04-13-2016, 05:24 AM
6. A 24-year-old male college student comes to student health services for a follow-up examination 2 weeks after starting sertraline for treatment of major depressive disorder. Before starting the medication, the patient had a 6-month history of decreased motivation, lack of interest in academic work and fraternity activities, and feelings of sadness and worthlessness. He also had a decreased appetite and difficulty falling asleep at night. He had thought about suicide but made no attempts. Physical examination shows no abnormalities. On mental status examination, he says that he feels better but still has difficulty sleeping. Which of the following is the most appropriate next step in management?
WRONG A) Maintain the current dosage of sertraline and schedule a follow-up examination in 4 months
B) Maintain the current dosage of sertraline and schedule weekly follow-up examinations for the next month
C) Maintain the current dosage of sertraline and add amitriptyline to the medication regimen
D) Discontinue sertraline and begin fluoxetine
E) Increase the dosage of sertraline and schedule a follow-up examination in 2 months
16. An 82-year-old man comes to the physician with his wife because of difficulty sleeping during the past year. He goes to bed around 10 pm and is able to fall asleep easily but awakens around 4 am and is unable to return to sleep. His wife says she has not noticed any changes in his sleeping habits, such as restlessness, snoring, or any other irregularity in breathing. He sometimes dozes off when he is reading a newspaper during the day or watching television at night. He has allergic rhinitis treated with loratadine as needed. His only other medication is a daily multivitamin. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, he is alert. He has a euthymic mood and reactive affect. He is pleasant and cooperative but appears anxious when describing his problem sleeping. His Mini-Mental State Examination score is 28/30. He says the day is Tuesday, but it is Wednesday, and he makes one error when performing serial sevens. In addition to providing instructions about sleep hygiene, which of the following is the most appropriate next step in management?
A) Reassurance
B) Neuropsychological testing
C) Pulse oximetry
WRONG D) Modafinil therapy
E) Continuous positive airway pressure therapy
F) Sleep EEG
27. A 42-year-old woman comes to the physician because of suicidal thoughts, depression, emotional !ability, and poor concentration. She is unable to recall when her symptoms began. Her father and sister have a history of similar symptoms. She also has had intermittent abdominal pain. She does not drink alcohol or take medications because they exacerbate her gastrointestinal distress. Abdominal examination shows no abnormalities. Neurologic examination shows decreased joint position sense. Romberg sign is present. Mental status examination shows a depressed mood. There is evidence of suicidal ideation. Which of the following is the most likely cause of this patient's symptoms?
A) Acute intermittent porphyria
B) Lyme disease
WRONG C) Multiple sclerosis
D) Somatization disorder
E) Systemic lupus erythematosus
28. A 5-year-old girl is brought to the physician by her parents because of difficulty learning. They are concerned that she is not "catching on" as quickly as the other children in her kindergarten class. She is confused even by simple homework assignments and struggles to write the alphabet. Her teacher describes her as a happy, eager-to-please child who is having trouble learning. She appears to enjoy going to school and carries her backpack with pride. She wears glasses. She is at the 30th percentile for height and 65th percentile for weight. Vital signs are within normal limits. Physical examination shows epicanthal folds. A grade 2/6 murmur is heard best at the left sternal border. She can run well but climbs stairs by placing both feet on each step before proceeding to the next one. She has difficulty hopping on one foot. She can recite the alphabet and identify half of the letters. Which of the following is the most likely diagnosis?
A) Angelman syndrome
B) Down syndrome
C) Fetal alcohol syndrome
D) Fragile X syndrome
E) Prader willi syndrome
WRONG F) Rett disorder
41. A 23-year-old man with a 3-year history of bipolar disorder well controlled with lithium carbonate would like to discontinue drug therapy because of adverse effects. He is upset because he has gained 6.8 kg (15 lb) and developed acne. He has tried trials of other mood stabilizers that were ineffective in controlling his symptoms. He has a 2-year history of social isolation characterized by fears that he will be rejected by women because of his weight gain and acne. He recently graduated and is concerned about his ability to get a job because of mandatory drug testing. Which of the following is the most appropriate next step in management?
A) Write a letter about lithium carbonate therapy for the patient to give to his employer
B) Explain the risk of illness recurrence without medication
WRONG C) Initiate cognitive behavior therapy
D) Switch to fluoxetine therapy
E) Switch to haloperidol decanoate therapy
48. A 4 7-year-old woman is admitted to the hospital because of a 12-hour history of tremors and confusion. She has a history of alcoholism and last consumed alcohol 24 hours ago. She has no other history of serious illness. She does not smoke cigarettes or use illicit drugs. On admission, she is agitated, diaphoretic, and oriented to person but not to time or place. Vitamin 8 1 (thiamine), folic acid, and three doses of diazepam are administered intravenously. Thirty-five minutes later, respiratory compromise develops; the patient is intubated, and mechanical ventilation is started at a respiratory rate of 20/min. Two hours later, she remains agitated. She is pulling at her peripheral intravenous and urethral catheters and picking at her blankets. Her pulse is 140/min, and blood pressure is 160/100 mm Hg. Neurologic examination shows tremor of the upper and lower extremities and hyperreflexia bilaterally. Which of the following is the most appropriate next step in pharmacotherapy?
WRONG A) Add flumazenil to the medication regimen
B) Add haloperidol to the medication regimen
C) Add phenytoin to the medication regimen
D) Administer additional diazepam
E) Administer additional vitamin B 1 (thiamine)
4. A 5-year-old boy has had temperatures to 38.9°C (102°F), cough, and coryza for 2 days and visual hallucinations of animals and people for 2 hours. His mother has been giving him an over-the-counter cold medicine for 24 hours, but it has not relieved his symptoms. His temperature is 38.8°C (101.8°F). Examination shows a clear nasal discharge. Which of the following is the most likely reason for the child's hallucinations?
A) Behavioral abnormalities
B) Drug toxicity
C) Hyperpyrexia
D) Increased intracranial pressure
WRONG E) Neuronal inflammation
9. A previously healthy 27-year-old woman comes to the physician because of a 2-month history of crying spells, poor concentration, fatigue, and lethargy. She says that she sleeps at least 12 hours daily and is no longer interested in socializing. She recently broke up with her boyfriend of 10 months, and her work performance has begun to decline; she is afraid that she will lose her job if it does not improve. She does not drink alcohol or use illicit drugs. Menses occur at regular 28- to 30-day intervals. Her last menstrual period was 2 weeks ago. She has had a 9-kg (20-lb) weight gain over the past 9 months. She is 168 cm (5 ft 6 in) tall and weighs 66 kg (145 lb); BMI is 23 kg/m2. Physical examination shows no abnormalities. Mental status examination shows a sad mood and restricted affect. Which of the following is the most likely diagnosis?
WRONG A) Adjustment disorder with depressed mood
B) Dysthymic disorder
C) Generalized anxiety disorder
D) Major depressive disorder
E) Premenstrual dysphoric disorder
11. A 67-year-old woman, whose husband died 18 months ago, is admitted to the hospital because of severe headaches for 4 weeks. She is quiet and seems sad. She believes that she has brain cancer, deserves to be punished for her sins, and is being punished by God for past misdeeds. She has had fatigue and a 6.8-kg (15-lb) weight loss over the past 4 months. Physical and neurologic examinations show no abnormalities. Which of the following is the most likely diagnosis?
A) Adjustment disorder with mixed disturbance of emotions and conduct
WRONG B) Delusional disorder
C) Major depressive disorder
D) Schizophrenia
E) Somatization disorder
14. A 27-year-old man comes to student health services because of a 6-week history of increasingly severe insomnia and persistent fatigue. During this time, he also has had feelings of guilt, emptiness, hopelessness, and profound sadness. He is a graduate student and has withdrawn from most social activity. He says that during the past 4 years he has heard "Sauron" from a fantasy novel instructing him to renounce his family and forswear all sexual activity. He notes that he has had two episodes of depressed mood during the past 2 years. He began sertraline therapy during the second episode and had improvement in his mood; he discontinued the therapy 6 months ago because he was feeling well apart from intermittent hallucinations. He has no other history of serious illness and currently takes no medications. Physical examination shows no abnormalities. On mental status examination, he has a depressed mood and restricted affect. His thought processes are mildly tangential. He does not appear to be responding to internal stimuli. He has not had suicidal ideation. Which of the following is the most likely diagnosis?
A) Dysthymic disorder
WRONG B) Major depressive disorder with psychotic features
C) Schizoaffective disorder
D) Schizophrenia
E) Schizotypal personality disorder
15. A 16-year-old boy comes to the physician because of a 1-year history of progressive headaches that have caused him to miss several days of school. They now occur daily and are always present on awakening in the morning. He describes the headaches as a diffuse, constant pressure that occasionally throbs. He feels better after taking acetaminophen and resting in front of the television for 10 to 20 minutes. He has not noticed any particular events that cause the headaches, and he says that they are not exacerbated by light, sound, coughing, or straining. He has not had nausea or vomiting. Two months ago, he sustained a whiplash injury in a motor vehicle collision. His parents say that he snores loudly. His mother and maternal aunt have migraines, and his father has major depressive disorder. The patient is 168 cm (5 ft 6 in) tall and weighs 86 kg (189 lb); BMI is 31 kg/m2. He breathes through his mouth. Respirations are 20/min. Examination shows 3 to 5 beats of jerk nystagmus with far lateral gaze bilaterally. Which of the following is the most likely cause of this patient's headaches?
A) Hydrocephalus
WRONG B) Idiopathic intracranial hypertension
C) Major depressive disorder
D) Migraine
E) School-related anxiety
F) Sleep-related hypoventilation
18. A 47-year-old woman comes to the physician because she has had difficulty sleeping at night since her youngest daughter left for college 2 months ago. During the past week, she has been struggling to stay awake at work. She drinks two to three cocktails to help her fall asleep and 3 to 4 oz of vodka in the morning to help calm her nerves. She is often anxious and has frequent heartburn. She was told by her physician that the heartburn is likely caused by her alcohol consumption. She does not want to alter her routine because she has become increasingly anxious and irritable when she has tried to do so. Her temperature is 37.2°C (99°F), pulse is 90/min, respirations are 12/min, and blood pressure is 150/90 mm Hg. Physical examination shows no other abnormalities. On mental status examination, she is mildly anxious but polite and friendly. She says that she is not depressed but that it was difficult for her to adjust when her daughter first left for college. Laboratory studies show:
Erythrocyte count 3500/mm3
Mean corpuscular volume 102 μm3
Leukocyte count 4500/mm3
Serum
Mg2+ 1.5 mEq/L
Thyroid-stimulating hormone 3.5 μU/mL
AST 40 U/L
ALT 25 U/L
An ECG shows a normal sinus rhythm. Which of the following is the most likely diagnosis?
WRONG A) Adjustment disorder
B) Alcohol dependence
C) Circadian rhythm sleep disorder
0) Generalized anxiety disorder
E) Major depressive disorder
F) Primary insomnia
24. A 29-year-old man comes to the physician because of the inability to maintain an erection through completion of sexual activity. He has been married for 3 months and has not been able to complete coitus over the past 2 months. He is usually able to attain an erection by direct penile stimulation and is often aware of nocturnal erections when waking during the night. For the past month, he and his wife have attempted to have intercourse about twice a week. He drinks several alcoholic beverages before engaging in sexual activity in an effort to relax. He has had two major depressive episodes over the past 4 years and was successfully treated with desipramine; he has not taken the medication since his marriage. He has borderline hypertension but takes no medications for it. He has a strong family history of type 2 diabetes mellitus. He takes ranitidine for stomach problems. His vital signs are normal. Cranial nerve function appears normal. He walks normally. Laboratory studies show:
Hemoglobin11 g/dl
Platelet count 178,000/mm3
Serum
Fasting glucose 86 mg/dl
y-Glutamyltransferase 70 U/L (N=5-50)
Which of the following is the most likely explanation for these findings?
A) Alcohol use
B) Desipramine therapy
C) Diabetes mellitus
D) Generalized anxiety disorder
E) Major depressive disorder
F) Marital conflict
WRONG G) Ranitidine therapy
25. A 7-year-old boy is brought to the physician by his adoptive parents because of ongoing concern about his behavior and academic performance. He is two grade levels behind his peers in reading and frequently has fights with other children. He has no history of serious illness and takes no medications. His biological mother abused multiple substances before and during pregnancy. On adoption at the age of 15 months, there was some evidence that she may have physically abused him. He is at the 10th percentile for height and 5th percentile for weight. His pulse is 82/min, and blood pressure is 116/78 mm Hg. Examination shows a flattened nasal bridge, a long philtrum, and prominent ears. During the interview, he is friendly but becomes frustrated and distracted and is unable to sit still. Which of the following is the most likely diagnosis?
A) Angelman syndrome
B) Fetal alcohol syndrome
WRONG C) Fragile X syndrome
D) Rett disorder
E) Shaken baby syndrome
28. A 37-year-old man comes to the physician because of increasing distress about his procrastination and indecision. He has been late for work often because he is easily distracted by any task; as a result, he has received poor job performance ratings. He arrived late for today's examination because he was awake late last night creating a new computer folder system and then had to refold the clothes in his closet several times this morning. He says he becomes nervous if he is unable to finish similar minor projects. He sometimes daydreams about projects and must complete them in his daydreams before attending to other tasks. He reports that his family is exasperated by his behavior. He has no history of serious illness and takes no medications. He appears fatigued. Physical examination shows no abnormalities. On mental status examination, he is fully oriented. He is cooperative but fidgets and has poor eye contact. He is able to repeat six digits forward, spell "world" backward, and perform serial sevens. He gives four interpretations of a proverb and is unable to decide on a final answer. Which of the following is the most likely diagnosis?
WRONG A) Attention-deficiUhyperactivity disorder
B) Delusional disorder
C) Generalized anxiety disorder
D) Obsessive-compulsive disorder
E) Schizotypal personality disorder
43. A 15-year-old boy is brought to the physician by his parents because "he does whatever he wants and comes and goes as he pleases." They report that he always has been challenging to manage and has not responded to disciplinary measures since he was 10 years of age. During the past 2 years, his behavior has become worse; he has been arrested twice in the past month, once for assault and once for vandalism. He is currently on probation. His parents state that they have found him intoxicated in his room on several occasions, and they recently found marijuana paraphernalia in his room. Today, the patient is sullen and minimally cooperative. He says he is frequently irritable and short tempered. His clothes smell of cigarette smoke. Physical examination shows several tattoos over the chest and upper extremities and several body piercings; no other abnormalities are noted. Mental status examination shows an irritable mood and poor eye contact. Which of the following is the most likely diagnosis?
A) Antisocial personality disorder
B) Bipolar disorder
C) Conduct disorder
WRONG D) Dysthymic disorder
E) Intermittent explosive disorder
F) Oppositional defiant disorder
5. An unconscious 7-year-old boy is brought to the emergency department by his parents. The family emigrated from rural Southeast Asia 4 years ago. An interpreter is used because the parents do not speak English. They say, "Our child has been possessed by a spirit since birth who speaks through his mouth with spit and blood and then takes his powers away." He has had these spells all of his life. He does not attend school. They recently sacrificed a piglet as an offering to the spirit, but there has been no change in the child's condition. The parents seem devoted. He awakens during the physical examination and smiles vacantly at his parents. He appears confused and speaks in monosyllables. No other abnormalities are noted. Which of the following is the most appropriate next step in diagnosis?
A) Contact child protective services
WRONG B) Psychoeducational assessment
C) Family therapy
D) Throat culture
E) X-ray of the chest
F)ECG
G)EEG
8. A 57-year-old man comes to the physician with his wife because of a 1-month history of bizarre behavior at night. His wife says that most nights he falls asleep at approximately 11 pm and begins kicking and groaning in the bed shortly after 12:30 am. Seven times during this period, he has jumped out of the bed and run back and forth across the room, punching the air. She tries to wake him during these episodes because she is afraid that he might hurt her or himself. She reports that when she succeeds, he seems alert but tells her that he was being attacked and needed to defend himself or escape. The patient tells the physician that he does not recall the behavior his wife is describing but remembers having a recurrent dream in which he is in danger and cannot breathe. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, he has a pleasant and full range of affect. His thought process is rational and goal directed. He says that based on his wife's description of his behavior at night, he is afraid that he might hurt her. Results of laboratory studies are within the reference range. Which of the following is the most likely diagnosis?
A) Central sleep apnea
B) Nocturnal panic disorder
C) Nocturnal paroxysmal dystonia
D) REM sleep behavior disorder
E) Restless legs syndrome
F) Sleep-related complex partial seizure disorder
WRONG G) Sleep terror disorder
11. Over the past 7 years, a 25-year-old graduate student has had increasingly severe palpitations, tremulousness, nausea, sweating, and inability to concentrate while taking examinations. He is worried because he recently failed an examination despite being thoroughly prepared. Examination shows normal findings. Which of the following is the most appropriate next step in diagnosis?
A) Ambulatory ECG monitoring
B) 24-Hour urine collection for 5-hydroxyindoleacetic acid
WRONG C) 24-Hour urine collection for measurement of catecholamine and metanephrine concentrations
D) Measurement of serum thyroxine (T 4) and thyroid-stimulating hormone concentrations
E) Psychiatric evaluation
12. A 27-year-old woman, gravida 1, para 1, comes to the physician with her husband because of progressive irritability and anxiety since the birth of her child 3 weeks ago. Pregnancy was complicated by premature labor that was managed with bed rest. Delivery occurred at term with no complications. Examination of her newborn at birth showed no abnormalities. The patient reports that he feeds well and appears healthy, but she has constant worries about his health and her own health. She adds that she has had a decreased appetite and difficulty sleeping. Her husband notes that she has been increasingly withdrawn from family and friends and that she has reported thoughts of suicide. The patient has no history of serious illness or major depressive disorder. Her only medication is a multivitamin. She appears tired. Physical examination shows no abnormalities. On mental status examination, she has an irritable mood and depressed affect. She is oriented to person, place, and time. Which of the following is the most likely diagnosis?
A) Adjustment disorder
B) Bipolar disorder
WRONG C) Generalized anxiety disorder
D) Major depressive disorder
E) Post-traumatic stress disorder
13. An 8-year-old girl is brought to the physician by her mother because of frequent stomachaches over the past 3 months. She has a 1-year history of difficulty falling asleep and poor concentration. She has always been a good student and excels in extracurricular activities. Her parents divorced 6 months ago. Physical examination shows no abnormalities. Mental status examination shows an anxious affect and coherent thought process. She says that she is worried about her classes and about her performance in the school band and on the soccer team. Which of the following is the most likely diagnosis?
A) Generalized anxiety disorder
B) Obsessive-compulsive disorder
C) Panic disorder
D) Post-traumatic stress disorder
WRONG E) Separation anxiety disorder
20. A 32-year-old Bosnian man is brought to the emergency department by police 30 minutes after they found him sitting in a cemetery and muttering to himself. The police officers report that the patient appeared lost in thought and did not respond to their questions; he then passively accompanied them to the hospital. Identification in the patient's wallet indicates that he is a construction worker. The physician calls the patient's employer and learns that he was part of a crew working on a bridge that morning when a crane collapsed, causing multiple injuries to people working in trailers on the ground. A hospital interpreter says that the patient had been an ambulance driver in a military war zone 10 years ago. The patient sits quietly and stares ahead; he appears unaffected by the bustling activity in the emergency department. His pulse is 72/min, and respirations are 14/min. Physical examination shows no abnormalities. Mental status examination shows a reserved demeanor. He speaks in monotone and responds to questions with vague, noncommittal answers. He says he is not depressed or anxious. Which of the following is the most likely diagnosis?
WRONG A) Adjustment disorder
B) Catatonia
C) Dissociative disorder
D) Generalized anxiety disorder
E) Schizotypal personality disorder
43. A 23-year-old man is brought to the emergency department because of progressive paranoia and agitation for 48 hours. His roommate reports that the patient has not been sleeping or eating during this period but had been staying up all night studying for examinations for the past 4 days. He adds that last night the patient crouched below their apartment window peering out and insisting that every passing car was occupied by FBI agents. The patient has no history of psychosis. He states that he has been under stress from his new position as a software engineer. Physical examination shows 4-mm pupils, dry mouth, and mild tremulousness. On mental status examination, he is agitated, and his speech is rapid with increased volume. There is evidence of paranoid delusions about persecution by the police. Which of the following is the most likely diagnosis?
WRONG A) Bipolar disorder
B) Delusional disorder
C) Generalized anxiety disorder
D) Schizophrenia
E) Substance-induced psychotic disorder
WRONG A) Maintain the current dosage of sertraline and schedule a follow-up examination in 4 months
B) Maintain the current dosage of sertraline and schedule weekly follow-up examinations for the next month
C) Maintain the current dosage of sertraline and add amitriptyline to the medication regimen
D) Discontinue sertraline and begin fluoxetine
E) Increase the dosage of sertraline and schedule a follow-up examination in 2 months
16. An 82-year-old man comes to the physician with his wife because of difficulty sleeping during the past year. He goes to bed around 10 pm and is able to fall asleep easily but awakens around 4 am and is unable to return to sleep. His wife says she has not noticed any changes in his sleeping habits, such as restlessness, snoring, or any other irregularity in breathing. He sometimes dozes off when he is reading a newspaper during the day or watching television at night. He has allergic rhinitis treated with loratadine as needed. His only other medication is a daily multivitamin. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, he is alert. He has a euthymic mood and reactive affect. He is pleasant and cooperative but appears anxious when describing his problem sleeping. His Mini-Mental State Examination score is 28/30. He says the day is Tuesday, but it is Wednesday, and he makes one error when performing serial sevens. In addition to providing instructions about sleep hygiene, which of the following is the most appropriate next step in management?
A) Reassurance
B) Neuropsychological testing
C) Pulse oximetry
WRONG D) Modafinil therapy
E) Continuous positive airway pressure therapy
F) Sleep EEG
27. A 42-year-old woman comes to the physician because of suicidal thoughts, depression, emotional !ability, and poor concentration. She is unable to recall when her symptoms began. Her father and sister have a history of similar symptoms. She also has had intermittent abdominal pain. She does not drink alcohol or take medications because they exacerbate her gastrointestinal distress. Abdominal examination shows no abnormalities. Neurologic examination shows decreased joint position sense. Romberg sign is present. Mental status examination shows a depressed mood. There is evidence of suicidal ideation. Which of the following is the most likely cause of this patient's symptoms?
A) Acute intermittent porphyria
B) Lyme disease
WRONG C) Multiple sclerosis
D) Somatization disorder
E) Systemic lupus erythematosus
28. A 5-year-old girl is brought to the physician by her parents because of difficulty learning. They are concerned that she is not "catching on" as quickly as the other children in her kindergarten class. She is confused even by simple homework assignments and struggles to write the alphabet. Her teacher describes her as a happy, eager-to-please child who is having trouble learning. She appears to enjoy going to school and carries her backpack with pride. She wears glasses. She is at the 30th percentile for height and 65th percentile for weight. Vital signs are within normal limits. Physical examination shows epicanthal folds. A grade 2/6 murmur is heard best at the left sternal border. She can run well but climbs stairs by placing both feet on each step before proceeding to the next one. She has difficulty hopping on one foot. She can recite the alphabet and identify half of the letters. Which of the following is the most likely diagnosis?
A) Angelman syndrome
B) Down syndrome
C) Fetal alcohol syndrome
D) Fragile X syndrome
E) Prader willi syndrome
WRONG F) Rett disorder
41. A 23-year-old man with a 3-year history of bipolar disorder well controlled with lithium carbonate would like to discontinue drug therapy because of adverse effects. He is upset because he has gained 6.8 kg (15 lb) and developed acne. He has tried trials of other mood stabilizers that were ineffective in controlling his symptoms. He has a 2-year history of social isolation characterized by fears that he will be rejected by women because of his weight gain and acne. He recently graduated and is concerned about his ability to get a job because of mandatory drug testing. Which of the following is the most appropriate next step in management?
A) Write a letter about lithium carbonate therapy for the patient to give to his employer
B) Explain the risk of illness recurrence without medication
WRONG C) Initiate cognitive behavior therapy
D) Switch to fluoxetine therapy
E) Switch to haloperidol decanoate therapy
48. A 4 7-year-old woman is admitted to the hospital because of a 12-hour history of tremors and confusion. She has a history of alcoholism and last consumed alcohol 24 hours ago. She has no other history of serious illness. She does not smoke cigarettes or use illicit drugs. On admission, she is agitated, diaphoretic, and oriented to person but not to time or place. Vitamin 8 1 (thiamine), folic acid, and three doses of diazepam are administered intravenously. Thirty-five minutes later, respiratory compromise develops; the patient is intubated, and mechanical ventilation is started at a respiratory rate of 20/min. Two hours later, she remains agitated. She is pulling at her peripheral intravenous and urethral catheters and picking at her blankets. Her pulse is 140/min, and blood pressure is 160/100 mm Hg. Neurologic examination shows tremor of the upper and lower extremities and hyperreflexia bilaterally. Which of the following is the most appropriate next step in pharmacotherapy?
WRONG A) Add flumazenil to the medication regimen
B) Add haloperidol to the medication regimen
C) Add phenytoin to the medication regimen
D) Administer additional diazepam
E) Administer additional vitamin B 1 (thiamine)
4. A 5-year-old boy has had temperatures to 38.9°C (102°F), cough, and coryza for 2 days and visual hallucinations of animals and people for 2 hours. His mother has been giving him an over-the-counter cold medicine for 24 hours, but it has not relieved his symptoms. His temperature is 38.8°C (101.8°F). Examination shows a clear nasal discharge. Which of the following is the most likely reason for the child's hallucinations?
A) Behavioral abnormalities
B) Drug toxicity
C) Hyperpyrexia
D) Increased intracranial pressure
WRONG E) Neuronal inflammation
9. A previously healthy 27-year-old woman comes to the physician because of a 2-month history of crying spells, poor concentration, fatigue, and lethargy. She says that she sleeps at least 12 hours daily and is no longer interested in socializing. She recently broke up with her boyfriend of 10 months, and her work performance has begun to decline; she is afraid that she will lose her job if it does not improve. She does not drink alcohol or use illicit drugs. Menses occur at regular 28- to 30-day intervals. Her last menstrual period was 2 weeks ago. She has had a 9-kg (20-lb) weight gain over the past 9 months. She is 168 cm (5 ft 6 in) tall and weighs 66 kg (145 lb); BMI is 23 kg/m2. Physical examination shows no abnormalities. Mental status examination shows a sad mood and restricted affect. Which of the following is the most likely diagnosis?
WRONG A) Adjustment disorder with depressed mood
B) Dysthymic disorder
C) Generalized anxiety disorder
D) Major depressive disorder
E) Premenstrual dysphoric disorder
11. A 67-year-old woman, whose husband died 18 months ago, is admitted to the hospital because of severe headaches for 4 weeks. She is quiet and seems sad. She believes that she has brain cancer, deserves to be punished for her sins, and is being punished by God for past misdeeds. She has had fatigue and a 6.8-kg (15-lb) weight loss over the past 4 months. Physical and neurologic examinations show no abnormalities. Which of the following is the most likely diagnosis?
A) Adjustment disorder with mixed disturbance of emotions and conduct
WRONG B) Delusional disorder
C) Major depressive disorder
D) Schizophrenia
E) Somatization disorder
14. A 27-year-old man comes to student health services because of a 6-week history of increasingly severe insomnia and persistent fatigue. During this time, he also has had feelings of guilt, emptiness, hopelessness, and profound sadness. He is a graduate student and has withdrawn from most social activity. He says that during the past 4 years he has heard "Sauron" from a fantasy novel instructing him to renounce his family and forswear all sexual activity. He notes that he has had two episodes of depressed mood during the past 2 years. He began sertraline therapy during the second episode and had improvement in his mood; he discontinued the therapy 6 months ago because he was feeling well apart from intermittent hallucinations. He has no other history of serious illness and currently takes no medications. Physical examination shows no abnormalities. On mental status examination, he has a depressed mood and restricted affect. His thought processes are mildly tangential. He does not appear to be responding to internal stimuli. He has not had suicidal ideation. Which of the following is the most likely diagnosis?
A) Dysthymic disorder
WRONG B) Major depressive disorder with psychotic features
C) Schizoaffective disorder
D) Schizophrenia
E) Schizotypal personality disorder
15. A 16-year-old boy comes to the physician because of a 1-year history of progressive headaches that have caused him to miss several days of school. They now occur daily and are always present on awakening in the morning. He describes the headaches as a diffuse, constant pressure that occasionally throbs. He feels better after taking acetaminophen and resting in front of the television for 10 to 20 minutes. He has not noticed any particular events that cause the headaches, and he says that they are not exacerbated by light, sound, coughing, or straining. He has not had nausea or vomiting. Two months ago, he sustained a whiplash injury in a motor vehicle collision. His parents say that he snores loudly. His mother and maternal aunt have migraines, and his father has major depressive disorder. The patient is 168 cm (5 ft 6 in) tall and weighs 86 kg (189 lb); BMI is 31 kg/m2. He breathes through his mouth. Respirations are 20/min. Examination shows 3 to 5 beats of jerk nystagmus with far lateral gaze bilaterally. Which of the following is the most likely cause of this patient's headaches?
A) Hydrocephalus
WRONG B) Idiopathic intracranial hypertension
C) Major depressive disorder
D) Migraine
E) School-related anxiety
F) Sleep-related hypoventilation
18. A 47-year-old woman comes to the physician because she has had difficulty sleeping at night since her youngest daughter left for college 2 months ago. During the past week, she has been struggling to stay awake at work. She drinks two to three cocktails to help her fall asleep and 3 to 4 oz of vodka in the morning to help calm her nerves. She is often anxious and has frequent heartburn. She was told by her physician that the heartburn is likely caused by her alcohol consumption. She does not want to alter her routine because she has become increasingly anxious and irritable when she has tried to do so. Her temperature is 37.2°C (99°F), pulse is 90/min, respirations are 12/min, and blood pressure is 150/90 mm Hg. Physical examination shows no other abnormalities. On mental status examination, she is mildly anxious but polite and friendly. She says that she is not depressed but that it was difficult for her to adjust when her daughter first left for college. Laboratory studies show:
Erythrocyte count 3500/mm3
Mean corpuscular volume 102 μm3
Leukocyte count 4500/mm3
Serum
Mg2+ 1.5 mEq/L
Thyroid-stimulating hormone 3.5 μU/mL
AST 40 U/L
ALT 25 U/L
An ECG shows a normal sinus rhythm. Which of the following is the most likely diagnosis?
WRONG A) Adjustment disorder
B) Alcohol dependence
C) Circadian rhythm sleep disorder
0) Generalized anxiety disorder
E) Major depressive disorder
F) Primary insomnia
24. A 29-year-old man comes to the physician because of the inability to maintain an erection through completion of sexual activity. He has been married for 3 months and has not been able to complete coitus over the past 2 months. He is usually able to attain an erection by direct penile stimulation and is often aware of nocturnal erections when waking during the night. For the past month, he and his wife have attempted to have intercourse about twice a week. He drinks several alcoholic beverages before engaging in sexual activity in an effort to relax. He has had two major depressive episodes over the past 4 years and was successfully treated with desipramine; he has not taken the medication since his marriage. He has borderline hypertension but takes no medications for it. He has a strong family history of type 2 diabetes mellitus. He takes ranitidine for stomach problems. His vital signs are normal. Cranial nerve function appears normal. He walks normally. Laboratory studies show:
Hemoglobin11 g/dl
Platelet count 178,000/mm3
Serum
Fasting glucose 86 mg/dl
y-Glutamyltransferase 70 U/L (N=5-50)
Which of the following is the most likely explanation for these findings?
A) Alcohol use
B) Desipramine therapy
C) Diabetes mellitus
D) Generalized anxiety disorder
E) Major depressive disorder
F) Marital conflict
WRONG G) Ranitidine therapy
25. A 7-year-old boy is brought to the physician by his adoptive parents because of ongoing concern about his behavior and academic performance. He is two grade levels behind his peers in reading and frequently has fights with other children. He has no history of serious illness and takes no medications. His biological mother abused multiple substances before and during pregnancy. On adoption at the age of 15 months, there was some evidence that she may have physically abused him. He is at the 10th percentile for height and 5th percentile for weight. His pulse is 82/min, and blood pressure is 116/78 mm Hg. Examination shows a flattened nasal bridge, a long philtrum, and prominent ears. During the interview, he is friendly but becomes frustrated and distracted and is unable to sit still. Which of the following is the most likely diagnosis?
A) Angelman syndrome
B) Fetal alcohol syndrome
WRONG C) Fragile X syndrome
D) Rett disorder
E) Shaken baby syndrome
28. A 37-year-old man comes to the physician because of increasing distress about his procrastination and indecision. He has been late for work often because he is easily distracted by any task; as a result, he has received poor job performance ratings. He arrived late for today's examination because he was awake late last night creating a new computer folder system and then had to refold the clothes in his closet several times this morning. He says he becomes nervous if he is unable to finish similar minor projects. He sometimes daydreams about projects and must complete them in his daydreams before attending to other tasks. He reports that his family is exasperated by his behavior. He has no history of serious illness and takes no medications. He appears fatigued. Physical examination shows no abnormalities. On mental status examination, he is fully oriented. He is cooperative but fidgets and has poor eye contact. He is able to repeat six digits forward, spell "world" backward, and perform serial sevens. He gives four interpretations of a proverb and is unable to decide on a final answer. Which of the following is the most likely diagnosis?
WRONG A) Attention-deficiUhyperactivity disorder
B) Delusional disorder
C) Generalized anxiety disorder
D) Obsessive-compulsive disorder
E) Schizotypal personality disorder
43. A 15-year-old boy is brought to the physician by his parents because "he does whatever he wants and comes and goes as he pleases." They report that he always has been challenging to manage and has not responded to disciplinary measures since he was 10 years of age. During the past 2 years, his behavior has become worse; he has been arrested twice in the past month, once for assault and once for vandalism. He is currently on probation. His parents state that they have found him intoxicated in his room on several occasions, and they recently found marijuana paraphernalia in his room. Today, the patient is sullen and minimally cooperative. He says he is frequently irritable and short tempered. His clothes smell of cigarette smoke. Physical examination shows several tattoos over the chest and upper extremities and several body piercings; no other abnormalities are noted. Mental status examination shows an irritable mood and poor eye contact. Which of the following is the most likely diagnosis?
A) Antisocial personality disorder
B) Bipolar disorder
C) Conduct disorder
WRONG D) Dysthymic disorder
E) Intermittent explosive disorder
F) Oppositional defiant disorder
5. An unconscious 7-year-old boy is brought to the emergency department by his parents. The family emigrated from rural Southeast Asia 4 years ago. An interpreter is used because the parents do not speak English. They say, "Our child has been possessed by a spirit since birth who speaks through his mouth with spit and blood and then takes his powers away." He has had these spells all of his life. He does not attend school. They recently sacrificed a piglet as an offering to the spirit, but there has been no change in the child's condition. The parents seem devoted. He awakens during the physical examination and smiles vacantly at his parents. He appears confused and speaks in monosyllables. No other abnormalities are noted. Which of the following is the most appropriate next step in diagnosis?
A) Contact child protective services
WRONG B) Psychoeducational assessment
C) Family therapy
D) Throat culture
E) X-ray of the chest
F)ECG
G)EEG
8. A 57-year-old man comes to the physician with his wife because of a 1-month history of bizarre behavior at night. His wife says that most nights he falls asleep at approximately 11 pm and begins kicking and groaning in the bed shortly after 12:30 am. Seven times during this period, he has jumped out of the bed and run back and forth across the room, punching the air. She tries to wake him during these episodes because she is afraid that he might hurt her or himself. She reports that when she succeeds, he seems alert but tells her that he was being attacked and needed to defend himself or escape. The patient tells the physician that he does not recall the behavior his wife is describing but remembers having a recurrent dream in which he is in danger and cannot breathe. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, he has a pleasant and full range of affect. His thought process is rational and goal directed. He says that based on his wife's description of his behavior at night, he is afraid that he might hurt her. Results of laboratory studies are within the reference range. Which of the following is the most likely diagnosis?
A) Central sleep apnea
B) Nocturnal panic disorder
C) Nocturnal paroxysmal dystonia
D) REM sleep behavior disorder
E) Restless legs syndrome
F) Sleep-related complex partial seizure disorder
WRONG G) Sleep terror disorder
11. Over the past 7 years, a 25-year-old graduate student has had increasingly severe palpitations, tremulousness, nausea, sweating, and inability to concentrate while taking examinations. He is worried because he recently failed an examination despite being thoroughly prepared. Examination shows normal findings. Which of the following is the most appropriate next step in diagnosis?
A) Ambulatory ECG monitoring
B) 24-Hour urine collection for 5-hydroxyindoleacetic acid
WRONG C) 24-Hour urine collection for measurement of catecholamine and metanephrine concentrations
D) Measurement of serum thyroxine (T 4) and thyroid-stimulating hormone concentrations
E) Psychiatric evaluation
12. A 27-year-old woman, gravida 1, para 1, comes to the physician with her husband because of progressive irritability and anxiety since the birth of her child 3 weeks ago. Pregnancy was complicated by premature labor that was managed with bed rest. Delivery occurred at term with no complications. Examination of her newborn at birth showed no abnormalities. The patient reports that he feeds well and appears healthy, but she has constant worries about his health and her own health. She adds that she has had a decreased appetite and difficulty sleeping. Her husband notes that she has been increasingly withdrawn from family and friends and that she has reported thoughts of suicide. The patient has no history of serious illness or major depressive disorder. Her only medication is a multivitamin. She appears tired. Physical examination shows no abnormalities. On mental status examination, she has an irritable mood and depressed affect. She is oriented to person, place, and time. Which of the following is the most likely diagnosis?
A) Adjustment disorder
B) Bipolar disorder
WRONG C) Generalized anxiety disorder
D) Major depressive disorder
E) Post-traumatic stress disorder
13. An 8-year-old girl is brought to the physician by her mother because of frequent stomachaches over the past 3 months. She has a 1-year history of difficulty falling asleep and poor concentration. She has always been a good student and excels in extracurricular activities. Her parents divorced 6 months ago. Physical examination shows no abnormalities. Mental status examination shows an anxious affect and coherent thought process. She says that she is worried about her classes and about her performance in the school band and on the soccer team. Which of the following is the most likely diagnosis?
A) Generalized anxiety disorder
B) Obsessive-compulsive disorder
C) Panic disorder
D) Post-traumatic stress disorder
WRONG E) Separation anxiety disorder
20. A 32-year-old Bosnian man is brought to the emergency department by police 30 minutes after they found him sitting in a cemetery and muttering to himself. The police officers report that the patient appeared lost in thought and did not respond to their questions; he then passively accompanied them to the hospital. Identification in the patient's wallet indicates that he is a construction worker. The physician calls the patient's employer and learns that he was part of a crew working on a bridge that morning when a crane collapsed, causing multiple injuries to people working in trailers on the ground. A hospital interpreter says that the patient had been an ambulance driver in a military war zone 10 years ago. The patient sits quietly and stares ahead; he appears unaffected by the bustling activity in the emergency department. His pulse is 72/min, and respirations are 14/min. Physical examination shows no abnormalities. Mental status examination shows a reserved demeanor. He speaks in monotone and responds to questions with vague, noncommittal answers. He says he is not depressed or anxious. Which of the following is the most likely diagnosis?
WRONG A) Adjustment disorder
B) Catatonia
C) Dissociative disorder
D) Generalized anxiety disorder
E) Schizotypal personality disorder
43. A 23-year-old man is brought to the emergency department because of progressive paranoia and agitation for 48 hours. His roommate reports that the patient has not been sleeping or eating during this period but had been staying up all night studying for examinations for the past 4 days. He adds that last night the patient crouched below their apartment window peering out and insisting that every passing car was occupied by FBI agents. The patient has no history of psychosis. He states that he has been under stress from his new position as a software engineer. Physical examination shows 4-mm pupils, dry mouth, and mild tremulousness. On mental status examination, he is agitated, and his speech is rapid with increased volume. There is evidence of paranoid delusions about persecution by the police. Which of the following is the most likely diagnosis?
WRONG A) Bipolar disorder
B) Delusional disorder
C) Generalized anxiety disorder
D) Schizophrenia
E) Substance-induced psychotic disorder