Pysc. Final I Flashcards

Question

A patient has ?Gonorrhoea. They have had a previous adverse reaction to penicillin. How does this change your treatment plan? [1]

Answer 1

**Give IM gentamicin and oral azithromycin**

Answer 2

The patients **height, weight and BMI** should be recorded - In those **under the age of 18**, the BMI should be **plotted on a centile chart**. Evaluate the **patient's hydration status** - dehydration can be significant, and may warrant inpatient management. **Vital signs:** - **bradycardia, hypothermia and postural blood pressure** drop are all red flags for severe disease. **Sit-up, Squat–stand test**: tests the patient's ability to sit up from lying and to squat down and stand back up. Scored from 0-3 with increasing risk with lower scores: * **0**: unable to complete action * **1**: requires the assistance of upper limbs * **2**: noticeable difficulty * **3**: no difficulty

Answer 3

Tricyclic OD is managed by **Sodium bicarbonate**

Answer 4

adults: **40mg** - adults over 65: **20mg** - adults with hepatic impairment: **20mg**

Answer 5

when **checking lithium levels**, the sample **should be taken 12 hours post-dose** after starting lithium levels **should be performed weekly** and after **each dose change until concentrations are stable** **once** **established**, lithium blood level should 'normally' be checked **every 3 months** **thyroid and renal function** should be **checked every 6 months**

Answer 6

**Elderly patients with dementia-related psychosis**: - There is an **increased risk of cerebrovascular adverse events and mortality in this population.** Use of antipsychotics should be carefully evaluated against potential risks. - In particular, **atypical antipsychotics** have been associated with an elevated **risk of stroke and transient ischemic attack in elderly patients**. **Parkinson's disease and Lewy body dementia**: - Patients may exhibit **sensitivity to the extrapyramidal side effects of antipsychotics.** **Epilepsy**: - Antipsychotics may **lower seizure threshold;** caution should be exercised with patients with a **history of seizures or EEG abnormalities**. **Cardiovascular disease:** - Antipsychotics, especially atypical ones, may cause **QT prolongation and postural hypotension**. Regular monitoring of **ECG** is recommended in patients with cardiovascular disease. **Liver and renal impairment**: - Dose adjustments may be necessary due to altered drug metabolism and elimination.

Answer 7

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)

Answer 8

For people at high risk, measure the serum sodium level **before starting treatment,** **2-4 weeks after starting** treatment and **every 3 months thereafter.'**

Answer 9

“Schizophrenia is a condition that affects how the brain processes information. **Normally**, the brain is **very good at understanding reality**, deciding what is important and **what is not, and organising thoughts in a structured way**. With schizophrenia, the **brain struggles to understand the world**, makes **mistakes** in **deciding what information is important and organises thoughts in a confused way**. This can lead to **strong beliefs that do not fit with reality, called delusions**. They may also **experience voices that are not there, called hallucinations**. The **disorganised thoughts** can lead to **unusual speech and behaviours**, which is called **thought** **disorder**. When these symptoms occur, it is called **psychosis**.”

Answer 10

Schizophrenia is considered to be the result of genetic and environmental factors. Specific genes that increase the risk of schizophrenia have been identified. Having an affected family member is a risk factor. - Social adversity such as **childhood trauma** or **neglect** can contribute to the onset of schizophrenia by **altering stress response systems.** - **Cannabis use, particularly during adolescence**, is a significant environmental risk factor. - **Prenatal complications such as maternal infections, malnutrition, hypoxia, or stress during pregnancy** may increase schizophrenia risk by disrupting normal brain development. - Several susceptibility genes have been identified through genome-wide association studies (GWAS) and candidate gene studies. Notably, variants in **DRD2, COMT, DAT1, and NRG1** are associated with schizophrenia. ## Footnote **NB**: now thought that person who has genetic predisposition to psychosis, who then experiences maternal infection, who then stress trauma, who then has dopamine excess in brain

Answer 11

**Psychosis** is the **central feature of schizophreni**a. The key features of psychosis, called **positive symptoms**, are: * **Delusions** (beliefs that are strongly held and clearly untrue) * **Hallucinations** (typically **auditory**; perceiving things that are not real) * **Thought disorder** (disorganised thoughts causing abnormal speech and behaviour) **Other key positive features are:** * **Somatic passivity** (believing that an external entity is controlling their sensations and actions) * **Thought insertion or thought withdrawal** (believing that an external entity is inserting or removing their thoughts) * **Thought broadcasting** (believing that others are overhearing their thoughts) * **Persecutory delusions** (a false belief that a person or group is going to harm them) * **Ideas of reference** (a false belief that unconnected events or details in the world directly relate to them) * **Delusional perceptions** **Lack of insight** is an important feature of psychosis. They lack awareness that the delusions and hallucinations are not based in reality.

Answer 12

**Negative symptoms** of schizophrenia include the **four As:** * **A**ffective flattening (minimal emotional reaction to emotive subjects or events) * **A**logia (“poverty of speech” – reduced speech) * **A**nhedonia (lack of interest in activities) * **A**volition (lack of motivation in working towards goals or completing tasks) AND **Cognitive impairment** - one of most important determinents of prognossi

Answer 13

CT/MRI head HIV and syphilis screen Drug testing Routine bloods including FBC and TFTs

Answer 14

**Lipid profile** (hypercholesterolaemia) **HbA1c** (diabetes) **Weight** **ECG** (QT prolongation) - Haloperidol, quetiapine

Answer 15

**Weekly** blood tests for **18 weeks** Then blood tests **every other week** till **first year** **Then monthly for rest of life**

Answer 16

**Symmetrical lesions** around 3rd ventricle (mammillary bodies)

Answer 17

**Anterograde amnesia, Confabulation**

Answer 18

**Wernicke’s plus** **Marked widening** in **frontal intratemporal fissure** **Reduced** **blood flow to frontal lobes** (fMRI)

Answer 19

**Stabilisation on Methadone** * Long half life opioid * Risk of diversion * Titration of dose * Gradual reduction **Treatment with Buprenorphine** * Partial agonist with strong affinity * Lower risk of diversion * Must be in withdrawal before using **Treatment with Naltrexone** * Opioid receptor antagonist * Long term prevention Generally Opiate withdrawal would be managed with harm reduction methods * This might include **opiate substitution e.g. with methadone and buprenorphine** * **Controlled detox** over a period of time. * **Withdrawal** can be monitored with a **COWS score** (Clinical Opiate Withdrawal Scale) **Overdose** * Overdose is a significant risk with opiates particularly those new or changing dose of opiates and IV drug users. * **Naloxone** would generally be issued to those at risk

Answer 20

**chest pain:** * **benzodiazepines + glyceryl trinitrate** * if myocardial infarction develops then primary percutaneous coronary intervention **hypertension**: - **benzodiazepines + sodium nitroprusside**

Answer 21

Opiate withdrawal presents with **diarrhoea, mydriasis, muscular aches, yawning, a runny nose and insomnia**. Patients show features of **sympathetic** **stimulation** with **tachycardia, hypertension and piloerection** (goosebumps). Likely that there is **difficult venous access;** therefore, it is likely that this man injects IV heroin and thus has damaged his veins.

Answer 22

Relapse can be prevented using **neltrexone** once detox is complete. Overdose can be managed with **naloxone**

Answer 23

**A Excessive anxiety and worry**, occurring **more days than not for at least 6 months**, about a number of events or activities **B The individual finds it difficult to control the worry** **C** The anxiety and worry are associated with at least three of the following symptoms: * **Restlessness** * **Being easily fatigued** * **Difficulty concentrating or mind going blank** * **Irritability** * **Muscle tension** * **Sleep disturbance** **D** The **anxiety/worry or physical symptoms cause clinically significant distres**s or impairment in important areas of functioning **E** The disturbance is not better explained by physiological effects of a substance, or by another medical condition

Answer 24

PM: **If functional impairment is mild low-intensity psychological treatments:** * **cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)** * If this is insufficient or can't engage in psychological therapy, then offer choice of either a course of an **SSRI or more intensive CBT (including ERP)** **If moderate functional impairment** * offer a choice of either a course of an SSRI (**any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)** **If severe functional impairment** * **offer combined treatment with an SSRI and CBT (including ERP)** **ZtF**: - **Mild OCD** may be managed with education and self-help resources. More **significant OCD** may require: * Cognitive behavioural therapy (**CBT**) with exposure and response prevention (**ERP**) * **SSRIs** * **Clomipramine** (a tricyclic antidepressant)

Answer 25

**HARD** - features of PTSD * **H**yperarousal/hypervigiliance: poor sleep, irritability, difficulty concentrating * **A**voidance: avoiding people * **R**e-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images * **D**ull/ emotional numbing - lack of ability to experience feelings, feeling detached **Features** * **re-experiencing:** flashbacks, nightmares, repetitive and distressing intrusive images * **avoidance**: avoiding people, situations or circumstances resembling or associated with the event * **hyperarousal**: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating * **emotional numbing** - lack of ability to experience feelings, feeling detached ZtF: Key symptoms include: **Intrusive thoughts** relating to the event **Re-experiencing** (experiencing flashbacks, images, sensations and nightmares of the event) **Hyperarousal** (feeling on edge, irritable and easily startled) **Avoidance of triggers** that remind them of the event (e.g., people, places or talking about the event) **Negative emotions** (e.g., fear, anger, guilt or worthlessness) **Negative beliefs** (e.g., the world is dangerous) **Difficulty with sleep** **Depersonalisation** (feeling separated or detached) **Derealisation** (feeling the world around them is not real) **Emotional numbing** (unable to experience feelings) ## Footnote **NB**: One of the DSM-IV diagnostic criteria is that symptoms have been present for **more than one month.**

Answer 26

**Two doctors & AMHP** (independent) to detain **Right of appeal to First Tier Tribunal** * Completely independent panel * Burden of proof is on the detaining authority * Bound to order the patient's discharge if not found to be detainable **Hospital Managers' meetings** **Consent to treatment after 3/12** Second Opinion Approved Doctor (SOAD) CQC oversight NR discharge ## Footnote Tribunal (judge, independent pyschiatrist and lay person) is majority decision whereas hospital managers (3 lay people) is unaninmous

Answer 27

Any patient can apply for hospital managers review at any point during their stay Tribunal: have to appeal within first 14 days of stay ## Footnote Can apply to both

Answer 28

**Section 4** - Section 4 is used to detain patients for up to **72 hours** in **urgent scenarios where other procedures cannot be arranged in time.** It requires an **AMHP** and **one doctor**. It is followed by a Mental Health Act assessment. **Section 5(2)** - Section 5(2) is used in **an emergency to detain patients** who are **already in hospital voluntarily**. - It lasts up to **72 hours and requires only one doctor**. It is followed by a Mental Health Act assessment. **Section 5(4)** - Section 5(4) is used in an **emergency to detain patients who are already in hospital voluntarily**. It lasts up to **6 hours and requires only one nurse**. It is followed by a Mental Health Act assessment.

Answer 29

If underlying **depression** - **sertraline** is used Agitation and irritability - **trazadone** **BDZ** - reduce agitation but risk of falls, sedation and worsening congition **Antipsychotics** - **2nd generation** have been linked with 2-3x increased risk of CV adverse events and death. BUT: re-exam of data shows that actual psychotic sx respond well - **1st generation**: have linked risk of EPSE and arrythmias - **Risperidone** is the only antipsychotic liscenced in dementia

Answer 30

Patients with histrionic personality disorder tend to be excessively attention-seeking.

Answer 31

1. **Psychomotor agitation** (agitated depression) and slowing much more common 2. **Psychotic depressive syndromes** much more present, think **Cotard**'s, **nihilistic delusions regarding poverty, status** 3. **Hallucinations** and **paranoia** can be a more prominent component 4. **Somatic** and **anxious** **symptoms** usually more marked than mood component

Answer 32

**Px for two years post remission** as relapses are more common and intense

Answer 33

**Persecutory delusions** the **more marked symptom** relating to commonplace themes e.g., spying neighbours, people entering their homes, theft, nihilism Negative symptoms and thought form disorder are much less common Can be very difficult to achieve symptom remission. Often highly debilitating.

Answer 34

**2 cardinal features of post-partum depression need to address**; - **Feelings of guilt and shame** - Ilccit these when look at others - e.g. how do you feel when you see other mothers? - **Feelings of detachment from the baby** - Do you feel love for your child? Do you feel disconnected? **Need to ask about risk** - do you ever feel like it would better that baby is without you? - AND - have you ever had feelings (fleeting) of not having baby

Answer 35

**Recurrent binge eating** * Clearly excessive amounts, defined period, loss of control, negative affect AND **Inappropriate compensatory behaviours** * E.g. purging, excessive exercise, fasting NELFT **at least weekly over last 3 months** AND **Not just during AN**

Answer 36

Any presentation that doesn't fit neatly into other categories - could be a mixed picture - e.g. symptoms haven't gone on long enough for 3 months - Or anorexic like behaviour, but started on large weight so aren't at low weight yet

Answer 37

Marked dietary restriction **WITHOUT** weight and shape concern

Pysc. Final I Flashcards

(61 cards)