Category Archives: Psychiatry

VA Ambulatory Report 12.20.17 – Night Sweats for a Decade and the Million Dollar work-up

Thank you Dan for presenting this great ambulatory care.  We discussed a young male with a decade of night sweats with unremarkable work-up whose symptoms improved  after starting an alpha-blocker.  We had an interesting discussion of psychological disorders such as PTSD and anxiety as a cause of night sweats.

Night sweats

  • Pathologic =  drenching sweats that require changing pajamas or sheets
  • LT pearl Pathologic night sweats occur as result of the exaggeration of the normal diurnal temperature changes.
    • Max temperature occurs at 10pm
    • Sweating occurs in the following 2-4 hours. Therefore pathologic night sweats almost always occur after midnight

Approach to a patient with night sweats

  • A similar approach can be used with a patient with flushing or diffuse hyperhidrosis)
  • Break down by organ system
    • Malignancy
      • Lymphoma
      • Solid tumors: germ cell, medullary thyroid, RCC, prostate
    • Infections
      • Mycobacterial
      • Bacterial: Abscess, brucellosis, endocarditis, osteomyelitis
      • Fungal:
      • Viral: HIV, HCV
    • Endocrine
      • Carcinoid
      • DI
      • hyperthyroid
      • Pheo
      • Post-orchiectomy
      • Ovarian Failure
    • Medications: The list is extensive.  Some are more likely to cause flushing vs. night sweats
    • Substance withdrawal
      • Alcohol, cocaine, opiates
    • Neuro
      • Autoimic dysreflexia, autonomic neuropathy, stroke
    • Other/Mimickers
      • Hot flashes from Menopause
      • Overbundling
      • Hypoglycemia
      • OSA
      • PTSD
      • Panic disorder
      • Chronic fatigue syndrome
      • Food additives
      • GERD
        • There is an association between GERD and night sweats and some evidence patient’s symptoms improve after treatment with antireflux meds
      • Mastocytosis
      • Temporal arteritis
      • Takayasu’s arteritis
      • Idiopathic hyperhidrosis
      • Roseacea

How can we evaluate this non-specific compliant in a cost-effective manner?

  • Key is a focused history and physical to help target your diagnostic work-up
  • Always review the medication list
  • If no clear localized signs or symptoms the AAFP suggests a step-wise approach
    • Step 1: CBC, ppd, TSH, CXR
    • Step 2: HIV, ESR
    • Step 3: Trial of anti-reflux meds
    • Step 4: Diary of noctural temperature
    • Step 5: Blood cultures specifically looking for HACEK organisms
    • Step 6: Consider CT abdomen, CT chest, and/or Bone Marrow biopsy
    • Step 7: Reassurance and monitoring for new symptoms
  • Check out the full article here: AAFP Article on the Diagnosis of night sweats.

Link to Evernote:


Moffitt Pearls – 8.11.17 – Saddle Nose Deformity, Upper GI Bleeding &Munchausen Syndrome

Thank you to HH and Neil for both presenting today! HH first presented a mini case of a patient who came in for a gout flare that was found to have a saddle nose deformity.

Neil then presented the interesting case of a young woman with a hx of gastric ulcers presented with epigastric pain and hematemesis who after extensive work-up including CT and EGD was found to have Munchausen syndrome!************************************************************************************

Key Pearls

  1. The differential diagnosis for saddle nose deformity falls into the classic triad of infectious, inflammatory and malignancy per table below.
  2. 80% of upper GU bleeds are due to four causes: peptic ulcer disease (35%), esophagogastric varices (30%), esophagitis (10%) and Mallory-Weiss tears (~5%).
  3. The management strategy for a pt. w/ munchausen syndrome is VERY difficult, but should include a single provider (w/ help from psychiatry) and goal to limit interventions + discuss diagnosis with patient in a supportive manner.


Differential Diagnosis for Saddle Nose Deformities

Infectious Inflammatory Malignancy Other
Syphilis GCA (formerly Wegner’s) NK T-cell Lymphoma Trauma
Leprosy Sarcoidosis Locally invasive tumor (BCC) Cocaine
TB Relapsing polychondritis Lymphomatoid Granulomatosis Surgery
Cutaneous Leishmaniosis      
Septal abscess      

 Differential Diagnosis for Hematemesis AND Fever

  • Mallory-Weiss Tear
  • Peptic ulcer bleeds c/b perforation
  • Hemosuccus pancreaticus (pseudoaneurysm/aneurysm)
  • Upper GI Malignancy – hemobilia, widespread esophageal/gastric malignancy

Munchausen Syndrome or Factitious d/o Imposed on Self

  • Definition: Falsified general medical or psychiatric symptoms
  • Risk Factors: Females, Unmarried, Healthcare professional
  • Diagnostic Criteria (DSM-5):
  1. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception
  2. The individual presents himself or herself to others as ill, impaired, or injured
  3. The deceptive behavior is evident even in the absence of obvious external rewards
  4. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorderPrognosis: Very poor even as multiple studies have shown limited benefit even with psychotherapy
  • Management: One provider should oversee pt with help of psychiatry w/ goal to limit interventions. One should be sure to exclude all possible medical conditions and then discuss diagnosis w/ pt in supportive manner


ZSFG Pearls: Jaundice, biliary anatomy, and antipsychotic med recs from psychiatry

Thanks go to Scott who gave us the chance to discuss a patient with painless jaundice today! Now a review of bilirubinemia is in order, obvi.
From a recent intern report blog post, here is a non-exhaustive table of possible causes of jaundice/hyperbilirubinemia:

Causes of Conjugated Hyperbilirubinemia Causes of Unconjugated Hyperbilirubinemia
Extrahepatic cholestasis (biliary obstruction)

-Intrinsic and extrinsic tumors (eg, cholangiocarcinoma, pancreatic ca) -Primary sclerosing cholangitis
– AIDS cholangiopathy
– Acute and chronic pancreatitis
– Strictures after invasive procedures
– Parasitic infections: liver flukes, Ascaris

Increased bilirubin production

– Extravascular hemolysis
– Intravascular hemolysis
– Dyserythropoiesis
– Wilson Disease

Intrahepatic cholestasis

-Viral hepatitis
– Alcoholic hepatitis
– Nonalcoholic hepatitis
– Primary biliary cholangitis
– Drugs and toxins: herbal meds, arsenic, halothane
– Sepsis and hypoperfusion states
– Infiltrative processes (amyloidosis, lymphoma, sarcoidosis, tuberculosis)
– Cholestasis of pregnancy

Impaired Hepatic bilirubin uptake

– Heart Failure
– Portosystemic shunts
– Certain drugs: rifampin, probenecid

Rare Causes

-Rotor Syndrome: defect in reuptake of conjugated bilirubin
-Dubin-Johnson Syndrome: Defect of canalicular organic anion transport

Impaired bilirubin conjugation

– Gilbert’s (stress-induced, asymptomatic except mild bilirubin elevation)
– Crigler-Najjar syndrome – Hyperthyroidism
– Liver diseases


What’s the anatomy and where does an obstruction occur to cause intra/extra-hepatic biliary dilation:

gb picobst


Generally, a painless jaundice ddx includes:

  • Cancer: pancreatic, cholangiocarcinoma
  • Meds/toxins
  • Hemolytic anemia
  • HF
  • ELSD
  • Viral hepatitis

Which imaging first?

  • First: Ultrasonography (see weird depiction of this below) as it’s more cost-effective, noninvasive, and the most sensitive imaging technique for detection of stones
  • Then consider CT w/ con for better detection of parenchymal disease of the liver
  • Neither CT nor ultrasound have the best sensitivity to rule out an obstructing intra-ductal stone or mass, so consider (and talk to GI) if ERCP or MRCP is necessary





On a much less related note, after last month’s INTERN HALF DAY small group discussions, there was a call in to psychiatry for help in understanding what medications they have experience with and use on an emergent basis (if needed), how the choice of emergent medications changes with elderly/frail patients, and how the QTc factors in to that equation…

***Below is the compiled commentary from psychiatry—quite lengthy, so file away to reference when needed***


Do you have a patient who is acutely agitated? Have you tried verbal de-escalation? Called IP/security?

Prep work per psychiatry: Nursing staff and physicians/residents have little experience managing the acutely agitated/potentially dangerous patient. If you are even considering using IM meds, make sure that IP (security) is present for the administration. In addition, if there is time to briefly meet with IP about the plan (ie, will you offer the patient PO meds before IM, will physical restraints be needed) BEFORE the team approaches the patient for meds=that’s the ideal. Sometimes you can avoid giving IM meds if IP is present, as the patient may end up accepting PO with the show of force. Remember that someone who just got an injection is likely to continue to be agitated and so physical restraints are often necessary when they can’t be in a room that has been cleared of dangerous objects/people.

But for “emergent” or “chemical restraints”…

haldol1st line) The easiest, go-to is always Haldol (unless there’s a contraindication like h/o haldol allergy, dystonic reaction, NMS, parkinsons, etc…). Psychiatry usually uses 5mg Haldol, 2mg Ativan, 50mg Benadryl with the alternative of 5mg Haldol, 1mg Ativan, 1mg of Cogentin. Benadryl is for the ppx from EPS and for the sedating effect.

  • For older folks, probably hold the Benadryl and Ativan. While Cogentin is historically more expensive than IM/IV Benadryl, there is less anticholinergic effects and less sedation with Cogentin, so you could maybe consider it in people who are elderly with dementia.
  • Haldol is nice because can be used either IV or IM.  For particularly problematic patients, psychiatry will recommend IV Haldol 2mg q30min until behaviorally under control.
  • Checking EKG’s frequently to monitor QTc.
  • IV Haldol is nice because, while it does carry risk of QT prolongation, it does not carry the same risk of dystonic reaction as IM/PO.  Haldol dosing is not quite equivalent, PO:IM/IV = 2:1. For folks who are frail/old, you can probably just give Haldol 1-2mg IM!


2nd line)    In general, SL or IM Zyprexa (Olanzapine) 10mg is a great option.  DO NOT give IM BENZOS within 1 hour of IM Zyprexa given a risk of life threatening respiratory depression.

  • Zyprexa is convenient because po, SL, IM dosing is all equivalent.   No IV version though.
  • For older/frail folks, cut the dose in half, at least, to 5mg


2nd/3rd line)   IM Geodon (Ziprasidone) can be a good choice if you are worried about the whole IM benzos thing with Zyprexa or if there was previous dystonic reaction which is far less likely with Geodon.

  • IM Geodon is 4X as strong as PO. You can use 10-20mg IM which is equivalent to 80mg PO dose. No SL or IV version.
  • If you use IM Geodon, make sure to get an EKG afterwards once the patient has calmed down – it is one of the most QT-prolonging.


2nd/3rd/4th line)   Consider the sedating power of Risperidone or Risperdal. 2mg of Risperdal is about equivalent to a 5mg Haldol emergent dose.

  • You can use 1-2 mg PO or even much lower doses for someone smaller, older, or antipsychotic naive such as 0.5mg.
  • No IM/IV formulation available.


Overall suggestions:
-for older or frail folks, cut the doses by at least half (2mg Haldol, 5mg Zyprexa) prior to giving. Some will go as low as 0.5mg Haldol.
-SL formulations are always a good step right before the point of needing to go to emergent chemical restraint if you can speak with a patient and have them agree to take it. Common SL options include Zyprexa Zydis, Risperdal M-tabs. At UCSF, Zyprexa (zydis) is the most commonly used SL form–you can still offer benzos with it as long as it isn’t given IM. You may see more Risperdal M-tabs at ZSFG (on formulary) than Zydis (non-formulary, need pharmacy approval) but you could use either, especially if you know the patient is routinely on Risperdal or Zyprexa, then that could guide you.
-Psychiatry likes sedating antipsychotics (Olanzapine, Risperidone, Haldol) in an acute situation, and those three tend to be interchangeable
-You can often ask someone: “We can get you some medication that might help you feel less afraid.” or “Hey, is there anything that has helped you feel better and calm when you’re upset and agitated?”
-If someone is already on a standing antipsychotic, giving an extra dose of that is a safe bet (i.e. an extra 50-100 of Seroquel if they’re already getting some
-If you are in more emergent territory or aren’t sure about safety, then you will probably want to just go IV/IM route for safety to both patient and staff.
-If a patient is not at all psychotic or delirious and seem purely behavioral (meth agitation maybe) or if you are really concerned about a prolonged QT, you could always give IM benzos alone, such as 2-3mg Ativan to start.


Examples of emergent meds at the General:
Risperdal M tabs
Olanzapine Zydis (non-formulary therefore required approval by pharmacy formulary manager)
Olanzapine IM (non-formulary therefore required approval by pharmacy formulary manager)
Geodon IM
Fluphenazine IM
Haloperidol PO/IM
Chlorpromazine PO/IM

With cases of QTc prolongation, consider using olanzapine IM or fluphenazine IM per psychiatry pharmacy. Haldol PO is actually not a big concern, the parenteral formulations (IM/IV) are more likely to prolong QT. If you’re interested, here is a quick table (reference below) of antipsychotics/QTc increase.

Examples of QTc prolongation associated with select antipsychoticsa

Antipsychotic Approximate QTc interval prolongation in millisecondsb
Aripiprazole4,17 -1 to -4
Clozapine4 10
Haloperidol1,2 7 to 15
Mesoridazine16 39 to 53
Olanzapine1 2 to 6.5
Paliperidone4 2 to 4
Pimozide2 19
Quetiapine1,2 6 to 15
Risperidone1,2 3.5 to 10
Sertindole1 30
Thioridazine2,16 33 to 41
Ziprasidone1,2 16 to 21
aList is not comprehensive. Other antipsychotics may be associated with QTc prolongation bQTc prolongation interval may depend on the route of administration