Case Questions Flashcards
John Doe is an otherwise healthy 20-year-old male admitted to the Emergency Services for acute psychosis. He is dangerously aggressive and refusing to cooperate with all staff attending to him.
Which is the most appropriate intervention for John?
(A) De-escalate by counselling him on need for admission
(B) Administer oral Lorazepam 0.5mg STAT
(C) Restrain him for safety
(D) Restrain him and administer IM Haloperidol 5mg STAT
(E) Restrain him and administer IM Lorazepam 2mg STAT
(D) Restrain him and administer IM Haloperidol 5mg STAT
Rationale:
1. Antipsychotics calm the patient down
2. Benzodiazepines reduce the pain and may impair consciousness at high enough doses. However, for young and old people, paradoxical excitement can occur.
3. If you are unsure that the patient is agitated because of a substance, give IM lorazepam
John Doe received IM Olanzapine 5mg daily for the past 4 days and developed a fever of 38.8oC with lead-pipe rigidity, tachycardia, labile blood pressure, altered consciousness, with serum creatine kinase >10,000 IU/L. Thyrotoxicosis, seizures & infections were ruled out.
Identify this emergent condition.
(A) Akathisia
(B) Antidepressant discontinuation syndrome
(C) Cholinergic rebound
(D) Neuroleptic malignant syndrome
(E) Panic attack
(D) Neuroleptic malignant syndrome
Rationale: Rule out infection from thyroid storm for fever
John Doe has a BMI of 30 kg/m2 and is working as an art teacher. He is concerned with the side effects of antipsychotics.
He requests for options with lower risks of tremors, muscle stiffness, weight gain and diabetes.
Which is the most appropriate recommendation?
(A) Aripiprazole
(B) Chlorpromazine
(C) Haloperidol
(D) Olanzapine
(E) Quetiapine
(E) Quetiapine - Lower potency antipsychotic but higher risk of DM
Chlorpromazine: D2 antagonist – By nature EPS; Can cause weight gain
Haloperidol cause EPS
John Doe achieved no significant improvements in his positive symptoms of schizophrenia after adhering to 2 months of Risperidone 6 mg/day followed by 2 months of Quetiapine 600 mg/day. Which is the most appropriate recommendation now?
(A) Increase dose of Quetiapine to 800mg/day
(B) Add Risperidone 2mg/day to Quetiapine 600 mg/day
(C) Switch to Risperidone oral solution
(D) Switch to Clozapine
(E) No changes to current medication
(D) Switch to Clozapine
Rationale:
1. Treatment Resistant Schizophrenia (More than 2 adequate trials of antipsychotics for 2-6 weeks with at least one atypical SGA
John Doe achieved remission on oral Haloperidol 20 mg/day but he subsequently relapsed and was readmitted due to poor adherence to his medications at home. His family is not able to supervise his medications. Which is the best relapse prevention strategy for him?
(A) Admit him to a Psychiatric Nursing Home
(B) Convert to 4-weekly IM Haloperidol Decanoate 200mg
(C) Convert to Haloperidol oral solution 20mg/day for family to spike into his meals
(D) Monthly home visits by Community Psychiatric Nurse
(E) Electroconvulsive Therapy
(B) Convert to 4-weekly IM Haloperidol Decanoate 200mg
Rationale:
(C) is wrong, don’t endorse his delusion
(D) Community Psychiatric Nurse is good but need the nurse to administer IM combination therapy
James is an underweight 18-year-old male diagnosed with Major Depressive Disorder, along with bothersome insomnia and poor appetite. Which of the following is the most appropriate antidepressant for him?
(A) Amitriptyline
(B) Bupropion
(C) Mirtazapine
(D) Moclobemide
(E) Trazodone
(C) Mirtazapine - Counsel on suicidality
Rationale:
1. TCAs are not firstline for antidepressants
2. Bupropion is not suitable for eating disorder
3. Moclobemide is a RIMA but not firstline
4. Trazodone is SARI and sedative is profound
5. Mirtazapine (NaSSA) is firstline to target at serotonin selectively
Jim is a 40-year-old male following up with the Community Health Clinic. He seeks your advice and treatment for emergent insomnia, nausea, flu-like symptoms and “electric shock sensations” over his extremities. His medication history was significant for Paroxetine 40 mg ON for major depressive disorder. He stopped it two days ago upon achieving remission after taking it for two months.
Which is the most likely explanation for his symptoms now?
(A) Antidepressant discontinuation syndrome
(B) Serotonin syndrome
(C) Cholinergic rebound
(D) Neuroleptic malignant syndrome
(E) Panic attack
(A) Antidepressant discontinuation syndrome
Rationale:
- FINISH symptoms (Flu-like, Insomnia, Nausea, Sensory disturbance of electric shocks
Jacky is a 50-year-old diagnosed with severe Major Depressive Disorder and distressed by psychomotor agitation and anxiety. His medical history is significant for uncontrolled hypertension . Which of the following is the most appropriate treatment for him?
(A) Amitriptyline
(B) Bupropion
(C) Venlafaxine
(D) Sertraline
(E) Moclobemide
(D) Sertraline (SSRI)
Rationale:
The rest can worsen the HTN, especially venlafaxine. TCA and RIMA have lots of ADR
Jane is a 60-year-old female newly diagnosed with major depressive disorder. She has osteoarthritis, chronic musculoskeletal pain and asthma.
Which of the following is the most appropriate
antidepressant for her?
(A) Amitriptyline
(B) Bupropion
(C) Clomipramine
(D) Duloxetine
(E) Escitalopram
(D) Duloxetine is also licensed for diabetic peripheral neuropathy (DPN), chronic musculoskeletal pain, although SNRIs and TCAs can be considered for use.
Rationale:
- Should avoid muscle related side effects
Judy is an 80-year-old female on metoprolol 50mg OM, digoxin 62.5mcg OM, simvastatin 10mg ON, aspirin 100mg OM and enalapril 5mg BD. She is currently diagnosed with major depressive disorder. No history of gastritis.
Labs today: TG 0.6mmol/L, LDL 1.5mmol/L.
Which is the most appropriate antidepressant for her?
(A) Fluvoxamine
(B) Bupropion
(C) Escitalopram
(D) Mirtazapine
(E) Vortioxetine
Ranking of choice - Fewer ADRs
(D) Mirtazapine
(C) Escitalopram
(E) Vortioxetine
Rationale:
(A) Fluvoxamine is a potent inhibitor of 1A2, 2C19 and has the most CYP interactions
(B) Bupropion is a potent inhibitor of 2D6
Ms. Jane Doe is a previously healthy 20-year old student with no known drug allergy and nil significant medical and medication history. She is referred by her psychotherapist to your clinic today for complains of depressed mood, poor appetite, lethargy and impaired concentration, with feelings of worthlessness, which persisted for most days of the past 2 months. She was the top student but these distressful symptoms resulted in her drastically poor academic performance this semester, which causes her to feel even more anxious and frustrated. She denies any significant psychosocial stressors prior to the onset of these symptoms. Her routine biochemistry screen and ECG results are unremarkable. She does not use cigarettes, alcohol or substances. She is a single child who stays with her parents in a HDB flat.
Based on Jane’s initial symptoms, what is the most likely condition?
Major Depressive Disorder
Ms. Jane Doe is a previously healthy 20-year old student with no known drug allergy and nil significant medical and medication history. She is referred by her psychotherapist to your clinic today for complains of depressed mood, poor appetite, lethargy and impaired concentration, with feelings of worthlessness, which persisted for most days of the past 2 months. She was the top student but these distressful symptoms resulted in her drastically poor academic performance this semester, which causes her to feel even more anxious and frustrated. She denies any significant psychosocial stressors prior to the onset of these symptoms. Her routine biochemistry screen and ECG results are unremarkable. She does not use cigarettes, alcohol or substances. She is a single child who stays with her parents in a HDB flat.
Based on Jane’s presentation, what is the most appropriate treatment?
(A) Escitalopram
(B) Bupropion
(C) Clomipramine
(D) Moclobemide
(A) Escitalopram
Which drug is the safest option in terms of drug interaction?
(A) Desvenlafaxine
(B) Fluvoxamine
(C) Bupropion
(D) Agomelatine
(A) Desvenlafaxine
Along with poor appetite, if Jane also reports frequent nausea with unintentional 8% weight loss over the past 2 months, which of the following will be the most appropriate treatment for her?
(A) Venlafaxine
(B) Fluoxetine
(C) Bupropion
(D) Mirtazapine
(D) Mirtazapine
Ms. Jane Doe is a previously healthy 20-year old student with no known drug allergy and nil significant medical and medication history. She is referred by her psychotherapist to your clinic today for complains of depressed mood, poor appetite, lethargy and impaired concentration, with feelings of worthlessness, which persisted for most days of the past 2 months. She was the top student but these distressful symptoms resulted in her drastically poor academic performance this semester, which causes her to feel even more anxious and frustrated. She denies any significant psychosocial stressors prior to the onset of these symptoms. Her routine biochemistry screen and ECG results are unremarkable. She does not use cigarettes, alcohol or substances. She is a single child who stays with her parents in a HDB flat.
In addition to initial symptoms, Jane also reports frequent insomnia over the past 2 months, which monotherapy is most appropriate?
(A) Zopiclone
(B) Mirtazapine
(C) Hydroxyzine
(D) Quetiapine
(B) Mirtazapine
