Psych Qbank

A 48-year-old woman with a history of depression has been maintained on phenelzine (Nardil) for several years. She comes to the health care provider complaining about the worsening of her depression and insists on switching to a newer medication such as an SSRI. She is also "sick of sticking to such a rigid diet." Which of the following statements is correct concerning switching her from phenelzine (Nardil) to an SSRI A. Abrupt switching may cause hypotension B. A 4-week washout after discontinuing phenelzine (Nardil) is needed before starting an SSRI C. It is safe to switch right away D. Stopping phenelzine (Nardil) causes discontinuation syndrome E. A 10-day washout period after discontinuing phenelzine (Nardil) is needed before an SSRI can be started

E. Serotonin syndrome can develop with concomitant use of MAO inhibitors and serotonergic agents, or if there has been too short a period of washout in crossing over from one to another agent. At least 10 days after MAO inhibitor discontinuation and 5 weeks after discontinuation of fluoxetine (Prozac) should pass to avoid this possible complication. Clinical presentation includes tremor, hypertension, confusion, incoordination, fever, myoclonus, diarrhea, restlessness, and diaphoresis.

A 28-year-old anesthesiology resident has been having a hard time in his demanding residency because of the back pain he experiences after long hours of duty. He was involved in a motor vehicle accident 4 years ago and suffered a serious back injury. One day his wife, who is also a physician, comes home early to find him in bed, wrapped in a blanket complaining of fever, chills, and runny nose. He complains of body aches and soon afterward develops diarrhea and cramps. The wife confronts him about possible drug use and he admits that he is "finally trying to quit for good." Based on these symptoms, he is most likely experiencing withdrawal from which of the following substances? A. Alprazolam (Xanax) B. Amphetamine C. Cocaine D. Nicotine E. Opioid

E. Symptoms of opioid withdrawal follow cessation or reduction of prolonged and heavy opioid use and include at least 3 of the following criteria: dysphoric mood, nausea or vomiting, muscle aches, yawning, diarrhea, lacrimation or rhinorrhea, piloerection, pupillary dilatation, sweating, fever, and insomnia. The symptoms cause significant distress in social or occupational functioning and are not caused by a general medical condition.

A 55-year-old woman was diagnosed with schizophrenic disorder, paranoid type at age 23. She has been on neuroleptic medications for the majority of time since diagnosis. Which of the following conditions would be most likely to appear at this time as a consequence of her treatment? A. Akathisia B. Anticholinergic symptoms C. Dystonia of the laryngeal muscles D. Neuroleptic malignant syndrome E. Tardive dyskinesia

E. Tardive dyskinesia is a result of long-term treatment with neuroleptic medications and is seen more frequently in older women. The condition presents with abnormal choreoathetoid movements, often involving the face and mouth in adults and the limbs in children. Once tardive dyskinesia develops, there is no known treatment to mitigate the symptoms. In order to prevent this long-term sequela of tardive dyskinesia, patients may be placed on drug holidays or are placed on the smallest effective dose in order to control symptoms.

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 in for treatment. In a discussion about his drinking habits, the young man brags that he can now drink more before he gets drunk. Which of the following terms best characterizes this phenomenon? A. Blackout B. Confabulation C. Dereism D. Resistance E. Tolerance

E. Tolerance describes the phenomenon of a drinker needing greater amounts of alcohol to get the same effect. It develops over time and is an indication of dependence.

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, but the patient's movements seem slow. He is laughing inappropriately, complaining of being hungry, and has a dry mouth. His gait is somewhat slow and his coordination is impaired. There is significant conjunctival injection, which he tries to explain as being caused by pollen allergy. Which of the following drugs will most likely appear on a urine drug screen? A. Amphetamines B. Benzodiazepines C. Cocaine D. Opiates E. Tetrahydrocannabinol

E.Cannabis intoxication is usually characterized by sensitivity to external stimuli, subjective slowing down, impairment of motor skills (including problems with operation of motor vehicles), conjunctival injection, dry mouth, tachycardia, and increased appetite.

A 32-year-old woman with a history of panic disorder is brought to the emergency clinic by her husband after he found her heavily sedated and minimally responsive upon his arrival home from work. The husband informs the health care provider that his wife had become increasingly depressed over the past few weeks since the death of her mother. He states that her psychiatrist had recently increased her doses of alprazolam (Xanax) and sertraline (Zoloft) because of increasing panic attacks along with worsening depression. Her temperature is 37º C (98.6º F), blood pressure 105/65 mm Hg, pulse 65/min, and respirations 12/min. She is heavily sedated and only able to utter a few phrases, with slurred speech. She did state that she took a diazepam (Valium) and several extra alprazolam (Xanax) because of panic attacks. During the physical examination her respiratory rate drops to 8/min. Which of the following medications would be the most appropriate to administer at this time? A. Benztropine (Cogentin) B. Flumazenil (Romazicon) C. Haloperidol (Haldol) D. Lorazepam (Ativan) E. Naloxone (Narcan)

B. Flumazenil is a benzodiazepine receptor antagonist, which reverses the psychophysiologic effects of benzodiazepine medications, such as alprazolam, diazepam, and lorazepam. After IV administration, flumazenil has a half-life of 7-15 minutes. For the initial management of a known or suspected benzodiazepine overdose, the recommended initial dose of flumazenil is 0.2 mg administered IV over 30 seconds. If the desired level of consciousness is not obtained after waiting 30 seconds, a further dose of 0.3 mg can be administered over 30 seconds. Additional doses can be administered up to a cumulative dose of 3.0 mg. A secure airway and IV access should be established before administration of the drug.

A 26-year-old man with schizophrenia comes to the emergency department with a 2-hour history of involuntary contractions of the muscles in his neck. He states that he was watching television and "all of a sudden I turned my head and my neck locked." He began taking a high-potency antipsychotic agent 3 days earlier. Examination shows no abnormalities except torticollis. Which of the following is the most appropriate pharmacotherapy? A. Amantadine (Symmetrel) B. Benztropine (Cogentin) C. Bromocriptine (Parlodel) D. Clonidine (Catapres) E. Propranolol (Inderal)

B. This patient has acute dystonia. Dystonia is characterized by involuntary muscle spasms, which in this patient are caused by a high potency antipsychotic agent. Dystonia is most common in young men and often begins within days of starting the drug therapy. It usually involves the muscles of the head and neck, leading to torticollis and blepharospasm. It can produce a life-threatening laryngospasm requiring intubation. The treatment of acute dystonia is with anticholinergic medications, such as benztropine (Cogentin) or diphenhydramine (Benadryl).

A patient is seen on the psychiatry consultation liaison service by a health care provider. To assess cognitive functions, the health care provider asks the patient what the proverb "Don't cry over spilled milk" means. The patient answers that if you spill what you cook, you have to do it all over again. Which of the following types of thinking is this patient most likely exhibiting? A. Abstract thinking B. Blocking C. Concrete thinking D. Confabulation E. Magical thinking

C. Concrete thinking is described as literal thinking that shows a lack of understanding of the nuances of meaning. These individuals lack the ability to use metaphors.

A 45-year-old woman comes to her primary care provider because of blurred vision. She states that this symptom started about 2 days ago. She denies any past history of significant medical or neurologic problems. She does state that several days ago she started treatment for depression with a psychiatrist because of a 2-month period during which she had several depressive symptoms. On review of systems, she admits to having increased her water consumption over the last several days because of a dry mouth. She also complains of dizziness when she stands up from lying or sitting. Her temperature is 37º C (98.6º F), blood pressure lying down is 135/75 mm Hg, blood pressure standing is 110/64 mm Hg, pulse lying down is 84/min, pulse standing is 95/min, and respirations are 16/min. Physical examination is unremarkable except for mild pupillary dilation. Which of the following medications most likely accounts for this patient's symptoms? A. Bupropion (Wellbutrin) B. Citalopram (Celexa) C. Imipramine (Tofranil) D. Nefazodone (Serzone) E. Sertraline (Zoloft)

C. Imipramine is a tricyclic antidepressant (TCA) that inhibits norepinephrine and serotonin reuptake. Like most TCAs, imipramine also has antagonistic effects at muscarinic, histaminic, and α-adrenergic receptors. This patient's complaint of blurred vision is most likely caused by the antimuscarinic effects of the medication. The blockade of muscarinic acetylcholine receptors causes mydriasis (pupillary dilation) resulting in blurred vision. Dry mouth is also caused by the anticholinergic effect of imipramine. Orthostatic hypotension is caused by the α1-adrenergic receptor blockade associated with TCAs.

A 37-year-old woman with a history of bipolar disorder comes to her health care provider for a medication check. She has been taking the same dose of lithium carbonate daily for over 3 years. She is in generally good health, does not smoke, and has not had a manic episode for several years. She uses a diaphragm and condoms for birth control and has no plans to get pregnant in the near future. Given this patient's history, the values for which of the following routine lab tests are most likely to have remained the same over time? A. Serum blood urea nitrogen level (BUN) B. Serum creatinine level C. Serum lithium level D. Thyroid stimulating hormone level (TSH) E. White blood cell count

C. In general, lithium reaches a steady state level in the bloodstream once a dosage is maintained over a given period of time, and its level does not change unless conditions exist or medication changes that affect drug level interferes with this equilibrium.

A 36-year-old woman comes to a health care provider for an initial appointment after relocating from her home several states away because of a transfer of her job. She is on lithium for bipolar disorder, and has been stable for several years after two manic episodes in her early 30s. She was previously seen by a psychiatrist every 2 months and had blood drawn for routine monitoring related to her lithium treatment every 6 months. Because it has been about 8 months since her last appointment, the health care provider decides to order lab work and to see the patient back in 1 week to finish gathering history, to review the laboratory results, and to provide the patient with another prescription. Which of the following laboratory studies would be most appropriate for the health care provider to order? A. Liver transaminases B. Platelet count C. Thyroid-stimulating hormone D. Urine culture E. Vitamin B12 level

C. Lithium affects thyroid function, and thyroid-stimulating hormone (TSH) levels should be monitored every 6-12 months. Lithium often causes a generally benign and often transient decrease in the concentration of thyroid hormones. About 30% of patients receiving long-term treatment with lithium will have elevated TSH levels. If symptoms of hypothyroidism emerge, treatment with levothyroxine may be indicated. During routine monitoring of lithium maintenance treatment, lithium plasma concentration and serum creatinine should also be measured periodically.

A 29-year-old woman comes to her new primary care provider requesting medication to help with her recent spells of anxiety and depression. She wishes to be started on a medication that will not cause too much sedation. Examination of the patient's old records reveals 2 previous suicide attempts by overdose, once with acetaminophen at age 16 and another with aspirin during college. She is otherwise healthy and does not smoke cigarettes or drink alcohol. She is not currently taking any medication. Given this history, which of the following antidepressant medications would most likely be contraindicated for this patient? A. Buspirone (Buspar) B. Fluoxetine (Prozac) C. Nortriptyline (Pamelor) D. Paroxetine (Paxil) E. Sertraline (Zoloft)

C. Nortriptyline is a tricyclic antidepressant, which is lethal in overdose and is the leading cause of overdose-related deaths in the psychiatric population. Overdose is associated with prolongation of the QT interval, leading to cardiac arrhythmia and death. Given this patient's history of previous overdoses, a tricyclic antidepressant would not be indicated.

An 82-year-old nursing home resident with moderate dementia secondary to Alzheimer disease has been agitated for the past month. She has been accusing the staff at the nursing home of stealing her belongings. Over the past 2 weeks she has also become physically aggressive toward the staff. Which of the following is the most appropriate management? A. Administer low doses of benzodiazepines when the patient becomes agitated B. Begin a trial of a low dose of an antidepressant medication, such as fluoxetine (Prozac) C. Begin a trial of a low dose of an atypical antipsychotic medication, such as risperidone (Risperdol) D. Recommend insight-oriented psychotherapy E. Recommend the frequent use of physical restraints as part of a behavior modification regimen

C. Patients who have senile dementia, Alzheimer type often develop paranoid delusions and agitation in the course of their illness. Memory impairment is a specific risk for the development of delusions that people are stealing from the patient, as patients misplace or lose their belongings. The treatment of choice for agitation and paranoia in the elderly demented patient includes low doses of atypical antipsychotic medication.

A 1,400-g infant born at 35 weeks' gestation is 42 cm in length and has a head circumference of 28 cm. One day after birth, she becomes very irritable, tremulous, and inconsolable. Her cry is high-pitched. Her pulse is 174/min. There are no dysmorphic facial features. Her mother had inconsistent prenatal care and has a history of multiple inpatient hospitalizations for substance overdoses. To which of the following substances was this newborn most likely exposed in utero? A. Alcohol B. Barbiturates C. Cocaine D. Marijuana E. Opiates

C. The most commonly abused drug by pregnant mothers is cocaine. Infants are usually small for gestational age (SGA) and sometimes have microcephaly and neurodevelopmental abnormalities. Exposed infants are very irritable and inconsolable in the withdrawal period. Their cries are often high-pitched. They are also at increased risk for sudden infant death syndrome (SIDS). Periventricular leukomalacia (a CNS ischemic lesion) is also associated with cocaine exposure.

A 40-year-old man is brought to the emergency department by his friends. Apparently he has ingested some unknown medication in a suicide attempt. The patient is disoriented to time. His temperature is 39.3º C (103º F), blood pressure 120/85 mm Hg, pulse 100/min and irregular, and respirations 22/min. The skin is flushed and dry. Dilated pupils and muscle twitching are also noted. An electrocardiogram reveals that the QRS complexes are prolonged. Hepatic transaminases are normal, and blood gas analysis shows a normal pH. These findings are most likely caused by intoxication with which of the following substances? A. Acetaminophen B. Alcohol C. Benzodiazepines D. Clonidine (Catapres) E. Monoamine oxidase (MAO) inhibitors F. Tricyclic antidepressants

F. This patient's clinical picture is consistent with tricyclic antidepressant intoxication with amitriptyline (Elavil) or imipramine (Tofranil). Toxic effects are mediated by peripheral anticholinergic activity and "quinidine-like" action. The anticholinergic effects include mydriasis, tachycardia, impaired sweating with flushed skin, dry mouth, constipation, and muscle twitching. Quinidine-like effects (caused by block of sodium channels in the heart) result in cardiac arrhythmias, especially ventricular tachyarrhythmias. In this setting, prolongation of the QRS complex is particularly important in the diagnosis. QRS width is, in fact, an even more faithful parameter of drug toxicity than serum drug levels. In severe intoxication, patients will develop seizures, severe hypotension, and coma.

A 27-year-old man with schizophrenia, chronic paranoid type comes to the clinic for a follow-up visit. He has been stably maintained on risperidone (Risperdal) 3 mg twice a day for a few months, but the dose was recently changed to 6 mg twice a day when he was hospitalized for pneumonia. In the clinic he is alert, oriented, well related, and his thought process is completely organized. He is not complaining of any auditory hallucinations and does not seem to be responding to internal stimuli. He has psychomotor agitation and has difficulty staying in his chair during the interview. When specifically questioned about the agitation, he says that he constantly feels like he has to move around. He denies any suicidal or homicidal intent, ideation, or plan. Which of the following is the most appropriate next step in management? A. Add an antidepressant B. Add haloperidol to control psychotic agitation C. Decrease the dosage of risperidone D. Increase the dose of risperidone because of incomplete treatment response E. Recommend electroconvulsive therapy for refractory psychosis

C. The patient's presentation is one of akathisia, a sense of restlessness and psychomotor agitation that patients can experience while taking antipsychotic medication. The atypical antipsychotic medications (olanzapine [Zyprexa], quetiapine [Seroquel], ziprasidone [Geodon], risperidone [Risperdal]) all confer less of a risk for the development of akathisia. With risperidone in particular, however, higher dosing is associated with an increased risk for the development of akathisia. The patient in question most likely had an escalation in risperidone dose while hospitalized secondary to agitation, which occurred during a delirious episode as a result of pneumonia and possible sepsis. Maintaining the patient on this dosage indefinitely, especially given these side effects, is unnecessary.

A 12-year-old boy is brought to the health care provider because of a pattern of behavior that has been worsening over the past year. His mother states that he has been bullying other boys at school, staying out late without permission, setting small fires in abandoned lots, and physically abusing neighborhood cats. During the examination, a speculum from the examination room drawer falls out from underneath his shirt. Which of the following is the most likely diagnosis? A. Antisocial personality disorder B. Attention deficit hyperactivity disorder (ADHD) C. Conduct disorder D. Oppositional defiant disorder (ODD) E. Tourette syndrome

C. This patient has conduct disorder. The diagnosis requires a pattern of behavior that violates societal rules and the basic rights of others. Common features include lying, stealing, running away, staying out without permission, setting fires, truancy, vandalism, cruelty to animals, bullying, physical aggression, and sexual aggression. At least three of these features must be present to make the diagnosis. 25-50% of these patients go on to have antisocial personality disorder as an adult.

Three hours after an uneventful appendectomy, a previously healthy (except for appendicitis) 78-year-old man becomes disoriented and confused. He repeatedly asks the nurses where he is, and his speech pattern is disorganized and rambling. His temperature is 37º C (98.6º F), blood pressure 120/80 mm Hg, pulse 70/min, and respirations 18/min. The patient is uncooperative but shows no physical abnormalities. Mental status examination is not possible because of an altered level of consciousness. Laboratory studies show no abnormalities. Which of the following is the most likely diagnosis? A. Adjustment disorder B. Brief psychotic disorder C. Delirium D. Delusional disorder E. Dementia

C. This patient has delirium, which is also called acute confusional state. It is very common in hospitalized and institutionalized elderly individuals. It is characterized by a rapid onset of impaired cognition, altered level of consciousness, disturbances in attention and psychomotor activity, and altered sleep-wake cycles. The symptoms tend to fluctuate and it is usually reversible when the underlying disorder is identified and treated. Common causes include psychologic and physical stress (for example, surgery), metabolic disturbances, neoplasms, infections, medications, cerebral and cardiovascular diseases, and withdrawal from alcohol and prescription medications. As opposed to dementia, the onset of delirium can definitely be identified because of its acute presentation.

A 58-year old man is admitted to the trauma service after a motor vehicle accident that caused a fracture of his pelvis and right femur. His family reports that he recently lost his job because of poor work performance related to a worsening problem with alcohol. On day 3 of hospitalization (third postoperative day after internal fixation of the femoral fracture), the patient is noted to be disoriented. He tells the nursing staff about feeling and seeing snakes crawling in his bed. What is the most appropriate initial step in the management of this patient's altered mental status? A. Clonidine (Catapres) B. Haloperidol (Haldol) C. Lorazepam (Ativan) D. Naloxone (Narcan) E. Olanzapine (Zyprexa)

C. This patient is most likely experiencing alcohol withdrawal delirium (delirium tremens). This most severe form of alcohol withdrawal is a medical emergency that can result in significant morbidity and mortality. Untreated, delirium tremens has a mortality rate of approximately 20%. In addition to delirium, patients in this stage of withdrawal exhibit autonomic hyperactivity and fluctuating levels of psychomotor activity. About 5% of all alcohol-dependent hospitalized patients will develop delirium tremens. The condition frequently develops unexpectedly around the third hospital day. Benzodiazepines, such as lorazepam, are the treatment of choice. Lorazepam can be administered PO, IM, or IV. Supportive management, including hydration and very close monitoring, should also be initiated.

A 43-year-old woman comes to the emergency department complaining of dizziness, tremor, diaphoresis, and shortness of breath. She indicates to the health care provider that she has come into the hospital with similar complaints twice in the past several weeks. On those occasions, as today, her physical examination, routine laboratory studies, electrocardiogram, and cardiac enzymes have been unremarkable. The patient states that these episodes are starting to concern her greatly and she is worried about going out of her house alone. Which of the following is the most likely diagnosis? A. Factitious disorder B. Generalized anxiety disorder C. Panic disorder D. Schizophrenia E. Social phobia

C. This patient's symptoms are all suggestive of panic attacks. Her symptoms do not appear to be related to substance use or a general medical condition. The frequency of her symptoms and her agoraphobia (fear of social situations) are also indicative of a diagnosis of panic disorder.

A 26-year-old man comes to his primary care provider complaining that he has been more and more afraid to leave his house because he has been having frequent anxiety attacks that occur without warning. He is worried that he will have an attack at some time while he is in public. He has no other medical conditions. Physical examination is unremarkable. Which of the following is the most appropriate initial medication for this patient in an acute situation? A. Buspirone (Buspar) B. Chlorpromazine (Thorazine) C. Clonazepam (Klonopin) D. Mirtazapine (Remeron) E. Trifluoperazine (Stelazine)

C. This patient's symptoms suggest that he has panic disorder, which is most appropriately treated acutely with a benzodiazepine with a medium length half-life and duration of action, such as clonazepam.

A 39-year-old man with schizophrenia comes to the health care provider for a follow-up visit. He has been in a residential treatment program for several weeks, after being discharged from the hospital. While in the hospital he had been started on clozapine (Clozaril). He had initial complaints about sedation and increased salivation but was able to continue with the medication. His blood count is checked weekly and remains within normal limits. Today he complains of generalized weakness, fatigue, palpitations, chest pain, fever, and shortness of breath. His case manager confirms that he has not been feeling well throughout the whole week. His blood pressure, although on the lower side, is basically unchanged since the last visit. Which of the following side effects of clozapine should be considered as the most concerning, given this clinical picture? A. Hepatitis B. Hyperglycemia C. Hyponatremia D. Myocarditis E. Vertigo

D. Clozapine-induced myocarditis has been reported in several cases that ended fatally. Additional black-box warning regarding possibility of myocarditis should be provided for patients and their caregivers. Education about possible symptoms and signs should be provided. In this case the description of symptoms in a patient who has been on a stable dose of clozapine should raise a suspicion of possible myocarditis.

A 45-year-old woman returns to her psychiatrist for her routine biweekly appointment 2 months after being hospitalized for an episode of severe, recurrent major depressive disorder with psychotic features. During her hospitalization, she was started on 2 medications, an antidepressant and an antipsychotic, and she has continued these medications daily as an outpatient. At her appointment, she complains to her health care provider that she has missed her menstrual period for 2 months. She also complains of tenderness in her breasts, and an occasional small amount of milky discharge from her breasts onto her blouse. When questioned further, she also admits to low libido over the past month. Which of the following medications is most likely responsible for this constellation of symptoms? A. Olanzapine (Zyprexa) B. Paroxetine (Paxil) C. Quetiapine (Seroquel) D. Haloperidol (Haldol) E. Sertraline (Zoloft)

D. Haloperidol is a classic antipsychotic that can cause significant elevations in plasma prolactin levels. Conventional antipsychotics and risperidone can cause hyperprolactinemia because of their dopamine antagonism, which results in excessive amounts of dopamine being released. Clinical manifestations of hyperprolactinemia may include galactorrhea, sexual dysfunction, menstrual irregularities including amenorrhea, infertility, and weight gain.

A patient who has a long history of bipolar disorder, mixed type, was recently started on an anticonvulsant that he was told would help with his mood swings. He had been on it for 5 weeks when he developed atypical targetoid lesions with focal confluence and detachment of the epithelium of about 10% of his body surface. Which of the following medications did this patient most likely take? A. Lithium (Lithobid) B. Clonazepam (Klonopin) C. Gabapentin (Neurontin) D. Lamotrigine (Lamictal) E. Valproate (Depakene)

D. Lamotrigine is approved as an adjunct in the treatment of refractory seizures. Its effectiveness in bipolar disorder has been demonstrated in open trials. The most serious side effect of lamotrigine is rash. When the dose is titrated up too quickly, the potentially fatal Stevens-Johnson syndrome can occur.

A 16-year-old boy is brought into the emergency department by his friends. He is semicomatose, with a pulse of 60/min and respirations of 6-8/min. His pupils are constricted. Which of the following will most likely be revealed on a urine toxicology screen? A. Amphetamine intoxication B. Cocaine intoxication C. Ethanol intoxication D. Opiate intoxication E. Tricyclic antidepressant intoxication

D. Opioids (e.g., heroin, codeine, methadone) can cause respiratory depression, coma, sinus bradycardia, and pupillary constriction. Death usually results from aspiration of gastric contents, respiratory arrest, or cerebral edema.

A heroin addict is found unconscious in an alley with an empty syringe beside him. When his blood gases are checked, which of the following would be expected? A. Metabolic acidosis B. Metabolic alkalosis C. Normal pH balance D. Respiratory acidosis E. Respiratory alkalosis

D. Opioids, such as heroin, depress respiration centrally by reducing the responsiveness of brainstem respiratory centers to CO2. The resulting hypoventilation leads to CO2 retention because of the inability of the patient to blow off the CO2. This increases the production of carbonic acid (H2CO3) by carbonic anhydrase present in red blood cells (which converts CO2 to carbonic acid). Dissociation of carbonic acid to bicarbonate (HCO3-) and protons produces a respiratory acidosis.

A 54-year-old woman comes to her primary care provider for her routine yearly health maintenance examination. She denies any new problems. Her only significant medical history includes a 25-year history of schizophrenia, which has been well controlled with antipsychotic agents, and a 5-year history of hypertension for which she takes a diuretic. Vital signs and physical examination are within normal limits. The patient is noted to have occasional irregular puckering and lip-smacking movements, however. She denies having noticed the abnormal movements, and her speech is normal. Which of the following is the most likely diagnosis? A. Acute dystonia B. Akathisia C. Pseudoparkinsonism D. Tardive dyskinesia E. Tardive dystonia

D. Tardive dyskinesia (TD) is a syndrome characterized by abnormal choreiform and athetoid movements occurring late in onset in relation to initiation of antipsychotic treatment. TD usually develops after months to years of treatment with antipsychotic agents, and is presumably much less likely to occur with the use of atypical antipsychotics. Risk factors for TD include older age, longer duration of antipsychotic treatment, and presence of an affective disorder. The abnormal involuntary movements usually involve orofacial muscles but may include the trunk and extremities. Regular examinations should be done to ensure that patients treated with these medications do not develop signs of TD.

A former drug abuser visits his health care provider to ask for pain medication for a back pain that has a true physiologic cause. The patient's previous history of drug abuse is taken into account when the health care provider plans the patient's treatment regimen. Which of the following medications used in this setting has the greatest potential for abuse? A. Codeine B. Dextromethorphan C. Loperamide (Imodium) D. Meperidine (Demerol) E. Nalbuphine (Nubain)

D. The drug that is most likely to be abused is that which causes the greatest euphoric effect. Euphoria is mediated by mu opioid receptors, and meperidine is the only drug listed that is a full mu agonist. Meperidine is rarely a good choice for pain control because of its rapid onset of activity (rapid peak) and of its inability to provide a sustained pain relieving response for an adequate time before the next dose is due.

A 41-year-old man with a long history of schizophrenia, paranoid type, has been on the inpatient unit for almost 2 weeks. This is his third admission in the past 6 months, and each time he seems to be less responsive to treatment. In the past he has been on typical antipsychotics and then risperidone (Risperdal), with limited success. His family is supportive and makes sure he takes his medication. Given his most recent poor response, which of the following is the most appropriate next step in treatment? A. Clozapine (Clozaril) B. Droperidol (Inapsine) C. Electroconvulsive treatment D. Lamotrigine (Lamictal) E. Topiramate (Topamax)

A. Clozapine is an atypical agent that has been proven to be more effective than conventional antipsychotics in the treatment of patients who have resistant schizophrenia. It exerts an antagonistic effect on D1 and D4 receptors, as well as on the alpha-adrenergic, histaminergic, serotonergic, and cholinergic systems. It may be effective in the treatment of resistant schizophrenia in the first 6 weeks. It produces troublesome side effects, however. Its most serious side effect: agranulocytosis. Cardiomyopathy and myocarditis are also known side effects of this medication. Clozapine requires regular blood count monitoring because of this serious but rare side effect.

A 49-year-old man comes to a mental health care provider for depressive symptoms. He talks about his past psychiatric problems. He also mentions he is an alcoholic and has been taking disulfiram (Antabuse) for some time to keep sober. He once tried to drink after taking the drug and ended up being terribly sick. Which of the following principles best describes the particular treatment for alcoholism? A. Conditioned avoidance B. Extinction C. Flooding D. Positive reinforcement E. Reciprocal inhibition

A. Conditioned avoidance is a term that describes the pairing of an unpleasant stimulus with the stimulus that causes maladaptive behavior. This aversive conditioning technique makes it uncomfortable or painful, in order to have the patient avoid the behavior that is trying to be eliminated.

A 32-year-old man with a history of panic disorder who works as a salesman returns to his health care provider after several weeks of treatment with paroxetine (Paxil). Although he has noted significant improvement in his symptoms, he still notes residual anxiety when put into social situations in which he has to speak in public or become the center of attention. He has been taking the medication as prescribed and has not missed any doses. Given that he had some improvement on his current medication regimen, which of the following would be the most appropriate next step in management? A. Cognitive-behavior therapy B. Electroconvulsive therapy C. Medication change D. Psychoanalysis E. Seeing the patient more often for supportive psychotherapy

A. In many cases of panic disorder, effective treatment involves the use of cognitive behavior therapy, which incorporates exposing the patient to disturbing stimuli in an attempt to develop coping mechanisms in response to the stimuli.

A 49-year-old veteran comes to the health care provider to discuss smoking cessation. He was recently diagnosed with high blood pressure, hypercholesterolemia, and coronary artery disease, and he now realizes that it is finally time to quit. He has been a heavy smoker for years and finds it impossible to stop on his own, but his wife has heard about the use of bupropion (Zyban) for the treatment of nicotine dependence. After discussing the pros and cons of starting bupropion (Zyban), the patient agrees to give it a try. Which of the following instructions should be given to the patient about the use of this medication and its relationship to smoking cessation? A. He should decrease smoking after 5-7 days of treatment B. He should set a quit date after reaching the therapeutic dose of 450 mg C. He should stop smoking on day 3 after starting bupropion D. He should stop smoking right away E. His stopping date should be after 6 months of treatment with bupropion

A. Instructions to the patient regarding smoking cessation once medication treatment has started include gradual discontinuation of smoking and stopping smoking after 5-7 days of treatment. While the dose is titrated up after the first three days of therapy. Because bupropion (Zyban) is effective in cutting down cravings, the patient who is slowly titrating down smoking patterns will be more effective as the clinical effects of bupropion are seen.

A 33-year-old woman comes to the health care provider because of anxiety and irritability. She states that approximately 10 days before the onset of her menses, she goes from "feeling fine" to "feeling awful." She has frequent angry outbursts toward her husband and children, feels depressed and irritable, and cries easily. She also develops severe breast tenderness during this time. The symptoms resolve soon after the start of her menses and she feels fine until the symptoms start over again as the next menses approach. She has had this constellation of symptoms every cycle over the past year and feels that she can't go on like this anymore, as her job and family relations are suffering greatly. She has no other medical problems and takes no medications. Her physical examination is entirely normal. Which of the following is the most appropriate management? A. Fluoxetine (Prozac) B. Oophorectomy C. Primrose oil D. Progesterone E. Vitamin B6 (pyridoxine)

A. This patient has a presentation that is consistent with premenstrual dysphoric disorder (PMDD). This disorder is considered a form of premenstrual syndrome (PMS) with more severe emotional symptoms. Selective serotonin reuptake inhibitors (SSRIs) are the initial drugs of choice for PMDD or severe PMS. Fluoxetine (Prozac) and sertraline (Zoloft) are both approved for the management of this disorder. Patients who have severe PMS may be placed on a daily dose. Another approach that has been shown to be effective is intermittent therapy, in which the SSRI is administered only during the symptomatic phase. This method reduces the overall rate of side effects and is less expensive. Fluoxetine (Prozac) has the longest half-life of all the SSRIs, thus may be especially helpful in this disorder as missed doses are not as impactful.

A 31-year-old man is brought to the emergency department by a friend because he has been complaining that he is having auditory hallucinations and tremors, along with associated nausea and vomiting. He feels very anxious. On Mini-Mental Status Examination, he scores 22 of 30, and he appears to be obtunded. From which of the following substances is this patient most likely withdrawing? A. Alprazolam (Xanax) B. Caffeine C. Cocaine D. Heroin E. Nicotine

A. This patient has the symptoms of withdrawal from benzodiazepines, such as alprazolam. Symptoms include insomnia, tremor, GI distress, hallucinations, and anxiety. Withdrawal from benzodiazepines can also be accompanied by generalized seizures.

A 32-year-old woman with a history of recurrent depression, borderline personality disorder, and alcohol abuse becomes pregnant. She is admitted to the crisis stabilization unit during an episode of depression with suicidal ideation after a fight with her current boyfriend and an alcohol binge. On morning rounds, the patient appears irritable. She denies being suicidal but admits to being in a bad mood and worrying about her baby. The health care provider addresses the issue of alcohol abuse and warns her about the problems related to the chronic use of alcohol during pregnancy. She gets upset about being considered an alcoholic but is willing to listen to a substance abuse counselor, who among other things describes the features of fetal alcohol syndrome. Which of the following features is associated with fetal alcohol syndrome? A. Intrauterine growth acceleration B. Large hands and feet C. Macrocephaly D. Microcephaly E. Neurofibromas

D. The most common clinical features of fetal alcohol syndrome (FAS) include microcephaly, short palpebral fissures, midfacial hypoplasia, and cognitive defects, which can include difficulty with attention, verbal learning, and executive function.

A 37-year-old nursing assistant is admitted to the general medicine inpatient unit for evaluation of new onset of seizures. She recently was at a family picnic and accidentally discovered that she was an adopted child, by way of a family member who assumed she had known the true story. Initially she was in absolute shock and was unable to discuss it with her parents. She loves and respects her parents deeply and was brought up in a very religious environment; her adopted father was a minister. About a month ago her parents came to visit for Thanksgiving and stayed at her house for a few days. One day while finishing lunch she started complaining of a headache and soon afterward had a tonic-clonic seizure. She was taken to the emergency department. The initial evaluation was negative and she was advised to follow up in the clinic. Since then she has had several similar attacks and has not been able to go back to work. Her parents have stayed around to help, but the seizures have continued and she is admitted to the hospital. Neurologic and medical workup is completely unremarkable and the psychiatric consult team is asked for an assessment. After 3 days, the patient seems much better and is extremely interested in talking about her symptoms. If this patient were to have another seizure, which of the following features will most likely be present? A. Alternating flailing limb movements B. Disorientation C. Incontinence D. Loss of body tone E. Retrograde amnesia

A. This patient is most likely experiencing psychogenic seizures characterized by the lack of organized bilateral clonic jerks. Patients usually have asynchronous, alternating limb movements with suggestive pelvic thrusting. These seizures typically do not cause urinary or bowel incontinence or postictal confusion.

A 24-year-old man presents to the emergency department with hypertension, tachycardia, elevated body temperature, diaphoresis, mydriasis, and severe agitation. His mother reports that he uses illicit drugs, although she is not sure which kind. Which of the following agents is the most appropriate therapy? A. Atropine B. Flumazenil (Romazicon) C. Fluoxetine (Prozac) D. Diazepam (Valium) E. Naloxone (Narcan)

D. The patient described above is probably under the influence of a CNS stimulant, such as methamphetamine or cocaine. Diazepam or another benzodiazepine are used to treat hypertension, agitation, tachycardia, and seizures. Supportive care should be given as needed to control the hyperthermia and to maintain breathing.

A 29-year-old woman is climbing the stairs in her new home when the house collapses. She is taken to the hospital with a fractured left femur. A month later the psychiatry team is consulted because the patient complains of nightmares and flashbacks and is afraid to go to sleep. During the interview she is tearful and afraid that her fear of falling is preventing her from fully participating in her rehabilitation, for which she fears the team will discharge her from the hospital. Which of the following is the most appropriate treatment? A. Insight-oriented psychotherapy B. No therapy because the patient needs to take responsibility for her treatment C. A sitter who will stay in the patient's room 24 hours a day to calm her anxiety D. Antidepressant E. Benzodiazepine

D. The patient is having symptoms of post-traumatic stress disorder (PTSD), as well as depressive symptoms. Sertraline (Zoloft) and paroxetine (Paxil) are SSRI antidepressants FDA-approved for treatment of this disorder. Other antidepressants and anticonvulsants have also been shown to be effective in the treatment of PTSD.

A 68-year-old woman with hypertension comes to the health care provider because of decreased appetite, fatigue, insomnia, inability to concentrate, and feelings of worthlessness over the past 2 months. She states that her grandchildren are coming to stay with her for 3 weeks and she "wants to get to the bottom of this" before they arrive. Her antihypertensive medication was changed 3 months ago. Which of the following antihypertensive medications is the most likely cause of the patient's new symptoms? A. Captopril (Catapres) B. Furosemide (Lasix) C. Minoxidil (Minoxidil) D. Propranolol (Inderal) E. Verapamil (Calan, Isoptin)

D. The symptoms of change in appetite, fatigue, insomnia, lack of concentration, and worthlessness for greater than 2 weeks are consistent with depression. Propranolol is one of the most common pharmacologic agents to cause depression. Other side effects of propranolol include dizziness, bronchospasm, nausea, vomiting, diarrhea, and constipation. It may also precipitate asthma, congestive heart failure, and hypoglycemia in susceptible patients.

A 35-year-old woman comes to the health care provider for a periodic health maintenance examination. She has no physical complaints but she is concerned that she hardly ever feels happy. She says that she has basically been "down" for at least 3 years. She rarely goes out with friends and keeps to herself at work. Her work performance has been stable but she usually feels tired and "blah." Which of the following is the most likely diagnosis? A. Antisocial personality disorder B. Cyclothymic disorder C. Depression D. Dysthymic disorder E. Schizoaffective disorder

D. This patient has dysthymia, a mild, chronic form of depression. In adults, the diagnosis requires 2 years of a depressed mood, whereas in teens and adolescents it requires 1 year of symptoms to meet this criteria. Teens may manifest with irritability rather than depression. The condition may be associated with changes in appetite, sleep, and concentration, and with fatigue and hopelessness. Treatment is psychotherapy and antidepressant therapy.

A mother brings her 8-year-old son to a mental health provider for new-onset enuresis. A prior workup to determine a medical cause was negative. In conversation, it seems that the enuresis started following parental arguments and separation. The boy wets himself at least twice a week and feels upset about it, refusing to go for a sleepover at his friend's house. Which of the following is the most commonly used treatment for this condition? A. Behavioral therapy B. Interpersonal therapy C. Pharmacotherapy D. Psychodrama E. Psychotherapy

Answer: A. Behavioral therapy is the most frequently used treatment in children who have enuresis. Dry nights are recorded on a calendar and rewarded with a star as a gift. The buzzer and pad apparatus is used whenever other therapies fail.

A 58-year-old woman arrives at her health care provider's office complaining of moderate anxiety. Which of the following drugs will help relieve her anxiety, with a minimum of unwanted sedative side effects? A. Buspirone (Buspar) B. Chlordiazepoxide (Librium) C. Lorazepam (Ativan) D. Trazodone (Oleptro) E. Zolpidem (Ambien)

Answer: A. Buspirone is a nonbenzodiazepine anxiolytic that is devoid of the sedative (or anticonvulsive and muscle relaxant) properties typically associated with the benzodiazepines. It is a partial agonist at 5-HT1A receptors, and it binds to both serotonin and dopamine D2 receptors. Because this is not a benzodiazepine, there is less chance of severe drug interactions if the patient drinks alcohol along with taking this medication.

A 39-year-old businessman with no prior medical problems is rushed to the emergency department following the sudden onset of dizziness, shortness of breath, and palpitations. His blood pressure on admission is 190/110 mm Hg, pulse 124/min, and he is diaphoretic. His wife says that his behavior has changed over the past couple month since he became CEO of his company. He has become moody. At times he seems energetic, euphoric, or irritable; then he seems "to be down" for no reason. He just returned from one of many business meetings and again spent more money than ever before. The patient is smiling inappropriately and denies any alcohol or drug abuse. Which of the following will most likely be found on a urine drug screen? A. Cocaine B. Heroin C. Nicotine D. Organic inhalants E. Phencyclidine

Answer: A. Cocaine intoxication is characterized by sympathic stimulation, including tachycardia, hypertension, and sweating. The mood is elated and euphoric while intoxicated, and there is restlessness and pressured speech. Psychotic symptoms can occur with prolonged use.

A 27-year-old successful businesswoman has developed a fear of flying after an extremely rough landing. She is paralyzed with fear and unable to travel for business. Her health care provider tried giving her lorazepam (Ativan) to take during the flight, but it didn't help. She returns to the health care provider and asks if there is anything else that she can do to reduce her fear because she is not getting a promotion at work because she cannot travel. Which of the following is the most commonly used non-drug intervention for this disorder? A. Exposure therapy B. Hypnosis C. Insight-oriented psychotherapy D. Medication E. Supportive therapy

Answer: A. Exposure therapy, a type of cognitive behavior therapy, is the most commonly used treatment of specific phobia. The therapist usually desensitizes the patient by a gradual exposure to the phobic stimulus. Relaxation and breathing control are important parts of the treatment.

A 42-year-old woman is admitted for outpatient elective cosmetic surgery. After the surgery, she develops acute shortness of breath, and pulmonary embolus is diagnosed. Two days later, an emergency psychiatric consultation is called, as the patient has developed a shaking tremor, is pulling out her IV lines, and appears to be watching snakes crawl around the floor of her room and ants crawling on her skin. Which of the following aspects of the patient's history would be most likely to point to the diagnosis? A. Alcohol use B. Depression C. Past LSD use D. Schizophrenia E. Traumatic childhood

Answer: A. The patient's hallucinations, agitation, and tremor point to the diagnosis of delirium tremens (DTs), which should always be considered when a patient does not have access to alcohol after admission to the hospital.

An 18-year-old woman comes to her health care provider along with her mother, who states that she doesn't know what to do with her daughter. Ever since the daughter started modeling, she became concerned about being fat. Over the past 6 months she has lost 25 pounds. The daughter states that she has a fear of gaining weight. She has not had her menstrual period for 5 months. She denies use of laxatives or diuretics. On examination she is thin and has fine hair all over her body. Her weight is about 20% below her expected body weight. Her blood pressure is 90/70 mm Hg and pulse 54/min and regular. Which of the following is the most appropriate next step in management? A. Admit her to the hospital to reestablish weight and correct metabolic abnormalities B. Refer the patient for psychodynamic psychotherapy C. Send the patient for evaluation for electroconvulsive treatment D. Start the patient on hormone therapy to induce her menstrual cycle E. Tell the mother not to worry and send them home

Answer: A. This patient has lost a significant amount of weight in a short period of time. As indicated by her vital signs and percentage of weight loss, she may need a full evaluation of her physical status to determine and correct metabolic abnormalities because her refusal to eat has placed her in a potentially life-endangering situation.

A 74-year-old woman with a long history of type 2 diabetes mellitus undergoes surgery for small bowel obstruction. After surgery, she develops acute renal failure. She refuses to undergo dialysis despite the advice of her health care provider who then calls for an immediate psychiatric consultation. The patient tells the mental health specialist that she has lived a long life and does not want to be kept alive by or attached to a machine, even if it means she will die. A mental status examination shows that she is not psychotic, that she is fully oriented and alert, and that she has no fluctuations of cognition or level of consciousness. The patient's family is insistent that she be dialyzed immediately. Which of the following is the most appropriate statement the health care provider could make? A. The patient is aware of the consequences of her decision and does not show signs of a major psychiatric illness. B. The patient is competent to decide on treatment, and her refusal to undergo dialysis must be respected. C. The patient is competent to decide on treatment, but her refusal can be overruled because of a medical emergency. D. The patient is operating in a suicidal manner and should be committed for treatment against her will. E. The patient is temporarily incompetent, so start her on dialysis.

Answer: A. This patient raises one of the most difficult legal and ethical problems in psychiatry. It is important to understand that competency, or lack of competency (choices B, C, and E), can be determined only by a legal authority, such as a court of law. The role of mental health professionals is solely advisory in determining competency. In this situation, only if the patient is suicidal by virtue of a major psychiatric illness, or if the patient were subject to an immediate medical emergency, could treatment be involuntarily administered. The mental health professional's role is to assess a person's mental status for evidence of cognitive impairment, as well as to ascertain that the patient has a thorough understanding of the consequences of treatment decisions that are made. This patient does not meet criteria for treatment against her will (choice D), which requires both a mental disorder and the threat of impending immediate harm to self or others.

A 24-year-old student is brought to the emergency department because of a sudden change in behavior. His friends report that he has been acting "weird" and confused and has been talking about "flying above the floor." He laughs without a reason and then burst into tears. He had been at a party the night before and may have used some drugs. He appears hot and has uncoordinated movements. He has horizontal nystagmus, ataxia, and muscular rigidity. He becomes very agitated and combative during the examination. He is placed in a nonstimulating environment. Which of the following agents should be administered at this time to treat his agitation? A. Chlorpromazine (Thorazine) B. Diazepam (Valium) C. Flumazenil (Romazicon) D. Naltrexone (Revia) E. Trihexyphenidyl (Artane)

Answer: B. Diazepam (Valium) is used for treatment of agitation related to phencyclidine (PCP) intoxication. Benzodiazepines may be effective in treating violent behavior. Cranberry juice or ascorbic acid may be useful in acidifying the urine and speeding up the elimination of the drug.

A 31-year-old woman has a 7-year history of binging and purging. She also exercises excessively, often for 4 hours, 6 days a week. She has not sought medical attention for this problem in the past, but for the past couple of months she has had a depressed mood, a lack of energy, poor sleep, and decreased ability to concentrate. She comes to the health care provider now complaining of these new symptoms and would like treatment. Which of the following medications would be the most appropriate to initiate? A. Bupropion (Wellbutrin) B. Fluoxetine (Prozac) C. Haloperidol (Haldol) D. Lithium carbonate (Lithobid) E. Valproic acid (Depakene)

Answer: B. This patient appears to have symptoms of major depression in the context of bulimia. She should therefore be treated with an antidepressant medication, and a selective serotonin reuptake inhibitor (SSRI), such as fluoxetine, would be most appropriate.

A 33-year-old woman with bipolar disorder and history of alcohol and drug abuse is brought to the emergency department after being found at home. She was found unresponsive to voice and touch, with 16 empty packets of medication next to her, each containing 50 mg of diphenhydramine. There was also an empty bottle of acetaminophen and a half-empty whiskey bottle near her bed. A suicide note was present on a nearby table. In the field, her temperature was 36º C (96.8º F), blood pressure 90/55 mm Hg, pulse 140/min and regular, and respirations 8/min. Additional data obtained in the field included a finger stick glucose of 20 mg/dL and an oxygen saturation of 87% on room air. Of the data available in the field, which of the following findings is most immediately threatening to her outcome? A. Blood pressure of 90/55 mm Hg B. Finger stick glucose of 20 mg/dL C. Oxygen saturation of 87% on room air D. Pulse of 140/min E. Respirations of 8/min

Answer: B. When blood glucose level drops ≤25 mg/dL, as in this case, cerebral glucose reserves are quickly depleted. In response, protein and lipid components of neurons are metabolized, which can lead to irreversible brain damage. Prompt treatment with intravenous glucose is therefore critical in this patient's initial management.

A 30-year-old woman comes to her primary care provider with multiple symptoms of depression. She complains of about 2 months of feeling sad and anxious. She describes difficulty falling asleep at night, decreased appetite with a 15-lb weight loss, diminished interest in her hobbies, and poor concentration. The patient denies any other problems. Physical examination is within normal limits. The patient and her health care provider discuss initiating treatment with an SSRI. Which of the following would be the most important additional information to gather before starting the SSRI? A. Family history of depressive episodes B. Family history of alcoholism or drug dependence C. Past history of hypomanic or manic episodes D. Past history of kidney diseases E. Past history of obsessions or compulsions

Answer: C. Although all of the choices are valuable pieces of further information, a past history of hypomanic or manic episodes is the one choice that might significantly alter treatment planning. It is likely that all antidepressants, including SSRIs, have a potential to cause a switch into hypomania or mania, or to accelerate cycling in patients who have bipolar disorder. If the patient has a history of hypomanic or manic episodes, her depression would be considered a bipolar depression rather than a unipolar depression. In this case, the patient would likely need to be started on a mood stabilizer before beginning treatment with an antidepressant medication.

A 35-year-old engineer with a history of heroin abuse has been having marital problems because of his addiction. His wife insists that he needs treatment and that unless he deals with his addiction, she will file for divorce. The patient has been successful and has stayed clean for several years but relapsed recently when he ran into one of his old "drug buddies." In the meantime, he developed a fever and a cough and is admitted to the hospital for the treatment of pneumonia. While in the hospital he develops cramps, diarrhea, frequent yawning, and stays wrapped in a blanket because of chills and body aches. While waiting for the substance abuse consult, which of the following medications would be most useful for treating his autonomic symptoms? A. Alprazolam (Xanax) B. Clonazepam (Clonopin) C. diazepam (Valium) D. Flumazenil (Romazicon) E. Methylphenidate (Ritalin)

Answer: C. Of the medications listed, the only one that would actually help relieve the autonomic symptoms of withdrawal would be diazepam (Valium) for muscle cramps and relaxation. Other medications can be given for specific symptoms: loperamide for diarrhea, promethazine for vomiting, dicyclomine for abdominal cramping, and ibuprofen for muscle pain.

A 23-year-old woman is brought into the emergency department by ambulance at midnight, after her roommate found her using a paper clip to make lacerations on her wrists. The patient had been seen in the same emergency department twice during the past 2 weeks with a complaint of feeling very depressed and at times suicidal. She has a history of one drug overdose on children's vitamins. In both presentations to the emergency department, she was prescribed benzodiazepines for anxiety and sent home with an outpatient psychiatric clinic referral. On this presentation she states that if she is not admitted to the hospital she will go out and find a bridge to jump off. Which of the following is the most appropriate initial step in management? A. Admit the patient to the medical ward and await psychiatric consultation in the morning B. Explain to the patient that her attempts to mutilate herself will not result in suicide, and that she needs outpatient psychotherapy C. Order an emergency psychiatric assessment D. Remove the patient from hospital grounds by security escort E. Set up a new outpatient psychiatric clinic appointment

Answer: C. The fact that this patient has a history of a suicide gesture and expresses present suicidal ideation puts her at risk for harming herself. She should be kept in the hospital, at least until a psychiatric assessment can be made.

A 30-year-old woman with a history of tonic-clonic seizures complains of double vision, thickened gums, and growth of facial hair since starting a new medication. Which of the following anticonvulsant medications is most likely responsible for her symptoms? A. Carbamazepine (Tegretol) B. Ethosuximide (Zarontin) C. Phenobarbital (Phenobarb) D. Phenytoin (Dilantin) E. Valproic acid (Depakene)

Answer: D. Diplopia, gingival hyperplasia, and hirsutism are classic side effects of phenytoin. Other side effects include nystagmus, sedation, ataxia, and enzyme induction. Phenytoin is used in the treatment of grand mal and tonic-clonic seizures. It is not used for absence seizures.

A 35-year-old woman is referred by her dermatologist to a mental health practitioner. For the past several years, she has had a compulsive need to wash her hands after shaking hands with someone. Because she is in the public relations business, hiding her problem while still performing her ritual has become increasingly difficult. She knows that if she doesn't do it, she becomes nervous and tense. Which of the following is the most appropriate treatment? A. Buspirone (Buspar) B. Clonazepam (Klonopin) C. Diazepam (Valium) D. Fluvoxamine (Luvox) E. Risperidone (Risperdal)

Answer: D. Fluvoxamine is an SSRI that has been approved for the treatment of obsessive-compulsive disorder (OCD). Its efficacy has been established in several trials. It is FDA-approved for the management of obsessive-compulsive disorder.

A 48-year-old obese woman with a history of psychotic depression and polycystic ovary syndrome is brought to the psychiatric emergency department following a suicide threat. She is difficult to interview because she feels tired and sleepy and states she is on a continuous positive airway pressure (CPAP) machine at home secondary to having obstructive sleep apnea. She reports that she has been on fluoxetine (Prozac) and other medications, which she got for "the voices." Her medication list has been obtained off of her electronic medical record. During the interview, the health care provider learns she has gained 20 pounds in the past several months. Which of the following medications most likely caused this significant weight gain? A. Amoxapine B. Lorazepam (Ativan) C. Nefazodone (Serzone) D. Olanzapine (Zyprexa) E. Metformin (Glucophage)

Answer: D. Olanzapine (Zyprexa) is an atypical antipsychotic indicated for the management of psychotic disorders. Weight gain and type 2 diabetes have been associated with the use of this medication.

The mother of a 35-year-old man calls her health care provider for advice on a drug treatment program for her son. She states that he has lived with her since the loss of his job and apartment 4 months ago. She reports that he goes out on weekends and uses drugs heavily. When he returns home, usually on Monday mornings, he sleeps for the entire day and seems very depressed. He is also very irritable and anxious over the course of the next day. She knows of no other withdrawal symptoms. She believes that he uses the drug throughout the week, but with more intense binges on the weekends. On several occasions he has called her from the local psychiatric emergency center after admitting himself for suicidal ideation after use of the drug. Which of the following drugs is most likely responsible for this man's withdrawal state? A. Alcohol B. Benzodiazepines C. Cannabis D. Cocaine E. Heroin

Answer: D. The use of cocaine, especially crack cocaine (an extremely potent, freebase form that is sold in small, ready-to-smoke amounts) is associated with the withdrawal symptoms described in this case. After cessation of the use of cocaine, or after acute intoxication, a post-intoxication depression (crash) often occurs. This depression is associated with dysphoria, anhedonia, anxiety, irritability, fatigue, hypersomnolence, intense craving, and suicidal ideation.

A 36-year-old woman with a long history of alcoholism presents to the emergency department intoxicated. On physical examination she is disoriented and confused, and has dysarthria and oculomotor paralysis. She is unable to coordinate muscle activity during voluntary movement. Which of the following intravenous substances should most likely be administered first? A. Glucose B. Haloperidol (Haldol) C. Lorazepam (Ativan) D. Thiamine E. Valproic acid (Depakene)

Answer: D. This patient appears to have Wernicke encephalopathy, which is caused by a deficiency of thiamine that is quite common in chronic alcoholic patients. Symptoms of Wernicke encephalopathy include oculomotor disturbances, cerebellar ataxia, and mental confusion. Treatment consists of giving at least 3 days of thiamine, 100 mg IV or IM three times daily, along with magnesium sulfate given before loading with glucose. Patients in this situation should also be given niacin and pyridoxine (vitamin B6) since most of these patients are also deficient in these water-soluble vitamins.

A 42-year-old HIV-positive man is being treated for his first episode of Pneumocystis jirovecii pneumonia on an inpatient medical ward when he begins to become increasingly disoriented, combative, and agitated. Pulse oximetry shows that he is oxygenating at 93% on room air. He is currently receiving nortriptyline (Pamelor) for depression and gabapentin (Neurontin) for pain caused by peripheral neuropathy. He has a history of alcohol abuse for the past several years before hospitalization and a remote history of opioid abuse. Which of the following is the most likely diagnosis? A. Alcohol withdrawal B. HIV dementia C. Hypoxemic encephalopathy D. Major depressive disorder E. Multifactorial delirium

Answer: E. In a patient such as this who has a medical illness, a history of the acute onset of agitation, disorientation, and confusion is consistent with and most suggestive of the diagnosis of delirium.

A 25-year-old moderately obese woman with a history of bipolar disorder diagnosed at age 19 complains to her health care provider that her recent struggles with her weight and eating have caused her to feel depressed. She states that she has recently had increased difficulty sleeping, has felt excessively anxious and agitated, and has had increasing thoughts of suicide. She often finds herself fidgety and unable to sit still for extended periods of time. Her family tells her that she is increasingly irritable. She has never attempted suicide. Her current medications include lithium carbonate (Lithobid) and zolpidem (Ambien) as needed for sleep. Which of the following is more consistent with a diagnosis of major depressive disorder than bipolar depression in this patient during this episode? A. Early onset of bipolar disorder B. Increased appetite C. Insomnia D. Increased thoughts of suicide E. Psychomotor agitation

Answer: E. Major depressive disorder is a syndrome that requires a depressed mood or loss of interest or pleasure and causes clinically significant distress or impairment in occupational, social, or other important areas of functioning. The diagnosis of bipolar depression requires that the patient have also had a manic episode of bipolar disorder. Bipolar depression is associated with less psychomotor agitation compared with unipolar depression (major depressive disorder), and thus the patient's agitation is more consistent with a major depressive disorder diagnosis than with the depression of bipolar disorder.

A 30-year-old woman has had a history since adolescence of multiple vague physical complaints, including headaches, nausea, bloating, abdominal pain, dysmenorrhea, fatigue, fainting, and dysuria. She is now being seen in a health care provider's office, where she describes her current abdominal symptoms as "the worst imaginable." On physical examination no abdominal stiffness or masses are noted. Tenderness on palpation of the abdomen is elicited, but the site varies and is not reproducible, even a minute or so later. On talking with the patient, she does not seem concerned about any specific life events. Which of the following is the most likely diagnosis? A. Conversion disorder B. Hypochondriasis C. Malingering D. Munchausen syndrome E. Somatization disorder

Answer: E. This patient has somatization disorder. The physical complaints are usually vague and not adequately explained by a physical disorder. Formal criteria for the diagnosis have been defined and include onset before age 30, symptoms involving at least 4 different body parts, two or more GI symptoms, at least one reproductive or sexual symptom, and at least one neurologic symptom other than pain. Patients may have coexistent personality disorders, notably histrionic, borderline, and antisocial. Treatment is difficult, and the condition tends to wax and wane throughout life. Suicide is a definite risk with overtly depressed patients who have longstanding disease.

A 16-year-old boy is brought to the clinic by his father who says that he has been increasingly aggressive and has been stumbling and tripping around the house for several weeks. He is especially worried about his uncharacteristic violent behavior. The patient's temperature is 38º C (100.4º F), blood pressure 140/90 mm Hg, pulse 90/ min, and respirations 22/min. He has slightly dilated pupils and nystagmus. He begins to have convulsions on the table, making the remainder of the examination impossible. Which of the following is the most likely cause of these findings? A. Cocaine withdrawal B. Heroin C. Marijuana D. Morphine E. Phencyclidine (PCP)

Answer:E. This patient is displaying the signs and symptoms of PCP intoxication. PCP causes aggression, distortion of body image, disorganized thoughts, ataxia, nystagmus, mid-dilated pupils, myoclonus, fever, hypersalivation, and hyperacusis. It can lead to seizures, coma, and death. It can also lead to an acute psychosis with a high risk for violent behavior and suicide. Initial therapy for an agitated or psychotic state is diazepam (Valium), whereas persistent psychotic states may need antipsychotics such as haloperidol (Haldol).

Cognitive therapy for depression is based on the theory that the disorder is caused by which of the following? A. Anger toward others that is turned on the self B. Distorted negative beliefs and self-talk that reinforces those beliefs C. Fluctuating neurotransmitter levels D. Genetic predisposition E. Significant object loss in the first 3 years of life

B. Cognitive therapy is based on the theory that depressed persons have acquired negative cognitions about themselves, reinforcing these cognitions with self-talk that is often not verbalized. The goal of therapy is to identify the negative cognitions, question the validity of the beliefs, and substitute more positively reinforcing self-talk for the aversive self-criticism.

An infant born to an alcoholic mother had microcephaly and cardiac abnormalities and died despite resuscitative efforts. During which of the following periods of pregnancy is alcohol most teratogenic? A. First 2 weeks B. 3rd through 9th weeks C. 9th through 12th weeks D. 12th through 16th weeks E. 16th through 20th weeks

B. Embryonic tissue is most susceptible to teratogens during the 3rd through 9th weeks of pregnancy. This is when organogenesis, as well as most major congenital anomalies, occurs. Because brain development occurs throughout pregnancy, however, it is wisest for a pregnant woman to avoid alcohol for all 9 months of gestation.

A 26-year-old man is brought to the hospital by his family after sitting in his room with the lights out and the door closed for 2 days. He has not eaten over this time. About a week ago, the family noticed the patient becoming increasingly agitated and paranoid about cars driving by on the street in front of their house. He covered the windows of his bedroom with newspaper and unplugged his radio and television. At night, he was heard pacing in his room and talking to himself. Although he had taken olanzapine (Zyprexa) after a psychiatric hospitalization about 6 months previously, the family reported that he threw away the medication about a month ago. On admission, the patient is sitting in a chair with his head hung low. He is disheveled and malodorous, after having urinated on himself several times over the past 2 days. During physical examination, the patient appears to be awake, but firmly resists any attempts to be moved. He does not follow instructions, and the nurse was unable to move his arm to obtain a blood pressure measurement without assistance. Which term would best describe this patient's resistance to being moved? A. Akathisia B. Cataplexy C. Echopraxia D. Negativism E. Stereotypy

D. This patient is exhibiting the catatonic symptom known as negativism, which is a motiveless resistance to all attempts to be moved or to all instructions. Signs of catatonia include stupor, negativism, rigidity, posturing, mutism, stereotypies, mannerisms, waxy flexibility, and catatonic excitement. Catatonia may be associated with schizophrenia (catatonic type), mood disorders (with catatonic features), or general medical conditions.

A 34-year-old woman with documented bipolar disorder comes to the hospital because of feelings of guilt and worthlessness. She has amassed thousands of dollars of credit card debt in the past 2 months. Her parents are going to pay it off for her, but she believes that this will bankrupt them. On further questioning she reveals that she bought a gun earlier in the day because it would be easier for everyone if she "wasn't here anymore." She plans to go to the roof of her building with her new purchase "and do what needs to be done." Which of the following is the most appropriate next step in management? A. Send home with lithium B. Send home with valproic acid (Depakene) C. Send home with carbamazepine (Tegretol) D. Observe in the emergency department E. Admit to the hospital

E. Anyone who has serious suicidal thoughts, suicidal intent, and a plan, must be hospitalized, against her will if necessary. The patient expressed a desire to die and she bought a weapon and developed a believable plan. She needs to be hospitalized for her own safety. Patients with bipolar have a lifetime suicide rate of 10-15%.

A 17-year-old girl is found unconscious in a bathroom after ingesting a large amount of unknown sleeping pills. On arriving at the emergency department, she is somnolent; her temperature is 37.2º C (98.9º F), blood pressure is 120/74 mm Hg, pulse is 68/min, and respirations are 12/min. She responds to painful stimuli and to hearing her name loudly by opening her eyes briefly. She returns to the somnolent state immediately afterward, however. Which of the following is the most appropriate initial intervention? A. IV administration of caffeine B. IV administration of droperidol (Inapsine) C. IV administration of 500 mL of normal saline D. Ipecac-induced emesis E. Gastric lavage

E. Gastric lavage should be used in this somnolent patient. It is best done within the first 60 minutes of ingestion of the unknown substance. It is performed by inserting a large-caliber orogastric tube and then flushing the tube with a large amount of normal saline. The saline is then aspirated from the stomach to a container in an attempt to evacuate any ingested substance that persists in the stomach cavity. Identification of the ingested substance is also very important. With certain ingested substances, gastric lavage is contraindicated. For example, the procedure should not be used if hydrocarbon ingestion is suspected because aspiration is much more likely to happen during a lavage or an induced emesis. Furthermore, ingestion of alkaline substances causes esophageal necrosis. In this setting, gastric lavage may cause esophageal perforation.

A 50-year-old woman with a past history of recurrent major depressive disorder is currently on a maintenance dose of an antidepressant. She has been well for the past 2 years. She is complaining to her mental health provider about her decreased ability to reach orgasm. Which of the following medications has most likely caused her anorgasmia? A. Amitriptyline (Elavil) B. Bupropion (Buspar) C. Mirtazapine (Remeron) D. Nefazodone (Serzone) E. Paroxetine (Paxil)

E. Paroxetine, along with other selective serotonin reuptake inhibitors, can cause decreased libido and difficulties reaching orgasm. In studies, the incidence of these side effects was 2-9% in patients on paroxetine compared with those on placebo.