A 4-year-old boy is brought to the office because he has become unmanageable at his day-care center. He constantly interrupted situations, seeking his mother's attention. She now reports that during the past few months his fighting, refusal to obey the day-care workers and violations of "time out" have become much worse. The boy has a 6-month-old sister who also attends the same day-care center.
The most likely cause for this child's worsening behavior is:
Correct Answer D:
This question inquires about what may have caused the behavior to worsen in the “past few months”. A stressor coinciding with the changes in behavior would be most likely, although numerous stressors may have been listed. In this case, the birth of the sister six months previously corresponds to the worsening in the behavior. The needy infant competes for already scarce attention with the four-year-old boy.
A 17-year-old boy is brought to the office by his mother who says that he has been increasingly withdrawn and preoccupied for several weeks. He has been sleeping poorly and has refused to leave the house for the past week because he believes he is being followed. When his father insisted he attend school this morning, the patient threatened him with a knife. On examination, the patient is sweating, has dilated pupils and is obviously fearful.
Rapport with this patient can best be established by asking which of the following?
Rapport is defined as an empathic and trusting working relationship between a psychiatrist and patient. Rapport is usually best established by addressing the feelings of the patient. Most patients respond best to a doctor who first attempts to understand a person’s emotional state and clarifies symptoms afterwards.
Asking about symptoms may give you information, but it does not establish rapport. Similarly, asking about specific thoughts the patient is having will give you information, but will not establish a collaborative relationship.
A 32-year-old woman who is a single mother of two small children comes to the office saying that she feels "halfway tired all the time." Her physical examination is normal. Toward the end of the visit she says anxiously, "My children just don't listen. They make me so angry that I feel out of control sometimes." She pauses. "Yesterday my 6-year-old daughter talked back to me and I slapped her in the face." Her eyes fill with tears.
Which of the following is the most accurate statement concerning this patient?
There is insufficient evidence from the information given that the mother is abusing her child. The patient describes feeling overwhelmed; engaging the mother and the two children in family therapy may be of great value in assisting her with coping mechanisms.
There is insufficient evidence from the question to indicate that she was clearly a victim of child abuse herself or that she would benefit from antidepressant medication, although this may be a consideration upon further determination of the patient’s mood and ability to adjust to her social environment.
A 26-year-old man is brought to the emergency department by his family because he says that he is being followed by gangsters and that they are going to kill him. Temperature is 37.8°C (100.0°F), pulse is 110/min and blood pressure is 160/95 mm Hg. His pupils are dilated. The remainder of the physical examination is normal. The family states that he has a history of drug abuse.
Which of the following drugs most likely caused this reaction?
Correct Answer B:
This patient shows symptoms of paranoia and sympathetic stimulation. Common symptoms of cocaine use include the classic ones associated with sympathetic stimulation, such as tachycardia, hypertension, mydriasis, and sweating. Paranoia, suspiciousness, and psychosis may occur with prolonged use.
Although at low levels alcohol induces some behavioral stimulation, it is a CNS depressant. Occasionally chronic alcohol use induces paranoia, but dementia and memory loss are more common symptoms.
Diazepam, sold under the trade name Valium, is commonly prescribed as an antianxiety drug or muscle relaxant, and does not produce the symptoms noted. Heroin, like most opioids, is also a CNS depressant, and symptoms associated with its use include drowsiness, slurred speech, memory impairment, occasional perceptual disturbances, and pinpoint pupils.
A 40-year-old male professional consults you about his recent onset of depression. He generally feels well, but sometimes feels “high and out of control”. This is followed by significant depression which usually remits after a long weekend of sleep at his cabin on the lake. He also complains of persistent nasal congestion and a 4.5kg (10 lb) weight loss. His psychiatric history is negative, but he is suspicious and feels that people are against him. His mental status otherwise reveals normal thought content and processes.
His physical examination is normal except for inflamed nares and enlarged nasal turbinates. The most likely diagnosis is:
Correct Answer E:
A chronic user of cocaine, like the chronic user of alcohol, does not always fit the classic description of dependence, and the physician must therefore consider the diagnosis in all patients with episodic depression and peculiar mood swings. Organic symptoms are like those of amphetamine use, mainly hyperpyrexia, tachycardia, and even cardiac arrhythmias. Routine, continued cocaine “snorting” often leads to nasal mucosal congestion and occasional septal perforation. Paranoid ideation is sometimes seen with the use of cocaine and other stimulants. The patient’s age and normal mental status make schizophrenia unlikely. Panic disorder is not complicated by paranoid behavior.
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