The patient is a 9-year-old girl brought into the urgent care clinic by both of her parents. Over the past 18 months, they have noticed emerging "habits" including repetitive squinting and grimacing, along with associated clearing of her throat and grunting noises. These behaviors occur almost every day and frequently occur together. She has gotten increasingly teased because of her peculiarities and her anxiety has only worsened her symptoms. She has no major illnesses and is not taking any medications. Her physical examination is within normal limits with the exception of the above stereotypes.
A history of infection with which of the following organisms would be most likely in this patient?
A. herpes simplex virus
B. HIV
C. influenza virus
D. Staphylococcus
E. Streptococcus
Correct Answer: E Section: (none)
Explanation:
This patient has Tourette disorder, characterized by the existence of both motor and vocal tics which have been present for 1 year. There is not a significantly increased comorbidity for autistic disorder, major depressive disorder, panic disorder, or conduct disorder. There is a very high comorbidity, however, for both ADHD and OCD in individuals with Tourette's disorder. Lorazepam, a benzodiazepine, may be useful in the short-term management of the anxiety associated with Tourette's disorder, but it is not indicated for the treatment of the tics themselves. Methylphenidate, a stimulant, may be used if there is associated ADHD along with the tic disorder, but it may increase the frequency of tics. Paroxetine, a SSRI, is used in treating both depressive disorders and OCD, but it is not indicated for treatment of Tourette disorder. Clonidine, an alpha-2 adrenergic agonist, can be somewhat helpful in reducing some symptoms of Tourette's disorder. The most efficacious, and first-line, treatment for Tourette's disorder is the use of dopamine antagonists such as antipsychotics (e.g., haloperidol). The etiology of several disorders, among them Tourette's and OCD, may be related to an autoimmune process. It is believed that infection with certain microorganisms, specifically streptococcal infections, may act synergistically with a genetic vulnerability to cause those mental illnesses. The full significance of this in terms of diagnosis, prevention, and treatment of these conditions has yet to be determined.
Question 252:
The patient is a 9-year-old girl brought into the urgent care clinic by both of her parents. Over the past 18 months, they have noticed emerging "habits" including repetitive squinting and grimacing, along with associated clearing of her throat and grunting noises. These behaviors occur almost every day and frequently occur together. She has gotten increasingly teased because of her peculiarities and her anxiety has only worsened her symptoms. She has no major illnesses and is not taking any medications. Her physical examination is within normal limits with the exception of the above stereotypes.
Which of the following would be the most effective pharmacotherapy for her presenting illness?
A. clonidine
B. haloperidol (Haldol)
C. lorazepam (Ativan)
D. methylphenidate (Ritalin)
E. paroxetine (Paxil)
Correct Answer: B Section: (none)
Explanation: This patient has Tourette disorder, characterized by the existence of both motor and vocal tics which have been present for 1 year. There is not a significantly increased comorbidity for autistic disorder, major depressive disorder, panic disorder, or conduct disorder. There is a very high comorbidity, however, for both ADHD and OCD in individuals with Tourette's disorder. Lorazepam, a benzodiazepine, may be useful in the short-term management of the anxiety associated with Tourette's disorder, but it is not indicated for the treatment of the tics themselves. Methylphenidate, a stimulant, may be used if there is associated ADHD along with the tic disorder, but it may increase the frequency of tics. Paroxetine, a SSRI, is used in treating both depressive disorders and OCD, but it is not indicated for treatment of Tourette disorder. Clonidine, an alpha-2 adrenergic agonist, can be somewhat helpful in reducing some symptoms of Tourette's disorder. The most efficacious, and first-line, treatment for Tourette's disorder is the use of dopamine antagonists such as antipsychotics (e.g., haloperidol). The etiology of several disorders, among them Tourette's and OCD, may be related to an autoimmune process. It is believed that infection with certain microorganisms, specifically streptococcal infections, may act synergistically with a genetic vulnerability to cause those mental illnesses. The full significance of this in terms of diagnosis, prevention, and treatment of these conditions has yet to be determined.
Question 253:
The patient is a 9-year-old girl brought into the urgent care clinic by both of her parents. Over the past 18 months, they have noticed emerging "habits" including repetitive squinting and grimacing, along with associated clearing of her throat and grunting noises. These behaviors occur almost every day and frequently occur together. She has gotten increasingly teased because of her peculiarities and her anxiety has only worsened her symptoms. She has no major illnesses and is not taking any medications. Her physical examination is within normal limits with the exception of the above stereotypes.
Further history would most likely reveal which of the following comorbid diagnoses?
A. autistic disorder
B. major depressive disorder
C. OCD
D. panic disorder
E. conduct disorder
Correct Answer: C Section: (none)
Explanation:
This patient has Tourette disorder, characterized by the existence of both motor and vocal tics which have been present for 1 year. There is not a significantly increased comorbidity for autistic disorder, major depressive disorder, panic disorder, or conduct disorder. There is a very high comorbidity, however, for both ADHD and OCD in individuals with Tourette's disorder. Lorazepam, a benzodiazepine, may be useful in the short-term management of the anxiety associated with Tourette's disorder, but it is not indicated for the treatment of the tics themselves. Methylphenidate, a stimulant, may be used if there is associated ADHD along with the tic disorder, but it may increase the frequency of tics. Paroxetine, a SSRI, is used in treating both depressive disorders and OCD, but it is not indicated for treatment of Tourette disorder. Clonidine, an alpha-2 adrenergic agonist, can be somewhat helpful in reducing some symptoms of Tourette's disorder. The most efficacious, and first-line, treatment for Tourette's disorder is the use of dopamine antagonists such as antipsychotics (e.g., haloperidol). The etiology of several disorders, among them Tourette's and OCD, may be related to an autoimmune process. It is believed that infection with certain microorganisms, specifically streptococcal infections, may act synergistically with a genetic vulnerability to cause those mental illnesses. The full significance of this in terms of diagnosis, prevention, and treatment of these conditions has yet to be determined.
Question 254:
The patient is a 7-year-old boy brought in for evaluation by his father. He has been concerned with his son's behavior. At school conferences, he has been told that his son will not stay in place and moves around the room despite being informed about the rules. He neither listens at home nor at school when given feedback. For example, he continues to have difficulty waiting in line, completing his homework, and cleaning up his toys, regardless of numerous consequences. In department stores, he will run around and grab at items, and this has resulted in his breaking merchandise on many occasions. The father states that his son has been this way "since he could walk" and is worried about his son's future.
After further history is obtained and consultation with the school is initiated, a definitive diagnosis is made. The recommendation to begin a stimulant is presented to the father, but he has concerns regarding that treatment choice. How should he be counseled regarding the use of this medication?
A. It may cause paradoxical sedation.
B. It only improves behavior and not school performance.
C. It requires regular BP monitoring.
D. It should be taken daily, throughout the year.
E. It will increase the risk of future addiction.
Correct Answer: C Section: (none)
Explanation:
This patient suffers from ADHD as evidenced by numerous inattentive and hyperactive/ impulsive
symptoms and signs. Autistic disorder is a pervasive developmental disorder (PDD) consisting of
impairments in social interaction and communication, in addition to stereotyped behaviors. Conduct
disorder is a disruptive behavior disorder characterized by aggression and violation of the rights of others.
While oppositional defiant disorder is also a disruptive behavior disorder, it is not as severe as conduct
disorder, occurring at an earlier age and demonstrating a pattern of negativistic and defiant behaviors.
OCD is an anxiety disorder not uncommonly seen in children, diagnosed by the presence of recurrent,
distressing obsessions and/or compulsions.
Stimulants are the first-line treatment for ADHD. However, there are many misconceptions regarding their
use, which may necessitate the use of more detailed psychoeducation.
It was previously believed that stimulants exert their clinical effect through sedation, but this is no longer
considered to be true. Stimulants not only improve behavior, but there is evidence that they actually
"normalize" school performance as well. The use of drug holidays, such as weekends and during the
summer, is recommended in order to make up for any growth suppression.
Question 255:
The patient is a 7-year-old boy brought in for evaluation by his father. He has been concerned with his son's behavior. At school conferences, he has been told that his son will not stay in place and moves around the room despite being informed about the rules. He neither listens at home nor at school when given feedback. For example, he continues to have difficulty waiting in line, completing his homework, and cleaning up his toys, regardless of numerous consequences. In department stores, he will run around and grab at items, and this has resulted in his breaking merchandise on many occasions. The father states that his son has been this way "since he could walk" and is worried about his son's future. Which of the following is his most likely diagnosis?
A. attention deficit/hyperactivity disorder (ADHD)
B. autistic disorder
C. conduct disorder
D. obsessive-compulsive disorder (OCD)
E. oppositional defiant disorder
Correct Answer: A Section: (none)
Explanation:
This patient suffers from ADHD as evidenced by numerous inattentive and hyperactive/ impulsive
symptoms and signs. Autistic disorder is a pervasive developmental disorder (PDD) consisting of
impairments in social interaction and communication, in addition to stereotyped behaviors. Conduct
disorder is a disruptive behavior disorder characterized by aggression and violation of the rights of others.
While oppositional defiant disorder is also a disruptive behavior disorder, it is not as severe as conduct
disorder, occurring at an earlier age and demonstrating a pattern of negativistic and defiant behaviors.
OCD is an anxiety disorder not uncommonly seen in children, diagnosed by the presence of recurrent,
distressing obsessions and/or compulsions.
Stimulants are the first-line treatment for ADHD. However, there are many misconceptions regarding their
use, which may necessitate the use of more detailed psychoeducation.
It was previously believed that stimulants exert their clinical effect through sedation, but this is no longer
considered to be true. Stimulants not only improve behavior, but there is evidence that they actually
"normalize" school performance as well. The use of drug holidays, such as weekends and during the
summer, is recommended in order to make up for any growth suppression.
Question 256:
A 48-year-old man with no prior psychiatric history is seen in the acute care clinic because of concerns over having a sexually transmitted disease. He denies any dysuria, penile discharge, or lesions. His physical examination is unremarkable. When informed of this information, he insists on being tested. When inquiries are made regarding his sexual history, he claims to be monogamous with his wife, who happens to be Senator Hilary Clinton. When confronted with the fact that she is already married to someone else and living in another state, he states that he married her 2 years ago in a "secret" ceremony. He adds that she flies in on weekends to have "conjugal visits," but he is afraid that she has been unfaithful to him and has given him a venereal disease. He has no medical problems and is not taking any medications currently. Further history reveals that he holds a steady job as a security guard. He lives alone in an apartment. He denies alcohol or illicit drug use. On MSE, he appears well-dressed and groomed. He is cooperative overall. His mood and affect are anxious. His thoughts are logical. He denies any suicidal or homicidal ideation, or any perceptual disturbances.
Which of the following is his most likely diagnosis?
A. bipolar disorder, manic
B. delusional disorder
C. paranoid personality disorder
D. schizoaffective disorder
E. schizophrenia
Correct Answer: B Section: (none)
Explanation:
Bipolar disorder usually has its onset in late adolescence or early adulthood. A manic episode consists of symptoms such as decreased need for sleep, increased energy, talkativeness, and an elevated or irritable mood. Individuals with paranoid personality disorder are chronically mistrustful and suspicious. Although they can distort reality, they are not overtly delusional as in the above case. Both schizoaffective disorder and schizophrenia display overt psychotic symptoms, including delusions, hallucinations, and disorganization. Patients with schizoaffective disorder additionally have either a major depressive or manic episode, while patients with schizophrenia require significant social or occupational impairment. Neither of these criteria is present in the above case. The patient demonstrates delusional disorder, which consists of a nonbizarre delusion (i.e., one that could actually exist) without significantly impaired function, odd behavior, or the presence of a major mood disorder. The age of onset for delusional disorder is commonly during middle age, whereas evidence of the other disorders is generally present at a much earlier age (DSM IV-TR).
Question 257:
The patient is a 28-year-old female medical student who is referred to the Office of Student Affairs due to receiving an incomplete on her surgery clerkship. Upon questioning, she admits to "sneaking out" of the operating room in order to avoid participating in surgeries. When confronted with her unprofessional behavior and expectations of the rotation, she claims to have significant anxiety revolving around the operating room. She states, "It's not that I mind the surgery itself, just the blood." She proceeds to reveal numerous instances of feeling dizzy, lightheaded, and even fainting when seeing blood. As a result, she has been unable to donate blood while in college or medical school and has, thus far, been able to "work around" drawing blood in other clerkships. Which of the following treatment modalities would be the most effective for this individual?
A. beta-blocker
B. exposure therapy
C. insight-oriented therapy
D. SSRI
E. supportive therapy
Correct Answer: B Section: (none)
Explanation:
Agoraphobia is characterized by anxiety about being in places where escape might be difficult or help might not be available in the event that a panic attack occurs (e.g., crowds, bridges, standing in lines). GAD involves excessive worry about a number of events for at least 6 months. Panic disorder is diagnosed if there are recurrent, unexpected panic attacks along with concerns about having further attacks or about the consequences of having an attack (e.g., heart attack, losing control). Social phobia is characterized by a persistent dread of social or performance situations due to fears of acting in an embarrassing or humiliating way. This woman experiences symptoms consistent with a specific phobia, blood-injectioninjury type (DSM IV-TR). Due to the sympathetic discharge, individuals with certain phobias, most notably social phobia, can sometimes be managed with the use of beta-blockers.
This is particularly useful when a known exposure will occur. Beta-blockers could worsen the symptoms of blood-injury phobia, however, given the vasovagal nature of the response. Insightoriented and supportive therapies are not particularly helpful with treating phobias, as phobias usually require specific behavioral techniques. SSRIs can be efficacious in certain anxiety disorders, such as social phobia, panic disorder, and GAD; however, they are not useful for phobias such as blood-injury type. Exposure therapy is considered to be the optimal treatment for phobias in general, especially specific phobias. In this therapy, the patient is exposed to particular phobic stimuli of an increasingly anxiety-provoking nature, and certain relaxation techniques are introduced.
Question 258:
The patient is a 28-year-old female medical student who is referred to the Office of Student Affairs due to receiving an incomplete on her surgery clerkship. Upon questioning, she admits to "sneaking out" of the operating room in order to avoid participating in surgeries. When confronted with her unprofessional behavior and expectations of the rotation, she claims to have significant anxiety revolving around the operating room. She states, "It's not that I mind the surgery itself, just the blood." She proceeds to reveal numerous instances of feeling dizzy, lightheaded, and even fainting when seeing blood. As a result, she has been unable to donate blood while in college or medical school and has, thus far, been able to "work around" drawing blood in other clerkships. Which of the following is her most likely diagnosis?
A. agoraphobia
B. generalized anxiety disorder (GAD)
C. panic disorder
D. social phobia
E. specific phobia
Correct Answer: E Section: (none)
Explanation:
Agoraphobia is characterized by anxiety about being in places where escape might be difficult or help might not be available in the event that a panic attack occurs (e.g., crowds, bridges, standing in lines). GAD involves excessive worry about a number of events for at least 6 months. Panic disorder is diagnosed if there are recurrent, unexpected panic attacks along with concerns about having further attacks or about the consequences of having an attack (e.g., heart attack, losing control). Social phobia is characterized by a persistent dread of social or performance situations due to fears of acting in an embarrassing or humiliating way. This woman experiences symptoms consistent with a specific phobia, blood-injectioninjury type (DSM IV-TR). Due to the sympathetic discharge, individuals with certain phobias, most notably social phobia, can sometimes be managed with the use of beta-blockers.
This is particularly useful when a known exposure will occur. Beta-blockers could worsen the symptoms of blood-injury phobia, however, given the vasovagal nature of the response. Insightoriented and supportive therapies are not particularly helpful with treating phobias, as phobias usually require specific behavioral techniques. SSRIs can be efficacious in certain anxiety disorders, such as social phobia, panic disorder, and GAD; however, they are not useful for phobias such as blood-injury type. Exposure therapy is considered to be the optimal treatment for phobias in general, especially specific phobias. In this therapy, the patient is exposed to particular phobic stimuli of an increasingly anxiety-provoking nature, and certain relaxation techniques are introduced.
Question 259:
A32 year-old male presents to the primary care clinic with recurrent episodes of bronchitis. He is otherwise healthy but admits to a 14 packyear history of cigarette smoking. He is prescribed another trial of appropriate antibiotics, but he has "had enough" of smoking and wants to quit. Use of which of the following modalities would most likely give him the best chance of quitting?
A. bupropion
B. nicotine gum
C. nicotine inhaler
D. nicotine nasal spray
E. nicotine patch plus behavioral therapy
Correct Answer: E Section: (none)
Explanation:
Any of the nicotine replacement therapies (gum, patch, or inhaler) have been found to double cessation rates. Bupropion has also been shown to double quit rates. Several studies have demonstrated that the combination of nicotine replacement and behavior therapy increases quit rates over either alone.
Question 260:
A 67-year-old man is seen in the clinic for a scheduled visit. He complains of walking difficulties that have progressively worsened over many months. He also has noticed "shaking" of his hands, resulting in his dropping objects occasionally. He is greatly upset by these problems and admits to frequent crying spells. His only chronic medical illnesses are gastroesophageal reflux disease and hyperlipidemia. He is currently prescribed a proton pump inhibitor and cholesterol-lowering agent. His MSE is notable for little expression or range of affect. His vitals signs are within normal limits. On physical examination, there is a noticeable coarse tremor of his hands, left greater than right. His gait is slow moving and broad-based.
Some time after initiation of treatment with the proper medication, he becomes agitated and is noted to be hallucinating. Which of the following medications would be the most appropriate to treat these new symptoms?
A. clozapine (Clozaril)
B. haloperidol (Haldol)
C. risperidone (Risperdal)
D. quetiapine (Seroquel)
E. thioridazine (Mellaril)
Correct Answer: D Section: (none)
Explanation:
This patient suffers from Parkinson's disease, a disorder involving decreased dopaminergic transmission. The nigrostriatal system originates in the substantia nigra. It is the primary dopaminergic tract in the central nervous system and is significantly affected in Parkinson's disease. The caudal raphe nuclei are the origin of the serotonergic system in the brain. The hippocampus is responsible for emotional and memory processing. The locus ceruleus is the location of the norepinephrine cell bodies. The nucleus basalis of Meynert is where the neurotransmitter acetylcholine originates.
The concern with treating agitation and psychosis in patients with Parkinson's disease is that antipsychotics block certain dopamine receptors, which can subsequently worsen the Parkinson's symptoms. While clozapine has minimal extrapyramidal symptoms (EPS), its risk of agranulocytosis and need for regular blood monitoring make it less practical as a first-line agent. Haloperidol is a high potency neuroleptic. It is efficacious in treating psychotic symptoms and reducing agitation, but its potency also presents a significant risk of worsening the Parkinson's disease. Risperidone is an atypical, or second-generation, antipsychotic. Although the risk of EPS at low doses is less than with haloperidol, risperidone tends to still be more of a problem when compared with other atypical medications. Thioridazine is another older antipsychotic. While its lower potency creates less EPS and, therefore, less likelihood of worsening Parkinson symptoms, it has significant anticholinergic side effects that may worsen the confusion. A more concerning risk is prolongation of the QTc interval on ECG, potentially causing a ventricular arrhythmia. Quetiapine is a second-generation antipsychotic medication with essentially no EPS. This gives it a unique advantage in treating the psychosis and/or agitation in Parkinson's patients without also worsening the movement disorder.
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