All practice questions

A 20-year-old collegiate gymnast is evaluated at the university clinic after reporting several weeks of profound muscle weakness, generalized fatigue, and intermittent muscle cramps. Her vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), heart rate 94/min, blood pressure 105/65 mm Hg, and respiratory rate 18/min. BMI is 19.5 kg/m $^2$. Physical examination reveals dry mucous membranes and diminished deep tendon reflexes bilaterally. Her dental enamel is completely intact, and there are no calloused lesions on the dorsal aspects of her hands. The parotid glands are not enlarged.

Laboratory studies are obtained and show the following:

Which of the following compensatory behaviors is most likely responsible for this patient's clinical and laboratory findings?

During a routine follow-up at a community health clinic, a $29$-year-old male construction worker describes experiencing severe restlessness, diffuse muscle aches, abdominal cramping, and insomnia over the previous $36$ hours. The patient discloses that he had been illicitly purchasing oxycodone to self-medicate for chronic lower back pain. However, he abruptly discontinued its use $2$ days ago to 'get clean.' He is highly motivated to remain abstinent and emphatically declines any opioid-based substitution therapy, emphasizing his desire for a non-addictive treatment option. Vital signs reveal a temperature of $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure of $156/98\text{ mm Hg}$, heart rate of $118\text{ /min}$, and respiratory rate of $18\text{ /min}$. Physical examination demonstrates an anxious, diaphoretic patient with prominent piloerection, frequent yawning, and mydriasis. To specifically target this patient's acute autonomic hyperarousal, the physician prescribes a non-opioid medication. Which of the following neuropharmacological mechanisms best describes the action of the most appropriate drug for this indication?

A 24-year-old woman presents to the outpatient psychiatry clinic complaining of persistent sadness, fatigue, and lack of motivation for the past month. She reports sleeping up to 14 hours a day, an increased appetite with a 4 kg (8.8 lb) weight gain, and difficulty concentrating at work. Medical history is unremarkable, and she does not use illicit substances. During the interview, she mentions that two years ago, she experienced a distinct 6-day period where she felt exceptionally energetic and creative. During that time, she slept only 2 hours a night without feeling tired, spoke much faster than usual, and impulsively booked an expensive vacation she could not afford. Her symptoms during that period did not require hospitalization and resolved spontaneously. If initiated as monotherapy for her current presentation, which of the following medications is most likely to precipitate an adverse psychiatric outcome?

A 72-year-old woman is brought to the emergency department from an assisted living facility due to a sudden onset of severe abdominal pain out of proportion to physical findings, accompanied by bloody diarrhea. An urgent CT angiogram of the abdomen confirms acute mesenteric ischemia. Emergency bowel resection is indicated to prevent death. The patient has a 40-year history of treatment-resistant schizophrenia. During the evaluation, she is actively hallucinating and states, "The government put snakes in my belly. If you cut me open, they will escape and eat everyone." She adamantly refuses the surgery. Her vital signs are temperature 37.8°C (100.0°F), blood pressure 90/60 mmHg, pulse 115/min, and respirations 22/min. The medical record includes a valid advance directive executed five years ago during a period of psychiatric stability. This document appoints her eldest daughter as her sole healthcare proxy. The daughter is contacted by phone, understands the grave prognosis, but declines the surgery, stating, "When she was lucid, my mother explicitly told me she never wanted major surgery or life support at this stage of her life." The patient's younger son arrives at the emergency department shortly after. He is distraught and demands that the surgical team operate immediately, stating, "I am her son too! You have to save her, do the surgery now!" Which of the following is the most appropriate next step in management?

A 32-year-old woman is brought to the emergency department by her sister due to a 3-week history of worsening social withdrawal, profound sadness, and extreme fatigue. The patient sleeps up to 15 hours a day and frequently states, "Everyone would be better off without me." Her sister notes the patient recently stopped attending her job as an accountant.

Review of her medical history reveals a depressive episode three years ago, for which her primary care physician prescribed fluoxetine. Three weeks into that treatment, the patient abruptly quit a previous job, flew to another continent alone, and spent her entire life savings over the course of seven days while sleeping less than two hours per night. She was hospitalized abroad, the fluoxetine was discontinued, and her mood gradually stabilized over the next month.

The patient currently takes no medications and uses no illicit substances. Vital signs are within normal limits. Physical examination reveals a flat affect and psychomotor retardation.

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

An 81-year-old retired teacher is accompanied to the outpatient geriatrics clinic by her daughter. The daughter reports that over the past six to nine months, the patient has become increasingly forgetful and struggles to plan her usual weekly garden club meetings. Furthermore, the patient has recently stopped visiting her friends because she is embarrassed by frequent episodes of urinary incontinence. When asked about her mobility, the patient states, 'My feet feel like they are stuck to the ground.' Medical history is significant for well-controlled type 2 diabetes mellitus and mild osteoarthritis. Vital signs are within normal limits. Neurologic examination reveals a wide-based, slow, shuffling gait, but there is no resting tremor, cogwheel rigidity, or bradykinesia of the upper extremities. Cognitive testing reveals prominent deficits in executive function and attention. Which of the following is the most likely diagnosis?

A 27-year-old man is evaluated in the clinic for severe anxiety and sleep disturbances. Three months ago, he survived a severe house fire in which he sustained extensive burns to his right lower extremity. The burns were complicated by methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis, for which he is currently in the second week of a 6-week course of oral linezolid. He reports that for the past two months, he has been having intense nightmares about the fire and frequently wakes up drenched in sweat. He actively avoids cooking or being near stoves and feels "on edge" most of the day. During the interview, a loud siren sounds outside; he suddenly drops to the floor, covers his head, and appears briefly unresponsive to the physician's voice, vividly reliving the fire. He has no previous psychiatric history. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation with the underlying histopathologic or pathophysiologic finding most likely responsible for her condition.

During a routine telehealth appointment, a 28-year-old marketing executive describes a 6-week history of worsening dysphoria, profound anhedonia, and debilitating fatigue. She reports sleeping up to 12 hours a day and experiencing a 5-kg (11-lb) weight gain over this period. The patient expresses excessive guilt over her recent decline in work performance. She has no significant past medical history and does not consume alcohol or illicit substances. The physician considers initiating pharmacotherapy with a selective serotonin reuptake inhibitor. Which of the following is the most appropriate next step in the management of this patient?

An addiction medicine consultation team is reviewing multiple complex patient cases in the emergency department involving suspected acute intoxications. Match each distinct clinical presentation to the most likely responsible substance.

A 25-year-old woman is admitted to the inpatient psychiatric unit for an acute exacerbation of schizoaffective disorder. During the evening shift, she becomes increasingly distressed, claiming that the nursing station is broadcasting her thoughts. She begins throwing plastic cups across the hallway and screaming at the staff to stop the broadcast. She is hypervigilant, visibly tense, and standing defensively in the hallway corner, but she has not attacked anyone. Arrange the following interventions in the most appropriate stepwise escalation sequence for managing this patient's acute agitation, starting with the initial preferred step.

A 45-year-old woman presents to the clinic with a 6-month history of difficulty falling asleep and staying asleep. She states that her sleep problems began after a stressful period at work but have persisted despite the stress resolving. She reports daytime fatigue that is noticeably affecting her job performance. She has no other medical conditions and takes no medications. Arrange the following steps in the most appropriate chronological sequence for the standard clinical management of this patient's condition.

A 27-year-old male actor comes to the clinic for a routine evaluation prior to starting filming for a new movie. Over the past 5 months, he has purposefully lost $14 \text{ kg}$ ($30.8 \text{ lb}$) by restricting his caloric intake to fewer than $500 \text{ kcal/day}$ and engaging in strenuous cardiovascular exercise for 3 hours daily. He states, "I have to look absolutely emaciated for this role, but I feel so weak and dizzy when I stand up." He strongly denies binge eating, self-induced vomiting, or the use of laxatives or diuretics. His body mass index is $16.2 \text{ kg/m}^2$. Vital signs show a blood pressure of 88/58 mm Hg and a heart rate of 48/min. Physical examination reveals temporal wasting, dry skin, and fine, downy hair on his upper back.

Laboratory studies show:

Arterial blood gas (room air):

Which of the following best describes this patient's primary acid-base disturbance and its underlying etiology?

A 38-year-old male software engineer is evaluated in the clinic for worsening mood. He reports feeling profoundly sad, having no energy, sleeping up to 14 hours a day, and gaining 4.5 kg (10 lb) over the past 6 weeks. His husband notes that the patient has been unable to concentrate on his work and frequently expresses feelings of worthlessness. The patient has no other medical conditions and currently takes no medications. A review of his medical records reveals a psychiatric hospitalization three years ago for a 10-day episode characterized by an abnormally elevated mood, a decreased need for sleep (averaging 2 hours per night), pressured speech, and reckless financial investments that led to personal bankruptcy. His vital signs and physical examination today are unremarkable. Which of the following are appropriate pharmacological interventions for this patient's current condition? (Select all that apply)

A 28-year-old woman is evaluated in the emergency department after her roommate called emergency services. The roommate reported that the patient threatened to 'jump off the balcony' following a breakup with her boyfriend of one month. During the interview, the patient is calm and states, 'I did not actually mean it. I just wanted him to realize how much pain he caused me.' She says her boyfriend was 'the most perfect man ever' until yesterday, when she realized he is 'a complete monster.' The roommate notes that the patient has a history of impulsive spending, intense mood swings that typically last for a few hours, and a chronic feeling of emptiness. The patient mentions that when she gets extremely stressed, she sometimes hears a muffled voice calling her name, but this goes away quickly once she calms down. Her medical history includes atypical depression, for which she currently takes phenelzine. She asks the physician, 'Please do not tell my workplace about this visit; I told my manager I had a severe migraine.' The patient has no current suicidal ideation or plan.

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

A 29-year-old woman presents to the outpatient psychiatry clinic accompanied by her husband, 4 weeks after delivering a healthy full-term infant. She reports severe, exhausting anxiety and highly distressing, recurrent images of accidentally drowning her baby while giving him a bath. She is horrified by these images, recognizes them as irrational, and states, 'I would never hurt my child, but my brain keeps flashing this terrible picture.' Consequently, she refuses to bathe the baby and frequently checks the crib to ensure the baby is breathing, sometimes up to 20 times an hour.

Her psychiatric history is notable for a hospitalization at age 20 during which she experienced a 3-week period of decreased need for sleep, rapid pressured speech, and grandiose spending. She was diagnosed with a mood disorder at that time but discontinued all medications five years ago. Currently, she exhibits no signs of elevated mood, hallucinations, or delusions. She is exclusively breastfeeding.

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

Match each patient's clinical presentation with the most accurate DSM-5 diagnosis based on the primary motivation for their symptoms or avoidance behavior.

A 30-year-old man comes to the clinic for a routine psychiatric evaluation. He was recently diagnosed with schizophrenia and has been experiencing auditory hallucinations. During the interview, he becomes visibly angry and states, "The voices are telling me that my neighbor is an undercover agent trying to destroy me. I am going to buy a gun today and shoot him when he gets home." The patient has no previous history of violence but is adamant about his plan. He refuses voluntary admission to the hospital and attempts to leave the clinic. Which of the following is the most appropriate next step in management?

A $28$-year-old man is brought to the emergency department by his partner due to worsening lethargy and near-syncope. Over the past year, he has severely restricted his dietary intake and exercises intensely for $3$ hours daily, expressing a profound fear of gaining weight. Physical examination reveals temporal wasting and lanugo over his trunk. Temperature is $35.2^\circ\text{C}$ ($95.4^\circ\text{F}$), blood pressure is $82/50 \text{ mm Hg}$, pulse is $38\text{/min}$, and respirations are $12\text{/min}$. His body mass index is $12.4 \text{ kg/m}^2$. Electrocardiogram reveals sinus bradycardia with a prolonged QTc interval. Initial laboratory studies show:

Arrange the following clinical management steps in the most appropriate chronological sequence for this patient.

Match each distinct clinical presentation with the most likely underlying neurocognitive etiology.