Beat the Boards

qs

What is pseudo-addition?

• Maladaptive behavior when pain is under treated

• Similar behavior to addiction BUT go away once pain is well controlled.

What are the neuropsych symptoms of Wilson’s disease and who is at risk?

• Subacute neuropsych symptoms with hepatic dysfunction

• Young and middle aged

• Sxs: psychosis, behavior change, parkinsonims, dystonia, catatonia and abnormal reflexes

Labs: Low ceruplasmin ( initial testing) and 24-hour urine copper, slit lamp for Kayser-Fleischer rings or liver biopsy for confimatory labs

MRI brain: T2 hyperintensities in basal ganglia, thalamus or cerebelum

By what mechanism does disulfram result in psychosis?

Inhibition of enzyme (dopamine beta-hydroxylase) that converts dopamine to norepinephrine → leads to increase in dopamine

Describe PANDAS

• Young patient with sore throat ( strep infection) that develops neuropsych symptoms

• Sxs: choreiform movements, irritability, ADHD, OCD

• Its autoimmune reaction

• Tx: antibiotics (PCN), behavior therapy, anti-inflammatory drugs and plasma exchange

Patient presents with history of depression and anxiety and now has physical symptoms of HA, palpitations, diaphoresis and HTN. Urine-24 hours has elevated metanepharine. Whats the diagnosis? what are addition labs to look at ?

Pheochromocytoma - rare catecholamine-producing tumor of the adrenal glands

Labs: hyperglycemia, hypercalcemia, hypokalemia, erythrocytosis and urine-24 hr shows elevated metanephrine

High ACTH levels indicate what?

• Cushing syndrome (caused by anterior pituitary tumor)

• Small cell lung carcinoma ( non-pituitary ectopic ACTH)

Medication for vasomotor symptoms for patient with breast cancer?

• Gabapentin up to 900mg daily (esp if they dont have psych hx)

• SNRI ( if they have psych hx)

For olanzapine, which receptor leads to weight pain and polyuria?

Antoagonism of Serotonin 2B ( B looks fat no?)

NOT 2A, 2C or histamine

What are the most common psych disorders comorbid with COPD

• Tobacco use disorder (MOST COMMON)

• Depression

You find a thyroid nodule, what will you do next?

• Examination

• Check thyroid studies

• Check thyroid scintigraphy

• Fine need aspiration ( at the end)

What is the classic triad for wernicke’s encephalopathy

• ataxia

• nystagmus

• confusion

Which of the following symptoms will be present in an individual with a posterior cerebral artery stroke that affects the mesial portion of both temporal lobes?

Anterograde amnesia is a characteristic symptom that is present in individuals with bilateral medial temporal lobe lesions.

What psychiatric medication should be discontinued in patient who are diagnosed with oetopenia or osteroperosis?

SSRI

What are contraindication for liver transplant?

According to the American Association for the Study of Liver Diseases (AASLD), some of the contraindications to liver transplant include: a) MELD score <15, b) severe cardiac or pulmonary disease, c) AIDS (an example of immunosuppressive state), d) ongoing alcohol or illicit substance use, e) hepatocellular carcinoma with metastatic spread, f) uncontrolled sepsis, g) persistent noncompliance, and h) lack of adequate social support.

What are signs for secondary adrenal insufficiency ?

Sxs: depression like, anorexia and weight loss

Labs: hyponatremia and hyperkalemia

Hx: chronic steroid use

Test: corticotropin simulation text

The efficacy of a drug refers to which one of the following measurements?

The ability of a drug to treat whatever condition it is indicated for

What is drug-induced nephrogenic diabetes insipidus?

• Impair kidney function such that they cant concentrate the urine → leads to excess water loss

• Labs: Hypernatremia

• For lithium - occurs in 50% of patient with prolonged use

Describe huntington’s disease

• Autosomal dominant genetic neurodegenerative disease

• Trinucleotide repeats CAG

• Sx: abnormal movements, behavior/psych changes and demention

• Neuropsych: OCD, depression, apathy

Note: psychosis is only in minority of patients

What are the hallmark criteria for SLE?

SOAP BRAIN MD

1. Malar rash: A butterfly-shaped rash that appears across the cheeks and nose.

2. Discoid rash: Raised red patches of skin with scaling and follicular plugging, which may cause atrophic scarring in older lesions.

3. Photosensitivity: An unusual skin reaction, such as a rash, that develops after exposure to sunlight.

4. Oral ulcers: Painless sores that appear in the mouth or nose.

5. Nonerosive arthritis: Inflammation of two or more peripheral joints, characterized by tenderness, swelling, or fluid buildup, but without erosion of the bones.

6. Serositis: Inflammation of the lining around the heart (pericarditis) or lungs (pleuritis), which can cause pain or fluid accumulation.

7. Renal disorder: Evidence of kidney problems, such as persistent proteinuria (excessive protein in the urine) or the presence of cellular casts.

8. Neurologic disorder: Seizures or psychosis that cannot be attributed to other conditions, such as medication or metabolic imbalances.

9. Hematologic disorder: An abnormal blood count, such as hemolytic anemia, leukopenia (low white blood cells), lymphopenia (low lymphocytes), or thrombocytopenia (low platelets).

10. Immunologic disorder: The presence of specific antibodies, such as anti-double-stranded DNA (anti-dsDNA), anti-Smith (anti-Sm), or antiphospholipid antibodies.

11. Positive antinuclear antibody (ANA): A positive ANA blood test result, in the absence of medications known to cause drug-induced lupus. 

Which antipsychotic can be use for patient on antiretroviral therapy (like protease inhibitors)

Abilify

(Even though its metabolized by 2D6 and 3A4 it does not interact with HIV meds. Also its lower propensity for metabolic side effects is advantageous for an HIV-positive patient, as HIV and its treatment can predispose patients to metabolic complications)

Antipsychotics that do interact: ziprasidone, quetiapine ( metabolized by CYP3A4), fluphenazine (3A4 + interaction), colazapine ( complications with HIV positive patient and agranulocytosis)

Treatment of choice for trigeminal neuralgia?

Carbamazepine

Carbamazepine in pregnancy - what supplements to give preconception/first trimester and third trimester?

Preconception: Folate for neural tube defects

Vitamin K: for Vit k deficiency and coagulopathy in neonates

After her thyroidectomy, a 32 y.o. female became irritable and agitated, she also developed some muscle cramps. What is the best treatment?

Calcium

This is the case of acute hypocalcemia, intravenous calcium is the treatment of choice.

This patient has cancer and has now presented with confusion. When asked about his consent for a therapeutic lumbar puncture, he shrugs and says he does not know. What is the most appropriate next step in management?

Ask about advanced directives and living will

Which regions of the brain are most affected by HIV-associated dementia (HAD)?

Basal ganglia and hippocampus

HAD is considered subcortical dementia impacting the fronto-subcortical regions.

Best antipsychotic to use in patients with Hx of seizures and positive + negative symptoms of schizophrenia?

Risperidone.

Risperidone is an atypical antipsychotic that helps improve both the positive and negative symptoms of schizophrenia. It binds loosely to dopamine receptors and has a more favorable side-effect profile than typical antipsychotics. According to recent studies, risperidone is not associated with an increased risk of seizures and can be safely administered in patients with comorbid epilepsy. Risperidone is therefore the most appropriate therapeutic option for this patient.

Which of the following first-generation antipsychotic is associated with the highest prevalence of impaired glucose tolerance?

Chlorpromazine

Phenothiazines are associated with a high prevalence of impaired glucose tolerance, but among them, aliphatic phenothiazines have a higher propensity of causing hyperglycemia. Aliphatic phenothiazines include chlorpromazine, promazine, and triflupromazine. Among phenothiazines, aliphatic phenothiazines have the highest prevalence of causing hyperglycemia.

Patient presents in psychosis. Current medication include tacrolimus and low-dose steroids. Which antipsychotic is most appropriate?

Olanzapine ( the one with low Qtc prolongation)

Tacrolimus can lead to qtc prolongation. Its interactions with quetiapine, risperidone would increase qtc

A 45-year-old woman developed symptoms of "heart fluttering and palpitations." An echocardiogram was performed, demonstrating mitral valve prolapse. Which of the following anxiety disorders is historically associated with this condition?

Panic disorder

What is the epidemiology of developing post-stroke depression (PSD)?

One-third of the survivors are likely to develop PSD

Which antipsychotic does not require renal dose adjustment?

Haldol

Patients with which organ transplantation have the greatest non-adherence rates?

Kidney

What is the MRI brain finding for Korsakoff syndrome?

Atrophic lesions in the anterior thalami and small mammillary bodies support a diagnosis of Korsakoff syndrome.

What is the difference between addison’s and cushing’s syndrome?

Cushings

• Hyper cortisol state

• Maybe due to pituitary, adrenal or lung tumor. Or exogenous cortisol

• Sxs: weight gain ( face and abd), thinning of skin, easy bruising, fatigue, High blood pressure

Addison’s

• Low cortisol state

• Leads to pituitary increasing ACTH production

• Sxs: weight loss, darkening of skin and low blood pressure

Patient with a known history of irritable bowel syndrome, now has abdominal bloating and satiety. No indication for depression. What medication would be appropriate?

Metoclopramide

Metoclopramide is a prokinetic agent that increases gastric emptying and improves symptoms of bloating in patients with functional gastrointestinal disorders such as irritable bowel syndrome.

You are seeing a 50-year-old man who has suffered elevated liver function tests after a Valproate overdose. The best medication option to help with his liver injury is:

L-carnitine

Which one of the following SSRIs will most likely raise serum levels of theophylline and haloperidol?

Fluvoxamine is both a potent inhibitor of the CYP 1A2 isoform and a substrate for it. Both theophylline and haloperidol are metabolized by this isoform, thus their levels will be raised with the addition of fluvoxamine.

What are the most common symptoms for vitamin B deficiencies?

• Folate (B9): depressive, lethargy and anhedonia. Labs - megaloblastic anemia

• B12: depressive but also peripheral neuropathy

• Niacin (B3): 3 Ds (diarrhea, dementia and dermatitis)

• Pyridoxine (B6): Peripheral neuropathy, depression AND seizures, HA, chronic pain and rarely psychosis

• Riboflavin (B2): Corneal neovascularization and cheilosis and magenta-colored tongue. (Can happen with use of antipsychotics)

• Thiamine (B1): Nystagmus, ataxia and confusion

What is the known side effect of digoxin?

• visual hallucinations with yellow rings around objects

• depression

Which one of the following male sexual dysfunctions is the most prevalent?

Most common is erectile dysfunction.

After that reduced libido, premature ejaculation, pain on penetration and anorgasmia's

What medication can be used to treat behavior concerns for FTD?

SSRI

What are the common symptoms of hyperthyroidism? What is the treatment?

• Irregular HR and tachycardia.

• Elevated BP

• Weight loss

• Increased sweating/heat intolerance

• N/V/D

• Muscle weakness

• Thinning of hair

Treatment: antithyroid medication (methimazole) and beta blockers

Which antipsychotics are know for frequently causing new onset DM? and lead to DKA?

Olanzapine and clozapine

Also risperidone, quetiapine and abilify

What are signs of DKA?

• Excessive thirst

• Frequent urination

• N/V

• Abdominal pain

• Confusion

• Fruity breath

What are the four principles of ethics in medicine?

• Autonomy: the right to make his own decisions by choosing a treatment option

• Non-maleficence: to not do harm to the patient or proposing a treatment that is unlikely to be beneficial.

• Justice: it entails the equitable distribution of medical resources.

• Beneficence: the physician should work for the greater good of the patient.

What is a known side effect of amiodarone ?

Depression and fatigue

What lab value ( other than thyroid labs) would be present for hypothyroidism?

Elevated LDL

In hypothyroidism, thyroid hormone deficiency results in hyperlipidemia because T4 is needed for the upregulation of the LDL receptor on cell surfaces and subsequent catabolism of low-density lipoprotein (LDL). Patients with hypercholesterolemia should be screened for hypothyroidism before statin therapy is initiated.

What is the strongest predictor of mortality for the patient during his postoperative ICU course?

Delirium

delirium was an independent predictor of higher 6-month mortality and longer hospital stay even after adjusting for relevant covariates including coma, sedatives, and analgesics in patients receiving mechanical ventilation.

What treatment is most effective for specific phobia?

Behavioral therapy

How to determine if someone have diabetes insipidus (instead of other causes of polydypsia)? And between different causes of it?

Dx of DI → Water restriction test: Pts with DI wont have reduced and concentrated urine after restriction

B/w causes of DI→ Desmopressin test: Central will respond to added vasopressin, Nephorgenic wont.

What are restriction for varenicline?

Renally cleared → needs dose adjust for renal insufficiency

Patient with parkisons disease is complaining of compulsive behavior that is draining her saving. what is the likely diagnosis?

Impulse control disorder

Patient presents with acute psychosis and delirium/AMS with history of hypothyroidism. What should you suspect? Whats level of TSH?

Hashimoto’s encephalopathy

Normal TSH or very minimally high

Delirium is most highly correlated to the disruption of which one of the following neurotransmitters?

Acetylcholine

What are the most common symptoms of BDZ withdrawal?

• Anxiety

• Sleep disturbance → can lead to REM sleep

What are common side effects of topiramate?

• Weight loss

• Metabolic acidosis

What is the side effect of ifosfamide (in chemo)? and how do we treat it?

• Side effect: Neurotoxicity

• Treatment: methylene blue

Which atypical antipsychotic does not undergo substantial hepatic metabolism?

palperidone

What is common in depression and PCOS?

Increase in insulin

Which of the following is the most significant in determining a patient's risk for type II diabetes?

Family history of immediate relative

Patient cannot finish/ejaculate with rigorous stimulation and long masturbation. What is the disorder?

Delayed ejaculation

Patient has HIV and now infected with Cryptococcus Neoformans. What is the treatment?

Amphoterin B for immediate treatment

Note: oral fluconazole is prophylaxes to avoid reccurance, not treatment.

What are classic signs of hypokalemia ?

• muscles weakness and cramps

• palpitations and arrhythmias

• paresthesia

• polyuria

ECG: Inverted T waves and visible U waves

Note: Eating disorder in young patients can present as hypokalemia

Timeline of symptoms in alcohol withdrawal

• Withdrawal tremulousness (the shakes or the jitters) usually begins 6 to 8 hours after cessation of drinking.

• Psychotic and perceptual symptoms begin 8 to 12 hours

• Seizures usually occur between 12 and 24 hours after the last drink.

• Delirium tremens, if it is going to happen, will occur between 72 hours and up to 1 week after the last drink.

Patient has HIV and now infection with toxoplamosis. What is the MRI finding? What is the treatment?

MRI brain: multiple ring enhancing lesions in the deep white matter

Treatment: Pyrimethamine, Leucovorin and Clindamycin

What is the first line treatment for panic disorder?

CBT

Patient with headache and uncontrolled laughing?

Hypothalamic Hamartoma

What is the criteria for fibromyalgia diagnosis?

1) widespread pain index (WPI) 7 or greater and symptom severity (SS) scale score 5 or greater (or WPI 3-6 and SS scale score 9 or greater

2) symptoms have been present at a similar level for at least 3 months

3) the patient does not have a disorder that would otherwise explain the pain.

Fatigue, sleep disturbance, MSK tenderness and cognitive impairment are common.

No longer need to have tender points for criteria.

Treatment

Medications approved by the FDA for this condition include milnacipran, pregabalin and duloxetine. Drug therapy should be combined with cognitive-behavioral therapy including guided imagery, relaxation training, activity pacing and distraction training.

Zinc deficiency symptoms?

Sxs: diarrhea, weight loss, hair loss, major depression, impaired immunity, and wound healing. It may also proceed to psychosis.

Cause: impaired absorption, reduced dietary intake, or those who drink alcohol as it impairs the absorption of zinc.

What medication can help delirium agitation (not aggression) in patients with parkinsons or lewy body dementia?

Rivastigmine

A 35 y.o. man presents with moderate Major Depression. He is open to taking medication but is concerned about sexual side effects. What medication would you consider first?

Vilazodone

Also consider bupropion (Wellbutrin SR, Wellbutrin XL, others), mirtazapine (Remeron) and vortioxetine (Trintellix).

Which antipsychotic does not interact with Tacrolimus?

Fluphenazine

Which immunosuppressant in transplant patient is most likely to cause neurospsych symptoms?

Tacrolimus

What is the most correct consequence of this patient's subthreshold depresssion?

Increase risk of disability 

What medication is effective for clozapine induced weight gain AND constipation?

orlistat

Metformin is only for weight gain

Which of the following receptors is the primary driver in increasing the risk of developing diabetes in individuals taking antipsychotics for schizophrenia?

Muscarinic receptors - M3

What is the therapy of choice in Chronic Fatigue Syndrome?

CBT

What is treatment for cushings syndrome?

surgical resection of tumor 

Etomidate - inhibits steroidogenesis on multiple levels 

What psychiatric condition is commonly associated with acromegaly ?

Personality changes is most common

cognitive impairment and psychosis may also occur

Which antiviral medication (used to treat HIV or syphilis) has most neurpsych symptoms? Describe the symptoms?

Efavirenz

Sxs: fatigue, insomnia, nightmares, agitation and nervousness. Can progress to severe depression and suicidal ideation

What is the electrolytes changes seen in refeeding syndrome?

• Hypophosphatemia 

• Hypokalemia 

• Hypomagnesemia 

What are the typical features of hypothyroid?

menorrhagia, fatigue, mood disturbance, weight gain, bradycardia, facial myxedema (puffy appearance), thinning of the eyebrows, and diminished deep tendon reflexes with delayed relaxation, all of which are typical features of hypothyroidism.

What are known side effects of tamoxifen?

• Menopause sxs or irregular menses or vaginal discharge 

• Weight gain 

• Leg swelling 

• HA

• At risk for DVT 

What is a metabolic abnormality common in bulimia nervosa, purging type?

Hypochloremic metabolic alkalosis

Adding which one of the following SSRIs to a patient's medication regimen is most likely to raise serum levels of several tricyclic antidepressants?

Fluoxetine as it is a strong CYP2D6 inhibitor

What are the FDA approved treatment for fibromyalgia?

Pregabalin, Duloxetine, and Milnaciprin.

Which drugs due to CYP interaction should be avoided with tamoxifen ?

CYP2D6

Tamoxifen is prodrug that needs to converted to its active form endoxifen

Avoid meds like fluoxetine, paroxetine, high dose sertraline, duloxetine and buproprion

Which antimalaria medication is likely to cause neuropsych sxs of insomnia, nightmares, psychosis, mania and aggression?

Hydroxychloroquine

Which pharmacological treatment class for autoimmune diseases has lower prevelance of depression and anxiety as a side effect?

Biological response modifiers like TNF-antagonist (Etanercept) and “Mab” or “Nibs”

What is the most common psych sxs of neuropsych lupus?

cognitive impairment 

What is the criteria for chronic fatigue syndrome?

• Unexplained fatigue ongoing for 6 months PLUS four or more of the following

• sore throat

• tender lymph nodes

• unrefreshed sleep

• post exertional malaise >24hours

• joint pain

• HA

• Memory impairment 

The presence of which one of the following signs is most helpful in distinguishing amphetamine-induced psychosis from schizophrenia?

Tactile and visual hallucination

How long at a minimum should a patient be abstinent from alcohol before safely starting disulfiram?

24 hours

What are the lab findings that help with diagnosis of acromegaly? 

• Elevation in serum insulin-like GF1

Which DM medication can lead to vitamin B12 def?

Metformin