A 15-year-old male is brought in to the Adolescent Clinic by his mother. The mother complains that he had recently been put on suspension from school for frequent fights he initiated with other peers and vandalism of school property. He frequently takes his mother’s money from her purse without permission and then denies that he has stolen the money. He has been grounded for staying out past curfew, but sneaks out of the home to see friends. The patient states his mother is “overreacting”. The mother feels his behavior has been unmanageable since he was 10 years old.
Which of the following is the most likely diagnosis?
Correct Answer C: There is a persistent pattern of behavior that violates the basic rights of other or societal norms or rules. Behaviors include either aggression toward others, destruction of property, deceitfulness or theft, and serious violations of rules, beginning in childhood.
A. ODD consists of a pattern of negativistic, hostile, and defiant behaviors. Opposition toward authority figures is demonstrated by persistent disobedience, argumentativeness and violation of major rules. Legal violations are more characteristic of conduct disorder.
B. In autistic disorder, aggressive behavior does not necessarily lead to a violation of the basic rights of other.
D. Antisocial personality disorder develops in adolescence but is diagnosed when the individual is 18 years or older.
E. Although attention deficit disorder may be seen in such an individual, impulsive behavior does not necessarily lead to a violation of rules or the basic rights of others.
A 36 year old woman with a long history of alcoholism presents to the emergency department intoxicated. On physical examination, she is disoriented and confused, and has ataxia, dysarthria, and oculomotor paralysis.
Which of the following intravenous substances should most likely be administered first?
Correct Answer D:
This patient appears to have Wernicke encephalopathy, which is due to a deficiency of thiamine that is quite common in chronic alcoholics. Symptoms of Wernicke encephalopathy include oculomotor disturbances, cerebellar ataxia, and mental confusion. Treatment consists of giving thiamine, 100 mg IV or IM, along with magnesium sulfate given prior to or concurrently with treatment of glucose. Administering dextrose to an individual in a thiamine-deficient state exacerbates the process of cell death.
A 59-year-old female presents to the emergency room after coming to work very confused. She had difficulty answering questions, and her coworkers saw her stumbling. Her coworkers are puzzled because she doesn’t seem to smell of any alcohol. They report repeated episodes of the patient coming to work intoxicated and state she has been alcoholic for most of her life. On exam you find her disoriented with a disconjugate gaze and staggering gait.
The diagnosis that is most consistent with this presentation and most worrisome is:
Correct Answer C:
Wernicke’s encephalopathy is characterized by acute confusion, sixth nerve palsy, and unsteady gait. Though the triad is characteristic, it may occur with very subtle eye or gait findings that are initially missed. Since this is potentially reversible it is important to be actively looking for these findings to ensure the diagnosis is not missed.
A. Though it can appear as if the patient is intoxicated, remember that most intoxicated people are not disoriented, nor do they have ophthalmoplegia on exam.
B. Patients with thiamine deficiency may have cardiovascular disease, but this would not be a typical TIA presentation. The more worrisome diagnosis is Wernicke’s, which can be treated if recognized quickly.
D. Korsakoff’s syndrome is a persistent form of thiamine deficiency. It presents more slowly and is characterized as a failure in short-term memory. The patient may confabulate her history to conceal her memory deficits. If Wernicke’s encephalopathy progresses to Korsakoff’s syndrome, the chances of recovery diminish to only 20%.
All of the following are classified as paraphilias, except:
Correct Answer B:
Paraphilias are recurrent, intense, sexually arousing fantasies, urges, or behaviors that are distressing or disabling and that involve inanimate objects, children or other nonconsenting adults, or suffering or humiliation of oneself or the partner. Paraphilias include fetishism, exhibitionism, sexual sadism and transvestism.
Homosexuality has not been considered a disorder or paraphilia for > 3 decades. About 4 to 5% of the population identify themselves as exclusively homosexual for their entire lives. Like heterosexuality, homosexuality results from complex biologic and environmental factors leading to an ability to become sexually aroused by people of the same sex.
Which of the following statements concerning anorexia nervosa and bulimia nervosa is false?
Anorexia nervosa is characterized by a relentless pursuit of thinness, a morbid fear of obesity, a refusal to maintain a minimally normal body weight, and, in women, amenorrhea. Diagnosis is clinical. Treatment is with cognitive behavioral therapy; olanzapine may help with weight gain, and SSRIs, especially fluoxetine, may help prevent relapse. Complications of anorexia nervosa include myocardial atrophy, mitral valve prolapse, pericardial effusion, bradycardia, functional hypothalamic amenorrhea, antenatal and postpartum problems, osteoporosis, gastroparesis, and constipation. In addition, growth disturbance can occur in adolescents.
Bulimia nervosa is recurrent episodes of binge eating followed by self-induced vomiting, laxative or diuretic abuse, vigorous exercise, or fasting. Diagnosis is based on history and examination. Treatment is with psychotherapy and SSRIs, especially fluoxetine. The DSM-5 diagnosis of binge eating disorder requires binge eating episodes to occur, on average, at least once a week for three months.
In anorexia, the illness begins between early adolescence (13-18 y) and early adulthood, earlier-onset and later-onset are encountered. In some patients with early-onset (ie, age 7-12 y). In bulimia, eating disorders usually develop in adolescence, but about 5% of people develop the disorder when they are older than 25 years. Peak onset of bulimia nervosa occurs at 18 years. Both anorexia nervosa and bulimia are more common in women than men.
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