A 9-year-old boy is brought to the clinic by his parents due to difficulty at school. According to his teachers, the boy has grunted frequently in class for the past year. Recently, it has reached the point of significantly distracting other students. His parents have also noted the grunting at home. They are concerned that he is being teased by his classmates and have noticed that since the behavior started he seems less interested in playing with his classmates after school. There is no family history of similar symptoms. The patient's medical history includes attention-deficit hyperactivity disorder treated with behavioral therapy and mild asthma treated with an albuterol inhaler. He takes no other medications and has no medication allergies. Temperature is 36 C (96.8 F), blood pressure is 119/78 mm Hg, and pulse is 82/min. The lungs are clear to auscultation. During the physical examination, the patient makes several sudden grunting noises and frequently shrugs his shoulders. Neurologic examination reveals normal strength and sensation in all extremities. Although he has an increased rate of blinking, he has no nystagmus. This patient is at greatest risk of developing which of the following?

Question

A 9-year-old boy is brought to the clinic by his parents due to difficulty at school.  According to his teachers, the boy has grunted frequently in class for the past year.  Recently, it has reached the point of significantly distracting other students.  His parents have also noted the grunting at home.  They are concerned that he is being teased by his classmates and have noticed that since the behavior started he seems less interested in playing with his classmates after school.  There is no family history of similar symptoms.  The patient's medical history includes attention-deficit hyperactivity disorder treated with behavioral therapy and mild asthma treated with an albuterol inhaler.  He takes no other medications and has no medication allergies.  Temperature is 36 C (96.8 F), blood pressure is 119/78 mm Hg, and pulse is 82/min.  The lungs are clear to auscultation.  During the physical examination, the patient makes several sudden grunting noises and frequently shrugs his shoulders.  Neurologic examination reveals normal strength and sensation in all extremities.  Although he has an increased rate of blinking, he has no nystagmus.  This patient is at greatest risk of developing which of the following?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c06a_d539_8f63_dd7de23db94c_MD0005_00 The presence of both vocal and motor tics is consistent with a diagnosis of Tourette syndrome (TS), which typically manifests before age 11. Diagnosis of this condition is based on clinical symptoms alone, as there are no diagnostic laboratory tests. Vocal tics can range from simple sounds (eg, coughing, grunting, throat clearing, clicks, sniffing), as in this patient, to blurting out inappropriate comments or obscenities (coprolalia). Motor tics typically involve the face and head and may also include complex movements of the torso and limbs. TS is frequently associated with comorbid psychiatric conditions; attention-deficit hyperactivity disorder and obsessive-compulsive disorder (OCD) are the most common. Therefore, this patient is at greatest risk of developing OCD. Comprehensive management of TS requires careful screening for and treatment of these common comorbid disorders. (Choices A and E) Although anxiety and mood disorders are significantly more common in children with TS than in those without, they are not as common as OCD. (Choice C) Oppositional defiant disorder or conduct disorder is often coexistent in patients with TS. However, OCD is the more common comorbid condition. (Choice D) Schizophrenia is not commonly associated with TS. Educational objective: Tourette syndrome is associated with several comorbid conditions; attention-deficit hyperactivity disorder and obsessive-compulsive disorder are the most common. References: Tourette syndrome and comorbid neuropsychiatric conditions. (http://www.ncbi.nlm.nih.gov/pubmed/27891299) Lifetime prevalence, age of risk, and genetic relationships of comorbid psychiatric disorders in Tourette syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/25671412)

A 9-Year-Old Boy Is Brought to the Clinic by His