Bipolar Disorder
The patient is a 19-year-old woman with bipolar disorder who was admitted to the psychiatric hospital with a manic episode with mixed features. On admission, she was irritable with pressured speech and had a depressed mood with dysphoric affect. She reported suicidal thoughts but denied any suicidal intent or plan, as she is future-oriented about her career as an actress. She was started on a mood stabilizer while in the hospital and enjoyed a robust response. Following discharge, her mood remained stable, but several weeks later, at an appointment with her outpatient provider, she complains that hair began to grow on her chin. The patient was horrified by this and reported that it is very important to her career that she maintain her image. Which of the following medications most likely caused this adverse effect?
A. Lamotrigine
B. Valproic acid
C. Oxcarbazepine
D. Lithium
E. Carbamazepine
B. Valproic acid
All answer choices are mood stabilizer medications that might be used in a patient with this presentation. Her symptoms are most consistent with polycystic ovarian syndrome (PCOS), of which hirsutism is a common symptom. The risk of PCOS is increased during treatment with valproic acid, making it the correct answer. Lamotrigine, oxcarbazepine, lithium, and carbamazepine are not known for causing PCOS or hirsutism.
A 32-year-old woman presents to the emergency department because of shortness of breath and chest pain for the past 20 minutes. These symptoms are associated with sweating, nausea, dizziness, shortness of breath, and feelings of impending doom. She has had similar episodes of chest pain over the past few months. Examination findings reveal tachycardia, and laboratory tests including thyroid function tests, cardiac enzymes and toxicology screening are normal. Which of the following would be the most appropriate for immediate relief of her symptoms?
A. Clomipramine
B. Buspirone
C. Phenelzine
D. Bupropion
E. Alprazolam
E. Alprazolam
Panic disorder is characterized by recurring episodes of intense fear and anxiety with physical symptoms including sudden onset of palpitations, chest pain, trembling, dizziness, nausea, choking sensations and shortness of breath. These attacks are unexpected and do not occur in response to a particular object or situation without an identifiable trigger. When these patients are not having panic attacks they are actively worried about having another panic attack. Benzodiazepines like alprazolam have the most rapid onset of action against panic attacks. These medications can be reasonably used as the first agent to treat panic disorder while a serotonergic drug is being slowly titrated to a therapeutic dose. Care should be taking when prescribing alprazolam, due to its very high abuse potential. Other benzodiazepines such as clonazepam are viewed as having less abuse potential and should be considered for longer term use. Answer A is incorrect. Tricyclic antidepressants (TCAs) like clomipramine are efficacious in the treatment of panic disorder, but due to their side effects at the higher dosage required to treat panic disorder they are not considered first line in treatment. Answer B is incorrect. Buspirone is a serotonin 5-HT1A agonist used in the treatment of generalized anxiety disorder. Stimulation of these receptors increases the firing of the locus ceruleus, which is thought to underlie panic attacks. Medications like buspirone, mirtazapine, propranolol and pindolol have limited or no evidence for their effectiveness in treating panic disorders. Buspirone may augment the effects of other medications, but has little effectiveness on its own. Answer C is incorrect. Monoamine oxidase inhibitors like phenelzine may also be used to treat panic disorder, and seem to cause less overstimulation than SSRIs or TCAs, but require treatment for at least 8-12 weeks with full dosages to be effective. They also require strict dietary restrictions which have limited their use. Answer D is incorrect. Bupropion is an atypical antidepressant that inhibits the neuronal uptake of norepinephrine and dopamine. Although it has anxiolytic properties for generalized anxiety (or the “worry” type of anxiety), it appears to be devoid of anti-panic properties, and may actually worsen panic.
A 65-year-old woman with a 20-year history of schizophrenia presents to the emergency department complaining of involuntary lip-smacking which has developed over the past 3 months. The patient has been well controlled on low-dose haloperidol for the past 15 years. Which one of the following statements is true regarding tardive dyskinesia (TD)?
A. Improvement is immediate after discontinuation of the antipsychotic medication
B. Her symptoms will resolve completely with the addition of quetiapine
C. Her haloperidol dose should be increased
D. Switching to an atypical antipsychotic may reduce her symptoms.
E. Her symptoms will resolve completely with the addition of deutetrabenazine
D. Switching to an atypical antipsychotic may reduce her symptoms.
Explanation:
Tardive dyskinesia (TD) is a disorder of involuntary movements associated with dopamine agonists. It is more common in the elderly and is more commonly caused by first-generation antipsychotics like haloperidol.
Changing to a second-generation antipsychotic or lowering her dose is the ideal next step. This may reduce her symptoms or possibly cause remission, although this will not be immediate.
Adding a second-generation antipsychotic is not advised. The haloperidol should be stopped as the new medication is started. Increasing the dose of haloperidol may actually reduce her symptoms for a time, but will likely increase them in the long term.
Deutetrabenazine, or valbenazine, are vesicular monoamine transporter (VMAT) inhibitors. They are FDA approved for the treatment of TD, but may only reduce the symptoms. It is best to still lower the dose of haloperidol or switch to a new medication in addition to starting a VMAT inhibitor.
A 63-year-old man with a long history of alcohol use disorder presents to the ED after a recent binge. He reports that he developed nausea and vomiting. In addition, he subsequently stopped eating. He now complains of severe abdominal pain, shortness of breath, and dizziness. His breath has a fruity smell. He is most likely to be suffering from which one of the following conditions?
A. Cholecystitis
B. Impending delirium tremens
C. Ketoacidosis
D. Korsakoff's syndrome
E. Wernicke's encephalopathy
C. Ketoacidosis
Explanation:
Alcoholic ketoacidosis is seen in the setting of heavy alcohol use, decreased food intake, and dehydration, where liver glycogen is depleted, insulin production decreased, and lipolysis increases with release of free fatty acids that are converted to ketones, giving the fruity smell to the breath. Tachypnea is a result of acidosis with respiratory compensation. Abdominal pain is present is 60% of cases and may progress to pancreatitis. There are no clinical features here of delirium, cranial nerve deficits, or short term memory loss, which would suggest delirium tremens, Wernicke's encephalopathy, or Korsakoff's syndrome.
A 20-year-old man presents to the psychiatry clinic with his parents who report their son has been behaving oddly for the past 6 months. He was found talking to himself quite a lot of times and is unable to carry out his daily tasks. Upon further questioning, the patient says he has been hearing voices when nobody is in the room. He denies any suicidal ideations. Upon mental status examination, the patient's appearance looks disheveled with poor eye contact, speech is coherent, thoughts are tangential, and judgment is poor. Which of the following is the most likely diagnosis?
A. Social anxiety disorder
B. Bipolar disorder
C. Schizotypal personality disorder
D. Schizophrenia
E. Major depressive disorder
D. Schizophrenia
Explanation:
Schizophrenia is diagnosed when at least 2 of the following are present for a significant period of time in one month and the symptoms should be persistent for at least 6 months.
At least one of (1), (2), or (3) must be present:
1. Delusions
2. Hallucination
3. Disorganized speech
4. Disorganized or catatonic behavior
5. Negative symptoms (flat affect, apathy, social withdrawal etc.)
The patient described has odd behavior, flat affect, auditory hallucinations and disorganized behavior for 6 months which meet the DSM V criteria to be diagnosed as a case of schizophrenia. Social anxiety disorder previously known as social phobia is defined as excessive fear and avoidance of public settings in which the individual is an object of attention.
Individuals with social anxiety disorder fear of being judged and negatively evaluated by others and often avoid such situations which can cause them distress. Social anxiety disorder significantly impairs social, occupational and other important areas of functioning, so this option is incorrect. Bipolar disorder is a mood disorder which causes alternating bouts of depression and mania. This patient doesn't exhibit symptoms of bipolar disorder, so this option is incorrect.
Patient's with schizotypal personality disorder have magical thinking, odd beliefs which are inconsistent with societal norms. They have paranoid ideations and their appearance is eccentric. These personality traits appear in early years of life, so the diagnosis is highly unlikely. The patient doesn't meet the DSM V criteria of major depressive disorder, so this option is incorrect as well.
A 22-year-old woman with bipolar disorder is started on a mood stabilizer. Within a couple of months, she begins to develop acne, hirsutism, male-pattern hair loss and irregular menstrual cycles. Which one of the following mood stabilizers is she most likely to have been prescribed?
A. Carbamazepine
B. Gabapentin
C. Lamotrigine
D. Lithium
E. Valproate
E. Valproate
Valproic acid increases Na+ channel inactivation and increases GABA concentration by inhibiting GABA transaminase. It is used in the treatment of simple, complex, tonic-clonic, absence and myoclonic seizures, migraine prophylaxis, acute manic and mixed episodes in adults, and relapse prevention in bipolar disorder. Treatment with valproate is associated with polycystic ovarian syndrome in females which manifest as acne, irregular menstrual cycles, male pattern baldness, weight gain, and hirsutism. Valproate increases the risk of fertility, therefore extra caution is recommended with use of valproic acid in women of reproductive age. Other common side effects of valproic acid include hepatotoxicity, GI distress, pancreatitis, neural tube defects, weight gain and tremor. Treatment with lithium, carbamazepine, gabapentin or lamotrigine is not associated with polycystic ovarian syndrome
What is the average age of onset of panic disorder or agoraphobia?
A. 7
B. 22
C. 31
D. 44
E. 55
B. 22
The correct option is 22 years old. Panic disorder is an anxiety disorder during which the patient experiences bouts of unexpected recurrent panic attacks. These attacks are characterized by a sudden overwhelming fear that takes over along with signs such as numbness, sweating, palpitations, shaking, shortness of breath, or a gut feeling that something bad is about to happen. The disorder commonly has an unknown origin and is seen to run in the family. About 2.5% of people are affected by panic disorders throughout their lifetime. The disorder is not that common among children and older people. Therefore, the lower and higher age groups are incorrect. Women are more commonly affected than men. Counseling strategies such as cognitive behavioral therapy have proven to be very effective in their treatment.
A 22-year-old female presents to your office for a second opinion. She had recently been started on Valproic acid for a bipolar disorder and migraine headache. She is worried since she was told by her neighbor that Valproic acid is associated with a lot of adverse effects. Which among the following conditions can occur secondary to Valproic acid use?
A. Glioblastoma multiforme
B. Retinitis pigmentosa
C. Polycystic ovarian syndrome
D. Generalized epilepsy
E. Myelodysplastic syndrome
C. Polycystic ovarian syndrome
Explanation:
Valproic acid (VPA) is an antiepileptic drug (AED) that is largely regarded as a first-choice agent for most forms of generalized epilepsies and is also used for bipolar disorders and migraine headaches. It is also being investigated for a myriad of diseases such as glioblastoma multiforme, retinitis pigmentosa, and myelodysplastic syndrome. Available data suggests that menstrual maladies and some reproductive system conditions may be more common in women treated with VPA than in those treated with other AEDs. In females, intake of VPA is associated with polycystic ovarian syndrome, hyperandrogenism, menstrual disorders, and ovulatory failure. Men undergoing VPA treatment show erectile dysfunctions, abnormalities in androgens blood levels and sperm motility. VPA affects the release of luteinizing hormone, prolactin, and follicle stimulating hormone. It also interferes with peripheral endocrine hormones and has a wide inhibitory action on glucuronidation and cytochrome systems leading to high serum concentration of androstenedione, testosterone, and dehydroepiandrosterone sulfate. VPA-dependent hyperinsulinemia and obesity can further contribute to an increase in sexual dysfunctions. Thus, it is very important for physicians to conduct strict monitoring on patients taking VPA so as to identify these adverse effects at an early stage.
A 25-year-old man is brought by police to the emergency department because his girlfriend called 911 to report that he is seeing things that are not there and is sure people want to hurt him. He is anxious, guarded, suspicious, and ignores most questions. He is hyperactive, underweight, and complains about the "strangers" darting behind the curtains of the ED and talking about him. His heart rate and blood pressure are moderately elevated. Intoxication with which of the following types of substances is most likely responsible for this patient's presentation?
A. Alcohol
B. Sedative/hypnotic
C. Stimulant
D. Opioid
E. Hallucinogen
C. Stimulant
Explanation:
Common symptoms and signs of stimulant intoxication include auditory hallucinations, paranoia, anxiety, hyperactivity, and elevated heart rate and blood pressure. Secondary to stimulant-induced appetite suppression, individuals with stimulant use disorder may be underweight. Alcohol, sedative/ hypnotics, and opioids would not cause anxiety in intoxication, but in withdrawal. Hallucinogens typically result in much more complex hallucinations than thinking there are people in the room and do not necessarily cause weight loss or anxiety.
A 42-year-old woman with a history of treatment-resistant schizophrenia presents to the outpatient department with a complaint of significant weight gain for the last 4 weeks. Five weeks ago, a drug best suited for treatment-resistant disease was initiated. On examination, her weight is 95 kg (209 lbs.) while the weight recorded 5 weeks ago was 75 kg (165 lbs.). Her BMI is 30 kg/m2. Which of the following drugs is the most likely cause of her weight gain?
A. Risperidone
B. Clozapine
C. Aripiprazole
D. Amisulpride
E. Ziprasidone
B. Clozapine
Explanation:
Clozapine is correct because it is a second-generation antipsychotic which is reserved for cases of treatment-resistant schizophrenia. Olanzapine is generally viewed as the worst offender in regards to weight gain, but clozapine, quetiapine, and risperidone are also associated with significant weight gain.
Risperidone is incorrect because it is a second-generation antipsychotic associated with moderate weight gain, but it is not the treatment of choice for resistant schizophrenia, so it is unlikely to be the offending drug in this patient.
Aripiprazole is incorrect because it is not typically associated with significant weight gain and is often used as an alternative to other antipsychotics causing weight gain or as an adjunct with clozapine to reduce weight. It also is not used in treatment refractory cases as a monotherapy agent.
Amisulpride is incorrect because it does not cause significant weight gain, nor is it a drug of choice for resistant schizophrenia.
A 37-year-old woman consults for a second opinion regarding her bipolar disorder (BD).
She has been taking valproate for her condition with her symptoms well controlled. Unfortunately, during the course of her treatment she delivered a dead neonate with multiple neural tube defects. She is asking if switching to carbamazepine would be better since she is planning to have another baby and her insurance entirely co-pays for this medicine. You would reply:
A. No, carbamazepine is associated with craniofacial defects
B. No, carbamazepine is associated with autism spectrum disorders
C. Yes, carbamazepine is associated with the least maternal side effects
D. Yes, carbamazepine is associated with better pregnancy outcomes
E. Yes, carbamazepine has a beneficial effect in the depressed phase of BD
A. No, carbamazepine is associated with craniofacial defects
Carbamazepine has demonstrated efficiency for acute manic and mixed episodes in adults with bipolar disorders (BD). Due to its multiple drug interactions and side effects, it is less commonly used now. Side effects with carbamazepine use includes nausea, vomiting, drowsiness, diplopia, blurred vision, and ataxia. Hematological side effects such as mild anemia, leucopenia, and thrombocytopenia are also common. It may also cause electrolyte disturbances such as hyponatremia and hepatotoxicity. The development of a rash is a common side effect within the first 6 months of treatment and may warrant discontinuation of the drug due to the risk of Stevens-Johnson syndrome (SJS) and other serious dermatological reactions. Its use has been reported to lead to congenital abnormalities when used during pregnancies. First trimester exposure to carbamazepine can cause an increase in malformations such as craniofacial defects, neural tube defects, developmental delays, and behavioral changes. Children of epileptic pregnant women treated with carbamazepine had a 10 mm decrease in fetal head circumference, which did not become normal by the age of 18 months. Overall, carbamazepine is deemed to be a human teratogen since it leads to major and minor abnormalities in fetuses and babies.
When diagnosing bipolar disorder, how many episodes of mood disturbance in the previous 12 months meeting criteria for major depressive, manic, hypomanic, or mixed episode must have occurred in order to specify with rapid cycling?
A. 2
B. 4
C. 6
D. 8
E. 12 (one per month)
B. 4
Explanation:
"Rapid cycling" is a specifier that can be applied to either Bipolar I or Bipolar II disorders, requiring at least four episodes of a mood disturbance in the previous 12 months that meet criteria for a major depressive, manic, mixed, or hypomanic episode. The episodes must be demarcated either by partial or full remission for at least 2 months or by a switch to an episode of opposite polarity.
Which one of the following sets of drugs is FDA approved for treating diabetic peripheral neuropathy?
A. Gabapentin and quetiapine
B. Duloxetine and pregabalin
C. Venlafaxine and sertraline
D. Haloperidol and duloxetine
E. Pregabalin and Valproic acid
B. Duloxetine and pregabalin
Explanation:
Medications used to help relieve diabetic nerve pain include lidocaine, tricyclic antidepressants, (nortriptyline and desipramine), other types of antidepressants (duloxetine and fluoxetine), anticonvulsants (pregabalin, gabapentin, carbamazepine, and lamotrigine), and opioids and opioid-like drugs (controlled-release oxycodone, tramadol and tapentadol). Duloxetine and pregabalin are approved by the FDA specifically for treating painful diabetic peripheral neuropathy. Valproic acid, haloperidol, quetiapine and sertraline are not used for diabetic neuropathy.
A 26-year-old man with a stimulant use disorder presents to the clinic after not following up with you for 2 months. To detect any drug use during that 2 month period, which of the following body samples should you obtain?
A. Urine
B. Oral fluid
C. Hair
D. Sweat
E. Blood
C. Hair
Explanation:
For this patient, the use of a hair sample would be correct, since a hair sample can help detect drug use for up to 90 days. In addition, a nail sample can also be used to detect drug usage within 90 days. Some drawbacks to using these two samples is that they are invasive to the patient, and high cost. Urine would be incorrect, since it only has a detection window of one to three days, depending on the amount of amphetamine consumed. Oral fluid would be incorrect, since its window of detection is 12 to 48 hours, while sweat testing can have an accumulation period of one to 14 days, after which the patch (collecting the sweat) will be remove. One major drawback to sweat testing is the minute amount of analytes that accumulate on the patch (versus that of urine and blood), thus confounding the testing and re-testing process. In addition, the patch has to be worn for seven to 14 days (depending on the kit) before the screening results can be obtained. A blood sample is incorrect, since amphetamines can only be detected in the blood for a few hours.
A 61-year-old man is brought to the emergency room. He is new to San Francisco, having traveled from his home to buy a large quantity of Buddha statues for unclear reasons. He stored the statues in his small hotel room. This caused such congestion that the room could not be cleaned; the hotel management requested he removes the statues or vacates the premises. The patient became extremely agitated and accused the hotel manager of conspiring to kill his family. He is very concerned about his family in Denver, whom he believes has become a target of a large terrorist organization. He heard the news anchors talk to him directly about this threat. He denies any drug use, and his urinary toxicology screen is negative. He denies any medical symptoms apart from significant tiredness from not sleeping for the past 3-4 nights. His physical exam is within normal limits and on a mental status exam, the patient is distraught. His wife and son are relieved to hear that the patient has been located. They suspected that he has not been taking his long-term medications as prescribed, and started to call the hospitals and the morgues in their area after his disappearance, fearing the worst. They mention that he's been "obsessively" purchasing Buddha statues, for protection. What would be the best treatment for the patient, once he is acutely stabilized?
A. Habit Reversal Training (HRT)
B. Long acting injectable antipsychotic (LAI)
C. Selective serotonin reuptake inhibitor (SSRI)
D. Support group for hoarding behaviors
E. Lamotrigine
B. Long acting injectable antipsychotic (LAI)
Explanation:
The patient presents predominantly with psychotic symptoms and appears to have a psychotic disorder such as schizophrenia or schizoaffective disorder, or mood disorder with psychotic features such as bipolar I disorder. The purchasing and hoarding of Buddha statues appear to be in line with his belief that he and his family need protection against a delusional threat. This motivation makes his behavior unlikely to be a symptom of hoarding disorder. Since he has difficulty with medication adherence, a depot antipsychotic (combined with a mood stabilizer if he has schizoaffective or bipolar disorder) would be an effective therapeutic option. Answer A is incorrect. HRT is indicated for disorders such as Tourette's disorder and trichotillomania. It is not indicated for psychotic illness. Answer C is incorrect. An SSRI would be helpful for hoarding disorder, but would not address the patient's psychotic symptoms. Answer D is incorrect. A support group for hoarding behaviors can help patients who don't respond to individual psychotherapy and SSRIs. However, since his primary diagnosis is unlikely to be hoarding disorder, a support group would not be helpful. Answer E is incorrect. Lamotrigine has efficacy as maintenance treatment of bipolar disorder, but given the patient's nonadherence with medications, intermittent use of lamotrigine would place him at risk for Stevens-Johnson syndrome or toxic epidermal necrolysis (TEN).
A 15-year-old girl was brought in by her mother, who was concerned about her daughter's behavior and mood over the last year. Her mother reports periods of excessive crying, difficulty waking (and increased school absenteeism as a result), and a lack of interest in spending time with friends. These symptoms occur for weeks at a time. At other times, according to her mother, her daughter is excitable, energetic (to the point of restless), and very talkative, with conversations jumping from topic to topic. During these times (which last 1-2 days), her mother finds her daughter to be very irritable. The patient herself concurs and reports that she "just doesn't feel right most of the time," indicating that she either feels "down and scared about everything" or "like I can handle anything and everyone." She denies, however, changes in appetite, energy, or concentration and does not report feelings of guilt or worthlessness. What diagnosis is most appropriate?
A. Bipolar I
B. Bipolar II
C. Cyclothymic disorder
D. Persistent depressive disorder
E. Disruptive mood dysregulation disorder
C. Cyclothymic disorder
The most appropriate diagnosis is cyclothymic disorder. Her symptoms are consistent with this diagnosis in terms of the time course (e.g., lasting a year) as well as the severity of her symptoms along both spectrums (e.g., depressive and manic). This diagnosis requires the presence of symptoms for 1 year in children/adolescents (2 years in adults). Although she experiences significant and frequent mood swings, as is the case for bipolar I, these alternating periods do not meet the criteria for severity that would be required for bipolar I, in which case symptoms of a full episode of mania are required. Although she exhibits symptoms consistent with features of bipolar II, namely mood fluctuations and hypomanic symptoms, her depressive episodes are less severe and with fewer symptoms than is required to meet criteria for major depressive episodes (minimum of 5). Also, her hypomanic symptoms do not full criteria for hypomania, as they last less than 4 days. Persistent depressive disorder does present with more chronic depressive episodes, as seen here, but without episodes of hypomania. Disruptive mood dysregulation disorder is a newly classified disorder in the DSM-5 and consists of persistent irritability. In this patient, irritability occurred specifically during periods of elevated mood and was not noted during periods associated with depressive symptoms.
A 35-year-old man comes to the clinic due to frequent headaches, fatigue, restlessness, and insomnia for the last 8 months. Nine months ago, he started a new job. He lies awake at night thinking about his future and worrying about his upcoming deadlines. He can no longer concentrate on his work during the day. He feels irritable and avoids hanging out with his friends. His vitals signs are within normal limits. The patient had an alcohol use disorder 15 years back, but now he does not drink alcohol at all. Mental state examination shows an anxious, tense, and irritated man. Psychotherapy with medication is advised. The patient says that he has struggled off and on with erectile dysfunction in the past and requests a medication that will not exacerbate his erectile dysfunction. Which of the following drugs will be the most appropriate for the management of this patient's condition?
C. Buspirone
The correct response is buspirone as it is an anxiolytic used in the management of generalized anxiety disorder. It has no potential for dependence and is the most appropriate choice in patients with sexual dysfunction. To minimize the risk of relapse with this drug, the treatment should be continued for one year.
Propranolol is incorrect as it is a beta-blocker used in the management of social anxiety disorder, performance type only. This patient's excessive worries about several situations for ≥6 months is suggestive of generalized anxiety disorder, and propranolol is not the appropriate medication for its management.
Clonazepam is incorrect as it is a benzodiazepine used in the management of generalized anxiety disorder as an adjunct. It cannot be used as long-term management due to its risk of dependence, tolerance, and addiction. This patient has a history of alcohol abuse, so benzodiazepines are contraindicated in this case.
Amitriptyline is incorrect as it is a tricyclic antidepressant and has many adverse effects. It is not used as a first-line drug for the management of generalized anxiety disorder.
Fluoxetine is a selective serotonin reuptake inhibitor. It is used as a first-line treatment option for generalized anxiety disorder, but can often cause sexual side effects, including erectile dysfunction.
Which of the following oral analgesic is recommended as a first-line pain therapy for small fiber neuropathic pain?
A. Oxycodone
B. Indomethacin
C. Duloxetine
D. Tramadol
E. Aspirin
C. Duloxetine
Explanation:
Small fiber neuropathy is characterized by pain that can be pricking, burning, shooting, and aching in nature and is often triggered by increasing temperatures. Thinly myelinated Aδ and unmyelinated C-fibers are affected by small fiber neuropathy. This leads to excessive functioning of pain and temperature sensations, along with some secondary autonomic symptoms. Small fiber neuropathy presents in two patterns: length-dependent and non-length dependent. The length-dependent form first affects the toes and then moves upwards, whereas the non-length dependent has a patchy distribution that can involve the face, upper limbs, or trunk. Treatment comprises antidepressants, antiepileptics, and analgesic medications. The recommended first-line treatment options based on efficacy are serotonin norepinephrine reuptake inhibitors (SNRIs) like duloxetine and venlafaxine, tricyclic antidepressants (TCAs) like amitriptyline and nortriptyline, and anticonvulsants like pregabalin and gabapentin. Tramadol is considered second-line treatment. Oxycodone is considered a third-line treatment. There is no therapeutic indication for indomethacin or aspirin.
A 77-year-old man with alcohol use disorder is 4 days status-post hip replacement surgery and is confused and combative with the nursing staff. He is also responding to internal stimuli. His pulse is 112 beats per minute, his blood pressure is 178/103 mmHg, and his temperature is 99.8°F. Laboratory testing reveals mild leukocytosis, macrocytosis of red blood cells, thrombocytopenia, normal urinalysis, elevated aspartate transaminase (AST), normal electrolytes, normal glucose, and normal creatinine. Chest X-ray reveals no acute cardiopulmonary disease. Ordering which of the following options is the most appropriate next step in the management of this patient?
A. Broad-spectrum antibiotic
B. Emergent CT scan of the head
C. Lorazepam
D. Haloperidol
E. Diazepam
C. Lorazepam
Explanation:
The patient's presentation is consistent with alcohol withdrawal delirium. This should always be in the differential diagnosis of postoperative delirium accompanied by elevated vital signs--especially if there is a known history of a substance use disorder. The laboratory values also provide clues to ongoing heavy alcohol use (transaminitis, thrombocytopenia, macrocytosis). The most important acute measure in a case of alcohol withdrawal delirium is to administer intravenous (if possible) benzodiazepines. For older adults, especially those with acutely inflamed livers, lorazepam is the treatment of choice because of its shorter half-life and less complicated liver metabolism (phase II glucuronidation only). Diazepam and its metabolites have a long half-life in older adults, accumulate in fat tissue, and require phase I cytochrome P450 metabolism--all increasing the chance of cumulative benzodiazepine toxicity. For this reason, it should be avoided. Haloperidol may help acute psychosis or agitation not responsive to benzodiazepines in withdrawal delirium, but benzodiazepines are lifesaving. Fever and mild leukocytosis may occur in acute alcohol withdrawal. After stabilizing the withdrawal, consideration of further workup and treatment, including workup for infections or a central nervous system lesion/infarct, might be indicated if the patient has residual concerning symptoms, physical exam findings, or abnormal labs. This would include a CT scan of the head. Broad spectrum antibiotics would be indicated if there is a suspected infection. It is not clear these are necessary yet in this case.
Which environmental factor carries an increased risk for the development of schizophrenia?
A. Pediatric illness
B. Major paternal stress
C. Birth in winter
D. Birth in summer
E. Low socioeconomic status
C. Birth in winter
Explanation:
This question asks about the environmental risk factors for the development of schizophrenia. Birth in winter is the correct answer with a 5%-15% increased risk. Pediatric illness is incorrect as prenatal illness is associated with increased risk rather than pediatric illness. Major paternal stress is incorrect as the risk is maternal stress. Birth in summer is incorrect as it is the opposite of the correct answer. Low socioeconomic status is incorrect, as most data shows no causal factor for socioeconomic status.
Bipolar disorder patients with rapid cycling have a higher prevalence of which one of the following endocrine abnormalities as compared to bipolar patients without rapid cycling?
A. Addison's Disease
B. Dexamethasone suppression test non-suppression
C. Hyperprolactinemia
D. Hypocortisolemia
E. Hypothyroidism
E. Hypothyroidism
Thyroid problems are more common in the complex forms of bipolar disorder (mixed states and rapid cycling) than in classic bipolar manic patients. Perturbations of the circadian biological and social rhythms might influence the expression of rapid cycling. No major effect of the menstrual cycle has been found. Despite the absence of firm empirical data, the possible contribution of the kindling phenomenon on the acceleration of cycles cannot be excluded. Finally, there is evidence that Rapid Cycling can be induced by the use of antidepressant drugs, especially for women.
A 22-year-old man presents to the emergency department because he thinks he might be having a heart attack. He has had recurrent episodes of severe anxiety and chest pain for the past two weeks. These episodes occur randomly at least once a week and last about 5 minutes; he denies any associated symptoms. Examination findings and extensive work-up, including thyroid function tests and toxicology screening are normal. Which of the following is the most likely diagnosis?
A. Panic disorder
B. Social anxiety disorder
C. Agoraphobia
D. Specific phobia
E. Other specified anxiety disorder
E. Other specified anxiety disorder
Although this man is having unexpected episodic attacks of intense anxiety that do not occur in response to a particular object or situation, he does not meet the criteria for panic disorder; therefore, he is suffering from other specified anxiety disorder- limited symptom attacks.
Panic disorder is characterized by recurring episodes of intense fear and anxiety with at least 4 or more physical symptoms including sudden onset of palpitations, chest pain, trembling, sweating, chills, dizziness, numbness, nausea, choking sensations, and shortness of breath. These attacks are unexpected and do not occur in response to a particular object or situation. This man does not meet the criteria for panic disorder.
In social anxiety disorder, the individual is anxious about or avoidant of social interactions and situations where they might be scrutinized by others. This can include interacting with unfamiliar people, being observed whilst eating, or performing in front of an audience. The fear is related to receiving a negative evaluation by others, such as by humiliating or embarrassing themselves. This man has random attacks of panic and fear, which are not related to social interactions with others.
Individuals with agoraphobia are anxious or fearful of certain situations, such as being trapped inside an elevator or being outside alone; however, this stems from the fear of being trapped in a situation where escape is perceived to be difficult if they develop panic-like or other incapacitating symptoms. Individuals with this condition suffer from these symptoms in a wide range of situations. This man has had multiple random episodes of intense anxiety and fear which were not related to being in a situation where escape would be difficult or help would not be available. Individuals with a specific phobia develop fear or anxiety in response to certain objects or situations. The fear, anxiety, or avoidance is induced immediately by the phobic stimulus, which is persistent, irrational, and out of proportion to the actual risk posed. This man has had multiple episodes of intense anxiety and fear without any identifiable triggers.
While all of the syndromes listed below can be associated with some motor loss in the lower extremities and possible loss of some functioning of both bladder and bowel, which syndrome is associated with a more sudden onset of symptoms, some symmetric motor loss, and early onset of bladder and bowel involvement with hyper reflexia?
A. Conus medullaris syndrome
B. Acute disk herniation
C. Degenerative disk disorder
D. Cauda equina syndrome
E. Brown-Sequard syndrome
A. Conus medullaris syndrome
Explanation:
The correct answer is Conus Medullaris Syndrome: the Conus Medullaris, the most distal part of the spinal cord, can be associated with BOTH upper and lower motor lesions, hyperreflexia, and present as a Bilateral and Symmetrical Pattern of symptoms along with the early onset of bladder and bowel dysfunction. Any motor loss is symmetrical but not as marked due to its location (S3-S5.)
Answers B and C are incorrect. The acute disc herniation and degenerative disc disorders can present w/ either no real motor change but with pain or weakness/numbness but not typically with sudden involvement of bladder and bowel dysfunction.
Answer D is incorrect. In Cauda Equina ( the horsetail of spinal roots), the syndrome typically presents with hyporeflexia or areflexia, mostly lower motor neuron involvement, and a more asymmetrical pattern with later involvement of bladder and bowel dysfunction. Cauda Equina syndrome is more typically gradual and unilateral, and the pain is more severe.
A 29-year-old G2P0 woman who is 20 weeks pregnant has been using intranasal heroin, 1-2 grams daily, for the duration of her pregnancy. She presents to the hospital requesting detoxification. Assuming good adherence, which treatment for opioid use disorder would be most likely to result in the best maternal outcome and the lowest risk of neonatal abstinence syndrome for the newborn?
A. Opioid withdrawal (detoxification)
B. Buprenorphine
C. Naltrexone
D. Methadone
E. Pentazocine
B. Buprenorphine
Explanation:
Although both methadone and buprenorphine are considered to be suitable treatments for pregnant women, option B (rather than option D) is correct, because if available it is preferred or methadone. A meta-analysis of 12 RCTs published in 2014 compared buprenorphine to methadone in pregnant women with opioid use disorder. The conclusions were that the risk of neonatal abstinence syndrome (NAS), mean length of hospital stay, and other well-being factors of the newborn were better with the buprenorphine group relative to the methadone group. In addition in the landmark trial Maternal Opioid Treatment: Human Experimental Research trial (MOTHER) showed statistically superior results for buprenorphine relative to methadone in the outcome measures of NAS and mean neonatal hospital stay. It used to be thought that only buprenorphine should be given to the mother without the naloxone, however recent evidence suggests that this formulation can be given to mothers and that the naloxone has little teratogenic risk to the developing fetus. Option A is incorrect because opioid agonist treatment, rather than detoxification, remains the standard of care for pregnant women due to the high risk of relapse and associated overdose risk after detoxification.
Option C is incorrect because there is much more evidence for buprenorphine and methadone compared to naltrexone. Naltrexone is used for OUD, but it is not the first line therapy for pregnant mothers with OUD.
Option E is incorrect because pentazocine (primarily a kappa and sigma opioid receptor agonist with weak mu activity) has not been studied for treatment of opioid use disorder in pregnancy.
A 36-year-old woman is brought to the clinic by his husband to review her medications taken to manage schizophrenia diagnosed 3 months back. At her first visit, she was prescribed optimal doses of risperidone and was monitored with dose titration as per the guidelines, but there was no clinical improvement. She was switched to olanzapine 3 weeks ago and is currently taking 20mg/day. The mental status examination reveals irrelevant speech with loosening of associations, persistent apathy, and persecutory delusions. She has had auditory hallucinations throughout the course of her illness, but they have recently become commanding in nature. What is the next best step in the management of this case?
A. Switch to clozapine
B. Add aripiprazole to olanzapine
C. Increase the dose of olanzapine to 40mg/day
D. Switch the patient to once monthly injectable antipsychotics
E. Stop all antipsychotics and start cognitive behavioral therapy
A. Switch to clozapine
Explanation:
Switching to clozapine is correct because the guidelines suggest that if 2 different medications at optimal doses do not improve the clinical picture of a patient with schizophrenia, the patient can be labeled as having treatment-resistant schizophrenia. The best choice of antipsychotic for treatment-resistant schizophrenia is clozapine. Although it poses a high risk of causing metabolic syndrome just like olanzapine, specific measures can be taken to prevent drastic consequences. Since there has been no clinical improvement in her first-rank symptoms of schizophrenia, treatment with clozapine is deemed necessary.
Adding aripiprazole to olanzapine is incorrect because this option is valid if there are only issues related to tolerability or side-effects, especially weight gain, but in this patient, there has been no clinical improvement with olanzapine. it is best to avoid using 2 antipsychotics whenever possible. The condition has been worsening, as evident by newly discovered commanding hallucinations that can prove highly fatal to the patient and others around her.
Increase the dose of olanzapine to 40mg/day is incorrect because the manufacturer's recommended maximum dose of olanzapine is 20mg/day, which the patient has already been taking. There have been studies that show some patients require higher doses, but it would not be advised to double the dose like this as it would likely lead to an increase in adverse effects. Clozapine is a much better option.
Switching to a long acting injectable antipsychotic is incorrect because this patient has treatment-resistant schizophrenia, which is best managed with clozapine. Long acting injectable antipsychotics are drugs of choice in patients in which treatment compliance is an issue, they are not any more effective than oral medications.
Stop all antipsychotics and start cognitive behavioral therapy is incorrect because this patient has active phase schizophrenia symptoms that require psychopharmacological treatment. CBT can be useful in the maintenance phase of treatment, most often in addition to medication.