Module 6 Flashcards
Psychotic disorders are
disturbances of thought content and/or process and signal a departure from reality, often accompanied by a combination of hallucinations and delusions, disorganized thinking (speech), disorganized or abnormal motor behavior (including catatonia), and negative symptoms
annual health-related expenses of someone with chronic schizophrenia averaged more
than $15,000
schizophrenia
acute or insidious onset
symptoms for six months, at least 2 or more positive or negative symptoms for 1 month. one positive symptom must be delusion, hallucination, disorganized speech
schizoaffective disorder
2 weeks or longer with psychotic symptoms in absence of mood symptoms, negative symptoms less severe
schizophrenia age of onset
typically during adolescence or early 20s, earlier in men than women
teens with schizophrenia have this risk of attempted suicide
50%
plays role in poor health outcomes with schizophrenia
poor engagement in health maintenance initiatives such as cancer screenings, exercise, nutrition, tobacco cessation, and identification of other comorbid chronic medical diseases
risk factors schizophrenia
immigration, living in an urban area, OB complications, late winter/ early spring births, advanced paternal age
transmitter systems that are likely involved in patho of schizophrenia
dopamine
glutamate
GABA
acetylcholine
4 symptom clusters in schizophrenia
positive symptoms
negative symptoms
cognitive impairments
affective disturbances
Positive symptoms refer to
the “active” qualities of these symptoms that are abnormal and are synonymous with psychosis. Positive symptoms include delusions, hallucinations, disorganized thinking (speech), and grossly disorganized or abnormal behavior (catatonia). Delusions are the hallmark of positive symptoms,
Delusions are
fixed beliefs that are not amenable to change despite conflicting evidence. They can include persecutory, referential, somatic, religious, or grandiose themes.
Hallucinations are
sensory impressions without basis of reality. They can be vivid and clear to the individual experiencing them and may occur in any sensory modality such as auditory, visual, somatic, olfactory, or gustatory, with auditory followed by visual hallucinations most common.
Tangentiality
—getting off topic without answering questions appropriately
Circumstantiality
—will answer question in markedly roundabout manner
Derailment
—switching topics without a logic sequence
Neologisms
—creation of new, idiosyncratic words
Word salad—
words are placed together without any sensible meaning
Negative symptoms represent
diminished or a lack of normal characteristics—diminished emotional expression and avolition
Avolition represents
decline in motivated self-initiated purposeful activities. This encompasses loss of affective responsiveness, verbal expression, and communication, personal and social motivation, and enjoyment
Cognitive impairments include
difficulties with memory, attention, psychomotor speed, and executive function. Cognitive impairments, along with negative symptoms, are the most common contributors to disability in schizophrenia.
Affective disturbances
, which are difficulties with mood and affect, are seen with schizophrenia. Depression and anxiety can be detected before, during or after a psychotic episode, and providers must be alert for risk of suicide
pharm therapy schizophrenia
antipsychotics, early intervention is key. effective in addressing positive symptoms but not negative and cognitive symptoms
best way to treat negative and cognitive symptoms
CBT in combo with meds
pts with first episode of schizophrenia
typically more responsive to meds than multiple episodes
typical antipsychotics
effective, but have more motor system side effects
atypical antipsychotics
equally effective to typical
reduce positive symptoms
less likely to have motor side effects
associated with weight gain, metabolic disturbance
Extrapyramidal symptoms (EPS)
are potentially troubling side effects of antipsychotics and include Parkinson-like symptoms, akathisia (an inability to sit still), and dystonia (akin to muscle cramps). In some cases, tardive dyskinesia develops
Persons experiencing a first episode should remain on the antipsychotic medication for at least
18 months.
Currently the manufacturer recommends evaluation of cataracts at baseline and every 6 months for patients taking
quetiapine (Seroquel
Patients with schizophrenia have an average life span that is reduced by
20 years compared with population norms,
OCD
OCD is characterized by the presence of obsessions, compulsions, or both. Only one category of symptoms is required for diagnosis. Distress is present or acts are time consuming or significantly affects normal routine
Obsessions are
recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted.
Compulsions are
repetitive behaviors or mental acts that an individual feels forced to perform due to either an obsession or strict rules of conduct. Compulsions help to temporarily decrease anxiety from obsessions and thus, over time become reinforced
OCD onset
acute, typically after significant stressful event
pediatric autoimmune neuropsychiatric disorders associated with group A beta-hemolytic streptococcal infection (PANDAS)
haracterized by rapid onset and other neuropsychiatric symptoms, including tics, restricted eating, anxiety, and/or irritability. It is thought to be triggered by a throat infection or other illness, leading to the production of autoimmune antibodies against streptococci, which also cross-react with the basal ganglia. This cross-reaction is thought to result in neuropsychiatric symptoms
OCD most common obsessions
The most common obsessions are fears of contamination, pathological self-doubt, intrusive thoughts, and symmetry.
1st line treatment OCD
SSRI, higher doses and trials (12 weeks) required
CBT
Body dysmorphic disorder
Preoccupation with perceived defects or flaws in physical appearance, leading to repetitive behaviors or mental acts.
Excoriation (skin-picking) disorder
Repeated skin picking results in skin lesions. The most common areas impacted are the face, arms, and hands
Hoarding disorder
Persistent difficulty discarding or parting with objects, regardless of their actual value or importance, due to a perceived need to save them and distress associated with discarding them.
Trichotillomania (hair-pulling) disorder
Recurrent hair-pulling from any part of the body resulting in hair loss. There are repeated attempts to stop or decrease the hair pulling.
OCD treatment as last resort
DBS, must be chronic severe and treatment resistant
Body dysmorphia disorder typically presents as
pt requesting referrals for perceived imperfection
1st line treatment BDD
no FDA approved treatment, first line is SSRI
CBT
hoarding prevalence
increased among unmarried or divorced individuals
risk factors for developing an eating disorder include
female sex, a family history of an eating disorder, perfectionism, obsessive personality traits, and susceptibility to societal pressures for thinness.
anorexia nervosa
AN is characterized by a refusal to maintain a minimally normal body weight and an intense fear of gaining weight due to a body image disturbance.
two types of anorexia nervosa
restricting
binge eating/purging
One in 10 patients with AN
die suddenly from starvation, cardiac arrest, or suicide
Binge eating is characterized by
eating an excessive amount of food within a 2-hour period. Persons with BN undergo feelings of loss of control during bingeing episodes, and their self-esteem is excessively influenced by their body shape and weight.
most pts with bulimia nervosa are
normal weight or overweight
eating disorder risk between women and men
10x higher in women
Diagnostics with eating disorders
CBC
ESR
CMP
UA
EKG
outpatient management eating disorder
weight pt weekly, then monthly
provide symptom relief
CBT
SSRI (fluoxetine is FDA approved)
The primary consequences of acute insomnia are
sleepiness, negative mood, and impairment of performance, with severity related to the amount of sleep lost on one or more nights
insomnia medications
benzo or benzo receptor agonist meds
all have potential for dependence
RLS is
a neurological, sensorimotor condition that is typified by uncomfortable sensations in the lower extremities, such as burning, tingling, crawling, or itching, and an uncontrollable desire to move the legs, with associated sleep disturbance. Relief of symptoms is usually obtained once the individual moves his or her legs
RLS treatment
baths, massage, exercise
relaxis (vibrating pad)
pramipexole, ropinirole
percentage of accidents with poisoning that occur involving children
46%
TCA overdose risk
toxic cardiovascular and CNS effects
similar to anticholinergic med effects
QTc prolongation
barbiturate overdose
depressed CNS tone, inhibition of cardiac contractibility
Diagnostic tests for poisoning
BMP
coag profile
acetaminophen level
ASA level
UA
The most common form of GI decontamination is the use of
activated charcoal. best if used within 1 hour of ingestion
bee and wasp stings cause more deaths annually than
any other venomous animal
brown recluse bite
spider has “fiddleback” marking on back
causes local tissue destruction
black widow bite
orange red hourglass shaped marking on abdomen
neurotoxin
The normal or usual reaction following an insect sting is
local erythema, pain, pruritus, and swelling. Insect stings almost always cause pain. This initial reaction should subside in 1 to 2 hours
large local reaction
can spread more than 6 inches beyond the sting and is characterized by prolonged and marked edema at the site of the sting injury, peaking at 48 hours and lasting as long as 1 week. This reaction may be accompanied by nausea, vomiting, and fatigue. A large local reaction can involve one or more neighboring joints and may even produce airway obstruction due to tissue swelling if the sting occurs in the mouth or throat
toxic reaction occurs when
there is a history of multiple stings, often more than 10 in number. Toxic reactions are caused by nonantigenic properties of Hymenoptera venom. They resemble systemic reactions but have a greater frequency of GI disturbances. Diarrhea, nausea, vomiting, light-headedness, and syncope are common signs. The patient may also have headache, drowsiness, fever, involuntary muscle spasms, edema without urticaria, and occasionally seizures. Urticaria and bronchospasm are not present, and symptoms usually subside within 48 hours
The shorter the interval between the sting and the onset of symptoms,
the more severe the reaction
Hymenoptera (bee and wasp) stings produce
immediate pain and a red papule surrounded by a pale zone of edema, with varying amounts of local swelling
Fire ant stings produce
vesicles that become sterile pustules; these pustules subsequently become necrotic within several hours and may take up to 10 days to heal
Brown recluse spider bites are
unusual in that persons bitten usually do not feel pain for 2 to 3 hours. A single necrotic lesion occurs, usually measuring 0.5 to 2 cm in size, self-limited in spread, and lacking adenopathy or sustained general toxicity. The typical bull’s-eye lesion is created when the red blister is encircled by a pale, irregularly shaped and ischemic halo, which in turn is surrounded by extravasated blood. The pustule may gradually grow to form a crater-like lesion over 3 to 4 days, with associated lymphadenopathy and low-grade fever
Black widow spider bites create
an initial puncture wound that disappears rapidly, leaving a local swelling where tiny red spots appear. Symptoms of envenomation occur within 10 to 60 minutes, including severe pain in the bitten extremity and muscle spasms of the abdomen and trunk. Diffuse paresthesias, ptosis, and hyperactive deep tendon reflexes may be noted. Victims experience agonizing pain and may develop hypertension, headache, muscular rigidity and spasm, hyperreflexia, vomiting, abdominal pain, agitation, or psychosis. Symptoms peak at 2 to 3 hours after the bite and may last up to 24 hours.
Scorpion stings are
immediately intensely painful, with little or no erythema or swelling. Generalized reactions may occur within 1 hour and progress to maximum severity in 5 hours
Tick bites can
produce lesions that vary from small pruritic nodules to extensive ulceration, induration, and erythema. The lesions may be accompanied by malaise, fever, and chills
Flea bites produce
lesions that are so similar to those of lice and scabies that diagnosis is often difficult. Flea bites produce itching papules, found in zigzag lines, especially on the legs and in the waist area. The lesions present as central hemorrhagic puncta surrounded by erythematous and urticarial patches. Pruritus is intense
chigger bites is
usually noticed 4 to 8 hours after chiggers have attached or have been removed. Initially, a papule develops and ultimately enlarges over 24 to 48 hours to form a nodule. Pruritus peaks on the second day. The fluid injection causes nodules to appear, which may last for 2 weeks.
puss caterpillar’s sting causes
intense, immediate pain, often in spasms. This is followed by local edema, pruritus, and a rash of red blotches and ridges. The lesions consist of red or white papules and vesicles, often forming perfect gridlike markings where the caterpillar made contact
mosquito bites includes
erythema, wheal formation, and severe pruritus. A delayed reaction 12 to 24 hours later consists of more intense redness, edema, and a burning pruritus. Blistering and necrosis can also occur.
large local reaction treatment
antihistamine
corticosteroids over 5 days
if needed, nerve block anesthesia
delayed serum sickness reaction treatment
prednisone tapered over 2 weeks
hydroxyzine
topical corticosteroids
remover stinger by
scraping it away from skill with dull object (not grasped and pulled)
brown recluse spider bite treatment
ice intermittently x4 days over sterile dressing
oral abx
elevation of affected body part
black widow spider bite treatment
ice to bite wound
narcotic analgesic if needed
monitor for htn
Heat rash
, also known as prickly heat or miliaria, is a group of skin conditions caused by environmental heat and excessive perspiration. The condition occurs when sweat is trapped under the skin due to closed pores. This forms an uncomfortable and often pruritic rash ranging from pinpoint to small, clear to red vesicles. The rash usually occurs on the face and neck. It is more common in the elderly, overweight persons, and infants.
Heat cramps are
muscle spasms that usually occur in large muscle groups like the calves, abdomen, thighs and shoulders, during or shortly after exercising in the heat
Heat syncope is
a heat-related fainting episode. It may occur because of vasodilation and peripheral pooling of blood to release body heat, volume deficits, or sluggish vasomotor tone. Syncope occurs when the venous return of blood flow does not support the required cardiac output. Thus, heat syncope can result from inadequate cardiac output and postural hypotension. Typically, recovery is immediate once the patient lies flat.
Heat exhaustion occurs when
the body overheats and is unable to maintain a normal core temperature. Symptoms may include thirst, heavy sweating, tachycardia, dizziness, nausea, vomiting, and weakness. Heat exhaustion is usually caused by strenuous work in hot and/or humid environments. Treatment includes rest, moving to a cooler environment, removal of clothing that prevents evaporative cooling, and hydration
Risk factors for heat exhaustion include
the use of alcohol, dehydration, advanced age, and age younger than 5 years.
Heat stroke or sunstroke is characterized by
a core body temperature of 104°F (40°C) or higher, mental confusion, and more severe clinical manifestations that go beyond the symptoms of heat exhaustion. Heat stroke occurs when heat production is greater than heat loss. There may be damage to multiple organ systems and breakdown of muscle tissue (rhabdomyolysis), and mortality may be as high as 10%.
acclimatization
is a term that refers to the body’s ability to adapt to heat stress. This adaptation primarily involves the sweating mechanism.
safest, most practical method to cool patient
remove all clothing
spray warm water over patients entire body surface area
goal for heat stroke treatment
reduce temp to 102 in the first hour
further active cooling cease when core temp reaches 101
Hypothermia
is a medical emergency that can threaten life and limb and is defined by a core temperature of less than 95°F
risk factor hypothermia
older
uninsured
use more critical care than most pts in ED
problems with alcoholism, homelessness, mental illness
mild hypothermia
tempt 89.6-95
moderate hypothermia
temp 82.4-89.6
severe hypothermia
temp less than 82.4
hypothermia is a
medical emergency
individuals at greatest risk for frostbite
age 30-49
First-degree frostbite (partial skin freezing)
: Erythema, edema, hyperemia, no blisters or necrosis, occasional skin desquamation (5–10 days later), transient stinging and burning, and possible throbbing and aching; the patient may also have hyperhidrosis (excessive sweating)
Second-degree frostbite (full-thickness injury)
: Erythema, substantial edema, vesicles with clear fluid, blisters that desquamate and form blackened eschar, numbness, and vasomotor disturbances in severe cases.
Third-degree frostbite (full-thickness injury and subcutaneous freezing)
: Violaceous/hemorrhagic blisters, skin necrosis, and blue-gray discoloration; initially, no sensation (tissue feels like a block of wood), but shooting pains, burning, throbbing, and aching develop later.
Fourth-degree frostbite (full-thickness injury and subcutaneous tissue, muscle, tendon, and bone freezing)
: Initially, skin is mottled, deep red, or cyanotic; later, skin becomes dry, black, and mummified. Minimal edema is present, with possible joint discomfort
treatment frostbite
rewarm affected area with warm water, do not rub affected area
give narcotics (painful)
