A
A 36-year-old woman presents to the clinic with the complaint of a depressed mood for the past 2 months, shortly after she lost her job. She feels sad throughout the day and has stopped going out with her colleagues. She has less energy and struggles to look for another job. Despite this, she still attends services and social events through her church. She has no suicidal ideation, her appetite is normal, and she reports fair sleep. On physical examination, her pulse is 72 bpm, her respiratory rate is 13/min, her temperature is 98.6°F (37°C), and her blood pressure is 118/78 mmHg. Her thoughts are logical, and she is well-oriented to time, place, and person. Which of the following is the appropriate next step in the management of this patient?
A. Escitalopram B. Psychotherapy C. Olanzapine D. Levothyroxine E. Buspirone
Psychotherapy is the correct answer. This patient is experiencing adjustment disorder after losing her job. She has a depressed mood and decreased energy, which is not sufficient to diagnose MDD.
The treatment for adjustment disorder is primarily psychotherapy that focuses on identifying the trigger and helping the patient develop coping mechanisms in response to the trigger.
A 56-year-old obese man presents to the primary care clinic because his loud snoring has led to conflicts with his wife. On the interview, the patient endorses feeling tired during the day, and is being treated for hypertension. His wife has commented that she sometimes witnesses him stop breathing during his sleep. His physical and mental status exams display no significant abnormalities other than a morbidly obese male with a BMI of 36 kg/m2 and a neck circumference of 41 cm. Which intervention should be considered next?
A. Prescribe modafinil B. Order polysomnographic study C. Order continuous positive airway device D. Prescribe methylphenidate E. Refer for assessment for bariatric surgery
The correct response is order polysomnographic study. This patient is most likely suffering from obstructive sleep apnea (OSA), a disorder in which recurrent closure of the upper airway results in episodes of cessation (apnea) or reduction (hypopnea) in airflow.
A 50-year-old woman visits the psychiatric clinic for a follow-up visit and psychotherapy following diagnosis of acute stress disorder. She recently lost her husband and her house in a hurricane. She has moved to a different state to live with her daughter. She says that she still has nightmares that are affecting her sleep, although there has been a decrease in the rest of her symptoms. She has diabetes and takes metformin. Which of the following can be beneficial for this patient's symptoms?
A. Triazolam B. Gabapentin C. Nefazodone D. Prazosin E. Venlafaxine
Prazosin is alpha 1 blocker which is the only recommended drugs for the treatment of trauma-related nightmares.
A 54-year-old man presents to the psychiatric outpatient department complaining of a depressed mood, lack of interest in cooking which he used to adore, a 10% loss of body weight despite not dieting, hypersomnia, and constant fatigue for the past 4 weeks. He complains that his friends have stopped coming to visit citing his attitude as the problem. He has no history of any medical disorder or medication use apart from the occasional analgesics. He reports no episodes of mania or hypomania during this period. Which of the following is the next best step in the management of this patient?
A. Fluoxetine B. Quetiapine C. Azithromycin D. Propranolol E. Amitriptyline
Correct response is fluoxetine because the use of selective serotonin reuptake inhibitors (SSRIs) is preferred in severely ill patients with major depressive disorder (MDD) due to the minimum risk for lethality following an intentional overdose and a benign side effect profile.
A 32 y/o with a history of depression, obesity and asthma had partial response in her depressive symptoms with max dose escitalopram. Addition of which of the following medications would be the most appropriate next step ?
A. Lithium B. Modafinil C. Phenelzine D. Gabapentin E. Olanzapine
Lithium
A 45-year-old woman with a prior history of major depressive disorder, single episode, mild, presents to her psychiatrist complaining of chills, myalgia, and headache for the last 2 days following a decrease in the dose of paroxetine. She has not experienced any major depressive symptoms for over a year, and with the recommendation of her psychiatrist she started to taper down her paroxetine 3 days ago. She still is able to fulfill her work and family obligations but complains of not feeling well. What is the next best step in the management of this patient?
A. Initiate atropine B. Reassurance C. Initiate mirtazapine D. Initiate fluvoxamine E. Increase dose of paroxetine
The correct response is reassurance because the patient presents with mild symptoms following discontinuation of paroxetine. These symptoms require only reassurance that these symptoms will pass within a few days. If her symptoms were interfering with her ability to fulfill her home or work obligations, or if they persisted for an excessive amount of time then doing some intervention (increasing dose or adding fluoxetine) could be considered.
A 27-year-old woman presents to the clinic complaining of amenorrhea, weight gain, and decreased libido for the past 2 months. She also complains that her breasts have started feeling fuller. She is compliant with medications for schizophrenia which was diagnosed 3 years ago. She denies any hallucinations and suicidal ideation. Which of the following medication is most likely responsible for this patient's symptoms?
A. Clozapine B. Risperidone C. Sertraline D. Lithium E. Trazodone
Risperidone is correct. It belongs to the class of atypical antipsychotics and blocks the D2 receptor at the tuberoinfundibular dopamine pathway, which increases prolactin levels. Its major side effects include gynecomastia, infertility, amenorrhea, weight gain, galactorrhea, and sexual dysfunction. It is also implicated that chronic hyperprolactinemia causes breast cancer and osteoporosis.
A 30-year-old woman presents to the clinic with the complaints of dyspnea, dizziness, chest pain and palpitations. For the past two years she experiences these symptoms whenever she is exposed to insects. She gives the history of similar phobia in her mother. On examination, heart rate is 100 beats/min, and blood pressure of 120/80mmHg is recorded. ECG and chest x-ray are normal. She is offered multiple sessions of exposure therapy, but she refuses to take them due to her busy schedule and the high cost of the treatment. Which of the following is an appropriate treatment option for her?
A. Sertraline for 6-12 months B. One-session exposure therapy C. Quetiapine for 6 months D. Sertraline for 3 months E. Alprazolam for 3 months
This question describes a patient with specific phobia and one-session exposure therapy being the appropriate treatment for her as it is time saving and cost-effective. One-session exposure therapy is a type of massed exposure therapy used for the treatment of specific phobias. It combines exposure, cognitive challenges, participant modeling, and reinforcement in a single session, that takes a maximum of three hours. By this technique, the advantages of graduated exposure could be achieved in a one prolonged treatment session with good results. Some researchers say that one-session exposure may be slightly less efficient than multiple sessions, However, with this technique, patients show better compliance, and it is cost-effective as well.
A 31-year-old woman is brought to the emergency department for a severe throbbing headache, nausea, and photophobia for 3 hours. She had severe occipital pain and chest tightness. Prior to the onset of symptoms, she had attended a networking event where she had red wine and, shortly after, a snack consisting of salami and some dried fruits. The patient has recurrent migraine headaches and depression, for which she takes medication daily. She is mildly distressed, diaphoretic, and her face is flushed. Her temperature is 98.6°F (37°C), her pulse is 90/min, her respiratory rate is 20/min, and her blood pressure is 195/130 mmHg. She is alert and oriented. Deep tendon reflexes are 2+ bilaterally. This patient's symptoms are most likely caused by a side effect of which of the following medications?
A. Sumatriptan B. Phenelzine C. Topiramate D. Sertraline E. Amitriptyline
Phenelzine, a monoamine oxidase inhibitor (MAOI), is typically reserved for treatment-resistant or atypical major depressive disorder given its severe side effect profile and numerous drug interactions. Monoamine oxidase breaks down excess tyramine in the body. Since MAOIs block this enzyme, the consumption of tyramine-rich foods (e.g., red wine, certain nuts, aged cheeses or meats, dried fruits) leads to an accumulation of tyramine. This, in turn, leads to a release of norepinephrine that can provoke a hypertensive crisis, as seen in this patient.
Which of the following augmentation agents has been shown to be both well tolerated and effective in managing treatment resistant depression?
A. Estrogen B. Atomoxetine C. St john's wort D. Triiodothyronine E. Tranylcypromine
Triiodothyronine : enhance neurogenesis , increase serotonin levels and improve sensitivity of serotonin receptors.
Which of the medications may be helpful in the treatment of anti-psychotic induced drooling?
A. Metoprolol B. Mirtazapine C. Lorazepam D. Glycopyrrolate E. Tetracaine solution
Glycopyrrolate: an anticholinergic drug that helps control drooling, and secretions.
Which of the following hormones is released from the adipose tissue and enters the brain to provide negative feedback signals and reduce food intake?
A. Leptin B. Ghrelin C. Peptide YY Cholecystokinin
E. Glucagon like peptide
A. Leptin
Which of the following medications, when taken in overdose is associated with an increased risk of seizures? a. Duloxetine b. Trazodone c. Fluoxetine, d. Clomipramine e. Mirtazapine
Clomipramine is a TCA that can cause arrythmias, seizures and hypotension at toxic levels of doses over 300 mg per day or when used with meds that inhibits CYP450 2D6.
Antidote to TCAs toxicity - IV NaHco3.
Which of the following selective serotonin reuptake inhibitors (SSRIs) poses the most risk to the fetus during pregnancy? A. Fluoxetine B. Sertraline. Citalopram. Escitalopram. Paroxetine
Paroxetine: paroxetine has been most clearly associated with an increased risk of congenital cardiac defects.
What is the name of the first drug to have ever been approved by the US FDA specifically for the treatment of postpartum depression (PPD) in adult females.
Brexanolone approved in 2019 in treating PPD. It acts in part as a synthetic supplement for possible deficiencies in endogenous allopregnanolone) in postpartum women susceptible to PPD.