All practice questions

A 26-year-old woman is evaluated in the outpatient clinic for emotional instability. She reports a long history of chronic feelings of emptiness, recurrent superficial self-harm, and frantic efforts to prevent her friends from abandoning her. She states that her mood frequently shifts from intense sadness to rage, often multiple times within the same day based on minor perceived slights. The patient is currently prescribed fluoxetine for depressive symptoms but demands an immediate switch to phenelzine, a medication she read about online. When the physician hesitates, she becomes intensely angry and devalues the physician's competence. Which of the following statements regarding this patient's diagnosis and management are accurate? (Select 3)

Match each clinical presentation with the most likely underlying breast pathology.

A 26-year-old male software engineer is evaluated in the clinic for a 4-week history of low mood, hypersomnia, and poor concentration. He reports that he feels exhausted despite sleeping up to 12 hours a day and has lost interest in his usual hobbies. He has no significant past medical history. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 2.1 µU/mL (normal: 0.5-5.0 µU/mL) and free T4 of 1.2 ng/dL (normal: 0.9-1.7 ng/dL). During the psychiatric interview, the patient casually mentions that three years ago he experienced a two-week period where he felt 'invincible.' During that time, he slept only 3 hours per night, had racing thoughts, and spent his entire life savings on impulsive business ventures. He is not currently taking any medications. Which of the following is the most appropriate next step in the management of this patient?

A 23-year-old woman is evaluated in the emergency department after sustaining superficial lacerations to her left forearm. She reports that she cut herself with a razor blade because she felt 'empty' after her romantic partner of three weeks stopped returning her text messages. She describes her partner as 'the only person who has ever truly understood my soul.' The patient's medical history is significant for multiple previous emergency visits for similar behaviors, as well as a diagnosis of treatment-resistant atypical depression for which she currently takes tranylcypromine. While in the department, she is highly cooperative with the attending physician but frequently yells at the nursing staff, claiming they are 'incompetent and cruel.' When asked for emergency contacts, she provides her partner's phone number but explicitly states, 'Do not tell him I am here or why I am here.'

Which of the following interventions are appropriate in the management of this patient? (Select all that apply)

A 48-year-old man presents to a new primary care physician to establish care. Upon entering the examination room, he immediately questions the physician about the security protocols of the electronic health record system, stating, "I am well aware that medical institutions frequently leak data to insurance conglomerates to orchestrate coverage denials." He refuses to provide a comprehensive family history, claiming such information will be "weaponized" against him. During the interview, he notes that he was recently terminated from his job as a civil engineer because his coworkers were "secretly coordinating to undermine my structural reports and take credit for my designs." When the physician asks if he has definitive evidence of this, he replies, "I don't need a smoking gun; the subtle glances they exchanged were proof enough." He also mentions he restricts his wife's access to their shared bank accounts because "loyalty is a rare commodity." The patient is well-groomed, his speech is organized, and he denies any history of hearing voices or seeing things others do not. Which of the following features of this patient's presentation most strongly supports a diagnosis of paranoid personality disorder rather than delusional disorder?

A 42-year-old woman comes to the general surgery clinic for evaluation of a left breast mass that she noticed 3 months ago. She reports that the lump has been growing rapidly during this time. The patient has no personal or family history of breast or ovarian cancer. Physical examination reveals a 5.5-cm, firm, mobile, well-circumscribed mass in the upper outer quadrant of the left breast. The overlying skin appears stretched and shiny with prominent superficial veins, but there is no skin dimpling, nipple retraction, or erythema. Axillary examination shows no palpable lymphadenopathy. Diagnostic mammography and targeted ultrasound demonstrate a large, lobulated, hypoechoic solid mass with internal cleft-like cystic spaces. An image-guided core needle biopsy is performed. Histopathology reveals a cellular fibroepithelial lesion with leaf-like architectural patterns and a hypercellular stroma with moderate atypia, consistent with a borderline phyllodes tumor. Which of the following is the most appropriate next step in management?

A 35-year-old patient is diagnosed with severe Major Depressive Disorder without psychotic features. Arrange the following interventions in the standard sequential order of a stepped-care approach for this patient, progressing from the initial evaluation and management to interventions for highly treatment-resistant disease. Assume an inadequate clinical response to each preceding step.

A 28-year-old woman is diagnosed with major depressive disorder and prescribed an oral selective serotonin reuptake inhibitor (SSRI). Arrange the following clinical events and milestones in the typical chronological order in which they are expected to occur during her treatment course, from the initial days of therapy to long-term management.

During morning rounds and surgical consultations, the consultation-liaison psychiatry team is asked to evaluate five different patients who are complicating their own medical care through deeply ingrained, inflexible behavioral patterns. Evaluate the interpersonal dynamics and defense mechanisms presented in each scenario, and pair each patient with the most accurate underlying psychiatric diagnosis.

A 34-year-old woman is admitted to the inpatient psychiatric unit due to a 4-week history of severe depressed mood, hypersomnia, profound fatigue, and passive suicidal ideation. Her psychiatric history is significant for a severe manic episode at age 26 that required a 2-week hospitalization, establishing a diagnosis of bipolar I disorder. She discontinued her prescribed maintenance lithium two years ago due to weight gain. For the past month, she has been taking daily over-the-counter St. John's wort and 5-hydroxytryptophan (5-HTP) supplements. Her past medical history includes a non-functioning pituitary microadenoma diagnosed incidentally last year, for which she currently takes no medications.

Physical examination reveals a flat affect, psychomotor retardation, and delayed deep tendon reflexes.

Laboratory studies show:

Comprehensive metabolic panel and complete blood count are within normal limits.

Which of the following are appropriate management steps for this patient? (Select all that apply)

A 24-year-old woman is evaluated in the psychiatric clinic for worsening mood. For the past two months, she has experienced pervasive sadness, anhedonia, hypersomnia (sleeping 12 to 14 hours a day), and a 6-kg (13-lb) weight gain. She describes her arms and legs as feeling "heavy like lead," though she notes her mood brightens temporarily when her sister comes to visit. Three years ago, she was hospitalized for a one-week episode during which she slept only two hours a night, spoke extremely rapidly, and spent her entire savings. During that admission, she heard a voice telling her she was a prophet, but this hallucination resolved completely within 5 days alongside her other symptoms after she received acute treatment. She is currently taking fluoxetine, which was prescribed by her primary care physician three weeks ago, but she reports no improvement.

Which of the following is the most appropriate next step in management?

A medical student is reviewing the pharmacological management of bipolar disorder. Match each medication to its most appropriate baseline screening and monitoring requirement prior to initiation.

A 27-year-old man is referred to a psychiatrist for an evaluation requested by his employer. Over the past four years, his coworkers have complained that he behaves oddly, often wearing heavy winter clothing in the middle of summer and muttering to himself in the breakroom. During the interview, the patient makes poor eye contact and displays a constricted affect. He explains that he avoids social gatherings because he feels "out of sync" with others. When discussing his lack of friends, he utilizes fantasy as a defense mechanism, explaining that he does not need physical companions because he maintains strong telepathic connections with others on an "astral plane." He denies ever hearing external voices, seeing things that are not there, or feeling that his thoughts are being controlled by outside forces. His thought processes, while highly eccentric, remain logical. These traits have been stable since his late teens. Which of the following is the most likely diagnosis?

A 35-year-old woman is evaluated in the psychiatric clinic for severe anxiety and intrusive memories. Six months ago, she was the victim of a violent home invasion. Since the event, she has experienced frequent nightmares about the attack, avoids leaving her house, and remains excessively vigilant. She also reports a 3-week history of depressed mood, severe fatigue, and anhedonia. Her past psychiatric history is significant for two hospitalizations in her early twenties for episodes characterized by a markedly decreased need for sleep, rapid speech, and grandiose delusions. Her only current medication is phenelzine, an MAOI, which was started by a different physician two months ago for depression. Which of the following statements regarding the appropriate diagnosis and management of this patient are correct?

A 35-year-old woman presents to her primary care physician reporting intermittent, reddish-brown discharge from her right nipple over the past 3 weeks. She has noticed small stains on her bra but denies any localized breast pain, overlying skin changes, or fever. Her menstrual cycles are regular, and she takes no daily medications. She has no family history of breast or ovarian cancer. Vital signs are within normal limits. On physical examination, the breasts are symmetric with no skin dimpling, erythema, or nipple retraction. Palpation reveals no discrete masses or axillary lymphadenopathy. Gentle pressure around the right areola elicits a single drop of bloody discharge from a single duct. Which of the following is the most appropriate initial step in the evaluation of this patient?

A 72-year-old woman is brought to the emergency department by her husband due to a progressive physical decline over the past week. She has a history of persistent depressive disorder since her late 40s and was diagnosed with a superimposed major depressive episode 6 months ago following her husband's stroke. During the current episode, she sequentially failed 8-week trials of sertraline and venlafaxine at maximum tolerated doses. Four weeks ago, her psychiatrist initiated a combination of fluoxetine 40 mg and bupropion 150 mg daily. Over the past 7 days, she has entirely refused to eat or drink, stating that her "stomach has been replaced by a block of ice" and that eating is a sin. On examination, she is mute, exhibits severe psychomotor retardation, and avoids eye contact. Her temperature is 37.0°C (98.6°F), pulse is 110/min, and blood pressure is 105/65 mm Hg. Her mucous membranes are extremely dry, and skin turgor is poor. Laboratory results show a blood urea nitrogen (BUN) of 48 mg/dL and a serum creatinine of 1.9 mg/dL (baseline 4 weeks ago was 0.8 mg/dL). Which of the following is the most appropriate next step in management?

Paramedics bring a 30-year-old primigravid woman at 32 weeks gestation to the emergency department. She called 911 reporting sudden, overwhelming chest tightness, diaphoresis, and a sensation of smothering. Upon arrival in the ED, the patient is tremulous and states, "I thought I was having a heart attack and going to die." She reports the symptoms began while she was watching television and peaked within five minutes. She admits to having three similar episodes over the past four weeks. Consequently, she has stopped driving and refuses to go to the supermarket out of fear that a similar event might occur in public.

Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, heart rate is 118/min, and respiratory rate is 26/min. Pulse oximetry is 99% on room air. Lungs are clear to auscultation bilaterally. Cardiac examination reveals a regular rhythm with a grade 2/6 early systolic murmur at the left upper sternal border. No lower extremity edema is present. An electrocardiogram demonstrates sinus tachycardia. Arterial blood gas on room air shows a pH of 7.50, $pCO_2$ of 27 mm Hg, and $pO_2$ of 104 mm Hg. A plasma D-dimer level is 0.7 mg/L (normal non-pregnant $\leq$ 0.5 mg/L).

Which of the following is the most appropriate next step in management?

A 29-year-old woman presents to the outpatient gynecology clinic for a routine wellness examination and contraception counseling. During the initial interview, she is exceptionally complimentary, telling the physician, "You are the only doctor I have ever met who truly listens. My last gynecologist was completely incompetent, ignored my concerns, and practically ruined my health." Toward the end of the appointment, she asks for the physician's personal cell phone number, stating she needs it "just in case I have a medical emergency after hours." When the physician politely declines and explains the clinic's standard answering service and on-call procedures, the patient's demeanor changes abruptly. She becomes visibly furious, yells that the physician is "just as cold and heartless as the rest of them," and threatens to leave without undergoing the physical examination. The patient has no history of mania, psychosis, or substance use disorder. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical and histopathological description of a breast lesion with its most appropriate definitive management or critical diagnostic association.

A 22-year-old college student is referred to the university psychiatric clinic by his academic advisor due to social isolation and eccentric behavior. For the past three years, the patient has had no close friends and spends most of his weekends extensively researching clairvoyance, telepathy, and astral projection. He tells the physician that he can frequently "feel the vibrational energy" of other people in the room, which makes him highly uncomfortable in crowds. He wears a heavy trench coat adorned with multiple mismatched scarves, regardless of the weather. His speech is vague and highly circumstantial, often drifting into tangential discussions about "cosmic alignments," but his thought process remains goal-directed without frank disorganization. He explicitly denies auditory or visual hallucinations, and there is no evidence of major depressive or manic episodes. He occasionally takes citalopram, which was prescribed by his primary care physician for mild generalized anxiety. Which of the following statements regarding the diagnosis and management of this patient's condition are accurate? (Select 2)