Young female BMI 16bcoming to you with 1ry amenorrhea first inv…..

US

Female BMI 16 with bony pain first inv……DEXA scan ..osteoporosis

Priority in anorexia nervosa….electrolytes(hypo K)

:Most common

Effect of anorexia nervosa on pregnancy……Low birth weight

Effect of malaria on pregnancy…….low birth weight

Effect of cocaine on pregnancy……low birth weight

Effect of smoking on pregnancy……..low birth weight

Inv NOT routine in anorexia nervosa……gonadotropins

Main difference bet bulimia and anorexia nervosa...normal weight

Long term prognosis of bulimia nervosa……depression

Long term prognosis of OCD…..PSYCHOSIS

Long term prognosis of borderline personaity disorder….psychosis

Long term prognosis of generalized anxiety…..depression

Long term prognosis of panic attack…….depression

Psychiatric disorder causing highest rate of death…anorexia nervosa

Female always feel that she is overweight although normal BMI….body

dysmorphic disorder

?Causes of body dysmorphic disorder

bulimia nervosa-1

anorexia nervosa-2

amputated limb-3

acromegaly-4

neglect syndrome -5
Most common course of obsessive compulsive disorder….wax and wane

Most common course of depression……..regressive

Distrustiful suspicious person…….paranoid

Female with history of crimes, drug abuse, sexual troubles, left her
family and lives alone……borderline

Male with history of crimes, drug abuse, sexual troubles, left his family
and lives alone more than 18 ys……antisocial

Most risk with borderline……suicide

Psychotherapy for borderline……dialectal

Psychotherapy for trichillomania…..aversion

Male lives alone doesnot care about people……schizoid

Male lives alone feels being rejected……..avoidant

Male lives alone with with ideas of reference……schizotypal

Male with high self esteem doesnot show empathy….narcissitic

Female being abused by her boy friend but still feels as if she can never
live without him…… dependent
Female gives great care to the order of furniture in her home and has a
strict schedule of her life routine... Obsessive compulsive
Female during interview wears sexy clothes and tries to seduce the
employer to get the job……historionic

Child 5 ys his mother complains of his overactivity and that he doesnot

listen to what she says…..ADHD

First step to confirm ADHD……call the teacher and ask for his grades

Drug of choice for ADHD…….methyphenidate

Most imp test for ADHD………..hearing test

Boy 4 ys old with low IQ limited social activity, limited language

development , fascinating with certaing toys…..AUTISM
Boy 4 ys old with normal IQ , limited social activity, normal language
development , fascinating with certaing toys…..asperger

:Kid diagnosed as asperger syndrome on SSRI now agitated

Most common cause……….SSRI ( side effect)

2nd most common cause…….part of the disease

ys child doing recurrent grimacing and recurrent strange 8

sounds….Tourret's

Most common association with Tourret's……OCD

Drug of choice for tourret's……antipsychotic

Child 14 ys with history of drinking alcohol and recurrent fighting with

his peers in school…….conduct

ys old kid doesno have many friends accused before of making making 6
fights……….oppositionsl deficient disorder

Is masturbation normal act?.....yesssssss

Is being Gay or lesbian normal act ?....yesssss

: TTT of choice for

Anorgasm………..self stimulation

Premature ejaculation……….squeeze technique

Vaginismus…………vaginal dilators

Male feels orgasm by wearing his girl friend underwear….transvestism

Male feels orgasm by rubbing his body against clothed females in

crowded places……frotteruism

Male feels orgasm by having sex with kids….pedophilia

Male feels that he is a woman in male's body and asking for plastic
surgeries to change his sex…..transsexualism
Young females with recurrent attacks of hyperventilation, palpitationg
and feeling as if she will die….panic

Long term prognosis of panic ….depression

Most common association with panic…agoraphobia

TTT of acute attack of panic……benzodiazepine

Lab of panic….. alkalosis, hypocapnea and increased O2

Woman with marked fear each time she has to give public
speaking…..social phobia
Best ttt for specific phobia…..gradual exposure
Imp test for dementia……..MMSE test|( less than 24)
There is no definitive investigation for Alzheimer
Alzheimer is not preventable nor curable
First to be affected in Alzheimer…….memory
Least likely to be affected with Alzheimer is face recognition
Psychiatric illness increases in incidence………..dementia
2nd most common cause of death in australia….dementia
Memory affection with normal aging sometimes very similar to
Alzheimer except that there is no impairment of normal function…….. he
lives independently
Drug of choice for alzeheimer….donepezil, tacrine
Best drug for alzeheimer with heart disease……..memantine
Dementia + visual hallucinations + parkinsonism….lewy body
Dementia+personality changes+abnormal movements…Huntington
Dementia + marked personality and attitude changes…..frontal lobe
dementia
Dementia+urine incontinence+abnormal gait…..normal pressure
hydrocephalus
Dementia+young aged male with uncontrolled HTN….vascular
Short history of dementia+sleeping troubles….depression
Old age in the hospital sleeping during the day, agitated…delerium
Most imp inv for delirium…….urine analysis
Most imp drug to control agitation in delerium…..antipsychotic
Agitation in admitted person…..think of alcohol withdrawal
TTT of alcohol withdrawal…..diazepam
Female being raped now complains of flashbacks and troubles in
sleeping……PTSD
Most effective ttt in PTSD…..group councelling
Drug of choice for PTSD…..SSRI
Drug of choice for OCD……SSRI
Drug of choice for depression…..SSRI
Drung of choice for GAD……SSRI
Long term ttt for panic….SSRI
Female patients with long history of hospital admissions with many
procedures and surgeries done…..factitious
Kid admitted hospital becomes sick only when his mom visits him…..
mauchusen syndrome by proxy

Male patient presents with symptoms of insomnia and dereased

appetite but has problems with immigration……think of malingering
Male patient comes to the clinic with severe renal colic asking for strong
analgesics, his investigations normal…..malingering
First step in this patient…urine sampling in front of you
Male patient alcoholic now complains of nystagmus, gait instability and
drowsy….wernike's encephalopathy
Main cause of wernike's encephalopathy….thiamine deficiency
TTT of wernike's encephalopathy….THIAMINE then GLUCOSE
18 ys female patient failed an exam 6 months age, since that time she
doesnot feel she is the same person before the exam…..adjustment
disorder

Police brings to you male confused doesn't know his name, addressor
any thing about his work…. dissociative fugue

:Causes of IMPULSE CONTROL DISORDER

KLEPTOMANIA-1

PYROMANIA-2

TRICHILLOMANIA-3

PATHOLOGICAL GAMBLING-4

Female patient with recurrent acts of stealing of stuff she doesnot really
needs…. KLEPTOMANIA

Main ttt of kleptomania…..aversion

Male patient with recurrent episodes of doing firing in home and
school……pyromania

Why pyromanics do firing……satisfaction

Female patient with no hair on half of her scalp… TRICHILLOMANIA

Most common cause of fires in australia……….pyromania

Main ttt of grief……support
TTT of grief and depression……SSRI
TTT of marked insomnia with grief…..benzodiazepines
Most imp to depression with grief………suicidal ideation
Grief + visual hallucination…..normal grief
Imp question to patient with postpartum …… if she have any feeling of
hurting herself or her baby

Main risk factor for postpartum psychosis……….primipara

Most imp to check in mom after labor…..mood

Main ttt of mild post partum depression……family support

Important steps for mild postpartum blue……family involvement and

continue breast feeding

Treatment of cases of postpartum psychosis…involuntary admission and

.ECT

Inability to answer a question without giving excessive, unnecessary

detail.. but eventually will answer the question…….Circumstantiality

if doesnot answer the question…..tangentiality

feeling that you saw this situation before….deja vu

Female patient told you that a very famous celebrity loves her…delusion
of erotomania

Male patient came to told shouting that he is the God and should be
followed…..delusion of grandiosity

Old age patient anxious telling you his neighbors trying to kill him by
putting poisons in his food ….delusion of persecution
Patient feels that the people are talking about him….delusions of
reference

Main ttt of delusions………antipsychotics

sisters sharing the same psychotic's symptoms…folie a deux 2

Female patient with recurrent thoughts of cleaning her hands..OCD

When you commit the recurrent tought ………compulsions

Long term prognosis of OCD……psychosis

Most common course of OCD………wax and wane

TTT of choice of OCD…….SSRI

TTT of choice of OCD in kids……….fluvoxamine

BEST PSYCHOTHERAPY……exposure and prevention

Female patient worries about her financial condition and also about her
husband's work ……GAD

Main ttt of GAD…..SSRI

Long term prognosis of GAD……depression

Female patient with recurrent thoughts of washing her hands…OCD

Young boy taking more than 10 showers per day…OCD

Drug of choice for OCD in kids……fluvoxamine

Young male with recurrent attacks of sleeping per day that are
accompanied with hallucinations……narcolepsy

Main ttt of narcolepsy……psychostimulant

:Types of hallucinations with narcolepsy

Hypnogogic ………..before sleep

Hypnopompic ……after walking up

Middle age male obese with recurrent attacks of sleeping and his wife
complains of his snoring……Obstructive sleep apnea

Inv of choice…….polysomonography

First advice for this patient…..loss weight

TTT of choice……CPAP

What does insomnia means……bad quality of sleep

Main ttt of insomnia……non pharmacological

Drug of choice for insomnia….short acting benzodiazepine

Duration to diagnose depression……2 weeks

Duration to diagnose schizophrenia……6 months

Duration to diagnose schizophreniform….1-6 months

Duration to diagnose brief psychotic disorder..less than I month

Drug of choice for depression……SSRI

No effect after usage of SSRI for 1 week….just continue

Effect of SSRI appears after……2-6 weeks

When to shift to another drug…..no effect after 2 months

If NO effect after 2 months……shift to another SSRI

How long to use SSRI…..at least 6 months

How long to use SSRI in suicidal patient….2 YEARS

Withdraw over at least…………….. 2 weeks

Old age + severe depression…………..ECT

Depression+insomnia……..mirtazapine

Depression + decreased appetite……….mirtazapine

Most common season for depression………..winter

Most common season for suicide……………spring

Most common season for SIDS……………..winter

Depression+ memory impairement…………pseudodementia

Depression and suicide

Highest risk of suicide……………. first two weeks after leaving hospital

??Most important question to depressed patient……..suicidal thoughts

Highest probability of suicide……..history of previous suicidal attempt

Once you discover suicidal thoughts……involuntary admission

Most risky patients……have a plan of suicide

Farmer patient went to the downtown made sex with many

prostitutes and spent all his money…..acute mania
If Acute and marked psychosis……involuntary admission
1st line for acute mania………antipsychotics
First line drug for bipolar…….lithium
Second line drug…..valproic acid
Others…………….carbamazepine
If pregnant or lactating………..carbamazepine
Resistant and severe cases…….ECT
If marked psychotic symptoms……antipsychotic drugs

ys male recently showed marked drop in his school grades, doesnot 18

leave home and experienced hallucinations……prodrome of
schizophrenia

Epidemiology of schizophrenia:
General population………1%
First degree relative………12%
Second degree relative……6%
Single parent……………..12%
Two parents………………40%
Monozygotic twins………47%
dizygotic twins…………..12%

grand father…………..…6%

Male patient stands at the train stations for many hours on one
leg……..catatonic

Drug of choice for catatonic schizophrenia…….benzodiazepines

Causes of death with schizophrenia: IMP

1- CVS………most common cause

2- SUICIDE………2nd most common

TREATMENT
Acute and marked psychosis……involuntary admission

Antipsychotics drugs
Severe and resistant cases…….ECT

Good prognostic indicators in schizophrenia: vvvimp

)-( ……Family history

Sex………female

Onset………acute (first attack)

Precipitating factors……yes

Catatonic symptoms…..yes

Positive symptoms……yes
Negative symptoms….noo

Most important sign in schizophrenia…….impaired insight

What is mannerism?..... abnormal repetitive behavior

TTT of weight gain secondary to antipsychotic drug……orlistat

First step in ttt of any psychiatric patient……establish good

relationship with the patient

Patient tells you , he woke up in the morning, war is very

close to happen, Barcelona is the best foot ball team in the
world, he loves his parents……….derailement

Most common side effect of SSRI….abdominal pain and

agitation
Effective dose of sertraline……….50 – 100 mg

If patient on low dose and o effect 1st step……….increase the dose

SSRI + Ectasy…….serotonin syndrome

SSRI + tramadol or amphetamine…….serotonin syndrome

1st step in serotonin syndrome………hospitalization

First step in serotonin syndrome…..stop both drugs

If you have to select one of them……..stop offending drug 1st

Food should be avoided in patient taking MAOI….cheese and wine

What should be screened in patient taking MAOI….blood pressure

Patient on SSRI comes back to you complaining that there is no

improvement……….just.continue the medications

NERVER TO STOP SSRI SUDDENLY ……….TAPPERING SHOULD BE DONE

FOR 2 to_4 WEEKS
Effect of overdose of TCA……arrhythmia

Most imp Inv……ECG

How to asses severity…….duration of QRS complex

Antidote for TCA overdose……NaHco3

Tests should be done in patient on lithium….TSH and RFTs

Main SE of lithium toxicity….. ataxia, dysarthria delirium

TTT of lithium toxicity……dialysis

Main SE of carbamazepine……leucopenia

Main SE of lamotrigine……rash

Patient coming to ER with neck contracted to one side…dystonia

TTT of acute dystonia……diphenhydramine and benztropine

Main 2 categories of drugs causing extrapyramidal symptoms…

antipsychotic and anti emetics drugs ( metochlopramide)

Patient on antipsychotic with continuous urge to move around the

room……akathesia

Patient on antipsychotic with twitching of his face, tongue and

hand…….tardive dyskinesia

Patient on antipsychotic coming to ER with high fever, high blood

pressure and rigidity…….neuroleptic malignant syndrome

Risk with neuroleptic malignant syndrome …rhabdomyolosis….acute

renal failue

TTT of choice for neuroleptic malignant syndrome…dantrolene or

bromocriptine

Monitor of clozapine……CBC( AGRANULOCYTOSIS)

Most common antipsychotic to cause palpitations….clozapine

Monitor of olanzapine……FBS and lipid profile

First line therapy for schizophrenia……..olanzapine

schizophrenia + insomnia…….olanzapine
drug with the least side effects…..olanzapine
schizophrenia+ oversleeping…..respiridone
drug for delusions in pregnancy………olanzapine
Most important step in psychotherapy…..establish good relationship
with the patient
Least effective antipsychotic drug………..quetiapine
TTT of choice of old male severely depressed refusing to eat…..ECT
Main SE of ECT….. Transient memory disturbance

From who you get consent before ECT…….health tribunal authority

Main benefit of ECT…………immediate effect

Schizophrenic patient taking marijuana first step….stop marijuana

Duration of usage of SSRI in suicidal patients……2 ys

Type of SSRI in kids…….fluvoxamine

Most imp to monitor in venalfaxine……blood pressure

Patient with pin point pupil and RR 6/min….morphine toxicity

TTT of morphine toxicity,……naloxone

Drug for morphine withdrawal……..methadone

Drug for drug rehabilitation…………methadone

Patient with piloerection, yawning, rhinorrhea and myalgia….morphine

withdrawal

TTT of morphine withdrawal…..methadone

Main SE of benzodiazepine withdrawal…..agitation

TTT of benzodiazepine overdose…… Flumazenil

Effect of cocaine oh brain…..stroke
Effect of cocaine on nose…..septal perforation
Effect of cocaine on heart…….MI
 Effect of cocaine on skin…..bugs under skin
Effect of cocaine on placenta…..abruptio placenta
Effect of cocaine on fetus…..low birth weight.
Effect of cocaine on fetus……teratogenic
Most common teratogenic substance…..alcohol followed by smoking
Main SE of cocaine withdrawal……..skin bugs
Main SE of PCP toxicity…… vertical/horizontal nystagmus
Main SE of LSD toxicity……hallucination

Main SE of cannabis toxicity….. increased appetite, dry mouth,

conjunctival injection,
Active form of cannabis……..tetra hydro cannabinoid
Main TTT to help patient stop smoking….nicotine patch
alcohol questionnaire
1. Have you ever felt the need to Cut down on your drinking?
2.Have you ever felt Annoyed by criticism of your drinking?
3. Have you ever felt Guilty about drinking?
4. Have you ever had to take a morning Eye opener?
Most imp question to detect alcohol addiction…….morning eye opener

Most important risk factor for:

Anorexia nervosa........ family history of atheletism
Bulimia nervosa ....... history of child abuse
Binge eating...... family history of obesity
Weight loss in young female without others symptoms
except psychic problems...... drug or alcohol abuse
Drug of choice for catatonic schizophrenia…..benzodiazepine

Most common drug used in parties ………. Ecstasy (MDMA)

Most important sign of amphetamine withdrawal……paranoia
Most important sign of amphetamine toxicity……psychosis followed by
hallucinations

Drug of choice for agitation of drugs……….antipsychotic

 SSRI takes at least 2-6 weeks to be effective

Patient on SSRI comes back to you complaining that there is no
improvement……….just.continue the medications
Patient on SSRI still have symptoms first step…..increase dose

Patient on SSRI developed side effects…..shift to anoher SSRI

Most common side effect of SSRI….abdominal pain and

agitation

Patient on SSRI after taking tramadol developed serotonin

syndromes first step……….stop both of them

Donepezil and SSRIs

Synergistic effect

First step……..stop both of them

: Police brings to you homeless psychotic patient

First step………….collateral history from the police

If agitated………antipsychotic then admission

If not agitated………….admission

Where to admit……….psychiatric unit

??DD of sudden withdrawal manifestation in teenagers

drug abuse……..need to be excluded first-1

depression…..associated with decreased appetite, enegery, sleep and -2

suicisal thoughts

prodrome of schizophrenia……associated with delusions and -3

hallucinations

:N;B

Delusion with pregnancy…………olanzapine

Drug causing teratogenicity in first trimester…..anticonvulsant

Drug causing teratogenicity in last trimester…..antipsychotic

First step if mom complains of behaviouir of her son …..interview with
the son

Child refuses to take his medications first step…..talk to the boy

:Currently ttt of choice in agitated person if

Psychotic patient………..antipsychotic medications

Delirious patient………..antipsychotic medications

Postoperative……………..antipsychotic medications

Amphetamine toxicity…………………antipsychotics

Alcoholic………diazepam

Alcoholic and liver impairment……..lorazepam

Mentally retarded kid……….respiridone

Selective Mutism…………. where children will speak freely in

somesettings (usually at home) but not in others

Patient with dementia needs urgent surgery first step….ask for

advanced directive

Main Psychiatric disease that increases rapidly in Australia……

dementia

Most imp to check in a female after labor……..mood

Treatment of choice of lithium toxicity …… dialysis.

Most common drug used in parties…..Ectasy( MDMA)

patient doesnot speak English……….get interpretor on telephone

Least effective antipsychotic drug……..quetiapine