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  #1  
Old 07-23-2016
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Default Psychiatry Question CMS form 2

Nightmare disorder or Primary insomnia??

1. A 20-*year-*old woman comes to student health services because of a 6*week history of difficulty sleeping. She says that two to three times weekly, she wakes up during the night in the middle of a vivid dream that usually involves the need to escape from a physical threat such as a rapist. When she tries to run in her dreams, her legs feel progressively heavier until she is barely able to move; it is at this point that she wakes up. She says that she has difficulty falling back to sleep; during the past 2 weeks, she has been drinking a glass of wine to aid her in falling back to sleep. She feels tired throughout the day and is concerned that her grades will begin to decline. Three months ago, she broke up with her boyfriend of 1 year because he refused to stop using marijuana. She has not dated since the breakup, but she spends time with friends. Physical examination shows no abnormalities. On mental status examination, she is friendly and cooperative. She appears mildly anxious, but she smiles and laughs on occasion. She says she is tired. Her thought process is logical and goal directed. She is oriented to person, place, and time. There is no evidence of auditory or visual hallucinations. Which of the following is the most likely diagnosis?

A) Adjustment disorder with anxiety
B) Dysthymic disorder
C) Generalized anxiety disorder
D) Nightmare disorder
E) Primary insomnia
F) Sleep terror disorder
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  #2  
Old 07-26-2016
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Quote:
Originally Posted by doc2530 View Post
Nightmare disorder or Primary insomnia??

1. A 20-*year-*old woman comes to student health services because of a 6*week history of difficulty sleeping. She says that two to three times weekly, she wakes up during the night in the middle of a vivid dream that usually involves the need to escape from a physical threat such as a rapist. When she tries to run in her dreams, her legs feel progressively heavier until she is barely able to move; it is at this point that she wakes up. She says that she has difficulty falling back to sleep; during the past 2 weeks, she has been drinking a glass of wine to aid her in falling back to sleep. She feels tired throughout the day and is concerned that her grades will begin to decline. Three months ago, she broke up with her boyfriend of 1 year because he refused to stop using marijuana. She has not dated since the breakup, but she spends time with friends. Physical examination shows no abnormalities. On mental status examination, she is friendly and cooperative. She appears mildly anxious, but she smiles and laughs on occasion. She says she is tired. Her thought process is logical and goal directed. She is oriented to person, place, and time. There is no evidence of auditory or visual hallucinations. Which of the following is the most likely diagnosis?

A) Adjustment disorder with anxiety
B) Dysthymic disorder
C) Generalized anxiety disorder
D) Nightmare disorder
E) Primary insomnia
F) Sleep terror disorder

Thank you for the reply.

How about an adjustment disorder with anxiety after her breakup?
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Old 07-26-2016
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I am terrible at psych but I would have chosen A as well
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Old 07-26-2016
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Quote:
Originally Posted by saxo View Post
I am terrible at psych but I would have chosen A as well
Thank you so much Saxo.

Would you mind taking a look at these questions and see if you have any ideas?

40. A 67-year-old woman, whose husband died 18 months ago, is admitted to the hospital because of severe headaches for 4 weeks. She is quiet and seems sad. She believes that she has brain cancer, deserves to be punished for her sins, and is being punished by God for past misdeeds. She has had fatigue and a 6.8-kg (15-lb) weight loss over the past 4 months. Physical and neurologic examinations show no abnormalities. Which of the following is the most likely diagnosis?

A) Adjustment disorder with mixed disturbance of emotions and conduct
B) Delusional disorder
C) Major depressive disorder
D) Schizophrenia
E) Somatization disorder

44. A 7-year-old girl is brought to the physician because her parents are concerned about her recent preoccupation with death. Her dog died 2 months ago, and since th time she has repeatedly asked her parents if they are going to die. When her mother travels, the daughter worries that the plane will crash. She has begun to talk wi her friends about the possibility of their parents dying. She continues to excel academically and participate in sports. Her pulse is 86/min, and blood pressure is 110/70 mm Hg. Physical examination shows no abnormalities. Mental status examination shows a neutral mood and an appropriately reactive affect. Which of the following is the most likely explanation for these findings?

A) Bereavement
B) Obsessive-compulsive disorder
C) Post-traumatic stress disorder
D) Separation anxiety disorder
E) Age-appropriate

47. A 27-year-old man comes to the physician because of anxiety about a major speech that he must deliver in 3 days. He has a great fear of public speaking and is convinced that his apprehension and tremulous delivery will damage his performance. He requests a tranquilizer to help with his anxiety. He takes theophylline and uses corticosteroid and albuterol inhalers for asthma. He has a family history of alcohol dependence. He does not drink alcohol or use drugs. His pulse is 66/min, respirations are 12/min, and blood pressure is 132/80 mm Hg. Examination shows normal findings.

For each patient with anxiety, select the most appropriate pharmacotherapy.
A) Bupropion
B) Buspirone
C) Chlorpromazine
D) Fluoxetine
E) Haloperidol
F) lmipramine
G) Lorazepam
H) Perphenazine
I) Propranolol

50. An otherwise healthy 25-year-old man comes to the physician because he has a severe fear of flying and must attend an essential business meeting in Europe in 2 days. He has no substance abuse problems or other mental or physical problems.
For each patient with anxiety symptoms, select the most appropriate pharmacotherapy.

A) Bupropion
B) Chlorpromazine
C) Fluoxetine
D) Haloperidol
E) Imipramine
F) Lorazepam
G) Perphenazine
H) Propranolol

----------------------------------------------------------------
This is what I am thinking:

40) MDD~complicated bereavement, C?

44)Is she presenting with age appropriate behavior?

47) performance anxiety part of social phobia, since he is asthmatic should avoid propranolol? but D is incorrect..which one would you give him? I thought lorazepam should stay away from since he has a dependency issue in his family.

50) specific phobia=benzo F?

Thanks again for all the help so far.
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Old 07-26-2016
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Quote:
Originally Posted by DocMinion View Post
Thank you so much Saxo.

Would you mind taking a look at these questions and see if you have any ideas?

40. A 67-year-old woman, whose husband died 18 months ago, is admitted to the hospital because of severe headaches for 4 weeks. She is quiet and seems sad. She believes that she has brain cancer, deserves to be punished for her sins, and is being punished by God for past misdeeds. She has had fatigue and a 6.8-kg (15-lb) weight loss over the past 4 months. Physical and neurologic examinations show no abnormalities. Which of the following is the most likely diagnosis?

A) Adjustment disorder with mixed disturbance of emotions and conduct
B) Delusional disorder
C) Major depressive disorder
D) Schizophrenia
E) Somatization disorder

44. A 7-year-old girl is brought to the physician because her parents are concerned about her recent preoccupation with death. Her dog died 2 months ago, and since th time she has repeatedly asked her parents if they are going to die. When her mother travels, the daughter worries that the plane will crash. She has begun to talk wi her friends about the possibility of their parents dying. She continues to excel academically and participate in sports. Her pulse is 86/min, and blood pressure is 110/70 mm Hg. Physical examination shows no abnormalities. Mental status examination shows a neutral mood and an appropriately reactive affect. Which of the following is the most likely explanation for these findings?

A) Bereavement
B) Obsessive-compulsive disorder
C) Post-traumatic stress disorder
D) Separation anxiety disorder
E) Age-appropriate

47. A 27-year-old man comes to the physician because of anxiety about a major speech that he must deliver in 3 days. He has a great fear of public speaking and is convinced that his apprehension and tremulous delivery will damage his performance. He requests a tranquilizer to help with his anxiety. He takes theophylline and uses corticosteroid and albuterol inhalers for asthma. He has a family history of alcohol dependence. He does not drink alcohol or use drugs. His pulse is 66/min, respirations are 12/min, and blood pressure is 132/80 mm Hg. Examination shows normal findings.

For each patient with anxiety, select the most appropriate pharmacotherapy.
A) Bupropion
B) Buspirone
C) Chlorpromazine
D) Fluoxetine
E) Haloperidol
F) lmipramine
G) Lorazepam
H) Perphenazine
I) Propranolol

50. An otherwise healthy 25-year-old man comes to the physician because he has a severe fear of flying and must attend an essential business meeting in Europe in 2 days. He has no substance abuse problems or other mental or physical problems.
For each patient with anxiety symptoms, select the most appropriate pharmacotherapy.

A) Bupropion
B) Chlorpromazine
C) Fluoxetine
D) Haloperidol
E) Imipramine
F) Lorazepam
G) Perphenazine
H) Propranolol

----------------------------------------------------------------
This is what I am thinking:

40) MDD~complicated bereavement, C?

44)Is she presenting with age appropriate behavior?

47) performance anxiety part of social phobia, since he is asthmatic should avoid propranolol? but D is incorrect..which one would you give him? I thought lorazepam should stay away from since he has a dependency issue in his family.

50) specific phobia=benzo F?

Thanks again for all the help so far.
40. Yea looks like C

44. E or A? Not sure
What I remember is less than 6 years - do not understand the concept of death (will ask when the pet will come back), at 7 yrs - understands finality of death but do not think they can die, at 9 yrs - understands they can die as well.

47. G?
Like you said cannot use beta blocker in the case but I don't think a family hx of dependence is a contraindication for use of lorazepam

50. Yes F

Last edited by saxo; 07-26-2016 at 07:54 PM.
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  #6  
Old 07-26-2016
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From uptodate,
Benzodiazepines can also be used on an "as needed" basis to treat performance-only SAD [35]. Clonazepam 0.25 to 1 mg or lorazepam 0.5 to 2 mg can be given 30 to 60 minutes before the performance. Tolerance and physical dependence are not a concern with occasional use. But the potential for abuse, highest in persons with a history of alcohol or other substance use, should also limit their use in this context.
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  #7  
Old 07-28-2016
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Thank you so much saxo.
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