All practice questions

A 27-year-old male civil engineer is brought to the psychiatric emergency service by his roommate. The patient has been isolating in his bedroom for the past month, sleeping over 14 hours a day, and neglecting his personal hygiene. During the interview, he exhibits profound psychomotor retardation and admits to active suicidal ideation with a plan to ingest household chemicals. His medical history is unremarkable. Upon review of his psychiatric history, his roommate reports that three years ago, the patient experienced a distinct three-week period during which he slept only two hours per night, spoke so rapidly he was nearly incomprehensible, and frantically wrote a 500-page manifesto believing he had independently solved major problems in quantum physics. The patient was hospitalized at that time but subsequently lost to follow-up. Vital signs and routine laboratory studies are within normal limits. Which of the following pharmacological interventions are appropriate for this patient's current presentation? (Select all that apply)

A 26-year-old woman comes to the outpatient psychiatric clinic reporting severe anxiety, insomnia, and nightmares. Exactly three weeks ago, she was sexually assaulted by an acquaintance at a party. She has not disclosed the assault to anyone else and explicitly asks the physician not to notify law enforcement, stating she is not ready for an investigation. Since the incident, she has avoided social gatherings, feels constantly 'on edge,' and experiences distressing flashbacks. Her past medical history is significant for bipolar I disorder. Her current medications include lithium and tranylcypromine, the latter having been added two months ago for depressive symptoms. She asks if a medication like sertraline could be prescribed, as she has heard it is effective for trauma. Vital signs are within normal limits. Which of the following is the most appropriate next step in management?

A 78-year-old man with an 8-year history of Parkinson disease is brought to the geriatrics clinic by his daughter. Over the past 6 months, he has exhibited progressive memory loss, difficulty paying bills, and fluctuating attention. During the last 2 weeks, he has developed vivid, terrifying visual hallucinations of strangers in his bedroom, leading to severe agitation. His vital signs and physical examination are unchanged from his baseline. His current medications include carbidopa-levodopa, pramipexole, trihexyphenidyl, and omeprazole. The physician determines that a stepwise approach is required to manage his neuropsychiatric symptoms while attempting to preserve motor function.

Arrange the following management steps in the most appropriate sequential order, from the initial most necessary action to the final therapy of last resort.

A 19-year-old college student is evaluated in the university health center. His roommate brought him in because he has been "acting strange" for the past two hours. The roommate notes that the patient has been laughing inappropriately, speaking slowly, and eating unusually large amounts of snack foods. The patient has no past medical history and takes no medications. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 115/75 mm Hg, pulse of 118/min, and respirations of 14/min. Physical examination shows prominent conjunctival injection and a dry oral mucosa. Pupils are equal and reactive to light. Neurologic examination is unremarkable, and there is no nystagmus. Which of the following is the most likely cause of this patient's current condition?

A 37-year-old man is brought to the clinic by his sister due to a 6-week history of profound fatigue, hypersomnia, and a 4-kg (9-lb) weight gain. He states he feels completely devoid of energy, struggles to get out of bed, and expresses unwarranted guilt over taking time off from his job as an accountant. His sister notes that three years ago, the patient experienced a highly unusual two-week period during which he slept only three hours a night, exhibited pressured speech, and impulsively emptied his savings account to invest in unproven cryptocurrency. He has no other medical history and takes no medications. Vital signs are within normal limits. Laboratory evaluation shows a thyroid-stimulating hormone (TSH) level of 2.1 µU/mL (normal: 0.5-5.0 µU/mL) and a normal free T4 level. Which of the following is the most appropriate initial pharmacotherapy for this patient?

An 18-year-old male is brought to the emergency department by his older sister because he has been unable to stand up from the couch for the past two hours. Over the last $3$ weeks, his sister notes he has been increasingly withdrawn, occasionally talking to people who are not present, and failing to show up for his part-time job. His medical history includes major depressive disorder, for which he has been taking fluoxetine for the past year.

On physical examination, the patient is lethargic but arousable. An erythematous, flaky rash is noted around his mouth and nares. Lungs are clear to auscultation. Heart rate is $105/\text{min}$, blood pressure is $112/70\text{ mm Hg}$, and respiratory rate is $24/\text{min}$. Neurologic examination reveals symmetric $2/5$ muscle strength in the lower extremities bilaterally, with absent patellar reflexes.

Laboratory results:
$Na^+$: $140\text{ mEq/L}$
$K^+$: $1.8\text{ mEq/L}$
$Cl^-$: $115\text{ mEq/L}$
$HCO_3^-$: $14\text{ mEq/L}$
$BUN$: $10\text{ mg/dL}$
$Cr$: $0.7\text{ mg/dL}$
$TSH$: $1.8\text{ }\mu\text{U/mL}$
Urine toxicology screen: Negative for opioids, amphetamines, cocaine, PCP, and cannabis.

Arterial blood gas on room air:
pH: $7.22$
$P_{a}CO_2$: $36\text{ mm Hg}$
$P_{a}O_2$: $85\text{ mm Hg}$

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

A 68-year-old man is brought to the geriatric psychiatry clinic by his son for evaluation of worsening memory. The son reports that his father has been increasingly forgetful over the past 4 months, frequently missing appointments and neglecting to pay bills. The patient's wife passed away unexpectedly 6 months ago. Since her death, the patient has lost 5 kg (11 lbs), complains of waking up at 3:00 AM every morning and being unable to return to sleep, and has lost interest in his usual hobby of gardening. During the interview, the patient makes poor eye contact and appears apathetic. When asked about recent news events to test his memory, he immediately sighs and responds, "I just don't know, my memory is terrible." With significant encouragement and prompting, he is able to recall 2 out of 3 words after 5 minutes and correctly draw a clock. His physical and neurological examinations are unremarkable. Which of the following clinical features most strongly supports a diagnosis of major depressive disorder with cognitive impairment (pseudodementia) rather than Alzheimer disease in this patient?

A 19-year-old female is evaluated in the emergency department for severe generalized weakness and muscle cramps. Her roommate reports that the patient is heavily preoccupied with her body image and frequently goes to the bathroom immediately after meals. Vital signs show a blood pressure of 100/60 mm Hg and a heart rate of 98/min. Physical examination reveals bilateral parotid gland enlargement, dry mucous membranes, and calluses on the dorsum of her right hand. Which of the following sets of laboratory abnormalities is most likely to be found in this patient?

A $68$-year-old man is brought to the geriatric clinic by his daughter for a follow-up evaluation. For the past $3$ months, he has experienced profound sadness, anhedonia, early morning awakenings, and a $6$-kg ($13$-lb) weight loss. Three weeks ago, he began stating that his "stomach has turned to dust" and now frequently refuses to eat.

Three weeks ago, his primary care physician diagnosed a major depressive episode and prescribed citalopram. The patient took it for $14$ days but stopped it entirely $7$ days ago because "it wasn't doing anything." His past medical history includes severe osteoarthritis, for which he takes daily tramadol.

His daughter privately reports that when the patient was $32$ years old, he had a distinct $6$-week period where he slept only $2$ hours a night, exhibited pressured speech, and impulsively bought two boats, which led to a brief psychiatric hospitalization.

Vital signs are within normal limits. Physical examination is unremarkable.
Laboratory results show:
- Thyroid-stimulating hormone (TSH): $1.2$ $\mu$ U/mL (normal: $0.4$–$4.0$ $\mu$ U/mL)
- Free thyroxine (T4): $0.5$ ng/dL (normal: $0.9$–$2.4$ ng/dL)

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

A 55-year-old asymptomatic woman undergoes a routine screening mammogram. The radiology report notes a new, 8-millimeter cluster of pleomorphic microcalcifications in the upper outer quadrant of the left breast. The patient has no personal or family history of breast cancer. On physical examination, the breasts are symmetric with no skin dimpling, nipple retraction, or erythema. Palpation reveals no distinct masses, and there is no axillary lymphadenopathy. Arrange the following steps in the most appropriate chronological sequence for the evaluation and definitive management of this patient's findings, assuming the lesion is confirmed to be an early-stage malignancy.

Match each patient's clinical presentation and symptom timeline to the most appropriate DSM-5 psychiatric diagnosis.

Nipple discharge can be a presenting symptom for various benign and malignant breast pathologies. Based on the characteristics of the discharge and associated physical exam findings, match each patient's clinical scenario with the most appropriate underlying diagnosis.

A 19-year-old woman is brought to the emergency department after intentionally ingesting ten 500-mg acetaminophen tablets following a recent breakup. She is medically stabilized, and her acetaminophen levels remain well below the treatment threshold. During the psychiatric evaluation, she is tearful and states she feels 'completely empty inside' and hates being alone. She describes a history of intense, short-lived relationships and frequently changing her college major because she 'does not know who she is.' When the physician explains that she will be discharged with a psychiatric outpatient follow-up appointment, she becomes suddenly enraged, yelling, 'You doctors do not care about anyone!' Moments later, she apologizes profusely and begs the physician not to abandon her. She reports that under extreme stress, she sometimes feels like she is detached from her body. Which of the following statements regarding this patient's diagnosis and management are accurate? (Select all that apply)

A 16-year-old girl is brought to the emergency department by her parents due to severe fatigue and dizziness. She has lost 15 kg (33 lb) over the last 4 months and restricts her daily intake to under 500 calories. Her temperature is 35.8°C (96.4°F), blood pressure is 85/50 mm Hg, and pulse is 42/min. Her BMI is 14.2 kg/m². Physical examination reveals fine downy body hair and temporal wasting. The patient is admitted to the hospital.

Arrange the following management steps in the most appropriate chronological order from initial acute management to long-term therapy.

A 26-year-old man comes to the clinic for a follow-up visit. Three weeks ago, he was diagnosed with major depressive disorder after presenting with a 6-week history of depressed mood, anhedonia, significant weight loss, and severe fatigue. At his initial evaluation, a comprehensive psychiatric history confirmed the absence of any past episodes of abnormally elevated mood, impulsivity, or decreased need for sleep. He was started on sertraline 50 mg daily. Today, the patient reports that his sleep has improved slightly, but he still feels sad most days and lacks the energy to resume his usual hobbies. He denies suicidal ideation, auditory hallucinations, or racing thoughts. His vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in management?

A 32-year-old male accountant presents to the psychiatric clinic for evaluation of worsening anxiety. For the past 6 months, he has been overwhelmingly preoccupied with the intrusive thought that he might accidentally send confidential client financial data to the wrong email address. To prevent this, he spends 2 to 3 hours every evening repeatedly checking his outbox and reading every sent email multiple times. He recognizes these thoughts are irrational and excessive, but he states he cannot stop the checking behavior. His performance at work has declined significantly, and his manager has recently issued a formal warning. He was diagnosed with atypical depression by another provider and started on phenelzine 2 weeks ago; however, he abruptly stopped taking it 5 days ago due to severe orthostatic hypotension. He asks the physician to provide a medical note explaining his diagnosis to his employer to prevent termination.

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

Match each clinical scenario to the most appropriate pharmacologic intervention.

A 79-year-old woman is brought to the emergency department from a memory care facility due to a 3-day history of extreme agitation and visual hallucinations. Staff report she has been picking at the air and describing "spiders on the ceiling." The patient has a 4-year history of Major Neurocognitive Disorder due to Alzheimer disease, with a baseline Mini-Mental State Examination score of $17/30$. Five days ago, she was evaluated for new-onset urinary incontinence, and a new medication was prescribed.

Her current daily medications include donepezil and sertraline. Her son, who is visiting from out of state and is not her legally appointed healthcare proxy (her daughter holds this role), is highly distressed and demands the physician immediately administer heavy sedatives to "calm her down."

On examination, the patient's temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), pulse is $110/\text{min}$, and blood pressure is $142/86 \text{ mm Hg}$. She is disoriented, continuously muttering, and unable to participate in cognitive testing. Pupils are $6 \text{ mm}$ bilaterally and minimally reactive to light. Mucous membranes are extremely dry. Abdominal examination reveals absent bowel sounds and a palpable, dull suprapubic mass.

Laboratory results show:
Thyroid-stimulating hormone (TSH): $0.2 \text{ \mu U/mL}$ (Normal: $0.5 - 5.0 \text{ \mu U/mL}$)
Free T4: $1.3 \text{ ng/dL}$ (Normal: $0.9 - 1.7 \text{ ng/dL}$)
Urinalysis: Negative for leukocyte esterase and nitrites.

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

A 74-year-old retired teacher presents to the geriatrics clinic accompanied by her husband. Over the past 6 months, she has become increasingly unsteady on her feet, with her husband describing her walking as if her feet are 'glued to the floor.' Recently, she has also experienced several episodes of urinary incontinence and seems more forgetful than usual. Physical examination reveals a magnetic, broad-based gait with preserved arm swing. There are no focal motor or sensory deficits. To properly evaluate and manage this patient's most likely condition, arrange the following clinical steps in the most appropriate sequential order.

A 24-year-old woman presents to the primary care clinic seeking assistance to quit smoking. She also reports a 4-month history of persistently low mood, decreased energy, and feelings of worthlessness. Her medical history is significant for active bulimia nervosa, characterized by episodes of binge eating followed by self-induced vomiting three times a week. Her vital signs are within normal limits, and her BMI is 22 kg/m². The physician is considering a pharmacological intervention that can simultaneously target her depressive symptoms and aid in smoking cessation. Which of the following medications is absolutely contraindicated in this patient?