Psychiatry MS3 Board Review2012-2013

1. Dementia in Contrast to Delirium has which of the following clinical features?

A. Acute onset B. Disrupted AttentionC. Acutely worse cognitive dysfunctionD. Fluctuation of symptomsE. Impoverished speech

E Memory problems + (1/4) Aphasia, apraxia, Agnosia, Executive functioning*

2. A 6 year old boy comes to the doctor with a history of complaint of constantly getting in trouble at school for talking out of turn, running and he just doesnt listen. Mother has placed the child in a smaller individualized class but he continues to have difficulty focusing and is falling behind in school. The psychiatrist prescribes methylphenidate. Which is a possible side effect of this medication?

A. SeizureB. Motor TicsC. Weight loss/anorexiaD. insomniaE. All of the above

E. *

3. Which of the following is an approved medication for Treatment of Alzheimers Dementia?

A. ParoxetineB. SertralineC. HaloperidolD. RivastigmineE. methylphenidate

D. Rivastigmine cholinesterase inhibitor*

4. 55 year old patient with history of bipolar is admitted after intentional overdose with altered mental status, ataxia and then has a seizure. Thorough workup reveals Lithium level of 4.1 meq/L. Which of the following treatments would be recommended?

A. IV normal salineB. Emergent dialysisC. Administration of IV benztropineD. Cardiac MonitoringE. Flumazenil

Diarrhea, vomiting, weakness, dizziness, slurred speech 1.5-2.0Giddiness or confusion, ataxia, blurred vision, hyperreflexia, tinnitus and large output of dilute urine 2.0-3.0Multiorgan involvement and seizures and can be fatal (>3.0)Dialysis usually required for elevated levels: Chronically >2.5 acutely >4.0

T wave flattening*

5. A 57 y/o homeless male is brought into the Emergency Dept after he was found acting confused in a local park. Police noted the man to be stumbling and unable to maintain his gait. He seemed altered and could not give answers to simple questions. On arrival, patient remained confused, he was disoriented to person, time, and place. He was unable to walk on his own and had noted ophthalmoplegia on physical exam. Which of the following most likely explains his presentation?A. Alcoholic hallucinosisB. Wernickes encephalopathyC. Korsakoff syndromeD. DementiaE. Schizophrenia

*B. Wernickes encephalopathy is characterized by impairment of consciousness, ataxia, and ophthalmopegia, typically palsy of the sixth cranial nerve. These symptoms reverse rapidly with administration of vitamin B1 (thiamine). Alcohol hallucinosis, schizophrenia, and dementia by definition occur without impairment of consciousness. Korsakoff syndrome is characterized by anterograde amnesia and impairment in learning. Usually seen after Wernickes encephalopathy (esp. if untreated). Sensorium is intact with relative preservation of long term memory. Confabulation can be present.

6. A 1 y/o girl is brought in to the physician by her mother. The child had been developing normally until about 6-9 months of age. At 9 months, her mother noticed that the girls head growth had begun to decelerate, she seemed floppy, and she had lost interest in playing. She had recently been noted to have episodes of crying, screaming, and intense hyperactivity. Which of the following is the most likely diagnosis?A. Aspergers disorderB. Down syndromeC. Congenital rubellaD. Retts disorderE. Childhood disintegrative disorder

*D. The characteristic feature of Rett syndrome is the development of numerous deficits after initial period of normal functioning following birth. The child has a deceleration of head growth between the ages of 5 and 48 months. The child shows a loss of previously acquired hand skills and subsequently develops stereotyped hand movements like hand wringing. The child also develops deficits in expressive and receptive language. It is associated with severe to profound retardation. Retts is only seen in FEMALES and is extremely rare.

Pervasive developmental disorders (autism, Asperger's, Retts, Childhood disintegrative disorder, and PDD NOS)Characterized by severe and pervasive delays and impairment in several domains (communication, socialization, cognition)Autism: Social, communication, and patterns of behavior (restrictive, repetitive, stereotyped behavior and interests); 75 % have mental retardationAsperger's: Restricted, repetitive, and stereotyped behavior, interests, activities and abnormal social interactions; Contrast to autismno significant delay in language or cognitive development and do not suffer from mental retardationDown syndrome: Trisomy 21, most common genetic cause of mental retardationCongenital rubella: Triad (hearing loss, blindness, heart defects (PDA)) and neurologic deficits/malformations; Chronicgrowth retardation, mental retardation, radiolucent bone disease, hepatosplenomegaly, thrombocytopenia, jaundice, purple skin lesions (blueberry muffin spots)

Childhood disintegrative disorder: Child develops normally until age 2 and thereafter have progressive loss of skills across multiple areas (language, behavior, bowel and bladder control, motor skills, and play). Usually associated with severe mental retardationContrast with Retts: Retts usually occurs earlier (5 months v 3-4 years) and CDD does not have the stereotypic hand movements

7. A patient is admitted with overdose of desipramine, he is tachycardic and has dry mucous membranes, his VBG shows metabolic acidosis. what would be expected on the EKG?

A. Inverted T wavesB. Frequent PVCsC. QRS prolongationD. Right axis deviation

C. QRS widening and long RP and QT intervals are hallmarks of TCA overdose. cardiac arrythmias may occur as a result of Sodium fast channels being blocked. AV block may result from IV conduction delay and sinus tachycardia. Dry mouth urinary retention, dilated pupils, sedation (anticholinergic) are seen on physical exam. tachy/hypertension and seizures from inhibition of catecholamine reuptake. Treat with charcoal - Bicarb for metabolic acidosis and to alkalinize the urine*

8. An 18 y/o girl is brought into the office by her family because of concern about continued weight loss and amenorrhea. Her mother states that patient is a ballet dancer and has intense fear of gaining weight. She refuses to have dinner with the family, and when forced she cuts food into small pieces and rearranges them on the plate, but will not eat. She is engaging in excessive exercise routines and has repeatedly stated to others that she is fat and will never make it as a dancer with these thunder thighs. In the office, patient is noted to be cachectic with a BMI of 17. Which of the following medical complications is seen with this condition?A. LeukopeniaB. Hypokalemic alkalosisC. LanugoD. Fatty degeneration of the liverE. All of the above

*The following medication complications are associated with anorexia nervosa: leukopenia, hypokalemic alkalosis, electrolyte disturbances, cardiac arrythmia, loss of cardiac muscle, fatty degeneration of the liver, elevated serum cholesterol levels, and amenorrhea. Lanugo is fine, baby like hair present all over the body of anorexics.

Anorexia: a. Refusal to maintain body weight at or above normal weight for age and height (

9. Which of the following is true of Capgras Syndrome?A. It is also called erotomania.B. It is also called delusion of doubles.C. It is usually associated with brain disease.D. It is the same as hysteria.E. It is seen in husbands of pregnant women.

*B. In Capgras syndrome, patients falsely perceive that someone in their environment, usually a close relative or friend, has been replaced by a double. In erotomania, the individual has strong erotic feelings toward another person and has the persistent unfounded belief that the other person is deeply in love with him or her. Erotomania is also called de Clerambault syndrome. The condition seen in husbands of pregnant women is called Couvade syndrome.

10. A 2 y/o girl is being toilet trained by her parents. Each time she soils her diaper, she is told that she is a very bad girl and she is punished by having a toy taken away. When she uses the toilet appropriately, she is not praised by her parents. Which of the following sequelae is the child likely to experience as a result of this kind of parental behavior?A. A basic sense of mistrustB. Shame and self-doubtC. GuiltD. Stagnation of her developmentE. An absence of intimacy as an adult

*B Shame and self-doubtErik Erikson: Epigenetic model of development: Eight stages of the life cycle are sequential with each stage relying on the next. If a stage is not completed, the unresolved issues continue to arise and create problems in subsequent stages.1. Basic trust v mistrust (birth to 1 year): trust from attachment and consistent care (infants)2. Autonomy v shame and doubt (1-3 years): sense of self based on ability to control bodily functions (potty training)3. Initiative v guilt (3-6 years): establish relationship with same sex parent; fantasy allows child to feel powerful, also guilt of having imagined power to do harm to others 4. Industry v inferiority (6-12 years): strives for sense of accomplishment, inferiority when cannot master all tasks, parents are no longer perceived as the only authorities (grade school kids )5. Identity v role confusion (12-20 years): adolescents must identify within themselves and with society at large (confused teens)6. Intimacy v isolation (20-40 years): must have reasonable sense of self to establish stable love relationship, mature individual chooses vulnerable position of intimacy over loneliness of isolation (medical students )7. Generativity v stagnation (40-65 years): childrearing, community; stagnation when adult is unable to give to others and remains isolated 8. Ego integrity v despair (65 and older): integrity in those who feel they have led a fulfilled life, despair in those who find no meaning

Erickson1. Basic trust v mistrust (birth to 1 year)2. Autonomy v shame and doubt (1-3 years3. Initiative v guilt (3-6 years)4. Industry v inferiority (6-12 years) 5. Identity v role confusion (12-20 years6. Intimacy v isolation (20-40 years):7. Generativity v stagnation (40-65 years)8. Ego integrity v despair (65 and older)

11. Which of the following is most important when trying to differentiate between autistic disorder and Aspergers disorder?A. Normal cognitive abilitiesB. Restricted patterns of interestC. Language developmentD. Inflexible adherence to routinesE. Impairment in peer relationships

*C. Language developmentAutism: 1. Impaired social interaction2. Impaired communication3. Repetitive behaviorOnset prior to age 3 years; 75% mentally retardedAspergers: Similar to autism in social interactions and restricted repetitive behavior/activities No delay in language; No delay in age appropriate self care, adaptive behavior (except social), or curiosity about environment(delay in spoken language, impaired ability to initiate/sustain conversation, stereotyped repetitive language or idiosyncratic language, lack of varied spontaneous make-believe play or social imitative play)Retts: we already talked aboutChildhood disintegrative disorder: Similar to autism except normal development for first 2 years the REGRESSION (language, behavior, bowel and bladder control, play, motor skills); Impaired social interactions, communication, behavior; Associated with severe MR

12. A gait disorder characterized by broad base, flexed trunk, and small shuffling steps, is more likely to be associated with which of the following conditions?A. Cerebrellar ataxiaB. Huntingtons choreaC. Cervical spondylosisD. Parkinsons diseaseE. Normal pressure hydrocephalus

*D. Parkinsons diseaseParkinsons disease: Classic tetrad of 1)slowness or poverty of movement - bradykinesia 2)muscular rigidity (lead-pipe or cogwheel) 3) resting tremor (pill-rolling, disappears with movement and sleep) 4) postural instability (shuffling gait and festination). Patients also may have dementia and depression. The mean age of onset is 60 years. The cause is loss of dopaminergic neurons in substantia nigra, which projects in basal ganglia.

Cerebellar ataxia: in children, Friedrich ataxia, or ataxia-telangiectasion. Autosomal recessive disorder, GAA triplet repeat, starts b/w 5 and 15 years. In adults it is associated most commonly with : alcoholism, tumor, ischemia/hemorrhage, or MS. Cerebellar: Nystagmus, fast saccadic eye movements, truncal ataxia, dysarthria, dysmetria. Lower motor neuron lesion: absent deep tendon reflexes. Pyramidal: extensor plantar responses, and distal weakness are commonly found. Dorsal column: Loss of vibratory and proprioceptive sensation occurs.Huntingtons chorea: autosomal dominant condition, beginning b/w 35-50 years. It is characterized by: choreiform movements, progressive intellectual deterioration, dementia, and psychiatric disturbances. Atrophy of caudate nucleau may be seen on CT/MRI.Cervical spondylosis: Cervical spondylosis is a common degenerative condition of the cervical spine that most likely is caused by age-related changes in the intervetebral disks. Clinically, several syndromes, both overlapping and distinct, are seen: neck and shoulder pain, suboccipital pain and headache, radicular symptoms, and cervical spondylotic myelopathyNormal pressure hydrocephalus: NPH is a clinical symptoms complex: abnormal gait, urinary incontinence, and dementia (Wacky, wobbly, and Wet). It is an important clinical diagnosis bc is a potentially reversible cause of dementia.

13. A 25 y/o patient is evaluated for hoarding, intrusive thoughts, and frequent handwashing, which started 2 years ago and now interferes with daily life. In addition to psychotherapy, which of the following medications would be most appropriate to begin?A. BupropionB. OlanzapineC. ClomiprimineD. MirtazepineE. Alprazolam

*C. ClomiprimineThe mainstay of OCD treatment is antidepressants. Only four SSRIs are FDA approved : fluvoxamine, fluoxetine, paroxetine, and sertraline. Bupropion and Mirtazepine are neither FDA approved nor used off-label. Clomiprimine is a TCA with strong serotonergic properties and also FDA approved for tx of OCD (although typically after SSRIs have failed). Benzos (alprazolam) are not generally effective as sole tx for OCD. Antipsychotics (Olanzapine) may boost efficacy of antidepressant treatment for OCD but not first line treatment

14. A 15 y/o teenager is found unresponsive by parents after returning home from a party. The parents suspect a drug overdose and friends admit that the teenager had heroin at the party. Which of the following signs are most likely present in this teen?A. DiarrheaB. PiloerectionC. Pupillary constrictionD. RhinorrheaE. Hypertension

*C. Pupillary constrictionHeroin overdose is associated with depressed mental statusdecreased respiratory ratedecreased tidal volumedecreased bowel soundsMiotic (constricted) pupilsTreat heroin overdose with naloxone, a short acting opiod antagonist.Piloerection, diarrhea, rhinorrhea, and hypertension are signs of heroin withdrawal

15. A mother brings her 8 y/o son for an evaluation because he needs some medicine for his behavior. The child reportedly argues with his mother and is described as being angry and rude with her. The boy has a temper tantrum when the examiner refuses to allow him to get a drink of water. A discussion with the boys teacher reveals no trouble attending to school work, but occasional refusal to do certain projects and frequent bothering of other children. The most likely diagnosis is :A. DepressionB. Conduct disorderC. Reactive attachment disorderD. Oppositional Defiant DisorderE. ADHD

*D. Oppositional defiant disorderNegative, hostile, defiant behavior for at least 6 months. Usually directed at an authority figure. Cannot be diagnosed if conduct disorder is present.

Conduct disorder: pattern of behavior in which the rights of others or societal rules/norms are violated. Four categories: Aggression toward peopleDestruction of propertyDeceitfulness or theftSerious violation of rulesReactive attachment disorder: markedly disturbed and developmentally inappropriate social relatednedd in most contexts, beginning BEFORE age 5, eitherPersistent failure to initiate or respond in developmentally appropriate fashionDiffuse attachments, indiscriminate sociability and marked inability to exhibit appropriately selective attachmentsADHD: Inattention, hyperactivity, impulsivity for 6 months Impairment must be noted in at least 2 settings

16. A 25 y/o man experienced a closed head injury in a motor vehicle collision. Initially he had no loss of consciousness, behaved normally, and looked alert, oriented, and coherent. Twenty minutes later, the patient turned pale and fell to the ground unconscious. He recovered in 5 minutes. The most likely cause of this episode was:A. Subdural hematomaB. Subarachnoid hematomaC. Intracranial hemorrhageD. Vasovagal syncopal attackE. Dissecting aneurysm of the internal carotid artery

*D. Vasovagal syncopal attackClues: Turned pale, acute LOC with quick recoveryPresents usually with prodrome of light-headedness, sweating, nausea, or visual disturbancesSubdural: comatose or with lucid interval followed by deterioration as the hematoma expands (bridging vv.)Subarachnoid: thunderclap headache, patient becomes less responsive, develops hemiplegia or changed pupillary reflexes, 3rd n palsy (aneurysm) 50% fatalIntracranial hemorrhage: N/V, HA, less alert, difficulty swallowing, coordination, balancing or focusing eyesDissecting aneurysm or internal carotid: Headache followed by a major ischemic stroke, seizure, altered level of consciousness

SDH*

SAH (pia / arachnoid)*

17. A 35 y/o patient is brought into the ED by a friend. The patient is hypoventilating and has blue lips, pinpoint pupils, crackles on lung auscultation, and a mild arrhythmia on EKG. Which of the following drugs is most likely to be responsible for the symptoms?A. CodeineB. AlcoholC. LSDD. CocaineE. Diazepam

*A. CodeineOpiod medication. Symptoms of opiod intoxication include initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment, pupillary constriction, drowsiness or coma, decreased respirations (resulting in crackles in the lungs), slurred speech, and impairment in attention or memory.In severe opiod overdose, pupillary dilatation may occur due to anoxia.Treat with NALOXONE (reverses effects).

Alcohol intoxication: inappropriate sexual or aggressive behavior, mood lability, impaired judgment, impaired social or occupations functioning, slurred speech, incoordination, unsteady gait, nystagmus, impairment in attention or memory, and stupor, coma.

LSD: hallucinogen. Intoxication causes marked anxiety or depression, ideas of reference, fear of losing ones mind, paranoid ideation, impaired judgment, subjective intensification of perceptions, depersonalization, illusions, hallucinations, and synesthesias.Signs of intoxication: Pupillary dilation, tachycardia, sweating, palpations, blurred vision, tremorsCocaine: euphoria or affective blunting; hypervigilence, interpersonal sensitivity, anxiety, tension, or anger; stereotyped behaviors, impaired judgmentIntoxication: tachycardia, pupillary dilation, elevated (or lowered) blood pressure, perspiration or chills, nausea/vomiting, evidence of weight loss, psychomotor agitation, chest pain, cardiac arrhythmias, seizures

Diazepam (benzodiazepine): intoxication may cause inappropriate or aggressive behavior, mood lability, impaired judgment, slurred speech, unsteady gait, nystagmus, impaired attention or memory, stupor, coma

18. The parents of a 2 y/o child come to see the childs pediatrician because their once happy-go-lucky infant has become oppositional and obstinate. According to Freudian theory, which of the following developmental stages is this child in?A. Oral B. Anal C. PhallicD. OedipalE. Latency

*B AnalFreud psychosexual stages of developmentOral phase (birth to 1 year): Urges focused on feeding and suckling the breast. Source of satisfaction and frustration.Anal phase (1-3 years): Childs urges are centered on bowel functioning. Ability to control bodily functions becomes the main issue in relationship with child and caretakerPhallic (genital) phase (3-5 years): Genitals are focusOedipal complex: the child falls in love with parent of the opposite sexCastration anxiety: boy fears father will cut off his penis in retaliation for coveting his motherPenis envy: girls curiosity and desire to have a penisResolution of oedipal complex: child identifies with same sex parent and begins to form relationships with same sex peers.Latency (6-11 years): sexual development is stagnantAdolescence (12-18 years): Genital sexuality develops and proceeds into adulthood

19. A 46 y/o M is being monitored in a sleep study lab. After he has been asleep for 90 minutes, his EEG shows low voltage, random fast activity with sawtooth waves. When awakened during this period, the patient reports that he was dreaming. Which of the following sleep stages was this patient in when awakened?A. Alpha wavesB. Theta wavesC. Sleep spindlesD. Delta wavesE. Rapid eye movement (REM)

*E REMDreaming is the main characteristic of REM sleep. The EEG shows characteristic low voltage waves, random, fast, and sawtoothed. REM is also characterized by elevated HR and BP and penile or clitoral nocturnal erections.

Alpha waves seen while awakeTheta waves during NREM 1Theta waves, sleep spindles, K complexes during NREM 2Delta waves during NREM 3 and 4

Sleep architecture: NREM 1 then 2,3,4,3,2 then REM, repeats about every 90 minutes. Muscle tone and activity present during NREM 1 and 2, markedly decreased during NREM 3 and 4, and absent during REM.

Light sleep stage disorders: sleep talking and bruxism, usually during NREM 1 and 2NREM sleep disorders: usually in 3 and 4 (slow wave sleep): Sleep walking and night terrorsREM sleep disorders: Nightmare disorder and REM behavior disorder (pts appear to be acting out dream content through simple to complex movements; brain stem pathology and alcoholism)

20. A young woman presents to the emergency room with a history of intractable seizures and mental retardation. You discover she has sever acne, skin depigmentation on her back and blotchy patches on her retinal surface on fundoscopic examination. The most likely diagnosis is:A. Downs syndromeB. Retts disorderC. NeurofibromatosisD. Tuberous sclerosisE. Prader-Willi syndrome

*Tuberous sclerosis

Autosomal dominantClassic features: Seizures, mental retardation, and behavioral problems. Cutaneous lesions include the ash leaf spot (hypomelanotic macule), adenoma secaceum (facial angiofibromas) and shagreen spots (irregularly shaped skin lesion on back). Retinal hamartomas can be seen in many

C. Neurofibromatosis: 2 typesNF1: caf au lait spots, subcutaneous neurofibromas, axillary freckling, Lisch nodules (pigmented iris hamartomas), optic nerve glioma, neurofibromas, and schwannomasNF2: few cutaneous lesions; bilateral vestibular (CN VIII) schwannomas.William syndrome: autosomal dominant mental retardation syndromeShort stature, unusual facial features (depressed nasal bridge, broad forehead, widely spaced teeth, elfin-like facies), thyroid, renal, and cardiovascular anomalies. Psych symptoms include anxiety, hyperactivity, hypermusicality. Seizures and skin lesions NOT observed.

21. A young girl who was underweight and hypotonic in infancy is obsessed with food, eats compulsively, and at age 4, is already grossly overweight. She is argumentative, oppositional, and rigid. She has a narrow face, almond-shaped eyes, and a small mouth. Which of the following is the most likely diagnosis?A. Down syndromeB. Fragile X syndromeC. Fetal alcohol syndromeD. Lesch-Nyhan syndromeE. Prader-Willi syndrome

*E Prader-Willi syndrome: Genetic disorder caused by defect of the long arm of chromosome 15. Underweight in infancyDue to hypothalamic dysfunction: start eating voraciously and become overweightCharacteristic facial featuresAutonomic dysregulation, muscle weakness, hypotonia, mild-mod MRTemper tantrums, violent outbursts, perseveration, skin pickingArgumentative, oppositional, rigid(Imprinting: differential expression whether chromosome is from maternal or paternal origindeletion on the same arm of maternally derived chromosome results in ANGELMAN syndrome = Seizures, severe MR, little to no speech, abnormal ataxic gait, behavioral problems).Down syndrome: Trisomy 21, most common GENETIC cause of MR; palpebral fissures, epicanthal folds, flat nasal bridge, low set ears, protruding tongue; short stature, congenital heart disease, duodenal atresia, hypothroidism; Early decline in cognition suspicious for Alzheimers diseaseFragile X syndrome: Increased number of triplet CGG repeats in FMR1 gene on X chromosome; Most common INHERITED form of MR; Large head, long face, prominent jaw and forehead, large ears, large testes, connective tissue diseases; Mod-severe MR, PDD, ADHD, mood labilityFetal alcohol syndrome: Severity is dose related; Characteristic facial appearance: Microcephaly, flattened mid face, epicanthal folds, flat philtrum, thin upper lip, small jaw; pre and post natal growth deficiencies, cardiac abnormalities; Prominent oppositional behaviors, ADHD, depressionLesch-Nyhan: X linked, seen in boys; hyperuricemia; Hallmark is development of SELF INJURIOUS behavior and SELF MUTILATORY behaviors (biting lips, fingers, head banging); Tx with allopurinol and behavioral techniqesWilsons disease: mutation on chromosome 13, COPPER deposition in CNS and liver; jaundice, hepatitis, cirrhosis, movement d/o, dysarthria, seizures; cognitive decline, personality changes, mood lability; Kayser-Fleisher rings (brownish green rings on the iris)Turner syndrome: loss of an entire X; 45, X females with short stature, excess skin or webbing of the neck, broad and flat chest, congenital heart defects, hypothroidism, gonadal dysgenesis (infertility, failure to achieve secondary sex characteristics); ADHD, learning disabilitiesKlinefelter syndrome: addition of an X; 47, XXY males; tall, long legs, small penis and testes; ADHD, learning disabilitiesHuntington disease: increased number of triplet repeats of CAG in HD gene of chromosome 4; Progressive motor decline of both voluntary and involuntary movements, development of chorea; Personality changes, dementia, disordered thought and psychosis

22. A child is brought into your office for depression. During the course of your interview you see that the patient can think abstractly, reason deductively, and define abstract concepts. This child would fit into which of Piagets developmental stages?A. SensorimotorB. Preoperational thoughtC. Concrete operationsD. Formal operationsE. Symbiosis

*D. Formal operationsPiaget identified four stages of cognitive development:Stages of Cognitive developmentSensorimotor (0-2 years): The infant is egocentric and believes that everything happens in relation to him. Object permanence is fully developed around the age of 18 months.Preoperational stage (2-7 years): The child learns to use the symbols of language, exhibit EGOCENTRISM, phenomenalistic causality (events that occur together cause one another), ANIMISTIC thinking (inanimate objects are given thoughts and feelings), Immanent justice (sense that punishment for bad deeds is unavoidable)Concrete operational stage (7-14 years): The child exhibits logical thought processes and more subjective moral judgments. Egocentric thought changes to operational thought, anothers point of view can be taken into consideration. The child also understands the law of conservation and reversibility.Formal operational stage (>14 years): The child has the ability to think in abstract terms, reason deductively, and define abstract concepts.

23. A 45 y/o woman with bipolar disorder complains of amenorrhea, galactorrhea, decreased libido and anorgasmia. She presents to the emergency room with an elevated serum prolactin level and is on risperidone 4mg daily for bipolar disorder. On neurologic examination you discover decreased vision in both lateral fields. The most likely diagnosis is:A. Acute right parietal strokeB. Thalamic hemorrhageC. Pituitary macroadenomaD. Acute left parietal strokeE. Midbrain infarct

*Pituitary macroadenoma

Clinical picture is hyperprolactinemia induced by dopamine blockade in the tuberoinfundibular system by a neuroleptic medication. Conventionals and risperidone can increase the volume of pituitary microadenomas by blocking dopaime and increasing serum prolactin levels. When an adenoma grows in can encroach on the medial portion of both optic nerves outside of the sella turcica. The optic nerve involvement results in the classic clinical signs of bitemporal hemianopia. TX would be d/c offending agnet and possible bromocriptine, some require surgical intervention.

24. A 48 y/o woman presents to your office with complaints of lancinating, brief, sharp pain to the left side of her face. The pain is short-lived and recurrent. It is triggered frequently by cold air touching her face. The pharmacologic treatment of choice for this condition isA. Divalproex sodiumB. ClonazepamC. CarbamazepineD. TiagabineE. Risperidone

*C. CarbamazepineTrigeminal neuralgia (tic douloureaux), unilateral in 90%, affects V2 and V3

25. A middle aged man has been referred to your office by a plastic surgeon. The man is seeking a face lift for his excessively large cheeks. The surgeon has not been able to find anything abnormal about the mans face or skin, and when he comes to see you, you fail to see anything wrong either. The patient insists that his cheeks are grotesque and ruining his whole appearance. When pressed, he admits that others may not consider his cheeks to be as bad as he does. His most likely diagnosis is:A. MalingeringB. SchizophreniaC. Somatization disorderD. Conversion disorderE. Body dysmorphic disorder

*E. Body dysmorphic disorder

26. A young woman comes to the emergency room with a one week history of pressured speech, decreased sleep, grandiosity, and loosening of associations. The patient feels that she is being monitored by a satellite and she is seen talking to herself when no one else is in the room. Which one of the following criteria must be met to diagnose this patient with schizoaffective disorder instead of bipolar disorder?A. Presence of maniaB. Psychotic symptoms in the absence of mood symptoms for a 1 week periodC. At least one prior episode of depressionD. Presence of psychotic symptoms during a manic episodeE. Psychotic symptoms in the absence of mood symptoms for a 2 week period

*E. Psychotic symptoms in the absence of mood symptoms for a 2 week period

27. Which of the following therapies would be best-suited to a bipolar patient in a manic episode during pregnancy?A. HaloperidolB. LithiumC. AripiprazoleD. DivalproexE. Electroconvulsive therapy

*E. Electroconvulsive therapy

28. A 26 y/o woman comes into the ER. She reports that she has been having mood swings that go from depressed to elated to rageful in minutes to hours. She has been having paranoid feelings and vague auditory hallucinations over the past week since breaking up with her boyfriend. On this past Monday she cut her arms with a razor, but only superficially. Her history reveals promiscuity, unstable relationships, and cocaine use. She now reports suicidal ideation. Her most likely diagnosis is:A. Bipolar disorderB. Major depressive disorder, with psychotic featuresC. Schizoid personality disorderD. Borderline personality disorderE. Schizotypal personality disorder

*D. Borderline personality disorder

29. The police bring a man into the hospital who has been stealing satellite dishes off of houses and setting them up in his own yard because he feels that he has a chip in his head that allows him to talk directly to God. He states that God has instructed him to do this as preparation for the second coming. When his wife is questioned about her husbands behavior she responds that indeed God has been directly communicating with her husband, and that she has helped him steal some of the larger satellite dishes. The wifes condition can best be described as:A. Schizoid personality disorderB. Delusional disorderC. Shared psychotic disorderD. Bipolar disorderE. Substance induced psychotic disorder

*C. Shared psychotic disorder

30. A 45 y/o woman comes to the emergency room by ambulance unconscious and barely breathing. Paramedics found an empty bottle of 90 tablets of 2mg clonazepam on her dresser that was filled at the pharmacy the day before. One of the first agents to administer to this patient in the acute setting is:A. NaloxoneB. FlumazenilC. DimercaprolD. AtropineE. Epinephrine

*B. Flumazenil

31. A 60 y/o woman is 63 pounds overweight. She comes to her psychiatrists office with a complaint of increased irritability, noting a fight with her husband over how much sugar he put in her coffee one morning. She is fatigued and naps several times each day. She has no history of psychiatric problems, but adds that her husband now sleeps in the living room because of her snoring. Which one of the following is the most likely cause of the patients symptoms?A. Night terrorsB. Major depressive disorderC. Bipolar disorderD. NarcolepsyE. Sleep apnea

*E. Sleep apnea

32. A patient is brought into the ER unconscious with signs of respiratory depression. The patient was found unconscious on the bathroom floor and has written a suicide not saying the he wanted to die. An empty pill bottle which had contained his mothers prescription for morphine was found on the bathroom floor. Which one of the following would the knowledgeable physician use to treat this patient?A. BuprenorphineB. BenztropineC. NaloxoneD. NaltrexoneE. Bromocriptine

*C. Naloxone

33. A 55 y/o woman lives on her own. She wears odd clothes and pokes around in her neighbors garbage cans. She claims to have psychic powers but does not report hearing voices. What is the most likely diagnosis for her condition?A. Schizoid personality disorderB. Schizotypal personality disorderC. Asperger syndromeD. Avoidant Personality disorderE. Schizophrenia

*B. Schizotypal personality disorderDiscomfort in close relationships, cognitive and perceptual distortions, eccentric behavior. IOR, suspiciousness, magical thinking, superstitious, premonitions, clairvoyance

Schizoid: detached from social relationships, prefers to do things alone, reclusive, minimal interestAvoidant: wants relationships, but highly anxious in social settings, considered shy

34. A 26 y/o woman presents who appears to have generalized anxiety disorder with panic attacks. Terrified by the panic attacks, she requests medication, saying I need something to control them immediately. She is otherwise fit and healthy and has no history of any substance abuse or dependence. A reasonable approach would be toA. Start the patient on intensive psychotherapyB. Start the patient on a combination of Bupropion and clonazepamC. Start the patient on an SSRID. Start the patient on an SSRI and refer the patient to cognitive-behavioral therapyE. Start the patient on a combination of an SSRI for the long term and low-dose clonazepam for a short duration

*E. Start the patient on a combination of an SSRI for the long term and low-dose clonazepam for a short duration

35. The DSM IV diagnostic criteria for Acute Stress disorder include most of the criteria for PTSD, but they add and emphasize one of the following:A. Dissociative symptomsB. Psychotic symptomsC. Neurotic symptomsD. Depressive symptomsE. Cognitive symptoms

*A. Dissociative symptomsDerealization, depersonalization, dissociative amnesia

36. A 28 y/o woman is admitted to a general medical unit for hypoglycemia. A psychiatry consultation is requested because the patients story doesnt fit. The patient tells the psychiatrist how bad the problem is and uses medical jargon. She appears to be an intelligent person with strong dependency needs. The nurse interrupts the psychiatrist and tells him that she found insulin-filled syringes beneath the patients pillow. This upsets the patient and she bolts. The most likely diagnosis isA. Somatization disorderB. HypochondriasisC. Factitious disorderD. MalingeringE. Munchausen syndrome by proxy

*C. Factitious disorder

37. A 34 y/o male is seen in the psychiatric ER of a city hospital for bizarre presentation. Social worker tells the psychiatrist that after obtaining extensive collateral information, she learned that the patient lives in a nearby town and was normal until a severe earthquake hit the town recently. He is not able to recall his personal information, and neither is he able to explain how he traveled the 65 miles from his town or when he arrived in this city. There is no history of any substance abuse and family members are concerned. What is the most likely diagnosis?A. Dissociative amnesiaB. Dissociative fugueC. Transient global amnesiaD. MalingeringE. Dissociative identity disorder

*B. Dissociative fugueCommonly seen after natural disasters and in men in their second to fourth decades of life. This is associated with inability to recall ones past.

Dissociative amnesia: No history of travel away from ones homeDID: 2 or more distinct personalities

38. A 25 y/o woman begins to see a therapist because of loneliness and feelings of being unloved and unwanted with some mild depressive symptoms. She flirts constantly with the therapist and is hurt when the therapist does not reciprocate. Which of the following disorders is she most likely to have?Antisocial personality disorderBorderline personality disorderSchizotypal personality disorderObsessive-compulsive disorderHistrionic personality disorder

*E. Histrionic personality disorderInappropriate behavior (seductive, provocative); Need to be center of attention; Perceive relationships as being closer than they really are; Emphasis on appearance as most important; vulnerable to the suggestions of others; Exaggerated emotional expression, shallow and shifting emotions; Impressionistic manner of speaking

39. Which of the following is true regarding factitious disorder?The goal of the person exhibiting the symptoms is to avoid unpleasant consequences at work.It is easily diagnosed.It is the same as malingering.The goal of the person exhibiting the symptoms is to assume the sick role.

*D. Assume the sick role

Factitious Disorder is to gain sympathy and assume the sick role (sympathy), Inject stuff, fake / exaggerate symptoms

Malingering is for other secondary gain (get out of work, disability)

Somataform - Actually experience but without organic cause

40. A 38 y/o man presents with unilateral periorbital pain with ipsilateral tearing and nasal discharge. He also has ptosis and miosis. The pain is sharp and lasts for about 1 hour. What is the most likely diagnosis?Brain tumorMigrainesTension headacheCluster headacheRetinal detachment

*D. Cluster headacheSevere headaches occur daily for a period of 4-8 weeks, usually in the spring. The headaches are sharp, nonthrobbing, and bore into one eye and around the eye. The pain is excrutiating and is associated with tearing, conjunctival injection, nasal congestion, and Horner-like syndrome. Cluster HA condition is more common in men aged 20-40.

Brain tumor and tension headache less dramatic.Retinal detachment does not typically cause pain.

41. You are asked to see a 42 y/o male patient on a surgical ward who had a major operation 2 days ago and is now exhibiting bizarre behavior. He expresses fears that aliens are coming to take him away and appears to be responding to hallucinations. On examination he is tremulous and sweating. His laboratory workup is subnormal with increased MCV and GGT. What is the most likely cause of his symptoms?Alcohol withdrawalSchizophreniaSevere depressionDelirium tremensAlcoholic hallucinosis

*D. Delirium tremensClouded consciousness, difficulty sustaining attention, disorientation, autonomic hyperactivity with tachycardia, excess sweating, and lability of blood pressure. Patients have fleeting delusions and hallucinations.

Alcohol withdrawal: 2 or more of autonomic hyperarousal, hand tremor, insomnia, n/v, transient hallucinations, psychomotor agitation, anxiety, grand mal seizuresAlcoholic hallucinosis: Intact reality testing; occur in the absence of delirium

The main symptoms of Delirium Tremens are confusion, diarrhea, insomnia, nightmares, disorientation and agitation and other signs of severe autonomic instability (fever, tachycardia, hypertension).[7] These symptoms may appear suddenly but can develop 23 days after cessation of drinking heavily with its highest peak/ intensity on the fourth or fifth day.[8] Also, these "symptoms are characteristically worse at night".[9] Other common symptoms include intense perceptual disturbance such as visions of insects, snakes, or rats. These may be hallucinations, or illusions related to the environment, e.g., patterns on the wallpaper or in the peripheral vision that the patient falsely perceives as a resemblance to the morphology of an insect. Unlike hallucinations associated with schizophrenia, delirium tremens hallucinations are primarily visual, in the peripheral field of vision, but are also associated with tactile hallucinations such as sensations of something crawling on the subject a phenomenon known as formication. Delirium Tremens usually includes extremely intense feelings of "impending doom". Severe anxiety and feelings of imminent death are symptomatic of DT.

DT can sometimes be associated with severe, uncontrollable tremors of the extremities and secondary symptoms such as anxiety, panic attacks and paranoia. Confusion is often noticeable to onlookers as patients will have trouble constructing simple sentences or making basic logical calculations. In many cases, people who rarely speak out of turn will have an increased tendency for gaffes even though they are sober.

DT should be distinguished from alcoholic hallucinosis, the latter occurring in approximately 20% of hospitalized alcoholics and not carrying a significant mortality. In contrast, DT occurs in 510% of alcoholics and carries up to 15% mortality with treatment and up to 35% mortality without treatment.[2] DT is characterized by the presence of altered sensorium; that is, a complete hallucination without any recognition of the real world. DT has extreme autonomic hyperactivity (high pulse, blood pressure, and rate of breathing), and 35-60% of patients have a fever. Some patients experience seizures.

42. An 18 y/o girl presents to the student guidance clinic at her school. She reports that she has a problem with eating. She describes eating too much and faster than usual in episodes that she is unable to control. She usually does this when not in the presence of others. She does not report any purging behavior. What is the name of the disorder she describes?Bulimia nervosa, non purging typeImpulse control disorderBinge eating disorderAnorexia, binge-eating/purging type

*C. Binge eating disorderCharacterized by frequent episodes of binging (eating a large amount of food in short timemore than most people can eat in 2hours period). During episodes, patients have a sense of lack of control over eating and they report that they are unable to stop eating. Episodes occure at least 2 days a week for 6 months and are not associated with purging behavior.

Bulimia nervosa, nonpurging type: Meet criteria for bulimia (recurrent binge eating, compensatory behavior, occurs twice a week for 3 month period, self evaluation influenced by weight, NOT occur during episodes of anorexia). During the current episode of bulemia, the patient is using OTHER inappropriate compensatory behaviors (fasting, excessive exercise) but NOT regularly using vomiting, laxative, diuretics, enemas.

Anorexia, binge-eating/purging type: Meet criteria for Anorexia nervosa (refusal to maintain body weight,

43. A 32 y/o man is seen in the psychiatry outpatient clinic after going crazy. He states that 4 months ago he was involved in an automobile accident and was trapped in his car for several hours. Since then he has not been able to drive and has nightmares about the accident. He also complains of difficulty sleeping and inability to concentrate at work; he says that he feels nervous and on edge all the time. The diagnosis is:Acute PTSDAcute stress disorderChronic PTSDMajor depressive disorderPanic disorder

*C. Chronic PTSDExperienced or witnessed event involving actual or threatened death or serious injuryResponse involved intense fear, helplessness, horrorReexperiencing sx x 1 (intrusive thoughts, dreams, flashbacks, etc)Avoidance x 3 (avoidance of thoughts, conversations; avoidance of people, places, activities; inability to recall an important aspect of the trauma; diminished interest; estrangement from others; restricted affect; sense of foreshortened future)Hyperarousal x 2 (difficulty falling or staying asleep; irritability or outbursts of anger; difficulty concentrating; hypervigilence; exaggerated startle)Duration >1 monthAcute if 3 monthsDelayed onset if 6 months after the stressor

44. A 45 y/o policeman who has demonstrated great courage on more than one occasion while on duty is terrified of needles.AgoraphobiaPanic disorderObsessive-compulsive disorderSocial phobiaAdjustment disorderSpecific phobiaAcute stress disorder

*Phobias: Overwhelming, persistent, irrational fearsF. Specific phobia ( fear cued by presence or anticipation of specific object or situation; Animal type, Natural environment type, Blood-injection-injury type, Situational type, Other)

45. For several months, a 32 y/o housewife has been unable to leave her house unaccompanied. When she tries to go out alone, she is overwhelmed by anxiety and fear that something terrible will happen to her and nobody will be there to help.AgoraphobiaPanic disorderObsessive-compulsive disorderSocial phobiaAdjustment disorderSpecific phobiaAcute stress disorder

*Phobias: Overwhelming, persistent, irrational fearsA. Agorophobia (Anxiety about being in places or situations in which escape might be difficult (or embarrassing)outside alone, being in a crowd or standing in a line, on a bridge, traveling in a bus, train, car)

46. A 17 y/o girl blushes, stammers, and feels completely foolish when one of her classmates or a teacher asks her a question. She sits at the back of the class hoping not to be noticed because she is convinced that the other students think she is unattractive and stupid.AgoraphobiaPanic disorderObsessive-compulsive disorderSocial phobiaAdjustment disorderSpecific disorderAcute stress disorder

*Phobias: Overwhelming, persistent, irrational fears4. Social phobia (Fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others)

47. Two years after she was saved from her burning house, a 32 y/o woman continues to be distressed by recurrent dreams and intrusive thoughts about the event.Somatization disorderSpecific phobiaDissociative identity d/oOCDDissociative fuguePTSDBody dysmorphic d/oDysthymia

*6. PTSDG. Body dysmorphic disorder (Person of normal appearance is preoccupied with some imaginary physical defect, sometimes of delusional intensity)

48. A 20 y/o student is very distressed by a small deviation of his nasal septum. He is convinced that this minor imperection is disfiguring, although others barely notice it.Somatization disorderSpecific phobiaDissociative identity d/oOCDDissociative fuguePTSDBody dysmorphic d/oDysthymia

*7. Body dysmorphic disorder (Person of normal appearance is preoccupied with some imaginary physical defect, sometimes of delusional intensity)

49. A nun is found in a distant city working in a cabaret. She is unable to remember anything about her previous life.Somatization disorderSpecific phobiaDissociative identity d/oOCDDissociative fuguePTSDBody dysmorphic d/oDysthymia

*5. Dissociative fugue (Sudden unexpected travel from home or customary place of work, with inability to recall ones past; confusion about personal identity or assumption of a new identity, lasts hours to months)

50. A 35 y/o woman is often late to work because she must shower and dress in a very particular order or else she becomes increasingly anxious.Somatization disorderSpecific phobiaDissociative identify d/oOCDDissociative fuguePTSDBody dysmorphic d/oDysthymia

*4. OCD (Persistent thoughts, impulses, or repetitive behaviors, unable to stop them voluntarily; Obsessions and compulsions are ego-dystonic and source of distress.)

51. For the past three years, a 24 y/o college student has suffered from chronic headache, back, neck, hand and shoulder pain, fatigue, shortness of breath, dizziness, ringing ears, impotence, nausea, and constipation. He is incensed when his primary physician recommends a psychiatric evaluation because no organic cause for his symptoms can be found.Somatization disorderSpecific phobiaDissociative identity d/oOCDDissociative fuguePTSDBody dysmorphic d/oDysthymia

*5. Somatization disorder (History of multiple physical complaints not explained by organic factors; 4 pain, 2 GI, 1 sexual, 1 pseudoneurological)

The DSM-IV-TR diagnostic criteria are:[1]

* A history of somatic complaints over several years, starting prior to the age of 30. * At least four different sites of pain on the body, AND at least two gastrointestinal problems, AND one sexual dysfunction, AND one pseudoneurological symptom. * Such symptoms cannot be fully explained by a general medical condition or substance use OR, when there is an associated medical condition, the impairments due to the somatic symptoms are more severe than generally expected. * Complaints are not feigned as in malingering or factitious disorder.

The symptoms do not all have to occur at the same time, but may occur over the course of the disorder. A somatization disorder itself is chronic but fluctuating that rarely remits completely. A thorough physical examination of the specified areas of complaint is critical for Somatization disorder diagnosis. Medical examination would provide object evidence of subjective complaints of the individual.[1]

Somatization disorder is uncommon in the general population. It is thought to occur in 0.2% to 2% of females,[3][4][5][6] and 0.2% of males. Research showed cultural differences in prevalence of somatization disorder. For example, somatization disorder and symptoms were found to be significantly more common in Puerto Rico.[7]

There is usually co-morbidity with other psychological disorders, particularly mood disorders or anxiety disorders.[1][8] Research also showed comorbidity between somatization disorder and personality disorder, especially antisocial, borderline, narcissistic, histrionic, avoidant, and dependent personality disorder.[9]

52. A 26 y/o female reports daily depressed mood for 6 months with increased sleep and appetite, and decreased interest and concentration. Upon questioning, she denies nay periods of euphoric mood but her spouse admits a few days of up mood every now and then, with increased energy, decreased need for sleep, increased house cleaning, and increased talkativeness. She denies that those up periods interfere with her function; in fact, she functions better during those periods. What is the most likely diagnosis?A. Bipolar disorder, type IB. CyclothymiaC. DysthymiaD. Unipolar depressionE. Bipolar disorder, type II

*E. Bipolar disorder, type IISpouse report is valid. Meets DIGFAST criteria of hypomania but did not have significant social/occupational dysfunction.

Manic episode: Elevated, expansive, irritable mood lasting 1 week with 3 (4 if irritable) AND causes significant social impairmentHypomanic episode: Elevated, expansive, irritable mood for 4 days with 3 (4 if irritable):DistractibilityImpulsivityGrandiosityFOIActivities (increased GDA)Sleep Talkativeness

53. Ideally, what is the BEST first treatment in a patient with bipolar disorder, type II?A. An antidepressantB. Cognitive behavioral therapyC. LithiumD. An anti-anxiety medicationE. ECT

*C. LithiumA mood stabilizer is always the best treatment for any patient with bipolar disorder, even with milder type II where depression predominates

54. By what age should a child have a six-word vocabulary, be able to self-feed, and be able to walk up steps with his hand being held?A. 6 monthsB. 9 monthsC. 12 monthsD. 18 monthsE. 24 months

*D 18 months

6 weeks: social smile, follows past midline2 months: recognizes mother, sits with head steady, reaches for object4 months: rolls over, holds a rattle, coos6 months: sits alone, laughing, passing cube from hand to hand, imitates speech sounds8-10 months: stranger anxiety, plays peek-a-boo, creeping or crawling, stands, waving bye-bye, dada-mama nonspecific12 months: drinks from a cup, walks, dada and mama specific, thumb-finger grasp14-18 months: throws a ball overhead, FOUR cube tower, 6 word vocabulary, combines 2 words, feed self, walk up stairs with help24 months: plays interactive games, makes circular scribbles, can copy a horizontal line, rides a TRICYCLE, EIGHT cube tower, knows 50+ words3 years: gives first and last name, can copy a circle, knows age and sex, climbs stairs4 years: dresses with supervision, hops on one foot, can copy a +, recognizes colors, can tell a story5 years: dresses alone, copies a square, asking about word meanings, domestic role playing, copying a triangle, skipping

55. A 20 y/o M comes to your office with his mother because of behavioral problems. On examination, you note that he is verbally inappropriate, mildly mentally retarded, very tall and has a small penis and scrotum. His condition is most likely due to which one of the following?A. Absence of an X chromosome (XO)B. Presence of an extra X chromosome (XXY)C. Trisomy21D. Deletion on the paternal chromosome 15E. Trisomy 18

*B Klinefelter syndrome (XXY triploidy)Turners is absence of X (XO): short stature and lack of secondary sex characteristics, webbed neck, heart and kidney anomaliesDeletion of paternal chromosome 15 is Prader-Will syndrome: profound MR, hypogonadism, hypotonia, behavioral disinhibition, rapid and excessive weight gain, facial dysmorphism

56. A 50 y/o man is brought to the ER by ambulance. His respirations are shallow and infrequent, his pupils are constricted, and he is stuporous. He was noted to have suffered a grand mal seizure in the ambulance. Which of the following drugs is this man likely to have overdosed on?A. CocaineB. LSDC. MeperidineD. PCPE. MDMA (Ecstasy)

*C. MeperidineSevere opiate intoxication is associated with respiratory depression, stupor or coma, and sometimes pulmonary edema. Less severe intoxication is associated with slurred speech, drwsiness, and impaired memory or attention. Early on, the pupils are constricted, but they dilate if the patient becomes anoxic due to the respiratory depression. Blood pressure is typically reduced. Meperidine intoxication in a chronic user is often complicated by delirium or seizures due to the accumulation of normeperidine, a toxic metabolite with cerebral irritant properties.

57. After ensuring adequate ventilation for this patient, which of the following interventions should be next?A. IV naloxoneB. IV phenobarbitolC. IV diazepamD. Forced diuresisE. IM haloperidol

*IV naloxone

Opiate antagonist used to reverse the effects opiates

58. A 35 y/o man stumbles into the emergency room. His pulse is 100 bpm, blood pressure is 170/95, and he is diaphoretic. He is tremulous and has difficulty relating a history. He does admit to insomnia the past two nights and sees spiders walking on the walls. He has been a drinker since age 19, but has not had a drink in three days. Which of the following is the most likely diagnosis?A. Alcohol-induced psychotic disorderB. Wernickes psychosisC. Alcohol withdrawal deliriumD. Alcohol intoxicationE. Alcohol idiosyncratic intoxication

*C. Alcohol withdrawal deliriumDelirium tremens

Wernickes=confusion, ataxia, ophthalmoplegia; thiamine deficiencyAlcohol psychosis/hallucinosis=vivid visual hallucinations with clear sensorium, autonomic abnormalities but not severe as with DTs

59. Three policemen, with difficulty, drag an agitated and very combative young man into an emergency room. Once there, he is restrained because he reacts with rage and tries to hit anyone who approaches him. When it is finally safe to approach him, the resident on call notices that the patient has a generalized seizure. Which of the following substances of abuse is the most likely to produce this presentation?A. AmphetamineB. PCPC. CocaineD. MeperidineE. LSD

*B. PCPCharacterized by neurological, behavioral, cardiovascular, and autonomic manifestations. Intoxicated patients are often agitated, enraged, aggressive, and scared. Due to their exaggerated and distorted sensory input, they may have unpredictalbe and extreme reactions to environmental stimuli. Nystagmus and signs of neuronal hyperexcitability (from increased DTRs to status epilepticus) and hypertension are typical findings.

Put them in a room. Or treat symptoms with benzos or antipsychotics

60. A 27 y/o professional football player sees flashes of light brightly colored triangles and circles on the white walls of his home. He also sees trailing images following moving objects and what seems to be a pattern in the air. He has had similar experiences in the past, mostly when he was ill or very tired. Which of the following past experiences is most likely to be the cause of such perceptions?A. He sniffed paint thinner twice at age 14B. He used LSD four or five times at age 22C. He smoked three to four joints every day from age 17 to 21D. He drinks five to six cups of coffee a dayE. He used to binge on alcohol once a week during college years

*B. He used LSD four or five times at age 22Hallucinogen induced visual disturbances may persist for years after cessation of drug use. Sporadic visual symptoms are called flashbacks, while more lingering hallucinations are considered to be a hallucinogenic persistent perception disorder. These are NOT dose dependent and may develop after a single use. Geometric hallucinations, flashes of color, and afterimages. Patients often complain about the persistence of trailing images while an object moves through the visual field. Reality testing is intact, they know their perceptions are not real. Symptoms are triggered by stimulants (caffeine, decongestants), MJ, fatigue, infections. Most people recover completely within five years, but others may be irreversible.

61. A 19 y/o man is diagnosed with paranoid schizophrenia. He has command auditory hallucinations and persecutory delusions, but is also apathetic and withdrawn, with a flat affect. Which of the following medications is most likely to treat both the positive and the negative symptoms of this patient?A. ChlorpromazineB. FluphenazineC. OlanzapineD. QuetiapineE. Trifluoperazine

*C. OlanzapineOlanzapine and Clozapine better for negative symptoms, olanzapine better side effect profile/safety etc.

Chlorpromazine is thorazine

Fluphenazine is prolixin

62. A 25 y/o man with MDD discusses the potential benefits and side effects of various antidepressants with his psychiatrist. He clearly indicates that he does not want a medication that could decrease his libido or interfere with his ability to obtain and maintain an erection. Which of the following antidepressants would be most appropriate for this patient?A. BupropionB. ClomipramineC. AmitriptylineD. SertralineE. Paroxetine

*A. Bupropion

63. An 85 y/o M is brought to the psychiatrist by his wife. She states that for the last four months since the death of his son, the patient has been unable to sleep, has lost 20lb, has crying spells, and in the last week has been starting to talk about suicide. She notes that he has numerous other medical problems, including prostatic hypertrophy, hypertension, insulin-dependent diabetes, and a history of myocardial infarction. Which of the following medications is most appropriate for the treatment of this patient?A. DoxepinB. ClonazepamC. SertralineD. TranylcypromineE. Amitriptyline

*C. SertralineThe SSRIs are well tolerated in the elderly (as are bupropion, venlefaxine, nefazodone, mirtazepine). The TCAs are effective tx for depression, anxiety d/os, enuresis, ADHD. TCAs have diff side effect profiles, but all are at least somewhat anticholinergic and sedating, and should NOT be used 1st line for depression in the elderly. Phenelzine and Tranylcypromine are both MAOIs whose major side effect is hypotensiondo not use this in old peeps if can be avoided.

64. A couple comes into the ER. The wife says that her husband had become convinced that she is cheating on him, and that it is not true. He has been following her, smelling her clothing, going through her purse, and making regular accusations. He does not meet criteria for a mood disorder. He denies other psychotic symptoms. Medical and substance abuse history are negative. What is his diagnosis?A. SchizophreniaB. Major depressive disorder with psychotic featuresC. Delusional disorderD. DeliriumE. Shared psychotic disorder

*C. Delusional disorder

65. A 70 y/o male with a dementing disorder dies in a car accident. During the previous five years, his personality had dramatically changed and he had caused much embarrassment to his family dur to his intrusive and inappropriate behavior. Pathological examination of his brain shows frontotemporal atrophy, gliosis of the frontal lobe white matter, characteristic intracellular inclusions, and swollen neurons. Amyloid plaques and neurofibrillary tangles are absent. Which of the following is the most likely diagnosis?A. Alzheimers diseaseB. Picks diseaseC. Creutzfeld-Jakob diseaseD. B12 deficiency dementiaE. HIV dementia

*B. Picks diseaseClinically distinguishable from AD by prominence and early onset of personality changes, disinhibition or apathy, socially inappropriate behavior, mood changes, and psychotic symptoms. Language is affected early in disease but memory loss, apraxia, and agnosia characteristic of AD are not prominent until the late stages of the disorder. Picks bodies (intracellular inclusions) and Pick cells (swollen neurons) are characteristic path findings.

B12 Def. Dementia - memory loss, behavior changes and agitation, weight loss, fatigue (macrocytic anemia)

CJD - Rapidly progressive, earlier onset (50s)

66. For the past 10 years, the memory of a 74 y/o woman has progressively declined. Lately, she has caused several small kitchen fires by forgetting to turn off the stove, she cannot remember how to cook her favorite recipes, and she becomes disoriented and confused at night. She identifies an increasing number of objects as that thing because she cannot recall the correct name. Her muscle strength and balance are intact. Which of the following is the most likely diagnosis?A. Picks diseaseB. Multi-infarct dementiaC. Huntingtons diseaseD. Alzheimers disease

*D. Alzheimers diseaseProgressive memory loss, aphasia, anomia, apraxia (inability to perform voluntary motor activities but without motor or sensory deficits), and agnosia. Motor functions spared until the end. Personality preserved at the beginning, deterioration in later stages.

67. A woman feels jealous and hurt when, at a family gathering, her husband flirts with her younger cousin. She makes a conscious decision to put her feelings aside and to wait for a more appropriate moment to confront her husband and convey her emotions. Which of the following defense mechanisms this woman exhibiting?A. DistortionB. RepressionC. Isolation of affectD. SuppressionE. Displacement

*D SuppressionCONSCIOUS avoidance of attending to an impulse or conflict

Distortion: Altering ones perception of the environment by replacing reality with a more acceptable version in order to suit inner needs. The degree of distortion can be mild or severe (psychotic)Repression: Excluding distressing material from conscious awareness; Stopping an idea before it reaches consciousness (primary) or removing from consciousness what was once experienced (secondary)Isolation of affect: Separation of an idea and its accompanying affect; the AFFECT is kept out of conscious awareness and the idea, now without emotional charge, can be more easily dealt with on conscious levelDisplacement: Transfer of the emotion attached to the conflict onto one where expression is permitted or less forbidden (shooting the messenger)

68. A 34 y/o M is deeply envious of his younger but much more successful brother. Although it is difficult for him to admit, he believes the younger brother was their parents favorite as well. He tells his friends that his younger brother is envious of his good looks and successes with women, even though there is some evidence that this is not so. Which defense is this man exhibiting?A. DenialB. ProjectionC. Reaction formationD. IntellectualizationE. Splitting

*B ProjectionCasting out or projecting onto others the thoughts or feelings that a person cannot tolerate as being his own (accusing his wife of cheating when he has been pining after another woman)

Denial: Reality is ignoredReaction formation: Unacceptable wishes are transformed into their oppositeIntellectualization: Extreme or exclusive use of thinking to deal with emotional issues (emotion is restricted, just deal with it attitude)Splitting: Divides external objects into all good and all bad categories, ambivalence is not possible but rapid shifts can be seen with little to no recall of previous view or awareness of self-contradiction

69. A young woman with Bipolar Disorder is started on Aripriprazole 10 mg per day. Two days later she reports feeling unable to sit still, trouble sleeping, restlessness, cant get comfortable, and needs to pace to relieve these feelings. What is the most likely explanation?A. Early manifestation of NMSB. Worsened ManiaC. AkathisiaD. TorticollisE. Allergic to Aripriprazole (Abilify)

*Akathisia subjective restlessness or inability to sit still, pacing, shifting. Often confused with worsened mania or psychosis because can be very agitated/uncomfortable.

Early in treatment. NMS later on or after rapid dose escalation of antipsychotics.

70. Which medication will be most helpful for treating Akathisia?A. PropranololB. PhenytoinC. AmantadineD. BenztropineE. Haloperidol

*Beta-Blockers for akathisia

Anti-Cholinergics for EPS Balances out Dopamine inhibition ( Decreased Dopamine leads to over stimulation because of relative elevated ACh in Caudate/Putamen so inhibiting ACh helps restore function)

71. A 25 Y/O male with MDD is interested in anti-depressant treatment but is worried about reported sexual side effects of some medications. Which of the following anti-depressants has the lowest incidence of sexual side effects (decreased libido, difficulty achieving or maintaining an erection, delayed orgasm or anorgasmia)?A. ClomipramineB. AmitriptylineC. SertralineD. ParoxetineE. Bupropion

*Bupropion has the lowest incidence. Can use to augment SSRIs if they are effective for mood but have sexual side effects. Very common with SSRI use (about 25%)

72. A 25 Y/O man is admitted to the MICU following a suicide attempt by toxic ingestion. In the ER noted to be obtunded and urine output was half of expected for his age. Lithium level was 4.5 meq/L. What is the best next step in treatment of this patient?A. IV Normal Saline at 1L/HourB. Emergency DialysisC. Administration of Benztropine IMD. Admit to MICU for close monitoring and telemetryE. Administration of Flumazenil

*Mild lithium toxicity (Levels under 3 meq/L) symptoms are tremor, mild confusion, GI upset Tx is supportive (NS and monitoring of urine output)

Severe Lithium Toxicity renal failure, Ataxia (incoordination), tremor, Slurred Speech, Confusions, Coma, Nystagmus

73. A 41 year old woman visits her local psychiatrist out of sheer boredom. She is started on a new medication and 10 days later her nipples start leaking. What class of medication was started?A. BenzodiazepinesB. SSRIC. Anti-epileptic medication with mood stabilizing propertiesD. Anti-Psychotic (Neuroleptic)E. TCA

*Dopamine inhibits prolactin. Inhibit dopamine and prolactin increases which can lead to lactation.

74. A 35 Year Old woman with Bipolar Disorder was recently started on carbamazepine. She develops a high fever, chills, bleeding gums, pallor and fatigue. What is she experiencing?A. Stevens Johnson SyndromeB. Acute Aplastic AnemiaC. Serotonin SyndromeD. Neuroleptic Malignant SyndromeE. Malignant Hypertension

*SJS Lamotrigine (Lamictal) Bullae, large portion of body, affects mucous membranes, secondary infections/dehydration can be fatal.

Aplastic Anemia carbemazepine (Tegretol) neutropenia, cant fight off infections

Serotonin Syndrome SSRIs, TCAs, MAOIs, some opiods (why we have work hours now. Libby Zion at Cornell got phenelzine (MAOI) and Demerol (Tramadol also serotonergic): SSx Tachycardia, HTN, Diaphoresis, Fever, Shivering, Myoclonus, Hyperreflexia, Restlessness, Aggitation, Delirium, Coma

NMS: Tachycardia, HTN, Hypotension, Diaphoresis, Fever, Dystonia, Aggitation, Delirium, Coma, Elevated CK, Elevated ABC, Abnormal LFTs

Differences between NMS and SS: on shelf it will tell you treatment. SS has myoclonus and no rigidity. NMS dystonia, muscle breakdown leading to rhabdo and kidney failure.

E Memory problems + (1/4) Aphasia, apraxia, Agnosia, Executive functioning*E. *D. Rivastigmine cholinesterase inhibitor*Diarrhea, vomiting, weakness, dizziness, slurred speech 1.5-2.0Giddiness or confusion, ataxia, blurred vision, hyperreflexia, tinnitus and large output of dilute urine 2.0-3.0Multiorgan involvement and seizures and can be fatal (>3.0)Dialysis usually required for elevated levels: Chronically >2.5 acutely >4.0

T wave flattening**B. Wernickes encephalopathy is characterized by impairment of consciousness, ataxia, and ophthalmopegia, typically palsy of the sixth cranial nerve. These symptoms reverse rapidly with administration of vitamin B1 (thiamine). Alcohol hallucinosis, schizophrenia, and dementia by definition occur without impairment of consciousness. Korsakoff syndrome is characterized by anterograde amnesia and impairment in learning. Usually seen after Wernickes encephalopathy (esp. if untreated). Sensorium is intact with relative preservation of long term memory. Confabulation can be present.*D. The characteristic feature of Rett syndrome is the development of numerous deficits after initial period of normal functioning following birth. The child has a deceleration of head growth between the ages of 5 and 48 months. The child shows a loss of previously acquired hand skills and subsequently develops stereotyped hand movements like hand wringing. The child also develops deficits in expressive and receptive language. It is associated with severe to profound retardation. Retts is only seen in FEMALES and is extremely rare.

Pervasive developmental disorders (autism, Asperger's, Retts, Childhood disintegrative disorder, and PDD NOS)Characterized by severe and pervasive delays and impairment in several domains (communication, socialization, cognition)Autism: Social, communication, and patterns of behavior (restrictive, repetitive, stereotyped behavior and interests); 75 % have mental retardationAsperger's: Restricted, repetitive, and stereotyped behavior, interests, activities and abnormal social interactions; Contrast to autismno significant delay in language or cognitive development and do not suffer from mental retardationDown syndrome: Trisomy 21, most common genetic cause of mental retardationCongenital rubella: Triad (hearing loss, blindness, heart defects (PDA)) and neurologic deficits/malformations; Chronicgrowth retardation, mental retardation, radiolucent bone disease, hepatosplenomegaly, thrombocytopenia, jaundice, purple skin lesions (blueberry muffin spots)

Childhood disintegrative disorder: Child develops normally until age 2 and thereafter have progressive loss of skills across multiple areas (language, behavior, bowel and bladder control, motor skills, and play). Usually associated with severe mental retardationContrast with Retts: Retts usually occurs earlier (5 months v 3-4 years) and CDD does not have the stereotypic hand movements

C. QRS widening and long RP and QT intervals are hallmarks of TCA overdose. cardiac arrythmias may occur as a result of Sodium fast channels being blocked. AV block may result from IV conduction delay and sinus tachycardia. Dry mouth urinary retention, dilated pupils, sedation (anticholinergic) are seen on physical exam. tachy/hypertension and seizures from inhibition of catecholamine reuptake. Treat with charcoal - Bicarb for metabolic acidosis and to alkalinize the urine**The following medication complications are associated with anorexia nervosa: leukopenia, hypokalemic alkalosis, electrolyte disturbances, cardiac arrythmia, loss of cardiac muscle, fatty degeneration of the liver, elevated serum cholesterol levels, and amenorrhea. Lanugo is fine, baby like hair present all over the body of anorexics.

Anorexia: a. Refusal to maintain body weight at or above normal weight for age and height (14 years): The child has the ability to think in abstract terms, reason deductively, and define abstract concepts.

*Pituitary macroadenoma

Clinical picture is hyperprolactinemia induced by dopamine blockade in the tuberoinfundibular system by a neuroleptic medication. Conventionals and risperidone can increase the volume of pituitary microadenomas by blocking dopaime and increasing serum prolactin levels. When an adenoma grows in can encroach on the medial portion of both optic nerves outside of the sella turcica. The optic nerve involvement results in the classic clinical signs of bitemporal hemianopia. TX would be d/c offending agnet and possible bromocriptine, some require surgical intervention. *C. CarbamazepineTrigeminal neuralgia (tic douloureaux), unilateral in 90%, affects V2 and V3*E. Body dysmorphic disorder*E. Psychotic symptoms in the absence of mood symptoms for a 2 week period*E. Electroconvulsive therapy*D. Borderline personality disorder*C. Shared psychotic disorder*B. Flumazenil*E. Sleep apnea

*C. Naloxone*B. Schizotypal personality disorderDiscomfort in close relationships, cognitive and perceptual distortions, eccentric behavior. IOR, suspiciousness, magical thinking, superstitious, premonitions, clairvoyance

Schizoid: detached from social relationships, prefers to do things alone, reclusive, minimal interestAvoidant: wants relationships, but highly anxious in social settings, considered shy*E. Start the patient on a combination of an SSRI for the long term and low-dose clonazepam for a short duration

*A. Dissociative symptomsDerealization, depersonalization, dissociative amnesia*C. Factitious disorder*B. Dissociative fugueCommonly seen after natural disasters and in men in their second to fourth decades of life. This is associated with inability to recall ones past.

Dissociative amnesia: No history of travel away from ones homeDID: 2 or more distinct personalities*E. Histrionic personality disorderInappropriate behavior (seductive, provocative); Need to be center of attention; Perceive relationships as being closer than they really are; Emphasis on appearance as most important; vulnerable to the suggestions of others; Exaggerated emotional expression, shallow and shifting emotions; Impressionistic manner of speaking*D. Assume the sick role

Factitious Disorder is to gain sympathy and assume the sick role (sympathy), Inject stuff, fake / exaggerate symptoms

Malingering is for other secondary gain (get out of work, disability)

Somataform - Actually experience but without organic cause*D. Cluster headacheSevere headaches occur daily for a period of 4-8 weeks, usually in the spring. The headaches are sharp, nonthrobbing, and bore into one eye and around the eye. The pain is excrutiating and is associated with tearing, conjunctival injection, nasal congestion, and Horner-like syndrome. Cluster HA condition is more common in men aged 20-40.

Brain tumor and tension headache less dramatic.Retinal detachment does not typically cause pain.*D. Delirium tremensClouded consciousness, difficulty sustaining attention, disorientation, autonomic hyperactivity with tachycardia, excess sweating, and lability of blood pressure. Patients have fleeting delusions and hallucinations.

Alcohol withdrawal: 2 or more of autonomic hyperarousal, hand tremor, insomnia, n/v, transient hallucinations, psychomotor agitation, anxiety, grand mal seizuresAlcoholic hallucinosis: Intact reality testing; occur in the absence of delirium

The main symptoms of Delirium Tremens are confusion, diarrhea, insomnia, nightmares, disorientation and agitation and other signs of severe autonomic instability (fever, tachycardia, hypertension).[7] These symptoms may appear suddenly but can develop 23 days after cessation of drinking heavily with its highest peak/ intensity on the fourth or fifth day.[8] Also, these "symptoms are characteristically worse at night".[9] Other common symptoms include intense perceptual disturbance such as visions of insects, snakes, or rats. These may be hallucinations, or illusions related to the environment, e.g., patterns on the wallpaper or in the peripheral vision that the patient falsely perceives as a resemblance to the morphology of an insect. Unlike hallucinations associated with schizophrenia, delirium tremens hallucinations are primarily visual, in the peripheral field of vision, but are also associated with tactile hallucinations such as sensations of something crawling on the subject a phenomenon known as formication. Delirium Tremens usually includes extremely intense feelings of "impending doom". Severe anxiety and feelings of imminent death are symptomatic of DT.

DT can sometimes be associated with severe, uncontrollable tremors of the extremities and secondary symptoms such as anxiety, panic attacks and paranoia. Confusion is often noticeable to onlookers as patients will have trouble constructing simple sentences or making basic logical calculations. In many cases, people who rarely speak out of turn will have an increased tendency for gaffes even though they are sober.

DT should be distinguished from alcoholic hallucinosis, the latter occurring in approximately 20% of hospitalized alcoholics and not carrying a significant mortality. In contrast, DT occurs in 510% of alcoholics and carries up to 15% mortality with treatment and up to 35% mortality without treatment.[2] DT is characterized by the presence of altered sensorium; that is, a complete hallucination without any recognition of the real world. DT has extreme autonomic hyperactivity (high pulse, blood pressure, and rate of breathing), and 35-60% of patients have a fever. Some patients experience seizures.*C. Binge eating disorderCharacterized by frequent episodes of binging (eating a large amount of food in short timemore than most people can eat in 2hours period). During episodes, patients have a sense of lack of control over eating and they report that they are unable to stop eating. Episodes occure at least 2 days a week for 6 months and are not associated with purging behavior.

Bulimia nervosa, nonpurging type: Meet criteria for bulimia (recurrent binge eating, compensatory behavior, occurs twice a week for 3 month period, self evaluation influenced by weight, NOT occur during episodes of anorexia). During the current episode of bulemia, the patient is using OTHER inappropriate compensatory behaviors (fasting, excessive exercise) but NOT regularly using vomiting, laxative, diuretics, enemas.

Anorexia, binge-eating/purging type: Meet criteria for Anorexia nervosa (refusal to maintain body weight, 1 monthAcute if 3 monthsDelayed onset if 6 months after the stressor

*Phobias: Overwhelming, persistent, irrational fearsF. Specific phobia ( fear cued by presence or anticipation of specific object or situation; Animal type, Natural environment type, Blood-injection-injury type, Situational type, Other)*Phobias: Overwhelming, persistent, irrational fearsA. Agorophobia (Anxiety about being in places or situations in which escape might be difficult (or embarrassing)outside alone, being in a crowd or standing in a line, on a bridge, traveling in a bus, train, car)*Phobias: Overwhelming, persistent, irrational fears4. Social phobia (Fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others)*6. PTSDG. Body dysmorphic disorder (Person of normal appearance is preoccupied with some imaginary physical defect, sometimes of delusional intensity)

*7. Body dysmorphic disorder (Person of normal appearance is preoccupied with some imaginary physical defect, sometimes of delusional intensity)*5. Dissociative fugue (Sudden unexpected travel from home or customary place of work, with inability to recall ones past; confusion about personal identity or assumption of a new identity, lasts hours to months)*4. OCD (Persistent thoughts, impulses, or repetitive behaviors, unable to stop them voluntarily; Obsessions and compulsions are ego-dystonic and source of distress.)*5. Somatization disorder (History of multiple physical complaints not explained by organic factors; 4 pain, 2 GI, 1 sexual, 1 pseudoneurological)

The DSM-IV-TR diagnostic criteria are:[1]

* A history of somatic complaints over several years, starting prior to the age of 30. * At least four different sites of pain on the body, AND at least two gastrointestinal problems, AND one sexual dysfunction, AND one pseudoneurological symptom. * Such symptoms cannot be fully explained by a general medical condition or substance use OR, when there is an associated medical condition, the impairments due to the somatic symptoms are more severe than generally expected. * Complaints are not feigned as in malingering or factitious disorder.

The symptoms do not all have to occur at the same time, but may occur over the course of the disorder. A somatization disorder itself is chronic but fluctuating that rarely remits completely. A thorough physical examination of the specified areas of complaint is critical for Somatization disorder diagnosis. Medical examination would provide object evidence of subjective complaints of the individual.[1]

Somatization disorder is uncommon in the general population. It is thought to occur in 0.2% to 2% of females,[3][4][5][6] and 0.2% of males. Research showed cultural differences in prevalence of somatization disorder. For example, somatization disorder and symptoms were found to be significantly more common in Puerto Rico.[7]

There is usually co-morbidity with other psychological disorders, particularly mood disorders or anxiety disorders.[1][8] Research also showed comorbidity between somatization disorder and personality disorder, especially antisocial, borderline, narcissistic, histrionic, avoidant, and dependent personality disorder.[9]*E. Bipolar disorder, type IISpouse report is valid. Meets DIGFAST criteria of hypomania but did not have significant social/occupational dysfunction.

Manic episode: Elevated, expansive, irritable mood lasting 1 week with 3 (4 if irritable) AND causes significant social impairmentHypomanic episode: Elevated, expansive, irritable mood for 4 days with 3 (4 if irritable):DistractibilityImpulsivityGrandiosityFOIActivities (increased GDA)Sleep Talkativeness*C. LithiumA mood stabilizer is always the best treatment for any patient with bipolar disorder, even with milder type II where depression predominates*D 18 months

6 weeks: social smile, follows past midline2 months: recognizes mother, sits with head steady, reaches for object4 months: rolls over, holds a rattle, coos6 months: sits alone, laughing, passing cube from hand to hand, imitates speech sounds8-10 months: stranger anxiety, plays peek-a-boo, creeping or crawling, stands, waving bye-bye, dada-mama nonspecific12 months: drinks from a cup, walks, dada and mama specific, thumb-finger grasp14-18 months: throws a ball overhead, FOUR cube tower, 6 word vocabulary, combines 2 words, feed self, walk up stairs with help24 months: plays interactive games, makes circular scribbles, can copy a horizontal line, rides a TRICYCLE, EIGHT cube tower, knows 50+ words3 years: gives first and last name, can copy a circle, knows age and sex, climbs stairs4 years: dresses with supervision, hops on one foot, can copy a +, recognizes colors, can tell a story5 years: dresses alone, copies a square, asking about word meanings, domestic role playing, copying a triangle, skipping*B Klinefelter syndrome (XXY triploidy)Turners is absence of X (XO): short stature and lack of secondary sex characteristics, webbed neck, heart and kidney anomaliesDeletion of paternal chromosome 15 is Prader-Will syndrome: profound MR, hypogonadism, hypotonia, behavioral disinhibition, rapid and excessive weight gain, facial dysmorphism*C. MeperidineSevere opiate intoxication is associated with respiratory depression, stupor or coma, and sometimes pulmonary edema. Less severe intoxication is associated with slurred speech, drwsiness, and impaired memory or attention. Early on, the pupils are constricted, but they dilate if the patient becomes anoxic due to the respiratory depression. Blood pressure is typically reduced. Meperidine intoxication in a chronic user is often complicated by delirium or seizures due to the accumulation of normeperidine, a toxic metabolite with cerebral irritant properties.

*IV naloxone

Opiate antagonist used to reverse the effects opiates*C. Alcohol withdrawal deliriumDelirium tremens

Wernickes=confusion, ataxia, ophthalmoplegia; thiamine deficiencyAlcohol psychosis/hallucinosis=vivid visual hallucinations with clear sensorium, autonomic abnormalities but not severe as with DTs*B. PCPCharacterized by neurological, behavioral, cardiovascular, and autonomic manifestations. Intoxicated patients are often agitated, enraged, aggressive, and scared. Due to their exaggerated and distorted sensory input, they may have unpredictalbe and extreme reactions to environmental stimuli. Nystagmus and signs of neuronal hyperexcitability (from increased DTRs to status epilepticus) and hypertension are typical findings.

Put them in a room. Or treat symptoms with benzos or antipsychotics*B. He used LSD four or five times at age 22Hallucinogen induced visual disturbances may persist for years after cessation of drug use. Sporadic visual symptoms are called flashbacks, while more lingering hallucinations are considered to be a hallucinogenic persistent perception disorder. These are NOT dose dependent and may develop after a single use. Geometric hallucinations, flashes of color, and afterimages. Patients often complain about the persistence of trailing images while an object moves through the visual field. Reality testing is intact, they know their perceptions are not real. Symptoms are triggered by stimulants (caffeine, decongestants), MJ, fatigue, infections. Most people recover completely within five years,