Psychiatric Eval, Mgmt, DoA Flashcards

1
Q

Describe common medical complaints that may be related to organic psychiatric illness?

A
  • Palpitations
  • Chest pain, tightness
  • SOB
  • Abd pain, N/V
  • HA
  • Syncope
  • Seizures
  • Paresthesia
  • Throat tightness
  • Tremors
  • Fear/panic
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2
Q

Name several organic causes of psychaitric illness, and several inorganic causes

A
  • Organic
    • Drug toxicity/intox
    • Withdrawal
    • Head trauma
    • Encephalopathy
    • Hypoglycemia
    • Metabolic/electrolyte derrangement
    • Hypoxia
    • Organ failure
    • Postictal
    • Hyper/hypothyroid
  • Inorganic
    • Primary psychiatric illness
      • Depression, psychosis, anxiety/panic, bipolar, schizophrenia
    • Behavioral disturbance
      • Autism
      • Dementia
      • Cognitive disability
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3
Q

Name your red flags that a patient’s psychiatric illness has an organic root cause

A
  • Rapid onset of new psych symptoms
  • New onset > 40 years old
  • Any onset > 65 years old
  • Delirium present
  • Focal neuro deficit
  • Presence of toxidrome
  • Traumatic injury/illness evident
  • Abnormal vitals: Fever, tachycardia, hotn, hypoxia, tachypnea
  • Visual vs auditory hallucinations
    • Visual tend to be a/w delirium, whereas auditory tend to be a/w psychosis
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4
Q

What is your diagnostic workup for acute psychiatric illness?

What are your key pharmacologic considerations re: poisonings, adverse drug effects, and OTC meds?

A
  • Dx workup
    • None if inorganic/primary psychiatric
    • Based on history and physical
    • Rule out underlying medical causes that require tx
    • Consider differentials beyond the psych symptom
  • Poisonings
    • Dilantin
    • Digoxin
    • TCAs
  • ADEs
    • Depakote
    • Prednisone
    • SSRI/SNRI in bipolar patient
    • Phentermine
  • OTC meds
    • Pseudoephedrine
    • Diphenhydramine
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5
Q

1st Gen Antipsychotic: Haldol

  • Route:
  • MOA:
  • AEs:
  • Benefits:

2nd Gen Antipsychotic: Olanzapine, Ziprasidone, Aripiprazole, Risperidone (PO), Quetiapine (PO)

  • MOA:
  • Efficacy:
  • Safety profile:
A
  • Haldol
    • Route: PO, IM, IV
    • MOA: Selective D2 receptor antagonist
    • AEs: Prolonged QT with IV admin, high doses; EPS side effects
    • Benefits: Low risk of resp depression with other CNS depressants
  • 2nd Gen Antipsychotics
    • MOA: D2 and Serotonin 2A receptor Antagonists
    • Efficacy: Similar to Haldol, not inferior
    • Safety profile: Not as well studied as haldol
      • lower risk of prolonged QT, EPS
      • Resp depression can occur with other CNS depressants
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6
Q

Benzodiazepines: Loraze, diaze, midazo

  • Route:
  • MOA:
  • AEs:
  • DDIs:
  • Notes

Ketamine:

  • Indication:
  • Advantages:
  • Disadvantages:
  • Dose:
A
  • BZDs
    • Route: IV, IM, PO
    • MOA: GABA receptor agonist, induces sedation
    • AEs: Resp depression, hotn
    • DDIs: EtOH intox, CNS depressants
    • Notes:
      • Not used as monotherapy for psychosis
      • Avoid in elderly
  • Ketamine
    • Indication: excited delirium syndrome
    • Advantages: rapid onset, no respiratory depression
    • Disadvantages: may require rescue sedation, emergence phenomenon
    • Dose: 5mg/kg IM
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7
Q

Dexmedetomidine:

  • MOA
  • Indication
  • Advantages
  • Disadvantages
A
  • MOA: Selective alpha-2 agonist
  • Indication: Sedation, delirium, severe EtOH withdrawal
  • Advantages: Low risk of resp depression, less delirium induction
  • Disadvantages: Hotn, bradycardia, hypertension
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8
Q

Your patient abuses drugs by the following routes, what are your route-specific medical considerations/complications?

  • IV
  • Nasal
  • Rectal
A
  • IV
    • Infxn: bacteremia, endocarditis, cellulitis, abscess (cutaneous, spinal cord, brain, psoas muscle), osteo
    • Retained foreign body
    • DVT, arterial thrombosis, limb ischemia
    • Poor venous access
  • Nasal
    • Loss of smell
    • Nosebleeds
    • Perf of nasal septum/soft palate
    • Dysphagia
    • Lung dz
  • Rectal
    • OD - bypasses liver/first pass
    • Necrosis
    • Inestinal ischemia, perforation
    • Fecal incontinence
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9
Q

Describe your medical concerns for each of the following class of drug intoxication/abuse:

  • Opioids
  • Sympathomimetics
  • EtOH
  • Hallucinogens
A
  • Opioids
    • Life threatening resp/CNS depression
  • Sympathomimetics
    • Hyperthermia, tachycardia, htn, diaphoresis
    • CHF, MI, arrhythmia, vasospasm, stroke
    • Dehydration, rhabdo, renal failure
    • Violence, psychosis
    • Loss of pain perception
  • EtOH
    • Life threatening resp/CNS depression
    • Delirium, agitation
    • Starvation ketoacidosis
    • Wenicke vs hepatic encephalopathy
    • Delirium tremens/severe withdrawal
    • Occult injury
  • Hallucinogens
    • Psychosis and agitation
    • Potentially permament psychosis
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10
Q

Describe your dx workup for a patient who presents severely intoxicated

A
  • None necessary if NO medical issues and patient admits to drug use
    • Tox screening usually unnecessary
  • If clinically indicated, workup is directed by age, comorbidites, likely complications
  • Possible scenarios:
    • Cardiac: EKG, troponin, BNP, monitoring
    • Renal: BMP, CK, UA
    • Intentional OD: ASA/APAP
    • Infxn: Wound cultures, blood cultures
    • Female: urine preg
    • IVDA: CXR, PE screen
    • Trauma: imaging
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