A 24-year-old man who is postoperative day 1 after an emergency appendectomy is evaluated by the team managing his care. He complains that he still has not been able to urinate after removal of the urinary catheter that was inserted during surgery. Given this issue, he is started on a medication that acts on a post-synaptic receptor and is resistant to a synaptic esterase. Which of the following is most likely another use of the medication that was administered in this case?
Q162
A 67-year-old man presents to the emergency department acutely confused. The patient's wife found him mumbling incoherently in the kitchen this morning as they were preparing for a hike. The patient was previously healthy and only had a history of mild forgetfulness, depression, asthma, and seasonal allergies. His temperature is 98.5°F (36.9°C), blood pressure is 122/62 mmHg, pulse is 119/min, and oxygen saturation is 98% on room air. The patient is answering questions inappropriately and seems confused. Physical exam is notable for warm, flushed, and dry skin. The patient's pupils are dilated. Which of the following is also likely to be found in this patient?
Q163
A 71-year-old male is admitted to the hospital with a Staphylococcal aureus infection of his decubitus ulcers. He is diabetic and has a body mass index of 45. His temperature is 37°C (98.6°F), respirations are 15/min, pulse is 67/min and blood pressure is 122/98 mm Hg. The nurse is monitoring his blood glucose and records it as 63 mg/dL. She then asks the resident on call if the patient should receive glargine insulin as ordered seeing his glucose levels. Which of the following would be the most appropriate response by the resident?
Q164
A 53-year-old woman presented to her PCP with one week of difficulty falling asleep, despite having good sleep hygiene. She denies changes in her mood, weight loss, and anhedonia. She has had difficulty concentrating and feels tired throughout the day. Recently, she was fired from her previous job. What medication would be most helpful for this patient?
Q165
A 54-year-old man comes to the emergency department because of burning oral mucosal pain, chest pain, and shortness of breath that started one hour ago. He reports that the pain is worse when swallowing. Two years ago, he was diagnosed with major depressive disorder but does not adhere to his medication regimen. He lives alone and works as a farmer. He smokes 1 pack of cigarettes and drinks 6 oz of homemade vodka daily. The patient is oriented to person, place, and time. His pulse is 95/min, respirations are 18/min, and blood pressure is 130/85 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. Examination of the oropharynx shows profuse salivation with mild erythema of the buccal mucosa, tongue, and epiglottis area. This patient has most likely sustained poisoning by which of the following substances?
Q166
A 43-year-old man is brought to the emergency department 45 minutes after his wife found him on the floor sweating profusely. On arrival, he is lethargic and unable to provide a history. He vomited multiple times on the way to the hospital. His temperature is 37.3°C (99.1°F), pulse is 55/min, respirations are 22/min, and blood pressure is 98/65 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 80%. Examination shows profuse diaphoresis and excessive salivation. He withdraws his extremities sluggishly to pain. The pupils are constricted and reactive. Scattered expiratory wheezing and rhonchi are heard throughout both lung fields. Cardiac examination shows no abnormalities. There are fine fasciculations in the lower extremities bilaterally. Muscle strength is reduced and deep tendon reflexes are 1+ bilaterally. His clothes are soaked with urine and feces. Which of the following is the mechanism of action of the most appropriate initial pharmacotherapy?
Q167
A 22-year-old man, accompanied by his brother, presents to the emergency department with palpitations for the past 30 minutes and nausea for the past hour. When the patient meets the physician, he says, “Doctor, I am the happiest person in the world because I have the best brain possible. It’s just that my heart is saying something, so I came to check with you to see what it is”. The brother says the patient was diagnosed with attention-deficit/hyperactivity disorder (ADHD) 5 years ago. When the doctor asks the patient about his ADHD treatment, he replies, “Doctor, the medicine is wonderful, and I love it very much. I often take one or two tablets extra!” He has no history of a known cardiovascular disorder, alcohol abuse, or smoking. The patient’s temperature is 99.2ºF (37.3ºC), heart rate is 116/minute, respiratory rate is 18/minute, and blood pressure is 138/94 mm Hg. Generalized perspiration is present. Which of the following signs is most likely to be present on ocular examination?
Q168
A 46-year-old female with estrogen receptor positive invasive ductal carcinoma is prescribed tamoxifen. Which of the following is the MOST concerning side effect that requires patient counseling regarding potentially life-threatening complications?
Q169
A 34-year-old male presents to clinic today complaining that his medication has stopped working. He states despite being able to manage the side effects, a voice has returned again telling him to hurt his Mother. You prescribe him a drug which has shown improved efficacy in treating his disorder but requires frequent followup visits. One week later he returns with the following lab results: WBC : 2500 cells/mcL, Neutrophils : 55% and, Bands : 1%. What drug was this patient prescribed?
Q170
A 60-year-old woman and her son are visited at her home by a health aid. He is her caregiver but has difficulty getting her out of the house. Her son is concerned about continuous and repetitive mouth and tongue movements that started about 2 weeks ago and have become more evident ever since. She is non-verbal at baseline and can complete most activities of daily living. She suffers from an unspecified psychiatric disorder. Her medications include fluphenazine. Today, her heart rate is 90/min, respiratory rate is 17/min, blood pressure is 125/87 mm Hg, and temperature is 37.0°C (98.6°F). On physical exam, she appears gaunt and anxious. She is drooling and her mouth is making a chewing motion that is occasionally disrupted by wagging her tongue back and forth. She seems to be performing these motions absentmindedly. Her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally. CMP, CBC, and TSH are normal. A urine toxicology test is negative. What is the next best step in her management?
Cholinergic/Adrenergic drugs US Medical PG Practice Questions and MCQs
Question 161: A 24-year-old man who is postoperative day 1 after an emergency appendectomy is evaluated by the team managing his care. He complains that he still has not been able to urinate after removal of the urinary catheter that was inserted during surgery. Given this issue, he is started on a medication that acts on a post-synaptic receptor and is resistant to a synaptic esterase. Which of the following is most likely another use of the medication that was administered in this case?
A. Glaucoma management
B. Bronchial airway challenge test
C. Pupillary contraction
D. Neurogenic ileus (Correct Answer)
E. Diagnosis of myasthenia gravis
Explanation: ***Neurogenic ileus***
- The medication described is **bethanechol**, a direct-acting muscarinic agonist that acts on post-synaptic M3 receptors and is **resistant to acetylcholinesterase** (unlike acetylcholine)
- Bethanechol is used for **post-operative urinary retention** by stimulating detrusor muscle contraction and relaxing the trigone and sphincter
- Another major clinical use is treating **neurogenic ileus** and post-operative ileus by stimulating GI smooth muscle motility and increasing peristalsis
- It directly activates muscarinic receptors on bladder and GI smooth muscle
*Diagnosis of myasthenia gravis*
- This is **incorrect** - bethanechol is NOT used for myasthenia gravis diagnosis
- **Edrophonium** (Tensilon test) or **neostigmine** are used for MG diagnosis - these are acetylcholinesterase inhibitors, not direct muscarinic agonists
- Bethanechol's mechanism (direct muscarinic agonist) would not effectively test for nicotinic receptor antibodies at the neuromuscular junction
*Glaucoma management*
- While some muscarinic agonists are used in glaucoma (e.g., **pilocarpine**), bethanechol is not typically used for this indication
- Pilocarpine reduces intraocular pressure by contracting the ciliary muscle and increasing aqueous humor outflow
- Bethanechol's systemic effects and lack of ocular specificity make it unsuitable for glaucoma management
*Bronchial airway challenge test*
- **Methacholine**, not bethanechol, is the muscarinic agonist used for bronchial provocation testing in asthma diagnosis
- While bethanechol can cause bronchoconstriction, it is not standardized or used for airway challenge tests
- Methacholine has better-characterized dose-response relationships for pulmonary function testing
*Pupillary contraction*
- While muscarinic agonists cause miosis (pupillary contraction), this is a **side effect** rather than a therapeutic indication for bethanechol
- Direct application of muscarinic agonists to the eye (like pilocarpine) would be used if miosis were the goal
- Bethanechol is given systemically for bladder and GI indications, not for ophthalmologic purposes
Question 162: A 67-year-old man presents to the emergency department acutely confused. The patient's wife found him mumbling incoherently in the kitchen this morning as they were preparing for a hike. The patient was previously healthy and only had a history of mild forgetfulness, depression, asthma, and seasonal allergies. His temperature is 98.5°F (36.9°C), blood pressure is 122/62 mmHg, pulse is 119/min, and oxygen saturation is 98% on room air. The patient is answering questions inappropriately and seems confused. Physical exam is notable for warm, flushed, and dry skin. The patient's pupils are dilated. Which of the following is also likely to be found in this patient?
A. Hypoventilation
B. QRS widening
C. Coronary artery vasospasm
D. Increased bronchial secretions
E. Urinary retention (Correct Answer)
Explanation: ***Urinary retention***
- The patient's symptoms (dilated pupils, warm/flushed/dry skin, confusion, tachycardia) are consistent with **anticholinergic toxidrome**.
- **Urinary retention** is a common manifestation of anticholinergic toxicity due to the paralysis of the detrusor muscle and contraction of the urethral sphincter.
*Hypoventilation*
- Anticholinergic toxicity typically causes **tachycardia** and may lead to tachypnea, not hypoventilation.
- Respiratory depression is more characteristic of **opioid** or **sedative-hypnotic** overdose.
*QRS widening*
- **QRS widening** is characteristic of **sodium channel blockade**, as seen with tricyclic antidepressant overdose, which can have anticholinergic effects but primarily causes cardiac toxicity via sodium channel blockade.
- While anticholinergics can cause arrhythmias, QRS widening specific to this mechanism isn't a primary feature of pure anticholinergic toxidrome.
*Coronary artery vasospasm*
- **Coronary artery vasospasm** is not a direct effect of anticholinergic toxicity.
- It is more commonly associated with drug use such as **cocaine**, or certain medications like **5-fluorouracil**.
*Increased bronchial secretions*
- Anticholinergic agents **decrease bronchial secretions** by blocking muscarinic receptors in the airway smooth muscle and glands.
- Increased bronchial secretions are characteristic of **cholinergic overdose**.
Question 163: A 71-year-old male is admitted to the hospital with a Staphylococcal aureus infection of his decubitus ulcers. He is diabetic and has a body mass index of 45. His temperature is 37°C (98.6°F), respirations are 15/min, pulse is 67/min and blood pressure is 122/98 mm Hg. The nurse is monitoring his blood glucose and records it as 63 mg/dL. She then asks the resident on call if the patient should receive glargine insulin as ordered seeing his glucose levels. Which of the following would be the most appropriate response by the resident?
A. No, due to his S. aureus infection he is more likely to have low blood glucose and glargine insulin should be held until he has recovered.
B. No, glargine insulin was probably ordered in error as it is not recommended in type 2 diabetes.
C. No, glargine insulin should be stopped and replaced with lispro insulin until his blood glucose increases.
D. Yes, glargine insulin is a long-acting insulin and should still be given to control his blood glucose over the next 24 hours.
E. No, glargine insulin should not be given during an episode of hypoglycemia as it will further lower blood glucose. (Correct Answer)
Explanation: ***No, glargine insulin should not be given during an episode of hypoglycemia as it will further lower blood glucose.***
- The patient's blood glucose is **63 mg/dL**, which is **hypoglycemic** (typically defined as <70 mg/dL). Administering additional long-acting insulin like glargine would further decrease blood glucose and potentially cause serious harm.
- **Glargine insulin** is a **long-acting basal insulin** designed to provide a steady release of insulin over 24 hours. While crucial for long-term glucose control, it should be held during acute hypoglycemic episodes to prevent severe glucose drops.
*No, due to his S. aureus infection he is more likely to have low blood glucose and glargine insulin should be held until he has recovered.*
- Infections, especially severe ones, cause **physiological stress** and typically lead to **increased blood glucose levels** due to elevated counter-regulatory hormones, not lower levels.
- While insulin should be held during a hypoglycemic episode, the reasoning given here regarding infection causing low blood glucose is generally incorrect; infections usually cause hyperglycemia.
*No, glargine insulin was probably ordered in error as it is not recommended in type 2 diabetes.*
- **Glargine insulin** is a commonly used and **effective basal insulin** for managing type 2 diabetes, especially when oral agents or other shorter-acting insulins are insufficient.
- Basal insulin, like glargine, is a cornerstone in the treatment of many patients with **type 2 diabetes** to maintain stable glucose levels overnight and between meals.
*No, glargine insulin should be stopped and replaced with lispro insulin until his blood glucose increases.*
- **Lispro insulin** is a **rapid-acting insulin** used to cover meals or correct acute hyperglycemia; it is not a direct replacement for basal insulin like glargine, particularly in a hypoglycemic state.
- **Stopping glargine** during hypoglycemia is correct, but replacing it with another insulin, especially rapid-acting, without addressing the hypoglycemia and understanding the cause would be inappropriate and potentially dangerous.
*Yes, glargine insulin is a long-acting insulin and should still be given to control his blood glucose over the next 24 hours.*
- While glargine is a long-acting insulin, administering it during an active state of **hypoglycemia (63 mg/dL)** is not appropriate, as it would worsen the low blood sugar.
- The immediate priority in hypoglycemia is to **safely raise blood glucose**, not to administer more insulin, regardless of its duration of action.
Question 164: A 53-year-old woman presented to her PCP with one week of difficulty falling asleep, despite having good sleep hygiene. She denies changes in her mood, weight loss, and anhedonia. She has had difficulty concentrating and feels tired throughout the day. Recently, she was fired from her previous job. What medication would be most helpful for this patient?
A. Citalopram
B. Diphenhydramine
C. Quetiapine
D. Diazepam
E. Zolpidem (Correct Answer)
Explanation: ***Zolpidem***
- This patient presents with **insomnia** characterized by **difficulty falling asleep**, which is the primary indication for zolpidem.
- Zolpidem is a **non-benzodiazepine GABA-A receptor agonist** that acts quickly to induce sleep, making it effective for sleep onset insomnia.
*Citalopram*
- **Citalopram** is an **SSRI** primarily used for treating depression and anxiety disorders, which are not explicitly indicated as primary issues for this patient.
- While it can sometimes help with sleep in depressed patients, its **onset of action is slow** (weeks), and it is not a first-line agent for acute insomnia.
*Diphenhydramine*
- **Diphenhydramine** is an **antihistamine** with sedative properties, often used for occasional insomnia, but it can lead to significant **daytime sedation, anticholinergic side effects**, and is generally not recommended for chronic use.
- The patient's presentation suggests a need for more targeted and potentially long-term management beyond an over-the-counter antihistamine.
*Quetiapine*
- **Quetiapine** is an **antipsychotic** medication that is sometimes used off-label for insomnia due to its sedative effects, but it carries significant **side effects** like metabolic syndrome, orthostatic hypotension, and tardive dyskinesia.
- It is generally **not recommended as a first-line treatment for insomnia** without co-occurring psychiatric conditions like bipolar disorder or schizophrenia.
*Diazepam*
- **Diazepam** is a **benzodiazepine** that can be used for insomnia, but it has a **long half-life** leading to daytime sedation and a **high potential for dependence and abuse**.
- Its use should be limited to short-term treatment of severe insomnia and is generally avoided in patients who deny mood changes and anhedonia, suggesting a less complex underlying issue.
Question 165: A 54-year-old man comes to the emergency department because of burning oral mucosal pain, chest pain, and shortness of breath that started one hour ago. He reports that the pain is worse when swallowing. Two years ago, he was diagnosed with major depressive disorder but does not adhere to his medication regimen. He lives alone and works as a farmer. He smokes 1 pack of cigarettes and drinks 6 oz of homemade vodka daily. The patient is oriented to person, place, and time. His pulse is 95/min, respirations are 18/min, and blood pressure is 130/85 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. Examination of the oropharynx shows profuse salivation with mild erythema of the buccal mucosa, tongue, and epiglottis area. This patient has most likely sustained poisoning by which of the following substances?
A. Morphine
B. Amitriptyline
C. Parathion
D. Potassium hydroxide (Correct Answer)
E. Ethylene glycol
Explanation: ***Potassium hydroxide***
- The patient's symptoms of **burning oral mucosal pain**, worse with swallowing, along with **profuse salivation** and **erythema of the oropharynx**, are highly suggestive of a **caustic injury**.
- **Potassium hydroxide** is a strong alkali that causes liquefactive necrosis, leading to deep penetrating injuries of the esophageal and gastric mucosa.
*Morphine*
- **Morphine** is an opioid that typically causes **central nervous system depression**, pinpoint pupils, and respiratory depression.
- It does not cause localized burning pain or mucosal irritation as described.
*Amitriptyline*
- **Amitriptyline** is a tricyclic antidepressant; an overdose would likely present with anticholinergic effects like **tachycardia**, **mydriasis**, **dry mouth**, and potential cardiac arrhythmias.
- It would not cause burning oral pain and erythema.
*Parathion*
- **Parathion** is an organophosphate insecticide that causes cholinergic crisis with symptoms such as **salivation**, lacrimation, urination, defecation, gastrointestinal upset, and emesis (**SLUDGE** syndrome).
- While salivation is present, the absence of other prominent cholinergic signs (e.g., miosis, muscle fasciculations, bradycardia) and the highly localized burning pain make it less likely than a caustic injury.
*Ethylene glycol*
- **Ethylene glycol** poisoning typically presents with **metabolic acidosis**, renal failure, and CNS depression.
- Immediate symptoms are often related to CNS effects (e.g., inebriation) and cardiopulmonary symptoms, not acute oral mucosal burning.
Question 166: A 43-year-old man is brought to the emergency department 45 minutes after his wife found him on the floor sweating profusely. On arrival, he is lethargic and unable to provide a history. He vomited multiple times on the way to the hospital. His temperature is 37.3°C (99.1°F), pulse is 55/min, respirations are 22/min, and blood pressure is 98/65 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 80%. Examination shows profuse diaphoresis and excessive salivation. He withdraws his extremities sluggishly to pain. The pupils are constricted and reactive. Scattered expiratory wheezing and rhonchi are heard throughout both lung fields. Cardiac examination shows no abnormalities. There are fine fasciculations in the lower extremities bilaterally. Muscle strength is reduced and deep tendon reflexes are 1+ bilaterally. His clothes are soaked with urine and feces. Which of the following is the mechanism of action of the most appropriate initial pharmacotherapy?
A. Non-selective α-adrenergic antagonism
B. Competitive antagonism of mACh receptors (Correct Answer)
C. Alkaloid emesis-induction
D. Enteral binding
E. Urine alkalization
Explanation: ***Competitive antagonism of mACh receptors***
- The patient's symptoms, including **profuse sweating, salivation, constricted pupils, wheezing, bradycardia, hypotension, fasciculations**, and incontinence, are classic signs of **cholinergic crisis** due to **organophosphate poisoning**.
- **Atropine**, a competitive antagonist of muscarinic acetylcholine (mACh) receptors, is the primary initial pharmacotherapy for organophosphate poisoning, counteracting the excessive parasympathetic stimulation.
*Non-selective α-adrenergic antagonism*
- This mechanism would typically be used to treat conditions involving **excessive alpha-adrenergic activity**, such as a pheochromocytoma or severe hypertension.
- It would **worsen the hypotension** already present in this patient and does not address the underlying cholinergic overstimulation.
*Alkaloid emesis-induction*
- While vomiting occurred, inducing further emesis with an alkaloid is **contraindicated** in cases of organophosphate poisoning due to the risk of **aspiration pneumonitis** and the patient's altered mental status.
- Furthermore, modern management of poisoning rarely recommends routine emesis induction.
*Enteral binding*
- **Activated charcoal** acts by enteral binding to prevent absorption of toxins from the gastrointestinal tract.
- While it may be considered in some poisonings, the rapid onset of severe symptoms and the potential for aspiration in a lethargic patient makes **airway protection** and **antidote administration** the immediate priorities.
*Urine alkalization*
- Urine alkalization is a technique used to enhance the renal excretion of certain acidic drugs by increasing their ionization in the urine, preventing reabsorption.
- It is **not relevant** for the initial management of organophosphate poisoning, which primarily requires anticholinergic agents and cholinesterase reactivators.
Question 167: A 22-year-old man, accompanied by his brother, presents to the emergency department with palpitations for the past 30 minutes and nausea for the past hour. When the patient meets the physician, he says, “Doctor, I am the happiest person in the world because I have the best brain possible. It’s just that my heart is saying something, so I came to check with you to see what it is”. The brother says the patient was diagnosed with attention-deficit/hyperactivity disorder (ADHD) 5 years ago. When the doctor asks the patient about his ADHD treatment, he replies, “Doctor, the medicine is wonderful, and I love it very much. I often take one or two tablets extra!” He has no history of a known cardiovascular disorder, alcohol abuse, or smoking. The patient’s temperature is 99.2ºF (37.3ºC), heart rate is 116/minute, respiratory rate is 18/minute, and blood pressure is 138/94 mm Hg. Generalized perspiration is present. Which of the following signs is most likely to be present on ocular examination?
A. Bilateral optic disc edema
B. Conjunctival injection
C. Bilateral foveal yellow spots
D. Rotatory nystagmus
E. Dilated pupils (Correct Answer)
Explanation: ***Dilated pupils***
- This patient presents with symptoms such as **palpitations, nausea, hypertension, tachycardia, and generalized perspiration** following an overdose of his ADHD medication. This strongly suggests **sympathomimetic toxicity**, likely due to stimulant overdose.
- **Stimulants** like those used for ADHD (e.g., methylphenidate, amphetamines) characteristically cause **mydriasis (dilated pupils)** due to their sympathomimetic effects on the autonomic nervous system.
*Bilateral optic disc edema*
- **Bilateral optic disc edema** is typically associated with **increased intracranial pressure**, not directly with sympathomimetic stimulant overdose.
- While hypertension is present, it's usually **severe and prolonged hypertension** that can lead to hypertensive retinopathy and disc edema, which is not the primary ocular sign of acute stimulant toxicity.
*Conjunctival injection*
- **Conjunctival injection (red eyes)** is often seen in conditions like **allergic conjunctivitis, viral conjunctivitis, bacterial conjunctivitis, or glaucoma**, and is also a common sign of **cannabis use**.
- It is **not a typical finding in sympathomimetic stimulant overdose**, which primarily affects adrenergic receptors leading to pupillary dilation.
*Bilateral foveal yellow spots*
- **Bilateral foveal yellow spots** can be a non-specific finding or associated with conditions like **macular degeneration**, certain **retinal dystrophies**, or **tamoxifen retinopathy**.
- This finding is **not characteristic of acute stimulant toxicity** or its cardiovascular effects.
*Rotatory nystagmus*
- **Rotatory nystagmus** is an involuntary eye movement typically associated with **vestibular dysfunction, cerebellar lesions, or certain drug toxicities (e.g., phencyclidine, anticonvulsants)**.
- While some drug intoxications can cause nystagmus, **stimulant overdose typically does not produce rotatory nystagmus** as a primary ocular sign, rather it affects pupillary size.
Question 168: A 46-year-old female with estrogen receptor positive invasive ductal carcinoma is prescribed tamoxifen. Which of the following is the MOST concerning side effect that requires patient counseling regarding potentially life-threatening complications?
A. Increased risk of deep vein thrombosis (Correct Answer)
B. Hot flashes and menopausal symptoms
C. Improved bone density in postmenopausal women
D. Increased risk of endometrial cancer
E. Increased risk of hypertension
Explanation: ***Increased risk of deep vein thrombosis***
- Tamoxifen, a **selective estrogen receptor modulator (SERM)**, has estrogen receptor agonist effects in some tissues, including the coagulation system.
- This can lead to an increased risk of **thromboembolic events**, such as **deep vein thrombosis (DVT)** and **pulmonary embolism (PE)**, which are potentially life-threatening cardiovascular/hematologic complications.
*Hot flashes and menopausal symptoms*
- While tamoxifen commonly causes **hot flashes**, night sweats, and vaginal dryness due to its anti-estrogenic effects in the hypothalamus and vaginal tissue, these are generally a quality-of-life issue and not the **most concerning cardiovascular/hematologic side effect** requiring immediate intervention or counseling regarding life-threatening complications.
- These symptoms are usually manageable and anticipated but do not pose the same acute danger as a thromboembolic event.
*Improved bone density in postmenopausal women*
- Tamoxifen has **estrogen-agonist effects on bone**, leading to improved bone mineral density in postmenopausal women.
- This is generally considered a **beneficial side effect** rather than a concerning one, especially in women at risk for osteoporosis.
*Increased risk of hypertension*
- While cardiovascular side effects can occur with tamoxifen, a significantly increased risk of **hypertension** is not one of its primary or most concerning cardiovascular/hematologic complications.
- Blood pressure needs to be monitored, but DVT/PE risk is a far greater concern.
*Increased risk of endometrial cancer*
- Tamoxifen has **estrogen-agonist effects on the endometrium**, increasing the risk of **endometrial hyperplasia** and **endometrial cancer**.
- While this is a serious and well-known side effect that requires patient counseling and monitoring, it is an oncologic complication, not a cardiovascular or hematologic one.
Question 169: A 34-year-old male presents to clinic today complaining that his medication has stopped working. He states despite being able to manage the side effects, a voice has returned again telling him to hurt his Mother. You prescribe him a drug which has shown improved efficacy in treating his disorder but requires frequent followup visits. One week later he returns with the following lab results: WBC : 2500 cells/mcL, Neutrophils : 55% and, Bands : 1%. What drug was this patient prescribed?
A. Clozapine (Correct Answer)
B. Lurasidone
C. Olanzapine
D. Chlorpromazine
E. Haloperidol
Explanation: ***Clozapine***
- **Clozapine** is an atypical antipsychotic known for its superior efficacy in **treatment-resistant schizophrenia**, which fits the patient's presentation of a recurrence of symptoms despite prior medication.
- The given lab results (WBC 2500 cells/mcL, Neutrophils 55%, Bands 1%) show signs of **neutropenia**, a severe side effect of clozapine that necessitates frequent monitoring of complete blood counts (CBCs).
*Lurasidone*
- **Lurasidone** is an atypical antipsychotic, but it is not typically considered a first-line treatment for treatment-resistant cases and does not carry the same risk of agranulocytosis requiring frequent CBC monitoring as clozapine.
- It would not explain the **observed neutropenia** and the need for frequent follow-up for blood work.
*Olanzapine*
- While **olanzapine** is an effective atypical antipsychotic, it is not uniquely indicated for treatment-resistant cases in the same way clozapine is, nor does it typically require the intensive hematological monitoring.
- Its main severe side effects are metabolic (e.g., weight gain, dyslipidemia), not **neutropenia** that would manifest in these lab results.
*Chlorpromazine*
- **Chlorpromazine** is a first-generation antipsychotic and, while effective, is not known for superior efficacy in treatment-resistant cases compared to clozapine and has a different side effect profile.
- It can cause **agranulocytosis** but is not the drug of choice for treatment-resistant schizophrenia and its side effect profile does not align.
*Haloperidol*
- **Haloperidol** is a potent first-generation antipsychotic, effective for acute psychosis, but less effective for negative symptoms and carries a high risk of extrapyramidal side effects.
- It is not typically chosen for treatment-resistant cases and does not cause the specific hematological issues seen in the lab results that would necessitate weekly follow-up for blood counts.
Question 170: A 60-year-old woman and her son are visited at her home by a health aid. He is her caregiver but has difficulty getting her out of the house. Her son is concerned about continuous and repetitive mouth and tongue movements that started about 2 weeks ago and have become more evident ever since. She is non-verbal at baseline and can complete most activities of daily living. She suffers from an unspecified psychiatric disorder. Her medications include fluphenazine. Today, her heart rate is 90/min, respiratory rate is 17/min, blood pressure is 125/87 mm Hg, and temperature is 37.0°C (98.6°F). On physical exam, she appears gaunt and anxious. She is drooling and her mouth is making a chewing motion that is occasionally disrupted by wagging her tongue back and forth. She seems to be performing these motions absentmindedly. Her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally. CMP, CBC, and TSH are normal. A urine toxicology test is negative. What is the next best step in her management?
A. Reduce the dosage
B. Stop the medication (Correct Answer)
C. Start clozapine
D. Switch to chlorpromazine
E. Expectant management
Explanation: ***Stop the medication***
- The patient is presenting with symptoms of **tardive dyskinesia**, characterized by **involuntary, repetitive movements**, often involving the face (e.g., lip smacking, tongue protrusion, chewing motions), which are a known side effect of long-term use of **first-generation antipsychotics** like fluphenazine.
- The recommended management for drug-induced tardive dyskinesia is to discontinue the offending medication if possible, especially given the severity and recent onset of symptoms.
*Reduce the dosage*
- While dosage reduction might be considered in some side effects, for established **tardive dyskinesia**, simply reducing the dose of the causative agent often does not halt the progression or alleviate symptoms effectively and may even worsen them in some cases.
- The goal is to remove the underlying cause to prevent further neurological damage and potentially reverse the symptoms.
*Start clozapine*
- **Clozapine** is an atypical (second-generation) antipsychotic that is sometimes used in the management of severe tardive dyskinesia because it has a **lower risk of causing extrapyramidal symptoms** and can sometimes ameliorate existing ones.
- However, the initial step should be to remove the offending agent (fluphenazine) before introducing a new medication, especially one with its own significant side effect profile like agranulocytosis.
*Switch to chlorpromazine*
- **Chlorpromazine** is also a **first-generation antipsychotic** and carries a significant risk of causing **extrapyramidal symptoms and tardive dyskinesia**, similar to fluphenazine.
- Switching to another first-generation antipsychotic would not address the root cause of the tardive dyskinesia and would likely continue or worsen the symptoms.
*Expectant management*
- **Expectant management** (watching and waiting) is inappropriate for tardive dyskinesia because the condition can be **permanent** and worsen over time if the causative medication is continued.
- Prompt intervention by discontinuing the culprit drug is crucial to prevent irreversible symptoms and improve the patient's quality of life.
