Save my name, email, and website in this browser for the next time I comment. Download Cases in Clinical Medicine PDF Features of Case Files Pediatrics PDF: Following are the few important features of case files pediatrics are given below; High-yield over more than 60 paediatrics cases help students sharpen their diagnostic and problem-solving skills.
This 5th edition is updated to reflect the most current high-yield clerkship topics and the latest in medical management and treatment. USMLE types question answers section. Leave a Reply Cancel reply Your email address will not be published. They are generally safe in overdose if used alone. They are metabolized mainly in the liver. Their side effects include sedation, behavioral disinhibition especially in the young or the elderly , psychomotor impairment, cognitive impairment, confusion, and ataxia.
They are addictive, and after prolonged use, withdrawal may cause seizures and death. Table lists commonly used benzodiazepines. Drugs used to treat the side effects of other psychotropic medications 1. Anticholinergic agents used to treat dystonias caused by the use of antipsychotic medication include benztropine, biperiden, diphenhydramine, and trihexyphenidyl. Medications used to treat akathisias restlessness caused by the use of antipsychotic medication include propranolol and benzodiazepines.
Medications used to treat parkinsonian side effects caused by the use of antipsychotic medication include amantadine and levodopa. Which of the following medications is most likely responsible? What is the next step? He has no medical problems, states that he feels fine, and says that last night he even had a nice meal with wine. Which of the following medications is he most likely taking?
She takes imipramine each evening for depression. Which of the following is the most likely cause of her symptoms? He enjoys drinking beer on the weekends. Which of the following side effects is most likely to occur? Alcohol potentiation Alcohol withdrawal Sexual dysfunction Diabetes insipidus 40 [2.
He comes to the emergency department several days later with muscle spasms, confusion, fever, tachycardia, and hypertension. Which of the following is the most likely cause? Which of the following medications should be avoided? Bipolar disorder B. Major depression C. Panic disorder D. Schizophrenia E. Social phobia [2. Haloperidol Risperidone Clozapine Thioridazine Fluphenazine [2.
On hospital day 2, she experiences auditory and visual hallucinations, has tremors, and is agitated. Which of the following would be the best therapy?
Which of the following is the most likely etiology? Advanced maternal age Mood-stabilizing medication Folate excess Ethnicity [2. He is rushed to the emergency room where resuscitation is attempted but fails. Which of the following is most likely to be noted during the attempted resuscitation or the autopsy?
Massive coronary artery occlusion Aortic valve stenosis Electrocardiographic conduction abnormalities Cardiac tamponade Massive pulmonary embolism Match the following therapies A through F to the clinical scenarios listed questions [2. Answers [2. High doses of thioridazine are associated with irreversible pigmentation of the retina, leading initially to symptoms of night vision difficulty and ultimately to blindness.
This priapism is most likely caused by trazodone. One treatment is epinephrine injected into the corpus of the penis. This patient probably experienced a hypertensive crisis induced by an interaction between the wine and phenelzine, a MAOI. Sexual dysfunction is a very common side effect of SSRI medications. Because both agents increase serotonin levels, 5 weeks should elapse between discontinuation of one medication and initiation of the other.
The danger is very serious serotonin syndrome, which has features similar to those of NMS. Seizure disorders and eating disorders are contraindications for bupropion because of its possible lowering of the seizure threshold and its anorectic effects. This patient has symptoms of diabetes insipidus, a side effect of lithium used in the treatment of bipolar disease. This individual has neutropenic fever as a result of agranulocytosis, a side effect of the atypical antipsychotic agent clozapine.
This woman is probably experiencing either alcohol or benzodiazepine withdrawal; in either case, benzodiazepines would be the treatment. This woman was likely taking valproic acid, a mood stabilizer used in treating bipolar disorder, which increases the risk for teratogenicity eg, a neural tube defect.
A tricyclic antidepressant overdose may lead to increased QT intervals and ultimately to cardiac dysrhythmias. Dialysis is used to treat lithium toxicity when it is severe and lifethreatening, such as causing seizures or coma. Akithisia restlessness can be treated with propranolol. A benzodiazepam overdose can be treated with flumazenil, which is a benzodiazepam antagonist. The parkinsonian-like symptoms of neuroleptic agents are treated with amantadine or levodopa. An exception to this rule is amoxapine.
Selective serotonin reuptake inhibitors are the most commonly used medications for depression but should not be used in conjunction with MAOIs. One medication should be discontinued for at least 5 weeks before the other is initiated to avoid serotonin syndrome. Serotonin syndrome is similar to NMS and is characterized by confusion, muscle rigidity, high temperature, muscle twitching, shivering, and loss of consciousness.
It may be fatal. The most common side effects of SSRIs are gastrointestinal and sexual dysfunction. Individuals taking MAOIs should avoid cheese, wine, liver, and aged foods tyramine or an acute hypertensive crisis may ensue. Trazodone can lead to priapism; thus, a prolonged painful erection that is trazodone-induced is considered an emergency and is treated with an intracorporeal injection of epinephrine or drainage of blood from the penis. Bupropion is used for smoking cessation but must be avoided in patients with eating disorders or seizures.
Lithium is cleared through the kidneys and must be used with caution in older patients and in those with renal insufficiency. Lithium and valproic acid are both teratogenic and must be used with caution in women of childbearing age. Antipsychotic agents produce many adverse effects, including EPS, sedation, and orthostatic hypotension. Neuroleptic malignant syndrome can be caused at any time by an antipsychotic agent. It typically includes movement disorder muscle rigidity, dystonia, agitation and autonomic symptoms high fever, sweating, tachycardia, hypertension.
Clozapine can cause fatal agranulocytosis, and thus leukocyte count monitoring is mandatory. Benzodiazepine withdrawal resembles alcohol withdrawal and can be fatal. He was diagnosed with major depression for the first time 20 years ago. During a second episode, which occurred 15 years ago, he was treated with imipramine, and once again his symptoms remitted after 4 to 6 weeks. He denies illicit drug use or any recent traumatic events.
The man states that although he is sure he is experiencing another major depression, he would like to avoid imipramine this time because although it worked in the past, it produced unacceptable side effects such as dry mouth, dry eyes, and constipation.
Previously he was successfully treated with a tricyclic antidepressant TCA , although this class of medication often produces anticholinergic side effects such as dry mouth, dry eyes, and constipation, which this patient complains about. The question becomes what medication should be used to treat recurrent major depression when tricyclics are not an option.
Common side effects: Gastrointestinal symptoms—stomach pain, nausea, and diarrhea—occur in early stages of the treatment. Minor sleep disturbances—either sedation or insomnia—can occur.
Other common side effects include tremor, dizziness, increased perspiration, and male and female sexual dysfunction most commonly delayed ejaculation in men and decreased libido in women.
Analysis Objectives 1. Understand the treatment of uncomplicated major depression without psychotic features. Be able to counsel a patient in regard to the common side effects of SSRIs.
Considerations Although the patient has been successfully treated with a TCA imipramine two times in the past, these medications are no longer considered first-line treatments because of their common side effects and their potential lethality. If taken all at once, a weekly dosage of one these medications can produce lethal cardiac arrhythmias.
For a patient such as this one, who has a successful history of being treated with imipramine on two prior occasions, one might consider using this medication again. However, the patient specifically requests another type of medication because of his previous discomfort with the side effects.
SSRIs, the current first-line treatment approach for patients with major depression, are thus the logical choice; they have fewer side effects and are safer. Table lists the criteria for major depression, recurrent. Depressed mood 2. Anhedonia 3. Significant weight change or change in appetite 4.
Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feelings of worthlessness or excessive guilt 8. Decreased ability to concentrate or indecisiveness 9. These agents are used as antidepressants and in treating eating disorders, panic, obsessive-compulsive disorder, and borderline personality disorder. Venlafaxine: A phenylethylamine antidepressant structurally different from other antidepressant agents, which acts as a nonselective inhibitor of the reuptake of norepinephrine, serotonin, and dopamine.
Clinical Approach Major depression is a common problem. In the United States, about one in seven individuals will suffer from this disorder at some time in their life. Women are affected twice as often as men, with a mean age of occurrence at 40 years, and half of affected individuals are between the ages of 20 and 50 years.
Those without close personal relationships are at greater risk. A common hypothesis concerning the etiology of major depressive disorder involves the alteration of biogenic amines, particularly norepinephrine and serotonin. Genetics plays a role, as evidenced by family studies. The course of major depression is chronicity and a propensity for relapse.
Good prognostic signs include a short hospital stay, the absence of psychotic symptoms, stable family functioning, and close social relationships. Given the frequency with which depression is a presenting complaint in the primary care setting, a mnemonic is helpful in remembering the criteria for an episode of major depression. Each letter stands for a criteria except for depressed mood used in diagnosing an episode of major depression: S—sleep changes I— decreased interest G— excessive guilt E— decreased energy C— decreased concentration A—appetite changes P—psychomotor agitation or retardation S—suicidal ideation.
Differential Diagnosis It is important to rule out other disorders that could be causing a depressed state, including medical diseases eg, hypothyroidism or multiple sclerosis , medications eg, antihypertensives , or substances eg, alcohol use or cocaine withdrawal. Obtaining a thorough history, performing a physical examination, and ordering appropriate laboratory studies are crucial in the assessment of any new onset of depression.
Many psychiatric illnesses are characterized by depressive symptoms, including psychotic disorders, anxiety disorders, and personality disorders. A critical distinction to make, especially in recurrent episodes of depression, is between major depressive disorder, recurrent, and bipolar disorder, depressed. This distinction is essential not only for making the correct diagnosis but also for proper treatment. Standard therapies for major depression may be less effective and actually worsen bipolar illnesses.
It is necessary to obtain any current or past history of episodes of mania, as well as any family history of bipolar disorder. Assessment of Suicide Risk One of the most important determinations a clinician must make in the case of a depressed individual is the risk of suicide.
The best approach is to ask the patient directly using questions such as, Are you or have you ever been suicidal? Do you want to die? A patient with a specific suicide plan is of special concern. Also, the psychiatrist should be alert to warning signs such as an individual becoming uncustomarily quiet and less agitated after a previous expression of suicidal intent or making a will and giving away personal property. The results of a careful mental status examination, risk factors, prior suicidal attempts, and suicidal thoughts and intent must be all considered.
Many experience what is known as postpartum blues, in which there is sadness, strong feelings of dependency, frequent crying spells, and dysphoria. These feelings, which do not constitute major depression and therefore should not be treated as such, seem to be attributable to a combination of the rapid hormonal shifts occurring during the postpartum period, the stress of childbearing, and the sudden responsibility of caring for another human being. Postpartum blues usually lasts for only several days to a week.
In rare cases, postpartum depression exceeds in both severity and length that observed in postpartum blues and is characterized by suicidality and severely depressed feelings. Women with postpartum depression need to be treated as one would treat a patient with major depression, taking care to educate them as to the risks of breast-feeding an infant when the antidepressant appears in the milk. Left untreated, postpartum depression can worsen to a point where the patient becomes psychotic, in which case antipsychotic medication and hospitalization may be necessary as well.
As the risk of recurrence increases not only with each subsequent episode but also with the occurrence of residual symptoms of depression between episodes, proper, adequate treatment resulting in full remission is the goal. The treatment options for recurrent episodes of major depression are not significantly different from those for a first episode: pharmacotherapy, psychotherapy for mild or moderate symptomatology , a combination of the two, or electroconvulsive therapy ECT in major depression with psychotic features or where a rapid response is required.
Common first-line pharmacotherapy for episodes of major depression includes SSRIs such as fluoxetine, sertraline, paroxetine, and citalopram , venlafaxine, bupropion, and mirtazapine. Side effects vary among the specific medications and include sedation or activation, weight gain, headache, gastrointestinal symptoms, tremor, elevated blood pressure for venlafaxine at higher doses , and sexual dysfunction, particularly with SSRIs and venlafaxine. Monoamine oxidase inhibitors MAOIs are used less frequently because of their significant drug—drug interactions and because dietary restrictions are necessary.
A rule of thumb in managing recurrent episodes of major depression is that the particular medication that achieved remission in past episodes is likely to achieve remission in subsequent episodes, often at the same dose.
Additional factors to consider when choosing a medication are prior side effects, drug—drug interactions, and patient preference. Comprehension Questions [1. She admits to difficulty falling asleep, a poor appetite with a lb weight loss, and thoughts of wanting to die.
She uses an albuterol inhaler only as needed. Which of the following symptoms is necessary in order to make a diagnosis of major depressive disorder?
She recently received a diagnosis of major depressive disorder and began treatment with citalopram an SSRI 6 weeks ago. Her appetite has improved, and she has been able to focus at work and enjoy time with her family.
Although she experienced occasional headaches and loose stools at the beginning of her treatment, she no longer complains of any side effects. What is the most appropriate next step in her treatment? Anorgasmia Insomnia Nausea Tremor Answers [1. Although a change in appetite, decreased energy, fatigue, and suicidal ideation are all criteria used in diagnosing major depressive disorder, one of the symptoms must be either a depressed mood or anhedonia.
The risk of recurrent episodes of major depression increases with the number of prior episodes, the occurrence of residual symptoms of depression between episodes, and the presence of comorbid either psychiatric or chronic medical conditions. The proper strategy in the management of an episode of major depression that has recently remitted is to continue treatment at the same dose if it can be tolerated.
Early discontinuation of medication can lead to an early relapse. Although activation causing insomnia , gastrointestinal symptoms including nausea , and tremor are common side effects of SSRIs, only sexual dysfunction generally occurs later in the treatment course after weeks to months. The risk of further episodes of major depression increases with the number of prior episodes, the occurrence of residual symptoms of depression between episodes, and any comorbid psychiatric or chronic medical illnesses.
The treatment that was successful for prior episodes of major depression has a higher likelihood of achieving remission in future episodes. Selective serotonin reuptake inhibitors—bupropion, venlafaxine, and mirtazapine—are all first-line treatment options for major depressive disorder.
Practice guidelines for the treatment of major depressive disorder. Stoudemire A. Clinical psychiatry for medical students, 3rd ed. He denies that he currently uses drugs or alcohol, although he reports that he occasionally smoked marijuana in the past. On a mental status examination the patient is noted to be dirty and disheveled, with poor hygiene.
He appears somewhat nervous in his surroundings and paces around the examination room, always with his back to a wall. His speech is of normal rate, rhythm, and tone. His thought processes are tangential, and loose associations are occasionally noted. His thought content is positive for delusions and auditory hallucinations. He denies any suicidal or homicidal ideation. What conditions are important to rule out before a diagnosis can be made?
Should this patient be hospitalized? For at least 1 year he has experienced delusions and auditory hallucinations. He has become socially isolated and dysfunctional as a result of these symptoms. He denies current drug use or medical problems. A mental status examination shows several abnormalities. Disturbances in grooming, hygiene, and behavior paranoia are noted, and he has a flat affect.
His thought processes are occasionally loose, and he reports auditory hallucinations and delusions. Important conditions to rule out: To make a diagnosis of schizophrenia, substance abuse and general medical conditions must be ruled out. In addition, schizoaffective disorders and mood disorders must also be excluded.
He clearly is unable to care for himself because he listens to voices and acts on their instructions in such a manner that makes him behave dangerously ie, sitting in the middle of a busy street. Be able to diagnose schizophrenia in a patient. Understand that other conditions must be ruled out before such a diagnosis can be made. Understand admission criteria and know when a patient should be admitted. Considerations This patient demonstrates the two main diagnostic criteria for schizophrenia: delusions thinks people are not who they say they are and auditory hallucinations.
See Table for diagnostic requirements. The hallucinations have several characteristics seen in schizophrenic psychoses—several voices are speaking to each other about the patient and there are command hallucinations. On a mental status examination the patient shows loosening of thought associations as well. He has had the disorder for at least 1 year. He denies mood symptoms, drug abuse, and medical problems, although of course these issues would need to be further investigated by obtaining a more complete history, performing a physical examination, and ordering the appropriate laboratory tests.
Delusions Hallucinations Disorganized speech Disorganized or catatonic behavior Negative symptoms. Delusions: Fixed, false beliefs that remain despite evidence to the contrary and are not culturally sanctioned. Flat affect: The absence of a noticeable emotional state eg, no facial expression.
Ideas of reference: False beliefs that, for example, a television or radio performer, a song, or a newspaper article is referring to oneself. Loose associations: Thoughts that are not connected to one another or illogical answers to questions. Negative symptoms of schizophrenia: Anhedonia, poor attention, low motivation, and a flat affect.
Positive symptoms of schizophrenia: Ideas of reference, paranoia, delusions, and hallucinations. Tangentiality: Thoughts may be connected to each other although the patient does not come back to the original point or answer the question.
The average age of onset is 15 to 25 years in men and 25 to 35 years in women. Women tend to have better outcomes than men. Fifty percent of schizophrenics attempt suicide; those with depressive symptoms, a younger age of onset, and a higher level of premorbid functioning are at increased risk.
The etiology is not known. There are five subtypes of schizophrenia: 1. Paranoid: Characterized by preoccupation with one or more delusions or frequent auditory hallucinations 2.
Disorganized: Usually characterized by disorganized speech and behavior and a flat or inappropriate affect 3. Undifferentiated: Manifested by two or more of the following: delusions, hallucinations, disorganized speech, grossly disorganized behavior, and negative symptoms; however, the patient does not meet the criteria for the other types of this disorder.
Continuing evidence of disturbance is indicated by the presence of negative symptoms or two or more criteria in an attenuated form. Differential Diagnosis Most important and immediate in the differential diagnosis are medical conditions characterized by psychotic symptoms such as deliria, dementias, severe hypothyroidism, and hypercalcemia.
Alcohol and illicit drugs, either during intoxication hallucinogens, cocaine or withdrawal alcohol, benzodiazepines , can produce psychotic symptoms. In fact, symptoms of phencyclidine intoxication can appear identical to those of schizophrenia.
A thorough history of substance use, a physical examination including the measurement of vital signs, a determination of blood alcohol level, and a urine toxicology screening reveal substance use as a causal factor in most cases.
A careful examination of the medications a patient is taking, including over-the- counter and herbal supplements, is also important, as many medications eg, steroids and anticholinergics can cause psychotic states.
Patients are frequently poor historians given their psychotic symptoms, and so gathering information from other sources such as prior records, family members, or significant others is imperative because a complete history can help clarify the issue. Table highlights these differences. The above distinctions are important not only for the diagnosis but also in determining the treatment and the prognosis.
In general, mood disorder with psychotic features has a better prognosis than schizoaffective disorder, which has a better prognosis than schizophrenia. Although clozapine is beneficial, especially in treatment-resistant schizophrenia, the posssibility that it may cause agranulocytosis prevents it from being a first-line drug. Although typical medications adequately treat the positive symptoms of schizophrenia, they can worsen or actually cause negative symptoms.
Atypical medications appear to treat the positive symptoms at least as well as the older medications and also treat the negative symptoms. Older antipsychotics also have a higher likelihood of causing unwanted side effects, namely, extrapyramidal symptoms dystonias, parkinsonian symptoms, and akathisia , hyperprolactinemia leading to impotence, amenorrhea, or gynecomastia , and tardive dyskinesia.
Acute symptoms such as dystonic reactions and parkinsonian symptoms can be managed by reducing the dose or adding an anticholinergic drug such as benztropine. Unfortunately, tardive dyskinesia is usually a permanent condition and can be both disfiguring and disabling. Neuroleptic malignant syndrome NMS can occur with any antipsychotic at any time during treatment. The treatment is intended to provide supportive management, although dantrolene and bromocriptine may also be beneficial.
Comprehension Questions [2. Auditory hallucinations Belief that one has the power of an alien species Catatonic symptoms Depression Inappropriate affect Match the most likely diagnosis A through D with the following case scenarios questions [2. Major depression with psychotic features Schizoaffective disorder Schizophrenia Psychosis secondary to a general medical condition [2.
He is certain that the government is involved because they often communicate with him through a microchip they have implanted in his brain. Although he feels frustrated at being taken advantage of, he denies any significant depressive symptoms and is often able to enjoy playing cards with his peers at the group home.
He reports difficulty sleeping, a lb weight loss, frequent crying spells, and profound guilt over surviving her. For the last several days, he has been convinced that his body is literally decaying.
She insists that he has professed his intentions to marry her through messages in his song lyrics. She has written numerous letters to him and loitered around his home, resulting in several arrests. Although all these symptoms can be seen in various psychotic disorders, the presence of a bizarre delusion is the most specific to schizophrenia. Only one psychotic symptom is needed to diagnose schizophrenia if there are bizarre delusions, auditory hallucinations commenting on the patient, or two or more voices speaking to each other.
The most likely diagnosis for this man is schizophrenia. He has been suffering from psychotic symptoms including delusions and auditory hallucinations for more than 6 months. Although he may have brief periods of depressed mood, he does not have a history of major mood disorder. The most likely diagnosis for this man is major depression with psychotic features. Significant depression and neurovegetative symptoms are present, as well as delusions and auditory and visual hallucinations. Each case includes a complete discussion, clinical pearls, references, and USMLE-style review questions with answers.
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