Pass medicine 1 Flashcards
(100 cards)
1
Q
A 21-year-old female with paranoid schizophrenia is currently being treated on an antipsychotic regimen under section 3 of the Mental Health Act as an inpatient. Recently she has started to complain of breast tenderness & enlargement. Given that the current antipsychotic regimen is not being tolerated well, what is the best anti-psychotic for her to be started on to reduce these side effects?
Risperidone Chlorpromazine Aripiprazole Amisulpride Haloperidol
A
Aripiprazole has the most tolerable side effect profile of the atypical antispsychotics, particularly for prolactin elevation
2
Q
What is the main advantage of using atypical antipsychotics?
A
a significant reduction in extra-pyramidal side-effects
3
Q
What are the adverse effects of atypical antipsychotics?
A
- weight gain
- clozapine is associated with agranulocytosis
4
Q
What are the side effects of antipsychotics which mean you have to be careful when treating old people?
A
- increased risk of stroke (especially olanzapine and risperidone)
- increased risk of venous thromboembolism
5
Q
Give examples of atypical antipsychotics
A
risperidone aripiprazole olanzapine quetiapine amisulpride clozapine
6
Q
What are the adverse effects of clozapine? What must you do?
A
- agranulocytosis (1%)
- neutropaenia (3%)
- reduced seizure threshold - can induce seizures in up to 3% of patients
- weight gain
- excessive salivation
- agranulocytosis
- neutropenia
- myocarditis
- arrhythmias
Full blood count monitoring is therefore essential during treatment.
7
Q
What is the mechanism of action of antipsychotics?
A
dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways
8
Q
What are the side effects of antipsychotics?
A
Extrapyramidal side-effects
- Parkinsonism (tremor, bradykinesia, rigidity, and postural instability)
- acute dystonia (e.g. torticollis, oculogyric crisis)
- akathisia (severe restlessness)
- tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
- increased risk of stroke
- increased risk of venous thromboembolism
Other side-effects
- antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
- sedation, weight gain
- raised prolactin: galactorrhoea, impaired glucose tolerance
- neuroleptic malignant syndrome: pyrexia, muscle stiffness
- reduced seizure threshold (greater with atypicals)
- prolonged QT interval (particularly haloperidol)
9
Q
What class of drug is imipramine?
A
TCA
10
Q
What are TCAs used for?
A
Not depression as toxic in OD.
Used at low doses for neuropathic pain and prophylaxis of headache (both tension and migraine)
11
Q
What are the side effects of TCAs?
A
Anti-muscarinic:
- drowsiness
- dry mouth
- blurred vision
- constipation
- urinary retention
12
Q
Give examples of TCAs. Which are the most dangerous in OD?
A
More sedative:
- Amitriptyline
- Clomipramine
- Dosulepin
- Trazodone*
Less sedative:
- Imipramine
- Lofepramine
- Nortriptyline
lofepramine has a lower incidence of toxicity in overdose
amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose
13
Q
A 52-year-old man is admitted to hospital with acute pancreatitis. He drinks 90 units of alcohol per week. When is the peak incidence of delirium tremens following alcohol withdrawal?
A
48 to 72 hours
14
Q
What is the mechanism of alcohol withdrawal?
A
- chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
- alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
15
Q
What are the features of alcohol withdrawal?
A
- symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
- peak incidence of seizures at 36 hours
- peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
16
Q
What are the features of delirium tremens?
A
Delusions Tachycardia Fever Coarse tremor Confusion Auditory and visual hallucinations
(Delirium tremens frequently cause auditory and visual hallucinations)
17
Q
How do you manage alcohol withdrawal?
A
- first-line: benzodiazepines e.g. chlordiazepoxide. Typically given as part of a reducing dose protocol
- carbamazepine also effective in treatment of alcohol withdrawal
- phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures
18
Q
A 65-year-old female with a history of ischaemic heart disease is noted to be depressed following a recent myocardial infarction. What would be the most appropriate antidepressant to start?
Paroxetine Imipramine Flupentixol Venlafaxine Sertraline
A
Sertraline is the preferred antidepressant following a myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants
19
Q
Which drug is used to treat depression in children?
A
Fluoxetine
20
Q
What are the side effects of SSRIs?
A
- gastrointestinal symptoms are the most common side-effect
- there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
- patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
- fluoxetine and paroxetine have a higher propensity for drug interactions
21
Q
Which drugs are associated with dose-dependent QT interval prolongation?
A
Citalopram and escitalopram
22
Q
Which drugs interact with SSRIs?
A
- NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
- warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
- aspirin: see above
- triptans: avoid SSRIs
23
Q
When should people be followed up if put on an SSRI?
How should they be stopped?
A
- reviewed by a doctor after 2 weeks
- if <30 yrs or at increased risk of suicide they should be reviewed after 1 week
- If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
24
Q
What are the discontinuation symptoms of SSRIs?
A
- unsteadiness
- sweating
- paraesthesia
- increased mood change
- difficulty sleeping
- restlessness
- gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
US President is dangerous, ridiculous and greedy
25
What are the risks of using SSRIs in pregnancy?
- Use during the first trimester gives a small increased risk of congenital heart defects
- Use during the third trimester can result in persistent pulmonary hypertension of the newborn
- Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
26
What test can be used to assess alcohol withdrawal severity?
The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale
27
Which screening tools are designed to identify patients who may have problem drinking behaviours or alcohol misuse problems?
The Alcohol Use Disorders Identification Test (AUDIT) and the CAGE questionnaire
28
Which test is used for assessing the severity of schizophrenia?
The Positive and Negative Syndrome Scale (PANSS)
29
A 23-year-old man presents to his GP surgery asking to be referred to a plastic surgeon. He is concerned that his ears are too big in proportion to his face. He now seldom leaves the house because of this and has lost his job. On examination his ears appear to be within normal limits. What is the most appropriate description of this behaviour?
Dysmorphophobia
30
DSM IV criteria for body dysmorphia
- Preoccupation with an imagine defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive
- The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
- The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa)
31
A 28-year-old female attends an appointment with her psychiatrist for a review of her bipolar disorder. She is on Lithium. Where in the body does this medication get concentrated?
Bone and thyroid
32
What's the therapeutic range for lithium?
0.4-1.0 mmol/L
33
What are the theories for how lithium works?
- interferes with inositol triphosphate formation
| - interferes with cAMP formation
34
What are the adverse effects of lithium?
- nausea/vomiting, diarrhoea
- fine tremor
- nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
- thyroid enlargement, may lead to hypothyroidism
- ECG: T wave flattening/inversion
- weight gain
- idiopathic intracranial hypertension
35
The belief that your movements or sensations are controlled by an external force is known as.....
Passivity
36
What is avolition?
A decrease in motivation to perform directed, purposeful activities
37
What are Schneider's first rank symptoms?
Schneider's first rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions:
Auditory hallucinations of a specific type:
- two or more voices discussing the patient in the third person
- thought echo
- voices commenting on the patient's behaviour
Thought disorder*:
- thought insertion
- thought withdrawal
- thought broadcasting
Passivity phenomena:
- bodily sensations being controlled by external influence
- actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
Delusional perceptions
- a two stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. 'The traffic light is green therefore I am the King'.
38
What's the term for a made up word?
neologism
39
What are the side effects of sodium valproate?
VALPROATE
V-very fat (inc weight)
A-increased appetite and aggression
L- liver failure
P-pancreatitis
R- reversible hair loss which grows back curly
O-oedema
A- ataxia
T- teratogenicity, tremor, thrombocytopaenia, tiredness
E-encephalopathy, due to hyperammonaemia, emesis
40
What are the side effects of lithium?
| What are the side effects in toxicity?
GI and lithium
```
GI: nausea, diarrhoea
Leucocytosis
Impaired renal function
Tremor (fine), tired (fatigue)
Hypothyroidism/hair loss
Increased weight and fluid retention
Urine inc (polyuria and poly dipsia)
Metallic taste, muscle weakness
```
```
Tremor (coarse)
Oliguric renal failure
X ataXia
Increased reflexes
Convulsions/coma/consciousness decreased
```
41
What are the side effects of olanzapine?
weight gain
| type 2 diabetes
42
What are the side effects of carbamazapine?
```
drowsiness
leucopaenia
diplopia
blurred vision
rash
```
43
Which antipsychotics carry a high risk of weight gain?
Olanzapine and Clozapine
44
How do you manage schizophrenia?
- oral atypical antipsychotics are first-line
- cognitive behavioural therapy should be offered to all patients
- close attention should be paid to cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates)
45
What are the signs of Wernicke's encephalopathy?
ataxia, ophthalmoplegia and confusion
46
What are the symptoms of Korsakoff?
- anterograde amnesia (unable to form new memories)
- retrograde amnesia (unable to recall past memories)
- confabulation (making up new memories)
47
What causes Korsakoff syndrome?
thiamine deficiency causes damage and haemorrhage to the mammillary bodies of the hypothalamus and the medial thalamus
48
What is an obsession?
an intrusive, unpleasant and unwanted thought
49
What is a compulsion?
a senseless action taken to reduce the anxiety caused by the obsession
50
What is Dialectical behaviour therapy (DBT)?
DBT is a psychological intervention for patients with borderline personality disorder.
51
What is Exposure-response prevention (ERP) therapy?
ERP therapy, as well as cognitive behavioural therapy, is recommended and a first line intervention for OCD.
52
What is OCD associated with?
- depression (30%)
- schizophrenia (3%)
- Sydenham's chorea
- Tourette's syndrome
- anorexia nervosa
53
What is somatisation syndrome?
- multiple physical SYMPTOMS present for at least 2 years
| - patient refuses to accept reassurance or negative test results
54
What is hypochondrial disorder?
- persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
- patient again refuses to accept reassurance or negative test results
55
What is conversion disorder?
- typically involves loss of motor or sensory function
- the patient doesn't consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
- patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies
56
What is dissociative disorder?
- dissociation is a process of 'separating off' certain memories from normal consciousness
- in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
- dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
57
What is munchhausen syndrome?
- also known as factitious disorder
| - the intentional production of physical or psychological symptoms
58
What is malingering?
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
59
You see a young man who has recently been diagnosed with schizophrenia. He wants to know what his future with the condition may be like.
A prodromal phase of schizophrenia is....
Associated with poor prognosis
60
Which factors are associated with a poor prognosis in schizophrenia?
- strong family history
- gradual onset
- low IQ
- premorbid history of social withdrawal
- lack of obvious precipitant
61
A 40-year-old man is being evaluated by a psychiatrist for his symptoms of low mood, lack of interest, fatigue and suicidal thoughts. He lost his job and divorced his wife about a year ago. He is struggling financially. He has been drinking alcohol heavily in recent years and attempted suicide 3 years ago.
Which of the following is his stronger risk factor for future suicide completion?
A previous suicide attempt is one of the strongest risk factors for future suicide completion
62
What are the risk factors for completing suicide?
```
Sex (male)
Age (young adult or elderly)
Depression
Previous attempt (highest risk factor)
Alcohol or drug use
No spouse or other social support
Stated future intent
```
63
Which factors have shown to be associated with an increased risk of suicide?
- male sex (hazard ratio (HR) approximately 2.0)
- history of deliberate self-harm (HR 1.7)
- alcohol or drug misuse (HR 1.6)
- history of mental illness (depression, schizophrenia)
- history of chronic disease
- advancing age
- unemployment or social isolation/living alone
- being unmarried, divorced or widowed
64
If a patient has actually attempted suicide, which factors associated with an increased risk of completed suicide at a future date?
- efforts to avoid discovery
- planning
- leaving a written note
- final acts such as sorting out finances
- violent method
65
Which factors protect against suicide?
- family support
- having children at home
- religious belief
66
You are the newly appointed resident on the medical assessment unit attending the consultant-led ward round. A 43-year-old male with a past medical history of alcohol-related liver failure becomes agitated and threatens to punch the consultant. He has coarse tremors in both hands and looks very anxious.
He is a chronic alcoholic.
Which one of the following is the preferred drug for managing his symptoms?
```
Chlordiazepoxide
Lorazepam
Naloxone
Flumazenil
Phenytoin
```
In patients with hepatic failure, lorazepam is preferred over chlordiazepoxide for alcohol withdrawal syndrome to avoid the risk of increased sedation
67
Which drug opposes the action of benzodiazepines?
Flumazenil
68
Which drug is given for opiate over dose?
Naloxone is a partial opioid receptor antagonist used in opioid overdose and opioid-induced respiratory depression.
69
What are benzodiazepines used for?
```
sedation
hypnotic
anxiolytic
anticonvulsant
muscle relaxant
```
Sam HAM
70
How should you take someone off benzos?
The dose should be withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight. A suggested protocol for patients experiencing difficulty is given:
- switch patients to the equivalent dose of diazepam
- reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
- time needed for withdrawal can vary from 4 weeks to a year or more
71
What are the features of benzo withdrawal?
```
anxiety
loss of appetite
insomnia
irritability
perspiration
perceptual disturbances
seizures
tremor
tinnitus
```
72
What class of drug is Milnacipran?
SNRI
73
Which drug is contraindicated in anorexia nervosa/bulimia?
Bupropion is an atypical antidepressant which is commonly used for smoking cessation. It is however contraindicated in anorexia nervosa or bulimia nervosa as it lowers the seizure threshold and predisposed these patients to seizures.
74
Which antipsychotics typically cause galactorrhoea?
It most commonly occurs with risperidone but can also occur with the other antipsychotic such as olanzapine or quetiapine.
75
You are a medical student based in general practice. A 38-year-old male with chronic back pain presents for a repeat prescription of his amitriptyline. What is the mechanism of action of this medication?
TCAs action on the presynaptic neurone- not the postsynaptic. Their main mechanism of action is to inhibit the uptake of monoamines at the presynaptic membrane. They do this by binding to the ATPase monoamine pump within the presynaptic membrane.
76
How often do people on clozapine require blood tests?
- weekly blood tests for the first 18 weeks
- every 2 weeks until 1 year
- every 4 weeks thereafter
77
What type of delusions are typical of psychotic depression?
Mood congruent. i.e depressing delusions.
78
What tools can be used to assess the level of depression?
Hospital Anxiety and Depression (HAD) scale and the Patient Health Questionnaire (PHQ-9).
79
How is agranulocytosis diagnosed?
The diagnosis is made using a full blood count, which will show an absolute neutrophil count < 500 cells/mm³. The main treatment of agranulocytosis consists of the removal of the offending drug, in this case clozapine.
80
A 19-year-old woman is being by a psychiatrist due to her eating habits. She admits to binge eating followed by self-induced vomiting for the past 6 months. On physical examination, her body mass index (BMI) is 20 kg/m² and she has enamel erosion.
Which of the following acid-base and electrolyte abnormalities is most likely associated with her eating disorder?
metabolic alkalosis, hypokalemia and hypochloraemia
81
What are ddx for anxiety?
- GAD
- hyperthyroidism
- cardiac disease
- medication-induced anxiety
Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants and caffeine
82
How do you manage GAD?
NICE suggest a step-wise approach:
step 1: education about GAD + active monitoring
step 2: low intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
step 3: high intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
step 4: highly specialist input e.g. Multi agency teams
83
What medication could you consider for GAD?
Sertraline.
For patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month
84
How do you manage panic disorder?
Again a stepwise approach:
step 1: recognition and diagnosis
step 2: treatment in primary care - see below
step 3: review and consideration of alternative treatments
step 4: review and referral to specialist mental health services
step 5: care in specialist mental health services
Treatment in primary care
NICE recommend either cognitive behavioural therapy or drug treatment
SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
85
What is knight's move thinking?
In Knight's move thinking there are no discernible links between the topics that the patient jumps between in conversation. This is known as loosening of association. Associated with schizophrenia.
86
What is circumstantiality?
Circumstantiality is the inability to answer a question without giving excessive, unnecessary detail.
87
What is tangentiality?
Tangentiality refers to wandering from a topic without returning to it.
88
What's the term for new word associations?
Neologism
89
What's it called when ideas are related to each other only by the fact they sound similar or rhyme?
Clang association
90
What's the term for completely incoherent speech where real words are strung together into nonsense sentences?
Word salad
91
What's the term for repetition of ideas or words despite an attempt to change the topic?
Perseveration
92
What's the term for the repetition of someone else's speech, including the question that was asked?
Echolagia
93
What's the term for severe restlessness?
Akathisia
94
The risk of developing schizophrenia if one monozygotic twin is affected is approximately:
50%
95
What's the risk of schizophrenia if a relative has it?
monozygotic twin has schizophrenia = 50%
parent has schizophrenia = 10-15%
sibling has schizophrenia = 10%
no relatives with schizophrenia = 1%
96
What's the personality type?
prefer to be alone, don't like relationships, low libido
Schizoid
97
What's the personality type?
nightmare boyfriend/girlfriend, severe sudden mood swings, rages, self harming, intensely jealous.
Borderline
98
What's the personality type?
Rely on reassurance of others, rely on others to make decisions.
Dependent
99
What's the personality type?
don't trust anyone including partners, fear people lie or will harm them.
Paranoid
100
What's the personality type?
people generally have unusual beliefs and behaviours
Schizotypal
