1) Nucleus basalis of Meynert • Nucleus basalis of Meynert produces acetycholine; destruction → ↓ ACh → Alzheimer disease • Amygdaloid nucleus: Kluver-bucy syndrome • Caudate nucleus: Huntington disease • Medial geniculate nucleus: Auditory pathway • Red nucleus: mostly vestigial in mammals; crawling in human babies
• Substantia nigra: Parkinson disease • Subthalamic nucleus: Hemiballismus
2) Caudate nucleus
• Caudate & Putamen destruction → ↓ ACh and GABA → Huntington disease
• Amygdaloid nucleus: Kluver-bucy syndrome • Medial geniculate nucleus: Auditory pathway • Nucleus basalis of Meynert: Alzheimer disease • Red nucleus: mostly vestigial in mammals; crawling in human babies
• Substantia nigra: Parkinson disease • Subthalamic nucleus: Hemiballismus
3) Delirium due to anticholinergic medication • Certain antiparkinson drugs (eg, benztropine, trihexyphenidyl) curb excess cholinergic activity → side effects of dry mouth, flushed skin, tachycardia, etc.
4) PCP intoxication • PCP intoxication presents with violent behavior, dissociation, hallucinations, amnesia, ataxia, and nystagmus • Benzodiazepines treat severe psychomotor agitation
5) Reassure the father that this is normal development • Weight unchanged from the previous year, normal growth and development
6) Schizoaffective disorder • Delusions or hallucinations for ≥ 2 weeks in the absence of prominent mood symptoms
7) Borderline personality disorder
• Often have a history of childhood trauma (eg, physical/sexual abuse or neglect) → insecure attachment, unstable relationships, and fear of abandonment
• Cluster B personality disorders have a high rate of self-mutilation and suicide
8) Fragile site on the X chromosome • High forehead, large everted ears, prominent jaw, low IQ = Fragile X syndrome
• Fragile sites are discontinuity of staining in the region of the trinucleotide repeat on the long arm of the X chromosome (a diagnostic lab artifact)
9) Quetiapine
• This patient has Parkinson psychosis • Tx: Quetiapine or clozapine (lowest propensity to cause EPS)
10) Corticosteroid-induced psychotic disorder • Glucocorticoids, particularly at high doses, are often implicated in new-onset psychotic symptoms
11) Contact child protective services • Children who are victims of physical abuse often avoid eye contact on physical exam
12) Enlarged lateral and third ventricles on CT scan of the head • CT scans of patients with schizophrenia often show ventriculomegaly (particularly the lateral cerebral ventricles) and diffuse cortical atrophy
13) Obtain a rectal temperature under supervision • Temp of 107.6 F raises suspicion for factitious disorder
14) Conduct disorder • Repetitive and pervasive behavior that violates the basic rights of others or societal norms (eg, destruction of property)
15) Creutzfeldt-Jakob disease • Rapidly progressive dementia (weeks to months) • Periodic sharp waves on EEG • ↑ 14-3-3 protein in CSF
16) Discontinue clozapine therapy • Clozapine may lead to agranulocytosis (non-dose related) and seizures (dose related) • This patients leukocyte count is < 3000 and he has flu-like symptoms
17) Major depressive disorder • MDD has an atypical presentation with physical symptoms (eg, headache) in the elderly
• Sadness
• Guilt
• Weight loss
• Fatigue
• Psychomotor retardation (slowing of physical and/or emotional reactions, including speech and affect)
• Somatization and illness anxiety disorders require 6 months to diagnose (she has only been experiencing her headaches for 4 weeks)
18) Valproic acid • Valproic acid block box warning: hepatotoxicity, pancreatitis, fetal abnormalities
19) Drug-drug interaction • Switching from most antidepressants to a MAOI requires a 2-week washout; Fluoxetine, an SSRI, has a relatively long half-life and requires a 5 week washout
• Excess serotonin → serotonin syndrome
20) Discontinue desipramine therapy • TCA may cause prolonged QT • Tx: Stop medication and give NaHCO3 (prevents arrhythmia)
21) Alcohol use
• This patient drinks ‘several’ alcoholic beverages before sex and has ↑ GGT
• Alcohol is a depressant that can make it difficult to achieve erections or reach an orgasm
22) Propranolol
• The tremors in this patients hand are of 1 month duration which doesn’t indicate any anxiety disorder
• This patient likely has essential tremor (patients often self medicate with alcohol which decreases tremor amplitude, hence this patients alcohol abuse)
• Nonselective beta-blockers (eg, propranolol) are the treatment of choice
23) Lorazepam • This patient has a specific phobia • 1st-line tx: CBT with exposure; short-acting benzodiazepines are helpful if therapy is unavailable or insufficient time
24) Amitriptyline
• TCA are contraindicated in the elderly due to anticholinergic and antihistamine effects
• Hydrophilic β-blockers don’t cross the BBB and therefore don’t cause psychosis; Lipophilic β-blockers (eg, propranolol, nadolol) cross the BBB and therefore can cause psychosis and depression
25) Polysomnography • Polysomnography showing reduced REM sleep latency will diagnosis narcolepsy
26) Zolpidem • Psychotherapy is the first line therapy for Adjustment disorder (SSRIs aren’t given)
• Nonbenzodiazepine hypnotics (eg, zolpidem) can be given to treat insomnia
27) Buspirone
• Generalized anxiety disorder: excessive and persistent worry about multiple issues for ≥ 6 months
• First-line tx: CBT + SSRI/SNRI
• Second-line tx: Buspirone and benzodiazepines
28) Alcohol dependence • Drinks vodka in the morning, ‘eye-opener' = ⊕ CAGE questions • Must rule out any substance or medical related mood disorders before diagnosing a psychiatric condition (eg, Adjustment disorder)
29) Schizotypal • Cluster A personality disorder; genetic association with schizophrenia • Eccentric appearance, odd thoughts, beliefs, perceptions and behavior
30) Electroconvulsive therapy • ECT is appropriate for severely depressed geriatric patients who require rapid intervention • Antidepressants + antipsychotics would take too long to be effective
31) Post-traumatic stress disorder • Nightmares, functional impairment, psychological trauma, and detachment for > 1 month • Tx: Trauma focused CBT + SSRI/SNRI
32) Major depressive disorder • Diagnosis can’t be Adjustment disorder because this patient meets 5/9 criteria for MDD • Crying spells, sad mood = depressed • Poor concentration • Fatigue and lethargy = low energy • Not interested in socializing = anhedonia • 20lb weight gain = appetite/weight change
33) Alcohol • Gait disturbance is characteristic of alcohol intoxication
• Normal vitals rule out cocaine or amphetamine use
34) Drug reaction • Neuroleptic malignant syndrome: Fever, Muscle rigidity, Abnormal vitals, ↑ CK
35) Fetal alcohol syndrome • Facial abnormalities in FAS: long smooth philtrum, thin vermillion border, small palpebral fissures
36) Risperidone • Tourette syndrome - onset before age 18 • Tx: Antipsychotics, Tetrabenazine, Alpha-2-agonists (eg, guanfacine, clonidine)
37) “Have you been feeling like just giving up?” • Sense of hopelessness requires further investigation/questioning
38) Psychiatric assessment • This patient has a normal physical exam and has completed a battery of tests without any abnormalities (possible somatic symptom disorder)
39) Obsessive-compulsive disorder
• Ego-dystonic (behavior inconsistent with one’s own beliefs and attitude)
40) Antisocial personality disorder • Violate the rights of others, social norms, and laws • Consistently irresponsible and is deceitful • Truancy (absent from school for no good reason) is characteristic
• Borderline and Narcissistic don’t have many friends/relationships
41) Obsessive-compulsive personality disorder • This patients disorder is ego-syntonic (behavior consistent with own beliefs) • Tx: CBT + SSRI (clomipramine and venlafaxine are second line)
42) Provide information about the range of reactions to trauma • This will help normalize the patient’s symptoms as a consequence of the trauma, so that they are more receptive and more likely to seek help if symptoms persist or deteriorate • This approach also respects the patients autonomy of not wanting to talk to anyone regarding the trauma
43) Drug toxicity • OTC cold medications (pseudoephedrine, ephedrine, antihistamines, antitussives) should be used cautiously in young children, with recommended doses not exceeded, as they can have unwanted side effects including confusion and hallucinations
44) Bipolar disorder
• Grandiosity, pressured speech, excess energy → sleeping 2 hours/night
• Schizoaffective disorder must have delusions or hallucinations for ≥ 2 weeks in the absence of prominent mood symptoms; Bipolar or major depression with psychotic features have psychotic symptoms occurring exclusively during mood episodes
45) Sleep-related hypoventilation • This obese, male teenager snores and breaths through his mouth = ventilation disrupted by physical obstruction of airflow • Tx: nasal continuous positive airway pressure (nCPAP), weight loss
46) Methamphetamine
• Amphetamines → prolonged wakefulness, aggressive behavior, fever, HTN
• Cannabis → dry mouth, conjunctival injection
• Ecstasy → ↑ sociability, euphoria
• Heroin → CNS depression, miosis
• LSD → hallucinations (visual, auditory), depersonalization
47) Explanation of the risks and benefits of antidepressant therapy
• This patients depression has returned and she should have the risks and benefits of restarting an antidepressant explained to her
• This patient has no suicidal or homicidal ideation; deliberating about an abortion doesn’t merit hospitalization
48) Admit her to a psychiatric hospital
• Indications for hospitalization in anorexia nerves include unstable vital signs, cardiac dysrhythmias, electrolyte derangements, and severely low body weight
• Cannot start parenteral nutrition without admitting her due to risk of re-feeding syndrome
49) Clonazepam therapy • Benzodiazepine for treatment of insomnia
50) Panic disorder
• Recurrent and unexpected attacks with at least 1 month of preoccupations with the attack (eg, persistent concern of additional attacks)
• May be misdiagnosed as somatic symptom disorder, but the abrupt onset and characteristic physical symptoms that resolve within minutes can help differentiate the two
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