A 43-year-old chronically mentally ill man was admitted to the medical floor for ketoacidosis. His previously prescribed antipsychotic haloperidol was stopped and not restarted when he was transferred to an extended care facility several weeks later. A routine follow-up examination by his primary care physician finds the patient with tic-like movements of his face and tongue and lip smacking.
Based on this information, what is the most likely diagnosis?
Correct Answer E:
Tardive dyskinesia is a common side effect to prolonged antipsychotic medication usage. More advanced cases may exhibit choreoathetoid movements of the limbs and trunk.
Which one of the following predisposing factors for tardive dyskinesia (TD) is incorrect?
Correct Answer B:
Males can develop tardive dyskinesia, but females have a higher risk of developing this condition. Both the prevalence and severity of TD increase with age. Unipolar depression as well as positive family history of affective disorder in relatives of schizophrenic patients are predisposing factors.
Which of the following have not been beneficial in treating tardive dyskinesia?
Correct Answer D:
Haloperidol may mask the dyskinetic movements associated with TD, but ultimately this relatively pure D2 blocking agent will worsen the condition. There is no universally effective treatment for TD, but the atypical antipsychotic clozapine with serotonergic and D4 affinities has been helpful for some individuals with TD. Some patients who have had TD for a short duration benefit from the antioxidant vitamin E. Propranolol as a beta blocking agent and tetrabenazine as a monoamine depleting agent have been helpful.
A 38-year-old alcoholic male has successfully completed outpatient alcohol detoxification and has plans to participate in Alcoholics Anonymous.
Which one of the following pharmacologic agents can aid in relapse prevention?
Correct Answer A:
Pharmacological agents can be useful adjunct to counseling in preventing relapse in patients with alcohol dependence. Naltrexone and disulfiram are currently approved by the FDA for treatment of alcohol-dependent patients.
→ Bupropion is of value for smoking cessation.
→ Mirtazapine is an antidepressant.
→ Naloxone is used to treat opioid overdose.
→ Flumazenil treats benzodiazapine overdose.
You are treating an 89-year-old white male who has lived alone since his wife died 5 years ago. His niece found him helpless in his apartment. The patient is filthy, listless, and weak, and complains of thirst. He is orientated to self, but he is sure that you are his pastor and that Nixon is president. His general physical examination reveals cardiomegaly and peripheral edema. Findings on neurologic examination include horizontal and vertical nystagmus, weakness of lateral recti, ataxia, and peripheral areflexia. Plantar responses are down pointing. A CBC is pending; electrolyte, BUN, and glucose levels obtained in the emergency department reveal hypertonic dehydration for which 5% dextrose in 1/2 normal saline is running at 200 cc/hr. The patient’s drowsiness increases during your examination.
You order which one of the following?
Alcoholism, while less frequent in the elderly, is often masked by isolation. Elderly widowers are in the highest risk group. Several features of this case, including the long-term inattention to self, gaze disturbance, cerebellar signs, confabulation (confidence in the face of confusion), and better past that present memory, all suggest Wernicke’s encephalopathy. The presence of signs of wet beriberi related to the same nutritional deficiency support the diagnosis. The patient is at immediate risk and thiamine should be administered right away.
Other diagnosis are less likely. Pernicious anemia causes no prominent eye motor signs; temporal arteritis, lupus, and Takayasu’s vasculitis causes lateralization signs; lead poisoning doesn’t generally cause cardiomegaly; and carbon monoxide intoxication is more acute, causing headache and non-selective confusion.
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