All practice questions

A 24-year-old woman comes to the primary care clinic reporting feeling "constantly on edge" for the past 3 months. She states she has been worrying excessively about her academic performance, her finances, and her parents' health. The patient reports experiencing restlessness, muscle tension in her neck and shoulders, and difficulty concentrating on her studies. These symptoms began 3 months ago when she moved to a new city to start a rigorous graduate program. She acknowledges that the transition has been very stressful, and her academic performance has declined because she is so distracted by her worries. She denies any history of trauma, panic attacks, or periods of elevated mood. Her physical examination and laboratory studies, including thyroid-stimulating hormone, are within normal limits. Which of the following is the most likely diagnosis?

A 32-year-old woman presents to the outpatient clinic with a 2-month history of severely depressed mood. She reports sleeping up to 14 hours a day, an increased appetite with a 5-kg (11-lb) weight gain, and a frequent sensation that her arms and legs are "made of lead." She states that she briefly feels better when her friends visit, but her low mood quickly returns. She has no prior psychiatric history and has never been treated for depression. She tearfully requests an antidepressant medication so she can return to her job as an accountant. Her vital signs and physical examination are unremarkable. Laboratory studies reveal a thyroid-stimulating hormone (TSH) level of 1.5 mU/L (normal: 0.4-4.0 mU/L) and a free T4 at the lower limit of normal. A urine toxicology screen is negative. The physician diagnoses a major depressive episode with atypical features and considers initiating pharmacotherapy. Which of the following is the most appropriate next step in management?

A 38-year-old man, a self-employed clock repairman, presents to a primary care clinic for a physical examination required to renew his commercial driver's license. He has not interacted with the healthcare system in over a decade. During the interview, the patient is guarded and reluctant to answer questions regarding his medical history. When asked about his living situation, he becomes irritable, demanding to know why the physician is "prying into my personal life" and questioning whether the clinic intends to share his information with government agencies to revoke his license. The patient's brother, who is in the waiting room, privately informs the nurse that the patient has always been "highly suspicious" of others since his early twenties. The brother notes that the patient frequently accuses his clients of trying to defraud him and has completely cut off contact with several family members because he suspects they are secretly plotting to ruin his business. The patient has never experienced hallucinations, his speech is goal-directed and organized, and he does not hold magical or bizarre beliefs. Which of the following is the most likely diagnosis?

A primary care physician is evaluating a 71-year-old retired mechanic who is accompanied by his son. The son reports that over the past 14 months, his father has exhibited progressive short-term memory loss, missed several bill payments, and recently struggled to recall the names of his grandchildren. The patient feels he is "doing just fine" and is mildly annoyed by the visit. Vital signs are normal, and the neurological examination is nonfocal. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for evaluating and managing this patient's suspected major neurocognitive disorder, from initial clinical assessment to definitive management.

A 24-year-old woman is evaluated in the outpatient psychiatry clinic. She reports a 4-week history of severe sadness, loss of interest in her usual activities, hypersomnia, and low energy. She is diagnosed with major depressive disorder and prescribed escitalopram. The physician counsels her extensively on what to expect during the course of her treatment. Arrange the following clinical events in the typical chronological order of their occurrence after initiating this pharmacotherapy, from earliest to latest.

A $52$-year-old woman comes to the surgical clinic for evaluation of a newly discovered lump in her left breast. She first noticed the mass $2$ weeks ago. $6$ months prior, she underwent a bilateral reduction mammoplasty. She has no personal or family history of breast disease. On physical examination, there is a $3$-cm, firm, irregular mass in the lower outer quadrant of the left breast. The skin overlying the mass shows mild dimpling. There is no axillary lymphadenopathy. Diagnostic mammography reveals a localized area of increased density with coarse, irregular calcifications and spiculated margins. A core needle biopsy of the mass is performed. Which of the following is the most likely histopathologic finding in this patient's breast lesion?

A $26\text{-year-old}$ female graduate student presents to the outpatient psychiatry clinic accompanied by her roommate due to worsening isolation and depression. For the past $3 \text{ weeks}$, the patient has stayed in her room, slept up to $14 \text{ hours}$ a day, and consumed large amounts of junk food, leading to a $4 \text{ kg}$ ($8.8 \text{ lb}$) weight gain. She tells the physician, "I am a failure and I hear a voice whispering that I should just give up." Her roommate mentions that the patient has been taking an over-the-counter herbal supplement, St. John's wort, for the past $2 \text{ months}$ to "help with her mood," but it has not provided any relief.

Review of her psychiatric history reveals that $2 \text{ years}$ ago, she had a distinct $6\text{-day}$ period where she felt "incredibly energized," slept only $3 \text{ hours}$ per night, and simultaneously wrote three term papers while serving as the president of a student club. She did not require hospitalization during that time, and her overall functioning was arguably enhanced.

Her vital signs and physical examination are normal. Laboratory studies, including a TSH of $4.5 \text{ \mu U/mL}$ (normal: $0.5 - 5.0 \text{ \mu U/mL}$) and a free T4 of $0.9 \text{ ng/dL}$ (normal: $0.8 - 1.8 \text{ ng/dL}$), are unremarkable.

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

A 16-year-old girl is hospitalized for severe malnutrition secondary to anorexia nervosa, restricting subtype. Her body mass index (BMI) is $13.2 \text{ kg/m}^2$. The medical team plans to initiate careful nutritional rehabilitation but is acutely concerned about a potentially fatal metabolic complication characterized by severe electrolyte derangements. Arrange the following pathophysiological steps of this syndrome in the correct chronological sequence, starting from the initial dietary trigger to the ultimate clinical manifestations.

Which psychiatric diagnosis or behavioral characterization best corresponds to each of the following patient scenarios?

Match each of the following distinct clinical presentations to the most likely psychiatric medication-induced emergency or movement disorder.

Match each pediatric neurodevelopmental and behavioral clinical vignette with the primary neuropharmacological mechanism of action of the most appropriate targeted pharmacotherapy.

A 72-year-old woman is seen by the surgical team on the fifth day following a right total hip arthroplasty. She complains of new, progressive aching pain in her right thigh and calf that began the previous evening. Her temperature is 38.3°C (100.9°F), blood pressure is 135/85 mm Hg, pulse is 96/min, and respiratory rate is 14/min. Pulse oximetry shows 98% on room air. Physical examination reveals asymmetric edema of the right lower extremity from the mid-thigh down to the ankle, along with localized tenderness over the posterior calf. The surgical incision over the lateral hip is well-approximated with no erythema, warmth, or discharge. Cardiopulmonary examination is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

Accompanied by her roommate, a 22-year-old female university student is evaluated at the student health center for progressive social withdrawal over the past month. The patient reports pervasive sadness, sleeping up to 14 hours daily, and an inability to concentrate on her coursework. The roommate mentions that two years prior, the patient had a distinct two-week period where she painted her entire apartment overnight, slept only 2 hours a night without feeling tired, and exhibited pressured speech, which culminated in an emergency department visit. Currently, the patient's vital signs are within normal limits. Physical examination shows no abnormalities. Mental status examination reveals a tearful young woman with psychomotor retardation and a restricted affect. She denies active suicidal ideation, homicidal ideation, or psychotic symptoms. She explicitly requests that her parents not be contacted regarding her evaluation. Laboratory results, including a comprehensive metabolic panel and thyroid-stimulating hormone levels, are normal. Which of the following is the most appropriate next step in management?

A 76-year-old retired architect is brought to the clinic by his son. Over the past $8$ months, the patient has experienced a progressive decline in his cognitive abilities. His son notes that the patient's alertness fluctuates significantly from day to day; he sometimes stares blankly for several minutes during conversations. The patient also frequently reports seeing unfamiliar children playing in his living room, though he is not distressed by their presence. His medical history includes major depressive disorder, for which he has taken fluoxetine for $5$ years. Vital signs are within normal limits. Neurological examination reveals a resting tremor in the left hand, symmetric rigidity, and a slow, shuffling gait. The Montreal Cognitive Assessment (MoCA) score is $19/30$. Laboratory studies show:

Thyroid-stimulating hormone (TSH): $2.4 \text{ \mu U/mL}$ (normal: $0.4-4.0 \text{ \mu U/mL}$)
Free thyroxine (T4): $1.3 \text{ ng/dL}$ (normal: $0.9-2.4 \text{ ng/dL}$)

The son is overwhelmed by the recent changes and demands that his father be admitted to a locked psychiatric facility immediately. However, the patient's previously executed advance directive designates his wife as the healthcare proxy and expresses a clear preference for home-based care.

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

Match each patient's clinical presentation to the primary pathophysiological mechanism responsible for their psychiatric emergency or drug-induced toxicity.

Match each psychological therapy modality with its core clinical focus and primary indicated psychiatric condition.

A 29-year-old woman presents to the psychiatric clinic for evaluation of severe, pervasive anxiety, muscle tension, and sleep disturbance that have been present for the past 8 months. She constantly worries about her finances, her family's health, and her job security, which has severely impaired her daily functioning. Her past psychiatric history is significant for a depressive episode at age 22. At that time, she was prescribed fluoxetine, but within two weeks of starting the medication, she developed a markedly elevated mood, decreased need for sleep, and grandiosity, leading to hospitalization. Her symptoms resolved shortly after fluoxetine was discontinued. She is currently taking phenelzine for her anxiety, but she reports it is ineffective and she struggles with the dietary restrictions.

Recent laboratory tests, ordered by her primary care physician to investigate her fatigue, reveal the following:

She requests a new medication for her anxiety and asks what her laboratory results mean.

Which of the following are appropriate next steps in the management of this patient? (Select all that apply)

Parents bring their $16$-year-old son to the acute care clinic due to the sudden onset of profound lower extremity weakness. The patient states that his legs feel "like jelly" and he is unable to stand independently. Over the past several months, his parents have noted a significant decline in his academic performance, increased irritability, and a tendency to isolate himself in the family's poorly ventilated detached garage for hours. Vital signs are within normal limits. Physical examination reveals flaccid paralysis of the bilateral lower extremities with absent deep tendon reflexes. A well-demarcated, erythematous, scaling dermatitis is noted surrounding his mouth and nares. His breath emits a faint, sweet, chemical odor. Laboratory studies are obtained and reveal the following:

Which of the following is the most likely primary mechanism underlying this patient's clinical presentation and laboratory findings?

A 33-year-old woman is brought to the outpatient psychiatry clinic by her wife. The patient reports a 3-week history of profound sadness, overwhelming fatigue, increased appetite, and sleeping up to 14 hours a day. She states she has been unable to go to work because she "cannot concentrate on anything." Her medical history is significant for primary hypothyroidism diagnosed 5 years ago, for which she is prescribed levothyroxine. Laboratory tests obtained this morning show a thyroid-stimulating hormone (TSH) level of $1.5 \text{ mIU/L}$ (normal: $0.4-4.0 \text{ mIU/L}$) and a free thyroxine (T4) level of $1.2 \text{ ng/dL}$ (normal: $0.8-1.8 \text{ ng/dL}$).

Further psychiatric interview reveals that two years ago, the patient experienced a 10-day episode where she felt "on top of the world," required only 2 hours of sleep per night, started multiple simultaneous home renovation projects, and spoke so rapidly it was difficult to interrupt her. She was prescribed a medication at that time but discontinued it after a month. She currently takes no psychiatric medications.

Which of the following are appropriate pharmacological interventions for this patient's current episode? (Select all that apply)

A 24-year-old woman is brought to the emergency department by her older sister due to increasingly erratic behavior. The patient has a history of major depressive disorder, for which she currently takes no medications. For the past two weeks, she has been sleeping only 2 hours a night, exhibiting pressured speech, and endorsing grand delusions that she is a highly-trained secret agent. Today, she told her sister, "I have to jump off the hospital roof tonight to prove my immortality to the agency." In the emergency department, the patient is highly agitated, pacing the room, and attempting to elope. She adamantly refuses voluntary admission and any medical treatment. The patient has a valid advance directive from a previous depressive episode that explicitly names her sister as her healthcare proxy. However, the patient's father arrives at the emergency department, states that psychiatric care is a "hoax," and demands to take his daughter home immediately. Which of the following is the most appropriate next step in management?