Psychiatry NBME’s

1) a 55 year old woman is brought to the emergency department by her parents because of strange behavior for 3 months. She insist that her father and next door neighbor want to steal money from her. She also said that there were fumes that her neighbors were blowing under her door causing headaches and skin tone changes. She has called the radio station for the same. Other than this she has no problems and insist that she is normal. Mental status shows no incoherence, loose associations, hallucinations. She is oriented to time, place, person.

1) Schizophreniform
2) Paranoid.
3) shizo
4) MDD
5) Delusional

Delusional!

2) A 47 year old man comes to the physician because of 4 weeks of depression, lack of energy, poor concentration, daytime sleepiness. He started a program for weight loss 6 weeks ago, consisitng of diet and exercise, and had a 5.9(13kg) weight loss.He has HTn and was switched to water pill from propranolol. no h/o psych illness. He is 180cm tall and now weights 97kg. Bim is 30. Bp 1135/90. Mental status shows depressed mood and poor concentration. What is the diagnosis?

1) adjustement disorder with depressed moon
2) Dysthymic
3) MDD
4) mood disorder to to medical condition
5) substance induced

5) Substance-induced mood disorder – Propranolol can cause depression

3) A 67 year old with parkinson is bought by his wife. She said, “he has become increasingly withdrawn and tearful during the past 3 weeks. He has had poor energy and decreased sleep for 2 months.” Current medications is Cari-levadopa and pramipexole. He has had a 6.kg weight loss in 3 months. He is 5ft 3 inches tall and now weights 90lbs. Resting tremor and hand bradykinesia have increased since last visit. On examination he has flat affect and downcast gaze, speech is slow and soft. When asked about the crying spells he said, “Who wouldn’t be sad with the damn disease I got?” He doesn’t want to go anywhere because he doesn’t want people to see him with his tremor. Most likely diagnosis

1) Adjustement with depressed moos
2) Normal reaction to medical condition
3) MDD
4) Dysthymic
5) D/t carbi-levadopa

3) MDD

4) a 13 year old girl is brought by her mother because she has not started menstruation yet. The patient has MDD which was treated with fluoxetine for 8months. Not sexually active and physical examination is normal. Sexual development is at tanner stage 2. Mental status shows mild depression and anxiety. What do you do next?

1) Discuss normal pubertal development
2) reassessment by her psychiatrist
3) Prolactin measurement
4) discontinue fluoxetine
5) begin benzo

1) Discuss normal pubertal development

8) a 47yo woman is admitted to the hospital because of a 12 hr history of tremors and confusion. she has a history of alcoholism and last consumed alcohol 24 hours ago. she has no other history of serious illness. she does not smoke cigarettes or use illicit drugs. on admission, she is agitated, diaphoretic, orientnted to person but not to time or place. vitamin B1 , folic acid, and three doses of diazepam are administered intravenously. 35 min later, respiratory compromise develops. patient is intubated, mechanical ventilation is started . 2 hr later, she remains agitated. she is pulling at her peripheral intravenous and urethral catheters and picking at her blankets. pulse 140/min, bp160/100, neurologic exam show tremor of upper and lower extremities and hyperreflexia bilaterally. next step pharmacotherapy?

1) add flumazenil
2) add haloperidol
3) add phenytoin
4) Additional diazepam
5) Add B1 (thiamine)

4) This is refractory DT’s -> give more BDZ’s

1. 47 yo woman with schizophrenia. Treated with haloperidol for 15 yrs and well controlled. PE is normal. MSE shows neutral mood and blunted affect. No auditory or visual hallucinations. Mentions that she is worried about tardive dyskinesia and she wants to decrease her risk for this condition. Most appropriate measure?
A) Decrease dosage of haloperidol
B) Swith from haloperidol to aripriazole
C) Switch from haloperidol to carbamazepine
D) Add citalopram
E) Add lorazepam
F) Maintain current regimen
B!

67 yo male comes in complaining of 2 mont history of fatigue and decreased libido. Used to sleep 8 hr every night, but now sleeps 10 hours at night and naps during day. 10lbs weight loss during this period. Has Type 2DM, HTN, degenerative arthritis of knee, back hips; HLD. On metformin, ibuprofen, simvastatin, sildenafil, lisinopril, HCTZ. 5’10”, weight 230lbs. BMI 33. HR 74, BP 130/82. Pedal pulses decreased. HEberden nodes over DIP joints. Sensation to pinprick decreased over feet. MSE shows constricted affect. Says losing interest in life because multile meds are so hard to manage. No suicidal ideation. Glucose 155; Cholesterol 162 (HDL 46, LDL 90), TG 128. What is most appropriate next step?
A) add bupropion
B) add insulin
C) add venlaxafine
D) discontinue lisinopril
E) discontinue simvastatin
A!

47 yo man comes to ED 1 hour after hit his head on glass door he thought was open. Fell to ground fo a few seconds and said he felt faint. Parents assist him to chair. No loss of consciousness and recalls the whole sequence of events. Dx with schizophrenia at 17 and institutionalized until 19. Lived at home with parents since then. Only medication is olanzapine. HR 80, BP 120/70 while supine; HR 90, BP 105/75 while standing. PE shows 2cm circular ecchymosis on left side of forehead. Neuro exam shows fine tremor and occasional protrustions of the tongue. AOx3. CT of head will show what?
A) accumulation of fluid in subdural space in left temporoparietal area
B) bilateral calcification of nuclei basales
C) contustions of frontal lobes
D) symmetric enlargement of ventricles
E) tumor in pituitary gland
D!

3.5 year old boy been wetting bed 2x per week since being toilet trained at age of 2. Says their 2 daughters were toilet trained at 2 years old and haven’t wet bed since. Tried all available treatments including bedwetting alarm and waking child up at midnight to have him use bathroom. They believe child is wetting the bed just to make them angry. Which is most appropriate intervention?
A) Reassurance that this is normal behavior
B) Play therapy
C) Family therapy
D) Imipramine
E) Sulfamethoxazole
A! He is less than 5 years old – still normal

A 32-year-old woman with schizoaffective disorder is brought to the emergency department because of a 7day history of progressive lethargy, loss of appetite, nausea, and leg swelling; she has had jaundice since this morning. Five weeks ago, she was hospitalized for treatment of her psychiatric symptoms. Treatment with three medications was started during hospitalization, but she does not remember their names. She has no history of liver disease or other serious illness. She appears drowsy. Her pulse is 72/min, and blood pressure is 105/70 mm Hg. There is scleral icterus. Abdominal examination shows tenderness in the right upper quadrant. Neurologic examination shows a fine bilateral hand tremor. Mental status examination shows no evidence of hallucinations or delusions. She is oriented to person, place, and year but not to the day of the week or month.

Serum studies show:
Bilirubin, total 5 mg/dL
Alkaline phosphatase 160 U/L
AST 240 U/L
ALT 210 U/L

Which of the following medications is most likely responsible for these findings?
A) Clozapine
B) Haloperidol
C) Lithium carbonate
D) Trazodone
E) Valproic acid

E! Valproate – recall that it can cause fatal hepatotoxicity

A 37-year-old man is brought to the emergency department by police after he was found wandering on the street. The officers say that the patient was screaming and talking to himself. He is unkempt and agitated, and he is wearing winter clothes on a hot summer day. Neurologic examination shows no focal findings. During the examination, he says that he is not going to take any medicine, and the “television told me about the murders.” Which of the following is the most likely additional finding in this patient?
A) Cerebral edema on CT scan of the head
B) Enlarged lateral and third ventricles on CT scan of the head
C) Increased serum dopamine concentration
D) Increased serum and urine copper concentrations
E) Temporal spikes on EEG
B! Ventriculomegaly is often seen in schizophrenia

One month after undergoing liver transplantation, a 47yearold woman is admitted to the hospital for treatment of organ rejection. Twentyfour hours after intravenous methylprednisolone therapy is begun, she begins to have visual hallucinations that her organ donor has entered her hospital room naked and is drawing symbols on her skin with an eyebrow pencil. Current medications include tacrolimus, mycophenolate mofetil, omeprazole, trimethoprimsulfamethoxazole, acyclovir, and nystatin. The patient has no history of psychiatric illness. She is awake and alert. Physical examination shows a wellhealing surgical incision over the abdomen. On mental status examination, she says she is worried about her visual hallucinations. She is oriented to person, place, and time. Which of the following is the most likely explanation for this patient’s psychiatric symptoms?
A) Adjustment disorder with anxious mood
B) Corticosteroidinduced psychotic disorder
C) Delirium
D) Malingering
E) Schizophrenia
B! 24 hours after getting IV methylprednisolone

A 27-year-old man is brought to the emergency department 30 minutes after his brother found him agitated, tremulous, and complaining of a headache. He had eaten a peanut butter sandwich 12 hours before his symptoms began. He has a 10 year history of severe major depressive disorder. During this period, he has attempted suicide three times despite treatment with both selective serotonin reuptake inhibitors and tricyclic antidepressants. Eight days ago, he went to a new physician because of increasing despondency. This physician immediately discontinued the fluoxetine and substituted tranylcypromine to start 1 week later. He also instructed the patient to start a monoamine oxidase inhibitor diet immediately. Current medications also include diphenhydramine as needed for seasonal allergies. He has no history of hypertension, diabetes mellitus, or migraine. On arrival, he is agitated. His temperature is 40.6°C (105°F), pulse is 130/min, respirations are 26/min, and blood pressure is 180/120 mm Hg. Physical examination shows diaphoresis and tremor of the upper extremities. Deep tendon reflexes are 3+ bilaterally; there are no pathologic reflexes. On mental status examination, he is complaining of occipital headache. He is oriented to person but not to place or time. Which of the following is the most likely cause of these findings?
A) Acute anxiety attack
B) Acute fluoxetine withdrawal
C) Drugdrug interaction
D) Ingestion of peanut butter
E) Use of diphenhydramine
C! Started tranylcypromine (an MAOI) 1 week after discontinuing an SSRI. According to First aid, you should allow at least 2 weeks of no overlap between the 2 to prevent serotonin syndrome

An 87-year-old man is admitted to the hospital because of dehydration and emaciation. He appears catatonic and is unresponsive to questions. One month ago, he began withdrawing from relatives and talking constantly about death. He gradually stopped eating and drinking and has had a 9kg (20lb) weight loss during this time. He has a 35year history of major depressive disorder and has attempted suicide twice. He has no chronic medical conditions and currently takes no medications. He appears cachectic and is staring into space. He does not respond to verbal stimuli. He is 168 cm (5 ft 6 in) tall and weighs 50 kg (110 lb); BMI is 18 kg/m . Examination shows temporal wasting. Which of the following is the most appropriate next step in management?
A) Biofeedback
B) Desipramine therapy only
C) Fluoxetine therapy only
D) Desipramine and risperidone therapy
E) Fluoxetine and risperidone therapy
F) Electroconvulsive therapy
F! He has catatonia likely 2/2 MDD
ECT is the most effective therapy for MDD, especially with psychotic features, acute mania, and catatonia!

A 37-year-old male police officer comes to the physician at the request of his superiors 1 week after he witnessed a terrorist bombing during which several civilians and three fellow police officers were killed. He sustained only minor injuries and assisted in rescuing survivors and gathering body parts. Since the bombing, he has felt emotionally numb and has been unable to enjoy activities he used to find pleasurable. He has continued to work but has requested assignments far removed from the site of the attack. He describes his sleep as fitful. Two years ago, he sustained a bullet wound to the right calf, which left him with a slight limp. He has no other history of medical or psychiatric illness. He says he used to drink one to two beers nightly but has been drinking two to three beers nightly for the past week. Physical examination confirms the previous gunshot injury to the calf and shows no other abnormalities. On mental status examination, he is irritable and says he is not depressed. He tells the physician, “They made me come. I’m not interested in talking with anyone. I just want to spend time with my buddies and be left alone.” Which of the following is the most appropriate initial step in management?
A) Encourage the patient to discuss the trauma in detail
B) Provide information about the range of reactions to trauma
C) Recommend group therapy with other trauma survivors
D) Recommend a 1month medical leave of absence from active duty
E) Recommend a physician led trauma debriefing series
F) Recommend a 12step program
G) Begin clonazepam therapy
H) Begin fluoxetine therapy
B!

A 27-year-old woman is brought to the emergency department 2 hours after cutting her arms superficially with a razor blade. On arrival, she appears calm and is holding a stuffed animal. She says that she cut herself because she wanted to “feel something” and is unsure if she will be able to stop herself from doing this again. She says that she sleeps 8 hours each night and has a good appetite. From the ages of 10 to 15 years, she was physically and sexually abused by her stepfather and mother on several occasions. She has never had a longterm relationship and has been fired from several jobs because of difficulty getting along with her supervisors. Her pulse is 80/min, respirations are 16/min, and blood pressure is 120/60 mm Hg. Physical examination shows lacerations over both forearms. Neurologic examination shows no abnormalities. On mental status examination, she denies depressed mood or suicidal ideation but is convinced that she is worthless and deserves to die. Which of the following is the most likely diagnosis?
A) Borderline personality disorder
B) Conversion disorder
C) Dissociative identity disorder
D) Hypochondriasis
E) Major depressive disorder
F) Malingering
G) Posttraumatic stress disorder
A! Borderline personality disorder – cutting herself to feel something is a very characteristic sign

A 13-year-old girl is brought to the physician by her father for a wellchild examination. He is concerned about her weight and eating habits. He says that she is always “on the go” and never sits down for a full meal. She will often just grab a piece of fruit when she is on her way to an activity. She will eat a full meal when the family has dinner together every Sunday. She has talked about wanting to become a vegetarian because of her concern for animals. She has had the same group of friends since elementary school. She is the captain of her soccer team and practices 4 days weekly. She is active in an afterschool drama program 3 days weekly and is the lead in this season’s play. She maintains a B grade average. Her father says that she talks on the telephone “constantly” and is animated and cheerful most of the time. When she is in her bedroom, she prefers to keep the door closed and stops talking if she is on the telephone and her father walks into the room. She has a disorganized bedroom and often falls fast asleep on a bed covered with piles of clothes. Menarche has not occurred. She appears thin and muscular. She is at the 50th percentile for height and 35th percentile for weight, which is unchanged from last year. Vital signs are within normal limits. Breast and pubic hair development are Tanner stage 2. Physical examination shows no abnormalities. When interviewed alone, she is animated. She shrugs and rolls her eyes when asked about her diet and weight. She thinks she is fine and does not understand why her father is so upset. Which of the following is the most appropriate next step?
A) Reassure the father that this is normal development
B) Recommend individual psychotherapy
C) Recommend nutritional counseling
D) Recommend that the father keep a log of what his daughter eats
E) Schedule weekly examination and weighing
A! She has an unchanged weight from the previous year and seems healthy “thin and muscular”

A 22-year-old woman is brought to the emergency department because of a 4hour history of violent, agitated behavior. Her college roommates are concerned that she may have used illicit drugs. She has no known history of similar behavior or serious illness. She takes no medications. Her temperature is
38°C (100.4°F), pulse is 120/min, respirations are 20/min, and blood pressure is 140/90 mm Hg. On mental status examination, her speech is loud and rapid in rate and rhythm. She describes her mood as “wild”; her affect is reactive but primarily exuberant and irritable. Her thought process is tangential. She reports no hallucinations. During the examination, she tries to leave the emergency department, pushing a security guard aside and throwing a clipboard on the floor. Intoxication with which of the following substances is the most likely cause of this patient’s symptoms?
A) Cannabis
B) Ecstasy (3,4methylenedioxymethamphetamine)
C) Heroin
D) LSD
E) Methamphetamine
E! Methamphetamine – she has evidence of psychomotor agitation

A 47-year-old man with Down syndrome is brought to the physician because of increasing forgetfulness and irritability over the past 10 months. He has been awakening at 3 am to get dressed for the day and now gets lost when he takes his daily walk. He appears disheveled. Examination shows decreased memory and a normal mood and affect. During the interview, he attempts to leave the office, saying “take me home.”

A) Amygdaloid nucleus
B) Caudate nucleus
C) Medial geniculate nucleus
D) Nucleus basalis of Meynert
E) Red nucleus
F) Substantia nigra
G) Subthalamic nucleus

D! Early onset AD from Down Syndrome

A 37-year-old man is brought to the physician because of a change in personality over the past 4 months. He has become sexually disinhibited, tactless, impulsive, and easily irritated. His father had similar symptoms at the age of 42 years. Examination shows involuntary movements of the tongue. He has a sudden coarse involuntary jerking movement of the upper extremity that he attempts to hide by pretending to straighten his hair.

A) Amygdaloid nucleus
B) Caudate nucleus
C) Medial geniculate nucleus
D) Nucleus basalis of Meynert
E) Red nucleus
F) Substantia nigra
G) Subthalamic nucleus

B! Huntington disease

A 24yo man is brought to the emergency department from a psychiatric hospital because of a decreasing level of consciousness over the past 3 days. He has become progressively less responsive and has remained in bed for the past 12 hours without speaking or following commands. He has a history of schizophrenia with multiple psychiatric hospitalizations and is currently being treated with haloperidol and benztropine. His temperature is 39.4°C (103°F), pulse is 120/min, respirations are 28/min, and blood pressure is 180/100 mm Hg. He withdraws weakly to noxious stimuli. His eyes are open, but he does not fix or follow visual stimuli or gaze around the room. He is mute and does not follow commands. Examination shows marked rigidity of the neck and all extremities. Laboratory studies show:

Leukocyte count 18,000/mm3
Segmented neutrophils 80%
Lymphocytes 20%
Serum creatine kinase 12,000 U/L

Cerebrospinal fluid:
Erythrocyte count 2/mm3
Leukocyte count 1/mm3
Protein 28 mg/dL
Glucose 78 mg/dL

A CT scan of the head shows no abnormalities. Which of the following is the most likely underlying cause?
A) Catatonia
B) Conversion reaction
C) Dissociative fugue
D) Drug reaction
E) Infection
F) Malingering
G) Toxin

D! Drug reaction (likely NMS from haloperidol)

A 3-year-old girl is brought to the emergency department 1 hour after injuring her right arm. This is her third visit to the emergency department in 6 months. The parents say that she fell. The child is too upset to say how she injured herself. Her parents note that she is overly aggressive in day care, where she is not responding to instructions, and has hit other children. During her previous visit for a wrist injury, an xray of the wrist showed normal findings. On examination, the child appears fearful of the examiner, provides limited responses, and is restless and easily distracted. An x-ray of the right humerus shows a closed fracture. Which of the following is the most appropriate next step in management?
A) Admit to hospital
B) Cognitive behavior therapy
C) Contact child protective services
D) CT scan of the head
E) Family counseling
F) Followup outpatient appointment in 2 weeks
G) Neuropsychological testing
H) Psychiatric assessment
C! Contact CPS for child abuse

A 57-year-old woman comes to the physician because of difficulty sleeping, tearfulness, and restlessness since her daughter was diagnosed with metastatic breast cancer 3 days ago. She reports that when she goes to bed at night, she is unable to fall asleep for several hours and lays in bed worrying about her daughter’s situation. The patient underwent a mastectomy for breast cancer 7 years ago. She takes acetaminophen/butalbital for occasional migraines. Her vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, she is tearful and tense but calms during the conversation. There is no evidence of suicidal ideation. Which of the following is the most appropriate next step in management?
A) Biofeedback
B) Carbamazepine therapy
C) Clonazepam therapy
D) Clonidine therapy
E) Imipramine therapy
F) Olanzapine therapy
G) Pentobarbital therapy
H) Sertraline therapy
C! Tricky question – she likely has adjustment d/o

An 8-year-old boy is brought to the physician because of a 1year history of increasingly frequent episodes of eye blinking and facial grimacing during the past 6 months that now occur several times daily. He also frequently makes grunting and throat clearing noises. His teacher often sends him out of the room for being disruptive. He says that he will repeatedly shrug one of his shoulders and attempt to hide this behavior by smoothing his hair. He is embarrassed by these behaviors and can suppress them with effort, but they often return when he is distracted and are exacerbated by stress. The behaviors do not occur during sleep. He has no history of serious illness and takes no medications. During the examination, he has several episodes of rapid, forceful eye blinking and throat clearing. Physical examination shows no other abnormalities. Mental status examination shows a mildly anxious mood and affect. Which of the following is the most appropriate pharmacotherapy?
A) Dextroamphetamine
B) Hydroxyzine
C) Imipramine
D) Lithium carbonate
E) Methylphenidate
F) Risperidone
F! Risperidone for Tourette’s
(first line is alpha2 agonists like clonidine, guanfacine)

A 47-year-old man has had tension and hand tremors for 1 month. He has been treated for bipolar disorder with lithium carbonate for 6 months. He has a 2year history of alcohol abuse on weekends. His temperature is 36.7°C (98°F), pulse is 90/min, respirations are 16/min, and blood pressure is 140/86 mm Hg. Examination shows mild tremors of the fingers and hands. Serum lithium carbonate concentration is 1 mEq/L (therapeutic range=0.6-1.2). Serum electrolyte concentrations and thyroid function tests are within normal limits.
A) Bupropion
B) Chlorpromazine
C) Fluoxetine
D) Haloperidol
E) Imipramine
F) Lorazepam
G) Perphenazine
H) Propranolol
H – Essential tremor

An 82-year-old man with dementia, Alzheimer type, is brought to the physician because of a 4day history of visual hallucinations and irritability. He has a 2month history of insomnia. He has osteoarthritis, hypertension, and hypothyroidism. His medications are rivastigmine, ibuprofen, atenolol, levothyroxine, and amitriptyline. His blood pressure is 128/88 mm Hg. Physical examination shows no abnormalities. On mental status examination, he recalls zero of three objects after 5 minutes. During the examination, he points his finger and sternly says, “You need to stop doing that right this minute.” When asked whom he is addressing, he says, “that tiny little man shouting over in the corner.” Results of a complete blood count, measurement of serum glucose concentration, and kidney and liver function tests are within the reference ranges. Urinalysis shows no abnormalities. Discontinuation of which of the following of this patient’s medications is most appropriate at this time?
A) Amitriptyline
B) Atenolol
C) Ibuprofen
D) Levothyroxine
E) Rivastigmine
A! Amitriptyline

A previously healthy 27-year-old man is brought to the emergency department by his girlfriend because of a 6week history of daily episodes of hearing a voice telling him that he is Christ. He is convinced that he has the power to heal the sick and requests that he be admitted into the wards to help the patients. During the past 4 weeks, he has had a 10kg (22lb) weight loss. He has not slept more than 2 hours nightly for 2 weeks. When he is awake at night, he watches television or calls strangers on the telephone. He does not drink alcohol or use illicit drugs. He is 173cm(5ft8in)tall and weighs80kg(176lb); BMIis27kg/m . His temperature is 37°C (98.6°F), pulse is 110/min, and blood pressure is 160/90 mm Hg. Physical examination shows no other abnormalities. On mental status examination, he appears restless and agitated. He flirts with female staff members and tries to convince people of his powers. He has pressured speech and talks incessantly. There is no evidence of visual hallucinations. Recall is difficult to assess because he cannot concentrate. Longterm memory is intact. He is oriented to person, place, and time. Which of the following is the most likely diagnosis?
A) Bipolar disorder
B) Cyclothymic disorder
C) Major depressive disorder with psychotic features
D) Schizoaffective disorder
E) Schizophrenia
A! Bipolar disorder

A 28-year-old man is brought to the emergency department because of flulike symptoms and cough productive of clear sputum for 24 hours. He has been hospitalized eight times over the past 5 years because of bizarre delusions and hallucinations during which a voice tells him what to do. He has a 9year history of type 1 diabetes mellitus. In addition to insulin, he is receiving clozapine therapy (400 mg daily) for his psychotic condition. During mental status examination, he is hallucinating and says that he is being pursued by special agents of the government. Leukocyte count is 2750/mm3, and serum glucose concentration
is 140 mg/dL. Urinalysis is within normal limits. Which of the following is the most appropriate next step in management?
A) Add lithium carbonate therapy
B) Add penicillin therapy
C) Decrease the dose of clozapine
D) Discontinue clozapine therapy
E) Increase the dose of clozapine
D! Discontinue clozapine therapy – tricky does not meet clear indications for discontinuation based on ANC recommendations

An unconscious 7-year-old boy is brought to the emergency department by his parents. The family emigrated from rural Southeast Asia 4 years ago. An interpreter is used because the parents do not speak English. They say, “Our child has been possessed by a spirit since birth who speaks through his mouth with spit and blood and then takes his powers away.” He has had these spells all of his life. He does not attend school. They recently sacrificed a piglet as an offering to the spirit, but there has been no change in the child’s condition. The parents seem devoted. He awakens during the physical examination and smiles vacantly at his parents. He appears confused and speaks in monosyllables. No other abnormalities are noted. Which of the following is the most appropriate next step in diagnosis?
A) Contact child protective services
B) Psychoeducational assessment
C) Family therapy
D) Throat culture
E) X-ray of the chest
F)ECG
G)EEG
G! EEG – confused after regaining consciousness – likely post-ictal state

57-year-old man comes to the physician with his wife because of a 1-month history of bizarre behavior at night. His wife says that most nights he falls asleep at approximately 11 pm and begins kicking and groaning in the bed shortly after 12:30 am. Seven times during this period, he has jumped out of the bed and run back and forth across the room, punching the air. She tries to wake him during these episodes because she is afraid that he might hurt her or himself. She reports that when she succeeds, he seems alert but tells her that he was being attacked and needed to defend himself or escape. The patient tells the physician that he does not recall the behavior his wife is describing but remembers having a recurrent dream in which he is in danger and cannot breathe. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, he has a pleasant and full range of affect. His thought process is rational and goal directed. He says that based on his wife’s description of his behavior at night, he is afraid that he might hurt her. Results of laboratory studies are within the reference range. Which of the following is the most likely diagnosis?
A) Central sleep apnea
B) Nocturnal panic disorder
C) Nocturnal paroxysmal dystonia
D) REM sleep behavior disorder
E) Restless legs syndrome
F) Sleep-related complex partial seizure disorder
G) Sleep terror disorder
D! REM sleep behavior disorder

Over the past 7 years, a 25-year-old graduate student has had increasingly severe palpitations, tremulousness, nausea, sweating, and inability to concentrate while taking examinations. He is worried because he recently failed an examination despite being thoroughly prepared. Examination shows normal findings. Which of the following is the most appropriate next step in diagnosis?
A) Ambulatory ECG monitoring
B) 24-Hour urine collection for 5-hydroxyindoleacetic acid
C) 24-Hour urine collection for measurement of catecholamine and metanephrine concentrations
D) Measurement of serum thyroxine (T 4) and thyroid-stimulating hormone concentrations
E) Psychiatric evaluation
E! Psych eval

A 27-year-old woman, gravida 1, para 1, comes to the physician with her husband because of progressive irritability and anxiety since the birth of her child 3 weeks ago. Pregnancy was complicated by premature labor that was managed with bed rest. Delivery occurred at term with no complications. Examination of her newborn at birth showed no abnormalities. The patient reports that he feeds well and appears healthy, but she has constant worries about his health and her own health. She adds that she has had a decreased appetite and difficulty sleeping. Her husband notes that she has been increasingly withdrawn from family and friends and that she has reported thoughts of suicide. The patient has no history of serious illness or major depressive disorder. Her only medication is a multivitamin. She appears tired. Physical examination shows no abnormalities. On mental status examination, she has an irritable mood and depressed affect. She is oriented to person, place, and time. Which of the following is the most likely diagnosis?
A) Adjustment disorder
B) Bipolar disorder
C) Generalized anxiety disorder
D) Major depressive disorder
E) Post-traumatic stress disorder
D! She meets criteria for MDD

An 8-year-old girl is brought to the physician by her mother because of frequent stomachaches over the past 3 months. She has a 1-year history of difficulty falling asleep and poor concentration. She has always been a good student and excels in extracurricular activities. Her parents divorced 6 months ago. Physical examination shows no abnormalities. Mental status examination shows an anxious affect and coherent thought process. She says that she is worried about her classes and about her performance in the school band and on the soccer team. Which of the following is the most likely diagnosis?
A) Generalized anxiety disorder
B) Obsessive-compulsive disorder
C) Panic disorder
D) Post-traumatic stress disorder
E) Separation anxiety disorder
A! She worries about multiple domains

A 32-year-old Bosnian man is brought to the emergency department by police 30 minutes after they found him sitting in a cemetery and muttering to himself. The police officers report that the patient appeared lost in thought and did not respond to their questions; he then passively accompanied them to the hospital. Identification in the patient’s wallet indicates that he is a construction worker. The physician calls the patient’s employer and learns that he was part of a crew working on a bridge that morning when a crane collapsed, causing multiple injuries to people working in trailers on the ground. A hospital interpreter says that the patient had been an ambulance driver in a military war zone 10 years ago. The patient sits quietly and stares ahead; he appears unaffected by the bustling activity in the emergency department. His pulse is 72/min, and respirations are 14/min. Physical examination shows no abnormalities. Mental status examination shows a reserved demeanor. He speaks in monotone and responds to questions with vague, noncommittal answers. He says he is not depressed or anxious. Which of the following is the most likely diagnosis?
A) Adjustment disorder
B) Catatonia
C) Dissociative disorder
D) Generalized anxiety disorder
E) Schizotypal personality disorder
Dissociative disorder!

A 23-year-old man is brought to the emergency department because of progressive paranoia and agitation for 48 hours. His roommate reports that the patient has not been sleeping or eating during this period but had been staying up all night studying for examinations for the past 4 days. He adds that last night the patient crouched below their apartment window peering out and insisting that every passing car was occupied by FBI agents. The patient has no history of psychosis. He states that he has been under stress from his new position as a software engineer. Physical examination shows 4-mm pupils, dry mouth, and mild tremulousness. On mental status examination, he is agitated, and his speech is rapid with increased volume. There is evidence of paranoid delusions about persecution by the police. Which of the following is the most likely diagnosis?
A) Bipolar disorder
B) Delusional disorder
C) Generalized anxiety disorder
D) Schizophrenia
E) Substance-induced psychotic disorder
While he has been staying up and has rapid speech, he lacks a lot of the grandiosity, elevations in mood, etc… for acute mania. It also hasn’t been going on long enough.

Doesn’t meet criteria for any of the others so E) substance-induced is most likely

A 72-year-old woman comes to the physician because of a 3-month history of fatigue and difficulty sleeping. She has had a 5.4-kg (12-1b) weight loss during this period because of decreased appetite. Her husband died 18 months ago. She has a 15-year history of hypertension treated with verapamil and a 3-month history of insomnia treated with zolpidem. Laboratory studies 1 week ago showed no abnormalities. She is 170 cm (5 ft 7 in) tall and weighs 60 kg (133 lb); BMI is 21 kg/m 2. Her pulse is 74/min, and blood pressure is 131/84 mm Hg. Physical examination shows no abnormalities. Mental status examination shows an irritable and tearful mood. She expresses hopelessness about the future. Which of the following is the most likely finding in this patient?

A) Decreased hemoglobin concentration
B) Decreased serum vitamin B (thiamine) concentration
C) Increased percentage of bands on complete blood count
D) Increased serum cortisol concentration
E) Increased serum prolactin concentration

D! She meets criteria for MDD – high cortisol has been implicated in development of depressive d/o per First aid

A 30-year-old woman has had frontal headaches, stomach upset, and poor appetite for 4 weeks; she has had a 2-kg (5-1b) weight loss during this period. She has pain in the left upper quadrant of the abdomen 1 to 3 hours after eating dinner. Over-the-counter antacids have been ineffective. She blames herself for not taking better care of her body. The headaches occur at night and awaken her. She feels fatigued in the morning and has difficulty getting up and going to work. Over the past month, her supervisor has complained about her recent errors, which she attributes to difficulty concentrating. She says that she is so tired when she comes home that she has stopped going out with her friends and just goes to sleep. Which of the following is the most likely diagnosis?

A) Adjustment disorder with depressed mood
B) Borderline personality disorder
C) Dysthymic disorder
D) Major depressive disorder
E) Somatization disorder
F) Ulcerative colitis

D! MDD

Sleep – fatigued in the morning/awakened by headache

Interest- not going out with friends anymore -> anhedonia likely

Guilt – blames herself for not taking better care of her body
E – fatigue
C – poor concentration
A – weight loss
P – probable
S – wasn’t asked

>= 2 weeks
Likely has depressed mood but she meets so many other criteria I think we can infer here

A 52-year-old woman comes to the physician for a routine follow-up examination. She has received inpatient psychiatric treatment several times since the age of 25 years for auditory hallucinations and the belief that her thoughts and movements were being controlled by a local television station; her last admission to the hospital was 10 years ago. Treatment with haloperidol for the past 20 years has decreased the occurrence of symptoms. She attempted suicide at the ages of 30 and 38 years. She lives in a supervised residence and does not work. During the examination, she repeatedly smacks her lips and slightly protrudes her tongue. When the physician asks if she is chewing gum, she laughs and opens her mouth to show she is not. She can hold her mouth and tongue still when asked but begins lip smacking when the physician resumes the examination. Which of the following is the most appropriate next step in pharmacotherapy?

A) Continue haloperidol and add alprazolam
B) Continue haloperidol and add propranolol
C) Discontinue haloperidol
D) Discontinue haloperidol and begin chlorpromazine
E) Discontinue haloperidol and begin risperidone

E! Discontinue haloperidol and begin risperidone

An 8-month-old male infant who was adopted recently is brought to the physician because of poor weight gain. He was born at term and weighed 2410 g (5 lb 5 oz). He was formula fed at birth and has consistently been below the 3rd percentile for weight. Currently, his diet consists of 16 ounces of iron-fortified cow milk formula, juice, cereal, prepared fruit, and pureed green vegetables. There is no history of vomiting. He has one formed stool daily. He is alert and appears well. He currently weighs 7002 g (15 lb 7 oz). On examination, he says “mama” and “bye-bye” while waving. He sits unsupported. He is wary of strangers. There are narrow palpebral fissures, epicanthal folds, a thin upper lip with a “fish mouth” appearance of the oral cavity, and an indistinct nasal philtrum. His ears are normally set, the nasal bridge is flattened, and the tongue is not enlarged. There is a single palmar crease on the left hand. Cardiopulmonary examination shows no abnormalities. There is no hepatosplenomegaly, and no masses are palpated. There is no peripheral edema. Which of the following is the most likely diagnosis?

A) Celiac disease
B) Down syndrome
C) Fetal alcohol syndrome
D) Psychosocial deprivation
E) Silver-Russell syndrome

Most likely fetal alcohol syndrome!

A 23-year-old man comes to the physician because of anxiety since beginning a second part-time job as a courier for a photographer 6 weeks ago. He reports a fear of heights and of riding in elevators. He takes stairs and escalators whenever possible, which prevents him from completing his deliveries on time. He has not had panic attacks. He has no history of serious illness and takes no medications. His temperature is 36.8°C (98.2°F), pulse is 80/min, respirations are 18/min, and blood pressure is 118/73 mm Hg. Physical examination shows no abnormalities. On mental status examination, he has an anxious mood and full range of affect. He reports no symptoms of depression or suicidal ideation. Which of the following is the most appropriate next step in management?

A) Cognitive behavioral therapy
B) Interpersonal therapy
C) a-Adrenergic agonist therapy
D) I3-Adrenergic blocker therapy
E) Selective serotonin reuptake inhibitor therapy

Very important question!
CBT is the tx of choice for specific phobia!!!
SSRI’s are nice distractors

A 27-year-old woman comes to the physician for an examination prior to starting a new job. She has a 10-year history of binge-eating and self-induced vomiting. She takes no medications. She does not drink alcohol or use illicit drugs. She is 178 cm (5 ft 10 in) tall and weighs 72 kg (160 lb); BMI is 23 kg/m 2. Her temperature is 37°C (98.6°F), pulse is 70/min, respirations are 10/min, and blood pressure is 120/70 mm Hg. Physical examination shows yellow dental enamel and abdominal striae. Serum studies are most likely to show which of the following abnormalities?

A) Decreased bicarbonate concentration
B) Increased amylase activity
C) Increased magnesium concentration
D) Increased potassium concentration
E) Increased sodium concentration

B!

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