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FAMILY MEDICINE PAEA – PSYCHIATRY FINAL EXAM
COMPLETE QUESTIONS & DETAILED ANSWERS ALREADY
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A child has been under treatment for attention-deficit hyperactivity disorder (ADHD). No response has occurred with behavioral adaptations. Which of the following categories of medication should this patient be given? o A. stimulants o B. anxiolytics o C. antipsychotics
o D. antidepressants - CORRECT ANSWER >>> A
( Stimulants, such as Ritalin, Dexedrine, and Cylert, are effective in 50 to 80% of children with ADHD) Which of the following antipsychotic medications is associated with significant agranulocytosis but not with extrapyramidal side effects? o A. Clozapine (Clozaril) o B. Haloperidol (Haldol) o C. Chlorpromazine (Thorazine) o D.
Fluphenazine (Prolixin) - CORRECT ANSWER >>> ( Clozapine is referred as an
"atypical" antipsychotic agent. It can cause agranulocytosis and should be monitored with weekly CBC. This is not a first line treatment drug) Which of the following is effective in the long-term treatment of panic attacks? o A. Triazolam
o B. Propranolol (Inderal) o C. Lorazepam (Ativan) o D. Fluoxetine (Prozac) -
CORRECT ANSWER >>> D
(SSRI's, such as fluoxetine, are the initial drugs of choice for the long-term treatment of panic disorders) Phenothiazines exert their antipsychotic effects by blocking o A. alpha-adrenergic receptors o B. dopamine receptors o C. histamine receptors
o D. serotonin receptors - CORRECT ANSWER >>> B
(Blockage of the dopamine receptors in the mesolimbic areas of the brain is responsible for the antipsychotic effects of the phenothiazines; blockage of the dopamine receptors in the nigrostriatal areas lead to the motor side effects, such as dystonia and akathisia) Which of the following historical factors differentiates post-traumatic stress disorder from acute stress disorder? o A. The inability of the person to recall an important aspect of the event o B. Avoidance of stimuli that invokes recollections of the event o C. A belief that their future has been foreshortened because of the event o D. The presence of sleep
disorder - CORRECT ANSWER >>> C
(Post-traumatic stress disorder and acute stress disorder have many of the same characteristics. A sense of a foreshortened future, such as not expecting a normal life span or a career due to the trauma, distinguishes post-traumatic stress disorder from an acute stress disorder. The other answers are common to both disorders) A patient with obsessive-compulsive disorder would most likely have which of the following findings?
concentrating for the past 3 weeks. His wife also notes that he no longer goes bowling with his friends and has lost interest in any sexual intimacy. Physical examination is unremarkable. Which of the following is the most likely diagnosis? o A. major depression o B. dysthymic disorder o C. atypical depression
o D. drug-induced depression - CORRECT ANSWER >>> A
(Diagnostic criteria for a major depressive disorder include a loss of pleasure in usual activities, vegetative or physical changes (poor appetite, loss of energy), and cognitive changes such as difficulty in concentrating)
- A 56 year-old man is admitted to a hospital unit for evaluation of rectal bleeding and weight loss. He has a strong family history of cancer. Soon after admission, a barium enema is scheduled. The patient refuses the "prep" because he fears x-ray radiation. He states he has had previous x-rays, but becomes frightened at the thought of an x-ray and "can't face it." The most likely diagnosis is o A. hysterical personality o B. dissociative state o C. conversion reaction
o D. phobic neurosis - CORRECT ANSWER >>> D
(Phobic neurosis is a phobic ideation of displacement where the patient transfers feelings of anxiety from the object to one that can be avoided) Rates of alcohol use in the adolescent are reportedly higher in: o A. families with rigorous parental monitoring o B. Japanese families o C. adoptive children whose biological parent is an alcoholic o D. mood
disorders in a grandparent - CORRECT ANSWER >>> C
(There is a three-to fourfold increase in risk for alcohol dependence in adopted children whose biological parents are alcohol dependents)
A divorced female patient presents for an employment physical. She states she has had a "run of bad luck" with jobs and has not been able to hold any job for longer than 2-3 months. She also states she has been arrested several times for getting into fights when she is out with the girls. She states she drinks an occasional beer, but denies any significant problems with alcohol. Which of the following laboratory findings would support your suspected diagnosis? o A. decreased triglycerides o B. decreased serum uric acid o C. increased LDL cholesterol
o D. increased mean corpuscular volume - CORRECT
ANSWER >>> D
(This patient most likely has alcohol abuse as evidence by her social, occupational and legal issues. Laboratory tests will reveal the presence of an elevated mean corpuscular volume, triglycerides, serum uric acid and liver function tests.) A 20 year-old male presents to the ED with complaints of palpitations and agitation, which developed suddenly while attending a party. On examination, the patient is moderately agitated and tremulous. Vital signs include a pulse of 110/minute and regular; respiratory rate 22/minute and blood pressure 160/92 mmHg. Skin is diaphoretic and pupils are dilated. Which of the following is the most likely diagnosis? o A. Heroin use o B. Cocaine use o C. Scombroid
ingestion o D. Alcohol intoxication - CORRECT
ANSWER >>> B
(Cocaine, as well as amphetamines, leads to a clinical picture of increased sympathetic stimulation and dilated pupils) A 19 year-old female presents with complaints of intermittent abdominal pain associated with recent, frequent episodes of regurgitation of food for the past several months and worsening over the past 12 hours. She maintains a normal weight for her height however she seems
o A. Amitriptyline (Elavil) o B. Bupropion (Wellbutrin) o C. Fluoxetine (Prozac)
o D. Phenelzine (Nardil) - CORRECT ANSWER >>> C
(Selective serotonin reuptake inhibitors are the drugs of first choice for treating major depression) A 32 year-old mother of three presents with complaints of headache, abdominal pain, and general anxiety. Upon questioning, she admits that her husband has pressured her into sexual activity and has humiliated her in front of friends and family by implying that she is stupid and worthless. He gives her a weekly allowance, but does not allow her use of credit cards. She feels trapped and hopeless, and does not see any way out of this relationship. She finds herself crying often when the children are at school. You should o A. encourage her to leave the home immediately o B. refer to a marriage counselor o C. ask if she has considered killing her
husband o D. prescribe fluoxetine (Prozac) - CORRECT ANSWER >>> C
(Victims of domestic abuse may see no way out of a relationship besides homicide to protect themselves and/or their children. Risk of injury or homicide requires further psychiatric evaluation immediately) A 65 year-old presents with mental status changes, including lack of attention to personal hygiene increasing social isolation, and is no longer engaging in previously enjoyed actvities, such as the daily crossword puzzle. Of the following tests, which would be most helpful in determining the nature of these changes? o A. Beck Depression Inventory o B. Halstead- Reitan neuropsychological test o C. Myers-Briggs inventory o D. Rorschach test of
emotional functioning - CORRECT ANSWER >>> B
(The Halstead-Reitan neuropsychological test is used to evaluate cognitive functioning, and is helpful in assessing brain damage, dysfunction, and dementia)
You are screening an adolescent for suicide risk. Which of the following is a risk factor for completed suicide? o A. Female gender o B. Lack of previous psychiatric disorder o C. Presence of firearms in the house o D. Youngest child in
family - CORRECT ANSWER >>> C
(Access to firearms in the home is an independent risk factor for completed suicide) A 42 year-old has a 40-pack year history of smoking cigarettes, having started at the age of 10. Several attempts to quit "cold turkey" have failed. The patient is motivated to quit because of family concerns. In addition to cognitive behavior counseling, which pharmacotherapeutic approach is best? o A. Nicotine replacement plus naltrexone (ReVia) o B. Nicotine replacement plus bupropion (Wellbutrin) o C. Bupropion (Wellbutrin) plus
nortriptyline (Pamelor) o D. Nortriptyline(Pamelor) plus disulfiram -
CORRECT ANSWER >>> B
( A combination of cognitive behavior, nicotine replacement, and pharmacotherapy with bupropion or nortriptyline seem to be the best approach to assist patients to quit smoking) A 22 year-old presents with over 6 months of increasing problems with hallucinations and delusions. The patient states that the extraterrestrials are sending messages to a chip implanted in his brain via channel 8 on television, and sometimes also via WYYZ on the radio. Most of the time they are telling him to avoid talking to his friends because they are planning to sell his kidneys to a man in India and his heart to a man in Ethiopia. A medical screening and drug screen revealed no obvious causes for the hallucinations. First line pharmacotherapeutic treatment of this patient includes which of the following drugs? o A. Chlorpromazine (Thorazine) o B. Clozapine (Clozaril) o C. Haloperidol (Haldol)
(Risperidone is one of the first line options for the treatment of schizophrenia due to its effectiveness and lower side effect profile compared to other drugs) Chronic thiamine deficiency associated with alcoholism is associated with which of the following pathologic processes? o A. Fatty liver o B. Hypertension o C. Renal failure
o D. Cerebellar degeneration - CORRECT ANSWER >>> D
(Chronic thiamine deficiency leads to atrophy of the cerebellum and peripheral nerves, resulting in the Wernicke syndrome. Korsakoff syndrome is characterized by memory loss, and most likely results from combined direct toxicity and thiamine deficiency) A 5 year-old is being evaluated for autism. Of the following, the finding most consistent with this diagnosis is o A. extremely high IQ o B. avoids eye contact o C. easily consoled by hugging
when hurt o D. frequently plays "house" or "cops and robbers" - CORRECT ANSWER >>> B
(Children with autism do not tend to make eye contact, and even avoid it) A patient presents with elevated mood for over two weeks, during which time she went to Las Vegas and ran up a $145,000 gambling debt, charged $4500 for clothes on her credit cards, and contracted gonorrhea from one of the seven men that she had sex with during this time. She has slept for less than two hours a night for the past several weeks. She was brought in by ambulance after attempting to gain entrance to the White House by declaring that she was the wife of the President of the United States. Medical and drug screening are within normal limits. Which of the following is the most likely diagnosis? o A. Acute schizophrenia o B. Bipolar disorder o C. Schizoid personality
o D. Obsessive-compulsive disorder - CORRECT ANSWER
>>> B
(The manic phase of bipolar disorder is characterized by an expansive and euphoric mood, with inflated self- esteem or grandiosity, decreased need for sleep, talkative, flight of ideas, distractibility, increase in goal- directed activity, excessive involvement in high-risk fun activities (spending money, sexual indiscretions). The mood disturbance is so severe that it interferes with normal social functioning, and is not related to substance abuse) You are screening an adolescent for suicide risk. Which of the following is a risk factor for completed suicide? o A. Female gender o B. Lack of previous psychiatric disorder o C.
Presence of firearms in the house o D. Youngest child in family - CORRECT ANSWER
>>> C
(Access to firearms in the home is an independent risk factor for completed suicide) A 27 year-old presents with acute shortness of breath with chest pain, dizziness, sweating, and nausea that started about a half hour ago. She has had episodes like this in the past, the first of which occurred about six months after her mother died. They resolved with breathing into a paper bag. In between attacks, she feels fine. Which of the following is the most likely diagnosis? o A. Panic attack o B. Grief reaction o C. Histrionic personality
o D. Generalized anxiety disorder - CORRECT
ANSWER >>> A
( Panic attacks are characterized by sudden onset of intense apprehension, fear, or a sense of impending doom, accompanied by at least four somatic symptoms, such as shortness of breath, dizziness, palpitations, sweating, trembling, chest pain, nausea, and others)
A. Serum TSH o B. Urine drug screen o C. Minnesota Multiphasic Personality Inventory (MMPI)
o D. Electroencephalogram (EEG) - CORRECT ANSWER >>> B
(A drug screen would be helpful for many drugs of abuse that might cause these symptoms, but may not be definitive for amphetamines) A 36 year-old man has a 30 pack-year history of smoking cigarettes and wants to quit. He is otherwise healthy at this time. Which of the following drugs would be appropriate for him? o A. Amitriptyline (Elavil) o B. Bupropion (Wellbutrin) o C. Fluoxetine (Prozac)
o D. Venlafaxine (Effexor) - CORRECT ANSWER >>> B
(The only two approved drugs for aiding smoking cessation are nicotine and bupropion) A 25 year-old female graduate student presents to the student health center for the eighth time in three weeks to be sure she does not have meningitis. She read that there was a student on campus who had meningitis last month, and now she has headaches and is requesting to be tested to make sure she does not have meningitis. She has been evaluated at each visit, and physical examination has been completely normal each time. Which of the following is the most likely diagnosis? o A. Conversion disorder o B. Hypochondriasis o C. Malingering
o D. Somatization disorder - CORRECT ANSWER >>> B
( Hypochondriasis is the chronic preoccupation with the idea of having a serious disase, which is usually not amenable to reassurance)
Early clues to impending delirium tremens include o A. agitation and decreased cognition o B. visual hallucinations and diaphoresis o C. autonomic hyperactivity and dehydration.
D. mental confusion and sensory hyperacuity. - CORRECT ANSWER >>> A
(Anxiety, decreased cognition, tremulousness, increasing irritability, and hyperactivity are common early clues to impending delirium tremens) Which of the following drugs is first-line therapy for schizophrenia? o A. Chlorpromazine (Thorazine) o B. Clozapine (Clozaril) o C. Haloperidol (Haldol)
o D. Olanzapine (Zyprexa) - CORRECT ANSWER >>> D
(Initial pharmacologic therapy of schizophrenia should begin with one of the newer, "atypical" antipsychotic drugs, such as olanzapine, risperidone, quetiapine, ziprasidone, and clozapine because their side effect profile is significantly better than the older drugs, and they may be more effective for negative psychotic symptoms) The DSM-IV classifies mental disorders by using five axes in completing the process. Axis III is used to identify which of the following? o A. Clinical disorders and other conditions that may be the focus of clinical attention o B. Any physical disorder or general medical condition that is present in addition to the mental disorder o C. The psychosocial and environmental problems that have had a significant contribution to the development or exacerbation of the disorder o D. Personality disorders and/or mental
retardation - CORRECT ANSWER >>> B
and handing out $100 bills to all passers-by. Her friends noted that she had been depressed lately, but now seems completely euphoric. She had a similar episode two years ago. Which of the following is the most appropriate treatment? o A. Inpatient olanzapine (Zyprexa) therapy o B. Inpatient electroconvulsive therapy o C. Outpatient paroxetine (Paxil) therapy
o D. Outpatient psychotherapy - CORRECT ANSWER >>> A
(Treatment of the manic phase is usually done in the hospital to protect patients from behaviors associated with grandiosity (spending inordinate amounts of money, making embarrassing speeches, etc.). Lithium, valproate, and olanzapine are considered effective in the manic stage; the depressive stage is treated with antidepressants) A mother brings her 6 year-old boy for evaluation of school behavior problems. She says the teacher told her that the boy does not pay attention in class, that he gets up and runs around the room when the rest of the children are listening to a story, and that he seems to be easily distracted by events outside or in the hall. He refuses to remain in his seat during class, and occasionally sits under his desk or crawls around under a table. The teacher told the mother this behavior is interfering with the child's ability to function in the classroom and to learn. The mother states that she has noticed some of these behaviors at home, including his inability to watch his favorite cartoon program all the way through. Which of the following is the most likely diagnosis? o A. Antisocial disorder o B. Dysthymic mood disorder o C. Obsessive-
compulsive disorder o D. Attention deficit hyperactivity disorder - CORRECT
ANSWER >>> D
(Attention deficit hyperactivity disorder is characterized by inattention, including increased distractibility and difficulty sustaining attention; poor impulse control and decreased selfinhibitory capacity; and motor overactivity and motor restlessness, which are pervasive and interfere with the individual's ability to function under normal circumstances) A 17 year-old patient presents to the emergency department with agitation and hallucinations, and has one seizure. He admits to using "some drugs" but does not know what they were. On
physical examination, temperature is 103 degrees F, BP 140/90, pulse 120, respirations 20. Remainder of the examination is unremarkable. Which of the following diagnostic studies will be of most help in managing this patient? o A. Drug screen o B. Urine dipstick o C. Complete blood count
o D. Serum creatinine kinase - CORRECT ANSWER >>> D
(Serum creatinine kinase is the most sensitive test to detect rhabdomyolysis, a serious complication of seizures and hyperthermia related to drug abuse) A mother brings in her five year-old boy for his school physical. She voices some concerns about his readiness for school, saying he seems to be socially immature. She has noticed he does not interact with other children well, and that when he plays with them, he has a tendency to "place them" and then run around them as if they were statues. He rarely cries when he is hurt, and he shrugs off any attempt to hug him. He has good attention to details, and will sit and draw the same geometric shapes over and over again, but does not seem interested in learning the alphabet. He avoids eye contact with anyone. Which of the following is the most likely diagnosis? o A. Normal 5 year-old o B. Social phobia o C. Autism
o D. Avoidant personality - CORRECT ANSWER >>> C
( Children with autism do not tend to make eye contact, and even avoid it. They do not accept comfort when hurt and stiffen up when hugged. They do not tend to play with others, and do not tend to imitate grown-ups in play. They approach play in a more mechanical way, using others as props rather than interacting with them.) A 22 year-old female presents to the emergency department with rapid heart rate. She appears quite thin and dehydrated. She denies that she is thin, stating "I am so fat that I can hardly stand myself! That is why I exercise every day." She runs twelve to fifteen miles a day, and on weekends also bicycles forty to fifty miles. Her LMP was six months ago. On exam, she is 5' 6" tall and weighs 98 pounds. Temp 98 degrees F, pulse 100, respirations 18, BP 98/60. EKG shows sinus tachycardia. Laboratory findings include Na 138 mEq/L, K 2.8 mEq/L, Cl 91 mEq/L, BUN 35 mg/dL, Creatinine 1.1 mg/dL. Which of the following is the next most appropriate treatment?
blink frequency, and lip-smacking behavior. These involuntary movements are most suggestive of o A. tardive dyskinesia o B. Parkinson's disease o C. Huntington's disease
o D. Tourette's syndrome. - CORRECT ANSWER >>> A
(Tardive dyskinesia is characterized by abnormal involuntary movements of the face, mouth, tongue, trunk, and limbs and may develop after months or years of treatment with neuroleptic drugs) A patient with advanced AIDS complicated by toxoplasmosis presents with altered mental status, recent onset of seizures, and focal neurologic deficits. Which of the following diagnostic studies is most helpful? o A. EEG o B. MRI o C. lumbar puncture o D. Toxoplasma gondii
antibody titers - CORRECT ANSWER >>> B
(An MRI showing multiple isodense or hypodense ring-enhancing mass lesions is the most useful test for such a patient) A 28 year-old male patient is being treated for depression and has been taking paroxetine (Paxil) for the past two and a half months with a marked improvement in symptoms. The patient reports problems with sexual functioning which he believes is related to the medication. Which of the following is an immediate concern with abrupt discontinuation of the medication? o A. increased risk of suicide o B. diminished sexual functioning o C. risk of drug withdrawal symptoms o D. worsened depressive
symptoms - CORRECT ANSWER >>> C
(The greatest risk of abrupt withdrawal of short acting SSRIs is a withdrawal syndrome or withdrawal delirium which represents cholinergic rebound.) A 56 year-old man is admitted to a hospital unit for evaluation of rectal bleeding and weight loss. He has a strong family history of cancer. Soon after admission, a barium enema is
scheduled. The patient refuses the "prep" because he fears x-ray radiation. He states he has had previous x-rays, but becomes frightened at the thought of an x-ray and "can't face it." The most likely diagnosis is o A. hysterical personality o B. dissociative state o C. conversion reaction
o D. phobic neurosis - CORRECT ANSWER >>> D
(Phobic neurosis is a phobic ideation of displacement where the patient transfers feelings of anxiety from the object to one that can be avoided) A 26 year-old female has a long history of sexual promiscuity and substance abuse. She frequently expresses anger when she feels abandoned. She also has difficulty in controlling her anger at times. Her past relationships have been intense and short-lived. She has attempted suicide twice in the past 18 months. This patient exhibits which of the following disorders? o A. bipolar o B. avoidant personality o C. borderline personality
o D. dissociative - CORRECT ANSWER >>> C
(Borderline personality disorder is characterized by instability of interpersonal relationships, marked impulsivity that is potentially self-damaging, inappropriate, intense anger or control of anger, recurrent suicidal attempts, gestures or threats, and identity disturbances. All of these are exhibited in this patient) A child has been under treatment for attention-deficit hyperactivity disorder (ADHD). No response has occurred with behavioral adaptations. Which of the following categories of medication should this patient be given? o A. stimulants o B. anxiolytics o C. antipsychotics
o D. antidepressants - CORRECT ANSWER >>> A
