All practice questions

Following a severe industrial accident where he fell approximately three stories, a 51-year-old male worker is evaluated in the trauma bay. He is deeply comatose, exhibiting a Glasgow Coma Scale score of 6. Initial vitals demonstrate a blood pressure of 72/38 mm Hg, a pulse of 142/min, and a respiratory rate of 36/min. During the primary evaluation, the clinician notes tracheal deviation toward the right side and a complete lack of breath sounds on the left. Furthermore, the patient's abdomen is markedly distended with guarding on palpation, and the pelvic ring demonstrates obvious mechanical instability.

Arrange the following interventions in the most appropriate chronological sequence for this patient's acute resuscitation, in accordance with standard trauma protocols.

A 74-year-old woman is brought to the emergency department due to the sudden onset of severe, unremitting abdominal pain that began 2 hours ago. She has a medical history of hypertension, hyperlipidemia, and atrial fibrillation, but has not been taking her prescribed anticoagulant medication. On physical examination, she appears distressed and diaphoretic. Her temperature is 37.1°C, blood pressure is 118/74 mmHg, and heart rate is 112/min and irregularly irregular. Abdominal examination reveals a soft, non-distended abdomen with mild diffuse tenderness but no guarding or rebound tenderness. Bowel sounds are hypoactive. Laboratory studies show a leukocyte count of 18,500/mm³ and a serum lactate of 3.8 mmol/L. Arrange the following management steps in the most appropriate sequential order for this patient.

A 32-year-old male is evaluated at the behavioral health center for profound distress. Five months prior, he witnessed a catastrophic scaffolding collapse at his construction site. Since the incident, he suffers from severe hyperarousal, nightly harrowing dreams about the collapse, and active avoidance of any construction zones. He feels emotionally estranged from his spouse. Over the previous six weeks, he has also manifested a severely depressed affect, extreme fatigue, and complete loss of interest in his usual recreational activities.

Review of his psychiatric history reveals an involuntary psychiatric admission at age 23. During that 18-day admission, he exhibited expansive mood, pressured speech, a perceived lack of need for sleep, and auditory hallucinations of a voice declaring him 'the chosen architect.' These hallucinations ceased entirely within days of mood stabilization.

Five days ago, the patient abruptly stopped taking phenelzine—prescribed by a different provider for his low mood—due to his inability to maintain the required dietary restrictions. He is currently taking no medications.

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

On his sixth day of recovery following an open appendectomy for perforated appendicitis, a 65-year-old man reports progressive abdominal bloating and bilious vomiting. He has not passed flatus or stool for the past 48 hours. Vital signs show a heart rate of 110/min and blood pressure of 115/75 mmHg. Physical examination reveals a markedly distended, tympanitic abdomen with high-pitched 'tinkling' bowel sounds. There is diffuse mild tenderness but no rebound or guarding. Arrange the following management steps in the most appropriate chronological sequence for this patient's condition, progressing from initial intervention to definitive management.

You are evaluating five different patients who have recently initiated psychotropic medications. Each patient is now presenting with a specific adverse effect based on their history and examination findings. Which primary pharmacological mechanism best corresponds to the responsible medication for each patient's clinical presentation?

A 54-year-old postmenopausal woman comes to the clinic due to a 3-month history of an itchy, flaking rash on her left nipple and areola. She states that the rash initially began as a small red patch but has gradually spread and thickened. She applied an over-the-counter hydrocortisone cream twice daily for 4 weeks with no improvement. She has no personal or family history of breast cancer. On physical examination, there is a unilateral, well-demarcated, erythematous, scaly plaque confined to the left nipple-areolar complex with small areas of superficial crusting and ulceration. The nipple appears slightly flattened. Palpation of the left breast yields no distinct masses. Axillary lymph nodes are not palpable. Bilateral diagnostic mammography reveals no abnormalities. Which of the following is the most appropriate next step in management?

A 25-year-old woman is brought to the outpatient psychiatric clinic by her sister due to a 4-week history of profound sadness, lack of motivation, and sleeping up to 14 hours daily. For the past week, the patient has been hearing an unfamiliar voice repeatedly telling her she is "hopeless and already dead." Her past psychiatric history is notable for a 3-week hospitalization two years ago when she exhibited extremely rapid speech, required only two hours of sleep per night, and harbored grandiose delusions about being a spiritual prophet. Following her discharge from that hospitalization, she returned to her baseline functioning and experienced no mood or psychotic symptoms until the current episode. The patient currently takes no medications. Vital signs are within normal limits. Laboratory evaluation reveals a thyroid-stimulating hormone (TSH) level of $1.4 \mu U/mL$ (normal: $0.5-5.0 \mu U/mL$) and a free thyroxine (T4) level of $0.8 ng/dL$ (normal: $0.9-1.7 ng/dL$). Which of the following is the most appropriate next step in management?

During morning rounds on a surgical ward, an internal medicine consultant is asked to evaluate a patient recovering from a right femoral neck fracture repair performed 48 hours ago. The nursing staff reports that the patient was awake, alert, and conversational yesterday, but overnight she became highly agitated, attempted to remove her urinary catheter, and claimed that insects were crawling on her bed sheets. The patient's daughter confirms her mother lived independently and had no history of memory issues or psychiatric illness prior to the fall. Physical examination reveals an inattentive patient who drifts off to sleep during questioning. Vital signs are stable, and a basic metabolic panel is unremarkable. Which of the following is the most likely diagnosis for this patient's acute presentation?

A 22-year-old college student presents to the university outpatient clinic reporting a 5-week history of feeling profoundly sad, crying frequently, and lacking the motivation to attend her classes. She reports sleeping up to 12 hours a day and eating significantly more than usual, resulting in a 4 kg (8.8 lb) weight gain. She has no significant past medical history, and her vital signs are within normal limits. Laboratory tests, including a complete blood count and thyroid-stimulating hormone (TSH) level, are normal. She currently takes no medications or illicit substances. The physician suspects a major depressive episode and plans to prescribe fluoxetine. Which of the following is the most appropriate next step in the clinical evaluation and management of this patient?

An unmarried 29-year-old accountant is referred for a psychiatric evaluation by his corporate human resources department due to ongoing interpersonal difficulties. For the past seven years, he has worked in an isolated cubicle and consistently refuses to attend team meetings or company events. During the clinical interview, the patient sits rigidly, avoids eye contact, and appears visibly apprehensive. He explains that he avoids his colleagues because he is convinced they are harboring malicious intentions and secretly sabotaging his energy fields. He notes that this intense anxiety persists even with colleagues he has known for years. He describes his mind as being 'tuned to a specialized frequency that intercepts cosmic warnings.' His speech is markedly abstract and circumstantial, yet it remains goal-directed without derailment or neologisms. He firmly denies ever experiencing auditory or visual hallucinations. A review of his medical history reveals that these eccentric behaviors and beliefs have been present continuously since his late teens, without distinct episodes of clinical deterioration or full recovery. He denies any periods of pervasive sadness or elevated mood. Which of the following is the most likely diagnosis?

A 35-year-old teacher visits her primary care physician due to chronic fatigue and neck pain. During the interview, she reveals that she feels constantly 'on edge' and struggles to control her worries. Over the last 7 months, she has experienced relentless anxiety concerning her family's health, financial stability, and school responsibilities, despite no recent changes in her life circumstances. She notes that these thoughts frequently prevent her from falling asleep. Physical examination is unremarkable, and recent laboratory studies, including thyroid-stimulating hormone levels, are within normal limits. Which of the following is the most likely diagnosis?

A 26-year-old woman is brought to the clinic by her sister due to a 5-week history of severe depression. The patient describes her mood as "bottomless" and complains that her arms and legs constantly feel "heavy as lead." She reports sleeping 14 to 16 hours daily and has gained 6 kg (13.2 lb) over the past month, which she attributes to intense carbohydrate cravings. Despite her profound sadness, the sister notes that the patient's mood brightened considerably yesterday when she was presented with a surprise gift, though she relapsed into despondency hours later. The patient has experienced two similar depressive episodes in the past. The sister confidentially shares that during the patient's sophomore year of college, there was a distinct 10-day period where she seemed "like a completely different person." During that time, she slept only 3 hours a night without feeling fatigued, rapidly repainted her entire apartment, and abruptly spent her tuition money on a business venture that never materialized. She has no significant past medical history. Physical examination is unremarkable. Which of the following is the most appropriate next step in pharmacotherapy for this patient?

A 29-year-old woman presents to the clinic 4 weeks postpartum for a follow-up evaluation. She reports feeling profoundly sad, tearful, and unable to enjoy time with her newborn. She states, "I feel completely overwhelmed and guilty for being a terrible mother." She wakes up at 3:00 AM every day and is unable to fall back asleep, despite her husband handling the nighttime feedings. She has a poor appetite and has lost 4.5 kg (10 lb) since her delivery. She denies any thoughts of harming herself or her infant. She had an uncomplicated vaginal delivery but required a second-degree perineal laceration repair; she takes tramadol occasionally for residual pain. When reviewing her psychiatric history, she mentions that during her sophomore year of college, she experienced a distinct 5-day period where she felt "invincible," required only 2 hours of sleep per night, and started three different student organizations while speaking so rapidly her friends could hardly understand her. This college episode resolved spontaneously without hospitalization. Which of the following is the most appropriate next step in management?

A $26$-year-old woman comes to the psychiatric clinic for a follow-up evaluation regarding persistent low mood, hypersomnia, and severe fatigue. She has an established diagnosis of bipolar II disorder. Six weeks ago, she began taking lamotrigine for a major depressive episode. Her dosage was gradually increased according to standard protocols to a maintenance dose of $200 \text{ mg}$ daily, which she has been taking consistently for the past $2$ weeks. Despite medication adherence, the patient states she feels "just as depressed as before" and struggles to complete basic daily tasks. Her medical history is notable for polycystic ovary syndrome, which is well-controlled with a combined ethinyl estradiol and norgestimate oral contraceptive pill. Vital signs are within normal limits. Laboratory testing reveals a serum lamotrigine concentration of $1.2 \mu\text{g/mL}$ (therapeutic reference range: $3-15 \mu\text{g/mL}$).

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

A 24-year-old woman comes to the office after discovering a lump in her right breast while showering 3 days ago. She has not noticed any nipple discharge, skin changes, or breast pain. Her menstrual periods occur every 28 days and last for 4 to 5 days. Her last menstrual period ended 2 weeks ago. Her medical history is unremarkable, and she takes no medications. She has no family history of breast or ovarian cancer. Vital signs are within normal limits. On physical examination, there is a 2.5-cm, firm, mobile, non-tender, well-circumscribed mass in the upper outer quadrant of the right breast. There is no overlying skin erythema, dimpling, or nipple retraction. No axillary or supraclavicular lymphadenopathy is appreciated. Which of the following is the most appropriate next step in management?

A 22-year-old man is brought to the psychiatrist by his parents due to ongoing behavioral changes. Six weeks ago, the patient was hospitalized in the psychiatric unit for 4 days after presenting with severe agitation, auditory hallucinations, and paranoid delusions about being monitored by the government. At that time, his urine toxicology screen was markedly positive for amphetamines. He was discharged after brief treatment with haloperidol. His parents report that since discharge, he has lived at home and has been completely abstinent from all illicit drugs, a claim corroborated by weekly negative urine toxicology screens over the past 5 weeks. Despite his abstinence, the patient continues to experience daily auditory hallucinations of voices conversing about him and firmly believes his neighbors are tracking his movements. He has no prior psychiatric history, and there is no family history of psychiatric illness. His mood is described as 'fine,' and he exhibits no depressive or manic symptoms. Vital signs and physical examination are unremarkable. Which of the following is the most likely diagnosis?

A 28-year-old man is brought to the psychiatric clinic by his spouse. Over the past 3 weeks, the patient has slept only 2 hours per night, spoken at an unusually rapid pace, and claimed he is on the verge of single-handedly solving the global energy crisis. He also reports hearing the voices of angels who provide him with daily guidance. The spouse confirms this is his third episode of this nature in the past five years. Crucially, the spouse notes that even between these highly energetic episodes, during periods when the patient's mood is completely stable and normal for several months at a time, he continues to hear the angels' voices and firmly believes he possesses supernatural powers. A comprehensive medical and toxicological workup is negative. Which of the following is the most likely diagnosis?

A 47-year-old male executive seeks psychiatric evaluation for profound sadness, early morning awakening, and severe anhedonia that have progressively worsened over the past four months. His past medical history is unremarkable, and he is currently taking no medications. Arrange the following therapeutic steps in the exact sequence recommended by standard clinical guidelines for the progressive pharmacological and procedural management of major depressive disorder. Assume that each step is implemented sequentially only after the preceding intervention has yielded an inadequate clinical response (either non-response or insufficient partial response) despite optimal dosing and duration.

A 73-year-old retired architect is evaluated in the hospital for severe agitation. He was admitted 24 hours ago for cellulitis of the right lower extremity, for which wound cultures grew methicillin-resistant *Staphylococcus aureus* (MRSA). His medical history is significant for bipolar I disorder (not currently taking mood stabilizers), severe osteoarthritis (managed with scheduled tramadol), and a 3-year history of progressive cognitive decline, prominent visual hallucinations of small animals, and a resting tremor. He has a documented diagnosis of major neurocognitive disorder with Lewy bodies.

Currently, he is severely agitated, attempting to pull out his intravenous line, and striking at the nursing staff. He is unable to cooperate with a medical examination or verbal de-escalation. His husband, who is his legally appointed healthcare proxy, requests that the medical team administer medication to calm him down. However, the patient's daughter, who just arrived, demands that no mind-altering medications be given and suggests using physical restraints instead.

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

A 72-year-old woman is brought to the clinic by her son due to a 6-month history of progressive memory impairment, apathy, and severe psychomotor slowing. She frequently forgets conversations and has stopped participating in her usual social activities. She also reports worsening fatigue, constipation, and feeling cold constantly. Her medical history is significant for bipolar I disorder, which has been well-controlled on lithium monotherapy for 15 years, and hypertension. Current medications are lithium and lisinopril. Vital signs show a blood pressure of 130/80 mm Hg and a heart rate of 52/min. Physical examination reveals delayed relaxation of the deep tendon reflexes, dry skin, and a slightly puffy face. Cognitive assessment yields a Montreal Cognitive Assessment (MoCA) score of 19/30.

Laboratory results are as follows:

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