A 19-year-old newly married female presents to the emergency room, accompanied by her spouse. She states that she awoke this morning to find that she could not move her legs. She denies any pain but claims that she is unable to feel anything below her abdomen. She denies any trauma or past medical history. She is 24 weeks' pregnant, has had an uneventful pregnancy, and only takes prenatal vitamins. She is concerned if her symptoms will get better and wonders whether the "baby is pulling on my spinal cord." Her neurologic examination is remarkable for 0/5 motor strength in her lower extremities bilaterally, with decreased sensation to light touch and pinprick below the level of her umbilicus. Her cranial nerves and reflexes are normal, and she does not display any upper motor neuron signs. A STAT MRI performed is read as normal.
Which of the following is the most appropriate approach for this patient?
A. administer intravenous fluids, informing her it will cure her symptoms
B. admit her to the inpatient neurologic unit for further tests
C. confront the patient regarding the nature of her symptoms
D. obtain consultation with a psychiatrist in the emergency room
E. reassure her and suggest that her symptoms will improve
Correct Answer: E Section: (none)
Explanation:
This young woman would be diagnosed with conversion disorder. The conscious production of symptoms to assume the sick role is the motivation underlying factitious disorder. Malingering is not a diagnosable mental illness but is the conscious inventing or exaggerating of physical or psychiatric symptoms in order to obtain secondary gain, such as disability benefits, or avoidance of work or a prison sentence. Given her unremarkable MRI, normal reflexes, absence of pathologic reflexes, and hemianesthesia along her umbilicus, her presentation is not consistent with either central or peripheral nervous system pathology. The apparent stressors of a new marriage and pregnancy are likely related to the genesis of her symptoms. Conversion symptoms are created through the unconscious production of neurologic symptoms due to unconscious conflict. While administering a "placebo," such as intravenous saline, may resolve her symptoms, it is both dishonest and unethical. Admission to neurology is unnecessary unless there is a concern regarding an actual underlying or comorbid disease. It may also serve to reinforce the somatization of her conflict. Confronting a patient with conversion disorder often results in a subsequent worsening of symptomatology. Consultation with a psychiatrist may be useful in helping the patient cope with the stress of her dysfunction but, in the emergency room, may also lead to feelings of not being believed and an increase in symptoms. Many cases of conversion disorder spontaneously remit, but recovery may be significantly facilitated through support, reassurance, and actual suggestion that improvement will occur
Question 272:
A 19-year-old newly married female presents to the emergency room, accompanied by her spouse. She states that she awoke this morning to find that she could not move her legs. She denies any pain but claims that she is unable to feel anything below her abdomen. She denies any trauma or past medical history. She is 24 weeks' pregnant, has had an uneventful pregnancy, and only takes prenatal vitamins. She is concerned if her symptoms will get better and wonders whether the "baby is pulling on my spinal cord." Her neurologic examination is remarkable for 0/5 motor strength in her lower extremities bilaterally, with decreased sensation to light touch and pinprick below the level of her umbilicus. Her cranial nerves and reflexes are normal, and she does not display any upper motor neuron signs. A STAT MRI performed is read as normal.
Which of the following is the most likely explanation for her current symptoms?
A. conscious production of symptoms to assume the sick role
B. conscious production of symptoms to obtain secondary gain
C. pathology involving the central nervous system
D. pathology involving the peripheral nervous system
E. unconscious production of symptoms due to unconscious conflict
Correct Answer: E Section: (none)
Explanation:
This young woman would be diagnosed with conversion disorder. The conscious production of symptoms to assume the sick role is the motivation underlying factitious disorder. Malingering is not a diagnosable mental illness but is the conscious inventing or exaggerating of physical or psychiatric symptoms in order to obtain secondary gain, such as disability benefits, or avoidance of work or a prison sentence. Given her unremarkable MRI, normal reflexes, absence of pathologic reflexes, and hemianesthesia along her umbilicus, her presentation is not consistent with either central or peripheral nervous system pathology. The apparent stressors of a new marriage and pregnancy are likely related to the genesis of her symptoms. Conversion symptoms are created through the unconscious production of neurologic symptoms due to unconscious conflict. While administering a "placebo," such as intravenous saline, may resolve her symptoms, it is both dishonest and unethical. Admission to neurology is unnecessary unless there is a concern regarding an actual underlying or comorbid disease. It may also serve to reinforce the somatization of her conflict. Confronting a patient with conversion disorder often results in a subsequent worsening of symptomatology. Consultation with a psychiatrist may be useful in helping the patient cope with the stress of her dysfunction but, in the emergency room, may also lead to feelings of not being believed and an increase in symptoms. Many cases of conversion disorder spontaneously remit, but recovery may be significantly facilitated through support, reassurance, and actual suggestion that improvement will occur.
Question 273:
A40-year-old single male with chronic schizophrenia is seen for a routine primary care clinic appointment for diabetes management. He is currently taking glyburide 5 mg bid and aripiprazole (Abilify) 20 mg daily. He claims to be compliant with his medications but appears poorly groomed with noticeable body odor. He is reluctant to talk, being somewhat guarded, but he eventually confides that he has been programmed by the government to kill his landlord, who he is convinced is working for Al Qaeda. His orders have been transmitted through his apartment walls to a receiver in his brain. He has been informed that if he does not comply, he will be sent to hell, so he has recently purchased several knives and plans to carry out "my mission" as soon as possible. When the subject of voluntary admission is brought up, he adamantly refuses.
After consultation with a psychiatrist, the decision is made to admit the patient involuntarily. This course of action is in compliance with which of the following forensic psychiatry provisions?
A. Durham rule
B. M'Naghten rule
C. Tarasoff I
D. Tarasoff II
E. Testamentary capacity
Correct Answer: D Section: (none)
Explanation:
The patient has chronic schizophrenia with an acute exacerbation consisting of disorganization, paranoia, persecutory delusions, and command hallucinations to kill his landlord. Although all of the choices may be indicated, this patient appears to be at significant risk of harm to others, namely his landlord. Therefore, only admission to the hospital for treatment (either voluntary or involuntary) would adequately protect the landlord. The Durham rule refers to criminal responsibility, that one is not criminally responsible if the illegal act was a product of a mental disease or defect. The M'Naghten rule was established by the British courts and posits that one is not guilty by reason of insanity if, due to a mental disease, one was unaware of the nature of the act or was incapable of realizing the act was wrong. Testamentary capacity refers to one's competence to make a will. The Tarasoff I and Tarasoff II rulings refer to the duty to warn others of danger and duty to protect others from danger, respectively
Question 274:
A40-year-old single male with chronic schizophrenia is seen for a routine primary care clinic appointment for diabetes management. He is currently taking glyburide 5 mg bid and aripiprazole (Abilify) 20 mg daily. He claims to be compliant with his medications but appears poorly groomed with noticeable body odor. He is reluctant to talk, being somewhat guarded, but he eventually confides that he has been programmed by the government to kill his landlord, who he is convinced is working for Al Qaeda. His orders have been transmitted through his apartment walls to a receiver in his brain. He has been informed that if he does not comply, he will be sent to hell, so he has recently purchased several knives and plans to carry out "my mission" as soon as possible. When the subject of voluntary admission is brought up, he adamantly refuses.
What is the most appropriate next step in his management?
A. admit the patient involuntarily
B. call the landlord and warn him
C. continue current medications with close follow-up
D. discuss the potential legal issues with the patient
E. switch the patient to another atypical antipsychotic
Correct Answer: A Section: (none)
Explanation:
The patient has chronic schizophrenia with an acute exacerbation consisting of disorganization, paranoia, persecutory delusions, and command hallucinations to kill his landlord. Although all of the choices may be indicated, this patient appears to be at significant risk of harm to others, namely his landlord. Therefore, only admission to the hospital for treatment (either voluntary or involuntary) would adequately protect the landlord. The Durham rule refers to criminal responsibility, that one is not criminally responsible if the illegal act was a product of a mental disease or defect. The M'Naghten rule was established by the British courts and posits that one is not guilty by reason of insanity if, due to a mental disease, one was unaware of the nature of the act or was incapable of realizing the act was wrong. Testamentary capacity refers to one's competence to make a will. The Tarasoff I and Tarasoff II rulings refer to the duty to warn others of danger and duty to protect others from danger, respectively.
Question 275:
A4-year-old boy is brought into the emergency room by his mother for evaluation. When the child is asked regarding specific complaints, he looks anxiously away and states, "It hurts when I go pee-pee." His mother confidently adds, "He has another urinary tract infection (UTI)." She lists the antibiotics that he has been treated with in the past and then demands that he be admitted for a workup. On examination, his vitals signs are unremarkable except for a temperature of 102°F. His physical examination is notable for suprapubic tenderness and some evidence of recent urethral trauma. His urinalysis is consistent with a UTI. Further review of his medical chart reveals multiple emergency room visits for various physical complaints including similar presentations for recurrent UTIs. Prior inpatient and outpatient assessments have not been able to adequately account for any underlying etiologies.
What is the most likely explanation for the mother's behavior?
A. conscious production of symptoms to assume the sick role
B. conscious production of symptoms to obtain secondary gain
C. expectable reaction from a concerned parent
D. hysterical reaction from an overly concerned parent
E. unconscious production of symptoms due to unconscious conflict
Correct Answer: A Section: (none)
Explanation:
The child's mother demonstrates factitious disorder by proxy, categorized by a parent or caretaker intentionally inducing an illness in someone under their care. Confronting the mother in the emergency room setting would likely lead to defensiveness, denial, and anger. The mother could possibly leave abruptly with the child. Having a psychiatrist present in this situation may also create a similar result. While a referral to urology and treatment of the infection may be indicated and appropriate, it does not address the immediate concern, which is the mother's abuse of her son. As factitious disorder by proxy is considered a form of child abuse, the physician has the legal obligation to notify child protective services. Admitting the boy to the hospital will both enable treatment of his medical illness and provide time for the proper authorities to intervene if necessary. The conscious production of symptoms for secondary gain (e.g., avoidance of work, school, jail, military service) is the rationale behind malingering. Although the mother's apparent concern for her child may appear expectable, her elaborate methods of abusing her son demonstrate significant pathology. The unconscious production of symptoms or signs due to unconscious conflict is the classic drive in conversion disorder. The motivation for factitious disorder is believed to be the purposeful production of an illness in order to assume the sick role (DSM IV-TR).
Question 276:
A4-year-old boy is brought into the emergency room by his mother for evaluation. When the child is asked regarding specific complaints, he looks anxiously away and states, "It hurts when I go pee-pee." His mother confidently adds, "He has another urinary tract infection (UTI)." She lists the antibiotics that he has been treated with in the past and then demands that he be admitted for a workup. On examination, his vitals signs are unremarkable except for a temperature of 102°F. His physical examination is notable for suprapubic tenderness and some evidence of recent urethral trauma. His urinalysis is consistent with a UTI. Further review of his medical chart reveals multiple emergency room visits for various physical complaints including similar presentations for recurrent UTIs. Prior inpatient and outpatient assessments have not been able to adequately account for any underlying etiologies.
What is the most appropriate next step in the management of this patient?
A. admit to inpatient and notify child protective services
B. confront the mother regarding the suspicions
C. consult with a psychiatrist to speak with the mother
D. refer the patient to a urologist
E. treat the patient for a UTI and send home
Correct Answer: A Section: (none)
Explanation:
The child's mother demonstrates factitious disorder by proxy, categorized by a parent or caretaker intentionally inducing an illness in someone under their care. Confronting the mother in the emergency room setting would likely lead to defensiveness, denial, and anger. The mother could possibly leave abruptly with the child. Having a psychiatrist present in this situation may also create a similar result. While a referral to urology and treatment of the infection may be indicated and appropriate, it does not address the immediate concern, which is the mother's abuse of her son. As factitious disorder by proxy is considered a form of child abuse, the physician has the legal obligation to notify child protective services.
Admitting the boy to the hospital will both enable treatment of his medical illness and provide time for the proper authorities to intervene if necessary. The conscious production of symptoms for secondary gain (e.g., avoidance of work, school, jail, military service) is the rationale behind malingering. Although the mother's apparent concern for her child may appear expectable, her elaborate methods of abusing her son demonstrate significant pathology. The unconscious production of symptoms or signs due to unconscious conflict is the classic drive in conversion disorder. The motivation for factitious disorder is believed to be the purposeful production of an illness in order to assume the sick role (DSM IV-TR).
Question 277:
A 16-year-old girl is brought into the family practice clinic for her yearly health maintenance examination. Her height is average and her weight is above average. When this is mentioned to her, she blushes and quickly states that she is trying to lose weight. When asked further about her dieting habits, she eventually admits to routinely eating large amounts of food at one sitting, such as two pizzas, a large sandwich, and a gallon of ice cream. She also confides that she frequently will self-induce vomiting in order to compensate
but denies laxative use. She realizes that her behavior is unhealthy, but she feels "out of control."
After discussion of her condition with her parents, it is decided to begin her on psychotropic medication and
refer her to an eating disorder program.
What class of pharmacotherapy would be the most efficacious in this patient?
A. anticonvulsants
B. antipsychotics
C. benzodiazepines
D. mood stabilizers
E. SSRIs
Correct Answer: E Section: (none)
Explanation:
This patient is suffering from bulimia nervosa, categorized by recurrent episodes of binge eating associated with compensatory behaviors including self-induced emesis, diuretic, or laxative abuse. Because of the repeated vomiting of gastric fluids, patients are prone to develop various electrolyte abnormalities, such as hypochloremic alkalosis or hypokalemia. Hypernatremia and leukopenia are not commonly seen. Anticonvulsants, such as valproic acid and carbamazepine, as well as mood stabilizers such as lithium, may be helpful for treating comorbid bipolar disorder but are not in and of themselves efficacious in the treatment of bulimia nervosa. Similarly, antipsychotics and benzodiazepines may be used in co-occurring psychotic or anxiety disorders, but do not help with binging or purging. Antidepressants, especially the SSRIs, have been shown to be successful in decreasing both the binging and purging behaviors
Question 278:
A 16-year-old girl is brought into the family practice clinic for her yearly health maintenance examination. Her height is average and her weight is above average. When this is mentioned to her, she blushes and quickly states that she is trying to lose weight. When asked further about her dieting habits, she eventually admits to routinely eating large amounts of food at one sitting, such as two pizzas, a large sandwich, and a gallon of ice cream. She also confides that she frequently will self-induce vomiting in order to compensate but denies laxative use. She realizes that her behavior is unhealthy, but she feels "out of control."
Routine blood work would most likely demonstrate which of the following?
A. acidosis
B. hyperchloremia
C. hypernatremia
D. hypokalemia
E. leucopenia
Correct Answer: D Section: (none)
Explanation:
This patient is suffering from bulimia nervosa, categorized by recurrent episodes of binge eating associated with compensatory behaviors including self-induced emesis, diuretic, or laxative abuse. Because of the repeated vomiting of gastric fluids, patients are prone to develop various electrolyte abnormalities, such as hypochloremic alkalosis or hypokalemia. Hypernatremia and leukopenia are not commonly seen. Anticonvulsants, such as valproic acid and carbamazepine, as well as mood stabilizers such as lithium, may be helpful for treating comorbid bipolar disorder but are not in and of themselves efficacious in the treatment of bulimia nervosa. Similarly, antipsychotics and benzodiazepines may be used in co-occurring psychotic or anxiety disorders, but do not help with binging or purging. Antidepressants, especially the SSRIs, have been shown to be successful in decreasing both the binging and purging behaviors.
Question 279:
A 38-year-old married female is brought in to the primary care clinic by her husband. She is minimally responsive to questioning, head bowed, and staring at the floor. Most of the history is obtained from her spouse. He denies any known personal or family history of mental illness, but he claims for the past several months his wife has become increasingly depressed and withdrawn. Instead of taking part in her usual hobbies, she is lying around the house. "She tosses and turns" throughout the night. Her husband ensures that she eats a limited amount of food, but she has lost a significant amount of weight. She has been ruminating about guilty feelings regarding a number of issues and recently has been speaking about suicide, although she has no plan or intent. She has refused to come in to see a doctor. Her husband insisted that she come today, as she informed him that the devil has possessed her and told her she will "go to hell."
What is the most effective pharmacologic treatment for this patient?
A. antidepressant alone
B. antidepressant and antipsychotic
C. antipsychotic alone
D. mood stabilizer alone
E. mood stabilizer and antipsychotic
Correct Answer: B Section: (none)
Explanation:
While patients with bipolar depression do present with psychotic features, this individual does not give any history of manic episodes, making the diagnosis difficult at this time. The bizarre delusions (those that cannot possibly exist in life) and auditory hallucinations that this patient has are not consistent with delusional disorder. Schizoaffective disorder, depressed type, includes both psychotic as well as depressive symptoms. However, the psychotic symptoms must last at least 1 month and occur in the absence of a depressed mood. The diagnosis of schizophrenia also requires at least 1 month of active psychosis but a total of 6 months of attenuated or residual symptoms. Although a depressed mood is very commonly seen in schizophrenia, the total duration of depression is brief overall compared to the psychotic symptoms. This patient presents with major depression with psychotic features, consisting of a depressed mood with neurovegetative symptoms for at least 2 weeks, as well as psychotic symptoms, which are only present along with the mood symptoms (DSM IV-TR).
Mood stabilizers alone or with antipsychotic medications are not the first-line treatments for major depression with psychotic features, but rather for mania with or without psychotic features. Studies have demonstrated that the combination of antidepressants and antipsychotics is more effective in treating major depression with psychotic features than either pharmacotherapy alone.
Question 280:
A 38-year-old married female is brought in to the primary care clinic by her husband. She is minimally responsive to questioning, head bowed, and staring at the floor. Most of the history is obtained from her spouse. He denies any known personal or family history of mental illness, but he claims for the past several months his wife has become increasingly depressed and withdrawn. Instead of taking part in her usual hobbies, she is lying around the house. "She tosses and turns" throughout the night. Her husband ensures that she eats a limited amount of food, but she has lost a significant amount of weight. She has been ruminating about guilty feelings regarding a number of issues and recently has been speaking about suicide, although she has no plan or intent. She has refused to come in to see a doctor. Her husband insisted that she come today, as she informed him that the devil has possessed her and told her she will "go to hell."
What is her most likely diagnosis?
A. bipolar disorder, depressed, with psychotic features
B. delusional disorder, somatic type
C. major depressive disorder with psychotic features
D. schizoaffective disorder, depressed type E. schizophrenia, paranoid type
Correct Answer: C Section: (none)
Explanation:
While patients with bipolar depression do present with psychotic features, this individual does not give any history of manic episodes, making the diagnosis difficult at this time. The bizarre delusions (those that cannot possibly exist in life) and auditory hallucinations that this patient has are not consistent with delusional disorder. Schizoaffective disorder, depressed type, includes both psychotic as well as depressive symptoms. However, the psychotic symptoms must last at least 1 month and occur in the absence of a depressed mood. The diagnosis of schizophrenia also requires at least 1 month of active psychosis but a total of 6 months of attenuated or residual symptoms. Although a depressed mood is very commonly seen in schizophrenia, the total duration of depression is brief overall compared to the psychotic symptoms. This patient presents with major depression with psychotic features, consisting of a depressed mood with neurovegetative symptoms for at least 2 weeks, as well as psychotic symptoms, which are only present along with the mood symptoms (DSM IV-TR).
Mood stabilizers alone or with antipsychotic medications are not the first-line treatments for major depression with psychotic features, but rather for mania with or without psychotic features. Studies have demonstrated that the combination of antidepressants and antipsychotics is more effective in treating major depression with psychotic features than either pharmacotherapy alone.
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