An 18-year-old man presents to the student health department at his university for recurrent palpitations. The patient had previously presented to the emergency department (ED) for sudden onset palpitations five months ago when he first started college. He had a negative cardiac workup in the ED and he was discharged with a 24-hour Holter monitor which was also negative. He has no history of any medical or psychiatric illnesses. The patient reports that since his initial ED visit, he has had several episodes of unprovoked palpitations associated with feelings of dread and lightheadedness though he cannot identify a particular trigger. Recently, he has begun sitting towards the back of the lecture halls so that he can “quickly escape and not make a scene” in case he gets an episode in class. Which of the following is the most likely diagnosis?
Q32
During a psychotherapy session, a psychiatrist notes transference. Which of the following is an example of this phenomenon?
Q33
A 45-year-old woman presents to her primary care physician with complaints of muscle pains, poor sleep, and daytime fatigue. When asked about stressors she states that she "panics" about her job, marriage, children, and finances. When asked to clarify what the "panics" entail, she states that it involves severe worrying. She has had these symptoms since she last saw you one year ago. What is the most likely diagnosis?
Q34
A previously healthy 24-year-old woman comes to the physician because of recurrent episodes of a choking sensation, palpitations, diffuse sweating, and shortness of breath over the past 3 months. These episodes occur without warning and last for about 10 minutes before gradually resolving. One episode occurred while at a shopping center, and she now avoids busy areas for fear of triggering another. She has been evaluated in the emergency department twice during these episodes; both times her ECG showed normal sinus rhythm and serum cardiac enzymes and thyroid hormone levels were normal. She does not currently have symptoms but is concerned that the episodes could occur again at any time and that there may be something wrong with her heart. She does not smoke or drink alcohol. Her only medication is an oral contraceptive. Vital signs are within normal limits. Physical examination shows no abnormalities. Urine toxicology screening is negative. Which of the following is the most appropriate next step in management?
Q35
A 13-year-old girl is brought to the physician by her parents for the evaluation of progressive hair loss over the past 2 months. The parents report that they have noticed increased number of hairless patches on their daughter's head. The patient denies any itching. There is no personal or family history of serious illness. The patient states that she has been feeling tense since her boyfriend broke up with her. She does not smoke or drink alcohol. She does not use illicit drugs. Her vital signs are within normal limits. Physical examination shows ill-defined patchy hair loss and hair of different lengths with no scaling or reddening of the scalp. Further examination shows poor hair growth of the eyebrows and eyelashes. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?
Q36
A 30-year-old woman comes to the physician because of difficulty sleeping. She is afraid of falling asleep and gets up earlier than desired. Four months ago, she was the driver in a car accident that resulted in the death of her unborn child. She has vivid nightmares of the event and reports that she frequently re-experiences the accident. She blames herself for the death of her child, has stopped working as an accountant, avoids driving in cars, and has withdrawn from her parents and close friends. Which of the following is the most likely diagnosis?
Q37
A 26-year-old woman thinks poorly of herself and is extremely sensitive to criticism. She is socially inhibited and has never had a romantic relationship, although she desires one. Which of the following is the most likely diagnosis?
Q38
A 35-year-old man presents to the psychiatry OPD with an intense fear of spiders (arachnophobia) that significantly interferes with his daily activities. He reports avoiding certain areas of his house and experiencing panic attacks when encountering spiders. What is the most appropriate first-line treatment for this patient?
Q39
A 25-year-old male presents to his primary care physician with a chief complaint of anxiety and fatigue. The patient states that during this past week he has had final exams and has been unable to properly study and prepare because he is so exhausted. He states that he has been going to bed early but has been unable to get a good night’s sleep. The patient admits to occasional cocaine and marijuana use. Otherwise, the patient has no significant past medical history and is not taking any medications. On physical exam you note a tired and anxious appearing young man. His neurological exam is within normal limits. The patient states that he fears he will fail his courses if he does not come up with a solution. Which of the following is the best initial step in management?
Q40
A 17-year-old girl is brought to her pediatrician by her mother for a wellness checkup. The patient states she is doing well in school and has no concerns. She has a past medical history of anxiety and is currently taking clonazepam as needed. Her family history is remarkable for hypertension in her mother and father and renal disease in her grandparents and aunt. Her temperature is 98.6°F (37.0°C), blood pressure is 97/68 mmHg, pulse is 90/min, respirations are 19/min, and oxygen saturation is 99% on room air. The patient's BMI is 23 kg/m^2. Cardiac, pulmonary, and neurological exams are within normal limits. Laboratory values are ordered as seen below.
Hemoglobin: 10 g/dL
Hematocrit: 29%
Leukocyte count: 6,500/mm^3 with normal differential
Platelet count: 190,000/mm^3
Serum:
Na+: 137 mEq/L
Cl-: 97 mEq/L
K+: 3.5 mEq/L
HCO3-: 29 mEq/L
BUN: 20 mg/dL
Glucose: 67 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.2 mg/dL
Urine:
pH: 4.5
Color: yellow
Glucose: none
Chloride: 4 mEq/L
Sodium: 11 mEq/L
Which of the following is the most likely diagnosis?
Anxiety US Medical PG Practice Questions and MCQs
Question 31: An 18-year-old man presents to the student health department at his university for recurrent palpitations. The patient had previously presented to the emergency department (ED) for sudden onset palpitations five months ago when he first started college. He had a negative cardiac workup in the ED and he was discharged with a 24-hour Holter monitor which was also negative. He has no history of any medical or psychiatric illnesses. The patient reports that since his initial ED visit, he has had several episodes of unprovoked palpitations associated with feelings of dread and lightheadedness though he cannot identify a particular trigger. Recently, he has begun sitting towards the back of the lecture halls so that he can “quickly escape and not make a scene” in case he gets an episode in class. Which of the following is the most likely diagnosis?
A. Social phobia
B. Specific phobia
C. Adjustment disorder
D. Panic disorder (Correct Answer)
E. Somatic symptom disorder
Explanation: ***Panic disorder***
- The patient experiences **recurrent, unprovoked panic attacks** characterized by palpitations, feelings of dread, and lightheadedness, which align with the diagnostic criteria for panic disorder.
- His behavior of sitting at the back of lecture halls to "quickly escape" indicates **avoidance behaviors** and **anticipatory anxiety** related to potential future attacks, a hallmark of panic disorder.
*Social phobia*
- This condition is characterized by **fear or anxiety about social situations** where the individual might be scrutinized or judged, which is not the primary driver of the patient's symptoms or avoidance behavior.
- While he avoids public situations, his motivation is fear of a panic attack, not fear of social judgment.
*Specific phobia*
- This involves an **intense, irrational fear of a specific object or situation** (e.g., heights, spiders, flying), which does not fit the generalized, unprovoked nature of the patient's panic attacks.
- The patient's symptoms are not tied to a single, clearly defined phobic stimulus.
*Adjustment disorder*
- This diagnosis is typically made when individuals experience **emotional or behavioral symptoms in response to an identifiable stressor**, arising within three months of the onset of the stressor.
- While starting college is a stressor, the patient's panic attacks are recurrent and unprovoked, evolving into a pattern beyond a typical adjustment response, and he has a negative cardiac workup.
*Somatic symptom disorder*
- This involves **distressing somatic symptoms accompanied by excessive thoughts, feelings, or behaviors related to the symptoms**, such as disproportionate thoughts about the seriousness of one's symptoms or high levels of anxiety about health.
- Although the patient experiences physical symptoms (palpitations), the presence of clear panic attacks, dread, and avoidance behavior points more specifically to panic disorder rather than a primary focus on the somatic symptoms themselves.
Question 32: During a psychotherapy session, a psychiatrist notes transference. Which of the following is an example of this phenomenon?
A. The patient feels powerless to change and blames his problems on the situation into which he was born
B. The doctor feels that the patient's unwillingness to change is frustrating as it is similar to the feelings the doctor has towards his/her child with behavior problems
C. The patient feels that her father is too controlling and interferes with all aspects of her life
D. The patient is annoyed by the doctor because he feels the doctor is lecturing like his mother used to do (Correct Answer)
E. The doctor has feelings of sexual attraction towards the patient
Explanation: ***The patient is annoyed by the doctor because he feels the doctor is lecturing like his mother used to do***
- This is a classic example of **transference**, where the patient unconsciously projects feelings and attitudes from significant past relationships (like with a parent) onto the therapist.
- The patient is reacting to the doctor not based on the doctor's current behavior, but through the lens of past experiences with their **mother's lecturing style**.
*The patient feels powerless to change and blames his problems on the situation into which he was born*
- This describes an **external locus of control** and possibly a sense of learned helplessness, but it doesn't involve projecting past relational patterns onto the therapist.
- While it's a patient's feeling, it's about their life situation rather than their perception of the therapist based on past figures.
*The doctor feels that the patient's unwillingness to change is frustrating as it is similar to the feelings the doctor has towards his/her child with behavior problems*
- This scenario describes **countertransference**, where the **therapist's** unresolved issues or feelings towards significant others (like their child) are projected onto the patient.
- Transference specifically refers to the patient's projection, not the therapist's.
*The patient feels that her father is too controlling and interferes with all aspects of her life*
- This is a direct statement about the patient's current relationship with her father, or a past experience, and does not involve projecting these feelings onto the **therapist**.
- While it might be a topic explored in therapy, it's not a manifestation of transference *within* the therapeutic relationship itself.
*The doctor has feelings of sexual attraction towards the patient*
- This is an example of **countertransference**, as it describes the **therapist's** feelings towards the patient, rather than the patient's feelings towards the therapist.
- Such feelings, especially sexual attraction, are considered unethical in therapy and need to be managed by the therapist.
Question 33: A 45-year-old woman presents to her primary care physician with complaints of muscle pains, poor sleep, and daytime fatigue. When asked about stressors she states that she "panics" about her job, marriage, children, and finances. When asked to clarify what the "panics" entail, she states that it involves severe worrying. She has had these symptoms since she last saw you one year ago. What is the most likely diagnosis?
A. Generalized anxiety disorder (Correct Answer)
B. Social phobia
C. Adjustment disorder
D. Obsessive-compulsive disorder
E. Panic disorder
Explanation: ***Generalized anxiety disorder***
- This patient presents with **chronic, excessive, and uncontrollable worry** about multiple life circumstances (job, marriage, children, finances), fulfilling the core diagnostic criterion for GAD.
- The associated symptoms of **muscle pains**, **poor sleep**, and **daytime fatigue** are common physical manifestations of GAD, and the duration of symptoms for over a year supports the diagnosis.
*Social phobia*
- **Social phobia**, or social anxiety disorder, involves intense fear and anxiety in **social situations** where one might be scrutinized or judged.
- The patient's reported worries are broad and not limited to social interactions, making social phobia less likely.
*Adjustment disorder*
- **Adjustment disorder** is characterized by emotional or behavioral symptoms developing within **three months of an identifiable stressor**, not diffuse chronic worry.
- The symptoms in adjustment disorder typically resolve within **six months** after the stressor or its consequences have ended, whereas this patient's symptoms are chronic and pervasive.
*Obsessive-compulsive disorder*
- **Obsessive-compulsive disorder (OCD)** involves recurrent, intrusive **obsessions** (thoughts, urges, images) and/or **compulsions** (repetitive behaviors or mental acts) performed to reduce anxiety.
- While the patient experiences severe worrying, there's no mention of specific obsessions or compulsive behaviors aimed at neutralizing those anxieties.
*Panic disorder*
- **Panic disorder** is characterized by recurrent, unexpected **panic attacks**—sudden surges of intense fear or discomfort accompanied by physical and cognitive symptoms.
- While the patient uses the term "panics," she clarifies it involves "severe worrying," not discrete, intense, and short-lived panic attacks.
Question 34: A previously healthy 24-year-old woman comes to the physician because of recurrent episodes of a choking sensation, palpitations, diffuse sweating, and shortness of breath over the past 3 months. These episodes occur without warning and last for about 10 minutes before gradually resolving. One episode occurred while at a shopping center, and she now avoids busy areas for fear of triggering another. She has been evaluated in the emergency department twice during these episodes; both times her ECG showed normal sinus rhythm and serum cardiac enzymes and thyroid hormone levels were normal. She does not currently have symptoms but is concerned that the episodes could occur again at any time and that there may be something wrong with her heart. She does not smoke or drink alcohol. Her only medication is an oral contraceptive. Vital signs are within normal limits. Physical examination shows no abnormalities. Urine toxicology screening is negative. Which of the following is the most appropriate next step in management?
A. Administer lorazepam
B. Administer propranolol
C. D-dimer measurement
D. Echocardiography
E. Prescribe fluoxetine (Correct Answer)
Explanation: ***Prescribe fluoxetine***
* The patient's presentation with recurrent, unprovoked episodes of **choking sensation, palpitations, sweating, and shortness of breath**, lasting about 10 minutes, and leading to avoidance behavior (agoraphobia), is highly consistent with **panic disorder with agoraphobia**.
* **Selective serotonin reuptake inhibitors (SSRIs)** like fluoxetine are first-line pharmacologic treatments for panic disorder, demonstrating efficacy in reducing the frequency and severity of panic attacks.
*Administer lorazepam*
* **Lorazepam** is a **benzodiazepine** that can provide rapid relief of acute panic symptoms due to its anxiolytic effects.
* However, it is typically used for **acute symptom management** or short-term bridging therapy due to the risk of **dependence, tolerance, and withdrawal**, and is not considered a first-line long-term solution for panic disorder.
*Administer propranolol*
* **Propranolol** is a **beta-blocker** that can alleviate some physical symptoms of anxiety, such as palpitations and tremor, by blocking adrenergic receptors.
* It is more commonly used for **performance anxiety** or specific phobias and does not address the core psychological components of panic disorder or the avoidance behaviors associated with agoraphobia.
*D-dimer measurement*
* **D-dimer measurement** is used to rule out **thrombotic events** such as deep vein thrombosis (DVT) or pulmonary embolism (PE).
* The patient's symptoms are episodic, resolve spontaneously, and are not continuous or worsening, and previous ED evaluations for cardiovascular issues were normal, making a thrombotic event unlikely in this context.
*Echocardiography*
* **Echocardiography** is an imaging test to evaluate the **structure and function of the heart**.
* Given that the patient's ECG was normal, cardiac enzymes were normal, and she has experienced several such episodes without cardiac dysfunction, further cardiac workup like echocardiography is unlikely to reveal an underlying cardiac cause and would be an unnecessary investigation at this point.
Question 35: A 13-year-old girl is brought to the physician by her parents for the evaluation of progressive hair loss over the past 2 months. The parents report that they have noticed increased number of hairless patches on their daughter's head. The patient denies any itching. There is no personal or family history of serious illness. The patient states that she has been feeling tense since her boyfriend broke up with her. She does not smoke or drink alcohol. She does not use illicit drugs. Her vital signs are within normal limits. Physical examination shows ill-defined patchy hair loss and hair of different lengths with no scaling or reddening of the scalp. Further examination shows poor hair growth of the eyebrows and eyelashes. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?
A. Telogen effluvium
B. Alopecia areata
C. Trichotillomania (Correct Answer)
D. Scarring alopecia
E. Tinea capitis
Explanation: ***Correct: Trichotillomania***
- This is a **hair-pulling disorder** classified as an obsessive-compulsive related disorder in which individuals repeatedly pull out their own hair.
- The diagnostic features in this case are highly characteristic: **ill-defined patchy hair loss with hairs of different lengths** (indicating repeated pulling over time), absence of scalp inflammation (no scaling or redness), and involvement of **eyebrows and eyelashes**.
- The patient's recent emotional stressor (breakup) is a common **precipitating factor** for this impulse control behavior, particularly in adolescents.
- The lack of itching and inflammatory changes helps distinguish this from dermatological causes of hair loss.
*Incorrect: Telogen effluvium*
- This condition presents with **diffuse hair shedding** following a significant physiological or emotional stressor (typically 2-3 months after the trigger).
- While stress can precipitate telogen effluvium, it causes **uniform hair thinning** across the scalp rather than distinct patches with hairs of different lengths.
- The patchy distribution and varying hair lengths are inconsistent with telogen effluvium.
*Incorrect: Alopecia areata*
- An autoimmune condition characterized by **well-demarcated, smooth, circular patches** of complete hair loss, often with "exclamation point hairs" at the margins.
- While it can affect eyebrows and eyelashes, the description of **"ill-defined" patches with hairs of different lengths** is atypical for alopecia areata, which typically shows complete hair loss in well-circumscribed areas.
- The patches in alopecia areata are usually round and sharply defined, not ill-defined.
*Incorrect: Scarring alopecia*
- Involves **permanent destruction of hair follicles** with fibrosis, leading to smooth, atrophic patches where hair cannot regrow.
- Usually presents with **visible scarring, scaling, erythema, or signs of inflammation** on the scalp.
- The absence of any inflammatory changes, scaling, or scarring on examination makes this diagnosis unlikely.
*Incorrect: Tinea capitis*
- A **fungal infection** of the scalp that typically presents with scaling, erythema, and broken hairs, often accompanied by pruritus.
- Characteristic findings include **"black dot" pattern** (broken hairs at scalp surface), cervical lymphadenopathy, and inflammatory changes.
- The patient's lack of itching and absence of scaling or redness effectively rule out this diagnosis.
Question 36: A 30-year-old woman comes to the physician because of difficulty sleeping. She is afraid of falling asleep and gets up earlier than desired. Four months ago, she was the driver in a car accident that resulted in the death of her unborn child. She has vivid nightmares of the event and reports that she frequently re-experiences the accident. She blames herself for the death of her child, has stopped working as an accountant, avoids driving in cars, and has withdrawn from her parents and close friends. Which of the following is the most likely diagnosis?
A. Acute stress disorder
B. Normal grief
C. Major depressive disorder
D. Adjustment disorder
E. Post-traumatic stress disorder (Correct Answer)
Explanation: ***Post-traumatic stress disorder***
- The patient's symptoms, including **re-experiencing the trauma** (nightmares, flashbacks), avoidance behaviors (avoiding driving, withdrawing from social interactions), and negative alterations in cognition and mood (difficulty sleeping, self-blame), persisting for **four months** after a traumatic event, are characteristic of PTSD.
- The severity and chronicity of these symptoms, significantly impacting her daily functioning, align with the diagnostic criteria for PTSD.
*Acute stress disorder*
- This diagnosis also involves exposure to a traumatic event and similar symptoms (intrusive thoughts, negative mood, avoidance) but is diagnosed only when symptoms last for a minimum of **3 days and a maximum of 1 month** after the trauma.
- Since the patient's symptoms have persisted for **four months**, acute stress disorder is ruled out.
*Normal grief*
- While grief is a natural response to loss, the patient's symptoms extend beyond typical grief, involving specific **trauma-related re-experiencing** and **avoidance behaviors** that are not primarily focused on the deceased, but rather on the traumatic event itself.
- Normal grief typically does not involve the severe, persistent avoidance and intrusive symptoms of a traumatic nature seen here.
*Major depressive disorder*
- Although the patient exhibits symptoms that could overlap with depression (difficulty sleeping, withdrawal, loss of interest), the primary driver of her symptoms is the **traumatic event** and its associated re-experiencing and avoidance.
- A diagnosis of MDD would be considered if the depressive symptoms are paramount and not better explained by the trauma response, but in this case, the **trauma-specific symptoms** are central.
*Adjustment disorder*
- This disorder is characterized by the development of emotional or behavioral symptoms in response to an identifiable stressor, occurring within **3 months of the stressor**.
- While a traumatic event could be a stressor, adjustment disorder is diagnosed when the symptoms **do not meet the criteria for another specific mental disorder**, like PTSD, and are generally less severe and pervasive than what is described in this patient.
Question 37: A 26-year-old woman thinks poorly of herself and is extremely sensitive to criticism. She is socially inhibited and has never had a romantic relationship, although she desires one. Which of the following is the most likely diagnosis?
A. Schizoid personality disorder
B. Paranoid personality disorder
C. Depression
D. Dysthymia
E. Avoidant personality disorder (Correct Answer)
Explanation: ***Avoidant personality disorder***
- Characterized by **social inhibition**, feelings of **inadequacy**, and **hypersensitivity to negative evaluation**, leading to avoidance of social interactions despite a desire for connection.
- The patient's self-perception, sensitivity to criticism, and absence of romantic relationships are classic signs.
*Schizoid personality disorder*
- Individuals with schizoid personality disorder exhibit a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression.
- Unlike avoidant personality disorder, they typically **do not desire social connection** and are indifferent to criticism or praise.
*Paranoid personality disorder*
- Marked by pervasive **distrust and suspiciousness of others**, interpreting their motives as malevolent.
- This patient's symptoms are more focused on self-perception and social anxiety rather than paranoid ideation.
*Depression*
- Depression involves a sustained period of **low mood**, loss of interest or pleasure, and other vegetative symptoms, which are not explicitly described as the primary, long-standing issue here.
- While feelings of worthlessness can occur in depression, the chronic, pervasive social inhibition and desire for relationships point away from a primary depressive episode as the sole diagnosis.
*Dysthymia*
- Dysthymia, or persistent depressive disorder, is characterized by a chronically depressed mood for at least two years, but it usually includes more pervasive depressive symptoms like low energy and anhedonia.
- While it can involve poor self-esteem, it doesn't fully explain the specific pattern of social avoidance and hypersensitivity to criticism, especially the patient's desire for social connection, which is often dampened in dysthymia.
Question 38: A 35-year-old man presents to the psychiatry OPD with an intense fear of spiders (arachnophobia) that significantly interferes with his daily activities. He reports avoiding certain areas of his house and experiencing panic attacks when encountering spiders. What is the most appropriate first-line treatment for this patient?
A. Benzodiazepines
B. Antidepressants
C. Cognitive behavioral therapy (Correct Answer)
D. Beta-blockers
E. Anxiolytics
Explanation: ***Cognitive behavioral therapy***
- **Cognitive Behavioral Therapy (CBT)**, specifically exposure therapy, is the **first-line treatment** for specific phobias due to its high efficacy in reducing fear and avoidance.
- The patient's significant interference with daily activities and panic attacks necessitate a direct and effective intervention like CBT.
*Benzodiazepines*
- **Benzodiazepines** can provide short-term relief for acute anxiety, but they do not address the underlying phobia and have a **risk of dependence** and withdrawal symptoms.
- They are generally not recommended as a first-line or monotherapy for specific phobias because they can interfere with the learning process of exposure therapy.
*Antidepressants*
- **Antidepressants**, particularly SSRIs, are effective for generalized anxiety disorder or panic disorder but are **not typically first-line for specific phobias** unless there are co-occurring conditions.
- Their action mechanism is slower, and they are less effective than exposure therapy for specific phobias.
*Beta-blockers*
- **Beta-blockers** help manage the **physical symptoms of anxiety** (e.g., palpitations, tremors) but do not address the psychological component of specific phobias.
- They are used symptomatically and are not a cure for the phobia itself.
*Anxiolytics*
- **Anxiolytics** is a broad term that includes benzodiazepines; while they can reduce anxiety, they are **not a primary treatment** for specific phobias and carry risks.
- For specific phobias, the goal is not just symptom reduction but overcoming the fear through behavioral changes, which anxiolytics do not facilitate.
Question 39: A 25-year-old male presents to his primary care physician with a chief complaint of anxiety and fatigue. The patient states that during this past week he has had final exams and has been unable to properly study and prepare because he is so exhausted. He states that he has been going to bed early but has been unable to get a good night’s sleep. The patient admits to occasional cocaine and marijuana use. Otherwise, the patient has no significant past medical history and is not taking any medications. On physical exam you note a tired and anxious appearing young man. His neurological exam is within normal limits. The patient states that he fears he will fail his courses if he does not come up with a solution. Which of the following is the best initial step in management?
A. Polysomnography
B. Sleep hygiene education (Correct Answer)
C. Alprazolam
D. Melatonin
E. Zolpidem
Explanation: ***Sleep hygiene education***
- This is the **best initial step** because it addresses lifestyle factors that commonly contribute to **insomnia and fatigue**, especially during periods of stress like final exams.
- Helping the patient establish **regular sleep patterns**, avoid stimulants, and create a conducive sleep environment can significantly improve sleep quality without medication.
*Polysomnography*
- This is a diagnostic test typically reserved for when a **primary sleep disorder** like sleep apnea or restless legs syndrome is suspected.
- Given the patient's acute stressor (final exams) and **drug use**, lifestyle interventions should be tried first before pursuing expensive and invasive testing.
*Alprazolam*
- This is a **benzodiazepine** that can be used for acute anxiety or insomnia, but it carries a risk of **dependence, tolerance, and withdrawal**.
- It is not a first-line treatment for a patient experiencing sleep difficulties primarily due to stress and poor sleep habits, and its use should be avoided in those with a history of substance abuse.
*Melatonin*
- Melatonin can be helpful for **circadian rhythm disorders** or jet lag, but its efficacy for primary insomnia is limited and inconsistent.
- While it has fewer side effects than prescription hypnotics, **sleep hygiene education** is still a more fundamental and effective initial approach for this patient.
*Zolpidem*
- This is a **non-benzodiazepine hypnotic** often prescribed for short-term insomnia, but it has potential side effects like **next-day drowsiness** and can be abused, especially in individuals with a history of substance use.
- **Sleep hygiene** should always be optimized first, especially in a young patient whose sleep issues are clearly linked to stress and lifestyle.
Question 40: A 17-year-old girl is brought to her pediatrician by her mother for a wellness checkup. The patient states she is doing well in school and has no concerns. She has a past medical history of anxiety and is currently taking clonazepam as needed. Her family history is remarkable for hypertension in her mother and father and renal disease in her grandparents and aunt. Her temperature is 98.6°F (37.0°C), blood pressure is 97/68 mmHg, pulse is 90/min, respirations are 19/min, and oxygen saturation is 99% on room air. The patient's BMI is 23 kg/m^2. Cardiac, pulmonary, and neurological exams are within normal limits. Laboratory values are ordered as seen below.
Hemoglobin: 10 g/dL
Hematocrit: 29%
Leukocyte count: 6,500/mm^3 with normal differential
Platelet count: 190,000/mm^3
Serum:
Na+: 137 mEq/L
Cl-: 97 mEq/L
K+: 3.5 mEq/L
HCO3-: 29 mEq/L
BUN: 20 mg/dL
Glucose: 67 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.2 mg/dL
Urine:
pH: 4.5
Color: yellow
Glucose: none
Chloride: 4 mEq/L
Sodium: 11 mEq/L
Which of the following is the most likely diagnosis?
A. Bartter syndrome
B. Anorexia nervosa
C. Diuretic abuse
D. Bulimia nervosa
E. Gitelman syndrome (Correct Answer)
Explanation: ***Gitelman syndrome***
- The patient presents with **hypokalemia**, **metabolic alkalosis** (bicarbonate = 29 mEq/L), and **hypochloremia** (chloride = 97 mEq/L), which are characteristic features.
- The **low urine chloride** (4 mEq/L) and **low urine sodium** (11 mEq/L) despite normal blood pressure indicate renal tubular dysfunction resembling the effect of **thiazide diuretics**.
- Gitelman syndrome is associated with **hypocalciuria** and typically presents in adolescence or young adulthood, often with a family history of renal disease.
*Bartter syndrome*
- Typically presents with **hypokalemia**, **metabolic alkalosis**, and **hypochloremia**, similar to Gitelman syndrome.
- However, Bartter syndrome usually presents in **infancy or early childhood** and is associated with **hypercalciuria** (vs. hypocalciuria in Gitelman), which helps differentiate the two conditions.
- The adolescent presentation and family history of renal disease favor Gitelman syndrome.
*Anorexia nervosa*
- Patients with anorexia nervosa often present with a very **low BMI** (<17.5 kg/m^2) and may have electrolyte imbalances due to starvation or purging behaviors.
- This patient's BMI is normal (23 kg/m^2), and there are no other signs suggesting an eating disorder like amenorrhea, bradycardia, or lanugo.
*Diuretic abuse*
- While **diuretic abuse** can cause hypokalemia, metabolic alkalosis, and hypochloremia, active diuretic use would typically show **elevated urine chloride** (>20 mEq/L).
- The **low urine chloride** (4 mEq/L) in this case suggests either remote diuretic use or, more likely, a chronic tubular defect like Gitelman syndrome.
- No history of diuretic access or suspicious behavior is mentioned, and the presentation with family history points towards a congenital tubulopathy.
*Bulimia nervosa*
- Bulimia nervosa involves recurrent episodes of **binge eating followed by compensatory behaviors** like vomiting, laxative abuse, or excessive exercise.
- While it can cause hypokalemia and metabolic alkalosis due to vomiting, the patient's normal BMI, lack of any suggestive signs (e.g., dental erosions, Russell's sign, parotid gland enlargement), and the specific pattern of low urine chloride make this diagnosis less likely.
