, eat, or enjoy her interests?

answer

Uncomplicated Bereavement --No *suicidal ideation* (other than thoughts of wanting to be with loved one) --No *psychosis* (other than hearing/seeing loved one)

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Treatment for Uncomplicated Bereavement?

answer

Rarely; treat with antidepressants for symptoms

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Diagnosis: Four months following the death of her chihuahua, a woman still feels guilty, can't sleep, concentrate, eat, or enjoy her interests?

answer

Adjustment Disorder Symptoms present *within 3 months* of stressor and are out of proportion to inciting event --Can't persist longer than 6 months

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What is Adjustment disorder?

answer

Emotional symptoms (i.e. 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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Treatment for adjustment disorder?

answer

Psychotherapy

question

Prevalence of Bipolar disorder in the population?

answer

1%

question

Prevalence of Bipolar disorder in MZ twin?

answer

90%

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Diagnosis: 75 year old man with first manic phase of lifetime?

answer

Medical cause --Right frontal hemisphere stoke

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What is Generalized anxiety disorder?

answer

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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Treatment for GAD?

answer

SSRIs, SNRIs, buspirone, cognitive behavioral therapy

question

How many symptoms and for how long do you need to have in order to diagnose schizophrenia?

answer

Bizarre delusions or hearing voices = 1 month Otherwise = 2 or more symptoms for 6 months

question

Incidence of mania in the population?

answer

1%

question

Risk for diagnosis of mania in a MZ twin?

answer

80-90%

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Diagnosis: Symptoms of manic depression in 75 year old patient for the *1st time* in that patient's lifetime?

answer

Medical cause --Right frontal hemisphere stroke

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What medication need to be avoided in a patient with manic depression

answer

SSRI and TCA can trigger mania

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Medications to start in a manic depressive patient? For maintenance?

answer

Haloperidol or clonazepam for *acute* agitation/delusion (if you cant interview them) Maintenance: Lithium or valproic acid or carbamazepine

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Diagnosis: Manic patient takes Advil and develops n/v/d, coarse tremor, ataxia, confusion, and slurred speech?

answer

LIthium toxicity *Precipatated by NSAIDs* Preferred pain medications for patients on Li: aspirin or sulindac

question

EKG findings in Lithium toxicity?

answer

--*T wave flattening* or *inversion* --*U inversions*

question

Treatment For Lithium toxicity?

answer

Depends on serum Li levels: 4: Emergent dialysis

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Side effects of Lithium?

answer

Weight gain, acne, GI irritation, and cramps

question

Mechanism of action of Lithium?

answer

Suppresses inosital triphosphate (ITP)

question

What is the therapeutic window for Lithium?

answer

0.6- 1.2

question

What is the medical monitoring protocol for Lithium use?

answer

Li serum levels every 4-8 weeks TFTs every 6 months (can cause hypothyroidism) Cr, UA, CBC, EKG

question

Contraindications to Lithium use?

answer

Severe renal disease, because decreased serum clearence NOT for pregnant or breastfeeding patients

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What does Lithium do to fetus?

answer

Ebstein abnormality

question

Preferred treatment for bipolar in pregnant patients?

answer

Benzodiazapene

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Drug: Bipolar patient with elevated LFTs, hepatitis, n/v/d, and skin rash?

answer

Valproate

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Drug: Bipolar patient with Steven Johnson's syndrome?

answer

Lamotrogene, also can be cambazepeine

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Drug: Bipolar patient with agranulocytosis?

answer

Carbamazepine --*check CBC regularly* If ANC < 2000 = watch closesly every week If ANC <1000 = Stop

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Drug: Pregnant bipolar patient with an increase AFP at 20 weeks gestation?

answer

Valproate or carbamazepine --> Neural tube defect Anyone of reproductive age should take 4 g of folate daily

question

Most common complications of carbamezapine?

answer

Rash Drug-drug interaction

question

Therapeutic levels of Valproate?

answer

6 - 12

question

Theraputic levels of carbamezapine?

answer

60 -120

question

Diagnosis: 28 year old 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. Work up?

answer

Panic disorder + agoraphobia Work up: Medical work up first, EKG, drug screen, TSH/T4, cardiac enzymes

question

Treatment for panic disorder?

answer

Short term: low dose Alprazolam or clonazepam PRN Long term: SSRI

question

Contraindications to benzodiazepines?

answer

Drug addicts, COPDers, or restrictive lung disease (suppress the respiratory drive)

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Patient with panic disorder on benzodiazepines discontinues medications and comes in with T=101, convulsions, confusion, and hypertension

answer

Acute benzodiazepine withdrawal reaction --Similar to DT

question

Treatment for acute benzodiazepine withdrawal reaction?

answer

Diazepam or cholardiazepoxide *+ haloperidol, if psychotic*

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Patient 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?

answer

Specific phobia

question

Treatment for specific phobia?

answer

CBT with flooding or exposure/extinction + benzodiazepine

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Patient presents with a deathly fear of presenting a case at grand rounds because the surgeons will laugh at her. Diagnosis and treatment?

answer

Social phobia

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Treatment for social phobia?

answer

Propranolol stops hyperarousal + situational benzodiazepine

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Patient keeps to herself and doesn't talk to peers because she is afraid they will laugh at her

answer

Avoidant personality disorder

question

Treatment for Avoidant personality disorder?

answer

CBT

question

Diagnosis: Patient is having a difficulty falling asleep because she keeps thinking about failing biochem. She can't concentrate in class because she worries her boyfriend will leave her. If her symptoms have lasted 6 months.

answer

Generalized anxiety disorder

question

Treatment for GAD?

answer

Buspirone 5-HT 1a partial agonist Bridging treatment with benzodiazepines

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Diagnosis: 18 year old patient college student with declining grades. He spends 2-3 hours in the shower scrubbing, because on days he doesn't, he worries about contracting an illness?

answer

Obsessive compulsive disorder

question

Co-morbid condition with OCD?

answer

--Vocal motor ticks --5-7% of OCD patients have Tourette

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What is the treatment for OCD?

answer

*Gold standard = Clomipramine* First line = SSRI

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Diagnosis: 25 year old sexual assault survivor comes to you with a 6 week history of recurrent nightmares when she was raped at knifepoint. She now avoids situations where unknown men are present, and she had to quit her job.

answer

PTSD --Re-living, hyperarousal, and avoidance

question

Treatment for PTSD?

answer

SSRI = sertraline or paroxetine *Nightmares = alpha blockers, e.g. prazosin*

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Diagnosis: Patient with hyperarousal, avoidance behaviors, and re-living of an experience present for *only 3 weeks* in response to a traumatic event like rape.

answer

Acute stress reaction --Symptoms must stop within 1 month

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Diagnosis: Patient with hyperarousal, avoidance behaviors, and re-living of an experience present for only 3 weeks in response to a bad breakup?

answer

Adjustment disorder --Onset within 3 months and goes away by 6 months

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Diagnosis: Female patient complains of pelvic pain during menses and chart reveals pain in low back, neck, arms, and feet. She complains of tingling in her arms and constipation?

answer

Somatoform disorder

question

Co-morbid condition with somatoform disorder?

answer

Depression/anxiety + personality disorder

question

Treatment for somatoform disorder?

answer

Frequent follow up with a physcian

question

What are the criteria for somatization disorder?

answer

--NOT intentionally produced --Onset before age 30 --4 pain symptoms --1 GI symptoms --1 sexual --1 pseudoneurological symptom

question

Diagnosis: Patient is brought to the ER after having a seizure in the waiting room of her neurologist office. Her worried husband describes the episode as lasting 20 minutes, consisiting of shaking with her eyes closed

answer

Conversion disorder

question

What is Conversion Disorder?

answer

--Not intentially produced --Not limited to pain or sexual dysfunction --View as a cry for help --NOT always la belle indifference

question

What is the best tests to confirm or deny a seizure?

answer

High Prolactin or Normal EEG

question

Diagnosis: 54 year old RN has a history of 2 months of diarrhea and abdominal pain. He has been to 4 other hospitals with the same complaints. Colonoscopy reveals pigmentation in the wall of the colon?

answer

Munchausen syndrome Melanosis coloni from laxatives

question

What is Munchausen syndrome?

answer

More severe then simple factitious (complaints of symptoms but don't do anything to create them) --Patients actually induce symptoms and do it for primary gain

question

Diagnosis: Concerned mother presents with 15 month old baby who is having recurrent seizures. She requests an MRI, sleep deprived EEG with intercranial leads.

answer

Munchausen syndrome by proxy Form of child abuse --> Call CPS

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Diagnosis: Patient is unemployed man 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?

answer

Malingering --Secondary gain Associated with antisocial personality disorder

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Diagnosis: Patient presents with no menstrual cycle for 3 mo. A pregnancy test is negative, but her BMI is 17. Her teeth are eroded and she has calluses on her knuckles?

answer

Anorexia, purging type --Amenorrhia (endocrine abnormality) --Low BMI

question

Vital signs typical of anorexia?

answer

Hypotension, bradycardia, and hypothermia

question

Labs typical of anorexia?

answer

CBC = leukopenia Chemistry = high H3CO, low Cl, low K, high LFTs and amylase TFT = normal Fasting lipid profile = elevated Hormones = elevated cortisol, low estrogen, low LH/FSH

question

Long term complications of anorexia?

answer

Osteoporosis

question

Most common cause of death anorexia?

answer

Heart disease, due to arrhythmias Suicide (close second)

question

Complications of anorexia?

answer

--Intensive counseling --Nutrition, i.e. TPN

question

Complications of TPN in anorexia?

answer

Re-feeding syndrome = *low PO4*, low mg, low ca *caused by fluid retention*

question

EEG: What are the characteristics of alertness?

answer

Beta --Highest frequency, lowest amplitude

question

Characteristics of Stage 1 sleep EEG

answer

Theta --Consists about 5% of sleep

question

Characteristics of Stage 2 sleep EEG

answer

Deeper sleep --Sleep spindles and K complexes --Consists about 45% of sleep --Bruxism occurs

question

Characteristics of Stage 3 sleep EEG

answer

*Delta --Lowest frequency, highest amplitude)* 25% --Consists about 25% of sleep --Deepest non-REM sleep (slow-wave sleep); when sleepwalking, night terrors, and bedwetting occur Stage 3 is the less then 50% theta waves and stage 4 is greater then 50% theta waves

question

What drugs decrease Stage 3/4 sleep?

answer

Impramine (used to decrease bedwetting) Benzodiapazenes Alcohol also decrease stage 3 and 4 sleep

question

Characteristics of REM sleep EEG

answer

REM --Consists about 25% of sleep --Skeletal muscle paralysis ---Loss of motor tone, increase brain O2 use --Variable pulse and blood pressure; when dreaming and penile/clitoral tumescence occur; may serve a memory processing function

question

Sleep EEG in depression

answer

Decreased REM latency and increased REM

question

Sleep EEG in the elderly

answer

Decreased REM latency and increased cycling, often less REM

question

Diagnosis: Trouble falling asleep or staying asleep causes impairment in functioning for over one month?

answer

Insomnia --Educate about *sleep hygiene 1st*, then try benzos (reduce sleep latency and increase SWS and REM)

question

Treatment for insomnia?

answer

Zolpidem, zaleplon, escopiclone = GABAa agonist

question

Diagnosis: As patient is falling asleep, they feel creepy-crawlies on legs. Symptoms improve when they get up and move

answer

Dyssomnia --Restless leg syndrome and periodic leg movement syndrome --Rule out medical causes 1st --> Fe-def anemia or chronic kidney disease/neuropathy

question

Treatment for Dyssomnia?

answer

Ropinirole (side effect of pathological gambling) or Pramipexole = Dopamine agonists

question

Diagnosis: Daytime sleepiness and depression in a big fat guy with a big neck.

answer

Obstructive Sleep Apnea

question

Diagnosis of OSA?

answer

Need polysomnogram to diagnose and must have over 10 hypopneic/apneas per hour

question

Treatment for OSA?

answer

CPAP --> reduce pulmonary HTN

question

Diagnosis: Irresistible attacks of refreshing (REM) sleep. Upon intense emotion, they lose muscle tone or have hallucinations as waking or falling asleep.

answer

Narcolepsy --Must have cataxplexy or hypnogognic or hypnopomonic hallucinations

question

Treatment for narcolepsy?

answer

Modafinil and scheduled naps

question

Diagnosis: 30 year old man and his wife present for couples counseling. He constantly accuses her of cheating. He's in a feud with the neighbor because he feels they are attacking his character when they say they like his flowerbeds.

answer

Paranoid Personality Disorder

question

Treatment for Paranoid Personality Disorder

answer

Low dose anti-psychotics

question

Diagnosis: 30 year old 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.

answer

Schizoid Personality Disorder --Distinguish from Avoidant because they don't WANT relationships

question

Diagnosis: 30 year old 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."

answer

Schizotypal Personality Disorder Distinguish from Schizoid by magical thinking/interests Distinguish from Schizophrenia by lack of delusions/hallucinations

question

Diagnosis: 25 year old man comes to court mandated counseling for beating his girlfriend. He was kicked out of high school for fighting and just got out jail for stealing a car.

answer

Antisocial Personality Disorder 2/3 have substance abuse (most common co-morbid condition)

question

Diagnosis: Patient has a history of unstable relationships, has superficial cuts on both wrists, and is impulsive in her spending and sexual practices.

answer

Borderline Personality Disorder

question

Common defense mechanism in Borderline?

answer

Splitting

question

Diagnosis: 26 year old MS2 is asked to seek counseling. Her classmates complain that she dresses too provocatively to class. She recently tried to seduce a professor.

answer

Histrionic Personality Disorder

question

Co-morbid conditions with Histrionic?

answer

Substance abuse Eating disorders

question

Diagnosis: 22 year old MS1 doesn't feel like he needs to come to any classes or labs because he "already has the brilliance to be a doctor.

answer

Narcissistic Personality Disorder

question

Treatment for Narcissistic?

answer

Individual therapy

question

Diagnosis: 30 year old 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".

answer

Avoidant Personality Disorder

question

Treatment for Avoidant?

answer

Treat social phobia symptoms with beta-blocker or SSRI

question

Diagnosis: 30 year old 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.

answer

Dependent Personality Disorder

question

Co-morbid conditions with Dependent?

answer

Depression Anxiety

question

Treatment for Dependent?

answer

SSRI

question

Diagnosis: 25 year old 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"

answer

Obsessive Compulsive Personality Disorder Different from OCD because actions are ego-syntonic

question

Diagnosis: 78 year old 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 the work up of this patient?

answer

Medical work-up is the first step in suspected delrium UA and culture Glucose, chemistry, blood culture, B12, RPR Medications: Benadryl, opiates, benzos

question

What is the biggest risk factor for delrium?

answer

1) Age 2) Underlying dementia

question

What is a common cause of delrium?

answer

Acute substance withdrawal

question

What are the EEG changes of the Delrium?

answer

*Diffuse slowing of the background rhythm* = Slow waves

question

What are the EEG changes of psychosis?

answer

Normal

question

Treatment for Delrium?

answer

--Reduce excessive stimuli, calendar and clock to orient the patient --STOP unecessary medications --Haloperidol for agitation

question

Diagnosis: 78 year old female presents with memory loss, in addition to aphasia, apraxia, and gets lost while driving?

answer

Alzheimer's Dementia

question

What is the most common type of dementia?

answer

Alzheimer's Dementia

question

What is the pathology of Alzheimer's Dementia on MRI?

answer

--Diffuse brain atrophy, beta-amyloid plaques or tau tangles *tangles correlate with the degree of dementia* --Decreased ACH (Basal nucleous of Meyhert)

question

What are the genes associated to Alzheimer's Dementia?

answer

Early onset: APP (Chr 21), presenilin-1 (Chr 14), presenilin-2 (Chr 1) Late onset: ApoE4 (Chr 19), *ApoE2 (Chr 19) is protective*

question

Treatment for Alzheimer's Dementia?

answer

Rivastigmine, Donepezil, Galantamine --> Ach-esterase inhibitors = *cause diarrhea* Memantine --> NMDA antagonist - decrease excitability *None of these improve memory, only decrease rate of decline*

question

Diagnosis: 78 year old female presents with memory loss, becomes more sexually explicit, apathy?

answer

Frontotemporal Dementia/Pick's Disease

question

Pathology of Frontotemporal Dementia/Pick's Disease?

answer

Lobar atrophy, with sparing of the parietal lobe *intra-neuronal silver staining inculsions*

question

What is the treatment for Frontotemporal Dementia/Pick's Disease?

answer

Olanzepine (for severe disinhibition, stops behavioral problems)

question

Diagnosis: 78 year old female presents with memory loss, fluctuation in consciousness, *visual hallucinations* and shuffling gait

answer

Lewy-body Dementia

question

Pathology of Lewy-body Dementia?

answer

Intra-cytoplasmic, alpha-synuclein inclusions in neocortex

question

Treatment for Lewy-body Dementia?

answer

Ach-Esterase inhibitors *NOT L-dopa* Avoid neuroleptic - *no haliperdol or benzos*

question

Diagnosis: 78 year old female presents with memory loss, sudden, step-wise decrease in memory/cognitions. Work up?

answer

Vascular Dementia. Work-up: MRI and MRA

question

Diagnosis: 78 year old female presents with memory loss, loss of vibration sense, and labile affect. Pupils accommodate but don't react. What is the test?

answer

Tertiary Syphilis. Tests: +RPR, VDRL Spinal tap to look for spirochetes, if seen IV pencillin

question

Treatment for Tertiary Syphilis?

answer

IV penicillin If Pen-allergic, must desensitize

question

Diagnosis: 78 year old female presents with memory loss, myoclonus, startle response, and seizures. Recently had a corneal transplant. What is the pathology ?

answer

Creutzfeldt Jakob Pathology: Spongiform encephalopathy

question

What are the EEG findings in Creutzfeldt Jakob?

answer

Triphasic Bursts

question

Diagnosis: 78 year old female presents with memory loss Incontinence, gait disturbance with frequent falls, and rapidly developing. Work up?

answer

Normal Pressure Hydrocephalus. CT/MRI shows hydrocephalus Spinal tap shows normal opening pressure

question

Treatment for Normal Pressure Hydrocephalus?

answer

Ventriculoperitoneal shunt Improves cognitive function in 50-67% of patients

question

50 year old known alcoholic presents to the ER with tonic clonic seizures. BP 180/110, HR 118, T 100.1. How long since the last drink?

answer

12-24 hours Bimodal peak at 8 and 48 hours

question

Diagnosis: 50 year old known alcoholic presents to the ER with tonic clonic seizures. BP 180/110, HR 118, T 100.1. How long until he develops confusion, fluctuations in consciousness, and the feeling of ants crawling on him?

answer

Delirium tremens 48-72 hours since last drink

question

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?*

answer

~9hrs, Alcohol is metabolized by zero order kinetics (same amt/unit time = 25mg/hr)

question

50 year old 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?

answer

Hyperreflexia Beta-blockers mask signs of autonomic hyperactivity Dose benzos based on hyperreflexia

question

Best initial treatment for alcohol withdrawal?

answer

Diazepam or chloridiazepoxide, due to long 1/2 lives; 80 & 120 hours, respectively

question

Best initial treatment for alcohol withdrawal if the alcoholic is child class C?

answer

Lorazepam, oxazepam, or tempazepam in settings of cirrhosis

question

Most specific test for ETOH consumption in the past 10 days?

answer

Carbohydrate-deficient transferrin Less specific: *elevated GGT* and AST >2xAST

question

Diagnosis: Patient with a history of alcohol use comes in with confusion, ataxia, opthalmopelegia?

answer

Wernicke Encephalopathy Cause: thiamine deficiency

question

Treatment for Wernicke Encephalopathy?

answer

Give thiamine first, then glucose containing fluids

question

Is Wernicke Encephalopathy reversible?

answer

Yes!

question

Wernicke Encephalopathy can progress to what and how can you tell?

answer

Korsakoff's syndrome Due to irreversible damage to mamillary bodies Mamillary body atrophy on MRI

question

Characteristics of Korsakoff's syndrome?

answer

Apathy, anter/retrograde amnesia, and confabulation

question

Diagnosis: 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?

answer

Heroin overdose Best initial step: Intubate (under 8 = intubate) Next: IV or IM naloxone (full mu-opiate antagonist)

question

Diagnosis: 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. You realize his pupils are dilated.

answer

Heroin overdose Hypoxia 2/2 to respiratory depression can cause pupil dilation

question

What symptoms do you expect as he starts to withdraw from heroin?

answer

Joint and muscle pain, photophobia, goosebumps, diarrhea, tachycardia, HTN, GI cramps, dilated pupils, anxiety/depression

question

Treatment for heroin withdrawal?

answer

--Clonidine for autonomic symptoms --Ibuprofen for muscle cramps --Loperimide for diarrhea --Methadone, buprenorphrine or Naltrexone can be used for long-term dependence

question

Diagnosis: Patient presents with horizontal nystagmus, dilated pupils, ataxia, and acute psychosis.

answer

Hallucinogen (PCP) intoxication

question

Treatment for Hallucinogen (PCP) intoxication?

answer

Haloperidol for acute psychosis

question

Diagnosis: Patient presents s/p MVC with injected conjunctiva, sedation, and is asking for Doritos.

answer

Cannabis intoxication

question

Diagnosis: Patient presents with suicidal ideation, hypersomnia, depression, and anergia

answer

Cocaine/Amphetamine withdrawal

question

Diagnosis: Patient presents with dilated pupils, seizure, tachycardia and HTN. Best first test?

answer

Cocaine/Amphetamine intoxication Test: EKG Next: Urine tox screen

question

How do you treat seizures induced by cocaine/amphetamine intoxication?

answer

Lorazepam

question

How do you treat HTN and tachycardia in a patient with cocaine/amphetamine intoxication?

answer

Calcium channel blocker *Beta-blockers are CONTRAINDICATED*

question

Piaget's Stages: When is death considered permanent?

answer

6 - 11 years Concrete operational

question

IQ of 40-55...

answer

Moderate retardation

question

IQ of 55-70...

answer

Mild retardation

question

IQ of 25-40...

answer

Severe retardation

question

IQ of <25...

answer

Profound retardation

question

What is the average and standard deviation for IQ?

answer

Average = 100 STD deviation = 15

question

Where does mental retardation go in DSM IV?

answer

Axis 2

question

Diagnosis: 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 macro-orchidism. What is the genetic inheritance? What are the co-morbid genetic conditions

answer

Fragile X X-linked dominate inheritance, CGG repeats with anticipation

question

What are the co-morbid genetic conditions with Fragile X?

answer

Seizures, MVP, dilation of the aorta, tremors, ataxia, ADHD-like behavior.

question

Diagnosis: A newborn baby has decreased tone, oblique palpebral fissures, a simian crease, big tongue, white spots on his iris.

answer

Down Syndrome White spots: Brushfield spots

question

What can you tell the mother of Down Syndrome newborn about his expected IQ?

answer

Likely mild-moderate MR Expected speech, gross, and fine motor skill delays

question

Common medical complications Down Syndrome?

answer

--Heart: VSD, endocardial cushion defects --GI: Hirschsprung's, intestinal atresia, imperforate anus, annular pancreas --Endocrine: Hypothyroidism --MSK: Atlanto-axial instability - careful for intubation --Neuro: Increased risk of Alzheimer's by 30-35x - APP is on Chr21 --Neoplasm: 10x increased risk of ALL

question

Diagnosis: Café-au-lait spots, seizures, large head. Genetic inheritance?

answer

Neurofibromatosis Autosomal dominant

question

Diagnosis: Coarse facies, short stature, cloudy cornea. Genetic inheritance?

answer

Hurler Syndrome Autosomal recessive

question

Diagnosis: Broad, square face, short stature, self-injurious behavior. Allelic anomaly?

answer

Smith Magenis Deletion on Chr17

question

Diagnosis: Hypotonia, hypogonadism, hyperphagia, skin picking, agression. Allelic anomaly?

answer

Prader-Willi Deletion on paternal Chr15.

question

Diagnosis: Seizures, strabismus, sociable with episodic laughter. Allelic anomaly?

answer

Angelman Deletion on maternal Chr15.

question

Diagnosis: Elfin-appearance, friendly, increased empathy and verbal reasoning ability. Allelic anomaly?

answer

Williams Deletion on Chr7

question

Diagnosis: ADHD-like symptoms, microcephaly, smooth philtrum. Most common cause of mental retardation.

answer

Fetal Alcohol Syndrome

question

Diagnosis: Seizures, chorioretinitis, hearing impairments, *periventricular calcifications*, petechiae at birth, hepatitis.

answer

Congenital CMV infection

question

Diagnosis: Seizures, hearing impairments, *cloudy cornea/retinitis*, heart defects, low birth weight.

answer

Congenital Rubella Syndrome

question

Diagnosis: Abnormal muscle tone, unsteady gait, seizures, mental retardation or learning disability.

answer

Cerebral Palsy from birth asphyxia.

question

Diagnosis: IUGR, hypertonia, distinctive facies, limb malformation, self-injurious behavior, hyperactive.

answer

Cornelia de Lange

question

Diagnosis: Coloboma, heart defects, choanalatresia, growth retardation, GU anomalies, ear deformity and deafness.

answer

CHARGE

question

Diagnosis: Autism spectrum, heart disease, palate defects, hypopasticthymus, hypocalcemia. Allelic anomaly?

answer

DiGeorge Chr22 deletion

question

Diagnosis: Vomiting, seizures, lethargy, coma, acidosis with stress, illness. Causes neurological damage.

answer

Maple Syrup Urine Disease

question

Diagnosis: Exclusively in girls, normal development for 6-8 months then regression, handwringing, loss of speech and use of hands. Allelic anomaly?

answer

Rett Syndrome X-linked dominant deletion of MECP2.

question

Diagnosis: Normal development until age 2 then major loss of verbal, social skills with autistic-like behavior.

answer

Childhood Disintegrative Disorder

question

Diagnosis: Lack of mother-child eye contact, language delay/repetitive language, preoccupation with "parts of toys" before age 3.

answer

Autism

question

Diagnosis: Problems with social skills (usually recognized in preschool) with preserved verbal ability.

answer

Aspergers

question

Diagnosis: 7 year old boy is 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. Next best step?

answer

Normal age appropriate behavior Diagnosis of ADHD needs misbehavior in 2+ settings Next best step: How does he do at school?

question

Risk factors for ADHD?

answer

--Family history = 77% heritability --LBW --Tobacco and ETOH exposure

question

Co-morbid conditions with ADHD?

answer

ODD/CD in 30-50%

question

Treatment and side effects for ADHD?

answer

Methylphenidate: DA antagonist Amphetamine: DA and NE antagonist Atomoxetine: NE antagonist, non stimulant Side Effects: Nausea, decreased appetite, increase HR and BP, stunted growth

question

Diagnosis: 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.

answer

Conduct Disorder Symptoms must be present for at least 6 months

question

Co-morbidity with Conduct Disorder?

answer

Substance abuse

question

Diagnosis: 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.

answer

Oppositional Defiant Disorder Symptoms must be present for at least 12 months Stops short of law-breaking or physically harming others

question

Diagnosis: 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.

answer

Tourette Tics must occur at *x1/day for 1 year* WITHOUT *tic-free period longer than 3 months*

question

Co-morbid conditions with Tourette?

answer

Compulsions of OCD

question

Treatment for Tourette?

answer

First line: Clonidine, relatively benign side effects Most Effective: Haloperidol or pimozide (DA antagonists)

question

Diagnosis: 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.

answer

Separation Anxiety Disorder

question

Diagnosis: 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.

answer

Reactive Attachment Disorder

question

Diagnosis: 18 month old baby has recently been regurgitating and re-chewing her food. She had previously been eating normally. Test?

answer

Rumination Disorder Check lead levels

question

Diagnosis: 6 year old stools in her clothes once every 2 weeks. Next best test? Tx?

answer

Next best test: Check for fecal retention

question

Treatment for fecal retention?

answer

Behavioral modification that only rewards

question

Diagnosis: 6 year old that urinates in her clothes once a day. Next best test?

answer

Test: Rule out UTI

question

Treatment for bed-wetting?

answer

Treatment: Alarm and pad

Emma Holliday – Psychiatry – Flashcards

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