Life Long Learning in Neurology - part 6 doc

Which of the following mechanisms is the most likely cause of this patient's worsening parkinsonian symptoms?... Although this patient's worsening symptoms could be due to the natural hi

1 An 82-year-old man without previous significant neurological history is hospitalized for pneumonia On the

second hospital evening he develops severe agitation and confusion His symptoms wax and wane over the next

several days and resolve with improvement of his pneumonia Which of the following options represents the

current model of neurotransmitter deficiency/ excess in the pathophysiology of this patient's neuropsychiatric

symptoms?

A Acetylcholine deficit and dopamine excess

B Dopamine deficit and serotonin excess

C [gamma]-Aminobutyric acid (GABA) deficit and glutamine excess

D Serotonin deficit and acetylcholine excess

E Glutamine deficit and GABA excess

Correct Answer: The correct answer is A This patient's symptoms and signs are most consistent with delirium The

current pathophysiological model of delirium suggests the pathophysiological role of a simultaneous cholinergic

deficit and dopamine excess, although these alterations probably exist within a more global derangement of

multiple neurotransmitter systems

2 A 35-year-old woman has presented to her physician with three different acutely distressing symptoms in the

past 2 years Shortly after the holidays 2 years ago, she complained of dysphagia No abnormalities were found on

a barium swallow or upper endoscopy She experienced no weight loss, and the dysphagia gradually improved with

reassurance She returned to the physician the next spring with complaints of intermittent shortness of breath A

fairly detailed cardiopulmonary evaluation failed to demonstrate any abnormalities She was placed in a graded

exercise program and experienced a gradual amelioration of this problem However, this year she returned with

complaints of diffuse myalgias and weakness Evaluation failed to show any objective signs of weakness or

laboratory evidence of muscle disease This woman's constellation of somatic symptoms meets the diagnostic

criteria for which of the following disorders?

A Conversion disorder

B Hypochondriasis

C Somatization disorder

D Abridged somatization disorder

E Multisomatoform disorder

Correct Answer: The correct answer is E Multisomatoform disorder is a diagnostic option defined as the presence

of three or more acutely distressful and medically unexplained symptoms over a 2-year period Symptoms to

consider are identified on a checklist of 15 common symptoms found in the primary care setting developed from

the Primary Care Evaluation of Mental Disorders This patient's disorder does not meet diagnostic criteria for the

abridged somatization disorder, which require lifetime symptoms and presence of four somatic complaints in males

and six in females Patients with somatization disorder must present with many unexplained physical complaints,

including four pain syndromes, two gastrointestinal complaints, one sexual problem, and one pseudoneurological

symptom, with the onset by age 30 years Her disorder does not meet criteria for diagnosis of the other disorders

listed as alternative choices

Correct Answer: Kroenke K, Spitzer RL, Williams JB The PHQ-15: validity of a new measure for evaluating the

severity of somatic symptoms Psychosom Med 2002;64:258-266

3 A 5-year-old boy was first noted at age 1 year to not respond when called by his name and has always seemed

emotionally remote to his parents compared with their recollections of his siblings As a toddler and in preschool he

was less likely to share things with other children or to show things to others He has had normal language

development and communication skills In the last year, he has started to develop troubling restricted behaviors,

including preoccupation with parts of objects and stereotyped and repetitive motor mannerisms Which of the

following is the most likely diagnosis?

A Autistic disorder, high functioning

B Autistic disorder, low functioning

C Asperger syndrome

D Pervasive developmental disorder not otherwise specified

E Attention deficit hyperactivity disorder

Correct Answer: The correct answer is D This boy has features consistent with impaired social skills noted by age

1 He does not meet enough criteria to be diagnosed with autistic disorder by age 3 However, starting at age 4 he

begins to develop behavioral abnormalities that are suggestive of autistic spectrum disorders and thus merits the

diagnosis of pervasive developmental disorder not otherwise specified

4 A 44-year-old man with a 30-year history of complex partial seizures comes to the office for a follow-up visit

He describes a 6-month history of feeling depressed, with diminished appetite, poor sleep, and anhedonia His only

medication is carbamazepine, with which he is compliant; he has not had a seizure in more than 2 years

Neurological examination is normal Which of the following medications is the most appropriate to consider for this patient's current symptoms?

A Bupropion

B Citalopram

C Clomipramine

D Desipramine

E Maprotiline

Correct Answer: The correct answer is B This patient's symptoms are compatible with depression, for which an antidepressant medication is indicated Citalopram is one of the antidepressant medications associated with a low risk of exacerbation of seizures; other medications with relatively low seizure risk include escitalopram, fluvoxamine, mirtazapine, and fluoxetine The other choices listed above, including bupropion, maprotiline, and the tricyclic antidepressants (eg, clomipramine and desipramine), should be avoided in patients with seizures because

of their more frequent association with seizures

5 Which of the following cognitive symptoms frequently present with postconcussive syndrome after a mild head trauma?

A Difficulties with calculation

B Executive dysfunction

C Ideomotor apraxia

D Impaired constructional ability

E Right-left disorientation

Correct Answer: The correct answer is B Common cognitive behavioral symptoms of postconcussive syndrome include impaired attention and concentration, memory deficits, impaired executive functions, personality changes, irritability, affective changes, and anxiety The cognitive deficits listed could occur with traumatic brain injury but are not common in postconcussive syndrome due to mild trauma

6 A 58-year-old woman develops acute confusion and agitation while hospitalized for sepsis from a urinary tract infection Because of the risk of self-injury, parenteral haloperidol is ordered She has no significant past medical history Which of the following laboratory tests should be performed in this patient prior to initiation of haloperidol?

A Echocardiogram

B Electrocardiogram (ECG)

C Electroencephalogram (EEG)

D Multigated acquisition cardiac scan

E Serum creatine kinase level

Correct Answer: The correct answer is B Because haloperidol is associated with QT corrected for heart rate (QTc) prolongation, pretreatment cardiac assessment with ECG and regular ECG monitoring are needed when this agent

is used in patients with delirium None of the other cardiac tests listed would specifically assess for the QTc duration A QTc duration of greater than 500 msec at baseline or during treatment makes torsade de pointes more likely and requires discontinuation of haloperidol Although neuroleptic medications can be associated with a lowering of the seizure threshold or the neuroleptic malignant syndrome, EEG and baseline serum creatine kinase level are not necessary prior to administration

7 A couple has one 7-year-old son with autism There is additional family history with a maternal nephew who has been diagnosed with Asperger syndrome The couple has just had a second son, and the mother is worried that he could have an autism spectrum disorder She asks what sorts of signs she should look for so that she might seek early intervention if there is a concern that the second son might be affected Which of the following clinical characteristics is potentially suggestive of autistic pathology?

A Febrile seizures

B Increased sleeping

C Constant desire to show off artwork

D Reduced reaction to sounds

E Smiling at other babies

Correct Answer: The correct answer is D One sensory behavior red flag is reduced reaction to sounds and intolerance to certain sounds Febrile seizures are not related to autism spectrum disorders Requiring less sleep and having frequent awakenings, not increased sleeping, at age 1 year may be adaptive-skill red flags Two-year-old children may be noted to show reduced joint attention behaviors, such as pointing and showing, and 1-year-old children may show reduced attention to other babies

8 A 72-year-old man with a 20-year history of Parkinson's disease (PD) is brought to the office by his wife because

of 2 months of nocturnal visual hallucinations of small children and animals He states that he is aware that the

visions are not real and he is not very distressed by them His medications include carbidopa-levodopa,

pramipexole, and amantadine, with no changes in dose over the past year On examination he is alert; his

Mini-Mental State Examination score is 29/30 He has severe bradykinesia, bilateral rest tremor, and a shuffling gait with

intact postural reflexes Which of the following options represents the most appropriate management of this

patient's hallucinations?

A Add clozapine

B Add quetiapine

C Discontinue amantadine

D Discontinue carbidopa-levodopa

E Discontinue pramipexole

Correct Answer: The correct answer is C This patient's hallucinations are most likely due to overstimulation of

mesocortical and mesolimbic regions due to his dopaminergic medications Since amantadine is likely the least

effective antiparkinsonian medication this patient is taking, its discontinuation should be attempted first Addition

of an antipsychotic medication would not be the best choice at this time since his symptoms are not very distressing

or disruptive, and a lower-risk intervention should be attempted first

9 A 45-year-old woman is well known to her local hospital She has had several admissions for acute abdominal

pain associated with ileus, nausea, vomiting, and abdominal distention During these spells, she is often restless and

anxious-appearing and complains of "pain all over." She also had a brief hospitalization for diffuse weakness 3

months ago, but many of her physicians felt that it was psychogenic weakness because it improved rapidly with rest

and hydration over 2 days She now presents to the emergency department with tachycardia, hypertension, similar

gastrointestinal symptoms, excessive sweating, mild disorientation, and some degree of paranoia Her serum

sodium is 122 mmol/L Which of the following options should be considered initially as a likely diagnosis for this

woman?

A Arsenic poisoning

B Somatization disorder

C Hypochondriasis

D Anxiety disorder

E Porphyria

Correct Answer: The correct answer is E This patient's problems could all be manifestations of acute intermittent

porphyria Before considering a diagnosis of a somatoform disorder, a reasonable diagnostic evaluation should be

performed for other medical conditions that may explain the patient's symptoms Somatoform disorders are a

diagnosis of exclusion

10 A 46-year-old man is thrown from his motorcycle after hitting a tree Paramedics find him dazed and

disoriented They remove his helmet and do not note any external injuries He is evaluated at a local emergency

department, and a computed tomographic (CT) scan reveals a small left temporal polar contusion Otherwise his

examination and workup are unremarkable While hospitalized for observation, a nurse finds him yelling at dogs he

reports seeing around his bed Which of the following medications would be most helpful to control the

hallucinations and agitation after a head injury?

A Clozapine

B Diazepam

C Haloperidol

D Quetiapine

E Valproate

Correct Answer: The correct answer is D Atypical antipsychotic agents are preferred to typical antipsychotic

agents because they have fewer dopamine-blocking properties Typical antipsychotic agents may cause a functional

decline in brain-injured patients, who may already have diminished dopamine circuits from frontal lobe injury

Clozapine is less useful as an antipsychotic agent because of its potential systemic side effects, ability to lower the

seizure threshold, and anticholinergic properties, which may worsen cognitive function Benzodiazepines may also

worsen cognitive dysfunction and cause behavioral disinhibition Valproate is primarily helpful with mood lability,

impulsivity, and aggression

11 A 64-year-old man with a 5-year history of PD is brought to the office by his wife because she has noticed that

he has had worsening stiffness and tremor for the past 4 weeks Six weeks ago he began treatment with a selective

serotonin reuptake inhibitor (SSRI), sertraline, for symptoms of depression, including feelings of hopelessness,

sleep disturbance, and diminished appetite; these symptoms have improved He has been on a stable dose of

carbidopa-levodopa for the past 2 years Examination shows tremor and bradykinesia that are worse than seen on

his previous visit 3 months ago Which of the following mechanisms is the most likely cause of this patient's

worsening parkinsonian symptoms?

A Down-regulation of dopamine neurotransmission

B Natural history of his PD

C Pseudo-worsening of PD symptoms due to depression

D Reduced gastric absorption of carbidopa-levodopa

E Denervation supersensitivity

Correct Answer: The correct answer is A Some patients with PD have worsening motor symptoms with SSRI treatment; this has been proposed to be due to down-regulation of dopamine neurotransmission by the SSRI Despite the potential for worsening of PD symptoms with SSRIs, many patients with PD and depression can be successfully treated with SSRIs, which are typically started with low doses The patient should be closely followed for worsening parkinsonian symptoms Although this patient's worsening symptoms could be due to the natural history of his illness, this is less likely since the observed symptoms coincided with the onset of SSRI treatment If motor symptoms worsen with SSRI treatment, consideration could be given to lowering the dose of the SSRI, switching to a different antidepressant, or increasing the patient's antiparkinsonian therapy

12 Which of the following features is included in the diagnostic criteria for autism but not Asperger syndrome?

A Lack of social or emotional reciprocity

B Stereotyped and repetitive motor mannerisms

C Delay in the development of spoken language

D Preoccupation with parts of objects

E Lack of spontaneous seeking to share enjoyment or interests with other people

Correct Answer: The correct answer is C Children with Asperger syndrome develop without a general delay in language or cognition Communication impairment is one of the integral features of autistic spectrum disorders The other choices may all be present in both autism spectrum disorders and Asperger syndrome

13 A 35-year-old man loses control of his bicycle on gravel while making a turn and hits his head on a concrete embankment He is wearing a helmet and suffers a relatively minor concussion Over the next 3 months, he develops many features of a postconcussive syndrome, including memory deficits, impaired attention, irritability, and insomnia However, the symptoms that most trouble him are severe anxiety and nervousness To which brain structure is trauma likely to cause postconcussive anxiety syndromes?

A Amygdala

B Orbitofrontal structures

C Prefrontal areas

D Diffuse white matter axonal injury

E Temporal poles

Correct Answer: The correct answer is A The amygdala has been proposed as the site of traumatic injury to produce posttraumatic anxiety disorders It is prone to injury because of its mesial temporal location Injury to the orbitofrontal structures may cause impulsive aggression Prefrontal area injury may be associated with psychotic symptoms as well as many other deficits Diffuse axonal injury may be associated with apathy, lack of motivation, decreased processing speed, and distractibility Injury to the temporal poles may correlate with acquired bipolar symptoms

14 A 74-year-old woman with a 6-year history of Alzheimer's disease becomes severely confused and agitated and attempts to get out of bed without assistance 1 day after admission to the hospital for a hip fracture She has a history of diabetes and hypertension Her medications are insulin, hydrochlorothiazide, and donepezil She received haloperidol for a similar episode of confusion during a previous hospitalization 1 year ago, but this was complicated by QTc prolongation Routine serum chemistries, glucose, and oxygen saturation are normal, and her current QTc duration is normal Which of the following medications would be the most appropriate alternative to haloperidol in this patient?

A Clozapine

B Olanzapine

C Quetiapine

D Thioridazine

E Ziprasidone

Correct Answer: The correct answer is C In patients with prolonged QTc from haloperidol, the atypical antipsychotic agents olanzapine or quetiapine appear to be reasonable alternatives due to their relatively lower risk

of prolonged QTc than other atypical antipsychotic medications, such as ziprasidone In this diabetic patient quetiapine appears to be the most appropriate option since olanzapine is associated with the risk of increased serum glucose Clozapine is significantly anticholinergic and is contraindicated in delirium Thioridazine is inappropriate because it is associated with a high risk of QTc prolongation

15 A 37-year-old woman is referred to a neurologist for evaluation of right arm tremor, which developed suddenly

after finalization of her divorce The tremor is somewhat unusual in that at times it is more prominent in resting

positions and at other times it is more consistent with a postural tremor It worsens with direct attention to the right

arm and lessens with distractions The frequency of the tremor varies during contralateral voluntary arm

movements A trial of propanolol did not help the tremor Past medical history is positive for a history of migraine,

atypical chest pain, fibromyalgia, chronic low back pain, dysphagia, irritable bowel syndrome, and dyspareunia

Most of these have been chronic over 10 to 15 years and fluctuating in severity at various times Which of the

following diagnoses is most likely for this woman?

A Factitious disorder

B Somatization disorder

C Conversion disorder

D Pain disorder

E Hypochondriasis

Correct Answer: The correct answer is B This woman presents with a tremor that has many features to suggest a

psychogenic cause With the development of this new pseudoneurological symptom, her constellation of problems

now meets the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR)

diagnostic criteria for somatization disorder, with four pain syndromes, two gastrointestinal problems, one sexual

problem, and one pseudoneurological symptom

16 A 43-year-old woman was unloading crates of merchandise at a retail chain distribution center 2 months ago

She slipped and fell off the loading dock approximately 6 feet to the floor below She hit her head on the concrete

when she landed and was dazed for perhaps 10 minutes Initially she was more concerned with headache and

dizziness However, those problems are gradually receding, and she is now more concerned with problems with her

memory Which of the following treatments would be likely to help with her memory impairment?

A Amantadine

B Bupropion

C Donepezil

D Methylphenidate

E Propanolol

Correct Answer: The correct answer is C Multiple studies have demonstrated the efficacy of donepezil in treatment

of memory and attentional deficits in patients with traumatic brain injury Amantadine may be helpful to treat

apathy and lack of motivation Bupropion may be used to treat depression Methylphenidate may improve

processing speed and attention after brain injury Propanolol is helpful for management of postconcussive

syndrome headache, agitation, and aggressive behavior

17 Memory impairment is a common complaint in patients with postconcussive syndromes and is attributed to

injury at which of the following sites?

A Bilateral frontal lobe injury

B Mesial temporal lobes

C Diffuse axonal injury

D Orbitofrontal injury

E Brain stem reticular formation

Correct Answer: The correct answer is B The mesial temporal lobes are predisposed to injury due to the

sphenoidal bony protuberances In addition, the hippocampus is sensitive to physiological stress Bilateral frontal

injury may cause apathy and lack of motivation and other frontal lobe dysfunctions Diffuse axonal injury may be

associated with decreased processing speed and inattention Orbitofrontal injury is associated with impulsive

aggression Injury to the brain stem reticular formation may be associated with disruption of consciousness and

lethargy/inattention

18 A 68-year-old man is brought to the emergency department by his wife because of a 2-day history of

drowsiness, confusion, and intermittent agitation He has a history of prostatic hypertrophy and a distant history of

depression; his only medication is finasteride His temperature is 37.9°C, blood pressure 102/74 mm Hg, and pulse

112/min On examination he is agitated and not oriented to year or place Speech is fluent, and there is no aphasia

or dysarthria He is diffusely tremulous, but no focal weakness or sensory loss is seen; reflexes are normal

Complete blood count, comprehensive metabolic panel, and oxygen saturation are normal Noncontrast brain CT

and lumbar puncture are normal Which of the following diagnostic steps is most likely to lead to determination of

the cause of this patient's symptoms?

A Assessment of clinical response to haloperidol

B CT of brain with contrast

C EEG

D Medical evaluation for underlying systemic illness

E Neuropsychological testing

Correct Answer: The correct answer is D This patient's findings are most compatible with delirium Evaluation of delirium should include a prompt and thorough evaluation for an acute systemic illness underlying the delirium Although this patient may benefit from administration of a neuroleptic medication if the agitation is impacting his safety, this response is nonspecific and will not lead to a determination of the cause His symptoms are unlikely to

be due to subclinical seizures, so EEG is unlikely to be very helpful Neuropsychological testing can define and assess delirium but will not determine the specific underlying systemic cause of delirium in this patient

19 A 6-year-old boy spends so much time performing repetitive stereotyped behaviors, such as spinning objects or hand-waving, that it is difficult to engage him in an individualized behavioral program For which of the following treatments is there research evidence of efficacy to reduce stereotyped behaviors?

A Atypical antipsychotic agents

B Mood stabilizers

C Stimulants

D SSRIs

E Tricyclic antidepressants

Correct Answer: The correct answer is A An improvement in restricted, repetitive, and stereotyped behaviors has been shown with treatment with the atypical antipsychotic agent risperidone (McCracken et al, 2002; cited in the chapter Autism-Presentation, Diagnosis, and Management in this issue) Mood stabilizers may help with affective instability, impulsivity, and aggressive behaviors Stimulants may be useful to reduce hyperactivity SSRI agents may benefit social interactions, mood, ritualistic behavior, aggression, and obsessive-compulsive tendencies Correct Answer: McCracken JT, McGough J, Shah B, et al Risperidone in children with autism and serious behavioral problems N Eng J Med 2002;347:314-321

20 A 27-year-old woman has presented to her general hospital many times with generalized seizures The frequency and control of the seizures show no improvement with trials of antiepileptic drugs It has been difficult to get a detailed description of her behavior during spells from a careful observer Eventually she is referred to an epileptologist and is admitted to an epilepsy-monitoring unit for evaluation During one of her spells, she displays forced closure of her eyes, head turning from side to side, and movements of her limbs that are asynchronous from side to side The EEG shows no epileptic activity during her spells Which of the following is the best approach to subsequent management of her spells?

A Tell her that you know that she is intentionally feigning seizures

B Tell her that her problems are strictly psychiatric

C Discharge her without neurological follow-up

D Help her to understand that the spells are real signs of psychic stress but are not caused by abnormal electrical discharges

E Tell her spouse that she is probably having these spells to get out of work or some other onerous responsibility Correct Answer: The correct answer is D Her neurologist should help her to come to the understanding that the spells are real signs of psychic stress but are not caused by abnormal electrical discharges as in typical epileptic seizures Pseudoseizures or nonepileptic seizures are a common type of conversion disorder The key to treatment

is the development of a therapeutic alliance It is important not to brusquely dismiss the symptoms as "imaginary"

or psychiatric as this will often result in a worsening Rather, it is most effective to gradually work on helping the patient to understand the relationship between psychological stress and somatization as a poor coping strategy Referral to a psychologist or psychiatrist and/or use of psychotropic medication may be useful

21 A 58-year-old woman comes to the emergency department because of diaphoresis, tremulousness, and anxiety that began 3 hours ago She has a 6-year history of PD manifested mainly by a mild rest tremor and bradykinesia; she has been treated with pramipexole and selegiline for the past 4 years Eight weeks ago, paroxetine was begun for depression, and the dose has gradually been increased She has a temperature of 37.9°C, pulse 110/min, and blood pressure 150/90 mm Hg She appears anxious, diaphoretic, and diffusely tremulous with a severe postural tremor of both hands Which of the following conditions is the most likely cause of this patient's current symptoms and signs?

A Anxiety disorder

B Hyperthyroidism

C Neuroleptic malignant syndrome

D Pheochromocytoma

E Serotonin syndrome

Correct Answer: The correct answer is E Although most of the listed options could cause similar findings, this patient's symptoms are most consistent with the serotonin syndrome, a rare but important adverse event, which can

occur due to the combination of an SSRI (such as paroxetine) with selegiline Although the occurrence of serotonin

syndrome in patients taking a combination of an SSRI or a serotonin-norepinephrine reuptake inhibitor with

selegiline appears to be rare, combination of these agents with selegiline should be avoided Rasagiline, a new

monoamine oxidase type B-inhibitor antiparkinsonian agent, carries the same potential theoretical risk and warning

regarding administration with antidepressants, although clinical experience with this agent is limited An anxiety

disorder would not explain the patient's acute and severe autonomic symptoms, including fever and diaphoresis

22 A-53-year old woman was involved in a motor vehicle accident and sustained a mild head injury with

concussion Although she had no past history of psychiatric disorder, over the next year she develops fairly rapid

cycling mood symptoms with episodes of mania and depression She is hospitalized due to suicidality in the context

of a mixed episode; she exhibits symptoms of depressed mood with elevated energy and impulsivity The

psychiatrist requests neurological consultation to determine whether special considerations regarding treatment of

her mood disorder are needed given her history of head injury Which of the following would be the best

medication to try first for management of her psychiatric disorder?

A Lithium

B Olanzapine

C Sertraline

D Valproate

E Venlafaxine

Correct Answer: The correct answer is D Bipolar symptoms can be caused by brain injury Valproate is the agent

that has been best studied for effectiveness for treatment of bipolar symptoms in patients with postconcussive

syndrome Lithium should be avoided in brain-injured patients because of lowering of the seizure threshold,

potential neurotoxicity, and narrow therapeutic window Antidepressants sertraline and venlafaxine may play a

secondary role in treating depression but should not be given as primary mood stabilizers in patients with bipolar

symptoms Olanzapine and other atypical antipsychotics represent another treatment option for such patients,

especially with psychotic features, but have not been as well studied in this population

23 Fink and colleagues (2003) report that 50% of the patients seen by neurologists have a comorbid psychiatric

illness Which of the following do they contend is the most common comorbid psychiatric condition seen in this

group?

A Anxiety disorders

B Bipolar disorder

C Chemical dependency

D Depression

E Somatoform disorders

Correct Answer: The correct answer is E Fink and colleagues (2003, 2005) report that somatoform disorders

represent the most common comorbid psychiatric condition seen by neurologists and estimate that up to 60% of the

patients seen by neurologists have unexplained complaints without an apparent physical cause

Correct Answer: Fink P, Hansen MS, Sondergaard L, Frydenberg M Mental illness in new neurological patients J

Neurol Neurosurg Psychiatry 2003;74:817-819 Fink P, Steen Hansen MS, Sondergaard L Somatoform disorders

among first-time referrals to a neurology service Psychosomatics 2005;46:540-548

24 A 44-year-old woman develops severe confusion and agitation 1 day after undergoing an uncomplicated

cholecystectomy She has a history of alcohol abuse; her last drink was 1 day prior to admission, 48 hours ago She

has no other significant past medical history and takes no medications Her temperature is 37.7°C, blood pressure

150/94 mm Hg, and pulse 100/min She is disoriented to place and is agitated and tremulous In addition to

intravenous thiamine, which of the following medications should be administered?

A Diazepam

B Haloperidol

C Lorazepam

D Olanzapine

E Ziprasidone

Correct Answer: The correct answer is C Benzodiazepine monotherapy is the treatment of choice when delirium is

due to alcohol withdrawal, as in this patient Lorazepam is a preferable benzodiazepine because of several

attributes, including its properties of sedation, short duration of action, lack of major active metabolites, and low

risk of accumulation

25 A 15-year-old boy has been pressured by his father to play football His father was very successful as a high

school defensive lineman and earned a football scholarship to a Division 1 school He remains an avid football fan

The son did well on the junior varsity team last year but really does not enjoy the game He has sometimes wished

that he might spend more time on his studies and perhaps try out for the high school musical if his participation in

football was not so important to his father On the morning of his tryouts for the varsity team, he awakens with weakness of his left leg and numbness of his right hand He is tearful and worried that he is having a stroke or some other threatening medical condition His neurological examination shows give-way weakness of hip flexion and ankle dorsiflexion on the left Reflexes are preserved and symmetrical bilaterally He reports numbness involving the entire right hand in no nerve or radicular distribution Which of the following is the most likely diagnosis for this neurological presentation?

A Conversion disorder

B Factitious disorder

C Hypochondriasis

D Malingering

E Vasculitic neuropathy

Correct Answer: The correct answer is A This adolescent presents with a pseudoneurological complaint in the setting of an internal conflict most consistent with a conversion disorder He has not had the ability to assert his desire not to play football with his father The development of these symptoms will prevent him from trying out for football and resolve his internal conflict about football and are not consciously produced or feigned Vasculitic neuropathy seems very unlikely given the lack of pain, the give-way quality of his weakness, and the lack of a nerve distribution for his right hand numbness

26 A 22-year-old man with an 8-year history of complex partial seizures is brought to the emergency department

by his family because of 2 days of severe paranoia and agitation Four days ago he had two of his typical complex-partial seizures with secondary generalization His only medication is carbamazepine; there has been no recent change in dose He has had no previous similar psychiatric symptoms He is afebrile with normal vital signs He appears suspicious, and his speech is pressured Neurological examination is otherwise normal EEG shows occasional left temporal spikes Routine laboratory studies are normal, and carbamazepine level is 13.4 mcg/mL Which of the following is the most likely diagnosis?

A Acute postictal psychosis

B Antiepileptic drug toxicity

C Chronic interictal psychosis

D Schizophrenia

E Status epilepticus

Correct Answer: The correct answer is A This patient's symptoms are most compatible with acute postictal psychosis Acute postictal psychosis presents within 1 week of a seizure and typically lasts from 1 day to 1 week Symptoms of acutepostictal psychosis resemble those of mood disorders with psychotic features This patient's risk factors for acute postictal psychosis include partial seizures and the clustering of his seizures As opposed to acute postictal psychosis, chronic interictal psychosis is the insidious onset of delusions and other psychotic symptoms in patients with epilepsy This patient has no other history to suggest schizophrenia Although his carbamazepine level

is slightly high, his symptoms are unlikely to be due to carbamazepine toxicity Finally, status epilepticus is always

a consideration in patients with new behavioral symptoms and a history of seizures, but this has been excluded by the EEG findings

27 An 82-year-old woman develops lethargy alternating with agitation 1 day after hospitalization for chest pain She has a history of hypertension, coronary artery disease, and a hyperactive bladder Her medications include enalapril, metoprolol, hydrochlorothiazide, oxybutynin, isosorbide, and aspirin Vital signs are normal, and neurological examination is normal except for mild confusion Routine laboratory studies are normal A trial of discontinuation of which of this patient's medications would be most appropriate?

A Enalapril

B Hydrochlorothiazide

C Isosorbide

D Metoprolol

E Oxybutynin

Correct Answer: The correct answer is E This patient has symptoms of delirium In patients with delirium, discontinuation of a medication that is potentially "deliriogenic" is appropriate In this case, oxybutynin, an anticholinergic medication, is the most likely of the patient's medications to be contributory to her delirium

28 Abnormalities in the cerebellar hemispheres in children with autism are thought to be associated with which of the following cognitive or behavioral abnormalities?

A Impaired integration of brain regions leading to sensory deficits

B Detection of threats in facial images

C Proper production of the behavioral responses such as fear

D Increased anxiety and stress levels

E Abnormal adjustments of attention levels

Correct Answer: The correct answer is E Cerebellar dysfunction has been linked to inaccurate attentional

adjustments, which may interfere with the ability to follow the natural flow of conversations or events Decreased

function of the frontal cortex may lead to impaired integration of brain regions with resultant sensory, emotional,

and language deficits in autism Evidence suggests that amygdala hypofunctionality may be associated with

abnormal detection of threats in facial images and production of behavioral responses to the environment along

with increased tendencies toward anxiety and stress

29 A 28-year-old woman comes to the office for follow-up of her multiple sclerosis (MS) She was diagnosed with

MS 2 years ago when she presented with diplopia and magnetic resonance imaging showed multiple bilateral

periventricular lesions; 1 year earlier she had mild weakness and numbness in both legs that improved without

treatment within 1 week There is no family history of MS, but there is a family history of depression in her father

and paternal grandfather She has been taking interferon beta-1a since her diagnosis 2 years ago, and she is

tolerating the injections well; she has had no definite attacks of MS since treatment was started Upon questioning,

she admits that over the past 4 months she has been feeling depressed, with diminished appetite and difficulty with

sleep She denies suicidal ideation Neurological examination is normal Which of the following represents the

most appropriate management of this patient at this time?

A Add an SSRI

B Discontinue interferon

C No changes in management are necessary

D Switch the patient from interferon beta-1a to interferon beta-1b

E Switch the patient from interferon beta-1a to glatiramer acetate

Correct Answer: The correct answer is A Depression is a common accompaniment of MS and is also a potential

side effect of treatment with either interferon beta-1a or beta-1b This patient is at particularly increased risk of

depression due to her family history Since she is otherwise doing well on her interferon medication, addition of an

SSRI appears to be the most appropriate option A switch from interferon to glatiramer acetate (which is not

associated with the depression risk of the interferons) would be another reasonable option and should be considered

if she fails to benefit from the addition of an SSRI to her regimen

30 A 45-year-old veteran presents to the emergency department with a report of a ripping chest and back pain and

tingling numbness in his left hand The emergency department physician finds an asymmetry between the right and

left brachial pulses This prompts not only noninvasive workup, such as chest CT and echocardiogram, but also

invasive arteriography of the aortic arch and branches to rule out aortic dissection No pathological finding explains

the asymmetry of his pulses

When the case is presented at morning report, one of the interns, who was a medical student at a different

institution just months before, states that this case sounds familiar to him and he wonders if the same patient had

been seen at his medical school hospital More investigations are made, and it turns out that the patient has been

seen at several hospitals in the region for the same complaint This information is shared with the patient, and he

leaves the hospital surreptitiously without completion of psychiatry consultation or formal discharge Which of the

following diagnoses is most likely for this patient?

A Conversion disorder

B Factitious disorder

C Hypochondriasis disorder

D Malingering

E Pain disorder

Correct Answer: The correct answer is B The discovery of repeated similar presentations and evaluations at other

hospitals and the fact that the patient did not share this information makes this most likely to be a factitious

disorder There is no indication that the patient is seeking some type of secondary gain, such as shelter, food, or

excuse from work Rather the patient seems to capitalize on his asymmetrical pulses and fabricated chest/back pain

to assume the "sick role" and gain medical attention

31 Which of the following clinical features is a symptom potentially suggestive of autistic pathology?

A No babble at 6 months of age

B No words at 12 months of age

C No two-word phrases at 15 months of age

D Excessive hand gesturing at 16 months of age

E Absence of symbolic play at 2 years of age

Correct Answer: The correct answer is E Absence of symbolic play or the presence of repetitive, nonfunctional

play are abnormalities of adaptive skills that should raise potential concern, and parents should be encouraged to

obtain further evaluation of these children Lack of babble should raise concern at 1 year of age, not 6 months

Lack of single words should not raise significant concern until age 18 months of age, and lack of two-word phrases should not raise significant concern until 24 months of age Absence of hand gesturing rather than excessive meaningful hand gesturing at 12 months of age is concerning

32 A 42-year-old woman with a 14-year history of MS is brought to the office by her husband because of several months of episodes of uncontrollable laughing alternating with crying These episodes seem to occur without obvious provocation, and the patient denies feeling especially sad or happy during these attacks She denies feeling depressed, and there has been no change in her appetite or sleep patterns Examination shows a Mini-Mental State Examination score of 22/30, severe dysarthria, and diffuse spasticity and ataxia; these signs are unchanged from her last visit 6 months ago Which of the following is the most appropriate management option for this patient's inappropriate laughing and crying?

A Discontinue interferon beta-1b

B Begin desipramine

C Begin gabapentin

D Begin lithium

E Begin supportive psychotherapy

Correct Answer: The correct answer is B This patient's symptoms are consistent with pathological laughing and crying (PLC), a symptom complex that is more common in advanced MS and is often associated with cognitive impairment Patients with PLC have uncontrollable episodes of crying or laughing unassociated with a mood-congruent state or mood disorder PLC responds well to antidepressants, including tricyclic antidepressants (eg, desipramine) at lower-than-therapeutic doses for depression The other listed options would not be as appropriate as

a trial of an antidepressant in this patient There is no evidence for depression in this patient to warrant discontinuation of interferon beta

TYPE R QUESTIONS (EXTENDED MATCHING)

Theme: Duration of therapy after remission

A Two to 3 months

B Six to 9 months

C Two to 3 years

D Six to 10 years

E Lifetime

For each of the following patients with a psychiatric disorder in remission, choose the most appropriate duration of continued medication therapy Each choice may be used once, more than once, or not at all

33 A 32-year-old woman is on an SSRI for her first episode of depression without suicidal ideation She has just entered remission

Correct Answer: The correct answer is B Antidepressant duration for this patient should be approximately 6 to 9 months after remission Therapy should be ongoing for those with three or more major depressive episodes, chronic symptoms, or risk for suicide

34 A 26-year-old man is on a mood-stabilizing agent for bipolar disorder, which was diagnosed 6 years ago He has had no episodes of mania or severe depression in the past 2 years

Correct Answer: The correct answer is E Patients with bipolar disorder require lifelong treatment of their condition

35 A 24-year-old woman has been taking an atypical antipsychotic medication since she was diagnosed with schizophrenia 2 years ago She is currently employed and has had no episodes of overt psychosis since beginning her medication

Correct Answer: The correct answer is E Patients with schizophrenia require lifelong treatment of their condition

Theme: Monotherapy

A Bupropion

B Olanzapine

C Haloperidol

D Lithium

E Mirtazapine

F Sertraline

G Valproate

H Clonazepam

For each of the following patients with a psychiatric disorder that is currently not being treated, choose the medication that would be the most appropriate choice in monotherapy Each choice may be used once, more than once, or not at all