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NRNP 6660 MIDTERM EXAM
Agreement as to process - Solution 1. introduction
- consent to proceed
- nature of interaction
- amount of time for the interview
- assess if treatment is voluntary or involuntary Define privacy and confidentiality - Solution 1. Assure privacy, explain meaning of confidentiality and who information will be shared with
- explain duty to warn
- fee family members with the patient present, ensure consent is given (provider should listen not present information.
- If recordings or one way mirrors are used patient must be informed and give consent. Define respect and consideration - Solution Treatment patients with respect and be considerate to circumstance to alleve or not further aggravate anxiety Define Rapport - Solution Harmonious responsiveness of the provider to the patient. Empathic interventions increase rapport to understand patient feelings while maintaining objectivity mostly nonverbal (putting pen down or leaning towards patient) What is a crucial element of empathy - Solution Objectivity as it differentiates empathy from identification. Identification causes lose of objectivity and blurs boundaries. What are the ingredients for good patient provider relationship - Solution 1. Desire for help
- Providers respect and consideration
- non-judgmental attitude
- demonstration by provider they understand what patient is stating or emoting
- patient thinks provider cares
- genuiness of provider.
What questions about self should the provider answer - Solution 1. Provider qualifications, if sarcastic address issue that provoked it.
- No personal information directly unless it is patient centered, NO physician centered information. Define unconscious transference in a patient - Solution The process of a patient unconsciously and inappropriately displacing onto individual in patients current life those patteren of behavior and emotional reactions that originated with significant figures usually from childhood. What is unconscious counter-transference - Solution The provider unconsciously displaces onto the patient patterns of behavior or emotions as if they were a significant figure from earlier in the providers life. What are resistances - Solution The processes conscious or unconscious that interfere with the therapeutic objectives of treatment What is repression, and how do interpretations help? - Solution Repression causes unawareness, interpretations are interventions that undo the processes of repression and allow the unconscious thought and feelings that come to awareness. What does a patient centered interview? - Solution Focus of interview is on understanding the patient and enabling the patient to tell his or her story, the individuality of the patients experience is the main theme What information according to Adolf Meyer is collected in the interview - Solution 1. early life experiences
- family
- education
- occupation
- religious beliefs
- hobbies/talents
- relationships
- losses. What type of questions are asked in a patient centered approach. - Solution Focuses on strengths and weaknesses. tell me what you do best? Open ended questions can be affected by patient mood or self image.
What is completed in the waiting room - Solution demographic and insurance forms information given on practice contact for after hours HIPAA mandated information. list of medications requested name and address of primary care identification of major medical problems and allergies. major reason for the visit. rating scales PHQ-9, or QIDS-SR How should the interview room be set up. - Solution 1. choice of hardback or soft chair
- interviewer and patient chairs should be equal in height.
- patient and psychiatrist should be seated 5-6 feet apart.
- provider should not be behind a desk.
- provider should be dressed professionally and be well groomed.
- distractions should be kept to a minimum How do you initiate the interview. - Solution 1. greet patient in waiting room
- introduce self
- extend hand and see if patient shakes it if not may be important.
- indicate way to waiting room 5 in interview room offer to hang coat up
- indicate where patient can sit.
- ask what the patient prefers to be called.
- indicate how much time is alloted for the interview
- explain process, confidentiality 10 begin inquiry with open ended questions
- if referred elicit the patients understanding of why they are being referred. What are open ended question used for in the initial interview. - Solution allows the patient to telol his or her story which is the primary goal of the data collection to elicit the patients story of their health and illness. Does open ended questions provide structure - Solution NO, they identify an area but provide minimal structure as to how to respond. does close ended questions provide structure - Solution YES, provides much structure and narrows the field from which a response may be
chosen. the ultimate closed ended question leads to a yes or no answer. and can be used to understand some of the specifics of the patients history. What are the parts of the psychiatric interview - Solution 1. identifying data
- source and reliability
- chief complaint
- present illness
- past psychiatric history
- substance use abuse
- past medical history
- family history
- developmental and social history
- review of systems
- mental status examination
- physical examination
- formulation
- DSM-5 diagnosis
- treatment plan. What are the 2 overarching elements of the psychiatric interview - Solution patient history and mental status examination. Identifying Data includes - Solution 1. patients name
- pts. age
- pts. sex
- pts marital status/SO
- race
- ethnicity
- occupation Source and reliability includes - Solution Important to clarify where the information has come from especially if others have provided information or records reviewed and the interviewers assessment of how reliable the data is. Chief complaint includes - Solution The patients presenting complaint ideally in pts own words.
What questions do you ask in the psychiatric interview for anxiety - Solution 1. Generalized anxiety symptoms (where when who how long, how frequent)
- panic disorders symptoms: HOw long until peak somatic symptoms including racing heart sweating shortness of breath trouble swallowing sense of doom fear of recurrence agoraphobia
- obsessive-compulsive symptoms: checking cleaning organizing rituals, hang-ups, obsessive thinking, counting, rational vs. irrational beliefs
- posttraumatic stress disorder: Nightmares, flashbacks, startle repsonse, avoidance,
- social anxiety symptoms
- simple phobias, heigts, planes spiders etc. What questions do you ask in the psychiatric interview ofr psychosis - Solution Hallucinations: auditory visual olfactory tactile paranoia delusions: TV, radio, thought broadcasting, mind control refernetial thinking patients perceptions: spiritual or cultural context of symptoms relaity testing. What other questions should be ask in the psychiatric interview - Solution ADHD symptoms Eating disorder ymptoms: binging purging excessive exercising. what is included in the psychiatric history - Solution all psychiatric illnesses over lifetime including symptoms and treatment any comorbid conditions description of past s/s inclding when they occured how long they lassted and frequency and severity What is included in past treatment of episodes. - Solution outpatient treatment psychotherapy day treatment partial hospitalization inpatient treatment voluntary or involuntary admissions what precipitated the need for the highter level of care support groups
vocational training medication electroconvulsive therapy light therapy alternative treatments what questions should be ask about prior medications - Solution how long what doses- to establish adequacy of the trialis why stopped response side effects was there compliance What is included in the lethality history - Solution past suicidal ideation, intent, plan attempts- nature perceived lethality , save potential, suicide notes, giving away things or death preparations. what is included in violence and homicidality hisotry - Solution 1. domestic violence violent actions or intent legal complications, outcome of the victiom what is included in the hisotory of nonsuicidal self injurious behavior. - Solution cutting burning banging head biting oneself feelings include relief of distress that acoompany or follow behavior degree gone to to hide evidence of these behbaviors. What information is gathered in the substance abuse section - Solution what substances (prescribed or not) route of use, frequency and amount (pts minimize) tolerance understanding of volume withdrawal symptoms impact of use on social interactions, work, school, legal consequences and DUI periods of sobriety
important consideration when determining potential causes of mental illness as well as comorbid or confounding factors and may dictate potential treatment options or limitations. what affects can medical illnessess have on psychiatric disorders - Solution medical illnesses can precipitate a psychiatric disorder mimic a psychiatric disorder (hyperthyroid) be precipitated by a psychiatric diorder or treatment (metabolic syndrom) and influence the choice of treatment (hepatic disease) What neurological issues should be revied in the PMH - Solution seizures, head injury pain disorders Where does prenatal, birth, or developmental issues go in the Psych assess. - Solution PMH Were should the assess of menstual cycle, reproductive history, or preganancy plans be placed. - Solution PMH Where are current medications charted - Solution PMH Where are allergies charted - Solution PMH Why is the family history important - Solution many psychiatric illnesses, and responses to medication can be familial. fomation of psychoscial background What is charted in the family history - Solution psychiatric dianoses, medicxations hospitalizations, substance use disorders lethality of suicide attempts medical illnesses family traditions beliefs expectations role in family What does the developmental and socual hisotry cover. - Solution reviews the stages of the patients life
why is the dev/social hx important - Solution tool in determining the context of psychiatric symptoms and illnesses and may identify some of the major factors in the evolution of disorder. how should the deve/social hx be obtained - Solution chronologically what information is covered in the deve./social hx - Solution prenatal/birth hx developmental milestones childhood history including home environment members of the family social environmnet including the number and quality of friendships detailed school history how far education went special education circumstances learning disorders bheaivoral problems at school academic performance extracurricular activities physical or sexualo abuse work hixoty including jobs, performance, reasons for changing jobs, current work status relationships with supervisors or coworkers income financial issues insurance including pharmacy military history including rank achieved, combat exposure disciplinary actions discharge status marriage/relationships sexual preference current family structure interpersonal relationships legal history hobbies, interests, pets leisure activities cultural and religious influences practices. What are the screening questions in the sexual hx - Solution 1. are you sexually active
- have you noticed any changes or problems with sex recently what are the screening questions for sexual development - Solution 1. acquisition of sexual knowledge
What is the MSE - Solution the psychiatric equivalent of the physical examination. explores all the areas of mental functioning and denotes evidence of s/s of mental illness. information is gathered throughout interview. What are the parts of the MSE - Solution Appearance behavior motor activity Speech mood affect thought content thought process perceptual disturbances cognition abstract reasoning insight judgement physical exam how is appearnce important, what is charted. - Solution Is a general description of how the patient looks and acts during the interview includes: ⁍ clothing ⁍body jewelry ⁍distinguishing features ⁍disfigurations ⁍scars ⁍tattoos ⁍grooming/hygiene why is patient behavior important what is charted. - Solution description of pts behavior includes a general statement about if the pt is exhibiting actue distress, and approach to interview. ⁍cooperative ⁍agitated ⁍disinhibited ⁍disinterested ⁍context is important in the consdieration of behavior.
How is motor activity descibed. - Solution normal slowed (bradykinesia) agitatied (hyperkinesia) gait freedom of movement unusual or sustained postres pacing hand wringing tics jitteriness tremor restlessness lip/tongue smaking protursions tardive dyskinesia akathisia parkinsonian features How is speech described - Solution elements considered are fluency amount rate tone volume stuttering word finding difficulties paraphasic errors amount of speech refers to: normal increased decreased tone and volume described: irritable anxious dysphoric loud quiet timid angry childlike
What is flight of ideas - Solution patient rapidly moves from one thought to another at a pace that is difficult for the listner to keep up with but ideas are logically connected what is circumstantial thought process - Solution pt overincludes details and material that is not directly relevant to the subject or an answer to the question but does eventually return to address the subject/question. What is a tangential thought process - Solution similar to circumstantial thought process but pt never returns to the original point or question. thoughts are seen as irrelevant and related in aminor and insignifiacant manner define loose thought or associations - Solution thought process that is diffcult or impossible to see the connections between the sequential content. Define preservation in thought process - Solution the tendency to focus on a specific idea or content without the ability to move on to other topics. Systematic errors are - Solution Caused by flaws in the hospital system What substance has been implicated in mood disorders with a seasonalo patter. - Solution Melatonin If a patient receiving clozapine shows a WBC of 2,000per cc the clinician should - Solution Stop the administration of clozapine at once Somatizing patients can be difficult to treat because - Solution They may be reluctant to engage in self relection and psychological exploration Common pretreatment lithium tests include - Solution Serum electrolytes serum BUN ECG Pregnancy test The medical record is ac cessible to who - Solution the patient In a psychiatric interview of a violent patient what may be required - Solution patient may have to be medicated before taking history
increased serum calcium has been associated with what mood disorder - Solution depression serum bicarbonate, and serum amylase may be elevated in patients with what disorder - Solution bulimia nervosa Serum bicarbonate may be decreased in patients with what dx - Solution panic disorder What polysomnography anbormalities are present in schizophrenia - Solution increased sleep latency Thyroid function test changes in hypothyroidism include3 - Solution serum protien bound iodine is decreased serum free thyroxine is decreased serum T3 uptake is decreased serum T3 concentration is decreased What is a patient's account of a medical history. - Solution Psychiatric history or anamnesis test of concentration include - Solution calculations spelling world backward repeating a series of random numbers repeating three or four unrelated objects after 5 to 10 minutes. What is a good test for recent memory - Solution ask the patient what they had to eat for their last meal what is an inhibitor of panic attacks triggered by sodium lactate - Solution alprazolam Panic attacks triggered by sodium lactate are NOT inhibitied by - Solution propranolol WHAT CHEMICAL PROVOKES PANIC ATTACKS IN A MAJORITY OF PATIENT WITH PANIC DISORDER - Solution sodium lactate
Extrapyramidal side effects (EPS; such as dystonia, akathisia, dyskinesia, muscle rigidity, parkinsonism) Sedation Dizziness Dysgeusia Oral hypoaesthesia Increased alanine aminotransferase Fatigue behaves as a partial agonist at the 5-HT1A receptors. Carbamezapine -tegratol - Solution used primarily in the treatment of epilepsy and neuropathic pain.[2] It is not effective for absence seizures or myoclonic seizures. It is used in schizophrenia along with other medications and as a second-line agent in bipolar disorder. Carbamazepine appears to work as well as phenytoin and valproate Common side effects include nausea and drowsiness.Serious side effects may include skin rashes, decreased bone marrow function, suicidal thoughts, or confusion It should not be used in those with a history of bone marrow problems. plasma half-life is about 30 hours when it is given as single dose, but it is a strong inducer of hepatic enzymes and the plasma half-life shortens to about 15 hours when it is given repeatedly. a sodium channel blocker. It binds preferentially to voltage-gated sodium channels in their inactive conformation, which prevents repetitive and sustained firing of an action potential. Carbamazepine has effects on serotonin systems but the relevance to its antiseizure effects is uncertain. There is evidence that it is a serotonin releasing agent and possibly even a serotonin reuptake inhibitor iloperidone -fanapt - Solution treatment of schizophrenia Iloperidone is a monoamine directed towards acting upon and antagonizing specific neurotransmitters, particularly multiple dopamine and serotonin receptor subtypes. high affinity to serotonin 5HT2A , dopamine D2 and D3 and noradrenaline α receptors , moderate affinity for dopamine D4, serotonin 5HT6 5HT7, and low affinity for the serotonin 5HT1A dopamine D1 and histamine H receptors hypotension, dizziness, and somnolence were very common side effects ranging from mild to moderate in severity. A second study showed that co administration of food decreased the severity of these effects. This
study also indicated that repeat administration of iloperidone could decrease the effects of hypotension lamotrigine -lamictal - Solution anticonvulsant medication used to treat epilepsy and bipolar disorder. For epilepsy, this includes focal seizures, tonic-clonic seizures, and seizures in Lennox-Gastaut syndrome. In bipolar disorder, it is used to treat acute episodes of depression, rapid cycling in bipolar type II, and prevent recurrence in bipolar type I. Common side effects include sleepiness, headache, vomiting, trouble with coordination, and rash.Serious side effects include lack of red blood cells, increased risk of suicide, Stevens-Johnson syndrome, and allergic reactions the sodium channel blocking class of antiepileptic drugs. This may suppress the release of glutamate and aspartate, two of the dominant excitatory neurotransmitters in the CNSIt antagonises the following receptors with the following IC50 values 5-HT3, IC50=18μM σ receptors, IC50=145μM a half-life of 29 hours and volume of distribution of 1.36 L/kg.Lamotrigine is rapidly and completely absorbed after oral administration. Its absolute bioavailability is 98% and its plasma Cmax occurs from 1.4 to 4.8 hours Lithium - Solution lithium salts, are primarily used as a psychiatric medication This includes the treatment of major depressive disorder that does not improve following the use of other antidepressants, and bipolar disorder. In these disorders, it reduces the risk of suicideCommon side effects include increased urination, shakiness of the hands, and increased thirst. Serious side effects include hypothyroidism, diabetes insipidus, and lithium toxicity. Blood level monitoring is recommended to decrease the risk of potential toxicity If levels become too high, diarrhea, vomiting, poor coordination, sleepiness, and ringing in the ears may occur. inhibits recycling of neuronal membrane phosphoinositides which may ↓generation of seond messengers in a-adrenerigc and muscarinic neurotransmission thereby blunting hyperactivity in these pathways. may directly affect neurotransmitter activie inclduing ↑5-HT effecst and ↓AD and NE trunover lurasidone -Latuda - Solution atypical antipsychotic r the treatment of schizophrenia since 2010and depressive episodes associated with bipolar I disorderLurasidone is contraindicated in individuals who are taking strong
