PsychiatryBlock 2Q

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• 4 A 45-year-old Caucasian woman comes to the emergency department complaining of a recent onset of anxiety and depression. The
• 5 patient says that she worries about everything and has felt very depressed lately. She complains of a lack of energy, difficulty
• 6 sleeping, and a decreased appetite. She reports difficulties in her relationship with her husband and that she depends on him
• 7 financially. Her husband does not talk to her very much and often leaves home for long periods. She has 6-year-old twin sons who
• 8 were recently diagnosed with autism and require a lot of attention, and she is feeling overwhelmed with her family and financial
• 9 problems. She appears to be an adequate historian, is cooperative during the interview, but appears slightly disheveled. Her mood and
10 affect are depressed and anxious. She becomes tearful during the interview. Her flow of thought is coherent, and her thought content
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reveals feelings of low self-esteem. There is absence of delusions, or hallucinations. The patient denies suicidal ideas. The patient also
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states that her husband is not violent, and she denies any threats or physical injuries inflicted by him. She is oriented to date, place,
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and person with intact recent and remote memory. The patient denies any previous medical or psychiatric problems. Her vital signs
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are normal, and physical examination is unremarkable.
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• 16 Which of the following is the most appropriate next step in management?
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• 18 0 A. Admit the patient to the hospital because of severe depression and anxiety
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• 20 0 B. Call for a psychiatric consult to evaluate for possible depression
• 21 0 C. Call for a social worker consult to assist with management

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0 D. Discharge patient from the emergency department with antidepressant medication
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• 24 0 E. Discharge patient from the emergency department with anxiolytic medication
• 25 0 F. Discharge patient from the emergency department with outpatient mental health followup
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• 27 0 G. Report spousal abuse to social services and inform the patient of available help
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• 4 A 47 -year-old Hispanic woman who has no past psychiatric history presents with poor sleep, decreased appetite, and sadness. These
• 5 symptoms began 3 months ago when she discovered that her husband was having an affair. Her husband apologized to her and
• 6 promised to end the affair. Despite this, the woman reports feeling betrayed and has feelings of being a bad wife and mother to her
• 7 three children. She also reports that she has been more reluctant to see friends and do her usual hobbies in the past few months and
• 8 wonders if her life is worth living like this. What is the most appropriate next step in the management of this patient?
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0 A. Admit her to the inpatient unit
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• 12 0 B. Arrange for couples therapy
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0 C. Arrange for individual therapy
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• 15 0 D. Assess for suicidal thoughts
• 16 0 E. Prescribe antidepressant medication

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• 4 A 34-year-old divorced man presents to the outpatient clinic for consultation. He recently moved from another state where he was
• 5 being treated with sertraline, 150 mg/d for a major depressive episode. He has no prior psychiatric history. He has been on sertraline
• 6 for 2 months. He complains of intermittent nausea that does not significantly affect his life, but he is otherwise doing well on the
• 7 medication, with improvement in all of his symptoms of depression. He is concerned about taking too much medication and asks your
• 8 opinion. Which of the following is the most appropriate management of this patient's medication?
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0 A. Change medication to bupropion secondary to nausea
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• 12 0 B. Continue sertraline indefinitely
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0 C. Continue sertraline for 6 more months
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• 15 0 D. Gradual taper of sertraline
• 16 0 E. Stop sertraline; he is doing well

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A 26-year-old medical student is arrested for threatening a neighbor with a knife. The student is brought to the hospital because he
• 5 tried to slit his wrists on the way to the police station. His roommate arrives and states that the patient has been doing "weird things"
• 6 over the past two months and has been "acting as if he had no emotions". The patient is socially withdrawn and has been overheard
• 7 saying that the FBI is gMng him tips on patient care and that "people from the sky" are telling him to do "bad things." He says he does
• 8 not want to be a doctor anymore. His face is expressionless and unresponsive. His physical examination is otherwise normal.
• 9 Toxicologic screening is negative. Which of the following is the most likely diagnosis?
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0 A. Bipolar I disorder
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• 13 0 B. Brief psychotic disorder
• 14 0 C. Delusional disorder
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• 16 0 D. Schizophrenia
• 17 0 E. Schizophreniform disorder
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• 4 A 46-year-old African American man who has a history of chronic schizoaffective disorder is admitted for acute psychosis. He
• 5 presents with auditory hallucinations, paranoia, depression with suicidal ideation, anhedonia, blunted affect, increased appetite, a
• 6 10-lb weight gain over the past month, and increasing somnolence. The patient is stabilized in the hospital with haloperidol. Wh ich of
• 7 the following is the best atypical antipsychotic medication to prescribe for this patient?
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A. Clozapine
• 11 0 B. Olanzapine
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• 14 0 0 . Risperidone
• 15 0 E. Ziprasidone
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• 4 A 59-year-old woman had a diverticulectomy. During the observation period, the intern notices that the patient's vital signs are all
• 5 increased and she seems confused, disoriented, and delirious. She starts having seizures. On review of her chart, the intern notices
that the woman has a past history of hypertension, diabetes mellitus, anxiety, gout, and peMc inflammatory disease. She is on
• 7 thiazide, metformin, alprazolam, and allopurinol. Her father has bipolar disorder and is on lithium. She is hepatitis 8 positive. She is a
• 8 smoker, and drinks only socially. Which of the following would be the most appropriate next step?
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0 A. Dialysis to wash out lithium
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• 12 0 B. Start dantrolene
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0 C. Start lorazepam
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• 15 0 D. Start naloxone
• 16 0 E. Start promethazine
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• 4 A 3-year-old boy is brought to the office by his parents for a regula r health supervision examination. His cond ition has not changed
• 5 significantly since his last visit 6 months ago. He still prefers to play by himself. The mother has finally adjusted to the fact that her son
• 6 never returns the hug when she hugs him. On physical examination, the boy is non-cooperative and utters unintelligible mumbles when
• 7 approached him. The physic ian fails to establish any eye contact with him. The child has had th ree attacks of otitis media since birth.
• 8 Wh ich of the following is the most likely diagnosis?
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0 A. Asperger disorder
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• 12 0 B. Autism
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0 C. Hearing loss due to repeated otitis media
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• 15 0 D. Mental retardation
• 16 0 E. Rett syndrome
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• 4 A 24-year-old student is brought to the emergency department because of a sudden change in behavior. His friends report that he has
• 5 been acting "weird" and confused and has been talking about "flying above the floor." He laughs without a reason and then bursts into
• 6 tears. He had been at a party the night before. He appears hot and has uncoordinated movements. He has horizontal nystagmus,
• 7 ataxia, and muscular rigidity, and becomes very agitated and combative during the examination. Which of the following agents should
be administered at this time to treat his agitation?
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0 A. Alprazolam
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• 12 0 B. Chlorpromazine
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0 C. Flumazenil
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• 15 0 D. Haloperidol
• 16 0 E. Midazolam
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• 4 A 31 -year-old woman with schizophrenia is brought to the emergency department by the police because she was found in a park,
• 5 actively hallucinating and talking to herself. She is cooperative but irritable. She denies command hallucinations and is not violent or
• 6 suicidal. She admits that she ran out of her medication several days ago and was unable to get in touch with her case manager. She
• 7 has been IMng in a personal care home for the past 3 months and was stable on her medication, but says she left the personal care
• 8 home yesterday and never returned.
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Which of the following is the most appropriate next step in management?
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0 A. Admit her to the psychiatry inpatient service for further treatment
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• 14 0 B. Contact her case manager to ensure support and follow-up
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0 C. Convince her to take a haloperidol decanoate shot and stay "medicated" for a month
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• 17 0 D. Give her a new prescription and discharge her to the personal care home
• 18 0 E. Send her back to the personal care home and let the owner handle her
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• 4 An 86-year-old Caucasian woman is brought in by her daughter. The patient has a past medical history of gout, hypothyroidism, and
• 5 hyperlipidemia. Her daughter is concerned about her because she has been forgetting the names of her grandchildren and friends
• 6 and misplacing items, such as her keys and purse. The problem has been worsening over the past 10 years. The patient lives alone, is
• 7 able to take care of her daily needs, such as cooking, cleaning, paying the bills, and daily hygiene, and denies difficulty with attention
• 8 or orientation. She has been progressively falling asleep earlier and awakening earlier, but denies much trouble with sleep. She
• 9 denies suicidal ideation, feelings of guilt, and difficulty with appetite. What is the most likely cause of her forgetfulness?
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0 A. Age-associated cognitive decline
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• 13 0 B. Alzheimer disease
• 14 0 C. Delirium
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• 16 0 D. Depression
• 17 0 E. Vascular dementia
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• 4 A 24-year-old Caucasian man is brought to the emergency department. He was picked up by the police after yelling and cursing at
• 5 another driver who he believed cut him off inappropriately on the highway. He has been stopped by the police in the past and has
• 6 been on probation for multiple driving violations. The young man describes a history of aggressive behavior and states, "I tend to
• 7 over-react." He reports a history of physical fights that have resulted in holes in the walls of his home. He also reports that his mother
• 8 told him he once had a seizure when he had a high fever as a child. He works in a factory as a production assistant and has done well
• 9 at this job for the past 3 years. Which of the following is the most appropriate diagnosis for this patient?
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• 13 0 B. Intermittent explosive disorder
• 14 0 C. Oppositional defiant disorder
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• 16 0 D. Psychotic disorder
• 17 0 E. Seizure disorder
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• 4 A 27 -year-old man with schizophrenia, chronic paranoid type, comes to the clinic for a follow-up visit. He is alert, oriented, and well
• 5 related , and his thought process is completely organized. He is not complaining of any auditory hallucinations and does not seem to
• 6 be responding to internal stimuli. He denies any suicidal or homicidal intent, ideation, or plan. He says he has difficulty staying in his
• 7 chair during the interview and constantly feels an urge to move around. His past medical history is significant for pneumonia 1 month
• 8 ago, when he needed hospitalization and his dose of risperidone was changed. Which of the following is the most appropriate next
• 9 step in management?
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0 A. Add an antidepressant
• 13 0 B. Add haloperidol to control psychotic agitation

• 14 0 C. Decrease the dosage of risperidone
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• 16 0 D. Increase the dose of risperidone because of incomplete treatment response
• 17 0 E. Recommend electroconvulsive therapy for refractory psychosis
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• 4 A 20-year-old man is brought to the clinic by his parents, who are concerned that he is an alcoholic. They want him to check himself
• 5 in for treatment In a discussion about his drinking habits, the young man brags that he can now drink more before he gets drunk.
• 6 Which of the following statements is true about this patient?
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0 A. The ability to drink more is related to the patienfs age
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• 10 0 B. The patient does not have alcoholism
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0 C. The patient win have withdrawal symptoms on cessation of alcohol
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• 13 0 0 . There is not sufficient information to determine if this patient has alcoholism or not
• 14 0 E. This patient has developed alcohol dependence
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• 4 A 51 -year-old man comes to the emergency department several days after being discharged from the hospital where he had an
• 5 extensive workup for abdominal pain; the workup was negative. He now complains of similar abdominal pain, and when the physician
• 6 tries to reassure him that his physical findings and studies are normal, he refuses to leave, accusing the medical team of "not doing
• 7 enough." He insists on calling the surgeon. Instead, a psychiatry consult is called. The psychiatrists describe the patienrs mental
• 8 status as normal. There is no evidence of suicidal or homicidal ideation. The interview with the patient, however, reveals that 6 weeks
• 9 ago, after 24 years of marriage, he lost his wife in a car accident. Which of the following is the most appropriate initial step in
• 10 management?
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0 A. Admit the patient to psychiatry for further evaluation
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0 B. Explore the patienrs feelings about the recent loss
• 15 0 C. Order an abdominal x-ray
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• 17 0 D. Prescribe an antidepressant
• 18 0 E. Prescribe benzodiazepines on an as-needed basis

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0 F. Reassure the patient that his pain is most likely stress-related
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• 4 A 52-year-old African American woman complains of outbursts of crying spells, hopelessness, guilt, inability to concentrate, loss of
• 5 appetite, sleep problems, and memory problems. She says she would like to be with her son, who died 5 weeks ago, even though she
• 6 denies suicidal ideation, intent, or plan. She expresses extreme anger at God and questions her religious faith. She states that she has
• 7 no interest in activities that used to bring pleasure. Which of the following is the most appropriate next step in the management of this
• 8 patient?
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0 A. No treatment necessary
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• 12 0 B. Prescribe amitriptyline
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0 C. Prescribe oxazepam
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• 15 0 D. Prescribe sertraline
• 16 0 E. Psychiatric consultation
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0 F. Refer patient for psychotherapy
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• 4 A 9- year-old boy comes to a new physician with his mother because of a significant decline in functioning and increased social
• 5 withdrawaL He has always had difficulties at school and was timid and anxious when speaking in front of others. Looking back, the
• 6 mother remembers that she had first noticed problems when he started at a new school after the family relocated because of her
• 7 husband's new job a year ago. After a month in the new school, she had taken him to a pediatrician because of recurrent episodes of
• 8 abdominal pain, nausea, and tiredness that caused repeated absences from schooL All medical evaluations have been negative but
• 9 his symptoms seem to persist. Which of the following is the most likely diagnosis?
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0 A. Adjustment disorder with anxiety somatization disorder
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• 13 0 B. Factitious disorder
• 14 0 C. Hypochondriasis
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0 D. Separation anxiety disorder
• 17 0 E. Somatization disorder
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• 4 A 35-year-old woman presents to the outpatient clinic for evaluation. She reports that the apartment building where she lives had a
• 5 serious fire approximately 1 year ago, and she narrowly escaped. Many others were injured and had to be taken to the hospital for
• 6 medical care. Since that time, she has had nightmares about being trapped in her apartment and unable to escape, she cannot
• 7 concentrate at work because she often thinks of the fire, and she even feels scared when she sees someone light a match. She has
• 8 not been participating in her usual hobbies and feels detached from her friends and family. She reports difficuHy falling asleep,
• 9 because she is afraid she will have more nightmares, as well as reports a poor appetite, and a short fuse with coworkers and friends.
• 10 Which of the following is the most appropriate intervention for this patient?
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0 A. Hospitalization
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• 14 0 B. Long-term psychodynamic psychotherapy
• 15 0 C. Psychologic debriefing of the trauma
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0 D. Start alprazolam
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• 18 0 E. Start sertraline
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• 4 A philosophy student has always been different from others and believes in supernatural powers. She thinks that at times she hears
• 5 the voice of God. She believes that there is evil in the form of witchcraft in the world but feels protected because she "can spread an
• 6 energy shield around" her body. She has tried to be a medium for communicating with the deceased based on what she thought was
• 7 one communication with her dead grandmother. Some of her friends think she is a little bit odd, but she feels that is okay because
• 8 nothing is really wrong with her. She admits that she is quite different from the rest of her siblings and acquaintances. She is
• 9 otherwise functional. Which of the following is the most likely diagnosis?
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0 A. Avoidant personality disorder
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• 13 0 B. Mania
• 14 0 C. Paranoid personality disorder
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• 16 0 D. Schizoid personality disorder
• 17 0 E. Schizotypal personality disorder
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• 4 A 69-year-old woman is brought to her primary care physician for her routine yearly examination. This year, her daughter drove her
• 5 to the appointment When asked about this, the daughter whispers to the physician that her mother has gotten lost while driving to the
• 6 supermarket on two occasions over the past 6 months. II becomes clear during the history that the woman does not remember the
• 7 physician's name and seems to have some word-finding difficulties. The daughter also mentions to the physician that she has recently
• 8 begun managing her mother's checking account and other finances, due to the mother's forgetfulness. The patient has osteoarthritis
• 9 of the knees, and a history of "a treated, very serious sexually transmitted disease many years ago," but is otherwise healthy. Vital
10 signs are within normal limits, and physical examination is unremarkable. An informal mental status examination reveals slow thinking
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and impaired attention. Which of the following is the most appropriate next step for evaluating this patienrs memory decline?
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0 A. Computed tomography (CT) scan of the brain
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• 15 0 B. ELISA for HIV
• 16 0 C. Lumbar puncture
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0 D. Mini-Mental State Examination
• 19 0 E. Referral for neuropsychological testing

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• 4 A 19-year-old woman is brought to the emergency department by her friends after a week-long history of "bizarre behavior." The
• 5 friends say that she has been ''talking a mile a minute" and staling that she has special powers from God. The patient has not slept in
• 6 the past 3 days and yet has been "running all over the place and spending to the limit on her credit cards." On mental status
• 7 examination, the patient is distracted with pressured speech and flight of ideas. When asked about her mood, the patient replies that
• 8 she has never fell this good before. She denies any suicidal or homicidal intent, ideation, or plan. She has never been depressed in
• 9 her life. There is no history of substance abuse, and urinary toxicology is negative. Which of the following is the most likely diagnosis?
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• 11 0 A. Bipolar disorder, type I
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• 13 0 B. Bipolar disorder, type II
• 14 0 C. Cyclothymic disorder
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0 D. Major depressive disorder with atypical features
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• 17 0 E. Mood disorder not otherwise specified (NOS)
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0 F. Schizophrenia, chronic paranoid type
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• 4 A 23-year-old man is brought to the emergency department for evaluation of altered mental status and fevers. His friend is with him
• 5 and says that the man has been healthy recently but saw a psychiatrist several days ago for complaints of "hearing voices." He was
• 6 started on a new medication, but the friend does not know the name of it. He has a temperature of 40" C (1 04.1° F). On examination
• 7 the patient is obtunded and not able to respond coherently to questioning. He has rigidity in all of his extremities. His creatinine
• 8 phosphokinase level is 8000 U/l. Which of the following is the most likely diagnosis?
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0 A. Bacterial meningitis
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• 12 0 B. Fungal meningitis
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• 15 0 D. Neuroleptic malignant syndrome
• 16 0 E. Status epilepticus
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• 4 A 28-year-old college student comes to the ER with the complaint of skin rashes that he developed 2 days ago. The patient was taken
• 5 to a psychiatrist 5 weeks ago because he was very loud and talkative. He stated that had not slept for the previous 4 days because he
• 6 had been making frequent trips to the library, but had been able to stay up all night to study without a problem. He knew he was going
• 7 to excel in his exams, because he recently had gained some power from God. The psychiatrist started him on an anticonvulsant that
• 8 the patient was told would help with his mood swings. His past history is significant for chickenpox at the age of 10. On examination
• 9 today, he is noted to have atypical targetoid lesions with focal confluence and detachment of the epithelium over about 10% of his
• 10 body surface. Which of the following medications did this patient most likely take?
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0 A. Lithium
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• 14 0 B. Clonazepam
• 15 0 C. Gabapentin
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• 17 0 D. Lamotrigine
• 18 0 E. Valproate
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• 4 A 64-year-old man is undergoing chemotherapy and has occasional nausea and vomiting, which are treated with IV prochlorperazine.
• 5 After several days of therapy, the patient complains that he feels very restless and agitated and he cannot stop moving his legs. He
• 6 has never experienced these symptoms before and is concerned that they were caused by his recent therapy. Which of the following
• 7 medications would best treat his symptoms?
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• 11 0 B. Haloperidol
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• 14 0 0 . Paroxetine
• 15 0 E. Sertraline
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• 4 A 35-year-old man is brought to the emergency clinic by his mother because of an episode of slurred speech associated with the
• 5 uncomfortable sensation that his tongue is thick and curling up. The episode started suddenly 30 minutes ago. The patient is noted to
• 6 be holding onto his tongue with his thumb and forefinger. His mother reports that the patient has had schizophrenia for 10 years and
• 7 consistently takes medications prescribed by his psychiatrist. Several days ago he ran out of one of his medications, but has
• 8 continued to take the others. Administration of which of the following should be included in the initial step in the management of this
• 9 patient?
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0 A. Alprazolam
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• 13 0 B. Benztropine
• 14 0 C. Haloperidol
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• 16 0 D. Lorazepam
• 17 0 E. Olanzapine
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• 4 A 42-year-old recently divorced woman started weekly cognitive-behavioral therapy for symptoms of depression, including a 4-month
• 5 history of anhedonia, poor appetite, difficulty sleeping, low self-esteem, and poor concentration. After 8 weeks of cognitive-behavioral
• 6 therapy, her symptoms have not improved. She has lost weight, feels tired every day, and is feeling hopeless about her future. She is
• 7 referred for psychiatric consunation. Which of the following is the most appropriate next step in the management of this condition?
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O A.ECT
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• 11 0 B. Hospitalization
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0 C. Increase cognitive behavioral therapy to twice per week
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• 14 0 0 . Reassurance and continue once-weekly cognitive behavioral therapy
• 15 0 E. Start a selective serotonin reuptake inhibitor
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• 4 A 29-year-old, previously successful woman was climbing stairs in her new home about a month ago, when the house collapsed. She
• 5 was taken to the hospital with a fractured left femur. The psychiatry team was consulted because the patient complained of nightmares
• 6 and nash backs and was afraid to go to sleep as a result. During the interview, she is tearful, and afraid that her fear of falling is
• 7 preventing her from fully participating in her rehabilitation, for wh ich she fears the team will discharge her from the hospital. Wh ich of
• 8 the following is the most appropriate treatment?
• 9
• 10
0 A. Insight-oriented psychotherapy
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• 12 0 B. No therapy because the patient needs to take responsibility for her treatment
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0 C. Put a sitter to stay in the patienrs room 24 hours a day to calm her anxiety
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• 15 0 D. Start an antidepressant
• 16 0 E. Start benzodiazepines
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• 4 A medical student is interviewing a 78-year-old man who was brought from the nursing home to the emergency department The
• 5 student has been talking to the man for almost 30 minutes and has obtained very little information. Every time he asks a question, the
• 6 patient starts talking and goes into unnecessary details, eventually answering the question but only after he has told his entire story to
• 7 the medical student The student is becoming frustrated with the patient because there are two other patients waiting to be interviewed.
• 8 This patient's speech is an example of which of the following?
• 9
• 10
0 A. Circumstantiality
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• 12 0 B. Flight of ideas
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0 C. Loose associations
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• 15 0 D. Tangentiality
• 16 0 E. Word salad
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• 4 A 20-year-old woman has a history of repeated admissions for sudden abdominal pain. No known etiology has been found for this
• 5 pain despite intensive metabolic, infectious, and endocrine evaluations. The patient has also had repeated imaging studies of her
• 6 abdomen and one exploratory laparotomy. She comes to the emergency department complaining of similar pain and is admitted to the
• 7 hospital for management. A social-work consun is called and reveals that the patient is a single mother with two small children. Now on
• 8 the inpatient noor, the patient is relaxed. Extensive imaging and laboratory studies are all normal. Which of the following is the most
• 9 likely diagnosis?
• 10
• 11
0 A. Body dysmorphic disorder
• 12
• 13 0 B. Conversion disorder
• 14 0 C. Factitious disorder
• 15
• 16 0 D. Hypochondriasis
• 17 0 E. Malingering
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• 4 A 80-year-old woman presents to the outpatient clinic with her daughter. She reports that she has had difficulty sleeping for the past
• 5 few months, including taking 45 to 60 minutes to fall asleep, frequent midnight awakenings to use the bathroom and stretch her legs,
• 6 and sleeping on average 5 to 6 hours per night. She finds that she needs to take a short nap during the day. She reports that her
• 7 husband of 55 years died 1 year ago, and she misses him very much. She reports that she lives alone and has some mild memory
• 8 loss. She denies change in her appetite or weight. She reports an active social life with friends from her retirement community and her
• 9 family. She denies a history of snoring at night. Her physical examination is unremarkable. What is the most likely diagnosis?
• 10
• 11
0 A. Age-related sleep changes
• 12
• 13 0 B. Bereavement
• 14 0 C. Early Alzheimer disease
• 15
• 16 0 D. Major depressive disorder
• 17 0 E. Restless legs syndrome
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• 4 A 72-year-old woman is brought to the emergency department by her daughter, who is concerned her mother had a "stroke."
• 5 According to the daughter, the woman woke up that morning not knowing where she was. She was confused and did not remember
• 6 what had happened the day before. Her history is significant for hypertension, diabetes mellitus type 2, angina, and anxiety disorder;
• 7 and she takes atenolol, hydrochlorothiazide, metformin, and alprazolam. On physical examination, she is found to have a BP of 128/76
• 8 mm Hg, PRof 86/ min, RR of 14/min, and temperature of 98.8 •F (37.1 •c). Neurologic examination is unremarkable. EKG and ABG
• 9 are found to be normal. Which of the following should be the next step?
• 10
• 11
0 A. Carotid duplex scanning
• 12
• 13 0 B. Discontinue atenolol
• 14 0 C. Echocardiogram
• 15
• 16 0 D. Order troponins
• 17 0 E. Stop alprazolam
• 18
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• 2 a Ite m: 31 of 44 • f> MarK <J [:> il , . ~
• 3 Prevtous Next lab Values Notes Calculator
• 4
A 31 -yea r-old man with schizoaffective disorder comes with his family to the psychiatrist for follow-up. He has been stable and
• 5
compliant with his medication. He is very concerned, however, about the 15 lb he has gained in the past 3 months, despite trying to
• 6
watch his diet and increase his exerc ise. His wife tells the physic ian that she heard about a new medication that is available for the
• 7
treatment of schizophrenia and is seemingly weight-neutral. She requests that her husband be switched to th is new drug. To wh ich of
• 8 the following antipsychotic medications is she most likely referring?
• 9
• 10
• 11 0 A. Clozapine
• 12
0 B. Olanzapine
• 13
• 14 0 C. Quetiapine
• 15 0 D. Risperidone
• 16
• 17 0 E. Ziprasidone
• 18
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• 5
A 10-year-old boy comes to the physician with his parents at the request of school authorities. In the past couple of months the
• 6
teachers have noticed that he has become more fidgety in class and at times coughs. He also makes sudden arm movements to touch
• 7
his peers in the middle of conversation. He also blinks often, and this has recently worsened. He says he has a feeling of tightness
• 8 that is relieved by arm extension, and a burning feeling in his eye before an eye blink. The main reason for the schoors calling the
• 9 parents and insisting on a medical evaluation is the boy's sudden screams that distract and scare the other students in class. He
• 10 seems very upset when it occurs and admits that he is aware that other children make fun of him and avoid him because of it but he
• 11 cannot control it. He is successful academically and is very neat, and there are no other behavioral or emotional problems. What other
• 12 psychiatric disorder can be associated with this patienfs condition?
• 13
• 14
• 15 O A.ADHD
• 16 0 B. Autistic disorder
• 17
• 18 0 C. Absence seizure
• 19 0 D. Huntington disease
• 20
0 E. Oppositional defiant disorder
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• 6
A 34-year-old woman in her first trimester of pregnancy is evaluated by a psychiatrist She recently started saying that she hears
• 7
voices telling her to kill herself because she does not deserve to live. When questioned, she reports that she feels extremely
• 8
depressed, guilty, and worthless. Her husband says that before this, she was a stable, content woman who was very happy about
• 9
having this child. Which of the following is the most appropriate treatment at this time?
• 10
• 11 .---
• 12 0 A. Clonazepam
• 13
0 B. Electroconvulsive therapy (ECT)
• 14
• 15 0 C. Fluoxetine
• 16
0 0 . Lithium
• 17
• 18 0 E. Psychotherapy
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• 7
A 17-year-old adolescent is brought to the hospital by police after being stopped for driving too slowly. He denies any use of alcohol,
• 8
but seems slow. He is laughing inappropriately, and has a dry mouth. His gait is somewhat slow and his coord ination is impaired. His
• 9
eyes are red, wh ich he explains as being due to pollen allergy. Wh ich of the following drugs will most likely appear on a uri ne drug
• 10
screen?
• 11
• 12 .---
• 13 0 A. Amphetamines
• 14
0 B. Benzodiazepines
• 15
• 16 0 C. Cocaine
• 17
0 0 . Opiates
• 18
• 19 0 E. Tetrahydrocannabinol
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• 8
A 21 -year-old man drops out of college because of poor performance. On questioning, he explains that he is afraid of having another
• 9
episode of sudden discomfort in wh ich he develops a fear of losing control. He had four such attacks in the last month. He became so
• 10
afraid that he could not concentrate in class and is no longer willing to sit in class because he would not be able to leave. Wh ich of the
• 11
following is the most likely diagnosis?
• 12
• 13
• 14 O A.ADHD
• 15
0 B. Agoraphobia
• 16
• 17 0 C. Mental retardation
• 18
0 D. Social phobia
• 19
• 20 0 E. Somatization disorder
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• 9
A 65-year-old woman comes to a primary care physician with a complaint of poor memory. Her husband died 6 months ago and she
• 10
has recently decreased her church involvement and had less interest in her hobbies. She complains of feeling tired and worried , and
• 11
has difficulty with attention and memory. She has a history of a major depressive episode approximately 10 years ago, which required
• 12
hospitalization. She was treated with an antidepressant for 2 years until it was tapered and discontinued. She currently denies
• 13 depressed mood. She states that her mother died of Alzheimer disease, and that she finds her memory loss particularly worrisome in
• 14 light of this family history. Which of the following factors would be more likely if this patient has a pseudodementia of depression
• 15 rather than a true dementia?
• 16
• 17
• 18 0 A. The patient appears unconcerned
• 19
0 B. The patient seems concerned due to memory loss
• 20
• 21 0 C. The patient has more difficulty with recent memory than remote memory
• 22 0 D. The patient tends to conceal the difficulty
• 23
24 0 E. The patient tries hard to answer questions about orientation and registration
•
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• 10
A 45-year-old woman comes to her primary care physician because of blurred vision. She states that this symptom started about 2
• 11
days ago. She denies any past history of significant medical or neurologic problems. She does state that several days ago she started
• 12
treatment for depression with a psychiatrist, due to a 2-month period during which she had several depressive symptoms. On review
• 13 of systems, she admits to having increased her water consumption over the last several days due to a dry mouth. She also complains
• 14 of dizziness when she stands up from lying or sitting. Her temperature is 37" C (98.6" F), blood pressure lying down is 135/75 mm Hg,
• 15 blood pressure standing is 110/64 mm Hg, pulse lying down is 84/min, pulse standing is 95/min, and respiratory rate is 16/ min.
• 16 Physical examination is unremarkable except for mild pupillary dilation. Which of the following medications most likely accounts for
• 17 this patienrs symptoms?
• 18
• 19
• 20 0 A. Bupropion
• 21 0 B. Citalopram
• 22
• 23 0 c. Imipramine
• 24 0 D. Nefazodone
• 25
0 E. Sertraline
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A 26-year-old single, unemployed Caucasian man who has a history of paranoid schizophrenia presents to the outpatient clinic. He
• 12
reports that his previous psychiatrist prescribed risperidone, 2 mg/d, but he does not take it regularly. He states that it makes him tired
• 13
and occasionally stiff, and he does not think he needs to take medication on a daily basis. He is mildly disorganized and somewhat
• 14
disheveled but denies acute psychotic symptoms or thoughts of self-harm. Which of the following interventions should be tried next?
• 15
• 16
• 17 0 A. Depot medication
• 18
0 B. Hospitalization
• 19
• 20 0 C. Increase risperidone to 4mg/d
• 21
0 D. Mental health court hearing
• 22
• 23 0 E. Switch to aripiprazole
• 24
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• 12
A 32-year-old man is brought to the emergency department by a friend because he has been euphoric, sedated, and indifferent to
• 13
pain since last night. Physical examination is significant for a constricted pupils. This is the third time that the patient has been brought
• 14
to this hospital for this reason. After the administration of appropriate treatment and a complete physical examination, which of the
• 15
following laboratory studies is most important in the evaluation of this patient to provide long-term follow-up care?
• 16
• 17 .---
• 18 0 A. Albumin level
• 19
0 B. Echocardiogram
• 20
• 21 0 C. Electroencephalogram
• 22
0 0 . HIV antibody test
• 23
• 24 0 E. Plasma liver enzyme levels
• 25
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• 13
A 19-year-old obese girl comes to her physician because she often feels tired and sleeps throughout the course of the day. She says
• 14
that she sleeps for about 7 hours each night, and snores wh ile sleeping. A few weeks ago, she colla psed to the floor when she met her
• 15
father for the first time after he had a stroke. She has no significant medical history and denies substance use. Her vital signs are
• 16
within normal limits. Her physical examination appears normal except for obesity. Wh ich of the following is the most appropriate
• 17
treatment for th is condition?
• 18
• 19
• 20 0 A. Benzodiazepine
• 21
0 B. CPAP
• 22
• 23 0 C. Ethosuccimide
• 24 0 D. Modafinil
• 25
• 26 0 E. No treatment is required at this time
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• 14
A 30-year-old single woman who works as a computer programmer for a large corporation presents for outpatient treatment She
• 15
describes a long-standing history of feelings of low self-esteem, difficulty forming satisfying relationships, and inadequacy in her
• 16
work. She tries not to attend work-related meetings and dreads interactions with coworkers, preferring to stay in her office. She feels
• 17
that her coworkers think she isn't as qualified as other programmers and is very sensitive to criticism by her peers. She sometimes
• 18 thinks that coworkers speak about her behind her back. She would like to have more friends, both at the office and in her community,
• 19 but tends to feel inferior to others. This presentation is most consistent with a diagnosis of which of the following?
• 20
• 21
• 22 0 A. Avoidant personality disorder
• 23
0 B. Dependent personality disorder
• 24
• 25 0 C. Paranoid personality disorder
• 26 0 D. Schizoid personality disorder
• 27
• 28 0 E. Schizotypal personality disorder
• 29
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• 4 1.
• 13
• 14
• 15
A 42-year-old married man presents to the outpatient clinic. He reports that he was diagnosed in his late teens with schizophrenia,
• 16
paranoid type, after suffering from persecutory delusions, auditory hallucinations, and poor school and occupational functioning. He
• 17
reports that he has a number of stressors at this time, including the death of his father and problems with his wife. He has a family
• 18
psychiatric history significant for major depressive disorder on his mother's side of the family. He is currently stable on aripiprazole,
• 19 15 mg/d, and he works in a factory. Which of the following features of this patient is associated with a poor prognosis?
• 20
• 21
• 22 0 A. Being married
• 23
0 B. Family history of a mood disorder
• 24
• 25 0 C. History of positive symptoms
• 26 0 D. Onset of symptoms at an ear1y age
• 27
• 28 0 E. Precipitating stressors at the start of psychotic symptoms
• 29 0 F. Quick onset of symptoms
• 30
• 31
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• 34
• 35
• 36
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• 38
• 39
• 14
• 15
• 16
A 35-year-old woman is brought to the emergency department because she is stiff and unable to swallow or talk. She is confused and
• 17
tremulous, and her family is concerned because she developed a high fever last night and they suspect she has developed an
• 18
infection. Her past medical history is significant for bipolar disorder for 10 years. She was recently treated in the hospital for an acute
• 19
manic episode and started on lithium. She had an elective cholecystectomy 1 week ago. In the past couple of days, her family reports
• 20 that she has appeared "strange." Her temperature is 39.5 •c (103.1 °F), blood pressure is 160/ 108 mm Hg, pulse is 124/min, and
• 21 respirations are 24/min. She appears tremulous, diaphoretic, and confused. She has increased tone in her neck and extremities. Her
• 22 leukocyte count is 21 ,200/ mm3 and the serum creatinine phosphokinase is 5,238 U/L. A thorough evaluation for infection is negative.
• 23 Which of the following should be the management?
• 24
• 25 0 A. Antibiotics for meningitis
• 26
• 27 0 B. Dantrolene
• 28 0 C. Dialysis
• 29
0 D. Halothane
• 30
• 31 0 E. Succinylcholine
• 32
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• 43 Suspend End BlocK
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• 16
• 17
A mother brings her 8-year-old son to a psychiatrist for new-onset enuresis. A prior workup to determine a medical cause was
• 18
negative. In conversation, it seems that the enuresis started following parental arguments and separation. The boy wets himself at least
• 19
twice a week and feels upset about it, refusing to go for a sleep-over at his friend's house. Which of the following is the most effective
• 20 first step in management for this condition?
• 21
• 22
• 23 0 A. Behavioral therapy
• 24
0 B. Interpersonal therapy
• 25
• 26 0 C.DDAVP
• 27 0 D. Imipramine
• 28
• 29 0 E. Psychotherapy
• 30
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• 41

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•

• 21 0 C. Call for a social worker consult to assist with management

• 16 0 E. Prescribe antidepressant medication

• 16 0 E. Stop sertraline; he is doing well

• 13 0 B. Add haloperidol to control psychotic agitation

• 18 0 E. Prescribe benzodiazepines on an as-needed basis

• 9 otherwise functional. Which of the following is the most likely diagnosis?

• 19 0 E. Referral for neuropsychological testing

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