All practice questions

A 22-year-old man is diagnosed with schizophrenia. His psychiatrist is planning a long-term pharmacological management strategy and outlining potential next steps depending on his clinical response over time. Arrange the following treatment steps in the correct standard sequential order for the management of schizophrenia, proceeding from initial therapy to the management of severe treatment-resistant disease.

A 52-year-old woman presents to the clinic complaining of progressive left breast swelling, redness, and heaviness over the past month. She reports no fever, chills, or breast trauma. She is postmenopausal and has never had breast cancer. Two weeks ago, she visited an urgent care clinic and was prescribed a 10-day course of oral dicloxacillin for presumed mastitis. She completed the antibiotics, but her symptoms have continued to worsen. On physical examination, her vital signs are within normal limits. The left breast is visibly enlarged and erythematous compared to the right. The skin of the left breast exhibits diffuse thickening and prominent pores, resembling the skin of an orange. The left nipple is newly retracted. Palpation of the left axilla reveals a firm, fixed, 2.5-cm lymph node. Which of the following is the most appropriate next step in the evaluation of this patient?

A 42-year-old man is evaluated on the surgical ward due to severe agitation and confusion. He was admitted two days ago after sustaining a right femur fracture in a motor vehicle collision, for which he underwent an uncomplicated open reduction and internal fixation. His medical history is significant for a 15-year history of heavy daily alcohol consumption, but he has had no access to alcohol since his admission. His temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $168/102\text{ mmHg}$, pulse is $124/\text{min}$, and respirations are $22/\text{min}$. On examination, the patient is profusely diaphoretic and tremulous. He is disoriented to time and place and repeatedly swats at the air, claiming that spiders are crawling down the walls. The surgical incision site is clean, dry, and intact. Which of the following is the most appropriate next step in the management of this patient?

A 36-year-old man, who works as a software quality assurance manager, comes to his primary care physician for a routine physical examination. He hands the physician a neatly bound, color-coded 20-page document detailing his daily blood pressure readings, caloric intake, and sleep duration for the past six months. He complains of chronic fatigue, stating that he often stays awake until 3:00 AM reviewing his subordinates' code. He says, "If I do not check every single line myself, they will ruin the product. It is just more efficient if I take over their tasks." He mentions that his wife recently threatened to separate from him because he refuses to let her load the dishwasher, arguing she "never follows the optimal spatial configuration." The patient does not believe his behavior is problematic; rather, he is highly frustrated that others fail to meet his exacting standards. He denies experiencing recurrent intrusive thoughts that cause him distress, and he does not perform repetitive physical rituals to neutralize anxiety. Which of the following is the most likely diagnosis?

During a scheduled appointment at the university health center, the parents of a 20-year-old undergraduate student express deep concern regarding their son's recent behavior. Over the previous 16 weeks, the student has dedicated up to 5 hours every evening to vigorously washing his hands and disinfecting his living space. When questioned about the necessity of this routine, the patient becomes visibly agitated and insists, 'My room is covered in microscopic parasites. If I don't eliminate them completely, they will infest my family and cause a fatal disease.' The evaluating physician probes further, asking if there is any chance this fear might be disproportionate. The patient responds, 'Absolutely not. It is an undeniable reality; I can feel them crawling on my epidermis.' He denies experiencing any auditory or visual hallucinations, and his thought process remains linear and goal-directed. Despite the extensive time consumed by these rituals, he has sustained excellent academic performance. Physical examination is notable only for severe erythema and desquamation on both hands. Urine toxicology is negative.

Which of the following is the most appropriate initial pharmacological therapy for this patient's condition?

A 52-year-old man is evaluated on postoperative day 3 following an emergency exploratory laparotomy and repair of a perforated duodenal ulcer. The nursing staff reports that he has become increasingly combative over the last few hours. The patient is shouting that there are "swarms of insects" crawling on the walls of his room. He has no known psychiatric history. His medical history is significant for hypertension and a 20-pack-year smoking history. Social history is notable for drinking 6 to 8 beers daily, though he stated he was planning to quit while in the hospital. Vital signs are temperature 38.8°C (101.8°F), blood pressure 168/102 mmHg, pulse 122/min, and respirations 22/min. Physical examination reveals a diaphoretic, agitated man. Abdominal exam shows a clean, intact surgical incision with mild tenderness but no rebound or guarding. Neurologic examination shows a coarse, rhythmic tremor of the outstretched hands. Which of the following is the most appropriate next step in the management of this patient?

A 19-year-old female college student is evaluated at the student health clinic after her resident advisor expressed concerns about her behavior. According to the advisor, the patient has isolated herself in her dormitory for the past seven months. During this entire period, she has consistently claimed that the university's Wi-Fi network is transmitting government mind-control signals into her brain. She is frequently observed pacing the hallways at night while mumbling and responding to unseen individuals. The patient's academic performance has dropped significantly, and her emotional expression during the interview is noticeably flat. She has no history of substance use or medical illnesses, and a urine toxicology screen is negative. Which of the following is the most appropriate diagnosis?

A 24-year-old male is evaluated in the outpatient psychiatry clinic for the management of a recently diagnosed bipolar I disorder. The physician discusses various maintenance medication options, their baseline monitoring requirements, and their characteristic adverse effect profiles. Match each psychotropic medication discussed during the consultation to its correct baseline monitoring requirement and specific adverse effect risk.

A 22-year-old woman is admitted to the inpatient psychiatric unit for the management of severe anorexia nervosa, restricting subtype. On admission, her body mass index (BMI) is 13.8 kg/m². Her vital signs show a blood pressure of 88/54 mm Hg, pulse of 44/min, and respiratory rate of 12/min. Physical examination reveals temporal wasting and fine, downy hair on her arms and back. Initial laboratory studies show normal serum electrolytes. A closely monitored nutritional rehabilitation program is initiated with enteral feedings. On the third day of hospitalization, the patient develops acute-onset profound muscle weakness, areflexia, and difficulty breathing. An electrocardiogram demonstrates premature ventricular complexes. Which of the following pathophysiologic mechanisms is the primary cause of this patient's acute clinical deterioration?

A 35-year-old female marketing director is evaluated in the outpatient psychiatry clinic for a 4-week history of severely depressed mood. She reports sleeping up to 14 hours daily, profound fatigue, a 4-kg (8.8-lb) weight gain, and feelings of worthlessness. She states, 'My family would be better off if I were gone,' but she denies an active plan or intent for self-harm. Three years ago, she was brought to the emergency department after a 10-day period of sleeping only 2 hours per night, rapid speech, and impulsive spending that depleted her savings. She is currently medically healthy and takes no medications. Vital signs and physical examination are unremarkable. Following the evaluation, the patient's husband leaves a voicemail for the physician, requesting an update on his wife's condition. Which of the following are appropriate components of this patient's management plan? (Select all that apply)

A 64-year-old man is brought to the clinic by his husband for a 9-month history of progressive memory impairment, worsening apathy, and newly developed difficulty managing their household finances. His husband notes that the patient experienced a severe major depressive episode following an early retirement a year ago, which was partially responsive to a selective serotonin reuptake inhibitor. Physical and neurologic examinations reveal no focal deficits. The physician suspects a neurocognitive disorder but must carefully differentiate this from other etiologies, particularly given the prominent psychiatric history.

Arrange the following diagnostic steps in the most appropriate sequential clinical order, proceeding from the initial baseline evaluation to the most advanced, specialized investigations.

Match each clinical presentation to the most appropriate diagnostic category.

An otherwise healthy 47-year-old female patient schedules an appointment after discovering a firm, painless lump in the upper outer quadrant of her left breast. She has no significant medical history and no family history of breast cancer. Assuming each diagnostic step indicates a high suspicion for malignancy, arrange the following clinical actions in the standard chronological order for evaluating and managing this patient's finding.

A 24-year-old male medical student presents to the student health clinic reporting severe anxiety about his upcoming surgery clerkship. He states that whenever he sees blood or surgical instruments, he experiences severe nausea, lightheadedness, and profound diaphoresis. During a minor suture workshop 6 months ago, he had a similar reaction and fainted. He states, "I know my fear is completely irrational, but in those moments, I feel so disconnected from reality that the room seems to be shrinking." He is terrified of failing his rotation. His past medical history is significant for mild intermittent asthma, for which he uses an albuterol inhaler as needed, and bipolar I disorder, for which he stopped taking his mood stabilizer 8 months ago because he "felt cured." Which of the following is the most appropriate next step in management?

During a follow-up visit at the university health center, a 24-year-old graduate student reports persistent feelings of profound sadness and lack of motivation that have severely impacted her studies over the past eight weeks. She mentions sleeping 11 to 13 hours daily, a recent 5-kg (11-lb) weight gain, and a sensation that her limbs are "made of lead." Two weeks prior to this visit, a physician prescribed citalopram. The patient reveals she abruptly stopped taking it three days ago due to mild nausea and a belief that "the pills were completely useless." While exploring her psychiatric history, she mentions a distinct 2-day period during her freshman year when she felt "euphoric and full of energy," requiring only a few hours of sleep while celebrating the end of final exams with friends. Her mood returned to baseline shortly after the weekend. She currently takes no medications and uses no illicit substances. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old man is evaluated in the outpatient psychiatry clinic at the insistence of his husband. For the past 8 months, the patient has been absolutely convinced that a rival accounting firm has hacked his home network and is monitoring his digital footprint. Consequently, he has disconnected the home Wi-Fi and sweeps the house weekly for hidden listening devices. Despite these behaviors at home, the patient continues to excel as a senior accountant at his firm, socializes appropriately with peers, and exhibits a normal, reactive affect with no evidence of disorganized speech or hallucinations.

Two months ago, the patient developed a pervasively depressed mood, early morning awakenings, anhedonia, and a 4-kg (9-lb) weight loss. He stated he felt "hopeless about ever regaining my privacy." These mood symptoms lasted for exactly 3 weeks before completely resolving after he purchased a sophisticated electronic signal jammer. He currently reports feeling emotionally well but remains convinced of the ongoing surveillance. Physical examination and urine toxicology screens are unremarkable. Which of the following is the most likely diagnosis?

An 82-year-old man arrives at the emergency department accompanied by his daughter due to severe agitation, disorientation, and visual hallucinations that began acutely $48$ hours ago. He repeatedly points to the corner of the room, claiming that intruders are hiding there. His daughter notes that over the past $3$ years, he has developed mild forgetfulness, such as occasionally misplacing his keys, but he has always remained independent in his daily activities. His medical history includes hypertension, osteoarthritis, and major depressive disorder. His daily medications include lisinopril and fluoxetine. Two weeks ago, he was prescribed tramadol for worsening knee pain. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $130/80\text{ mmHg}$, and a heart rate of $82\text{/min}$. Physical examination reveals no focal neurologic deficits, normal muscle tone, and absent clonus. He is unable to recite the months of the year backward. Laboratory testing reveals a thyroid-stimulating hormone (TSH) level of $2.1\text{ }\mu\text{U/mL}$ (normal: $0.5-5.0\text{ }\mu\text{U/mL}$) and free thyroxine (T4) of $1.2\text{ ng/dL}$ (normal: $0.9-2.4\text{ ng/dL}$). Urinalysis is positive for leukocyte esterase, nitrites, and numerous leukocytes. What is the most accurate diagnosis for this patient's current presentation?

Match each clinical vignette describing a psychiatric presentation to the most appropriate DSM-5 diagnostic category based on core clinical features, symptomatology, and timeframe.

A 45-year-old man presents to the primary care clinic for a routine check-up. He has a history of hypertension. Vital signs show a blood pressure of 148/92 mmHg, a heart rate of 88/min, and a respiratory rate of 14/min. Physical examination reveals mild hepatomegaly. Upon questioning, he reports drinking 6 to 8 beers daily and screens positive for severe alcohol use disorder. The physician plans to use the Transtheoretical Model (Stages of Change) to guide behavioral counseling. In what chronological order do the stages of change typically occur, progressing from an initial lack of awareness to long-term sustained behavior change?

A 45-year-old woman is evaluated for worsening right-sided back pain, nausea, and decreased urine output on postoperative day 2 following an uncomplicated total laparoscopic hysterectomy for uterine fibroids. Her temperature is 38.3°C (100.9°F), blood pressure is 120/80 mmHg, and pulse is 95/min. Physical examination shows right costovertebral angle tenderness. An indwelling Foley catheter is in place and has drained 20 mL of urine over the past 3 hours. Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order to evaluate and manage this patient's condition.