High Yield Psychiatry Shelf Exam Review Notes Part 1

High Yield Psychiatry Shelf Exam Review Emma Holliday Ramahi A smelly 20 y/o college kid’s grades have been declining over the past 2 semesters as he keeps to himself, has flattened affect and no motivation. For the past 6wks, he has locked himself in his dorm room stating President Obama “put a hit on him”. He was told this by 2 voices having a discussion in his head. • • • • • Diagnosis? Schizophrenia, Paranoid type (MC and best prog) Prevalence? 0.5-1% Risk for MZ twin? 50% Sibling? 10% Neurobiology? Positive Sxs-excess DA in limbic area binding D2 recept. Neg Sxs- decr DA in prefrontal cortex/meso-cortical tract *This is why typical antipsychotics make negative sxs worse. Brief Psychotic Disorder (>1wk, <1mo) as had persecutory or the past 3 years. go he started ess, guilt, concentration, SI. as had MDD for 3 eports hearing g him he is nd to kill himself. onvinced Miley love with him but is functional. Delusional Disorder. Erotomanic type. Non-bizzare. Tx w/ therapeutic relationship + meds MDD with Psychotic Features. Delusions are typically mood congruent. * Tx w/ Atypical antipsychotic + SSRI or ECT (esp in preggos) Schizoaffective Disorder. (delusions/hallucinations for >2wks in absence of mood ss) *Tx w/ Atypical antipsychotics + SSRI if depression and + Li if manic. ths? Schizophreniform Disorder (>1m, <6mo) as delusions, ns, and flattened weeks. • A patient delusions 6 months having sad insomnia, • A patient years and voices telli worthless • A man is Cyrus is in otherwise – For 3 mo • A patient hallucinati affect for • DOC for acute agitation IM haloperidol. or psychosis? D2 receptor antagonist. @ mesolimbic tract Æ helps + sxs. Causes hyperprolactinemia and EPS. • MOA? • Low Potency? Chlorpromazine and Thioridazine. Less EPS more anti-Ach • High Potency? Haloperidol and Fluphenazine. More EPS. • If patient has a history Can give decanoate forms ever 2-4wks. of medication nonadherence? • Purple grey metallic rash Chlorpromazine over sun-exposed areas and jaundice? Thioridazine • Prolonged QTc and pigmentary retinopathy? • Pt wakes up with eyes Acute Dystonia. (<12hrs). Tx w/ benztropine or “stuck” looking up or head diphenhydramine “stuck” turned to the side. • Pt reports feeling like they Akathesia. (30-90 days). Tx w/ propranolol (1st line) or benzo “always have to move”. • Coarse resting tremor, Parkinsonism. (>6mo) masked facies, unsteady Tx w/ benztropine/diphenhydramine, amantidine or bromocriptine. NOT L-dopa!! gait, bradykinesia. • After 10 years on Tardive Dyskinesia. (>years) Tx by stopping antipsychotic and fluphenazine, tongue movments and gimacing.switching to and atypical or clozapine. • W/in hours of a haloperidol Neuroleptic Malignant Syndrome. injections, pt has ↑CPK, T = 1st- d/c the offending med. 2nd- cooling blankets and dantroline Na 103F, rigidity, autonomic or bromocriptine (2nd line). instability, and delirium. Remember that metoclopramide, compazine and droperidol can cause. • Atypical agent w/ highest risk Risperidone. But comes in depo shot for EPS and ↑prolactin? • Weight neutral but prolongs Ziprazodone. the QTc? • Weight neutral but increases Aripiprazole. akathesia? • Most assoc w/ weight gain? Olazepine (but #1 S/E is sedation.) • Causes orthostasis and Quetiapine (alpha blocking properties) cataracts? • Good for tx-refractory Clozapine schizophrenia? Ziprazodone and QTz Aripiprazole and Akathesia Buproprion and Clozapine both decrease seizure threshold – Most Common S/E- Sedation, weight gain, ↑blood sugar and lipids – Most Dangerous S/Es- Agranulocytosis, decreased seizure threshold. – Monitoring? CBC Æ ANC qweek for 6mo and x2wks for next 6mo. D/c if WBCs<3000 or ANC<1500 A woman comes in complaining of decreased appetite and 5lb weight loss, no longer enjoys knitting, insomnia and decreased energy, unable to concentrate and feeling guilty for 2 weeks. • Most important 1st question? Assess for suicidal ideation. • RF for this? *Prior attempt*, >45, white, male, serious illness, detailed plan, no support, lack of support, ETOH/drugs • Seen on polysomnogram? Shortened REM latency, more freq REM • Atypical lab test? Dexamethasone suppression test Æ failure to suppress • Medications that might cause this? IFN, beta-blockers, αmethyldopa, L-dopa, OCPs, ETOH, cocaine /amph withdrawal, opiates. • Medical diseases that might cause this? HIV, Lyme, Hypothyroidism, Porphyria, Uremia, Cushings Dz, Watch out for that L-MCA stroke as a cause of depression Liver disease, Huntington’s, MS, Lupus, L • 1st line for MDD– – – – SSRIs. Also indicated for OCD, bulemia, anxiety, PTSD or premature ejaculation H D F H s • Myo BP, • Wh Most amine I) – C • • • • Erec Goo Avo Pou myo drin decongestant or merperidine? . A kid ate some unidentified pills out of grandma’s purse. Grandma has HTN, HLP, fibromyalgia, insomnia and peptic ulcer disease. He now has dry mouth, tachycardia, vomiting, urinary retention, and seizures. “Widened QRS complexes and prolonged QT interval” • What did the kid ingest? Tricyclic Antidepressant • Most common cause of death? Arrhythmia Æ torsades, v-fib, death • Treatment? Activated charcoal if ingestion w/in 1-2hrs. (helps met acidosis and cardioprotective)