Psych Week 1 Flashcards
A patient comes into the ER, is slurring their speech and has a very unsteady gate. You see in EPEC that they’ve been here for the same condition 8 times in the last two weeks. You try to take their history but they’re very confused. You begin to do a physical exam and you notice their eyes making involuntary/irrecular movements.
What pathology (i.e. diagnosis) do you think is occurring in this patient?
What component of the limbic system is usually affected?
Wernicke-Korsakoff (Thiamine/B1 deficiency)
Commonly occurs in alcoholics and presents as a triad of ataxia, eye movement abnormalities, and confusional states
Typically bilateral necrosis of mamillary bodies, but may also have medial diencephalic and other periventricular nuclei affected
Lecture 84b: Limbic system
Objective 5: Describe clinical syndromes associated with limbic system disruption
Fill in the blank
_______ (hormone) increases transmission of/sensitivity to glutamate and decreases synthesis of GABA resulting in a________ (higher or lower) seizure threshold
_______ (hormone) increases synthesis of GABA resulting in a ________ (higher or lower) seizure threshold
_______ (hormone) increases transmission of/sensitivity to glutamate and decreases synthesis of GABA resulting in a________ (higher or lower) seizure threshold
- Estrogen (more specifically estradiol, E2)
- Lower (more likely to have a seizure)
_______ (hormone) increases synthesis of GABA resulting in a ________ (higher or lower) seizure threshold
- Progesterone and allopregnenalone (metabolite of progesterone)
- Higher (less likely to have a seizure)
- Lecture 85b: Women’s Issues in neurology*
- Objective 2: Understand the role of estrogen and progesterone in determining seizure threshold*
Mechanistically, how are benzodiazepines and barbiturates similar? How are they different?
What does this mean in regards to the relative safety of these two classes of drugs? (i.e. which is safer and why)
Similar: The both activate the GABAA channel
Different; Benzodiazepines cause the GABAA channel to open more frequently while barbiturates cause the GABA-gated channel to open for longer duration.
Benzodiazepine exhibits a ceiling effect (you can only open a channel so fast!) and saturates at low anesthetic levels. However with barbiturates you can continue to increase sedation, potentially leading to coma or death.
Lecture 89b: Sedatives and Hypnotics
Objective 3: Explain why the benzodiazepines are relatively safe drugs to prescribe compared to the barbiturates and propofol.
One of your patients has been taking methotrexate for their severe rheumatoid arthritis. They mention during their appointment that they’ve noticed some tingling in their fingers during the day for the past two weeks.
What could be the cause of this?
The patient is probably deficient in folate (vitamin B9).
Methotrexate inhibits folate metabolism which results in impaired production of adenine, guanine, and thymine therefore impacting DNA synthesis. This commonly leads to a peripheral neuropathy being experienced by this patient.
Lecture 91b: Neurology and Nutrition
Objective 2: To describe neurological dysfunction related to nutritional deficiency
Match the following anticonvulsant medications with their mechanism of action
- Benzodiazepines (Lorazepam, Midazolam, Diazepam)
- Gabapentin (Neurontin)
- Barbiturates (Phenobarbital)
- Carbamazepine
- Tiagabine (Gabatril)
- Vigabatrin (Sabril)
- Ethosuximide
a. Blocks T-type Ca2+ channels in the thalamus in a voltage dependent manner
b. Bind to allosteric site on GABAA receptor, increase frequency of channel opening
c. Blocks voltage gated Na channels
d. Bind to allosteric site on GABAA receptor, increase length of channel opening
e. Increase GABA at the synapse by reversing direction of GABA pump
f. Inhibits catabolism of GABA by irreversibly inhibiting GABA transaminase
g. Selective GABA reuptake inhibitor
-
Benzodiazepines (Lorazepam, Midazolam, Diazepam)
b. Bind to allosteric site on GABAA receptor, increase frequency of channel opening -
Gabapentin (Neurontin)
e. Increase GABA at the synapse by reversing direction of GABA pump -
Barbiturates (Phenobarbital)
d. Bind to allosteric site on GABAA receptor, increase length of channel opening -
Carbamazepine
c. Blocks voltage gated Na channels -
Tiagabine (Gabatril)
g. Selective GABA reuptake inhibitor -
Vigabatrin (Sabril)
f. Inhibits catabolism of GABA by irreversibly inhibiting GABA transaminase -
Ethosuximide
a. Blocks T-type Ca2+ channels in the thalamus in a voltage dependent manner
Lecture 92b: Anticonvulsants
Objective 1: Describe mechanisms of action which are necessary medications used to treat seizures
A hospitalized patient is unconscious with no purposeful responsiveness to external stimuli. The patient will occasionally open her eyes unintentionally and show roving eye movements, and displays other signs of cycling between sleep/wakeful states. This patient is currently in a state of:
- Stupor
- Vegetative state
- Delirium
- Coma
- Minimal consciousness
B, this patient is in a vegetative state. Vegetative state is like a coma, but with return of some circadian rhythm that causes periods of eye opening, roving eye movements, autonomic changes typically seen with sleep/wake cycling, etc; still with no evidence of any awareness of self or the environment. Patients typically transition from coma to vegetative state in 10-30 days.
Other choices: In stupor, a state between alert and coma, patient can respond purposefully but requires constant stimulation to engage.
In delirium, a patient is in a state of fluctuating attention and cognitive clarity often accompanied by sensory misperceptions/hallucinations.
In a coma, the patient is in a state of unresponsiveness where the patient cannot be stimulated to respond purposefully; there is no evidence of awareness of self or the environment; no eye opening or evidence of circadian rhythm.
In minimal consciousness, a patient is in a state of severely impaired consciousness with minimal but definite behavioral evidence of self or environmental awareness.
Learning objective covered: Explain the observable, clinical differences between delirium, stupor, coma and chronic vegetative states (SM 83b)
During wakefulness, these 3 neurotransmitter systems are most active:
- Monoamines, MCH, VLPO
- Orexin/Hypocretin, VLPO, acetylcholine
- Acetylcholine, MCH, monoamines
- Orexin/hypocretin, acetylcholine, monoamines
D, as the three neurotransmitter systems active during wakefulness are: acetylcholine, monoamines, and orexin/hypocretin.
Objective: Discuss the neuroanatomy and neurophysiology of sleep and wake (SM 87b)
What is the best treatment for insomnia?
- Melatonin receptor agonists
- Behavioral therapy
- Benzodiazepine receptor agonists
- Orexin antagonist
- Light therapy
B. Cognitive behavioral therapy is the best treatment for insomnia, and includes: stimulus control (strengthening the bedroom and bed as stimuli for sleep), sleep restriction (limiting the time in bed to just actual sleep), cognitive therapy, relaxation techniques, and sleep hygiene education. Medications are only for short term use in most cases, and include: GABA agonists (zolpidem, eszopiclone, and zaleplon), (doxepin (histamine antagonist), ramelteon (melatonin agonist), suvorexant (orexin/hypocretin antagonist)).
The Ebb therapy headband is a device that can also be used for treatment of insomnia.
Objective: List the types of insomnia and identify therapy options (SM 88b)
You are talking to a friend when he has sudden spastic, automatic movements of his left upper body. You try to get his attention but he is unresponsive to your questions and appears to have no awareness and attention of his surroundings. This episode lasts for about 90 seconds. After this, he is confused and fatigued for the next 10 minutes, and has difficulty remembering what just happened.
Your friend most likely had a:
- Generalized tonic-clonic seizure
- Complex partial seizure
- Simple partial seizure
- Absence seizure
- Generalized atonic seizure
B. Complex partial seizures (Focal Seizures with impairment of consciousness/awareness) are focal (starting in one side) but are marked by impaired consciousness. The remain in one side, which makes them different from secondary generalized seizures.
Generalized tonic-clonic seizures cause loss of consciousness associated with an initial tonic phase of stiffening, a fall, and often an ictal cry. This is followed by a clonic phase of rhythmic extremety jerking.
Simple partial seizures do not have an alteration in consciousness.
Absence seizures are brief episodes of staring with impaired awareness and responsiveness. The person is immediately alert and attentive after.
Generalized atonic seizures are marked by sudden loss of postural tone, often with impaired consciousness. Duration is rarely more than one minute.
Objective: Be able to classify epilepsies and seizures and understand the difference between the classification systems (SM 90b)
What are the most common reversible causes of dementia?
What labs must be done to rule these out?
Reversible causes: Alcoholism and drug/medication toxicity
Labs and tests: CBC, CMP, U/A, tox screen, B12, TSH, Vit D, RPR, CSF, EEG
See Harrison’s Principles of Internal medicine
Objective: The learner will be able to describe the most common reversible causes of dementia. (SM 94b)
A patient is no longer able to remember how to tie her shoelaces.
What type of memory is affected, and what are the associated neuroanatomical structures involved?
Is this type of memory limbic-dependent?
Implicit memory, involving the basal ganglia and cerebellum.
This is limbic independent
Objective: Identify the neuroanatomical structures/networks relevant to both implicit and explicit memory (SM 93b)
This neuroanatomical network is found in the left hemisphere perisylvian region. Damage to this network can result in aphasia, agraphia, or alexia. What specific network is this, and what overall main type of network is this?
- Learning and memory, state
- Language, channel
- Executive functions; channel
- Language, state
- Executive functions; state
B. The language network is found in the left hemisphere perisylvian region
(includes Broca’s area and Wernicke’s area). It is a type of channel network, as it involves a specific type of information processing, while state networks set the tone of information processing in general (wakefulness/arousal/attention, and mood/motivation)
Objective: List and describe the major functional networks of the human brain (SM 95b)
What are the 5 steps in establishing validity in a psychiatric diagnosis?
To establish a psychiatric diagnosis, the five steps needed are:
- Clinical Description
- Delimitation from other disorders
- Follow-up study (including treatment response)
- Family study
- Laboratory studies
Objective: List three (out of five) steps of establishing validity in psychiatric diagnosis (SM 96b)
Delirium is a disturbance in ___________\_ and additional disturbance in cognition hat develops over a (short/long) period of time and tends to (stay constant/fluctuate) over the course of a day. Evidence from the history/exam/labs shows that the disturbance (is/is not) due to direct physiological consequences of another medical condition/intoxication or withdrawal/toxin/multiple etiologies
Attention and Awareness
Delirium is a disturbance in attention and awareness** and additional disturbance in cognition hat develops over a **short** period of time and tends to **fluctuate** over the course of a day. Evidence from the history/exam/labs shows that the disturbance **is due to direct physiological consequences of another medical condition/intoxication or withdrawal/toxin/multiple etiologies
Objective: Describe the DSM-V criteria for delirium (SM 86b)
