psych path Flashcards
27 yr old man is brought to the ED by his roommate, who found the pt barricading himself in a closet at home and saying “They’re coming to get me. No one can be trusted”. The pt was laid off from his job and broke up with his girlfriend last month. He has heard voices threatening to kills him a few times daily for the past 2 weeks. He has no medical or psychiatric history and does not use alcohol or illicit drugs. Physical exam and lab exam results are unremarkable. On mental status exam, The pt is fearful and tense. He describes being followed by men in black cars who are spying on him. What is the most likely dx?
brief Psychotic disorder
39 yr old man is brought to the office by his wife who is concerned about his behaviour over the past year. She says, “He used to be outgoing and upbeat, but now he seems uncharacteristically depressed and distant from the family. He has lost interest in his work and has difficulty making decisions.” Over the past month, he has become increasingly paranoid and believes that his business partner is trying to kill him. The pt has no psychiatric hx. Both his father and grandfather were hospitalised in ling-term care facilities and died in their 50’s. Physical examination shows random, abrupt, uncoordinated movements of the left leg. On mental status examination, the pt is restless and irritable. He is convinced that not only his business partner but also the governemtn is out to harm him. What is the most likely dx?
Huntington disease.
16 yr old boy with suicidal thoughts is brought to the office by his parents. He has been in constant conflict with his parents since refusing to stoop drinking alcohol, which he does on a daily basis. The pt is the oldest of 6 children, his mother suffers from lower back pain and relies on him for child care, which he finds overwHelming. His father works 2 jobs and is often not around when she is alone with the children at night. The pt dropped out of high school last year after getting dumped by his gf. He recently contracted Lyme disease with resultant symptoms of fatigue and myalgia. What intervention is the best next step to decrease this pt’s risk of completed suicide?
take away the fire arm
48 yr old woman with MDD is brought to the ED by her husband. The pt is severely depressed, she says she wants to die and has a plan to hang herself. She has no energy or appetite and has lost 6kg over the past month. The pt has difficulty falling asleep and awakens at 4AM each morning. Over the past week, she has head a voice saying she is evil and doesn’t deserve to live. In the hospital, she seldom speaks and refuses to eat and drink. What would provide the most RAPID IMPROVEMENT of this pt’s symptoms?
Electric therapy
79 yr old man is brought to the office by his wife for eval of memory impairment. The pt is a recently retired professor who began having memory problems a month ago. He has been forgetting to take his medication, has had difficulty remembering the names of his grandchildren, and has neglected to turn off the stove on more than one occasion. The pt used to enjoy reading and playing with his grandchildren but has recently stopped going both of these activities. He also has difficulty staying asleep, low appetite, and decreased energy. The pt has hypertension and type 2 diabetes for which he takes medications. He has a family history of Alzheimer disease. The pt says “ i just feel so worthless since retiring. Montreal Cognitive Assessment score is 23. What is the most likely dx?
depression related cognitive impairment.
2 yr old boy is brought to the clinic by his mother who is concerned about his language development. She says “i know children speak at different ages and he is still young, but i am concerned that his speech isn’t progressing and that he needs to interact with other children more. His day care teacher says that he is shy and sits in a corner playing with his favourite truck. We have also been busy with a recent move and have not given him as much attention, which doesn’t help”. The pt’s birth history, medical history and audiology screening are unremarkable. His mother is 6 months pregnant with her second child, and the family moved to a new home 3 months ago. In the examination room, the pt sits in a corner, avoiding eye contact with the doctor and repeatedly spinning the wheels of a toy truck. He does not respond to his name. He makes occasional grunting sounds but says no fully formed words. When his mother tries to take his truck away, he begins screaming and pulls it back. What is the most likely dx?
autism spectrum disorder
69 yr old woman comes to the office due to memory concerns. The pt first began having difficulties with her memory a year ago and her symptoms have steadily worsened. She often forgets the content of conversations she has with her son and frequently walks to another room, only to forget what she went there to do. The pt lives alone and has no difficulty cooking, cleaning or otherwise caring for herself. She manages her own finances. Medical hx is significant for hypertension, hyperlipidemia and type 2 DM. The pt is alert and oriented. Neuro exam reveals no focal deficits. She scores 22/30 on the Montreal Cognitive Assessment. What is the most likely dx?
mild cognitive impairment
25 yr old graduate student with a hx of recurrent ear infections as a child feels anxious and sweats when she is in the examination room with her pcp. She recently got a roommate, a nursing student, who leaves her steth . This pt’s response to her roommate’s steth is an example of what phenomena?
classical conditioning
27 yr old woman comes to the office due to concerns about her weight. She is frustrated about gaining a few pounds, although she maintains a well-balanced diet and exercise for an hour 3 times a weeks. The pt has been worried for years that her thighs are “huge” and”covered in cellulite”. She always wears loose-fitting pants and spends hours a day researching leg exercises and measuring the circumference of her thighs. The pt generally stays at home and avoids social activities as she feels people tends to stare at her. She weighs 58 kg and is 170cm tall. Physical exam is normal. What is the most likely dx?
Body dysmorphic disorder
72 yr old man is hospitalised due to a leg injury following a high-speed motor vehicle collision. Medical hx is significant for hypertension, hypercholestrolemia, and hearing loss. The pt drinks a glass of wine every day. Exam shows localised swelling and severe tenderness under the right knee; the presence of a tibial fracture is confirmed by imaging. The pt undergoes open reduction and internal fixation without any perioperative complications. On the first postoperative night, he describes visual hallucinations of his deceased brother in the hospital room with him and preservatives about people invading his home. Vital signs are normal. The pt is disoriented and unable to cooperate with the mental status exam. He appears to respond to internal stimuli. What intervention is most likely indicated to prevent further worsening of his condition?
facilitating uninterrupted nocturnal sleep
10 yr old boy is brought to the office due to poor grades and behavioural problems. Although the pt is very intelligent, his parents report that he struggles at school and has received failing grades because he is easily distracted, makes careless mistakes, and often loses his homework. His teacher has called several times to report that he repeatedly disrupts the class by getting out of his seat and by blurting out answers when he is not called on. At home, the pt does not listen to his parents, does not clean up after himself, and fails to complete chores despite repeated redirection. he has no other medical conditions. Fam hx is significant for a substance use disorder in the pt’s 16 yr old brother and depression in his mother. Treatment options are discussed with the parents. They would like to try medication but prefer a nonstimulant option. What is the most appropriate pharmacotherapy for this pt?
atomoxetine
28 yr old man comes to the office due to persistent fatigue. For the past several weeks, he has been having trouble sleeping and is frequently late for work as he has difficulty getting out of bedd. At work, his mind wanders and his supervisor has commented that the quality of his work has deteriorated. The pt says, “i’ve been feeling down and don’t feel like doing anything. My appetite is poor. I no longer go out with my friends and haven’t gone to the gym in weeks”. The pt has no significant medical or psychiatric hx. He has 1 0r 2 alcoholic drinks several days a week but does not use illicit drugs. Physical exam is unremarkable. Mental stats exam shows a cooperative man with sad affect. No delusions are elicited. The pt says he sometimes wishes he could go to sleep and no wake up but has no suicidal intent or plan. First line pharmacotherapy for this p most likely involves a drug with which mechanism of action?
serotonin reuptake inhibition
46 yr old is admitted to the hospital for atypical chest pain. His medical hx is significant for hypertension controlled with amlodipine and hypercholestrolemia treated with atorvastatin; he has a family hx of depression and heart disease. During review of his substance use hx, the pt says that he has been a regular drinker for the last 5 years. He drinks a 6 pack of beer every night and has 2 more beers in the morning to help him get through the day. He also admits to smoking marijuana occasionally but does not use tobacco or other illicit drugs. What symptom or signs is most likely to appear earliest during this pt’s hospitalisation?
tremulousness
62 yr old woman comes to the office for f/u of worsening hypertension. The pt admits to not taking her antihypertensive medications as prescribed. She says she feels fine and adds “i always listen to my bodily rhythms when deciding whether to take medication on a particular day”. The pt explains that her crystal jewellery has healing powers and she maintains an online forum about the health benefits of crystals. The pt does not trust most people and believes that she can predict the weather based on the number of birds in her yard. She lives alone, has few friends and is unemployed. On exam, the pt makes limited eye contact and appears mildly anxious. She has no auditory hallucinations and no specific delusions are elicited. What is the most likely explanation for this clinical presentation?
schizotypical personality disorder
32 yr old man with schizophrenia comes to the office for f/u. The pt has been stable on his antipsychotic medication for many years. He has infrequent auditory halucinations and says that the medication “has helped a lot to turn down the volume of the voices” The pt works stocking grocery shelves patt-tie and lives with his parents, who are supportive. His symptoms first developed gradually at age 14 when he exhibited nonspecific anxiety and became increasingly paranoid that other were talking about hime behind his back; he also became preoccupied with finding special meanings in certain numbers. A year later he was hospitalised for a psychotic episode characterised by paranoid delusions and auditory hallucinations that respond rapidly to antipsychotic medication. The pt was able to finish high school. He was hospitalised again briefly at age 22 but has remained out of hospital since them. What factor is most predictive of a favourable prognosis for this pt?
positive psychotic symptoms
40 yr old woman comes to the ED fearing she is having a heart attach. While clutching and breathing heavily, she says “ i feel like im dying” Temp is 37, BP is 125/86, pulse is 10/min. Pulse OX show 98% on room air. Lab eval and ECG show no abnormalities. The pain resolves within 10 minutes without tx and the pt reports “ i was taking the bus home from work when my chest started feeling realy tight. Im lucky my friend was there and able to help me get to the hospital. What if she’s not there next time?” she describes experiencing similar episodes at random places and times that are characterised by a pounding heart, trembling, dizziness and sweating. She drinks alcohol socially and does not use any medications. The pt is most likely to develop what disorder as a result of her current condition?
agarophobia
2 day old infant is evaluated in the newborn nursery due to poor feeding. The infant is irritable, is not sleeping well, and has had several episodes of vomiting and loose stools today. A review of the maternal hx reveals that the mother had poor prenatal care and that the pregnancy was complicated by foetal growth restriction. On exam, the infant is diaphoretic and has a high-pitched cry. The infant is also noted to have occasional sneezing and is mildly tachypneic. No dysmoprhic features are noted, and the remainder of the examination is unremarkable. This infant’s symptoms are most likely caused by prenatal exposure to what?
heroine.
32 yr old woman comes to the office due to overwhelming anxiety and stress. The pt is an accountant and has been under increasing job-related pressure for the past 6 weeks due to an upcoming tax deadline. She says, “the worst part is that i get really nervous all of a sudden and then feel shaky, dizzy and nauseated and start to sweat. It happened while i spoke to my boss a few weeks ago and i had to excuse myself”. the pt is especially worried about havig an episode during work meeting, although she notes her symptoms have also occurred while she was relaxing at home. She says “Ive stopped going out with my friends because i never know when im going to feel this way”. The pt has no significant medical hx and does not use alcohol or illicit drugs. BP is 120/70. Physical exam and lab eval show no abnormalities. What is the most likely dx?
Panic disorder
28 yr old man is hospitalised due to the acute onset of severe depression and suicidal ideation for several days. He was recently thrown out of his mother’s home after stealing her money ti support his drug habit. The pt reports fatigue and vivid disturbing dreams. The nursing staff note that he is irritable withdrawn, hyper-somnolent and hyperphagic. The pt has an extensove hx of substance abuse and has been hospitalised previously for alcohol detox. BP is 110/80 and pulse is 64. Physical exam shows old injuries from a motorcycle accident but no other abnormaliies. On mental status exam, He appears lethargic and dysphoric. The pt’s current symptoms are most likely result of what condition?
cocaine withdrawal.
60 yr old woman comes to the office due to uncontrollable movements that has worsened. Med hx is significant for hypertensions, hyperlipidemia, OA, and schizo and she has been on a stable medication regimen for years. Throughout the interview, she exhibits facial grimacing, lip smacking and twisting movements of her hands and feet. The pt has lived in a group home for years and worries that her housemates are avoiding her because her symptoms make her look “strange”. On mental status exam, the pt makes poor eye contact and is generally distrustful but has no specific delusions or hallucinations. What is the dx?
tardive dyskinesia
