• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/161

Click to flip

161 Cards in this Set

  • Front
  • Back
Differentiating psychotic disorders?
Duration
Positive symptoms
associated with dopamine receptors, delusion, disorganized, hallucinations, agitation.
Negative symptoms
associated with muscarinic receptors, flat affect, social withdrawl, anhedonia, apathy, poverty of thought, Tx with atypical antiphsycotics
Schizophrenia
positive symptoms that affect social/occupational function for longer than 6 months. Males ~15 Females ~25
Schizophreniform
less than 6mths more than 1mth. 2/3 will progress to schizophrenia.
Brief Psychotic Disorder
<1mth with return to baseline, look for stressful life event
Psychotic symptoms with no impairment of baseline functioning.
Delusional disorder, or Personality disorders, schizotypal PD. Tx is Psychotherapy, they will not respond to antipsychotics.
Differential and must be ruled out?
substance abuse -drug screen, siezure -temporal lobe epilepsy (hallucinations)
Important in the workup of schizophrenia
suicidal ideation, 50% of Schizo's attempt suicide in there lifetime. 10% successful.
Better prognosis for schizophrenia
females and paranoid schizophrenia
Poor prognosis of schizophrenia (5)
early age, negative symptoms, poor premorbid funcioning, family history, disorganized or deficient subtype
Managment of schizophrenia?
1-hospitalize? 2- Agitated-Benzo's, start antipsychotics. 3-longterm psychotherapy
how long do you give antipsychotics
6mth, long term if history of repeat episodes
Indications for antipsychotics
1-quieting effect in acute psychotic attacks and delay relapse. 2-sedation when benzo's contraindicated 3-movement disorders: Huntington's, Tourette disordder
Which antipsychotic do you use?
based on side effect profile, not efficacy
High potency antipsychotics? disadvantage? advantage?
Fluphenazine, Haloperidol: Disadvantage:Extrapyramidal systems. Advantage: less sedating fewer anticholinergic effects, less hypotension, useful as depot injection, IM for acute psychosis.
Low potency antipsychotics? disadvantage? advantage?
Thioridazine, chlorpromazine: Disadvantage: anticholinergic effects, sedating, postural hypotension Advantage:Less likely to cause EPS.
Atypical antipsychotics? disadvantage? advantage?
Risperidone, olanzapine, quetiapine, clonzapine: Disadvantage: Clozapine reserved for tx resistant px bc of agranulocytosis Advantage: DOC for initial therapy, greater effect on negative symptoms, little or no risk of EPS.
What do you need to do before using clozapine?
always do CBC before starting this medication
Side effects of low potency antipsychotics?
alpha blockage-orthostatic hypotension, anticholinergic effect-acute urinary retention, dry mouth, blurry vision and delerium.
Side effects of Thioridazine? what do you do if they present?
1-prolonged QT and arrhythmias. Chest pain, SOB or palpatations GET AN EKG 2-abnormal eye pigmentation, routine eye exams.
Common reason for noncompliance in males?
Impotence and inhibition of ejaculation from a-blocker effect
Common reason for noncompliance in females?
Hyperprolactinemia leading to weight gain.
A newly diagnosed schizophrenic patient complains of insomnia. What is the most appropriate antipsychotic to initiate therapy?
Olanzapine, quetiapine, ziprasidone, aripiprazole are used if insomnia is a problem
A schizophrenic px has been maintained on olanzapine for the past 6 mths. He is complaining of daytime sedation, and he has lost 2 jobs in the past month because of impaired performance. What is the next step in managment?
Change to risperadone, a first line medication for the treatment of schizophrenia when sedation is a problem.
Young male schizophrenic, presents with muscle spasm, difficulty swallowing. Dx? time frame? what do you do next?
Acute Dystonia, days, reduce the dose and Rx: anticholinergics, benzotropine, diphenhydramine, trihexyphenidyl
Elderly Schizophrenic, presents with tremors, rigidity, Dx? what do you do next?
Bradykinesia, weeks, reduce the dose and Rx: anticholinergics, benzotropine, diphenhydramine, trihexyphenidyl
Schizophrenic, presents with motor restlessness, may look like anxiety or agitation. Dx? what do you do next?
Akathesia, months, reduce the dose and Rx: anticholinergics, benzotropine, diphenhydramine, trihexyphenidyl
Schizophrenic, presents with choreoathetosis and other involuntary movements, Dx? what do you do next?
Tardive dyskinesia, years, stop older antipsychotics, switch to newer antipsychotics. NOTE symptoms may worsen after medication discontinuation.
Muscle rigidity, hyperthermia, volatile vital signs, altered LOC, increased WBC and CK Dx? Next step?
Neuroleptic malignant syndrome, stop antipsychotic and transfer to ICU for monitoring, mortalitiy rate is 20%.
35yo male presents with poor adherence to chlorpromazine and haloperidol. He complains of tics and other uncontrolled movements. His wife reports that even when he takes his medications, they don't appear to help his paranoia. What is the next step in management?
Change to clozapine, is the most effective antipsychotic for schizophrenia and also has no incidence of movement disorder. It is a second line therapy because of the risk of seizures and agranulocytosis. Monitor CBC for bone marrow suppression.
78yo male with a slow growing stomach tumor in palliative care is brought in by the family, who has noticed increased sedation and difficulty eating. They are concerned bc he continues to lose more weight. On examination, he has repetitive movements of his lips tongue. He has limited facial expression. His medications include morphine, metoclopramide, and hydrochlorothiazide. Which of the following is the most appropriate management?
Discontinue metoclopramide, chronic use of dopamine antagonists can result in tardive diskinesia.
define anxiety disorder
anxiety that interferes with daytime functioning and is not due to any other identifiable causes of symptoms
conditions that must be ruled out before you diagnose any anxiety disorder
Medical causes: Hyperthyroidism, Pheochromo, excess cortisol, heart failure, arrhythmias, asthma, and COPD. Drugs: corticosteroids, cocaine, amphetamines, and caffiene, as well as withdrawl from alcohol and sedatives.
adjusment disorder, define and tx
normal reaction to profound change in person's life (divorce, migration, birth of handicap child) Not a true anxiety disorder. Tx counseling do not give medication.
panic disorder, define and tx
brief attacks of intense anxiety with autonomic symptoms. Episodes occur regularly, without obvious precipitant and in the absence of other psychiatric illnesss. Tx cognitive behavioral therapy and/or relaxation training and desensitization. SSRI, benzo, imipramine, MAOIs
Phobic Disorder define differentiate from PTSD/ASD and tx
persistent, unreasonable, intense fear of situations, curcumstances or objects. PTSD, Acute stress disorder both have a history of a traumatic event (life threatening) Tx is usually exposure therapy, benzos or bblockers.
Agoraphobia
fear or avoidance of places due to anxiety about not being able to escape.
Social Phobia define and differentiate from avoidant personality disorder.
fear of humiliation or embarrassment in either general or specific social situation, the patient knows that the responce is excessive and unreasonable. Differentiate from avoidant personality disorder, where the person does not believe the avoidance is excessive or unreasonable.
A 19yo ballet dancer presents because of extreme anxiety on stage. She reports that she fell 3mths ago at a national ballet competition and since then suffers extreme anxiety, trembling, diaphoresis and breathlesssness when she has to go on stage. She denies any problems with ballet practice and has no other medical problems. Which of the following is the diagnosis?
Panic disorder, presents with a clear precipitating event which subsequently results in anxiety in similar circumstances.
Obsessive compulsive disorder define and tx
individual recognizes that the behavior is unreasonable and excessive. Px with Tourette syndrome often have OCD. Depression and substance abuse are common. Tx behavioral psychotherapy and SSRI's or clomipramine.
Misdiagnosis of OCD
Obsessive symptoms in psychotic disorders, differentiate from OCD by looking for a lack of insight and loss of contact from reality.
Acute Stress Disorder and PTSD define
Following a life threatening event. Less than one month ASD, lasting longer than one month PTSD.
Key symptoms in ASD/PTSD
reexperiencing of traumatic event, avoidance of stimuli, increased arousal (anxiety, sleep disturbance, hypervigilance, emotional lability)
Treatment for ASD/PTSD
Benzodiazapines for acute anxiety symptoms. SSRIs for long term therapy.
A school bus involved in a major collision. Two children are killed, and seven others are injured. What is the most important therapy to prevent PTSD?
Group counseling is the most effective therapy.
Generalized anxiety disorder define, coexistance with? and tx
anxiety that occurs daily for more than 6 mths. No single event or focus. Coexists with major depression, specific phobia, social phobia and panic disorder. Tx supportive psychotherapy, relaxation training. Medication, SSRIs venlafaxine, buspirone and benzodiazapines.
Benzodiazepines
Do not change dosages abruptly. Use the lowest dose in the elderly. Advise against using machinery or driving. Shortest to longest half life. Alprazolam, Lorazepam, Diazepam
Buspirone
Therapeutic effect can take up to 1 week. safely used with other sedative hypnotics (no additive effect) Best option for people in occupations where driving or machinery. No withdrawl syndrome.
Major depressive disorder
depressed mood or anhedonia lasting at least 2 weeks.
SIGECAPS
sleep, interest, guilt, energy, concentration, appetite, psychomotor activity, suicide
Differential in MDD, 4 major ones.
MOPS up depression, Medication(corticosteroids, bblockers, antipsychotics, reserpine). HypOthyroidism: TSH, tx thyroxine. Parkinson's disease. Substance disorder: alcohol, amphetamines.
Tx of Major depressive disorder.
1-suicidal or homicidal paranoia HOSPITALIZE. 2-Antidepressant medication SSRI 3-Benzodiazepine if agitated. 4-Electroconvulsive therapy, best choice if px is suicidal.
Dysthymic disorder define differential tx
low level depression symptoms, present on most days for 2 years. Differential: Seasonal affective disorder Tx long term individual, insight oriented psychotherapy
Seasonal affective disorder define tx
depressive symptoms in winter months, absence during summer months. Tx phototherapy or sleep deprivation.
Bipolar disorder define, common differential
Episodes of depression, mania or mixed symptoms for at least 1 week. Rapid cycling bipolar is indicated by >4 episodes of mania per year.
MOST COMMONLY MISSED DIAGNOSIS ON USMLE - differential
mistaken for depression or mania alone, always work up if these are present. Focus on history, if suggest drug use - do a drug screen. Elevated blood pressure or low TSH, consider medical conditions: pheo or hyperthyroidism.
Steps in management of acute mania. 5 steps.
(Help Manage Acute Peoples manic Disorder) 1-Hospitlaize 2-Mood stabilizers DOC lithium 3-Antipsychotics until acute mania is controlled DOC rispiradone. 4-IM depot Phenothiazine in noncopliant, manic patients. 5-Antidepressants may be given only if history of recurrent episodes of depression, and only wiht a mood stabilizer.
What is the most common cause of progression to rapid cycling bipolar?
Use of antidepressants, do not give unless previous severe depressive episodes and if given only give for a few weeks.
How should you manage rapid cycling bipolar?
Gradually stop all antidepressants, stimulants, caffiene, benzos and alcohol.
What other medical conditions predispose a patient to rapid cycling bipolar?
Hypothyroidism, check TSH and replace with thyroid hormones if needed.
What drug has been shown to prevent suicidal ideation in bipolar disorder?
Lithium
32yo known bipolar px who is undergoing maintenance therapy with lithium presents with a positive pregnancy test. How will you manage this patients bipolar disorder?
Discontinue lithium, choose ECT therapy for first trimester px with manic episode, Lamotrogine for 2-3rd trimester px.
Cyclothymia define and tx
Recurrent episodes of depressed mood and hypomanic mood for at least 2 years, mild bipolar. Tx psychotherapy first step in management, many function without medications. NaValproate/Valproic acid combo- Divalproex is given when functioning is impaired, better than lithium for cylcothymia.
Grief vs Depression (symptoms, guilt, suicide, time, baseline return, tx)
Same symptoms in both. Grief: symptoms wax and wane, guilt less common, suicide less often, symptoms may last up to a yr, px returns to baseline functioning within 2 mths. Tx is supportive. (depresion is opposite tx with antidepressant meds)
32yo woman who recently gave birth 4 months ago is brought in by her husband because of depressed mood. Husband reports that she has been depressed since the birth of there child, refuses to eat, has trouble sleeping, unable to concentrate. The woman reports lost of intrest in everything ans sometimes can't even get out of bed. She reports that she's recently had visions of seeing her deceased mother talking to her and criticizing her skills as a new mother. She also admits that she hears her voice talk to her constantly too. She denies homicidal or suicidal ideation. Which of the following is the best initial treatment?
Rispiridone, mood and psychotic symptoms respond to both antidepressants and antipsychotic meds. TREAT WORST SYMPTOM FIRST, here it is psychosis.
45yo presents with 2 months after the sudden loss of her son in a car accident. She reports "not being able to cope well". She is constantly teary, has lost her appetite and has decreased 2 dress sizes. She finds herself laying out a dinner plate every night for him. Recently, she believes she has heard his voice and every night she has nightmares about the car accident. She denies suicidal ideation. Which of the following is the most appropriate next step in management?
Supportive therapy, all normal grief reaction symptoms. If symptoms last longer than 6 months may be classified as major depressive disorder, tx is antidepressants.
Postpartum blues, onset, emotion to baby, symptoms, treatment?
after any birth, cares about baby, mild depression, self-limited, no tx necessary.
Postpartum depression, onset, emotion to baby, symptoms, treatment?
Usually after 2nd birth, thoughts about hurting the baby, severe depression, antidepressants.
Postpartum psychosis, onset, emotion to baby, symptoms, treatment?
Usually after 1st birth, thoughts about hurting the baby, psychotic symptoms along with severe depressive symptoms, mood stabilizers or antipsychotics and antidepressants. (BREASTFEEDING do ECT, no meds)
Managment of suicidal patient 2 parts.
1-Risk factors 2-Emergency assessment
Risk factors for suicidal patient.
History of suicide threat or attempt is most important predictor of suicide. family history, demoralization, schizo/borderline/antisocial PD, drug/alcohol use, Male >65yo, divorced or widowed, chronic physical illness, low job satisfaction ro unemployment.
Emergency assessment for suicidal patient. 7points.
1-take all threats seriously 2-detain and hospitalize 3-never transport without trained personel 4-do not identify with the px. 5-do not leave unsupervised 6-TOC: Psychotherapy + Antidepressant medications (SSRI) 7-Acute, severe risk of self harm TOC: ECT.
Indications for ECT, complications
1-Major depression unresponsive to meds 2-High risk for immediate suicide 3-Contraindication to antidepressant medication 5- good responce to ECT in the past. Complication: Transient memory loss, resolves after several weeks. ECT induces transient intercranial pressure, caution if px has space occupying lesion.
Guidlines for antidepressants?
SSRI first line, choose based on side effect profile, switch if px does not respond after 8 weeks or cannot tolerate side effects, treat px for 6 mths and consider long term for multiple episodes,
safe in pregnancy
SSRI's and TCA's safe in pregnancy except paroxetin-paxil
px concerned with weight gain or sexual side effect?
Buproprion
px poor appetite, weight loss, or insomnia
Mirtazapine
px severe insomnia
Trazodone
young male recently started on antidepressants develops prolonged erection. What is the antidepressant he was most likely taking?
Trazadone
elderly px presents with depression and agitation. What is the most appropriate medication?
antidepressant with sedative effects, doxepin, trazadone
25yo male with history of seizures is diagnosed with depression. Medication he should avoid?
Buproprion and TCAs, first line tx for this patient is SSRI
Middle aged woman is brought into ER with confusion and disorientation. An overdose of prescription medication is suspected. BP 90/53, HR 111bpm, Pupils are dialated, mucous membranes are dry, she has facial flushing. follow up questions....
Cause of acute intoxication?
TCA, anticholinergic side effects and alpha blocking. Peripheral vasodilation, hypotension. affect Na channels in cardiac tissue.
Most important test to determine severity and prognosis?
EKG, serious complication is ventricular tachycardia and fibrillation
EKG shows PR and QRS prolongation and sinus tachycardia. Most appropriate next step?
Sodium bicarbonate, alkalinize blood, uncouple TCA from myocardial tissue and increases extracellular sodium concentration.
42yo woman history of HTN, DM, and depression presents to clinic with dry eyes and dry mouth. Her medications include hydrochlorothiazide, metformin, amitryptaline. Which is the next step in management?
Discontinue amitryptaline and change to sertraline
Lithium side effects? Most common? Dose related? Complication?
Most common acne and weight gain. Dose related: tremors, GI distress, headaches (decrease dose). Hypothyroidism in 5%. Medication induced DI-polyuria. Cardiac defects in first trimester.
Divalproex?
First line in rapid cycling bipolar disorder, or when lithium is ineffective, impractical or contraindicated.
Carbamazepine?
Second line for bipolar disorder, not commonly used bc of agranulocytosis and sedation.
MEDICATION OVERDOSES
Lithium toxicity: who do you see it in? symptoms? management?
Elderly or px with renal failure or hyponatremia. n/v, acute disorientation, tremors, increased DTR's and even siezures. TOC dialysis
Neuroleptic malignant syndrome: type of patient-2? symptoms? management?
Px recently started taking antipsychotics, (haloperidol) or parkinson's px recently stopped levodopa. Look for high fever, tachycardia, muscle rigidity, altered consciousness and autonomic dysfunction. (unrelated to dosage, 20% mortality rate). 1- transfer to ICU, 2-discontinue antipsychotic, 3- bromocripine to overcome dopamine receptor blockade, 4-muscle relaxant dantrolene or diazepam to reduce msl rigidity.
Serotonin syndrome: type of patient? symptoms? management?
History of SSRI use, use of migrane medication or MAOI. Agitation, hyperreflexia, hyperthermia, msl rigidity with volume contraction (sweating and insensible fluid loss) Management: 1-IV fluids 2-cyproheptadine to decrease serotonin production 3-benzo's reduce msl rigidity.
MAOI induced hypertensive crisis: type of patient? symptoms? management?
acute hypertension and history of MAOI use and antihistamines, nasal decongestants, concurrent TCA or consumption of tyramine rich foods (cheese, pickled foods).
TREATMENT OF MAOI INDUCED HTN??????????????
What is the first assessment prior to prescribing antidepressants?
Suicidal Ideation, there is an increased risk in suicidal ideation within the first 2 weeks. If acutely suicidal: Hospitalize and ECT.
47yo presents with shortness of breath, chest pain, abdominal pain, back pain, double vision, and difficulty walking due to weakness in the legs. She remembers being sick all fo the time for the past 10yrs. According to her husband, she constantly takes medications for all of her ailments. She has visited numerous physicians and none has been able to diagnose her condition correctly. Next step in management?
Schedule regular monthly visits.
Somatization disorder define? management?
No medical explanation. At least 4 pain symptoms, 2 gastrointestinal symptoms, 1 sexual, 1 pseudoneurologic to make diagnosis. 1-single physician 2- schedule brief monthly visits 3-avoid diagnostic testing or therapies. 4-individual psychotherapy 5-do not hospitalize.
Conversion disorder: define? management?
one or more neurologic symptoms that cannot be explained by any medical or neurologic disorder. Px are unconcerned about there impairment. Rule out other medical conditions first. Tx 1-supportive physician-patient relationship 2-psychotherapy.
Hypochondriasis: define? management?
Falsly believes that he has a specific disease, despite repeated negative medical tests and workup. Symptoms present for at least 6 months and physician's reasurance has failed to relieve concerns. Tx 1-identify primary caregiver 2-schedule regular routine visits 3-provide psychotherapy
Factious and Malingering Disorders: define? management?
Intentionally feigned symptoms. 1-TOC Supportive psychotherapy 2-do not confront or accuse 3-Provide the minimum amount of treatment and workup.
Factitious disorder is seen in what type of patient?
Px that has seen many doctors, visited many hospitals, has a large amount of medical knowlege and demands treatment. Typically agitated and threaten litigation if tests return negative. Factitious disorder by proxy, faked by another person.
Malingering is seen in what patient?
Obvious gain (shelter, medication, disability insurance) px is more preoccupied with reward or gain than alleviation of presenting symptoms.
23yo nursing student presents to the emergency department with fever and chills at home. She has had multiple admissions in other hospitals because of pheumonia and chronic pain problems. She was found to be tampering wiht the blood culture bottles and dipping her temperature thermometer in hot water. Which of the following is the most likely diagnosis?
Factitious disorder.
46yo homeless man presents to the hospital reportingthat he had a siezure this morning. He is adamant that he be admitted, however, he refuses all bloodwork and imaging studies. He cannot answer questions about the seizure. Instead he demands to be admitted and is wondering shy you're taking so long. When you ask about his social history, he admits that he is homeless at the moment as he was "kicked out of the shelter" because of drug taking and alcohol abuse. Which of the following is the most likely diagnosis?
Malingering
Anorexia and Bulemia nervosa management?
1-Hospitalize for IV hydration if electrolyte disturbances are present. 2-Olanzapine helps with weight gain. 3-SSRI (fluoxetine) prevents relapses, 4-Prescribe behavioral psychotherapy.
Anorexia seen in what type of patient?
young female who is underweight due to food restriction and excessive exercise and has not had a menstrual period for 3 cycles or more. Px may purge (50%)
Bulimia seen in what type of patient?
young female in normal weight range, frequent binge eating followed by guilt, anxiety, self induced vomiting, laxitives, diuretics or enema use.
Electrolyte disturbance seen in bulimia?
Emesis: hypocloremic metabolic alkalosis and hypokalemia. Ipecac (emetic) risk of cardiomyopathy. Laxitive abuse: metabolic acidosis.
Body dysmorphic disorder: seen in? Tx?
young woman preoccupied with imagined or slight defect in appearance, causing impaired ability to function in a social or occupational setting. Tx 1- First line, high dose SSRI
Intermittent explosive disorder: define and tx?
aggression out of proportion to stressor, patient does not believe there impusle is excessive. if there is a history of drug use IED is not the dx. TOC: SSRI and mood stabilizers
Most common type of child abuse? Physicians role? Who is at risk?
Physical is MC. Neglect, sexual, mental cruelty. Mandatory reporting up to 18yo. Separate the child, hospitalize if need be. Younger than 1, stepchildren, premature, very active, "defective" children.
Most common type of elderly abuse? Physicians role? Who is at risk?
Neglect is MC (50%). Physical, psychological, financial. Report all suspected cases. Protect the px from abuser and hospitalize if needed. Caretaker/spouse is likely source.
Most common type of spousal abuse? Physicians role? Who is at risk?
Physical is MC, number one cause of injury to american women. psychological, financial. Provide information and counseling. More frequent in families with drug/alcoholism, victims of violent homes, married at young age, dependant personality, pregnant- last trimester.
Personality disorder clusters. TOC? Tx?
Wierd-A Wild-B Wimpy-C TOC: Psychotherapy. Cluster B, use of mood stabilizers and antidepressants if needed.
62yo man lives in an apartment and constantly accuses his neighbours of stealing his mail and prying into his apartment. He believes that all his neighbors are conspiring to have him removed from the building. Dx? Defense mechanism?
Paranoid PD, main defence mechanism is projection.
68yo man lives in the countryside maning a lighthouse near a remote village. He is seen in town 2-3 times a year to purchase supplies. He has no known friends or family. Dx? Defence mechanism?
Schizoid-Hermitoid PD, main defence mechanism is projection.
28yo man lives in a small coastal town attempting to start his own internet herbal buisness. He believes that the herbs have magical powersand he sells their magical properties of healing for the living. He believes that spirits are guiding him to wealth. Dx?
Schizotypal PD
30yo woman presents to the doctor's office dressed in a sexually seductive manner and insists that the doctor comment on her appearance. When the doctor refuses to do so she becomes upset. Dx?
Histrionic PD
30yo female presents to the clinic. She reports that she has been to many doctors, she said thay ere all wonderful until they started ignoring her or cutting her visits short, when she realized what terrible doctors they were. She starts the visit saying that the assistant at the front desk is the "worst she's ever seen" because she didn't smile at her. The other assistant was just wonderful accoding to her. Dx? Defence Mechanism?
Borderline, main defence mechanism is splitting.
26yo male caught lighting forest fires during a recent spate. He has a history of legal problems since childhood. He has history of legal problems since childhood. He reports that his mother is to blame. He denies feeling regret. He has no friends and is found to be hostile to everyone at the police station. Dx?
Antisocial PD
A patient is in the hospital for chest pain and becomes agitated because he feels he is not getting enough attention. He reports that he is an important CEO and demands a special VIP room and more consideration and a dedicated nurse to attend his needs. Dx?
Narcissistic PD
45yo single male fears an upcoming social party being hosted by his parents. He dreads having to meet other people and doesnt feel confortable speaking with others. He is planning on staying at home to avoid speaking to others. Dx?
Avoidant PD
38yo male presents wiht his wife for marital counseling. The wife reports that he is inflexible and has unrealistic demands of orderliness and an inflexible schedule. Both partners agree that his demands are causing marital problems. Dx?
Obsessive complusive PD, individual preocupied with orderliness, perfectioinism, and control. Different from Obsessive compulsive disoder.
Hypochondiasis what is the underlying PD?
Dependant, Histrionic or borderline.
Self aggression or self mutilation what is the underlying PD?
passive aggressive PD (acting out)
Define alcohol dependance?
frequent use resulting in TOLERANCE and physical and psychological dependance.
Define alcohol abuse?
failure to fulfill obligations, legal troubles, or exposure to physically dangerous situations.
Most accurate diagnosis of alcohol abuse?
CAGE questions, Cut down? Annoyed by criticizim? Guilty? Eye opener to steady nerves or alleviate hangover?
Initial managment of alcohol abuse?
1-Order Toxicology: look for other drugs. 2-Labs: Look for secondary effects of alcohol use (GGTP, AST, ALT, LDH) 3-IV drug use? HIV, Hep B/C, PPD
Acute outpatient management?
1-prevent further ETOH intake 2-prevent individual from driving car, operating machinery 3-sedate patient if she becomes agitated 4-transfer to inpatient.
Acute inpatient management?
1-look for withdrawl symptoms 2-prevent wernicke-korsackoff, give IV/IM thiamine and Mg ASAP; B12 and Folate. 3-Chlorodiazepoxide or Diazepam if liver toxicity give lorazepam or oxazepam 5-do not give siezure prophylaxis, treat each one with diazepam 6-HALDOL IS NEVER THE ANSWER, reduces siezure threshold.
Chronic maintenance management?
1-refer to inpatient rehabilitation or outpatient group therapy AA most effective 2-Never give drug therapy without group psychotherapy 3-Naloxone and acamprosate decrease relapse rate only when given with psychotherapy. 4-Disulfram has poor compliance and hasn't been shown to be effective.
38yo male presents to the ED with acute-onset, right lower quadrant abdominal pain. He undergoes an appendectomy. Two days after surgery, he is found in his room disoriented and agitated, and he is claiming to see snakes in his room. Physical exam reveals tachycardia and temp of 101. Which of the following is the most likely diagnosis?
Delirium Tremens
Insomnia, tremulousness, mild anxiety, headache, diaphoresis, palpitations? last drink?
Mild withdrawl symptoms, 6 hrs
Visual hallucinations, auditory or tactile hallucinations?
Alcoholic hallucinations, 12 hrs NOTE: if generalized cloudy sensorium, this is not the answer.
Tonic clonic siezures?
Withdrawl siezures, 48 hrs. Must get a CT scan if repeated siezures to rule out structural or infectious cause.
Hallucinations, disorientation, tachycardia, hypertension, low grade fever, agitiation and diaphoresis?
Delirium Tremens >48hrs, time of onset is important!! 2 days after las drink.
Talkative, sullen, gregarios, moody. Substance? Tx?
Alcohol intoxication, tx Mechanical ventilation if severe.
Tremors, hallucinations, siezures, delirium. Tx?
Alcohol withdrawl, tx Long acting benzo's, no siezure prophylaxis. Disulfram or naloxone for adjunct to supervised therapy after acute withdrawl.
Euphoria, hypervigilance, autonomic hyperactivity, weight loss, pupil dilation, disturbed perception, stroke, myocardial infarction. Dx? Tx?
Amphetamine/cocaine intoxication, Short term antipsychotics
Anxiety, tremors, headache, increased appetite, depression, risk of suicide. Dx? Tx?
Amphetamine/cocaine withdrawl, antidepressants
impaired coordination, impaired time perception, social withdrawl, increased appetite, dry mouth, tachycardia, conjunctival redness? Dx? Tx?
Cannabis intoxication, no tx
Ideas of reference, hallucinations, impaired judgment, dissociative symptoms, pupil dilation, panic, tremors, incoordination. Dx? Tx?
Hallucinogens, LSD. Tx supportive counseling, antipsychotics, benzodiazepines.
Belligerence, apathy, assaultiveness, impaired judgement, blurred vision, stupor, coma. Dx? Tx?
Inhalants. Tx antipsychotics if delirious or agitated.
apathy, dysphoria, constricted pupils, drowsiness, slurred speech, impaired memory, coma, death. Dx? Tx?
Opiates, Naloxone
Fever chills, lacrimation, runny nose, abdominal cramps, muscle spasm, insomnia, yawning? Dx? Tx?
Opiate withdrawl, tx Clonidine, Methadone
Panic reaction, assaultiveness, agitation, nystagmus, HTN, seizures, coma, hyperacusis. Dx? Tx?
PCP intoxication, Talk down, benzodazepines, antipsychotics, support respiratory function
Inappropriate sexual or aggressive behavior, impaired memory or concentration. Dx? Tx?
Barbituates and Benzo's Intoxication, Tx Flumazenil
Autonomic hyperactivity, tremors, insomnia, seizures, anxiety. Dx Tx?
Barbituates and Benzo's Withdrawl Tx long acting barbituates.
Alpha 1 blocker
impaired ejaculation
SSRI's
inhibit orgasm
b-blockers
erectile dysfunction
Trazadone
priaprism
Dompamine agonists
increase erection and libido
Neuroleptics
erectile dysfunction
Paraphilias define tx
recurrent, sexual arousing preoccupation for more than 6mths. Impairment in px level of functioning. Tx individual psychotherapy and aversive conditioning. If sever give antiandrogens or SSRI's to decrease sexual drive.
Most common paraphilia?
pedophilia
act of humiliation
masochism
physical or psychological suffering of a victim
sadism