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Exam 3: Psychiatry

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Question 41

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A 57-year-old man is brought to the emergency department after being found confused and agitated in a park.  Medical records indicate that he has a history of schizophrenia, alcohol use disorder, and liver cirrhosis.  The patient states that he has not been taking his medications "because they never help."  Temperature is 37.2 C (99 F) , blood pressure is 160/80 mm Hg, pulse is 118/min, and respirations are 24/min.  On examination, the patient is disheveled and disoriented, claiming that FBI agents have been chasing him.  His breath smells of alcohol.  Pupils are equal and reactive, and the neck is supple.  The abdomen is distended but nontender.  The skin and mucous membranes are dry.  There is mild edema in both lower extremities but no deformity.  Laboratory results are as follows: During evaluation, the patient is initially cooperative but becomes increasingly aggressive and combative.  For safety reasons, he is given intravenous haloperidol and lorazepam.  Shortly afterward, the cardiac monitor displays the rhythm shown in the exhibit.  Which of the following most likely contributed to this patient's abnormal rhythm?

A) Elevated blood alcohol level
B) Elevated blood ammonia level
C) Haloperidol adverse effect
D) Lorazepam adverse effect
E) Low glucose level
F) Low sodium level

G) A) and B)
H) A) and C)

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Question 42

Multiple Choice

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A 14-year-old boy is brought to the office by his mother for a well-child visit.  Before entering the room, the mother takes the physician aside in private and says, "My son does really well in school and helps out at home, but I'm concerned that he doesn't play sports like other boys and has started wearing makeup.  I don't know whether that's normal or not."  When interviewed alone, the patient says, "I'd rather spend my time on clothes and makeup than sports, but that doesn't make me less of a boy.  My friends don't mind, but I think my mom does."  The patient reports no depressed mood, bullying at school, or difficulty at home, other than occasional disagreements with his mother about how he dresses.  He is not sexually active.  Medical history is noncontributory.  Vital signs are within normal limits; the patient's height and weight are tracking adequately on growth curves.  He is dressed in colorful clothes and is wearing eyeliner and nail polish.  Tanner stage is 4.  The remainder of the physical examination is unremarkable.  Which of the following is the most appropriate response to the mother's concerns?

A) "Adolescents often go through phases to figure out their likes and dislikes; your son's behaviors are likely temporary."
B) "I can see that your son's choices are causing you distress; meeting with a therapist may help you gain a better understanding of your son's experience."
C) "It is normal to explore and develop ways of expressing gender in adolescence; your son is comfortable expressing himself in a way that is not traditionally masculine."
D) "Puberty can be a difficult time for adolescents; your son may be expressing himself in a more feminine way to counteract the changes he's noticing in his body."
E) "Your son seems to dress and prefer activities that are not typically associated with his assigned gender, which may be a sign of gender dysphoria."

F) C) and D)
G) A) and D)

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Question 43

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A 32-year-old man comes to the office for follow-up a month after being hospitalized for treatment of a manic episode related to schizoaffective disorder.  The patient has no other medical history.  His mania has resolved and he appears calm.  Although he continues to hear a voice narrating his daily activities, the voice has diminished in frequency and intensity.  The patient is less anxious and his sleep has improved.  Vitals signs are within normal limits.  He is 175 cm (5 ft 9 in) tall and weighs 95.2 kg (210 lb) ; he has gained 4.5 kg (10 lb) since discharge.  Physical examination shows no other abnormalities.  Laboratory results are as follows: Which of the following medications is most likely to have caused this patient's physical examination and laboratory findings?

A 28-year-old woman is brought to the hospital by her family due to depressed mood, disorganized behavior, and hearing voices.  Over the past 2 months, the patient has developed worsening auditory hallucinations and now fears that her family has been replaced by imposters.  She is afraid to leave the house, stays in bed most of the day, and is unable to care for herself.  The patient's psychiatric history is significant for 4 previous hospitalizations for depressive and psychotic symptoms over the past 8 years.  During the first hospitalization, she was suicidal and heard voices.  During her most recent hospitalization a year ago, she was severely depressed and preoccupied with paranoid delusions and auditory hallucinations.  Between hospitalizations, the patient has had rare month-long periods during which she is not depressed but continues to hear voices.  On mental status examination, she makes poor eye contact.  Her mood is depressed, but she has no suicidal ideation.  She is convinced that her mother is an imposter trying to harm her.  The patient does not use alcohol or illicit drugs.  Physical examination is unremarkable.  Which of the following is the most likely diagnosis in this patient?

A 58-year-old man is brought to the emergency department by his wife for "unusual behavior."  She says that since last night, the patient has been afraid to go into their bedroom because he sees "evil children" there.  He spent most of the night pacing back and forth in the living room and got minimal sleep.  Five days ago, when the patient had an asthma exacerbation, his primary care physician added a new oral medication to his regimen.  Medical history also includes hypertension and non-insulin-dependent diabetes mellitus.  The patient does not drink alcohol but has used marijuana as recently as last week.  Vital signs and physical examination are within normal limits.  The patient is alert and aware of his surroundings.  He reports hearing children laughing at him and frequently covers his ears with his hands.  The patient has no suicidal ideation.  Which of the following is the most likely diagnosis?

A 22-year-old woman comes to the emergency department for acute onset of nausea and diarrhea.  By the time the patient is seen, the abdominal distress has resolved, but she remains agitated and is certain "there is something really wrong with me."  Over the past 2 months, the patient has had 4 similar episodes during which she experienced a sudden sinking feeling in her stomach, accompanied by nausea, sweating, rapid heart rate, and shortness of breath.  On 2 occasions, these symptoms were also accompanied by diarrhea.  She has become increasingly fearful of leaving her home and tearfully reports, "I am going to lose my job."  The patient works as a receptionist and has called in sick 5 times in the past 4 weeks because she fears having an episode at work.  She does not use illicit drugs.  Medical history is unremarkable.  Temperature is 37 C (98.6 F) , blood pressure is 121/77 mm Hg, pulse is 87/min, and respirations are 14/min.  Physical examination is within normal limits and laboratory results are unremarkable.  While awaiting discharge, the patient suddenly feels nauseous again.  Her breath becomes shallow and rapid.  She sweats profusely and says, "My heart is pounding…going to die."  Which of the following is the most appropriate immediate step in management of this patient?

A 28-year-old woman is brought to the office by her husband, who is concerned about her recent behavior.  For the past 6 months, she has refused to eat any food that is not prepackaged out of fear of becoming ill.  The patient has also placed a lock on the cabinet where she keeps her food and refuses to eat in restaurants.  Before eating, she examines the food on her plate systematically, carefully checking for any possible contaminants.  The patient believes that someone has been poisoning her food; as evidence, she points to a rash on her arms and says she is more fatigued than usual.  The patient worries that the rash will spread to other areas and fears that she is developing a slowly progressive illness.  She has continued to work but seldom interacts with coworkers.  The patient has no psychiatric history.  Vital signs are stable.  Examination shows a 2.27-kg (5-lb) weight loss since a prior visit 9 months ago, and small, dry, scaling, patchy areas in her elbow creases, consistent with eczema.  The patient's mood is anxious and her affect is tense.  Which of the following is the most likely diagnosis?

A 73-year-old man with bipolar disorder is brought to the emergency department by his daughter, who has been visiting him for several days.  She reports that "he's not himself."  The patient has become increasingly confused, which is not typical for him.  He has bilateral hand tremors, has difficulty walking straight, and has vomited over the past few days.  Two weeks ago, he saw his new primary care physician, who added hydrochlorothiazide to the patient's medication regimen.  The patient has been psychiatrically stable for many years and has been seeing a psychiatrist, who has prescribed mood stabilizers and antipsychotics.  He has no history of alcohol or substance use disorders.  His daughter does not know which psychiatric medications he takes.  Temperature is 37.2 C (99 F) , blood pressure is 130/80 mm Hg, pulse is 65/min, and respirations are 16/min.  The patient's pulse oximetry shows 93% on room air.  He is disoriented and ataxic.  As he is being assessed, he has a generalized seizure that lasts 2-3 minutes.  Which of the following medications is the most likely cause of this patient's symptoms?

A 22-year-old man comes to the office for a psychiatric evaluation at his mother's insistence.  She is worried that her son has no close friends, does not date, and shows no interest in activities popular with young adults.  His mother describes normal developmental milestones but says, "I thought he would outgrow his shyness, but he seems more isolated than ever."  The patient attends a local university where he studies engineering and performs well academically.  After class, he returns home and enjoys playing computer games or reading comic books.  When interviewed alone, the patient makes limited eye contact.  He gives brief responses and appears somewhat anxious and uncomfortable at times, but his affect is predominantly flat.  In response to questioning about reasons for avoiding social activities, he replies, "I'm just not comfortable around people.  I don't like it when people try to get too personal and would rather keep to myself."  This patient's behavior is most consistent with which of the following?

A 48-year-old woman comes to the office with her sister for a preventive visit.  Her sister says, "I got diagnosed with stage I breast cancer a year ago and want to make sure my sister is okay.  It took a lot of convincing, but she finally agreed to come in for a checkup."  The patient last saw a physician 10 years ago and says, "Doctors always try to find something wrong so that they can bill."  She has no health issues and takes no medications.  The patient does not use tobacco, alcohol, or illicit drugs.  She lives alone and has never dated or married because she believes others may try to exploit her for the small inheritance she received from her parents.  On physical examination, the patient appears older than her stated age; she is wearing baggy clothing, and her hair is unkempt.  The patient agrees only to a breast examination and asks the physician, "Why would you need to examine anything else?"  Throughout the examination, her gaze is fixated on the physician, and her affect is constricted.  Which of the following best explains this patient's behavior?

A 32-year-old man is brought to the office by his mother for a follow-up visit for depressive disorder.  The mother is very concerned because the patient has become increasingly withdrawn and has behaved strangely for the past 2 weeks.  She reports that he expresses fears that his body is decomposing and hears the voice of his long-deceased father telling him, "Come to me."  Current medications include venlafaxine and lorazepam as needed for anxiety.  Vital signs are normal and physical examination is unremarkable.  On mental status examination, the patient appears depressed and makes poor eye contact.  At times, he does not answer and mumbles to himself.  The decision is made to add quetiapine to treat psychosis.  Which of the following is the primary mechanism of action of this medication?

A 5-year-old boy is brought to the office by his parents for evaluation of behavioral concerns.  The mother states that for the past year, the patient has had difficulty remaining calm during thunderstorms.  His fear has worsened to the point that it is starting to disrupt his sleep schedule and school attendance.  Each time the patient notices storm clouds or hears thunder, he starts to cry and hides under his bed.  The patient has started refusing to leave the house if the sky looks cloudy and becomes very worried if one of his parents is not at home when it is raining.  If a storm occurs while he is at school, he becomes upset and asks the teacher if he can go home.  Vital signs are within normal limits; height and weight are tracking consistently at the 60th percentile.  Physical examination shows no abnormalities.  Which of the following is the most appropriate recommendation to provide the parents?

A 7-year-old boy is brought to the office by his parents for evaluation of behavioral concerns at school.  The patient's father states, "He's repeating exactly what other kids say and can't seem to make any friends.  Last year, he kept raising his hand but would say he was 'just stretching' when the teacher called on him.  Luckily, he has stopped doing that."  The patient says, "I try not to be bad, but sometimes I can't help it."  He plays alone during recess to avoid bullying by other children and prefers to read books and complete jigsaw puzzles.  Medical history is unremarkable.  Family history is significant for obsessive-compulsive disorder in the father.  Vital signs are within normal limits; height and weight are tracking consistently at the 60th percentile.  Physical examination is unremarkable apart from frequent head turning and shoulder shrugging.  On mental status examination, the patient appears remorseful and anxious.  Which of the following is the most appropriate next step in management of this patient?

A 24-year-old woman is seen for a routine physical examination before starting a new job.  In review of systems, she indicates intermittent headaches, occasional abdominal bloating, seasonal allergies, fatigue, and insomnia.  Her vital signs are within normal limits.  Examination and laboratory evaluation show no abnormalities.  During the visit, the physician notes that the patient seems sad.  She says, "I'm feeling low because a guy I was dating stopped returning my phone calls last week, but my mother said he wasn't my type anyway.  The truth is that I never feel good and have always had low self-esteem.  Ever since I started college 5 years ago, my energy is low and I always feel run down."  She has always been able to work and has a close relationship with her mother, with whom she lives.  Although the patient dates, she has never had a serious relationship and believes this is because she is unattractive and does not have much to contribute.  She has no thoughts of suicide.  Which of the following is the most likely diagnosis?

A 23-year-old woman comes to the office for a checkup.  She reports that a family friend was diagnosed with multiple sclerosis 6 months ago.  Since then, the patient has become increasingly preoccupied with the thought that she may have a neurologic illness.  She spoke with her sister, who briefly reassured her, but has since been unable to get the thought out of her head and stays up at night researching symptoms on the internet.  The patient double-checks food labels for preservatives and washes produce multiple times to remove pesticides because she read this could be linked with neurologic conditions.  She has noticed that her eyes get tired and that she has cramping in her fingers when she spends long hours writing on the computer.  She worries that this may be an early sign of multiple sclerosis and that she will not be able to support herself as a freelance journalist if she cannot write.  The patient has no psychiatric history but acknowledges that she is a "worrier."  Family history is significant for schizophrenia in a paternal uncle and anxiety in her mother.  Physical examination, including neurologic evaluation, is normal.  Which of the following is the most likely diagnosis in this patient?

A 37-year-old woman is brought to the hospital by the police after she was found wandering in the street.  The patient is unable to provide a coherent history of recent events but mentions that she had a psychiatric hospitalization in her 20s.  She has no medical history.  Temperature is 36.7 C (98 F) , blood pressure is 110/70 mm Hg, pulse is 88/min, and respirations are 16/min.  The patient is disheveled and malodorous, but physical examination is otherwise unremarkable.  On mental status examination, she is alert and smiles pleasantly, but it is difficult to hold her attention.  The patient gets up from her chair several times to stare at the air conditioning vent and put her ear against the wall as if listening for something.  When asked about her behavior, she says, "Jingle jangle, doctor.  Jingle jangle."  A decision is made to admit her to the psychiatric unit.  Which of the following medications is the most appropriate initial treatment for this patient?

A 31-year-old woman comes to the office due to chronic abdominal pain that is unrelated to meals and has persisted for the past 2 years.  The patient reports no weight loss, nausea, vomiting, fever, or changes in bowel movements.  She has consulted several physicians and undergone endoscopy, colonoscopy, and CT scan of the abdomen, as well as an exploratory laparoscopy, all without any significant findings.  The patient was placed on sick leave because she has been unable to focus on anything other than her physical discomfort.  She is anxious and frustrated that physicians have been unable to arrive at a diagnosis and fears that she will be unable to return to work.  Other medical issues include obesity and tension headaches.  Family history is significant for hypertension and diabetes in her father, who died of colon cancer at age 59.  Physical examination shows diffuse abdominal tenderness on palpation and no other abnormalities.  Which of the following is the most likely diagnosis?

A 74-year-old man is hospitalized due to severe depression and a 9-kg (19.8-lb) weight loss over the last month.  The patient has become progressively withdrawn from friends and family, stopped attending his weekly bridge game, and refuses to leave the house to visit his children and grandchildren.  He sleeps poorly and ruminates at night about his financial situation and past events such as fighting with his brother when they were adolescents.  The patient has a history of depression and responded to treatment with a tricyclic antidepressant 30 years ago.  A recent trial of a selective serotonin reuptake inhibitor was ineffective and was discontinued.  The patient has a history of controlled hypertension and a myocardial infarction 10 years ago from which he recovered completely.  In the hospital, efforts to get him to eat and drink are unsuccessful.  On mental status examination, the patient's eyes are downcast and he gives brief, barely audible responses.  He reluctantly discloses that he has been hearing the voice of his brother, who died 15 years ago, accusing him of committing multiple crimes.  Which of the following is the most appropriate treatment for this patient?

A 7-year-old boy is brought to the office by his parents for an annual checkup.  He is in 2nd grade, does well academically, and has no medical problems.  His mother worries that he has no friends and prefers to play computer games by himself or spend time repeatedly organizing his extensive baseball card collection.  On further questioning, she says that the boy moved to a new school this year because he was being bullied.  The mother says, "He is different from the other kids and struggles to join in their games and conversations."  She also mentions that he eats only 3 specific foods and has unusual food rituals.  "He likes his glass to be filled to a certain level and doesn't want different foods touching each other on the plate."  The father disagrees and says, "He's just a picky eater, like I was as a kid.  Other kids can be mean; it's just part of growing up.  It'll take time for him to get used to this new school and make friends."  Developmental milestones are within normal range.  There is no known psychiatric history.  On examination, the boy makes poor eye contact and answers the physician's questions in a polite but formal manner.  Physical examination and growth curves are normal.  The father asks the physician to reassure his wife that nothing is wrong.  Which of the following is the most appropriate course of action?

A 4-year-old boy is brought to the office by his mother for a well-child visit.  As they walk down the hallway to the examination room, the mother yells at the patient to stop banging his toy car against the wall and pulls on his sleeve to hurry him up.  The mother says, "He is a real handful.  He never sits still, doesn't listen, and jumps on the furniture.  I give him candy to get him to behave, but even that doesn't work.  What am I supposed to do?"  The mother receives frequent phone calls from the patient's preschool about the boy's disruptive behavior.  She often has to leave work early to pick him up, which has started to affect her job performance.  The patient's height and weight are tracking at the 50th percentile, and all developmental milestones are within normal range.  Physical examination is normal apart from abrasions on both knees and a bruise on his right shin, which the mother explains he sustained while riding his bicycle and playing soccer.  Which of the following is the most appropriate intervention?