All practice questions

Evaluate the clinical scenarios describing older adult patients presenting with progressive cognitive or behavioral changes. Match each distinct clinical presentation with its definitive diagnostic finding or most likely underlying pathophysiological mechanism.

A $31$-year-old man presents via telehealth for an initial psychiatric evaluation. He reports a $7$-week history of persistent low mood, extreme lethargy, and a $6$-kg ($13$-lb) weight gain. He sleeps up to $15$ hours a day and describes his limbs as feeling 'unnaturally heavy.' For the past $2$ weeks, he has also been hearing a distinct, critical voice telling him he is 'toxic and contagious' whenever he is alone in his room. Upon detailed psychiatric history taking, he reveals that $3$ years ago, he was hospitalized for a $10$-day period during which he believed he was a divine messenger, slept only $1$ hour per night, and paced the streets preaching. He was stabilized and discharged but stopped his prescribed medications shortly afterward. He recently began taking a high-dose over-the-counter St. John's wort supplement to improve his mood, but it has provided no relief. A recent primary care blood panel shows a thyroid-stimulating hormone (TSH) level of $2.1$ mU/L (normal: $0.5$-$5.0$) and a free thyroxine (T4) level of $1.1$ ng/dL (normal: $0.8$-$1.8$). Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old man is brought to the emergency department by police due to erratic behavior in public. He is pacing the evaluation room, speaking loudly, and appears acutely agitated. He has not yet committed any acts of physical violence but is becoming increasingly uncooperative and hostile. Arrange the following interventions in the standard stepwise order for managing this acutely agitated patient, from the initial, least restrictive measure to the final, most restrictive measure.

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

Match the following psychiatric legal and ethical concepts with their most appropriate clinical scenario.

Match each psychotropic medication with its most characteristic adverse effect, specific monitoring requirement, or clinical contraindication.

A 28-year-old man is brought to the emergency department by police after he was found running through traffic, shouting that he is "being hunted by assassins." He is highly agitated, uncooperative, and combative. The patient has a history of major depressive disorder. Medical records indicate he takes citalopram. A friend who arrives at the ED reports the patient recently started taking an over-the-counter herbal supplement for mood enhancement and was also prescribed linezolid for a skin infection at an urgent care clinic two days ago. His temperature is $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$), pulse is $134/\text{min}$, respirations are $24/\text{min}$, and blood pressure is $172/98\text{ mm Hg}$. Physical examination reveals severe diaphoresis and mydriasis. Neurological examination is notable for hyperreflexia and sustained bilateral ankle clonus. The patient is delirious, disoriented to time and place, and violently resists examination, screaming, "You're not touching me! I'm leaving!" as he attempts to climb off the stretcher. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old woman comes to the clinic reporting progressive fatigue, mild shortness of breath on exertion, and tingling in her fingertips over the past two weeks. She has a long-standing history of binge-eating disorder characterized by eating large amounts of food with a sense of loss of control, without any compensatory purging behaviors. Three weeks ago, her psychiatrist initiated a new medication that is also indicated for migraine prophylaxis to help manage her binge-eating episodes and promote weight loss. Her body mass index (BMI) is $32.4 \text{ kg/m}^2$. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), pulse is $88/\text{min}$, blood pressure is $118/76\text{ mm Hg}$, and respirations are $18/\text{min}$.

Which of the following best describes the acid-base disturbance in this patient resulting from her new psychiatric medication?

A 50-year-old man is evaluated on the surgical ward on postoperative day 3 following an uncomplicated partial colectomy for recurrent diverticulitis. The cross-cover physician is called because the patient has become acutely disoriented, diaphoretic, and extremely agitated, stating that he sees spiders descending from the ceiling. Vital signs reveal a temperature of $38.5^\circ\mathrm{C}$ ($101.3^\circ\mathrm{F}$), blood pressure of $172/106\text{ mmHg}$, pulse of $128/\text{min}$, and respiratory rate of $24/\text{min}$. Physical examination shows a coarse tremor of the extended hands. His surgical dressings are clean and intact, and the abdomen is nondistended with mild expected incisional tenderness. A review of his preoperative social history indicates he consumes one pint of whiskey daily. Which of the following is the most appropriate next step in management?

Paramedics rush a $34$-year-old woman to the emergency department. Her husband discovered her unresponsive in their bedroom alongside an empty bottle of her recently prescribed antidepressant. According to the husband, she suffers from major depressive disorder and has been enduring a severe relapse over the past month.

Upon arrival, her temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $90/60\text{ mmHg}$, pulse is $128/\text{min}$, and respirations are $6/\text{min}$. Physical examination reveals dilated, minimally reactive pupils, completely dry mucous membranes, and absent bowel sounds. She is deeply obtunded and withdraws only to painful stimuli. An electrocardiogram demonstrates sinus tachycardia with a QRS duration of $150\text{ ms}$.

As the medical team prepares for immediate endotracheal intubation, the husband produces a legally valid, notarized advance directive that the patient completed one year ago. The document explicitly mandates: 'I refuse mechanical ventilation and cardiopulmonary resuscitation under any circumstances.' The husband pleads, 'She has been expressing a desire to end her life for weeks. She meant every word in this document. You must respect her legal rights and not put her on a breathing machine.'

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

For each of the following pediatric patients presenting with behavioral or neurodevelopmental concerns, identify the most appropriate next step in evaluation or management.

Match each patient's clinical presentation with the most likely substance-related toxidrome or diagnosis.

A 28-year-old woman is brought to the trauma bay by emergency medical services after being ejected from a motorcycle at highway speeds. She is confused, tachypneic, and covered in significant abrasions. According to Advanced Trauma Life Support (ATLS) principles, arrange the following initial assessment and management steps in the correct chronological order.

Match the following brief clinical scenarios detailing symptom onset, duration, and core clinical features to their most appropriate DSM-5 psychiatric diagnosis.

A 34-year-old woman, gravida 2, para 1, undergoes suction dilation and curettage for an early pregnancy loss at 9 weeks gestation. The procedure is performed under general anesthesia. Cervical dilation is uncomplicated. However, during suctioning, the physician notes a sudden loss of resistance, and the cannula advances significantly further than the previously measured uterine depth. The suction is immediately turned off. Inspection of the aspirated contents in the tubing reveals fragments of yellow, fatty tissue. The patient's blood pressure is 118/76 mm Hg and heart rate is 82/min. Which of the following is the most appropriate next step in management?

A 45-year-old woman is brought to the emergency department by her husband due to a severe, throbbing headache, blurred vision, and chest palpitations that began 45 minutes ago. She has a 10-year history of major depressive disorder that was poorly responsive to multiple trials of selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. Six weeks ago, her psychiatrist started her on tranylcypromine. Vital signs are temperature 37.2°C (99.0°F), blood pressure 228/132 mm Hg, pulse 118/min, and respirations 20/min. Physical examination reveals profuse diaphoresis, facial flushing, and pupillary dilation. Neurological examination shows normal muscle tone, 2+ deep tendon reflexes symmetrically, and absent clonus. Mental status examination reveals an anxious woman who is fully oriented to person, place, and time. Her husband mentions they were celebrating their anniversary at a restaurant earlier this evening, where they shared a large platter of aged cheeses and cured meats. Which of the following is the most appropriate initial pharmacological intervention for this patient's current condition?

A $34$-year-old man comes to the clinic requesting assistance with smoking cessation. He has smoked one and a half packs of cigarettes daily for the past $15$ years. His past medical history is significant for bipolar I disorder. His last manic episode occurred $4$ years ago, and he is currently stable on valproate monotherapy without any recent depressive or manic symptoms. The patient states, 'I tried using nicotine patches and nicotine gum together last year, but the cravings were too strong and I went back to smoking within a week.' He is highly motivated to quit and asks for an oral prescription medication to help reduce his cravings. Physical examination and vital signs are within normal limits. Which of the following is the most appropriate pharmacotherapy for this patient?

A 27-year-old woman is brought to the psychiatric clinic by her husband due to bizarre behavior. She gave birth to her first child 9 weeks ago via an uncomplicated vaginal delivery. Her husband reports that exactly 2 weeks after the delivery, the patient began claiming that the television was transmitting coded messages from a secret government agency regarding her infant's "chosen destiny." Shortly thereafter, she started hearing two unfamiliar men's voices debating whether she is a suitable mother. These symptoms have been present consistently every day since they started. The patient has no prior psychiatric history and takes no medications. Her husband has taken over all infant care, as the patient is frequently preoccupied with the voices and appears emotionally detached. During the interview, the patient's affect is blunted and she avoids eye contact. She denies feeling sad, hopeless, or overly energetic. Her husband confirms her sleep and appetite have remained normal throughout this period. Medical workup, including a comprehensive metabolic panel and thyroid-stimulating hormone, is unremarkable. Urine toxicology screen is negative. Which of the following is the most likely diagnosis?

A 24-year-old man is brought to the emergency department via ambulance after sustaining a gunshot wound to his left thigh. On arrival, he is diaphoretic and confused. His temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure is $82/50\text{ mm Hg}$, heart rate is $134/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals a single penetrating wound on the anteromedial aspect of the left distal thigh. There is a rapidly expanding, pulsatile hematoma surrounding the wound, and bright red blood is actively spurting from the site. The left foot is pale and cold to the touch. The dorsalis pedis and posterior tibial pulses are not palpable on the left but are $2+$ on the right. Intravenous access is established, and isotonic fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

A $31$-year-old man comes to the physician for evaluation of a painless neck mass he noticed while shaving two weeks ago. For the past four months, he has experienced episodic, severe headaches accompanied by profound sweating and palpitations, which he attributed to work-related stress. His blood pressure is $172/98$ mm Hg, and his pulse is $108$/min. Physical examination reveals a $2.5$-cm, firm, mobile, non-tender mass in the right anterior neck. Laboratory studies show a serum thyroid-stimulating hormone (TSH) level of $6.2$ $\mu$ U/mL (normal: $0.4$–$4.0$ $\mu$ U/mL) and a free thyroxine (T4) level of $1.1$ ng/dL (normal: $0.9$–$2.4$ ng/dL). An ultrasound of the neck demonstrates a $2.3$-cm solid, hypoechoic nodule with microcalcifications in the right thyroid lobe. Fine-needle aspiration biopsy of the nodule reveals clusters of spindle-shaped cells with pleomorphic nuclei and extracellular deposits that demonstrate apple-green birefringence under polarized light after Congo red staining. Which of the following is the most appropriate next step in the management of this patient?