History and Physical
A 32-year-old Yazidi female from Iraq is brought to your office to establish care. She is a refugee who was relocated 2 weeks ago. Which one of the following would be appropriate at this visit?
A) Having a family member who speaks English serve as an interpreter
B) Screening for posttraumatic stress disorder
C) Hepatitis B vaccine
D) Varicella vaccine
ANSWER: B
A full history and physical examination are indicated for all refugees within 30 days of arrival in the United States, with a professional medical interpreter if needed (SOR C). In addition to addressing medical needs, the focus should be on emotional support and barriers to health care access (SOR C). All refugees should be screened for depression, anxiety, and posttraumatic stress disorder (SOR C). They should also be screened for anemia, hypertension, impaired fasting glucose, nutritional deficiencies, tuberculosis, and COPD (SOR C). If there is no vaccination documentation, routine vaccines should be provided except for varicella and hepatitis B. Serology should be performed before these vaccines are administered (SOR C).
A 34-year-old female has posttraumatic stress disorder that started 6 months ago after she was a victim of an armed robbery. She also has nightmares, anxiety, hypervigilance, and some paranoia and has been reexperiencing the robbery. She has been receiving psychotherapy but would now like to start a medication. Which one of the following would be the most appropriate medication to start?
A) Bupropion (Wellbutrin)
B) Buspirone
C) Lorazepam (Ativan)
D) Risperidone (Risperdal)
E) Venlafaxine (Effexor XR)
ANSWER: E
It is important for patients with posttraumatic stress disorder (PTSD) to receive psychotherapy. For those who continue to have symptoms it is appropriate to initiate medications. SSRIs and venlafaxine are considered first-line medications for the treatment of PTSD. Bupropion and buspirone have not been found to be effective treatments. The use of benzodiazepine medications is not recommended because of the high risk of misuse. Antipsychotic medications would be appropriate in patients with disabling symptoms and behaviors that do not respond to psychological or drug treatment.
A 48-year-old male comes to your office for follow-up of recently diagnosed panic attacks. As part of his treatment plan he is taking sertraline (Zoloft), 50 mg daily, and working with a mental health provider who has diagnosed posttraumatic stress disorder associated with a traumatic childhood. He reports that his sleep continues to be interrupted by nightmares. Which one of the following additional medications may provide long-term control of his symptoms?
A) Atenolol (Tenormin)
B) Lorazepam (Ativan)
C) Prazosin (Minipress)
D) Risperidone (Risperdal)
E) Zolpidem (Ambien)
ANSWER: C
An SSRI or SNRI should be used first as monotherapy for posttraumatic stress disorder (PTSD), and should be optimized before an additional agent is added. Prazosin is an effective augmenting therapy for patients with PTSD and sleep disturbance (SOR B). Other -blockers and -blockers have been shown to be ineffective in the treatment of PTSD. Benzodiazepines such as lorazepam can treat symptoms of hyperarousal but have been associated with adverse effects and should be avoided in the treatment of PTSD (SOR B). Hypnotics such as zolpidem are generally reserved for short-term use. There is no evidence to support the use of atypical antipsychotics for PTSD and their use should be avoided (SOR C).
A 32-year-old Yazidi female from Iraq is brought to your office to establish care. She is a refugee who was relocated 2 weeks ago. Which one of the following would be appropriate at this visit?
A) Having a family member who speaks English serve as an interpreter
B) Screening for posttraumatic stress disorder
C) Hepatitis B vaccine
D) Varicella vaccine
ANSWER: B
A full history and physical examination are indicated for all refugees within 30 days of arrival in the United States, with a professional medical interpreter if needed (SOR C). In addition to addressing medical needs, the focus should be on emotional support and barriers to health care access (SOR C). All refugees should be screened for depression, anxiety, and posttraumatic stress disorder (SOR C). They should also be screened for anemia, hypertension, impaired fasting glucose, nutritional deficiencies, tuberculosis, and COPD (SOR C). If there is no vaccination documentation, routine vaccines should be provided except for varicella and hepatitis B. Serology should be performed before these vaccines are administered (SOR C)
A 26-year-old female presents to your office after surviving a tornado that destroyed her home 3 months ago. She reports continued intense fear and anxiety when there is a storm. You diagnose her with posttraumatic stress disorder.
Which one of the following has the best evidence of effectiveness for her condition?
A) Amitriptyline
B) Atypical antipsychotics
C) Benzodiazepines
D) Topiramate (Topamax)
E) Cognitive-behavioral therapy
Answer: E) Cognitive-behavioral therapy
According to the Agency for Healthcare Research and Quality’s 2018 guidelines, cognitive-behavioral therapy (CBT), either exposure or mixed treatment, has the best evidence of effectiveness in the treatment of posttraumatic stress disorder (PTSD) (SOR A). CBT focused on either artificial exposures or real-life exposures reduces PTSD and depression symptoms. Artificial exposures can be imagined, written, or virtual reality. Mixed modalities such as cognitive restructuring, exposure-guided imagery, and mindfulness training also reduce PTSD and depression symptoms. Other types of cognitive therapy also have evidence of effectiveness, but the study results are less precise.
The SSRIs fluoxetine and paroxetine and the SNRI venlafaxine have moderate evidence to support their use in the treatment of PTSD (SOR B). The guidelines recommend against the use of amitriptyline, atypical antipsychotics, and topiramate. Benzodiazepines are not recommended in the treatment of PTSD.
A 32-year-old female sees you for a health maintenance visit. She reports that she experiences severe anxiety when involved in social situations. She lives with her mother and dreads meeting unfamiliar people. At work she remains in her cubicle throughout the day and avoids staff parties. She has a history of alcoholism in remission. She has otherwise been in good health and a physical examination is normal. Which one of the following would be first-line treatment for this patient?
A) Amitriptyline
B) Bupropion (Wellbutrin)
C) Escitalopram (Lexapro)
D) Lorazepam (Ativan)
E) Pregabalin (Lyrica)
ANSWER: C
Social anxiety disorder can be treated with psychotherapy, pharmacotherapy, or both. Several medications have been used for the treatment of social anxiety disorder. SSRIs are considered to be the first-line pharmacologic treatment. Response rates reported for the SNRI venlafaxine have been similar to those reported for SSRIs. Randomized trials have also supported the efficacy of benzodiazepines for social anxiety disorder, but they carry a risk of physiologic dependence and withdrawal symptoms and are not recommended for patients with coexisting depression or a history of substance abuse. Response rates to pregabalin have been lower than with SSRIs. Tricyclic antidepressants and bupropion are not considered to be useful in the treatment of social anxiety disorder.
Intensive behavioral intervention has more benefit than other treatment modalities in treating children who have been diagnosed with
A) attention-deficit/hyperactivity disorder
B) autism
C) depression
D) obsessive-compulsive disorder
E) posttraumatic stress disorder
ANSWER: B
The only evidence-based treatment that confers significant benefits to children with autism is intensive behavioral interventions, which should be initiated before 3 years of age. Attention-deficit/hyperactivity disorder can be treated with cognitive-behavioral therapy (CBT) but medication is often required. CBT is as effective, if not more effective, than medication for treating anxiety, depression, and trauma-related disorders.
A 34-year-old female comes to your office for follow-up after an emergency department visit because of anxiety. She notes persistent anxiety, poor focus, and palpitations. She also reports that she is not hungry and has lost several pounds. She reports “odd things happening” such as sudden weakness in her legs, falling, and getting lost.
When taking her history you note that the patient is hyperverbal and displays tangential speech. She has a temperature of 37.4°C (99.3°F), a heart rate of 134 beats/min, a respiratory rate of 20/min, and a blood pressure of 117/69 mm Hg. A physical examination reveals an anxious-appearing female who is tremulous at rest. A HEENT examination shows exophthalmos but no thyromegaly. A cardiac examination is unremarkable aside from tachycardia. A pulmonary examination reveals faint bibasilar crackles. An EKG shows sinus tachycardia. Laboratory results are as follows:
CBC within normal limits Basic metabolic panel within normal limits TSH <0.08 U/mL (N 0.35–3.00) Free T 4 4.51 ng/dL (N 0.89–1.80) Free T 3 >19.0 pg/dL (N 2.3–4.2)
Which one of the following would be most appropriate at this point?
A) Start methimazole (Tapazole)
B) Check for thyroid receptor antibody
C) Obtain a radioactive iodine uptake scan
D) Refer her to endocrinology
E) Admit her to the hospital
ANSWER:
E) Admit her to the hospital
Hyperthyroidism is a common condition with a generally favorable prognosis. However, it is important to remember that life-threatening complications such as thyrotoxicosis, also known as thyroid storm, can occur. Symptoms of thyroid storm include fever, central nervous system dysfunction, gastrointestinal or liver dysfunction, and cardiovascular complications such as tachycardia and heart failure. The diagnosis is made using the Burch-Wartofsky Point Scale, which produces a total score based on the presence or absence of various diagnostic criteria. In this case, the patient has a score of 45, which is highly suggestive of thyroid storm. This acute, life-threatening condition typically requires care in an intensive-care unit. It would therefore be inappropriate to start treatment with an agent such as methimazole prior to hospitalization. While a thyroid receptor antibody test may be useful in identifying the cause of the condition it should not delay hospitalization. A radioactive iodine uptake test is also useful for identifying the underlying cause of hyperthyroidism but should be avoided until the thyroid storm has resolved. This patient requires hospitalization, so a referral to endocrinology would not be most appropriate at this time.
A 32-year-old female presents to your office 3 months after surviving a serious rollover car accident. Since the accident she has had flashbacks, nightmares, and difficulty sleeping. She has been unable to resume work or care for her young children due to difficulty concentrating and feeling like she is in a daze. She has not been able to drive, and riding in a vehicle triggers anxiety and fear. She tells you that she cannot stop feeling responsible for the accident. She does not take any medications and has no history of substance use. After performing a structured diagnostic interview and review of DSM-5 criteria to confirm your diagnosis, you discuss treatment options. She is not willing to consider psychotherapy at this time. Which one of the following would be the most appropriate pharmacotherapy?
A) Clonazepam (Klonopin)
B) Divalproex (Depakote)
C) Fluoxetine (Prozac)
D) Quetiapine (Seroquel)
E) Risperidone (Risperdal)
C) Fluoxetine
This patient has posttraumatic stress disorder (PTSD). She was exposed to threatened death and injury (DSM-5 criterion A) and exhibits multiple symptoms from several clusters of the DSM-5 criteria for PTSD (reliving of the traumatic event [criterion B], avoidance of trauma-related stimuli [criterion C], negative thoughts or feelings that began or worsened after the trauma [criterion D], and trauma-related arousal and reactivity that began or worsened after the trauma [criterion E]). She has symptoms that have caused distress and functional impairment for more than 1 month and are not triggered by medication or substance use (criteria F–H). Individual, trauma-focused psychotherapy has strong evidence for benefit in the treatment of PTSD and is recommended as the first-line treatment. If psychotherapy is not available or preferred by the patient, pharmacotherapy is then recommended. Among the options listed, fluoxetine has the strongest evidence of efficacy as monotherapy for PTSD. There is a lack of evidence for the efficacy of benzodiazepines such as clonazepam, antiepileptics such as divalproex, and atypical antipsychotics such as quetiapine and risperidone. Furthermore, risks outweigh any potential benefits from these medications.
A 48-year-old male comes to your office for follow-up of recently diagnosed panic attacks. As part of his treatment plan he is taking sertraline (Zoloft), 50 mg daily, and working with a mental health provider who has diagnosed posttraumatic stress disorder associated with a traumatic childhood. He reports that his sleep continues to be interrupted by nightmares. Which one of the following additional medications may provide long-term control of his symptoms?
A) Atenolol (Tenormin)
B) Lorazepam (Ativan)
C) Prazosin (Minipress)
D) Risperidone (Risperdal)
E) Zolpidem (Ambien)
ANSWER: C
An SSRI or SNRI should be used first as monotherapy for posttraumatic stress disorder (PTSD), and should be optimized before an additional agent is added. Prazosin is an effective augmenting therapy for patients with PTSD and sleep disturbance (SOR B). Other -blockers and -blockers have been shown to be ineffective in the treatment of PTSD. Benzodiazepines such as lorazepam can treat symptoms of hyperarousal but have been associated with adverse effects and should be avoided in the treatment of PTSD (SOR B). Hypnotics such as zolpidem are generally reserved for short-term use. There is no evidence to support the use of atypical antipsychotics for PTSD and their use should be avoided (SOR C).
Intensive behavioral intervention has more benefit than other treatment modalities in treating children who have been diagnosed with
A) attention-deficit/hyperactivity disorder
B) autism
C) depression
D) obsessive-compulsive disorder
E) posttraumatic stress disorder
ANSWER: B
The only evidence-based treatment that confers significant benefits to children with autism is intensive behavioral interventions, which should be initiated before 3 years of age. Attention-deficit/hyperactivity disorder can be treated with cognitive-behavioral therapy (CBT) but medication is often required. CBT is as effective, if not more effective, than medication for treating anxiety, depression, and trauma-related disorders.
A 38-year-old white female presents with abdominal pain and insists that she be referred for surgical evaluation. She has a history of multiple unexplained physical symptoms that began in her late teenage years. She is vague about past medical evaluations, but a review of her extensive medical record reveals multiple normal blood and imaging tests, several surgical procedures that have failed to alleviate her symptoms, and frequent requests for refills of narcotic analgesics. This patient’s history is most compatible with
A) illness anxiety disorder
B) malingering
C) panic disorder
D) generalized anxiety disorder
E) somatic symptom disorder
ANSWER: E
Somatic symptom disorder (formerly called somatization disorder) usually begins in the teens or twenties and is characterized by multiple unexplained physical symptoms, insistence on surgical procedures, and an imprecise or inaccurate medical history. These patients also commonly abuse alcohol, narcotics, or other drugs. Patients with illness anxiety disorder are overly concerned with bodily functions, and can often provide accurate, extensive, and detailed medical histories. Malingering is an intentional pretense of illness to obtain personal gain. Patients with panic disorder have episodes of intense, short-lived attacks of cardiovascular, neurologic, or gastrointestinal symptoms. Generalized anxiety disorder is characterized by unrealistic worry about life circumstances accompanied by symptoms of motor tension, autonomic hyperactivity, or vigilance and scanning.
A 48-year-old male presents with a 1-year history of feeling nervous. He feels well otherwise except for mild discomfort from arthritis in both knees. A physical examination is normal, and laboratory studies, including thyroid function, are also normal. You make a diagnosis of generalized anxiety disorder. The patient declines psychotherapy and prefers pharmacologic treatment.
Which one of the following is the first-line long-term treatment for this patient?
A) Alprazolam (Xanax)
B) Buspirone
C) Duloxetine (Cymbalta)
D) Imipramine (Tofranil)
E) Quetiapine (Seroquel)
C) Duloxetine (Cymbalta)
Most adults with generalized anxiety disorder (GAD) should be offered drug therapy if nondrug therapies are ineffective or if the patient is not interested in them. SSRIs and SNRIs are recommended as first-line drug therapies because of their tolerability and efficacy compared with other drug therapies. Of the options listed, the SNRI duloxetine would be most appropriate for the treatment of this patient’s GAD. Alprazolam may be helpful for short-term treatment of anxiety but not as a long-term treatment. Buspirone, imipramine, and quetiapine are not indicated as initial therapy.
A 25-year-old male presents to your office with anxiety. During questioning he reveals that he struggles with opioid addiction since he underwent an appendectomy 2 years ago, and is anxious because of random drug screens in his workplace. He averages using about 30 mg of hydrocodone daily and goes through cycles of use and withdrawal. Screening is negative for alcohol and substance use disorders other than opioids, and for depression or other mental health disorders. You consider maintenance treatment for opioid use disorder with buprenorphine. For this patient, buprenorphine therapy
A) is inferior to methadone maintenance therapy
B) should not be combined with naloxone therapy because of potential side effects
C) should be initiated when he is in mild to moderate withdrawal from opioids
D) can be initiated only after inpatient detoxification
E) should be continued for 1 year and then tapered
ANSWER: C
Buprenorphine therapy is an important option for maintenance therapy for patients with opioid use disorder. It can be initiated in the outpatient setting but should be done when the patient is in mild to moderate withdrawal in order to avoid the risk of precipitated withdrawal (SOR C). Buprenorphine therapy is more convenient than methadone maintenance therapy and is equally as effective. Buprenorphine/naloxone combinations are preferred over buprenorphine monotherapy due to lower abuse potential, except when naloxone is contraindicated such as in patients who are pregnant or breastfeeding (SOR C). Because relapse rates are higher in patients who discontinue medication-assisted therapy for opioid use disorder, long-term use is recommended.
A 45-year-old female sees you because of an increase in fibromyalgia pain. On examination she has a BMI of 35.6 kg/m2 and normal vital signs except for a blood pressure of 156/91 mm Hg. Her other medical problems include obstructive sleep apnea, type 2 diabetes mellitus, hypertension, and generalized anxiety disorder. She smokes one pack of cigarettes daily and does not drink alcohol. She is currently taking metformin (Glucophage), 500 mg twice daily; lisinopril (Prinivil, Zestril), 10 mg daily; gabapentin (Neurontin), 300 mg 3 times daily; oxycodone (OxyContin), 10 mg every 6 hours; and lorazepam (Ativan), 1 mg 3 times daily. Which one of the following findings in this patient’s history greatly increases her risk of an accidental overdose?
A) Tobacco use
B) Morbid obesity
C) Use of oxycodone
D) Use of oxycodone and lorazepam
E) Use of lorazepam and gabapentin
ANSWER: D
The increase in opiate-related accidental overdoses has become a significant concern in recent years, prompting the CDC to release updated guidelines for the use of narcotic medications for chronic noncancer pain. There are several concerning issues in this patient’s care. Her obstructive sleep apnea, psychiatric ailments, and concurrent use of opiates and benzodiazepines all increase the risk of an accidental overdose. The CDC also warns against using opiates in patients with heart failure, chronic pulmonary diseases, and a personal history of drug or alcohol abuse.
A 35-year-old female comes to your office for follow-up of an emergency department (ED) visit for palpitations. She tells you that she was driving on the highway with her three small children when she suddenly felt her heart racing, along with chest tightness, lightheadedness, and severe anxiety. She pulled over and called 911. While she waited for EMS she took diltiazem (Cardizem), 30 mg orally, which had been prescribed following a similar episode several years ago. Her symptoms lasted about 10 minutes and had improved by the time EMS arrived. An examination, EKG, and chest radiograph in the ED were all normal.
Which one of the following findings in her previous medical record would confirm your diagnosis?
A) A Generalized Anxiety Disorder–7 (GAD-7) score of 6
B) An elevated TSH level
C) P waves hidden within a narrow QRS complex on an event recorder
D) Mitral valve prolapse on an echocardiogram
E) Atherosclerotic plaque seen on carotid ultrasonography
ANSWER:
C) P waves hidden within a narrow QRS complex on an event recorder
This patient presents with a history consistent with typical atrioventricular nodal reentrant tachycardia, which is the most common type of supraventricular tachycardia (SVT). She is also using “pill-in-the-pocket” treatment, which is effective for infrequent SVT. Because the symptoms are episodic and the tachycardia is paroxysmal, patients generally present with normal examination and EKG findings. Further evaluation with event monitoring may identify a narrow-complex tachycardia with P waves hidden within the QRS complex or identified early after it. Most patients with SVT have structurally normal hearts.
An elevated Generalized Anxiety Disorder–7 (GAD-7) score is consistent with a diagnosis of generalized anxiety disorder (GAD). However, GAD is a common misdiagnosis in patients with SVT, particularly females. While hyperthyroidism is associated with tachycardia, hypothyroidism usually is not. Mitral valve prolapse is not specifically associated with SVT. Carotid atherosclerosis is not associated with SVT either, but knowledge of its presence may help determine treatment.
A 78-year-old male with terminal lung cancer and long-standing COPD is admitted to a regular medical-surgical care unit pending transfer to the hospice unit within the next day. You are called about worsening anxiety and dyspnea. The patient is alert and anxious. He has a blood pressure of 150/94 mm Hg, a pulse rate of 96 beats/min, a respiratory rate of 24/min, and an oxygen saturation of 93% on 2 L/min of oxygen via nasal cannula. Which one of the following would be most effective in this situation?
A) 40% oxygen by venti-mask
B) Dexamethasone
C) Hyoscyamine (Anaspaz)
D) Lorazepam (Ativan)
E) Morphine sulfate
Answer) E
Opiates are the most effective agents for treating dyspnea and the resultant anxiety in patients with terminal cancer. Higher levels of oxygen are indicated if the patient’s oxygen saturation is <92% and with caution in patients with COPD so as not to suppress respiratory drive. Dexamethasone, hyoscyamine, and lorazepam have a frequent role in patients such as this one, but morphine sulfate or a similar fast-acting opiate is the drug of choice (SOR B).
You have assumed the care of a well established patient in your practice whose medications include chronic alprazolam (Xanax) treatment for anxiety and codeine for chronic back pain following a work accident years earlier. His Prescription Drug Monitoring Program report shows a consistent pattern of filling the medications as prescribed. You order a urine immunoassay for opioids and benzodiazepines. The results are positive for opioids but negative for benzodiazepines.
Which one of the following would be the most appropriate next step?
A) Perform confirmatory testing for alprazolam
B) Repeat the urine immunoassay for benzodiazepines
C) Investigate for possible diversion of alprazolam
D) Stop prescribing alprazolam
E) Stop prescribing controlled substances
ANSWER:
A) Perform confirmatory testing for alprazolam
Because of the importance of urine drug testing and the ramifications for patients, it is essential that physicians understand and properly interpret these results. The most appropriate next step in this case is to perform confirmatory testing for alprazolam. Immunoassays can have false-positive and false-negative results, and unexpected negative results must have confirmatory testing for verification (SOR C).
The immunoassay for benzodiazepines detects the metabolite nordiazepam only, which is a metabolite of diazepam, oxazepam, and temazepam but not of alprazolam, lorazepam, or clonazepam. This negative immunoassay screening test would require confirmatory testing for alprazolam.
A repeat immunoassay for benzodiazepines would likely show the same negative result and would not change decision-making. The immunoassay for opioids detects only nonsynthetic opioids such as morphine and codeine, and a positive immunoassay for codeine would be expected in this case. It would be inappropriate to suspect drug diversion, or to stop prescribing alprazolam or controlled substances, based upon the negative immunoassay for benzodiazepines in this patient.