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2. A 58-year-old woman has a history of major depressive disorder that has been in remission for the past ten years. She takes phenelzine daily and sees her psychiatrist every other month. While on vacation, the patient and her husband indulge in a gourmet meal. Afterward, the patient becomes concerned as she believes one of the dishes may have contained aged cheese, which her psychiatrist had warned her about eating. She comes to the emergency department of the local hospital to express her concerns. Which of the following is most appropriate to monitor?

1. A 57-year-old Caucasian man presents complaining of "feeling overwhelmed by life." He has felt depressed for the past six months, and states that he has difficulty focusing on daily activities. His sleep is poor and he wakes frequently at night. Further inquiry reveals that he is a Vietnam War veteran and that he experiences flashbacks and nightmares about his combat experiences. He notes that the flashbacks began prior to his feelings of depression. He avoids watching war movies and refuses to discuss with anyone his time spent in Vietnam. This is his first visit to a psychiatrist and he asks to be started on some medication. Which of the following should be avoided in this patient?

3. While working as the attending pediatrician in the neonatai ICU, you are called by nursing to examine a two-day-old male child who has recently begun vomiting. The child has failed to pass meconium since birth. Physical examination demonstrates significant abdominal distention. A rectal examination reveals no stool in the vault. You strongly suspect Hirschsprung disease and inform the child's mother that an abdominal radiograph and barium enema are necessary. The mother forbids you from proceeding with any further testing or procedures because she does not believe "there is anything wrong." What is the most appropriate next step?

4. A 24-year-old female veterinary assistant is referred to a psychiatrist for the presumptive diagnosis of dysthymia. She reports having a three-year history of low energy levels and gradual worsening in her ability to focus on her work. She feels "sad, hopeless," and experiences little pleasure. She denies any suicidal thoughts. She has never been on any psychotropic medications before, and denies any family history of psychiatric illness. She has gastroesophageal reflux disease, for which she takes omeprazole. She has no known allergies, and does not drink alcohol or smoke cigarettes. The psychiatrist decides to treat her dysthymia with bupropion. Which of the following is a contraindication to the use of bupropion

5. A 35-year-old woman has chronic auditory hallucinations in which she hears her father's voice. His voice said encouraging things to her in the past, but it has recently been scolding her and saying derogatory things about her. The woman is started on risperidone, and she returns two weeks later for a follow-up visit. Although she states that the hallucinations are much better, you notice that she is walking much slower than usual and is not swinging her arms. Also, the patient's facial expressions are rather flat and unchanging, and she admits that her writing has become smaller since starting the medication. Which of the following pharmacologic changes would be most appropriate?

6. A 29-year-old gravida 1, para 0 Caucasian female with a history of bipolar disorder presents at eight weeks of gestation for prenatal counseling. She has been taking a stable dose of lithium for the past year. Her last depressive episode was 16 months ago. Her family history is significant for bipolar disorder in her mother, which was successfully controlled with lithium. She does not smoke cigarettes or consume alcohol. She asks whether her baby will have any congenital abnormalities. Which of the following complications is her fetus at increased risk for?

7. A 16-year-old girl is brought to clinic by her mother, who complains that the girl is "difficult to get along with lately." The mother says her daughter can no longer concentrate for prolonged periods and is easily fatigued. She has found her tossing in her sleep at night. She says that her daughter is generally considered by friends and family to be "high strung." Upon inquiry, the girl admits to feeling extremely apprehensive when taking tests at school. She feels this stems from her naturally competitive nature and her desire to be class valedictorian. She worries about being accepted to a good university and then business school. She says that she is unable to control her thoughts and sometimes takes a day off from school to "escape all the stress that comes with it” Which of the following is the most likely diagnosis?

8. You are the internist caring for a 26-year-old male who is stricken with alcoholic gastritis. The man has remained absent from his work as a waiter for several days due to his illness. His employer calls you for more information about the illness and the prognosis. He says that he just spoke with his employee on the phone and was granted permission to talk with you. What is the most appropriate response to this request?

9. A 30-year-old man presents to his primary care physician and describes a sense of generalized fatigue. He reports having been very energetic and healthy during his college days but says that "everything has seemed to be go wrong" for at least the last 6 years. He eats poorly and has lost 8 pounds over the last three years. He sleeps 12 hours per night and says that he has difficulty concentrating on most tasks. His past medical history is otherwise unremarkable, and he does not abuse drugs or alcohol. The patient says that he is not suicidal and still enjoys watching baseball with his friends. Based on the above presentation, what is the most likely diagnosis?

10. A single mother brings her 10-year-old son to see the pediatrician. The mother says that she is "absolutely fed up" with her son's behavior and is unable to control him. The boy frequently gets into fights with his siblings, neighbors, and classmates at school. When asked to help with household chores, he refuses. He is very short-tempered and argues frequently with his parents and teachers. A few days ago, he got into an argument with the elderly woman who lives next door, and in a fit of anger he "grabbed a marker and wrote an obscenity on her front door." What is the most likely diagnosis?

11. A 22-year-old woman is brought to the emergency department by her father because she is demonstrating "strange, disorganized behavior." Earlier that day, she had insisted that the television news anchorman was talking directly to her about the risks of "poison rays" from the moon. She was also apparently attempting to re-organize her bedroom closet when her father found her mumbling incoherently and counting the same pair of socks over and over. She is agitated when examined in the emergency department and the decision is made to admit her to the psychiatric ward. There, after a detailed interview, the diagnosis of schizophrenia is made. She is stabilized with antipsychotics and then discharged home. Her father asks what can be done to ease her return to everyday life and to decrease the likelihood of re-hospitalization. Which of the following measures would be most helpful in this regard?

12. A middle-aged Asian American married couple comes to clinic for a routine examination. Both the husband and wife have been known patients of yours for many years. The husband is being treated for coronary artery disease and tension headaches. Today, he mentions that he "cannot get an erection" even when he feels sexual desire. He adds that he still finds his wife physically attractive and that they are mutually compatible in every respect. This recent development has been causing him significant anxiety and has been a source of concern for his wife. After ruling out medical and psychological causes for his erectile dysfunction by taking a detailed history and pursuing a thorough workup, you agree to his request that he be started on sildenafil. One week later, his wife places an urgent call to your office, reporting that her husband developed severe chest pain "after taking the new medication you prescribed." An EKG done in the emergency department reveals new inferior wall ischemia. You immediately realize that you should not have written him the prescription for sildenafil because he was already using a nitroglycerin patch for his coronary artery disease. What is the most appropriate next step?

13. A middle-aged, divorced woman brings her 18-year-old daughter to the physician with the complaint that her daughter "seems abnormal." She is concerned because her daughter has no close friends, does not date, and shows no interest in the activities that are popular with young adults. The girl prefers solitude and keeps to her room for most of the day. When she does go out, she hikes in the woods alone for hours at a time. She attends a local university where she studies engineering and performs well academically. During the office visit, the daughter avoids eye contact. In response to questioning about her reasons for being aloof, shereplies, "I just don't enjoy being in the company of others. People do not interest me much and I would rather keep to myself." Her thought process appears devoid of delusions or hallucinations. Which of the following personality disorders is demonstrated by her behavior?

14. A 38-year-old male with a chronic history of schizophrenia is admitted to the hospital for deterioration in his condition. He is a known patient and was stable on risperidone for the past few years. Today, the patient does not respond when spoken to and he sits motionlessly. He makes no eye contact and his face remains expressionless. Vital signs include temperature of 37.0C (98.6F), blood pressure of 132/80 mm Hg, pulse of 88/min, and respirations of 14/min. Physical examination demonstrates diffuse muscle rigidity but is otherwise unremarkable. Which of the following would be the most appropriate next step?

15. A 7 -year-old boy is brought to the pediatrician by his mother for a routine check-up. Physical examination is normal, but during the exam the mother reveals that her son's behavior has been poor. She says that he is always running around (even during dinner), doesn't listen, and keeps his room a mess. She hopes he will grow out of this soon. Upon further questioning, the pediatrician learns that the patient's second-grade teacher has reported that he answers questions impulsively and out of turn, and that he cannot sit at his desk for a very long time without fidgeting. He also frequently forgets to bring in his homework. The mother states that her son has had these symptoms for about a year, and that his grades have been falling over the past six months. The diagnosis of attention deficit hyperactivity disorder is made and the boy is started on methylphenidate. Which of the following side effects is most likely to occur in patients who take methylphenidate?

16. A middle-aged, divorced mother brings her 19-year-old daughter in for an evaluation. She says that her daughter has "a serious problem." The woman is concerned because her daughter always keeps to herself, does not date, has no close friends, and refuses to participate in activities popular with women of her age. The daughter is extremely fascinated by witchcraft, spending countless hours in her room gazing into a crystal ball and muttering under her breath. When confronted about her behavior, she says, "I have some supernatural powers that I am not willing to discuss." She attends college regularly and earns good grades. Which one of the following is the most likely diagnosis?

17. A Hispanic married couple brings in their 17-year-old son because his behavior has been abnormal for the past two weeks. Normally, the boy is polite and soft spoken but he has recently become irritable and rude. His parents dismissed his behavior as a "phase" with the expectation that he would grow out of it, but they became very concerned upon discovering that he had been spending large sums of money from his college fund without their consent. When questioned by his father about his strange behavior, the boy responded, "I'm on a secret mission. The king of Norway has sent me here to spy on the U.S. government." His vital signs include temperature of 36.6C (98.0F), blood pressure of 132/94 mm Hg, pulse of 105/min, and respirations of 18/min. On physical examination, the boy appears to be in no distress. His pupils are dilated. Which of the following is the most likely diagnosis?

18. A 32-year-old woman is brought in to clinic by her husband of four years because she has been "restless and hyperactive" for the past two weeks. The husband describes her as unusually talkative, and says she speaks so quickly that others have difficulty understanding her. She has spent large sums of money on new clothing, makeup, and perfumes. When asked about her purchases, she says that she needs to look elegant since she is "a member of the royal family." She stays up very late each night to thoroughly clean the house, often sleeping only an hour or two. The husband has never observed these symptoms before in his wife. Physical examination of her is unremarkable. Which of the following is this woman most likely suffering from?

19. A 74-year-old woman is brought to the clinic by her daughter-in-law. The woman is a regular patient and has a long history of hypertension and ischemic heart disease. She lives with her son and daughter in-law, who are concerned that she has become increasingly forgetful over the past year. Initially, they attributed her forgetfulness to normal aging but her memory impairment has progressively worsened over the past several months. Of late, she has also developed some difficulty with speech and now is no longer able to perform the activities of daily living. Which one of the following is the most likely diagnosis?

20. A 34-year-old obese female is brought to the emergency department complaining of severe right upper quadrant abdominal pain that began suddenly earlier this morning. She is accompanied by her husband. An ultrasound evaluation is performed and the woman is diagnosed with acute cholecystitis. Because her symptoms worsen with conservative treatment, the decision is made to operate. The patient is discharged home five days after her successful cholecystectomy. Upon discharge, the patient and her husband request all medical records associated with her stay. What is the most appropriate response on the behalf of the physician?

21. A 4-year-old boy is brought to his pediatrician by his mother for "multiple fainting spells." Although physical examination reveals no abnormalities, the boy is admitted to the hospital for an extensive diagnostic workup. Laboratory evaluation reveals no abnormalities except for low serum glucose, high serum insulin, and low levels of serum C-peptide. The test results are revealed to the boy's mother, who works as a nurse in the hospital. Which of the following is the most likely diagnosis?

22. A 16-year-old boy presents to his pediatrician with scattered petechiae and a three-week history of fatigue. Laboratory evaluation and a bone marrow biopsy confirm the diagnosis of acute lymphoblastic leukemia. The boy's parents are divorced and have joint custody of him. His mother consents to the proposed chemotherapy and blood transfusion and requests that his treatment be started immediately. The father, however, refuses to agree to the treatment because of his religious beliefs. What is the most appropriate means of handling this situation?

23. An 18-year-old college freshman is brought to the emergency department by his friends. They say that he is normally happy and good-natured, but became unusually withdrawn and aloof a few hours after a football game. He complains of a dry mouth. Physical examination reveals injected conjunctivae and tachycardia. Which of the following is most consistent with this patient's presentation?

24. A 34-year-old male presents to the emergency department complaining of severe lower back pain. He rates the pain as 10/10 in severity and describes it as non-radiating, sudden in onset, and aggravated by movement. He refuses to be examined, insisting that any examination will worsen his pain. He denies any history of trauma or lifting of heavy weights. He says, "Doc, the only thing that can relieve my pain is morphine ... You've got to have mercy on me." The patient has a long history of opioid dependence and has been admitted to the hospital multiple times while intoxicated. His last admission was two weeks ago and he was referred to a drug rehabilitation program upon discharge. Given the clinical presentation, what is the most likely diagnosis?

25. A young Caucasian mother brings her 5-year-old daughter to the pediatrician two months after the girl first began attending kindergarten. She says that earlier this week, her daughter's teacher called to say that the girl persistently refuses to answer questions or to speak to others in class. The teacher added that the girl also does not smile at, play with, or otherwise engage her fellow students. The mother finds this very surprising because her daughter is very verbal and talkative at home, plays happily with her siblings, and is an affectionate child. Further questioning reveals that the girl is "a little shy" at social gatherings. Which of the following is the most likely diagnosis?

26. A middle-aged married couple brings their 10-year-old daughter to the pediatrician because "she just is too tired to play nowadays and sleeps all the time." The parents say that their daughter is winded with minimal exertion. Further inquiry reveals that for the past two weeks, the girl has had bleeding gums when she brushes her teeth. Physical examination demonstrates pallor and hepatosplenomegaly. An extensive workup indicates that the girl is suffering from acute lymphoblastic leukemia, and her parents are informed that chemotherapy will be necessary. The parents firmly refuse to comply with this treatment plan, however, because they are convinced that the side effects will be too severe. Despite a lengthy discussion about the benefits of treatment and the likely consequences for their daughter if therapy is withheld, the girl’s parents insist upon taking her home. What is the most appropriate next step?

27. A 72-year-old man presents for a follow-up visit regarding his depressed mood after his wife's death seven months ago. The patient complains of lethargy and episodes of tearfulness. He has attended three sessions of supportive psychotherapy so far and expresses appreciation for the referral because he likes the therapist. However, he continues to feel depressed and is now experiencing insomnia. He is also feeling very guilty about his wife's death and feels that he should have somehow done more for her in her final months. He admits that during a particularly dark moment last month he briefly contemplated committing suicide so that he could "join her," although he is adamant that he does not feel suicidal at this time and will readily contract for safety. Physical examination reveals the patient has lost 13 lbs (5.9 kg) since his wife's death. What is the most appropriate next step?

28. A 60-year-old Caucasian man presents to his family physician complaining of weight loss and fatigue. A review of systems is positive for a change in bowel habits. He says that in the past several weeks, he has developed pencil-thin stools. Further evaluation reveals the presence of colon carcinoma. The patient is told the diagnosis, and his treatment options and prognosis are discussed. He refuses any treatment and says he wants to die peacefully at home without any medical intervention. What would be the most appropriate means of handling the situation?

29. A 12-year-old boy is accused of setting his neighbor's house on fire. His parents describe him as a hyperactive, talkative child. He earns excellent grades in school but frequently gets into fights with schoolmates and siblings. Two years ago, he was caught setting the interior of his father's car on fire. He has also been linked to several suspicious fires in the neighborhood, though no criminal charges were brought against him Based on this information, what is the most likely diagnosis?

30. A 39-year-old agitated female with an unknown medical history is brought to the emergency department by police after she was found assaulting an innocent pedestrian on the street. She tells the attending physician that she has unusual powers and has been sent on a special mission by God. She is proud of frequently communicating with God, both telepathically and verbally, and says that he assists her in "punishing all of the wicked people in the world” Which of the following is most demonstrated in her thought content?

31. A 28-year-old female presents to her family doctor with her mother, who complains that her daughter has been behaving eccentrically and has been socially withdrawn for the past year. The mother says that her daughter used to be very lively and friendly, but that she abruptly quit her job as a data analyst one year ago and now prefers to stay home in her bedroom most of the time. The patient is thoroughly evaluated by a psychiatrist. During that interview, she reveals to the psychiatrist that she constantly hears "so many voices" in her head. The voices tell her various things of a critical and suspicious nature. She also adds that she feels very sad and has had numerous severe crying spells after her pet dog's death four months ago. She prefers to be alone and does not enjoy interacting with others. She has poor sleep and little appetite. Which of the following is the most likely diagnosis in this woman?

32. A 20-year-old female college student is brought to the emergency department by police at 2:30 am after she was caught attempting to enter the White House. She is highly agitated and is pacing around the examination room. Upon further questioning, she states that she just flew in from Texas to meet with the president because she has a "fool proof plan for eliminating terrorism worldwide in just seven days." She adds that she has barely slept for the past ten nights because she has been working intensively on this plan. She speaks very quickly, but periodically stops to angrily shout, "I'm going to sue all of you for interfering with my right to meet with the president." The evaluation has to be stopped because she demands that she be allowed to leave. Family history is significant for major depression in her mother. Vital signs are temperature 37.0°C (98.6.F), blood pressure 148/84 mmHg, pulse 98/min, and respiratory rate 22/min. Which of the following medications should be administered to this patient immediately?

33. A 52-year-old obese male presents with complaints of episodes of daytime sleepiness that prove irresistible. He reports feeling very refreshed and energized upon awakening from these "naps." A detailed history reveals he also frequently experiences a complete loss of muscle tone, especially when he laughs suddenly or feels a surge of intense emotion. Of particular concern to this patient is that he occasionally finds himself unable to move upon waking, and says he feels temporarily "frozen." His previous diagnoses include gout and external hemorrhoids. His family history is noncontributory. He does not smoke cigarettes or drink alcohol and denies recreational drug use. Physical examination reveals no abnormalities. Which of the following is the most appropriate treatment for this patient?

34. A 28-year-old woman is brought to the emergency department by her sister after she experiences a generalized tonic-clonic seizure. The patient appears confused and is unable to answer any questions. The sister says the patient has never had a seizure before. The patient's medical history is unremarkable except for a long history of panic disorder for which she has been taking high doses of "some medication." The sister adds that the patient missed a few doses recently because they were staying at a friend's house, but she is sure that the patient was otherwise regular in taking her medication. Which of the following medications was the patient most likely taking?

35. A 27-year-old man is brought to his primary care physician by his wife because he has not been himself for the past ten days. His wife says that her formerly reserved, quiet husband has been staying up all night lately gambling their savings away while playing poker with friends that he recently met. He is also not concerned about having missed work for the past week. When asked about this recent change in behavior, the man smiles and replies proudly that he no longer needs to work because he has invested a large sum of money in a company that will soon make him rich. He speaks very quickly and it is difficult for him to focus his attention at times. Which one of the following medications would be most appropriate in the treatment of this patient?

36. A 10-year old girl is brought to the office by her mother for the evaluation of recent changes in behavior. She has been sleeping poorly at night and has started wetting her bed. Her school grades have dropped significantly, and she has become irritable and cranky. She refuses to sleep at night until her father returns home and goes to bed. Her father works as a taxi driver, and is an alcoholic. Her mother is a close friend of yours, and appears very concerned. Prior to this office visit, you have known this girl to be cheerful and lively; however, as you attempt to talk to the young girl in the office, she suddenly bursts into tears. Which of the following should you consider at this point?

37. A 19-year-old woman makes an appointment to see her primary care physician about a "personal concern." When she comes in for her visit, she says that she has been "deeply depressed" for the past several months because of her "enormous nose." She proceeds to describe in detail the numerous cosmetic aspects of her nose that prove troubling. She says that she is now so embarrassed that she is unwilling to go out with friends because "everyone just stares at my nose." She finds it difficult to concentrate on her studies because she is preoccupied with thoughts about undergoing corrective surgery. On examination, her nose appears completely normal. She pleads for a referral to a good plastic surgeon. Which of the following is the most likely diagnosis?

38. A long-time patient calls your office to speak with you directly. She voices frustration with your receptionist, who has repeatedly refused to allow her to schedule an appointment to see you. The patient says that at her last visit, she had a heated argument with the receptionist about a minor detail regarding her insurance coverage. When she has called since then, the receptionist always responds by saying, "I'm sorry, but there are too many patients waiting ahead of you." Which of the following defense mechanisms is the receptionist demonstrating?

39. A 27-year-old man presents to his primary care physician complaining of feelings of inadequacy and hopelessness. In a quavering voice, he reports that he gets "extremely anxious" when he has to speak before a group of people at business meetings or other social events. He is unable to "just relax," even at small parties with friends or family, and he isolates himself as a result. He feels his social seclusion is limiting his career advancement, which bothers him greatly. Which of the following treatment combinations would be the most appropriate choice for this patient?

40. You are an internist making your rounds at a local nursing home. While you are reviewing a medical chart, one of the nurses approaches you to complain about a 62-year-old male patient who frequently masturbates in front of the staff and other nursing home residents. He has been taking olanzapine for years for schizophrenia. Upon interviewing him, you find the patient's thought processes to be devoid of hallucinations or delusions. There are several times when he laughs inappropriately during the interview. His speech is rambling and unpredictably shifts from one topic to another. Based on his clinical presentation, how should his illness be classified?

41. A 33-year-old businessman with an unremarkable past medical history presents to you complaining of fatigue and some weight loss over the past three months. He awakens at 4:00 am each morning and is unable to fall back asleep. He also mentions that he used to enjoy playing golf twice per week, but now has little interest. Although he used to excel at work, he now finds himself losing interest and "spacing out" at times. He denies considering suicide. His TSH is normal. He is diagnosed with major depression and prescribed fluoxetine, and is asked to return for a follow-up appointment in two weeks. At the return visit, he states that his symptoms have not worsened, but have not improved either. He says, "I don't feel like the medication is doing anything." What is the most appropriate next step in the management of this patient's condition?

42. While working as the medical resident on call, you are paged to see a 72-year-old woman who complains of a headache. Upon seeing you, she snaps, "You look young and foolish. I hope you're more efficient than you seem." While you are performing a basic physical examination on her, she says, "I'm going to complain to the hospital administrators about you because you have no idea how to properly deal with a patient." Which of the following is the best response to her threat?

43. A 22-year-old woman presents to the emergency department in an agitated state, certain that she is "about to die." Fifteen minutes ago, she developed heart palpitations and a severe "viselike" tightness in her chest. She experienced a similar episode last week, which resolved in twenty minutes. She denies using any drugs and her medical history is unremarkable. Her father has a history of heart disease and her mother has diabetes mellitus. She takes no medications. Vital signs are temperature 37.0°C (98.6.F), blood pressure 132/74 mmHg, pulse 118/min, and respiratory rate 30/min. She is sweating profusely. EKG reveals sinus tachycardia. The most appropriate next step is administration of which of the following?

44. As the on-call surgery resident, you are paged to see a patient on the ward who is having seizures. The patient is a 35-year-old male who underwent a cholecystectomy yesterday. His surgery was uneventful and the man appeared to be doing well until an hour ago when he developed altered sensorium. Upon arriving on the floor, you discover the patient to be confused and agitated. His vital signs include a temperature of 38C (100.4F), blood pressure of 134/86 mm Hg, pulse of 110/min, and respirations of 18/min. The man is diaphoretic and has tremors. His wound incisions show no evidence of inflammation, and biliary drainage appears adequate. A review of his medical record indicates his medical history to be unremarkable except for mild esophagitis. He smokes a pack of cigarettes per day and drinks 6-10 beers per night. His medications include folic acid, thiamine, and omepra zole. Laboratory results include the following: CBC: Hb 14.1 g/dL Leukocyte count 7,100/cmm Serum Chemistry: Sodium 137 mEq/L Potassium 4.0 mEq/L Chloride 101 mEq/L Bicarbonates 24 mEq/L BUN 12 mg/dL Creatinine 1.0 mg/dL Glucose 104 mg/dL Arterial Blood Gas: PH 7.40 PO2 94 mm Hg PCO2 40 mm Hg Which of the following should be initiated immediately in this patient?

45. A 35-year-old Caucasian male with a chronic history of paranoid schizophrenia presents to the mental health clinic. He strongly believes that his wife recently stole his pill bottle of risperidone, which he feels caused him to start experiencing more frequent and intense auditory hallucinations. He says that the "voices" tell him to kill his wife because she cannot be trusted. He admits to having homicidal thoughts about his wife but denies any specific plan for harming her. He requests a refill of his risperidone. What is the most appropriate next step?

46. A 34-year-old woman who describes herself as a "holistic healer" brings her two children aged four years and three years to the pediatrician for routine physical examinations. This is a first visit as they have recently moved from another state. The medical records for the children indicate that no immunizations have been given. When the mother is questioned about this, she proudly replies, "My children are wonderfully healthy on their own and have no need for these artificial vaccines." The principles and benefits of immunization are discussed at length, as well as the risks inherent in not being immunized. The physician recommends that the children be given all age-appropriate vaccinations today. The mother remains convinced that immunizations cause more harm than good, and she steadfastly refuses to allow her children to be vaccinated. What is the most appropriate next step?

47. A 48-year-old woman notices a firm, fixed mass in her right breast but chooses to ignore it. The mass is then detected on her annual physical examination eight months later. By that point, the mass has increased greatly in size. When questioned as to why she did not report the mass when she first noticed it, the woman states that she was not concerned about the mass because she does not have a family history of breast cancer This response is an example of which of the following defense mechanisms?

48. A 60-year-old physician is admitted to the hospital for jaundice and weight loss. He denies other symptoms, including abdominal pain and alterations in bowel movements. His past medical history is noncontributory. He denies any history of significant alcohol intake but admits to a 30-pack-year smoking history. A detailed work-up eventually reveals the diagnosis of pancreatic carcinoma. Shortly after his discharge, he spends several hours per day on his laptop computer so that he can obtain the latest information on his illness. Which of the following psychological defense mechanisms is this physician most likely employing?

49. A 37-year-old obese man returns to his doctor for a follow-up visit. One month ago, he was diagnosed with type II diabetes mellitus and was started on metformin. His fasting glucose is 122 mg/dl, and his blood pressure is 145/85 mm Hg. The patient looks rather dejected and admits it has been difficult to come to terms with his diagnosis. He has tried to exercise, watch his diet, and quit smoking as was suggested, but lately he has been feeling unmotivated and without energy. He admits to feeling sad and guilty about his weight, but is not sure he will be able to do anything about it. He continues to smoke despite attempts to cut back, and has been spending much of the day in bed watching television or sleeping. He has withdrawn from friends and family and took the last two weeks off from work, as he did not feel "up to going." Which of the following would be the best medication to prescribe at this time?

50. A 27-year-old male presents to clinic complaining of "marital problems." He says that for the past year that he has been married, he and his wife have not successfully had sexual intercourse on even one occasion. He strongly feels that she either finds him physically unattractive or is having an affair with another man. He adds that he is extremely frustrated with his wife "contracting herself," which prevents any kind of vaginal penetration. After several failed attempts, his wife now avoids any sexual intimacy with him. Which of the following is the most likely diagnosis?

51. A 19-year-old student is referred to the university health center for inability to complete his assignments. He has always been a good student, and was valedictorian of his high school class. However, since starting college, he has found it difficult to keep up with all the work. He audio- records every class, playing the tapes back later in the day to transcribe each entire lecture word for word. He admits to sometimes needing to go over certain sections multiple times to be sure he has heard correctly. He also takes a long time to complete assignments, as he always checks his work multiple times prior to handing it in. Because of this, he has had to ask for many extensions on his assignments. He is sure to complete all his assignments, even after they have been reviewed in class and even though they are not graded. He spends all his time doing his classwork, and is not involved in social activities. What is the most likely diagnosis?

52. A 46-year-old man with a history of medication-controlled hypertension sees his doctor for a routine check-up. His blood pressure is 115/80 mm Hg and an electrocardiogram shows a normal sinus rhythm. The doctor notes that the man seems more down than usual. The man admits that he has been "stressed out" for the past two weeks, as a few people at work recently quit and he has had to take on more work while management finds replacements. He has been sleeping poorly at night, feels tired during the day, and states that he hates his job right now, but has no other choice. He continues to get his work done and enjoys social activities, remarking that he "can still golf on the weekends." What is the patient's most likely diagnosis?

53. A colleague who works as a pediatrician in your group practice comes to your office to inquire about a patient you examined earlier this morning. The colleague says that he recognized the patient as a former neighbor of his who is also a good friend of the family. The patient was recently diagnosed as HIV-positive and is now on antiretroviral medication. Your colleague asks what the patient is being treated for. What is the most appropriate response to such an inquiry?

54. A 54-year-old male with a history of chronic alcoholism is admitted to the hospital with hematemesis and abdominal distension. Upper gastrointestinal endoscopy reveals the presence of esophageal varices. Continued workup of his condition results in a diagnosis of cirrhosis of the liver. He is treated appropriately and strongly counseled about the need to abstain from alcohol. He is then discharged home. After discharge, he begins to work as a full-time volunteer for a non-profit organization that assists patients with alcoholic cirrhosis. Which of the following defense mechanisms is this man using?

55. A 28-year-old attorney presents complaining of a six-month history of extreme nervousness, irritability, and restlessness. He is "plagued" by recurrent thoughts of not being able to properly carry out his responsibilities at the office. He dreads the possibility of not being offered a position as partner in the law firm. As a result, he finds himself unable to concentrate well or perform his duties efficiently. He is also engaged to be married, and spends sleepless nights thinking about the responsibilities of married life. He worries that he will not be a good husband or father. He denies any history of alcohol intake, but has recently begun drinking two bottles of beer every night for the past month as a means of escaping from his distressing thoughts. Which of the following is the treatment of choice for this patient?

56. A 16-year-old female presents to her pediatrician's office for a routine examination. She is wearing a sweater despite the warm weather, and admits she often feels cold. She states that she has otherwise been feeling fine, except for having difficulty losing weight. She wants to lose about 10 lbs (4.5 kg) because she believes she is "too fat." She has been on a strict diet and exercises two hours daily. She is also requesting a pregnancy test because she has not had a menstrual period for the past three months. Past medical history is significant for a supracondylar fracture of her right humerus at the age of seven. She is alert, cooperative, and in no apparent distress. Vital signs are temperature 36.2°C (97.2.F), blood pressure 88/58 mmHg, pulse 56/min, and respiratory rate 16/min. Her height is 5'5" (165 cm) and weight is 90 lbs (40.9 kg). What is the most appropriate next step in the management of her symptoms?

57. A 21-year-old male is admitted to the intensive care unit after attempting to commit suicide by overdosing on some pills he found in the medicine cabinet at home. A psychiatry consult is ordered. While interviewing the patient, the psychiatrist observes that the patient has a "blank" expression on his face and is minimally responsive. He refuses to make eye contact and speaks in monosyllables. An attempt is made to obtain a more detailed history from the patient's father. He describes his son as very aloof, having avoided the other children in the neighborhood and participated in few activities as a child. His son dropped out of school in ninth grade and has not been able to maintain jobs throughout the years because of his social difficulties. He adds that his son has been increasingly isolated this past year and that he has complained his deceased mother frequently asks him to "join her in heaven." Which of the following medications would provide the greatest benefit to this patient?

58. A 26-year-old graduate student presents at her husband's urging, complaining of severe pain during sexual intercourse. She says that she was a virgin when she married her husband two years ago, and that she has been experiencing severe "genital pain" during sex since then. As a result, she avoids sexual intimacy with her husband, which is placing a strain upon their marriage. She also complains of intense pain with her menses and when passing stool. She admits to sporadic pelvic pain that waxes and wanes with no discernible trigger. What would be the most appropriate treatment given this woman's condition?

59. A 28-year-old male presents for a follow-up visit regarding his bipolar disorder, which has been managed with valproic acid for several years. He is accompanied by his mother who is very concerned because her son has been behaving strangely for the past two weeks, saying that he can hear the voice of his long-deceased father telling him to "come to me." The patient insists that he is able to ignore his father's voice and that he is not considering suicide at this time. The decision is made to start risperidone to treat the auditory hallucinations. This medication predominantly produces its antipsychotic effect by blocking which of the following receptors?

60. A 52-year-old Caucasian male presents complaining of diminished energy for the past three months. He appears very sad and moves slowly. He says that he has been feeling terrible after his wife died in a car accident three months ago. He is filled with thoughts of guilt because he was driving the car when the accident took place. Since then, he has been suffering from disturbed sleep and finds himself unable to focus on his favorite activities, like coin collecting or fishing. He reports being disturbed by repeated flashbacks of the event. He keeps himself aloof and isolated from others because he "just doesn't feel like socializing anymore." He adds that he has a poor appetite and has gained 20 lbs (9.1 kg). He admits to wanting to "end my life in order to escape the memories of that nightmarish day." He is able to contract for safety. What is the most appropriate next step?

61. A 59-year-old man well known to his primary care physician presents complaining of excessive fatigue during the daytime. He is accompanied by his wife, who says that he wakes frequently during the night and snores loudly. She worries because sometimes it sounds like he is gasping for breath at night. The only finding on physical examination is morbid obesity. The diagnosis of obstructive sleep apnea is made. Which of the following is not true about this disorder?

62. An anxious mother brings her 4-year-old son to clinic for a new patient visit. She says that her son was progressing well developmentally and meeting all milestones until three months ago. Since then, she and her husband have noticed a marked restriction in the boy's activities. He keeps to himself, refuses to play with his siblings, speaks only when spoken to, and appears indifferent to the presence of others. Attempts to engage the child in conversation are unsuccessful. He seems disinterested and refuses to make eye contact. While in the examination room, he starts banging his head against the wall. Given this clinical presentation, which of the following is the most likely diagnosis?

63. A 19-year-old college student presents for a first visit because she is concerned about her "abnormal behavior." She says that she worries excessively about her door being locked and that she wakes several times throughout the night to confirm that the door is properly locked. She finds these thoughts distressing. Although she agrees that her fears are not rational, she feels unable to stop from acting on them. This frequent waking grossly impairs her sleep and as a result, she is finding it increasingly difficult to perform well academically. She has no history of psychiatric conditions, but her mother was recently diagnosed with trichotillomania. Vital signs include a temperature of 37.0C (98.6F), blood pressure of 118/84rnrnHg, pulse of 76/min, and respirations of 12/min. Physical examination is unremarkable. Which of the following medications would be the most appropriate treatment for her condition?

64. A 68-year-old woman with a history of well-managed sick sinus syndrome and osteoporosis is brought to the physician by her daughter. According to the daughter, her mother has become increasingly forgetful and irritable over the past two years. She adds that she felt less concerned about her mother's forgetfulness as "it just comes with aging," but that the "mood swings have become a problem in terms of her getting along with family members." A Folstein Mini-Mental Status Examination is performed and suggests significant cognitive decline. Dementia is strongly suspected. After potentially causative medical or psychiatric conditions have been ruled out, the diagnosis of Alzheimer's dementia is made. Which of the following medications would be most appropriate in the treatment of this woman's condition?

65. A 59-year-old Caucasian female presents to the emergency department with sudden onset paralysis of her bilateral lower extremities. She has no other symptoms. Physical examination reveals normal tone, normal deep tendon reflexes, and no Babinski sign. Her motor strength is 3/5 in both lower extremities. The remainder of her examination is unremarkable. The patient dramatically improves after she is injected with sodium amytal. What is the most likely diagnosis?

66. A mother brings in her 3-year-old son to the pediatrician because she is concerned about his "poor development." She says that she thinks her son's behavior is "very different from that of other children his age." She says that ever since he was a toddler, he has seemed indifferent to her presence. She previously attributed this to her son being "unique" compared to his two older sisters. However, she is increasingly worried about her son because he does not play with his siblings or the neighborhood children who come to visit, and she suspects that his speech development is limited. Upon examination, the child is spinning continuously in a circle. When questions are asked of him, he makes no eye contact and responds with "A house for the mouse." His physical appearance is otherwise normal. Which of the following is the most likely diagnosis?

67. A 21 -year-old college junior requests an urgent appointment with her family physician to discuss a "personal concern." During her conversation with the doctor, the woman appears tense, speaks very little, and makes minimal eye contact. After gentle questioning, she breaks down and says that her father is taking lithium for a manic episode experienced two years ago. She had not realized this could have any bearing on her own situation until she encountered an article on the Internet that mentioned genetics appears to play a role in the pathogenesis of bipolar disorder. Since then, she has had disturbed sleep and has been very worried that she too will one day develop bipolar disorder. Based on clinical data, what is the likelihood that she will have a manic episode during her lifetime?

68. A 25-year-old married female is brought to the emergency department by her mother for excruciating right-sided abdominal pain. A urine pregnancy test is positive and a pelvic ultrasound reveals an empty uterus. Ruptured ectopic pregnancy is suspected, and an operating room is reserved for an emergent laparotomy. The patient's medical history is unremarkable except for a psychiatric diagnosis of paranoid schizophrenia. Who should sign the informed consent paperwork for the procedure?

69. A 34-year-old male calls his primary care physician's office, requesting an urgent appointment to discuss a personal problem. The receptionist informs him that the physician is preparing to leave as it is near closing time, but that an appointment is available for early the next morning. The patient declines the offer of an appointment and hangs up. Fifteen minutes later, as the physician is locking the office up, the patient arrives and insists on being seen immediately. He breathlessly says that he has "some kind of red rash" on his penis, which has him very worried. He asks again to be examined now. What is the most appropriate response?

70. A 36-year-old known patient of yours presents for a routine annual examination. Toward the end of the visit, she glumly mentions that she intends to file for a divorce from her husband. She says that he is always in an irritable or depressed mood, and that she is "sick and tired of him spending huge sums of money on gambling." Although she was aware of his placing the occasional bet before they got married, she says his passion for gambling has increased significantly since his mother's death two months ago. He was recently fired from his job as an insurance agent after he was caught forging signatures in an attempt to finance some gambling trips to Las Vegas. She has confronted him about his behavior on many occasions in the past, but he has always denied that it was a problem. Now he admits that he finds it hard to control himself and that he is in debt to several creditors. Although he has lost a considerable amount of money, he is convinced that he could win it all back if he could just borrow enough from friends. Which of the following is the most likely diagnosis?

71. A 19-year-old known patient with bipolar disorder presents to her psychiatrist for a follow-up visit. She experienced her first manic episode three years ago and was then immediately placed on lithium. She has had no relapses and remains asymptomatic. Today she inquires about the possibility of discontinuing her medication. Her mother is apprehensive, however, about the prospect and asks the psychiatrist to continue the medication for a longer period. Which of the following is the most appropriate management of this patient's condition?

72. A 31-year-old woman voices her anger at the increasing number of immigrants who compete for job opportunities in her chosen field of computer science. She observes that many of her friends in the local community are also experiencing difficulty in securing appealing employment because of the influx of immigrants. This woman volunteers in her spare time to provide vocational guidance to new immigrant families in the community. Which of the following psychological defense mechanisms is she demonstrating?

73. A 25-year-old Caucasian woman presents as a new patient after having recently moved to the neighborhood. She says that she was diagnosed with anorexia nervosa two years ago, and that her disorder resolved after intensive psychotherapy. Although her eating pattern is normal now, she is still underweight. Her menstrual cycles have been regular for the past year. She recently married and is now interested in starting a family with her husband. She asks whether her history of anorexia nervosa will affect her ability to conceive or carry a healthy child to term. Given this clinical presentation, which of the following complications is most likely?

74. A fourth-year medical student develops a new onset headache that he describes as "excruciating." He denies any fever or vomiting. He requests the emergency department physician to order a CT scan of his head, as he is certain that he has developed an intracranial hemorrhage. A complete workup, including an ophthalmologic evaluation, is negative. In spite of reassurance from the physician, the student continues to be excessively worried and is unable to focus on his studies due to persistent thoughts about having a "brain bleed." Which of these would be the most effective step in resolving this patient's symptoms?

75. A 57-year-old Caucasian woman presents for a follow-up visit regarding her lower back pain. She originally presented with this complaint last month and was advised to limit activity and use ibuprofen as needed. When her pain persisted, she was scheduled for an MRI of her back. The MRI report returned today and describes the presence of metastatic deposits in her spine. The source of the primary neoplasm remains undetermined. The patient has not yet been told about the findings and will need to be informed today. Which of the following is the best means of initiating a conversation about her condition?

76. A 44-year-old woman presents for a follow-up visit regarding her severe depression. She has taken numerous antidepressants over the years with little symptomatic relief, and continues to spend the majority of her time in seclusion, experiencing intense feelings of worthlessness and despair. Her husband is deeply concerned about the impact her depression has had on their marriage and their two teenage children. He requests information about "all available options" to improve his wife's symptoms. The prospect of electroconvulsive therapy (ECT) is discussed, and the husband inquires about potential drawbacks to the procedure. Which of the following is a common side effect of electroconvulsive therapy?

77. An anxious mother brings in her 12-year-old daughter to your clinic for "severe hair loss". On examination, you find several alopecic patches on her head. While taking a detailed history, you find out that the young girl has been pulling out her hair when stressed. Although she has been indulging in this behavior periodically since childhood, she finds a recent increase in the same. She reveals to you that she is "really nervous" about her upcoming exams, and has disturbed sleep. She also adds that she feels so stressed that she has been avoiding going out with her friends and keeps to her books all the time. She denies any alterations in weight, but does admit to a decreased appetite. What do you think is the underlying diagnosis in this case?

78. A 42-year-old Caucasian man presents to the emergency department complaining of a two-day history of fever to 40C (104F), headache, and vomiting. Physical examination reveals petechiae and purpura on his trunk and lower extremities. Examination of his cerebrospinal fluid is consistent with bacterial meningitis. The patient is told of his diagnosis and the need for antibiotics and hospitalization is discussed. The patient refuses to be admitted to the hospital, however, and insists upon being treated at home. What is the most appropriate next step?

79. A 21-year-old woman presents to the physician at her mother's urging because she has been experiencing significant sleep disturbances. Three months ago, she was the victim of a sexual assault in the parking lot of her workplace. Since then, she has had recurrent nightmares about the assault, and dreads falling asleep at night. During the day, she has flashbacks about the assault. She has become very withdrawn, quit her job, and avoids other people. The woman is very distressed about the flashbacks and says that they "dominate her life." She has difficulty concentrating and startles easily when others speak to her. Which of the following is the most likely diagnosis?

80. A 32-year-old married woman presents with lower back pain that has persisted for the past week. She says she developed the pain after lifting some heavy furniture. She denies any other symptoms. A thorough physical examination reveals mild paraspinal muscle spasm. There is no significant pain with a straight leg raise on either side. Multiple bruises on her abdomen, back, and chest are also evident. When the topic of the bruises is raised, the woman becomes tearful and begins to cry. Which of the following is the most appropriate response?

81. A 31 -year-old Caucasian female with a chronic history of schizophrenia presents for a prescription refill at her local mental health clinic. She has been treated with olanzapine for the last six months. The psychiatrist notes at this visit that the woman appears less agitated and complains of fewer auditory hallucinations. When asked questions, the woman gives detailed but irrelevant responses. Her answers drift away from the subject but eventually return. Which of the following is she demonstrating?

82. A 27-year-old female is brought to the emergency department by her husband after she fainted at home. The patient admits that she has been fasting and exercising vigorously for the past two days to compensate for the excessive amount of food she ate three days ago. She admits to a similar pattern of eating large amounts of food followed by a period of fasting since she lost her job a few months ago. She is very distressed by these "uncontrollable eating episodes" because she feels awful afterward. Periodically, she breaks down in tears while telling her story. Review of systems is otherwise unremarkable. Her menstrual periods are regular. Vital signs are temperature 37C (98.6.F), blood pressure 98/62 mmHg, pulse 96/min, and respiratory rate 14/min. Her height is 5'4" (163 cm) and weight is 120 lbs (54 kg). Physical examination is unremarkable. What is the most likely diagnosis?

83. A 28-year-old married nurse who works with you in clinic comes to you privately, saying that she "missed a period" this month. An over-the-counter urine pregnancy test confirms that she is pregnant. The first-trimester laboratory testing is performed, and she is found also to be HIV-positive. When you reveal the news of her HIV status to her, she is devastated. She hesitantly reveals that she had unprotected sexual intercourse with a former boyfriend several months ago. You explain that her husband's HIV status must be evaluated. Upon hearing this, the nurse is horrified and says. "No, I cannot tell him about this. He would never forgive me!" What is the most appropriate next step?

84. You are seeing a 41-year-old woman and her 19-year-old daughter in the emergency room because they think that they have been poisoned. The woman states that they have not been getting along with their landlord lately because they have been late on their last few rent payments. They say that the landlord is harassing them by banging on their floor at all hours of the night, turning down their heat, and asking the other tenants to spy on them. Last month, the woman thinks the landlord tried to spy on them by installing video cameras in her living room while they were out. Today, she tasted something odd in her food, and is convinced that she and her daughter have been poisoned in an attempt to get them out of the apartment once and for all. She came immediately to the hospital for treatment and to collect evidence of the poisoning. The mother is very protective of her daughter, who seems rather submissive and passive. She completely agrees with her mother's description of the events. Which of the following is the best course of action?

85. A 42-year-old man comes to the emergency room with the chief complaint that “the men are following me.” He also complains of hearing a voice telling him to hurt others. He tells the examiner that the news anchorman gives him special messages about the state of the world every night through the TV. Which of the following psychiatric findings best describes this last belief of the patient?

86. A 32-year-old woman is seen in an outpatient psychiatric clinic for the chief complaint of a depressed mood for 4 months. During the interview, she gives very long, complicated explanations and many unnecessary details before finally answering the original questions. Which of the following psychiatric findings best describes this style of train of thought?

87. A 23-year-old man comes to the psychiatrist with a chief complaint of a depressed mood. He is very anxious and obviously uncomfortable in the physician’s office. Which of the following actions should be used to help develop rapport with this patient?

88. An 18-year-old man is seen by a psychiatrist in the emergency room. During the history, the patient is asked to describe his mood. He answers the following, “My mood is flextitating, I am up and down.” The patient is exhibiting which of the following thought disorders?

89. A 56-year-old man has been hospitalized for a myocardial infarction. Two days after admission, he awakens in the middle of the night and screams that there is a man standing by the window in his room. When the nurse enters the room and turns on a light, the patient is relieved to learn that the “man” was actually a drape by the window. This misperception of reality is best described by which of the following psychiatric terms?

90. A 22-year-old woman is seen by a psychiatrist in the emergency room after she is found walking in the middle of a busy street with no shoes on. During her interview she is asked to count backwards from 100 by 7’s. Which of the following best describes the cognitive functions being tested by this request?

91. A 72-year-old woman is admitted to the burn unit with second- and third-degree burns covering 35% of her body, which she received in a house fire. At 8 pm on the fourth day of her hospital stay, she pulls out her IV and begins screaming that people are trying to hurt her. Several hours later she is found to be difficult to arouse and disoriented. Which of the following is the most likely diagnosis?

92. A psychiatric resident is called to consult on the case of a 75-year-old woman who had undergone a hip replacement 2 days before. On examination, the resident notes that the patient states the date as 1956, and she thinks she is at her son’s house. These impairments best illustrate which aspect of the mental status examination?

93. A 52-year-old man is sent to see a psychiatrist after he is disciplined at his job because he consistently turns in his assignments late. He insists that he is not about to turn in anything until it is “perfect, unlike all of my colleagues.” He has few friends because he annoys them with his demands for “precise timeliness” and because of his lack of emotional warmth. This has been a lifelong pattern for the patient, though he refuses to believe the problems have anything to do with his personal behavior. Which of the following is the most likely diagnosis for this patient?

94. A 23-year-old woman comes to the psychiatrist because she “cannot get out of the shower.” She tells the psychiatrist that she has been unable to go to her job as a secretary for the past 3 weeks because it takes her at least 4 hours to shower. She describes an elaborate ritual in which she must make sure that each part of her body has been scrubbed three times, in exactly the same order each time. She notes that her hands are raw and bloody from all the scrubbing. She states that she hates what she is doing to herself but becomes unbearably anxious each time she tries to stop. She notes that she has always taken long showers, but the problem has been worsening steadily for the past 5 months. She denies problems with friends or at work, other than the problems that currently are keeping her from going to work. Which of the following is the most likely diagnosis?

95. A 37-year-old man with chronic schizophrenia is brought to see a new psychiatrist for treatment. While taking the history, the psychiatrist finds that the patient functions with a flat affect and circumstantial speech all the time. He has few friends. He is able to hold a menial job at the halfway house where he lives, and his behavior is not influenced by delusions or hallucinations currently. What should the psychiatrist rate the patient on Axis V (global assessment of functioning)?

96. A 23-year-old woman comes to the emergency room with the chief complaint that she has been hearing voices for 7 months. Besides the hallucinations, she has the idea that the radio is giving her special messages. When asked the meaning of the proverb “People in glass houses should not throw stones,” the patient replies, “Because the windows would break.” Which of the following mental status findings does this patient display?

97. A 22-year-old woman is seen in the emergency room after a suicide attempt. She swallowed 10 aspirin in the presence of her mother, with whom she had just had an argument. The patient has a long history of cutting herself superficially with razor blades, which her psychiatrist of the last 5 years confirms by telephone. The patient currently lives in a stable environment (a halfway house) where she has been for 3 years. Which of the following option is the best course of action for the physician in the emergency room?

98. A 69-year-old man is brought to see his physician by his wife. She notes that over the past year he has experienced a slow, stepwise decline in his cognitive functioning. One year ago she felt his thinking was “as good as it always had been,” but now he gets lost around the house and can’t remember simple directions. The patient insists that he feels fine, though he is depressed about his loss of memory. He is eating and sleeping well. Which of the following is the most likely diagnosis?

99. An 18-year-old man is brought to the emergency room by police after he is found wandering in the street, screaming loudly at passersby. In the emergency room he is placed in an examination room, and paces the floor and pounds his fist against the door repeatedly. Which of the following actions should be taken by the psychiatrist first?

100. A 6-year-old girl is brought to the physician by her mother, who says the child has been falling behind at school. She notes that the girl did not speak until the age of 4. She is friendly at school, but is unable to complete most tasks, even when aided. She is noted to have a very short attention span and occasional temper tantrums at school and at home. Which of the following tests would be most helpful in establishing the diagnosis?

101. A psychiatrist is seeing a patient in his outpatient practice. The patient treats the psychiatrist as if he were unreliable and punitive, though he had not been either. The patient’s father was an alcoholic who often did not show up to pick her up from school and frequently hit her. The psychiatrist begins to feel as if he must overprotect the patient and treat her gingerly. Which of the following psychological mechanisms best describes the psychiatrist’s behavior?

102. A patient is able to appreciate subtle nuances in thinking and can use metaphors and understand them. This patient’s thinking can be best defined by which of the following terms?

103. A 65-year-old man, who had been hospitalized for an acute pneumonia 3 days previously, begins screaming for his nurse, stating that “there are people in the room out to get me.” He then gets out of bed and begins pulling out his IV line. On examination, he alternates between agitation and somnolence. He is not oriented to time or place. His vital signs are as follows: pulse, 126 beats per minute; respiration, 32 breaths per minute; blood pressure (BP), 80/58; temperature, 39.2C (102.5F). Which of the following diagnoses best fits this patient’s clinical picture?

104. A 59-year-old man goes to a psychiatrist for a 3-month history of panic attacks. He notes for the past 3 months he has experienced “out of the blue,” extreme episodes of fearfulness that last about 20 minutes. During that time, he experiences palpitations, sweating, shortness of breath, and trembling. He denies any substance abuse, and has never had symptoms like this before these past 3 months. Which of the following signs or symptoms would likely lead the physicians to expect a diagnosis of anxiety secondary to a general medical condition in this case?

105. A 24-year-old man returns from Iraq after a 13-month tour of duty. During that tour he was involved in battle situations and saw one of his friends injured by a car bomb. What percentage of American soldiers returning home from Iraq have posttraumatic stress disorder (PTSD)?

106. A 23-year-old man presents to the emergency room with the history of a fever up to 38C (100.5F) intermittently over the past 2 weeks, a persistent cough, and a 10-lb weight loss in the past month. He notes that he has also been becoming increasingly forgetful for the past month and that his thinking is “not always clear.” He has gotten lost twice recently while driving. Which of the following diagnostic tests will be most helpful with this patient?

107. A 19-year-old woman presents to the emergency room with the chief complaint of a depressed mood for 2 weeks. She notes that since her therapist went on vacation she has experienced suicidal ideation, crying spells, and an increased appetite. She states that she has left 40 messages on the therapist’s answering machine telling him that she is going to kill herself and that it would serve him right for leaving her. Physical examination reveals multiple well-healed scars and cigarette burns on the anterior aspect of both forearms. Which of the following diagnoses best fits this patient’s clinical presentation?

108. A 29-year-old man is brought to the emergency room by his wife after he woke up with paralysis of his right arm. The patient reports that the day before, he had gotten into a verbal altercation with his mother over her intrusiveness in his life. The patient notes that he has always had mixed feelings about his mother, but that people should always respect their mothers above all else. Which of the following diagnoses best fits this patient’s clinical picture?

109. A 28-year-old business executive sees her physician because she is having difficulty in her new position, as it requires her to do frequent public speaking. She states that she is terrified she will do or say something that will cause her extreme embarrassment. The patient says that when she must speak in public, she becomes extremely anxious and her heart beats uncontrollably. Based on this clinical picture, which of the following is the most likely diagnosis?

110. Which of the following terms best fits the definition “the proportion of a population affected by a disorder at a given time”?

111. A diagnostic test has a sensitivity of 64% and a specificity of 99%. Such a test would carry the risk of which kind of problem?

112. A 56-year-old man is brought to the physician’s office by his wife because she has noted a personality change during the past 3 months. While the patient is being interviewed, he answers every question with the same three words. Which of the following symptoms best fits this patient’s behavior?

113. A 32-year-old patient is being interviewed in his physician’s office. He eventually answers each question, but he gives long answers with a great deal of tedious and unnecessary detail before doing so. Which of the following symptoms best describes this patient’s presentation?

114. An 18-year-old man is brought to the emergency room by the police after he is found walking along the edge of a high building. In the emergency room, he mumbles to himself and appears to be responding to internal stimuli. When asked open-ended questions, he suddenly stops his answer in the middle of a sentence, as if he has forgotten what to say. Which of the following symptoms best describes this last behavior?

115. A 26-year-old woman with panic disorder notes that during the middle of one of her attacks she feels as if she is disconnected from the world, as though it were unreal or distant. Which of the following terms best describes this symptom?

116. A patient with a chronic psychotic disorder is convinced that she has caused a recent earthquake because she was bored and wishing for something exciting to occur. Which of the following symptoms most closely describes this patient’s thoughts?

117. A 45-year-old man with a chronic psychotic disorder is interviewed after being admitted to a psychiatric unit. He mimics the examiner’s body posture and movements during the interview. Which of the following terms best characterizes this patient’s symptom?

118. A 24-year-old man with chronic schizophrenia is brought to the emergency room after his parents found him in his bed and were unable to communicate with him. On examination, the man is confused and disoriented. He has severe muscle rigidity and a temperature of 39.4 C (103 F). His blood pressure is elevated, and he has a leucocytosis. Which of the following is the best first step in the pharmacologic treatment of this man?

119. A 54-year-old man with a chronic mental illness seems to be constantly chewing. He does not wear dentures. His tongue darts in and out of his mouth, and he occasionally smacks his lips. He also grimaces, frowns, and blinks excessively. Which of the following disorders is most likely in this patient?

120. A 58-year-old woman with a chronic mental disorder comes to the physician with irregular choreoathetoid movements of her hands and trunk. She states that the movements get worse under stressful conditions. Which of the following medications is most likely to have caused this disorder?

121. A 24-year-old woman comes to the emergency room with the chief complaint that “my stomach is rotting out from the inside.” She states that for the last 6 months she has been crying on a daily basis and that she has decreased concentration, energy, and interest in her usual hobbies. She has lost 25 lb during that time. She cannot get to sleep, and when she does, she wakes up early in the morning. For the past 3 weeks, she has become convinced that she is dying of cancer and is rotting on the inside of her body. Also, in the past 2 weeks she has been hearing a voice calling her name when no one is around. Which of the following is the most likely diagnosis?

122. A 19-year-old man is brought to the physician by his parents after he called them from college, terrified that the Mafia was after him. He reports that he has eaten nothing for the past 6 weeks other than canned beans because “they are into everything––I can’t be too careful.” He is convinced that the Mafia has put cameras in his dormitory room and that they are watching his every move. He occasionally hears the voices of two men talking about him when no one is around. His roommate states that for the past 2 months the patient has been increasingly withdrawn and suspicious. Which of the following is the most likely diagnosis?

123. A 36-year-old woman is brought to the psychiatrist by her husband because for the past 8 months she has refused to go out of the house, believing that the neighbors are trying to harm her. She is afraid that if they see her they will hurt her, and she finds many small bits of evidence to support this. This evidence includes the neighbors’ leaving their garbage cans out on the street to try to trip her, parking their cars in their driveways so they can hide behind them and spy on her, and walking by her house to try to get a look into where she is hiding. She states that her mood is fine and would be “better if they would leave me alone.” She denies hearing the neighbors or anyone else talk to her, but is sure that they are out to “cause her death and mayhem.” Which of the following is the most likely diagnosis?

124. A 35-year-old woman has lived in a state psychiatric hospital for the past 10 years. She spends most of her day rocking, muttering softly to herself, or looking at her reflection in a small mirror. She needs help with dressing and showering, and she often giggles and laughs for no apparent reason. Which of the following is the most likely diagnosis?

125. A 20-year-old woman is brought to the emergency room by her family because they have been unable to get her to eat or drink anything for the past 2 days. The patient, although awake, is completely unresponsive both vocally and nonverbally. She actively resists any attempt to be moved. Her family reports that during the previous 7 months she became increasingly withdrawn, socially isolated, and bizarre; often speaking to people no one else could see. Which of the following is the most likely diagnosis?

126. A 21-year-old man is brought to the emergency room by his parents because he has not slept, bathed, or eaten in the past 3 days. The parents report that for the past 6 months their son has been acting strangely and “not himself.” They state that he has been locking himself in his room, talking to himself, and writing on the walls. Six weeks prior to the emergency room visit, their son became convinced that a fellow student was stealing his thoughts and making him unable to learn his school material. In the past 2 weeks, they have noticed that their son has become depressed and has stopped taking care of himself, including bathing, eating, and getting dressed. On examination, the patient is dirty, disheveled, and crying. He complains of not being able to concentrate, a low energy level, and feeling suicidal. Which of the following is the most likely diagnosis for this patient?

127. A 47-year-old woman is brought to the emergency room after she jumped off an overpass in a suicide attempt. In the emergency room she states that she wanted to kill herself because the devil had been tormenting her for many years. After stabilization of her fractures, she is admitted to the psychiatric unit, where she is treated with risperidone and sertraline. After 2 weeks she is no longer suicidal and her mood is euthymic. However, she still believes that the devil is recruiting people to try to persecute her. In the past 10 years, the patient has had three similar episodes prior to this one. Throughout this time, she has never stopped believing that the devil is persecuting her. Which of the following is the most appropriate diagnosis for this patient?

128. A 40-year-old woman is arrested by the police after she is found crawling through the window of a movie star’s home. She states that the movie star invited her into his home because the two are secretly married and “it just wouldn’t be good for his career if everyone knew.” The movie star denies the two have ever met, but notes that the woman has sent him hundreds of letters over the past 2 years. The woman has never been in trouble before and lives an otherwise isolated and unremarkable life. Which of the following is the most likely diagnosis?

129. 30-year-old man is brought to the emergency room after he was found wandering on the streets with no shoes on in the middle of winter. He is admitted to the inpatient psychiatric unit and stabilized on antipsychotic medication. Looking at past records, his psychiatrist notes that he is repeatedly noncompliant with his medication post discharge, and each time he relapses within 6 months. Which of the following medications is the best one for this patient to be maintained on?

130. A 26-year-old woman is brought to the emergency room by her husband after she begins screaming that her children are calling to her and becomes hysterical. The husband states that 2 weeks previously, the couple’s two children were killed in a car accident, and since that time the patient has been agitated, disorganized, and incoherent. He states that she will not eat because she believes he has been poisoning her food, and she has not slept for the past 2 days. The patient believes that the nurses in the emergency room are going to cause her harm as well. The patient is sedated and later sent home. One week later, all her symptoms remit spontaneously. Which of the following is the most likely diagnosis for this patient?

131. A 28-year-old woman is brought to see a psychiatrist by her mother. The patient insists that nothing is wrong with her, but the mother notes that the patient has been slowly but progressively isolating herself from everyone. She now rarely leaves the house. The mother says she can hear the patient talking to “people who aren’t there” while she’s in her room. On examination, the patient is noted to have auditory hallucinations and the delusional belief that her mother is going to kick her out of the house so that it can be turned into a theme park. Which of the following is the lifetime prevalence for this disorder?

132. A 25-year-old woman is diagnosed with schizophrenia when, after the sudden death of her mother, she begins complaining about hearing the voice of the devil and is suddenly afraid that other people are out to hurt her. Her history indicates that she has also experienced a 3-year period of slowly worsening social withdrawal, apathy, and bizarre behavior. Her family history includes major depression in her father. Which of the following details of her history leads the physician to suspect that her outcome may be poor?

133. A 22-year-old man is brought to the emergency room after he became exceedingly anxious in his college dormitory room, stating that he was sure the college administration was sending a “hit squad” to kill him. He also notes that he can see “visions” of men dressed in black who are carrying guns and stalking him. His thought process is relatively intact, without thought blocking or loose associations. His urine toxicology screen is positive for one of the following drugs. Which drug is the most likely cause of these symptoms?

134. A 72-year-old woman is brought to the emergency room by her daughter after she found her mother rummaging in the garbage cans outside her home. The daughter states that the patient has never had any behavior like this previously. On interview, the patient states she sees “martians hiding around her home, and on occasion, hears them too.” She also demonstrates a constructional apraxia, with difficulty drawing a clock and intersecting pentagons. All of these symptoms point to a medical cause for this patient’s behavior except one. Which symptom is common in patients with a psychiatric cause for their behavior (ie, not a medical cause)?

135. Families of patients with schizophrenia, who are overtly hostile and overly controlling, affect the patient in which one of the following ways?

136. A 62-year-old man with chronic schizophrenia is brought to the emergency room after he is found wandering around his halfway house, confused and disoriented. His serum sodium concentration is 123 meq/L and urine sodium concentration is 5 meq/L. The patient has been treated with risperidone 4 mg/day for the past 3 years with good symptom control. His roommate reports that the patient often complains of feeling thirsty. Which of the following is the most likely cause of this patient’s symptoms?

137. A 23-year-old woman was diagnosed with schizophrenia after a single episode of psychosis (hallucinations and delusions) that lasted 7 months. She was started on a small dose of olanzapine at the time of diagnosis, which resulted in the disappearance of all her psychotic symptoms. She has now been symptom free for the past 3 years. Which of the following treatment changes should be made first?

138. A 75-year-old man is being cared for in a hospice setting. He has widely spread prostatic carcinoma and is considered terminal. Which of the following psychiatric symptoms are seen in 90% of all terminal patients?

139. A 52-year-old man is seen by a psychiatrist in the emergency room because he is complaining about hearing and seeing miniature people who tell him to kill everyone in sight. He states that these symptoms developed suddenly during the past 48 hours, but that he has had them “on and off” for years. He states that he has never previously sought treatment for the symptoms, but that this episode is particularly bad. He denies the use of any illicit substances. The patient is alert and oriented to person, place, and time. His mental status examination is normal except for his auditory and visual hallucinations. His thought process is normal. His drug toxicology screen is positive for marijuana. He is quite insistent that he needs to be “put away” in the hospital for the symptoms he is experiencing. Which of the following is the most likely diagnosis?

140. A 25-year-old man is brought to the physician after complaining about a visual hallucination of a transparent phantom of his own body. Which of the following specific syndromes is this patient most likely to be displaying?

141. A 28-year-old woman is diagnosed with bipolar disorder, manic type, when she was hospitalized after becoming psychotic, hypersexual, severely agitated, and unable to sleep. She is started on a medication in the acute phase of her illness. Which of the following medications, recommended for acute use in manic patients, is recommended to be continued on into maintenance therapy?

142. A 30-year-old man comes to the psychiatrist for the evaluation of a depressed mood. He states that at least since his mid-20s he has felt depressed. He notes poor self-esteem and low energy, and feels hopeless about his situation, though he denies suicidal ideation. He states he does not use drugs or alcohol, and has no medical problems. His last physical examination by his physician 1 month ago was entirely normal. Which of the following treatment options should be tried first?

143. A 26-year-old man comes to the physician with the chief complaint of a depressed mood for the past 5 weeks. He has been feeling down, with decreased concentration, energy, and interest in his usual hobbies. Six weeks prior to this office visit, he had been to the emergency room for an acute asthma attack and was started on prednisone. Which of the following is the most likely diagnosis?

144. What percentage of new mothers is believed to develop postpartum depression?

145. How long after a stroke is a patient at a higher risk for developing a depressive disorder?

146. A 22-year-old college student calls his psychiatrist because for the past week, after cramming hard for finals, his thoughts have been racing and he is irritable. The psychiatrist notes that the patient’s speech is pressured as well. The patient has been stable for the past 6 months on 500 mg of valproate twice a day. Which of the following is the most appropriate first step in the management of this patient’s symptoms?

147. A 24-year-old woman, 5 days after delivery of a normal, full-term infant, is brought to the obstetrician because she is so tearful. She states that her mood is quite labile, often changing within minutes. She has trouble sleeping, both falling asleep and awakening early. She notes anhedonia, stating she doesn’t enjoy “much of anything” right now. Which of this patient’s symptoms point preferentially to a postpartum depression?

148. A 28-year-old woman sees her physician with the chief complaint of a depressed mood. She also notes that she is sleeping more than usual––up to 14 hours per night––but does not feel rested and that she feels tired and fatigued all the time. She has gained 14 lb in the last month, something that she is very unhappy about, but she says that she seems to have such a craving for sweets that the weight gain seemed inevitable. Which of the following is the most likely diagnosis?

149. A 38-year-old woman with bipolar disorder has been stable on lithium for the past 2 years. She comes to her psychiatrist’s office in tears after a 2-week history of a depressed mood, poor concentration, loss of appetite, and passive suicidal ideation. Which of the following is the most appropriate next step in the management of this patient?

150. A 27-year-old woman has been feeling blue for the past 2 weeks. She has little energy and has trouble concentrating. She states that 6 weeks ago she had been feeling very good, with lots of energy and no need for sleep. She says that this pattern has been occurring for at least the past 3 years, though the episodes have never been so severe that she couldn’t work. Which of the following is the most likely diagnosis?

151. A 19-year-old woman comes to the psychiatrist for a history of anger and irritability, which occurs on monthly on an average. During this time the patient also reports feeling anxious and “about to explode,” which alternates rapidly with crying spells and angry outbursts. The patient notes during this time she can’t concentrate and sleeps much more than she usually needs to do. During the several days these symptoms last, the patient must skip most of her classes because she cannot function. Which of the following is the most likely diagnosis?

152. 42-year-old woman sees her physician because she has been depressed for the past 4 months. She also notes that she has gained 20 lb without trying to. She notes that she does not take pleasure in the activities that she once enjoyed and seems fatigued most of the time. These symptoms have caused the patient to withdraw from many of the social functions that she once enjoyed. The physician diagnoses the patient with hypothyroidism and starts her on thyroid supplementation. Six weeks later, the patient’s thyroid hormone levels have normalized, but she still reports feeling depressed. Which of the following is the most appropriate next step in the management of this patient?

153. A 54-year-old man sees a physician complaining of a depressed mood and inability to sleep for the past 3 weeks. He tells the physician that in the past when he has had similar episodes, he was placed on a monoamine oxidase inhibitor, which proved effective. The physician diagnoses the patient with major depression and agrees to use an MAOI. Which of the following foods must be completely avoided by this patient while on this medication?

154. A 64-year-old man is admitted to the psychiatric unit after an unsuccessful suicide attempt. Following admission, he attempts to cut his wrists three times in the next 24 hours and refuses to eat or drink anything. He is scheduled to have electroconvulsive therapy (ECT) because he is so severely depressed that an antidepressant is deemed too slow acting. Which of the following side effects should the patient be informed is most common after ECT?

155. A 14-year-old boy is brought to the psychiatrist because for the past 15 months he has been irritable and depressed almost constantly. The boy notes that he has difficulty concentrating, and he has lost 5 lb during that time period without trying. He states that he feels as if he has always been depressed, and he feels hopeless about ever feeling better. He denies suicidal ideation or hallucinations. He is sleeping well and doing well in school, though his teachers have noticed that he does not seem to be able to concentrate as well as he had previously. Which of the following is the most likely diagnosis?

156. A 29-year-old man is brought to the hospital because he was found running around on the streets with no shoes on in the middle of winter, screaming to everyone that he was going to be elected president. Upon admission to the hospital, he was stabilized on olanzapine and lithium and then discharged home. Assuming the patient is maintained on the olanzapine and the lithium, which of the following tests should be performed at least once per year?

157. A 45-year-old woman comes to her physician for help with her insomnia. She states “ever since my husband died, I just can’t sleep.” The patient states her 57-year-old husband died suddenly of a heart attack 9 weeks ago. Since that time, the patient has had a very depressed mood, had been crying, has lost interest in activities, is fatigued, and has insomnia. Which of the following symptoms, if present, should make the physician think this patient has a major depression instead of bereavement?

158. A 10-year-old boy is brought to the psychiatrist by his mother. She states that for the past 2 months he has been increasingly irritable, withdrawn, and apathetic. He has been refusing to do his homework, and his grades have dropped. Which of the following is the best next step in management?

159. A 35-year-old woman is seeing a psychiatrist for treatment of her major depression. After 4 weeks on fluoxetine at 40 mg/day, her psychiatrist decides to try augmentation. Which of the following is the most appropriate medication?

160. Which of the following is a relative contraindication for ECT?

161. A 32-year-old man is admitted to the psychiatric unit after his wife brought him to the emergency room in a severe major depression. The patient signs himself in voluntarily because he “didn’t think he is safe” at home. Which of the following factors most increases a patient’s risk of suicide while on the inpatient unit?

162. A middle-aged woman presents with a variety of cognitive and somatic symptoms, fatigue, and memory loss. She denies feeling sad, but her family physician is aware of this patient’s lifelong inability to identify and express feelings. He suspects she is depressed. Which of the following results is most likely to confirm a diagnosis of depression?

163. A 32-year-old man is being treated for a severe major depression. Which of the following symptoms, if present, is one of the most accurate indicators of long-term suicidal risk?