Snapshot A 21-year-old male college student has become increasingly bizarre over the course of the last semester and is referred by his academic advisor to the student health clinic. He will not leave his room for weeks at a time because he believes that voices in his head are telling him to continue searching the internet for hidden alien messages. He believes he is the only one on earth with this special ability. He is paranoid that the FBI knows this secret and is trying to prevent him from receiving these messages. A consulting psychiatrist admits the patient to the psychiatry ward. The patient is started on low doses of risperidone. Introduction Epidemiology genetic factors outweigh environmental factors in etiology 1.4 times more diagnoses in men than women presents earlier in men late teens to early 20s in men late 20s to early 30s in women higher risk for suicide than general population Potential causes overactive dopaminergic activity (association for board exams) in reality, this hypothesis is weak based on fact that the weakest D2 antagonist used for treatment (clozapine) is most effective agent for schizophrenia NMDA, GABA, acetylcholine are all implicated NOTE: subtypes (paranoid, disorganized, catatonic, undifferentiated, residual) have been eliminated from DSM-V due to poor validity and low reliability Associated conditions brief psychotic disorder schizophrenic symptoms lasting < 1 month usually stress related schizophreniform disorder schizophrenic symptoms lasting between 1 and 6 months schizoaffective disorder schizophrenic symptoms with manic or depressed episode mood disturbance must be present for majority of total duration of disorder Presentation Positive symptoms delusions fixed, false beliefs hallucinations sensory perceptions without physical stimuli auditory is most common disorganized speech loose associations, word salad, tangential speech grossly disorganized behavior Negative symptoms flat affect social withdrawal lack of motivations lack of speech or thought grossly catatonic behavior symptoms improve with lorazepam Evaluation Diagnostic criteria at least 2 of symptoms listed above (so-called Criterion A symptoms) at least 1 must be a delusion, hallucination, or disorganized speech these have to manifest for a 1 month period persistent symptomatic dysfunction lasting > 6 months rule out schizoaffective disorder mood disturbances only present during minority of symptomatic period rule out depressive/bipolar disorder with psychotic features schizophrenic symptoms manifest only during mood disturbances rule out substance use and other medical conditions Imaging (boards knowledge, not part of diagnostic criteria) may demonstrate increased ventricular size, decreased cerebral mass, decreased hippocampal mass, decreased temporal mass Management Hospitalization for acute psychotic episode baseline physical and neurological exam important to establish existing musculoskeletal symptoms investigations: best initial test: urine toxicology to rule out an easy and reversible cause CBC, Chem-7, LFTs, TSH, fasting glucose, EKG important to assess presence or absence of metabolic syndrome important to know baseline QTc interval before starting antipsychotic atypical (2nd generation) antipsychotic medications first-line drug due to less extrapyramidal side effects compared to 1st generation (typical) antipsychotics typical first agents: olanzapine, ziprazidone, quetiapine if not compliant, long-acting risperidone or depot haloperidol may be used clozapine used as a last-line drug for refractory schizophrenia refractoriness established if first-line drug fails to improve symptoms after 2-6 weeks adding a second first-line drug is not effective
QUESTIONS 1 of 9 1 2 3 4 5 6 7 8 9 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.PY.79) A 17-year-old patient with a past medical history of recent marijuana use presents to her primary care physician for a routine check-up. Although the patient has been well-groomed on past visits, the patient is noticeably disheveled, with a strong odor and dirty clothes. When asked why she has come to the office, she responds, "I just returned from the moon." During follow-up questions, she seems distracted, often stopping in the middle of a sentence. Which of the following is most likely to denote a poor prognosis in this patient? Review Topic QID: 106915 1 Female gender 20% (1/5) 2 Mostly positive symptoms 0% (0/5) 3 Early age of onset 80% (4/5) 4 An absence of a family history 0% (0/5) 5 Recent use of marijuana 0% (0/5) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (M2.PY.81) A 63-year-old man with a past medical history of schizophrenia is brought to the emergency room by his daughter after he wandered off from her home for several days. He appears disheveled, has a strong body odor, and has lost 10 pounds since his previous visit 1 month ago. He is prescribed quetiapine, but his daughter reports that she has difficulty making sure that he takes his medications every day. Which of the following medications may be most appropriate for this patient? Review Topic QID: 106934 1 Risperidone 50% (2/4) 2 Quetiapine 0% (0/4) 3 Chlorpromazine 25% (1/4) 4 Sertraline 0% (0/4) 5 Clozapine 25% (1/4) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (M2.PY.54) A 29-year-old man with a chronic mental disorder marked by disorganized speech, catatonic behavior, a flat affect, and social withdrawal, presents with his family after his third psychiatric hospitalization in the last four months. The patient's family is concerned because his disease has been extremely resistant to first line treatments. You start him on a medication which is used primarily for treatment-resistant schizophrenia. The feared side effect of this drug is also a potential side effect of which of the following? Review Topic QID: 105724 1 Carbamazepine 59% (27/46) 2 Phenytoin 9% (4/46) 3 Methotrexate 20% (9/46) 4 Lithium 7% (3/46) 5 Halothane 2% (1/46) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (M2.PY.61) A 26-year-old male presents with 'voices in my head." The patient was well until 8 months ago when he began to hear voices of two men plotting to kill him. His fear of being killed has resulted in his missing multiple days of work, and he was recently fired. On physical exam he is disheveled and has incoherent, disorganized speech. Which of the following findings would you NOT expect to see on head CT? Review Topic QID: 105731 1 Decreased cerebellar mass 100% (6/6) 2 Increased ventricular size 0% (0/6) 3 Decreased cerebral mass 0% (0/6) 4 Decreased hippocampal mass 0% (0/6) 5 Decreased temporal mass 0% (0/6) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (M3.PY.15) A 24-year-old male presents with 6 months of auditory hallucinations, paranoid delusions, and gross disorganization. The patient's head CT is shown in Figure A. Which of the following would favor a good prognosis for this man's condition? Review Topic QID: 103750 1 Insidious onset 0% (0/3) 2 Prior psychiatric history 0% (0/3) 3 Negative symptom predominance 0% (0/3) 4 History of a precipitating event 100% (3/3) 5 Family history of mental illness 0% (0/3) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 4