ling
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. A 19-year-old man comes to the physician because of frequent nosebleeds over the past 3 weeks. He has bipolar disorder currently well controlled with lithium carbonate, bupropion, and valproic acid. Physical examination shows no abnormalities except for dried blood in the nares. Mental status examination shows an anxious mood and slight motor restlessness. Serum studies show a lithium carbonate level of 1.3 mEq/L (therapeutic range=0.6–1.2), and valproic acid level of 77 μg/mL (therapeutic range=40–100). Which of the following is the most appropriate next step in management?
A
) Measurement of serum aspartate aminotransferase (AST, GOT) activity
B
) Measurement of serum bupropion level
C
) Platelet count
D
) Discontinuation of lithium carbonate therapy
E
) Discontinuation of valproic acid therapy
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| nadiabarati
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valproic acid causes thrombocytopenia as it's side effect. So I'm wondering between C and E?
I go with E.
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| robin082006
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C--> Platelet count
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| maiya
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robin082006 wrote:
C--> Platelet count
why C?
i chose E when i did the test for the reason of thrombocytopenia.
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| ashfaque
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Answer D acc to question valproic acid is with in normal therapeutic range plus dried blood in nasal mucosa where as lithium levels are shown to be eleveted plus signs of motor restlessness favours lithium toxicitiy . as lithium has a very narrow therapeutic index so (any suspicion of intoxication should lead to immediate withdrawl of lithium treatment and close monitoring of lithium levels===Oxford textbook
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| hanialkhadher
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Slight tremors is not dangerous at time only may need to decrease dosage and infact the level in blood is fine <1.5 ,
what infront of you ,deal with. which is platelets.
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| r_albayunen
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C
VA is in the normal values
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| Justice
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I would go with (C)
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| young_doc
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I go with E.
Just because Valproic acid is in the therapeutic range, doesn't rule it out as the culprit!!
Thrombocytopenia seen with Valproic acid is a SIDE-EFFECT (in other words it can be seen at therapeutic levels).
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| young_doc
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(Tremors/Motor restlessness is also a side-effect of Valproic Acid)
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| nadiabarati
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I agree with young)doc. Side effect is not related to dose!!!
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| vradojc1
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So, he might have been picking his nose which is the most common reason for nosebleeds. Why would you discontinue a beneficial drug even before knowing whether it caused a side effect? I'm going with C. If the platelets are low, then I'll discontinue Divalproex.
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| mdwannabe
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Get Platelet count first. No discontinuation of effective therapy untill proven neccessity.
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| young_doc
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vradojc1 wrote:
So, he might have been picking his nose which is the most common reason for nosebleeds. Why would you discontinue a beneficial drug even before knowing whether it caused a side effect? I'm going with C. If the platelets are low, then I'll discontinue Divalproex.
Picking your nose doesnt give you tremors, last i checked.
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| fongch
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I chose C too
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| caduceus
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so finally whats the answer...i checked the book format of nbme it says E
bt i feel its c?
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| caduceus
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anyone????
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| romano
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caduceus_indya wrote:
so finally whats the answer...i checked the book format of nbme it says E
bt i feel its c?
That sounds stupid to me. Why withdrawing the drug before you're sure about the correlation? Checking the thrombocytes is quick and simple and you wouldn't really just send this patient home without knowing what the count is? Next step in management must be C...
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| mildus
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I agree with you romano, it is logical first to see if there is trombocytopenia, since bleeding can be caused by other factors as well, and how do we know without checking that in given patient there is valproate-induced trombocytopenia and consequent bleeding!?
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| ifiMD
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i agree with Romano... we first have to know the platelet count, then we´ll decide what to do.
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| tamerbashir
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still E !
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| romano
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Anyway, Valproate isn't given as an infusion, that's why I think it sounds weird to answer E. Sure, I would tell the patient not to take anymore of the pills before I had checked the trombocytes etc. I just think that alternative E sounds like you should withdraw it right at the spot, just like you should do e.g. if you expect an allergic reaction in a patient given i.v. antibiotics.
Well, sure E should be the answer, but I think the question qould be better formulated.
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| Ivonne
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Just found out that the answers given by the downloaded form of the NBMEs are not necessary the right ones. Any voice is very welcome but with evidence means that the answers are given by NBME.
Will go with C
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| Korotkoff
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Should we check whether there is thrombocytopenia first? I mean before we blame it on VA. Not Veteran Affairs, valproic acid.
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