USMLE step 2 ck: CMS: Psychiatry Form 3

Psychiatry form 3 answers All info is from upto date site; most authentic . 1.right answer is A .its a bipolar disorder type 1

In this case psychotic is must to fulfill the criteria .

Why not most close option of major depression because it has only 3 feature of MDD so despite having psychosis it cant be right answer because it need 5 feature to label MDD.for other options duration is not fulfilled as it has began 6 weeks ago. 2.right is d

Adults with DS usually develop neuropathologic and functional changes typical of Alzheimer disease by the sixth decade of life [8,18,19]. In one report, dementia was present in 49 of 96 (51 percent) DS individuals over the age of 35 years [18]. The average age of onset was 54 years, and seizures developed in 84 percent of patients. .nucleaus of mynert is acetylcholine storage area so it wl be deficient in Alzahemer disease A=kluver buccy syndrome B=huntigton C=auditory problem E=A lesion of the red nucleus causes resting tremor, abnormal muscle tone and choreoathetosis. F=Parkinson G=hemiblismus 3.answer is B Symptoms of Huntigton Disease begin insidiously with movement abnormalities and/or with psychiatric and cognitive features. Chorea is a key feature of HD, and the defining sign at the time of diagnosis. Psychiatric problems can include irritability, depression, dysphoria, agitation, apathy, anxiety, paranoia, delusions, and hallucinations. The dementia of HD is characterized by executive dysfunction. Rest explained above 4. answer is C …desimpramine is TCA drug A typical history should include questions about known heart disease (including congenital or acquired long QT syndrome), syncope, palpitations, dyspnea on exertion, shortness of breath, or chest pain [19]. In addition, clinicians should ask about a family history of heart disease, particularly sudden death, cardiac dysrhythmias, or cardiac conduction disturbances. Baseline screening laboratory tests should include serum potassium to rule out hypokalemia [19]. We also recommend that patients over age 40 years have a baseline ECG for this purpose. Patients younger than 40 years can be screened by history for cardiac disease and do not require an ECG if the history is negative.

In cases where QT is prolonged it is sign of drug overdose or silent heridetry QT prolongation defect which appeared now .so do ECG plus K level imp. Switch to pimoline after discontinuation of TCA drug as first best step ..pemoline is stimulant LIKE methamphetamine used for ADHD

5 right answer is E Clinicians should consider the diagnosis of methamphetamine intoxication in any diaphoretic patient with hypertension, tachycardia, severe agitation, and psychosis. Patients with methamphetamine intoxication range from the virtually asymptomatic to those in sympathomimetic crisis with imminent cardiovascular collapse. ●Methamphetamine can cause a host of respiratory, cardiac, vascular, otolaryngologic, neurologic, integumentary, psychiatric, infectious, traumatic, and dental maladies. Agitation, tachycardia, hypertension, and psychosis are among the most frequent findings. (

Ecstasy MDMA intoxication can cause a myriad of dangerous effects including severe hypertension, hyperthermia, delirium, psychomotor agitation, and profound hyponatremia. Potential life-threatening complications of these effects include intracranial hemorrhage, myocardial infarction, aortic dissection, disseminated intravascular coagulation, rhabdomyolysis, seizure, and serotonin syndrome Although there are specific serum and urine assays for MDMA, we advise against the use of these assays to guide clinical management. A positive MDMA screening test cannot confirm that a patient's symptoms are the result of MDMA toxicity. A negative test can occur despite the presence of MDMA congeners, of which there are over 100. Such congeners may cause clinical symptoms that are indistinguishable from MDMA toxicity. Regardless of whether the inciting agent is MDMA or a related drug, management is identical and based solely on the patient's clinical status. So in short we screen amphetamine by urine but not ectasy drug only difffernce except hyopnatrimia I found after much searching Other option dnt cause so much agitation 6.right is C Always rule out suicidal ideation in a patient on pain medication or severly debillated patient After that next option should be medication evaluation 7.ans is D

Pcp specific sign is nystgmus Alcohl ontoxication is not so much stimulatory and without nystgmus Other option are easy to rule out 8 right answer is A Visual hallucination is initial sign of delirium .alll antidepressant are cayuse of delirium so fist step is to stop them in elderly .its due to antimuscrinic effects .Acetylcholine plays a key role in the pathogenesis of delirium [13,14]. Anticholinergic drugs cause delirium when given to healthy volunteers and are even more likely to lead to acute confusion in frail elderly persons. This effect can be reversed with cholinesterase inhibitors such as physostigmine .uptodate 9.right answer is D . its high yield qz so learn its dd Most problematic in the differential diagnosis of NMS, malignant catatonia shares clinical features of hyperthermia and rigidity with NMS. However, in this syndrome, there is usually a behavioral prodrome of some weeks that is characterized by psychosis, agitation, and catatonic excitement. The motor symptoms are also characterized by more positive phenomena (dystonic posturing, waxy flexibility, and stereotyped repetitive movements) than are described in NMS [47,48]. Laboratory values are more typically normal

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10.ans is A DIAGNOSIS — DSM-5 diagnostic criteria for borderline personality disorder are as follows [55]:

A. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or selfmutilating behavior covered in Criterion 5.) 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance: markedly and persistently unstable self-image or sense of self. 4. Impulsivity in at least two areas that are potentially self-damaging (eg, spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or selfmutilating behavior covered in Criterion 5.) 5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 6. Affective instability due to a marked reactivity of mood (eg, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger (eg, frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideation or severe dissociative symptoms. B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. E. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder. F. The enduring pattern is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition (eg, head trauma).

All nine of the DSM-5 diagnostic criteria are common in patients with BPD. The frequency of each diagnostic criterion in a group of 201 patients with BPD was [56]: ●Affective instability (95 percent) ●Inappropriate anger (87 percent) ●Impulsivity (81 percent) ●Unstable relationships (79 percent) ●Feelings of emptiness (71 percent) ●Paranoia or dissociation (68 percent) ●Identity disturbance (61 percent) ●Abandonment fears (60 percent) ●Suicidality or self-injury (60 percent) 11. d is right Behavioral features — The behavioral phenotype of boys with FXS shares features with ADHD, anxiety, and autism spectrum disorder (eg, hyperactivity, inattention, gaze aversion, and stereotypic movements, such as hand flapping, hyperarousal, social anxiety, unusual speech patterns)

HOX mutation lead to appendages in wrong location .this gene regulates fetal limb location .. Other options are not associated with autism spectrm disorder 12.b is right answer ..here is why DIAGNOSIS — Alcohol use disorder in DSM-5 replaces two psychiatric disorders in DSM-IV, alcohol abuse and alcohol dependence. Alcohol use disorder can be specified as mild, moderate, or severe, based on the number of DSM-5 criteria present. Alcohol dependence in DSM-IV is best represented by moderate to severe alcohol use disorder in DSM-5; alcohol abuse is similar to the mild subtype of alcohol use disorder. DSM-5 diagnostic criteria for alcohol use disorder are [9]: ●Recurrent drinking resulting in failure to fulfill role obligations ●Recurrent drinking in hazardous situations ●Continued drinking despite alcohol-related social or interpersonal problems

●Evidence of tolerance ●Evidence of alcohol withdrawal or use of alcohol for relief or avoidance of withdrawal ●Drinking in larger amounts or over longer periods than intended ●Persistent desire or unsuccessful attempts to stop or reduce drinking ●Great deal of time spent obtaining, using, or recovering from alcohol ●Important activities given up or reduced because of drinking ●Continued drinking despite knowledge of physical or psychological problems caused by alcohol ●Alcohol craving He has all the features according to DSM 5 .plus he has raisedESR MCV mean alcoholism main disorder .other main distractor is primary insomnia but here are feature oof primary insomnia which is not present in this patient Diagnostic criteria — insomnia is confirmed when all four of the following criteria are met [1]: ●The patient reports difficulty initiating asleep, difficulty maintaining asleep, or waking up too early. In children or individuals with dementia, the sleep disturbance may manifest as resistance to going to bed at the appropriate time or difficulty in sleeping without caregiver assistance. ●Sleep difficulties occur despite adequate opportunity and circumstances for sleep. ●The patient describes daytime impairment that is attributable to the sleep difficulties. This may include fatigue or malaise; attention, concentration, or memory impairment; social dysfunction, vocational dysfunction, or poor school performance; mood disturbance or irritability; daytime sleepiness; motivation, energy, or initiative reduction; errors or accidents at work or while driving; and concerns or worries about sleep. ●The sleep-wake difficulty is not better explained by another sleep disorder. 13.he dnt have lithium toxicity and dnt have hyperthyroidism both ruled out by test …first line treatment of adult onset essential tremor is propranolol ..so answer is H 14.answer is F .uptodate recommendations is SUMMARY AND RECOMMENDATIONS ●For most presentations of specific phobia, we recommend first-line treatment with a cognitivebehavioral therapy (CBT) that includes exposure treatment over other psychotherapeutic or pharmacologic interventions (Grade 1B). (See "Psychotherapy for specific phobia in adults".) ●When CBT/exposure is unavailable or when patients prefer medication to psychotherapy, we suggest treatment of specific phobia with an infrequently encountered phobic stimulus with a benzodiazepine. (Grade 2C). Benzodiazepine are best suited for patients who lack a history of a substance-use disorder and for situations where the drug’s sedating effects do not interfere with functioning (eg, as a passenger on a plane flight). •A benzodiazepine lorazepam is used .The patient should take a test dose prior to using the medication for the phobic situation to ensure it does not lead to oversedation. Patients should be warned not to consume alcohol and the drug together due to the risk of additive side effects such as sedation, confusion, and impaired coordinati'

●When CBT/exposure is unavailable or when patients prefer medication to psychotherapy, we suggest treatment of specific phobia with a frequently encountered phobic stimulus with a selective serotonin reuptake inhibitor (SSRI) (Grade 2C). As an example, sertraline can be started at 50 mg/day and titrated up to a therapeutic dose over two to three weeks. See the difference requent and infrequent stimulus …amother point is SSRI would take long time to take effect but he need to present in confrense in 2 days so u got it now . 15.right is D .

He dnt have hallucination in depressive time but when he is OKy with mood symptoms then he got intermittent hallucination so that’s the core line to get in this ..he also dnt have dysthymia because

16 answer is C …she has 1.sad 2.weight loss 3.quiet 4.fatigue 5 ,negative feelings about herslf duration more than 2 weeks .she dnt have illness anxiety disorder because feature of of illness anxiety disorder =hypochondriosis are

She also dnt have delusional disorder somatic type because he has met all criteria for MDD so cant label it as delusional … 17 .right ans is C .his age is less than 18 so conduct disorder is main diagnosis as he is assaultive in nature ,oppositianal disorder dnt assault . 18 right answer after discussion is C Here is recommendation of uptodate : patients who continue to have insomnia that is severe enough to require an intervention, we suggest cognitive behavioral therapy for insomnia (CBT-I) as the initial therapy ●For patients whose insomnia continues to be severe enough to require an intervention despite CBT-I, we suggest the addition of a medication to CBT-I rather than changing to a strategy of medication alone ●For patients who require medication for sleep onset insomnia, we suggest a short-acting medication rather than a longer-acting agent ●For patients who require medication for sleep maintenance insomnia, we suggest a longer-acting medication rather than a short-acting agent (Grade 2C). Alternatively, a formulation of zolpidem has been approved for use in the middle of the night. Patients should be warned about the risk for daytime drowsiness, impaired driving, dizziness, and lightheadedness Biofeedback has no role in sleep disorder ,other best thing to do are following

Other drugs have no role in insomnia 19.answer is A Diagnostic criteria — A number of criteria for the diagnosis of sCJD have been proposed [2,108-110]. Appropriate clinical and laboratory features generally are sufficient for a "probable" diagnosis of sCJD. The Centers for Disease Control and Prevention (CDC) outline the following criteria for probable sporadic CJD [111]: 

Progressive dementia and

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At least two out of the following four clinical features: myoclonus; visual or cerebellar disturbance;pyramidal/extrapyramidal dysfunction; akinetic mutism and

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Atypical electroencephalogram (EEG) during an illness of any duration, and/or a positive 14-3-3 cerebrospinal fluid (CSF) assay with a clinical duration to death less than two years, and/or magnetic resonance imaging (MRI) high signal abnormalities in caudate nucleus and/or putamen on diffusion-weighted imaging (DWI) or fluid attenuated inversion recovery (FLAIR) and

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Routine investigations should not suggest an alternative diagnosis

20 .here diagnosis is insomnia not MDD because he has only 2 feature of MDD so as I explained above here treatment wl be first line CBT and next Zolpedim ..so answer is E

21.answer is B Psychosis – Psychosis can occur but does so almost exclusively at doses of prednisone above 20 mg/day given for a prolonged period [7,77,78]. Approximately 10 percent of patients have persistent symptoms that may require treatment despite reduction of glucocorticoid dose [79]. Response to antipsychotic drug treatment is typically complete and occurs within two weeks of initiation of neuroleptics. Hypoalbuminemia may be a risk factor for glucocorticoid-induced psychosis in patients with SLE [80]. Patients with SLE who are on higher glucocorticoid doses present a particular problem, since it is often difficult to differentiate psychosis due to prednisone from neuropsychiatric lupus, which may require highdose glucocorticoid treatment He dnt have delirium as he is oriented to time place and person . 22.answer is F treatment of acute catatonia generally occurs in hospital settings where the patient’s general medical health can be monitored and optimized. Malignant catatonia in particular is life-threatening and generally warrants admission to an intensive care unit. ●Concurrently treating the underlying psychiatric or general medical disorder along with the catatonia may improve outcomes. Clinicians should avoid using dopamine blocking drugs, even if patients are psychotic, impulsive, or aggressive. Treating catatonia with an antipsychotic is a risk factor for the neuroleptic malignant syndrome (NMS). Antipsychotics are contraindicated in malignant catatonia ●Mortality in malignant catatonia may increase if electroconvulsive therapy (ECT) does not begin within five days of symptom onset. For patients with malignant catatonia, we recommend ECT rather than a benzodiazepine (Grade 1C). A benzodiazepine should be administered during preparations for ECT; if malignant catatonia improves significantly with the benzodiazepine during the first 24 to 48 hours, it can be continued in lieu of ECT.

23.answer is F ..full feature of panic unexpected attack 24. answer is D UPTODATE SAYS We recommend symptomatic treatment of psychosis with an antipsychotic medication, even if the specific psychiatric disorder or medical condition underlying the psychosis has not yet been established (Grade 1B). As antipsychotic drugs are largely similar in efficacy, selection among them is typically made on the basis of patient presentation and the medication’s side effect profile, cost, and formulations available

25.answer is C ..he has all typical features of child abuse ..and closed humerus fracture also called

bucket handle fracture typical for abuse so next step wl be history is seperation and cantact child protective services 26.b .enlarged ventricles in schizophrenia Temporal spikes occurs in temporal lobe epilepsy 27.answer is c.he has normal finding all except temperature so may be he is having factitious or malingering behavior so test Temperature under supervision 28 . For pregnant patients with mild to moderate major depression, we suggest interpersonal psychotherapy or cognitive-behavioral therapy (CBT) as initial treatment, rather than pharmacotherapy (Grade 2B). However, pharmacotherapy is a reasonable choice if psychotherapy is not successful, or is declined or not available. In addition, antidepressants can be used for patients who responded to medications for past episodes of depression and patients with a past history of severe depression. Adjunctive exercise may possibly help as well ●Patients and clinicians must weigh the risks of fetal exposure to medications against the maternal and fetal risks of untreated illness. The risks of medications during pregnancy include teratogenicity, miscarriage, spontaneous preterm birth, low birth weight, and postnatal effects. The risks of untreated illness include missed obstetrical appointments; anorexia, suicidality, and other depressive symptoms; and comorbid substance use disorders. So explain risk and benefit of ADD medication to her .answer is B 29.right answer is C All feature present …no insight ..plus she thinks she is the only one who can do best ‘perfectionest ‘

30 ans is A.ataxia restless plus normal vital are sign of alcohl intoxication ..if same patient but with abnormal vitals then click for amphetamine . 31.ANS ; I

Schizoid Personality :A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1.Neither desires nor enjoys close relationships, including being part of a family 2.almost always chooses solitary activities 3.has little, if any, interest in having sexual experiences with another person 4.takes pleasure in few, if any, activities

5.lacks close friends or confidants other than first-degree relatives 6.appears indifferent to the praise or criticism of others 7.shows emotional coldness, detachment, or flattened affectivityClinical Features of Schizotypal Personality Disorder 1.These patients often display peculiarities in thinking, behavior and communication 2.Discomfort in social situations, and inappropriate behavior may occur. 3.Magical thinking, belief in "extra sensory perception", illusions and derealization are common. 4.Familiarity does not decrease social anxiety since it is based on paranoid concerns and not self-consciousness. 5.The patient may have a vivid fantasy life with imaginary relationships. 6.Speech may be idiosyncratic such as unusual use of phrasing or terminology.as in this patient speech is stilted

So schizotypal here wl be right 32.diagnosis is Tourette syndrome Treatment is tetrabenzene according to uptodate and uw say antipsychotics ,,so F is answer here 33 answer is b .First line treatment for post traumatic stress disorder is CBT and in CBT we explain all range of features after trauma …although it has many things in CBT click CBT not group therapy 34 .she has generalized anxiety disorder .so first line is SSRI and CBT both have same efficacy .For patients who experience a partial response to the maximally tolerated SsRI dose (or no response to two SRIs), we suggest augmentation of the SRI with buspirone rather than other medication Here reasonable option is buspiron …..bupropion is given for depression untreated with SSRI

35 .her BMI is low so strt parentral nutrition because without this she is going to collapse ..at the moment she is also having hypotention 36 .ans is D .atpyical depression with weight gain and increased sleep ..all criteria of 5 feature are full here . 37 answer is A .age above 18 And all features of antisocial disorder 38 d ..OCD very simple 39.d is right .post traumatic flash back after 1 month is called PTSD . 40.multiple worries and depression causing her physical symptoms because all her investigation are negative ,when symptom persist despite all negative evaluation by test then psychiatric assesment is next step so ans is B 41 .ans is F ..he has headache due to sleep related hypoventilation morning headache is due to increased CO2 accumulation in sleep due to closed glottis in this obese boy … Morning headaches are reported by 10 to 30 percent of patients with untreated OSA [7,8]. They are usually bifrontal and squeezing in quality, with no associated nausea, photophobia, or phonophobia. They typically occur daily or most days of the week and may last for several hours after awakening in the morning. The cause of the headaches is not well established and may be multifactorial; proposed mechanisms include hypercapnia, vasodilation, increased intracranial pressure, and impaired sleep quality. Some studies have identified higher OSA disease severity as a predictor of headache, although this has not been consistent [8-10]. The headaches usually resolve completely within several weeks of initiating positive airway pressure therapy; lack of improvement may suggest an alternative cause of headache 42. Patients taking clozapine should receive routine weekly-to-monthly monitoring and maintain an neutrophil ≥1500/microL(≥1000/microL for benign ethnic neutropenia). Lower ANC levels require more frequent monitoring, and possible interruption of clozapine and/or reevaluation of its use.

In this case Neutrophil is in lower limit plus symptomatic so temporary interruption is next best step 43.fetal alcohlic syndrome is right ..large only does not confirm that he has fragile x syndrome ..all other fature plus typical drug history is best clue . 44.he has typical sleep disorder narcolepsy …Polysmonagraphy is confirmatory test … 45.ans is valopric acid ..severe hepatotoxic 46,ans is A ..alochol relaxes everything so after long time of alchol use he can feel erection and everything so here alcohl is issue ..only cimetidine causes sexual dysfunction not ranitidone UPtodate Marital conflict they would not do sex 2 time per week . 47.ans is A ,all features of anticholinergics .no severe fever and hypertension no rigididty,hyperreflexia to label it as neuroleptic malignant syndrome 48.answer is A ,,,normal teenage behavior know its all features 49.ans is B ,,,rye syndrome 50.diagnosis here is Serotonin syndrome resulting from drug interaction so ans is C

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