Psychiatry Flashcards
Most important test for patient on clozapine
FBC
Patient had knee surgery was not taking usual drug for anxiety disorder. Now she has coarse tremors, agitated, can’t sleep. What class of drugs is she not taking at the moment?
benzodiazepines
Neuroleptic Malignant Syndrome - recently started on antipsychotic what test would you do?
Creatine kinase
Dad walked out asking about schizophrenia. Teenager daughter then asks at end of consultation whats the likelihood of schizophrenia herself?
10%
Treatment for patient with manic episode
olanzipine and diazepam (short course)
Medical management of OCD?
Fluoxetine + continue for at least 12 months after remission of symptoms
Treatment for torticollis
procyclidine
Woman with dementia, which part of brain is likely to be affected early?
Hippocampus
How would differentiate between mild, moderate and severe depression?
Mild: 2 core + 2 extra symptoms
Moderate: 2 core + 3-4 extra symptoms
Severe: 3 core + 5 cognitive/any features of psychosis
What pathway is responsible for the positive symptoms of schizophrenia?
mesolimbic
What pathway is responsible for the negative symptoms of schizophrenia?
mesocortical
What pathway is responsible for the extrapyramidal symptoms of schizophrenia?
nigrostriatal pathway
What pathway is responsible for prolactinaemia in the treatment of schizophrenia?
tuberoinfundibular pathway
Epidemiology of schizophrenia?
1% of population
Passivity question?
Do you ever get the feeling that someone is controlling your body?
What would you monitor in a patient on antipsychotics?
renal and liver function FBC lipids + glucose = metabolic syndrome ECG Prolactin CK in neuroleptic malignant syndrome is affected
What antipsychotic is associated with weight gain?
olanzapine
Who can manage finances, housing and employment?
Care coordinator
Define CBT?
CBT is a talking therapy that explores the link between someones thought, feelings and behaviours.
Man presents with itching but no cause. In the past has presented with tingling, headache, and abdominal pain
somatisation disorder
Drug to give for depression in a man who had a previous MI?
What is avoided
sertraline
citalopram is generally avoided in patients with a recent MI due to its potential for dose-dependent QT prolongation
Someone else kicking off and de-escalation has failed, what drugs?
Intramuscular lorazepam
IM haloperidol and promethiazine
Patient with Lewy body dementia, given a drug that makes him worse, what drug?
haloperidol
Man comes requesting for codeine for his back, concerned his painkiller use is spiralling, see some degeneration in his spine on imaging – what do you do?
Buprenorphine/methadone + addiction clinic referral
Someone with dilated pupils, urinary retention, obs normal-ish - cause of overdose?
TCAs/amytriptiline
What are the signs of lithium overdose?
tremor, hyperreflexia, and confusion
Man prescribed citalopram, name one possible side effect he should be told about?
Sexual dysfunction
Woman with dementia, which part of brain is likely to be affected early?
Hippocampus
Which drug is most likely to cause neuroleptic malignant syndrome?
haloperidol/promethazine
What drug class is mirtazapine
noradrenergic and specific serotonergic antidepressant
What is the treatment of neuroleptic malignant syndrome?
Dantrolene
How long does a section 2 last?
28 days
How long does a section 3 last?
6 months
What is required from section 2 or 3?
2Drs + AMHP
nearest relative
patients has a right to appeal and discharge
RC/tribunal/managers hearing can be used to rescind the section
Addict patient presenting with dilated pupils and goosebump flesh. What does he have and how do you manage this patient?
Patient presenting with opioid withdrawal.
Methadone
7 year old with ADHD, 1st line treatment
ADHD-focused group parent-training programme
MEDICAL: Methylphenidate for 6 week trial
Which AMTS score suggests delerium or dementia?
6 or less
How long can a normal grief reaction last for?
up to 6 months
What electrolyte changes result from the massive insulin surge in refeeding syndrome?
Hypophosphatemia
Hypokalemia
Hypomagnesemia
Adolescent with 6m or so of depression symptoms, what’s the next step in management?
1st line CBT
BUT if needs not met in 2-3 months refer to CAMHS
Family therapy
Woman on antipsychotics is having fertility trouble, what blood level would you check?
prolactin
Fragile X IQ
<55
On the day of discharge from the medical ward, admitted for an overdose, woman with diagnosed schizophrenia starts having hallucinations but wants to leave, what section would be suitable?
Section 5(2)
Medical student 4 weeks before exams, severe anxiety (sob, palpitations), tried propanolol and hasn’t worked and declined psychological intervention, what tx?
fluoxetine
What type of hallucinations are seen in schizophernia?
auditory hallucinations - 3rd person voice, voice echo
How do you assess alcohol dependence?
AUDIT (Alcohol Use Disorders Identification Test) if >20, move to 2nd line full assessment
2nd line: SADQ
Man with worsening short-term memory. Which part of the brain is affected?
frontal lobe/prefrontal cortex
What antidepressants cause prolonged QT on ECG?
citalopram = SSRI amitriptyline = TCA
Not an antidepressant BUT Quetiapine
Treatment of severe PTSD
Eye movement desensitisation and reprocessing
Patient on anti-psychotic starts feeling restless. Next mx?
Change antipsychotic
2nd lower dose
Man thinks bloke on TV is talking about him, what is this phenomenon known as?
delusions of reference
Woman w dementia keeps leaving care home at 3:00, what legal provisions/ which legal act would you consider to stop this from happening?
Deprivation of liberty safeguards (MCA 2005)
1st line medical management for anorexia
fluoxetine
Man thinks his wife is cheating on him and he has been verifying this by checking her underwear. What is the most likely diagnosis?
Othello’s syndrome
Woman with schizophrenia describes experiences when she feels like she is not real. What phenomenon is this?
Depersonalisation?
Probability of being permanently paralysed from epidural
1:250,000
Question to explore insight into condition?
Is there any chance your mind could be playing tricks on you?
What questions do you ask for autism?
Impairment of social interaction
“Did you have many friends at school?”
“Do you enjoy playing with yourself or with others?”
Impairment in verbal and non verbal communication
“How many words does your child use?”
“How does your child let you know what they want/need?”
Restrictive, repetitive and stereotyped patterns of behaviour
“How do you feel if someone interrupts your daily routine?”
“Do you have any hobbies… what are they?” → probs weird
What are the differential diagnoses for for autism?
Asperger's Syndrome (form of ASD) Deafness Anxiety disorder (agoraphobia) COP Depression
How would you differentiate between aspergers and autism?
Aspergers is an autistic spectrum disorder but the patient will have normal language ability, cognitive development and intelligence.
IQ will be above 70, unlike other ASD.
Much better prognosis than autism.
How would investigate this patient to rule out other possible diagnoses and confirm autism?
A more detailed history focusing on developmental and behavioural features consistent with the ICD 10 and DSM Criteria for ASD/Aspergers.
Collateral history from mum and also school.
Rule out other conditions such as depression and anxiety by using screening tools
Refer the child to the autism team who would then conduct autism diagnostic assessment.
How is autism managed?
Support and education for the patient
Support and education for the family e.g. National Autistic Society.
Behaviour therapy - reinforce positive behaviours
Speech and language therapy
Define autism?
A developmental disorder of variable severity that is characterised by difficulty in social interaction and communication and by restricted or repetitive patterns of thought and behaviour.
Counsel a somatisation
Physical manifestation of psychological stresses. When your body is hurt, your brain detects this and sends out signals of pain to protect you. What is happening is your brain is detecting that you are emotionally hurt and sending out signals to the wrong places.
This DOESN’T mean the pain in not real, it is very real. It just means the solution isn’t as easy as if you break your arm
Tend to occur most when you are experiencing that stress eg going to school or just before school
What is the management for a child with somatisation associated with school?
Don’t do graded return to school - they should attend as normal
Don’t reinforce taking time off/getting out of homework
“would like to invite your parents in to talk about this at a different point, can help explain that this isn’t you just making it up”
Distraction techniques - relaxation etc
Some people find mindfulness techniques/yoga v.helpful
Refer to psych to help in case this doesn’t go away with the techniques we’ve discussed but takes time, until then make a diary of symptoms and how you’re feeling at the time, what stresses you have coming up
Referral to CAHMS - CBT + Family therapy
CBT - you will have to attend multiple sessions for this to work so be prepared for this
Counsel a lady on lithium and is pregnant
So although certain medications carry some risks to the baby in terms of congenital defects etc these are often small and frequently outweigh the risks of stopping the medication. Risk of stopping the medication include withdrawal symptoms and relapse which could actually result in more harm to both you and the baby. Often in pregnancy and after the birth, mental health conditions are worse this is because there’s lots of emotions and changes going on in your body and in your environment, and sometimes women who didn’t have mental health conditions before getting pregnant suffer from things like depression or psychosis and so this is another reason we sometimes like to continue medication.
There are 3 main options that we like to consider in this situation
Continue medication
Change medication to a different try or try psychological treatment
Stop the treatment all together
We on which option to take depending on risk to both mum and baby. From what you’ve told me so far about your history of bipolar and also relapses I think it is really important that you continue to take your lithium medication. If you feel really really strongly about not taking it we could discuss trying some of the different medications you may have tried before or high intensity psychological treatment such as CBT which you may have also had before but if these did not work in the past it is a risk that you would relapse if you switch to these methods.
MSE
Example: ASPECTIC
A&B: laying in hospital bed, looked comfortable at rest, poor eye contact, blank facial expression
Speech: slow and soft speech, monotonous voice
Mood: objectively low, subjectively reports ‘fine’
Affect: flat, unreactive affect
Thoughts: no evidence of thought disorder
Perception: no perceptive abnormalities
Cognition: cognitive impairment, 5/10 on AMTS
Insight: bad insight into the possibility of mental disorder
A - disheveled, lack of eye contact, poor self care, catatonic
S - slow, quiet volume, neutral tone
E - flat and low, mood congruent, blunted affect
P - assess for severe depression with psychotic symptoms
T - usually normal
I - variable
C - usually normal
What questions to ask for a suicide history?
Start:
You’ve really gone through a lot today. Would you mind telling me what happened?
What first made you think of harming yourself? How did you feel immediately after?
Middle:
It sounds like you planned things through very carefully, how did you end up coming to hospital?
End:
How do you feel now?
Do you regret trying to hurt yourself?
Do you have any further plans to harm yourself?
SEE SAFE G
After talking to patient who has attempted suicide what would you do for the investigation?
Document EVERYTHING
Formal capacity/MHA assessment
Physical assessment
Rule out head injury
Give antidote if needed (NAC/paracetamol, activated charcoal → decreases gut absorbance of some substances)
Wound healing of sutures
Analgesia
Risk assessment incl MSE (if not done already)
Meticulous planning, final acts, isolation at time, precaution to avoid being found, definite intent to die, believed method to be lethal, violent method, ongoing wish to die
Immediate
Admission if high risk
Try and remove immediate triggers
Plan for future similar thoughts - who to tell, how to get help
Crisis card
Follow up
1/52 appt
Treat any underlying disorders
If psychotic → refer to EIS
Benefit of HTT?
Biological therapies: antidepressants (short prescription and regular review to avoid stockpiling)
Psychological therapies: IAPT self referral, CBT, mentalisation treatment, transference focused therapy
Social therapies: sick note for time off work, support groups, family support
Coping strategies
Distraction techniques, mood raising activities
Harm reduction - not sharing blades, learn first aid
Prevention - sharps out of reach, avoid triggers, surround with support
Alternatives - squeeze ice, bit food, snap rubber bands, red food dye/marker pen for blood
How many 500mg tablets of paracetamol must be taken as an overdose to warrant administration of N-acetyl cysteine?
10g in total
20 tablets
What investigations would you order for alcohol abuse?
Investigations
A-E
- Abdo exam
- Breathalyzer testing
- BP
- Urine drug screen
- Bloods: alcohol level, FBC (raised MCV), thiamine, B12, LFTS (raised GGT), clotting profile, glucose, U&Es – low potassium
- SAD-Q questionnaire (severity of alcohol dependence questionnaire)
- AUDIT tool – Alcohol Use Disorders Identification Test
- (Imaging - Liver US)
- Collateral history
What is the management for acute intoxication of alcohol?
- A-E assessment and stabilise.
- Detox: Oral chlordiazepoxide (if outpatient)/ IV diazepam (if inpatient) and Pabrinex (vitamin B1, B6 vitamin C)
o Outpatient chlordiazepoxide. Most uncomplicated alcohol-dependent patients. If doubt about compliance you should see pt every morning, breathalyse and don’t give more than 2 days at once. 2-4 meetings/week and intensive community assisted withdrawal programmes (4-7 days per week).
o Inpatient IV diazepam if fit admission criteria below. Can use fixed dose or symptom-dependent regimen - Seizures: Carbamazepine
- Hallucinations: Haloperidol
- ADMIT if:
o history of complex withdrawal (delirium tremens/ seizures etc.)
o symptoms of Wernicke-Korsakoff or confusion or delirium tremens
o co-morbid mental illness, suicide risk, polydrug use
o severe nausea/ vomiting or severe malnutrition
o no stable home envt.
o V HIGH SAD-Q score/ >30 units a day
What is the bio approach for the treatment of alcoholism?
o Acamprosate/ naltrexone (anti-craving drugs)
o Disulfiram (aversive drug: blocks aldehyde dehydrogenase and makes you feel sick)
o Treat co-morbid psych problems – depression/ anxiety etc
o Treat seizures with carbamazepine
o Laxatives – if constipated
What are the signs of acute alcohol intoxication?
Labile mood, aggressiveness, impaired judgement, slurred speech, unsteady gait, ataxia POISONING: - CUPS: - Cold, clammy, bluish skin - Unconscious - Puking - Slow breathing
What is the mechanism of alcohol’s effects?
Anxiolytic – increasing GABA transmission
Euphoric – increasing dopamine release in mesolimbic system
Amnesic – inhibition of NMDA mediated glutamatergic release
What is the recommended maximum alcohol intake in the UK for men and women?
14 units a week for both, spread drinking over 3 days, have several alcohol free days. Women 2-3 units per day, Men 3-4 per day.
What is delirium tremens?
Acute confusional state secondary to alcohol WITHDRAWAL 48 hours after abstinence. Lasts 3-4 days. Feels like ‘DEATH’
- Delirium
- Extreme fear/hilarity
- Autonomic disturbances (sweating, tachycardia, hypertension, dilated pupils, fever)
- Tremor
- Hallucinations (mainly visual- eg. bugs on the skin - formication)
What are this signs and symptoms of opioid overdose
Euphoria and ‘warmth’ –> sedation, bradycardia
Overdose: ‘pinpoint’ pupils (miosis) + low RR
• Treat with Naloxone (opiate antagonist)
• Immediate start of withdrawal symptoms
Low-dose SEs: constipation, anorexia, decreased libido
What are the withdrawal symptoms of opioid overdose?
Withdrawal symptoms (begins 6 hours after injection, peak 36-48hrs, last 5-7 days) – most common*
Craving, nausea, insomnia, agitation
*‘Runs’ (i.e. D+V, lacrimation, rhinorrhoea)
*Flu-like (feverish, abdominal cramps, aches)
*‘Goose-flesh’ (pilomotor unit erection), yawning
*Mydriasis (dilation)
Essentially, rarely life-threatening
What are the investigations for heroin abuse?
Standard: physical exam, bedside/basic obs, biochemical
but also important to do –> Blood borne infections (RPR, hepatitis serology, HIV test)
What is the management of heroin overdose?
General recommendations:
Appoint a key worker (single point of contact) and develop a care plan)
Harm reduction (pragmatic approach) – complete abstinence unlikely, be pragmatic:
• Needle-exchanges for IVDUs
• Offer vaccinations and testing for blood-borne pathogens
Health education (i.e. sleep hygiene, support groups *, diet, etc.)
Opioid substitution therapy
1st –> OST given in controlled environment (for 3-6m)
2nd –> if suitable –> ‘take-home’ some medications
Established maintenance therapy be reached before detoxification with methadone/buprenorphrine can begin.
What is the mechanism of action of methadone and buprenorphrine?
Methadone = long-acting synthetic opiate Buprenorphine = partial opiate agonist
List some short and long acting BDZs and what is the treatment for withdrawal?
o Short-acting BDZs = lorazepam
o Long-acting BDZs = chlordiazepoxide, diazepam
Options for withdrawal:
(1) Slow-dose reduction
(2) Switch to equivalent dose of Diazepam, and slow-dose reduction; used in those…
o Difficult to physically taper down the dose
o On short-acting potent BDZs (i.e. lorazepam)
What signs of autism would you see in a child?
Clumsy walking, minimal babbling, avoid eye contact, no smiling, avoids hugs, plays alone and exhibits repetitive behaviour, doesn’t respond to name being called, disturbed sleep pattern
