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1.A 31-year-old woman presents to the emergency department (ED) 20 minutes after the sudden onset of chest pain; palpitations; shortness of breath; and numbness of her mouth, fingers, and She tells you that it feels like she has a lump in her throat. Her medical history includes multiple visits to the ED over a period of 6 months with a similar presenta- tion. Her only medication is an oral contraceptive. She occasionally drinks a glass of wine after a busy day of work when she feels stressed. She tells you that her mom takes medication for anxiety. Her blood pressure (BP) is 125/75 mm Hg, heart rate (HR) 88 beats per minute, and oxygen satura- tion 99% on room air. An electrocardiogram (ECG) shows a sinus rhythm. Her symptoms resolve while in the ED. Which of the following is the most likely diagnosis?
- Paroxysmal atrial tachycardia
- Major depressive disorder
- Panic disorder
- Posttraumatic stress disorder
2. A 23-year-old woman is brought to the ED for vision loss in her left eye that began shortly after waking up in the She states that she is very depressed since her father was diagnosed with terminal cancer. She was supposed to visit her father today in the hospital but is now in your ED because of her vision loss. Your physical examination is unremarkable. An evaluation by the ophthalmologist is also normal. A head computed tomographic (CT) scan is normal. Which of the following is the most likely diagnosis?
- Somatization disorder
- Conversion disorder
- Retinal detachment
- Anxiety disorder
3. Which of the following clinical presentation requires hospitalization?
- A 37-year-old man with paranoid schizophrenia who has been off his medica- tions for a week and is hearing voices with no apparent violence in his thought content.
- A 19-year-old woman who ingested 10 multivitamin pills after an argument with her boyfriend.
- A 39-year-old man with no previous psychiatric history presents with pressured speech, no sleep for 4 days, and is feeling “great.”
- A 22-year-old woman who is having visual hallucinations after ingesting D-lysergic acid diethylamide (LSD).
- A 43-year-old homeless man with a history of schizophrenia who was recently dis- charged from the psychiatric ward being managed on antipsychotic medications.
4. A 35-year-old woman is eating dinner at a Approximately 1 hour after finishing the main course of lamb, red wine, and a fine selec- tion of cheese, the patient experiences a severe occipital headache, diapho- resis, mydriasis, neck stiffness, and palpitations. Which of the following medications is this patient most likely taking?
5. You walk into the examining room to interview a He refused giving vital signs at the triage station until he saw a doctor because he was afraid that the nurse would inject poison into him. He appears agitated and starts raising his voice as soon as you are in the room. You ask him in a calm voice if you could help him and he replies by shouting obscenities and throwing a box of gloves at you. You start to walk toward him, but he says he will kill you if you get any closer. Which of the following is the most appropriate next step in management?
- Tell the patient he is being uncooperative and is to leave the ED immediately.
- Have the nurse go into the room alone to try to calm the patient.
- Let the patient sit in the room for another hour and see if he calms down.
- Ask the nurse to prepare an injection of lorazepam that you will give to sedate the patient.
- Alert hospital security that there is a violent patient and prepare to place the patient in physical restraints.
6. A 42-year-old man with a history of schizophrenia is brought into the ED by a friend who states that the patient has not taken his medication for over 2 weeks and is now behaving His BP is 130/70 mm Hg, HR 89 beats per minute, respiratory rate (RR) 15 breaths per minute, and oxygen saturation 99% on room air. On examination he appears agitated and is shouting, “the aliens are about to get me.” He is cooperative enough that you decide to use pharmacologic sedation. Which of the following is the most appropriate choice for sedating this patient?
- Haloperidol and lorazepam
- Etomidate and succinylcholine
- Chlorpromazine and lorazepam
- Ketamine and lorazepam
7. A 48-year-old man is brought to the ED by family members who state that the patient has remained home-bound for weeks, sleeping for many hours, and appears The patient states that he is “fine” and denies any medical symptoms. Initial vitals include HR of 77 beats per minute, BP of 118/55 mm Hg, and RR of 12 breaths per minute with oxygen saturation of 97% on room air. The patient is afebrile with an unremarkable physical examination. He denies any chest discomfort, difficulty breathing, consti- pation, cold intolerance, weakness, weight changes, or pain. The patient reports that he has had difficulty concentrating, a decreased appetite, and excessive sleeping patterns. The family reports that this has happened before, but that his symptoms self-resolved and were not nearly as severe. Given this patient’s presentation, which of the following is the most likely etiology of this patient’s symptoms?
- Major depressive episode
- Diabetes mellitus
- Subdural hematoma
- Cushing syndrome
8. A 32-year-old woman presents to the ED after an aggressive outburst at work where her behavior was deemed a threat to Her coworkers state that she is normally very dependable, kind, and gracious, but that over the course of the week they noticed that she was especially reserved and at times found her conversing with herself. Her initial vitals include HR of 89 beats per minute, RR of 15 breaths per minute, and BP of 130/75 mm Hg with oxygen saturation of 99% on room air. She tells you that she was recently started on a new medication. Which of the following types of medications may be responsible for this patient’s behavior?
- Oral contraceptives
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Calcium channel blockers
9. A 23-year-old woman is brought to the ED by police officials who state that they found the patient in the middle of a busy intersection Upon arrival, you see a disheveled woman who is yelling, “You can’t get away with this! I’m the Queen of England!” She does not allow for the triage nurse to obtain her vitals, but you can see a young woman who is of normal habitus without any signs of trauma. Her speech is pressured, she is easily distracted by the commotion of the ED, and begins to answer your questions but then continues to describe grandiose ideas about her social status. Given this patient’s acute presentation, what is the most likely etiology of her symptoms?
- Hypothyroid disorder
- Manic episode
- Benzodiazepine overdose
- Anticonvulsant overdose
- Barbiturate overdose
10. A mother brings her 7-year-old daughter to the ED with a reported illness of 3 days where the child has been weak and not eating her usual The mother also reports that she noticed her daughter’s urine to be of a reddish color and that her stools have been smaller in caliber. She brings a specimen of her daughter’s urine with her. She reports that her daughter has been hospitalized multiple times before for similar reasons and dehydration. Upon physical examination, the patient is without dis- tress, quiet, and states that she feels tired. Her chest is clear to ausculta- tion, her abdomen is benign and her neurologic examination nonfocal. A urinalysis performed fails to show any blood or myoglobin in the child’s urine. Which of the following should be included in the differential diag- nosis of this child?
- Factitious disorder
- Munchausen syndrome
- Munchausen syndrome by proxy
- Munchausen syndrome by proxy
11. A 62-year-old man presents to the ED after he was found talking to himself by witnesses on a nearby Upon arrival, the patient appears confused and is actively hallucinating. His initial vitals include an irregular HR of 80 to 110 beats per minute, an RR of 14 breaths per minute, and a BP of 160/80 mm Hg with an oxygen saturation of 97% on room air. An ECG indicates atrial fibrillation. The patient can be redirected but states that he is distracted by colorful, floating images in the room. Given this patient’s presentation, what is the most likely etiology of his symptoms?
- Acute psychotic disorder
- Conversion disorder
- Digoxin overdose
- Antidepressant overdose
12. An 18-year-old man presents to the ED after telling a school counselor that he wanted to harm His physical examination is unremarkable without any signs of trauma. He reports occasional excessive alcohol use. He states that his parents recently separated and that he has been living with either parent on a rotating schedule. Overall, he feels supported by family and friends but continues to feel hopeless despite this. Which of the following factors in this patient is most likely to increase his risk of an actual suicidal attempt?
- Alcohol use
- Parent separation
13. A thin 16-year-old girl is brought in the ED after collapsing at Her initial vitals include an HR of 110 beats per minute, BP of 80/55 mm Hg, and an RR of 18 breaths per minute with an oxygen saturation of 98% on room air. Upon physical examination, you note a cachectic female in mild distress. Her chest is clear to auscultation; her sunken-in abdomen is soft and nontender. Upon inspecting her extremities, you notice small areas of erythema over the dorsum of her right hand distally. Given this patient’s presentation and physical examination, which of the following etiologies must be further explored in this patient?
- Factitious disorder
14. A 55-year-old woman presents to the ED after a reported syncopal Her initial vitals include an HR of 105 beats per minute, an RR of 16 breaths per minute, a BP of 125/60 mm Hg, and an oxygen saturation of 98% on room air. Her ECG is shown below. Which of the following sub- stances is responsible for this patient’s ECG findings?
- Tricyclic antidepressant (TCA)
- Valproic acid
15. A 28-year-old presents to the ED with depressive symptoms and feel- ings of She denies any active suicidal ideation but has had increasing feelings of guilt over the last few weeks. The patient denies any past medical history except for giving birth 8 weeks ago. Her initial vitals are within normal limits. Given this patient’s presentation, which of the following etiologies is most likely?
- Dysthymic disorder
- Bipolar disorder
- Postpartum depression
- Major depressive disorder
- Cyclothymic disorder