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Question 1
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Tim displays odd behavior, such as avoiding stepping on thresholds due to superstition, and provides excessively detailed answers to questions. He strongly believes in UFOs and government contact with them, and his social life revolves around an online community focused on these beliefs. He lives with his mother and has never been in a romantic relationship. His family has expressed concern about his odd behavior and potential for schizophrenia, but he has not exhibited hallucinations like his aunt. Based on these symptoms, what do you suspect Tim has?
Your Answer: Schizotypal PD
Explanation:Schizotypal PD is classified differently in DSM-IV and ICD-10, with the latter listing it under psychotic disorders. It is genetically linked to schizophrenia and often found in first-degree relatives of those with the disorder. In this case, there is no evidence of schizophrenia or schizoaffective disorder, but the individual’s beliefs are outside of cultural norms. The DSM-IV criteria for schizotypal PD include social and interpersonal deficits, cognitive of perceptual distortions, and eccentric behavior. The individual must exhibit at least five of the listed criteria, such as odd beliefs of magical thinking, unusual perceptual experiences, and suspiciousness of paranoid ideation. The disorder cannot be exclusively attributed to another mental health condition.
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- Diagnosis
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Question 2
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John is a 25-year-old man who has been referred for depression that has not improved with two courses of SSRIs. He reports feeling low, but his mood improves significantly when he spends time with his friends. He used to enjoy playing video games, but now finds it difficult to concentrate on them.
John believes that his current problems stem from his recent breakup with his girlfriend. He feels like he is carrying a heavy weight on his shoulders. He denies having trouble sleeping, but is concerned about his recent weight gain.
He complains of having an insatiable appetite and has had to buy new clothes because his old ones no longer fit. John feels like people are treating him differently because of his weight gain. When asked about his eating habits, he becomes upset and feels like he is being judged for being overweight.
What is the most likely diagnosis?Your Answer: Atypical depression
Explanation:Atypical depression can often be mistaken for a personality disorder due to its symptoms, which include sensitivity to rejection, low but reactive mood, some ability to experience pleasure (though not to normal levels), hyperphagia with at least 3 kg of weight gain in three months, hypersomnia, and a feeling of heaviness in the limbs. However, the key to diagnosing atypical depression is a change in function. It is important to gather collateral history to determine if there is a lifelong pattern of problems that have been exacerbated of if the break-up is due to the depression and the resulting sensitivity to rejection. The preferred treatment for atypical depression is MAOIs.
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- Diagnosis
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Question 3
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A teenage girl refuses to attend social events with her peers due to her fear of having bad breath, even though others have told her she does not have it. She insists on staying home alone. What is the probable diagnosis?
Your Answer: Taijin-jikoshu-kyofu
Explanation:Culture-bound syndromes are conditions that are specific to certain cultures and are often accompanied by culturally accepted beliefs and practices for treatment. These syndromes may not fit into the diagnostic criteria of Western medicine and are often unique to certain regions of ethnic groups. Examples of culture-bound syndromes include Taijin-jikoshu-kyofu in Japan, Piblokto in the Arctic, Koro in Malaysia, Locura among Latinos in the United States and Latin America, and Susto among Latinos in the United States and in Mexico, Central America, and South America. These syndromes are often associated with social and cultural factors and may require culturally sensitive approaches to treatment.
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- Diagnosis
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Question 4
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A 45-year-old woman presents to a dual-diagnosis outpatient clinic for psychiatric evaluation. She reports an increase in her alcohol consumption over the past week due to frustration with her colleagues and partner. Over the past two weeks, she has been more productive at work, leading to conflicts with her colleagues whom she accuses of holding her back. She frequently argues with her partner, who accuses her of being too friendly with male colleagues. She has experienced similar episodes in the past, lasting about a month and occurring twice a year. During these times, she drinks more alcohol than usual as she finds it difficult to relax and fall asleep in the evenings. She is concerned that her alcohol consumption could have negative health consequences if this pattern continues. What is the most likely diagnosis?
Your Answer: Cyclothymia
Correct Answer: Type II bipolar affective disorder
Explanation:The patient is experiencing a hypomanic episode, which is characterized by increased concentration, productivity, over-familiarity, possible increased sexual drive, and poor sleep. Her alcohol use is likely a result of her mood disturbance. Although she has shown increased irritability and alcohol consumption, she has been able to maintain her employment and there is no evidence of psychosis. Based on these symptoms, the patient can be diagnosed with hypomania, rather than cyclothymia of depressive disorder. It is common for individuals with bipolar affective disorder to have comorbid substance misuse. However, the patient’s alcohol use appears to be secondary to her disrupted sleep and other signs of mood disturbance, rather than harmful alcohol use disorder. It is important to note that the patient does not meet the criteria for type I bipolar disorder, as she has not experienced episodes of mania of severe disruption to social functioning.
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- Diagnosis
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Question 5
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A 35-year-old man was at a concert when a firework exploded nearby. He was standing at the time and the force of the blast threw him to the ground. He suffered a broken arm and multiple cuts. Several people were killed and many others were injured.
After four months, he experiences nightmares about the incident, struggles to sleep, has avoided going to concerts since, and jumps at sudden sounds. He often finds himself unable to stop thinking about what happened.
What is the probable diagnosis?Your Answer: Post-traumatic stress disorder
Explanation:Post-traumatic stress disorder (PTSD) is a condition that develops in response to an exceptionally threatening of catastrophic event of situation, such as the one described above. It is only diagnosed if symptoms arise within six months of the traumatic event. The symptoms of PTSD can be categorized into three groups: re-experiencing the traumatic event (such as through nightmares of vivid thoughts), persistent avoidance of stimuli associated with the trauma, and persistent symptoms of increased arousal (such as difficulty sleeping of concentrating).
Agoraphobia is a fear of being in situations of places from which escape is difficult, leading to avoidance of many situations and confinement to the home. This fear is typically triggered by situations such as crowds, public places, of traveling alone of away from home.
Generalized anxiety disorder is characterized by persistent anxiety that is not limited to any specific environmental circumstance. To receive this diagnosis, a patient must experience symptoms of anxiety on most days for several weeks of months, with evidence of impairment in important areas of functioning. However, this diagnosis is not appropriate for the scenario described above, as the anxiety is related to a specific event of trigger.
Panic disorder involves sudden onset of severe anxiety, with at least three panic attacks experienced over a three-week period. Symptoms may include sweating, palpitations, shortness of breath, nausea, trembling, chest pain of discomfort, dizziness of lightheadedness, chills of hot flushes, fear of losing control of dying, paraesthesia, feeling of choking, and derealization or depersonalization.
Social phobia is characterized by a marked fear of social situations in which embarrassment may occur, leading to avoidance of these situations.
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Question 6
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What is the probable diagnosis for an adult physicist who avoids teaching and publishing, is known for walking barefoot and dressing casually, and prefers solitude over socializing with colleagues and students?
Your Answer: Anankastic personality disorder
Correct Answer: Schizoid personality disorder
Explanation:Schizoid personality disorder is a personality disorder that is only recognized in the ICD-10. It is characterized by a lack of enjoyment in activities, emotional detachment, difficulty expressing emotions, indifference to praise of criticism, little interest in sexual experiences, a preference for solitary activities, excessive introspection, a lack of close relationships, and insensitivity to social norms. When diagnosing this disorder, it is important to differentiate it from an autistic spectrum disorder. One way to do this is to look for a lack of reliance on routines and rituals, as well as a lack of desire for friendship of relationships. While individuals with an autistic spectrum disorder may struggle with relationships, they typically desire them and experience feelings of loneliness.
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- Diagnosis
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Question 7
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A 45-year-old woman accompanied by her husband was seen by her GP. Over several months she had begun to hear voices. These voices could be heard at any time. Sometimes the voices would demand her to do things; sometimes they would hum of laugh. Over the months she had developed the notion that her husband was having an affair and was planning to leave her. In addition, she believed that she had a deadly illness and was unlikely to live for more than a year.
The arguments that followed these 'ideas' had caused a huge rift between her and her husband, as he had been unable to convince her that they were not true. She had lost over a stone in weight, had become increasingly nervous and was neglecting her appearance. She had no known medical problems and was not taking any regular medication. She was a smoker of 10 cigarettes per day and drank 10 units of alcohol per week. She worked as a teacher, but had recently taken time off sick. She had a brother with schizophrenia, but there were no other known family illnesses.
On examination, she appeared withdrawn and unkempt. She continued to fidget with her clothes and continually commented she could smell smoke. She was able to talk fluently about her childhood and university years which appeared to be happy times. The death of her father three years ago had been 'difficult'. She scored 28/30 on mini-mental state examination. Cranial nerve and peripheral nervous system examination did not reveal any abnormalities. An MRI scan of her brain was normal.
What is the most likely diagnosis in this patient?Your Answer: Paranoid schizophrenia
Explanation:Paranoid Schizophrenia Diagnosis
This patient’s symptoms include hearing hallucinatory voices that command him to do things of non-verbal forms such as humming of laughing. He also experiences delusions with a persecutory of jealousy theme, as well as hallucinations of smell, changes in weight, and neglect of personal hygiene. These symptoms are consistent with a diagnosis of paranoid schizophrenia.
The patient’s clinical picture is dominated by fixed delusions, with less emphasis on mood changes, making diagnoses of psychotic depression and bipolar disease less likely. There is no evidence of epileptic-form activity of altered awareness during episodes of delusions or hallucinations.
It is important to differentiate paranoid schizophrenia from other disorders, such as schizoid personality disorder, which is characterized by emotional coldness, detachment, limited capacity to express emotion, and subsequently, few friends of close relationships.
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- Diagnosis
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Question 8
Incorrect
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A 35-year-old individual presents with symptoms consistent with social anxiety disorder. To further assess their condition, you inquire about their seating preference when dining out.
Which of the following responses would best support your suspicion?Your Answer: No preference
Correct Answer: In a quiet corner
Explanation:Individuals with social phobia experience anxiety and apprehension regarding the possibility of receiving unfavorable attention from others, leading them to avoid eating in public.
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This question is part of the following fields:
- Diagnosis
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Question 9
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You receive a call from a fellow physician who is worried she might be experiencing panic disorder. What symptom is most indicative of this diagnosis?
Your Answer: Episodic anxiety
Explanation:Panic disorder is a mental health condition that is characterized by sudden and intense episodes of anxiety that often occur without warning. Physical symptoms such as palpitations and dizziness are common during these episodes. Fear of collapsing of dying is a common psychological symptom associated with this disorder. Free-floating anxiety is a feature of generalized anxiety disorder, while situational anxiety is more characteristic of specific phobic anxiety. The International Classification of Diseases (ICD-10) classifies panic disorder as F41.0, also known as episodic paroxysmal anxiety.
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- Diagnosis
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Question 10
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Which of the following diagnostic characteristics is most strongly linked to schizophrenia?
Your Answer: Running commentary' hallucinations
Explanation:Somatisation is a clinical feature that can be present in a variety of disorders and is not exclusive to schizophrenia. Delusions of guilt and grandeur are more commonly associated with affective psychosis, while running commentary is a classic symptom of schizophrenia and is given diagnostic significance in ICD-10.
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- Diagnosis
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Question 11
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You observe a 42-year-old woman with delusions referred by her primary care physician. She is convinced that George Clooney is deeply in love with her. Over the past two months, she has attempted to send him 50 handwritten letters, along with numerous gifts. She frequently visits locations associated with the actor and places where he is attending public events. She believes that he is unable to express his true feelings for her due to the potential backlash from his wife and fans. What syndrome is being exhibited in this scenario?
Your Answer: De Clérambault's syndrome
Explanation:De Clérambault’s syndrome is characterized by amorous delusions where the patient believes that a person of higher social status, often a public figure, is in love with them. These delusions are not based on any actual contact of encouragement from the subject. Patients with this syndrome may also experience delusions of persecution. Due to their strong belief in the reality of their delusions, patients often lack insight and may not seek help. Treatment can include psychotherapy and antipsychotics. Other syndromes with delusional symptoms include Capgras syndrome, Cotard’s syndrome, Ekbom’s syndrome, and Othello’s syndrome.
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- Diagnosis
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Question 12
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Which of the following statements is true about OCD?
Your Answer: There is decreased blood flow in the frontal lobe in obsessive-compulsive disorder
Correct Answer: Can be diagnosed in the presence of delusions and hallucinations
Explanation:According to current diagnostic criteria in both the ICD-10 and DSM IV, OCD can co-occur with psychotic disorders. OCD is a chronic and debilitating disorder characterized by intrusive and distressing obsessions and/of compulsions that cause significant distress to the individual and their loved ones. Obsessions are recurrent and unpleasant thoughts, images, of impulses, while compulsions are repetitive behaviors that a person feels compelled to perform. These behaviors are often ritualistic and follow intrusive thoughts, with resistance to carrying out compulsions resulting in increased anxiety. Patients with OCD typically recognize that their obsessions and compulsions are irrational and experience them as ego dystonic. While an obsessional personality is over-represented among OCD patients, about a third of patients have other types of personality. While magnetic resonance imaging has not revealed any consistent structural brain abnormality specific to OCD patients, studies using SPECT and PET have shown increased activity in certain brain regions, such as the frontal lobe and orbitofrontal activity. Contrary to Freud’s theory, OCD has been linked to anal fixation rather than oedipal fixation, with obsessional symptoms occurring as a way of avoiding impulses related to the subsequent genital and oedipal stages.
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- Diagnosis
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Question 13
Incorrect
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A 45-year-old male alcoholic presents to the Emergency department with symptoms of ataxia, abnormal eye movements, confusion, and signs of dehydration. He also has a low blood sugar level. What is the initial treatment that should be given to this patient?
Your Answer: Thiamine IV
Correct Answer: Thiamine IV, IV replacement of other vitamins, then both orally thereafter
Explanation:Wernicke’s encephalopathy is a medical emergency that requires immediate replacement of thiamine. The preferred route of administration is intravenous (IV). It is important to note that correcting hypoglycemia should not be attempted before thiamine replenishment, as a large dose of sugar, especially glucose, can worsen the encephalopathy. Rehydration to restore blood volume should follow as needed.
In the UK, Pabrinex is the usual treatment for thiamine replacement, which also contains vitamins B2, B3, B6, and C. Parenteral treatment is given for at least 5 days. The prognosis depends on the severity of the condition. Early treatment leads to rapid and complete recovery. However, established Wernicke’s encephalopathy can have serious long-term consequences, and patients may require permanent inpatient care.
Source: https://www.nice.org.uk/guidance/cg100/chapter/Recommendations#wernickes-encephalopathy
https://academic.oup.com/alcalc/article/48/4/514/533760 -
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- Diagnosis
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Question 14
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A 68-year-old retired teacher was referred to your team by the liaison service for further assessment following a recent episode of confusion during hospital admission for a surgical procedure. Her acute confusion was treated with haloperidol and she developed severe rigidity.
The patient's family reported that she has been somewhat forgetful in the last 12-18 months. They also gave a longer history of disturbed sleep almost once a week, in which she screams and sometimes acts out her dreams. She herself was more troubled by 'tremors' and few episodes in evenings when she saw a 'strange army' in her lounge. On MMSE she scored 23/30.
What is the most likely diagnosis?Your Answer: Lewy body dementia
Explanation:Research has shown that there is a connection between idiopathic rapid eye movement (REM) sleep behavior disorder (IRBD) and the onset of neurodegenerative diseases that involve alpha synucleinopathy, such as Parkinson’s disease (PD), dementia with Lewy bodies (DLB), and multiple systems atrophy (MSA).
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- Diagnosis
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Question 15
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A 72-year-old woman, with a lengthy history of alcohol misuse, presents in a disorganized and bewildered state. She has significant difficulty maintaining her balance. What clinical manifestation would provide the strongest evidence for a diagnosis of Wernicke's encephalopathy?
Your Answer: Nystagmus and ataxia of gait
Explanation:The typical symptoms of Wernicke’s encephalopathy include ophthalmoplegia (such as horizontal and vertical nystagmus, weakness of paralysis of the lateral rectus muscles, and weakness of paralysis of conjugate gaze), ataxia (primarily affecting stance of gait, often without clear intention tremor), and confusion. If a patient presents with drowsiness, jaundice, and metabolic flap, it may indicate hepatic encephalopathy. On the other hand, nystagmus and intention tremor are indicative of alcohol withdrawal.
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- Diagnosis
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Question 16
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A 42-year-old man presents with a potassium reading of 3.1 mmol/L. As there is no apparent cause, you schedule an appointment to conduct a thorough assessment. During the history-taking, you discover that he experiences strong cravings to consume large amounts of food and frequently engages in binge eating. He then takes laxatives but denies inducing vomiting. These episodes occur approximately three times per week, and his body mass index is 19.5 kg/m2. What is the most probable diagnosis?
Your Answer: Bulimia nervosa
Explanation:Diagnosis of Bulimia Nervosa
Bulimia nervosa is the likely diagnosis for the patient, given her recurrent binges and use of laxatives to compensate for them. The DSM-IV criteria for bulimia nervosa require that these features occur more than twice weekly for three months. Weight loss is not a diagnostic requirement. In both anorexia nervosa and bulimia nervosa, self-worth is judged largely of exclusively in terms of shape and weight, and obtaining a reliable dietary history from the patient is unlikely. A key feature of bulimia nervosa is a feeling of loss of control during binge eating episodes.
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Bulimia nervosa is the likely diagnosis for the patient, given her recurrent binges and use of laxatives to compensate for them. The DSM-IV criteria for bulimia nervosa require that these features occur more than twice weekly for three months. Weight loss is not a diagnostic requirement.
In both anorexia nervosa and bulimia nervosa, self-worth is judged largely of exclusively in terms of shape and weight, and obtaining a reliable dietary history from the patient is unlikely.
A key feature of bulimia nervosa is a feeling of loss of control during binge eating episodes.
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- Diagnosis
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Question 17
Incorrect
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John is a 35-year-old businessman. He is seeking therapy for his anxiety and the therapist is struggling to understand his constant need for attention and validation. They are also confused by his rapid mood swings, going from feeling hopeless and defeated to being overly confident and grandiose. He often shows up to sessions in flashy clothing and talks about his accomplishments and successes. His wife mentions that he has always been this way and that his charisma was what initially attracted her to him.
What is the probable diagnosis?Your Answer: Narcissistic personality disorder
Correct Answer: Histrionic personality disorder
Explanation:John’s behavior is causing distress and impairment in his ability to participate in family therapy and may have contributed to his child’s depression. His behavior is consistent with histrionic personality disorder, which is only found in the ICD-10. This disorder is characterized by self-dramatization, exaggerated emotions, suggestibility, a shallow and unstable emotional state, a constant need for attention and excitement, inappropriate seductive behavior, and an excessive concern with physical appearance. Other associated features may include egocentricity, self-indulgence, a constant desire for appreciation, easily hurt feelings, and manipulative behavior to meet personal needs.
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- Diagnosis
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Question 18
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A middle-aged woman presents with concerns about a possible bipolar disorder diagnosis. Upon reviewing her psychiatric history, it is noted that she has a long standing pattern of impulsive self-harm, which has not been linked to any treatable mental illness. This behavior dates back to her teenage years and often occurs during crises in tumultuous romantic relationships. Additionally, she has a history of child protection involvement due to abuse. The patient reports feeling constantly unhappy and experiencing extreme emotional reactions that frighten those around her. She frequently falls deeply in love, but these relationships inevitably become abusive. She is unsure of her sexual orientation and struggles with a sense of identity. What is the most likely diagnosis?
Your Answer: Impulsive-unstable personality disorder - borderline type
Explanation:Borderline personality disorder is often a result of childhood abuse of neglect, according to research. In the ICD-10, impulsive-unstable personality disorder is divided, and borderline PD is distinguished by a fundamental uncertainty about identity. Emotional instability is a common trait, and the patient’s self-image, goals, and internal preferences, including sexual preferences, are often unclear of disturbed. Chronic feelings of emptiness are also common. The patient may have a tendency to engage in unstable relationships, leading to emotional crises and efforts to avoid abandonment. Suicidal threats of self-harm may occur without obvious triggers.
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- Diagnosis
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Question 19
Incorrect
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You are on call for a general medical ward and are asked to evaluate a 45-year-old woman who has been experiencing intermittent confusion and aggression for the past three days. She recently recovered from a severe respiratory infection but has been experiencing 20-minute periods of lucidity and confusion, preceded by abdominal discomfort. There is no history of substance abuse of alcohol dependence, and all blood and urine tests have come back negative. A CT scan of her brain is normal, and she has not been taking her prescribed medication during her hospital stay. What is the most likely diagnosis?
Your Answer: Acute confusional state
Correct Answer: Temporal lobe epilepsy
Explanation:Differential Diagnosis for a Patient with Temporal Lobe Epilepsy
Temporal lobe epilepsy, also known as complex partial seizures, is characterized by an aura of abdominal symptoms followed by altered consciousness and behavior. This episodic condition can occur rapidly. The presenting symptoms of this patient suggest an acute confusional state, ruling out antibiotic-induced psychosis, which is associated with ongoing antibiotic treatment. Delirium tremens, a severe form of alcohol withdrawal, is also unlikely. Early onset dementia cannot be associated with this presentation due to insufficient information. A differential diagnosis is necessary to determine the underlying cause of the patient’s symptoms.
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- Diagnosis
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Question 20
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A concerned individual informs you that their 40-year-old friend has been housebound for the past year due to anxiety. The friend last went shopping a year ago and expressed feeling too nervous to leave the house again. The individual reports no knowledge of any panic attacks. The friend is now experiencing low mood and has begun to lose contact with friends. What is the probable diagnosis?
Your Answer: Agoraphobia
Explanation:Agoraphobia is the most probable diagnosis, even though not all individuals with agoraphobia experience panic attacks.
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