Exam 3 Flashcards
What is the most common psychiatric disorder in the US?
Anxiety
What is are the DSM-5 symptom criteria for diagnosis of GAD?
A. Excessive anxiety and worry predominating for at least 6 months
B. Patient finds it difficult to manage the worry
C. 3/6 Anxiety Physical symptoms present most days
D. The disturbance is not due to a medication or other diagnosis
What are the six physical symptoms listed in the DSM-5 as associated with GAD?
-Restlessness
-Easily fatigued
-Difficulty concentrating or mind going blank
-Irritability
-Muscle tension
-Sleep disturbance
What are the DSM-5 symptom criteria for major depressive disorder?
Five or more symptoms present during the same 2 weeks period and represent a change from previous functioning. Symptoms: depressed mood, anhedonia (loss of interest or pleasure), weight loss or gain, insomnia or hypersomnia, psychomotor agitation, fatigue, feeling worthless or guilty, decreased concentration, suicidal ideation
What are the risk factors for major depression?
-Adolescent or older adult
-Female gender
-Family Hx
-Hx of migraines, pain, recent MI, peptic ulcer disease
-Medical conditions: chronic disease or insomnia
-Lifestyle: stress, poverty, lack of education, trauma
What are the common presenting symptoms of depression in the geriatric patient?
-Poor appetite, disrupted sleep, pain, feelings of guilt and worry, suicidal ideation, memory problems, psychomotor agitation
What are the first line pharmacologic treatment options for major depressive disorder?
SSRIs, SNRIs, TCAs, bupropion (a norepinephrine dopamine reuptake inhibitor)
What are the concerns about pharmacological treatment for major depression in the elderly?
-SSRI- increased risk for development of SIADH in elderly
-Increased risk for falls, osteoporosis, and fractures
-Generally the elderly are more sensitive to side effects of medications, have decreased drug metabolism, multiple medical morbidities, and polypharmacy
What are the nonpharmacological treatment options for major depressive disorder?
-Interpersonal and cognitive behavioral therapy
-Support group, counseling
-Establish a routine, increase activities, relaxation, massage, exercise, good nutrition
What are the pharmacological treatment options for GAD?
First line- SSRIs (escitalopram, paroxetine, sertraline),
Acute treatment: SNRIs (Buspirone, venlafaxine)
If needing sedation- TCAs (imipramine)
Antihistamines- hydroxyzine
What are the nonpharmacological treatment options for GAD?
-Cognitive-behavioral therapy/Counseling
-Patient education: symptom recognition, interpretation, decrease intake of stimulants (caffeine/nicotine), relaxation skills
What is the difference between major mood disorders (unipolar) and bipolar disorders I and II?
Unipolar: another name for major depressive disorder, unipolar meaning without mania
Bipolar I: at least one episode of reported mania with or without depression episode; essential feature is mania
Bipolar II: recurrent moods of hypomania and depression
Mnemonic DIGFAST for manic episode
Distractibility
Insomnia
Grandiosity (inflated self-esteem)
Flight of ideas (racing thoughts)
Activities (increased, goal-directed)
Speech (increased)
Thoughtlessness (poor judgement)
How do you assess suicide risk?
Mnemonic SAD PERSONS;
S- Male Sex
A- <19, >45yrs
D- Depression
P- Previous attempts
E- Excessive alcohol/substance use
R- Rational thinking loss
S- Social supports lacking
O- Organized plan
N- No spouse
S- Sickness
What are the stages of grieving?
-Denial
-Anger
-Bargaining
-Depression
-Acceptance
What are the phases of grief?
-Avoidance
-Confrontation
-Accommodation
How would you identify intimate partner violence?
a pattern of assaultive and coervice behaviors that my include inflicted physical injury, psychological abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation, and threats by an intimate partner
What is the clinical presentation of PTSD?
Patient would describe reexperiencing of the event, a pattern of avoidance, and emotional numbing (negative thoughts or feelings, hyperarousal symptoms such as jumpiness)
What are some screening tools for PTSD?
Primary care PTSD Screen for DSM-5 (PC-PTSD-5), Trauma Screening Questionnaire (TSQ)
What are the DSM-5 criteria for a diagnosis of PTSD?
Traumatic or threatened event results in symptoms of re-experiencing the trauma, avoidance, and cognitive mood changes that last greater than a month and cause active distress
What is the pharmacological management for PTSD?
SSRIs- paroxetine, sertraline
TCAs
Anxiolytics- Buspirone to reduce intrusive sx
What is the nonpharmacological management for PTSD?
Safety assessment, trauma-focused psychotherapy, CBT, written narrative exposure
S&S of anorexia nervosa
Hypothermia, constipation, lethargy, nervous energy, hypotension, dehydration, dry skin, hypertrophy of salivary glands
S&S of bulimia nervosa
Tooth erosion, periodontal disease, swollen salivary glands, esophageal irritation, GERD, calluses on the back of hands, abdominal pain, irregular menses
What are the warning signs that a patient might have an eating disorder?
-Weight loss
-Depression/mood swings
-Preoccupation with weight, calories, and food
-Wears baggy clothes
-Excessive exercise
-Hypotension, bradycardia
-Amenorrhea
What are some sleep hygiene strategies for a patient complaining of insomnia?
-Maintain a regular sleep/wake schedule
-Eat regular meals
-Develop a relaxing bedtime routine
-Avoid consuming liquids/caffeine/tobacco/alcohol later in the day and evening
-Avoid naps
-Exercise
-Limit exposure to light in the evenings
-Attempt a quiet activity after 20 minutes of failed sleep attempt
What is the first-line treatment for chronic insomnia?
CBT
How long can benadryl be taken for insomnia?
Short-term: less than 2 weeks
Which is the most energizing SSRI?
Fluoxetine
Which is the most sedating SSRI?
Paroxetine
Which SSRI has a dose limitations due to potential QT prolongation?
Citalopram
Which SSRI has the least drug interaction potential?
Escitalopram
Which SSRI has the longest 1/2 life?
Fluoxetine
Which SSRI has the most drug interaction potential?
Fluoxetine
A patient that was recently started on an SSRI presents to the clinic 2 weeks later with complaint that the medication is not working and is causing frontal headache. What do you do?
-Educate her that the lag of a number of weeks in the onset of SSRI therapeutic effect is expected; these meds need 4-6 weeks of continued use before benefits are seen
-Frontal headache is a common short-term problem with early SSRI use
What are some signs of antidepressant discontinuation syndrome?
Nausea, Flu-like symptoms, anxiety, headaches
Which SSRI is the best choice for a 67-yr-old female patient with multiple comorbidities?
Escitalopram- less risk for drug interactions
Which blood test should be periodically checked while on olanzapine (zyprexa)?
Blood sugar and lipid profile- risk for weight gain and metabolic problems
What would indicate a positive screening for substance abuse?
Positive response to two items on the CAGE questionnaire
What are some symptoms of alcohol withdrawal?
Irritability, tremors, insomnia, seizures, delirium tremens, death
What are some pharmacological treatment options for alcohol withdrawal?
-Benzos: lorazepam, diazepam, carbamazepine
-Antipsychotics: haldol
-Beta blockers, clonidine, phenytoin
What are some non-pharmacological interventions for substance use disorder?
-Motivational interviewing
-Education of effects of drugs
-Inpatient rehab
Symptom criteria for diagnosis of schizophrenia:
-Onset acute or insidious
-Symptoms present for at least 6 months with 2+ positive or negative sx present for at least 1 month
-Social, employment, or self-care impairment
What are the positive symptoms of schizophrenia?
-delusions, hallucinations, disorganized speech
How would you differentiate between a diagnosis of gastroenteritis and irritable bowel syndrome?
Gastroenteritis would likely present with sudden onset and nausea/vomiting/fever; for IBS diagnosis symptoms must be present for at least 3 months continuously or recurrently and no symptoms of systemic disease
What are the negative symptoms of schizophrenia?
-Flat affect
-Alogia- poverty of speech
-Asociality- lack of pleasure in acts that are normally pleasurable
-Apathy
What are the goals of therapy for schizophrenia?
-Management of symptoms, evaluation of community issues such as housing, employment, and association of other illnesses such as PTSD, substance use
Pharmacological intervention for schizophrenia targets what symptoms?
Positive symptoms
Which antipsychotic medication has the lowest risk of causing extrapyramidal symptoms?
Clozapine (but increased risk for agranulocytosis- check CBC)
What are the common side effects to anticipate when prescribing atypical antipsychotics for schizophrenia?
Antcholinergic (dizziness/hypotension)
Metabolic effects- increased lipids, weight gain
Prolonged QT interval
Agranulocytosis (Check CBC)
EPS
Which class of medications for schizophrenia is least likely to cause motor symptoms?
Atypical antipsychotics- equally as effective as typical antipsychotics
Name some atypical antipsychotics
Clozapine, olanzapine (Zyprexa), Quetiapine (Seroquel), Risperidone
What is the only drug approved for treatment of bulimia nervosa?
fluoxetine
What is the difference in the mode of transmission for Hep A, Hep B, and Hep C?
Hepatitis A- contaminated food or water (fecal-oral route_
Hepatitis B- direct contact with infected blood/blood products or sex
Hep C- percutaneous exposure to blood and blood products (most commonly injected drugs)
Describe the clinical presentation of appendicitis
-Acute onset mild-severe epigastric or periumbilical pain; localizes to RUQ in first 24 hours and exacerbated by walking/coughing
-N/V/D or constipation
-Fever/chills
-HTN
-tachycardia, fever
-Flexed knees when lying on side
-Rebound tenderness
-Signs: Rovsing’s, Psoas, obturator
Describe Rovsing’s sign for appendicitis
Deep palpation over the LLQ with sudden, unexpected release of pressure- + if this causes rebound tenderness over RLQ
Describe the Psoas sign for appendicitis
Patient should lift the right leg against gentle pressure applied by the examiner or extend the right leg while in the left lateral decubitus position- increased pain is +
Describe the obturator signs for appendicitis
Right hip and knee flexed, examiner rotates right leg internally; pain in RLQ is +
Describe the McBurney’s sign for appendicitis
Pressure is applied to McBurney’s point (halfway b/w the umbilicus and the anterior spine. of the ilium); + if causes pain
Describe the clinical presentation for GERD
S- hearburn, regurgitation, reflex salivation, dysphagia, sour taste in mouth in the morning, belching, coughing, hoarsness, wheezing
O- PE is usually normal, possible occult blood in stool
How is GERD diagnosed?
Usually by history alone which has a sensitivity of 80%
When should you refer someone with GERD to GI specialist?
If a patient is being treated with a PPI BID without improvement of symptoms in 8 weeks
Describe lifestyle changes recommended for patients with GERD
-Weight loss
-Avoid eating large meals, tight clothing, or bending and straining
-Eat small, frequent meals
-Don’t eat within 4 hours of bedtime
-Avoid smoking
Describe medical management of GERD
Initial: Weight loss, elevate HOB 6-8 in., avoid meals 2-3 hours before bedtime, avoid food irritants, PPI once daily for 8 weeks–> move to twice daily if needed
-After 8 weeks with no response: if EGD shows Barrett’s esophagus, chronic PPI
Monitoring and adverse effects for patients with chronic PPI use
Every 6 months- Vitamin B12, osteoporosis, c.diff, pneumonia are common adverse effects
Differentiate between management of GERD and peptic ulcer disease
GERD- PPI, lifestyle modifications
PUD- PPIs are drug of choice; TUMS or antacids with calcium SHOULD NOT be used, Sucralfate, bismuth preparations, or misoprostol to promote ulcer healing
Describe the diagnosis criteria for IBS
Two of the following must be present for 3 or more months:
-abdominal pain relieved by defecation
-change in frequency in stool
-change in the appearance of the stool
What is the pharmacological management for IBS?
-Anti-diarrheal (Ioperamide, diphenoxylate)
-Antispasmodics- dicyclomine, hyoscyamine
-TCA/SSRI
What is the non-pharmacological management for IBS?
-Identify and eliminate IBS triggering foods
-High fiber diet with at least 8 8-oz glasses of water per day, probiotics
What are the risk factors for cholelithiasis?
-Female
-Obesity
-Pregnancy
-Increased age
-Drugs (BC)
-Cystic fibrosis
-DM
-Sickle cell anemia
What is the clinical presentation of cholecystitis?
S- indigestion, nausea, vomiting, acute colicky pain in RUQ or epigastric area exacerbation after a meal high in fat
O- guarding as pain becomes severe, + Murphy’s sign (severe pain with deep inspiration at the right subcostal region), may have fever and diminished bowel sounds
What lab findings would you expect to see with acute cholecystitis?
-Elevated WBC- up to 15,000
-Alkaline phosphatase elevated
-Elevated bilirubin
What is the gold standard lab test for diagnosis of pancreatitis? What other labs would be elevated on the first day of acute symptoms?
-Elevated serum amylase level, also lipase would be elevated
What lab diagnostics can be used for pancreatitis?
-Amylase (gold standard)
-Lipase level- also elevated
-WBC between 12000-20,000
What is the clinical presentation of chronic pancreatitis?
S- abdominal pain in left epgastric area or LUQ, weight loss, diarrhea, indigestion, nausea, vomiting, pain is exacerbated by food or alcohol
O- mild-moderate epigastric tenderness with no rebound tenderness or guarding
What are the guidelines for colon cancer screening?
If average risk: Starting at age 45 - Colonoscopy every 10 years (gold standard), FIT annually if they decline, or flex sig every 5-10 years, CT colon every 5 years, hemmocult every 3 years
If high risk (close family relative with colerectal CA before age 60)- colonoscopy every 5 years starting at age 40
What is the clinical presentation for diverticular disease?
S- LLQ pain, pain is worse after eating, pain relieved with BM or flatus, fever/chills/tachycardia if inflamed
O- LLQ tenderness, possible firm mass, guarding, rigidity
How would you manage a patient with an incidental finding of uncomplicated diverticular disease?
No further intervention but can be managed with a high-fiber diet or daily fiber supplements with psyllium
Should a patient with ulcerative colitis be encouraged to eat high fiber foods such as raw fruit and veggies?
No, raw fruit and veggies or foods high fiber can cause trauma to the already inflamed mucosal surface
Should a patient with Crohn’s disease be encouraged to eat high fiber foods such as whole grain bread and pumpkin seeds?
No, a patient with Crohn’s should be encouraged to eat a low-residue diet and avoids foods high in fiber; patient should consume canned fruit and vegetables and only white breads
Should a person with IBS slowly increase their fiber intake to 20-30 g/day?
Yes, fiber helps to prevent excessive hydration or dehydration of stool
Clinical presentation of ulcerative colitis
S: Mild case- 4 or less loose stools per day associated with abdominal cramps relieved by defecation; stools may have small amount of blood and mucous present, tenesmus also present
More severe cases- 6 or more loos stools a day that contain blood and mucus; also may have systemic symptoms such as tachycardia, fever, weight loss, and edema
O- tenderness in LLQ or diffuse with guarding and abdominal distention
Pharmacological treatment for ulcerative colitis
-Anti-diarrheals for more mild cases (Lomotil/Imodium)
-Topical mesalamine for disease limited to rectosigmoid area
-Steroid enemas at night for 2 weeks
-PO 5-ASA medications (Azulfidine) can help to maintain remission
Non-pharmacological treatments for ulcerative colitis
-Nutrition counseling: avoid caffeine, raw fruits and vegetables, and other foods high in fiber
-Lactose-free diet for some patients
-Bland diet high in calories and protein but low in fat to help prevent diarrhea
Clinical presentation for Crohn’s disease
S- abdominal cramping and tenderness, fever, anorexia, weight loss, flatulence, RLQ pain or mass; increased Sx when stressed; sometimes has blood in the stool and stools are frequently soft or semi-liquid
O- abdominal tenderness with tubular, tender mass in the RLQ, perianal fissures
Pharmacological treatment for Crohn’s disease
-Sulfasalazine (Azulfidine)- this has many side effects and efficacy is questionable
-Glucocorticoids- prednisone 40-60 mg /day for initial treatment
-Metronidazole for treatment if intolerant to azulfidine
-Immunomodulating agents such as Humira/Remicade
Non-pharmacological treatment for Crohn’s disease
-Low residue diet and avoid foods high in fiber, including whole grain bread and fresh fruit and vegetables, seeds, and nuts
What medications should NOT be used in the treatment of Crohns or severe UC?
Anticholinergics and antidiarrheal medications due to the risk of ileus or megacolon; antidiarrheals are OK with caution in more mild cases of UC
Differentiate between the different GI diagnosis: IBS, Crohn’s, Ulcerative Colitis, and Diverticulosis
IBS- a functional GI disorder, characterized by abdominal pain and change in bowel habit that is either diarrhea alone or diarrhea with constipation
Crohn’s- patchy inflammation of the bowel wall involving any portion of the GI tract from mouth to anus; abdominal cramping and tenderness, fever, anorexia, weight lloss, flatulance, RLQ mass
UC- involves inflammation and infiltration of WBCs of only the mucosal surface of the colon which results in bleeding and erosions; loose bowel movements and pain relieved by defecation
Diverticulitis- when the outpouchings of the intestinal wall become inflamed or bleed; patients can be febrile with chills, tachycardia, nausea, vomiting
What is a direct inguinal hernia?
when the transversus abdominis & internal oblique muscles are attached, caused by increased abdominal pressure to the area; 25% of hernias are this
What is an indirect inguinal hernia?
The tissue herniates through the internal inguinal ring, which in men extends the length of the spermatic cord
What is a femoral hernia?
Hernia that occurs at the fossa ovalis where the femoral artery exits from the abdomen
Clinical presentation for direct inguinal hernia
-Many are asymptomatic
Painless and easily reducible
-Hernia bulges anteriorly during examination
Clinical presentation for inguinal hernia
May have pain or bulge; Soft swelling within the internal ring that often descends within the scrotum
What type of abdominal hernia is the most common?
Indirect inguinal hernia
What does the DSM V criteria for major depressive disorder require?
Five or more symptoms including at least one depressed mood or loss of interest present in the same two weeks and present nearly everyday
Which treatment option for major depressive disorder has fewer sexual side effects?
Buproprion
A 45-yr-old obese woman presents with severe pain and tenderness in the RUQ with nausea, vomiting, and a fever. + Murphy’s sign. What is the most likely diagnosis?
Cholecystitis
A 46-yr-old M complains of dysphagia, hoarseness, and a cough. He states he wakes up with a sour taste in his mouth. What is the most likely diagnosis?
GERD
What is the best recommendation to reduce the incidence of diverticular disease?
Increase amount of fiber in diet
What is chronic hepatitis?
elevation in AST and ALT levels for more than 6 months; occurs frequently in infants with HBV
What are the symptoms of hepatitis?
Abrupt or insidious onset: anorexia, N/V, malaise, URI, fever, abdominal pain
Later- jaundice, dark urine, light-colored stools
What is the gold standard lab test for diagnosis of acute Hepatitis A?
detection of IgM
Lab tests to draw if expecting cirrhosis or hepatitis?
AST/ALT, bilirubin, alkaline phosphatase (elevated), WBC (normal or low)
What is the DSM-5?
A descriptive manual of mental health disorders authorized by the American Psychiatric Association; it provides the diagnostic criteria for each mental disorder
What symptom would you not expect from a patient with typical GERD symptoms? What are some expected symptoms?
Weight loss; expected findings are hoarseness, cough, chronic pharyngitis
Lab tests to draw if expecting cirrhosis or hepatitis?
AST/ALT, bilirubin, alkaline phosphatase (elevated), WBC (normal or low)
What are some differential diagnosis for partial esophageal obstruction?
Esophageal cancer, esophageal stricture, esophagitis
What symptom would you not expect from a patient with typical GERD symptoms? What are some expected symptoms?
Weight loss; expected findings are hoarseness, cough, chronic pharyngitis
What are some anticipated clinical findings for a patient with acute appendicitis?
2-hour history of sudden onset vomiting and generalized abdominal pain accompanied by. a fever
What is the most helpful imaging study for a diagnosis of appendicitis?
Abdominal CT with contrast
Patient has the following lab results: HBsAg= +, Anti-HAV= positive, Anti-HCV= negative, AST 56, ALT 98. What is the likely diagnosis?
Chronic hepatitis B due to positive HBsAG and mildly elevated liver function tests (these would be very elevated if acute); patient has evidence of hepatitis A immunity
What is the recommended screening guidelines for Hep C?
All adults 18-79 should be screened regardless of risk factors
What is the most common diagnostic screening tool used for anxiety?
GAD-7 from Pfizer
What is the most common diagnostic screening tool used for depression?
PHQ-9 from Pfizer
When should you do a stool culture on someone that presents with gastroenteritis
If the patient has severe diarrhea, a fever of 101.3 or higher, bloody stools, or stools that test positive for leukocytes or occult blood
Medications that treat diarrhea
Pepto-Bismol, loperamide (Imodium), and diphenoxylate with atropine (Lomotil)
When should a patient with hepatitis follow up?
If HCV- refer to hepatology due to high risk of chronic infection
HAV- often no follow-up needed
HBV- 1 month and blood draw for HBsAg after 6 months; if elevation is persistent– refer to hepatology
