07-22-2016, 11:44 PM
1. A 10-year-old boy is brought by his parents for a well-child examination. His parents report that he is rambunctious with a high energy level, and he has been retained in one grade. He sleeps approximately 6-1⁄2 hours nightly. He has always been a handful and difficult to discipline; he argues about everything. For the past 2 years, he has often refused to go to school, so that his father then has to drive him there and walk him into his classroom. Several times, he has left school during the day. One month ago, he killed the family cat when he was playing too roughly. Although he said that it was an accident, he is not remorseful. His older brother is currently in a juvenile detention facility for grand larceny. The patient is at the 50th percentile for height and weight. His vital signs are within normal limits. Physical examination shows several ecchymoses in various stages of healing over the extremities. During the examination, he picks his nose. On mental status examination, he is initially insolent, but then he describes how he worries at night that something will happen to someone in his family. Which of the following is the most likely diagnosis?
A) Adjustment disorder
B) Antisocial personality disorder
C) Attentiondeficit/hyperactivity disorder (wrong)
D) Conduct disorder
E) Generalized anxiety disorder
F) Learning disorder
2. A 47-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 B1 (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 hyper-reflexia bilaterally. Which of the following is the most appropriate next step in pharmacotherapy?
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 B1 (thiamine) (WRONG)
3. A 42-year-old man is brought to the physician by his wife because of a 2month history of staring spells that last 1 to 2 minutes each. During episodes, he also smacks his lips and picks at his shirt collar. Four years ago, he was comatose for 2 weeks after sustaining a head injury in a motorcycle collision; he required 6 months of rehabilitation. He reports that over the past year, he has had intermittent episodes of smelling burnt rubber; episodes occur approximately every 2 weeks. He also hears an intense hissing sound during these episodes. Examination shows no abnormalities. Which of the following is the most likely finding on EEG?
A) Burst-suppression pattern
B) Diffuse 3Hz spike and slow wave activity
C) Focal spikes localized to the temporal lobe
D) Hypsarrhythmia
E) Periodic lateralized epileptiform discharges
F) Polyspike and slow wave activity
G) Triphasic waves
5. A 37yearold woman is admitted to the hospital after a suicide attempt by an overdose of pills and alcohol. She has a 6year history of major depressive disorder treated with various antidepressants. During this period, she has attempted suicide by hanging herself twice, jumping from a bridge, and taking several overdoses of pills. She is 163 cm (5 ft 4 in) tall and weighs 50 kg (110 lb); BMI is 19 kg/m . Her pulse is 64/min, and blood
pressure is 110/70 mm Hg. Mental status examination shows a depressed mood. She says that she has had difficulty sleeping and that she feels hopeless and helpless. There is still evidence of suicidal ideation. Laboratory findings are within the reference range. Urine toxicology screening is negative. This patient is most likely to have which of the following abnormalities?
A) Decreased concentration of 5-hydroxyindoleacetic acid in cerebrospinal fluid analysis
B) Delayed REM sleep on nighttime polysomnography
C) Enlarged lateral ventricles on CT scan of the head
D) Increased sensitivity to lactate infusion
E) Serology positive for human leukocyte antigenDR2
6. A 77-year-old man is brought to the physician by his wife because of a 6month history of confusion and "slowing down." She says he talks to people who are not there. The patient says he sometimes sees and has conversations with nonthreatening persons sitting by his bedroom window. He is otherwise asymptomatic. He has hypertension. Fifteen years ago, he underwent coronary artery bypass grafting for coronary artery disease. Current medications are atenolol and 81mg aspirin. He retired from his position as a pharmacist 6 years ago. His temperature is 37°C (98.6°F), pulse is 102/min and irregular, and blood pressure is 145/100 mm Hg. Cardiopulmonary examination shows no abnormalities. Muscle tone in all the extremities is decreased. Gait is slow and narrow based. On mental status examination, his affect is pleasant but dulled. He can recall one of three words after 2 minutes. He reports serial sevens as 100, 91, 73, and 65. He is unable to spell "world" backward or draw the hands on a clock accurately. Results of a complete blood count and serum studies are within the reference ranges. An ECG shows a regular sinus rhythm. Which of the following is the most likely diagnosis?
A) Alzheimer disease
B) Drug abuse
C) Lewy body dementia
D) Multi-infarct (vascular) dementia
E) Tumor of the parietal lobe
7. A 67-year-old man comes to the physician because of a 2-month history of increased fatigue and decreased libido. He used to sleep 8 hours every night, but now he sleeps 10 hours every night and takes a nap during the day. He has had a 4.5kg (10lb) weight gain during this period. He has type 2 diabetes mellitus; hypertension; degenerative arthritis of the back, hips, and knees; and hypercholesterolemia. Current medications include metformin, ibuprofen, simvastatin, sildenafil, lisinopril, and hydrochlorothiazide. He is 178 cm (5 ft 10 in) tall and weighs 104 kg (230 lb); BMI is 33 kg/m . His pulse is 74/min, and blood pressure is 130/82 mm Hg. Pedal pulses are decreased. Examination shows Heberden nodes over the distal interphalangeal joints. Sensation to pinprick is decreased over the feet. Mental status examination shows a constricted affect. He says he is losing interest in life because his multiple medical problems are so difficult to manage. There is no evidence of suicidal ideation.
Serum studies show:
Glucose 155 mg/dL
Cholesterol, total 162 mg/dL
HDL-cholesterol 46 mg/dL
LDL-cholesterol 90 mg/dL
Triglycerides 128 mg/dL
Which of the following is the most appropriate next step in pharmacotherapy?
A) Add bupropion to the medication regimen
B) Add insulin to the medication regimen
C) Add venlafaxine to the medication regimen
D) Discontinue lisinopril
E) Discontinue simvastatin
8. A 27-year-old first-year surgical resident comes to the physician to request a prescription for a sleeping aid. He says that during the past 2 months, he has had increasing anxiety. On days when he is not on call, he spends hours reading medical texts because he cannot remember as well as he did in medical school. He avoids participating in social activities with friends. His wife has told him that he has been increasingly irritable. He falls asleep easily in the evening but wakes up multiple times during the night with the feeling that he has not read enough. He cannot sleep any later than 3 am even though he is tired. He and his wife now sleep in different bedrooms, so that she is not disturbed when he wakes up. He has had a 2.7kg (6lb) weight loss during this time. He recalls that he was always cheerful and reliable in medical school and did not experience this much anxiety. He has no history of serious illness and takes no medications. Physical examination shows no abnormalities. On mental status examination, he appears concerned and has a reactive affect. Which of the following is the most appropriate next step in management?
A) Reassure the patient that this is a normal reaction to the first year of a residency program
B) Advise the patient to consider alternatives to his surgical residency program
C) Recommend overthecounter diphenhydramine therapy as needed
D) Begin escitalopram therapy
E) Begin quetiapine therapy
9. A 20-year-old college student comes to the physician because of a 1-year history of anxiety, dry mouth, sweating, nausea, and palpitations. She first noticed her symptoms when she tried to join a sorority and became embarrassed when she was asked to speak in front of the group. She says that she is failing a public speaking class because of overwhelming anxiety when she stands in front of the class to speak. She now avoids situations where she might have to speak in public. She says that her anxiety is "stupid" and thought taking a public speaking class would help with her symptoms. Physical examination shows no abnormalities. Mental status examination shows no abnormalities. Which of the following is the most likely diagnosis?
A) Generalized anxiety disorder
B) Obsessive-compulsive disorder
C) Panic disorder
D) Social phobia
E) Specific phobia (wrong)
A) Adjustment disorder
B) Antisocial personality disorder
C) Attentiondeficit/hyperactivity disorder (wrong)
D) Conduct disorder
E) Generalized anxiety disorder
F) Learning disorder
2. A 47-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 B1 (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 hyper-reflexia bilaterally. Which of the following is the most appropriate next step in pharmacotherapy?
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 B1 (thiamine) (WRONG)
3. A 42-year-old man is brought to the physician by his wife because of a 2month history of staring spells that last 1 to 2 minutes each. During episodes, he also smacks his lips and picks at his shirt collar. Four years ago, he was comatose for 2 weeks after sustaining a head injury in a motorcycle collision; he required 6 months of rehabilitation. He reports that over the past year, he has had intermittent episodes of smelling burnt rubber; episodes occur approximately every 2 weeks. He also hears an intense hissing sound during these episodes. Examination shows no abnormalities. Which of the following is the most likely finding on EEG?
A) Burst-suppression pattern
B) Diffuse 3Hz spike and slow wave activity
C) Focal spikes localized to the temporal lobe
D) Hypsarrhythmia
E) Periodic lateralized epileptiform discharges
F) Polyspike and slow wave activity
G) Triphasic waves
5. A 37yearold woman is admitted to the hospital after a suicide attempt by an overdose of pills and alcohol. She has a 6year history of major depressive disorder treated with various antidepressants. During this period, she has attempted suicide by hanging herself twice, jumping from a bridge, and taking several overdoses of pills. She is 163 cm (5 ft 4 in) tall and weighs 50 kg (110 lb); BMI is 19 kg/m . Her pulse is 64/min, and blood
pressure is 110/70 mm Hg. Mental status examination shows a depressed mood. She says that she has had difficulty sleeping and that she feels hopeless and helpless. There is still evidence of suicidal ideation. Laboratory findings are within the reference range. Urine toxicology screening is negative. This patient is most likely to have which of the following abnormalities?
A) Decreased concentration of 5-hydroxyindoleacetic acid in cerebrospinal fluid analysis
B) Delayed REM sleep on nighttime polysomnography
C) Enlarged lateral ventricles on CT scan of the head
D) Increased sensitivity to lactate infusion
E) Serology positive for human leukocyte antigenDR2
6. A 77-year-old man is brought to the physician by his wife because of a 6month history of confusion and "slowing down." She says he talks to people who are not there. The patient says he sometimes sees and has conversations with nonthreatening persons sitting by his bedroom window. He is otherwise asymptomatic. He has hypertension. Fifteen years ago, he underwent coronary artery bypass grafting for coronary artery disease. Current medications are atenolol and 81mg aspirin. He retired from his position as a pharmacist 6 years ago. His temperature is 37°C (98.6°F), pulse is 102/min and irregular, and blood pressure is 145/100 mm Hg. Cardiopulmonary examination shows no abnormalities. Muscle tone in all the extremities is decreased. Gait is slow and narrow based. On mental status examination, his affect is pleasant but dulled. He can recall one of three words after 2 minutes. He reports serial sevens as 100, 91, 73, and 65. He is unable to spell "world" backward or draw the hands on a clock accurately. Results of a complete blood count and serum studies are within the reference ranges. An ECG shows a regular sinus rhythm. Which of the following is the most likely diagnosis?
A) Alzheimer disease
B) Drug abuse
C) Lewy body dementia
D) Multi-infarct (vascular) dementia
E) Tumor of the parietal lobe
7. A 67-year-old man comes to the physician because of a 2-month history of increased fatigue and decreased libido. He used to sleep 8 hours every night, but now he sleeps 10 hours every night and takes a nap during the day. He has had a 4.5kg (10lb) weight gain during this period. He has type 2 diabetes mellitus; hypertension; degenerative arthritis of the back, hips, and knees; and hypercholesterolemia. Current medications include metformin, ibuprofen, simvastatin, sildenafil, lisinopril, and hydrochlorothiazide. He is 178 cm (5 ft 10 in) tall and weighs 104 kg (230 lb); BMI is 33 kg/m . His pulse is 74/min, and blood pressure is 130/82 mm Hg. Pedal pulses are decreased. Examination shows Heberden nodes over the distal interphalangeal joints. Sensation to pinprick is decreased over the feet. Mental status examination shows a constricted affect. He says he is losing interest in life because his multiple medical problems are so difficult to manage. There is no evidence of suicidal ideation.
Serum studies show:
Glucose 155 mg/dL
Cholesterol, total 162 mg/dL
HDL-cholesterol 46 mg/dL
LDL-cholesterol 90 mg/dL
Triglycerides 128 mg/dL
Which of the following is the most appropriate next step in pharmacotherapy?
A) Add bupropion to the medication regimen
B) Add insulin to the medication regimen
C) Add venlafaxine to the medication regimen
D) Discontinue lisinopril
E) Discontinue simvastatin
8. A 27-year-old first-year surgical resident comes to the physician to request a prescription for a sleeping aid. He says that during the past 2 months, he has had increasing anxiety. On days when he is not on call, he spends hours reading medical texts because he cannot remember as well as he did in medical school. He avoids participating in social activities with friends. His wife has told him that he has been increasingly irritable. He falls asleep easily in the evening but wakes up multiple times during the night with the feeling that he has not read enough. He cannot sleep any later than 3 am even though he is tired. He and his wife now sleep in different bedrooms, so that she is not disturbed when he wakes up. He has had a 2.7kg (6lb) weight loss during this time. He recalls that he was always cheerful and reliable in medical school and did not experience this much anxiety. He has no history of serious illness and takes no medications. Physical examination shows no abnormalities. On mental status examination, he appears concerned and has a reactive affect. Which of the following is the most appropriate next step in management?
A) Reassure the patient that this is a normal reaction to the first year of a residency program
B) Advise the patient to consider alternatives to his surgical residency program
C) Recommend overthecounter diphenhydramine therapy as needed
D) Begin escitalopram therapy
E) Begin quetiapine therapy
9. A 20-year-old college student comes to the physician because of a 1-year history of anxiety, dry mouth, sweating, nausea, and palpitations. She first noticed her symptoms when she tried to join a sorority and became embarrassed when she was asked to speak in front of the group. She says that she is failing a public speaking class because of overwhelming anxiety when she stands in front of the class to speak. She now avoids situations where she might have to speak in public. She says that her anxiety is "stupid" and thought taking a public speaking class would help with her symptoms. Physical examination shows no abnormalities. Mental status examination shows no abnormalities. Which of the following is the most likely diagnosis?
A) Generalized anxiety disorder
B) Obsessive-compulsive disorder
C) Panic disorder
D) Social phobia
E) Specific phobia (wrong)