1) A 3-year-old girl is brought to the physician by her parents because they are concerned about her behavior.

They
describe their daughter as stubborn and always on the go. She can rarely sit still for more than 10 minutes. She
often refuses to comply with their requests and sometimes throws 3- to 5-minute temper tantrums. They report
that she dawdles at bedtime and requires frequent direction and assistance in preparing for bed. Her preschool
teacher notes that she is active and talkative without being disruptive and is beginning to demonstrate more
interactive play with her peers. She generally sleeps through the night and occasionally wets the bed. Her appetite is
good. Her first word was at the age of 11 months, and she began walking without assistance at the age of 14
months. Physical examination shows no abnormalities. On mental status examination, she initially hides behind her
mother but warms to the interviewer after a few minutes and begins playing with toys in the office. Her speech is
90% intelligible, and her vocabulary is large for her age. Which of the following is the most appropriate next step in
management?
(A) Reassurance
(B) Play therapy
(C) Speech therapy
(D) Enuresis alarm
(E) Trial of fluoxetine
(F) Trial of methylphenidate
1) A 3-year-old girl is brought to the physician by her parents because they are concerned about her behavior. They
describe their daughter as stubborn and always on the go. She can rarely sit still for more than 10 minutes. She
often refuses to comply with their requests and sometimes throws 3- to 5-minute temper tantrums. They report
that she dawdles at bedtime and requires frequent direction and assistance in preparing for bed. Her preschool
teacher notes that she is active and talkative without being disruptive and is beginning to demonstrate more
interactive play with her peers. She generally sleeps through the night and occasionally wets the bed. Her appetite is
good. Her first word was at the age of 11 months, and she began walking without assistance at the age of 14
months. Physical examination shows no abnormalities. On mental status examination, she initially hides behind her
mother but warms to the interviewer after a few minutes and begins playing with toys in the office. Her speech is
90% intelligible, and her vocabulary is large for her age. Which of the following is the most appropriate next step in
management?
(A) Reassurance
(B) Play therapy
(C) Speech therapy
(D) Enuresis alarm
(E) Trial of fluoxetine
(F) Trial of methylphenidate
2) A 27-year-old woman is brought to the emergency department 1 hour after a friend found her
barely arousable in her disorderly apartment with a nearly starving cat. The patient appears
extremely thin. Her pulse is 90/min, respirations are 6/min, and blood pressure is 90/60 mm Hg.
Physical examination shows small pupils, cracked lips, and bruises and scratches over the upper
extremities. Mental status examination shows mild obtundation, blunted affect, and slow,
incoherent speech. Which of the following is the most appropriate next step in management?
(A) Observation in a quiet darkened room
(B) Oral administration of chlorpromazine
(C) Intramuscular administration of naloxone
(D) Intravenous administration of haloperidol
(E) Intravenous administration of lorazepam
2) A 27-year-old woman is brought to the emergency department 1 hour after a friend found her
barely arousable in her disorderly apartment with a nearly starving cat. The patient appears
extremely thin. Her pulse is 90/min, respirations are 6/min, and blood pressure is 90/60 mm Hg.
Physical examination shows small pupils, cracked lips, and bruises and scratches over the upper
extremities. Mental status examination shows mild obtundation, blunted affect, and slow,
incoherent speech. Which of the following is the most appropriate next step in management?
(A) Observation in a quiet darkened room
(B) Oral administration of chlorpromazine
(C) Intramuscular administration of naloxone
(D) Intravenous administration of haloperidol
(E) Intravenous administration of lorazepam
3) A 45 yo F is brought to the ED by concerned family members who recently noticed repetitive
stereotypical movements of the patient’s tongue. She has no other symptoms. She has a long
history of schizophrenia that has been well controlled with Haloperidol. What is the next best
step in the management of this patient?
a. Decrease the dose of haloperidol.
b. Change her medication to Clozapine.
c. Change her medication to fluphenazine.
d. Increase the dose of haloperidol.
e. Discontinue haloperidol and try electroconvulsive therapy.
f. Change her medication to Aripiprazole.
3) A 45 yo F is brought to the ED by concerned family members who recently noticed repetitive
stereotypical movements of the patient’s tongue. She has no other symptoms. She has a long
history of schizophrenia that has been well controlled with Haloperidol. What is the next best
step in the management of this patient?
a. Decrease the dose of haloperidol.
b. Change her medication to Clozapine.
c. Change her medication to fluphenazine.
d. Increase the dose of haloperidol.
e. Discontinue haloperidol and try electroconvulsive therapy.
f. Change her medication to Aripiprazole.
4) A 56 yo business executive is 1 day out from an uncomplicated cholecystectomy for
symptomatic cholelithiasis. The nurse notices a significant variation in his VS compared to what
was measured in the PACU. HR is 153 bpm, BP is 170/105. He has tremors and has been feeling
nauseous. He is given a beta blocker for symptomatic relief. 24 hrs later he begins to describe a
feeling of bugs crawling under his skin, appears delirious, and has a mild fever. He begins to have
generalized tonic-clonic movements of his hands and legs. What is the next best step in the
management of this patient?
a. IV Lorazepam therapy.
b. IV Phenobarbital therapy.
c. A 4-6 week course of Bupropion.
d. Referral for Alcoholics Anonymous counseling.
4) A 56 yo business executive is 1 day out from an uncomplicated cholecystectomy for
symptomatic cholelithiasis. The nurse notices a significant variation in his VS compared to what
was measured in the PACU. HR is 153 bpm, BP is 170/105. He has tremors and has been feeling
nauseous. He is given a beta blocker for symptomatic relief. 24 hrs later he begins to describe a
feeling of bugs crawling under his skin, appears delirious, and has a mild fever. He begins to have
generalized tonic-clonic movements of his hands and legs. What is the next best step in the
management of this patient?
a. IV Lorazepam therapy.
b. IV Phenobarbital therapy.
c. A 4-6 week course of Bupropion.
d. Referral for Alcoholics Anonymous counseling.
5) You are called to evaluate a 25 yo M prior to discharge after spending 3 days in central booking
for driving under the influence. He feels completely dissatisfied with life, is restless, and has not
slept for the past 2 days. You wonder how boring you must be as he constantly yawns during the
interview. He has a bad runny nose and there’s copious amounts of saliva dripping from the
lateral side of his mouth. His PE is notable for marked pupil dilation. He runs to use the restroom
3x during the interview. What is the next best step in the management of this patient?
a. Dextroamphetamine therapy
b. Supportive care
c. Referral to alcoholics anonymous
d. Naltrexone therapy
e. Flumazenil therapy
5) You are called to evaluate a 25 yo M prior to discharge after spending 3 days in central booking
for driving under the influence. He feels completely dissatisfied with life, is restless, and has not
slept for the past 2 days. You wonder how boring you must be as he constantly yawns during the
interview. He has a bad runny nose and there’s copious amounts of saliva dripping from the
lateral side of his mouth. His PE is notable for marked pupil dilation. He runs to use the restroom
3x during the interview. What is the next best step in the management of this patient?
a. Dextroamphetamine therapy
b. Supportive care
c. Referral to alcoholics anonymous
d. Naltrexone therapy
e. Flumazenil therapy
6) A 24-year-old female is brought into the psychiatric ED after threatening suicide following an
arrest for assaulting her partner. As you walk in, you notice her joking around with the police
officers who have her under arrest. When you interview her, she denies any suicidal ideation and
claims she is sorry for what happened, but that the partner had it coming for constantly
antagonizing her. Collateral information from the Mother reveals a long history of violence and
fighting dating back to when the patient was a child, as well as unstable relationships. The
Mother also states she has always had constant fights with the patient over not following the
rules and is on the verge of kicking her out. What is the most likely personality disorder?
a)Antisocial Personality Disorder
b)Borderline Personality Disorder
c)Narcissistic Personality Disorder
d)Histrionic Personality Disorder
6) A 24-year-old female is brought into the psychiatric ED after threatening suicide following an
arrest for assaulting her partner. As you walk in, you notice her joking around with the police
officers who have her under arrest. When you interview her, she denies any suicidal ideation and
claims she is sorry for what happened, but that the partner had it coming for constantly
antagonizing her. Collateral information from the Mother reveals a long history of violence and
fighting dating back to when the patient was a child, as well as unstable relationships. The
Mother also states she has always had constant fights with the patient over not following the
rules and is on the verge of kicking her out. What is the most likely personality disorder?
a)Antisocial Personality Disorder
b)Borderline Personality Disorder
c)Narcissistic Personality Disorder
d)Histrionic Personality Disorder
7) You are called to the medical ED to psychiatrically evaluate a 49 y/o woman who presents after
a fall. When you enter you find the patient to be oddly dressed and arguing with the nurse about
getting garlic to “ward off evil”. When you speak to her, she tells you a strange story about
chasing “ghosts” out of the house and then falling down the steps. She has worked as a medium
and tarot card reader for many years. She is unable to provide you any family or friends to
contact for collateral. What is the most likely diagnoses?
(A) Schizoid Personality Disorder
(B) Schizotypal Personality Disorder
(C) Schizophrenia
(D) Delusional Disorder
(E) Autism Spectrum Disorder
7) You are called to the medical ED to psychiatrically evaluate a 49 y/o woman who presents after
a fall. When you enter you find the patient to be oddly dressed and arguing with the nurse about
getting garlic to “ward off evil”. When you speak to her, she tells you a strange story about
chasing “ghosts” out of the house and then falling down the steps. She has worked as a medium
and tarot card reader for many years. She is unable to provide you any family or friends to
contact for collateral. What is the most likely diagnoses?
(A) Schizoid Personality Disorder
(B) Schizotypal Personality Disorder
(C) Schizophrenia
(D) Delusional Disorder
(E) Autism Spectrum Disorder
8) A 52-year-old woman whose husband died 2 months ago consults a physician because of
headaches and feelings of uncertainty. She describes the headaches as a band around her head;
they occur unpredictably and are not accompanied by any other symptoms. She has no history of
psychiatric illness. While talking with the physician, the patient begins to cry and talk about her
deceased husband; she feels her life is empty now and worries about her future. Which of the
following is most appropriate at this point?
(A) Allow her to express herself
(B) Prescribe an antianxiety drug
(C) Prescribe an antidepressant drug
(D) Refer her for psychological testing
(E) Obtain a psychiatric consultation
8) A 52-year-old woman whose husband died 2 months ago consults a physician because of
headaches and feelings of uncertainty. She describes the headaches as a band around her head;
they occur unpredictably and are not accompanied by any other symptoms. She has no history of
psychiatric illness. While talking with the physician, the patient begins to cry and talk about her
deceased husband; she feels her life is empty now and worries about her future. Which of the
following is most appropriate at this point?
(A) Allow her to express herself
(B) Prescribe an antianxiety drug
(C) Prescribe an antidepressant drug
(D) Refer her for psychological testing
(E) Obtain a psychiatric consultation
9) A healthy 9-year-old boy is brought to the physician by his parents because they are concerned that he dislikes
attending school. Every morning he cries and begs to stay home. He misses school at least 1 day weekly because his
mother is exhausted from fighting with him to attend. His teachers report that he is quiet in class and rarely
participates. He has difficulty reading at the level of his peers and lacks confidence. At home, he tends to stay in the
same room as his mother and will sometimes follow her around the house. When his parents plan an evening out,
he often becomes tearful and asks many questions about when they will return. He likes to have friends over to his
house and appears to enjoy being with them. Physical examination shows no abnormalities. During the examination,
he sits on his mother’s lap and is quiet but cooperative. He makes brief eye contact and speaks in a low volume,
becoming tearful when questioned about being away from his mother. Which of the following is the most likely
diagnosis?
(A) Dysthymic disorder
(B) Mild mental retardation
(C) Oppositional defiant disorder
(D) Reading disorder
(E) Separation anxiety disorder
(F) Social phobia
9) A healthy 9-year-old boy is brought to the physician by his parents because they are concerned that he dislikes
attending school. Every morning he cries and begs to stay home. He misses school at least 1 day weekly because his
mother is exhausted from fighting with him to attend. His teachers report that he is quiet in class and rarely
participates. He has difficulty reading at the level of his peers and lacks confidence. At home, he tends to stay in the
same room as his mother and will sometimes follow her around the house. When his parents plan an evening out,
he often becomes tearful and asks many questions about when they will return. He likes to have friends over to his
house and appears to enjoy being with them. Physical examination shows no abnormalities. During the examination,
he sits on his mother’s lap and is quiet but cooperative. He makes brief eye contact and speaks in a low volume,
becoming tearful when questioned about being away from his mother. Which of the following is the most likely
diagnosis?
(A) Dysthymic disorder
(B) Mild mental retardation
(C) Oppositional defiant disorder
(D) Reading disorder
(E) Separation anxiety disorder
(F) Social phobia
10) A 33 yo G2P1 female at 33 weeks gestation is brought to the ED by her husband after he
found her trying to take 10 tablets of fluoxetine with robitussin to “take the edge off”. For the
past 4 weeks, she has expressed a desire to give up the baby for adoption before leaving the
hospital after delivery. Concerned, the physician decides to involuntarily hospitalize the patient.
For the next 3 days, the patient strongly refuses all food offered in the hospital. Prior to
attempting definitive management, the patient should be warned about?
a. The risks of neural tube defects associated with this treatment.
b. The risks of memory impairment with this treatment.
c. The risks of a seizure disorder with this treatment.
d. The risks of severe GI bleeding with this treatment.
e. The risks of severe radiation exposure with this treatment
10) A 33 yo G2P1 female at 33 weeks gestation is brought to the ED by her husband after he
found her trying to take 10 tablets of fluoxetine with robitussin to “take the edge off”. For the
past 4 weeks, she has expressed a desire to give up the baby for adoption before leaving the
hospital after delivery. Concerned, the physician decides to involuntarily hospitalize the patient.
For the next 3 days, the patient strongly refuses all food offered in the hospital. Prior to
attempting definitive management, the patient should be warned about?
a. The risks of neural tube defects associated with this treatment.
b. The risks of memory impairment with this treatment.
c. The risks of a seizure disorder with this treatment.
d. The risks of severe GI bleeding with this treatment.
e. The risks of severe radiation exposure with this treatment
11) A 24 y/o male with no medical history presents to the psychiatric ED after a suicide attempt
via hanging. He presents with flat affect, psychomotor retardation, and slowed speech. He is
reports several weeks of depression, hopelessness, and suicidal intent that is still active. A review
of the history reveals two past psychiatric hospitalization, one after the patient was not sleeping
for a couple of weeks and flew to the White House to tell the President about his plan for world
peace. The other was following another suicide attempt via overdose on Acetaminophen. What
is the best treatment for this patient?
a. Quetiapine
b. Valproate
c. Fluoxetine
d. Lithium
e. Buproprion
11) A 24 y/o male with no medical history presents to the psychiatric ED after a suicide attempt
via hanging. He presents with flat affect, psychomotor retardation, and slowed speech. He is
reports several weeks of depression, hopelessness, and suicidal intent that is still active. A review
of the history reveals two past psychiatric hospitalization, one after the patient was not sleeping
for a couple of weeks and flew to the White House to tell the President about his plan for world
peace. The other was following another suicide attempt via overdose on Acetaminophen. What
is the best treatment for this patient?
a. Quetiapine
b. Valproate
c. Fluoxetine
d. Lithium
e. Buproprion
12) A 37-year-old man presents to your office complaining of auditory hallucinations that have
worsened over the last several months. He notes that the Devil has been telling him that he is
“no good,” and that he will not “amount to anything.” During the last several months, the patient
also reports feeling “depressed” and has been sleeping poorly. He has no desire to get out of bed
and has lost interest in even watching sports (normally one of his favorite activities). The patient
states that even when his mood is improved, he still cannot “get the voices out of my head”
Which diagnosis best accounts for this patient’s symptoms?
(A) major depression
(B) schizophrenia
(C) schizoaffective disorder
(D) bipolar II disorder
(E) schizoid personality disorder
12) A 37-year-old man presents to your office complaining of auditory hallucinations that have worsened over the
last several months. He notes that the Devil has been telling him that he is “no good,” and that he will not “amount
to anything.” During the last several months, the patient also reports feeling “depressed” and has been sleeping
poorly. He has no desire to get out of bed and has lost interest in even watching sports (normally one of his favorite
activities). The patient states that even when his mood is improved, he still cannot “get the voices out of my head”
Which diagnosis best accounts for this patient’s symptoms?
(A) major depression
(B) schizophrenia
(C) schizoaffective disorder
(D) bipolar II disorder
(E) schizoid personality disorder

The most likely diagnosis in this case is schizoaffective disorder. The patient has prominent psychotic symptoms, including
auditory hallucinations and paranoid ideation, but also has concurrent mood symptoms, including depressed mood, decreased
sleep, anhedonia, and decreased motivation. Also important, the patient’s hallucinations have occurred in the absence of mood
symptoms, and his mood symptoms appear to have been present for a substantial portion of the total duration of his illness. The
presence of prominent psychotic symptoms in the absence of mood symptoms makes major depression unlikely. A diagnosis of
schizophrenia alone would not adequately account for this patient’s mood symptoms. Bipolar II disorder is not a valid choice
since there is no clear history of a hypomanic episode. Schizoid personality disorder is unlikely because that diagnosis would not
account for the patient’s psychotic and mood symptoms
13) A 49-year-old bank teller without a psychiatric history is referred to your office for the first
time by her internist for an evaluation. For the past 2 months, she has been increasingly
convinced that a well-known pop music star is in love with her and that they have had an
ongoing affair. She is well-groomed, and there is no evidence of thought disorder or
hallucinations. Her husband reveals that she has been functioning well at work and in other
social relationships. Which of the following is the most likely diagnosis?
(A) delusional disorder
(B) acute reactive psychosis
(C) prodromal schizophrenia
(D) paranoid personality disorder
(E) schizophreniform disorder
13) A 49-year-old bank teller without a psychiatric history is referred to your office for the first
time by her internist for an evaluation. For the past 2 months, she has been increasingly
convinced that a well-known pop music star is in love with her and that they have had an
ongoing affair. She is well-groomed, and there is no evidence of thought disorder or
hallucinations. Her husband reveals that she has been functioning well at work and in other
social relationships. Which of the following is the most likely diagnosis?
(A) delusional disorder
(B) acute reactive psychosis
(C) prodromal schizophrenia
(D) paranoid personality disorder
(E) schizophreniform disorder

This patient is likely suffering from a delusional disorder. This woman’s age, lack of prior psychiatric illness, and high level of social
and occupational functioning are not consistent with a schizophrenia-spectrum diagnosis. Although she is delusional, her
delusion is not bizarre (i.e., it could possibly happen) and there is no associated hallucinations or disorganization.
14) A 42-year-old business executive presents for his first contact with a mental health provider. He reports that for
the last 4 months he has been feeling depressed. His low energy level and poor motivation are affecting his job
performance and the CEO of his company advised him to “take a couple of weeks off.” The patient reports that he
started feeling down when his wife discovered that he was involved in his third extramarital affair. Since then he has
moved into a small apartment by himself. He is sleeping almost 12 hours every night, has a poor appetite, and is
experiencing financial difficulty due to indiscriminate purchases. He laments the loss of his former self. He reports
that he used to need only 4–5 hours of sleep and once was able to “party all night and work all day.” This case best
illustrates an Axis I diagnosis of which of the following?
(A) bipolar I disorder
(B) bipolar II disorder
(C) MDD
(D) narcissistic personality disorder
(E) impulse control disorder not otherwise specified
14) A 42-year-old business executive presents for his first contact with a mental health provider. He reports that for
the last 4 months he has been feeling depressed. His low energy level and poor motivation are affecting his job
performance and the CEO of his company advised him to “take a couple of weeks off.” The patient reports that he
started feeling down when his wife discovered that he was involved in his third extramarital affair. Since then he has
moved into a small apartment by himself. He is sleeping almost 12 hours every night, has a poor appetite, and is
experiencing financial difficulty due to indiscriminate purchases. He laments the loss of his former self. He reports
that he used to need only 4–5 hours of sleep and once was able to “party all night and work all day.” This case best
illustrates an Axis I diagnosis of which of the following?
(A) bipolar I disorder
(B) bipolar II disorder
(C) MDD
(D) narcissistic personality disorder
(E) impulse control disorder not otherwise specified
This patient’s history is most consistent with a mood pattern defined by prolonged periods of hypomania (symptoms of mania
not severe enough to cause occupational dysfunction or psychiatric treatment) and now a major depressive episode. Hypomania
with major depression defines bipolar II disorder. In bipolar I disorder, the mania is more severe causing notable occupational
dysfunction and usually contact with psychiatrists. This patient is in the midst of a major depressive episode but his history of
mania indicates a bipolar diagnosis. This is an important distinction to make in diagnosis because improper treatment with
antidepressants can precipitate a manic episode. Narcissistic personality disorder is an Axis II diagnosis. This patient does display
impulsivity but impulse control disorder, not otherwise specified, can be diagnosed only after the exclusion of major mental
illness such as bipolar disorder, which may have impulsive features.
15) A 47-year-old male novelist feared contamination from anything he believed was dirty. In restaurants, he would
use his own plastic utensils. Elsewhere, he would wear gloves or use paper towels to avoid touching “dirty objects.”
Upon returning home, he would wash his hands five times at night before going about his activities. If he
accidentally touched anything prior to washing his hands, he would experience a vague uncomfortable feeling and
would be unable to perform his usual nightly activities. As a result of these symptoms he was unable to have a
meaningful social life. The most effective agent for this syndrome is which of the following?
(A) clomipramine
(B) mirtazapine
(C) clonazepam
(D) phenelzine
(E) olanzapine
15) A 47-year-old male novelist feared contamination from anything he believed was dirty. In restaurants, he would
use his own plastic utensils. Elsewhere, he would wear gloves or use paper towels to avoid touching “dirty objects.”
Upon returning home, he would wash his hands five times at night before going about his activities. If he
accidentally touched anything prior to washing his hands, he would experience a vague uncomfortable feeling and
would be unable to perform his usual nightly activities. As a result of these symptoms he was unable to have a
meaningful social life. The most effective agent for this syndrome is which of the following?
(A) clomipramine
(B) mirtazapine
(C) clonazepam
(D) phenelzine
(E) olanzapine
Clomipramine, a TCA with potent serotonin reuptake inhibition, is the most widely studied agent with efficacy in OCD. Several
SSRIs, including fluoxetine, fluvoxamine, sertraline, and paroxetine, have demonstrated efficacy in OCD. Other tricyclic agents are
not as effective as clomipramine probably because they lack the potent serotonin reuptake inhibition of clomipramine.
Clonazepam may be used for anxiety associated with OCD but it is not effective in treating the underlying disorder. Mirtazapine is
an antidepressant that is a central alpha2-antagonist, leading to increased norepinephrine and serotonin release, and an
antagonist of both 5-HT2 and 5-HT3 . However, it has not been used in OCD. Phenelzine is an MAOI that is not used in OCD.
Olanzapine is an atypical neuroleptic. Neuroleptics generally are not effective in OCD.
16) A 77-year-old woman is brought to the emergency department by her husband because of agitation and
confusion for 3 hours. He states that she has been intermittently crying out and does not appear to recognize him. A
routine health maintenance examination 3 days ago showed no abnormalities except for mild memory deficits. Her
current temperature is 37.8°C (100°F), pulse is 100/min, respirations are 14/min, and blood pressure is 130/60 mm
Hg. Physical examination shows no abnormalities except for mild tenderness to palpation of the lower abdomen.
Mental status examination shows confusion; she is oriented to person but not to time or place. Which of the
following is the most appropriate next step in diagnosis?
(A) Determination of erythrocyte sedimentation rate
(B) Measurement of serum alkaline phosphatase activity
(C) Measurement of serum folate concentration
(D) Urinalysis
(E) Western blot assay
16) A 77-year-old woman is brought to the emergency department by her husband because of agitation and
confusion for 3 hours. He states that she has been intermittently crying out and does not appear to recognize him. A
routine health maintenance examination 3 days ago showed no abnormalities except for mild memory deficits. Her
current temperature is 37.8°C (100°F), pulse is 100/min, respirations are 14/min, and blood pressure is 130/60 mm
Hg. Physical examination shows no abnormalities except for mild tenderness to palpation of the lower abdomen.
Mental status examination shows confusion; she is oriented to person but not to time or place. Which of the
following is the most appropriate next step in diagnosis?
(A) Determination of erythrocyte sedimentation rate
(B) Measurement of serum alkaline phosphatase activity
(C) Measurement of serum folate concentration
(D) Urinalysis
(E) Western blot assay
17) 72-year-old woman presents to the emergency department from a nursing home. On physical examination, she appears
malnourished and dehydrated. The medical service initiates intravenous fluid replacement. On MSE, she is alert and oriented to
person only. She reports that the president is Lyndon B. Johnson. During the interview, the patient is easily distracted. She often
forgets things shortly after she learns them. One hour later, her MSE has improved, reporting the correct day, time, and place.
However, she cannot remember why she is there. When asked about the current president, she cannot remember his name but
describes his appearance. She is able to perform serial sevens slowly but accurately without distraction. Based on the information
in this case, the most appropriate diagnosis for this patient’s presenting symptoms is which of the following?
(A) amnestic disorder not otherwise specified
(B) cognitive disorder not otherwise specified
(C) delirium
(D) dementia not otherwise specified
(E) major depression
17) 72-year-old woman presents to the emergency department from a nursing home. On physical examination, she appears
malnourished and dehydrated. The medical service initiates intravenous fluid replacement. On MSE, she is alert and oriented to
person only. She reports that the president is Lyndon B. Johnson. During the interview, the patient is easily distracted. She often
forgets things shortly after she learns them. One hour later, her MSE has improved, reporting the correct day, time, and place.
However, she cannot remember why she is there. When asked about the current president, she cannot remember his name but
describes his appearance. She is able to perform serial sevens slowly but accurately without distraction. Based on the information
in this case, the most appropriate diagnosis for this patient’s presenting symptoms is which of the following?
(A) amnestic disorder not otherwise specified
(B) cognitive disorder not otherwise specified
(C) delirium
(D) dementia not otherwise specified
(E) major depression
This patient’s MSE is most consistent with delirium in that it is remarkable for relatively rapidly fluctuating memory, orientation,
and attention. Also, her apparent dehydration and malnourishment provide evidence for an underlying medical cause of her
mental status change. Amnestic disorder is not likely given this patient’s shifts in attention and memory fluctuations. Cognitive
disorder, not otherwise specified, is reserved for cases exclusive of dementia and delirium such as cases of traumatic brain
injury. Although this patient would seem a likely person to have dementia because she came from a nursing home, her
fluctuating mental status is indicative of a delirium. Dementias are diagnosed in the context of a relatively stable set of deficits
on an MSE, and the underlying causes are rarely associated with acute medical insults. Importantly, however, the presence of
dementia does predispose to delirium. Major depression can cause cognitive deficits on MSEs that are reversible with
antidepressant treatment. These pseudodementias, like dementia, most often present as a more stable examination than is
illustrated in this case
18) Psychotic depression is diagnosed in a 14-year-old boy, and he is treated with an antipsychotic agent, risperidone, and an
antidepressant. Three months later, his mood symptoms have resolved, and he is no longer psychotic. Which of the following best
describes the next step?
A. Both medications should be discontinued via a taper.
B. The antipsychotic medication should be discontinued via a taper.
C. The antidepressant medication should be discontinued via a taper.
D. Both agents should be continued for 6 to 9 months.
E. The antipsychotic medication should be stopped immediately
18) Psychotic depression is diagnosed in a 14-year-old boy, and he is treated with an antipsychotic agent, risperidone, and an
antidepressant. Three months later, his mood symptoms have resolved, and he is no longer psychotic. Which of the following best
describes the next step?
A. Both medications should be discontinued via a taper.
B. The antipsychotic medication should be discontinued via a taper.
C. The antidepressant medication should be discontinued via a taper.
D. Both agents should be continued for 6 to 9 months.
E. The antipsychotic medication should be stopped immediately

The antipsychotic agent should be discontinued because the psychotic symptoms have abated. The antidepressant should be
continued for approximately 6 to 9 months in a patient with the first onset of major depression, and for longer (perhaps
indefinitely) for a patient with recurrent depression
19) A 16-year-old boy began having repetitive eye blinking at the age of 6. By age 12, he began blurting stereotyped phrases such
as “Balls!” and “Shitty!” as well as making kissing noises. Concomitant with this, he had increasing difficulty with paying attention
in school and occasionally displayed wild, disinhibited behavior. Which of the following is the treatment of choice for the primary
condition evident in this case?
(A) pimozide (Orap)
(B) methylphenidate (Ritalin)
(C) fluoxetine (Prozac)
(D) topiramate (Topamax)
(E) clonidine (Catapres)
19) A 16-year-old boy began having repetitive eye blinking at the age of 6. By age 12, he began blurting stereotyped phrases such
as “Balls!” and “Shitty!” as well as making kissing noises. Concomitant with this, he had increasing difficulty with paying attention
in school and occasionally displayed wild, disinhibited behavior. Which of the following is the treatment of choice for the primary
condition evident in this case?
(A) pimozide (Orap)
(B) methylphenidate (Ritalin)
(C) fluoxetine (Prozac)
(D) topiramate (Topamax)
(E) clonidine (Catapres)

This patient is most likely suffering from Tourette syndrome. Pimozide, a dopamine blocker, has been shown to most clearly
suppress tic activity compared to agents affecting other neurotransmitter systems. Although methylphenidate may help this
patient’s apparent ADHD symptoms, it may also exacerbate his tic disorder. Fluoxetine, topiramate, and clonidine may be
effective for comorbid conditions found with Tourette disorder but have not been found to be specifically helpful for this primary
condition
20) A 14-month-old girl presents with her parents who report that she has become less
responsive to them and less interactive with her 6-year-old brother. In addition, her gait has
become clumsy, and most recently, she has been noted to habitually rub her knuckles together.
The parents also bring the chart from their daughter’s pediatrician with a note indicating that
although her head circumference was normally sized at birth, it has now fallen into the 10th
percentile for her age. The girl most closely fulfills criteria for which of the following?
(A) autistic disorder
(B) childhood disintegrative disorder
(C) Rett syndrome
(D) Asperger syndrome
(E) childhood-onset schizophrenia
20) A 14-month-old girl presents with her parents who report that she has become less responsive to them and less
interactive with her 6-year-old brother. In addition, her gait has become clumsy, and most recently, she has been
noted to habitually rub her knuckles together. The parents also bring the chart from their daughter’s pediatrician
with a note indicating that although her head circumference was normally sized at birth, it has now fallen into the
10th percentile for her age. The girl most closely fulfills criteria for which of the following?
(A) autistic disorder
(B) childhood disintegrative disorder
(C) Rett syndrome
(D) Asperger syndrome
(E) childhood-onset schizophrenia

Rett syndrome has been described only in girls. Diagnostic criteria require symptom onset between ages 5 months and 4 years
with apparently normal prior development. Criteria for autism do not require deceleration of head growth. In childhood
disintegrative disorder, as in Rett syndrome, development is initially normal. However, in childhood disintegrative disorder,
development is normal for at least the first 2 years after birth. In Asperger syndrome, there is no delay in language. Childhood
schizophrenia cannot be diagnosed in children meeting criteria for a pervasive developmental disorder who do not have
prominent delusions and hallucinations