Psych EOR Practice Questions

31M with MDD depression responding to venla 150 QD - acknowledges relationship probs d/t poor labido - worsened with med but present prior, mood has improved - Tx strategy?

A) Decrease dose

B) Switch to norepi and dopamine reuptake inhibitor

D) Switch to SSRIs

C) Augment with sildenafil

A) Decrease dose

B) Switch to norepi and dopamine reuptake inhibitor - Bupropion 75-150mg 1-2 max before intercourse or skip SSRI or SNRI the day before intercourse- better to augment rather stop what is working

D) Switch to SSRIs

C) Augment with sildenafil - Augmenting is a good option, but rather with bupropion - PCP can prescribe viagra with further workup

*Pharm decreasing dopaminergic fxn increases sexual dysfxn thus switching to SDRI improve do

Which of the following sx is not consistent with persistent depressive disorder?

A) Depressed Mood

B) Hopelessness

C) Insomnia

D) Poor appetite

E) Suicidal thoughts

Suicidal thoughts – PDD is not as severe as MDD, this sx makes more severe

Pt presents following a breakup with his girlfriend a month ago. He reports that for the last 4 wks he has been experiencing low mood, psychomotor slowing, increased appetite, and hypersomnolence. He also reports multiple episodes of tearfulness when he perceives rejection from his coworkers. What diagnosis is most likely with these symptoms?

A) Bipolar disorder

B) Mdd with catatonic features

C) Mdd with atypical feature

D) Dependent personality disorder

E) Persistent dysthymic disorder

MDD w atypical features -

Low mood, psychomotor slowing, hypersomnolence - all typical sx of MDD

increased appetite - less typical to MDD but still common

tearfulness when he perceives rejection - this is atypical to MDD and makes the correct dx MDD w atypical features

7yo boy brought by parents who are at wits end. pt has 10-15 tantrums q d sometime 2-3/h during some he punches walls and doors and sometimes bangs his head, has extremely low frustration tolerance and little things set him off, in between tantrums he is cranky and irritable,. attends special school. had this behavior since he was a toddler, gradually increasing in severity

A) bipolar disorder

B) adhd

C) disruptive mood dysregulation disorder

D) intermittent explosive disorder

E) oppositional defiant disorder

C) disruptive mood dysregulation disorder

66M brought to clinicl by wife, weepy, responds lowly to queries, poor hygreine, AOx3, does not respond to other queries, wife denies past hx of depression. What is the next clinical step?

A) complete medical work up

B) start paroxetine

C) start citalopram

D) monitor and follow up in 1 mo

E) refer for ECT eval

Complete medical work-up - so new - need to r/o organic reasons be

26F brought to clinic by BF notes a dramatic shift in mood over last few days - fidgety, dysphoric, cheerful, freely admits to suicidal thoughts with no plan, pmh for medical conditions with meds that she has stopped taking, recent drug use but stopped.

What drug/med did she most likely stop using recently?

A) alcohol

B) amphetamine

C) interferon

D) prednisone

E) isotretinoin

amphetamine - stimulant withdrawal

22 yo f presents to ED with 4 days sustained low food anhedonia, low app, hypersomnolence, Not suicidal, So tearful difficult to get more hx

Most likely dx based on this limited info?

A) Other specified depressive disorder

B) Borderline Personality Disorder

C) Cyclothymia

D) Disruptive mood dysregulation disorder

E) Adjustment disorder with depressive features

Other specified depressive disorder (depressive symptoms, cause clinically significant distress but doesn’t meet other criteria aka depressive sx with insufficient sx) - not enough info for anything else - current brief depressive 2-15days, once per month x 12 months, always less than 2 weeks - like depression but doesn't fully meet criteria

Major depressive disorder most likely to be comorbid with?

A) Substance use disorders

B) Anxiety disorders

C) Personality disorders

D) Impulse control disorders

E) Psychotic disorders disorders

Anxiety disorders - Most common but can be comorbid with any of these

MDD has 72% lifetime comorbidity with any other psychiatric disorder

#1 Anxiety 60%

#2 SUD - 25%

#3 Impulse control - adhd, conduct disorder,explosive disorder

55 yo female, crying spells, fatigue, sad anxious mood, hx - fatigue, LH, muscle weakness, F, WL, N, D, HA, sweating, joint pain, darkening of palmar creases - most likely dx?

A) Hypocortisol / addisons diease

B) Hyperadrenalcortisolism/Cushing

C) Cortical encephalopathy

D) Lymphocytic thyroiditis - hashimotos

E) SLE

Hyperadrenalcortisolism/Cushing --> dark palmar creases key

26 F tx for MDD episode 8mo ago - 2mo into tx noticeable sx improve, last 5mo nearly sx free. According to general commission which of the following best describes her current MDD state

A - response

B - remission

C - recovery

D - Relapse

E - recurrence

According to general commission

A - response - improvement from initial onset of illness of at least 50%

B - remission - sx significantly improved for up to 6 months (almost completely improved)

C - recovery - past 6 mo - absence of sx for at least 4 months following onset of remission

D - Relapse - full return of depressive sx once remission has occurred but before recovery has taken hold

E - recurrence - sx return after a patient has been recovered for a period of time

38 yo with depression, depressed mood, anhedonia, lack of energy

Sx of reduced pos affect are hypothetically more likely to respond to medications that target:

A) Reduce positive affect -

B) Serotonin and dopamine fxn

C) Dopamine and possibly norepi fxn

D) Norepi and possibly serotonin fxn

Dopamine and possibly norepi fxn

Reduction in positive affect - depressed mood, anhedonia → dopamine and norepir dysfxn

Increase in negative affect - irritability → mostly serotonin but can be norepi too

Denise 56yr perimenopausal pt with hx of depression.

Depressed mood seems to be responding to current Tx with SRRI fluoxetine 40mg qd but she is troubled by hot flashes, night sweats and residual depressed mood. What tx strategy is most like to optimize this patients treatment?

A) Maintain current dose

B) Decrease fluoxetine dose

C) Switch to a different SSRI

D) Switch to an SNRI

Switch to an SNRI - SSRI can be worsening the perimenopausal symptoms, SNRI have less vasomotor sx (hot flash, night sweats sx) and tend to be better for perimenopausal patients -

switching to another SSRI will most likely cause the same sx

42 yo untreated depression, Reluctant to begin antidepressant tx due to risk of weight gain Which is associated with the highest risk of weight gain?

A) Escitalopram

B) Mirtazapine

C) Vilazodone

Mirtazapine - short and long term weight gain - serotonin 2c and histamine 1 - average wt gain with any antidepressant is small, more likely to be related to genetics

Low dose 7.5-50mg - sedative medication

Higher dose - acts more as antidepressant

48yo women with hx tx resistant depression currently taking duloxetine 60mg with partial response plus trazodone 50mg for insomnia. Feel empty, useless, thoughts of death, does not have plan to kill self. Clinician tries maoi

Which of pt current medications would you discontinue before initiating maoi?

A) Duloxetine

B) Trazodone

C) Both

D) Neither

A) Duloxetine - dose does not matter - should not start MAOI w/in 14d after SNRi

B) Trazodone - should also be stopped but only if at higher dose - doses up to 100-150 have more sedative effects, above 150 more antidepressant effects

When initiating MAOI → Avoid use 14 days after SSRI, SNRI, or vilazodone, Fluoxetine 5 weeks (bc longer half life), Avoid other medications that have effects on serotonin or norepinephrine

52 yo male, sx of hypertn crisis, currently taking MAOI inhibitor. which of following need to be avoided:

Fresh fish

Aged cheese

Bananas

Bottled beer

All

None

Aged cheese

56 yo male with pmh of MDD presents to ED with Cardiac arrhythmia poss cardiac arrest, suffers a seizure, may have ingested increased dose of medication which is most likely for this OD rxn?

A) Fluvoxamine

B) Clomipramine

C) Atomoxetine

C) Venlafazine

Fluvoxamine (SSRI) -low toxicity in overdose. Symptoms are often minimal: nausea, vomiting, dizziness and somnolence. There is one reported case of prolonged cerebral depression after ingestion of 5.5 g. Overdoses of up to 9 g have produced minimal symptoms and full recovery.

Clomipramine (TCA) - Overdose symptoms may include irregular heartbeats, feeling restless or agitated, confusion, severe sweating, slow or jerky muscle movements, extreme drowsiness, slow breathing, feeling like you might pass out, seizure, or coma

Atomoxetine(SNRI) - can be fatal Overdose symptoms can include sleepiness, behavior changes, nausea and vomiting, blurred vision, rapid heartbeat, hallucinations, seizures, pupil enlargement, and increased heart rate

Venlafazine (SNRI) - overdoses can be life threatening. Signs of toxicity include seizure and prolongation of the QRS and QTc. Large venlafaxin

36 yo has partial response to 2nd mono therapy with 1st line antidepressant

Best evidence of efficacy in pts with inadequate response?

A) Adding atypical antipsychotic

B) Adding buspirone

C) Adding stimulant

A) Adding atypical antipsychotic

B) Adding buspirone - anxiolytic, can be used as augmenting med but for anxiety only - its a very weak anxiety medication - need high dose for a response and then you have more SEs

After remission from a single major depression episode, medication should be continued for how long and at what dose?

3-5mo at

3-5 at 50%

6-12 mo at same dose

6-12 at 50%

Indefinitely

6-12 mo at same dose

30 yo m tx for depression presents with lethargy, confusion, diaphoresis, flushing, tremor, myoclonic jerks, most likely dx?

A) Anticholinergic delirium

B) Serotonin syndrome

C) Ssri d/c syndrome

D) Neuroleptic malignant syn

E) hypoalbuminemia

Serotonin syndrome

symptoms - My hyper dog is the dumbest animal around here

Myoclonus, hyperreflexia, diaphoresis, incoordination, tremor, diarrhea, agitation, AMS, hyperthermia, increased GI motility

SSRI that has the most interaction with other drugs?

Fluvoxamine

AE of SSRI and SNRI

serotonin syndrome, platelet adhesion, hyponatremia due to SIADH

31F presents hx depression with insomnia and anxiety rx mirtazapine 15mg at bed 2 wks later pt reports s/t cough, severe fatigue, temp 102.6 what tell her

A) Its cold season treat symptomatically

B) Schedule appt with PCP

C) Schedule appt with you

D) Stop mirtazapine go to ER

E) Stop mirtazapine and start citalopram

D) Stop mirtazapine go to ER

Rare SE of mirtazapine = agranulocytosis - pt is having sx of neutropenia - 1/1000 patients

26F increase severe seasonal affective sx - begin oct - crying spells, low motivation and self esteem, hypersomnia, increase food cravings and appetite.

What accurate regarding bright light therapy?

A) Sessions in the morning

B) Sessions should last 2-3 hours

C) Light intensity should be 2000 lux

D) Light source should be 5 feet away

E) Patients should stare directly into the light source

A) Sessions in the morning - they should last no more than 60 mins

B) Sessions should last 2-3 hours - SHOULD NOT LAST MORE THAN 60 MIN

C) Light intensity should be 2000 lux - should be 10,000 Lux

D) Light source should be 5 feet away - should be 18in away

27 F in second trimester remains on maintenance tx on sertraline bc severe MDD. PCP consults on discontinuation of sertraline. What condition are they concerned with?

A) Cleft palate

B) Epstein's anomaly

C) Infant ssri w/drawal

D) Pulmonary hypertension in the newborn

E) Excessive wt gain during third trimester

Pulmonary hypertension in the newborn

Epstein's anomaly - caused by lithium or benzos

26 yo G2P1 in 10th wk preg presents with freq unexpected panic attack exclude med and substance use causes. What will be the initial treatment?

A) Venlafaxine

B) Fluoxetine

C) Alprazolam

D) CBT

E) Panic Focused psychodynamic therapy

A) Venlafaxine - not safe in early pregnancy

B) Fluoxetine - safer in pregnancy than some other antidepressants

C) Alprazolam - not safe in pregnancy

D) CBT - always first for someone med naïve, pregnant

E) Panic Focused psychodynamic therapy

The best kind of CBT for someone with agoraphobia is exposure therapy

Key feature about agoraphobia?

A) Fear being in open space

B) Fear a situation where escape is difficult (or no one might be able to help them escape)

C) Fear losing control over aggressive impulse

D) Fear being exposed and humiliated

E) fear falling when away from walls

B) Fear a situation where escape is difficult (or no one might be able to help them escape)

Has to be persistent 6+ months for dx

Psychotherapeutic approach to GAD would most likely include

Breathing retraining

DBT

Chemo -

Mentalization training

emdr

Breathing retraining

21 yo M in college, Present with dep intense fear and avoid of almost all social situations. He's failed trials of several SSRI - venlafaxine, mirtazapine, clomipramine, propranolol (his dx is social anxiety)

In addition to CBT which med would you most likely recommend?

Phenelzine

Quetiapine

Levothyroxine

Valproic acid

Lithium

Phenelzine- MAOI

Quetiapine - antipsychotic second gen

Levothyroxine

Valproic acid - mood stabilizer

Lithium - mood stabilizer

**Blushing the hallmark for social anxiety, median age 13y

Use propranolol during performance situations +/- benzo (use care bc can cause sedation)

35F police officer present with overwhelming fear of insects - inherited from mother interfering with ability to work in field. Does not want psych med

Support therapy

Exposure therapy

Psychodynamic therapy

Career therapy

Interpersonal therapy

Exposure therapy

The PANDAS pediatric autoimmune neuropsychiatric syndrome is hypothesized to be cause by:

Group a strep

Group a staph

Carcinoid

Hyperthyroidism

SLE

Group a strep - disorders associated with strep

**Patients have generalized anxiety, not occuring more days than not, KHYAL cap

Khyal - wind attacks, panic like sx, attack of nerves, obsessive or compulsive sx, mood lambility (rapid mood swings), oppositional symptoms

46 yo male returned last week to us from japan, after arriving at home, he sob, tired, panicky, when feelings dont subside, goes to ED. tell doc he has hx of anxiety but has overcome it

What is initial condition to rule out?-

Hypothyroidism

PE

Panic disorder

GAD

PE

31F two school age kids, fam financial probs recent took job, redeveloped anxiety that waxed and waned since childhood, hard to focus on work - repeatedly calls school to ask if children are okay, pulled them from school multiple times and brought them to work, husband is furious because she is interfering with their education. What is her most likely dx?

Agoraphobia

GAD

Hypochondriasis

Panic disorder

Separation anxiety disorder

Separation anxiety disorder

4yr old has not spoken a work in 4mo since preschool started. Appears hesitant and shy in class, does assignments, observes other kids but does not interact, chatterbox at home, does not talk to other adults including her aunts/uncles

A) GAD

B) Selective mutism

C) SAD - Social anxiety disorder

D) Separation anxiety

E) Specific phobia

Selective mutism

35 yo male with hx mdd presents with acute onset irritability, Decreased need for sleep, feelings of guilt, intermittent suicidal thoughts, crying spells. What is the most likely dx?

A) Mdd recurrent

B) Bipolar 1 with mix ep of mania with mx features

C) Bipolar 1 with mdd features

D) Bipolar 2

E) Borderline

Bipolar 1 with mix ep of mania with mx features

50% have psychotic symptoms at some point

37 yo mother of 2 with pmh of depression presents to pcp for annual. Fidgety, irritable, only sleeps 3 hours nightly for 4 days. Increased energy, painting house. Racing thoughts, more talkable

Most likely dx

Histrionic

Bipolar 1

Bipolar 2

Cyclothymia

Minor depressive disorder

Bipolar 1 - likely daily activities are impacted

Bipolar 2 - still doing daily activities

20 yo College student for psych eval. Moderately depressed to happily energetic. Never had a manic episode.

MDD

Cyclothymia

Bipolar 2 with rapid cycling

Borderline

Bipolar 1 with rapid cycling

Cyclothymia

Which of the follow increase index of suspicion that manic episode is related to medical

Family hx of bipolar

Later age of onset

Good response to tx with lithium

Hx of early mood ep

Grandiosity and euphoria

Later age of onset

42m to psych er with 2 weeks dep sx anhedonia insomnia psychomotor slowing and SI with plan to shoot himself. Prior 3 days increase mood, euphoria with decr need for sleep, grandiosity and racing, thoughts, able to go to work. Does not abuse drugs. What is most likely dx?

Schizoaffective

Psychotic depression

Dipolar II

Cyclothymia

Bipolar disorder unspecified

Bipolar disorder unspecified

40 F BP d/o 4 depressive and 2 manic episodes in last 12 mos, presents with mod mania w.o psychotic features. Which regimen would you recommend?

Lithium 1200

Valproate 1500

Lamotrigine 200

Olanzapine 20

Zoloft 150

Lithium 1200 - BP I maintenance 600-1800/d - MAY BE FOR MORE ACUTE MANIA

Val pro 1500 - probably the answer bc of the moderate mania and its not current acute

Lamotrigein 200 - dose BP I maintenance 200mg

Olanzapine 20 - dose 5-20mg

When you have someone with bipolar and there is suspicion of hypomanic manic or mixed feature or rapid cycling, best thing to do is to not start antidepressant or taper if already on it → risk of driving them into manic episode

Lithium exposure during first trimester increases risk for

Cleft lip

Epstein anomaly

PHTN

Pancreatitis

Epstein anomaly

Can also have floppy baby syndrome - happens 2/1000 cases (hypotonic, cyanotic)

22 f with bp d/o started on mood stabilizer within a couple months develops acne hirsutism, male pattern hair loss, irregular periods. What was she most likely prescribed?

Carbamazepine

Gabapentin

Lamotrigine

Lithium

Valproate

Valproate - avoids in females that are of fertile age, 30% teratogenic effects, best to avoid, also has androgenizing effects - hirsutism, hair loss, acne, irregular menses

Black box - hepatotoxicity, thrombocytopenia

Renal problems - depakote better option

Liver problems - lithium better option

Cogentin aka Benztropine - side effects + use

insomnia and cognitive impairment, also should not discontinue immediately because possibility of withdrawal - used to treat extrapyramidal symptoms/ SEs of antipsychotic medications

Carbamazepine bb warning

Mortality in elderly

Dermatologic rxn - SJS

Teratogenesis

Osteomyelitis

Hemorrhagic pancreatitis

**Black box warnings alert doctors and patients about drug effects that may be dangerous. Severe skin reaction warning: This drug may cause life-threatening allergic reactions called Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN).

A clinically significant change in the concentration of lamotrigine may occur if coadministered with what?

Lithium

Carbamazepine

Valproate

Clozapine

Olanzapine

Valproate

19 yo AA male brought by parents with 3 week increasing isolation decrease school function, insomnia anxiety paranoid hallucinations? Which dx most likely?

Schizophrenia

Schizophreniform

Mdd

Substance Dependence

Brief psychotic disorder

Brief psychotic disorder - the time frame is the key to this dx

What condition is essential for schizoaffective disorder?

A) Duration sx >1yr

B) Both manic and depressive

C) Pt must have 2 weeks of psychotic sx without mood sx

D) Pt cannot have catonic sx

E) 6 mos psychotic sx without mood sx

Pt must have 2 weeks of psychotic sx without mood sx

48F hispanic with 7mo h x of belief that someone is planting dry laundry soap in bed to make her itch.

Schizophreniform

Psychotic d/o unspecified

Brief psychotic d/o

Delusional d/o

Conversion d/o

Delusional d/o

In what way do antipsychotic meds affect women diff

Women respond best to FGA

Less sensitive to prolactin elevations - elevated prolactin likely seen in women

Need combo of antipsychotic

More likely to have SE

Women need higher doses for them to be effective

More likely to have SE

What is the rate of comorbid substance abuse nonnicotine in pts with schizophrenia

20%

40%

50%

60%

75%

50% - from a few years ago, but should be similar

What is the rate of conversion to schizophrenia for patients first dx with brief psych disorder?

10

30

50

75

90

50

Mr L is a 20 yo AA male with recent dx schizophrenia present to ED. which sx suggests catatonia?

Delusions of control from TV

Insomnia

Mutism

Command auditory hallucinations

Mood lability

Mutism

Catatonia 3+ of following: Stupor, no psychomotor activity, resistance to repositioning by provider, mutism, no/very little verbal response , no response to instructions/stimuli, posturing, manerism, stereotype, Agitation, grimacing, echolalia, echopraxia (mimic movement, not speech)

John is an 18y single male going to college, parents brought him to ER for his bizarre behavior. You interview John alone initially - he is unclear as to why he was brought to ER, he relates not going to class for several weeks bc of problems with his teachers minds. He is uncertain if Professors in class are trying to send messages about what to do thru thoughts. He also reports they are able to control the TV programs so he has been avoiding watching TV. What is the best explanation for his statement about his teachers thoughts?

Paranoia

Delusion of reference

Thought broadcasting

Thought insertion

Auditory hallucination

Thought insertion - feels as though someone else is inserting

18 yr old senior brought to ED by police Agitated and aggressive and talks of people who are deliberately trying to confused rambling and disjointed, admits to speed, difficulty focusing, disorientation to time and place, unable to repeat names of objects after 5 min. Abrupt d.c of amphetamines would produce all the following EXCEPT:

Fatigue

Dysphoria

Nightmares

Agitation

Appetite decrease

Appetite decrease - No = increased appetite!

Fatigue - yes

Nightmares - yes

Hypersomnolence, increased appetite, vivid, unpleasant dreams, psychomotor retardation, craving, fatigue (increased need for sleep)

23 yo male with athletic build and facial acne, post MVA with multiple injuries, 6 months hx of mood instability and sudden burst of anger, serum and urine tox are neg. Which of the following might help support anabolic steroid abuse.

Low bp

Enlarged testes

Excessive facial and body hair

Gynecomastia

Deepening of voice

Gynecomastia - enhances female secondary sex characteristics in males

Enlarged testes- incorrect bc small testes

Lifetime use of inhalants most common in which age group

18-25

26-34

8-17

40-65

Over 65

8-17 - they can get their hands on this compared to having more access to other drugs at older ages

Which of the following is true about MDMA? What other names does it have?

Produces selective long lasting damage to serotonergic receptors in animals

Produce sympathomimetic effects

Can cause psychotic reactions

Produces sx of increase confidence

All of the above

All of the above

20yo male who drinks beer occasionally has highest risk of developing alcohol use disorder if he has which of the following in his history?

Chinese ethinc background

Poor academics

Family hx of alc

Being a student athlete

Smoking tobacco when he drinks

Family hx of alc

The AMA states women should Fewer than how many drinks for women per week?

7

14

21

38

25

7 - per week for women

14 - for men

Delirium tremens are most likely to develop at what point of the intoxication withdrawal cycle?

12h after last drink

24h

2-3d

7-14d

14-28d

2-3d - 48-72h

**Peak time for presentation of seizures would be after 24h of EtoH cessation

Alcoholics wernicke's encephalopathy highest risk - triad ataxia, nystagmus and ophthalmoplegia (and can also have confusion) tx with thiamine!!

If continues it can turn in to korsokoffs and then thiamine is too late - main difference is that they develop anterograde amnesia (short term memory) and confabulation

3 medications FDA approved for treatment of alcohol withdrawal/cessation

Disulfram, acamprocet, naltrexone (also approved for opioids)

Sx associated with acute alcohol w/d are associated with over activity of which neurotransmitter

Gaba

Glutamate

Serotonin

Dopamine

Nitric oxide

Glutamate - mostly related to alc withdrawal sx

Gaba- no b/c hypofunction, also related too but less strongly

Which medication strongly contraindicated in patient with advanced renal disease?

Acamprosate

Buprinorphine

Disulfram

Meperidine

Naltrexone

Acamprosate - contraindicated for CrCl <30 - renal metabolism, has t be given 3x day

Which of the following is MC adverse effect of naltrexone

Dizziness

HA

Fatigue

Nausea

vomiting

Nausea

Decreases cravings overall, provent to help with alcohol and opioids (acts on different receptors to help with opioid), helps with cravings overall - ex for smoking or food - can be written off label for that

CANNOT GIVE WITH PAIN MEDS - with opioids

Also has inj form given 1x month

Black box warning - hepatocellular injury with higher doses

Black box warning for naltrexone?

hepatocellular injury with higher doses

C/I to naltrexone

CANNOT GIVE WITH PAIN MEDS - with opioids

off label use for naltrexone

Decreases cravings overall, provent to help with alcohol and opioids (acts on different receptors to help with opioid), helps with cravings overall - ex for smoking or food - can be written off label for that

You are employed in substance abuse tx center where clients are subject to mandatory drug screen

If client has negative urine - you can be confident they have not consumed any of the following drugs in the last 2-3 days except:

Marijuana

Cocaine

Heroine

Toluene

Marijuana - can take 3-30 days to leave body, and takes longer with higher body fat

Cocaine - 6h-3d - depends on what way you use the cocaine

Heroine -

Toluene - inhalant - leaves body very quickly, others have longer half life

Methadone 7-9 days

PCP - 8 days

Opiates 1-3d

Opioid intox is generally characterized by which of the following physiologic changes:

Pupillary dilation

Piloerection

Increased BP

Depressed respiration

Increased body temp

Depressed respiration

s/s opioid intox - euphoria, pupillary constriction, depression of resp and gag reflex, bradycardia, hypotension, constipation

Tx - airway protection, judicious use of naloxone

Chronic use tx - dc of use, target medical care of infections complications

Overdose - intubation and naloxone

Which of the following is not a sx of opioid withdrawal:

Incr body temp

Depressed respiration

Increased bp

Piloerection

Pupillary dilation

Incr body temp - withdrawal sx

Dep respiration - intoxication sx

Increased bp - withdrawal sx

Piloerection - yes it is a sx

Pupillary dilation - yes it is a sx

· Uncomplicated acute opioid withdrawal

o Dysphoric mood Nausea/vomiting Muscle aches

o Lacrimation Rhinorrhea Pupillary dilation

o Diarrhea Yawning Piloerection/sweating

oFever Insomniabradycardia, hypertension

Which of the following statements is true about starting buprenorphine?

A) Should be started when pt is intoxicated with opiate

B) When objective evidence of withdrawal

C) Should be started at time pt consumes heroine

D) It should be administered prn

E) It should be administered PO

When objective evidence of withdrawal - If the patient is not in full withdrawal, it will displace the full agonist and cause precipitated opioid withdrawal (never severe withdrawal sx, only mild-mod)

3 medications that are used and approved SUD bc of opioid

Methadone - can be given to pt daily, usu has to go to methadone clinic and they do a UDS, full agonist which is why it can be very addicting too- can be very difficult for stop - want to transition to bupriphone or suboxone (partial agonist of mu2 receptor which is why when in combo with buprinorphine naloxone - hard to abuse)

Naltrexone - full agonist - which is why its contraindicated for pts on opioid tx for pain management

Subozone and methadone are okay during pregnancy - approved for use

39F nurse with GAD who suspect taking more than Rx amount of clonazepam. Pt states run out meds early d/t increased stress at work. Reports to the office 5 days early this month.

Sx of benzo withdrawal you expect include all except:

Dysphoria

Intolerance for bright lights

Nausea

Muscle twitching

Pinpoint pupils

Pinpoint pupils - sx of intoxication

Sx of withdrawal

· Anxiety, agitation Increased sensitivity to light and sound

· Muscle cramps Paresthesias, strange sensations

· Myoclonic jerks Sleep disturbance Headache

· Dizziness Dry heaves/nausea Palpitations

· Seizures, delirium following high-dose usage sedation, pupillary constriction, slurred speech, staggering gait

Severe sx - resp depression, hypothermia, coma and death

OD tx - gastric lavage, supportive care, warming blanket, ICU care

Withdrawal - increased hand tremor, nausea, vomiting, anxiety, possible grand mal seizures

Need to taper pts of benzo SLOWLY - esp if been on long term

In addition to behavioral and psych sx such impaired motor coordination anxiety euphoria, withdrawal from social situation, and subjective feeling of time slow

Cannabis intox has all of following except

Dry mouth

Conjunctival injection

Tachycardia

Decreased appetite

Impaired judgement

Decreased appetite

Cannabis Intoxication:

o Euphoria, Relaxation, Increased appetite, Cognitive impairment, Impaired motor coordination, Anxiety, paranoia, psychosis (rare cases)

34F recently diagnosed with MDD upon Q few episodes of suicide attempts - cut wrists and hang herself

Which med is contraindicated?

Busprione

Fluoxetine

Parocetine

Amitriptyline

esticalopram

Amitriptyline - this TCA - high OD risk

21 women with headache bloating breast pain and swelling, irritability and 7-10 da prior to menses, relieved 2-3 after resolution of menses. Using sick days.

Which most likely dx?

Premenstrual syndrome

MDD

Premenstrual dysphoric disorder

Somatization disorder

Premenstrual dysphoric disorder - more severe sx to the point that it interferes with patients life - she is using sick days and missing work

25F with hx of depression brought to eR by friend after find sweatin and mumbling on floor of dorm room -now appears confused and complains of blurred vision, palpitations, cotton mouth, no piloerection, pupils dilated, decreased bowel sounds, QRS 160ms with hr160 bpm

which most likely substance use?

Cannabis

Oxycodone

Ethanol intox

TCA overdose

Methadone overdose

Oxycodone - no piloerection and pupils are dilated so this doesnt fit

Ethanol intox - skin is dry, not moist

TCA overdose - strong anticholinergic SEs, increased QRS - SLUDD

5 C’s for substance use disorder (Addiction)

Craving, compulsion, lost of control, continued use, chronic maladaptive behavior

A 3yo SE Asian boy is brought to the clinical for eval. His mother is concerned about him not being interactive. He is also accompanied by his paternal grandmother who insists there is nothing wrong with the child and "he will grow out of this phase." Upon initial eval, the child appears to have autistic features. Which of the following is the next most appropriate course of action?

Ask the paternal grandmother to leave the room

Ask the mother to leave the room

Call the patient's father to come in

Ask both the attendants for their views

Ask the paternal grandmother to leave the room - dismissing would be disrespectful.. This is a more cultural question

Ask the mother to leave the room - what if she is the legal guarding

Call the patient’s father to come in - he’s not even mentioned in the question

Ask both the attendants for their views

A 17yo male is found unresponsive lying on his bedroom floor with an empty pill bottle next to him. His skin is pale, and extremities are cool. He is diaphoretic, and his breathing is shallow. EMS are notified and transported him to the nearest ED. His BP is 100/80, pulse 80 bpm, respirations 8/min, and temp 98.0 F. On PE, his pupils are 1mm bilaterally. He is confused and unable to cooperate with the exam. Which of the following is the best treatment for the pt?

Diazepam

Naloxone

Flumazenil

Activated charcoal

Naloxone

A 7yo boy has problems with being uncooperative, disruptive, and sometimes combative in school. His parents initially ignored the behaviors, which resulted in increasing problematic behaviors at school and also at home. What would be the best next step for using a behavioral model to address this problem?

Reason with the child to get him to cooperate

Allow the outburst for a limited time and then redirect

Set clear behavioral expectations and provide consequences for loss of control

Continue therapy with or without cooperation

Set clear behavioral expectations and provide consequences for loss of control

An 11yo male pt is brought to a child psychiatrist d/t behavioral problems. His mother states the pt has been irritable and cranky for a long time. She noted that the pt throws temper tantrums over little things. He has been stealing money from his friend and family. The pt got school suspension a few weeks ago d/t initiating a physical fight and destroying school property. His mother describes the pt as a manipulative liar. The pt has never seen a mental health provider in the past. Which of the following tx approach could be most beneficial for this patient?

Multisytemic therapy

Psychodynamic psychotherapy

Individual supportive psychotherapy

Maudsley family therapy

Multisytemic therapy - effective for conduct disorder and oppositional defiant d/o - aim of therapy is to reduce criminal activity, incarceration, use of drugs, effective in violent juvenile offenders

Psychodynamic psychotherapy - focuses on unconscious processes

Individual supportive psychotherapy

Maudsley family therapy - for eating disorders

***When pt starts to destroy property - would lean more towards conduct disorder*antisocial personality disorder is related to conduct disorder (when pt becomes adult)

A 23yo male pt with a past psychiatric hx of ADHD presents to the office with intense worry and difficulty sleeping at night for the past 2 years. He admits he stays up late worrying about things that he cannot control and freq has to write his actions down in a diary so he can go to sleep. He allows his diary to be read by the provider. In reviewing the log, his actions do not change from hour to hour but instead say, "I will not check the lock again" repeatedly. The patient would like to avoid pharmacological interventions. Which of the following is the best tx for this pt?

Exposure and response prevention (ERP)

Dialectical Behavioral Therapy (DBT)

Encourage the patient to try a SSRI

Group therapy

dx is OCD -

Exposure and response prevention (ERP)

A 22yo man is admitted to the inpt psychiatry unit for aggressive behavior. Upon interview, the patient is unable to provide reliable hx bc of slowed speech. Pt exhibits psychomotor agitation and inappropriate affect. Collateral was contacted and the patient is reported to have had a significant intellectual disability since childhood. Urine drug screen and blood alcohol level are unremarkable. What is the first step the physician should do to screen for the visual problems?

A) Formal acuity testing and visual fields

B) Observe the pt for deficits during the ADL screening

C) Improve lighting in the pt's environment

D) Refer the pt to an optometrist or ophthalmologist

Observe the pt for deficits during the ADL screening - his mental capacity is not there for the conducting formal

A pt has been depressed and takes an OD of TCA. She presents with hallucinations, confusion, dilated pupils, tachycardia, and hypotension. Which of the following is the antidote of choice?

Atropine

Norepinephrine

Naloxone

Diazepam

Atropine - - dilates pupils and increases HR - NO

Norepinephrine - counter agent to anticholinergic side effects - will increase HR, dilates pupils

Naloxone - no indication of opioid

**sodium bicarbonate is the antidote of choice

A 25yo women presents to the clinic seeking advice for an upcoming presentation in the next weel. She states how she feels her heart racing each time she presents something for her work. She says this has been affecting her performance. She denies any alcohol or tobacco use but does state how she has wheezing and SOB with exercise and exposure to dust and pollen. Her current mes include OCPs and albuterol prn. She was to know whether you can prescribe her something to help with her anxiety during her presentation, stating how one of her friends uses a beta blocker for performance anxiety. What is the best next step in the management of this patient?

A) Prescribe her a SSRI

B) Prescribe her a nonselective beta blocker

C) Explain to her that beta blocker is contraindicated

D) Refer to a psychologist for CBT

Explain to her that beta blocker is contraindicated - BB contraindicated for asthma- she needs to know why it wont be a good choice for her. Just because it works for her friend doesnt mean its for her too!

-Prescribe her a SSRI - wont have a fast enough onset to help within the next week

A depressed patient was started on a drug known to inhibit catecholamine degradation. Recently she started another drug and required emergency admission bc of the combined effect. Which of the following is most likely drug added?

Lithium

Fluoxetine

Aspirin

Heroine

Fluoxetine - MAOI inhibit catecholamine degradation and SSRIs inhibit catecholamine degradation should not be combined - will cause serotonin syndrome - cyproheptadine tx of choice for serotonin syndrome

A 40yo male pt has been taking oral opioids for 2mos for a work related back injury. He ran of his meds 5 days ago and present to ED somewhat agitated, asking for a new Rx. What tool could be used to determine if he has opioid withdrawal?

COWS score

CIWA score

CAGE questions

Urine toxicology screen

COWS score - CLINICAL OPIOID WITHDRAWAL SCALE

A Male pt was brough for a consult by his mother. He started having intermittent grunting sounds at the back of his throat and that more prominent when he is under stress. This was accompanied by head jerking and eye blinking. He would occasionally utter loud incomprehensible sounds even while in class. The physical and neurologic exam were normal. Which of the following neuropsychological problems is most commonly associated with this syndrome?

OCD

ADHD

Depression

Behavioral problems

o ADHD (60 %), Sleep disorders (50%), OCD (30%), Learning disorder (23 %)

oConduct disorder/oppositional defiant disorder (15 %)

A 15yo boy with a hx of autism presents to clinic with his mother. Upon questioning, the pt simply repeats the question back to the provider. Further prompting results in further vocal repetitions by the patient. When is this behavior considered normal?

A) Never

B) In children just learning to speak

C) Autism spectrum disorder

D) Tourette's disorder

In children just learning to speak - echolalia

***Echolalia is actually a normal part of child development: as toddlers learn to speak, they imitate the sounds they hear. 2 Over time, however, a typically developing child will start to use language to communicate their wants, needs, and ideas by stringing together sounds and words in novel ways. - usually gone by age 3 (sometimes 4)

A 9yo girl is brought to the out-pt department by her parents d/t abn actions and behaviors. Her parents report that she frequently blinks her eyes, protrudes her tongue, and grimaces her face. She grunts, snorts, and clear her throat frequently. These symptoms started a year ago and worsened in the past few months. For the past 6 months, she has also been unable to sit still, constantly fidgets, talks, and has been unable to perform her activities quietly. Her teachers have mentioned that she does not complete her tasks on time, blurts out answers, and is unable to wait for her turn. The patient appears healthy and constantly blinks her eyes. Vitals are within normal limits. In addition to behavioral therapy, which of the following pharmacotherapy, can be considered for this patient?

A) Pimozide

B) Risperidone

C) Fluoxetine

D) Guanfacine

Guanfacine - First line to manage ADHD, esp in pt with tourettes, -- FDA APPROVED IN KIDS - unclear response for tics - from the stem seems like the ADHD sx are the most troublesome

Pimozide - suppresses the physical (motor) and vocal (phonic) symptoms of tics when these symptoms interfere with daily life function. Pimozide is not for use in treating motor tics that are not caused by Tourette's syndrome.

Risperidone - 60-80% response to manage tics - may consider when patients start to become aggressive like punching walls - used a pharmaco therapy for tourettes with no other comorbidities

Fluoxetine - can help comorbid SSRI

An 8yo girl is brought to the outpt department by her parents d/t abn actions. Her parents report that she frequently blinks her eyes, jerks her head, scratches her body and shrugs her shoulders. She has also developed a bizarre gait. She grunts and clears her throat frequently. These sx started a year ago and the parents dismissed them as playful behavior. Over the past few months, the symptoms have progressively worsened. The parents are worried and want to start her on pharmacotherapy. The child's height and weight are at the 55th and 60th percentile, respectively. Vitals are within normal limits. PE reveals a healthy child who freq jerks her head and scratches different parts of her body. Which of the following is a SE of the txx that is frequently considered for the patient's condition?

A) Hyperprolactinemia

B) Weight loss

C) Agranulocytosis

D) Arrhythmias

This is just tourettes with no comorbidities - can do risperidone or an atypical antipsychotics

Hyperprolactinemia - SE for risperidone - or other atypical antipsychotic

Which of the following disorders most equally distributed between males and females

Gad

Ocd

Panic disorder

Ptsd

SAD

Ocd - 1:1 ratio - overall prevalence of OCD is equal in males and females

Which of following sx considered a compulsion

Freq images of stabbing ones infant

Intrusive sexual thoughts

Fears about germs and contamination

Mental repetition of specific phrases

Persistent impulsive to shout obscenities

Mental repetition of specific phrases

For pts with ocd with good response to med tx, full dose med should be continued for how long before discontinuation trial should be considered

3-6 mos

6-12 mo

1-2 years

4-5 years

indefinitely

1-2 years - can try it but it would probably fail even with really good therapy

Which type of dysmorphia commonly experienced by males with body dysmorphic disorder?

Body weight

Buttock and abd

Ethnic characteristics

Muscle and genital size

Nose and face

Muscle and genital size

66M brought in by son visiting from out of town, found pt had newspapers and mags stacked to ceiling in appt. Son fears father hoarding is out of control. PT minimizes the seriousness of hoarding and denies medication and therapy at this time.

What is most likely the next clinical step?

A) Start sertraline and tell the patient its a multivitamin

B) Ask patient to return if patient changes mind

C) Put son in touch with attorney

D) Schedule pt for motivation enhancement session

E) Admit pt involuntarily due to health and safety concerns

Schedule pt for motivation enhancement session

Tx for hoarding with CBT - motivation enhance, cognitive restructuring, exposure therapy

What type of behavior therapy found to most effective in treating trichotillomania?

Habit reversal training

Response prevention

Fault cognition

PICA

Social skill training

Habit reversal training - proven to be most successful therapy

College student brought to ER by roommate cleaning room for 18 h nothing makes it clean enough visibly agitated

Which drug mostly likely precipitated this presentation?

Clonazepam

Fluoxetine

Olanzapine

Methylphenidate

Tylenol

Methylphenidate - stimulant

Which infection is thought to be associated with OCD symptoms.

Staph

Group a strep

Mycoplasma

Syphilis

Herpes simplex

Group a strep - one of PANDAS - comes with a lot of obsessions and compulsions

What is Shubo-kyofu?

variant of taijin kyofusho

excessive fear of having body deformity

- similar to BDD - characterized by obsessive fear of body dysmorphia - subset of taijinkyofusho interpersonal fear syndrome