A 28-year-old man is brought to the emergency department by his parents due to agitation, paranoid delusions, and hearing voices. The patient has no medical issues. He drinks a beer each day but does not use illicit drugs. Family history is significant for Graves disease and depression in his mother and hypertension and coronary heart disease in his father. Medical and substance-induced causes of psychosis are ruled out; further history indicates that the patient has become increasingly paranoid and withdrawn over the past year. He is diagnosed with schizophrenia and hospitalized, then started on olanzapine and as-needed lorazepam. After a week the patient is significantly calmer and less paranoid and reports that the voices have decreased in frequency and intensity. He is discharged on olanzapine 20 mg.
The patient is seen for a routine medical checkup 3 months later. Apart from an upper respiratory infection a month ago, he has been well. Vital signs and physical examination are unremarkable. He no longer hears voices and has no suicidal ideation.
Which of the following tests is the most appropriate at this visit?

Question

A 28-year-old man is brought to the emergency department by his parents due to agitation, paranoid delusions, and hearing voices.  The patient has no medical issues.  He drinks a beer each day but does not use illicit drugs.  Family history is significant for Graves disease and depression in his mother and hypertension and coronary heart disease in his father.  Medical and substance-induced causes of psychosis are ruled out; further history indicates that the patient has become increasingly paranoid and withdrawn over the past year.  He is diagnosed with schizophrenia and hospitalized, then started on olanzapine and as-needed lorazepam.  After a week the patient is significantly calmer and less paranoid and reports that the voices have decreased in frequency and intensity.  He is discharged on olanzapine 20 mg.
The patient is seen for a routine medical checkup 3 months later.  Apart from an upper respiratory infection a month ago, he has been well.  Vital signs and physical examination are unremarkable.  He no longer hears voices and has no suicidal ideation.
Which of the following tests is the most appropriate at this visit?

Quizplus · Accepted Answer

11ec193a_9698_175a_853d_79bd78b52883_MD0002_00 Second-generation antipsychotics (eg, olanzapine) are increasingly used as first-line therapy as they have a lower risk of extrapyramidal side effects compared with first-generation antipsychotics. However, as a class, they are associated with metabolic adverse effects (eg, weight gain, dyslipidemia, hyperglycemia, increased risk of diabetes). Olanzapine and clozapine are associated with the greatest risk and can result in significant weight gain, dyslipidemia, and new-onset diabetes. Drugs with lower risk include aripiprazole and ziprasidone. Guidelines for patients on second-generation antipsychotics recommend monitoring BMI monthly and checking fasting plasma glucose and lipids, blood pressure, and waist circumference at baseline, 3 months, and annually thereafter. Patients with preexisting diabetes or who gain >5% of their initial weight should be monitored earlier and more frequently. (Choice A) Olanzapine rarely causes agranulocytosis, and routine monitoring of complete blood counts is not recommended. The antipsychotic clozapine, not olanzapine, requires weekly blood counts during the first 6 months of treatment due to the risk of agranulocytosis. (Choice B) Olanzapine treatment in patients without preexisting cardiac disease does not require routine ECG monitoring. The second-generation antipsychotic ziprasidone is associated with QT prolongation at higher doses. (Choice D) Olanzapine has been associated with asymptomatic increase in liver enzymes. However, significant liver enzyme elevation is rare and routine monitoring of liver function tests is not indicated. (Choice E) Treatment with olanzapine does not require routine thyroid function tests. Patients on the mood stabilizer lithium require regular testing due to the drug's known adverse effects on thyroid function. Educational objective: Second-generation antipsychotics are associated with metabolic side effects, and patients should be routinely monitored for weight gain, hyperglycemia, and dyslipidemia. Olanzapine and clozapine are associated with the greatest risk. __________ References: Clinical monitoring and management of the metabolic syndrome in patients receiving atypical antipsychotic medications. (http://www.ncbi.nlm.nih.gov/pubmed/19083283) Weight gain and changes in metabolic variables following olanzapine treatment in schizophrenia and bipolar disorder. (http://www.ncbi.nlm.nih.gov/pubmed/21495734) Second-generation antipsychotics and metabolic side effects: a systematic review of population-based studies. (http://www.ncbi.nlm.nih.gov/pubmed/28585153)

A 28-Year-Old Man Is Brought to the Emergency Department by His