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step2ck_form7/Block 4/Question#39 (9.1 difficulty score)
A 20-year-old man is brought to the physician ...

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submitted by chris07(63),

The patient's "bizarre" behavior has been occurring for the past year. He has only been treated for hypothyroidism with levothyroxine for 6 months. Since the bizarre behavior he was brought in about today predates him even starting on levothyroxine, the diagnosis is Schizophrenia (Hallucinations, >6 months).

I fell for the trap and went down the road of thinking his thyroid was being overrated, causing hyperthyroid induced psychosis, but after reading that the behavior predated it, it made it not the correct answer.

chris07  overtreated* +1  

submitted by athleticmedic(13),

Can anyone help explain to me why he has lower extremity hyperreflexia and upper extremity resting tremor? I can't find anything that associates those symptoms to Schizophrenia.

krewfoo99  I think its because his hypothyroidism is being overtreated with levothyroxine. +  
wasifp  So I respectfully disagree that he is being over treated because the TSH would drop below 0.5 if that was the case. His hyperreflexia and resting tremor along with mutism and staring are consistent with catatonia which is seen in severely schizophrenic patients. Catotonia can be both "excited" and "retarded". The excited aspect of his catatonia is the hella purposeless movement (eg, tremor) and his spasticity maybe actually be a manifestation of posturing seen in these patients. +2  
fkstpashls  they're parkinsonian symptoms more than catatonia symptoms, though. +  

submitted by step_prep5(196),
  • Young male patient (perfect demographic for onset of schizophrenia) who presents with 1 year of auditory hallucinations and negative symptoms, most consistent with schizophrenia
  • TSH is normal, so patient would not have psychosis secondary to thyroid dysfunction // Urine toxicology is normal so would not be substance-induced psychotic disorder
  • Brief psychotic disorder: 3 days to 1 month
  • Schizophreniform disorder: 1 month to 6 months
  • Schizophrenia: >6 months

submitted by dlw(1),

I totally thought this guy had Huntington's possibly.

happyyoyo  that would be really young, but we also don't have a family history, and he doesn't have the choreiform movements seen in Huntingtons, and those pts also tend to have depression. +  

submitted by medstudenttears(1),

Was anyone else thinking bath salts? Why cant it be bath salt intox & withdrawal?