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A 55-year-old woman with a history of schizoaffective disorder presents to your office to discuss her current treatment regimen. She was started on olanzapine at her last visit and wants to know what type of monitoring is recommended while taking this medication. Which of the following is the most appropriate diagnostic test to order? - ✔ ✔ Lipid profile
A 35-year-old woman presents to her primary care office with a three-month history of dull headaches, insomnia, and irritability. She has difficulty concentrating and says she is disinterested in her favorite activities. She states she has been having nightmares and frequent flashbacks of her time overseas. The patient recently left the military and is currently employed as a nurse at a local hospital. What important historical feature has she provided that distinguishes her symptoms as post-traumatic stress
disorder rather than acute stress disorder? - ✔ ✔ Duration
Notes:
Post-traumatic stress disorder (PTSD) can be differentiated from acute stress disorder based on duration. Acute stress disorder is characterized as occurring and resolving within one month after a traumatic event whereas post-traumatic stress disorder typically occurs anywhere from a few months to six months from the time of an event and last for many years.
A 25-year-old woman presents to the emergency department with complaints of abdominal pain, vomiting, and diarrhea that has been present for five years. She states that no one has been able to help her up to this point. She has numerous allergies to a variety of medications. Physical exam reveals moist mucous membranes, multiple well- healed incisions on her abdomen, and vital signs within normal limits. Which of the following is the most likely diagnosis? - ✔ ✔ Factitious disorder
oppositional defiant disorder. Assessing for the presence of what common co-occurring disorder is key in effective treatment? - ✔ ✔ Attention-deficit/hyperactivity disorder
A 9-year-old boy presents to the office with his mother because he is often losing his temper at home. He is argumentative and refuses to listen when she asks him to do his chores. Additionally, he is making fun of his brother to the point where his brother no longer wants to be around him. He is always blaming his brother for making him mad. Upon further questioning, you find out that the behavior began worsening about 6 months ago and seems worse than the usual behavior for his age. She reports that her children spend a lot of time at home alone and she is often nagging or yelling at them to behave. What type of clinical intervention would work best for this family to address the patient's behavior? - ✔ ✔ Refer the family to parent management therapy that includes the patient and his mother
Notes:
Oppositional Defiant Disorder (ODD):
At least 6 months of symptoms in a child
Angry, argumentative, defiant behavior
Vindictiveness
Evaluate for other comorbidities
Treat with psychotherapy
Which of the following symptoms, if present in a patient more days than not for six months or more, would aid in the diagnosis of generalized anxiety disorder? - ✔ ✔ Being easily fatigued
Notes:
Generalized anxiety disorder is characterized by excessive worry or anxiety that is difficult to control and lasts most of the day, more days than not, for at least six months.
In addition, three of the following six symptoms must be present more days than not for six months or more: being easily fatigued, sleep disturbances, irritability, muscle tension, restlessness, and difficulty concentrating.
Notes:
Methylphenidate is a central nervous system stimulant and is the best medication to use in patients with conduct disorder who are experiencing worsening symptoms despite behavioral and psychologic intervention.
A 13-year-old boy and his parents present to the clinic to discuss his history of diet controlled attention deficit hyperactivity disorder and new persistent behavior problems over the past year. He began with breaking items in the home and has since started fights at school and set his sister's toys on fire. He recently made threats to hurt the family dog. He is not responding to the parents' disciplinary efforts. In addition to psychotherapy, which of the following medications would be most beneficial for this patient? - ✔ ✔ Methylphenidate
A 15-year-old boy is brought to your office by his mother. She states over the past year he has been repeatedly in trouble at school for engaging in or starting fights. He is frequently truant and has subsequently been held back from advancing to 10th grade. He has also been arrested for stealing at a local mall. The patient denies that any of his mother's concerns are valid and says "everyone else is
doing the same stuff". Which of the following do you suspect? - ✔ ✔ Conduct disorder
Notes:
Frequent fighting, truancy, theft and discrediting those with concerns about behavior are indicative of conduct disorder. An affected individual can also display cruelty to animals or people, destroy property, or intimidate others, and generally shows no remorse for his or her actions.
Medication is not routinely prescribed for conduct disorder, however, severe aggression may be treated with an antipsychotic such as risperidone or quetiapine.
Question: What is the difference between conduct disorder and oppositional defiant disorder?
Answer: Conduct disorder involves aggression towards people or animals.
A 16-year-old boy has a two-year history of defiant behavior toward authority figures. His parents report that he is constantly getting into fights at school. They feel he has no
Notes:
Hypophosphatemia is the hallmark and predominant cause of refeeding syndrome. Refeeding syndrome can be fatal and patients are most at risk during the first two weeks of nutritional supplementation.
A 17-year-old previously healthy young woman presents to your office with her mother who has parental concerns about her weight. Her mother says that the patient has been steadily losing weight, is very focused on her appearance, and spends a lengthy amount of time in the bathroom several times a week. Which additional physical exam finding would suggest a diagnosis of bulimia nervosa rather than anorexia nervosa? - ✔ ✔ Dental caries
A 19-year-old man presents to clinic for intermittent mood swings, coughing, headaches, nausea, and loss of appetite. His mother states he often emerges from the family's home office or his bedroom with these symptoms, which usually resolve within a few hours. Additionally, she states he has an unusual odor when the symptoms occur. Which of the following physical exam finding is likely due to the
substance being abused? - ✔ ✔ Erythematous rash about the mouth
Notes: erythematous rash about the mouth is a common finding in patients inhaling solvents (glue, paint thinner, lacquer). It is usually caused by a contact dermatitis to the solvent and other chemicals in the substance abused and may be associated with a secondary bacterial infection.
Erythematous streaks on the antecubital fossa (B) are indicative of intravenous drug use and are not directly associated with solvent inhalation. Severe tooth decay with gingivitis (C) is associated with methamphetamine use. Skin abscesses (D) are associated with subdermal or subcutaneous injection of heroin or methamphetamine (skin popping) and may be a significant risk factor for the development of necrotizing fasciitis, particularly if "black tar" heroin is injected.
A 19-year-old young woman presents to your office with a concern about her weight. She tells you that she often eats excessive amounts of food, followed by either self-induced vomiting or excessive exercise. Physical exam findings
full neurological workup. A psychological evaluation reveals that the patient is not intentionally feigning illness. Which of the following is the most likely diagnosis? - ✔
✔ Conversion disorder
A 20-year-old previously healthy woman with a body mass index of 20 kg/m2 presents to your office for her annual exam. She tells you that she is very concerned about her weight and has been weighing herself daily. Vital signs reveal a blood pressure of 92/65 mm Hg and pulse of 102 bpm. Physical exam findings include bilateral parotid gland enlargement, dental caries, and abrasions on the knuckles of her right hand. Which of the following is the most likely diagnosis? - ✔ ✔ Bulimia nervosa
Notes:
Treatment is cognitive behavioral therapy
SSRIs: Fluoxetine
A 20-year-old woman presents to the clinic complaining of an inability to keep food down which has become increasingly worse over the past six months. She also complains of cold intolerance, amenorrhea, constipation,
and thinning of her hair. She states she watches what she eats very closely and spends a significant amount of time calculating her daily caloric intake. Her body mass index is currently 15 kg/m2. Which of the following physical examination findings would be expected? - ✔ ✔ Fine, downy, unpigmented hair growth
Notes:
Physical examination findings include fine, downy, unpigmented hair growth (i.e., lanugo hair growth), low body mass index, hypothermia, bradycardia, hypotension, hypoactive bowel sounds, xerosis, and abdominal distention.
A 20-year-old woman presents to the clinic complaining of excessive fear of embarrassment and humiliation, which has caused her to isolate herself from her peers. This has worsened over the past three years. In situations where she is unable to avoid interaction with others, she notes that she sweats and feels as though her hands are shaking. She has been unable to obtain a part-time job and struggles to participate in group activities in school because of this. Which additional finding would suggest a diagnosis of
Obsessions are intrusive, unwanted thoughts, often of a sinister nature, which cause the patient considerable anxiety and distress. Compulsions are repetitive behaviors performed in response to the obsessive thoughts and for the purpose of relieving the anxiety those thoughts cause.
Obsessive-Compulsive Disorder
Recurrent thoughts (obsessions), behaviors (compulsions)
Difficult to control
Disruption of daily living
Need to perform rituals
Yale-Brown Obsessive-Compulsive Scale
Treat with medications and therapy
A 20-year-old woman presents to the clinic for a sports physical. Her body mass index is 15 kg/m2. She reports restricting her diet for the past 3 months to 800 calories per day and running at least 10 miles each day. She states she wants to be healthy and fears being out of shape. Which of the following would lead to a diagnosis of
anorexia nervosa in this patient? - ✔ ✔ The patient believes she is currently overweight
Notes:
Anorexia nervosa is an eating disorder which can be diagnosed when the patient demonstrates each of three conditions. First, the patient is actively restricting calorie intake and has a low body weight for their age, development, growth trajectory, and medical status. Second, the patient is fearful of gaining weight or becoming overweight, or persists in behavior that prevents weight gain despite being underweight. Third, the patient has a distorted perception of her body size or shape, places undue emphasis on body weight as a source of self-worth, or refuses to accept the medical consequences of her weight loss.
A 21-year-old man presents to the clinic for a physical. While obtaining a detailed history, the patient reveals that last year he suffered a "mental breakdown" where he heard voices, believed his deceased grandmother was following him everywhere, had trouble communicating and would make up new words, had academic problems due to
Schizoaffective disorder: psychosis + mania or depression
A 21-year-old woman presents to the clinic for a work physical. She states she has never had blood work done and refuses to have any labs drawn today because she is fearful of needles. She reports avoiding clinics and hospitals for fear of seeing needles and is feeling very anxious, diaphoretic, and nauseous during her current visit. What is the most likely diagnosis? - ✔ ✔ Specific phobia
A 22-year-old man presents to the emergency department by emergency transport. His girlfriend reports he uses amyl nitrite recreationally. On exam, there is significant cyanosis, a clear airway, and good respiratory effort. He remains cyanotic despite oxygen delivery at 10 liters per minute through a non-rebreathing mask. Lab analysis confirms methemoglobinemia. Which of the following reactions mediates the formation of methemoglobinemia from amyl nitrite exposure? - ✔ ✔ Oxidation
Notes:
Methemoglobinemia is mediated by oxidation of heme, changing the physiologic form of iron from ferrous (Fe2+) to ferric (Fe3+)
A 22-year-old man with a history of anxiety presents to your office with a complaint of three days of increased sweating, anxiety, nausea, and mild hand tremors. He is a college student and has a considerable amount of stress related to exams and extracurricular activities. He has been taking alprazolam 0.5 mg at bedtime for the past six months but stopped filling his prescription when he ran out about a week ago because he did not want to become dependent. He states that he has been trying other methods of helping his anxiety including exercise, yoga, and has been seeing a therapist at his school. Upon physical examination, the patient has slightly dilated pupils and a pulse of 115 bpm, but he is alert and oriented to self, time, and place with normal speech and reasoning. What is the best next step for treatment of this patient's symptoms?
- ✔ ✔ Switch patient to a benzodiazepine with a longer half-life and taper him off slowly over the next few weeks
Notes:
