EXAMMASTER PSYCH 1

The mother of a 5-year-old girl walks into her daughter's bedroom without knocking and discovers the girl stimulating her genitals. The girl's parents are concerned, but seem to be receptive to advice. Question What is the best response a physician could give? Answer Choices 1 "Do you think that someone's been molesting her?" 2 "Don't you think you should knock before going into her room?" 3 "She probably has a vaginal infection. Bring her in so I can examine her." 4 "This is not normal behavior for a child this age." 5 "What disturbs you about this behavior?"

Correct Answer: "What disturbs you about this behavior?" Show Explanation Explanation The correct response is "What disturbs you about this behavior". Before the physician can provide guidance for the parents, the parents' concerns need to be understood. While the described behavior is perfectly normal for a 5-year-old, and it is appropriate for parents to knock on the door of their child's room before entering to teach children respect for privacy through modeling, the parents' concerns must first be understood. To immediately assume there is something physically wrong with the child, or that the child has been sexually abused, suggests that the physician may have some personal issues with children's normal sexuality.

A 33-year-old woman presents after being found unresponsive in the bedroom of her home. She has a past medical history of depression, and her mother found an empty bottle of amitriptyline by her bedside. Otherwise, the patient has no other medical or surgical history. She is a nonsmoker and does not drink alcohol. On physical exam, her pulse is 138/minute, blood pressure is 80/60 mm Hg, temperature is 101.2° F (38.4° C), and respirations 6/minute. Her heart sounds are normal and she has thready pulses. Her breath sounds are normal, but with shallow effort. The abdomen is soft and nontender. Neurologically, she moves her limbs from painful stimuli. Her skin is flushed; there are no needle marks. Her chest X-ray is normal, and the electrocardiogram demonstrates a wide complex tachycardia without ectopy. The patient is intubated and hyperventilated. Question What is the next best step in the patient's management? Answer Choices 1 Administer intravenous lactated Ringer's solution 2 Administer phenytoin 3 Administer physostigmine 4 Administer sodium bicarbonate 5 Hemodialysis

Correct Answer: Administer sodium bicarbonate Show Explanation Explanation The correct response is to administer sodium bicarbonate. The patient has taken amitriptyline, which is a tricarboxylic acid antidepressant (TCA); her set of symptoms are consistent with TCA toxicity. The mechanisms of action of TCA are via anticholinergic effects, norepinephrine reuptake blockade, a quinidine effect, a sodium channel blocker, and peripheral alpha blockade. TCA cardiotoxicity may be demonstrated on an electrocardiogram via sinus tachycardia, QRS complex prolongation >100 milliseconds, right bundle branch block, ventricular tachycardia, ventricular fibrillation, and QT prolongation. Sodium bicarbonate is the drug of choice for the treatment of ventricular dysrhythmias and/or hypotension, secondary to tricarboxylic acid antidepressant (TCA) poisoning. Hyperventilation and hypertonic saline (i.e., lactated Ringer's) may also be useful, but clinical and experimental experience with these modalities is less extensive than with sodium bicarbonate. In patients with severe toxicity, bicarbonate needs to be given in order to achieve a serum pH of 7.50 - 7.55. Intermittent boluses of sodium bicarbonate are preferred to a constant infusion. Procainamide is not recommended due to similarity in action of TCAs as class 1A antiarrhythmics. Sodium bicarbonate works by alkalinization of blood, thereby promoting protein binding of drugs; this results in less of the toxic drug in circulation. It improves conduction through sodium channels, and treats acidosis that results from seizure activity. After treatment with sodium bicarbonate, peripheral maneuvers to improve the TCA-induced hypotension include placing the patient in the Trendelenburg position, administering intravenous fluids, administering pressor agents (e.g., norepinephrine) for the treatment of alpha-blockade-induced hypotension, and administering dopamine. Intermittent dosing of dopamine stimulates beta-receptors, allowing increases in cardiac output; higher dosing stimulates alpha-blockade. TCA-associated seizures should be aggressively treated in order to avoid cardiotoxicity resulting from acidosis. Benzodiazepines, phenobarbital, and intubation are the mainstay of treatment. In general, phenytoin is not efficacious for the treatment of toxic seizures. Physostigmine in a hemodynamically unstable patient is not the first-line drug; it may even be contraindicated. It should be considered if there are severe life-threatening anticholinergic effects. Hemodialysis and hemoperfusion are not effective in TCA poisoning because small amounts of free TCA are present in the serum (mostly bound to serum proteins); they are not recommended.

A 32-year-old man presents with a 4-year history of worsening hypersomnolence. The symptoms began in his teens, and he would often fall asleep in class. He states that he sometimes becomes extremely sleepy while driving and has come close to being in accidents on several occasions. He sleeps 6 to 7 hours a night, but he still feels sleepy during the day. The patient also admits to occasional hypnagogic hallucinations. Question What regarding the patient's condition is true? Answer Choices 1 Symptoms are similar in adults and in children 2 An MRI of the brain is the main diagnostic test for this condition 3 Antidepressants may be used in treatment of this condition 4 The condition is indistinguishable from idiopathic hypersomnia 5 Men are affected more often than women

Correct Answer: Antidepressants may be used in treatment of this condition Show Explanation Explanation The diagnosis in this patient is narcolepsy. Narcolepsy is characterized by daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis. It is a chronic sleep disorder caused by the brain's inability to regulate sleep-wake cycles normally. Antidepressant drugs, such as tricyclics and selective serotonin reuptake inhibitors, have proven effective in controlling cataplexy in many patients. There is no cure for narcolepsy. Modafinil is used for the treatment of symptoms. CNS stimulants, such as methylphenidate, dextroamphetamine sulfate, methamphetamine, and amphetamine, may be used. Patients should avoid alcohol and caffeine-containing beverages before bedtime. Narcolepsy is thought to result from genetic predisposition, abnormal neurotransmitter functioning and sensitivity, and abnormal immune modulation. Human leukocyte antigen subtypes and abnormalities in monoamine synaptic transmission are thought to be involved. The cause of narcolepsy remains unknown. Men and women are affected equally, and children as young as 2 years old may also be affected. The age of onset distribution is biphasic; the highest peak occurs at the age of 15, and a smaller peak occurring at around age 36. Symptoms in children may be variable and subtler than they are in adults. This often makes the age of diagnosis later. In idiopathic hypersomnia, features of cataplexy or megaphagia are absent. Sleep-onset REM episodes, the characteristic polysomnographic feature of narcolepsy, are also absent. It should be noted that patients with narcolepsy do not always present with cataplexy or a history of cataplexy. They will still have the hallmark symptoms, such as excessive daytime sleepiness, sleep-onset REM episodes, hypnagogic hallucinations, etc.

A 6-month-old healthy infant presents with an inability to sleep through the night. He has 3 - 4 nighttime awakenings, and his parents spend a long time getting him to go back to sleep. Both parents work and their sleep continues to remain disrupted, which affects their work performance the next day. Question What best describes the physiology of sleep in this patient? Answer Choices 1 The longest nighttime sleep period during the 1st 3 months is approximately 6 - 8 hours long and lengthens to 10 - 12 hours at 4 - 6 months of age 2 The 2 key sleep milestones in infancy are sleeping in a separate room and having dreams 3 The 3 distinct stages of non-REM sleep emerge by the end of the 1st year of life 4 Approximately 25% - 50% of 6 - 12-month-olds, and 30% of 1-year-olds, have problematic night waking 5 Infants develop the ability to consolidate sleep by 8 - 12 months of age

Correct Answer: Approximately 25% - 50% of 6 - 12-month-olds, and 30% of 1-year-olds, have problematic night waking Show Explanation Explanation The correct response is that approximately 25% - 50% of 6 - 12-month-olds, and 30% of 1-year-olds have problematic night waking. Both transient and chronic sleep problems are common in infancy. The longest nighttime sleep period during the 1st 3 months is approximately 3 - 4 hours long, and it lengthens to 6 - 8 hours at 4 - 6 months of age. The 2 key sleep milestones in infancy are sleep consolidation and sleep regulation. Sleep consolidation is defined as the ability to sleep for a continuous period of time (concentrated during the nocturnal period), which is supplemented in young children by shorter periods of diurnal sleep (naps). This is commonly referred to as sleeping through the night. The 3 distinct stages of non-REM sleep emerge by around 6 months of age. Infants develop the ability to consolidate sleep in the 1st 8 - 12 weeks of life; by 9 months of age, approximately 70% - 80% of infants will have achieved this milestone. Sleep regulation, or the ability of the infant to 'self-soothe', begins to develop in the 1st 3 months of life; it is defined as the ability to master the sleep-wake transition at sleep onset, as well as to return to sleep independently after normal night arousals/awakenings.

A 10-year-old boy is brought in by his mother for a camp physical. He has been fairly well; however, he occasionally feels short of breath with only light exertion. He has become more sedentary in his activities, spending most of his time indoors on the computer, watching TV, or playing video games. His appetite has increased, and it has been accompanied by progressive weight gain. His last physical was 4 years ago; his weight was at the 75th percentile. His weight today is 132 lb (60 kg), which is > 95th percentile, and his height is 57 inches (145 cm) at the 90th percentile. His BP is 105/60 mm Hg. On exam, he appears as a well-developed, moderately obese boy. Heart and lung exam are normal; his abdomen is large, protuberant, and without hepatosplenomegaly. His skin is normal. You review the patient's growth chart with him and his mother, and you express your concerns about his rapidly rising weight gain. His mom asks you what they should do. You discuss different management strategies. Question What may be the most important facet of his obesity treatment? Answer Choices 1 Exercise regimen 2 Dietary management 3 Behavioral intervention 4 Bariatric surgery 5 Anorectic agents

Correct Answer: Behavioral intervention Show Explanation Explanation Behavioral intervention is ideally provided through frequent group or individual treatment sessions, and it provides possibly the most important facet of obesity treatment. Better outcomes are produced by frequent monitoring and feedback. Treatment also needs to be long term due to the chronicity of the condition and frequent relapse. A good treatment program should screen for readiness to change and consist of controlling the environment, self-monitoring, and contracting for reasonable goals. High-risk foods need to be removed from the home environment. Shopping and cooking routines need to be developed toward the prescribed diet. The patient needs to be taught how to regulate behavior, and realistic and achievable goals should be set. The family needs to be involved in counseling and ongoing support. Referral for psychotherapy and possibly pharmacotherapy may be necessary. An exercise program should be put into place; its goals should be to assist in weight control via increasing caloric expenditure, resting metabolic rate, and lean muscle mass. However, exercise alone is rarely successful in achieving meaningful weight loss. Combined with diet, this can be a powerful tool to enhance well-being and self esteem. Aerobic activity often is recommended; sometimes, a 1-mile walk can be used as an initial benchmark of fitness, and the patient should gradually increase the distance of the walk and speed at which he is walking. Home aerobic activity may be prescribed; lifestyle exercise that attempts to build more exercise into regular activities may be easier to sustain long-term. Dietary management should not compromise a child's growth and development by excessively restrictive dieting. Weight maintenance over a period of time can change the body mass index of a growing child significantly. Eliminating snacking and reducing high-sugar/high-fat foods and drinks can result in some weight loss. Keeping a food journal is usually recommended because both children and families tend to underreport intake. This can provide insight into the source of additional calories. A popular diet is the traffic light diet; it categorizes food into 'green' foods that can be eaten in unlimited quantities because they are non-fat or low-fat foods, 'yellow' foods that should be eaten with more caution due to their fat content, and 'red' foods that should be eaten rarely because they are high in fat. This diet has shown long-term success when combined with both behavioral and exercise components. In cases where obesity is more than 100% of ideal body weight or life-threatening, bariatric surgery has emerged as an option. Both gastroplasty, which involves the formation of a 15 to 30 mL stomach pouch, and gastric bypass surgery, which bypasses the duodenum to deliver food directly to the jejunum, have gained popularity in adults. A plethora of complications were found in a small study, including renal disorders, gallstones, and nutritional deficiencies. Surgery for the pediatric population is not recommended by most experts. Drug intervention with anorectic agents is associated with significant adverse effects; it has shown limited benefit in adults, and it is not recommended for children.

A 70-year-old woman presents with a poor appetite and a history of depressive disorder with seasonal pattern. Every October or November, she has decreased appetite, decreased energy, and wants to sleep all of the time and hibernate. Question What drug is most likely to benefit this client? Answer Choices 1 Paroxetine 2 Fluoxetine 3 Sertraline 4 Bupropion 5 Amitriptyline

Correct Answer: Bupropion Show Explanation Explanation The FDA has approved bupropion (Wellbutrin) as the drug of choice for depressive disorder with seasonal pattern. The effectiveness of bupropion for the prevention of episodes was established in 3 double-blind, placebo-controlled trials in adults with a history of major depressive disorder in autumn and winter. Seasonal pattern is a specifier of depressive disorders, characterized by recurrent seasonal patterns of depressive episodes; its onset is most commonly in the fall or winter, and remission occurs in spring or summer. It usually begins in October or November and ends by February or March. Etiology of depressive disorder with seasonal pattern is unclear; it may be caused by an increase in the duration of secretion of melatonin (a hormone produced by the pineal gland) that normally occurs at night. Symptoms include lethargy, decreased interest in and withdrawal from usual activities, hypersomnia, and overeating (e.g., carbohydrate craving and weight gain). There is depression and anxiety along with fatigue, loss of libido, and decreased socialization Phototherapy is the most effective treatment for depressive disorder with seasonal pattern. Pharmacotherapy with antidepressants is also used for seasonal affective disorder. Bupropion is a noradrenaline and dopamine re-uptake inhibitor. It is beneficial in the prevention of recurrence of depressive disorder with seasonal pattern, in cases of decreased energy, pleasure, and interest, in major depression with concomitant anxiety, as well as in elderly depressed patients. The mechanism of action of bupropion (Wellbutrin) in SAD is not clear; it appears to be a dopamine re-uptake inhibitor and a weak serotonin and norepinephrine reuptake inhibitor. Dry mouth and insomnia are the common side effects. Because of its favorable side effect profile, bupropion is safe and effective in elderly depressed patients. Paroxetine hydrochloride is a selective serotonin reuptake inhibitor (SSRI). One of its side effects is sedation in elderly and it is the most sedating of the SSRIs. Because of its sedation, it is not preferred in SAD patients who are likely to have hypersomnia. Other side effects include low blood pressure, headaches, dizziness, insomnia, ear pain, or eye pain. Typical dosing in the elderly is 20-30 mg. Fluoxetine hydrochloride (Prozac) belongs to the class of SSRIs and causes fewer side effects than tricyclics, but it does have a long half-life. As in most antidepressant therapies, they take at least 2-4 weeks to reach a therapeutic level. Dosing is usually once daily and at a 10-20 mg level. Higher doses are not usually recommended in the elderly. Fluoxetine hydrochloride is known to cause agitation, nervousness, and insomnia in the elderly; it is not recommended in clients who have sleeping disturbances or are agitated. Sertraline is also an SSRI and is usually not a first choice of drug to use in treatment of depression in the older population. It usually has more side effects than Fluoxetine hydrochloride. Common side effects include nausea, anorexia, dry mouth, insomnia, and sexual dysfunction. This drug also begins with lower dosing and has a 4-week window period. Amitriptyline hydrochloride is a tricyclic antidepressant drug. Patients aged over 60 are highly susceptible to hazardous anticholinergic side effects of amitriptyline, such as dry mouth, blurred vision, constipation, urinary dysfunction, hypotension, tachycardia, and cognitive impairment. Therefore, it is not preferred in the elderly.

A 15-year-old boy presents with a diagnosis within the autism spectrum disorder. He is considered high-functioning: he attends a public school, goes to daily cognitive/behavioral sessions, and he attends weekly counseling sessions with a provider who specializes in treating adolescent patients with a diagnosis within the autism spectrum disorder. His mother has noted a significant increase in episodes of what she can only describe as temper tantrums; severe irritability and quickly changing moods are also present. These occurrences have become so severe that they have begun to disrupt the patient's daily activities. Question Of the following, what medication is used to treat irritability in children and adolescents with autism spectrum disorder? Answer Choices 1 Sertraline 2 Paroxetine 3 Atomoxetine 4 Clonidine 5 Risperidone

Correct Answer: Risperidone Show Explanation Explanation The correct response is risperidone. Adolescents classified as having a diagnosis within the autism spectrum disorder (ASD) will have varying degrees of impairment in their social and behavioral function. Family education, behavioral and educational interventions, and counseling have a significant place in this treatment plan; pharmacotherapy may be considered, but it should be used as adjunctive therapy. In 2006, the United States Food and Drug Administration (FDA) approved risperidone, an atypical antipsychotic (in the oral disintegrating tablet form), for the symptomatic treatment of irritability in both children and adolescents with autism spectrum disorder. This is considered the 1st FDA-approved drug treatment for behaviors specifically associated with ASD, and it has been used off-label for many years for these symptoms. Other symptoms that risperidone could be considered to help treat in patients with ASD include aggression and deliberate self-injury. When beginning any pharmacotherapy for these patients, having a 'start low and go slow' regimen is strongly recommended, with consistent follow-up visits for evaluation of alleviation of the symptoms. Selective serotonin reuptake inhibitor (SSRI) pharmacologic agents (e.g., sertraline or fluoxetine) are generally introduced to help alleviate anxiety symptoms. The patient in the above scenario is currently not experiencing or expressing any excessive anxiety. Although paroxetine is a type of SSRI that is used to treat patients with depression, obsessive-compulsive disorder, anxiety disorder, post-traumatic stress disorder, or premenstrual dysphoric disorder, it is currently not a recommended first-line treatment option for symptomatic behavior in ASD patients. Patients who express symptoms consistent with hyperactivity and inattention should be treated with methylphenidate, atomoxetine, or clonidine; this is not consistent with the symptoms described in this patient.

A 32-year-old woman with a history of a schizoaffective disorder presents with an increase in auditory hallucinations and suicidal ideation. A psychiatrist is consulted; he assesses the patient and makes a recommendation for a 72-hour admission. After reviewing the patient's current medications and past therapeutic trials, the patient is started on clozapine. Question Due to the risk of toxicity with this medication, what lab test must be monitored in this patient? Answer Choices 1 Liver function tests (AST, ALT) 2 Renal function tests (BUN, creatinine) 3 Coagulation studies (PT/INR, aPTT) 4 Complete blood count (CBC) with absolute neutrophil count (ANC) 5 Fasting blood sugar

Correct Answer: Complete blood count (CBC) with absolute neutrophil count (ANC) Show Explanation Explanation Clozapine (Clozaril®) is a second-generation antipsychotic medication indicated for the management of treatment-resistant schizophrenia and for reducing the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder. Due to the risk of agranulocytosis (low white blood cell [WBC] count, specifically neutrophils), patients taking clozapine must have a baseline CBC and ANC before initiation of treatment and a WBC count and ANC every week for the first 6 months. If counts have been acceptable up to this point, the frequency of blood draws can be reduced.

A 6-year-old girl presents with hematuria. Review of the child's prior medical records reveals approximately 20 visits to 8 different emergency departments and clinics over the past year for the same complaint. Thorough urologic evaluations have been negative, except for the occasional and inconsistent finding of elevated red blood cells on urinalysis without casts. The child is admitted to the general pediatric ward. Physical examination is negative except for mild erythema of the urethral meatus. Initial laboratory evaluation, including a serum BUN of 8 mg/dl, serum creatinine of 1.0 mg/dl, serum total protein of 7.1 mg/dl, and serum albumin of 4.3 mg/dl, is normal. Urinalysis performed on a sample brought to hospital by the girl's mother is positive for blood. This sample is grossly bloody. However, samples subsequently obtained in hospital under nursing supervision are negative. Renal ultrasonography is normal. The child's mother appears quite cheerful and is rather conversant with medical terms concerning renal disease, such as glomerulonephritis and gross hematuria. She is happy to suggest additional diagnostic tests. Question What is the most appropriate next step in the evaluation of this child? Answer Choices 1 Consultation with child protective services 2 Hematology consultation to rule out coagulopathy 3 Intravenous pyelography 4 Surreptitious video monitoring of the child's room 5 Urology consultation

Correct Answer: Consultation with child protective services Show Explanation Explanation Multiple negative evaluations, inconsistent positive findings, the use of multiple health care facilities, and inappropriate maternal affect should suggest a condition fabricated by a caregiver. Once called "Munchhausen syndrome by proxy," this scenario can be taken to dangerous lengths, sometimes causing multiple invasive and unnecessary surgeries and diagnostic procedures. It is considered a form of child abuse; therefore, the situation warrants the involvement of child protective services. The absence of conclusive evidence of hematuria, as well as the lack of historical or physical findings of bleeding elsewhere, renders a coagulopathy unlikely. The lack of conclusive evidence of hematuria and evidence of normal renal function do not support performing intravenous pyelography. While video monitoring may gather evidence of the mother's manipulating urine specimens or of injuring the child, the physician should not be cast in the primary role of detective in this situation. Such efforts should be coordinated by child protective services. Again, the absence of any real evidence of renal or genitourinary pathology argues against a urology consultation as the next step.

A 42-year-old man is found unconscious in his apartment. A friend states that the patient is in treatment for depression, but he does not know what kind of medicine his friend is taking. Physical examination reveals that the patient has a BP of 90/58, pulse of 100/min (irregular), and respiratory rate of 12/min. The patient is lethargic and has dry skin, mydriasis, irregular cardiac rhythm at auscultation, superficial respiration, absent bowel sounds, urinary retention, decreased motor power in his extremities, and absent tendon reflexes. Question What is the most likely diagnosis? Answer Choices 1 Lithium toxicity 2 Cyclic antidepressant overdose 3 Cerebrovascular accident 4 Acute psychosis 5 Cocaine overdose

Correct Answer: Cyclic antidepressant overdose Show Explanation Explanation The patient above presents clinical manifestations of cyclic antidepressant overdose; his antecedent of treatment for depression helps to make the diagnosis. Cyclic antidepressants are the leading cause of death by intentional overdose of a prescription medication. Most cyclic antidepressants have an anticholinergic effect which is characterized by xerostomia, dry skin, blurred vision, mydriasis, urinary retention, and delirium. Agitation and myoclonic jerks are also common findings. In severe poisonings, hypotension, seizures, respiratory depression, and cardiac dysrhythmias are classic findings. In advanced poisonings, findings include adult respiratory distress syndrome (ARDS), rhabdomyolysis, and disseminated intravascular coagulation (DIC). In lithium toxicity, the CNS signs are the most common, especially tremors, fasciculations, movement disorders, and a Parkinsonian-like syndrome. Cerebrovascular accident and acute psychosis are not probable diagnoses in this patient. Patients with cocaine overdose may be euphoric, anxious, paranoid, and agitated; they may experience chest pain, hypertension, and cardiac dysrhythmias.

A 36-year-old man with a history of diabetes and obesity presents with weakness and flu-like symptoms. His girlfriend reports that he had taken several caffeine pills the day before, but he denies a suicide attempt. During evaluation at the hospital, he experiences vomiting and seizures. A laboratory work-up is within normal limits. He is admitted to the hospital and improves over the course of his 3-day admission. He is subsequently released with no lingering effects. Question What is the most common treatment for this patient after hospital discharge? Answer Choices 1 Anti-anxiety medication 2Decrease caffeine intake 3 Steroids 4 Levothyroxine 5 Antidepressant medication

Correct Answer: Decrease caffeine intake Explanation This patient is demonstrating symptoms of caffeine intoxication caused by the consumption of large amounts of caffeine. Symptoms of caffeine intoxication can include insomnia, nervousness, restlessness, tachycardia, diuresis, and agitation. Caffeine is not considered to be a drug by many people; therefore, they do not consider excessive consumption to be a problem. Many food and drinks contain caffeine, and people consume them unaware that it is present. It becomes easy to ingest large quantities without realizing it. When caffeine is ingested, it enters the bloodstream and can lead to an increase in the secretion of norepinephrine in the brain. This causes an increase in activity in neurons. It binds to adenosine receptors and can block the sedative effect that adenosine can produce. As a result, people become more alert and feel less tired. Anti-anxiety medications are not appropriate since the patient is not suffering from anxiety. They are not used to treat caffeine intoxication. Steroids would not be used in treating a patient with caffeine intoxication. Levothyroxine would be used in a patient with hypothyroidism, which this patient does not have. The patient's laboratory results were within normal limits. Antidepressant medications would not be helpful, since the underlying disease is not depression.

A 10-year-old boy has a history of problems at school and at home. Teachers report he rarely can focus on one task for longer than a few minutes, and describe his behavior as chaotic. His mother states that he never gets tired of running, talking, and playing around the house; she usually has to repeat instructions over and over because he seems to not listen. She also reports that he failed at school and is now repeating the 4th grade. A psychostimulant, an indirect-acting adrenergic receptor agonist that centrally releases dopamine (DA), serotonin (5-HT), and norepinephrine (NE) to the synaptic cleft, is prescribed. Question What drug is most likely the medication prescribed for this patient? Answer Choices 1 Dextroamphetamine 2 Imipramine 3 Selegeline 4 Atomoxetine 5 Fluoxetine

Correct Answer: Dextroamphetamine This patient has classical symptoms of attention deficit hyperactivity disorder (ADHD); dextroamphetamine is most likely the drug prescribed. Dextroamphetamine is a dextrorotary stereoisomer of amphetamine; it releases stored dopamine (DA), norepinephrine (NE), and serotonin (5-HT) from the presynaptic neuron, increasing their level at the synaptic cleft. Dextroamphetamine, together with methylphenidate, are the mainstay stimulant drugs used for the treatment of ADHD. The most common side effects of these stimulant medications are insomnia, appetite suppression, weight loss, stomach upset, and headache. Growth suppression in children is a concern, but decreases in expected height early in treatment are usually compensated for later in life. Other physical adverse effects of stimulants include tachycardia, pupil dilation, blurred vision, dry mouth, difficulty urinating, constipation (anticholinergic effects), cardiac arrhythmia, Raynaud's phenomenon (reduced blood flow to extremities), nausea, sweating, dizziness, and reduced seizure threshold. Psychological adverse events include mood swings (lethargy, irritability), akathisia (restlessness), repetitive or obsessive behaviors, and changes to the libido. Stimulants above the recommended dose level are associated with substance abuse and psychosis. Imipramine, a tricyclic antidepressant (TCA), is also considered an indirect-acting adrenergic receptor agonist, but it has a slightly different mechanism of action than dextroamphetamine. Imipramine inhibits reuptake of 5-HT and NE into the presynaptic neuron, increasing their concentrations in the synaptic cleft. Imipramine is not indicated for ADHD. This TCA is indicated for patients with narcolepsy that present with cataplexy (sudden weakness and collapse after a laugh). It is also used for childhood nocturnal enuresis (2nd after desmopressin acetate). Anticholinergic effects (see above) are among the common side effects; serious side effects include orthostatic hypotension, high blood pressure, arrhythmia, heart attack, stroke, seizures, and hepatitis. Selegeline is a selective monoamine oxidase B (MAO-B) inhibitor that metabolizes dopamine over NE and 5-HT, thereby increasing the availability of dopamine in the CNS. Amphetamine and methamphetamine are active metabolites of selegeline. Selegeline is not indicated for ADHD; it is an adjunct treatment of L-dopa for Parkinson's disease and may enhance the adverse effects of L-dopa (as arrhythmias from increased peripheral formation of catecholamines). Atomoxetine is a non-stimulant NE reuptake inhibitor used for the treatment of ADHD. There has been some suggestions that atomoxetine might be a helpful adjunct in major depression, especially when associated with ADHD. Atomoxetine has side effects in common with dextroamphetamine and methylphenidate (stimulant ADHD drugs) including nausea, dry mouth, insomnia, and headache. Fluoxetine is the prototype of the selective serotonin reuptake inhibitor (SSRI) drug class and specifically inhibits 5-HT receptors; fluoxetine is not indicated for ADHD. This SSRI is mainly used for depression and has several other indications (e.g., bulimia nervosa, obsessive compulsive disorder, panic disorder, and premenstrual dysphoric disorder). Adverse effects are sexual dysfunction, agitation, anxiety, gastrointestinal symptoms (nausea, vomiting, and diarrhea), sedation, and seizures (with overdose).

A 6-year-old boy's parents are concerned about their son's behavior. There have been complaints from his teachers that he is frequently fidgeting and disruptive in class. His parents state that he is extremely active at home and requires frequent disciplining. After a complete history and physical exam, your suspected diagnosis is Attention Deficit Hyperactivity Disorder (ADHD). Question In addition to behavioral therapy, what drug should be considered as first-line therapy for the management of this disorder? Answer Choices 1 Pemoline 2 Dextroamphetamine 3 Imipramine 4 Diazepam 5 Clonidine

Correct Answer: Dextroamphetamine Show Explanation Explanation The 2011 AAP guidelines for the treatment of a school-going child (6-11 years of age), include prescribing US Food and Drug Administration-approved medications for ADHD and/or evidence-based parent and/or teacher-administered behavior therapy as treatment. Particularly strong evidence exists for the use of stimulant medications. Dextroamphetamine and methylphenidate are commonly used. Although these agents are stimulants, in patients with ADHD, they paradoxically improve attention and reduce symptoms of hyperactivity. Less strong, however sufficient evidence, exists for atomoxetine, extended-release guanfacine, and extended-release clonidine (in that order).

A 35-year-old woman, with no significant past medical history, presents with a feeling of constant worry for the past year. She states that she is anxious about numerous elements in her life (e.g., constant deadlines at her job, obligations to her family, financial constraints, repairs to her car, and the health of her 2 young children). She denies any cigarette, alcohol, or drug use. She also reports fatigue, restlessness, and muscle tightness, especially around her neck. She denies any chest pain, shortness of breath, palpitations, cough, edema, diaphoresis, or changes in weight, diet, or caffeine intake. Her physical exam reveals cervical myospasms. Otherwise, she has normal vital signs, a nontender and nonenlarged thyroid gland, a normal skin exam, and a normal cardiovascular exam. Question What medication is expected to induce the most rapid clinical response in this patient? Answer Choices 1 Escitalopram 2 Oxazepam 3 Lithium 4 Buspirone 5 Diazepam

Correct Answer: Diazepam Show Explanation Explanation This patient demonstrates manifestations consistent with generalized anxiety disorder (GAD). A combination of pharmacologic and psychotherapeutic interventions is most effective in GAD. Diazepam is a benzodiazepine that is lipid-soluble, is absorbed rapidly, and has a rapid onset of action. Certain SSRIs (e.g., escitalopram) are effective, but typically only after being taken for at least a few weeks. Unlike diazepam, oxazepam is a benzodiazepine that has a slow onset of action. Buspirone is also effective; however, it can take at least 2 weeks before it begins to help. Lithium is the mainstay of treatment in bipolar disorder, and as prophylaxis in recurrent mania and depression. The therapeutic effects of lithium may not appear until 7 - 10 days of treatment.

A 60-year-old woman presents to be evaluated for bizarre behavior. Her daughter arrives with her and speaks with you alone; she describes her mother's behavior as consisting of mood swings, lavish trips, spending foolishly, staying up at night, and being hyper. According to her daughter, her mother has been diagnosed with bipolar disorder in the past. She feels her mother needs a mood stabilizer; however, you would rather not try lithium because of excessive weight gain. Question What drug might you consider? Answer Choices 1 Risperidone (Risperdal) 2 Haloperidol (Haldol) 3 Divalproex (Depakote) 4 Trazodone (Desyrel) 5 Trifluoperazine (Stelazine)

Correct Answer: Divalproex (Depakote) Divalproex (Depakote) is a preferred or suggested drug as a mood stabilizer; it has also been used to treat aggressive behavior in patients with Alzheimer's disease. It has been shown to be more favorable than using lithium, especially in nursing homes, because lithium can cause excessive weight gain; however, it should not be used in the elderly who already have poor liver functioning. Risperidone (Risperdal) is actually a drug better used in treating non-psychotic dementia and managing psychotic episodes of schizophrenia and other disorders in the elderly. It often is used in nursing homes for patients with dementia, but it should be used with caution because it is a high potency drug with effects of agitation, fatal cardiac arrhythmia, low blood pressure, electrolyte imbalances, infections, and central nervous system effects. Trifluoperazine (Stelazine) is an acceptable form of treatment for a number of disorders (e.g., psychosis, depressive disorders, alcohol withdrawal, nausea, and dementia); it is sometimes used to treat Huntington's disease. It is usually not suggested as a mood stabilizer, and there is the potential for many side effects. Trazodone (Desyrel) is used as an antidepressant, but it has actually been shown to be a better drug for insomnia treatment in the elderly; it has been used to treat aggressive behaviors in the elderly who have Alzheimer's disease. It is usually very effective in nursing homes. Haloperidol (Haldol) is a suggested treatment for acute episodes of agitation and aggressive behavior in the elderly who have dementia. It is also used for paranoid episodes and psychotic episodes, but it does have a lot of potential side effects such as memory loss, agitation, cardiac arrhythmias, dangerously low blood pressure, and pseudo-Parkinson like symptoms.

A 7-year-old boy presents for an evaluation of a 6-month history of behavioral problems in school; the evaluation was recommended by his teacher. Although the boy tests at grade level, he seems to make careless mistakes on schoolwork, has trouble paying attention to instructions, does not finish homework, and often loses his homework, pencils, and books. The boy is often seen fidgeting at his desk; he blurts out answers and has difficulty awaiting his turn. The parents agree that they have seen similar traits at home (e.g., forgetting to do daily activities and easy distractibility) for several years. They view him as a happy, bright boy who is very active; he has had normal vision and hearing screenings. The father reports that he was very similar to his son when he was a child, and still struggles with focus and concentration as an adult; the father never received any help. The parents deny any major changes in the family situation. They would like medical help to improve their son's performance in school. The boy has been seen regularly for his well-child exams and has always met milestones. Today, he quickly moves about the exam room looking at a book for a few moments, then to the window, then interrupting his parents. Question What has been identified as the primary neurotransmitter responsible for this child's likely disorder? Answer Choices 1 Acetylcholine 2 Dopamine 3 Gamma-aminobutyric acid (GABA) 4 Glutamate 5 Histamine

Correct Answer: Dopamine Show Explanation Explanation This child meets the criteria for attention deficit hyperactivity disorder (ADHD), a disorder most associated with dopamine abnormality. Medications such as methylphenidate, a central nervous system stimulant, are considered a first-line therapy for ADHD; the drugs work by regulating dopamine and norepinephrine levels. Acetylcholine was the 1st neurotransmitter to be discovered. It has several roles in central and peripheral neurologic actions and within the parasympathetic system. It is not directly linked to ADHD. Gamma-aminobutyric acid (GABA), an amino acid, plays a major inhibitory role as a neurotransmitter. Some anticonvulsants are thought to work through the GABA receptors. GABA has some links to schizophrenia and panic disorder but is not currently thought to have a major role in ADHD. Glutamate, derived from glutamine or aspartate, is the major excitatory neurotransmitter in the central nervous system. Much attention has been focused on N-methyl-d-aspartate (NMDA), a glutamate receptor. Overstimulation of NMDA receptors is thought to lead to excitotoxicity of the cells and play a role in neurodegenerative disorders (e.g., Alzheimer's and Huntington's diseases). Glutamate is not directly linked to ADHD. Histamine is commonly associated with its role in immune/inflammatory responses and gastric acid secretion; however, it is also a neurotransmitter associated with stimulated wakefulness, suppressed appetite, and enhanced cognition. It is not associated with ADHD.

A 19-year-old man with a family history of schizophrenia is receiving medical attention for his 1st presentation of psychosis. After ruling out organic causes and substance abuse as etiologies of his symptomatology, antipsychotic therapy with haloperidol is initiated. Within 48 hours, the patient begins to experience involuntary spasmodic contractions of the muscles in his face and neck. Question Inhibition of what neurotransmitter/receptor is causing the patient's symptoms? Answer Choices 1 Histamine 1 (H1) 2 Serotonin (5-HT2A) 3 Dopamine (D2) 4 Muscarinic cholinergic (M1) 5 Alpha-adrenergic (α-1)

Correct Answer: Dopamine (D2) Show Explanation Explanation Typical antipsychotic drugs (e.g., haloperidol) are often used in the acute management of psychosis in schizophrenia as well as other psychotic disorders. These medications are direct dopamine D2-receptor antagonists, occupying receptors in each of the dopamine pathways, including the mesolimbic, mesocortical, nigrostriatal, and tuberoinfundibular tracts. Blockage of the mesolimbic tractis crucial to the efficacy of antipsychotic therapy because excessive dopamine transmission here is believed to cause the positive symptoms of schizophrenia (hallucinations, delusions, agitation, and disorganized behavior/speech). However, blockage of the other dopaminergic tracts can lead to unwanted side effects, including cognitive dysfunction (mesocortical tract), hyperprolactinemia (tuberoinfundibular tract), and extrapyramidal symptoms (nigrostriatal tract). Extrapyramidal symptoms (EPS) are usually dose-dependent, and they are divided into acute and delayed effects. The early effects include a Parkinson-like syndrome (bradykinesia, rigidity, and tremor), akathisia (restlessness and psychomotor agitation), and dyskinesias (intermittent spasmodic or sustained involuntary contractions of muscles in the face, neck, trunk, pelvis, and extremities).Thesedystonic reactions can occur within 48 hours of the initiation of neuroleptic drug therapy. While these symptoms are rarely life threatening, they are very uncomfortable and often produce significant anxiety and distress for patients. Delayed EPS are tardive dyskinesia (choreoathetoid movements of the muscles of the lips and buccal cavity) and tardive dystonia (late onset involuntary muscle contractions). Typical antipsychotic medications also have variable affinities for other neurotransmitter receptors, including histamine, muscarinic cholinergic, and alpha-1-adrenergic receptors, further adding to the side effect profile of these medications. • Antagonism of histamine 1 (H1) results in sedation and weight gain. • Muscarinic receptor blockade can cause common anticholinergic side effects such as blurred vision, dry mouth, urinary retention, constipation, and decreased cognition. • Inhibition of alpha-1 adrenergic receptors can lead to sedation, orthostatic hypotension, and reflex tachycardia. Serotonin (5-HT) receptors are targeted primarily in the treatment of depression. However, recent interest in the role of serotonin (5-HT) in antipsychotic drug action is based mainly upon the fact that atypical newer antipsychotic drugs are potent 5-HT2A receptor antagonists and relatively weaker dopamine D2 antagonists. These agents share in common low extrapyramidal side effects at clinically effective doses and possibly greater efficacy to reduce negative symptoms. As a class, they also have a superior effect on cognitive function and greater ability to treat mood symptoms in both patients with schizophrenia or affective disorders than typical antipsychotic drugs.

An 89-year-old man presents with pneumonia. You suspect lung cancer, which would require surgery and possibly chemotherapy. Upon hearing the news regarding his diagnosis, the patient becomes tearful and sad. He confides his thoughts of suicide. You notice the patient seems confused at times; he does not know the place or people who surround him. When the patient is asked to sign the informed consent for scheduled thoracotomy, he vehemently refuses any and all treatments of his condition, stating he is going to die anyway. What should you do? Answer Choices 1 Respect the patient's decision to receive no further treatment of his lung cancer, since the patient is clearly competent to make decisions about his medical care. 2 Disregard the patient's stated wishes and proceed with surgery because the patient is demonstrating impaired judgment (as evidenced by his suicidality). 3 Request psychiatric consultation; only psychiatrists are capable of verifying decision-making capacity in depressed patients. 4 Evaluate the patient for the presence of depression and delirium, as both of these conditions may impair judgment and decision-making capacity. 5 Refuse to treat the patient due to patient's lack of cooperation and refer him to a colleague.

Correct Answer: Evaluate the patient for the presence of depression and delirium, as both of these conditions may impair judgment and decision-making capacity. Show Explanation Explanation When considering a patient's right to refuse or ability to consent to treatment, several issues must be addressed. One needs to consider the competence, or the decision-making capacity, of the patient in question. Other considerations include the emergent nature of the condition, informed consent, and the ethical principles guiding current practice of medicine. First, in assessing a patient's refusal of treatment, the physician must ascertain whether the patient is capable, both mentally and psychologically, of making that decision. Conditions that are known to temporarily or permanently cloud a person's ability to make decisions must be evaluated and treated, with the emphasis being on restoration of the patient's competence. The factors necessary to consider in competency evaluations are the patient's understanding of the nature of his or her illness and the proposed treatment, the side effects of the treatment, the availability of alternative treatments, and the ramifications of no treatment. A decision based on a thorough understanding of these issues is referred to as informed consent. Pervasive depressed mood, clouding of consciousness, and states of intoxication and withdrawal from drugs and alcohol all may affect a patient's capacity to make decisions. Therefore, conditions that can be treated or reversed must be eliminated prior to obtaining informed consent. In the case of the 89-year-old mathematician, suicidal thinking may point toward the diagnosis of depression, and confusion might indicate delirium. Both conditions have to be treated prior to further assessment of his decision-making capacity. The ethical principle guiding the current practice of medicine is based on autonomy theory. Based on the writings of Immanuel Kant, autonomy theory postulates that the relationship between the physician and the patient is that of 2 responsible parties. This presumes responsibilities and obligations on the part of both people. Thus, a normal adult patient is deemed capable of making responsible decisions concerning his or her life and health, even if the decisions contradict the physician's recommendations based on consideration of the patient's best interest. Paternalism can be defined as performing actions for others' benefit without requiring their consent. Paternalism in medicine is currently an acceptable practice only if the patient is incapable of making decisions due to mental illness, psychological distress, or cognitive impairment. In that case, the physician is obligated to seek other sources who would be familiar with the patient's belief system and be able to tell what the patient would have wanted if he or she were able to make decisions. Only in cases of life-threatening emergencies, unavailability of family members, or uncertainty on the part of the doctor about the motivations of family members, is the physician allowed to make decisions for the patient. The physician must keep the patient's best interests in mind. The utilitarian principle demands maximizing the benefit to the greatest number of people in making decisions. It operates in medicine in the mandatory reporting of a number of communicable diseases and in quarantines. When an adult is deemed competent to make medical decisions, no other considerations, such as age, family wishes, or benefit to society, are relevant in his or her refusing or consenting to treatment. If the physician perceives that actions requested by a patient contradict the physician's own ethical code, the physician has the right to refer the patient to someone who would feel comfortable providing services in accordance with the wishes of the patient. This is commonly the case in requests for elective abortion.

A 32-year-old woman presents for follow-up after being seen in the emergency department 2 days prior; her mother brought her in after she witnessed the patient having a seizure. While in the ED, the patient was observed having another seizure; she appeared to be shaking with nonparallel movement of her right and left arms, and she remained conscious throughout the episode. EEG monitoring was negative for any seizure-like activity. The patient was also seen in the ED 3 months ago following a sexual assault. The patient notes poor sleep and difficulty motivating herself to complete her daily activities. On examination, the patient appears tearful. Neurological examination is normal. Question Of the following, what is the most appropriate medication for this patient? Answer Choices 1 Levetiracetam 2 Lamotrigine 3 Lorazepam 4 Fluoxetine 5 Oxycodone

Correct Answer: Fluoxetine Show Explanation Explanation The correct response is fluoxetine. The patient's history describes seizures, but the episode observed in the ER is not consistent with a seizure; the lack of synchronous movement and absence of EEG findings shows that this patient is not having seizure-like activity. This, paired with her recent history of sexual assault, is suggestive of conversion disorder. Conversion disorder is a somatoform disorder in which psychological stress is converted into physical symptoms. The recommended treatment is therapy; if medications are used, antidepressants or antianxiety medications are recommended. The patient appears to be exhibiting signs of depression; fluoxetine would be an appropriate choice. The patient should undergo therapy with close follow-up, in addition to taking fluoxetine. Levetiracetam and lamotrigine are anticonvulsant medications. The patient does not exhibit any clinical signs of actual seizure activity, and the use of levetiracetam or lamotrigine would be inappropriate. Lorazepam has many uses, including antiepileptic and sedative effects. This patient is not suffering from seizures; furthermore, sedative medications are often overused in patients with somatoform disorders. Its use should be avoided. Oxycodone is incorrect. The patient is not currently complaining of pain, so oxycodone should not be prescribed. Patients with somatoform disorders are at higher risk of drug dependence and abuse due to the potentially long duration of their condition. Addictive medications should be avoided in this population.

A 23-year-old woman presents to her psychiatrist's office for a follow up regarding her 2-year history of bulimia nervosa. Until this time, she has been undergoing cognitive behavioral therapy (CBT) several times per week. She has shown great improvement, but she would like to consider additional measures to control her disorder. Question What medication would be an appropriate adjunctive treatment for the patient's bulimia nervosa while she continues to undergo CBT? Answer Choices 1 Fluoxetine (Prozac) 60 mg daily 2 Diazepam (Valium) 2 mg twice daily 3 Carbamazepine (Tegretol) 200 mg twice daily 4 Donepezil (Aricept) 5 mg daily 5 Methylphenidate HCl (Concerta) 18 mg daily

Correct Answer: Fluoxetine (Prozac) 60 mg daily Show Explanation Explanation The correct answer is fluoxetine (Prozac) 60 mg daily. While CBT is considered to be the first-line treatment for bulimia nervosa, antidepressant medications have been shown to be helpful. The antidepressant medications can reduce binging and purging regardless of whether the patient also has a concurrent mood disorder. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that is commonly used to treat major depressive disorder, depressive episodes in patients with bipolar disorder, and bulimia nervosa. The initial dose is usually 20 mg daily, but the dose usually needs to be titrated up to 60-80 mg daily in order to effectively decrease binge eating. Other antidepressants used in the treatment of bulimia nervosa are effective at the same dosages that they are used to treat depressive disorders and do not require the increased titration that fluoxetine does. Diazepam (Valium) 2 mg twice daily is not the correct answer, as this medication is used to treat anxiety and not bulimia nervosa. Diazepam is a benzodiazepine that is typically given as 2-10mg 2-4 times daily in order to treat adults with anxiety disorders. Carbamazepine (Tegretol) 200 mg twice daily is not the correct answer. Carbamazepine is a dibenzazepine used in the treatment of generalized tonic-clonic, partial, or mixed seizures; it is not used for the treatment of bulimia nervosa. Donepezil (Aricept) 5 mg daily is not the correct answer. Donepezil is a reversible acetylcholinesterase inhibitor that is used to treat Alzheimer's dementia, and it is not used to treat bulimia nervosa. Methylphenidate HCl (Concerta) 18 mg daily is not the correct answer. Methylphenidate is a stimulant used in the treatment of adults and children with attention deficit hyperactivity disorder, and it is used not in the treatment of bulimia nervosa.

A 25-year-old woman presents with inability to achieve intercourse with her partner since their relationship began 6 months prior. She states that she cannot even insert a tampon due to the pain. Further history reveals that a year ago, her partner at that time forcefully made her have intercourse on several occasions. What is the next step in the workup of this patient to confirm the suspected diagnosis? Answer Choices 1 Referral to psychiatrist 2 Laboratory workup to expose the underlying medical condition 3 Transvaginal ultrasound 4 Gynecologic examination 5 Transabdominal ultrasound

Correct Answer: Gynecologic examination Show Explanation Explanation This patient is presenting with Genito-Pelvic Pain/Penetration Disorder, also known as vaginismus. The characteristics of Genito-Pelvic Pain/Penetration Disorder is continuing or repeated problems with any of the following: penetration vaginally during intercourse, significant pelvic or vulvovaginal pain during attempts at penetration or vaginal intercourse, anxiety or fear in anticipation of, during, or as a result of vaginal penetration that causes pelvic or vulvovaginal pain, or significant tensing of the muscles of the pelvic muscles when vaginal penetration is being attempted. To confirm diagnosis, a gynecologic exam must be performed to identify possible physical causative factors or any associated conditions. The exam is also useful to confirm the diagnosis; involuntary spasm of the muscles around the vagina will be palpable during the exam. Laboratory workup and ultrasound will show nothing definitive to confirm the diagnosis of Genito-Pelvic Pain/Penetration Disorder.

An 86-year-old woman living in a long-term care facility tells you that she is taking 8 different medications. On examination, you note that her lips pucker, her tongue twists around in her mouth and exits her mouth constantly, and she grimaces spontaneously. Question What medication is most likely to cause these involuntary movements? Answer Choices 1 Haloperidol 2 Lorazepam 3 Nortriptyline 4 Fluoxetine 5 Hydrochlorothiazide

Correct Answer: Haloperidol Show Explanation Explanation The patient is demonstrating tardive dyskinesia, which is a side effect of neuroleptics such as haloperidol. Haloperidol is a neuroleptic medication that is typically used to treat psychoses, agitation, and occasionally hyperactivity. Tardive dyskinesia may or may not cease once medication has been withdrawn. The other medications listed are not neuroleptics and do not cause tardive dyskinesia as frequently as neuroleptics.

A 16-year-old girl is belligerent and has slurred speech; she had brandished a knife in her kitchen and threatened to go find her ex-boyfriend. A neurological examination reveals difficulty with hand coordination, decreased deep tendon reflexes, and an ataxic gait. There are also several beats of horizontal nystagmus and a tremor in both of her upper extremities. The girl's stepmother states that the patient was in a rehab center last year while living with her mother, but she does not know any details about the admission. Question Based on this information, what is the most likely diagnosis? Answer Choices 1 Opioid intoxication 2 Phencyclidine intoxication 3 Sedative, hypnotic, or anxiolytic intoxication 4 Cocaine intoxication 5 Inhalant intoxication

Correct Answer: Inhalant intoxication Show Explanation Explanation Inhalant intoxication is characterized by behavioral changes that include apathy, assaultiveness, and impaired judgment. Physiological changes include nystagmus, slurred speech, psychomotor retardation, and movement abnormalities (e.g., incoordination, depressed reflexes, ataxic gait, and tremor). Mood presentation can range from euphoria to stupor. Opioid intoxication is characterized by behavioral changes that include euphoria followed by apathy, shortened attention span and memory dysfunction, psychomotor agitation or retardation, and poor judgment. Physiological changes that may present include slurred speech, drowsiness, and pupillary constriction. Phencyclidine intoxication is characterized by disinhibition, aggressive behavior, anxiety, panic, rage, and impaired judgment. Physiological changes can include hyperthermia, elevated blood pressure, tachycardia, hyperacusis, nystagmus, diminished pain responsiveness, dysarthria, and seizures. Sedative, hypnotic, or anxiolytic intoxication is characterized by disinhibition, mood lability, and impaired judgment. Physiological symptoms may include slurred speech, poor coordination, nystagmus, impaired memory, and coma. Cocaine intoxication is characterized by behavioral changes that include euphoria, hypervigilance, paranoia, interpersonal sensitivity, anxiety, and poor judgment. There are also possible physiological changes that include pupillary dilation, tachycardia or bradycardia, elevated or lowered blood pressure, psychomotor agitation, cardiac arrhythmias, seizures, and diaphoresis.

A 7-year-old boy presents for evaluation of behavior problems in school; the problems have been occurring for over 6 months. The boy's teacher recommended he be evaluated. She reports that he tests at grade level, but he seems to make careless mistakes on schoolwork and has trouble maintaining attention to instruction; he does not finish his homework, and he often loses his homework, pencils, and books. The boy is seen often fidgeting at his desk; he blurts out answers and has difficulty waiting his turn. The parents tell you that they have seen similar traits at home, such as forgetting to do daily activities; for the past several years, he has been easily distracted. They view him as a happy, bright boy, and they report that he is very active. He has had normal vision and hearing screenings. The father reports that he was very similar as a child and still struggles with focus and concentration as an adult, but he has never received any help. The parents deny any major changes in the family situation. They would like medical help to improve their son's performance in school. The boy has been seen regularly for his well-child exams, and he has always met milestones and had normal exams. Today, he is quickly moving about the exam room; he looks at a book for a few moments, and then he looks out the window for a short time before interrupting his parents. Question What is the most appropriate intervention in this case? Answer Choices 1 Advise the parents to hold the child back 1 year in school 2 Contact child protective services for suspected abuse 3 Initiate medication 4 Order head magnetic resonance imaging (MRI) 5 Referral for counseling

Correct Answer: Initiate medication Show Explanation Explanation This child meets criteria for attention deficit hyperactivity disorder (ADHD), and it would be most appropriate to initiate medication at this time. If the diagnostic criteria are met with no concerning presentation for other disorders, treatment can begin immediately. The treatment of choice is prescription stimulant medications. ADHD is often seen (diagnosed or undiagnosed) in the family history. Often, young children may be less mature than their peers and could benefit from being held back a year in school; however, the patient is testing at the appropriate grade level. If he repeats the year in school, this intervention will do nothing to address the root problem of ADHD. It is likely that he would continue having the same problems with inattentiveness and hyperactivity. A behavior change in a child could indicate some type of abuse or stressful situation for the child; however, nothing in this child's history is indicative of child abuse. The behavioral problems have been present for longer than 6 months; they have been seen at home and at school, and nothing in his history or physical suggests abuse. Contacting child protective services is not appropriate at this time. ADHD is a clinical diagnosis. It is primarily based upon patient history; neither imaging nor blood tests are routinely recommended. This boy's history and exam do not demonstrate any neurologic deficits suggestive of a brain tumor or other anatomic defect. Therefore, MRI is not recommended. A counseling referral would be reasonable if the child had a history suggestive of anxiety, depression, or psychosocial stressors. However, counseling has very little-to-no role in the treatment of ADHD, especially in grade-school-aged children. Other forms of psychosocial intervention, such as parent training and classroom interventions, are recommended for children with ADHD.

An 8-year-old boy presents for evaluation of problems at school and at home. His parents report that he does not pay attention in class; he is frequently in trouble for disrupting the class, and he often forgets to do his schoolwork. He has had similar problems since starting school (in kindergarten), but they are becoming more problematic; his teacher suggested medical evaluation. The teacher reports the patient often seems distracted. He rarely sits still at his desk; he fidgets often, and when he does pay attention to the class discussions, he blurts out comments without waiting his turn. His parents report that the boy has always been 'on the go' and talks excessively; he does not seem to listen when spoken to. He seems capable of doing his schoolwork, but he appears to make careless mistakes. The parents feel the boy is generally well-adjusted; he enjoys sports, has friends, and sleeps well. The parents deny any known medical history, and his prenatal course and delivery were unremarkable. He has never had any surgeries; he takes no medications and does not have any allergies. He lives at home with his biological parents and a younger sister. On physical exam, the boy appears normally developed. Some increased motor activity is noted, but the physical exam is otherwise normal. Question What is the best intervention for this patient's condition? Answer Choices 1 Change patient's diet to eliminate all refined sugars 2 Initiate short-acting benzodiazepines 3 Initiate stimulant medication 4 Order electroencephalogram 5 Refer for biofeedback

Correct Answer: Initiate stimulant medication Show Explanation Explanation This patient is presenting with attention deficit hyperactivity disorder (ADHD). Patients with ADHD may have inattentive, hyperactive, and/or impulsive behaviors. To meet the criteria for ADHD, some symptoms must have been present by age 7 years. When the diagnosis is clear and parents are agreeable, the first-line treatment for ADHD is to initiate stimulant medication. These medications come in short and long-acting formulations, and they have shown the best efficacy for ADHD. This patient's symptoms are not attributable to dietary factors; elimination diets are not recommended for patients with ADHD. It would not be necessary to change this patient's diet to eliminate all refined sugars. Sometimes, anxiety symptoms can mimic ADHD symptoms; however, it would be inappropriate to initiate short-acting benzodiazepines, both because of this patient's age and his lack of anxiety symptoms. While benzodiazepines would likely 'slow down' this patient due to their sedation effects, they are risky to use in a pediatric population; there is no support for their use in cases of ADHD. Absence (or petit mal) seizures are characterized by brief (5 - 30 seconds) episodes of staring and then a rapid return to normal, with the affected individual unaware of his/her seizure. This patient's inattention could possibly be attributed to such seizures, but the hyperactivity and impulsivity are not explained by absence seizures. It is unnecessary to order an electroencephalogram. Some forms of psychotherapy are useful for ADHD, especially if there are associated behavior problems; however, it would not be helpful to refer this patient for biofeedback, a relaxation/stress-reduction technique that allows the patient to control his or her body through mental exercises. Biofeedback may be difficult to master for young children, and it has not been shown to be particularly useful for ADHD.

A 25-year-old woman presents after collapsing at work. She has a medical history significant for a mood disorder that causes her to have wild mood swings and reckless behavior. She was diagnosed with this disorder 1 year ago; since then, she has been taking her prescribed medication. Her symptoms consist of nausea, vomiting, fatigue, tremor, and hyperreflexia. Lab results show an elevation in BUN and creatinine and elevated serum drug levels, but the results are otherwise normal. Question What drug is most likely responsible for her symptoms? Answer Choices 1 Carbamazepine 2 Lithium 3 Lorazepam 4 Valproic acid 5 Risperidone

Correct Answer: Lithium Show Explanation Explanation Lithium is usually the first-line treatment for mood stabilization; however, it does have side effects that can be quite serious (e.g., polyuria, tremors, seizures, and coma). Other less common side effects include rashes, drowsiness, blurred vision, diarrhea, polyuria, polydipsia, and a metallic taste. Lithium toxicity can result in movement disorders, seizures, and even coma. Lithium should not be used in patients with poor renal function, hypersensitivity to the drug, or cardiovascular disease. In this patient, her elevated BUN and creatinine point to an underlying renal disease that caused her lithium level to become elevated. Carbamazepine is known to cause aplastic anemia and agranulocytosis; therefore, patients must be monitored during treatment. Lorazepam may cause agitation, ataxia, slurred speech, nystagmus, and an altered mental status. Valproic acid may cause confusion, headache, cerebral edema, hallucinations, and irritability. Risperidone may cause an oculogyric crisis, neuroleptic malignant syndrome, and autonomic instability (often manifested as an elevation in core body temperature).

A 7-year-old boy presents with his parents for evaluation of behavior problems in school; the problems have been ongoing for over 6 months. The boy's teacher recommended he be evaluated. She reports that he tests at grade level, but he seems to make careless mistakes on schoolwork and has trouble maintaining attention to instruction; he does not finish his homework, and he often loses his homework, pencils, and books. The boy is seen often fidgeting at his desk; he blurts out answers and has difficulty waiting his turn. The parents agree that they have seen similar traits at home, such as forgetting to do daily activities and being easily distracted, for several years. They view him as a happy, bright boy who is very active. He has had normal vision and hearing screenings. The father reports that he was very similar as a child and still struggles with focus and concentration as an adult, but he never received any help. The parents deny any major changes in the family situation. They would like medical help to improve their son's performance in school. The boy has been seen regularly for his well-child exams and has always met milestones and had normal exams. Today, he is quickly moving about the exam room; he looks at a book for a few moments, and he then looks to the window for a short while before interrupting his parents. Question Assuming the parents agree to medication for their son, what medication is the most appropriate initial treatment? Answer Choices 1 Amitriptyline 2 Bupropion 3 Clonazepam 4 Methylphenidate 5 Sertraline

Correct Answer: Methylphenidate Show Explanation Explanation This child meets criteria for attention deficit hyperactivity disorder (ADHD), and it would be most appropriate to start methylphenidate, a central nervous system stimulant. This medication is considered a first-line therapy for ADHD; it works by regulating dopamine and norepinephrine levels. Amitriptyline is a tricyclic antidepressant (TCA). Sometimes, TCA's are used off-label for ADHD, but they are used after other first-line therapies have failed or if there are comorbidities. However, due to the side effect profile and lower efficacy for ADHD symptoms, amitriptyline is not recommended at this time for this patient. Bupropion is an antidepressant; it also regulates dopamine and norepinephrine levels. It is used off-label for adult ADHD, but it is not indicated for use in children under the age of 18. It would not be a first-line treatment for this child. Clonazepam is a benzodiazepine medication; it is approved for seizure disorders in children. It functions as a sedative and can be used for panic disorder and associated anxiety problems in adults. It may seem useful to 'calm down' this patient's hyperactivity, but the first-line stimulant (methylphenidate) will accomplish this. Clonazepam is inappropriate for a 7-year-old with ADHD. Sertraline is an antidepressant approved for use in children with obsessive-compulsive disorder. It has no role in treating ADHD. If the child's symptoms were thought to be anxiety-related with some obsessive traits, sertraline may be considered.

A 58-year-old woman presents for a follow-up; she is accompanied by her adult daughter. The patient had gone to the emergency department via ambulance after the daughter discovered her mother, confused and shaking, at home. The patient underwent several days of inpatient treatment for substance withdrawal. Her initial symptoms included hallucinations, tremor, nausea, anxiety, insomnia, and a seizure. The patient denies current symptoms. The patient and daughter both note the patient has increased tolerance to greater amounts of her substance and loss of control; the patient has a frequent need for the substance. Her work and home relationships suffer due to her condition. The patient has no other medical conditions, is menopausal, has had no surgeries, takes no medications, and has no allergies. The patient readily admits abuse and dependence on her substance of choice, with a desire to prevent relapse. She has not used any other substances, and has been abstinent of all substance use since hospital discharge. She is currently in individual and group programs to assist her in relapse prevention. She would like pharmacological help to maintain her sobriety. Question What medication is most appropriate in preventing this patient from returning to her likely substance of abuse? Answer Choices 1 Diazepam (Valium) 2 Methadone (Methadose/Dolophine) 3 Naloxone (Narcan) 4 Naltrexone (ReVia/Vivitrol) 5 Varenicline (Chantix)

Correct Answer: Naltrexone (ReVia/Vivitrol) Show Explanation Explanation The acute episode described by the patient and her daughter is consistent with delirium tremens, a serious and possibly fatal condition resulting from alcohol withdrawal. Symptoms include seizures, tremor, nausea, anxiety, visual and auditory hallucinations, confusion, and diminished orientation. Delirium tremens can progress to coma and death if not recognized and treated. Alcohol dependence is common, and many patients diminish and hide their alcohol consumption. Acute intervention includes supportive treatment of symptoms and benzodiazepines. In order to maintain abstinence, psychosocial support is vital. In addition, 2 medications, naltrexone (ReVia/Vivitrol) and acamprosate (Campral), are approved for maintenance treatment of alcohol dependency. Diazepam (Valium) is a benzodiazepine and is often indicated for acute alcohol withdrawal; it is not appropriate for use in preventing relapse in alcoholics. As a controlled substance with abuse potential, it would be risky to prescribe diazepam to this patient. Methadone (Methadose/Dolophine) is a long-acting opioid. It is used for pain treatment and acute detox and maintenance treatment of opioid addiction; this patient's history does not suggest opioid addiction. Acute intoxication symptoms may include sedation, euphoria, pinpoint pupils, unconsciousness, and withdrawal symptoms (e.g., nausea, vomiting, dilated pupils, abdominal cramps, and insomnia). Naloxone (Narcan) is an opioid antagonist used for opioid overdose and reversal. This patient's presentation does not suggest dependence or abuse of opiates. Varenicline (Chantix) affects nicotinic acetylcholine receptors and is approved for smoking cessation. This patient's presentation does not indicate tobacco dependence.

A world famous trial attorney, who defends cases that you feel strongly against, recently discovers that he has Hodgkin's Lymphoma. The attorney seeks advice and treatment from you. You have never established a patient-physician relationship with this individual in the past. Based on your personal beliefs, you refuse to treat the patient. Question Have you violated an ethical code of conduct with your actions? Answer Choices 1No, because a physician can refuse to treat and care for a patient under any circumstances. 2 Yes, because physicians must treat patients who are ill and in need of assistance, regardless of their personal or political beliefs. 3 Yes, because to not treat a patient in this scenario would be to violate the patient-physician relationship. 4 No, because any physician can refuse to treat any patient unless the patient-physician relationship has been established. 5Yes, because it is the legal right of the patient to receive treatment by any physician they wish. 6 No, because the physician dictates care under the patient-physician relationship and can choose not to treat a patient or terminate a clinical relationship without cause.

Correct Answer: No, because any physician can refuse to treat any patient unless the patient-physician relationship has been established. Show Explanation Explanation The American Medical Association Code of Ethics states that physicians are free to choose whom they serve but they have an obligation to support continuity of care for their patients. Thus, once the patient-physician relationship has been established, physicians should not neglect their patients. In the case above, since the patient-physician relationship had not been established, the physician has a right to choose not to see or treat the patient.

A 3-month-old boy presents with a 12-hour history of lethargy. Physical exam reveals a child who cries and becomes irritable when examined. There is edema noted over the left side of the head. There is no papilledema, and his mother denies a history of the child vomiting. There is a single faint bruise on the upper lip. A CT of the head reveals a linear skull fracture of the left parietal bone; there is no evidence of intracranial injury. On further questioning, the mother states, "My baby rolled over the sofa onto a carpeted floor 2 days ago." Question What is the best management in this case? Answer Choices 1 Give 80cc of 0.9% normal saline (i.e 20mL/Kg) 2 Give intravenous mannitol to lower intracranial pressure 3 Discharge the child after a 4 hour observation period if the infant is asymptomatic 4 Discharge the child immediately with instructions about precautions following head injury 5 Obtain a skeletal survey to rule out child abuse

Correct Answer: Obtain a skeletal survey to rule out child abuse Show Explanation Explanation Child abuse frequently is unrecognized and unreported, and non-accidental injuries cause 1000's of childhood deaths per year. The possibility of abuse should be considered in any child who presents with a serious injury. Therefore, a skeletal survey should be obtained in this case. A detailed history is the crucial initial step in differentiating accidental from intentional injury. An incomplete or changing history, a history of injury not appropriate for the developmental age of a child, or a history that is incompatible with the type of severity of the injury also are suggestive of the abuse. Linear skull fractures may occur when a child falls onto a hard surface. Rolling off a sofa or a bed, as was reported for this child, is usually associated with only minor injuries, such as abrasions or soft tissue injuries. Also, when a parent seeks medical care for a child who has sustained an accidental head injury, he or she usually volunteers a clear history concerning recent trauma or injury immediately. Failure to give any history for a head injury until confronted with obvious evidence of trauma (e.g., hematoma, skull fracture) is highly suggestive of either neglect or non-accidental trauma. Signs and symptoms of head trauma and central nervous system injury in young children are non-specific and include vomiting, lethargy, seizure activity, and irritability. More serious signs are a rise in intracranial pressure present with a significantly altered level of consciousness, apnea or other respiratory abnormality, hemodynamic instability, or shock. The triad of vomiting, headache, and papilledema, called the Cushing triad, is considered classic of raised intracranial pressure. Findings on physical examination include soft-tissues swelling or lacerations of the scalp, bony step-offs, a bulging fontanelle, split sutures, or pupillary abnormalities. An infant who is the victim of suspected non-accidental trauma should never be discharged to the care providers without a full evaluation for other injuries and further investigations of all of the circumstances surrounding the injury. Bruises over the face in younger children and over the shin, elbow, or forearm in older children should raise suspicion. Skeletal surveys are indicated for all infants who are suspected victims of abuse to document the presence of recent or healed fractures. CT is the most appropriate investigation to evaluate whenever there are signs or symptoms of head trauma. In the absence of findings consistent with increased intracranial pressure, intravenous mannitol is not indicated. Intravenous fluids should be administered judiciously, and fluid boluses are contraindicated in the absence of shock.

A 25-year-old woman has a 2-month history of panic attacks that occur more than 3 times a week. After a thorough history and examination of the patient, she is diagnosed with a panic disorder. What is the first-line drug used in the pharmacological management of a panic disorder, in association with psychotherapy? Answer Choices 1 Alprazolam 2 Clonazepam 3 Paroxetine 4 Imipramine 5 Clomipramine

Correct Answer: Paroxetine Explanation The correct response is paroxetine. Panic attacks frequently start in the late teenage years or early adulthood. These attacks can be very distressing and debilitating, with feelings of derealization and depersonalization occurring. Other common symptoms are dizziness, nausea, other gastrointestinal discomfort, and a feeling of choking or imminent death. The goal of treatment is to reduce the intensity of these attacks and to decrease the frequency of their occurrence. Selective serotonin reuptake inhibitors (SSRIs) are the first-line agents for the treatment of a panic disorder since SSRIs are better tolerated than other drugs. The SSRIs that are used in the treatment of panic disorder include paroxetine, fluoxetine, fluvoxamine, sertraline, and citalopram. The mechanism of action of SSRIs is the selective inhibition of presynaptic reuptake (reabsorption) of serotonin. As a result, more serotonin is available in the brain; this enhances the neurotransmission and improves mood. Paroxetine is administered in a dose of 10 - 40 mg daily. Adverse effects include agitation, restlessness, nausea, diarrhea, headache, nervousness, diaphoresis, and weight gain. Alprazolam and clonazepam belong to the benzodiazepine class; they are also used in the treatment of panic disorders. They are used as adjuncts to SSRIs in the initial treatment. Clonazepam is the benzodiazepine of choice; alprazolam use has been discouraged because of a higher potential of dependency. Tricyclic antidepressants (TCAs) (e.g., imipramine and clomipramine) are the second-line drugs for panic disorders. Some severe adverse effects (e.g., cardiotoxicity and autonomic disturbances) may occur. Patients taking TCAs may also experience weight gain, constipation, headache, photosensitivity, blurred vision, and urinary retention.

A 31-year-old woman presents with recurrent episodes of palpitations, tachycardia, dyspnea, and impending dread that began shortly after the birth of her first child. Question Based on her most likely diagnosis, what is best for the sustained treatment of her condition? Answer Choices 1 Lorazepam 2 Hydroxyzine 3 Buspirone 4 Phenobarbital 5 Paroxetine

Correct Answer: Paroxetine Show Explanation Explanation Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment options for chronic, sustained treatment of panic disorder. Some SSRIs like paroxetine (Paxil) can be used in conjunction with a benzodiazepine, such as lorazepam or clonazepam, for short periods of time for acute panic attacks. Hydroxyzine is used primarily as an antihistamine and can be used for sleep. Buspirone is an anxiolytic used for anxiety. Phenobarbital is a barbiturate used to control seizures as well as anxiety.

A 29-year-old man presents with bouts of severe depression; the depression is accompanied by suicidal thoughts. Although he is well-educated, he has been unable to get a job that fits his training because of his illegal status in this country. He has been doing odd jobs, and he has barely been making a living. His relationship with his girlfriend has become stormy over the last few months, and he confesses that he wants to kill his girlfriend. You believe his intent to kill his girlfriend to be serious and suspect that the underlying cause of his fury and homicidality, is untreated depression. For his own safety, you recommend admitting himself to a psychiatric hospital for further evaluation and treatment. He vehemently refuses. Under these circumstances, considering your professional obligations, what should you do? Answer Choices 1 Having thoroughly explained to the patient the risks and benefits involved in his decision, and having deemed him to be a competent adult, leave the decision regarding hospitalization up to him. 2Call the girlfriend and other friends and relatives in the hope of influencing the patient to change his mind and consent to hospitalization. 3 Proceed with the procedure for involuntary hospitalization. 4 Call the police to have patient arrested. 5 Call a responsible adult who can assure the safety of patient and his girlfriend.

Correct Answer: Proceed with the procedure for involuntary hospitalization. Show Explanation Explanation The relationship between the physician and the patient is protected by the concept of confidentiality or privileged information. No information shared with the physician may be released to another party without the explicit and written consent of the patient. This includes release of medical information to other physicians and health care facilities. The right of the patient to confidentiality is protected by law. It is both illegal and unethical to notify the authorities of the patient's illegal status. The doctor's sole task in this case is to evaluate and treat the patient. The exception to this rule concerns information released to the physician that may threaten the life of the patient or others. Under these circumstances, the physician is required to assure safety of the patient in the case of suicidal plans and to notify the victim and the police in the case of homicidal plan. This is generally known as the Tarasoff rule, which was named after a case in California in 1976 in which a therapist was found guilty for failure to inform the victim of a planned homicide. The physician has the responsibility to proceed with emergency detention of a clearly dangerous patient. In the presence of mental illness, the patient is to be detained in the hospital with the intention of providing treatment for the condition that led to the threat to self or others. If the patient refuses to admit himself to the hospital, the physician, in most states, is given jurisdiction to hospitalize the patient against his will for 48 hours. This allows the judicial process to be initiated so that further treatment can take place.

A 16-year-old girl presents with a 4-hour history of loss of consciousness. Her older sister states that the patient has been depressed and was found with an empty medication bottle containing what she can only describe as prophylaxis for tuberculosis. The patient has now begun having generalized tonic-clonic seizures. Examination reveals a developed teenage girl responsive only to painful stimuli; there are intermittent tonic-clonic movements of the extremities. Question Besides the general care of an unconscious patient with seizures, what should be given as a specific antidote in this case? Answer Choices 1 Atropine 2 Diphenylhydantoin 3 Methylene blue 4 Pyridoxine 5 Vitamin K

Correct Answer: Pyridoxine Show Explanation Explanation Isoniazid (INH) is an antibiotic commonly used for tuberculosis prophylaxis. It binds to pyridoxal-5-phosphate, the active form of pyridoxine, which is a cofactor in GABA synthesis. An overdose of INH can result in decreased GABA levels, causing cerebral excitability and seizures. Seizures in acute INH overdose are frequently refractory to standard anticonvulsants. Pyridoxine (Vitamin B6), administered on a gram for gram basis with the amount of INH ingested, is usually needed for seizure control. Atropine is used for ingestion of agents with cholinergic activity, such as organophosphate pesticides. Diphenylhydantoin is not a specific antidote to isoniazid, and, in fact, isoniazid decreases diphenylhydantoin metabolism, placing such a patient at risk for phenytoin toxicity as well. Methylene blue is used to treat methemoglobinemia. Vitamin K is used to treat Coumadin toxicity.

A 9-year-old boy presents with episodes of severe impulsivity, lack of attention, poor listening skills and organization, as well as obsessive and compulsive characteristics that have been evident to both his mother and teachers. He has had mild evidence of these signs since he was in kindergarten, but they have become substantially worse in the last few years. The patient is diagnosed with attention deficit hyperactivity disorder (ADHD) and is started on atomoxetine. Common side effects are described to the patient and his mother. Question What side effect most likely warrants the need to investigate an alternative treatment plan? Answer Choices 1 Weight loss 2 Abdominal pain 3 Racing heart 4 Nausea 5 Headache

Correct Answer: Racing heart Show Explanation Explanation The correct response is racing heart. Pediatric and adolescents patients with diagnosed ADHD may be started on the prescription atomoxetine to help alleviate the symptoms. This diagnosis must always be primarily approached as a comprehensive treatment plan; other measures such as psychological, education, and social interventions must be taken along with the medication approach. In general, atomoxetine can be an alternative for treatment of ADHD. The pharmacokinetics of atomoxetine in children and adolescents are similar to those in adults, but overall use of atomoxetine in children younger than 6 years old has not been investigated. After considering the clinical need and the potential risks, initiation of atomoxetine can begin. Common side effects reported with use of this medication seen in clinical trials includes abdominal pain, vomiting, nausea, fatigue, irritability, weight loss, headache, and dizziness. Significant side effects that the prescriber health care provider should be notified about immediately include a clinically significant blood pressure increase, terminal insomnia, flushing, mydriasis, sinus tachycardia, mood swings, and dyspepsia. A black box warning that all patients and parents must be educated about is the possibility of suicidal ideations.

A 35-year-old woman is reluctant to try an antidepressant for fear of becoming a drug addict. How should the physician respond? Answer Choices 1 Respect her scruples and treat her with psychotherapy alone 2 Give her the medication and refer her to a 12-step program 3 Reassure her that antidepressants are not drugs of abuse because of oral administration, lack of immediate reward, and lack of tendency to cause tolerance 4 Prescribe lower than recommended doses to avoid inducing a "high", explain to the patient she will not become addicted as long as she stops the drug after a few weeks 5 Tapering to avoid withdrawal symptoms

Correct Answer: Reassure her that antidepressants are not drugs of abuse because of oral administration, lack of immediate reward, and lack of tendency to cause tolerance Show Explanation Explanation You should reassure the patient that antidepressants are not drugs of abuse because of oral administration, lack of immediate reward, and lack of tendency to cause tolerance. Drugs can be screened in animals for abuse potential. Abusable drugs are rewarding (animals will self-administer them in preference to eating/drinking) and tend to induce both tolerance and withdrawal. The more rapid the onset of the sought for changes, the more likely the drug will be abused. Rapidity of onset is related to the particular drug taken and to the mode of administration. Drugs that are injected or inhaled are especially quick in action. Inhalation, in particular, bypasses first pass metabolism in the liver. Therefore, IV use of heroin or snorting of cocaine (especially highly concentrated forms known as crack) quickly leads to abuse. Conversely, patients may be reassured that most prescribed medications, even psychotropics (except benzodiazepines), are not abusable drugs and patients do not become addicted to them. Giving lower doses of antidepressants or prescribing them for a few weeks would be incorrect, since the onset of action is delayed up to 3 or 4 weeks, and the drugs should be continued for at least 4 months. (Short courses followed by tapering would be correct for a benzodiazepine). Antidepressants, especially cyclic antidepressants, may precipitate a withdrawal syndrome if stopped abruptly, but this alone does not make them abusable.

A 16-year-old boy is brought in by his mother. According to her, he mistakenly cut his wrist with a kitchen knife. She states that he has been a good student until recently, has never taken drugs, and does not drink alcohol. He has never been under psychiatric care or had counseling. She is sure that this was an accident. You examine the patient alone; he presents with 2 superficial lacerations on the left wrist. The boy is right-handed. No suturing is necessary, so you clean the wounds and update his tetanus status. While talking to him, you ascertain that his schoolwork has dropped 2 grade levels; he tells you that he is not sleeping and not eating well. Recently, he has taken to drinking alcohol he stole from his parents' liquor cabinet, and last week he started thinking he "wanted it all to end". An on-call psychiatrist is contacted and will be there in about 1 hour. You tell the mother that you are concerned about her son's mental status and you want him to see a psychiatrist in about an hour. She wants to take her son home, and she appears anxious. Question What action should you take? Answer Choices 1 Have the mother sign an AMA (Against Medical Advice) form and take her son home 2 Agree to release the patient if the mother agrees to take him to a psychiatrist within 24 hours 3 Arrange for the patient's transfer to a psychiatric hospital 4 Refuse to release the patient until he is evaluated by the psychiatrist 5 Tell the mother to get her husband and you will release her son to both parents

Correct Answer: Refuse to release the patient until he is evaluated by the psychiatrist Show Explanation Explanation The correct response is to refuse to release the patient until he is evaluated by the psychiatrist. The 1st patient advocate is the physician. In that role, he/she must do no harm and always act to protect the patient; nowhere else is this more evident than in the case of minors. Laws vary from state to state. There are instances in which the adolescent's level of maturity plays a significant role in his legal rights and his ability to give or deny consent, even when a parent is present; however, in the case of suicide or possible suicide, the physician must act in the best interests of the patient, even to the point of denying the parents' requests or demands. Laws have been changing regarding adolescent rights as far as consent is concerned, and much more responsibility is now given to the patient. The statistics regarding suicide methods and age and sex differentiation is voluminous. In this case, it was rightly decided that this young man attempted suicide, and a psychiatric evaluation is necessary prior to disposition. The most important aspect of this case is the refusal to capitulate to the parent.

A 16-year-old, slightly overweight girl presents because she wants to lose weight. She has learned from the internet that diet pills called amphetamine salts (Adderall) are available to lose weight. She wants to know if these are safe to take. She is told to avoid them because they can become habit-forming and their effectiveness is short-lived. Question Which of the following correctly describes the mechanism of action of this drug? Answer Choices 1 Releases dopamine and norepinephrine stores 2 Enhances effect of GABA 3 Interferes with sodium and potassium transport 4 Blocks the effect of serotonin 5 Blocks binding of acetylcholine to nicotinic receptors

Correct Answer: Releases dopamine and norepinephrine stores Show Explanation Explanation Amphetamines act by causing the release of stores of dopamine and norepinephrine from the nerve endings; this is achieved by converting the respective transporters into open channels. Reuptake is also inhibited, so that large amounts of the neurotransmitters are present at the synaptic cleft; this, in turn, enhances neuronal transmission. Serotonin is also released from synaptic vesicles. Amphetamines (alpha-methyl-phenethylamine) are drugs mainly used for the treatment of attention deficit disorder (ADD); they are homologues of phenethylamine. The medical drug is a racemic mixture of equal amounts of "dextro" and "levo" forms. Dextroamphetamine, levoamphetamine, and methamphetamine are together called amphetamines. The physiological effects seen are decreased appetite, increased energy, and a state of arousal. Increased serotonin is said to have a role in their hallucinogenic and anorexic effects, psychosis, and aggressive behavior. Amphetamines are used to treat ADD and narcolepsy. Due to the potential side effects and risk of addiction, they are no longer the preferred method for weight reduction in the United States. These drugs carry several side effects, the most well-known (acute) being cardiac irregularities and gastric disturbances. Chronic use can cause insomnia, hyperactivity, and aggression. Amphetamine-induced psychosis and development of tolerance are other problems associated with long-term use. Tolerance develops rapidly, which results in patients seeking a dosage increase. Abusers take more of the drug during withdrawal, setting up a vicious cycle. Illegal use of the drug is rampant due to the euphoric effects. Enhanced effect of GABA at its receptor is seen with barbiturates, not amphetamines. Amphetamines do not interfere with sodium or potassium transport. They cause serotonin release at synaptic vesicles and do not affect the binding of acetylcholine to nicotinic receptors.

A 28-year-old woman begs to make the voices in her head stop arguing. She is very soft-spoken, polite, and well-groomed. She explains that she often becomes confused and finds herself in unfamiliar places. She believes that 1 of the voices might be trying to kill her. She has a history of alcohol abuse, but no drug abuse. She has an extensive medical history of unexplained injuries, stomach problems, and unusual bruising beginning in early childhood. The woman denies being physically or sexually abused as a child, but states that she has weird nightmares about a strange dark figure standing over the bed of a small child; she does not recognize the child or the man. The following week the patient's behavior is very different; she is speaking loudly, acts as if she never has seen you before, refuses to answer most questions, and is very uncooperative. According to the post-traumatic model, what is the most likely etiologic cause for this client's symptoms? Answer Choices 1 Severe child abuse 2 Genetics 3 Witnessing a traumatic event 4 The therapist planting dissociative suggestions 5 High score on hypnotizability scales

Correct Answer: Severe child abuse Show Explanation Explanation This patient's symptoms are consistent with dissociative identity disorder. Common symptoms of dissociative identity disorder are auditory hallucinations that come from within (as opposed to outside of the head), losing time (being unaware of how one ends up places), confusion, dramatic changes in personality, a history of somatic complaints, and nightmares. These patients almost always have a history of severe abuse, and although this patient does not recall abuse, her nightmares and medical history are consistent with abuse. There are 2 main theories for the etiology of dissociative identity disorder: the iatrogenic model and the post-traumatic model. The iatrogenic model basically states that DID does not actually exist, but it is often created by therapists and others of influence in the person's life. These influential people suggest dissociative symptoms to vulnerable individuals, and the symptoms are then reinforced through the use of hypnosis and role-playing. According to the post-traumatic model of dissociation, some people are genetically predisposed to express post-traumatic stress disorder in the form of dissociation. This model supports the contention that separate personalities are created as a defensive response to severe childhood trauma.

A 2-year-old boy presents because of his mother's concerns about his sleep. She notes that he is easy to put to sleep, and he has a regular bedtime of 7:30 P.M. Most nights for the past 3 weeks, about 90 minutes after being put to sleep, he begins to thrash violently in the bed; at times, he lets out blood-curdling screams. He has his eyes open and seems to be talking, but he does not respond to either parent when spoken to. He sweats a lot. The episodes last about 15 minutes, and he then goes back to sleep; he seems fine in the morning. He naps for about an hour in the morning and an hour in the afternoon, but these episodes do not occur with naps. Question What is the most likely diagnosis? Answer Choices 1 Confusional arousal 2 Nightmares 3 Sleep terrors 4 Sleep association disorder 5 Sleep-wake transition disorder

Correct Answer: Sleep terrors Show Explanation Explanation Sleep terrors occur between 18 months and 6 years of age in about 3% of children; they are not indicative of a mental health problem. Stress, a full bladder, or loud noises may be precipitating factors. They occur more frequently in boys and also when there is a positive family history. They may occur for a few weeks, disappear for months, and then recur. The underlying cause is disordered arousal from stage III or IV sleep which occurs 60 - 90 minutes after going to sleep. Confusional arousals also occur about 60 - 100 minutes after going to sleep. The child may be sleeping very deeply so that as he/she transitions from stage IV to rapid eye movement (REM) sleep there may be thrashing and moaning that lasts between 5 - 15 minutes. The child may appear to be awake; he or she might have open eyes and seem confused or upset. The episodes are difficult to interrupt, and children do not respond to parental consoling. They may occur multiple times, but tend to decrease in intensity if they extend into the 2nd half of the night. They occur more commonly when the child's schedule has been altered, the child is overly tired, or the child is upset or ill. Nightmares, or scary dreams, occur during REM sleep and are more common early in the morning when REM sleep occurs more frequently. Unlike night terrors, the child is easily arousable and comforted when having a nightmare. They are most common between 3 and 6 years, which is when children develop their imaginations and do not easily distinguish fantasy from reality; however, children do dream at an earlier age. About 7% of children who have nightmares have a positive family history. It is more common in children with an intellectual disability (intellectual developmental disorder), depression, and certain CNS disorders. Sleep association disorders are the most common reason infants wake within the first 30 minutes of going to sleep. This is a situation in which an infant has an association with going to sleep, such as nursing or having a parent lie down in the bed. If the child wakes and does not have the association present, then the child does not have the skills to go back to sleep alone. Sleep-wake transition disorder, a type of circadian rhythm sleep disorder, is described by a disrupted sleep pattern that is persistent or recurrent. This leads to excessive sleepiness or insomnia; it is mostly due to a change in the body's circadian system or a misalignment between the rhythm and the person's schedule.

A 7-year-old boy presents because he is fidgety, impulsive, and unable to sit still. The patient is observed running around; there is no evidence of any hallucinations or delusions. The mother notes that the child speaks excessively and loudly, makes simple arithmetic errors, and has short-term memory deficiencies. He finds it difficult to wait in lines or wait his turn in games or group situations. Question What is correct regarding this patient's condition? Answer Choices 1 Serological lab tests are confirmatory for the illness 2 Stimulant medications are considered first-line pharmacologic therapy 3 The onset must be over 13 years of age to qualify the suspected diagnosis 4 This disorder is more common in female patients and resolves completely in adulthood 5 Thought content disturbances and a heightened suicide risk are expected

Correct Answer: Stimulant medications are considered first-line pharmacologic therapy Show Explanation Explanation This patient is demonstrating manifestations of attention deficit hyperactivity disorder (ADHD). Stimulants (e.g., methylphenidate, dextroamphetamine) are first-line therapy and probably the most effective treatment. For related areas of functioning such as social skills and academic performance, medications combined with behavioral treatments may be indicated. The diagnosis of ADHD is based on clinical evaluation. No laboratory-based medical tests areavailable to confirm the diagnosis. ADHD is a developmental disorder that requires an onset of symptoms before age 7 years. In children, ADHD is 3 - 5 times more common in boys than in girls; some studies report an incidence ratio of as high as 5:1. The predominantly inattentive type of ADHD is found more commonly in girls than in boys. After childhood, symptoms may persist into adolescence and adulthood, or they may ameliorate or disappear. The percentages in each group are not well established, but at least an estimated 15 - 20% of children with ADHD maintain the full diagnosis into adulthood. As many as 65% of these children will have ADHD or some residual symptoms of ADHD as adults. Thought content should be normal, with no evidence of suicidal, homicidal, or psychotic symptoms.

A 25-year-old man is referred to you for evaluation. He has no previous history of psychiatric disturbance, and there is no family history of psychiatric illness. During the evaluation, he states that he has seen people following him; additionally, he has been having difficulty concentrating. He believes that he is in danger and that the people following him are FBI agents. When asked about the onset of the symptoms, the patient states that they began about a month ago, and they have persisted ever since. The patient is not currently taking any psychiatric drugs, but he has been taking antihistamines to treat allergies for about 1 month. Question What is the mostly likely diagnosis? Answer Choices 1 Schizophrenia 2 Schizoaffective disorder 3 Schizophreniform disorder 4 Brief psychotic disorder 5 Substance/medication-induced psychotic disorder

Correct Answer: Substance/medication-induced psychotic disorder Show Explanation Explanation The most probable cause of the patient's symptoms is substance/medication-induced psychotic disorder. The patient's symptoms had a sudden onset approximately 1 month ago, which is when the patient began taking antihistamines. Visual hallucinations with an absence of auditory hallucinations are commonly associated with substance-induced psychotic disorders, but they are rare in other psychotic disorders. In order for a diagnosis of schizophrenia, the symptoms need to have persisted for at least 6 months. Schizophrenia also has a gradual onset of symptoms that lead up to the first full-blown psychotic episode. Schizoaffective disorder can also be ruled out due to the absence of mood symptoms and due to the fact that the onset and presentation of psychotic symptoms are similar to those seen in schizophrenia. Schizophreniform disorder is diagnosed when symptoms of schizophrenia are present for at least 1 month but less than 6 months; as with schizophrenia, sudden onset and visual hallucinations in the absence of auditory hallucinations are not common in schizophreniform disorder, making the diagnosis of schizophreniform disorder unlikely in this patient. Brief psychotic disorder can be ruled out because the symptoms have persisted for at least 1 month. Correct Answer: Substance/medication-induced psychotic disorder Show Explanation Explanation The most probable cause of the patient's symptoms is substance/medication-induced psychotic disorder. The patient's symptoms had a sudden onset approximately 1 month ago, which is when the patient began taking antihistamines. Visual hallucinations with an absence of auditory hallucinations are commonly associated with substance-induced psychotic disorders, but they are rare in other psychotic disorders. In order for a diagnosis of schizophrenia, the symptoms need to have persisted for at least 6 months. Schizophrenia also has a gradual onset of symptoms that lead up to the first full-blown psychotic episode. Schizoaffective disorder can also be ruled out due to the absence of mood symptoms and due to the fact that the onset and presentation of psychotic symptoms are similar to those seen in schizophrenia. Schizophreniform disorder is diagnosed when symptoms of schizophrenia are present for at least 1 month but less than 6 months; as with schizophrenia, sudden onset and visual hallucinations in the absence of auditory hallucinations are not common in schizophreniform disorder, making the diagnosis of schizophreniform disorder unlikely in this patient. Brief psychotic disorder can be ruled out because the symptoms have persisted for at least 1 month.

A 45-year-old woman presents with sweating, tremors, and insomnia. About 6 months ago, the patient divorced her husband of 15 years; she was placed on Xanax 0.5 mg daily due to frequent panic attacks. A week ago, her court proceedings were resolved. Question What is the most likely cause of the patient's symptoms? Answer Choices 1 The patient is experiencing common side effects of the medication from chronic usage 2 The patient has developed a tolerance to the medication 3 The patient abruptly stopped taking the medication 4 The patient requires a increase in dosage of medication 5 The patient has overdosed on the medication

Correct Answer: The patient abruptly stopped taking the medication The correct response is that the patient abruptly stopped taking the medication. Benzodiazepines, such as Xanax, can cause physical dependence. When alprazolam is stopped abruptly, the patient has signs and symptoms of withdrawal (e.g., sweating, tremors, and insomnia). Tolerance and side effects from the medication would result in signs and symptoms of anxiety (e.g., restlessness, irritability, and muscle tension). Since the patient has been on the medication for 6 months, an increase would not yet be required.

A 23-year-old man presents with an unspecified personality disorder; although his group and individual therapy sessions are going well, he wants to gain even more improvement with his diagnosis. He feels that his mood, self-image, and personal relationships have improved overall; however, he specifically states he wants to have better anger management. When he becomes angry, for whatever reason, he still becomes extremely irritated, hostile, and even aggressive. Question What pharmaceutical therapy would be most beneficial for this patient? Answer Choices 1 Methylphenidate 2 Lithium 3 Sertraline 4 Topiramate 5 Fluoxetine

Correct Answer: Topiramate Show Explanation Explanation The correct response is topiramate. Although it is not stated specifically, this patient most likely has the diagnosis of borderline personality disorder (BPD). BPD is commonly seen in all psychiatric and medical settings. Distinctions of this disease process include instability of self-image, mood, behavior, and relationships. BPD patients are hypersensitive and become very easily angered; they very frequently will express inappropriate and intense anger. Treatment for patients with any 1 of the personality disorders (which includes BPD) should consist of a multi-faceted approach: psychosocial therapy (individual, group) and (usually) the addition of other components, which includes pharmacotherapy. Mood stabilizers such as lamotrigine and topiramate are extremely useful in anger management and mood stability in these patients. Methylphenidate is a central nervous system stimulant utilized in patients who are diagnosed with attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), and narcolepsy. Lithium is most commonly utilized in patients diagnosed with bipolar disorder, specifically to treat the manic episodes of manic depression. Sertraline and fluoxetine are both selective serotonin reuptake inhibitors (SSRI) antidepressants; they are used to treat major depressive disorder, bulimia nervosa, panic disorder, obsessive-compulsive disorder, as well as other psychiatric diagnoses.