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1. A 24-year-old man is brought to the psychiatric emergency department by police after picking a fight with the manager of a local deli because "he was making me nervous." In the emergency department, the patient paces back and forth and looks as if he has not washed or changed his clothes in several weeks. Although his speech is often difficult to understand, he talks over and over about an alien spacecraft from Mars, which is controlling his bodily movements and transmitting thoughts into his head. Which of the following diagnoses is most likely in this patient?
a. Bipolar disorder
b. Generalized anxiety disorder
c. HIV encephalopathy
d. Major depressive disorder
e. Obsessive compulsive disorder
2. Felicia is a 30-year-old graduate student in particle physics who is brought to the psychiatric emergency department by her husband. He reports that over the past week, she has been intrusive and talks incessantly. She has not been eating or sleeping well but seems to have plenty of energy. Earlier in the week, she had disappeared for 24 hours before coming home. Yesterday, Felicia became convinced that the United States was about to be bombed by a coalition of Middle Eastern countries who were worried that she will ascend to power. In the emergency department, she appears very frightened. With hoarse and rapid speech, she reports that "they" will try to hurt her emotionally by doing something bad to her husband. Which of the following diagnostic categories is most likely in this patient:
a. Adjustment disorder with mixed emotional features
b. Bipolar disorder with psychotic features
c. Chronic schizophrenia, paranoid type
d. Delusional disorder
e. Generalized anxiety disorder
f. Obsessive compulsive disorder
3. A 34 year old man is referred to an employee assistance program by his supervisor because of chronic lateness in arriving at work. In all other respects, his performance in his job as an insurance actuary is good. His supervisor has described him as a quiet, steady and reliable worker. His calculations are always precise and he is well-liked by his colleagues. Upon assessment, he reports the following:
"I know my job is in jeopardy if I keep getting to work late, but I can't seem to help myself. Whenever I drive somewhere, I keep thinking I hit someone whenever I feel a bump. I know it's a silly thought but I just can't help it. And if I don't go back and check in the road, I really get worried that someone is lying there hurt, or even dead. Sometimes I have to check more than once before I can drive on, even though I know I'll be in trouble when I finally reach work."
Which of the following best describes this man's concern that he has hit someone on the road?
e. Social Phobia
f. Specific Phobia
4. A 21 year old male with chronic schizophrenia is seen for a follow-up outpatient clinic appointment. He is poorly groomed and malodorous and appears to be conversing with someone who is not in the room. His flow of thought shows looseness of associations. Which of the following will best describe the pattern of the patient's speech?
a. Connecting one topic to the next but never answering the question.
b. Jumping from subject to subject without any apparent logical connection.
c. Providing tedious and unnecessary details but eventually reaching the point.
d. Skirting questions without ever directly answering them.
e. Using a fluent and coherent collection of words and phrases.
5. A 29 year old man is brought to the medical emergency room by police after receiving a head laceration in a fight outside a local bar. The triage nurse noted the patient to have "Alcohol On Breath" and recorded the patient's vital signs as BP 146/88, P 92, RR 16, T 992 F. When the physician enters the room and begins to take a history, the patient yells "Can't you see that I'm bleeding? Are you stupid or what?" He then throws a nearby urinal screaming, "Just get out of here if you don't know what you're doing." Which of the following initial responses by the physician is most appropriate?
a. Administer an intramuscular injection of a benzodiazepine.
b. Administer an intramuscular injection of a high potency antipsychotic medication.
c. Ask provocative questions to test the patient’s impulse control.
d. Ignore any feelings of anxiety and use an empathic style in continuing to interview the patient.
e. Offer to let the patient sign out of the hospital Against Medical Advice if he does not want further evaluation.
f. Summon additional backup staff before continuing the interview.
g. Tell the patient he will be hospitalized involuntarily if he does not behave.
6. A 38 year old University professor is seen for an initial outpatient psychiatric evaluation. In the last 2 years, he has not been completing his lecture notes on time because he has been increasingly checking and rechecking every sentence for mistakes. For many years he has been troubled by thoughts that other people are contaminating him with germs. However, he recently stopped seeing his girlfriend because he could not bear to let her touch him anymore. Although he knows the idea is illogical, he fears that he will "catch something" from her and become ill. Which of the following diagnoses is most likely in this patient?
a. Delusional disorder
b. Generalized anxiety disorder
c. Obsessive compulsive disorder
d. Post-traumatic stress disorder
e. Specific phobia
7. A 62 year old attorney visits his primary care physician for evaluation of a 1 month history of increasing difficulty with his memory. His medical history includes a corneal transplant at age 52 after an eye injury, a 100 pack year history of tobacco use, and chronic obstructive pulmonary disease treated with Albuteral inhalers as needed. Physical examination shows a barrel-chested man who appears his stated age. His chest is clear but hyper-resonant to percussion. He has a regular cardiac rate and rhythm, with no rubs, gallops or murmurs and no carotid bruits. Neurological examination shows occasional myoclonic jerks and a slowed, mildly ataxic gait. On cognitive testing, he registers 3 of 3 items after 2 trials but can only recall 1 of 3 items at 3 minutes. He is alert and oriented to person, state, and year but is unable to recall the city, the month, the date or the physician's name. Serum electrolytes and liver function tests, including an ammonia level, are within the normal range. EEG shows triphasic periodic complexes at a rate of about 1 Hz. Which of the following diagnoses is most likely in this patient?
a. Amnestic disorder
b. Creutzfeldt–Jakob disease
c. Dementia, Alzheimer’s type
d. Hepatic encephalopathy
e. Major depressive disorder
f. Normal pressure hydrocephalus
g. Vascular dementia
8. A 17-year-old female high school student is evaluated by a Mobile Crisis Team in her home. Until 6 weeks before, she had been a good student and planned to go to an Ivy League College. Since that time her behavior changed. Without giving any specific reason, she refused to go to school and spent her days isolated in her room. For 3 days, she had not eaten and the Mobile Crisis Team was called after she boarded her windows shut. Her parents report no history of substance use and no family history of psychiatric illness. Upon their arrival, the Mobile Crisis Team entered the bedroom and noted a tall thin woman with a pale complexion. She frequently averted her gaze and moved her lips as if consulting with some unseen person. The room smelled of urine and the walls were covered with bizarre writings. When asked about the superficial lacerations on her face, she reported that bloodletting would cleanse the food poisons from her body. Which of the following diagnoses is most likely in this patient?
a. Brief reactive psychosis
b. Post-hallucinogen persisting perceptual disorder
c. Schizoaffective disorder
d. Schizophrenia, Disorganized type
e. Schizophrenia, Paranoid type
f. Schizophreniform disorder
9. An 83 year old man is brought to the emergency department by ambulance for evaluation after setting fire to his home. His wife reports that he has been preoccupied over the past week with a "snake infestation" and was trying to "smoke them out." She herself has not seen any snakes and, since her husband has occasionally seemed confused and disoriented, she wonders if there is any snake problem at all. His medications include Vasotec for hypertension. Since prostate surgery in 1992, he has also taken Ditropan for urinary incontinence. On arrival in the ED, vital signs show BP 152/88, P 116, R 20, and T 1026. Mental status examination shows a somnolent elderly man who answers questions in short phrases after several inquiries. His speech is soft and slow, but fluent and coherent. His mood is described as "OK" and appears neutral with a perplexed affect. At times, he picks at the bed sheets as if seeing something. However, he denies having hallucinations or delusions. He is oriented to person only, can register 3/3 items after 3 trials but recalls none of them at 3 minutes and was unable to complete the remainder of the mini-mental state examination. Results of blood, urine and sputum cultures are pending. Other laboratory results include:
Na 141 WBC 19.2 Sp. Gr. 1.020
K 4.0 Hct 41.2 pH 5
Cl 99 Segs 68 Dipstick Negative
CO2 26 Bands 12 RBC 1-2
BUN 21 Monos 14 WBC 10-15
Cr 1.1 Lymphs 6 Leuk. Est. Positive
Which of the following medications is most appropriate at this time?
10. A 59 year old man is brought to the emergency department by police after being found wandering in a parking lot. Examination shows BP 134/82, P 72, R 16, T 988. He has multiple spider angiomata and palmar erythema noted on physical examination. Although he is alert, he is unable to give his name, the place or the date. When asked why police brought him to the hospital, he states "I was on my way to the Mets game and had a flat tire." He registers only 1/3 items but can follow commands, draw interlocking pentagons, and name objects. Post-mortem neuropathological examination of this patient's brain would be most likely to show which of the following?
a. Argentophilic "ball shaped" cytoplasmic aggregates in the frontal lobe
b. Atrophy of the mammillary bodies
c. Central pontine myelinolysis
d. Loss of pigmented neurons in the substantia nigra
e. Neuronal loss in the nucleus basalis of Meynert
f. Spongiform changes of gray matter
11. A 34 year old man visits his outpatient psychiatrist for a routine follow-up appointment. His only medication is Clozapine, which he has been taking for the past 4 months. He has been on a stable dose of 400 mg po qhs for two months and, on the day before the visit, his white blood count was 8.6. He states that the FBI has not been bothering him much recently. Occasionally they will still send him a message through the transmitter in his tooth, but when they do, it is a helpful message. He has not heard their voices at night for several weeks now and he has been sleeping well. He enjoys attending a psychosocial program during the day and reports being in a good mood most of the time. In terms of monitoring for adverse effects of treatment, which of the following would be most important to assess during the appointment?
a. Electrocardiogram to assess for QTc changes
b. Hepatic function tests
c. Ocular history to assess for evidence of cataracts
d. Prolactin level
e. Weight, to permit calculation of Body Mass Index (BMI)
12. A 25 year old woman visits her primary care physician for evaluation of palpitations that have been increasing in frequency over the past 4 months and that now occur 3 to 4 times each week. The palpitations usually last for 5 to 15 minutes and are associated with rapid breathing, sweating, shakiness, tingling of extremities, and a fear of "going crazy." Although they sometimes occur with stress, they can also occur "out of the blue." Cardiac auscultation is remarkable for mid-to-late systolic click that is heard best at the cardiac apex. With Valsalva, the click is heard earlier and is associated with a I/VI murmur. EKG shows a normal sinus rhythm with normal intervals and a rate of 68. In this patient, symptoms would most likely be precipitated by intravenous infusion of which of the following?
13. A 60 year old businessman comes to his primary care physician for evaluation of weight loss and fatigue. In the past 6 months, he has lost 30 lbs. "without trying" and he says he feels constantly tired. Ten months ago he learned that his wife of 35 years was having an affair and they have now been separated for eight months. Since that time, he has been increasingly despondent and isolative and no longer takes pleasure in his usual activities. He describes feeling worthless and guilty about being unable to satisfy his wife. His sleep has been poor and he awakens at 4 AM, unable to return to sleep. As a result, he says that mornings are "absolutely unbearable." At work, he has had increasing difficulties with concentration and states that his thinking is much slower than usual. Which of the following steps is most important for the physician to take next?
a. Determine whether his job is in jeopardy because of his poor concentration.
b. Discuss the advantages and disadvantages of antidepressant treatment.
c. Inquire specifically about suicidal ideas and plans.
d. Prescribe a short-acting sedative to help with sleep.
e. Recommend outpatient treatment with a cognitive behavior therapist.
14. A 24 year old woman comes to the emergency department after taking an overdose of over-the-counter sleeping tablets in response to an argument with her boyfriend. She has been seen in the emergency department on multiple previous occasions for overdoses, self-induced lacerations and intoxication with alcohol and with cocaine. On evaluation, she reports taking the overdose impulsively and denies suicidal intent. She also notes frequent "mood swings" that are often precipitated by interpersonal difficulties and associated with feelings of emptiness. Which of the following defense mechanisms is this patient most likely to utilize?
c. Isolation of affect
d. Reaction formation
15. A 21 year old woman and her 24 year old husband visit a psychiatrist because of marital problems. They have been married for 2 years and over the past 9 months have been increasingly arguing about the woman's "clingy" behavior. Although her mood is good and she enjoys being around people, she seems to require an inordinate amount of reassurance from others. She is also reluctant to make even minor decisions without input from her husband. On evenings when he works late, she calls frequently "just to touch bases." The husband reports feeling increasingly irritated by this. However, the woman notes "It's not like I've changed at all. You knew I was like this when we started dating 4 years ago." Which of the following personality disorders is most likely in this woman?
16. A 35-year old male executive in seen in the emergency department after being involved in a minor motor vehicle accident. Physical examination is remarkable for a BP of 142/94 P 88 R 18 and T 99.6. There is an area of ecchymosis across his chest that corresponds to the pattern of an air bag inflating and is associated with tenderness but no crepitus. His lungs are clear to auscultation and percussion although he reports some discomfort with deep inspiration. Laboratory studies are remarkable for a blood alcohol level of 0.05 % (50 mg/dl). When asked about this, the patient reports that he always enjoyed “a night out with the boys” but rarely drank during the week. However, over the past year, with increased stress at work, he has begun stopping at a local bar each night for a drink. At first, he would have a single beer before heading home, but over the past month he has needed two or even three beers to feel relaxed. He also has been drinking additional beer throughout the evening. On weekends, he begins drinking beer in the early afternoon and this prevents the afternoon shakiness and anxiety he feels during the week. Which of the following sets of alcohol related syndromes is MOST consistent with this patient's history and presentation?
Tolerance Dependence Withdrawal
a. Present Present Present
b. Present Present Absent
c. Present Absent Present
d. Present Absent Absent
e. Absent Present Present
f. Absent Present Absent
g. Absent Absent Present
h. Absent Absent Absent
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