Emergency Psychiatry
You are suspecting a medical cause of psychotic symptoms in the ED.
What's the next step?
Airway, Breathing, Circulation
(Always mark this if this appears on the test)
16F presents to ED after collapsing on the dance floor at a rave. She is dehydrated, complains of nausea, behaves seductively, and is mildly paranoid. What did she use?
MDMA
Methylenedioxyamphetamine
Antipsychotic administered IM caused significant hypotension. Which one is it?
5 signs of LMN lesion
Hyporeflexia, Flaccidity, Atrophy, Fasciculations, Weakness
In terms of psychotherapy, the most important thing to do with a patient in the ER setting is to?
Restore their self-esteem.
Listen to them, demonstrate you understand them, and bolster their defenses.
Young female arrives at the ER with acute overanxiety, restlessness, irritability, flushed face, nausea, diarrhea, diuresis and insomnia. She ascribes all of her symptoms to work. What she is most likely intoxicated with?
Caffeine
Lithium
Brain structure with greatest number of neurons
Cerebellum
The percentage of rape committed by people known to the victim
About 1/3
About 10% are perpetrated by close relatives. Alcohol is involved in about 35% rapes. Most rapists are between 25-44 and most victims are between 16-24. Only 10-25% are reported.
True or False and state the reason.
True.
They can potentiate the anticholinergic effects of PCP.
This antidepressant has the highest risk of developing tardive dyskinesia
Amoxapine
Which area of the brain is the most associated with Deja-vu states?
Entorhinal cortex.
Also linked with delusions.
Symptoms of catatonia
1. Motoric immobility (catalepsy and stupor)
2. Excessive motor and verbal activity (purposeless motor activity and verbigeration)
3. Extreme Negativism (motiveless resistance to all instructions, posturing, decreased sensitivity to pain or mutism)
4. Peculiarities of voluntary movements (posturing, stereotyped movements, mannerisms, or grimacing)
5. Echophenomena (echolalia, echopraxia)
6. Note that symptoms can alternate (immobility giving rise to hyperactivity)
Typical symptoms of NMS in order of their occurrence (chronologically).
Rigidity
AMS- confusion, coma, stupor
Hyperthermia (>40C)
Autonomic instability (hyper or hypotension, tachycardia, pallor and diaphoresis)
Usually, during first month. RFs- prior episodes, rapid increases in AP doses, male, previous diagnosis of mood disorder, and hot climate
36M with MDD recently had the dose of Citalopram increased from 20 to 40 mg daily, with addition of Trazodone 100 mg nightly for insomnia. Ten days later, patient is brought to the ED for severe restlessness, nausea, vomiting, and diarrhea. Serum toxicology screen is negative for illicit substances. Upon examination patient is confused, mildly agitated, febrile and tachycardic. Neurological exam is notable for nystagmus, BL hyperreflexia and ankle clonus. Tone is normal throughout without rigidity. In addition to stopping all medications should be used to manage patient's symptoms?
Serotonin Syndrome.
Lorazepam, Cyproheptadine
Which areas of the brain lack a BBB?
Area postrema in the medulla, some parts of the hypothalamus, and circumventricular organs
47F with SCAF disorder is brought to the ER by caregiver, who reported that the patient has become increasingly disoriented in the past week. The patient has been sick with "flu" and complained of a sore throat earlier in the week. The caregiver insists that the patient has no history of drug abuse and has "never" been suicidal. After taking an antipsychotic for a year, the patient experienced stabilization of her psychotic symptoms for the first time in 20 years, but she gained 40lbs during that time. Ten days ago, she was prescribed low dose of fluvoxamine because of persistently depressed mood and OC symptoms. On exam, patient is pale and unresponsive to verbal stimuli. Her BP is 95/60, RR 14, HR 105 and N temp. What lab tests and/or interventions would assist to narrow down the DD and develop an appropriate course of action?
CBC with diff (flu), BMP and LFT
?septic
?Clozapine, and agranulocytosis (ANC <500).
Adding Fluvoxamine (potent 1A2 inhibitor), raised Clozapine levels
Delirium and delusions- Wernicke's encephalopathy
Delirium, mania, depression, acne-like rash, headache, lethargy- Korsakoff's syndrome
Confusion, agitation, impulsivity- Cimetidine psychosis
Alcohol stigmata, amnesia, confabulation- Alcohol persisting dementia
Confusion, occulomotor disturbances, ataxia- Bromide intoxication
Delirium and delusions- Cimetidine psychosis
Delirium, mania, depression, acne-like rash, headache, lethargy- Bromide intoxication
Confusion, agitation, impulsivity- Alcohol persisting dementia
Alcohol stigmata, amnesia, confabulation- Korsakoff's syndrome
Confusion, oculomotor disturbances, ataxia- Wernicke's encephalopathy
Pick from the following as a treatment for the listed conditions: (a) Physostigmine, (b) Atropine, (c) Neither
1. Imipramine OD
2. Belladonna OD
3. OPC ingestion
4. Phenothiazine OD
5. LSD intoxication
6. Scopolamine intoxication
7. L-dopa intoxication
1. Imipramine OD- Physostigmine
2. Belladonna OD- Neither
3. OPC ingestion- Atropine
4. Phenothiazine OD- Neither
5. LSD intoxication- Neither
6. Scopolamine intoxication- Neither
7. L-dopa intoxication- Neither
1. Chorea and athetosis
2. Weakness and spasticity
3. Resting tremor and rigidity
4. Intention tremor and ataxia
5. Hypoactive reflexes and flaccidity
1. Chorea and athetosis- Caudate lesion
2. Weakness and spasticity- UMN lesion
3. Resting tremor and rigidity- Substancia Nigra lesion
4. Intention tremor and ataxia- Cerebellar lesion
5. Hypoactive reflexes and flaccidity- LMN lesion