All practice questions

During a routine prenatal visit at 14 weeks gestation, a 34-year-old G2P1 woman mentions a lump in her right breast that she noticed two weeks ago. The patient has no personal or family history of breast cancer. She reports no fever, chills, or nipple discharge. Vital signs are within normal limits. Physical examination reveals a 3-cm, firm, non-tender, and relatively immobile mass in the upper outer quadrant of the right breast. There is no overlying skin erythema, dimpling, or axillary lymphadenopathy. Which of the following is the most appropriate next step in the evaluation of this patient's breast mass?

A 38-year-old freelance artist is accompanied to a primary care appointment by her older sister. The patient is wearing heavily layered, mismatched clothing adorned with various metallic charms that she claims "deflect negative electromagnetic frequencies." During the interview, she speaks in a circumstantial and overly abstract manner, describing her health as being "out of alignment with the lunar cycles." She avoids eye contact, appearing highly uncomfortable, and mentions that she rarely leaves her apartment because she is overwhelmed by the "intense auras" of other people. Her sister expresses frustration, stating that this behavior has persisted since the patient's early twenties, and requests that the physician "prescribe medication to stop these delusions." The patient denies hearing voices or believing that others are trying to harm her. She is fully oriented and correctly answers questions about her medical history. Which of the following is the most appropriate action by the physician?

A 38-year-old man is hospitalized for intravenous antibiotic therapy for severe lower extremity cellulitis. Over the past 48 hours, the nursing staff reports escalating behavioral difficulties. The patient exhibits rapid, unpredictable shifts in affect, ranging from profound tearfulness to intense, sarcastic outbursts. He recently told the attending physician, "You are the only competent doctor in this hospital; the morning nurses are maliciously ignoring my needs." Following a minor delay in receiving his morning meal tray, he became extremely distressed and reported briefly hearing a voice telling him he is "worthless." This perceptual disturbance completely resolved within two hours after a supportive conversation with the clinical social worker. His medical record indicates a history of recurrent impulsive medication overdoses, chronic feelings of emptiness, and tumultuous interpersonal relationships. His home medications include phenelzine for a history of treatment-resistant depression. The patient is currently demanding that the team "do something to fix my severe depression right now."

Which 3 of the following interventions are appropriate components of this patient's comprehensive management plan during this admission?

A 34-year-old man comes to the clinic seeking a second opinion regarding his "chronic fatigue and workplace stress." He brings a 5-page typed document detailing his symptoms, previous doctors' visits, and a list of medical literature he has reviewed. He states that he is constantly exhausted because he works 80 hours a week as a software developer. He explains, "I have to do everything myself because my colleagues are incompetent and careless. If I delegate, the code will be messy, and I refuse to release anything less than perfect." Because of this rigid standard, he frequently misses project deadlines, which recently led to a formal reprimand from his manager. The patient expresses anger at his manager's "inability to appreciate true quality." He denies any repetitive rituals or intrusive thoughts that cause him distress. He reports no periods of elevated mood, impulsivity, or decreased need for sleep. He has no close friends because he finds socializing to be "an inefficient use of time." Which of the following is the most likely diagnosis?

A 31-year-old woman comes to the clinic with her husband due to a 4-week history of profound sadness, frequent crying spells, and a feeling of being "completely overwhelmed." She delivered her first child 2 months ago via an uncomplicated vaginal delivery. She states that she sleeps heavily when the infant sleeps but still feels exhausted throughout the day. She has a poor appetite and expresses immense guilt over being a "terrible mother." She denies any thoughts of harming herself or the infant. Her medical history is unremarkable. Vital signs are normal. Laboratory testing shows a thyroid-stimulating hormone (TSH) level of $4.2 \mu U/mL$ (normal: $0.5-5.0 \mu U/mL$) and a free T4 of $1.1 ng/dL$ (normal: $0.8-2.8 ng/dL$). During the interview, her husband mentions that during her second trimester of pregnancy, she experienced a 3-week period where she "barely slept for days," rapidly renovated their entire house single-handedly, and spoke so quickly that he struggled to follow her train of thought. He had assumed this was a severe case of "pregnancy nesting." Which of the following is the most appropriate next step in pharmacological management?

A 72-year-old woman is brought to the clinic by her daughter due to a 1-year history of progressive memory loss, misplacing items, and getting lost in familiar neighborhoods. Arrange the following steps in the most appropriate chronological order for the initial diagnostic evaluation of this patient's progressive cognitive decline.

Match each postoperative clinical presentation with the most likely specific surgical complication or underlying pathophysiology.

A 22-year-old man visits a community health clinic reporting a 3-week period of severely depressed mood, hypersomnia, and intense feelings of worthlessness. During the psychiatric history, the physician learns that one year ago, the patient experienced a distinct 10-day period where he felt 'invincible,' required only 3 hours of sleep per night to feel fully rested, and engaged in impulsive, high-risk financial investments. He currently takes no medications and has no other medical conditions. Which of the following represent appropriate initial management steps for this patient's current condition? (Select all that apply)

A 19-year-old female college student is evaluated at the student health center due to significant weight loss and academic decline. For the past eight months, she has experienced overwhelming anxiety when eating in the campus dining hall, constantly fearing that other students are intensely watching and negatively judging her table manners. To avoid this distress, she has been skipping meals, resulting in a 5-kg (11-lb) weight loss. She denies any fear of gaining weight or distorted body image. She also strictly avoids raising her hand or speaking in seminars. Her medical history is significant for a recent methicillin-resistant *Staphylococcus aureus* (MRSA) skin abscess, for which she was started on oral linezolid three days ago. Her psychiatric history includes an episode at age 17 characterized by severe depression, which was followed by a distinct two-week period of euphoric mood, decreased need for sleep, and hypersexuality.

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

A 21-year-old man is brought to the emergency department by his friends due to severe agitation and confusion. His friends report that they were at an electronic music festival when he suddenly became profusely sweaty, disoriented, and collapsed. His medical history is significant for major depressive disorder, for which he takes fluoxetine daily. His temperature is 39.4°C (102.9°F), blood pressure is 170/105 mm Hg, pulse is 128/min, and respirations are 22/min. Physical examination shows diffuse diaphoresis, bilateral mydriasis, and tremors. Neurologic examination reveals prominent hyperreflexia and sustained clonus in the lower extremities. Which of the following illicit substances did this patient most likely consume?

A 31-year-old man presents to the psychiatry clinic deeply distressed. For the past 3 weeks, since the birth of his daughter, he has been experiencing recurrent, intrusive images of himself dropping the infant down the stairs. He states, "I love her more than anything and would never hurt her, but these terrifying thoughts keep popping into my head." To neutralize his anxiety, he mentally recites the alphabet backward exactly three times every time the image occurs. This cycle repeats dozens of times a day. He has refused to hold the baby, placing significant strain on his marriage.

His medical history is notable for congenital long QT syndrome. His psychiatric history includes a severe manic episode with psychotic features at age 24, for which he was hospitalized and successfully treated. However, he discontinued all psychiatric medications two years ago and has been euthymic since. An electrocardiogram today shows a QTc interval of $490 \text{ ms}$.

Which of the following are the most appropriate steps in the clinical management of this patient? (Select exactly 2)

A $28$-year-old male architect is brought to the outpatient psychiatric clinic by his husband. The patient reports a $4$-week history of feeling "profoundly empty," sleeping $14$ hours a day, gaining $7$ kg ($15$ lbs), and experiencing an inability to concentrate on his design projects. His husband notes that $3$ years ago, the patient had a distinct $2$-week period where he slept only $2$ hours a night, maxed out several credit cards investing in cryptocurrency, and firmly believed he was communicating telepathically with extraterrestrials. That episode resulted in a $10$-day psychiatric hospitalization. The patient's only current medication is daily omeprazole. His vital signs and physical examination are unremarkable. Which of the following statements regarding the appropriate pharmacological management for this patient are correct? (Select all that apply)

Match each clinical presentation of early-onset or familial breast cancer with the most likely underlying genetic mutation.

A 34-year-old woman, G2P1, at 18 weeks gestation comes to the physician after discovering a lump in her left breast. She first noticed the lump a month ago and feels it has slightly increased in size. Her medical history is unremarkable, and she has no family history of breast cancer. On physical examination, her breasts are symmetrically enlarged and diffusely nodular. There is a 3-cm, firm, mobile, well-circumscribed, non-tender mass in the left upper outer quadrant. No skin changes, dimpling, or nipple discharge are present. Axillary lymph nodes are not palpable. Which of the following is the most appropriate next step in management?

A 34-year-old female software engineer presents to the clinic with a 6-week history of profound fatigue, sleeping 12 to 14 hours a day, significant weight gain, and an inability to focus on her work. She reports feeling hopeless and admits to passive thoughts of death, though she denies active suicidal ideation or any specific plan. She has no significant past medical history. A review of her medical records indicates that three years ago she was brought to the emergency department by her family for severe agitation, grandiosity, and going four consecutive days without sleep. She was hospitalized, diagnosed with a psychiatric condition, and prescribed medication, which she discontinued shortly after discharge. Vital signs are within normal limits. Physical examination is unremarkable. Laboratory evaluation reveals a thyroid-stimulating hormone (TSH) level of $1.8 \mu\text{U/mL}$ (normal: $0.4-4.0 \mu\text{U/mL}$) and a free T4 level of $1.2 \text{ ng/dL}$ (normal: $0.9-2.4 \text{ ng/dL}$). Which of the following is the most appropriate pharmacological management for this patient?

A 29-year-old man comes to the clinic reporting severe anxiety, poor sleep, and frequent nightmares for the past 3 weeks. Three weeks ago, he was the driver of a commercial truck that was involved in a fatal collision with a pedestrian. Although he was not physically injured, he witnessed the aftermath. Since the incident, he has experienced intense intrusive memories of the event, refuses to drive or be near large vehicles, feels emotionally numb, and is constantly hypervigilant. His medical history is significant for bipolar I disorder, diagnosed at age 22, and chronic lower back pain. He discontinued his maintenance lithium 6 months ago because he felt well, and he currently takes no psychiatric medications. He takes tramadol as needed for his back pain. He expresses intense distress about his symptoms. Which of the following is the most appropriate next step in management?

A 41-year-old chef is brought to the outpatient clinic by his business partner due to a severe decline in functioning over the past six weeks. The patient describes a pervasive feeling of emptiness, increased appetite, and sleeping up to 12 hours daily. He also reports occasionally hearing a voice telling him he is a 'complete failure.' He has stopped going to the restaurant and avoids social contact. The business partner notes that four years ago, the patient had a distinctly different episode lasting three weeks during which he slept only three hours a night, talked incessantly, and maxed out multiple credit cards to launch an ill-advised catering business. The patient takes no medications and has no other medical conditions. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in management?

A 28-year-old woman presents to the psychiatry clinic with a 4-month history of recurrent, unexpected episodes of intense fear. These episodes are accompanied by palpitations, sweating, shortness of breath, and a feeling of impending doom. She constantly worries about having another episode and has started avoiding public transportation as a result. Her past medical history is significant for bipolar I disorder, but she discontinued all her psychiatric medications 2 years ago against medical advice and currently takes no medications. The physician and patient are discussing treatment options for her current symptoms. Which of the following is the most appropriate next step in management?

For each of the following patient scenarios involving depressive symptoms or related disorders, select the most appropriate targeted pharmacotherapy or management step.

Match each clinical vignette with the most appropriate personality disorder diagnosis.