SSRI + Tramadol- serotonin syndrome
tramadol: weak opiod agonist. also inhibits 5-HT and NE reuptake; SE: dec seizure threshold. serotonin syndrome

clomipramine (TCA)- OCD

PTSD: tx: CBT, SSRI, venlafaxine

acute stress disorder: tx: CBT;

respiratory depression, pupil constriction= opioids tox (morphine, heroin, methadone)

TCA- tri-C’s: convulsions, coma, cardiotoxicity; tx: NaHCO3 to px arrhythmia;

16. 47yM, depression * 4wk;
started a wt loss program 6wk ago, consisting of diet and exercise, had 13ib wt loss during this period;
HTN hx, med thiazide switch to propranolol 8wk ago; dx?
substance-induced mood disorder
dx- sx develop during (or within 4wk of) intox or withdrawal, or caused by a medication use.

25. depression- serotonin- 5-HIAA

complex partial seizure- staring spells, automatism, post-ictal confusion;
EEG- unlike in absence seizure, hyperventilation can’t stimulate a complex partial seizure;
case: 24yM, 2mo h/o staring spells that last 1-2min. during episodes, smacks lips and picks at shirt collar (automatism);
past year, intermitent episodes of smelling burnt rubber, every 2wk; hear intense hissing sound during these episodes.
most likely fx on EEG?

dx:partial seizure
EEG- focal spikes localized to temporal lobe

NOT absence seizure;

hypsarrhythmia- infant spasm

27. bupropion- no sexual side effects; inc seizure

28. alcohol withdrawal/ cocaine abuse- bug crawling
cocaine/ agitation- tx: BZ

40. 1st year surgical resident
sleeping problem, 2mo
anxiety, spends hr reading
avoid social
sleep- wake up multiple times
wt loss
ans- begin escitalopram therapy

41. normal aging- sleeing pattern

BZ overdose:
mild to moderate impairment of CNS funciton.
paradoxical reaction- anxiety, delirium, combativeness, hallucination, aggression can also occur.
GI also been occ reported.

Narcolepsy- dec REM latency

pervasive development disorder- Rett syndrome, autism specturm disorder.

Counseling after a stressful event may prevent PTSD from developing. Group psychotherapy with other survivors is helpful. Pharmacotherapy includes SSRIs, other antidepressants, and benzodiazepines. Prazosin has been used to reduce nightmares.

2-8. A 25-year-old woman comes to the physician at her husband’s request because of
increasing irritability and tense mood over the past yeaL Her husband would like to start
a family, and he is concerned about her ability to handt€ the added responsibility. She
says that she worries about their finances despite the fact that they have no debt and
she and her husband have jobs that pay well. Her pulse is 84/min, and blood pressure is
120/70 mm Hg. Physical examination shows no abnormalities except lor sweaty palms.
Mental status examination shows tension and anxiety. She admits to occasional dilflcutty
sleeping and periods of mild depression but does not think thatlhis is out of the
ordinary. Laboratory studies show:
Erythrocyte count
Leukocyte count
Thyroid – stimu~ting hormone
Thyroxine (T J
4 millionlmml
Toxicology screening is negative. Which 01 the following is the most appropriate
pharmacotherapy for this patient?
tl A) Bupropion
tl B) Buspirone
tl C) Levothyroxine
tl 0) Melhimalot€
tl E) Quetiapine

10. Five weeks after being discharged from the hospital after treatment for a psychotic
episode, a 27 -year-okJ man comes to the physician for a follow-up examination. Durirrg
hosp italization, he claimed that he was instructed by the Lord to found a new religion
and that a famous gospel singer was inlOV€ with him. Today, he says that he still hears
the voices of the Lord and members of the church he attends in his apartment and
when he shops in the supermarket He no longer believes the world ne€ds a new
religion because the Lord is no longer instructing him to create one. He states, “My
father in heaven tells me that he is at peace, and therefore, so am I.” Current
medications include ri speridone and lorazepam. He drinks one to two beers on
weekend s. He used marijuana regularly in coltege but has abstained for the pastS
years. He appears clean and is ca sually dressed. His temperature is 36.rC (98°F ),
pulse is 72Jmin, respirations are 20/min, and blood pressure is 130/72 mm H9.
Physical examination shows no abnormalities. Mental status exa mination shows a
calm affect. He is cooperative, alert, and oriented to person, place, and time. Based on
this information, which of the followi rrg is the most likely current diagnosis for this
pati ent?
~ A) Bipolar disorder
~ B) Cyclothymic disorder
~ C) Delusiona l disorder
~ D) Schizoaflective disorder
~ E) Substance-induced mood disorder

A 17 -year-old boy is brought to the emergency department by his mother because of
a 20-minute episode of severe chest pain and sweating that started 1 hour ago
while he was watching television. On arrival, he is alert and repeatedly expresses
concern that something is ”very wrong” He reports that during the episode, his heart
was “pounding,” he feel short of breath, and he was sure he was having a heart
attack and was going to die. One month ago, he had a similar episode that occurred
in the evening approximately 30 minutes after his high schoolloolball practice. At
that time, results of laboratory sllKJies and an ECG obtained in the emergency
department showed no abnormalities. After the initial episode, he quit the football
team, and he has continued 10 limit his physica l activity because he is afraid of
bri ng ing on another episode. He reports no insomnia or changes in appetite. His
mOlher states that he was diagnosed wilh an innocent heart murmur at the age of 6
months, but it has not been noted on examinations since the age of 1 year. His
paternal grandfather died of a myoca rdial infarction 3 years ago atlhe age of 68
years. The palientlakes no medications. He does not smoke cigarettes, drink
alcohol, or use illicit drugs. He performs well in school. He is 180 cm (5 ft 11 in) tall
and weighs 73 kg (161 Ib); BMI is 23 kglm2 His temperature is 37″C (98.WF), p u~e
is 98/min, respirations are 20/min, and blood pressure is 130/83 mm Hg. Cardiac
examination shows a normal S1 and S2 with variation of S2 on respirati on. The
remainder of the examination shows no abnormalities. Which of the following is lhe
most li ke ly diagnosis?
0) Hypenrophlc cardiomyopalhy
F) Panic disorder (ans)

A 7 -year-okJ boy is broughllo the physician by his mother because of dilflcutty at
school since beginning fi rst grade 6 weeks ago_ His teachers state that he has been
daydreaming frequently, does oot complete his work, and does not parti cipate in
cla ssroom discussions_ His mother reports that he is very shy, will not go to s!eepovers,
and has stomachaches every weekday moming_ He played on a soccer team, but he
quit when his mother coukJ not drive him to games and he had to carpool with another
family_ Physica l examiJ)[lti on shows no abnormalities_ On mental status examination,
the boy sits on his mother’s lap, does not make eye contact with the physician, and is
hesilantlo aJlSwer questioJlS but seems eager to please_ Which of the following is the
most likely explanation for these fi nd ing s?
0 ) Separati on anxiety disorder

1 B. A 47-year-old woman is brought to the emergency department by her husband
because of increasing confusion during the past 2 days. On arrival, she has a
generalized tonic-clonic seizure la sting 4 minutes. She has bipolar disorder treated
with several medications, but her husband is unsure of their names. He knows that she
sometimes takes ibuprofen for mild arthritis pain caused by exercise. He says that she
has been active and exercising more lately, but he cannot think of other changes in her
rolJline. She has no history of seizure disorder. She is oriented to person but not to
place and time. Her pulse is 9O/min, and blood pressure is 140/90 mm Hg. On physical
examination, she is tremulous and somno!ent There is bilateral nystagmus. AIl ECG
shows a second-degree atrioventricular block. The most likely cause of this patient’s
symptoms is an adverse effect of which of the following medications?
Q5) pt has bipolar…pt is taking NSAID plus she has seizure, confusion , tremor, nystagmus, Av block……lithium toxicity

24. A 32-year-old woman is hosp italized for evaluation of a 5-month history of he adaches.
While recovering from sedation with lorazepam for cerebral angiography, she has dull,
aching abdominal pain that is localized to the right upper quadrant of the abdomen
without radiation. ~ has occurred several times over the past week after meals. She
has had no nausea or vomiting. Following a CT scan 3 months ago, she had aphonia
for 48 hours. She has a history of cholecystectomy, appendectomy, hysterectomy, and
exploratory laparoscopy lor endometriosis. Cerebral angiogra phy shows normal
findings. Repeat neurologic examinations and CT scan of the head are negative. Her
temperature is 36.4°C (97.WF), puJse is 68/min, respirations are 12/min, and blood
pressure is 122176 mm Hg. During examination, she complains of unbearable pain,
atthough the abdomen is tender to light palpation without guarding or rebound. No
masses are palpated. Bowel sounds are normal. PeMc examination shows normal
findings. Test of the
E) Somatization disorder

case: visual hallucination *4d; med: amitriptyline
TCA tox: tri-C’s: convulson, coma, cardiotoxicity; also respiratory depression, hyperpyrexia;
confusion and hallucinations in elderly due to anticholinergic side effects.

30. A 29-year-old man comes to the physician because of the inability to maintain an erection through completion of sexual activity. He has been married lor 3 months and has not been able to complete coitus over the past 2 months. He is usually able to attain an erection by direct penile stimulation and is often aware of nocturnal erections when waking during the night For the past month, he and his wife have attempted to have intercourse about twice a week. He drinks several alcoholic beverages before engaging in sexual activity in an effort to relax. He has had two major depressive episodes over the past 4 years and was successfully treated with desipramine; he has not taken the medication since his marriage. He has borderline hypertension but takes no medications for it He has a strong family hi story of type 2 diabetes mellitus. He takes ranitidine lor stomach problems. His vital signs are normal. Cranial nerve function appears normal. He walks normally. Laboratory
studies show:
Platelet count
Fasting glucose
y- G lutamy~ra nsferase
11 gldL
86 mg/dL
70 U/L (N=5-50)
Which of the following is the most likely explanation for these findings?
A) Alcohol use

case: 6mo h/o depressed mood, fatigue, poor concentration, diff sleeping;
he says his wife sleeps in a separate room because of his loud snoring; BMI=35
MME: mildly depressed mood.
G) Mood disorder due to a general medica l cond ition

speech is slow; conjunctivae are injected- marijuana intox

cloazepam- sedative; onset of action: within an hour

case: alcoholism, agitated, confused, trembling; UA- oxalate crystal
– ethylene glycol toxicity
note: NOT methanol

SSRI + MAOI= serotonin syndrome
waiting 2wk between the discontinuation of an MAOI (eg. phenelzine) and the start of a SSRI is deemed sufficient to avoid the risk of developing serotonin syndrome.

2-42. A 32-year-old woman comes to the physician because of increasingly severe pain that
originates in her lell shoulder and radiates to her elbow. She describes the pain as
constant and burning, rating her current pain as a 7 on a 1 O-point sca le. Eighte€n
months ago, she sustained a nerve injury of the lell upper extremity in a motor vehicle
colli sion. Since that time, she has be€n unable to return to work. Current medications
include oxycodone and gabapentin. Physical examination shows atrophy of the lell
thenar eminence. Muscle strength in the lell forearm and fi nger flexors is 3/5. On
sensory examination, there is severe pain with light stroking of the anterolateral aspect
of the lell arm. Further sensory testing is deferred. During the examination she tells her
physician, “I’m tired of all this. My medication is not strong enough. ~ only takes the
edge 011 my pain, which is only getting worse. I’m realizing I’ll be like this forever”
Which of the following is the most appropriate response by the physician?
A) “Are you worried about more nerve damage developing?”
B) “Do you ever use more pain medication than is prescribed?”
C) “Have you been fe€ling like just giving up?”
D) “Is the pain ca used by touch soci ally limiting?”
E) “LeI’s revi ew your medical concerns”
C) “Have you been fe€ling like just giving up?” C. You want to determine whether she has symptoms of depression, as well as determining whether she is suicidal in her thoughts. If she answers yes to that question, the test answer will be to 302 her.

desusional disorder- nonbizarre
schizophrenia- bizarre

45. An 18-year-old man is brought to the emergency department by friend s 1 hour after
they found him on the couch at a party unable to move. Earlier that evening, he had
been using synthetic heroin. On arrival, his pulse is 85/min, respirations are 18/min,
and blood pressure is 130/80 mm Hg. Examination shows stiffness in all extremities,
drooling, and slow response to questions. Which of the following brain regions is most
li ke ly affected?
tI F) Substantia nigra

46_ A 15-year-old boy is brought to the emergency department by his two friends because
of unusua l behavior that began at a party 1 hour ago_ His friends say that he became
raucous and made an unwanted sexual advance to a girl he had just met He then ran
into the stre€t, ca re ~ss to oncoming cars, saying he was able to avoid them_ His pulse
is 84/min, respirations are 12Jmin, and blood pressure is 11 ono mm Hg_ He is
agitated when !eft alone, but he calms down when spoken to by nursing staff_ Physical
examination shows an unsteady gait Pupils are equal and reactive_ Which of the
following is the mostlikeiy drug taken?
~ A) Alcohol
~ 8 ) Amphetamine
~ C) Coca ine
~ OJ Heroin
~ E) LSD
~ F) Marijuana
~ 8 ) Amphetamine

dysthymia For the past two years, Nick has experienced poor appetite, insomnia, fatigue, and several other symptoms. These symptoms have kept him from feeling happy, and yet they do not indicate a major depressive episode. When assessing Nick, what disorder …

Manic Episode Elevated or Irritable mood for at LEAST 1 WEEK, 3 or MORE of following (4 if mood irritable): Grandiosity, Decreased need for sleep, more talkative, Flight of ideas / racing thoughts, Distractibility, Increased goal-directed activity and Excessive involvement …

Bipolar disorder describes mood disorders. It is also known as manic-depressive illness. Bipolar disorder results in unusual shifts in the person’s mood, energy and functioning ability of a person. In bipolar disorder, both the depression and mania are present at …

Mood Disorders Psychological disorders characterized by emotional extremes Major Depressive Disorder A mood disorder in which a person experiences, in the absence of drugs or a medical condition, two or more weeks of significantly depressed moods, feelings of worthlessness, and …

Individuals who have bipolar disorder go through different periods of moods that are dictated by time. At one point, they may seem to be in a deep depression and exhibit most or all of the symptoms of depressive disorder. Then, …

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