Hi Guys i made some Points about Diagnostic tests, Most Commons scenarios and Red flags in
flags. I hope it helps
1) Nutrition and Deficiencies • Breast milk has an inadequate supply of vitamin D and exclusively breast-fed infants must receive supplemented vitamin D. • Introduce pureed foods at 6 months • Introduce cow’s milk at 1 year • Full term infants are born with adequate iron stores to prevent anemia in the 1st 4-6 months of life regardless of diet. But pre-term infants need Iron supplementation • Early introduction to cow’s milk can cause iron deficiency anemia • Supplement B-12, if mother is strictly vegan. • Formula is associated with more colic (excessive crying in an infant) then breast milk. • In case of constipation increase dietary fiber (too much stool leads to dilation and sphincter relation which can cause fecal incontinence), watch out for urinary incontinence. • Term infants are born with adequate iron supply until 6 months, exclusively breast feed infants after 6 months should get iron supplements. 2) Diagnostic Tests • CT-Scan has excessive radiation exposure, and is avoided if possible in infants and children. X- rays and fluoroscopy (e.g. upper GI series) use less radiation. • Abdominal Ultrasound is preferred for Pyloric stenosis • Serial X-rays are used to follow non-surgical conditions like, ileus and mild necrotizing enterocolitis • Normal bowel has air only in the bowel lumen, necrotizing enterocolitis has air in the bowel lumen resulting in “Train” or “Double line” appearance. • In Biliary atresia the first step is ultrasound (may show absent or abnormal gallbladder) , maybe then Scintigraphy (failure of liver to excrete tracer in small bowel) but Cholangiogram in the OR is a gold standard. • IN children if constipation presistce despite standard therapy, then we can evaluate using anorectal manometry. • Audiometry is the best initial screening test for Acoustic Neuromas • Abdominal Ultrasound is the 1st step in diagnosing Wilms tumor. • Diagnose strep pharyngitis with Rapid strep antigen testing, ASO titers take a month after the infection to be detected. • Hetrophill antibody test can be negative in the 1st week on infection, so negative test does not rule out IM. • The atypical lymphocytes in the peripheral smear are non-specific for IM. • Complete skeletal survey is ordered when child abuse is suspected and we try to determine if there are other healing injuries. • Voiding cystourethrogram is used to diagnose urinary reflux. • Chest physiotherapy is helpful in removing tenacious secretions and mucous plugs and is indicated in patients with bronchiectasis. • Chest tube placement is indicated for patients with respiratory distress secondary to a large pneumothorax, hemothorax or pleural effusion 3) Most common’s Things • Most common heart defect associated with Downs is Complete Atrioventricular septal defect • Most common heat defect associated with Digeorge syndrome is Truncus Arteriosus and transposition of the great vessels. • Most common heart defect associated with Edwards Syndrome is Ventricular septal defect. • Most common condition with congenital heart block is lupus • Most common complication with Trisomy 18 and rubella is PDA (check murmur) • Most Common Risk factor for cerebral Palsy is Pre-maturity • Interventricular hemorrhage is most commonly seen in premature and low birth weight infants. • Lennox gastaut most commonly presents less than 7, with a variety of seizures and mental retardation. • Most common age of ITP is 2-5 • Iron deficiency is the most common nutritional deficiency in children. • Most common primary bone tumor affecting children and adult’s osteosarcoma • Pilocytic astrocytoma is the most common brain tumor in children • Ependymomas are tumor of the ventricles, they have increased ICP but no seizure • CT may show nothing in the 1st few hours of a stroke. • Most common complication of sickle cell trait is painless hematuria. • Headache is the most common early symptom of cavernous sinus thrombosis. • Most common cause of neonatal sepsis in term infants is GBS • Most common cause of sepsis in preterm infants is E. coli • A common cause of neonatal conjunctivitis is Chlamydia (via birth canal → 50% neonates get conjunctivitis and 30% get pneumonia) and presents as bilateral chemosis (thickened, injected conjuctivae) eyelid swelling and watery or purulent discharge. • Dacryostenosis is the most common cause of neonatal eye discharge due to poor drainage through nasolacrimal duct, no conjunctival or eyelid inflammation. Gentle massage over the nasolacrimal duct is recommended. • Chemical conjunctivitis most commonly occurs in the 1st few days of life, because silver nitrate is used to prevent bacterial conjunctivitis. • Lymphadenitis is diagnosed when the lymph node becomes tender and erythematous in addition to being enlarged. Acute, unilateral lymphadenitis in children is usually caused by bacterial infection and staph aureus is the most common cause followed by group A strep. Patient with bacterial lymphadenitis are less than five and non-toxic appearing • Measles tend to more severe than rubella, with high fever up to 40 C 0, coryza and malaise. The rash in measles spread gradually and appears darker (reddish-brown) in comparison to rubella which spreads quickly and has lighter red kind of rash. • Gram negative rods, pseudomonas, klebseilla are a common cause of osteomyelitis when the patient has a Hx of UTI or urinary tract instruments. • In rabies infected patients, the feeling of air or water in the throat → involuntary pharyngeal muscle spasms. • Most common cause of Rabies in the US are Bats, other causes include raccoons, skunks, and foxes. In contrast to theses other animals, bat bites are small, painless and can often go unnoticed (can occur in sleep). • Treatment of HUS is supportive and plasmapheresis to remove toxins. • Most common cause of viral meningitis are the enteroviruses (echovirus and coxsackeiviruses) • Transient synovitis is the most common cause of hip pain in children. • Growing pains are not related to growth despite their name. • Most common age for legg-clave perthes disease is 4-10 • Symptoms of transient synovitis should resolve in 1-4 weeks after URI • Most common cause of a bloody synovial fluid is an ACL tear. • Hyperparathyroidism most commonly affects patients >50 years. • A solitary lytic lesion and hypercalcemia in a toddler has an increased likelihood of Langerhans histocytosis. • Posterior urethral valves are the most common cause of urinary tract obstruction in the newborns. • Oxybutynin is most commonly used with desmopressin in children with daytime incontinence to increase bladder capacity. • Children with isolated enuresis who do not respond to desmopressin maybe given TCA’s (not first line) • Electron microscopy finding of alport syndrome include alternating areas of thinned and thickened capillary loops with splitting of the GBM. • Oral succimer is used as chelating agent to treat mild to moderate lead poisoning. • Calcium EDTA for moderate to severe cases of lead poisoning. • # of wet diapers should equal age in the first week of life. After the first week’s infants should have >6 wet diapers per day. • Most common long term complication of vesicoureteral reflex is renal scaring. • In the newborn dry flaky peeling of the skin, hands and feet are normal and is expected as the skin adjust to the dry extrauterine environment • Normally infants loose up to 7% of birth weight in the first 5 days due to excretion of fluid acquired in utero. • Urate crystals “pink stains” are common in the newborn and until the uric acid levels get to adult levels. • Infants have immature kidneys that cannot reabsorb sodium effectively, plain water should never be given to an infant <6 months as it can dilute the blood → hyponatremia and seizures. • Cryptorchidism is the most common congenital anomaly of the genitourinary tract, orchiopexy is done before 1 year and can reduce all complications but there might still be subfertility. • At the first year of life a child’s weight should triple from birth weight and height should 50% • Do fish if karyotype is normal and turners is suspected. • Kartageners syndrome is characterized by the triad of recurrent sinusitis, bronchiectasis and situs inverus. • CAH is a cause of peripheral precocious puberty and serum FSH and LH are low, central causes of precocious puberty present with ↑FSH and LH. • Estrogen replacement therapy is given to all patients with turners to promote maturation and reduce the risk of osteoporosis. • In DKA hyper osmolality and volume reduction → ↑ADH production. • Newborns can develop vaginal spotting or bleeding, because in intrauterine life maternal hormones cross the placenta and trigger pubertal effects in the newborn which wear off after maternal hormones disappear from the infant’s circulation. • The most common cause of congenital hypothyroidism is thyroid dysgenesis (aplasia, hypoplasia and ectopic gland) • Hypothalamic-pituitary-gonadal axis immaturity → ↓gonadotropin secretion is a cause of irregular menstrual cycles (anovulatory) in women shortly following menarche. • Pubertal gynecomastia is seen up to 2/3 of adolescent boys during mid to late puberty. It can be unilateral, bilateral and even painful. No workup or treatment is necessary as it usually within a few months to years • Most common cause of a unilateral breast mass in an adolescent is fibroadenoma. The pathogenesis is related to fluctuating levels of estrogen and progesterone so premenstrual breast tenderness is typical. Adolescent with fibroadenoma → schedule follow up after next menses, if the mass ↓ in size or tenderness → reassurance, ultrasound for persistent mass or older patients • Most common cause of death in friiedreich’s ataxia is cardiomyopathy, second is respiratory complications. • They karyotype of patients with Kallman syndrome will be consistent with their male or female phenotype. • Ovarian Dysgerminoma occur in patients less than 30 that secrete LDH and B-HCG. • Granulosa cell tumor is an estrogen producing ovarian tumor that can present in pre-pubertal girls and postmenopausal women. • Large for gestational age are at ↑ risk for developing hip subluxation. • Air bronchgrmas is a signs of lung consolidation. • IUGR, maternal HTN, intra-uterine stress from PROM → ↓ risk of respiratory distress syndrome due to intra-uterine stress that helps fetal lung maturity. • In divorced parents, only patients with custody may give consent for medical care. Those who have conjoined custody might each give a consent but the doctor needs just 1 okay to proceed with care. • children are predisposed to middle ear infections due to narrower and straighter Eustachian tubes. • Meconium aspiration: is seen in post term infants with no-clear meconium on amnionotomy. • Persistent pulmonary hypertension should be suspected in all term and post term newborns with cyanosis, ↑ pulmonary vascular resistance → right to left shunt via foramen ovale. The diagnosis is rare in low birth weight infants. • Infants with SCID who do not undergo bone marrow transplantation usually die before age 1 from fulminant infections. • Needle tracheostomy is the 1st line treatment for tension pneumothorax • First step after delivery? Dry the infant and keep warm, the thermoregulatory system in the infant is under developed and they can lose heat easily. • Apgar is score is good in assessing the status not prognosis of the neonate, low Apgar score at 1 minute may need positive pressure ventilation, the Apgar score at 5 minutes can give us a clue if we need to resuscitate aggressively. • Recommendations for anaphylaxis? Carry injectable epinephrine at all times. • In cystic fibrosis approximately 10% of patients with normal pancreatic function during infancy and childhood develop recurrent or chronic sinusitis in their teens or 20’s. patients with early pancreatic insufficiency (e.g. oily stools) rarely have pancreatitis. But almost all male patients have obstructive azoospermia from congenital bilateral absence of the vas deferens. The vas deferens fail to develop due to inspissated mucus in the fetal genital tract. 4) Red Flags • If a kid ingests batteries, magnets or Sharp Objects and there are signs like Malena or hematochezia. Then immediately go for surgery. • Toddler with sudden onset of wheezes, cough, dyspnea or stridor. Suspect foreign body aspiration and go for Rigid bronchoscopy. • 1kg of acute weight loss = 1 L of fluid loss, a child’s weight fluctuates which can make it hard to determine the last well weight. • Glasgow coma scale < 13 (normal 13-15) is associated with dangerous or serious traumatic brain injury. • Loss of consciousness for > 5 min is associated with Serious traumatic brain injury. <5 min is associated with mild TBI. Head Trauma = Minor, Mild TBI and Serious TBI. • A forced vital capacity (TV, IRV and ERV) < 20ml/Kg indicated impending respiratory arrest requiring endotracheal tube (Spirometry should be done after diagnosing GBS or MG) • Differential for t wave inversion = MI, myocarditis (remember a cause of HF in Frederic’s), pericarditis, myocardial contusion and digoxin toxicity) • Cow’s milk <1 year → ↓ iron stores and intestinal blood loss • Children >1 year should drink <24 ounces of cow’s milk to ↓ the risk of iron deficiency. • Rely on the reticulocyte count only when the anemia is normocytic (severe iron deficiency anemia → Iron stores and hence reduced reticulocytes) • avoid contact sports for >3 weeks with infectious mononucleosis • Fatigue may persist months after infectious mononucleosis is treated. • Signs and symptoms of neonatal sepsis include, poor oral intake, irritability, hyper/hypothermia, respiratory distress, vomiting and jaundice • Oral erythromycin is associated with risk of developing infantile pyloric stenosis but treatment of chlamydial conjunctivitis outweighs the risk • Local lymphadenopathy is usual is impetigo but fever is unusual. • Extensive bullous impetigo (flaccid bullae containing yellow fluid) is an indication for oral antibiotics (cephalexin, dicloxacillin and clindamycin). • Flaccid bullae mean’s very loose (nikolosky positive) • Poor feeding and decreased level of consciousness are among the earliest signs of a serious infection in neonate. • Physical exam does not distinguish between sepsis and meningitis is neonates. • Doxycycline is contraindicated in children <8 years and pregnant women. because of poor bone and teeth development, use amoxicillin or cefuroxime for Lyme’s disease. • Obstructive sleep apnea impairs sleep arousal and can therefore result in nocturnal enuresis. • Every case of leukocoria is considered retinoblastoma until proven otherwise, immediate referral to an ophthalmologist is warranted. Failure to diagnose early → brain, liver metastasis and death. • Intermittent stra • Hepatitis B is a risk factor for developing membranous nephropathy. • Corneal neovasculization, think chlamydia trochamitis (Trachoma) • Cognitively, infants develop object permanence (ability to recognize when, something or someone is missing • When IV access cannot be obtained, interosseous (in bone) access requires less skills and is safer than central venous access. • Gonococcal conjunctivitis = copious purulent eye discharge at 2-5 days, chlamydia conjunctivitis = 5-14 watery mucoid discharge. • Snellen chart, visual acuity worse than 20/40 at age 3-5 or worse than 20/30 at age >6 years should prompt ophthalmological referral. Visual acuity should be tested in every well child visit for strabismus (cover/uncover and cover test) and the Snellen chart. • Most hydrocele (cystic scrotal mass that transiluminates with light) disappear by age 12 months and can be watched. Caused by failure of the tunica vaginalis to obliterate. • Renal biopsy not obtained in patients less than 10. • Remember iron is radiopaque and can be visualized on x-ray. • ADPCKD are at risk for developing diverticulitis. • Patients with Henoch-Schonlein purpura are at ↑ risk of developing intussusception due to bowel wall edema and localized hemorrhage, which can act as lead points for the intussusception. • Normal kid at birth→ gradually develops apathy, weakness, hypotonia, large tongue, sluggish movements, abdominal bloating, and an umbilical hernia (think Congenital Hypothyroidism) • Werdnig-Hoffman Syndrome is an autosomal recessive disorder that involves degeneration of the anterior horn cells and cranial nerve motor nuclei and a cause of “floppy baby syndrome” • Myotonic congenital myopathy is an autosomal dominant disorder characterized by muscle weakness and atrophy (most predominant in the distal muscles of upper and lower extremities), myotonia, testicular atrophy and baldness • Severe coughing paroxysms may → subcutaneous emphysema, where air leaks from the chest wall in to the subcutaneous tissue due to ↑ intra-alveolar pressure provoked by coughing. By similar process pneumothorax can occur, therefor in such patients with apparent subcutaneous emphysema, a chest x-ray should be obtained to rule out pneumothorax. • Acute otitis media common in infants 6-36 months as their Eustachian tubes are short and easily clogged. Risk factors include formula intake, exposure to cigarette smoke, allergic rhinitis and URI. • Cricothyroidotomy should be avoided in children because the trachea is incompletely developed and children age <12 have an ↑ risk of subglottic stenosis
High Yield Psychiatry And Poisoning Review:
(This includes Uworld, Past Exam Questions and Other relevant information). (Please correct me if i am wrong anywhere). 1- Drugs decresing the siezure threshold: Imipenem, Bupriopion, TCAs and Clozapine. 2- Known case of difficult to treat OCD, already on a drug regimen now comes to the emergency dept with the complain of a siezure attack, altered level of consciousness and palpitations. ECG shows QRS widening and PR prolongation. Dx: TCA Overdosage/ toxicity. Next step---- Administer sodium bicarbinate immediately. (If arrythmias, QRS widening and hypytension in suspected TCA overdosage then directly administer Sodium Bicarbonate). 3- There are no absolute contraindications to Electro convulsive therapy. 4-Anorexia Nervosa and Bulimina Nervosa Treatment Plan: Both needs Cognitive behavioral therapy. Both needs nutriotional Rehabiliation. Olenzapine For Anorexia Nervosa. SSRIs for Bulimia Nervosa. Caution: Remember Bupropion is contraindicated in Anorexia and Bulimia Nervosa! 5- 18 years old girl BMI of 15, diagnosed as Anorexia nervosa. Electrolytes are deranged and she is hypovolemic. Hosiptal Admission is done. (Recall the criteria of hospital admission in the patients of anorexia nervosa). She is st arted on Total parenteral nutrition. Three hours after starting of the feed she becomes unresponsive. Stat Chest Xray Shows Pulmonary Edema and ECG shows ventricular tachycardia. Dx? Dx is Refeeding Syndrome. (Clinical Manifestations are Arrythmias, CHF, Siezures and Wernickes' encephalopathy). 6- Major Depressive Disorder Treatment Strategy: First Episode- Treat for 6 month with Antidepressants Second Episode- Treat for 01 year with ADs. Recurrent Episodes- Lifelong Treatment with ADs. 7- Treatment Strategy for OCD: First Step- Exposure and Response Congnitive Behavioral Therapy (Recall that the same therapy is also used for specific phobias). OR- High Dose SSRIs. If The above fails or unresponsiveness then: Antipsychotics OR TCA (Clomipramine). If all the above fails: Deep Brain Stimulation. 8- Non REM Sleep Disorders: Night Terrors and Sleep Walking. Usually they are self limiting- Just reassure and dont treat as such. If significant distress and episodes are frequent and persistent then give low dose BZDs( Clonazepam) before bedtime. (Remember patient wont be able to recall the dreams and whatever happened in the NON REM Sleep Disorders) . 9- REM Sleep Disorders: Nightmares and REM Sleep behavior Disorder. (Patient can recall the dreams). Nightmares Rx: Behavioral therapy is 1st line. BZDS before bedtime is second line. REM Sleep behaviour Disorder Rx: Melatonin. 10- Most effective pharmacotherapy for smoking cessation is Varenicline (But its use is limited due to increased risk of cardiovascular events, depression and suicidal ideationf). So most effective becomes the Nictoine Replacement therapy. If Depression plus Smoker= Give Bupropion. Remember Bupropion contrainidcated if the patient has any siezure disorder or concomittant eating disorder). 11- Oppositional Defiant Disorder and Conduct Disorder: Both are aggressive. Both have same age group of presentation. ODD- These people dont break the rules. Conduct- Breaking the rules is the diagnostic Clue. Rx plan for ODD: 1- Main reason for ODD is poor parenting. Therfore improve the parenting. 2- Reward the child if he does anything good. 3- As soon as he breaks any law label it conduct disorder. Rx plan for Conduct Disorder: 1- Punishment and Incarceration wont help (Remember this). 2- Support Programs. 3- Structured Living setting. 12- Starting Clozapine/Olenzapine: Do baseline CBC/ Fasting Glucose/ Fasting Lipid Profile and Blood Pressure. Measure Waist Circumference-- At Baseline, three months and then annually. Do BMI Monthly. For clozapine also check CBC every week due to risk of agranulocytopenia. If WBC < 3000 OR ANC <1500 = Stop Clozapine. 13- Personality Disorders- No as such impairment in functional living-- Rx by psychotherapies. 14- Schizoid Personality Disorder And Avoidant Personality Disorder: They both are loners. They both are socially inhibited. The main difference is that schizoid people are emotionally cold and just dont want any relationships. BUT Avoidant people want to be with people and make relationships but they dont do so due to fear of criticism and rejection. 15-Derpession= Increased REM Sleep. (Decreased Latency). Decreased stage 4 sleep therefore early morning awakenings. 16- Lactate Infusion can trigger Panic Attacks. 17- Psychiatric Radiology: Schizophrenia= Increased Size of lateral cerebral ventricles. (NPH-- Also increased size of ventricles) Autism= Increased Total Brain Volume. OCD= Structural abnormalities in the orbitofrontal coretx. Panic attacks: Decreased Volume of Amygdala and Left temporal Lobe. PTSD= Decreased volume of Hippocampus. 18- Tourette Syndrome people have increased incidence of OCD. 19- Treatment plan for Tourrette Syndrome: First Line: Habit Reversal CBT. Second Line: Antipsychotics. 20- Alcoholic patient found unconscious lying on the road in winters. Temp is 84F. First step to do? EKG. Whats the most specific thing you'll find on ecg? "J waves of Osborn (Looks like ST segment elevation). Rx Strategy for hypothermia: - Intubate all those who are comatose. - Warmed (107F) Crystalloids to all patients. 21- Burns: Acute cause of death- CO poisoning. Late cause of death- Infections/Sepsis. First step- Give 100% Oxygen. Then Fluid Administration according to Parkland's Formula. Fluids= 4ml multiplied %BSA multiplied Body weight. (Whatever the value comes give half of it in the first 8 hours and the remaining half of it in the other 16 hours) . 22- Organophosphates Poisoning: First Thing to do- Remove clothing and wash the rest of the patient. Best initial- Atropine infusion Most effective- Pralidoxime. 23- Malignant Hyeprthermia and Neuroleptic Malignant Syndrome has no clinical difference. Just the difference of triggerer. Malignant Hyperthermia- After use of anesthetic. NMS- After use of antipsychotics/ Antiemetics (Metoclopramide etc). Both are treated with Dantrolene. 24- Chocolate Brown Blood- Methemoglobinemia. (Normal pO2 on ABGs)- Administer Methylene Blue as antidote. 25- MDD patient presents to the ER with the complain of muscle twitching around the mouth and over all tetani. Meanwhile he had an episode of hematuria and flank pain. Urinalysis shows gross blood and envelop shaped crystals. Dx- Ethylene Glycol Poisoning. Rx- Ethanol or fomepizole. Dialysis. (Note: Ethylene Glycol Poisoning can also cause cranial nerve palsies) . 26- Both ethylene glycol and methanol poisoning can case increased anion gap metabolic acidosis with increased osmolar gap. 27- Methanol Posining- Formic Acid- Causes retinal hyperemia, Blindness, central scotoma and visual blurring. 28- Aspirin Toxicity: Direct Stimulant to Brainstem--- Causes Hyperventilation. Tinnitus. Direct toxin to Lungs---- ARDS. Labs- Anion Gap Metabolic Acidosis. Then Respiratory Alkalosis. Increased Prothrombin Time. Rx- Sodium Bicarbonate Dialysis in severe cases. 29- Treatment strategy for Enuresis: -First Step- Do urinalysis. -Start with behavioral Modifications. - If fails then Enuresis Alarms (Best Longterm Outcome). -Pharmacological therapy (Best for Short term Improvement). first line- Desmopressin Second Line- Imipramine (TCA). 30- Most Common Paraphilia--- Pedophilia (Child sexual abuse) 31- Psychiatric Drugs and Sexual effects: - Alpha blockers= Impaired Ejaculation. -SSRIs= Decreased Orgasm. -Beta Blockers= Erectile Dysfunction - Trazadone= Priapism -Neuroleptics= Erectile Dysfunction . 31- 6 hours after last alcohol drink- Mild withdrawal Symtpoms 12-24 hours after last drink- Alcoholic Hallucinosis (These are purely the hallucinations. No Altered Mentation. If altered mentation change your diagnosis) 48 hours after last drink- Withdrawal siezure. 48-96 hours after last drink- Delirum Tremens. (In Alcohol Withdrawal agigated restless patient, give BZDs, no antipsychotics, they may provoke a siezure). 32- Explosive Disorders: (Intermittent Explosive Disorder, Kleptomania, pyromania, Pathological gambling.) -They all dont have an insight (that is they dont feel if they are doing anything wrong). -Intermittent Explosive Disorder: Always first rule out cocaine intoxication. Anger bursts twice weekly for three months confirms the diagnosis. Rx: SSRIs, Mood Stabilizers. -Pyromania: Remember the trick, if they give you a child in question who gets an anger burst because his mom refused him for driving and then he goes out and burn all the cars. This is not pyromania. There is no secondary gain or anger in pyromania. -Pathological gambling: Treat by Group Psychotherapy. 33- Body Dysmorphic Disorder: High Dose SSRIs. If the only concern is body wight and shape then its not BDD. Its anorexia nervosa. If only concern is sexuality then its not BDD. Its Gender Identity Disorder. (Delay Puberty in them). 34- Conversion disorder: Establish physician patient relationship. And do psychotherapies. 35- SSRIs Use + concomitant use of Triptans OR MAO Inhibitors= Serotonin Syndrome (Hyperreflexia, High Blood Pressure, Myoclonus, Hyperthermia). Rx: Fluids, Cyprohepatdine 36- MAO Inhibitors Use + TCAs/ Tyramine containing food/ Antihistamines/ Nasal Decongestants= MAO Inhibitor induced hypertensive crisis. (High Blood pressure). Rx- IV Phentolamine . 37- Elderly Man Known case of Bipolar Disoder and Chronic renal failure- Presents with the complain of Nausea, Vomiting tremors, disorientation, Increased Deep tendon reflexes. Dx- Lithium Toxicity Rx- Dialysis. 38- TCAs and SSRIs are safe in pregnancy except for Paroxetine. 39- Panic Disorders: -Best and Most Effective Rx: CBT and/or Relaxation training and desensitization. -Immediate Rx: Benzodiazepines. Remember that specific phobia patients might have a panic attack when exposed to the stimulus, Dont label it as panic disorder. It remains the same specific phobia. 40- Specific Phobias: Symptoms for 6 or more than 6 months. (Eg: Fear of exams, fear of plane, fear of crowded places etc). They dont have fear of scrutiny like Social anxiety disorder. Rx: First Line- CBT (Exposure and Response Prevention) Second Line- Benzodiazepines 30 mins prior to exposure. If recurrent panic attacks-- Initiate SSRIs. (In Specific phobias we play around SSRIs and Benzos) (In social phobias we play around Benzos and beta blockers).