UW MED psych drugs cases (Nr 17 - 27 ) marijuana Flashcards
(17) A 16-year-old boy is brought to the emergency department by his friends for severe anxiety. He became paranoid and unusually withdrawn at a party and began rocking back and forth, saying, “I feel like I can’t breathe” and “I’m afraid I’m going to die.” Prior to the party, he was his regular “happy and outgoing” self. The patient has intermittent back pain from a bicycle accident last year for which he takes oxycodone as needed. Temperature is 36.1 C (97 F), blood pressure is 140/80 mm Hg, pulse is 110/min, and respirations are 18/min. Pulse oximetry is 98% on room air. Examination shows an anxious and withdrawn boy with 3-mm pupils, conjunctival injection, dry oral mucosa, and a healed scar on his right thigh from his bicycle accident. Which of the following is most consistent with this patient’s presentation?
CANNABIS INTOXICATION
Physiologic effects include conjunctival injection (red eyes), dry mouth, tachycardia, and increased appetite. Cognitive effects include slow reaction time, incoordination, impaired short-term memory, and poor concentration. Some individuals may experience dysphoria, social withdrawal, anxiety, and paranoia when exposed to higher doses of THC. Psychomotor impairment lasts beyond the timeframe of euphoria and can persist for up to a day.
(17) Cannabis intoxication. kiti ats. Bath salts (synthetic amphetamine analogues) intoxication presents with?
tachycardia, hypertension, mydriasis, agitation, and violent behavior at higher doses.
(17) Bath salts = what group?
synthetic amphetamine analogues
(17) Cannabis intoxication. kiti ats. Lysergic acid diethylamide (LSD). CP?
tachycardia, hypertension, visual hallucinations, and paranoia at higher doses.
(17) Cannabis intoxication. kiti ats. Opioid intoxication is characterized?
Characterized by the triad of respiratory depression, pinpoint pupils, and central nervous system depression.
(17) Cannabis intoxication. kiti ats. Opioid withdrawal is characterized?
lacrimation, pupillary dilation, yawning, diaphoresis, and gastrointestinal symptoms (eg, nausea, vomiting, diarrhea).
(17) Cannabis intoxication. kiti ats. Phencyclidine intoxication?
nystagmus and ataxia. Although patients may experience psychosis, they usually have associated violent behavior, agitation, and dissociation.
(18) A 42-year-old man is brought to the emergency department by police after he became physically aggressive toward his wife. The wife, who accompanied the patient, says that he has not slept or eaten for days; he became agitated and started accusing her of plotting with her former boyfriend to murder him. He had a brief psychiatric hospitalization 8 months ago when he was admitted with insomnia and visual hallucinations. The patient was a successful stockbroker but has been unemployed for the past 2 years. Temp. 37.8 C (100 F), BP 140/90 mm Hg, pulse is 104/min, and RR 20/min. Physical examination shows a thin, diaphoretic man with poor grooming and dentition. The patient picks at his skin and has multiple sores on his face and body. He is uncooperative with the evaluation, speaks rapidly and loudly, gets up to pace during the interview, and shouts, “I don’t trust any of you; you’re in this together.” Which of the following is the most likely diagnosis in this patient?
methamphetamine use disorder
This patient’s paranoid delusions, aggressive behavior, severe insomnia, and physical findings of poor dentition, anorexia, and skin sores are suggestive of chronic methamphetamine use disorder.
(18) methamphetamine use disorder.
Methamphetamine—also known as “meth,” “crystal,” “ice,” and “Tina”—is a highly addictive and very potent CNS stimulant.
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(18) methamphetamine use disorder. Skin?
Heavy methamphetamine use frequently causes marked weight loss, psychotic symptoms, and excoriations due to chronic skin picking.
(18) methamphetamine use disorder. Dental?
Severe dental symptoms (“meth mouth”) can include brown discoloration, tooth decay, and cracked teeth due to extreme bruxism and dry mouth.
(18) methamphetamine use disorder. Other features of intoxication include mood disturbances, anxiety, irritability, confusion, violent behavior, and signs of sympathetic overactivity (eg, elevated pulse and blood pressure, hyperthermia, sweating, pupillary dilation).
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(18) methamphetamine use disorder.
Patients with chronic methamphetamine use disorder can develop psychosis that may be difficult to distinguish from primary psychiatric disorders. However, acute fleeting visual and/or tactile hallucinations (eg, bugs crawling under the skin) tend to be more common in substance-induced psychotic disorders. Long-term management includes both cognitive-behavioral treatment to prevent relapse and antipsychotic medication for psychosis.
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(18) methamphetamine use disorder. kiti ats.
Methamphetamine intoxication can resemble a manic episode because patients experience increased energy and talkativeness and can go for days without eating or sleeping. They may also experience the psychotic symptoms (eg, delusions, paranoia, hallucinations) seen in primary psychotic disorders. Diagnosing a primary mood or psychotic disorder requires that substance use must first be ruled out; this patient’s physical findings (ie, sympathetic overactivity, skin sores due to picking, tooth decay, anorexia) and history of transient visual hallucinations make methamphetamine use disorder the more likely diagnosis
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(18) methamphetamine use disorder. kiti ats. Inhalant?
Inhalant intoxication may involve agitation and violent behavior shortly after use; however, general symptoms of CNS depression (eg, incoordination, unsteadiness, lethargy, psychomotor retardation), followed by quick resolution of symptoms, are expected
(19) A 26-year-old woman is brought to the emergency department by coworkers due to agitated behavior. She is alert but appears distracted by unseen stimuli. During triage, the patient yells at a nurse for being “too close” to her; she also attempts to lift an equipment cart and throws the blood pressure cuff across the room. The patient provides nonsensical responses when asked about her medical history. Her coworkers say that she has depression and anxiety but do not know what medications she takes. Temperature is 37.2 C (99 F), blood pressure is 160/90 mm Hg, pulse is 126/min, and respirations are 18/min. Physical examination shows equal and reactive pupils, intact extraocular movements, and nystagmus. Mild rigidity is noted and is most prominent in the upper extremities. Upper and lower limb deep tendon reflexes are 2+. No tremors are observed, and gait is ataxic. The remainder of the examination is unremarkable. Which of the following is the most likely cause of this patient’s presentation?
phencyclidine (PCP) intoxication
The onset of action is rapid, and the duration of action is generally <8 hours.
(19) phencyclidine (PCP) intoxication Tx?
supportive therapy and benzodiazepines
(20) Alcohol use disorder case. First line Tx?
NALTREXONE
Disulfiram was wrong. its second line after naltrexone and acamprosate. only in motivated patients
(21) A 28-year-old woman is brought to the emergency department by her sister after a generalized tonic-clonic seizure. The patient appears confused and is unable to answer questions. Her sister says that the patient has never had a seizure before and does not use alcohol or illicit drugs. The sister is unaware of any medical or psychiatric history but reports that sometimes the patient feels anxious and sad and has trouble sleeping. For the past 6 months the patient has been taking medication, prescribed by her primary care doctor, to help with these issues. The sister says that the patient had not taken any of the medication in 2 days, as they were on their way to a concert in another state. There is no family history of seizure disorder. Which of the following medications was this patient most likely taking?
ALPRAZOLAM
(21) ALPRAZOLAM.
This patient had a first seizure after missing doses of her medication for 2 days. Of the medications listed, alprazolam, a short-acting benzodiazepine, is the most likely to result in seizures following abrupt discontinuation.
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(21) ALPRAZOLAM.
Symptoms of withdrawal from benzodiazepines with short half-lives can appear as early as ???
as early as 24 hours after cessation and include seizures, tremors, anxiety, perceptual disturbances, and psychosis.
(21) ALPRAZOLAM. Benzodiazepines with shorter half-lives, such as alprazolam, have a greater risk of more severe withdrawal reactions.
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(22) A 26-year-old man is brought to the emergency department after an attempted suicide by medication overdose. He has had 2 seizures in the past hour. Temperature is 38.8 C (102 F), blood pressure is 90/60 mm Hg, pulse is 110/min, and respirations are 22/min. The patient is not oriented to time, place, and person. Pupils are dilated and respond poorly to light; the skin is flushed and dry. Abdominal examination shows reduced bowel sounds. ECG shows prolonged QRS complexes (0.19 sec). Toxicology studies are pending. Which of the following is the best predictor of complications due to overdose of the suspected drug?
QRS duration
(22) TCA overdose. CP?
causes mental status changes, seizures, tachycardia, hypotension, cardiac conduction delay, and anticholinergic effects (eg, dilated pupils, hyperthermia, flushed and dry skin, intestinal ileus).
(22) TCA overdose. What group os symptoms can occur?
anticholinergic effects!!!
(22) TCA overdose. Cardiotoxicity is due to blockade of cardiac fast sodium channels, leading to QRS prolongation and risk of developing ventricular arrhythmia (similar to class IA antiarrhythmic drugs such as quinidine). ECG should be obtained immediately and monitored frequently in suspected TCA overdose.
!!!!!!!! QRS duration >100 msec is associated with increased risk for ventricular arrhythmia and seizures and is used as an indication for sodium bicarbonate therapy.
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(23) 58-year-old man is brought to the office by his daughter for evaluation of “abnormal behavior.” The patient has been anxious and irritable for the past several days, and over the past 2 days, he has repeatedly said that “bad men” are following him. He has no history of psychiatric illness but was diagnosed with polymyositis 2 weeks ago. The patient has been taking high-dose prednisone with improvement in muscle weakness. He has no other medical conditions and takes no other medications. Vital signs are within normal limits. Physical examination shows mild symmetric, proximal muscle weakness. During the examination, the patient frequently looks around the room and startles easily when the nurse knocks on the door. He reports no suicidal ideation or hallucinations. Based on the patient’s responses to questions, his memory and recall are intact. Which of the following is the most appropriate first step in the management of this patient’s current symptoms?
Decrease prednisone dosage
The acute onset of behavioral changes with paranoia in this patient with no psychiatric history is most likely due to high-dose prednisone used to treat his polymyositis.
(23) Prednisone intox.
Psychosis following initiation of a new medication (eg, glucocorticoids) capable of producing these symptoms indicates a medication-induced psychotic disorder. Although psychiatric symptoms secondary to corticosteroids may begin at any time during treatment, they are more likely to manifest when high doses are used for longer periods of time. Therefore, because this patient’s physical symptoms have improved, reducing or, if possible, discontinuing his prednisone dosage would be the most appropriate first step in managing the patient’s psychiatric symptoms.
Other neuropsychiatric symptoms that may occur in patients taking glucocorticoids include mood and anxiety symptoms, sleep disturbances, restlessness, and memory loss.
Reassurance alone is unlikely to resolve psychiatric symptoms with continued exposure to high-dose prednisone.
(24) A 22-year-old woman is brought to the emergency department by friends after she passed out at a party. They report that alcohol and multiple substances were available at the party but are not sure what the patient used. The friends have seen her use cocaine in the past. Bottles of prescription alprazolam and hydrocodone are found in her handbag. The patient has no known history of medical conditions, and there is no evidence of trauma. On examination, she is stuporous. Temperature is 36.1 C (97 F), blood pressure is 90/60 mm Hg, pulse is 110/min, and respirations are 6/min. Pupils are 4 mm and reactive to light. Heart and lung examination is normal and bowel sounds are present. On neurologic examination, the patient responds only to painful stimuli and has decreased reflexes bilaterally. Administration of naloxone has no effect. Which of the following substances is the most likely cause of these findings?
ALCOHOL and BENZODIAZEPINES
This patient’s presentation is consistent with a sedative-hypnotic overdose, most likely due to the combined effects of alcohol and benzodiazepines. An isolated overdose of oral benzodiazepines can cause slurred speech, ataxia, hyporeflexia, and sedation. However, it is unlikely to cause this degree of CNS depression (most patients with isolated benzodiazepine overdose are still arousable), and vital signs typically remain normal.
Given this patient’s abnormal vital signs (eg, hypotension, severe bradypnea), coingestion of another sedative-hypnotic should be suspected, the most common being alcohol. Alcohol induces peripheral vasodilation and volume depletion (from diuresis) that can lead to hypotension (and compensatory tachycardia), which is not commonly seen in isolated benzodiazepine overdose (Choice E). In addition, the synergistic effects of alcohol and benzodiazepines cause profound CNS and respiratory depression, as seen in this patient.
(25) A 58-year-old man is brought to the emergency department by his wife for “unusual behavior.” She says that since last night, the patient has been afraid to go into their bedroom because he sees “evil children” there. He spent most of the night pacing back and forth in the living room and got minimal sleep. Five days ago, when the patient had an asthma exacerbation, his primary care physician added a new oral medication to his regimen. Medical history also includes hypertension and non-insulin-dependent diabetes mellitus. The patient does not drink alcohol but has used marijuana as recently as last week. Vital signs and physical examination are within normal limits. The patient is alert and aware of his surroundings. He reports hearing children laughing at him and frequently covers his ears with his hands. The patient has no suicidal ideation. Which of the following is the most likely diagnosis?
Medication-induced psychotic disorder
Introduction of a new medication, most likely high-dose glucocorticoid for his asthma exacerbation.
High-dose glucocorticoids, often given for allergic, inflammatory, or autoimmune conditions, may cause glucocorticoid-induced psychosis, an example of medication-induced psychotic disorder.
(25) Glucocorticoids psychosis. vs Brief psychotic disorder.?
Brief psychotic disorder is characterized by psychotic symptoms lasting ≥1 day but <1 month. This diagnosis is excluded if the symptoms are better explained by the effects of a medication or medical illness.
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(26) A 37-year-old man is brought to the emergency department by police officers after being found naked and yelling in the street. The patient was walking up to cars stopped at a traffic signal, cursing at drivers, and banging on windows. He has been admitted to the hospital several times due to agitation resulting from substance use. Medical history includes depression. The patient is highly agitated; attempts to elicit a history are unsuccessful. He repeatedly says, “They are all out to get me. They are coming through the walls, ready to kill me.” The patient alternates between screaming and pounding on the walls. Temperature is 38.3 C (100.9 F), blood pressure is 148/100 mm Hg, pulse is 98/min, and respirations are 16/min. Physical examination shows ataxia, nystagmus, and muscle rigidity. Which of the following is the most appropriate next step in management of this patient?
PCP intox => TX WITH BENZODIAZEPINES (buvo LORAZEPAM ANSWER)
(27) A 17-year-old boy is brought to the office due to vomiting, abdominal pain, and watery diarrhea for 24 hours. He also has had difficulty sleeping for the last 2 days and generalized aches. The patient has had no fever. Temperature is 36.6 C (97.9 F), blood pressure is 110/74 mm Hg, pulse is 88/min, and respirations are 16/min. Physical examination shows a diaphoretic, thin boy in considerable distress. Mucous membranes are dry. What is the most likely diagnosis in this patient?
Withdrawal from heroin.
This patient has vomiting, diarrhea, sleep disturbance, myalgia, and diaphoresis, symptoms consistent with abrupt opioid (eg, heroin) withdrawal following prolonged use.
(27) Withdrawal from heroin. Patients with opioid dependence typically develop withdrawal symptoms within?
within 4 to 48 hours of the last dose.
(27) Withdrawal from heroin.
Symptoms primarily arise from noradrenergic hyperactivity in the locus caeruleus, a pontine nucleus involved in wakefulness, breathing, and autonomic function. When opioids are stopped after chronic use, the loss of their usual inhibitory effect leads to a sudden increase in norepinephrine. This results in withdrawal symptoms, which commonly include sleep disturbances, nausea/vomiting, abdominal pain (eg, cramping), diarrhea, and arthralgia/myalgia.
On examination, patients may be restless and irritable. Vital signs are often normal (as in this patient). Mild elevations in heart rate and blood pressure can also occur in opioid dependence but, when present, are less severe than in other withdrawal states (eg, alcohol, benzodiazepine) that are associated with profound autonomic instability. Diaphoresis, pupillary dilation (mydriasis), piloerection, and yawning may also be evident. Hyperthermia and altered mental status (eg, confusion, psychosis) do not typically occur; the presence of either suggests an alternate diagnosis.
(27) Withdrawal from heroin. pupils?
PUPILARY DILATION (MYDRIASIS)
(28) A 66-year-old man comes to the office to follow up on his prostate cancer treatment. The patient has painful, bony metastasis in the pelvis and is being treated with hormonal therapy and radiotherapy. He has been receiving long-acting and as-needed short-acting morphine, but he continues to have significant pain. In the past 2 weeks, the patient has also experienced insomnia due to the pain, leading to worsening fatigue. He has no nausea, constipation, drowsiness, or suicidal ideation. Urine drug screen is positive for opioids and negative for other substances. A review of the state prescription drug monitoring program database reveals no irregularities. In addition to titration of opioid therapy to improve pain control, which of the following responses is the most appropriate recommendation for this patient?
I will prescribe naloxone in case of overdose and talk to your family about how to use
zymejau: to prevent addiction, I’ll prescribe naltrexone to lessen the euphoria associated with morphine.
!!!Esp. sensitive patients what use BZD
(28) chronic morphine use in cancer.
Patients receiving chronic opioid therapy are at risk for opioid overdose, including those with cancer. In general, patients with prostate cancer and isolated bony metastasis can live for many years; therefore, balancing adequate pain control versus avoiding opioid overdose is crucial.
Naloxone, an opioid receptor antagonist, should be offered to every patient receiving chronic opioid therapy, especially those at high risk for overdose; family members should be trained on its use.
(29) A 35-year-old man with a history of schizoaffective disorder and substance use disorders comes to the emergency department due to depression, auditory hallucinations, and suicidal ideation. The patient says, “I’ve been using any drugs that I can get my hands on because my depression is unbearable.” He has a history of alcohol, benzodiazepine, heroin, and cocaine misuse. The patient has been psychiatrically hospitalized on 5 occasions and has attempted suicide twice, once by an intentional overdose of prescribed medications and on another occasion by an attempted hanging. His medications include risperidone, lithium, and escitalopram. The patient is hospitalized with suicide precautions. His doses of risperidone and escitalopram are increased to target the hallucinations and depression respectively, and the lithium is continued. On the second day of hospitalization, he reports muscle pains, abdominal cramping, nausea, and diarrhea. Temperature is 37.2 C (99 F), blood pressure is 130/85 mm Hg, and pulse is 84/min. The patient is alert and restless, his pupils are dilated, and he is diaphoretic. Bowel sounds are hyperactive and neurologic examination is normal. Lithium level is 1.1 mEq/L. Which of the following is the most likely explanation for his symptoms?
OPIOID WITHDRAWAL
Lithium intoxication presents with coarse tremors, ataxia, altered mental status, nausea, vomiting, and diarrhea. It is more likely to occur with lithium levels above the therapeutic range (ie, ≥1.2 mEq/L).
