Ditt Step 2 Day 1 Neuro/psych

Front 1

what is the treatment for an MI due to cocaine overdose?

Back 1

Note: don’t use β-blockers! (don’t want to block the β-2 vasodilation, which would lead to ↑ vasoconstriction)
Tx: Lorazepam (Ativan), Ca2+ channel blockers
Management: Rule out CAD if pt >35 yrs

Front 2

In which immunodeficiency is there an absence of a thymic shadow on newborn CXR?

Back 2

(1) DiGeorge Syndrome
(2) Severe Combined Immunodeficiency (SCID) (Most commonly due to Adenosine Deaminase (ADA) def)

Front 3

A post-op patient has poor UOP, BUN 85, creatinine of 3, and clear lungs. what is the next step in the management of this pt?

Back 3

anytime you see a BUN:Cr >20, think dehydration or pre-renal azotemia
(azotemia is a term for elevated BUN & Cr, azotemia can become uremia if there are symptoms present)

next step = IV fluids

Front 4

Which vaccines should not be given to a HIV (+) pt?

Which vaccines can be given?

Back 4

Live virus vaccines = Varicella/ Zoster, Intranasal influenza, Oral polio, Yellow fever, BCG (tuberculosis), Anthrax, Oral typhoid, Small pox

Exception: can give MMR, if:
-No evidence of immunity
-CD4 ct >200
-No AIDS-defining condition

Vaccines that you can give to HIV (+) pts:
-IM influenza
-Hepatitis B
-S. pneumoniae
-Hepatitis A (For MSM)

Front 5

When would you suspect thrombocytopenia due to heparin use? What is the most feared complication of heparin-induced thrombocytopenia?

Back 5

Suspect HIT anytime platelets drop by at least 50% in a patient on heparin

Complication of HIT: thrombosis

Front 6

What is the next step in the management of a child with severe asthma exacerbation and persistently low oxygen saturation despite medication?

Back 6

-Give O2

Indications for intubation in children with asthma:
- Unable to maintain oxygen saturation despite supplementation
-altered mental status
-unable to speak due to work of breathing

Front 7

What is the classic presentation of a pt with androgen insensitivity syndrome?

Back 7

Normal appearing female
Rudimentary vagina
Absent uterus
Absent fallopian tubes
Testosterone present
High testosterone, estrogen & LH

Front 8

What is the most common foodborne bacterial GI tract infection?

Back 8

salmonella

Front 9

What is the classic presentation of a pt with hyperprolactinemia?

Back 9

For women, it depends whether they are pre- or post-menopausal:

Premenopausal female: Galactorrhea, Hypogonadism (Infertility, Oligo- or amenorrhea)

Post-menopausal: Already hypogonadal, +/- galatorrhea

Male: ↓ testosterone: ↓ libido, impotence, ↓ sperm ct, gynecomastia, +/- galactorrhea

Front 10

What lab changes will be seen in a pt with hyperaldosteronemia?

Back 10

Think of spironolactone side effects (b/c this drug inhibits aldosterone):

Hypokalemia
Mildly ↑ Na+
Metabolic alkalosis
↑ 24 hr urine aldosterone

Front 11

what is the antidote for the following type of overdose?

Back 11

see above

Front 12

What type of oral contraceptive can be given to lactating women?

Back 12

Progestin-ONLY pills

Front 13

label the arteries & brain structures

Back 13

see above

Front 14

What is the definition of primary amenorrhea?

Back 14

Absence of menses at age 16 in the presence of normal growth & 2° sex characteristics

Absence of menses by age 13 without 2° sex characteristics

Front 15

Label the Circle of Willis

Back 15

see above, also pg 170

Front 16

Label the Circle of Willis, intracranial view

Back 16

see above, also pg 170

Front 17

Magnetic resonance arteriography illustrating the circle of Willis and its branches

Back 17

see labels above

Front 18

What do you see?

Back 18

Lateral common carotid arteriogram in a patient with a neck bruit. Note the focal narrowing of the proximal internal carotid artery (arrow). In severe cases, the kink may require carotid artery reconstruction.

DIT says that you need to be able to recognize a stenosis vs aneurysm

Front 19

What do you see?

Back 19

Left oblique cerebral angiogram in a patient with multiple intracranial aneurysms shows an anterior communicating aneurysm and a middle cerebral artery aneurysm. The patient underwent a frontotemporoparietal craniotomy, during which surgical clips were placed in both lesions in one setting.

DIT says that you need to be able to recognize the difference btw an aneurysm and arterial stenosis on an angiogram

Front 20

what do you see?

Back 20

(from Medscape): Left oblique cerebral angiogram in a patient with a proximal intracranial internal carotid artery aneurysm. The surgical approach to this aneurysm requires a craniotomy with an orbitotomy and drilling of the anterior clinoid process; however, this aneurysm has a favorable neck-to-fundus ratio for endovascular coil placement.

DIT says that you need to be able to recognize the difference btw aneurysm & stenosis on angiogram imaging

Front 21

A 49yo, presents with sudden onset of vertigo, nausea, vomiting, dysphagia, hoarseness, and nystagmus in addition to ipsilateral Horner syndrome, limb ataxia, and impairment of all sensory modalities over the face. There is also impairment of pinprick and temperature appreciation in the contralateral limbs.

Back 21

This case illustrates the development of the lateral medullary syndrome (Wallenberg's syndrome) as a result of occlusion of the posterior inferior cerebellar artery (PICA).

-Loss of pain & temp over contralateral body
-Loss of pain & temp over ipsilateral face
-Cerebellar defects
- Involvement of the sympathetic pathways may lead to Horner's syndrome
- Vertigo results from involvement of the vestibular nuclei and hemiataxia from involvement of the inferior cerebellar peduncle.

Front 22

What viruses preferentially infect the ventral horn of spinal cord, leading to a flaccid paralysis?

Back 22

polio & west nile

Front 23

Which spinal tract carries touch, vibration, and pressure sensation?

Back 23

Dorsal columns:
Fasciculus gracilis & cuneatus

Front 24

Which spinal tract carries voluntary motor commands from motor cortex to body?

Back 24

Lateral & ventral corticospinal tracts

Front 25

Which spinal tract carries voluntary motor commands from motor cortex to head/neck?

Back 25

Corticobulbar tract

Front 26

Which spinal tract carries pain & temp sensation?

Back 26

Lateral spinothalamic tract

Front 27

Which spinal tract is important for postural adjustments & head mvmts?

Back 27

Vestibulospinal tract

Front 28

Which CN is responsible for Eyelid opening?

How do you differentiate between benign & serious cause of deficit of this nerve?

Back 28

CN 3 (oculomoter)

Benign cause (ie HTN or Diabetes) of CNIII palsy - the pupil will be normal in size & reactive - no treatment is needed

Serious causes (ie aneurysm, tumor, or uncal herniation) - pupil will be dilated & nonreactive ("blown") - urgent CT/MRI is needed

Front 29

Which CN is responsible for
Taste from ant 2/3 of tongue?

What other sxs would you look for to distinguish whether the damage to this nerve was UMN or LMN?

Back 29

CN 7 (Facial)

UMN lesion of Facial nerve = forehead is spared on the affected side, cause is usually stroke or tumor

LMN lesion of Facial nerve = forehead is involved, and cause is usually Bell's palsy or tumor

Front 30

Which CN is responsible for
Head turning?

How do you know which side the lesion is located?

Back 30

CN 11 (spinal accessory)

Patients with CN 11 lesions have trouble turning their head to the side OPPOSITE the lesion & have ipsilateral shoulder droop (due to loss of innervation to SCM & trapezius)

Front 31

Which CN is responsible for
Tongue movement?

How do you know which side the lesion is located?

Back 31

CN 12 (hypoglossal)

protruded tongue will deviate to the SAME side of the lesion

Front 32

Which CN is responsible for
Muscles of Mastication?

What pathological condition of this nerve is provoked by chewing?

Back 32

CN 5 (trigeminal) - also innervates facial sensation

Trigeminal Neuralgia ("Tic doulourex") = unilateral shooting pains in the face & often triggered by chewing, brushing the teeth - tx with Carbamazepine

Front 33

Which CN is responsible for balance?

Kids with balance probs - likely cause is?
Adults with balance probs - likely cause?

Back 33

CN 8 (Vestibulocochlear) - needed for hearing & balance

Lesions of CN 8 can cause deafness, tinnitus, and/or vertigo -

in kids, think of meningitis as a cause
in adults - think of medications (aspirin, aminoglycosides, loop diuretics, cisplatin), infection (labyrinthitis, tumor, or stroke

Front 34

Which CN is responsible for monitoring carotid body & sinus chemoreceptors & baroreceptors?

Back 34

CN 9 (glossopharyngeal)

Front 35

What are the 2 most common locations of aneurysms in the Circle of Willis?

Back 35

Anterior communicating artery
Posterior communicating artery

Front 36

Where is the brain lesion if pt presents with:
contralateral hemiballismus

Back 36

subthalamic nucleus

Front 37

Where is the brain lesion if pt presents with:
eyes look toward the side of the lesion

Back 37

frontal eye fields (Prefrontal cortex)

Front 38

Where is the brain lesion if pt presents with:
eyes looking away from the side of the lesion

Back 38

PPRF

Front 39

Where is the brain lesion if pt presents with:
paralysis of upward gaze

Back 39

Superior colliculi (Parinaud syndrome)

Also known as dorsal midbrain syndrome, this is a distinct supranuclear vertical gaze disorder caused by damage to the posterior commissure. It is a classic sign of hydrocephalus from aqueductal stenosis.

Pineal region tumors, cysticercosis, and stroke also cause Parinaud's syndrome.

Features include loss of upgaze (and sometimes downgaze), convergence-retraction nystagmus on attempted upgaze, downward ocular deviation ("setting sun" sign), lid retraction (Collier's sign), skew deviation, pseudoabducens palsy, and light-near dissociation of the pupils.

Front 40

Where is the brain lesion if pt presents with:
hemispatial neglect syndrome

Back 40

non-dominant parietal lobe

Front 41

Where is the brain lesion if pt presents with:
coma

Back 41

reticular activating system (RAS) - in the ventral pons

likely a/w Basilar Artery occlusion

Front 42

Where is the brain lesion if pt presents with:
poor repetition

Back 42

arcuate fasciculus

Front 43

Where is the brain lesion if pt presents with:
poor comprehension

Back 43

Wernicke's area

Front 44

Where is the brain lesion if pt presents with:
poor vocal expression

Back 44

Broca's area

Front 45

Where is the brain lesion if pt presents with:
resting tremor - think of the classic "pill rolling" tremor that disappears with movement or sleep

What conditions cause a resting tremor?

Back 45

basal ganglia (↓ dopamine)- think Parkinson's Disease

Other conditions other than Parkinson's disease that can cause resting tremors:
- hyperthyroidism, anxiety - tx with Beta blockers
- Drug withdrawal or intoxication (MPTP found in designer drugs)
Or Antipsychotics used to treat Schizophrenia - treat this side-effect with anticholinergics (benztropine, trihexyphenidyl) or antihistamines (diphenhydramine)
- benign hereditary tremor - usually Aut Dom (look for fam hx)


Also beware of:
Wilson's disease (hepatolenticular degeneration) - causes chore-like movements
Liver failure - causes asterixis (slow, involuntary flapping of outstretched hands

Front 46

Where is the brain lesion if pt presents with:
intention tremor

Back 46

cerebellar hemisphere

this is why alcoholics will have INTENTION tremors

Front 47

Where is the brain lesion if pt presents with:
hypororality, hypersexuality, disinhibited behavior

Back 47

bilateral amygdala (Kluver-Bucy)

Front 48

Where is the brain lesion if pt presents with:
Personality changes - apathy, inattention, disinhibition, labile affect

Back 48

frontal lobe

Front 49

Where is the brain lesion if pt presents with:
dysarthria (trouble articulating words - slurred speech)

Back 49

cerebellar vermis - this is why alcoholics have slurred speech

Front 50

Where is the brain lesion if pt presents with:
agraphia & acalculia
inability to read, write, name or do math

Back 50

dominant (left) parietal lobe

Front 51

Where do the dorsal columns decussate?

Back 51

medulla

recall the dorsal columns carry touch, vibration, pressure sensation

Front 52

where does the lateral corticospinal tract decussate?

Back 52

medullary pyramids

Front 53

Where does the spinothalamic tract decussate (crossover)?

Back 53

Anterior white commissure at the spinal cord level

spinothalamic carries pain & temperature sensation

correlation: syringomyelia, in which there is central cavitation of the spinal cord (usually in cervical or upper thoracic region) presents with loss of pain & temp sensation in a "cape" distribution b/c damage to the lateral spinothalamic tracts
MRI is best test to diagnose, tx with surgical creation of a shunt

Front 54

fill out this chart - 4star topic!!

what are the common organisms and empiric IV antibiotic choices for bacterial meningitis based on age of the patient?

Back 54

see above

Front 55

What is the rational for dosing dexamethasone prior to or along with the first dose of antibiotics for empiric treatment of bacterial meningitis?

Back 55

Dexamethasone when given with or prior to the first dose of antibiotic reduces the risk of neurologic sequelae (ie hearing loss) in children with meningitis, esp in the cases of H. influenza Type B or Tuberculosis (TB) meningitis
In adults with bacterial mengingitis, dexamethasone reduces both morbidity and mortality esp in the case of pneumococcal meningitis

Front 56

Do you always need to get a CT scan (prior to an LP) if you suspect meningitis?

Back 56

No – you do not have to get a CT scan in a patient you suspect of having meningitis

Front 57

In which situations do you need to get a CT scan prior to an LP?

Back 57

Focal neurologic defects
Papilledema
Pupil asymmetry
Suspect hematoma
Suspect brain tumor

Front 58

What is the treatment for viral meningitis?

Back 58

Acetominophen for pain
IV fluids as needed
Empiric antibiotics until bacterial meningitis can be excluded
if younger than 3 yrs, severely ill, or immunocompromised, continue empiric antibiotics until bacterial culture results confirm nonbacterial etiology
*** Give empiric Acyclovir if suspicion of HSV or signs of encephalitis such as focal neurologic findings
d/c if HSV PCR and cultures are negative or alternative diagnosis is made

Front 59

An infant is brought to the ER. The parents say that over the last day the infant has developed a fever, refused to eat, vomited, and is lethargic. The PE reveals petechiae and confirms the fever. WBC is elevated, and CSF results show a ↓ glucose and ↑ neutrophils. On which medications should this patient be started?

Back 59

Cover: E. coli, Listeria, Group B Strep (GBS)
Tx: Ampicillin + cefotaxime
Ampicillin + gentamicin

Front 60

What other drug should be given just before or along with the first dose of antibiotics in a pt suspected of having bacterial meningitis?

Back 60

Dexamethasone

Front 61

Fill in the table of CSF findings in cases of meningitis caused by different types of pathogens:

Back 61

Think: Bacterial eat sugar, viruses increase protein a little but noting else, TB/fungis same as bacteria

Front 62

When should a CT scan be performed as a next step instead of an LP in a pt suspected of having meningitis?

Back 62

When there are signs of ↑ ICP or other comorbidity
Focal neurologic defect
Papilledema
Focal seizure
Suspicion of mass effect
Soft tissue infection at site of LP
Bleeding diathesis
Cardiopulmonary instability

Front 63

You suspect an AIDS pt may have meningitis. What specific CSF preparation should be ordered in addition to the usual CSF analysis, gram stain, and culture?

Back 63

India Ink stain to look for Cryptococcus meningitis

Front 64

When would you suspect West Nile Viral infection? How would you make the dx? what's the tx?

Back 64

Birds are the resevoir, and mosquitoes are the vectors. Human, horses, and dogs are incidental hosts
S/S: usually only headache, malaise, back pain, myalgia, and anorexia for 3-6 days (“flu like”)
Severe S/S in 1/150: meningitis +/- encephalitis including muscle weakness and flaccid paralysis (via anterior-horn involvement), alteration in consciousness, possibly death
Dx: serology – check for IgM Abs against West Nile Virus
Tx: supportive

Front 65

What is the treatment for Reye's syndrome?

Back 65

d/c salicyclate (ie Aspirin)
Hospitalization (usually ICU) for cardiorespiratory monitoring (+/- mechanical ventilation), supportive care, fluid & electrolyte management
Maintain euglycemia: accuchecks, IV dextrose or insulin as needed
Maintain isovolemia: IVF or Lasix as needed, Foley catheter for strict I/Os
Reduce brain swelling: avoid hypo-osmotic fluids, elevate head of bed, +/- corticosteroids, +/- ICP monitor
If seizures: phenytoin

Front 66

How should you treat a pt that has been bitten by an animal suspected of having rabies, or an animal that cannot be observed for 10 days?

Back 66

Clean the wound with iodine
Administer rabies immunoglobulin & rabies vaccine
Tetanus prophylaxis

Front 67

A pt is brought into the ED with progressive muscle weakness, intact sensation, headache, vomiting, neck pain, and fever. CSF analysis shows ↑ lymphocytes and normal glucose and protein. What life-threatening complication can result in this disease process?

Back 67

Dx: Polio (muscle weakness is key to dx)
Complication: respiratory muscle paralysis

Front 68

What other term should you remember when considering Reye’s syndrome?

Back 68

Hepatoencephalitis

Front 69

A pt is recovering in the ICU after suffering a subdural hematoma that occurred b/c of a MVC. The neurosurgery team performed a craniotomy and drain placement to evacuate the clot. For the past few days the drainage in the collection bulb was serous. Now however, the drainage is thick and yellow. Along with this, the pt’s neurological exam has deteriorated. What is the likely cause of this clinical picture?

Back 69

Dx: abscess within subdural space
Likely etiology: Staph aureus
Tx: cover for MRSA, gram (+) and Gram negs with Vancomycin and Ceftazidime

Front 70

What are the differences in the acute treatment of tension headaches, cluster headaches, and migraine headaches?

Back 70

see above

Front 71

What agents can be used for prophylaxis of migraine headaches?

Back 71

Ca2+ channel blockers: verapamil (often first-line b/c safe and well tolerated)

β-blockers: propanolol, metoprolol (good choice if comorbid HTN)

Tricyclic antidepressants (TCA): amitriptyline, nortriptyline (good choice if comorbid depression, incsomnia, pain syndrome)
Note – nortriptyline has fewer side effects

NSAIDs: naproxen (good choice if menstrual migraine or comorbid osteoarthritis or other pain that could benefit from NSAIDs)

Anticonvulsants: valproic acid (good if h/o Bipolar disorder), topiramate, gabapentin

Front 72

What is the most likely cause of a pt's headache if:
Made worse by foods containing tyramine

Back 72

migraine

Front 73

What is the most likely cause of a pt's headache if:
Obese female with papilledema

Back 73

pseudotumor cerebri

Front 74

What is the most likely cause of a pt's headache if:
Jaw muscle pain when chewing

Back 74

Giant cell (temporal) arteritis

Front 75

What is the most likely cause of a pt's headache if:
Periorbital pain with ptosis and miosis

Back 75

cluster headache

Front 76

What is the most likely cause of a pt's headache if:
Photophobia, Phonophobia

Back 76

migraine

Front 77

What is the most likely cause of a pt's headache if:
Bilateral frontal/ occipital pressure

Back 77

tension headache

Front 78

What is the most likely cause of a pt's headache if:
Lacrimation and/or rhinorrhea

Back 78

cluster headache

Front 79

What is the most likely cause of a pt's headache if:
Elevated ESR

Back 79

Giant cell (temporal) arteritis

Front 80

What is the most likely cause of a pt's headache if pt states:
“Worst headache of my life”

Back 80

Subarachnoid hemorrhage

Front 81

What is the most likely cause of a pt's headache if:
Headache + extraocular muscle palsies

Back 81

Cavernous sinus thrombosis

Front 82

What is the most likely cause of a pt's headache if:
Scintillating scotomas prior to headache

Back 82

Migraine with aura

Front 83

What is the most likely cause of a pt's headache if:
Headache occurring either before or after orgasm

Back 83

Post-coital cephalgia

Front 84

What is the most likely cause of a pt's headache if:
Responsive to 100% Oxygen supplementation

Back 84

cluster headache

Front 85

What is the most likely cause of a pt's headache if:
Trauma to the head → headache begins days after the event, persists for over a week and does not go away

Back 85

Subdural hematoma

Front 86

What headache symptoms would lead you to suspect a brain tumor as a cause of a headache?

Back 86

mild headache which progressively worsens over days to weeks
new onset after age 50
Papilledema: worsened by a bending, lifting, cough, or Valsalva maneuver (= ↑ in ICP)
Associated seizures, confusion, altered mental status (AMS)
Abnormal neurologic signs and symptoms (ie focal numbness or weakness)
Disturbs sleep or present immediately upon awakening
Vomiting precedes headache
Known systemic illness (ie cancer, HIV, or collagen-vascular disorder)

Front 87

What are the characteristic features of pseudotumor cerebri?

Back 87

Young, obese female
Headaches – daily (worse in the morning), pulsatile, possible nausea/vomiting, possible retroocular pain worsened by eye movement
Papilledema
Most worrisome sequela is vision loss
CT Scan: (normal) no ventricular dilation, no mass
CSF pressure elevated > 200 mmH2O in non-obese, >250 in obese pt)

Front 88

What treatment options are available for managing pseudotumor cerebri?

Back 88

Confirm absence of other pathology with CT and MRI of the head (r/o central venous thrombosis)
d/c any inciting agents (ie Vit A excess, tetracyclines, withdrawal from corticosteroids)
Weight loss in obese pts
Acetozolamide – first line (start 250mg qid or 00mg bid → increase to 500mg qid to 1000mg qid)

Invasive treament options:
Serial lumbar punctures
Optic nerve sheath decompression
Lumboperitoneal shunting (CSF shunt)

Front 89

A 25 yo M is seen in the ER with a severe headache. He tells you that the headache always occurs at around the same time of day, and that the pain is localized around the right eye. On exam his pupils are unequal and his right eye is tearing. While he waits for a CT scan of the head, what treatment should he receive?

Back 89

Dx: cluster headache
Tx: 100% O2, Sumitriptan or IV ergotamines

Front 90

30 yo F is in the office with a complaint of facial pain. She describes that whenever her face is lightly touches that she experiences incredible electricity-like pain. What is the 1st line therapy for this condition?

Back 90

Dx: Trigeminal neuralgia
Tx: Carbamazepine or Baclofen

Front 91

27 yo M comes to the clinic b/c of progressively worsening headache. He denies a prior h/o headaches. He adds that this one was easy to ignore at first, but over the last few weeks has never let up and is increasing in severity. What should be next for this pt?

Back 91

next step: MRI of brain (if it’s getting worse, be worried!)

Front 92

What are the demographic characteristics of a typical pseudotumor cerebri patient?

Back 92

obese female in 20's-30's

Front 93

A pt with longstanding poorly-controlled diabetes has tension headaches. What should you check before recommending pharmacologic treatment?

Back 93

Kidney function (Creatinine, BUN, GFR) – because NSAIDs are treatment for Tension Headaches

Front 94

Which spinal cord lesion matches the following description?
Fasciculations but also spastic paralysis

Back 94

ALS

Front 95

Which spinal cord lesion matches the following description?
Impaired proprioception + pupils do not react to light

Back 95

Syphilis (Tabes Dorsalis & Argyll Robinson pupils)

Front 96

Which spinal cord lesion matches the following description?
Bilateral loss of pain and temp below lesion + hand weakness

Back 96

Syringomyelia

Front 97

Which spinal cord lesion matches the following description?
Bilateral loss of vibration sense + spastic paralysis of legs then arms

Back 97

Vit B12 Deficiency

Front 98

Which spinal cord lesion matches the following description?
Bilateral loss of pain/temp below lesion + bilateral spastic paralysis below lesion + bilateral flaccid paralysis at level of lesion

Back 98

Occlusion of Anterior Spinal Artery

Front 99

What are the characteristic features of Brown-Sequard syndrome?

Back 99

Ipsilateral vibration & discrimination below lesion
Ipsilateral spastic paralysis (below lesion)
Ipsilateral flaccid paralysis (level of lesion)
Contralateral pain & temp (below lesion)

Front 100

HYQ: most likely cause of headache in a 40yo woman with frontal headache that is made worse by bending over?

Back 100

Sinus headache

Front 101

HYQ: What would be the preferred antihypertensive in a pt with chronic hypertension and recurrent migraines?

Back 101

β-blockers or Ca2+ channel blockers

Front 102

HYQ: What medication should be given to close contacts of those with either meningococcal or HIB meningitis?

Back 102

Rifampin or Ciprofloxacin

Front 103

HYQ: What are the four most common sequelae of meningitis in children?

Back 103

Hearing loss
Mental retardation
Seizure disorder
Spastic paralysis

Front 104

What is the treatment for fungal meningitis?

Back 104

Amphotericin B

Front 105

What medications are used in combination in the treatment of TB meningitis?

Back 105

RIPE – Rifampin, Isoniazid, Pyrazinamide, Ethambutol

Front 106

What cerebral artery infarct can cause aphasia?

Back 106

MCA infarction

Front 107

What organism is responsible for bacterial meningitis given the following findings on CSF examination?
Gram (+) diplococci

Back 107

Streptococcus pneumoniae

Front 108

What organism is responsible for bacterial meningitis given the following findings on CSF examination?
Gram neg diplococci

Back 108

Neisseria meningitis

Front 109

What organism is responsible for bacterial meningitis given the following findings on CSF examination?
Small pleomorphic gram neg coccobacilli

Back 109

Haemophilus influenza

Front 110

What organism is responsible for bacterial meningitis given the following findings on CSF examination?
Gram (+) rods and coccobacilli

Back 110

Listeria

Front 111

What is the anticoagulant of choice in a pt with a h/o stroke or TIA?

Back 111

First TIA ➔ Aspirin
TIA/stroke due to Atrial Fibrillation ➔ Warfarin
TIA/Stroke + coronary artery disease ➔ Clopidogrel (Plavix)
Repeat TIA/stroke while on aspirin ➔ Clopidogrel (Plavix)

Front 112

What are the classic signs and symptoms of carotid artery stenosis?

Back 112

Carotid bruit
Transient ischemic attacks (TIAs)
Reversible ischemic neurologic deficits lasting up to 3 days
Amaurosis fugax (transient unilateral blindness)
Cerebrovascular accidents (CVAs)
(Vertigo & Syncope are NOT caused by carotid artery stenosis)

Front 113

What are the surgical indications for carotid endarterectomy?

Back 113

Symptomatic carotid stenosis 70-99%: strong benefit
Symptomatic carotid stenosis 50-69%: marginal benefit (more benefit in men and if performed w/in 2 wks of stroke/TIA)
Asymptomatic pts with 80-99% stenosis who are expected to live longer than 5 yrs by a surgeon with a perioperative complication rate of less than 3% (some books will mention a blanket >60% and asymptomatic rule, but this varies by surgeon and patient)

Front 114

What are the important nonsurgical treatments for carotid artery stenosis?

Back 114

HTN control to < 140/90
Dyslipidemia control to LDL < 100mg/dL, HDL >35, TGs <200
Lipid control with statin reduces stroke while other lipid lowering drugs do not
Niacin reduces carotid artery intima thickness
ADA diet
DM control to fasting glucose <126 and HgA1c <7%
Smoking avoidance, consider varenicline (Chantix)
↑ physical activity to at least 30-60 minutes 4x weekly
alcohol consumption up to 2 drinks daily is beneficial. Avoidance of heavy drinking
Evaluation for CAD and PAD
Aspirin Anticoagulation if history of TIA/stroke while on aspirin → use Aggrenox or clopidogrel instead

Front 115

What are some major signs and symptoms of a TIA?

Back 115

Amaurosis fugax (brief unilateral blindness)
Weakness
Slurred speech
Impaired coordination
Impaired sensation/ paresthesias

Front 116

What anticoagulant would you give a pt who has just had their first TIA? What if the pt had another TIA while on ASA, what would you add?

Back 116

First TIA: Aspirin
Second TIA, while on Aspirin: add Clopidogrel (Plavix) or combination of Aspirin + dipyridamole

Front 117

What is the maximum amt of time a TIA may last?

Back 117

24 hrs or less

Front 118

What medication should be taken by a pt with atherosclerotic disease and risk of stroke?

Back 118

Statin & Aspirin

Front 119

What are the indications for carotid endarterectomy?

Back 119

Asymptomatic men with narrowing of 80-99%
Symptomatic men with narrowing of 50-69%
Symptomatic women with narrowing of 70-99%

Front 120

What are the 5 main lacunar syndromes that may arise from a lacunar infarct?

Back 120

1) Pure motor hemiparesis: (most common, about 50% of lacunar strokes) – weakness of the face, arm, and leg on one side of the body + absent sensory or cortical signs (aphasia, neglect, apraxia, hemianopsia)
2) Pure sensory: sensory defect (numbness) of the face, arm, and leg on one side of the body + absent motor or cortical signs
3) Ataxic hemiparesis: ipsilateral weakness and limb ataxia out of proportion to the motor defect, possible gait deviation to the affected side + absent cortical signs
4) Sensory motor stroke: weakness and numbness of the face, arm, and leg on one side of the body + absent cortical signs
5) Dysarthria – Clumsy Hand Syndrome: (least common) – facial weakness, dysarthria, dysphagia, and slight weakness and clumsiness of one hand + absent sensory or cortical signs

Front 121

A stroke, by definition, must last how long?

Back 121

> 24 hrs

Front 122

What thrombolytics are used in the treatment of an acute ischemic stroke?

Back 122

tPA, streptokinase (streptase)

Front 123

What long-term medications should be started within 2-3 days of ischemic stroke?

Back 123

Antiplatelet (aspirin) + statin

Front 124

What would be the most likely initial imaging for a pt suspected to have a stroke?

Back 124

Noncontrast CT scan

then, If the above study did not yield useful information, then what study might you get?
MRI of the head

Front 125

What is the next step in management of a pt with ischemic stroke symptoms after a hemorrhagic stroke has been ruled out by noncontrast CT?

Back 125

Thrombolytic therapy

Front 126

To maintain cerebral perfusion during the acute treatment of ischemic stroke, hypertension is generally not actively treated. At what blood pressure does treatment become necessary?

Back 126

BP > 220/120

Front 127

Hemorrhagic stroke requires the following treatment:

Back 127

Reversal of any anticoagulation
Control of intracranial pressure (ICP)
Control of blood pressure
Surgical decompression may be needed

Front 128

What is the treatment for a subarachnoid hemorrhage?

Back 128

d/c all anticoagulants and reverse and anticoagulation
systolic BP < 150 only if cognitive function is intact (adequate cerebral perfusion pressure) until the aneursm is clipped or coiled to prevent rebleeding. If the cerebral perfusion pressure is not adequate then lowering the BP will increase the risk of infarction
Labetalol preferred
Avoid Nitroprusside & Nitroglycerin which can ↑ ICP
Nimodipine (a CCB) to prevent vasospasm
Prevent physiologic derangements that may worsen brain injury
Avoid hypoxia and hyperglycemia
Maintain a normal pH, euvolemia, and normothermia
(Phenytoin for seizure prophylaxis is controversial and generally avoided due to poorer outcomes)
Ventriculostomy to monitor ICP in select patients
Surgical clipping or metal coil into aneurysm

Front 129

Are patients with parenchymal hemorrhage at an increased risk of seizures?

Back 129

yes

Front 130

In which scenario is seizure prophylaxis with anticonvulsants recommended? Parenchymal hemorrhage or subarachnoid hemorrhage (SAH)?

Back 130

Parenchymal → always start prophylaxis
SAH → only if seizures develop

Front 131

How can AVMs and/or aneurysms be treated?

Back 131

Coil or clip

Front 132

What diseases are associated with berry aneurysms?

Back 132

Polycystic Kidney Disease
Marfan’s Syndrome

Front 133

What are 3 feared complications of parenchymal hemorrhage?

Back 133

Uncal herniation
CSF flow obstruction
Death

Front 134

How may a pt describe the symptom of a subarachnoid hemorrhage?

Back 134

"worst headache of my life"

Front 135

What 2 studies must be performed to rule out SAH?

Back 135

Noncontrast CT scan of the head
Lumbar puncture

Front 136

How does one differentiate between SAH and a traumatic LP as a cause of bloody CSF?

Back 136

collect several tubes of CSF, if blood decreases then more likely due to traumatic LP than SAH

Front 137

What are the most common causes of an epidural hematoma and subdural hematoma?

Back 137

Epidural hematoma: rupture of middle meningeal artery
Subdural hematoma: rupture of bridging veins

Front 138

Commonly a pt with an epidural hematoma will have the typical three part history of:

Back 138

(1) head trauma with brief LOC
(2) Lucid interval
(3) Deterioration (expansion of epidural hematoma)

Front 139

What is the definitive treatment of an epidural hematoma?

Back 139

Evacuation of hematoma

Front 140

Where is the bleeding in a subdural hematoma? What shape would be expected on a head CT of a pt with subdural hematoma?

Back 140

Bleeding is btw dura & arachnoid
Classic finding: crescent shape on CT scan

Front 141

If you suspect a pt has an epidural or subdural hematoma, should you perform a LP to confirm the diagnosis?

Back 141

NO! can ↑ risk of brain herniation

Front 142

Describe the differences between Broca’s aphasia and Wernicke’s aphasia?

Back 142

Broca’s: expressive
Wernicke’s: receptive

Front 143

What are the three Ws that help diagnose normal pressure hydrocephalus?

Back 143

Wacky – cognitive impairment
Wet – incontinence
Wobbly – gait disturbance

Front 144

Which medications or medication withdrawal are known for causing seizures?

Back 144

Medications that ↓ seizure threshold:
Buproprione
Buspirone
Enflurane


Medication withdrawals that can cause seizures:
Barbiturates
Alcohol
Anticonvulsants
Benzodiazepines - choose the short acting (Alprazolam, Lorazepam) if given more than one to choose from

Front 145

What medications are used for prevention of grand mal (tonic-clonic) seizures?

Back 145

Valproate, carbamazepine, phenytoin, lamotrigine, topiramate

Front 146

What medications are used for prevention of partial seizures?

Back 146

(same as prevention of grand mal seizures)
Carbamazepine, Phenytoin, Lamotrigine > Valproate, Topiramate

Front 147

What medications are used for prevention of absence seizures?

Back 147

Ethosuximide

Front 148

What seizure medications are used for prevention of myoclonic seizures?

Back 148

Valproic Acid

Front 149

Which seizure medication matches the following description?
Gingival hyperplasia

Back 149

phenytoin (Dilantin)

Front 150

Which seizure medication matches the following description?
DOC for absence seizures

Back 150

Ethosuximide (Zarontin)

Front 151

Which seizure medication matches the following description?
2nd choice for absence seizures

Back 151

Valproic Acid (Depakene)

Front 152

Which seizure medication matches the following description?
DOC for Trigeminal Neuralgia

Back 152

carbamazepine

Front 153

Which drugs are known for causing Stevens-Johnson syndrome?

Back 153

“sulfa, -cillin & seizure”
most commonly lamotrigine (lamictal)

Front 154

Which drugs are known for inducing the cytochrome P450 system thereby speeding up the metabolism of other drugs such as OCPs and warfarin?

Back 154

“BCG PQRS”
Barbiturates
Carbamazepine
Griseofulvin
Phenytoin
Quinidine
Rifampin
St John’s Wort

Front 155

what is Arnold-Chiari Malformation?

Back 155

Downward displacement of the cerebellar tonsils and medulla thru the foramen magnum
Type I is the most common type and is often asymptomatic. Manifestations may include headaches and/or cerebellar symptoms
Type II (of IV severity) is usually accompanied by other neurologic anomalies

Front 156

What other neurologic anomalies are associated with an Arnold-Chiari malformation?

Back 156

Hydrocephalus
Syringomyelia
Myelomeningocele

Front 157

What are some of the possible presenting features of cerebral palsy?

Back 157

Spastic features: spastic paresis of any or all limbs, clonus present
Athetosis features: slow, writhing movements in distal muscles
Chorea features: rapid, irregular, unpredictable contractions of muscles in face or extremities
Dystonic features: uncontrollable jerking, writhing, or posturing
Infants have persistence of primitive reflexes, involuntary grimacing, tendency to drool, and delayed psychomotor development
Ataxia: difficulty coordinating purposeful movements
Atonic features: severe hypotonia present at birth with no future ability to stand or walk
Neonates: may show signs of encephalopathy including lethargy, ↓ spontaneous movement, hypotonia, and suppressed primitive reflexes
Associated disorders: mental retardation, epilepsy, sensory impairment (speech, hearing, vision)

Front 158

What type of seizure fits each description?
Focal sensory or motor deficit with no loss of consciousness

Back 158

simple partial

Front 159

What type of seizure fits each description?
Focal sensory or motor deficit, with impaired consciousness (commonly localized to temporal lobe on EEG)

Back 159

Complex partial

Front 160

What type of seizure fits each description?
Involves both hemispheres of brain with a pattern of neuromuscular activation: tonic, clonic, toni-clonic, myoclonic, or atonic. Loss of consciousness present with postictal period

Back 160

Generalized

Front 161

What type of seizure fits each description?
Characterized by a brief (few second) impairment of consciousness often with automatisms such as blinking or picking at shirt. No postictal period. Spike and wave pattern on EEG

Back 161

Absence

Front 162

What is status epilepticus?

Back 162

Uninterrupted seizure > 20min

Front 163

What is the initial treatment for a pt in status epilepticus?

Back 163

Monitor ABCs

Front 164

Once ABCs are under control, what is the treatment for a pt in status epilepticus?

Back 164

IV Benzos - Lorazepam

Front 165

What is the DOC for absence seizures?

Back 165

Ethosuximide

Front 166

A 45yo M is brought to the ER for new-onset status epilepticus. What are some of the components of the workup to determine epilepsy?

Back 166

Hx & PE (ask about trauma, drugs, illness)
CBC
Fasting blood glucose
BMP & LFTs
Toxic drug screen
CT head (if not actively seizing… )
LP for CSF infection (r/o meningitis)

Front 167

How long must a focal neurologic deficit last to qualify as a stroke?

Back 167

> 24 hrs

Front 168

In what timeframe must thrombolytic therapy be instituted in cases of ischemic stroke?

Back 168

Within 3 hrs

Front 169

HYQ: What is the treatment for an epidural hematoma or subdural hematoma?

Back 169

Evacuation of the hematoma via surgical drainage

Front 170

HYQ: Most common predisposing consition for an intracranial hemorrhage?

Back 170

hypertension

Front 171

HYQ: What is the principle cause of a lacunar infarct?

Back 171

hypertension

Front 172

HYQ: CT Scan of the head shows a cresent shaped lesion. What event most likely caused this lesion?

Back 172

Subdural hematoma → blunt head trauma, rupture of bridging veins

Front 173

HYQ: What is the preferred treatment for febrile seizures?

Back 173

Acetominophen or ibuprofen (No Aspirin)
Reassure parents

Front 174

HYQ: A patient with a DVT develops a stroke. What study would most would most likely identify the underlying etiology of the stroke?

Back 174

Transesophageal echocardiogram (TEE)

Front 175

What neurologic defects would be seen with an infarction of anterior cerebral artery

Back 175

Contralateral loss of sensory and/or motor information
Legs, feet, trunk

Front 176

What neurologic defects would be seen with an infarction of middle cerebral artery (MCA)

Back 176

Loss of sensory and/or motor info in hands, face, arms
Aphasia: Broca’s, Wernicke’s, Conduction, global

Front 177

What neurologic defects would be seen with an infarction of posterior cerebral artery

Back 177

Visual defects: unilateral hemaniopia, macular sparing

Front 178

What neurologic defects would be seen with an infarction of lacunar arteries?

Back 178

one of the lacunar syndromes:

Pure motor hemiparesis
Pure sensory stroke
Ataxic hemiparesis
Sensorimotor stroke
Dysarthria – Clumsy hand syndrome

Front 179

What neurologic defects would be seen with an infarction of the basilar artery?

Back 179

Cranial nerve abnormalities

Front 180

What are the 5 main lacunar syndromes that may arise from a lacunar infarct?

Back 180

Pure motor hemiparesis
Pure sensory stroke
Ataxic hemiparesis
Sensorimotor stroke
Dysarthria – Clumsy hand syndrome

Front 181

An aphasic patient has great trouble producing words but understands everything you say. What type of aphasia does he most likely have?

Back 181

Broca’s aphasia

Front 182

Although benzodiazepines are used to end a seizure in status epilepticus, what is of more concern in the initial treatment?

Back 182

Monitor ABCs

Front 183

What is the treatment for subarachnoid hemorrhage?

Back 183

Stop anticoagulants
BP < 150 (Labetalol)
Avoid nitroprusside/ nitroglycerin
etc

Front 184

What neurotransitter changes do you see with anxiety disorders?

Back 184

↑ NE ↓ 5-HT ↓ GABA

think - aNxiety due to excess Norepinephrine

Front 185

What neurotransitter changes do you see with depression?

Back 185

↓ NE ↓ Dopamine ↓ Serotonin

think: Depression = all Down (plus, this is why SSRIs, SNRI & MOAIs all work in treating depression)

Front 186

What neurotransitter changes do you see with mania?

Back 186

↑ NE ↑ 5-HT

Front 187

What neurotransitter changes do you see with Alzheimer's?

Back 187

↓ ACh

Front 188

What neurotransitter changes do you see with Huntington's Disease?

Back 188

↓ ACh ↓ GABA

Front 189

What neurotransitter changes do you see with Schizophrenia?

Back 189

↑ Dopamine

Front 190

What neurotransitter changes do you see with Parkinson's Disease?

Back 190

↓ Dopa ↑ ACh

Front 191

At what point does grief/bereavement become pathological?

Back 191

Grief becomes pathological when any of the following present:
● Depression criteria met for at least 2 weeks after the first 2 months following the loss
● Generalized feelings of hopelessness, helplessness, worthlessness
● Guilt
● Distressed feelings do not diminish in intensity by suicidal ideation
● Inability to move-on, trust others, and reengage in life by 6 months

Front 192

What medical conditions can cause severe depression?

Back 192

hypOthyroidism
hyperparathyroidism
Parkinson’s disease
Stroke, CNS tumors
Pancreatic cancer

Front 193

What medications are known for causing symptoms of depression in patients?

Back 193

● Sedatives: alcohol, benzos, antihistamines
● Stimulant withdrawal
● ** Methyldopa (Aldomet) – antihypertensive often used for HTN in pregnancy
● 1st Gen antipsychotics (ie Haloperidol)
● anti-nausea drugs including metoclopramide (Reglan) and prochlorperazine (compazine)
● ** Glucocorticoids
● Insufficient thyroid replacement → hypothyroidism
● ** α-interferon – used in viral hepatitis treatment

Front 194

What scale can be used to determine a pt’s risk of suicide?

Back 194

SAD-PERSONS Scale
(S)ex - men are 3x more likely to complete suicide, Give 1 pt for being male
(A)ge: suicide is more likely if <!9 or >45. Give 1 pt if age not btw 19-45 yr old
(D)epression: depression greatly increases risk. Give 1 pt if mood is significantly depressed.
(P)rior attempts: Give 1 pt for one of more prior attempts
(E)tOH: intoxication ↑ risk. Give 1 pt for alcohol or drug dependent
(R)ational thought process: give 1 pt for significant psychotic symptoms
(S)upport lacking: give 1 pt if pt does not have significant sources of emotional & social support
(O)rganized plan: give 1 pt if pt articulates an organized plan for suicide (more than simple ideation or impulses)
(N)o spouse: Give 1 pt if family support unavailable (can be family members other than spouse
(S)ickness: give 1 pt for other medical problems that are not well controlled and that are a source of distress


Guidelines for Action:
- 0-2 pts → outpt f/u, assist with arrangements
- 3-4 pts → supervised/ supported outpt f/u; consider admission for some pts
- 5-6 pts → consider hospitalization unless safe alternative can be arranged and verified
- 7-10 pts → generally will require hospitalization. May need commitment involuntary

Front 195

What are some symptoms of atypical depression? What medications work well for atypical depression?

Back 195

S/S: Hypersomnia (↑ sleep), Leaden paralysis/ psychomotor retardation, hyperphagia (weight gain), hypersensitivity to rejection
Tx: MAOIs better than TCAs

Front 196

What is the first line treatment for seasonal affective disorder?

Back 196

Phototherapy
Drugs – SSRIs, bupropion

Front 197

Depression has what neurotransmitter derangements?

Back 197

↓ NE ↓ Dopamine ↓ Serotonin

Front 198

List the symptoms of depression:

Back 198

“SIG E CAPS”
Sleep disturbance
Interest/pleasure reduction
Guilt feelings or thoughts of worthlessness
Energy changes/fatigue
Concentration/attention impairment
Appetite change
Psychomotor disturbances
Suicidal thoughts

Front 199

Diagnosis of major depressive disorder (MDD) requires 5 of the above symptoms including depressed mood or anhedonia that must last how long?

Back 199

> 2 weeks

Front 200

What is the diagnosis of a pt that has periods of mood disturbances while psychotic as well as periods of psychosis with normal affect?

Back 200

Schizoaffective disorder

Front 201

What medical conditions can cause severe depression?

Back 201

hypOthyroidism, hyperparathyroidism, Parkinson’s Disease
Stroke, CNS neoplasm, Pancreatic cancer

Front 202

List the Selective Serotonin Reuptake Inhibitors (SSRIs)

Back 202

Fluoxetine (Prozac), Sertraline (Zoloft)
Paroxetine (Paxil) Citalopram (Celexa)
Fluvoxamine (Luvox, Lescol)
Escitalopram (Lexapro)

Front 203

List the Tricyclic Antidepressants (TCAs)

Back 203

Amitriptyline (Elavil), Imipramine (Tofranil)
Desipramine (Norpramin)
Nortriptyline (Aventyl)
Clomipramine (Anafranil)
Doxepin (Silenor, Sinequan)

Front 204

List the Monoamine

Back 204

Phenelzine (Nardil)
Tranylcypromine (Parnate)
Selegiline (Eldepryl, Emsam, Zelapar)

Front 205

List the dopamine-norepinephrine reuptake inhibitors (NDRIs)

Back 205

Buproprion (wellbutrin)

Front 206

List the selective serotonin-norepinephrine reuptake inhibitors (SNRIs)

Back 206

Venlafaxine (Effexor, Pristiq)
Duloxetine (Cymbalta)
Milnacipran (Savella)
Nefazodone (Serzone)

Front 207

List the tetracyclic antidepressants (dual mode of action by enhancing both serotonergic & noradrenergic neurotransmission but not a reuptake inhibitor, plus histaminergic & alpha-adrenergic antagonist)

note: don't really need to know how they work, just that these drugs don't fit with any other group

Back 207

Mirtazapine (Remeron)
Trazodone (Desyrel, Oleptro)

Front 208

What drugs, when combined with SSRIs are known for causing Serotonin syndrome?

Back 208

SSRIs, SNRIs, MAOIs
LSD, St. John’s wort, Levodopa, Meperidine, Lithium
Amphetamines, cocaine, ectasy

Front 209

What are the characteristic features of serotonin syndrome?

Back 209

● Mental status changes: anxiety, agitation, delirium, restlessness, disorientation
● Autonomic excitation: diaphoresis, tachycardia, hyperthermia, hypertension, vomiting, diarrhea
● Neuromuscular: tremor, muscle rigidity, myoclonus, hyperreflexia
→ Ocular clonus: slow, continuous, horizontal eye mvmts
→ Spontaneous or inducible clonus
→ Babinski signs bilaterally

Front 210

What is the treatment for serotonin syndrome?

Back 210

(1) d/c serotonergic agents: symptoms usually resolve in 24hrs
(2) supportive care to normalize vital signs
- oxygen, IVF, cardiac monitoring
- if medical treatment for tachycardia or hypertension is needed, use short acting agents ie esmolol, nitroprusside
- sedation with benzodiazepines
- if temp > 41.1°C → sedation, paralysis, and ET tube → mechanical COOLING (ie ice, cooling blankets, misting fans)
- PARALYSIS should relieve the hyperthermia which is caused by muscle activity
- there’s no benefit in using antipyretics in this case
- if AGITATION despite benzos → Serotonin antagonist
- after resolution of symptoms, assess need to resume serotonergic agent

Front 211

What evaluation should take place prior to the initiation of TCAs in children?

Back 211

b/c TCAs can cause arrhythmias, the following is needed:
● Screen the pt's family history for heart disease, palpitations, syncope, near syncope
● Screen family history for SUDDEN DEATH prior to age 40, long QT syndrome, arrhythmias, and hypertrophic cardiomyopathy
● EKG prior to initiation and again when medication is optimized

Front 212

What are the symptoms of overdose with tricyclic antidepressants (TCAs)?

Amitriptyline (Elavil),
Imipramine (Tofranil)
Desipramine (Norpramin)
Nortriptyline (Aventyl)
Clomipramine (Anafranil)
Doxepin (Silenor, Sinequan)

Back 212

● Cardiotoxicity: tachycardia, hypotension, conduction abnormalities
● CNS toxicity: sedation, obtundation, coma, seizures
● Anticholinergic symptoms: mydriasis, xerostomia, ileus, urinary retention

Front 213

How is TCA overdose managed?

Back 213

● ABCs – Airway, Breathing, Circulation
● Activated charcoal 1g/kg up to 50kg (unless ileus is present)
● Continuous cardiac monitoring for at least 6 hrs → if no problems, then clear for psych eval
● Frequent neuro checks
● Lab/Studies: TCA level, Chem 7, EKG

● If ingestion < 2 hrs → gastric lavage
● If hypotension → IVF (LR or NS) → if ineffective, then norepinephrine
● If QRS > 100msec → trial Bicarb then infusion if effective
● If seizures → Benzos, barbiturates, and/or propofol (but not phenytoin which is ineffective against toxin-induced seizures)

Front 214

What food substances should be avoided when taking MAOIs in order to avoid a tyramine induced hypertensive crisis?


Phenelzine (Nardil)
Tranylcypromine (Parnate)
Selegiline (Eldepryl, Emsam, Zelapar)

Back 214

Foods that are spoiled, pickled, aged, smoked, fermented or marinated contain tyramine. The following foods should be avoided b/c of sufficient quantities of tyramine to be problematic while on MAOIs:
● Fermented cheeses (cream cheese & cottage cheese OK)
● Smoked or aged meats (sausage, bologna, pepperoni, salami, smoked or pickled fish)
● Chianti, most beers and wines (esp over 120mL)
● Soy sauce, shrimp paste, miso soup
● Sauerkraut, avocados
● Brewer’s yeast and yeast extracts (yeast used in baking is ok)

Front 215

In what group of pts is bupropion (Wellbutrin) contraindicated?

Back 215

b/c of an ↑ risk of lowering the seizure threshold, bupropion should be avoided in pts with:
(1) seizure disorder
(2) eating disorder
(3) Benzo or alcohol withdrawal

Front 216

What are the indications for electroconvulsive therapy (ECT)?

Back 216

Severe debilitating depression refractory to antidepressants
Psychotic depression
Severe suicidality
Depression with catatonic stupor
Depression with food refusal leading to nutritional compromise
Situations where a rapid antidepressant response is required (ie pregnancy)
Previous good response to ECT
Medical condition preventing the use of antidepressants (ie elderly patients)
Bipolar disorder/mania
Schizophrenia/psychosis (esp catatonic)

Front 217

How long must a pt expect to take an SSRI before they see improvement in their depression?

Back 217

3-4weeks (maybe up to 6 wks)

Front 218

In TCA overdose, what can be used to correct the prolonged QRS interval and possible seizures?

Back 218

IV Bicarb for prolonged QRS interval
IV Benzodiazepines to end seizure

Front 219

Consumption of tyramine rich food in conjunction with MAOI treatment can result in what dangerous condition?

Back 219

Hypertensive crisis

MOAIs =

Phenelzine (Nardil)
Tranylcypromine (Parnate)
Selegiline (Eldepryl, Emsam, Zelapar)

Front 220

What food are known to be rich in tyramine?

Back 220

“aged food” – cheese, wine, pizza

Front 221

Trazodone’s side effect of sedation makes it useful in what population of pts who have difficulty sleeping?

Back 221

Elderly

Front 222

Which commonly used antidepressant should be avoided in pts at risk for seizure?

Back 222

Buproprion
Contraindications: seizure disorder, eating disorder, Benzo or alcohol withdrawal

Front 223

Which antidepressant is preferred in the treatment of depression with comorbid neuropathic pain?

Back 223

SNRIs – Duloxetine (Cymbalta)

Front 224

What are the potential side effects of lithium use in the treatment of bipolar disorder?

Back 224

(1) CNS depression, tremor, cognitive dulling
(2) Thyroid changes – hyper- or hypothyroidism, or euthyroid goiter
(3) Nephrogenic diabetes insipidus – reversible on discontinuation → thirst, polydipsia, polyuria
(4) GI side effects – nausea, vomiting, diarrhea, metallic taste changes, weight gain

Front 225

What is the treatment for nephrogenic diabetes insipidus caused by lithium toxicity?

Back 225

Amiloride + hydrochlorothiazide

Front 226

How is depression managed in pts with bipolar disorder?

Back 226

● Mild depression → lithium or lamotrigine
● Moderate depression → add a second mood stabilizer (lamotrigine) or add an atypical antipsychotic (olanzapine, quetiapine, or risperidone)
● Lamotrigine has significant drug interactions with valproate and carbamazepine
● Adding an antidepressant to a mood stabilizer does not have proven effectiveness (NEJM 2007;356;1711)
● Severe depression → consider ECT

Front 227

What are the diagnostic criteria for adjustment disorder?

Back 227

● Clinically significant emotional or behavioral reaction causing marked distress or impairment in social or occupational functioning
● Symptoms develop in response to an identifiable psychosocial stressor (ie divorce, failure at school, peer problems) other than bereavement
● Symptoms begin WITHIN 3 MONTHS of the stressor
● s/s disappear w/in 6mos of disappearance of the stressor
● If the stressor is chronic (ie ongoing parental conflict) then the disorder may last > 6mos and is termed chronic

Front 228

Concern about Benzos → What are the 7 D’s?:

Back 228

(1) Depression of CNS
(2) Dependence
(3) Disinhibition
(4) Deficits in memory
(5) Dizziness
(6) Drug interactions
(7) Dangerous

Front 229

Manic – “DIGFAST” stand for:

Back 229

(D)istractibility
(I)nsomnia
(G)randiosity
(F)light of ideas
(A)ctivity
(S)peech
(T)aking risks

Front 230

How is acute stress disorder different than posttraumatic stress disorder?

Back 230

Acute stress: < 30days (1 month)

PTSD: > 30 days

Front 231

What are the treatment options for PTSD?

Back 231

(1) Psychotherapy including behavioral (exposure) therapy and cognitive therapy
(2) SSRIs – first line
(3) α-blockers (prazosin) improves nightmares & sleep disturbance

Other antidepressants: TCAs (imipramine/amitriptyline), MAOIs

(Benzodiazepines should be avoided in PTSD due to lack of efficacy and potential for abuse)

Mood stabilizers (carbamazepine or valproate) improve impulsive behavior, arousal, and flashbacks

atypical antipsychotics if refractory to other therapies

Front 232

What are 3 important distinctions of dysthymic disorder that distinguish it from MDD in making a diagnosis?

Back 232

(1) Symptoms cannot include suicidal ideation
(2) Symptomatic for more than 2 yrs
(3) No history of major depressive disorder (MDD)

Front 233

What is an imp diff btw manic episode & hypomanic one?

Back 233

Manic episode: will significantly impair pts ability to function

Front 234

What is the 1st line treatment for bipolar disorder?

Back 234

Lithium

Front 235

Should a bipolar pt who is treated with a mood stabilizer & has concurrent depression be started on an antidepressant?

Back 235

No proven effectiveness in adding an antidepressant

Front 236

Bereavement & adjustment disorder share similar time tables in a pt’s symptomatology. What are the key diff btw them?

Back 236

Adjustment disorder impairs ability to function normally, bereavement does NOT
Adjustment d/o may be tied to stressors other than death

Front 237

What should be used for the long-term tx of Panic attacks?

Back 237

SSRI

Front 238

What is the antidote for benzodiazepine overdose?

Back 238

Flumazenil

Front 239

What are the diagnostic criteria for schizophrenia?

Back 239

At least 2 of the following during 1 month period:
● Delusions (irrational belief that cannot be changed by rational argument)
● Hallucinations (most common type is auditory)
● Disorganized speech (ie freq derailment or incoherence)
● Grossly disorganized or catatonic behavior
● Negative symptoms (ie flat affect, poverty of speech, lack of emotional reactivity)
(Only one of the above if required if delusions are bizarre or hallucinations consist of a voice keeping a running commentary on the person’s behavior or thoughts, or 2+ voices conversing with each other)
Social / occupational dysfunction
Duration of at least 6 months

Front 240

What is the difference btw the following disorders?

Schizotypal
Schizophrenia
Schizoaffective
Schizoid
Schizophreniform
Brief psychotic d/o

Back 240

see above

Front 241

What can you see on neuroimaging of a pt with schizophrenia?

Back 241

Enlargement of ventricles & reduction in cortical volume

Front 242

What is the difference btw schizophrenia & delusional d/o?

Back 242

Delusional disorder → non-bizarre delusions, disorganized behavior, no hallucinations, no disorganized speech

Front 243

What drugs are known to cause psychosis in pts?

Back 243

LSD, PCP, Cocaine, amphetamines, steroids
Withdrawal from alcohol, benzos, barbiturates

Front 244

What are the high potency typical neuroleptics?

Back 244

Haloperidol (Haldol)
Fluphenazine (Prolixin)
Thiothixene (Navane)

Front 245

What are the low potency typical neuroleptics?

Back 245

Chlorpromazine (Thorazine)
Thioridazine (Mellaril)
Droperidol (Inapsine)

Front 246

What are the moderate potency typical neuroleptics?

Back 246

Molindone, Loxapine,
Trifluoperazine, Perphenazine

Front 247

What are the atypical antipsychotics (second generation)

Back 247

Olanzapine (Zyprexa),
Quetiapine (Seroquel)
Risperidone (Risperdal)
Clozapine (Clozaril)
Aripiprazole (Abilify)
Paliperidone (Invega)

Front 248

HYQ: A pt previously diagnosed with schizophrenia arrives at the Psych EF with a severe neck spasm that forces his head to be maintained in an unusual position. What’s the tx?

Back 248

Dx: acute dystonia (torticollis in this case) due to antipsychotics
Tx: diphenhydramine (Benadryl) – anticholinergic

Front 249

What features characterize tardive dyskinesia that may develop from the use of high potency typical neuroleptics?

Back 249

Choreoathetosis mvmts of tongue, face, neck, trunk or limbs

Front 250

In what time frame would you expect to see Parkinsonian symptom side-effects in a pt taking antipsychotics?

Back 250

4 days → 4 mos

Front 251

What are the signs & symptoms of neuroleptic malignant syndrome (NMS)?

Back 251

(1) Mental status change – initial symptom in most pts (agitated delirium with confusion rather than psychosis
(2) Muscular rigidity +/- tremor
(3) Hyperthermia greater than 38-40°C
(4) Autonomic instability – tachycardia, labile, or high BP, tachypnea, diaphoresis
(5) Rhabdomyolysis appearing over 1-3 days

Front 252

What is the treatment for NMS?

Back 252

● Stop the offending medication
● Supportive care in the ICU → IVF, lower fever with cooling blankets, ice packs in the axilla, Tylenol
- Reduce HTN with clonidiine and/or nitroprusside ( → cutaneous vasodilation can facilitate cooling)
- DVT prevention with heparin or lovenox
- For agitation use benzos (clonazepam, lorazepam)
● Dantrolene → prevents rigidity & hyperpyrexia by inhibiting calcium release
● Other possible therapies: Bromocriptine, Amantidine (↑ Dopamine)

Front 253

What is the treatment for tardive dyskinesia?

Back 253

Discontinue or decrease dose of neuroleptic
Consider switching to neuroleptic with less extrapyramidal side effects

Front 254

What is the treatment for Parkinsonian symptoms that have developed from neuroleptic administration?

Back 254

Anticholinergics or Dopamine agonists (Bromocriptine, Amantidine)

Front 255

Give examples of negative symptoms of schizophrenia

Back 255

Social withdrawal, Flat affect, Apathy, Anhedonia, Avolition

Front 256

By what mechanism do antipsychotic meds work?

Back 256

Dopamine D2 receptors

Front 257

What are some examples of extrapyramidal side effects?

Back 257

Dystonia/ Parkinsonism
Tardive dyskinesia
Neuroleptic Malignant syndrome

Front 258

What differentiates delusional disorder from schizophrenia or schizophreniform disorder?

Back 258

In delusional disorder the delusions are plausible/ NON-bizarre

Front 259

What is the tx of neuroleptic malignant syndrome (NMS)?

Back 259

Stop the offending medication
Give Dantrolene
Benzodiazepines

Front 260

What 2 side effects should a physician be aware of when using atypical antipsychotics?

Back 260

Weight gain
New onset diabetes

Front 261

What side effects would you expect to develop with administration of thioridazine (Mellaril)?

Back 261

Anticholinergic side effects (dry mouth… etc)

Front 262

HYQ: what is the drug category of choice for the treatment of the negative symptoms of schizophrenia?

Back 262

(+) symptoms → typicals
neg symptoms → atypicals

Front 263

HYQ: What is the DOC for bipolar disorder in a pt with renal failure?

Back 263

Valproic acid or carbamazepine

Front 264

HYQ: What is the treatment of choice for OCD?

Back 264

1st line → SSRI
2nd line → clomipramine

Front 265

HYQ: A pt on haloperidol develops fever, muscle rigidity, confusion and diaphoresis. What is the DOC in the treatment of this pt’s condition?

Back 265

Dx: Neuroleptic malignant syndrome (NMS)
Tx: Dantrolene

Front 266

HYQ: What is the most problematic congenital malformation a/w maternal lithium use?

Back 266

Ebstein’s anomaly

Front 267

HYQ: What is the most common AE of olanzapine (zyprexa)?

Back 267

weight gain

Front 268

What are the symptoms of TCA overdose?

Back 268

Cardiotoxicity, CNS toxicity, Anticholinergic symptoms

Front 269

What drug has SE of priapism?

Back 269

Trazodone

Front 270

What drug lowers the seizure threshold & can be used for smoking cessation

Back 270

Buproprion

Front 271

What drug is an appetite stimulant that is likely to result in weight gain

Back 271

Mirtazapine (Remeron)

Front 272

What drug works well with SSRIs and ↑ REM sleep

Back 272

Trazodone (Desyrel)

Front 273

what drug can be used for bedwetting in children ?

Back 273

imipramine (Tofranil)

Front 274

What are the different treatments for acute dystonia, tardive dyskinesia, and neuroleptic malignant syndrome (NMS)?

Back 274

(1) Acute dystonia → anticholingeric drug
(2) Tardive dyskinesia → discontinue drug & switch to one with fewer exptrapyrimidal effects
(3) NMS → dantrolene

Front 275

HYQ: What is the DOC for mania with psychosis?

Back 275

Atypicals

Front 276

What are the symptoms of serotonin syndrome?

Back 276

(1) Mental status changes: anxiety, agitation, delirium, restlessness, disorientation
(2) Autonomic excitation: diaphoresis, tachycardia, hyperthermia, hypertension, vomiting, diarrhea
(3) Neuromuscular: tremor, muscle rigidity, myoclonus, hyperreflexia
- Ocular clonus: slow, continuous, horizontal eye mvmts
- Spontaneous or inducible clonus
- Babinski signs bilaterally

Front 277

Which neuroleptics are known for their extrapyramidal side effects?

Back 277

High potency typical neuroleptics

Front 278

What are the tx options for generalized anxiety disorder?

Back 278

SSRIs, Buspirone, Venlafaxine, β-blockers

Front 279

How does adjustment disorder with depressed mood differ from major depressive disorder (MDD)?

Back 279

Adjustment disorder: arises w/in 3 months of a stressor & resolves w/in 6 mos of when the stressor is removed
Stressor has to be something other than bereavement
Does NOT meet criteria for MDD