Question 1

A 24-year-old male veteran comes to the office for evaluation of chronic knee pain.  He has no other medical history.  He takes naproxen for knee pain due to an old athletic injury and says that he borrowed some oxycodone/acetaminophen from a friend on 2 occasions when the pain was particularly severe.  He requests a prescription for pain medication "just in case the pain does not improve.  I used to work in construction and I can't be in pain or I won't get a job."  The patient has been unable to find steady employment since returning from his last deployment and worries about providing for his wife and 2-year-old son.  He discloses that he has been drinking more when he feels depressed and can't sleep.  The patient has difficulty both falling and staying asleep and problems concentrating.  He feels guilty for not wanting to spend time with his son and for punching a hole in the wall during a recent argument with his wife.  His appetite is unchanged and he has no suicidal ideation.  Physical examination is unremarkable.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c05d_67ac_8f63_3bb544d0b93c_MD0005_00 This patient's history of military deployments and symptoms of depression, sleep disturbance, impaired concentration, angry outbursts, and emotional detachment raise concern for post-traumatic stress disorder (PTSD). Patients with PTSD may try to avoid discussing past trauma and minimize their symptoms. Military personnel, in particular, may be reluctant to disclose PTSD symptoms due to stigmatization and fear of professional repercussions. Primary care physicians should be especially alert to screening for PTSD in returning veterans and individuals experiencing new-onset anxiety, insomnia, interpersonal conflicts, or escalating substance use. Screening to elicit symptoms of PTSD includes inquiring about disturbing memories, nightmares, and flashbacks of traumatic events and assessing for symptoms of hypervigilance, amnesia, and avoidance. Patients with PTSD frequently use substances to self-medicate symptoms and are at high risk for developing substance use disorders. (Choice A) Although the patient exhibits some symptoms of depression, it would be premature to initiate antidepressant treatment without screening him for PTSD. Optimal management of PTSD includes trauma- focused psychotherapy in addition to pharmacotherapy. (Choice B) Over time, it would be important to inquire further about the patient's anger, impulse control, and violence in the home. However, asking to speak with the wife alone before rapport is established and a full assessment is made would be inappropriate and could damage the physician-patient relationship. (Choice C) Support programs for veterans may be helpful but would not substitute for screening for PTSD. If further inquiry supports a PTSD diagnosis, the patient should be referred for comprehensive mental health services. (Choice D) This patient's alcohol use and possible misuse of pain medications require further evaluation, but referral to a rehabilitation program is premature. Substance use disorders are commonly comorbid with PTSD and must be addressed concurrently for optimal outcomes. Educational objective: Physicians should be alert to the possibility of post-traumatic stress disorder (PTSD) in veterans reporting new-onset insomnia, substance use, and interpersonal conflicts. Optimal treatment of PTSD involves a combination of trauma-focused psychotherapy and medication. References: Posttraumatic stress disorder in veterans and military personnel: epidemiology, screening, and case recognition. (http://www.ncbi.nlm.nih.gov/pubmed/23148803) Investigation of abbreviated 4 and 8 item versions of the PTSD Checklist 5. (http://www.ncbi.nlm.nih.gov/pubmed/27137973) Treating veterans and military families: evidence based practices and training needs among community clinicians. (http://www.ncbi.nlm.nih.gov/pubmed/27155870)

Question 2

A 36-year-old woman is brought to the outpatient psychiatry clinic by her husband.  He says that his wife was fine and working as a store clerk until about 8 months ago, when they relocated to another state for his new job.  Soon after, the patient's behavior abruptly changed.  She became suspicious of her neighbors and has remained convinced that they are secretly monitoring her with hidden cameras planted outside the couple's new apartment.  She claims that she hears the neighbors whispering about her every night, and her husband has seen her shout at other people when no one is in the room.  The patient has stopped cleaning and cooking and is fearful of going outside.  For the past month, she has refused to pick up their daughter at school as she believes the child has been replaced by an imposter.  She hears voices warning her that "this is not your child."  The patient has no history of similar signs or symptoms, and there is no family history of psychiatric illness.  Physical examination is unremarkable.  Recent results of blood work, urine toxicology, and a brain CT scan were also normal.  The husband asks if his wife will be okay.  Which of the following is the most appropriate statement regarding this patient's prognosis?

Accepted Answer

Explanation: 11ec2b69_c060_9bfe_8f63_03ef7979a5fc_MD0005_00 The presence of psychotic symptoms (not due to substances or a medical condition) for more than 6 months is consistent with a diagnosis of schizophrenia. Schizophrenia generally presents in late adolescence and early adulthood (peak age: men, early 20s; women, late 20s) and can have a gradual or acute onset. Good prognostic factors include a later age of onset and acute onset. In contrast, patients with schizophrenia who have an early onset in childhood or adolescence and who exhibit a gradual or insidious onset over months to years (the prodrome) have a worse prognosis. The prodromal period is characterized by nonspecific mood and anxiety symptoms (eg, idiosyncratic thinking, perceptual disturbances, deterioration in academic or occupational functioning, increasing social isolation) without overt delusions and hallucinations. This patient's older age at first episode and acute onset (no prodrome) are favorable prognostic factors (Choices A and B). The presence of positive psychotic symptoms (eg, delusions, hallucinations), which typically respond well to antipsychotic medication, is considered a good prognostic factor (Choice C). Early intervention that limits the duration of untreated psychosis has also been associated with better outcome. In contrast, patients with predominantly negative symptoms (eg, flat affect, loss of motivation, anhedonia) and longer duration of untreated psychosis have a worse prognosis. (Choice D) Although this patient has many favorable prognostic factors for schizophrenia, most patients exhibit some residual symptoms between episodes of active psychosis and do not completely return to their premorbid condition. Educational objective: Good prognostic factors in schizophrenia include acute onset (lack of prodrome), older age at onset, and positive psychotic symptoms. Antipsychotic medications are more effective for treating positive psychotic symptoms than negative symptoms, and early intervention to decrease duration of active psychosis improves the course of illness. References: Early-onset schizophrenia. (http://www.ncbi.nlm.nih.gov/pubmed/22797279) Adolescent vs. adult onset of a first episode psychosis: impact on remission of positive and negative symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/27102425)

Question 3

A 22-year-old man comes to the clinic for routine follow-up of his mild asthma.  He has a history of keeping his appointments but has missed the last three.  Today he seems distracted and uninterested, answering various questions with very brief replies.  At one point, the patient says that he would like to hurry the visit along so he can get home sooner.  Following inquiries about his social life, he becomes more animated and describes spending time with new friends who "really know how to party."  On further questioning, he says, "I have been snorting cocaine sometimes but it's not a big deal.  I haven't used any this past week.  I quit school because it was just stupid and I was wasting my money.  I'm working as a waiter now and enjoying it.  At least I can make my own money and not be dependent on my parents."  The patient says that he has been living with his new friends since his parents asked him to move out 2 weeks ago, but he would "rather not talk about that."  He denies any symptoms of depression, mania, or psychosis.  Temperature is 37.7 C (99.9 F), blood pressure is 120/82 mm Hg, pulse is 86/min, and respirations are 15/min.  Physical examination shows perforations of the nasal septum. After discussion, the patient agrees to curtail his cocaine use and says that it will not be a problem.  He is receptive to a back-up plan of referrals to 12-step group programs and outpatient substance abuse programs.  The physician asks for permission to speak with his parents, and the patient says he will think about it.  However, he fails to attend his 1-month follow-up appointment.  Six months later, the patient makes an appointment to renew his asthma medications.  When the physician notes multiple track marks on his arms, the patient admits he has been injecting cocaine.  He has lost his job as a waiter and is currently unemployed.  He has not spoken to his parents and is temporarily staying with a friend who also uses drugs.  The patient says he tried a few Narcotics Anonymous meetings but did not attend regularly and has been unable to stop using.  He admits to feeling depressed and has lost 4.5 kg (10 lb).  He has no suicidal ideation.  Which of the following is the most appropriate step in managing the patient's substance use problem?

Accepted Answer

Explanation: Substance abuse treatment can be provided in various settings and at different levels of intensity. Appropriate referral requires an individualized assessment of the patient, including severity of substance use, whether the patient is currently intoxicated or in withdrawal, evaluation of medical and psychiatric comorbidity or complications, motivation to change, degree of support in the home environment, and level of functional impairment. This patient has progressed from intranasal to intravenous use and is increasingly impaired. He now exhibits depressive symptoms that are most likely substance-induced. He has no social support and is surrounded by people who are using and have ready access to drugs. The best approach is an inpatient rehabilitation program that can provide a safe, drug-free environment; assessment and management of medical and psychiatric complications; and a highly structured, intensive substance abuse treatment. (Choice A) Although cognitive-behavioral therapy is effective in substance use disorders, it is unlikely to be helpful for this patient unless it is incorporated into a comprehensive drug rehabilitation program that restricts his access to drugs. Bupropion may alleviate stimulant withdrawal symptoms by facilitating dopamine neurotransmission, but it is not effective in treating cocaine use disorder. (Choice B) A peer self-help group such as Narcotics Anonymous is a powerful tool for many people in recovery. However, this patient's inability to stop using and lack of support at home suggest that meetings alone would be ineffective. Once abstinence is achieved, attendance in 12-step programs can be critical to maintaining long-term abstinence. Random urine drug tests independent of a comprehensive drug treatment program would not be beneficial. (Choice D) Outpatient rehabilitation programs are appropriate for higher-functioning patients who are self-motivated and have good support systems. This patient is unemployed, is in a temporary living arrangement with a friend who uses drugs, and has increasing symptoms of depression. He has missed a number of follow-up appointments with his physician and is unlikely to adhere to or do well in an outpatient program at this point. (Choice E) Psychiatric hospitalization is indicated for patients experiencing severe intoxication or physical withdrawal symptoms or those who pose a danger to themselves or others. If this patient were actively suicidal, inpatient hospitalization followed by referral to a drug rehabilitation program once he is stabilized would be appropriate. Educational objective: Referral to the appropriate level of treatment for substance use disorders requires individualized assessment of the patient for severity of substance use, intoxication/withdrawal, medical and psychiatric comorbidity, degree of self-motivation, adequacy of social support, and level of functional impairment. References: Residential treatment for individuals with substance use disorders: assessing the evidence. (http://www.ncbi.nlm.nih.gov/pubmed/24445598)

Question 4

A 58-year-old woman comes to the office for follow-up for smoking cessation. Four weeks ago, the patient asked to be started on nicotine replacement therapy and was prescribed a maximal-dose nicotine transdermal patch with nicotine gum. Since then, smoking has been reduced from 2 packs a day to less than a pack a day. Medical history includes hypertension, type 2 diabetes mellitus, and peripheral artery disease. Blood pressure is 132/84 mm Hg and pulse is 86/min. BMI is 32 kg/m². She is determined to quit smoking and requests that varenicline be added to her therapy. In combining these two therapies, this patient is at increased risk for which of the following serious complications?

Accepted Answer

Explanation: 11ec2b69_c062_49b0_8f63_f9fb6a966f41_MD0005_00 The most commonly used pharmacotherapies for smoking cessation include nicotine replacement, varenicline, and bupropion. Nicotine replacement therapy (NRT) can be used in smoking cessation to decrease withdrawal symptoms and reduce nicotine cravings. Combining a long-acting NRT (eg, patch) with a short-acting NRT (eg, gum, lozenge, nasal spray), termed a "patch-plus regimen," is more effective than either modality alone. Typically, NRT produces no significant adverse effects other than skin irritation from the patch. Varenicline, a partial nicotine receptor agonist, also reduces nicotine cravings and withdrawal symptoms. Varenicline is generally well tolerated, with mild adverse effects (eg, nausea, insomnia, unusual dreams). In the past, the drug carried a black-box FDA warning for suicide/depression, but the warning was removed in 2016 after more data became available (Choice C). In head-to-head randomized trials, varenicline was more effective than buproprion, nicotine patch, or placebo. A number of randomized control studies have looked at the combination of varenicline and NRT, and most have shown increased effectiveness of the combination therapy, without increase of serious adverse effects. Combination therapy is associated with mild adverse effects, such as nausea, insomnia, and mild skin reactions. (Choice A) Initially, varenicline was thought to increase the frequency of cardiovascular events, but later studies have shown no significant link (alone or in combination with NRT), and there is no evidence that the combination of varenicline and NRT increases the risk for angina. Furthermore, the benefits of smoking cessation likely outweigh any increase in risk. (Choices B and D) Bupropion is an antidepressant frequently used for smoking cessation; it increases the risk for seizures and can worsen hypertension. However, there is no evidence that varenicline, NRT, or their combination affects blood pressure or seizure threshold. Educational objective: Varenicline is the most effective pharmacologic intervention for smoking cessation; combination of varenicline with nicotine replacement therapy increases its effectiveness even further, without serious adverse effects. References: . (http://www.ncbi.nlm.nih.gov/pubmed/1)

Question 5

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. The patient is encouraged to contact the physician with any further questions and concerns.  She returns 6 months later for a pre-camp physical and tells the physician that she has continued to have sex with her boyfriend.  The patient says, "Everything is going well; we have so much in common."  On questioning, she admits that her boyfriend is not a boy in her class, but actually her 25-year-old, married, high school art teacher.  She says, "We're doing our best to keep the relationship a secret because he is not ready to tell his wife.  He promised me that he will leave her eventually."  The patient mentions that her boyfriend has been tremendously helpful in developing her artistic ability and believes that he will help her gain admission to a prestigious art college.  She says her chances of admission are increased by her A+ art grade and his positive letter of recommendation.  Her parents are suspicious about the relationship with the teacher but have avoided discussing it.  When asked if she feels coerced into performing any sexual acts, the patient adamantly insists the relationship is consensual.  Physical examination is normal and urine pregnancy test is negative.  Aside from the age of the patient and the age difference with her partner, which of the following is the most important determining factor as to whether this patient is in an abusive situation?

Accepted Answer

Explanation: Open and confidential communication between the physician and the adolescent patient now reveals information that raises concern about possible abusive or coercive sexual encounters. Specifically, the power inequality inherent in the teacher-student relationship and the patient's belief that the teacher will help her gain admission to college are worrisome. The possibility that the patient may be acceding to sexual demands to gain favor with the teacher must be considered. From a legal standpoint, the age of consent varies from state to state, and some jurisdictions may require professionals to report knowledge or suspicion of statutory rape to authorities based on the patient's age alone; others may take into account the age differential in the relationship and whether the partner is in a position of influence. The physician should discuss these concerns with the patient and explain the rationale of a duty to protect her before reporting concerns to state child protective services or law enforcement agencies. During the reporting process, every effort should be made to maintain the physician-patient relationship. (Choice A) The parents' failure to act on their suspicions does not constitute child abuse. If, however, the parents knew that their daughter was in an abusive relationship and did not try to help her, this could be considered a form of neglect. (Choices C and E) The patient's belief that the teacher will leave his wife and the secretive nature of the relationship are worrisome, but they are not as important as the power differential due to the teacher's position of authority. (Choice D) This patient's insistence that the relationship is consensual should not be used to determine if abuse is occurring as it may reflect that she is unaware of or in denial about its exploitative nature. A 16-year-old's perception does not remove the duty to disclose if the relationship appears to be abusive on ethical and/or legal grounds. Educational objective: Sexually active adolescents should be carefully assessed for abusive or coercive sexual encounters. Situations involving sexual partners who occupy positions of power or authority in relation to the teenage patient should raise concerns for coercion. A physician who finds evidence of abuse or exploitation is obligated to notify the state's child protective services or law enforcement agencies. References: Adolescent relationship abuse and reproductive and sexual coercion among teens. (http://www.ncbi.nlm.nih.gov/pubmed/24018873)

Question 6

A 24-year-old man is brought to the emergency department by his friend due to disorientation and restlessness.  His friend says, "He's gone crazy.  I had a tough time bringing him in.  He kept moving from side to side in the car, banging his body against the door.  Then he started pushing me while I was driving.  I almost ran off the road."  The patient is well known from past emergency department admissions for similar behavior of agitation; he often becomes coherent in 7-8 hours.  He is homeless and has a history of using multiple illicit substances.  He was also hospitalized a month ago for opioid overdose with subsequent aspiration pneumonia.  The patient has no other active medical illnesses except for injuries due to trauma while intoxicated.  He does not have any other psychiatric disorders.  Temperature is 37.2 C (99 F), blood pressure is 160/100 mm Hg, and heart rate is 120/min.  He is not oriented to time and place but recalls his name and date of birth.  Examination shows prominent nystagmus as well as multiple cuts and abrasions of the shoulders and extremities.  The patient is restless and paces in his room.  He then stops, sits down, stands up again, bangs his body against the wall, and yells, "They're pushing a rock on me."  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: This patient has signs and symptoms suggestive of phencyclidine (PCP) intoxication and is at risk of harming himself and others. PCP is a hallucinogen that is primarily an NMDA receptor antagonist. Typical symptoms include agitated, combative, or bizarre behaviors usually lasting 8 hours and leading to traumatic injuries, hypertension, tachycardia, ataxia, and prominent nystagmus (including horizontal, vertical, or rotary nystagmus). At high doses, severe agitation, hallucinations, and violent behavior can occur and require immediate management. Intoxicated patients may have delusions of strength and diminished pain perception. They may become violent in response to believing that they are being attacked. In these cases, rapid control of agitation with adequate chemical sedation is the primary intervention. Benzodiazepines (eg, lorazepam) are typically used as a first-line treatment. Physical restraints may also be needed if the patient cannot be redirected verbally. In contrast, mildly intoxicated patients commonly have dissociative symptoms, including detachment and withdrawal. In these patients, providing a low-stimulation environment is likely to be the primary treatment (Choice E). (Choice A) Assuming that airway, breathing, and circulation are intact, secondary physical injuries can be addressed once severe agitation has been managed and the patient is no longer at an acute risk of harming himself or others. (Choice B) Antipsychotics (eg, haloperidol) are typically used as adjunctive therapy when benzodiazepines fail to adequately control agitation. (Choice D) Some hospital urine toxicology screens test for PCP, but false positives are common. Although a toxicology screen is an appropriate step in assessing substance abuse, the results would not be available quick enough to be helpful during acute management of agitated behavior. Educational objective: PCP intoxication leading to severe agitation and violent behavior should be treated immediately with benzodiazepines to provide sedation. A low-stimulation environment (with or without benzodiazepines) is more appropriate for patients with milder symptoms of PCP intoxication. References: Emergency department visits involving phencyclidine (PCP). (http://www.ncbi.nlm.nih.gov/pubmed/27656747)

Question 7

A 34-year-old man comes to the psychiatry outpatient clinic for follow-up accompanied by his parents.  He has a 15-year history of schizophrenia characterized by auditory hallucinations, disorganized thoughts, and paranoid delusions.  The patient was diagnosed at age 19 and has been hospitalized 6 times for acute psychotic episodes.  He has had multiple trials of antipsychotic medication, including risperidone, olanzapine, and fluphenazine, with minimal improvement.  He is currently taking aripiprazole.  Despite adherence to his medication regimen, the patient has persistent psychotic symptoms.  He has been unable to work, hears voices throughout the day, and is too paranoid to attend group therapy.  He lives with his parents, who supervise his medication.  The patient has no other medical problems.  There is a family history of hypertension, diabetes, and coronary artery disease.  After a discussion of the risks and benefits, the patient agrees to begin a trial of clozapine.  What should he be told regarding treatment with this medication?

Accepted Answer

Explanation: Clozapine is a highly effective antipsychotic reserved for the treatment of refractory schizophrenia and schizoaffective disorder. Clozapine is not used as first-line treatment due to its association with neutropenia/agranulocytosis. It must be prescribed through a central patient registry that requires mandatory monitoring of the absolute neutrophil count. Blood tests must be performed weekly during the first 6 months of treatment, every other week for the second 6 months, and every 4 weeks thereafter. Physicians are guided by an algorithm that specifies the minimum absolute neutrophil count required to initiate and continue clozapine therapy. Patients should also be advised to immediately report symptoms consistent with infection (eg, fever, weakness, lethargy, sore throat). Other adverse events associated with clozapine include weight gain, metabolic syndrome, seizures, pulmonary embolus, myocarditis, excessive salivation, constipation, and ileus. (Choice A) It is uncommon for clozapine to cause hepatoxicity and thrombocytopenia, and periodic monitoring for these is unnecessary. Patients treated with the anticonvulsant mood stabilizer valproate should have baseline and periodic monitoring of liver function tests. (Choice B) Dietary restrictions (avoiding foods containing tyramine) are necessary while taking monoamine oxidase inhibitors, medications used in treatment-resistant depression. (Choice C) Although clozapine plasma levels may assist in dosage adjustment, they are not required. A clozapine plasma level can be checked after an initial target dose is reached and then adjusted based on clinical response and adverse effects. Serum drug levels are routinely monitored with medications such as lithium, valproate, and nortriptyline. (Choice E) Lithium (not clozapine) requires evaluation of thyroid and kidney function before initiation of therapy. Creatinine and thyroid function tests are monitored periodically (eg, every 3-6 months) in lithium-treated patients due to risks of hypothyroidism and renal toxicity. Educational objective: Clozapine treatment requires regular monitoring and registry reporting of absolute neutrophil counts due to the increased risk of developing neutropenia/agranulocytosis. References: Medical management of patients on clozapine: a guide for internists. (http://www.ncbi.nlm.nih.gov/pubmed/25809850) Guide to the management of clozapine-related tolerability and safety concerns. (http://www.ncbi.nlm.nih.gov/pubmed/27732102)

Question 8

A 32-year-old man comes to the office for a follow-up appointment accompanied by his sister.  The patient has a long history of schizophrenia and was hospitalized multiple times in his early 20s.  He has been on fluphenazine decanoate, depot form, for several years.  He has no current delusions or hallucinations.  The patient describes his mood as "okay" and he is sleeping and eating well.  During the interview, the physician notices that he answers questions appropriately but offers monosyllabic responses.  He makes no small talk and does not speak unless asked a question.  His affect is flat, and he speaks in a monotone voice.  The patient's sister confirms that he is adherent with his medications and has not been "acting or thinking strangely" for some time.  He says that he would like to work but has made no effort to find a job in more than a decade.  Physical examination is unremarkable, and there are no signs of extrapyramidal side effects.  At the end of the appointment, the sister asks, "Is there anything you can recommend that will make him get out of the house or look for some kind of work?  All he does is sit at home and watch TV.  It's like he doesn't care."  Which of the following is the most appropriate response?

Accepted Answer

Explanation: Although this patient does not currently experience positive symptoms of schizophrenia (eg, delusions, hallucinations, disorganized speech and behavior), he suffers from significant negative symptoms (eg, alogia, flat affect, amotivation, social withdrawal). Negative symptoms cause significant functional impairment and poor quality of life, affecting independent living skills, social functioning, and occupational performance and attainment. Antipsychotic medication is effective in treating positive symptoms, as in this patient, but does not significantly improve negative symptoms. Earlier hopes that second-generation antipsychotics would be more effective than first-generation antipsychotics in treating negative symptoms have not been realized. Perceived benefits of newer antipsychotics in treating negative symptoms are believed to result from fewer extrapyramidal side effects (ie, decreased incidence of drug-induced parkinsonism) rather than true efficacy in treating core negative symptoms. Switching to a second-generation (atypical) antipsychotic (Choice E) is unlikely to significantly improve this patient's negative symptoms and could result in recurrence of his positive psychotic symptoms, which are currently well controlled. Psychosocial intervention, specifically social skills training, is an effective augmentation strategy to target negative symptoms. Social skills training consists of behavioral techniques to improve the patient's social skills and apply them to specific problems and activities, such as initiating and maintaining conversations and negotiating interpersonal situations. Other psychosocial interventions that may be helpful for this patient include supported employment that serves a therapeutic role. (Choice A) This patient's lack of motivation and social withdrawal are negative symptoms of psychosis, not depression. There is no consistent evidence that mood stabilizers such as valproate are effective in treating negative symptoms. (Choice B) It is important to educate family members about negative symptoms and help them understand that the patient's lack of motivation, flat affect, and social withdrawal are symptoms of schizophrenia and not due to laziness. Although family members should provide support, giving critical feedback and pressure to be more active could be overly stressful and destabilizing. (Choice C) The patient's positive symptoms are well controlled. Increasing his medication might result in an increased side effect burden, including possible sedation, which could worsen rather than improve his apathy and social withdrawal. Educational objective: Negative symptoms in schizophrenia cause significant functional impairment and respond poorly to antipsychotic medication. Referral for social skills training is an important option to consider in managing persistent negative symptoms. References: Treatments of negative symptoms in schizophrenia: meta-analysis of 168 randomized placebo-controlled trials. (http://www.ncbi.nlm.nih.gov/pubmed/25528757) Treating negative symptoms in schizophrenia: an update. (http://www.ncbi.nlm.nih.gov/pubmed/27376016) Psychological interventions for psychosis: a meta-analysis of comparative outcome studies. (http://www.ncbi.nlm.nih.gov/pubmed/24525715)

Question 9

A 36-year-old woman comes to the clinic for smoking cessation counseling.  She has smoked 2 packs of cigarettes daily for 18 years.  The patient has tried to quit multiple times but failed.  She works as a corporate attorney and has 2 important cases she is closing this month.  The patient says, "Every time I try to quit smoking, I start shaking really badly.  I can't sleep, and I get very anxious, depressed, and frustrated.  I can't seem to concentrate, which is bad because my job is very demanding.  I need to perform well and show my boss that I can handle the more difficult cases she gives me.  I'm also concerned about gaining weight if I stop smoking."  The patient is recently married.  Her husband does not smoke and has asthma, which is worsened by her smoking.  The patient feels motivated to stop but concerned about her ability to do so.  She has a history of a seizure disorder but discontinued anticonvulsant therapy 5 years ago after a few years of being seizure free.  She also has a history of depression successfully treated with psychotherapy in her 20s.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c062_bee1_8f63_e7f6980ad6aa_MD0005_00 Withdrawal symptoms are common in patients attempting to quit smoking, especially those with a heavy smoking history. Common symptoms include restlessness, anxiety, irritability, decreased concentration, insomnia, and depressed mood. Withdrawal symptoms and the associated craving for cigarettes are responsible for the majority of relapses. The best initial approach for patients wishing to quit smoking is a combination of behavioral (eg, problem solving, skill building, support, follow-up) and pharmacological therapy. Nicotine replacement therapy (NRT) (eg, gum, patch, inhaler) acts by maintaining a low level of nicotine in the blood and is indicated for amelioration of withdrawal symptoms during the early stages of smoking cessation. Combining a long-acting NRT (eg, patch) with a short-acting NRT (eg, gum, lozenge, nasal spray), a "patch-plus" regimen, is more effective than either modality alone. Varenicline, a partial nicotine receptor agonist, would be another option for this patient. Despite initial concerns about depression and increased suicidality with varenicline, newer findings have not substantiated this, and the black box warning for these adverse effects was removed in 2016. (Choice B) Bupropion is an effective therapy for smoking cessation and can help decrease the weight gain seen in smokers who quit. However, it reduces the seizure threshold and would be contraindicated in this patient with a history of seizure disorder. (Choice C) Motivational interviewing is a useful intervention to increase motivation in patients who are not ready to quit. Buspirone, however, is used in the treatment of generalized anxiety disorder. It has not been shown to be effective for smoking cessation. (Choice D) Selective serotonin reuptake inhibitors (eg, sertraline) are indicated for depression and anxiety, but they have not been proven effective for smoking cessation. (Choice E) Setting a quit date is an important aspect of cessation. However, a date should be set within 2-4 weeks to keep the patient motivated and prevent second-guessing. In addition, a low-dose nicotine patch is unlikely to ameliorate the withdrawal symptoms in a patient with a history of heavy smoking. This patient should initially receive combination nicotine replacement therapy. Educational objective: Smoking cessation is best managed with a combination of behavioral support and pharmacotherapy, which decreases craving and withdrawal, helping to prevent relapse. Pharmacological options include nicotine replacement therapy, varenicline, and bupropion. References: Optimising nicotine replacement therapy in clinical practice. (http://www.ncbi.nlm.nih.gov/pubmed/23781531) Nicotine replacement therapy for smoking cessation. (http://www.ncbi.nlm.nih.gov/pubmed/23152200) Pharmacological interventions for smoking cessation: an overview and network meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23728690)

Question 10

A 63-year-old woman comes to the office for a hypertension follow-up.  Her blood pressure was high at her 2 previous visits despite changes in diet and exercise routine.  The patient has a history of bipolar disorder with 3 hospitalizations for treatment of manic and depressive episodes.  She has not been hospitalized during the past 6 years, and her symptoms have been well controlled on lithium.  The patient has no other medical conditions and takes no other medications.  Blood pressure is 148/90 mm Hg and pulse is 78/min.  Findings from neurologic and cardiovascular examinations are within normal limits.  On mental status examination, the patient is calm and speech is nonpressured.  Affect is euthymic; there is no suicidal ideation.  A recent serum chemistry panel, including electrolytes and renal function markers, is normal.  ECG is also normal.  The physician decides to prescribe an antihypertensive medication but wants to continue the patient's lithium, which is working well.  Which of the following medications will be most appropriate?

Accepted Answer

Explanation: 11ec2b69_c05e_03ed_8f63_53bd19ded018_MD0005_00 Lithium is a mineral salt used in the treatment of bipolar disorder. It is eliminated exclusively by the kidneys; lithium is readily filtered in the glomerulus but can be reabsorbed by transport proteins in the proximal tubule that normally handle sodium and potassium. Lithium has a narrow therapeutic index (ie, the difference between the minimum effective dose and the toxic dose is relatively small) and drugs that affect glomerular filtration or renal reabsorption can dramatically alter serum levels, leading to toxicity or loss of therapeutic effect: Nonsteroidal anti-inflammatory drugs (eg, ibuprofen), ACE inhibitors (eg, lisinopril), and angiotensin II receptor blockers (eg, losartan) can acutely reduce glomerular filtration and therefore clearance of lithium, potentially leading to drug toxicity (Choices C and D). Thiazide diuretics (eg, hydrochlorothiazide) inhibit reabsorption of sodium in the distal convoluted tubule, causing a compensatory increase in reabsorption of sodium-and concurrently lithium-in the proximal tubule (Choice B). Some potassium-sparing diuretics (eg, spironolactone) also can raise lithium levels, whereas others (eg, amiloride) can lower lithium levels, likely due to effects on both sodium transport and glomerular filtration (Choice E). Calcium channel blockers (eg, amlodipine) are usually considered safe because they do not significantly affect sodium level or glomerular filtration rate. Educational objective: Many antihypertensive medications can interact with lithium due to their effects on renal function and electrolyte reabsorption. Thiazides, ACE inhibitors, and angiotensin II receptor blockers can increase serum lithium levels. Calcium channel blockers are generally considered safe.

Question 11

A 26-year-old man comes to the office accompanied by his wife, who says, "He needs help with a major anger problem that has been going on for years.  Every time I talk to a man, he becomes irrationally angry and jealous.  Whenever I am delayed due to traffic, he interrogates me about where I have been.  Last week, we had a big fight because he accused me of being unfaithful when I had to work late."  The patient says, "I'm only here because of my wife.  I can't have her turning against me too, though I'm sure she wishes she were with someone else."  The patient apologizes to his wife for his angry outbursts and attributes his behavior to being under stress at work.  He feels that his boss treats him unfairly and that his coworkers might be "setting me up to look bad."  He adds, "I had to leave my last job when I discovered that people were talking behind my back and the supervisor was deliberately giving me all the bad shifts."  The patient has no significant medical or psychiatric history.  He does not use alcohol or illicit drugs because he likes to "keep my head clear so I can anticipate when someone is trying to mess with me."  He acknowledges feeling depressed and anxious about his work situation and that he sometimes can't sleep because "I am up at night thinking about my problems."  The patient's maternal uncle was diagnosed with major depression and he thinks his maternal grandfather died in a "mental hospital."  On examination, the patient is alert and guarded.  Although non-spontaneous, he is cooperative in answering questions.  He describes his mood as "down."  He has no suicidal thoughts or auditory hallucinations.  Which of the following is the most likely diagnosis?

Accepted Answer

Explanation: 11ec2b69_c05c_2f2b_8f63_ed587de1c52d_MD0005_00 This patient's pattern of suspiciousness and distrust in home and work relationships is suggestive of paranoid personality disorder. Individuals with this disorder are often hypervigilant and hostile and interpret others' motives as malevolent. They are controlling in personal relationships and may be pathologically jealous (eg, suspecting that their partner is unfaithful without justification). Patients with paranoid personality disorder rarely present on their own for treatment, although they may seek help for comorbid depression or substance use. In some patients, paranoid personality disorder may precede the development of delusional disorder or schizophrenia. The diagnosis of paranoid personality disorder requires excluding psychotic disorders (eg, schizophrenia, delusional disorder) and mood disorders (eg, major depression with psychotic features). These disorders are characterized by persistent psychotic symptoms (eg, delusions, hallucinations). Patients with paranoid personality disorder are generally paranoid and distrustful but do not have fixed delusions. (Choice A) Borderline personality disorder (BPD) is characterized by instability in interpersonal relationships, self-image, and affect; marked impulsivity; and suicidality. Although suspiciousness and angry reactions may also occur in BPD, this patient's distrust is more pervasive, and he lacks the self-destructive behavior and impulsivity that characterizes BPD. (Choice B) This patient has a general distrust of everyone but lacks specific delusions. Delusional disorder is characterized by >1 delusions in the absence of other psychotic symptoms. Functioning may be normal apart from the direct impact of the delusion. (Choice C) Major depression with psychotic features is a severe subtype of major depressive disorder in which the patient develops delusions and/or hallucinations, typically with depressive themes of guilt and worthlessness. This patient does not have sufficient depressive symptoms to diagnose a major depressive episode. (Choice E) Individuals with schizotypal personality disorder typically exhibit magical beliefs, eccentric behavior, and odd perceptual experiences that do not reach the threshold for diagnosis of a psychotic disorder. Schizotypal personality disorder may be comorbid with paranoid personality disorder. Educational objective: Paranoid personality disorder involves a pervasive, lifelong pattern of suspiciousness and mistrust of others. It is differentiated from psychotic disorders by the absence of persistent psychotic symptoms and the nonspecific nature of the distrust (generalizes to every interpersonal interaction). References: Personality disorders: review and clinical application in daily practice. (http://www.ncbi.nlm.nih.gov/pubmed/22150659)

Question 12

A 43-year-old woman comes to the office for an initial evaluation.  The patient recently moved to the area for a new job and is worried about her poor health.  She explains that she had to call in sick several times this past month because either "I felt too exhausted" or "I was lightheaded and had an upset stomach."  The patient has a history of hypothyroidism, chronic headaches, insomnia, and dysmenorrhea.  She describes a long history of fatigue, but previous doctors have assured her that her hypothyroidism is well controlled with medication.  She also describes chronic problems with urinary frequency; stomach bloating; and dry, itchy skin.  The patient is worried about her symptoms and wonders if all the doctors she has seen may have "missed something."  Her medications include levothyroxine, daily multivitamins, and zolpidem and naproxen as needed.  The patient does not smoke or use illicit drugs.  She stopped drinking alcohol a year ago as it made her symptoms worse.  Blood pressure is 110/70 mm Hg, pulse is 84/min, and respirations are 12/min.  Physical examination is normal.  T4 is 10 µg/dL and TSH is 1.3 µU/mL. 
Which of the following is the most likely diagnosis in this patient?

Accepted Answer

Explanation: 11ec2b69_c063_f763_8f63_b58af0bf4c54_MD0005_00 This patient's preoccupation with multiple unexplained medical symptoms suggests somatic symptom disorder. The diagnosis requires excessive preoccupation with >1 somatic symptom(s) for >6 months, causing significant social and occupational impairment. Symptoms may represent catastrophic interpretations of normal bodily sensations or discomfort that does not generally signify serious disease. These patients often have excessive health anxiety that typically interferes with their ability to work and causes stress in their relationships. They often make extensive use of medical services and are rarely reassured by negative findings. Physicians must keep in mind that these patients are truly suffering, even if their symptoms are not medically explained, and that concurrent medical illness (eg, this patient's hypothyroidism) is not mutually exclusive. (Choice A) Factitious disorder is characterized by the intentional falsification of symptoms in the absence of obvious external rewards. There is no evidence that this patient has fabricated her symptoms. (Choice B) Although generalized anxiety disorder is frequently accompanied by multiple anxiety-related somatic symptoms (eg, tension headaches, palpitations, gastrointestinal distress, fatigue, dizziness), this patient's anxiety is restricted to her physical concerns. Patients with generalized anxiety disorder have excessive anxiety about multiple issues and situations, not just their health. (Choice C) In illness anxiety disorder, the patient has minimal or no actual symptoms but is preoccupied with having a serious undiagnosed specific disease (eg, if the patient feared having a brain tumor). This patient has multiple somatic symptoms and would be more accurately diagnosed with somatic symptom disorder. (Choice D) In malingering, there is clear evidence of external gain. Although this patient's somatic symptom disorder affects her job performance, she is not consciously feigning symptoms to avoid work. Malingering patients typically exhibit antisocial personality traits and have a history of avoiding responsibilities and seeking long-term disability. Educational objective: Patients with somatic symptom disorder have excessive anxiety and preoccupation with >1 somatic symptoms. They may have concurrent medical illness, or the symptoms may represent misinterpretations of normal bodily sensations. References: Somatic symptom disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26760840)

Question 13

A 43-year-old woman comes to the office for an initial evaluation.  The patient recently moved to the area for a new job and is worried about her poor health.  She explains that she had to call in sick several times this past month because either "I felt too exhausted" or "I was lightheaded and had an upset stomach."  The patient has a history of hypothyroidism, chronic headaches, insomnia, and dysmenorrhea.  She describes a long history of fatigue, but previous doctors have assured her that her hypothyroidism is well controlled with medication.  She also describes chronic problems with urinary frequency; stomach bloating; and dry, itchy skin.  The patient is worried about her symptoms and wonders if all the doctors she has seen may have "missed something."  Her medications include levothyroxine, daily multivitamins, and zolpidem and naproxen as needed.  The patient does not smoke or use illicit drugs.  She stopped drinking alcohol a year ago as it made her symptoms worse.  Blood pressure is 110/70 mm Hg, pulse is 84/min, and respirations are 12/min.  Physical examination is normal.  T4 is 10 µg/dL and TSH is 1.3 µU/mL. The physician assures the patient that her blood tests and physical examination are normal.  She schedules an appointment 2 weeks later and now reports frequent headaches in addition to her ongoing concerns.  The patient says, "These headaches just make me even more tired."  Her headaches occur 2-3 times a week and are bilateral and nonthrobbing.  She reports, "My neck is sore and my shoulders are so tight I can hardly turn my head without it being painful."  The patient has no aura and the headaches are relieved by naproxen.  Physical examination is normal apart from some muscle tenderness in the shoulders and neck.  When the physician inquires if moving and starting a new job have been stressful, she replies, "It's not the job or the move; it's not feeling well that is stressful.  Maybe I should see a neurologist."  The patient is very anxious and asks if the physician can order a repeat brain MRI to determine the diagnosis.  Her records indicate that a brain MRI performed last year was normal.  Which of the following is the most appropriate response to the patient?

Accepted Answer

Explanation: 11ec2b69_c064_93a4_8f63_d34c20976de1_MD0005_00 The best approach to patients with somatic symptom disorder is regularly scheduled visits (eg, monthly) with the same physician, who can develop a trusting physician-patient relationship. In contrast to symptom-driven visits, regular visits decrease overall health care use. Patients seen regularly do not need to have a "new" symptom to see the physician, and unnecessary diagnostic testing and referral to specialists are avoided. Physicians should treat symptoms conservatively and focus on the patient's functioning. Once a trusting physician-patient relationship is developed, strategies include educating the patient about the interaction of psychosocial stressors and somatic symptoms, and promoting stress reduction and healthy behaviors (eg, diet, exercise, return to productive activities). The physician must validate the patient's physical distress and provide reassurance that serious medical illness has been ruled out. Statements that the condition is "psychogenic" or "all in your head" should be avoided. Psychiatric consultation is appropriate to assist with the diagnosis and treatment of psychiatric disorders; however, patients will feel invalidated and rejected by the primary physician if this is done early in the physician-patient relationship. (Choice A) Although it is appropriate to reassure the patient that serious medical conditions have been ruled out, telling her there is nothing to worry about would likely be perceived as invalidating and dismissive. It is important to acknowledge the patient's distress and provide an opportunity to develop the physician-patient relationship through regularly scheduled follow-up visits. (Choices B and C) This patient has no insight into the nonmedical nature of her symptoms as demonstrated by her negative response to the physician's suggestions that they may be stress related. At this point, it would be premature and damaging to the physician-patient relationship to suggest that stress is the major cause of her symptoms or to refer her to a psychiatrist. As the physician-patient relationship develops over the course of regular visits, the patient may become more receptive to these suggestions. (Choice D) Recommending neurology consultation is inappropriate as the patient's symptoms are consistent with tension-type headaches and the diagnosis is not in question. This would serve only to maintain the cycle of repeated consultations and unnecessary evaluations, which are rarely reassuring. Educational objective: Somatic symptom disorder is best managed with regularly scheduled patient visits, minimizing diagnostic testing and specialist referrals, and focusing on functional improvement. References: Approach to the patient with multiple somatic symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/25134874)

Question 14

A 19-year-old man is brought to the emergency department by his mother.  She says that he has been acting strangely for the past 2 months, spending significantly less time with his friends and more time on the computer.  Over the past few nights the mother has observed the patient shouting at the computer screen.  She became alarmed when he suddenly disconnected all electronic devices in the house and warned his family that encrypted messages were being sent over the internet to control his brain.  The patient's grades at the local community college have recently declined, and he stopped attending classes after he became convinced that other students were laughing at him behind his back.  He has no medical history.  Psychiatric history is significant for mild anxiety in high school that was never treated.  The patient does not use tobacco or alcohol but smokes marijuana daily.  He also has used cocaine on several occasions.  There is a family history of schizophrenia in a maternal uncle.  Vital signs are within normal limits and physical examination shows no abnormalities.  The patient is cooperative, guarded, and anxious during the interview.  Blood work and a CT scan of his brain are normal.  Urine toxicology is positive for tetrahydrocannabinol.  The mother asks if her son is going to be okay.  After obtaining consent from the patient to speak with his mother, which of the following is the most appropriate response to her at this time?

Accepted Answer

Explanation: This patient's 2-month history of paranoia, delusions of reference, and social withdrawal is consistent with a diagnosis of schizophreniform disorder. However, the possibility of a substance-induced psychotic disorder must be considered due to his history of daily marijuana and occasional cocaine use. High-potency cannabis has been associated with paranoia, depersonalization, and hallucinations. Some experts suggest that early cannabis use may be a causal factor in developing schizophrenia in those with susceptibility. Cocaine intoxication and withdrawal can also present with acute psychotic symptoms. When encountering a patient with new-onset psychosis in the emergency department, the physician must first rule out medical and substance-induced causes. In this case, the most appropriate response is to acknowledge the seriousness of the patient's psychotic symptoms but avoid making a premature diagnosis as there is a possibility that the symptoms are caused or exacerbated by drug use. (Choice A) Reassurance that the patient's symptoms are entirely substance related is inappropriate. This patient has classic psychotic symptoms that may or may not resolve if he abstains from drugs. (Choice B) Positive psychotic symptoms, such as delusions or hallucinations, are considered good prognostic features and respond well to antipsychotic medication (as compared to negative symptoms, such as social withdrawal and loss of motivation, which respond less well). However, this statement would be premature, as a primary psychotic diagnosis has not yet been made. Other good prognostic features in schizophrenia include acute onset, later age of onset, affective symptoms, good premorbid functioning, and family support. (Choices C and E) This patient's age is typical for the onset of schizophrenia in males, and his family history increases his risk. Early intervention is important for psychotic illness. However, it would be premature and inappropriate to overwhelm the patient and his mother with the diagnosis of a major mental illness before the role of his substance use is clarified. Educational objective: Assessment of new-onset psychosis requires ruling out substance-induced and medical etiologies. If substances are identified as a possible factor, monitoring the patient off the substances is an appropriate initial strategy. Physicians should inform the patient and family of the diagnostic possibilities while avoiding a premature diagnosis or false reassurance. References: The impact of cannabis use on age of onset and clinical characteristics in first-episode psychotic patients: data from the Psychosis Incident Cohort Outcome Study (PICOS). (http://www.ncbi.nlm.nih.gov/pubmed/23290558) Cannabis-induced attenuated psychotic symptoms: implications for prognosis in young people at ultra-high risk for psychosis. (http://www.ncbi.nlm.nih.gov/pubmed/27821204) Alcohol and substance use by patients with psychosis presenting to an emergency department: changing patterns. (http://www.ncbi.nlm.nih.gov/pubmed/21851228)

Question 15

A 25-year-old woman is brought to the emergency department after her boyfriend called police and reported that she was threatening to kill herself.  They had been arguing when the woman suddenly grabbed a kitchen knife, waved it in the air, and threatened to stab herself.  The patient says to the emergency physician, "I didn't mean what I said.  This is all a big misunderstanding.  I don't know why my boyfriend overreacted.  We both had a little too much to drink tonight.  I'm sure you know how that can get!  I got upset when we were arguing and I just said something stupid.  I have no intention of killing myself."  The patient has no psychiatric history.  She drinks socially and smokes marijuana.  She does not use any other drugs or prescription medications.  Vital signs are within normal limits.  Examination shows no abnormalities.  On mental status examination, the patient is alert with loud, slightly slurred speech.  She says her mood is "fine" and denies any suicidal ideation, intent, or plan. 
Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: This patient denies suicidal intent and dismisses her suicidal threat as a mistake made under the influence of alcohol. However, she still exhibits signs of possible alcohol intoxication (loud, slightly slurred speech; social disinhibition), and her assurance that she is not suicidal cannot be accepted. In general, physicians should not clear patients for discharge from the emergency department when they are still intoxicated. Intoxication with alcohol or other substances is a known risk factor for completed suicide due to increased impulsivity and impaired judgment. When there is concern that the patient may be suicidal, the physician must observe the patient and perform a suicide assessment when the patient is completely sober. Speaking with the boyfriend and contacting family members for collateral information would also be advisable. (Choices A and B) It would be inappropriate to discharge this patient as her denial of suicidality while still intoxicated is unreliable. If the patient is considered appropriate for discharge when reevaluated in a sober state, then referrals for psychiatric follow-up could be made. (Choice C) This patient should be reevaluated when sober and it is premature to hospitalize her at this point. Hospitalization would be necessary if further evaluation indicated that she had active suicidal ideation with intent or plan. (Choice E) Although there is a rough correlation between blood alcohol levels and alcohol effects in a typical social drinker, the level should not be used as the sole criterion for discharge. It is more important to perform a suicide assessment when the patient is clinically sober. Educational objective: Decisions regarding discharge from the emergency department should not be based on an intoxicated patient's statements. Patients with suicidal threats or behavior must be reassessed when they are clinically sober. References: Alcohol: the lubricant to suicidality. (http://www.ncbi.nlm.nih.gov/pubmed/23440995) Alcohol and suicidal behavior: what is known and what can be done. (http://www.ncbi.nlm.nih.gov/pubmed/25145740)

Question 16

A 32-year-old woman, gravida 2 para 0 aborta 1, at 7 weeks gestation comes to the office to initiate prenatal care. The patient has had nausea and vomiting unresponsive to an oral antiemetic but has not had abdominal pain or vaginal bleeding. Her first pregnancy 2 years ago ended in a first-trimester spontaneous abortion. The patient has a history of epilepsy that is managed with antiepileptic medication. However, because she had been seizure free for 3 years, the medication was stopped prior to pregnancy. She has smoked a pack of cigarettes daily for the past 14 years. The patient has tried to quit several times and is unsure if she is ready to try again. She does not use alcohol or illicit drugs. Vital signs are within normal limits. BMI is 27 kg/m². Pelvic examination is normal. Ultrasound reveals a 7-week intrauterine gestation with a normal heartbeat. Which of the following is the best initial advice regarding smoking cessation for this patient?

Accepted Answer

Explanation: 11ec2b69_c063_5b22_8f63_83af118cdf0b_MD0005_00 Smoking is associated with multiple pregnancy-related complications, including spontaneous abortion, congenital anomalies, preterm premature rupture of membranes, abruptio placentae, preterm delivery, low birth weight, and fetal demise. It also is associated with long-term complications in the infant, including sudden infant death syndrome and an increased risk of diabetes mellitus, asthma, and obesity. Smoking cessation during pregnancy decreases these risks. Therefore, pregnant patients are asked about tobacco use and cessation is encouraged in those who smoke. Smoking-cessation interventions initiated by health care providers are generally successful in helping patients quit. However, risk factors for continued cigarette use during pregnancy include heavy tobacco use (more than half a pack a day) and the presence of another smoker in the home. Initial steps in smoking cessation include assessing the patient's willingness to quit. If the patient is unwilling, the barriers to cessation readiness are identified and addressed; education about the risks of smoking during pregnancy is provided. (Choices A and E) Bupropion and varenicline can be used to facilitate smoking cessation. However, insufficient data exist to determine their safety during pregnancy and lactation. In addition, bupropion is contraindicated in patients with epilepsy as it lowers the seizure threshold. (Choice B) E-cigarettes are not indicated for smoking cessation. The long-term effects of e-cigarettes are not known, and they are avoided during pregnancy as they expose the fetus to nicotine and other chemicals. (Choice D) Rather than waiting for patient readiness, providers should provide education, counseling, and a discussion of strategies to help facilitate smoking cessation. Educational objective: Cigarette use is associated with multiple adverse pregnancy complications. Provider-initiated smoking-cessation interventions are successful in helping patients quit. Initial steps include determining patient readiness and addressing barriers to smoking cessation. References: Psychosocial interventions for supporting women to stop smoking in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/24154953) Interventions for promoting smoking cessation during pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/19588322) Committee opinion no. 471: smoking cessation during pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/20966731)

Question 17

A 25-year-old woman is brought to the emergency department after her boyfriend called police and reported that she was threatening to kill herself.  They had been arguing when the woman suddenly grabbed a kitchen knife, waved it in the air, and threatened to stab herself.  The patient says to the emergency physician, "I didn't mean what I said.  This is all a big misunderstanding.  I don't know why my boyfriend overreacted.  We both had a little too much to drink tonight.  I'm sure you know how that can get!  I got upset when we were arguing and I just said something stupid.  I have no intention of killing myself."  The patient has no psychiatric history.  She drinks socially and smokes marijuana.  She does not use any other drugs or prescription medications.  Vital signs are within normal limits.  Examination shows no abnormalities.  On mental status examination, the patient is alert with loud, slightly slurred speech.  She says her mood is "fine" and denies any suicidal ideation, intent, or plan. The physician reassesses the patient several hours later.  She says, "I am so embarrassed.  I never should have said that.  I lose control of myself when I am drunk."  The patient explains that she and her boyfriend are having relationship difficulties and she is afraid that he will leave her.  She reaffirms that she has never received any psychiatric treatment, although she took an intentional overdose of sleeping pills when she was 18 and wanted to die after breaking up with her boyfriend.  The patient has a family history of depression and thinks that her maternal uncle may have committed suicide, although "my family never talks about it."  She has been feeling depressed and describes difficulties with sleep and concentration.  Her appetite is decreased and she has lost 3.17 kg (7 lb) over the past month.  The patient works at a coffee shop and is a part-time student at a local community college.  She is thinking of dropping out of school as she has no interest in the classes and her grades are poor.  Apart from her boyfriend, she has few friends and is estranged from her family.  Which of the following is this patient's strongest risk factor for suicide?

Accepted Answer

Explanation: 11ec2b69_c067_2bb5_8f63_df2b38d60fa5_MD0005_00 This patient has multiple risk factors for suicide, but her history of trying to kill herself with a sleeping pill overdose is the most significant. History of attempted suicide is the strongest predictive risk factor for suicide. The greatest predictor of future behavior is past behavior; patients with a previous suicide attempt are 5-6 times more likely to make another attempt than those who have not made a previous attempt. (Choices A, B, and E) Additional risk factors for suicide in this patient include her current depressive symptoms, unstable relationship with her boyfriend, family history of suicide, and lack of family support. However, the single strongest predictive factor for suicide is a history of attempts. (Choice D) Impulsivity, especially in young adults, is also associated with increased suicide risk. The disinhibiting effect of alcohol and its potential to increase the risk of this patient acting on suicidal thoughts is concerning and should be addressed in counseling. Educational objective: History of suicide attempts is the strongest risk factor for suicide. Comprehensive suicide assessment requires a careful analysis of both risk and protective factors. References: Determinants and outcomes of serious attempted suicide: a nationwide study in Finland, 1996-2003. (http://www.ncbi.nlm.nih.gov/pubmed/18343881) Suicide risk assessment and formulation: an update. (http://www.ncbi.nlm.nih.gov/pubmed/24011694) Risk factors for suicide in individuals with depression: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/23411024)

Question 18

A 22-year-old man comes to the clinic for routine follow-up of his mild asthma.  He has a history of keeping his appointments but has missed the last three.  Today he seems distracted and uninterested, answering various questions with very brief replies.  At one point, the patient says that he would like to hurry the visit along so he can get home sooner.  Following inquiries about his social life, he becomes more animated and describes spending time with new friends who "really know how to party."  On further questioning, he says, "I have been snorting cocaine sometimes but it's not a big deal.  I haven't used any this past week.  I quit school because it was just stupid and I was wasting my money.  I'm working as a waiter now and enjoying it.  At least I can make my own money and not be dependent on my parents."  The patient says that he has been living with his new friends since his parents asked him to move out 2 weeks ago, but he would "rather not talk about that."  He denies any symptoms of depression, mania, or psychosis.  Temperature is 37.7 C (99.9 F), blood pressure is 120/82 mm Hg, pulse is 86/min, and respirations are 15/min.  Physical examination shows perforations of the nasal septum. 
Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: This patient's change in behavior and physical examination finding of septal perforation suggest a cocaine problem. When substance abuse presents in the primary care setting, the physician should take a comprehensive history (amount, frequency, route of administration, date of last use, perceived benefits, and negative consequences) and perform a non-judgmental, brief counseling intervention. Components of such an intervention include initially engaging the patient in a discussion, educating the patient about the personal risks of substance use, developing collaborative goals for reducing use, and openly discussing treatment options. An empathic, nonjudgmental approach with emphasis on patient autonomy and self-efficacy are critical to developing a treatment alliance. The diagnosis of cocaine use disorder is based on the patient's history and collateral sources (if obtainable with the patient's permission). A urine drug test would confirm only recent cocaine use (2-3 days). Because the patient has already admitted to cocaine use, it would be more productive and less costly to ask additional screening questions to clarify the extent of use and whether he is using other substances. (Choices A and E) This patient appears disengaged with the physician and does not view his cocaine use as problematic. At this stage (pre-contemplation), he would likely be unreceptive to recommendations to attend a 12-step mutual help group or drug counseling. The first step is to engage the patient in a collaborative discussion of the perceived benefits and consequences of his drug use. (Choice B) Although this patient should be informed about his perforated septum, it is important to engage him in an open-ended discussion of his substance use. Telling him that he should abstain without his input would be perceived as authoritarian and judgmental and is unlikely to be beneficial. A brief counseling intervention that fosters autonomy and collaborative decision-making is more likely to lead to internal motivation to change. (Choice C) A positive urine toxicology screen would confirm cocaine use and identify other drugs being used. However, it would detect only recent use and would not change management of the patient. Urine drug screens can be helpful when the clinical picture is uncertain or when patients are receiving prescribed controlled substances and need monitoring to prevent diversion or combination with other substances. Educational objective: Taking a thorough history can effectively identify substance abuse in the primary care setting. Once it is identified, the initial approach consists of engaging the patient in a brief counseling session to discuss personal risk and develop collaborative goals and a treatment plan. References: Integrating screening, brief intervention, and referral to treatment (SBIRT) into clinical practice settings: a brief review. (http://www.ncbi.nlm.nih.gov/pubmed/23210379)

Question 19

A 22-year-old woman is brought to the emergency department after overdosing on benzodiazepines.  On presentation, her speech is slurred and her gait is unsteady.  She is admitted to the hospital and improves with supportive care.  When questioned later, she states that she had wanted to die because her boyfriend of 4 months ended their relationship a week ago.  Currently she is less depressed and no longer suicidal, and feels that "he was the worst person for me."  The patient describes "mood swings" since she was a teenager characterized by feelings of severe depression lasting from a few hours to several days.  She has a history of 2 suicide attempts involving medication overdose.  The patient has been treated with fluoxetine but stopped taking it 6 months ago because "it didn't seem to make a difference in how low I was feeling." Which of the following is the most effective treatment for this patient's condition?

Accepted Answer

Explanation: Psychotherapy is the first-line treatment for borderline personality disorder (BPD), with the best evidence for dialectical behavior therapy (DBT). DBT is a structured treatment developed for BPD that consists of weekly individual psychotherapy and group skills training for approximately one year. DBT techniques include skills training to target self-injurious behavior and impulsivity and mindfulness training to target emotional dysregulation. Other types of psychotherapy developed to treat BPD include schema-focused therapy, mentalization-based therapy, and transference-focused therapy. Medications (eg, mood stabilizers, antipsychotics, antidepressants) do not treat the core BPD pathology. They are used adjunctively to target specific symptom clusters associated with the disorder (eg, mood instability, impulsivity, aggression), or to treat comorbid disorders such as major depression. (Choices A and E) The antidepressants bupropion and venlafaxine are not first-line treatments for BPD. They would be appropriate to treat a comorbid major depressive disorder. (Choice C) Interpersonal psychotherapy is an evidenced-based treatment for depression, not BPD. It focuses on four problem areas: grief over loss, interpersonal disputes, role transitions, and interpersonal skill deficits. (Choice D) Valproate is a mood stabilizer used primarily in bipolar disorder. It can also be used as an adjunct to psychotherapy to target the mood instability and impulsivity in BPD, but it is not a first-line monotherapy. Educational objective: Dialectical behavior therapy is a first-line treatment for borderline personality disorder. Pharmacotherapy may be used as an adjunct, but it does not treat the core disorder. References: Psychological therapies for people with borderline personality disorder. (http://www.ncbi.nlm.nih.gov/pubmed/22895952) Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials. (http://www.ncbi.nlm.nih.gov/pubmed/20044651) Dialectical behaviour therapy (DBT) in the treatment of borderline personality disorder. (http://www.ncbi.nlm.nih.gov/pubmed/24191948)

Question 20

A 22-year-old woman is brought to the emergency department after overdosing on benzodiazepines.  On presentation, her speech is slurred and her gait is unsteady.  She is admitted to the hospital and improves with supportive care.  When questioned later, she states that she had wanted to die because her boyfriend of 4 months ended their relationship a week ago.  Currently she is less depressed and no longer suicidal, and feels that "he was the worst person for me."  The patient describes "mood swings" since she was a teenager characterized by feelings of severe depression lasting from a few hours to several days.  She has a history of 2 suicide attempts involving medication overdose.  The patient has been treated with fluoxetine but stopped taking it 6 months ago because "it didn't seem to make a difference in how low I was feeling." 
Which of the following is the most likely diagnosis?

Accepted Answer

Explanation: 11ec2b69_c05b_1dba_8f63_45a7f5348f9e_MD0005_00 This patient's suicide attempt following the end of a relationship and her history of longstanding mood instability and recurrent suicide attempts are suggestive of borderline personality disorder (BPD). Patients with BPD experience marked instability in mood, self-image, impulse control, and relationships. Their relationships typically involve extremes of idealization and devaluation (splitting) as demonstrated by this patient's changing view of her boyfriend. Acute depression, intense anger, and suicidal threats and behavior are often triggered by feelings of rejection and abandonment. In contrast to primary mood disorders, the mood shifts in BPD occur in response to situational stressors and typically last a few hours, rarely more than a few days. This patient's rapid improvement and history of poor response to antidepressants are characteristic of BPD. (Choice A) Acute stress disorder is characterized by symptoms of intrusion, negative mood, dissociation, avoidance, and arousal within a month of exposure to a traumatic event. (Choices B and E) Although mood disorders may co-occur, this patient does not have distinct mood episodes of sufficient duration to diagnose unipolar or bipolar depression. Bipolar II disorder is characterized by major depressive episodes (requiring a duration >2 weeks) and hypomanic episodes (requiring a duration >4 days). Major depressive disorder involves major depressive episodes with no history of (hypo)mania. This patient's rapid and brief mood shifts (lasting from hours to days) in response to interpersonal triggers are better explained as the mood reactivity associated with BPD. (Choice D) Fears of abandonment are also characteristic of dependent personality disorder, but these individuals lack the impulsivity, uncontrolled anger, and history of unstable, intense relationships seen in BPD. Feelings of rejection typically lead to increasing submissiveness rather than rage and impulsive suicidal behavior. Educational objective: Borderline personality disorder (BPD) involves a persistent pattern of unstable relationships and self-image, mood instability, impulsivity, and recurrent suicidal behavior. BPD is characterized by transient mood shifts in response to situational stressors rather than sustained mood changes seen in mood disorders. References: Borderline personality disorder and bipolar disorder: what is the difference and why does it matter? (http://www.ncbi.nlm.nih.gov/pubmed/25536097) Assessment and emergency management of suicidality in personality disorders. (http://www.ncbi.nlm.nih.gov/pubmed/18638651)

Exam 1: Advanced Clinical Medicine