Question 1

The patient is diagnosed with major depressive disorder and begins weekly psychotherapy.  Arrangements are made to have extra help in the home.  Despite these interventions, she becomes increasingly depressed and anxious.  The patient's husband is concerned that she is getting worse.  He says, "Although the baby is healthy, she continues to worry about the baby's feeding and growth and berates herself for being a bad mother.  She even has difficulty making everyday decisions such as what diapers and groceries to buy."  The patient has difficulty falling and staying asleep.  Her appetite is poor, and she has lost 15 pounds over the past month.  She says, "Maybe my baby would be better off without me" but has no intention or plan to take her own life or hurt her baby.  No delusions or hallucinations are elicited.  The patient is willing to take medication but wants to continue breastfeeding and does not want to take anything that would harm the baby.  Which of the following is the most appropriate intervention?

Accepted Answer

Explanation: Antidepressant therapy is indicated as this patient's depression is not responding to psychotherapy alone. Although all antidepressants are secreted in breast milk, research shows that the risk to infants from most antidepressants is low, and mothers should not be discouraged from breastfeeding (Choice E). Selective serotonin reuptake inhibitors (SSRIs) are the most widely studied class of antidepressants, with the best safety data for the drugs sertraline and paroxetine. The amount of these drugs secreted in breast milk is negligible and may be lower compared to other SSRIs and other classes of antidepressants. Sertraline and paroxetine are therefore considered first-line choices for postpartum, lactating patients who are starting treatment with an antidepressant. Patients who were treated with antidepressants during pregnancy up until delivery should be maintained on the same medication that was prescribed before delivery. (Choice A) Bupropion is generally not recommended as an initial choice in lactating women because there is less evidence for the safety of infant exposure to bupropion through breast milk, and a case report shows a possible association between infant exposure and seizures. (Choice B) Electroconvulsive therapy is considered a safe treatment option in the perinatal period; however, it is typically reserved for patients with treatment-resistant depression. (Choice D) This patient can be treated on an outpatient basis as she has no suicidal intent or plan and has adequate support. In addition, hospitalization could interfere with her ability to bond with the infant and develop a sense of competence as a mother. Patients with suicidal intent or plan, thoughts of harming the infant, or psychosis should be hospitalized. Educational objective: Patients with postpartum depression can be treated with antidepressants and continue breastfeeding. Sertraline and paroxetine are first-line drugs as they have the best safety record, and amounts secreted into breast milk are low or undetectable. References: Sertraline and breastfeeding: review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/25589155) Serotonin reuptake inhibitors and breastfeeding: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/25572308)

Question 2

A 16-year-old girl comes to the office for an annual checkup, accompanied by her mother.  The patient is a junior in high school and lives with her parents and 2 younger siblings.  During the visit, she discloses that she has had sexual intercourse several times with a boy in her class.  The patient believes she may be in love and says that the sex is consensual.  Her partner is using condoms.  When the physician inquires if her parents are aware that she is sexually active, the patient says, "I would never tell them.  They are totally against premarital sex.  They don't even allow me to date.  They would be furious if they knew."  Physical examination is normal and urine pregnancy test is negative.  Routine laboratory screening for common sexually transmitted diseases is performed, and the patient is educated about safe sex and contraceptive options.  The patient asks the physician to say nothing to her parents. 
Which of the following is the most appropriate response to the patient?

Accepted Answer

Explanation: Physicians are instrumental in ensuring that sexually active adolescents have access to health care and counseling services. Protecting the adolescent's confidentiality may be critical to maintaining a trusting physician-patient relationship and establishing an atmosphere of safety in which the adolescent feels comfortable discussing sexuality. Laws pertaining to parental disclosure differ by state, and the physician must be aware of these laws. Some states give the physician the option to disclose issues related to sexual health, mental health, or substance abuse to parents, particularly if the adolescent's health is at risk. Although adolescents should be encouraged to talk with their parents, the physician must use judgment about whether disclosure against the patient's wishes would benefit or harm the patient. If there is reasonable suspicion of child abuse or neglect, or a risk of harm to self or others, the patient's confidentiality should be broken. In this case, the adolescent is practicing safe sex, denies abuse, and asks the physician to maintain her confidentiality. Because there is no evidence of harm and disclosure would likely negatively affect the trusting relationship without clear benefit, the physician should not inform the parents against the patient's wishes (Choice A). (Choice B) Different states have differing requirements regarding parental consent when prescribing contraceptives, and it is possible that parental consent may be required. However, this adolescent has not asked for oral contraceptives, and making this statement so early in the interaction is likely to interfere with building rapport. (Choices C and E) Adolescents should generally be encouraged to involve their parents in their decisions; however, they should not feel pressured to disclose information if they are not ready or willing to do so. This patient has requested that the physician not speak with her parents due to her fear of receiving a harsh and judgmental response. Insisting on disclosure or setting up a meeting with her parents would likely damage the physician-patient relationship and may jeopardize her willingness to confide in health care providers in the future. Educational objective: Physicians should maintain the confidentiality of sexually active adolescents and ensure access to health care and counseling as much as possible. If child abuse is suspected, or if there is a risk of harm to self or others, breaking confidentiality becomes mandatory. References: Adolescents, contraception and confidentiality: a national survey of obstetrician--gynecologists. (http://www.ncbi.nlm.nih.gov/pubmed/21843691) Confidentiality concerns and sexual and reproductive health care among adolescents and young adults aged 15-25. (http://www.ncbi.nlm.nih.gov/pubmed/27996934)

Question 3

A 31-year-old man comes to the office with his wife, who is threatening to leave him if he does not get help.  The patient was recently fired from his job as a computer programmer due to frequent lateness and absences caused by his elaborate morning showering ritual.  He feels compelled to clean each part of his body in a specific order while counting to 27.  If he misses a body part or makes a mistake in counting, he must start over.  His wife adds that he often takes 3 showers in a row because "he won't accept that the towels I give him were just cleaned.  It has become extremely difficult to live with him."  Once dressed, the patient must go out of his way to take a certain route to work to avoid "dirty" street corners that may soil or contaminate his clothes.  He says, "I know it makes no sense, but I can't get rid of the thought that my clothes are splattered with urine.  Once this idea takes hold, I have to go home and change."  The patient became concerned with cleanliness as a young teen and wonders whether this was inherited from his mother, whom he describes as "a control freak."  He says, "I know I need help but prefer not to take medication if possible." 
Which of the following nonpharmacologic approaches would be most effective for this patient?

Accepted Answer

Explanation: 11ec2b69_c056_b0e6_8f63_35cf54091c91_MD0005_00 This patient is suffering from obsessive-compulsive disorder (OCD), and his obsessional fears of contamination and time-consuming cleaning rituals cause significant occupational and marital dysfunction. Exposure and response prevention therapy, a specific form of cognitive-behavioral therapy (CBT), is considered first-line psychotherapy for OCD. Exposure and response prevention therapy involves gradual and repetitive exposure to anxiety-provoking stimuli that produce obsessional thoughts (eg, contamination fears), followed by prevention of performing the associated compulsion or ritual (eg, compulsive cleaning, repetitive showers). Effective exposure and response prevention therapy requires that the patient remain in the exposure situation until the obsessional distress decreases spontaneously, without attempts to reduce the distress by performing the compulsion. Through the process of habituation, in which anxiety levels subside over time, OCD symptoms are reduced. (Choice A) Dialectical behavioral therapy is a form of CBT developed for the treatment of borderline personality disorder. (Choice C) Interpersonal psychotherapy focuses on improving dysfunctional relationships and interpersonal functioning. It is used primarily in the treatment of depressive disorders. (Choice D) Psychodynamic psychotherapy, which traces problems back to their origins in childhood, may provide the patient with insight but is not effective in changing the compulsive behaviors seen in OCD. (Choice E) Although supportive psychotherapy is helpful to reduce stress and improve coping skills, it does not specifically target obsessive and compulsive symptoms. Educational objective: Exposure and response prevention, a form of cognitive-behavioral therapy, is considered a first-line nonpharmacologic intervention for obsessive-compulsive disorder. References: Symptom dimensions in obsessive-compulsive disorder: phenomenology and treatment outcomes with exposure and ritual prevention. (http://www.ncbi.nlm.nih.gov/pubmed/23615340)

Question 4

A 14-year-old girl comes to the office accompanied by her mother for an annual examination.  The patient's medical problems include acne, for which she takes clindamycin.  When seen alone for examination, she is shy and quiet.  The patient says everything is "going okay."  She does not have a boyfriend and is not sexually active.  When asked about drug and alcohol use, she says, "No, but I have tried alcohol and marijuana a few times at parties."  Physical examination is normal other than mild acne, which has improved since her last visit.  Following the examination, the physician informs the mother that everything is fine, renews the patient's clindamycin prescription, and asks if she has any questions.  With the daughter present, the mother replies, "I remember what it's like to be a teenager, but she is really impossible to deal with now.  I can't get her up on time in the morning because she stays up late on her computer.  She no longer wants to spend time with the family.  In the morning, she refuses to eat breakfast and then sleeps during the entire drive to school.  I worry because her school friends use drugs.  I think they are a bad influence and now her grades are falling.  I don't know how she will get into a decent college.  We warned her that she wouldn't be allowed to go on the family vacation if she doesn't improve her grades, but she doesn't seem to care." 
Which of the following is the most appropriate next step in response to the mother's concerns?

Accepted Answer

Explanation: In this scenario, the mother has raised concerns about the patient's behavior at the close of the visit. It is unclear whether these are legitimate concerns regarding declining academic performance and possible substance misuse or whether the mother is overreacting to normal adolescent changes in sleep patterns and/or the patient's need for increasing privacy and independence. Although the patient reported that she was "okay" when first seen alone, she was quiet and not forthcoming. The mother's report of changes in her behavior is concerning and requires further assessment. The most appropriate step is to ask to speak with the patient alone again to obtain a better understanding of these issues from the patient's perspective. Adolescents often feel uncomfortable speaking with a parent present, and sensitive topics, such as substance use and mental health issues, are better addressed privately. This will build trust and allow the patient to be more open than she might be if questioned in the presence of her mother. (Choice A) Asking the patient to respond directly to the mother may place her in an awkward and defensive position and inhibit her from speaking truthfully. (Choice B) Although a urine drug test might identify unreported substance use, the patient has been forthcoming about her occasional drug use; as a result, requesting a screening would likely damage the physician-patient relationship. (Choice C) There is not enough information to reassure the mother that these are normal adolescent behaviors. (Choice E) Although this mother might benefit from feedback regarding her critical communication style with her daughter, it is not appropriate at this time. The mother is genuinely concerned, and the most important step is to perform further assessment. Educational objective: Developing rapport and trust is particularly important in treatment of the adolescent patient. When a parent raises concerns, assessment should include interviewing the patient alone. References: Effective interviewing and counseling of the adolescent patient. (http://www.ncbi.nlm.nih.gov/pubmed/16570482) Skills for interviewing adolescent patients: sustainability of structured feedback in undergraduate education on performance in residency. (http://www.ncbi.nlm.nih.gov/pubmed/27413448)

Question 5

A 72-year-old woman is brought to the emergency department after a fall. The patient landed on her side and has extensive bruising over the right hip area. She was able to reach her phone and call an ambulance to bring her to the hospital. She says, "I lost my balance on the way to the bathroom. I usually have to get up to go to the bathroom once or twice a night." The patient has no history of lightheadedness, dizziness, or syncope. She leads an active lifestyle and walks 2 miles every day. Her medical problems include type 2 diabetes mellitus, urge incontinence, chronic insomnia, transient ischemic attacks, and osteoarthritis. Her daily medications include aspirin, glyburide, lorazepam, and naproxen. The patient lives alone. She does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. Physical examination and subsequent x-rays reveal a right-sided femoral neck fracture. Neurological examination is normal. Item 1 of 2 Which of the following is the most appropriate intervention to reduce this patient's risk of falls?

Accepted Answer

Explanation: Medication use is one of the most common modifiable risk factors for falls and subsequent hip and femur fractures. In older adults, most falls result in injury, with 10%-15% resulting in fractures. Benzodiazepine use is strongly associated with a risk of falls and increased mortality in older patients. Intermediate- and long-acting agents and higher doses increase this risk further by contributing to impaired balance and decreased mental alertness. Discontinuing lorazepam in this patient would be the most appropriate intervention to reduce her risk of falls and fractures. Other risk factors associated with increased falls include advanced age, female sex, history of a fall, use of other psychotropic medications (eg, antipsychotics, antidepressants), cognitive impairment, lower-extremity weakness, balance problems, and arthritis. (Choice A) Although this patient's urge incontinence likely contributes to her need to use the bathroom at night, adding a strongly anticholinergic agent such as oxybutynin would create a high risk of delirium and increased falls. The first step is to assess the role her current medications play in her symptoms. (Choice C) A structured program of muscle strengthening and balance training is highly useful in preventing falls in susceptible persons. However, this patient's osteoarthritis is not associated with significant limitations or balance problems, and avoiding benzodiazepines would take precedence. (Choice D) This patient's normal neurological examination makes it unlikely that she has diabetic neuropathy, which could contribute to imbalance and falls. Strict control of diabetes in older individuals is associated with a higher incidence of hypoglycemia, which could lead to more frequent falls. (Choice E) Providing a walker is not indicated as the patient leads an active life and walks without difficulty. Educational objective: The use of benzodiazepines in older adults is associated with a higher incidence of falls and resulting fractures, with overall increases in mortality. The need for such drugs should be reevaluated periodically, and they should be avoided if possible. References: Association between benzodiazepines and recurrent falls: a cross-sectional elderly population-based study. (http://www.ncbi.nlm.nih.gov/pubmed/21267523) Polypharmacy including falls risk-increasing medications and subsequent falls in community-dwelling middle-aged and older adults. (http://www.ncbi.nlm.nih.gov/pubmed/25313240)

Question 6

A 32-year-old woman comes to the office for prenatal counseling.  The patient recently married and hopes to start a family soon.  She has a history of severe bipolar disorder and chronic insomnia.  The patient has been treated previously with quetiapine, valproate, and citalopram.  After several hospitalizations for severe manic and depressive episodes in her late 20s, she has been stable on lithium for the past 2 years.  She also takes lorazepam occasionally for sleep.  The patient has a history of 2 suicide attempts.  She says, "I can't wait to be a mother, but I am worried about the effects of medication on the baby.  I also don't want to get manic or depressed again.  Being in the hospital is so awful and I am doing so well now.  I have such a supportive husband and my work is going well."  The patient receives counseling regarding management of her condition and treatment options during pregnancy.  Which of the following is the most important medication to avoid prescribing at this time?

Accepted Answer

Explanation: All psychotropic medications cross the placenta, and the risks of using psychotropics in pregnancy must be weighed against the benefits of treating the psychiatric condition. Psychiatric illness itself has been associated with negative outcomes, including preterm birth and lower Apgar scores. General guidelines for prescribing psychotropics in pregnancy include avoiding first-trimester exposure, if possible, and using the lowest doses and as few agents as possible. The anticonvulsant valproate is commonly used as a mood stabilizer in the acute and maintenance treatment of bipolar disorder. It should be avoided in pregnancy if possible due to its high risk of major congenital malformations, especially neural tube defects (eg, spina bifida). Women exposed to valproate in the first trimester, the critical period of organogenesis, are at particularly high risk, with studies indicating up to a 20-fold increase over the general population (an absolute risk of 1%-2%). Compared with valproate, other psychotropic agents used to treat bipolar disorder, including lithium, have lower teratogenic potential. (Choices A and D) Most systematic reviews have not shown a significantly increased risk of major malformations with the use of most antidepressants (eg, citalopram) or antipsychotics (eg, quetiapine). These drugs are not considered major teratogens and can be used during pregnancy when clinically indicated. Their risks and benefits must be weighed against the risks of untreated psychiatric illness to the mother and fetus (eg, suicide, inadequate self-care and nutrition). (Choice B) Lithium is potentially teratogenic and has been associated with an increased risk of Ebstein anomaly, characterized by apical displacement of the tricuspid valve leaflets and atrialization of the right ventricle. However, the absolute risk of Ebstein anomaly is very low due to the rarity of the condition. This patient has severe bipolar illness that has stabilized only with the use of lithium. Her risk of recurrence without treatment is significant and could negatively impact her ability to care for herself and a fetus, especially if she were to become suicidal again. The risks of recurrence may therefore outweigh the low risk of Ebstein anomaly. Patients with severe bipolar illness that is responsive to lithium may elect to continue this medication with close monitoring. (Choice C) Benzodiazepines (eg, lorazepam) are not associated with an increased risk of congenital malformations. However, chronic use close to delivery can cause neonatal withdrawal. Educational objective: The anticonvulsant valproate, used to treat epilepsy and bipolar disorder, is a teratogen associated with a wide range of malformations, particularly neural tube defects. Women taking this medication should be warned that it is a teratogen and advised to plan their pregnancies. References: Managing your own mood lability: use of mood stabilizers and antipsychotics in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/26685903) Sodium valproate and the fetus: a case study and review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/19892633) Teratogenesis associated with antibipolar agents. (http://www.ncbi.nlm.nih.gov/pubmed/19330496)

Question 7

A 38-year-old man was brought to the emergency department after nearly being hit by a car that swerved to avoid hitting him as he walked down the middle of a busy city street.  On arrival, the patient was ataxic and his speech was slurred.  He had evidence of polysubstance abuse on toxicology testing.  He received intravenous fluids and was monitored for several hours in the emergency department.  The patient's vital signs are now stable.  He is oriented to time, place, and person, and he feels badly about his behavior.  As the patient is about to be discharged, his wife arrives.  He informs the staff that he does not wish to see her.  Before the staff can intervene, she bursts into his room and they begin a heated argument about his substance use, recent job loss, and neglect of family responsibilities.  The nurse asks the patient's wife to leave, but she says, "I'm not leaving.  He is going to hear everything I have to say!"  The patient becomes increasingly agitated and starts shouting.  His fists are clenched and his loud voice and offensive language disrupt nearby staff and patients.  Which of the following is the most appropriate next step in management?

Accepted Answer

Explanation: This patient is ready for discharge but becomes agitated when unexpectedly confronted with his angry spouse. The priority in this situation is to protect the patient, his wife, and the staff from violent acts. Initial management should involve nonpharmacologic interventions. Separating the patient from his wife would be the best initial step. Hospital security should be called to ask the patient's wife to leave (and escort her outside if necessary). If the patient becomes increasingly agitated and threatening despite her removal, then medication to calm him should be considered. Physical restraints are typically necessary for administering intramuscular medication or for patients who are at risk for harming themselves or others despite adequate medication. Safety in the emergency department requires the presence of adequate security personnel and protocols for managing agitated patients and visitors. Hospital security should be used in situations that may escalate quickly and that require prompt action to protect staff and other patients. Medications (benzodiazepines and antipsychotics) should be reserved for situations in which nonpharmacologic interventions fail to de-escalate an agitated patient. (Choice A) Chemical restraints should be implemented only if other strategies to defuse the situation fail or there is imminent risk of violence. In this case, a show of force by security and separating the patient from his wife would be the best next step. (Choice B) This situation is escalating rapidly and the wife has already refused to leave when asked by the nurse. In the interest of safety, it would be best to separate them immediately. The wife should not be encouraged to return, as her presence is a cause of his agitation. (Choice D) Discharging the patient in an agitated state is inappropriate and increases the risk of potential violence. (Choice E) It would be unsafe to have a social worker attempt to de-escalate this situation without security present. Prior to discharge from the emergency department, a social worker may counsel a receptive patient (and the patient's spouse with the patient's permission) about community support and resources for substance use treatment. Educational objective: Ensuring the safety of patients and staff in the emergency department is essential for effective patient care. This requires the presence of adequate security personnel and protocols for managing agitated patients and visitors. Medications (benzodiazepines and antipsychotics) are reserved for situations in which nonpharmacologic interventions fail to de-escalate an agitated patient. References: Workplace violence in emergency department and its effects on emergency staff. (http://www.ncbi.nlm.nih.gov/pubmed/25585480) The assessment and management of the violent patient in critical hospital settings. (http://www.ncbi.nlm.nih.gov/pubmed/23260370) A systematic review of the literature: workplace violence in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/20846214)

Question 8

A 63-year-old man with Parkinson disease, hypertension, and a history of depression returns to the office accompanied by his wife.  His current medications include amantadine and carbidopa/levodopa, to which he has responded well, in contrast to his insufficient response to previous medications prescribed for Parkinson disease.  During his last visit, his dosage of carbidopa/levodopa was increased to target continued shuffling gait, rigidity, and frequent falls.  The patient's wife says that initially he did very well after the recent dosage increase.  They were able to partake in more social activities, dine out, and visit with friends, and the patient's falls became far less frequent.  However, over the past week, she has become increasingly concerned about his behavior.  He has become more withdrawn and started to avoid his friends.  The patient falsely accused her of infidelity and suddenly refused to see his son, saying, "All he wants is to get his hands on my money."  He also called the police on several occasions because he reported seeing strangers in his bedroom.  The patient is afebrile; blood pressure is 114/76 mm Hg and pulse is 64/min.  Physical examination shows mild rigidity and tremor, which have improved since his last visit.  The remainder of the examination is unremarkable.  He shows no signs of dementia, delirium, or infection.  Which of the following medication adjustments would be most appropriate in management of this patient?

Accepted Answer

Explanation: Most medications for Parkinson disease increase dopamine activity, either through direct receptor stimulation (eg, dopamine agonists, carbidopa/levodopa), decreased dopamine breakdown (eg, monoamine oxidase [MAO-B] inhibitors), or increased dopamine release (eg, amantadine). Other medications include anticholinergics (which can decrease acetylcholine effect in relation to dopamine effect) and catechol-O-methyl transferase (COMT) inhibitors, which can prolong levodopa's effect. Any medication that increases dopamine activity can cause psychotic symptoms. This patient has developed paranoid delusions and visual hallucinations following an increase in levodopa. Although dosage reduction or discontinuation of carbidopa/levodopa is an option (Choice D), this would not be the appropriate first step as this medication has significantly improved the patient's motor symptoms and quality of life. To maintain therapeutic effect, the least potent medications should be reduced or discontinued first, in the following order: anticholinergics, amantadine, MAO-B inhibitors, COMT inhibitors, dopamine agonists, and, finally, carbidopa/levodopa. The first step would be to reduce or taper off amantadine while maintaining the dosage of carbidopa/levodopa. Addition of low-dosage antipsychotics is indicated for medication-induced psychosis that persists despite adjustments to determine the minimum effective dosage of anti-parkinsonian medication. The low-potency second-generation antipsychotics quetiapine (Choice A) and clozapine have the lowest incidence of drug-induced parkinsonism and may be indicated. In contrast, potent D2 dopamine receptor antagonists such as first-generation antipsychotics and the second-generation antipsychotic risperidone (Choice B) should be avoided due to the risk of motor symptoms. Recently, pimavanserin, a serotonin 5HT-2A receptor inverse agonist, has been approved by the FDA for the treatment of psychotic symptoms in patients with Parkinson disease. (Choice C) Although this patient has a history of depression, his recent behavioral change is more consistent with psychosis than depression. His recent social withdrawal is most likely due to his increasing paranoia. Educational objective: Anti-parkinsonian medications can cause psychosis due to their dopaminergic effects. After ruling out dementia, delirium, or other medical etiologies for psychosis, the least potent medications should be withdrawn first before considering reducing carbidopa/levodopa. If psychosis continues despite adjustments of dopaminergic medications, quetiapine, clozapine, or pimavanserin should be considered. References: Psychosis in Parkinson disease: a review of etiology, phenomenology, and management. (http://www.ncbi.nlm.nih.gov/pubmed/27830568)

Question 9

A 9-year-old boy and his 5-year-old sister are brought to the office by their mother.  The boy has been sad and has cried frequently since the family dog was hit by a car and died 10 days ago.  His mother says, "The other day he had a severe stomachache and did not want to go to school.  I later learned from his teacher that he was very embarrassed after crying in front of his classmates.  I am also worried that he has been asking to sleep in my bed.  He hasn't done that in years."  In contrast, his sister is cheerful and acts as though nothing has happened.  The mother says, "She doesn't seem sad at all.  She's excited about her upcoming birthday party this weekend and plans to set a place for the dog at the table."  Neither child has a history of medical or psychiatric problems or takes any medications.  Their developmental and growth milestones are normal.  Which of the following is the most appropriate response to the mother's concerns?

Accepted Answer

Explanation: Bereavement in children can present in different ways, depending on the child's age. The type of death, nature of the relationship to the deceased, personality and temperament of the child, pre-existing risk factors such as mental illness, quality of family support, and concurrent life stressors may also contribute to the varieties of response. Preschool children usually react to the loss of a loved person or pet with disbelief and may think that death is temporary or reversible. For example, they may think that the dead person or animal is only sleeping and will later wake up or come back to life. The 5-year-old girl acting as though the dog is still alive and her magical thinking that it can reappear are not pathological. It would not be helpful to explain the finality of death to a 5-year-old (Choice B). (Choices C and D) Older children (age >7), in contrast, are aware that death is final. They may react with sadness, crying, self-blame, inability to concentrate, anger, nightmares, regression to earlier behaviors, social isolation, and school problems such as avoidance or academic difficulty. The 9-year-old boy's sadness, crying, school avoidance, and regressive behavior are normal reactions in the weeks following the unexpected death of a beloved pet. Support from the parents, including encouragement to express feelings at the child's own pace and reassurance that the child is not to blame, is usually sufficient to help him or her through the bereavement period. Psychiatric/psychology referral should be pursued if there are signs of persistent mood disturbance or academic or social impairment does not improve. (Choice E) Regression to earlier behaviors is common during periods of stress and is typically self-limiting. Recommending that the 9-year-old boy return to his bed may further embarrass him or invalidate his appropriate distress at losing his pet. Educational objective: Bereavement in children can present in different ways, depending on the child's age. Preschool children tend to react with disbelief and may have magical thoughts that death is temporary or reversible. Older children understand the finality of death and may experience a range of emotional and behavioral reactions, including sadness, anxiety, anger, self-blame, regression, and avoidance.

Question 10

A 26-year-old woman, gravida 1 para 0, at 8 weeks gestation is brought to the emergency department by her husband after saying that she wants to die and threatening to hang herself.  In the past few weeks, the patient has become increasingly depressed and uninterested in doing anything.  She spends most of her time in bed and sleeps 14 hours a day.  She has lost 4.5 kg (10 lb) due to refusal to eat or drink.  The patient says that food is "polluting my body and allowing my demon child to grow."  She has a long history of poorly controlled bipolar disorder with episodes of depression and mania.  The patient made 2 suicide attempts during her teens.  She takes no medications currently and is not under the care of a therapist or psychiatrist.  The patient appears thin, with dry and chapped mucous membranes.  Physical examination is otherwise normal.  During examination, she makes monosyllabic responses and has slowed movements.  The patient is admitted to the psychiatric unit.  Which of the following is the most appropriate next step in management?

Accepted Answer

Explanation: 11ec2b69_c05a_3359_8f63_43a487eb7c9b_MD0005_00 This patient's severe depression with psychotic features (delusions about food and the baby), refusal to eat or drink, and active suicidality require emergency treatment. Electroconvulsive therapy (ECT) is a highly effective treatment for unipolar or bipolar depression in patients with psychotic features or persistent suicidality, or who require a rapid treatment response (eg, severe neurovegetative symptoms, nutritional depletion). ECT is considered relatively safe during pregnancy and would be most likely to achieve a rapid response in this patient, whose untreated mental illness poses great risk to herself and the fetus. (Choices B and E) Antidepressant monotherapy should be avoided in bipolar patients due to the risk of inducing mania. (Choice C) Lithium is used to treat bipolar mania and depression. However, the time required for titration and for lithium to take effect make it a poor choice in this emergency situation. Lithium is associated with a slightly increased risk of cardiac malformations (Ebstein anomaly) but can be used during pregnancy in patients with severe bipolar illness. (Choice D) Valproate, an anticonvulsant mood stabilizer, is used to treat mania and depression in bipolar disorder. However, it should be avoided in pregnant women due to the significantly increased risk of neural tube defects, craniofacial abnormalities, microcephaly, growth retardation, cleft lip and palate, limb defects, and genital anomalies. Educational objective: Electroconvulsive therapy is the treatment of choice for severely depressed patients who require urgent treatment (eg, imminent suicidality, nutritional depletion). It is relatively safe in pregnancy. References: A systematic review of the safety of electroconvulsive therapy use during the first trimester of pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/27327556) A meta-review of the safety of electroconvulsive therapy in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/28009621) Electroconvulsive therapy in pregnant patients. (http://www.ncbi.nlm.nih.gov/pubmed/23890597)

Question 11

A 31-year-old man comes to the office with his wife, who is threatening to leave him if he does not get help.  The patient was recently fired from his job as a computer programmer due to frequent lateness and absences caused by his elaborate morning showering ritual.  He feels compelled to clean each part of his body in a specific order while counting to 27.  If he misses a body part or makes a mistake in counting, he must start over.  His wife adds that he often takes 3 showers in a row because "he won't accept that the towels I give him were just cleaned.  It has become extremely difficult to live with him."  Once dressed, the patient must go out of his way to take a certain route to work to avoid "dirty" street corners that may soil or contaminate his clothes.  He says, "I know it makes no sense, but I can't get rid of the thought that my clothes are splattered with urine.  Once this idea takes hold, I have to go home and change."  The patient became concerned with cleanliness as a young teen and wonders whether this was inherited from his mother, whom he describes as "a control freak."  He says, "I know I need help but prefer not to take medication if possible." After 12 weeks of twice-weekly therapy, the patient has made some improvement but still has significant anxiety and difficulty changing his rituals.  Although he is better able to resist counting, he continues to shower excessively and still changes his clothes several times a day.  The patient was offered a new job but turned it down when he learned that it would require him to share a computer keyboard with coworkers.  He and his wife are frustrated that he has not made more progress.  The patient is now more receptive to the idea of taking medication.  His other medical problems include obesity and premature ejaculation.  He takes no medication other than acetaminophen as needed.  Physical examination is normal.  Which of the following medications is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: Serotonergic antidepressants have demonstrated efficacy in the treatment of obsessive-compulsive disorder (OCD). All selective serotonin reuptake inhibitor (SSRI) antidepressants (eg, fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram) and the tricyclic antidepressant clomipramine are effective. Although no medication has demonstrated superior efficacy over another, SSRIs are recommended as first-line treatment due to their superior side-effect profile compared with that of clomipramine. High doses and prolonged therapeutic trials are typically required, and gradual up-titration is necessary to enhance tolerability. Although SSRIs can cause sexual dysfunction in general, they would be beneficial in this patient. SSRIs are also used as first-line agents in the treatment of premature ejaculation due to their potential to cause delayed ejaculation. (Choice A) Bupropion is a nonserotonergic antidepressant that inhibits the reuptake of norepinephrine and dopamine. It is not effective in the treatment of OCD. (Choice B) Buspirone is used in the treatment of generalized anxiety disorder; it is not used to treat OCD. (Choice C) Clomipramine is considered a second-line agent due to its adverse effects, which include orthostatic hypotension, anticholinergic effects, and cardiac conduction delay. (Choice D) Olanzapine is a second-generation antipsychotic used to treat schizophrenia and bipolar disorder. It is not used as monotherapy in OCD. Antipsychotics may be added to an SSRI or clomipramine in treatment-refractory cases. Educational objective: Selective serotonin reuptake inhibitors (SSRIs) are first-line medications for obsessive-compulsive disorder. High doses and prolonged trials are typically required, and gradual up-titration is necessary to enhance tolerability. The tricyclic antidepressant clomipramine or antipsychotic augmentation can be used in patients who do not respond to SSRIs. References: Obsessive-compulsive disorder (OCD): practical strategies for pharmacological and somatic treatment in adults. (http://www.ncbi.nlm.nih.gov/pubmed/25681005) Pharmacotherapy of obsessive-compulsive disorder: evidence-based treatment and beyond. (http://www.ncbi.nlm.nih.gov/pubmed/23125399)

Question 12

A 65-year-old woman is brought to the emergency department by her son. The patient lives alone and works as a librarian. The son became concerned 2 days ago when "she didn't sound right and seemed somewhat confused over the phone." When he arrived at her home this morning, the patient was disoriented and her speech was slurred. Medical history is significant for diabetes mellitus controlled with metformin. The son says that a "mood disorder" runs in the family and that she has taken lithium, escitalopram, and risperidone for the past several years. A month ago, the patient was diagnosed with hypertension and arthritis, and treatment with chlorthalidone and acetaminophen was initiated. She does not use tobacco, alcohol, or illicit drugs. Temperature is 36.1 C (97 F), blood pressure is 150/90 mm Hg, pulse is 52/min, and respirations are 16/min. Physical examination shows coarse hand tremor and an unstable gait. The patient is oriented to person but not to time or place. Item 1 of 2 Which of the following is the most likely cause of this patient's symptoms?

Accepted Answer

Explanation: Lithium, a mood stabilizer used in bipolar disorder, has a narrow therapeutic index. This patient's gradual onset of neurologic symptoms (slurred speech, confusion, tremors, and ataxia) is consistent with lithium toxicity. Therapeutic lithium levels are 0.8-1.2 mEq/L. Serum lithium levels >1.5 mEq/L confirm toxicity, and levels >2.5 mEq/L require emergency management. Risks for lithium toxicity include low glomerular filtration rates (eg, the elderly, patients in renal failure), volume depletion, and drug interactions. This patient's lithium toxicity is most likely due to a drug interaction with chlorthalidone. Thiazide diuretics, such as chlorthalidone, increase sodium excretion in the distal tubule and cause slight volume depletion. The resulting increased proximal tubular reabsorption of sodium also promotes lithium reabsorption, leading to lithium toxicity. ACE inhibitors and nonsteroidal anti-inflammatory drugs (NSAIDs) also increase lithium levels. Patients who are co-administered these medications require close lithium level monitoring and lithium dosage reduction if necessary. (Choice A) NSAIDs, not acetaminophen, increase lithium levels and can result in lithium toxicity. (Choice C) Neuroleptic malignant syndrome is an acute, potentially fatal, idiosyncratic reaction to antipsychotic medications and is characterized by fever, extreme generalized rigidity, autonomic instability, and altered mental status. This patient is afebrile, has no rigidity, and has been on risperidone for several years. (Choice D) Serotonin syndrome can include confusion and tremulousness. However, it is typically caused by use of multiple serotonergic agents; myoclonus, hyperreflexia, hyperthermia, and tachycardia would also be expected. This patient's symptoms are more characteristic of lithium toxicity. (Choice E) This patient has several risk factors for stroke (eg, hypertension, diabetes). However, patients with stroke have an abrupt onset of focal neurologic deficits rather than the insidious onset of confusion, ataxia, and neuromuscular excitability seen in this patient. Educational objective: Lithium has a narrow therapeutic index, and serum levels >1.5 mEq/L confirm toxicity. Lithium toxicity (eg, confusion, ataxia, neuromuscular excitability) can be precipitated by volume depletion and drug interactions with thiazide diuretics, ACE inhibitors, and nonsteroidal anti-inflammatory drugs. References: Drug interactions with lithium: an update. (http://www.ncbi.nlm.nih.gov/pubmed/26936045) Antihypertensive therapy in patients on chronic lithium treatment for bipolar disorders. (http://www.ncbi.nlm.nih.gov/pubmed/26630207)

Question 13

A 21-year-old woman comes to the office due to poor sleep and depression.  She has been feeling progressively depressed and unmotivated over the past month, and also describes decreased appetite, a 2.2-kg (5-lb) weight loss, poor concentration, and low energy.  The patient has no suicidal ideation or manic or psychotic symptoms.  She drinks 1 or 2 beers twice a week but does not use illicit drugs.  She has never felt like this before and is worried as her symptoms have worsened to the point that she has trouble getting out of bed and attending college.  Major depressive disorder is diagnosed, and the patient is started on citalopram 20 mg.  One month later, she returns for a follow-up visit.  She now reports feeling much better, has improved energy and sleep, and has returned to school.  The patient has no side effects from the medication and wonders how long she should continue it.  Which of the following is the most appropriate recommendation?

Accepted Answer

Explanation: This patient has a first episode of major depression that has responded to acute treatment with citalopram. To reduce the risk of depressive relapse, guidelines recommend that patients with a single episode of major depressive disorder should continue antidepressant treatment for approximately 6 months following acute response (referred to as "continuation phase treatment"). The dosage that achieved response should be maintained and not reduced (ie, the dose that gets the patient well keeps the patient well) (Choice A). Patients with a history of multiple episodes (recurrent major depressive disorder), chronic episodes (≥2 years), strong family history, or severe episodes (eg, suicide attempt) should be considered for maintenance treatment. This typically involves continuing antidepressant medication for 1-3 years following remission to reduce the risk of recurrence (Choice D). Patients with a history of highly recurrent (eg, ≥3 lifetime episodes) and very severe, chronic major depressive episodes may need to continue maintenance treatment indefinitely. (Choices B and E) Discontinuing the antidepressant in several weeks or in 2 months would increase the patient's risk for relapse. Antidepressants should be continued for approximately 6 months into the continuation phase. Ideally, they should be tapered when discontinued. Educational objective: Patients with a single episode of major depressive disorder should continue antidepressants at the same dosage for an additional 6 months following acute response to reduce the risk of relapse. Those with recurrent, chronic, or severe episodes should be considered for maintenance treatment (1-3 years or indefinitely) to reduce the risk of recurrence. References: Duration of initial antidepressant treatment and subsequent relapse of major depression. (http://www.ncbi.nlm.nih.gov/pubmed/25502491) Antidepressant dose reduction and the risk of relapse in major depressive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/17700046)

Question 14

A 75-year-old man comes to the office due to difficulty sleeping for the past several months.  The patient says, "I think I would be fine if I could just get some sleep."  He describes taking at least 45 minutes to an hour to fall asleep at night.  He also awakens 2-3 times in the middle of the night and has difficulty falling back asleep, often staying up for an hour or more at a time.  He wakes up naturally at his usual time of 6:30 AM but then feels tired throughout the day.  The patient lives in a retirement community.  His wife died last year and he lives alone.  He misses his wife but has no other psychosocial stressors and enjoys playing golf and socializing with a group of friends.  He does not feel anxious or depressed and is not sure what keeps him awake or why he is waking up so often.  His medical history is significant for aortic stenosis, well-controlled hypertension, osteoporosis, benign prostatic hyperplasia, and constipation.  His current medications include terazosin, alendronate, and over-the-counter fiber supplements and multivitamins.  The patient does not smoke or use illicit drugs.  He drinks alcohol rarely on social occasions.  Physical examination is noncontributory.  Which of the following is the most appropriate management of this patient's condition?

Accepted Answer

Explanation: Nonpharmacological management, rather than hypnotic medications, is the recommended first-line treatment for insomnia. Cognitive-behavioral therapy (CBT) for insomnia is the treatment of choice and should be recommended to this patient. CBT typically combines several approaches, including addressing dysfunctional thoughts about sleep with cognitive therapy, and behavioral measures such as sleep hygiene, sleep restriction, stimulus control, and relaxation techniques. Benefits of CBT persist beyond the active treatment period. Hypnotic medications should be reserved for patients who do not improve with CBT and should be used with particular caution in the elderly. The elderly are at high risk of adverse effects from hypnotic drugs as these patients are slower to metabolize and eliminate most medications, resulting in a longer duration of effect. Common adverse effects include daytime sedation, cognitive impairment, delirium, night wandering, agitation, balance problems, falls, and fractures. (Choice A) Diphenhydramine is an antihistamine with sedative properties that can be used to promote sleep. However, it has anticholinergic properties that can cause confusion and worsen benign prostatic hyperplasia and constipation. (Choices B and C) Benzodiazepines are not recommended for treatment of chronic insomnia. These should be avoided in the elderly due to the risks of residual daytime sedation, cognitive impairment, abuse and dependence, and motor incoordination resulting in falls and hip fracture. (Choice D) The nonbenzodiazepine zolpidem is effective for the short-term treatment of insomnia but is also associated with adverse effects, including cognitive impairment, somnolence, dizziness, and falls. It should not be used as an initial treatment for insomnia in the elderly. When prescribed for elderly patients, the lowest dose should be used. Educational objective: Cognitive-behavioral therapy is the preferred initial therapy for insomnia. Elderly patients have an increased risk for adverse effects of hypnotic medications, including daytime sedation, cognitive impairment, delirium, night wandering, agitation, balance problems, falls, and fractures. If medications are necessary, they should be prescribed with caution and in the smallest possible dose. References: Review of safety and efficacy of sleep medicines in older adults. (http://www.ncbi.nlm.nih.gov/pubmed/27751669) Nonbenzodiazepine sedative hypnotics and risk of fall-related injury. (http://www.ncbi.nlm.nih.gov/pubmed/26943470)

Question 15

A 39-year-old man with schizoaffective disorder comes to the office for a follow-up appointment.  The patient has a history of 4 hospitalizations for manic and psychotic episodes and lives in a supervised group home.  Three months ago, he was hospitalized for a manic episode characterized by euphoria, racing thoughts, and grandiose delusions of being a famous performer.  At the time, he heard voices telling him that he was "chosen" and commanding him to "sing for glory."  During the hospitalization, the patient was successfully treated with valproate and risperidone and continued on these medications following discharge.  One month ago, a trial of lowering his risperidone dose was terminated when it resulted in an increased frequency of auditory hallucinations.  At today's visit, the patient's mood remains stable but he feels restless and uncomfortable, reporting, "I can't seem to sit still or relax."  The patient appears nervous and shakes his right leg constantly during the examination.  At one point, he gets up and paces around the room.  Vital signs and physical examination are unremarkable.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: This patient is experiencing akathisia, a side effect of antipsychotic drugs characterized by a subjective feeling of inner restlessness, urge to move, and inability to sit still. Although more common with first-generation antipsychotics, it also occurs with second-generation antipsychotics. It is distressing for patients and a common cause of medication nonadherence. It is important to recognize akathisia and manage it appropriately; mistaking a patient's restlessness and pacing for increasing psychotic agitation may lead to increasing the antipsychotic dose and potentially worsening akathisia. The initial approach to akathisia is cautious reduction of the antipsychotic dose and monitoring for psychotic exacerbation. However, in this case, reduction in antipsychotic dose resulted in worsening auditory hallucinations. When dose reduction is not feasible, the addition of a beta blocker, such as propranolol, is indicated. Benztropine and benzodiazepines have also been used. (Choice A) Adding haloperidol, a high-potency, first-generation antipsychotic, would only worsen the patient's akathisia. (Choice C) Decreasing the dosage of valproate may result in the return of manic symptoms. Akathisia is not a common side effect of this medication. (Choice D) Lorazepam can be used to treat akathisia. However, discontinuing risperidone would likely result in psychotic relapse. (Choice E) Because the patient is already experiencing side effects from his current dose of risperidone, increasing the dose would likely result in worsening of akathisia. In addition, there is no mention of additional psychotic symptoms that would warrant a dosage increase. Educational objective: Akathisia, characterized by a feeling of inner restlessness, urge to move, and inability to sit still, is a common side effect of antipsychotic drugs that is distressing for patients and can lead to medication nonadherence. When antipsychotic dose reduction is not feasible, a beta blocker, such as propranolol, can be added to treat akathisia. References: Akathisia: an updated review focusing on second-generation antipsychotics. (http://www.ncbi.nlm.nih.gov/pubmed/19389331) Revisiting antipsychotic-induced akathisia: current issues and prospective challenges. (http://www.ncbi.nlm.nih.gov/pubmed/27928948)

Question 16

A 58-year-old man comes to the office due to low motivation and loss of interest.  He says, "I love my family and work is okay, but I'm just not able to enjoy anything anymore.  On weekends, I sit on the couch all day and avoid my friends.  I prefer to be alone."  The patient has a history of hypertension, hypercholesterolemia, and coronary heart disease.  Family history is significant for a father with cardiovascular disease and mother with osteoporosis and breast cancer.  The patient's uncle died following a myocardial infarction at age 62.  After a full evaluation, the patient is diagnosed with major depressive disorder.  Treatment options, including psychotherapy and antidepressants, are discussed, but the patient is reluctant to consider either treatment.  He says, "With my schedule I have no time for therapy and I don't like to talk about these things.  I am also concerned about the effects of medication on my heart.  I don't want to die at such a young age like my uncle did."  Which of the following is the most accurate statement when counseling the patient?

Accepted Answer

Explanation: Research has repeatedly shown a bidirectional link between major depression and coronary artery disease, with depression being an independent risk factor for increased morbidity and mortality in cardiovascular disease (CVD). Patients with CVD experience a greater likelihood of developing depression. Physiological mechanisms for this include increased inflammation, endothelial cell dysfunction, abnormal platelet activation, and increases in cortisol and sympathetic tone. Similarly, patients with depression have increased disability from cardiovascular conditions, possibly due to having less motivation for medication adherence or lifestyle modifications as well as being physically inactive. This patient should be counseled that antidepressants are safe and effective in treating major depression in patients with CVD. Due to the patient's concern about having a fatal heart attack, he should be informed of the association of increased mortality with untreated depression. (Choices A and B) Studies indicate that antidepressants, especially selective serotonin uptake inhibitors, are overwhelmingly safe and likely to be effective in the treatment of depression in patients with CVD. Full antidepressant doses are required, and drug interactions with cardiac medications are generally not significant. (Choice C) Although depression is established as an independent predictor of mortality in patients with CVD, there is no evidence that antidepressant treatment directly prevents heart attacks. (Choice D) It would be inappropriate to only monitor the patient's depression when treatment can improve his functioning and quality of life. Educational objective: Major depression is an independent risk factor for increased morbidity and mortality in cardiovascular disease. Treatment with selective serotonin reuptake inhibitors is considered a safe and effective option. References: Persistent psychological distress and mortality in patients with stable coronary artery disease. (http://www.ncbi.nlm.nih.gov/pubmed/28652315) Depression as a risk factor for adverse outcomes in coronary heart disease. (http://www.ncbi.nlm.nih.gov/pubmed/23675637) Treatment of affective disorders in cardiac disease. (http://www.ncbi.nlm.nih.gov/pubmed/26246788)

Question 17

A 65-year-old woman is brought to the emergency department by her son.  The patient lives alone and works as a librarian.  The son became concerned 2 days ago when "she didn't sound right and seemed somewhat confused over the phone."  When he arrived at her home this morning, the patient was disoriented and her speech was slurred.  Medical history is significant for diabetes mellitus controlled with metformin.  The son says that a "mood disorder" runs in the family and that she has taken lithium, escitalopram, and risperidone for the past several years.  A month ago, the patient was diagnosed with hypertension and arthritis, and treatment with chlorthalidone and acetaminophen was initiated.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.1 C (97 F), blood pressure is 150/90 mm Hg, pulse is 52/min, and respirations are 16/min.  Physical examination shows coarse hand tremor and an unstable gait.  The patient is oriented to person but not to time or place. The patient's lithium level was found to be 4.2 mEq/L (normal: <1.5 mEq/L).  Which of the following is the most effective management strategy?

Accepted Answer

Explanation: 11ec2b69_c055_9f74_8f63_71030a915da8_MD0005_00 Hemodialysis is the most effective method to rapidly remove lithium (a small, charged, non-protein-bound particle). The indications for hemodialysis in lithium toxicity are: Lithium level >4 mEq/L Lithium level of 2.5-4 mEq/L with severe neurologic symptoms or acute kidney injury A rising lithium level despite appropriate volume resuscitation (Choice A) Hydration with isotonic saline increases renal filtration and lithium excretion by the kidneys. All patients with lithium overdose, except those with specific contraindications (eg, decompensated congestive heart failure), should be hydrated with intravenous fluids. However, hydration alone at higher lithium levels is not sufficient. (Choice B) Charcoal does not bind to charged particles like lithium and is not useful in lithium toxicity. Gastrointestinal decontamination in acute poisoning can be performed using a polyethylene glycol solution. (Choice C) Furosemide can cause volume depletion, increase lithium reabsorption in the proximal tubules, and worsen lithium toxicity. (Choice E) Although lithium toxicity may precipitate distal (type 1) renal tubular acidosis, it rarely results in actual metabolic acidosis or the need for sodium bicarbonate infusion. Educational objective: Lithium toxicity presenting with severe neurologic symptoms is an absolute indication for urgent hemodialysis. Other indications for hemodialysis include a lithium level >4 mEq/L or an increasing lithium level despite saline administration. References: Lithium: updated human knowledge using an evidence-based approach: part III: clinical safety. (http://www.ncbi.nlm.nih.gov/pubmed/19453201) Extracorporeal treatment for lithium poisoning: systematic review and recommendations from the EXTRIP Workgroup. (http://www.ncbi.nlm.nih.gov/pubmed/25583292)

Question 18

A 28-year-old woman, gravida 1 para 1, comes to the office for a postpartum check-up 3 weeks following a cesarean delivery due to cephalopelvic disproportion.  She is accompanied by her husband who expresses concern that his wife is crying frequently and having difficulty adjusting to being a new mother.  He says, "She was so happy to get pregnant.  Apart from the gestational diabetes and having to watch her diet, she was fine through much of the pregnancy.  Now, she seems stressed and anxious and not as happy about the baby as I expected."  The baby is doing well and had a normal check-up at the pediatrician.  The patient describes mild discomfort at the incision site, tension headaches, poor appetite, and fatigue from frequent nighttime awakenings to breastfeed.  She says, "I have no energy and feel guilty that I can't even enjoy the baby."  The patient spends her time searching the internet for baby care advice but has difficulty remembering what she has read.  She worries about the baby's health and fears "I'm a bad mother."  Her medical problems include obesity and gastroesophageal reflux.  The patient has no past psychiatric history.  Family history is significant for alcohol abuse and type 2 diabetes in the patient's father and anxiety disorder in the mother.  Physical examination is normal.  Hemoglobin is 12.5 g/dL and TSH is 2.1 µU/mL.  Her oral glucose tolerance test is within the normal range.  Mental status examination reveals a depressed and anxious mood and a tearful affect.  The patient has no thoughts of suicide or of harming the baby.  Which of the following is the most likely diagnosis?

Accepted Answer

Explanation: This patient's symptoms are concerning for major depressive disorder (depressed mood, anhedonia, sleep disturbance, poor appetite, impaired concentration, tearfulness, guilt). All patients should be screened for postpartum depression at the postpartum visit. Postpartum depression is diagnosed using the same diagnostic criteria used to diagnose a major depressive episode (>2 weeks of at least 5 of 9 symptoms that include depressed mood plus SIGECAPS: Sleep disturbance, loss of Interest, Guilt, low Energy, impaired Concentration, change in Appetite, Psychomotor retardation or agitation, and Suicidal thoughts). A screening instrument such as Edinburgh Postnatal Depression Scale can also be used to assess which women require a more thorough evaluation. Postpartum blues (Choice D) is a self-limited condition consisting of milder depressive symptoms with less impact on functioning. It typically peaks at 5 days postpartum and resolves within 2 weeks. By contrast, this patient's depressive symptoms have persisted beyond 2 weeks and appear to be worsening. (Choice A) Adjustment disorder is diagnosed only if symptoms do not meet criteria for another specific disorder such as major depressive disorder. (Choice B) Generalized anxiety disorder is characterized by persistent worry about multiple issues lasting at least 6 months. This patient's excessive anxiety is an associated symptom of her acute depression and revolves around the care of her infant. (Choice C) This diagnosis is given when the mood disturbance is directly caused by another medical condition (eg, hypothyroidism, anemia). This patient's laboratory results indicate that she is euthyroid, not anemic, and her gestational diabetes has resolved. Educational objective: All women should be screened for depression at the postpartum visit. Postpartum depression is diagnosed using the same diagnostic criteria for major depressive episodes that occur outside of the postpartum period. Postpartum blues is a milder form of depression with less impact on functioning and usually resolves within 2 weeks. References: The American College of Obstetricians and Gynecologists Committee Opinion no. 630. Screening for perinatal depression. (http://www.ncbi.nlm.nih.gov/pubmed/25932866) Identification and management of peripartum depression. (http://www.ncbi.nlm.nih.gov/pubmed/27175720) Postpartum psychiatric disorders: early diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/26330638)

Question 19

A 23-year-old man newly diagnosed with bipolar disorder was admitted to the psychiatry unit 3 days ago.  Since admission, he has spent all of his time at the nurses' station trying to convince the staff to discharge him.  His speech is very loud and difficult to interrupt.  He states that his roommate is "hitting" on him because of his good looks, and refuses to eat the food because it is not up to his standards.  In addition, he is worried that he will miss his meeting with the President, which he says may cause the country to be forced into war.  Despite attempts to redirect the patient, he becomes progressively more agitated and starts to verbally threaten the staff.  He bangs on the desk at the nurses' station and throws a chair down the hallway.  The patient is given emergency intramuscular haloperidol to decrease his agitation.  A few hours later, the patient approaches the nurses' station screaming, "Something is wrong.  Look what you did to me!  I have been poisoned!  Get me out of here immediately before I die!"  Examination shows sustained upward deviation of the eyes and tilting of the neck to the right side.  Which of the following is the most appropriate course of action?

Accepted Answer

Explanation: 11ec2b69_c052_9232_8f63_473ad2c9fdab_MD0005_00 This patient is experiencing an acute dystonic reaction manifested by torticollis and an oculogyric crisis (forced, sustained elevation of the eyes in an upward position). Acute dystonia is a type of extrapyramidal symptom (EPS) that develops within hours to days of starting or dose escalation of antipsychotics. This patient's risk factors include young age, male sex, and use of a high-potency, first-generation antipsychotic (haloperidol). Other types of EPS include akathisia (inner restlessness) and drug-induced parkinsonism (tremor, rigidity, bradykinesia, masked facies). Very distressing acute dystonic reactions are best treated with anticholinergic medication administered intravenously or intramuscularly. Diphenhydramine, an antihistamine with significant anticholinergic activity, or benztropine is commonly used. (Choice A) Amantadine is a dopamine agonist used to treat drug-induced parkinsonism, not acute dystonic reactions. (Choice B) Dantrolene is a muscle relaxant that has been used in severe cases of neuroleptic malignant syndrome, a rare but life-threatening condition characterized by mental status change, high fever, autonomic instability, and diffuse muscle rigidity. (Choice D) Lorazepam may be given to help reduce anxiety but will not relieve acute dystonia. Lorazepam is sometimes used to treat akathisia, another type of EPS. (Choice E) Although acute dystonic reactions can resolve spontaneously with discontinuation of the offending medication, they are usually very distressing and uncomfortable for the patient. Therefore, this patient should be treated with diphenhydramine. Educational objective: Acute dystonic reaction is a type of extrapyramidal symptom that is highly disturbing to patients. It is most commonly seen with high-potency, first-generation antipsychotics and is treated with anticholinergics (benztropine) or antihistamines (diphenhydramine). References: Acute dystonic reaction as medical emergency: a report of two cases. (http://www.ncbi.nlm.nih.gov/pubmed/24116333)

Question 20

A 34-year-old woman comes to the office for a routine checkup.  She initially says, "Everything's fine."  Later she says, "I have been in a funk since being passed over for a promotion at work last month.  I guess it's normal to be disappointed, but I am down on myself and feel totally worthless.  It's really hard to be motivated now and some days I wish I could stay in bed all day."  The patient describes difficulty concentrating on her work assignments and explains that she is tired at work because she sleeps poorly at night.  She has lost 1.8 kg (4 lb) without dieting and says, "I used to enjoy cooking, but now I just snack or eat prepared foods."  The patient lives with her husband and describes him as supportive.  She does not use tobacco or illicit drugs.  She drinks a glass of wine 4-5 times a week.  The patient has no history of psychiatric illness or treatment.  Her mother and sister suffered from depression and were treated successfully with antidepressants.  On mental status examination, the patient has depressed mood and sad affect but no suicidal ideation.  Physical examination and routine laboratory testing are unremarkable.  A diagnosis of major depressive disorder is made and treatment options are discussed.  The patient is open to psychotherapy or taking antidepressants but would like to avoid medications that may cause weight gain.  She asks the physician which treatment is most effective.  Which of the following is the most appropriate response to this patient?

Accepted Answer

Explanation: Options for the initial treatment of major depressive disorder include antidepressants, psychotherapy, or a combination of both. Studies have shown that the combination of pharmacotherapy and psychotherapy is more effective than either pharmacotherapy or psychotherapy alone. Factors that influence treatment selection include patient preference, availability of psychotherapy, comorbidity, psychosocial issues, and cost. Antidepressant efficacy is generally comparable across and within classes (Choice D). Most patients will be initiated on a selective serotonin reuptake inhibitor for a first episode. However, there is no clear evidence that one antidepressant is significantly more effective than another, and other classes (eg, serotonin norepinephrine reuptake inhibitors) may also be used as first-line therapy. Side effect profiles and patient preference should be taken into consideration. Among the major psychotherapies, cognitive-behavioral therapy and interpersonal psychotherapy are frequently recommended as they have been more widely studied than other types of psychotherapies. (Choice A) Although many antidepressants cause weight gain and this is a factor in treatment selection, it is not true of all antidepressants. For example, bupropion is an antidepressant that is not associated with weight gain and could be considered in this patient. (Choice B) The efficacy of antidepressants and psychotherapy is generally comparable. (Choice C) There is no evidence that the presence of an identifiable stressor predicts poor antidepressant treatment response. Educational objective: For the initial treatment of major depressive disorder, the combination of pharmacotherapy and psychotherapy is more effective than either alone. Although selective serotonin reuptake inhibitors are typically used as first-line therapy, there is no evidence that one class of antidepressant is more effective; other classes can be considered depending on side effect profile and patient preference. References: Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/24497254)

Exam 1: Advanced Clinical Medicine