High Yield Psychiatry Shelf Exam Review Notes Part 3

A 18 y/o F presents with no menstrual cycle for 3mo. A pregnancy test is negative but her BMI is calculated to be 17. Her teeth are eroded and she has calluses on her knuckles (Russel sign). • Laboratory abnormalities- Anorexia, purging type Hypotension, Bradycardia, Hypothermia Vital signs Leukopenia CBC Chemistry High HCO3, low Cl, low K, high carotene, high LFTs and amylase hypochloremic hypokalemic metabolic alkalosis TFTs normal normal thyroid Fasting Lipid Profile High cholesterol Hormones High cortisol, low LH/FSH, low estrogen • Long term complications- Osteoporosis lanugo hair • Most common cause of death- Heart disease. Then suicide. – – – – – – • Treatment- Admit them to maximize nutrition. SSRI’s help bulemia, anoexia needs intensive counseling. • Complications of TreatmentRe-feeding syndrome = low PO4, low Mg, low Ca and fluid retention. low M P K Sleep EEGs BATS Drink Blood Awake Stage 1 Stage 2 Slow wave sleepStage 3 <50% delta, Stage 4 >50% Nightmares/ REM. Dreaming Skeletal muscle paralysis Insomnia. Educate about sleep heigyne 1st, then try benzos (reduce sleep latency and incr SWS and REM). Zolpidem, zaleplon, escopiclone are GABAa recp • Trouble falling asleep or staying asleep causes impairment in fxn >1mo. • As falling asleep, feel Dyssomnia NOS. creepy-crawlies on legs, R/o medical causes 1st Æ Fe-def anemia better when they get up or chronic kidney dz. Neuropathy. Tx w/ ropinirole or pramipexole (Da-ag) and move. Obstructive Sleep Apnea. • Daytime sleepiness and depression in a big fat guy Goes on axis III, “breathing related sleep d/o” goes on axis I. with a big neck. Need polysomnogram to diagnose Æ >10 hypopneic/apneas per hour. Need CPAP • Irresistible attacks of refreshing (REM) sleep. Upon intense emotion, Narcolepsy. they lose muscle tone or Tx w/ scheduled naps and Modafinil. have hallucinations as waking of falling asleep. Restless Leg Syndrome- creep-crawlies on legs Periodic Leg Movement Disorder- random kicking motion • 30 y/o man and is wife present for couples counseling. He constantly accuses her of cheating. He’s in a feud w/ the neighbor b/c he feels they are attacking his character when they say they like his flowerbeds. • 30 y/o man, never been married or have any close friends. Works as a night security guard and in his free time works on his model ships in his basement. • 30 y/o man, never been married or have any close friends because “people make him uncomfortable”. He is unemployed because he spends his time reading books on how to communicate with animals so he can “be at one with nature”. Paranoid PD Low dose antipsychotics can help paranoid behavior. Schizoid PD Distinguish from Avoidant b/c they don’t WANT relationships Schizotypal PD Distinguish from Schizoid by magical thinking/ interests. Distinguish from Schizophrenia by lack of delus/hallu • 25y/o man comes to court mandated counseling for beating his girlfriend. He was kicked out of high school for fighting & just got out jail for stealing a car. • His girlfriend has a hx of unstable relationships, has superficial cuts on both wrists, is impulsive in her spending and sexual practices. • 26 y/o MS2 is asked by Nan Clare to seek counseling. Her classmates complain that she dresses too provocatively to class. She recently tried to seduce a professor. • A 22 y/o MS1 doesn’t feel like he needs to come to any classes or labs because he “already has the brilliance to be a doctor. He refuses to talk to Nan Clare about this, instead insisting to deal directly with President Henrich. Antisocial PD. 2/3 have Borderline PD. Commonly use Histrionic PD. Look for Narcissistic PD. Can be confused w/ hypomania b/c of grandiosity. • 30 y/o woman has no friends and avoids happy hours with her coworkers b/c she fears ridicule and rejection. She feels “no one would want to be friends with me”. • 30 y/o woman has jumped from one relationship to another because she “doesn’t do well alone”. She calls her friends and family >20x a day to get their input on her daily decisions. • 25 y/o MS4 spends more time color coding her notes and textbook highlighting than actually studying. She makes lists and study schedules 3 times per day. People don’t like to work with her because she is so “anal”. Avoidant PD. Can tx social phobia sxs w/ bblocker or SSRI Dependent PD. Look for comorbid SSRI Obsessive Compulsive PD. Different from OCD b/c the actions are “ego syntonic” 78 y/o lady is brought in from her nursing home for altered mental status. She sleeps more during the day and becomes agitated at nightreporting seeing green men in the corner. She also complains of pain upon urination. • First step? In her case, UA and culture. Work up also includes glc, Na, blood cultures, B12, RPR Make sure to look at med list- benadryl, opiates, Bzs factor? Underlying dementia is the 2nd biggest • Biggest risk • Other common causes? The biggest risk factor for developing delirium is ADVANCED AGE Acute substance withdrawal. Look for it on the 2nd or 3rd post-op day in alcoholic. • EEG findings? Psychosis has normal EEG. • Treatment? Reduce excessive stimuli, calendar and clock to orient patient. Stop unnecessary meds. Give haloperidol if agitated. A 78 y/o female presents with memory loss… • Aphasia, apraxia, gets lost while driving? Alzheimer’s Dementia. MC type. On MMSE, prompting does not ↑recall – Pathology? Global brain atrophy. in addition to making plaques on the neurons, can – Genes? APP (on chr 21), ApoE E2 amyloid, cause deposition on the walls of the arteries= amyloid angiopathy (amyloid is apple green birifringent) – Treatment? Donepezil, rivastigmine, galantamine (diarrhea). Memantine NMDA Antagonist • Becomes more sexually Frontotemporal Dementia. (Pick’s Dz). explicit, apathy. – Pathology? Lobar atrophy. – Treatment? Olanzepine for severe disinhibition. • Fluctuation in consciousness, Lewy Body Dementia visual hallucinations and shuffling gait. – Pathology? – Treatment? Give Ach-Ease inhibitors. . A 78 y/o female presents with memory loss… • Sudden, step-wise decrease in memory/cognitions. • Loss of vibration sense, labile affect. Pupil that accommodates but doesn’t react. – Dx? – Tx? Vascular Dementia. Tertiary Syphilis. Argyll Robertson Pupils +RPR, VDRL. Do spinal tap to look for spirochetes. IV penicillin. If Pen-allergic, must desensitize. • Myoclonus, startle response, seizures. Recently had a corneal transplant. Creutzfeldt Jakob. Corneal transplantaton is a risk factor – Pathology? Spongiform encephalopathy – EEG findings? • Incontinence, gait disturbance/freq Normal Pressure Hydrocephalus. falls, and rapidly developing dementia. – Dx? CT/MRI shows hydrocephalus, spinal tap shows nl opening pressure – Tx? Ventriculoperitoneal shunt improves cognitive fxn in 50-67% of pts A 50 y/o known alcoholic presents to the ER with tonic clonic seizures. BP 180/110, HR 118, T 100.1. • How long since his last drink? ~12-24hrs. (bimodal peak at 8 and 48hrs) • How long till he develops confusion, fluctuations in consciousness and the . feeling of ants crawling on him? • His blood alcohol level is 225mg/mL. ~9hrs, Alcohol is metabolized by How long till its out of his system? • If his medications included Beta-blockers mask the signs of propranolol, lactulose, and allopurinol, what would be the best autonomic hyperactivity, but you can follow to dose sign to monitor for his withdrawals? the benzos during w/drawal.