A 22 year-old male comes to your office because he needs an urgent prescription for alprazolam. He shouts at your staff for keeping him too long in the waiting room even though he arrived late for his appointment. He called himself Jack Snyder even though his driver’s license shows a different name. Your office staff reports that he has a very ‘negative vibe around him’. Finally, when you meet him in the room, he states, ‘Doc, I respect you. But listen, if I don’t get some xanax today, I might seriously harm someone in this office or outside.I took buprenorphine from a friend. It’s crap. It’s not helping me to calm down’. As you explore his history, he informs you that during his school years, teachers warned him to respect the rights of other students, to control his impulsive behavior, and to take the safety of others seriously. He has a history of arrests for shoplifting and imprisonments for violent behavior and possession of drug paraphernalia. He has a family history of alcoholism, drug abuse, imprisonments and hysteria. During his school years, he was diagnosed with conduct disorder. When you inform him that he needs another follow up, he shouts, ‘I am in between jobs. I don’t have money to pay for these visits. I still owe a lot of money to a lot of people. My girlfriend left me last week’. In the physical and mental health examination, you notice an aggressive individual with a manipulative attitude, low frustration tolerance, high propensity for anger, poor impulse control and poor judgment. His orientation and cognition appear normal. He has no delusions or hallucinations. He has a tattoo on his right deltoid which indicates a gang affiliation. What is the most likely diagnosis in this patient?

A 23 year old female is brought to your office by her mother for psychological evaluation. Her mother reports that the patient prepares food for the entire family but she does not eat much. Even if she eats, she vomits out with self-induced vomiting. This behavior has gotten worse over the last 3 years. She is very goal oriented in her social life. She thinks she is overweight and spends 3-4 hours a day doing all kinds of physical exercises to ‘burn the extra calories in buttocks’. She thinks something bad will happen soon unless she changes how she looks. She is fearful of fat. She has been seeing her psychologist for the last 6 months but it does not seem to help much. She reports cold intolerance, muscle weakness, loss of stamina, constipation, abdominal pain, and feeling down. She has irregular menses with some months going with no periods. She feels depressed but ‘not enough to see a doctor’. Vital signs: Height: 5 feet 1 inch, Weight: 74 pounds, Temperature = 95 F, BP = 85/65 mm Hg, Pulse = 48/minute General: looks fatigued, stressful Mental status: oriented to place, person and time Head: Parotid gland hypertrophy Oral: Dental decay, white patches on tongue Lungs: clear to auscultation Heart: normal S1,S2, sinus bradycardia with occasional irregular beats Abdomen: non-tender Musculoskeletal: ⅗ strength, decreased range of motion in extremities Extremities: Peripheral edema in the ankles, scars and calluses on the back of the hand Nervous system: hyporeflexia Skin: Petechiae, sallow complexion, dry, scaly skin Hair: presence of downy body hair on trunk and extremities Diagnostic tests: Hemoglobin 10.1 g/dl Blood film: Echinocytes and acanthocytes. Sodium 129 mEq/L Potassium 3.1 mEq/L FSH 3 mIU/ml LH 4 mIU/ml TSH 7 microU/mL BUN 22 mg/dL LDL 423 mg/dl ECG: sinus bradycardia, QTc 542 ms Of the following, what is the next best step in the management of this patient?

A 23 year old female is brought to your office by her mother for psychological evaluation. Her mother reports that the patient prepares food for the entire family but she does not eat much. Even if she eats, she vomits out with self-induced vomiting. This behavior has gotten worse over the last 3 years. She is very goal oriented in her social life. She thinks she is overweight and spends 3-4 hours a day doing all kinds of physical exercises to ‘burn the extra calories in buttocks’. She thinks something bad will happen soon unless she changes how she looks. She is fearful of fat. She has been seeing her psychologist for the last 6 months but it does not seem to help much. She reports cold intolerance, muscle weakness, loss of stamina, constipation, abdominal pain, and feeling down. She has irregular menses with some months going with no periods. She feels depressed but ‘not enough to see a doctor’. Vital signs: Height: 5 feet 1 inch, Weight: 74 pounds, Temperature = 95 F, BP = 85/65 mm Hg, Pulse = 48/minute General: looks fatigued, stressful Mental status: oriented to place, person and time Head: Parotid gland hypertrophy Oral: Dental decay, white patches on tongue Lungs: clear to auscultation Heart: normal S1,S2, sinus bradycardia with occasional irregular beats Abdomen: non-tender Musculoskeletal: ⅗ strength, decreased range of motion in extremities Extremities: Peripheral edema in the ankles, scars and calluses on the back of the hand Nervous system: hyporeflexia Skin: Petechiae, sallow complexion, dry, scaly skin Hair: presence of downy body hair on trunk and extremities Diagnostic tests: Hemoglobin 10.1 g/dl Blood film: Echinocytes and acanthocytes. Sodium 129 mEq/L Potassium 3.1 mEq/L FSH 3 mIU/ml LH 4 mIU/ml TSH 7 microU/mL BUN 22 mg/dL LDL 423 mg/dl ECG: sinus bradycardia, QTc 542 ms How severe is this individual’s anorexia?

A 23 year old female is brought to your office by her mother for psychological evaluation. Her mother reports that the patient prepares food for the entire family but she does not eat much. Even if she eats, she vomits out with self-induced vomiting. This behavior has gotten worse over the last 3 years. She is very goal oriented in her social life. She thinks she is overweight and spends 3-4 hours a day doing all kinds of physical exercises to ‘burn the extra calories in buttocks’. She thinks something bad will happen soon unless she changes how she looks. She is fearful of fat. She has been seeing her psychologist for the last 6 months but it does not seem to help much. She reports cold intolerance, muscle weakness, loss of stamina, constipation, abdominal pain, and feeling down. She has irregular menses with some months going with no periods. She feels depressed but ‘not enough to see a doctor’. Vital signs: Height: 5 feet 1 inch, Weight: 74 pounds, Temperature = 95 F, BP = 85/65 mm Hg, Pulse = 48/minute General: looks fatigued, stressful Mental status: oriented to place, person and time Head: Parotid gland hypertrophy Oral: Dental decay, white patches on tongue Lungs: clear to auscultation Heart: normal S1,S2, sinus bradycardia with occasional irregular beats Abdomen: non-tender Musculoskeletal: ⅗ strength, decreased range of motion in extremities Extremities: Peripheral edema in the ankles, scars and calluses on the back of the hand Nervous system: hyporeflexia Skin: Petechiae, sallow complexion, dry, scaly skin Hair: presence of downy body hair on trunk and extremities Diagnostic tests: Hemoglobin 10.1 g/dl Blood film: Echinocytes and acanthocytes. Sodium 129 mEq/L Potassium 3.1 mEq/L FSH 3 mIU/ml LH 4 mIU/ml TSH 7 microU/mL BUN 22 mg/dL LDL 423 mg/dl ECG: sinus bradycardia, QTc 542 ms You discussed your impression of your observations and diagnostic tests to the patient and her mother. But the patient does not take you seriously. What is the most likely diagnosis in this patient?

A 28 year-old female presents in the emergency room for lower abdominal pain and hematuria, inability to move her left hand for two days. She has a history of several emergency room visits and hospitalization visits over the last three years. Over the years, innumerable urinalyses, urine cultures, blood tests, abdominal CT scans, ultrasounds were done, which yielded negative results except for hematuria in urinalysis. She insists on admission to the intensive care unit until a proper diagnosis is made of her abdominal pain and hematuria. She works as a part-time medical assistant. She has been to ‘every damn hospital in the county’. She doesn’t mind admissions to hospitals and subjecting herself to painful invasive procedures, but she is frustrated because ‘no doctor is smart enough to diagnose her condition’. She argues, ‘maybe they should update the DSM-V manual to incorporate new disorders’ like hers. As you go through her medical records, you notice there are many bracketed aliases beside her name. There are no emergency contacts on her chart. Physical examination: normal 5/5 strength in both extremities, normal reflexes in all extremities, multiple scars on the lower abdomen, a partially healed wound on the inner surface of the left wrist, minimal bloody discharge from the urethra. During this admission, the patient was transferred to a room and observed for the night. Next morning, she complained of ‘the worst abdominal pain in my entire life’. She was sent to get an emergency abdominal CT scan. While she was at the radiology department to get her CT scan, one of the room cleaning staff found disturbing objects in the rest room of her room. There are three blood-stained knitting needles wrapped in tissue paper beside the commode seat. CT scan of the abdomen came negative except for some minor injury to the lower urethra. What is the most likely diagnosis in this individual?

A 29 year-old female comes to the emergency room for continued chest pains for the last 8 months. The pain comes almost every day after she exercises in the gym, where she spends one to two hours every evening. For a few months, she self-medicated with omeprazole for possible GERD. Then she underwent a stress echocardiogram which yielded normal results. Her family doctor told her that her chest pains are most likely musculoskeletal in origin and she should take ibuprofen as needed. One of her friends died of pulmonary embolism and the patient would like to prevent a blood clot in her lungs by taking every precaution she can. For the last 8 months, she studied everything about pulmonary embolism. She volunteers in a health club where she frequently gives lectures on the prevention of pulmonary embolism. She makes TikTok videos, three to four times a week, on pulmonary embolism and participates in discussions with people who make comments under the videos. She has had over 6 pulmonary angiograms to rule out pulmonary embolism in the last 8 months. During one of those procedures, she got an anaphylactic reaction to the contrast dye, and ‘almost died’. All of them showed normal results but she is still worried. She drinks alcohol every day to soothe her anxiety. She does not want to die like her friend with a blood clot in her lungs. She requests you to order one more CT angiogram to rule out pulmonary embolism. She insists that would make her sleep better tonight. What is the next best step in the management of this patient?

A 29 year-old female comes to the emergency room for continued chest pains for the last 8 months. The pain comes almost every day after she exercises in the gym, where she spends one to two hours every evening. For a few months, she self-medicated with omeprazole for possible GERD. Then she underwent a stress echocardiogram which yielded normal results. Her family doctor told her that her chest pains are most likely musculoskeletal in origin and she should take ibuprofen as needed. One of her friends died of pulmonary embolism and the patient would like to prevent a blood clot in her lungs by taking every precaution she can. For the last 8 months, she studied everything about pulmonary embolism. She volunteers in a health club where she frequently gives lectures on the prevention of pulmonary embolism. She makes TikTok videos, three to four times a week, on pulmonary embolism and participates in discussions with people who make comments under the videos. She has had over 6 pulmonary angiograms to rule out pulmonary embolism in the last 8 months. During one of those procedures, she got an anaphylactic reaction to the contrast dye, and ‘almost died’. All of them showed normal results but she is still worried. She drinks alcohol every day to soothe her anxiety. She does not want to die like her friend with a blood clot in her lungs. She requests you to order one more CT angiogram to rule out pulmonary embolism. She insists that would make her sleep better tonight. Which of the following is the most likely diagnosis in this patient?

You are called to evaluate a 27 year-old male, who was brought from a local prison and was accused of a homicide. You reviewed his medical and mental health records, which are unremarkable. When you do psychological evaluations of this individual, he acts bizarrely, reports auditory and visual hallucinations, loss of interest in life, no appetite, suicidal and homicidal intentions. Your staff reports that his behavior is usually normal when you are not visiting him. He eats well and demands for more food. One of your staff members overheard his phone conversation with his defense attorney. During the phone conversation, the patient said that he would like to feign mental illness to evade criminal prosecution. Of the following, which best explains this patient’s condition?

An 18 year-old female reports to your office reporting that she feels like a robot, floating in the air above herself and has no control of what she says or how she moves. She feels like a ‘brain in a vat’, like in the Matrix movie. She feels unreal and detached with respect to her thoughts, feelings, sensations and actions. She feels emotionally numb. She reports cravings to cut herself to feel real. She is afraid that she is going crazy. Four weeks ago, she was assaulted on the college campus during a sorority party. She regularly uses alcohol and marijuana. Which of the following statements is true concerning her condition?