All practice questions

Review the following patient summaries describing complex depressive presentations. Match each clinical profile with the most appropriate next step in pharmacologic or somatic management.

Review the following succinct patient profiles observed during a psychiatric intake clinic. Pair each patient's core symptomatology with the most accurate DSM-5 diagnosis.

A 45-year-old man is admitted to the internal medicine ward for the management of acute pancreatitis. He is a self-employed auditor. Shortly after admission, he becomes highly guarded and refuses his prescribed intravenous analgesics. He states, 'I know that hospitals get kickbacks for addicting patients to opioids. You are trying to prolong my stay to maximize your billing.' He closely inspects his intravenous line, demanding to see the exact manufacturer label on the saline bag, suspecting the staff is tampering with his fluids. He demands to review the medical license of every clinician who enters his room. Despite his intense accusations, his thought process is logical, he is fully oriented, and he denies hearing voices or having visions. He has no history of psychiatric hospitalizations. His sister, who is visiting, reports that he has 'always been like this.' She notes that since his early twenties, he has frequently lost friends because he bears grudges over minor perceived slights and constantly suspects others are trying to exploit him. He is currently estranged from his wife due to his unfounded accusations of her infidelity. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's clinical presentation with the most appropriate primary or adjunctive treatment modality.

A 42-year-old man is admitted to the cardiac telemetry unit for observation following an episode of unstable angina. On hospital day 2, the cardiology team requests a psychiatric consultation due to disruptive behavior. The nursing staff reports that the patient frequently presses the call button and becomes irate if not answered immediately, accusing the nurses of "deliberately ignoring" him. However, when the attending cardiologist rounds, the patient is highly complimentary, describing the attending as "the only competent doctor in this entire hospital" and stating that the rest of the staff are "idiots who are going to kill me." Later that afternoon, after a resident physician informs him that he cannot have an extra portion of dessert on his cardiac-restricted diet, the patient becomes tearful, threatens to leave against medical advice, and screams that nobody cares if he starves to death. Which of the following is the most appropriate recommendation for the medical team in managing this patient?

A 32-year-old primigravid woman at 8 weeks gestation presents to the clinic after noticing a firm, painless lump in her right breast. Examination reveals a 4-cm, hard, immobile mass in the upper outer quadrant with clinically positive axillary lymphadenopathy. She strongly desires to continue the pregnancy and wants to pursue comprehensive treatment to maximize her survival. Assuming the diagnostic workup ultimately confirms invasive ductal carcinoma, arrange the following management steps in the strictly indicated chronological order for this specific patient, from initial evaluation through to postpartum care.

Match each clinical scenario describing a patient with a bipolar spectrum disorder to the most appropriate next step in pharmacological management.

A 68-year-old retired female executive presents to an outpatient memory clinic, expressing profound distress that she is developing early-onset Alzheimer disease. She reports a 3-month history of significant cognitive decline, stating, "My brain is just broken; I can't remember anything anymore." During the Montreal Cognitive Assessment (MoCA), she makes poor eye contact and frequently answers "I don't know" to orientation and recall questions; however, when gently encouraged by the physician to guess, she answers the majority of the questions correctly. She also reports early morning awakenings, a 4.5-kg (10-lb) weight loss, and a feeling that her life lacks purpose since her retirement 4 months ago. She currently takes no medications. A recent laboratory workup shows a normal thyroid-stimulating hormone (TSH) level and a normal free T4 level. Which of the following is the most appropriate initial management step for this patient?

A family medicine physician evaluates a 22-year-old college student who scheduled an urgent appointment. The student is highly distressed, stating that her roommate recently asked her to move out. The patient has a well-documented history of borderline personality disorder, characterized by recurrent superficial self-harm, chronic feelings of emptiness, and chaotic interpersonal relationships. During the visit, she insists that the physician call her roommate to explain that her behaviors are due to a medical condition and that she should not be evicted. Additionally, she demands a prescription for a combination of fluoxetine and phenelzine, claiming she read on an internet forum that this combination 'cures mood swings.' Which of the following is the most appropriate action for the physician to take?

A 27-year-old woman is seen at a primary care clinic for a 3-week history of overwhelming sadness, excessive daytime sleepiness, and a complete loss of interest in her usual hobbies. She is accompanied to the waiting area by her husband, but she insists on speaking with the physician privately, stating, "Please do not tell my husband anything about my mental health; he is highly critical and will not understand." Review of her medical record reveals a psychiatric hospitalization three years ago for a 7-day episode of severe agitation, euphoric mood, near-total lack of sleep, and delusions of possessing telepathic abilities. She was stabilized and discharged but has not taken any prescription medications since. Currently, she reports taking St. John's wort daily to manage her low mood. Which of the following are appropriate actions for the physician to take? (Select all that apply)

A 24-year-old woman, gravida 1, para 1, comes to the emergency department 4 weeks postpartum due to a 3-day history of a painful, swollen right breast. She is exclusively breastfeeding her infant. She reports subjective fevers, chills, and fatigue. Her temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, and pulse is $102/\text{min}$. Physical examination of the right breast reveals a 4-cm area of marked erythema, induration, and tenderness in the lower outer quadrant. Careful palpation of this area reveals a distinct, centrally fluctuant mass. There is no overlying skin retraction or purulent nipple discharge. Which of the following is the most appropriate next step in management?

An 18-year-old female university freshman is evaluated at the student health center. Her roommate insisted she be seen because, over the last five weeks, the patient has been skipping classes, crying uncontrollably, and sleeping excessively. The patient reports severe anhedonia, a significant increase in appetite resulting in a 5-kg (11-lb) weight gain, and a sensation of profound physical heaviness in her limbs. Review of her medical records reveals a psychiatric hospitalization eight months ago. During that admission, which lasted 14 days, she exhibited pressured speech, severe psychomotor agitation, an almost complete lack of sleep, and auditory hallucinations commanding her to lead a new global government. She was stabilized and discharged, but subsequently stopped attending follow-up appointments. Three weeks ago, she visited an urgent care clinic for her current depressive symptoms and was started on daily citalopram. She has taken the medication faithfully but reports no improvement in her mood. Vital signs and physical examination are within normal limits. She denies any illicit substance use. Which of the following is the most appropriate pharmacological recommendation at this time?

A concerned spouse brings her 28-year-old husband to the office for evaluation of severe lethargy and persistent low mood. For the past month, the patient has spent most days in bed, stopped attending his weekly basketball games, and experienced a 4-kg (9-lb) weight gain. During the interview, he appears visibly psychomotor retarded. Further history gathering from the spouse reveals a distinct two-week timeframe last summer when the patient slept roughly two hours nightly, exhibited pressured speech, and impulsively purchased an expensive sports car he could not afford. The patient is physically healthy and takes zero prescription or over-the-counter supplements. Which of the following is the most appropriate pharmacotherapy for this patient's current episode?

Correlate the following classic clinical symptom constellations with their most appropriate neurocognitive disorder diagnosis.

A 20-year-old university student presents to the student health center complaining of severe fatigue, hypersomnia, and a deeply depressed mood over the past three weeks. Review of his medical records reveals a prior hospitalization during his freshman year for an episode characterized by pressured speech, grandiosity, and severe insomnia lasting for ten days. He is currently unmedicated. Which of the following pharmacological options are appropriate for managing this patient's current condition? (Select all that apply)

A 19-year-old college student presents to the student health clinic reporting that he is spending over three hours a day organizing his dorm room. He states that all his books, clothes, and desk items must be perfectly aligned and symmetrical. If a roommate moves an object even slightly, he experiences intense distress and feels an overwhelming urge to rearrange everything until it feels "just right." He recognizes that this behavior is excessive and says it is severely interfering with his ability to study and attend classes. He has no other medical or psychiatric history. Which of the following is the most appropriate first-line pharmacotherapy for this patient's condition?

A primary care physician is evaluating a 74-year-old patient who presents with her son for a routine wellness visit. The son mentions that his mother has been repeatedly asking the same questions and occasionally getting lost in familiar neighborhoods over the past year. Arrange the following steps in the most appropriate chronological order for the standard clinical evaluation and management of this patient's suspected cognitive impairment.

Review the following psychiatric patient histories and pair each presentation with its definitive diagnosis according to established clinical criteria.

Match each clinical presentation of a breast disorder with its most likely corresponding histopathologic finding on biopsy.

A psychiatrist is evaluating a 32-year-old female patient who presents with a 4-week history of severe depressed mood, anhedonia, sleeping up to 14 hours per day, and profound fatigue. During the clinical interview, she reports feeling worthless but denies any active suicidal plans. A review of her medical records reveals a previous psychiatric hospitalization eight years ago for a 10-day episode of impulsivity, grandiosity, racing thoughts, and a significantly decreased need for sleep. Her medical history includes opioid use disorder, for which she is maintained on daily methadone therapy. She currently takes no other medications. Vital signs are normal. A baseline 12-lead electrocardiogram (ECG) is obtained and demonstrates a QTc interval of 515 ms. Based on this clinical presentation, which of the following is the most appropriate medication to initiate?