Psych EM

PAS 5441 Emergency Medicine — Psychiatric Emergencies

50-Question PANCE-Style Practice Exam

South College Atlanta — ATL-2026 Cohort

Topics: Delirium vs. Psychosis · Alcohol/Opioid/Benzo/Cocaine Withdrawal · Schizophrenia · Serotonin Syndrome · Mood Disorders · Bipolar · Anxiety · Agitation/Restraints · Suicide · Civil Commitment · Elder Abuse · IPV

PART I — QUESTIONS

Question 1

A 78-year-old male with no psychiatric history is brought to the ED from a nursing home with confusion, agitation, and picking at imaginary objects. Staff reports his mental status fluctuates throughout the day — he was lucid at breakfast but is now combative. Vitals: HR 108, BP 158/94, Temp 38.6°C. Which diagnosis is most consistent with this presentation?

A. Acute schizophrenic episode

B. Bipolar disorder with mania

C. Delirium due to an organic cause

D. Somatoform disorder

Question 2

Which of the following findings would favor a diagnosis of psychiatric psychosis rather than delirium?

A. Fluctuating mental status throughout the day

B. Visual hallucinations and asterixis

C. Sustained auditory hallucinations with patient fully alert and normal vital signs

D. Tachycardia, diaphoresis, and tremor

Question 3

A 55-year-old male presents with AMS, diaphoresis, tachycardia, and picking at his clothes. He has no prior psychiatric history. Which of the following mnemonic categories is the MOST complete framework for identifying organic causes of delirium?

A. SIGECAPS

B. DELIRIUMS (Drugs, Electrolytes, Lack of drugs/withdrawal, Infection, Reduced sensory input, Intracranial pathology, Urinary retention/fecal impaction, Myocardial/pulmonary)

C. MUDPILES

D. AEIOU-TIPS

Question 4

Which of the following lab panels is included in the standard medical clearance order set for a psychiatric patient in the ED?

A. TSH, lipid panel, HbA1c, urine culture

B. Electrolytes, CBC, serum alcohol, urine drug screen, pregnancy test, acetaminophen/salicylate levels

C. ABG, lactate, procalcitonin, and blood cultures only

D. LFTs, coagulation studies, ESR, and CRP

Question 5

A 48-year-old chronic alcoholic was last drinking 18 hours ago. He now presents with tremulousness, diaphoresis, tachycardia, hypertension, and anxiety. He is alert and oriented. Which phase of alcohol withdrawal is he most likely experiencing?

A. Delirium tremens

B. Alcoholic hallucinosis

C. Early alcohol withdrawal with autonomic hyperactivity

D. Wernicke's encephalopathy

Question 6

A 42-year-old male chronic alcohol user presents 30 hours after his last drink with a witnessed generalized tonic-clonic seizure. He is now post-ictal but arousable. Which statement about alcohol withdrawal seizures is most accurate?

A. They are focal in onset and associated with a prolonged post-ictal period

B. They occur as late as 7–10 days after the last drink

C. They are brief tonic-clonic events with minimal post-ictal period; 60% have multiple seizures; 90% occur within 48 hours

D. They only progress to delirium tremens in the majority of patients

Question 7

Which of the following is the FIRST-LINE pharmacologic treatment for alcohol withdrawal seizures?

A. IV phenytoin (Dilantin)

B. IV haloperidol

C. PO or IV lorazepam or diazepam (benzodiazepines)

D. IV levetiracetam (Keppra)

Question 8

A patient develops delirium tremens (DTs) 72 hours after his last drink. Which of the following accurately describes DTs and its management?

A. DTs occur in 50% of alcohol withdrawal patients and are treated with haloperidol alone

B. DTs affect 5% of withdrawal patients, cause life-threatening autonomic instability, and are treated with benzodiazepines, phenobarbital, propofol, and/or haloperidol

C. DTs occur within 6 hours of the last drink and resolve spontaneously

D. DTs are characterized by focal neurologic deficits and are managed with IV thiamine only

Question 9

A patient with alcohol-induced psychosis presents with auditory hallucinations, paranoia, and agitation 24 hours after his last drink. He is at high risk for which complication?

A. Wernicke's encephalopathy from thiamine deficiency

B. Suicide

C. Aspiration pneumonia from oversedation

D. Torsades de pointes from QT prolongation

Question 10

A 28-year-old heroin user presents 48 hours after his last use with dilated pupils, tearing, rhinorrhea, yawning, piloerection, nausea, vomiting, diarrhea, and abdominal cramps. His vital signs show tachycardia and hypertension. What is the diagnosis?

A. Sympathomimetic toxidrome

B. Opioid withdrawal

C. Delirium tremens

D. Serotonin syndrome

Question 11

A patient on long-term methadone maintenance therapy is found unresponsive with miosis and respiratory rate of 6/min. Which cardiac complication is specifically associated with methadone use?

A. Atrial fibrillation

B. QT prolongation leading to Torsades de Pointes

C. Hypertrophic cardiomyopathy

D. Atrioventricular block

Question 12

A 27-year-old cocaine user presents with hypersomnia, increased appetite, restlessness, irritability, hypotension, and bradycardia following abrupt cessation. Which withdrawal syndrome does this represent?

A. Opioid withdrawal

B. Alcohol withdrawal

C. Cocaine withdrawal ('cocaine crash')

D. Benzodiazepine withdrawal

Question 13

A 27-year-old cocaine user in withdrawal would be LEAST expected to exhibit which finding?

A. Hypersomnia

B. Increased appetite

C. Piloerection and dilated pupils

D. Worsening depression

Question 14

A 55-year-old woman who abruptly stopped her chronic alprazolam (Xanax) prescription 9 days ago presents with tremulousness, anxiety, hypertension, tachycardia, insomnia, visual hallucinations, and a generalized seizure. Which withdrawal syndrome is this most consistent with?

A. Opioid withdrawal

B. Cannabis withdrawal

C. Cocaine withdrawal

D. Benzodiazepine withdrawal

Question 15

A 24-year-old male with no medical history presents with auditory hallucinations, paranoid delusions, disorganized speech, and social withdrawal for 6 months. He is fully alert with normal vital signs. His symptoms have been constant, not fluctuating. Which diagnosis is most likely?

A. Delirium from encephalitis

B. Bipolar disorder with psychotic features

C. Schizophrenia

D. Cocaine intoxication

Question 16

Which of the following represents a NEGATIVE symptom of schizophrenia?

A. Auditory hallucinations

B. Paranoid delusions

C. Anhedonia and emotional withdrawal

D. Disorganized speech and catatonia

Question 17

A 35-year-old woman on sertraline, tramadol, and St. John's Wort presents with agitated delirium, diaphoresis, tachycardia, hyperthermia, tremors, myoclonus, and hyperreflexia with bilateral Babinski signs. What is the most likely diagnosis?

A. Neuroleptic malignant syndrome

B. Serotonin syndrome

C. Anticholinergic toxidrome

D. Sympathomimetic toxidrome

Question 18

What is the FIRST step in the management of serotonin syndrome?

A. Administer cyproheptadine (serotonin antagonist)

B. Discontinue all serotonergic agents

C. Intubate for airway protection

D. Administer IV lorazepam immediately

Question 19

A 68-year-old widower presents with depressed mood, anhedonia, insomnia, fatigue, poor concentration, and a 15-lb weight loss over the past 3 weeks. He denies suicidal ideation. Which of the following correctly characterizes major depressive disorder (MDD)?

A. Symptoms must be present for > 2 weeks including depressed mood or anhedonia

B. Symptoms must include visual hallucinations and psychomotor agitation

C. Diagnosis requires at least one prior manic episode

D. MDD is rarely seen in the elderly and carries low suicide risk

Question 20

An 18-year-old male has had one week without sleep, believes he is writing a screenplay for Steven Spielberg (untrue), and presents with pressured speech, flight of ideas, and psychomotor agitation. He has a history of alternating depression and mania. What is the most appropriate ED management?

A. CT head, urine tox, basic labs, and discharge home

B. Inpatient psychiatric hospitalization

C. Outpatient treatment with an antidepressant

D. Outpatient treatment with lithium

Question 21

Which of the following correctly differentiates Bipolar I from Bipolar II disorder?

A. Bipolar I has hypomania + depression; Bipolar II has full mania + depression

B. Bipolar I has full mania + depression; Bipolar II has hypomania + depression; Bipolar II cannot have full psychotic symptoms during hypomania

C. Bipolar I occurs only in women; Bipolar II occurs only in men

D. Bipolar II is more severe and requires more hospitalizations than Bipolar I

Question 22

A 32-year-old woman presents with sudden-onset palpitations, chest pain, dyspnea, dizziness, tachycardia, and diaphoresis. She reports these episodes are unprovoked and have caused her to avoid malls and crowded places. Cardiac workup is negative. What is the most likely diagnosis?

A. Generalized anxiety disorder

B. PTSD

C. Panic disorder

D. Conversion disorder

Question 23

Before diagnosing an anxiety disorder in the ED, which organic etiology must be ruled out?

A. Pneumonia and UTI

B. Hyperthyroidism, caffeine/medication effects, and illicit drug use

C. Anemia and vitamin B12 deficiency

D. Diabetes and hypothyroidism

Question 24

A patient becomes increasingly agitated and is pacing, clenching his fists, and shouting threats. Which of the following is the FIRST-LINE intervention for managing an agitated patient?

A. Immediate physical restraints

B. B52 regimen IM injection

C. Verbal de-escalation techniques

D. IV lorazepam 4 mg push

Question 25

De-escalation is not working for an agitated patient with schizophrenia who is responding to internal stimuli and unable to follow commands. What is the most appropriate next pharmacologic step?

A. IV midazolam 10 mg push

B. IM haloperidol 5 mg

C. Oral lithium

D. IV phenytoin

Question 26

The classic 'B52' IM regimen for acute agitation in the ED consists of which three medications?

A. Benadryl 50 mg + Haldol 5 mg + Lorazepam 2 mg

B. Benzotropine 1 mg + Haldol 5 mg + Lithium 2 mg

C. Benadryl 25 mg + Haldol 10 mg + Lorazepam 4 mg

D. Buprenorphine 4 mg + Haldol 5 mg + Lorazepam 2 mg

Question 27

Which of the following is a legal requirement before physically restraining a patient in the ED?

A. Written consent from the patient's family

B. Court order signed by a judge

C. Documentation that the patient is dangerous to self/others, less restrictive measures were tried and failed, and the patient was educated about the restraints

D. Attending physician approval only, no documentation needed

Question 28

Which pharmacologic class is the FIRST choice for an acutely violent or threatening patient in the ED, and what must be monitored closely afterward?

A. Antipsychotics; monitor for neuroleptic malignant syndrome

B. Benzodiazepines (lorazepam 2–4 mg IV/IM); monitor for respiratory compromise

C. Mood stabilizers; monitor for lithium toxicity

D. Anticholinergics; monitor for urinary retention

Question 29

Suicide is the 10th leading cause of death in the US. Which is the MOST common method, and which method accounts for more than 50% of completed suicides?

A. Overdose is most common; poisoning accounts for 50%

B. Firearms account for over 50%; asphyxiation is 2nd; overdose is 3rd

C. Asphyxiation is most common; overdose accounts for 50%

D. Drowning accounts for 50%; firearms are 2nd

Question 30

Which psychiatric diagnosis carries the HIGHEST lifetime suicide risk?

A. Generalized anxiety disorder

B. Somatization disorder

C. Major depressive disorder (lifetime risk 1 in 7)

D. Adjustment disorder

Question 31

When assessing suicide risk, which question is the MOST critical to ask after establishing that a patient has suicidal ideation?

A. 'How long have you been feeling this way?'

B. 'Have you made a PLAN? What is it?'

C. 'Do you have family support at home?'

D. 'Have you ever been hospitalized for psychiatric issues?'

Question 32

Which profession has the HIGHEST rate of completed suicide among all skilled professions?

A. Lawyers

B. Anesthesiologists

C. Physicians (specifically anesthesiologists and psychiatrists at highest risk)

D. Nurses

Question 33

What are the appropriate suicide precautions for a patient with suicidal ideation in the ED?

A. Verbal agreement from patient not to harm themselves; document in chart

B. Change patient to hospital attire, remove potential means (belts, pills, weapons), designate safe room, and implement continuous monitoring (sitter/video)

C. Place patient in waiting room and reassess in 2 hours

D. Discharge with crisis hotline number and follow-up appointment

Question 34

A patient with schizophrenia refuses inpatient psychiatric admission but is responding to voices commanding him to hurt his neighbor. He has no insight. Which legal mechanism allows the physician to detain him against his will?

A. Voluntary treatment — the patient must consent

B. Civil commitment / involuntary inpatient placement if patient is danger to self or others

C. Court order obtained before any detention is possible

D. Physician may not detain a patient without written consent

Question 35

A 78-year-old woman is brought by her adult son. She has multiple bruises in various stages of healing on her inner thighs, buttocks, and mastoid areas, poor hygiene, and appears malnourished. She is alert but hesitant to speak in front of her son. What is the most likely concern?

A. Normal aging changes and accidental falls

B. Elder abuse — physical abuse and neglect

C. Alcohol withdrawal

D. Vitamin K deficiency causing spontaneous bruising

Question 36

Which type of elder abuse is the SECOND most common form?

A. Physical abuse

B. Sexual abuse

C. Financial or material exploitation

D. Emotional/psychological abuse

Question 37

Which of the following patient populations requires a THOROUGH complete physical exam in the ED because they may be unable to articulate complaints?

A. Fully ambulatory adults with normal cognition

B. Pediatric patients, elderly patients, cognitively impaired patients, and non-English speaking patients

C. Only patients with altered mental status

D. Patients over age 85 only

Question 38

A 28-year-old woman presents with multiple injuries: bruising to her face and neck, defensive injuries on her forearms, and old healed bruises on her back. She states she 'fell.' Which physical exam pattern is most consistent with intimate partner violence (IPV)?

A. Single acute injury consistent with the stated mechanism

B. Injuries to head/face/neck, defensive injuries on extremities, inconsistent history, injuries in multiple stages of healing

C. Injuries exclusively to the lower extremities

D. Injuries that perfectly correlate with the stated mechanism of a fall

Question 39

A patient discloses that her injuries were caused by her partner. She does not want to go to a shelter and plans to return home. What is the MOST appropriate ED response?

A. Refuse to treat unless she agrees to leave her abuser

B. Forcibly contact police and have her partner arrested

C. Treat injuries, document carefully, provide support and empathy, help access community resources, and assess safety of patient and children

D. Discharge without documentation to protect her privacy

Question 40

A 23-year-old is brought in with agitation, tachycardia, hypertension, hyperthermia, dilated pupils, and diaphoresis after using cocaine. Which toxidrome does this represent and what is the risk with acute cocaine use?

A. Cholinergic toxidrome; risk of bronchospasm

B. Sympathomimetic toxidrome; risk of MI, stroke, and hyperthermia

C. Opioid toxidrome; risk of respiratory depression

D. Serotonin syndrome; risk of neuromuscular hyperactivity

Question 41

Cannabis withdrawal begins approximately how many hours after last use, and which symptoms are characteristic?

A. 1–2 hours; tachycardia, diaphoresis, and seizures

B. 24–48 hours; insomnia, irritability, mood swings, depression, loss of appetite, and cravings

C. 7–10 days; severe autonomic instability and hallucinations

D. 72–96 hours; dilated pupils and piloerection

Question 42

A 65-year-old man with no psychiatric history presents with acute confusion, visual hallucinations, asterixis, tachycardia, and fever of 38.8°C. His granddaughter reports he takes multiple medications and has been having urinary frequency. What should be the PRIMARY diagnostic focus?

A. Psychiatric evaluation for new-onset schizophrenia

B. Organic workup for delirium — check for UTI, medications, metabolic abnormalities, and intracranial pathology

C. Detox protocol for alcohol withdrawal

D. Start an antipsychotic immediately and reassess

Question 43

An elderly patient's mental status change is found to be caused by a UTI. She has been intermittently seeing 'spiders on the wall.' Which benzodiazepine use consideration is important in elderly delirious patients?

A. Benzodiazepines are the drug of choice and can be given freely in delirium

B. Benzodiazepines should be AVOIDED in delirium if possible due to risk of paradoxical agitation and worsening confusion; antipsychotics are preferred

C. Benzodiazepines are safe in all delirious patients and should be given before antipsychotics

D. Benzodiazepines have no effect on elderly patients with delirium

Question 44

A 30-year-old male with schizophrenia is brought by EMS after being evicted for violent behavior. He is agitated, responding to auditory hallucinations, and unable to follow commands. Vital signs are normal. He has no known drug allergies. What is the most appropriate initial management?

A. CT head, labs, urine tox screen, discharge if normal

B. Oral lithium and outpatient follow-up

C. IM haloperidol as part of rapid tranquilization regimen

D. IV phenytoin for seizure prophylaxis

Question 45

Medical clearance in the ED is required before transfer to an inpatient psychiatric facility. Which finding would MOST delay or prevent psychiatric transfer?

A. History of chronic schizophrenia with prior hospitalizations

B. Elevated acetaminophen level in a patient who presented with suicidal ideation

C. Patient's refusal to change into a hospital gown

D. History of smoking and alcohol use

Question 46

An agitated patient is placed in physical restraints after verbal de-escalation and medication failed. What monitoring is required during restraint?

A. Vital signs every 4 hours and daily documentation

B. Continuous vital sign monitoring and hourly documentation per hospital/CMS standards

C. No monitoring required once physically restrained

D. Only neurovital checks every 2 hours

Question 47

A patient with bipolar disorder presents in a manic episode with pressured speech, grandiosity, insomnia, and reckless spending. He refuses hospitalization. Under what circumstances is hospitalization indicated against his will?

A. Only if he has a prior psychiatric hospitalization

B. If he is acutely manic, severely depressed with SI, or psychotic and manic — danger to self or others criteria met

C. Only if a family member requests it in writing

D. Hospitalization is never indicated against a patient's will

Question 48

A patient presents after ingesting an unknown substance. She has tearing, rhinorrhea, dilated pupils, piloerection, and tachycardia. Which toxidrome/withdrawal syndrome is this consistent with?

A. Opioid intoxication — miosis, bradycardia, respiratory depression

B. Opioid withdrawal — HEENT symptoms, piloerection, autonomic hyperactivity

C. Anticholinergic toxidrome — dry skin, urinary retention, flushing

D. Cholinergic toxidrome — SLUDGE (salivation, lacrimation, urination, defecation, GI distress, emesis)

Question 49

Buprenorphine (Suboxone) is used in medication-assisted treatment (MAT) for opioid use disorder. What is its mechanism and preferred formulation?

A. Full opioid agonist; given as a patch

B. Partial opioid agonist and weak antagonist; preferred combined with naloxone to deter IV misuse

C. Pure opioid antagonist; given as an implant

D. Opioid antagonist + GABA agonist; given by injection only

Question 50

A 19-year-old male presents with 1 month of worsening social withdrawal, odd speech, and suspiciousness. He has no prior psychiatric history and no substance use. His symptoms are sustained (not fluctuating) and he is alert with normal vitals. His parents report he was always 'eccentric.' Which diagnosis should be considered, and what is the FIRST priority in the ED?

A. Bipolar disorder; start lithium immediately

B. First-episode psychosis (possible schizophrenia); first priority is to RULE OUT organic causes before attributing to primary psychiatric illness

C. Panic disorder; discharge with SSRI prescription

D. Delirium; full septic workup and ICU admission

PART II — ANSWER KEY WITH CLINICAL RATIONALES

Q1.  Answer: C

Delirium is a transient disorder with an ORGANIC cause characterized by impaired attention, perception, memory, and cognition. Key differentiators from psychiatric psychosis: course FLUCTUATES over 24 hours, consciousness is altered (reduced or hyperalert), visual hallucinations predominate, abnormal vital signs may be present, and delusions are transient. No prior psychiatric history + fever + fluctuating course = delirium until proven otherwise.

Q2.  Answer: C

Psychiatric psychosis (e.g., schizophrenia) features: auditory hallucinations (rather than visual), sustained symptoms that do NOT fluctuate within 24 hours, patient is ALERT, NO abnormal vital signs, and NO abnormal movements. Delirium features fluctuating consciousness, visual hallucinations, autonomic instability (tachycardia, diaphoresis, tremor), and asterixis.

Q3.  Answer: B

The DELIRIUMS mnemonic covers organic causes: Drugs, Electrolyte abnormalities, Lack of drugs (withdrawal), Infection (UTI, pneumonia), Reduced sensory input (vision/hearing), Intracranial pathology (stroke, infection, mass), Urinary retention/fecal impaction, Myocardial or Pulmonary (MI, COPD, CHF, hypoxia). SIGECAPS is for depression. MUDPILES is for metabolic acidosis. All organic causes must be excluded before attributing AMS to a primary psychiatric disorder.

Q4.  Answer: B

Standard medical clearance for psychiatric patients includes: electrolytes, CBC, serum alcohol level, urine drug screen (UDS), pregnancy test (if appropriate), and acetaminophen/salicylate levels (especially in suicidal patients — critical to detect occult overdose). Salicylate and acetaminophen toxicity can present with psychiatric symptoms and are life-threatening if missed.

Q5.  Answer: C

Early alcohol withdrawal (6–48 hours after last drink) presents with autonomic hyperactivity: tremulousness, diaphoresis, tachycardia, hypertension, and anxiety. Seizures occur 6–48 hours after last drink. Alcoholic hallucinosis features hallucinations with intact sensorium. Delirium tremens (DTs) occurs 24–96 hours after cessation with severe confusion, agitation, and life-threatening autonomic instability.

Q6.  Answer: C

Alcohol withdrawal seizures are brief generalized tonic-clonic seizures with minimal to no post-ictal period. 40% are single, 60% are multiple. They occur as early as 6 hours after the last drink, with 90% occurring within 48 hours. Only 1/3 progress to delirium tremens. Treatment: benzodiazepines (PO or IV lorazepam or diazepam).

Q7.  Answer: C

Benzodiazepines (lorazepam or diazepam) are the first-line treatment for alcohol withdrawal seizures. They work via GABA-A receptor potentiation, mimicking alcohol's CNS depressant effects. Phenytoin and levetiracetam are NOT effective for alcohol withdrawal seizures. Haloperidol is used for psychosis/agitation but does NOT prevent seizures or DTs.

Q8.  Answer: B

Delirium tremens affects approximately 5% of alcohol withdrawal patients. It features acute and fluctuating changes in consciousness, psychomotor agitation, impaired cognition/perception, and life-threatening fluid, metabolic, and electrolyte abnormalities. Treatment requires ICU-level care with benzodiazepines (first-line), phenobarbital (refractory cases), propofol (intubated patients), and haloperidol for psychosis.

Q9.  Answer: B

Alcohol-induced psychosis (paranoia, agitation, auditory > visual hallucinations) carries HIGH RISK for suicide. These patients often require ICU admission. Treatment is short-term antipsychotics (haloperidol). Suicide risk in alcohol-related psychiatric emergencies is a critical clinical pearl — always assess and document suicidal ideation.

Q10.  Answer: B

Opioid withdrawal presents with: HEENT (dilated pupils, tearing/lacrimation, rhinorrhea, yawning), GI (nausea/vomiting, diarrhea, abdominal cramps), and Derm (piloerection/'gooseflesh'). Vital signs show tachycardia and hypertension. Heroin withdrawal begins 36–72 hours after last use. Methadone withdrawal is delayed (72–96 hours) due to high tissue binding. Remember: OPPOSITE of opioid intoxication (which causes miosis, bradycardia, respiratory depression).

Q11.  Answer: B

Methadone is associated with QT prolongation, which can lead to Torsades de Pointes (a potentially fatal ventricular arrhythmia). This is a critical pharmacologic pearl for opioid maintenance therapy. Buprenorphine (Suboxone) is a preferred alternative because it is a partial opioid agonist + weak antagonist and has a better cardiac safety profile when combined with naloxone.

Q12.  Answer: C

Cocaine withdrawal ('cocaine crash') is characterized by hypersomnia, increased appetite, restlessness/irritability, worsening depression, hypotension, and bradycardia. This is the OPPOSITE of cocaine intoxication (sympathomimetic effects). There is no risk of life-threatening seizures or DTs with cocaine withdrawal, unlike alcohol or benzodiazepine withdrawal.

Q13.  Answer: C

Piloerection and dilated pupils are hallmarks of OPIOID withdrawal, not cocaine withdrawal. Cocaine withdrawal ('crash') features hypersomnia, increased appetite, restlessness, irritability, worsening depression, hypotension, and bradycardia. Differentiating withdrawal syndromes by their autonomic profiles is high-yield for PANCE.

Q14.  Answer: D

Benzodiazepine withdrawal develops 7–10 days after stopping chronic use and MIMICS alcohol withdrawal: hypertension, tachycardia, tachypnea, tremulousness, anxiety, insomnia, AMS (hallucinations, delirium), and seizures. Life-threatening without treatment. Management mirrors alcohol withdrawal — benzodiazepine taper or phenobarbital. Cannabis and cocaine withdrawal do NOT cause seizures or autonomic instability.

Q15.  Answer: C

Schizophrenia typically presents in late adolescence/early adulthood with SUSTAINED (non-fluctuating) positive symptoms (auditory hallucinations, delusions, disorganized speech/behavior, catatonia) and negative symptoms (blunted affect, anhedonia, social withdrawal). Patient is alert with normal vitals — distinguishing from delirium. Childhood history often includes 'odd/eccentric behavior.' Patients rarely seek care themselves due to lack of insight.

Q16.  Answer: C

Negative symptoms of schizophrenia represent DEFICITS in normal function: blunted/flat affect, emotional withdrawal, anhedonia (inability to experience pleasure), and impaired attention. Positive symptoms represent ADDITIONS: hallucinations, delusions, disorganized speech/behavior, catatonia. Negative symptoms are less responsive to antipsychotics and portend a worse long-term prognosis.

Q17.  Answer: B

Serotonin syndrome is a clinical diagnosis (Hunter Toxicity criteria) caused by excess serotonergic activity, presenting with the triad: (1) Mental status changes (agitated delirium, restlessness), (2) Autonomic hyperactivity (diaphoresis, tachycardia, hyperthermia, HTN, vomiting/diarrhea), and (3) Neuromuscular hyperactivity (tremors, myoclonus, hyperreflexia, bilateral Babinski). Multiple serotonergic agents (SSRIs, tramadol, triptans, St. John's Wort) are the culprit.

Q18.  Answer: B

The five principles of serotonin syndrome management: (1) DISCONTINUE all serotonergic agents, (2) Supportive care to normalize vital signs, (3) Sedation with benzodiazepines, (4) Administer serotonin antagonists (cyproheptadine), (5) Assess need to resume causative agents after resolution. Discontinuation is the critical first step — without removing the offending agents, all other treatment is inadequate.

Q19.  Answer: A

MDD requires depressed mood for > 2 weeks AND/OR anhedonia, plus ≥5 total SIGECAPS symptoms: Sleep disturbance, Interest loss, Guilt, Energy loss, Concentration impairment, Appetite change, Psychomotor changes, Suicidal ideation. Lifetime suicide risk is 1 in 7. Psychosis can be a feature of SEVERE depression. Treatment: SSRI or SNRI (not acutely started in the ED).

Q20.  Answer: B

This patient has acute mania with psychosis (grandiose delusions — believing he works for Spielberg) and is unable to care for himself safely. Hospitalization is indicated for: severe depression with SI, acute mania, and psychotic mania. Outpatient lithium is the long-term treatment but is NOT initiated in the ED. Discharging an acutely manic, psychotic patient is unsafe.

Q21.  Answer: B

Bipolar I = full manic episodes + depressive episodes (psychosis can occur during mania). Bipolar II = hypomania (less severe, no psychotic features) + depressive episodes (depressive episodes are often more frequent). Both affect males and females equally. Onset is typically 30–40 years old, and both are associated with ADHD and anxiety disorders.

Q22.  Answer: C

Panic disorder features recurrent sudden surges of severe anxiety (panic attacks) — provoked or unprovoked — with autonomic symptoms (palpitations, chest pain, dyspnea, dizziness, tachycardia, diaphoresis, tremulousness). Agoraphobia (avoidance of places where attacks occurred) is a classic feature. Cardiac workup must rule out arrhythmia, PE, and ACS first. GAD has persistent worry (>6 months) without discrete attacks.

Q23.  Answer: B

Before diagnosing any anxiety disorder, organic causes must be excluded: hyperthyroidism (anxiety, palpitations, weight loss), excessive caffeine, medication side effects (stimulants, decongestants, bronchodilators), and illicit drugs (cocaine, methamphetamine, cannabis). This is required for medical clearance in every psychiatric-type complaint.

Q24.  Answer: C

Verbal de-escalation is the FIRST-LINE intervention for an agitated patient. The 10 domains include: respecting personal space (stay 2 arm lengths away), avoiding provocative body language, one-person interaction, concise communication, identifying wants/feelings, active listening, agreeing when possible, setting clear limits, offering choices, and debriefing after. Medications and physical restraints are escalated only after de-escalation fails.

Q25.  Answer: B

For acute agitation due to psychiatric disorder (e.g., schizophrenia), haloperidol (Haldol) IM is first-line antipsychotic treatment. The classic B52 regimen for severe agitation is: Benadryl 50 mg IM + Haldol 5 mg IM + Lorazepam (Ativan) 2 mg IM. Benzodiazepines can be used in addition to antipsychotics. Avoid benzodiazepines as sole agent in delirium. Monitor vitals for respiratory depression.

Q26.  Answer: A

The B52 IM regimen: Benadryl (diphenhydramine) 50 mg IM + Haldol (haloperidol) 5 mg IM + Ativan (lorazepam) 2 mg IM. Diphenhydramine provides sedation and reduces extrapyramidal side effects (akathisia, dystonia) from haloperidol. Lorazepam augments sedation via GABA. This combination is used for rapid tranquilization of severely agitated patients when de-escalation has failed.

Q27.  Answer: C

Physical and chemical restraints are legally indicated only when: (1) patient is imminently dangerous to self or others AND (2) less restrictive measures have failed. Documentation must include: the patient is a danger to themselves/others, less restrictive measures were attempted, the patient was educated about the restraints and indications for removal. Hourly documentation is required to meet hospital/CMS standards. Restraints require continuous vital sign monitoring.

Q28.  Answer: B

Benzodiazepines (lorazepam 2–4 mg IVP or IM) are first-line for acutely violent/threatening patients. They work rapidly and are non-specific sedatives. Key monitoring: respiratory compromise (especially with repeated dosing or in elderly/COPD patients). Use small doses once behavior is controlled to avoid overmedication. Avoid benzodiazepines alone in delirium (may paradoxically worsen confusion). Monitor vitals continuously.

Q29.  Answer: B

Firearms are involved in over 50% of completed suicides — making them the most common and lethal method. Asphyxiation (hanging) is the 2nd most common method. Overdose is the 3rd. Suicide rates have increased more than 30% in the US since 1999. Access to lethal means (firearm counseling) is one of the most effective prevention strategies.

Q30.  Answer: C

Major depressive disorder carries a lifetime suicide risk of 1 in 7. Other high-risk diagnoses include bipolar disorder, substance use disorders, psychotic disorders, borderline personality disorder, and PTSD. 90% of those who die by suicide have an underlying diagnosable psychiatric disorder at the time of death. Alcohol-induced psychosis also carries high suicide risk.

Q31.  Answer: B

After establishing suicidal ideation, the most critical question is whether the patient has a SPECIFIC PLAN and ACCESS to the means. A plan with access dramatically increases lethality. The assessment should also cover: frequency and intensity of thoughts, prior attempts, hallucinations commanding self-harm, and potential to harm others. Plan + means + intent = immediate intervention required.

Q32.  Answer: C

Physicians have the highest rate of completed suicide of ANY skilled profession. The rate is more than double that of the general population — approximately one completed suicide per day in the US. Anesthesiologists and psychiatrists are at the highest risk within medicine. Farmers, construction workers, and law enforcement also rank among high-risk occupational groups.

Q33.  Answer: B

Suicide precautions include: (1) change to hospital attire (facilitates exam, removes ligature risks), (2) remove all potential means of self-harm (belts, shoelaces, pills, weapons, IV tubing), (3) designate a well-lit, single-occupancy 'safe room' devoid of harmful objects, (4) continuous one-on-one monitoring via sitter, security, or video surveillance. Verbal contracts do NOT substitute for structural precautions.

Q34.  Answer: B

Civil commitment (involuntary inpatient placement) allows detention of a patient against their will when they meet criteria: danger to self, danger to others, or gravely disabled and unable to care for self. Details of the process vary by state (Baker Act in Florida, 5150 in California, etc.), but the ED physician can initiate the hold. Voluntary treatment requires competent consent; this patient lacks insight and is dangerous.

Q35.  Answer: B

Elder abuse red flags: bruises on suspicious locations (palms, feet, torso, inner thighs, arms, buttocks, mastoid areas), injuries in multiple stages of healing, restraint marks, poor hygiene/malnourishment (neglect), and patient reluctance to speak freely in front of caregiver. Physical abuse is the most common form; financial exploitation is the second most common. Mandatory reporting is required. Always examine elderly patients THOROUGHLY who cannot advocate for themselves.

Q36.  Answer: C

Physical abuse is the most common and most easily recognized form of elder abuse. Financial/material exploitation (illegal or improper use of funds, property, or assets) is the second most common. Chemical restraint (using sedating medications to control behavior) is a subtle form of physical abuse. All forms require mandatory reporting per state law.

Q37.  Answer: B

The lecture emphasizes: 'ALWAYS COMPLETE A THOROUGH EXAM ON PATIENTS WHO CANNOT ARTICULATE WELL.' This includes: pediatric patients, elderly patients, anyone with cognitive impairment, and non-English speaking patients. These populations cannot reliably report injuries, symptoms, or abuse. Physical findings (ulcers, bruising, STDs, restraint marks, traumatic alopecia) may be the only evidence of abuse or medical illness.

Q38.  Answer: B

IPV physical exam findings mirror child abuse: (1) injuries to head, face, neck (strangulation evidence), (2) defensive injuries (forearms, hands, back), (3) injuries that DO NOT fit the stated history, (4) evidence of sexual assault or recurrent STIs, (5) injuries in MULTIPLE STAGES OF HEALING. An inconsistent or minimizing history is a key red flag.

Q39.  Answer: C

ED management of IPV: (1) treat injuries as any traumatic injury, (2) document history and injuries carefully in the medical record, (3) provide support and empathy (no one deserves abuse; help is available), (4) help access community resources — this is the PRIMARY ED goal, (5) inquire about safety of the patient AND any children in the home. NOT all survivors want shelter placement. Survivors must be respected — forcing action can increase danger.

Q40.  Answer: B

Cocaine causes a sympathomimetic toxidrome: tachycardia, hypertension, hyperthermia, dilated pupils, agitation, and diaphoresis (due to catecholamine surge). Acute risks include: myocardial infarction (coronary vasospasm), stroke, malignant hyperthermia, and seizures. Treatment: benzodiazepines for agitation/seizures, avoid beta-blockers (can cause unopposed alpha vasoconstriction).

Q41.  Answer: B

Cannabis withdrawal begins 24–48 hours after last use (peak days 2–6). Symptoms: insomnia, irritability, mood swings, depression, loss of appetite, and cravings. IMPORTANTLY — cannabis withdrawal does NOT cause seizures or life-threatening autonomic instability (unlike alcohol and benzodiazepine withdrawal). This differentiates it from more dangerous withdrawal syndromes.

Q42.  Answer: B

New-onset confusion with visual hallucinations, asterixis, autonomic instability, and fever in an elderly patient = delirium from organic cause until proven otherwise. Primary psychiatric illness does NOT present de novo in a 65-year-old. Organic workup (CBC, CMP, UA/culture, serum alcohol, medications review) must be performed. Red flags for organic disease precede any psychiatric diagnosis.

Q43.  Answer: B

The lecture specifically notes: 'Avoid benzos in delirium if possible.' In elderly delirious patients, benzodiazepines can paradoxically worsen agitation and cause oversedation, falls, and respiratory depression. Antipsychotics (haloperidol, atypical antipsychotics) are preferred for delirium-related agitation. Benzodiazepines remain first-line for alcohol and benzodiazepine withdrawal delirium specifically.

Q44.  Answer: C

This patient has acute agitation from a known psychiatric disorder (schizophrenia) with psychotic symptoms. Verbal de-escalation should be attempted first, but given the severity (unable to follow commands, responding to hallucinations, violent history), IM haloperidol as part of the B52 regimen is appropriate. Lithium is a long-term mood stabilizer, not for acute agitation. The lecture case specifically matches this — the answer is IM haloperidol.

Q45.  Answer: B

An elevated acetaminophen (Tylenol) level in a suicidal patient is a medical emergency requiring N-acetylcysteine (NAC) treatment — this MUST be addressed before psychiatric transfer. Psychiatric facilities cannot manage acetaminophen toxicity or other medical emergencies. This is why acetaminophen AND salicylate levels are included in the medical clearance order set for ALL suicidal patients, even without a reported overdose.

Q46.  Answer: B

Physical restraints require: continuous monitoring of vital signs and behavior, and hourly documentation to meet hospital/CMS standards. Restraints must be used only when patients pose a severe threat that cannot be controlled by any other means. The documentation must record that: (1) patient is dangerous, (2) less restrictive measures failed, (3) patient was educated about restraints and indications for removal.

Q47.  Answer: B

Bipolar patients require inpatient hospitalization (voluntary or involuntary) when: severely depressed with suicidal ideation, acutely manic, or psychotic and manic. This patient is acutely manic and — if he meets criteria for danger to self (reckless behavior, impaired judgment) or inability to safely care for himself — civil commitment can be initiated. Mood stabilizers (lithium) are NOT started in the ED; this is managed by inpatient psychiatry.

Q48.  Answer: B

Dilated pupils (mydriasis), tearing (lacrimation), rhinorrhea, yawning, piloerection, and autonomic hyperactivity (tachycardia, hypertension) are the hallmarks of OPIOID WITHDRAWAL. This is the opposite of opioid intoxication (which causes MIOSIS, bradycardia, respiratory depression). The HEENT constellation (dilated pupils + lacrimation + rhinorrhea + yawning) is pathognomonic for opioid withdrawal.

Q49.  Answer: B

Buprenorphine is a PARTIAL opioid agonist (high-affinity, low-efficacy at mu receptors) and weak antagonist. The preferred formulation is combined with NALOXONE (Suboxone) — if injected IV, the naloxone precipitates withdrawal (deterring misuse). If taken sublingually as prescribed, naloxone has minimal effect. This combination reduces diversion and IV abuse while treating opioid dependence. Contrast with methadone (full agonist, QT prolongation risk).

Q50.  Answer: B

First-episode psychosis in a young adult requires ruling out ALL organic causes first: substance use (UDS), metabolic abnormalities (electrolytes, glucose, renal/hepatic function), intracranial pathology (CT head), and infection. Only after organic causes are excluded can a primary psychiatric diagnosis be established. Schizophrenia onset is late adolescence/early adulthood; childhood 'eccentric' behavior and prodromal social withdrawal are classic. These patients typically require psychiatric hospitalization for evaluation and initiation of antipsychotic therapy.