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A 3-year-old girl is brought to the emergency department by her mother because of "fever and a rash." When asked to give a more detailed history, the mother has difficulty providing any additional information. The mother appears tearful and the child cannot take her eyes off the floor. You are unable to engage the child in any conversation. Her temperature is 36.7 C (98.0 F). Physical examination is unremarkable. The most appropriate next step is to A. admit the child to the hospital for evaluation and protection B. ask if there is anyone else in the house that is sick C. ask the mother and child separately what is concerning them D. obtain a psychiatry consult immediately E. send the child home and arrange for a family assessment on a home visit Explanation: The correct answer is C. Because the mother brought her child to the emergency department because of a nonexistent fever and rash, it seems like there is something else that is going on. You also need to be able to interpret a patient's posture and facial expression. The mother is tearful and the child is looking at the ground; this makes it seem like there are other issues that need to be explored. There could be many things going on, but child abuse and domestic violence should be high on your differential. Abuse and violence often present in vague and indirect ways with complaints of abdominal pain, headaches, and other symptoms. After talking to both together, you need to interview each individually because this may allow you to obtain more information. Direct and nonjudgmental questions are often helpful in eliciting information. At this time, you first need to try to obtain more information by talking to each individually before you assume that this is a case of child abuse or domestic violence and considering admitting the child to the hospital for evaluation and protection (choice A). Since this patient's physical examination is completely normal, it seems more appropriate at this time to ask the mother and child separately what is concerning them, as opposed to asking if there is anyone else in the house that is sick (choice B). As a physician you should be able to try to elicit what is concerning these individuals and while a psychiatry consult may be necessary in the future, it is not immediately (choice D) necessary. At this time you should try to determine what is concerning these individuals before you jump to any conclusions about abuse or anything else. Also, if your suspicions of abuse are high, you should not send the child home with the parents under any circumstances. Sending the child home and arranging for a family assessment on a home visit leaves the child open for continued 1 abuse (choice E). The physician should take steps to both protect the child and investigate further. If you do not believe that there are any signs of abuse or any other causes for concern, then a family assessment on a home visit is not necessary. Either way, this is an incorrect answer at this time. A 26-year-old Spanish-speaking woman presents to your clinic for a bruised left arm. The patient is a local woman who speaks no English and has recently moved to this area from overseas. She works at the local telephone company and has moved in with her fiancee. This is her fourth visit to the clinic for various bruises and injuries. On this visit she has a diffuse ecchymoses and purpura over her entire left arm and forearm in the shape of “hand prints.” She claims that she fell while walking down the stairs. On her previous visits, she has had similar bruises on her chest, abdomen, and back, all of which she attributed to various “falls”. She is otherwise healthy, denies tobacco or alcohol. She does report that he fiancee drinks ethanol to intoxication quite frequently and has recently lost his job. She is somewhat tearful when mentioning him. Her physical examination is remarkable for the left arm bruising as above, various bruises in her back and abdomen is various stages of healing, and a valgus deformity of her left leg. The remainder of her examination is unremarkable. The most appropriate course of action is to A. ask the patient in simple, direct language if she has been hit by her fiancee B. contact the police for intervention C. no action is indicated as the patient has no active medical issues D. no action is indicated as the patient will be offended and leave the clinic E. question the patient in the presence of other health care workers in the clinic Explanation: The correct answer A. Ask the patient in simple, direct language if she has been hit by her fiancee. Because of the high prevalence of domestic violence (DV) and the wide range of clinical settings in which it can be seen, routine screening must be a part of preventative care. A number of studies have demonstrated reasonable sensitivity for the Partner Violence Screen that consists of three simple and direct questions. Contacting the police (choice B) is not appropriate given that it has not even been established that this patient suffers from DV and you should first try to address the issue with the patient. There are a number of barriers to effective physician screening of DV; the belief that no action is indicated as the patient has no active medical issues (choice C) as well as that no action is indicated as the patient will be offended and leave the clinic (choice D) are among the more common reasons. It is vital to make the patient feel safe and secure and to question them in private (choice E). 2 A 32-year-old woman comes to the office "for a prescription of propranolol for stage fright." She tells you that she is professional singer and lately she has been experiencing "butterflies" and palpitations before performances. She has been so worried about having one of these symptoms that she is having trouble sleeping at night. She tells you that a friend of hers has a similar problem and propranolol has "cured her." She has been a patient of yours for the past 10 years and you remember that she has severe asthma, requiring many hospitalizations, the most recent being 2 weeks ago. Her asthma attacks have been increasingly more severe and have been occurring at an increased frequency. She tells you that she is in a rush and all she needs is the prescription. The most appropriate next step is to A. administer a pulmonary function test B. explain that propranolol is not a good drug for her C. give her a referral to a psychiatrist D. order a chest x-ray E. prescribe propranolol for her to take before her performances Explanation: The correct answer is B. This patient most likely has performance anxiety, which is a form of social phobia. The treatment usually involves beta-blockers before a performance to decrease the symptoms. However, a patient with severe asthma should avoid beta-blockers because they can cause bronchoconstriction and precipitate into an asthmatic attack. A pulmonary function test (choice A) and a chest x-ray (choice D) are not indicated at this time. You already know that she has asthma that has required hospitalizations and the results of these tests are unlikely to change your management. A referral to a psychiatrist (choice C) may be helpful in treating her performance anxiety, but she is in your office for propranolol, so it is your responsibility to first try to explain to her that her asthma makes her a bad candidate for this treatment. You should not prescribe propranolol for her to take before her performances (choice E) because she has severe asthma, which makes beta-blockers a dangerous medication for her. Beta-blockers can cause airway obstruction, which may lead to worsening asthma. A 23-year-old woman is admitted to the hospital from home for altered mental status. On evaluation in the emergency department, the patient was found to have severe hypernatremia, a serum sodium of 161 mEq/L. There is no other past medical history or allergy history available. The patient appeared pale and profoundly dehydrated. She had evidence of prior scars, possibly surgical, on her abdomen, chest, and arms. The patient was admitted to the hospital and over the next few days the patient's hypernatremia was corrected and her metabolic parameters normalized. She was able to give a more detailed history about her social situation. She describes feeling very 3 depressed lately and having had an argument with her new boyfriend several days prior to her admission. You suspect that she may be a victim of domestic abuse. The most appropriate initial step in addressing your concern is to A. ask her for the number of her boyfriend to address your concerns with him directly B. ask her to offer more details about the nature of her relationship with her new boyfriend C. explain to her that her relationship is obviously not having a positive impact on her life D. refer her case to the department of social services in obligation of your reporting duty as a physician E. refer her to a psychiatrist who specializes in domestic abuse Explanation: The correct answer is B. The concern for potential abuse must be addressed as any other new piece of clinical suspicion. The best initial step is to try to gather more information in a non-threatening way that is comfortable for the patient. While the physician will ultimately want to ask her directly if she is being abused, it is often better to let that disclosure “fall out” from a discussion about the particulars of the relationship. While physicians often feel the desire to “take things in their own hands” to address alleged abusers directly (choice A), this approach can be extremely dangerous for the abused party. Abusers obviously dread be discovered, and are likely to act with retribution against the abused party if they are confronted by a doctor. Explaining that her relationship is not having a positive impact on her life (choice C) is presumptuous without first exploring all of the particulars of the relationship. Physicians in most states are obligated to report (choice D) potential abuse only in the case of children under 18 and adults older than 65. There is no obligatory reporting for domestic abuse not falling within these parameters. While the patient may respond very well to treatment from a psychiatrist who specializes in domestic abuse (choice E), this referral, like any other, should be made after an earnest attempt to gather the clinical and social details from the patient by the referring physician. A 27-year-old African American man is brought to the emergency department by his girlfriend stating, "I can't swallow." He tells you his symptoms started 2 hours ago with a feeling that his head was "pulled to the side" and his neck was "tight". Since then he has had difficulty speaking and eating. His medical history is significant for a remote appendectomy. A chart review reveals that he has no allergies, was diagnosed with schizophrenia last year, and has been resistant to taking oral medications. He denies hallucinations and his 4 girlfriend confirms the "voices" are controlled with the injections he receives each month. His last injection was yesterday. His temperature is 37.0 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 26/min. He is an anxious appearing man with excessive drooling. His head seems fixed in an unusual position and you palpate spasms in several neck muscles. The most appropriate next step in management is to administer A. benztropine, intramuscularly B. benztropine, orally C. diphenhydramine, orally D. haloperidol, intramuscularly E. haloperidol, orally Explanation: The correct answer is A. This patient has acute dystonia, which is a brief or prolonged muscle spasm, usually of the head or neck muscles including the larynx and pharynx. He most likely received haloperidol or a similar highpotency neuroleptic in his injection yesterday and is experiencing an acute dystonia as a medication side effect. Oral benztropine (choice B) and diphenhydramine (choice C) are reasonable choices for dystonic reactions but this patient's airway is compromised and he may aspirate his secretions. For this reason, he needs to be given benztropine intramuscularly and his symptoms will improve in about 30 minutes. Haloperidol (choices D and E) is not indicated as his schizophrenic symptoms are controlled. He most likely received haloperidol or a similar high-potency neuroleptic in his injection yesterday and is experiencing an acute dystonia as a medication side effect. A 17-year-old girl is brought to the office by her mother because she has missed “many periods”. The girl admits to binge eating and exercising in order to prevent weight gain. She tells you that she is definitely not pregnant, because she has not had any sexual relations in the past 11 months and thinks she is not getting her menstrual period because of the excessive physical exercise she has been doing in the past several weeks. Physical examination is significant for bradycardia and significant weight loss compared to the last year. A pregnancy test is negative.At this time you should order A. amylase B. BUN and creatinine C. liver function tests 5 D. serum potassium E. thyroid function tests Explanation: The correct answer is D. Bulimic patients frequently engage in compensatory behaviors to prevent weight gain. Those include self-induced vomiting, abuse of diuretics, laxatives, enemas, or diet pills. The metabolic disorders frequently seen in these patients are, mostly hypokalemia and hypomagnesemia. Amylase (choice A) is not a routine test ordered in bulimic patients. If there has been evidence of long starvation and suspicion of other medical conditions, its level might alter. BUN and creatinine (choice B) can be increased if there are signs of dehydration, secondary to the abuse of diuretics. Otherwise, these values should not be changed significantly. Liver function tests (choice C) are usually not changed in bulimic patients. They can be ordered to rule out other medical conditions if necessary. Thyroid function tests (choice E) should be done as a part of regular workup of patients presenting with this clinical picture. It is not, however, the first to be ordered. A 20-year-old college student comes to the clinic because her parents told her that they are going to make her come home if she does not "get help." She says that she is not sure what her parents are so concerned about. She exercises "regularly", gets good grades in school, has a couple of fraternity guys that she goes out with, and drinks 2-3 beers on the weekends at parties. She believes that she has a "typical college lifestyle." Her menstrual periods occur at regular 29-day intervals and have been normal. Her blood pressure is 120/80 mm Hg, pulse is 65/min, and respirations are 15/min. She is 157 cm (5 ft 2 in) tall and weighs 54.1 kg (119 lb). Physical examination shows many dental caries, periodontal disease, pharyngeal abrasions, nail changes, and multiple, linear lacerations on her forearms in various stages of healing. Laboratory studies show: Sodium 139 mEq/L Potassium 2.8 mEq/L Chloride 94 mEq/L Bicarbonate 32 mEq/L The most appropriate question to help establish a diagnosis is: A. "Do you ever feel guilty about drinking alcohol?" B. "Do you typically restrict your diet to under 800 calories a day?" 6 C. "Have you ever taken laxatives as a way to lose weight?" D. "Have you ever consumed large quantities of food and then regurgitated it to prevent weight gain?" E. "Please describe your exercise routine" Explanation: The correct answer is D. This patient most likely has bulimia nervosa, which is an eating disorder characterized by recurrent episodes of binge eating followed by a compensatory behavior to prevent weight gain (vomiting, exercise, laxative abuse). Other features include stealing food, alcohol and drug abuse, self-mutilation, and depression. The individuals are usually at or slightly over the normal weight for their body, sexual activity is normal or increased, and they continue to menstruate. Clinical findings that are caused by recurrent vomiting include dental caries, periodontal disease, pharyngeal lacerations, and nail changes. Metabolic alkalosis and hypokalemia are often present and are due to repeated vomiting. Complications include aspiration and rupture of the esophagus or stomach. "Do you ever feel guilty about drinking alcohol?" (choice A) is a question that would be asked if you suspected alcohol abuse. While alcohol abuse has been associated with bulimia nervosa, it does not seem that this patient is an alcoholic. "Do you typically restrict your diet to under 800 calories a day?" (choice B) would be an indication of anorexia nervosa, which is characterized by the refusal to maintain a normal, healthy body weight and the disturbance of body image. These individuals have an intense fear of gaining weight and therefore restrict food intake to dangerously low levels. Women become amenorrheic, have decreased sexual desire, ritualized exercise routines, and changes in their skin and hair. Complications include ventricular tachyarrhythmias. "Have you ever taken laxatives as a way to lose weight?" (choice C) and "Please describe your exercise routine" (choice E) are questions that should be asked to both anorexics and bulimics. Laxative abuse and exercise rituals are common in both diseases but laxative abuse is probably more common in bulimia, while ritualized exercise is more common in anorexia. This patient has the clinical findings associated with vomiting and therefore the question about binge eating and purging would more likely establish a diagnosis. A 29-year-old attractive married woman has been calling your office several times in the past week. Her physician is out of town, and you, as his younger colleague, are covering in his absence. She has called twice at the end of office hours complaining of vague symptoms. She also appeared in the office without an appointment, insisting she needed a physical examination, because she has a new lump on her breast. You provided the examination in the presence of a female nurse as a chaperone and found nothing. A review 7 of her previous medical records shows no significant medical problems. She appears again after several days at the office demanding to be seen, just after all of the office staff has left. She tells you that she has established trust in you and admires your patience to listen to people's problems. She shares that she had never experienced that with your colleague and questions if she could switch providers. The most appropriate intervention at this time is to A. bring her into the office and call her husband letting him know about her need for understanding B. point out that she is only attention-seeking and there is nothing wrong with her C. reassure her calmly that she will be seen at the next appointment given during office hours D. refuse to talk to her and tell her that you are going to call security to escort her out E. see her since she has shown up, even though it is after normal office hours Explanation: The correct answer is C. Any patient is entitled to a thorough medical evaluation. However, they should be respectful of boundaries. Patients should be seen when others are present in the office to avoid potential conflicts and accusations, especially because these patients tend to be manipulative. Staying alone with the seductive patient in the office (choice A) and calling her husband, are not appropriate interventions. They are not aimed at helping the patient, and may cause more damage to both parties. Pointing out attention-seeking behavior (choice B) even though it may be true, is not an appropriate intervention. In order to change it, the patient needs to understand the origins of such needs. Refusing to talk to her (choice D) is unacceptable and unethical. Even if this is only attention-seeking behavior, it indicates the presence of a certain pathology, and needs to be addressed appropriately. Security should be called though if the patient still adamantly refuses to leave after a calm and direct suggestion to schedule an appointment during office hours or go to the emergency room if there is anything urgent. After hours consultations (choice E) are not appropriate. This patient crossed the boundaries several times and most probably will take advantage of such a situation. In a case of emergency, a referral to the emergency room should be made and the physicians there should be contacted. A 64-year-old chronic alcoholic is admitted to the hospital for the evaluation of an occult gastrointestinal bleed and anemia. He has been a heavy drinker for years and reports numerous admissions to the hospital because of injuries, seizures, and other medical problems related to alcohol abuse. He gives a 8 history of "the shakes" when he does not drink and a history of having been in delirium tremens a few times. On the CAGE questionnaire he scores a 4 out of 4. The patient is also a heavy smoker and has been diagnosed with COPD. The team is aware that this patient may need to be detoxified because he might end up developing withdrawal symptoms while in the hospital. His physical examination is significant for an enlarged liver and spider angiomata, as well as polyneuropathy secondary to alcohol abuse. His liver function tests show values 4 times greater than normal. Given this patient's medical condition, the most appropriate first-line detoxification agent is A. carbamazepine B. chlordiazepoxide C. disulfiram D. lorazepam E. phenobarbital Explanation: The correct answer is D. Lorazepam is a short acting benzodiazepine with no active metabolites. Lorazepam is metabolized to the glucuronide form and excreted by the kidneys. The drug is tapered over 4-6 days for detoxification purposes. It is safe in patients with severe liver damage, and it won't compromise respiration in severe COPD. Carbamazepine (choice A) is an anticonvulsant that, according to several studies, is as effective as benzodiazepines in the control of symptoms associated with alcohol withdrawal. The potential risk of adverse side effects including the induction of liver enzymes, limits its clinical usefulness for this application. Chlordiazepoxide (choice B) is a long-acting benzodiazepine that is used for detoxification from alcohol in uncomplicated cases. It has several metabolites that are long acting, thus making it difficult to efficiently manage the detoxification without risking the accumulation of drug and its metabolites because of impaired liver metabolism. In patients with severe COPD, it can compromise respiration secondary to sedative effects. Disulfiram (choice C) inhibits the enzyme aldehyde dehydrogenase leading to elevated levels of acetaldehyde. It has been used for long-term treatment of alcoholism in order to maintain abstinence, but it has not been used for detoxification. Phenobarbital (choice E) is like all barbiturates metabolized through liver, and causes the induction of hepatic enzymes. It can be used for uncomplicated detoxification from other barbiturates or benzodiazepines, but has not been used for detoxification from alcohol. 9 A 3-year-old girl is brought to the emergency department by her mother because of "fever and a rash." When asked to give a more detailed history, the mother has difficulty providing any additional information. The mother appears tearful and the child cannot take her eyes off the floor. You are unable to engage the child in any conversation. Her temperature is 36.7 C (98.0 F). Physical examination is unremarkable. The most appropriate next step is to A. admit the child to the hospital for evaluation and protection B. ask if there is anyone else in the house that is sick C. ask the mother and child separately what is concerning them D. obtain a psychiatry consult immediately E. send the child home and arrange for a family assessment on a home visit Explanation: The correct answer is C. Because the mother brought her child to the emergency department because of a nonexistent fever and rash, it seems like there is something else that is going on. You also need to be able to interpret a patient's posture and facial expression. The mother is tearful and the child is looking at the ground; this makes it seem like there are other issues that need to be explored. There could be many things going on, but child abuse and domestic violence should be high on your differential. Abuse and violence often present in vague and indirect ways with complaints of abdominal pain, headaches, and other symptoms. After talking to both together, you need to interview each individually because this may allow you to obtain more information. Direct and nonjudgmental questions are often helpful in eliciting information. At this time, you first need to try to obtain more information by talking to each individually before you assume that this is a case of child abuse or domestic violence and considering admitting the child to the hospital for evaluation and protection (choice A). Since this patient's physical examination is completely normal, it seems more appropriate at this time to ask the mother and child separately what is concerning them, as opposed to asking if there is anyone else in the house that is sick (choice B). As a physician you should be able to try to elicit what is concerning these individuals and while a psychiatry consult may be necessary in the future, it is not immediately (choice D) necessary. At this time you should try to determine what is concerning these individuals before you jump to any conclusions about abuse or anything else. Also, if your suspicions of abuse are high, you should not send the child home with the parents under any circumstances. Sending the child home and arranging for a family assessment on a home visit leaves the child open for continued 10 abuse (choice E). The physician should take steps to both protect the child and investigate further. If you do not believe that there are any signs of abuse or any other causes for concern, then a family assessment on a home visit is not necessary. Either way, this is an incorrect answer at this time. A 29-year-old woman who you have been treating for bipolar disorder comes to the office because of feelings of "sadness" over the past few months. She has been taking lithium carbonate for 3 years and has not had any "periods of sadness" or manic episodes requiring hospitalization since starting therapy. Before that time, she had been hospitalized 4 times for manic episodes. She feels "sluggish" and tired and has difficulty concentrating at the office. Her skin is dry and cool, but the remainder of the examination is unremarkable. Laboratory studies show: With regard to her drug regimen, the most appropriate action at this time is to A. add St. John's wort B. add fluoxetine to her current therapy C. begin levothyroxine therapy D. discontinue lithium carbonate therapy E. lower the dose of lithium carbonate F. make no changes in therapy Explanation: The correct answer is C. This patient has hypothyroidism, which is a known side effect of lithium carbonate therapy. It occurs in approximately 5-9% of patients taking the drug and for this reason, routine testing of thyroid function is recommended at least every year during therapy. In addition to routine testing, hypothyroidism should be ruled out in any patient who experiences depressive symptoms during lithium therapy. Treatment with levothyroxine is indicated in patients on lithium therapy who develop symptoms of hypothyroidism. Some believe that treatment for asymptomatic thyroid dysfunction is also necessary. Since this patient has laboratory 11 studies consistent with hypothyroidism, signs and symptoms including a sad mood, difficulty concentrating, "sluggishness", and cool, dry skin, she should be treated. It is incorrect to add St John's wort (choice A) to her current therapy because she has symptomatic hypothyroidism that needs to be treated with thyroid replacement therapy. St. John's wort is an herbal medication that many people believe is effective in the treatment of depression. It is not FDA approved. Adding fluoxetine (choice B) is the incorrect treatment for this patient's "sadness" because she has hypothyroidism, which is likely either causing or contributing to this mood disorder. Treating the hypothyroidism is the most appropriate next step. Since this patient has symptomatic hypothyroidism, she needs to be treated with levothyroxine and it is inappropriate to discontinue lithium carbonate therapy (choice D). This patient needs the lithium for her bipolar disorder, especially because she required hospitalizations in the past. Lowering the dose of lithium carbonate (choice E) is not appropriate. This patient's bipolar disorder is being adequately treated with the dose that she is taking and her levels are within the therapeutic range. Since thyroid dysfunction is a known side effect of this therapy it is important to watch for it and treat it, but lowering the dose in her case is not necessary. As stated above, this patient has symptomatic hypothyroidism and should be treated with levothyroxine, therefore making no changes in her therapy (choice F) is incorrect. A 20-year-old comes to the clinic because of problem that has bothered her for "a while". She has had difficulty throughout her academic career in spite of studying an average of 5 hours per night and taking many extra sessions of tutoring in her classes. She is not able to concentrate due to having to continually check that the door in her apartment or study area of the library is locked. She checks to see that it is locked an average of 15 times an hour while trying to study. She is fully aware each time she checks that the door is locked behind her, but cannot resist the temptation to check to make sure. She sometimes counts to 100 backward and forward after checking that her door is locked in order to distract herself, however, this only provides temporary relief. There is no history of abuse, no history of hallucinations, and the patient states overtly that she does not fear for her safety while checking her door. An appropriate medication to treat this patient's condition is A. haloperidol B. lithium C. lorazepam 12 D. paroxetine E. valproic acid Explanation: The correct answer is D. This patient suffers from obsessive-compulsive disorder and demonstrates compulsive checking rituals that she acknowledges are not grounded in reality-based concerns. The treatment of choice for obsessive-compulsive disorder is higher dose selective serotonin reuptake inhibitors such as paroxetine, fluvoxamine, sertraline, citalopram, and fluoxetine. Haloperidol (choice A) is an antipsychotic medication that has no indication in the treatment of obsessive-compulsive disorder. Lithium (choice B) is used in the treatment of bipolar disorder and may be used as an augmentation strategy for the treatment of unipolar depression. It has no indication, however, for the treatment of obsessive-compulsive disorder. Lorazepam (choice C) is an anxiolytic and antiepileptic medication that is effective for treatment of some anxiety disorders such as panic disorder and generalized anxiety disorder. However, it is not indicated in the treatment of obsessive-compulsive disorder. Valproic acid (choice E) is an anticonvulsant used in the treatment of bipolar disorder. It has no indication in the treatment of obsessive-compulsive disorder. A 27-year-old woman who was trained as a psychiatrist comes to the office for the first time because of recurrent intermittent abdominal pain. She complains of "vague" pain that is usually present at night and typically resolves by mid-morning the following day. She denies any change in bowel habits, blood per rectum, or weight loss. Her husband is a professional football player and he was recently transferred to your city's team from across the country. The patient is tearing small pieces from a tissue that she is holding as she relays her past medical history, which is unremarkable. She does not have any children yet, but tells you that her husband wants her to have a "son" for him soon. Abdominal examination is unremarkable. There is a 2 cm yellowish ecchymosis on her left buttock and a 3.2 cm purple ecchymosis on her right upper arm. When asked about these findings, she tells you with a clenched fist and watery eyes averted to the ground that she is "accident-prone." The most appropriate remark at this time is: A. "For such a smart woman, you seem to have gotten yourself in a dangerous position." B. "I can't help but notice that you seem to be feeling anxious about something." 13 C. "These bruises are more consistent with spousal abuse than accidents." D. "You are leaving out the most important part of the story." E. "You are lucky that you do not have children because your husband would probably abuse them, too." Explanation: The correct answer is B. From this patient's behavior you should be able to recognize that she is obviously anxious and upset (tearing at the tissue, clenched fist, and watery eyes). It is important to carefully confront her with your observations and try to encourage her to clarify the discrepancies in her history. By saying, "I can't help but notice that you seem to be feeling anxious about something," you are opening the door for her to try to explain a situation that she is obviously denying. It is inappropriate to say, "For such a smart woman, you seem to have gotten yourself in a dangerous position" (choice A). This type of remark will make her defensive and is actually insulting. It is certainly possible that she obtained these bruises from accidents, but it is also possible that she is being abused. It is very important to try to differentiate this issue while trying to remain neutral and calm. It is inappropriate to jump to conclusions by saying "these bruises are more consistent with spousal abuse than accidents" (choice C). While it seems as if she is not telling you the whole story, it is best to try to encourage her to explain the situation by carefully confronting her, as opposed to accusing her of "leaving out the most important part of the story" (choice D). Making accusations will make the patient defensive and hostile. Because you have not yet determined if she is being abused, it is incorrect to say, "you are lucky that you do not have children because your husband would probably abuse them too" (choice E). The patient will not appreciate your rush to judgment. It is best to try to demonstrate understanding and support by interpreting her behavior with a comment such as, "you seem upset." A 34-year-old man is postoperative day number 3 from an appendectomy. He had presented 3 days earlier to the emergency department complaining of epigastric pain radiating to his right side in association with an elevated white blood cell count and mild fever. A CT scan of the abdomen revealed appendiceal stranding and the patient was taken to the operating room for an uneventful appendectomy under general anesthesia. His past medical history is significant for intravenous heroin abuse for the past 8 years. He has been hospitalized for withdrawal reactions on numerous occasions but continues to use heroin daily. His last use of heroin was 5 days ago. Now, he continues to have an ileus and has yet to pass flatus or stool. His temperature is 37.0 C (98.6 F) and blood pressure is 120/80 mm Hg. He has a non-tender, nonerythematous surgical site. His medications consist of intravenous morphine 14 for pain control and diazepam for anxiety. The most likely cause of this patient's ileus is A. heroin use B. infection C. intraabdominal abscess D. intravenous morphine E. low-fiber diet Explanation: The correct answer is A. All patients that abuse intravenous narcotics are constipated. Sometimes, these patients have such severe constipation that they develop ulcerations of their rectal mucosa from impaction. These people present a challenge for surgical care since all post-surgical abdominal patients have an ileus secondary to manipulations during their surgery and from anesthesia. For this patient, 3 days after an appendectomy, his operative causes of ileus are all resolved and any residual ileus is most likely secondary to preexisting conditions. The fact that he has not used heroin for days is not relevant since the impacted material in his colon will not be expelled even with increased colonic motility. Generalized infection (choice B) is a cause of postoperative ileus, but there is no evidence from the physical examination or from the patient history that suggests such a process, the same is true for a localized intraabdominal abscess (choice C). These patients almost universally manifest fever and an elevated white blood cell count. Although intravenous morphine (choice D) can certainly be responsible for ileus, especially in non-sensitized patients, in this case, the morphine, when compared to the heroin, is not a concern. This patient is highly tolerant to opiates and therefore the morphine will have no effect. A low-fiber diet (choice E) is not a cause of postoperative ileus but it is a cause of constipation. A 4-year-old girl is brought to the emergency department by her babysitter because of "bumps on her vagina." The babysitter was giving the girl a bath when she noticed the lesions and was so concerned that she brought her to the hospital without calling the girl's parents. The patient is very withdrawn and will not speak directly to you. The babysitter, who is 13 years old, whispers to you that the girl's father has made "inappropriate passes" towards her in the past and the girl has told her that her father touches her and "does other things to her." Her grandparents live in the apartment directly next door. Physical examination shows multiple vesicles on her vagina and a frothy vaginal discharge. A wet mount of the discharge shows motile flagellated organisms. You administer a dose of metronidazole and call her 15 house. Nobody is home in the house, but they have an answering machine. The most appropriate next step is to A. call the patient's grandparents and have them come pick her up B. contact the state child protective services agency C. leave a message on the family's machine saying that you would like to talk about "what they do to their daughter" D. prescribe metronidazole and acyclovir and send her home with the babysitter with written instructions to give to her parents E. keep her in the emergency department until her parents arrive and she can be discharged to them Explanation: The correct answer is B. This patient most likely is a victim of sexual abuse, given that she has trichomonas and may have herpes and that she told her babysitter that her father touches her and "does other things to her." Physicians MUST report abuse to the state child protective services agency. This patient should be admitted to the hospital for treatment and protection. It is inappropriate to call the patient's grandparents and have them come pick her up (choice A) because she needs to be protected at this time while a full evaluation of the situation is done. While you should try to call the patient's parents, you should not leave a message on the family's machine saying that you would like to talk about "what they do to their daughter" (choice C). You should not accuse them directly and you should especially not do it on an answering machine. It is wrong to prescribe metronidazole and acyclovir and send her home with the babysitter with written instructions to give to her parents (choice D) because this should be reported to the state child protective services agency and she should be admitted to the hospital for treatment and protection. Keeping her in the emergency department until her parents arrive and she can be discharged to them (choice E) is wrong because this patient is most likely a victim of sexual abuse and needs to be admitted to the hospital for treatment and protection. This case must also be reported to the state child protective services agency. Discharging her to her parents is wrong because she has told the babysitter that her father is the abuser. A 6-month-old infant is brought to the emergency department by his mother because of a 3-hour history of vomiting, abdominal distention, and general "crankiness". She asks to see the surgical resident on call because she "knows that her baby has an obstruction." She tells you that he has had 3 previous surgeries at 3 different hospital within a 60 mile radius of your hospital, the first at 1 month of age for a volvulus, and the next 2 were exploratory laparoscopies with lysis of adhesions at 3 months and 4 months of age. His temperature is 37 C (98. 6 F), blood pressure is 90/60 mm Hg, 16 pulse is 130/min, and respirations are 30/min. His abdomen is soft with normal, active bowel sounds. He does not wince or move as you palpate his abdomen. Rectal examination shows soft, brown stool that is guaiac negative. He is laughing and smiling as you perform the examination. You ask the mother why she came to this particular hospital tonight and she says, "they don't know what they are doing in those other places." She then asks you if you paged the surgical resident. The most appropriate next step is to A. admit him, page the surgery resident, and prepare him for immediate surgery B. draw blood for electrolytes and a complete blood count C. order a barium enema D. order a supine and upright radiograph of the abdomen E. try to obtain a more detailed history from the mother and physicians at the other hospitals Explanation: The correct answer is E. This seems to be a case of Munchausen's syndrome by proxy, which is a factitious disorder characterized by the intentional production or feigning of symptoms in order to assume the sick role. The mother is the one who is producing or making up the symptoms for her infant son, who is unfortunately the one suffering the consequences from unnecessary procedures. He may have truly had a volvulus initially, and the first surgeries may have been warranted, however at this time it seems necessary to look into this further, before subjecting this apparently healthy child to more tests. Admitting him and preparing him for surgery (choice A) is inappropriate because he appears healthy and it seems that this may be a case of Munchausen's syndrome by proxy. Drawing blood for electrolytes and a complete blood count (choice B) would be correct if you thought that this patient was sick, however he appears healthy. A barium enema (choice C) and a supine and upright radiograph of the abdomen (choice D) are not indicated at this time because he appears completely fine, even though the mother tells a different story. These may possibly be necessary at a later time, after you look into the possibility of Munchausen's syndrome by proxy. A 49-year-old Caucasian woman with a history of bipolar disorder type I has come to the clinic because of increased fatigue, forgetfulness, and poor concentration in the past couple of weeks. She complains that it takes her forever to clean the house, and that she doesn't feel as efficient as usual. Her daughter criticizes her weight gain, even though the patient denies increased appetite. She denies any recent mood swings, and admits to being compliant with her prescribed lithium. She is worried that she is getting Alzheimer's 17 dementia, because her paternal grandmother suffered from it. Her daughter is worried that the mother is getting depressed, even though this depression seems different from the previous episodes she has had in the past. Her physical examination, aside from mild obesity and mild lower extremities edema, is otherwise unremarkable. Her lithium level is 1.1mEq and complete blood count and basic metabolic profile are within normal limits. The most appropriate next step is to A. begin treatment with selective serotonin reuptake inhibitor B. discontinue lithium C. order a dexamethasone suppression test D. order thyroid stimulating hormone level E. schedule a brain MRI Explanation: The correct answer is D. The most reasonable step in the management of this patient is to order serum TSH. The symptoms that the patient describes can be a consequence of hypothyroidism. Long-term lithium treatment can cause iatrogenic hypothyroidism. The psychiatric manifestations of hypothyroidism include fatigue, depression, lethargy, psychomotor retardation, poor concentration, and forgetfulness. If a patient has been otherwise stable on lithium for years, there is no need to switch to another mood stabilizer, but rather, add substitutional therapy with levothyroxine . Beginning treatment with an SSRI (choice A) would need to be justified after other medical conditions that can present with depressive like symptoms are ruled out. One would also need to be careful about the lithium-SSRI interactions and the possibility of lithium toxicity. Discontinuing lithium (choice B) is an inappropriate choice because the patient has a diagnosis of bipolar I disorder and has been stable on the drug of choice for that disorder, which is lithium. Only, if other severe side effects from lithium were to be detected, would switching to another mood stabilizer be justified. A dexamethasone suppression test (choice C) is not used as a routine test for diagnosis of psychiatric conditions. It has been used in the past to help confirm major depressive disorder since severely depressed patients show nonsupression of cortisol after the administration of dexamethasone. Since the sensitivity of the test is only 45% and there are a variety of medical conditions and pharmacological agents that may interfere with its results, it is used nowadays infrequently for research purposes. Scheduling a brain MRI (choice E) should be considered only if cognitive disturbances secondary to other medical conditions or depression are ruled out or if there is significant neurological findings that could justify the procedure. It is not the first step in management in this case. 18 A 58-year-old man comes to the office 7 weeks after his wife died from complications during breast cancer surgery. He says that he "misses her like crazy" and it is so hard for him because he did not expect to "ever lose her." He often finds himself crying in the bathroom at work. However, it is the weekends that are especially difficult. He goes out for dinner and to the movies with their 2 children and his friends, but he typically feels a little detached. It is "really hard to handle" seeing other men with their wives. He is very "sad" and wants to know if he is going to be "okay". The most appropriate response to this patient is A. "It seems like you are experiencing a major depressive episode that we can treat with fluoxetine" B. "Let's see how you feel in a few weeks and we will discuss the most appropriate treatment then" C. "You are experiencing grief, which is a completely normal and expected reaction to the loss of your wife" D. "You have an adjustment disorder that should be treated with psychotherapy" E. "You should have your friends set you up with a widowed woman who will understand you" Explanation: The correct answer is C. This patient is most likely experiencing a normal and expected grief reaction to the loss of his wife. It is normal to have intense feelings of loss, a decreased enjoyment of activities, frequent crying spells, and a "sad", depressed mood. Minor dysfunction may occur, but it is not pronounced or persistent. It often diminishes with time and is not associated with suicidal ideation or psychotic symptoms. It is inappropriate to say, "It seems like you are experiencing a major depressive episode that we can treat with fluoxetine" (choice A) because he is experiencing normal grief. A major depressive episode would be the diagnosis if he had marked functional impairment, psychomotor retardation, a preoccupation with worthlessness, suicidal ideation, or psychotic symptoms. It is inappropriate to say, "Let's see how you feel in a few weeks and we will discuss the most appropriate treatment then" (choice B) because he needs reassurance right now, not in few weeks. "You have an adjustment disorder that should be treated with psychotherapy" (choice D) is wrong because he is most likely having a normal grief reaction, not an adjustment disorder. An adjustment disorder is an abnormal, maladaptive response to a stressor that leads to significant functional impairment and extreme sadness and stress. It is similar to depression, but it does not meet the criteria for a major depressive episode. The patient in this case is "sad" and has normal feelings of loss. He is able to go to work and go out with friends and family and therefore, does not have an adjustment disorder. 19 You should not say to him, "You should have your friends set you up with a widowed woman who will understand you" (choice E). It is not the physician's place to give advice as to when he should start dating again. That should happen when he is ready. Support groups, family, and friends may be helpful during these difficult times. You are called to meet with a patient's family on the oncology floor. The patient is a 60-year-old Caucasian man who is on the board of trustees of the hospital where you are employed. His family describes the patient as an extremely controlling and arrogant, yet emotionally vulnerable person. The results of a recent metastatic work up indicate that the patient has disseminated colon cancer and he has been told that the chances for 'cure' of his cancer are 1-5%. The patient's family requests that, even if the patient asks, he not be told of the results of his testing as it will only "depress him". On the patient's previous mental status examination, he is found to be fully oriented, meticulously groomed, and well related. His attitude is noted to be dismissive; he frequently asks why you are assessing him without a surgeon present and writes down your name for credentials verification. There is no evidence of any psychotic process, and the patient laughs when asked about depressive symptoms or suicidal ideation. During his hospital course, he has frequently asked that he be kept fully informed of all pertinent details of his medical testing. The most appropriate response to give to the patient's family regarding their request would be that you A. are going to comply with the patient's wishes given his rights as a competent person with self determination of care B. feel that, given the patient's personality, chemotherapy should be initiated promptly with the family consenting in lieu of the patient C. recognize the personality traits described by the family in your interaction with the patient and will comply with their request D. will begin a titration of antidepressant medication for approximately 1 week prior to revealing the patient's prognosis to him E. will discharge the patient imminently given that nothing acute needs to be done and you will let the patient's family divulge whatever they feel is appropriate Explanation: The correct answer is A. The patient described does have personality traits that suggest a possible narcissistic personality disorder. He is extremely haughty during interaction with someone he feels does not have sufficient training to take care of a man of his importance, is described as arrogant by his family, and seems to make demands for special treatment while hospitalized. However, the patient clearly demonstrates an ability to participate in decisions pertaining to his health. He is not psychotic, nor gives any evidence of dementing illness or severe depression. Therefore, if his request is to know exact details about his diagnosis and prognosis, then 20 that wish must be honored. Telling them that you feel that, given the patient's personality, chemotherapy should be initiated promptly with the family consenting in lieu of the patient (choice B) is also incorrect due to the patient's competence and rights to decide appropriate treatment for himself. Telling them that you recognize the personality traits described by the family in your interaction with the patient and will comply with their request (choice C) is incorrect due to the fact that the patient is competent and should therefore be allowed to know his diagnosis, treatment options, and prognosis. Telling them that you will begin a titration of antidepressant medication for approximately 1 week prior to revealing the patient's prognosis to him (choice D) is incorrect for two primary reasons. The first is the patient's obvious competence. The second is that the patient does not appear to be clinically depressed, and even if he were, the patient has the right to decide whether he receives pharmacologic treatment for depression. Telling them that you will discharge the patient imminently given that nothing acute needs to be done and you will let the patient's family divulge whatever they feel is appropriate (choice E) is incorrect due to the fact that the patient is competent and has asked that his condition be explained to him in detail by a medical professional. A 37-year-old woman with a history of bipolar disorder is brought to the emergency department by ambulance obtunded and ataxic. The patient has not been hospitalized in over 5 years and has been stably maintained on outpatient therapy with a regimen of lithium carbonate 600 mg by mouth twice a day. While you are examining her, she has a tonic-clonic seizure lasting approximately 30 seconds. As part of the laboratory work-up, the patient's lithium level is found to be 4.2 mEq/L. After basic airway and cardiovascular support, the most appropriate next step in this patient's management is to A. administer a loading dose of phenytoin B. get a renal consultation for emergent dialysis C. order an MRI of the patient's head D. provide conservative management including fluid and electrolyte replacement E. send liver function tests Explanation: The correct answer is B. The patient presents to the emergency department with potentially life-threatening lithium toxicity. The treatment of choice for lithium levels greater than 4.0 mEq/L is hemodialysis. 21 A loading dose of phenytoin (choice A) is not indicated after one generalized seizure when the patient's metabolic encephalopathy can be treated with dialysis. An MRI of the patient's head (choice C) may be an acceptable follow-up study after the patient receives dialysis, especially if after dialysis treatment the patient continues to have seizures. For lower levels of lithium toxicity, fluid and electrolyte replacement (choice D) may be sufficient treatment. Hepatic toxicity, as demonstrated by liver function tests (choice E) is not suggested by the patient's presentation in the presence of a lithium level of greater than 4.0 mEq/L given lithium's exclusively renal metabolism. A 14-year-old boy is brought to the office because he has been "out of control" at home and in school for the past 6 months. The mother states that she can no longer handle his "argumentative" and "annoying" behavior. He refuses to do any of his assigned household chores, and he always replies to her requests with "hostile and angry" remarks. His teacher called their house last week to tell her that he loses his temper in class when annoyed, and frequently blames his other classmates for mistakes that she knows that he made. Everybody is frustrated with his behavior and they are concerned that he is only "getting worse." A few years ago they were worried that he had a learning disability, however tests failed to show any abnormalities. There have not been any recent changes at home or in school. The most likely diagnosis is A. attention-deficit hyperactivity disorder B. bipolar disorder C. conduct disorder D. depression E. oppositional defiant disorder Explanation: The correct answer is E. This patient most likely has oppositional defiant disorder, which is a pattern of negative, hostile, defiant behavior that is characterized by frequent arguments with adults, refusing adult's requests, deliberately annoying others, and blaming others for his mistakes. These individuals frequently lose their temper, and they are often spiteful, vindictive, angry, resentful, and easily annoyed. This disorder is less severe than conduct disorder. Attention-deficit hyperactivity disorder (choice A) is a pattern of behavior that is characterized by inattention, hyperactivity, and impulsiveness. These individuals are easily distracted, have difficulty staying seated, finishing 22 tasks, and following instructions, appear not to listen, often lose things, and avoid tasks with sustained mental effort. They are fidgety, have impulsive speech, have difficulty waiting in lines or for the teacher to call on them, and seem to be "driven by a motor". This description does not fit with the boy in this case who is hostile, angry, and argumentative. Bipolar disorder (choice B) is characterized by manic or hypomanic episodes and periods of depression. During a manic episode, individuals have a persistently elevated, expansive, or irritable mood and often have inflated self-esteem, have racing thoughts, participate in increased goal-oriented activity and pleasurable activity with painful consequences. They have a marked impairment in social and occupational functioning. Hypomania is a less severe form of mania. Conduct disorder (choice C) is a pattern of behavior characterized by the persistent violation of societal rules and the basic rights of others. These individuals are aggressive towards animals, threaten and fight with other people, use weapons, start fires, destroy property, lie, cheat, steal, run away from home, skip school, and stay out late at night. It is a more severe disorder than oppositional defiant disorder, which is the diagnosis for the boy in this case. Depression (choice D) is characterized by a sad mood, diminished pleasure, weight loss, insomnia, psychomotor retardation, fatigue, feelings of guilt, worthlessness, and suicidal ideation. The patient in this case is not experiencing any of these symptoms. A 17-year-old girl is brought into your clinic by her mother, who is concerned that "she really just doesn't look well to me." Her medical history is unremarkable except for irregular menses since menarche at age 16. She has no surgical history, does not take any medications, and has no known drug allergies. You ask her mother to leave the room and ask the patient about sexual activity, tobacco, drug, and alcohol use, which she denies. There are no problems at home. She is in her senior year of high school and is doing very well, participating in track and field as well as maintaining a 3.9 average. She is planning to attend college and hopes to become a lawyer. Review of systems is negative except for weight loss, but the patient states, "I have always been a little too heavy. This last year I just lost my baby fat, that's all." She acknowledges running several miles a day as part of her training regimen for the track team. The patient denies any problem with eating, although she feels as though "I could still stand to lose a few pounds. My face is way too chubby." When you speak alone with her mother, you elicit that the patient is very strict about what foods she considers appropriate to eat and insists on preparing her own meals. Her temperature is 37.0 C (98.6 F), blood pressure is 105/68 mm Hg, pulse is 59/min, and respirations are 12/min. She weighs 44.5 kg (98 lb) and is 5'5". The body-mass index (BMI) calculates to 16 kg/m2. She is an alert, cooperative, thin young female in no distress. Her hair appears dry and brittle. However, the remainder of the physical examination is unremarkable. Laboratory studies, including 23 biochemical profile, erythrocyte sedimentation rate (ESR,) complete blood count, and thyroid studies are within normal limits. The most appropriate next step in the management of this patient is to A. begin treatment with megestrol (Megace) to stimulate appetite B. begin treatment with oral contraceptives to regulate her menses C. enroll her in a multidisciplinary treatment program for eating disorders D. immediately admit her to the hospital on psychiatric hold since she is a danger to herself E. refer her to an endocrinologist to treat hyperthyroidism F. refer her to an oncologist to rule out occult malignancy Explanation: The correct answer is C. This patient has many historical and physical exam findings that are consistent with anorexia nervosa. Most patients will not readily discuss an eating disorder with a primary physician; therefore the index of suspicion must always remain very high. Some of the historical signs include an altered body image, strict control of dietary intake, oligomenorrhea, and frequent exercise. Most patients, though not all, are female and are high achievers. Physical findings in this case include dry brittle hair and slight bradycardia. Other findings might include hypotension, cold and mottled extremities, lanugo hair, syncope, and osteopenia or fractures. Although there are other reasons for weight loss, which must be kept in the differential diagnosis, these conditions do not generally have an overriding preoccupation with body image. It is also important to recognize signs and symptoms of bulimia, since both eating disorders often coexist. Treatment is aimed at restoring normal weight. This is often best accomplished by a multidisciplinary team consisting of a physician, nutritionist, mental health worker, and a nurse. Resumption of normal menses is a very good indicator that an appropriate weight has been achieved. Use of megestrol (choice A) is not correct because the underlying disorder is not one of decreased appetite. This medication is sometimes used as an appetite stimulant for patients with weight loss secondary to malignancy or AIDS. However, it is not appropriate in this setting. Treatment of oligomenorrhea with oral contraceptives (choice B), is incorrect because this also does not address the patient's main problem. Although she does have irregular menses, this is most likely the result of her anorexia rather than the cause of her symptoms. At this stage, it would be more beneficial to address the main diagnosis. Admission to the hospital (choice D), is not the most appropriate next step. Indications for hospitalization include: weight which is 30% below normal for age and development, continued weight loss despite treatment, rapid weight loss (over 3 months), cardiac arrhythmias, systolic blood pressure less than 24 70 mm Hg, heart rate slower than 50-60 bpm, hypothermia, suicidal ideation or intent, electrolyte disturbances, or significant dehydration. The young woman in this case may be initially treated as an outpatient. An endocrinologist to treat hyperthyroidism (choice E) is not correct because she has no findings consistent with hyperthyroidism. Referral to an oncologist (choice F) should be considered if there were there were any findings on history, physical exam, or laboratory and imaging studies to suggest malignancy. At this point, however, this patient's case does not warrant referral. A 28-year-old woman is brought to the office by her husband who says that the police were called to their house last night because she "brandished a knife at the neighbor." He says that his wife has been "pretty crazy" for the past 8 months. It all started with her "believing that their neighbor's son, who has been dead for years, has been communicating with her through the shower faucet, and telling her to kill his parents." At first, he thought that this was just a joke, but then he began to realize that something had to be "off" because she began to see faces of other dead acquaintances in the refrigerator. She stopped her daily showers, started wearing dirty cloths from the hamper, and cut off all communication with friends and relatives. She was constantly so disheveled and "out there" that she was fired from her job as a grocery store clerk. Approximately 5 months ago, there was a 3-week period where she had difficulty sleeping, a 15-pound weight loss, and there was a generalized "sadness about her." During this period, she repeatedly expressed feelings of worthlessness, and rarely got out of bed to watch television, which up until then had been her most exciting activity. The husband says that she has recently begun to complain about sleeping "troubles" again, and she has had difficulty getting out of bed. She now says that she "needs to get out of the office to kill those people once and for all." She does not take any medications, use any drugs, or drink alcohol. The most likely diagnosis is A. brief psychotic disorder B. delusional disorder C. major depressive disorder D. schizoaffective disorder E. schizophrenia F. schizophreniform disorder Explanation: The correct answer is D. This patient most likely has schizoaffective disorder, which is characterized by a mood disorder and separate psychotic symptoms. The individual must have at least 2 weeks of delusions or 25 hallucinations in the absence of prominent mood symptoms. Mania or depression may be present. This patient has hallucinations, delusions, and disorganized behavior, which are suggestive of schizophrenia. However, the presence of the depressive symptoms makes schizoaffective disorder the diagnosis. A brief psychotic disorder (choice A) is characterized by delusions, hallucinations, disorganized speech and behavior for more than 1 day but less than 1 month. This patient's symptoms have been present for longer than a month and she has intermittent and prominent depressive symptoms. Delusional disorder (choice B) is the presence of non-bizarre delusions for more than a month. The belief that one is being followed is a common symptom. The patient in this case is having bizarre delusions. Major depressive disorder (choice C) is characterized by a major depressive episode, which is associated with a depressed mood, sleep disturbances, feelings of guilt, fatigue, a change in appetite, psychomotor agitation or retardation, and suicidal thoughts. Psychotic features may be present. However, they resolve when the mood disorder has resolved. The patient in this case has the psychotic symptoms in the absence of the depressive symptoms. Schizophrenia (choice E) is characterized by the presence of psychotic symptoms and functional impairment for at least 6 months. Unusual thoughts, perceptions, and behaviors are called positive symptoms, while social withdrawal, a flat effect, and lack of energy are called negative symptoms. The presence of positive and negative symptoms for 6 months in the absence of a mood episode is schizophrenia. The patient in this case has positive and negative symptoms, but also has major depressive episodes, which is consistent with schizoaffective disorder. Schizophreniform disorder (choice F) is characterized by the presence of delusions, hallucinations, disorganized speech and behavior, without a mood episode, that lasts between 1 month and 6 months. This patient has had these symptoms for longer than 6 months and has had depressive episodes. A 36-year-old man is admitted to the hospital for acute management of his schizophrenia. He is a homeless man that you often see hanging out around the neighborhood. He has had multiple hospitalizations over the past 5 years and they usually occur when he stops taking his medications. He usually believes that his dead cousin speaks directly to him through fire hydrants and that she tells him that he does not need to take any medication. Unfortunately, she is the only person that he listens to. You are called to see him because you have treated him many times in the past. When you get to the floor, the nurse tells you that you should be careful when you enter the room because orders for the medication have not been written yet. You hear howling as you are talking to the nurse and when you get to his room you see 26 that he is kneeling at the window "howling at the moon." He becomes angry and violent when you try to enter his room. You go back to the nurse station and tell her to give him an injection of haloperidol and diazepam. In addition, at this time you should A. begin psychosocial treatment with behavior skills training B. give dantrolene to prevent neuroleptic malignant syndrome C. prescribe benztropine to prevent parkinsonian-like symptoms D. prescribe clozapine to treat his negative symptoms E. schedule immediate electroconvulsive therapy Explanation: The correct answer is C. In acute psychiatric emergencies, a neuroleptic agent (haloperidol) and a benzodiazepine (diazepam) are typically given to control the patient and aid in sedation. An anticholinergic agent, such as benztropine, should be added to prevent parkinsonian-like symptoms (rigidity and akinesia) that may occur in patients treated with high-potency antipsychotic agents (haloperidol). In this acute situation, it is inappropriate to begin psychosocial treatment with behavior skills training (choice A). Psychosocial treatment, including behavior skills training, multi-family groups, vocational training, and workshops, is very important in the long-term management of schizophrenia. During the patient's hospitalization, after the patient is stabilized, the treatment plan should focus on practical issues, and set the stage for outpatient psychosocial issues. Dantrolene is the treatment for neuroleptic malignant syndrome (choice B), which may be caused by high-potency antipsychotic agents (haloperidol). It is not routinely given to prevent this condition. NMS is associated with a high fever, autonomic instability, rigidity, behavioral changes, and laboratory abnormalities such as elevated white blood cell count, creatine kinase, and abnormal liver function tests. Clozapine (choice D) is used as a second-line antipsychotic agent for patients who do not respond to the typical antipsychotic medications and have prominent negative symptoms (flat affect, poverty of speech, and asociality). It is not typically the first agent given in an acute psychiatric emergency. It is associated with agranulocytosis (1%) and requires weekly monitoring of the white blood cell count. Electroconvulsive therapy (choice E) may be used in cases of nonresponsive catatonia. It is not often used to treat an acute psychiatric emergency with a wild and out of control patient. A 25-year-old Caucasian woman with no past medical history presents to the emergency department for the fifth time with a complaint of chest palpitations, 27 shortness of breath, distal paresthesias, and nausea. A full metabolic and cardiac workup is unremarkable. Urine toxicology is also negative. You diagnose this patient as having a panic attack. Appropriate pharmacotherapy for this patient may include A. haloperidol B. lithium C. naltrexone D. paroxetine E. valproic acid Explanation: The correct answer is D. Selective serotonin reuptake inhibitors in the higher dosing range are the treatment of choice for panic disorder. Benzodiazepines may also be used in the initial phases of treatment while selective serotonin reuptake inhibitors are being titrated. Antipsychotics such as haloperidol (choice A) have no demonstrated efficacy in the treatment of panic attacks. Lithium (choice B) may be used as a mood stabilizer in patients with bipolar disorder or as an augmentation strategy for unipolar depression. It has no indication in the treatment of panic disorder. Naltrexone (choice C) is an opiate antagonist that has a specific use in the treatment of opiate and alcohol dependence. It cannot be used as antipanic prophylaxis. Valproic acid (choice E) may also be used as a mood stabilizer in patients with bipolar disorder and may be more effective than lithium for patients with rapid cycling bipolar disorder. It has no indication in the treatment of panic disorder. A 74-year-old man is admitted to the hospital for radiation treatment for malignant melanoma of the eye that was diagnosed 7 months ago. The treatment is performed early in the day and you are called to see him late that night because of a sudden deterioration in his mental status. When you arrive, he does not recognize you, even though you have been taking care of him for many years, and he repeatedly asks where he is. His speech pattern is disorganized and rambling. He is normally a highly functional elderly man who lives alone and volunteers at the local nursing home. His temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 16/min. He is uncooperative, but a modified physical examination is unremarkable. Mental status examination is not possible because he has an altered level of consciousness. Laboratory studies show no abnormalities. The most likely explanation for his symptoms is that 28 A. although he appeared normal before he was admitted to the hospital, he now has a delusional disorder B. he already had a low level of dementia prior to hospitalization that is being exacerbated by psychologic and physical stress C. he is experiencing an adjustment disorder due to the recent diagnosis of melanoma D. he is having a brief psychotic disorder from the radiation treatment E. he is in an acute confusional state from the psychologic and physical stress of this hospital experience Explanation: The correct answer is E. This patient has delirium, which is also sometimes called acute confusional state. It is very common in hospitalized and institutionalized elderly individuals. It is characterized by a rapid onset of impaired cognition, altered level of consciousness, disturbances in attention and psychomotor activity, and altered sleep-wake cycles. The symptoms tend to fluctuate and it is usually reversible when the underlying disorder is identified and treated. Common causes include psychologic and physical stress (for example, surgery), metabolic disturbances, neoplasms, infections, medications, cerebral and cardiovascular diseases, and withdrawal from alcohol and prescription medications. Delusional disorder (choice A) is characterized by the presence of nonbizarre delusions that last for more than 1 month. Functioning is not usually impaired. Antipsychotic agents and psychotherapy may be necessary. This patient is not delusional. He is in an acute confusional state. Dementia (choice B) is the slow and insidious onset of cognitive and intellectual deficits with no changes in consciousness. The symptoms are stable and irreversible. The most common causes are Alzheimer disease and multi-infarct dementia. There is no evidence in this case that he had dementia prior to this hospital admission. Also, the case states that he has an altered level of consciousness, which is typically associated with delirium, not dementia. Adjustment disorder (choice C) is a maladaptive response to a stressful event. The symptoms include mood disturbances, behavioral changes, and impaired functioning. It usually resolves within 6 months. Since he was diagnosed with melanoma 7 months ago, it is unlikely that this acute confusional state is due to an adjustment disorder. Delirium is a more likely diagnosis. Brief psychotic disorder (choice D) is the abrupt onset of psychotic symptoms including hallucinations, delusions, and disorganization with impaired functioning. It is present for more than 1 day, but less than 1 month. It is usually preceded by a stressful life event. This patient has been experiencing these symptoms for less than a day, and therefore he cannot be diagnosed with a brief psychotic disorder. 29 A 71-year-old retired police officer comes to the clinic for his annual physical examination. He has no complaints, but you notice that he is not his usual self. He appears distraught and distant, speaks in a low voice, and avoids eye contact. He seems to have lost some weight, and admits to not caring about his meals. The physical examination and routine laboratory tests are unremarkable. On further questioning the patient shares that his wife had died several months ago. He lives alone, has no children, and misses her a lot. You ask him about his daily activities. It seems that he stays to himself and rarely sees his fellow officers or friends any more. The most important next step is evaluation for A. Alzheimer's dementia B. feelings of guilt C. religious preference D. suicidal ideation E. weight loss Explanation: The correct answer is D. It is important to ask this patient openly about suicidal ideation, plans, or an existing wish not to live anymore. Apart from anhedonia and other signs of depression or complicated grief, he seems to have all the risk factors for suicide present. These risk factors include being male, older, retired, widowed, having potential access to weapons since he was a police officer, and having no close social support. Alzheimer's dementia (choice A) in an elderly patient who seems to have some cognitive difficulties, should be considered. However, in this case, pseudodementia secondary to depression may be present. The imminent risk of a possible suicide attempt is, in this case, more important to assess. If that is ruled out, other tests and steps can be taken to rule out other medical conditions. Guilt feelings (choice B) may be a part of the depressive syndrome or grief, if a patient feels that he should have been the one that deserved to die. Guilt feelings can sometimes also lead to suicidal ideation. However, it is important to ask about suicidal ideation independently before continuing further assessment. Religious preference (choice C) can be explored in light of the possible suicidal ideation. If a patient is practicing his religion, even though suicidal ideation may be present, the fact that most religious beliefs stand against self-harm, may be helpful in preventing suicide. However, exploring this comes only after the presence of suicidal ideation is established. Weight loss (choice E) in light of other normal findings is not the most urgent concern. It should be considered as a part of the depressive syndrome and monitored. 30 A 16-year-old girl comes to the office after her boyfriend of 2 years abruptly ended their relationship. She has been a patient of yours for the past 7 years and seems to feel very comfortable talking about relationships and sexual issues with you. She says that she just decided to have sexual intercourse with him a month ago and that this was a "huge deal" because it was her first time. Now, after "trusting him" with such a "personal thing”, he has "abandoned" her. She suddenly becomes silent and begins to cry. She takes a tissue out her pocketbook and remains silent. At this point you should A. advise her to "pull herself together" B. maintain eye contact, and after a few minutes say, "I understand that this is hard for you" C. remain silent for however long she needs to compose herself D. tell her not to cry and say, "he is not worth getting so upset over" E. use this time to review the notes in her chart F. recommend that she go talk to a psychiatrist Explanation: The correct answer is B. Silence during a patient interview can be uncomfortable for both the patient and the physician. It is important to use this time to show that you are supportive and attentive. You can hand her a box of tissues if she does not have any and maintain eye contact to show that you are "still with her" (not dozing off thinking about other things). After a little while (a couple of minutes) you should say something to show your support and understanding and to try to facilitate the conversation. "I understand that this is hard for you" is perfect for this time. Advising her to "pull herself together" (choice A), and telling her not to cry, and that "he is not worth getting so upset over" (choice D) is incorrect because this only implies that it is not "okay" to show emotions and that she is being immature or foolish. While it is important to remain silent for a few minutes to allow her to release tension by crying, it is not realistic to remain silent for however long she needs to compose herself (choice C). You probably have other patients waiting to be seen, so you need to give her some time, but not however long she needs. Leaning forward, maintaining eye contact, and after a few minutes making a supportive comment is the most appropriate way to manage this situation. Using this time to review the notes in her chart (choice E) might seem like a good idea, but it just makes it seem like you are not "there for her" emotionally and that she is wasting time that can be better spent "reviewing notes." You need to seem supportive (eye contact) and make her feel comfortable. Reviewing notes at this time will only make you seem aloof. 31 Recommending that she go talk to a psychiatrist (choice F) is unnecessary at this time. She is willing to discuss these issues with you and so you should be helpful and supportive. A psychiatrist may be appropriate in the future if she has any thoughts of suicide or wants to discuss these issues at great lengths. A 78-year-old African American woman with no past psychiatric history is admitted to the inpatient geriatric floor with urosepsis. Prior to hospitalization she lived in the community by herself and was able to tend to her own cooking, cleaning, and shopping. On the second night in the hospital, the nursing staff alerts you that the patient is extremely agitated and combative. She had pulled out her intravenous lines and appears to be speaking to people who are not in the hospital room. After placing her in soft restraints, the most appropriate pharmacologic treatment for behavioral management of this patient may include A. diazepam B. electroconvulsive therapy C. fluoxetine D. haloperidol E. lithium Explanation: The correct answer is D. Low doses of high potency antipsychotics such as haloperidol are the treatment of choice for agitation in the context of delirium. In this patient, haloperidol may be used in conjunction with environmental measures such as dim light in the room, soft restraints, and a bedside companion. Diazepam (choice A) would not be an appropriate treatment for this patient, given the potential for disinhibition when administered to the elderly patient and its long half-life and potential for prolonged sedation and accumulation in adipose tissue after repeated doses. Electroconvulsive therapy (choice B) would not be an appropriate treatment for a patient with delirium. It is indicated in conditions such as severe depression, depression in pregnancy, for neuroleptic malignant syndrome, and refractory mania. Fluoxetine (choice C) is used to treat depression. It is not used for acute delirium. Lithium (choice E) is not an established treatment for delirium. It does not offer control for agitation after 1 dose and is potentially dangerous in patients for whom dehydration may be a medical comorbidity. 32 A 33-year-old man comes to the emergency department because of a 12hour history of increasing dizziness and palpitations. He tells you that he knows that he is "lapsing into severe hypoglycemia" because of an untreated insulinoma. He is an intensive care nurse at a hospital in a neighboring town but says that he does not like the doctors there so he goes to many different area hospitals. He tells you that he has been treated for hypoglycemia on 3 separate occasions at 3 different hospitals and is too frightened to undergo the surgery to remove the tumor. He tells you that he is otherwise healthy and does not take any medications. His last food intake was 12 hours ago. His temperature is 37.2 C (99.0 F), blood pressure is 130/90 mm Hg, pulse is 11/min, and respirations are 18/min. Physical examination shows diaphoresis and pallor. His glucose level is 35 mg/dL. He has high insulin levels with a decreased C-peptide level. You give the patient glucose-containing fluids and try to obtain his previous medical records from your hospital but they were destroyed in a flood. You are unable to reach any of the other doctors that have treated him in the past. The next step in management is to A. consult with a surgeon for possible resection of the insulinoma B. discuss the possibility that he is producing these symptoms C. measure blood levels of sulfonylureas D. order a CT scan of the abdomen E. tell him that he is malingering Explanation: The correct answer is B. This patient most likely has a factitious disorder (Munchausen syndrome), which is the active production of symptoms to assume the sick role, and so you should discuss the possibility that he is producing these symptoms. Individuals with this disorder are often health care workers who know how to fake symptoms. In this case, this nurse is complaining of hypoglycemia and an insulinoma and while he does have low glucose and high insulin levels, he has a decreased C-peptide level. These values are consistent with exogenous insulin and not an insulinoma. Cpeptide levels are increased when there is endogenous insulin production (insulinoma, autoimmune hypoglycemia, or sulfonylureas) because Cpeptide is produced during the processing of proinsulin. As stated above, this patient's laboratory studies are inconsistent with an insulinoma and so there is no reason to consult with a surgeon for possible resection of an insulinoma (choice A). Measuring the blood levels of sulfonylureas (choice C) would be the next step if he had elevated C-peptide levels and you still suspected a factitious disorder. Sulfonylureas stimulate endogenous insulin production and is therefore associated with an elevated C-peptide. The only way to distinguish this from autoimmune hypoglycemia and an insulinoma is to measure drug levels. 33 A CT scan of the abdomen (choice D) is inappropriate because this patient's laboratory studies are consistent with a factitious disorder, not an insulinoma. It is incorrect to tell him that he is malingering (choice E) because malingering means that a secondary gain is present, such as financial gain or the avoidance of unwanted duties. This patient appears to have a factitious disorder, which is the production of symptoms to induce medical testing and assume the sick role. There is no clear secondary gain. A 33-year-old man comes to the emergency department because of a 12hour history of increasing dizziness and palpitations. He tells you that he knows that he is "lapsing into severe hypoglycemia" because of an untreated insulinoma. He is an intensive care nurse at a hospital in a neighboring town but says that he does not like the doctors there so he goes to many different area hospitals. He tells you that he has been treated for hypoglycemia on 3 separate occasions at 3 different hospitals and is too frightened to undergo the surgery to remove the tumor. He tells you that he is otherwise healthy and does not take any medications. His last food intake was 12 hours ago. His temperature is 37.2 C (99.0 F), blood pressure is 130/90 mm Hg, pulse is 11/min, and respirations are 18/min. Physical examination shows diaphoresis and pallor. His glucose level is 35 mg/dL. He has high insulin levels with a decreased C-peptide level. You give the patient glucose-containing fluids and try to obtain his previous medical records from your hospital but they were destroyed in a flood. You are unable to reach any of the other doctors that have treated him in the past. The next step in management is to A. consult with a surgeon for possible resection of the insulinoma B. discuss the possibility that he is producing these symptoms C. measure blood levels of sulfonylureas D. order a CT scan of the abdomen E. tell him that he is malingering Explanation: The correct answer is B. This patient most likely has a factitious disorder (Munchausen syndrome), which is the active production of symptoms to assume the sick role, and so you should discuss the possibility that he is producing these symptoms. Individuals with this disorder are often health care workers who know how to fake symptoms. In this case, this nurse is complaining of hypoglycemia and an insulinoma and while he does have low glucose and high insulin levels, he has a decreased C-peptide level. These values are consistent with exogenous insulin and not an insulinoma. Cpeptide levels are increased when there is endogenous insulin production (insulinoma, autoimmune hypoglycemia, or sulfonylureas) because Cpeptide is produced during the processing of proinsulin. 34 As stated above, this patient's laboratory studies are inconsistent with an insulinoma and so there is no reason to consult with a surgeon for possible resection of an insulinoma (choice A). Measuring the blood levels of sulfonylureas (choice C) would be the next step if he had elevated C-peptide levels and you still suspected a factitious disorder. Sulfonylureas stimulate endogenous insulin production and is therefore associated with an elevated C-peptide. The only way to distinguish this from autoimmune hypoglycemia and an insulinoma is to measure drug levels. A CT scan of the abdomen (choice D) is inappropriate because this patient's laboratory studies are consistent with a factitious disorder, not an insulinoma. It is incorrect to tell him that he is malingering (choice E) because malingering means that a secondary gain is present, such as financial gain or the avoidance of unwanted duties. This patient appears to have a factitious disorder, which is the production of symptoms to induce medical testing and assume the sick role. There is no clear secondary gain. An 81-year-old woman is admitted to the medical floor for depression and questionable dementia. She has a past medical history of insulin-dependent diabetes mellitus, hypertension, and an anterior wall myocardial infarction 10 years ago. She takes nifedipine, atenolol, insulin, aspirin, furosemide, simvastatin, multivitamins, docusate sodium and was recently started on methylphenidate for depression by her primary care physician. She lives at home and her family reports that she has become increasingly withdrawn and confused over the past few months.She is an obese woman in no distress with normal vital signs. Her neck is supple with a normal thyroid, clear lungs, and 1+ non-pitting lower extremity edema. She is alert to person, month, but not to date or location. She has poor concentration. In addition to evaluation of her medication list for potential causes of confusion, the most important test to order in the evaluation of this patient's confusion is A. calcium level B. diffusion weighted MRI of brain C. head CT scan with contrast D. rapid plasma reagin test E. thyroid stimulating hormone Explanation: The correct answer is E. Hypothyroidism is an uncommon cause of confusion. However, in the elderly, especially women, hypothyroidism or subclinical hypothyroidism is extremely common; up to 20% of all medical inpatients in some series. Given this, the evaluation of new confusion or 35 suspected dementia should always include a screening TSH level when the patient is of this age demographically. Calcium level (choice A) is included as well in the initial laboratory evaluation, but interpretation of this test is difficult. The primary reason for this is that asymptomatic hypercalcemia is very common in the elderly, with as much as a 50% prevalence rate. Given this, even the finding of elevated total serum calcium is without obvious significance and hypothyroidism is still a much more common cause of altered mental status despite its lower prevalence. Diffusion weighted MRI of brain (choice B) is an MRI that uses diffusion weighting which allows visualization of areas of acute infarction. This is only used in special circumstances when the question of an evolving infarct is suspected. Head CT scan with contrast (choice C) is not indicated unless there is clinical suspicion for old infarcts or a bleed. Rapid plasma reagin test (choice D) is the screening test for syphilis. Although this test is routinely sent with the panel of tests for the evaluation of dementia, tertiary syphilis is exceedingly rare and not a very common cause of dementia in any age demographic in the United States. A 2-year-old boy is brought to the office for the first time by both his parents for a well-child visit. The family just moved to your city from a small town, where they were very dissatisfied with the medical care. They tell you that the boy has been "a little off since birth." He failed to ever develop a social smile, his face is expressionless, and he does not make eye contact. He often plays by himself in the corner, despite the parent's effort to make numerous playdates with other children his age. They often find him twirling the buttons on his shirt for hours at a time. He appears to be a well-developed child, however he refuses to speak to you. The parents are not actually sure if he is able to speak. The most likely diagnosis is A. attention-deficit hyperactivity disorder B. autistic disorder C. childhood-onset schizophrenia D. oppositional defiant disorder E. Tourette's disorder Explanation: The correct answer is B. This child most likely has autism, which is a pervasive developmental disorder that is characterized by the impairment of social interactions, impairment of communication, and repetitive, stereotyped behaviors. It is more common in boys and in a sibling of a child with autism. It is associated with mental retardation, seizures, and self-mutilation. The 36 treatment includes structured classroom training with behavioral management techniques and haloperidol. Mood stabilizers may decrease the self-harming behaviors. Attention-deficit hyperactivity disorder (ADHD) (choice A) is a childhood disorder characterized by impulsiveness, hyperactivity, easy distractibility, and inattention. Methylphenidate, a psychostimulant, is the pharmacotherapy of choice. Weight loss and insomnia are major side effects. The child in this case is not overactive or inattentive. Childhood-onset schizophrenia (choice C) may be diagnosed in a child that develops positive and negative psychotic symptoms between 5 years of age and adolescence or early adulthood. The children often have normal intelligence. Childhood-onset schizophrenia is often associated with a gradual lifelong decline in functioning and a poor response to medication. Treatment includes antipsychotic agents and structured classroom training with behavioral management techniques. It is unlikely that this 2-year-old child has this disorder. He appears to have impairment of social interactions and impairment of communication, not psychotic symptoms. Oppositional defiant disorder (choice D) is a pattern of behavior characterized by the unwillingness to comply with the rules of others and majorly difficult, disruptive behavior. It is generally regarded as a less severe form of conduct disorder. The child in this case does not fit this description. Tourette's disorder (choice E) is characterized by motor and vocal tics. Patients say that they try to control the behavior, but the urge is often too overwhelming. It is associated with obsessive-compulsive disorder. The child in this case does twirl his shirt buttons a lot, however this is not a tic, which is a sudden, recurrent, rapid behavior. You are called to obtain surgical consent from an 84-year-old man who is hospitalized after suffering a right femoral neck fracture, for repair of that fracture. The patient has a long history of multi-infarct dementia and major depression. He lives with his daughter and her husband. They report to you that he lost his footing while walking and suffered a fall. There was no loss of consciousness and no evidence by history that the fall was syncopal in nature. You read the psychiatric evaluation in his chart that notes that the patient, despite some dementia, confusion, and odd mannerisms, is competent to make his own medical decisions and fully understands the nature of his condition. When you enter the room to obtain consent from the patient for surgery, he responds with situation-inappropriate responses, fails to make eye contact with you, and is not oriented to place or time. The patient has no power of attorney or health care proxy listed in his medical record. The most appropriate course of action is to A. call a family member to consent for the patient B. consent the patient for surgery, he has been cleared by psychiatry 37 C. consent the patient for surgery with a note explaining his condition in the chart D. do not consent the patient for surgery E. perform your own competency test on this patient Explanation: The correct answer is D. Situations such as this frequently arise in in-patient settings. The concept of informed consent has at its core, the requirement that the patient is clear of mind so that they may understand the conversation being had. Although many people argue that most patients fail to understand complex medical issues involved in such decisions, a patient must be at least of a mental status that allows their independent intelligence and thinking ability to be the limiting factor. Calling a family member to consent for the patient (choice A) is only appropriate if that family member has been appointed as a designated health care proxy or has legal power of attorney for the patient. Family members cannot be used as a convenience tool when a patient has altered mental status. Consent the patient for surgery, he has been cleared by psychiatry (choice B) is incorrect because irrespective of what another physician's opinion is, the consenting physician must feel that the patient is able to understand the conversation that they will be having. Consent the patient for surgery with a note explaining his condition in the chart (choice C) presupposes that the surgery being considered is emergent. In such cases, when the patient is an adult and no advance directive exists, the surgery may be performed regardless of mental status. In the case of this patient, since the procedure is non-emergent, consent must be obtained. Performing your own competency test on this patient (choice E) is not an option since competency is a legal term. Judges determine competence. A 48-year-old woman with diabetes mellitus is brought by her ex-husband and son to the emergency department following a suicide attempt by overdosing on "some pills". She has been depressed and saw a counselor after her husband left her for his secretary. She has had a hard time dealing with the separation and has, according to her son, become withdrawn lately. He knows that she was receiving some psychiatric medication from her primary care physician because of pain related to her diabetes mellitus. She has flushed dry skin, dilated pupils, tachycardia, and confusion. After the bottles are checked, it seems that the patient overdosed on amytriptyline. The family is concerned about her. They feel she needs to deal with her psychiatric problem. The most appropriate intervention at this time is to A. admit her to psychiatry for further treatment B. admit her to the intensive care unit 38 C. admit her to the medical floor D. call psychiatry to schedule an outpatient clinic appointment E. talk to her ex-husband about the need to get marital counseling Explanation: The correct answer is B. This patient needs continuous monitoring because she overdosed on a tricyclic antidepressant. This attempt can lead to cardiac arrhythmias and death. This patient also needs close monitoring because of her current delirious condition and suicidality. Thus, the only setting that provides this level of care, even if it is for one day only, should be the intensive care unit. The levels of amytriptyline should be monitored . Admission to psychiatry (choice A) is a reasonable consideration once the patient is medically stable. This decision should be left up to the psychiatry consult team after they have fully evaluated the patient. Admission to regular medical floor (choice C) is not an immediate option. It can be done after the patient has been stabilized in the intensive care unit, and the need for less intense monitoring is established. However, given the patient's serious suicide attempt, suicide precautions should be placed, until the psychiatrist's final decision. An outpatient psychiatry appointment (choice D) is currently not an option since the patient has precipitating events that lead to this suicide attempt. It seems that she currently lacks enough coping skills to handle separation in a more appropriate way. It may be placed later after the acute and critical issues are addressed. Talking to ex-husband about marital counseling (choice E) is not an appropriate thing to do in this situation. Even if there was a possibility of reconciliation, this should be done in therapy on an outpatient basis, by people trained to specifically provide that treatment. A 45-year-old homeless man is brought to an emergency department by ambulance after being found in the street obtunded, combative, and agitated. The patient is unable to provide any history in the emergency room due to his altered mental status. His temperature is 38.1 C (100.6 F), blood pressure is 200/110 mm Hg, and pulse is 110/min. While in the emergency department, the patient has a generalized tonic-clonic seizure lasting approximately 30 seconds. The patient's presentation is most consistent with withdrawal from A. alprazolam B. caffeine C. cocaine D. heroin 39 E. tricyclic antidepressants Explanation: The correct answer is A. Withdrawal from a benzodiazepine, such as alprazolam, is a potentially fatal condition that can involve psychomotor agitation, frank delirium, autonomic instability, and seizures. In this patient, another consideration with a similar clinical presentation would be delirium tremens from alcohol withdrawal. Both conditions would be treated with supportive measures and acute parenteral benzodiazepine treatment. Caffeine (choice B) has a potential withdrawal syndrome associated with irritability, possible concentration difficulties, and headache. However, even abrupt discontinuation of caffeine use is not considered to be at all dangerous. Cocaine withdrawal (choice C) is characterized by intense feelings of dysphoria, loss of energy, increase in appetite, and intense cravings for the drug. It is not usually associated with delirium, autonomic instability, or seizures and does not carry an associated risk of fatality. Heroin withdrawal (choice D) is characterized by piloerection, nausea, and diarrhea and can include modest increases in blood pressure and heart rate. However, it is not characterized by delirium, withdrawal seizures, or autonomic instability and is not considered to carry a high risk of fatality. Clonidine or a long-acting opiate agonists such as methadone are the treatments of choice for withdrawal from heroin. Tricyclic antidepressants (choice E) do not have an associated withdrawal syndrome and may be discontinued abruptly, especially if treatmentemergent complications arise. A 29-year-old woman who just delivered a healthy baby boy 4 days earlier comes to the office because she "is just not feeling right." She says that she has been very anxious and "tearful" over the past 2 days. She is not exactly sure that she is "doing everything correctly" and she feels like she is going to be an incompetent mother. She is on a 2-month maternity leave from her job, but her husband is unable to take any time off. There are tears rolling down her cheeks and her hands are trembling. At this time the most appropriate next step is to A. admit her to the hospital for treatment and observation B. give her a prescription for diazepam and tell her that she can continue to breast-feed C. prescribe fluoxetine and advise her to discontinue breast-feeding while on the medication D. reassure her that this is very common and no medication is indicated at this time 40 E. try to contact her husband and advise him that his wife currently needs extra support and understanding Explanation: The correct answer is D. This patient most likely has postpartum "blues", which is a common term used for the mild depression that more than 50% of women experience approximately 3 days postpartum. This syndrome is characterized by anxiety, confusion, sadness, and irritability. It is usually a self-limited syndrome that spontaneously resolves within 2 weeks. These patients often need reassurance, understanding, and education. It is important for them to receive this extra support from both medical personnel, and their family/spouse. Admission to the hospital for treatment and observation (choice A) is not necessary at this time for what seems like a common case of postpartum blues. Medical, and family support, and reassurance is all that is indicated right now. If she were to begin to display psychotic symptoms with delusions or severe depressive symptoms, hospitalization may be necessary to treat the symptom,s and to prevent suicide or infanticide. It is inappropriate to give her a prescription for diazepam, and tell her that she can continue to breast-feed (choice B), because she seems to be experiencing postpartum blues, which is a very common, transitory disorder. Medication is not generally indicated. Also, she should discontinue breastfeeding if she were to take diazepam. You should not prescribe fluoxetine and advise her to discontinue breastfeeding while on the medication (choice C) at this time. It seems that this patient has postpartum blues, which is a very common syndrome that women experience after giving birth. It is often transitory and only requires support and understanding. True "postpartum depression" is generally not diagnosed until the woman experiences 2 weeks of depressed mood with changes in sleep, guilt, hopelessness, anxiety, fear, jealousy, impaired concentration, and other depressive symptoms. The exact cause is unknown, but it is thought to be due to changes in hormone levels, family history, and stress. It is correct to tell her to stop breast-feeding while taking antidepressants. While it is correct that this woman with postpartum "blues" needs family support now, it is not appropriate to try to contact her husband and advise him that his wife currently needs extra support and understanding (choice E). This woman is your patient and you should try to educate her and reassure her that this is very common. If the husband was in the room at the time, you could try to explain to both of them that this is a stressful time and that everybody needs to give extra support. Calling the husband is not the best choice. A 58-year-old woman is admitted to the hospital with a 2-day history of lethargy and decreased oral intake. She is unable to give a clear history, but her daughter who brought her to the hospital says that she lives alone and 41 she usually calls her every few days. When her mother did not answer her phone she went to her home and found her asleep on the couch with alcohol on her breath. She was difficult to arouse and walked with an unsteady gait. Her mother is reluctant to go to doctors and has lived alone since her husband died 5 years ago. Her mother has always enjoyed drinking but in the last few years has increased the frequency and quantity. She has a history of hypertension but is on no medications. On admission, she appears disheveled and has a non-focal neurological examination. Laboratory studies are normal except for an elevated alcohol level. A CT scan of the head is normal. After 3 days of inpatient hydration and feeding, the patient is feeling much better and is scheduled for discharge. The most important intervention prior to her discharge is A. abdominal pelvic CT scan to evaluate for ascites B. health care proxy C. liver biopsy to assess the extent of alcohol damage D. social work consult to evaluate her living situation and arrange referral to an alcohol abuse program E. benzodiazepines to prevent alcohol withdrawal Explanation: The correct answer is D. The patient's change in mental status was most probably due to her alcohol abuse and this issue should be addressed prior to her discharge. The patient also lives alone which is a potentially dangerous situation for her. The care of patients in the modern health care environment requires a multidisciplinary approach and the ability to work with non-physicians. Social workers can be helpful in referring patients to substance abuse programs and in evaluating their living conditions. At the present time there is no indication to perform a CT scan (choice A) on this patient. On physical exam there is no mention of ascites. Evaluation of ascites usually involves an imaging study of the abdomen along with diagnostic paracentesis. It is important for all adults to have a health care proxy (choice B) to designate an individual to make decisions for them if they become incapacitated. This is especially relevant for the chronically ill or elderly. But this is not the most pressing issue facing this patient. Her alcoholism and living situation should be dealt with prior to discharge and the issue of a health care proxy can be dealt with as outpatient. Liver biopsy (choice C) is indicated in the evaluation of unexplained liver disease or elevated transaminases. This patient has none of the above. She has normal LFTs and no evidence of liver disease on physical exam. She certainly could have occult liver disease secondary to her drinking but this in itself is not an indication for biopsy. The most important measure she could take is to stop alcohol her alcohol consumption. Alcohol abusers who show evidence of withdrawal should certainly receive 42 benzodiazepines to prevent delirium tremens and seizures. But this patient has no clinical signs of withdrawal (autonomic instability or restlessness) or a previous history of seizures when she stops drinking. In addition, she has been stable in the hospital for 3 days and therefore at this point is unlikely to benefit from benzodiazepines (choice E). A 16-year-old boy is brought to the emergency department by the paramedics, accompanied by his parents who called 911. The parents report that their son has been acting strangely off and on for the past couple of weeks. They say that he has been going to parties with his friends and comes home late. He often gets up and is irritable and at times makes inappropriate comments. When asked what he meant by the comments, he would just move on to another topic. In the past week he has been locking himself in his room, playing loud music, and talking loudly, even though there is no phone in his room. This morning he started talking about the great silver cross that can be found buried on the cemetery in the east side of town. He claimed that he was hearing God's voice telling him to fly like a bird through the window and get it. The parents grabbed him as he was reaching for the window. The patient has no prior psychiatric history. Medical history is significant for an appendectomy at the age of 11. The parents say that he was always a good student, and basically a good, somewhat introverted, child. The parents are confident that he is not on any drugs or prescription medication. The family history is negative for psychiatric disorders. The patient looks tired, sleepy, and unkempt. His blood pressure and pulse are slightly elevated, but other than that, his physical examination is unremarkable. He is cooperative with the examination, and oriented appropriately, but seems to be responding to internal stimuli and unable to carry on a meaningful conversation. The most appropriate first step in this patient's management is to A. order a head CT B. place the patient in 4-point restraints C. prescribe an antipsychotic agent D. send urine for drug screen E. set up a psychology consult to do a Rorschach test Explanation: The correct answer is D. The first step in this patient's management would be to order a urine drug screen. Even though the parents seem to think he is not using drugs, his age, recent onset, and history of behavior in the past several weeks may indicate possible drug abuse. Therefore, substance induced psychotic disorder should be ruled out first. Head CT (choice A) is a part of a workup for delirium. It also is a part of the workup for first break psychosis. There seems to be no indication that the patient is delirious and physical exam seems to be normal. If other laboratory vales are unremarkable, a head CT can be done once the patient 43 is admitted to the unit. Putting the patient in 4-point restraints (choice B) is currently not indicated. The patient seems calm, cooperative, and not currently endangering himself or anyone else. However, given the history of commanding hallucinations, close observation of the patient should be in place. Prescribing an antipsychotic (choice C) before the patient has been medically cleared and a provisional psychiatric diagnosis established is not justified. It should be done only in emergency situations, such as when the patient is agitated and there is increased paranoia, hallucinatory behavior, etc. If it is done, it should be only as a temporary measure until the final disposition is made because of the possibility of side effects and the need to follow up on treatment results. This patient is being cooperative, and is not combative and so this is not immediately necessary, it can wait until a more thorough evaluation is performed, including a drug screen. A psychology consult to do a Rorschach test(choice E) is not necessary at this point. Rorschach is projective test that is used to test for psychotic material. Since this patient seems overtly psychotic and actively responds to internal stimuli, it would be difficult and fruitless to perform this test. A 16-year-old boy is brought to the emergency department by the paramedics, accompanied by his parents who called 911. The parents report that their son has been acting strangely off and on for the past couple of weeks. They say that he has been going to parties with his friends and comes home late. He often gets up and is irritable and at times makes inappropriate comments. When asked what he meant by the comments, he would just move on to another topic. In the past week he has been locking himself in his room, playing loud music, and talking loudly, even though there is no phone in his room. This morning he started talking about the great silver cross that can be found buried on the cemetery in the east side of town. He claimed that he was hearing God's voice telling him to fly like a bird through the window and get it. The parents grabbed him as he was reaching for the window. The patient has no prior psychiatric history. Medical history is significant for an appendectomy at the age of 11. The parents say that he was always a good student, and basically a good, somewhat introverted, child. The parents are confident that he is not on any drugs or prescription medication. The family history is negative for psychiatric disorders. The patient looks tired, sleepy, and unkempt. His blood pressure and pulse are slightly elevated, but other than that, his physical examination is unremarkable. He is cooperative with the examination, and oriented appropriately, but seems to be responding to internal stimuli and unable to carry on a meaningful conversation. The most appropriate first step in this patient's management is to A. order a head CT B. place the patient in 4-point restraints C. prescribe an antipsychotic agent 44 D. send urine for drug screen E. set up a psychology consult to do a Rorschach test Explanation: The correct answer is D. The first step in this patient's management would be to order a urine drug screen. Even though the parents seem to think he is not using drugs, his age, recent onset, and history of behavior in the past several weeks may indicate possible drug abuse. Therefore, substance induced psychotic disorder should be ruled out first. Head CT (choice A) is a part of a workup for delirium. It also is a part of the workup for first break psychosis. There seems to be no indication that the patient is delirious and physical exam seems to be normal. If other laboratory vales are unremarkable, a head CT can be done once the patient is admitted to the unit. Putting the patient in 4-point restraints (choice B) is currently not indicated. The patient seems calm, cooperative, and not currently endangering himself or anyone else. However, given the history of commanding hallucinations, close observation of the patient should be in place. Prescribing an antipsychotic (choice C) before the patient has been medically cleared and a provisional psychiatric diagnosis established is not justified. It should be done only in emergency situations, such as when the patient is agitated and there is increased paranoia, hallucinatory behavior, etc. If it is done, it should be only as a temporary measure until the final disposition is made because of the possibility of side effects and the need to follow up on treatment results. This patient is being cooperative, and is not combative and so this is not immediately necessary, it can wait until a more thorough evaluation is performed, including a drug screen. A psychology consult to do a Rorschach test(choice E) is not necessary at this point. Rorschach is projective test that is used to test for psychotic material. Since this patient seems overtly psychotic and actively responds to internal stimuli, it would be difficult and fruitless to perform this test. A 66-year-old woman comes to the office because of difficulty sleeping, a decreased appetite, fatigue, an inability to concentrate, and a general "down" mood for the past 2 weeks. She states that she and her husband are going on a 3-week trip to Italy and France next month, and she "wants to get to the bottom of this" before they go. She has been coming to you since her first child was born, and over the years you have treated her for gastroenteritis, several yeast infections, and most recently, high blood pressure. She has always been a very compliant patient. You notice in her chart that you prescribed propranolol for her hypertension 1 month ago, after trying to control it with weight reduction, smoking cessation, alcohol elimination, salt and fat reduction, and aerobic exercise. Her blood pressure at 3 previous visits was 150/90 mm Hg and today it is 135/80 mm Hg. She does not take 45 any other medications. At this time you should A. advise her to start a "gentle" walking routine to "lift her spirits" B. advise her to stop taking propranolol and give her a prescription for hydrochlorothiazide C. explain to the patient that she is stressed about her trip, and these symptoms will pass D. give her a prescription for tranylcypromine E. increase the dose of propranolol and prescribe phenelzine Explanation: The correct answer is B. The symptoms of change in appetite, fatigue, insomnia, lack of concentration, and worthlessness for greater than 2 weeks are consistent with depression. Propranolol is one of the most common pharmacological agents to cause depression. Other side effects of propranolol include dizziness, bronchospasm, nausea, vomiting, diarrhea, and constipation. It may also precipitate asthma, congestive heart failure, and hypoglycemia in susceptible patients. The patient should be switched to another antihypertensive agent. Just advising her to start a "gentle" walking routine to "lift her spirits" (choice A) is inappropriate because she is having real depressive symptoms that are most likely due to the propranolol. It is inappropriate to explain to the patient that she is stressed about her trip, and these symptoms will pass (choice C). She is obviously having real symptoms that require serious attention, and in this case the depressive symptoms are most likely due to propranolol. It is inappropriate to give her a prescription for tranylcypromine (choice D) because her depressive symptoms are most likely due to propranolol. Also, tranylcypromine, which is an MAOI, is not the best first choice for an antidepressive agent due to the necessary dietary restrictions and the risk of orthostatic hypotension. If you were going to give her an antidepressant, an SSRI or a tricyclic, such as nortriptyline, is better because of the relatively low risk of orthostatic hypotension or anticholinergic effects. Since propranolol is most likely causing her depressive symptoms, it is incorrect to increase the dose of propranolol and prescribe phenelzine (choice E). Also, phenelzine, which is an MAOI, is not the best first choice for an antidepressive agent due to the necessary dietary restrictions and the risk of orthostatic hypotension. A 39-year-old woman comes to the office for a periodic health maintenance examination. You have been treating her for anorexia nervosa for the past 15 years. She has required 4 hospitalizations during this time. She tells you that she is "doing as well as can be expected" now and that she has a new boyfriend who is very helpful. She is 157 cm (5 ft 2 in) tall and weighs 41 kg 46 (90 lb). She admits that she still does not have a menstrual period. Her temperature is 36.7 C (98.0 F), blood pressure is 100/70 mm Hg, and her pulse is 55/min. Physical examination shows lanugo, dry, scaly skin, yellow discoloration of the palms, and pharyngeal abrasions. At this time the most correct statement is: A. Electrocardiography will show shortened QT intervals B. Fluoxetine is not effective in reducing binge eating and purging episodes C. Her immune function is seriously affected and she is at risk for severe infections D. Laboratory studies will show hyperkalemia E. She is at an increased risk for developing osteoporosis Explanation: The correct answer is E. This patient has anorexia nervosa with some signs of purging (pharyngeal abrasion) and she is at an increased risk for developing osteoporosis. The exact cause for decreased bone density in unknown, but some believe that it is due to estrogen deficiency or cortisol excess. It is interesting to note that giving estrogen replacement therapy to these patients has not been shown to restore bone density. Individuals with anorexia are at an increased risk for developing ventricular arrhythmias and sudden death. An EKG often shows prolonged QT intervals, not shortened QT intervals (choice A). It is incorrect to say that fluoxetine is not effective in reducing binge eating and purging episodes (choice B) because it has been shown to be effective. While anorexia nervosa is sometimes associated with leukopenia and low levels of IgG and IgM, severe immune dysfunction and severe infections are very rare. Therefore, it is incorrect to say that her immune function is seriously affected and that she is at risk for severe infections (choice C). Hypokalemia, not hyperkalemia (choice D), is often found in patients with anorexia nervosa. This is thought to be secondary to vomiting and other behaviors common in anorexics. A 35-year-old homeless man is admitted to the hospital because of psychosis and agitation. He received intramuscular haloperidol while in the emergency department 16 hours earlier. He is now obtunded, with a temperature of 39.1 C (102.4 F) and has muscular rigidity. He has had wide fluctuations in blood pressure over the past 12 hours. Laboratory studies show a creatine phosphokinase in excess of 20,000 U/L and a leukocyte count of 12,800/mm3. Supportive measures such as intravenous fluids and airway support are given and the patient is noted to be hemodynamically stable. The pharmacologic agent that would be contraindicated at this time is 47 A. acetaminophen B. benztropine C. bromocriptine D. dantrolene E. lorazepam Explanation: The correct answer is B. The patient has a diagnosis of neuroleptic malignant syndrome due to rapid administration of high doses of intramuscular haloperidol. The patient's relatively young age and male sex are predispositions for the development of neuroleptic malignant syndrome, though the biggest risk for any patient is the rapid administration of high potency neuroleptics. Because of the patient's fever and autonomic instability, benztropine, an anticholinergic medication with a tendency to promote heat retention, would be contraindicated in a patient with neuroleptic malignant syndrome. Because of the high fevers associated with neuroleptic malignant syndrome, an antipyretic such as acetaminophen (choice A) that is usually given parenterally may be necessary. Bromocriptine (choice C) is a dopamine agonist that is frequently used in the treatment of neuroleptic malignant syndrome. One of the etiologic theories of neuroleptic malignant syndrome is a dysregulation of dopamine receptors in the hypothalamus resulting in impairment in body temperature control from overblockade of hypothalamic dopamine receptors. Dantrolene (choice D) is a muscle relaxant frequently used in the treatment of neuroleptic malignant syndrome and may have efficacy in preventing renal failure secondary to myoglobinuria. Lorazepam (choice E) can be used in the treatment of neuroleptic malignant syndrome both for its muscle relaxant and sedative qualities. A 4-year-old girl is brought to the emergency department by her parents because of pain and swelling in the girl's right forearm. The father says that the girl was playing on a swing when she fell off and landed on her arm. Physical examination reveals edema and erythema over the distal aspect the right forearm. The girl does not want her arm to be touched and is crying quietly. A radiograph of the right forearm demonstrates a small corner fracture in the distal metaphysis of the radius. You are concerned about this child because the head nurse tells you privately that this is the child's third emergency department visit in the last 6 months. You decide to discuss your concern for the child and the need for further evaluation with the parents. As you are talking to them, the father becomes very angry and says he would like to take his daughter home immediately. The most appropriate step for 48 you to take now is A. admit the child to the pediatrics service for evaluation and protection B. keep the child in the emergency department and call the police to report child abuse C. keep the child in the emergency department until another relative or family friend is found that can care for her D. send the child home with her parents and call the police to report child abuse E. send the child to a foster care facility for protection Explanation: The correct answer is A. In all suspected cases of child abuse and neglect, the physician has the authority to admit a child to the hospital for further evaluation and protection against the wishes of the child's parents. In fact, since the passage of the Child Abuse and Prevention Act, most states have passed legislation to make the reporting of all cases of suspected child abuse and neglect, by physicians and most healthcare workers, mandatory. Signs of child abuse include multiple injuries that require visits to the emergency department, fractures of varying ages, and “corner” fractures of the metaphysis of long bones which are usually sustained by a twisting type trauma. Since there is enough suspicion in this case for physical abuse, you not only have the authority, but are required to protect this child and to report the situation to the child protective service agency. The most appropriate action is to admit the child for further evaluation and protection. Keeping the child in the emergency department and calling the police (choice B) does not address the problem of what to do with the child. The appropriate authority to notify in suspected cases of child abuse and neglect, is the child protective service agency. Keeping the child in the emergency department until another relative can be found (choice C) is not appropriate. The goal is to provide protection for the child as well as to further evaluate her for signs of abuse. This cannot be accomplished if the child is released with another adult. The most appropriate action is to admit the child to the hospital for evaluation and protection. Sending the child home with her parents and calling the police (choice D) is inappropriate in this case. There are enough signs of possible child abuse in this case that the child should get further evaluation as well as protection from further potential abuse. It is a physician's duty to protect the child by admitting her to the hospital and calling the child protective service agency. Sending the child to a foster care facility (choice E) at this time is premature. Child abuse is suspected and the child should be admitted to the hospital for further evaluation as well as protection from potential abuse. If child abuse is established and if the home setting carries a high risk to the child's health, temporary removal from the home is considered. Removal requires a court 49 petition, presented by the legal counsel of the appropriate welfare department. The procedure varies from state to state, but usually entails a family court testimony by a physician. A 57-year-old man with schizoaffective disorder, whose symptoms were in remission until 2 weeks ago, is brought to the emergency department by his girlfriend. He will not talk with you but the girlfriend tells you that he has a history of "overdoses", and she is afraid he has taken a lot of "his pills". He has been complaining of voices telling him he "should be dead". He has not left the house in a month and has spent several hours a day looking out the window for the "king and savior" to "come take him". His medications include haloperidol, valproic acid, and a small dose of amitriptyline for chronic pain related to nerve damage in his leg, which occurred in a motor vehicle accident 10 years ago. He has no other medical problems. A chart review reveals that he has no allergies and was diagnosed with schizoaffective disorder 30 years ago. His temperature is 37.0 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 26/min. He is a depressed appearing man with very poor eye contact. He smells of alcohol. He does not acknowledge you, but will answer some questions for his girlfriend. He does admit to feeling that "life is not worth living" and feeling "more religious than usual". He seems slightly drowsy and knows the date. His physical examination is normal. The most appropriate next step in management is to order A. acetaminophen and salicylate levels B. blood alcohol level C. electrocardiography D. urine toxicology for street drugs E. valproic acid level Explanation: The correct answer is C. This patient may have taken several cardiotoxic medications. Haloperidol and other antipsychotics increase the QT interval, as do the tricyclics. In an overdose for either medication, he is at risk for sudden death from torsades. Acetaminophen and salicylate levels (choice A) and urine toxicology (choice D) are helpful in patients suspected of intentional overdose, but as above, risk for sudden death is the immediate concern. A blood alcohol level (choice B) and a valproic acid level (choice E) are reasonable choices for a lethargic patient, but this patient is awake and alert and is not showing signs of CNS depression. A 37-year-old man has been coming to you for a month for management of 50 depression that has not improved despite "years of wasted psychiatrist visits." You prescribed a full dose of fluoxetine 4 weeks earlier after you ruled out a medical etiology for his condition. He returns today to tell you that he has not noticed any improvement in his mood, energy level, or ability to concentrate. He promises you that he is taking the medication exactly as prescribed and that he is not drinking any alcohol. Physical examination is unremarkable. He denies any suicidal ideation and does not have any psychotic symptoms. He really wants you to prescribe a different medication. At this time you should A. add buspirone to his current treatment regimen B. advise him to go back to his psychiatrist C. explain that fluoxetine requires at least 5 weeks to reach a steady state and that treatment response should be reevaluated in 2-4 weeks D. recommend that he taper the medication over a week and initiate a trial with a different agent E. tell him that the medication is probably not working because he has a negative attitude Explanation: The correct answer is C. Fluoxetine is a serotonin reuptake inhibitor that requires 5 weeks to reach a steady state in the body and takes approximately 6-8 weeks to show an adequate response. This should be explained to patients before and during treatment to help them understand the importance of staying on the medication even though they do not feel any effects. Adding buspirone to his current treatment regimen (choice A) may be the appropriate management in the future but at this time, you should not make any additions until the full response has been achieved (at least 6-8 weeks). While a psychiatrist may be helpful, it does not seem like he was very successful with his old psychiatrist. Advising him to go back to his psychiatrist (choice B) is not the best idea. You should first try to explain that he should give the medication a chance to work and if there is still no improvement, a referral to a mental health specialist should be made. Recommending that he taper the medication over a week and initiate a trial with a different agent (choice D) is appropriate after unacceptable side effects develop or after the 6 weeks, if the target dose of the drug results are inadequate. It is too early to say that this medication is not working. While a positive attitude is usually helpful, it is incorrect to tell him that the medication is probably not working because he has a negative attitude (choice E). "Blaming" the patient is inappropriate and it is not a good way to maintain a good physician-patient relationship. A 68-year-old man is admitted to the hospital for weight loss, anemia, and worsening of his stomach pain that he thinks is due to an ulcer. However, the 51 results of tests that are performed confirm the diagnosis of an inoperable cancer. You are told that when one of your residents tried to break the news to him, he became mad, frustrated, and began to yell. He accused him of being ignorant and threatened to sue him. You go to see the patient and he says, "You think I am crazy and don't see what you are doing? They called you so that I don't sue your young doctor for not knowing what he is doing. You just want to help your buddies here, but you really can't help me". The most appropriate management is to A. clarify that the other physician is not a "buddy" and offer to help him explore his decision about a lawsuit B. empathize with his feelings of anger, grief, and fear indicating that anger is a defense against intolerable emotions C. explain that suing physicians is not always successful, and instead suggest that the patient should take care of his affairs given his prognosis D. offer to refer the patient to another team and physician in order to help him find someone he can trust E. sympathize with how badly he is treated and support the lawsuit Explanation: The correct answer is B. The appropriate intervention is to validate the patient's feelings of anger and fear in order to help him deal with his powerlessness in this situation. One must remain neutral, and yet recognizes the difficulty of the patient's position. Clarifying that physicians are not buddies (choice A) shows anger and frustration towards the other physician. It is confrontational, and even though exploring a lawsuit decision offers some comfort, this intervention with a frustrated patient would only increase his anger. Explaining that a lawsuit won't succeed and making sure that the patient understands the fatality of his diagnosis (choice C) indicates the doctor's frustration and the need to punish the "nasty patient". This intervention is inappropriate and would likely increase the patient's frustration even more. Offering to refer the patient to another team (choice D) is sending a message of avoidance and confirming wrongdoing. It is not an intervention that helps the patient deal with his feelings, but rather confirms his suspicion. Sympathizing (choice E) with the patient means recognizing the patient's feelings as justified and taking his side. It is not helping, but rather contributing to the patient's anger. A 50-year-old woman comes to the office because of a "discrete right-sided breast mass." She says that she discovered it in the shower 9 months ago, and has been to 6 different physicians for evaluation. None of the other physicians were able to palpate this " mass" and so they told her that it must be "in her head." This is the first time that you are seeing this patient, so you 52 ask her to review her complete history. She is a married homemaker and is the mother of 2 children who are both at out-of-town colleges. Her husband is a traveling salesman. She has not had any medical problems in the past, and her family history is unremarkable. Menarche was at age 14 and she is still menstruating. She exercises 3 times a week, eats a low-fat diet, and drinks 13 glasses of wine a week. She has had normal Pap smears for the past 30 years and has never had a mammogram. She tearfully tells you that her best friend died of breast cancer 2 years ago. She denies any episodes of "sadness", insomnia, or feelings of hopelessness, helplessness, or guilt. Physical examination is completely normal. You cannot palpate any breast masses, even after she guides you to the "exact location" on the right breast. You send her for a mammogram and a breast sonogram, and tell her that you will let her know the results as soon as they return. The results, which return in 2 days, show normal breast tissue and no abnormalities. You have your nurse call the patient and tell her to schedule an appointment at her convenience to discuss the results. Today, at the return visit, you explain the results of the tests and she still seems to feel that there is "something there." You try to be as patient as possible and tell her that there is most likely no mass present. She looks at the ground and says that it "will show up" if you order more studies. After you discuss the situation further, the most appropriate next step is to A. advise her to voluntarily commit herself to the hospital for psychiatric evaluation B. encourage her to get a "second opinion" from another general physician C. order a CT scan of the chest D. order a fine needle aspiration of the right breast E. schedule regular weekly 15 minute appointments and recommend that she also see a psychiatrist Explanation: The correct answer is E. This patient most likely has hypochondriasis, which is a disorder where the patient has a firm conviction of having a serious illness, despite repeated evidence to the contrary. Even when presented with definitive evidence, these patients remain convinced that they are ill. Patience, compassion, regularly scheduled appointments, and collaboration with a psychiatrist may be effective in treating these patients. Since this patient is not depressed, suicidal, or homicidal, hospitalization (choice A) is not indicated. She should probably go to talk to a psychiatrist, and make regularly scheduled appointments to see you. A "second opinion" (choice B) is not necessary in this case of hypochondriasis because she has already seen 6 other physicians, and does not seem to have a breast mass. She needs regularly scheduled appointments, and she should see a psychiatrist. Because the clinical breast examination, mammogram, ultrasound, and CT 53 scan were unremarkable, a CT scan (choice C) and a fine needle aspiration (choice D) are not necessary. This patient most likely has hypochondriasis and usually a thorough medical work-up is enough, but unnecessary procedures should be discouraged. Also, a FNA is used when there is a discrete mass, and there is nothing in this case. A 32-year-old pregnant woman comes to the office because of "terrible headaches." When asked to describe the headaches, she states that there is just a "general, constant tenseness." She is unable to identify any specific triggers. She has been coming to you for periodic health maintenance examinations for the past few years, but has been going to an obstetrician that her mother-in-law recommended for routine prenatal care. Over the years, you have noticed that she has become more and more withdrawn, and you have tried to gently approach the issue several times but she always changes the subject. She has been married to a prominent lawyer, whom you have never met, for the past 8 years. A neurologic examination is normal. The medical gown falls open during the examination and you notice multiple purple and yellowish-green ecchymoses on her breasts. When asked to tell you about these findings, she looks down to the floor and quietly says that she is "clumsy" and is "always banging into something." As she raises her head, you notice that her cheeks are wet and that she is sniffling. The most appropriate remark at this time is A. "How long has your husband been abusing you?" B. "I believe that your husband has been abusive for a while. Why would you stay with him?" C. "Those bruises are caused by a clotting abnormality that is common during pregnancy" D. "Why haven't you told me that your husband is abusive during our previous appointments?" E. "You need to leave your husband as soon as possible." F. "You seem really upset about the circumstances under which you got those bruises." Explanation: The correct answer is F. This patient is most likely a victim of spousal abuse and it is important to call attention to the inconsistencies between her response and her body language by saying, "You seem really upset about the circumstances under which you got those bruises." It is usually good to start out the conversation with an open-ended question, like "tell me about these bruises." When she got visibly upset and made up an unlikely excuse, it is appropriate to confront her (to point out that there is a discrepancy with her statement and behavior). You can tell that she is upset because she is looking down at the floor, speaking quietly, and obviously crying (wet cheeks and sniffling). Spousal abuse is very common and women typically seek medical attention for headaches, abdominal pain, pelvic pain, or depression. It is rare that they come in complaining of spousal abuse. The physician 54 must be able to recognize the signs and symptoms of abuse. It is not correct to ask her, "How long has your husband been abusing you?" (choice A), "I believe that your husband has been abusive for a while. Why would you stay with him?" (choice B) or "You need to leave your husband as soon as possible" (choice E) because she has not yet told you that she has been abused. To maintain a good doctor-patient relationship it is important to allow the patient to feel comfortable and share information with you, without feeling like you are jumping to conclusions. It is best to try to get her to talk to you, rather than you automatically "blurting out" your opinions and putting her on the defensive. A direct question, such as "does your husband ever hit you?" may be necessary, but it is best to start out by allowing the patient to describe the situation and speak freely. From the physical examination and her body language, it seems more likely that she is a victim of spousal abuse than a coagulopathy. Therefore it is incorrect to tell her that "Those bruises are caused by a clotting abnormality that is common during pregnancy" (choice C). Also, it is not normal to have multiple bruises in various stages of healing on the breasts during pregnancy. It is inappropriate to ask her, "Why haven't you told me that your husband is abusive during our previous appointments?" (choice D), because this automatically puts her on the defensive. You should never "accuse" a patient of not acting in the way which you think is best. She is obviously very upset about the situation, and you will only make her feel worse by this statement. Patients should not be criticized about their decisions. This will only alienate them and destroy the doctor-patient relationship that is built on trust and confidence. You are notified that one of your patients, a 32-year-old woman, delivered a healthy baby girl 6 hours earlier. You happen to be in the hospital discharging another patient, so you go to the labor and delivery floor to see her. You have been treating her for dysthymia and for a couple of episodes of major depressive disorder over the years. She developed postpartum "blues" after her last child was born that resolved spontaneously after 5 days. You hear a woman screaming as you get off the elevator and head towards her room. As you get closer, you recognize the voice and realize that it is your patient. She is running around her room, tearing off the hospital gown, and yelling that, "they are coming to get her." When she sees that you are standing in the room, she begins to throw flower vases, the telephone, and the bedding at you. The nurses appear and tell you that she has been very disorganized and has had bizarre, grandiose delusions. She then goes back to the nurse's station. You notice the newborn in the corner of the room. The most appropriate next step is to A. ask the nurse to get haloperidol from the medication closet B. call for an immediate psychiatry consultation 55 C. encourage her to breastfeed and bond with her newborn D. remove the newborn from the room E. try to talk to her and calm her down Explanation: The correct answer is D. This woman is experiencing postpartum psychosis and may harm herself and/or her newborn. You must immediately remove the newborn from the room before the mother has a chance to harm her. Postpartum psychosis is a relatively uncommon disorder that may affect women with bipolar disorder, depression, and schizophrenia. It may also occur in women with no previous psychiatric history. The treatment includes the protection of the newborn, the administration of an antipsychotic medication, and observation. Both suicide and infanticide may occur with postpartum psychosis. Haloperidol (choice A) is part of the acute treatment of postpartum psychosis. However the action that is most likely to have the most immediate effect is to remove the newborn from the room as fast as possible and then to administer medication to the mother. The antipsychotic agent will not have an immediate effect so it is first mandatory to protect the baby from the mother's rage. An immediate psychiatry consultation (choice B) may be necessary, but it is important to first protect the newborn by removing her from the mother's room. At this time it is completely inappropriate to encourage her to breastfeed and bond with her newborn (choice C). This woman most likely has postpartum psychosis and is out of control. You must remove the newborn from the room and then administer antipsychotic agents. She then needs close observation. Encouraging bonding at this time may only worsen her condition and endanger the life of the baby. After you remove the baby from the room and administer an antipsychotic agent, you can try to talk to her and calm her down (choice E). It will most likely be useless to do this before the medication, and you first need to remove the infant from this violent situation. A 37-year-old obese man comes to the office because he has been "feeling really bad lately." He says that for the past three months he has been having trouble sleeping and has not been "in the mood" to go out. He has even stopped going to basketball games with friends, which was his favorite hobby. He has missed many days of work and finds it very difficult to concentrate. He states that he feels "pretty helpless." All of his friends from college are married with kids, and he says that he "can't even get a date," so he basically gave up on having a family. He just feels "worthless". The most vital question to ask at this time is 56 A. "Are you currently questioning your sexual orientation?" B. "Do you ever feel like 'life really is not worth it and that you should end it all'?" C. "Do you think that your life would be much better if you were dating?" D. "Have any of your friends ever tried to set you up on a blind date?" E. "Why haven't you tried to lose weight?" Explanation: The correct answer is B. This patient has symptoms suggestive of major depressive disorder, and assessment of suicide risk is paramount in interviewing him. Depressed patients have a significantly higher risk of attempting suicide compared with the general population. Therefore, determining whether a depressed patient is at high risk is essential early in their management. "Are you currently questioning your sexual orientation?" (choice A) is incorrect because it is most important to ask about suicidal ideation at this time, and it does not seem like this question applies to this case. It is important for physicians to remain open about issues concerning sexuality, and when one questions a patient about sexual orientation, it is appropriate to remain nonjudgmental and ask, "Are you sexually active with women, men, or both?" This, however, is not the most vital question in this case. "Do you think that your life would be much better if you were dating?" (choice C) and "Have any of your friends ever tried to set you up on a blind date?" (choice D) are not vital questions at this time and will not immediately affect your management. This patient has symptoms suggestive of major depressive disorder and therefore must be asked about suicidal ideation. "Why haven't you tried to lose weight?" (choice E) is an inappropriate question because it sounds like you are accusing him of not trying to lose weight. Also, his weight is not the most important issue at this time. While obesity is associated with many serious medical conditions, his depression may lead him to commit suicide soon, and it is therefore vital to assess his risk. A 54-year-old woman comes to your office. She has been your patient for several years, and you usually see her for her annual physical. You have long suspected depression because of her vague somatic complaints, but she has previously denied being in a depressed mood or anhedonia. At this visit she admits to feeling depressed "more often than not" and she is no longer interested in her gardening club or playing with her grandchildren. She tearfully reports increasing difficulty in falling asleep and exhaustion during the day for the last several weeks. She has a decreased appetite and has lost 25 pounds in the last 3 months. She denies suicidality, homicidality, or psychotic symptoms. She denies drug and alcohol use. She is a depressed- 57 appearing woman with very poor eye contact and moderate psychomotor retardation. She scores a 29/30 on the Mental Status Exam. Her physical examination is normal. You review the chart, and recall this patient has no allergies and her only medication is estrogen replacement status post a total hysterectomy 10 years ago. You order a TSH and decide to start an antidepressant. You prescribe a selective serotonin reuptake inhibitor. You should advise her that A. she should call you if you she has any problems, but most people have no difficulty with this medicine B. early on, this medicine can cause headaches and nausea, while later on, some people have a decreased desire for sex or an increase in the time to orgasm C. early on, this medicine can cause an increase in thirst and urination, while later on, some people have a decreased desire for sex or an increase in time to orgasm D. early on, this medicine can cause weight gain and hair loss, while later on, some people have a decreased desire for sex or an increase in the time to orgasm E. early on, this medicine can cause muscle rigidity and tremors, while later on, some people have a decreased desire for sex or an increase in the time to orgasm Explanation: The correct answer is B. Headaches and GI distress are common side effects that usually resolve in the first week of treatment. If the patient cannot tolerate a lower dose, change the medicine. Sexual side effects usually begin a few weeks into treatment. She should call you if you she has any problems, but most people have no difficulty with this medicine (choice A) is incorrect because sexual side effects should be described specifically, and discussed during the follow up visits, although many people tolerate the SSRIs without any problems. Sexual side effects are the most common reason SSRIs are stopped. Obviously she should be told to call if there are any problems, but first you should advise her about the common side effects. Early on, this medicine can cause an increase in thirst and urination, while later on, some people have a decrease in desire for sex or an increase in time to orgasm (choice C) is incorrect. Lithium can cause diabetes insipidus and patients will report an increase in thirst and urination. Early on, this medicine can cause weight gain and hair loss, while later on some people have a decreased desire for sex or an increase in the time to orgasm (choice D) and early on this medicine can cause muscle rigidity and a tremor (choice E) is incorrect. Antipsychotic medicines can cause parkinsonian symptoms. Patients will have bradykinesia, rigidity, postural instability, and tremor. 58 A 35-year-old woman comes to the office asking you to drug test her 12-year-old son. She states that her son is normally a very kind and interactive child, however, for the last 3 months, he has become increasingly withdrawn. He is in his room most of the time except for when he is at school. His grades have dropped from an A- average to C- this past semester. He refuses to see any of his friends and does not even eat much during dinner anymore. She has confronted her son multiple times about his situation, but he continually denies everything, including drug or alcohol use. The mother is visibly upset at this situation and is tearful about it. She tells you that you are her son's "only help." The most appropriate response to the mother's request is: A. "Just bring your son in and we can then get a urine test for alcohol and substance use." B. "I am sorry but I can't legally test your son for any drugs without him consenting to it first." C. "It is possible that your son may be suffering from depression and I think that you should bring him in for me to talk to him." D. "These are classic symptoms for schizophrenia. The best thing to do would be to start him on some anti-psychotic medications." E. "Your son is most probably abusing drugs and alcohol, so you should send him to a rehabilitation facility immediately." Explanation: The correct answer is C. The mother is right to be concerned over her son's change in behavior. Certainly drugs and alcohol abuse can cause such dramatic behavioral changes. However, more likely would be a mental illness such as depression. The DSM–IV criteria for major depressive episode includes that at least one of the symptoms is either (1) depressed mood or (2) loss of interest in pleasure. The patient would also need to have 5 (or more) of the symptoms such as depressed mood, weight loss, insomnia, fatigue, suicidal tendencies, etc. Additionally, the symptoms should cause clinically significant distress or social impairment. It would also be important to screen the son for suicidality when the mother brings him in. "Just bring your son in and we can then get a urine test for alcohol and substance use." (choice A) would be appropriate if the son consented to the drug test. However, covert use of the son's urine would only cause him to distrust not only his mother but also the physician, making any future interventions more difficult. "I'm sorry but I can't legally test your son for any drugs without him consenting to it first." (choice B) is not true because the child is a minor and the parent is consenting to a drug test. However, it wouldn't be going to the root of this child's problem since he most likely suffers from a depressive disorder. "These are classic symptoms for schizophrenia. The best thing to do would be to start him on some anti-psychotic medications." (choice D) would be a premature statement since the diagnosis of schizophrenia requires both positive and negative symptoms occurring for 6 months. However, further questioning of the child may reveal that he is having a beginning prodrome for schizophrenia and starting him on anti-psychotics may be appropriate in the future. "Your son is most probably abusing drugs and alcohol, so you should send him to a rehabilitation facility immediately." (choice E) is inappropriate given the high likelihood 59 that the son is suffering from depression. It is important to make sure that his depression is not due to the direct effects of a substance (e.g., a drug of abuse, a medication). However, evidence of substance abuse should first be obtained through discussion with the son or consented toxicology screens. 60