Block 13 USMLE Behavior And Pharm

Flumazenil is a benzodiazepine antagonist and has been approved to hasten the recovery from benzodiazepines used in anesthetic and diagnostic settings and to reverse the CNS depressant effects following an overdose with benzodiazepines. Flurnazenil can only be used for benzodiazepines and is not useful to reverse the effects of other CNS depressants such as barbiturates and ethanol.
Glucagon is an antidote for beta-blocker overdose.
Naloxone, an opioid receptor antagonist, is an antidote for °plaid overdose. Nitrite, or sodium nitrite, is an antidote for cyanide poisoning.
Protamine is an antidote for heparin overdose.

The man described is exhibiting the signs of narcissistic personality disorder. This condition is characterized by excessive grandiosity and an exaggerated sense of self-importance accompanied by a feeling of entitlement and a need for attention or admiration.
Avoidant personality disorder is characterized by feelings of inadequacy and extreme sensitivity to criticism, leading to social inhibition and withdrawal.
Borderline personality disorder is characterized by unstable interpersonal relationships, instability of affect, impulsivity, feelings of emptiness or anger, and in some cases, paranoid or clIssociative symptoms.
Dependent personality disorder is characterized by the need for constant support and reassurance with unrealistic anxieties over being forced to fend for oneself.
Schizotypal personality disorder is characterized by eccentricities of behavior, odd beliefs or magical thinking, and difficulties with social and interpersonal relationships.

The patient described in this question is suffering from absence seizures, which typically appear during childhood, between the ages of 5 and 7. In absence seizures, the patient has many episodes of brief disruption of consciousness throughout the day. These seizures are not accompanied by the convulsions and complete loss of consciousness often associated with epilepsy, but rather by the absence of motor or sensory symptoms (hence, the blank look on the patient's face).
Children with attention deficit hyperactivity disorder also have a limited attention span and normal intelligence. However, they also exhibit hyperactivity, impulsiveness, emotional lability, and irritability, which lead to behavioral problems in school.
Children with infantile autism may present with a short attention span, but their most striking deficits lie in their difficulty with social interactions and communication skills. Infantile autism is a developmental disease that usually manifests itself before age 3, and most autistic children have an IQ below the normal range.
Phonological disorders are a class of communication disorders in which the age- and intelligence-appropriate speech sounds are developmentally delayed.
Schizophrenia with childhood onset is quite rare. Children with this disorder demonstrate normal intelligence and may show a limited attention span. However, these children also manifest the same psychiatric symptoms seen in adult-onset schizophrenics, including hallucinations, delusions, abnormal affect, and limited social skills, which lead to behavioral problems in school.

The patient is experiencing the classic symptoms of withdrawal from opioids, which are anxiety, insomnia, anorexia, sweating, piloerection, fever, rhinorrhea, nausea, stomach cramps, diarrhea, and yawning. Symptoms usually appear within 8 to 10 hours after abstinence. The onset is longer if methadone has been withdrawn. These symptoms peak within 48 to 72 hours and then disappear in 7 to 10 days. Methadone lessens the effects of withdrawal. It should be given no more than 20-50 mg/day.
Alcohol withdrawal appears within a few hours of stopping or decreasing alcohol consumption. It lasts for 3 to 4 days and sometimes as long as a week. The patient experiences tachycardia, tremulousness, diaphoresis, nausea, orthostatic hypotension, malaise, anxiety, and irritability. Benzodiazepine should be administered in a tapering dose over 3 days. Cocaine withdrawal is classified by psychological symptoms such as increased sleep, REM rebound causing nightmares, lassItude, increased appetite, depression, and suicide attempts. Treatment would consist of an antidepressant such as bupropion. Amphetamine withdrawal would include a post-use crash, including anxiety, lethargy, headache, stomach cramps, hunger, severe depression, dysphorla mood, fatigue, and insomnia or hypersonnnia. Barbiturate withdrawal Is characterized by anxiety, seizures, delirium, and life-threatening cardiovascular collapse.

This case is a classic description of mania without clear evidence of psychosis. Thus, the patient is euphoric, pressured, and grandiose. Her disorganized appearance is consistent with her mild cognitive Impairments (errors on serial sevens, slight disorientation, slightly reduced digit span). These are consistent with lack of attention/concentration or lack of motivation to respond accurately but not with severe brain dysfunction. The difference between her judgment as measured with a standardized question and as revealed in her history is typical In mania, where patients behavior is often more disordered than their language and self-presentation would lead one to expect.

Schizoid describes people who are uninterested in social attachment. Obsessive-compulsive personality describes people who are perfectionistic, preoccupied with rules and order, overconscientious, rigid, stubborn and stingy. Many obsessive-compulsive people work excessive hours and for idiosyncratic reasons that do not reflect economic necessity or the real demands of their jobs. Schizotypal people have both diminished capacity for relationships and peculiar patterns of thought, including magical thinking, odd beliefs, odd perceptual experiences, and subtle, low grade abnormalities of thought form. Antisociality describes disregard for the rights of others shown in lack of remorse. People with this disorder also show irritability and aggressiveness, risk taking, irresponsibility and impulsivity. Histrionic personality connotes people who are dramatic, seductive, suggestible and shallow. Efforts have been made to define histrionicity in gender blind terms, though it derives from the earlier concept of hysterical personality that applied mainly to women. Borderline traits include impulsivity, unstable relationships driven by fears of abandonment, problems of identity, chronic feelings of emptiness, suicidal thinking and behavior, and dysphoric moods, including irritability. Mistrust, projection, and the attribution of malevolence are all elements of paranoia, which may be either psychotic, implying a break from reality, or nonpsychotic, as in personalty disorder. Splitting, while not automatically linked to paranoia, is an immature defense similar to projection. The two often co-occur.

Schizotypal people have both diminished capacity for relationships and peculiar patterns of thought, including magical thinking, odd beliefs, odd perceptual experiences, and subtle, low grade abnormalities of thought form. Obsessive- compulsive personality describes people who are perfectionistic, preoccupied with rules and order, overconscientious, rigid, stubborn and stingy. Many obsessive-compulsive people work excessive hours and for idiosyncratic reasons that do not reflect economic necessity or the real demands of their jobs. Schizoid describes people who are uninterested in social attachment. Antisociality describes disregard for the rights of others shown in lack of remorse. People with this disorder also show irritability and aggressiveness, risk taking, irresponsibility and impulsivity. Histrionic personality connotes people who are dramatic, seductive, suggestible and shallow. Efforts have been made to define histrionicity in gender blind terms, though it derives from the earlier concept of hysterical personality that applied mainly to women. Borderline traits include impulsivity, unstable relationships driven by fears of abandonment, problems of identity, chronic feelings of emptiness, suicidal thinking and behavior, and dysphoric moods, including irritability. Mistrust, projection, and the attribution of malevolence are all elements of paranoia, which may be either psychotic, implying a break from reality, or nonpsychotic, as in personality disorder. Splitting, while not automatically linked to paranoia, is an immature defense similar to projection. The two often co-occur.

The DSM criteria for alcohol abuse are recurrent use resulting in failure to fulfill obligations, recurrent use in hazardous situations, recurrent legal problems related to use, and continued use despite negative consequences. It is also important to note that the patient has never met the criteria for dependence.
A persistent desire or unsuccessful efforts to cut down is also a symptom of dependence.
Seizures are a symptom of severe withdrawal in chronic alcoholics. When the patient develops withdrawal symptoms and tolerance, requiring larger amount to achieve the desired effect, he or she has met the criteria for dependence.
Suicidal ideation in this patient is a consequence of his depression, which in turn, is secondary to alcohol use. Continued use of a substance despite knowledge of persistent or recurrent physical or psychological problems is also a criterion for dependence.
Tolerance is defined as the need to increase substance use to achieve the desired effect, or as diminished effect with continuous use of the same amount. Tolerance is a major criterion of dependence.

Bipolar disorder, type I is the appropriate diagnosis because the patient has had repeated manic episodes. The inappropriate grandiose activity with her clients accounts (without the benefit of consultation), decreased need for sleep, and involvement in potentially self-destructive behavior (i.e. excessive alcohol consumption) support this diagnosis.
There is no history of depressive episodes, which is mandatory for the diagnosis of bipolar disorder, type II.
Since her behavior is of psychotic proportion and there is no history of depressive episodes, cyclothymic disorder is incorrect.
Persons with schizophrenic disorder, paranoid type have a major thought and affect disorder and characteristically hallucinate. During an episode, they are unable to function in reality, unlike the patient described above.
The hallmark of delirium is a fluctuating level of consciousness. There are no indications that she is manifesting this symptom

In the condition described, a person is in a social situation and fears that he or she will not be able to perform in the same manner as most everyone else can. The 2 most common social phobias concern public speaking and restroom performance (sometimes called "shy bladder.")
Anxiety disorder due to a general medical condition is diagnosed when a medical condition precipitates anxiety, e.g., hypoglycemia.
Panic disorder is characterized by sudden paroxysms of anxiety. It can strike unexpectedly in uncued situations, so it would not occur only when others are present.
Specific phobias are unreasonable fears of some identifiable thing, not situation (e.g., elevators).
Substance-induced anxiety disorder is diagnosed when anxiety is precipitated by ingestion of a psychoactive substance, e.g., hallucinogens.

Many drugs used to treat epilepsy can cause pancreatitis, but from the ones mentioned in this list, only valproic acid can cause it, even with therapeutic levels. Hemorrhagic pancreatitis has been reported with this drug. The condition can occur soon after starting a patient on the drug or several years after use. Other major adverse effects include hepatotoxicity, thrombocytopenia, CNS depression, and dermatological reactions. The medicine should be suspended and should not be used in this patient again.
Vigabatrin is an anticonvulsant, which may cause psychosis, depression, and somnolescence. Ethosuximide may cause dermatological reactions, pancytopenia, sleep abnormalities, and restlessness. Diazepam can cause a paradoxical CMS stimulation in some patients, ataxia, dizziness, and/or headache in others. Phenytoin can cause osteomalacia, agranulocytosis, and gum hypertrophy.

This is an example of displacement. In this defense mechanism, there is a transfer of emotion from a person, object, or situation with which it is appropriately associated to another that causes less distress. Displacement is common and often destructive to other individuals, such as when a man is fired from his job and subsequently beats his wife or children. In the medical setting, the hospital staff is a frequent target of displacement when farnly members react to their own feelings of guilt about someone's death.
Projection occurs when someone attributes his or her own thoughts to a different person. Reaction formation Is the unconscious adoption of behavlor opposite to one's true feelings. Regression is the adoption of behavior more appropriate to a younger age.
Repression is the deeply subconscious blocking of memories or emotions.
Buxbauming is a severe behavioral disorder in which the person has extreme delusions of their intellect and importance. They tend to present very detailed stories with lots of insignificant details, then ask question which require even more details that were not presented in the original manotonous story. By presenting an unsolvable problem, the patient demonstrates his superiotity over the rest of the world. An even better definition, though longer, would be to just combine all other DSM disorders into one.

The sick role as defined by Talcott Parsons provides a useful way of understanding many of the problems that arise between physicians and patients. Rather than ascribe difficulties to faults or deficits in either person, social role theory, would question how each individual might be deviating from the expectations of his/her role, and how the other party is attempting to re-establish role appropriate behavior.
The four defining qualities of the sick role are two rights and two responstilities. Although it Is desirable to educate patients about their conditions, this is not a necessary aspect of the sick role. Patients need only recognize they are in some way ill. The responsibility for understanding the illness belongs to the doctor role, though the doctor can (and should) share this understanding with the patient.
The sick role Is necessary and useful in society, but undesirable or deviant. Patients are not fulfilling their normal obligations. They are expected to want to get well and relinquish the sick role as soon as possible. Indeed, the sick role is time-limited. Patients who remain in it too long move into the more devalued disabled role. People who are too eager to assume the sick role may be looked down upon as manipulative, malingering, or inadequate. Paradoxically, the sick role is given most readily to patients who are least eager to remain in it for any length of time.
Patients with borderline personality traits often manage distress by 'splitting' - oscillating between one feeling and its opposite, without being aware of the incompatibility. They may express anger and resentment to one person and act helpless and deeply appreciative with another. This inconsistency can divide treatment groups into those who respond to the borderline patient's angry, manipulative behavior and those who are privy to the person's underlying distress. Paranoid patients mistrust physicians. They tend to scrutinize every bit of advice or information they are given, and will often be noncompliant out of fear of unforeseen, negative consequences. Schizotypal patients often have idiosyncratic perceptions and odd reasoning that also can impair their ability to understand and follow medical advice. Conversely, patients with deeply felt desires to be cared for by others will readily adopt the sick role when ill. The experience of receiving care may be so gratifying, however, that they have trouble appropriately relinquishing the sick role when they are better. Any personality trait that people may exhibit is likely to influence their behavior in a given social role. Histrionic personality style implies that the person is flamboyant, dramatic, and often seductive or impulsive. Patents with this quality may describe their medical symptoms In dramatic terms, without being able to substantiate them on cross-questioning.

Delirium is an acute or subacute condition in which clouding of consciousness is accompanied by abnormalities of perception and mood. The impairment of consciousness can range from mild befuddlement to serious disorientation and confusion. The degree of impairment classically fluctuates with intermittent lucid intervals. Confusion is usually worse at night. Transient hallucinations, usually visual, and delusions may occur. The patient may be restless, suspicious, frightened and uncooperative.
Delirium may be caused due to various reasons.
Brief reactive psychosis is seen in patients as a response to severe emotional stress. Orientation is preserved in this condition.
Mania is an elevated, expansive, or irritable mood that is characterized by hyperactivity, delusion of grandiosity, increased sex drive, and decreased need for sleep. Orientation is preserved.
Psychotic depression is major depression with delusions and/or hallucinations, but with preservation of orientation.
Schizophrenia is a diverse group of disorders characterized by incoherence of speech and thought, auditory hallucinations, thought withdrawal, insertion and interruption, delusions, and external control of emotions.
Causes of delirium
Systemic infection Conditions with high fever (e.g. malaria)
Metabolic distrubance Hepatic failure, renal failure, electrolyte imbalance, hypoxia
Drug intoxication Anticonvulsant, anxiolytic, opiates, industrial poisons
Withdrawal Drug/alcohol
Intracranial causes Trauma, tumor, epilepsy
Endocrine Hypoglycemia, Cushing's syndrome
Vitamin deficiency Wernicke-Korsakoff syndrome, ben i beri, Vitamin B12

This patient has schizoaffective disorder. She has a clear depressive syndrome, but by history she also has psychotic symptoms when not depressed. If she hallucinated only in close proximity to her depressive episodes, she would be classifiable as having major depressive episode with mood congruent psychotic features. Her poor social functioning is also more typical of a major psychotic disorder than of a mood disorder (though people with mood disorders often have social impairments that persist between episodes).

TRIAZOLAM is a potent, short-acting benzodiazepine with ultra rapid elimination. Its peak effect occurs soon ( FLURAZEPAM is a long-acting benzodiazepine and has a long elimination time. Residual effects are likely the next morning and can produce day-time sedation. Hence, it is not recommended for shift workers who need short early sleep with no hangover. Side effects include dizziness, clumsiness, drowsiness, abdominal discomfort, and dry mouth. It usually does not produce a psychiatric disturbance.
Diazepam is a long-acting benzodiazepine. Its occasional use is free of residual effects, but with regular use accumulation occurs and prolonged anxiolytic effect may be obtained. Psychiatric disturbances are not usually seen after treatment with diazepam.
TEMAZEPAM is an intermediate-acing benzodiazepine. Absorption is slow in tablet form. It is good for individuals with middle of night insomnia. Accumulation can occur on daily ingestion. Side effects include allergic reactions. Psychiatric disturbance are not commonly seen with tennazepam.
ZOLPIDEM is a non-benzodiazepine hypnotic. It shortens sleep latency and prolongs sleep duration in insomniacs. Psychiatric disturbances are not seen with zolpidem.

The patient is presenting with signs and symptoms of acute cholecystitis, which is associated with gallstones in more than 90% of all cases. This condition occurs when a stone becomes impacted in the cystic duct and inflammation develops behind the obstruction. The acute attack is often precipitated by a large fatty meal and is characterized by the sudden appearance of severe, steady pain localized to the epigastrium or right hypochondnum. Laboratory findings often include elevated white blood cells (2,000 - 15,000/mL). Total serum bilirubin values of 1-4 mg/dL may be seen in some instances, and serum amylase may be elevated. In noncomplicatecl cases, treatment often includes IV alimentation, analgesics, and antibiotics, as well as withholding of oral feedings.
Meperidine is the narcotic of choice, as it is least likely to cause spasm of the sphincter of Oddi, probably because of its antimuscarinic properties.
It is therefore preferred over morphine, oxycodone, and propoxyphene. Furthermore, propoxyphene is a narcotic agonist with mild analgesic properties; hence, it would most likely not be able to effectively treat this patient's severe pain.
Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) indicated for the treatment of mild to moderate pain; this agent would most likely not provide sufficient pain control for this patient.

In this case, the two main diagnoses to be considered are some form of schizophrenia or schizophreniform disorder. The patient has many schizophrenic symptoms, Including disorganized behavior, decreased social and occupational functioning, auditory hallucinations and thought disorder. However, she does not meet the criterion for schizophrenia that symptoms, either psychotic, prodromal, or residual, be present for at least six months. This places her in the category of schlzophreniform disorder.

The symptom profile (of increased voiding, dry mouth, and profuse sweating at night) along with the increase blood glucose levels prompt the diagnosis of diabetes mellitus. However, current recommendations require the estimation of HbA1c levels for the solid diagnosis.
Out of the given therapeutic agents, sulfonylureas (glyburide) and insulin only decrease TGs; acarbose does not affect lipids; and the effect of repaglinide is uncertain.
Pioglitazone (thiazolidinedione) increases HDL and decreases TGs but also increases LDL and total cholesterol.
However, metformin, another insulin "sensitizer," decreases TGs and LDL cholesterol but does not affect HDL levels.

The patient is a schizophrenic overmedicated with haloperidol. When the patient is first brought into the hospital, he is suffering from Parkinsonian motor symptoms that are a significant side effect of many neuroleptics (particularly haloperidol). Over the next few days, he remains unmeclicated, and the effects of naloperidol begin to wear off, which relieves his motor symptoms but leads to the reappearance of his psychotic symptoms.
While alcohol withdrawal can produce delirium tremens, it would not explain the initial presentation with Parkinsonian symptoms.
Chronic amphetamine use can result in an amphetamine-induced psychosis that resembles an acute schizophrenic attack. However, these attacks abate within a few days after drug use ceases. This patient's psychosis surfaced after a few days without medication.
Chronic schizophrenics with an extensive history of neuroleptfc use can develop tardive dyskinesia, which is characterized by involuntary jaw and tongue movements.
A Parkinsonian patient overmedicated with L-dopa may suffer from visual and auditory hallucinations as well as involuntary movements. These symptoms are the result of increased activity in the dopamine system and would be expected to abate after several days without treatment. Parkinsonian motor symptoms repressed by L-dopa would be expected to re-emerge as the drug is cleared from the system.

Tetracaine is a more potent and long acting ester linked local anesthetic. It is rapidly absorbed from the mucus membrane and abraded skin, but absorption from intact skin is poor. Its use is mainly restricted to topical application in the eyes, nose, throat, and tracheobronchial tree. Tetracane is slowly hydrolysed by plasma pseudocholinesterase to paraaminobenzoic acid and cliaminoethanol. It is more potent due to slow hydrolysis.
Bupivacaine is a potent and long acting amide-linked local anaesthetic used for infiltration, nerve block, epidural, and spinal anesthesia of long duration. It is cardiotoxic and can produce prolonged QTc interval and can induce ventricular tachycardia or cardiac depression. It should not be used for intravenous regional analgesia.
Benzocaine is an ester-linked local anaesthetic and has very low aqueous solubility, hence is not significantly absorbed from mucus membranes or abraded skin. It is mostly used as lonzenges, dusting powders, or ointments.
Chloroprocaine is also an ester-linked local anesthetic but very short acting with intermediate potency. It is contraindicated as spinal anesthesia as it may cause paraplegia due to the presence of sodium rnetabisulphite as a preservative, which is neurotoxic. It is given by injection during minor surgical procedures.
Lignocaine is also known as Lidocaine and is an amide-linked local anesthetic. It is good for both surface application as well as infiltration, nerve block, epidural, spinal, and intravenous regional block. It has a medium duration of action. It is antiarrhythmic and is the drug of choice for ventricular tachycardia but can precipitate malignant hyperthermia due to release of calcium.

Cases of severe idiosyncratic hepatocellular injury have been reported following the administration of troglitazone. The hepatic injury is usually reversible, but rare cases of hepatic failure leading to death or liver transplantation have been reported. The initial signs and symptoms of hepatic dysfunction include recent onset of nausea, vomiting, abdominal pain, anorexia, and a dark colored urine. Once these signs and symptoms begin to appear, the patient taking troglitazone should have liver function tests performed. An AST and ALT of greater than 3 times the normal limits and/or the appearance of jaundice are typical.
Acarbose is an alpha-glycosidase inhibitor used as an adjunctive treatment measure for NIDDM; the most common side effects are abdominal discomfort and flatulence.
Glipizide is a sulfonylurea oral hypoglycemic agent associated with the development of hypoglycemia and cholestatic jaundice (a rare complication).
Metformin is a biguanide oral hypoglycemic agent associated with the development of lactic acidosis and malabsorption of amino acids.
Repaglinide is the non-sulfonylurea moiety of glyburide; it is commonly associated with hypoglycemia, nausea, and vomiting.

The clinical presentation of this patient associated with a history of etomidate administration should raise suspicion for acute adrenal insufficiency, which should rapidly respond to intravenous hydrocortisone. Etomidate, an imidazole derivative hypnotic, Is commonly used for induction of anesthesia. The hypnotic effects of this drug in the central nervous system are probably related to the GABA-adrenergic system. As a side effect, etomidate acts on the adrenal gland mainly by inhibiting the enzyme 11b-hydroxylase that converts 11-deoxycorticosterone to corticosterone (one step before synthesis of aldosterone) and 11-deoxycortisol to cortisol (see image). This effect is reversible with discontinuation of the drug and can be observed even after a single administration, such as in induction of anesthesia. Full-blown adrenal insufficiency is only rarely seen after etomidate; however, most patients present some degree of adrenal suppression with blunt response of cortisol to ACTH stimulation. Similar to acute adrenal insufficiency, patients fail to respond to intravenous fluids (saline solution and colloid infusion), vasopressors (dopamine, dobutamine), and atropine, but respond well to intravenous hydrocortisone 100 mg every 8 hours, which should be maintained for at least 24 hours.