All practice questions

A 68-year-old woman is brought to the emergency department by her son due to progressive behavioral changes over the past 5 weeks. She has developed profound sadness, anhedonia, and terminal insomnia, typically waking at 3:00 AM and unable to return to sleep. For the past week, she has refused all food and water, repeatedly stating, "My stomach has turned to dust, it cannot process anything." She has lost 6 kg (13.2 lbs) during this period. Her medical history is significant for Parkinson disease, for which she has been taking carbidopa-levodopa and selegiline for three years.

Vital signs show a blood pressure of 96/60 mmHg and a heart rate of 112/min. Physical examination reveals severely dry mucous membranes and decreased skin turgor.

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

A 32-year-old man comes to the primary care clinic seeking advice on weight management. He reports a long history of fluctuating weight and significant distress regarding his body size. His body mass index is 35 kg/m². During the interview, he describes frequent episodes where he consumes unusually large amounts of food, such as eating an entire family-sized pizza and a large carton of ice cream in less than an hour. During these times, he feels a complete loss of control over his eating. These episodes occur at least twice a week and are followed by intense feelings of guilt and self-disgust. He explicitly denies inducing vomiting, using laxatives, fasting, or engaging in excessive exercise after these eating episodes. Which of the following is the most likely diagnosis?

Review the following psychiatric clinical scenarios and correlate each presentation with the most accurate DSM-5 diagnostic classification.

A 28-year-old woman, 3 months postpartum, is brought to the clinic by her husband for a psychiatric evaluation. She has been exclusively formula-feeding her infant. For the past 4 weeks, she has experienced profound sadness, frequent crying spells, excessive sleepiness, and an inability to care for her baby. She states, "I am a terrible mother and my baby deserves better." Three weeks ago, her obstetrician prescribed sertraline, but she discontinued it after 5 days because she "felt it wasn't working fast enough." Her husband notes that 4 years ago, she had a 2-week period where she slept only 2 hours a night, spoke rapidly, and claimed she was chosen by God to lead a new religion; this episode required a brief psychiatric hospitalization. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $110/70 \text{ mm Hg}$, and pulse is $78/\text{min}$. Physical examination is unremarkable. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $1.5 \ \mu\text{U/mL}$ (normal: $0.5-5.0$). She is currently taking no medications. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation with the most appropriate next step in management or pharmacotherapy.

Match each of the following patient clinical vignettes with the most appropriate personality disorder diagnosis.

A 17-year-old male is evaluated in the emergency department after experiencing a syncopal episode during cross-country track practice. He reports strictly limiting his food intake over the past 8 months to 'optimize his race times' and has subsequently lost 18 kg (40 lb). Temperature is 35.8°C (96.4°F), blood pressure is 80/50 mmHg, pulse is 38/min, and BMI is 13.5 kg/m². Physical examination reveals temporal wasting, lanugo on his back, and cold, cyanotic extremities. An electrocardiogram reveals marked sinus bradycardia with a prolonged QTc interval. Laboratory studies demonstrate significant hypokalemia, hypomagnesemia, and hypophosphatemia. Arrange the following interventions in the most appropriate chronological order for the comprehensive management of this patient, from the most immediate acute intervention to long-term follow-up.

A 41-year-old man is brought to the emergency department by emergency medical services due to severe agitation and abdominal cramps. The patient states he was discharged earlier this morning from a residential rehabilitation facility after completing a 5-day medically supervised withdrawal for alcohol use disorder. His past medical history is significant for a 10-year history of severe opioid use disorder, for which he has been enrolled in a methadone maintenance program for the last 3 years with no recent illicit opioid use. At the time of his discharge from the alcohol rehabilitation facility today, he was prescribed a daily oral medication to reduce alcohol cravings. He took the first dose of this new medication 45 minutes ago and rapidly developed his current symptoms. He denies consuming any alcohol since entering the rehabilitation program. His temperature is 37.8°C (100.0°F), blood pressure is 156/94 mm Hg, pulse is 112/min, and respirations are 22/min. Physical examination reveals a restless, profusely diaphoretic man. He is yawning frequently and has prominent rhinorrhea. Pupils are dilated at 7 mm bilaterally and reactive to light. Neuromuscular examination reveals diffuse myalgias but no rigidity or clonus. Bowel sounds are hyperactive. The medication prescribed at discharge most likely exerts its primary effect at which of the following targets?

A 36-year-old nulligravida seeks medical advice because she has noticed red-tinged fluid staining her bra over the past three weeks. The leakage occurs spontaneously and is limited to her right side. She denies any associated breast pain, skin changes, or recent trauma. Menarche occurred at age 12, and her menstrual cycles are regular. She takes no medications and has no family history of breast or ovarian malignancy. On physical examination, vital signs are within normal limits. Careful palpation reveals no discrete breast masses or axillary lymphadenopathy. Gentle pressure around the right areola elicits a few drops of frankly bloody discharge from a single duct. A urine pregnancy test is negative. Which of the following is the most appropriate next step in management?

A 41-year-old male electrician is brought to the outpatient psychiatric clinic by his brother. The patient reports a 6-week history of overwhelming fatigue, anhedonia, and sleeping 12 to 14 hours daily. He has been unable to work and struggles to perform basic personal hygiene. Review of his psychiatric history reveals an episode three years ago during which he experienced a persistently elevated mood, believed he had discovered a groundbreaking theory of electricity, and stayed awake for 8 days straight working on erratic diagrams. That episode culminated in involuntary psychiatric hospitalization. He currently takes no medications, and his basic laboratory workup, including a thyroid panel, is unremarkable. Which of the following is the most appropriate pharmacotherapy for this patient's current presentation?

An $80$-year-old man with a history of moderate Alzheimer disease and benign prostatic hyperplasia is brought to the emergency department by his daughter, who is his legally appointed healthcare proxy. Over the past $48$ hours, he has become acutely agitated, disoriented, and has been grasping at invisible objects. Two days ago, he started taking an over-the-counter diphenhydramine preparation for insomnia. The patient's visiting son arrived today and insists the patient be transferred immediately to a psychiatric facility. A recent outpatient urine culture grew $>10^5 \text{ CFU/mL}$ of Escherichia coli sensitive to nitrofurantoin and cephalexin. Recent thyroid tests showed a serum thyroid-stimulating hormone of $1.5 \ \mu\text{U/mL}$ (normal: $0.4-4.0 \ \mu\text{U/mL}$) and a free thyroxine of $0.5 \text{ ng/dL}$ (normal: $0.9-2.4 \text{ ng/dL}$). Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $135/85 \text{ mm Hg}$, pulse $108\text{/min}$, and respirations $16\text{/min}$. Physical examination reveals dry oral mucosa, flushed skin, and a palpably distended bladder. Which of the following is the most appropriate initial management for this patient?

Match each clinical presentation of acute substance intoxication to the primary molecular mechanism of the offending agent.

Match each patient's clinical presentation with the most appropriate tailored pharmacotherapy or neuromodulation therapy.

Match the following brief clinical presentations to their most appropriate DSM-5 psychiatric diagnosis.

Match each clinical vignette with the most likely underlying neurocognitive diagnosis.

A 24-year-old woman is admitted to the inpatient medical-surgical ward for intravenous antibiotic treatment of a complicated lower extremity cellulitis. Over the past 48 hours, her behavior has become increasingly disruptive. During morning rounds, she tells the daytime attending physician, "You are the only brilliant doctor in this hospital. The night shift nurses and doctors are completely incompetent, and I think they are trying to ruin my recovery on purpose." She is pleasant and cooperative with the daytime medical team. However, later that evening, the night charge nurse reports that the patient was screaming at the staff, calling the daytime doctors "clueless," and demanding that the night team ignore the morning care plan. The patient has a history of multiple brief, intense relationships and recurrent suicidal gestures, though she currently denies suicidal ideation. This situation has caused significant arguments between the day and night shift staff regarding her care. Which of the following is the most appropriate next step in management?

Match each highly specific clinical presentation and diagnostic finding to the most likely corresponding substance-related etiology.

A 32-year-old female high school teacher presents to the clinic reporting a 4-week history of severely depressed mood, profound fatigue, and sleeping up to 14 hours a day. She says she can no longer concentrate on grading her students' assignments and feels completely worthless. The patient mentions she had a similar period of depression in her mid-twenties. When asked about periods of unusually elevated mood, she recalls an episode three years ago that lasted for 12 days. During that time, she felt "invincible," slept only 2 hours a night without feeling tired, spoke so rapidly that friends could not understand her, and impulsively spent her life savings on a high-risk investment. Her vital signs are within normal limits. Physical examination is unremarkable. Laboratory tests reveal a thyroid-stimulating hormone (TSH) level of 2.1 µU/mL (normal: 0.4-4.0 µU/mL) and free thyroxine (T4) of 1.2 ng/dL (normal: 0.8-1.8 ng/dL). Which of the following is the most appropriate next step in the management of this patient?

Match each patient presentation with the most appropriate next step in clinical management.

A 24-year-old woman with a 3-year history of schizophrenia is admitted to the inpatient psychiatric unit. For the past four days, she has been entirely mute, refuses all food and fluids, and maintains rigid postures for hours. When the examiner attempts to reposition her arm, it remains exactly where placed. Her current medication is oral risperidone 4 mg daily, which her parents state she took consistently until three days ago. Her vital signs are within normal limits. Arrange the following management steps in the most appropriate chronological sequence for this patient's episode of care, assuming sequential escalation is required due to refractory symptoms before eventual resolution.