PREP 2012 Question

• An 18-year-old college student with a history of ADHD presents to your office as a new

patient.

• She requests a renewal prescription for her methylphenidate.

• You note her current supply, according to the empty bottle that she hands you, should be

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• She fills out a release of information form for her prior physician, but that person cannot be reached today.

• When you ask why she takes this medication, she replies, “It helps me pay attention.”

• When you ask why the bottle is empty, she states, “The pills spilled in the sink.”

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• The MOST appropriate next step is to

A. Ask for a urine sample to perform a urine drug screen B. Ask her to return in 1 to 2 weeks to give you adequate

time to contact the previous prescribing physician

C. Complete a brief medical history and write a prescription for a 1-month supply

D. Complete an inventory to assess risk for alcohol and recreational drug use and write the requested

prescription for 1 month

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• Medication diversion

– When prompted, answers to questions about the medication are limited and vague

– Some medications are more difficult to assess diversion than others.

– Be educated about potential drug diversion

• Establish individual office policies and procedures that address such concerns

16. PREP 2012 Question 142

• You are seeing a 17-year-old boy in your office for suture removal following a laceration to

the left index finger.

• He reports that he cut himself while operating a meat slicer at a local deli, where he has

worked since dropping out of school.

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• He has a past history of ADHD, which you briefly treated with methylphenidate.

• In addition to the healing, sutured 2-cm finger laceration, you observe tachycardia and

injected conjunctivae bilaterally.

• The boy appears nervous and has difficulty recalling details of the accident at work.

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• You obtain a psychosocial history that includes family functioning, drug history, sexual history, peer interaction, and mood and anxiety

assessment.

• Upon further questioning, he admits to daily marijuana use for more than 2 years.

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• The MOST appropriate next step is to

A. Advise him to stop use and follow up in 1 month B. Arrange urine drug testing

C. Notify his parents of his marijuana use

D. Obtain a more detailed substance abuse history E. Resume methylphenidate therapy

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• Detailed drug history

– Life history of use of each substance – The frequency of use

– The context of use

– Details regarding the effects upon the patient’s life – Decide the degree of substance use

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• Experimental drug use

– Occasional use without drug-seeking behavior

• Problematic drug use

– Substance use that has resulted in social, financial, psychological, physical, or legal problems

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• Substance abuse – any one of the following:

– Recurrent failure to meet important responsibilities

– Recurrent use in situations when such use is likely to be physically dangerous

– Recurrent legal problems arising from drug use – Continued use despite knowledge of problems

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• Substance dependence – three or more of the following:

– Tolerance – Withdrawal

– Using more for longer periods than intended – Desire to or unsuccessful efforts to cut down

– Considerable time spent in obtaining the substance or using or recovering from its effects

– Important social, work, or recreational activities given up because of use

– Continued use despite knowledge of problems caused by or aggravated by use

17. PREP 2012 Question 251

• The parents of a 15-year-old boy would like your help in sending their son to a drug

rehabilitation facility.

• He disagrees and feels he can stop use of illicit drugs on his own.

• He reportedly started smoking and drinking at age 12 years.

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• His mother recently found drug paraphernalia in his room, prompting the visit.

• He tells her his friend asked him to hold these items for him but they are not his.

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• This boy’s prognosis is MOST influenced by

A. Age at which substance abuse began B. Duration of substance use

C. His current age

D. Peer substance use

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• Drug abuse in adolescents

– The younger the age on onset, the higher the incidence of future abuse and dependence. – Adolescents who begin use later and use

substances for a shorter period of time are more likely to be able to stop.

– The route of administration leads to a substance being more addicting and, thus, harder to give up.

18. PREP 2012 Question 267

• You are seeing a 17-year-old boy whose mother is concerned.

• “He is not eating as well as before and appears to be losing weight.”

• He is upset about being brought in…

• “I am just stressed about my tests, and I’m not sleepin’ as well.”

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• Vital signs reveal BP 130/95 mm Hg, HR 95 bpm, and body mass index 19.7.

• He appears restless and has cold and sweaty palms.

• He has mildly dilated pupils, very active bowel sounds, and hyperactive reflexes.

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• The MOST likely cause for this boy’s weight loss is A. Anxiety disorder B. Eating disorder C. Hyperthyroidism D. Sleep disorder E. Stimulant abuse

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• Adrenergic toxidrome (amphetamines or

cocaine)

– Decreased sleep and appetite

– Restlessness

– Increased blood

pressure and heart rate – Dilated pupils – Increased reflexes • Other symptoms – Headaches, dizziness – Dysphoria, tremors – N/V/D, loss of libido • Chronic use – Malnutrition – Hostility, paranoia • Large doses