All practice questions

A 36-year-old woman comes to the clinic reporting spontaneous, intermittent bloody discharge from her left nipple for the past 6 weeks. She has noticed dark stains on her bra but denies breast pain, skin changes, or a palpable lump. She has no personal or family history of breast cancer. She takes no medications. Vital signs are within normal limits. Physical examination reveals no palpable breast masses, skin dimpling, or axillary lymphadenopathy. Gentle pressure applied to the periareolar area of the left breast elicits a few drops of serosanguineous discharge from a single duct. Diagnostic mammography and targeted ultrasound of the left breast show no abnormalities. Which of the following is the most appropriate next step in management?

A 24-year-old man is brought to the clinic by his mother for a general checkup. He tells the physician that he feels nervous around other people because he can sense their "negative auras." He spends most of his time alone in his room studying astrology and believes that he can predict the weather by reading tea leaves. The mother reports that he has always been a "loner" with odd beliefs since early adolescence. He has never experienced auditory or visual hallucinations, and his thought processes are organized. He does not have any history of major depressive or manic episodes. Which of the following is the most likely diagnosis?

Match each pharmacological agent used in psychiatric practice with its characteristic adverse effect profile or specific clinical warning regarding its use in bipolar disorder.

A 31-year-old male accountant presents to the clinic for an urgent follow-up appointment. He initially presented two weeks ago with a one-month history of severe sadness, hypersomnia, and profound anhedonia. At that time, he was diagnosed with a major depressive episode and prescribed fluoxetine. Today, he reports that his mood has not improved, but he now feels "extremely irritable, wired, and completely unable to sit still." His physical examination is notable for rapid, pressured speech and psychomotor agitation. Upon detailed psychiatric review, the patient admits that he experienced a similar "wired" state twice in his twenties. During those episodes, which each lasted approximately ten days, he required only two hours of sleep per night and impulsively spent thousands of dollars on unneeded electronics. He has no significant past medical history and denies any illicit substance use. Which of the following is the most appropriate next step in management?

Match each clinical presentation to the most likely personality disorder diagnosis.

A 22-year-old law student schedules an appointment at the university health center due to severe distress regarding his upcoming moot court arguments. He explains that whenever he has to speak in front of a panel of judges, he experiences intense palpitations, a prominent hand tremor, and a trembling voice. These symptoms begin roughly 30 minutes before he is scheduled to speak and severely impair his performance. He does not experience this anxiety during written exams, while studying in groups, or in everyday social interactions. He is otherwise healthy, exercises regularly, and takes no daily medications. His pulse is 78/min and blood pressure is 118/76 mm Hg. Which of the following is the most appropriate initial pharmacotherapy to manage this patient's symptoms?

A 33-year-old woman comes to the office after noticing a firm, painless lump in her left breast 2 weeks ago. Physical examination reveals a 2.5-cm, hard, nonmobile mass in the upper outer quadrant of the left breast without overlying skin changes. There is no palpable axillary lymphadenopathy. Assuming the mass is highly suspicious for early-stage invasive breast carcinoma, arrange the following steps in the most appropriate chronological sequence for her standard diagnostic workup and management.

A 42-year-old male architect is brought to his primary care physician by his husband due to a 2-month history of severe depressed mood, excessive guilt, and terminal insomnia. The patient states that he has completely lost interest in his architectural projects, feels like a burden to his family, and has lost 6.8 kg (15 lb) over this period. His medical history is significant for primary hypothyroidism, which has been well-controlled on levothyroxine. Review of his past medical records reveals a prior psychiatric admission at age 26 after he spent his entire life savings on a spontaneous trip to Europe, during which he believed he was a prophet destined to unite the world. He was treated with an unknown medication and stabilized but stopped all psychiatric care a year later. His current vital signs are stable. Physical examination is unremarkable. Mental status examination reveals a disheveled appearance, marked psychomotor retardation, flat affect, and poverty of speech. He denies current suicidal ideation or auditory hallucinations. Laboratory testing demonstrates a thyroid-stimulating hormone (TSH) level of 1.8 µU/mL (normal: 0.5-5.0 µU/mL) and a free thyroxine (T4) level of 1.3 ng/dL (normal: 0.9-1.7 ng/dL). Which of the following is the most appropriate next step in pharmacotherapy?

An asymptomatic $56$-year-old female presents to the clinic to discuss her recent imaging and biopsy results. During a routine health maintenance visit last month, a bilateral mammogram was ordered which demonstrated a highly suspicious $1.8$-cm stellate density with clustered, fine linear branching calcifications in the upper outer quadrant of her left breast (BI-RADS $5$). A subsequent image-guided stereotactic core needle biopsy of the lesion was performed. The histopathology report describes classic lobular carcinoma in situ (LCIS) without evidence of invasive malignancy, atypical ductal hyperplasia, or ductal carcinoma in situ. The patient has a history of hypertension and diet-controlled type 2 diabetes mellitus. Menopause occurred at age $51$. She currently takes lisinopril. Vital signs are within normal limits. Breast examination reveals symmetrical breasts with no skin dimpling, nipple retraction, or palpable masses. There is no cervical, supraclavicular, or axillary adenopathy. Which of the following is the most appropriate next action for this patient?

An outpatient psychiatric evaluation is requested for a 31-year-old female software developer who reports feeling 'empty and constantly on edge.' The patient states that she has struggled with intense, unstable interpersonal relationships since late adolescence, often fluctuating between idealized infatuation and extreme devaluation of her partners. She exhibits the defense mechanism of splitting, explicitly categorizing her current treatment team as 'the only ones who actually care' and her previous providers as 'malicious and incompetent.' Her history is notable for recurrent non-suicidal self-injury via superficial skin cutting following perceived abandonments. Over the past week, following a severe conflict with her roommate, she has experienced transient, stress-induced auditory hallucinations of a voice whispering her name. Furthermore, she describes short-lived periods of profound depressive symptoms interspersed with significant irritability and impulsive spending. She is currently prescribed paroxetine for anxiety. During the interview, she mentions having found a bottle of phenelzine in her mother's medicine cabinet and asks if she should start taking it alongside her paroxetine for 'extra help.' She also expresses intense anger toward her roommate, vaguely stating she would 'love to see her get hit by a bus,' but when assessed further, she denies any actual plan or intent to harm her. Which of the following is the most appropriate management strategy for this patient?

A 28-year-old woman is evaluated in the outpatient psychiatric clinic for maintenance pharmacotherapy following a recent hospitalization for an acute manic episode. Her past psychiatric history includes two prior episodes of major depression. Physical examination is unremarkable, and on mental status examination, her mood is euthymic with normal speech and thought processes. The physician discusses several medication options, emphasizing the importance of specific baseline laboratory testing, adverse effect profiles, and appropriate prescribing practices in bipolar disorder. Match each psychotropic intervention with its characteristic adverse effect profile, required monitoring, or primary clinical risk.

A 62-year-old man comes to the cardiology clinic for a routine follow-up 6 weeks after being hospitalized for an acute anterior wall myocardial infarction, for which he received a drug-eluting stent. His cardiac function has stabilized, and he is compliant with his medication regimen, which includes aspirin, clopidogrel, metoprolol, lisinopril, and atorvastatin. Today, his wife expresses deep concern about his emotional well-being since discharge. The patient states, 'My life is basically over. I am just a burden to my family now, and there is no point in going on.' He reports a 10-lb (4.5-kg) weight loss due to poor appetite and says he wakes up every day at 3:00 AM unable to fall back asleep. He admits to recurrent thoughts that his family would be better off if he were dead, though he lacks a specific suicide plan. His physical examination is unremarkable, and an electrocardiogram shows normal sinus rhythm with a QTc interval of 420 ms. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

Select the most accurate personality disorder diagnosis for each described patient presentation.

A 41-year-old man is brought to the clinic by his wife due to severe anhedonia, feelings of worthlessness, and hypersomnia lasting for the past six weeks. He has a past medical history of obesity (BMI 36 kg/m²), poorly controlled type 2 diabetes mellitus, and essential hypertension. His current daily medications are metformin, valsartan, and indapamide. His wife reports that three years ago, he experienced a distinct three-week period where he slept only two hours per night, spoke incessantly, and exhibited grandiosity, claiming he was a covert operative for a secret intelligence agency. That episode resolved without psychiatric intervention, and he has taken no psychotropic medications since. Mental status examination reveals psychomotor slowing, poor eye contact, and a severely depressed mood, but no current delusions or hallucinations. Which of the following is the most appropriate next step in pharmacologic management?

A 34-year-old woman comes to the clinic reporting a 6-week history of pervasive sadness, frequent tearfulness, and profound fatigue. She states that her arms and legs feel "like they are made of lead" and she is sleeping up to 14 hours a day. She feels immense guilt about being an inadequate mother to her 4-month-old infant, whom she is exclusively breastfeeding. Three years ago, the patient was prescribed paroxetine for generalized anxiety. Two weeks after starting the medication, she became unusually energetic, slept only 2 hours a night without feeling tired, and began making impulsive, large investments in cryptocurrency, which depleted her savings. The paroxetine was immediately discontinued, but her hyperactive and grandiose state persisted for another 5 weeks before gradually resolving. She has not taken any psychiatric medications since that time. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate pharmacotherapy for this patient's current symptoms?

Match the following clinical presentations to the most appropriate psychiatric diagnosis based on DSM-5 criteria.

During a routine health clearance appointment, a 20-year-old nursing student confides in the physician about severe anxiety that is jeopardizing her clinical rotations. For the past 4 months, she has experienced overwhelming fear, nausea, diaphoresis, and lightheadedness exclusively when asked to perform venipuncture or assist with wound care. On two occasions, she lost consciousness while observing minor surgical procedures. She states, "I understand the procedures logically, but the moment I see blood or needles, the room starts spinning." She denies anxiety during lectures, written examinations, or general patient interactions. She has no past psychiatric history, takes no medications, and her physical examination today is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old woman is brought to the clinic by her sister due to profound behavioral changes over the past 5 weeks. Six weeks ago, the patient was sexually assaulted at a social gathering. She has not reported the incident to law enforcement and explicitly asks the physician to keep the event completely confidential. The patient describes experiencing intense, intrusive flashbacks of the assault and has actively avoided leaving her apartment. She exhibits an exaggerated startle response and reports severe insomnia. Her past psychiatric history is significant for a hospitalization at age 22 for a distinct episode of elevated mood, decreased need for sleep, and grandiosity. She currently takes lithium for maintenance therapy. She also mentions that she recently started taking over-the-counter St. John's wort to help manage her current distress. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in the management of this patient?

A 44-year-old woman comes to the clinic after noticing a new lump in her right breast 2 weeks ago. She performs intermittent breast self-examinations and has no family history of breast or ovarian cancer. Her medical history is significant for primary hypothyroidism, for which she takes levothyroxine. Menarche was at age 12, and she has regular menstrual cycles. She had a routine screening mammogram 4 months ago, which was reported as normal with heterogeneously dense breast tissue (BI-RADS 1). Vital signs are within normal limits. On physical examination, there is a 2.5-cm, firm, non-tender, and freely mobile mass in the upper outer quadrant of the right breast. There are no overlying skin changes, nipple retraction, or nipple discharge. There is no palpable cervical, supraclavicular, or axillary lymphadenopathy. Which of the following is the most appropriate next step in management?

Match each clinical vignette describing a patient's pervasive interpersonal and behavioral patterns to the most likely personality disorder diagnosis.