Common Psychiatry Oral Exam Questions

  1. What are the criteria for certification under the mental health act?
    1. Form 1: must have a mental disorder, be dangerous to oneself or others, and have no other way to arrange for a hospital admission; 24 hours, 30 days;
    2. Form 2: renewal certificates, 2 must be filled out at a time; 30 days, 30 days, 6 months
    3. If patient is considered competent and consents to treatment, patient will be treated. If patient is competent but refuses treatment:
      1. Physician may respect their decision
      2. Physician may make a request to the Review Panel for a Treatment Order via Form 12. If the Review Panel issues a Treatment Order, patient will be treated against their will. Treatment is in their best interest based on the following four conditions:
        1. You are likely to improve with treatment
        2. You are likely to get worse without treatment
        3. The benefit of treatment outweighs the risks of the treatment; and
        4. The treatment is the least limiting and invading of all possible treatments that fill the first three requirements
    4. If patient is not competent, they cannot legally consent to treatment. The doctor must complete a Form 11 certificate. The Form 11 certificate will state reasons why patient is deemed not competent. A copy of the Form 11 certificate must be given to patient and guardian/relative. This person will be asked to make treatment decisions for the patient. If the patient has been deemed incompetent and refuses treatment, a second physician must examine the patient and also find them incompetent. If a second physician also finds them incompetent, they may postpone being treated against their will by appealing the Form 11 certificate to the Review Panel
  2. Management of an acutely agitated patient: drugs, doses, environmental, etc.
    1. Chemical restraints
      1. Benzodiazepines – Lorazepam, effective dose is 0.5 to 2 mg every 1 to 6 hours administered PO, SL, IM, IV. *Respiratory depression is a relative contraindication
      2. Haldol – 2 to 5 mg PO, I
    2. Seclusion (must be monitored)
    3. Physical restraints
      1. Limb restraints
      2. Soft cervical collar (biting, head banging)
      3. Kept in open area
      4. Undress and search patien
  3. Patient on Li comes in looking tired and down – Differential diagnosis?
    1. Depression
    2. Hypothyroidism 20 L
  4. Signs and symptoms of Li toxicity?
    1. ‘Past VD’
      1.  P – Painful Abdomen
      2. A – Ataxia
      3. S – Slurred Speech
      4. T – Tremors
      5. V – Vomiting
      6. D – Diarrhoea
      7. Comas, seizures, confusio
  5. If Li didn’t work, what are some other mood stabilizers?
    1. Valproate
      1. GI, asymptomatic serum transaminase elevation, tremor, sedation, PCOD, pancreatitis
    2. Carbamazepine
      1. skin rash (Steven-Johnson syndrome), impaired coordination, drowsiness, dizziness, slurred speech, ataxia, transient leucopenia, aplastic anemia (rarely), agranulocytosi
  6. If a patient is on an antidepressant and it isn’t working what do you do?
    1. O ptimize (raise dose)
    2. S witch (same class if some effect or different class)
    3. C ombine
    4. A ugment (T3, stimulants, Li, atypical)
    5. R e-evaluation (substance abuse, compliance, stressors, medical condition, misdiagnosis)
  7. This still doesn’t work, what do you do?
    1. Augmentation (Li, Cytomel, thyroid hormones)
    2. Switching meds (washout periods if indicated)
  8. Evaluating suicide (risks)
    1. S ex [Assign one point only if male – more likely to be SUCCESSFUL]
    2. A ge [Assign one point only if <19 yrs or >45 years old
    3. D epression
    4. P revious attempts
    5. Ethanol abuse [alcohol or substance abuse]
    6. R ational thinking loss
    7. S ocial supports lacking [lack of family, friends, etc]
    8. O rganized plan [lethal, affairs in order, note]
    9. N o spouse [divorced, widowed, separated, single, no children]
    10. S ickness [chronic, debilitating and severe]
    11. 0-2: Consider sending home with family.
    12. 3-4: Close follow-up. Consider hospitalization.
    13. 5-6: Seriously consider hospitalization
    14. 7-10: Hospitalization
    15. Other big factors include recent loss and access to firearms…
  9.  What are the common side effects of SSRIs?
    1. Nausea, loss of appetite, diarrhea.
    2. Anxiety or irritability.
    3. Problems sleeping or drowsiness.
    4. Loss of sexual desire or ability.
    5. Headaches or dizziness.
    6. Serotonin syndrome: MAOi, lethargy, restless, confusion, flushing, diaphoresis tremor, myoclonic jerks
  10. How long do you treat with antidepressants?
    1. Treat to remission (6 to 12 months)
  11.  Family risk of BAD depression
    1. Twin studies demonstrate a concordance of 33-90% for BPI in identical twins.
    2. First-degree relatives of people with BPI are approximately 7 times more likely to develop BPI than the general population. Remarkably, offspring of a parent with bipolar disorder have a 50% chance of having another major psychiatric disorder.
  12. Serotonin syndrome
    1. Serotonin syndrome is a condition caused by an excess of serotonin in the brain. The effects of serotonin syndrome may progress from headaches, dizziness, euphoria, abnormal movements of the foot and ankle, hyperreflexia, and vomiting, to coma and death. Rarer effects include rapid changes of mood, from severe depression to the point of being suicidal, to manic phases characterized by violence towards others and destruction. Since serotonin’s action is increased by anti-depressants such as Prozac, Luvox, and Paxil, the signs are often mistaken for extreme Bipolar Disorder, prompting an increase in dosage.
    2. Symptoms affect three major nervous systems:
      1. Autonomic nervous system: increased body temperature, sweating, hypertension, increased heart rate, nausea, diarrhoea;
      2. Somatic nervous system and muscles: muscle twitching, alternating contraction and relaxation (e.g. jaw, giving rise to teeth chattering), hyperreflexia, rigidity, tremor;
      3. Cognitive functioning of the brain: confusion, agitation, headache, coma.
    3. Serotonin syndrome is generally caused by interactions between serotonergic drugs, for example by concurrent use of MAOIs and SSRIs, and also from combining SSRIs and DXM. It is also caused by an overdose of SSRIs
  13.  Depression in elderly
    1. Last longer in elderly adults
    2. Increases their risk of death
    3. The presence of depression substantially increased the likelihood of death from an existing physical illness
    4. Associated with increased risk of death following a heart attack
    5. More likely to lead to suicid
  14. MAO inhibitors
    1. When ingested orally, they inhibit the catabolism of dietary amines. Sufficient intestinal MAO-A inhibition can lead to hypertensive crises when foods containing tyramine are consumed, or hyperserotonemia if foods containing tryptophan are consumed. Hypertensive crises can sometimes result in stroke or cardiac arrythmia if not treated. This risk is not present with RIMAs. Both kinds of intestinal MAO-inhbition can cause hyperpyrexia if levodopa-containing foods are consumed.

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