1st Aid/Emma Holliday's review Flashcards
(125 cards)
1
Q
A patient who is crying on minute and laughing the next is said to have a ___ affect.
A
Labile
2
Q
What is the difference between MOOD and AFFECT?
A
Mood is what the pt tells you
Affect is how thier mood appears
3
Q
What is psychosis?
What are the common types?
A
A general term used to describe a distorted perception of reality.
Common types:
- delusions (false beliefs)
- hallucinations (perceptions without acutal extermal stimuli)
- disorganized thinking/behavior
4
Q
What are the common causes of psychosis?
A
- Secondary to another medical condition
- Substance induced
- Delerium
- Dementia
- Bipolar (manic and/or mixed episodes)
- MDD with psycotic features
- Brief psychotic disorder
- Schizophrenia
- Schizophreniform
- Schizoaffective
- Delusional disorder
5
Q
What are the common causes of psychosis secondary to another medical condition?
A
- CNS diseases (CVD, MS, neoplasm, Alzheimer, Parkinson, Huntington, AIDS, epilepsy, prion, enchephalitis, syphilis)
- Endocrinopathies (Addison/Cushing, hyper/hypothyroid)
- Vitamin deficiency (B12, folate, niacin)
- SLE, temporal arterits
6
Q
What are the labs to order when doing an initial work up of psychosis?
A
TSH, RPR, drug screen,
7
Q
What are the POSITIVE symptoms of schizophrenia?
A
Things that are ADDED to baseline. Hallucinations, delusions, bizarre behavior, disorganized speech.
These tend to respond to anti-psychotics
8
Q
What are the NEGATIVE symptoms of schizophrenia?
A
Things that are SUBTRACTED from baseline. flat/blunted affect, anhedonia, apathy, alogia
These tend to be resistent to anti-psychotics (responds a little better to atypicals than typicals)
9
Q
What are the 3 phases fo schizophrenia?
A
- Prodromal: decline in global function that precedes the FIRST episode
- Psychotic: “The episode” Delusions, halucinations, and disordered thought
- Residual: follows a psychotic episode. mild delusions/halucinations, negative symptoms.
10
Q
Which antipsychotic can lead to agranulocytosis?
A
Clozapine
11
Q
What is the downward drift of schizophrenia?
A
People with schizophrenia tend to be unable to function in society and thus find themselves in a lower SES, often homeless.
12
Q
schizophrenia often involves neologisms. What is a neologism?
A
A new word/expression that only has meaning to the schizophrenic
13
Q
What are the 1st Gen antipsychotics?
Are they typical or atypical?
A
1st Gen = typical
The 1st Gen antipsychotics are:
Haloperidol
Fluphenazine
Trifluoperazine
Pimozide
Holy Fuck That’s Psycho!
14
Q
What are the 2nd Gen antipsychotics?
Are they typical or atypical?
A
2nd Gen = atypical
The 2nd Gen antipsychotics are:
Risperidone Quentiapin Olanzapine Aripiprazole Ziprasidone
15
Q
What is a common side effect of 2nd Gen antipsychotics?
A
metabolic sybndrome
16
Q
What is a common side effect of HIGH potency antipsychotics?
A
extra-pyramidal:
- dystonia of face, neck, and tongue
- Parkinsonism (resting tremor, bradykinesia)
- akathisia (uncontrollable restlessness)
17
Q
What is a common side effect of LOW potency antipsychotics?
A
Anticholinergic:
- dry mouth
- constipatoin
- hyperthermia
18
Q
What is Neuroleptic Malignant Syndrome?
A
A rare potential side effect of 1st Gent anti-psycotics that NBME likes to test.
S/Sx:
- AMS
- Autonomic instablility (fever, labile BP, tachycarida, tachypnea, diaphoretic)
- “lead pipe” rigidity
- high CPK
- leukocytosis
- metabolic acidosis
Tx: dantrolene
19
Q
What is Schizophreniform d/o?
A
Schizophrenia lasting between 1 and 6 months
20
Q
What is Schizoaffective d/o?
A
Meet criteria of BOTH schizophrenia and a major depresive/manic episode with the delusions/hallucinations predominating and also existing during a >2week period of absence of the mood episode
21
Q
What is a brief psychotic d/o?
A
Schizophrenia lasting less than 1 month
22
Q
What is Delusional d/o?
A
Pt has 1+ delusions lating >1month, but does not meet the criteria for schizophrenia and it does not significantly impact function.
Can be:
- Erotomanic (false belief that someone is in love with them)
- Grandiose (false belief that they have a great talent)
- Somatic (false belief that they have some physical difference)
- Persecutory (false belief that they are being persecuted)
- Jealous (false belief that thier significant other is unfaithful)
- Mixed/unspecified (multiple/none of the above)
23
Q
What is Koro?
A
a delusion specific to southeast asian cultures that one’s penis will recede into your body and you will die.
note: none of my residents or attendings can ever recall seeing this on a test but….I had to include this…I just had to…
24
Q
What is the difference between a mood episode and a mood disorder?
A
An episode are the distinc periods of time (or, you know, episode) in which the patient is experiencing said mood
A disorder is a pathologic pattern of reccurent mood episodes.
25
What are the criteria for a Major Depressive Episode?
Depressed mood/anhedonia plus 4 of the SIGECAPS for >2weeks
26
What are the criteria for Major Depressive Disorder?
at least ONE major depressive episode and ZERO episodes of mania
27
What are the criteria for a Manic Episode?
A period of persistantly elevated mood and energy plus 3 of the DIGFAST for >1week and impairs social/occupational function
28
What does SIGECAPS stand for?
```
S= sleep changes: increase during day or decreased sleep at night
I= interest (loss): of interest in activities that used to interest them
G= guilt (worthless): depressed elderly tend to devalue themselves
```
E= energy (lack): common presenting symptom (fatigue)
```
C= cognition/concentration: reduced cognition &/or difficulty concentrating
A= appetite (wt. loss); usually declined, occasionally increased
P= psychomotor: agitation (anxiety) or retardations (lethargic)
S= suicide/death preocupation
```
29
What does DIG FAST stand for?
```
D = Distractibility and easy frustration
I = Irresponsibility and erratic uninhibited behavior
G = Grandiosity
```
```
F = Flight of ideas
A = Activity increased with weight loss and increased libido
S = Sleep is decreased
T = Talkativeness
```
30
What is a hypomanic episode?
Elevated mood/energy lasting >FOUR days but does not impair function, require hospitalization, or come with psycotic features.
31
What are the criteria for Bipolar I Disorder?
at least ONE manic episodes. thats it. no depressive episodes needed.
32
What are the criteria for Bipolar II Disorder?
at least ONE depressive episodes and at least ONE hypomanic episodes.
If there is a single manic episode it is BP I.
33
What is the first line treatment of MDD?
SSRI and therapy.
34
What is the neurobiology of the positive symptoms of schizophrenia?
Too MUCH DA in the limbic system.
| 1st Gen Antipsychotics work by blocking D2 receptors
35
What is the neurobiology of the negative symptoms of schizophrenia?
Too LITTLE DA in the prefrontal/meso-cortical tract
| this is why 1st Gen Antipsychotics tend to make negative sx worse
36
How do you treat Schizophreniform d/o? Brief psychotic d/o? Does treatment prevent progression to schizophrenia?
You treat both Schizophreniform d/o and Brief psychotic d/o with typical antipsychotics.
Treatment DOES NOT prevent progression to schizophrenia
37
You have a 22yo female with a 3 year history of MDD who comes to you saying she has been hearing voices saying that she needs to kill herself despite adhering to her medication regimen. What is the treatment of choice?
Electroconvulsive therapy (ECT).
It can be used for mania and refractory MDD with psychotic features in non-pregnant pts as well. This just points out that it is safe in pregnancy.
38
a 35yo schizophrenic is brought to the ED by his brother and begins to get disruptive and threatening to the nursing staff. What is the drug of choice? Why?
Haloperidol.
It is fast acting and comes in an IM form (not going to trust him to take PO meds or let you start an IV)
39
What are the 2 low-potency antipsychotics that the NBME tests the most?
Chlorpromazine
Thioridazine
40
What are the 2 high-potency antipsychotics that the NBME tests the most?
Fluphenazine
Haloperidol
41
Which antipsychotic do you give to non-compliant patients? why?
Risperdal decanoate, Fluphenazine decanoate and Haloperidol decanoate.
decanoate means that it's an IM that last 2-4 weeks
42
What is the biggest risk factor for suicide?
Prior suicide attempt.
43
What is seen on polysonography in pts with MDD?
decreased REM latency (they get into REM faster) and increased cycles of REM.
*remember REM is not "restful" 3rd/4th phase ("deep") sleep is. More REM=less deep sleep.
44
What medical conditions can mimic MDD?
lots!
These 4 kept coming up in all of the resources:
HIV, Hypothyroid, Lyme, and a left MCA stroke
45
A patient complains of decreased mood, increased eating, gaining weight, sleeping more and has leaden paralysis in the morning. What is the diagnosis? Treatment of choice?
Atypical Depression. Apparently leaden paralysis is NBME buzzword for atypical depression.
Best treated w/ MAOIs.
46
A 75 yo man is brought in by his daughter because he has been sleeping very little for the past 8 days, had sex with 15 different women at the home, and talked so quickly that he has been stumbling over his words. What must be on your differential as to the cause of this manic episode?
Right frontal hemisphere stroke
47
Which drug classes can trigger a manic episode in a misdiagnosed Bipolar patient?
SSRIs and TCAs
48
A bipolar patient begins taking advil daily for low back pain and develops n/v/d, coarse tremor, ataxia, confusion, and slurred speech.
What is the diagnosis?
What are the pathologic ECG findings?
What is the treatment?
Lithium toxicity. It can be precipitated by NSAIDs.
ON ECG you will classically find T-wave flattening/inversion and U waves
The treatment is fluid resuscitation. you have to flush it out. Emergent dialysis if lithium level is >4 or they begin to show signs of acute kidney disease
49
What is the therapeutic level of lithium?
0.6-1.2
50
Why is lithium contraindicated in pregnant women? What is the preferred treatment?
If taken in the 1st trimester it can cause ebstien anomoly in the fetus (malformed tricuspid valve)
The preferred treatment is Clonazepam.
51
A bipolar pt comes in with elevated LFTs and hepatitis. What drug are they taking?
Valproate
52
A bipolar pt comes in with Steven’s Johnson Syndrome. What drug are they taking?
Lamotrigine
53
A bipolar pt comes in with agranulocytosis. What drug are they taking?
Carbamazepine
54
If a pregnant woman is bipolar and on Valproate or Carbamazepine what is the risk? How do you mitigate it?
It can lead to neurotube defects. mitigate with 4g of folate daily and monitor for increase AFP.
55
A 28 y/o female is brought in by EMS complaining of
shortness of breath, palpitations and chest pain. She
has had these attacks previously and afraid of having another one.
What is the next step?
What is the most likely diagnosis?
What is the treatment?
The next step is to rule out deadly etiologies. That means ordering an EKG, cardiac enzymes, TSH and urine drug screen
The most likely diagnosis is Panic Disorder as she has anxiety about her anxiety.
Treatment is low dose PRN Alprazolam or clonazepam (benzos) for panic attacks and SSRIs are the preferred drug for chronic panic disorder
56
a 48yo female presents complaining of feeling "down" for the last 2 years. she says that she is tired all of the time and it makes it hard to think. She denies all other SIGECAPS.
What is the most likely diagnosis?
What is the treatment?
This is Persistent Depressive Disorder (formerly Dysthymia)
this is diagnoesde as 2+years of depression, with 2+ CHASES criteria, and never asymptomatic for >2months.
It is treated with combination psychotherapy and SSRIs
57
What are the CHASES criteria of Dysthymia?
```
C=concentration, poor
H=hoplessness
A=appetite change
S=sleep change
E=energy, low
S=self-esteem, low
```
58
What is cyclothymic disorder?
Bipolar lite. doesnt quite meet all of the criteria for hypomania and doesnt quite meet all of the criteria of a major depressive episode. Must have at least one episode of each, must never be symptom free > 2 months over a 2 year period.
usually coexists with BPD.
1/3 progress to BP I/II
59
You have a pissed off 9 year old brought in by his mom. This has been going on for over a year. He's getting in trouble at home and at school.
what are the 2 most likely diagnosis? how can you differentiate?
Angry kid is either Disruptive Mood Dysregulation Disorder (DMDD) or Oppositional Defiant Disorder (ODD)
How can you tell the difference? No body seems to fucking know because DMDD is a new disorder in DSM-V and the criteria are very similar.
The best adivce I recieved for test taking is look for the word vindictive (It indicates ODD) or if the kid is angry with his peers (indicates DMDD). And if you are still in doubt remeber that shelf exam questions are generally old questions so pick the disease that existed earlier, ODD.
60
What are the signs/symptoms of a panic attack?
DD PANICS
```
Dizzy
Disconected (feeling of detachement from self/reality. "I feel like im watching whats going on"), Palpitatons
Abdominal pain
Numbness
Intense distress
Chest pain
SOB
```
61
A 45yo woman with a history of panic disorder has progressed to the point over the last 6 months that she cannot get on the metro or go to the store without having a panic attack.
What is the most likely diagnosis?
What is the treatment?
She has agoraphobia (its not just for complete recluses anymore! 2+ of the following:bridges, crowds, public transportation, stores, or open spaces)
Treatement is CBT and SSRIs
62
18y/o who just started college has declining grades. He states he can’t make it to class on time because he spends 2-3 hours scrubbing in the shower each morning. He knows this is excessive but on days he takes shorter showers, he states he can “feel the bacteria” and worries about contracting an illness.
What is the most likely diagnosis?
What is the treatment?
This patient has OCD.
He is OBSESSED with contracting an illness.
He is then COMPELLED to act up on it and clean his shower.
Treatment: Clomipramine is gold standard
SSRIs are first line.
63
A 25 y/o sexual assault survivor comes to you with a 6wk history of recurrent nightmares of when she was raped at knifepoint. She now avoids situations where unknown men will be present, to the point that she had to quit her job at a bank. She reports being “jumpy” anytime she hears footsteps behind her.
What is the most likely diagnosis?
What is the treatment?
Post Traumatic Stress Disorder.
Treatment is Sertraline or paroxetine. Combined w/ CBT.
64
A 23yo grad student from India finds that he is unable to speak in the presence of women. He states that this has been going on since he arrived in the US over a year ago.
What is the most likely diagnosis?
What is the treatment?
This is Selective Mutism. It only occurs in select social situations. Must persist for more than a month.
Treatment is CBT.
65
A 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.
What is the most likely diagnosis?
What is the treatment?
This is separation anxiety disorder. Remember that separation anxiety is normal for a toddler.
treatment is CBT and family therapy`
66
A 22yo med student is having difficulty falling asleep b/c she keeps thinking about failing anatomy. This causes her to be always tired. In class she cannot concentrate b/c she worries her boyfriend will leave her. Sxs lasting >6mo
What is the most likely diagnosis?
What is the treatment?
This is Generalized Anxiety Disorder (GAD), it presents as excessive anxiety about many aspects of daily life.
Treatment is CBT and SSRIs
67
Munchausen Syndrome and Munchausen Syndrome by proxy have been grouped together and renamed as _____.
Factitious disorder.
68
A 54 y/o RN presents w/ a history of 2mo of diarrhea and abd pain. He has presented to 4 other hospitals w/ the same complaint. Colonoscopy reveals pigmentation in the wall of the colon.
What is the most likely diagnosis?
What is the treatment?
This is factitious disorder. The key here is that there is no external reward for this. They do it for primary gain.
Treatment is difficult. It requires psychotherapy and nonthreatening confrontation.
69
A 27y/o man presents for frequent seizures and states that he thinks he had a cousin who had epilepsy. You schedule an EEG. At the end of the appointment he asks you to sign off on his disability paperwork.
What is the most likely diagnosis?
This is malingering. The key here is there is an external reward. They do it for secondary gain.
Associated w/ antisocial personality disorder.
70
A 31 y/o woman presents with abdominal pain. Her history reveals that she has had multiple ex-laps and extensive workups. she reports that you are her 4th doctor and that "my other doctors couldn't help me." She states that her symptoms started in college and is worried that she will be fired from work due to frequent sick days.
What is the most likely diagnosis?
Somatic Symptom Disorder. The key here is that it is a physical symptom, that seems to cause her distress (meaning that she is not getting any primary or secondary gain)
71
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).
What is the most likely diagnosis?
What is the treatment?
What is the major complication of treatment?
This is a bulimic/
treatment is SSRI’s to help bulimia/anorexia and needs intensive counseling.
If bad enough then they may need to be hospitalized to maximize nutrition.
Beware of Re-feeding syndrome which presents as low PO4, low Mg, low Ca and fluid retention.
72
What are some common lab abnormalities of bulimia?
Long term complications?
--CBC: Leukopenia
–Chemistry: High HCO3, low Cl, low K, high carotene, high LFTs and amylase
–Fasting Lipid Profile: High cholesterol
–Hormones: High cortisol, low LH/FSH, low estrogen
Long term complications include osteoporosis and heart disease
73
Trouble falling asleep or staying asleep >3 times/week and causes impairment in function. lasts at least 3mo.
What is the most likely diagnosis?
What is the treatment?
Insomnia
treat with: CBT focused on sleep hygiene--> benzos
74
Irresistible attacks of refreshing (REM) sleep. Upon intense emotion, they lose muscle tone or have hallucinations as waking of falling asleep.
What is the most likely diagnosis?
What is the treatment?
This is narcolepsy. It differs from hypersomnolence in that they fall asleep at impropriate times and may have hallucinations.
You treat both however with long term Modafinil
75
A soldier just returned home from a deployment 2 days ago and has been having trouble sleeping. He notes that he falls asleep early in the evening and finds himself wide away at 2 AM.
What is the most likely diagnosis?
What is the treatment?
Circadian rhythm sleep-wake disorder. This can also be caused by shift work or living at high latitudes and having very short/long days.
Treat with sleep hygiene, light phototherapy, and melatonin
76
30 y/o man and is wife present for couples counseling. He constantly accuses her of cheating. He states that his previous employer fired him "because I did a better job." Claims that his neighbors are "shady as fuck."
What is the most likely diagnosis?
What's a good differential and how does this differ?
What is the treatment?
Paranoid PD
Ddx:
-Schizophrenia: PPD does not have any fixed delusions or frank psychosis. Reality is intact.
Tx:
Psychotherapy. Low dose anti-psychotics can help paranoid behavior.
77
30 y/o researcher has never been married or have any close friends. He states that he has no desire to make friends and is content being single.
What is the most likely diagnosis?
What's a good differential and how does this differ?
What is the treatment?
Schizoid PD
Ddx:
-Schizophrenia: Schizoid PD does not have any fixed delusions or hallucinations. Reality is intact.
- Avoidant PD:Schizoid PD does not want a relationship and is not bothered by their lack of connections.
- Schizotypal PD: Schizoid PD does not have the odd, magical thinking.
Tx:
None. This is not distressing to them
78
30 y/o LARPer who lives in his moms basement and has never been married. He is unemployed because he spends his time working on "trying to find evidence of aliens"
What is the most likely diagnosis?
What's a good differential and how does this differ?
What is the treatment?
Schizotypal PD
Ddx:
-Schizophrenia: Schizotypal PD does not have any fixed delusions or hallucinations. Reality is intact.
-Schizoid PD: Schizotypal PD have magical thinking.
Tx:
Psychotherapy. Low dose anti-psychotics can help
79
A 26yo bank executive (lets call him P. Batemen) has been accused of murdering 3 women. He is an exceedingly charming man who would lure them back to his condo. He expresses no guilt. He was arrested several times as a teenager for auto theft and assault.
What is the most likely diagnosis?
What's a good differential and how does this differ?
What is the treatment?
Antisocial PD
Think conduct disorder in adults
Ddx:
-Drug Abuse: usually co-exist. Which one came 1st?
Tx: nothing works well. Psychotherapy is ineffective. SSRIs can treat symptoms of anxiety.
80
A 21yo woman presents with multiple shallow cuts on her wrists. She states she did it because her boyfriend of 2 months "is an asshole" who "couldn't handle me." She has a history of drug use and binge/purge behavior. She laments about being "alone again."
What is the most likely diagnosis?
What's a good differential and how does this differ?
What is the treatment?
```
Borderline PD
(Impulsive, moody, unstable self image, fear of abandonment)
```
both sources felt it neccesaary to point out they commonly use "splitting" ie seeing everything in black and white
Ddx:
-Schizophrenia: Though they may have transient psychosis, pts with BPD dont have frank psychosis
-Bipolar II: Though they can appear to have hypomania pts with BPD wont have the frank depression of BP2
Tx: Psychotherapy
81
A 16 yo woman is in for her annual physical. You note that she is dressed very provocatively and she is flamboyant and flirty. Her mother, who accompanied her, reports that she is a "drama queen" who must "always be the center of attention."
What is the most likely diagnosis?
What's a good differential and how does this differ?
What is the treatment?
Histrionic PD
Ddx:
-BPD: Pts with histrionic PD are generally not suicidal and are more functional
Tx: Psychotherapy
82
A 27 yo O3 presents to the ED after a minor MVC. He demands that the chief of surgery is the only one who can evaluate him. when trying to elicit his history he states "do you know who I am?"
What is the most likely diagnosis?
What's a good differential and how does this differ?
What is the treatment?
Narcissistic PD
Ddx:
-Antisocial PD: While both lack empathy and tend to exploit others, pts with NPD are motivate by praise/recognition while pts with ASPD are motivated by material/power
TX:
Psychotherapy
83
30 y/o woman has no friends and avoids
happy hours with her coworkers b/c she
fears ridicule and rejection. She wants to make friends but is "too shy."
What is the most likely diagnosis?
What's a good differential and how does this differ?
What is the treatment?
Avoidant PD
DDx:
- Schizoid PD: Pts with APD WANT companionship but are afraid. Pts with SPD have no desire.
- Social Anxiety Disorder: SAD is generally a fear of embarrassment in certain situations (fear of public speaking, peeing in public) APD is a fear of rejection in most situations.
TX:
Psychotherapy
84
A 30 yo female who lives with her husband calls him 10-15 times a day to ask his input on trivial decisions. She is only here because her husband told her to come.
What is the most likely diagnosis?
What's a good differential and how does this differ?
What is the treatment?
Dependent Personality Disorder
DDx:
-Borderline PD/Histrionic PD: All are very clingy, but DPD pts will work to maintain long lasting relationships.
TX: Psychotherapy
85
A 29yo Female who is a self described perfectionist, who spends more time on formatting and color coding than on her work.
What is the most likely diagnosis?
What's a good differential and how does this differ?
What is the treatment?
Obsessive Compulsive PD
DDx:
-OCD: OCD is ego dystonic. They only perform the compulsions to relieve their obsessions. OCPD is ego-syntonic, they don't see it as a problem.
TX: Psychotherapy
86
How is alcohol metabolized?
Alcohol--> acetaldehyde (via alcohol dehydrogenase)
| acetaldehyde--> acetic acid (via aldehyde dehydrogenase)
87
What are the signs/symptoms of alcohol withdraw?
What is the treatment?
Alcohol is a depressant, therefore withdrawal will mimic stimulant action:
insomina, anxiety, tremor, irritability, autonomic hyperactivity
most severe is DTs (delirium, hallucinations, seizures)
Tx:
-Benzodiazepines (-zepam)
88
A 16yo kid comes in passed out and reeking of alcohol. his BAC is .16
What is the treatment?
Monitor: ABCs, glucose, electrolytes, acid/base
Give Thiamine (prevents wernicke's encephalopathy) and folate
only "pump their stomach" if the ingestion was less than an hour ago.
89
What are the signs and symptoms of wernicke's encephalopathy? Treatment?
S/Sx: confusion, ataxia, and eyes that dont follow at the same rate (ophthalmoplegia)
Tx: Thiamine then glucose
90
What are some medications you can give to a patient to prevent/reduce future alcohol use?
Naltrexone (opiod receptor blocker, decreases positive feelings of drinking)
Disulfram (aldehyde dehydrongenase blocker, increases negative feelings, ie hangover)
91
What are the signs of cocaine intoxication?
What is the treatment?
S/Sx:
-mild/moderate use: euphoria, increase self esteem, tachy/brady cardia, hyper/hypotension
-heavy use: anxiety, respiratory depression, arrythmias, hyperthermia, tactile hallucinations, MI or stroke (due to vasoconstriction)
TX: Symptomatic: haldol for anxiety, CCBs for rate control, (NEVER use beta blockers for cocain OD. This leads to unopposed alpha stimulation-->siezure/death)
92
a 21yo man with trackmarks in his arm is brought in unresponsive.
Whats he on?
Whats the treatment?
heroin
Tx:
- naloxone (full mu-opiate antagonist)
93
You are volunteering in a methadone clinic. What signs/sympotms would you expect from someone withdrawing from heroin? how do you treat them?
Heroin is a depressant, withdrawl symptoms will mimic signs of stimulant intoxication. (Joint/muscle pain, photophobia, goosebumps, diarrhea, tachycardia/
HTN, anxiety)
Tx: Methadone
94
Pt presents with horizontal nystagmus (this is the NBME key word), and some other symptoms like ataxia and acute psychosis.
Whats he on?
Whats the treatment?
PCP
TX: Monitor, benzos +/- haldol for psychosis
95
a 15yo is brought in by his mother who says she caught him smoking weed. What physical sign does the NBME want you to associate with him? how do you treat him?
injected conjunctiva (red eyes)
no treatment. no one has every died from cannabis. give the kid a glass of water and some Doritos.
96
a 78yo woman is brought to the ED by her husband for increasing confusion and disorientation over the course of the day but has been worse since the sun went down. What is going on? 1st test?
Delirium as this is acute onset. The most likely cause of delirium in the female outpatient geriatric patient is UTI so 1st test is a UA.
97
a 78 yo woman is brought in by her husband for gradual memory loss, aphasia, and apraxia over the last 18 months. Yesterday she got lost while driving to the store.
What is the diagnosis?
Pathology?
Treatment?
Alzheimers (the most common dementia)
Pathology: Global brain atrophy. B-amyloid plaques or tau tangles. Associated with APP (on chr 21), ApoE, and E2
Tx:
Donepezil, rivastigmine, galantamine
98
a 78 yo woman is brought in by her husband for memory loss. She says that it stated with a difficulty remembering names, and then recently she has noticed difficulty with planing. Her father died of a stroke.
What is the diagnosis?
Pathology?
Treatment?
this is vascular dementia (i tried to paint it as STEPWISE progression)
Pathology: repeated brain infarcts
Treatment: none
99
A 56yo man recently was fired for watching porn at work. He wife says that he is just mean now. Also some memory loss.
What is the diagnosis?
Pathology?
Treatment?
Frontotemporal dementia (FTD)
Pathology: Lobar atrophy. Intra-neuronal silver staining inclusions.
Tx: SSRIs for anxiety and disinhibition. Olanzepine for severe disinhibition.
100
a 45yo man has been having memory issues, problems concentrating, and poor executive function. on PE you notice chorea and bradykinesia.
What is the diagnosis?
Pathology?
Treatment?
Huntingtons disease
Pathology: CAG repeats on chr 4
treatment: none. relieve symptoms
101
a 78 yo woman is brought in by her husband for memory loss. She has a labile affect. on PE her pupils accommodate but don’t react.
What is the diagnosis?
Treatment?
Tertiary Syphilis
TX: PCN
102
What are the Erickson/Freud development stages for Birth-1 year?
Erickson: Trust v Mistrust
Freud:Oral (babies like pacifiers)
103
What are the Erickson/Freud development stages for 1 year - 3 year?
Erickson: Autonomy v Shame
Freud: Anal
104
What are the Erickson/Freud development stages for 3 year - 5 years?
Erickson: Initiative vs Guilt
Freud: Phallic
105
What are the Erickson/Freud development stages for 5 years - 11 years?
Erickson: Industry vs Inferiority
Freud: Latent
106
What are the Erickson/Freud development stages for puberty and adolescence?
Erickson: Identity vs role diffusion (Teenagers are just trying to fit in)
Freud: Genital (remember freud's stages stopped here)
107
What is the Erickson developmental stage for young adult (up to 40yo)?
Intimacy vs isolation
108
What is the Erickson developmental stage for middle adult (40-65yo)?
Generativity vs stagnation
109
What is the Erickson developmental stage for geriatric (>65yo)?
Integrity vs Despair (how are you going to die? with integrity or in despair?)
110
What test is used to determine mental retardation/Intellectual delay? what are the levels/associated scores?
IQ test
Mild-55-70
Moderate-40-55
Severe-25-40
Profound-<25
111
What is the most likely inherited cause of Intellectual delay? What is the gene mutation?
Fragile X
CGG repeats, X link recessive
112
What is the most likely non-inherited cause of Intellectual delay? What is the gene mutation?
Down Syndrome
Trisomy 21
113
What are the common non-genetic causes of Intellectual delay?
TORCH! Remember that shit?
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Toxoplasmosis
Other (like fetal alcohol syndrome and drugs)
Rubella
CMV
HSV
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114
A 7 year old boy is brought in by his parents because he has difficulty focusing. He has to be told numerous times to do his homework or complete his chores. He is constantly forgetting where he put his shoes, glasses, ect.
What's wrong with him?
nothing. this is normal, if not annoying as fuck.
he does not have the hyperactivity of ADHD and it is not occurring in more than one setting.
115
A 7 year old boy is brought in by his parents because he has difficulty focusing since last year. His mom reports he "has a high motor," and is easily distractible. His teachers report that he doesn't follow directions and will blurt out answers without raising his hand.
What's the diagnosis?
What's the treatment?
ADHD. He is hyperactive and it is occurring in more than one setting.
Remember that he must have 6 inattentive symptoms and/or 6 hyperactive symptoms for >6months. The onset must be prior to age 12.
Tx:
Methylphenidate (Concerta, Ritalin)-Blocks DA reuptake, may cause stunted growth
Amphetamine(Adderall)-Blocks DA/NE reuptake & stimulates release, may cause stunted growth
Atomoxetine(Strattera)- NE reuptake inhibitor. Non stimulant, may cause dry mouth, insomnia
116
A 14 year old boy is sent for court mandated counseling. He was arrested for setting fire to his neighbors tool shed. He calmly tells you how he was going to steal his neighbor’s lawn mower and run over some kittens. He assaulted a school mate last year.
What's the diagnosis?
What's the treatment?
This kid has Conduct Disorder (BTW this vignette is what Jeffrey Dahmer did as a child). These are kids who willinlgy violate the rights of others (to include animals) through physical/sexual violence and lack remorse or empathy. like everything else it has to be going on for >6months.
Tx: behavior modification, family therapy, +/-antipsychotics and mood stabilizers for aggression.
117
A 14 year old boy is brought in by his mother. She states that over the last year he has become angry, defiant, and vindictive. He reports that he has lots of friends.
What's the diagnosis?
What's the treatment?
Oppositional Defiant Disorder.
Very similar to Conduct Disorder. Apparently the way to distinguish on the test is that pts with ODD rebel against authority but get along with their (non-sibling) peers and does NOT involve physical/sexual violence.
TX: is the same as Conduct Disorder. behavior modification, family therapy, +/-antipsychotics and mood stabilizers for aggression.
118
What is tourettes? What is the differential? How do you treat it?
Tourettes is the most sever tic disorder. multiple motor and AT LEAST 1 vocal tic (grunts, barks, cuss words, echolalia) at least 1x a day for at least 1 year (without any breaks >3 months).
DDx:
- Persistent motor/vocal tic disorder: Has either motor or vocal tics, not both, >1 year
- Provisional tic disorder: 1+ motor and/or vocal tic for < 1year
Tx: Behavior modification. Guanfacine if the tics become impairing.
119
6y/o poops in her clothes once every 2 weeks.
What is the next best test?
What is the differential?
How do you treat?
next test is a physical exam/KUB (depending on the source) to test for fecal retention/constipation.
DDx/TX:
- Constipation- treat with stool softeners and high fiber diet.
- Encopresis (inappropriate defecation)- Reward based behavior modification
120
6y/o pees in her clothes almost daily.
What is the next best test?
What is the differential?
How do you treat?
Next test is a UA to rule out UTI.
DDx:
-Nocturnal enuresis: initial treatment is restrict fluids before bed and a bed alarm for "bladder training." DDAVP if that fails
-Diurnal enuresis: DDAVP is the first line treatment
121
A 21yo man is found in an different state 2 weeks after being reported AWOL. He is unable to recall his name or any other autobiographical information.
What is the diagnosis?
What is the treatment?
He is malingering!
Ok, probably, but for the purposes of the shelf he has Dissociative Amnesia. Since he traveled in this state he has associated Dissociative Fugue (as in FUGative)
Tx: Psychotherapy
122
What is the difference between amnesia, depersonalization, and derealization?
Amnesia is loss of memory
Depersonalization is feelings of detachment from one's self
Derealization is feelings of detachment from one's surroundings.
All three are associated with trauma and are best treated with psychotherapy.
123
What is dissociative identity disorder (DID)?
What is the pathology?
What is the treatment?
formerly known as multiple personalities. this is 2+ distinct personalities, that are unaware of each other, who may be dominant at different times. Pts will have lapses in memory as a result.
develops as a response to significant and chronic trauma, usually in childhood.
Tx: is psychotherapy +/- SSRIs for any comorbid anxiety, depression, or PTSD.
124
What is the difference between Somatic and Conversion disorder?
Patients with somatic disorder perseverate over their physical complaint, which is usually chronic.
Patients with conversion disorder, classically (as in on the NBME) experience la belle indifference (they are unconcerned about it) and it is usually fairly rapid onset.
125
What is the difference between factitious disorder (formerly Munchhausen) and malingering?
Patients with factitious disorder have no secondary gain/external reward. Patients with malingering
