Life Long Learning in Neurology - part 6 doc

93 1. An 82-year-old man without previous significant neurological history is hospitalized for pneumonia. On the second hospital evening he develops severe agitation and confusion. His symptoms wax and wane over the next several days and resolve with improvement of his pneumonia. Which of the following options represents the current model of neurotransmitter deficiency/ excess in the pathophysiology of this patient's neuropsychiatric symptoms? A. Acetylcholine deficit and dopamine excess B. Dopamine deficit and serotonin excess C. [gamma]-Aminobutyric acid (GABA) deficit and glutamine excess D. Serotonin deficit and acetylcholine excess E. Glutamine deficit and GABA excess Correct Answer: The correct answer is A. This patient's symptoms and signs are most consistent with delirium. The current pathophysiological model of delirium suggests the pathophysiological role of a simultaneous cholinergic deficit and dopamine excess, although these alterations probably exist within a more global derangement of multiple neurotransmitter systems. 2. A 35-year-old woman has presented to her physician with three different acutely distressing symptoms in the past 2 years. Shortly after the holidays 2 years ago, she complained of dysphagia. No abnormalities were found on a barium swallow or upper endoscopy. She experienced no weight loss, and the dysphagia gradually improved with reassurance. She returned to the physician the next spring with complaints of intermittent shortness of breath. A fairly detailed cardiopulmonary evaluation failed to demonstrate any abnormalities. She was placed in a graded exercise program and experienced a gradual amelioration of this problem. However, this year she returned with complaints of diffuse myalgias and weakness. Evaluation failed to show any objective signs of weakness or laboratory evidence of muscle disease. This woman's constellation of somatic symptoms meets the diagnostic criteria for which of the following disorders? A. Conversion disorder B. Hypochondriasis C. Somatization disorder D. Abridged somatization disorder E. Multisomatoform disorder Correct Answer: The correct answer is E. Multisomatoform disorder is a diagnostic option defined as the presence of three or more acutely distressful and medically unexplained symptoms over a 2-year period. Symptoms to consider are identified on a checklist of 15 common symptoms found in the primary care setting developed from the Primary Care Evaluation of Mental Disorders. This patient's disorder does not meet diagnostic criteria for the abridged somatization disorder, which require lifetime symptoms and presence of four somatic complaints in males and six in females. Patients with somatization disorder must present with many unexplained physical complaints, including four pain syndromes, two gastrointestinal complaints, one sexual problem, and one pseudoneurological symptom, with the onset by age 30 years. Her disorder does not meet criteria for diagnosis of the other disorders listed as alternative choices. Correct Answer: Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 2002;64:258-266. 3. A 5-year-old boy was first noted at age 1 year to not respond when called by his name and has always seemed emotionally remote to his parents compared with their recollections of his siblings. As a toddler and in preschool he was less likely to share things with other children or to show things to others. He has had normal language development and communication skills. In the last year, he has started to develop troubling restricted behaviors, including preoccupation with parts of objects and stereotyped and repetitive motor mannerisms. Which of the following is the most likely diagnosis? A. Autistic disorder, high functioning B. Autistic disorder, low functioning C. Asperger syndrome D. Pervasive developmental disorder not otherwise specified E. Attention deficit hyperactivity disorder Correct Answer: The correct answer is D. This boy has features consistent with impaired social skills noted by age 1. He does not meet enough criteria to be diagnosed with autistic disorder by age 3. However, starting at age 4 he begins to develop behavioral abnormalities that are suggestive of autistic spectrum disorders and thus merits the diagnosis of pervasive developmental disorder not otherwise specified. 4. A 44-year-old man with a 30-year history of complex partial seizures comes to the office for a follow-up visit. He describes a 6-month history of feeling depressed, with diminished appetite, poor sleep, and anhedonia. His only medication is carbamazepine, with which he is compliant; he has not had a seizure in more than 2 years. 94 Neurological examination is normal. Which of the following medications is the most appropriate to consider for this patient's current symptoms? A. Bupropion B. Citalopram C. Clomipramine D. Desipramine E. Maprotiline Correct Answer: The correct answer is B. This patient's symptoms are compatible with depression, for which an antidepressant medication is indicated. Citalopram is one of the antidepressant medications associated with a low risk of exacerbation of seizures; other medications with relatively low seizure risk include escitalopram, fluvoxamine, mirtazapine, and fluoxetine. The other choices listed above, including bupropion, maprotiline, and the tricyclic antidepressants (eg, clomipramine and desipramine), should be avoided in patients with seizures because of their more frequent association with seizures. 5. Which of the following cognitive symptoms frequently present with postconcussive syndrome after a mild head trauma? A. Difficulties with calculation B. Executive dysfunction C. Ideomotor apraxia D. Impaired constructional ability E. Right-left disorientation Correct Answer: The correct answer is B. Common cognitive behavioral symptoms of postconcussive syndrome include impaired attention and concentration, memory deficits, impaired executive functions, personality changes, irritability, affective changes, and anxiety. The cognitive deficits listed could occur with traumatic brain injury but are not common in postconcussive syndrome due to mild trauma. 6. A 58-year-old woman develops acute confusion and agitation while hospitalized for sepsis from a urinary tract infection. Because of the risk of self-injury, parenteral haloperidol is ordered. She has no significant past medical history. Which of the following laboratory tests should be performed in this patient prior to initiation of haloperidol? A. Echocardiogram B. Electrocardiogram (ECG) C. Electroencephalogram (EEG) D. Multigated acquisition cardiac scan E. Serum creatine kinase level Correct Answer: The correct answer is B. Because haloperidol is associated with QT corrected for heart rate (QTc) prolongation, pretreatment cardiac assessment with ECG and regular ECG monitoring are needed when this agent is used in patients with delirium. None of the other cardiac tests listed would specifically assess for the QTc duration. A QTc duration of greater than 500 msec at baseline or during treatment makes torsade de pointes more likely and requires discontinuation of haloperidol. Although neuroleptic medications can be associated with a lowering of the seizure threshold or the neuroleptic malignant syndrome, EEG and baseline serum creatine kinase level are not necessary prior to administration. 7. A couple has one 7-year-old son with autism. There is additional family history with a maternal nephew who has been diagnosed with Asperger syndrome. The couple has just had a second son, and the mother is worried that he could have an autism spectrum disorder. She asks what sorts of signs she should look for so that she might seek early intervention if there is a concern that the second son might be affected. Which of the following clinical characteristics is potentially suggestive of autistic pathology? A. Febrile seizures B. Increased sleeping C. Constant desire to show off artwork D. Reduced reaction to sounds E. Smiling at other babies Correct Answer: The correct answer is D. One sensory behavior red flag is reduced reaction to sounds and intolerance to certain sounds. Febrile seizures are not related to autism spectrum disorders. Requiring less sleep and having frequent awakenings, not increased sleeping, at age 1 year may be adaptive-skill red flags. Two-year-old children may be noted to show reduced joint attention behaviors, such as pointing and showing, and 1-year-old children may show reduced attention to other babies. 8. A 72-year-old man with a 20-year history of Parkinson's disease (PD) is brought to the office by his wife because of 2 months of nocturnal visual hallucinations of small children and animals. He states that he is aware that the 95 visions are not real and he is not very distressed by them. His medications include carbidopa-levodopa, pramipexole, and amantadine, with no changes in dose over the past year. On examination he is alert; his Mini- Mental State Examination score is 29/30. He has severe bradykinesia, bilateral rest tremor, and a shuffling gait with intact postural reflexes. Which of the following options represents the most appropriate management of this patient's hallucinations? A. Add clozapine B. Add quetiapine C. Discontinue amantadine D. Discontinue carbidopa-levodopa E. Discontinue pramipexole Correct Answer: The correct answer is C. This patient's hallucinations are most likely due to overstimulation of mesocortical and mesolimbic regions due to his dopaminergic medications. Since amantadine is likely the least effective antiparkinsonian medication this patient is taking, its discontinuation should be attempted first. Addition of an antipsychotic medication would not be the best choice at this time since his symptoms are not very distressing or disruptive, and a lower-risk intervention should be attempted first. 9. A 45-year-old woman is well known to her local hospital. She has had several admissions for acute abdominal pain associated with ileus, nausea, vomiting, and abdominal distention. During these spells, she is often restless and anxious-appearing and complains of "pain all over." She also had a brief hospitalization for diffuse weakness 3 months ago, but many of her physicians felt that it was psychogenic weakness because it improved rapidly with rest and hydration over 2 days. She now presents to the emergency department with tachycardia, hypertension, similar gastrointestinal symptoms, excessive sweating, mild disorientation, and some degree of paranoia. Her serum sodium is 122 mmol/L. Which of the following options should be considered initially as a likely diagnosis for this woman? A. Arsenic poisoning B. Somatization disorder C. Hypochondriasis D. Anxiety disorder E. Porphyria Correct Answer: The correct answer is E. This patient's problems could all be manifestations of acute intermittent porphyria. Before considering a diagnosis of a somatoform disorder, a reasonable diagnostic evaluation should be performed for other medical conditions that may explain the patient's symptoms. Somatoform disorders are a diagnosis of exclusion. 10. A 46-year-old man is thrown from his motorcycle after hitting a tree. Paramedics find him dazed and disoriented. They remove his helmet and do not note any external injuries. He is evaluated at a local emergency department, and a computed tomographic (CT) scan reveals a small left temporal polar contusion. Otherwise his examination and workup are unremarkable. While hospitalized for observation, a nurse finds him yelling at dogs he reports seeing around his bed. Which of the following medications would be most helpful to control the hallucinations and agitation after a head injury? A. Clozapine B. Diazepam C. Haloperidol D. Quetiapine E. Valproate Correct Answer: The correct answer is D. Atypical antipsychotic agents are preferred to typical antipsychotic agents because they have fewer dopamine-blocking properties. Typical antipsychotic agents may cause a functional decline in brain-injured patients, who may already have diminished dopamine circuits from frontal lobe injury. Clozapine is less useful as an antipsychotic agent because of its potential systemic side effects, ability to lower the seizure threshold, and anticholinergic properties, which may worsen cognitive function. Benzodiazepines may also worsen cognitive dysfunction and cause behavioral disinhibition. Valproate is primarily helpful with mood lability, impulsivity, and aggression. 11. A 64-year-old man with a 5-year history of PD is brought to the office by his wife because she has noticed that he has had worsening stiffness and tremor for the past 4 weeks. Six weeks ago he began treatment with a selective serotonin reuptake inhibitor (SSRI), sertraline, for symptoms of depression, including feelings of hopelessness, sleep disturbance, and diminished appetite; these symptoms have improved. He has been on a stable dose of carbidopa-levodopa for the past 2 years. Examination shows tremor and bradykinesia that are worse than seen on his previous visit 3 months ago. Which of the following mechanisms is the most likely cause of this patient's worsening parkinsonian symptoms? 96 A. Down-regulation of dopamine neurotransmission B. Natural history of his PD C. Pseudo-worsening of PD symptoms due to depression D. Reduced gastric absorption of carbidopa-levodopa E. Denervation supersensitivity Correct Answer: The correct answer is A. Some patients with PD have worsening motor symptoms with SSRI treatment; this has been proposed to be due to down-regulation of dopamine neurotransmission by the SSRI. Despite the potential for worsening of PD symptoms with SSRIs, many patients with PD and depression can be successfully treated with SSRIs, which are typically started with low doses. The patient should be closely followed for worsening parkinsonian symptoms. Although this patient's worsening symptoms could be due to the natural history of his illness, this is less likely since the observed symptoms coincided with the onset of SSRI treatment. If motor symptoms worsen with SSRI treatment, consideration could be given to lowering the dose of the SSRI, switching to a different antidepressant, or increasing the patient's antiparkinsonian therapy. 12. Which of the following features is included in the diagnostic criteria for autism but not Asperger syndrome? A. Lack of social or emotional reciprocity B. Stereotyped and repetitive motor mannerisms C. Delay in the development of spoken language D. Preoccupation with parts of objects E. Lack of spontaneous seeking to share enjoyment or interests with other people Correct Answer: The correct answer is C. Children with Asperger syndrome develop without a general delay in language or cognition. Communication impairment is one of the integral features of autistic spectrum disorders. The other choices may all be present in both autism spectrum disorders and Asperger syndrome. 13. A 35-year-old man loses control of his bicycle on gravel while making a turn and hits his head on a concrete embankment. He is wearing a helmet and suffers a relatively minor concussion. Over the next 3 months, he develops many features of a postconcussive syndrome, including memory deficits, impaired attention, irritability, and insomnia. However, the symptoms that most trouble him are severe anxiety and nervousness. To which brain structure is trauma likely to cause postconcussive anxiety syndromes? A. Amygdala B. Orbitofrontal structures C. Prefrontal areas D. Diffuse white matter axonal injury E. Temporal poles Correct Answer: The correct answer is A. The amygdala has been proposed as the site of traumatic injury to produce posttraumatic anxiety disorders. It is prone to injury because of its mesial temporal location. Injury to the orbitofrontal structures may cause impulsive aggression. Prefrontal area injury may be associated with psychotic symptoms as well as many other deficits. Diffuse axonal injury may be associated with apathy, lack of motivation, decreased processing speed, and distractibility. Injury to the temporal poles may correlate with acquired bipolar symptoms. 14. A 74-year-old woman with a 6-year history of Alzheimer's disease becomes severely confused and agitated and attempts to get out of bed without assistance 1 day after admission to the hospital for a hip fracture. She has a history of diabetes and hypertension. Her medications are insulin, hydrochlorothiazide, and donepezil. She received haloperidol for a similar episode of confusion during a previous hospitalization 1 year ago, but this was complicated by QTc prolongation. Routine serum chemistries, glucose, and oxygen saturation are normal, and her current QTc duration is normal. Which of the following medications would be the most appropriate alternative to haloperidol in this patient? A. Clozapine B. Olanzapine C. Quetiapine D. Thioridazine E. Ziprasidone Correct Answer: The correct answer is C. In patients with prolonged QTc from haloperidol, the atypical antipsychotic agents olanzapine or quetiapine appear to be reasonable alternatives due to their relatively lower risk of prolonged QTc than other atypical antipsychotic medications, such as ziprasidone. In this diabetic patient quetiapine appears to be the most appropriate option since olanzapine is associated with the risk of increased serum glucose. Clozapine is significantly anticholinergic and is contraindicated in delirium. Thioridazine is inappropriate because it is associated with a high risk of QTc prolongation. 97 15. A 37-year-old woman is referred to a neurologist for evaluation of right arm tremor, which developed suddenly after finalization of her divorce. The tremor is somewhat unusual in that at times it is more prominent in resting positions and at other times it is more consistent with a postural tremor. It worsens with direct attention to the right arm and lessens with distractions. The frequency of the tremor varies during contralateral voluntary arm movements. A trial of propanolol did not help the tremor. Past medical history is positive for a history of migraine, atypical chest pain, fibromyalgia, chronic low back pain, dysphagia, irritable bowel syndrome, and dyspareunia. Most of these have been chronic over 10 to 15 years and fluctuating in severity at various times. Which of the following diagnoses is most likely for this woman? A. Factitious disorder B. Somatization disorder C. Conversion disorder D. Pain disorder E. Hypochondriasis Correct Answer: The correct answer is B. This woman presents with a tremor that has many features to suggest a psychogenic cause. With the development of this new pseudoneurological symptom, her constellation of problems now meets the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) diagnostic criteria for somatization disorder, with four pain syndromes, two gastrointestinal problems, one sexual problem, and one pseudoneurological symptom. 16. A 43-year-old woman was unloading crates of merchandise at a retail chain distribution center 2 months ago. She slipped and fell off the loading dock approximately 6 feet to the floor below. She hit her head on the concrete when she landed and was dazed for perhaps 10 minutes. Initially she was more concerned with headache and dizziness. However, those problems are gradually receding, and she is now more concerned with problems with her memory. Which of the following treatments would be likely to help with her memory impairment? A. Amantadine B. Bupropion C. Donepezil D. Methylphenidate E. Propanolol Correct Answer: The correct answer is C. Multiple studies have demonstrated the efficacy of donepezil in treatment of memory and attentional deficits in patients with traumatic brain injury. Amantadine may be helpful to treat apathy and lack of motivation. Bupropion may be used to treat depression. Methylphenidate may improve processing speed and attention after brain injury. Propanolol is helpful for management of postconcussive syndrome headache, agitation, and aggressive behavior. 17. Memory impairment is a common complaint in patients with postconcussive syndromes and is attributed to injury at which of the following sites? A. Bilateral frontal lobe injury B. Mesial temporal lobes C. Diffuse axonal injury D. Orbitofrontal injury E. Brain stem reticular formation Correct Answer: The correct answer is B. The mesial temporal lobes are predisposed to injury due to the sphenoidal bony protuberances. In addition, the hippocampus is sensitive to physiological stress. Bilateral frontal injury may cause apathy and lack of motivation and other frontal lobe dysfunctions. Diffuse axonal injury may be associated with decreased processing speed and inattention. Orbitofrontal injury is associated with impulsive aggression. Injury to the brain stem reticular formation may be associated with disruption of consciousness and lethargy/inattention. 18. A 68-year-old man is brought to the emergency department by his wife because of a 2-day history of drowsiness, confusion, and intermittent agitation. He has a history of prostatic hypertrophy and a distant history of depression; his only medication is finasteride. His temperature is 37.9°C, blood pressure 102/74 mm Hg, and pulse 112/min. On examination he is agitated and not oriented to year or place. Speech is fluent, and there is no aphasia or dysarthria. He is diffusely tremulous, but no focal weakness or sensory loss is seen; reflexes are normal. Complete blood count, comprehensive metabolic panel, and oxygen saturation are normal. Noncontrast brain CT and lumbar puncture are normal. Which of the following diagnostic steps is most likely to lead to determination of the cause of this patient's symptoms? A. Assessment of clinical response to haloperidol B. CT of brain with contrast C. EEG 98 D. Medical evaluation for underlying systemic illness E. Neuropsychological testing Correct Answer: The correct answer is D. This patient's findings are most compatible with delirium. Evaluation of delirium should include a prompt and thorough evaluation for an acute systemic illness underlying the delirium. Although this patient may benefit from administration of a neuroleptic medication if the agitation is impacting his safety, this response is nonspecific and will not lead to a determination of the cause. His symptoms are unlikely to be due to subclinical seizures, so EEG is unlikely to be very helpful. Neuropsychological testing can define and assess delirium but will not determine the specific underlying systemic cause of delirium in this patient. 19. A 6-year-old boy spends so much time performing repetitive stereotyped behaviors, such as spinning objects or hand-waving, that it is difficult to engage him in an individualized behavioral program. For which of the following treatments is there research evidence of efficacy to reduce stereotyped behaviors? A. Atypical antipsychotic agents B. Mood stabilizers C. Stimulants D. SSRIs E. Tricyclic antidepressants Correct Answer: The correct answer is A. An improvement in restricted, repetitive, and stereotyped behaviors has been shown with treatment with the atypical antipsychotic agent risperidone (McCracken et al, 2002; cited in the chapter Autism-Presentation, Diagnosis, and Management in this issue). Mood stabilizers may help with affective instability, impulsivity, and aggressive behaviors. Stimulants may be useful to reduce hyperactivity. SSRI agents may benefit social interactions, mood, ritualistic behavior, aggression, and obsessive-compulsive tendencies. Correct Answer: McCracken JT, McGough J, Shah B, et al. Risperidone in children with autism and serious behavioral problems. N Eng J Med 2002;347:314-321. 20. A 27-year-old woman has presented to her general hospital many times with generalized seizures. The frequency and control of the seizures show no improvement with trials of antiepileptic drugs. It has been difficult to get a detailed description of her behavior during spells from a careful observer. Eventually she is referred to an epileptologist and is admitted to an epilepsy-monitoring unit for evaluation. During one of her spells, she displays forced closure of her eyes, head turning from side to side, and movements of her limbs that are asynchronous from side to side. The EEG shows no epileptic activity during her spells. Which of the following is the best approach to subsequent management of her spells? A. Tell her that you know that she is intentionally feigning seizures B. Tell her that her problems are strictly psychiatric C. Discharge her without neurological follow-up D. Help her to understand that the spells are real signs of psychic stress but are not caused by abnormal electrical discharges E. Tell her spouse that she is probably having these spells to get out of work or some other onerous responsibility Correct Answer: The correct answer is D. Her neurologist should help her to come to the understanding that the spells are real signs of psychic stress but are not caused by abnormal electrical discharges as in typical epileptic seizures. Pseudoseizures or nonepileptic seizures are a common type of conversion disorder. The key to treatment is the development of a therapeutic alliance. It is important not to brusquely dismiss the symptoms as "imaginary" or psychiatric as this will often result in a worsening. Rather, it is most effective to gradually work on helping the patient to understand the relationship between psychological stress and somatization as a poor coping strategy. Referral to a psychologist or psychiatrist and/or use of psychotropic medication may be useful. 21. A 58-year-old woman comes to the emergency department because of diaphoresis, tremulousness, and anxiety that began 3 hours ago. She has a 6-year history of PD manifested mainly by a mild rest tremor and bradykinesia; she has been treated with pramipexole and selegiline for the past 4 years. Eight weeks ago, paroxetine was begun for depression, and the dose has gradually been increased. She has a temperature of 37.9°C, pulse 110/min, and blood pressure 150/90 mm Hg. She appears anxious, diaphoretic, and diffusely tremulous with a severe postural tremor of both hands. Which of the following conditions is the most likely cause of this patient's current symptoms and signs? A. Anxiety disorder B. Hyperthyroidism C. Neuroleptic malignant syndrome D. Pheochromocytoma E. Serotonin syndrome Correct Answer: The correct answer is E. Although most of the listed options could cause similar findings, this patient's symptoms are most consistent with the serotonin syndrome, a rare but important adverse event, which can 99 occur due to the combination of an SSRI (such as paroxetine) with selegiline. Although the occurrence of serotonin syndrome in patients taking a combination of an SSRI or a serotonin-norepinephrine reuptake inhibitor with selegiline appears to be rare, combination of these agents with selegiline should be avoided. Rasagiline, a new monoamine oxidase type B-inhibitor antiparkinsonian agent, carries the same potential theoretical risk and warning regarding administration with antidepressants, although clinical experience with this agent is limited. An anxiety disorder would not explain the patient's acute and severe autonomic symptoms, including fever and diaphoresis. 22. A-53-year old woman was involved in a motor vehicle accident and sustained a mild head injury with concussion. Although she had no past history of psychiatric disorder, over the next year she develops fairly rapid cycling mood symptoms with episodes of mania and depression. She is hospitalized due to suicidality in the context of a mixed episode; she exhibits symptoms of depressed mood with elevated energy and impulsivity. The psychiatrist requests neurological consultation to determine whether special considerations regarding treatment of her mood disorder are needed given her history of head injury. Which of the following would be the best medication to try first for management of her psychiatric disorder? A. Lithium B. Olanzapine C. Sertraline D. Valproate E. Venlafaxine Correct Answer: The correct answer is D. Bipolar symptoms can be caused by brain injury. Valproate is the agent that has been best studied for effectiveness for treatment of bipolar symptoms in patients with postconcussive syndrome. Lithium should be avoided in brain-injured patients because of lowering of the seizure threshold, potential neurotoxicity, and narrow therapeutic window. Antidepressants sertraline and venlafaxine may play a secondary role in treating depression but should not be given as primary mood stabilizers in patients with bipolar symptoms. Olanzapine and other atypical antipsychotics represent another treatment option for such patients, especially with psychotic features, but have not been as well studied in this population. 23. Fink and colleagues (2003) report that 50% of the patients seen by neurologists have a comorbid psychiatric illness. Which of the following do they contend is the most common comorbid psychiatric condition seen in this group? A. Anxiety disorders B. Bipolar disorder C. Chemical dependency D. Depression E. Somatoform disorders Correct Answer: The correct answer is E. Fink and colleagues (2003, 2005) report that somatoform disorders represent the most common comorbid psychiatric condition seen by neurologists and estimate that up to 60% of the patients seen by neurologists have unexplained complaints without an apparent physical cause. Correct Answer: Fink P, Hansen MS, Sondergaard L, Frydenberg M. Mental illness in new neurological patients. J Neurol Neurosurg Psychiatry 2003;74:817-819. Fink P, Steen Hansen MS, Sondergaard L. Somatoform disorders among first-time referrals to a neurology service. Psychosomatics 2005;46:540-548. 24. A 44-year-old woman develops severe confusion and agitation 1 day after undergoing an uncomplicated cholecystectomy. She has a history of alcohol abuse; her last drink was 1 day prior to admission, 48 hours ago. She has no other significant past medical history and takes no medications. Her temperature is 37.7°C, blood pressure 150/94 mm Hg, and pulse 100/min. She is disoriented to place and is agitated and tremulous. In addition to intravenous thiamine, which of the following medications should be administered? A. Diazepam B. Haloperidol C. Lorazepam D. Olanzapine E. Ziprasidone Correct Answer: The correct answer is C. Benzodiazepine monotherapy is the treatment of choice when delirium is due to alcohol withdrawal, as in this patient. Lorazepam is a preferable benzodiazepine because of several attributes, including its properties of sedation, short duration of action, lack of major active metabolites, and low risk of accumulation. 25. A 15-year-old boy has been pressured by his father to play football. His father was very successful as a high school defensive lineman and earned a football scholarship to a Division 1 school. He remains an avid football fan. The son did well on the junior varsity team last year but really does not enjoy the game. He has sometimes wished that he might spend more time on his studies and perhaps try out for the high school musical if his participation in 100 football was not so important to his father. On the morning of his tryouts for the varsity team, he awakens with weakness of his left leg and numbness of his right hand. He is tearful and worried that he is having a stroke or some other threatening medical condition. His neurological examination shows give-way weakness of hip flexion and ankle dorsiflexion on the left. Reflexes are preserved and symmetrical bilaterally. He reports numbness involving the entire right hand in no nerve or radicular distribution. Which of the following is the most likely diagnosis for this neurological presentation? A. Conversion disorder B. Factitious disorder C. Hypochondriasis D. Malingering E. Vasculitic neuropathy Correct Answer: The correct answer is A. This adolescent presents with a pseudoneurological complaint in the setting of an internal conflict most consistent with a conversion disorder. He has not had the ability to assert his desire not to play football with his father. The development of these symptoms will prevent him from trying out for football and resolve his internal conflict about football and are not consciously produced or feigned. Vasculitic neuropathy seems very unlikely given the lack of pain, the give-way quality of his weakness, and the lack of a nerve distribution for his right hand numbness. 26. A 22-year-old man with an 8-year history of complex partial seizures is brought to the emergency department by his family because of 2 days of severe paranoia and agitation. Four days ago he had two of his typical complex- partial seizures with secondary generalization. His only medication is carbamazepine; there has been no recent change in dose. He has had no previous similar psychiatric symptoms. He is afebrile with normal vital signs. He appears suspicious, and his speech is pressured. Neurological examination is otherwise normal. EEG shows occasional left temporal spikes. Routine laboratory studies are normal, and carbamazepine level is 13.4 mcg/mL. Which of the following is the most likely diagnosis? A. Acute postictal psychosis B. Antiepileptic drug toxicity C. Chronic interictal psychosis D. Schizophrenia E. Status epilepticus Correct Answer: The correct answer is A. This patient's symptoms are most compatible with acute postictal psychosis. Acute postictal psychosis presents within 1 week of a seizure and typically lasts from 1 day to 1 week. Symptoms of acutepostictal psychosis resemble those of mood disorders with psychotic features. This patient's risk factors for acute postictal psychosis include partial seizures and the clustering of his seizures. As opposed to acute postictal psychosis, chronic interictal psychosis is the insidious onset of delusions and other psychotic symptoms in patients with epilepsy. This patient has no other history to suggest schizophrenia. Although his carbamazepine level is slightly high, his symptoms are unlikely to be due to carbamazepine toxicity. Finally, status epilepticus is always a consideration in patients with new behavioral symptoms and a history of seizures, but this has been excluded by the EEG findings. 27. An 82-year-old woman develops lethargy alternating with agitation 1 day after hospitalization for chest pain. She has a history of hypertension, coronary artery disease, and a hyperactive bladder. Her medications include enalapril, metoprolol, hydrochlorothiazide, oxybutynin, isosorbide, and aspirin. Vital signs are normal, and neurological examination is normal except for mild confusion. Routine laboratory studies are normal. A trial of discontinuation of which of this patient's medications would be most appropriate? A. Enalapril B. Hydrochlorothiazide C. Isosorbide D. Metoprolol E. Oxybutynin Correct Answer: The correct answer is E. This patient has symptoms of delirium. In patients with delirium, discontinuation of a medication that is potentially "deliriogenic" is appropriate. In this case, oxybutynin, an anticholinergic medication, is the most likely of the patient's medications to be contributory to her delirium. 28. Abnormalities in the cerebellar hemispheres in children with autism are thought to be associated with which of the following cognitive or behavioral abnormalities? A. Impaired integration of brain regions leading to sensory deficits B. Detection of threats in facial images C. Proper production of the behavioral responses such as fear D. Increased anxiety and stress levels 101 E. Abnormal adjustments of attention levels Correct Answer: The correct answer is E. Cerebellar dysfunction has been linked to inaccurate attentional adjustments, which may interfere with the ability to follow the natural flow of conversations or events. Decreased function of the frontal cortex may lead to impaired integration of brain regions with resultant sensory, emotional, and language deficits in autism. Evidence suggests that amygdala hypofunctionality may be associated with abnormal detection of threats in facial images and production of behavioral responses to the environment along with increased tendencies toward anxiety and stress. 29. A 28-year-old woman comes to the office for follow-up of her multiple sclerosis (MS). She was diagnosed with MS 2 years ago when she presented with diplopia and magnetic resonance imaging showed multiple bilateral periventricular lesions; 1 year earlier she had mild weakness and numbness in both legs that improved without treatment within 1 week. There is no family history of MS, but there is a family history of depression in her father and paternal grandfather. She has been taking interferon beta-1a since her diagnosis 2 years ago, and she is tolerating the injections well; she has had no definite attacks of MS since treatment was started. Upon questioning, she admits that over the past 4 months she has been feeling depressed, with diminished appetite and difficulty with sleep. She denies suicidal ideation. Neurological examination is normal. Which of the following represents the most appropriate management of this patient at this time? A. Add an SSRI B. Discontinue interferon C. No changes in management are necessary D. Switch the patient from interferon beta-1a to interferon beta-1b E. Switch the patient from interferon beta-1a to glatiramer acetate Correct Answer: The correct answer is A. Depression is a common accompaniment of MS and is also a potential side effect of treatment with either interferon beta-1a or beta-1b. This patient is at particularly increased risk of depression due to her family history. Since she is otherwise doing well on her interferon medication, addition of an SSRI appears to be the most appropriate option. A switch from interferon to glatiramer acetate (which is not associated with the depression risk of the interferons) would be another reasonable option and should be considered if she fails to benefit from the addition of an SSRI to her regimen. 30. A 45-year-old veteran presents to the emergency department with a report of a ripping chest and back pain and tingling numbness in his left hand. The emergency department physician finds an asymmetry between the right and left brachial pulses. This prompts not only noninvasive workup, such as chest CT and echocardiogram, but also invasive arteriography of the aortic arch and branches to rule out aortic dissection. No pathological finding explains the asymmetry of his pulses. When the case is presented at morning report, one of the interns, who was a medical student at a different institution just months before, states that this case sounds familiar to him and he wonders if the same patient had been seen at his medical school hospital. More investigations are made, and it turns out that the patient has been seen at several hospitals in the region for the same complaint. This information is shared with the patient, and he leaves the hospital surreptitiously without completion of psychiatry consultation or formal discharge. Which of the following diagnoses is most likely for this patient? A. Conversion disorder B. Factitious disorder C. Hypochondriasis disorder D. Malingering E. Pain disorder Correct Answer: The correct answer is B. The discovery of repeated similar presentations and evaluations at other hospitals and the fact that the patient did not share this information makes this most likely to be a factitious disorder. There is no indication that the patient is seeking some type of secondary gain, such as shelter, food, or excuse from work. Rather the patient seems to capitalize on his asymmetrical pulses and fabricated chest/back pain to assume the "sick role" and gain medical attention. 31. Which of the following clinical features is a symptom potentially suggestive of autistic pathology? A. No babble at 6 months of age B. No words at 12 months of age C. No two-word phrases at 15 months of age D. Excessive hand gesturing at 16 months of age E. Absence of symbolic play at 2 years of age Correct Answer: The correct answer is E. Absence of symbolic play or the presence of repetitive, nonfunctional play are abnormalities of adaptive skills that should raise potential concern, and parents should be encouraged to obtain further evaluation of these children. Lack of babble should raise concern at 1 year of age, not 6 months. 102 Lack of single words should not raise significant concern until age 18 months of age, and lack of two-word phrases should not raise significant concern until 24 months of age. Absence of hand gesturing rather than excessive meaningful hand gesturing at 12 months of age is concerning. 32. A 42-year-old woman with a 14-year history of MS is brought to the office by her husband because of several months of episodes of uncontrollable laughing alternating with crying. These episodes seem to occur without obvious provocation, and the patient denies feeling especially sad or happy during these attacks. She denies feeling depressed, and there has been no change in her appetite or sleep patterns. Examination shows a Mini-Mental State Examination score of 22/30, severe dysarthria, and diffuse spasticity and ataxia; these signs are unchanged from her last visit 6 months ago. Which of the following is the most appropriate management option for this patient's inappropriate laughing and crying? A. Discontinue interferon beta-1b B. Begin desipramine C. Begin gabapentin D. Begin lithium E. Begin supportive psychotherapy Correct Answer: The correct answer is B. This patient's symptoms are consistent with pathological laughing and crying (PLC), a symptom complex that is more common in advanced MS and is often associated with cognitive impairment. Patients with PLC have uncontrollable episodes of crying or laughing unassociated with a mood- congruent state or mood disorder. PLC responds well to antidepressants, including tricyclic antidepressants (eg, desipramine) at lower-than-therapeutic doses for depression. The other listed options would not be as appropriate as a trial of an antidepressant in this patient. There is no evidence for depression in this patient to warrant discontinuation of interferon beta. TYPE R QUESTIONS (EXTENDED MATCHING) Theme: Duration of therapy after remission A. Two to 3 months B. Six to 9 months C. Two to 3 years D. Six to 10 years E. Lifetime For each of the following patients with a psychiatric disorder in remission, choose the most appropriate duration of continued medication therapy. Each choice may be used once, more than once, or not at all. 33. A 32-year-old woman is on an SSRI for her first episode of depression without suicidal ideation. She has just entered remission. Correct Answer: The correct answer is B. Antidepressant duration for this patient should be approximately 6 to 9 months after remission. Therapy should be ongoing for those with three or more major depressive episodes, chronic symptoms, or risk for suicide. 34. A 26-year-old man is on a mood-stabilizing agent for bipolar disorder, which was diagnosed 6 years ago. He has had no episodes of mania or severe depression in the past 2 years. Correct Answer: The correct answer is E. Patients with bipolar disorder require lifelong treatment of their condition. 35. A 24-year-old woman has been taking an atypical antipsychotic medication since she was diagnosed with schizophrenia 2 years ago. She is currently employed and has had no episodes of overt psychosis since beginning her medication. Correct Answer: The correct answer is E. Patients with schizophrenia require lifelong treatment of their condition. Theme: Monotherapy A. Bupropion B. Olanzapine C. Haloperidol D. Lithium E. Mirtazapine F. Sertraline G. Valproate H. Clonazepam For each of the following patients with a psychiatric disorder that is currently not being treated, choose the medication that would be the most appropriate choice in monotherapy. Each choice may be used once, more than once, or not at all. [...]... headache syndrome-an exquisitely indomethacin-sensitive continuous head pain with migrainelike exacerbations-is consistent with hemicrania continua Recent positron emission tomographic imaging showed activation of contralateral posterior hypothalamus and ipsilateral rostral pons in some patients with the clinical diagnosis of hemicrania continua 28 A recent study from two neurology clinics in Spain reported... borderline personality disorder: impulsivity in self-destructive behavior (drug abuse), difficulty in controlling anger, idealization and then devaluing of others (in this case, the neurologist) Schizotypal individuals would be unlikely to engage in these types of interactions or relationships; avoidant individuals evade confrontation A dependent individual, in this case, would more likely bring a family... treated with an insulin pump and has early retinal changes Renal function has been normal, but she had a recent episode of chest pain for which she is undergoing cardiac testing The consultant determines that she has been overusing triptans and has developed medication overuse headache (MOH) Which of the following bridging therapies is indicated in this patient to treat her MOH? A Dihydroergotamine (DHE)... course of NSAIDs in this patient who has been determined to have normal renal function would be a reasonable choice for a bridging medication in the setting of several comorbid medical conditions 18 Which of the following adverse effects is the most likely to occur in a patient taking oral ergotamine titrate 2 mg in the acute treatment of migraine? 109 A Chest pain B Diarrhea C Nasal stuffiness D Nausea... patient's migraine? A Fluoxetine B Propranolol C Topiramate D Valproic acid E Verapamil Correct Answer: The correct answer is C In this patient with asthma, a beta-blocker is contraindicated Calcium channel blockers (verapamil) and selective serotonin reuptake inhibitors (fluoxetine) appear to have limited efficacy in the treatment of migraine and generally should not be used as first-line agents in patients... The correct answer is D In addition to developing new headaches, the patient has developed several vegetative symptoms, including weight gain and fatigue; hypersomnia would be consistent with these other symptoms and signs of clinical depression Poor compliance with prescribed medicines may be seen in normal individuals, as might the decision to quit his job An increase in spending habits may have more... "support" and reinforcement of learned helplessness regarding pain A narcissist would likely involve more self-promotion as an individual deserving of special treatment The borderline patient described above represents a significant therapeutic challenge 17 A 35-year-old woman is seen in consultation for severe daily headaches for 1 year She has a history of poorly controlled Type I diabetes since childhood,... headache In counseling this patient, which of the following medicinal herbs, vitamins, and minerals has the strongest rigorous clinical data to support its use? A A Calcium citrate B Hypericum perforatum (St John's wort) C Petasites hybridus (butterbur) D Tanacetum parthenium (feverfew) E Vitamin B1 (thiamine) 105 Correct Answer: The correct answer is C The data to support herbal, vitamin, and mineral... with anxiety, venlafaxine (not listed above) or an SSRI, eg, sertraline or paroxetine (not listed), are good first-line agents Mirtazapine can also be beneficial for depression with anxiety, but this is usually considered a second-line agent for this indication Bupropion is not indicated for anxiety so this is not an appropriate choice Benzodiazepines (such as clonazepam) are indicated for anxiety... answer is E Protriptyline is a secondary tricyclic antidepressant and is the least likely to produce sedation In fact, it often produces insomnia and should be administered in the morning and not at bedtime Nortriptyline also is less likely to be sedating than amitriptyline 23 With respect to the direct costs of migraine, which of the following statements is most accurate? A Emergency department visits were . combination of an SSRI (such as paroxetine) with selegiline. Although the occurrence of serotonin syndrome in patients taking a combination of an SSRI or a serotonin-norepinephrine reuptake inhibitor. dopamine-blocking properties. Typical antipsychotic agents may cause a functional decline in brain-injured patients, who may already have diminished dopamine circuits from frontal lobe injury 30. A 45-year-old veteran presents to the emergency department with a report of a ripping chest and back pain and tingling numbness in his left hand. The emergency department physician finds an