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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

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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

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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

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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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Q u i c k T a b l e s © OnlineMeded 119

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

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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

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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

Q u i c k T a b l e s © OnlineMeded 127

Psych

01 PRIME: Notes

02 ACQUIRE: Video & Audio

03 CHALLENGE: Questions

04 ENFORCE: Flashcards

& Quicktables

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