Treatment-resistant schizophrenia US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Treatment-resistant schizophrenia. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Treatment-resistant schizophrenia US Medical PG Question 1: A 37-year-old woman presents with a 3-day history of fever. Past medical history is significant for chronic schizophrenia, managed with an antipsychotic medication. The patient has a low-grade fever and is slightly tachycardic. Physical examination is significant for the presence of tonsillar exudates. A CBC shows a markedly decreased WBC count. The patient’s antipsychotic medication is immediately discontinued. Which of the following is the antipsychotic medication that could have caused this problem?
- A. Haloperidol
- B. Risperidone
- C. Olanzapine
- D. Quetiapine
- E. Clozapine (Correct Answer)
Treatment-resistant schizophrenia Explanation: ***Clozapine***
- **Clozapine** is well-known for its rare but severe side effect of **agranulocytosis**, characterized by a marked decrease in the white blood cell count, particularly neutrophils.
- The patient's symptoms of fever, tonsillar exudates (indicating infection), and significantly decreased WBC count strongly suggest **agranulocytosis** induced by clozapine.
*Haloperidol*
- **Haloperidol** is a typical antipsychotic and is generally not associated with a high risk of agranulocytosis.
- Its primary side effects often include **extrapyramidal symptoms** and QT prolongation.
*Risperidone*
- **Risperidone** is an atypical antipsychotic with a low association with agranulocytosis.
- Common side effects include **sedation**, weight gain, and hyperprolactinemia.
*Olanzapine*
- While **olanzapine** is an atypical antipsychotic, it is not primarily associated with agranulocytosis, although it can cause other hematologic abnormalities rarely.
- It is more commonly linked to **metabolic syndrome**, significant weight gain, and sedation.
*Quetiapine*
- **Quetiapine** is another atypical antipsychotic with a very low incidence of agranulocytosis.
- Its frequent side effects include **sedation**, orthostatic hypotension, and weight gain.
Treatment-resistant schizophrenia US Medical PG Question 2: A 22-year-old male with a history of difficult-to-treat bipolar disorder with psychotic features is undergoing a medication adjustment under the guidance of his psychiatrist. The patient was previously treated with lithium and is transitioning to clozapine. Which of the following tests will the patient need routinely?
- A. Thyroid-stimulating hormone, prior to introducing the medication
- B. Basic metabolic panel, weekly
- C. Hemoglobin A1c, weekly
- D. Dexamethasone suppression test, monthly
- E. Complete blood count, weekly (Correct Answer)
Treatment-resistant schizophrenia Explanation: ***Complete blood count, weekly***
- **Clozapine** can cause **agranulocytosis** (a severe drop in white blood cell count), which is a potentially life-threatening side effect.
- Due to this risk, initial treatment with clozapine requires **weekly complete blood count (CBC)** monitoring to detect early signs of agranulocytosis.
*Thyroid-stimulating hormone, prior to introducing the medication*
- While initial thyroid function tests might be considered in the workup for bipolar disorder, routine and specific monitoring of **TSH** is not a primary requirement for **clozapine** initiation.
- **Lithium**, not clozapine, is more directly associated with thyroid dysfunction, so monitoring would be more relevant to the patient's previous medication.
*Basic metabolic panel, weekly*
- A **basic metabolic panel (BMP)** assesses **electrolyte levels**, **kidney function**, and **glucose**, which can be affected by various psychotropic medications.
- While important for overall health monitoring, a **weekly BMP** is not specifically mandated for **clozapine** due to the specific and severe risk of agranulocytosis.
*Hemoglobin A1c, weekly*
- **Clozapine** is associated with a risk of **metabolic side effects**, including **weight gain**, **dyslipidemia**, and **new-onset diabetes**.
- While **HbA1c** is used to monitor long-term glycemic control, it's typically checked less frequently (e.g., quarterly or annually) for metabolic monitoring, not weekly, and is not the primary immediate safety concern for clozapine.
*Dexamethasone suppression test, monthly*
- The **dexamethasone suppression test (DST)** is used to assess **adrenal gland function** and can be relevant in certain psychiatric conditions like **depression with melancholic features** or to rule out **Cushing's syndrome**.
- It is **not a routine monitoring test** for patients starting or on **clozapine** therapy.
Treatment-resistant schizophrenia US Medical PG Question 3: A 45-year-old obese man is evaluated in a locked psychiatric facility. He was admitted to the unit after he was caught running through traffic naked while tearing out his hair. His urine toxicology screening was negative for illicit substances and after careful evaluation and additional history, provided by his parents, he was diagnosed with schizophrenia and was treated with aripiprazole. His symptoms did not improve after several dosage adjustments and he was placed on haloperidol, but this left him too lethargic and slow and he was placed on loxapine. After several dosage adjustments today, he is still quite confused. He describes giant spiders and robots that torture him in his room. He describes an incessant voice screaming at him to run away. He also strongly dislikes his current medication and would like to try something else. Which of the following is indicated in this patient?
- A. Haloperidol
- B. Olanzapine
- C. Chlorpromazine
- D. Fluphenazine
- E. Clozapine (Correct Answer)
Treatment-resistant schizophrenia Explanation: ***Clozapine***
- This patient has **treatment-resistant schizophrenia**, indicated by a lack of response to multiple trials of antipsychotics, including aripiprazole (atypical), haloperidol (typical), and loxapine (atypical).
- **Clozapine** is the only antipsychotic proven effective for treatment-resistant schizophrenia, significantly reducing psychotic symptoms and suicidality.
*Haloperidol*
- Haloperidol is a **first-generation antipsychotic** that the patient has already tried and found to be too sedating and slow.
- Continuing with haloperidol would likely result in persistent side effects and inadequate symptom control given his prior negative experience.
*Olanzapine*
- Olanzapine is a **second-generation atypical antipsychotic**; however, it is not typically indicated as a first-line treatment for treatment-resistant schizophrenia after failure of multiple agents.
- While effective for schizophrenia, it would be less effective than clozapine in a patient who has failed several previous antipsychotic trials.
*Chlorpromazine*
- Chlorpromazine is a **first-generation antipsychotic** that carries a higher risk of sedation, extrapyramidal symptoms, and anticholinergic side effects.
- It is unlikely to be more effective than haloperidol, which the patient already found too sedating and slow, and would not be the preferred choice for treatment-resistant schizophrenia.
*Fluphenazine*
- Fluphenazine is a **first-generation antipsychotic** with potent dopamine D2 receptor blockade, often leading to significant extrapyramidal side effects.
- Like other first-generation antipsychotics, it is not indicated as the next step for treatment-resistant schizophrenia after failure of multiple trials.
Treatment-resistant schizophrenia US Medical PG Question 4: A 31-year-old woman comes to the emergency department requesting an abortion. She hears voices telling her that she needs ""to undergo a cleanse."" She experiences daytime sleepiness because she repeatedly wakes up at night. She says that she is no longer interested in activities that she used to enjoy. About 2 months ago, her psychiatrist switched her medication from aripiprazole to risperidone because it was not effective even at maximum dose. Vital signs are within normal limits. Mental status examination shows accelerated speech, and the patient regularly switches the conversation to the natural habitat of bees. A urine pregnancy test is positive. Toxicology screening is negative. Pelvic ultrasonography shows a pregnancy at an estimated 15 weeks' gestation. Following admission to the hospital, which of the following is the most appropriate next step in management?
- A. Quetiapine therapy
- B. Lithium therapy
- C. Clomipramine therapy
- D. Clozapine therapy (Correct Answer)
- E. Electroconvulsive therapy
Treatment-resistant schizophrenia Explanation: ***Clozapine therapy***
- This patient presents with **treatment-resistant psychosis** having failed aripiprazole at maximum dose and showing persistent symptoms despite 2 months on risperidone. She exhibits **auditory hallucinations**, **mood symptoms** (anhedonia, sleep disturbance), and **thought disorganization** (tangentiality), suggesting possible schizoaffective disorder.
- **Clozapine is the gold standard treatment** for schizophrenia that has failed at least two adequate trials of other antipsychotics. It is the **only FDA-approved medication** specifically indicated for treatment-resistant schizophrenia.
- While clozapine requires close monitoring for **agranulocytosis** (weekly CBC for 6 months, then biweekly), it can be used during pregnancy when benefits outweigh risks. The patient requires psychiatric stabilization, and clozapine offers the best chance of symptom control given her refractory illness.
*Electroconvulsive therapy*
- ECT is highly effective for severe psychiatric illness but is typically reserved for: **severe catatonia**, medication failures **including clozapine**, or situations requiring **rapid response** when medications are contraindicated.
- This patient has not yet tried clozapine, which should be the next step before considering ECT. She does not have catatonia (insomnia and tangentiality are not catatonic features).
- ECT would be appropriate if clozapine fails or is contraindicated, but it is not the most appropriate **next** step when a proven medication option remains untried.
*Quetiapine therapy*
- Quetiapine is another atypical antipsychotic, but simply switching to another non-clozapine antipsychotic after two failures is not the recommended approach for treatment-resistant schizophrenia.
- The patient has already failed aripiprazole and shows insufficient response to risperidone, indicating the need for clozapine rather than another trial of a conventional atypical antipsychotic.
*Lithium therapy*
- Lithium is a mood stabilizer used primarily for bipolar disorder and can be used as augmentation in treatment-resistant psychosis. However, it is **not first-line monotherapy** for psychotic symptoms.
- Lithium has **teratogenic risks** including Ebstein's anomaly when used in the first trimester, and requires careful therapeutic monitoring. Given that this patient is at 15 weeks gestation and needs antipsychotic control, clozapine monotherapy is more appropriate than introducing lithium.
*Clomipramine therapy*
- Clomipramine is a tricyclic antidepressant primarily used for **obsessive-compulsive disorder** and severe depression. It is not indicated for treatment-resistant psychosis.
- While the patient has depressive features (anhedonia, sleep disturbance), her primary presentation is psychotic with treatment resistance, requiring antipsychotic optimization rather than antidepressant therapy.
Treatment-resistant schizophrenia US Medical PG Question 5: A 35-year-old woman comes to the physician accompanied by her husband after he started noticing strange behavior. He first noticed her talking to herself 8 months ago. For the past 6 months, she has refused to eat any packaged foods out of fear that the government is trying to poison her. She has no significant past medical history. She smoked marijuana in college but has not smoked any since. She appears restless. Mental status examination shows a flat affect. Her speech is clear, but her thought process is disorganized with many loose associations. The patient is diagnosed with schizophrenia and started on olanzapine. This patient is most likely to experience which of the following adverse effects?
- A. Dyslipidemia (Correct Answer)
- B. Diabetes insipidus
- C. Agranulocytosis
- D. Myoglobinuria
- E. Seizures
Treatment-resistant schizophrenia Explanation: ***Dyslipidemia***
- **Olanzapine** is a **second-generation antipsychotic** commonly associated with significant **metabolic side effects**, including **weight gain**, **dyslipidemia**, and **insulin resistance**.
- These metabolic disturbances increase the risk of cardiovascular disease.
*Diabetes insipidus*
- This is a rare side effect, not typically associated with **olanzapine** or other **second-generation antipsychotics**.
- **Lithium** is an antimanic agent that can cause **nephrogenic diabetes insipidus**, but it is not relevant here.
*Agranulocytosis*
- While a serious side effect of some antipsychotics, **agranulocytosis** is most notably associated with **clozapine**,
- **Olanzapine** has a much lower risk of causing **agranulocytosis** compared to clozapine.
*Myoglobinuria*
- **Myoglobinuria** is associated with conditions like significant muscle damage (e.g., rhabdomyolysis).
- It is not a direct or common adverse effect of **olanzapine** therapy.
*Seizures*
- While some antipsychotics can lower the **seizure threshold**, **olanzapine** generally has a relatively low risk of inducing seizures.
- The risk is higher with certain other antipsychotics, particularly at high doses, or in patients with pre-existing seizure disorders.
Treatment-resistant schizophrenia US Medical PG Question 6: A 21-year-old man presents to an outpatient psychiatrist with chief complaints of fatigue and “hearing voices.” He describes multiple voices which sometimes call his name or say nonsensical things to him before he falls asleep at night. He occasionally awakes to see “strange people” in his room, which frighten him but then disappear. The patient is particularly worried by this because his uncle developed schizophrenia when he was in his 20s. The patient also thinks he had a seizure a few days ago, saying he suddenly fell to the ground without warning, though he remembers the episode and denied any abnormal movements during it. He is in his 3rd year of college and used to be a top student, but has been getting C and D grades over the last year, as he has had trouble concentrating and fallen asleep during exams numerous times. He denies changes in mood and has continued to sleep 8 hours per night and eat 3 meals per day recently. Which of the following medications will be most beneficial for this patient?
- A. Haloperidol
- B. Valproic acid
- C. Risperidone
- D. Modafinil (Correct Answer)
- E. Levetiracetam
Treatment-resistant schizophrenia Explanation: ***Modafinil***
- This patient presents with **narcolepsy**, characterized by the **classic tetrad**: excessive daytime sleepiness (falling asleep during exams), **cataplexy** (sudden fall without loss of consciousness or abnormal movements), **hypnagogic hallucinations** (hearing voices before sleep), and **hypnopompic hallucinations** (seeing people upon awakening).
- The hallucinations are **not true psychotic symptoms** but rather dream-like phenomena occurring at sleep-wake transitions, which are common in narcolepsy.
- **Modafinil** is a first-line **wakefulness-promoting agent** that treats the excessive daytime sleepiness and improves alertness, addressing the primary pathology.
- The patient's family history of schizophrenia is a red herring; his symptoms are explained by narcolepsy, not a primary psychotic disorder.
*Risperidone*
- Risperidone is an **atypical antipsychotic** used for schizophrenia and other psychotic disorders.
- This patient does **not have a primary psychotic disorder**—the hallucinations are hypnagogic/hypnopompic phenomena associated with narcolepsy, not true psychotic hallucinations.
- Using an antipsychotic would be inappropriate and could **worsen daytime sleepiness** due to sedating effects, exacerbating the patient's core problem.
*Haloperidol*
- Haloperidol is a **first-generation antipsychotic** with significant risk of **extrapyramidal side effects**.
- Like risperidone, it would be inappropriate here as the patient does not have a psychotic disorder, and it would worsen sedation and daytime sleepiness.
*Valproic acid*
- Valproic acid is a **mood stabilizer and anticonvulsant** used for bipolar disorder and seizure disorders.
- The described "seizure" event is actually **cataplexy** (preserved consciousness, no abnormal movements), not a true seizure, so an anticonvulsant is not indicated.
- It would not address the narcolepsy symptoms and can cause sedation.
*Levetiracetam*
- Levetiracetam is an **anticonvulsant** medication.
- The patient's description (remembering the episode, no abnormal movements) is inconsistent with a seizure and consistent with **cataplexy**, which is treated by addressing the underlying narcolepsy, not with anticonvulsants.
Treatment-resistant schizophrenia US Medical PG Question 7: A 25-year-old woman is brought to a psychiatrist's office by her husband who states that he is worried about her recent behavior, as it has become more violent. The patient's husband states that his family drove across the country to visit them and that his wife 'threatened his parents with a knife' at dinner last night. Police had to be called to calm her down. He states that she has been acting 'really crazy' for the last 9 months, and the initial behavior that caused him alarm was her admission that his deceased sister was talking to her through a decorative piece of ceramic art in the living room. Initially, he thought she was joking, but soon realized her complaints of 'hearing ghosts' talking to her throughout the house were persisting and 'getting worse'. Over the past 9 months, she has experienced multiple periods of profound sadness, with persistent insomnia and an unintentional weight loss of 12 pounds over several months. She has been complaining of feeling 'worthless' and has had markedly diminished interest in activities for much of this time period. Her general hygiene has also suffered from her recent lack of motivation and she insists that the 'ghosts' are asking her to kill as many people as she can so they won't be alone in the house. Her husband is extremely concerned that she may harm herself or someone else. He states that she currently does not take any medications or illicit drugs as far as he knows. She does not smoke or drink alcohol. The patient herself does not make eye contact or want to speak to the psychiatrist, allowing her husband to speak on her behalf. Which of the following is the most likely diagnosis in this patient?
- A. Schizophreniform disorder
- B. Schizophrenia
- C. Delusional disorder
- D. Schizoaffective disorder (Correct Answer)
- E. Brief psychotic disorder
Treatment-resistant schizophrenia Explanation: ***Schizoaffective disorder***
- This patient exhibits symptoms of both a **major depressive disorder** (multiple periods of profound **sadness**, persistent **insomnia**, **weight loss** over several months, feelings of **worthlessness**, and markedly **diminished interest in activities**) and a **psychotic disorder** (auditory **hallucinations**, command hallucinations, **delusions**, violent behavior).
- The total symptom duration is **9 months**, with **mood symptoms present for the majority of this period**, meeting the key DSM-5 criterion for schizoaffective disorder.
- The patient also demonstrates **psychotic symptoms (hallucinations) that persist throughout**, including periods when mood symptoms may fluctuate, satisfying the requirement for delusions or hallucinations for ≥2 weeks in the absence of a major mood episode.
- The combination of prominent mood episodes concurrent with schizophrenia-spectrum symptoms, with mood symptoms present for the majority of the illness duration, confirms schizoaffective disorder.
*Schizophreniform disorder*
- This disorder involves symptoms characteristic of **schizophrenia** lasting **between 1 and 6 months**.
- The patient's symptoms have been present for **9 months**, exceeding the maximum duration for schizophreniform disorder.
*Schizophrenia*
- Schizophrenia requires persistent psychotic symptoms lasting **at least 6 months**, with at least one month of active-phase symptoms.
- While this patient has psychotic symptoms for 9 months, the **prominent and prolonged depressive symptoms** that are present for the **majority of the illness duration** distinguish this from schizophrenia.
- In schizophrenia, mood symptoms, if present, are **brief relative to the total duration** of the psychotic illness, which is not the case here.
*Delusional disorder*
- Delusional disorder is characterized by **non-bizarre delusions** for at least 1 month, without other prominent psychotic symptoms.
- This patient experiences prominent **auditory hallucinations** ("hearing ghosts," "deceased sister talking to her") and **command hallucinations**, which are not features of delusional disorder.
- The presence of hallucinations rules out this diagnosis.
*Brief psychotic disorder*
- This diagnosis involves sudden onset of psychotic symptoms lasting **more than 1 day but less than 1 month**, with eventual full recovery.
- The patient's symptoms have persisted for **9 months**, far exceeding the duration criterion for brief psychotic disorder.
Treatment-resistant schizophrenia US Medical PG Question 8: A 27-year-old woman is brought to the office at the insistence of her fiancé to be evaluated for auditory hallucinations for the past 8 months. The patient’s fiancé tells the physician that the patient often mentions that she can hear her own thoughts speaking aloud to her. The hallucinations have occurred intermittently for at least 1-month periods. Past medical history is significant for hypertension. Her medications include lisinopril and a daily multivitamin both of which she frequently neglects. She lost her security job 7 months ago after failing to report to work on time. The patient’s vital signs include: blood pressure 132/82 mm Hg; pulse 72/min; respiratory rate 18/min, and temperature 36.7°C (98.1°F). On physical examination, the patient has a flat affect and her focus fluctuates from the window to the door. She is disheveled with a foul smell. She has difficulty focusing on the discussion and does not quite understand what is happening around her. A urine toxicology screen is negative. Which of the following is the correct diagnosis for this patient?
- A. Schizoaffective disorder
- B. Schizophrenia (Correct Answer)
- C. Schizoid personality disorder
- D. Schizophreniform disorder
- E. Schizotypal personality disorder
Treatment-resistant schizophrenia Explanation: ***Schizophrenia***
- The patient exhibits core symptoms of schizophrenia, including **auditory hallucinations** (hearing thoughts speaking aloud), **disorganized thinking** (difficulty focusing, fluctuating focus), and **negative symptoms** (flat affect, disheveled, foul smell, loss of job due to poor function). These symptoms have been present for **at least 6 months** (8 months of hallucinations, 7 months of job loss), which meets the diagnostic criteria.
- The duration of symptoms (over 6 months) differentiates it from schizophreniform disorder, and the absence of prominent mood episodes rules out schizoaffective disorder.
*Schizoaffective disorder*
- This diagnosis requires a **major mood episode** (depressive or manic) concurrent with Criterion A of schizophrenia, along with a period of **at least 2 weeks of delusions or hallucinations in the absence of prominent mood symptoms**.
- While the patient has some signs of distress (lost job, disorganized), a full major mood episode is not described, and the primary symptoms are clearly psychotic.
*Schizoid personality disorder*
- This is characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression, often appearing indifferent to praise or criticism.
- The patient's symptoms are primarily psychotic (hallucinations, disorganized thought), not just social withdrawal or emotional flatness. She doesn't necessarily avoid social contact, but her psychosis interferes with it.
*Schizophreniform disorder*
- This disorder presents with symptoms identical to schizophrenia but with a **duration of at least 1 month but less than 6 months**.
- The patient's symptoms, particularly the auditory hallucinations, have been present for 8 months and are therefore outside the timeframe for schizophreniform disorder.
*Schizotypal personality disorder*
- This disorder involves a pervasive pattern of **social and interpersonal deficits** marked by acute discomfort with, and reduced capacity for, close relationships, as well as **cognitive or perceptual distortions** and eccentric behaviors.
- While there may be some odd beliefs or magical thinking, **full-blown psychotic symptoms like prominent auditory hallucinations** (hearing thoughts speaking aloud) are generally not present as consistently or severely as seen in this patient, who meets criteria for a major psychotic disorder.
Treatment-resistant schizophrenia US Medical PG Question 9: A 36-year-old woman with schizophrenia comes to the office for a follow-up appointment. She has been hospitalized 4 times in the past year, and she has failed to respond to multiple trials of antipsychotic medications. Six weeks ago, she was brought to the emergency department by her husband because of a bizarre behavior, paranoid delusions, and hearing voices that others did not hear. She was started on a new medication, and her symptoms have improved. Laboratory studies show:
Hemoglobin 13.8 g/dL
Leukocyte count 1,200/mm3
Segmented neutrophils 6%
Eosinophils 0%
Lymphocytes 92%
Monocytes 2%
Platelet count 245,000/mm3
This patient was most likely started on which of the following medications?
- A. Clozapine (Correct Answer)
- B. Promethazine
- C. Fluphenazine
- D. Lithium
- E. Quetiapine
Treatment-resistant schizophrenia Explanation: ***Clozapine***
- The patient's presentation of **treatment-resistant schizophrenia** (failure to respond to multiple antipsychotics and recurrent hospitalizations) strongly points to clozapine as the most likely effective treatment.
- The abnormal lab results, particularly **leukopenia** (total WBC 1,200/mm³) and severe **neutropenia** (segmented neutrophils 6%, absolute neutrophil count ~72/mm³), are a known and serious side effect of clozapine, requiring careful monitoring.
*Promethazine*
- Promethazine is an **antihistamine** with antiemetic and sedative properties, not a primary antipsychotic for schizophrenia.
- It would not be used for chronic management of severe, treatment-resistant schizophrenia and is not associated with the severe hematological side effects seen here.
*Fluphenazine*
- Fluphenazine is a **first-generation antipsychotic** that could be used for schizophrenia, but the patient's history indicates failure of multiple antipsychotic trials.
- While it can cause some side effects, severe leukopenia and neutropenia to the degree seen here are not characteristic of fluphenazine.
*Lithium*
- Lithium is a **mood stabilizer** primarily used for bipolar disorder, not typical first-line or even second-line treatment for schizophrenia as a monotherapy.
- Notably, lithium typically causes **leukocytosis** (increased WBC count), not leukopenia, making it inconsistent with the lab findings showing severe leukopenia and neutropenia.
*Quetiapine*
- Quetiapine is a **second-generation antipsychotic** that is used for schizophrenia, but it is less effective for treatment-resistant cases compared to clozapine.
- While some antipsychotics can cause mild hematologic changes, quetiapine is not known for causing the profound leukopenia and severe neutropenia seen in this patient, which are distinctly associated with clozapine.
Treatment-resistant schizophrenia US Medical PG Question 10: A 32-year-old man is brought to the emergency department with fever, dyspnea, and impaired consciousness. His wife reports that he has also had an episode of dark urine today. Two weeks ago, he returned from a trip to the Republic of Congo. His temperature is 39.4°C (103°F), pulse is 114/min, and blood pressure is 82/51 mm Hg. Physical examination shows scleral icterus. Decreased breath sounds and expiratory crackles are heard on auscultation of the lungs bilaterally. His hemoglobin concentration is 6.3 g/dL. A blood smear shows red blood cells with normal morphology and ring-shaped inclusions. Further laboratory testing shows normal rates of NADPH production. Which of the following is the most appropriate pharmacotherapy for this patient?
- A. Proguanil
- B. Dapsone
- C. Chloroquine
- D. Artesunate (Correct Answer)
- E. Atovaquone
Treatment-resistant schizophrenia Explanation: ***Artesunate***
- This patient presents with **severe malaria**, indicated by fever, impaired consciousness, hypotension, dyspnea, dark urine (hemoglobinuria), scleral icterus (hemolysis), and anemia, following travel to an endemic area (Republic of Congo). The blood smear finding of **ring-shaped inclusions** with normal red cell morphology is characteristic of **Plasmodium falciparum** infection.
- **Artesunate** is the drug of choice for **severe malaria** due to its rapid parasitic clearance and superior efficacy compared to other antimalarials, especially in regions with high chloroquine resistance, as is typical in the Republic of Congo for *P. falciparum*.
*Proguanil*
- Proguanil is primarily used in **malaria prophylaxis** or in combination with other drugs (e.g., atovaquone-proguanil) for uncomplicated malaria.
- It is not indicated as monotherapy for **severe *P. falciparum* malaria**, nor is it suitable for emergency treatment of life-threatening infections.
*Dapsone*
- Dapsone is an **antibiotic** primarily used in the treatment of **leprosy** and prevention of *Pneumocystis jirovecii* pneumonia or toxoplasmosis in immunocompromised patients.
- It has **no significant role** in the treatment of malaria, especially severe *P. falciparum* infection.
*Chloroquine*
- Chloroquine was historically a first-line treatment for malaria but is largely ineffective against **chloroquine-resistant *P. falciparum***, which is widely prevalent in the Republic of Congo and contributes to severe disease.
- Administering chloroquine in this context would likely lead to **treatment failure** and worsening of the patient's severe condition.
*Atovaquone*
- Atovaquone, usually combined with proguanil (Malarone), is effective for **uncomplicated malaria** and prophylaxis.
- However, it is **not the preferred agent for severe malaria** due to slower action and lack of intravenous formulation for initial critical management.
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