Psychiatry

Question 1

Side effects of lithium

Answer 1

short term - NVD, polyuria, polydipsia, fine tremor

Long term - weight gain, hypothyroidism, impaired kidney function

Question 2

Lithium toxicity

Answer 2

Coarse tremor, hyperreflexia, ataxia, nystagmus, renal impairment - oliguria, dysarthria, seizures convulsions

Question 3

Advice when starting lithium

Answer 3

-Its a mood stabiliser drug, advise you to stay on this for at least 3 yrs - before that the rate of relapse with bi-polar is high.
- Shouldn’t rapidly change the amount of salt in your diet.
- Should use contraception and have a discussion with doctors before trying to become pregnant
- Take the lithium at the same time every evening - allows accurate blood tests when we measure the levels so we can make sure they’re in the right range.
- If you miss a dose don’t double your dose, just leave the missed tablet ad continue as normal the next day. but if you regularly miss your dose then it won’t be as effective and there is risk of recurrence.
- regular blood tests to maintain the levels of lithium in your blood at the correct level.
some things interact with lithium so you shouldn’t use NSAIDs over the counter, other drugs to be avoided include diuretics, ace inhibitors ( a type of BP med), SSRIs + haloperidol.

Question 4

Life threatening adverse effects of clozapine

Answer 4

• Blood dyscrasia
• Seizures
• PE
• Myocarditis

Question 5

Workup before starting clozapine

Answer 5

FBC
Weight + BMI
blood glucose
fasting lipid profile
ECG

Question 6

non life threatening side effects of clozapine

Answer 6

Sedation
hyper salivation 
weight gain 
HTN
tachycardia
constipation
fever

Question 7

what is the starting dose of clozapine?

Answer 7

12.5mg OD take at night b/c of hypotension. then 12.5mg BD, work up to a total of 300-450mg/day with plasma level of 350mcg/L

Question 8

How often are bloods done on a patient on clozapine?

Answer 8

Weekly for first 18 wks, then bi-weekly until end of first yr, monthly after that first yr.

Question 9

Bloods to be done before starting lithium

Answer 9

renal function

TFTs

Question 10

Alternatives to lithium

Answer 10

sodium valproate, carbamazepine, lamotrigine

Question 11

Treatment of acute mania

Answer 11

Stop anti-depressant
consider anti-psychotic = olanzapine for behaviour short term
consider short acting Benzo or sodium valproate
long term Goal will be to start lithium therapy,

Question 12

Side effects of SSRI

Answer 12

nausea, vomiting, sleep disturbance, Dizziness, increased suicide risk.

Serotonin syndrome - tremor, hyperthermia, CV collapse

Question 13

Example of SSRIs

Answer 13

Sertaline, citalopram, fluoxetine

Question 14

What type of drug is venlafaxine

Answer 14

SNRI

Question 15

Side effects of Amitryptyline

Answer 15

Atropine like effects

- constipation, blurred vision, dry mouth, postural hypotension.

Question 16

Side effects of ECT

Answer 16

short term - headaches, muscles aches, nausea, confusion,

• possible that Short term memory + executive functioning would be impaired - should improve but there is some evidence to suggest that this can be long term.
• less likely with unilateral electrode use ( done now vs the bilateral which was the old way)

Question 17

Indications for ECT

Answer 17

Catatonia
Severe treatment resistant depression or when a rapid response is needed,
Refractory psychosis
Refreactory or life threatening mania

Question 18

Side effects of anti-psychotics

Answer 18

Postural hypotension, sedation, weight gain, dry mouth, increased QTc
Major side effects include extra-pyramidal SE’s, Tardive dyskinesia, endocrine se - hyperprolactinemia, metabolic syndrome.

Question 19

What are the extra-pyramidal side effects and when do they occur?

Answer 19

Dystonic reactions ( hrs) - e.g. oculogyric crisis
Akathasia (1-2wks)= restlessness
Parkinsonism (1-6wks) - pill rolling tremor

Question 20

What is tardive dyskinesia

Answer 20

A long term side effect of anti-psychotic medication ( but is less common with the newer medications). A movement disorder that is often irreversible, tremor, writhing?, oro-facial dyskinesia.

Question 21

Symptoms of delirium tremens

Answer 21

Confusion
Vivid hallucinations
Marked tremor

Question 22

Symptoms of Wernicke’s encephalopathy

Answer 22

Confusion, ataxia, ophthalmoplegia

Question 23

Risk factors for neuroleptic malignant syndrome

Answer 23

• rapid dose increase
• rapid withdrawal
• anti-psychotic polypharmacy
• male
• younger age
• dehydration
• parkinson’s
• alcoholism
• hyperthyroidism

Question 24

S+S of neuroleptic malignant syndrome

Answer 24

Fever, diaphoresis, 
rigidity
confusion 
tachycardia, fluctuating BP, elevated CK, 
altered LFTs, 
leukocytosis

Question 25

List the causes of delirium

Answer 25

Infections
Withdrawal - benzo, alcohol 
Acute metabolic syndrome
Trauma
Cns pathology - SOL
Hypoxia
Deficiency B12, B1, folate, 
Endocrine
Acute vascular - stroke, TIA
Toxins - drugs
Heavy metals - lead

Question 26

Key features of delirium

Answer 26

1. Acute onset + fluctuating course
2. Inattention
   + Disorganised thinking / altered LOC

Question 27

What are the somatic symptoms of depression?

Answer 27

sleep distubance
apetite
diurnal mood variation 
flattened affect
psychomotor agitation 
poor concentration 
anhedonia

Question 28

What are the first rank symptoms of schizophrenia?

Answer 28

Auditory hallucinations
Thought interference - TI,TW,TB
Passivity phenomena
Delusional perception.

Question 29

What are the +ve symptoms of schizophrenia?

Answer 29

Delusions
hallucinations
thought disorder

Question 30

What are the negative symptoms of schizophrenia?

Answer 30

flattened affect
social withdrawal
loss of volition - passivity