PSYCH EOR ROSH

A 23-year-old man presents to your office to request mental health treatment. He has a family history of schizophrenia and is concerned because he has been hearing voices telling him to do things. Which of the following is most likely to be found on the mental status exam?

Flat affect

Which of the following laboratory abnormalities would most likely be seen in a patient with severe anorexia nervosa?

Increased total cholesterol Total cholesterol may be increased due to increased production of cardioprotective high-density lipoprotein without an increase in low-density lipoproteins

Which of the following best distinguishes somatic symptom disorder from illness anxiety disorder?

Intensity of somatic symptoms

Which of the following developmental delays is consistent with an early sign of autism spectrum disorder?

Lack of orientation to name by 12 months

What are the components of the "female athlete triad"?

Low bone density, menstrual dysfunction, low energy availability

A 30-year-old man presents to a therapist at the request of his family. He values organization but states that he struggles to get work done because he spends four hours organizing his desk daily. His wife states that it takes him six hours to clean the kitchen at home because it must be done perfectly. These struggles have been occurring for 10 years and have led to occupational and relational distress. Which of the following is the most likely diagnosis?

Obsessive-compulsive personality disorder

A 30-year-old woman presents to the clinic with recurrent episodes of chest pain, sweating, dyspnea, and palpitations that often occur abruptly. She has previously had similar episodes, with the most recent being approximately two months ago. She reports a persistent concern about having additional episodes and has started to avoid exercising for fear of dying from a heart attack. On physical exam, she is noted to be tachycardic. ECG reveals sinus tachycardia with a normal axis and no acute ST-T abnormality. Laboratory studies are within normal limits. Which of the following is the most likely diagnosis?

Panic disorder

Which instrument is used to monitor changes in the severity of panic disorder?

Panic disorder severity scale

What is required before initiation of quetiapine?

Slit lamp exam

Which of the following structural changes can be seen in the brains of individuals diagnosed with long-standing and untreated depression?

Smaller hippocampal volume

A 14-year-old boy is brought to the ED from school after his teacher found him having difficulty breathing. The patient has a perioral rash, and his breath has a remarkable glue-like odor. Dizziness, tremor, and unsteady gait are observed. Inhalation of glue most commonly results in which of the following effects in the body?

Vasodilation Although the initial and desired effect of usage of inhalants is euphoria, their most common adverse effect is CNS depression.

A 55-year-old man with a history of alcohol use disorder presents to the emergency department by ambulance with confusion. He is very thin and appears malnourished. He is oriented to self only. On physical exam, he has sluggish pupillary reflexes and nystagmus, and he is unable to walk by himself without falling. He is given an intravenous dose of thiamine, and his confusion improves rapidly. Which of the following is the most likely diagnosis?

Wernicke encephalopathy

A woman presents to the clinic with her husband. He states she has not slept in two days and has been preoccupied with politics, stating she could easily be the next president. During examination, the patient's speech seems rushed and she jumps from one idea to another quickly without coherence. After control of this acute episode, which of the following serum concentrations of the first-line maintenance medication indicates appropriate dosing?

1.0 mEq/L lithium

A 33-year-old woman presents to her primary care provider to discuss the possibility of artificial insemination. She mentions her loss of sexual drive is causing conflict with her wife of 5 years, and she has been worrying about what this means for their family plans. She has been taking fluoxetine 80 mg ever since a major depressive episode 3 years ago and "feels stable." She scored a 9 on a self-administered Patient Health Questionnaire-9 today. She takes no other medications. Her gynecological history is G1P0010 with a voluntary termination of pregnancy in her 20s. She reports no partner violence or abuse, findings on gynecological exam are normal, and there are no marks on her body. What is the best next step in the treatment of this patient?

Addnbuproprion to fluoxetine

A 35-year-old woman presents to the psychiatric clinic complaining of increased stress. She denies marital difficulties, emotional difficulties and compulsive behaviors, but states that people around her seem to have no regard for the "rules". Co-workers do not follow procedures, her children do not perform their chores in proper order, and other drivers on the road do not strictly obey traffic laws as she does. This "lack of order" causes her great stress. Which of the following is the next best step in treatment of this patient's condition?

Administer the Working Alliance Inventory Psychotherapy is often beneficial for OCD, and assessing the therapist-patient relationship using a tool such as the Working Alliance Inventory is helpful while initiating and during treatment. The Working Alliance Inventory contains 36 (long form) or 12 (short form) self-reported items that both the healthcare provider and the patient use to determine goals for therapy and level of therapist-patient bond.

A mother completes the Modified Checklist for Autism in Toddlers during her son's 18-month well visit. The questionnaire is subsequently reviewed by the clinician with a score of 3. Which of the following is the best next step?

Administration of the second stage Parents of children identified as having a moderate risk of autism spectrum disorder (i.e., score of 3-7) require administration of the second stage of this questionnaire to determine whether referral and early intervention are necessary.

A 44-year-old woman presents to the clinic with concerns for parasites. She states that she has noticed parasites in her skin for the last six months. She has seen dermatologists and had skin biopsies that have been negative but is insistent that they pop up out of her skin and then burrow down in before she can catch one. She is otherwise healthy and has never had this problem in the past. She is upset because the dermatologists have not diagnosed her. Physical exam is benign. Which of the following medications would be best for this patient, considering the most likely diagnosis?

Aripiprazole

A 4-year-old boy is brought to the clinic by his father, who is concerned with his pattern of repetitive head banging. He reports that the patient prefers solitary play and exhibits excessive sporadic aggression and irritability. During examination, the patient avoids eye contact and demonstrates hand flapping motions. Which of the following agents is most appropriate?

Aripiprazole Second-generation (atypical) antipsychotics commonly used for irritability, aggression, and self-injurious behaviors include risperidone and aripiprazole.

A 42-year-old patient with a 20 pack-year smoking history was prescribed nicotine patches and ceased smoking one month ago. Which of the following represents appropriate health maintenance for this patient?

Arrange a follow-up visit at three months, and one year to discuss adherence to abstinence

A 23-year-old man presents to the clinic with concerns after losing his job. He states that he has difficulty concentrating at work and performing routine tasks at home. Organization and prioritizing tasks are particularly difficult for him. He notes that he got fired after his supervisor was discussing his job performance with him and he "lost his temper." While he is talking, he seems to fidget in his chair and gets up a few times when emphasizing his point. When asked how long he has had these types of issues, he states that it has been since childhood. He had difficulty in school and with relationships. He also has a history of polysubstance use but has been sober for a few years. Which of the following treatment options would be best at this time, considering his most likely diagnosis?

Atomoxetine First-line treatment is generally with amphetaminesalthough these medications have the potential for abuse. Atomoxetine has little abuse potential and is an optimal choice for patients with a history of substance use.

Which of the following symptoms, if present in a patient more days than not for six months or more, would aid in the diagnosis of generalized anxiety disorder?

Being easily fatigued In addition, three of the following six symptoms must be present more days than not for six months or more: being easily fatigued, sleep disturbances, irritability, muscle tension, restlessness, and difficulty concentrating

A 7-year-old girl presents with a caregiver for concerns about having episodes of seizures and low blood sugar. The child has no documented medical problems and reportedly takes no medications. The child does not speak, appears frail, and is held closely by the caregiver throughout the visit. The caregiver presses you to admit the child to the hospital for an extensive workup. Which of the following is the most common caregiver population in which this disorder is diagnosed?

Biological mothers

Which of the following is one of the mechanisms by which cocaine use affects the body? A. Blocking calcium channels in cardiac tissue B. Blocking the reuptake of biogenic amines C. Decreasing glutamate and aspartate in brain tissue D. Slowing the centrally mediated sympathetic pathway

Blocking the reuptake of biogenic amines

A 30-year-old woman presents to the clinic for follow-up after being hospitalized for anorexia nervosa. She is currently seeing a psychiatrist and nutritional specialist. Which of the following tests represents necessary health maintenance for this patient?

Bone density scan

A 26-year-old woman presents to the office requesting treatment for substance use. She says that she has been injecting heroin daily for the past three years, numerous attempts at quitting on her own have been unsuccessful, and she has never tried any pharmacotherapy to address her symptoms. Which of the following is the most appropriate therapy?

Buprenorphine Buprenorphine is a partial opioid agonist that is combined with naloxone and administered in an outpatient office setting. Buprenorphine has a lower risk of overdose than methadone and is therefore safer for patients and should be offered as first-line pharmacotherapy.

A 34-year-old man presents with cyclic episodes of nausea and vomiting that often resolve spontaneously within 48 hours. Physical exam reveals tachycardia, dry mouth, conjunctival injection, and delayed reaction time. Urine drug screen is positive for delta-9-tetrahydrocannabinol. Which of the following therapies is the most appropriate for this patient?

CBT

A 32-year-old woman presents to her primary care provider with her partner for her annual exam. Her partner informs the clinician that the patient has been overly worried about catching the flu and has been washing her hands over 30 times per day for the last several weeks to the point that her skin has started to peel. In addition, she has become overly worried that someone will break into their home, and she checks every lock exactly five times prior to leaving the home or going to bed. He also reports that they were taking a road trip about 2 weeks ago when the patient made him turn the car around 2 hours into the drive because she needed to check the locks despite reassurance that the doors were locked. Which of the following treatment options is first line for her condition?

CBT Recommended treatment for OCD includes psychotherapy and medications. However, the first-line treatment for OCD is psychotherapy with cognitive behavioral therapy (CBT).

A 28-year-old woman with a medical history of hypertension and bipolar I disorder presents to the emergency department on an involuntary hold. Emergency services were called when the woman was observed yelling at cars from the third lane of a busy highway. During the interview, she develops sharp, nonmigratory chest pain. Vital signs include a heart rate of 100 bpm, blood pressure of 80/50 mm Hg, respiratory rate of 24/minute, oxygen saturation of 96% on room air, and temperature of 98.8°F. Physical exam reveals pupillary dilation, a weak carotid pulse, and a diastolic decrescendo murmur. Urine toxicology is positive for cocaine. Which of the following is required for definitive identification of the suspected diagnosis?

Cardiovascular imaging Cocaine-induced aortic dissection is a rare vascular emergency in which the aortic intima tears following ingestion of cocaine.

A 26-year-old woman presents to a counselor to discuss her difficulty with interpersonal relationships. Her family members state that she becomes attached rapidly but fears abandonment and has frequent conflict over trivial matters. Which of the following additional findings is supportive of the most likely diagnosis?

Chronic feelings of emptiness

A 26-year-old woman has complaints of an intense fear of enclosed spaces, which she says is getting worse over time. She thinks it began when she got locked in a closet by accident as a child. She recently got hired at a new job and is starting to have anxiety about riding in the elevator to the floor where she works and sitting in a small cubicle during work hours. Which of the following is the most appropriate first-line treatment for this patient, considering the most likely diagnosis?

Cognitive behavioral therapy

A 45-year-old woman presents with anxiety. She is anxious about her work and home duties, her marriage, and her children's performance in school. It is difficult for her to control her anxiety and she has felt restless, fatigued, and irritable for the past year. Which of the following is considered most effective for her management?

Cognitive behavioral therapy

A 15-year-old boy presents to the pediatric psychiatry clinic with his mom. His mom states that he recently vandalized his school and killed two of his neighbor's pets. The patient is unapologetic for his actions. Which of the following is the most likely diagnosis?

Conduct disorder

A 7-year-old boy presents for an outpatient evaluation about two weeks before the start of second grade due to parental concerns about hyperactivity interfering with school again this year. His parents report receiving nearly daily calls from the school during his first-grade year due to his behavior distracting the other students. His father reports a history of an excellent response to amphetamine (D,L) during his own teenage years. The boy is physically healthy and has no history of heart murmurs or unexplained fainting spells. His family history is negative for congenital heart defects, dysrhythmias, and sudden deaths in those under the age of 50 years. Which of the following is the best next step?

Consider a medication trial after obtaining parent and teacher forms to assess symptoms

A 20-year-old man presents to your office with depressed mood, insomnia, and low energy for 1 week. He denies changes in appetite or concentration and denies suicidal thoughts. He reports that his depressed mood never lasts longer than 1 week. Further history reveals intermittent and distinct periods of insomnia, and improved mood with increased energy, during which time he starts several home improvement projects. He recalls that these episodes began 2 years ago. They usually occur for 3 days at a time. He denies a history of rapid speech, impulsivity, grandiosity, and psychotic symptoms. He enjoys the periods of increased energy but has grown tired of his depressive symptoms, which occur for several days at a time at least once a month. He has trouble turning in school assignments on time during periods of depression. There is no history of alcohol or illicit drug use. He has no other medical problems. Laboratory results, including complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, free T4, urine drug screen, vitamin B12, and vitamin D, are within normal limits. Which of the following is the most likely diagnosis?

Cyclothymic disorder

A 22-year-old woman presents to the office, reporting periods of depression and mood swings that she has had at least once per month since she was an adolescent. She only recently decided to speak to a medical professional about treatment because it is affecting her ability to work. She states she has episodes of intense sadness and hopelessness that resolve on their own after a few days. Other days, she is excitable and unable to sleep due to racing thoughts and anxiety that last a few days. She is not taking any medications. While taking her history, you notice she is unable to sit still, she has pressured speech, and she is talking excessively. The physical exam is otherwise unremarkable. Which of the following best describes her diagnosis?

Cyclothymic disorder

A 35-year-old man presents believing that something is wrong with his body. He reports being infected with insects that "crawl all over my body." He has been evaluated multiple times for the same complaint, the most recent being approximately two months ago. Physical examination and laboratory studies are unremarkable. A urine drug test is negative. Which of the following is the most likely diagnosis?

Delusional parasitosis

A 21-year-old man with a history of generalized anxiety disorder presents to the clinic with worsening anxiety for 4 months. He is afraid that his neighbors have been spying on him through cracks in the wall. He has not changed clothes or showered for the past month to avoid being filmed nude by his neighbors. Vital signs today include a heart rate of 94 bpm, blood pressure of 126/88 mm Hg, respiratory rate of 22/minute, oxygen saturation of 99% on room air, and temperature of 98.2°F. Physical examination reveals a fast heart rate and regular rhythm, clear lung sounds, and intact cranial nerves. Mental status examination reveals blunted affect, echolalia, circumstantial thought process, and impaired attention. Which of the following qualifies as required diagnostic criteria for the suspected condition? A. Catatonic behavior B. Delusions C. Impaired functioning D. Negative sx

Delusions Dx is schizophreniform - The diagnostic criteria require the presence of two or more psychotic symptoms and one of those symptoms must be either delusions, hallucinations, or disorganized speech.

A 44-year-old man with no significant medical history presents to the clinic with 3 months of detachment. He believes the world is an inherently dangerous place and has found it difficult to feel close to others. He has not bathed or showered to avoid intense anxiety and tearfulness that accompanies his attempts to bathe. He has poor concentration, restless sleep, and a decreased interest in his hobbies. He has not been employed for the past 3 months. He quit his job as an apartment handyman 4 months ago after finding a deceased tenant in the bathtub. Vital signs are a heart rate of 88 bpm, blood pressure of 126/84 mm Hg, respiratory rate of 24/min, oxygen saturation of 99% on room air, and temperature of 98.8°F. Physical examination reveals a regular heart rate and rhythm and clear lung fields. Mental status reveals a blunted affect, linear thought process, and normal cognition. Which of the following symptoms is most consistent with the suspected diagnosis?

Derealization Dx is PTSD

Which of the following provides the best assessment for diagnosing attention deficit hyperactivity disorder in adults?

Diagnostic interview for attention deficit hyperactivity disorder in adults

A 42-year-old woman presents to the emergency department after ingesting "a whole bottle of some random pill" she had in her medicine cabinet. She is agitated, swiping at the air, and screaming about shape-shifters coming towards her. On exam, she is hyperreflexive, hyperthermic, and tachycardic, with mydriasis unresponsive to light, decreased bowel sounds, a distended bladder, and very erythematous, dry skin. Which of the following represents the best treatment for this patient's suspected overdose?

Diazepam Anticholinergic OD

Which of the following is associated with an organic cause of psychosis? A. Auditory hallucinations B. Disorientation C. Normal vital signs D. Slow onset of symptoms

Disorientation Additionally, those with organic psychosis are more likely to have a sudden onset of symptoms, abnormal vital signs or physical examination findings, and social immodesty. In patients over 40 years of age without a prior psychiatric history, an organic cause of psychosis should always be assumed.

A 23-year-old man with no significant medical history presents to the emergency department with his partner after acting abnormally for the past 2 weeks. The patient believes that he was given a solo mission to save the planet from global warming. He quit his job last week to focus on cleaning his neighborhood and spent several thousand dollars on various tools. On mental status exam, the patient is extremely talkative and states that he feels like his thoughts are racing. Which of the following additional symptoms is this patient most likely experiencing? A. Anhedonia B. Distractibility C. Insomnia D. Psychomotor slowing

Distractibility A diagnosis of bipolar I disorder requires the presence of at least 1 manic episode, which is defined as a distinct period of abnormal, persistently elevated, expansive, or irritable mood that is present for most of the day and lasts at least 1 week. Additionally, the patient must also experience at least three of the following additional symptoms (or four if the mood is irritable): grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal-directed behavior, or excessive involvement in activities that have a high potential for painful consequences

A 35-year-old woman was recently diagnosed with tobacco use disorder and is being treated with bupropion. The drug acts by inhibiting which of the following processes?

Dopamine and norepinephrine reuptake

A 35-year-old woman presents to her primary care office with a 3-month history of dull headaches, insomnia, and irritability. She has difficulty concentrating and says she is disinterested in her favorite activities. She states she has been having nightmares and frequent flashbacks of her time overseas. The patient recently left the military and is currently employed as a nurse at a local hospital. What important historical feature has she provided that distinguishes her symptoms as post-traumatic stress disorder rather than acute stress disorder?

Duration Acute stress disorder is characterized as occurring and resolving within 1 month after a traumatic event whereas post-traumatic stress disorder typically occurs anywhere from a few months to 6 months from the time of an event and lasts for many years.

A man is brought to the emergency department following a suicide attempt. He has a medical history of bipolar I disorder and expresses persistent suicidal ideation with current specified plans and intent. Psychiatry is consulted as a result. Which of the following recommendations would be most effective for his current presentation?

Electroconvulsive therapy

A 32-year-old woman with no significant medical history and a recent diagnosis of schizophrenia presents to the clinic for a follow-up appointment. She has been taking her medication as prescribed for the past 3 months and has not been experiencing hallucinations or delusions. Vital signs include a heart rate of 65 bpm, blood pressure of 125/78 mm Hg, respiratory rate of 16/minute, oxygen saturation of 98% on room air, and temperature of 98.7°F. Which of the following laboratory values should be monitored in this patient?

Fasting glucose Second-generation antipsychotics can still have side effects and require laboratory monitoring. Weight gain, glucose abnormalities, and dyslipidemia are all potential side effects of these medications. Therefore, it is important to monitorweight, waist circumference, blood pressure, fasting plasma glucose, and fasting lipid panels while patients are on these medications.

A 27-year-old man is being evaluated for pervasive preoccupation with perfectionism, orderliness, and inflexibility. He is excessively obsessed with work and productivity and has no "time for leisure activities or friends." As a supervisor, he tends to control minute details of every project and rejects assistance from co-workers despite being behind schedule. He rarely spends money, believing that money should be saved for future disasters. In addition to psychotherapy, which of the following is the most appropriate therapy?

Fluoxetine

A 28-year-old woman presents with concerns over abnormal behaviors. She states that she constantly feels the urge to move things into better order, or reorganize objects, and does so until the feeling eases. She states that this has gone on for a few years and seems to be worsening. She now spends a significant amount of time rearranging objects in her house, specifically worrying about if objects are symmetrical and balanced. Which of the following medications would be best for this patient, considering the most likely diagnosis?

Fluvoxamine

Which of the following neurotransmitters mediate symptoms of generalized anxiety disorder?

Gamma-aminobutyric acid

A 52-year-old woman presents to the clinic with symptoms of depression for the past year. She reports no alcohol or drug use and is on no daily medications. She appears disheveled and smells of alcohol. The physical exam reveals multiple spider angiomata scattered over her torso, multiple bruises in various stages of healing, and hepatomegaly. Which of the following laboratory studies would be most informative in the workup of this woman's suspected diagnosis?

Gamma-glutamyltransferase Elevated GGT is indicative of excessive alcohol consumption.

Which of the following is the predominant mechanism underlying attention-deficit/hyperactivity disorder?

Genetic predisposition

A previously healthy 28-year-old man presents to the clinic for his annual exam. Social history reveals that he has never had a job and has been incarcerated multiple times due to assault. He expresses no remorse for his past legal involvement. Which of the following is the most appropriate laboratory test for this patient?

HIV Because of poor impulse control in individuals with personality disorders, screening for sexually transmitted infections, including human immunodeficiency virus, is recommended.

A 49-year-old neuroscientist comes to your office. He states that he smokes marijuana once per month. He says that he uses marijuana to relax and finds that it helps relieve the stress that he experiences from writing grant applications. Given the relevance to his profession, he asks about the specific neurobiological effects of the substance. Which of the following brain regions contains the most cannabinoid receptors in the brain?

Hippocampus

A 26-year-old woman presents to the clinic complaining of lethargy, irregular menses, and abdominal pain with bloating. Physical examination reveals sialadenitis and abrasions on the dorsal aspect of the right hand and fingers. She denies use of medications or supplements. Which of the following is most likely found on laboratory studies?

Hypochloremia

A 25-year-old woman presents to the clinic complaining of lethargy and amenorrhea. Vitals reveal HR 48 bpm, RR 19/min, BP 99/62 mm Hg, T 94.9°F, and SpO2 99% on room air. Her calculated body mass index is 16.2 kg/m2, and physical examination demonstrates an emaciated appearance with fine, downy body hair. Which of the following is the hallmark laboratory finding indicating overly aggressive initial outpatient therapy?

Hypophosphatemia

A 38-year-old woman presents to the emergency department with nausea, vomiting, diaphoresis, hypertension, tachycardia, muscle spasms, and agitation. Emergency medical personnel state they administered naloxone to the patient 10 minutes ago after finding her unresponsive. Friends relayed to the emergency personnel that she is a chronic heroin user and overdosed. Which of the following is the best treatment for this patient's acute opioid withdrawal syndrome?

IV diazepam 2 mg

A 26-year-old woman presents to a psychiatrist for a new patient appointment along with her sister. Her sister states that the patient has always been a perfectionist, but this has recently started to interfere with her social life and personal relationships. She elaborates that the patient has been working over 70 hours per week on tasks that are not due for several weeks. In addition, she reports that the patient has an entire team to work with but does not delegate tasks, as she wants everything completed her way. Furthermore, despite the amount of time she pours into her work, she does not meet deadlines due to getting caught up in details and to-do lists. The addition of which historical element would help solidify this patient's diagnosis?

Inability to discard worthless objects To make a diagnosis of OCPD, patients must experience at least four of the following symptoms: perfectionism that interferes with the completion of tasks, excessive devotion to productivity at the expense of interpersonal relationships, inability to discard worthless objects without sentimental value, inflexible thinking, preoccupation with rules, details, and lists to which the essence of the activity is lost, reluctance to delegate tasks, miserly spending habits, or rigidity and stubbornness.

A 43-year-old woman presents to the primary care office for concerns of sadness. She states that she has had some stress in her family recently. She has noticed, and her partner has mentioned, that her mood seems very labile and she usually seems sad. She struggles to gain interest in going to the gym, which she used to love to do daily. She feels tired most days for "no reason" as she gets 7-8 hours of sleep nightly. She is having a hard time concentrating at work and has noticed she is withdrawing from friendships. After discussion, the patient decides she would like to try medication. You are going to start her on the recommended first-line class of medications for the suspected diagnosis. What are the early side effects of the first-line medication that you should discuss with the patient? A. Hyperthermia, tachycardia, sedation B. Insomnia, anxiety, headache C. Nausea, dizziness, diaphoresis D. Sedation, hyperlipidemia, hyperglycemia E. Weight gain, dizziness, involuntary muscle twitches

Insomnia, anxiety, headache

A 52-year-old man presents to the emergency department complaining of confusion and trouble walking. He is awake but not oriented to time or place. His gait is widely spaced with small, shuffling steps. On exam, alcohol can be smelled on his breath, and a lateral rectus palsy is apparent bilaterally. Which of the following represents appropriate treatment for this patient?

Intravenous thiamine administration Wernicke's encephalopathy

Which of the following best describes the post-traumatic stress disorder self-report checklist known as the PCL-5?

It can be used for screening purposes and to monitor symptom severity over time in post-traumatic stress disorder

A 23-year-old woman with a medical history of bipolar I disorder reports a positive home pregnancy test, which is confirmed in the office. Which of the following medications is best indicated for maintenance therapy?

Lamotrigine

A 21-year-old man was recently arrested for masturbating while exposing his genitals to a child. Six months ago, he was fired from his place of employment because he exposed his genitals to an unsuspecting, nonconsenting female coworker. He continues to have strong urges to expose himself despite the initiation of first-line therapy. Which of the following is indicated at this time? CBT, fluoxetine, group therapy or leuprolide

Leuprolide

A 32-year-old woman presents for evaluation. She has a medical history of bipolar II disorder and has been without signs or symptoms of the disorder for the past five months. The medication used to treat her acute hypomanic episode is unknown. Which of the following has the most evidence as a first-line treatment for maintenance therapy in bipolar disorder?

Lithium

A 30-year-old man has a history of depressive and hypomanic episodes. He initially is treated with quetiapine, which alleviated the symptoms of his most recent hypomanic episode. However, he is no longer tolerating quetiapine due to side effects. Which of the following is the preferred medication for the patient to switch to for maintenance therapy?

Lithium Patients with bipolar II disorder with frequent mood relapses are often treated with a combination of lithium or valproate and a second-generation antipsychotic, such as quetiapine

A 29-year-old man presents to your office with a history of excessive drinking over the past 12 months. One month ago, he had a motor vehicle collision as a result of driving under the influence, in which no one was badly injured. He has tried to stop drinking several times but so far has been unsuccessful. The patient has no significant past medical or psychiatric history, and he does not take any regular medications. His father, grandfather, and grandmother were all heavy drinkers who died from liver failure. Vital signs include BP 134/86 mm Hg, HR 81 bpm, and T 98.4°F. Physical examination shows an increased abdominal circumference, hepatosplenomegaly, gynecomastia, and palmar erythema. Which of the following would be most diagnostic of alcohol use disorder in this patient? A. A history of more than four drinks per day B. Blood alcohol level ≥ 0.08 g/dL C. Loss of a job due to drinking D. Serum gamma-glutamyltransferase > 30 U/L

Loss of a job due to drinking

A 43-year-old woman presents for her yearly physical. She reports that she is doing well other than a few recent life stressors. Upon further questioning, she opens up and explains that for the past 2 months, someone has been spying on her and following her, but she does not know who they are. She states she has made multiple police reports, but the police have not found any evidence of this. She reports she has been taking different ways to work each day, but her boss is starting to become concerned with her behavior. She reports no changes in medical history or medications. She reports no drug use. There are no present hallucinations during the interview. Which of the following is most likely to be a comorbid condition?

Major depressive disorder The most common comorbid condition with delusional disorder is major depressive disorder.

Which of the following best represents an indication for use of electroconvulsive therapy as first-line treatment in bipolar I disorder?

Major depressive episode with malignant catatonia Patients with bipolar I disorder who present with an episode of major depression and malignant catatonia would be considered candidates for first-line treatment with electroconvulsive therapy because of the life-threatening nature of the illness. Malignant catatonia involves immobility or waxy flexibility with fever, rigidity, and signs of autonomic instability.

A 26-year-old man presents to the neurologist for a follow-up visit regarding unexplained right arm weakness that has caused decreased function of his right arm. An extensive evaluation has been performed, and there is no medical or neurologic explanation for his symptoms. His providers have explained to him that there is inconsistency between the symptoms and recognized neurologic or medical disease. Which of the following tests should be performed in all patients with the most likely diagnosis?

Mental status exam

A 29-year-old woman with a history of bipolar II disorder, borderline personality disorder, and antipsychotic-induced akathisia presents to the clinic for a routine follow-up. She has been treated with olanzapine 15 mg daily and propranolol 10 mg twice daily for the past 18 months. During this time, she has noticed an even mood, restful sleep, and the ability to function well within her social and work environments. She has not engaged in suicidal or self-harming activities for 6 months. Vital signs include a weight of 175 lbs, height of 64 in, heart rate of 92 bpm, blood pressure of 128/88 mm Hg, respiratory rate of 16/min, oxygen saturation of 98% on room air, and temperature of 98.0°F. Physical examination reveals increased body habitus, multiple well-healed scars on the bilateral forearms, regular heart rate and rhythm, and clear lung fields. Mental status exam reveals euthymic affect, linear thought process, no suicidal thought content, and mild psychomotor agitation. A1C is 5.5%. Which of the following would be indicated at this time?

Metformin In addition to behavioral modifications, several medications have been proven to support weight loss in patients with antipsychotic-induced weight gain, including metformin, topiramate, aripiprazole, and liraglutide

A 20-year-old woman presents to a family medicine clinic because she is concerned that she has undiagnosed breast cancer. She performs breast self-examinations twice daily and has been to four different primary care clinicians with negative breast imaging. The patient does not have any breast pain or palpable masses during her self-exams. Which of the following features distinguishes the most likely diagnosis from somatic symptom disorder?

Minimal or absent physical complaints

A 27-year-old woman with a history of major depressive disorder presents to the emergency department with her partner after she attempted to overdose on one of her medications. Vital signs include a heart rate of 120 bpm, blood pressure of 90/55 mm Hg, respiratory rate of 13/minute, oxygen saturation of 98% on room air, and temperature of 101.2°F. On physical exam, the patient is sedated and confused. Bowel sounds are hypoactive. An ECG is shown above. Which of the following additional exam findings is most likely in this patient?

Mydriasis Patients with TCA poisoning most often present with sedation, although confusion, delirium, and hallucinations may also occur. Cardiac conduction delays, hypotension, dysrhythmias, and anticholinergic toxicity symptoms (e.g., hyperthermia, mydriasis, intestinal ileus, urinary retention) are also common.

48-year-old man with a history of hypertension treated with amlodipine presents to the emergency department following a fall. The patient drank 12 beers while working at a construction site, tripped, and fell on gravel. He did not hit his head, lose consciousness, or fall on an outstretched arm. He has had an increasing range of 6-18 beers per day for the past 4 years. His work has been inconsistent due to his alcohol use. He has not been successful in decreasing his daily alcohol intake despite a desire to do so. Vital signs include a heart rate of 98 bpm, blood pressure of 150/94 mm Hg, respiratory rate of 20/minute, oxygen saturation of 98% on room air, and temperature of 98.8°F. Physical exam reveals a regular heart rate and rhythm, full range of motion, and no neurological abnormalities. Blood alcohol concentration is 90 mg/dL. In addition to psychosocial interventions, what is a first-line pharmacologic treatment for the suspected condition?

Naltrexone

A 22-year-old man with no significant medical history presents to the emergency department with altered mental status for 1 hour. During the interview, he does not directly answer most questions and instead repeats words or asks personal questions. Vital signs include a heart rate of 100 bpm, blood pressure of 118/76 mm Hg, respiratory rate of 20/minute, oxygen saturation of 98% on room air, and temperature of 98.8°F. Physical exam reveals a regular rate and rhythm, no respiratory distress, and no abdominal tenderness to palpation. Blood alcohol concentration is 120 mg/dL. Which of the following exam findings is associated with the suspected diagnosis?

Nystagmus Alcohol intox

A 25-year-old man presents to the clinic complaining of anxiety. He states that he keeps checking the local news for reports of fatalities resulting from motor vehicle collisions. He reports persistent thoughts that he might have run over someone while driving home. His car has no signs of having been in a collision. He spends a great deal of time retracing his route after work to look for signs of an accident. During the mental status exam, he reports distress over violent images of him driving a vehicle over his partner of 5 years. His partner reports no fear of him and that the man has always been kind and loving. Which of the following is the most likely diagnosis?

OCD

A 25-year-old woman presents to the ED with immobility and unresponsiveness. She is awake but does not respond to questions or instructions. She occasionally repeats questions asked by the examiner but does not answer the questions. Vital signs are normal. On physical examination, her gaze is noted to be fixed, but pupils are equal and reactive. She grimaces at times and initially resists attempts to move her limbs. Physical examination is otherwise normal. Laboratory studies, including complete blood count, comprehensive metabolic panel, thyroid function tests, and creatine kinase, are within normal limits. Findings on EEG, brain MRI, and lumbar puncture are normal. Which of the following is the most appropriate next step?

Obtain psychiatric and medication history from a collateral source

A 52-year-old man with a history of alcohol use disorder presents to the ED with a simple laceration on the forearm. The injury occurred 2 hours earlier while the patient was cooking with a steak knife. He does not take any home medications. Vital signs include a heart rate of 98 bpm, blood pressure of 130/86 mm Hg, respiratory rate of 18/minute, oxygen saturation of 97% on room air, and temperature of 98.2°F. Mental status exam reveals alert sensorium, full orientation, and impaired delayed recall. Physical exam reveals a thin build, regular heart rate and rhythm, no respiratory distress, and slowed rapid alternating movements. Nonfasting glucose level is 100 mg/dL. Blood alcohol concentration is 200 mg/dL. Administration of which of the following is the most appropriate next step?

Oral thiamine

An 18-year-old woman presents to the clinic complaining of exertional weakness and cold intolerance. Her mother who accompanies her reports the patient has recently lost a substantial amount of weight and frequently engages in extensive, intense exercise multiple times throughout the day. Observation reveals an emaciated appearance with the physical exam findings shown above. Which of the following indicates a need for inpatient treatment?

PR interval of 0.31 seconds

A 16-year-old girl presents to the ED via ambulance for generalized pain. She is a refugee from a conflict area who is known to have frequent nighttime visits to the ED over the past year for the same chief concern. She has undergone multiple medical workups that have all been negative. In the ED, she appears angry, irritable, and she demonstrates hypervigilance. After a brief conversation with the patient, her pain resolves, and she feels much better. Which of the following is the most likely diagnosis?

PTSD

A 16-year-old girl presents to the office with frequent epistaxis, sneezing, and headaches for the past month. The patient has no significant medical history. Her parent reports she had an episode of delirium last week and was stumbling around their home. The physical exam reveals evidence of epistaxis but is otherwise within normal limits. Vital signs reveal an HR of 85 bpm, RR of 16/minute, BP of 110/74 mm Hg, SpO2 of 97% on room air, T of 98.6°F, and BMI of 23.5 kg/m2. What is the most likely substance contributing to the patient's reported symptoms?

Paint thinner Inhalant intoxication can include euphoric behavior, slurred speech, dizziness, headache, ataxia, and hallucinations. Chronic use can also result in frequent epistaxis, chronic headaches, vision, hearing and speech changes, and tremor.

A 19-year-old woman with no significant medical history presents to the emergency department with chest pain, dizziness, and shortness of breath. She states that these symptoms started about 30 minutes ago and woke her in the middle of the night. Vital signs include a heart rate of 110 bpm, blood pressure of 115/70 mm Hg, respiratory rate of 22/minute, oxygen saturation of 99% on room air, and temperature of 97.9°F. On physical exam, the patient appears diaphoretic and anxious. An ECG is shown above. Laboratory studies are within normal range. Which of the following additional symptoms is this patient most likely experiencing? A. Hallucinations B. Muscle tension C. Paresthesias D. Restlessness

Paresthesias Dx is panic attack

A 22-year-old woman presents with concerns for anxiety. She states that she has always been shy, but for the past few years, she gets very nervous when asked to meet up with friends or even eat in the office lunchroom. She has avoided parties and gatherings for fear that others will notice how nervous she is in public situations. Which of the following would be the best pharmacotherapeutic treatment, given the most likely diagnosis?

Paroxetine Typically, selective serotonin reuptake inhibitors (SSRIs) such as paroxetine are used as first-line therapy for social anxiety disorder.

A 56-year-old woman presents to her follow-up appointment today via telemedicine for the medication management of frequent episodes of anxiety. She states that her anxiety is manageable "unless I have to leave the house." She only leaves her house once every 3 weeks for groceries, and she usually goes to the local store when she knows it will not be busy. Over the past several years, she has become more isolated because of her panic attacks, which usually happen in public places. She is currently prescribed clonazepam 0.5 mg three times daily as needed. She insists that clonazepam is the only thing that has ever worked for her, and she does not want to lower her dose, even after you inform her about the potential long-term risks of benzodiazepines. You also strongly recommend psychotherapy, but she defers that suggestion because she is afraid of talking to someone new and having to "go through my entire life history again." She states that she constantly worries about something bad happening and is frustrated because she does not know why she feels this way. Which of the following concepts is the main distinguishing factor between her diagnosis and other anxiety disorders?

Persistent concern about having another panic attack

A 24-year-old woman presents to the clinic with depressed mood, lack of appetite, decreased sleep, lack of interest in pleasurable activities, and thoughts of guilt for the past two weeks. These symptoms occur every day, for most of the hours of the day, and are causing her distress. Her family history is significant for a father with major depressive disorder and a mother with bipolar I disorder. Which of the following is the next best step in diagnosis of this patient's condition?

Question the patient about previous manic episodes Bipolar I disorder is characterized by at least one manic episode. It is more common in those with a family history of the disease.

A 23-year-old man presents to the office with his parents for concerns about mood changes. The parents state that the patient began going through periods of extreme energy about 1 year ago. During these episodes, the patient will be very irritable, sleep < 4 hours per night, be very talkative, have racing thoughts, and have thoughts of buying several mansions. He is unable to function at work during these episodes, which often last for more than 1 week and are occurring every few months. He currently has been in an episode of extreme energy for 2 weeks. His parents also note episodes of sadness and hopelessness that have occurred a few times in the past year as well. His vital signs show a HR of 88 bpm, RR of 17/min, oxygen saturation of 98% SpO2, BP of 117/69 mm Hg, and T of 98°F. Urine drug screen is negative. The patient is disheveled on exam, and he begins talking about unrelated subjects to you with very pressured speech. Based on the patient's suspected diagnosis, which medication is appropriate first-line management? A. Buproprion B. Carbamazepine C. Paroxetine D. Quetiapine E. Venlafaxine

Quetiapine First-line pharmacotherapy for acute mania in bipolar I disorder includes quetiapine. Other first-line agents include lithium, aripiprazole, and risperidone.

A 22-year-old man has experienced recurrent major depressive episodes and at least one hypomanic episode. He had been resistant to medication interventions but is now asking for help due to the severity of his current depression. Which one of the following medications is the most appropriate choice? Buproprion, lamotrigine, quetiapine, or venlafaxine

Quetiapine Quetiapine has demonstrated particular efficacy in the treatment of bipolar depression and is approved by the FDA for that indication as well as for acute mania, bipolar maintenance, and as an adjunctive medication for unipolar depression.

A 55-year-old man with a history of persistent depressive disorder is admitted to the hospital with suicidal ideation. He is currently taking escitalopram 20 mg daily. Vital signs include a heart rate of 75 bpm, blood pressure of 110/70 mm Hg, respiratory rate of 18/minute, oxygen saturation of 98% on room air, and temperature of 98.8°F. Which of the following would be an indication to use electroconvulsive therapy as a first-line treatment?

Refusal to eat resulting in malnutrition

A patient diagnosed with unipolar major depression returns to the clinic to evaluate the efficacy of escitalopram. He has adhered to the maximum dose of this medication since his initial diagnosis 6 weeks prior. During examination, he reports no suicidal ideation but has continued feelings of anhedonia with associated somnolence, decreased appetite, and impaired concentration. Which of the following is the best management plan for this patient at this time? A. Continue escitalopram at maximum dosage for another 6 weeks B. Discontinue medication and initiate adjuvant psychotherapy C. Discontinue medication and initiate electroconvulsive therapy D. Replace escitalopram with buproprion and add aripiprazole E. Replace escitalopram with venlafaxine

Replace escitalopram with venlafaxine Venlafaxine has been extensively studied and is a common choice when an SSRI, such as escitalopram, does not effectively treat a patient's symptoms.

A 24-year-old man presents to the psychiatry clinic with recent elevated mood. He states he has been able to work 20 hours per day for the past four days without feeling fatigued. He states he feels like his thoughts are racing and he has elevated self-esteem. During the exam, he is easily distracted. He has a history of depressive episodes and denies any drug use or psychotic features. Which of the following is the recommended first-line treatment? A. Amitriptyline B. Fluoxetine C. Lamotrigine D. Risperidone

Risperidone

A 21-year-old man presents to the clinic for a physical. While obtaining a detailed history, the patient reveals that last year he suffered a "mental breakdown" where he heard voices, believed his deceased grandmother was following him everywhere, had trouble communicating and would make up new words, had academic problems due to memory deficits, and felt apathetic and without energy. These symptoms lasted for six weeks and then resolved completely. The patient denies current or past substance use and also denies any other psychiatric or developmental disorders. Which of the following is the most likely diagnosis?

Schizofreniform disorder

A 32-year-old disheveled man, wearing a construction hat, presents to the clinic for a rash. He believes the rash was "sent" to him by a neighbor who hates him and put a curse on him. He knows the neighbor hates him because he feels a dark aura follow the neighbor around. He lives alone because he fears any roommate will rob him while he sleeps. He wears a construction hat at all times, to protect his head from falling objects. While speaking, he often searches for words and seems to daydream. He is employed from home, takes no medications, does not use drugs or alcohol, has no previous psychiatric diagnoses, denies depression, and answers questions appropriately. Family members state he has always been "like this". Which of the following is the most likely diagnosis?

Schizotypal disorder

A 27-year-old woman presents with concerns about recurrent panic attacks. She states that she had a sudden onset of intense fear associated with chest pain and shortness of breath last month while out at a restaurant. She went to the emergency department, where they did not find an acute etiology for her symptoms. Since then, she has avoided going out to eat or social situations for fear that her symptoms might recur. Which of the following medications would be the best treatment option for this patient?

Sertraline

A 45-year-old man presents to the clinic for his annual physical. He says he is an "alcoholic." Further questioning reveals a history of excessive alcohol use despite losing his wife and his job, cravings for alcohol, withdrawal symptoms when alcohol cessation was attempted, using alcohol to stave off withdrawal symptoms, repeated attempts to quit drinking, and drinking large amounts of alcohol for longer periods of time than intended. The patient states that he joined a support group this year and has not had an alcoholic beverage in six months. Which of the following is the appropriate diagnosis?

Severe alcohol use disorder in early remission

Which of the following statements best describes a contributing factor in the pathogenesis of panic disorder?

Smoking in childhood increases the risk of development of panic disorder as an adult

A 46-year-old man with a history of epilepsy presents to your office for regular follow-up with symptoms of hopelessness and depressed mood for the past 3 weeks. He reports difficulty falling asleep most nights, and he has hardly any motivation to get out of bed in the morning to go to work. He stopped going to his weekly pickup basketball games because he "doesn't feel like being around anybody." He has lost 4 lbs in the past several weeks because he lost his appetite. The last time he felt this depressed was after he was laid off from his job about a year and a half ago. He reports no suicidal thoughts. He is currently prescribed sertraline 200 mg daily and has been diligent about taking it for the past 6 months. What is the most appropriate next step in this patient's medication management? A. D/C sertraline and trial lithium B. Initiate buproprion in addition to sertraline C. Switch sertraline to desvenlafaxine D. Switch sertraline to fluoxetine

Switch sertraline to desvenlafaxine

A 15-year-old boy presents for a follow-up evaluation. He was recently diagnosed with oppositional defiant disorder. He does not meet the criteria for conduct disorder. Of the following, which is most likely a characteristic of his presentation?

Symptoms have lasted for at least six months Oppositional defiant disorder is a condition characterized by at least six months of angry mood and argumentative, defiant, and vindictive behavior that includes at least four of the following exhibited during an interaction with at least one person who is not the patient's sibling: often loses temper, is easily annoyed, is often angry, argues with adults or those in authority, actively defies rules, deliberately annoys others, often blames others for one's mistakes, and has been vindictive.

A 31-year-old woman with a history of bulimia nervosa presents with poor exercise tolerance and dyspnea on exertion. An electrocardiogram is performed and shows nonspecific T wave abnormalities and an intraventricular conduction delay. An echocardiogram confirms cardiomyopathy with associated congestive heart failure. Which of the following etiologies is consistent with this diagnosis?

Syrup of ipecac abuse Syrup of ipecac is still available by mail in the United States and is often abused by individuals with bulimia nervosa as a means to induce vomiting. Ipecac contains emetine, which is eliminated from the body slowly and is toxic to myocytes. Chronic use leads to muscle cell damage and can affect cardiac tissue.

A 25-year-old woman with a past medical history significant for social anxiety disorder is concerned about her new job that involves frequent public speaking. She is prescribed a benzodiazepine to take as needed before public speaking situations. Which of the following would be important to discuss with the patient regarding this medication?

Take a test dose in advance of an event to assess effectiveness

A 32-year-old woman presents after being referred by her primary care physician. She mentions that she eats large quantities of food in short time periods during which she lacks control to restrain eating, eats rapidly, and continues to eat despite being full. The episodes occur approximately four times per week and have persisted for four months. She has no history of a psychotic, mood, or anxiety disorder. She does not smoke or drink alcohol. She denies using illicit drugs. She is disgusted by her eating behavior and would like resolution. Her body mass index is 32 kg/m2, and she would like to lose weight. Which of the following is most likely to reduce her binge eating behaviors and help with weight loss?

Topiramate

A 54-year-old woman presents to the office, stating she has not been feeling well after running out of her medication yesterday. She states she is having a difficult time sleeping, has been feeling more anxious, and is experiencing nausea. The physical exam reveals tachycardia on heart auscultation and mild hyperreflexia. Vital signs reveal an HR of 113 bpm, RR of 21/minute, BP of 140/92 mm Hg, SpO2 of 98% on room air, T of 98.7°F, and BMI of 21.5 kg/m2. Which of the following additional exam findings might you observe based on the most likely medication she is withdrawing from? A. Increased appetite B. Piloerection C. Tremor D. Yawning

Tremor Benzo withdrawal

A 23-year-old man with no significant medical history presents to the emergency department with his partner, who states that he has been acting abnormally for the last 10 days. They explain that he has been staying up all night working on a book. The patient believes he has been sent on a mission by the Messiah to create a new religion and gain followers. On mental status exam, the patient appears agitated and exhibits pressured speech. He is easily distracted and rapidly changes topics when you try to ask him questions. He becomes aggressive when the nurse tries to obtain his vital signs. In addition to olanzapine, what other medication should this patient be given?

Valproate Patients who present during acute mania should be treated with lithium or valproate plus an antipsychotic medication (e.g., olanzapine, quetiapine, risperidone).