Psych nbme form 4

Psych nbme form 4 DEFAULT

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1:A 52-year-old homeless man with alcoholism is brought to the emergency by police after being found…

Ethylene glycol toxicity

  • Middle-aged homeless man with alcohol use disorder who presents with confusion/agitation and oxalate crystals in his urine, most consistent with ethylene glycol toxicity
  • Ethylene glycol can lead to renal pathologies via 2 mechanisms corresponding to the 2 metabolites because when it is metabolized to glycolic acid it can lead to acute tubular necrosis whereas if it is metabolized to oxalic acid it can lead to precipitation of calcium oxalate stones
  • Methanol –> Eye symptoms (blindness, blurred vision, painful eye movements, etc.)

2.A 42-year-old man comes to the physician because of a 6-month history of sexual problems. He can achieve…

Performance anxiety

  • Key idea: If a patient has normal morning erections= Physiologic causes of erectile dysfunction (vascular, neurologic, endocrine) are RULED OUT and patient most likely has psychological component to ED (and in this question rules out all answer choices except for D)
  • Note: Beta blockers such as metoprolol can also lead to sexual dysfunction, and SSRIs are specifically known for causing delayed/impaired orgasm
  • Note: Alcohol use also often associated with sexual dysfunction in men

3. A 30-year-old woman has had frontal headaches, stomach upset, and poor appetite for 4 weeks; she has had…

Major depressive disorder

  • Patient with >2 week history of SIGECAPS symptoms (specifically Sleep changes, Guilt, decreased Energy, Cognitive dysfunction, Appetite changes) and somatic symptoms most consistent with major depressive disorder
  • Adjustment disorder would not have as severe a presentation
  • Borderline –> Chronic time course
  • Dysthymic disorder –> At least 2 years of symptoms
  • Somatization disorder –> Patient has somatic symptoms AND SIGECAPS

4.A 42-year-old man is brought to the emergency department by police after they found him hiding under a…

Schizophrenia

  • Young man with >6 months of hallucinations, delusions and disorganized behavior most consistent with schizophrenia
  • Schizophrenia > Bipolar disorder with psychotic features because patient does not have other DIG FAST components of mania/hypomania like decreased sleep, increased activity, etc.
  • Key idea: Patients with schizophrenia can also be described as speaking quickly and loudly even though that is more associated with mania/hypomania = bipolar disorder
  • Brief psychotic disorder: At least 1 positive symptom (hallucination, delusion, etc.) for less than 1 month that often comes on due to stress
  • Schizophrenia: At least two of the following symptoms (delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, negative symptoms) for at least 1 month with at least 6 months of decline in functioning
  • Schizophreniform disorder: Same as schizophrenia except for 1-6 months
  • Schizoid personality disorder = Patient who prefers to be alone and not engage in contact with others

5.A 14-year-old boy is brought to the physician for a well-child examination. His mother says her son is self-centered…

Physical/Sexual Development: Normal // Cognitive/Social Development: Normal

  • Adolescent boy with more independent activities, questionable hygiene habits, and mood swings with Tanner Stage 3 development most consistent with normal development
  • Note: Delayed puberty in males defined by lack of testicular enlargement (Tanner Stage 2) by age 14, whereas delayed puberty in females defined by lack of breast development by 13 or lack of menarche by 15

6. A 47-year-old woman comes to the physician 2 hours after the onset of heart palpitations. She had a myocardial…

Marijuana intoxication

  • Middle-aged woman with known marijuana use presenting with paranoia, sensation of things slowing down around her, dry mouth, conjunctival injection and sinus tachycardia most consistent with marijuana intoxication
  • Key idea: Symptoms commonly ascribed to marijuana intoxication on NBME exams include conjunctival injection, tachycardia, paranoia and dry mouth
  • Panic disorder: Unprovoked panic attack with at least one month of psychosocial stress related to fears of having another attack

7. Five weeks after being discharged from the hospital after treatment for a psychotic episode…

Schizoaffective disorder

  • Young man recently hospitalized for psychotic episode without much detail but most consistent with schizophrenia vs schizophreniform disorder vs schizoaffective disorder
  • Bipolar disorder –> Decreased sleep, Increased talkativeness, decreased appetite, distractibility, etc.
  • Cyclothymic disorder –> 2 year history of fluctuations between mild depression and mild mania/hypomania, which would typically not lead to psychiatric hospitalization
  • Delusional disorder –> Defined as a delusion for at least 1 month that does not significantly impair function (and likely would not lead to hospitalization)
  • Substance-induced mood disorder –> No history of drug use
  • Note: Important to differentiate schizoaffective disorder from mood disorder with psychotic feature, with schizoaffective disorder having at least 2 weeks of psychotic features without mood symptoms

8.A 32-year-old Bosnian man is brought to the emergency department by police 30 minutes after they found…

Dissociative disorder

  • Young man who recently experienced a traumatic event who now has trouble answering basic questions most consistent with some form of dissociative disorder, potentially dissociative fugue
  • Adjustment disorder: Often leads to sadness or anxiety in reaction to stressor
  • Catatonia: More severe presentation characterized by waxy flexibility, repeating other people’s behaviors or words, negativism, etc.
  • Generalized anxiety disorder: Need symptoms for >6 months
  • Schizotypal PD: Magical thinking and odd behaviors consistently and for a long time

9.A 52-year-old man with schizophrenia comes to the physician for a follow-up examination. At his last examination…

Increased sensitivity of the dopamine receptors

  • Patient with chronic history of schizophrenia treated with antipsychotics who presents with abnormal tongue movements and choreoathetoid movements most consistent with tardive dyskinesia, which is due to increased sensitivity of the dopamine receptors
  • In setting of chronic antipsychotic use, patient has had chronic inhibition of dopamine receptors –> Compensatory upregulation of dopamine receptors leading to increased sensitivity of dopamine receptors because more of them are around ready to be bound by dopamine
  • KEY IDEA: The reason patients experience withdrawal symptoms related to drugs/substances often related to up-regulation of receptors (if they are taking a receptor inhibitor) or down-regulation of certain receptors(if they are taking a receptor agonist)
  • Example: Patients with chronic alcoholism –> Chronic stimulation of GABA receptors by alcohol –> Down-regulation of GABA receptors (which are responsible for tempering/calming nervous sytem), such that when patient stops taking alcohol they lose increased GABA related to alcohol, leading to relatively decreased binding of GABA to GABA receptors –> overstimulation of brain –> seizures, delirium tremens, etc.

10. An 8-year-old girl is brought to the physician by her mother because of frequent stomachaches over the past 3…

Generalized anxiety disorder

  • Pediatric patient with >6 month history of worries/anxiety about multiple life stressors with somatization most consistent with generalized anxiety disorder
  • Key idea: Formal diagnosis requires at least 6 months of symptoms with at least 3 of the following symptoms:
    • Restlessness
    • Fatigue
    • Difficulty concentrating
    • Irritability
    • Muscle tension
    • Sleep disturbance
  • Separation anxiety disorder: Somatic symptoms, nightmares and difficulty sleeping associated with reluctance to leave parent/guardian due to fear of separation or excessive concern about bad events happening to parent/guardian

11.A 77-year-old man comes to the physician at his wife’s insistence because of a 2-year history of progressive memory…

Cholinergic

  • Elderly man with chronic progressive memory problems that have impaired day-to-day functioning (getting lost close to home, forgetting to turn off oven, etc.) with an MMSE less than or equal to 23 most consistent with Alzheimer’s disease
  • 2 main treatment options for Alzheimer’s disease are:
    • Acetylcholinesterase inhibitors (which lead to increased acetylcholine): Donepezil, Rivastigmine, Galantamine
    • NMDA receptor inhibitor: Memantine
  • Anticholinergic –> Used in Parkinson’s disease
  • Antidopaminergic –> Used in Schizophrenia
  • Dopaminergic –> Used in Parkinson’s
  • Serotonergic –> Used in MDD, GAD, PTSD, and many other psychiatric diseases (anything treated with SSRIs)

12.A 23-year-old man is brought to the emergency department because of progressive paranoia and agitation for…

Substance-induced psychotic disorder

  • Young man with 2 days of paranoia and agitation with normal pupil sizes (2-4 mm normal), dry mouth and tremulousness most associated with marijuana-induced psychosis
  • Key idea: Presence of physiologic signs (dry mouth, etc.) tells us that patient does NOT have pure psychiatric condition and likely has psychiatric symptoms secondary to substance or medical condition (often endocrine disease)
  • Key idea: Signs/symptoms that are associated with marijuana on NBME exams are injected conjunctivae, dry mouth, tachycardia and paranoia
  • Key idea: Rapid speech with increased volume can be seen in both psychosis and mania/hypomania

13.A 46-year-old man is brought to the emergency department following a self-inflicted gunshot wound to the right upper…

Lorazepam

  • Middle-aged man with chronic alcoholism who on hospital day 3 begins to develop anxiety, insomnia and tachycardia likely associated with alcohol withdrawal who should be managed with a short-acting benzodiazepine
  • Key idea: Potential manifestations of alcohol withdrawal and time since last drink include (1) Nonspecific symptoms (3-36 hours): Tremors, insomnia, GI upset, agitation, diaphoresis, etc. (2) Withdrawal seizures (6-48 hours) (3) Alcoholic hallucinations (12-48 hours) (4) Delirium tremens: Altered mental status, tremors, autonomic hyperactivity, etc. (48-96 hours)

14.A 74-year-old widower comes to the physician because of gradually increasing insomnia over the past 2 years…

Reassure the patient that his sleep pattern is normal for his age

  • Normal changes in sleep patterns observed with aging:
    • Decreased total sleep time
    • Peak sleepiness earlier in evening
    • Nocturnal awakenings
    • Daytime napping with reduced daytime sleep latency (time it takes to fall asleep)
    • Decreased slow-wave sleep
    • Decreased REM latency

15. A 62-year-old woman is brought to the emergency department by her husband because of confusion for…

Discontinue doxepin

  • Middle-aged woman on a TCA (doxepin) who is showing signs of anti-histaminetoxicity (confusion), anti-cholinergic toxicity (mydriasis, dry skin) and ECG changes (AV block with widened QRS complex), which is consistent with TCA toxicity and should be treated by discontinuing doxepin and starting IV sodium bicarbonate for the ECG changes

16. A 27-year-old woman comes to the physician for an examination prior to starting a new job. She has…

Increased amylase activity

  • Young woman with bulimia nervosa (normal weight with history of binge-eating with compensatory behaviors) who would therefore likely have increased amylase activity because recurrent vomiting leads to increased salivary production of amylase
  • Key idea: Both bulimia nervosa and anorexia nervosa can be associated with purging behavior (vomiting, exercise, etc.), with the difference being that anorexia patients will have BMI < 18.5 and bulimia patients will have normal weight and history of binge eating
  • Vomiting –> Loss of hydrogen chloride (HCl) –> Metabolic alkalosis (high serum bicarb) and hypochloremia
  • Vomiting –> Hypovolemia –> Activation of RAAS system –> Increased aldosterone levels (which leads to hypokalemia because aldosterone mediates reabsorption of sodium in exchange for potassium and hydrogen ions at the collecting ducts via ENaC channels) and increased ADH levels (which leads to hyponatremia due to increased reabsorption of free water at the collecting ducts via aquaporin channels)
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3204380/

17. A 37-year-old woman comes to the physician with her husband because of a 1-year history of fatigue…

Focal white matter lesions

  • Young woman who presents with neurological symptoms disseminated in time and space (blurry vision, leg numbness, memory problems) most consistent with multiple sclerosis (which is a demyelinating disease that leads to focal white matter lesions)
  • Key idea: Patient’s history of leg numbness that worsens with long walks likely consistent with Uhthoff’s phenomenon (MS symptoms worsen in heat), which is often tested on NBME by saying that patient’s symptoms worsen with exercise or have come on/worsened since moving to Florida, Arizona, etc.
  • Key idea: Neurological symptoms consistent with multiple sclerosis on NBME exam include optic neuritis (unilateral painful eye with blurry vision)

18.An unconscious 7-year-old boy is brought to the emergency department by his parents. The family emigrated from rural…

EEG

  • 7 year old boy is brought to ED for chronic episodes where he “becomes possessed” and then becomes confused with depressed mental status which is likely related to epilepsy or seizure disorder –> Work-up with EEG given chronic history and potential secondary intellectual disability
  • Contact child protective services: Patients may not have good health literacy, but they don’t seem to be actively hurting the child

19.A 47-year-old man comes to the physician because of a 2-day history of intense anxiety. He has been receiving…

Adverse effect of prochlorperazine

  • Middle-aged man with recent initiation of a high-potency typical antipsychotic (prochlorperazine) who now presents with pacing, hand wringing and trouble sitting still which is most consistent with the extrapyramidal adverse effect akathisia
  • Key idea: High-potency typical antipsychotics (Haloperidol, Trifluoperazone, Fluphenazine) are most associated with extrapyramidal side effects of antipsychotics (acute dystonia, Parkinsonism, Akathisia, Tardive dyskinesia)
  • Key idea: Extrapyramidal symptoms associated with antipsychotics include (1) Acute dystonia: Sudden, sustained contraction of neck, eye muscles, etc./ tx: benztropine, diphenhydramine (2) Akathisia: Restlessness that worsens with escalating antipsychotic use / tx: benztropine, beta blocker, benzo / (3) Parkinsonism: Resting tremor, rigidity, shuffling gate, etc. / tx: benztropine, amantadine (4) Tardive dyskinesia: Prolonged antipsychotic therapy with dyskinesia of the mouth, face and extremities / tx: Valbenazine and deutetrabenazine

20. A 72-year-old woman comes to the physician because of a 3-month history of fatigue and difficulty sleeping…

Increased serum cortisol concentration

  • Elderly woman with signs of major depressive disorder (fatigue, insomnia, decreased appetite, hopelessness, etc.) which is associated with increased serum cortisol levels
  • Decreased hemoglobin –> Anemia –> Shortness of breath, low energy, etc.
    • In this age demographic, next best step would be colonoscopy
  • Decreased thiamine –> Wernicke-Korsakoff syndrome
  • Increased percentage of bands –> Increased PMNs/Neutrophils –> Acute infection
  • Increased serum prolactin –> Galactorrhea, sexual dysfunction, etc.
  • http://www.aamj.eg.net/journals/pdf/2394.pdf

21. A 32-year-old financial analyst comes to the physician at her employer’s request because of bizarre behavior…

Cocaine abuse

  • Young woman with 6 month history of changes in behavior (including long lunch breaks) paranoia, sympathetic hyperactivity (tachycardia, hypertension, mydriasis) and pressured speech most consistent with cocaine abuse/intoxication
  • Key idea: Signs of sympathetic activity and dilated pupils –> Patient does NOT have a pure psychiatric disorder (such as bipolar disorder or schizophrenia) and likely has a non-psychiatric medical condition or is using substances
  • Key idea: PCP abuse would be associated with more violent behavior and nystagmus

22. A 23-year-old man comes to the physician because of anxiety since beginning a second part-time job as a courier…

Cognitive behavioral therapy

23. A 2-year-old girl who was adopted is brought to the physician because of developmental delay; she does not…

Trisomy of an autosomal chromosome

  • 2 year old child with developmental delay (motor and speech) with epicanthal folds, prominent tongue and small low-set ears consistent with Down syndrome which is due to Trisomy 21
  • Defect in N-acetylglutamate synthetase –> Urea cycle disorder (severe developmental delay but not the characteristic facial features)
  • Fetal alcohol syndrome –> intellectual disability, behavior problems, smooth philtrum, microcephaly, small patient
  • Phenylalanine hydroxylase deficiency –> Phenylketonuria –> Fair skin, musky body odor, intellectual disability, seizures, eczema

24.A 26-year-old man comes to the physician because of increasing daytime sleepiness over the past 3 years. He has begun…

Decreased REM latency

  • Young man with 3 year history of lapses into sleep during the day with hypnagogic hallucinations most concerning for narcolepsy
  • Narcolepsy diagnosis: 
    • Recurrent lapses into sleep at least 3 times for at least 3 months and
    • AT LEAST 1 of the following :
      • Cataplexy [brief loss of muscle tone with laughter or strong emotion]
      • Low hypocretin-1 in CSF
      • Shortened REM sleep latency on polysomnography)
  • Key idea: Often associated with sleep paralysis and hypnagogic (while going to sleep) or hypnapompic (upom waking up) hallucinations
  • Key idea: Polysomnography used to evaluate for many sleep disorders, such as narcolepsy, periodic limb movement disorder, REM sleep behavior disorder and sleep apnea

25.An 18-year-old man is brought to the emergency department by friends 1 hour after they found him on the couch…

Substantia nigra

  • Young patient taking synthetic heroin who presents with stiffness and akinesia most consistent with MPTP-mediated substantia nigra damage leading to Parkinson’s like symptoms
  • Key idea: Synthetic heroin can be tainted with MPTP which directly destroys dopaminergic neurons in the substantia nigra and leads to permanent symptoms of Parkinson’s disease
  • Mnemonic for Parkinson’s disease symptoms is TRAPS: resting Tremor, Rigidity, Akinesia, Postural instability, Shuffling gait

26. A 16-year-old girl is brought to the physician by her father because of unusual behavior since returning…

Marijuana intoxication

  • Young girl who came home after a party (which should equal drug use on NBME) and demonstrates paranoia, tachycardia, and conjunctival injection most consistent with marijuana intoxication
  • Marijuana: Paranoia, conjunctival injection, dry mouth, tachycardia
  • PCP: Nystagmus, violent behavior, dissociative symptoms
  • LSD: Visual hallucinations + Mydriasis
  • Cocaine: Chest pain, mydriasis, agitation/psychosis, hypertension, tachycardia
  • Methamphetamine: Same as cocaine + violent behavior, choreaform movements and tooth decay
  • Heroin: Respiratory depression, pinpoint pupils, depressed mental status, constipation

27.A 24-year-old man is brought to the emergency department from jail by police because he has had numbness in his…

No treatment is indicated

  • Young man who was recently imprisoned with a long history of law-breaking (likely associated with antisocial personality disorder) who presents with numbness of the hand from the wrist to the finger tips with normal motor function which is not consistent with any known neurological/nerve disorder and most likely represents malingering –> No treatment indicated

28.A 32-year-old man is admitted to the hospital because of refusal to speak or move since he returned home after being…

Lorazepam

  • Young man who experienced a very traumatic event and presents with symptoms consistent with catatonia (mute, negativism, resists commands and being moved) which can be treated with benzodiazepines (lorazepam) or electroconvulsive therapy
  • Signs of catatonia:
    • Mutism and stupor
    • Negativism (resistance to instructions or movements)
    • Waxy flexibility (initial resistance to movement but then maintains position/posture after being moved)
    • Posturing (assuming positions against gravity)
    • Immobility or purposeless activity
    • Mimicking speech and movements

29.An 8-month-old male infant who was adopted recently is brought to the physician because of poor weight gain…

Fetal alcohol syndrome

  • 8 month old infant brought in for poor weight gain with narrow palpebral fissures, thin upper lip and a smooth/indistinct nasal philtrum which are highly specific for fetal alcohol syndrome
  • Fetal alcohol syndrome –> intellectual disability, behavior problems, smooth philtrum, microcephaly, small patient
  • Celiac disease –> Steatorrhea, weight loss, vesicular rash on extensor surfaces, iron deficiency anemia (due to villous blunting in the duodenum)
  • Down syndrome –> Can also have epicanthal folds and single palmar crease but more associated with intellectual disability (which this patient does not have), hypertonia, enlarged tongue, and low-set ears
  • Psychosocial deprivation –> Global delay in milestones
  • Silver-Russell syndrome: https://rarediseases.org/rare-diseases/russell-silver-syndrome/#:~:text=Russell%2DSilver%20syndrome%20(RSS),asymmetry%20and%20significant%20feeding%20difficulties.

30. A 20-year-old woman is admitted to the hospital because of severe swelling of the lower extremities…

Decreased serum albumin concentration

  • Young woman with severely diminished BMI (<15) in the setting of anorexia nervosa (still believes she is fat and is working out obsessively +/- using laxatives/diuretics) found to have lower extremity edema likely due to decreased albumin concentration
  • Key idea: Albumin main component of oncotic pressure, which helps to hold fluid in vessels so in a patient who is malnourised –> low protein levels –> low albumin –> low oncotic pressure –> increased gradient for fluid to move from vessels to tissue
  • Key idea: Anorexia nervosa diagnosed by BMI<18.5

31.An 82-year-old man is brought to the physician by his daughter because he has been forgetful during the past 6 weeks…

Mini-Mental State Examination

  • Elderly man with 6 week history of forgetfulness that is not entirely consistent with Alzheimer disease based on time course and may be related to depression (“pseudo-depression”) and therefore should be worked-up with MMSE
  • Note: If patient has confirmed Alzheimer disease, then you would start donepezil therapy (acetylcholinesterase inhibitor –> increased cholinergic activity)
  • Routine tests in setting of suspected cognitive impairment:
    • Cognitive tests
      • MMSE less than or equal to 23
      • MOCA less then or equal to 25
      • Abnormal 3-word recall and/or clock draw
    • Labs
      • CBC
      • BMP
      • B12 level
      • TSH level
      • +/- folate, syphilis work-up
    • +/- Imaging (head CT or brain MRI)

32. A 7-year-old girl is brought to the physician because her parents are concerned about her recent preoccupation…

Age-appropriate behavior

  • Young child who begins to ask about death and has slight worries about her parents dying but who is showing no impaired functioning and therefore falls under the umbrella of age-appropriate behavior
  • Key idea: In order for a psychiatric disorder to be diagnosed, it must lead to impaired functioning
  • Separation anxiety disorder: Same theme of anxiety/worries but it leads to somatic symptoms, apprehension going to school, etc.

33.A 19-year-old man has had restless sleep and feelings of sadness for 1 week; he has had a 0.9-kg (2-lb) weight loss…

Adjustment disorder with depressed mood

  • Young patient who had a life stressor 2 weeks ago and presents with 1 week of sadness, insomnia and impaired functioning most consistent with adjustment disorder
  • MDD would require >2 weeks of symptoms and would require at least 5 of the following symptoms: Depressed mood and SIGECAPS symptoms
  • Acute stress disorder leads to <1 month of HARD symptoms (Hyperarousal, Avoidant behavior, Reliving experience (often nightmares), Disturbed thinking/mood) often after a life-threatening or dangerous event

34.A 57-year-old man comes to the physician with his wife because of a 1-month history of bizarre behavior at night. His wife says…

REM sleep behavior disorder

  • Middle-aged man who acts out his dreams most consistent with REM sleep behavior disorder
  • Key idea: Normally during REM sleep are muscles are completely paralyzed so that we do not act out dreams, but in this disorder muscles maintain some activity and can lead to acting out dreams
  • Key idea: REM sleep behavior disorder very strongly associated with Parkinson’s disease and Lewy body dementia

35. Over the past 6 months, a 24-year-old woman has had 12 episodes of sudden apprehension associated…

Cognitive behavioral therapy

  • Young woman with unprovoked panic attacks who does not want pharmacotherapy and therefore can be managed with cognitive behavior therapy
  • Hypnotherapy –> Drug/substance use history
  • Psychodynamic therapy –> Personality disorders primarily
  • Acute panic attack –> Benzodiazepines
  • Chronic panic attacks or panic disorder –> SSRI/SNRI + CBT
  • Key idea: This patient technically does NOT have panic disorder because they do not have anxiety associated with unprovoked panic attacks

36.A 37-year-old man is brought to the emergency department by the police after they found him sitting in an alley

Vitamin B1 (thiamine)

  • Young man with signs of cirrhosis (gynecomastia, palmar erythema, RUQ tenderness, easy bruising) who presents with confusion, ophthalmoplegia and likely ataxia (unable to stand/walk despite normal muscle strength) most consistent with Wernicke encephalopathy due to thiamine deficiency in the setting of alcoholism
  • Key idea: On the NBME, Alcoholism = Nutritional deficiency
  • Folic acid and B12 deficiency both lead to megaloblastic anemia, with B12 deficiency also leading to neurologic symptoms compatible with subacute combined degeneration
  • Niacin deficiency –> Pellagra –> Diarrhea, Dermatitis, Dementia, Death
  • Vitamin B6 deficiency –> Neuropathy, seborrheic dermatitis, glossitis, etc.

37.A 27-year-old man comes to the physician because of anxiety about a major speech that he must deliver in 3 days…

  • Young man with performance-specific social anxiety disorder (concern about being publicly embarrassed) which is best treated with a beta blocker > benzodiazepine
  • Key idea: Patients with alcohol use disorder or family history of alcohol dependence often should not receive benzodiazepines if they can be avoided (similar mechanism of action)

38.A 27-year-old man comes to the physician because of anxiety about a major speech that he must deliver in 3 days…

  • Young man with performance-specific social anxiety disorder who also has severe asthma and no personal or family history of alcohol dependence who in this setting should receive benzodiazepine > beta blocker
  • Beta blockers –> Blockade of Beta-2 receptors in smooth muscle of airways –> Bronchoconstriction –> Worsening asthma

39.A 25-year-old man comes to the physician with his wife because of bizarre behavior for the past 3 months. She reports…

Sertraline

  • Young man with obsessions (cleanliness, bad air quality) that causes him distress most consistent with Obsessive-compulsive disorder which should be treated with (1st-line) SSRIs vs CBT (2nd line) Clomipramine vs SNRIs
  • Common obsessions in OCD: Cleanliness, thoughts of hurting somebody else or conducting sexual behaviors, etc.
  • Buspirone –> Specific for generalized anxiety disorder

40. A 37-year-old woman is brought to the emergency department 30 minutes after the onset of a severe occipital…

Phentolamine

  • Patient on a MAO inhibitor (phenelzine) who presents with a hypertensive emergency after eating tyramine-containing foods (mainly the cheese and pepperoni themselves) who should therefore be treated with phentolamine
  • Phentolamine: Reversible alpha blocker used first-line for MAO-induced hypertensive emergency and 2nd-line for cocaine-induced hypertension (benzo’s are first line)
  • Phenoxybenzamine: Irreversible alpha blocker used in setting of pheochromocytoma
  • MAO inhibitors can be remembered with First Aid mnemonic that Mao Takes Pride In Shanghai –> Tranylcypromine, Phenelzine, Isocarboxazid, Selegiline
  • Key idea: MAO inhibitors associated with hypertensive crisis after eating tyramine-containing foods (cheese, cured/processed meats, alcohol) and serotonin syndrome (when used with other serotonergic drugs)

41. A previously healthy 37-year-old man comes to the physician because of a 6-month history of depressed mood, fatigue…

Mood disorder due to a general medical condition

  • Young obese man with mood symptoms in the setting of loud snoring + difficulty sleeping, being tired during the day, etc. most consistent with mood disorder secondary to obstructive sleep apnea
  • Risk factors for obstructive sleep apnea can be remembered by STOP-BANG mnemonic (Snoring, Tired, Observed snoring/chocking, Pressure (elevated BP), BMI >35, Age>50, Neck size > 16 cm and Gender (Male > Female))
  • Key idea: Polysomnography used to diagnose virtually all NBME sleep disturbance questions (obstructive sleep apnea, narcolepsy, REM sleep behavior disorder, etc.)

42. A 23-year-old graduate student comes to the physician because of depressed mood and feelings of hopelessness…

Adjustment disorder with depressed mood

  • Young woman who experienced a recent stressor and is now presenting with depression symptoms insufficient to meet formal criteria for MDD (need at least 2 weeks with at least 5 symptoms of depressed mood + SIGECAPS), most consistent with adjustment disorder
  • Substance use occurred AFTER the acute stressor and therefore substance-induced mood disorder is not correct
  • Key idea: Pay CLOSE attention to the time course/parameters of psychiatric diseases as they are essential to diagnosing disease and can help you quickly rule out answer choices (>2 weeks for MDD, >6 months for Generalized anxiety disorder, etc.)

43.A 42-year-old man comes to the physician for advice concerning his fear of flying. One year ago, he was on an airplane that…

Specific phobia

  • Young patient with a fear of flying who also had a previous episode consistent with social anxiety disorder (panic attack while giving a presentation), most consistent with a specific phobia
  • Mitral valve prolapse and caffeine can predispose to anxiety secondary to a general medical condition, but would not lead to anxiety only about specific situations

44. A 32-year-old woman comes to the physician because of depressed mood for 2 weeks; she went…

“How would you feel about entering the hospital?”

  • Young depressed woman with suicidal ideation with organized plan and access to means who will need to be hospitalized involuntarily but often in these cases it is best to first ask the patient if they will voluntarily enter the hospital (better for doctor-patient relationship if possible)
  • Key idea: Passive suicidal ideation can be managed as an outpatient, but if patient has an organized plan and access to means then they should be involuntarily hospitalized

45. A 52-year-old woman comes to the physician for a routine follow-up examination. She has received…

Discontinue haloperidol and begin risperidone

  • Middle-aged woman with severe schizophrenia who has been treated with haloperidol for the past 20 years and has developed signs of tardive dyskinesia (smacks her lips and protrudes her tongue) and therefore should discontinue high-potency antipsychotic and start an atypical antipsychotic (such as risperidone)
  • Key idea: Patient’s schizophrenia is so severe that we cannot only discontinue haloperidol and not start her on another antipsychotic with lower extrapyramidal risks
  • Chlorpromazine is a low-potency typical antipsychotic which carries more extrapyramidal risk than an atypical antipsychotic such as risperidone
  • Key idea: High-potency typical antipsychotics (Haloperidol, Trifluoperazone, Fluphenazine) are most associated with extrapyramidal side effects of antipsychotics (acute dystonia, Parkinsonism, Akathisia, Tardive dyskinesia)

46.A 37-year-old man is brought to the emergency department after the pilot of a boat found him in the river at 2 am with rocks in…

Admit to the psychiatric unit involuntarily

  • Young man with symptoms of depression (weight loss, fatigue, tearful mood, psychomotor slowing) who presented after a failed suicide attempt and therefore should be hospitalized involuntarily
  • Key idea: Patients with passive suicidal ideation do not need to be hospitalized against their will, but if the patient has an organized plan and access to means then they need to be admitted involuntarily
  • Key idea: These patients should first be offered voluntary hospital admission in the name of patient-physician relationship, but even if they don’t want to be admitted they need to be forcefully admitted

47. A 27-year-old woman, gravida 1, para 1, comes to the physician with her husband because of progressive…

Major depressive disorder

  • Young woman who presents 3 weeks postpartum with >2 weeks ofdepressed mood and SIGECAPS components (Sleep changes, decreased Interest in friends/family, low Energy, Appetite changes, Suicidal thoughts) most consistent with major depressive disorder
  • Key idea: MDD requires at least 2 weeks of at least 5 of the following 9 symptoms (depressed mood, Sleep changes, decreased Interest in activities, Guilt, low Energy, Cognitive changes, Appetite changes, Psychomotor slowing, Suicidal thoughts)
  • Key idea: Important to differentiate from postpartum blues which is mild depressive symptoms that develop 2-3 days after delivery and RESOLVE WITHIN 2 WEEKS (require monitoring without treatment unless it develops into postpartum depression)
  • Generalized anxiety disorder would require at least 6 months of symptoms
  • PTSD requires at least 1 month of symptoms

48.Over the past 7 years, a 25-year-old graduate student has had increasingly severe palpitations, tremulousness, nausea…

Psychiatric evaluation

  • Patient with symptoms of anxiety that is always brought on when he is taking a test most consistent with a psychiatric/anxiety condition
  • Key idea: All of the other diagnostic tests pertain to medical conditions, some of which can lead to similar symptoms but would not be as highly associated with taking tests
  • 24-hour urine collection for 5-HIAA –> Carcinoid syndrome –> Episodic wheezing, flushing, diarrhea, and right-sided valvular problems
  • 24-hour urine catecholamines/metanephrines –> Pheochromoctycoma –> Recurrent episodes of hypertension, sweating, headaches and palpitations

49. A 47-year-old woman is brought to the emergency department by her husband because of increasing confusion…

Lithium

  • Middle-aged woman with bipolar disorder (which is almost always treated with lithium > valproate) who has been taking higher amounts of NSAIDs recently who presents with confusion, tremor, and AV block most consistent with lithium toxicity
  • Key idea: Common signs of lithium toxicity are GI symptoms, confusion, tremors/fasciculations and seizures +/- ECG changes
  • Key idea: Common triggers of lithium toxicity are drugs that affect the function of the kidney, most often thiazides, ACE inhibitors, nephrotoxic agents and NSAIDs (which leads to afferent arteriole vasoconstriction)
  • Key idea: Indications for hemodialysis in setting of lithium toxicity is serum lithium level > 4 mEq/L or serum lithium level > 2.5 mEq/L + signs of lithium toxicity (seizures, altered mental status) OR inability to secrete lithium (CKD, CHF, etc.)

50. A 47-year-old man is brought to the physician by his wife because of “unbearable” behavior during the past 2 weeks…

Bipolar disorder

  • Middle-aged man with signs of mania/hypomania (impulsivity, grandiosity, etc.) and psychosis most consistent with bipolar disorder
  • Mania/Hypomania leads to DIG FAST symptoms (Distractibility, Impulsivity, Grandiosity, Flight of ideas, decreased Appetite, decreased Sleep need, Talkativeness)
  • Key idea: Can sometimes be difficult to differentiate between schizophrenia and bipolar disorder on NBME when patient presents with psychosis, but look for DIG FAST symptoms to differentiate between them
  • Key idea: Cocaine use can also lead to psychosis with signs of mania/hypomania, but this patient had a negative urine toxicology
  • Key idea: 3 key differences that are consistent with Mania rather than hypomania:
    • (1) Causes significant functional impairment or leads to hospitalization
    • (2) Episode lasting >7 days
    • (3) Presence of psychotic features

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PsycN NBME FOrm 4

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psych NBME Form 4 shelf answer and explanations to incorrects

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psych NBME Form 4 shelf answer and explanations to incorrects

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● Tardive dyskinesia management


○ If on haloperiodl then stop haloperiodl and bein risperidione
● Multiple sclerosis
○ Can have major mood swigs, be very happy and bright despite deficits, or have times of euphoria, or
seem very unconcerned about dx
● Narcolepsy = decreased REM latency
● TCAs = doxepin, nortriptyline, clomipramine, amoxapine, amitriptyline, desipramine, nortriptyline, trimipramine,
imipramine, protriptyline
● Chornic alcoholic presents with altered menstal stasus, ecchmoses over face and extremites, restricted gaze,
bilateral nystagmus, gynecomastia, palmar erythema, enlarged liver, unable to stand or walk, DTR are absent
○ Thiamine deficiency:
■ Wernicke korsafkoff syndrome = confusion, opthalmoplegia, ataxia + confabulation, personatil
change, memory loss - damage to medail dorsal nucleus of thalamus, mamillary bodies
■ Dry beriberi = polyneuropathy, muscle wstnig
■ Wet berberi = high output cardiac failure, dilated cardiomyopathy, edema
○ B12 deficiency = megaloblastic anemia, parestehsaias and subacute combined degeneration
● Beta blockers = contrandicated in asthma!!!!! Prinzmetal angian, bradycardia, heart block, peripheral
vascular disease, acute decompensated heart failure
○ So if panic disorder when public speaking with fam hx of alcohol dependence but no use, and asthma
then you pick BDZ.
● Acute stress disorder vs adjustment disorder - time frames can overlaps so look more at defining reasons
○ Acute stress disorder (basically a baby PTSD!)
■ A: exposure to actual or threatened death, serious injry, or sexual violation in one o rmore of the
following ways:
● Direclty expereincing teh trauamtic event
● Witnessing in persont eh events as it occurred to thers
● Learnign the event that occurred to a close family member of riend - must be violent or
accidental if happened to someone else and you are hearing about it
● Expreincing repeated or extreme exposur to aversive details fo the traumatic event - first
respondents collecting human remains, police officers repeatedly exposed to details fo
child abuse)
■ B: presence of nine o rmore fo the foloinw sx of any of the five categories of intrusion, neg
dmood, diissociation, avoidance, arousal, beginning or owresning after trauamtic events that
occurred
● Intrusion sx: recurrent, involutary, adn intrusive distressing memories of teh trauamtic
event (kids often will have violent or sexual themes in pretend play). Distressing dreams,
dissociative rxns like flashbacks, can have diossication as well, trauma specifi
creneactment may occur in play for kids, intense of prolonged psychological distress in
response to cues that remidn ppl of the event
● Negative mood: persistent inability to expereince positive emotions, inability to experience
happiness, satisfaction or loving feeligns
● Dissociation sx: altered sense fo realtity, inabiltity or emember an importan aspect of
trauamatic event (not bc of brain injury alc drugs etc)
● Avoidacne sx: efforts to avid distressing memorie sthoughts or feelings assoc with
traumatic event, avoiding external reminds of event,
● Arousal sx: sleep distrubances, irritabile behavior and angry outbursts, hypervigiliance,
concentration problem, exaggereated startle response
■ C duation fo diturbance is 3 days to 1 mo after expsoure (sx usually begin right after event but
have to persist for at least 3 days but not longer than 1 month to meet disorder criteria
● Adjustment Disorder - development of emotinal or behavioral sx in response to identifiable stressor occuring
within 3 months of onset of stressor
○ Marked distress that is out of proportion to the severit yof intesity fo the stressor -
○ Signifiant impairment in soical occupational or other important areas of functioning
● TD with long use of haloperidol: management is to stop haloperiodl and begin risperidone
● Pt held at gunpoint yesterday now is mute in acute emotinal distress, sitting uprigh twth eyes closed, does not
follow commands, resits being moved, flat affect. What med to give?
○ Answer id BDZ not haloperidol
● Prochlorperzine: D2 blocker for nausea drug
● Tanner staging and age look up
● Anorexia = decreased serum albumin
● Heroin use, on couch unable to move, stiffness in all extremties, drooling, slow response to questions, which of
follow brain resgions is most likely affected?
○ Substantia nigra bc mpmt
● Rem sleep behavior disorder
● Dissociative disorder
Sours: https://es.scribd.com/document/436522782/Psych-NBME-Form-4
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the HY Medicine

1) Lorazepam (alcoholic cant sleep) • Alcohol withdrawal symptoms should be managed with benzodiazepines • Lorazepam, Oxazepam, and Temazepam are the benzos that should be used in those with liver disease (chronic alcoholism) due to minimal first-pass metabolism

2) Dissociative disorder

• This patient has depersonalization/derealization disorder

• Acute stress (accident at construction site) → detachment from one’s own thoughts, actions, or environment; patients often seem like they’re in a fog or spaced out and in their own world

• Personal information collected from interpreter makes the diagnosis of dissociative amnesia unlikely

3) Substance-induced psychotic disorder

• This patient is using stimulants (eg, amphetamine, methylphenidate) to study → psychosis

4) Increased amylase activity • Recurrent vomiting → parodic gland enlargement/inflammation → ↑ Amylase

5) Major depressive disorder

• Post-partum depression

6) Schizoaffective disorder • Delusions or hallucinations for ≥ 2 weeks in the absence of prominent mood symptoms

• Bipolar or major depression with psychotic features have psychotic symptoms occurring exclusively during mood episodes (this patient is still having psychotic features even though his mania has resolved after hospitalization)

7) Mini-Mental State Examination • This depressed geriatric patient that recently developed symptoms of dementia likely has pseudo-dementia, however it is imperative to rule out organic causes of dementia with an MMSE due to his old age • Neuropsychiatric testing would be a better choice (MMSE is now proprietary)

8) Discontinue haloperidol and begin risperidone • This patient is experiencing Tardive dyskinesia • This patient has attempted suicide twice, and therefore is not a candidate for drug cessation • Second generation antipsychotics are less likely to cause EPS than first generation antipsychotics (eg, haloperidol)

9) Psychiatric evaluation

• Long standing condition (over 7 years) that is situational (exams) → origin of problem is psychiatric

• Thyroid disease would present with additional symptoms and would be more pervasive (not just during exams)

10) Increased serum cortisol concentration

• MDD is associated with hyperactivity of the HPA axis → ↑ cortisol

• MDD patients may have an atypical (failure to suppress) dexamethasone suppression test

11) Specific phobia • Marked anxiety about a specific object or situation for >6 months

• Tx: CBT with exposure

12) Sertraline • OCD tx: SSRI and CBT (venlafaxine and clomipramine are second line)

13) Adjustment disorder with depressed mood • Identifiable stressor causing marked distress and significant functional impairment with onset within 3 months of stressor

14) Performance anxiety • Nocturnal/early morning erections = cause of sexual dysfunction is psychological

15) Ethylene glycol toxicity

• Ethylene glycol (antifreeze) → glycoaldehyde (toxic) → glycolate (anion gap) → calcium oxalate → kidney stones

• Methanol (moonshine) → formaldehyde (toxic) → formate → blindness

• Ethanol → acetaldehyde (toxic) → acetate (non-toxic)

16) Cholinergic • Alzheimer disease → ↓ ACh • Tx: AChE inhibitor (eg, donepezil, rivastigmine, galantamine) → ↑ ACh

17) EEG • This child is likely having seizures and should be evaluated with an EEG

• “Spit” = drooling, “blood” = from biting tongue, “takes his power” = loss of consciousness

18) Marijuana intoxication • Dry oral mucosa, injected conjunctive, tachycardia, HTN • Always rule out substance or medical related disorder before diagnosing a psychiatric condition

19) Admit to the psychiatric unit involuntarily • This patient is actively suicidal (recent attempt) and should be admitted to the psychiatric unit regardless of his refusal

20) Substantia nigra • MPTP induced Parkinsonism • MPTP (synthetic potent analog of meperidine (demerol)) is toxic to the substantial nigra

21) Schizophrenia • Delusion: Dementors searching for him to turn him into an alien

• Hallucination: Dementors look him in the eyes • Disorganized speech/thinking: Thought process not 100% linear

• Disorganized behavior: Disheveled appearance • Negative symptoms: Lives alone, no friends, poor eye contact

22) Adverse effect of prochlorperazine • The anti-emetic agent prochlorperazine has additional antipsychotic effects (by blocking D2 receptors) and may cause EPS

• Tx: β-blockers or benzos

23) Mood disorder due to a general medical condition

• This patient has OSA (obstructive sleep apnea)

24) Adjustment disorder with depressed mood • Distress with functional impairment within 3 months of a stressor

• MDD requires symptoms for ≥ 2 weeks

25) Cognitive behavior therapy • This patient has a specific phobia (heights & elevators)

• Tx: CBT with exposure

26) Reassure the patient that his sleep pattern is normal for his age

• Sleep changes in elderly: ↓ REM sleep time, ↑ REM latency, ↓ N3

27) Phentolamine

• Hypertensive crisis (tyramine displaces neurotransmitters (eg, NE) in the synaptic cleft → ↑ sympathetic stimulation)

• Phentolamine is a nonselective α-blocker that is giving to patients on MAO inhibitors that eat tyramine-contains foods

28) Normal, Normal • This teenage boy is developing normally, both physically and socially

29) Bipolar disorder • This patients grandiosity, impulsivity, talkativeness, flight of ideas and increased goal directed activity are consistent with a manic episode • Presence of psychotic features (“god is talking to me”) makes this a manic (not hypomanic) episode • This patients presentation is episodic (previous similar episodes)

30) Major depressive disorder • Patient presents with 5/9 SIG E CAPS

• Sleep disturbances • Anhedonia: stopped going out with friends • Guilt: blames self • Fatigue and energy loss • Concentration problems • ↓ appetite and weight loss

31) Decreased serum albumin concentration

• Anorexia → malnutrition → ↓ albumin → ↓ oncotic pressure → edema

• Low albumin denotes low synthetic capacity of the liver secondary to malnourishment

32) Cocaine abuse

• “Sometimes she appears withdrawn/lethargic and other times appears energetic” is consistent with substance abuse

• Dilated pupils (without nystagmus), impulsivity, delusion = cocaine abuse (she’s a financial analyst...)

33) Increased sensitivity of the dopamine receptors • Tardive dyskinesia develops in the meeting of prolonged exposure to dopamine-blocking agents, which is thought to result in the up regulation and super- sensitivity of dopamine receptors

34) Fetal alcohol syndrome • Epicanthal folds, small palpebral fissures, low nasal bridge, smooth philtrum, thin vermillion border • Single palmar crease is sensitive but not specific for Down syndrome

35) REM sleep behavior disorder

• Paralysis that normally occurs during REM sleep is incomplete pr absent, allowing the person to ‘act out’ their dreams

• In older patients, REM sleep behavior disorder may be a sign of neurodegeneration (eg, Parkinson disease)

36) Discontinue doxepin

• TCA toxicity → Coma, Convulsions, Cardiotoxicity (arrhythmia), prolonged QT interval

• Tx: ECG, NaHCO3

37) Vitamin B1 (thiamine)

• Wernicke-Korsakoff syndrome → confusion, ataxia, nystagmus, ophthalmoplegia, memory loss

38) Decreased REM latency • Narcolepsy sleep changes: ↓ sleep latency, ↓ REM latency, ↓ sleep efficiency

39) Lorazepam • Catatonia: immobility, mutism, waxy flexibility • Tx: benzodiazepines (lorazepam), ECT

40) Marijuana intoxication • Injected conjunctive, tachycardia, HTN, slow reaction time, hallucination • Always rule out substance or medical related disorder before diagnosing a psychiatric condition

41) Trisomy of an autosomal chromosome • Trisomy 21 (down syndrome): Epicanthal folds, up slanting palpebral fissures, low-set small ears, flat facial profile, furrowed tongue

42) Lithium

• NSAIDS → ↓ renal clearance → ↑ lithium levels → toxicity

43) Age-appropriate behavior

• Between ages 6-11 (concrete operational stage), kids begin to understand that death is irreversible

• This child has no functional impairment (she continues to excel academically and participate in sports)

44) Cognitive behavioral therapy • This patient has panic disorder

• Tx: CBT ± SSRI/SNRI

45) Focal white matter lesions

• Intermittent blurred vision, focal neurologic changes, and paresthesia affecting a woman in her 30s is concerning for Multiple sclerosis

• Brain imaging would show Periventricular plaques and Multiple white matter lesions disseminated in time & space

46) Generalized anxiety disorder

• Excessive and persistent worry about multiple issues for ≥6 months with significant distress or impairment

• First-line tx: CBT + SSRI/SNRI

47) No treatment is indicated • This patient with normal pulses and DTRs is likely malingering (secondary gain: temporarily leaving jail)

48) “How would you feel about entering the hospital?” • A suicidal patient should be admitted to a psychiatric unit (ideally voluntarily, but involuntarily if the patient refuses)

49) Propranolol

• Performance only social anxiety disorder

• Tx: β-blockers or benzodiazepines

• This patient should receive a β-blocker (benzos may cause drowsiness, which isn’t ideal when giving a presentation)

50) Lorazepam • Performance only social anxiety disorder • Tx: β-blockers or benzodiazepines • This patient should receive a Benzo (β-blockers are contraindicated in asthma)

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Psychiatry NBME Form 4 Questions And Answers

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Witness advertisementExam Section : Item 1 of 50
An 82-year-old man is brought to the physician by his daughter because he has been forgetful during the past 6 weeks. She is particularly concerned because a small fire started recently when he left a pot unattended on the stove. The patient's wife died 1 year ago, and he says he has been distracted recently and cannot stop thinking about her. He lives alone and pays his bills, does routine household chores, and drives short distances for errands. His daughter says he was doing well on his own until recently. He is 168 cm (5 ft 6 in) tall and weighs 63 kg (140 1b); BMI is 23 kg/m2. His temperature is 370C (98.60F), pulse is 78/min and regular, respirations are 18/min, and blood pressure is 130/80 mm Hg. Physical examination shows no abnormalities. On mental status examination, he is alert and cooperative.
He becomes very sad when he talks about his wife's death. Which of the following is the most appropriate next step in management?
A) Follow-up examination in 3 months
B) Mini-Mental State Examination
C) Recommend assisted living
D) CT scan of the head
E) Begin donepezil therapy

Answer: (B) Mini-Mental state examination

Exam Section : Item 2 of 50
A 37-year-old man is brought to the emergency department after the pilot of a boat found him in the river at 2 am with rocks in his pockets. He reports that he jumped from the bridge to go for a swim and was not attempting suicide. He insists that the rocks were only to give him ballast when he jumped so that he would not hit the bridge tower. He immigrated to the USA 1 year ago and left most of his family behind. He has been living in a single furnished room and has been working numerous low-paying jobs. Over the past month, he has had a 4.5-kg (10-1b) weight loss. He reports that he always feels tired but has not seen a physician because he has no health insurance. He does not usually drink but had two shots of whiskey earlier that night. He has no history of medical or psychiatric illness. Physical examination shows numerous lacerations and abrasions over the chest and all extremities. On mental status examination, he describes his mood as fine but often appears tearful. His speech is slow with frequent pauses, and he is guarded in his responses. He says that he has not had hallucinations. He is alert and oriented to person, place, and time. The physician recommends voluntary admission to the psychiatric unit, but the patient refuses, saying there is nothing wrong with him. Which of the following is the most appropriate next step in management?
A) Recommend a mental health facility in his neighborhood
B) Recommend a social service agency
C) Observe in the emergency department for 36 hours
D) Begin fluoxetine therapy
E) Begin risperidone therapy
F) Admit to the psychiatric unit involuntarily
 
Answer: F) Admit to the psychiatric unit involuntarily
 
Exam Section : Item 3 of 50
Five weeks after being discharged from the hospital after treatment for a psychotic episode, a 27-year-old man comes to the physician for a follow-up examination. During hospitalization, he claimed that he was instructed by the Lord to found a new religion and that a famous gospel singer was in love with him. Today, he says that he still hears the voices of the Lord and members of the church he attends in his apartment and when he shops in the supermarket. He no longer believes the world needs a new religion because the Lord is no longer instructing him to create one. He states, "My father in heaven tells me that he is at peace, and therefore, so am l." Current medications include risperidone and lorazepam. He drinks one to two beers on weekends. He used marijuana regularly in college but has abstained for the past 5 years. He appears clean and is casually dressed. His temperature is 36.7 oc (980F), pulse is 72/min, respirations are 20/min, and blood pressure is 130/72 mm Hg. Physical examination shows no abnormalities. Mental status examination shows a calm affect. He is cooperative, alert, and oriented to person, place, and time. Based on this information, which of the following is the most likely current diagnosis for this patient?
A) Bipolar disorder
B) Cyclothymic disorder
C) Delusional disorder
D) Schizoaffective disorder
E) Substance-induced mood disorder
 
Answer: C) Delusional disorder
 
Exam Section : Item 4 of 50
The response options for the next 2 items are the same. Select one answer for each item in the set.
For each patient with depressed mood, select the most likely diagnosis.
A) Adjustment disorder with depressed mood
B) Bereavement
C) Bipolar disorder, depressed
D) Cyclothymic disorder
E) Dysthymic disorder
F) Major depressive disorder
G) Mood disorder due to a general medical condition
H) Substance-induced mood disorder
A previously healthy 37-year-old man comes to the physician because of a 6-month history of depressed mood, fatigue, poor concentration, and difficulty sleeping. He works as an accountant and has had difficulty staying awake at work, particularly in the afternoon. He says that his wife sleeps in a separate room because of his loud snoring. He drinks alcohol at social functions only. He is 175 cm (5 ft 9 in) tall and weighs 109 kg (240 1b); BMI is 35 kg/m2. Physical examination shows no other abnormalities. Mental status examination shows a mildly depressed mood.
 
Answer: G) Mood disorder due to a general medical condition
 
Exam Section: Item 5 of 50
A) Adjustment disorder with depressed mood
B) Bereavement
C) Bipolar disorder, depressed
D) Cyclothymic disorder
E) Dysthymic disorder
F) Major depressive disorder
G) Mood disorder due to a general medical condition
H) Substance-induced mood disorder
A 23-year-old graduate student comes to the physician because of depressed mood and feelings of hopelessness since breaking up with her boyfriend 1 week ago. During this period, she has rarely left her apartment, has only eaten a small amount of food, and has isolated herself from her friends and family. She has been drinking more alcohol than normal during this period. Physical examination shows no abnormalities. On mental status examination, she becomes tearful when she describes the breakup. When asked about her mood, she says, "I'm miserable. He was my life!" There is no evidence of suicidal ideation.
 
Answer: A) Adjustment disorder with depressed mood
 
Exam Section : Item 6 of 50
A 37-year-old woman is brought to the emergency department 30 minutes after the onset of a severe occipital headache, palpitations, and tremulousness. Shortly before this episode, she ate several slices of pepperoni pizza. She has a 2-month history of atypical major depressive disorder treated with phenelzine. She is otherwise healthy. She appears anxious and tremulous. Her temperature is 37.80C (IOOF), pulse is 94/min, respirations are 20/min, and blood pressure is 210/110 mm Hg. Physical examination shows no other abnormalities. The most appropriate next step is administration of which of the following?
A) Bromocriptine
B) Diazepam
C) Diphenhydramine
D) Fluvoxamine
E) Haloperidol
F) Naloxone
G) Phentolamine
H) Physostigmine
 
Answer: B) Diazepam

Exam Section : Item 7 of 50
A 20-year-old woman is admitted to the hospital because of severe swelling of the lower extremities for 10 days. She has been amenorrheic for 6 months and has had a 23-kg (50-1b) weight loss over the past year. She has been receiving treatment with fluoxetine for major depressive disorder. She is evasive responding to questions about laxatives or diuretics. She states that she believes she is overweight and therefore she works out twice daily at the health club. She appears emaciated. She is 165 cm (5 ft 5 in) tall and weighs 32 kg (70 1b); BMI is 12 kg/m2. Her pulse is 601min, and blood pressure is 100/60 mm Hg. Examination shows 3+ pitting edema of the lower extremities. Which of the following is the most likely explanation for these findings?
A) Adverse effect of fluoxetine
B) Decreased serum albumin concentration
C) Impaired serotonergic function
D) Increased serum corticotropin-releasing hormone concentration
E) Ipecac-induced cardiomyopathy
 
Answer: B) Decreased serum albumin concentration
 
Exam Section : Item 8 of 50
A 42-year-old man is brought to the emergency department by police after they found him hiding under a parked truck. Police say the patient claimed to be hiding from "dementors" who would look him in the eyes and make him an alien through "viral-spatial worms." During the past 5 years, he has been brought to the emergency department eight times for similar behavior. He has no other history of serious illness and takes no medications. He does not use illicit drugs. He lives alone and does not have friends. He appears disheveled. Physical examination shows no abnormalities. On mental status examination, he is fully oriented. He makes poor eye contact and speaks quickly and loudly. He has an anxious affect. His thought process is predominantly linear. During the examination, he opens his eyes only after he counts out loud to 13 and says that doing so helps him to counteract "evil forces." Which of the following is the most likely diagnosis?
A) Bipolar disorder
B) Delusional disorder
C) Obsessive-compulsive disorder
D) Schizoid personality disorder
E) Schizophrenia
  
Answer: E) Schizophrenia
 
Exam Section : Item 9 of 50
An 8-month-old male infant who was adopted recently is brought to the physician because of poor weight gain. He was born at term and weighed 2410 g (5 1b 5 oz). He was formula fed at birth and has consistently been below the 3rd percentile for weight. Currently, his diet consists of 16 ounces of iron-fortified cow milk formula, juice, cereal, prepared fruit, and pureed green vegetables. There is no history of vomiting. He has one formed stool daily. He is alert and appears well. He currently weighs 7002 g (15 1b 7 oz). On examination, he says "mama" and "bye-bye" while waving. He sits unsupported. He is wary of strangers. There are narrow palpebral fissures, epicanthal folds, a thin upper lip with a "fish mouth" appearance of the oral cavity, and an indistinct nasal philtrum. His ears are normally set, the nasal bridge is flattened, and the tongue is not enlarged. There is a single palmar crease on the left hand. Cardiopulmonary examination shows no abnormalities. There is no hepatosplenomegaly, and no masses are palpated. There is no peripheral edema. Which of the following is the most likely diagnosis?
A) Celiac disease
B) Down syndrome
C) Fetal alcohol syndrome
D) Psychosocial deprivation
E) Silver-Russell syndrome
 
Answer: C) Fetal alcohol syndrome
 
Exam Section : Item 10 of 50
A 57-year-old man comes to the physician with his wife because of a I-month history of bizarre behavior at night. His wife says that most nights he falls asleep at approximately 11 pm and begins kicking and groaning in the bed shortly after 12:30 am. Seven times during this period, he has jumped out of the bed and run back and forth across the room, punching the air. She tries to wake him during these episodes because she is afraid that he might hurt her or himself. She reports that when she succeeds, he seems alert but tells her that he was being attacked and needed to defend himself or escape. The patient tells the physician that he does not recall the behavior his wife is describing but remembers having a recurrent dream in which he is in danger and cannot breathe. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, he has a pleasant and full range of affect. His thought process is rational and goal directed. He says that based on his wife's description of his behavior at night, he is afraid that he might hurt her. Results of laboratory studies are within the reference range. Which of the following is the most likely diagnosis?
A) Central sleep apnea
B) Nocturnal panic disorder
C) Nocturnal paroxysmal dystonia
D) REM sleep behavior disorder
E) Restless legs syndrome
F) Sleep-related complex partial seizure disorder
G) Sleep terror disorder
 
Answer: D) REM sleep behavior disorder
 
Exam Section : Item 11 of 50
A 27-year-old woman, gravida 1, para 1, comes to the physician with her husband because of progressive irritability and anxiety since the birth of her child 3 weeks ago. Pregnancy was complicated by premature labor that was managed with bed rest. Delivery occurred at term with no complications. Examination of her newborn at birth showed no abnormalities. The patient reports that he feeds well and appears healthy, but she has constant worries about his health and her own health. She adds that she has had a decreased appetite and difficulty sleeping. Her husband notes that she has been increasingly withdrawn from family and friends and that she has reported thoughts of suicide. The patient has no history of serious illness or major depressive disorder. Her only medication is a multivitamin. She appears tired. Physical examination shows no abnormalities. On mental status examination, she has an irritable mood and depressed affect. She is oriented to person, place, and time.
Which of the following is the most likely diagnosis?
A) Adjustment disorder
B) Bipolar disorder
C) Generalized anxiety disorder
D) Major depressive disorder
E) Post-traumatic stress disorder
 
Answer: D) Major depressive disorder
 
Exam Section : Item 12 of 50
A 42-year-old man comes to the physician because of a 6-month history of sexual problems. He can achieve and maintain erections but is rarely able to ejaculate during intercourse. He has erections on awakening in the morning and nocturnal emissions approximately once monthly. He has a 2-year history of coronary artery disease well controlled with metoprolol, lisinopril, and aspirin. He and his wife of 12 years divorced 3 years ago. Over the past 6 months, he has been sexually active with two female partners, and they use condoms for contraception. Examination shows a normal-appearing penis and testes. Which of the following is the most likely explanation for this patient's sexual dysfunction?
A) Decreased pituitary production of gonadotropins
B) Disruption of arterial inflow to the penis by metoprolol
C) Obstruction at the bladder neck
D) Performance anxiety
E) Testicular insensitivity to testosterone
 
Answer: D) Performance anxiety
 
Exam Section : Item 13 of 50
A 77-year-old man comes to the physician at his wife's insistence because of a 2-year history of progressive memory problems. His wife notes that he often asks questions that have been answered minutes earlier. On three occasions, he got lost while walking a few blocks from their house, and he has forgotten to turn off the burner several times when making coffee. He has been otherwise healthy.
He takes no medications. He is awake and alert. Physical examination shows no abnormalities. On questioning, he states that he has not been aware of any memory problems. His Mini-Mental State Examination score is 21/30. He recalls one of three objects after 2 minutes. An MRI of the brain shows moderate atrophy. Administration of a medication with which of the following properties is the most appropriate treatment?
A) Anticholinergic
B) Antidopaminergic
C) Antiserotonergic
D) Cholinergic
E) Dopaminergic
F) Serotonergic
 
Answer: D) Cholinergic
 
Exam Section : Item 14 of 50
A 32-year-old man is admitted to the hospital because of refusal to speak or move since he returned home after being robbed at gunpoint yesterday. His wife says that her husband was physically unharmed but seemed to be in acute emotional distress. He stopped talking, would not move from his chair, and began staring into space. His wife reports that he has no history of serious illness and takes no medications. The patient is sitting upright with his eyes closed. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, he is mute, does not follow commands, and resists being moved. His affect is flat. Which of the following is the most appropriate pharmacotherapy?
A) Buspirone
B) Dexamphetamine
C) Haloperidol
D) Lorazepam
E) Sertraline
 
Answer: D) Lorazepam
  
Exam Section : Item 15 of 50

A 23-year-old man comes to the physician because of anxiety since beginning a second part-time job as a courier for a photographer 6 weeks ago. He reports a fear of heights and of riding in elevators. He takes stairs and escalators whenever possible, which prevents him from completing his deliveries on time. He has not had panic attacks. He has no history of serious illness and takes no medications. His temperature is 36.80C (98.2 OF), pulse is 80/min, respirations are 18/min, and blood pressure is 118/73 mm Hg. Physical examination shows no abnormalities. On mental status examination, he has an anxious mood and full range of affect. He reports no symptoms of depression or suicidal ideation. Which of the following is the most appropriate next step in management?
A) Cognitive behavioral therapy
B) Interpersonal therapy
C) a-Adrenergic agonist therapy
D) ß-Adrenergic blocker therapy
E) Selective serotonin reuptake inhibitor therapy
 
Answer: A) Cognitive behavioral therapy
 
Exam Section : Item 15 of 50
A 47-year-old man is brought to the physician by his wife because of "unbearable" behavior during the past 2 weeks. His wife reports that he has been talking about his various inventions constantly and recently bought a new recreational vehicle, even though they do not travel long distances. He repeatedly tells his wife that "the time to make and enjoy money has come." He has been openly critical of their pastor's prayers during church services. He claims that the pastor does not know what he is talking about because "God is talking to me, not him." His wife says that he has had episodes of similar behavior during the past 10 years that have been more tolerable. He has peptic ulcer disease treated with ranitidine and hypertension treated with triamterene. He does not smoke or drink alcohol. He is 170 cm (5 ft 7 in) tall and weighs 82 kg (180 1b); BMI is 28 kg/m2. His pulse is 80/min, and blood pressure is 150/95 mm Hg. Physical examination shows no other abnormalities. On mental status examination, he is relaxed and talkative, jumping from one topic to another. He claims that his wife does not understand him and that she has been plotting with the pastor against him. He denies any problems and says that he feels great and is capable of great things. Laboratory findings are within the reference range. Urine toxicology screening is positive for marijuana. Which of the following is the most likely diagnosis?
A) Bipolar disorder
B) Delusional disorder
C) Mood disorder due to a general medical condition
D) Schizophrenia
E) Substance-induced mood disorder
Answer: E) Substance-induced mood disorder
 
Exam Section : Item 16 of 50
An 18-year-old man is brought to the emergency department by friends 1 hour after they found him on the couch at a party unable to move. Earlier that evening, he had been using synthetic heroin. On arrival, his pulse is 85/min, respirations are 181/min, and blood pressure is 130/80 mm Hg. Examination shows stiffness in all extremities, drooling, and slow response to questions. Which of the following brain regions is most likely affected?
A) Cerebellar vermis
B) Globus pallidus
C) Locus ceruleus
D) Mammillary bodies
E) Nucleus accumbens
F) Substantia nigra
 
Answer: F) Substantia nigra
 
Exam Section : Item 18 of 50
A 72-year-old woman comes to the physician because of a 3-month history of fatigue and difficulty sleeping. She has had a 5.4-kg (12-1b) weight loss during this period because of decreased appetite. Her husband died 18 months ago. She has a 15-year history of hypertension treated with verapamil and a 3-month history of insomnia treated with zolpidem. Laboratory studies 1 week ago showed no abnormalities. She is 170 cm (5 ft 7 in) tall and weighs 60 kg (133 1b); BMI is 21 kg/m2. Her pulse is 74/min, and blood pressure is 131/84 mm Hg. Physical examination shows no abnormalities. Mental status examination shows an irritable and tearful mood. She expresses hopelessness about the future. Which of the following is the most likely finding in this patient?
A) Decreased hemoglobin concentration
B) Decreased serum vitamin Bl (thiamine) concentration
C) Increased percentage of bands on complete blood count
D) Increased serum cortisol concentration
E) Increased serum prolactin concentration
 
Answer: D) Increased serum cortisol concentration
 
Exam Section• Item 19 of 50
A 24-year-old man is brought to the emergency department from jail by police because he has had numbness in his right hand from the wrist extending to the fingers for 4 hours. He has been in jail for 10 days awaiting trial for automobile theft. He has an extensive history of juvenile offenses and was released from state prison 6 months ago. Examination shows equal pulses in all extremities; he can move all extremities. Deep tendon reflexes are normal. He has numbness from the wrist to the tips of the digits of the right hand. His skin is warm to the touch, and he has multiple tattoos. The distal phalanx of the ring finger of the right hand is absent with a well-healed scar. Which of the following is the most appropriate next step in management?
A) Brachial nerve conduction studies
B) CT scan of the head
C) Ultrasound venography
D) Lumbar puncture
E) No treatment is indicated
 
Answer: E) No treatment is indicated

Exam Section : Item 20 of 50
A 62-year-old woman is brought to the emergency department by her husband because of confusion for 4 hours. Her husband says that she has been exhibiting strange behavior for 3 days; she forgets pots on the stove or does not know what day it is. This morning she was completely disoriented and thought that her husband was a burglar. She has been taking fluoxetine (20 mg daily) for 2 weeks for treatment of major depressive disorder. Current medications also include propranolol (40 mg three times daily) for hypertension and doxepin (50 mg at bedtime) for insomnia. She appears to be having visual hallucinations and is unable to give any useful information. Her pulse is 110/min, respirations are 14/min, and blood pressure is 140/95 mm Hg. Examination shows dilated pupils, dry flushed skin,and a mild tremor. She is disoriented to person, place, and time. An ECG shows first-degree atrioventricular block and a widened QRS complex. Urine toxicology screening is negative. Which of the following is the most appropriate next step in management?
A) Measurement of serum doxepin and desmethyldoxepin concentrations
B) Measurement of serum fluoxetine and norfluoxetine concentrations
C) Begin lorazepam (2 mg every 8 hours)
D) Discontinue doxepin
E) Insert temporary pacemaker
 
Answer: D) Discontinue doxepin
 
Exam Section : Item 21 of 50
A 19-year-old man has had restless sleep and feelings of sadness for 1 week; he has had a 0.9-kg (2-1b) weight loss during this period. He also has had tension headaches, difficulty concentrating, and difficulty completing his assignments for college. His first relationship ended 2 weeks ago. He states, "My life is over. My girlfriend meant everything to me." He has no history of similar symptoms. He does not intend to harm himself. Which of the following is the most likely diagnosis?
A) Acute stress disorder
B) Adjustment disorder with depressed mood
C) Generalized anxiety disorder
D) Major depressive disorder
E) Uncomplicated grief reaction

Answer: B) Adjustment disorder with depressed mood

Exam Section : Item 22 of 50
A 25-year-old man comes to the physician with his wife because of bizarre behavior for the past 3 months. She reports that he will only travel to work by taking certain routes and is overly concerned about air quality, routinely inspecting for dust on the furniture and closing the windows when he returns from work. He has organized his office and his home in a particular way and becomes extremely upset when anything is rearranged. He realizes that his demands are unreasonable but says that "l would be very nervous and tense if it were arranged any other way." He has had no changes in sleep pattern.
Physical examination shows no abnormalities. On mental status examination, he reports feeling mildly anxious and depressed "all the time." Results of laboratory studies are within reference ranges. Which of the following is the most appropriate pharmacotherapy?
A) Bupropion
B) Buspirone
C) Clonazepam
D) Haloperidol
E) Sertraline

Answer: E) Sertraline

Exam Section : Item 23 of 50
A 47-year-old woman is brought to the emergency department by her husband because of increasing confusion during the past 2 days. On arrival, she has a generalized tonic-clonic seizure lasting 4 minutes. She has bipolar disorder treated with several medications, but her husband is unsure of their names. He knows that she sometimes takes ibuprofen for mild arthritis pain caused by exercise. He says that she has been active and exercising more lately, but he cannot think of other changes in her routine. She has no history of seizure disorder. She is oriented to person but not to place and time. Her pulse is 90/min, and blood pressure is 140/90 mm Hg. On physical examination, she is tremulous and somnolent. There is bilateral nystagmus. An ECG shows a second-degree atrioventricular block. The most likely cause of this patient's symptoms is an adverse effect of which of the following medications?
A) Bupropion
B) Haloperidol
C) Lithium
D) Risperidone
E) Valproic acid

Answer: C) Lithium

Exam Section : Item 24 of 50
A 2-year-old girl who was adopted is brought to the physician because of developmental delay; she does not walk independently and is not yet talking. She was born at term to a 41-year-old woman, gravida 2, para 1, aborta 1. No information is available about pregnancy and delivery. The patient is at the 40th percentile for length and 80th percentile for weight. Examination shows epicanthal folds, a prominent tongue, small low-set ears, and short extremities. Developmental testing shows a developmental quotient of 60. Which of the following is the most likely cause of this patient's condition?
A) Defect in N-acetylglutamate synthetase
B) Fetal exposure to alcohol
C) 45,X karyotype
D) Phenylalanine hydroxylase deficiency
E) Trisomy of an autosomal chromosome

Answer: E) Trisomy of an autosomal chromosome
 
Exam Section : Item 24 of 50
A 47-year-old woman comes to the physician 2 hours after the onset of heart palpitations. She had a myocardial infarction 6 years ago and is suddenly afraid that she might be having another heart attack. She does not have chest pain. She says that 2 hours ago, she was feeling "extremely good and enjoying how things seemed to be moving slowly around me." An exercise stress test 2 months ago showed no abnormalities. She has been taking alprazolam up to three times daily for 3 years for anxiety and took her last dose 3 hours ago. Her father died of a myocardial infarction at the age of 46 years. She had not used an illicit substance for 20 years, but 2 months ago, she was promoted to a managerial position and began smoking marijuana daily to relax. Her temperature is 37.50C (99.50F), pulse is 120/min, respirations are 20/min, and blood pressure is 150/95 mm Hg. Physical examination shows dry oral mucosa and injected conjunctivae. Neurologic examination shows difficulty with finger-nose testing. On mental status examination, she has an anxious affect, and she repeatedly asks for something to be done. Her speech is staccato and rushed but clear and rational. An ECG shows sinus tachycardia. Which of the following is the most likely cause of this patient's current symptoms?
A) Acute myocardial infarction
B) Anxiolytic intoxication
C) Anxiolytic withdrawal
D) Generalized anxiety disorder
E) Histrionic personality disorder
F) Hypochondriasis
G) Major depressive disorder
H) Marijuana intoxication
l) Panic disorder

Answer: H) Marijuana intoxication
 
Exam Section : Item 26 of 50
A 52-year-old woman comes to the physician for a routine follow-up examination. She has received inpatient psychiatric treatment several times since the age of 25 years for auditory hallucinations and the belief that her thoughts and movements were being controlled by a local television station; her last admission to the hospital was 10 years ago. Treatment with haloperidol for the past 20 years has decreased the occurrence of symptoms. She attempted suicide at the ages of 30 and 38 years. She lives in a supervised residence and does not work. During the examination, she repeatedly smacks her lips and slightly protrudes her tongue. When the physician asks if she is chewing gum, she laughs and opens her mouth to show she is not. She can hold her mouth and tongue still when asked but begins lip smacking when the physician resumes the examination. Which of the following is the most appropriate next step in pharmacotherapy?
A) Continue haloperidol and add alprazolam
B) Continue haloperidol and add propranolol
C) Discontinue haloperidol
D) Discontinue haloperidol and begin chlorpromazine
E) Discontinue haloperidol and begin risperidone

Answer:  E) Discontinue haloperidol and begin risperidone
 
Exam Section : Item 27 of 50
A 7-year-old girl is brought to the physician because her parents are concerned about her recent preoccupation with death. Her dog died 2 months ago, and since that time she has repeatedly asked her parents if they are going to die. When her mother travels, the daughter worries that the plane will crash. She has begun to talk with her friends about the possibility of their parents dying. She continues to excel academically and participate in sports. Her pulse is 86/min, and blood pressure is 110/70 mm Hg. Physical examination shows no abnormalities. Mental status examination shows a neutral mood and an appropriately reactive affect. Which of the following is the most likely explanation for these findings?
A) Bereavement
B) Obsessive-compulsive disorder
C) Post-traumatic stress disorder
D) Separation anxiety disorder
E) Age-appropriate behavior

Answer: E) Age-appropriate behavior
  
Exam Section : Item 28 of 50
A 14-year-old boy is brought to the physician for a well-child examination. His mother says her son is self-centered and shows decreasing interest in his family. He showers twice daily but will not keep his room neat. He frequently shifts from being pleasant and cooperative to being very disagreeable. He has not begun dating. Pubic hair development began at the age of 12 years. Examination shows no facial hair and minimal axillary hair. Pubic hair and genital development are Tanner stage 3. Which of the following is the most accurate assessment of this patient's development?
I)    Normal Normal

Exam Section : Item 29 of 50
A 52-year-old man with schizophrenia comes to the physician for a follow-up examination. At his last examination 1 week ago, the physician noticed that the patient's tongue occasionally protruded. When asked, the patient was unaware of this movement, but he was able to voluntarily prevent it. At that time, physical examination showed normal muscle strength. He had been taking risperidone for 5 years; treatment was discontinued to stop his tongue movements. Today, examination shows worsening tongue movements and writhing choreoathetoid movements of the upper extremities. Which of the following is the most likely underlying cause of this patient's symptoms?
A) Atrophy of the caudate nucleus
B) Increased acetylcholine
C) Increased sensitivity of the dopamine receptors
D) Loss of volume in the basal ganglia
E) Vascular changes in the small vessels
 
Answer: C) Increased sensitivity of the dopamine receptors

Exam Section : Item 30 of 50
A 42-year-old man comes to the physician for advice concerning his fear of flying. One year ago, he was on an airplane that had to abort a takeoff. He was so anxious that he was unable to get back on the plane once the problem was resolved and has been unable to fly since that time. His job requires him to travel, and he is concerned that his fear of flying might jeopardize an anticipated promotion.
Twenty years ago, he had a panic attack while giving an oral presentation in a college class. He has mitral valve prolapse. He drinks three cups of coffee daily. His pulse is 90/min, and blood pressure is 110/70 mm Hg. Cardiac examination shows a late systolic click followed by a grade 2/6 late systolic murmur. Mental status examination shows a neutral mood and intense affect. Which of the following is the most likely diagnosis?
A) Anxiety disorder due to a general medical condition
B) Generalized anxiety disorder
C) Panic disorder with agoraphobia
D) Specific phobia
E) Substance-induced anxiety disorder

Answer: D) Specific phobia

Exam Section : Item 31 of 50
A 26-year-old man comes to the physician because of increasing daytime sleepiness over the past 3 years. He has begun to unexpectedly fall asleep at work and is concerned that he will lose his job if he does not change his behavior. He has stopped driving because of fear that he will fall asleep at the wheel. He generally sleeps well at night. He states that he avoids exercise and caffeine ingestion in the evening and does not read or watch television in bed. His wife states that he does not snore or have restless leg movements while sleeping. He has vivid dream-like images just before falling asleep and on awakening. He describes his mood as generally good despite his worry about his job security. Polysomnography is most likely to show which of the following?
A) Decreased REM density
B) Decreased REM latency
C) Decreased stage 1 sleep
D) Increased sleep efficiency
E) Increased sleep latency

Answer: B) Decreased REM latency

Exam Section : Item 32 of 50
A) Bupropion
B) Buspirone
C) Chlorpromazine
D) Fluoxetine
E) Haloperidol
F) Imipramine
G) Lorazepam
H) perphenazine
l) Propranolol
A 27-year-old man comes to the physician because of anxiety about a major speech that he must deliver in 3 days. He is excited about the opportunity for his career but is concerned that his apprehension and great fear of public speaking will affect his performance. He requests a tranquilizer to help with his anxiety. He has no history of medical problems. He has a family history of alcohol dependence. He does not drink alcohol or use drugs. His pulse is 76/min, respirations are 12/min, and blood pressure is 130/82 mm Hg. Examination shows normal findings.

Answer: l) Propranolol
 
Exam Section : Item 33 of 50
A) Bupropion
B) Buspirone
C) Chlorpromazine
D) Fluoxetine
E) Haloperidol
F) Imipramine
G) Lorazepam
H) perphenazine
l) Propranolol
A 27-year-old man comes to the physician because of anxiety about a major speech that he must deliver in 3 days. He has a great fear of public speaking and is convinced that his apprehension and tremulous delivery will damage his performance. He requests a tranquilizer to help with his anxiety. He takes theophylline and uses corticosteroid and albuterol inhalers for asthma. He has a family history of alcohol dependence. He does not drink alcohol or use drugs. His pulse is 66/min, respirations are 12/min, and blood pressure is 132/80 mm Hg. Examination shows normal findings.

Answer: G) Lorazepam
 
Exam Section : Item 34 of 50
Over the past 7 years, a 25-year-old graduate student has had increasingly severe palpitations, tremulousness, nausea, sweating, and inability to concentrate while taking examinations. He is worried because he recently failed an examination despite being thoroughly prepared. Examination shows normal findings. Which of the following is the most appropriate next step in diagnosis?
A) Ambulatory ECG monitoring
B) 24-Hour urine collection for 5-hydroxyindoleacetic acid
C) 24-Hour urine collection for measurement of catecholamine and metanephrine concentrations
D) Measurement of serum thyroxine (T 4) and thyroid-stimulating hormone concentrations
E) Psychiatric evaluation

Answer: E) Psychiatric evaluation
 
Exam Section : Item 35 of 50
A 32-year-old financial analyst comes to the physician at her employer's request because of bizarre behavior and poor work productivity over the past 6 months. She has been arriving late, leaving early,and frequently taking long breaks. She has had daily mood swings; sometimes she appears withdrawn, lethargic, and belligerent and other times she appears energetic and loquacious. Over the past 2 weeks, she has had several arguments with coworkers in which she accused them of stealing or sabotaging her work. This morning, she threatened to physically assault her supervisor after he questioned her about a 2-hour absence from work. Her temperature is 37oc (98.60F), pulse is 90/min, respirations are 16/min, and blood pressure is 160/100 mm Hg. The pupils are dilated and reactive to light. Deep tendon reflexes are increased. On mental status examination, she is angry but cooperative. She describes her supervisor's unfairness and the unfriendliness of other analysts; she suspects that they are jealous of her. She speaks in a loud, rapid voice, frequently interrupting the physician. She is oriented to person, place, and time. She is able to recall three of three objects after 5 minutes and quickly and accurately performs 2-digit calculations. Which of the following is the most likely diagnosis?
A) Alcohol withdrawal
B) Bipolar disorder
C) Cocaine abuse
D) Delusional disorder, persecutory type
E) Inhalant abuse
F) Paranoid personality disorder
G) PCP abuse
H) Schizophrenia, paranoid type

Answer: C) Cocaine abuse
 
Exam Section : Item 36 of 50
A 47-year-old man comes to the physician because of a 2-day history of intense anxiety. He has been receiving chemotherapy for hepatoma for 5 days. His nausea is well controlled with prochlorperazine. He has no history of similar symptoms or psychiatric illness. His pulse is 104/min, and blood pressure is 142/86 mm Hg. Mental status examination shows an anxious affect. He paces, wrings his hands, and says, "l feel as though I am going to jump out of my skin!" Which of the following is the most likely cause of this patient's symptoms?
A) Acute stress disorder
B) Adjustment disorder with anxiety
C) Adverse effect of prochlorperazine
D) Anxiety disorder due to hepatoma
E) Generalized anxiety disorder
F) Panic disorder

Answer: B) Adjustment disorder with anxiety
 
Exam Section : Item 37 of 50
A 52-year-old homeless man with alcoholism is brought to the emergency department by police after being found agitated and confused. He says he feels nervous and could use a drink. His temperature is 37oc (98.60F), pulse is 120/min, respirations are 20/min, and blood pressure is 138/86 mm Hg. He is trembling. His hematocrit is 30%. Urinalysis shows 7 WBC/hpf and many oxalate crystals. Which of the following is the most likely cause of this patient's symptoms?
A) Ethylene glycol toxicity
B) Lactic acidosis
C) Methanol toxicity
D) Paraldehyde toxicity
E) Sepsis

Answer: A) Ethylene glycol toxicity

Exam Section : Item 37 of 50
A 32-year-old woman comes to the physician because of depressed mood for 2 weeks; she went on a drinking binge over the weekend and has been binge eating for 2 days but has not purged. She has a history of bulimia nervosa. She has been sexually active with multiple partners over the past month; she uses an oral contraceptive, and her partners use condoms. She takes paroxetine for dysthymic disorder. Abdominal examination shows mild tenderness in the right upper quadrant. She has poor eye contact and appears close to tears. She describes many new stressors in her life and has thought about taking a full bottle of aspirin. Which of the following is the most appropriate question to ask this patient?
A) "Do you exercise regularly to relieve stress?"
B) "How do you feel about attending an alcohol treatment program?"
C) "How would you feel about entering the hospital?"
D) "Is there someone I could call to get some support for you?"
E) "What would you like me to do?"

Answer: C) "How would you feel about entering the hospital?"

Exam Section : Item 39 of 50
A 46-year-old man is brought to the emergency department following a self-inflicted gunshot wound to the right upper hemithorax. On the third postoperative day, he states that his wife is divorcing him after 28 years of marriage because of his chronic alcoholism. He is anxious and frightened and is unable to sleep. His temperature is 37.70C (99.80F), pulse is 1 1 0/min, respirations are 20/min, and blood pressure is 140/90 mm Hg. Which of the following is the most appropriate initial pharmacotherapy?
A) Carbamazepine
B) Haloperidol
C) Lorazepam
D) Propranolol
E) Secobarbital

Answer: C) Lorazepam
 
Exam Section : Item 40 of 50
An unconscious 7-year-old boy is brought to the emergency department by his parents. The family emigrated from rural Southeast Asia 4 years ago. An interpreter is used because the parents do not speak English. They say, "Our child has been possessed by a spirit since birth who speaks through his mouth with spit and blood and then takes his powers away." He has had these spells all of his life. He does not attend school. They recently sacrificed a piglet as an offering to the spirit, but there has been no change in the child's condition. The parents seem devoted. He awakens during the physical examination and smiles vacantly at his parents. He appears confused and speaks in monosyllables. No other abnormalities are noted. Which of the following is the most appropriate next step in diagnosis?
A) Contact child protective services
B) Psychoeducational assessment
C) Family therapy
D) Throat culture
E) X-ray of the chest
F) ECG
G) EEG
 
Answer: G) EEG
 
Exam Section : Item 41 of 50
A 23-year-old man is brought to the emergency department because of progressive paranoia and agitation for 48 hours. His roommate reports that the patient has not been sleeping or eating during this period but had been staying up all night studying for examinations for the past 4 days. He adds that last night the patient crouched below their apartment window peering out and insisting that every passing car was occupied by FBI agents. The patient has no history of psychosis. He states that he has been under stress from his new position as a software engineer. Physical examination shows 4-mm pupils, dry mouth, and mild tremulousness. On mental status examination, he is agitated, and his speech is rapid with increased volume. There is evidence of paranoid delusions about persecution by the police.
Which of the following is the most likely diagnosis?
A) Bipolar disorder
B) Delusional disorder
C) Generalized anxiety disorder
D) Schizophrenia
E) Substance-induced psychotic disorder

Answer: E) Substance-induced psychotic disorder

Exam Section : Item 42 of 50
An 8-year-old girl is brought to the physician by her mother because of frequent stomachaches over the past 3 months. She has a I-year history of difficulty falling asleep and poor concentration. She has always been a good student and excels in extracurricular activities. Her parents divorced 6 months ago. Physical examination shows no abnormalities. Mental status examination shows an anxious affect and coherent thought process. She says that she is worried about her classes and about her performance in the school band and on the soccer team. Which of the following is the most likely diagnosis?

A) Generalized anxiety disorder
B) Obsessive-compulsive disorder
C) Panic disorder
D) Post-traumatic stress disorder
E) Separation anxiety disorder

Answer: A) Generalized anxiety disorder
 
Exam Section : Item 43 of 50

A 37-year-old woman comes to the physician with her husband because of a I-year history of fatigue, intermittently blurred vision, and numbness of her legs that is exacerbated by walking long distances. Her husband adds that she has begun to have difficulty remembering where she put things around the house and says that when he points out her memory problem to her, she does not seem to care. She states that she does the best she can but does not have the energy to devote to his concerns. Cardiopulmonary examination shows no abnormalities. Sensation to pinprick is decreased over the lower extremities. Muscle strength in the upper and lower extremities is 3/5. On mental status examination, her mood and affect are incongruously bright. She is oriented to person, place, and time. She recalls two of three objects after 5 minutes. Which of the following abnormalities is most likely to be present in this patient on imaging studies?
A) Arteriovenous malformation
B) Edema of the right cerebral hemisphere
C) Enlarged cortical sulci
D) Focal white matter lesions
E) Left cerebellar atrophy

Answer: B) Edema of the right cerebral hemisphere
 
Exam Section : Item 44 of 50

Over the past 6 months, a 24-year-old woman has had 12 episodes of sudden apprehension associated with a sense of doom, hypervigilance, and tingling and numbness in her extremities. During these episodes, she feels dizzy and has a dry mouth and palpitations. She has been seen in the emergency department several times, and an ECG has shown no abnormalities. In between episodes, she has a minimal amount of anxiety. She is unwilling to take medications. Which of the following is the most appropriate next step in management?
A) Group therapy
B) Cognitive behavior therapy
C) Hypnotherapy
D) Interpersonal therapy
E) Psychodynamic therapy

Answer: B) Cognitive behavior therapy

Exam Section : Item 45 of 50

A 27-year-old woman comes to the physician for an examination prior to starting a new job. She has a 10-year history of binge-eating and self-induced vomiting. She takes no medications. She does not drink alcohol or use illicit drugs. She is 178 cm (5 ft 10 in) tall and weighs 72 kg (160 1b); BMI is 23 kg/m2. Her temperature is 37 oc (98.60F), pulse is 70/min, respirations are 10/min, and blood pressure is 120/70 mm Hg. Physical examination shows yellow dental enamel and abdominal striae. Serum studies are most likely to show which of the following abnormalities?
A) Decreased bicarbonate concentration
B) Increased amylase activity
C) Increased magnesium concentration
D) Increased potassium concentration
E) Increased sodium concentration

Answer: B) Increased amylase activity

Exam Section : Item 46 of 50

A 30-year-old woman has had frontal headaches, stomach upset, and poor appetite for 4 weeks; she has had a 2-kg (5-1b) weight loss during this period. She has pain in the left upper quadrant of the abdomen 1 to 3 hours after eating dinner. Over-the-counter antacids have been ineffective. She blames herself for not taking better care of her body. The headaches occur at night and awaken her. She feels fatigued in the morning and has difficulty getting up and going to work. Over the past month, her supervisor has complained about her recent errors, which she attributes to difficulty concentrating. She says that she is so tired when she comes home that she has stopped going out with her friends and just goes to sleep. Which of the following is the most likely diagnosis?
A) Adjustment disorder with depressed mood
B) Borderline personality disorder
C) Dysthymic disorder
D) Major depressive disorder
E) Somatization disorder
F) Ulcerative colitis

Answer: D) Major depressive disorder

Exam Section : Item 47 of 50

A 16-year-old girl is brought to the physician by her father because of unusual behavior since returning from a party early this morning. Her father reports that when she arrived home, she barricaded herself in her room and refused to respond to his pleas to open the door. When he entered the room 1 hour later, he found her huddled in a corner in the dark, saying that the police wanted to kill her. She has no history of medical or psychiatric illness. Her pulse is 115/min, and blood pressure is 150/90 mm Hg. The pupils are 2 mm, equal, and reactive to light and accommodation. The conjunctivae are injected. On mental status examination, she appears apprehensive but is cooperative. Her speech is slow with a prolonged response latency. She believes that she is being followed by plainclothes police officers who want to assassinate her. She hears a male voice making threatening comments. She is oriented to person and place but not to time. She can perform double-digit money calculations but not serial sevens. Which of the following is the most likely cause of this patient's symptoms?
A) Alcohol intoxication
B) Alcohol withdrawal
C) Cocaine withdrawal
D) Delusional disorder, persecutory type
E) Marijuana intoxication
F) Marijuana withdrawal
G) Panic disorder
H) Paranoid personality disorder
l) Schizophrenia, paranoid type

Answer: E) Marijuana intoxication

Exam Section : Item 48 of 50

A 37-year-old man is brought to the emergency department by the police after they found him sitting in an alley unaware of his surroundings or situation. On arrival, he cannot remember his name, date of birth, or age. Vital signs are within normal limits. Examination shows numerous ecchymoses over the face and extremities. Right lateral gaze is severely restricted. On left lateral gaze, there is bilateral nystagmus. There is mild gynecomastia and palmar erythema. Abdominal examination shows right upper quadrant tenderness. The liver edge is palpated 4 cm below the right costal margin. Muscle strength is normal, but he is unable to stand or walk. Deep tendon reflexes are absent. The most likely cause of these findings is a deficiency of which of the following?
A) Folic acid
B) Niacin
C) Vitamin Bl (thiamine)
D) Vitamin
E) Vitamin (cobalamin)

Answer: C) Vitamin Bl (thiamine)

Exam Section : Item 49 of 50

A 74-year-old widower comes to the physician because of gradually increasing insomnia over the past 2 years. He goes to bed at 11:30 pm and awakens at 5:00 am. He sleeps soundly except for awakening to go to the bathroom once during the night. He is concerned because he used to sleep 8 hours daily. He is active and prepares his own meals. Medications include ranitidine at bedtime for gastroesophageal reflux disease and verapamil for hypertension. His pulse today is 881min, and blood pressure is 160/88 mm Hg. He appears mildly anxious. Examination shows no other abnormalities.
Which of the following is the most appropriate next step in management?
A) Reassure the patient that his sleep pattern is normal for his age
B) Recommend staying up later to avoid getting up so early
C) Recommend warm milk before bedtime
D) Recommend an over-the-counter drug containing diphenhydramine at bedtime
E) Prescribe temazepam at bedtime, as needed

Answer: A) Reassure the patient that his sleep pattern is normal for his age

Exam Section : Item 50 of 50

A 32-year-old Bosnian man is brought to the emergency department by police 30 minutes after they found him sitting in a cemetery and muttering to himself. The police officers report that the patient appeared lost in thought and did not respond to their questions; he then passively accompanied them to the hospital. Identification in the patient's wallet indicates that he is a construction worker. The physician calls the patient's employer and learns that he was part of a crew working on a bridge that morning when a crane collapsed, causing multiple injuries to people working in trailers on the ground. A hospital interpreter says that the patient had been an ambulance driver in a military war zone 10 years ago. The patient sits quietly and stares ahead; he appears unaffected by the bustling activity in the emergency department. His pulse is 721min, and respirations are 14/min. Physical examination shows no abnormalities. Mental status examination shows a reserved demeanor. He speaks in monotone and responds to questions with vague, noncommittal answers. He says he is not depressed or anxious. Which of the following is the most likely diagnosis?
A) Adjustment disorder
B) Catatonia
C) Dissociative disorder
D) Generalized anxiety disorder
E) Schizotypal personality disorder

Answer: C) Dissociative disorder

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Form 4 nbme psych

Psychiatry NBME Form 4 Questions And Answers

Psychiatry NBME Form 4 Questions And Answers
Psychiatry NBME Form 4 Questions and Answers pejo Psychiatry NBME Form 4 Questions and Answers 2018-03-30 7308

Exam Section : Item 1 of 50
An 82-year-old man is brought to the physician by his daughter because he has been forgetful during the past 6 weeks. She is particularly concerned because a small fire started recently when he left a pot unattended on the stove. The patient’s wife died 1 year ago, and he says he has been distracted recently and cannot stop thinking about her. He lives alone and pays his bills, does routine household chores, and drives short distances for errands. His daughter says he was doing well on his own until recently. He is 168 cm (5 ft 6 in) tall and weighs 63 kg (140 1b); BMI is 23 kg/m2. His temperature is 370C (98.60F), pulse is 78/min and regular, respirations are 18/min, and blood pressure is 130/80 mm Hg. Physical examination shows no abnormalities. On mental status examination, he is alert and cooperative.
He becomes very sad when he talks about his wife’s death. Which of the following is the most appropriate next step in management?

  • A) Follow-up examination in 3 months
  • B) Mini-Mental State Examination
  • C) Recommend assisted living
  • D) CT scan of the head
  • E) Begin donepezil therapy

Answer: (B) Mini-Mental state examination

Exam Section : Item 2 of 50
A 37-year-old man is brought to the emergency department after the pilot of a boat found him in the river at 2 am with rocks in his pockets. He reports that he jumped from the bridge to go for a swim and was not attempting suicide. He insists that the rocks were only to give him ballast when he jumped so that he would not hit the bridge tower. He immigrated to the USA 1 year ago and left most of his family behind. He has been living in a single furnished room and has been working numerous low-paying jobs. Over the past month, he has had a 4.5-kg (10-1b) weight loss. He reports that he always feels tired but has not seen a physician because he has no health insurance. He does not usually drink but had two shots of whiskey earlier that night. He has no history of medical or psychiatric illness. Physical examination shows numerous lacerations and abrasions over the chest and all extremities. On mental status examination, he describes his mood as fine but often appears tearful. His speech is slow with frequent pauses, and he is guarded in his responses. He says that he has not had hallucinations. He is alert and oriented to person, place, and time. The physician recommends voluntary admission to the psychiatric unit, but the patient refuses, saying there is nothing wrong with him. Which of the following is the most appropriate next step in management?

  • A) Recommend a mental health facility in his neighborhood
  • B) Recommend a social service agency
  • C) Observe in the emergency department for 36 hours
  • D) Begin fluoxetine therapy
  • E) Begin risperidone therapy
  • F) Admit to the psychiatric unit involuntarily

Answer: F) Admit to the psychiatric unit involuntarily

Exam Section : Item 3 of 50
Five weeks after being discharged from the hospital after treatment for a psychotic episode, a 27-year-old man comes to the physician for a follow-up examination. During hospitalization, he claimed that he was instructed by the Lord to found a new religion and that a famous gospel singer was in love with him. Today, he says that he still hears the voices of the Lord and members of the church he attends in his apartment and when he shops in the supermarket. He no longer believes the world needs a new religion because the Lord is no longer instructing him to create one. He states, “My father in heaven tells me that he is at peace, and therefore, so am l.” Current medications include risperidone and lorazepam. He drinks one to two beers on weekends. He used marijuana regularly in college but has abstained for the past 5 years. He appears clean and is casually dressed. His temperature is 36.7 oc (980F), pulse is 72/min, respirations are 20/min, and blood pressure is 130/72 mm Hg. Physical examination shows no abnormalities. Mental status examination shows a calm affect. He is cooperative, alert, and oriented to person, place, and time. Based on this information, which of the following is the most likely current diagnosis for this patient?

  • A) Bipolar disorder
  • B) Cyclothymic disorder
  • C) Delusional disorder
  • D) Schizoaffective disorder
  • E) Substance-induced mood disorder

Answer: C) Delusional disorder

Exam Section : Item 4 of 50
The response options for the next 2 items are the same. Select one answer for each item in the set.
For each patient with depressed mood, select the most likely diagnosis.

  • A) Adjustment disorder with depressed mood
  • B) Bereavement
  • C) Bipolar disorder, depressed
  • D) Cyclothymic disorder
  • E) Dysthymic disorder
  • F) Major depressive disorder
  • G) Mood disorder due to a general medical condition
  • H) Substance-induced mood disorder

A previously healthy 37-year-old man comes to the physician because of a 6-month history of depressed mood, fatigue, poor concentration, and difficulty sleeping. He works as an accountant and has had difficulty staying awake at work, particularly in the afternoon. He says that his wife sleeps in a separate room because of his loud snoring. He drinks alcohol at social functions only. He is 175 cm (5 ft 9 in) tall and weighs 109 kg (240 1b); BMI is 35 kg/m2. Physical examination shows no other abnormalities. Mental status examination shows a mildly depressed mood.

Answer: G) Mood disorder due to a general medical condition

Exam Section: Item 5 of 50

  • A) Adjustment disorder with depressed mood
  • B) Bereavement
  • C) Bipolar disorder, depressed
  • D) Cyclothymic disorder
  • E) Dysthymic disorder
  • F) Major depressive disorder
  • G) Mood disorder due to a general medical condition
  • H) Substance-induced mood disorder

A 23-year-old graduate student comes to the physician because of depressed mood and feelings of hopelessness since breaking up with her boyfriend 1 week ago. During this period, she has rarely left her apartment, has only eaten a small amount of food, and has isolated herself from her friends and family. She has been drinking more alcohol than normal during this period. Physical examination shows no abnormalities. On mental status examination, she becomes tearful when she describes the breakup. When asked about her mood, she says, “I’m miserable. He was my life!” There is no evidence of suicidal ideation.

Answer: A) Adjustment disorder with depressed mood

Exam Section : Item 6 of 50
A 37-year-old woman is brought to the emergency department 30 minutes after the onset of a severe occipital headache, palpitations, and tremulousness. Shortly before this episode, she ate several slices of pepperoni pizza. She has a 2-month history of atypical major depressive disorder treated with phenelzine. She is otherwise healthy. She appears anxious and tremulous. Her temperature is 37.80C (IOOF), pulse is 94/min, respirations are 20/min, and blood pressure is 210/110 mm Hg. Physical examination shows no other abnormalities. The most appropriate next step is administration of which of the following?

  • A) Bromocriptine
  • B) Diazepam
  • C) Diphenhydramine
  • D) Fluvoxamine
  • E) Haloperidol
  • F) Naloxone
  • G) Phentolamine
  • H) Physostigmine

Answer: B) Diazepam

Exam Section : Item 7 of 50
A 20-year-old woman is admitted to the hospital because of severe swelling of the lower extremities for 10 days. She has been amenorrheic for 6 months and has had a 23-kg (50-1b) weight loss over the past year. She has been receiving treatment with fluoxetine for major depressive disorder. She is evasive responding to questions about laxatives or diuretics. She states that she believes she is overweight and therefore she works out twice daily at the health club. She appears emaciated. She is 165 cm (5 ft 5 in) tall and weighs 32 kg (70 1b); BMI is 12 kg/m2. Her pulse is 601min, and blood pressure is 100/60 mm Hg. Examination shows 3+ pitting edema of the lower extremities. Which of the following is the most likely explanation for these findings?

  • A) Adverse effect of fluoxetine
  • B) Decreased serum albumin concentration
  • C) Impaired serotonergic function
  • D) Increased serum corticotropin-releasing hormone concentration
  • E) Ipecac-induced cardiomyopathy

Answer: B) Decreased serum albumin concentration

Exam Section : Item 8 of 50
A 42-year-old man is brought to the emergency department by police after they found him hiding under a parked truck. Police say the patient claimed to be hiding from “dementors” who would look him in the eyes and make him an alien through “viral-spatial worms.” During the past 5 years, he has been brought to the emergency department eight times for similar behavior. He has no other history of serious illness and takes no medications. He does not use illicit drugs. He lives alone and does not have friends. He appears disheveled. Physical examination shows no abnormalities. On mental status examination, he is fully oriented. He makes poor eye contact and speaks quickly and loudly. He has an anxious affect. His thought process is predominantly linear. During the examination, he opens his eyes only after he counts out loud to 13 and says that doing so helps him to counteract “evil forces.” Which of the following is the most likely diagnosis?

  • A) Bipolar disorder
  • B) Delusional disorder
  • C) Obsessive-compulsive disorder
  • D) Schizoid personality disorder
  • E) Schizophrenia

Answer: E) Schizophrenia

Exam Section : Item 9 of 50
An 8-month-old male infant who was adopted recently is brought to the physician because of poor weight gain. He was born at term and weighed 2410 g (5 1b 5 oz). He was formula fed at birth and has consistently been below the 3rd percentile for weight. Currently, his diet consists of 16 ounces of iron-fortified cow milk formula, juice, cereal, prepared fruit, and pureed green vegetables. There is no history of vomiting. He has one formed stool daily. He is alert and appears well. He currently weighs 7002 g (15 1b 7 oz). On examination, he says “mama” and “bye-bye” while waving. He sits unsupported. He is wary of strangers. There are narrow palpebral fissures, epicanthal folds, a thin upper lip with a “fish mouth” appearance of the oral cavity, and an indistinct nasal philtrum. His ears are normally set, the nasal bridge is flattened, and the tongue is not enlarged. There is a single palmar crease on the left hand. Cardiopulmonary examination shows no abnormalities. There is no hepatosplenomegaly, and no masses are palpated. There is no peripheral edema. Which of the following is the most likely diagnosis?

  • A) Celiac disease
  • B) Down syndrome
  • C) Fetal alcohol syndrome
  • D) Psychosocial deprivation
  • E) Silver-Russell syndrome

Answer: C) Fetal alcohol syndrome

Exam Section : Item 10 of 50
A 57-year-old man comes to the physician with his wife because of a I-month history of bizarre behavior at night. His wife says that most nights he falls asleep at approximately 11 pm and begins kicking and groaning in the bed shortly after 12:30 am. Seven times during this period, he has jumped out of the bed and run back and forth across the room, punching the air. She tries to wake him during these episodes because she is afraid that he might hurt her or himself. She reports that when she succeeds, he seems alert but tells her that he was being attacked and needed to defend himself or escape. The patient tells the physician that he does not recall the behavior his wife is describing but remembers having a recurrent dream in which he is in danger and cannot breathe. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, he has a pleasant and full range of affect. His thought process is rational and goal directed. He says that based on his wife’s description of his behavior at night, he is afraid that he might hurt her. Results of laboratory studies are within the reference range. Which of the following is the most likely diagnosis?

  • A) Central sleep apnea
  • B) Nocturnal panic disorder
  • C) Nocturnal paroxysmal dystonia
  • D) REM sleep behavior disorder
  • E) Restless legs syndrome
  • F) Sleep-related complex partial seizure disorder
  • G) Sleep terror disorder

Answer: D) REM sleep behavior disorder

Exam Section : Item 11 of 50
A 27-year-old woman, gravida 1, para 1, comes to the physician with her husband because of progressive irritability and anxiety since the birth of her child 3 weeks ago. Pregnancy was complicated by premature labor that was managed with bed rest. Delivery occurred at term with no complications. Examination of her newborn at birth showed no abnormalities. The patient reports that he feeds well and appears healthy, but she has constant worries about his health and her own health. She adds that she has had a decreased appetite and difficulty sleeping. Her husband notes that she has been increasingly withdrawn from family and friends and that she has reported thoughts of suicide. The patient has no history of serious illness or major depressive disorder. Her only medication is a multivitamin. She appears tired. Physical examination shows no abnormalities. On mental status examination, she has an irritable mood and depressed affect. She is oriented to person, place, and time.
Which of the following is the most likely diagnosis?

  • A) Adjustment disorder
  • B) Bipolar disorder
  • C) Generalized anxiety disorder
  • D) Major depressive disorder
  • E) Post-traumatic stress disorder

Answer: D) Major depressive disorder

Exam Section : Item 12 of 50
A 42-year-old man comes to the physician because of a 6-month history of sexual problems. He can achieve and maintain erections but is rarely able to ejaculate during intercourse. He has erections on awakening in the morning and nocturnal emissions approximately once monthly. He has a 2-year history of coronary artery disease well controlled with metoprolol, lisinopril, and aspirin. He and his wife of 12 years divorced 3 years ago. Over the past 6 months, he has been sexually active with two female partners, and they use condoms for contraception. Examination shows a normal-appearing penis and testes. Which of the following is the most likely explanation for this patient’s sexual dysfunction?

  • A) Decreased pituitary production of gonadotropins
  • B) Disruption of arterial inflow to the penis by metoprolol
  • C) Obstruction at the bladder neck
  • D) Performance anxiety
  • E) Testicular insensitivity to testosterone

Answer: D) Performance anxiety

Exam Section : Item 13 of 50
A 77-year-old man comes to the physician at his wife’s insistence because of a 2-year history of progressive memory problems. His wife notes that he often asks questions that have been answered minutes earlier. On three occasions, he got lost while walking a few blocks from their house, and he has forgotten to turn off the burner several times when making coffee. He has been otherwise healthy.
He takes no medications. He is awake and alert. Physical examination shows no abnormalities. On questioning, he states that he has not been aware of any memory problems. His Mini-Mental State Examination score is 21/30. He recalls one of three objects after 2 minutes. An MRI of the brain shows moderate atrophy. Administration of a medication with which of the following properties is the most appropriate treatment?

  • A) Anticholinergic
  • B) Antidopaminergic
  • C) Antiserotonergic
  • D) Cholinergic
  • E) Dopaminergic
  • F) Serotonergic

Answer: D) Cholinergic

Exam Section : Item 14 of 50
A 32-year-old man is admitted to the hospital because of refusal to speak or move since he returned home after being robbed at gunpoint yesterday. His wife says that her husband was physically unharmed but seemed to be in acute emotional distress. He stopped talking, would not move from his chair, and began staring into space. His wife reports that he has no history of serious illness and takes no medications. The patient is sitting upright with his eyes closed. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, he is mute, does not follow commands, and resists being moved. His affect is flat. Which of the following is the most appropriate pharmacotherapy?

  • A) Buspirone
  • B) Dexamphetamine
  • C) Haloperidol
  • D) Lorazepam
  • E) Sertraline

Answer: D) Lorazepam

Exam Section : Item 15 of 50

A 23-year-old man comes to the physician because of anxiety since beginning a second part-time job as a courier for a photographer 6 weeks ago. He reports a fear of heights and of riding in elevators. He takes stairs and escalators whenever possible, which prevents him from completing his deliveries on time. He has not had panic attacks. He has no history of serious illness and takes no medications. His temperature is 36.80C (98.2 OF), pulse is 80/min, respirations are 18/min, and blood pressure is 118/73 mm Hg. Physical examination shows no abnormalities. On mental status examination, he has an anxious mood and full range of affect. He reports no symptoms of depression or suicidal ideation. Which of the following is the most appropriate next step in management?

  • A) Cognitive behavioral therapy
  • B) Interpersonal therapy
  • C) a-Adrenergic agonist therapy
  • D) ß-Adrenergic blocker therapy
  • E) Selective serotonin reuptake inhibitor therapy

Answer: A) Cognitive behavioral therapy

Exam Section : Item 15 of 50
A 47-year-old man is brought to the physician by his wife because of “unbearable” behavior during the past 2 weeks. His wife reports that he has been talking about his various inventions constantly and recently bought a new recreational vehicle, even though they do not travel long distances. He repeatedly tells his wife that “the time to make and enjoy money has come.” He has been openly critical of their pastor’s prayers during church services. He claims that the pastor does not know what he is talking about because “God is talking to me, not him.” His wife says that he has had episodes of similar behavior during the past 10 years that have been more tolerable. He has peptic ulcer disease treated with ranitidine and hypertension treated with triamterene. He does not smoke or drink alcohol. He is 170 cm (5 ft 7 in) tall and weighs 82 kg (180 1b); BMI is 28 kg/m2. His pulse is 80/min, and blood pressure is 150/95 mm Hg. Physical examination shows no other abnormalities. On mental status examination, he is relaxed and talkative, jumping from one topic to another. He claims that his wife does not understand him and that she has been plotting with the pastor against him. He denies any problems and says that he feels great and is capable of great things. Laboratory findings are within the reference range. Urine toxicology screening is positive for marijuana. Which of the following is the most likely diagnosis?

  • A) Bipolar disorder
  • B) Delusional disorder
  • C) Mood disorder due to a general medical condition
  • D) Schizophrenia
  • E) Substance-induced mood disorder
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FOR AN EXPANDED TYPE OF THIS NBME PSYCHIATRY SELF ASSESSMENT FORM 1 ANSWERS ALONG WITH A CORRECTLY FORMATTED VERSION OF THE INSTANCE MANUAL PAGE ABOVE. 272 reads Tainted Rose The Darkness Trilogy 2 Abby Weeks 346 reads I Am Alice The Last Apprentice Wardstone Chronicles 12 Joseph Delaney 621 reads Mgmt 591 Final Exam Answers 285 reads 42 Solutions Manual Fluid Mechanics Sixth Edition 303 reads Ae92 4afe Engine Parts Diagram Exploded Ruger Lcp 380 Manual 318 reads What Are Bill Of Engineering...

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so hi you guys welcome my name is Emma for those of you who don't know me I'm a fourth year medical student feels like just two seconds ago I was a third-year medical student but I guess it wasn't that many weeks ago so house third you're going it's a nice way to start on psychiatry tree-sweet life so so good no one's been too mean to you yet very nice the psychiatry people are all very nice so it was my hello and hello friends in Harlingen how many friends do I have three four I don't have my glasses on three four now we got another one coming fair enough okay so I wrote this review actually in preparation for my own step two exam that I took about three weeks ago and I did these because OB Jen there's a faculty who gives a shelf review a couple days before the shelf and I found it really helpful before the OB Jin shelf and I was like why don't we do these for all of them so talked with dr. Kinsey and his office agreed to sponsor these shelf reviews so it's the first time we've done h

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  • Do military members have to pay any fee for leave or fiancee forms?

    NOOOOOOO. You are talking to a military romance scammer. I received an email from the US Army that directly answers your question that is pasted below please keep reading.I believe you are the victim of a military Romance Scam whereas the person you are talking to is a foreign national posing as an American Soldier claiming to be stationed overseas on a peacekeeping mission. That's the key to the scam they always claim to be on a peacekeeping mission.Part of their scam is saying that they have no access to their money that their mission is highly dangerous.If your boyfriend girlfriend/future husband/wife is asking you to do the following or has exhibited this behavior, it is a most likely a scam:Moves to private messaging site immediately after meeting you on Facebook or SnapChat or Instagram or some dating or social media site. Often times they delete the site you met them on right after they asked you to move to a more private messaging siteProfesses love to you very quickly & seems to quote poems and song lyrics along with using their own sort of broken language, as they profess their love and devotion quickly. They also showed concern for your health and love for your family.Promises marriage as soon as he/she gets to state for leave that they asked you to pay for.They Requests money (wire transfers) and Amazon, iTune ,Verizon, etc gift cards, for medicine, religious practices, and leaves to come home, internet access, complete job assignments, help sick friend, get him out of trouble, or anything that sounds fishy.The military does provide all the soldier needs including food medical Care and transportation for leave. Trust me, I lived it, you are probably being scammed. I am just trying to show you examples that you are most likely being connned.Below is an email response I received after I sent an inquiry to the US government when I discovered I was scammed. I received this wonderful response back with lots of useful links on how to find and report your scammer. And how to learn more about Romance Scams.Right now you can also copy the picture he gave you and do a google image search and you will hopefully see the pictures of the real person he is impersonating. this doesn't always work and take some digging. if you find the real person you can direct message them and alert them that their image is being used for scamming.Good Luck to you and I'm sorry this may be happening to you. please continue reading the government response I received below it's very informative.   You have contacted an email that is monitored by the U.S. Army Criminal Investigation Command. Unfortunately, this is a common concern. We assure you there is never any reason to send money to anyone claiming to be a Soldier online. If you have only spoken with this person online, it is likely they are not a U.S. Soldier at all. If this is a suspected imposter social media profile, we urge you to report it to that platform as soon as possible. Please continue reading for more resources and answers to other frequently asked questions:  How to report an imposter Facebook profile: Caution-https://www.facebook.com/help/16... < Caution-https://www.facebook.com/help/16... >   Answers to frequently asked questions:  - Soldiers and their loved ones are not charged money so that the Soldier can go on leave.  - Soldiers are not charged money for secure communications or leave.  - Soldiers do not need permission to get married.  - Soldiers emails are in this format: [email protected] < Caution-mailto: [email protected] > anything ending in .us or .com is not an official email account.  - Soldiers have medical insurance, which pays for their medical costs when treated at civilian health care facilities worldwide – family and friends do not need to pay their medical expenses.  - Military aircraft are not used to transport Privately Owned Vehicles.  - Army financial offices are not used to help Soldiers buy or sell items of any kind.  - Soldiers deployed to Combat Zones do not need to solicit money from the public to feed or house themselves or their troops.  - Deployed Soldiers do not find large unclaimed sums of money and need your help to get that money out of the country.  Anyone who tells you one of the above-listed conditions/circumstances is true is likely posing as a Soldier and trying to steal money from you.  We would urge you to immediately cease all contact with this individual.  For more information on avoiding online scams and to report this crime, please see the following sites and articles:   This article may help clarify some of the tricks social media scammers try to use to take advantage of people: Caution-https://www.army.mil/article/61432/< Caution-https://www.army.mil/article/61432/>   CID advises vigilance against 'romance scams,' scammers impersonating Soldiers  Caution-https://www.army.mil/article/180749 < Caution-https://www.army.mil/article/180749 >   FBI Internet Crime Complaint Center: Caution-http://www.ic3.gov/default.aspx< Caution-http://www.ic3.gov/default.aspx>   U.S. Army investigators warn public against romance scams: Caution-https://www.army.mil/article/130...< Caution-https://www.army.mil/article/130...>   DOD warns troops, families to be cybercrime smart -Caution-http://www.army.mil/article/1450...< Caution-http://www.army.mil/article/1450...>   Use caution with social networking  Caution-https://www.army.mil/article/146...< Caution-https://www.army.mil/article/146...>    Please see our frequently asked questions section under scams and legal issues. Caution-http://www.army.mil/faq/ < Caution-http://www.army.mil/faq/ > or visit Caution-http://www.cid.army.mil/ < Caution-http://www.cid.army.mil/ >.  The challenge with most scams is determining if an individual is a legitimate member of the US Army. Based on the Privacy Act of 1974, we cannot provide this information. If concerned about a scam you may contact the Better Business Bureau (if it involves a solicitation for money), or local law enforcement. If you're involved in a Facebook or dating site scam, you are free to contact us direct; (571) 305-4056.   If you have a social security number, you can find information about Soldiers online at Caution-https://www.dmdc.osd.mil/appj/sc... < Caution-https://www.dmdc.osd.mil/appj/sc... > . While this is a free search, it does not help you locate a retiree, but it can tell you if the Soldier is active duty or not.  If more information is needed such as current duty station or location, you can contact the Commander Soldier's Records Data Center (SRDC) by phone or mail and they will help you locate individuals on active duty only, not retirees. There is a fee of $3.50 for businesses to use this service. The check or money order must be made out to the U.S. Treasury. It is not refundable. The address is:  Commander Soldier's Records Data Center (SRDC) 8899 East 56th Street Indianapolis, IN 46249-5301 Phone: 1-866-771-6357  In addition, it is not possible to remove social networking site profiles without legitimate proof of identity theft or a scam. If you suspect fraud on this site, take a screenshot of any advances for money or impersonations and report the account on the social networking platform immediately.  Please submit all information you have on this incident to Caution-www.ic3.gov < Caution-http://www.ic3.gov > (FBI website, Internet Criminal Complaint Center), immediately stop contact with the scammer (you are potentially providing them more information which can be used to scam you), and learn how to protect yourself against these scams at Caution-http://www.ftc.gov < Caution-http://www.ftc.gov > (Federal Trade Commission's website)
  • How do we know the eligibility to fill out Form 12 BB?

    Every year as a salaried employee many of you must have fill Form 12BB, but did you ever bothered to know its purpose. Don’t know ??It is indispensable for both, you and your employer. With the help of Form 12BB, you will be able to figure out how much income tax is to be deducted from your monthly pay. Further, with the help of Form 12BB, you will be in relief at the time of filing returns as at that time you will not have to pay anything due to correct TDS deduction.So, before filing such important form keep the below listed things in your mind so that you may live a tax hassle free life.For More Information:- 7 key points which must be known before filling Form 12BB

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