Ch 24. Psychiatry

Question 1

Suicide risk factors (10)


Answer 1

SADPERSONS 

1. Sex (male)

2. Age >65

3. Depression
4. Previous attempt
5. Ethanol use
6. Rational thinking - lacking
7. Social supports – lacking
8. Organized plan
9. No spouse
10. Sickness (medical)
* 5 or more points is high risk

Question 2

Treatment of acute dystonia/akathisia (2)


Answer 2

Acute dystonia is from acetylcholine dysregulation, Rx: Anticholinergic’s
1. Diphenhydramine 50mg IV

2. Benztropine (Cogentin) 2mg

Question 3

Life-threatening adverse drug reaction with carbamazepine and lamotrigine (1), clozapine (1)


Answer 3

1. Steven-Johnson syndrome 


2. Clozapine: agranulocytosis

Question 4

Diagnosis of depression (9)


Answer 4

M-SIG-E-CAPS

1. Sleep
2. Interest

3. Guilt

4. Energy

5. Concentration

6. Appetite

7. Psychomotor

8. Suicide

And depressed mood, >2weeks

Question 5

Symptoms of serotonin syndrome (4)


Answer 5

1. Neuromuscular hyperactivity (tremor, myoclonus, ocular clonus, hyper-reflexia, seizures)

2. Altered mental status (restless, agitated, confused, altered)
3. Autonomic hyperactivity (fever, HTN, tachycardia, diaphoresis)

4. GI irritability (NVD)


Question 6

Benzo equivalents: Lorazepam to Midaz to Diazepam (1)


Answer 6

1. 1mg Lorazepam = 2mg Midaz = 5mg Diazepam


Question 7

Symptoms of Wernicke encephalopathy (3)


Answer 7

Wernicke’s = WACO

1. Ataxia

2. Confusion

3. Opthalmoplegia

Question 8

How to treat opioid withdrawal? (1)


Answer 8

1. Suboxone (buprenorphine/naloxone)
* Use in mild withdrawal. Caution in moderate-severe as the buprenorphine can displace opioid from the u receptor and worsen withdrawal Sx


Question 9

Hot and crazy DDx (6)


Answer 9

1. Sympathomimetics: Methamphetamines, Caffeine, Anticholinergics 

2. Syndromes: Serotonin Syndrome, NMS, MH 

3. Infectious: Sepsis, Meningitis, Encephalitis

4. Metabolic: Pheochromocytoma, Thyrotoxicosis

5. Environmental: Heat stroke

6. Toxicological: MDMA, ASA Withdrawal EtOH/Benzodiazepines

Question 10

DDx for drugs that cause wide complex tachycardia?(9)


Answer 10

PASTA CACA

1. Phenothiazine’s can be on the differential but they don’t tend to be the ones we use in Canada (Mesoridazine and Thioridazine have been used in the past and may be more likely to be associated with WCT)
2. Antihistamines (diphenhydramine, dimenhydrinate)
3. Sotalol, TCA, Antipsychotics, Cocaine,
4. Anti-spasmodic including cyclobenzaprine
5. Anti-diarrheal like loperamide can be abused. They act at the mu receptors peripherally and do not cross the BBB until they are taken in large doses i.e. 100s of mg. At that point they give central opioid-like effects
6. Chloroquine, Anti-malaria
7. Anti-arrhythmic class 1A. Class IB anti-arrhythmics do not tend to affect the QRS because they have fast on and off kinetics.

Question 11

How to differentiate NMS and SS? (2)


Answer 11

• Both are rigid, wet, and febrile. SS has increasing reflexes, rigidity, and ocular clonus
  
1. Serotonin Syndrome (antidepressants) has a predictable effect of excess serotonin and tends to come on quickly and go away quickly (24-48 hrs).
  2. NMS (antipsychotics) has a much more indolent onset (Scott Lucyk Grandma Fever – elderly individual has been acting funny for a few days and now she has a fever). It has a less predictable onset and may not go away for days to weeks. It is rare and a diagnosis of exclusion.