Metabolic monitoring in psychotic disorders — MCQs

10 questions

A 52-year-old man comes to the physician for a routine health maintenance examination. He feels well. His blood pressure is 125/70 mm Hg. His glomerular filtration rate is calculated to be 105 mL/min/1.73 m2 and glucose clearance is calculated to be 103 mL/min. This patient is most likely being treated with which of the following agents?

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 study is conducted to investigate the relationship between the development of type 2 diabetes mellitus and the use of atypical antipsychotic medications in patients with schizophrenia. 300 patients who received the atypical antipsychotic clozapine and 300 patients who received the typical antipsychotic haloperidol in long-acting injectable form were followed for 2 years. At the end of the observation period, the incidence of type 2 diabetes mellitus was compared between the two groups. Receipt of clozapine was found to be associated with an increased risk of diabetes mellitus relative to haloperidol (RR = 1.43, 95% p<0.01). Developed type 2 diabetes mellitus Did not develop type 2 diabetes mellitus Clozapine 30 270 Haloperidol 21 279 Based on these results, what proportion of patients receiving clozapine would not have been diagnosed with type 2 diabetes mellitus if they had been taking a typical antipsychotic?

A 20-year-old student is referred to his college's student health department because his roommates are concerned about his recent behavior. He rarely leaves his room, has not showered in several days, appears to be praying constantly even though he is not religious, and has not been studying despite previously being an extremely good student. After evaluating this patient, a physician decides to recommend initiation of pharmacological treatment. The patient's family is concerned because they heard that the drug being recommended may be associated with heart problems. Which of the following characteristics is a property of the most likely drug that was prescribed in this case?

A 27-year-old man presents to the emergency department for bizarre behavior. The patient had boarded up his house and had been refusing to leave for several weeks. The police were called when a foul odor emanated from his property prompting his neighbors to contact the authorities. Upon questioning, the patient states that he has been pursued by elves for his entire life. He states that he was tired of living in fear, so he decided to lock himself in his house. The patient is poorly kempt and has very poor dentition. The patient has a past medical history of schizophrenia which was previously well controlled with olanzapine. The patient is restarted on olanzapine and monitored over the next several days. Which of the following needs to be monitored long term in this patient?

A 45-year-old woman presents to your office with a serum glucose of 250 mg/dL and you diagnose diabetes mellitus type II. You intend to prescribe the patient metformin, but you decide to order laboratory tests before proceeding. Which of the following basic metabolic panel values would serve as a contraindication to the use of metformin?

A 49-year-old woman presents to the family medicine clinic with concerns about her weight. She has been constantly gaining weight for a decade now as she has not been able to control her diet. She has tried exercising but says that she is too lazy for this method of weight loss to work. Her temperature is 37° C (98.6° F), respirations are 15/min, pulse is 67/min, and blood pressure is 122/88 mm Hg. Her BMI is 30. Her labs from her past visit show: Fasting blood glucose: 149 mg/dL Glycated hemoglobin (HbA1c): 9.1% Triglycerides: 175 mg/dL LDL-Cholesterol: 102 mg/dL HDL-Cholesterol: 35 mg/dL Total Cholesterol: 180 mg/dL Serum creatinine: 1.0 mg/dL BUN: 12 mg/dL Serum: Albumin: 4.2 gm/dL Alkaline phosphatase: 150 U/L Alanine aminotransferase: 76 U/L Aspartate aminotransferase: 88 U/L After discussing the long term issues that will arise if her health does not improve, she agrees to modify her lifestyle and diet. Which of the following would be the best pharmacotherapy for this patient?

A 34-year-old man presents to the behavioral health clinic for an evaluation after seeing animal-shaped clouds in the form of dogs, cats, and monkeys. The patient says that these symptoms have been present for more than 2 weeks. Past medical history is significant for simple partial seizures for which he takes valproate, but he has not had his medication adjusted in several years. His vital signs include: blood pressure of 124/76 mm Hg, heart rate of 98/min, respiratory rate of 12/min, and temperature of 37.1°C (98.8°F). On physical examination, the patient is alert and oriented to person, time, and place. Affect is not constricted or flat. Speech is of rapid rate and high volume. Pupils are equal and reactive bilaterally. The results of a urine drug screen are as follows: Alcohol positive Amphetamine negative Benzodiazepine negative Cocaine positive GHB negative Ketamine negative LSD negative Marijuana negative Opioids negative PCP negative Which of the following is the most likely diagnosis in this patient?

A 45-year-old man presents to a psychiatrist by his wife with recent behavioral and emotional changes. The patient’s wife says that her husband’s personality has completely changed over the last year. She also says that he often complains of unpleasant odors when actually there is no discernible odor present. The patient mentions that he is depressed at times while on other occasions, he feels like he is ‘the most powerful man in the world.’ The psychiatrist takes a detailed history from this patient and concludes that he is most likely suffering from a psychotic disorder. However, before prescribing an antipsychotic medication, he recommends that the patient undergoes brain imaging to rule out a brain neoplasm. Based on the presence of which of the following clinical signs or symptoms in this patient is the psychiatrist most likely recommending this imaging test?

Q10

A 21-year-old woman presents into the clinic worried that she might be pregnant. Her last menstrual period was 4 months ago and recalls that she did have unprotected sex with her boyfriend, despite not having sexual desire. They have since broken up, and she would like to do a pregnancy test. She appears very emaciated but is physically active. She says that she spends a few hours in the gym almost every day but would spend longer if she was to stray from her diet so that she does not gain any weight. Her calculated BMI is 17 kg/m2, and her urine pregnancy test is negative. Which of the following additional findings would most likely be present in this patient?

Metabolic monitoring in psychotic disorders US Medical PG Practice Questions and MCQs

Question 1: A 52-year-old man comes to the physician for a routine health maintenance examination. He feels well. His blood pressure is 125/70 mm Hg. His glomerular filtration rate is calculated to be 105 mL/min/1.73 m2 and glucose clearance is calculated to be 103 mL/min. This patient is most likely being treated with which of the following agents?

A. Ifosfamide
B. Acarbose
C. Canagliflozin (Correct Answer)
D. Glipizide
E. Metformin

Explanation: ***Canagliflozin*** - The key finding is that **glucose clearance (103 mL/min) approximately equals GFR (105 mL/min)**, indicating nearly complete failure of glucose reabsorption. - **Canagliflozin** is an **SGLT2 inhibitor** that blocks the sodium-glucose cotransporter 2 in the proximal tubule, preventing glucose reabsorption. - This causes filtered glucose to be excreted in urine, resulting in **glucose clearance approaching GFR** - exactly what is seen in this patient. - SGLT2 inhibitors are increasingly used as first-line agents in Type 2 Diabetes, especially with cardiovascular or renal benefits. *Metformin* - **Metformin** is a biguanide that decreases hepatic gluconeogenesis and increases peripheral insulin sensitivity. - It does **NOT affect renal glucose handling** or glucose clearance, which would remain near zero in patients on metformin. - The elevated glucose clearance in this patient rules out metformin monotherapy. *Ifosfamide* - **Ifosfamide** is an alkylating chemotherapy agent used for cancer treatment, not diabetes management. - It can cause **Fanconi syndrome** (proximal tubule dysfunction) leading to glycosuria, but this would also cause decreased GFR, proteinuria, and electrolyte abnormalities. - This patient's normal GFR and otherwise normal presentation makes ifosfamide-induced toxicity unlikely. *Acarbose* - **Acarbose** is an alpha-glucosidase inhibitor that slows carbohydrate absorption in the intestine. - It works in the **GI tract**, not the kidneys, and does not affect glucose clearance. - It would not explain the elevated renal glucose excretion seen here. *Glipizide* - **Glipizide** is a sulfonylurea that stimulates pancreatic insulin release. - It does **NOT affect renal glucose handling** and would not cause elevated glucose clearance. - The patient's glucose clearance pattern is inconsistent with sulfonylurea therapy.

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)

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.

Question 3: A study is conducted to investigate the relationship between the development of type 2 diabetes mellitus and the use of atypical antipsychotic medications in patients with schizophrenia. 300 patients who received the atypical antipsychotic clozapine and 300 patients who received the typical antipsychotic haloperidol in long-acting injectable form were followed for 2 years. At the end of the observation period, the incidence of type 2 diabetes mellitus was compared between the two groups. Receipt of clozapine was found to be associated with an increased risk of diabetes mellitus relative to haloperidol (RR = 1.43, 95% p<0.01). Developed type 2 diabetes mellitus Did not develop type 2 diabetes mellitus Clozapine 30 270 Haloperidol 21 279 Based on these results, what proportion of patients receiving clozapine would not have been diagnosed with type 2 diabetes mellitus if they had been taking a typical antipsychotic?

A. 1.48
B. 0.3 (Correct Answer)
C. 0.43
D. 0.03
E. 33.3

Explanation: ***0.3*** - The question asks for the **proportion of patients** receiving clozapine who *would not have been diagnosed* with type 2 diabetes if they had been taking a **typical antipsychotic (haloperidol)**. This is essentially asking for the **attributable risk proportion** among the exposed. - First, calculate the **incidence of diabetes in the clozapine group**: 30/300 = 0.10. Then, calculate the **incidence of diabetes in the haloperidol group**: 21/300 = 0.07. The difference in incidence (attributable risk) is 0.10 - 0.07 = 0.03. To find the proportion among those exposed, divide this difference by the incidence in the clozapine group: 0.03 / 0.10 = **0.3**. *1.48* - This value is close to the **Relative Risk (RR)** of 1.43, which indicates how many times more likely the clozapine group is to develop diabetes compared to the haloperidol group. It does not represent the proportion of patients who would benefit from switching medications. - The question asks for a proportion that reflects the prevention of diabetes, not a measure of relative risk. *0.43* - This value is close to the **attributable risk fraction** (attributable risk percent / 100), which is calculated as (RR - 1) / RR = (1.43 - 1) / 1.43 = 0.43 / 1.43 ≈ 0.30. It's not a direct proportion of patients. - While related to the increased risk, 0.43 does not directly answer the question about the proportion of patients who would *not* have developed diabetes if they had taken haloperidol. *0.03* - This value represents the **absolute difference in risk (attributable risk)**: 0.10 (clozapine incidence) - 0.07 (haloperidol incidence) = 0.03. - This is the difference in incidence, not the proportion of clozapine users who would avoid diabetes if they were on haloperidol. The question asks for a proportion *among* those receiving clozapine. *33.3* - This value is likely derived from incorrect calculations or misinterpretation of the question as an alternative percentage. - It does not align with any standard epidemiological measure for comparing the impact of switching medications in the context of attributable risk or risk reduction.

Question 4: A 20-year-old student is referred to his college's student health department because his roommates are concerned about his recent behavior. He rarely leaves his room, has not showered in several days, appears to be praying constantly even though he is not religious, and has not been studying despite previously being an extremely good student. After evaluating this patient, a physician decides to recommend initiation of pharmacological treatment. The patient's family is concerned because they heard that the drug being recommended may be associated with heart problems. Which of the following characteristics is a property of the most likely drug that was prescribed in this case?

A. May cause weight gain and metabolic changes
B. Lower risk of extrapyramidal symptoms
C. High affinity for serotonin 5-HT2A receptors
D. Prolongs the QT interval (Correct Answer)
E. Generally less sedating than older antipsychotics

Explanation: ***Prolongs the QT interval*** - The patient presents with **first-episode psychosis** (social withdrawal, poor hygiene, bizarre behavior, academic decline in a previously high-functioning young adult) - The family's specific concern about **"heart problems"** is the key clue pointing to **QT interval prolongation** - Among antipsychotics used for first-episode psychosis, **ziprasidone** is most notably associated with QT prolongation and carries an FDA warning about this cardiac effect - While other antipsychotics may also prolong QT to varying degrees, ziprasidone's association with this adverse effect is well-established and would prompt specific family counseling about cardiac risks - QT prolongation increases risk of **torsades de pointes**, a potentially fatal arrhythmia *May cause weight gain and metabolic changes* - **Weight gain and metabolic syndrome** (hyperglycemia, dyslipidemia) are common adverse effects of many **atypical antipsychotics**, particularly olanzapine and clozapine - While these are serious long-term concerns, they would typically be described as "weight" or "diabetes" problems rather than acute "heart problems" - This is not the distinguishing feature being emphasized by the family's concern *Lower risk of extrapyramidal symptoms* - **Lower EPS risk** is a characteristic feature of **atypical (second-generation) antipsychotics** compared to typical (first-generation) agents - This is actually a therapeutic advantage and would not be a concern for the family - This property applies to most atypical antipsychotics, not specifically to the one causing family concern about cardiac effects *High affinity for serotonin 5-HT2A receptors* - **5-HT2A receptor antagonism** is a defining pharmacological property of **atypical antipsychotics** that contributes to their lower EPS risk and efficacy for negative symptoms - This mechanism applies broadly to the atypical antipsychotic class - It does not explain the specific family concern about "heart problems" *Generally less sedating than older antipsychotics* - Sedation profiles vary widely among antipsychotics; some atypicals (quetiapine) are quite sedating while others (aripiprazole, ziprasidone) are less so - Sedation is not typically characterized as a "heart problem" - This does not address the cardiac safety concern highlighted in the question

Question 5: A 27-year-old man presents to the emergency department for bizarre behavior. The patient had boarded up his house and had been refusing to leave for several weeks. The police were called when a foul odor emanated from his property prompting his neighbors to contact the authorities. Upon questioning, the patient states that he has been pursued by elves for his entire life. He states that he was tired of living in fear, so he decided to lock himself in his house. The patient is poorly kempt and has very poor dentition. The patient has a past medical history of schizophrenia which was previously well controlled with olanzapine. The patient is restarted on olanzapine and monitored over the next several days. Which of the following needs to be monitored long term in this patient?

A. CBC
B. HbA1c levels (Correct Answer)
C. ECG
D. Monitoring for acute dystonia
E. Renal function studies

Explanation: ***HbA1c levels*** - **Olanzapine** is associated with significant metabolic side effects, including **weight gain**, **dyslipidemia**, and **new-onset diabetes mellitus**, necessitating long-term monitoring of **glucose metabolism** - **HbA1c** provides an average of blood glucose levels over the past 2-3 months, making it an excellent indicator for assessing the risk and progression of **diabetes** in patients on olanzapine. *CBC* - While some antipsychotics can cause hematological side effects like **agranulocytosis** (e.g., **clozapine**), **olanzapine** is not typically associated with severe bone marrow suppression requiring routine, long-term CBC monitoring. - CBC monitoring would be more relevant in the short-term if there were specific concerns for infection or adverse drug reactions. *ECG* - Some atypical antipsychotics can prolong the **QTc interval**, which would warrant ECG monitoring, but this adverse effect is less commonly associated with **olanzapine** compared to other antipsychotics like **ziprasidone** or **haloperidol**. - While a baseline ECG might be considered, long-term routine ECG monitoring is not typically indicated without specific cardiac risk factors or symptoms. *Monitoring for acute dystonia* - **Acute dystonia** is an extrapyramidal symptom that typically occurs early in treatment with antipsychotics, especially first-generation agents or at the initiation of therapy with second-generation agents like **olanzapine**. - While important to monitor acutely, it is not a long-term monitoring requirement once the patient is stable on the medication. *Renal function studies* - **Olanzapine** is primarily metabolized by the liver, and **renal excretion** plays a minor role in its elimination. - Therefore, long-term monitoring of renal function is not routinely recommended for patients on olanzapine unless there are pre-existing kidney conditions or other nephrotoxic medications.

Question 6: A 45-year-old woman presents to your office with a serum glucose of 250 mg/dL and you diagnose diabetes mellitus type II. You intend to prescribe the patient metformin, but you decide to order laboratory tests before proceeding. Which of the following basic metabolic panel values would serve as a contraindication to the use of metformin?

A. HCO3- > 30
B. Na+ > 140
C. K+ > 4.0
D. Glucose > 300
E. Creatinine > 2.0 (Correct Answer)

Explanation: ***Creatinine > 2.0*** - An elevated **serum creatinine** level indicating significant renal impairment is a contraindication to metformin use, as it markedly increases the risk of **lactic acidosis**. - **Metformin** is primarily excreted by the kidneys unchanged, and impaired renal function leads to drug accumulation and potential toxicity. - Traditional contraindication thresholds include serum creatinine >1.5 mg/dL in men or >1.4 mg/dL in women; a value **>2.0 mg/dL** clearly indicates significant renal dysfunction requiring avoidance of metformin. - Current guidelines emphasize using **eGFR** (contraindicated if <30 mL/min/1.73m²), but creatinine remains a key marker of renal function on basic metabolic panels. *HCO3- > 30* - An elevated **bicarbonate level** (HCO3-) above 30 mEq/L typically indicates **metabolic alkalosis**, which is not a direct contraindication for metformin. - While metabolic alkalosis should be investigated, it does not pose the specific risk of lactic acidosis associated with renal dysfunction and metformin use. *Na+ > 140* - A slightly elevated **sodium level** (Na+) above 140 mEq/L (normal: 135-145 mEq/L) is often associated with **dehydration** or other electrolyte imbalances and is not a contraindication for metformin. - While significant electrolyte imbalances should be addressed, mild hypernatremia does not directly increase the risk of metformin-induced lactic acidosis. *K+ > 4.0* - A potassium level of >4.0 mEq/L is within the **normal range** (typically 3.5-5.0 mEq/L) and is not a contraindication for metformin. - Significant hyperkalemia or hypokalemia would require evaluation and management, but a normal or slightly elevated potassium level does not preclude metformin use. *Glucose > 300* - While a blood **glucose level** >300 mg/dL indicates poorly controlled diabetes, this is actually an **indication** for initiating glucose-lowering therapy like metformin, not a contraindication. - Metformin's primary therapeutic purpose is to lower elevated glucose levels, and severe hyperglycemia itself does not increase the risk of metformin's specific adverse effects.

Question 7: A 49-year-old woman presents to the family medicine clinic with concerns about her weight. She has been constantly gaining weight for a decade now as she has not been able to control her diet. She has tried exercising but says that she is too lazy for this method of weight loss to work. Her temperature is 37° C (98.6° F), respirations are 15/min, pulse is 67/min, and blood pressure is 122/88 mm Hg. Her BMI is 30. Her labs from her past visit show: Fasting blood glucose: 149 mg/dL Glycated hemoglobin (HbA1c): 9.1% Triglycerides: 175 mg/dL LDL-Cholesterol: 102 mg/dL HDL-Cholesterol: 35 mg/dL Total Cholesterol: 180 mg/dL Serum creatinine: 1.0 mg/dL BUN: 12 mg/dL Serum: Albumin: 4.2 gm/dL Alkaline phosphatase: 150 U/L Alanine aminotransferase: 76 U/L Aspartate aminotransferase: 88 U/L After discussing the long term issues that will arise if her health does not improve, she agrees to modify her lifestyle and diet. Which of the following would be the best pharmacotherapy for this patient?

A. Insulin
B. Metformin (Correct Answer)
C. Dietary modification alone
D. Sitagliptin
E. Glipizide

Explanation: ***Metformin*** - This patient has newly diagnosed **type 2 diabetes mellitus** (Fasting blood glucose 149 mg/dL, HbA1c 9.1%) in the setting of obesity (BMI 30). **Metformin** is the **first-line pharmacotherapy** for type 2 diabetes due to its efficacy, favorable safety profile, and potential for weight neutrality or modest weight loss. - Metformin works by **decreasing hepatic glucose production**, decreasing intestinal glucose absorption, and increasing insulin sensitivity. *Insulin* - While insulin is highly effective in lowering blood glucose, it is typically reserved for patients with **very high HbA1c** (often >10%), **symptomatic hyperglycemia**, or those who have failed oral pharmacotherapy, it can also cause **weight gain**. - Initiating insulin as first-line therapy can be overly aggressive and may lead to **hypoglycemia** in patients who can respond to oral agents. *Dietary modification alone* - Although **lifestyle changes** (diet and exercise) are crucial and can be remarkably effective, this patient's **HbA1c of 9.1%** indicates that **monotherapy with diet and exercise alone is insufficient** to achieve glycemic control. - Pharmacotherapy is generally recommended for HbA1c levels **above 7.5%**, even with a commitment to lifestyle changes. *Sitagliptin* - **Sitagliptin** is a **DPP-4 inhibitor** that increases insulin secretion and decreases glucagon secretion in a glucose-dependent manner. - It is often considered a **second-line agent** or an add-on therapy, as its HbA1c-lowering effect is generally less potent than metformin. *Glipizide* - **Glipizide** is a **sulfonylurea** that works by stimulating insulin release from pancreatic beta cells. - It can cause **weight gain** and has a significant risk of **hypoglycemia**, making it a less favorable first-line agent, especially in an obese patient, compared to metformin.

Question 8: A 34-year-old man presents to the behavioral health clinic for an evaluation after seeing animal-shaped clouds in the form of dogs, cats, and monkeys. The patient says that these symptoms have been present for more than 2 weeks. Past medical history is significant for simple partial seizures for which he takes valproate, but he has not had his medication adjusted in several years. His vital signs include: blood pressure of 124/76 mm Hg, heart rate of 98/min, respiratory rate of 12/min, and temperature of 37.1°C (98.8°F). On physical examination, the patient is alert and oriented to person, time, and place. Affect is not constricted or flat. Speech is of rapid rate and high volume. Pupils are equal and reactive bilaterally. The results of a urine drug screen are as follows: Alcohol positive Amphetamine negative Benzodiazepine negative Cocaine positive GHB negative Ketamine negative LSD negative Marijuana negative Opioids negative PCP negative Which of the following is the most likely diagnosis in this patient?

A. Delusion
B. Alcohol withdrawal
C. Visual hallucination
D. Cocaine intoxication
E. Illusion (Correct Answer)

Explanation: ***Illusion*** - The patient is seeing **animal shapes in the clouds**, which is a misinterpretation of a real external stimulus. This is the definition of an **illusion**. - Unlike hallucinations, illusions involve a distorted perception of an existing object, rather than perceiving something that is not present. *Delusion* - A **delusion** is a **fixed, false belief** that is not amenable to change in light of conflicting evidence, and it is not what is being described here. - The patient is experiencing a perceptual distortion, not a false belief system. *Alcohol withdrawal* - While the patient tests positive for alcohol, the symptoms described are **perceptual distortions** (misinterpretation of clouds), not typical signs of alcohol withdrawal which include tremors, seizures, and delirium tremens. - The timeline of "more than 2 weeks" also makes acute alcohol withdrawal less likely, as withdrawal symptoms typically peak within days. *Visual hallucination* - A **hallucination** is a perception in the absence of an external stimulus; the patient would be seeing animals when no clouds (or other visual stimuli) are present. - The patient is seeing animal shapes *in the clouds*, indicating an existing external stimulus that is being misinterpreted. *Cocaine intoxication* - While cocaine intoxication can cause psychiatric symptoms like paranoia and hallucinations, the specific description of **seeing animal shapes in clouds** (misinterpretation of a real stimulus) points more directly to an illusion rather than a primary effect of cocaine use. - The patient's presentation does not include other common symptoms of acute cocaine intoxication like severe agitation, dilated pupils, or hyperthermia beyond a rapid heart rate.

Question 9: A 45-year-old man presents to a psychiatrist by his wife with recent behavioral and emotional changes. The patient’s wife says that her husband’s personality has completely changed over the last year. She also says that he often complains of unpleasant odors when actually there is no discernible odor present. The patient mentions that he is depressed at times while on other occasions, he feels like he is ‘the most powerful man in the world.’ The psychiatrist takes a detailed history from this patient and concludes that he is most likely suffering from a psychotic disorder. However, before prescribing an antipsychotic medication, he recommends that the patient undergoes brain imaging to rule out a brain neoplasm. Based on the presence of which of the following clinical signs or symptoms in this patient is the psychiatrist most likely recommending this imaging test?

A. Olfactory hallucinations (Correct Answer)
B. Echolalia
C. Anhedonia
D. Delusions of grandeur
E. Thought broadcasting

Explanation: ***Olfactory hallucinations*** - The presence of **olfactory hallucinations** ("unpleasant odors when actually there is no discernible odor present") in the context of new-onset psychotic symptoms and personality changes, particularly in a middle-aged adult, raises suspicion for an underlying **structural brain lesion**, such as a **frontal or temporal lobe tumor**. - Brain neoplasms in these regions can irritate cortical areas, leading to atypical psychotic symptoms and these specific types of hallucinations, making imaging crucial before initiating antipsychotic therapy. *Echolalia* - **Echolalia** is the involuntary repetition of words or phrases spoken by another person, often associated with conditions like **autism spectrum disorder**, **Tourette's syndrome**, or severe **psychotic disorders**, particularly **schizophrenia**. - While it can be a feature of psychiatric illness, it is not a red flag for structural brain pathology in the same manner as new-onset olfactory hallucinations. *Anhedonia* - **Anhedonia** is the inability to experience pleasure from activities usually found enjoyable, a prominent symptom of **major depressive disorder** and other mood disorders, as well as some psychotic disorders. - Although the patient reports feeling "depressed at times," anhedonia is a common psychiatric symptom and does not specifically point to a need for urgent brain imaging in the absence of other alarming features. *Delusions of grandeur* - **Delusions of grandeur** are false beliefs that one is much greater or more powerful than they truly are, as described by the patient feeling like "the most powerful man in the world." This symptom is characteristic of **bipolar disorder (manic episodes)** or some **psychotic disorders**. - While present in this patient, grandiose delusions are part of the core symptomatology of many psychiatric conditions and, by themselves, do not typically necessitate brain imaging to rule out a tumor. *Thought broadcasting* - **Thought broadcasting** is the belief that one's thoughts are being transmitted into the minds of others, a classic **first-rank symptom of schizophrenia**. - This symptom is indicative of a severe thought disorder within the spectrum of psychotic illnesses but does not specifically raise the suspicion of an underlying brain lesion requiring neuroimaging.

Question 10: A 21-year-old woman presents into the clinic worried that she might be pregnant. Her last menstrual period was 4 months ago and recalls that she did have unprotected sex with her boyfriend, despite not having sexual desire. They have since broken up, and she would like to do a pregnancy test. She appears very emaciated but is physically active. She says that she spends a few hours in the gym almost every day but would spend longer if she was to stray from her diet so that she does not gain any weight. Her calculated BMI is 17 kg/m2, and her urine pregnancy test is negative. Which of the following additional findings would most likely be present in this patient?

A. Hypocholesterolemia
B. Orthostasis (Correct Answer)
C. Primary amenorrhea
D. Hypokalemic alkalosis
E. Increased LH and FSH

Explanation: ***Orthostasis*** - This patient's presentation is highly suggestive of **anorexia nervosa** (BMI 17 kg/m2, amenorrhea, excessive exercise, fear of weight gain despite emaciation, and lack of sexual desire). **Orthostasis** (a drop in blood pressure upon standing) is a common finding due to **dehydration** and **volume depletion** often present in patients with anorexia nervosa. - **Bradycardia** and **hypotension** (which contributes to orthostasis) are frequent cardiovascular complications of anorexia nervosa as the body attempts to conserve energy. *Hypocholesterolemia* - Patients with anorexia nervosa more commonly present with **hypercholesterolemia**, not hypocholesterolemia. - This paradox is thought to be due to **decreased cholesterol degradation** and **impaired metabolism** in the setting of severe caloric restriction. *Primary amenorrhea* - The patient's last menstrual period was 4 months ago, indicating she has experienced menstruation in the past. Therefore, her amenorrhea is **secondary** (cessation of menses for 3 consecutive months in a woman who has previously menstruated), not primary (absence of menses by age 15 or within 5 years of thelarche). - The **hypothalamic-pituitary-gonadal axis dysfunction** due to low body weight and nutritional deficiency leads to secondary amenorrhea in anorexia nervosa. *Hypokalemic alkalosis* - **Hypokalemic alkalosis** is typically associated with **purging behaviors** like vomiting or laxative abuse, which are characteristic of the bulimia nervosa subtype or the binge-eating/purging subtype of anorexia nervosa. - While this patient's exercise is excessive, there is no direct evidence of purging in the provided vignette; her symptoms more strongly point towards the **restrictive subtype** of anorexia nervosa, where metabolic alkalosis is less common unless purging is also occurring. *Increased LH and FSH* - In anorexia nervosa, the severe caloric restriction and low body fat lead to **hypothalamic dysfunction**, specifically affecting the release of **gonadotropin-releasing hormone (GnRH)**. - This results in **decreased production of LH and FSH** from the pituitary gland, leading to hypogonadotropic hypogonadism, which explains the amenorrhea.

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