Question of the Week # 353

353)  A 54 year old woman is found by her husband wandering and trying to undress herself two miles away from her home . Her husband tried to question her, however, she did not recognize him, did not respond to his questions and when he tried to restrain her, she became physically aggressive. Upon presentation in the Emergency Department, she appears confused and does not recall the event. There is no history of drug abuse or alcoholism. There is no history of any significant past medical problems. Examination shows normal vitals. There are no focal neurological deficits. She is confused and not oriented to place and person. Which of the following is the most likely diagnosis?

A)  Temporal Lobe Epilepsy

B) Depersonalization Disorder

C) Domestic abuse

D) Dissociative Fugue

E) Manic Episode

Question of the Week # 352

352)  A 26 year old man is brought by the Emergency Medical Services because he was found on the streets of Miami and as per by-standers, was unable to recall where he came from. Upon questioning in the Emeregency Room, he denies any drug abuse or alcoholism. He reports that his name is John and he worked as a plumber. He does not remember if he had a family or what work he did.  He says he can not remember how he got to Miami and where he traveled from. A flight ticket receipt from Las-Vegas to Miami is found in his coat pocket. He has an identity card in his wallet that states his name as Steven and that he serves as a Cop in Los Angeles Police Department. He appears comfortable.  Examination shows normal vitals. There are no focal neurological deficits. An official from Los Angeles police department reports that Steven had always been a great colleague, did not have any problems in the past and he was surprised that he suddenly did not show up at work for the past two days. Which of the following is the most likely diagnosis?

A) Post Traumatic Stress Disorder

B) Dissociative Identity disorder

C) Dissociative amnesia

D) Depersonalization

E) Dissociative Fugue

Question of the Week # 351

351)  A 22 year old woman presents to the emergency room with complaints of shortness of breath, dizziness and tingling in her extremities. Her past medical history is unremarkable.  She denies any history of blood clots in her family.  She denies any recent long flight trips. She does not smoke. On examination, pulse is 110/min and  respiratory rate is 26/min. She is afebrile and blood pressure is within normal limits.  Pulse oximetry reveals 99% on room air. There are no physical abnormalities . A D-dimer level is 50µg/l . An electrocardiogram shows sinus tachycardia without ant ST-T changes. Chest x-ray is unremarkable. Which of the following is the most appropriate next step in management?

A) Start Conazepam

B) Re-breathing in to a paper bag

C) Start Calcium Gluconate

D) Re-assure and teach to deliberately slow down respiration

E) Admit to ward and start high flow oxygen

Question of the Week # 350

350)  A 68 year old man with recently diagnosed Parkinson’s disease is evaluated during a follow-up visit. He was started on medications to help with the motor symptoms of his disease. He reports that the medications have not helped him much however, he has been experiencing difficulty concentrating on his job and has lost interest in life. He reports inability to relish his life, sadness and decreased appetite. On examination, his mood is depressed . His facial expressions are masked. He has a resting tremor and generalized slowness of movements.  Which of the following is the most appropriate next step in management?

A) Discontinue Anti-parkinson’s medications

B) Increase the dose of anti-parkinson’s medications

C) Inquire about Suicidal ideation

D) Refer to Neurology

E) Admit to Psychiatry ward

Question of the Week # 255

A 16 year old woman is brought to your office by her mother for medical evaluation. Her mother has been out of country on a long business trip for 8 months and upon her return, she was shocked to notice that her daughter looked much skinnier than she was 8 months ago. The patient has lost about 30 lbs weight in the past 8 months and reports irregular menstruation. She is fearful of gaining weight and has been exercising excessively.  Physical examination reveals a very thin woman with a Body Mass Index (BMI) of 16. She has fine, downy dark hair all over her body. Which of the following findings are frequently seen in association with this condition?

A)     Diarrhea

B)     Tachycardia

C)      Hyperkalemia

D)     Decreased Bone mineral density

E)     Metabolic Acidosis

Question of the Week # 250

250 )  A 30 year old woman presents to your office with complaints of fatigue and headache.  She reports that the headaches occur almost daily and are mild to moderate. They are not associated with nausea or vomiting and are unrelated to menstrual cycles. She also reports chronic diffuse abdominal pain and pelvic pain for the past several months for which she did not seek any medical attention. Her chart reveals that she was seen by your colleague few months ago for similar complaints. She was asked to return after few laboratory investigations but she had been non-compliant with her follow-ups. Physical examination reveals an anxious appearing woman who otherwise appears healthy. She does not make an eye contact. Abdominal and pelvic examination is benign. There are no tender points. There are no neurological deficits. The most appropriate next step in managing this patient:

A)     Support and Counseling

B)     Refer to Psychiatry

C)      Start Selective Serotonin Reuptake Inhibitors

D)     Trial of Tricyclic anti-depressants

E)     Screen for Domestic Violence

Question of the Week # 213

213 )  A 38 year old woman with manic depressive illness is evaluated in the emergency department for slurred speech and severe fatigue of one day duration. She also has nausea and vomiting since morning. She denies any recent fever. She has been on Lithium Carbonate for the past 3 months and her level was therapeutic 1 month ago. She is a very compliant patient and denies overdosing herself with lithium. Her past medical history is significant for hypertension for which she was started on combination of  Hydrochlorthiazide and Enalapril one week ago. She does report “salt craving” for past few days and has been taking excessive amount dietary salt though she is aware that it is not good for blood pressure. Physical examination reveals coarse tremors and fasciculations. Laboratory investigations reveal slightly increased serum creatinine at 1.2mg%. Her  baseline creatinine is 1.0mg%.  Today, the Lithium level is 3.0 mmol/L. Which of the following is responsible for acute lithium toxicity in this patient?

A) Acute renal failure

B) Drug interaction

C) Increased absorption

D) Excess Salt intake

E) Intentional overdose

Question of the Week # 212

212 )  A 40 year old man is brought by his sister to the Emergency room for a change in his mental status. The patient appears slightly confused but as per his sister, he reported weakness and blurred vision yesterday. She also noticed that his gait has been abnormal and un-coordinated for the past one day. She reports that he was diagnosed with a psychiatric disorder few months ago and was started on a medication 4 months ago. He seems to be compliant with his medications but  has not followed up with his psychiatrist for the past 3 months. His Past Medical History is unremarkable except for the mental illness. Physical examination reveals a slightly confused male. Neck examination shows mild but diffuse enlargement of thyroid with out any nodules. Nystagmus and exaggerated reflexes are noted.  The drug that is most likely responsible for this patient’s presentation?

A) Fluoxetine

B) Venlafaxine

C) Lithium

D) Amitryptyline

E) Escitalopram

Question of the Week # 150

Q150) A 34 year old male nurse is brought to the Emergency Room by the EMS with altered mental status. As per his sister, the patient has been on Lithium for his manic symptoms for the past one year. However, his psychiatrist added Fluoxetine and Amitriptyline about 1 week ago for history of depression symptoms.

On physical examination, he has low grade fever at 100.5F, Blood pressure of 110/82 and Heart rate of 120/min. He is confused and the pupils are dilated. There is rigidity in extremities and deep tendon reflexes are exaggerated. Complete blood count, creatinine and Creatine kinase level are within normal limits. Most likely diagnosis:

A)     Neuroleptic Malignant Syndrome

B)      Lithium Toxicity

C)      Serotonin Syndrome

D)     Amphetamine abuse

E)      Cocaine Intoxication

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