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Phase 3a > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

What class of antipsychotic is Haloperidol and what is it’s MOA?

A

Typical Antipsychotic

Dopamine Receptor Antagonist (D2 Post-synaptic)

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2
Q

Name some common adverse effects of typical antipsychotics?

A

Extrapyramidal side effects; Tardive Dyskinesia(chewwing and pouting of jaw), Tremor, Stiffness, Involuntary Movements, Restlessness (Akathisia)

Hyperprolactinaemia

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3
Q

Name 2 Typical Antipsychotics

A

Haloperidol

Chlopromazine

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4
Q

Name 3 Atypical Antipsychotics

A

Clozapine
Risperidone
Olanzapine

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5
Q

What is neuroleptic malignant syndrome?

A

Life threatening neurological disorder associated with anti-psychotics

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6
Q

Give 3 medications that can cause neuroleptic malignant syndrome

A

Typical antipsychotics - Haloperidol (most common)

Atypical antipsychotics (olanzapine, risperidone, quetiapine, aripiprazole)

Anti-emetics - Metoclopramide

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7
Q

Give 5 clinical features of neuroleptic malignant syndrome

A

Fever
Nausea and vomiting
Muscle rigidity
Autonomic instability
Mental status change (agitation, confusion, fluctuating consciousness)

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8
Q

When does neuroleptic malignant syndrome typically present?

A

Typically during the first 2 weeks of therapy.

But can develop years into treatment with no increase in dose.

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9
Q

Give 3 blood test findings that would be raised in neuroleptic malignant syndrome

A

Raised creatinine kinase

Raised LFTs (AST, ALT)

Raised leukocytes (leukocytosis)

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10
Q

Define illusion

A

An abnormal perception caused by a sensory misinterpretation of an actual stimulus

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11
Q

Define hallucination

A

An abnormal sensory experience that occurs in the absence of a direct external stimulus.

Perceived as real.

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12
Q

Define Pseudohallucination

A

An involuntary sensory experience that is similar to a hallucination but is recognised by the person experiencing it as subjective or unreal.

Perceived as unreal.

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13
Q

Define over-valued idea

A

A false or exaggerated and sustained belief that is maintained

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14
Q

Define delusion

A

A false, unshakable belief that’s out of keeping with the person’s cultural, intellectual and social background

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15
Q

Define delusional perception

A

A true perception to which a patient attributes a false meaning.

i.e a normal event such as traffic lights turning red is interpreted by the patient as meaning martians are about to land.

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16
Q

Define concrete thinking

A

Reasoning based on what you can see, hear, feel and experience here and now.

i.e if someone tells them to ‘break a leg’ they may wonder why they should snap their bone in two.

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17
Q

Define loosening of associations. What is it a feature of?

A

Aka derailment/knights move thinking.

Thought disorder describing a lack of connection between ideas.

Feature of schizophrenia

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18
Q

Define circumstantial speech

A

Aka fullness of detail

Describes when lots of unnecessary and insignificant details are used in conversation.

Patient returns to original point

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19
Q

Define tangential speech

A

Describes when the speaker wanders and drifts from the original topic, never returning to the original topic

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20
Q

Define confabulaiton

A

Describes the production or creation of false or erroneous memories without intent to deceive/lie

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21
Q

Define pressure of speech. What is it a sign of?

A

Describes a tendency to speak rapidly

Sign of mania/hypomania (linked to bipolar disorder)

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22
Q

Define anhedonia

A

Inability to enjoy things (common in depression/psychosis)

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23
Q

Define apathy

A

Complete lack of interest

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24
Q

Define incongruity of affect

A

Describes no link between the emotion their feeling and the story their telling.

I.e smiling when talking about their dog dying.

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25
Q

Define blunting of affect

A

No emotional response whatsoever to an emotional situation.

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26
Q

Define Belle indifference. What is it a feature of?

A

Describes lack of concern and/or feeling of indifference about medical symptoms they may have.

Feature of conversion symptoms/hysteria

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27
Q

Define conversion disorder

A

Disorder where a person experiences blindness, paralysis or other nervous system symptoms that cannot be explained by physical illness or injury

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28
Q

Define depersonalisation

A

Describes a feeling where the self is felt to be unreal or detached from reality

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29
Q

Define thought blocking

A

Describes when ones train of thought suddenly ceases

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30
Q

Define thought broadcasting

A

Describes an experience that ones thoughts are being transmitted from ones mind and broadcasted to everyone

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31
Q

Define thought disorder

A

Describes a disorder of the form of thought, where associations between ideas are lost or loosened

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32
Q

Describe thought echo

A

Describes where thoughts are heard as if they were spoken aloud

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33
Q

Describe thought insertion

A

The experience of alien thoughts being inserted into the mind

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34
Q

Describe thought withdrawal

A

The experience of thoughts being removed or extracted from ones mind

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35
Q

Define thought alienation

A

Describes when a patient feels their own thoughts are no longer in their control.

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36
Q

Define akathisia

A

Describes an inner feeling of excessive restlessness, provoking the patient to fidget or pace.

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37
Q

Define anterograde amnesia

A

Describes loss of memory subsequent to any cause e.g brain trauma

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38
Q

Define retrograde amnesia

A

Describes loss of memory for a period of time prior to any cause

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39
Q

Describe catatonia

A

A state where someone is awake but doesn’t seem to respond to other people and their environment.

Patient may stop voluntary movement or stay still in an unusual position

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40
Q

Define stupor

A

A state of near unconsciousness or insensibility

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41
Q

Define psychomotor retardation

A

Describes the slowing down or hampering of a persons mental or physical activities (i.e slowed speech, decreased movement ect)

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42
Q

Define flight of ideas. What condition is it commonly seen? (2)

A

Describes when thoughts become pressured and ideas may race from topic to topic, often guided by rhymes or puns.

Ideas are associated though, unlike thought disorder.

Seen in mania/hypomania

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43
Q

Define derealisation

A

An experience where a person perceives the world around them as unreal.

Linked to depersonalisation

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44
Q

Define cyclothymia

A

A variability of mood over days/weeks, cycling from positive to negative mood states.

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45
Q

Define compulsion

A

Describes the behavioural component of an obsession.

The individual feels the need to repeat a behaviour which has no immediate benefit beyond reducing the anxiety associated with the obsessional idea.

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46
Q

Define obsession (2)

A

Describes an unpleasant or nonsensical thought which intrudes into a person’s mind, despite a degree of resistance.

Patient recognises this thought as pointless or senseless.

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47
Q

Define stereotyped behaviour

A

Well-defined behavioural acts which are repeated over and over and seem to be aimless. (e.g pacing, body rocking

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48
Q

Define hypomania

A

An affective disorder characterised by elation, overactivity and insomnia

Lasts < 7 days

Doesn’t exhibit psychotic symptoms

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49
Q

Define mania

A

An affective disorder characterised by intense euphoria, overactivity and loss of insight

Lasts for at least 7 days

May present with psychotic symptoms (hallucinations/delusions of grandeur ect)

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50
Q

Define agnosia

A

Inability to organise sensory information to recognise objects (visual agnosia) or parts of the body (hemisomatoagnosia)

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51
Q

Define affect

A

Describes an individuals immediate emotional state which a person can recognise subjectively/objectively by others.

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52
Q

Describe asthenia

A

Abnormal physical weakness or lack of energy

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53
Q

Define passivity phenomena

A

When an individual feels some aspect of themselves is under the external control of another/others.

i.e made movements where they feel their arms and legs are under someone elses control, made thoughts (insertion/withdrawal) ect

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54
Q

What are Schneider’s First Rank Symptoms? (5)

A

Used in diagnosis of schizophrenia.

Auditory hallucinations

Thought disorders (insertion, withdrawal, echo, broadcasting)

Delusional perceptions

Somatic hallucinations

Passivity phenomena (when an individual feels some aspect of themselves is under the external control of another/others)

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55
Q

Give 5 positive (psychotic) symptoms seen in schizophrenia

A

Delusions

Hallucinations

Disorganised speech (hebephrenia)

Disorganised behaviour

Catatonic behaviour (decreased motor activity)

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56
Q

Give 5 negative symptoms of schizophrenia

A

Social withdrawal

Demotivation (Avolition)

Self-neglect

Alogia

Anhedonia

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57
Q

What age does schizophrenia tend to present?

A

Late teens to mid 30s

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58
Q

Describe the pathophysiology of schizophrenia

A

Thought to be due to;
- Increased activity in the mesolimbic neuronal pathway
and
-Decreased activity in the prefrontal cortical pathway

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59
Q

What are the 3 phases of schizophrenia?

A

Prodromal phase (withdrawal)

Active phase (positive symptoms)

Residual phase (cognitive symptoms)

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60
Q

Describe the prodromal phase (withdrawal) of schizophrenia. Give 4 features

A

Can precede active phase by 18 months

Features;
- Patients become withdrawn/socially isolated.
- Transient, low intensity psychotic symptoms
- Reduced interest in daily activities
- Anxiety, irritability or depressive features

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61
Q

Describe clinical features of the active phase (positive symptoms) of schizophrenia (5)

A

Follows the prodromal phase;

Delusions

Hallucinations

Disorganised speech (hebephrenia)

Disorganised behaviour

Catatonic behaviour (decreased motor activity)

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62
Q

Describe the residual phase (cognitive symptoms) of schizophrenia

A

Follows the active phase.

May display cognitive symptoms effecting;

Memory

Learning

Understanding

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63
Q

How is schizophrenia diagnosed?

A

Diagnosis requires at least 2 of the following ongoing for 6 months (with 1 month of active phase symptoms.

Delusions*

Hallucinations*

Disorganised speech*

Disorganised/catatonic behaviour

Negative symptoms.

Patients must have at least one of * for diagnosis.

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64
Q

Name 3 types of schizophrenia, which is most common?

A

Paranoid (most common - hallucinations/delusions are most prominent)

Hebephrenic (age of onset 15-25 years, poor prognosis)

Catatonic (stupor)

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65
Q

Describe schizoaffective disorder

A

Describes a combination of both schizophrenia and affective (mood) disorders (mania/depression)

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66
Q

Describe the management of schizophrenia

A

1st line - Oral atypical antipsychotics (olanzapine, risperidone, quetiapine, aripiprazole ect)

2nd line - Clozapine

Clozapine offered to patients whom have not responded to sequential use of at least 2 different antipsychotics

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67
Q

What investigation should be performed before starting clozapine?

A

ECG (as can cause myocarditis)

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68
Q

What is the MOA of clozapine?

A

Dopamine receptor (D2) and Serotonin receptor (5HT3) antagonist

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69
Q

Give 3 side effects of clozapine

A

Metabolic side effects;

Weight gain

Hyperglycaemia (type 2 diabetes)

Dyslipidaemia

Agranulocytosis (decreased neutrophils)

Constipation/intestinal obstruction (common)

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70
Q

What can clozapine increase the risk of?

A

Seizures

As lowers seizure threshold

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71
Q

What side effects are associated with olanzapine?

A

Dyslipidaemia and weight gain

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72
Q

What side effects are associated with quetiapine?

A

Dyslipidaemia and weight gain

Also postural hypotension

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73
Q

What side effects are associated with risperidone?

A

Extrapyramidal side effects, postural hypotension and sexual dysfunction

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74
Q

Give 3 examples of acute dystonia

A

Torticollis (abnormal twisting of neck)

Oculogyric crisis (sustained upward deviation of both eyes)

Involuntary contractions of muscles in face, neck, abdomen or pelvis. Can lead to abnormal movement or postures

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75
Q

What is acute dystonia? Why can it occur?

A

Involuntary contractions of muscles in face, neck, abdomen or pelvis. Can lead to abnormal movements or postures.

Oculogyric crisis may occur (sustained upward deviation of both eyes)

Can occur 2nd to starting anti-psychotics

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76
Q

What is used to manage acute dystonia/parkinsonism following starting anti-psychotic treatment?

A

Procyclidine

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77
Q

What type of drug is procyclidine?

A

Anticholinergic

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78
Q

How is akathisia following starting antipsychotic treatment managed?

A

Propranolol +/- cyproheptadine

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79
Q

What is the moa of cyproheptadine?

A

Antihistamine + Anti serotonin

Used with propranolol for treatment of akathesia

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80
Q

What is a common symptom of high dose atypical antipsychotics (olanzapine, risperidone, ect)

A

Extrapyramidal side effects;

Tremor

Slurred speech

Akathesia (restlessness)

Dystonia (spasms/muscle contractions)

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81
Q

Describe Section 2 of the Mental Health Act

A

Section 2 - 28 day detainment

Act allows a patient to be detained in a hospital setting for assessment and treatment of a mental disorder.

Patients may be detained under section 2 if there is a risk to their own safety or the safety of others

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82
Q

Describe Section 3 of the Mental Health Act. What 2 medical recommendations are required?

A

Section 3 - 6 month detainment

2 medical recommendations are required;
- One from a psychiatrist approved under section 12
- One from a doctor who has a previous acquaintance with the patient (i.e GP)

Section 3 enables treatment to be restarted in a hospital setting.

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83
Q

Can patients appeal against their detention under Section 3?

A

Yes. This can be supported by an independent mental health advocate. A mental health is then conducted to review the patients detention.

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84
Q

Describe Section 5 (2) of the mental health act

A

Section 5(2) - 72 hour detention

Applies to patients whom are voluntary or whom are already a patient.

Patients under this section must be assessed by 2 doctors who decide whether they need more time in hospital. (then put under section 2/3)

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85
Q

Describe Section 135 of the Mental Health Act

A

Section 135 - Police detainment allowing entry into a property

Requires a warrant.

Patient can be kept in hospital for up to 24 hours.

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86
Q

Describe Section 136 of the Mental Health Act

A

Section 136- Police detainment from a public space (doesn’t require a warrant)

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87
Q

Give 2 core symptoms of Autism Spectrum Disorder

A

Persistent deficits in social communication and social interaction

Restricted, repetitive patterns of behaviour, interests or activities

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88
Q

When does ASD tend to present?

A

During childhood (before 2-3 years)

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89
Q

Give 5 clinical features of ASD

A

Impaired social communication and interaction

Repetitive behaviours, interests and activities (solitary play)

Impaired imagination

Ritualistic/insists on following routines in precise detail

Intellectual/language impairment

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90
Q

Give 2 conditions associated with ASD

A

ADHD

Epilepsy

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91
Q

Give 3 management strategies for ASD. Drugs (3)

A

Early intensive behavioural intervention (speech therapy, starting school at 3 can increase IQ)

Parent training

Drugs;
- Risperidone (reduces aggression)
- SSRIs (reduce repetitive behaviour)
- Melatonin (sleep)

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92
Q

What triad of symptoms is seen in ADHD?

A

Impulsivity

Hyperactivity

Inattention

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93
Q

Give 3 features of impulsivity that may be seen in a child with ADHD

A

Blurts out answers in class

Interrupts others

Cannot take turns

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94
Q

Give 3 features of hyperactivity that may be seen in a child with ADHD

A

Squirming/fidgeting

Talks constantly

Restless

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95
Q

Give 4 features of inattention that may be seen in a child with ADHD

A

Often unable to;

Listen/attend closely

Follow instructions

Organise tasks

Forgets/loses things

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96
Q

Between what ages are children commonly diagnosed with ADHD?

A

3-7 years old

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97
Q

What are the 1st and 2nd line non-pharmacological treatments for ADHD?

A

1st line - 10 week wait (observe symptoms)

2nd line - If symptoms persist, refer to secondary care > CAHMS referral

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98
Q

What are the 1st, 2nd and 3rd line drug therapies for ADHD? From what age can they be given?

A

Only given to children >5

1st line - Methylphenidate (ritalin)

2nd line - Lisdexamfetamine

3rd line - Dexafetamine

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99
Q

For how long is methylphenidate initially given to children with ADHD?

A

Initially given on a 6 week trial

100
Q

What is the MOA of Methylphenidate (ritalin) (ADHD)

A

Dopamine/norepinephrine reuptake inhibitor

101
Q

Give 3 side effects of Methylphenidate (ritalin) (ADHD)

A

Abdominal pain

Nausea

Dyspepsia

102
Q

What should be monitored in children on Methylphenidate (ritalin)?

A

Height and Weight every 6 months

103
Q

What investigation should be performed before starting ADHD drugs? Why?

A

ECG

As they’re cardiotoxic

104
Q

What is required for ADHD diagnosis? (6)

A

> 6 Inattentive symptoms

> 6 Hyperactive/impulsive symptoms

Other conditions;
- Several symptoms occur before age of 12
- Symptoms must be present in 2 or more settings (home, school, work ect)
- Symptoms cannot be explained by another mental disorder
- There is clear evidence that symptoms interfere with school, social or work functioning.

105
Q

What can long term lithium treatment cause?

A

Hyperparathyroidism and resultant hypercalcaemia.

Also hypothyroidism

Symptoms;

‘Stones, bones, abdominal moans and psychic groans’

106
Q

What is the 1st line pharmaceutical for generalised anxiety disorder?

A

Sertraline

107
Q

What is the SSRI of choice in children/adolescents?

A

Fluoxetine

108
Q

Give 2 common side effects of SSRIs

A

Gastrointestinal symptoms (most common)

GI bleeding

109
Q

What side effect is Citalopram associated with? Who is it contraindicated in?

A

Dose Dependent QT interval prolongation (torsades de points)

Contraindicated in;
Congenital Long QT syndrome

110
Q

In patients on warfarin/heparin, what should be given instead of an SSRI?

A

Mirtazapine

111
Q

How do NICE define generalised anxiety disorder?

A

A feeling of excessive worry about a number of different events associated with heightened tension

112
Q

Give 3 alternative causes of generalised anxiety disorder

A

Hyperthyroidism

Cardiac disease

Medication-induced anxiety

113
Q

Give 5 medications that may trigger anxiety

A

Salbutamol

Theophylline

Corticosteroids

Antidepressants

Caffeine

114
Q

How is generalised anxiety disorder managed? (4)

A

Stepwise approach

Step 1 - Education about GAD + active monitoring

Step 2 - Low intensity psychological interventions (self guided/non-facilitated help)

Step 3 - High intensity psychological interventions (CBT) or drug treatment

Step 4 - Highly specialised input (multi agency teams)

115
Q

Give 4 risk factors for GAD

A

Aged between 35-54

Being divorced or separated

Living alone

Being a lone parent

116
Q

Give 2 protective factors against GAD

A

Being aged 16-24

Being married or cohabiting

117
Q

Describe the drug treatment for generalised anxiety disorder (1st, 2nd and 3rd line)

A

1st line - Sertraline (SSRI)

2nd line - Duloxetine or Venlafaxine (Serotonin-noradrenaline reuptake inhibitor)

3rd line - Pregabalin

118
Q

In whom may pregabalin be contrandicated?

A

Diabetes (can cause weight gain)

Renal impairment

Respiratory depression

119
Q

Define panic disorder

A

A disorder of recurrent, unexpected panic attacks and persistent concern about having panic attacks

120
Q

Define panic attack

A

A state of extreme acute, intensity anxiety and unreasoning fear accompanied by disorganization of personality function

121
Q

Give 5 symptoms of a panic attack

A

Feeling of impending doom

Dyspnoea

Dizziness

Loss of balance or faintness

Palpitations, sweating, nausea

122
Q

What is agoraphobia?

A

Fear of being in situations where escape may be difficult or that help wont be available if things go wrong.

123
Q

How is panic disorder managed? What are the 1st and 2nd line drug treatments?

A

CBT or Drug treatment

1st line - SSRI

2nd line/no response after 12 weeks - Imipramine or clomipramine (tricyclic antidepressant)

124
Q

What is the MOA of cocaine?

A

Blocks uptake of dopamine, noradrenaline and serotonin

125
Q

Give 5 cardiovascular effects of cocaine

A

Coronary artery spasm > MI/ischemia

Tachy/Bradycardia

Hypertension

QRS widening and QT prolongation

Aortic dissection

126
Q

Give 4 neurological effects of cocaine

A

Seizures

Mydriasis (dilated pupils)

Hypertonia

Hyperreflexia

127
Q

Give 4 additional adverse effects of cocaine abuse

A

Ischemic colitis (abdominal pain/rectal bleeding)

Hyperthermia

Metabolic acidosis

Rhabdomyolysis

128
Q

How is cocaine toxicity managed? (chest pain + hypertension)

A

Benzodiazepines are 1st line

Chest pain : Benzodiazepines + Glyceryl trinitrate

Hypertension: Benzodiazepines + Sodium nitroprusside

129
Q

How is paracetamol overdose managed? (2)

A

If presenting within 1 hour - Activated charcoal

Acetylcysteine (infused over 1 hour)

130
Q

What is the MOA of acetylcysteine?

A

Replenishes body stores of glutathione (needed to detoxify toxic intermediary product of paracetamol metabolism - NAPQI)

131
Q

What is a common adverse reaction of acetylcysteine use? How is it managed?

A

Anaphylactoid reaction (non IgE mediated mast cell release)

Managed by stopping infusion and restarting at a slower rate

132
Q

When is a paracetamol overdose considered as staggered?

A

When all tablets are not taken within an hour

133
Q

What is the King’s Collage Hospital criteria for liver transplantation (paracetamol liver failure)

A

Arterial pH <7.3, 24 hours after ingestion

or all of the following;

PT time >100 seconds
Creatinine >300 umol/L
Grade III or IV encephalopathy

134
Q

Give 4 early features of tricyclic antidepressant (Amitriptyline + Imipramine) overdose (antimuscarinics)

A

Dry mouth

Dilated pupils/Blurred vision

Agitation

Sinus tachycardia

135
Q

Give 4 severe symptoms of tricyclic antidepressant overdose

A

Arrhythmias

Seizures

Metabolic acidosis

Coma

136
Q

Give 3 ECG changes seen in tricyclic antidepressant overdose

A

Sinus tachycardia

Widening of QRS complex

QT prolongation

137
Q

How is tricyclic antidepressant overdose managed?

A

IV bicarbonate (1st line for hypotension or arrhythmias)

138
Q

How is beta blocker overdose managed?

A

Bradycardia - Atropine

If resistant - Glucagon

139
Q

How does salicylate overdose (i.e aspirin) manifest?

A

As mixed respiratory alkalosis and metabolic acidosis

140
Q

Give 5 features of salicylate overdose

A

Hyperventilation
Tinitus

Lethargy

Sweating, pyrexia, nausea and vomiting

Seizures

Hyperglycemia and hypoglycemia

141
Q

How is salicylate overdose managed?

A

ABC + Charcoal

IV sodium bicarbonate (increases aspirin elimination in urine)

Haemodialysis

142
Q

Give 5 indications for haemodialysis use in salicylate overdose

A

Serum concentration >700mg/L

Metabolic acidosis resistant to treatment

Acute renal failure

Pulmonary oedema

Seizures/coma

143
Q

Describe the emergency management of opioid overdose

A

IV or IM naloxone (rapid onset)

144
Q

What medications are used in the management of opioid dependence?

A

Methadone or Buprenorphine (sublingual tablet - alternative to methadone)

145
Q

Define tolerance

A

Refers to the way someone has become physically dependent on a substance (alcohol or heroine) no longer responds to it the same way.

Leads to increasing the dose in order to feel the same effects

146
Q

Define withdrawal

A

Describes onset of symptoms, both physical and mental, when a substance is reduced or not given to the body.

147
Q

What is the recommended number of alcohol units per week

A

14 per week

If you do drink 14, spread over 3 days or more

148
Q

How long does it take the kidney to eliminate one unit of alcohol?

A

1 hour

149
Q

How is the number of units in a drink calculated?

A

Multiply the number of millilitres by the ABV and divide by 1000.

i.e 1 pint of 5% beer

1 pint = 568ml

(568*5)/1000 = 2.8 units

150
Q

Describe the pathophysiology of chronic alcohol consumption

A

Enhances GABA mediated inhibition of CNS

Inhibits NMDA type glutamate receptors

151
Q

Give 4 features of alcohol withdrawal

A

Symptoms start 6-12 hours after stopping;

Tremor

Sweating

Tachycardia

Anxiety

152
Q

When is the peak incidence of seizures in alcohol withdrawal?

A

36 hours

153
Q

When is the peak incidence of delirium tremens in alcohol withdrawal? How may it present? (5)

A

48-72 hours

Presents with;

Coarse tremor

Confusion

Delusions

Auditory/visual hallucinations

Fever + Tachycardia

154
Q

How is alcohol withdrawal managed?

A

Hospital admission (if experiencing delerium tremens, seizures or blackouts)

1st line - Long acting Benzodiazepines (chlordizepoxide or diazepam)

2nd line - Lorazepam (in hepatic patients)

155
Q

What medication is used as a deterrent to prevent alcohol relapse?

A

Disulfiram (acetaldehyde dehydrogenase inhibitor)

Causes severe vomiting after alcohol consumption

156
Q

What medication is seen as an ‘anti-craving’ medication for preventing alcohol relapse?

A

Acamprosate

157
Q

Define alcoholic ketoacidosis

A

Describes a non-diabetic euglycaemic form of ketoacidosis, occurring in people who regularly drink large amounts of alcohol.

Occurs due to malnourishment 2nd to not eating/vomiting from alcohol consumption

158
Q

Give 4 features of alcoholic ketoacidosis

A

Metabolic acidosis

Elevated anion gap

Elevated serum ketone levels

Normal or low glucose

159
Q

How is alcoholic ketoacidosis managed?

A

Infusion of saline and thiamine

Thiamine required to avoid Wernicke encephalopathy or Korsakoff psychosis

160
Q

Give 5 features of opioid misuse

A

Rhinorrhoea

Needle track marks

Pinpoint pupils

Drowsiness

Watering eyes

161
Q

A patient misses > 2 days of their clozapine dose, how should this be managed?

A

Re-titrate clozapine doses again slowly

162
Q

Give 3 features of SSRI discontinuation syndrome

A

Occurs when SSIRs are suddenly stopped/reduced.

Features;

Dizziness
Electric shock sensations
Anxiety
GI side effects (diarrhoea)

163
Q

How may Bulimia nervosa present in an emergency setting?

A

May present with features of Hypokalemia;

ECG (features of hypokalaemia);
Tall P waves
Flattened T waves
First degree heart block

ABG
Metabolic alkalosis
Hypochloremia (due to loss of HCL in stomach from vomiting)

164
Q

What metabolic disturbance is seen in anxiety?

A

Respiratory alkalosis (due to hyperventilation)

165
Q

Describe the process of grief (5)

A

Denial - Numbness and pseudohallucinations of deceased (auditory/visual)

Anger - Directed against family members and medical professionals

Bargaining

Depression

Acceptance

166
Q

Give 2 questionnaires used to screen for depression

A

Hospital Anxiety and Depression (HAD) scale

Patient Health Questionnaire (PHQ-9)

167
Q

What 2 ‘depression identification’ questions are asked to a patient presenting with depression?

A

During the last month, have you often been bothered by feeling down, depressed, or hopeless?

During the last month, have you often been bothered by having little interest or pleasure in doing things?

168
Q

How is depression diagnosed?

A

Depressive symptoms present most days, most of the time for at least 2 weeks.

Patients must have at least 2 core symptoms and 2 or more typical symptoms

169
Q

What are the core symptoms of depression? (3)

A

Depressed mood for most of the day, nearly every day

Anhedonia (loss of interest/pleasure in daily life)

Fatigue (lack of energy which goes beyond poor sleep)

170
Q

What are the typical symptoms of depression? (7)

A

Poor appetite with marked weight loss (>5%) or Rarely increased appetite

Disrupted sleep (early waking/initial insomnia)

Psychomotor retardation or agitation

Decreased libido

Reduced ability to concentrate

Feeling of worthlessness/excessive guilt

Recurrent thoughts of death, suicide ideation or suicide attempts.

171
Q

Describe the criteria for depression severity

A

Mild - 2 typical + 2 core symptoms

Moderate - 2 typical symptoms + 3+ core symptoms

Severe - 3 typical symptoms + 4+ core symptoms

172
Q

What is the 1st line for mild depression?

A

Guided self-help.

Do not routinely offer antidepressants unless the person wishes to start drug treatment, then offer SSRI.

173
Q

What antidepressants should be avoided in depression, and why?

A

Tricyclic antidepressants (except lofepramine)

Venlafaxine (SNRI)

Due to risk of death from overdose.

174
Q

What are the preferred 1st line antidepressants for patient with chronic physical conditions?

A

Sertraline or Citalopram (SSRI)

175
Q

When should an initial review be conducted in an 18-25 year old starting antidepressant medication?

A

1 week after starting medication

176
Q

What antidepressants should be avoided in a patient taking NSAIDs for a chronic physical condition? What is suitable instead?

A

SSRIs and SNRIs (due to increased risk of GI bleeding)

Mirtazapine (atypical antidepressant) may be given instead

177
Q

What antidepressants should be avoided in patients taking Warfarin/Heparin? What may be offered instead?

A

Warfarin - Tricyclic antidepressants, SSRIs or SNRIs

Heparin - SSRIs and SNRIs

Mirtazapine may be offered instead

178
Q

What is the 1st line antidepressant for patients on anti-epileptic drugs?

A

SSRIs - Sertraline/Citalopram

179
Q

What antidepressants should be avoided in patients taking anti-epileptic drugs? Why?

A

Tricyclic antidepressants - Amitriptyline ect

As they lower the seizure threshold

180
Q

What antidepressant should be avoided in patients on Clozapine or Theophylline? What can be given instead?

A

Fluvoxamine (SSRI)

Give Sertraline/Citalopram instead

181
Q

What kind of electrolyte imbalance can SSRIs cause?

A

Hyponatremia

182
Q

What are the 1st, 2nd and 3rd line medications for treatment of depression?

A

1st line - SSRI (Fluoxetine, Sertraline, Citalopram)

2nd line - Alternative SSRI

3rd line - Mirtazapine (NaSSA) or Venlafaxine (SNRI)

183
Q

Give 2 side effects of mirtazapine

A

Increased appetite > weight gain

Increased fatigue

Mmmmm - Makes you hungry
Zzzzz - Makes you tired

184
Q

Name 2 MAOIs - Monoamine oxidase inhibitors (anti-depressants)

A

Moclobemide and Phenelzine

185
Q

Describe the process of swapping from an MAOI to another anti-depressant (2)

A

Withdraw drug and wait 2 weeks.

For moclobemide wait 24 hours

186
Q

How should antidepressant medication be stopped?

A

Advise slowly tapering dose in steps over time

187
Q

Define serotonin syndrome

A

Describes a life threatening condition caused by serotonergic overactivity

188
Q

Give 4 causes of serotonin syndrome

A

SSRIs taken with St John’s wort

Monoamine oxidase inhibitors

Ecstasy

Amphetamines

189
Q

Give 3 clinical features of serotonin syndrome

A

Acute onset - Hours

Tremor, myoclonus, rigidity, hyperreflexia

Hyperthermia, sweating, restlessness

Confusion/Convulsions

190
Q

How is serotonin syndrome managed?

A

Mild/moderate - IV fluids + Benzodiazepines (sedation)

Severe - Cyproheptadine (serotonin receptor antagonist) +/- Chlorpromazine

191
Q

Define bipolar disorder

A

Describes psychiatric condition characterised by episodes of mania (or hypomania) and major depression, separated by periods of normal mood and functioning.

192
Q

Define mania and describe how an episode of mania may present? (5)

A

Describes functional impairment/psychotic symptoms for >7 days

Elevated mood

Talkativeness (pressured speech)

Racing thoughts (flight of ideas)

Psychosis (impaired perception of reality - delusions (grandiose) /hallucinations)

Decreased need for sleep

193
Q

Define hypomania

A

Describes decreased of increased function for 4 days or more. Similar to mania but without psychotic symptoms.

194
Q

Name 2 types of bipolar and state how they are defined

A

Type 1 Bipolar disorder - Defined by at least one episode of mania

Type 2 Bipolar Disorder - Defined by at least 1 episode of hypomania AND one major depressive episode (no previous episodes of mania)

195
Q

How may a manic episode present in children? (3)

A

Sleeping only for a few hours and not feeling tired

Difficulty staying focused in school

Increased interest in risky activities (dangerous sports without proper training(

196
Q

How may a depressive episode present in children? (3)

A

Sleeping more than usual (>12 hours several days in a row)

Lack of interest in activities they previously enjoyed

Feelings of doing everything wrong

197
Q

How is an acute episode of mania treated in secondary care? (1st, 2nd and 3rd line)

A

1st - Trial oral antipsychotic (Haloperidol, Olanzapine, Quetiapine or Risperidone)

2nd - Trial alternative antipsychotic (list above)

3rd - Lithium +/- Sodium valproate (if lithium not suitable)

198
Q

How is mania/hypomania managed in patients taking antidepressants?

A

Stop antidepressant and start antipsychotic therapy (i.e olanzapine)

199
Q

How is depression treated in an acute bipolar episode? (4)

A

Quetiapine alone, or
Fluoxetine + olanzapine, or
Olanzapine alone, or
Lamotrigine alone.

200
Q

To prevent further relapses of acute bipolar episodes, what may a patient be offered?

A

To continue current treatment for mania, or

Start long term Lithium (to prevent relapses), or

If Lithium is ineffective, add Sodium Valoprate, or

If Lithium is poorly tolerated, Valporate alone or Olanzapine may be considered

201
Q

How should treatment with lithium be monitored? (3)

A

Check serum Lithium levels weekly (12 hours post dose).

Once level is constant, check blood levels every 3 months

Also check thyroid and renal function every 6 months

202
Q

After increasing a dose of lithium, when should a patients blood levels be re-checked?

A

1 week later

203
Q

What should be suspected if lithium levels are slowly rising (in weekly checks)?

A

Nephrotoxicity (polyuria, DI)

204
Q

Give 4 adverse effects of lithium use

A

Nausea/vomiting/Diarrhoea

Fine tremor

Hypothyroidism

Weight gain

205
Q

Lithium toxicity occurs in concentrations above?

A

> 1.5mmol/L

206
Q

What may lithium toxicity be precipitated by? (3)

A

Dehydration

Renal failure

Drugs: diuretics (thiazides), ACEi/ARBs, NSAIDs, Metronidazole

207
Q

Give 5 clinical features of lithium toxicity

A

Coarse tremor

Hyperreflexia

Polyuria

Acute confusion

Seizure/coma

208
Q

How is lithium toxicity managed? (3)

A

Mild/moderate - IV fluids (volume resuscitation)

Severe - Haemodialysis

Adjunct - Sodium bicarbonate (increasing alkalinity of urine promotes lithium excretion)

209
Q

What medication can cause iatrogenic mania in patients taking Lithium?

A

Tricyclic antidepressants

210
Q

Define dissociative identity disorder

A

Describes when a patient has multiple personalities.

211
Q

Define fugue

A

Describes an inability to recall ones past +/- loss of identity or formation of a new identity.

212
Q

Define delirium

A

Acute confusion state (ACS).

Describes a state of fluctuating, impaired consciousness with onset over hours or days, or a rapid deterioration in pre-existing cognitive function

213
Q

Name 4 behavioural changes seen in delirium

A

Cognitive function - Worsened concentration, slow responses, confusion and disorientation in time

Perception - Visual/auditory hallucinations

Physical function (fluctuating) - Reduced mobility/movement, restlessness, agitation

Social behaviour - Lack of cooperation, withdrawal, mood changes, poorly developed delusions.

214
Q

Give 6 common causes of delirium

A

Infection

Drugs (benzodiazepines, opiates, digoxin, L-dopa)

Hypoglycemia

AKI

Alcohol withdrawal

Trauma/surgery

215
Q

How is delirium managed?

A

Remove precipitating cause

Optimize supportive surroundings and nursing care

Avoid sedation unless extreme agitation (Haloperidol/Olanzapine - as benzodiazepines can precipitate delirium).

216
Q

What medications should be avoided in patients taking SSRIs?

A

Triptans

NSAIDs

217
Q

How may OCD present to primary care? (3)

A

Dermatological symptoms (excessive hand washing)

Genital or anal symptoms (Excessive checking/washing)

General stress (losing job/interpersonal relationships)

218
Q

Give 5 common obsessions seen in OCD

A

Contamination from dirt, germs of viruses

Fear of harm

Excessive concern with order or symmetry

Superstition (bad umbers, magical thinking)

Forbidden thoughts (such as being a paedophile, blasphemy, harming others ect)

219
Q

Give 5 common compulsions

A

Repetitive hand washing (fear of contamination)

Checking (doors are locked, electrical items unplugged)

Ordering, arranging and/or repeating

Mental compulsions (prayers, asking for forgiveness, counting)

Memory checking

220
Q

What scale is used to measure severity of OCD?

A

Yale-Brown Obsessive-Compulsive Scale

221
Q

How is OCD managed in adults with mild functional impairment?

A

Low intensity CBT including exposure and response prevention (ERP)

10 hours per person

222
Q

How is OCD managed in adults with moderate functional impairment

A

Offer choice of CBT including ERP or SSRI

Consider clomipramine as 2nd line is SSRI is contraindicated or if they had a good response to it in the past

223
Q

How is OCD with severe functional impairment managed?

A

Combined therapy of CBT (inc ERP) with SSRI

2nd line - Clomipramine

224
Q

What SSRIs are used in OCD? (5)

A

Escitalopram

Fluoxetine

Fluvoxamine

Paroxetine

Sertraline

225
Q

SSRIs after 20 weeks pregnancy increase the risk of what?

A

Persistent pulmonary hypertension of the newborn and/or neonatal withdrawal

226
Q

SSRIs after 20 weeks pregnancy increase the risk of what?

A

Persistent pulmonary hypertension of the newborn and/or neonatal withdrawal

227
Q

What type of drug is clomipramine?

A

Tricyclic antidepressant

228
Q

Give 4 clinical features of autism spectrum disorder

A

Impaired social communication and interaction

Impaired imagination

Poor range of activities and interests

Intellectual impairment, ADHD or epilepsy

229
Q

Give 2 protective factors against GAD

A

Being aged 16-24

Being married or cohabiting

230
Q

Define copropraxia

A

Involuntary performing of obscene or forbidden gestures/ inappropriate touching

231
Q

Define echopraxia

A

Meaningless repetition or imitation of movements of others

232
Q

Define neologism

A

Made up word

233
Q

Define palilalia

A

Automatic repetition of one’s own words, phrases or sentences

234
Q

Define Cotard Delusion/Syndrome. What is it a feature of?

A

Patients believe they are dead or non-existent

Feature of severe depression

235
Q

Define De Clerambault Delusion/Syndrome (erotomania). What is it a feature of?

A

Delusional idea what someone of higher social/professional standing is in love with them.

Feature of major depressive disorder

236
Q

Describe Othello Syndrome. What is it a feature of?

A

Paranoid delusion of jealousy, characterised by false absolute certainty of the infidelity of a partner.

Feature of Paranoid Schizophrenia

237
Q

Describe Capgras delusion. What is it a feature of?

A

Delusional misidentification syndrome. Characterised by a false belief that an identical duplicate has replaced someone significant to the patient.

Feature of dementia

238
Q

What is the MOA of benzodiazepines?

A

Enhances effect of GABA (gamma-aminobutyric acid)

By increasing the frequency of chloride channels

239
Q

What is the MOA of duloxetine?

A

Serotonin Noradrenaline Reuptake Inhibitor (SNRI)

240
Q

What additional medication should be offered to patients on a combination of SSRI and NSAID?

A

PPI - To lower risk of GI bleeding

241
Q

What scoring system is used to assess alcohol withdrawal severity?

A

Clinical institute withdrawal assessment (CIWA-Ar)

242
Q

What should be monitored at initiation and dose titration of Venlaflaxine?

A

Blood pressure

SNRIs are associated with hypertension

243
Q

Give 4 factors associated with a poor prognosis in schizophrenia

A

Strong family history

Gradual onset

Low IQ

Prodromal phase of social withdrawal

244
Q

How is sexual aversion disorder characterised?

A

By disgust at the thought of sex

245
Q

How is female sexual arousal disorder characterised?

A

Patients lack the desire to have sex and also experience vaginal dryness when trying to have sex

246
Q

How is hypoactive sexual desire disorder characterised

A

Typically follows starting antidepressant (SSRI).

Patient show reduced libido following starting SSRI/depression

Phase 3a (6 decks)

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