A 23-year-old woman comes to the office for follow-up after a recent hospitalization. The patient had no known psychiatric history prior to being arrested by police 2 months ago after breaking into city hall to "find evidence of a secret organization plotting to take over the world." When police officers took her into custody, she was speaking so rapidly that they had difficulty understanding her. She was subsequently hospitalized and prescribed appropriate treatment; symptoms improved, and she was discharged 2 weeks later. Since then, the patient has been taking medications as prescribed. She is "doing much better" and has no symptoms. Vital signs are within normal limits and physical examination is unremarkable. The patient's speech is regular in rhythm and rate and she appears calm. She is fully oriented and does not appear distracted. Laboratory studies are unremarkable except for serum calcium of 13.4 mg/dL. This patient is most likely taking which of the following medications?

Question

A 23-year-old woman comes to the office for follow-up after a recent hospitalization.  The patient had no known psychiatric history prior to being arrested by police 2 months ago after breaking into city hall to "find evidence of a secret organization plotting to take over the world."  When police officers took her into custody, she was speaking so rapidly that they had difficulty understanding her.  She was subsequently hospitalized and prescribed appropriate treatment; symptoms improved, and she was discharged 2 weeks later.  Since then, the patient has been taking medications as prescribed.  She is "doing much better" and has no symptoms.  Vital signs are within normal limits and physical examination is unremarkable.  The patient's speech is regular in rhythm and rate and she appears calm.  She is fully oriented and does not appear distracted.  Laboratory studies are unremarkable except for serum calcium of 13.4 mg/dL.  This patient is most likely taking which of the following medications?

Quizplus · Accepted Answer

This patient's acute onset of rapid speech and symptoms of psychosis (ie, delusions about a secret organization), followed by a return to normal functioning with treatment, is consistent with a bipolar manic episode. Pharmacotherapy for an acute manic episode includes a mood stabilizer and/or an antipsychotic medication. This patient's serum calcium level suggests that she was prescribed lithium, which can cause hyperparathyroidism and associated hypercalcemia. Lithium is indicated for acute mania and maintenance treatment of bipolar disorder. In addition to hyperparathyroidism, potential long-term side effects include nephrogenic diabetes insipidus, chronic kidney disease, and thyroid dysfunction (most often hypothyroidism). Furthermore, first-trimester lithium exposure is associated with teratogenic effects (eg, Ebstein anomaly). Current guidelines recommend a baseline basic metabolic panel (including blood urea nitrogen and creatinine), calcium, urinalysis, pregnancy test in women of childbearing age, and thyroid function tests before lithium is prescribed. An ECG is also recommended in patients with risk factors for coronary artery disease because lithium may cause dysrhythmias in these patients. Current guidelines (Choices A and E) The second-generation antipsychotics aripiprazole and quetiapine may be used in the treatment of bipolar disorder but are not associated with hypercalcemia. The most significant potential side effects of second-generation antipsychotics are weight gain, hyperlipidemia, and diabetes mellitus. (Choices B, C, and F) The anticonvulsant mood stabilizers carbamazepine, lamotrigine, and valproate are not known to cause clinically significant hypercalcemia. Carbamazepine and lamotrigine are noted for their risk of producing the mucocutaneous rash known as Stevens-Johnson syndrome. Valproate is known for its risk of inducing fetal neural tube defects and should be used with caution in women of childbearing age. Educational objective: Lithium is indicated both for the treatment of acute mania and for maintenance therapy in bipolar disorder. Long-term side effects include hyperparathyroidism with hypercalcemia, nephrogenic diabetes insipidus, chronic kidney disease, and thyroid dysfunction, as well as teratogenic effects. References: Lithium side effects and toxicity: prevalence and management strategies. (http://www.ncbi.nlm.nih.gov/pubmed/27900734) Lithium-associated hypercalcemia: pathophysiology, prevalence, management. (http://www.ncbi.nlm.nih.gov/pubmed/29260296)

A 23-Year-Old Woman Comes to the Office for Follow-Up After