Non-stimulant ADHD treatments US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Non-stimulant ADHD treatments. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Non-stimulant ADHD treatments US Medical PG Question 1: A 9-year-old boy is brought to the psychiatrist due to unusual behavior over the past several months. His mother reports that he has started to blink more frequently than usual. His parents initially attributed this behavior to attention-seeking but he has not stopped despite multiple disciplinary efforts and behavioral therapy from a clinical psychologist. He previously performed well in school but has recently become more disruptive and inattentive in class. He has not been sick recently and denies any drug use. His parents report multiple episodes in the past in which the child seemed overly elated and hyperactive for several days followed by periods in which he felt sad and withdrawn. On examination, he is a well-appearing boy in no acute distress. He is alert and oriented with a normal affect but gets distracted easily throughout the exam. He blinks both eyes several times throughout the examination. Strength, sensation, and gait are all normal. Which of the following medications is most appropriate for this patient?
- A. Fluoxetine
- B. Guanfacine
- C. Amitriptyline
- D. Venlafaxine
- E. Lithium (Correct Answer)
Non-stimulant ADHD treatments Explanation: ***Lithium***
- This patient presents with **episodic mood disturbances** including periods of being "overly elated and hyperactive for several days followed by periods in which he felt sad and withdrawn," which is highly suggestive of **pediatric bipolar disorder**.
- While he also displays **inattention, disruptive behavior, and motor tics** (eye blinking), the prominent **cyclical mood episodes** indicate that the primary diagnosis is a **mood disorder** that requires stabilization before addressing comorbid ADHD or tic symptoms.
- **Lithium** is a **first-line mood stabilizer** for bipolar disorder in children and adolescents. Stabilizing the mood is critical before treating ADHD symptoms, as stimulants or even non-stimulant ADHD medications can exacerbate manic symptoms.
- Lithium requires monitoring of blood levels and thyroid/renal function, but it remains the most appropriate choice for this presentation.
*Guanfacine*
- **Guanfacine** is a **selective alpha-2 adrenergic agonist** used for ADHD and can help with comorbid tics. While this patient has ADHD-like symptoms and a motor tic, the more pressing concern is the **cyclical mood episodes** described.
- Treating ADHD without first addressing the underlying mood disorder in pediatric bipolar disorder can worsen mood instability and manic symptoms.
- Guanfacine would be appropriate as an **adjunct** after mood stabilization is achieved.
*Fluoxetine*
- **Fluoxetine** is an **SSRI** used for depression and anxiety. In a child with bipolar disorder, antidepressants can precipitate **manic or hypomanic episodes** and worsen mood cycling.
- SSRIs should generally be avoided or used with extreme caution (alongside a mood stabilizer) in pediatric bipolar disorder.
*Venlafaxine*
- **Venlafaxine** is an **SNRI** used for depression and anxiety. Similar to SSRIs, SNRIs can trigger **mood destabilization** and mania in patients with bipolar disorder.
- It is not appropriate as monotherapy in a child with suspected bipolar disorder and could worsen the clinical picture.
*Amitriptyline*
- **Amitriptyline** is a **tricyclic antidepressant** with significant anticholinergic side effects and a less favorable safety profile in children.
- Like other antidepressants, it can induce **mania or mood cycling** in bipolar disorder and is not a first-line treatment for this presentation.
- TCAs are generally avoided in pediatric psychiatry due to safety concerns and the availability of better-tolerated alternatives.
Non-stimulant ADHD treatments US Medical PG Question 2: A 19-year-old man is seen by his primary care physician. The patient has a history of excessive daytime sleepiness going back several years. He has begun experiencing episodes in which his knees become weak and he drops to the floor when he laughs. He has a history of marijuana use. His family history is notable for hypertension and cardiac disease. His primary care physician refers him for a sleep study, which confirms your suspected diagnosis.
Which of the following is the best first-line pharmacological treatment for this patient?
- A. Zolpidem
- B. Lisdexamfetamine
- C. Modafinil (Correct Answer)
- D. Methylphenidate
- E. Dextroamphetamine
Non-stimulant ADHD treatments Explanation: ***Modafinil***
- This patient presents with symptoms of **narcolepsy** (excessive daytime sleepiness, cataplexy triggered by laughter). **Modafinil** is a non-amphetamine stimulant and a **first-line treatment** for the **excessive daytime sleepiness** component of narcolepsy due to its efficacy in improving wakefulness with a relatively low side effect profile.
- It works by increasing the release of **monoamines (norepinephrine, dopamine, serotonin)** and histamine, promoting wakefulness without significant cardiovascular effects or abuse potential compared to traditional stimulants.
- **Note:** While modafinil addresses the daytime sleepiness, **cataplexy** would typically require additional treatment with **sodium oxybate** (first-line for cataplexy) or antidepressants (SSRIs, SNRIs, or TCAs).
*Zolpidem*
- **Zolpidem** is a **sedative-hypnotic** primarily used for the short-term treatment of **insomnia**, not for excessive daytime sleepiness or narcolepsy.
- Administering a sedative would worsen the patient's primary complaint of daytime sleepiness.
*Lisdexamfetamine*
- **Lisdexamfetamine** is a **prodrug of dextroamphetamine**, a potent central nervous system stimulant used for **ADHD** and sometimes narcolepsy.
- While effective, it is generally considered a **second-line treatment** for narcolepsy after non-amphetamine stimulants like modafinil, especially given its higher potential for abuse and side effects.
*Methylphenidate*
- **Methylphenidate** is a **central nervous system stimulant** commonly used for **ADHD** and, in some cases, narcolepsy.
- Similar to lisdexamfetamine, it is a stronger stimulant with greater potential for side effects and abuse compared to modafinil, making it a less preferred first-line option.
*Dextroamphetamine*
- **Dextroamphetamine** is a potent **amphetamine stimulant** effective for increasing wakefulness in narcolepsy.
- However, due to its **higher abuse potential**, cardiovascular side effects, and more significant impact on dopamine pathways, it is usually reserved for cases refractory to safer options like modafinil.
Non-stimulant ADHD treatments US Medical PG Question 3: A 20-year-old female presents to student health at her university for excessive daytime sleepiness. She states that her sleepiness has caused her to fall asleep in all of her classes for the last semester, and that her grades are suffering as a result. She states that she normally gets 7 hours of sleep per night, and notes that when she falls asleep during the day, she immediately starts having dreams. She denies any cataplexy. A polysomnogram and a multiple sleep latency test rule out obstructive sleep apnea and confirm her diagnosis. She is started on a daytime medication that acts both by direct neurotransmitter release and reuptake inhibition. What other condition can this medication be used to treat?
- A. Obsessive-compulsive disorder
- B. Bulimia
- C. Attention-deficit hyperactivity disorder (Correct Answer)
- D. Tourette syndrome
- E. Alcohol withdrawal
Non-stimulant ADHD treatments Explanation: ***Attention-deficit hyperactivity disorder***
- The patient's presentation is consistent with **narcolepsy type 2 (without cataplexy)**, given the excessive daytime sleepiness, short latency to REM sleep (immediate dreaming), and exclusion of sleep apnea. The medication described, acting via **direct neurotransmitter release and reuptake inhibition**, is characteristic of a stimulant like **methylphenidate** or an amphetamine-based drug.
- These stimulants are commonly used as first-line treatment for **attention-deficit hyperactivity disorder (ADHD)** due to their effects on dopamine and norepinephrine in the brain, improving focus and reducing impulsivity.
*Obsessive-compulsive disorder*
- **Obsessive-compulsive disorder (OCD)** is typically treated with selective serotonin reuptake inhibitors (SSRIs) or cognitive behavioral therapy.
- Stimulants are not indicated for OCD and may even worsen anxiety symptoms in some individuals.
*Bulimia*
- **Bulimia nervosa** is often managed with a combination of psychotherapy (e.g., cognitive behavioral therapy) and antidepressants like fluoxetine.
- Stimulants are not a primary treatment for bulimia and could potentially exacerbate some symptoms or risks due to their appetite-suppressing effects.
*Tourette syndrome*
- **Tourette syndrome** involves motor and vocal tics and is often treated with alpha-2 adrenergic agonists (e.g., guanfacine, clonidine) or dopamine receptor blocking agents.
- Stimulants generally are not used for Tourette syndrome as they can sometimes worsen tics.
*Alcohol withdrawal*
- **Alcohol withdrawal** is a medical emergency managed with benzodiazepines to prevent seizures and delirium tremens.
- Stimulants are contraindicated in alcohol withdrawal as they can increase seizure risk and cardiac complications.
Non-stimulant ADHD treatments US Medical PG Question 4: A 49-year-old woman presents to her primary care physician with fatigue. She reports that she has recently been sleeping more than usual and says her “arms and legs feel like lead” for most of the day. She has gained 10 pounds over the past 3 months which she attributes to eating out at restaurants frequently, particularly French cuisine. Her past medical history is notable for social anxiety disorder. She took paroxetine and escitalopram in the past but had severe nausea and headache while taking both. She has a 10 pack-year smoking history and has several glasses of wine per day. Her temperature is 98.6°F (37°C), blood pressure is 130/65 mmHg, pulse is 78/min, and respirations are 16/min. Physical examination reveals an obese woman with a dysphoric affect. She states that her mood is sad but she does experience moments of happiness when she is with her children. The physician starts the patient on a medication to help with her symptoms. Three weeks after the initiation of the medication, the patient presents to the emergency room with a severe headache and agitation. Her temperature is 102.1°F (38.9°C), blood pressure is 180/115 mmHg, pulse is 115/min, and respirations are 24/min. Which of the following is the mechanism of action of the medication that is most likely responsible for this patient’s symptoms?
- A. Inhibition of serotonin and norepinephrine reuptake
- B. Inhibition of the adrenergic alpha-2 receptor and serotonin-2 and -3 receptors
- C. Inhibition of serotonin reuptake
- D. Partial agonism of serotonin-1A receptor
- E. Inhibition of amine degradation (Correct Answer)
Non-stimulant ADHD treatments Explanation: **Inhibition of amine degradation**
- This mechanism of action describes **monoamine oxidase inhibitors (MAOIs)**. Given the patient's symptoms of **hypertensive crisis** (headache, agitation, hypertension, tachycardia, fever) after starting a new medication and her history of **eating French cuisine** (which could include tyramine-rich foods like aged cheeses and wines), an MAOI is the most likely culprit.
- MAOIs prevent the breakdown of **monoamine neurotransmitters** (serotonin, norepinephrine, dopamine, tyramine), leading to their accumulation. In the presence of **tyramine-rich foods**, this can precipitate a **hypertensive crisis** due to excessive norepinephrine release.
*Inhibition of serotonin and norepinephrine reuptake*
- This describes **SNRIs (serotonin-norepinephrine reuptake inhibitors)** or **TCAs (tricyclic antidepressants)**. While these can cause side effects, a sudden and severe **hypertensive crisis** as described, especially without a clear dietary trigger interaction, is less characteristic than with MAOIs.
- The patient's prior negative experiences with paroxetine and escitalopram (SSRIs) might make a physician choose a different class, but the dramatic symptoms point away from typical SNRI/TCA side effects for this presentation.
*Inhibition of the adrenergic alpha-2 receptor and serotonin-2 and -3 receptors*
- This mechanism is characteristic of **mirtazapine**. While mirtazapine can cause sedation and weight gain (presenting symptoms), it does not typically lead to a **hypertensive crisis** of this severity three weeks after initiation, nor does it have severe food interactions like MAOIs.
- Mirtazapine's primary side effects often include sedation, increased appetite, and weight gain, but not the acute constellation observed here.
*Inhibition of serotonin reuptake*
- This describes **SSRIs (selective serotonin reuptake inhibitors)**. The patient had severe nausea and headache with paroxetine and escitalopram, which are SSRIs. While SSRIs can contribute to **serotonin syndrome** (which shares some features like agitation and hyperthermia), the profound **hypertension** and context of food interaction strongly favor an MAOI-induced hypertensive crisis.
- SSRIs are less likely to cause such a severe **hypertensive crisis** acutely, and the patient's history suggests a physician would likely avoid this class due to past adverse reactions.
*Partial agonism of serotonin-1A receptor*
- This is the mechanism of action for **buspirone**, an anxiolytic. Buspirone is generally well-tolerated and does not cause the severe side effects seen in this patient, particularly **hypertensive crisis** or food interactions.
- Buspirone is often used for generalized anxiety disorder, and while the patient has social anxiety, the described adverse event does not align with buspirone's known side effect profile.
Non-stimulant ADHD treatments US Medical PG Question 5: A 51-year-old male presents to his primary care provider for a normal check-up. He reports that he “hasn’t felt like himself” recently. He describes feeling down for the past 8 months since his mother passed away. He has had trouble sleeping and has unintentionally lost 15 pounds. He feels guilty about his mother’s death but cannot articulate why. His performance at work has declined and he has stopped running, an activity he used to enjoy. He has not thought about hurting himself or others. Of note, he also complains of numbness in his feet and fingers and inability to maintain an erection. His past medical history is notable for diabetes. He is on metformin. His temperature is 98.6°F (37°C), blood pressure is 125/65 mmHg, pulse is 90/min, and respirations are 16/min. On exam, he is alert and oriented with intact memory and normal speech. He appears tired with a somewhat flattened affect. The best medication for this patient inhibits which of the following processes?
- A. Amine degradation
- B. Norepinephrine and dopamine reuptake
- C. Norepinephrine and serotonin reuptake (Correct Answer)
- D. Serotonin reuptake only
- E. Dopamine receptor activation
Non-stimulant ADHD treatments Explanation: ***Norepinephrine and serotonin reuptake***
- This patient presents with symptoms highly suggestive of **major depressive disorder**, including persistent sadness, anhedonia, sleep disturbance, weight loss, and guilt, lasting for 8 months.
- Given his concurrent **diabetic neuropathy** (numbness in feet and fingers) and erectile dysfunction, a medication that targets both depression and neuropathic pain, such as a **Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)** like **duloxetine**, would be the most appropriate choice, as SNRIs block the reuptake of both norepinephrine and serotonin.
*Amine degradation*
- Inhibiting amine degradation is the mechanism of action for **MAO inhibitors (MAOIs)**, which are effective antidepressants but are typically reserved for **refractory depression** due to their significant drug-drug and drug-food interactions (e.g., tyramine crisis).
- They are not considered first-line for a patient who can benefit from an SNRI, especially given the comorbid neuropathy.
*Norepinephrine and dopamine reuptake*
- This describes the mechanism of action of **bupropion**, an antidepressant that can be useful for **atypical depression** or in patients with concerns about sexual side effects.
- However, bupropion does not typically help with **neuropathic pain**, a significant co-morbidity in this patient.
*Serotonin reuptake only*
- This describes the mechanism of action of **Selective Serotonin Reuptake Inhibitors (SSRIs)**, which are often first-line for depression due to their generally favorable side effect profile.
- While effective for depression, SSRIs are generally **not effective for neuropathic pain** and may even worsen erectile dysfunction, making an SNRI a more suitable choice given the patient's full clinical picture.
*Dopamine receptor activation*
- **Dopamine receptor activators** (agonists) are primarily used in conditions like **Parkinson's disease** or for **restless legs syndrome**.
- They are not considered a primary treatment for major depressive disorder, nor do they address neuropathic pain.
Non-stimulant ADHD treatments US Medical PG Question 6: An 11-year-old boy is brought to the clinic by his parents for poor academic performance. The patient’s parents say that his teacher told them that he may have to repeat a grade because of his lack of progress, as he does not pay attention to the lessons, tends to fidget about in his seat, and often blurts out comments when it is someone else’s turn to speak. Furthermore, his after-school karate coach says the patient no longer listens to instructions and has a hard time focusing on the activity at hand. The patient has no significant past medical history and is currently not on any medications. The patient has no known learning disabilities and has been meeting all developmental milestones. The parents are vehemently opposed to using any medication with a potential for addiction. Which of the following medications is the best course of treatment for this patient?
- A. Sertraline
- B. Diazepam
- C. Olanzapine
- D. Methylphenidate
- E. Atomoxetine (Correct Answer)
Non-stimulant ADHD treatments Explanation: ***Atomoxetine***
- This medication is a **non-stimulant** selective norepinephrine reuptake inhibitor. It is a good choice for **ADHD patients** whose parents are opposed to any medication with a potential for addiction because it does not have the same addictive potential as stimulants.
- It works by increasing the levels of **norepinephrine** in the brain, improving attention and hyperactivity symptoms typically seen in ADHD.
*Sertraline*
- This is a **selective serotonin reuptake inhibitor (SSRI)** and is primarily used to treat depression, anxiety disorders, and obsessive-compulsive disorder.
- Sertraline would not be effective for ADHD symptoms like inattention and hyperactivity.
*Diazepam*
- This is a **benzodiazepine** primarily used for anxiety, seizures, and muscle spasms due to its sedative and anxiolytic properties.
- It would likely worsen the patient's inattention and academic performance due to its **sedative effects** and has a significant potential for addiction.
*Olanzapine*
- This is an **atypical antipsychotic** medication used to treat conditions like schizophrenia and bipolar disorder.
- Olanzapine is not indicated for ADHD and could cause severe side effects like **sedation, weight gain, and metabolic issues**.
*Methylphenidate*
- This is a **stimulant medication** commonly used to treat ADHD and is highly effective in improving attention and reducing hyperactivity.
- While effective, methylphenidate has a **potential for abuse and addiction**, which the patient's parents are explicitly against.
Non-stimulant ADHD treatments US Medical PG Question 7: A 43-year-old woman comes to the physician because of a 3-month history of tremor, diarrhea, and a 5-kg (11-lb) weight loss. Her pulse is 110/min. Examination shows protrusion of the eyeball when looking forward. A bruit is heard over the anterior neck on auscultation. Serum studies show autoantibodies to the thyroid-stimulating hormone receptor. The patient decides to undergo definitive treatment for her condition with a radioactive tracer. The success of this treatment directly depends on the activity of which of the following?
- A. Anion-oxidizing enzyme
- B. Transmembrane carrier (Correct Answer)
- C. Lysosomal protease
- D. Binding globulin
- E. Hormone-activating enzyme
Non-stimulant ADHD treatments Explanation: ***Transmembrane carrier***
- Radioactive iodine treatment relies on the uptake of iodine by thyroid follicular cells via the **sodium-iodide symporter (NIS)**, a **transmembrane carrier protein**.
- NIS actively transports iodide into thyroid cells, allowing the radioactive iodine to concentrate in the thyroid and destroy overactive tissue.
*Anion-oxidizing enzyme*
- This refers to **thyroid peroxidase (TPO)**, an enzyme that oxidizes iodide to iodine, incorporates iodine into thyroglobulin, and couples iodinated tyrosines.
- While essential for thyroid hormone synthesis, TPO's activity does not directly determine the success of **radioactive iodine uptake** for treatment.
*Lysosomal protease*
- **Lysosomal proteases** are involved in the breakdown of thyroglobulin to release thyroid hormones (T3 and T4) into circulation.
- They are important for the *release* of hormones but not for the *uptake* of iodine for radioactive treatment.
*Binding globulin*
- **Thyroxine-binding globulin (TBG)** is a plasma protein that transports thyroid hormones in the blood, maintaining a reservoir of T3 and T4.
- TBG's activity affects the availability of free thyroid hormones but has no direct role in the cellular uptake of radioactive iodine by the thyroid gland.
*Hormone-activating enzyme*
- This typically refers to deiodinases, enzymes that convert T4 (prohormone) into the more active T3 in peripheral tissues.
- These enzymes act *outside* the thyroid gland to activate hormones, and their activity does not directly influence the uptake of radioactive iodine.
Non-stimulant ADHD treatments US Medical PG Question 8: A 13-year-old boy has been suspended 5 times this year for arguing with teachers. He has presented a pattern of negativism and hostility that has lasted for about 8 months. When asked about the suspensions, he admits that he loses his temper easily and often blames the principal for not being fair to him. He usually finds an argument before finishing his homework. At home, he goes out of his way to annoy his siblings. He gets furious if his legal guardian finds out about it and confiscates his smartphone. Which of the following is the primary behavior characteristic of this patient's most likely diagnosis?
- A. Destruction of property and theft
- B. Hostile and disobedient behavior towards authority (Correct Answer)
- C. Physical aggression
- D. Violating the rights of others
- E. Killing and/or harming small animals
Non-stimulant ADHD treatments Explanation: ***Hostile and disobedient behavior towards authority***
- This is the **primary characteristic of Oppositional Defiant Disorder (ODD)**, which best fits this clinical presentation
- The patient demonstrates a **pattern of angry/irritable mood, argumentative/defiant behavior** lasting 8 months with significant functional impairment (5 suspensions)
- Key ODD features present: **loses temper easily, argues with authority figures (teachers), deliberately annoys others (siblings), blames others** for his mistakes
- ODD is defined by a pattern of **negativistic, hostile, and defiant behavior** toward authority figures, not physical aggression
*Physical aggression*
- Physical aggression is **NOT a primary feature of ODD** - it would suggest **Conduct Disorder** instead
- The vignette describes **verbal defiance, arguing, and annoying behaviors**, but **no physical violence** or aggression toward people
- The anger described (getting furious) represents emotional dysregulation, not physical acting out
*Destruction of property and theft*
- These are characteristic behaviors of **Conduct Disorder**, a more severe diagnosis involving violation of societal norms
- The patient shows **oppositional behavior without property destruction or stealing**
- ODD may progress to Conduct Disorder if untreated, but this patient hasn't crossed that threshold
*Violating the rights of others*
- This is a core feature of **Conduct Disorder**, including behaviors like **bullying, intimidation, theft, or forced sexual activity**
- While the patient annoys siblings, this **doesn't constitute serious violation of basic rights** seen in Conduct Disorder
- The behavior is better characterized as **oppositional and defiant rather than rights-violating**
*Killing and/or harming small animals*
- Animal cruelty is a **serious red flag for Conduct Disorder** and potentially future antisocial behavior
- This represents **severe lack of empathy and callousness** not present in this case
- No evidence in the vignette suggests the patient engages in animal harm
Non-stimulant ADHD treatments US Medical PG Question 9: A parent-teacher conference is called to discuss the behavior of a 9 year-old boy. According to the boy's teacher, he has become progressively more disruptive during class. When asked to help clean up or read out-loud, he replies with "You're not the boss of me." or "You can't make me." He refuses to participate in gym class, but will play the same games during recess. He gets along with and is well-liked by his peers. His mother reports that her son can "sometimes be difficult," but he is helpful around the house and is very good playing with his 7-year-old sister. What is the most likely diagnosis?
- A. Conduct disorder
- B. Attention deficit disorder
- C. Separation anxiety disorder
- D. Oppositional defiant disorder (Correct Answer)
- E. Antisocial personality disorder
Non-stimulant ADHD treatments Explanation: ***Oppositional defiant disorder***
- The boy exhibits a pattern of **defiant and disobedient behavior** towards authority figures (teacher) but a generally good relationship with peers and family, which is characteristic of ODD.
- His refusal to participate in formal class activities while still engaging in informal play highlights a specific defiance towards structured rules rather than a general aversion to activity.
*Conduct disorder*
- This disorder involves a more severe pattern of **aggression, destruction of property, deceitfulness, or serious rule violations**, which are not described in the boy's behavior.
- The boy's ability to get along with peers and be helpful at home suggests he does not meet the criteria for significant social impairment or callousness seen in conduct disorder.
*Attention deficit disorder*
- This disorder is characterized by **inattention, hyperactivity, and impulsivity**, which are not the primary symptoms described here.
- While defiance might be a secondary issue, the core problem is not difficulty sustaining attention or controlling impulsive behaviors.
*Separation anxiety disorder*
- This involves **excessive fear or anxiety concerning separation from home or attachment figures**, which is not indicated by any of the behavioral descriptions.
- The boy's issues are related to defiance and authority, not fear of separation.
*Antisocial personality disorder*
- This diagnosis can only be made in individuals **18 years or older** and requires a pervasive pattern of disregard for and violation of the rights of others.
- The boy's age (9 years old) and his reported positive relationships with peers and family rule out this diagnosis.
Non-stimulant ADHD treatments US Medical PG Question 10: A 21-year-old woman presents into the clinic worried that she might be pregnant. Her last menstrual period was 4 months ago and recalls that she did have unprotected sex with her boyfriend, despite not having sexual desire. They have since broken up, and she would like to do a pregnancy test. She appears very emaciated but is physically active. She says that she spends a few hours in the gym almost every day but would spend longer if she was to stray from her diet so that she does not gain any weight. Her calculated BMI is 17 kg/m2, and her urine pregnancy test is negative. Which of the following additional findings would most likely be present in this patient?
- A. Hypocholesterolemia
- B. Orthostasis (Correct Answer)
- C. Primary amenorrhea
- D. Hypokalemic alkalosis
- E. Increased LH and FSH
Non-stimulant ADHD treatments Explanation: ***Orthostasis***
- This patient's presentation is highly suggestive of **anorexia nervosa** (BMI 17 kg/m2, amenorrhea, excessive exercise, fear of weight gain despite emaciation, and lack of sexual desire). **Orthostasis** (a drop in blood pressure upon standing) is a common finding due to **dehydration** and **volume depletion** often present in patients with anorexia nervosa.
- **Bradycardia** and **hypotension** (which contributes to orthostasis) are frequent cardiovascular complications of anorexia nervosa as the body attempts to conserve energy.
*Hypocholesterolemia*
- Patients with anorexia nervosa more commonly present with **hypercholesterolemia**, not hypocholesterolemia.
- This paradox is thought to be due to **decreased cholesterol degradation** and **impaired metabolism** in the setting of severe caloric restriction.
*Primary amenorrhea*
- The patient's last menstrual period was 4 months ago, indicating she has experienced menstruation in the past. Therefore, her amenorrhea is **secondary** (cessation of menses for 3 consecutive months in a woman who has previously menstruated), not primary (absence of menses by age 15 or within 5 years of thelarche).
- The **hypothalamic-pituitary-gonadal axis dysfunction** due to low body weight and nutritional deficiency leads to secondary amenorrhea in anorexia nervosa.
*Hypokalemic alkalosis*
- **Hypokalemic alkalosis** is typically associated with **purging behaviors** like vomiting or laxative abuse, which are characteristic of the bulimia nervosa subtype or the binge-eating/purging subtype of anorexia nervosa.
- While this patient's exercise is excessive, there is no direct evidence of purging in the provided vignette; her symptoms more strongly point towards the **restrictive subtype** of anorexia nervosa, where metabolic alkalosis is less common unless purging is also occurring.
*Increased LH and FSH*
- In anorexia nervosa, the severe caloric restriction and low body fat lead to **hypothalamic dysfunction**, specifically affecting the release of **gonadotropin-releasing hormone (GnRH)**.
- This results in **decreased production of LH and FSH** from the pituitary gland, leading to hypogonadotropic hypogonadism, which explains the amenorrhea.
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