pm Flashcards
(45 cards)
A 45-year-old man taking chlorpromazine for schizophrenia develops involuntary pouting of the mouth. What side-effect of antipsychotic medication is this an example of?
tardive dyskinesia - acute dystonia is involuntary postures
paranoid personality disorder vs schizotypal
Paranoid personality disorder (PPD), another cluster A personality disorder shares some similarities to this presentation, though is distinct. PPD shares the suspicious and mistrustful nature (which can verge on psychotic) of SPD, like how this patient is mistrustful of his local community. However, suspicions of PPD tend to be more focused on feelings of perceived threats and insults towards the individual, with PPD being less associated with social isolation as a result of disinterest as in SPD. PPD is associated with ‘positive’ symptoms such as paranoid ideas, but ‘negative’ symptoms such as social isolation are not prominent.
Patients ≤ 25 years who have been started on an SSRI should be reviewed after
1 week
A 26-year-old musician attends an appointment with his general practitioner to seek help for his anxiety. He describes worrying a great deal about social interactions with others. He prefers to be alone and doesn’t like to share his beliefs with others, which others find odd.
After prompting the patient to talk about his beliefs, he talks in a high-pitched voice about horror movies and his ‘spirit-guide’ that helps keep him safe.
The patient denies visual or auditory hallucinations and exhibits no delusional thinking. There is no pressure of speech.
What is the most likely diagnosis?
The correct answer is schizotypal personality disorder. Individuals with schizotypal personality disorder characteristically show ‘magical thinking’ that focuses on paranormal phenomena, evidenced by the patient’s discussion of a ‘spirit guide’. Those with schizotypal personality disorder may also have odd speech, such as that high-pitched voice the patient uses during the consultation.
Schizoid personality disorder is incorrect, as this is characterised by social isolation, a lack of interest in sexual relationships, emotional coldness, and a preference for solitary activities.
A 25-year-old man has changes in mental status. Over the last month, he has stayed up most nights and is writing to finish 4 novels at the same time. He has not left home or eaten during the last week and refuses to, and has started gambling.
During the consultation, he is easily distracted and replies to questions with sentences that do not make sense, made of random words, so a collateral history was used. There is no drug misuse. He is being treated for depression.
When his family have tried to understand his behaviour, he accuses them of wanting to ‘hold him back from achieving fame’.
What is the most likely diagnosis?
bipolar type 1
Disorganised speech in the form of ‘word salad’ is associated with psychosis and mania
Bipolar disorder (type I) is correct. This patient has presented with elevated mood and energy following treatment for depression, which can often be the first way a patient with bipolar disorder presents, due to antidepressants unmasking it. Although there is no clear psychotic thought at first glance (such as believing oneself to be royalty) that would immediately suggest a diagnosis of bipolar I, the presence of disorganised speech in the form of ‘word salad’ is evidence of psychosis which suggests this diagnosis. A ‘word salad’ is evidence of psychosis characterised by total loss of association characterised by random words strung together in sentences that do not make sense. This is different to racing thoughts (rapid succession of thoughts that are continued without restraint) and pressured speech (speaking faster than usual), which are seen in both bipolar I and II.
Bipolar disorder (type II) is incorrect. Although at first glance there is no clear psychotic thought (such as thinking of oneself as royalty), this patient is speaking in a ‘word salad’, which is evidence of psychosis, supporting a diagnosis of bipolar I over II according to the DSM-V criteria. This is different to racing thoughts (rapid succession of thoughts that are continued without restraint) and pressured speech (speaking faster than usual), which are seen in both bipolar I and II. As well as this, he has not slept or eaten in the last week, which suggests severe functional impairment necessitating hospital admission, which further supports a diagnosis of bipolar I over II.
bipolar 1 vs 2
An 82-year-old man is brought to his GP by his wife. She is concerned that he cannot recall significant parts of his past, such as his previous job and their former address. He also notes that he has difficulty sleeping at night. These symptoms appeared suddenly and have persisted for the past month.
Which option is the most likely diagnosis?
depression- short history and rapid onset
vascular wld have stepwise decline followed by periods of stability
what is one of the strongest risk factors for future suicide completion
A previous suicide attempt
unemployment is a RF but not as high as previous attempt
what drug should never be given with SSRI
rasagaline - SSRIs and MAOIs should never be combined as there is a risk of serotonin syndrome
slightly raised WBC in pt taking lithium with no symptoms management
Lithium can precipitate a benign leucocytosis - safety netting for infective or malignant signs, and continuing the normal monitoring schedule is most appropriate in this case.
An 80-year-old man visits the clinic with their family, who report that the patient has been experiencing memory problems, difficulty concentrating, and a lack of interest in previously enjoyed activities for the past two months.
What is the most likely diagnosis?
major depressive disorder
A 40-year-old man presents with feelings of sadness, low energy, and difficulty concentrating that began after he lost his job three months ago. He reports increased stress about his financial situation and difficulty sleeping, but denies any history of previous depressive episodes or significant mood disturbances. He feels overwhelmed but is otherwise functioning relatively well in his daily activities.
adjustment disorder -
Adjustment disorder is correct because the patient’s symptoms of low mood and stress began in response to a clear external stressor (job loss). The symptoms are relatively mild and short-term, and there is no history of more severe mood disturbances or chronic depression, making adjustment disorder the most likely diagnosis.
Major depressive disorder (MDD) is incorrect because MDD involves more severe and persistent depressive symptoms that are not clearly tied to an external stressor. The patient’s symptoms appear to be a reaction to the recent job loss, which is more characteristic of adjustment disorder.
A 60-year-old-male goes to his GP complaining of forgetfulness for the past 2 months. He has difficulty remembering details such as leaving the kettle on and where he left his keys. He works as the director of a pharmaceutical company and describes stress at work. He also has difficulty sleeping at night. His mini mental state examination (MMSE) score is 26 out of 30. Patient answered ‘I don’t know’ to the last two letters when asked to spell WORLD backwards. His medical history includes hypertension and gout.
What is the most likely diagnosis?
Depression is the correct diagnosis in this case. The key features supporting this diagnosis include the relatively short duration of symptoms (2 months), presence of work-related stress, sleep disturbance, and a relatively high MMSE score of 26/30. The patient’s difficulty with concentration, as evidenced by his inability to spell ‘WORLD’ backwards, is a common feature of depression rather than a primary cognitive disorder. Depression in older adults often presents with cognitive symptoms, termed ‘pseudodementia’, which can mimic true dementia but is potentially reversible with appropriate treatment.
migraine meds avoided in SSRIs
sumatriptan
when is a direct switch possible with SSRIs with no cross tapering
When switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI a direct switch is possible
A 29-year-old woman is brought to the emergency department by the police after trying to break into a movie set. She stated that she was ‘only there to see the actor’ which whom she claimed she has a romantic relationship. She has never met the actor before though has repeatedly sent him letters over the years. She describes her mood as ‘excellent.’ She denies any auditory or visual hallucinations. Her appearance is normal and her speech is clear and unremarkable.
Given her behaviour, what is the most likely diagnosis?
delusional disorder - Erotomania (De Clerambault’s syndrome) is the presence of a delusion that a famous is in love with them, with the absence of other psychotic symptoms
anorexia features
Anorexia features
most things low
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
The tyramine cheese reaction is a classic side effect of MAOI (monoamine oxidase inhibitor) antidepressants, such as phenelzine. Consumption of foods high in tyramine (such as cheese) can result in a hypertensive crisis.
MAOI (monoamine oxidase inhibitor) antidepressants, such as phenelzine. Consumption of foods high in tyramine (such as cheese) can result in a hypertensive crisis.
Mirtazapine -what is a characteristic side effect
Mirtazapine - increased appetite is a characteristic side effect
Mirtazapine is an antidepressant that works by blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters.
Mirtazapine has fewer side effects and interactions than many other antidepressants and so is useful in older people who may be affected more or be taking other medications. Two side effects of mirtazapine, sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite.
It is generally taken in the evening as it can be sedative.
A 45-year-old man with schizophrenia taking chlorpromazine develops an oculogyric crisis. What side-effect of antipsychotic medication is this an example of?
The correct answer is Acute dystonia. An oculogyric crisis, which involves prolonged involuntary upward deviation of the eyes, is a type of acute dystonia. Acute dystonias are extrapyramidal side effects that can occur within hours to days after initiating or increasing the dose of antipsychotic medication like chlorpromazine. They are characterized by sustained, often painful muscle contractions leading to abnormal postures or movements.
ardive dyskinesia is another potential side effect of long-term use of antipsychotic medications, but it typically presents with repetitive, involuntary movements such as grimacing, tongue protrusion or rapid blinking rather than oculogyric crisis.
clomipramine SE
Dry mouth (anticholinergic) and weight gain (antihistaminic) are side effects of clomipramine (TCAs)
A 28-year-old woman is reviewed in a psychiatric unit. When asked about her current interests, she starts by talking about her favourite childhood book, which was about a dog. She then moves on to talking about her childhood pet dog and playing in her garden. After this, she talks about an injury during adolescence while using a lawnmower and continues to talk about her teenage years.
When asked further questions, she demonstrates similar behaviour and talks slowly throughout.
Which option is the best description of her behaviour?
tangentiality - never returns to original topic
flight of ideas would be fast speech,
circumstantiality - XS detail but does answer question
If CBT or EMDR therapy are ineffective in PTSD, the first line drug treatments are
venlafaxine or a SSRI
negative schizophrenia symptoms
Negative symptoms suggestive of schizophrenia include:
incongruity/blunting of affect
anhedonia (inability to derive pleasure)
alogia (poverty of speech)
avolition (poor motivation)
social withdrawal
