All practice questions

A 31-year-old woman is evaluated in the clinic for severe mood changes. She delivered her first child 5 months ago without complications. Over the past 8 weeks, she has experienced profound sadness, anhedonia, and a 5-kg (11-lb) weight loss. She awakens at 3:00 AM daily and cannot return to sleep. She notes her depressed mood is worst in the mornings and is completely unreactive to positive events, including playing with her infant. Two weeks ago, her primary care physician prescribed escitalopram; however, she discontinued it 4 days ago, stating it was ineffective. Her husband reports that five years ago, she had a 7-day episode where she slept only 2 hours per night, spoke incessantly, and compulsively purchased thousands of dollars of baby clothes despite not being pregnant. She has no other medical conditions and does not use illicit substances. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in the management of this patient?

A $22$-year-old college student is brought to the emergency department by his roommate due to severe agitation and bizarre behavior. The roommate reports that for the past $2$ weeks, the patient has barely slept, paced the room continuously, and claimed that government agents are monitoring his thoughts. The roommate found empty plastic baggies containing residual white powder on the patient's desk. The patient has a history of major depressive episodes and is currently prescribed sertraline. His family history is notable for a mother with bipolar disorder. In the emergency department, the patient is combative, diaphoretic, and uncooperative. Temperature is $38.2^\circ \text{C}$ ($100.8^\circ \text{F}$), blood pressure is $165/100 \text{ mmHg}$, pulse is $128/\text{min}$, and respirations are $22/\text{min}$. Physical examination reveals bilaterally dilated pupils and a fine resting tremor. Which of the following is the most appropriate next step in the management of this patient?

Emergency medical responders bring a $32$-year-old woman, who is at $28$ weeks gestation, to the emergency department after she was found wandering in traffic. The patient has a history of schizoaffective disorder and stopped taking her medications $3$ months ago. On arrival, she is actively vomiting large amounts of bright red blood. Vital signs are temperature $37.1^\circ\text{C}$, pulse $135/\text{min}$, respirations $24/\text{min}$, and blood pressure $80/50\text{ mmHg}$. She is extremely agitated, striking at the nursing staff, and screaming, "The doctors are vampires trying to steal my baby's soul!" She physically resists all attempts at medical intervention. The physician determines she lacks the capacity to make medical decisions due to acute psychosis.

The patient's sister, who is her legally appointed healthcare proxy, arrives at the emergency department. The sister provides a signed, notarized advance directive that the patient completed $5$ years ago during a period of psychiatric stability. The document explicitly states: "I refuse the administration of any blood products under all circumstances due to my religious convictions." The sister states, "I know what the document says, but she is pregnant and bleeding to death. As her proxy, I am authorizing you to give her the blood transfusion to save her and the baby."

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

A 42-year-old woman is brought to the emergency department by her husband due to worsening confusion, severe nausea, vomiting, and a prominent hand tremor. Her husband reports that she has been unusually unsteady on her feet for the past three days. Her medical history is significant for bipolar disorder, which has been well-controlled on a stable dose of lithium for the past five years. Three weeks ago, she was diagnosed with essential hypertension by her primary care provider and was started on a new daily medication. On physical examination, the patient is lethargic and exhibits a coarse resting tremor, hyperreflexia, and ataxia. Her serum lithium level is 2.1 mEq/L (therapeutic range: 0.6-1.2 mEq/L). Which of the following antihypertensive medications was most likely prescribed to this patient?

A physician at a community health clinic evaluates a 34-year-old man who reports feeling "constantly tense and detached" for the past half-year. Seven months ago, the patient survived a severe factory explosion in which two of his colleagues died. Since the incident, he experiences recurrent, vivid nightmares about the explosion and becomes visibly diaphoretic and tachycardic whenever he hears loud metallic noises. He has completely stopped driving near the industrial park where he used to work and mentions that he feels entirely disconnected from his wife and children. His medical history is significant for treatment-resistant major depressive disorder, for which his psychiatrist prescribed tranylcypromine three weeks ago after multiple other medication trials failed. His blood pressure is 128/82 mm Hg, and his pulse is 76/min. The patient expresses a strong desire for immediate relief from his hyperarousal and intrusive memories. Which of the following is the most appropriate next step in the management of this patient?

A 48-year-old man is evaluated in the outpatient clinic for a 6-week history of persistently low mood, severe fatigue, anhedonia, and waking up at 3:00 AM every day without being able to return to sleep. He reports feeling "completely empty" and has unintentionally lost $4.5\text{ kg}$ ($10\text{ lb}$) over this period. His past medical history is significant for chronic lumbar radiculopathy, for which he takes daily tramadol. His past psychiatric history reveals a psychiatric hospitalization at age 32 for a 3-week episode of abnormally euphoric mood, hypersexuality, decreased need for sleep, and impulsive spending that led to significant debt. Vital signs are within normal limits. Physical examination is unremarkable. Mental status examination reveals a disheveled man with psychomotor retardation, restricted affect, and depressed mood. He denies active suicidal ideation. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $1.8\text{ }\mu\text{U/mL}$ and a free thyroxine (T4) level of $1.2\text{ ng/dL}$. Which of the following is the most appropriate next step in management?

A 78-year-old man residing in an assisted living facility is evaluated for a decline in his cognitive abilities over the past 3 months. The nursing staff report that he has stopped participating in social activities, frequently stays in his room with the blinds drawn, and has lost 4.5 kg (10 lb) during this period. When asked about his memory, the patient becomes distressed and repeatedly states, "My mind is completely gone; I cannot remember anything anymore." On cognitive testing, he makes poor eye contact and frequently responds to questions with "I don't know," exhibiting minimal effort. However, when strongly encouraged by the examiner, he successfully performs complex attention tasks. His neurological examination shows no focal deficits. A non-contrast head CT performed 2 months ago after a mechanical fall was unremarkable. Laboratory studies, including thyroid-stimulating hormone and vitamin B12, are within normal limits. Which of the following is the most appropriate initial management for this patient?

Match each patient's clinical presentation with the most appropriate first-line management strategy or pharmacological principle.

A 42-year-old male is admitted for an acute exacerbation of schizophrenia and is started on intramuscular haloperidol. Three days later, he develops severe, generalized muscle rigidity, profound diaphoresis, and mutism. His temperature is 103.8°F (39.9°C), pulse is 122/min, respirations are 24/min, and blood pressure is 178/104 mm Hg. Physical examination reveals "lead-pipe" rigidity in all extremities. Laboratory studies reveal a serum creatine kinase level of 5,500 U/L. Based on standard clinical guidelines, arrange the following management steps in the correct sequential order from the most immediate initial intervention to the most advanced treatment reserved for refractory cases.

A 20-year-old man presents to the university health clinic complaining of excessive daytime sleepiness that has progressively worsened over the past 8 months. He reports struggling to stay awake during lectures and has fallen asleep several times while eating meals. The patient also describes episodes where he suddenly loses muscle tone in his knees when he hears a funny joke, causing him to occasionally fall to the floor. He remains fully awake and aware of his surroundings during these brief events. Additionally, he mentions seeing vivid, frightening shadows in his room just before he falls asleep at night. He has no past medical history, does not use illicit drugs, and takes no medications. Vital signs and physical examination are unremarkable. Which of the following is the most likely diagnosis?

A 21-year-old female university student is brought to the emergency department by her roommate due to generalized weakness, muscle cramps, and a syncopal episode earlier that morning. The roommate mentions that the patient is under immense stress due to impending final exams. For the past year, the patient has drastically restricted her food intake during the day, but at night, she frequently consumes unusually large quantities of high-calorie foods, followed by prolonged periods in the bathroom with the water running. The patient recently visited the campus clinic for low mood and to get help quitting smoking; she was prescribed a new medication that she began taking two days ago.

Physical examination reveals a frail-appearing woman. Her BMI is 17.1 kg/m². Vital signs show a temperature of 36.3°C (97.3°F), blood pressure of 90/56 mm Hg, heart rate of 112/min while supine that increases to 138/min upon standing, and respiratory rate of 10/min. She has bilateral parotid gland enlargement, poor dentition with enamel erosion, and fine, downy hair over her back.

Based on the clinical and laboratory findings, which of the following is the most accurate statement regarding this patient's condition and management?

A psychiatry resident is evaluating five different patients presenting with depressive symptoms in various clinical settings. Match each patient's clinical vignette with the most appropriate best next step in management or definitive diagnosis.

A 42-year-old woman is evaluated on the surgical ward due to increasing restlessness and new-onset left shoulder pain. She underwent an uncomplicated laparoscopic Roux-en-Y gastric bypass for severe obesity two days ago. Her medical history is significant for obstructive sleep apnea and type 2 diabetes mellitus. She is currently receiving intravenous fluids, prophylactic subcutaneous enoxaparin, and patient-controlled analgesia with hydromorphone. Her temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), pulse is $134/\text{min}$, blood pressure is $122/78\text{ mmHg}$, and respirations are $22/\text{min}$. Pulse oximetry shows $95\%$ on room air. The patient appears extremely anxious. Physical examination reveals an obese abdomen with mild, diffuse tenderness but no rebound or guarding. The surgical incisions are clean, dry, and intact. Breath sounds are slightly decreased at the left lung base. The Jackson-Pratt drain in the left upper quadrant has accumulated $30\text{ mL}$ of serosanguinous fluid over the past 24 hours. Which of the following is the most appropriate next step in the management of this patient?

A $28$-year-old woman with a history of severe bipolar I disorder presents to the clinic for an initial prenatal visit at $6$ weeks gestation. She is currently stable on lithium carbonate and has not experienced a manic episode in $3$ years. However, she has a history of life-threatening manic episodes with psychotic features whenever she has attempted to discontinue her medication in the past. She wishes to continue her pregnancy. Arrange the following steps in the optimal pharmacological and obstetric management of this patient in chronological order, from the first trimester through the immediate postpartum period.

A 54-year-old man with a severe alcohol use disorder is brought to the emergency department for severe confusion, tremulousness, and an unsteady gait. Initial vital signs reveal a heart rate of 115/min and a blood pressure of 160/95 mm Hg. Point-of-care blood glucose is 55 mg/dL. Neurologic examination shows prominent bilateral horizontal nystagmus and resting hand tremors.

Arrange the following clinical interventions in the most appropriate chronological sequence for managing this patient, from first to last.

Match the following brief clinical scenarios and symptom duration timelines with the most appropriate DSM-5 psychiatric diagnosis.

Match each gastrointestinal disorder to its primary underlying pathophysiological mechanism of malabsorption or characteristic histologic finding.

Match each advanced clinical research scenario with the epidemiologic study design that best characterizes its methodology.

A $74$-year-old woman is brought to the emergency department via ambulance after her daughter found her unresponsive at home. The daughter mentions that the patient slipped and struck the right side of her head against a doorframe two weeks prior, but did not seek medical care at the time. Her medical history includes paroxysmal atrial fibrillation, for which she is prescribed apixaban. On arrival, her blood pressure is $185/105$ mmHg, heart rate is $52$/min, and respiratory rate is $10$/min with an irregular pattern. Her Glasgow Coma Scale score is $6$ (eye opening $1$, verbal response $1$, motor response $4$). Neurological examination is notable for a right pupil that measures $7$ mm and does not react to light, while the left pupil is $3$ mm and briskly reactive. Painful stimuli elicit decerebrate posturing of the left upper and lower extremities. She is immediately intubated for airway protection. Which of the following is the most appropriate next step to acutely manage her neurological deterioration prior to surgical intervention?

A 68-year-old man is evaluated in the emergency department for a 2-day history of escalating lower abdominal pain, nausea, and fever. Seven days ago, he underwent a transurethral resection of the prostate (TURP) and cystolitholapaxy for severe benign prostatic hyperplasia and concurrent bladder stones. His urethral catheter was removed on postoperative day 2 prior to an uncomplicated discharge. Today, his temperature is 38.9°C (102.0°F), blood pressure is 105/65 mm Hg, and pulse is 112/min. Physical examination reveals marked suprapubic tenderness with voluntary guarding. Laboratory studies show a leukocyte count of 18,500/mm³. A CT scan of the abdomen and pelvis with intravenous contrast reveals a 5-cm rim-enhancing fluid collection in the prevesical space (space of Retzius) with adjacent fat stranding. The intraperitoneal cavity has no free fluid. Which of the following is the most appropriate next step in management?