Examination and Diagnosis of the Psychiatric Patient Flashcards

Question

1.25. A patient recently started on valproate seems confused and lethargic. Which of the following blood levels should be checked urgently? A. Ammonia B. BUN C. Platelets D. Sodium E. WBC

Answer 1

1.25. A. Ammonia While valproate (valproic acid, Depakene; divalproex, Depakote) can cause hematologic abnormalities including leukopenia and thrombocytopenia, if a patient is presenting as lethargic or has a change in mental status, ammonia levels should be checked urgently, as valproate can increase ammonia levels. Elevated liver function tests (LFTs) and acute pancreatitis are also risks of valproate treatment.

Answer 2

1.26. D. Liver function tests (LFTs) Treatment with MAOIs can occasionally be associated with hepatotoxicity. Thus, LFTs are usually obtained at the initiation of treatment and periodically after. Blood pressure should also be obtained before initiating treatment and monitored afterward.

Answer 3

1.27. B. Vitamin B12 Vitamin B12 and folate deficiencies are associated with dementia, delirium, psychosis, and paranoia and should be checked as part of a workup. These deficiencies are especially common in patients who abuse alcohol

Answer 4

1.28. C. Hypomagnesemia A QTc measurement on an EKG greater than 500 milliseconds is considered prolonged and can increase the risk of a severe arrhythmia. Factors that can prolong QTc include certain drugs, in addition to bradycardia, hypokalemia, or hypomagnesemia.

Answer 5

1.29. A. A recent myocardial infarction Ziprasidone (Geodon) is associated with a dose-related prolongation of the QTc interval and can lead to fatal arrhythmias. An EKG should be checked before initiation. Ziprasidone is contraindicated in patients with a history of known QTc prolongation, recent myocardial infarctions, and uncompensated heart failure. It should also be used with caution in those with bradycardia, hypokalemia, hypomagnesemia, or those on other QTc prolonging drugs.

Answer 6

1.30. B. Calcifications MRIs are typically preferred over CTs for most purposes due to a lack of radiation exposure. CTs are primarily used in emergent situations. The only component of the brain seen better on CT scans are calcifications, which can be invisible on MRIs.

Answer 7

1.31. A. Language When using instruments such as the Gesell Infact Scale, the Bayley Cales of Infant and Toddler Development, and the Denver Developmental Screening Test with very young infants the tests focus on sensorimotor and social responses to objects and interactions. When used for older infants and preschoolers, the emphasis is on language acquisition.

Answer 8

1.32. E. Vineland adaptive behavior scale The Vineland Adaptive Behavior Scale is used for those 0 to 19 years old to provide a standard score measuring adaptive behavior and communication, skills of daily living, and socialization. There are separate standardization groups for normal, visually handicapped, hearing impaired, emotionally disturbed, and those with intellectual disability. The BASC has teacher and parent rating scales as well as a child self-report of personality across various domains at home, school, and the community in those ages 4 to 18 years. The HSQ-R is a test of attentional capacity in which parents rate the child’s specific problems with attention and concentration. The LNNB:C tests sensory-motor, perceptual and cognitive functioning. The TAT is a type of projective test that can assess interpersonal functioning.

Answer 9

1.33. C. Paternal origin of 15q12 Prader–Willi syndrome involves a deletion in 15q2 of paternal origin and presents with hypotonia, failure to thrive in infancy, then obesity, small hands and feet, and microorchidism. Compulsive behavior, hyperphagia, hoarding, and anxiety/aggression, and skin picking are also features of Prader–Willi syndrome. Rubinstein– Taybi syndrome is sporadic or likely autosomal dominated, though there have been microdeletions documented in some cases at 16q13.3. It presents with short stature, microcephaly, broad thumb, big toes, etc., feeding difficulties, seizures, distractibility and expressive language difficulties. Often these kids are loving and responsive to music. Cri-du-chat syndrome is from a partial deletion on 5p including the elastin locus on 7q11-23 and presents with a round face, hypertelorism, epicanthal folds, slanting palpebral fissures, a broad flat nose, etc. along with congenital heart disease, severe intellectual disability, self-injury, and an infant-like cry. Cornelia de Lange syndrome is due to a lack of PAPPA linked to chromosome 9q33 and presents with a continuous eyebrow, thin downturning of the upper lip, microcephaly and short stature, etc. along with failure to thrive, self-injury, language delays, profound intellectual disability, etc.

Answer 10

1.34. C. Inactivation of the FMR-1 gene The child depicted has fragile X syndrome, which is caused by an inactivation of the FMR-1 gene at X q27.3. Features consist of a long face, large ears, midface hypoplasia, a high-arched palate, short stature, and macroorchidism. Mitral valve prolapse, joint laxity, and strabismus are other features. ADHD symptoms of hyperactivity and inattention are often noted along with anxiety, speech and language delays, and learning disorders. Deletion of 15q12 of maternal origin causes Angelman syndrome. Fair hair and blue eyes are common along with dysmorphic facial features of wide-smiling mouth, thin upper lip, and pointed chin. The syndrome is notable for a happy disposition and paroxysmal laughter and hand flapping. Deletions that include the elastin locus on chromones 7q11-23 include features such as short stature, broad forehead, depressed nasal bridge, and elf-like features. It presents with anxiety and hyperactivity. Cri-du chat involves a partial deletion on 5p and signs include an infantile cry, severe intellectual disability, and a round face with hypertelorism and epicanthal folds. Down syndrome features include upward-slanted palpebral fissures, midface depression, and a flat, wide nausea bridge, along with short stature. Hyperactivity and increased depression and Alzheimer are notable in down syndrome which is caused by trisomy 21.

Answer 11

1.35. C. Loneliness Suicide is a leading cause of death in the elderly, and loneliness is the most common reason cited by older adults who consider suicide. Feelings of loneliness, worthlessness, hopelessness, and helplessness are all symptoms of depression, which is highly linked to suicide. Approximately 75% of those who complete suicide suffer from depression and/or alcohol abuse.

Answer 12

1.36. B. Phenothiazine Mental status examination symptoms of adverse effects of phenothiazine medication include a pill-rolling tremor, shuffling gait, stooped posture, and body asymmetry, along with abnormal movements of the mouth and tongue.

Answer 13

1.37. D. Prosopagnosia Prosopagnosia is the inability to recognize faces. A denial of illness is called anosognosia. A denial of a body part is atopognosia and an inability to recognize objects is called visual agnosia. Anosmia is the loss of smell.

Answer 14

1.38. D. Phenylalanine Phenylketonuria involves a defect in phenylalanine hydroxylase or biopterin, resulting in accumulation of phenylalanine. It typically presents in those with fair skin, blue eyes, blond hair, and rashes and if untreated can lead to intellectual disability, language delays, selfinjury, and hyperactivity. Generalized seizures can occur later in development. Galactosemia is caused by a defect in galactose-1- phosphate uridyltransferase or galactokinase and presents as vomiting, jaundice, hepatosplenomegaly, cataracts, food refusal, increased intracranial pressure, langue disorders, behavioral problems, and anxiety. Hurler syndrome is caused by a deficiency in alpha-L-iduronidase activity resulting in short stature, hepatosplenomegaly, hirsutism, corneal clouding, dwarfism, coarse facial features, and typically death before 10 years old. Hunter syndrome is caused by a deficiency in iduronate sulfatase resulting in a coarse face with flat nasal bridge, hearing loss, ataxia, enlarged liver and spleen, recurrent infections, hyperactivity, sleep abnormalities and intellectual disability. Uric acid builds up in Lesch–Nyhan syndrome due to a defect in hypoxanthine guanine phosphoribosyl-transferase, resulting in ataxia, chorea, kidney failure, gout, along with aggression and self-biting.

Answer 15

1.39. E. Williams The symptoms are consistent with a diagnosis of Williams syndrome, caused by a deletion that includes the elastin locus on chromosome 7q11-23 and is inherited in an autosomal dominant fashion. Cri-duchat syndrome, caused by a partial deletion in 5p presents with a round face with hypertelorism, epicanthal folds and slanting palpebral fissures along with heart disease, GI abnormalities, severe intellectual disability, self-injury, and cat-like cries. Fragile X is due to inactivation of FMR-1 gene at Xq27.3 de ot CGG base repeats, accounts for 10% to 12% of intellectual disability in males and presents with a long face, large ears, midface hypoplasia, a higharched palate, etc. Prader–Willi syndrome presents with a 15q12 deletion of paternal origin and symptoms include hypotonia, obesity, small hands and feet, microorchidism, short stature, almond-shaped eyes, hyperphagia, hoarding, aggression and skin picking. Smith– Magenis syndrome is caused by a complete or partial deletion of 17p11.2 and presents with a broad face and hands, small toes, a deep voice, severe intellectual disability, hyperactivity, severe self-injury including hand biting and head banging.

Answer 16

1.40. A. Luria-Nebraska The Luria-Nebraska Neuropsychological Battery: Children’s Revision (LNNB:C) provides standard measure for sensory–motor, perceptual, and cognitive tests. The Millon Adolescent Personality Inventory (MAPI) provides standard scores for personality styles, expressed concerns, and behavioral correlates. The Mullen Scales of Early Learning is a test of language and visual scales for receptive and expressive ability in newborns to 5 year olds. The Rotter Incomplete Sentences Blank Test is a qualitative projective test for children and adolescents, with an adult version as well. The Thematic Apperception Test (TAT) is also a projective test involving generating stories for 6 year olds and up and can give data regarding interpersonal functioning.

Answer 17

1.41. D. Thought content Both suicidality and homicidality fall under the category of thought content. Obsessional thoughts and compulsions also go under thought content, along with delusions. Mood is what the patient reports as their internal emotional state. Thought process does not describe what the patient is thinking, rather how the thoughts are formulated, organized, or expressed. Perceptual disturbances include hallucinations, illusions, depersonalization, and derealization. Judgment refers to the patient’s capacity to make good decision and act on them

Answer 18

1.42. B. Breathlessness with little changes in exertion In conducting a medical review of systems during a psychiatric interview it is important to tease apart obstructive airway and other organic pulmonary diseases from breathing problems due to psychiatric conditions. In depression, breathlessness is experienced at rest and shows little change with exertion and can fluctuate in minutes. Often, a history can show the breathing problems coincided with the depressive episode and is accompanied by panic attacks including symptoms such as dizziness, sweating, palpitations, and paresthesias. Often with depression, the emphasis is placed on struggles with inspiration, whereas in true pulmonary disease the difficulty is with expiration. In pulmonary obstructive airway disease, the onset is typically insidious. Of course, when in doubt of the origin of respiratory symptoms, a referral should be made to the primary care doctor or pulmonologist.