What can be seen on neuroimaging for PTSD?
Decreased hippocampal volume
Why shouldn?t you use methylphenidate under 6 yo?
MC AE is decreased appetite so can cause to fall off growth curve
What may be a CC in a woman with AE from antipsychotics affecting the tuberoinfundibular pathway?
What is the mgmt of mucormycosis?
Surgical debridement and amphotericin B (look for in DKA, leukemia)
Name 3 MAOI's
Phenelzine, Tranylcypromine, and selegiline
What is required for delusional disorder?
Presence of NONBIZARRE delusions for > 1 month
Pts with a FMHx of _____ are at increased risk of trichotillomania? Tx?
OCD (ego dystonic); CBT
When should pts technically get vaccinated perioperatively for splenectomy
14 days prior or 14 days after (HiB, pneumococcus, and meningococcus)
What is the major AE of azathioprine?
Dose related diarrhea
What is the best immediate mgmt of frostbitten extremity?
Rapid re-warming with warm water; NO IMMEDIATE ATTEMPT AT DEBRIDMENT
T/F: imaginary friends are normal
True in kids 2-6; tend to abandon the imaginary friends when starting elementary school
What is the greatest risk factor for completing homicide
Access to GUNS
How do you treat acute mania?
Antipsychotic plus a mood stabilizer because faster onset than mood stabilizer alone! Then taper off the antipsychotic
What is required to dx adjustment disorder?
Development of emotional or behavioral sx WITHIN 3 MONTHS of identifiable stressor (not go longer than 6 months)
OCD may develop in a kid after what infection?
Streptococcus pyogenes pharyngitis (PANDAS)
Are genetics relevant to Bipolar?
yes it has one of the strongest genetic components of any psychiatric disorder (if primary relative risk is 5-10%, if both it is 60%)
What is MOA of cyclosporine and what is the MC AE?
Inhibits transcription of IL-2; nephrotoxicity (can also cause gum hypertrophy)
Why may a person with heat stroke bleed?
There can be coagulopathic bleeding likely from denaturation of the proteins
What can you do for pts with symptomatic cholelithiasis who don?t want surgery?
Ursodeoxycholic acid and avoid fatty foods
Where is the MC site of lacunar infarct? What would this cause?
Posterior limb of internal capsule; pure motor stroke (i.e. due to htn and small vessel lipohyalinosis)
What can be seen on neuroimaging for autism?
Increased total brain volume
What do you do in a pt with newly dx'd cirrhosis and nonbleeding varices who also has asthma?
Endoscopic variceal ligation because cant give nonselective BB
What are some tests you should order prior to starting lithium?
BMP (for kidneys, i.e. serum creatinine), TFT's for baseline thyroid fxn, and B-hCG if a woman to prevent Ebstein's
What is the MC electrolyte in Addison's?
HYPONATREMIA, but hyperkalemia is prob the one you'll pick up on in a question
How do you manage acute exacerbations of MS? What if no response?
What are the 2 major types of acute dystonic rxn
Torticollis and oculogyric crisis
What do you call factitious disorder when the pt is willing to consent to invasive procedures?
What is the best course of action when a patient is having command auditory hallucinations?
Hospitalize the patient involuntarily ESPECIALLY if telling the pt to hurt self or others
Ketamine and PCP both cause what physical sx? What class of drug?
T/F: midazolam is a good drug for panic attacks
False it is used for conscious sedation, consider lorazepam
What should be suspected in pt with COPD who has catastrophic worsening of their COPD?
Ruptured apical bleb (i.e. pneumothorax)
What does the term "Response" refer to in psychiatric illnesses?
50% reduction in symptoms, different from remission which is no sx
What is the timeline for brief psychotic disorder, schizophreniform, and schizophrenia?
Brief psychotic = less than a month; schizophreniform less than 6 and schizophrenia is after 6
How should pts with folie a deux be interviewed?
SEPARATELY (shared psychotic disorder)
What is the major AE of mycophenolate mofetil?
What may you want to think about in a pt with chronic cough productive of mucopurulent sputum?
Bronchiectasis (check CT)
What can be seen on neuroimaging for OCD?
Orbitofrontal cortex and striatum abnormalities
When do you surgically remove brain mets vs. whole brain radiation
Solitary met = surgery; Many mets = whole brain radiation and need to watch for herniation
When does hypochondriasis often develop?
During periods of stress, so you should ask about recent stressors
When can unemancipated minors consent to their own medical procedures
ONLY if it is a true emergency but still try to get parents!!
What is required to dx schizoaffective disorder?
2 weeks of psychotic sx in the absence of mood sx (need to rule out primary mood disorder with psychotic features)
What drugs are used acutely for panic attacks? What are used long term?
What enzyme is inhibited by lithium?
Inosotol-1-phosphatase in neurons
Which personality disorder had chronic feelings of emptiness?
What bug is most likely to be isolated from a secondarily infected allergic contact dermatitis?
What can paroxetine cause in newborns of mothers taking it?
Persistent Pulmonary HTN
In whom do you commonly see otosclerosis?
Young adults 20-30's, conductive hearing loss
Why can chronic NSAID use cause hyponatremia?
NSAIDs potentiate ADH and can lead to SIADH
Why do anorexics often need to be hospitalized?
Due to dehydration or electrolyte imbalances and to monitor for sx of refeeding syndrome
What is the general mgmt for schizoaffective pts?
Antipsychotic + whatever they need for mood i.e. SSRI if depressed, lithium or mood stabilizer if manic
Which benzo is preferred in preventing DT in a pt with cirrhosis?
Lorazepam because renally excreted (hope they don?t got dat hepatorenal syndrome doe!)
Why may hairy cell leukemia cause a dry tap?
It induces bone marrow fibrosis and myelophthisic process leading to the extramedullary hematopoiesis that causes the characteristic splenomegaly
What do you do if you suspect ischemia but EKG is normal
What risk do valproate and carbemazipine pose to the fetus?
Neural tube defects
Tx of antipsychotic induced parkonsonism?
What is the mgmt of choice for generalized anxiety disorder?
SSRI and cognitive behavioral therapy (avoid benzo's b/c substance abuse)
What is the MC cause of constrictive pericarditis in a foreigner? US?
TB; pmhx radiation
What is the immediate tx of NMS?
DC the antipsychotic and give dantrolene, monitor in ICU (more nurses per pt, better monitoring)
What is a major AE of giving recombinant EPO in pts with CKD induced anemia?
Worsening of HTN; also if low iron stores it will precipitate a microcytic anemia
Which EPS is not primarily treated with benztropine?
Neuroleptic malignant syndrome, requires dantrolene!!! Also acute dystonic rxn can be txd with diphenhydramine or benztropine; Tardive not really fixable
What is the significance of Streptococcus gallolyticus?
i..e S. bovis can cause endocarditis in setting of CRC, do colonoscopy
What are the lights criteria
1) pleural fluid protein:serum protein > 0.5 2) Pleural LDH:Serum LDH > 0.6 or 3) Pleural LDH > 2/3 upper limit of normal of serum LDH
What is the significance of Clostridium septicum?
It is a normal gut flora and in CRC it can get into blood stream and cause a spontaneous gas gangrene secondary to hematogenous spread; treat and do colonoscopy
What should be considered in any child or adolescent that has major changes in emotion, behavior, or social circles?
How do you treat exertional heat stroke?
Rapid cooling and supportive mgmt (don?t think it?s the same for nonexertional, i.e. old ppl)
What can be seen on neuroimaging in panic disorder?
Decreased amygdala volume
T/F: kids must legally be immunized
False but risks and benefits should be discussed with the parents; then document that this discussion took place
In acute mania if you had to choose between an antipsychotic and a mood stabilizer which would you pick?
Antipsychotic because it kicks in faster; in reality you give both for acute mania and taper off of the antipsychotic
What should all pts with hypothyroidism be screened for?
HLD; And all pts with HLD should be screened for hypothyroidism! (Recall Dr. John: hypothyroidism accelerates atherosclerosis, hyperthyroidism potentiates osteoporosis)
Why shouldn?t you give antipsychotics to ppl withdrawing from alcohol?
Lowers the seizure threshold
What is the best way to guide abx therapy in pts with acute bacterial prostatitis?
Obtain a midstream urine sample for bacteria and guide based on Cx
Which antipsychotic is least likely to cause EPS?
Clozapine but limited by risk of agranulocytosis
Which is synpharyngitic, IgA nephropathy or post-streptococcal GN?
IgA nephropthy (IgA in mesangium)
For whom is clozapine reserved for?
Pts who have failed 2 antipsychotics or who have suicidal thoughts
With which personality disorder is malingering heavily assoc?
Antisocial personality disorder
What is dissociative fugue?
They have to travel and they have to forget who they are
How is lithium cleared from the body?
Renally, that?s why its important to check creatinine prior to starting
What is the most common AE of ECT?
Amnesia (retrograde or anterograde)
Which SSRI has longest half life
What is maintenance therapy for bipolar after 1st bipolar episode? 2nd?
AT least 1-2 years; lifetime
When is colonoscopy screening for CRC indicated in UC?
8 years s/p dx and then repeat every 1-2 years
What sx preceding a liver abscess point you towards E. histolytica? Tx?
Bloody diarrhea; metronidazole
What is DOC for atypical depression?
What TCA is used for tx of OCD?
What is the best tx for noncompliant schizophrenics?
Long-acting injectable! ONLY if they were treated but noncompliant not if they were refractory
What is the most critical first step for lactic acidosis in shock?
A very low pleural fluid pH likely indicates?
When can bicarb be used in acidosis?
Rarely only if pH
What are 3 psych drugs that can cause agranulocytosis?
Clozapine, carbamazepine, and mirtazepine
Where do you see the double duct sign?
What is the preferred stimulant for narcolepsy?
Modafinil (and regularly scheduled naps)
How long should you wait prior to starting an SSRI after discontinuing an MAO-I
4 weeks to prevent serotonin syndrome (Tx = dantrolene, cyproheptadine)
Does a schizophrenic patient who is not acutely psychotic have decision making capacity for surgery?
What is the major difference between avoidant personality and schizoid?
Avoidants desire to have friends whereas schizoids do not
What is the mgmt of 1st degree AV block? PR length?
Observation (no real clinical significance); PR > 200
What characterizes the autism spectrum disorders?
Impairments in communication and social interaction with repetitive/stereotyped behaviors and abnormal reactivity to sensory input
What are 3 types of delusions?
Paranoid, grandiose, or somatic (fixed false beliefs that DO NOT respond to reason)
What effect do OCD and OCPD have on ego?
OCD is ego dystonic, bothers them; OCPD is ego syntonic, they have no idea
Why cant you give bupropion with MAOI's
T/F: a pregnant woman has the right to refuse certain treatments even if it puts the baby at risk
T/F: a 21 year old can develop tourrettes
False. Must develop prior to 18
What is first line tx for OCD?
SSRI or clomipramine (TCA) and CBT
What kind of meds often precipitate hepatic encephalopathy?
Sedative medications like benzos (contraindicated!) or hydrocodone
When do terminal patients need SSRI's?
If they meet criteria for MDD, i.e. not just normal grieving but hit 5 SIGECAPS
What is the cause of scabies
What does heroin withdrawal present like?
RHINORRHEA, sweating, muscle aches with severe sx OOP to physical findings
What is the best tx for akithisia?
What do you do if a cervical LN is positive for SCC?
Triple endoscopy = EGD, laryngoscopy, and bronchoscopy
What should all pts with a nonprovoked first seizure get?
Non-Contrast CT of head to r/o bleeding
How long should you wait prior to switching SSRI's if one doesnt seem to be working?
What should a pt with renal dysfunction and bipolar receive?
Valproate? NO LITHIUM
what are the EKG findings of ventricular aneurysm?
Q waves and persistent ST elevation
What causes renal papillary necrosis in sickle cell?
The hypoxic renal medulla can cause sickling of RBCs' and can cause papillary necrosis; predisposes to renal medullary CA
What should you use to manage HTN in a pt presenting acutely with weight loss and erythema of the septum and nasal turbinates?
CCB's for cocaine overdose, BB's can lead to unopposed alpha
What is the best thing to do if a healthcare proxy disagrees with a living will?
Meet with BOTH the healthcare proxy and the family to have a meeting
Crystal-Induced nephropathy is a well known AE of what AIDS med
Indinavir (protease inhibitor)
What can be seen on neuroimaging for schizophrenia? Also seen in???
Increased ventricle size (lateral ventricular widening); Huntington's due to degeneration of caudate (makes up lateral wall of lateral ventricle)
What drug prevents urate nephropathy from TLS? What drug can prevent damage from pre-existing urate?
What physical exam technique should never be done in febrile neutropenia?
What is the major AE of abacavir?
What is the best diagnostic test in a pt with amaurosis fugax? What are the cholesterol particles in the eye called?
Duplex US of neck; Hollenhorst plaques
What is the major cause of post-ictal acidosis?
Post-ictal hypoventilation (i.e. respiratory acidosis)
What do you do in a lifethreatening situation where a wife is saying her husband is Jehovah's witness and doesnt want blood but you have no documentation from the pt?
Fuck the bitch give the damn blood!
What do you do for nonbleeding esophageal varices?
Give a nonselective BB i.e. propanolol or nadolol for primary ppx against bleeding (if given before they ever develop, then it is pre-primary prevention)
What is the best drug for dysthymia
What are the effects of antipsychotics on the 3 main DA pathways?
Mesolimbic (antipsychotic efficacy), Nigrostriatal (EPS), and tuberoinfundibular (hyperprolactinemia)
What characterizes Torrette's?
Onset before 18 with multiple motor and 1 or more vocal tics (Tx is antipsychotics or clonidine for lower AE proflile)
Hoarding disorder is a type of what disorder? Responds to what?
OCD (ego dystonic); responds to SSRI's and CBT
How could furosemide lead to ventricular tachycardia?
Causes hypokalemia and hypomagnesemia both of which predispose to arrhythmias
Lithium decreases rates of what in bipolar (3)?
Relapse, suicide, and hospitalizations
What SNRI is given in pts with fibromyalgia refractory to exercise?
Duloxetine; also TCA's are common
What are the 2 main reasons to start ACE-I in DM?
If pt has HTN or microalbuminuria
Which standard AMI med is CI if the pt presents with MI and flash pulmonary edema? What should you give?
BB (because this is new onset acute decompensated CHF); Furosemide
When can you share patient information to other docs in a group practice?
Only when the dr is directly involved in the patients care
Though Hodgkin lymphoma is often curable in young ppl what is the major future issue in young ppl tx'd?
Treatment related MDS or AML; i.e. secondary malignancy and these do not respond as well to chemo and often have complex cytogenetics
Which arteriole is affected by angiotensin II
How long does somatiform disorder have to last?
> 6 months
What is the MC AE of methylphenidate?
Depressed appetite (don?t give to young kids under 6 because can fall off growth curve)
What is the mgmt of Tourette's?
Antipsychotics or for lower side effect profile, clonidine
What drug is contraindicated in acute MI with new onset JVD and clear lungs?
NITRATES, i.e. RV infarct (check right sided leads) give fluids
T/F: after resumption of normal eating patterns pts with PMHx of anorexia are at increased risk for small for gestational age baby
how long should a single episode of depression be treated for
At least 6 months
What is the most common AE of olanzapine?
Sedation and WEIGHT GAIN, also has metabolic AE such as metabolic syndrome and frank DM II
What do you give in acute esophageal hemorrhage?
ABC's and IV octreotide
What is hypochondriasis?
Characterized by misinterpretation of bodily symptoms and persistent fear of fatal illness despite negative tests; develops during times of stress
How do you manage Warfarin Skin Necrosis?
DC warfarin and give Protein C Concentrate
Define heat stroke
Core body temp > 40 C with AMS
When can a physician disclose pt information to an employer?
ONLY if the pt has provided either written or verbal consent; you should only ever disclose the minimum necessary information
What is opisthotonus?
Back spasm (i..e acute dystonic rxn, tetanus)
What do you do if there is sexual dysfunction in SSRI's?
What can often normalize homocysteine levels in hyperhomocystenemia?
B6 and folate (B6 is a cofactor for Cystathione B synthase)
What is Russel's sign?
Scars on the hands and knuckles from self induced vomiting
Why would diabetic autonomic neuropathy cause incontinence
Overflow incontinence due to neurogenic bladder (high post void residual)
How do you tx syphilis in pts allergic to pcn? What if pregnant?
Doxycycline; desensitize to pcn then give benzathine pcn G(i..e cant give preggo doxy)
What are the main AE of antipsychotic action on the tuberoinfundibular pathway?
Gynecomastia/galactorrhea and decreased libido
What is the strongest indicator of suicide attempt?
Prior suicide attempt
Lid lag and tremor are commonly seen in what?
Graves dz; also thyroid bruit is pretty specific
What cause of restricive CMP is reversible? Dilated?
Hemochromatosis if control ferritin levels with phlebotomy; alcoholic if DC alcohol
What are 2 tx options for scabies
Topical 5% permethrin neck down left overnight; PO ivermectin
What is the MC location of ectopic foci for atrial fibrillation? Atrial flutter?
Pulmonary veins; Tricuspid annulus
What is the first line therapy for specific phobia?
behavioral therapy (Don?t pick benzo!!)
What hematologic disorder can occur with carbamazepine? What atypical antidepressant can also do it?
What is alcholic hallucinosis?
Predominately auditory hallucinations that develop often 12-24 hours after no alcohol, NOT the same thing as DT's