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Terms in this set (100)
Woman with multiple SAs; labs all normal, Utox neg., patient most likely to have what abnormality in her CSF?
Decreased concentration of 5HTA
Decreased binding of dopamine at postsynaptic receptor
Pt has schizophrenia treated w Haloperidol, She would like to decrease likelihood of developing tardive dyskiesia; appropriate next step?
Switch Haloperidol to AAP like aripiprazole
Pt BIB police to ED after threatening her bf with meat cleaver. Physical and history shows evidence of DV. She was treated for MDD with ADs, but bf flushed Rx down toilet. She has HI, no SI. Next step?
Admit to hospital psych unit +HI
Pt presents w 5 hour hx of confusion and agitation. Bugs crawling all over his skin. Been using cocaine 6x daily for 3 days. Prolonged QT interval. Most appropriate pharmacotherapy?
53yo woman BIB husband for personality changes in past 6 years. Irritable, sexually uninhibited, loud. Intermittent jerky movements. Father had similar symptoms starting at age 56. MRI of brain will most likely show?
87yo w MDD, GAD, and Parkinsons disease presents increased anxiety for 2 wks. Been accusing staff at care facility of stealing. Been heard talking when alone in room. One month ago venlafaxine was doubled and carbidopa-levodopa was increased by 50%. Next step with meds?
Decreased the dosage of carbidopa-levodopa
47yo with remote history of cocaine abuse and meperidine dependence, but has not used illicit drugs in 9 years presents after MVA. Extensive wound debridement and suturing. Most appropriate step for pain management?
42yo w 2wk hx of daily episodes of dizziness and feeling like she's going to pass out. Afraid to go to sleep for fear she won't wake up. She has gone to ED 4x in past 3months. 6 years ago she had an MI. ECG shows sinus tachycardia. Most likely cause of her sx?
21yo college student with 3 year hx of distressing thoughts that he will hurt other people. Violent sexual thoughts he cannot control. He is embarrassed to talk about these thoughts. Appropriate pharmacotherapy?
Clomipramine (the TCA for OCD); also can use SSRIs
23yo pt with bipolar disorder well controlled with lithium. Upset bc he has gained weight and now has acne. Other mood stabilizers were ineffective for him. Appropriate next step in mgmt?
Explain the risk of illness recurrence without medication
82yo w difficulty sleeping in past year. Falls asleep easily, but wakes up early unable to fall back asleep. Sometimes dozes off during the day. On MSE, he is alert with euthymic mood and reactive affect. In addition to providing sleep hygiene instructions, provide:
16yo who prefers to eat alone. Mom found food hidden under bed. Patient is 5.6 and weighs 96lbs. She is most likely to have a hx of?
42yo woman w SI, depression, emotional lability and poor concentration. Cannot recall when Sx began. Father and sister have similar history of Sx. Intermittent abdominal pain. Neurologic exam shows decreased joint position sense. Romberg sign is present. Most likely cause of these Sx?
Acute intermittent porphyria
67yo man w 2month hx of fatigue and decreased libido. Now sleeps 10 hours a night with nap during day. 10lb weight gain. Losing interest in life bc of multiple medical problems: DM2, HTN, hypercholesterolemia, osteoarthritis. Most appropriate step in pharmacotherapy?
Add bupropion to regimen
22yo w 3 year hx of headaches and diarrhea. Worried about new job, money to pay bills and school loans. Last year of college she was worried if she would graduate and find a job. Asks bf for reassurance often. Dx?
52yo w hx difficulty sleeping and fatigue. Describes uncomfortable sensation in calves she firsts notices a few minutes after going to bed-keeps her awake for up to 2hours. Dx?
Restless leg syndrome [extra: tx w DA agonists ie pramipexole- can make sleepy]
27yo first year surgical resident to request sleeping aid Rx. Past 2months has had increased anxiety; avoids social activities; wakes up multiple times at night and cannot sleep past 3am; 6lb weight loss. Next appropriate step?
77yo w 6month hx of confusion and 'slowing down.' Sometimes sees and has convos with "people sitting by his bedroom window." Affect dulled. Fails serial 7s and cannot spell world backward or draw hands on a clock accurately. Dx?
Lewy Body Dementia
42yo man presents for routine health maintenance. Fatigue, anxiety, decreased work performance since divorce 2 months ago. No weight loss or gain, does not feel depressed. Labs all normal. Next appropriate step?
20yo woman brought to ED after found comatose at her desk with blood glucose level of 15mg/dL. Mother has DM2. Insulin concentration increased, but C-peptide WNL. Likely explanation?
Surreptitious administration of insulin
57yo woman with progressive loss of voice since her husband of 20 years died 10 months ago. She now has to communicate w writing, bc voice so weak. On day of husbands death they had gotten into fight and she said she wished he would die. Most likely dx?
5yo girl BIB parents bc of difficulty learning. Likes to go to school and carries backpack w pride. Epicanthal folds. Grade 2/6 murmur. Dx?
67yo w Parkinsons disease BIB wife bc increasingly withdrawn. Poor energy, decreased sleep for 2 moths. 15lb weight loss. Flat affect, downcast gaze. Avoids socializing bc of tremor. Crying, says "who wouldn't be sad with this damn disease?" Dx?
10yo boy. High energy level, difficult to discipline, argues about everything. 1 month ago killed family cat, not remorseful. Older brother in juvenile detention for grand larceny. PE shows several ecchymoses in various stages of healing over extremities. Worries at night that something will happen to someone in his family. Dx?
42yo BIB wife bc of 2month hx of staring spells that last 1-2 minutes. Smacks lips and picks at his shirt collar. 4 years ago in coma for 2 weeks after MVA; required 6 months rehab. Smells burnt rubber intermittently. Hears intense hissing sound too. EEG will likely show?
Focal spikes localized to the temporal lobe.
62yo woman w 1wk auditory hallucinations. She was the star of a play that closed after one performance. Dx?
Brief psychotic disorder
47yo woman w 12hour history of tremors and confusion. Hx of alcoholism and last consumed alcohol 24 hours ago. Given thiamine, folic acid, and 3 doses of diazepam. Intubated and placed on mechanical ventilation. 2 hours later remains agitated. Upper extremity tremor continues and lower extremity hyperreflexia bilaterally. Next best step in Rx?
Administer additional diazepam
32yo BIB wife bc of increasing confusion and agitation since he came home from work 2 hours ago. One wk ago began taking tamadol. Hx of MDD and takes fluoxetine. Dilated pupils, hyperreflexia, and generalized muscle rigidity. Dysregulation of which neurotransmitter?
10month old boy brought in bc of irritability throughout the night. Mother says he's been crying and has refused to bear weight on lower extremities since she picked him up from babysitter. X ray shows mild demineralization and spiral fracture of right femur. Mechanism of injury?
7yo boy w difficulty at school. Will not go to sleepovers, has stomachaches every weekday morning. Played on soccer team but quit when his mother could not drive him to games. Sits on mother's lap and does not make eye contact with the physician. Dx?
Separation anxiety disorder
17yo BIB mother bc of 9lb weight loss. BMI 16. Depressed mood and irritable affect. ECG shows sinus bradycardia. Worried about being overweight and recently binges and purges. Dx?
13yo girl BIB mother bc not yet had menstrual period. Physical exam shows no abnormalities. Next appropriate step?
Discuss normal pubertal development
24yo male f/u appt 2 weeks after starting sertraline for MDD and SI. Says he feels better but still has trouble sleeping. Next appropriate step?
Maintain the current dose and schedule weekly f/u exams for the next month
20yo college student comes to student health bc she has been feeling 'terrible' for past wk. She has been tearful and distracted since her bf broke up with her 1 week ago. She performed poorly on an exam 3 days ago and has not been sleeping well. Dx?
27yo teacher comes to physician requesting Rx for sleep medication. She has been unable to fall asleep until 2 or 3am since the start of school year 3 months ago. During vacations and on weekends she typically sleeps from 3am until noon and feels energetic and well rested. Dx?
Circadian rhythm sleep disorder
37yo man f/u post alcoholic cirrhosis dx. He has missed 3 prior appts bc of transport issues. His driver's license was suspended for DUI. GGT = 158. Next step in management?
Recommend alcohol rehab
47yo man w 4wk hx of depressed mood, lack of energy, poor concentration, 13lb weight loss (intentional!). Most likely dx?
Adjustment disorder with depressed mood
27yo post MVA, feels he's being followed by FBI, mild hyperreflexia, affective lability, rapid speech. Agitated.
Previously healthy 25yo w sudden behavior change. Anxious bc everyone around her has "turned into spacemen." She avoids medical staff bc they look like "large furry monsters." She sees "multicolored snakes singing Hail Mary." Agitated by AAOx3. Tox screen negative
47yo man struck his head on glass door that he thought was open. No LOC. Hx of schizophrenia on medication. CT scan most likely to show?
Symmetric enlargement of the ventricles.
55yo woman w strange behavior for 3 months. Believes that her father and next-door neighbors have been taking money away from her, blowing fumes under her door. Nothing noteworthy on MSE. AAOx3. Dx?
3 and 1/2 yo continues to wet his bed. Most appropriate intervention?
Reassurance that this is normal behavior
4yo bib father bc of behavior problems. Increasing tantrums. Last night threw dinner plate at younger brother. Not hyperactive. Behaves at day care and when she visits her grandmother. Which of the following is the most appropriate step in mgmt?
Begin parent mgmt training
25yo woman bib police bc she had been running in front of cars at a busy downtown intersection; she told police she is on a mission to save earth from pollution. She hears the voice of Mother Earth asking for her protection. Best INITIAL Rx for acute symptoms?
Ziprasidone (only AAP)
15 min after administration of IM Haloperidol, 21yo woman has torticollis. Antagonism of what neurotransmitter is most likely responsible?
32 yo man with intrusive thoughts of killing his 4yo son. He does not want to do it and considers the thoughts ridiculous. Finds the thoughts repulsive. Most likely dx?
37yo woman BIB police - found begging in front of stores for 4 days. Oriented to place and time but is unable to recall her own identity or where she lives. Dx?
20yo college student with 1 year hx of anxiety, dry mouth, sweating, nausea, and palpitations. First noticed symptoms when asked to speak in front of group. Failing a public speaking class. Now avoids situations where she might have to speak in public. Dx?
46yo woman brought to ED in resp. depression after attempting suicide by ingesting large amount of unknown drug. Exam shows pinpoint pupils. Most likely drug ingested?
5yo boy w temp to 102, coryza, cough for 2 days and 2 hours visual hallucinations. Mother has been giving him over the counter medication for 24 hours. Most likely reason for hallucinations?
Previously healthy 23yo brought into ED 20min after bizarre behavior at a party. Friends say he became paranoid and starting threatening them. Agitation, diaphoresis, horizontal nystagmus, dysarthria, combativeness, and occasional myoclonus. Most likely dx?
17yo BIB mother bc of 20 minute episode of severe chest pain and sweating. During episode, his heart was pounding, he felt short of breath, and was sure he was going to die of a heart attack. One month ago had similar Sx after football practice--quit the football team and limits his physical activity for fear of bringing on another attack. Dx?
37yo w 3wk Hx of fatigue, insomnia, and anxiety. Divorce was finalized 1 month ago. Otherwise fine. Best drug for him?
23yo man believes he has special abilities to predict the future since the age of 15 years. Personality disorder?
47yo difficulty sleeping at night. Drinks 2-3 cocktails to help her fall asleep and 3-4oz of vodka in the AM. AST>ALT, both slightly elevated. Dx?
82yo with dementia, Alzheimer type has 4 day hx of visual hallucinations and irritability. Medications: rivastigmine, ibuprofen, atenolol, levothyroxine, and amitriptyline. Discontinuation of which med most appropriate?
37yo man BIB police - was screaming, talking to himself, wandering street. Wearing winter clothes on a hot summer day. What is most likely additional finding in this pt?
Enlarged lateral and 3rd ventricles on CT scan of the head.
Previously healthy 57yo woman comes to the physician bc of 8week hx of progressive confusion and memory loss. No longer to work at her job, bc she is so withdrawn. Speech is dysarthric. Diffuse hyperreflexia, mini-mental state exam is 8/30. EEG shows generalized slowing with periodic sharp waves. Most likely Dx?
27yo woman brought to ED after cutting her arms superficially w a razor blade. She says she cut herself to "feel something." She sleeps and eats well. Was sexually abused as a teenager. Never had longterm relationship and has been fired from several jobs bc of difficulty getting along w supervisors. Denies depressed mood or SI but is convinced she is worthless and deserves to die. Most likely Dx?
Borderline personality disorder
42yo man comes in for regular checkup. Wife states he is competitive, rigid, stubborn, opinionated. Anxious and obsessed w being early. Successful lawyer, and coworkers have said he believes his way is the only way of getting things done. Dx?
Obsessive-compulsive personality disorder
27yo man brought in 30min after brother found him agitated, tremulous, and complaining of a headache. 8 days ago physician discontinued fluoxetine and substituted tranlycypromine to start 1 wk later. Temp is 105, diaphoresis, tremor, hyperreflexia. Most likely cause?
25yo primigravid 16wks gestation has had increased episodes of crying, difficulty falling asleep, decreased energy, loss of appetite. Hx of recurrent MDD. Next appropriate step?
Explanation of the risks and benefits of antidepressant therapy
30yo law school grad caught cheating on bar exam. Previous allegations of cheating. Adolescence with truancy, fights, and lying. Cannot hold a job, has been bankrupt, divorced bc of failure to provide proper care for his children. Angry about accusation of cheating and insists the incident is a misunderstanding. Dx?
Antisocial personality disorder
37yo male police officer comes to the physician 2 wk after witnessing terrorist bombing during which several civilians and 3 fellow police officers were killed. He has felt numb and unable to enjoy things he used to. Sleep is fitful. Says he's not depressed. Does not want to talk to the physician or anyone, but was "made to come." Most appropriate initial step in mgmt?
Provide information about the range of reactions to trauma
24 yo w 3wk hx of recurrent fevers. 4 year history of MDD. Temp is 107. Leukocyte count is 7500.
15yo boy brought to physician by his parents bc he "does whatever he wants and comes and goes as he pleases." Arrested twice in past month, once for assault, once for vandalism. Several tattoos over chest and upper extremities and several body piercings. Most likely dx?
24yo woman comes to physician bc of 8year hx of increasing daytime fatigue. In high school she trained herself not to laugh bc she felt weak and could not remain standing after. Which of the following is most likely to confirm the Dx?
87yo man with catatonia. 1 month ago he began withdrawing and talking constantly about death. Stopped eating and drinking. Most appropriate next step?
8yo boy brought to the physician bc of 1 year hx of increasingly frequent episodes of eye blinking and facial grimacing. Grunts and clears throat a lot. Teacher often sends him out of room for being disruptive. Embarrassed by behaviors and cannot control them. Most appropriate pharmacotherapy?
24yo brought from psych hospital to ED bc of decreasing level of consciousness over past 3 days. Temp is 103, BP is 180/100. Withdraws weakly to noxious stimuli. Eyes are open but he does not fix or follow stimuli. Leukocyte count 18000. Schizophrenia treated with haloperidol and benztropine. Most likely underlying cause?
32yo woman w increasingly severe pain that originates in left shoulder and radiates to elbow from nerve injury post MVA. Pain is 7/10 and constant. On oxycodone and gabapentin. Says "I'm tired of all this..." Best physician response?
"Have you been feeling like just giving up?"
17yo girl brought to physician by parents bc of 45lb weight loss. BMI 16. Pleased w weight loss and thinks she has more to lose. Parents want her admitted, but she is opposed. Next step?
8yo boy brought for school phsyical. Dx w ADHD. Methylphenidate was d/c bc of persistent loss of appetite and weight loss. Despiramine was started. QTc is 0.5sec (N<0.44). Next appropriate step?
D/c despiramine therapy
28yo brought to ED bc of flu-like sx and clear sputum for 24hours. He is on clozapine. Leukocyte count is 2750. Next step?
22yo woman brought to ED bc of 4-hour hx of violent, agitated behavior. Temp is 100.4. BP 140/90. Describes her mood as "wild" and tries to leave ED, pushing a security guard aside and throwing a clipboard. Which substance?
8yo boy brought to physician for evaluation of difficulty reading. High forehead, prominent supraorbital ridges, protruding ears, prominent jaw. IQ is low. Most likely explanation?
Fragile site on the X chromosome
47yo w tension and hand tremors for 1 month. Treated for bipolar disorder w lithium for 6 months. Appropriate Rx?
25yo man w severe fear of flying but must attend business meeting in Europe. Rx?
32 yo woman w schizoaffective disorder brought in to ED bc of 7 day hx of lethargy, loss of appetite, nausea, leg swelling, and jaundice this am. AST and ALT elevated. Fine bilateral hand tremor. Likely medicine responsible for these findings?
27yo w 6wk hx of severe insomnia, persistent fatigue, guilt, emptiness, hopelessness, sadness. Past 4 years has heard "Sauron" from a fantasy novel instructing him to renounce his family and foreswear all sexual activity. Depressed mood and restricted affect. Dx?
Previously healthy 27yo woman comes to physician bc of 2 month hx of crying spells, poor concentration, fatigue, and lethargy. Sleeps 12hours daily. No longer interested in socializing. 20lb weight gain. Work performance declining. Dx?
37yo man comes to physician bc of increasing distress about his procrastination and indecision. Late for work bc he is easily distracted by a task. Sometimes daydreams about projects and must complete them in his mind before attending to other tasks. Dx?
47yo woman is admitted to hospital for treatment of organ rejection one month after liver transplant. 24hours after methylprednisone is begun, she begins to have visual hallucinations that her organ donor has entered her hospital room naked and is drawing sympbols on her skin w an eyebrow pencil. Dx?
Corticosteroid-induced psychotic disorder
15yo boy brought to ED by his friends bc of unusual behavior at a party. Friends say he became raucous and made an unwanted sexual advance on girl he had just met. Agitated alone, but calms down when spoken to. Unsteady gait. Drug taken?
13yo girl BIB dad who says she is always on the go. She eats a full meal with family but otherwise eats little. Became a vegetarian. Appropriate next step?
Reassure father that this is normal development
27yo bib gf bc of 6wk hx of hearing voice he is Christ. 22lb weight loss. Does not sleep more than 2 hours. Flirts with female staff. Tries to convince people of his powers to heal the sick. Dx?
42yo woman, g1p1 with increasing episodes of abdominal pain with BM, sex, menses. Analgesics do not help. Multiple laparoscopies reveal no abnormalities. Just lost job and anxious about finding new one. Next appropriate step?
3yo brought to ED 1 hour after injuring arm. 3rd visit in 6 months. Child too upset to say how she injured herself. Child is fearful of examiner. Xray shows right humerus closed fracture. Next step?
Contact child protective services
25yo woman comes to physician at her husband's request bc of increasing irritability and tense mood over past year. Husband would like to start a family, but she is worried ab finances even tho they have no debt and their jobs pay well. Rx?
Homeless 27yo treated with antipsychotic and antiparkinsonian drugs come to ED bc feels anxious and has difficulty urinating. Hyperactive and disoriented to time and place. Physical exam shows dry mouth, flushed skin, tachycardia. Most likely Dx?
Delerium due to anticholinergic medication
67yo whose husband died 18months ago. Severe headaches. Believes she has brain cancer and deserves to be punished for her sins. Phsyical and neuro exam show now abnormalities. Dx?
47yo w down syndrome w increasing forgetfulness and irritability. Affected region of brain?
Nucleus basalis of Meynert
37yo man brought to physician bc of change in personality over past 4 months. Sexually disinhibited, tactless, impulsive, easily irritated. Affected region of brain?
16yo boy comes to physician bc of 1 year hx of progressive headaches on awakening that have caused him to miss several days of school Feels better after watching TV. Mouth breather. Most likely cause of his headaches?
sleep related hypoventilation
29yoman unable to maintain erection for past 2 months. GGT elevated. Reasons for sx?
14yo girl w poor academic performance past 6 months. Recent move after death of patients father as a result of MVA in which the patient was a passenger. She has trouble concentrating, has frequent nightmares, is easily startled. Dx?
57yo woman difficulty sleeping after finding out her daughter has metastatic breast cancer. On exam, she is tearful and tense but calms during the conversation. No SI. Best therapy?
7yo boy brought to physician by adoptive parents bc of concerns ab his behavior and academic performance. Flattened nasal bridge, long philtrum. Dx?
Fetal alcohol syndrome
67 yo man brought to the physician by his wife bc of 1month hx of increasingly paranoid behavior. Reluctant to eat food unless containers opened in front of him. Has Parkinson's disease, so what drug can be given to him?
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