Behavioural Science Flashcards
What is the most likely diagnosis?
Alcohol withdrawal.
What is the pathophysiology of Alcohol withdrawal?
Alcohol is a central nervous system depressant that causes neuronal changes, including stimulation of the γ-aminobutyric acid (GABA)A receptor. Repeated consumption of alcohol desensitizes GABAA receptors, resulting in tolerance and physical dependence. When a person suddenly stops consuming alcohol, the nervous system is hyperaroused and synapses fire uncontrollably; the result is the symptoms seen in alcohol withdrawal. Increased serum norepinephrine and altered serotonin levels have also been implicated in both alcohol craving and tolerance.
What are the symptoms of Alcohol withdrawal?
Minor symptoms (occurring 6–36 hours after the last drink) include: diaphoresis, GI upset, headache, nausea and vomiting, palpitations, and tremulousness. Seizures can occur within 6–48 hours of the last drink. Visual (or less commonly, tactile or auditory) hallucinations can occur within 12–48 hours of the last drink, and delirium tremens may occur within 48–96 hours.
What is delirium tremens?
Delirium tremens is a collection of severe alcohol withdrawal symptoms that includes delirium, agitations, and autonomic instability such as tachycardia, hypertension, low-grade fever, and diaphoresis. Approximately 5% of patients with alcohol withdrawal symptoms develop delirium tremens.
What is the appropriate treatment for alcohol withdrawal?
Benzodiazepines, particularly lorazepam or diazepam, are the treatment of choice for all types of alcohol withdrawal symptoms.
What is the most likely diagnosis?
What class of drugs might be responsible for this patient’s symptoms?
What treatment was likely administered to this patient in the emergency department?
- Benzodiazepine toxicity, as characterized by respiratory depression, confusion, and other symptoms of central nervous system depression.
- Her friend’s description is consistent with a diagnosis of panic disorder. Benzodiazepines (such as clonazepam, lorazepam, and alprazolam) are commonly used in the short-term treatment of panic disorder.
- Flumazenil, a competitive antagonist at the γ-aminobutyric acid (GABA) receptor, is effective in reversing symptoms of benzodiazepine overdose.
How does the mechanism of action of benzodiazepines differ from that of barbiturates?
Normally, GABAA receptors respond to GABA binding by opening chloride channels, which raises the membrane potential of the neuron and inhibits neuronal firing. Benzodiazepines and barbiturates enhance the affinity of GABA for GABAA receptors. Benzodiazepines increase the frequency of chloride channel openings. Barbiturates increase the duration of chloride channel openings.
What are the advantages of treatment with benzodiazepines over barbiturates?
Benzodiazepines have a lower risk of dependence, P450 system involvement, respiratory depression, coma, and loss of rapid eye movement sleep. They are considered to be much safer than barbiturates in cases of overdose (specifically, barbiturates have a lower therapeutic index).
What 6 drugs, when taken with benzodiazepines, increase the risk of toxicity?
- Acetaminophen
- Alcohol
- Cimetidine
- Disulfiram
- Isoniazid
- Valproic acid
What is the most likely diagnosis?
Anorexia nervosa.
What other symptoms of this condition are common at presentation of Anorexia Nervosa?
Patients typically present with severe weight loss (with body weight < 85% of ideal body weight) and clinical manifestations of multiple nutritional deficiencies. Despite being underweight, anorexic patients are obsessed with calories, preoccupied with dieting, and intensely fearful of gaining weight. Dental caries and erosions (Figure 1-2) may be present if patients are also inducing vomiting. Additional purging via laxative abuse may cause palpitations, lightheadedness, or chest pain due to electrolyte abnormalities.
What is Russell’s sign?
Russell’s sign is scarring on the knuckles due to repeatedly sticking fingers down one’s throat to induce vomiting.
How is Anorexia Nervosa differentiated from bulimia?
Bulimia nervosa can present with findings similar to anorexia. Its hallmark is uncontrollable binge eating followed by purging. Patients with bulimia usually have normal weight and irregular menses. Nutritional deficiencies, however, are uncommon.
What nutritional deficiency may contribute to the ra- diographic findings in Figure 1-1?
Fractures of the fifth metatarsal bone in anorexic patients are often related in part to osteopenia or osteoporosis secondary to vitamin D and calcium deficiency.
What region of the brain regulates appetite and is thought to play a role in eating disorders?
The “feeding center” is located in the lateral nucleus of the hypothalamus. When stimulated, it promotes eating/appetite. The “satiety center” is located in the ventromedial nucleus. When stimulated, it signals the body to stop eating. Lesions to this area cause hyperphagia and obesity.
What kind of anemia does this patient likely have?
Low hematocrit and low MCV suggest microcytic anemia, most likely due to iron deficiency, a common feature in patients with anorexia. Inadequate vitamin B12 and folate intake cause macrocytic anemia. Some patients may have overall normocytic anemia due to the combined microcytic and macrocytic anemias.
What is the treatment and prognosis of Anorexia Nervosa?
A multidisciplinary treatment approach focuses on restoring the patient to a healthy weight and uses psychotherapy to correct the thoughts and behaviors that initially caused the disordered eating. Prognosis is variable, as one fifth of patients remain severely ill, one fifth recover fully, and three fifths have a fluctuating, chronic course.
In terms of study design, what is bias?
Bias refers to any source of error in the determination of association between the exposure (drug use, in this case) and outcome (reduction in anxiety, in this case).
What types of bias can be found in this study? What is another important type of bias found in the research design of some studies?
Late-look bias, which pertains to information gathered at an inappropriate time, is another type of bias; an example would be following up on results after another intervention outside of the study has taken place.
What are some ways that bias can be reduced?
Bias can be reduced by using placebos, randomizing the subjects who are using the drug, designing a double-blind study, and employing a crossover study in which the subject acts as his or her own control.
What is blinding and what types of blinding are there?
Blinding is an aspect of study design that conceals information that could bias the results of the study from some or all of the persons involved in the study. Trials may be single-blind or double-blind. In single- blind trials, subjects do not know whether they have been assigned to the experimental or the control group. In double-blind trials, neither the subjects nor the researchers know who has been assigned to the experimental group and who has been assigned to the control group.
What should the physician do in this scenario?
Because the patient is not considered to be a minor or an elderly patient (defined as being older than 65 years of age), the patient’s right to confidentiality must be respected. Although the physician should make all resources available to her, such as a battered women’s home, the ethical principles of patient autonomy and privacy must be followed.
Should the physician contact members of the woman’s family or close friends named in the social history?
No, the physician should not contact friends or relatives of the patient; doing so when clearly told not to by the patient would break the principle of autonomy. Also, the physician is bound by the privacy rule of the Health Insurance Portability and Accountability Act (HIPAA).
What are the exceptions to confidentiality?
There are a number of exceptions to confidentiality besides the age parameters that protect minors and the elderly. These exceptions rely on the physician’s judgment. If the potential harm to self or others is great or serious, then confidentiality may be violated to preserve the principle of beneficence. It is the responsibility of the physician to take steps to prevent harm if there are no alternative means to protect those at risk.
What is the Tarasoff decision?
The Tarasoff decision is a law requiring a physician to directly inform and protect potential victims from
harm. In this case, for example, if the woman told the physician that she had a gun and was going to go back home and kill her boyfriend for abusing her, the physician would have a duty to inform the boyfriend and detain the patient.
What is the physician’s duty if a patient has a serious infectious disease and is putting others at risk?
Physicians have a duty to warn public officials and other identifiable persons at risk if a patient has certain infectious diseases. These diseases include hepatitis A and B, salmonella, shigella, syphilis, measles, mumps, AIDS, rubella, tuberculosis, chickenpox, and gonorrhea.
If the patient decides, with full mental capacity, that he does not want to have this surgery, what should the physician do?
Under the core ethical principle of autonomy, the physician has an obligation to respect and honor the medical care choices of the patient.
If the physician believes that not proceeding with this surgery is against the patient’s best interest, what should the physician do?
The physician has a fiduciary duty to act in the patient’s best interest under the ethical principle of beneficence; however, if the patient can make an informed decision (ie, is aware of the risks, benefits, and alternatives to surgery/treatment), he has the right to decide what type of treatment he will receive and the physician must respect that decision.
What ethical principle is violated in all surgeries?
Because the benefits of a surgical intervention often outweigh the risks, the principle of nonmaleficence, or “do no harm,” is often broken as a means to a better end.
What is the fourth ethical principle that the physician must follow?
The last of the four core ethical principles is justice, which is to treat all persons fairly without exception.
If the patient decides he wants to proceed with the surgery, what should the physician do?
The physician must obtain informed consent from the patient. This is a process in which the physician discloses the risks and benefits of the procedure, the available alternatives, and the risks and benefits of refusing the procedure. As a result, the patient is able to make an informed decision about whether he will have the procedure.
What is the most likely diagnosis? 5 key features?
Delirium. Key features include:
1. Acute onset
2. Reduced attention
3. Waxing and waning course
4. Disorganized thinking
5. Altered level of consciousness.
What drugs of abuse could be involved in this case?
- Alcohol
- Amphetamines
- Benzodiazepines or barbiturates
- Cocaine
- Heroin (opioids)
- Lysergic acid diethylamide (LSD)
- Phencyclidine (PCP)
What signs and symptoms are associated with PCP and LSD intoxication and withdrawal?
What is the sensitivity of this test?
Sensitivity is defined as the percentage of test subjects who have the infection and test positive for it. In other words, sensitivity = true positives/(true positives + false negatives). Therefore, the sensitivity of this test is 30/57, or 52.6%.
What is the specificity of this test?
Specificity is defined as the percentage of test subjects who do not have the infection and test negative for it. In other words, specificity = true negatives/(true negatives + false positives). Therefore, the specificity of this test is 300/343, or 87.5%.
What is the positive predictive value (PPV) of this test?
PPV is defined as the probability that a person with a positive test result is actually infected. Therefore, the PPV of this test is 30/73, or 41.1%. The PPV is directly proportional to the prevalence of the disease being tested; therefore, if the disease is prevalent, the PPV of the test will be high.
What is the negative predictive value (NPV) of this test?
NPV is defined as the probability that a person who is truly uninfected will have a negative test result. Therefore, the NPV of this test is 300/327, or 91.7%.
What is the prevalence of HIV in the population tested?
Prevalence is defined as the proportion of people who actually have the infection in relation to the total population at a point in time. Therefore, the prevalence of HIV in this population is 57/400, or 14.3%.
What is the prevalence of HIV in the population tested?
Prevalence is defined as the proportion of people who actually have the infection in relation to the total population at a point in time. Therefore, the prevalence of HIV in this population is 57/400, or 14.3%.
Is it normal that the younger twin has not begun to walk?
Yes. The approximate age that children reach the motor milestone of walking is 15 months. Between 6 and 9 months of age, children should be able to sit without help.
What is an APGAR score?
APGAR is an acronym for the scoring system that measures: Appearance, Pulse, Grimace, Activity, and Respiration (Table 1-2). Each category is scored from 0–2 (Table 1-2); a total of 10 is a perfect score. Scoring is done at 1 and 5 minutes after birth. APGAR score is not a prognostic tool for future childhood developmental milestones.
What is a malpractice suit, and what criteria justify it?
A malpractice suit is a civil suit under negligence that requires four fundamental criteria, also referred to as the “four Ds”: duty, dereliction, damage, and direct. First, it must be understood that the physician had a duty or responsibility to the patient. Second, the physician must have breached that duty, which is called dereliction. Third, the patient must suffer harm or damage. Finally, the harm caused must be a direct cause of the dereliction.
In this case, if the physician decides not to perform a reparative procedure, are the grounds for malpractice justified?
It depends. Although the duty and damage are present in this case, it is unclear whether the physician was derelict in his duty and whether the patient’s abdomen dimple is the result of dereliction. For example, if the patient did not follow postoperative instructions, even though she was told to do so to prevent complications, the physician’s actions would not be the cause of the harm. But if the surgeon did not follow the standard of care in her treatment and this caused her complication, the woman would be justified in suing.
What action should the physician in this case take?
The physician should try to find the reason for the dimpling. If it is determined that he made an error in surgery, he should immediately apologize to the patient. Studies show that if a physician is honest and upfront about an error, he or she is less likely to be sued by the patient. Lastly, if miscommunication was the culprit, the physician should make every effort to prevent such miscommunication in the future.
What defense mechanism is the father using?
What defense mechanism is the child using?
What type of reinforcement is the child using on the mother?
The father is using displacement, which is characterized by the transfer of feelings from one object or person to another. In this case, the father’s anger at the mother is displaced onto the child.
The child is acting out, which is characterized by the use of extreme behavior to express a thought or feeling. In this case, the child is so overcome with anger that he cannot simply state, “I’m angry with you”; instead, he acts out by throwing food across the table.
This is an example of positive reinforcement, in which the consequences of a response increase the likelihood that the response will recur. Specifically, the child cries because crying makes it more likely the mother will continue to give him candy.
Which method of conditioning is the father using by removing the reward?
The father is employing extinction, which is the elimination of a behavior by nonreinforcement. The child likely will stop crying after discovering that there is no reward for the behavior.
What is the most likely diagnosis?
The infant most likely has opioid intoxication, heralded by the triad of (1) respiratory depression, (2) central nervous system depression, and (3) pinpoint pupils. Importantly, pinpoint pupils due to opioid intoxication will be present despite opioid tolerance. Other common findings in infants exposed to opioids include low birth weight, premature birth, and intrauterine growth retardation syndrome.
What is the most likely diagnosis on day 3 of life?
On day 3, the infant demonstrates symptoms of opiate withdrawal, also known as neonatal abstinence syndrome. Tachycardia, dilated pupils, diaphoresis, and other opiate withdrawal symptoms are related to sympathetic hyperactivity.
What is the appropriate long-term treatment for this patient? Once the newborn is stabilized, what other issues need to be addressed?
An opioid agonist, such as methadone, relieves symptoms of acute opiate withdrawal. Methadone administration can be tapered as the baby is weaned.
The mother may need substance abuse treatment and counseling. Drug abuse during pregnancy is associated with medical and psychological problems that require evaluation and treatment. If she admits to IV drug use, she should be screened for infectious diseases, including HIV, hepatitis B, and hepatitis C. Also, it is important to arrange adequate follow-up care within the first few weeks of discharge.
What is the diagnosis?
The hallucinations, sudden onset of sleep, and amphetamine treatment are consistent with a diagnosis of narcolepsy. This condition has a strong genetic component.
What kind of hallucinations is the patient having?
Hallucinations that occur before falling asleep are termed hypnagogic hallucinations (“gogic”—“go” to sleep). Hypnopompic hallucinations, which occur during waking, are also associated with narcolepsy.
What are the four classic signs and symptoms of narcolepsy?
In what stage of sleep is this patient’s enuresis occurring?
Enuresis occurs during stage 4 sleep, which is the deepest non–rapid eye movement (non-REM) sleep (Table 1-3).
