07-02-2016, 05:52 PM
Hi, please help me with the following questions, appreciate your help, thank you.
1. 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 (WRONG)
B) Haloperidol
C) Lithium carbonate
D) Trazodone
E) Valproic acid
2. 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 (WRONG)
D) Increased serum and urine copper concentrations
E) Temporal spikes on EEG
3. 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 (WRONG)
D) Malingering
E) Schizophrenia
4. 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 (WRONG)
5. 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 (WRONG)
F) Electroconvulsive therapy
6. 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 (WRONG)
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
7. 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 (WRONG)
8. 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 (WRONG)
D) Recommend that the father keep a log of what his daughter eats
E) Schedule weekly examination and weighing
9. 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) (WRONG)
C) Heroin
D) LSD
E) Methamphetamine
10. 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
11. 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
12. 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 (WRONG)
F) Malingering
G) Toxin
13. A 17-year-old girl is brought to the physician by her parents because of a 20kg (45lb) weight loss during the past 6 months. She also has become more isolated from her friends and has lost interest in activities she used to enjoy. Her academic performance has deteriorated from excellent to average. She has major depressive disorder treated with fluoxetine for 3 years. She recently stopped taking it because of concern that it was preventing her from losing weight. She is 160 cm (5 ft 3 in) tall and weighs 41 kg (90 lb); BMI is 16 kg/m . Her pulse is 46/min,
and palpable systolic blood pressure is 86 mm Hg. On mental status examination, she says she has been feeling poorly lately but has attributed it to stress at school and pressure from her parents to complete college applications. She is pleased that she has lost weight but feels that she has "more to lose." She says her appetite has not decreased and that she feels hungry a good part of the time. There is no evidence of suicidal ideation. She is adamantly opposed to beginning fluoxetine again. She is not interested in counseling and does not think there is "anything wrong" with her. Her parents want her to be admitted to a psychiatric hospital, but she is opposed. Which of the following is the most appropriate next step?
A) Begin outpatient psychotherapy
B) Recommend family counseling
C) Begin bupropion therapy
D) Begin parenteral nutrition (WRONG)
E) Admit her to a psychiatric hospital
14. 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 (WRONG)
H) Psychiatric assessment
15. 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 (WRONG)
E) Imipramine therapy
F) Olanzapine therapy
G) Pentobarbital therapy
H) Sertraline therapy
16. 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 (WRONG)
D) Lithium carbonate
E) Methylphenidate
F) Risperidone
17. 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 (WRONG)
G) Perphenazine
H) Propranolol
18. 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 (WRONG)
19. 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 (WRONG)
20. 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 (WRONG)
D) Discontinue clozapine therapy
E) Increase the dose of clozapine
1. 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 (WRONG)
B) Haloperidol
C) Lithium carbonate
D) Trazodone
E) Valproic acid
2. 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 (WRONG)
D) Increased serum and urine copper concentrations
E) Temporal spikes on EEG
3. 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 (WRONG)
D) Malingering
E) Schizophrenia
4. 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 (WRONG)
5. 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 (WRONG)
F) Electroconvulsive therapy
6. 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 (WRONG)
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
7. 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 (WRONG)
8. 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 (WRONG)
D) Recommend that the father keep a log of what his daughter eats
E) Schedule weekly examination and weighing
9. 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) (WRONG)
C) Heroin
D) LSD
E) Methamphetamine
10. 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
11. 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
12. 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 (WRONG)
F) Malingering
G) Toxin
13. A 17-year-old girl is brought to the physician by her parents because of a 20kg (45lb) weight loss during the past 6 months. She also has become more isolated from her friends and has lost interest in activities she used to enjoy. Her academic performance has deteriorated from excellent to average. She has major depressive disorder treated with fluoxetine for 3 years. She recently stopped taking it because of concern that it was preventing her from losing weight. She is 160 cm (5 ft 3 in) tall and weighs 41 kg (90 lb); BMI is 16 kg/m . Her pulse is 46/min,
and palpable systolic blood pressure is 86 mm Hg. On mental status examination, she says she has been feeling poorly lately but has attributed it to stress at school and pressure from her parents to complete college applications. She is pleased that she has lost weight but feels that she has "more to lose." She says her appetite has not decreased and that she feels hungry a good part of the time. There is no evidence of suicidal ideation. She is adamantly opposed to beginning fluoxetine again. She is not interested in counseling and does not think there is "anything wrong" with her. Her parents want her to be admitted to a psychiatric hospital, but she is opposed. Which of the following is the most appropriate next step?
A) Begin outpatient psychotherapy
B) Recommend family counseling
C) Begin bupropion therapy
D) Begin parenteral nutrition (WRONG)
E) Admit her to a psychiatric hospital
14. 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 (WRONG)
H) Psychiatric assessment
15. 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 (WRONG)
E) Imipramine therapy
F) Olanzapine therapy
G) Pentobarbital therapy
H) Sertraline therapy
16. 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 (WRONG)
D) Lithium carbonate
E) Methylphenidate
F) Risperidone
17. 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 (WRONG)
G) Perphenazine
H) Propranolol
18. 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 (WRONG)
19. 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 (WRONG)
20. 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 (WRONG)
D) Discontinue clozapine therapy
E) Increase the dose of clozapine