Psychiatry

Abstract

As the internal medicine resident prepares for the difficult task of learning such a broad range of material that encompasses the specialty over 3 years, repetition becomes crucial for the retaining of knowledge. The first “prescription” for internal medicine residents that I work with in this preparation in our program is for selecting a specialty topic per month to devote a large amount of study time over that month and for that month to be the same in each of the 3 years. This strategy allows internal medicine residents to focus on each specialty topic consistently every year for 3 years. An example would be to review allergy and immunology as the topic for July which is the first specialty by alphabet but fits nicely in July given the material is not as voluminous as the other 11 specialty topics and July tends to be a month of transition for internal medicine residents whether it is the first month of residency for interns or the first month as a senior level resident in the second year.

The format of this section is done in A–Z manner so as to help keep the reader engaged and to help with recall of facts in a much easier fashion. An example from the allergy section is from the F letter which leads to fleeting infiltrates headliner that then leads to allergic bronchopulmonary aspergillosis being tied into that phenomenon of that ever changing radiographic pattern. The 26 pearls or set of pearls for each letter of the alphabet set the stage for the internal medicine resident to pick up on necessary knowledge within that specialty topic in a consistent fashion every year for 3 years such that no stone is left unturned and encourages residents to further read for supplementation on the pearls that are given for each letter.

FormalPara Akathisia

Akathisia is a term used to describe motor restlessness and is considered one of the extrapyramidal symptoms of anti-psychotics. Useful in treatment is anticholinergic drugs (such as benztropine) and beta-blockers.

FormalPara Bupropion

Bupropion is generally contraindicated in patients with a seizure disorder.

FormalPara Clozapine Time

Clozapine can cause agranulocytosis when used in the treatment of schizophrenia and patients will require weekly CBCs in the first few months of treatment.

FormalPara Dyskinesia—Tardive Dyskinesia

Tardive dyskinesia refers to the generally irreversible automatisms that develop due to long-standing anti-psychotic treatment, and it can be marked by dramatic lip smacking in patients.

FormalPara Extrapyramidal Side Effects

Among the extrapyramidal side effects of several anti-psychotics is pseudo-Parkinson’s syndrome (resting tremor, cogwheel rigidity, shuffling gait). Treatment is with anticholinergic drugs and stopping or lowering the dose of the anti-psychotic drug.

FormalPara Forget Me Not Pearl

Early morning awakening is a usual finding in most cases of typical depression.

FormalPara Great Pearl to Remember

MAO-inhibitors and meperidine are contraindicated to be given in the same patient as there is a marked increase in seizures and hypertensive crises in patients that have received these medications concomittantly.

FormalPara Haldol

Haldol is useful in the treatment of tics and coprolalia associated with Tourette’s syndrome.

FormalPara Insomnia

Early morning awakening is a classic hallmark feature of depression’s effects on the sleep cycle.

FormalPara Just for Emergency

Acute serious lithium toxicity is treated with emergent hemodialysis.

FormalPara Knowledge Check

The stages of grief in a patient who is dying are the following five stages in order of presentation. Denial (shock), anger, bargaining, depression, and acceptance.

FormalPara Lithium

Lithium is associated with hypothyroidism. Lithium is associated with nephrogenic diabetes insipidus, which means there will be no response of the urine osmolality with administration of DDAVP.

FormalPara Manic Disorder Treatment

Valproic acid is used in the treatment of bipolar disorder (particularly if rapid cycling) and has associated side effects of alopecia, pancreatitis, and weight gain.

FormalPara Neuroleptic Malignant Syndrome

Among the signs of neuroleptic malignant syndrome are fever greater than 105 degrees Fahrenheit, rigidity, hypertension, seizures, metabolic acidosis, and myoglobinuria. It tends to occur within the first 30 days of treatment and is more common in young adults. Treatment is in an ICU with bromocriptine (first line) or even dantrolene with close monitoring of potassium and numerous supportive measures to decrease fever including gastric lavage with cool ice water if needed. If patients persist in hyperthermia for a prolonged time, there is a risk of development of a permanent cerebellar syndrome.

FormalPara Oh My MAO (Monoamine Oxidase Inhibitor)

Selegiline is an MAO-B inhibitor that at usual doses for Parkinson’s disease will cause seizures when given with meperidine.

FormalPara Psychoses

Severe depression in the elderly could present with psychoses and paranoid delusions. A diagnosis of new onset schizophrenia in a patient over age 65 is unlikely.

FormalPara Quiz Time

Clomipramine is a tricyclic antidepressant that is efficacious in the treatment of obsessive-compulsive disorder. It is second line after selective serotonin inhibitor (SSRI) therapy.

FormalPara Really Nice Buspirone Pearl

Buspirone is a non-sedating anxiolytic that is efficacious in the treatment of generalized anxiety disorder.

FormalPara SSRI

SSRI therapy is the first-line treatment of OCD, PTSD, social phobias (if drug therapy needed), and generalized anxiety disorder.

FormalPara TCAs

The tricyclic antidepressants with the fewest cholinergic side effects are the secondary amine compounds, which are desipramine and nortriptyline.

FormalPara U Better Know This: Side Effect Time

Side effects of trazadone therapy include sedation, priapism, and orthostatic hypotension.

FormalPara Venlafaxine

Side effects of venlafaxine include increased pulse and blood pressure as it is has noradrenergic/adrenergic effects.

FormalPara Widening of QRS

Widening of the QRS complex is a poor prognostic sign in patients with tricyclic antidepressant overdose.

FormalPara XTRA Good Pearl

Thorazine (Chlorpromazine) has been used in the treatment of chronic hiccups. It also can cause cholestatic liver disease.

FormalPara Yes I Would Like Another Pearl on Hyponatremia

Hyponatremia is a known lab abnormality that may occur during treatment of depression with SSRIs (such as paroxetine, fluoxetine).

FormalPara Zesty Final Fact on Psychiatry

Most serotonin syndrome episodes are marked by fever, along with confusion, diaphoresis, and seizures. Clonus is noted on neurological exam more than rigidity in serotonin syndrome episodes.