Hallucinogen-related disorders — MCQs

A 21-year-old male college student is brought to the emergency department by the campus police after he was found yelling at a bookshelf in the library. His roommate does not know of any prior episodes similar to this. His vital signs are within normal limits. The patient appears unkempt. On mental status examination, he talks very fast with occasional abrupt interruptions. He is agitated. He is disoriented to time and repeatedly tells the physician, “I hear the sun telling me that I was chosen to save the universe.” Urine toxicology screen is negative. Which of the following is the most appropriate pharmacotherapy?

A 23-year-old man is brought to the emergency department by the police for impaired cognition and agitation after being struck in the head at a local nightclub. The patient refuses to respond to questions and continues to be markedly agitated. An alcoholic smell is noted. His temperature is 36.9°C (98.4°F), pulse is 104/min, respirations are 24/min, and blood pressure is 148/95 mm Hg. He is confused and oriented only to person. Neurological examination shows miosis and nystagmus but is quickly aborted after the patient tries to attack several members of the care team. CT scan of the head shows no abnormalities. Ingestion of which of the following substances most likely explains this patient's symptoms?

A 19-year-old man is brought to the emergency department by his mother because of increasing agitation and aggression at home. He has a history of bipolar disorder. During the last week, he has refused to take his lithium medication because it makes him “feel empty inside.” The mother thinks he has experimented with illicit drugs in the past. He appears acutely agitated, yells at multiple medical staff members, and demands to be discharged. His temperature is 37.7°C (99.8°F), pulse is 95/min, respirations are 18/min, and blood pressure is 140/75 mm Hg. Haloperidol is administered and the patient is admitted. The next morning, the patient reports worsening neck pain. He states that his neck is locked to the left and he cannot move it. Examination shows rigidity of his upper body and neck, with the neck fixed in flexion and rotated to the left. Administration of which of the following is the most appropriate next step in the management of this patient?

A 34-year-old man presents to the behavioral health clinic for an evaluation after seeing animal-shaped clouds in the form of dogs, cats, and monkeys. The patient says that these symptoms have been present for more than 2 weeks. Past medical history is significant for simple partial seizures for which he takes valproate, but he has not had his medication adjusted in several years. His vital signs include: blood pressure of 124/76 mm Hg, heart rate of 98/min, respiratory rate of 12/min, and temperature of 37.1°C (98.8°F). On physical examination, the patient is alert and oriented to person, time, and place. Affect is not constricted or flat. Speech is of rapid rate and high volume. Pupils are equal and reactive bilaterally. The results of a urine drug screen are as follows: Alcohol positive Amphetamine negative Benzodiazepine negative Cocaine positive GHB negative Ketamine negative LSD negative Marijuana negative Opioids negative PCP negative Which of the following is the most likely diagnosis in this patient?

A 19-year-old man is brought to the emergency department by the police. The officers indicate that he was acting violently and talking strangely. In the ED, he becomes increasingly more violent. On exam his vitals are: Temp 101.1 F, HR 119/min, BP 132/85 mmHg, and RR 18/min. Of note, he has vertical nystagmus on exam. What did this patient most likely ingest prior to presentation?

A 23-year-old male is brought by police officers from a social gathering due to combative behavior and altered mental status. The police say that phencyclidine was found on the premises. The patient is alone, and acquiring an accurate history proves difficult. However, you do learn that the patient is having visual hallucinations. Vital signs show a blood pressure of 155/95 mmHg, pulse is 103/min, respirations is 20/min, oxygen saturation of 99%. Airway, breathing, and circulation are intact. The patient appears violent, and is trying to remove his clothes. Multiple hospital staff are needed to restrain the patient in bed. A finger-stick glucose show 93 mg/dL. The team is unable to place an IV, and thus intramuscular midazolam is administered to achieve sedation; however, he is still agitated. What is the mechanism of action of the best alternative sedative drug for this patient?

A 19-year-old man presents to a psychiatrist for the management of substance abuse. He reports that he started using the substance 2 years ago and that he smokes it after sprinkling it on his cigarette. He describes that after smoking the substance, he feels excited and as if he does not belong to himself. He also reports that when he is in his room, he sees vivid colors on the walls after using the substance; if he listens to his favorite music, he clearly sees colors and shapes in front of his eyes. There is no history of alcohol or nicotine abuse. The psychiatrist goes through his medical records and notes that he had presented with acute substance intoxication 1 month prior. At that point, his clinical features included delusions, amnesia, generalized erythema of his skin, tachycardia, hypertension, dilated pupils, dysarthria, and ataxia. Which of the following signs is also most likely to have been present on physical examination while the man was intoxicated with the substance?

A 77-year-old woman is brought to her primary care provider by her daughter with behavioral changes and an abnormally bad memory for the past few months. The patient’s daughter says she sometimes gets angry and aggressive while at other times she seems lost and stares at her surroundings. Her daughter also reports that she has seen her mother talking to empty chairs. The patient says she sleeps well during the night but still feels sleepy throughout the day. She has no problems getting dressed and maintaining her one bedroom apartment. Past medical history is significant for mild depression and mild osteoporosis. Current medications include escitalopram, alendronic acid, and a multivitamin. The patient is afebrile, and her vital signs are within normal limits. On physical examination, the patient is alert and oriented and sitting comfortably in her chair. A mild left-hand tremor is noted. Muscle strength is 5 out of 5 in the upper and lower extremities bilaterally, but muscle tone is slightly increased. She can perform repetitive alternating movements albeit slowly. She walks with a narrow gait and has mild difficulty turning. Which of the following is the most likely diagnosis in this patient?

A 68-year-old man, accompanied by his wife, presents to his physician with cognitive decline and hallucinations. The patient’s wife tells that his cognitive impairment progressed gradually over the past 6 years, and first began with problems counting and attention. The hallucinations began approximately a year ago. The patient describes them as realistic and non-frightening; most often, he sees his cat accompanying him everywhere he goes. The patient’s wife also notes frequent episodes of staring spells in her husband and prolonged daytime napping. The blood pressure is 130/80 mm Hg with the orthostatic change to 110/60 mm Hg, heart rate is 75/min, respiratory rate is 13/min, and the temperature is 36.6°C (97.8°F). The patient is alert and responsive, but he is disoriented to time and place. He is pale and hypomimic. The cardiac, lung, and abdominal examinations are within normal limits for the patient’s age. The neurological examination is significant for a bilateral symmetrical cogwheel rigidity in the upper extremities. What would you most likely see on additional radiological investigations?

Two days after undergoing hemicolectomy for colon cancer, a 78-year-old man is found agitated and confused in his room. He says that a burglar broke in. The patient points at one corner of the room and says “There he is, doctor!” Closer inspection reveals that the patient is pointing to his bathrobe, which is hanging on the wall. The patient has type 2 diabetes mellitus and arterial hypertension. Current medications include insulin and hydrochlorothiazide. His temperature is 36.9°C (98.4°F), pulse is 89/min, respirations are 15/min, and blood pressure is 145/98 mm Hg. Physical examination shows a nontender, nonerythematous midline abdominal wound. On mental status examination, the patient is agitated and oriented only to person. Which of the following best describes this patient's perception?