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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
10.ans is A
DIAGNOSIS DSM-5 diagnostic criteria for borderline personality disorder are as follows [55]:
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 drugs 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'
He dnt have hallucination in depressive time but when he is OKy with mood symptoms then he got
intermittent hallucination so thats 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
At least two out of the following four clinical features: myoclonus; visual or cerebellar
disturbance;pyramidal/extrapyramidal dysfunction; akinetic mutism and
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
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 patients 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.
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