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What drugs should be avoided with Kava Kava? Alprazolam CNS depressants (e.g., phenobarbital, zolpidem) What is the normal range for TSH? 0.5 - 5.0 mu/L What are lab values in Hyperthyroidism Decreased TSH Increased T4 and T What are labs in Hypothyroidism? Increased TSH Decreased T4 and T What are 5 primary symptoms of Hyperthyroidism? Heat intolerance Agitation, Anxiety, Irritability Tachycardia
Mood swings Weight loss What are 4 primary symptoms of Hypothyroidism? Cold intolerance Lethargy Weight gain Decreased libido Hypothyroidism mimics symptoms of what psychiatric disorder? Depression Hyperthyroidism mimics symptoms of what psychiatric disorder? Mania Valproic acid produces what teratogenic effect? Spina bifida (neural tube defect) What is the primary organ where valproic acid is toxic? Liver (hepatoxicity) What are 4 signs of hepatoxicity? Abdominal pain in the URQ Reddish-brown urine Yellowing of the skin and sclera Fatigue
Kava Kava liver damage What are 5 symptoms of Stephen's Johnson Syndrome? Fever - Key sx to suspect SJS; high yield (HY) burning of mouth/eyes - HY Body aches Severe red rash Peeling skin Facial and tongue swelling Which mood stabilizer causes the least weight gain? Lamotrigine (Lamictal) Which 3 SGAs cause the least weight gain? Lurasidone (Latuda) Aripiprazole (Abilify) Ziprasidone (Geodon) Which SGA is the least sedating? Aripiprazole (Abilify) Your pt is taking Kava and you need to add an AS to manage their SCZ, which do you add? Aripiprazole (least sedating) What are 2 hallmark symptoms of delirium? Acute onset
disturbance of LOC impaired cognition inattention How are agitation and psychotic symptoms treated in delirium? Low dose Haldol (QTc check first) 16 y/o C/O feeling funny after inhaling Acetone (nail polish remover). What is your action? Do UDS; chances are they may be abusing other substances What 4 drugs can cause mania? "SAID" Steroids Antidepressants (in BPD) Isoniazid (INH) Disulfiram (Antabuse) What 6 drugs can induce depression? "SIP BARB" Steroids Interferon, Progesterone Beta blockers Accutane, (Isotretinoin)
the mood stabilizer w/ anti-suicidal effects What mood stabilizer has anti-suicidal effects? Lithium What 5 labs should be drawn with lithium? Thyroid panel (TSH) Serum creatinine BUN Urinalysis HCG What is a normal SerumCr range? 0.6-1.2 mg/dL What is the normal range for BUN? 10 - 20 mg/dL When should you suspect kidney disease with a urinalysis? 4+ protein; if pt on Lithium-->monitor closely toxicity What are 7 side effects of lithium? Hypothyroidism Fine hand tremors Maculopapular rash GI upset (N/V/D, cramps, anorexia) Polyuria, polydipsia, diabetes insipidus T-wave inversions Leucocytosis What are 7 signs of lithium toxicity? Severe nausea, vomiting, diarrhea Confusion Drowsiness Muscle weakness Heart palpitations
Coarse hand tremor Unsteadiness while standing or walking Bold =must knows Which 3 drugs can increase lithium levels by decreasing renal clearance? NSAIDs (ibuprofen, indomethacin) Thiazides ACE-I What is a toxic level of lithium? 1.5 mEq/L or higher At what level do you monitor lithium closely (but not discontinue)? 1.3 - 1.4 mEq/L or higher With suspected lithium toxicity, what do you do first? D/C Li and draw Lithium level (not VS) What is the appropriate action if lithium level is 1.5 mEq/L? D/C lithium Check lithium level What 2 conditions can increase lithium levels? If this pt is going on a hike, what would you recommend? Dehydration Hyponatremia Take extra water to avoid dehydration What birth defect can lithium cause? Ebstein anomaly (congenital heart defect) When working with adolescents, parents often feel they have a right to know what is going on with their child, but the teen has a right to confidentiality. This can create an
the medication has been cleared from the body What are the lower age limits for stimulants for ADHD? AMPH = 3yrs MPH = 6yrs When considering Clonidine or Guanfacine for a pt, the PMHNP knows? Clonidine is more sedating than Guanfacine; Guanfacine lasts longer than Clonidine What does thought process assess? thoughts and ideas A normal thought process is described as Logical Linear Coherent Goal-oriented Moving from thought to thought and never getting to the point is called Tangentiality ("goes on tangent") Providing unnecessary detail but eventually getting to the point is called Circumstantiality ("goes in circles") Themes that occupy a patient's thoughts and perceptual disturbances is called Thought content Thought content includes 3 items Suicidal ideation Homicidal ideation Hallucinations/Delusions Asking a patient to count backward from 100 by seven (serial 7s), or anything going backwards measures what?
Concentration Attention Asking the year, season, date, month, and location measures Orientation Asking a patient to repeat "bed, red, ball" measures Registration (ability to learn new material) Asking a patient to repeat objects 5 minutes later measures Recall (memory) Asking the patient who is the president of the US or governor of state is measuring Fund of Knowledge What is a simple test that can be administered in a minute or two to measure possible dementia? Clock Drawing Test Impairments in the clock drawing test (CDT) can be associated with damage to Right parietal lobe (right hemisphere) Hyperactivity of dopamine in the mesolimbic pathway to the dorsolateral prefrontal cortex (DLPFC) modulates positive psychotic symptoms The safest drug switch strategy is to have a "washout period" of _______ half-lives between cessation of old med and the introduction of the new med. 5 1/ Decreased dopamine in the mesocortical pathway (dorsolateral prefrontal cortex) leads to what 2 symptoms? Negative symptoms: affect, anhedonia, asociality, alogia, apathy, avolition, Depressive symptoms
Skin rash SOB In which ethnic group must you screen for the HLA-B1502 allele before initiating CBZ (Tegretol) therapy? Why is it necessary?* Asians risk for SJS in Asians (+) for HLA-B*1502 allele Which 2 drugs have the highest likelihood of causing agranulocytosis? Clozaril Carbamazepine A sudden fever, chills, a sore throat, and weakness are symptoms of Agranulocytosis At what ANC should clozapine be stopped (even if asymptomatic)? < What is neutropenia? <2000 PMNs or WBC < What is agranulocytosis? <500 ANC What does DIGFAST stand for? D istractibility I ndiscretion G randiosity F OI A ctivity increased S leep decreased T alkativeness What neurological symptoms might one see in Conversion Disorder?
Blindness Mutism Paralysis Paresthesia (glove stocking syndrome) Seizures When do symptoms typically begin with Conversion Disorder? After a stressful experience (suddenly) What are 5 stressful events in a child's life that can cause adjustment disorder? Family move Parent divorce/separation Loss of pet Birth of sibling Sudden or chronic illness A child with an Adjustment Disorder with disturbances of conduct may have what symptoms? Not going to school, destroying property, driving recklessly, or fighting What are some key sx of Oppositional Defiant Disorder (ODD)? NOT aggressive (key difference vs CD) loses temper easily annoys others angry/resentful argues with authority easily annoyed blames others spiteful refuses to comply with rules/requests from authority figures What is the mainstay treatment of Oppositional Defiant Disorder (ODD)? Therapy, individual and family What is the primary therapy used to treat Oppositional Defiant Disorder (ODD)?
helps to develop natural support systems What is the range for MMSE? score 0-30. Higher the better 25+ normal 21 - 24 mild 10 - 20 moderate 0 - 9 severe What is the range for SLUM? score 0- 30 Higher the better 27+ normal 21 - 26 mild <21 dementia What is the range for HAM-D? range 0- 76 0 - 7 normal
8 mild 14 moderate 19 mod-severe 23+ severe Just moderate 14- 18 What is the moderate range for PHQ- 9 range 0- 27 0 - 4 normal 5 mild 10 moderate
> 15 mod-severe
20 severe Just moderate 10 - 14 What is the moderate range for BDI? range 0- 63 0 - 9 normal > 10 mild > 19 moderate > 30 severe Just moderate 19 - 29 What is the moderate range for HAM-A? 0 - 56 0 - 17 mild > 18 moderate > 25 severe Just moderate 18 - 24 What is the moderate range for GAD- 7 range 0- 23 0 - 4 normal > 5 mild > 10 noderate > 15 severe Just moderate 10 - 14 What is the moderate range for COWS? 13 - 24
If a patient has mild anxiety (<18 on HAM-A) (<10 on GAD-7), how do you treat? Therapy or nothing If a patient has severe anxiety (>24 on HAM-A) (>14 on GAD-7) how do you treat? Medication and/or therapy If a patient has moderate anxiety (18-24 on HAM-A) (10 - 14 on GAD-7) how do you treat it? Medication and/or therapy What are 4 areas in the brain that can cause aggression, impulsivity, and difficulty with abstract thinking? Prefrontal cortex Amygdala Basal ganglia Hippocampus Abnormalities in the Prefrontal cortex, Amygdala, Basal ganglia, and Hippocampus can cause what 3 symptoms? Aggression Impulsivity Difficulty with abstract thinking **What are 6 symptoms of NMS? *Extreme muscular rigidity Mutism Elevated labs CPK (creatine phosphokinase), LFT's and WBC's Myoglobinuria autonomic instability vBP, ^HR/RR Fever *= top 3 ways to differ from SS Elevated CPK (creatine phosphokinase) in NMS is caused from
muscle contraction and destruction What are 2 differentiating symptoms (Key indicators) of Serotonin Syndrome? Hyperreflexia Myoclonic jerks S/S of serotonin syndrome include: what are the 4 most often seen (in bold)? “Shits and Shivers” § Diarrhea (shits) § Shivering, § Hyperreflexia/myoclonic jerks § Increased temperature § Vital sign instability § Encephalopathy § Restlessness/anxiety § Sweating How do you treat NMS? DC offending agent Bromocriptine or Dantrolene What does Dantrolene treat in NMS? Muscle rigidity How do you treat Serotonin Syndrome? DC offending agent Cyproheptadine: H1 antihistamine that acts to block 5 - HT1A and 5-HT2A receptors
