Psych HY Flashcards
Indication for Haloperidol decanoates (Intra-muscular Depo formulation)
Medicine Non-adherence in Schizophrenia
(also for homeless or limited resourced pts due to med costs)
ECT indications and primary complication.
- Psych condition & hemodynamically unstable
*Acute Psych disorder needing an immediate fix
(ex: depressed, not eating and actively suicidal)
Complication → Amnesia (anterograde or retrograde) that self-resolves
GABA based agents MOA and their OD tx:
*Barbiturates
*Benzos
*Z-Drugs (Zolpidem, Zaleplon, Ezopiclone) → no OD tx
Barbiturates ↑ opening duration of Gabba receptors
OD tx: Sodium Bicarb (alkalinizes urine)
Benzos ↑ opening frequency of Gabba receptors
OD tx: Flumazenil (Gabba antagonist)
Z-Drugs Gabba A receptor agonist
Buspirone Use & MOA?
2nd line agent for GAD
Partial agonist at 5HT-1A (Seretonin) receptor
Acute manic episode tx.
Anti-psychotic + Lithium
Patient on a mood stabilizer that has to wake up 10x a night to urinate.
dx? ppx?
NDI s/t lithium
Amiloride, Triamterene
lithium enters ENAC channels (principal cell of collecting duct) → inhibit ADH function.
Prevent by blocking ENAC Channel w/ K+ sparing diuretics
SSRI uses:
MDD, GAD, PTSD, OCD
(4)
Pre-Menstrual Syndrome
Pre-mature ejaculation
Bulimia
Panic disorder
SSRI with the cleanest side effect profile
(still no OK for pregnant pt tho)
Citalopram
(lonely in the city)
Bupropion use/MOA/benefits/contraindications
MDD, Smoking Cessation
NorEpi Dopamine Reuptake Inhibitor
Weight-loss, No Sexual side effects, Smoking cessation
C/I in bulimia/anorexia or h/o seizure disorder
(Lowers seizure threshold)
Mirtazipine use/MOA/benefits (2)
MDD, Anorexia
Alpha 2 blocker releases more Norepinephrine
Helps with sleeping & improves appetite
SSRI that is safe in pregnancy?
Which is contraindicated in pregnancy?
Sertraline (Safe)
Paroxetine (c/i)
(parrots picking at baby’s lung - fetal HTN)
What TCA is used in treating OCD?
Clomipramine
(2nd line agent to SSRI)
Drug of choice for MDD in a terminally ill patient with a life expectancy of 4 weeks?
Methylphenidate
(stimulant)
Pt on SSRIs presents with seizures and hyponatremia
dx?
SIADH s/t SSRI
SIADH is most commonly caused by what medication?
(HY)
SSRIs
Hyperreflexia + Myoclonus in a pt with hx of MDD
dx/tx?
Classic triad of mental status changes + autonomic dysregulation + neuromuscular hyperactivity (babinski can be +)
Serotonin Syndrome
1st line BENZOS
2nd line Cyproheptadine
(technically first is supportive tx, but not on test)
Patient with flu-like symptoms 2 days after stopping paroxetine.
dx/NBSIM?
SSRI discontinuation syndrome
Restart old dose of SSRI → Taper off over weeks
CBT for specific phobias.
Systematic de-sensatization
(read a book about phobia, see a picture, etc)
CBT for PTSD.
Trauma focused Psychotherapy
Female presents with a slashed wrist
dx/tx?
Borderline Personality Disorder
Dialectical Behavioral Therapy
(Female+ Slashing wrist= BrPD end of story)
HY HY HY
2 drugs in psychiatry that have mortality benefits?
Lithium
Clozapine
(↓ risk of suicide)
HY HY HY
The 4 dopaminergic pathways & how ↓Dopamine levels affects it
Nigro-striatal →
Tubero-infundibular →
Mesolimbic (↑Dopamine) →
Mesocortical →
Nigro-striatal → Extrapyramidal sxs (acute dystonia, akathisia, tardive dyskinesia)
Tubero-infundibular → Hyperprolactinemia
Mesolimbic → Positive sxs of schizo
(hallucinations, disorganized speech) Improves w/ anti-psychotics
Mesocortical → Negative sxs of schizo
(social withdrawal, flat faces) Worsen w/ anti-psychotics
Atypical Antipsychotic treat positive sxs really well
and are _________ so they don’t worsen negative sxs as much.
serotonin 5HT antagonist
MOA
1st Gen antipsychotics (Typical antipsychotic: haloperidol)
1st: D2 antagonist
2nd D2-4 antagonist & 5HT antagonist
Antipsychotic that causes the side effect:
Amenorrhea:
metabolic syndrome (Avoid if DM/Obese pt) :
Neutropenic fever:
Torsades:
Amenorrhea: Respiridone
Metabolic syndrome: Olanzapine
Neutropenic fever: Clozapine
TdP: Ziprazidone
AMS, T 105ºF, BP 170/100 in a patient who was recently placed on a drug regimen for diabetic gastroparesis.
± Leukocytosis or Rhabdo
dx/tx?
Neuroleptic Malignant Syndrome (s/t Metoclopramide)
tx: Dantrolene (Ryanodine Ca2+ channel blocker)
Exposure is antipsychotic or metoclopramide
Extrapyramidal side effects and treatment:
Sustained abnormal posture few days after starting Antipsychotic:
Motor restlessness:
Cogwheeling:
Stereotypical mouth movements 2 years after starting Fluphenazine typical anti-psychotic:
Acute dystonia (weird face, eyes stuck looking up, neck is bent)
Tx: Benztropine or Diphenhydramine
Akathisia (Can’t sit still or stop moving)
Tx: Beta blocker (2nd line is Benzo)
Parkinsonism (EPS: rigidity, shuffling gate, resting tremor)
Tx: Benztropine (parking my Benz)
Bromocriptine, Carbergoline (dopamine agonist)
Tardive Dyskinesia (Weird Mouth movements)
Tx: Valbenazine (V-mat inhibitor)
Angry, irritable, argumentative with instructors, breaks rules.
No criminal behavior/ or violence
oppositional defiant d/o
Criminal behavior, forced sex, cruel to neighbor’s dog, stealing,
or fighting in an underaged pt. Dx?
Neuroanatomical association w/ this dx?:
MC Complication when > 18:
Conduct d/o
↓ serotonin in CSF
Cx > 18: Antisocial personality d/o
Fidgety, Forgetful 11 yo boy. Dx?
Neuroanatomical association:
Genetic dz association:
First line tx:
2nd line tx:
3rd line tx:
ADHD
↓ activity of pre-frontal cortex
Fragile X syndrome
1st → Stimulant (methyl-phenidate, dextroamphetamine)
2nd → non-stimulant (Atomoxetine)
3rd → alpha 2 agonist (Clonidine, Guanfacine)
Does not respond to social interactions (doesn’t respond to name or share), poor eye contact, fixated interests.
Dx?
Autism Spectrum d/o
The 2 “egos” & examples
Ego Dystonic:
Ego Syntonic:
Dystonic → Knowingly doing something irrational → OCD
(pt is distressed by sxs)
Syntonic → unknowingly doing something irrational → OCPD
(pt is unbothered/proud of sxs)
Holds grudges, suspects spousal infidelity,
asks you an enemy or a friend?
Fears exploitation.
Paranoid personality d/o
Lacks close friends, believes in the occult/conspiracy/magical
Wear yellow pants with red shirt.
Kind of like an odd or weird person
Schizotypal personality d/o
Emotionally cold, indifferent reaction to praise/criticism
not interested in sex/relationships/friends
Seeks solitude (Loner type)
Schizoid personality d/o
Impulsive, dysfunctional relationships, radial nerve damage from slashed wrist.
dx/defense mechanism?
Boderline Personality d/o
Splitting (black and white thinking)
Requires admiration/attention
Lacks empathy (can’t see other’s needs)
Sense of entitlement.
Narcissistic
Adult who is Remorseless, disobeys the law, lies.
In trouble with the law
Anti-Social
(≤18 yo it is called Conduct d/o)
Dramatic emotions (cries easily, gets offended easily)
wants to be center of attention
Seductive
Theatrical/Flamboyant behavior
Does not usually lack empathy
Histrionic
Afraid of social criticism
does not take risks/passes up good opportunities
Always feels inferior to others.
avoidant social personality d/o
Stubborn, rule oriented, perfectionistic
devoted to the cause/no leisure
Wants everyone to do it their way
Would rather do task alone if others disagree
Obsessive Compulsive Personality D/o
(NOT to be confused with real OCD)
Needs reassurance for every decision
problems initiating projects
needs urgent companionship.
Dependent personality d/o
Anorexic pt is hemodynamically unstable
request to leave ED
NBSIM?
Admit to hospital
(even if it against their will bc Anorexia is a psychiatric d/o)
Chronically Malnourished pt
(Alcoholic, Anorexic/Bulemic, Tea/Toast Diet)
dies while being given IVFs and Nourishment at hospital
hypophosphatemia
s/t Re-feeding syndrome
How can you differentiate b/w bulimia nervosa and binge eating disorder?
Bulimics eat, but have a compensatory behavior (exercise, laxatives)
Binge eaters do NOT have a compensatory behavior
ED-Antidepressant to avoid in pts w/ Eating d/o:
Best CBT for anorexia on NBMEs:
Best antidepressant for anorexia:
Best antidepressant for bulimia:
Avoid → Bupropion
CBT → Family therapy
Antidepressant Anorexia → Mirtazipine
Antidepressant Bulimia: → SSRI
MDD and EEG findings
↓ REM sleep Latency/Inhibition
↑ REM Sleep
Same as Narcolepsy.
Pt h/o Bulimia presents w/ sudden onset, severe chest pain + pneumomediastinum.
chest palpation/auscultation reveals crepitus
dx/NBSID/tx?
Esophageal Perforation
Water soluble contrast (Gastrograffin swallow)
SURGERY
(can be s/t Endoscopy (within 24hrs))
Outside observer to one’s thoughts.
No recollection of a traumatic event.
depersonalization d/o
High anxiety about their leg pain
but w/u is negative.
somatic sxs d/o
(have symptom but blown out of proportion)
tx: regular f/u w/same physician
Pt preoccupied with the fear of having HTN despite multiple nl BP checks.
dx/tx?
illness anxiety disorder
Regular physician visits w/ same clinician
Has no sxs or problems but is worrying about having a dz
Neuro sxs like Pain, pinprick, fine touch loss in LLE.
Not worried about sxs/Indifferent attitude during the physical exam.
Neuro sxs are not consistent with a localization
Functional Neurologic d/o
aka Conversion disorder
(usually s/t anxiety/stress)
Hyperthermia, Rhabdomyolysis, Hyponatremic seizures, Serotonin syndrome due to ____ toxicity.
MDMA toxicity (Ecstasy pill)
Takes Ecstasy pill (a seritonergic drug) & dance into hyperthermia and can’t stop so muscle get damaged. Starts drinking alot of water bc feeling hot causing hyponatremia.
Pt who is clearly abusing a substance & is difficult to restrain
presents with Nystagmus, Myoclonus and
aggression/violence towards others.
Dx/tx?
Phencyclidine (PCP)
NMDA receptor antagonist
tx: Benzos
Nystagmus separates this from cocaine or MDMA use
Lethargic pt with
Bradycardia & respiratory rate of 8
Pupils are 2mm (smallest they go)
____ Intoxication
Treating intoxication:
Is withdrawal fatal?
Cogwheeling/akinesia after use → ___ toxicity damaging the substantia nigra
Opioid over-dose
Naloxone (if it fails, try again)
Withdrawal is not fatal, but it feels shitty
Parkinsonian sxs→ MPTP toxicity
Pressured speech, tachycardia, mydriasis, HTN.
dx/tx?
Cocaine intoxication
tx: Benzo
Tachycardia, conjunctival injection, increased appetite, reduced rxn time.
Marijuana use
Tx (3) of terminal cancer pt w/ cachexia.
usually s/t loss of appetite
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Tx of terminal cancer pt w/ depression
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Tx (2) of terminal cancer pt w/ Dyspnea
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Tx of chemo or cancer pt w/ nausea & emesis?
what if pt has ↑ ICP
Megestrol (progestin analog), Dronabinol (cannabinoid), Corticosteroids
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Methylphenidate
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Opioids (Morphine) + bowel regimen
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Ondansetron (serotonin receptor antagonist)
Adverse effect? QT prolongation
↑ ICP → Glucocorticoids
2 days post-op pt develops diaphoresis, tachycardia &
visual hallucinations + seizures.
Dx/Tx?
Alcohol withdrawal
Tx: Benzos
Nystagmus, Ataxia (unable to walk right), Confusion:
+ Neuroanatomy:
+ Enzyme association:
Tx:
Irreversible progression:
Wernicke encephalopathy (acute, reversible)
+ Neuroanatomy: Mammillary body hemorrhagic infarction
+ Enzyme association: Transketolase does not work
Tx: IV thiamine (B1)
Progresses to Korsakoff’s (Irreversible)
• Amnesia + Confabulation aka makes things up
Tx of ETOH use disorder (3)
Alcoholic Anonymous
Acomprosate
Naltrexone
82F pulling IVs, attempting to get out of bed. ± UTI.
Dx:
Inducing agent:
Acute tx:
What med to avoid:
Acute Delirium
Anticholinergic Drugs (diphenhydramine, Scopolamine, TCAs)
Anti-Psychotic (± Sitter)
Avoid: Benzodiazepines (can worsen delirium)
Forgetfulness worsening & now impairs performance of activities of daily living
dx/Patho?
Alzheimers
↓ AcH s/t destruction of basal nucleus of meynart
Alzheimers treatment (3)
AchE inhibitors
*Rivastigmine
*Galantamine
*Donepezil
Dementia + Constantly “added” neuro deficits:
Vascular dementia
Rude language, lack of inhibition, sexually suggestive statements.
Fronto-temporal dementia
(Pick’s disease)
dementia + Abnormal gait + urinary incontinence:
NPH
What kind of hydrocephalus is seen in NPH
Tx strategies:
Non-obstructive/Communicating Hydrocephalus
s/t CSF reabsorption problems in arachnoid granulations
Tx: VP-shunt (reversible cause of dementia)
6 weeks of recurrent nightmares after being fired from role as COVID unit nurse.
dx/tx?
Tx of REM sleep problem?
PTSD (>1m sxs)
SSRIs + trauma focused psychotherapy
Prazosin for nightmares
Checks doors repeatedly to make sure they are locked.
Intrusive unwanted/worrying thoughts requiring a ritual to alleviate.
Dx:
Pharm tx:
CBT:
OCD
SSRI + Exposure & response prevention CBT
Feels humiliated and is terrified at the thought of giving speeches.
Dx/Tx (1st/2nd line)
When is 1st line tx c/i?
Performance Anxiety (subtype of Social anxiety d/o)
1st line: Beta Blocker
2nd line: Benzo
If pt has Asthma treat w/ Benzo
9 months of poor sleep, restless, impaired concentration & worrying about “multiple domains in life”
dx/tx?
Generalized Anxiety d/o (≥6m sxs)
Tx (2) of panic disorder:
Tx of an active panic attack?
Panic d/o: → SSRIs + CBT
Panic attack? → Benzos
Major Depressive Disorder
≥5/9 on SIGECAPS for ≥ 2 weeks
*Monoamine hypothesis:
*Adrenal axis anomaly:
*Fastest/most effective tx:
Monoamine hypothesis: low levels of Serotonin, Norepinephrine, & Dopamine
Adrenal axis: →High cortisol
Fastest/most effective tx: → ECT (ok in pregnancy)
Schizophrenia neuroanatomy abnormalities:
SCZ timelines:
(<1m) =
(1-6m) =
(≥6M) =
↑ size of lateral & 3rd ventricles
Psychotic sxs
(Hallucinations, bizarre Delusions or disorganized speech/thinking) present for:
(<1m) = Acute psychotic d/o
(1-6m) = Schizophreniform
(>6M) = Schizophrenia
Most predictive factor in completing suicide.
Who attempts more, M/F?
Who is more successful?
Predictive → h/o prior attempt
Women attempt more
Men succeed more (bc more lethal methods)
27M is brought to the ED by his mom with a 2 week history of reduced oral intake. BMI is 16.
PMH: MDD unresponsive to SSRIs, TCAs, & isocarboxazid
Pt is muted and reluctantly responds to questions.
Vitals: BP 60/40s HR 40, RR 7/min
No h/o suicide attempts.
NBSIM?
Admit to hospital for ECT
72M with 6 wk h/o impaired vision.
Letters and lines appear “more wavy”
Dx:
Visual field lost first:
Fundoscopic exam for Type 1:
Fundoscopic exam for Type 2:
Tx for Type 1:
Tx for Type 2:
Macular Degeneration (age related)
HY: Wavy vision = MD
Central vision loss first → then peripheral vision loss last
Fundoscopic Type 1: Dry Type + Yellow deposits (Drussen)
Fundoscopic Type 2: Wet Type + Yellow deposits + Neovascularization
Type 1 Tx: Beta Carotene or Vit.K (Antioxidants)
Type 2 Tx: VEG-F Inhibitor (Bevazizumab or Ranibizumab)
Vision loss in a diabetic that is worse at night
(problems reading signs, reading books, etc)
Dx/Tx?
Fundoscopic exam findings:
Most important risk factor:
Cataracts
tx: Lens Replacement
Lens Opacification
Age is BRF
