High Yield Psychiatry Shelf Exam Review Notes Part 4

• Best initial treatment of our patient? • What if he’s a Child’s class C cirrhotic? • Most specific test for ETOH consumption in the past 10 days? • Our next patient comes in w/ confusion, ataxia, and you find this on physical exam: Dx? Diazepam or chlordiazepoxide b/c they have 80 & 120hr ½-lives respectively. Lorazepam, oxazepam or temazepam b/c they are glucuronidated prior to elim LOT Less specific- elevated GGT and AST more than twice ALT. AST>ALT by 2x= another indication of alcoholic hepatitis Wernicke Encephalopathy. Caused by thiamine deficiency Give then glucose containing fluids. ataxia, confusion and opthalmaplegia Can progress to Korsakoff’s commons.wikimedia.org – Best 1st step? )- apathy, anter/retrograde amnesia and confabulation. Can see MB atrophy on MRI A patient is brought into the ER in a nonresponsive state. His BP is 100/60, HR is 50, RR is 6. He has multiple track marks on his arms. RRÑ> UNDER 8 INTUBATE • Best first step? Then give (full mu-opiate antagonist) • You realize his pupils are dilated. No. The hypoxia 2/2 respiratory depression can cause hypoxia Does that change your dx? heroin overdose still BUT if he is severely hypoxic, this would also cause him to have mydriasis • What sxs to you expect as he Joint and muscle pain, photophobia, goosebumps, diarrhea, tachycardia, starts to withdraw? Heroin withdrawal is JUICY and WET • Treatment? HTN, GI cramps, dilated pupils, anxiety/depression , Nystagmus= PCP • Pt presents with horizontal Hallucinogen (PCP) intoxication. Can use haloperidol for acute , dilated pupils, psychosis. ataxia and acute psychosis. • Pt presents s/p MVC with Cannabis intoxication. injected conjunctiva, sedation and is asking for Doritos (cool ranch plz). • Pt presents with SI, Cocaine/Amphetamine hypersomnia, depression and withdrawal. anergia. • Pt presents with dilated Cocaine/Amphetamine intoxication pupils, seizure, tachycardia and HTN. – Best 1st test? then – Tx of HTN and tachycardia? . Childhood Development Erikson Birth – 1 year 1 year-3 years 3 years-5 years 6 years- 11 years Trust vs Mistrust Autonomy vs Shame Initiative vs Guilt Piaget Freud Oral Sensorimotorcontrol motor function- object permanence Anal PreoperationalEgocentric Phallic Industry vs Inferiority Concrete Operational- 11 yearsadolescence Identity vs role diffusion Formal Operational- Genital 21 years – 40 years Intimacy vs isolation 40 years- 65 years. Generativity vs stagnation > 65 years Integrity vs Dispair Latent 6-7 years old 11 years old deductive reasoning, hypothetical thinking. An 11 year old boy is evaluated for developmental delay, poor school and social performance. Formal IQ testing reveal his IQ to be 50. He has a macrocephaly, Mild- 55-70 long face and macroorchidism Moderate- 40-55 Severe- 25-40 Profound- <25 • What degree of mental Moderate. retardation? • What is average and standard deviation for IQ? • Where does it go in the Axis II DSM-IV? • What is the most likely X-linked dominal inheritance cause in this case? CGG repeats w/ Cx = Seizures, MVP, dilation of the aorta, tremors, ataxia, ADHD-like behavior. MC cause of inherited MR. A newborn baby has decreased tone, oblique palpebral fissures, a simian crease, big tongue, Down’s Syndrome white spots on his iris Brushfield spots • What can you tell his mother about his expected IQ? • Common medical complications? – – – – – – He will likely have mild-moderate MR. Speech, gross and fine motor skill delay Heart? VSD, GI? Hirschsprung’s, intestinal atresia, imperforate anus, annular pancreas Endocrine? Hypothyroidism Msk? Atlanto-axial instability Neuro? Incr risk of Alzheimer’s by 30-35. (APP is on Chr21) Cancer? 10x increased risk of ALL • Café-au-lait spots, seizures large head. Neurofibromatosis Autosomal dominant Hurler Syndrome • Coarse facies, short stature, cloudy cornea. Autosomal recessive. • Broad, short stature, self- Smith Magenis injurious behavior. Deletion on Chr17 • Hypotonia, hypogonadism, Prader-Willi hyperphagia, skin picking, agression. Deletion on paternal Chr15. • Seizures, strabismus, sociable w/ Angelman episodic laughter. Deletion on maternal Chr15. • Elfin-appearance, friendly, increased Williams empathy and verbal reasoning ability. Deletion on Chr7. • ADHD-like sxs, microcephaly, smooth Fetal Alcohol Syndrome philtrum. Most common cause of mental retardation. • Seizures, chorioretinitis, hearing Congenital CMV infection. impairments, periventricular calcifications, petechiae @ birth, hepatitis. • Seizures, hearing impairments, cloudy Congenital Rubella Syndrome cornea/retinitis, heart defects, low birth weight. • Abnormal muscle tone, unsteady gait, Cerebral Palsy from birth asphyxia. seizures, mental retardation or learning disability. • IUGR, hypertonia, distinctive facies, limb malformation, self-injurious behavior, hyperactive. psychnet-uk.com Cornelia de Lange • Coloboma, heart defects, choanal CHARGE atresia, growth retardation, GU anomalies, ear deformity and deafness. Chr 8. • Autism spectrum sxs, heart disease, DiGeorge palate defects, hypopastic thymus, hypoCa. Chr 22 deletion. • Vomiting, seizures, lethargy, coma. Maple Syrup Urine Acidosis w/ stress, illness. Causes Disease neurological damage. • Exclusively in girls, normal Rett Syndrome development for 6-8mo, then regression, handwringing, loss of speech and use of hands. X-linked dominant deletion of MECP2. • Normal development until age 2 then Childhood Disintegrative major loss of verbal, social skills w/ Disorder autistic like behavior. • Lack of mother-child eye contact, Autism language delay/repetitive language, peroccupation w/ “parts of toys” before age 3. • Problems with social skills (usually Asperger recognized in preschool) w/ reserved verbal ability. preserved A 7 year old boy is brought in by his parents. They report he must be told several times to complete his chores, they cannot get him to focus on completing his homework (he is easily distracted), and that he often loses his shoes, pencils, books, etc. • • • • • Diagnosis? Normal, age appropriate behavior. Next best step? Get information from the child’s school/teacher Risk factors for ADHD? 77% heritability. LBW, tobacco/ETOH exposure Comorbid conditions? Treatment? MethylphenidateAmphetamineAtomoxetineRandoms- ADHD Meds Medication Methylphenidate (Concerta, Ritalin) MOA Blocks DA reuptake Side Effects Nausea, ↓appetite, incr HR and BP, stunted growth Amphetamine (Adderall) Blocks DA/NE reuptake & stimulates release Atomoxetine (Strattera) BP meds (clonidine, guanfacine) NE reuptake inhibitor. Non stimulant Alpha 2 agonists, reduce peripheral SNS Antidepressants (SNRIs, TCAs, MAOIs) Prevents NE reuptake and Dietary restictions w/ MAOI. increases in synapse Arrhythmias in TCAs Dry mouth, insomnia, decreased appetite Decreased BP. Causes sedation A 14 year old boy is sent for court mandated counseling. He stole his neighbor’s lawn mower and then set fire to his tool shed. He has a 5 year history of truancy from school and assaulted a 13 year old school mate. Conduct Disorder. Need sxs for 6mo. Comorbid substance abuse. May progress to anti-social personality disorder. A 14 year old boy is brought in by his grandmother. For the past year, he has been getting in trouble at school for being argumentative and disrespectful to his teachers. He defies the rules she sets for the house and often deliberately annoys her. Oppositional Defiant Disorder. Need sxs for 12mo. Stops just short of breaking the lay or physically harming others. A 9 year old boy is sent to counseling at the recommendation of his teacher. She states that at least once a day he makes loud grunting noises and hand movements that are disruptive to the class. • Dx? For tics to qualify as Tourettes they must occur at least once a day for 1 year w/o a tic-free period longer than 3mo. • Comorbid conditions? Look for the compulsions of OCD • Tx? – First line? Clonidine 2/2 relatively benign S/E profile – Most Effective? Haloperidol or pimozide- DA-receptor antagonists. • 7 year old complains of frequent abdominal pain resulting in many missed school days. He never gets the pain on the weekends or in the summer. • 6 year old adopted child is brought in because she has not formed a relationship with her adoptive parents. She is inhibited and hyper vigilant. • An 18mo old baby has recently been regurgitating and re-chewing her food. She had previously been eating normally. • 6y/o stools in her clothes once every 2 weeks. – Next best test? Check for fecal retention. – Tx? Behavioral modifcation that only Separation Anxiety Disorder Reactive Attachment Disorder Rumination Disorder. Encopresissoiling of underwear • 6 y/o urinates in her clothes once a day. – Next best test? UA and urine culture. – Tx? Alarm and pad for 6wks. TCAs reduce bed wetting but relapse is common. DDAVP has the same prob + S/E = headaches, nausea, and hyponatremia.