CMS - PSY

[Blind date18]

27 yr old M comes to the clinic with agitation complains of occipital headaches which started 30 minutes ago. He had a h/o of MDD including several suicide attempts's despite the t/t with SSRI and TCA . 8 days ago he went to PCP because of despodency during which he was switched to MOA inhibitor with d/c of fluoxetine , he was asked to sart taking this medication after 1 week and also start immediately MOA inhibitor diet. 12 hours ago the patient has a peanut butter sandwich . His vital's in the clinic are bp 180/120 , temp 105 , Pulse 120 , DTR +3 . He also has tremors and diaphoresis , oriented to Person not time and place . He also uses OTC diphenhydramine of seasonal allergies .Which had caused these symptoms?


a- drug drug interaction
b- drug - food interaction
c- Use of diphehydramine
d- Acute with drawal of SSRI



I can't tend to decide between seratonin syndrome or hypertensive crisis , any help would be highly appreciated . TIA?

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[Blind date18]

2- 16 yr old M complains to the clinic with early morning headaches from 1 year which have worsened and caused him to miss the school many days . The headaches are diffuse and occasionally throbs he gets relief with acteaminophen and resting in front of the television for 20 -30 minutes . His BMI is 31 kg/ m2 and he breaths through mouth with rr of 20 min. His mother complains that he snors at night time . He had an accident 1 year ago denies nausea and vomiting's O/E with later gaze on either sides he has nystagmus of 3-5 beats , FH for migrane in mom and brain cancer in grand father which of the following are causing symptoms?

- Obesity related Hypoventilation
- Idiopathic increased icp
-Migrane
- School related anxiety

 

[Blind date18]

7 yr old M child is brought to the clinic by his parents with problems related to his behavior and academics . His school performance is below 2 grades when compared to his peers. He was adopted at the ago of 15 yrs and his biological mother has h/o polysubstance abuse during pregnancy.During the time of adoption there was clear sign of physical abuse.His height is below 5th percentile and weight is below the 10 th percentile, vitals are normal. O/ e examination he has flat nasal bridge, Prominent ears . long plithirum . During the interview he is unable to sit still becomes frustated , which of the following is the most likely diagnosis?

- Fragile X syndrome
-Fetal alcoholic syndrome
-Rette syndrome
-Angle man syndorme

 

[Blind date18]

37 Yr old M presents ot hte clinic d/t excessive procarsination and Indecision . He is often late at work because he gets easily distracted by a task , even today he is late for the appointment because he was awake all night creating a computer folder system and also has to fold his clothes several times a day. He some times day dreams about projects and has to complete them in the dream before he can start any work. O/e MMS normal able to spell word world backward but when give 4 different interpretations of a proverb is unable to get to the final answer , what is the most probable diagnosis ?

-OCD
-ADHD
-GAD
-Schizotypal personality d/o

 

[Diphyllobothrium latum]

27 yr old M comes to the clinic with agitation complains of occipital headaches which started 30 minutes ago. He had a h/o of MDD including several suicide attempts's despite the t/t with SSRI and TCA . 8 days ago he went to PCP because of despodency during which he was switched to MOA inhibitor with d/c of fluoxetine , he was asked to sart taking this medication after 1 week and also start immediately MOA inhibitor diet. 12 hours ago the patient has a peanut butter sandwich . His vital's in the clinic are bp 180/120 , temp 105 , Pulse 120 , DTR +3 . He also has tremors and diaphoresis , oriented to Person not time and place . He also uses OTC diphenhydramine of seasonal allergies .Which had caused these symptoms?


a- drug drug interaction
b- drug - food interaction
c- Use of diphehydramine
d- Acute with drawal of SSRI



I can't tend to decide between seratonin syndrome or hypertensive crisis , any help would be highly appreciated . TIA?

Unstable vitals (not just hypertension) + tremors, diaphoresis, hyperreflexia point towards serotonin syndrome. Confirmed by the period between the SSRI and MAOI. You need two weeks between the last dose of the SSRI and the first dose of the MAOI to be safe.

2- 16 yr old M complains to the clinic with early morning headaches from 1 year which have worsened and caused him to miss the school many days . The headaches are diffuse and occasionally throbs he gets relief with acteaminophen and resting in front of the television for 20 -30 minutes . His BMI is 31 kg/ m2 and he breaths through mouth with rr of 20 min. His mother complains that he snors at night time . He had an accident 1 year ago denies nausea and vomiting's O/E with later gaze on either sides he has nystagmus of 3-5 beats , FH for migrane in mom and brain cancer in grand father which of the following are causing symptoms?

- Obesity related Hypoventilation
- Idiopathic increased icp
-Migrane
- School related anxiety

Early morning headaches are very characteristic of increased intracranial pressure, as more CSF backs up towards the brain during the night (lying vs standing). Confirmed by nystagmus (none of the other options should present with neuro signs). Obesity is a risk factor for IIP.

7 yr old M child is brought to the clinic by his parents with problems related to his behavior and academics . His school performance is below 2 grades when compared to his peers. He was adopted at the ago of 15 yrs and his biological mother has h/o polysubstance abuse during pregnancy.During the time of adoption there was clear sign of physical abuse.His height is below 5th percentile and weight is below the 10 th percentile, vitals are normal. O/ e examination he has flat nasal bridge, Prominent ears . long plithirum . During the interview he is unable to sit still becomes frustated , which of the following is the most likely diagnosis?

- Fragile X syndrome
-Fetal alcoholic syndrome
-Rette syndrome
-Angle man syndorme

Intellectual disability + facial features narrow the DDx between FAS and Fragile X. Of these, flat nasal bridge and long philtrum are specific for FAS and not Fragile X. The decreased height + weight are only found is FAS as well. Behavioral problems (they 're probably describing something inside the autism spectrum in the end) are very common in FAS. Finally the polysubstance abuse during pregancy tries to points us towards this direction.

 

[Blind date18]

Hi , thank you for your response but i'am still confused for increased Intracranial pressure question because , Idiopathic icp( Pseudo tumor cerebri) can cause 6 th nerve palsy which is also associated with obesity , which can result in nystagmus on conjugate gaze . So any thought's about this ?