Adolescents & Young Adults

A 14-year-old girl is admitted for left-sided paralysis. During a neurological evaluation, when the physician lifts the patient's hand and drops it onto her face, her hand falls next to her face. When examining her paralyzed leg, the physician notes pressure in the hand that is placed under the paralyzed leg when attempting a straight leg raise. Based on these findings, the patient is diagnosed with conversion disorder. When explaining the diagnosis of conversion disorder to the patient and her family, which statement is the most appropriate? "Paralysis is intentional, and she is feigning symptoms." "It is unlikely that her symptoms will remit within the next year." "She should be referred to a psychiatric clinic immediately for psychotherapy." "It is important to understand that this paralysis is involuntary."

"It is important to understand that this paralysis is involuntary." When treating conversion disorder, confrontation about the symptoms is contraindicated. Treatment recommendations include reassurance (in this case, emphasizing to the family that the symptoms are involuntary) and reasonable rehabilitation. To be diagnosed with conversion disorder, symptoms cannot be intentionally produced or feigned. Conversion disorder is typically of short duration, usually remitting spontaneously within 2 weeks in hospitalized patients. It is unlikely that her symptoms will persist for a year. Psychotherapy may be useful but may also be contraindicated, particularly if the patient is resistant to psychotherapy or the symptoms worsen when treatment is initiated.

Tourette's disorder needs to present symptoms before children reach a certain age. What is that age? 10 12 18 25

18

A certain percentage of children with oppositional defiant disorder (ODD) will develop conduct disorder. What is this percentage? 5% 15% 30% 50%

30% Although most children with ODD will outgrow their diagnosis, approximately 30% of children with ODD will develop conduct disorder.

Childhood-onset fluency disorder (formerly stuttering in DSM-IV) is prevalent in a small number of children. What is the precise percentage of children and adolescents that will have childhood-onset fluency disorder at some point in childhood? 1% 5% 10% 15%

5%

What is a Crisis intervention unit?

A Crisis intervention unit may be found in the emergency department of a general or psychiatric hospital or within centers in the community. Patients in crisis demonstrate severe symptoms and require a high intensity of nursing services.

In the previous question, what would be a placebo effect?

A placebo effect is a perceived or tangible improvement after administration with an inert medication (a "placebo"). In this case, marijuana is not a placebo, and the effect on memory recall is a known phenomenon.

On the previous question, how would viral encephalopathy would present?

A viral encephalopathy would present with possible confusion, focal neurological deficits, seizures, and decreased consciousness.

What is the Maintenance Stage?

A. Maintenance stage is characterized by completed goals being maintained.

On the previous question, why are the following wrong? Atypical antipsychotics are first-line treatment in treating children with both ADHD and aggression. Tardive dyskinesia occurs primarily on initiation of therapy. Sedation usually occurs after months of therapy.

A. Psychosocial/educational intervention and appropriate pharmacotherapy of primary psychiatric disorder should be optimized prior to atypical antipsychotics use. B. Tardive dyskinesia, involuntary movements, is seen after months to years on antipsychotic therapy, not upon initiation. D. Sedation is seen primarily with the initiation of therapy, not after months.

What is the Odds ratio?

A. The odds ratio (OR) is used to calculate risk in case-control studies and signifies the odds of a having a disease given an exposure and is calculated by dividing the odds of disease after an exposure of interest by the odds of disease without that exposure. For rare diseases, the odds ratio approximates the relative risk.

Why is not Preoperational?

A. This is ages 2-7 and involves perception-dominated thinking; he's too old for this stage.

Why are the other answers wrong?

A. While familial arguments are unpleasant, they don't support a conduct disorder diagnosis in a child. B. While disrespectful behavior is rude, it doesn't support a conduct disorder diagnosis in a child. D. Bullying classmates, while unkind, doesn't rise to the level of criminality or cruelty to support a conduct disorder diagnosis in a child.

What is ADHD characterized by?

ADHD is a condition characterized by the onset of limited attention span or impulse control that starts before the age of 12 and last for more than 6 months. There must be impairment in more than one setting such as at school, church, or home. Symptoms often persist into adulthood. Treatment includes stimulant medications or non-stimulant medications (guanfacine, clonidine, TCAs, or atomoxetine) and cognitive behavioral therapy.

What is the most prevalent childhood psychiatric disorder? ADHD Depression GAD ASD

ADHD is the most prevalent childhood psychiatric disorder. Data collected from a variety of sources from 2005-2011 show that children ages 3-17 years had ADHD (6.8%), behavioral or conduct problems (3.5%), anxiety (3.0%), depression (2.1%), autism spectrum disorders (1.1%), and Tourette syndrome (0.2% among children ages 6-17 years). Adolescents ages 12-17 years demonstrated illicit drug use disorder in the past year (4.7%), alcohol use disorder in the past year (4.2%), and cigarette dependence in the past month (2.8%). Generalized anxiety disorder is seen more frequently in girls than boys. Although autism spectrum disorders have had increasing attention and increased identification, this group of disorders is still rare compared to other childhood disorders

What is acting out?

Acting out is the expression of unconscious conflicts in a setting other than the one in which they initially arose.

From the previous question, what would be the symptoms from the inhalation of acrylamide?

Acute toxicity due to acrylamide (a chemical used in ore processing, wastewater management, gel chromatography, and certain foods) leads to encephalopathy and ataxia. Acute exposures may also lead to a delayed neuropathy. Chronic toxicity is marked by progressive, symmetric, large-fiber, axonal, sensory or sensorimotor peripheral neuropathy with minimal associated weakness. This neuropathy may also be associated with autonomic dysfunction. In contrast to n-Hexane exposure, the skin findings in acrylamide toxicity include dermatitis with erythema and exfoliation of the skin, including palmar erythema. Acrylamide toxicity may also be distinguished from n-Hexane exposure based on this patient's facial numbness and visual symptoms, which would be unusual in acrylamide poisoning.

A 21-year-old female presents to the ED after ingesting an unknown number of acetaminophen pills. She has no history of prior suicide attempts. The patient states that she was recently dumped after a year-long relationship. She is tearful and repeatedly explains that her dog recently became sick and that no veterinarians can figure out what is wrong. The patient states that her "inability" to care for her dog and hopelessness prompted her to ingest the acetaminophen. She denies feeling that this recent breakup contributed to her suicide attempt. She also denies decreased energy, increased need for sleep, unexpected or undeserved guilty notions, anhedonia, insomnia, previous suicidal ideation, psychomotor slowing, or recent alcohol or illicit drug use. What is the correct diagnosis? Cyclothymia Major depressive disorder Adjustment disorder with depressed mood Comorbid personality disorder

Adjustment disorder with depressed mood This description is classic for a "concatenation of events" in which a small event seems to "break the camel's back," leading to a maladaptive stress response. Stress that is longstanding (in this case, a relationship that soured) is intensified by what appears to be a smaller stressor (the dog becoming sick). This seemingly small detail prevents the patient from dealing with the much larger issue at hand. Adjustment disorder occurs within 3 months of a stressor and ceases within 6 months of a stressor ending. Has a change in emotional or behavioral symptoms that are out of proportion to severity of stressor and/or causes impairment. The symptoms should not be better explained by another psychiatric disorder. Specifiers of adjustment disorder include the following: with depressed mood, with anxiety, with mixed anxiety and depressed mood, with disturbance of conduct, with mixed disturbance of emotions and conduct, unspecified. The specifier "with depressed mood" consists of predominant tearfulness, low mood and hopelessness.

A 17-year-old ballet student presents for treatment of amenorrhea for 1 year. On physical exam, her weight is 70% of that expected for her age and height. When this is mentioned, the patient replies that she looks fat in her ballet outfit and refuses to eat because she cannot afford to gain any more weight. Her CMP shows mild hypokalemia, and CBC is within normal limits. Blood pressure is 79/60, and heart rate is 54. What is the next step in management? -Discharge and draw blood for CMP and CBC in 1 week -Refer to nutritionist as outpatient -Suggest seeing psychiatrist for weekly psychotherapy -Admit to hospital

Admit to hospital. This patient suffers from anorexia nervosa and needs admission because her blood pressure is <80 systolic and her weight is 30% below expected. While a blood draw in a week, a referral to a nutritionist, and psychotherapy may at some point play a role in her care, this ill patient requires hospitalization. She may have needed emergent medical hospitalization if results of her electrolyte values on CMP (specifically K+) were abnormal. With abnormal results, she may have been at considerable risk for developing cardiac arrhythmias, which would have warranted additional medical workup including an EKG. Other criteria often used for admission are: <75% ideal body weight or ongoing weight loss despite intensive management, refusal to eat, body fat <10%, heart rate <50bpm daytime or <45bpm nighttime, systolic pressure <80, orthostatic changes in pulse (increased >35bpm) or blood pressure (decreased >10 mmHg), hypothermia and arrhythmia.

Define the Age & Task(s) for the Identity vs. Role Confusion stage?

Age: 12 to 28 Tasks: Formation of identity, devotion.

Define the Age & Task(s) for the Autonomy vs. Shame stage?

Age: 18 months to 3 years Tasks: Control and independence.

Define the Age & Task(s) for the Intimacy vs. Isolation stage?

Age: 18 to 35 Tasks: Forming a relationship, commitment.

Define the Age & Task(s) for the Initiative vs. Guilt stage?

Age: 3 to 6 Tasks: Taking control of the environment, purpose.

Define the Age & Task(s) for the Generativity vs. Stagnation stage?

Age: 35 to 65 Tasks: Building a family, having a productive career.

Define the Age & Task(s) for the Industry vs. Inferiority stage?

Age: 6 to 12 Tasks: Confidence, competence, social skills.

Define the Age & Task(s) for the Ego Integrity vs. Despair stage?

Age: 65 to death Tasks: Viewing life as meaningful and fulfilling.

Define the Age & Task(s) for the Trust vs. Mistrust stage?

Age: birth to 18 months Task: Basic trust

Schizophrenia can occur in childhood. Which of the following is a true statement about childhood-onset schizophrenia? -Clozapine is first-line and the most effective agent in COS. -Olanzapine and quetiapine are less sedating than risperidone. -Akathisia may be confused with ADHD or agitation. -EPS occurs rarely in pediatric patients on first-generation antipsychotics.

Akathisia may be confused with ADHD or agitation. Akathisia is a movement disorder associated with anxiety and an inability to sit still. It occurs as a side effect of antipsychotics and antidepressants.

On the previous question, what would be the presentation with alcohol intoxication?

Alcohol intoxication would demonstrate slurred speech, unsteady gait, and incoordination.

You are working in a rural area in South Dakota and receive a subpoena from a judge regarding your treatment of a 13-year-old male with a history of neglect and sexual abuse. Which of the following statements about responding to the court is correct?

All states require a response to a subpoena request. According to the AACAP practice parameter for forensic evaluations, all states require a response to a court order. Failure to respond may result in a contempt-of-court action. Circumstances that allow you to object to a subpoena and potentially avoid having to produce documents or appear in court may include claims that the information sought is "privileged," lost, or violates your Fifth Amendment constitutional right against self-incrimination or that the request is overbroad or unduly burdensome.

A 19-year-old actress presents who is amenorrheic. The patient is 85% of her expected weight for her age and height and refuses to eat out of fear of being "too fat to get a part in movies." Her vital signs and labs (CBC and chemistry panel) are within normal limits. Psychiatric hospital admission is recommended, but she refuses to comply. What is the appropriate response? -Admit patient involuntarily -Ask ethics committee to review case -Refuse to treat patient if she will not be admitted -Allow patient to return home, as risk of imminent danger is low

Allow patient to return home, as risk of imminent danger is low. A patient with anorexia nervosa presenting to a physician should only be admitted against his or her will when there is a risk of probable death from complications of malnutrition. This patient's labs and vital signs are normal. The advice of an ethics committee is not required. Do not threaten the patient with abandonment or refer her, as these actions do not address her problem. Patients with anorexia should only be admitted against their will when there's a risk of probable death from malnutrition complications — this case doesn't reach that standard. The ethics committee isn't needed to weigh in on this case. Refusing to treat the patient doesn't address her problem.

How do hallucinogens intoxication may present as?

Altered states of perception and feeling, hallucinations. nausea, increased body temperature, HR, & BP, papillary dilation, poor appetite, sweating, sleeplessness, numbness, dizziness, rapid shifts in emotions, depression, anxiety.

Why dismissing the patient from the practice for noncompliance is not a good option?

Although a healthcare provider has the right to terminate a caring relationship with a patient, he or she must not abandon the patient. In general, the patient or parents must be given adequate opportunity to arrange a continuation of care with another healthcare provider.

What are side effects of marijuana?

Although short-term effects of marijuana may include sensory distortion, panic and anxiety, more common side-effect include poor coordination of movement, lowered reaction time, and feeling sleepy or depressed.

A 15-year-old female was recently diagnosed with a terminal melanoma and begins volunteering at a hospital to work with other terminally ill children. Which defense mechanism best describes her actions? Rationalization Intellectualization Sublimation Altruism

Altruism is the redirection of internal conflict through meeting the needs of others.

The PMH-NP is working at Student Health on a college campus in Colorado. Steve is 19 year old college sophomore who is brought to student health by his roommate Dave who states, "I think my roommate is going crazy. He has been studying for finals and has been up for hours, pacing the room, sweating and every time I tell him to relax he says shut up or he is going to punch me in the face". Dave is concerned Steve may have taken medication that was prescribed for Dave. To confirm the Dave's suspicion the PMH-NP orders a Urine Drug Screen (UDS). Which medication is most likely to show up positive on Steve's UDS? Opiates Barbiturates Marijuana Amphetamines

Amphetamines Side effects of amphetamines include: hyperactivity, insomnia, restlessness, irritability, and aggressiveness. An amphetamine, such as Vyvanse, would be prescribed for Dave for Attention Deficit Disorder with Hyperactivity, but Steve may have taken the amphetamine to help keep him awake to study.

A 16-year-old boy presents to the pediatrics office with his mom for "erratic behavior." He describes extreme mood swings, irritability, feelings of aggression toward his parents and teachers, and feelings of invincibility. Sometimes, he feels like he can fly and has been thinking about making his own hang glider "like Icarus in the story" and jumping off the top of his house. The patient's mom reports that he has never acted like this before. She says that he seems to be "somebody else's kid" and is worried that "all that sports talk about annihilating other teams" that he gets at football practice could be giving him "ideas." The patient's mom has a brother with bipolar disease, and she remembers seeing similar things in him at this age. The patient denies depressive feelings, states that mostly he feels "really good," denies suicidal or homicidal ideation, and finds it difficult to explain his behavior, saying "things just happen." In general, the patient seems unworried about his own state of mind. Physical exam reveals a physically fit, Tanner stage V young man with no apparent deficits. Besides bipolar disease, what other condition is likely to present in this way? -Marijuana intoxication -Nitrites intoxication -Viral encephalopathy -Anabolic steroid abuse

Anabolic steroid abuse. Anabolic steroid abusers seldom present for medical help and rarely seek treatment. These substances can produce a mania or hypomania, which may look like bipolar disease at first. However, closer examination and careful history will help the cautious physician know when to suspect that another pathology is in play.

An 18-year-old female with a BMI of 16 is intensely fearful of gaining weight, limits herself to <1,000 calories per day, and views herself as fat. She sometimes forces herself to vomit after eating what others would consider a normal meal. The patient has normal menses. What is the most likely DSM-5 diagnosis? Bulimia nervosa Eating disorder NOS Anorexia nervosa, purging type Unspecified eating disorder

Anorexia nervosa, purging type In the DSM-5, the diagnosis of anorexia nervosa no longer requires irregular menses in postmenarcheal females. This patient would have been diagnosed with eating disorder NOS in the DSM-IV-TR, but she is now diagnosed with anorexia nervosa, purging type in the DSM-5. Although the patient engages in purging behavior, the presence of anorexic behaviors eliminates a sole diagnosis of bulimia nervosa. Unspecified eating disorder replaces eating disorder NOS in the DSM-5, but it is not appropriate in this case given the change in the requirement of amenorrhea for a diagnosis of anorexia nervosa.

Certain treatment strategies can help adolescents diagnosed with psychotic depression recover more rapidly. Which of the following strategies can help adolescents diagnosed with psychotic depression recover more rapidly? Antidepressants combined with antipsychotics Antidepressants combined with mood stabilizers Antipsychotics used alone Mood stabilizers used alone

Antidepressants combined with antipsychotics Patients with psychotic depression appear to recover more rapidly when antidepressants are combined with antipsychotics. Antipsychotics carry the risk of tardive dyskinesia and should be tapered after remission of the psychosis. Atypical antipsychotics are generally used as an alternative to typical antipsychotics but carry an increased risk of type 2 diabetes and dyslipidemia; they should also be tapered after remission of psychosis. Anecdotal reports and literature reviews suggest that ECT may be efficacious for psychotic, depressed adolescents. Currently there are a limited number of studies accessing combinations of antidepressants and antipsychotics for this population and more research need to be done.

The PMHNP is evaluating Brody, 19 year old Marine who is currently in the brig. The NP asks Brody to tell her what happened that lead to his confinement to the brig. Brody states "Eh, I've been a bad, bad dude since I was 10 when my old man left. I ditched school for good when I was 15 because it wasn't my scene, but I got my GED so I could be a Marine. I've always loved to crack heads and get that high when my fists hit flesh. I got some practice with cracking heads tonight at the club. The local boys got what they deserved, a few less teeth and a free ambulance ride to the hospital. My sergeant was here. He's proud of the job I did on them fellas, even though he didn't tell me outright, I know he is. He said you'd be coming by. You're a pretty girl, I'm glad you're here. Do you have a smoke I can bum?" For which Disorder does Brody meet criteria? -Antisocial Personality Disorder -Histrionic Personality Disorder -Oppositional Defiant Disorder -Intermittent Explosive Disorder

Antisocial Personality Disorder. The patient described meets the criteria for APD by: 1. Pervasive pattern for disregard for others since age 15 as indicated by (at least 3 of 7 criteria): - breaking the law - impulsivity - aggressiveness - lack of remorse 2. Individual is at least 18 3. There is evidence of conduct disorder with onset before age 15.

Review: Why is it not Alcohol Withdrawal?

Anxiety, headaches, nausea, or shaking hands would happen if this were the case

The mother of a 10-year-old boy is concerned that his performance at school has been declining over the last 6 months. Teachers complain he frequently gets out of his seat, fidgets constantly, and disrupts other students. At home, the patient cannot sit still at family meals and often loses his shoes and toys. Which of the following is the best way to pursue a diagnosis of attention-deficit/hyperactivity disorder (ADHD) in this child? -Order a complete blood count -Interview the mother -Order genetic screening -Ask the parents and teachers to complete the Vanderbilt ADHD Rating Scale

Ask the parents and teachers to complete the Vanderbilt ADHD Rating Scale. Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that appears in early childhood. It is characterized by inattention, hyperactivity, and impulsivity that is developmentally abnormal. Boys are more commonly diagnosed than girls. There is no single test that can establish the diagnosis of ADHD. Information should be gathered directly from both parents and teachers on how the child's behavior impacts the ability to function at home, at school, and with other children. The inattentive, hyperactive, and impulsive behaviors must cause significant impairment in two separate environments to make a diagnosis. Validated rating measures such as the Conners-3 and the Vanderbilt ADHD Rating Scale (VARS) can help make the diagnosis. CBC is not relevant. Interviewing the parents is a great first step toward diagnosing ADHD, but input is needed from multiple adults in a minimum of two situations to confirm the diagnosis. This child is more likely to have ADHD if a parent or sibling also has the diagnosis. There is a high concordance of ADHD in identical twins, and multiple different genes contribute to the disorder. There is no specific genetic test at this time for ADHD.

What is the Assertive Community Treatment Model?

Assertive Community Treatment Model is an interdisciplinary team approach to the care of people with severe mental illness; it provides services in the individual's natural setting, including homeless shelters. The goals of ACT are to help patients meet the requirements of community living after discharge from another more restricted form of care, and to reduce recurrences of hospitalization.

What other drugs aside from stimulants, can be used to treat ADHD?

Atomoxetine can be used to treat ADHD but is not a first-line drug. It selectively inhibits presynaptic norepinephrine in the central nervous system. Tricyclic antidepressants (TCAs) can be used to treat ADHD but are not a first-line option. They work by inhibiting 5-HT and norepinephrine reuptake. Guanfacine is a non-stimulant alpha-2 agonist that can be used to treat ADHD, but it is not a first-line drug.

Atypical antipsychotics can be used to treat children with aggression. Which of the following is true about this treatment choice? -Atypical antipsychotics are first-line treatment in treating children with both ADHD and aggression. -Tardive dyskinesia occurs primarily on initiation of therapy. -Atypical antipsychotics should be tapered slowly. -Sedation usually occurs after months of therapy.

Atypical antipsychotics should be tapered slowly. Atypical antipsychotics should be tapered slowly to allow adjustment to the lowered dose and to prevent withdrawal akathisias. Aripiprazole (in 6-17 years old) and risperidone (in 5-16 years old) are FDA approved for irritability in autism (6-17 years old). Most atypical antipsychotics are used off-label for behavioral disturbances in children and adolescents. Clozapine is not due to side effect profile. Pimavanserin is not because it is only utilized for patients with Parkinson's disease hallucinations.

A 14-year-old boy is discharged on carbamazepine after an admission for acute mania. About 4 weeks later, he is again acutely manic despite having been initially stabilized on carbamazepine. What is the likely cause of this medication failure? -Grapefruit juice -Cimetidine -Erythromycin -Autoinduction

Autoinduction. Carbamazepine stimulates the transcriptional upregulation of genes involved in its own metabolism, which is called autoinduction. This causes autoinduction of CYP3A4 and CYP2B6. Autoinduction is usually complete 3-5 weeks after the initiation of a fixed dose when taken consistently. Incorrect: A. Carbamazepine serum levels may be increased if taken with food and/or grapefruit juice. B. Cimetidine generally increases the serum concentration of carbamazepine, usually temporarily. C. Erythromycin increases the serum concentration of carbamazepine

Why is is not OCD?

B. OCD is associated with intrusive thoughts and ritual performance to relieve the anxiety from intrusive thoughts. These patients do not present with the same extreme rule-following.

What is the Precontemplation Stage?

B. Precontemplation stage is characterized by not being cognizant of a need for change or resistance to change.

What are side effects of barbiturates?

Barbiturate act on the CNS and act as depressants. Side effects of barbiturates include: clumsiness or unsteadiness, dizziness or lightheadedness, drowsiness and "hangover" effect.

Review: S/Sx Benzos?

Benzodiazepines cause bradycardia, decreased respiratory rate, hypotension, confusion, and impaired cognitive functions.

A 16-year-old boy is brought to the emergency room by his mother. She states that his behavior has been "odd" since he returned from a friend's house this evening. He appears agitated and anxious but denies use of any substances. On physical exam, the patient is slightly tachycardic, his pupils are dilated, his blood pressure is slightly elevated, and he is perspiring. His speech is not affected. The patient denies GI symptoms or increased appetite. A drug screen is negative for cocaine. Which of the following is the most likely substance of intoxication? -Cannabis -Alcohol -Amphetamines -Opioids

C - Amphetamines This patient likely used an amphetamine (see table below). Symptoms of amphetamine intoxication include nausea, vomiting, psychomotor agitation, weight loss, perspiration or chills, tachycardia, pupillary dilation, and elevated or lowered blood pressure.

A 32-year-old man who has a history of imprisonment for 4 counts of assault and robbery states that he just does "whatever" he feels like. His family report that he has been lying and cheating since he was 12 years old. He often got into fights at school and in college. He has been fired from over 12 jobs and has alienated most of his family and friends. People with this disorder are likely to demonstrate which feature? -Self-mutilation -Onset of conduct disorder after age 18 -Onset of conduct disorder before age 15 -Brief psychotic states

C - Onset of conduct disorder before age 15. Patients with antisocial personality disorder have an onset of conduct disorder before age 15. A. Self-mutilation is associated with borderline personality disorder. B. Patients with antisocial personality disorder have an onset of conduct disorder before age 15. D. Patients with borderline personality disorder may experience brief psychotic states.

What is the Contemplation Stage?

C. Contemplation stage is characterized by ambivalence with a willingness to consider but not to commit to change.

Why is it not Narcissistic personality disorder ?

C. Narcissistic personality disorder does not present with a focus on rule-following. These patients are much more focused on themselves.

What is the Event Rate (ER)?

C. The event rate (ER) is calculated as the number of events over the number of subjects. This is used to calculate several measures, including relative risk and absolute risk reduction.

Why is is not Sensorimotor?

C. This is ages 0-2 years and involves interacting with the environment; he's too old for this stage.

On the previous question, what would be the presentation with cannabis intoxication?

Cannabis intoxication would present with conjunctival injection, dry mouth, and increased appetite.

From the previous question, what would be the symptoms from the inhalation of carbon disulfide?

Carbon disulfide (found in perfumes, varnishes, insecticides, and other manufacturing processes) may be inhaled. Acute exposure results in mucosal irritation and burns, encephalopathy, seizures, coma, and respiratory failure. Chronic exposure may lead to behavioral changes, extrapyramidal signs, cerebellar dysfunction, and peripheral neuropathy (sensory or sensorimotor with minimal weakness). Cranial nerve dysfunction may also occur.

Which of the following is a reason to use motivational interviewing with children and adolescents? -Children and adolescents are already motivated to change. -Children and adolescents are relieved to get a diagnostic label. -Children and adolescents prefer to be told what to do by a parental figure. -Child and adolescent resistance can be managed with less resistance and hostility.

Child and adolescent resistance can be managed with less resistance and hostility. MI is well-suited to treatment with children and adolescents. Of note, it is often used in substance abuse disorders to assess readiness to change and to help patients progress in their commitment when ready. Children and adolescents are likely to be resistant to change. Children and adolescents dislike diagnostic labels. Children and adolescents most likely to resist the advice of parental figures.

What are the side effects associated with Clozapine?

Clozapine is associated with severe side effects, including cardiovascular symptoms, hyperlipidemia, seizure, and nocturnal enuresis. Currently, other second-generation antipsychotics are first-line agents in treating psychosis. Clozapine is typically used after at least 2 adequate trials of other antipsychotics fail to resolve psychotic symptoms.

On the previous question, how could cocaine intoxication present as?

Cocaine (and meth) intoxication would present with hypertension, anxiety, and diaphoresis. Also increased in HR and temperature, exhilaration, increased energy, mental alertness, tremors, decreased appetite, anxiety, panic, paranoia, violent behaviors, stroke, seizure.

Review: S/Sx of Cocaine use?

Cocaine causes euphoria, anxiety/agitation, and dilated pupils.

What is Community-Based Care?

Community-Based Care refers to care delivered in partnership with patients in their homes, work sites, mental health clinics and programs, health maintenance organizations, shelters and clinics for the homeless, crisis centers, senior centers, group homes, and other community settings.

A 16-year-old girl is brought to the hospital by her parents following what they describe as a seizure. According to her parents, the patient complained of dizziness and double vision throughout the day and later began to shake uncontrollably while working on homework at her desk. Since arriving at the hospital, the patient has been in and out of consciousness. A neurological exam is normal except for mild confusion when the patient is asked direct questions. She is sent for several imaging studies, all of which appear normal. After 8 hours in the hospital, the patient becomes lucid and has little memory from the prior day, claiming that the last thing she remembers is working on her homework. History reveals that she has never had a seizure before, but she frequently complains of vertigo and often needs to lean on her parents to steady her walking. After a 24-hour observation, she is released from the hospital and is free of symptoms. Which of the following is the most likely diagnosis?

Conversion disorder presents as a pseudo-neurological syndrome. This patient most likely did not experience a true seizure, nor were her other symptoms (dizziness, unsteady gait) likely caused by a physiologic disorder. Normal labs and imaging rule out a neurological cause. Additionally, she recovers completely within 24 hours, which is characteristic of conversion disorder. While those with personality disorders may also be more likely to show conversion disorder symptoms, this patient does not meet the criteria for borderline personality disorder. To be diagnosed with somatic symptom disorder (SSD), the individual must be persistently symptomatic (typically at least for 6 months). This patient may also be depressed, but there is not enough information to make this diagnosis.

An adolescent begins to experiment with drugs and alcohol despite knowing the risks and being fearful of the consequences. What best describes this behavior? -Denial -Splitting -Acting out -Counterphobia

Counterphobia Counterphobia is seeking out experiences that are consciously or unconsciously feared. For example, the attraction to horror movies may stem from a counterphobic impulse.

What is it not Cyclothymia?

Cyclothymia involves depressive symptom cycling that persists for two years in adult patients and one year for pediatric patients.

If a patient with an eating disorder presents with certain criteria, they should be admitted. Which of the following is an indication for admission? A - Heart rate 65bpm B - Glucose 80 mg/dL C - Potassium <4.0mEg/L D - Temperature <97.0°F

D - Temperature <97.0°F A. This is a normal resting heart rate (60-100bpm is normal range), so it's not an indication for admission. B. This is a normal glucose reading (70-130 mg/dL is normal range), so it's not an indication for admission C. Potassium has to be below <3mEq/L to be an indication for admission — this is above that threshold.

What are the Hazard ratios (HR)?

D. Hazard ratios (HR) are similar to relative risk, but while relative risk ratios are cumulative over the course of a study, a hazard ratio reflects the instantaneous risk over a specific time period. This is helpful when 2 groups are experiencing events at different rates, even if the overall event rate may be similar.

On the previous question, what would be the presentation with opioid intoxication?

D. Opioid intoxication would present with drowsiness and slurred speech.

Why is it not Schizoaffective disorder?

D. Schizoaffective disorder patients would present with signs of schizophrenia with a depressive component, which is not seen in this patient.

Why is is not Concrete Operations?

D. This is ages 7-11.5 years and involves only applying logical reasoning to objects that are real or can be seen; he's too old for this stage.

What is denial?

Denial is the unconscious process through which unpleasant feelings, thoughts, or impulses are avoided.

The FDA sets maximum dosages for medications for patients' ages 6-17. Which of the following is a correct medication-maximum dosage pair for patients of this age? Dexmethylphenidate (Focalin IR): 20mg daily Methylphenidate: 40mg daily Methylphenidate LA: 80mg Methylphenidate-OROS (Concerta): 108mg

Dexmethylphenidate (Focalin IR): 20mg daily Dexmethylphenidate (Focalin) is a stimulant that inhibits reuptake of dopamine and norepinephrine. It is the d-isomer of methylphenidate and twice as potent as methylphenidate. It is FDA approved for ADHD in adults (XR only) and in children 6 years or older (XR and IR). Focalin (IR) and Focalin XR are the available formulations. Focalin (IR) can be started at 2.5 mg twice a day and the FDA maximum is 20 mg/day. The recommended starting dose of Focalin XR for adults is 10 mg/day and the FDA maximum for adults is 40 mg/day. The recommended starting dose of Focalin XR for children is 5 mg/day and the FDA maximum for children is 30 mg/day.

A 16-year-old female is treated with an antiepileptic drug for a seizure disorder. She decides to stop taking her medication because of weight gain, although it is the only medication that has successfully controlled her seizures. The patient and her parents understand the potential risk of increased seizure activity as a result of stopping this medication. What is the correct action? -Obtain a court order to continue therapy -Report parental refusal of continued therapy to child protective services -Discontinue treatment -Dismiss the patient from the practice for noncompliance

Discontinue treatment. For discontinuation of therapy that does not result in an immediate or imminent threat to the life of a minor, the parents' wishes should be respected. The parents of a young child have the right to refuse treatment, including treatments strongly recommended by the healthcare provider, unless refusal of treatment results in a serious and immediate risk to the life or health of the child. In this case, although it would be inappropriate (and illegal) to try to force the use of antiepileptic drugs, it would be appropriate to intervene if the child was in status epilepticus, which is an immediate threat

Development disorders can be treated with a range of techniques. Which of the following is a true statement about the techniques used to teach school children with developmental disorders? -Discrete trial training (DTT) is used with applied behavioral analysis (ABA) in school programs for children with pervasive developmental disorders. -ABA is based on a single set of norms and planning for a child with autism. -DTT is the only technique used to teach new skills in school programs using ABA. -Negative reinforcement is used in DTT

Discrete trial training (DTT) is used with applied behavioral analysis (ABA) in school programs for children with pervasive developmental disorders. Discrete trial training (DTT) is used in conjunction with applied behavioral analysis (ABA) in school programs for children with pervasive developmental disorder. B. ABA is a systematic approach to developing a program for each child. Steps include evaluating a child's strengths and weaknesses, identifying educational and treatment goals, and applying techniques for skill development. C. DTT is among many techniques used to teach new skills. D. Positive reinforcement is used in DTT.

Review: What is Displacement?

Displacement is the shift of a sexual or aggressive drive to a more acceptable target.

Stephanie is a 19-year-old woman attending a 4-year university on an academic scholarship. She works a part-time job and is maintaining a 4.0 GPA while attaining a biology degree. A recurring theme during her appointments is that her accomplishments in life have just been a fluke. She does well in school because she was lucky enough to get good teachers or studied the right content. What cognitive distortion is this patient demonstrating? Perfectionism Disqualifying the positive Selective abstraction Unrealistic expectations

Disqualifying the positive Disqualifying the positive is the correct answer for this question. This patient is chalking her success up to flukes and luck not to her hard work. There is not enough information in this scenario to determine if this patient is experiencing perfectionism and unrealistic expectations. Selective abstraction does not apply in this situation.

Divalproex sodium is used to treat acute mania. Which of the following statements about it is true? -Divalproex sodium is around 40-50% protein-bound -Divalproex sodium has an FDA indication for acute mania in children ages 12 and up. -Lithium increases risk of divalproex-related neurotoxicity. -Salicylates increase serum valproic acid levels

Divalproex sodium has an FDA indication for acute mania in children ages 12 and up. Divalproex sodium has FDA indications for the treatment of acute mania as well as seizure disorders in the pediatric population. Therapeutic levels in acute mania (adults) are 50-120mcg/mL. Prior to starting valproate, baseline laboratories should be drawn, including CBC with differential, liver function tests, and serum amylase levels. Absolute contraindications for use include hepatic disease or severe hepatic dysfunction, known urea cycle disorders, pregnancy, and polycystic ovarian disease in females of child-bearing age. Common side effects include alopecia, gastrointestinal, neurological, ophthalmological, and rash. Divalproex sodium is highly protein bound (80-90%). Maximum recommended dose is 60mg/kg/day.

You are asked to obtain consent for a lumbar puncture from a 17-year-old female with suspected meningitis in the ER. The procedure will be performed under a fluoroscope, and the radiologist feels that the patient is competent to make her own medical decisions. When you explain the procedure to the patient, she is disoriented and delirious. She is away from family, and you are unable to contact her parents, who live in a different town. Which of the following is the most appropriate action? -Have the patient sign a consent form. -Continue to call the patient's parents to get consent. -Do the lumbar puncture and treat the patient since she requires emergency care for a condition that could endanger life and limb. -Call another close relative for consent if the parents cannot be reached.

Do the lumbar puncture and treat the patient since she requires emergency care for a condition that could endanger life and limb. Consent for emergency care is implied in the ER. If the patient was not able to give informed consent due to her illness, then the NP should proceed with the procedure and treatment. The diagnosis will be made by a lumbar puncture, so it would be inappropriate to guess and subsequently make decisions about whether suspected meningitis is bacterial or viral. Bacterial meningitis is one type of life-threatening emergency situation that may be treated even if the patient is not able to understand the procedure, unless there is a prior instruction or proxy appointed to make decisions when the patient is incapacitated. In those cases, the proxy is expected to make decisions based on the best knowledge of the patient's healthcare preferences.

A 19-year-old actress presents with amenorrhea. The patient is 70% of her expected weight for her age and height and refuses to eat out of fear of being "too fat to get a part in movies." She is admitted to the inpatient psychiatric unit. On day 2 of admission, she asks for treatment for her severe constipation. What should be administered? Lactulose Senna Magnesium hydroxide Docusate

Docusate Patients with anorexia nervosa who are hospitalized for a treatment program may complain of constipation. This symptom is usually relieved when they begin to eat normally. Never give these patients laxatives; stool softeners are permissible. Lactulose, senna, magnesium hydroxide, and bisacodyl all have laxative activity. Docusate is a stool softener and not a laxative. It may be given in this setting.

What is Down syndrome (Trisonomy 21)?

Down syndrome. Down syndrome (Trisomy 21) is the most common causes of genetic intellectual disability. Physical characteristics include flat facies, single palmar crease and epicanthal folds. Associated with early onset Alzheimer Disease.

How do GHB (Gamma-hydroxybutyrate) intoxication may present as?

Drowsiness, nausea, headache, loos of coordination, memory loss / unconsciousness, seozures

How do cocaine (meth) withdrawal may present as?

Dysphoria, psychomotor slowing, fatigue, increased appetite, craving

Childhood bipolar disorder may be treated with pharmacologic treatment. Which of the following is a true statement about pharmacologic treatments for childhood bipolar disorder? -Anticonvulsants are used to treat the depressive phase of childhood bipolar disorder. -Early onset bipolar disorder is less responsive to lithium. -Therapeutic lithium levels are different in pediatric patients as compared to adult patients. -Stevens-Johnson syndrome occurs in 10% of children on lamotrigine.

Early onset bipolar disorder is less responsive to lithium. Early onset bipolar disorder is less responsive to lithium, therefore, is used often in conjunction with other medications. FDA approved medications for bipolar mania in adolescents are lithium and the following second generation antipsychotics: aripiprazole, risperidone, quetiapine, olanzapine, and asenapine. FDA approved medications for bipolar depression for adolescents are lurasidone and olanzapine/fluoxetine. None of the FDA approved medications for bipolar disorder are approved for children <10 years old.

From the previous question, what would be the symptoms from the inhalation of elemental mercury?

Elemental mercury contained in dental fillings and thermometers, for example, may be inhaled. The liquid form may be ingested. Inhalation may result in "erethism," consisting of gingivitis, tremor, and behavioral changes. This patient's presentation is not consistent with mercury poisoning.

A 6-year-old boy is brought to the pediatrician for evaluation of poor performance in first grade. Starting last school year, teachers report he is unable to sit still and often leaves the classroom during group activities. At home, he loses his toys, climbs on the furniture, and forgets to wash his hands after using the bathroom. After both teachers and parents complete the Vanderbilt Assessment Scale, he is diagnosed with attention-deficit/hyperactivity disorder (ADHD). The patient's parents agree to start a low dose of long-acting methylphenidate in addition to cognitive-behavioral therapy (CBT). Which of the following is the mechanism of action of this medication? -Enhances central nervous system catecholamine action via increased availability of dopamine and norepinephrine in the synaptic cleft in the brain -Selectively inhibits presynaptic norepinephrine transmitter in the central nervous system -Inhibits 5-HT and norepinephrine reuptake -Acts as an alpha-2 agonist

Enhances central nervous system catecholamine action via increased availability of dopamine and norepinephrine in the synaptic cleft in the brain Attention-deficit/hyperactivity disorder (ADHD) is a behavioral disorder that manifests in early childhood and is characterized by inattention, hyperactivity, and impulsivity that is developmentally abnormal. Boys are more commonly diagnosed than girls. The inattentive, hyperactive, and impulsive behaviors must cause significant impairment in two separate environments to merit a diagnosis.

What is Erythema multiforme?

Erythema multiforme is an acute, immune-medicated skin reaction from an infection or medication. Appears as target-like skin lesions and in rare cases develop into bullous lesions.

How do opioids intoxication may present as?

Euphoria, drowsiness, impaired coordination, dizziness, confusion, feeling of heaviness in the body, slowed or arrested breathing, constipation, flushing or feelings of warmth, pinpoint pupils.

How do sedative hypnotics (alcohol and benzodiazepines) intoxication may present as?

Exhilaration, loss of inhibitions, slurred speech, staggering gait, euphoria, marked motor impairment, confusion, stupor, coma.

When their struggling child receives an A on his 6-week report card, the Smith parents decided to reward him with $5 per A grade. In the next few months, the number of A grades the child receives increases until the both of the Smith parents are satisfied with his performance and stop providing this monetary incentive. At first, the child's grades do not change. Over time; however, the parents notice that his grades are slipping back to his original B and C. Which process describes this child's diminishing performance? Positive reinforcement Positive punishment Negative reinforcement Extinction

Extinction Extinction is the loss of a previously learned operant response after it is no longer reinforced by a stimulus. Good grades are the operant response (learned behavior) that has been stimulated by a monetary reward. Without the reward, the conditioned behavior is no longer reinforced and can fade over time.

Up to what percentage of pediatric patients can develop EPS symptoms?

Extrapyramidal signs occur in up to 75% of pediatric patients on first-generation antipsychotics. Acute episodes can be treated with anticholinergic agents, antihistamines, or amantadine.

The Treatment for Adolescents with Depression Study (TADS) studied a number of therapies for depressed youth. Which arm of the study was most efficacious? Fluoxetine Fluoxetine plus CBT CBT alone Fluoxetine was as effective as CBT

Fluoxetine plus CBT. The TADS study indicated that 60% of depressed youth respond to initial treatment with medication. Fluoxetine is FDA-indicated for the treatment of depression from ages 8-17. The TADS study indicated that 61% of the medication-only group improved, 71% of the combination CBT and medication group improved, 43% of those with CBT alone improved, and 35% of the placebo group improved.

A 19-year-old woman admits to eating large quantities of food in spurts. She then takes diuretics and exercises strenuously to try to "make up for the calories." The patient does this a few times a week. Otherwise, she claims to eat a "normal, healthy diet" and is a normal weight. What is the first-line of treatment? -Nothing (patient is displaying a variant of normal eating and dieting behavior) -Fluoxetine -Bupropion -Paroxetine

Fluoxetine. Fluoxetine is the only medication approved by the FDA for the treatment of bulimia nervosa. In general, any SSRI should be considered first-line in treating bulimia. TCAs should be avoided due to their potential to increase cardiac toxicity. MAOIs should be avoided in these patients. Bupropion should be avoided in all eating disorder patients due to seizure risk. Paroxetine, as an SSRI, is considered first-line treatment for treating bulimia, but isn't FDA-approved as fluoxetine is.

Billy is a 10th grader on the varsity football team. During practice, the coach talks strategy and Billy starts to understand how the team can be better by focusing on individual strengths. This makes Billy think about his own strengths and he realizes how his strengths can aid him in other parts of his life. Which of Jean Piaget's development stage is Billy in? Preoperational Formal operations Sensorimotor Concrete operations

Formal operations Billy is demonstrating abstract thinking by making analogies which is developed during Piaget's formal operations stage. Preoperational, Sensorimotor, and concrete operations, are not applicable in this scenario.

What is Fragile X?

Fragile X. Fragile X results from CGG repeats increasing methylation of the FMR1 gene causing decreased expression of FMR1 gene. Features associated with Fragile X include intellectual disability, macroorchidism, macrognathia, long faces, large ears, mitral valve prolapse and autism.

Children who have been sexually abused may manifest their trauma in a range of ways. Which of the following is a potential symptom of sexual abuse? -Functional somatic symptoms -Normal eating patterns -Reluctance to discuss sexual acts -Sleepwalking

Functional somatic symptoms. Medically not well-explained or functional somatic symptoms can be a symptom of sexual abuse in children. Children of sexual abuse can also have injuries in their genital area, infections, or blood in their underwear. Can see regression with thumb sucking or bedwetting. May be talking excessively about sexual acts, imitating sexual acts and have knowledge of sex beyond their age. At increased risk for depression, anxiety, eating disorders and self-harm. Incorrect Answers: B. Children who have been sexually abused may have eating disorders, not normal eating patterns. C. Children who have been sexually abused may talk excessively about sexual acts, not be reluctant to discuss sexual acts. D. Sleepwalking isn't known to be a symptom of sexual abuse in children.

A 16-year-old Jehovah's Witness female refuses any transfusions prior to a surgical procedure. Her parents are also Jehovah's Witnesses. The patient expresses an understanding of the potential consequences of her decision. The surgery is a low-risk elective procedure. However, during surgery, she experiences a life-threatening hemorrhage. Which of the following statements is true? -Give a blood transfusion because the patient is a minor. -Obtain a court order for a blood transfusion since it is in the patient's best interest. -Try repeatedly to obtain consent from her parents. -Do not perform a transfusion

Give a blood transfusion because the patient is a minor. Patient autonomy is the right of a competent and informed patient to determine his or her own healthcare decisions, even when doing so may be harmful. However, children under 18 years of age are minors and deemed legally incompetent. Parents of a minor cannot withhold treatment to save life or limb from their children; if there is an immediate emergency, the patient should be treated appropriately. If the danger is not immediate but still critical, a court intervention or referral to an ethics committee may be indicated.

You are reviewing the chart of a 21-year-old man who was recently diagnosed with schizophreniform disorder. His psychotic symptoms presented in the first 2 weeks during the first episode of noticeable behavioral changes. The patient also experienced severe confusion at the height of his psychotic episodes. His pre-morbid functioning had been good; he had been doing well in college and reported no social problems. In light of these considerations, what is his prognosis? Indeterminate Neither good nor poor Good Poor

Good The factors that imply good prognosis in schizophreniform disorder are at least 2 of the following: psychotic symptoms within 4 weeks of the first noticeable changes, confusion at the height of psychotic episodes, previously good occupational and social function, and the absence of flat affect

On the previous question, how would nicotine (green tobacco) poisoning may present as?

Green tobacco poisoning involves nausea, vomiting, and weakness. It is seen in tobacco workers who have absorbed nicotine through their skin.

In the previous question, what would be habituation?

Habituation is a form of non-associative learning whereby repetitive stimuli elicit weakening behavioral responses if the stimuli do not reinforce or punish the behavior.

A young man who is addicted to methamphetamine (speed) suddenly loses his supplier. Which of the following statements about his presentation and care is true? -He may display symptoms of chronic stimulant abuse (e.g. dental caries) and muscle cramping related to dehydration and depletion of magnesium and potassium. -Benzodiazepines cannot be used in this case. -He cannot be abruptly taken off methamphetamine. -There is no risk of psychiatric complications after methamphetamine cessation.

He may display symptoms of chronic stimulant abuse (e.g. dental caries) and muscle cramping related to dehydration and depletion of magnesium and potassium. It's correct that this patient may display symptoms of chronic stimulant abuse, such as dental caries, as well as muscle cramping related to dehydration and depletion of magnesium and potassium. B. Benzodiazepines may aid in sedating the patient, and can be used. C. Methamphetamine can be withdrawn abruptly. D. As suicide risk often rises after withdrawal from methamphetamines, the patient may require psychiatric admission

A 19-year-old male student presents to the ED with leg pain and is discharged with Tylenol. After 1 day, he returns with nausea, vomiting, profuse diarrhea, yawning, perspiration, and a runny nose. On examination, his pupils are dilated, twitching is noted in the muscles, and there is no abdominal tenderness. Which drug is most likely responsible for these withdrawal symptoms? Cocaine Alcohol Benzodiazepine Heroin

Heroin This patient is suffering from opioid withdrawal (see table below). The age of onset is generally in the teens, and the death rate among opioid abusers is 20x greater than in the non-using population. Timing of the withdrawal is dependent on the type of opioid used. Common withdrawal symptoms are depressed mood, nausea, vomiting, diarrhea, yawning, insomnia, myalgias, runny nose, watering eyes, dilated pupils, sweating, and fevers. Major complications with IV use of opioids are cellulitis, abscesses, septic arthritis, osteomyelitis, pneumonia, meningitis, pulmonary emboli, and nephrotic syndrome. Yawning, diarrhea, muscle twitching, and dilated pupils make cocaine withdrawal an unlikely diagnosis. Sweating, flushing, sleep disturbances, hallucinations, seizures, and mild mental status changes are early symptoms of alcohol withdrawal 8-10 hours after the last drink. Benzodiazepine withdrawal is as severe as alcohol withdrawal.

The NP is caring for a 19 year old man who is on life support following a motorcycle accident. His parents divorced when he was young and the patient lived most of his life with his father who had legal custody. For the past six months, the patient lived with his fiance. His mother has a signed Durable Power of Attorney for Health Care (DPOAHC) naming the mother as the person to make decisions for the patient. The NP knows that the legal decision-maker for this patient is: His father His mother His fiance The Ethics Committee of the hospital

His mother The patient's mother has the only legally signed document so she is the one with the legal authority to make decisions for the patient. Unless the patient has rescinded the document, it does not make any difference that the patient did not live with his mother as a child and young adult. A. The patient's father cannot make the decisions since his custody ended when his son turned 18. C. The patient's fiance has no legal authority to make decisions for the patient since they were not legally married. D. Although this might be reviewed as an ethical dilemma, the Ethics Committee does not have the authority to make decisions for the patient.

What is the answer not Histrionic Personality Disorder (HPD)?

Histrionic Personality Disorder (HPD) is a pervasive pattern of excessive emotionality and attention seeking beginning in early adulthood and present in a variety of contexts.

On the previous question, how would hyperkalemic alkalosis may manifest as?

Hyperkalemic alkalosis may occur with certian endocrine disorders (e.g. Cushing's syndrome) and syndromes affecting the renal system

How do anabolic steroids use may present as?

Hypertension, blood clotting, hostility, aggression, acne. Males: prostate cancer and shrunken testicles. Females: menstrual irregularities, development of masculine features.

On the previous question, how would hypochloremic acidosis may manifest as?

Hypochloremic acidosis. Diarrhea usually produces a hyperchloremic metabolic acidosis from bicarbonate losses in stool, but diarrhea associated with chronic laxative abuse is rich in potassium and chloride (70-90mEq/L). This typically results in hypokalemia and a saline (chloride)-responsive metabolic alkalosis.

On the previous question, how would hypokalemic alkalosis may manifest as?

Hypokalemic acidosis. Diarrhea usually produces a hyperchloremic metabolic acidosis from bicarbonate losses in stool, but diarrhea associated with chronic laxative abuse is rich in potassium and chloride (70-90mEq/L). This typically results in hypokalemia and a saline (chloride)-responsive metabolic alkalosis

A 19-year-old female is referred for evaluation and seems cachectic. She believes that she is fat and refuses to gain weight, despite her mother's pleas. She weighs approximately 78% of her ideal body weight for her height. She has been amenorrheic for several months. She also admits to using laxatives and diuretics. Which of the following findings are expected in this patient? Hypokalemic alkalosis Hypokalemic acidosis Hypochloremic acidosis Hyperkalemic alkalosis

Hypokalemic alkalosis. Hypokalemic alkalosis is likely due to use of laxatives and diuretic. Diarrhea usually produces a hyperchloremic metabolic acidosis from bicarbonate losses in stool, but diarrhea associated with chronic laxative abuse is rich in potassium and chloride (70-90mEq/L). This typically results in hypokalemia and a saline (chloride)-responsive metabolic alkalosis. It results from hypokalemia, increased renal-bicarbonate reabsorption, and volume contraction due to a profound loss of sodium and water in the stool. Diuretics also cause metabolic alkalosis, likely derived from multiple contributing mechanisms. Secondary hyperaldosteronism often develops due to volume depletion, renal chloride loss, or a contraction alkalosis. Chloride-unresponsiveness may also develop due to a profound K depletion from either chronic thiazide or loop-diuretic exposure. She might also have leukopenia with relative lymphocytosis, elevated bicarbonate, hypochloremia, and hypokalemia. These electrolyte abnormalities can cause cardiac arrhythmias and even death from cardiac arrest.

Review: What is Identification?

Identification is the unconscious modeling of one's self on another person's character and behavior.

A 14-year-old female who was reported missing 3 days ago is brought to the ED for evaluation after a failed suicide attempt. She is stable and doing well. Authorities have classified the patient as a runaway. What is the first step in the evaluation? -Base interview and mental status examination on age of child -Administer diphenhydramine (1.25mg/kg/dose PO or IM) if child is not allergic -Identify child's legal guardian(s) -Assess child's social situation

Identify child's legal guardian(s) The initial step in the assessment is identifying the child's legal guardian(s). In routine cases, the legal guardians are the biological parents who accompany the child to the hospital. In complex cases, the child's legal guardian may be court-ordered to be only 1 parent, another relative, a foster parent, or a representative of the state agency responsible for the care and protection of children. Children shouldn't be interviewed or treated with medication without a legal guardian present

John wants to graduate from high school and his grades suggest he will. He currently has no plans for attending college. He spends all his time playing video games and struggles with socializing. He doesn't feel like he fits in with any of his other peers and doesn't really know who he is. Which of Erikson's developmental stage is John struggling with? Industry vs. Inferiority Identity vs. Role confusion Intimacy vs. Isolation Generativity vs. Self-absorption or stagnation

Identity vs. Role confusion John is struggling with the developmental task of Identity vs. role confusion. This is evidenced by no plans for the future and no sense of identity or belonging. Industry vs. inferiority is more related to sense of accomplishment and the ability to work, which John is not struggling with. Intimacy vs. isolation could have been considered due to the lack of social relationships, however identify vs. role confusion was a better answer due to the lack of self-identity. Generativity vs. self-absorption or stagnation is experienced during middle adulthood.

A 14-year-old male continuously argues with his parents about how they "just don't understand him." He also refuses to attend the family's church, stating "I'm an atheist." Which basic conflict best describes this adolescent? Industry vs. inferiority Identity vs. role confusion Intimacy vs. isolation Generativity vs. stagnation

Identity vs. role confusion. This adolescent is facing identity vs. role confusion.

A 16-year-old boy presents to the pediatrics office with his mom for "erratic behavior." He describes extreme mood swings, irritability, feelings of aggression toward his parents and teachers, and feelings of invincibility. The patient's mom reports that he has never acted like this before. She says that he seems to be "somebody else's kid" and is worried that "all that sports talk about annihilating other teams" that he gets at football practice could be giving him "ideas." The patient denies depressive feelings, states that mostly he feels "really good," denies suicidal or homicidal ideation, and finds it difficult to explain his behavior, saying "things just happen." In general, the patient seems unworried about his own state of mind. He lifts weights and works out several hours each day and takes "some stuff that helps him get bigger, faster." Physical exam reveals an extremely muscular, physically fit, Tanner stage V young man with no apparent deficits. What treatment should be prescribed? -Immediate cessation with admission to hospital for monitoring and tapering of steroid dose -Immediate cessation with counseling about body image issues -Immediate cessation with IV fluids, complete metabolic testing, and kidney ultrasound -Graduated cessation with counseling on adverse long-term effects of anabolic steroids

Immediate cessation with counseling about body image issues. Immediate cessation of the steroids is important, and counseling on body image issues may help relieve some of the pressure to use steroids in addition to counseling on the adverse long-term effects of steroids. Hospitalization with a tapering dose is not necessary unless suicidal ideation is present. Since he is not taking corticosteroids, the danger of a suppressed hypothalamic-pituitary axis not producing enough endogenous corticosteroid is not an issue. IV fluids, complete metabolic testing, and kidney ultrasound aren't needed in this case. However, counseling about body image issues is needed.

What is Intellectualization?

Intellectualization is the excessive use of thinking to avoid expressing underlying emotion.

What is the answer not Intermittent Explosive Disorder?

Intermittent Explosive Disorder is recurrent behavioral outbursts representing a failure to control aggressive impulses. Physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals.

On the previous question, why marijuana intoxication is not a good choice?

It would be very unusual for marijuana intoxication to cause aggression, irritability, and extreme mood swings.

Conduct disorder is a serious behavioral and emotional disorder that can occur in children and teens. Which of the following behaviors most strongly indicates conduct disorder in a child? Chronic arguing with parents Disrespecting teachers, parents, and police Killing neighborhood cats Teasing/bullying classmates

Killing neighborhood cats Cruelty to or killing of animals is strongly tied to the diagnosis of conduct disorder. Childhood animal cruelty is one of the earliest and most specific symptoms of conduct disorder. Other criteria include other aggression towards animals or people, destruction of property, deceitfulness or theft, and serious rule/law violations. Many children diagnosed with childhood-onset conduct disorder also have comorbid ADHD or other neurodevelopmental diagnoses, and those with these comorbidities have poorer outcomes. Patients diagnosed in childhood as opposed to adolescence are more likely to have persistent conduct disorder into adulthood. Substance misuse and suicidal ideation are also more common in those diagnosed with conduct disorder. The prevalence of conduct disorder ranges from 2-10% (median is 4%). Risk factors include neglect, physical or sexual abuse, large family size, parental criminality, and a family history of substance use disorders.

A 14-year-old female is brought to the ED with an elated mood, racing thoughts, restlessness, and agitation after attending a party. She reports seeing halos around objects and flashes of colors and "hearing the sounds of colors." A physical examination reveals tachycardia, hypertension, dilated pupils, and tremors. Which drug is most likely responsible for her symptoms? LSD Cocaine Benzodiazepine PCP

LSD Lysergic acid diethylamide (LSD) is the prototypical synthetic hallucinogen. It is an odorless and tasteless chemical that is usually ingested as a solution or dissolved on paper or sugar cubes. No physical dependence or withdrawals are seen with LSD, but psychological dependence occurs. It typically induces euphoria in addition to delusions and visual hallucinations. "Bad trips" can be marked by feelings of intense fear. Physical effects include increased body temperature, heart rate, and blood pressure; sleeplessness; and loss of appetite. Treatment of acute intoxication with hallucinogens is largely supportive. Providing reassurance, support, and a quiet environment is the mainstay of treatment. For those with extreme feelings of panic or fear, a benzodiazepine may be warranted.

An 18-year-old female presents for a physical examination. She is new to your practice but reports she has no chronic medical conditions and takes no medications. She denies tobacco or alcohol use. Her menstrual cycles have been irregular for two years. Her blood pressure is 140/88 mm Hg. She weighs 85 kg and she is 65 inches tall. Examination reveals some lip and chin hair. The patient reports weight gain over two years despite diet and exercise. Which of the following is the best choice in management of this patient? -Referral to a nutritionist for a very-low-calorie diet -Laboratory evaluation of possible secondary causes of obesity -Pharmacologic treatment -Discussion with patient of risks of obesity and benefits associated with weight loss

Laboratory evaluation of possible secondary causes of obesity Obesity is a major public health problem in the United States. It can be defined by use of National Center for Health Statistics nomograms based on studies of large population samples in the United States. The body mass index (BMI) can be calculated from the height (inches) and weight (pounds) or by the following formula: BMI = weight (kilograms)/(height in meters)2 Obesity is generally considered to be consistent with a BMI greater than 30 kg/m2. After identifying obesity in a patient, patient evaluation should determine if the obesity is the result of an underlying pathological condition. The three most common causes of secondary obesity include Cushing syndrome, hypothyroidism, and genetic conditions. In this patient, evidence of hirsutism and menstrual irregularity suggest possible endocrine or genetic causes that should be ruled out. Active intervention is indicated for all patients with a BMI > 30 kg/m2. Obesity is associated with an increased risk of developing diabetes, hypertension, cardiovascular disease, pulmonary dysfunction, osteoarthritis, cholelithiasis, and some cancers. Although all patients who are obese should be counseled about the risks associated with obesity and the advantages of weight loss, the best choice in immediate management of this patient is to rule out a cause of secondary obesity. A weight reduction diet using a very low-calorie diet replaces the patient's daily food intake with a diet (or beverage) that contains no more than 800 kcal/day, 1 g of protein/kg body weight, and all necessary vitamins and minerals. Patients on a very-low-calories diet should be monitored in a comprehensive weight-loss program by a healthcare provider for serious adverse effects. Pharmacological treatment for obesity should be initiated only after secondary obesity has been excluded.

Why on the previous question the answer is not a Likely seizure with short post-ictal state?

Likely seizure with short post-ictal state. The history does not indicate a seizure and nitrite poisoning is the better option with the history of several empty incense bottles.

What is Lyme disease?

Lyme disease is a tick-bourne illness caused by bacteria Borrelia burgdoferi. The characteristic skin rash associated with Lyme disease is a target (sometimes referred to as bull's eye) pattern called erythema migrans. Rash develops at tick bite site within 1-2 weeks.

Which antidepressants are associated with a tyramine crisis? What are some examples of this drug group?

MAOIs are associated with the risk of a tyramine crisis. Isocarboxazid (Marplan) Phenelzine (Nardil) Selegiline (Emsam) Tranylcypromine (Parnate)

A range of psychiatric disorders may occur in childhood. Which of the following statements about the incidence and prevalence of psychiatric disorders in childhood is true? -Depression is the most prevalent childhood psychiatric disorder. -Generalized anxiety disorder occurs more frequently in boys than girls. -Major depression increases in prevalence with age. -Autism spectrum disorders are more common than mood disorders

Major depression increases in prevalence with age. Based on epidemiological studies and estimates, the prevalence is about 0.3% in preschoolers, 2% in children, and 1.5-9% in adolescents.

What is it not MDD?

Major depressive disorder (MDD). MDD is unlikely because a specific event or series of events seem to have triggered this patient's maladjusted response. For MDD at least five symptoms must be present for 2 weeks.

A 17-year-old high-school student is brought to the emergency room with reddened conjunctivae. He is speaking in hushed tones and has tachycardia and a dry mouth. The patient's parents are worried about his grades at school, but he says he has "got it all figured out." Which drug is responsible for his symptoms? -Nicotine (green tobacco) poisoning -Marijuana intoxication -PCP -Cocaine

Marijuana intoxication. Cannabis intoxication causes these symptoms and may also manifest with a slowed sense of time and paranoid ideation. Also relaxation, slowed reaction time, auditory hallucinations, impaired balance and coordination, increased HR, impaired learning and memory, anxiety, panic attacks, psychosis, increased appetitie

A 17-year-old female is evaluated by a nurse practitioner for a high fever, severe headache, neck stiffness and muscle pain. She recently returned from a camping trip and her mother reports that she began to develop a rash, parts of which are turning dark red and purple. The patient has a temperature of 102.8 degrees Fahrenheit, heart rate of 115, and blood pressure of 88/50 mm Hg. Her respiratory rate is 24/minute. Which of the following is the most likely diagnosis? Meningococcemia Rocky Mountain spotted fever Erythema multiforme Lyme disease

Meningococcemia, or dissemination of meningococci into the blood stream, can kill more rapidly than any other infectious disease. It is caused by infection with Neisseria meningitidis and is a major infectious cause of childhood death in developed countries, with a mortality rate of around 10%. Patients with acute meningococcal infection can present clinically with meningitis, meningococcemia, or both. The characteristic petechial skin rash is usually located on the trunk and legs and rapidly evolves into purpura. Meningitis is associated with headache, fever, vomiting, photophobia, lethargy, neck stiffness, rash, and seizures. Meningococcal septicemia is characterized by fever, rash that becomes purpuric and petechial; vomiting, headache, hypotension, tachycardia/tachypnea, cool extremities, and an initially normal level of consciousness.

Review:: Why is it not NMS?

NMS is characterized by high fever and confusion — neither of which is present

A 19-year-old college freshman presents to the emergency room after his parents came for a surprise visit but found him drowsy and disoriented. On exam, the patient has prominent miosis, bradycardia, slurred speech, impaired attention and memory, and drowsiness. What should be quickly administered? Naltrexone Methadone Naloxone Buprenorphine

Naloxone is the drug of choice for the acute treatment of opiate overdose. Patients addicted to opioids should be withdrawn gradually over time. Drugs often used for this include methadone, naltrexone, buprenorphine, and clonidine. Naltrexone is used to help prevent relapses into alcohol or drug abuse, but doesn't reverse overdoses. Methadone is used to treat narcotic drug addiction through medication-assisted treatment, but doesn't reverse overdoses. Buprenorphine can be used to treat addiction to opioids, but doesn't reverse overdoses.

What is negative reinforcement?

Negative reinforcement is the removal of an undesirable stimulus to increase a specific behavior.

On the previous question, how would nitrates intoxication would present?

Nitrites usually present with symptoms akin to alcohol intoxication.

A 22-year-old female arrives at the clinics for a wellness check. She was recently diagnosed with Oppositional defiant disorder (ODD). It has certain characteristics as a disorder, which affects its treatment. Which of the following is true about ODD? -Setting fires, vandalism, cruelty to animals, and criminal behavior are characteristic of ODD. -Pharmacological treatment is the mainstay of ODD treatment. -ODD is more prevalent in adolescent boys than girls. -No medication is FDA-approved for ODD.

No medication is FDA-approved for ODD. Treatment of ODD involves addressing symptoms targeted by the comorbid disorder.

Why on the previous question the answer is not Normal experimentation with self-stimulation?

Normal experimentation with self-stimulation. Self-stimulation alone does not lead to being unconscious. Nitrite poisoning is the better option with the history of several empty incense bottles.

A 19-year-old female is referred for evaluation and appears cachectic. The patient states that she is fat and that she refuses to gain weight, despite her mother's pleas. She weighs approximately 78% of the ideal body weight for her height. The patient has been amenorrheic for several months and admits to using laxatives and diuretics. According to a study in the 1990s, mothers of patients with this disorder have a significantly increased prevalence of which psychiatric disorder? -Major depression -Obsessive-compulsive disorder -Somatoform disorder -Dependent personality disorder

Obsessive-compulsive disorder. OCD was significantly more prevalent in the mothers of patients with anorexia nervosa in the study cited. DSM-5 diagnostic criteria for anorexia nervosa include the following: -Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal (or for children and adolescents, less than that minimally expected). - Intense fear of gaining weight or of becoming fat or persistent behavior that interferes with weight gain, while at a significantly low weight. -Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of currently low body weight.

The parents of an 18-year-old boy bring him in for evaluation. They are worried about his concern with rules and orderliness to the point of resisting and being incapable of adapting to change. They report that throughout his whole life, the patient has demonstrated little emotion and never seemed interested in making friends. Instead, he prefers concentrating on doing his homework perfectly but never manages to finish due to constant revisions. During the exam, the patient is emotionally detached and distant. He denies any history of significant mood episodes, psychotic symptoms, performance of rituals, intrusive thoughts, or paranoia. When asked how he feels about not having close friendships, he begins to discuss the evolutionary role of friendship in relation to survival and its impact on an individual's safety and health. What is the most likely diagnosis? Obsessive-compulsive personality disorder Obsessive-compulsive disorder Narcissistic personality disorder Schizoaffective disorder

Obsessive-compulsive personality disorder Patients with obsessive-compulsive personality disorder (OCPD) are characterized by strict adherence to rules and a lack of adaptability. OCPD is not associated with the intrusive thoughts and ritual performance that characterize obsessive-compulsive disorder (OCD). These people would colloquially be called anal or "control freaks." This patient also demonstrates intellectualization and isolation of affect, which are 2 common defense mechanisms seen in OCPD.

A local health department is investigating an outbreak of diarrhea in a school cafeteria. They question 200 children who developed diarrhea and 200 children who did not. Investigators asked all of the children if they ate lettuce from the cafeteria. Overall, 120 children who became ill reported eating the lettuce, and 40 children who did not become ill also reported eating the lettuce. Which of the following represents the association between eating lettuce and developing diarrhea? Odds ratio of 4 Odds ratio of 6 Relative risk of 15% Relative risk reduction of 0.03

Odds ratio of 6 This is a case-control study, which is a retrospective observational study designed to identify associations between an outcome and exposure to a risk factor. The study is performed by identifying subjects with and without a certain disease and determining the proportion in each group with exposure to an identified risk factor. The results are reported as an odds ratio (see image below). The relative risk, used in cohort studies, is calculated by dividing the probability of an outcome in the exposed vs unexposed groups, generalized to: (A x D) / (B x C) = (A/C) / (B/D) = (A/B) / (C/D) (120 x 160) / (80 x 40) = 6

Why on the previous question the answer is not Onanism with subsequent deep sleep?

Onanism with subsequent deep sleep. The child is engaging in onanism (masturbation), but key parts of the history are ignored, and this child's apparent unconscious period is alarming. Further investigation is required.

What is the answer not Oppositional Defiant Disorder (ODD)?

Oppositional Defiant Disorder (ODD) is a pattern of angry/irritable mood, argumentative /defiant behavior, or vindictiveness lasting at least 6 months. ODD does not include aggression towards people or animals, destruction of property, or a pattern of theft or deceit.

Oppositional defiant disorder (ODD) has specific diagnostic criteria in children. Which of the following is a true statement about ODD diagnosis in children? -Oppositionality is common in children at age 2. -Fit between adult caregiver and child is a key feature. -Resistance to multiple authority figures over various issues is not a feature. -Symptoms should represent gradually decreasing conflict around toilet training and dating.

Oppositionality is common in children at age 2, and its presence should not be used to diagnose a disorder.

Review: S/Sx PCP?

PCP causes accelerated heart rate, increased blood pressure, sweating, flushing, numbness, delirium, and a blank stare.

On the previous question, how would PCP intoxication present as?

PCP intoxication involves paranoia, hallucinations, aggression, violence. Nystagmus, dissociative symptoms, anxiety, tremor, numbness, memory loss, analgesia, psychosis, slurred speech, poor coordination.

A 17-year-old thin-appearing female with a history of major depressive disorder presents with increased fatigue. The patient states that while she normally runs and exercises after each meal until she has burnt off the number of calories she just ate, she has been feeling more tired during these workouts and is having difficulty completing them. The patient's motivation is still high to complete these workouts to avoid becoming overweight, so she makes herself do them. She states that she felt similarly during prior depressive episodes and thinks sertraline is no longer controlling her symptoms. The patient also notes that she has begun to feel "ugly" due to the appearance of thin soft hairs on her back and arms. She is concerned because her stress has become so severe she has stopped menstruating recently. What part of the patient's presentation is a relative contraindication to augmenting her depression treatment with bupropion? -Bupropion should never be used with sertraline; this combination can induce tyramine crisis. -Patient is at increased risk for seizures. -Patient is too young to be treated safely with bupropion. -If sertraline was ineffective, bupropion will also be ineffective.

Patient is at increased risk for seizures. The patient is demonstrating signs concerning for anorexia, as indicated by excessive exercise, lanugo, and amenorrhea. Patients with eating disorders are at increased risk for seizures, and bupropion further lowers a patient's seizure threshold. Using bupropion in a patient with an eating disorder is relatively contraindicated. Bupropion is not contraindicated for use in children, but like most other psychiatric medications, it may require closer monitoring and slower titration. Patients often respond differently to different medications, even if they are in the same class (i.e. patients who fail an SSRI may find success with another SSRI). This is often true if switching classes. If a patient fails sertraline, an SSRI, then trialing bupropion, an NDRI, is a reasonable next step

How long, at minimum, should patients with eating disorders be observed after meals? 15 minutes 30 minutes 1 hour 2 hours

Patients should be observed for a minimum of 2 hours after eating, even if this requires attendants to follow them to the bathroom. The primary purpose of the observation is to prevent purging of the meal.

How do opioids withdrawal may present as?

Piloerection, lacrimation and rhinorrhea, pain in joints and muscles, dysphoria, diarrhea, nausea, vomiting, dilated pupils, insomnia, autonomic hyperactivity, yawning.

A 17-year-old girl presents with abdominal pain to the ED. Her abdominal pain comes and goes and often is present when she lies down. She often feels full after eating only a few bites of a meal. The patient is thin and worries about being "too thin" but can't seem to eat much before she feels like she "just can't eat any more." On physical exam, she has some patches of thinner hair over her scalp. She admits to recent stress, stating that she and her boyfriend have been "going through a rough patch" but that she thinks he'll be back. The patient's abdomen is soft and non-tender, and the rest of the exam is benign. Near the end of the appointment, she is chewing on her hair. What test would be most appropriate to confirm the suspected diagnosis if all these findings are related? -Complete blood count -Complete metabolic panel -Plain film of abdomen -Plain film of chest

Plain film of abdomen. The primary objective at this time is to rule out a bezoar as the cause of her symptoms. The alopecia, hair chewing, and abdominal pain are concerning for this diagnosis. A CBC would be appropriate if this were a purely infectious process, however it would not confirm nor rule out a bezoar. A plain film of chest may be appropriate later in the investigation. These would not confirm or rule out a bezoar, but would be helpful to evaluate for other pathology.

What is positive punishment?

Positive punishment is the addition of an undesirable stimulus to reduce a specific behavior.

What is positive reinforcement?

Positive reinforcement is the addition of a desirable stimulus to increase a specific behavior.

In most states, a 17-year-old can sign consent without parental consent for certain health care and procedures. Of the following, which can a 17-year-old sign consent without parental consent for: -Tubal ligation for contraception -Prenatal care -School physical -Abortion

Prenatal care. In most states, a child of 17 does NOT have to have parental consent for any pregnancy-related care. A. In most states, a child of 17 does NOT have to have parental consent for contraception, but permanent surgical contraception is an exception to this. C. In most states, a child under the age of 18 must have parental consent for a school physical. The NP must know the laws that govern consent for treatment in the state where they practice. D. While 17-year-olds don't need parental consent for pregnancy-related care in most states, most states do parental involvement in a minor's decision to have an abortion

A teenage girl is smoking cigarettes. She is willing to quit and has a multistep plan to quit. This patient is most likely in which stage of change? Maintenance Precontemplation Contemplation Preparation

Preparation In preparation, the patient is willing to quit and is making a plan to quit but is not yet actively trying to quit.

What is primary prevention?

Primary prevention keeps a disease from occurring by removing its causes. Primary prevention includes counseling about lifestyle changes like drinking and smoking, immunizations, and suicide prevention programs.

In March of 2015, the CDC Advisory Committee on Immunization Practices (ACIP) issued new recommendations for human papillomavirus (HPV) vaccination. The new recommendation includes vaccination for men who have sex with men and immunocompromised men (including those with HIV infection) through age 26 years if not previously vaccinated. This recommendation is a:

Primary prevention strategy Preventive medicine includes primary, secondary, and tertiary preventive measures such as counseling, immunization, prophylaxis, and screening. Primary preventive strategies are designed to prevent the onset of the targeted disease or condition. These measures include smoking cessation to reduce the incidence of lung cancer, immunization, and prophylaxis.

What is the prognosis for an adolescent with adjustment disorder once the stressor has terminated, and how does this differ from an adult with adjustment disorder. -Prognosis is more favorable for adolescents, as they can bounce back more quickly. Overall prognosis is good for both adults and adolescents. -Prognosis of adolescents is more guarded than of adults, as adolescents diagnosed with adjustment disorder are more likely to develop a major psychiatric illness than adults with adjustment disorder. -Prognosis for adolescents is poor, and they frequently develop depression and other major psychiatric illnesses. Adults fare slightly better, but their prognosis is similarly guarded. -Prognosis for adolescents with adjustment disorder (once the stressor has terminated) is guarded. Those who have subtypes of adjustment disorder associated with depression tend to develop the most problems. Prognosis is similar for adults.

Prognosis of adolescents is more guarded than of adults, as adolescents diagnosed with adjustment disorder are more likely to develop a major psychiatric illness than adults with adjustment disorder. The prognosis for adolescents is less favorable than adults. Adolescents are more likely to develop major psychiatric morbidity. The prognosis for adults with adjustment disorder is good once the stressor is terminated (or the consequences of the stressor). The prognosis for adolescents is less favorable, as they are more likely to develop major psychiatric morbidity.

What is rationalization?

Rationalization is the use of false logic to convince oneself that no wrong has been done.

A 16-year-old male expresses resentment about having to care for his young child to his therapist. When the patient is with friends, he consistently reports how wonderful it is to be a father and that he is proud to be a good provider, and he spends much of his time planning special outings and activities for his son. He also volunteers to chaperone his son's preschool (daycare) class trips every week. Which defense mechanism describes this behavior? Identification Reaction formation Repression Displacement

Reaction formation. Reaction-formation involves the conversion of unconscious wishes into their opposites. The behavior is the opposite of what one really desires or feels.

A cohort study is designed to examine the development of major depressive disorder in the children of divorced parents versus those with married parents. Which outcome measure is appropriate for this study design? Odds ratio Relative risk Event rate Hazard ratio

Relative risk Relative risk (RR) expresses the probability of an event occurring when comparing an exposed and a non-exposed group and is calculated by dividing the probability of the outcome of interest in the exposed group by the probability of the outcome of interest in the unexposed group. RR is used in randomized control trials and cohort studies

What is relative risk?

Relative risk is the probabilty of an outcome of interest in an exposed or treated group divided by the probability of an outcome of interest in the unexposed or untreated group.

Review: What is Repression?

Repression involves avoiding pleasurable instincts or drives due to the threat of suffering if the drive is satisfied

Sarah is a 19 year old female who was involved in a motor vehicle accident when she was 15 that resulted in a traumatic brain injury. After a long hospitalization and intense rehabilitation, Sarah is now in a setting that includes psycho-education around symptom management and medications, assistance with vocational training and training for activities of daily living. Which of the following is best described as the setting where Sarah lives? -Crisis Intervention Unit -Residential Facility -Community-Based Care -Assertive Community Treatment Model

Residential Facility. A residential facility provides care for patients over a 24 hour period. Services in typical residential treatment facilities include psycho-education around symptom management and medications, assistance with vocational training, and, in the case of severely and persistently mentally ill, may include training for activities of daily living. Rehabilitation is often a goal for residential treatment facilities.

An 17-year old-female patient is intellectually disabled. Her mother brings her to your clinic and demands Norplant contraceptives be placed. The patient refuses. Which of the following should you do in this situation? -Implant the Norplant with the mother's consent -Respect the patient's wishes -Obtain a court order -Call child/adult protective services

Respect the patient's wishes. Explain the risks and benefits of long-acting contraceptives and the risks of engaging in unprotected sex. If the patient still declines the contraceptive, her wishes should be respected. There are several areas in which minors have rights to treatment or to refuse treatment. These areas include contraception, abortion, prenatal care, drug, alcohol, and mental health services. Intellectual disability and other limitations of decision making capacity, are not an absolute indication to deny the patient her reproductive rights, particularly when there is no substantial evidence to suggest that harm will come to the patient or to her child.

An adolescent presenting with major depression is being considered for ECT. How should their physician evaluate the possibility of using ECT for this patient (in other words, which of the following is true of ECT use for treating depression in adolescents)? -ECT is not recommended for adolescents. -ECT is only recommended for adolescents with psychotic or bipolar disorders. -Response to ECT is better for depressed adolescents than adults. -Response to ECT is similar in adolescents and adults

Response to ECT is similar in adolescents and adults. There have been few reports and literature reviews on the effectiveness of ECT in depressed and bipolar youth. The occurrence of side effects was similar to psychopharmacology, although memory impairment was much greater in patients who received ECT. Both indications and responses to treatment appear similar in adolescents and adults. ECT should be considered for a depressed adolescent who does not respond to conventional treatments and who remains completely dysfunctional or suicidal or who has a family history of depression and has not responded to any other treatment modality but ECT. Before ECT is used, 2 child and adolescent psychiatrists who are not the primary caregivers for the adolescent should be consulted and should agree that ECT is indicated.

What is Rocky Mountain spotted fever?

Rocky Mountain spotted fever is a tick-bourne illness caused by the bacteria Rickettsia rickettsii. The rash associated with this disease is a blanching erythematous rash with macules that with time become petechial.

An 18-year-old male with no prior psychiatric history has been increasingly socially isolated over the past 3 months. Although he had been a good student with many friends throughout high school, he dropped out of school in the spring of his senior year. Over the past 2 months, his family members report that he has started talking to himself and has yelled at them to stop talking to him when no one was actually speaking. Over this same time period, he has been increasingly concerned that aliens are living in his head. Urine toxicology and standard medical workup for secondary causes of psychosis are negative. The patient does not have any changes in his mood. What is the correct DSM-V diagnosis for this patient, with appropriate specifiers? Psychotic disorder not otherwise specified Schizophrenia, first episode, currently in acute episode Schizophreniform disorder with good prognostic features, provisional Brief psychotic disorder without marked stressor

Schizophreniform disorder with good prognostic features, provisional This patient has had a duration of symptoms of hallucinations and paranoia for >1 month but <6 months. Even though some change in functioning started 4 months ago, symptoms consistent with a psychotic disorder did not appear until the past 3 months. This symptom pattern and the duration of symptoms are consistent with schizophreniform disorder. The diagnosis is provisional since it is made before recovery. Since the symptoms did not develop rapidly within 1 month of the first sign of disturbance, the full range of affect and presence of confusion or perplexity constitute 2 positive prognostic factors to meet the "with good prognostic features" specifier. Psychotic disorder NOS is not likely since the presentation better meets the criteria for schizophreniform disorder and since NOS diagnoses are not included in DSM-V.

What is a secondary prevention strategy?

Secondary preventive strategies identify and treat asymptomatic individuals with certain risk factors or in whom the condition is not clinically apparent. These include screening tests that can result in early diagnosis and treatment to alter the course of a disease to improve patient well-being and minimize suffering.

A pediatrician provides a CRAFFT test to screen an adolescent for high-risk alcohol and drug disorders. Which kind of prevention does this represent? -Primary -Secondary -Tertiary

Secondary. The CRAFFT test is a short, self-administered behavioral-health tool developed to screen adolescents for high-risk alcohol and other drug-use disorders simultaneously. Secondary prevention detects diseases early when patients are asymptomatic and address treatment to halt its progression. Examples include HIV testing, screening for nutrition and exercise, depression screening for at-risk teens, urine drug testing, or identifying prodromal schizophrenia. CRAFFT screening is a form of secondary prevention.

Review:: Why is it not Schizoprenia?

Serotonin is an amino acid that helps regulate blood pressure, not a condition

A 16-year-old girl attended a rave with her friends. She now presents with hypertension and hyperthermia, and clinical examination indicates brisk reflexes. Her presentation is consistent with which of the following conditions? Neuroleptic malignant syndrome Serotonin syndrome Schizophrenia Alcohol withdrawal

Serotonin syndrome This patient's symptoms indicate serotonin syndrome, which is characterized by brisk reflexes. NMS is characterized by rigidity. She likely used MDMA (ecstasy) at the party, which resulted in serotonin syndrome. This is a known risk of intoxication with MDMA because the mechanism of action involves the release of serotonin.

What are side effects of opioids?

Side effects of opioids include: drowsiness, dizziness, confusion, headache and sedation.

A 14-year-old boy is noted by his teachers to struggle significantly in schoolwork that requires reading. Assessments indicate that he reads below the 10th percentile for his age. The patient's IQ is 100. What is the most likely diagnosis? Specific learning disorder Mild intellectual disability ADHD Vision problems

Specific learning disorder Specific learning disorder is a DSM-5 diagnosis that combines the DSM-IV diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified. Specific learning disorder in the DSM-5 is defined as a "neurodevelopmental disorder of biological origin manifested in learning difficulty and problems in acquiring academic skills markedly below age level and manifested in the early school years, lasting for at least 6 months, that is not attributed to intellectual disabilities, developmental disorders, or neurological or motor disorders." It can be specified as with impairment in reading, with impairment in written expression, or with impairment in mathematics. The severity may be mild, moderate, or severe. This IQ is too high for mild intellectual disability (IQ range 52-69) There's no indication the student doesn't pay attention in class, so ADHD doesn't seem right There's no mention of eyesight problems.

What is splitting?

Splitting is a defense that is created by the failure of an individual to unite the positive and negative attributes of self and others into a realistic whole (also known as all-or-none thinking).

A 17-year-old male presents to the psychiatric emergency room accompanied by the police due to public intoxication. During the interview, he admits to using several illicit substances but insists that the only drug he uses habitually is marijuana. He states that he studies for school while high and "has to take his tests that way too." Which of the following may underlie this patient's belief? Placebo effect Habituation State-dependent learning Higher consciousness

State-dependent learning. State-dependent learning assumes that both learning and memory recall occur most effectively under the same circumstances. This well-known phenomenon applies both to external states (the learning environment) and internal environments (intoxication).

What are the first-line meds for ADHD in children?

Stimulant medications are the first-line psychopharmacological management for children with ADHD. Eight of 10 children started on a stimulant medication will demonstrate an improvement in focus and a decrease in impulsive behavior. Methylphenidate is a stimulant and enhances central nervous system catecholamine action by increasing the availability of dopamine and norepinephrine in the synaptic cleft in the brain. Stimulants are available in short-acting and long-acting preparations. The onset of action occurs in about 30 minutes. If stimulant medications are stopped, children will not experience withdrawal and are unlike to become addicted. Treating children with ADHD with stimulants actually decreases the risk of drug abuse later in life.

How do inhalants intoxication may present as?

Stimulation, loss of inhibition, headache, Nausea/vomiting, slurred speech, poor motor coordination.

What is sublimation?

Sublimation is the transformation of negative emotions into a more positive emotion or behavior.

Which of the following is a risk factor for child/adolescent suicide? -Heterosexual -Substance abuse -Living with multiple family members -Low IQ

Substance abuse. Risk factors for child/adolescent suicide include substance use, exposure to violence, previous suicide attempts, immediate family member who completed suicide, previous psychiatric hospitalizations, recent losses, social isolation, bullying, access to guns, lower socioeconomic status, current psychiatric disorder, prior suicide attempts, age >16, male gender, and gay/lesbian/bisexual individuals.

How do sedative hypnotics (alcohol and benzodiazepines) withdrawal may present as?

Sweating, flushed face, insomnia, hallucinations, seizure, disorientation Major: hallucinations, profound disorientation, tremors, increased autonomic activity.

What is tertiary prevention?

Tertiary prevention is defined as activities that prevent the deterioration or reduce complications after a disease is already present. Examples include metabolic monitoring of patients on antipsychotics, use of assertive community treatment with schizophrenics, and intensive case management.

What is a tertiary prevention strategy?

Tertiary prevention refers to the management of an existing disease with the goals of restoration of function, minimization of negative consequences of disease, and prevention of disease-related complications.

What is odds ratio?

The odds ratio, which compares the odds of an outcome of interest in the group exposed to a risk factor to the odds of that outcome in the unexposed group, is used to describe results in case-control studies. The odds ratio is frequently used in retrospective studies while the relative risk is often prospective, however, the two tests can be used in either prospective or retrospective studies. The odds ratio approximates relative risk, but in rare diseases, the odds ratio and relative risk may be equivalent.

A 2-year-old girl with 21-hydroxylase deficiency undergoes genitoplasty. Which statement is true concerning her condition? -Her penis has been feminized in utero. -She has a lower-than-average chance of homosexual orientation. -There is a correlation between virilization degree and gender dysphoria. -Adequate hormone replacement therapy prevents gender identity disorder

There is a correlation between virilization degree and gender dysphoria. The degree of virilization (graded on the Prader scale) is correlated with the development of gender dysphoria and homosexuality. Incorrect A. Females with congenital adrenal hyperplasia (CAH) have a virilized clitoris. Boys with classic CAH have normal-appearing genitalia. B. A higher rate of homosexuality has been reported in individuals with CAH, which correlates with the degree of virilization. D. Successful HRT, while helpful, does not eliminate psychological issues with gender in intersex patients such as females with CAH.

Why obtaining a court order or reporting parental refusing are not good choices?

This case is a good example of the difference between "immediate threat to life and limb" and a refusal of maintenance therapy to prevent seizures at some distant point in the future. A similar case would be maintenance treatment for hypertension and treatment for an intracranial hemorrhage that results from failure to comply with therapy. There must be an immediately compelling reason to override the wishes of the patient and/or the patient's parent or surrogate decision-maker.

A psychiatrist decides to publish a parenting book and includes several "case studies" of patients who he helped with his unique treatment techniques. He wants to feature some of these patients and their parents on a talk show to discuss how the therapies worked for them. Travel, hotel, and food expenses are completely paid for by the talk show. What would be the recommendation based on APA's ethics resources in this situation? As long as willing consent is given by the child, there is no problem. As long as the physician is not paying patients' travel expenses and they give consent, there is no problem. As long as the parents give consent for the minor, there is no problem. This is not considered ethical by the APA, even if consent was willingly given.

This is not considered ethical by the APA, even if consent was willingly given. This would not be considered ethical. First, having former patients participate like this would be a deviation from the initial treatment plan that was agreed upon with them. More importantly, even if they give willing consent, their decision will be strongly influenced by a desire to "please" their physician and their transference feelings. A financial reward (free travel and expenses), even if not paid for by the physician, is still for the physician's benefit and is also considered unethical and an exploitation of a patient for personal gain.

A 20-year-old male college sophomore presents because his parents told him that they will not pay for his tuition if his grades don't improve. They also are concerned about his drinking. For the past year, the patient has had an escalating pattern of drinking alcohol, requiring greater amounts to achieve the same "buzz." He has been drinking about a case of beer each weekend and at least a 6 pack of beer on weeknights, even when he resolves to drink less on a given night. During this period, he has developed significant academic difficulty; he rarely attends early morning classes due to being "hungover" most days. The patient tried to avoid drinking at all on weeknights but has been unsuccessful. He sometimes starts to have tremors in his hands on occasional days when he does not drink. The tremors are improved after drinking a few beers. What is the most appropriate DSM-5 diagnosis? Alcohol use disorder, moderate Alcohol dependence Binge drinking disorder Alcohol use disorder, severe

This patient has severe alcohol use disorder. Severity specifiers are determined by the number of substance use disorder criteria that are met; at least 6 criteria are required for a "severe" disorder.

Regarding the orevious question, why is it not Generativity vs. Self-absorption or stagnation?

This stage involves establishing careers and families. John is too young for this stage (which should be ages 40-65).

Regarding the previous question, why is it not Industry vs. Inferiority?

This stage involves learning to read and create.. Presumably, John is beyond this stage (which should be ages 5-12).

Regarding the previous question, why is it not Intimacy vs. Isolation?

This stage is about seeking intimacy to avoid feeling isolated. John is too young for this stage (which should be ages 18-40).

A 12-year-old girl is evaluated in the ED and is diagnosed with bacterial meningitis. Her parents are divorced. Her mother, who has sole custody, refuses treatment. Which of the following is the best course of action in this case? -Seek a court order for treatment. -Respect the mother's wishes but admit the child for observation and isolation. -Treat the patient without regard for the mother's wishes. -Do not treat the patient unless consent is obtained from her father.

Treat the patient without regard for the mother's wishes. If there is a clear and imminent danger to the life of a child with a risk of death as a result of a delay in treatment, the healthcare provider can proceed with treatment without judicial review against the wishes of the custodial parent. After a divorce, only the parent with custody of the child is able to consent to treatment. The healthcare provider's decision should be based on the best interest of the patient; if treatment is required urgently, the healthcare provider can proceed.

What is Trisonomy 18?

Trisomy 18. Edwards (Trisomy 18) features include intellectual disability, micrognathia, rocker bottom feet, clenched fists with overlapping fingers, congenital heart defects and typically die within one year of life.

A 13-year-old boy is brought to the emergency room by his parents. They found him alone in his room, naked and unconscious, about an hour ago. They were unable to wake him, but he woke up in the car 15 minutes later, wondering what was going on. They live about an hour away from the hospital. A urine toxicology screen is negative, but the parents report finding bottles of "liquid incense" all around the room. They have brought a bottle with them. The father pulls you aside and says that it looked like the boy was masturbating and that he thinks his wife is blowing this out of proportion. The patient's mother says that she feels like her son has been "different" for the last couple weeks. On physical exam, the boy looks tired. Neurological exam, ECG, EEG, and CT scan are normal. Given the negative toxicology results, what is the most likely diagnosis? -Onanism with subsequent deep sleep -Normal experimentation with self-stimulation -Unconsciousness due to nitrite intoxication -Likely seizure with short post-ictal state

Unconsciousness due to nitrite intoxication. Nitrites (present in liquid incense) would not show on the toxicology screen, and are drugs of abuse, particularly in this population. They are used to heighten sexual pleasure. In nitrite poisoning can see nausea, vomiting, dizziness, cyanosis, hypotension, tachycardia and loss of consciousness. The nitrites cause methemoglobinemia and can use methylene blue as treatment to reverse the methemoglobinemia and restore hemoglobin.

A 15-year-old male is referred for evaluation. The consultation request from his primary care doctor indicates that the patient has become socially withdrawn and has been having auditory hallucinations. On examination, you note a scar on the child's lip from a previous cleft lip and palate surgery, as well as micrognathia and microcephaly. What underlying diagnosis do you suspect? -Down syndrome -Trisomy 18 -Fragile X -Velocardiofacial syndrome

Velocardiofacial syndrome. This patient likely has velocardiofacial syndrome (VCFS) (22q11.2 deletion syndrome, related to DiGeorge syndrome). The mnemonic "CATCH-22" is used: Cardiac abnormality (especially tetralogy of Fallot), Abnormal facies (microcephaly, micrognathia), Thymic aplasia, Cleft palate, and Hypocalcemia/Hypoparathyroidism. Psychiatric illnesses are common late-occurring features in these patients. VCFS is associated with a high rate of psychiatric disorders in childhood. Adults with DiGeorge syndrome are at a high risk for developing schizophrenia. About 30% have at least 1 incident of psychosis, and about 25% develop schizophrenia.

What is it not Comorbid personality disorder?

While a personality disorder may be present, there is no evidence that it caused the event.

In the previous question, what would be higher consciousness?

While some may feel that intoxication with various substances may allow users to reach a state of higher consciousness, this phenomenon has no relationship with learning and memory recall.

While working in a rural part of South Dakota, you receive a subpoena from a judge regarding your treatment of a 13-year-old male with a history of neglect and sexual abuse. After consulting an attorney, it is understood that you are being called as a fact witness. What is the definition of a fact witness? -Witness with specialized knowledge who assists a court in deciding a case -Witness who has knowledge about details of a case -Witness whose focus is to fulfill the basic and developmental needs of the child Witness whose information is not allowed in open court

Witness who has knowledge about details of a case A fact witness's testimony consists of facts or events as opposed to an expert witness, whose testimony consists of the presentation of an opinion or a diagnosis. A. An expert witness has specialized knowledge and assists a court in making a decision in a case. C. The focus of the best interests of the child standard is to fulfill the basic and developmental needs of the child. D. Privilege is the legal rule that protects certain information from being shared in open court. The individual possesses privilege, not the physician.

Are Olanzapine and quetiapine are more sedating than risperidone?

Yes. Olanzapine and quetiapine are more sedating than risperidone. Sedation can be managed by lowering the dosage.

You are speaking to a parent in regards to a potential treatment such as ECT for their 17-year-old child, whom has severe depression. He has failed multiple treatment options and therapies. While discussing a new treatment it is important to discuss informed consent. Due to it being imperative that certain information is provided, which is the most accepted standard for information disclosure that must be present? -You may refuse treatment, education, and/or treatment alternatives. -Review diagnosis, treatments, and consequences of treatment, also review any alternatives, and prognosis. -All possible outcomes, all black box warnings, risk versus benefits, prognosis. -Alternatives, prognosis, education, possible outcomes.

You may refuse treatment, education, and/or treatment alternatives. No consistent accepted standards for information disclosure for any medical or psychiatric treatments, therefore, a rule of thumb, is covering these three areas. The other answers are very important things to review although they are not the "rule of thumb" used by other providers for information disclosure about the treatment.

How do MDMA methyllenedioxy-methamphetamine) intoxication may present as?

mild hallucinogen effects, increased tactile sensitivity, empathetic feelings, lowered inhibition, anxiety, chills, sweating, teeth clenching, muscle cramping, sleep disturbances.

A 19-year-old male presents with facial numbness and bilateral vision loss. He reports tingling, cold feet with a bluish discoloration. His symptoms most likely resulted from inhalation of which substance? -Elemental mercury -n-Hexane -Acrylamide -Carbon disulfide

n-Hexane n-Hexane exposure is most commonly due to recreational inhalation of household glues. n-Hexane is metabolized to 2, 5-hexanedione, which has neurotoxic effects. These effects are potentiated by methyl ethyl ketone, which may also be contained in adhesives. Acute exposure leads to CNS depression. Repeated glue inhalation may cause "glue-sniffer neuropathy," a progressive, symmetric, ascending, sensorimotor, peripheral axonopathy. Motor symptoms may be predominant and similar in presentation to Guillain-Barré syndrome. The neuropathy may be associated with autonomic dysfunction, including bluish discoloration and decreased temperature of the involved extremities. This neuropathy has been referred to as a "central-peripheral-distal axonopathy," as it may also have central effects and lead to spasticity. Other symptoms may include facial numbness, maculopathy, and optic neuropathy. Coasting may occur when symptoms continue to worsen for some period of time following the cessation of exposure.