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Psych/Social/Random Flashcards

1
Q

Saw palmetto

A

used to treat BPH by quacks

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2
Q

kava kava

A

anxiety/insomnia quack tool. Not recommended bc of risk of liver toxicity

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3
Q

St Johns Wort

A

Depression

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4
Q

garlic and fish oil

A

hypercholesteremia. there is some evidence for fish oil in patients with triglycerides through the roof

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5
Q

glucosamine and chondroitin

A

OA

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6
Q

Summary of common herbal supplements and their risks (9 of them)

A

Ginkgo biloba - memory enhancement

  • increased bleeding risk

Ginseng - improved mental performance

  • increased bleeding risk

Saw palmetto - BPH

  • mild stomach discomfort
  • increased bleeding risk

Black cohosh - postmenopausal symptoms (hot flashes/dryness)

  • hepatic injury

St johns wort - depression, insomnia

  • drug interactions (OCPs, reduced INR with anticoagulants, serotonin syndrome with antidepressants, digoxin)
  • hypertensive crisis

kava - anxiety, insomnia

  • severe liver injury

licorice - stomach ulcers, bronchitis/viral infections

  • HTN
  • hypoK

Echinacea - treatment and prevention of cold and flu

  • anaphylaxis (more likely in asthmatics)

Ephedra (ma huang) - treatment of cold and flu, weight loss and improved athletic performance. this one is banned.

  • HTN
  • arrythmia/MI/SCD
  • stroke
  • seizure.
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7
Q

Adverse events during hospitalization

A

4 types (operative/post-procedure, adverse drug, general care events, hospital acquired infections)

Most common for someone who is not undergoing surgery is adverse drug events

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8
Q

mitochondrial inheritance pattern

A

Transmission occurs only through affected females and never through males. You’ll see and affected female pass it to all children, but then only the female children pass it on further.

Ex/mitochondrial encephalomyopathy with lactic acidosis and stroke like episodes

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9
Q

X linked dominant pattern

A

All female children of affected males have the condition

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10
Q

X linked recessive pattern

A

Male offspring of a female carrier have 50% chance of being affected. Female offspring typically have a 50% chance of being carriers.

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11
Q

Autosomal dominant pattern

A

Affect 50% of all children born to an affected parent. Appears in consective generations and father to son is common.

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12
Q

autosomal recessive pattern

A

25% of all children with 2 carrier parents will be affected. Offspring of a single affected parent will be carriers but unaffected. As a result, disease often skips generations.

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13
Q

Developmental milestones for age 12 months

A

Stands well, walks first steps on own, throws a ball.

2 finger pincer grasp

says first words (other than mama and dada)

Separation anxiety. follows 1 step commands with gestures.

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14
Q

Developmental milestones for age 18 months

A

Runs, kicks a ball

Builds a tower of 2-4 cubes, removes clothing

10-25 word vocab, identifies at least 1 body part

understands “mine.” begins pretend play

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15
Q

Developmental milestones for age 2 years

A

Walks up/down stairs with both feet on each step. Jumps.

Builds a tower of 6 cubes. Copies a line.

Vocab at least 50 words. 2 word phrases.

Follows 2 step commands. parallel play. Begins toilet training

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16
Q

Developmental milestones for age 3 years

A

Walks up/down stairs with alternating feet. Rides tricycle.

Copies circle. uses utencils. 3 word sentences. Speech is 75% intelligible.

Knows age/gender. Imaginative play.

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17
Q

Developmental milestones for age 4 years

A

Balances and hops on 1 foot

Copies a cross

Identifies colors. Speech 100% intelligible.

Cooperative play

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18
Q

Developmental milestones for age 5 years

A

Skips. Catches ball with 2 hands.

Copies a square. ties shoelaces. Dresses/bathes independently. Prints letters

Counts to 10. 5 word sentences.

Has friends. Completes toilet training.

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19
Q

Medicare program coverage

A

Part A

  • inpatient hospital services
  • skilled nursing facility (limited)
  • hospice and home health care

Part B

  • Outpatient physician services
  • preventive care
  • outpatient diagnostics (labs, XRs)
  • hospital observation services

Part C

  • Mediare advantage
  • allows private healthy insurance companies to provide medicare benefits

Part D

  • Prescription drugs
  • provided by private insurance companies with government contracts

Eligible for medicare at age 65 or if have ESRD , permanent disability and certain neurodegenertive disorders (ALS)

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20
Q

Risk factors for pediatric dental caries

A

History

  • diet
  • frequent sugary snacks/drinks
  • nighttime bottle or feedings
  • inadequate fluoride
  • family - caries
  • social - low socioeconomic status

Physical

  • visible plaque
  • white spots or enamel defects
  • brown/black discoloration
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21
Q

5 A’s

A

For smoking cessation

Ask about tobacco use every visit

Assess readiness to quit

Advise patients to quit

Assist patients with pharm or referral to cessation programs

Arrange a quit date and a follow up visit

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22
Q

Clozapine

A

For treatment resistent patients due to risk of agranulocytosis/neutropenia.

Requires regular monitoring of absolute neutrophil count. Weekly for first 6 months. every other week for next 6 months. every 4 weeks after.

Patients need to immediately report any signs of infection (fever, weakness, sore throat, lethargy)

Also associated with weight gain, metabolic syndrome, seizures, pulmonary embolus, myocarditis, excessive salivation, constipation and ileus

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23
Q

ADHD

A

Clinical features

  • Inattentive and/or hyperactive/impulsive for at least 6 months
    • inattentive symptoms: can’t focus, distractable, doesn’t listen to or follow instructions, disorganized, forgetful, loses/misplaces objects
    • hyperactive/impulsive symptoms: fidgety, unable to sit still, driven by a motor, hypertalkative, interrupts, blurts out answers
  • several symptoms present before age 12
  • symptoms occur in at least 2 settings (home, school) and cause functional impairment
  • Subtypes: predominantly inattentive, predominantly hyperactive/impulsive, combined type

Treatment

  • stimulants (methylphenidate, amphetamines)
  • nonstimulants (atomoxetine, alpha 2 agonists like clonidine)
  • behavioral therapy

Initial treatment is nonpharm in kids age 3-5. Anything else can get pharm as first line. Consider meds in preschool age when behavioral therapy fails or child is severely impaired (risks injuring others)

Get cardiac history/exam, baseline weight and vital signs prior to starting meds. No evidence that stimulant treated kids are at increased risk of cardiac deaeth so if history/exam show now cardiac issues no need to go further with ecg or anything.

If no response to crap response to initial med, can switch to a dif stimulant. No tapering/washout period is needed.

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24
Q

Schizoaffective disorder

A

DSM-5 criteria

  • MDD or manic episode concurrent with symptoms of schizophrenia
  • lifetime history of delusions or hallucinations for at least 2 weeks in the absence of major depressive or manic episode
  • mood episodes are prominent and recur throughout illness
  • not due to substances or another medical condition

Ddx

  • MDD or BP with psychotic features
    • psychotic symptoms occur ONLY during mood episodes
  • schizoprenia
    • mood symptoms may be present for relatively brief periods.
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25
Q

criterion A for schizophrenia

A

At least 2 of the following

  • delusions
  • hallucinations
  • disoganized speech
  • disorganized or catatonic behavior
  • negative symptoms
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26
Q

Delusional disorder, erotomatnic type

A

Delusions revolve around another person being in love with the patient. Don’t usually have other symptoms of psychosis and patient is able to function apart from the delusion

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27
Q

OCD

A

Clinical features

  • Obessions
    • recurrent, intrusive, anxiety-provoking thoughts, urges, or images (can involve imagining committing violent acts. point is they cause distress)
  • compulsions
    • response to obsessions with repeated behaviors or mental acts
    • behaviors not connected realistically with preventing feared event
  • Time consuming (more than an hour a day) or causing significant distress or impairment

Treatment

  • SSRIs
  • CBT (exposure and response prevention)
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28
Q

Histrionic personality disorder

A
  • pattern of excessive emotionality and attention-seeking behavior since early adulthood
  • inappropriate, sexually seductive or provocative behavior; uses appearance to draw attention
  • shallow, shifting, dramatic emotions
  • impressionistic, vague speech
  • suggestible (easily influenced)
  • considers relationships more intimate than they really are
  • exaggerate shit
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29
Q

dependent personality disorder

A

pervasive psychological dependence on others to meet their emotional and physical needs. Typically submissive and clingy

30
Q

Factitious disorder

A

Purposeful falsification of symptoms to assume the sick role.

31
Q

New onset psychosis in ER

A

First, rule out substance induced and medical causes

32
Q

Suicide risk and protective factors

A

Risk factors

  • Psych disorders, prior suicide attempts
  • hopelessness
  • never married, divorced, separated
  • living alone
  • elderly white man
  • unemployed or unskilled
  • physical illness
  • family history of suicide, family discord
  • access to firearms
  • substance abuse, impulsivity

Protective factors

  • Social support/family connectedness
  • pregnancy
  • parenthood
  • religion and participation in religious activities
33
Q

Assessment and management of suicidality

A

Assessment (SAD PERSONS)

  • Sex
  • Age
  • Depression
  • Previous attempt
  • EtOH (or other substance) use
  • Rational thought loss (psychosis)
  • Social support lacking
  • Organized plan
  • No spouse or significant other
  • Sickness or injury

Management

  • High imminent risk (ideation, intent and plan)
    • ensure safety - hospitalize immediately involuntary if necessary
    • remove personal objects and belongings in room that may present self harm risk
    • constant observation and security may be required to hold against will
  • High non-imment risk (ideation, intent, but no plan to act in near future)
    • ensure close follow up
    • treat modifiable risk factors (underlying deprssion, psychosis, substance abuse, pain)
    • recruit family or friends to help support
    • reduce access to potential means (guns, meds)

Immediate post discharge period is high risk. Get rid of guns/drugs in home on discharge.

34
Q

Hypomania in setting of new antidepressant

A

Many patients ultimately diagnosed with bipolar initially present as depressed and are put on antidepressants.

All antidepressants carry a risk of inducing hypomanic symptoms and should be abruptly discontinued when these occur to prevent further escalation of mania.

If symptoms persist beyond discontinuation of the antidepressant, consider adding a mood stabilizer

35
Q

Manic patient on lithium

A

If lithium level is top normal therapeutic and mania persists, add an antipsychotic. Combo therapy is indicated in severe mania or when monotherapy (lithium or valproate) fails

36
Q

Common side effects of SSRIs

A

GI and activating side effects (nausea, anxiety, and insomnia) are common at start of treatment and tolerance usually develops over several weeks. If patient is showing improvement, just continue until a full trial (6w) is done and reassess.

Sexual side effects do not go away and you should switch med.

37
Q

Ddx of depressed mood

A

MDD

  • at least 2 weeks
  • depressed mood and at least 5 of 9 SIGECAPS (sleep, interest, guildt, energy, concentration, appetite, psychomotor, SI)
  • significant functional impairment
  • no lifetime history of mania

Persistent depressive disorder (dysthymia)

  • chronic depressed mood at least 2 years
  • at least 2 of the following
    • appetite disturbance
    • sleep distruabance
    • low energy
    • low self esteem
    • poor concentration
    • hopelessness

Adjustment disorder

  • onset within 3 months of identifiable stressor
  • marked distress and/or functional impairment
  • does not meet dsm criteria for MDD or another disorder
  • can benefit from brief counseling/therapy

Normal stress response

  • not excessive or out of proportion to seerity of stressor
  • no significant functional impairment
38
Q

Lithium toxicity

A

Lithium has narrow therapeutic index (want 0.8-1.2). Anything over 1.5 is toxicity. 2.5 is emergency management.

Symptoms

  • Acute
    • GI (nausea, vomiting, diarrhea)
    • neuro is much later
  • chronic
    • neuro (ataxia, confusion, agitation, neuromuscular excitability like tremor)

Management

  • Li levels every 2-4 hrs
  • IV hydration
  • bowel irrigation (asymptomatic acute overdose)
  • HD
    • level greater than 4
    • level greater than 2.5 with symptoms of renal failure
    • increasing level despite IV fluids

Risks for toxicity: overdose, low gfr (elderly, renal failure), volume depletion, drug interactions.

Thiazides (chlorthalidone, hctz), Loops, spironolactone, ACE, ARBs, NSAIDs (not aspirin) can mess with lithium levels. Also antibiotics (tetracycline, metronidazole), CCBs (only verapamil), theophylline.

Thiazides, ACE, ARBs NSAIDs increase level

39
Q

NMS

A

acute, potentially fatal reaction to antipsychotics characterized by fever, extreme generalized rigidity, autonomic instability, and AMS

Differentiate from SS bc NMS has bradykinesia and lead pipe rigidily (SS has increased NM activity with clonus and tremors)

40
Q

Borderline personality disorder

A

Diagnostic criteria

  • Pervasive pattern of unstable relationships, self image and affects and marked impulsivity with at least 5 of the following
    • frantic efforts to avoid abandonment
    • unstable and intense interpesonal relationships
    • markedly and persistently unstable self image
    • impulsivitiy in at least 2 areas that are potentially self-damaging
    • recurrent suicidal behaviors or threats of self mutilation (cutting)
    • mood instability (marked mood reactivity)
    • chronic feelings of emptiness
    • inappropriate and intense anger
    • transient stress related paranoia or dissociation

Treatment

  • Primary treatment is psychotherapy (DBT best)
  • Adjunctive pharm to target mood instability and transient psychosis (second generation antipsychotics, mood stabilizers)
  • Antidepressants if comorbid mood or anxiety disorder
41
Q

Negative symptoms of schizophrenia

A

Alogia, flat affect, amotivation, social withdrawal

Antipsychotics treat positive symptoms well but not negative ones.

Psychosocial intervention with social skills training is best

42
Q

Treatment resistent depression

A

MDD that does not respond to adequate trials of 2 different antidepressants

Nonresponder - consider switching

  • monotherapy with a different antidepressant
  • psychotherapy
  • ECT
  • repetitive transcranial magnetic stimulation

Partial responder - consider augmentation

  • second gen antipsychotic
  • antidepressant with dif mechanism of action
  • lithium
  • thyroid hormone
  • psychotherapy
43
Q

ECT

A

Indications

  • Conditions treated
    • Unipolar and bipolar dipression
    • catatonia
    • bipolar mania
  • specific indications
    • treatment resistance
    • psychotic features present
    • emergency conditions
      • refusal to eat or drink
      • imminent risk for suicide
    • pharm contraindicated due to comorbid medical illness or poor tolerability
    • pregnancy when pharm is undersirable or ineffective
    • history of ect response

Safety

  • no absolute contraindications
  • increased risk
    • severed cardiovascular disease, recent MI
    • space occupying brain lesion
    • recent stroke, unstable aneurysm
44
Q

Anti-parkinsonian meds and psych

A

Due to dopaminergic effects, they can all cause psychosis. After ruling out dementia, delirium or other medical etiologies of psychosis, the least potent medications should be withdrawn first before considering reducing carbidopa/levodopa. The order would be first anticholinergics, then amantadine, MAO-B inhibitors, COMT inhibitors, dopamine agonists, and finally carbidopa/levodopa.

If persists beyond med adjustments, add a low dose antipsychotic like quetiapine or clozapine (lowest incidence of drug induced parkinsonism). Avoid first generation (haldol) or risperidone. Recently, pimavanserin is approved for psychotic symptoms in patients with parkinson’s

45
Q

Tourette Syndrome

A

Clinical

  • Both multiple motor and at least 1 vocal tics (don’t need to happen at same time) for more than a year
    • motor - facial grimacing, blinking, head/neck jerking, shoulder shrugging, tongue protrusion, sniffing
    • vocal - grunting, snorting, throat clearing, barking, coprolalia
  • onset before age 18

treatment

  • behavioral therapy (habit reversal traning)
  • antidopaminergic agents
    • tetrabenazine (dopamine depleter)
    • antipsychotics (receptor blockers) - second generation preferred
  • Alpha-2-adrenergic receptor agonists

Frequently associated with comorbid ADHD or OCD. Sometimes oppositional defiance or conduct disorder as well.

46
Q

Medical causes of psychosis

A

CNS

  • Trauma
  • space occupying lesion
  • infection
  • stroke
  • epilepsy
  • cerebral hypoxia

Metabolic/electrolyte disturbances

  • urea cycle disorders
  • acute intermittent porphyria
  • Wilson
  • Renal/liver failure
  • hypoglycemia
  • sodium/ca/mg disturbances

Systemic disorders

  • SLE
  • thyroiditis
47
Q

Manifestations of Lupus

A

Clinical symptoms

  • Constitutional - fever, fatigue and weight loss
  • symmetric, migratory arthritis
  • skin - butterfly rash and photosensitivity
  • serositis - pleurisy, pericarditis, and peritonitis
  • thromboembolic events (due to vasculitis and antiphospholipid antibodies)
  • neuro - cognitive dysfunction and seizures
  • psych - psychosis (up to 5%), mood changes, anxiety

Labs

  • hemolytic anemia, thrombocytopenia, leukopenia
  • hypocomplementemia (C3 and C4)
  • ANA (sensitive)
  • Anti dsDNA and Anti smith (specific)
  • Renal involvement - proteinuria, elevated Cr

If lupus psychosis is suspected, can treat with antipsychotics but tend to improve with oral steroids in a couple weeks

48
Q

Akathisia

A

Side effect of antipsychotics characterized by subjective feeling of inner restlessness, urge to move, and inability to sit still.

Initial approach is cautious reduction in antipsychotic dose, monitoring for psychotic exacerbation. If reduction in dose leads to worsening psychosis then add a beta blocker like propranalol. Benzos and benztropine may also be considered

49
Q

Acute stress disorder

A

Clinical

  • Duration at least 3 days and less than 1 month
  • exposure to actual or threatened trauma
  • symptoms from following categories
    • avoidance of internal memories or external reminders
    • intrusion (nightmares, flashbacks)
    • dissociation (amnesia for event, derealization)
    • arousal (insomnia, hypervigilance, startle)
    • negative mood

Management

  • Trauma focused brief CBT
  • consider meds for insomnia, intense anxiety
  • monitor for PTSD (symptoms over 1 month)
50
Q

Panic Disorder

A

Clinical

  • Recurrent and unexpected panic attacks with at least 4 of the following:
    • chest pain, palpitations, SOB, choking
    • trembling, sweating, nausea, chills
    • dizziness, paresthesia
    • derealization, depersonalization
    • fear of losing control or of dying
  • worry about additional attacks, avoidance behavior

Treatment

  • first line/mainteance - SSRI/SNRI and/or CBT
  • acute distress - benzo
51
Q

Stages of change model

A

Precontemplation - not ready to change. Does not acknowledge negative consequence

  • evaluate actions of current behavior.
  • explain and personalize risk
  • recommending action is premature here

Contemplation - thinkng about it. patient acknoledges consequences but is ambivalent

  • encourage evaluation of pros/cons of behavior change
  • promote new positive behaviors

Preparation - ready to change. patient decides to change

  • encourage small initial steps
  • reinforce positive outcome expectation

Action - making change. Patient makes specific overt changes

  • help ID appropriate change strategies and enlist social support
  • promote self efficacy for dealing with obstacles

Maintenance - changes integrated into patients life, focus on relapse prevention

  • f/u support
  • develop relapse prevention strategies

Identification - behavior is automatic - changed incorporated into sense of self

  • good job bruh
52
Q

Major depression vs Grief

A

Grief reaction

  • normal reaction to loss
  • sadness more specific to thoughts of the deceased
  • waves of grief at reminders
  • self esteem usually preserved
  • functional decline less severe
  • thoughts of dying involve wish to join the deceased; active suicidality uncommon
  • intensity decreases over time

Of course grief an precipitate a major deprssive episode

53
Q

Serotonin Syndrome

A

Causes

  • serotonergic meds, esp in combo (SSRI/SNRI, TCA, tramadol)
  • Drug interactions - serotenergic meds and MAOI or Linezolid
  • Intentional OD of serotonergic meds
  • Serotonergic drugs of abuse (MDMA)

Clinical

  • AMS (anxiety, agitation, delirium)
  • Autonomic dysregulation (sweating, HTN, tachycardia, hyperthermia, vomiting, diarrhea)
  • NM hyperactivity (tremor, myoclonus, hyperreflexia)

Management

  • stop all serotonergic meds
  • supportive care, sedation with benzos
  • serotonin antagonist (cyproheptadine) if supportive measures fail
54
Q

Abrupt d/c of SSRIs

A

Withdrawal symtpoms like agitation, irritibaility, headache, dizziness, flu-like symptoms, and paresthesias.

Fluoextine is least likely bc of it’s long elimination half life.

55
Q

SSRI associated sexual dysfunction

A

Features

  • decreased libido
  • anorgasmia
  • delayed ejaculation
  • common cause of nonaderence

Assessment and management

  • Rule out sexual dysfunction due to depression, medical conditions, primary sexual disorder, stress/relationship issues, substance abuse
  • switch to non-SSRI antidepressant - bupropion or mirtazepine
  • adjunctive therapy with sildenafil or bupropion if an SSRI responder
  • dose reduction for patients on high dose SSRI (monitor for loss of efficacy)
56
Q

First line treatment for insomnia

A

NOT drugs. It’s CBT

If patient fails to improve with CBT, then hypnotics can be used. use extreme caution in the elderly.

57
Q

non-REM sleep arousal disorders

A

Diagnosis

  • Recurrent incomplete awakenings from non REM sleep with 1 of the following:
    • sleepwalking - blank, staring face, relatively unresponsive to attempts to awaken
    • sleep terrors - abrupt arousals from sleep (panicked scream, terror, autonomic arousal, unresponsive to comfort)
  • Little or no dream recall
  • Amnesia for episodes

DDx

  • Nightmare disorder - occurs during REM with detailed dream recall
  • REM sleep related behavior disorder - occurs during REM. acts out dreams
  • Sleep-related seizures
  • Nocturnal panic attacks

Prognosis

  • mostly self limiting
  • administer low dose benzos at bedtime if episodes are frequent, persistent, and distressing

Usually between ages 4-12. Resolves over 1-2 years.

58
Q

Anorexia nervosa

A

Diagnostic criteria

  • Significantly low weight for age and sex
  • intense fear of weight gain
  • distorted views of body weight and shape

Indications for hospitalization

  • hemodynamic instability
    • pulse less than 40
    • BP less than 80/60 or light headedness
    • orthostatic changes
    • syncope
    • hypothermia
  • refeeding syndrome
    • lyte derangements
    • dysrhythmia
    • severe edema
  • less than 70% of expected weight or BMI less than 15
  • acute food refusal
  • suicidality, psychosis

Can have evidence of self-induced vomiting (scarred knuckles) and that would be purging type

Once stabilized, treatment is psychotherapy and nutritional rehab

59
Q

Management of refeeding syndrome

A

beings with empiric thiamine and correction of electrolytes, esp phosphate prior to starting feeds. Caloric intake must be increased gradually with vigilant lyte monitoring.

Oral phosphate is preferred to IV as IV can lead to life threatening hyperphosphatemia

60
Q

Antipsychotic extrapyramidal effects

A

Acute dystonia (torticolis, oculogyric crisis)

  • sudden, sustained contraction of neck, mouth, tongue and eye muscles
  • Treat with benztropine or diphenhydramine

Akathisia

  • Subjective restlessness, inability to sit still
  • treat with BB (propranalol), benzo (lorazepam) or benztropine

Parkinsonism

  • gradual-onset tremor, rigidity and bradykinesia
  • treat with benztropine or amantadine

Tardive dyskinesia

  • gradual onset after prolonged therapy (at least 6 months) - dyskinesia of mouth, face, trunk, extremities
  • treat with valbenazine or deutetrabenazine
61
Q

PTSD

A

DSM-5

  • Exposure to life threatening trauma
  • intrusion symptoms - nightmares, flashbacks
  • avoidance symptoms - avoids dsitressing thoughts, feelings and external reminders of the event
  • negative mood and cognitions - persistent horror, anger, guilt, negative beliefs about self and the world, decreased interest in activities, emotional detachment, amnesia for event
  • arousal symptoms - sleep disturbance, hypervigilance, impaired concentration
  • duration more than 1 month

Treatment

  • trauma focused CBT
  • antidepressants (SSRIs, SNRIs)
  • Prazosin for nightmares
62
Q

Somatic symptom and related disorders

A

Somatic symptom disorder - excessive anxiety and preoccupation with at least 1 unexplained symptom

  • at least 6 months
  • causes distress or impairment
  • treat with regularly scheduled visits with same provider.
    • limit unnecessary workup and specialist referrals
    • legitamize symptoms but make functional improvement the goal
    • focus on stress reduction and improving coping strategies
    • mental health referral if patient will aceept

Illness anxiety disorder - fear of having a serious illness despite few or no symptoms and consistently negative evaluations

Conversion disorder (functional neurologic symptom disorder) - neuro symptom incompatible with known disease

Factitious disorder - intentional falsification of illness in the abscence of obvious external rewards

Malingering - falsification or exaggeration of symptoms to obtain external rewards

63
Q

Naltrexone and alcohol use disorder

A

First line treatment for moderate to severe alcohol use disorder who are unable to achieve sobriety with therapy alone. It’s a mu opioid receptor antagonist. Naltrexone can be initiated while patient is still drinking. Long acting form available for peeps who just can’t listen.

Avoid in opioid users obviously.

Acamprosate is another first line agent (glutamate modulator).

Bupropion helps smoking

Benzos for alcohol withdrawal

Disulfiram is an aversive agent reserved for patients who are abstinent. Inhibits ADH. Patients need to be highly motivated.

64
Q

Initial approach to acutely psychotic patient

A

Maintain interpersonal distance and attempt to understand patient’s experience without challenging the patient’s delusions.

65
Q

contraindications to kidney donation

A
  • Age less than 18
  • lack of mental ability to make informed decision
  • uncontrolled HTN, HIV, DM
  • active or partially treated cancer
  • acute infection
  • high suspicion of donor coercion
  • high suspicion of illegal financial exchange from recipient to donor
  • uncontrolled psych illness
  • active substance abuse
66
Q

Paranoid personality disorder

A

Clinical

  • Pervasive pattern of distrust and suspiciousness beginning in early adulthood and occuring in a variety of settings (no clear delusions)
    • believes being exploited and deceived by others
    • interprets benign comments and events as threats; reacts angrily
    • bears grudges
    • questions loyalty of partner without justification

Ddx

  • Delusional disorder - delusions only
  • schizophrenia - delusions, hallucinations, disorganization, negative symptoms
  • schizotypical personality - eccentric behabior and thinking, unusual perceptual experiences
67
Q

Pharm for smoking cessation

A

Long acting NRT (nicotine patch) and short acting NRT (nasal spray, gum, lozenge, inhaler)

  • reduce cravings and daytime withdrawal symptoms
  • long acting may be combined with short acting (patch plus)
  • no significant negative effects, safe in almost everyone

Bupropion

  • lower post-cessation weight gain
  • good choice for patients with unipolar depression
  • contraindicated in patients with seizure or eating disorders

Varenicline

  • more effective than bupropion or NRT
  • possible increased risk of cardiovascular events
  • increased suicide/depression maybe

Best initial approach is combo of behavioral and pharm approach (patch). Patch plus is better than either alone.

68
Q

Prognostic factors in schizophrenia

A

Good

  • later onset
  • female
  • acute onset with precipitant
  • predominantly positive symptoms
  • no FHx
  • short duration of active symptoms

Poor

  • onset in childhood or teens
  • male
  • gradual onset (prodrome) with no precipitant
  • predominantly negative symptoms
  • FHx of psychotic illness
  • long duration of untreated psychosis
69
Q

Alcohol withdrawal

A

Mild

  • 6-24h since last drink
  • anxiety, insomnia, diaphoresis, palpitations, GI upset, intact orientation

Seizures

  • 12-48h
  • single or multiple generalized tonic clonic

Alcoholic hallucinosis

  • 12-48h
  • visual, auditory, or tactile
  • intact orientation, stable vitals

DT

  • 48-96h
  • confusion, agitation, fever, tachycardia, HTN, diaphoresis, hallucinations

Tx with lorazepam (intermediate acting). Avoid Librium in patients with liver dysfunction.

70
Q

Catatonia

A

Clinical

  • immobility or excessive pruposeless activity
  • mutism, stupor (decreased alertness and response to stimuli)
  • negativism (resistance to instructions and movement)
  • posturing (assuming positions against gravity)
  • waxy flexibility (initial resistance then maintenance of new posture)
  • Echolalia, echopraxia (mimicking speech and movement)

Management

  • benzo (lorazepam)
  • ECT

Lorazepam challenge test with releif in 5-10 mins confirms diagnosis. negative response doesn’t rule out though and patients need repeated doses often.

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