psychiatry pharm

Question 1

6 yr old boy is brought to he office by his mother due to behavioural difficulties at school. His teacher said “he interrupts the class, doesnt listen, and cannot sit still for more than a few minutes”. He has been sent home on a few occasions for hitting other children and taking their toys. The pt was adopted at age 6 months and his birth history is unknown. He runs around the office playing with various toys and is easily distracted. Vital signs are within normal limits. Weight and height tracking on the 210th percentile, head circumference is below 5th percentile for age and sex. Physical exam reveals short palpebral fissures, a smooth philtrum, thin upper lip and difficulty with both gross and fine motor coordination. What is the most likely cause of this pt’s condition?

Answer 1

intrauterine alcohol exposure

Question 2

22 yr old man is brought to the office by his mother due to a change in behaviour over the past year. Nine months ago, the pt abruptly decides to quit college in his last year and insisted on moving back home to work on research without being disturbed. Since then he has stopped going out with friends, seems uninterested in his usual hobbies of playing and watching football and spends hours on his computer researching government coverups. He stays up late at night, sleeps during the day and showers only once a week. The pt has no motivation to look for work, his mother reports that when she encourages him to go back to school or work, he becomes agitated and starts accusing her of being one of the black suits. Physical exam shows poor hygiene but is otherwise normal. Lab eval including drug screen test is unremarkable. A medication with what primary mechanism of action is most appropriate fo this pt’s condition?

Answer 2

dopamine receptor antagonist

Question 3

20 yr old college student comes to the office due to persistent fatigue, irregular menstrual periods and difficulty losing weight despite intensive exercise. Several times a week, the pt has episodes where she uncontrollably consumes large amounts of cookies, bread and potato chips. She feels disgusted with herself afterwards and subsequently does additional exercise. Although the pt hates her appearance and constantly compare herself to her slimmer friends, she denies feeling persistently depressed. She has no other medical problems. Examination shows pharyngeal erythema and minimal parotid enlargement B/L. Pregnancy test is negative. What medication would be most effective in treating this pt?

Answer 3

SSRI

Question 4

44 yr old man hospitalised for acute cholecystitis is being evaluated for anxiety and agitation. He underwent an open cholecystectomy w/o. having any operative complications. 2 days after admission, the pt experiences anxiety and tremulousness and he becomes irritable, severely agitated and verbally abusive to the nursing staff. He has no other medical problems. The pt does not use tobacco or illicit drugs but admits to drinking 6-8 beers daily for the last several years. He has no known drug allergies and family history is insignificant. Bp is 160/90 and pulse is 110/min. Examination shows hand tremors b/l. What is the most appropriate pharmacotherapy?

Answer 4

chlordiazepodxide

Question 5

43 yr old man comes to the office due to depression. He feels sad and unmotivated, sleeps 12 hours a day, and has increased appetite, poor concentration at work and fleeting thoughts of suicide. The pt has no medical history and laboratory evaluation is unremarkable. Major depressive disorder is diagnosed and anti-depressant medication is administered. Several weeks after starting the medication, the pt’s depressive symptoms are mildly improved, but he is now distressed by a significant decrease in libido and impaired sexual performance. He is considering stopping the medication and requests an alternate treatment. What drug might be the most appropriate for this pt?

Answer 5

buproprion

Question 6

40 yr old woman is brought to the emergency department due to ataxia and tremor. The pt’s symptoms started gradually 2 weeks ago and have worsened acutely over the past 2 days. She is having difficutly walking and almost fell while getting up from the chair. The pt’s medical problems include bipolar disorder and recently diagnosed hypertension. Her medication includes a stable dose of Lithium for many years and a new bp medication that was started several weeks ago. Vital signs are within normal limits. Neuro exam reveals a resting tremor and difficultly with balance. Physical exam is otherwise normal. A drug interaction involving which medication is most likely causing this pt’s condition?

Answer 6

hydrochlorothiazide

Question 7

25 yr old man is brought to the ED due to severe agitation and aggressive behaviour. He speaks loudly and rapidly, stating that he has “superpowers”of mind control and that violence is the only way to defend against “he conspiracy”. The pt has a history of bipolar disorder and is prescribed olanzapine, lithium and fluoxetine although it is unclear if he has been compliant. The pt requires several doses of medication in the ED to calm down and is subsequently admitted to the hopsital for further psych eval. The following night he is found lying very still on his bed and does not respond to questions. Exam is significant for diaphoresis and diffuse rigidity in upper and lower extremities. What is the most likely explanation for this pt’s current symptoms?

Answer 7

neuroleptic malignant syndrome

Question 8

30 yr old woman comes to the office due to chronic anxiety and tension. the pt says she worries constantly about multiple issues involving her work, finances and family. At work she has difficutly concentrating as she repeatedly calls to check on the whereabouts and safety of her husband and children. The pt also describes frequent headaches, back pain and fatigue. She does not feel depressed and says that her sleep and appetite are normal. Lab studies including thyroid function tests are within normal limits. In addition to a recommendation of psychotherapy , pharmacotherapy with buspirone is initiated. This medication is associated with what properties?

Answer 8

no risk of dependance

Question 9

34 yr old man is brought to the ED by his wife after she found him running around the yard in his underwear shouting “ I am going to change the world”. She reports that he has a lot of energy despite hardly sleeping for the past 7 days and that he recently quit his job to write a 500-page novel that he says ‘explains everything about the universe”. The pt’s history is significant for epilepsy with Generalised seizures since childhood and a psych hospitalisation a year ago for MDD episode. Fam history is significant for alcoholism and hypertension in his father and schizo in his grandmother. What medication would be most helpful for long term treatment for this pt’s psych condition as well as his seizure disorder?

Answer 9

valproate

Question 10

22 yr old college student seeks treatment for depressed mood, low energy, poor concentration and feelings of worthlessness and guilt following a breakup with her partner of 2 years. She is dx with MDD nad tx with bupropion and psychotherapy. Afer 3 weeks of tx, the pt reports that her energy and motivation have improved somewhat. Her grades, which had been deteriorating have stabilised. The pt is also continuing to receive psychotherapy and believes that it is beneficial. However she still feels ‘really down’ at times and has a poor appetite. Further history reveals that the pt consumes very little food each day and exercises excessively. Due to her ongoing mood problems, increasing the dose of her antidepressant medication is considered. What is the potential side effects of the increased dose would be of primary concern?

Answer 10

seizures

Question 11

31. yr old man is hospitalised after sustaining multiple injuries during a motor vehicle collision. The pt is not conscious initially, and no info is available regarding his medical hx. Two days after initial hospitalisation, he experiences palpitations and difficulty sleeping. Shortly thereafter, the pt suffres a generalised tonic-clonic seizure. When he recovers, he tells the physician that he usually takes medication for anxiety, bipolar disorder and chronic lower back pain. He appears anxious, tremulous and diaphoretic. Withdrawal of which medication is the most likely explanation of this pt’s condition ?

Answer 11

lorazepam.

Question 12

25 yr old graduate student comes to the office due for evaluation of anxiety. She describes episodes of sudden-onset palpitations, shortness of breath and diaphoresis during which she wants to run away before anyone notices. The pt arrives early for her classes to get a seat close to the door and has left during lectures due to feeling of “out of control”. There are no specific triggers for these events, but she is worried about having another episode next week during her final examinations. She does not drink alcohol or use illicit drugs. Physical exam, ECG and lab eval are normal. The pt is diagnosed with panic disorder. After discussion of treatment options, she decides to pursue cognitive-behavioural therapy and start a short term anxiolytic medication that also has muscle-relaxant and anticonvulsant properties What best describes the mechanism of action of this medication?

Answer 12

increased frequency of chloride channel opening

Question 13

39 yr old woman is brought to the ED after her husband found her confused. The pt was unable to answer questions about whhy she did not got to workd that day and could not remember the day of the week. She has a hx of bipolar disorder and has taken the same dose of lithium for the past 10 years. Over the past week, the pt started taking several doses of a new medication following a dental extraction. Yesterday, she felt nauseated and vomited twice, and earlier today she started having diarrhoea. Vital signs are within normal limits. The pt is alert and oriented to self only. The abdomen is soft and nontender with increased bowel sounds. Coarse tremors are noted in upper extremities. Depp tendon reflexes are 2+ in the b/l examination. Gait is mildly ataxic. A drug interaction involving what medication is most likely the cause of this pt’s reaction?

Answer 13

NSAID

Question 14

24 yr old man is hospitalised after a violent episode in which he destroyed his tv with a baseball bat. Over the past year, the pt was convinced that people on tv were monitoring his thoughts and movements and that certain newscasters were laughing at him. At night, he was unable to sleep and reported hearing the voices of demons threatening to kill him. The pt was dx with schizo and initially treated with chlorpromazine. He now is reluctant to take the medication saying “ i dont like how it makes me feel”. His medication is subsequently changed to fluphenazine. Compared to the pt’s initial treatment, fluphenzaine is more likely to cuase what side effect?

Answer 14

muscular rigidity

Question 15

48 yr old man comes to the office due to concern that his skin is excessively dry, red and cracked. The pt explains that he washes his hands ech times he touches something due to fear of contamination. He spends 3-4 hours a day washing his hands and showers multiple times daily. He was recently fired from his job after refusing to touch keyboards shared by coworkers and is worried that he will be unable to find employment. On physical exam, the palms are erythematous with peeling skin. Treatment of this pt’s disorder is most likely to involve a medication affecting which neurotransmitter?

Answer 15

serotonin

Question 16

34 yr old man is brought to the ED due to a severe headache and blurry vision. His symptoms began suddenly after having lunch at a new italian deli n his neighbourhood. The pt says he “ate a sandwich with lots of fancy meat and cheeses” and drank iced tea. His medical history is significant for treatment resistant major depressive disorder. He has no known allergies. BP is 210/130 mmHG and pulse is 110/min. On physical examination, he appears tremulous and diaphoretic. The medication used to treat this pt’s depression most likely affects what steps of monoamine neurotransmission?

Answer 16

monoamine breakdown

Question 17

55 yr old man comes to the office for a checkup. his. medical hx is significant for MDD treated with sertraline for the past 4 months, hypertension controlled with lisinopril and diabtes mellitus controlled with diet. He does not use tobacco and drinks a glass of wine with dinner a few times a week. Vital signs are all within normal limits and no abnormalities are noted on physical examination. HgA1C is within normal limits. What is the most likely side effect of the treatment prescribed for this pt’s depression?

Answer 17

sexual dysfucntion

Question 18

34 yr old man comes to the office for evaluation of opioid use disorder. He was prescribed oxycodone for a sports-related injury in his mid-20’s developed dependancy and began using intravenous heroin in its place. In the past few years, the pt has had multiple overdoses requiring naloxone administration. He recently tried quitting heroine on his own but experienced recurrent relapses. He has now been abstinent for 2 days but reports significant cravings. After a discussion of various treatment options, the pt is prescribed buprenorphine. What clinical pharmacological effects of buprenorpine is most likely?

Answer 18

buprenorphine can treat heorin withdrawal

Question 19

32 yr old man with history of bipolar disorder is brought to the ED by his wife. He has been unable to sleep for more than 3 hours at night for the past week. Over that past several weeks, the pt has been irritable at home and has argued constantly with his wife. He has racing thoughts and speaks rapidly. The pt has stopped going to his job as a plumber, having decided to stay home and “unravel the secrets of the universe”. He has been drawing shapes and equations on the walls, and he has accused his wife of working for the police and trying to steal his secrets. Prior to examination, the pt becomes increasingly agitated and is hospitalised against his will. He has no other medical conditions. Vital signs, physical examination and lab findings are normal. He is prescribed multiple medications to address his symptoms. Five days later, the pt is calm but has difficulty moving spontaneously or getting out of bed. He does not respond appropriately to questions and appears newly disoriented and confused. Dysregulation of what neurotransmitter is most likely to be the primary cause of this pt’s new symptoms?

Answer 19

dopamine

Question 20

23 yr old woman comes to the ED due to chest pain, dyspnea, palpitations, perioral numbness and sweating. She is extremely anxious and explains that her symptoms came on suddenly for no apparent reason. The pt has had similar episodes 2 or 3 times a week for the pst several months. Her BP is 150/90, pulse is 100/min and respirations are 28/min. Cardiac enzymes are normal, and an ECG shows normal sinus rhythm with no ST-elevations or t-WAVE ABNORMALITIES. tHE pt is diagnosed with panic disorder. She received medication and feels better within an hour. What best describes the mechanism of action of the medication she received?

Answer 20

Binds allosterically to the GABA receptor

Question 21

38 yr old woman comes to the office due to breast tenderness and absence of menstruation over the last 3 months. The pt has a history of schizo and familial hypercholesterolemia. Medication include risperidone, which has led to significant improvement in psychotic symptoms and atorvastatin. Basic serum chemistry panel and thyroid function tests are normal, and urine pregnancy test is negative. What is the most likely explanation fo this pt’s amenorrhoea?

Answer 21

drug induced

Question 22

42 yr old woman with a history of schizo is brought to the clinic by her parents after attempting to drink rubbing alcohol in response o voices telling her to kill herself. The pt believes that a tv newscaster is sending her secret messages and that the devil injects her with poison at night while she is sleeping. She first developed symptoms at age 23 and has had 7 previous psych hospitalisations and 2 suicide attempts. Trials of haloperidol, risperidone and olanzapine have yielded minimal improvement. Her medical conditions include hypertension and mild obesity. Physical exam is normal. Medication therapy with clozapine is initiated. What should be regularly monitored in this pt?

Answer 22

absolute neutrophil count

Question 23

35 yr old man was hospitalised for a psychotic episode in which he heard voices of God and the devil and believed that his family was plotting to kill him. He improved rapidly with medication therapy and was discharged. Three weeks later, the pt comes to the ED due to generalised muscle stiffness and shaking of his right hand. He has no other medical history and takes no other medications. On mental status examination, he is alert and oriented with mild paranoia ut no auditory hallucinations. What is the best treatment for this pt’s current symptoms?

Answer 23

benztropine

Question 24

60 yr old man is found by his daughter to be confused at home. EM services are called and he is brought to the ED by ambulance. The pt’s daughter who accompanies him says, that she found an empty bottle of amitriptyline next to his bed. He has not been taking any other medications. In the ED, the pt is delirious and says that he sees small animals running around in the corner of the room. He appears flushed. The pt has a brief seizure and becomes unconscious. Both pupils are dilated and equally reactive to light and his skin and mucous membranes are dry. Initial ECG shows QRS widening and QTc prolongation. He is transferred to the ICU but dies despite resuscitation attempts. What is the pharmacological effects most likely contributed to the pt’s death ?

Answer 24

sodium channel inhibition

Question 25

36 yr old woman comes to the office for f/u of a mood disorder. The pt has a history of several depressive episodes that started in her twenties. 2 years ago, she was hospitalised after staying up for several nights without sleeping and claiming that she had special powers to ‘end global poverty and climate change’. Her symptoms responded well to treatment and she has remained on the drug since then. However the pt now has new-onset constipation, dry skin and hair loss. She is also concerned about weight gain over that last 3-4 months, despite eating healthy, low calorie foods. The pt appears tired, but physical exam is otherwise normal. The diagnosis is established and her current condition is attributed to adverse effects from one of her medications. What is the most likely culprit drug?

Answer 25

Lithium

Question 26

65 yr old man is brought to the ED with new-onset confusion, suprapubic discomfort and lack of urine output. His past medical history is significant for benign prostate hyperplasia, hypertension hyperlipidoema and type 2 diabetes complicated by neuropathy. The pt also has a history of chronic insomnia and has been treated with severl medications with little benefit. He does not know his current medications. On examination, the pt is afebrile, confused and oriented only to self. Suprapubic fullness is present, but abdominal examination is otherwise unremarkable. A urinary catheter is placed and immediately drains 1000mL of urine. Which medications most likely has contributed to this pt’s current condition?

Answer 26

amitrptyline

Question 27

23 yr old woman comes to the office describing restlessness in her legs and inability to lie or sit still. the pt was diagnosed with schizo a month ago and medication therapy was initiated. Her dose was increased after 2 weeks. She says “I haven’t heard any voices since a few days after the medication was increased”. BP is 140/90 and pulse is 90. The pt is alert, oriented, fidgety and anxious. What is the most likely diagnosis in this pt?

Answer 27

akathisia

Question 28

58 yr old woman comes to the office with new onset low back pain. The pt was helping her friedn move yesterday and strained her back. She does not drink alcohol or use illicit drugs. Medical hx includes hypertension and mdd currently treated with captopril and citalopram. A short course of medication is prescribed and the pt is asked to monitor for development of diaphoresis, restlessness, tremors and diarrhoea. The pt was most likely described what medication?

Answer 28

tramadol

Question 29

an 83 yr old woman is sent to to ED from the nursing home where she resides for eval of mental state changes. At baseline, she has mild memory impairment but is otherwise cognitively intact, calm and cooperative with the nursing staff. Over the past 24 hours, she has become increasingly combative and agitated and stayed up all night. Behavioural interventions and a history of anxiety and depression. Neuro exam is normal but the pt is unable to attend to the conversation, is mildly disoriented and cannot state the days of the week backwards. W/o provocation, she striked out at a nurse’s aide standing next to her. Lab results are normal except urinalysis, which shows an increased presence of white blood cells and is positive for nitrites. Head CT is negative. In addition to starting antibiotic therapy, which medication is the most appropriate to treat this pt’s behavioural symptoms?

Answer 29

haloperidol

Question 30

24 yr oldman is found unconscious in the basement of his house. His mother calls emergency responders and informs them that the pt has a history of substance abuse and was recently hospitalised for MDD. In the ED the pt is found to be cyanotic and unresponsive to atimuli. respirations are 4/min. His pupils are constricted and minimally responsive to light. Resuscitation efforts are initiated. The pt receives IV medications and regains consciousness 2 minutes later. The drug most likely used to treat this pt has the greatest affinity for which receptor?

Answer 30

Mu

Question 31

42 YR OLD MAN IS BROUGHT to the hospital after a motoR vehicle collisiON. The pt was driving while intoxicated with alcohol and collided with another car. Evaluation reveals a left tibia and fibula fracture but no other major injuries. He reports no prior medical cnditions. The pt is hospitalised and operative repair of the fracture is performed. On the third day n the hopsital, he becomes agitated and demands do leave. On physical exam, The pt is diaphoretic, tremulous and disoriented. There are mild hand tremors but no other neurological abnormalities. Increased activity of what CNS receptor is the most likely cause of this pt’s condition?

Answer 31

NMDA glutamate receptor

Question 32

45 yr old woman with a hx of opioid use disorder and HIV infection is brought to the emergency department due to worsening lethargy. The pt receievs methadone maintenance therapy, which she restarted recently after being hospitalised for an HIV-related infection. Her infection improved after inpatient treatment and she continues to take the appropriate antimicrobials as an outpatient. On physical exam, the pt is somnolent and withdraws all extremities to painful stimuli. The pupils are small and sluggish to react. Brain imaging reveals no new findings and renal function tests are within normal limits. Use of what medication most likely contributed to this pt’s current condition?

Answer 32

fluconazole

Question 33

46 yr old woman comes to the office for a f/u after an episode of alcoholic pancreatitis. She was hospitalised 4 weeks ago for abdominal pain and concurrently underwent treatment with benzodiazepInes for alcohol withdrawal. Prior to hospitalisation, the pt was drinking 3L of boxed wine daily, however she has remained abstinent since discharge. She is interested in medication for her alcohol use disorder, but lives alone and is worried that her cravings will overwhelm her self control. A medication with what mechanism of action would be most effective in this pt?

Answer 33

Mu opioid receptor blockade

Question 34

67 yr old man comes to the hospital due to an acute worsening of chronic back pain associated with new onset b/l leg weakness and numbess. He has a history of colorectal cancer with vertebral metastases for which he has received colectomy, chemotherapy and radiation therapy. The pt takes oral morphine sulfate for his back pain. Examination shows focal vertebral tenderness, along with reduced muscular strength, decreased sensitivity to light touch and spasticity in both legs. Imaging studies reveal a vertebral compression fracture with cord compression. Surgical compression is planned. Which drug may precipitate opioid withdrawal symptoms if used in this pt?

Answer 34

bupronorphine

Question 35

Physical characteristics of Neuroleptic malignant syndrome?

Answer 35

lead-pipe rigidity, Hyperthermia, sympathetic hyperactivity

Question 36

physical characteristics of Serotonin syndrome ?

Answer 36

Hyperreflexia and mycoclonus

Question 37

43 yr old man comes to the office due to depression. He feels sad and unmotivated, sleeps 12 hours a day, and has increased appetite, poor concentration at work, and fleeting thoughts of suicide. The pt has no medical history and laboratory evaluation is unremarkable. Majore deprressive disorder is diagnosed and antidepressant medication administered. Several weeks after starting the medication, the pt’s depressive symptoms are mildly improved, but he is now distressed by a significant decrease in libido and impaired sexual performance. He is considering stopping the medication and requests an alternate treatment. Which drugs is most appropriate for this pt?

Answer 37

buproprion

Question 38

26 yr old woman is evaluated in the clinic due to absence of her last 3 menstrual periods. The pt has also developed B/L milky Nipple discharge. Menarche was at age 13. Until now, she has had regular menses, lasting 4-5 days, every 28 days. The pt says she takes acetaminophen for occasional headaches and a medication that “stops the voices” in her head. BMI is 29kg. Pelvic exam is unremarkable. Urine pregnancy test is negative. Interruption of which CNS pathway is the most likely cause of this pt’s presenting symptoms?

Answer 38

tuberoinfundibular pathway.

Question 39

OCD meds are associated with which neurotransmitter?

Answer 39

Serotonin

Question 40

diaphoresis, restlessness, tremors and diarrhoea are side effects of what medication?

Answer 40

serotonergic medications