A 25-year-old male presents to his psychiatrist for follow-up after a lengthy psychiatric hospitalization. He was diagnosed with schizophrenia and discharged on risperidone 6 mg daily. He has no known medical problems and is without physical complaints. He continues to have some paranoia and ideas of reference regarding CNN, but he is not overtly delusional. He denies hallucinations as well. Although he feels "depressed" regarding his illness, he denies suicidal or homicidal ideation.
The above patient continues to be compliant with his medication and remains asymptomatic. He returns 6 months later with complaints of urinary frequency and weight gain. Afasting glucose is 200. Consideration is given to switching to another antipsychotic. Which of the following medications would be the most appropriate?
A. aripiprazole (Abilify)
B. clozapine (Clozaril)
C. olanzapine (Zyprexa)
D. quetiapine (Seroquel)
E. thioridazine (Mellaril)
Correct Answer: A Section: (none)
Explanation:
Routine vital signs, ECG, and blood work such as CBC or LFTs are not required for ongoing use of second-generation (atypical) antipsychotics in healthy patients. Due to the risk of weight gain, hyperlipidemia, and diabetes ("metabolic syndrome"), regular monitoring for these is recommended. Due to variations in height, calculating a BMI is preferred when monitoring for weight gain in these patients. This patient has developed new-onset diabetes, presumably from the risperidone. Although all of the second-generation antipsychotics have Food and Drug Administration (FDA) warnings about causing metabolic syndrome, studies have demonstrated that they have varying rates of causing or exacerbating this: clozapine > olanzapine > quetiapine risperidone > aripiprazole ziprazidone. Therefore, assuming there is no contraindication to using one of the listed agents, aripiprazole would be the most appropriate choice based on its likely minimal risk of causing or exacerbating diabetes.
Question 232:
A 25-year-old male presents to his psychiatrist for follow-up after a lengthy psychiatric hospitalization. He was diagnosed with schizophrenia and discharged on risperidone 6 mg daily. He has no known medical problems and is without physical complaints. He continues to have some paranoia and ideas of reference regarding CNN, but he is not overtly delusional. He denies hallucinations as well. Although he feels "depressed" regarding his illness, he denies suicidal or homicidal ideation.
Which of the following should be routinely monitored in this patient?
A. body mass index (BMI)
B. BP
C. complete blood count (CBC)
D. electrocardiogram (ECG)
E. liver function tests (LFTs)
Correct Answer: A Section: (none)
Explanation:
Routine vital signs, ECG, and blood work such as CBC or LFTs are not required for ongoing use of second-generation (atypical) antipsychotics in healthy patients. Due to the risk of weight gain, hyperlipidemia, and diabetes ("metabolic syndrome"), regular monitoring for these is recommended. Due to variations in height, calculating a BMI is preferred when monitoring for weight gain in these patients. This patient has developed new-onset diabetes, presumably from the risperidone. Although all of the second-generation antipsychotics have Food and Drug Administration (FDA) warnings about causing metabolic syndrome, studies have demonstrated that they have varying rates of causing or exacerbating this: clozapine > olanzapine > quetiapine risperidone > aripiprazole ziprazidone. Therefore, assuming there is no contraindication to using one of the listed agents, aripiprazole would be the most appropriate choice based on its likely minimal risk of causing or exacerbating diabetes.
Question 233:
A 22-year-old male is brought into the emergency room by the police as he was found yelling in the middle of the street, naked. In the quiet room, he is unpredictable during the examination. He displays extreme lability, alternating between agitation with kicking the bed and listlessness. He is observed responding to internal stimuli and appears paranoid. A limited physical examination demonstrates mildly elevated BP and heart rate, nystagmus, ataxia, and muscle rigidity. Intoxication with which of the following substances is most likely in this patient?
A. alcohol
B. cannabis
C. heroin
D. lysergic acid diethylamide (LSD)
E. PCP
Correct Answer: E Section: (none)
Explanation:
This patient presents with agitation and psychosis, likely caused by intoxication with a substance of abuse. While intoxication with alcohol can cause unsteadiness and belligerence, it does not present with hypertension and tachycardia. Cannabis can cause tachycardia and feelings of paranoia but, by itself, does not usually spur violence or grossly disorganized behavior. Intoxication with heroin or other opiates more often presents with drowsiness or apathy rather than the overt psychotic symptoms and sympathetic discharge seen in the above case. While LSD and other hallucinogens obviously cause psychotic symptoms, the nystagmus and muscular rigidity are not as common. Patients are not characteristically as hostile as in the case example. PCP use classically presents with the unpredictability, paranoia, and aggressiveness similar to the above case. It is not uncommonly mistaken for schizophrenia. Physical findings may include nystagmus, hypertension, tachycardia, ataxia, and muscular rigidity (DSM IV-TR).
Question 234:
A 60-year-old male with a history of chronic schizophrenia and multiple hospitalizations checks into the emergency room with complaints of "funny movements." He has been compliant with risperidone (Risperdal) 3 mg bid, and he has been taking that dose for the last 6 years while living at a group home. He appears overweight but with adequate hygiene. His thoughts are somewhat tangential but not grossly disorganized. He denies any paranoia, ideas of reference, or delusions. He denies perceptual disturbances or suicidal/homicidal ideation. His physical examination is unremarkable except for occasional involuntary blinking and grimacing, as well as rotation of his left ankle. He is greatly distressed about these "habits" and wishes something to be done about them.
Which of the following would be the most appropriate management for this patient?
A. add benztropine to the risperidone
B. continue the current dose of risperidone
C. decrease the dose of risperidone
D. discontinue the risperidone
E. increase the dose of risperidone
Correct Answer: C Section: (none)
Explanation: The patient has likely developed tardive dyskinesia (TD), a late-occurring movement disorder associated with chronic antipsychotic use. Adding an anticholinergic agent like benztropine would be indicated for treating an acute dystonia but is not effective for TD. Continuing the current dose of his antipsychotic will not lessen his movements, and increasing it will more than likely worsen them over time. Discontinuing his psychotropic will not reduce his dyskinesia, and it will provide a high risk for relapse of his psychosis. Once an individual has TD, reducing the dose (if clinically indicated) may minimize the progression or even improve the abnormal movements. The patient displays features consistent with neuroleptic malignant syndrome (NMS), a life-threatening condition associated with antipsychotic therapy. Adding benztropine will not treat NMS. Immediate discontinuation of the antipsychotic is recommended. Initiation of dantrolene, a muscle relaxant, as well as bromocriptine, a dopamine receptor agonist, may also be used to manage the patient.
Question 235:
A 60-year-old male with a history of chronic schizophrenia and multiple hospitalizations checks into the emergency room with complaints of "funny movements." He has been compliant with risperidone (Risperdal) 3 mg bid, and he has been taking that dose for the last 6 years while living at a group home. He appears overweight but with adequate hygiene. His thoughts are somewhat tangential but not grossly disorganized. He denies any paranoia, ideas of reference, or delusions. He denies perceptual disturbances or suicidal/homicidal ideation. His physical examination is unremarkable except for occasional involuntary blinking and grimacing, as well as rotation of his left ankle. He is greatly distressed about these "habits" and wishes something to be done about them.
The same patient is brought back to the emergency room via ambulance 1 month later due to "catatonia." According to his chart, he was maintained on his current dose of risperidone by his outpatient psychiatrist. On examination, he is unresponsive to questions. His vital signs demonstrate a temperature of 103.5°F, BP of 180/95, pulse of 105, and respirations of 20. His physical examination is notable for significant diaphoresis, muscular rigidity, and lack of cooperation with much of the examination.
Which of the following would be the most appropriate management for this patient?
A. add benztropine (Cogentin) to the risperidone
B. continue the current dose of risperidone
C. decrease the dose of risperidone
D. discontinue the risperidone
E. increase the dose of risperidone
Correct Answer: D Section: (none)
Explanation:
The patient has likely developed tardive dyskinesia (TD), a late-occurring movement disorder associated with chronic antipsychotic use. Adding an anticholinergic agent like benztropine would be indicated for treating an acute dystonia but is not effective for TD. Continuing the current dose of his antipsychotic will not lessen his movements, and increasing it will more than likely worsen them over time. Discontinuing his psychotropic will not reduce his dyskinesia, and it will provide a high risk for relapse of his psychosis. Once an individual has TD, reducing the dose (if clinically indicated) may minimize the progression or even improve the abnormal movements. The patient displays features consistent with neuroleptic malignant syndrome (NMS), a life-threatening condition associated with antipsychotic therapy. Adding benztropine will not treat NMS. Immediate discontinuation of the antipsychotic is recommended. Initiation of dantrolene, a muscle relaxant, as well as bromocriptine, a dopamine receptor agonist, may also be used to manage the patient.
Question 236:
A 14-month-old girl is brought into the primary care clinic by her parents. Her prior wellbaby checks have been normal, but her parents have noticed that while she used to be "outgoing," she has now become shyer and less responsive. Whereas she had been beginning to walk, she has recently been falling more and unable to even stand up. Her mother noticed that she has been flapping her hands and that her sun hats have become too big for her.
Which of the following is the most likely diagnosis for this patient?
A. Asperger disorder
B. autistic disorder
C. childhood disintegrative disorder
D. fragile X syndrome
E. Rett's disorder
Correct Answer: E Section: (none)
Explanation:
Asperger disorder is a pervasive developmental disorder manifested with impairments in social interaction and stereotyped behaviors, without the additional language abnormalities seen in autism. Childhood disintegrative disorder is also a pervasive developmental disorder characterized by normal development until age 2, followed by a rapid decline in the use of language, motor skills, and social interaction. Fragile X syndrome is a genetic syndrome displaying mental retardation, characteristic physical features, and a high rate of pervasive developmental disorder. The above patient displays a history consistent with Rett's disorder, a progressively worsening pervasive developmental disorder seen only in females. Rett's patients routinely demonstrate normal development until at least 5 months of age, with subsequent head deceleration, stereotyped hand movements, loss of social engagement, gait difficulties, and impaired language
Question 237:
An 18-month-old boy is brought into the urgent care clinic by his mother who complains that he is "eating weird stuff." For the past few months since being able to walk, he has been found chewing and swallowing odd substances, such as hair, paper, and string. She has been more concerned since she recently noticed him eating clay from around the foundation of their apartment in the projects. His appetite has been affected because of this, and she is worried that he will become sick as a result.
Determination of which of the following blood levels would be the most appropriate next step in the workup and management of this patient?
A. folate
B. iron
C. lead
D. manganese
E. zinc
Correct Answer: E Section: (none)
Explanation:
This toddler has developed pica, the eating of nonnutritive substances. Decreased levels of folate may be associated with depression and dementia in adults but is not seen in cases of pica. Iron deficiency, a potential cause of pica, may present with eating of dirt. A lead level would be necessary to determine if the child were eating lead-based paint. Manganese levels have not been shown to be abnormal in pica. As zinc deficiency is another cause of pica, assessment of a zinc level is essential in children who consume clay (as is being done by the child in this case)
Question 238:
A19-year-old male United States Army veteran presents to the outpatient clinic. He recently returned from combat in Iraq where he was assigned to the infantry. While on patrol 1 month ago, he witnessed several friends killed by a road-side bomb. Since that time he has had difficulty sleeping, with frequent awakenings after recurrent nightmares about the event. He finds himself "jumpy" at times, especially with loud noises. He stayed in his parents' house around the July 4th holiday, and he became acutely anxious when hearing firecrackers. He has not spent time with friends or family. He refuses to watch any television or listen to the radio for fear of hearing news of more casualties. He complains of a sense of "numbness" and gets easily distracted. He denies suicidal ideation but sometimes feels that "my life ended over [in Iraq]."
Which of the following medications as monotherapy is most likely to be effective in treating his symptoms?
A. amobarbital (Amytal)
B. haloperidol (Haldol)
C. lorazepam (Ativan)
D. sertraline (Zoloft)
E. trazodone (Desyrel
Correct Answer: D Section: (none)
Explanation:
The patient is experiencing symptoms consistent with PTSD. Untreated, only approximately 30% of patients completely recover, 60% continue to have mild-to-moderate symptoms, and 10% remain unchanged or worsen. A rapid onset, short duration of symptoms, good premorbid functioning, strong social supports, and absence of other psychiatric or medical illnesses predict a better prognosis. Sertraline, and the other SSRIs, are very effective and well-tolerated treatments for PTSD. SSRIs have been shown to improve all of the symptom clusters of PTSD (i.e., reexperiencing symptoms, avoidance of stimuli, and increased arousal). Based on their efficacy, tolerability, lack of abuse potential, and safety in overdose, they are considered to be first-line agents for treating PTSD.
Administering amobarbital, or an amytal interview, has been used sometimes in conjunction with psychotherapy to help individuals work through their traumatic event. It has not been used as a treatment alone, however, given its addicting potential and lethality in overdose. Antipsychotics such as haloperidol have little evidence supporting their use in treating PTSD symptoms, but they may be used acutely to manage agitation or violence. Lorazepam can also be used in a similar manner, but given the high comorbidity of substance abuse in patients with PTSD, this is not recommended as a solo treatment. Trazodone, in lower doses, can be used to help treat insomnia in these individuals. Treatment of the PTSD symptoms, however, would likely require a full antidepressant dose, which carries significant side effects, such as daytime sedation and orthostasis.
Question 239:
A19-year-old male United States Army veteran presents to the outpatient clinic. He recently returned from combat in Iraq where he was assigned to the infantry. While on patrol 1 month ago, he witnessed several friends killed by a road-side bomb. Since that time he has had difficulty sleeping, with frequent awakenings after recurrent nightmares about the event. He finds himself "jumpy" at times, especially with loud noises. He stayed in his parents' house around the July 4th holiday, and he became acutely anxious when hearing firecrackers. He has not spent time with friends or family. He refuses to watch any television or listen to the radio for fear of hearing news of more casualties. He complains of a sense of "numbness" and gets easily distracted. He denies suicidal ideation but sometimes feels that "my life ended over [in Iraq]."
What is his likelihood of a complete recovery in1 year if not treated?
A. 020%
B. 2040%
C. 4060%
D. 6080%
E. 80100%
Correct Answer: B Section: (none)
Explanation:
The patient is experiencing symptoms consistent with PTSD. Untreated, only approximately 30% of patients completely recover, 60% continue to have mild-to-moderate symptoms, and 10% remain unchanged or worsen. A rapid onset, short duration of symptoms, good premorbid functioning, strong social supports, and absence of other psychiatric or medical illnesses predict a better prognosis. Sertraline, and the other SSRIs, are very effective and well-tolerated treatments for PTSD. SSRIs have been shown to improve all of the symptom clusters of PTSD (i.e., reexperiencing symptoms, avoidance of stimuli, and increased arousal). Based on their efficacy, tolerability, lack of abuse potential, and safety in overdose, they are considered to be first-line agents for treating PTSD.
Administering amobarbital, or an amytal interview, has been used sometimes in conjunction with psychotherapy to help individuals work through their traumatic event. It has not been used as a treatment alone, however, given its addicting potential and lethality in overdose. Antipsychotics such as haloperidol have little evidence supporting their use in treating PTSD symptoms, but they may be used acutely to manage agitation or violence. Lorazepam can also be used in a similar manner, but given the high comorbidity of substance abuse in patients with PTSD, this is not recommended as a solo treatment. Trazodone, in lower doses, can be used to help treat insomnia in these individuals. Treatment of the PTSD symptoms, however, would likely require a full antidepressant dose, which carries significant side effects, such as daytime sedation and orthostasis.
Question 240:
A 12-year-old boy is brought into the office by his mother, who states, "I can't deal with this anymore!" She appears exasperated, claiming that her son has been getting into more and more trouble over the past 15 months since the finalization of a particularly long and difficult divorce. He has been leaving the house at night without notifying his mother or telling her of his whereabouts. She suspects that he is responsible for the increased vandalism in the neighborhood. He has recently been caught shoplifting at a nearby store. His grades have always been poor, but he has just been suspended for missing classes and skipping school over the past year. He has often come home with evidence of having been in fights. She suspects that he may be hanging out with gang members. She is afraid of his ending up in jail and "becoming like his father."
Ahistory of which of the following premorbid diagnoses would most likely be found in this patient?
A. antisocial personality disorder
B. ADHD
C. autistic disorder
D. childhood schizophrenia
E. mental retardation
Correct Answer: B Section: (none)
Explanation:
This patient exhibits the criteria for conduct disorder. Antisocial personality disorder can only be diagnosed in a person who is over age 18. In fact, the diagnosis of antisocial personality disorder requires evidence of conduct disorder prior to age 15 (DSM IV-TR). Children with autism, schizophrenia, and mental retardation may display aggressive or disruptive behavior, but these illnesses do not necessarily predict future conduct disorder. Patients with ADHD and learning disorders are at an increased risk of developing conduct disorder as they get older.
It is not uncommon for patients with conduct disorder to have a history of oppositional defiant disorder as a younger child. Indeed, the disorders are often thought of as being on a spectrum, with oppositional defiant disorder early on, followed by conduct disorder and eventually antisocial personality disorder. Having conduct disorder does not by itself predict panic disorder, schizoid personality disorder, or the development of schizophrenia. If left untreated, there is a significantly increased risk of developing a substance use disorder, which also predicts a worse prognosis
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