WBR0514

Author	[[PageAuthor::Gonzalo A. Romero, M.D., Serge Korjian M.D. (Reviewed by Serge Korjian)]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Anatomy, MainCategory::Behavioral Science/Psychiatry, MainCategory::Embryology, MainCategory::Pathology, MainCategory::Pharmacology
Sub Category	SubCategory::Cardiology, SubCategory::General Principles
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. The physician suspects a medication related congenital abnormality. What is the most likely presentation of the mother considering the drug she was likely prescribed? ]]
Answer A	AnswerA::Multiple mild episodes of increased impulsivity, rapid speech and insomnia for at least 2 years
Answer A Explanation	[[AnswerAExp::Cyclothymia is a milder form of bipolar lasting for at least for 2 years. Treatment of cyclothemia is commonly with psychotherapy.]]
Answer B	AnswerB::Hypersomnia, overeating, and mood reactivity
Answer B Explanation	[[AnswerBExp::These 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 manic episodes characterized by significant distractibility, irresponsibility, hedonistic behavior, grandiosity, racing thoughts, psychomotor agitation, insomnia, and talkativeness or pressured speech.]]
Answer D	AnswerD::Recurring intrusive thoughts, feelings, or sensations that cause severe distress; relieved partly by repetitive actions
Answer D Explanation	[[AnswerDExp::These are the classical symptoms of obsessive compulsive disorder (OCD) which is commonly treated with SSRIs]]
Answer E	AnswerE::Excessive and unreasonable anxiety that interferes with normal function
Answer E Explanation	AnswerEExp::Generalized anxiety disorder is characterized by excessive and unreasonable anxiety that interferes with normal function. It is treated with SSRIs.
Right Answer	RightAnswer::C
Explanation	[[Explanation:: Ebstein’s anomaly is a congenital heart disease characterized by abnormalities of the tricuspid valve, right atrium and 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 200000. Patient's with severe forms present with cyanosis, dyspnea, and failure to thrive. A majority of these patients have early presentation soon after PDA closure as they and may be dependent on the PDA for pulmonary blood flow. The development of Ebstein's anomaly has be associated with Lithium intake particularly in the first trimester. Lithium is mood stabilizer that remains a first line agent for the treatment of bipolar disorder. Bipolar disorder classically presents with manic episodes characterized by significant distractibility, irresponsibility, hedonistic behavior, grandiosity, racing thoughts, psychomotor agitation, insomnia, and talkativeness or pressured speech. Educational Objective: Lithium is mood stabilizer used for the treatment of bipolar disorder that is associated with the devlopment of Ebstein's anomaly if administered to women in the first trimester. Bipolar disorder classically presents with manic episodes characterized by significant distractibility, irresponsibility, hedonistic behavior, grandiosity, racing thoughts, psychomotor agitation, insomnia, and talkativeness or pressured speech. References: Romfh A, Pluchinotta FR, Porayette P, Valente AM, Sanders SP. Congenital Heart Defects in Adults : A Field Guide for Cardiologists. J Clin Exp Cardiolog. 2012;(Suppl 8) (Image) First Aid 2014 p. 518]]
Approved	Approved::Yes
Keyword	WBRKeyword::Ebstein anomaly, WBRKeyword::Lithium, WBRKeyword::Bipolar disorder
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::