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PSYCHIATRY -Mental Status exam is always always the Dx test of choice -Tactile -Tac tile hallucin hallucination ation (formication) >> Rx >psych. = cocaine, cocaine, DT DT -olfactory hallucination >> temporal seizures -flight -flig ht of ideas are connected unlike loose assoc. which whic h are not connected -Con struction structional al Apraxia Apraxia > > affe affected cted is non-d no n-d ominant om inant parietal lob lobe e -a woman woma n whose husband died is cooking and playing = DENIA L -as long as denial denial ptn is not interfering w Tx >> leave him alone and do nothing, nothing, if interfering w Tx >> Intervene - died baby baby >> his father shows shows no emotions emotions -OCD who is washing his hands hands all the time >> UNDOING -OCD wants to touch everything everything (O) so he thinks thinks that everything is dirty dirty (C) & this this is R eaction formation (act = undoi undoing, ng, thought = reaction formation) -Sublimation is the most mature defense defense m echanism echanism (kill baby baby >> abortionist) abortionist) -Depression = more than 2 weeks -depression -depression more comm on in woman woman but suicide suicide in men is more -5HIAA -5HIA A is low in suicide suicide and aggression (disinhibition) -Aggression -Aggression >> R x: SSRI -Dexa -Dex a suppression suppression test >> abn. (high cortisol) in depression ( also TRH T RH >> no increase in TSH) TS H) -The most m ost effective and best Tx for depre depression ssion is ECT -psychoTx (individual (individual or cognitive) + SS RI are are better better than SSR I alone -ECT is safe in preg. preg. (R elative C I are high ICP and heart heart problems) problems) -right -right side CVA >> Apathy Apathy >> Depre Depressi ssion on -The strongest genetic assoc. >> Bipolar 75% monoZygote -Dysthimia >> if more than 2 yrs (Depression (Depression will go away in 1 yr) -Grief >> Support PsychTx -after -aft er death >> denial denial > anger > bargain bargain > depression depression > accept (not necessary in order) order) -Schizo -Sc hizo >> 6 Mo (men are young young and worse) -High emotion fam ily >> SCHIZO (Tx: relax) relax) -CT w Ventricular enlargement >> SCHIZO (more neg Sx w that) -PET scan hypo frontal lobe -supportive -supportive psych Tx in SCHIZO not intrusive -SCHIZO -S CHIZO who is masturbating in public or making bizarre v oices >> Disorganiz ed type YOUNG + worst (paranoid type occurs in late and in men>), men>) , echolalia, coprolalia = catatonic catat onic -catatonic type (psychomotor) (psychomotor) fixed position position or won’t stop moving -Resedual -R esedual type >> NO POS POS Sx (no hallucination, nor delusion) delusion) but a lot of neg. Symptom s -Schizoph -Sc hizophreniform reniform >> less less than 6 Mo, B rief psychotic is less than 1Mo -Delusional -Delusional disorders disorders >> indi individual vidual pychoTx to make ptn trust u -Brief -B rief psychosis psychosis >> Rx Respirido Respiridoll before halloo -SOmatiz ation = a lot of of Sx of diff. diff. organs (D ON’T refer them them – it should should be one one physician – Don’t tell them u absolute absolutely ly healthy healthy – DO REGULAR VISIT) -Hit on head >> paralysed >> Conversion Conv ersion (MUST (M UST be a stressor) -CONVER SION >> 1 gain = keep keep internal stress out, 2nd gain from being being sick (labelle indifference = don’t don’t care c are about about the injury) even if blind >> no trauma no going into walls -Pain disord disorder er >> individual individual psychTx -Malingering the problem is Sx while in Facticious is clinical finding -Compuls -Com pulsion ion = EgoDYStonic, Impulsion = EgoSYNtonic -Aggression -A ggression out of proportion to the stressor >> Intermittent explosive Disorder (tend (t end to have head head trauma, traum a, lessens lessens w age) -Violence Disorders >> SSRI, Mood stabilizers, stabilizers, BB -BULIMIA >> KLEPTOMANIA -Mood -M ood personality >> lessens lessens w age, thought personality >> worsens w age -Alone + no concern concern = Schizoid -Stage -S tage II is the longest in sleep -Deepest stages = delta = III, IV -REM is the easiest easiest to arouse (R EM is is comm on in the 2nd half of sleep) -short R EM latency latency (60 in depressi depression, on, 10 in Narcolepsy, Narcolepsy, 90 NL) -REM -R EM decreases in percentage in elderly -BZD -B ZD shouldn’t shouldn’t be given for more than 2 weeks -ETOH, BA RB >> less less R EM -Depression -Depression >> less less DELTA -NARCOLEPSY NARCOLEPSY fe els refreshed refreshed after sleep sleep (ETOH WON’T) =
day -Nightmare = REM we remember > Rx: TCAs, Nightterror >> no remember -Night walk = Delta sleep -best long term T x for insomnia = behavioral technique (stimulus c ontrol) -Sexual ID >> 2nd sexual characteristics -sexual gender (whats in head) is feeled by 3yrs (determined by parents) -sexual rule = ext. behavioral -sexual orientation = who u chose to love -Premature Ejaculation >> Tx: stop and go, partner squeeze, SSR I -Paraphilia >> Rx AntiA ndrogens reduces the ugre -ETOH is the commonest cause of periodic impotence -if due 2 medical cause >> DM, if 2 psych >> FEAR -old antipsych >> alfa, muscainic, histaminic B LOCKER S -newer which causes EPS >> Respiridone (D2 like old –new D4+5HT) -mesolimbic block >> antipsych (C LOzapine selectively) -nigrostriateal block >> movement disorder -tubuloinfundibular block >> PRL -Young man is more prone to acute dystonia (Rx: anti-ch also for prev.) -elderly is more prone to EPS (parkinsonism) Rx: amantadine or anti-ch -TD will go away in sleep (high sens after chronic blockade) -After NMS u can regive it in lower dose (not CI) but no one will do it! -elderly who need typical >> halo better than chlorpromazine (CH) -Clozapine >> SE drooling, weight gain -Ziprasidone >> prolong Qt, OlanZ, CloZ >> DM -NO CATARACT IN QUEITIAPINE -IF compliance is an issue >> Haldol, Fluphenazine -TD in IRReversible in the exam -Nortryptiline, desipramine are the safetest of T CAs (less sedation) -Am ytriptyline is the worst of TC As (hypotension-AntiCH) -don’t switch Rx for depression until 6W -Doxipen is the most cause sedation -Citalopram (SSR I) and Bupropione >> LEAST SEXUAL DYSFx -OCD >> Citalopram -B upropion = works on dopamine -Lithium >> Acne, HypoT4 (do TSH). Nephro Di -IF LITHIUM TOX (GAIT D) >> DIALYSIS -Rapid Bipolar >> Divaloproex -Bipolar >> 1st LI >> 2nd CARB AMA, Divalo -TOPIRA MATE >> helps to lose weight -BUSPIRONE IS NOT ADDICTIVE (LIKE BZD) + NO WITHDRAWL -OTL (Oxazepam, Timazepam, LORA Z) don’t mess w P450 (liver disease) -Number one risk factor for suicide = ELDERLY? p rior -if one w depression has friend who comm itted suicide >> ask how his friend comm itted suicide -HIV >> this is secret don’t tell anybody in the exam -Erik Erikson >> based on experience -Preoperational stage (2-7) child blame themselves, don’t understand death, don’t understand (amount and volume – tall+thin > short+wide) low of conservation -Understand the death is irreversible at 9-10 (operational) -Adjustment D. >> supportive Psych. -Adjustment occurs within 3 Mo from the stressor and once it occurred it has 6 Mo to resolve. NO adj after death -mild MR >> 6th grade (can make decision), m oderate MR >> 2nd (DOWN), severe no work -Methylphenidate for ADHD above 6 , Dextroamphe tamin for above 3 yrs -Bell is better than Rx for enuresis -stranger anxiety start at 8 Mo to 2 yrs -Separation from 1-3 yrs -School phobia 3-5 yrs = separation anxiety DISORDER -Tourrette >> 50% ADHD, 40% OCD (high Dopa > Rx: Pimoside, haldol, respiridone) -Anxiety >> mo st commo n NT >> GABA (BZD) -Panic attack occurs wo precipitant (Alpra for short, SSRI for long, also IMI) -PANIC >> Drugs over psych – CLOmipramine for OCD -Acute Distress disorder lasts less than 1 MO after stressor (PTSD more) -internal locus of control ( u r the one who determine the f uture) -external locus of control (luck is the one who determine future – don ’t want stop smoking coz his friend smoked wo illness and dad died wo smoking >> more prone to illness of psych + medical) -PTSD can occur months after the stress (worse than immediately) -Buspirone can be DOC for GAD (coz long Tx needs R x wo addicting features like Benzo) -fear of speak in public >> social phobia (NOT PANIC - doesn’t have stress) -MiniMental Exam >> if lower than 24 >> dementia -Senile plaque is the most specific finding in Alzheim er -Vascular > m ale, HTN, Stepwise, younger -ALZ >> women, elderly, no Finding -Kluever-B UCY syn. Hypersexuality, hyperphagia, passivity (Amy gdala D.) -HUNTINGTON >> loss of GABA (chromosome 4) -
. . -Dissociative FUGE = Travel + when asked about name >> new name -Dissociative A mnesia = doesn’t know his name (aware of memory loss) -Am nesia GAPS =Dissociative Identity disorder = someone is making me crazy -girl thinks she is obese although she is thin = ANOR EXIA -Anorexia is worse when is late -WHAT KILLS IN ANOREXIA IS ELECTROLYTES D. ESP. HYPOKALEMIA -WHAT IS THE PERSONALITY DISORDER THAT IS ASS OC. W EATING DOSORDERS >> BORDERLINE PERSONALITY DISORDER -BULIMIA = LOW SEROTONIN >> R x: SSRI -KLEPTOMANIA ASSOC. W BULIMIA NERVOSA -woman: 5 feet = 100 pound, every inch = 5pound (IDEAL B ODY WEIGHT) -man: 5 feet = 106, every inch = 6 pound -u can’t take the urine wo ptn concent -the drug that will stay for long time in urine is MAR IJUANA -short >> CAC AINE (2-3d), M ARIJUA NA 30 d -Naltrexone for ETOH -AA is the most effective way to stop alcohol -Heroine >> Methadone then tape gradually -Most frequently used illict drug is marijuana -COCAINE >> PARANOID, COCAINE WITHDRA W >> DEPRESSION >> SUICIDE -com monest Opioid = heroine -PCP >> VIOLENCE (>> PUT HIM IN DARK Q UIET ROO M) -LSD >> FLASH BACK AFTER 10 YRS -Anabolic steroid >> PSYCHOSIS -U don’t have to stop the whole drug to have withdraw just lowering the dose is sufficient -Hx of ETOH >> Folic + Thiamine + BZD to prevent DT for 5 d ays (peak DT) KAPLAN B OOK -EGO: shortly after birth, reality, object relationship, defense m echanism -no emotions for died baby = ISOLATION -W AIS-R for Adults, WISC-R for Children, Stanford-Binet fo r MR, supe r -projective personality test: T AT, Rorschach, sentence completion, drawing -Objective personality test: MMPI -trav eling m an w drowsiness through the day + diff sleep at night + early awakening + not able to sleep again = Circadian rhythm sleep disorder -Resident chose to put off his pity to handle ptn = Suppression -man w poor self image gives 1/5 of salary to charity = Altruism ( hob gher) -Erik Erikson: yr 1= trust/mistrust 1-3= Autonomy/doubt (COOPERATIVE/STUBBORN) 3-5=initiative/guilt (sexual CURIOSITY) 6-11= Industry/inferiority 11-20= identity/Role 20-40=intim acy/isolation 40-60= generativity /stagnation >60= integrit/despair -After 2 yrs object permanence is achieved ( won’t cry if mom gone) -death is IRReersible at 7-11, lack low of conservation in 2-7 -see things in other’s perspective = 7-11 -IV Rx Abuser said that his hep.C is due 2 inadequate control of hep.C = DISTORSION (this is real but he is altering the pe rception of REALITY) -Rationalism = explain but this is unreal (f ailed coz diff. exam while exam was easy) -Autism risk factors: encephalitis, rubella, PKU, Tuberus sclerosis, fragile X syn., perinatal anoxia -ADHD >> Tx: multiple sensory modality for teaching, short instruction w repeat -Strangers anxiety: 8-24 Mo -Separation anxiety: 12-36 Mo -Conduct disorder >> Tx: Role models + no punishment -Tourette assoc. w ADHD 50% and OCD 40% -Conduct assoc. w ADHD -Coprolalia >> schizoid, Tourette -duration of Tx for depression is 6 Mo -Depression >> individual and cognitive psychTx -Dysthemic > 2 yrs + psych > Rx -seasonal affective disorder is caused by abn. Melatonin (low M SH) -Grief >> treated by supportive psychTx, can last up to 1 yr but most will resolve within 2 Mo (depression can last for more than 1 yr) -PP depression usually after 2nd child while PP psychosis after 1st child -MANIA IN PREG. >> NO LITHIUM NO DIVALOPROEX Rx: new anti-psych -non-psych mania > if less than 12 yr (DIVALOPROEX) more than 12 yr Li -UTD : DOC initially for Bipolar = Li -schizo >> early in men + worse -large ventricles + cortical atrophy in SCHIZO assoc. w NEG. Sx -hypo in frontal + hyper in basal ganglia = SCHIZO -SCHIZO >> supportive -Regression to primitive >> DISORGANIZED -Echolali, coprolalia >> CATATONIC -Paranoid in older, disorganized in youner -3 manic episodes >> life-long LIT HIUM -1 manic episode >> 1 yr if wo new episodes -AVIOD BZD IN PTSD (Rx TCAs, SSRI) -ANOREXIA W NL PERIODS OR NL BMI = not otherwise classified -BULIMIA WO BINGE = not otherwise classified -BULIMIA MUST HAVE BINGE-EATING AND PURGING -
-kids of alcoholic even if raised by others are prone to be alcoholics -SOMA TIZAT ION’s RELATIVES: in male (antisocial) in female (histrionic) -SOMA TIZAT ION = 4 pain, 2 GI, 1 sexual, 1 pseudoneuro -Con version assoc. w HYSTRIONIC, ANTISOCIAL, DEPENDENT -Pick’s cells = swollen neurons, Pick’s bodies = intraneuronal argentophillic inclusions -PICK assoc. W Kluver-BUC Y syn. = hypersex, hyperphagia, PASSIVITY -B ehavioral changes + Disinhibition = PICK -Urinary In. + Gait problem = NPH -Depressive ptn will answer When asked “I Don’t know” -Demented ptn will answer when asked “CONFABULATE” -HUNTINGTON = loss of GABA -ergic neurons + CAUDATE Atroph y -Commonest cause of amnestic disorder is ETOH -Wernicke = Nystagmus + Ophthalmoplegia + Ataxia -Monitor BP in ptn taking Bupropion for smoking cessation (seizures is CI) -mothe r don’t want to VACC her child >> respect her wishes wo telling h er husband -ACUTE CATATONIC SCHIZO >> ECT or BZD -Mother of child w osteogenic CA tells u that she is no longer c oncern about prognosis coz she saw a dream tells her that her child will live long >> Defense mechanism = FANTASY -Highest risk factor for suicide = prior suicide attempt -MAOI + TCA = NO reaction -MA OI for major atypical depression -Masturbate in public + laugh inappropriately = DISORGANIZED -Mem ory gap >BOOK> Dissociative amnesia although in videos it was identity -I wrote (~UW) Dementia rem ember some of events in the past while amnesia can’t -Head Trauma >> Dissociative FUGE -Covert sensiti zatio n: smoker is trained to imagine himself lyi ng on bed w lung CA in or der to s to p smoking -less anxiety w repeated entry to psych room >> Habituation -Atypical features of depression = heavy feeling of ext. “leade n p aralysis” -Parkinson w L-dopa + psychosis >> Rx: CLOZAPINE (least D2 antagonist) -Needle sharing >> TB -comm onest abused SUB STANCE in USA is EtOH -comm onest used ILLICIT (FORB IDDEN) is Marijuana -Crystal or ice = methAmphetamine -PCP >> Psychosis, Violence -Designer = XTC = amphetamineS -Date Rape Rx = Flunitrazepam -COCA INE, AM PH = Euphoria (Tx VIT .C) withdraw = depression -cannabis (marijuana) = slow sense of time, conj. Injection, increase appetite -Hallucinogens >> Dissociation + IDEA OF REFERE NCE (thinks a news in TV is abou t him) -Opiates withdrawal = colicky abd pain, fever, chills, RUNNY NOSE, YAWNING -Intermittent explosive D. = low 5HIAA -ARSON = like pyromania but the go al is to get mo ney from insurance co. -Amenorrhea may preceed abn. Eating d. in anorexia -Anorexia has intrest in making food but not in eating -Anorexia >> Russel sign, peripheral edema -Anorexia >> Tx: FAMILY Tx (not insight oriented nor psychodynamic) -Anorexia >> may burges water or put water in her cloth to appear that she is gaining weight -DON’T USE ANTI-PSYCH in Bulimia -Ano rexia >> loss in gray matter (ant. Cingulated cortex) -Absolute CI to BuP roP ion = EP ileP sy (CHF is relative) -Mania >> if less than a week >> hypomania -Large ears, prominent jaw, high pitched voice, large testes = FRAGILE X -2nd comm onest cause of MR is Fragile X after Down -Antisocial + B orderline >> lessens w age -Paranoid + Schizoid + Narcissistic >> worsen w age -SLEEP ST AGE I = loss of alfa + appearance of thata -ST AGE II = longest + K complex + Spindles -REM >> Bursts of sawtooth waves -BZD >> suppress STAGE DELTA III, IV -REM latency = 90 Min (10 in NAR COLEPSY, 60 in DEPRESSION) -ETOH + BARB >> suppress REM (+TCAs) -Depression = short REM latency, increased REM time, less delta -NARC OLEPSY feels refreshed after sleep (ETOH doesn’t) -CAT APLEXY is PATHOGNOMONIC for NARC O -Forced naps is TOC for NAR CO -hot bath before sleep is helpful in insomnia -Nightmare = REM = Rx TCA s -Night TERROR = Delta = Rx BZD -Sleep talking = ANY STA GE = NO Tx -Sleep W ALK ING = Delta = Rx BZD -Dysthemia-Anxiety D. >> Cogn itive behavioral Tx (replace bad w happ y) -Magical thinking >> Schizotypial -XanaX withdraw >> Seizures -
, -HOMO is not a disorder but variant! -Desire, Arousal disorders >> Individual psycho Tx -Fetishisim = non-living objects -Frotteurism = rubbing agains non-conconsenting partner -Voyeurism = observe a person -periodic impotence >> ETOH -Verbigeration = repeating meaningless word -Lithium >> Flare of psoriasis, metallic taste, intention tremor -Old APM: D2, Respirodone: D2-5HT-2, C loza: D4-2-5HT-2, other: D2-4-5HT -cardiac conduct w thioridazine -Acute dystonia w young age and Parkinson w elderly -CLOZAPINE: 5% SEIZURES + DROOLING -Respiridone >> MINIMAL SE DATION, CLOZA + OTHERS >> SIG. SE DATION -Panic >> IMIPRAMINE, PAIN >> AM ITRY LPILINE, ENURESIS >> IMI -ADs + Sedation + ANTI-CH = Doxipen, Am itrypliline -Tertiary TCAs = Amitryp, Clomipramine, IM Ipramine -Secondary TC As = Desipramine, Nortryptiline -sedation + orthostatic hypotension = teriary (IM I, AMI, CLO) -phenelZine, isocarboxaZide = MAOI = Sedative Z -Tranylcypromine = activating, LITHIUM >> ACNE -BuSpirone >> anXieolytic, Buprop ione = AD + smoking cessation (PiP e) -B uspirone = no addiction, no withdrawal, no additive effect w others -PANIC assoc. w ETOH NOT MVP -Feels used by others + do favors to them = D M: Reaction formation -Ganser syn = malingering o f prisone r (middle traffic light is blue) High-Yield -0-15 the goal is attach to mothe r (recogn ize parent at 6 Mo ) -15-3 0 the goal is separation -Stranger anxiety 7-1 1 (8) Kaplan 8-24 -Separation anxiety 12-15 Kaplan 12-3 6 -If hospitalized 15 -30 Mo (1 2-36 sep aration anxiety) FEAR OF SEPARATION -If hospitalized 30 Mo – 6 yrs >> FE AR OF PHYSICAL INJURY (sexual curiosity is 3-5 yrs) worst time for elective SURG -social smile >> 2-3 Mo -sits un assisted >> 5-6 Mo -lifts head when lying on his stomach >> 2-3 Mo -Turn over >> 5-6 Mo -forms an attachment w caregiver >> 5-6 Mo -Coo s, gurgles > > 2-3 Mo -Babbles (repe at single sou nd o ver and o ver) >> 5-6 Mo -Imitate soun ds, use gestures >> 7 -11 Mo -says first words >> 12-15 Mo (1yr) -Two-word sentence >> 15-30 (2yr) -Complete sentence >> (2.5-4 yrs) -PLAYS INDEPENDENTLY, NEGATIVITY (fav. Word NO) >> 1 5-30 Mo -Play parallel but not w anothe r child >> 2.5-4 yrs -Play w other children > > 4-6 yrs -Tolerate ho spitalization well >> 6-11 yrs -Dextroamphetamine for over 3 yrs, methylphenidate for over 6 yrs -unusual specific abilities in autisim (girls have more severe disease, more common in boys) -Asperger >> onset 3-5 yrs more in boys -Rett >> onset before 4 yrs like Autisim -CHILDHOO D DISINTEGRATIVE DISORDER = regression in verbal, motor, social after 2 yrs of NL Fx + ONSET 2-10 yrs -Tourette is linked to AD HD + OCD -Selective mutisim = speaks in home but not in school (more in girls) T x behavioral or family T x Precipitated by stressful event -Separation anxiety DISORDER: onset 7-8 (prior n ame school pho bia but he is afraid that his mo ther die rather than schoo l fear) -Sep aration anxiety disorder at RISK for AGORAP HOBIA -Reactive attachment disorder of infancy o r early childho od (inhibited type: failure to responde in a socially normal way, DISINHIBITED type: formation o f indiscriminate attachment to othe rs even if he h asn’t seen the m befo re) = stanger anxiety that don ’t wanna go away -During Bargaining ptn uses UNDOING as defense m echanism (I will never smoke again if the tumor goes away) -Tx of NL grief = short sedatives ( high-yield didn’t mention AD) -PHYSICIAN DON’T HAVE TO TELL PARENTS THAT HE SUSPECTS AB USE -demented 83 yr smells of urine + bruises + deny that anyone has harmed him >> Elder abuse (neglect + tying to bed + spiral fractures) -erection + ejaculation don’t have to occur to say RA PE -SODOMY = oral or anal penetration -no resistant required for rape -there is spousal rape (no one can mandate anyone even spouse for sex) -Consensual sex may be considered rape “statutory rape” if the victim is und er 18 or 16 or mentally ill
Pub lic Health: Self-Study -1-35 commonest cause of death is unintended injury -35-65 the commo nest cause is death is CANCER (this is for both sexes + female), over 65 is cardiac -MALE: 1-4 5 unintend ed injury, 45-55 he art, 55-65 CANCER, over 65 heart
-Top nongenetic cause of death is smoking -Whites have the highest rate of suicide -Suicide >> April – September (summer) -Adolescent suicide >> Decembe r – March (winter) -over 65 >> August (summer) -Report all abuses EXCEP T spousal abuse, give information about local shelters and counselling -comm onest surg procedures are 1-D&C 2-HYSTERECTOMY -alfa + beta = awake -eyes closed + relaxed >> alfa -active mental concentration >> Beta -REM period is 10-40 min -REM deprivation (sleep deprivation) >> Psychosis, anxiety -Dopa awakes u (SAND) >> APM causes u to sleep m ore -high NorEpi >> less REM and less sleep -high Ach >> more REM and more sleep -high serotonin >> more sleep S^ A^ N! D! -DAMAGE TO DORSAL RAPHE NUCLEI (which produce s serotonin) d ecreases slee p time and de lta sleep
*Slow pulse + respiration + low BP = STAGE I *Bed-wetting (enuresis) = STAGE DELTA *increased cardiovascular + erection = REM -DEPRESS ION >> short R EM latency, REM increased early in the night and decreases later -Narcolepsy occurs in adolescents and young adults -Dyssomnia = insomnia, hypersomnia, OSA, Narcolepsy, circadian rhythm sleep disorder -parasomnia = sleepwalking, terrors, nightmare -SLEEP TERRO RS THAT BEGIN IN ADOLOSCENT MAY INDICATE TEMPORAL LOBE EPILEPSY (terror should be in a child) -Nocturnal myoclonus and restless leg syn. >> Rx: CLONAZEPAM -Menstural assoc. syn occurs in the premenstrual syn (hypersomnia, hyperphagia) -Sleep drunkiness = diff awakening after adequate sleep (genetic factors) -K LEINE- LEVIN S yn. = recurrent hyperphagia + hypersomnia (K ol + sLeep) -In delirium loss of orientation to time first then place then person -Subcortical dementia = HUN, PAR K, HIV (inf. Demyeilnation) -ANS dysfx occurs in delirium not dementia -Delirium > > worse at night (sund owning) -EEG NL in dementia abn in delirium -Thiamine deficiency (wernicke, korsakoff) >> damage to mam millary bodies, hippocampus, fornix -“speed, ice, ecstasy” = amphetamine -“crack, freebase” = inhaled cocaine -“angel dust” = PCP -Tactile hallucination = Cocaine, Amph et. Use + DT -cocaine, amphet withdraw = myosis, hunger, depression -opiates: hypothermia, EUPHORIA -opiates withdraw: runny nose, mydriasis, piloerection, lacrimation, cram ps, yawning, fever -Horizontal + vertical nystagmus = PCP -FLASH BACK = RE EXPE IRENCE OF THE ASSOC SENSATION IN THE ABSENCE O F Rx = LSD -Decreased motivation “amotivation syn” = chronic marijuana -halluc. = high serotonin, sedation= high GAB A, euphoria= high dopa -Marijuana + Hallucinogens >> calm him down -arabic: thought blocking is pathognomonic to schizo -2 schizo parents >> 40%, Monozygotic >> 50% -schizo >> decreased size of hippocampus, amygdale, parahypocampal -Schizo: high serotonin (hallucination – 5HT-2 b locker is useful) , high NorEpi (PARANOID) , high dopa, loss of GABA -EEG in schizoid = decreased alfa, increased theta + delta + epileptiform -schizo >> decreased FSH, LH -Blue-gray skin discoloration >> chlorpromazine -R etinal pigmentation = thioR idazine -deposits in lens and cornea = chlorpromazine -good prognosis for schizo = female, positive Sx -B rief psychotic disorder comm on in histrionic + borderline -Schizophreniform impairment or social dysfx are not necessary for Dx -Schizoaffective (high-yield) MOOD > PSYCH -19 yr girl whose psych mother believes that police are going to arrest her begins to believe the same thing. This disappears when her mom is pit of state >> Dx Shared p sychotic disorder (folie a deu x) -Delusional disorder >> psychT x and trial of Pimozide or haldol -Cyclothemic + dysthemic >> more than 2 yrs -Depression >> hypochondriasis, somatic delusion (my inside rotting) -Depression is better in the evening (Diurnal variation) -The most rapid onset Rx for depression (no 3-6w) is Methylphenedate or dextraamphetamine -MA OI is usefull for atypical depression (mixed w anxiety) -unTx depression lasts 6-12 Mo (self-limiting) Mania >> 3 Mo -Depression w substance abuse >> Admit to hospital -severe depression has no energy to commit suicide but once A D Rx is given the risk of suicide increases -prediction of Depression that will be part of bipolar: 1- mania/hypomania after AD 2- Depression w psych Sx (remember arabi) 3- POST
-Bipolar Monozygotic 75% (schizo 50%), 2 parents 60% (Schizo 40%), 1st degree 20% (schizo 12%), general 1% (=schizo) -UTD+UW 1 st degree relative bipolar >> 5-1 0 %, general 1%, mono Z 75% -Rapid bipolar = more than 4 episodes annually (D ivaloproex) -Double Depression = depression + dysthemia between episodes -Anxiety = less GABA, Serotonin + more NorEpi -Separation anxiety disorder assoc. w P ANIC ATTACKS + AGORAP HOBIA -PTSD >> no good Rx although sertraline can be used -OCD >> decreased REM latency (like depression) -After stress >> if life-threatening (9/11-earthquake-rape) ASD /PTSD, after serious but not life-threatening events (divorce, bankruptcy) adjustment -B uspirone = no addiction + need 2-3 weeks to work (5HT1A) -40 yr woman repo rts nausea. This Sx causes he r to drop from work. E verything is NL > > Dx Somato form disorder no t otherwise specified (just like somatization but just few Sx) -Dissociative amnesia = selected memory loss (don’t remember the battle) -Dissociative identity disorder = 2 or more personalities -enjoy dating men but not any sexual act including kissing = sexual aversion d isorder -Progesterone inhibit desire in both men and women -Sexual position for ptn w MI is to have the partner in the superior position -ETOH + Marijuana increases sexuality but chronic ETOH decreases it -Amphet. Cocaine increase sexuality -Heroine and methadone decrease interest -Necrophilia = desire w dead bodies, Telephone sscatologia = talk about sex w unsuspected women -Distress about o ne’s sexual preferen ce = sexual disorder not o therwise specified (fo rmerly called ego -dystonic ho mosexuality) -For obesity: Sibutramine, Orlisatat -Most effective Tx for ANOREXIA is FAMILY Tx -arabi: Binge eating disorder = binge wo restriction wo purging wo concern about body image -arabi: PURGING MUST BE FOUNF FOR BULIMIA otherwise it’s BED -Night eat syn NES: eat at night wo rest. Wo purging wo concern about image -bulimia wo bing eating = NOS, Anorexia w nl BM I, menses = NOS -me: Binge eating purging MUST BE FOUND FOR BULIMIA -Intermittent explosive disorder assoc. w low 5HIAA >> Rx SSR I -Adjustment disorder >> impairment in social functioning -AS D >> do poorly in work -most effective Tx for adjustment >> SUPPORTIVE disorder -Adjustment >> no more than 6 M o -45 yr says after fired said that her boss looks lazy compared to her hard working >> Personality >> PARANOID -mA d = psychosis, Bad = substance abuse + somatoform + mood Sad = anxiety -passive-aggressive Personality = procrastinates (tomatel) + inefficient -Paranoid >> Projection, denial -Histrionic >> somatzation, regression, repression -Narcissistic >> denial, displacement -B orderline >> displacement, denial, splitting -OCPD: intellectualization, rationalization, Isolation of affect -BRONCHIAL ASTHMA assoc. personality = DEPENDENCY -CANCER assoc. w inability to express feeling, bereavement, after death -Migrane, UC >> assoc w OCPD -OBE SITY >> REGRESSION (whene ver upset, she e ats like a child) -SEVERE DEPRE SSION >> 3 Mo later >> PANCREATIC CANCER -Suicidal threat >> suggest hosp. voluntarily then involuntarily -Thioridazine belongs to low potency older APM (low APM = 2) -Lithium for cluster he adache -Buspirone is ineffective in ptn who took BZD o r ETOH -Altruism, humor, sublimation, supresssion = mature defense m echanism -Denial, splitting, projection are immature -15 yr boy w no Hx of conduct disorder steals a car after divorce of his parents >> D M: Acting out -Soldier doesn’t remember the battle >> DM: Dissociation -a man who was physically abused abu ses his children >> DM: Ide ntification -physician puts off his pity of ptn >> suppression (consc.) -Tx of paraphilia (esp. pedophilia) = aversion conditioning (c video tape of children with electric shock) -Flood ing + implosion = Tx for phobia (IMagine p lane = IMplosion , agree to ride plane of 14h = flooding) -Token economy (desirable behavior like shaving is awarded w token) for MR -Biofeedback for migrane, HTN, Raynaud, … (ptn c the monitor of BP and try to use mental techniques to lower his B P) -Cognitive therapy = replace negative thoughts w positive self-assuring thoughts for depression -Family therapy for substance abuse, eating disorders, family conflict, Behavioral problems in children (opp ositional defiant)
POISONING WORLD -Serotonin toxicity = hyperthermia, tachycardia, my driasis, diaphoresis, hypertension wo anti-cholenergic Sx -Cocaine = Euphoria, HTN, cardiac ischemia, tachy, ICH -ETOH withdraw = hallucination = delirium tremens = Rx: Chlordiazepoxide -Opioid withdraw = Piloerection, dysphoria, abd. Pain, dilated pupils = Rx: Methadone -TCAs toxicity >> NaHco3 by Na red uces the block of Na chann els no t by alkalization of urine (ASA)
-U m ay C a case w opioid intox. Wo mydriasis (meperidine) -Fe intoxication > > GI phase 0-6h (N&V, me lena, hematemesis) >> aSx 6-24 h >> Sho ck + MET. Acidosis + he patotoxicity 6-72h > > BOWEL OBS due 2 mucosal scarring several weeks -Best indicator of severity and prognosis in TCA s >> QRS duration -ETOH >> hypoMg >> torsades de point -BZD, ETOH, Phenytoin> BZD causes no nystagmus while ETOH and PHT do -Mariuana is the most common illicit drug abuse in US and the most involved in the car accedents and causes increased appetite, conjunctival injection, impaired short time mem ory, slowed reaction time, HTN, Tachydardia, dry mouth -Most dialyzable toxin is LITHIUM -Opioid withdraw doesn’t cause seizures unlike sedatives and ETOH -Opioid withdraw = Mydriasis, piloerection, N&V , carm ping abd pain, increased bowel sound, diarrhea, restless, agitation, myalgia, arthralgia. -Hallucination + VERT ICAL nystagmus = phencyclidine PCP -Phencyclidine = HTN, Tachycardia, (the only Rx that causes vertical nystagmus), Hallucination (ETOH doesn’t cause hallucination), Psychosis -Tx o f Phe ncyclidine: URINE ACIDIFICATION, Haloperidol -BB intox. >> Rx: Fluids + A tropine >> Glucagone (increases cAMP and intracellular Ca and augemting cardian contractility ) >> Epinephrine -Acetaminophen intox. 2 h ago >> do n’t give N-acetyl csytein in the 1st 8h >> Give Charcoal in the 1st 4h >> Do serum level after 4 h from intox. And then decide whether u should give NAS or not -B itter almond (loz) breath = cyanide poisoning (burning of plastic o r rubber = mattat) -Alkaline ingestion >> contrast studies + endoscopy (no steroid) -Fluphenzine = typical anti-psych causes inhibition of thermoregulation and loss of shivering and HYPOTHER MIA
-ETHICS -Don’t go to court EVER -1st Role: let the person who knows the ptn decide (not necessary family) -2nd Role: when the ptn is incompetent >> Do best interest (even when religious say not) -3rd Role: ptns are who makes decisions not DOCs. -mother w bleed said no transfusion >> she has the right even if the child will die -warm wife + tell her u need her right now -parents can’t withhold Tx for emergency child unless they r infant -the only tim e u go to court is when parents refuses insulin for child (gonna die within few months wo Tx) for religious reasons -living will should be talked about by the doc as early as possible -anorexia + 19 yrs + refuses T x >> Court (if minor do what u want) -A competent ptn can refuse even life-saving Tx -older than 13 + living alone = emancipated -older than 13 + military or married or living alone -older than 15 + regarding birth control, S TD Tx, substance Rx Tx, prenatal care = emancipated (older than 15 = partial em ancipated = for certain issues only) -parents refuses Tx for child >> if emerg. Go ahead if not but critical (DM) Go to court, if nothing (stitches) go w parents -when surrogate make decision (1-what ptn said 2-what ptn could say 3-what is the best interest of ptn not the surrogate) -health power of attorney beats all rules = speak w ptn voice -ptn said he is going to kill som eone >> try to get after him before call police -Attorney is stronger than living will >> attorney is always gonna win -informed consent u should give alternatives -HIV ptn how would u tell his wife >> bring them together and inform her -Tx Schizo only if he let u treat him unless violence is on the table -consent can be oral, written is useless if ptn didn’t read it -what if family request not to tell ptn >> find out why + tell ptn -who own medical records >> health care provider but ptn can have copy -wife refuses emerg. T x for her unconscious husband >> Tx -if the wife has a card stating that >> don’t Tx -17 yr girl whose parents are out of the country living w baby sitter, from whom u should take consent? If a threat to health the physician can treat under doctrine of in locum parentis !! -if one parent ac cept and the other refuse >> only one permission needed -17 yr b oy nee d stitches coz of playing in schoo l but parents are ou t >> consent from de an of school (NOT FROM FAMILY PHYSICIAN) -man wo clothe s refuses to wear anything + refuses Tx but he is calm and not aggressive >> DETAIN HIM FO R OBSERVATION PE NDING A STATUS HEARING IN THE NEXT FEW DAYS -ptn who is not adhe rent to anti-HTN Rx says it seems it’s not a threat to me >> te ll him ab out aSx man who died of aSx HTN (don ’t give Rx/1d instead of 3 times a day) -Mandatory reportable diseases (gono, chlamydia, all hepatits, MMR, chickenpo x, syphilis, salmonella, TB, lyme, pertussis, legionella) -White man 70 yrs >> most likely to commit suicide -FHx of breat C A is stronger than obesity or early menarche or high education -43 female died after hospitalization >> most likely cause is CANC ER -Brain death >> physician may stop Tx -If Fx members request not tell ptn about his CA due 2 cultural issues and let them decide >> ask ptn “u r very sick and ask if he wishes to make these decisions or prefere to have them made by another -U must have credible evidence about ur zamil before reporting his illness -Paternalism = act of ignoring ptn wishes ’
-if u r married + have children >> from who should u take consent? Adult Children not parents, if u r alone >> d ocs make de cision for u -to declare brain death u have to have neurosurg or neurologist or intensivest -after brain death even if u have donor card from ptn stating that he wants his organs to be taken out, if family says no the n NO (this is why u should tell ur family befo re death and convince then should u die) -if u tried all possible Tx and no improvement and family wants more Tx >> stop T x coz u have nothing left -if u r in early Tx but u know that this is useless (futile) and family wants Tx >> then u cont. ur T x -if ptn said no blood while I am dying >> u can refuse and tell him that u can c a doc who can do this (sam e for abortion, if ptn wants abortion that doesn’t m ean u r the one who should do it) -if ptn doesn’t w ant blood >> NS >> don’t transfuse?? No, the NS is to discuss another option like IV fluid, ringer, .. -ptn unconsc. And wears a t-shirt says no Tx >> go w Tx and don’t listen to shirt even if his wife screaming don’t tx , u r still txing -IF PTN UNCONS + HIS WIFE W LIVING WILL SAY ING NO BLOOD >> T HEN NO BLOOD (OF COURS E THERE IS OTHER OPTIONS BUT NO BLOOD!) High-Yield Ethics -If brain death >> doc can remove support wo court or family -high yield says after death if appropriate request autopsy permission -in terminally ill + no reasonable prespe ct of recovery support can be withheld altho ugh no t legally dead (passive e uthanasia) under most circumstances -ptn w a docume nt (living will) says no he roic measures for saving comatose vegetative state >> after 5 days he ente rs in vegetative state and wife wants Tx >> Tx O NLY IF U EXP ECT PTN TO RECOVE R, WIFE IS IRRELEVANT -if ptn competence is in Qeustion >> judge makes the determination of competence -psych. ptn who chose to be in hospital is required to wait 24-48h before he can sign against m edical advice (AMA ) -emergent hospitalization >> one physician certificate, if invoulentary hosp. >> 2 physicians required -post partum psychosis killed her son >> this is not a crime -malpractice = 4Ds = Dereliction (negligence) of Duty that causes Damage Directly to ptn -sexual relationship w current or FORMER ptn is inappropriate (there is a limit which is longer for psychiatrists) -GENITAL HERPES DOESN’T HAVE TO BE RE PORTE D -drunk medical students >> dean of students -resident >> chief of medical staff -60 depressed ptn w Bx for suspecting CANCER, family request not to tell her if Bx is CA >> no, u should tell her but u can ask ptn if she want family to hear the result w her (U CAN DELAY TELLING HER IF U THINK HER HEALTH MAY BE ADVERSLY A FFECTED) -OVARIAN MAS S SUSPECT OF CA W HILE DOING TUB AL LIGATION >> AWA KE PTN AND GET CONSENT (for all as long as it’s not emerg.) -less than 18 but have child taking care of him >> emancipated -HIV wants Tx, can u refuse to treat him? NO -needle stuck from hiv pos. ptn >> must doc be tested?? Legally no but ethically and medically yes -can u refere ptn to HIV pos. doc >> as long as he is com petent and complies w precaution -HIV ptn having unprotected sex w his wife wants u not to tell her about hiv >> NO encourage him to tell her, then c them all in ur office, then tell her -HIV MAN WHO IS HAVING SE X W HIS WIFE W CONDOM REQUIRES U NOT TO TELL HER > > U DON’T HAVE TO TELL HER!! -sam er: child 10 yrs w disease >> say the Dx infront of his parents to keep child trusting u -even threatening te ptn of abandon is not acceptable -when ptn goes to surg waive means “if we were wrong I would like the doc to take care of what it was” DON’T ASSUME WAIVER UNLESS IT’S CLEARLY STATED IN THE Q -even confirm ing this ptn is urs is confidentiality
USLME WORLD -afraid of cheese + MA OI >> Monitor BP for HTN crises -suspect Hurschprung + need barium enema + parents said no >> this is an emergency (perforation risk) >> test em -ALL in not emerg. >> go to court -Buprop ion CIs = anything can cause seizures like eating disorde rs (lytes abn. >> seiaures) Bipo lar is o k coz there is depressed phase -ptn w resperidone + EPSx like bradykinesia >> Rx: ANTI-CH -Lithium in 1st trimester >> cardiac -in 3 rd Trimester Li >> Goitor + neonatal muscular dysfx -want to be perfectionestic + sleep problems + no concen tration + worry abo ut tests = GAD NOT OCD (no com pulsion) -To tell anybod y about any ptn get WRITTEN CONSENT (prefe rred o ver verbal on e) -The most effective way to prevent relapses of schizo is to keep conflicts to m inimum -I don’t enjoy being in company >> Schizoid -CATATONIC (rigidity, no respon se) >> ECT O R BZD -Methylphenedate decreses appetite -RR 18, dilated pupils, psychosis >> Amphetamine more comm on than Cocaine (both right, one was on the list) -If no focal >> multi-infarct dementia is unlikely -ptn request medical record >> give them a copy wo ASKING WHY (although this Q is justified) -when p tn refuses Tx >> ASK EM WHY BE FORE RESPE CTING HIS WISHES -Doe sn’t spe ak or answer in schoo l, talkative in home , little shy, do esn’t play w friends at school >> SELECTIVE MUTISM NOT SOCAIL PHOBIA -72 yrs was thinking of suicide but not anymore + insomnia >> SS RI (UW WORLD SAID NO BENZO, NO ECT ) -after going to college (ne w house) afraid of someo ne b reaking her house + insomnia + bad study = ADJUSTMENT W ANXIETY -XanaX withdraw = seizures (coz short-acting, long acting don’t cause seizures) -modafinil = psychostimulant for NARCOLEPSY or methylphenidate -UW: Lithium, Valproate, Carbamazepine are 1 st line for bipolar -10 yr girl whose her father is alcoholic presents w regression Sx (no sleep until her parent return, talk w her causes tears, wetting her
-after argument whenever ptn calls secretory he said there is a lot of ptns in front of u >> PASSIV E AGGRESSIV E BEHAV IOR (ptn expresses his aggression toward another person by repeated passive failure to meet the other’s needs. -Social phobia >> Tx of choice is SSRI + Assertiveness training (kind of cognitive behavioral psychotherapy) -ptn angry w u while doing physical >> NS >> ask “u r angry, and I don’t know why” NOT “let me do physical first, or I need ur cooperation to do physical” SOLVE ANGRY FIRST -MOM said no VA CC. >> then no VA CC (coz no life-threatening harm) don’t ask her husband -she saw a mass in her breast and didn’t seek medical attension coz she thinks it’s not CA coz she doesn’t have fam ily history >> DM: Rationalization (NOT INTELLECTUALIZATION) -Doc w pancreatic CA searches for latest information about pan CA >> this is intellectualization not rationalization -depressed who want to stop smoking >> Bupropion better than SSRI -no depression if he enjoys golf and works -ANOREX IA is 15% less than AVERG, if less than 25% > > ADMIT TO HOSP -Dyschezia + Dysparunia >> Endometriosis -less EPSx w newer APM, why? Coz 5HT-2A -ptn w flashbacks of de ath of his wife 2 mo ago + de creased appetite + GAINED WE IGHT 9 Kg + Depressed > > NS >> TF T NOT Refer for PTSD -4yr regressed milestones >> childhood disintegrative disorder -OCD >> Clomipramine or paroxitine ?? >> P aroxitine (SSRI) Clo (TCA) -ptn wants to c u now and u don’t ave time and as u r leaving he showed up and require to examin a rash on his penis >> examin him or ask him to come tomorrow as this is not an emerg. ?? >> come tomorrow -ANOREXIA >> POST PARTUM DEPRE SSION (NOT PSYCHOSIS), SMALL FOR GESTATIONAL AGE, HIGH CHOLESTERO L AND CAROTENE, ARRHYTHMIAS (LONG QT), EUTHYROID SICK SYN., HYPONATREMIA (THIS IS THE NOLY ;YTES ABN. IN ANOREXIA, ANY FURTHER ABN. INDICATE PURGING), IUGR, C-SECTION, MISSCARIAGE, HYPERE MESIS GRAVIDARUM -HYPOCHONDRIASIS >> Tx IS NOT RE ASSURING COZ NO B ENEFIT OF THAT, RATHER U SHOULD DISCUSS EMOTIO NAL STRESSOR + PYSCH Tx -Dx of CA >> initiate w “how r u feeling today” -Menengitis + rash = M ENENGIOCOCCIM IA >> T x against his wishes -u r covering ur colleague who did angio wo hydration, then ptn comes w ATN >> NS >> “I am not te bet to discuss this” or “seems related to angio but this should be discussed w my colleague” >> the 2nd one is the right -Folie a deux >> Tx put the mother and daughter in 2 different psych units -Panic Disorder >> assoc. w agorapho bia, substance abuse, DEP RESSION (DEPRESSION MORE COMMO N THAN ETO H ALTHOUGH BOTH R RIGHT) -Anorexia w NL menses = eating disorder NOS (not otherwise specified) -NMS >> Dantroline, EPS (like dystonia) >> Benztropine -Tourette >> ADHD or OCD ? >> ADHD 50%, OCD 40% -Olanzapine >> commonest SE is obesity/weight gain not DM -Presence of NL menses exclude the Dx of Anorexia -suspect child abuse >> in order 1- physical -2 skeletal survey 3- coag profile 4- report to services 5-admit if necessary 6- consult psych -ur friend’s w ife comes and wants to examine her breast wo appointment >> tell her to schedule an appointment -W ALL Sx OF DEPRE SSION U CAN IMAGINE AFTE R DEATH OF HER SON (WEIGHT LOSS, NO APPETITE, ON ENTHUSIASIM FOR WORK, UNREFRE SHED SLEE P , EASY FATIGABILITY, THINK TO BE W HER SON BY DEATH) SHE IS STILL WORKING BUT AVO ID TALKING W COWORKE RS WHENEVE R POSSIBLE >> Dx: NL BEREAVE MENT (COZ SHE IS JUST WORKING!!! UW) -wife doesn’t speak so her husband is answering u >> NS >> ask him to get out and talk w the wife alone. -ptn on lithium develops manic episode >> check urine and lithium serum level -palne phobia who will fly the next week wants Tx >> XanaX (buspirone takes 2-3 w to work, clonazepam is no short ac ting) -ETOH withdraw >> first anxiety, sweating, palpitation then ETOH hallucination (just hallucination resolves in 1-2 days, vitals NL and sensorium is intact), then DT -Acute dystonia >> Anti-CH or diphenhydramin -ptn w COP D ex. And in resp. failure need s intubation and ventilator bu t living will says n o rescu. And family wants u to Tx >> discuss th is w family (no Tx) and if they still want Tx GO TO COURT (I think n o Tx coz he is unlikely to recover) -wrecked the car after argument >> DM: Displacement (not only humans and dogs, also cars) -Bereavement = loss of something = lasts no longer than 2 w -Adjustment disorder >> d ynamic or cognitive p sychTx (preferred ove r Rx) -Citalopram c auses not only delayed ejaculation but also IMPOTENCE and DE CREASED LIBIDO -5 Sx of depression to have Dx of Depression -Chlorpromazine assoc. w non-hemolytic JUANDICE -wom an convinced that she has CA for 5 yrs when asked how could u know since all tests are neg. she said “when u have CA, u know!” >> Dx: Delusional disorder (hypochondriasis wasn’t on the list) -5yrs girl often talks w someone and when asked w who she replies nobody, when split milk she said this is MINDY >> she has imaginary friends which is NL for her age (remem ber me) and she will go oover that -Psych finished in 6 days w videos !
