@rosemaryusmle: your very much welcome
here are the explanations:
1. The answer is C. 2. The answer is D. The symptom that this patient describes is akathisia,
a subjective, uncomfortable feeling of motor restlessness related to use of some antipsychotics.
Restless legs syndrome also involves uncomfortable sensations in the legs, but it
is a sleep disorder (see Chapter 10), which causes difficulty falling and staying asleep.
Other antipsychotic side effects include neuroleptic malignant syndrome (high fever,
sweating, increased pulse and blood pressure, and muscular rigidity), pseudoparkinsonism
(muscle rigidity, shuffling gait, resting tremor, and mask-like facial expression), and
tardive dyskinesia (involuntary movements including chewing and lip-smacking). Highpotency
antipsychotics, such as haloperidol, are more likely to cause these neurologic
side effects than low-potency agents such as thioridizine, or atypical agents, such as risperidone,
olanzapine, and clozapine.
3. The answer is D. 4. The answer is A. These involuntary chewing and lip-smacking movements
indicate that the patient has developed tardive dyskinesia, a serious side effect
of treatment with antipsychotic medication (see also answer to Question 1). Tardive
dyskinesia usually occurs after at least 6 months of starting a high-potency antipsychotic
and is best treated by changing to a low-potency or atypical agent; stopping the
antipsychotic medication will exacerbate the symptoms.
5. The answer is B. 6. The answer is E. High body temperature and blood pressure, and muscular
rigidity indicate that the patient has developed an antipsychotic medication side
effect known as neuroleptic malignant syndrome (see also answer to Question 1). Neuroleptic
malignant syndrome is seen most commonly with high-potency antipsychotic
treatment and is best relieved by stopping the antipsychotic medication, providing medical
support, and administering dantrolene, a muscle relaxant. After recovering from this
life-threatening condition, the patient can be put on an atypical agent since they are less
likely than high potency agents such as haloperidol to cause this dangerous side effect.
7. The answer is D. This patient who became ill at a pizza party is most likely to be taking
tranylcypromine, a monoamine oxidase inhibitor (MAOI). These agents can cause a
hypertensive crisis if certain foods (e.g., aged cheese, smoked meats, beer, and wine)
are ingested. A patient who eats in an unfamiliar place (e.g., a party) may unwittingly
ingest forbidden foods. This patient ate pizza that probably contained aged Parmesan
cheese and drank punch that probably contained red wine. This resulted in a hypertensive
crisis (e.g., elevated blood pressure, sweating, headache, and vomiting). Fluoxetine,
lithium, nortriptyline, and haloperidol do not interact negatively with food.
8. The answer is D. The most effective pharmacological treatment for this patient who has
obsessive–compulsive disorder is an antidepressant, particularly a selective serotonin
reuptake inhibitor (see Chapter 13). Antipsychotics, antianxiety agents, and lithium are
less appropriate than an antidepressant for this patient.
9. The answer is C. The doctor decides to give this patient fluoxetine because, when compared
to a heterocyclic antidepressant, SSRIs such as fluoxetine have fewer side effects.
Heterocyclics and SSRIs have equal efficacy, equivalent speed of action, and equivalent
length of action. Neither SSRIs nor heterocyclics are likely to be abused.
10. The answer is D. The best choice of antianxiety agent for a 40-year-old patient with
generalized anxiety disorder and a history of BZ abuse is buspirone, a non-benzodiazepine
with very low abuse potential. Benzodiazepines such as flurazepam, clonazepam,
and chlordiazepoxide have higher abuse potential than buspirone. Bupropion
is an antidepressant, which is also used for smoking cessation. Zolpidem is a nonbenzodiazepine
sleep agent.
11. The answer is A. Zaleplon, a non-benzodiazepine sleep agent, is the best choice to aid
sleep on an overnight flight. Benzodiazepines have higher abuse potential than agents
such as zaleplon. Buspirone has little abuse potential but does not cause sedation, and, in
any case, takes weeks to work. Bupropion is an antidepressant agent and is non-sedating.
12. The answer is E. Because it is long acting and has relatively low abuse potential for a BZ,
chlordiazepoxide is the antianxiety agent most commonly used to treat the anxiety and
agitation associated with the initial stages of alcohol withdrawal.
13. The answer is A. Of the listed agents, BZs such as diazepam are most likely to be
abused. Antipsychotics such as haloperidol, antidepressants such as fluoxetine, mood
stabilizers such as lithium, and non-benzodiazepines such as buspirone (see also
answer to Question 10) have little or no abuse potential.
14. The answer is B. The most appropriate next step is to recommend a course of electroconvulsive
therapy (ECT) for this elderly, severely depressed patient. ECT is a safe, fast,
effective treatment for major depression. Diazepam, lithium, buspirone, and psychotherapy
will not be effective as ECT in relieving this patient’s suicidal depression quickly.
15. The answer is E. The antipsychotic agent that this patient is most likely to be taking is
clozapine. Like other atypical agents, clozapine is more effective against negative symptoms
(e.g., withdrawal) than traditional agents such as haloperidol. However, clozapine
is also is more likely to cause seizures and agranulocytosis than traditional agents or
other atypicals, such as risperidone and olanzapine.
16. The answer is E. 17. The answer is A. This patient’s good employment and relationship
history suggest that his psychotic symptoms are an acute manifestation of a manic
episode. While the most effective immediate treatment for this patient is a fast-acting,
high-potency antipsychotic agent, such as haloperidol, to control his hallucinations
and delusions, lithium, which takes 2–3 weeks to work, would be more effective for
long-term maintenance. Fluoxetine, amitriptyline, and diazepam are less appropriate
primary treatments for this bipolar patient.
18. The answer is F. In contrast to most antidepressant agents, which are associated with
weight gain, fluoxetine (Prozac) is associated with some weight loss. Thus it is the most
appropriate antidepressant agent for a patient who is afraid of gaining weight.
19. The answer is C. Trazodone is the agent most likely to cause priapism in this patient.
20. The answer is E. Amoxapine has antidopaminergic action and, thus, is the agent most
likely to cause gynecomastia as well as parkinsonian symptoms in this patient.
21. The answer is A. SNRIs may work more quickly than other antidepressants and, as
such, venlafaxine is a good choice for rapid relief of depressive symptoms in this young
woman.
22. The answer is C. Trazadone not only causes priapism (see also answer to Question 19)
but also is highly sedating. It is thus often used in patients who have depression with
insomnia.
23. The answer is C. Prolactin is the hormone responsible for galactorrhea, fluid discharge
from the nipples. Galactorrhea is more common with the use of low-potency antipsychotic
agents.
24. The answer is B. This patient is showing evidence of pseudoparkinsonism, a neurologic
side effect caused by excessive blockade of postsynaptic dopamine receptors during
treatment with high-potency antipsychotics, such as haloperidol. Because dopamine
normally suppresses acetylcholine activity, giving the patient an anticholinergic agent
(e.g., benztropine) will serve to increase dopaminergic activity and relieve the patient’s
symptoms. Antianxiety agents such as benzodiazepines can be used as adjuncts to
anticholinergics, but antidepressants and lithium are not effective for reversing parkinsonian
symptoms caused by antipsychotics.
25. The answer is E. TCAs such as imipramine cause sinus tachycardia, flat T waves, prolonged
QT interval and depressed ST segments. Bupropion, fluoxetine, lorazepam, and
valproic acid are less likely to cause these cardiovascular effects.
26. The answer is C. Because of her weight gain, type 2 diabetes and cardiovascular problem,
the best choice of atypical antipsychotic agent for this patient now is aripiprazole.
Clozapine and olanzapine carry high risk and ziprasidone and aripiprazole carry low
risk for weight gain and diabetes. However, ziprasidone prolongs the QT interval and so
should be avoided in this patient.
27. The answer is E. Metoclopramide (Reglan), a gastric motility agent and antiemetic, is
often used to control nausea and vomiting in cancer patients receiving chemotherapy.
It has antidopaminergic properties and can cause acute dystonic reactions such as are
occurring in this patient. Management includes stopping the metoclopramide and providing
an anticholinergic agent, such as benztropine, or an antihistamine, such as
diphenhydramine, both of which are usually given in intramuscular form for immediate
effect. Aspirin, digoxin, erythromycin, and fluoxetine are unlikely to cause dystonic
reactions.
28. The answer is B. This patient who is slowed down and has a fine resting tremor of his
upper extremities and stiffness is showing evidence of antipsychotic-induced parkinsonism,
often a side effect of high doses of high-potency antipsychotics such as
haloperidol. Benign essential tremor and Parkinson disease are not related to antipsychotic
medication. Although they can both be side effects of haloperidol treatment,
neuroleptic malignant syndrome and tardive dyskinesia are characterized by high fever
and abnormal tongue and facial movements respectively.
29. The answer is B. The most appropriate response for the physician is to tell the patient
that the risk for depression is greater after than before delivery and that depression
during pregnancy can often be safely treated. Most antidepressants are in pregnancy
Category C but two, bupropion and maprotiline, are in Category B. Discussing differential
suicide rates is not a helpful intervention. In any case the suicide rate is lower for
women who are pregnant than for those who are not pregnant. While ECT is quite safe
in pregnancy, psychopharmacology is less invasive and usually preferred.
Typical Board Question
The answer is D. Combinations of tramadol (Ultram) a serotonergic analgesic with SSRIs
such as fluoxetine can lead to the symptoms this patient shows, that is, the serotonin syndrome.
Opioids such as oxycodone and hydrocodone, mood stabilizers such as gabapentin or
ibuprofen are unlikely to produce this syndrome when combined with an SSRI.
( I have a doubt for question no. 26 , FA 2015 says all atypical antipsychotics may cause prolong QT interval so how to go on withe the answer aripiprazole ?
then definitely some new info is being added by solving theses questions some new facts are being known, like q no 21 22 18 14 12 etc etc
the challenging ones was 29
and the best integrated q was 27 the one about metoclopramide ! )
