Psychiatry Shelf Review Ii

Front 1

Name the 5 neuroleptic-induced syndromes

Back 1

acute dystonic reaction, akathisia, parkinsonism (including rabbit syndrome), Tardive dyskinesia, Neuroleptic malignant syndrome (NMS)

Front 2

What is the timeline for each neuroleptic induced syndrome?

Back 2

ADS (hrs-days), akathisia (days-wks), parkinsonism (wks-mos), TD (mos-yrs)

Front 3

Name 2 SSRI-related syndrome

Back 3

serotonin syndrome, SSRI-discontinuation syndrome

Front 4

Described acute dystonic reaction. Treatment?

Back 4

hrs-days: early EPS characterized by acute msucle spasm, more often d/t typical antipsychotics in a high dose or to an antipsychotic-naive patient. Can be torticollis or oculogyric crisis (painful upward deviations of eyes), and generally involves the neck/face/throat. Occurs w/in hurs but can be delayed up to a day after neuroleptic andminstration. Treat w/ benztropine (central acting anti-cholinergic/histamine) or IM diphenyldramine

Front 5

Which Rx, used as antiemitics, can also cause acute dystonic reactions?

Back 5

promethazine (phenegran), prochlorperazine (compazine), metoclopramide (Reglan).

Front 6

Which is the most dangerous dystonic reaction?

Back 6

laryngospasm (protect the airway)

Front 7

Describe akathisia. Treatment?

Back 7

inner feeling of restlessness + motoric restlessness that makes the person unable to sit still; takes days to weeks to occur. Can be d/t SSRI and by the antiemetics metoclopramide and prochlorperazine. Tx w/ BB, benzo (loraepam) or anticholinergic (benztropine/benadryl).

Front 8

Define parkinsonism (including rabbit syndrome)

Back 8

resembles PD but not idiopathic. Takes weeks to months.

Front 9

Define Tardive Dyskinesia. Management?

Back 9

takes months, usually years to develop. Associated w/ long-term or high dose use of dopamine antagonists. antipsychotics (typicals > atypicals) are usual culprits. Sx include involutnary purposeless reptitive tics and spasms, generally oro-buccal, which are NOT distressing. 50% cases reversible, failure to disclose this SE is a reaction for legal action!! stop offending agent, if 2/2 to antipsychotic, consider a switch to clozapine (least EPS)

Front 10

Define NMS. Rx?

Back 10

usually occurs days after starting antipsychotic or increasing its dose (usually typicals). Often missed or misdiagnosed. 10% fatal. Look for muscle cramps w/ lead pipe rigidity, high fever, autonomic instability, and mental status changes consistent with delirium. Leukocytosis and CPK increases (~20K). treatment involves stopping the offender, bringing down fever and hydrating to prevent renal failure from rhabdo. Rx: dantrolene and bromocriptine (dopamine agonist)

Front 11

What syndrome is very similar to serotonin syndrome?

Back 11

NMS! questions on this typically involve the addition of a new pro-serotonin Rx to a patient who is already on a medication that has pro-serotonin properties (i.e. linezolid, tramadol, SSRI, SNRI, TCA, MAOI) or an insufficient wash-out period b/t Rx (SSRI/SNRI/TCA + MAOI). Sx same as NME but may also have myoclonus (jerks) where NMS is more lead pipe rigidity. Tx by removing offending agents & supporting care. Tx by removing offending agents & supporting care.

Front 12

Define SSRI discontinuations syndrome.

Back 12

abrupt d/c of SSRI leads to the syndrome FLU-like sx. Rx at highest risk if d/c'd abruptly is paroxetine (shortest-half life). similar syndrome occurs w/ SNRIs (esp venlafaxine immediate release aka side effexor). SNRI d/c syndrome more likely to cause paresthesias and "electrical sensations" in extremities (the "zaps").

Front 13

Define Hypertensive crisis. Treatment?

Back 13

Pt on MAOI ingestes tyramine (wine, cheese, fava beans, cured meats, etc.). Can also be with MAOI +meperidine aka demerol). Tx: lower BP w/ phentolamine or Na nitroprusside infusions for true emergencies (diastolic > 120).

Front 14

Why is tyramine c/i in patients taking MAOI?

Back 14

tyramine is an indirect sympathomimetic which is converted to NE pre-synaptically.

Front 15

What serum level does lithium toxicity occur?

Back 15

serum levels > 1.5 (therapeutic levels 0.6-1.2).

Front 16

list symptoms at lithium levels b/w 1.5-2.0.

Back 16

n/v/ataxia, slurred speech, weakness, nystagmus

Front 17

list symptoms at lithium levels b/w 2.0-2.5

Back 17

axnorexia, blurred vision, fasiculations, delirium, stupor, increased DTRs

Front 18

list symptoms at lithium levels > 2.5

Back 18

generalized convulsions, oliguric renal failure.

Front 19

list symptoms at lithium levels > 3.5

Back 19

severe! cardiovascular collapse, potentially lethal.

Front 20

Treatment for mild v severe lithium toxicity?

Back 20

mild/moderate: IVF; severe: hemodialysis (look for seizures, delirium, stupor, coma, etc.)

Front 21

Lithium side effects (therapeutic levels)?

Back 21

hypothyroidism (F>M), nephrogenic DI, acne, weight gain, sedation, benign leukocytosis, psoriasis

Front 22

teratogenic side effects of lithium?

Back 22

ebsteins abnormality (highest risk in 1st trimester; tricuspid valve is displaced down)

Front 23

therapeutic trough levels of valproic acid

Back 23

50-100 (can titrate to side effects)

Front 24

Mild sx of valproic acid toxicity

Back 24

GI upset w/ n/v and confusion

Front 25

Sx of severe valproic acid toxicity

Back 25

hypotension, cerebral edema --> lethargy, coma, cardiac arrest. treat based on symptoms.

Front 26

Side effects of valproic acid (at therapeutic levels)

Back 26

sedation, weight gain and tremor (use propranolol).Alopecia, thrombocytopenia are rare. hepatotoxicity (encephalopathy, edema, jaundice) and pancreatitis (black box warning).

Front 27

T/F: any physician can prescribe clozapine

Back 27

False. need a special license to prescribe it

Front 28

What are the 5 black box warnings of clozapine?

Back 28

1. agranulocytosis 2. seziures 3 myocarditis (may see peripheral eosinophilia) 4. cardiopulmonary collapse 5. increased mortality in treating psychosis related to dementia

Front 29

Define agranulocytosis.

Back 29

absolute neutrophil count (ANC) < 1000.

Front 30

What CBC finds should make you suspicious of possible agranulocytosis in patients using clozapine?

Back 30

If WBC drops 3-4k, stop clozpaine. w/o neutrophils the body can't fight infections ))> malaise, fever, sepsis and death

Front 31

Other side effects of clozapine (not black box)

Back 31

significant drooling (d/t esophageal dysmotolity), orthostatic hypotension and can SIGNIFICANT (40+ lbs) we gain/metabolic syndrome

Front 32

Side effects of Lamotrigine

Back 32

Stevens-Johnson syndrome/toxic episdermal necrolysis; 8% w/ benign rash but up to 1:1000 develop SJS/TEN

Front 33

Major side effects of Carbamazepine

Back 33

aplastic anemia and agranulocytosis

Front 34

Acute dystonic reaction is a typical side effect in what psychiatric drug?

Back 34

typical antipsychotics (short-term use)

Front 35

Tardive dyskinesia is a long term side effect of what drug?

Back 35

typical antipsychotic

Front 36

Major side effect of tarzodone? Nefazodone?

Back 36

priapism and hepatotoxicity