Psychiatry Flashcards
Why do patients need regular bloods on clozapine?
Risk of agranulocytosis and neurogenic sepsis
Pt needs weekly bloods for first 6m and fortnightly onwards
CV drug increasing lithium toxicity
ACEi e.g. ramipril
Increases serum lithium level
Results in renal dyfunction -> dialysis req
What do the different sections of the MHA mean?
Sec 2 = assessment order and lasts up to 28 days
Sec 3 = treatment order that can last for up to 6 months
Sec 5 (2) = emergency holding order to keep pt in hospital for 72h
Sec 136 = police officer can take pt with acute MH to place of safety
Biochemistry and ABG changes in a purge
Hypokalaemia with metabolic alkalosis
Vitamin deficiency in alcohol misuse
B1 (thiamine)
Blurred vision can be caused by which type of antidepressant?
Tricyclic antidepressants
Antipsychotic causing reduced libido, low mood, amennorhea
Risperidone
- hyperprolactinaemia secondary
26yo 9 weeks gestation, depression well managed with venlafaxine, why would you not change meds in pregnancy?
- well stabilised on venlafaxine
- cardiac abnormalities caused by venlafaxine only occur within first 8w pregnancy
What antidepressant should you avoid in first trimester of pregnancy?
Paroxetine
- can cause heart defects
What antidepressant should be used in third trimester of pregnancy?
TCA (imipramine/amitryptiline)!
If SSRI necessary, use sertraline or fluoxetine
Can you use benzos in pregnancy?
NOOOOOOOO
Potential fetal malformation risk (cleft palate), floppy baby syndrome, and breastmilk accumulation
- the only acceptable one is in withdawal as least bad option
Sudden onset anterograde amnesia, with repetitive questioning and a preserved level of consciousness
Transient global amnesia
- up to 24 hours
What type f psych drug causes hyperprolactinaemia?
Dopamine antagonist e.g. metoclopramide
(manage with dopamine agonist e.g. cabergoline)
Which mood stabiliser can cause hypothyroidism?
Lithium
- e.g. bipolar pt presents with dry skin, fatigue and weight gain
Main GI side effect of donepezil vs memantine
Donepezil (mild-mod) = diarrhoea
Memantine (severe) = constipation
Anti-NMDA antibodies
Autoimmune encephalitis
- rapidly progressive cognitive decline and seizures (may not be noticed)
- manage with steroid and IVIG
What type of psych med is contraindicated in Lewy Body Dementia?
Antipsychotics e.g. haloperidol
- worsens parkinsonism symptoms
Thought blocking vs withdrawal
Stop in conversation for several minutes before speaking again
- blocking involves a change in conversation
- wihtdrawal pt believes thoughts are being taken from them
Liver transplant criteria
Arterial pH < 7.3 after 24 hours
OR all 3 of the following:
PT > 100
Creatinine > 300
Grade III or IV hepatic encephalopathy
MMSE grading for Alzheimer’s disease
<10 severe AD
10-20 moderate AD
21-26 mild AD
First line for acute episode of mania in bipolar
Olanzapine
- or another suitable mood stab antpsychotic
How long must symptoms be present for a PTSD diagnosis?
1 month
AND interfering with daily life
Anticholinergic side effects
Can’t see, pee, sh*t
+High HR
What is perceptional delusion?
delusion that is formed in response to an external stimulus without any logical sense
- e.g. from a TV show which is real, but pt is creating grandiose delusions from it
Management post partum psychosis
Almost always hospital admission if possible to mother and baby unit so they can bond while mum is treated
Short episodes of panic that feel like a heart attack but normal ECG
Panic disorder
- long term management with SSRI first line
Prominent U waves in a pt who has recently been admitted to hospital to treat an eating disorder
Refeeding syndrome
- caused by hypokalaemia
Acute confusion, impairment of short-term memory, seizures (often focal e.g. absence) and altered consciousness level
Limbic encephalitis
Investigations to rule out othwr causes of psychosis before diagnosing schizophrenia
Full blood count, serum electrolytes, liver function, urine drug screen, B12, folate and thyroid function tests
+ neuroimaging
+ ? HIV/syphilis
Antihistamine causing delirium in elderly
Chlorphenamine
How to diff between AI and viral encephalitis?
AI has normal MRI
Viral would have hyperintense temporal lobe lesion
Management iatrogenic opioid overdose
Fuuuuulll dose naloxone
- titrating dose risks further resp depression and hypoxic brain injury
3 key UEs changes in lithium toxicity
Incr creatinine
Reduced eGFR
Incr serum lithium
Metabolic acidosis, confusion, seizure, tachycardia, hypotension and dilated pupils in a suspected overdose…
Tricyclic antidepressant overdose
- lots of anticholinergics
- ECG may show prolonged QRS and QTc
When should duloxetine be taken?
In the morning to avoid insomnia
Mx Wernicke’s encephalopathy
Pabrinex
Drug given in acute benzo OD
Flumenazil
Mx depression in bipolar
Fluoxetine + olanzapine or another atypical
- never give SSRI on own to prevent mania
MoA of lithium in mania
Promotes GABAergic transmission
Management manic episode
Not on mood stab
- stop antidepressant
- start antipsych OR valproate OR lithium (if likely to adhere)
- consider short acting benzo
3 key drug reactions with lithium
ACE inhib
Thiazide diuretic
NSAID
What effect does D&V (or other dehydration) have on lithium levels?
Depletes sodium -> hyponatraemia -> incr plasma lithium levels
Lithium target range
0.4-1.0* mmol/l
Medical management of depression
SSRI
Different SSRI or SNRI
Switch or augment
- mirtazapine
- bupropion
- lithium
Alt drugs
- T3
- lamotrigine
Alt drugs
- TCA + something else
What class of psych drugs do SSRIs interact with?
SSRIs and MAOIs should never be combined as there is a risk of serotonin syndrome
What class is mirtazapine?
NaSSA
Drugs causing gynaecomastia
Digoxin, isoniazid, spironolactone, cimetidine and other (estrogens)
Metoclopramide and spironolactone have what effect on male breast tissue?
Meto = galactorrhoea (M for milk)
Spiro = gynaecomastia (S for swelling)
Moans groans stones
Hypercalcaemia
- short QT
Sweating, tremor, confusion and hyperreflexia
Serotonin syndrom
Hyperparathyroidism and hypercalcaemia after long term use of …..
Lithium
Medical management OCD
Sertraline
Clomipramine if ^CI or not tolerated
Management of negative schizophrenia or treatment resistant schizophrenia symptoms
Clozapine
Schizoid vs schizotypal PD?
SchizOID = avOIDant behaviour
SchizoTYPal = aTYPical (odd, eccentric) behaviour
Toxicity with tinnitus that goes from resp alkalosis -> metabolic acidosis
Aspirin overdose
Psych drug causing DI
Lithium
Dystonia, chorea and athetosis (involuntary writhing movements) caused by which neuro drug?
levodopa
Triptans and SSRIs?
No
Symptoms of SSRI discontinuation syndrome
Flu like symptoms
Insomnia
Restlessness
Mood changes
Sweating
Tummy problems (pain, cramps, D&V)
Off balance
Parasthaesia
When is blood test for lithium monitoring done?
12h post dose every 3 months
- also 1 week after a dose has been changed
Key side effect of long term use of atypical antipsychotics
Impaired glucose tolerance
- polyuria and polydipsia
Oculogyric crisis is assoc with which type of antipsychotic
First gen
- chlorpromazine
Manage with procyclidine
Name 3 foods you can’t have with MAO inhibitors
Cheese (MAOuse)
Bovril
Marmite
- precipitates severe hypertensive crisis
Which atypical has th most tolerable side effects?
Aripiprazole
How to diff between tardive dyskinesia and acute dystonia?
Tardive dyskinesia - Taking antipsychotics -> Tetrabenezine
acute dySTonia - STarting antipsychotics -> procyclidine
If pt needs to be on both NSAID and SSRI, what drug should be given as well?
Omeprazole/PPI
- to reduce risk of GI bleeding
4 key S side effects of SSRIs
Stomach Upset
Sexual Dysfunction
Sodium Low
Serotonin Syndrome
Name an MAOi
Rasagiline
- as well as being used in depression it’s used for Parkinson’s but is one that can induce the gambling/binging habits
Antipsychotics in elderly key adverse effect?
Stroke or VTE
Tardive vs akithisia?
Tardive - repetitive invol movements e.g. smacking lips, blinking
Akithisia - internal sense of restlessness causing repetitive movement e.g. bouncing leg
SSRI of choice in CAMHS
Fluoxetine
ECG changes with citalopram
Prolonged QT
Torsades de pointes (as a result of long QT)
Alcohol sobriety maintenance drug that causes vomiting when alcohol is ingested
Disulfiram
Anti craving drug used in long term alcohol sobriety, safe when consumed with alcohol
Acamprosate
2nd line opioid antagonist that is a tablet that goes under the tongue
Buprenorphine
Complication of Wernicke’s encephalopathy presenting with anterograde amnesia, retrograde amnesia, and confabulatio
Korsakoff syndrome
Sudden loss of motor or sensory function, positive Hoover sign
Conversion disorder (type of FND)
What happens to sertraline dose before pt starts ECT?
Reduce dose but don’t stop
Cholesterol in anorexia?
Hypercholesterolaemia
What are the two R parkinson’s drugs?
Rasigiline
Ropinirole
- both caution for impulsivity, gambling, binging etc
First line in acute stress disorder/reaction
(Trauma-focussed) CBT
78yo, post hip replacement opioid overdose, RR 8 breaths/min, what’s the management?
Naloxone, titrated
- full dose at this age and with this much pain is mad
Confusion, ataxia and bone marrow suppression are side effects of which antipsych?
Carbamazepine
Monitoring for venlafaxine
Blood pressure
4 components of a delirium diagnosis
1) acute onset with fluctuating course,
2) inattention,
3) disorganised thinking,
4) altered level of consciousness
Define circumstantiality
The patient moves onto different topics but there is a train of thought that can be followed. She eventually returns to answer the original question
Mechanism behind the seizure, behaviour change symptoms of auotimmune encephalitis
Demyelination
Patient has a significant focus on physical symptoms, such as pain, weakness or shortness of breath, to a level that results in major distress and/or problems functioning.
Somatisation disorder
Anxiety med likely to cause peptic ulcer disease
SSRI sertraline
Most common side effect of clozapine
Constipation
FL for delirium tremens
Oral lorazepam
Management of acute opioid withdrawal
Treat symptoms
e.g. constipation = loperamide
e.g. agitation = benzos
Restlessness, diaphoresis, clonus, hyperthermia, rigidity, hyperreflexia - taken amphetamine today and symptoms have come on in 4 hours
Serotonin syndrome
Tetrad of: hypertonia, hyperthermia, autonomic instability and mental state change in the context of an anti-psychotic medication over the course of 4 days
Neuroleptic malignant syndrome
Lab findings in NMS
Incr creatine kinase
Incr AST and ALT
Incr white cells
Two symptoms in SS that you don’t get in NMS
ClonuS
GI Upset (shitting)
Management of dementia with long QT and chronic diarrhoea and urge incontinence
Cog stimulation therpy
- or memantine if more severe dementia
- can’t give anticholinesterases as they will make his symptoms wors e
FL management for agitated patient with falls risk
One-to-one nursing and re-orientation
Intention or resting tremor in parkinson’
Resting tremor
Most common cause of postural hypotension in the elderly
Dehydration
Management of OCPD
DBT
Indication for ECT
catatonia
a prolonged or severe manic episode
severe depression that is life-threatening
treatment resistant depression
Key feature of weakness in FND/conversion disorder
does not correspond to a dermatomal distribution
