Mood stabilizers mechanisms and selection — MCQs

A 58-year-old man with a past medical history of diabetes, hypertension, and hyperlipidemia was brought into the emergency department by his wife after she observed him go without sleep for several days and recently open and max out several credit cards. She also reports that he has quit his bartending job and has been excessively talkative and easily annoyed for the last several weeks. The patient has no previous psychiatric history. Routine medical examination, investigations, and toxicology rule out a medical cause or substance abuse. Lab results are consistent with chronically impaired renal function. What is the single best treatment for this patient?

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 56-year-old man comes to the physician for a follow-up examination. One month ago, he was diagnosed with a focal seizure and treatment with a drug that blocks voltage-gated sodium channels was begun. Today, he reports that he has not had any abnormal body movements, but he has noticed occasional double vision. His serum sodium is 132 mEq/L, alanine aminotransferase is 49 U/L, and aspartate aminotransferase is 46 U/L. This patient has most likely been taking which of the following drugs?

A 32-year-old woman is brought to the physician by her husband, who is concerned about her ability to care for herself. Three weeks ago, she quit her marketing job to start a clothing company. Since then, she has not slept more than 4 hours per night because she has been working on her business plans. She used a significant portion of their savings to fund business trips to Switzerland in order to buy “only the best quality fabrics in the world.” She has not showered and has eaten little during the past 3 days. She has had 2 similar episodes a few years back that required hospitalization and treatment in a psychiatry unit. She has also suffered from periods of depression. She is currently not taking any medications. She appears unkempt and agitated, pacing up and down the room. She speaks very fast without interruption about her business ideas. She has no suicidal ideation or ideas of self-harm. Toxicology screening is negative. Which of the following is the most appropriate pharmacotherapy for the management of this patient?

A 28-year-old man is brought to the physician by his wife because she is worried about his unusual behavior. Two weeks ago, he was promoted and is now convinced that he will soon take over the firm. He has been working overtime at the office and spends most of his nights at parties. Whenever he comes home, he asks his wife to have sex with him and rarely sleeps more than 3 hours. He has a history of a similar episode and several periods of depression over the past 2 years. He currently takes no medications. He appears impatient, repeatedly jumps up from his seat, and says, "I have more important things to do." There is no evidence of suicidal ideation. Urine toxicology screening is negative. Long-term treatment with lithium is started. Which of the following endocrine parameters should be regularly monitored in this patient while he is undergoing treatment?

A 37-year-old African American man is brought to the emergency department by police. The patient refused to leave a petting zoo after closing. He states that he has unique ideas to revolutionize the petting zoo experience. The patient has a past medical history of multiple suicide attempts. His temperature is 99.5°F (37.5°C), blood pressure is 130/85 mmHg, pulse is 100/min, respirations are 16/min, and oxygen saturation is 99% on room air. The patient's cardiac and pulmonary exams are within normal limits. He denies any nausea, vomiting, shortness of breath, or systemic symptoms. The patient struggles to answer questions, as he is constantly changing the subject and speaking at a very rapid rate. The patient is kept in the emergency department overnight and is observed to not sleep and is very talkative with the nurses. Which of the following is the best long-term therapy for this patient?

A 28-year-old woman is brought to the emergency department by her friends. She is naked except for a blanket and speaking rapidly and incoherently. Her friends say that she was found watering her garden naked and refused to put on any clothes when they tried to make her do so, saying that she has accepted how beautiful she is inside and out. Her friends say she has also purchased a new car she can not afford. They are concerned about her, as they have never seen her behave this way before. For the past week, she has not shown up at work and has been acting ‘strangely’. They say she was extremely excited and has been calling them at odd hours of the night to tell them about her future plans. Which of the following drug mechanisms will help with the long-term management this patient’s symptoms?

A 25-year-old woman is brought to the emergency department by EMS after being found naked in a busy downtown square. The patient stated that she is liberating people from material desires and was found destroying objects. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 22/min, and oxygen saturation is 98% on room air. Physical exam is deferred due to patient combativeness. The patient is given diphenhydramine and haloperidol and transferred to the psychiatric ward. On day 1 on the ward, the patient is no longer aggressive or agitated and has calmed down. She states that she feels severely depressed and wants to kill herself. The patient is started on a medication and monitored closely. On day 3 of the patient's stay in the hospital she is found in her room drawing up plans and states that she has major plans to revamp the current energy problems in the country. Which of the following is the most likely medication that was started in this patient?

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 27-year-old man comes to the physician for a follow-up examination. Paroxetine therapy was initiated 6 weeks ago for a major depressive episode. He now feels much better and says he is delighted with his newfound energy. He gets around 8 hours of sleep nightly. His appetite has increased. Last year, he had two episodes of depressed mood, insomnia, and low energy during which he had interrupted his job training and stopped going to the gym. Now, he has been able to resume his job at a local bank. He also goes to the gym three times a week to work out and enjoys reading books again. His temperature is 36.5°C (97.7°F), pulse is 70/min, and blood pressure is 128/66 mm Hg. Physical and neurologic examinations show no abnormalities. On mental status examination, he describes his mood as "good." Which of the following is the most appropriate next step in management?