A pt is for acute management of his schizophrenia.

Discussion in 'USMLE Step 2 CK' started by Guest, Feb 11, 2010.

  1. Guest

    Guest Guest

    A 36-year-old man is admitted to the hospital for acute management of his schizophrenia. He is a homeless man that you often see hanging out around the neighborhood. He has had multiple hospitalizations over the past 5 years and they usually occur when he stops taking his medications. He usually believes that his dead cousin speaks directly to him through fire hydrants and that she tells him that he does not need to take any medication. Unfortunately, she is the only person that he listens to. You are called to see him because you have treated him many times in the past. When you get to the floor, the nurse tells you that you should be careful when you enter the room because orders for the medication have not been written yet. You hear howling as you are talking to the nurse and when you get to his room you see that he is kneeling at the window "howling at the moon." He becomes angry and violent when you try to enter his room. You go back to the nurse station and tell her to give him an injection of haloperidol and diazepam. In addition, at this time you should

    A. begin psychosocial treatment with behavior skills training
    B. give dantrolene to prevent neuroleptic malignant syndrome
    C. prescribe benztropine to prevent parkinsonian-like symptoms
    D. prescribe clozapine to treat his negative symptoms
    E. schedule immediate electroconvulsive therapy
  2. Guest

    Guest Guest

    C. prescribe benztropine to prevent parkinsonian-like symptoms
  3. Guest

    Guest Guest

    Explanation:

    In acute psychiatric emergencies, a neuroleptic agent (haloperidol) and a benzodiazepine (diazepam) are typically given to control the patient and aid in sedation. An anticholinergic agent, such as benztropine, should be added to prevent parkinsonian-like symptoms (rigidity and akinesia) that may occur in patients treated with high-potency antipsychotic agents (haloperidol).

    In this acute situation, it is inappropriate to begin psychosocial treatment with behavior skills training (choice A). Psychosocial treatment, including behavior skills training, multi-family groups, vocational training, and workshops, is very important in the long-term management of schizophrenia. During the patient's hospitalization, after the patient is stabilized, the treatment plan should focus on practical issues, and set the stage for outpatient psychosocial issues.

    Dantrolene is the treatment for neuroleptic malignant syndrome (choice B), which may be caused by high-potency antipsychotic agents (haloperidol). It is not routinely given to prevent this condition. NMS is associated with a high fever, autonomic instability, rigidity, behavioral changes, and laboratory abnormalities such as elevated white blood cell count, creatine kinase, and abnormal liver function tests.

    Clozapine (choice D) is used as a second-line antipsychotic agent for patients who do not respond to the typical antipsychotic medications and have prominent negative symptoms (flat affect, poverty of speech, and asociality). It is not typically the first agent given in an acute psychiatric emergency. It is associated with agranulocytosis (1%) and requires weekly monitoring of the white blood cell count.

    Electroconvulsive therapy (choice E) may be used in cases of non-responsive catatonia. It is not often used to treat an acute psychiatric emergency with a wild and out of control patient.

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