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A college student is brought to the student health center at the urging of his
roommate. He has been missing class because he needs to
check the room lock many times before he can leave. Once he starts to ride his
bicycle to class, he frequently returns several times to lock the
door. He repeats this ritual every morning and often when he leaves the house.
He misses his appointments and his academic performance
suffers. His hands are chafed.
Question 1 of 4

Which of the following is the most likely diagnosis?


/A. Generalized anxiety disorder
/B. Obsessive compulsive disorder
/C. Panic disorder
/D. Paranoid personality disorder
/E. Posttraumatic stress disorder
Explanation - Q: 1.1

Close

The correct answer is B. Patients with obsessive compulsive disorder


(OCD) suffer from obsessive thoughts and compulsive behaviors that impair
everyday function. Obsessions are defined as recurrent and persistent
thoughts, impulses, or images that are intrusive, inappropriate, and cause
anxiety and distress. Patients realize that these thoughts and images are a
product of their own mind and they will attempt to suppress them. In addition
to obsessions, patients experience compulsions. Compulsions are repetitive
behaviors or mental acts that a person performs in accordance with an
obsession. The behaviors are aimed at reducing distress or preventing some
dreaded event or situation. Locking doors is a common compulsion, and thus
this patient meets the diagnostic criteria for obsessive compulsive disorder.
Generalized anxiety disorder (choice A) is characterized by excessive
anxiety and apprehensive expectation for a period greater than 6 months.
Patients experience anxiety, cognitive vigilance, autonomic hyperactivity,
motor tension, irritability, and poor concentration. Compulsions are not a part
of this disorder.
Panic disorder (choice C) is characterized by episodes of panic. Patients
have a discrete period of intense fear with tachycardia, palpitations, sweating,
trembling, shortness of breath, chest pain and tightening, abdominal
discomfort, fear of dying, and paresthesias.
Paranoid personality disorder (choice D) is characterized by enduring
patterns of personality characterized by mistrust and suspiciousness of
people.
Posttraumatic stress disorder (choice E) is an anxiety disorder that develops

around a traumatic event. Symptoms revolve around the event and include
reexperiencing of the trauma, psychic numbing, and increased autonomic
arousal.
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A college student is brought to the student health center at the urging of his
roommate. He has been missing class because he needs to
check the room lock many times before he can leave. Once he starts to ride his
bicycle to class, he frequently returns several times to lock the
door. He repeats this ritual every morning and often when he leaves the house.
He misses his appointments and his academic performance
suffers. His hands are chafed.
Question 2 of 4

The patient's incessant door locking is an example of which of the following?


/A. Compulsion
/B. Delusion
/C. Magical thinking
/D. Obsession
/E. Paranoid ideation
Explanation - Q: 1.2

Close

The correct answer is A. Compulsions are repetitive behaviors or mental


acts that patients perform in accordance with an obsession (choice D). It is
important to realize that obsessions are the mental processes and that
compulsions are the actions or behaviors.
Delusions (choice B) are fixed false beliefs that are not culturally accepted.
(People that believe in Santa Claus are not deluded.)
Magical thinking (choice C) is a mental process, not a behavior, like door
locking. Patients with magical thinking believe they have special, "magical"
capacities that others do not have. Thus door locking does not exemplify
magical thinking.
Door locking does not exemplify paranoid ideation (choice E). However,
paranoid ideation, or the patient's belief that others are out to harm him/her,
may provide the source of anxiety to drive the compulsion.
A college student is brought to the student health center at the urging of his
roommate. He has been missing class because he needs to
check the room lock many times before he can leave. Once he starts to ride his
bicycle to class, he frequently returns several times to lock the
door. He repeats this ritual every morning and often when he leaves the house.
He misses his appointments and his academic performance
suffers. His hands are chafed.
Question 3 of 4

Which of the following is the most appropriate pharmacotherapy for this patient?
/A. CIozapine
/B. Desipramine
/C. FIuoxetine
/D. Haloperidol
/E. Lorazepam
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Explanation - Q: 1.3

Close

The correct answer is C. The effectiveness of selective serotonin reuptake


inhibitors (SSRIs) in treating OCD has contributed significant indirect
evidence to the role of the serotonergic system in the pathophysiology of
OCD. It is hypothesized that dysregulation of this neurotransmitter could
contribute to the repetitive obsessions and ritualistic behaviors. This
hypothesis is also supported by the relative ineffectiveness of noradrenergic
antidepressants, such as desipramine.
Clozapine (choice A) is an atypical antipsychotic, and would not play a role in
the treatment of OCD unless psychotic features were noted.
Desipramine (choice B) is a noradrenergic antidepressant, and as noted
above, has no effect on OCD symptoms.
Haloperidol (choice D) is an antipsychotic drug that has no effect on OCD
symptoms unless psychotic features were noted.
Lorazepam (choice E) is a benzodiazepine that is used to treat acute
agitation. It would not be used to treat OCD.
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A college student is brought to the student health center at the urging of his
roommate. He has been missing class because he needs to
check the room lock many times before he can leave. Once he starts to ride his
bicycle to class, he frequently returns several times to lock th
door. He repeats this ritual every morning and often when he leaves the house.
He misses his appointments and his academic performance
suffers. His hands are chafed.
Question 4 of 4

According to psychoanalytic theory, this patient's disorder develops when


defense mechanisms fail to contain the patient's anxiety. One
defense mechanism employed in this patient's constellation of symptoms is
reaction formation. Which of the following is an example of
reaction formation?
/A. A man ignores the fact that his spouse is cheating on him and they invest in
a house together
/B. A man in the intensive care unit becomes infantile and unruly

/C. A man

in the intensive care unit tells his nurse, "You that are the best nurse l
have ever seen-unlike those horrible nurses yesterday who
made me wait for pain medicine. Those nurses were horrible and l never want to
see them again."
/D. A man who is extremely angry with his spouse treats her gently and kindly
/E. A promiscuous man accuses his spouse of being unfaithful to him
Explanation - Q: 1.4

Close

The correct answer is D. Obsessional patients often show the defense


mechanism of reaction formation. Reaction formation is when affects are
transformed into their opposites and ambivalence is resolved in the opposite
manner from which it arises. This man resolves his anger with his wife by
creating the opposite affect.
Choice A exemplifies the defense mechanism known as denial. Denial is the
invalidation of an unpleasant or unwanted piece of information. He denies
that his marriage is compromised, and continues investing in it.
Choice B exemplifies regression. When regression is employed, patients
return to an earlier level of functioning. This patient's infantile behavior
represents regression. Regression is often seen in medically ill patients.
Choice C exemplifies splitting. In splitting, aspects of mental content are kept
separate. The man has overidealized those who met his needs, and devalued
those who frustrate him. This defense is often seen in patients with borderline
personality disorder.
Choice E exemplifies projection. In projection, a person rids him/herself of
unacceptable thoughts by attributing them to others. While this rids the
affected individual of the unwanted affect, he/she then lives in a world of
others who harbor the unacceptable material. This is often seen in paranoid
patients.
A 32-year-old married lawyer presents to the emergency department with a
complaint of "having a heart attack." He explains he was "doing
nothing particular" at home about 45 minutes ago when he began having chest
pain with shortness of breath and nausea. His symptoms
peaked within ten minutes, and he "knew this was the big one." His wife noted he
was "shaking and sweaty." His wife immediately brought
him to the hospitaI. He has no significant past medical history, takes no
medications, and denies substance use. His family medical history is
significant for a paternal grandfather that "died of a massive heart attack" at age
56. Physical examination reveals an anxious diaphoretic

man taking short, shallow breaths. Vital signs, cardiac auscultation, ECG, and
cardiac enzymes are completely normaI. The patient has been
to the emergency department 5 times in the last 6 weeks and apologizes for "the
million dollar workup," but explains "every time it happens l
just know l am doomed to die."
Question 1 of 6

Which of the following is the most likely diagnosis?


/A. Agoraphobia
/B. Generalized anxiety disorder
/C. Malingering
/D. Panic disorder
/E. Phobia
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Explanation - Q: 2.1

Close

NONE AVAILABLE
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A 32-year-old married lawyer presents to the emergency department with a


complaint of "having a heart attack." He explains he was "doing
nothing particular" at home about 45 minutes ago when he began having chest
pain with shortness of breath and nausea. His symptoms
peaked within ten minutes, and he "knew this was the big one." His wife noted he
was "shaking and sweaty." His wife immediately brought
him to the hospitaI. He has no significant past medical history, takes no
medications, and denies substance use. His family medical history is
significant for a paternal grandfather that "died of a massive heart attack" at age
56. Physical examination reveals an anxious diaphoretic
man taking short, shallow breaths. Vital signs, cardiac auscultation, ECG, and
cardiac enzymes are completely normaI. The patient has been
to the emergency department 5 times in the last 6 weeks and apologizes for "the
million dollar workup," but explains "every time it happens l
just know l am doomed to die."
Question 2 of 6

Which of the following criteria would serve to exclude the most likely diagnosis?
/A. Panic attacks beginning during sleep
/B. Panic attacks beginning while driving
/C. Panic attacks occurring at work and home
/D. Panic attacks occurring "out of the blue"
/E. Panic attacks occurring with caffeine intake
Explanation - Q: 2.2

Close

The correct answer is E. Panic attacks resulting from substances (especially


stimulants) or general medical conditions are not considered panic disorder.

Myocardial infarction, hypothyroidism, and carcinoid syndrome should be


ruled out.
Panic attacks may begin while driving, or awaken patients from sleep
(choices A and B).
Panic attacks may occur anywhere, including work and home (choice C).
Panic attacks ONLY occurring with the trigger of being in open spaces are
diagnostic of agoraphobia (a phobia).
In panic disorder, panic attacks are unprecipitated ("out of the blue"; choice
D). Panic attacks triggered by a feared event or object are seen in phobias.
A 32-year-old married lawyer presents to the emergency department with a
complaint of "having a heart attack." He explains he was "doing
nothing particular" at home about 45 minutes ago when he began having chest
pain with shortness of breath and nausea. His symptoms
peaked within ten minutes, and he "knew this was the big one." His wife noted he
was "shaking and sweaty." His wife immediately brought
him to the hospitaI. He has no significant past medical history, takes no
medications, and denies substance use. His family medical history is
significant for a paternal grandfather that "died of a massive heart attack" at age
56. Physical examination reveals an anxious diaphoretic
man taking short, shallow breaths. Vital signs, cardiac auscultation, ECG, and
cardiac enzymes are completely normaI. The patient has been
to the emergency department 5 times in the last 6 weeks and apologizes for "the
million dollar workup," but explains "every time it happens l
just know l am doomed to die."
uestion 3 of 6

Which of the following would be the most appropriate pharmacotherapy?


/A. CIozapine
/B. Disulfiram
/C. FIuoxetine
/D. Lithium
/E. Risperidone
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Explanation - Q: 2.3

Close

The correct answer is C. The selective serotonin reuptake inhibitors (SSRIs)


are considered first line treatment for panic disorder. Buspirone and the
benzodiazepines are also used.
Clozapine (choice A) is an atypical antipsychotic reserved for treatment of
refractory schizophrenia, due to the risk of agranulocytosis and myocarditis.
Disulfiram (choice B) is used as an adjunct treatment to maintain sobriety.
Patients ingesting alcohol while taking this medicine become ill, due to

accumulation of acetaldehyde.
Lithium (choice D) is a first line treatment for bipolar disorder, and can be
used to augment antidepressant medicines.
Risperidone (choice D) is an atypical antipsychotic medication with
prominent D2 blockade. It is used to treat psychotic conditions, such as
schizophrenia
A 32-year-old married lawyer presents to the emergency department with a
complaint of "having a heart attack." He explains he was "doing
nothing particular" at home about 45 minutes ago when he began having chest
pain with shortness of breath and nausea. His symptoms
peaked within ten minutes, and he "knew this was the big one." His wife noted he
was "shaking and sweaty." His wife immediately brought
him to the hospitaI. He has no significant past medical history, takes no
medications, and denies substance use. His family medical history is
significant for a paternal grandfather that "died of a massive heart attack" at age
56. Physical examination reveals an anxious diaphoretic
man taking short, shallow breaths. Vital signs, cardiac auscultation, ECG, and
cardiac enzymes are completely normaI. The patient has been
to the emergency department 5 times in the last 6 weeks and apologizes for "the
million dollar workup," but explains "every time it happens l
just know l am doomed to die."
Question 4 of 6

Years later, the patient develops a "fear of flying" and is started in once-weekly
therapy for systematic desensitization. Which of the following
forms of psychotherapy is systematic desensitization?
/A. Behavioral psychotherapy
/B. Cognitive psychotherapy
/C. Family psychotherapy
/D. Group psychotherapy
/E. Psychoanalytic psychotherapy
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Explanation - Q: 2.4

Close

The correct answer is A. Behavioral therapies are based on the learning


theory (operant and classical conditioning). If the anxiety is uncoupled from
the situation, the avoidant behavior will decrease. In systematic
desensitization, the patient constructs a hierarchy of images, and gradually
works to tolerate imagining the most fearful situation. Behavioral
psychotherapy explains behavior as being shaped by reward or punishment,
unlike cognitive psychotherapy which posits behavior as secondary to the
way a person thinks.
Cognitive psychotherapy (choice B) is based on the premise that behavior

can be changed by challenging errors in thinking (cognitive distortions).


"Homework" is used to ascertain the underlying (negative) assumptions.
Family psychotherapy (choice C) is based on the theory that a family is a
system striving to maintain homeostasis, which leads to behaviors.
Group psychotherapy (choice D) is based on many theories, and techniques
include identification and universalization.
Psychoanalytic psychotherapy (choice E) is an intensive type of therapy,
usually 4-5 times per week; the goal is for the patient to develop insight into
unconscious conflicts, and become more aware of the underlying causes of
behavior.
Also, it is not uncommon for a patient to develop more than one anxiety
disorder (panic disorder and a phobia).
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A 32-year-old married lawyer presents to the emergency department with a


complaint of "having a heart attack." He explains he was "doing
nothing particular" at home about 45 minutes ago when he began having chest
pain with shortness of breath and nausea. His symptoms
peaked within ten minutes, and he "knew this was the big one." His wife noted he
was "shaking and sweaty." His wife immediately brought
him to the hospitaI. He has no significant past medical history, takes no
medications, and denies substance use. His family medical history is
significant for a paternal grandfather that "died of a massive heart attack" at age
56. Physical examination reveals an anxious diaphoretic
man taking short, shallow breaths. Vital signs, cardiac auscultation, ECG, and
cardiac enzymes are completely normaI. The patient has been
to the emergency department 5 times in the last 6 weeks and apologizes for "the
million dollar workup," but explains "every time it happens l
just know l am doomed to die."
Question 5 of 6

A full cardiac workup of this patient is most likely to reveal which of the following?
/A. Coronary vasospasm
/B. Ebstein's anomaly
/C. Mitral valve prolapse
/D. Myocarditis
/E. QTc prolongation
Explanation - Q: 2.5

Close

The correct answer is C. As many as 50% of patients with panic disorder


also have mitral valve prolapse. A beta blocker may alleviate some

symptoms.
Coronary vasospasm (choice A) occurs with cocaine use and usually
presents with the signs and symptoms of a myocardial infarction (with a
positive urine toxicology screen for cocaine).
Ebstein's anomaly (choice B) is a rare, albeit notorious, congenital defect
associated with prenatal exposure to lithium.
Myocarditis (choice D) has occurred with clozapine, which received a "black
box" warning in the PDR in 2002.
QTc prolongation (choice E) can occur with antipsychotic medicines and
tricyclic antidepressants. Torsades may develop.
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A 32-year-old married lawyer presents to the emergency department with a


complaint of "having a heart attack." He explains he was "doing
nothing particular" at home about 45 minutes ago when he began having chest
pain with shortness of breath and nausea. His symptoms
peaked within ten minutes, and he "knew this was the big one." His wife noted he
was "shaking and sweaty." His wife immediately brought
him to the hospitaI. He has no significant past medical history, takes no
medications, and denies substance use. His family medical history is
significant for a paternal grandfather that "died of a massive heart attack" at age
56. Physical examination reveals an anxious diaphoretic
man taking short, shallow breaths. Vital signs, cardiac auscultation, ECG, and
cardiac enzymes are completely normaI. The patient has been
to the emergency department 5 times in the last 6 weeks and apologizes for "the
million dollar workup," but explains "every time it happens l
just know l am doomed to die."
Question 6 of 6

The patient returns to the emergency department in a "bizarre state." Friends


report he has been "Iaughing like a loon at all the wrong things,"
"Iooking over his shoulder in public places," and repeatedly questioning their
motives. Examination reveals tachycardia, scleral injection, and
a dry cough. Use of which of the following substances is most likely to explain
this patient's symptoms?
/A. AIprazolam
/B. Caffeine
/C. Cannabis
/D. Methamphetamine
/E. Pseudoephedrine
Explanation - Q: 2.6

Close

The correct answer is C. Inappropriate laughter, paranoia, and tachycardia,

scleral injection, and a dry cough are all associated with cannabis use.
Alprazolam (choice A) may cause sedation, slurred speech, disinhibition and
ataxia. Patients seem "drunken."
Caffeine use (choice B) may initially present with panic attacks, but when
carefully questioned, the patient will report caffeine intake (coffee, tea,
chocolate, cocoa, over-the-counter cold medications) and usually develops
headaches (during withdrawal) from caffeine. Caffeine intoxicated patients
could develop paranoia and tachycardia, but cannabis use explains all the
listed symptoms.
Methamphetamine (choice D) and pseudoephedrine (choice E) are
stimulants. Patients may initially present with panic attacks, and can develop
paranoia and tachycardia, but the additional history of inappropriate laughter
and scleral injection indicates cannabis use. Amphetamine abuse mimics
symptoms of schizophrenia.
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A 30-year-old man is brought to the emergency department by police, who


arrested him because he was in the parking lot of a local malI,
yelling "I am a golden god" as he stepped in front of moving cars. When
questioned about his identity, he talks incessantly in a rapid fashion
and threatens to "unleash God's wrath on those who do not submit." He reports
that he has not slept in a week, and does not need sleep. He
has spent the last week preparing for a secret government mission that only the
president knows about. When asked if he ever hears God
talking to him, he says, "Of course not, I am God!" Police report that he has had
several prior arrests for reckless driving and lewd acts. On
examination, he is disheveled and malodorous. It is nearly impossible to get any
further history, as he rapidly paces about and mutters, "I
must go, I must go" over and over again.
Question 1 of 7

Which of the following is the most likely preliminary diagnosis?


/A. Antisocial personality disorder
/B. Bipolar disorder
/C. Borderline personality disorder
/D. Post traumatic stress disorder
/E. Schizophrenia
Explanation - Q: 3.1

Close

The correct answer is B. This patient is displaying many of the diagnostic


criteria for bipolar disorder. He has had a distinct period of abnormally and
persistently elevated mood lasting at least one week. In addition, his thoughts
are grandiose ("I am a golden god"), he has a decreased need for sleep, and

he has pressured and excessive speech. His arrest history indicates possible
previous sexual indiscretions, which are a hallmark of bipolar disorder
(excessive involvement in pleasurable activities that have a high potential for
painful consequences). His pacing indicates psychomotor agitation, also a
hallmark of bipolar disorder. This patient probably has a history of severe
depressive episodes, but the occurrence of a single manic episode allows the
diagnosis of bipolar disorder to be made.
Antisocial personality disorder (choice A) refers to a long-standing pattern of
socially irresponsible behavior that reflects a disregard for the rights of others.
These individuals were formerly called psychopaths, and generally lack a
conscience. Many people with this disorder engage in unlawful acts. The
most pervasive characteristic is a lack of remorse for the harm they cause
others.
Borderline personality disorder (choice C) refers to a lifelong pattern of
unstable affect and self-image with erratic behavior. Borderlines have
interpersonal relationships that are intense, but very unstable ("love-hate"
relationships). They are prone to self-mutilation and the defense mechanism
of splitting. But they have a life of chaos, not a sense of grandeur and power,
so the diagnosis does not fit this case.
Posttraumatic stress disorder (choice D) is an anxiety disorder that develops
surrounding a traumatic event. Symptoms revolve around the event and
include reexperiencing of the trauma, avoidance of associated stimuli,
psychic numbing, and increased autonomic arousal.
While the psychotic symptoms of mania and schizophrenia (choice E) may,
at times, be difficult to distinguish, the grandiose content of this man's
symptoms suggest that he is having a manic episode. Note that his
comments that God does not talk to him can be taken as a denial of auditory
hallucinations.
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A 30-year-old man is brought to the emergency department by police, who


arrested him because he was in the parking lot of a local malI,
yelling "I am a golden god" as he stepped in front of moving cars. When
questioned about his identity, he talks incessantly in a rapid fashion
and threatens to "unleash God's wrath on those who do not submit." He reports
that he has not slept in a week, and does not need sleep. He
has spent the last week preparing for a secret government mission that only the
president knows about. When asked if he ever hears God
talking to him, he says, "Of course not, I am God!" Police report that he has had
several prior arrests for reckless driving and lewd acts. On
examination, he is disheveled and malodorous. It is nearly impossible to get any
further history, as he rapidly paces about and mutters, "I
must go, I must go" over and over again.

Question 2 of 7

Before a definitive diagnosis can be made, which of the following should be


performed?
/A. Cranial nerve exam
/B. CT scan of the head
/C. EIectroencephalogram
/D. Magnetic resonance imaging of the head
/E. Toxicological screen
Explanation - Q: 3.2

Close

The correct answer is E. Intoxication with a number of agents such as


amphetamines, cocaine, or other sympathomimetics can mimic mania seen in
bipolar disorder. Other possibilities to consider are antidepressant
medications, thyroid hormone replacements, hyperthyroidism, and other
neurologic conditions. It is often difficult to distinguish the mania of bipolar
disorder from the mania of substance abuse. Often the two are comorbid
conditions as patients "treat" their condition. If a manic episode is substanceinduced, it cannot contribute to a diagnosis of bipolar disorder.
Cranial nerve exam (choice A) cannot be performed on an uncooperative
patient and would likely not contribute to reaching a diagnosis in this patient.
CT scan of the head (choice B) would not likely aid in the diagnosis of this
patient unless something in the patient's medical history suggests an organic
cause (e.g., frontal neoplasm).
An electroencephalogram (choice C) would not contribute to the diagnosis of
this patient as there is no evidence of seizures.
MRI (choice D) would not contribute to the diagnosis for the same reasons a
CT scan would not.
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A 30-year-old man is brought to the emergency department by police, who


arrested him because he was in the parking lot of a local malI,
yelling "I am a golden god" as he stepped in front of moving cars. When
questioned about his identity, he talks incessantly in a rapid fashion
and threatens to "unleash God's wrath on those who do not submit." He reports
that he has not slept in a week, and does not need sleep. He
has spent the last week preparing for a secret government mission that only the
president knows about. When asked if he ever hears God
talking to him, he says, "Of course not, I am God!" Police report that he has had
several prior arrests for reckless driving and lewd acts. On
examination, he is disheveled and malodorous. It is nearly impossible to get any
further history, as he rapidly paces about and mutters, "I

must go, I must go" over and over again.


Question 3 of 7

This patient is started on lithium to stabilize his mood. BIood levels of lithium
need to be closely monitored as therapeutic levels are close to
toxic levels. The ratio of toxic dose to therapeutic dose is known as which of the
following?
/A. Fractional elimination constant
/B. Half life
/C. Loading dose
/D. Therapeutic index
/E. Volume of distribution
Explanation - Q: 3.3

Close

The correct answer is D. The therapeutic index of a drug is the ratio of the
toxic dose to therapeutic dose. For a drug with a small therapeutic index, care
must be taken not to overdose the patient. Small, stepwise increases in
dosing can aid in finding the therapeutic dose without experiencing toxicity.
A 30-year-old man is brought to the emergency department by police, who
arrested him because he was in the parking lot of a local malI,
yelling "I am a golden god" as he stepped in front of moving cars. When
questioned about his identity, he talks incessantly in a rapid fashion
and threatens to "unleash God's wrath on those who do not submit." He reports
that he has not slept in a week, and does not need sleep. He
has spent the last week preparing for a secret government mission that only the
president knows about. When asked if he ever hears God
talking to him, he says, "Of course not, I am God!" Police report that he has had
several prior arrests for reckless driving and lewd acts. On
examination, he is disheveled and malodorous. It is nearly impossible to get any
further history, as he rapidly paces about and mutters, "I
must go, I must go" over and over again.
Question 4 of 7

Which of the following is a known adverse effect of lithium?


/A. Agranulocytosis
/B. AItered judgement
/C. Aplastic anemia
/D. Hypothyroidism
/E. Male infertility
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Explanation - Q: 3.4
The correct answer is D. Patients on lithium chronically may develop
iatrogenic hypothyroidism. (Approx. 5% of patients taking the drug > 18
months.) Lithium exerts this effect by interfering with the synthesis and
release of thyroid hormone. Thus any patient experiencing prolonged

Close

depressive symptoms while taking lithium needs to have his/her thyroid


assessed.
Agranulocytosis (choice A) is commonly reported for patients taking the
atypical antipsychotic drug clozapine or carbamazepine, which is sometimes
employed as a second-line treatment for bipolar disorder.
Choice B is incorrect. Neurological side effects of lithium include tremor,
choreoathetosis, ataxia, motor hyperactivity, dysarthria, and aphasia.
Lithium is not known to cause aplastic anemia (choice C). Aplastic anemia is
a serious potential adverse effect of the mood stabilizer carbamazepine.
Carbamazepine would present an alternative to lithium in this patient, but a
periodic blood count must be performed to assess for aplastic anemia.
Lithium is not known to affect fertility in males (choice E) or females.
However, lithium has strong teratogenic effects (Ebstein's anomaly of the
tricuspid valve) and should NOT be given to any woman who is pregnant or
even thinking about becoming pregnant.
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A 30-year-old man is brought to the emergency department by police, who


arrested him because he was in the parking lot of a local malI,
yelling "I am a golden god" as he stepped in front of moving cars. When
questioned about his identity, he talks incessantly in a rapid fashion
and threatens to "unleash God's wrath on those who do not submit." He reports
that he has not slept in a week, and does not need sleep. He
has spent the last week preparing for a secret government mission that only the
president knows about. When asked if he ever hears God
talking to him, he says, "Of course not, I am God!" Police report that he has had
several prior arrests for reckless driving and lewd acts. On
examination, he is disheveled and malodorous. It is nearly impossible to get any
further history, as he rapidly paces about and mutters, "I
must go, I must go" over and over again.
Question 4 of 7

Which of the following is a known adverse effect of lithium?


/A. Agranulocytosis
/B. AItered judgement
/C. Aplastic anemia
/D. Hypothyroidism
/E. Male infertility
Explanation - Q: 3.5

Close

The correct answer is B. Benzodiazepines are frequently used to treat acute


agitation and can help manage acute mania until lithium can exert its effects.
Benzodiazepines potentiate the inhibitory effect on the CNS neurons by

binding to GABA receptors and increasing the frequency of the opening of


chloride channels in response to GABA stimulation. The net effect is CNS
depression and reduction in the patient's agitation.
Barbiturates bind the GABA receptor and prolong the duration of opening of
chloride channels in response to GABA (choice A). This acts to suppress the
CNS.
Lorazepam has no effect on dopamine receptors. Many antipsychotic
medications act by inhibiting dopamine receptors (choice C).
Lorazepam does not effect the release of epinephrine from the adrenal
medulla (choice D).
As noted above, lorazepam has no effect on dopamine receptors (choice E).
A 30-year-old man is brought to the emergency department by police, who
arrested him because he was in the parking lot of a local malI,
yelling "I am a golden god" as he stepped in front of moving cars. When
questioned about his identity, he talks incessantly in a rapid fashion
and threatens to "unleash God's wrath on those who do not submit." He reports
that he has not slept in a week, and does not need sleep. He
has spent the last week preparing for a secret government mission that only the
president knows about. When asked if he ever hears God
talking to him, he says, "Of course not, I am God!" Police report that he has had
several prior arrests for reckless driving and lewd acts. On
examination, he is disheveled and malodorous. It is nearly impossible to get any
further history, as he rapidly paces about and mutters, "I
must go, I must go" over and over again.
Question 6 of 7

The patient later reaches a steady state level of lithium that produces toxic side
effects. If he decides to discontinue his medication, how long
would it take for his lithium blood levels to reach 25% of his original steady state
levels assuming a half life of 22 hours for lithium?
/A. 11 hours
/B. 22 hours
/C. 33 hours
/D. 44 hours
/E. 55 hours
/F. 66 hours
/G. 77 hours
/H. 88 hours
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Explanation - Q: 3.6

Close

The correct answer is D. Lithium, like most drugs follows first-order kinetics,
which means a constant percent of the drug is eliminated per unit time. His
drug levels will decrease by 50% every half-life. Therefore, they will be 50%
of original levels after one half-life, 25% after two half-lives, 12.5% after three
half-lives, etc. Two half-lives is 22 x 2 = 44 hours.
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A 30-year-old man is brought to the emergency department by police, who


arrested him because he was in the parking lot of a local malI,
yelling "I am a golden god" as he stepped in front of moving cars. When
questioned about his identity, he talks incessantly in a rapid fashion
and threatens to "unleash God's wrath on those who do not submit." He reports
that he has not slept in a week, and does not need sleep. He
has spent the last week preparing for a secret government mission that only the
president knows about. When asked if he ever hears God
talking to him, he says, "Of course not, I am God!" Police report that he has had
several prior arrests for reckless driving and lewd acts. On
examination, he is disheveled and malodorous. It is nearly impossible to get any
further history, as he rapidly paces about and mutters, "I
must go, I must go" over and over again.
Question 7 of 7

A screening test is developed for assessing vulnerability to developing this


condition. A sample of 10,000 people between the ages of 18 to
24 is recruited from the general population and given the screening test. Of this
sample, 200 individuals are identified as likely to develop the
condition. The sample is tracked over the next twenty years. Forty of the original
sample, although none of those selected by the test, are lost
to follow-up. A total of 100 people from the sample eventually were diagnosed
with this condition, of which 90 were correctly identified by the
screening test. Based on this study, the positive predictive value of the screening
test is best estimated as which of the following?
/A. 45%
/B. 60%
/C. 75%
/D. 90%
/E. 100%
Explanation - Q: 3.7

Close

The correct answer is A. Positive predictive value assesses the proportion


of those identified as having the condition that actually end up developing the
condition. In this case, 90 of the original 200 identified by the test developed
the disorder. (90/200 = 45%). Note the test has a sensitivity (ability to detect

disease) of 90%. (90 of the 100 people who actually developed the condition
were correctly identified by the screening test)
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A 25-year-old man presents to the emergency department with multiple


lacerations to both wrists. He says he has a history of "every
diagnosis in the book, Doc." The patient reports several recent stressors,
including being fired from his job after "Iosing it" with a "rotten
customer," financial problems, and a fight with his girlfriend three hours ago.
When asked about suicidal ideation, the patient responds with
"would you want this life?" With permission, the doctor speaks with the man's
psychiatrist. His psychiatrist describes a long-standing pattern
of unstable relationships, career changes, and extreme mood swings with erratic
sleep patterns. The patient has taken multiple overdoses in
the past, usually when his psychiatrist is out of town. After the doctor listens
several minutes to the patient empathetically, the man responds
with multiple compliments, proclaiming the doctor is "the best doctor ever." An
hour later the doctor is summoned by the nurses to again see
the patient. The man is sullen and angry "You don't even care what happens to
me. You never did; none of you do, and you just let me sit here
forever. What kind of lousy doctor are you? You're an embarrassment to your
profession."
Question 1 of 6

Which of the following is the most likely diagnosis?


/A. Antisocial personality disorder
/B. Borderline personality disorder
/C. Histrionic personality disorder
/D. Narcissistic personality disorder
/E. Paranoid personality disorder
Explanation - Q: 4.1

Close

The correct answer is B. Borderline personality disorder is characterized by


a pattern of instability in 1) relationships (fights with girlfriend and customers),
2) self image (career changes may be one), 3) affect (mood swings), AND
marked impulsivity (multiple overdoses). Another clue is the frantic efforts to
avoid abandonment (overdoses precede separation from doctor, wrist
slashing after break up with girlfriend). Persons with borderline personality
are prone to rages and complain of chronic feelings of emptiness.
Antisocial personality disorder (choice A) is characterized by a pervasive
pattern of disregard for the rights of others.
Histrionic personality disorder (choice C) is characterized by a pervasive
pattern of excessive emotionality and attention-seeking. These individuals are

usually the "life of the party," and may be associated with "creating a scene."
They are not self-destructive, like persons with borderline personality
disorder.
Narcissistic personality disorder (choice D) is characterized by a pervasive
pattern of grandiosity, need for admiration, and lack of empathy. They exhibit
a stable self-image and are not self-destructive like persons with borderline
personality disorder.
Paranoid personality disorder (choice E) is characterized by a pervasive
pattern of distrust and suspiciousness.
A 25-year-old man presents to the emergency department with multiple
lacerations to both wrists. He says he has a history of "every
diagnosis in the book, Doc." The patient reports several recent stressors,
including being fired from his job after "Iosing it" with a "rotten
customer," financial problems, and a fight with his girlfriend three hours ago.
When asked about suicidal ideation, the patient responds with
"would you want this life?" With permission, the doctor speaks with the man's
psychiatrist. His psychiatrist describes a long-standing pattern
of unstable relationships, career changes, and extreme mood swings with erratic
sleep patterns. The patient has taken multiple overdoses in
the past, usually when his psychiatrist is out of town. After the doctor listens
several minutes to the patient empathetically, the man responds
with multiple compliments, proclaiming the doctor is "the best doctor ever." An
hour later the doctor is summoned by the nurses to again see
the patient. The man is sullen and angry "You don't even care what happens to
me. You never did; none of you do, and you just let me sit here
forever. What kind of lousy doctor are you? You're an embarrassment to your
profession."
uestion 2 of 6

The doctor repeatedly reassures the patient that he deserves the best care and
his doctors are working on it. The patient refuses to accept
the reassurance, and begins yelling loudly. The doctor screams at the patient to
be quiet. Later, he says " I Iet him have it, because what he
REALLY needed was some tough love for once." The doctor is using which of the
following defense mechanisms?
/A. Denial
/B. Isolation
/C. Rationalization
/D. Sublimation
/E. Suppression
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Explanation - Q: 4.2

Close

The correct answer is C. Rationalization, which is providing a logical reason

(what the patient needs) for a behavior, is usually employed to avoid being
blamed (e.g., for unprofessional behavior).
Denial (choice A) is usually used to avoid awareness of a painful reality, and
is often seen in patients given the news of a fatal illness, or in patients
confronted about substance abuse.
Isolation (choice B) splits the thought from the feeling, and can be seen
when doctors discuss "interesting cases" or "severe pathology" in completely
intellectual terms.
Sublimation (choice D) is replacing an unacceptable wish with a more
acceptable one. In this example, the doctor might have "taken out his
aggression" in the exercise room.
Suppression (choice E) is consciously deciding to remove an idea or feeling
from awareness. "I'm not going to think about that."
A 25-year-old man presents to the emergency department with multiple
lacerations to both wrists. He says he has a history of "every
diagnosis in the book, Doc." The patient reports several recent stressors,
including being fired from his job after "Iosing it" with a "rotten
customer," financial problems, and a fight with his girlfriend three hours ago.
When asked about suicidal ideation, the patient responds with
"would you want this life?" With permission, the doctor speaks with the man's
psychiatrist. His psychiatrist describes a long-standing pattern
of unstable relationships, career changes, and extreme mood swings with erratic
sleep patterns. The patient has taken multiple overdoses in
the past, usually when his psychiatrist is out of town. After the doctor listens
several minutes to the patient empathetically, the man responds
with multiple compliments, proclaiming the doctor is "the best doctor ever." An
hour later the doctor is summoned by the nurses to again see
the patient. The man is sullen and angry "You don't even care what happens to
me. You never did; none of you do, and you just let me sit here
forever. What kind of lousy doctor are you? You're an embarrassment to your
profession."
Question 3 of 6

Which coping mechanism is illustrated by the statement, "You are the best doctor
ever, the rest of the staff is cold and heartless."?
/A. Denial
/B. Projection
/C. Repression
/D. Splitting
/E. Suppression
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Explanation - Q: 4.3

Close

The correct answer is D. Splitting is a primitive defense that oversimplifies


all relationships into "good" and "bad." The self, others, and situations are
completely polarized into one category or the other. Persons with borderline
personality disorder have difficulty tolerating ambivalence (concurrent positive
and negative feelings).
Denial (choice A) is the outright rejection of information. "I do not have
cancer."
Projection (choice B) is attributing one's traits/feelings to another person.
"You're mad at me." When, in fact, I am mad at you.
Repression (choice C) is unconscious exclusion of thoughts/feelings, "What
anger? I was never angry."
Suppression (choice E) is active exclusion of thoughts/feelings from
consciousness, "I'm not going to think about that right now."
A 25-year-old man presents to the emergency department with multiple
lacerations to both wrists. He says he has a history of "every
diagnosis in the book, Doc." The patient reports several recent stressors,
including being fired from his job after "Iosing it" with a "rotten
customer," financial problems, and a fight with his girlfriend three hours ago.
When asked about suicidal ideation, the patient responds with
"would you want this life?" With permission, the doctor speaks with the man's
psychiatrist. His psychiatrist describes a long-standing pattern
of unstable relationships, career changes, and extreme mood swings with erratic
sleep patterns. The patient has taken multiple overdoses in
the past, usually when his psychiatrist is out of town. After the doctor listens
several minutes to the patient empathetically, the man responds
with multiple compliments, proclaiming the doctor is "the best doctor ever." An
hour later the doctor is summoned by the nurses to again see
the patient. The man is sullen and angry "You don't even care what happens to
me. You never did; none of you do, and you just let me sit here
forever. What kind of lousy doctor are you? You're an embarrassment to your
profession."
Question 4 of 6

This patient is started on trazodone to help with sleep. Common side effects of
trazodone include which of the following?
/A. Drowsiness, dizziness, fatigue, and fatal liver failure
/B. Drowsiness, dizziness, hypertension, and nervousness
/C. Drowsiness, dizziness, hypotension, and priapism
/D. Drowsiness, dizziness, nervousness, and seizures
/E. Drowsiness, nervousness, GI distress and sexual dysfunction
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Explanation - Q: 4.4

Close

The correct answer is C. This question illustrates the fact that many
antidepressant drugs have similar side effects, but often have a certain
particular side effect worth knowing. The clue to choice C (trazodone) is
priapism, a painful sustained erection. It is a medical emergency!
The clue to choice A (nefazodone) is fatal liver failure; this drug now has a
"black box" warning in the PDR.
The clue to choice B (venlafaxine) is hypertension, specifically diastolic
hypertension.
The clue to choice D (bupropion) is seizures. DO NOT give this medicine to
patients at risk for seizures (e.g., metabolic derangement, head injury).
The clues to choice E (any and all SSRIs) are GI distress and sexual
dysfunction, which are very troublesome side effects. Inquire about sexual
dysfunction in all patients taking SSRIs.
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A 25-year-old man presents to the emergency department with multiple


lacerations to both wrists. He says he has a history of "every
diagnosis in the book, Doc." The patient reports several recent stressors,
including being fired from his job after "Iosing it" with a "rotten
customer," financial problems, and a fight with his girlfriend three hours ago.
When asked about suicidal ideation, the patient responds with
"would you want this life?" With permission, the doctor speaks with the man's
psychiatrist. His psychiatrist describes a long-standing pattern
of unstable relationships, career changes, and extreme mood swings with erratic
sleep patterns. The patient has taken multiple overdoses in
the past, usually when his psychiatrist is out of town. After the doctor listens
several minutes to the patient empathetically, the man responds
with multiple compliments, proclaiming the doctor is "the best doctor ever." An
hour later the doctor is summoned by the nurses to again see
the patient. The man is sullen and angry "You don't even care what happens to
me. You never did; none of you do, and you just let me sit here
forever. What kind of lousy doctor are you? You're an embarrassment to your
profession."
Question 5 of 6

The doctor calls the insurance company to authorize admission for "mood
stabilization." When asked, the patient says he does not want to
harm himself at this point. The insurance company denies authorization for an
inpatient admission. The doctor determines the patient's
presentation is too despondent and hopeless to be safe. The most appropriate
intervention is for the doctor to call the insurance company
back and do which of the following?

/A.

Say "The patient is a danger to himself in my opinion, get your supervisor on


the phone now."
/B. Say "The patient is a danger to himself in my opinion, Iet me explain my
reasoning."
/C. Say "The patient says he is actively suicidal now.", even though he did not
/D. Tell the patient to say he is suicidaI, then say "The patient says he is
actively suicidal now."
/E. "This is unacceptable. Get your supervisor on the phone now, or you will be
exposing yourself to legal liability."
Explanation - Q: 4.5

Close

The correct answer is B. The FIRST intervention is for the doctor to calmly
explain the reasoning involved in the assessment.
Choice A is an unnecessary beginning to the conversation; calmly asking for
the supervisor later (if needed) would be the appropriate response.
Choice C is lying. It's illegal, for one. Contacting the attending, the board, the
administrator, etc., may help the doctor get the patient's needs met through
honest means.
Choice D is illegal and unethical, and the doctor will ultimately suffer for
modeling to the patient "we can make deals."
Choice E is a threat and implies coercion, at the very least it could damage
the doctor's professional reputation.
A 25-year-old man presents to the emergency department with multiple
lacerations to both wrists. He says he has a history of "every
diagnosis in the book, Doc." The patient reports several recent stressors,
including being fired from his job after "Iosing it" with a "rotten
customer," financial problems, and a fight with his girlfriend three hours ago.
When asked about suicidal ideation, the patient responds with
"would you want this life?" With permission, the doctor speaks with the man's
psychiatrist. His psychiatrist describes a long-standing pattern
of unstable relationships, career changes, and extreme mood swings with erratic
sleep patterns. The patient has taken multiple overdoses in
the past, usually when his psychiatrist is out of town. After the doctor listens
several minutes to the patient empathetically, the man responds
with multiple compliments, proclaiming the doctor is "the best doctor ever." An
hour later the doctor is summoned by the nurses to again see
the patient. The man is sullen and angry "You don't even care what happens to
me. You never did; none of you do, and you just let me sit here
forever. What kind of lousy doctor are you? You're an embarrassment to your
profession."
Question 6 of 6

The nurse calls to tell the doctor that the patient has taken an overdose in the
emergency department. When the doctor arrives, the patient
has slurred speech and is sedated. Within five minutes the patient is sleeping, his
respiratory rate is 10/min and he responds minimally to
painful stimuli. The family tells the doctor that the man takes clonazepam at
home for nocturnal myoclonus. The most appropriate
pharmacologic intervention is to administer which of the following?
/A. Dextrose
/B. FIumazenil
/C. Naloxone
/D. Naltrexone
/E. Thiamine
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Explanation - Q: 4.6

Close

The correct answer is B. The history is consistent with respiratory


depression secondary to benzodiazepine overdose. Flumazenil is a
benzodiazepine receptor antagonist.
Dextrose (choice A) treats hypoglycemia.
Naloxone (choice C), an opioid antagonist, reverses opioid overdose.
Thiamine, naloxone, and dextrose are often given to patients who are "found
down" and present to the emergency department in a coma without any
history.
Naltrexone (choice D) blocks the effects of opiates via opioid antagonism
(people cannot "get high"). It is used to prevent relapse in a previously opioid
dependent individual.
Thiamine (choice E) prevents Wernicke-Korsakoff syndrome.
A 69-year-old white man visits a physician in the outpatient clinic for the first time.
Over the past 5 months, he reports increasing lethargy,
weight loss, and crying "for no reason." The patient had always been an
optimistic person, but today he feels "detached from everything." He
describes his mood "as if there was a pane of glass between me and the rest of
the world and l don't think I'm going to make it. My family and
friends are like cardboard cutouts." His speech is slow and methodicaI,
punctuated by frequent sighs. The patient has also lost interest in
watching movies, which had been his favorite pastime. He also admits that his
drinking has become a problem over the past few weeks, and
he currently consumes a bottle of white wine every evening. He recently lost his
job and is currently filing for divorce, which would end a

seventeen-year marriage. His son has attention-deficit disorder, for which he is


prescribed amphetamine. The patient was hospitalized for
major depression three years ago. The patient's previous doctor had started him
on a medication, but he is unable to recall the name or
anything about it except that he is not supposed to eat cheese, aged meats, or
chocolate while taking it. On physical examination, the patient
appears emaciated. His abdomen is very distended, with hepatomegaly 3 cm
below the right costal margin. He also has a slight tremor. His
gait is normaI. His latest calcium level is 10.3 mg/dL.
Question 1 of 5

Which of the following is the most likely diagnosis at this time?


/A. Acute stress disorder
/B. Adjustment disorder
/C. AIcohol abuse
/D. Bipolar disorder
/E. Hypercalcemia
/F. Unipolar disorder
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Explanation - Q: 5.1

Close

The correct answer is F. The patient's symptoms of weight loss, lethargy,


tearfulness, hopelessness ("I'm not going to make it"), and depersonalization
("world through a pane of glass; family and friends are like cardboard
cutouts") for at least one month meet the criteria for unipolar disorder (major
depression). Even more specific are his loss of interest in favorite activities,
as well as the feelings of sadness. The symptoms have been going on for at
least two weeks and represent a change from previous functioning, which
defines depression. Three stressors in his life are job loss, the upcoming
divorce. and his son's attention-deficit disorder. The lifetime rate of major
depression in men in the US is about 10%.
Acute stress disorder (choice A) is the consequence of the experience of a
traumatic event outside the realm of normal human experience. Neither
divorce nor job loss fits this criterion. Symptoms of acute stress disorder
(ASD) must also include reexperiencing the event as dreams, recollections of
flashback, and avoidance of associated stimuli, along with diffuse other
symptoms such as irritability, sleep disruption, and difficulty concentrating.
Adjustment disorder (choice B) is a dysfunctional change in behavior within
three months of an identifiable stressor. The dysfunction can only last 6
months after the stressor has ended. An adjustment disorder cannot be a
grief response AND the diagnosis only applies if no other Axis I diagnosis can
be used. Given the patient's current symptoms and previous treatment
history, the criteria for this diagnosis are not met.
Alcohol abuse (choice C) is probably occurring as a coping mechanism for

the depression, and is unlikely to be a specific cause of the depressive


symptoms. Ascites, hepatomegaly, tremor, macrocytosis (raised mean
corpuscular volume, and increased liver enzymes are suggestive of chronic
alcohol use.
Bipolar disorder (choice D) can have a similar presentation to unipolar
disorder when in the depressive phase. The differential is based on being
able to identify one or more manic episodes in the patient's past. Because
none are presented here, there is no evidence for this diagnosis.
Hypercalcemia (choice E) may present with symptoms of confusion, polyuria,
polydipsia, and abdominal pain. This patient has none of these symptoms
and, in addition, his calcium levels are actually normal.
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A 69-year-old white man visits a physician in the outpatient clinic for the first time.
Over the past 5 months, he reports increasing lethargy,
weight loss, and crying "for no reason." The patient had always been an
optimistic person, but today he feels "detached from everything." He
describes his mood "as if there was a pane of glass between me and the rest of
the world and l don't think I'm going to make it. My family and
friends are like cardboard cutouts." His speech is slow and methodicaI,
punctuated by frequent sighs. The patient has also lost interest in
watching movies, which had been his favorite pastime. He also admits that his
drinking has become a problem over the past few weeks, and
he currently consumes a bottle of white wine every evening. He recently lost his
job and is currently filing for divorce, which would end a
seventeen-year marriage. His son has attention-deficit disorder, for which he is
prescribed amphetamine. The patient was hospitalized for
major depression three years ago. The patient's previous doctor had started him
on a medication, but he is unable to recall the name or
anything about it except that he is not supposed to eat cheese, aged meats, or
chocolate while taking it. On physical examination, the patient
appears emaciated. His abdomen is very distended, with hepatomegaly 3 cm
below the right costal margin. He also has a slight tremor. His
gait is normaI. His latest calcium level is 10.3 mg/dL.
Question 2 of 5

Which of the following medications is the patient most likely currently taking?
/A. Amitriptyline
/B. Chlorpromazine
/C. FIuoxetine
/D. Lorazepam
/E. Phenelzine
Explanation - Q: 5.2

Close

The correct answer is E. Monoamine oxidase inhibitors (MAOIs) include


phenelzine and tranylcypromine. MAOIs have the potential for severe side
effects when taken with sympathomimetic medications or tyramine-containing
foods (e.g., cheeses, red wines, beers, meats, fruits, beans, liver, yeast
extracts) because they can cause a hypertensive crisis. MAOIs can also
cause orthostatic hypotension, nausea, insomnia, and sexual dysfunction.
Tricyclic antidepressants include amitriptyline (choice A) and nortriptyline.
They take anywhere from 2 to 6 weeks to take effect. They have
anticholinergic side-effects including dry mouth, blurred vision, constipation,
ileus, urinary retention, and even delirium.
Neuroleptics such as chlorpromazine (choice B) reduce psychotic symptoms
that result from a number of illnesses, including schizophrenia, bipolar
disorder, major depressive disorder with psychotic features, psychosis
secondary to stimulant drugs, and organic psychoses from Alzheimer disease
or Huntington disease.
Selective serotonin reuptake inhibitors (SSRIs) include fluoxetine (choice C).
They have a reduced side-effect profile and are effective in depression
treatment. The risk of overdose is low. Their main pharmacologic effect is to
block the presynaptic serotonin uptake site. Increasing the availability of
serotonin in the synaptic cleft is thought to improve depressive symptoms.
A benzodiazepine such as lorazepam (choice D) is primarily used for anxiety
rather than depression. Adverse reactions include sedation, dizziness,
weakness, unsteady gait, headache, and sleep disturbance.
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A 69-year-old white man visits a physician in the outpatient clinic for the first time.
Over the past 5 months, he reports increasing lethargy,
weight loss, and crying "for no reason." The patient had always been an
optimistic person, but today he feels "detached from everything." He
describes his mood "as if there was a pane of glass between me and the rest of
the world and l don't think I'm going to make it. My family and
friends are like cardboard cutouts." His speech is slow and methodicaI,
punctuated by frequent sighs. The patient has also lost interest in
watching movies, which had been his favorite pastime. He also admits that his
drinking has become a problem over the past few weeks, and
he currently consumes a bottle of white wine every evening. He recently lost his
job and is currently filing for divorce, which would end a
seventeen-year marriage. His son has attention-deficit disorder, for which he is
prescribed amphetamine. The patient was hospitalized for
major depression three years ago. The patient's previous doctor had started him
on a medication, but he is unable to recall the name or

anything about it except that he is not supposed to eat cheese, aged meats, or
chocolate while taking it. On physical examination, the patient
appears emaciated. His abdomen is very distended, with hepatomegaly 3 cm
below the right costal margin. He also has a slight tremor. His
gait is normaI. His latest calcium level is 10.3 mg/dL.
Question 3 of 5

To gather more details about the patient's current state of mind, which of the
following questions would be most appropriate for the physician
to ask at this time?
/A. " Are you taking your antidepressant medications as your previous doctor
instructed?"
/B. " Have you ever made plans to kill yourself?"
/C. " Is there any history of depression in your family?"
/D. " On a depression scale of one to ten, how depressed do think you feel right
now?"
/E. " On average, how much alcohol do you drink in one day?"
Explanation - Q: 5.3

Close

The correct answer is B. At this stage, it is crucial to ask a direct question


about suicidal ideation, particularly because this is the first time the physician
is meeting the patient. In addition, the patient is a white male over the age of
50 who has already been hospitalized once for major unipolar depression,
which places him at a greater risk for suicide. The suicide rate among people
who have been hospitalized at least once for unipolar depression has been
estimated to be 15%. A physician is the last person patients have seen before
taking their own life in 10% of suicides. Asking this question as part of the
mental status examination also gives information on how severe the
depression is. If the patient has a plan about how they will take their own life,
then this suggests that they are more likely to follow through with their plan.
Compliance with medication (choice A) is an important cause of depression
relapse. It has been estimated that fewer than 10% of people suffering from
unipolar major depression are likely to be receiving a full therapeutic dose of
medication. More than 20% of patients fail to fill the first prescription they
receive for major depression, and the majority of patients who do begin
treatment discontinue the medication within 14 weeks, usually due to side
effects.
Depression in the family (choice C) is a risk factor for recurrent depression.
Pursuing this line of questioning is useful for the long-term management of
depression but does not address any major life-threatening issues. Other risk
factors for recurrent depression include a history of multiple episodes
(patients with 3 or more prior episodes have at least a 90% recurrence rate),
depression associated with dysthymia, onset after age 60, long duration of
individual episodes, poor symptom control during therapy, comorbid anxiety

disorder, or substance abuse.


Objective analysis of depression such as a depression score of 1 to 10
(choice D) is also useful in the long term care of patients with depression. In
doing so, the physician is able to objectively document the effectiveness of
the patient's antidepressant therapy. Another useful method is counting the
number of improvements in the quality of the patient's life, e.g., more family
interaction, being able to go to church, returning back to work. For this to be
useful, it is important to get an idea of where the patient is at in the initial visit.
It does not, however, take precedence over asking about suicidal ideation.
Alcoholic intake (choice E) is an important question to ask since the patient
appears to have signs of alcoholism (hepatomegaly, increasing abdominal
girth as an indication of ascites, weight loss, and tremor). However, it does
not necessarily have to be addressed on the initial visit. Suicidal risk is a
more ominous life-threatening event in this instance. Accurate answers can
be derived when asking the patient to describe their drinking habits during the
course of the day rather than asking about alcohol intake as a single
numerical quantity.
A 69-year-old white man visits a physician in the outpatient clinic for the first time.
Over the past 5 months, he reports increasing lethargy,
weight loss, and crying "for no reason." The patient had always been an
optimistic person, but today he feels "detached from everything." He
describes his mood "as if there was a pane of glass between me and the rest of
the world and l don't think I'm going to make it. My family and
friends are like cardboard cutouts." His speech is slow and methodicaI,
punctuated by frequent sighs. The patient has also lost interest in
watching movies, which had been his favorite pastime. He also admits that his
drinking has become a problem over the past few weeks, and
he currently consumes a bottle of white wine every evening. He recently lost his
job and is currently filing for divorce, which would end a
seventeen-year marriage. His son has attention-deficit disorder, for which he is
prescribed amphetamine. The patient was hospitalized for
major depression three years ago. The patient's previous doctor had started him
on a medication, but he is unable to recall the name or
anything about it except that he is not supposed to eat cheese, aged meats, or
chocolate while taking it. On physical examination, the patient
appears emaciated. His abdomen is very distended, with hepatomegaly 3 cm
below the right costal margin. He also has a slight tremor. His
gait is normaI. His latest calcium level is 10.3 mg/dL.
Question 4 of 5

The physician decides to discontinue his current medication and prescribes


sertraline instead. Sertraline directly affects which of the
following neurotransmitters?

/A. Acetylcholine
/B. Dopamine
/C. Epinephrine
/D. Norepinephrine
/E. Serotonin
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Explanation - Q: 5.4

Close

The correct answer is E. Sertraline specifically blocks the reuptake of


serotonin into the presynaptic axon terminal. This enhances serotonin
activation and brings about a cascade of events ultimately resulting in a
reduced sensitivity of presynaptic autoreceptors for serotonin and reduced
serotonin synthesis. The most common adverse reactions to the SSRIs are
gastrointestinal (especially nausea), neuropsychiatric (particularly headache
and tremor), and changes in sexual functioning. SSRIs also treat anxious
depression, dysthymia, and atypical depression.
Acetylcholine (choice A) has been cited as the main neurotransmitter
involved in Alzheimer dementia. Drugs that utilize this concept are tacrine and
donepezil, which work in the brain as cholinesterase inhibitors at the neuronal
synapse. By inhibiting the cholinesterase enzyme, they increase the level of
acetylcholine and aid in maintaining mental function, although they do not
stop the degeneration of cholinergic cells. Sertraline has no effect on the
levels of acetylcholine.
Dopamine (choice B) is found in both small and large neuronal pathways in
the CNS. The latter include the nigrostriatal pathway involved, in the etiology
of Parkinson disease and mesolimbic/mesocortical pathways, implicated in
psychosis. L-dopa, which is converted to dopamine, is the primary
replacement therapy in Parkinson disease. Dopamine antagonists are used in
the treatment of psychosis. Dopaminergic input to the chemoreceptor trigger
zone is the basis of the use of the agonist apomorphine as an emetic to treat
poisoning, and the use of antagonists as antiemetics. Hypothalamic
dopaminergic neurons inhibit prolactin secretion and lead to the use of
agonists in inhibiting lactation. There are a number of drugs that interact
presynaptically with dopamine terminals including reserpine, amphetamine,
MAO inhibitors, and cocaine.
Epinephrine (choice C) is a neurotransmitter, and a hormone. It stimulates
alpha1-, alpha2-, beta1-, and beta2-adrenergic receptors in a dose-related
fashion. It is the initial drug of choice for treating bronchoconstriction and
hypotension resulting from anaphylaxis as well as all forms of cardiac arrest.
It is useful in managing reactive airway disease, but beta-adrenergic agents
are often used initially because of their convenience and oral inhalation route.
Epinephrine is not a neurotransmitter specifically affected by any

antidepressants currently available.


Norepinephrine (choice D), like serotonin, is a neurotransmitter that may
induce depression if depleted. There are several antidepressants that
increase norepinephrine levels:

A 69-year-old white man visits a physician in the outpatient clinic for the first time.
Over the past 5 months, he reports increasing lethargy,
weight loss, and crying "for no reason." The patient had always been an
optimistic person, but today he feels "detached from everything." He
describes his mood "as if there was a pane of glass between me and the rest of
the world and l don't think I'm going to make it. My family and
friends are like cardboard cutouts." His speech is slow and methodicaI,
punctuated by frequent sighs. The patient has also lost interest in
watching movies, which had been his favorite pastime. He also admits that his
drinking has become a problem over the past few weeks, and
he currently consumes a bottle of white wine every evening. He recently lost his
job and is currently filing for divorce, which would end a
seventeen-year marriage. His son has attention-deficit disorder, for which he is
prescribed amphetamine. The patient was hospitalized for
major depression three years ago. The patient's previous doctor had started him
on a medication, but he is unable to recall the name or
anything about it except that he is not supposed to eat cheese, aged meats, or
chocolate while taking it. On physical examination, the patient
appears emaciated. His abdomen is very distended, with hepatomegaly 3 cm
below the right costal margin. He also has a slight tremor. His
gait is normaI. His latest calcium level is 10.3 mg/dL.
Question 5 of 5

Should this particular patient commit suicide, the likeliest method of suicide is
which of the following?
/A. A drug overdose
/B. By running his car in a closed garage for an extended period of time
/C. Cutting his wrists
/D. Hanging himself
/E. With a firearm
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Explanation - Q: 5.5

Close

The correct answer is E. Firearms were the commonest method of suicide


used by persons aged 65 years or older representing 71% of suicides. In
1998, firearms were the most common method of suicide by both males and
females, accounting for 78% of male and 35% of female suicides in this age
group.
Overdose with liquids, pills or gas (choice A), 17%, and suffocation (choice
D),11%, represents the other two most common methods of suicide used by
persons aged 65 years or older. Elderly patients make fewer attempts per
completed suicide, have a higher-male-to-female ratio than other groups,
have often visited a health-care provider before their suicide, and have more
physical illnesses. It is estimated that 20% of elderly (over 65 years) persons
who commit suicide visited a physician within 24 hours of their act, 41%
visited within a week of their suicide and 75% have been seen by a physician
within one month of their suicide. The suicide rate of white males rises
dramatically after age 65 and accounts for the majority of all suicides in the
elderly.
In 2000, the death rate by car exhaust fumes (choice B) was less than 1 per
100 000 per year.
Between the age group of 65 to 70 years, the mortality rate from suicide by a
cut or stab (choice C) was 0.32 deaths per 100 000 per year.