question

Woman with multiple SAs; labs all normal, Utox neg., patient most likely to have what abnormality in her CSF?

answer

Decreased concentration of 5HTA

question

Haloperidol mechanism

answer

Decreased binding of dopamine at postsynaptic receptor

question

Pt has schizophrenia treated w Haloperidol, She would like to decrease likelihood of developing tardive dyskiesia; appropriate next step?

answer

Switch Haloperidol to AAP like aripiprazole

question

Pt BIB police to ED after threatening her bf with meat cleaver. Physical and history shows evidence of DV. She was treated for MDD with ADs, but bf flushed Rx down toilet. She has HI, no SI. Next step?

answer

Admit to hospital psych unit

question

Pt presents w 5 hour hx of confusion and agitation. Bugs crawling all over his skin. Been using cocaine 6x daily for 3 days. Prolonged QT interval. Most appropriate pharmacotherapy?

answer

Clonazepam

question

53yo woman BIB husband for personality changes in past 6 years. Irritable, sexually uninhibited, loud. Intermittent jerky movements. Father had similar symptoms starting at age 56. MRI of brain will most likely show?

answer

Caudate atrophy

question

87yo w MDD, GAD, and Parkinsons disease presents increased anxiety for 2 wks. Been accusing staff at care facility of stealing. Been heard talking when alone in room. One month ago venlafaxine was doubled and carbidopa-levodopa was increased by 50%. Next step with meds?

answer

Decreased the dosage of carbidopa-levodopa

question

47yo with remote history of cocaine abuse and meperidine dependence, but has not used illicit drugs in 9 years presents after MVA. Extensive wound debridement and suturing. Most appropriate step for pain management?

answer

Morphine!

question

42yo w 2wk hx of daily episodes of dizziness and feeling like she's going to pass out. Afraid to go to sleep for fear she won't wake up. She has gone to ED 4x in past 3months. 6 years ago she had an MI. ECG shows sinus tachycardia. Most likely cause of her sx?

answer

Panic disorder

question

21yo college student with 3 year hx of distressing thoughts that he will hurt other people. Violent sexual thoughts he cannot control. He is embarrassed to talk about these thoughts. Appropriate pharmacotherapy?

answer

Clomipramine (OCD)

question

23yo pt with bipolar disorder well controlled with lithium. Upset bc he has gained weight and now has acne. Other mood stabilizers were ineffective for him. Appropriate next step in mgmt?

answer

Explain the risk of illness recurrence without medication

question

82yo w difficulty sleeping in past year. Falls asleep easily, but wakes up early unable to fall back asleep. Sometimes dozes off during the day. On MSE, he is alert with euthymic mood and reactive affect. In addition to providing sleep hygiene instructions, provide:

answer

Reassurance

question

16yo who prefers to eat alone. Mom found food hidden under bed. Patient is 5.6 and weighs 96lbs. She is most likely to have a hx of?

answer

Amenorrhea

question

42yo woman w SI, depression, emotional lability and poor concentration. Cannot recall when Sx began. Father and sister have similar history of Sx. Intermittent abdominal pain. Neurologic exam shows decreased joint position sense. Romberg sign is present. Most likely cause of these Sx?

answer

Acute intermittent porphyria

question

67yo man w 2month hx of fatigue and decreased libido. Now sleeps 10 hours a night with nap during day. 10lb weight gain. Losing interest in life bc of multiple medical problems: DM2, HTN, hypercholesterolemia, osteoarthritis. Most appropriate step in pharmacotherapy?

answer

Add bupropion to regimen

question

22yo w 3 year hx of headaches and diarrhea. Worried about new job, money to pay bills and school loans. Last year of college she was worried if she would graduate and find a job. Asks bf for reassurance often. Dx?

answer

GAD

question

52yo w hx difficulty sleeping and fatigue. Describes uncomfortable sensation in calves she firsts notices a few minutes after going to bed-keeps her awake for up to 2hours. Dx?

answer

Restless leg syndrome

question

27yo first year surgical resident to request sleeping aid Rx. Past 2months has had increased anxiety; avoids social activities; wakes up multiple times at night and cannot sleep past 3am; 6lb weight loss. Next appropriate step?

answer

Reassurance or escitalopram

question

77yo w 6month hx of confusion and 'slowing down.' Sometimes sees and has convos with "people sitting by his bedroom window." Affect dulled. Fails serial 7s and cannot spell world backward or draw hands on a clock accurately. Dx?

answer

Lewy Body Dementia

question

42yo man presents for routine health maintenance. Fatigue, anxiety, decreased work performance since divorce 2 months ago. No weight loss or gain, does not feel depressed. Labs all normal. Next appropriate step?

answer

Psychotherapy

question

20yo woman brought to ED after found comatose at her desk with blood glucose level of 15mg/dL. Mother has DM2. Insulin concentration increased, but C-peptide WNL. Likely explanation?

answer

Surreptitious administration of insulin

question

57yo woman with progressive loss of voice since her husband of 20 years died 10 months ago. She now has to communicate w writing, bc voice so weak. On day of husbands death they had gotten into fight and she said she wished he would die. Most likely dx?

answer

Conversion disorder

question

5yo girl BIB parents bc of difficulty learning. Likes to go to school and carries backpack w pride. Epicanthal folds. Grade 2/6 murmur. Dx?

answer

Downs

question

67yo w Parkinsons disease BIB wife bc increasingly withdrawn. Poor energy, decreased sleep for 2 moths. 15lb weight loss. Flat affect, downcast gaze. Avoids socializing bc of tremor. Crying, says "who wouldn't be sad with this damn disease?" Dx?

answer

MDD

question

10yo boy. High energy level, difficult to discipline, argues about everything. 1 month ago killed family cat, not remorseful. Older brother in juvenile detention for grand larceny. PE shows several ecchymoses in various stages of healing over extremities. Worries at night that something will happen to someone in his family. Dx?

answer

Conduct disorder

question

42yo BIB wife bc of 2month hx of staring spells that last 1-2 minutes. Smacks lips and picks at his shirt collar. 4 years ago in coma for 2 weeks after MVA; required 6 months rehab. Smells burnt rubber intermittently. Hears intense hissing sound too. EEG will likely show?

answer

Focal spikes localized to the temporal lobe.

question

62yo woman w 1wk auditory hallucinations. She was the star of a play that closed after one performance. Dx?

answer

Brief psychotic disorder

question

47yo woman w 12hour history of tremors and confusion. Hx of alcoholism and last consumed alcohol 24 hours ago. Given thiamine, folic acid, and 3 doses of diazepam. Intubated and placed on mechanical ventilation. 2 hours later remains agitated. Upper extremity tremor continues and lower extremity hyperreflexia bilaterally. Next best step in Rx?

answer

Administer additional diazepam

question

32yo BIB wife bc of increasing confusion and agitation since he came home from work 2 hours ago. One wk ago began taking tamadol. Hx of MDD and takes fluoxetine. Dilated pupils, hyperreflexia, and generalized muscle rigidity. Dysregulation of which neurotransmitter?

answer

Serotonin

question

10month old boy brought in bc of irritability throughout the night. Mother says he's been crying and has refused to bear weight on lower extremities since she picked him up from babysitter. X ray shows mild demineralization and spiral fracture of right femur. Mechanism of injury?

answer

Child abuse

question

7yo boy w difficulty at school. Will not go to sleepovers, has stomachaches every weekday morning. Played on soccer team but quit when his mother could not drive him to games. Sits on mother's lap and does not make eye contact with the physician. Dx?

answer

Separation anxiety disorder

question

17yo BIB mother bc of 9lb weight loss. BMI 16. Depressed mood and irritable affect. ECG shows sinus bradycardia. Worried about being overweight and recently binges and purges. Dx?

answer

Anorexia nervosa

question

13yo girl BIB mother bc not yet had menstrual period. Physical exam shows no abnormalities. Next appropriate step?

answer

Discuss normal pubertal development

question

24yo male f/u appt 2 weeks after starting sertraline for MDD and SI. Says he feels better but still has trouble sleeping. Next appropriate step?

answer

Maintain the current dose and schedule weekly f/u exams for the next month

question

20yo college student comes to student health bc she has been feeling 'terrible' for past wk. She has been tearful and distracted since her bf broke up with her 1 week ago. She performed poorly on an exam 3 days ago and has not been sleeping well. Dx?

answer

Bereavement

question

27yo teacher comes to physician requesting Rx for sleep medication. She has been unable to fall asleep until 2 or 3am since the start of school year 3 months ago. During vacations and on weekends she typically sleeps from 3am until noon and feels energetic and well rested. Dx?

answer

Circadian rhythm sleep disorder

question

37yo man f/u post alcoholic cirrhosis dx. He has missed 3 prior appts bc of transport issues. His driver's license was suspended for DUI. GGT = 158. Next step in management?

answer

Recommend alcohol rehab

question

47yo man w 4wk hx of depressed mood, lack of energy, poor concentration, 13lb weight loss (intentional!). Most likely dx?

answer

Adjustment disorder with depressed mood

question

27yo post MVA, feels he's being followed by FBI, mild hyperreflexia, affective lability, rapid speech. Agitated.

answer

Amphetamine intoxication

question

Previously healthy 25yo w sudden behavior change. Anxious bc everyone around her has "turned into spacemen." She avoids medical staff bc they look like "large furry monsters." She sees "multicolored snakes singing Hail Mary." Agitated by AAOx3. Tox screen negative

answer

Hallucinogen intoxication

question

47yo man struck his head on glass door that he thought was open. No LOC. Hx of schizophrenia on medication. CT scan most likely to show?

answer

Symmetric enlargement of the ventricles.

question

55yo woman w strange behavior for 3 months. Believes that her father and next-door neighbors have been taking money away from her, blowing fumes under her door. Nothing noteworthy on MSE. AAOx3. Dx?

answer

Delusional disorder

question

3 and 1/2 yo continues to wet his bed. Most appropriate intervention?

answer

Reassurance that this is normal behavior

question

4yo bib father bc of behavior problems. Increasing tantrums. Last night threw dinner plate at younger brother. Not hyperactive. Behaves at day care and when she visits her grandmother. Which of the following is the most appropriate step in mgmt?

answer

Begin parent mgmt training

question

25yo woman bib police bc she had been running in front of cars at a busy downtown intersection; she told police she is on a mission to save earth from pollution. She hears the voice of Mother Earth asking for her protection. Best INITIAL Rx for acute symptoms?

answer

Ziprasidone (only AAP)

question

15 min after administration of IM Haloperidol, 21yo woman has torticollis. Antagonism of what neurotransmitter is most likely responsible?

answer

Dopamine

question

32 yo man with intrusive thoughts of killing his 4yo son. He does not want to do it and considers the thoughts ridiculous. Finds the thoughts repulsive. Most likely dx?

answer

OCD

question

37yo woman BIB police - found begging in front of stores for 4 days. Oriented to place and time but is unable to recall her own identity or where she lives. Dx?

answer

Dissociative fugue

question

20yo college student with 1 year hx of anxiety, dry mouth, sweating, nausea, and palpitations. First noticed symptoms when asked to speak in front of group. Failing a public speaking class. Now avoids situations where she might have to speak in public. Dx?

answer

Panic disorder?

question

46yo woman brought to ED in resp. depression after attempting suicide by ingesting large amount of unknown drug. Exam shows pinpoint pupils. Most likely drug ingested?

answer

Opioid

question

5yo boy w temp to 102, coryza, cough for 2 days and 2 hours visual hallucinations. Mother has been giving him over the counter medication for 24 hours. Most likely reason for hallucinations?

answer

Drug toxicity

question

Previously healthy 23yo brought into ED 20min after bizarre behavior at a party. Friends say he became paranoid and starting threatening them. Agitation, diaphoresis, horizontal nystagmus, dysarthria, combativeness, and occasional myoclonus. Most likely dx?

answer

PCP intoxication

question

17yo BIB mother bc of 20 minute episode of severe chest pain and sweating. During episode, his heart was pounding, he felt short of breath, and was sure he was going to die of a heart attack. One month ago had similar Sx after football practice--quit the football team and limits his physical activity for fear of bringing on another attack. Dx?

answer

Panic disorder

question

37yo w 3wk Hx of fatigue, insomnia, and anxiety. Divorce was finalized 1 month ago. Otherwise fine. Best drug for him?

answer

Zolpidem

question

23yo man believes he has special abilities to predict the future since the age of 15 years. Personality disorder?

answer

Schizotypal

question

47yo difficulty sleeping at night. Drinks 2-3 cocktails to help her fall asleep and 3-4oz of vodka in the AM. AST>ALT, both slightly elevated. Dx?

answer

Alcohol dependence

question

82yo with dementia, Alzheimer type has 4 day hx of visual hallucinations and irritability. Medications: rivastigmine, ibuprofen, atenolol, levothyroxine, and amitriptyline. Discontinuation of which med most appropriate?

answer

Amitroptyline

question

37yo man BIB police - was screaming, talking to himself, wandering street. Wearing winter clothes on a hot summer day. What is most likely additional finding in this pt?

answer

Enlarged lateral and 3rd ventricles on CT scan of the head.

question

Previously healthy 57yo woman comes to the physician bc of 8week hx of progressive confusion and memory loss. No longer to work at her job, bc she is so withdrawn. Speech is dysarthric. Diffuse hyperreflexia, mini-mental state exam is 8/30. EEG shows generalized slowing with periodic sharp waves. Most likely Dx?

answer

Creutzfeldt-Jakob disease

question

27yo woman brought to ED after cutting her arms superficially w a razor blade. She says she cut herself to "feel something." She sleeps and eats well. Was sexually abused as a teenager. Never had longterm relationship and has been fired from several jobs bc of difficulty getting along w supervisors. Denies depressed mood or SI but is convinced she is worthless and deserves to die. Most likely Dx?

answer

Borderline personality disorder

question

42yo man comes in for regular checkup. Wife states he is competitive, rigid, stubborn, opinionated. Anxious and obsessed w being early. Successful lawyer, and coworkers have said he believes his way is the only way of getting things done. Dx?

answer

Obsessive-compulsive personality disorder

question

27yo man brought in 30min after brother found him agitated, tremulous, and complaining of a headache. 8 days ago physician discontinued fluoxetine and substituted tranlycypromine to start 1 wk later. Temp is 105, diaphoresis, tremor, hyperreflexia. Most likely cause?

answer

Drug-drug interaction

question

25yo primigravid 16wks gestation has had increased episodes of crying, difficulty falling asleep, decreased energy, loss of appetite. Hx of recurrent MDD. Next appropriate step?

answer

Explanation of the risks and benefits of antidepressant therapy

question

30yo law school grad caught cheating on bar exam. Previous allegations of cheating. Adolescence with truancy, fights, and lying. Cannot hold a job, has been bankrupt, divorced bc of failure to provide proper care for his children. Angry about accusation of cheating and insists the incident is a misunderstanding. Dx?

answer

Antisocial personality disorder

question

37yo male police officer comes to the physician 2 wk after witnessing terrorist bombing during which several civilians and 3 fellow police officers were killed. He has felt numb and unable to enjoy things he used to. Sleep is fitful. Says he's not depressed. Does not want to talk to the physician or anyone, but was "made to come." Most appropriate initial step in mgmt?

answer

Provide information about the range of reactions to trauma

question

15yo boy brought to physician by his parents bc he "does whatever he wants and comes and goes as he pleases." Arrested twice in past month, once for assault, once for vandalism. Several tattoos over chest and upper extremities and several body piercings. Most likely dx?

answer

Conduct disorder

question

24yo woman comes to physician bc of 8year hx of increasing daytime fatigue. In high school she trained herself not to laugh bc she felt weak and could not remain standing after. Which of the following is most likely to confirm the Dx?

answer

Polysomnography

question

87yo man with catatonia. 1 month ago he began withdrawing and talking constantly about death. Stopped eating and drinking. Most appropriate next step?

answer

ECT

question

8yo boy brought to the physician bc of 1 year hx of increasingly frequent episodes of eye blinking and facial grimacing. Grunts and clears throat a lot. Teacher often sends him out of room for being disruptive. Embarrassed by behaviors and cannot control them. Most appropriate pharmacotherapy?

answer

Risperidone

question

24yo brought from psych hospital to ED bc of decreasing level of consciousness over past 3 days. Temp is 103, BP is 180/100. Withdraws weakly to noxious stimuli. Eyes are open but he does not fix or follow stimuli. Leukocyte count 18000. Schizophrenia treated with haloperidol and benztropine. Most likely underlying cause?

answer

Drug reaction

question

32yo woman w increasingly severe pain that originates in left shoulder and radiates to elbow from nerve injury post MVA. Pain is 7/10 and constant. On oxycodone and gabapentin. Says "I'm tired of all this..." Best physician response?

answer

"Have you been feeling like just giving up?"

question

17yo girl brought to physician by parents bc of 45lb weight loss. BMI 16. Pleased w weight loss and thinks she has more to lose. Parents want her admitted, but she is opposed. Next step?

answer

Admit her

question

8yo boy brought for school phsyical. Dx w ADHD. Methylphenidate was d/c bc of persistent loss of appetite and weight loss. Despiramine was started. QTc is 0.5sec (N<0.44). Next appropriate step?

answer

D/c despiramine therapy

question

28yo brought to ED bc of flu-like sx and clear sputum for 24hours. He is on clozapine. Leukocyte count is 2750. Next step?

answer

D/c clozapine

question

22yo woman brought to ED bc of 4-hour hx of violent, agitated behavior. Temp is 100.4. BP 140/90. Describes her mood as "wild" and tries to leave ED, pushing a security guard aside and throwing a clipboard. Which substance?

answer

Methamphetamine

question

8yo boy brought to physician for evaluation of difficulty reading. High forehead, prominent supraorbital ridges, protruding ears, prominent jaw. IQ is low. Most likely explanation?

answer

Fragile site on the X chromosome

question

47yo w tension and hand tremors for 1 month. Treated for bipolar disorder w lithium for 6 months. Appropriate Rx?

answer

Propanolol

question

25yo man w severe fear of flying but must attend business meeting in Europe. Rx?

answer

Lorazepam

question

32 yo woman w schizoaffective disorder brought in to ED bc of 7 day hx of lethargy, loss of appetite, nausea, leg swelling, and jaundice this am. AST and ALT elevated. Fine bilateral hand tremor. Likely medicine responsible for these findings?

answer

Valproic acid

question

27yo w 6wk hx of severe insomnia, persistent fatigue, guilt, emptiness, hopelessness, sadness. Past 4 years has heard "Sauron" from a fantasy novel instructing him to renounce his family and foreswear all sexual activity. Depressed mood and restricted affect. Dx?

answer

Schizoaffective disorder

question

Previously healthy 27yo woman comes to physician bc of 2 month hx of crying spells, poor concentration, fatigue, and lethargy. Sleeps 12hours daily. No longer interested in socializing. 20lb weight gain. Work performance declining. Dx?

answer

MDD

question

37yo man comes to physician bc of increasing distress about his procrastination and indecision. Late for work bc he is easily distracted by a task. Sometimes daydreams about projects and must complete them in his mind before attending to other tasks. Dx?

answer

OCD

question

47yo woman is admitted to hospital for treatment of organ rejection one month after liver transplant. 24hours after methylprednisone is begun, she begins to have visual hallucinations that her organ donor has entered her hospital room naked and is drawing sympbols on her skin w an eyebrow pencil. Dx?

answer

Corticosteroid-induced psychotic disorder

question

15yo boy brought to ED by his friends bc of unusual behavior at a party. Friends say he became raucous and made an unwanted sexual advance on girl he had just met. Agitated alone, but calms down when spoken to. Unsteady gait. Drug taken?

answer

Alcohol

question

13yo girl BIB dad who says she is always on the go. She eats a full meal with family but otherwise eats little. Became a vegetarian. Appropriate next step?

answer

Reassure father that this is normal development

question

27yo bib gf bc of 6wk hx of hearing voice he is Christ. 22lb weight loss. Does not sleep more than 2 hours. Flirts with female staff. Tries to convince people of his powers to heal the sick. Dx?

answer

Bipolar disorder

question

42yo woman, g1p1 with increasing episodes of abdominal pain with BM, sex, menses. Analgesics do not help. Multiple laparoscopies reveal no abnormalities. Just lost job and anxious about finding new one. Next appropriate step?

answer

Psych assessment

question

3yo brought to ED 1 hour after injuring arm. 3rd visit in 6 months. Child too upset to say how she injured herself. Child is fearful of examiner. Xray shows right humerus closed fracture. Next step?

answer

Contact child protective services

question

25yo woman comes to physician at her husband's request bc of increasing irritability and tense mood over past year. Husband would like to start a family, but she is worried ab finances even tho they have no debt and their jobs pay well. Rx?

answer

Buspirone

question

Homeless 27yo treated with antipsychotic and antiparkinsonian drugs come to ED bc feels anxious and has difficulty urinating. Hyperactive and disoriented to time and place. Physical exam shows dry mouth, flushed skin, tachycardia. Most likely Dx?

answer

Delerium due to anticholinergic medication

question

67yo whose husband died 18months ago. Severe headaches. Believes she has brain cancer and deserves to be punished for her sins. Phsyical and neuro exam show now abnormalities. Dx?

answer

Somatization disorder

question

47yo w down syndrome w increasing forgetfulness and irritability. Affected region of brain?

answer

Nucleus basalis of Meynert

question

37yo man brought to physician bc of change in personality over past 4 months. Sexually disinhibited, tactless, impulsive, easily irritated. Affected region of brain?

answer

Caudate nucleus

question

16yo boy comes to physician bc of 1 year hx of progressive headaches on awakening that have caused him to miss several days of school Feels better after watching TV. Mouth breather. Most likely cause of his headaches?

answer

sleep related hypoventilation

question

29yoman unable to maintain erection for past 2 months. GGT elevated. Reasons for sx?

answer

Alcohol use

question

14yo girl w poor academic performance past 6 months. Recent move after death of patients father as a result of MVA in which the patient was a passenger. She has trouble concentrating, has frequent nightmares, is easily startled. Dx?

answer

PTSD

question

57yo woman difficulty sleeping after finding out her daughter has metastatic breast cancer. On exam, she is tearful and tense but calms during the conversation. No SI. Best therapy?

answer

Clonazepam

question

7yo boy brought to physician by adoptive parents bc of concerns ab his behavior and academic performance. Flattened nasal bridge, long philtrum. Dx?

answer

Fetal alcohol syndrome

question

67 yo man brought to the physician by his wife bc of 1month hx of increasingly paranoid behavior. Reluctant to eat food unless containers opened in front of him. Has Parkinson's disease, so what drug can be given to him?

answer

Quetiapine

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