All practice questions

A 28-year-old woman, G1P0, at 14 weeks gestation presents to the outpatient clinic reporting severe anxiety, insomnia, and a persistently depressed mood. Eight weeks ago, she was the victim of a violent armed mugging. Since the event, she has experienced recurrent, distressing nightmares about the attack and feels intensely fearful when leaving her home, constantly scanning her surroundings for threats. She actively avoids the street where the mugging occurred. Her psychiatric history is significant for Bipolar I disorder, with her last manic episode occurring at age 22. She was previously stabilized on lithium but successfully tapered off the medication under medical supervision six months prior to conception. She is currently taking only prenatal vitamins. Vital signs are within normal limits. Recent routine laboratory studies show a normal complete blood count, a free T4 of $1.2$ ng/dL (normal: $0.8-1.5$ ng/dL), and a TSH of $0.2$ $\mu$ U/mL (normal: $0.4-4.0$ $\mu$ U/mL). The patient is desperate for relief and asks for 'anything that will make this stop.' Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old man is evaluated in the surgical intensive care unit due to sudden clinical deterioration. He is currently on postoperative day 1 following an emergent open repair of a ruptured abdominal aortic aneurysm. During the surgery, he experienced significant hemorrhage and received 10 liters of crystalloid and 8 units of packed red blood cells. The patient remains mechanically ventilated and sedated. Over the past 4 hours, his total urine output has decreased to 15 mL. His temperature is 38.2°C (100.8°F), blood pressure is 86/50 mmHg, and heart rate is 118/min. Central venous pressure is measured at 22 mm Hg. The ventilator monitor reveals a sudden increase in peak inspiratory pressures from 24 cm H2O to 48 cm H2O, with a corresponding increase in plateau pressures from 20 cm H2O to 44 cm H2O. Physical examination shows a tense and massively distended abdomen. The surgical incision is dry and intact. Which of the following is the most appropriate next step in the management of this patient?

During morning rounds, the surgical team assesses a $48$-year-old man who is recovering from an elective open ventral hernia repair performed yesterday (postoperative day $1$). He notes some mild incisional discomfort but denies shortness of breath, dysuria, or calf pain. Vital signs show a temperature of $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), a pulse of $88/\text{min}$, a blood pressure of $128/82\text{ mm Hg}$, and a respiratory rate of $18/\text{min}$. Oxygen saturation is $96\%$ on room air. Auscultation of the chest demonstrates diminished breath sounds at the bilateral bases, but no crackles are heard. The abdominal incision is well-approximated, dry, and lacks any surrounding redness. Which of the following are the most appropriate management steps for this patient's current condition? (Select two)

A 71-year-old man is evaluated on postoperative day 4 following an open sigmoid colectomy for recurrent diverticulitis. Over the last several hours, he has developed worsening shortness of breath and a cough productive of pink, frothy sputum. His medical history is significant for ischemic cardiomyopathy with an ejection fraction of $35\%$ and severe chronic obstructive pulmonary disease. Since the operation, he has been receiving continuous $0.9\%$ normal saline at a rate of $150\text{ mL/hr}$ and scheduled intravenous piperacillin-tazobactam.

Temperature is $38.2^\circ \text{C}$ ($100.8^\circ \text{F}$), blood pressure is $168/94\text{ mmHg}$, pulse is $112/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows an oxygen saturation of $86\%$ on room air. Physical examination reveals elevated jugular venous pressure, an $S_3$ gallop, and coarse crackles over the bilateral lower and mid lung fields. Expiratory wheezing is absent. The surgical incision is clean, dry, and intact with no surrounding erythema or induration. The abdomen is soft, mildly tender near the incision, but not distended.

Laboratory studies show a leukocyte count of $12,500/\mu\text{L}$. A portable chest radiograph reveals cardiomegaly, bilateral fluffy alveolar opacities, and small bilateral pleural effusions.

Which of the following are the most appropriate next steps in management? (Select 2)

A 31-year-old man presents to the outpatient psychiatric clinic accompanied by his sister. He describes a 3-month history of severe anxiety, hypervigilance, and recurrent nightmares following a violent mugging. He actively avoids the neighborhood where the incident occurred and feels detached from his family. His past psychiatric history is significant for bipolar I disorder; however, he stopped taking his prescribed valproate a year ago. He currently describes his mood as 'very low' and states he has no energy or appetite. During the interview, the patient's sister steps out to take a phone call. Privately, the patient confesses that for the past two weeks, he has been hearing a voice telling him he is worthless. He explicitly requests that his condition and medical records be kept strictly private from his family. Later, when the sister returns, she asks the physician to share the details of the psychiatric evaluation so she can help arrange a medical leave of absence at his workplace.

Which of the following are appropriate actions by the physician? (Select all that apply)

Match each clinical research scenario with the most appropriate epidemiologic study design.

A 30-year-old male is evaluated in the trauma center shortly after sustaining a stab wound to the left anterior abdomen during an altercation. On arrival, he is lethargic and diaphoretic. Vital signs are temperature 36.7°C (98.1°F), pulse 142/min, and blood pressure 72/40 mmHg. His airway is secure, and breath sounds are present and equal bilaterally. The abdomen is rigid with severe, diffuse guarding and rebound tenderness. Intravenous access is rapidly obtained and isotonic fluid resuscitation is initiated. Which of the following is the most appropriate next step in the management of this patient?

A 75-year-old man is brought to the neurology clinic by his son. Over the past 8 months, the patient has developed a progressively unsteady gait. The son describes his father's walking as feeling "glued to the ground" with very short steps. For the past 4 months, the patient has had difficulty managing his finances, exhibits new-onset apathy, and struggles with short-term memory. Over the last month, he has had multiple episodes of urinary incontinence, toward which he appears indifferent. His medical history includes hypertension and type 2 diabetes mellitus. Neurological examination reveals a broad-based, magnetic gait, but muscle strength and deep tendon reflexes are normal. A magnetic resonance imaging (MRI) scan of the brain is obtained and is shown below, demonstrating enlarged lateral and third ventricles with relatively normal, uncrowded cortical sulci. What is the most appropriate next step in the management of this patient?

A 30-year-old male chef is brought to the emergency department by his husband due to worsening suicidal ideation. For the past month, the patient has experienced profound sadness, a 7-kg (15-lb) weight gain, hypersomnia, and a complete lack of energy. He has a history of major depressive disorder diagnosed in his early twenties. His husband reports that three years ago, the patient had a 3-week period where he slept only two hours per night, spoke so rapidly he was difficult to interrupt, and developed grandiose delusions that he had discovered the cure for aging. These delusions completely resolved when his mood returned to baseline. The patient is currently not taking any prescribed medications but consumes a high-dose St. John's wort supplement daily. Vital signs are within normal limits. Mental status examination reveals a cooperative patient with depressed mood, flattened affect, and psychomotor retardation. He denies current hallucinations or delusions. Which of the following is the most appropriate next step in management?

A 28-year-old man comes to the outpatient clinic for a routine psychiatric follow-up. He has a history of major depressive disorder, for which he takes sertraline. During the session, the patient appears visibly agitated, pacing the room and speaking loudly about his recent job termination. He states, "My former boss is completely ruining my life. Sometimes I get so furious that I just want to kill him." The physician immediately asks if the patient has any specific plan or true intent to harm his former boss. The patient sits down, shakes his head, and says, "No, of course not. I am just venting because I am so frustrated. I would never actually hurt anyone or risk going to jail." Further assessment reveals he has no access to firearms and no prior history of violent behavior. He denies any current suicidal ideation. Vital signs are within normal limits. Which of the following is the most appropriate next step in management?

A 58-year-old man is brought to the clinic by his wife due to an $8$-month history of progressive behavioral changes. His wife reports that he has become increasingly apathetic and socially withdrawn, frequently neglecting his personal hygiene. He recently began compulsively hoarding empty glass bottles and has made sexually explicit remarks to neighbors, which is entirely out of character. The patient has a history of bipolar I disorder following a single manic episode at age 22, but he has been euthymic and off psychiatric medications for over $30$ years. Mental status examination reveals an alert and oriented patient with a blunted affect. He displays poor insight and disinhibition during the interview. Memory recall is 3/3 after $5$ minutes, but he exhibits significant impairment on the Trail Making Test Part B. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $0.2 \mu U/mL$ (Normal: $0.4-4.0 \mu U/mL$) and a free thyroxine (T4) level of $0.6 ng/dL$ (Normal: $0.9-1.7 ng/dL$). The patient has a legally executed advance directive designating his eldest daughter as his sole healthcare proxy. However, the daughter is not present, and the wife vehemently demands the physician immediately start an antidepressant, believing his symptoms represent a severe depressive relapse. Which of the following is the most appropriate next step in management?

A 32-year-old man is brought to the emergency department by emergency medical services after his roommate found him lethargic with empty pill bottles nearby. The patient states he intentionally ingested "a handful" of his prescribed phenelzine and his roommate's fluoxetine two hours ago because he "wanted to sleep forever." Vital signs are temperature 39.1°C (102.4°F), blood pressure 165/100 mmHg, heart rate 122/min, and respiratory rate 20/min. Physical examination reveals profuse diaphoresis, bilateral ocular clonus, and hyperreflexia most prominent in the lower extremities. As the physician prepares to initiate treatment, the patient becomes agitated, states he has changed his mind about wanting to die, and demands to leave the hospital immediately. He explicitly forbids the physician from contacting his wife, stating, "If she finds out about this, she will take my kids away." Which of the following is the most appropriate next step in management?

A 26-year-old female graduate student is brought to the emergency department by her roommate. For the past month, the patient has exhibited profound sadness, a 4.5-kg (10-lb) weight loss, and severe psychomotor retardation. She sleeps 14 hours a day and refuses to attend her classes. During the interview, she stares blankly and admits she has been hearing a persistent voice saying she is "a fraud who deserves to die." The roommate reports that two years ago, the patient had a distinct 3-week period where she barely slept, spoke incredibly fast, bought thousands of dollars of unneeded laboratory equipment on credit, and claimed she had independently deciphered the human genome. That prior episode culminated in a 5-day psychiatric hospitalization. Her urine toxicology screen is negative. Which of the following is the most accurate diagnosis and most appropriate initial pharmacotherapy for this patient?

A 34-year-old woman presents to the clinic with a 6-week history of profound sadness, anhedonia, and terminal insomnia. She reports significant functional impairment, having recently taken a leave of absence from her job due to a severe inability to concentrate. Review of systems is notable for a 4.5-kg (10-lb) weight loss and mild psychomotor agitation. Thorough psychiatric screening confirms the absence of any past manic or hypomanic episodes, ruling out bipolar disorder. Over the next 14 months, her major depressive disorder exhibits a complex trajectory, requiring a progressive, stepped-care escalation of her management plan according to standard psychiatric guidelines. Arrange the following clinical interventions in the most appropriate chronological sequence, beginning with her initial presentation and escalating to the management of life-threatening psychiatric complications.

A $72$-year-old woman is brought to the geriatrics clinic by her husband due to progressive memory loss and confusion over the past $3$ months. Her husband states she spends most of her day in bed, has stopped cooking, and has lost $5$ kg ($11$ lb). Over the last $3$ weeks, she has been repeatedly stating that "the government is coming to arrest me for tax fraud," which is completely unfounded.

Past medical history is significant for Parkinson disease, treated with selegiline, and bipolar I disorder. She previously took lithium but discontinued it a year ago of her own volition.

On mental status examination, she exhibits marked psychomotor retardation and poor eye contact. When asked to perform serial sevens or spell "WORLD" backwards, she gives minimal effort, frequently stating, "I don't know, my mind is completely gone."

Her daughter, who is her legally appointed healthcare proxy, lives in another state. Her husband is frustrated with the patient's decline and demands that the physician immediately authorize her placement in a local nursing home.

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

A 54-year-old software developer with no prior psychiatric history is evaluated for Major Depressive Disorder (MDD). Arrange the following pharmacological and somatic management steps in the correct chronological sequence according to standard stepped-care escalation protocols, starting from the initial presentation to the eventual management of a severe, life-threatening refractory state.

A 34-year-old man with a history of treatment-resistant depression is brought to the emergency department by his partner. The patient was doing well on a newly prescribed psychiatric medication until this morning, when he took an over-the-counter nasal decongestant for a severe cold. Within an hour of taking the cold medication, he developed a severe, throbbing headache, blurred vision, and neck stiffness. On triage, his temperature is 37.1°C (98.8°F), pulse is 115/min, and blood pressure is 220/125 mm Hg. Physical examination shows diaphoresis and normal deep tendon reflexes without clonus. Which of the following psychiatric medications is this patient most likely taking?

A 28-year-old nulligravid woman comes to the clinic reporting severe, cyclic lower pelvic pain for the past 4 months. She states the pain lasts for 4 to 5 days each month and is accompanied by breast tenderness and bloating, but she has not had any vaginal bleeding during these episodes. Her last normal menstrual period was 6 months ago. Five months ago, the patient underwent a loop electrosurgical excision procedure (LEEP) for high-grade cervical intraepithelial neoplasia (CIN 3). She has a negative home pregnancy test. Her BMI is $24 \text{ kg/m}^2$. Vital signs are within normal limits. Pelvic examination reveals normal external genitalia. Speculum examination shows a scarred, flush cervix without a visible external os. Bimanual examination reveals a symmetrically enlarged, globular, and very tender uterus. Bilateral adnexa are normal. A transvaginal ultrasound demonstrates a distended uterine cavity filled with $45 \text{ mL}$ of echogenic fluid. Which of the following is the most appropriate next step in management?

Evaluate the following clinical scenarios encountered in an outpatient women's health clinic. Select the most accurate diagnosis that corresponds to each patient's specific presentation.

For each clinical presentation described below, select the most appropriate personality disorder diagnosis.