Class 10 Flashcards
What do you need to explore with him to decide if you should send him to the ER for investigation of a cardiac or pulmonary cause of the anxiety?
Vital signs (HR close to 200 can’t be anxiety, RR, O2), medical history, medication, drugs, what has changed, shortness of breath, EKG changes, labs, chest pain, full psychiatric and medical history, is there anything different? Arrythimia, PE, cardiomyopathy Is it worse when you’re active, trying to sleep, concentrating, if anxiety based= worse when they sleep
Asthenia
abnormal physical weakness or lack of energy, prolonged fatigue more than one month, fatigue without or before effort
Abulia
an absence of willpower or an inability to act decisively, as a symptom of mental illness
Apathy
lack of interest, enthusiasm, or concern
Clinophilia
tendancy to remain in an inclined position
When to do a head CT
something atypical, rapid onset, focal neuro, weight loss for no apparent reason, depressive sx less than the other sx
Psychiatric presentations associated with medical etiologies
herpes simplex encephalitis, hiv, progressive multifocal encephalopathy, syphilis, typhoid, estrogen withdrawal, SLE, MS, subarachnoid hemmorhage, subdural hematoma, huntingtons, parkinsons, temporal lope epilepsy, stroke, alzheimers, lewy body dementia, frontotemporal dementia, brain tumour, meningitis, zn/vitamin D deficiency, paraneoplastic limbic encephalopathy, pancreatic insulinoma, transient left ventricular apical ballooning syndrome, hypo/hyperthyroidism, cushings, adrenal insufficiency, hyperpara/hypoparathyroidism, pheochromocytoma, gonadal hormone dysregulation, heavy metals
High risk features for an underlying medical mimic
Over 40 yo, no psychiatric history No history of similar sx or worsening of previous sx Familial concern Chronic disease comorbidities History of head injury Change in headache pattern Pt worse after antipsychotic or anxiolytic Difficult/ unlikable pt History of changing psychiatric dx over time Polypharmacie Abnormal autonomic s/sx Visual sitrubance (field loss/ 2 vision) Visual, olfactory, tactile hallucination Nystagmus Illusions Speech deficits Abnormal body movement
Drugs and toxins with known psychiatric effects
antichol, antidépresseur, antihta, antipsychotiques, anxiolytiques,cimetidine, digitalis, interferon, indomethacin, insulin, levodopa, l-thyroxine, sedatives, steroids, sympathomimetics, xanthene derivatives
Psych sx of lupus
Cognitive dysfunction, DEP, acute confusion, psychosis, paranoia, auditory or visual hallucinations, insomnia, MANIA, anxiety, can mimic any psychiatric condition
psychiatric symptoms that can be seen with use of exogenous steroids.
Apathy (ranges from less frequent [≥1% to <4%] to more frequent [≥4% to <10%]), DEP (ranges from less frequent [≥1% to <4%] to more frequent [≥4% to <10%])), including agitation, anxiety, distractibility, euphoria, fear, hypomania, insomnia, irritability, labile mood, lethargy, pressured speech, restlessness, tearfulness, psychosis.
What is the typical time course of psychiatric symptoms with exogenous steroids?
While symptoms typically develop within 3 to 4days(median of 11days)followingthe initiation of corticosteroid therapy, they can occur atanytime, includingaftercompletion or discontinuation of therapy. Dose dependant.
What psychiatric symptoms can be produced by seizure activity in the temporal lobe?
A sudden or strange odor or taste, A sudden sense of unprovoked fear or joy, Loss of awareness of surroundings, A period of confusion and difficulty speaking, Inability to recall what occurred during the seizure, Extreme sleepiness, deja vu, agoraphobia, panic attacks. Rapid onset of very strong emotions, rising epigastric sensation, automatism (chewing, lip smacking) urinary incontinence, damage to their mouths/tongue, bruises, discrete periods of time
Syphilis sx
Personality disorder, psychosis, delirium, dementia, really like any psychiatric condition
Neuro sysphilis, how to check
lumbar puncture
Complication of prolonged QTC
This syndrome is associated with an increased risk of polymorphic ventricular tachycardia, a characteristic life-threatening cardiac arrhythmia also known as torsades de pointes. The primary symptoms in patients with LQTS include palpitations, syncope, seizures, and sudden cardiac death.
normalQTc
“normal”QTcvalues are generally considered to be between 350 and 440 ms. Abnormal over 450.
rx that elongate qtc
Chlorpromazine, haldol, ziprasidone, trazodone, citalopram, escitalopram, fluoxetine, TCAs, clozapine, risperdal, quetiapine, olanzapine, methadone
traditional risk factors for coronary artery disease
high LDL cholesterol, lowHDL cholesterol,high blood pressure (Effexor, bupropion),family history,diabetes,smoking.Obesitymay also be a risk factor.
What are common psychiatric symptoms post-MI? How long do they last?
Symptoms of depression manifest in about one-third of patients who suffered an AMI, and about one in five suffers from a major depressive disorder. Anxiety is also very common, with estimates ranging from 30-40% of hospitalized patients following an AMI. Symptoms do not necessarily lead to a clinical diagnosis such as a generalized anxiety disorder or posttraumatic stress disorder, but in 5% and 15% of patients respectively, a clinical diagnosis of a generalized anxiety disorder or post-traumatic stress disorder has been noted. Cardiac blues/ adjustment disorder resolves in first 2-3 months after cardiac event.
Trx: supportive interventions
What are common physical consequences post-MI that could be misattributed to psychiatric cause?
Fatigue, loss of appetite, insomnia, changes in sex drive
Which psychiatric medications are safe in a patient during the months following an MI?
Bupropion, SSRIs, mirtazapine, zopiclone
Which psychiatric medications are unsafe in a patient during the months following an MI?
All drugs that alter the QTc, stimulants, effexor, trazodone
When would you suggest he go to the ER for further cardiac evaluation if he presented to an appointment with a complaint of chest pain
Abnormal vital signs and EKG, pain that continues after nitro, new onset of pain that is different from what is usual
