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Table of Contents
1. Cardiology
a. Coronary Artery Disease 1 b. Congestive Heart Failure 2 c. Valve Disease 3 d. Cardiomyopathy 4 e. Pericardial Disease 5 f. Hypertension 6 g. Cholesterol 7 h. ACLS 8 i. Syncope 9
2. Pulmonology
a. Asthma 10 b. Lung Cancer 11 c. Pleural Effusion 12 d. DVT PE 13 e. COPD 14 f. ARDS 14 g. Diffuse Parenchymal Lung Disease 15
3. Gastroenterology
a. Gallbladder Disease 16 b. Esophagitis 17 c. Esophageal Disorders 18 d. Peptic Ulcer Disease 19 e. Misc. Gastric Disorders 20 f. Acute Diarrhea 21 g. Chronic Diarrhea 21 h. Malabsorption 22 i. Diverticular Disease 22 j. Colon Cancer 23 k. GI Bleed 24 l. Jaundice 25 m. Cirrhosis Etiologies 26 n. Cirrhosis Complications 27 o. Acute Pancreatitis 28 p. Viral Hepatitis 28 q. Inflammatory Bowel Disease 29
4. Nephrology
a. Acute Kidney Injury 30 b. Sodium 31 c. Calcium 31 d. Potassium 33 e. Kidney Stones 33 f. Cysts and Cancer 34 g. Acid Base 35
5. Hematology Oncology
a. Macrocytic Anemia 36 b. Microcytic Anemia 37 c. Normocytic Anemia 38 d. Leukemia 39
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e. Lymphoma 40 f. Plasma Cell Dyscrasia 41 g. Thrombophilia 41 h. Bleeding, Thrombocytopenia 42
6. Infectious Disease
a. Antibiotics 44 b. HIV 44 c. TB 45 d. Sepsis 45 e. Brain Inflammation 46 f. Lung Infection 47 g. UTI 47 h. Genital Ulcers 48 i. Skin Infections 49 j. Endocarditis 50 k. Antibiotics 50 l. Surgery 50
7. Endocrinology
a. Anterior Pituitary 52 b. Posterior Pituitary 53 c. Thyroid Nodules 54 d. Men Syndromes 54 e. Thyroid Disorders 55 f. Adrenals 56 g. Diabetes 58 h. Diabetic Emergencies 59
8. Neurology
a. Stroke 60 b. Dizziness 60 c. Seizure 61 d. Tremor 62 e. Headache 63 f. Back Pain 64 g. Dementia 65 h. Coma 66 i. Weakness 67
9. Rheumatology
a. Approach To Joint Pain 68 b. Lupus 69 c. Rheumatoid Arthritis 70 d. Other Connective Tissue Dz 71 e. Monoarticular Athropathies 72 f. Seronegative Arthropathies 73
10. Dermatology
a. Blistering Disease 74 b. Papulosquamous Dermatoses 75 c. Eczematous Dermatoses 76 d. Hypersensitivity Reactions 77 e. Hyperpigmentation 78 f. Hypopigmentation 79 g. Skin Infections 80 h. Alopecia 81
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11. Pediatrics
a. Newborn Management 82 b. Neonatal ICU 82 c. FTPM and Constipation 83 d. Neonatal Jaundice 84 e. Baby Emesis 85 f. Congenital Defects 86 g. Well Child Visit 87 h. Vaccinations 88 i. Preventable Trauma 89 j. Abuse 90 k. ALTE / BRUE and SIDS 90 l. Infectious Rashes 91 m. Acute Allergic Reactions 92 n. Chronic Allergic Reactions 92 o. ENT 93 p. Upper Airway 94 q. Lower Airway 95 r. GI Bleed 96 s. CT Surgery 97 t. Orthopedics 98 u. Peds Psych 99 v. Sickle Cell 99 w. Ophthalmology 100 x. Urology 101 y. Seizures 102 z. Immunodeficiencies 102
12. Psychiatry
a. Anxiety Disorders 104 b. Impulse Control Disorders 105 c. OCD and Related Disorders 106 d. PTSD and Related Disorders 107 e. Mood Disorders 108 f. Mood II Life and Death 109 g. Psychotic Disorders 110 h. Eating Disorders 111 i. Personality Disorders 112 j. Dissociative Disorders 113 k. Catatonia 114 l. Peds: Neurodevelopmental 116 m. Peds: Behavioral 118 n. Pharmacology I: Anti-Depressants + Mood Stabilizers 120 o. Pharmacology II: Anti-Anxiety + Anti-Psychotics 121 p. Addiction I: Substance Abuse 122 q. Addiction II: Drugs of Abuse 123 r. Sleep I: Physiology 124 s. Sleep II: Disorders 125 t. Gender Dysphoria 126 u. Somatic Symptom Disorder 127
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13. Gynecology
a. Gynecologic Cancers 128 b. Gestational Trophoblastic 129 c. Incontinence 130 d. Adnexal Mass 131 e. Pelvic Anatomy 132 f. Gyn Infections 133 g. Vaginal Bleeding:
Premenarchy 134 h. Vaginal Bleeding:
Reproductive Years 134 i. Vaginal Bleeding: Anatomy 135 j. Vaginal Bleeding: Puberty 136 k. Primary Amenorrhea 137 l. Secondary Amenorrhea 138 m. Infertility 139 n. Menopause 140 o. Virilization 141
14. Obstetrics
a. Physiology Of Pregnancy 142 b. Normal Prenatal Care 143 c. Genetic Diseases 144 d. Third Trimester Labs 144 e. Advanced Prenatal Evaluation 145 f. Medical Disease 146 g. Normal Labor 147 h. Abnormal Labor 148 i. L & D Pathology 149 j. Eclampsia 150 k. Multiple Gestations 151 l. Post-Partum Hemorrhage 152 m. Antenatal Testing 153 n. Third Trimester Bleeding 153 o. Alloimmunization 154 p. Prenatal Infections 155 q. OB Operations 156 r. Contraception 157
15. Surgery: General
a. Pre-op Evaluation 158 b. Post-op Fever 159 c. Chest Pain 159 d. Abdominal Distention 160 e. Fistula 161 f. Decreased Urinary Output 162 g. Obstructive Jaundice 163 h. Esophagus 164 i. Small Bowel 165 j. Pancreas 166 k. Leg Ulcers 167 l. Colorectal 168 m. Breast Cancer 170 n. Pediatrics First Day 171
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15. Surgery: Specialty
a. Pediatrics Weeks To Months 172 b. Surgical Hypertension 173 c. Endocrine 174 d. CT Surgery 176 e. Pediatrics CT 178 f. Vascular 180 g. Adult Ophtho 181 h. Skin Cancer 182 i. Pediatric Optho 184 j. Neurosurgery Bleeds 185 k. Neurosurgery Tumors 186 l. Urologic Cancer 187 m. Urology Peds 188 n. Urologic Miscellaneous 189 o. Ortho Injury 190 p. Ortho Hand 192 q. Ortho Peds 193
15. Surgery: Trauma
a. Shock 194 b. Head Trauma 195 c. Neck Trauma 196 d. Chest Trauma 197 e. Abdominal Trauma 198 f. Burns 199 g. Bites 200 h. Toxic Ingestion 201
16. Epidemiology and Stats
a. Prevention 202 b. Screening 202 c. Vaccinations 203 d. Diagnostic Tests 203 e. Study Design 204 f. Bias 204 g. Hypothesis Testing 205 h. Confidence Interval 205 i. Risk 205
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chaPter 12: PsychiaTry Anxiety Disorders
Path:
Dx:
Generalized anxiety disorder
Constant state of worry
Clinical
Path:
Panic attack
Random and unprovoked bouts of intense anxiety without warning
Pt:
Worry about most things on most days of most months (≥ 6 months)
≥ 3 Somatic Complaints
Pt:
Shortness of Breath Trembling
Unsteadiness Depersonalization Excessive heart
rate Numbness
Tingling Sweating
Palpitations Abdominal
distress Nausea
Intense fear of losing control/ dying
Chest pain
Dx:
Rule out medical disease ˗ ECG + troponins
˗ Asthma
˗ TSH, Toxicology
Tx:
Abort – Benzodiazepines CBT to abort without meds Control – SSRI
Tx:
PSYCHOTHERAPY, psychotherapy, psychotherapy
SSRI or Buspirone adjunct Benzos (only if panic attack)
social Phobia (social anxiety disorder)
Path:
Irrational and exaggerated fear related to social performance
Egodystonic
6 mo+ duration
Pt:
Anxiety and Avoidance of stimulus Public Speaking or Public Restrooms
Dx:
Clinical
Tx:
Cognitive Behavioral Therapy Beta-Blockers for Public Speaking
F/u:
Agoraphobia
sPecific Phobia
Path:
Irrational and Exaggerated learned fear response to a specific trigger
Egodystonic 6mo+ duration
Pt:
Anxiety and Avoidance of stimulus Spiders, heights, clowns, etc
Dx:
Clinical
Tx:
Cognitive Behavioral Therapy
˗ Desensitization: longer, better ˗ Flooding: faster, not as good
Control with SSRI during CBT
104
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Impulse Control Disorders
PsychiaTry
interMittent exPlosive disorder
Path:
Trigger = Anxiety
Violent Act = Relief
Response DISPROPORTIONATE to
stressor (verbal, physical, etc)
Pt:
2 times per week in 3 months WITHOUT harm
OR
3 times at all in a year WITH harm ♂ >> ♀
↓ Sxs with ↑ age
Dx:
Clx
theft
klePtoMania
Desire
Able to resist
↓ Anxiety Unable to Resist
HAS value
Pt CAN’T afford
Has NO value Pt CAN afford
Planned, with help, or provoked by external stimuli
UNplanned, WITHOUT help, and not provoked by external stimuli
Used or Kept NO remorse NO guilt
Stashed, gifted, or returned
Remorse, guilt
Tx: Drugs = Therapy = Drugs + Therapy (SSRI) (Self-reflection)
PyroMania
Path: Setting Fire = Relief or Pleasure
Dx: r/o Arson
F/u: Reaction Formation
klePtoMania
Path: Trigger = Anxiety Theft = Relief
Pt:
More than 1 occasion
Fire Setting for ↓ Anxiety, ↑ sexual
arousal, or ↑ pleasure ♂ >> ♀
Tx:
Ø… incarceration
arson
PyroMania
Monetary Gain
To Cause harm or to
destroy
↓ Anxiety Sexual Arousal Pleasure
Pt:
Steals things
˗ little to NO value
˗ pt CAN afford
˗ to ↓ anxiety
˗ gifts / hides items
˗ and feels guilt / remorse
˗ impulsively, alone, without
external ˗ provocation
Dx: r/o Petty Theft
Tx:
Ø… incarceration
SSRI? Therapy?
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Psych
chaPter 12: PsychiaTry
OCD and Related Disorders
obsessive coMPUlsive disorder
Path:
Obsessions = anxiety-PROVOKING thoughts, unwanted and intrusive
Compulsions = anxiety-REDUCING actions, behaviors, or mental acts
Pt:
Obsessions
Compulsions
Contamination Symmetry Safety
Cleaning, Washing Order, Counting Lock Checking
At least one hour per day
Causes impairment at school, work,
socially
Pt:
Obsessions
Compulsions
Muscle Size
Excessive Exercise
Anabolic Steroids
Roid Rage, Rhabdo (renal failure), Testicular atrophy, “copper disorder”
Tx:
CBT → SSRI
Dx: Clx
Path: OCD about throwing things away
Dx: Clx
body dysMorPhic disorder
Path: Perceived flaws in physical appearance
Dx: Clx
F/u: DO NOT perform surgery as desired
MUscle dysMorPhic disorder
Path: Perceived flaws in physical appearance
Dx: Clx
Path: General Anxiety with Hair pulling
Dx: r/o fungus (KOH prep)
r/o medical cause for alopecia
F/u: Small bowel obstruction (trichobezoar)
trichotilloMania
Tx:
CBT is best
SSRI or Clomipramine (a TCA)
Pt:
Obsessions
Compulsions
None in Particular
Pulling out hair items like trash
Alopecia with hair in different lengths
hoardinG disorder
Pt:
Obsessions
Compulsions
Ridding of Possessions
Retaining useless items like trash or trinkets
Unsafe or cluttered home
Tx:
CBT → SSRI
Tx:
CBT → SSRI
Pt:
Obsessions
Compulsions
Symmetry of body Hair, skin, nose Breasts, butt
Appearance Checking Approval Seeking
Attempt to have multiple surgeries to correct what isn’t broken
Tx:
CBT → SSRI
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PTSD and Related Disorders
Post-traUMatic and acUte stress disorders
Path:
Stressor
˗ Actual Death
˗ Threat Death
˗ Combat
˗ Rape
˗ Abuse
Exposure
Experienced (Self)
PsychiaTry
adJUstMent disorder
Path:
Stressor = Non-life-threatening event ˗ Marital strife, loss of a job,
moving away
Pt:
Disorder = Mood changes that don’t quite fit for another mood disorder
˗
˗ Witnessed (strangers)
˗ Learned (family) ˗ Repeated
exposure to effects
Dx: Begin < 3 months from stressor Lasts < 6 months from stressors
Tx:
Generally not needed
Pt:
Disorder
˗ Intrusion
˗ Neg Mood
˗ Dissociation ˗ Avoidance
˗ Arousal
Nightmares, Flashbacks, memories
Depression-like Depersonalization,
amnesia Symbols, locations,
memories Hypervigilance, irritability,
easily startled, CHANGED concentration
Dx:
> 3 daysAND < 1 month =Acute Stress
> 1 month = Post-Traumatic Stress
Tx:
Group Therapy (best) SSRI/SNRI (adjunct) Benzos (panic attack only) CBT
F/u: Mood disorder Substance abuse disorder
rad / desd
Path: Stressor = Neglect or Abuse in infancy
Dx: < 5 years old r/o Autism
F/u: Mood disorder Learning disabilities
Pt:
Disorder =
too much attachment (DSED) too little attachment (RAD)
Tx:
Caregiver – teach how to parent
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Psych
chaPter 12: PsychiaTry Mood Disorders
MaJor dePressive disorder
Path:
↓ mood OR Anhedonia And
Duration ≥ 2 weeks AND
5 of SIG-E-CAPS
Pt:
Sleep
Interest
Guilt
Energy Concentration Appetite Psychomotor Suicidal
↓ ↓ ↑ ↓ ↓ ↓ ↓ ↑
↑ ↓ ↑ ↓ ↓ ↑ ↓ ↑
dysthyMia = Persistent dePressive disorder
Pt: ↓ Mood for ≥ 2 years Symptoms Ø absent 2+ months
Tx: SSRI / SNRI
cyclothyMia
Pt: Mild Bipolar II
Dx:
r/o hypothyroid
Dx: r/o Suicidal Ideations
biPolar i
Path: Mania = “E” + 3 Duration ≥ 1 week
Dx: r/o Bipolar II r/o Cyclothymia
biPolar ii
Path: Hypomania AND major depression
Dx: r/o Bipolar I (catatonia, psychotic)
F/u: If Major Depression, started SSRI, then have Mania → reveals Bipolar I
Tx:
If + SI + Plan → Hospital
If + SI, NO Plan → Safety Contract Combo >> SSRI /SNRI > Psycho
Therapy
ECT best (refractory only)
Pt:
Distractibility Insomnia Grandiosity
Flight of Ideas Agitation
Sexual Exploits Talkative Elevated Mood Racing Thoughts
Tx:
Emergency department = Benzos Mood stabilizers = Lithium >
Valproate backup = Lamotrigine,
Carbamazepine Anti-Psychotics = Quetiapine
Pt:
Hypomania = mania, but less
Tx:
Bipolar I
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Mood II Life and Death
PsychiaTry
baby blUes
Post-PartUM dePression
Post-PartUM Psychosis
Baby
#1
Cares about baby
> #1
Doesn’t care about baby,
may hurt baby
># 1
Fears the baby,
likely to kill it
Timing
Onset and
Duration within 2 weeks
Onset within 1 month Duration ongoing
Onset within 1 month Duration ongoing
Depression Treatment
Onset
Dysthymic Nothing
Any
MDE Anti-depressants
≥ 6 months
MDE
Mood Stabilizers or Antipsychotics
Any
Psychosis
None
None
+
Grief
Pcbd
dePression
Duration
< 12 months
≥ 12 months
≥ 12 months
Focus
˗ Dysphoria
˗ Guilt
˗ Anhedonia
Focused on Deceased
Focused on Deceased
Pervasive, global
When mood symptoms
Waxes, wanes, can imagine happy
Persistent +
Cannot imagine being
happy
Persistent +
Cannot imagine being
happy
Behaviors
YES insight “Psychotic”
Talking TO deceased
Doing things as if they were there
NO Insight Psychotic features
NO Insight Psychotic
˗ Hallucinations
˗ Delusions Talking WITH
deceased
Believing they are there doing things with you
Why suicide
To be with deceased
To end suffering, despondent
Treatment
Time, Counseling
SSRI
SSRI
staGes of death and dyinG
Denial Depression Bargaining Anger Acceptance
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Psych
chaPter 12: PsychiaTry Psychotic Disorders
delUsions
Fixed False Belief without basis in reality
variants and dUration of treatMent
All variants have the exact same pathology, sxs, presentation, and diagnosis, EXCEPT the time those symptoms have been present. This leads to duration of treatment with anti-psychotics
Duration Sxs
Duration Tx
Do NOT confront delusion; it is a glaring truth to the patient, and you will not get anywhere by challenging them.
schizoPhrenia
Path:
Thought Disorder with unknown cause though there is certainly a genetic component
Receptor Pathology
˗ Dopamine (too much) → + Sxs ˗ Serotonin (too much) → – Sxs
Pt:
Psychotic Break = first break occurs in teenager with stressor (college) who then begins behaving bizarrely
Positive Symptoms (must have 1+)
˗ Bizarre Delusions
˗ Hallucinations, usually auditory
(voices)
˗ Disorganized speech
˗ Disorganized state / catatonia
Negative Symptoms:
˗ Anhedonia
˗ FlatAffect
˗ Cognitive Defects
Acute Psychotic Disorder
Schizophrenia
< 1 Month ≥ 6 Months
Wait (or treat) Lifetime
Schizophreniform
< 6 Months
3-6 weeks
Schizoaffective
Any with mood sxs
Lifetime treat delusion first
treatMent oPtions for Psychotic disorders
+ Sxs
Best
Typical
Haloperidol, Thiazide, Chlorpromazine
Clozapine
– Sxs
Atypical
Risperidone, Quetiapine, Olanzapine, Ziprasidone, Aripiprazole
Dx:
Clinical
r/o drug abuse (cocaine)
Tx:
Anti-psychotics
˗ Typical controls positive
symptoms
˗ Atypical controls negative
symptoms
˗ Clozapine when all else fails
110
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Eating Disorders
PsychiaTry
anorexia nervosa
Path:
Anxiety induced by the fear of being or becoming fat
Patient is not fat, but fears fat; sees herself as fat
Lacks recognition of how thin she is
Pt:
F:M 10:1, teens to 20s Severe
˗ hypotension, bradycardia, leukopenia
˗ CMP abnormalities, E-lytes and albumin
˗ BMI < 16 Non-Severe
˗ Lanugo, Cold-intolerance, Amenorrhea, Emaciation
Methods of eatinG disorders
Restriction
↓ Caloric intake (fasting, dieting)
↑ Caloric expenditure (exercise)
Binge Purge Emesis
Eating / Binging then induced emesis
Dorsal hand scars (from emesis) Dental erosion (from emesis) Metabolic Alkalosis, K, Mg
disorders
Binge Purge Laxative
Eating / Binging then induced diarrhea
Metabolic Acidosis Diarrhea
Dx: Clx
Tx:
Hospitalize if severe ˗ IVNutrition
˗ Correct E-Lytes
˗ Forced Feed Outpatient / ongoing
˗ Antipsychotics and CBT
F/u:
If OCD or MDD, add SSRI / SnRI Relapse in 5 years
Death from medical or suicide
bUliMia nervosa
Path:
Anxiety from the binge, then compensates
Normal weight to overweight
Pt:
F:M 10:1, teens to 20s
“normal” appearance except purge signs Purge ≥ 1 x per week x 3 months
Dx: Clx
F/u: NEVER Bupropion (causes seizures)
Dx: Clx
Tx:
SSRI / SnRI = Fluoxetine (best) CBT
binGe-eatinG disorder
Path:
Anxiety from the binge – no compensation
Overweight to obese
Pt:
F:M 10:1, teens to 20s
Cannot control eating habits Binge ≥ 1 x per week x 3 months
Tx:
Topiramate CBT
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Psych
chaPter 12: PsychiaTry Personality Disorders
A Paranoid Distrustful, suspicious, interpret others are malicious
B
“Enemy of the State”
Gene Hackman,
Clear, honest, nonthreatening
Pd
descriPtion
exaMPles
hoW to handle theM
Schizoid
Loners, have no relationships but also are happy not having any relationships
Night-Shift Toll Booth
You won’t see them
Schizotypal Magical Thinking, borders on psychosis,
Bizarre Thoughts, Behavior, and Dress
Lady Gaga
Brief Psychotic Episodes Clear, honest,
nonthreatening
Borderline
Unstable, Impulsive, Promiscuous, emotional emptiness, unable to control rapid changes in mood, suicidal gestures
“Girl Interrupted” “Fatal Attraction”
Suicidal Gestures may be successful
Splitting, Dialectic Behavioral Therapy
Histrionic
Theatrical, attention- seeking, hypersexual, use of physical appearance, dramatic, Exaggerated but superfluous emotions
“Gone with the Wind”
Marilyn Monroe
Set rules, insist they are followed
Narcissistic Inflated sense of worth “Zoolander” Set rules, insist they or talent, self-centered, Ron Burgundy are followed fragile ego, uses eccentric
dress to draw attention,
demands special treatment
Anti-Social
Criminal. No regards for rights of others, impulsive,
lacks remorse, manipulative. Must be >18 years old (conduct disorder)
Tony Soprano The Joker
Jail, Set rules, insist they are followed
C
Avoidant Fears rejection and criticism, wants relationships but
does not pursue them, Passes on promotions
“Napoleon Dynamite”
Shy hot librarian
Avoid power struggles, make patients choose
Dependent
Unable to assume responsibility.
Submissive, clingy, fears being alone
Stay at home mom in an abusive relationship
Giver clear advice, patient may
try to sabotage their own treatment
Obsessive- Rigid, orderly perfectionist. “Monk” Compulsive Order, Control.
Perfection at the expense of efficacy
112 Q u i c k T a b l e s © OnlineMeded
Dissociative Disorders
PsychiaTry
dissociative disorders in General
Path:
Severe + Prolonged Stressor causes separation of otherwise intact thought, memory, and identity
Pt:
Stressor proportional to Disorder
Dx:
Amytal Interview (truth serum) r/o malingering
r/o substance abuse
Tx:
Psychotherapy
dePersonalization derealization disorder
Path:
Adolescent with minor stressor (though stressor is relatively major for demographic)
Pt:
Seeing a video or dream of self, out-of-body experience (depersonalization)
Detached from reality, as though in a dream
Reality testing INTACT
F/u: Non-severe = recovery Severe =?
dissociative identity disorder
Path: ≥ 2 distinct identity states
Most severe and prolonged trauma
F/u: Fight Club, Sybil
dissociative aMnesia
Path: Stressors induces loss of memory
Pt:
Self experiences
˗ Memory gaps (blackouts)
˗ other dissociation symptoms
Others Witness
˗ Paradoxical behaviors ˗ Appearance changes
Pt:
Memory Loss of ˗ the event
˗ regular everyday occurrences / routine
˗ complete autobiographical self
F/u:
Law and Order, SVU
dissociative aMnesia With fUGUe
Path: Stressors induces loss of memory WITH Travel
F/u: Jason Bourne, Archer from FX
Pt:
Memory Loss of ˗ the event
˗ regular everyday occurrences / routine
˗ complete autobiographical self
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Psych
chaPter 12: PsychiaTry Catatonia
catatonia
Path:
Ø a disease state
Modifier to another disease
ψ – Bipolar, Depression >> schizophrenia
♥ – Autoimmune, paraneoplastic, nutritional Ø a disease state
Modifier to another disease
ψ – Bipolar, Depression >> schizophrenia
♥ – Autoimmune, paraneoplastic, nutritional
Pt:
Must have 3 or more: ˗ Stupor
˗ Cata-LEPSY
˗ Way flexibility ˗ Mutism
˗ Negativism
Retarded Catatonia
˗ Stereotypy
˗ Agitation or Grimace ˗ Echolalia
˗ Echopraxia
Retarded and Excited symptoms may occur together
Excited Catatonia
Dx: Clx… Lorazepam
Malignant Catatonia
Neuroleptic Malignant Hyperthermia
Serotonin Syndrome Malignant Hyperthermia
No meds, lorazepam corrects
Atypical Antipsychotics Lead-Pipe Rigidity
SSRIs and Hypertonicity/ Hyperreflexia
Halothane anesthesia, family history
Rigidity
Autonomic Dysfunction (↑ BP, ↑ HR, ↑ T)
Muscle breakdown (“↑ CK”)
Tx:
Lorazepam (diagnostic and therapeutic)
dz
Meds / hx
sxs
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PsychiaTry
Psych
chaPter 12: PsychiaTry
Peds: Neurodevelopmental
intellectUal disability disorder
Path:
Chromosomal:
˗ Down Syndrome ˗ Fragile X
˗ Cri-Du-Chat
Maternal Acquired
˗ EtOH in utero
˗ Hypothyroid in utero
Child Acquired
˗ Lead Poisoning ˗ Head Trauma
Pt:
↓ Cognitive skill
↓ Adaptive Functioning
+/- Syndromic physical features
Dx:
Clx; severity on adaptive functioning Severity based on IQ testing
(outdated)
Tx:
Assess social, conceptual (speak, read write), and practical (self mgmt)
Special education, supervision
50-70
Group home, Work and ADLs alone
35-49
Group home, Work and ADLs alone
20-34
Institutionalized, Supervised ADLs
< 20
Institutionalized, Total Care
aUtisM sPectrUM
Path:
Impaired Social Communication
˗ Social Reciprocity
˗ Social Relationships
˗ Nonverbal Communication ˗ Joint Attending
Restrictive / Repetitive Behavior
˗ Stereotypy
˗ Sameness
˗ Restricted Interests
˗ Change in perception
Pt:
Young child, 1-4 years old
No social smile or eye contact Repetitive useless behaviors Insistence on consistency
Dx: Clx; Severity on progress
F/u: NO ASSOCIATION WITH VACCINES
Tx:
Supportive
attention deficit hyPeractivity disorder
Path:
Impulsivity
˗ Blurts out answers ˗ Interrupts
˗ Fidgets a lot
˗ Cannot wait turn
Inattention
˗ Talks Fast
˗ Easily Distracted
˗ Fails to complete tasks
Timing and situation
˗ ≥ 2 settings
˗ onset 7-12
˗ duration ≥ 6 months
Pt:
The “bad kid” who is male, disrupts class and moves all over the place, fails to wait his turn, whose parents have a tough time controlling behaviorally, and who’s like this in every setting.
Ensure there are no absence seizures
Path:
Dx: F/u:
tic disorder (toUrette’s)
Essentially OCD
Clx
ADHD on stimulants who gets worse is Tic Disorder
Dx: Clx
F/u: Special ed classes, parent education If absence seizures, carbamazepine
Pt:
Onset < 18 years old
“Obsession” = impulse to perform tic “Compulsion” = the tic itself
Hidden: hair flicks, blinking, rubbing
Vocal: Grunt, cough, yell NEVER a swear word
Tx:
Dopamine Antagonists
˗ Fluphenazine,Tetrabenazine
Tx:
Stimulants (avoid at night to ↓ insomnia) ˗ Methylphenidate
˗ Dextroamphetamine
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Peds: Neurodevelopmental
learninG disabilities
Path: Performing substantially below expected for age and grade
PsychiaTry
Pt:
Medical Conditions
˗ Deaf,Blind,Non-nativeSpeaker
Poor Education to Date
˗ Low socioeconomic class,
home schooled
Dx:
Audiology test Vision testing Language assessment
Tx:
Remediate, fix the medical problem (glasses, hearing aids), fix the teacher to student ratio
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Psych
chaPter 12: PsychiaTry Peds: Behavioral
condUct disorder
Path: Antisocial personality disorder but… < 18 years old
Path:
enUresis – Was once dry
Regression, Abuse, Infection, Anatomic
Pt:
Bullying
˗ Hurts animals / people ˗ Uses torture / cruelty
˗ Forced Sex
Destruction
˗ Fire starting
˗ Lies, Cheats, Steal
˗ Breaks into property
Rules Violation
˗ Truancy
˗ Run-away at least twice
˗ Staying out at night before 13
Pt:
Was once dry, now is not
Dx:
U/A U/S Clx
Tx:
Infection (abx); if STI then abuse Anatomic (resection)
Regression (identify stressor); abuse
encoPresis and enUresis
Path:
Encopresis (stool) or Enuresis (urine) repeatedly on clothes or bed.
˗ Intentional (acting out)
˗ Incontinent(cognitiveimpairment) ˗ Medication side effect
˗ Anatomic (fistula)
˗ Regression (abuse, stressor)
Pt:
Dependent on patients. Look for new sibling, new step parent, or new house
Dx: Clx
F/u: Fights Authority HARMS peers
oPPositional defiant disorder
Path: Incongruent parenting Teen acting out
Tx:
Juvenile Detention
Pt:
NO Bullying
˗ DoesNOThurtanimals/people ˗ Does NOT use torture / cruelty ˗ Forced Sex
Destruction
˗ Lies, Cheats, Steal
˗ Breaks into property
Rules Violation
˗ Truancy
˗ Run-away at least twice
˗ Staying out at night before 13
Dx:
See above
Tx:
See above
Dx: Clx
F/u: Fights Authority COOPERATES with peers
enUresis – never been dry
Path: Normal toilet training takes up to 7 years old
Dx: Clx
F/u: TCAs may also be used Negative Reinforcement (never)
Tx:
Improved Parenting
Pt:
If < 7 and still wets bed, it’s NORMAL
Tx:
POSITIVE reinforcement Alarm Blankets
Water Restriction before bed DDAVP as last resort
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PsychiaTry
Psych
chaPter 12: PsychiaTry
Pharmacology I: Anti-Depressants + Mood Stabilizers
anti-dePressants
SSRIs
(Es)citalopram Fluoxetine Paroxetine Sertraline
↓ Libido sometimes
Delayed Ejaculation sometimes Serotonin Syndrome
GI, Insomnia
SnRIs
(Des)Venlafaxine Duloxetine
Cleaner, better versions of SSRIs. More expensive
Atypical
Bupropion Smoking cessation No weight gain
Bulimia NEVER (↑seizures)
SM
Mirtazapine
Appetite Stimulant
Trazadone
Sleep Aid, caution priapism
TCAs
“-tryptilines” Imipramine Desipramine Doxepin
Used for enuresis (anti-ach)
1st line use is neuropathic pain
Can be Lethal because of CCC: (Convulsions, Coma, Cardiac)
so get an ECG
Has Anti-Ach properties (dry mouth, sedation, Uretention, Constipation)
MAO-Is
Phenelzine Tranylcypromine Selegiline
HTN Crisis when mixed together, lack of washout or eating of tyramine (red wine/cheese)
Distinguish from other hypertensive-hyperthermia disorders in psych by the ABSENCE of lead-pipe rigidity and fever
Drug
Mood stabilizers
Indication
Side Effect
Lithium
First-Line, Drug of Choice for Bipolar Bipolar, Acute Mania, Depression
Augmentation
Teratogen Nephrotoxic > 1.5
Causes Nephro DI Narrow TI
Valproate
First Line in Bipolar if Li cannot be used Teratogen (Spina Bifida) Thrombocytopenia
Also treats Seizures Agranulocytosis Pancreatitis
Quetiapine
Second Line bipolar All phases of treatment
Weight gain
QTc prolongation
Lamotrigine
Benzos
β-Blockers
Second Line bipolar Newer anticonvulsant
Abort panic attack Treats EtOH withdrawal
Performance Anxiety
anti-anxiety
Blurred Vision SJS
Dependence Withdrawal Seizure
Carbamazepine
Third line bipolar Trigeminal Neuralgia Absence Seizures
Teratogen (Cleft palate) Rash, SJS
AV Block
SSRIs
First-Line long term medication for treatment of chronic anxiety: OCD, PTSD, GAD
See Anti-Depressants. Ø useful in acute attack
Bradycardia, Asthma
120 Q u i c k T a b l e s © OnlineMeded
Pharmacology II: Anti-Anxiety + Anti-Psychotics
PsychiaTry
Haloperidol Fluphenazine Thioridazine Chlorpromazine
Mesolimbic D2C-R-i treats + symptoms
Nigrostriatal Antagonism leads to EPS side effects
Tuberoinfundibular antagonism causes ↑ prolactin, gynecomastia
Potency of drug proportional to EPS
Potency inversely proportional to Anti-Ach
Risperidone Quetiapine Olanzapine Aripiprazole Ziprasidone
Both D2C and 5-HT1 so work on + and – sxs
More selective so lower risk of EPS Currently “first line” for psychosis
QTc prolongation
EPS, Gynecomastia, Sedation, Anti-Ach (small risk)
DM and Weight Gain
Unique to itself
The best antipsychotic The most selective for D2C
and 5HT1 ( and ) Drug of last resort
Agranulocytosis
Requiring CBC q week
Akathisia
Dyskinesia
antiPsychotics
Typicals = First Generation Antipsychotics (FGA)
Atypicals = Second generation Antipsychotics (SGA)
Clozapine
extraPyraMidal side effects
A Feeling of Restlessness
Parkinsonism
Dyskinesia = Bradykinesia
choosinG the riGht drUG
Acute Dystonia
Involuntary muscle contractions, hand ringing, torticollis, and oculogyric crisis
Anti-Ach (Benztropine)
Tardive Dyskinesia
Irreversible hypersensitization of dopamine-R = suppressible oral-facial movements
Stop Drug,
Sxs initially worsen
Compliant Young Adult, Any atypical po without complications
Everything else has failed Clozapine
↓Dose…. Beta blockers Anti-Ach (Benztropine)
Anti-Ach (Benztropine)
↓ SE profile
Best, most dangerous
Combative ER patient
Haloperidol Depot
Sedating
Noncompliant Psychotic Olanzapine depot q 1wk Risperidone depot
Haloperidol depot
Dysphagia or IM not available
Olanzapine ODT Risperidone ODT
Oral dissolving tablet
Hospitalized and off their meds
Atypical, ↑ Dose q Day until maxed, then try another
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Psych
chaPter 12: PsychiaTry
Addiction I: Substance Abuse
sUbstance abUse disorder
Path: Using a drug or alcohol in any other way than it is intended Substance = Drug, Alcohol, gambling, sex
Pt:
Difficulty Controlling Use
1. Consuming more than was intended
2. Difficulty cutting down or stopping
3. Investing time in obtaining of recovering from use 4. Craving
Adverse Social Outcomes
5. Failure of responsibilities at work, home, school 6. Choosing substance over people relationships
7. Giving up what you used to like to do
Risk Taking
8. Use in hazardous condition (legal issues, sex, driving) 9. Use despite previous consequences
Health Effects
10. Tolerance: needing more to feel the same effect 11. Withdrawal: physical symptoms when stopped
Dx:
Severity
Screen CAGE
Mild 2-3 Moderate 4-5 Severe 6+
Cut down
Anger about criticism
Guilt about using or what you do when using Eye-opener
Tx:
Pharm
Antabuse (di-sulfuram for EtOH) Naloxone (Opiate, EtOH) Methadone (Opiates)
Usually pharm doesn’t work
Group Therapy
Alcoholics Anonymous
F/u: 50-90% will relapse Relapse is not failure
Back on the horse
F Feedback
R Responsibility – sobriety and mistakes A Advice – help them
M Menu of options E Empathy
S Self-Efficacy
Pre-contemplative Preparation Maintenance
five staGes of sUbstance abUse
Unaware, denial Committed, taking steps Sustained changed behavior
Contemplative
Admits there’s a problem, acceptance
Action
Actual changing behavior
122 Q u i c k T a b l e s © OnlineMeded
Addiction II: Drugs of Abuse
PsychiaTry
drUG
intoxication
WithdraWal
drUG / antidote
EtOH
Slurred speech, Disinhibition, Ataxia, Blackouts, Memory Loss, Impaired Judgment
Tachycardia and HTN, Tremor, perspiration, hallucinations, and eventual seizures
Benzo Taper
(withdrawal) Disulfiram (Long-Term)
Benzos
Delirium in elderly,
Respiratory Depression and coma (with ↑ dose), amnesia
Tremor, Tachycardia, HTN, Seizures, Psychosis
Flumazenil
Opiates
Euphoria, pupil constriction, respiratory depression, and potential track marks
Yawning, lacrimation, Naloxone
N/V and hurts Methadone (long-term) everywhere, sweating
Cocaine
Psychomotor agitation,
HTN, tachycardia, dilated pupils, psychosis
Angina / HTN crisis
Depression, suicidality, irritability, “cocaine bugs”
Supportive Care Benzos / antipsychotics
for agitation
HTN treated with α then
β blockade
MDMA
Overheat (fever, Crash Supportive tachycardia) and water
intoxication. Pupillary
Dilation, Psychosis
PCP
Aggressive psychosis, vertical, lateral, or rotary nystagmus, impossible strength, blunted senses
Severe random Violence
Haloperidol to subdue Acidify Urine to
enhance excretion
LSD
Hallucinations, Flashbacks Supportive Flashbacks,
Heightened senses,
dissociative symptoms
THC
Tiredness, slowed reflexes,
conjunctivitis, the munchies, overdose brings paranoia
Ø
Supportive (often nothing required)
Barbs Low safety margins, Redistribute into fat Ø Benzos safer
Nicotine
None – just jittery and stimulated. Pt has to Overdose a lot → Vfib
Cravings
Bupropion
Chantix (Varenicline)
Amphetamines
Tachycardia, Crash None hypertension,
pressured speech,
flight of ideas
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Psych
chaPter 12: PsychiaTry Sleep I: Physiology
staGe
eeG
Awake
N II REM
State of arousal
K-Komplexes, Sleep Spindles
Awake EEG, Atony, Saccadic Eyes, Erections
More REM faster after Deprivation state
niGht terror
sleeP WalkinG / eatinG/ drivinG / sex
Path: N3 Sleep Stage
Dx: Clx
F/u: Worse with BZD1 (zolpidem)
NI
Theta Waves, Absence of Alpha
Pt:
Do actions without remembering
N III
Delta waves
Tx:
Reassurance
vocabUlary of sleeP
Sleep Latency
Going to bed to falling asleep ↑ in insomnia
↓ in sleep deprivation
REM Latency
Falling asleep (N1) to REM ↓ in Narcolepsy
↓ in sleep deprivation
REM Rebound
Path: N3 Sleep Stage
Dx: Clx
Path: Dreams gone bad, REM Dx: Clx
sleeP talkinG
Path: N3 Sleep Stage Dx: Clx
Pt:
Child 4-10 who will:
˗ maintaintone,situp,openseyes ˗ be asleep (inconsolable)
˗ not remember anything
Parents distressed, kids aren’t
Tx:
Reassurance
niGhtMare
Pt:
Any age group wakens from sleep, remembers the dream
Tx:
Treat underlying psych condition (PTSD)
If not part of syndrome, no need to treat
Pt:
Mumbling in sleep Will not reveal secrets
Tx:
Reassurance
124 Q u i c k T a b l e s © OnlineMeded
Sleep II: Disorders
PsychiaTry
obstrUctive sleeP aPnea
Path:
Excess tissue of oropharynx and chest wall (obesity) obstructs airway
Multiple awakenings prevent progression to REM
Ventilation spared (CO2 normal) Oxygenation impaired (↓ O2)
Pt:
Obese, snores, short neck, difficult to exam oropharynx
Daytime Somnolence (“sleeps” but never reaches REM, so not restful sleep)
Cor Pulmonale
Dx:
Polysomnography (Sleep Study) ˗ 15 apneas / hour
˗ 5 apneas / hr + snoring
Tx:
CPAP = PEEP Weight loss
insoMnia
Path:
Poor sleep hygiene
For this setting, assume no psych
illness
Pt:
Trouble falling asleep Trouble staying asleep
< 6 hrs / night total sleep
Dx:
r/o MDD… SIGECAPS
r/o Bipolar… DIGFASTER
r/o substance… caffeine, cocaine
Tx:
Life style = Sleep Hygiene
˗ Avoid stimulants w/I 5 hrs of
sleep
˗ Avoid exercise near sleep ˗ Avoid naps during the day ˗ Bed for sex and sleep only ˗ Lights Out = Sleep Time
Pharm
˗ Diphenhydramine→Trazadone
→ Quetiapine → Zolpidem
F/u: ↓ Alveolar Oxygen → Pulm Htn Pulm htn = isolated heart failure.
narcolePsy
Path: Uncertain Etiology
Dx: CSF Hypocretin – 1 (Also polysomnography)
Jet laG
Insomnia and Travel
Power through and Melatonin
central sleeP aPnea
Patient “forgets” to breather
↓ Ventilation = ↑ CO2 = Altered, Acidotic
Caused by opiates, stroke. Has Cheyne-stokes
Pt:
“Sleep Attack” … wakes REFRESHED
˗ Cataplexy, Paralysis
˗ ↓ REM Latency
˗ HypoGOgic / Hypnopompic ˗ Response to emotion or bang ˗ Wakeup Refreshed
3 times per week x 3 months
Tx:
Scheduled Naps
Stimulants (Amphetamines)
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Psych
chaPter 12: PsychiaTry Gender Dysphoria
Assignment Transgender
Transvestic Disorder
Gender terMs
Your Genitals at birth “What you are physically”
Someone who’s identity is more often incongruent than their assignment
Cross-Dressing but NOT transgendered
Gender dysPhoria
Gender Identity
Your gender in your mind “What you are mentally”
Transsexual
Not only identifying, but has socially or physically changed to another assignment
Path: Assignment DOES-NOT-EQUAL Identity AND
Distress over incongruence
Dx: Clx
Pt:
6-month duration AND any 1 of:
˗ AssignmentDOES-NOT-EQUAL
Identity
˗ desiretoBE,ortobeTREATED
as dif gender
˗ Wanting to rid sex char
˗ Beliefthattheyareanothergender
KIDS
˗ AddREJECTrolesofassignment
˗ Add ACCEPT roles of opposite
Tx:
Therapy >> surgery reassignment and hormones
Exhibitionism Frotteurism
Masochism
Transvestic disorder
defininG ParaPhilias
Common
Exposing genitals to strangers
Touching, rubbing or a nonconsenting person
Uncommon
Being humiliated or forced to suffer
Sexually aroused by cross dressing
Pedophilia
Sexual focus on children Often Male adult → female
child
Voyeurism
Observing private activities of unaware victims
Fetishism
Inanimate objects
Sadism
Inflicting humiliation or pain on others
126 Q u i c k T a b l e s © OnlineMeded
Somatic Symptom Disorder
PsychiaTry
soMatic syMPtoM disorder (neW soMatization)
Path: Somatic anxiety disorder with or without explanation
Tx: Psychotherapy
Tx: Psychotherapy Confront Stressor
illness anxiety disorder (hyPochondriasis)
Pt: Preoccupation with GETTING SICK Usually has no illness or complaint
Pt:
≥ 6 months AND
One or more somatic symptoms OR
˗ High level of Health related
anxiety
˗ Disproportionate concern to
seriousness
˗ Excessive time and energy devoted
to them
conversion disorder
Path:
Life Stressor NOT intentional NOT fabricated
Pt:
Sensory or Motor Related to the Stressor La belle Indifference
Will not harm self
Dx:
r/o organic disease
Tx:
One provider, set limits – do not over test
Psychotherapy
factitioUs / MUnchaUsen’s
Pt:
Conscious, intentional fabrication to play the sick role
Grid-Iron Abdomen
Flight at Confrontation
Abuse of a dependent (By Proxy)
Tx:
Confrontation of Factitious Jail of Factitious by proxy
MalinGerinG
Pt:
Conscious, intentional fabrication to obtain secondary gain
Get money (disability), get drugs (ED, UC), get freedom (out of jail)
Tx:
Confrontation
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Psych
01 PRIME: Notes
02 ACQUIRE: Video & Audio
03 CHALLENGE: Questions
04 ENFORCE: Flashcards
& Quicktables
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