Mehl. bullets: drugs - depression, drug-delirium, alco withdrawal, opositional, defiant Flashcards
M. Tx for diabetic neuropathic pain, second line?
Second-line is gabapentin
M. Tx for diabetic neuropathic pain, first line?
TCA (i.e., amitriptyline)
M. Tx for herpetic / post-herpetic neuralgia (i.e., from shingles)?
Gabapentin
M. 82M diabetic + neuropathic pain + already taking carbamazepine + gabapentin to no avail; next best
step?
switch the meds to nortriptyline (a TCA)
Student then asks, “Wait, I thought you said TCAs are first-line. Why does this Q have the guy on those two meds then?”
two points:
1) we don’t like giving TCAs to elderly because of their anticholinergic and anti-alpha-1 side-effects, so this vignette happen to try other agents first, but if you’re asked first-line, always choose TCA;
2) if we do give a TCA to an elderly patient, we choose nortriptyline because it carries fewer adverse effects.
M. can mention a kid was given an over-the-counter medication and now has low-grade fever and confusion. Dx?
Anti-cholinergic delirium
M. 8M + develops visual hallucinations after starting on over-the-counter cold med provided by his
mother; Dx?
Anticholinergic delirium caused by diphenhydramine or dextromethorphan (anti-
tussive opioid).
M. 82M + confusion + on various meds; Dx?
Various answers on NBME are:
“discontinuation of anticholinergic medications”;
“discontinuation of diphenhydramine” (1st gen H1 blocker);
“discontinuation of amitriptyline”;
“discontinuation of doxepin”;
“discontinuation of desipramine” (all TCAs): TCAs, 1st generation H1 blockers, and 2nd generation antipsychotics (atypicals) all cause a triad of side-effects:
o Anti-cholinergic (anti-muscarinic)
o Anti-alpha-1-adrenergic
o Anti-H1-histaminergic
M. “What do you mean by anticholinergic effects of meds?”
Start with knowing that DUMBBELSS is a mnemonic for cholinergic effects: Diarrhea, Urination, Miosis (pupillary constriction), Bradycardia, Bronchoconstriction, Excitation (neuromuscular), Lacrimation, Salivation, Sweatingàso by anti- cholinergic effects, it’s just the opposite of DUMBBELSS: constipation, urinary retention, mydriasis, tachycardia, bronchodilation not seen (M3 agonism can bronchoconstrict, but dilation is sympathetic beta-2-regulated), Flaccidity not seen, xerophthalmia (dry eye), xerostomia (dry mouth), anhidrosis.
M. “What do you mean by anti-H1-histaminergic effects?”
Sedation.
M. 82M + urinary hesitancy + interrupted stream + taking amitriptyline; next best step?
Discontinue
amitriptyline.
M. 5M + started on new psych med + is now hot and dry; Dx?
anticholinergic effects of TCA.
M. USMLE-favorite vignette is 40s male who gets tremulousness and tachycardia while in hospital 2ish days after surgery. Dx + Tx?
Answer is just benzo.
Dx = Delirium tremens
M. Can also show up on NBME as a guy who goes from drinking 12 beers a day to suddenly only 2 beers a day. Dx?
Dx = Delirium tremens
M. 16M + disruptive in class + numerous suspensions from school + caught stealing at the mall; Dx?
conduct disorder
pattern of law-breaking + must be under age 18; in contrast, a patient with oppositional defiant disorder does not break the law.
M. f the vignette mentions anything about crimes, then the USMLE wants what Dx?
conduct disorder instead.
M. teenager who engages in criminal behavior, such as killing an animal, destroying property, or engaging in theft. Dx?
Conduct disorder
M. USMLE won’t necessarily present to you a pattern of ongoing behavior, but rather just a snapshot of a child + ask for the diagnosis – i.e., 14-year-old killed an animal; what’s the most likely diagnosis?
Conduct disorder (because what he did is a crime); oppositional defiant disorder is wrong answer.
M. Tx for TCA toxicity?
sodium bicarb –> causes dissociation of drug from myocardial sodium channels.
M. Anti-depressant med causing seizures?
bupropion.
M. Other HY factoids about bupropion: smoking, sex, seizure?
also used for smoking cessation;
never give in electrolyte
disturbance or eating disorder patients because of seizure risk;
does not cause sexual dysfunction (unlike SSRIs which can cause anorgasmia);
bupropion is a reuptake inhibitor preferentially for NE and dopamine over serotonin.
M. Patient with MDD has fluoxetine discontinued + tranylcypromine commenced one week later + patient develops temp of 105F + HR 110 + RR 25; Dx?
serotonin syndrome;
will show up on Psych shelf as simply “drug-drug interaction”; can occur when combining SSRIs with St John Wort, or notably when commencing a MAOi too soon after being on another serotonergic medication.
M. Tx of serotonin syndrome?
answer = cyproheptadine (serotonin receptor antagonist).
M. Difference between serotonin syndrome and carcinoid syndrome?
serotonin syndrome is from drug-drug interactions and notably causes hyperpyrexia (high fever), tachycardia, and tachypnea;
carcinoid syndrome is a result of carcinoid tumors (usually small bowel, appendiceal, or bronchial)
secreting serotonin and causes flushing, diarrhea, abdominal pain, and bronchoconstriction.
M. How to Dx + Tx carcinoid syndrome?
Dx with urinary 5-HIAA (5-hydroxyindole acetic acid);
Tx with octreotide, among other agents.
M. 56M + 3-day Hx of cutting from 12 beers a day down to 4; develops tremulousness; Dx? Tx?
chlordiazepoxide (delirium tremens);
M. guy has surgery + two days later has tachycardia, tremulousness, and hallucinations Dx?
alcoholic hallucinosis
