ROSH - Psych

C. Phobia

A 19-year-old woman refuses to go to any park or playground because of an excessive fear and anxiety that she may see a dog. She has never been bitten or had a previous bad experience with a dog. Which of the following conditions is she most likely suffering from? A. Generalized anxiety disorder B. Panic disorder C. Phobia D. Post-traumatic stress disorder

C. Bulimia nervosa

A 27-year-old woman presents with symptoms of excessive eating followed by vomiting. Her BMI is 29 kg/m2 and her teeth are eroded. Which of the following is the most likely diagnosis? A. Anorexia nervosa B. Binge eating disorder C. Bulimia nervosa D. Purging disorder

B. Sinus bradycardia

Which one of the following cardiac rhythm abnormalities is most common in patients with anorexia nervosa? A. Atrial fibrillation B. Sinus bradycardia C. Sinus tachycardia D. Ventricular fibrillation

D. Sertraline OCD

You are seeing an 11-year-old girl for follow up of excessive handwashing and frequent worrying. You referred her for psychotherapy and she has been receiving cognitive behavioral therapy for 3 months with a child psychologist. However, her mother reports minimal improvement of her symptoms. The patient remains preoccupied with the thought of germs multiplying in her hands that may cause her to get sick. Her compulsion with handwashing is evident both at home and in school, causing impairment in school functioning as well as skin peeling and erythema of her hands. You decide that pharmacotherapy, in addition to cognitive behavioral therapy is the next best course of action. Which of the following is the most appropriate medication therapy to start? A. Alprazolam B. Paroxetine C. Risperidone D. Sertraline

A. Antisocial

You are working in the ED when the police bring in a 26-year old man who was involved in a bar fight. The patient is well known to staff, as he frequently seeks treatment in the ED for injuries related to fights and alcohol use. He has been caught smoking cigarettes in the ED bathroom, has urinated on the floor, and been known to steal food trays and other patients' belongings. As you enter his examination room, you overhear him giving the registration clerk a false identity. Which of the following personality disorders best fits with this patient's behavior? A. Antisocial B. Borderline C. Paranoid D. Schizoid

C. Methylphenidate

A 12-year-old boy presents to clinic with a history of conduct disorder and ADHD. His parents report he is having increased high-risk behavior despite behavioral and psychological therapy. They are concerned about his safety. Which of the following medications is the best choice for treating this patient with a diagnosed conduct disorder? A. Citalopram B. Lithium C. Methylphenidate D. Valproic acid

D. Methylphenidate The most effective medications, in the presence of ADHD are stimulants, specifically methylphenidate and dextroamphetamine

A 13-year-old boy and his parents present to the clinic to discuss his history of diet controlled attention deficit hyperactivity disorder and new persistent behavior problems over the past year. He began with breaking items in the home and has since started fights at school and set his sister's toys on fire. He recently made threats to hurt the family dog. He is not responding to the parents' disciplinary efforts. In addition to psychotherapy, which of the following medications would be most beneficial for this patient? A. Alprazolam B. Citalopram C. Haloperidol D. Methylphenidate

C. Marijuana can cause dependence and withdrawal

A 15-year-old girl presents to clinic for a well child check. During her Home and Environment, Education and Employment, Activities, Drugs, Sexuality, Suicide and Depression (HEADSS) exam, she reports using marijuana on a weekly basis for the past six months. She also drinks alcohol to excess once every few weeks. She denies smoking tobacco or using any other illicit substances. Which of the following is the most accurate information to give this patient? A. Chronic marijuana use improves focus and performance B. In human studies, marijuana has shown teratogenicity C. Marijuana can cause dependence and withdrawal D. Tetrahydrocannabinol concentrations are lower in today's marijuana compared to prior decades

A. Craving or strong urge to use alcohol

A 19-year-old man presents to the clinic after losing his job a month ago. During your interview, the patient reports he drinks daily. You suspect the patient has alcohol use disorder. Which of the following is a criterion for the diagnosis of alcohol use disorder? A. Craving or strong urge to use alcohol B. Drinking at least six alcoholic beverages per day C. Having legal problems related to alcohol use D. Symptoms lasting at least 6 months

C. Ecstasy

A 20-year-old man presents to the emergency department in police custody after his roommate called the police because the patient came home extremely agitated with altered mentation. His roommate reports he was at a rave party earlier tonight. Vital signs include HR of 125 bpm, BP of 180/120 mm Hg, RR of 22/minute, oxygen saturation of 98% on room air, and T of 100.2°F. Physical examination reveals an agitated and hyperactive patient who is oriented to person but not place, time, or situation. He has no focal neurologic deficits. His skin is diaphoretic, and his pupils are dilated. He has no nystagmus and exhibits no signs of delusions or hallucinations. Which of the following substances would most likely cause this presentation? A. Anticholinergics B. Benzodiazepines C. Ecstasy D. Ketamine E. Phencyclidine

C. Obsessive-compulsive personality disorder

A 20-year-old man presents to the primary care office with his parents, requesting an evaluation for attention-deficit/hyperactivity disorder. The patient has historically been a detail-oriented and high-achieving student. Since enrolling in college 2 years ago, the patient has been earning Cs in college. The patient does not understand why his parents are worried. He does not have any close friends or hobbies, in favor of devoting his time to creating detailed study guides, class schedules, and to-do lists. He spends 2-3 hours a day rewriting lists to ensure their accuracy. He recently failed a group project despite significant effort. He would not collaborate with his classmates because they did not work to his standards. The patient explains, "It's better to fail a project than to turn in something that is not up to par." What is the most likely diagnosis? A. Narcissistic personality disorder B. Obsessive-compulsive disorder C. Obsessive-compulsive personality disorder D. Schizoid personality disorder E. Schizotypal personality disorder

D. Quetiapine First-line pharmacotherapy for acute mania in bipolar I disorder includes quetiapine. Other first-line agents include lithium, aripiprazole, and risperidone. Quetiapine is a second-generation or atypical antipsychotic.

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. Bupropion B. Carbamazepine C. Paroxetine D. Quetiapine E. Venlafaxine

B. Borderline

A 23-year-old woman presents to the ED after taking six multivitamin tablets after her partner threatened to break up with her. She just started dating him last weekend and "knows he is the one." She has been treated for multiple sexually transmitted infections in the past and reports multiple "one-night stands." She has multiple shallow, linear scars on her forearms consistent with self-inflicted cutting. When you enter her examination room, she is upset and crying into the phone saying, "my nurse hates me." When asked why she feels this way, she tells you, "the nurse said she would get me a blanket but never came back." Which of the following personality disorders does this patient most likely have? A. Antisocial B. Borderline C. Paranoid D. Schizoid

D. Question the patient about previous manic episodes Bipolar I disorder is characterized by at least one manic episode

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? A. Administer a Patient Health Questionnaire - 9 item B. Perform a complete metabolic panel C. Perform a urine toxicology screen D. Question the patient about previous manic episodes

C. Opioids

A 25-year-old woman presents to the emergency department requesting help with detoxification from her substance use. She reports severe restlessness, anxiety, insomnia, and generalized myalgias in the past 24 hours since her last substance intake. Physical examination shows excessive lacrimation, diaphoresis, and piloerection. Withdrawal from which of the following substance is the most likely cause of this patient's condition? A. Amphetamines B. Cocaine C. Opioids D. Phencyclidine

B. Bipolar disorder

A 28-year-old woman is brought to the clinic by her sister, who is concerned about her recent reckless behavior. The patient has been spending money excessively, acting sexually promiscuous, speaking delusionally, and has not slept for three days. The patient is visibly irritated by her sister's comments. The patient reports periods of depression in the past, which were untreated, but now feels "absolutely great." She is extremely talkative, easily distracted in her thought process, and reports several different grand new ideas, which she explains within the space of a ten-minute discussion. What is the most likely diagnosis? A. Acute stress disorder B. Bipolar disorder C. Borderline personality disorder D. Dysthymic disorder

A. Anxiety occurring more days than not for at least six months

A 29-year-old woman presents to your office with a complaint of worsening anxiety. Which additional finding would suggest a diagnosis of generalized anxiety disorder rather than panic disorder? A. Anxiety occurring more days than not for at least six months B. Changes in personality C. Excessive concern about medically unexplained symptoms D. Frequent periods of intense fear

C. Attention deficit hyperactivity disorder Attention deficit hyperactivity disorder (ADHD) is characterized by impulsiveness, restlessness, inattention, difficulty staying on task or prioritizing tasks, and poor time management skills

A 30-year-old woman presents to her primary care physician's office with a history of difficulty paying attention, forgetfulness, poor time management skills, and impulsiveness dating back to her childhood. Which of the following is the most likely diagnosis? A. Alcohol use disorder B. Anxiety disorder C. Attention deficit hyperactivity disorder D. Bipolar disorder

D. Seizure disorder

A 30-year-old woman presents to your office requesting medication to help her quit smoking. Which of the following is a contraindication to prescribing bupropion? A. Cardiovascular disease B. Chronic obstructive pulmonary disease C. Depression D. Seizure disorder

A. Exposure therapy phobia

A 32-year-old man presents to the psychiatry clinic due to an excessive fear of needles. This fear has led him to avoid necessary medical care because he has panic attacks at the thought of having blood drawn. He recently had to be sedated in the emergency department to have a peripheral IV started. Vital signs include HR of 80 bpm, BP of 120/80 mm Hg, RR of 20/minute, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination reveals a regular rate and rhythm and lungs clear to auscultation. Which of the following is the recommended treatment for the suspected condition? A. Exposure therapy B. Lorazepam C. Quetiapine D. Sertraline E. Trauma-focused psychotherapy

B. Death of a child Prolonged or complicated grief is characterized by persistent, disruptive emotional responses for at least six months after the death of a loved one Crying uncontrollably (A), insomnia (C) and visual hallucinations (D) are all normal grief reactions

A 32-year-old woman presents to your office for her annual exam. She reveals that one month ago her 6-year-old daughter was killed in a motor vehicle accident. Since the accident she has been crying uncontrollably, can't sleep through the night, and sometimes sees her daughter walking in the upstairs hall. Which of the following is a risk factor for the development of poor bereavement outcomes? A. Crying uncontrollably B. Death of a child C. Insomnia D. Occurrence of visual hallucinations

D. Order thyroid function tests Lithium use can result in hypothyroidism.

A 33-year-old man presents for a follow-up to an outpatient psychiatry practice. He has previously been diagnosed with bipolar I disorder. His symptoms are currently stable on lithium and sertraline daily. His last lithium trough level was 1 mmol/L, and his last measured weight was 153 lbs. Today, he reports he has felt increasingly tired, has decreased concentration at work, and has decreased libido. His vital signs include a weight of 164 lbs, blood pressure of 115/77 mm Hg, heart rate of 59 bpm, respiration rate of 16/minute, temperature of 98.6°F, and oxygen saturation of 98% on room air. What would be the most appropriate next step in the management of this patient's condition? A. Add sildenafil as needed B. Discontinue sertraline and start escitalopram C. Order prolactin level D. Order thyroid function tests E .Refer the patient for cognitive behavioral therapy

D. Persistent depressive disorder Persistent depressive disorder (previously known as dysthymic disorder), is characterized by at least two years of depressed mood on most days during adulthood.

A 34-year-old woman presents to the outpatient family practice office for evaluation. During her interview, she reports that she feels depressed and that this has been her baseline for the last eight or nine years. During this time, she has experienced occasional periods of happiness lasting one to two weeks at the most before returning to a sad or depressed state. She reports a generally low self esteem and indecisiveness which has made career advancement difficult. What is the most likely diagnosis? A. Bipolar I disorder B .Bipolar II disorder C. Major depressive disorder D. Persistent depressive disorder

C. Normal saline and glucose This patient is suffering from alcoholic ketoacidosis, which is defined by the clinical triad of ketones in the blood or urine, an elevated anion gap and a normal glucose level. Treatment of alcoholic ketoacidosis includes vigorous volume repletion with normal saline, along with administration of thiamine and glucose

A 35-year-old man with a history of heavy alcohol use presents to your office with a 3-day history of abdominal pain and vomiting after a night of binge drinking. He has not eaten in days. Laboratory values show an elevated anion gap, ketonemia, and normal glucose levels. In addition to thiamine, what other treatment should be provided for this patient? A. Bicarbonate and insulin B. Glucagon and hydrocortisone C. Normal saline and glucose D. Pyridoxine

A. Administer the Working Alliance Inventory Obsessive-compulsive personality disorder is characterized by a controlling, rigid outlook which seeks to follow rules and maintain order in the surroundings, and is considered a cluster C personality disorder 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 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? A. Administer the Working Alliance Inventory B. Begin treatment with exposure therapy C. Prescribe buspirone 10 mg twice daily D .Prescribe fluoxetine 20 mg once daily

A. Factitious disorder actitious disorder imposed on self. This is a psychiatric disorder in which the individual feigns disease in an attempt to gain attention, sympathy, or reassurance

A 36-year-old man presents to the ED after having a seizure. He has a folder full of medical records dating back 15 years. Several of the records are from other cities and states. It is now 11:00 pm on a Friday night. His primary care physician, neurologist, and psychiatrist are "out of town" and he believes that he needs to be admitted for the duration of the weekend. He has another episode of shaking in the ED and immediately following this he returns to his baseline. He is now awake and alert. You immediately draw a serum lactate and it is normal. Which of the following diagnoses should be strongly considered in this patient? A. Factitious disorder B. Functional neurological symptom disorder C. Illness anxiety disorder D. Somatic symptom disorder

B. Going to bed only when feeling sleepy

A 40-year-old man with a history of generalized anxiety disorder, for which he takes sertraline, presents to the clinic with difficulty falling asleep for the past 2 months after losing his job. The difficulty sleeping has resulted in daytime sleepiness, which has impacted his relationships and ability to spend time finding a new job. Vital signs include HR of 80 bpm, BP of 120/80 mm Hg, RR of 20/minute, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination includes a regular rate and rhythm and lungs clear to auscultation. Which of the following is recommended sleep hygiene for patients with the suspected condition? A. Exercising before going to bed B. Going to bed only when feeling sleepy C. Remaining in bed reading even if unable to sleep D. Taking an afternoon nap E. Watching television before sleeping

A. Emergency psychiatric evaluation

A 46-year-old man with a history of depression presents to the emergency department with a self-inflicted laceration to the left arm. The wound is superficial and the patient states that he didn't want to hurt himself. He reports that he is recently divorced, lives alone, and has increased stress at work. These stressors have worsened his depression. Which of the following is the next best step in management of this patient? A. Emergency psychiatric evaluation B. Outpatient referral to psychiatry C. Prescribe antidepressant and discharge with follow up D. Prescribe anxiolytic and discharge

D. White blood cell count clozapine = agranulocytosis

A 53-year-old woman with a history of poorly controlled schizophrenia presented to the Emergency Department two weeks ago with altered mental status, auditory hallucinations, and agitation. During her inpatient psychiatry admission, she stabilized on clozapine. Which of the following laboratory tests should be performed at baseline and then weekly during treatment with clozapine? A. Fasting lipid panel B. Hemoglobin A1c C. Prolactin level D. White blood cell count

D. Diazepam This patient presents with alcohol withdrawal syndrome complicated by delirium tremens and requires treatment with benzodiazepines (diazepam)

A 54-year-old man with chronic alcohol use presents with confusion and visual hallucinations. Vital signs are HR 113 bpm, BP 164/95 mm Hg, finger stick blood glucose 113 mg/dL, and T 100.5°F. Physical examination reveals a disheveled man with tremors, tongue fasciculations, and agitation. What management should be pursued? A. Admission to psychiatry for management B. Cyproheptadine C. Dantrolene D. Diazepam

B. Adjustment disorder Adjustment disorder consists of maladaptive behavioral or emotional symptoms. These follow a stressful life event and occur within three months and end within six months.

A 55-year-old man presents with a chief complaint of "feeling low." He has been tearful and depressed since he lost his job four months ago. He has been unable to find a new job. The patient is frustrated and reports driving recklessly. What is the most likely diagnosis? A. Acute stress disorder B. Adjustment disorder C. Normal grief reaction D. Post traumatic stress disorder

B. Lipid profile Patients taking a second-generation antipsychotic need to be carefully monitored for the development of metabolic syndrome, as weight gain, dyslipidemia and diabetes mellitus are side effects of these agents.

A 55-year-old woman with a history of schizoaffective disorder presents to your office to discuss her current treatment regimen. She was started on olanzapine at her last visit and wants to know what type of monitoring is recommended while taking this medication. Which of the following is the most appropriate diagnostic test to order? A. Absolute neutrophil count B. Lipid profile C. Renal panel D. Thyroid stimulating hormone

E. Replace escitalopram with venlafaxine venlafaxine = SNRI

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 bupropion and add aripiprazole E. Replace escitalopram with venlafaxine

B. Buprenorphine and naloxone The use of substitute drugs that are partial agonists or less harmful (e.g., buprenorphine and naloxone) are frequently used to treat opioid use disorder

A patient with chronic spinal pain begins to obtain off-the-street opioids in an attempt to enhance his prescribed opioid analgesics. In addition to psychotherapy, which of the following medications can be used in the treatment of opioid use disorder? A. Bromocriptine B. Buprenorphine and naloxone C. Disulfiram D. Modafinil

A. Aripiprazole delusional disorder

A previously healthy 55-year-old man presents to your office requesting laboratory testing to confirm that his gastrointestinal tract has no abnormalities. The patient is a successful attorney, happily married, and convinced that the government has been trying to poison him for the past year. He refuses to eat any food in public, will not eat at a restaurant, and will not consume food prepared by others or brought by coworkers. He is concerned that the government may now be starting to poison food at the supermarket. He wonders if it will be safe to continue eating food at his house. Which of the following is the most appropriate therapy? A. Aripiprazole B. Citalopram C. Clozapine D .Fluoxetine

D. Modafinil narcolepsy

An 11-year-old boy is brought to the office by his mother for excessive daytime sleepiness. She states the patient sometimes falls asleep midconversation or while walking. He is sound asleep and rouses after 5-10 minutes. The patient reports occasional episodes of being awake but unable to move for several minutes as well. The patient also has an uncle who had similar symptoms when he was an adolescent. A physical exam is unremarkable. Which of the following medications is a first-line therapy for the treatment of this patient's condition and prominent symptom? A. Clonazepam B. Imipramine C. Melatonin D. Modafinil E. Venlafaxine

A. Cocaine

An 18-year-old man presents to the ED in police custody after using an unknown drug. Vital signs include a BP of 170/85 mm Hg, HR 120 bpm, T 37.8°C, RR 18 breaths/min, and pulse ox 99% on room air. On exam, he is agitated and diaphoretic. His pupils are 7 mm and reactive. Which one of the following substances did this patient most likely use? A. Cocaine B. Dextromethorphan C. Fluoxetine D. Phencyclidine

D. Panic attack

An 18-year-old woman complains of heart palpitations, diaphoresis, nausea, and shaking of her whole body along with a choking sensation. These symptoms have occurred three to four times per week for the last 2 weeks. She states that the symptoms are most common shortly before going to bed and begin suddenly peaking in 10 minutes and eventually spontaneously resolve. These symptoms are accompanied by an intense fear that she is going to die. Which of the following is the most likely diagnosis? A. Angina B. Bipolar disorder C. Generalized anxiety disorder D. Panic attack

C. Notify adult protective services

An 82-year-old woman presents for evaluation of pain on her sacrum. The patient is alert and oriented to person, place, and time. Physical examination is notable for a stage II pressure ulcer. Multiple bruises are noted on her legs as well. She acknowledges that she remains in bed most of the day and sometimes her son who is her caretaker forgets to give her meals or change her diaper. She also states that the son causes her pain by pinching her arms and legs when she does not move quickly enough. You are concerned about elder neglect and abuse. She does not wish to report her son or speak with social work. Which is your most appropriate action? A. Call the son to discuss the case B. Discharge the patient home C. Notify adult protective services D. Psychiatry consultation for capacity determination

B. "Doctor, you must be wrong." "Doctor you must be wrong" is the correct answer since it reflects the patient's inability to accept the information and indicates the denial of the first stage. denial anger bargaining depression acceptance

An oncologist tells his patient that her laboratory results support a diagnosis of advanced malignant melanoma with multiple metastases to the liver and brain. He also advises her that the prognosis is poor. Which of the following is most likely to be the first statement that the patient will make according to the classic Kubler-Ross's stages of death? A. "Can you keep me alive until my daughter graduates from medical school?" B. "Doctor, you must be wrong." C. "I think it is time that I make a will and say good-bye to everyone." D. "You have failed at your job because you should have caught this earlier!"

D. Word salad Positive symptoms of schizophrenia include hallucinations, delusions, and disorganization

Which of the following is an example of a positive symptom of schizophrenia? A. Anxiety B. Apathy C. Impaired memory D. Word salad

A. Adjustment disorder

What disorder is characterized by emotional or behavioral responses that develop within 3 months of a stressful event, in excess of what would be expected given the nature of the event, and not including the loss of a loved one? A. Adjustment disorder B. Bereavement C. Grief reaction D. Personality disorder

C. When she tries to leave the husband

During an intake history, a patient describes her husband as a violent, angry man. You suspect domestic violence of a physical nature. You counsel the woman that serious injury or death most commonly occurs during which of the following situations? A. After an argument about financial issues B. After an argument about sex-life issues C. When she tries to leave the husband D. When the husband tries to apologize for his actions

C. Schizophrenia

Katie is a 35-year-old woman who presents to the emergency department after being found wandering the streets yelling incoherently at imaginary people. After further investigation, you discover that she has been found arguing with an imaginary person for the past eight months and believes that she is being followed by the CIA. What is the most likely diagnosis? A. Delusional disorder B. Schizoaffective disorder C. Schizophrenia D. Schizophreniform disorder

C. Narcissistic personality disorder - dramatic/erratic (cluster B) cluster A = odd eccentric cluster B - dramatic, unpredictable cluster c = anxious and fearful

The DSM-5 groups personality disorders into three clusters: odd/eccentric, dramatic/erratic, and anxious/fearful. Which of the following is the correct personality disorder and cluster? A. Avoidant personality disorder - odd/eccentric (cluster A) B. Borderline personality disorder - odd/eccentric (cluster A) C. Narcissistic personality disorder - dramatic/erratic (cluster B) D. Schizoid personality disorder - anxious/fearful (cluster C)

D. Oppositional defiant disorder This child meets the DSM-V criteria for oppositional defiant disorder, defined as a pattern of negative, hostile, and defiant behavior lasting at least 6 months

The parents of a 7-year-old boy ask you to evaluate him because of increasing concerns about his temper tantrums over the past 9 months. He becomes angry and hostile, argues constantly, and refuses to follow rules or directions. The boy often becomes aggressive and destructive, breaking his toys and sweeping his dinner plate and glass of milk onto the floor. The parents believe that their son is deliberately behaving this way to annoy them. This history is most consistent with which one of the following? A. Antisocial personality disorder B. Bipolar disorder C. Conduct disorder D. Oppositional defiant disorder

C. Most frequently diagnosed behavioral disorder in children

Which of the following is true regarding attention-deficit/hyperactivity disorder? A. Characterized by speech delay, poor eye contact, and lack of stranger anxiety B .More prevalent in girls than boys C. Most frequently diagnosed behavioral disorder in children D. Symptoms most commonly begin in adolescence

D. 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 laboratory abnormalities would most likely be seen in a patient with severe anorexia nervosa? A. Increased creatinine B. Increased follicle-stimulating hormone C. Increased glomerular filtration rate D. Increased total cholesterol

B. Cognitive behavioral therapy

Which of the following psychotherapy techniques is most effective for panic disorder? A. Acceptance and commitment therapy B. Cognitive behavioral therapy C. Dialectical behavior therapy D. Interpersonal therapy

D. Prior history of suicide attempts

Which of the following risk factors is the strongest predictor of suicide? A. Access to firearms B. History of depression C. Male sex D. Prior history of suicide attempts

A. Dialectic behavioral therapy There are no proven therapies to reduce the severity of borderline personality disorder (BPD). The most promising psychological therapy is dialectic behavioral therapy (DBT

Which one of the following has been shown to render some improvement in individuals with borderline personality disorder? A. Dialectic behavioral therapy B. Omega-3 fatty acids C. Second-generation antipsychotics D. Selective serotonin reuptake inhibitors

C. Posterior rib fracture

Which one of the following is highly suspicious for non-accidental trauma in a pediatric patient? A. Clavicle fracture B. Distal radius fracture C. Posterior rib fracture D. Spiral fracture of the tibia

B. Retinal hemorrhage Abusive head trauma (previously referred to as shaken baby syndrome) is a form of inflicted head trauma and the leading cause of child abuse fatalities.

Which one of the following is the most common manifestation of abusive head trauma in infants? A. Epidural hematoma B. Retinal hemorrhage C. Subarachnoid hemorrhage D. Subdural hematoma

A. Attempts are more common in girls than boys

Which one of the following statements is true regarding teenage suicide? A. Attempts are more common in girls than boys B. Boys complete suicide most commonly by ingesting a poisonous substance C. Girls complete suicide more often than boys D. Suicide rates are decreasing in teenagers

B. Mood disorder questionnaire

You suspect bipolar I disorder in a 17-year-old student. Which of the following tools is most appropriate for screening for this diagnosis? A. Beck Depression Inventory for Primary Care B. Mood disorder questionnaire C. My Mood Monitor D. Myers-Briggs Type Indicator

D. Symptom control may be achieved with clonidine This patient presents with opiate withdrawal and management should focus on the relief of symptoms

A 23-year-old man with a history of opiate use presents to the emergency department with tachycardia, hypertension, and mydriasis. Which of the following is true regarding management? A. Antiemetics should be withheld as they may cause serious side effects B. Consider ICU admission for the potential for symptoms to worsen C. Naloxone should be given D. Symptom control may be achieved with clonidine

D. Posttraumatic stress disorder

A 24-year-old army veteran presents to clinic with a complaint of difficulty sleeping due to frequent nightmares. He has visual flashbacks and avoids large crowds due to the inability to escape easily. He is nervous, sweating, and startles easily on examination. Which of the following is the most likely diagnosis? A. Agoraphobia B. Generalized anxiety disorder C. Panic disorder D. Posttraumatic stress disorder

C. Methylphenidate

Martin is a 10-year-old boy recently diagnosed with attention deficit hyperactivity disorder, and his parents are interested in starting a medication. Which of the following medications is most appropriate for this patient? A. Clonidine B. Guanfacine C. Methylphenidate D. Sertraline

C. Denial, anger, bargaining, depression, acceptance

Which of the following represents the classic order of the stages of grief? A. Anger, denial, bargaining, depression, acceptance B. Bargaining, anger, denial, depression, acceptance C. Denial, anger, bargaining, depression, acceptance D. Depression, denial, anger, bargaining, acceptance

A. Erroneous beliefs that usually involve a misinterpretation of perceptions or experiences

Which one of the following best defines delusions? A. Erroneous beliefs that usually involve a misinterpretation of perceptions or experiences B. Hallucinations occurring in the absence of insight into their pathological nature C. Marked disorientation, confusion, and fluctuating consciousness D. Sensory perceptions without external stimulation

D. Physical aggression towards others

Which one of the following distinguishes conduct disorder from oppositional defiant disorder? A. Angry and resentful B. Argues with adults C. Deliberately tries to annoy someone D. Physical aggression towards others

B. Dissociative fugue Dissociative fugue is a subtype of dissociative amnesia in DSM-5 and is characterized by sudden unexpected travel or wandering in a dissociated state

A 19-year-old veteran returns from Afghanistan. Shortly after returning home, he is found wandering in a city far from his home and does not recall his name or how he got there. Which of the following is the most likely diagnosis? A. Depersonalization disorder B. Dissociative fugue C. Dissociative identity disorder D. Post-traumatic stress disorder

B. Fluoxetine SSRI

A 27-year-old woman presents to your office with complaints of depression and thoughts of suicide. She is interested in starting both counseling and medication to address her symptoms. Which of the following is the safest medication to consider prescribing? A. Amitriptyline B. Fluoxetine C. Nortriptyline D. Venlafaxine

A. Bioequivalence to the olanzapine tablet (bad question) In the ED, the rapid dispersible preparation is particularly valuable when managing acutely agitated patients due to its rapid absorption through the oral mucosa resulting in somnolence. Oral and rapid dispersible (wafer) preparations are considered bioequivalent. Overdose leads to tachycardia, rather than bradycardia (B),

Olanzapine is a commonly used medication in patients with schizophrenia. Which of the following can be expected with the rapid dispersing formulation (wafer) of olanzapine? A. Bioequivalence to the olanzapine tablet B. Bradycardia at overdose levels C. Increased risk of extrapyramidal side effects compared with haloperidol D. Rare association with orthostatic hypotension

B. Panic disorder

What condition is defined as the occurrence of repeated panic attacks that are associated with intense, debilitating fear of future panic attacks? A. Generalized anxiety disorder B. Panic disorder C. Posttraumatic stress disorder D. Specific phobia

B. Neglect Neglect is the most common type of child maltreatment in the United States (78.5%) and is caregiver failure to meet basic nutritional, medical, educational, and emotional needs of a child.

What is the most common form of child abuse in the United States? A. Emotional B. Neglect C. Physical D. Sexual

C. There is an adequate system in place for diagnosis and follow-up

You provide care to a middle-aged man with hypertension and diabetes. He recently lost his job, and you are concerned he may be exhibiting mild symptoms of depression. According to the US Preventive Services Task Force, screening for depression is recommended if which of the following exists? A. A local suicide prevention hotline routinely handles calls from your surrounding area B. The patient has strong social support of friends, family, and coworkers C. There is an adequate system in place for diagnosis and follow-up D. You have developed a detailed depression screening form

D. Recent release from incarceration

Which of the following is considered a risk factor for suicide? A. Female sex B. First trimester pregnancy C. First year of marriage D. Recent release from incarceration

A. Contraction alkalosis

Which of the following is consistent with a diagnosis of bulimia? A. Contraction alkalosis B. Heart failure C. Hyperkalemia D. Hypothermia

C. Early intervention with a multidisciplinary approach improves outcomes

Which of the following is correct with regards to autism? A. Caused by thimerosal-containing vaccines B. Developmental screening tests have good sensitivity for autism C. Early intervention with a multidisciplinary approach improves outcomes D. Onset typically occurs after the age of 5

E. Suicidal thoughts or unusual behaviors Suicidal thoughts or unusual behaviors are an FDA black box warning in children, adolescents, and adults younger than 25 years old who are started on selective serotonin reuptake inhibitors (SSRIs) for unipolar depressive disorder

A 13-year-old boy reports a 2-year history of anhedonia, depressed mood, decreased sleep, decreased appetite, and decreased concentration. He reports no symptoms consistent with manic behavior. You decide to start him on escitalopram, a selective serotonin reuptake inhibitor, and refer him for psychotherapy. What possible adverse reaction should you educate the patient and family to monitor for after initiating escitalopram? A. Elevated blood pressure B. Galactorrhea C. Seizures D. Somnolence E. Suicidal thoughts or unusual behaviors

C. Physical cruelty to animals Onset of CD occurs in early to middle childhood and the presence of CD is a risk factor for the development of antisocial personality disorder in adulthood.

A 14-year-old boy exhibits chronic conflict with his parents and siblings and has been suspended from school on a number of occasions. Which of the following additional findings would suggest a diagnosis of conduct disorder rather than oppositional defiant disorder? A. Being spiteful or vindictive B. Often losing temper C. Physical cruelty to animals D. Refusal to comply with requests from authority figures

C. Conduct disorder

A 14-year-old boy has been described by others as the "school bully." For the past 16 months he stole money from his parents, got into fights at school almost daily, failed to turn in most of his homework, and destroyed multiple items both at home and school. During parent-principal meetings the young boy denies having remorse for his actions and considers himself just a "normal" 14-year-old. Which of the following disorders is this individual suffering from? A. Antisocial personality disorder B. Attention deficit hyperactivity disorder C. Conduct disorder D. Obsessive compulsive personality disorder

B. Conduct disorder Frequent fighting, truancy, theft and discrediting those with concerns about behavior are indicative of conduct disorder. An affected individual can also display cruelty to animals or people, destroy property, or intimidate others, and generally shows no remorse for his or her actions

A 15-year-old boy is brought to your office by his mother. She states over the past year he has been repeatedly in trouble at school for engaging in or starting fights. He is frequently truant and has subsequently been held back from advancing to 10th grade. He has also been arrested for stealing at a local mall. The patient denies that any of his mother's concerns are valid and says "everyone else is doing the same stuff". Which of the following do you suspect? A. Attention deficit hyperactivity disorder B. Conduct disorder C. Intermittent explosive disorder D. Oppositional defiant disorder

A. Consultation with child services for suspected abuse This patient presents with a partial thickness second degree burn with a mechanism of injury that does not fit the injury pattern raising suspicion for child abuse

A 2-year-old boy presents with a burn to his right hand as seen above. The patient's mother states that he mistakenly got burned by hot water when she tipped a hot tea kettle over. What management is indicated? A. Consultation with child services for suspected abuse B. Consultation with plastic surgery for skin grafting C. Discharge home with silvadene and follow up D. Transfer to a burn center

D. Posttraumatic stress disorder

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 complaint. She has undergone multiple medical workups that have all been negative. In the ED, she appears angry, irritable, and 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? A. Adjustment disorder B. Borderline personality disorder C. Malingering D. Posttraumatic stress disorder

A. Administer intravenous naloxone Intravenous naloxone is an appropriate first step in managing a patient with acute heroin (opiate) overdose.

A 17-year-old boy is brought to the emergency department by his friends. They were at a house party and found their friend unconscious after he ingested an unknown substance. On physical exam, vital signs are temp 96F, heart rate 50, respiratory rate of 4, and oxygen saturation 92% on room air. The boys pupils are miotic. On lung auscultation, there are crackles bilaterally. You administer supplemental oxygen. Which of the following is the most appropriate clinical intervention? A. Administer intravenous naloxone B. Begin intravenous fluids with sodium bicarbonate C. Initiate therapy with benzodiazepines D. Perform gastric lavage

D. Sertraline Selective serotonin reuptake inhibitors such as sertraline are the most commonly used medications for postpartum depression.

A 21-year old woman sees you because of a depressed mood since the birth of her son 2 months ago. She is breastfeeding, and her baby is doing well. She denies any suicidal or homicidal ideation and has never had thoughts about hurting the baby. She has a history of depression 2 years ago that was associated with starting college. She began taking sertraline, changed her schedule, and spent more time exercising. Within 6 months her depression resolved and she stopped the medication. She reports this current depression feels worse than her previous depression. Which one of the following would be the most appropriate medication for this patient? A. Amitriptyline B. Diazepam C. Phenytoin D. Sertraline

D. Sertraline and olanzapine Major depressive disorder with psychotic features is defined by the above mentioned symptoms plus psychotic features of delusions or hallucinations, either auditory or visual. The first-line treatment for major depressive disorder with psychotic features is an antidepressant plus an antipsychotic medication. Studies show that sertraline, an antidepressant, in combination with olanzapine, an antipsychotic, works more effectively than just sertraline or just olanzapine alone.

A 17-year-old girl presents to your clinic with a chief complaint of sadness, loss of appetite, and the inability to sleep. She is having a hard time focusing at work and she is tired all of the time. She tells you that for the past month she has been hearing voices telling her to harm herself. She is interested in treatment. What is the most appropriate first-line therapy for this condition? A. Lithium B. Psychotherapy C. Sertraline D. Sertraline and olanzapine

B. Bipolar disorder

A 19-year-old man presents with his parents who state that their son has shown signs of impulsivity, pressured speech, racing thoughts, and a decreased need for sleep over the last three to four weeks that has caused him to miss school. What is the most likely diagnosis? A. Attention-deficit/hyperactivity disorder B. Bipolar disorder C. Major depressive disorder D .Schizophrenia

C. Naloxone The classic opioid toxidrome involves central nervous system depression, respiratory depression, and miosis

A 21-year-old man presents somnolent and altered. There is no evidence of trauma and his pupils are 2 mm. His vital signs are: T 36.8°C, HR 58, RR 6, BP 96/52, and oxygen saturation 93% on room air. His fingerstick glucose is 85 g/dL. Which of the following is an appropriate treatment? A. Atropine B. Fomepizole C. Naloxone D. Naltrexone

C. Fluoxetine Bulimia nervosa is an eating disorder characterized by recurrent episodes of binge eating and inappropriate compensatory behavior such as self-induced vomiting or laxative abuse.

A 21-year-old woman presents to your office for her annual exam. While taking the patient's history, she reveals that she has been eating excessive amounts of food and then vomiting almost daily for the past six months. She has started working with a nutritionist and is seeing a cognitive behavioral therapist but would like to know if there are any medications that might help her treatment. Which of the following is the most appropriate medication for this patient? A. Desipramine B. Diazepam C. Fluoxetine D. Lorazepam

C. Psychotherapy

A 24-year-old woman presents to clinic for follow-up on anorexia nervosa. She has gained four pounds in the last six months and currently has a body mass index of 19 kg/m². In addition to routine medical examination and dietary assessment, what other treatment component must be included in relapse prevention? A. Antihistamines B. Antipsychotics C. Psychotherapy D. Selective serotonin reuptake inhibitors

A. Factitious disorder Factitious disorder is characterized by falsified general medical or psychiatric symptoms. Patients deceptively misrepresent, simulate, or cause symptoms of an illness or injury in themselves, even in the absence of obvious external rewards

A 19-year-old woman is brought in by her husband for evaluation. He states that over the last week, she has exhibited a number of concerning symptoms including tremors and seizures. On entering the room, the patient is noted to be resting comfortably. When asked about the tremor, the patient begins to exhibit coarse diffuse tremors. During the evaluation the patient has generalized shaking but is able to respond to questions. Further discussion with the patient's husband reveals that they are currently going through a separation and there has been a lot of stress at home. Which of the following disorders accounts for the patient's symptoms? A. Factitious disorder B. Functional neurological symptom disorder C. Illness anxiety disorder D. Somatic symptom disorder

E. Schizophreniform disorder Schizophreniform disorder is a psychotic disorder diagnosed in patients who meet the criteria for schizophrenia, but the symptoms last less than 6 months Schizoid personality disorder (C) causes a patient to have a pattern of detachment from social relationships with difficulty in expressing emotions

A 17-year-old boy presents to a psychiatry office with his parents for a follow-up evaluation for behavioral and personality disturbances. On initial evaluation 1 month prior, the patient was withdrawn and did not show emotion throughout the visit. He was asked how he was doing and his answer involved pressured speech moving from subject to subject. He seemed unkept. His parents told you that he mentioned seeing vague objects, which he described as "shapes that talked" to him. Today, the patient presents very well kept with normal thought process and no hallucinations. His parents state his symptoms have resolved. His total length of symptoms was 4 months. No medication was started at the last visit at request of the parents. What would be the most likely diagnosis based on the patient's presentation? A. Adjustment disorder B. Brief psychotic disorder C. Schizoid personality disorder D. Schizophrenia E. Schizophreniform disorder

A. Bupropion Bupropion should be avoided in patients with a history of anorexia nervosa

A 34-year-old woman presents to her primary care provider desiring information on smoking cessation. She has a 15-pack-year history and currently smokes 1 pack per day. She has a past medical history of asthma, anorexia nervosa, hypothyroidism, and migraine headaches. Which of the following smoking cessation medications is contraindicated in this patient? A. Bupropion B. Buspirone C. Varenicline D .Venlafaxine

B. Feeling well rested after only 3 hours of sleep bipolar 1 disorder

A 34-year-old woman with a medical history of depression presents to a psychiatry office after being referred by her primary care clinician. The patient reports that, last month, she had a period of 7 days where she felt an inflated self-esteem, was more talkative than normal, engaged in risky sexual behaviors, and had racing thoughts. Her urine drug screen is negative and laboratory results are within normal limits. Which of the following is most likely an additional symptom the patient reports based on her suspected diagnosis? A. Feeling like someone is listening to her thoughts B. Feeling well rested after only 3 hours of sleep C. Having persistent, unwanted, intrusive thoughts D. Neglecting personal hygiene and grooming E. Repeated, distressing memories about past trauma

C. Illness anxiety disorder The patient has illness anxiety disorder. This was a new diagnosis that was introduced with the DSM-5, and it replaced reactive hypochondriasis.

A 35-year old man believes he has colon cancer. He reports that his "peristalsis is louder than usual" and he has "excessive flatulence." He shows you a logbook that he has been keeping of his bowel habits for the last 6 months. He reports no weight loss, fatigue, night sweats, blood in his stool, or family history of colon cancer. He is having difficulty sleeping. What is the most likely diagnosis? A. Body dysmorphic disorder B. Functional neurological symptom disorder C. Illness anxiety disorder D. Somatic symptom disorder

A. Delusional disorder Delusional disorder is diagnosed when a patient exhibits one or more persistent false beliefs, for one month or longer, in the absence of significant hallucinations or major functional impairment.

A 38-year-old woman presents to the clinic complaining of "chronic scabies". She states she has been to many clinics, received treatment for scabies multiple times, and yet continues to be infested. She states the parasites are even beginning to crawl around in her eyeballs. Prior records indicate negative findings for scabies from skin scrapings and dermoscopy. There are excoriations present on her upper extremities. Besides being distressed by her illness, she does not complain of depression, hallucinations, or cognitive impairment. She is steadily employed, denies any substance use, and has no psychiatric history. Which of the following is the most likely diagnosis? A. Delusional disorder B. Schizophrenia C. Schizotypal personality disorder D. Widespread scabies

C. Delusional disorder Delusional disorder is the presence of one or more delusions for a month or longer in a person who, except for the delusions and their behavioral ramifications, does not appear odd and is not functionally impaired.

A 67-year-old man is brought to the Emergency Department by his son and 70-year-old wife, who are concerned with his behavior. For the last six months, he has held a false belief that his wife is having sexual relationships with multiple men. His wife states she has not been sexually active for over ten years and denies the allegations. The son confirms he has been present with his mother when some of the alleged indiscretions have taken place and can confirm no other relationships are occurring. The patient has installed security cameras around the house in an attempt to "catch her in the act" and has not uncovered anything unusual. The patient is a recently retired detective, who explains that he is gathering evidence of his wife's infidelity. He denies alcohol and illicit drug use. He takes a statin to control his cholesterol, but is otherwise healthy. He has no prior mental health history and denies any manic or depressive symptoms. He denies hallucinations. His mood and affect are euthymic. His speech is organized and his behavior is polite. Which of the following is the most likely diagnosis? A. Bipolar disorder B. Brief psychotic disorder C. Delusional disorder D. Schizophrenia

B. Attention-deficit/hyperactivity disorder

A 7-year-old boy presents to the office with his mother for evaluation of his angry and defiant behavior that has been steadily worsening over the past year. The mother is teary and exasperated, explaining that it is a battle every day to get him to do normal tasks like getting ready for school or eating meals since he is often argumentative and does not do what he is told. He constantly blames her and her husband for making his life miserable. You suspect oppositional defiant disorder. Assessing for the presence of what common co-occurring disorder is key in effective treatment? A. Antisocial personality disorder B. Attention-deficit/hyperactivity disorder C. Autism spectrum disorder D. Disruptive mood dysregulation disorder

B. Autism spectrum disorder

A four-year-old boy is seen in your office for routine physical. His mother is concerned that he is not speaking like a normal four year old. On further evaluation, you notice he has poor eye contact and rapid hand movements, and he is preoccupied by repeatedly spinning the wheels on the toy cars he brought with him. What is the most likely diagnosis? A. Attention deficit hyperactive disorder B. Autism spectrum disorder C. Expressive speech delay D. Obsessive compulsive disorder

B. Biological mothers this caregiver is exhibiting behavior consistent with factitious disorder imposed on another. Factitious disorder imposed on another is characterized by the production or feigning of physical or psychological symptoms in another person, usually a child but may also be an adult under the care of the person with the disorder.

A seven-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? A. Adoptive fathers B. Biological mothers C. Foster parents D. Older siblings

B. Cannabis

An 18-year-old man presents to the urgent care after he was involved in a motor vehicle collision with a parked car. He was driving under 15 mph and did not know the parked car was there until he hit it. He does not recall wearing a seatbelt. He did not sustain a head injury nor does he report any other symptoms. On physical exam, his temperature is 98.6°F, blood pressure is 118/68 mm Hg, heart rate is 109 bpm, oxygen saturation is 98% on room air, and respiratory rate is 18/minute. The patient is alert and oriented to person, place, and event but not time. There is no evidence of trauma on a physical exam. He has trouble recalling details of the collision and appears to move slowly, and he is laughing at inappropriate times. A physical exam reveals bilateral conjunctival injection but is otherwise unremarkable. Which of the following substances is the most likely contributor to his presentation? A. Alcohol B. Cannabis C. Cocaine D. Opioids E. Phencyclidine

C. Low bone density, menstrual dysfunction, low energy availability

What are the components of the "female athlete triad"? A. Anemia, iron deficiency, menorrhagia B. Delayed puberty, ligamentous injuries, weight loss C. Low bone density, menstrual dysfunction, low energy availability D. menstrual dysfunction, hirsutism, ovarian cysts

C. Cognitive behavioral therapy

What is considered the first-line therapy for bulimia? A. Antidepressants B. Antipsychotics C. Cognitive behavioral therapy D .Weight management plan

A. Conduct disorder

Which of the following conditions, in which laws and social norms are repetitively violated, is the most common precursor to antisocial personality disorder? A. Conduct disorder B. Malicious compliance behavior disorder C. Oppositional defiant disorder D. Passive-aggressive personality disorder

A. Chest pain

Which of the following historical findings will most likely lead to a diagnosis of panic disorder? A. Chest pain B. Flashbacks C. Hyperarousal D. Loss of interest

B. Disorientation Patients with functional or psychiatric etiologies of psychosis are more likely to have auditory hallucinations (A) instead of visual ones, slow onset of symptoms (D), and normal vital signs (C).

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

C. Associated with a body image disturbance

Which of the following is true regarding anorexia nervosa? A. Affects men more than women B. Anti-depressants are an effective treatment C. Associated with a body image disturbance D. Menorrhagia is an early symptom

B. Citalopram first line = SSRI

A 28-year-old previously healthy woman presents to your office because she feels depressed. In the past 6 months, she has felt tired despite sleeping 10-12 hours per night, has no desire to exercise like she previously did, has lost 10 pounds, and reports not having an appetite. She says she has thoughts of wishing she weren't alive anymore, although she says she is not suicidal. Which of the following is considered first-line therapy for this patient? A. Amitriptyline B. Citalopram C. Olanzapine D. Phenelzine

D. Panic disorder

A 45-year-old woman presents to the office with a complaint of nausea, chest tightness, shortness of breath, and fear of losing control. These symptoms have occurred at the grocery store and when entering an elevator. For the past year, she has taken the stairs to avoid triggering the episode that happened in the elevator. However she is still having these episodes despite no clear trigger and they seem to come out of the blue. Which of the following is the most likely diagnosis? A. Generalized anxiety disorder B. Obsessive compulsive disorder C. Panic attack D. Panic disorder

A. Age over 85 years

You finish taking a history of a patient at risk for suicide. Which of the following would suggest the highest likelihood of committing suicide? A. Age over 85 years B. Cohabitation with parents C. Married with children D. Tactile hallucinations

C. Cyclothymic disorder Cyclothymic disorder is a mood disorder that shares features with many other psychiatric conditions. It is characterized by episodes of depression and hypomanic symptoms that do not meet the criteria for major depressive disorder or bipolar disorder, making it difficult to diagnose

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? A. Bipolar I disorder B. Bipolar II disorder C. Cyclothymic disorder D. Generalized anxiety disorder E. Schizoaffective disorder

B. Functional neurological symptom disorder The patient likely has functional neurological symptom disorder. This disorder is characterized by abnormalities or deficits of motor or sensory function that are not medically explained, such as blindness, seizure, paresis, paralysis, tremors, aphonia, or anesthesia. Classically, symptoms occur suddenly following a psychosocial stressor and are nonpainful. Somatic symptom disorder (D) has at least one somatic symptom that causes significant distress or disruption of daily life and is typically associated with excessive time, energy, and behavior changes related to the somatic symptom. However, in functional neurologic disorder, the presenting symptom is a loss of function, and there is often a lack of associated distress regarding the symptom itself.

A 24-year-old healthy woman presents to the ED reporting that she cannot move her legs. The symptoms occurred suddenly after she was told that her fiancé died in a motorcycle accident. She does not report associated symptoms, including pain. The sensation and deep tendon reflexes in her lower extremities are normal. She has normal muscle tone. What is the most likely diagnosis? A. Body dysmorphic disorder B. Functional neurological symptom disorder C. Illness anxiety disorder D. Somatic symptom disorder

D. Panic attack

A 27-year-old woman presents with chest pain. The patient reports that she was about to give a presentation at her job and suddenly had a feeling of impending doom. In addition to chest pain, she had palpitations and sweating. Which of the following is this patient experiencing? A. Acute stress disorder B. Agoraphobia C. Hypomania D. Panic attack

B. Avoidant personality disorder Avoidant personality disorder is characterized by this patient's symptoms of low self-esteem and desire for relationships which remains fruitless due to persistent fear of rejection.

A 29-year-old woman presents to the psychiatric clinic for a "lifetime" of intense anxiety not relieved by 12-weeks on fluoxetine. She reports low self-esteem, feeling "very uneasy" in social situations, and says she wishes she could make friends but worries that she'll say something "dumb" to people. Which of the following personality disorders does she most likely have? A. Antisocial personality disorder B. Avoidant personality disorder C. Dependent personality disorder D. Paranoid personality disorder

A. Autism spectrum disorder

A 4-year-old boy presents in clinic with his parents for evaluation of poor performance in preschool. His parents state he has never maintained eye contact, did not start walking until he was two years old, and has a restricted vocabulary but appears to understand most commands. Additionally, they state he has very specific interests and only plays with toy trains and toy clocks. He has one older brother, age 7 years, who has a normal developmental history and no significant medical history. The patient does not interact with his brother despite his brother's attempts to engage in play. On exam, he is well-nourished and well-developed, with no gross neurological abnormality. He avoids eye contact and does not answer questions. He prefers to sit alone in a chair with his toy clock. What is the most likely diagnosis? A. Autism spectrum disorder B. Conduct disorder C. Oppositional defiant disorder D. Social communication disorder

D. Venlafaxine Venlafaxine is an antidepressant approved by the FDA for treatment of generalized anxiety disorder. It is a selective serotonin-norepinephrine reuptake inhibitor (SNRI) and is considered a first-line treatment for anxiety disorder.

A 42-year-old woman presents to the clinic stating that she has constant feelings of "being worried." She notes that she has felt this way for over a year and notes that she has always been a worrier, but the constant thoughts are making it difficult to sleep and concentrate on her work. She feels restless and irritable most days. Which of the following medications is the most appropriate for long-term management of her diagnosis? A. Bupropion B. Methylphenidate C. Risperidone D. Venlafaxine

A. Admit the patient and start diazepam alcohol withdrawal = diazepam

A 49-year-old man presents to the Emergency Department complaining of sweating and tremors. The patient drinks a bottle of liquor per day and stopped suddenly because of a pending court case. His last alcoholic drink was 3 days ago. On physical examination, his blood pressure is 168/105 mm Hg, pulse rate is 106/minute, respirations are 22/minute, and temperature is 99.3°F. The patient appears agitated and restless with a visible tremor of bilateral hands. The triage team ordered folic acid, thiamine, and a multivitamin. Which of the following is the most appropriate disposition? A. Admit the patient and start diazepam B. Admit the patient and start disulfiram C. Discharge the patient with a prescription for diazepam D. Discharge the patient with a prescription for disulfiram

D. Increase the dose of fluoxetine to 30 mg daily

A 51-year-old woman presents for follow-up after being started on fluoxetine 20 mg daily 4 weeks ago for depressive symptoms. She has a history of major depression and was successfully treated with fluoxetine for several months after her last episode three years ago. The patient reports that the worst of the depressive symptoms have improved, but she still continues to experience mild sadness and tearfulness on occasion. She does not have any suicidal or homicidal ideation. She reports no side effects from the use of fluoxetine. No manic symptoms are present. Which of the following is the best approach to continuing pharmaceutical treatment? A. Continue fluoxetine and also start bupropion B. Discontinue fluoxetine and switch to lithium C. Discontinue fluoxetine and switch to sertraline D. Increase the dose of fluoxetine to 30 mg daily

A. Chlordiazepoxide Treatment includes monitoring, serial Clinical Institute Withdrawal Assessment for Alcohol (revised) (CIWA-Ar) testing and long acting benzodiazepines like chlordiazepoxide or diazepam.

A 52-year-old business executive presents to the ED with diaphoresis, tachycardia, visual hallucinations, and recent seizure. The patient states that he drinks alcohol daily but he is trying to quit. His last drink was one day ago. Which of the following is the most appropriate medication at this time? A. Chlordiazepoxide B. Haloperidol C. Phenytoin D. Quetiapine

E. Reassurance These patients and their parents should be reassured that sleep terrors are benign and usually resolve within 1-2 years. Avoiding sleep deprivation reduces the frequency of sleep terrors.

A 6-year-old boy presents to the clinic with his parents, who are concerned about nighttime episodes that have occurred once in each of the past 2 months. The parents report he will wake up in the middle of the night screaming and sweaty and does not remember these episodes the next morning. He is difficult to console during the episodes. Vital signs include HR of 80 bpm, BP of 105/65 mm Hg, RR of 20/minute, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination reveals a well-appearing boy with a regular rate and rhythm and lungs clear to auscultation. He has no sensory, motor, or cranial nerve deficits. Which of the following is the recommended next step in management? A. Cognitive behavioral therapy B. CT head without contrast C. Polysomnography D. Polysomnography with electroencephalography E. Reassurance

C. Paroxetine Generalized anxiety disorder (GAD) is defined by having uncontrollable anxiety and worry that interfere with daily activities for at least 6 months. Symptoms occur on more days than not during this time period. First-line medications for GAD include SSRI's or SNRI's, including paroxetine

A 60-year-old woman presents to your office accompanied by her adult daughter with a complaint of anxiety. She says that she's always been a "worrier," but since the birth of her grandchild last year her anxiety has gotten worse. Further discussion reveals that she sleeps only 2-3 hours per night, has daily headaches, and her daughter complains that she calls their house at least 15 times every day asking about her grandchild's safety. Which of the following is the most appropriate therapy? A. Imipramine B. Lorazepam C. Paroxetine D. Quetiapine

C. Conduct disorder conduct disorder is characterized by behavior which violates the basic rights of others, societal norms, or age-appropriate rules in a repetitive and persistent manner. These behaviors cause significant impairment in academic, social and occupational functioning and may be specified as occurring with limited pro-social emotions, such as lack of remorse or empathy.

A mother presents to clinic with her 15-year-old son. She is concerned because over the past 2 years he has been having significant behavioral problems. At home he is bullying his younger siblings, staying out past curfew, and she recently caught him setting fires in the backyard. At school he is consistently truant and failing all of his classes. Last weekend police picked him up for spray-painting graffiti on a local church. When asked to explain his behavior, the patient says, "I don't have to explain anything, I can do what I want." This patient meets criteria for which of the following disorders? A. Antisocial personality disorder B. Attention deficit/hyperactivity disorder C. Conduct disorder D. Oppositional-defiant disorder

A. Bipolar I

A patient with major depression spends $100,000 at a casino over the past week. He presents with his wife, who states they now are in severe debt and cannot make any more mortgage payments. She also reports that over the past week her husband talked all the time and never slept more than 3 hours at a time. Which of the following is the most likely diagnosis? A. Bipolar I B. Bipolar II C. Hypomanic episode D. Major depression, acute flare

D. White blood cell and absolute neutrophil count Use of clozapine involves a risk of life-threatening agranulocytosis, therefore regular monitoring of white blood cell and absolute neutrophil count (ANC) is required.

A patient with schizophrenia is starting treatment with clozapine. Which of the following needs to be monitored weekly? A. Electrocardiogram B. Fasting plasma glucose C. Hemoglobin and hematocrit D. White blood cell and absolute neutrophil count

A. Establish a strong therapeutic alliance Delusions of parasitosis (DoP) Initial management is by establishing a strong therapeutic alliance with the patient and respecting the patient's autonomy in all encounters. First-line pharmacologic treatment is with antipsychotic medications.

A previously healthy 52-year-old woman presents to your office with a complaint of diffuse pruritus. She is concerned about insects under her skin. She brought a sample of her skin mixed with debris that she believes are the insects. She is requesting that you send it to the lab. Physical exam reveals scattered ulcers and erosions in varying stages of healing with excoriations all over her body. Which of the following is the most effective management? A. Establish a strong therapeutic alliance B. Permethrin cream as needed C. Referral to psychiatry D. Referral to substance abuse treatment

D. Denial

A wife is upset about how her husband has behaved after receiving a new diagnosis of terminal lung cancer. He has spent the last few days on the internet feverishly looking up his old girlfriends in an attempt to find phone numbers and call them. He has only slept a few hours in this time period, and has eaten only pretzels and soda. When the wife is finally able to get his attention, she asked him what he was doing, to which he responded "I feel great, so I thought I'd catch up with some old friends." He does not meet diagnostic criteria for a manic episode, and has no history of bipolar disorder. You suspect he may be in which stage of the Kubler-Ross grief reaction? A. Anger B. Bargaining C. Catastrophizing D. Denial

B. Fetal alcohol syndrome

An 18-month-old adopted boy presents to the clinic for consult. He just recently transferred residence from another state where he used to have a pediatrician for his regular well baby consultation visits. The adoptive mother states that according to his previous physician, the boy has a ventricular septal defect and is need of early childhood intervention for developmental delay. Family histories of both biological parents are unknown. Upon physical examination, the child is both stunted and wasted with z scores less than 5% for both weight and height. Other pertinent findings include short palpebral fissures, a short nose, and a thin upper lip with a smooth philtrum. What is this child's most likely condition? A. Ehlers-Danlos syndrome B. Fetal alcohol syndrome C. Holt-Oram syndrome D. Turner syndrome

C. Selective serotonin reuptake inhibitors

Which of the following class of medications is used as first-line therapy for post-traumatic stress disorder? A. Atypical antipsychotics B. Benzodiazepines C. Selective serotonin reuptake inhibitors D. Tricyclic antidepressants

A. Fever, tachycardia, hypertension alcohol withdrawal with mild symptoms, alcohol related seizures, or in the most serious and life-threatening form of withdrawal, delirium tremens. The patient described here has several abnormal vital signs (fever, tachycardia, hypertension

Which of the following clinical scenarios in a patient with chronic ethanol use should prompt admission to the hospital? A. Fever, tachycardia, hypertension B. Intoxication with vomiting C. Mild tachycardia, tongue fasciculations D .Normal vital signs, one seizure six hours ago

D. Substance use

Which of the following factors predicts the highest risk of suicide completion? A. Female gender B. Married relationship status C. Poor financial status D. Substance use

A. Delusions and disorganized speech for six months

Which of the following is adequate for a new diagnosis of schizophrenia? A. Delusions and disorganized speech for six months B. Delusions and hallucinations for two weeks C. Flat affect and avolition for two weeks D. Hallucinations and chronic alcohol use

D. Psychotherapy Factitious disorder is characterized by deceptive and falsified symptoms with no apparent external gain to the patient.

Which of the following is first-line therapy for a patient with factitious disorder? A. Antidepressant medication B. Antipsychotic medication C. Electroconvulsive therapy D. Psychotherapy

B. Delirium, hallucinations, and tremor delirium tremens

Which of the following is most consistent with alcohol withdrawal? A . Agitation and increased appetite B. Delirium, hallucinations, and tremor C. Depressed mood with diarrhea D. Dilated pupils, runny nose, and watery eyes

A. Neglect

Which of the following is the most common type of child abuse? A. Neglect B. Physical C. Psychological D. Sexual

C. Has difficulty organizing tasks and activities, blurts out answers before questions have been completed, has difficulty waiting for his or her turn, is forgetful in daily activities

You partner with a local school to create a checklist of symptoms that the teachers fill out to aid in the diagnosis of attention deficit hyperactivity disorder. Which combination of symptoms would be most consistent with a diagnosis of attention deficit hyperactivity disorder? A. Actively defies or refuses to follow teachers' rules, is easily annoyed by classmates and is frequently angry or resentful, argues with teachers B. Bullies or intimidates peers, leaves seat when remaining seated is expected, lies to get out of trouble, skips school without permission C. Has difficulty organizing tasks and activities, blurts out answers before questions have been completed, has difficulty waiting for his or her turn, is forgetful in daily activities D. Is easily distracted, frequently worries, is afraid to go to school or be called on by the teacher to answer questions

D. Support airway and breathing opioid overdose

A 28-year-old man presents to the emergency department by ambulance. His family called for help after finding him unresponsive at home with a syringe on the floor beside him. His blood pressure is 120/78 mm Hg, pulse 95/min, and respirations are 6/min and shallow. On physical exam he is non-responsive to questions, his skin is cool with cyanosis, and his pupils are minimally reactive to light and constricted. Which of the following is the most appropriate next step in management? A. Administer naloxone B. Administer sodium bicarbonate C. Place a nasogastric tube and administer activated charcoal D. Support airway and breathing

D. Cognitive behavioral therapy Bipolar personality disorder First-line treatment for patients with BPD is psychotherapy, with different types of cognitive behavioral therapy being most effective.

A 28-year-old woman presents to your office with a complaint of mood swings. She tells you that she constantly fights with her boyfriend and gets angry easily. She often uses cocaine and binge eats when under stress. Last month, she held a knife to her wrist during an argument with her boyfriend but did not follow through with the suicide attempt. Which of the following is the most appropriate next step in management? A. Admission to an inpatient psychiatric unit B. Begin course of amitriptyline C. Begin course of lorazepam D. Cognitive behavioral therapy

C. Malingering This patient most likely is malingering, which is to purposefully feign physical symptoms for external gain.

A 34-year-old woman has been seen multiple times in the past several months for various pain-related complaints. On each occasion, no physical or laboratory findings were found to explain the symptoms. The patient is involved in a worker's compensation case and could make a significant amount of money if it is demonstrated that her physical complaints are related to work conditions. Which one of the following diagnoses characterizes her unexplained physical symptoms? A. Conversion disorder B. Factitious disorder imposed on self C. Malingering D. Somatic symptom and related disorders

C. Engage in conversation, discuss her symptoms, and validate her distress Borderline personality disorder (BPD

An 18-year-old woman with a history of frequent visits to the ED presents with multiple superficial lacerations to her left wrist. She is agitated and states she is suicidal. She is yelling at the nurses and demands to be seen only by the psychiatrist. Which of the following is the most appropriate next step in management? A. Administer 5 mg of intramuscular haloperidol B. Consult the psychiatry service C. Engage in conversation, discuss her symptoms, and validate her distress D. Place her alone in a private room and wait for her to calm down

C. Olanzapine Pharmacotherapy has not been shown to be an effective treatment for anorexia nervosa when used as monotherapy, but for those acutely ill who have not demonstrated a response to psychotherapy and nutritional rehabilitation, olanzapine can be added to the treatment regimen.

Which of the following medications can be prescribed to assist in weight gain for a patient with anorexia nervosa? A. Alprazolam B. Fluoxetine C. Olanzapine D. Risperidone

D. Propranolol This patient has social anxiety disorder, performance type. Propranolol is typically used prior to a public speaking situation in performance anxiety

A 22-year-old woman with a history of anxiety presents to your office, reporting a racing heart, sweating, and intense fear every time she has to give a presentation in her college class. This is a requirement for her class approximately every 4 months. She reports these symptoms have been ongoing for the past year and only occur when she is in front of large groups of peers because she is worried about embarrassing herself. Her blood work from her last visit was within normal limits, her urine drug screen was negative, and her physical exam reveals no abnormalities. She reports occasional alcohol use on the weekend. Which of the following is the most appropriate management of the suspected diagnosis? A. Buspirone B. Lorazepam C. Paroxetine D. Propranolol E. Venlafaxine

B. Borderline In the emergency department, these patients will often "split" providers: they will act with affection and respect to some providers and anger and disregard to others. Substance abuse and drug seeking behavior are often seen in borderline patients as well.

A 23-year-old man presents with leg pain for three months and requests hydromorphone for pain. The nurse approaches you because she believes the patient is "drug seeking" as he became extremely upset when she told him that he would have to wait for the doctor to evaluate him before pain medications could be given. Upon entering the room, the patient speaks pleasantly with you and compliments you on your kindness. He tells you that he only comes to this hospital because "it's the best in the world," and "none of the other doctors understand me." Upon informing the patient that you will not be prescribing hydromorphone, he becomes extremely upset and starts yelling. This patient is exhibiting traits that are consistent with which of the following personality disorders? A. Antisocial B. Borderline C. Histrionic D. Narcissistic

E. Discontinue risperidone The patient in the above vignette has signs and symptoms of neuroleptic malignant syndrome, a potentially fatal reaction to antipsychotic medications, such as risperidone.

A 24-year-old man is brought to the emergency department unresponsive. His mother accompanies him and states that he became confused earlier in the day, then gradually stopped talking, became rigid, and started sweating profusely. He was recently diagnosed with bipolar disorder and began taking lithium and risperidone 2 weeks ago. He has no other diseases and takes no other medications. He has been hospitalized once for a manic episode. Vital signs are temperature 103.4°F, heart rate 150 beats/minute, respirations 22/minute, and blood pressure 200/100 mm Hg. Physical exam reveals an unresponsive patient with very warm, diaphoretic skin, bodywide muscle rigidity, increased salivation, and pinpoint pupils. Urine toxicology findings are negative. Other laboratory findings are as follows: Serum lithium level: 1.0 mEq/L (reference range 0.8-1.2 mEq/L) Serum creatine kinase level: 2,200 U/L (reference range 22-198 U/L) WBC: 20.9 x 103/uL RBC: 5.27 x 106/uL Hemoglobin: 15.4 g/dL Hematocrit: 44.1% Mean corpuscular volume: 84 fL Mean corpuscular hemoglobin: 92.2 pg Mean corpuscular hemoglobin concentration: 34.9 g/dL Red blood cell distribution width: 13.7% Platelets: 301 x 103/uL Neutrophils: 12.1 x 103/uL Lymphocytes: 2.8 x 103/uL Monocytes: 0.7 x 103/uL Eosinophils: 0.4 x 103/uL Basophils: 0.0 x 103/uL What is the best next step in the management of this patient's condition? A. Add benztropine B. Add ceftriaxone C. Add lorazepam D. Discontinue lithium E. Discontinue risperidone

D. Taper sertraline and add bupropion The recommended management of this is to taper the selective serotonin reuptake inhibitor and switch to bupropion

A 24-year-old man with a history of unipolar depression, for which he is on sertraline, presents to the clinic with decreased libido and decreased sexual arousal for the past 2 months. The patient was started on a low dose of sertraline 3 months ago for unipolar depression. The patient reports his overall mood has improved since starting sertraline, and he is more interested in activities that he usually enjoys. However, he reports he experiences erectile dysfunction during almost all attempted sexual activity. Vital signs include HR of 80 bpm, BP of 120/80 mm Hg, RR of 20/minute, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination includes a regular rate and rhythm and lungs clear to auscultation. Which of the following is the recommended treatment? A. Add bupropion and continue sertraline B. Add sildenafil and continue sertraline C. Discontinue sertraline immediately and add bupropion D. Taper sertraline and add bupropion E. Taper sertraline and add duloxetine

B. Citalopram panic disorder Initial treatment for panic disorder is with an antidepressant, cognitive behavioral therapy, or a combination of the two. When a decision is made to treat with medication, first-line treatment is with a selective serotonin reuptake inhibitor (SSRI), such as citalopram.

A 24-year-old woman presents to your office with a complaint of severe anxiety. Approximately three times per week she has episodes of sweating, chest pain, heart palpitations, shaking and fear of losing control or dying. The episodes seem to occur and resolve spontaneously. Which of the following is the most appropriate therapy? A. Carbamazepine B. Citalopram C. Imipramine D. Risperidone

C. Recommend psychosocial treatment

A 25-year-old man presents to the clinic for follow-up after being diagnosed with alcohol use disorder of moderate severity. He was recently discharged from the hospital after being involved in a motor vehicle collision. During his stay, he expressed a desire to stop drinking and completed a medical detox. His last alcoholic drink was 10 days ago. Prior to discharge from the hospital, he was started on naltrexone 50 mg per day by mouth, which he is tolerating well and continues to take daily without issue. Which of the following is the most appropriate next step in management? A. Change naltrexone to acamprosate B. Change oral naltrexone to depot naltrexone C. Recommend psychosocial treatment D. Recommend residential treatment

B. Borderline personality disorder

A 27-year-old woman presents to your office requesting a referral for psychotherapy. She tells you that she is constantly fighting with her current partner, has not been able to maintain a romantic relationship for more than three months, has not been able to maintain employment because "they treat me unfairly", has a history of self mutilation by cutting and has multiple suicide attempts in the past. Which of the following is the most likely diagnosis? A. Anxiety disorder B. Borderline personality disorder C. Histrionic personality disorder D. Paranoid personality disorder

D. Somatic symptom disorder Somatic symptom disorder is characterized by physical complaints from various organ systems. Diagnostic criteria include a history of one or more somatic symptoms associated with excessive thoughts, feelings, and behaviors, such as devoting significant time and energy to the health concerns or persistent thoughts or anxiety about the symptoms or the patient's general health.

A 27-year-old woman presents to your office with complaints of pain and discomfort. She tells you that she has seen numerous doctors and none of them have been able to help her. Her symptoms today include nausea, irregular menses, weakness in her legs, headache, dysuria, dyspareunia, and back pain. She would like you to do a CT scan to determine the cause of her complaints. Which of the following is the most likely diagnosis? A. Factitious disorder B. Functional neurological symptom disorder C. Malingering D. Somatic symptom disorder

E. Taper and discontinue risperidone Tardive dyskinesia is a condition characterized by abnormal movements of the face, mouth, tongue, trunk, and limbs due to long-term treatment with antipsychotic agents

A 28-year-old woman with bipolar disorder presents to the office reporting involuntary facial movements that have worsened over the past 3 months. She was prescribed risperidone and lithium about 6 months ago. On a physical exam, the patient has difficulty sticking out her tongue and has occasional involuntary movements of the tongue at rest. She also has increased blinking frequency. A blood lithium level is 0.9 mEq/L. Which of the following is the best next step in the management of her symptoms? A. Add benztropine as needed B. Add propranolol as needed C. Discontinue lithium and start valproic acid D. Increase dosage of risperidone and decrease lithium dosage E. Taper and discontinue risperidone

C. Lamotrigine Lamotrigine is an anticonvulsant and mood stabilizer and can be used to treat migraines. It is especially useful as a maintenance drug to prevent the depressive episodes of bipolar I and II, this patient's likely diagnosis given her former medication with lithium. Lamotrigine is known to induce a mild maculopapular rash in 1 out of 10 people who take it

A 29-year-old woman presents to urgent care with concerns about a new rash. She was recently hospitalized for a depressive episode with suicidal thoughts (she almost swallowed all of her pills), prompting the hospital psychiatrist to replace her lithium with another medication because of the potential for permanent kidney damage. She cannot recall the name of the new medication, but the doctor had said it would reduce her migraines as well. Vital signs are a BP of 110/78 mm Hg, HR of 85 bpm, RR of 18/min, and T of 96.0°F. Exams of her eyes, ears, nose, and mouth are normal, and no lymphadenopathy is detected. Heart rhythm is regular, and lungs are clear to auscultation. A maculopapular rash extends across her chest and thighs. No vesicles are present. Which of the following medications is the most likely cause of her rash? A. Escitalopram B. Haloperidol C. Lamotrigine D. Olanzapine E. Topiramate

A. Ask about traditional medicinal practices being used

A 3-year-old boy from South America presents to your office with his father for a well-child exam. While listening to his lungs you notice that his back is covered with circular lesions approximately 3-4 cm in diameter with central ecchymosis and petechiae. Which of the following is the next best step? A. Ask about traditional medicinal practices being used B. Begin workup for bleeding disorders C. Call child protective services D. Obtain a urinalysis

D. Thyroid-stimulating hormone, complete metabolic panel, and complete blood count laboratory tests

A 30-year-old man, currently being treated with paroxetine daily for generalized anxiety disorder, presents to the clinic complaining of episodes of tachycardia, sensations of impending doom, chest pain, and shortness of breath over the past six months. The episodes are triggered by anticipation of certain stressful events and resolve themselves within 15 minutes. Which of the following would be the most appropriate evaluation to perform when considering the diagnosis of panic disorder in this patient? A. Erythrocyte sedimentation rate, C-reactive protein, and rheumatoid factor laboratory tests B. Mini-Mental State Exam assessment C. Panic Disorder Severity Scale assessment D. Thyroid-stimulating hormone, complete metabolic panel, and complete blood count laboratory tests

A. Escitalopram First-line treatment for depression is pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) such as escitalopram, psychotherapy, or a combination of both

A 31-year-old woman presents to your office with a complaint of feeling depressed. In the past two months she has lost 10 pounds, is experiencing insomnia, has low energy, difficulty concentrating, and feels worthless. She denies thoughts of suicide. Which of the following is the most appropriate therapy? A. Escitalopram B. Imipramine C. Lithium D. Risperidone

A. Aripiprazole While all medications in this class can have metabolic side effects, aripiprazole is the most favorable of the options listed

A 32-year-old man presents to an outpatient behavioral health office after experiencing almost daily symptoms of hallucinations. He also reports there is someone sending him messages through the television. His family reports he has had incoherent thoughts. All these symptoms have occurred over the past 7 months. His medical history includes obstructive sleep apnea. Vitals reveal a heart rate of 68 bpm, respiration rate of 17 breaths/minute, blood pressure of 116/78 mm Hg, oxygen saturation of 99%, temperature of 98.7°F, and BMI of 36 kg/m2. The patient appears disheveled with a flat affect. Which medication would be most appropriate for the suspected diagnosis? A. Aripiprazole B. Clozapine C. Lamotrigine D. Olanzapine E. Sertraline

C. Serotonin syndrome The patient is suffering from serotonin syndrome likely due to an interaction between her antidepressant medication, fluoxetine and dextromethorphan, a cough suppressant found in many over-the-counter cough and cold medications.

A 32-year-old woman is brought to the ED by her husband because she "has been acting strangely." She has a past medical history of depression that is well controlled with fluoxetine. He also reports she has been suffering from a cold and took over-the-counter cough medication a few hours prior to the onset of her symptoms. She is agitated and confused. Her blood pressure is 160/80 mm Hg, pulse is 140 beats per minute, and temperature is 39°C. She is flushed and her pupils are dilated. She has clonus and hyperreflexia in her lower extremities, as well as a tremor in her hands. What is the most likely diagnosis? A. Malignant hyperthermia B. Neuroleptic malignant syndrome C. Serotonin syndrome D. Tyramine reaction

A. Add bupropion to fluoxetine SSRI = sexual dysfunction Bupropion is often used as an add-on to an SSRI or SNRI for major depressive disorder resistant to first-line medications, as it uses different pathways and can also be added to an existing regimen to reduce the sexual side effects associated with SSRIs and SNRIs.

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? A. Add bupropion to fluoxetine B. Discontinue all psychiatric medications C. Discontinue fluoxetine and start paroxetine D. Increase fluoxetine dose E. Refer to a fertility specialist

A. Blood pressure Venlafaxine is a serotonin and norepinephrine reuptake inhibitor (SNRI) Common side effects include nausea, dizziness, dry mouth, and an increased risk of gastrointestinal bleeding. It can also cause elevated blood pressure secondary to the norepinephrine effects, especially at the maximum dose. It is recommended to monitor a patient's blood pressure every 2-6 months after initiating treatment.

A 35-year-old woman has a follow-up appointment in the office for unipolar major depression. On her initial visit 3 months ago, she stated she had recently lost her spouse tragically. She noted crying extensively, feeling down and sad, excessive sleepiness, weight loss, and poor energy level. Her symptoms have been persistent since her spouse's passing. At the initial visit, you began the patient on sertraline and titrated to a dosage of 150 mg daily. The patient noticed minimal to no improvement on sertraline. You decided to trial her on venlafaxine. She has been titrated to the maximum extended-release dose of 225 mg daily. She is now feeling much better and has had improvement in her symptoms. Her vital signs show a HR of 80 bpm, BP of 125/82 mm Hg, oxygen saturation of 98% SpO2, and T of 98°F. What should be monitored based on the patient's current medication class and dosage? A. Blood pressure B. Complete blood cell counts C. Electrocardiogram D. Kidney function E. Thyroid function tests

C. Histrionic Individuals with histrionic personality disorder tend to be excessively emotional and overall demonstrate attention-seeking behavior. They want to be the center of attention.

A 36-year old woman presents complaining of 10/10 low back pain. She dramatically describes how she injured herself during sexual intercourse with a younger man. Despite her pain, she is resting comfortably on the stretcher and talking loudly on her cell phone. Her hair and makeup are well done and she is dressed in provocative clothing. She demands to be evaluated by a male doctor. She makes a point to undress in front of the physician and is wearing lingerie. Which of the following personality disorders does this patient most likely have? A. Antisocial B. Borderline C. Histrionic D. Narcissistic

C. Opioid partial agonist Buprenorphine, an opioid partial agonist, is an evidence-based option for both pain relief and opioid use disorder.

A 36-year-old woman with a history of an opioid use disorder presents to your family practice. She explains that it was easier to purchase drugs on the street than obtain prescription for opioids to get relief from her whiplash injury. In the past 6 months, she has lost her job and her house, and last week, her daughter was placed in a foster home. She appears agitated but highly motivated to reverse her losses. She has no other substance use, and her last opioid use was this morning. You have received medications for opioid use disorder certification, and your clinic has a dedicated behavior health counselor. What is the best medication for her treatment? A. Long-acting opioid agonist B. Long-acting opioid antagonist C. Opioid partial agonist D. Short-acting opioid agonist E. Short-acting opioid antagonist

C. Paroxetine PTSD

A 38-year-old man presents to the office, reporting difficulty sleeping, with nightmares and anxiety for the past 2 months that have gotten more frequent. He returned from an overseas tour with the military 3 months ago. He also reports having flashbacks of his time in combat, especially when recalling his time there. The patient is alert and oriented but appears slightly withdrawn. A physical exam is unremarkable. Which of the following is the most appropriate pharmacotherapy for this patient in addition to immediate psychotherapy? A. Buspirone B. Clonidine C. Paroxetine D. Temazepam E. Trazodone

B. Insomnia, anxiety, headache SSRIs

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

C. Factitious disorder Factitious disorder imposed on self, previously known as Munchausen syndrome, is a disorder in which patients feign illness in order to obtain attention, sympathy, or to play the sick role rather than for external rewards such as medications or financial gain.

A 45-year-old man presents from home with a complaint of abdominal pain. A review of his previous visits shows two prior evaluations for similar abdominal pain during which he revealed that he had swallowed writing utensils. Endoscopic removal of the writing utensils was required in both cases. An X-ray today confirms the presence of a pen in the esophagus. What is his most likely diagnosis? A. Borderline personality disorder B. Drug-seeking behavior C. Factitious disorder D. Malingering

B. Delusional disorder The term delusional disorder refers to a condition whose core feature is persistent, nonbizarre delusions not explained by other psychotic disorders. It is a fixed false belief that has a certain level of plausibility

A 45-year-old man who lives alone and is a highly functional working individual, tells you that each night there are people around his house who are constantly watching him throughout the night. Which of the following is the most likely diagnosis? A. Delirium B. Delusional disorder C. Depression D. Schizophrenia

C: Escitalopram

A 45-year-old previously healthy woman presents to your office with a complaint of depressed mood. She says that over the past six months she has had difficulty sleeping, poor appetite, fatigue, lack of interest in her usual social activities, and recurrent episodes of crying. On physical exam she has lost 15 pounds since her last office visit and her hygiene is poor. She has never taken medication or had treatment for depression. Which of the following is the most appropriate therapy? A. Amitriptyline B. Aripiprazole C. Escitalopram D. St. John's Wort

B. Dextroamphetamine ADHD with accompanying oppositional and defiant behavior

An 8-year-old boy presents to his pediatrician's office with his mother after a recent parent-teacher conference. The teacher informed the mother that the boy is very disruptive in class, often leaving his seat or blurting out answers before being called. He is also impulsive and unable to wait for his turn. He often blames others for his mistakes and misbehaviors. As a result of this, he has few friends in his school and his academic performance has declined. At home, the mother reports that the child also has similar behaviors. He is spiteful and wants to get even with his sibling, he refuses to follow directions and constantly interrupts adult conversations. He is always "on the go" and runs about or climbs too much when remaining seated is expected. In the clinic, the child is restless and interrupts your conversation with the mother often. Which of the following is the most effective therapy for the child? A. Atomoxetine B. Dextroamphetamine C. Guanfacine D .Sertraline

B. Haloperidol Typical antipsychotics such as haloperidol have a relatively high risk of adverse effects such as tardive dyskinesia and parkinsonism, especially in older patients. They are mainly effective against the positive symptoms.

Which of the following medications is most likely to cause side effects such as tardive dyskinesia and have limited efficacy in treating the negative symptoms of schizophrenia? A. Aripiprazole B. Haloperidol C .Quetiapine D. Risperidone

C. Tardive dyskinesia Tardive dyskinesia is a hyperkinetic movement disorder that can occur after chronic use of dopamine receptor blockers, usually antipsychotic medications and the antiemetic medication metoclopramide

Which syndrome is chronic antipsychotic use associated with the development of? A. Palmar-plantar erythrodysesthesia B. Stevens-Johnson syndrome C. Tardive dyskinesia D. Vancomycin infusion reaction