Psych Shelf Questions Help!

[h11111987o]

Anyone know the answers to these??

2.) A 62 year old women is brought in to the emergency department by her husband because of confusion for 4 hours. Her husband says that she has been exhibiting strange behavior for 3 days she forgets pots on the stove or does not know what day it is. This morning she was completely disoriented and thought that her husband was a burglar. She has been taking fluoxetine (20mg daily) for 2 weeks for treatment of MDD. Current medications also include propranolol (40mg TID) for HTN and doxepin (50mg at bedtime) for insomnia. She appears to be having visual hallucinations and is unable to give any useful information. Her pulse is 110/min, respirations are 14/min and blood pressure is 140/95. Examination shows dilated pupils, dry flushed skin and mild tremor. She is disoriented to person, place and time. An ECG shows first-degree AV block and widened QRS complex. Urine toxicology screening is negative. Which of following is most appropriate next step in management?

A.) Measurement of serum doxepin and desmethyldoxepin concentrations
B.) measurement of serum floxetine and norfluoxetine concentrations
C.) Begin lorazepam (2mg every 8 hrs)
D.) d/c doxepin
E.) insert temporary pacemaker

over the past 7 yeras, a 25-year-old graduation student has had increasinly severe palpitations, tremulousness, nausea, swetaing, and inability to concentrate while taking examinations. He is worreid because he recently failed an examination despite being thoroughly prepared. Examination shows normal findings. Which of the following is the most appropriate next step in diagnosis

A.) ambulatory ECG monitoring
B.) 24 hour collection for 5-HIAA
C.) 24 hour collection for measurement of catecholamine and metanephrien concentration
D.) Measurement of T4 and TSH concentrations (not answer)
E.) Psychiatry evaluation

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[hamstergang]

I think I know the answers, but in the interest of you actually learning, could you explain your thoughts on each of these?

 

[benlinus]

Anyone know the answers to these??

2.) A 62 year old women is brought in to the emergency department by her husband because of confusion for 4 hours. Her husband says that she has been exhibiting strange behavior for 3 days she forgets pots on the stove or does not know what day it is. This morning she was completely disoriented and thought that her husband was a burglar. She has been taking fluoxetine (20mg daily) for 2 weeks for treatment of MDD. Current medications also include propranolol (40mg TID) for HTN and doxepin (50mg at bedtime) for insomnia. She appears to be having visual hallucinations and is unable to give any useful information. Her pulse is 110/min, respirations are 14/min and blood pressure is 140/95. Examination shows dilated pupils, dry flushed skin and mild tremor. She is disoriented to person, place and time. An ECG shows first-degree AV block and widened QRS complex. Urine toxicology screening is negative. Which of following is most appropriate next step in management?

A.) Measurement of serum doxepin and desmethyldoxepin concentrations
B.) measurement of serum floxetine and norfluoxetine concentrations
C.) Begin lorazepam (2mg every 8 hrs)
D.) d/c doxepin
E.) insert temporary pacemaker

over the past 7 yeras, a 25-year-old graduation student has had increasinly severe palpitations, tremulousness, nausea, swetaing, and inability to concentrate while taking examinations. He is worreid because he recently failed an examination despite being thoroughly prepared. Examination shows normal findings. Which of the following is the most appropriate next step in diagnosis

A.) ambulatory ECG monitoring
B.) 24 hour collection for 5-HIAA
C.) 24 hour collection for measurement of catecholamine and metanephrien concentration
D.) Measurement of T4 and TSH concentrations (not answer)
E.) Psychiatry evaluation

1. D (serotonin syndrome)

2. E ( technically speaking, providers like to have an ECG prior to starting a psychiatric medication (not all) so possibly A, but it's only in the exam setting so it doesn't seem likely a cardiac issue, though the worsening over seven years and increasingly severe palpitations may make someone lean towards cardiac clearance first)

 

[thoffen]

The first question has some not so great answer choices. Let's summarize the condition:
Pt. is clearly delirious with onset 3 days ago and 4 days of worsening, hallucinations, disorientation, delusional, but not clearly agitated
Pt. meds include SSRI, TCA, & B-blocker
Pt. has mild HTN/tachycardia, nml respirations, dilated pupils, dry skin, flushed, tremor
EKG with widened QRS and 1st degree AV block

So...this is most consistent with TCA poisoning, (not agitated/prominent tremor/febrile/sweaty/myoclonus that would be serious serotonin syndrome, plus would think about that most with MAOI involvement) has anticholinergic toxicity and EKG changes suggesting sodium channel blockade (widened QRS).

They don't really give you enough info for complete management, but here are some principles:
1. impending next concerns are arrhythmia and seizure
2. for seizures and agitation, use BZD, but cautiously since there is antihistamine/sedation effects and don't want to suppress respirations/worsen delirium; pt does not have either of these yet, and would not do it scheduled
3. need to get regular EKGs. Since there are changes, sodium bicarb would be next step
4. drug levels are not helpful in this setting

Of the choices, I'd pick stop doxepin, but I'm upset that they made the patient so sick because you should be thinking ABCs and intensive cardiac monitoring +/- bicarb. No need for pacer for 1st degree A/V block.

The second question...it's very limited to performance type in only 1 setting and pt has been otherwise healthy over 7 years time. And the answer choice was not even treatment but further evaluation. No compelling medical emergency, so psych evaluation wins hands down.

 

[h11111987o]

The first question has some not so great answer choices. Let's summarize the condition:
Pt. is clearly delirious with onset 3 days ago and 4 days of worsening, hallucinations, disorientation, delusional, but not clearly agitated
Pt. meds include SSRI, TCA, & B-blocker
Pt. has mild HTN/tachycardia, nml respirations, dilated pupils, dry skin, flushed, tremor
EKG with widened QRS and 1st degree AV block

So...this is most consistent with TCA poisoning, (not agitated/prominent tremor/febrile/sweaty/myoclonus that would be serious serotonin syndrome, plus would think about that most with MAOI involvement) has anticholinergic toxicity and EKG changes suggesting sodium channel blockade (widened QRS).

They don't really give you enough info for complete management, but here are some principles:
1. impending next concerns are arrhythmia and seizure
2. for seizures and agitation, use BZD, but cautiously since there is antihistamine/sedation effects and don't want to suppress respirations/worsen delirium; pt does not have either of these yet, and would not do it scheduled
3. need to get regular EKGs. Since there are changes, sodium bicarb would be next step
4. drug levels are not helpful in this setting

Of the choices, I'd pick stop doxepin, but I'm upset that they made the patient so sick because you should be thinking ABCs and intensive cardiac monitoring +/- bicarb. No need for pacer for 1st degree A/V block.

The second question...it's very limited to performance type in only 1 setting and pt has been otherwise healthy over 7 years time. And the answer choice was not even treatment but further evaluation. No compelling medical emergency, so psych evaluation wins hands down.

thanks- those are the answers I was thinking for both of them too (after I got them wrong of course), just wanted someone else's opinion!

 

[HarryMTieboutMD]

Question 1 is a good question not in terms of exact diagnosis (anticholinergic toxicity vs serotonin syndrom though given EKG and physical exam findings it is one or both of the two) but that the patient is DELIRIOUS and then STOPPING the offending agent (in real life I would stop all 3 and if pt's BP goes out of control I would prob use labetalol/something else non centrally acting... or that's what my tox friends would do).

For Question 2 the diagnosis is pretty obvious (being that it's situation related and that a purely cardiac/endo issue would not just occur around exam time), but I think "psychiatric evaluation" is not the best way of phrasing the correct answer.

 

[smalltownpsych]

For question one, I picked the right answer, but wondering why not test for UTI as answer?

 

[hamstergang]

For question one, I picked the right answer, but wondering why not test for UTI as answer?

Given the signs and symptoms @thoffen highlighted, we have a fairly good idea of what the culprit is. You likely would get a UA at some point, but stopping the offending agent is the most important first step.

 

[HarryMTieboutMD]

For question one, I picked the right answer, but wondering why not test for UTI as answer?

As above the question is testing whether you (thinking from a med student perspective with limited clinical experience) can identify a culprit agent and stop it, but there are obvious other things that would be done automatically.
1) Would want to know a detailed substance history from the husband (most ED UDSs have short detection windows and don't identify a lot of things); also pt could be in DTs... actually a very detailed history in general
2) Complete med list incl OTC meds/supplements (stimulants, also did someone give the patient Reglan or Compazine?)
3) Basic labs (CBC, BMP, +/- liver function), TSH, UA

Altered mental status with vital sign instability is an emergency with a broad differential, and an astute ED physician (or psychiatrist for that matter) will readily think through most likely to least likely with a focused history and exam. It's very easy to get lazy when this happens, and people LOVE to dx serotonin syndrome (even though it's not that common at all)- I've seen DTs, anticholinergic toxicity, and a few other things misdiagnosed as serotonin syndrome because the Dr wasn't thinking or paying close enough attention to history or exam.

 

[nitemagi]

It's the AV block and QRS widening that really gives away the answer.