Psychiatry

Question 1

Mental Status Exam components

Answer 1

Appearance/behavior
Speech
Mood
Affect
Thought process
Thought content/perceptual disturbances
Cognition: LOC, orientation, attention/concentration
Memory: registration, short-term, long-term
Fund of knowledge
Abstract thought
Insight
Judgment

Question 2

Characteristics of delirium

Answer 2

Waxing/waning, acute onset, sensorium is worse at night, disoriented, inattentive, impaired cognition, disorganized thinking, altered sleep/wake cycle, perceptual disorders

Question 3

Causes of delirium

Answer 3

Drugs (especially narcotics, benzodiazepines, anti holiness is, TCAs, steroids, diphenhydramine)
EtOH withdrawal
Metabolic causes (cardiac, respiratory, renal, hepatic, endocrine)
Infection
Neuro (increased ICP, encephalitis, postictal, stroke)

Question 4

Work-up for delirium

Answer 4

Start with CBC, CMP, thyroid tests, UA, CXR, urine tox, O2 sat, HIV testing.

Could add ABG, ECG, ionized Ca

Head CT or MRI if inconclusive, same with LP, EEG

Question 5

Delirium management

Answer 5

Identify and fix underlying cause
Simplify meds
Avoid benzodiazepines except if in EtOH withdrawal
Safe environment
Reassurance/education
Antipsychotics used judiciously for acute agitation

Question 6

S/Sx of Mania

Answer 6

DIG FAST: 
Distractibility
Irritable mood/insomnia
Grandiosity
Flight of ideas
Agitation/ more goal-directed activity
Speedy thoughts/speech
Thoughtlessness

Question 7

S/Sx for suicide risk

Answer 7

SAD PERSONS
Sex is male
Age >60
Depression
Previous attempt
EtOH/drug abuse
Rational thinking loss
Suicide in family
Organized plan/access
No support
Sickness

Question 8

S/Sx for Depression

Answer 8

SIGECAPS
Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor changes
Suicidal ideation - hopeless, helpless, worthless

Question 9

EtOH intoxication

Answer 9

Disinhibition, mood lability, incoordination, slurred speech, ataxia, blackouts, resp depression

Question 10

Benzo intoxication

Answer 10

Disinhibition, mood lability, incoordination, slurred speech, ataxia, resp depression

Question 11

EtOH withdrawal

Answer 11

Tremulousness, HTN, tachycardia, anxiety, psychomotor agitation, nausea, seizure, hallucinations, DTs

Question 12

Benzo withdrawal

Answer 12

Just like EtOH but without DTs

Question 13

Barbiturates intoxication

Answer 13

Resp depression

Question 14

Barbiturate withdrawal

Answer 14

Anxiety, seizures, delirium, life-threatening cardiovascular collapse

Question 15

Opioid intoxication

Answer 15

CNS depression, nausea, vomiting, sedation, decreased pain perception, decreased GI motility, pupillary constriction, resp depression

Question 16

Opioid withdrawal

Answer 16

Increased sympathetic activity, N/V/D, diaphoresis, rhinorrhea, piloerection (goosebumps!), yawning, stomach cramps, myalgia, anxiety, anorexia. Won’t kill you, it just sucks.

Question 17

LSD intoxication

Answer 17

Altered perceptual states like hallucinations and distortions of time and space, elevated mood, “bad trips” with panic reaction, flashbacks

Question 18

Cannabis intoxication

Answer 18

Euphoria, anxiety, paranoia, slowed time, social withdrawal, increased appetite, dry mouth, tachycardia, not really motivated

Question 19

Amphetamine or cocaine intoxication

Answer 19

Euphoria, increased attention span, aggressiveness, pupillary dilation, psychomotor agitation, HTN, tachycardia, cardiac arrhythmia, psychosis - paranoia on amphetamines and formication on cocaine

Question 20

Amphetamine or cocaine withdrawal

Answer 20

restlessness, headache, hunger, depression, irritability, insomnia or hypersomnia, cravings

Question 21

PCP intoxication

Answer 21

Belligerence, impulsiveness, psychomotor agitation, vertical/horizontal nystagmus, hyperthermia, tachycardia, ataxia, psychosis, homicidality

Question 22

PCP withdrawal

Answer 22

Symptoms of intoxication may recur due to reabsorption in the GI tract

Question 23

Nicotine or caffeine use symptoms

Answer 23

Restlessness, insomnia, anxiety, anorexia

Question 24

Nicotine or caffeine withdrawal

Answer 24

Irritability, headache, lethargy, increased appetite, weight gain

Question 25

Patient presents to hospital with diverticulitis and undergoes surgery. History of EtOH use. On POD 3 has delirium, agitation, fever, HTN, tachycardia, and is reporting auditory and visual hallucinations. What is this/how do you treat it?

Answer 25

Delirium tremens. Treat with benzos and hydration. Most commonly on days 2-4 after cessation of EtOH.

Question 26

A patient on multiple neuroleptic medications presents to the ED with fever, rigidity, autonomic instability, altered mental status. Labs show elevated WBC and elevated CPK. Infection does not appear likely based on additional workup. What is this/how do you treat it?

Answer 26

Neuroleptic malignant syndrome. It’s idiosyncratic and will resolve with time but is an emergency. Withhold the neuroleptics, give fluids, possibly give dantrolene or bromocriptine.

Question 27

A patient is admitted to the hospital with AMS, fever, agitation, tremors, myoclonus, shivering, and diarrhea. On exam the patient has some ataxia and is not well coordinated, and is diaphoretic. Review of the chart shows that the patient is on a MAOI and an SSRI. What is this/how do you treat it?

Answer 27

Serotonin syndrome. MAOI and SSRI are the likely cause. Discontinue those agents, give benzos, consider cyproheptadine.

Question 28

A patient comes into the ED with headache and neck stiffness, as well as sweating, nausea, and vomiting. Patient is hypertensive. Patient takes a MAOI but refuses to follow any diet requirements and just went on a beer and cheese tour yesterday. What is the likely cause, and how do you treat it?

Answer 28

Tyramine reaction, from ingesting foods containing tyramine while on a MAOI. Could cause stroke, could lead to death. Treat with nitroprusside or phentolamine.

Question 29

A patient with a history of BPAD I presents to the emergency room with nausea and vomiting. On exam the patient is altered and ataxic, with hyper reflex is, myoclonus, and slurred speech. The patient then has a seizure. Lab findings plus UA show that the patient also has nephrogenic diabetes insipidus. What is going on and how do you treat it?

Answer 29

Lithium toxicity, which can occur at any lithium level (usually >1.5). Discontinue lithium, hydrate aggressively. May need hemodialysis.

Question 30

A patient presents to the ED due to altered mental status. The patient has a history of depression and has tried multiple medications. On ECG you see widened QRS complexes. What could likely have caused this, and how do you treat it?

Answer 30

TCA toxicity! Give sodium Bicarb. Monitor ECG. Supportive care.