Year 3. Psych Nms: Ch1. Clinical Exam

Front 1

A 35 year old lawyer has been evaluated in the ED for cardiac dz after an episode of palpitation and tightening of the chest. His medical condition is entirely normal, but he remains anxious. A psych eval is considered. Special skills are required of the physician who conducts the exam for which of the following reasons?

A) pt may be embarrassed about disclosing emotional problems
B) Pt may threaten a lawsuit if psych questions are asked
C)A male pt is generally unwilling to discuss psych issues
D)the pt may still have cardiac dz that should be ruled out before a psych eval is performed
E) The pt will deny any psych problems if he thinks he has heart dz

Back 1

A) pt may be embarrassed about disclosing emotional problems

Front 2

a 38 yo man is evaluated for psych illness after being held hostage in a bank robbery in which he was a customer. He feels too upset to return to work, and he is on paid leave from his job. His request to remain on leave is an example of which of the following:

A)Counterphobic reaction
B) Malingering
C) Perceptual distortion
D) Psychotic distortion
E) Secondary gain

Back 2

E) Secondary gain

Front 3

During psychiatric eval of a 19 year old college student who has attempted suicide by overdose, the examiner asks the question: "did you take the pills before or after you talked to your boyfriend?" This is an example of which of the following kinds of interview techniques?

A)Clarification
B) Confrontation
C) Facilitation
D) Open-end question
E) Summarization

Back 3

A)Clarification

may include connections that the pt may not recognize

Front 4

a 27 yo man admits that he has persistent thoughts of curse words while attending church. Although he does not want to have the thoughts and is bothered by them, he cannot seem to stop them. He does not act on saying them aloud. Which of the following is the best description of this type of thinking:

A)Delusional
B)Derealization
C)Obsessional
D)Perseveration
E)Referential

Back 4

C)Obsessional

Front 5

a yound woman with schizophrenia is undergoing a psychiatric evaluation. The physician asks her why she has missed her last two appointments. The woman says that she does not want to be put in the hospital again and that the clinic reminds her of the hospital. Which of the following areas of the mental status exam best describes the problem?

A)Association
B) Cognition
C)Delusion
D)Insight
E) Judgment

Back 5

D)Insight

the woman shows a lack of insight into her illness which can lead to refusal of needed treatment. Although poor judgment may result, the problem is primarily caused by lack of insight

Front 6

The dexamethasone suppression test is not used extensively in general psychiatric evaluations for which of the following reasons?

A)too expensive
B) its side effects include adrenal suppression
C)it is contraindicated in pregnancy
D)it has too many false-positive results
E) It is associated with increased suicide

Back 6

D)it has too many false-positive results

the test shows a lack of suppression of plasma cortisol levels not only in pts with depression but also in those with other conditions such as dehydration, alcohol abuse, and weight loss. This lack of specificity is the major reason why it is not widely used; it is not expensive and doesn't have side effects

Front 7

A 40 yo man with a history of chronic undifferentiated schizophrenia for more than 20 years is being evaluated. No mediations have yet proved successful, and the man remains chronically psychotic. The best lab method to demonstrate decreased activity in his frontal cortex is which of the following?

A) CT
B) MRI
C) PET
D) Rorschach test
E) Single-photon emission computed tomography (SPECT)

Back 7

C) PET

PET shows specific areas of brain activity better than other scanning techniques

Front 8

65 yo woman is evaluated a few days after the death of her husband from a heart attack. She cries easily and says that she has difficulty sleeping, has trouble concentration, and is not sure if life is worth living. Her condition is best described by which of the following?

A)Adjustment disorder
B) Major depression
C) Minor depression
D) Normal reaction to stress
E) PTSD

Back 8

D) Normal reaction to stress

Front 9

According to the National Comorbiditiy Survey which involved diagnostic interviews of more than 8,000 Americans, the most common psychiatric disorder was which of the following?

A)Alcohol abuse
B)Depression
C)Generalized anxiety disorder
D) Panic disorder
E) Phobia

Back 9

B)Depression

Front 10

An 18 yo college freshman is referred after midterm exams for crisis help because he wants to quit school and is anxious and depressed. Although his grades are As and Bs, he states he is "failing". In high school, he was a straight-A student, and he believes that he is a failure if he does not receive all As in college. The young man's sx are best described by which of the following mechanisms:

A)External stress-induced response
B) Impulsive disorganization
C) Internal stress-induced response
D) Maladaptive request for help
E) Underlying psychotic illness

Back 10

C) Internal stress-induced response

pt cant deal with his own unrealistic expectations

Front 11

a 25 yo man is brought to the hospital by the police for emergency eval. He tried to assault the officer who was questioning him. He appears psychotic and confused. In evaluating his potential for violence, the physician should first assess which of the following?

A)Any history of hospitalization
B)Medication(s) the pt is using (if any)
C)Reports from relatives about the pts recent behavior
D) Presence of command hallucinations
E) Any history of violence

Back 11

D) Presence of command hallucinations

IN pt with psychotic thinking who is being evaled for dangerous violent command hallucinations are a significant acute risk factor for violence. Previous hx is also important, but not the first topic. No prescription meds are known to induce violence. Recent behavior is also important, but less-so. Past hospitalizations is not useful

Front 12

a 19 yo Female college student is brought to the ED after a suicide attempt that involved self-ingestion of benzos and antidepressant mediations. She states she no longer wishes to engage in any more self destructive behavior. Initially, a physician should take which of the following management steps?

A)Perform a careful mental status exam
B)Perform gastric lavage
C) hospitalize the pt-against her will if necessary
D) obtain blood lvls of the medications the pt took
E)Observe the pt carefully

Back 12

B)Perform gastric lavage

Front 13

You are a primary care physician treating a 59-yo Puerto rican lawyer for prostate cancer. He is divorced and living alone. IN assessing his risk for suicide, which of the following demographic characteristics decreases his risk?

A) Age
B) ethnicity
C) marital status
D) Medical illness
E) Occupation

Back 13

B) ethnicity

Front 14

A 60 year old woman is being tx for recurrent depression. She has attempted suicide twice in the past by OD. After each attempt, she was hospitalized. Denying true suicide intent in the past, she admits that she uses suicidal gestures to control her family. The woman now expresses some suicidal thoughts. The physician's best course of action is which of the following?

A) Explore the pts need to control others by threat
B) Contact family members to assess stress at home
C) Assess the lvl of the pts ambivalence about suicide
D) assess the physicians own countertransference reaction
E) Hospitalize the patient before further assessment

Back 14

E) Hospitalize the patient before further assessment

pt has many risk factors for suicide, protect the pt

Front 15

Because the majority of violent acts are committed by men, testosterone has been considered a potential causative agent. Yet antiandrogen tx has been shown to be effective in which one of the following disorders?

A) Alcohol dependence
B) Mania (bipolar I)
C) Pedophilia
D) Rape
E) Schizophrenia

Back 15

C) Pedophilia

rape isn't a psychiatric disorder

Front 16

• A 29 year old biker has been in an altercation with the police. A physician in the ED is suturing the man’s laceration. Because the pt is angry and threatens to injure anyone who gets in his way, the physician becomes more controlling than usual and sternly warns the patient to behave. Which of the following best describes the physician’s behavior?
o A)Authoritarian
o B) Counterphobic
o C) Limit setting
o D) Overly frightened
o E) Uninformed

Back 16

 B) Counterphobic: although the physician may think he is setting limits, he is responding as though there is no danger and he is in control. This is unconscious, ill-advised reaction is primarily counterphobic

Front 17

• A 20 year old woman is brought to the ED after a rape. States that her life was threatened with a knife by her assailant, but she appears unconcerned. She denies any feelings and states she just wants to be left alone. Which of the following best describes her mental state?
o A) Delusional
o B) Denial
o C) Emotional disorganization
o D) Malingering
o E) Resolution

Back 17

 B) Denial

Front 18

• Select the perceptual problem that most likely-applies to each patient
o A) Depersonalization
o B) Derealization
o C) Formication
o D) Illusion
o E) Olfactory Hallucination
 A 44 yo chronic cocaine abuser is tx for self-inflicted skin excoriations; the pt feels that there are “bugs crawling all over me”. He has scratched himself repeatedly in the past. He appears confused and admits to using cocaine that day.

Back 18

• C) Formication: hallucinations of insects crawling over the skin

Front 19

• Select the perceptual problem that most likely-applies to each patient
o A) Depersonalization
o B) Derealization
o C) Formication
o D) Illusion
o E) Olfactory Hallucination
 A 60 yo man in the coronary care unit becomes agitated because he believes the orderly moping the floor is going to attack him with a club. The pt has been unstable medically, and his PO2 is below normal.

Back 19

• D)Illusion: pts coronary care units are susceptible to delirious states, illusions are common in delerium

Front 20

• Select the perceptual problem that most likely-applies to each patient
o A) Depersonalization
o B) Derealization
o C) Formication
o D) Illusion
o E) Olfactory Hallucination
 A 29 yo woman who is being tx for anxiety describes an episode at work in which everyone appeared to be mechanical and unfeeling. At times like this, she becomes frightened and thinks she is going insane. She has had this experience before, and it always passes after a few minutes

Back 20

• B) Derealization: alteration in the sense of reality of the outside world. Objects may seem altered in size and shape, and people may appear dead or mechanical

Front 21

Select the impairment in thought process that most likely applies to each pt:
A) Blocking
B)Circumstantiality
C)Echolalia
D) Flight of ideas
E) Loose associations
F) Perseveration
G) Tangential thinking
A 50 yo woman is asked during a psychiatric exam if she had ever been a pt in a psychiatric hospital. She responds " that was the summer we were at the beach, it rained for 2 weeks. I was sad, but my sister Sarah did not help. She and I have never really gotten along"

Back 21

B)Circumstantiality

The pt has not responded to the question but is in the general topic area. Irrelevant details represent digressions

Front 22

Select the impairment in thought process that most likely applies to each pt:
A) Blocking
B)Circumstantiality
C)Echolalia
D) Flight of ideas
E) Loose associations
F) Perseveration
G) Tangential thinking
A 22 yo man is brought to the ED for evaluation. He appears confused but gives his name. When asked his occupation he says "Jesus was a carpenter. I am the right hand of God. I don't offend anyone."

Back 22

E) Loose associations

Loose associations are difficult to follow. There is no logical connection btw pt statements, and the pt does not appear to be aware that the ideas are not connected

Front 23

Select the impairment in thought process that most likely applies to each pt:
A) Blocking
B)Circumstantiality
C)Echolalia
D) Flight of ideas
E) Loose associations
F) Perseveration
G) Tangential thinking
A 30 year old man who is being treated for bipolar illness has discontinued his medications for several months. He is brought to the clinic in an agitated state. When asked how he is feeling, he replies, "I am wonderful, the most wonderful in the universe. The universal gym is my invention, but Jim is just Dandy"

Back 23

D) Flight of Ideas

this man, who is in a manic state, exhibits flight of ideas, which is seen in mania. In this case, this thought process involves rapid changes of idea that are associated by the sound of the words

Front 24

Select the impairment in thought process that most likely applies to each pt:
A) Blocking
B)Circumstantiality
C)Echolalia
D) Flight of ideas
E) Loose associations
F) Perseveration
G) Tangential thinking
A 29 yo woman with chronic schizophrenia rocks in her chair and does not seem to respond to an examiner's questions except to say, "No hope, no hope, no hope"

Back 24

F) Perseveration

the repetition of the same words or phrases despite the interviewer's direction to stop is perseveration

Front 25

Select the Axis that is used to asses the situation described
A)Axis I
B)Axis II
C)Axis III
D)Axis IV
E)Axis V

A 32 yo woman who has been tx for recurrent depression for 1 year has responded well to interpersonal psychotherapy and antidepressant medication. She tells her physician that her husband has just told her that he has been having an affair and wants a divorce.

Back 25

D) Axis IV

this is the domain of psychosocial and environmental problems, including interpersonal problems and change in marital status. These stresses may affect another axis such as the one that represents the disorder for which the patient is being treated

Front 26

Select the Axis that is used to asses the situation described
A)Axis I
B)Axis II
C)Axis III
D)Axis IV
E)Axis V
A 58 yo man is being tx for both recurrent depression and alcohol abuse. He has done well in tx for both disorders, with an occasional slip in his drinking, and he has been sober for more than 1 year. He has just been told he has a liver mass that may be cancerous and he is very upset.

Back 26

C)Axis III

The knowledge that the liver mass may be cancerous is likely to influence the man's tx for depression. However the tumor may also be a consequence of the alcohol abuse

Front 27

Select the Axis that is used to asses the situation described
A)Axis I
B)Axis II
C)Axis III
D)Axis IV
E)Axis V
A 24 yo man suffers a severe head injury from a motor cycle accident. After awakening from a coma, he seems to be a different person, with poor social skills, gross and disgusting behavior, and foul language.

Back 27

A) Axis I

Although this may appear to be a personality disorder (axis II), the disorder is a newly acquired clinical syndrome caused by brain injury. Physical causes of mental disorders (formerly called organic brain disorders) are listed on axis I

Front 28

Select the dx that most likely applies to the clinical situation
A) Antisocial personality disorder
B) Bipolar disorder, manic type
C) Intermittent explosive disorder
D) Paranoid disorder
E) Schizophrenia disorders
As the ED physician on call, you are asked to evaluate a 33 yo man brought in by the police, who found him naked in the park. He attacked one of the policemen who questioned him. The man insists that he is the "emperor of the United States" and will "smite all who oppose him"

Back 28

B) Bipolar disorder, manic type

This psychotic, hyperactive pt is manic. Public nakedness is nearly always pathognomonic for mania. When others attempt to control manic pts they can be violent

Front 29

Select the dx that most likely applies to the clinical situation
A) Antisocial personality disorder
B) Bipolar disorder, manic type
C) Intermittent explosive disorder
D) Paranoid disorder
E) Schizophrenia disorders
A 25 yo unemployed construction worker is brought to the ED by the police. He denies intoxication but states several men in a bar challenged him to "prove himself". During the ensuing fight the man broke both hands. The police report that extensive damage occurred. The man appears calm and somewhat content

Back 29

C) Intermittent explosive disorder

violence out of proportion to situation

Front 30

Select the dx that most likely applies to the clinical situation
A) Antisocial personality disorder
B) Bipolar disorder, manic type
C) Intermittent explosive disorder
D) Paranoid disorder
E) Schizophrenia disorders
You are asked to evaluate a 20 yo man arrested by the police for assaulting a drug dealer. The patient claims he is seeing visions of God, who talks to him. His mental status exam is otherwise normal. The man says that he is sorry he had to injure the drug dealer but knows that God will forgive him

Back 30

A) Antisocial personality disorder

The pt appears to have been involved in criminal activity. Although his story is not consistent with psychotic illness, it is possible. The examiner looks for inconsistencies in the history and clear secondary gain (i.e. avoiding legal consequences) to be had from feigning illness. If the pt had acted bc of psychotic illness, one would expect a more disorganized mental status