Questions 08/29/2012

Questions 08/30/2012PsychobehavioralQuestion 1A 37-year-old woman with a history of chronic schizophrenia, hypertension, hyperlipidemia, and seasonal allergies complains of neck pain and stiffness. She is unable to turn her head to the left. She takes several medications, but the one most likely to be causing her present symptoms is:HaloperidolLovastatinAmlodipineDoxazosinBenztropineAnswer 1Acute dystonic reactionMost common adverse effect seen in neuroleptic agents1-5% of patientsManifested as muscle spasms (face, neck, back), protrusions of the tongue (buccolingual crisis), deviation of the head to one side (acute torticollis), sustained upward deviation of the eyes (oculogyric crisis), extreme arching of the back (opisthotonos), or rarely laryngospasmAcute dystonia, the most common adverse effect seen with neuroleptic agents, occurs in 1-5% of patients. It involves the sudden onset of involuntary contraction of the muscles of the face, neck, or back. The patient may have a protrusion of the tongue (buccolingual crisis), deviation of the head to one side (acute torticollis), sustained upward deviation of the eyes (oculogyric crisis), extreme arching of the back (opisthotonos), or rarely laryngospasm. Dystonic reactions should be treated with IM or IV benztropine (Cogentin), 1-2 mg, or diphenhydramine (Benadryl), 25-50 mg. IV administration usually results in almost immediate reversal of symptoms. Patients should receive oral therapy with the same medication for 48-72 hours to prevent recurrent symptoms3Question 2A newly psychotic patient receives a dose of haolperidol and begins to undergo spasm of the neck. Which of the following medications listed is the MOST desireable medication to counteract this problem?BenztropineLorazepamPropanololBromocriptineAnswer 2Acute dystonic reactionMuscle spasms of the neck, face, and back are the most common dystoniasTreatment involves either benztropine (1-2 mg IV) or diphenhydramine (25-50 mg IV)Continue oral therapy of the same medication for 48-72 hours to prevent recurrence of symptomsThe scenario described is consistent with an acute dystonic reaction, for which either benztropine (1-2 mg IV) or diphenhydramine (25-50 mg IV are good choices5Question 3A 47-year-old man is brought by his caregivers from a boarding home. They tell you that hes had fevers up to 104 F for the past 24 hours. The patient has difficulty following your commands and is unable to provide a clear history. He is tachycardic, pale, and diaphoretic. He can move at will, but his muscles are rigid. When you review his list of medications, you find that he takes haloperidol. Your treatment for his current condition should include:Benztropine (Cogentin)Carbamazepine (Tegretol)Dantrolene (Dantrium)Diphenhydramine (Benadryl)Phenytoin (Dilantin)Answer 3Neuroleptic Malignant SyndromeNot the result of overdose but does commonly occur after start of therapy or after dose adjustmentTetrad of fever, muscular rigidity, autonomic dysfunction, and altered mental statusTreatment is primarily supportive (withdraw offending medication, external cooling)Dantrolene should be considered in cases of pronounced rigidityTreatment of neuroleptic malignant syndrome consists of fever reduction, intravenous rehydration, and supportive measures. Dantrolene, a direct-acting muscle relaxant, should be used in severe cases7Question 4Which of the following patients has the highest statistical chance of completed suicide?75-year-old black man75-year-old white man18-year-old black woman35-year-old pregnant woman50-year-old married white manAnswer 4Suicide riskPatients who die by suicide are more likely to be older, male, living alone, and/or physically ill.Older white males are more likely to complete suicide, young females aged 15-19 years are more likely to come to the ED having made nonfatal suicide attemptsMost common method of suicide attempt is drug overdoseElderly white men have the highest rate of completed suicide, representing three fourths of all suicide deaths, and women have the highest rate of suicide attempts. White patients are more likely to commit suicide than blacks or Hispanics, and nonpregnant women of child bearing age are more likely than pregnant women to do so. Divorced patients have higher rates than unmarried patients, who, in turn have higher rates than married patients. Most successful suicide attempts involved firearms and most unsuccessful attempts involve drug ingestions. The presence of a firearm in the house in an independent risk factor for completed suicide and the patient should be directly asked about this on history. Substance abuse, especially alcohol and cocaine, is extremely common in patients who complete suicide. Patients who present to the ED with attempted suicide must be evaluated for medical illness that may masquerade as mood disorder or thought disorder leading to the suicide attempt. Roughly 20% of patients with major depression and 10% of patients with schizophrenia commit suicide.9Question 5You are seeing an 84-year-old demented woman who is brought from a local nursing home for a feeding tube change. She has multiple deep bed sores and appears malnourished. You notice several bruises on her face and back. You suspect this may be elder abuse, so legally you are required to:Ask the patient if she is abused and call the police if she answers affirmativelyCall the police to arrest the nursing home managerConsult social services or case managementDo nothing, especially if the patient denies abuseAdmit the patient and file a report with the state department of health and human servicesAnswer 5Elder AbuseCharacteristics associated with higher risk for elder mistreatment are cognitive impairment, physical dependency, lack of social support, alcohol abuse, female sex, and a history of domestic violenceCharacteristics of perpetrators include a history of mental illness and/or substance abuse, excessive dependence on the elder for financial support, and a history of violence within or outside of the familyAbusers are most often the primary caregiverLaws have been enacted that pertain to the reporting and investigation of elder abuse in all 50 states and the District of Columbia. In 46 of the states, physicians are mandated to file a report if they know or reasonably suspect that elder abuse has occurred. Many states grant immunity to reporting physicians. Most state laws include a penalty for failure to report.11Question 6Your state recognizes living wills. A confused patient is accompanied by a friend who states that the patients wife died last month. The patient has been depressed and took an overdose of sleeping pills. In the patients possession is a properly executed living will date 1 week ago. He refuses treatment. Your most appropriate action is to:Follow the provisions of the living willQuestion the friend concerning the patients competencyContact the patients closest living relative to obtain consetObtain an emergency psychiatric consultation to determine the patients competencyTreat the patientAnswer 6Living willsBecome operative in terminally or severely ill patients where treatment would postpone deathLiving wills do not encompass suicide attempts

The emergency physician has an obligation to treat suicidal mentally incompetent patients. Choice a is incorrect because the intent of the living will does not encompass suicide attempts. Choices b, c, or d might be appropriate in other situations in helping to arrive at a decision on treatment. In this case, any refusal of treatment by the patient would not be a competent refusal and no further evidence is necessary, nor consent needed to treat him. Living wills become operative only if the patient is terminally or severely ill and treatment would merely postpone death.13Question 7You are evaluating a 26-year-old man who has been brought to the emergency department by his family for acting bizarre. The patient told his family that he was rescued from a sinking ship where he was king of the world. The family has always thought the patient was eccentric and on examination you also find the patient to have grossly disorganized behavior and speech. You diagnose the patient as having schizophrenia because:Through further questioning he also meets criteria for a mood disorderHe has a stable level of functioning at work and with self-careHe has had the presence of delusions and disorganized behavior and speech for 1 week without treatmentHe recently started abusing amphetamines after he was started on antianxiety medicine that was abruptly discontinuedHe has also had continuous signs of negative symptom disturbance for at least 6 monthsAnswer 7Schizophrenia DSM-IV CriteriaMood disorder or schizoaffective disorder with psychotic features ruled outSharp deterioration from prior baseline level of functioning (work, grooming, interpersonal relationships)Two or more positive symptoms (hallucinations, delusions, grossly disorganized speech or behavior or negative symptoms (flattened affect, poverty of speech, inability to perform goal-directed activitiesSymptoms not caused by substance abuse, medications, or general medical conditionContinuous symptoms for at least 6 months

The DSM-IV criteria for schizophrenia include the following 1) mood disorder or schizoaffective disorder with psychotic features has been ruled out 2) a sharp deterioration from prior baseline level of functioning such as in work, grooming, or interpersonal relationships 3) the presence of two or more positive symptoms: hallucinations, delusions, grossly disorganized speech or behavior (or catatonic behavior) and negative symptoms such as flattened affect, poverty of speech, or inability to perform goal-directed activities 4) symptoms not caused by substance abuse, medications, or a general medical condition 5) symptoms of continuous signs (including prodromal/negative symptoms) for at least 6 months15Question 8A 30-year-old insulin dependent diabetic man was brought to the ED after he had a hypoglycemic episode. The patient had told the ambulance crew that he did not want to go to the hospital because it makes him very anxious. After managing the patients glucose, the patient tells you he feels anxious because he feels like he will never get out of the hospital. The patient tells you he avoids the hospital at all costs because he will never escape. You suspect he also has:Panic disorderSocial phobiaAnxiety disorder caused by a general medical conditionAgoraphobiaGeneralized anxiety disorderAnswer 8AgoraphobiaAnxiety about or avoidance of situations or places from where escape may be difficultMay or may not be associated with panic attacks (sudden or intense fear associated with feelings of doom)Social phobia is anxiety brought on by social performance situationsGeneralized anxiety disorder is associated with at least 6 months of persistent and excessive anxiety

Agoraphobia is anxiety about or avoidance of situations or places from where escape might be difficult. Panic attack is a sudden and intense fear or terror often associated with feelings of impending doom. Social phobia is anxiety brought on by social or performance situations leading to avoidance behavior. Anxiety disorder caused by a general condition is associated with anxiety as a direct physiologic consequence of a general medical condition. In this patient, the diabetes has no relevance to his anxiety. Generalized anxiety disorder is associated with at least 6 months of persistent and excessive anxiety.17Question 9A 78-year-old man complains of appetite loss and weakness. While you are interviewing him, he starts to cry and tells you that his wife of 57 years died last month. On closer questioning, he admits that he has a pistol in the closet table and has thought about putting it in his mouth and pulling the trigger. You offer the patient psychiatric hospitalization, but he refuses. Your next step should be to:Ask why he does not wish to be hospitalizedInvoluntarily commit him using restraint as necessaryPhysically or chemically restrain him until a psychiatrist can evaluate himStart an antidepressant and discharge himStart antipsychotic medications and discharge him18Answer 9Suicide riskPatients who die by suicide are more likely to be older, male, living alone, and/or physically ill.Older white males are more likely to complete suicide, young females aged 15-19 years are more likely to come to the ED having made nonfatal suicide attemptsMost common method of suicide attempt is drug overdose

As an elderly man with a recent personal loss, this gentleman is at high risk for suicide. He may ultimately require involuntary commitment because he represents a significant danger to himself. Many depressed patients, thought, may be reticent to accept hospitalization on account of fear or anger. When a patient is reluctant to accept hospitalization, the physician should attempt to identify and address the specific reasons. Family or friends may help convince the patient to accept psychiatric care.19Question 10A patient presents with new-onset psychosis. Which of the following suggests a medical, rather than psychiatric, cause for the symptoms?Auditory hallucinationsVisual hallucinationsGradual onsetParanoid delusionsAge < 3520Answer 10Medical versus psychiatric psychosisPsychiatric disease Young patientAuditory hallucinationsGradual progressionFlat affectIntact orientation and consciousnessMedical diseaseAcute onsetOlder patientVisual hallucinationsDisorientation and impaired consciousnessPatients with new-onset psychosis must be evaluated in the ED for treatable medical illness before being assigned a psychiatric diagnosis. Signs of medical cause of the psychosis include acute onset, older patient, visual hallucinations, disorientation, and impaired consciousness. Abnormal physical examination findings, such as abnormal vital signs, aphasia, ataxia, and cranial nerve abnormalities usually indicate a medical cause. Many pharmacologic agents can also cause psychosis, including corticosteroids, antihistamines, antidepressants, and sedative hypnotic. True psychiatric disease is suggested by a young patient, auditory hallucinations, gradual progression, flat affect, and intact orientation and consciousness.21