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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor=[[User:Gonzalo Romero|Gonzalo A. Romero, M.D.]] [mailto:gromero@wikidoc.org]
|QuestionAuthor=[[User:Gonzalo Romero|Gonzalo A. Romero, M.D.]],  {{SSK}} (Reviewed by Serge Korjian and  {{YD}})
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Anatomy, Behavioral Science/Psychiatry, Embryology, Pathology, Pharmacology
|MainCategory=Pharmacology
|SubCategory=Cardiology, General Principles
|SubCategory=Cardiology
|MainCategory=Anatomy, Behavioral Science/Psychiatry, Embryology, Pathology, Pharmacology
|MainCategory=Pharmacology
|SubCategory=Cardiology, General Principles
|SubCategory=Cardiology
|MainCategory=Anatomy, Behavioral Science/Psychiatry, Embryology, Pathology, Pharmacology
|MainCategory=Pharmacology
|SubCategory=Cardiology, General Principles
|SubCategory=Cardiology
|MainCategory=Anatomy, Behavioral Science/Psychiatry, Embryology, Pathology, Pharmacology
|MainCategory=Pharmacology
|MainCategory=Anatomy, Behavioral Science/Psychiatry, Embryology, Pathology, Pharmacology
|MainCategory=Pharmacology
|SubCategory=Cardiology, General Principles
|MainCategory=Pharmacology
|MainCategory=Anatomy, Behavioral Science/Psychiatry, Embryology, Pathology, Pharmacology
|SubCategory=Cardiology
|SubCategory=Cardiology, General Principles
|MainCategory=Pharmacology
|MainCategory=Anatomy, Behavioral Science/Psychiatry, Embryology, Pathology, Pharmacology
|SubCategory=Cardiology
|SubCategory=Cardiology, General Principles
|MainCategory=Pharmacology
|MainCategory=Anatomy, Behavioral Science/Psychiatry, Embryology, Pathology, Pharmacology
|SubCategory=Cardiology
|SubCategory=Cardiology, General Principles
|MainCategory=Pharmacology
|MainCategory=Anatomy, Behavioral Science/Psychiatry, Embryology, Pathology, Pharmacology
|SubCategory=Cardiology
|MainCategory=Anatomy, Behavioral Science/Psychiatry, Embryology, Pathology, Pharmacology
|MainCategory=Pharmacology
|SubCategory=Cardiology, General Principles
|MainCategory=Pharmacology
|Prompt=A 1-year-old boy is brought by her mother to the ER because of difficulty breathing and cyanosis. The pediatrician on call orders an echocardiogram in order to confirm the diagnosis. The pediatrician on call is a professor at a prestigious university; therefore he uses his radiologic findings to create a picture of the pathophysiology behind the cardiologic malformation.  The picture is shown below. Upon interrogation the mother states that he consumed a medication during her pregnancy to treat a psychiatric condition. She states that she started receiving prenatal care during the third trimester of pregnancy. Which of the following clinical presentations in her mother made her take the drug associated with the child’s condition?
|SubCategory=Cardiology
[[File:WBR0514.png|center|400px]]
|Prompt=A 5-year-old boy is brought to the emergency department by his mother for difficulty breathing and cyanosis. Physical examination reveals cyanotic extremities and bounding jugular venous pulsations. Initial imaging reveals the cardiac anomaly shown below. Upon further investigation, the mother admits that she received several medications during her pregnancy and did not receive any prenatal care. The physician suspects a medication-induced congenital abnormality. The patient's mother has most likely received medications during pregnancy for which disorder? <br>
|Explanation=The picture is showing an atrialized portion of the right ventricle. The opening of the tricuspid valve is displaced towards the apex of the right ventricle of the heart (congenital apical displacement of the tricuspid valve that typically causes significant tricuspid regurgitation). This cardiologic malformation is known as Ebstein anomaly, which is highly associated with Lithium use during pregnancy. Lithium is used to treat bipolar disorder, which is characterized by intense depressive symptoms alternated with manic episodes (characterized by:  distractibility, irresponsibility, seeks pleasure without regard to consequences (hedonistic), grandiosity-inflated self-esteem, flight of ideas-racing thoughts, in goal-directed Activity/psychomotor agitation, insomnia, talkativeness or pressured speech.
[[File:WBR0514a.jpg|400px]]
<br>
|Explanation=[[File:Ebstein_anomaly.png|400px]]<br>
<font color="MediumBlue"><font size="4">'''Educational Objective:''' </font></font> bipolar disorder is treated with lithium, a mood stabilizer, which is associated with Ebstein anomaly, an atrialization of the right ventricle.
Ebstein’s anomaly is a congenital heart disease characterized by abnormalities of the tricuspid valve, the right atrium, and the right ventricle. Apical displacement of the tricuspid valve leaflets leads to an atrialized right ventricle that is often too small to circulate sufficient blood. Ebstein's anomaly is relatively rare with an incidence of 1 in 200,000. Patients with severe forms present with cyanosis, dyspnea, and failure to thrive. The majority of these patients have early manifestation of the disease following close of the PDA and may be dependent on the PDA for pulmonary blood flow. Nonetheless, it is not uncommon that manifestations be delayed until childhood, adolescence, and even early adulthood. The development of Ebstein's anomaly has been associated with lithium administration during pregnancy particularly in the first trimester. Lithium is a mood stabilizer indicated for bipolar disorder, which is characterized by alternating symptoms of depression and episodes of mania. Manic episodes are usually described as significant distractibility, irresponsibility, hedonistic behavior, grandiosity, racing thoughts, psychomotor agitation, insomnia, and talkativeness or pressured speech.
<br>
|AnswerA=Several mild episodes of increased impulsivity, rapid speech, and insomnia for at least 2 years
'''References:''' FA 2013, Psychiatry Chapter
|AnswerAExp=[[Cyclothymia]] is a mild form of bipolar that lasts for at least 2 years. Psychotherapy is the optimal management approach for patients with cyclothemia.
|AnswerA=Mild episodes of increased shopping, rapid speech and insomnia lasting at least 2 years
|AnswerAExp=<font color="red">'''Incorrect.'''</font> [[Cyclothymia]] is a milder form of bipolar lasting at least for 2 years, which commonly is treated with psychotherapy
|AnswerB=Hypersomnia, overeating, and mood reactivity
|AnswerB=Hypersomnia, overeating, and mood reactivity
|AnswerBExp=<font color="red">'''Incorrect.'''</font> This describes [[atypical depression]], which is typically treated with MAO inhibitors
|AnswerBExp=Hypersomnia, overeating, and mood reactivity are the classical symptoms of [[atypical depression]]. Treatment typically involves MAO inhibitors and psychotherapy.
|AnswerC=Alternating intense sad symptoms with episodes of increased shopping, rapid speech and insomnia intense in nature
|AnswerC=Alternating symptoms of depression with episodes of increased impulsivity, rapid speech, and insomnia
|AnswerCExp=<font color="Green">'''Correct.'''</font> See overall explanation
|AnswerCExp=Bipolar disorder classically presents with alternating symptoms of depression and episodes of mania. Manic episodes are usually described as significant distractibility, irresponsibility, hedonistic behavior, grandiosity, racing thoughts, psychomotor agitation, insomnia, and talkativeness or pressured speech.
|AnswerD=Recurring intrusive thoughts, feelings, or sensations that cause severe distress; relieved partly by repetitive actions
|AnswerD=Recurring intrusive thoughts or sensations that cause severe distress and are relieved partly by repetitive actions
|AnswerDExp=<font color="red">'''Incorrect.'''</font> This refers to [[OCD]] (Obsessive compulsive personality disorder) which is commonly treated with [[SSRIs]]
|AnswerDExp=Compulsions that are relieved by repetitive behavior are the classical symptoms of [[obsessive compulsive disorder]] (OCD). The optimal pharmacological therapy for OCD is [[SSRI]]
|AnswerE=Excessive and unreasonable fear that interferes with normal function
|AnswerE=Excessive and unreasonable anxiety that interferes with normal function
|AnswerEExp=<font color="red">'''Incorrect.'''</font> This refers to specific [[phobia]], which is treated with SSRIs
|AnswerEExp=[[Generalized anxiety disorder]] (GAD) is characterized by excessive and unreasonable anxiety that interferes with normal function. The optimal The optimal pharmacological therapy for GAD is [[SSRI]]
|EducationalObjectives=Lithium is a mood stabilizer indicated for bipolar disorder. Lithium administration during pregnancy is associated with the development of Ebstein's anomaly, especially when administered during the first trimester. Bipolar disorder classically presents with alternating symptoms of depression and episodes of mania.
|References=Romfh A, Pluchinotta FR, Porayette P, et al. Congenital heart defects in adults: a field guide for cardiologists. J Clin Exp Cardiolog. 2012;(Suppl 8) '''(Image)'''<br>
First Aid 2014 page 518
|RightAnswer=C
|RightAnswer=C
|WBRKeyword=Ebstein anomaly, Lithium, Bipolar
|WBRKeyword=Ebstein's anomaly, Lithium, Bipolar disorder, Mania, Depression, Congenital heart disease
|Approved=No
|Approved=Yes
}}
}}

Latest revision as of 00:49, 28 October 2020

 
Author [[PageAuthor::Gonzalo A. Romero, M.D., Serge Korjian M.D. (Reviewed by Serge Korjian and Yazan Daaboul, M.D.)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pharmacology
Sub Category SubCategory::Cardiology
Prompt [[Prompt::A 5-year-old boy is brought to the emergency department by his mother for difficulty breathing and cyanosis. Physical examination reveals cyanotic extremities and bounding jugular venous pulsations. Initial imaging reveals the cardiac anomaly shown below. Upon further investigation, the mother admits that she received several medications during her pregnancy and did not receive any prenatal care. The physician suspects a medication-induced congenital abnormality. The patient's mother has most likely received medications during pregnancy for which disorder?

]]

Answer A AnswerA::Several mild episodes of increased impulsivity, rapid speech, and insomnia for at least 2 years
Answer A Explanation [[AnswerAExp::Cyclothymia is a mild form of bipolar that lasts for at least 2 years. Psychotherapy is the optimal management approach for patients with cyclothemia.]]
Answer B AnswerB::Hypersomnia, overeating, and mood reactivity
Answer B Explanation [[AnswerBExp::Hypersomnia, overeating, and mood reactivity are the classical symptoms of atypical depression. Treatment typically involves MAO inhibitors and psychotherapy.]]
Answer C AnswerC::Alternating symptoms of depression with episodes of increased impulsivity, rapid speech, and insomnia
Answer C Explanation [[AnswerCExp::Bipolar disorder classically presents with alternating symptoms of depression and episodes of mania. Manic episodes are usually described as significant distractibility, irresponsibility, hedonistic behavior, grandiosity, racing thoughts, psychomotor agitation, insomnia, and talkativeness or pressured speech.]]
Answer D AnswerD::Recurring intrusive thoughts or sensations that cause severe distress and are relieved partly by repetitive actions
Answer D Explanation [[AnswerDExp::Compulsions that are relieved by repetitive behavior are the classical symptoms of obsessive compulsive disorder (OCD). The optimal pharmacological therapy for OCD is SSRI]]
Answer E AnswerE::Excessive and unreasonable anxiety that interferes with normal function
Answer E Explanation [[AnswerEExp::Generalized anxiety disorder (GAD) is characterized by excessive and unreasonable anxiety that interferes with normal function. The optimal The optimal pharmacological therapy for GAD is SSRI]]
Right Answer RightAnswer::C
Explanation [[Explanation::

Ebstein’s anomaly is a congenital heart disease characterized by abnormalities of the tricuspid valve, the right atrium, and the right ventricle. Apical displacement of the tricuspid valve leaflets leads to an atrialized right ventricle that is often too small to circulate sufficient blood. Ebstein's anomaly is relatively rare with an incidence of 1 in 200,000. Patients with severe forms present with cyanosis, dyspnea, and failure to thrive. The majority of these patients have early manifestation of the disease following close of the PDA and may be dependent on the PDA for pulmonary blood flow. Nonetheless, it is not uncommon that manifestations be delayed until childhood, adolescence, and even early adulthood. The development of Ebstein's anomaly has been associated with lithium administration during pregnancy particularly in the first trimester. Lithium is a mood stabilizer indicated for bipolar disorder, which is characterized by alternating symptoms of depression and episodes of mania. Manic episodes are usually described as significant distractibility, irresponsibility, hedonistic behavior, grandiosity, racing thoughts, psychomotor agitation, insomnia, and talkativeness or pressured speech.
Educational Objective: Lithium is a mood stabilizer indicated for bipolar disorder. Lithium administration during pregnancy is associated with the development of Ebstein's anomaly, especially when administered during the first trimester. Bipolar disorder classically presents with alternating symptoms of depression and episodes of mania.
References: Romfh A, Pluchinotta FR, Porayette P, et al. Congenital heart defects in adults: a field guide for cardiologists. J Clin Exp Cardiolog. 2012;(Suppl 8) (Image)
First Aid 2014 page 518]]

Approved Approved::Yes
Keyword WBRKeyword::Ebstein's anomaly, WBRKeyword::Lithium, WBRKeyword::Bipolar disorder, WBRKeyword::Mania, WBRKeyword::Depression, WBRKeyword::Congenital heart disease
Linked Question Linked::
Order in Linked Questions LinkedOrder::