UW MED psych drugs cases (Nr 1-4) Flashcards
(1) 17 y/o boy + recent change in behavior. The patient was previously polite and soft-spoken, but he has become intermittently irritable, impatient, and rude over the past few weeks. His parents initially dismissed his new behavior as a “phase”; however, they grew more concerned last night when they discovered that he had stolen money from their wallets and later found him pacing in his room at 4:00 AM. When questioned by his father about his strange behavior, the patient said, “I have to be careful because I’m being followed by CIA agents.” He has no medical conditions. His father has chronic pain and insomnia, for which he takes oxycodone and diphenhydramine. Temperature is 36.6 C (97.9 F), blood pressure is 164/98 mm Hg, pulse is 124/min, and respirations are 18/min. On physical examination, the patient appears fearful. He is sweating profusely and his pupils are dilated. He is observed in the emergency department for several hours, his condition improves, and he is discharged to the care of his parents. Which of the following is the most likely diagnosis for this patient?
AMPHETAMINE INTOXICATION
This patient’s episodic agitation, insomnia, psychosis (eg, delusions about the CIA), change in behavior (eg, stealing money), and signs of sympathetic hyperactivity (eg, mydriasis, tachycardia, hypertension, diaphoresis) with subsequent return to baseline functioning following an observed period of abstinence are consistent with amphetamine intoxication.
(1) AMPHETAMINE INTOXICATION vs psychiatric disorders? buvo 3
amphetamine - palaike ED ir po keliu valandu praejo. Psychiatric - nepraeitu tiesiog su stebejimu pora valandu. + psichiatrines turi laikotarpius.
+ psichiatrines turi but diagnozuotos tik after ruled out drugs effects.
A manic episode of bipolar disorder = at least a week of elevated/irritable mood, increased energy, decreased need for sleep, and pressured speech; it may also include psychotic features + would not subside quickly without any pharmacologic intervention.
Primary psychotic disorders = need to rule out substance-induced causes. Brief psychotic disorder is characterized by acute onset of one or more psychotic symptoms lasting ≥1 day but <1 month, with eventual complete resolution.
Delusional disorder can only be diagnosed if a delusion has been present for ≥1 month and does not result from intoxication, as in this patient.
(1) AMPHETAMINE INTOXICATION vs opioid withdrawal? CP?
Muscle spasms, joint pain, nausea and vomiting, diarrhea, abdominal cramps, rhinorrhea, lacrimation, and sweating.
Irritability, hypertension, and mydriasis may occur. However, delusions are unlikely.
(1) AMPHETAMINE INTOXICATION vs opioid withdrawal - how long symptoms last?
symptoms of opioid withdrawal often last 3-5 days.
(1) AMPHETAMINE INTOXICATION vs opioid withdrawal - delusions?
NO DELUSIONS
(1) AMPHETAMINE INTOXICATION = Dx?
Clinical.
A positive toxicology screen can be supportive. However, the decongestant pseudoephedrine and the antidepressants bupropion and selegiline can cause false positives for amphetamines on urine toxicology testing. Amphetamines include a range of substances, from those prescribed for the treatment of attention-deficit hyperactivity disorders to the newer synthetic cathinones (ie, bath salts), which are not detectable on routine toxicology screens.
(1) AMPHETAMINE INTOXICATION vs anticholinergic intoxication?
Cp kaip atropino effectas.
Some symptoms of anticholinergic poisoning (eg, mydriasis, hyperthermia, tachycardia) can occur due to amphetamine intoxication.
Anticholinergic poisoning is differentiated by the presence of dry skin and mucous membranes, motor symptoms (eg, myoclonic jerks, tremors), and other classic anticholinergic manifestations such as ileus and urinary retention.
Delirium is more likely than isolated psychotic symptoms.
(1) AMPHETAMINE INTOXICATION vs anticholinergic intoxication = what neuro CP?
Delirium is more likely than isolated psychotic symptoms.
Motor symptoms (eg, myoclonic jerks, tremors).
(1) Amphetamine intoxation educational: Amphetamine intoxication can present with psychiatric symptoms, including irritability, agitation, and psychosis. Common physical signs include tachycardia, hypertension, hyperthermia, diaphoresis, and mydriasis.
.
(2) A 45-year-old man comes to the office because he would like to quit smoking cigarettes. He has been concerned about his health since a close friend recently died of lung cancer. The patient has smoked a pack of cigarettes daily for the past 20 years. Two years ago, he tried and then stopped varenicline for smoking cessation because he did not like the way it made him feel. He takes no medications. Physical examination is unremarkable, and vital signs are normal. In addition to proper counseling and support, which of the following is the most effective smoking cessation therapy for this patient?
NICOTINE TRANSDERMAL PATCH + NICOTINE GUM
(sitie variantai po viena = wrong)
(2) Smoking cessation.
All patients who are ready to quit should be offered behavioral counseling, which has been proved to increase rates of sustained smoking cessation.
+ additionally benefit from pharmacotherapy => increased success rate.
.
(2) Smoking cessation. Pharmacotherapy. Short acting NRT (nicotine replacement therapy). what options?
Nasal spray, GUM, lozenge, inhaler
(2) Smoking cessation. Pharmacotherapy. Long acting NRT (nicotine replacement therapy). what options?
NICOTINE PATCH
(2) Smoking cessation. Pharmacotherapy. Short\Long acting NRT. Indications?
Decr. craving and daytime withdrawal symptoms
Long-acting may be combined with short-acting NRT (,,patch plus”) to improve efficacy.
(2) Smoking cessation. Pharmacotherapy. Short\Long acting NRT. Contraindications?
No significant effects, safe in almost all patients
(2) Smoking cessation. Pharmacotherapy. Bupropion. indications?
Decr. Postcessation weight gain
Good choice for patients with unipolar depression
(2) Smoking cessation. Pharmacotherapy. Bupropion. contraindications?
Contraindicated in patients with seizure or eating disorders
(2) Smoking cessation. Pharmacotherapy. Varenicline. Indications?
More effective than either bupropion OR combination NRT
(2) Smoking cessation. Pharmacotherapy. Varenicline. Contraindications?
Disordered sleep and abnormal dreams.
(2) Smoking cessation. Most effective Tx?
Varenicline. If not effective (as in case) –> NRT (nicotine path + gum)
(2) Smoking cessation. NRT can be used alone or concurrently with either bupropion or varenicline. NRT alone is an appropriate choice for this patient who did not tolerate varenicline.
.
(2) kiti ats - Naltrexone indication?
Naltrexone is indicated for alcohol use disorder but is not effective for sustained smoking cessation.
(3) Alcohol use disorder case. In addition to psychosocial interventions, which of the following is the most appropriate pharmacotherapy for this patient?
ACAMPROSATE (toks ats) (in pts with liver disease or opioid use)
Kiti tinkami ats: naltrexone
Disulfiram - 2nd line in highly motivated patients
(3) Alcohol use disorder case.
Alcohol withdrawal symptoms, Tx?
Benzodiazepines
!They do not treat AUD and have a high risk of abuse
(3) Alcohol use disorder case.
When used fomepizole?
Used as an antidote to treat methanol or ethylene glycol poisoning.
(4) 32 y/o man + recent insomnia. The patient has experienced stress at his job in the past month because he has had to work extra hours on multiple occasions while several coworkers have been on vacation or sick. Over the past 2 weeks, he has had difficulty falling asleep most nights and has been fatigued throughout the day. Recently, the patient has started drinking 1 or 2 beers at night to help him fall asleep as well as energy drinks throughout the day to stay alert. He describes feeling anxious and irritable and has experienced occasional palpitations and feelings of panic. The patient has a history of depression. He does not use illicit drugs. BP 140/90, pulse 95/min. The patient is restless and mildly tremulous with a flushed and agitated appearance, irritable mood, and rapid speech. Which of the following is the most likely explanation for this patient’s condition?
CAFFEINE INTOXICATION
Insomnia, anxiety, palpitations, hypertension, and tremulousness are suggestive of caffeine intoxication, likely due to his recent excessive consumption of energy drinks.
Energy drinks frequently contain high quantities of caffeine and may lead to toxicity when consumed in excess.
(4) Caffeine is a stimulant that, when used excessively, can result in insomnia, jitteriness, anxiety, gastrointestinal symptoms, and headaches, as well as more serious adverse effects including tachycardia, hypertension, panic attacks, agitation, psychosis, and seizures. Energy drink consumption is especially popular among adolescents and young men, and it should be considered in anyone with signs or symptoms of stimulant intoxication.
.
(4) Caffeine intox vs alcohol withdrawal.
Alcohol withdrawal can also result in anxiety, insomnia, tremulousness, hypertension, and palpitations.
However, it is usually associated with heavy drinking and other signs of dependence. The amount that this patient is drinking would be very unlikely to lead to withdrawal; furthermore, his history is more consistent with caffeine intoxication from energy drinks.
