Question 1

A 63-year-old woman comes to the office for her annual checkup.  Her medical problems include intermittent insomnia and chronic headaches and stomach pains for several years.  She reports no significant change in the frequency and intensity of her headaches or any change in bowel habits.  The patient has a history of major depressive disorder treated with citalopram 20 mg.  She reports that her mood is "okay" and her appetite is good.  She does not use tobacco or alcohol but confides, "I'm worried about my husband because he has been under a lot of stress lately and his drinking is getting worse.  We have been arguing and he promises that he will cut down his drinking, but it has been difficult."
Vital signs are within normal limits.  Physical examination shows normal heart and lungs; a soft, nontender abdomen with normal bowel sounds; and some mild bruising on her arms that the patient says she sustained while moving heavy furniture.  She is tearful when discussing her husband but denies depression or suicidal thoughts.
Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

11ec193a_98c2_710d_853d_63a2b78a8a5d_MD0002_00 All patients should be screened routinely for intimate partner violence (IPV), and this patient's distressed affect, bruises on examination, and report of her husband's escalating alcohol use are especially concerning. The most appropriate next step is to screen this patient for IPV by asking if she is being hurt or feels threatened by her husband. Women in abusive relationships may have chronic somatic symptoms and conceal, minimize, or deny abuse due to shame, feeling that there is no alternative or believing that the abuse is deserved. In responding to a positive screen for IPV, physicians should validate that any abuse is wrong and undeserved, but should not pressure the patient to disclose, report the abuse or leave the partner. The physician should ask the patient if she feels safe and assist in developing an emergency safety plan in the event she decides to leave or needs to escape immediately. Information regarding available community resources, including domestic violence shelters and counseling services, should be provided. (Choices A and D) Although this patient may benefit from participating in an Alcoholics Anonymous family support group and/or couple's therapy, the priority is to ascertain whether she is being abused. (Choice B) Although assessing depressive symptoms in greater detail would be helpful, the first step is to screen for IPV, as the patient's safety may be threatened. (Choice C) The reasons individuals stay in difficult relationships are complex, and exploring this before determining if the patient's safety is at risk would be inappropriate. Educational objective: Patients should be routinely screened for intimate partner violence. The presence of chronic somatic symptoms and poorly explained injuries should raise particular concern. __________ References: A scoping review of intimate partner violence screening programs for health care professionals. (http://www.ncbi.nlm.nih.gov/pubmed/27977769) Screening for intimate partner violence. (http://www.ncbi.nlm.nih.gov/pubmed/26990666)

Question 2

A 35-year-old man comes to the office for increasing anxiety associated with public speaking. The patient previously worked in product development but was recently promoted to a leadership sales position that requires leading daily team meetings and frequent public speaking. When speaking before a group of people, the patient becomes extremely anxious; his face turns bright red; he starts to sweat profusely; and he feels that his heart is racing. He also becomes acutely aware that other people notice his anxiety and judge him negatively. The patient reports that he has been uncomfortable in large groups and while meeting new people since he was a teenager. His new job has been very stressful as he can no longer avoid these situations. He recognizes that his anxiety and fear of public speaking are excessive. The patient has no depression and is otherwise healthy. Blood pressure is 118/68 mm Hg and pulse rate is 86/min. BMI is 23 kg/m². The remainder of the physical examination is unremarkable. Which of the following is the most appropriate pharmacologic treatment in management of this patient?

Accepted Answer

11ec193a_98c6_1a94_853d_b51326b76a94_MD0002_00 This patient's excessive anxiety in social situations in which he fears scrutiny and embarrassment is consistent with social anxiety disorder (SAD). Patients with SAD experience extreme distress in social situations, leading to avoidance behavior. In this case, the patient's job promotion has resulted in increased demands for public speaking and social interactions, thereby exacerbating his social anxiety that has been present since adolescence. Treatment of SAD includes cognitive-behavioral psychotherapy and pharmacotherapy. Selective serotonin reuptake inhibitors (SSRIs) such as sertraline and serotonin-norepinephrine reuptake inhibitors (SNRIs) are first-line medications. Benzodiazepines are reserved for patients who have an inadequate response to SSRI/SNRIs and should be used only in patients with no history of substance use disorder. Patients whose anxiety is restricted to performance situations (ie, performance-only subtype) and who have rarely recurring performance situations can be treated on an as-needed basis with beta blockers or benzodiazepines. (Choices A and C) Benzodiazepines (eg, alprazolam, clonazepam) have demonstrated efficacy in SAD but are generally used as second-line agents due to their potential for tolerance, abuse, and dependence. Adverse effects of sedation and impaired concentration may also be problematic when mental clarity is important for performance. (Choice B) Buspirone is ineffective in SAD. It has been used to treat generalized anxiety disorder. (Choice D) Beta blockers such as propranolol have been used as needed for the performance-only subtype of SAD (eg, propranolol 10 mg, an hour before a performance or speech). However, this patient shows evidence of more generalized social anxiety and encounters stressful social situations and performance situations on a daily basis. SSRIs/SNRIs would be preferred. Educational objective: Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are first-line pharmacotherapy for social anxiety disorder. Benzodiazepines can be considered for poor responders without a history of substance use. Beta blockers can be used as needed for rarely occurring performance situations. __________ References: The evidence-based pharmacotherapy of social anxiety disorder. (http://www.ncbi.nlm.nih.gov/pubmed/22436306) Social anxiety disorder in DSM-5. (http://www.ncbi.nlm.nih.gov/pubmed/24395386)

Question 3

A 65-year-old woman comes to the office due to involuntary facial and mouth movements.  The patient first noticed the condition 6 months ago with protruding and twisting movements of the tongue and puckering movements of the lips; the movements have worsened since then.  She has also experienced foot-tapping movements and an uncontrollable twisting of her neck to the right side.  The patient has type 2 diabetes mellitus and chronic gastroparesis.  She also has a long history of bipolar disorder that has been stable over the past year on a combination of lithium and quetiapine.  Other medications include metformin and metoclopramide.  She has no family history of a movement disorder or any neurologic disease.
Temperature is 37.5 C (99.5 F), blood pressure is 138/76 mm Hg, and pulse rate is 84/min.  Occasional tongue protrusion, facial grimacing, cervical torticollis, slow gait, and reduced arm swing are noted.
Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

11ec193a_98c4_e211_853d_e7bba43655a2_MD0002_00 This patient's lip puckering, tongue protrusion, foot tapping, and torticollis are consistent with tardive dyskinesia (TD), an involuntary movement disorder due to prolonged exposure to dopamine receptor-blocking medications (eg, antipsychotics, metoclopramide). The most appropriate treatment of medication-induced TD is discontinuation of the causative dopamine blocker agent. The antiemetic and prokinetic agent metoclopramide has a strong correlation with the occurrence of TD; risk factors include >12-week duration of treatment, older age, female sex, and history of diabetes mellitus. For patients taking antipsychotics who develop TD but still require treatment for psychosis, switching to a second-generation antipsychotic (SGA) (eg, clozapine, quetiapine) is recommended as SGAs are associated with a lower risk for TD compared to first-generation drugs. Another treatment option, recently approved by the FDA, is valbenazine, a vesicular monoamine transporter 2 inhibitor that modulates presynaptic dopamine release. (Choice A) Anticholinergic drugs such as benztropine are usually ineffective for TD and can exacerbate involuntary movements once they emerge. Benztropine is most commonly used to treat acute dystonia and parkinsonism. (Choice B) This patient's reduced arm swing and slow gait are suggestive of drug-induced parkinsonism, another extrapyramidal symptom associated with dopamine-blocking drugs that is best treated by discontinuing the offending drug. Carbidopa-levodopa can worsen dyskinetic movements and should be avoided in this patient. (Choice C) Lithium can induce tremors but would not explain this patient's lip puckering, tongue protrusion, and foot tapping, which are typical movements in TD. (Choice E) This patient is already taking an SGA (ie, quetiapine) associated with a negligible risk of TD. Among SGAs, risperidone is associated with comparatively greater dopamine antagonism and should be avoided in this patient. Educational objective: Tardive dyskinesia (TD) is a movement disorder due to prolonged exposure to dopamine receptor blockers (eg, antipsychotics, metoclopramide). Metoclopramide should be discontinued if TD develops. In cases of antipsychotic-induced TD when discontinuation is not feasible, options include switching to a second-generation antipsychotic or adding valbenazine. __________ References: Medication-induced tardive dyskinesia: a review and update. (http://www.ncbi.nlm.nih.gov/pubmed/28638290) Valbenazine for tardive dyskinesia. (http://www.ncbi.nlm.nih.gov/pubmed/28742396)

Question 4

A 52-year-old man comes to the office for follow-up of depression.  The patient was initially seen 6 months ago for symptoms of low energy, lack of motivation, anxiety, hypersomnia, increased appetite, weight gain, and poor concentration.  At that time, he was having difficulty functioning at his job as an accountant and was worried about being fired for poor performance.  Physical examination was unremarkable and routine laboratory tests were within normal limits.  The patient was diagnosed with major depression and started on sertraline 50 mg.  After several weeks, his dosage was gradually increased to 150 mg and he has steadily improved since then.  The patient has a history of 2 prior major depressive episodes at ages 35 and 49 but was never treated.
At today's visit, he reports that his mood is "good" and that he is functioning well at home and at work.  The patient is tolerating sertraline without difficulty and has no suicidal ideation.  He asks how long he should continue the medication.
Which of the following is the most appropriate recommendation for this patient?

Accepted Answer

Following response to acute treatment, patients with a single episode of unipolar major depression should continue antidepressants for an additional 6 months. However, patients with a history of multiple depressive episodes (ie, recurrent major depression) are at high risk for recurrence and are candidates for maintenance antidepressant treatment. Other risk factors for recurrence include early age of onset (≤18), persistent residual depressive symptoms, and comorbid psychiatric disorders. Patients with an increased risk of recurrence should be maintained on antidepressants for at least an additional 1-3 years to reduce risk of relapse and can also consider continuing treatment indefinitely. Those with a history of highly recurrent illness (eg, ≥3 lifetime depressive episodes), chronic episodes (≥2 years), or severe episodes (eg, suicide attempts) are particularly good candidates for maintaining antidepressant treatment indefinitely. This patient has a history of 2 prior episodes of major depression and would be an appropriate candidate for maintenance pharmacotherapy. For such patients, it may be helpful to conceptualize recurrent major depression as a chronic illness similar to other chronic medical diseases (eg, hypertension) that may also require long-term medications. (Choices A, B, D, and E) This patient should continue antidepressant medication for an additional 1-3 years due to his increased risk of recurrence. If the decision is made to discontinue medication, a gradual taper over several weeks to months is preferable. Patients with a history of recurrent episodes who discontinue antidepressants should be monitored closely, and antidepressant therapy should be reinstituted at the first signs of recurrence. Educational objective: Maintenance antidepressant pharmacotherapy (1-3 years) is indicated for patients with recurrent episodes. Patients with ≥3 lifetime depressive episodes, severe episodes (eg, suicide attempts), or episodes lasting ≥2 years can be maintained on treatment indefinitely. __________ References: Rationale for, barriers to, and appropriate medication for the long-term treatment of depression. (http://www.ncbi.nlm.nih.gov/pubmed/20371029)

Question 5

A 32-year-old woman comes to the office due to fatigue and loss of energy.  She sleeps poorly due to multiple awakenings to feed her 3-month-old son, and it takes her a long time to fall back asleep.  During the day, the patient is able to nap when the baby is sleeping but still feels tired all the time.  Although the baby is healthy, she worries about him constantly.  She has trouble concentrating and fears that she will neglect some aspect of his care.  The patient says, "I was elated for the first few weeks after giving birth, but for the last couple of months I haven't been able to enjoy him and just feel I am a bad mother."  Although still overweight, she has lost most of her baby weight and is less interested in food.  The patient has a history of psoriasis and asthma treated with topical corticosteroids and as-needed beta agonists.
Blood pressure is 120/70 mm Hg and pulse is 88/min.  Examination shows moist mucous membranes, clear lung fields, normal S1 and S2, no edema, and no neurological deficits.  On mental status examination, the patient appears tired and anxious.  She has no thoughts of suicide or harming the baby.
Which of the following is the most likely diagnosis?

Accepted Answer

The symptoms described, including fatigue, anxiety, poor sleep, loss of interest, and feelings of inadequacy, are consistent with postpartum depression, which can occur within the first few months after childbirth.

Question 6

A 61-year-old woman comes to the office due to insomnia.  She describes difficulty both falling and staying asleep over the past 6 months.  Her insomnia varies and is much worse some days than others.  In the mornings, she wakes up half an hour earlier than she would like and rarely feels well rested.  The patient has tried several over-the-counter sleep medications, but they make her feel too tired the next day.  She is not aware if she snores.  The patient drinks a glass of wine several times a week and does not use illicit drugs.  She has a history of osteoarthritis and major depression for which she takes ibuprofen and venlafaxine.  She has lived alone since her divorce 2 years ago and maintains close relationships with her adult children and grandchildren.  The patient is worried about one son who recently lost his job, but she has had no change in mood or appetite.  Physical examination is noncontributory.
Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

11ec193a_98c7_2c06_853d_dd8dc1ae5278_MD0002_00 Insomnia is a clinical diagnosis that requires a detailed sleep history that should include time needed to fall asleep, number and duration of awakenings, estimated time in bed and total sleep time, description of the sleep environment, and habits and associated symptoms (eg, snoring, kicking during the night, anxiety, depression). In the absence of clues suggesting another sleep disorder (eg, sleep apnea, periodic limb movements), the first step is to obtain a 2-week sleep diary that provides detailed information regarding the patient's quantity and quality of sleep, bedtime routine, daytime symptoms, use of causative substances, and relationship to environmental factors and psychosocial stressors. This is especially important for patients who describe variability in their sleep pattern and whose report may be affected by recall bias. In addition to confirming insomnia, a sleep diary can identify patterns and contributing factors to assist the physician in making specific sleep-hygiene recommendations (eg, avoiding caffeine or alcohol) and providing targeted behavioral guidance (eg, stimulus control, sleep restriction) or other recommendations (eg, cognitive-behavioral therapy [CBT] for insomnia, psychiatric evaluation). sleep restriction (Choices B and E) The next step is to confirm the patient's insomnia and identify contributing factors that could be altered with behavioral interventions. CBT is considered a first-line treatment of chronic insomnia for patients who do not improve with general behavioral recommendations. Low-dose zolpidem would be appropriate for patients who do not respond to nonpharmacological interventions. (Choice C) Polysomnography would be indicated for further evaluation of suspected sleep apnea, but it is not part of routine evaluation for insomnia. (Choice D) A psychiatric evaluation is appropriate when there is concern that psychiatric illness is the primary cause of the patient's insomnia (eg, untreated anxiety, depressive disorders). It would be premature, however, for this patient who denies significant mood changes. Educational objective: Initial evaluation of patients with chronic insomnia requires a detailed sleep history to clarify sleep patterns and identify contributing factors (eg, substances, psychosocial stressors, environmental issues). A 2-week sleep diary is a useful assessment tool that can help confirm the diagnosis and guide treatment interventions. __________ References: The consensus sleep diary: quantitative criteria for primary insomnia diagnosis. (http://www.ncbi.nlm.nih.gov/pubmed/25905662) Nonpharmacologic management of chronic insomnia. (http://www.ncbi.nlm.nih.gov/pubmed/26760592) Psychometric properties of the consensus sleep diary in those with insomnia disorder. (http://www.ncbi.nlm.nih.gov/pubmed/27231885)

Question 7

A 55-year-old man comes to the office due to the sudden onset 4 months ago of inability to maintain a firm erection. He is still interested in sex but feels guilty that he is disappointing his wife and ruining his marriage. The patient awakens with a normal erection but cannot maintain it to engage in intercourse. He has intermittent knee pain, decreased appetite, constipation, insomnia, and low energy. The patient has a history of hypercholesterolemia, hypertension, and type 2 diabetes mellitus. Medications include aspirin, metformin, atorvastatin, and lisinopril, which he has taken for the past 5 years. He denies any alcohol or substance abuse, except for smoking a pack of cigarettes daily for 20 years, which he stopped 5 years ago. Temperature is 36.7 C (98.1 F), blood pressure is 130/80 mm Hg, pulse is 70/min, and respirations are 16/min. BMI is 28 kg/m². Physical examination is normal. No hepatomegaly is present. The penis and testes appear normal, and there are no palpable masses. Neurologic examination is within normal limits. Complete blood count and chemistries are normal. Hemoglobin A1c is 7.3%. TSH is 3 µU/mL, alanine aminotransferase is 24 U/L, and aspartate aminotransferase is 37 U/L. Which of the following is the most likely cause of this patient's erectile dysfunction?

Accepted Answer

11ec193a_98c1_fbdc_853d_ab2e63c9e428_MD0002_00 Sudden onset of erectile dysfunction (ED) while continuing to have intact early morning erections suggests a psychogenic ("inorganic") etiology, in this case a mood disorder (characterized by depressive symptoms, including impaired sleep, poor appetite, low energy, and guilt). Nocturnal erections, which occur during periods of rapid eye movement (REM) sleep, often continue in a patient with psychogenic ED. However, in severely depressed men, who may no longer experience REM sleep, nocturnal and early morning erections may also be absent. Organic ED is typically slowly progressive and can be due to multiple causes (eg, diabetes, cardiovascular disease, hypertension, obesity, low testosterone, hyperprolactinemia, thyroid dysfunction, smoking). However, this patient's continued ability to have early morning erections indicates that his erectile dysfunction is not due to any anatomic or physiologic causes, such as diabetes or vascular disease (Choices A and E). Medications that may cause ED include serotonergic antidepressants, spironolactone, clonidine, and thiazide diuretics. Use of illicit substances and alcohol are also associated with ED. (Choice B) Hypogonadism is characterized by small testes and reduced interest in sex, neither of which is present in this patient. Also, ED associated with hypogonadism (ie, low testosterone) would not be consistent with early morning erections. (Choice C) Medication adverse effects are an unlikely explanation of this patient's sudden-onset ED 4 months ago and his intact early morning erections. Among antihypertensives, thiazide diuretics and beta blockers are most commonly associated with ED. ACE inhibitors are less likely and metformin and statins are uncommon causes. Educational objective: Erectile dysfunction can be due to multiple etiologies, including vascular, neurologic, hormonal, and psychological abnormalities. Psychogenic causes should be suspected if erectile dysfunction has a sudden onset and the patient is able to have early morning and nocturnal erections during REM sleep. __________ References: Erectile dysfunction. (http://www.ncbi.nlm.nih.gov/pubmed/23040455)

Question 8

A 32-year-old woman comes to the office at her husband's insistence for evaluation of weight loss. She is unconcerned about her weight loss and explains that she is training for a marathon and would like to lose more to reach an ideal running weight. The patient has lost 15.0 kg (33 lb) in the last 6 months and has not had a menstrual period for the past 2 months. Medical history is significant for depression in her 20s that responded well to selective serotonin reuptake inhibitors. Current medications include multivitamins, polyethylene glycol for constipation, and calcium and green tea extract supplements. She has no depressed or anxious mood, cold or heat intolerance, or change in sleep pattern. Temperature is 36.4 C (97.5 F), blood pressure is 105/60 mm Hg, pulse is 56/min and regular, and respirations are 12/min. There is no orthostasis. BMI is 16 kg/m². There is no edema. The abdomen is soft and nontender. Complete blood count and blood chemistry studies are normal. Pregnancy test is negative. In addition to referral for nutritional rehabilitation, which of the following is the most appropriate treatment for this patient?

Accepted Answer

11ec193a_98c3_f7af_853d_f5f7227cc622_MD0002_00 This patient's marked weight loss, significantly low body weight (BMI <18.5 kg/m²), distorted body perception, amenorrhea, and bradycardia are suggestive of anorexia nervosa (AN). First-line treatment for AN includes nutritional rehabilitation (establishing a structured and consistent meal pattern) and psychotherapy. Multiple guidelines recommend cognitive-behavioral therapy (CBT) as the treatment of choice although other types of psychotherapy are also effective (eg, family therapy, psychodynamic). CBT focuses on the dysfunctional thoughts (eg, negative self-evaluation based on weight and shape) and behaviors (excessive food restriction) that maintain the disorder. ² Pharmacotherapy is not a first-line treatment for AN. Olanzapine is a second-generation antipsychotic that has been used as an adjunctive treatment in patients who do not gain weight with nutritional rehabilitation and psychotherapy (Choice E). Other antipsychotics, including aripiprazole, have not shown any benefit in AN (Choice A). (Choice B) The antidepressant bupropion is contraindicated for use in eating disorders due to an increased risk of seizures. (Choice D) Fluoxetine is effective in bulimia nervosa but not AN. Educational objective: First-line treatment for anorexia nervosa consists of nutritional rehabilitation and psychotherapy. Adjunctive pharmacotherapy is indicated for treatment-resistant patients who do not respond to psychological interventions. __________ References: Psychological interventions for eating disorders. (http://www.ncbi.nlm.nih.gov/pubmed/27979882) Recent advances in psychological therapies for eating disorders. (http://www.ncbi.nlm.nih.gov/pubmed/27134740)

Question 9

A 68-year-old man is seen for follow-up of non-small cell lung cancer with bone metastases.  He is accompanied by his wife, who is worried about his condition.  The patient has undergone surgical resection and several courses of combination chemotherapy.  His prognosis is 3-6 months.  At today's visit, the patient reports that his cancer pain is generally controlled, but he feels extremely weak and fatigued.  He has difficulty falling asleep and also awakens at 2:00 and 4:00 AM.  His wife says, "I make his favorite foods but he barely takes a bite.  When the children visited last weekend, he seemed uninterested in spending time with his son and grandson and retired to his room while they were still there."  The patient says, "I am just so exhausted all the time.  I know I'm not getting better and feel guilty about being a burden to my family."
The patient has lost 8.2 kg (18 lb) since his last visit.  Physical examination is otherwise unchanged.  His mood is sad but he is able to smile when appropriate.  He thinks about death and dying but has no suicidal ideation, intent, or plan.
Which of the following symptoms is most suggestive of major depression in this patient?

Accepted Answer

Depression in cancer patients is under-recognized and undertreated. Diagnosis is challenging as somatic symptoms of depression (eg, low energy, anorexia, weight loss, sleep disturbance) overlap with the physiological effects of cancer itself and its treatment. Therefore, assessment should emphasize nonsomatic symptoms such as loss of interest and pleasure in activities, feelings of worthlessness, excessive guilt, and suicidal ideation. This patient's low energy, loss of appetite, and insomnia are less reliable indicators of depression as they may be caused by his metastatic lung cancer or chemotherapy side effects (Choices A and C). His loss of interest in spending time with his family and inability to engage with them in shared interests are the most concerning signs for depression. Nondepressed cancer patients may be periodically sad and discouraged, but they retain the ability to experience pleasure and engage with their loved ones. The American Society of Clinical Oncology recommends screening every patient with cancer for depression when the initial cancer diagnosis is made and periodically thereafter. There should be a low threshold for initiating treatment as untreated depression has a significant impact on quality of life for the patient and family. (Choice B) Guilt over burdening one's family is an understandable reaction to a cancer diagnosis with poor prognosis and can also occur in nondepressed cancer patients. In contrast, excessive guilt (eg, feeling sinful and deserving of punishment) associated with despair would be more indicative of depression. (Choice D) Thinking about death is normal for patients who have advanced cancer and only months to live. Patients should be assessed for thoughts of suicide, which would be concerning for depression. Educational objective: The diagnosis of depression in patients with advanced cancer should rely primarily on nonsomatic symptoms such as loss of interest and pleasure, worthlessness, excessive guilt, and suicidality. Patients with cancer should be evaluated periodically for symptoms of depression as treatment can improve quality of life for both patients and families. __________ References: Depressive spectrum disorders in cancer: diagnostic issues and intervention. A critical review. (http://www.ncbi.nlm.nih.gov/pubmed/28488207) Depressive spectrum disorders in cancer: prevalence, risk factors and screening for depression: a critical review. (http://www.ncbi.nlm.nih.gov/pubmed/28140731)

Question 10

A 28-year-old woman comes to the office for a routine evaluation. During the review of systems she reports weight gain, fatigue, bloating, flatulence, constipation, mild acne, and menstrual irregularity. The patient describes difficulty losing weight despite trying numerous low-calorie diets. She is depressed about her weight and feels that her appearance has always been a source of insecurity. She is also unhappy with her current position as an administrative assistant but lacks the motivation to look for another job. The patient has an active social life with friends but is not in a relationship. She smokes marijuana 1 or 2 times a month and has used cocaine at parties twice in the past year. Temperature is 37.1 C (98.8 F), blood pressure is 110/60 mm Hg, and pulse is 68/min. On physical examination, the patient has mild facial acne and is slightly overweight. BMI is 27 kg/m². The oropharynx is remarkable for painless, mildly swollen parotid glands. The remainder of the physical examination is normal. Complete blood count is normal and serum electrolytes are notable for mildly decreased serum potassium, slightly elevated serum bicarbonate, and mildly decreased serum chloride levels. Thyroid function tests, liver function tests, and urinalysis are unremarkable. Which of the following is the most likely diagnosis in this patient?

Accepted Answer

11ec193a_98c3_827e_853d_9f3ed8d5dc9e_MD0002_00 Patients with bulimia nervosa (BN) may be reluctant to disclose their binging and purging behavior, requiring the physician to be alert to physical signs, symptoms, and laboratory findings suggestive of the disorder. This patient's bilateral parotid gland hypertrophy and mild electrolyte abnormalities, as well as her preoccupation with her appearance and weight, are suggestive of BN. Parotid gland hypertrophy (sialadenosis) due to self-induced vomiting occurs in up to 25% of patients with BN and is typically bilateral and painless. Patients with BN are usually normal weight to slightly overweight and frequently have comorbid substance use, depression, and anxiety disorders. Common medical symptoms of BN include lethargy, menstrual irregularities, abdominal bloating, and constipation. Chronic purging can also lead to mild electrolyte abnormalities, including hypokalemia, slightly elevated serum bicarbonate, and slightly decreased serum chloride levels. Hypokalemia in otherwise healthy young adults is highly specific for covert BN. Other signs suspicious for this disorder include oropharyngeal ulcers, erosion of dental enamel, and scars and calluses on the back of the hand. (Choice B) This patient enjoys an active social life and her depressive symptoms revolve around dissatisfaction with her appearance and weight. Persistent depressive disorder (dysthymia) requires depressed mood and at least 2 other depressive symptoms for ≥2 years and would not explain this patient's physical examination and electrolyte abnormalities. (Choice C) Although this patient has some features of polycystic ovary syndrome (eg, weight gain, irregular menses), there would also be evidence of hyperandrogenism, such as hirsutism or inflammatory rather than mild acne. Her preoccupation with weight, coupled with parotid enlargement and electrolyte abnormalities, makes BN more likely. (Choice D) Patients with somatic symptom disorder are preoccupied with ≥1 unexplained physical symptoms, leading to high health care utilization. This patient's somatic symptoms and findings are consistent with BN. (Choice E) Surreptitious laxative ingestion may cause hypokalemia, but BN with self-induced vomiting is a more likely explanation of this patient's parotid hypertrophy. Educational objective: Bulimia nervosa should be suspected in otherwise healthy patients who present with bilateral parotid gland enlargement and mild electrolyte abnormalities. Other suspicious findings include oropharyngeal ulcers, erosion of dental enamel, and scars and calluses on the back of the hand. __________ References: Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. (http://www.ncbi.nlm.nih.gov/pubmed/25591200)

Question 11

A 40-year-old man comes to the office due to sleep difficulties over the past 2 years.  He regularly goes to bed at 11:00 PM but is unable to fall asleep until 12:30 AM.  As bedtime approaches, he typically becomes tense, watches the clock, and worries about the prospect of another sleepless night.  The patient eventually falls asleep and awakens by alarm at 6 AM in order to arrive at his office by 8 AM.  During the day he feels fatigued and is concerned that his insomnia is negatively affecting his work performance.  The patient does not take naps during the day.  His wife has not noticed any snoring or unusual limb movements during sleep.  His general health has been good and he takes no medication.  He would like to exercise but feels too tired.
Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

11ec193a_98c6_8fc5_853d_ab2c80464660_MD0002_00 This patient has developed chronic insomnia that is perpetuated by his association of the bed and bedroom with the fear of not sleeping. His sleep environment has therefore become a conditioned stimulus for sleep difficulty. As bedtime approaches, he anticipates another sleepless night, resulting in increasing tension and arousal that makes it even less likely that he will fall asleep. Among the behavioral therapies for insomnia, stimulus control would be most useful as it disrupts the association of the bedroom with not sleeping. Components include going to bed only when sleepy, using the bedroom for sleep and sex only (not reading, watching television, eating), leaving bed if unable to fall asleep within 20 minutes and returning only when sleepy, and avoiding daytime naps. Patients should be advised not to watch the clock as this heightens tension and arousal. When consistently applied, these techniques help the patient learn to reassociate bedtime and the sleep environment with restful sleep. In combination with good sleep hygiene, stimulus control therapy is recommended as an initial treatment for insomnia and should be attempted before considering hypnotic medications. (Choice A) Daytime naps should be avoided as they contribute to insomnia. (Choice B) Patients who are unable to fall asleep after 20 minutes are advised to leave the bed and go to another room and engage in a relaxing activity. They should return to bed only when sleepy. (Choice C) Exercising regularly for at least 20 minutes is a component of good sleep hygiene but should be done >4-5 hours prior to bedtime. Exercising before bedtime can be activating and further disrupts sleep. (Choice E) Restricting time in bed to one's actual sleep hours (ie, sleep restriction therapy) is another behavioral strategy that is preferred for insomnia patients who tend to stay in bed longer in an attempt to make up for lost sleep (eg, a patient who stays in bed 9 hours but sleeps only 5 hours). Limiting one's time in bed improves sleep efficiency (ie, the percentage of time in bed that the patient is asleep) by consolidating sleep hours. The patient's time in bed should be increased by 15 to 30 minutes once sleep efficiency is >90%. Educational objective: The initial behavioral approaches to insomnia consist of sleep hygiene and stimulus control therapy. With stimulus control, patients learn to reassociate the bedroom environment with restful sleep by using the bedroom only for sleep or sexual activity and going to bed only when sleepy. __________ References: Non-pharmacological management of chronic insomnia (http://www.ncbi.nlm.nih.gov/pubmed/26760592) Insomnia: psychological and neurobiological aspects and non-pharmacological treatments. (http://www.ncbi.nlm.nih.gov/pubmed/24637973)

Question 12

A 38-year-old woman comes to the office due to an 8-month history of fatigue and difficulty performing work-related tasks.  The patient works as a cashier and is unable to stand for a long time due to exhaustion and muscle aches.  After unloading stock, she feels tired and has no energy for hours.  The patient tries to rest at home after her shift but doesn't think this helps.  She gets 7-8 hours of sleep a night but awakens feeling unrefreshed.  Other than a viral infection 3 months ago, the patient has been in good health and takes no medication.  She does not use tobacco, alcohol, or illicit drugs.  She has no depression or anxiety.  Family history is significant for hypertension in her father and depression in her mother and brother.
Vital signs and physical examination are unremarkable.
Laboratory results, including complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, C-reactive protein, antinuclear antibody, TSH, and rheumatoid factor, are negative.
Which of the following is the most effective treatment for this patient's symptoms?

Accepted Answer

This patient's history of fatigue, exhaustion after exertion, lack of restful sleep, and inability to function at work is suggestive of chronic fatigue syndrome (CFS), also known as systemic exertion intolerance disease (SEID). CFS primarily affects young to middle-aged adults who had a high level of functioning prior to the onset of illness; it is twice as common in women. Diagnosis involves excluding other causes of fatigue, including psychiatric disorders and medical conditions, with a thorough history, physical examination, and laboratory evaluation (including complete blood count, comprehensive metabolic panel, TSH, and erythrocyte sedimentation rate). First-line treatment for CFS includes cognitive-behavioral therapy (CBT) to target thoughts or behaviors that hinder recovery and graded exercise therapy (ie, slowly increasing exercise tolerance over time under the supervision of a physical therapist). (Choice A) Although viral infections may precede the onset of CFS, there is no proven causal association between viral etiologies and CFS. Antiviral treatments have not been shown to be beneficial. (Choice B) Biofeedback includes the use of electronic devices to help patients recognize and control physiological processes. It is commonly used in the treatment of pain. There is insufficient evidence for its use in CFS. (Choice D) Depression is commonly seen with CFS either as a comorbid condition or secondary to the limitations associated with CFS itself. It can worsen symptoms of CFS and should be screened for and treated. However, this patient does not report depressed mood. Antidepressants are not indicated in the treatment of CFS without comorbid depression or anxiety. (Choice E) Patients with CFS are optimally treated with a combination of graded exercise and cognitive behavioral therapy. Increased rest is not recommended and should be discouraged. Educational objective: Management of chronic fatigue syndrome includes excluding other medical and psychiatric causes of fatigue followed by referral for cognitive-behavioral therapy and graded exercise therapy. __________ References: Chronic fatigue syndrome: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/23062157) Cognitive remediation training improves performance in patients with chronic fatigue syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/28830024)

Question 13

A 58-year-old man comes to the office complaining of feeling tired and having poor sleep. He was diagnosed with myocardial infarction (MI) three months ago and underwent percutaneous coronary revascularization. According to the patient, it was a "scary and life-changing experience". He also complains of occasional headaches in the morning, dry mouth, and sore throat. Sometimes he wakes up in the middle of the night with a choking sensation and pounding in his chest. He is afraid that he is going to have "another heart attack". His exercise tolerance is about three blocks and it is limited by weakness and shortness of breath. He denies any exertional chest pain. His other medical problems include hypertension, hyperlipidemia, gout, and gastro-esophageal reflux disease (GERD). He is a lifetime non-smoker. His mother suffers from diabetes mellitus. His father died of a stroke at age 70. His current medications include metoprolol, rosuvastatin, aspirin, clopidogrel, lisinopril, amlodipine, and esomeprazole. His blood pressure is 142/86 mmHg and his heart rate is 81/min and regular, and his oxygen saturation is 94% at room air. His BMI is 39 kg/m². On physical examination, the heart sounds appear distant. Lungs are clear on auscultation. He has 1+ bilateral pitting lower extremity edema to the mid-calf. Which of the following is the best next step in managing this patient?

Accepted Answer

11ec193a_98c8_b2a7_853d_ab09af62f33d_MD0002_00 This patient's clinical presentation is most consistent with obstructive sleep apnea (OSA). This condition is more common in individuals who are current smokers, obese, males aged 18-60, or who have upper airway soft tissue abnormalities. OSA is also associated with hypertension, cardiovascular disease, cerebrovascular disease, type 2 diabetes, renal disease, and gastroesophageal reflux disease.Polysomnography (full-night, attended, in sleep lab) is the preferred modality to confirm the diagnosis of OSA, defined as > 15 events (predominantly obstructive apneas or hypopneas) per hour of sleep in an asymptomatic patient or > 5 events/hour in a symptomatic patient. Treatment is recommended in symptomatic patients with positive airway pressure (CPAP), weight loss (for overweight patients), or oral appliances to protrude the mandible forward or hold the tongue anteriorly. Surgery is reserved for patients who have a severe obstructing surgically correctable lesion or who fail non-surgical therapy. (Choice A) Although post-MI angina is possible in this patient, the lack of exertional angina makes this less likely. His symptoms are most consistent with OSA. (Choice C) GERD induced asthma is a possibility. However, his symptoms of night time choking (apnea), dry mouth, morning headaches, and day time tiredness along with obesity suggests OSA the most likely diagnosis. His peripheral edema could be from longstanding undiagnosed OSA resulting in pulmonary hypertension and cor pulmonale. (Choice D) Cardiac rehabilitation is indicated for deconditioned patients who had a MI in the past 12 months, CABG, stable angina, or percutaneous coronary intervention. Although this patient may benefit from cardiac rehab, he should first be investigated for the etiology of his current symptoms to rule out other medical causes. (Choice E) Selective serotonin reuptake inhibitors (SSRI) can help treat PTSD, which can manifest as recurrent images of a traumatic event that cause significant impairment of daily activities and difficulty falling asleep. This patient's fatigue and headaches are less consistent with PTSD and more consistent with OSA. Educational objective: OSA should be suspected in high-risk patients who complain of snoring or excessive daytime sleepiness. Polysomnography is the preferred test to diagnose OSA and non-surgical therapy (weight loss and CPAP) is the mainstay of treatment. __________ References: Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults (http://www.ncbi.nlm.nih.gov/pubmed/19960649)

Question 14

A 38-year-old woman with type 2 diabetes mellitus comes to the office for follow-up. Although her laboratory results indicate good glycemic control, she describes low energy, fatigue, and difficulty concentrating at work. Further evaluation reveals that the patient has become increasingly depressed over the past month. She says, "All I do is work and then go home so I can get in bed and sleep. I feel bad that I stopped exercising. It takes too much effort see my friends or date and I have no interest in sex." The patient has no psychiatric history. Her sister takes paroxetine for depression and anxiety with good results. Physical examination is unremarkable apart from a BMI of 27.9 kg/m² and a 2.26-kg (5-lb) weight gain since her last visit. Mental status examination shows depressed mood and affect and no suicidal ideation. The patient is diagnosed with major depressive disorder and treatment options are discussed. Which of the following is the most appropriate pharmacotherapy for this patient?

Accepted Answer

Although selective serotonin reuptake inhibitors (SSRIs) are commonly selected as initial treatment for major depressive disorder, other first-line pharmacotherapies for major depressive disorder include serotonin-norepinephrine reuptake inhibitors (SNRIs) (eg, venlafaxine), norepinephrine dopamine reuptake inhibitors (eg, bupropion), and serotonin modulators (eg, mirtazapine). Because efficacy is generally comparable across antidepressant classes, drug selection is based on other factors, including side effect profile, specific depressive symptoms, patient preference, and cost. This patient has diabetes and depressive symptoms that include low libido, weight gain, and hypersomnia. Bupropion would be a preferred medication choice: It induces fewer sexual side effects compared to other antidepressants; in addition, it is associated with the least weight gain and, in some cases, modest weight loss. In contrast, SSRIs and SNRIs are associated with weight gain and significant sexual side effects. Bupropion is also activating and would be a good choice in a patient with low energy and hypersomnia. Bupropion should be avoided in patients with seizures and active eating disorders due to its lowering of the seizure threshold. (Choices B, D, and E) These SSRI (escitalopram, paroxetine) and SNRI (venlafaxine) medications are not preferred for this patient as they are associated with weight gain and sexual side effects. Although the patient's sister responded to paroxetine, this particular drug has been associated with the most weight gain among the SSRIs. (Choice C) Although mirtazapine does not cause sexual dysfunction, it is associated with increased appetite, weight gain, and sedation, which would be problematic for this overweight, hypersomnic patient. Educational objective: Drug side effect profiles and specific depressive symptoms can help guide initial antidepressant medication selection. Bupropion, a norepinephrine dopamine reuptake inhibitor, is a first-line treatment for major depressive disorder that is associated with less weight gain and fewer sexual side effects compared with selective serotonin reuptake inhibitors. __________ References: Weight gain and glucose dysregulation with second-generation antipsychotics and antidepressants: a review for primary care physicians. (http://www.ncbi.nlm.nih.gov/pubmed/22913904) Bupropion: a systematic review and meta-analysis of effectiveness as an antidepressant. (http://www.ncbi.nlm.nih.gov/pubmed/27141292)

Question 15

A 54-year-old woman comes to the office for her annual health maintenance visit. The patient's medical problems include hypercholesterolemia, gastroesophageal reflux disease, and alcohol use disorder. She was hospitalized for treatment of alcohol withdrawal last year and attended an outpatient substance abuse program after discharge. The patient maintained abstinence for 3 months following completion of the program. Since then, she has attempted to limit her consumption to 1 drink a day; however, since being let go from her job last month, she has started drinking heavily again and currently consumes 8-10 vodka drinks daily. She says, "I thought I could control it on my own, but the cravings are so intense." The patient lives alone and is currently looking for work. She has smoked a pack of cigarettes daily for 30 years but does not use illicit drugs. Temperature is 36.7 C (98 F), blood pressure is 130/80 mm Hg, pulse is 78/min, and respirations are 12/min. BMI is 27 kg/m². Examination shows no abnormalities. In addition to psychosocial interventions, which of the following is the most appropriate pharmacotherapy?

Accepted Answer

Pharmacotherapy is underutilized and should be considered in patients with moderate to severe alcohol use disorder and those who are unable to maintain abstinence with psychosocial treatment alone. Medications that target the reinforcing effects of alcohol by modulating opioid and glutamate function are effective. First-line treatment options include naltrexone, a mu-opioid receptor antagonist, and acamprosate, a glutamate modulator. This patient is actively drinking and unable to control strong cravings. Naltrexone can be initiated while she is still drinking; it has been shown to decrease alcohol cravings, reduce heavy drinking days (defined as >5 drinks for men and >4 for women), and increase days of abstinence. A depot form of naltrexone can be used when there are concerns regarding nonadherence. Naltrexone is contraindicated in patients taking opioids and in those with acute hepatitis or liver failure; in these patients, acamprosate is preferred. (Choice A) Bupropion is not effective in alcohol use disorder. It is used in the treatment of depression and for smoking cessation. (Choice B) Benzodiazepines (eg, chlordiazepoxide) are used to treat moderate to severe alcohol withdrawal. They are associated with high risk of abuse and dependence and have no role in the treatment of alcohol use disorder. (Choice C) The aldehyde dehydrogenase inhibitor disulfiram works as an aversive agent by causing an unpleasant physiological reaction when alcohol is consumed. It does not reduce cravings directly. Disulfiram is reserved for abstinent patients who are highly motivated or who take the medication in a supervised setting (a patient may skip a dose to avoid the aversive reaction when alcohol is desired). It is considered a second-line agent and would not be preferred in this patient, who is actively drinking and lives alone. (Choice D) Selective serotonin reuptake inhibitors (eg, fluoxetine) have not demonstrated efficacy in patients who have alcohol use disorder and no comorbid mood or anxiety disorder. Educational objective: Pharmacotherapy is appropriate for patients with moderate to severe alcohol use disorder. Naltrexone is a first-line treatment that decreases cravings and heavy drinking; it can be initiated in patients who are still drinking provided they do not take opioids and have no significant liver disease. __________ References: Review article: pharmacotherapy for alcohol dependence - the why, the what and the wherefore. (http://www.ncbi.nlm.nih.gov/pubmed/28220511) Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/24825644) Reductions in alcohol craving following naltrexone treatment for heavy drinking. (http://www.ncbi.nlm.nih.gov/pubmed/27402770)

Question 16

A 28-year-old man comes to the emergency department due to worsening dyspnea, cough, and blood-streaked sputum for the last 3 days.  He has had no fatigue, fever, chills, upper respiratory symptoms, skin rash, eye symptoms, or joint pains.  The patient has no history of lung disease but takes ibuprofen occasionally for knee pain.  He does not use tobacco, alcohol, or illicit drug.  His father had a myocardial infarction at age 65 and his mother has rheumatoid arthritis.
Blood pressure is 150/90 mm Hg, pulse is 100/min, and respirations are 24/min.  Bilateral crackles are present in both lung bases and mid-lung fields.  Extremity examination reveals 1+ pitting edema to the mid-shins bilaterally.  The remainder of the examination is unremarkable.
Laboratory results are as follows:
 Chest x-ray shows diffuse pulmonary opacities.
Which of the following is the most likely diagnosis in this patient?

Accepted Answer

11ec193a_98c9_4ee9_853d_295f7458193d_MD0002_00 This patient has evidence of pulmonary-renal syndrome (pulmonary hemorrhage and glomerulonephritis), which is commonly caused by anti-glomerular basement membrane (GBM) antibody disease (Goodpasture syndrome) or by granulomatosis with polyangiitis. His lack of constitutional vasculitic symptoms (eg, fever, weight loss, arthralgia, fatigue) makes anti-GBM antibody disease more likely. Patients with anti-GBM antibody disease typically have a progressive glomerulonephritis (eg, hematuria, red blood cell casts, proteinuria, hypertension) and acute renal failure. Pulmonary involvement occurs in up to 60% of patients and presents with dyspnea, cough, and hemoptysis with pulmonary infiltrates on chest x-ray. Diagnosis is suggested by positive serum anti-GBM antibody and is confirmed by renal biopsy showing linear immunofluorescence of IgG in glomerular capillaries. Plasmapheresis is the preferred treatment to remove circulating antibodies and is combined with corticosteroids and cyclophosphamide to prevent formation of new antibodies. Compared to anti-GBM antibody disease, granulomatosis with polyangiitis is an inflammatory vasculitis and therefore more likely to cause constitutional vasculitic symptoms; in addition, ear, nose, and throat and ocular manifestations are common (Choice D). (Choice B) Cryoglobulinemic vasculitis can involve the lung and kidney but more commonly presents with dyspnea, cough, and isolated proteinuria rather than hemoptysis and glomerulonephritis. In addition, systemic symptoms, elevated rheumatoid factor, and low complement levels would be expected in active disease. (Choice C) Churg-Strauss syndrome (allergic granulomatosis and angiitis) is a vasculitis that rarely causes hemoptysis and glomerulonephritis; it more commonly presents with severe asthma, rhinosinusitis, prominent eosinophilia, and systemic symptoms. (Choice E) Systemic lupus erythematosus can also cause nephritic syndrome and, rarely, hemoptysis. However, this patient's normal serum complement and negative double-stranded DNA make systemic lupus erythematosus unlikely. Educational objective: Anti-glomerular basement membrane antibody disease (Goodpasture syndrome) commonly presents with progressive glomerulonephritis, renal failure, and pulmonary hemorrhage. Systemic symptoms (eg, fever, weight loss, arthralgias, fatigue) are absent; their presence should raise suspicion for vasculitis. __________ References: Cutting edge issues in Goodpasture's disease. (http://www.ncbi.nlm.nih.gov/pubmed/21207195)

Question 17

A 43-year-old man comes to the office for follow-up 12 weeks after starting sertraline for major depressive disorder.  The patient was initially started on sertraline 50 mg and started to improve when his dose was increased to 100 mg.  He now feels that he is back to baseline and reports significant improvement in mood, sleep, appetite, and energy over the past several weeks.  He is painting again and feels more optimistic.  Despite these improvements, the patient is troubled by a 2-month history of erectile dysfunction that started shortly after sertraline was titrated up to 100 mg.  He still sometimes wakes up with an erection.  He is distressed by this sexual dysfunction and says that it is straining his relationship with his wife.  The patient has no previous history of sexual dysfunction.  Medical history includes hypertension, for which he takes lisinopril.
Blood pressure is 130/80 mm Hg and pulse is 72/min.  Physical examination shows clear lung fields, normal S1 and S2, and intact bilateral dorsalis pedis pulses.
Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

11ec193a_98c4_6ce0_853d_1d82f2318a75_MD0002_00 Up to 50% of patients treated with selective serotonin reuptake inhibitors (SSRIs) may experience some degree of sexual dysfunction (eg, impaired orgasm, decreased libido, erectile dysfunction) as a side effect of treatment. The choice of management strategy should take into account the patient's response to antidepressants. In SSRI responders, such as this patient, augmentation with a second agent is preferred to switching to an alternate agent. In men with erectile dysfunction, augmentation with a phosphodiesterase-5 inhibitor (eg, sildenafil) is recommended. For women, augmentation with bupropion is typically suggested, although a phosphodiesterase-5 inhibitor is a reasonable option in those whose sexual dysfunction is limited to anorgasmia. For patients with no response or only modest benefit from their SSRI, switching to a non-SSRI antidepressant is recommended. Options include bupropion and mirtazapine, as these antidepressants are associated with lower rates of adverse sexual effects compared with SSRIs. (Choice B) Switching to mirtazapine would be indicated for a patient with poor response to SSRI treatment. In this patient, discontinuing sertraline would risk the loss of the antidepressant response. (Choice C) Venlafaxine is a serotonin norepinephrine reuptake inhibitor shown to impair sexual function at a rate comparable to SSRIs. (Choice D) This patient responded to the 100-mg dose; decreasing the dose may diminish the therapeutic effects. (Choice E) Although watchful waiting may be a reasonable approach initially, it is typically ineffective. Intervention is indicated as this patient has experienced persistent and distressing sexual dysfunction for 2 months. Educational objective: Sexual dysfunction is a common side effect of selective serotonin reuptake inhibitors (SSRIs). In SSRI responders, augmentation with a phosphodiesterase-5 inhibitor (eg, sildenafil) or bupropion can be beneficial. SSRI nonresponders are best managed by switching to a non-SSRI antidepressant (eg, bupropion, mirtazapine) for lower rates of treatment-related sexual dysfunction. __________ References: Strategies for managing sexual dysfunction induced by antidepressant medication. (http://www.ncbi.nlm.nih.gov/pubmed/23728643) Antidepressant drugs and sexual dysfunction. (http://www.ncbi.nlm.nih.gov/pubmed/23732933)

Question 18

A 16-year-old girl comes to the office due to a 3-week history of constipation and stomachaches, which are getting worse despite over-the-counter laxatives. The patient has no significant medical history and takes no medication. She consumes a vegan diet and exercises 2 hours a day, which she says "is necessary so I don't become any fatter than I am already." Family history is significant for Hashimoto thyroiditis in her mother, as well as scleroderma and obsessive-compulsive disorder in her sister. Physical examination is significant for a thin, young female with fine hair on her face and body and with dry skin. Temperature is 37.2 C (99 F), blood pressure is 80/55 mm Hg, pulse is 39/min, and respirations are 14/min. BMI is 16.5 kg/m². Laboratory results are as follows: Which of the following is the best next step in management of this patient?

Accepted Answer

11ec193a_98c5_7e53_853d_6335d42eb5a8_MD0002_00 This patient's significantly low BMI (<18.5 kg/m²), distorted view of her body weight, lanugo hair, bradycardia, hypotension, and hypokalemia are consistent with anorexia nervosa (AN). The mainstay of treatment in medically stable patients is psychotherapy and nutritional rehabilitation. However, when malnutrition is severe, organ compromise (eg, cardiomyopathy, cardiac atrophy, arrhythmia, respiratory failure, seizures) resulting from lack of nutrients or from electrolyte and fluid imbalances can be fatal. In these cases, inpatient hospitalization is required for medical stabilization and careful refeeding. ² Hospitalization of patients with AN is indicated with ≥1 of the following symptoms: Unstable vital signs, BMI <15 kg/m², syncope, electrolyte disturbance, seizures, cardiac failure, or dysrhythmias. This patient's presentation includes abnormal vital signs (hypotension, bradycardia) and electrolyte disturbances (hypokalemia). (Choices A and C) Although nutritional counseling and psychotherapy are the main forms of treatment for AN, this patient is medically unstable and first must be hospitalized due to the risks of complications from organ failure and cardiac compromise. (Choice D) Psychiatric evaluation is important in assessing for comorbid disorders such as depression and anxiety, which are often seen with AN. Hospitalization, however, is a priority in this patient. (Choice E) Although hypothyroidism can lead to constipation, bradycardia, and dry skin, it more often results in weight gain and hypertension rather than the hypotension and very low weight seen in this patient. In addition, thyroid function tests may not be helpful in management of AN as patients can present with euthyroid sick syndrome (ie, low T3 or T4) due to the body's adaption to chronic nutritional depletion. Educational objective: The long-term treatment of anorexia nervosa includes psychotherapy and nutritional rehabilitation. However, a patient with unstable vital signs, BMI <15 kg/m², or serious medical complication of malnutrition (eg, syncope, electrolyte disturbance, seizures, cardiac failure, dysrhythmias) must be hospitalized to prevent mortality from organ failure. ² __________ References: Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. (http://www.ncbi.nlm.nih.gov/pubmed/25591200) Identification and management of eating disorders in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/21115584)

Question 19

A 58-year-old woman comes to the office for an annual health examination.  She has a history of hypothyroidism, hypercholesterolemia, and depression.  Medications include levothyroxine, simvastatin, and escitalopram.  The patient reports feeling "tired and worn out" due to difficulty falling asleep and also awakening several times a night over the past several months.  She reports no change in appetite, bowel habits, interest in activities, or concentration.  The patient limits her caffeine intake to mornings and does not drink alcohol.  She quit her job last year in order to care full-time for her mother, who has Alzheimer disease and lives with her.  The patient says, "It's been difficult to see my mother decline, and I worry because she is increasingly confused and wanders at night.  I feel badly, because I get irritable when I am tired and lose patience with her.  I would like to keep Mom at home as long as possible, but it is difficult."
Vital signs and physical examination are unremarkable.  TSH is within normal limits.
Which of the following is the most appropriate intervention for this patient?

Accepted Answer

This patient's sleep disturbance and irritability are suggestive of caregiver distress. The burden of caring for dementia patients at home is considerable and increases as cognitive function declines and behavioral symptoms worsen (eg, wandering, agitation, aggression, psychosis). Signs of caregiver distress include sleep disturbance, depression, irritability, and anxiety as well as negative effects on physical health. Without intervention, the situation can progress to caregiver burnout, mental and physical illness, and increased likelihood of early nursing home placement for those with dementia. Early recognition of caregiver burden and providing assistance with obtaining support services can reduce distress and prevent burnout. Respite care services include in-home care services, adult day centers, and overnight care, which allow caregivers to take a break or vacation. Other helpful interventions include caregiver support groups, as well as comprehensive support programs that can assist caregivers in assessing the needs of the patient with dementia and the appropriate level of care as the disease progresses. (Choices A and B) Although education about the course of Alzheimer dementia and praising the patient's efforts are important, these interventions are not a substitute for relieving her burden by providing respite services. (Choices C and E) Caregivers are at increased risk for depression, and the physician should be vigilant for signs of depressive relapse in this patient. However, this patient is not showing other symptoms of depression. Her poor sleep is likely a result of caregiver stress and the need to monitor her mother's nighttime wandering. Alleviating her caregiving burden rather than increasing her antidepressant medication or adding a sleep medication would be a more appropriate first step. Educational objective: Caregiver distress can result in poor physical health and sleep and mood disturbances, as well as early nursing home placement for relatives with dementia. Support services (eg, respite care, support groups and programs) can help reduce caregiver burden. __________ References: Prevalence and predictors of burden in caregivers of people with dementia. (http://www.ncbi.nlm.nih.gov/pubmed/24012226) Caregiver burden: a clinical review. (http://www.ncbi.nlm.nih.gov/pubmed/24618967) Formal support for informal caregivers to older persons with dementia through the course of the disease: an exploratory, cross-sectional study. (http://www.ncbi.nlm.nih.gov/pubmed/26832354)

Question 20

A 53-year-old man is seen for a routine health examination.  He has a 30-year history of schizophrenia and was recently diagnosed with type 2 diabetes mellitus.  The patient's other medical conditions include hypercholesterolemia and seborrheic dermatitis.  Medications include metformin, lovastatin, and haloperidol.  The patient's schizophrenia had been controlled for many years on olanzapine until he was hospitalized 6 months ago for an acute psychotic episode that occurred when he was forced to move into a group home following the death of his father.  Since discharge, his psychotic symptoms have been well controlled on a stable dose of haloperidol.
On examination, the patient is cooperative but makes little eye contact.  He appears extremely anxious and restless.  He shifts frequently in his chair and crosses and uncrosses his legs continually.  Vital signs are within normal limits.  The remainder of the physical examination, apart from moderate obesity, is unremarkable.  Laboratory studies, including comprehensive metabolic panel, complete blood count, and TSH, are within normal limits.  Hemoglobin A1c is 7%.
Which of the following is the most likely explanation for this patient's symptoms?

Accepted Answer

11ec193a_98c0_c35b_853d_f7c3da39b10b_MD0002_00 This patient's anxiety, motor restlessness, and difficulty sitting still are most likely due to akathisia, a common extrapyramidal symptom (EPS) caused by antipsychotic medication. It is more common with high-potency first-generation antipsychotics, such as haloperidol, but also occurs with second-generation antipsychotics. Patients with akathisia frequently fidget, pace, rock while standing, cross and uncross their legs while sitting, and may describe a sense of inner restlessness, inability to sit still and urge to move. Akathisia is often extremely uncomfortable and distressing for patients. It can manifest as anxiety and agitation that may be mistaken for psychotic decompensation. Recognition is important, as increasing the antipsychotic dose will only worsen akathisia. If feasible, the antipsychotic dose should be reduced. Other options include treatment with a beta blocker or benzodiazepine. (Choice A) Acute dystonic reaction is another form of EPS characterized by sudden onset of distressing involuntary contraction of the neck, mouth, tongue, or eye muscles. It typically occurs within the first few days of antipsychotic exposure and is rapidly treated with anticholinergic medication (eg, benztropine, diphenhydramine). (Choice B) This patient's prominent physical restlessness makes akathisia more likely than an anxiety reaction to stress. Adjustment disorder is diagnosed when behavioral symptoms develop within 3 months after the onset of an identifiable psychosocial stressor and are not better explained by another disorder. (Choice D) This patient's psychotic symptoms have been well controlled on a stable dose of haloperidol. Therefore, his anxiety and agitation are more likely manifestations of akathisia. (Choice E) Tardive dyskinesia is an involuntary movement disorder associated with prolonged use of antipsychotic medications. It is characterized by repetitive, purposeless rhythmic movements typically involving the buccolingual masticatory areas and choreoathetoid movements of the trunk and limbs. Although this patient is at risk for tardive dyskinesia, his symptoms of restlessness and inability to sit still are more characteristic of akathisia. Educational objective: Akathisia is a common extrapyramidal symptom caused by antipsychotic medication and is characterized by inner restlessness, difficulty sitting still, and an urge to move. It may be mistaken for psychotic agitation. Management includes antipsychotic dose reduction if feasible and treatment with beta blockers or benzodiazepines. __________ References: The clinical challenges of akathisia. (http://www.ncbi.nlm.nih.gov/pubmed/26683525) Akathisia: an updated review focusing on second-generation antipsychotics. (http://www.ncbi.nlm.nih.gov/pubmed/19389331)

Exam 3: Office/Health Center