Examkin

Psychiatry

814 soru

Tüm türler814Çoktan seçmeli418Çoklu seçim68Eşleştirme191Sıralama137
Soru 461Soru →

A 72-year-old woman is brought to the emergency department from an assisted living facility due to a sudden onset of severe abdominal pain out of proportion to physical findings, accompanied by bloody diarrhea. An urgent CT angiogram of the abdomen confirms acute mesenteric ischemia. Emergency bowel resection is indicated to prevent death. The patient has a 40-year history of treatment-resistant schizophrenia. During the evaluation, she is actively hallucinating and states, "The government put snakes in my belly. If you cut me open, they will escape and eat everyone." She adamantly refuses the surgery. Her vital signs are temperature 37.8°C (100.0°F), blood pressure 90/60 mmHg, pulse 115/min, and respirations 22/min. The medical record includes a valid advance directive executed five years ago during a period of psychiatric stability. This document appoints her eldest daughter as her sole healthcare proxy. The daughter is contacted by phone, understands the grave prognosis, but declines the surgery, stating, "When she was lucid, my mother explicitly told me she never wanted major surgery or life support at this stage of her life." The patient's younger son arrives at the emergency department shortly after. He is distraught and demands that the surgical team operate immediately, stating, "I am her son too! You have to save her, do the surgery now!" Which of the following is the most appropriate next step in management?

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Cevap: Withhold the surgical intervention and initiate palliative care measures as directed by the daughter.

Cevap

Withhold the surgical intervention and initiate palliative care measures as directed by the daughter.
This patient requires emergent surgery but lacks decision-making capacity due to her active psychotic delusions, which prevent her from understanding the risks and benefits of the procedure. When a patient lacks capacity, medical decisions are deferred to a surrogate decision-maker. This patient has a valid advance directive appointing her daughter as her healthcare proxy. The authority of a legally appointed healthcare proxy supersedes that of other family members, including the son. Because the daughter is making a decision that is consistent with the patient's previously expressed wishes during a lucid interval, the physician is ethically and legally bound to respect this decision, withhold surgery, and provide palliative care.

Adım Adım Çözüm

1
Evaluate the patient's decision-making capacity.
The patient lacks capacity because her active delusions prevent her from understanding the clinical reality of her condition.
A patient must have capacity to refuse life-saving medical treatment.
2
Identify the appropriate surrogate decision-maker.
The daughter is the legally appointed healthcare proxy from an advance directive executed when the patient was stable.
A designated healthcare proxy has legal authority that supersedes other family members.
3
Determine the appropriate clinical action based on the surrogate's decision.
The proxy refuses surgery based on the patient's known prior wishes.
The medical team must honor the patient's autonomy as exercised through her valid surrogate, despite the son's objections.

Anahtar Kavram

In patients lacking decision-making capacity, a legally appointed healthcare proxy has absolute authority over other family members, and their decisions—when based on the patient's previously expressed wishes—must be respected even if they result in the patient's death.
Soru 462Soru →

A 32-year-old woman is brought to the emergency department by her sister due to a 3-week history of worsening social withdrawal, profound sadness, and extreme fatigue. The patient sleeps up to 15 hours a day and frequently states, "Everyone would be better off without me." Her sister notes the patient recently stopped attending her job as an accountant.

Review of her medical history reveals a depressive episode three years ago, for which her primary care physician prescribed fluoxetine. Three weeks into that treatment, the patient abruptly quit a previous job, flew to another continent alone, and spent her entire life savings over the course of seven days while sleeping less than two hours per night. She was hospitalized abroad, the fluoxetine was discontinued, and her mood gradually stabilized over the next month.

The patient currently takes no medications and uses no illicit substances. Vital signs are within normal limits. Physical examination reveals a flat affect and psychomotor retardation.

Laboratory results are as follows:
TestResultReference Range
Thyroid-stimulating hormone (TSH)4.2 mU/L0.5 - 5.0 mU/L
Free thyroxine (T4)1.1 ng/dL0.9 - 1.7 ng/dL

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

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Cevap: Initiate quetiapine therapy

Cevap

The most appropriate next step is to initiate quetiapine therapy.
The correct intervention is to initiate quetiapine therapy. Although this patient is currently presenting with a severe depressive episode, a thorough review of her psychiatric history reveals a diagnosis of Bipolar I Disorder. Three years ago, she experienced an antidepressant-induced manic episode characterized by a decreased need for sleep, impulsivity (spending her life savings, traveling to a foreign continent), and functional deterioration requiring hospitalization. According to DSM-5 criteria, a full manic episode that emerges during antidepressant treatment and persists beyond the physiological effect of the treatment is sufficient to diagnose Bipolar I Disorder. When a patient with Bipolar I Disorder presents with an acute depressive episode, the standard of care is to initiate a medication with established efficacy for bipolar depression, such as specific atypical antipsychotics (e.g., quetiapine, lurasidone, cariprazine) or mood stabilizers (e.g., lithium, lamotrigine). Quetiapine is an excellent first-line choice because it acts rapidly to treat both the depressed mood and the associated severe insomnia.

Adım Adım Çözüm

1
Analyze the patient's current clinical presentation.
The patient is experiencing a severe major depressive episode characterized by hypersomnia, profound sadness, functional impairment, and passive suicidal ideation.
Establishing the current affective state is required before determining pharmacological needs.
2
Evaluate the psychiatric history for differentiating features between unipolar and bipolar depression.
The patient has a history of an antidepressant-induced manic episode (decreased sleep, reckless spending, impulsive travel) requiring hospitalization.
According to DSM-5, a full manic episode that emerges during antidepressant treatment and persists beyond the physiological effect of the drug establishes a diagnosis of Bipolar I Disorder.
3
Select the appropriate pharmacotherapy for acute bipolar depression.
Quetiapine (an atypical antipsychotic) is selected. Antidepressant monotherapy must be avoided.
In Bipolar I Disorder, antidepressant monotherapy is contraindicated due to the high risk of precipitating a manic switch. First-line treatments for bipolar depression include quetiapine, lurasidone, or mood stabilizers like lithium.

Anahtar Kavram

Prior to initiating pharmacotherapy for a major depressive episode, it is critical to screen for a history of mania or hypomania (including antidepressant-induced episodes). Patients with Bipolar I Disorder who present with depression should be treated with an atypical antipsychotic approved for bipolar depression (e.g., quetiapine, lurasidone) or a mood stabilizer, rather than antidepressant monotherapy.
Tahmini Süre:1m 30s
Soru 463Soru →

An 81-year-old retired teacher is accompanied to the outpatient geriatrics clinic by her daughter. The daughter reports that over the past six to nine months, the patient has become increasingly forgetful and struggles to plan her usual weekly garden club meetings. Furthermore, the patient has recently stopped visiting her friends because she is embarrassed by frequent episodes of urinary incontinence. When asked about her mobility, the patient states, 'My feet feel like they are stuck to the ground.' Medical history is significant for well-controlled type 2 diabetes mellitus and mild osteoarthritis. Vital signs are within normal limits. Neurologic examination reveals a wide-based, slow, shuffling gait, but there is no resting tremor, cogwheel rigidity, or bradykinesia of the upper extremities. Cognitive testing reveals prominent deficits in executive function and attention. Which of the following is the most likely diagnosis?

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Cevap: Normal pressure hydrocephalus

Cevap

The most likely diagnosis is Normal pressure hydrocephalus.
The correct answer is Normal pressure hydrocephalus (NPH). NPH is a potentially reversible cause of dementia characterized by the classic clinical triad of abnormal gait (described as magnetic, wide-based, or shuffling), urinary incontinence, and cognitive decline (particularly prominent executive dysfunction and psychomotor slowing). The gait abnormality is typically the first symptom to appear. The underlying pathophysiology involves decreased absorption of cerebrospinal fluid at the arachnoid granulations, leading to ventriculomegaly. The enlarged ventricles stretch the descending cortical fibers of the corona radiata, particularly those controlling leg movement and bladder function, resulting in the characteristic symptoms.

Adım Adım Çözüm

1
Analyze the patient's presenting clinical symptoms and their timeline.
The patient exhibits a triad of cognitive decline (executive dysfunction), urinary incontinence, and a 'glued to the ground' magnetic gait developing over several months.
Identifying the specific symptom cluster is crucial for distinguishing between various major neurocognitive disorders.
2
Evaluate the neurologic examination findings to rule out related differentials.
The absence of resting tremor, cogwheel rigidity, and upper extremity bradykinesia makes Parkinson disease dementia and Dementia with Lewy bodies highly unlikely.
Gait abnormalities can be seen in multiple disorders, but the specific pattern (magnetic gait without upper body parkinsonism) isolates the pathology.
3
Synthesize the findings to establish the underlying etiology.
The clinical picture strongly points to Normal pressure hydrocephalus, caused by decreased cerebrospinal fluid absorption leading to enlarged ventricles that stretch the corona radiata.
The triad of 'wacky, wet, and wobbly' is the hallmark presentation of this potentially reversible condition.

Anahtar Kavram

Normal pressure hydrocephalus presents with the classic clinical triad of gait apraxia (magnetic gait), urinary incontinence, and cognitive decline (dementia), and is characterized by enlarged ventricles out of proportion to sulcal enlargement.
Soru 464Soru →

A 27-year-old man is evaluated in the clinic for severe anxiety and sleep disturbances. Three months ago, he survived a severe house fire in which he sustained extensive burns to his right lower extremity. The burns were complicated by methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis, for which he is currently in the second week of a 6-week course of oral linezolid. He reports that for the past two months, he has been having intense nightmares about the fire and frequently wakes up drenched in sweat. He actively avoids cooking or being near stoves and feels "on edge" most of the day. During the interview, a loud siren sounds outside; he suddenly drops to the floor, covers his head, and appears briefly unresponsive to the physician's voice, vividly reliving the fire. He has no previous psychiatric history. Which of the following is the most appropriate next step in management?

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Cevap: Referral for trauma-focused cognitive behavioral therapy

Cevap

Referral for trauma-focused cognitive behavioral therapy
The correct answer is referral for trauma-focused cognitive behavioral therapy. This patient meets the criteria for Post-Traumatic Stress Disorder (PTSD), presenting with intrusive symptoms (nightmares, dissociative flashbacks), avoidance behavior, and hyperarousal lasting for more than one month following a life-threatening event. The first-line treatments for PTSD include trauma-focused psychotherapy (e.g., cognitive processing therapy, prolonged exposure) and pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). However, this patient is currently taking linezolid. Linezolid is an oxazolidinone antibiotic that also functions as a reversible, non-selective monoamine oxidase inhibitor (MAOI). Coadministration of linezolid with serotonergic agents (like SSRIs or SNRIs) is strictly contraindicated because it can precipitate serotonin syndrome, a potentially life-threatening condition characterized by autonomic instability, altered mental status, and neuromuscular hyperactivity. Therefore, non-pharmacological treatment with trauma-focused cognitive behavioral therapy is the safest and most appropriate first-line intervention.

Adım Adım Çözüm

1
Diagnose the patient's psychiatric condition based on the clinical presentation.
The patient has Post-Traumatic Stress Disorder (PTSD), evidenced by trauma exposure greater than 1 month ago, nightmares (intrusions), avoidance of triggers, hyperarousal, and dissociative flashbacks.
Accurate diagnosis is required to select the correct treatment algorithm.
2
Identify the patient's current medical treatments and potential contraindications.
The patient is taking linezolid for MRSA osteomyelitis. Linezolid is an oxazolidinone antibiotic with reversible, non-selective monoamine oxidase inhibitor (MAOI) properties.
Psychiatric pharmacotherapy often interacts with systemic medical treatments.
3
Select the most appropriate first-line treatment for PTSD that avoids dangerous drug interactions.
First-line treatments for PTSD include SSRIs, SNRIs, and trauma-focused cognitive behavioral therapy (TF-CBT). Because linezolid acts as an MAOI, adding an SSRI or SNRI is contraindicated due to the risk of serotonin syndrome. Therefore, TF-CBT is the best next step.
Maximizes therapeutic efficacy while preventing life-threatening pharmacological interactions.

Anahtar Kavram

Patients with PTSD who are taking medications with MAOI activity (such as the antibiotic linezolid) must not be prescribed serotonergic agents (SSRIs, SNRIs) due to the risk of serotonin syndrome; trauma-focused psychotherapy is the treatment of choice in these cases.
Tahmini Süre:1m 30s
Soru 465Soru →

During a routine telehealth appointment, a 28-year-old marketing executive describes a 6-week history of worsening dysphoria, profound anhedonia, and debilitating fatigue. She reports sleeping up to 12 hours a day and experiencing a 5-kg (11-lb) weight gain over this period. The patient expresses excessive guilt over her recent decline in work performance. She has no significant past medical history and does not consume alcohol or illicit substances. The physician considers initiating pharmacotherapy with a selective serotonin reuptake inhibitor. Which of the following is the most appropriate next step in the management of this patient?

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Cevap: Elicit a history of distinct periods featuring unusually elevated mood and decreased need for sleep

Cevap

Elicit a history of distinct periods featuring unusually elevated mood and decreased need for sleep
The most critical next step is to screen for a history of manic or hypomanic episodes. This patient presents with a major depressive episode, characterized by atypical features (hypersomnia, weight gain, profound fatigue). However, bipolar depression and unipolar depression cannot be reliably distinguished based solely on current depressive symptoms. Because a diagnosis of Major Depressive Disorder requires that there has never been a manic or hypomanic episode, the clinician must explicitly ask about past periods of elevated mood, impulsivity, and decreased need for sleep. Initiating antidepressant monotherapy in a patient with unrecognized bipolar disorder carries a significant risk of precipitating a manic or hypomanic episode (manic switch).

Adım Adım Çözüm

1
Analyze the patient's clinical presentation.
The patient meets criteria for a major depressive episode (dysphoria, anhedonia, fatigue, hypersomnia, weight gain, guilt for 6 weeks).
Establishing the current syndrome is the first step in psychiatric diagnosis.
2
Determine the differential diagnosis.
The presentation could represent Major Depressive Disorder (MDD) or the depressed phase of Bipolar Disorder.
Unipolar and bipolar depression present identically during an acute depressive episode.
3
Identify the critical pre-treatment evaluation step.
Screening for a history of manic or hypomanic episodes is required.
A diagnosis of MDD requires the absence of any past manic or hypomanic episodes. Prescribing an SSRI to a patient with unrecognized bipolar disorder can precipitate a manic switch.

Anahtar Kavram

Before diagnosing Major Depressive Disorder and initiating antidepressant therapy, clinicians must screen for a lifetime history of manic or hypomanic episodes to rule out Bipolar Disorder and prevent antidepressant-induced mania.
Soru 466Soru →

An addiction medicine consultation team is reviewing multiple complex patient cases in the emergency department involving suspected acute intoxications. Match each distinct clinical presentation to the most likely responsible substance.

Soldaki öğeye tıklayın, sonra eşleşen sağdaki öğeye tıklayın

Öğeler

3,4-Methylenedioxymethamphetamine (MDMA)
Synthetic cathinones
Gamma-hydroxybutyrate (GHB)
Dextromethorphan (DXM)

Eşleşmeler

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Cevap

MDMA matches with bruxism/hyponatremia; Synthetic cathinones match with prolonged delirium; GHB matches with rapid coma/awakening; Dextromethorphan matches with dissociative state/false-positive PCP.
Each substance produces a unique clinical toxidrome: MDMA is distinguished by hyponatremia and bruxism; synthetic cathinones by a remarkably prolonged severe agitated delirium; GHB by a deep but very brief coma; and DXM by dissociation and potential PCP cross-reactivity.

Adım Adım Çözüm

1
Analyze the clinical features associated with MDMA intoxication.
MDMA causes empathogenic effects, bruxism, hyperthermia, and uniquely, hyponatremia.
Identifying the specific serotonergic toxidrome allows matching it to the sociability/hyponatremia presentation.
2
Evaluate the presentation of synthetic cathinone intoxication.
Bath salts cause severe sympathomimetic toxidrome with an exceptionally prolonged delirium or psychosis lasting several days.
Differentiating bath salts from standard amphetamines or cocaine relies on the extended duration of delirium and the lack of detection on standard drug screens.
3
Assess the clinical course of GHB overdose.
GHB toxicity is characterized by rapid, deep CNS depression that resolves abruptly.
This distinct kinetic profile matches the presentation of sudden coma followed by sudden, unpredictable awakening.
4
Review the toxidrome of high-dose dextromethorphan.
High-dose DXM acts as an NMDA antagonist, causing dissociation, nystagmus, and ataxia, and can cross-react on UDS.
This pharmacological profile matches the dissociative presentation that may trigger a false-positive PCP screen.

Anahtar Kavram

Differentiating the unique acute toxidromes and clinical kinetics of specific illicit substances and over-the-counter drugs of abuse.
Tahmini Süre:1m 30s
Soru 467Soru →

A 25-year-old woman is admitted to the inpatient psychiatric unit for an acute exacerbation of schizoaffective disorder. During the evening shift, she becomes increasingly distressed, claiming that the nursing station is broadcasting her thoughts. She begins throwing plastic cups across the hallway and screaming at the staff to stop the broadcast. She is hypervigilant, visibly tense, and standing defensively in the hallway corner, but she has not attacked anyone. Arrange the following interventions in the most appropriate stepwise escalation sequence for managing this patient's acute agitation, starting with the initial preferred step.

Öğeleri doğru sıraya koymak için sürükleyin

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Cevap

The correct stepwise escalation protocol for acute agitation begins with verbal de-escalation, followed by offering voluntary oral medications, then administering involuntary intramuscular medications, and finally applying physical restraints as a last resort.
The management of acute agitation in a psychiatric setting strictly adheres to the principle of using the least restrictive means possible. The protocol escalates sequentially: it begins with verbal de-escalation techniques to calm the patient collaboratively. If unsuccessful, the next step is offering voluntary oral medications, which allows the patient to maintain autonomy. If the patient refuses and agitation escalates to a dangerous level, involuntary intramuscular medication (chemical restraint) is administered. Physical restraints are the most restrictive and dangerous intervention, carrying significant risks of trauma and injury, and must only be used as a last resort when there is an imminent threat to physical safety that cannot be managed otherwise.

Adım Adım Çözüm

1
Assess the immediate safety risk and the patient's current level of violence.
The patient is highly agitated, distressed, and throwing non-lethal objects, but has not committed acts of physical violence against others.
This assessment determines if immediate physical restraint is necessary. Since there is no imminent threat of severe physical harm, less restrictive measures must be used first.
2
Identify the least restrictive initial intervention.
Verbal de-escalation is identified as the required first step.
The standard of psychiatric care dictates starting with non-coercive, least restrictive measures to respect patient autonomy and prevent unnecessary trauma.
3
Determine the proper sequence for pharmacological intervention if verbal methods fail.
Voluntary oral medication must be offered before involuntary intramuscular medication is administered.
Voluntary intake of medication is less restrictive and less traumatic than an involuntary injection, aligning with the principle of least restrictive means.
4
Identify the intervention of last resort in the escalation protocol.
Physical restraints are placed at the very end of the sequence.
Physical restraints carry the highest risk of injury, asphyxiation, and profound psychological trauma, and are strictly reserved for situations of imminent physical danger.

Anahtar Kavram

Stepwise escalation protocol and the principle of least restrictive means in managing acute psychiatric agitation
Soru 468Soru →

A 45-year-old woman presents to the clinic with a 6-month history of difficulty falling asleep and staying asleep. She states that her sleep problems began after a stressful period at work but have persisted despite the stress resolving. She reports daytime fatigue that is noticeably affecting her job performance. She has no other medical conditions and takes no medications. Arrange the following steps in the most appropriate chronological sequence for the standard clinical management of this patient's condition.

Öğeleri doğru sıraya koymak için sürükleyin

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Cevap

The correct sequence for managing chronic insomnia is to first assess sleep patterns objectively using a sleep diary, then initiate Cognitive Behavioral Therapy for Insomnia (CBT-I) as first-line treatment, consider short-term nonbenzodiazepine hypnotics only if CBT-I is ineffective, and finally taper any medications to avoid physical dependence and rebound symptoms.
The standard stepwise approach to chronic insomnia begins with a thorough clinical assessment using a sleep diary. This is followed by the first-line treatment, Cognitive Behavioral Therapy for Insomnia (CBT-I). Pharmacotherapy (such as nonbenzodiazepine hypnotics, dual orexin receptor antagonists, or melatonin agonists) is reserved for cases refractory to CBT-I and should only be used short-term. When discontinuing these medications, they must be gradually tapered to prevent rebound insomnia.

Adım Adım Çözüm

1
Identify the patient's likely diagnosis based on the clinical vignette.
The patient has chronic insomnia disorder (symptoms > 3 months, causing daytime impairment, not explained by other conditions).
Establishing the correct diagnosis dictates the appropriate stepwise treatment algorithm.
2
Determine the initial assessment and diagnostic steps.
A sleep diary is the standard initial tool to quantify sleep latency, wake after sleep onset, and total sleep time.
Objective tracking is necessary to guide behavioral therapy and measure clinical progress.
3
Identify the recommended first-line therapy.
Cognitive Behavioral Therapy for Insomnia (CBT-I) is selected as the primary intervention.
Guidelines recommend CBT-I as the initial treatment due to its sustained efficacy and lack of side effects compared to medications.
4
Determine the role of pharmacotherapy.
Medications (like nonbenzodiazepine hypnotics) are reserved for patients who do not respond adequately to CBT-I.
Sleep medications carry risks of dependence, tolerance, and adverse effects, especially with prolonged use.
5
Identify the protocol for discontinuing pharmacotherapy.
Medications must be carefully tapered rather than stopped abruptly.
Abrupt cessation of hypnotics typically causes severe rebound insomnia, which can perpetuate the cycle of sleep anxiety and medication reliance.

Anahtar Kavram

The standard clinical management of chronic insomnia emphasizes objective assessment followed by targeted behavioral interventions (CBT-I) before considering short-term pharmacological therapies.
Tahmini Süre:1m 0s
Soru 469Soru →

A 27-year-old male actor comes to the clinic for a routine evaluation prior to starting filming for a new movie. Over the past 5 months, he has purposefully lost 14 kg14 \text{ kg} (30.8 lb30.8 \text{ lb}) by restricting his caloric intake to fewer than 500 kcal/day500 \text{ kcal/day} and engaging in strenuous cardiovascular exercise for 3 hours daily. He states, "I have to look absolutely emaciated for this role, but I feel so weak and dizzy when I stand up." He strongly denies binge eating, self-induced vomiting, or the use of laxatives or diuretics. His body mass index is 16.2 kg/m216.2 \text{ kg/m}^2. Vital signs show a blood pressure of 88/58 mm Hg and a heart rate of 48/min. Physical examination reveals temporal wasting, dry skin, and fine, downy hair on his upper back.

Laboratory studies show:

TestResultReference Range
Sodium139 mEq/L139 \text{ mEq/L}136−145 mEq/L136-145 \text{ mEq/L}
Potassium3.4 mEq/L3.4 \text{ mEq/L}3.5−5.0 mEq/L3.5-5.0 \text{ mEq/L}
Chloride104 mEq/L104 \text{ mEq/L}95−105 mEq/L95-105 \text{ mEq/L}
Bicarbonate15 mEq/L15 \text{ mEq/L}22−28 mEq/L22-28 \text{ mEq/L}
Blood urea nitrogen28 mg/dL28 \text{ mg/dL}7−18 mg/dL7-18 \text{ mg/dL}
Creatinine1.0 mg/dL1.0 \text{ mg/dL}0.6−1.2 mg/dL0.6-1.2 \text{ mg/dL}
Glucose62 mg/dL62 \text{ mg/dL}70−99 mg/dL70-99 \text{ mg/dL}

Arterial blood gas (room air):

ParameterResultReference Range
pH7.307.307.35−7.457.35-7.45
pCO230 mm Hg30 \text{ mm Hg}33−45 mm Hg33-45 \text{ mm Hg}
pO296 mm Hg96 \text{ mm Hg}75−105 mm Hg75-105 \text{ mm Hg}

Which of the following best describes this patient's primary acid-base disturbance and its underlying etiology?

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Cevap: High anion gap metabolic acidosis with appropriate respiratory compensation secondary to starvation ketosis

Cevap

The patient has a high anion gap metabolic acidosis with appropriate respiratory compensation secondary to starvation ketosis.
The correct answer identifies a high anion gap metabolic acidosis with appropriate respiratory compensation due to starvation ketosis. The patient is acidemic (pH = 7.30) with a primary metabolic acidosis (bicarbonate = 15 mEq/L). The anion gap is elevated at 20 mEq/L (139−(104+15)=20139 - (104 + 15) = 20), confirming a high anion gap metabolic acidosis. In the setting of severe caloric restriction, this is caused by starvation ketosis (accumulation of beta-hydroxybutyrate and acetoacetate). To check for a mixed disorder, Winter's formula is applied: Expected pCO2=1.5(HCO3)+8±2\text{Expected pCO}_2 = 1.5(HCO_3) + 8 \pm 2. For this patient, Expected pCO2=1.5(15)+8±2=30.5±2\text{Expected pCO}_2 = 1.5(15) + 8 \pm 2 = 30.5 \pm 2, meaning the expected pCO2 range is 28.5 to 32.5 mm Hg. The patient's actual pCO2 of 30 mm Hg falls squarely within this range, indicating appropriate physiological respiratory compensation without any concurrent primary respiratory disorder.

Adım Adım Çözüm

1
Analyze the patient's clinical presentation.
The patient has anorexia nervosa, restricting subtype, with severe caloric restriction, hypoglycemia, and signs of profound malnutrition.
Identifying the severe fasting state points toward starvation ketosis as the likely metabolic derangement.
2
Evaluate the primary acid-base disturbance.
The pH of 7.30 indicates acidemia, and the low bicarbonate of 15 mEq/L confirms a primary metabolic acidosis.
The initial step in acid-base analysis is determining the primary disorder using pH and bicarbonate levels.
3
Calculate the serum anion gap.
AG=Na−(Cl+HCO3)=139−(104+15)=20 mEq/LAG = Na - (Cl + HCO_3) = 139 - (104 + 15) = 20 \text{ mEq/L}.
Categorizing the metabolic acidosis as high or normal anion gap narrows the differential diagnosis. A gap of 20 is elevated.
4
Calculate the expected respiratory compensation using Winter's formula.
Expected pCO2=1.5(HCO3)+8±2=1.5(15)+8±2=30.5±2 mm Hg\text{Expected pCO}_2 = 1.5(HCO_3) + 8 \pm 2 = 1.5(15) + 8 \pm 2 = 30.5 \pm 2 \text{ mm Hg}.
To determine if a secondary respiratory acid-base disorder is present, the expected pCO2 must be compared to the actual pCO2.
5
Synthesize the findings.
The actual pCO2 of 30 mm Hg is within the expected range of 28.5 to 32.5 mm Hg, confirming appropriate respiratory compensation without a concurrent primary respiratory disorder.
Integrating the laboratory calculations with the clinical context provides the final diagnosis.

Anahtar Kavram

Evaluation of acid-base disturbances in eating disorders requires calculating the anion gap and Winter's formula to differentiate between starvation ketosis, laxative abuse, and vomiting.
Soru 470Soru →

A 38-year-old male software engineer is evaluated in the clinic for worsening mood. He reports feeling profoundly sad, having no energy, sleeping up to 14 hours a day, and gaining 4.5 kg (10 lb) over the past 6 weeks. His husband notes that the patient has been unable to concentrate on his work and frequently expresses feelings of worthlessness. The patient has no other medical conditions and currently takes no medications. A review of his medical records reveals a psychiatric hospitalization three years ago for a 10-day episode characterized by an abnormally elevated mood, a decreased need for sleep (averaging 2 hours per night), pressured speech, and reckless financial investments that led to personal bankruptcy. His vital signs and physical examination today are unremarkable. Which of the following are appropriate pharmacological interventions for this patient's current condition? (Select all that apply)

Geçerli olan tümünü seçin

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Cevap: Initiate treatment with lurasidone; Initiate treatment with quetiapine; Initiate treatment with lithium

Cevap

The appropriate pharmacological interventions for this patient are initiating treatment with lurasidone, quetiapine, or lithium.
The patient is experiencing an acute depressive episode in the context of Bipolar I Disorder, which is diagnosed based on his current presentation and a history of a severe manic episode that required hospitalization. The standard of care for acute bipolar depression includes initiating a mood stabilizer (such as lithium) or specific second-generation antipsychotics (such as quetiapine or lurasidone). These agents are favored because they have proven efficacy in treating the depressive phase of bipolar disorder without a significant risk of inducing a manic switch.

Adım Adım Çözüm

1
Evaluate the current presenting symptoms.
The patient exhibits profound sadness, hypersomnia, weight gain, anhedonia, and poor concentration lasting for 6 weeks, which meets the criteria for a major depressive episode.
Identifying the current phase of the mood disorder is essential to selecting the right intervention.
2
Review the patient's psychiatric history.
The patient has a history of a 10-day episode involving elevated mood, decreased need for sleep, pressured speech, and reckless behavior requiring hospitalization, establishing a past manic episode.
A history of a manic episode changes the diagnosis from Major Depressive Disorder to Bipolar I Disorder, fundamentally altering the treatment protocol.
3
Select appropriate pharmacological therapies for acute bipolar depression.
First-line treatments for acute bipolar depression include specific second-generation antipsychotics (quetiapine, lurasidone) and mood stabilizers (lithium, valproate).
These medications effectively treat depressive symptoms in bipolar patients without carrying the high risk of inducing a manic switch that is associated with antidepressant monotherapy.

Anahtar Kavram

The management of acute bipolar depression requires mood stabilizers or specific second-generation antipsychotics, explicitly avoiding antidepressant monotherapy due to the risk of precipitating a manic switch.
Tahmini Süre:1m 30s
Soru 471Soru →

A 28-year-old woman is evaluated in the emergency department after her roommate called emergency services. The roommate reported that the patient threatened to 'jump off the balcony' following a breakup with her boyfriend of one month. During the interview, the patient is calm and states, 'I did not actually mean it. I just wanted him to realize how much pain he caused me.' She says her boyfriend was 'the most perfect man ever' until yesterday, when she realized he is 'a complete monster.' The roommate notes that the patient has a history of impulsive spending, intense mood swings that typically last for a few hours, and a chronic feeling of emptiness. The patient mentions that when she gets extremely stressed, she sometimes hears a muffled voice calling her name, but this goes away quickly once she calms down. Her medical history includes atypical depression, for which she currently takes phenelzine. She asks the physician, 'Please do not tell my workplace about this visit; I told my manager I had a severe migraine.' The patient has no current suicidal ideation or plan.

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

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Cevap: Discharge the patient and provide a referral for dialectical behavior therapy

Cevap

The most appropriate next step is to discharge the patient and provide a referral for outpatient dialectical behavior therapy.
The patient's presentation is highly characteristic of borderline personality disorder (BPD). Key features include frantic efforts to avoid abandonment (threatening suicide after a breakup), unstable relationships with splitting (alternating between extreme idealization and devaluation of her boyfriend), impulsivity (spending), affective instability with mood swings lasting a few hours, chronic feelings of emptiness, and transient, stress-related psychotic symptoms (briefly hearing a voice). Given that she has no active suicidal ideation or plan and was making threats primarily to elicit a response, she does not meet the criteria for involuntary psychiatric hospitalization. The most appropriate next step is to discharge her and refer her for dialectical behavior therapy (DBT), which is the first-line evidence-based psychotherapy for BPD.

Adım Adım Çözüm

1
Analyze the patient's interpersonal behavior and affective symptoms.
The patient exhibits frantic efforts to avoid abandonment, splitting (idealizing then devaluing her boyfriend), impulsivity, affective instability, and feelings of emptiness.
Identifying these key features is necessary to diagnose borderline personality disorder (BPD).
2
Evaluate the patient's psychotic symptoms and timeline.
The auditory hallucinations are brief and strictly stress-related, ruling out a primary psychotic disorder like schizophreniform disorder.
Differentiating between transient stress-induced psychosis in BPD and primary psychotic disorders dictates the appropriate treatment pathway.
3
Assess the patient's safety risk.
The patient made a suicidal threat but currently denies any active suicidal ideation or plan, stating she did it to elicit a reaction.
Determining the level of danger to self or others establishes whether involuntary psychiatric admission is required.
4
Determine the appropriate management plan based on the diagnosis and safety assessment.
The patient is safe for discharge. The most effective long-term treatment for BPD is dialectical behavior therapy.
Since acute inpatient care is not indicated, establishing appropriate evidence-based outpatient psychotherapy is the correct intervention.

Anahtar Kavram

Borderline personality disorder is characterized by unstable relationships, impulsivity, affective instability, and transient stress-related paranoia or dissociation; management in the absence of active suicidal ideation involves outpatient dialectical behavior therapy.
Tahmini Süre:1m 30s
Soru 472Soru →

A 29-year-old woman presents to the outpatient psychiatry clinic accompanied by her husband, 4 weeks after delivering a healthy full-term infant. She reports severe, exhausting anxiety and highly distressing, recurrent images of accidentally drowning her baby while giving him a bath. She is horrified by these images, recognizes them as irrational, and states, 'I would never hurt my child, but my brain keeps flashing this terrible picture.' Consequently, she refuses to bathe the baby and frequently checks the crib to ensure the baby is breathing, sometimes up to 20 times an hour.

Her psychiatric history is notable for a hospitalization at age 20 during which she experienced a 3-week period of decreased need for sleep, rapid pressured speech, and grandiose spending. She was diagnosed with a mood disorder at that time but discontinued all medications five years ago. Currently, she exhibits no signs of elevated mood, hallucinations, or delusions. She is exclusively breastfeeding.

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

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Cevap: Refer the patient for cognitive-behavioral therapy incorporating exposure and response prevention

Cevap

The most appropriate next step is to refer the patient for cognitive-behavioral therapy incorporating exposure and response prevention.
The patient's clinical presentation—intrusive, distressing images of harming her infant combined with checking and avoidance behaviors—is classic for postpartum Obsessive-Compulsive Disorder (OCD). Because she has full insight and her thoughts are ego-dystonic, she does not have postpartum psychosis. First-line treatments for OCD include serotonergic antidepressants and cognitive-behavioral therapy featuring exposure and response prevention (ERP). However, her history of a manic episode (hospitalization for decreased sleep, rapid speech, and grandiosity) indicates underlying Bipolar I Disorder. In such patients, administering an SSRI without a mood stabilizer carries a high risk of inducing a manic switch. Therefore, ERP is the most appropriate next step, as it provides definitive treatment for the OCD while avoiding pharmacologic risks to both the mother (manic switch) and the breastfed infant.

Adım Adım Çözüm

1
Identify the primary psychiatric presentation.
The patient has highly distressing, intrusive thoughts of harming her infant, coupled with compulsive checking and avoidance behaviors. She retains insight and is horrified by the thoughts.
These symptoms are characteristic of ego-dystonic obsessions and compulsions, confirming a diagnosis of Obsessive-Compulsive Disorder (OCD) with postpartum onset.
2
Differentiate the presentation from postpartum psychosis and assess safety.
Unlike postpartum psychosis, the patient's reality testing is intact. She has no intent to harm the infant and takes protective measures. She does not pose an imminent danger.
This rules out the need for involuntary hospitalization, breaking confidentiality to call child protective services, or prescribing antipsychotics for a primary psychotic disorder.
3
Evaluate the patient's past psychiatric history.
The patient had a previous 3-week episode of decreased sleep, rapid speech, and grandiosity requiring hospitalization.
This meets the criteria for a manic episode, establishing a diagnosis of Bipolar I Disorder.
4
Determine the safest and most effective management strategy.
While SSRIs are typically first-line for OCD, monotherapy in a patient with Bipolar I Disorder risks inducing a manic switch. Cognitive-behavioral therapy (specifically exposure and response prevention) is highly effective.
Psychotherapy avoids the risks of pharmacologic mood destabilization and prevents medication exposure to the nursing infant.

Anahtar Kavram

Management of postpartum Obsessive-Compulsive Disorder (OCD) in patients with a history of Bipolar Disorder
Tahmini Süre:1m 30s
Soru 473Soru →

Match each patient's clinical presentation with the most accurate DSM-5 diagnosis based on the primary motivation for their symptoms or avoidance behavior.

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Öğeler

A 30-year-old avoids subways and crowded concerts because she fears escape would be difficult or help unavailable if she were to suddenly lose bladder control.
A 25-year-old avoids subways because he is intensely preoccupied with the belief that other passengers are observing his movements and judging him.
A 28-year-old avoids subways due to intrusive thoughts about contracting an infectious disease, which cause severe anxiety relieved only by repetitive hand sanitization.
A 40-year-old avoids all air travel due to an extreme fear triggered exclusively by airplanes, but comfortably takes subways and buses without distress.
A 35-year-old has recurrent, unexpected episodes of intense autonomic arousal. She does not avoid public places but worries daily about having another episode.

Eşleşmeler

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Cevap

The diagnoses are matched by identifying the underlying cognitive driver for each patient's distress: Agoraphobia involves fear of being trapped; Social Anxiety Disorder involves fear of scrutiny; OCD involves intrusive thoughts and compulsions; Specific Phobia involves an isolated situational trigger; and Panic Disorder involves unexpected attacks with anticipatory worry.
Each diagnosis in the DSM-5 anxiety and obsessive-compulsive spectrum is distinguished not merely by the presence of anxiety or avoidance, but by the specific cognitive etiology driving that behavior. Identifying whether avoidance stems from a fear of entrapment (Agoraphobia), fear of judgment (Social Anxiety), obsessions (OCD), or specific objects/situations (Specific Phobia) allows for precise diagnostic matching.

Adım Adım Çözüm

1
Analyze the underlying motivation for avoidance or distress in each clinical vignette.
Identified core fears such as inability to escape, negative evaluation, contamination, isolated situational triggers, or fear of future unprovoked panic attacks.
Different psychiatric disorders can present with identical surface behaviors (e.g., avoiding subways or crowds), making the underlying cognitive driver essential for accurate diagnosis.
2
Map each core fear to the corresponding DSM-5 diagnostic criteria.
Matched fear of trapped situations to Agoraphobia, fear of scrutiny to Social Anxiety Disorder, obsessions to OCD, specific situational trigger to Specific Phobia, and unexpected attacks with worry to Panic Disorder.
Ensures accurate differentiation between highly overlapping anxiety, obsessive-compulsive, and trauma-related disorders.

Anahtar Kavram

Differentiating anxiety and related disorders based on the core cognitive driver and motivation for avoidance behavior.
Soru 474Soru →

A 30-year-old man comes to the clinic for a routine psychiatric evaluation. He was recently diagnosed with schizophrenia and has been experiencing auditory hallucinations. During the interview, he becomes visibly angry and states, "The voices are telling me that my neighbor is an undercover agent trying to destroy me. I am going to buy a gun today and shoot him when he gets home." The patient has no previous history of violence but is adamant about his plan. He refuses voluntary admission to the hospital and attempts to leave the clinic. Which of the following is the most appropriate next step in management?

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Cevap: Arrange for involuntary psychiatric admission, and notify both law enforcement and the neighbor.

Cevap

Arrange for involuntary psychiatric admission, and notify both law enforcement and the neighbor.
The correct answer involves securing the patient and warning the intended victim. When a patient makes a specific, credible threat of physical violence against an identifiable third party, physicians have a legal and ethical obligation known as the 'duty to protect' (often referred to as the Tarasoff rule). Because this patient has a clear plan, the means to carry it out (intent to buy a gun today), and a specific target (the neighbor), he poses an imminent risk. The physician must breach confidentiality to warn the intended victim and notify law enforcement. Furthermore, because the patient is an imminent danger to others and refuses voluntary admission, he meets the clinical and legal criteria for involuntary psychiatric hospitalization.

Adım Adım Çözüm

1
Identify the nature of the patient's threat.
The patient has made a specific, credible, and imminent threat of violence against an identifiable victim (the neighbor).
Determining if a threat is specific and imminent is the essential first step in assessing homicide risk.
2
Determine the legal and ethical obligations regarding confidentiality.
The situation triggers the 'duty to protect' (often referred to as the Tarasoff ruling).
Physicians are legally and ethically obligated to breach confidentiality when a patient poses a serious risk of violence to a specific, identifiable third party.
3
Select the most appropriate clinical and legal management.
The patient must be involuntarily hospitalized due to being an imminent danger to others, and both the police and the intended victim must be warned.
Involuntary hospitalization secures the immediate safety of the public, while warning the victim and police explicitly fulfills the legal duty to protect.

Anahtar Kavram

When a patient presents a serious danger of violence to a specific, identifiable third party, physicians have a legal duty to protect the intended victim by warning them, notifying law enforcement, and taking necessary steps to secure the patient (e.g., involuntary hospitalization).
Soru 475Soru →

A 2828-year-old man is brought to the emergency department by his partner due to worsening lethargy and near-syncope. Over the past year, he has severely restricted his dietary intake and exercises intensely for 33 hours daily, expressing a profound fear of gaining weight. Physical examination reveals temporal wasting and lanugo over his trunk. Temperature is 35.2∘C35.2^\circ\text{C} (95.4∘F95.4^\circ\text{F}), blood pressure is 82/50 mm Hg82/50 \text{ mm Hg}, pulse is 38/min38\text{/min}, and respirations are 12/min12\text{/min}. His body mass index is 12.4 kg/m212.4 \text{ kg/m}^2. Electrocardiogram reveals sinus bradycardia with a prolonged QTc interval. Initial laboratory studies show:

Laboratory testResult
Potassium2.7 mEq/L2.7 \text{ mEq/L}
Magnesium1.2 mEq/L1.2 \text{ mEq/L}
Phosphorus1.8 mg/dL1.8 \text{ mg/dL}

Arrange the following clinical management steps in the most appropriate chronological sequence for this patient.

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Cevap

The correct sequence is: Admit to an inpatient medical telemetry unit → Administer intravenous electrolyte replacement → Initiate gradual enteral caloric rehabilitation → Transfer to an inpatient psychiatric eating disorder unit → Commence outpatient cognitive-behavioral therapy.
Patients with severe anorexia nervosa presenting with profound malnutrition, vital sign instability, and electrolyte abnormalities require a sequential step-up to step-down approach. The first priority is preventing sudden cardiac death. The presence of severe bradycardia, hypotension, and QTc prolongation mandates immediate admission to a medical unit with continuous cardiac telemetry. Second, profound electrolyte deficits (hypokalemia, hypomagnesemia, hypophosphatemia) must be aggressively corrected. If caloric rehabilitation is initiated before correcting these deficits, the resulting insulin surge will drive remaining electrolytes intracellularly, triggering fatal refeeding syndrome. Third, once electrolytes are being supplemented, gradual enteral caloric rehabilitation is initiated with strict monitoring. Fourth, when the patient becomes medically stable (normal vital signs, stable electrolytes on oral supplementation), they are transferred to an inpatient psychiatric unit specialized in eating disorders to continue supervised weight restoration and begin intensive behavioral therapy. Finally, upon achieving a safe weight and demonstrating sufficient behavioral control, the patient is discharged to initiate outpatient cognitive-behavioral therapy.

Adım Adım Çözüm

1
Assess the patient's medical stability and triage setting.
The patient has severe bradycardia (38/min38\text{/min}), hypotension (82/50 mm Hg82/50 \text{ mm Hg}), prolonged QTc, BMI <15 kg/m2< 15 \text{ kg/m}^2, and profound electrolyte derangements.
These critical findings indicate impending cardiovascular collapse. The patient requires immediate inpatient medical admission with cardiac telemetry, rather than direct psychiatric admission.
2
Determine the priority of interventions upon medical admission.
Intravenous electrolyte replacement must precede or accompany the very initiation of nutritional rehabilitation.
The patient already has hypophosphatemia, hypomagnesemia, and hypokalemia. Introducing calories (especially carbohydrates) without correcting these will precipitate refeeding syndrome, causing severe intracellular shifts of phosphorus and potassium, potentially leading to fatal arrhythmias.
3
Plan the long-term treatment pathway once medical stability is achieved.
Transfer to a psychiatric eating disorder unit, followed by outpatient psychotherapy.
Medical floors stabilize acute physiology but do not adequately treat the underlying eating disorder. Once hemodynamically and metabolically stable, intensive inpatient psychiatric care is required for weight restoration protocols, eventually transitioning to outpatient cognitive-behavioral therapy to prevent relapse.

Anahtar Kavram

Management of severe anorexia nervosa requires immediate medical stabilization (telemetry, electrolyte correction) to prevent refeeding syndrome and arrhythmias, followed by gradual nutritional rehabilitation, and subsequently transitioning to psychiatric step-down care.
Soru 476Soru →

Match each distinct clinical presentation with the most likely underlying neurocognitive etiology.

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Öğeler

Recurrent, well-formed visual hallucinations, fluctuating cognition, and spontaneous features of parkinsonism.
Prominent changes in personality, behavioral disinhibition, hyperorality, and relative sparing of memory in the early stages.
Stepwise cognitive decline, prominent executive dysfunction, and evidence of focal neurological deficits on examination.
Rapidly progressive dementia over weeks to months, accompanied by startle myoclonus and periodic sharp wave complexes on EEG.

Eşleşmeler

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Cevap

The clinical presentations map to their respective etiologies based on core diagnostic features: hallucinations and parkinsonism match with Lewy body disease; behavioral changes and hyperorality match with frontotemporal dementia; stepwise decline matches with vascular dementia; and rapid progression with myoclonus matches with Creutzfeldt-Jakob disease.
Each neurocognitive disorder presents with a distinct constellation of early symptoms and temporal progression patterns that allow for accurate clinical differentiation prior to neuropathological examination.

Adım Adım Çözüm

1
Evaluate the presentation featuring visual hallucinations, fluctuating cognition, and parkinsonism.
This maps to Major neurocognitive disorder with Lewy bodies.
These three symptoms constitute the core clinical criteria required for the diagnosis of Dementia with Lewy bodies.
2
Evaluate the presentation featuring early personality changes, disinhibition, and hyperorality.
This maps to Frontotemporal neurocognitive disorder.
These are the hallmark behavioral symptoms of the behavioral variant of frontotemporal dementia (Pick disease).
3
Evaluate the presentation featuring a stepwise cognitive decline and focal neurological deficits.
This maps to Vascular neurocognitive disorder.
Stepwise decline is characteristic of multi-infarct dementia, where each new microvascular or macrovascular event causes an abrupt drop in cognitive function.
4
Evaluate the presentation featuring rapid progression over weeks to months, accompanied by myoclonus.
This maps to Creutzfeldt-Jakob disease.
The extremely rapid timeline and the presence of startle myoclonus, confirmed by sharp waves on EEG, are classic pathognomonic signs of this prion disease.

Anahtar Kavram

Differentiating major neurocognitive disorders based on core clinical features and temporal progression.
Soru 477Soru →

A 74-year-old man with a 9-year history of Parkinson disease and emerging cognitive decline is brought to the emergency department by his daughter due to acute-onset, severe agitation and frightening visual hallucinations over the past 48 hours. He states that strangers are hiding in his room. His current medication regimen includes carbidopa-levodopa, pramipexole, and trihexyphenidyl. Arrange the following steps in the correct clinical escalation sequence for the evaluation and management of this patient's acute neuropsychiatric presentation, moving from initial assessment to therapies for refractory symptoms.

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Cevap

The correct sequence for managing acute psychosis and agitation in a patient with Parkinson disease or Lewy body dementia is: (1) medical evaluation for secondary causes, (2) discontinuation of anticholinergics, (3) discontinuation of dopamine agonists, (4) addition of a safe atypical antipsychotic like quetiapine, and finally (5) clozapine for refractory cases.
The management of acute behavioral changes and psychosis in patients with Parkinson disease or Lewy body dementia follows a strict, stepwise algorithm designed to balance psychiatric symptom control with the preservation of motor function. The essential first step is always to rule out an acute delirium secondary to a systemic illness. Once a systemic etiology is excluded, the existing medication regimen must be systematically simplified to eliminate medications that contribute most heavily to psychosis while providing the least critical motor benefit. Anticholinergic drugs (like trihexyphenidyl) are notoriously deliriogenic and are stopped first. Next, dopamine agonists (like pramipexole) are tapered off. Carbidopa-levodopa is maintained at the lowest effective dose because it is the most critical agent for motor function. If hallucinations persist despite this optimization, targeted pharmacotherapy is indicated. Only atypical antipsychotics with very low affinity for the dopamine D2 receptor (specifically quetiapine, pimavanserin, or clozapine) should be used, as other antipsychotics will induce severe parkinsonian rigidity. Quetiapine or pimavanserin are first-line choices. Clozapine is highly effective but is reserved for refractory cases due to the risk of agranulocytosis and the logistical burden of mandatory neutrophil monitoring.

Adım Adım Çözüm

1
Evaluate for Delirium
Identifies or excludes systemic triggers
Acute behavioral changes in neurocognitive disorders are frequently driven by underlying infections or metabolic issues that require immediate medical treatment.
2
Optimize existing medications by withdrawing the most deliriogenic agents
Discontinues trihexyphenidyl
Anticholinergics provide minimal motor benefit in advanced disease but carry a massive risk for delirium and visual hallucinations.
3
Further simplify the dopaminergic regimen
Discontinues pramipexole
Dopamine agonists are the next most likely culprits for psychosis. Levodopa is spared as long as possible to preserve motor function.
4
Introduce targeted psychiatric symptom control
Initiates quetiapine or pimavanserin
Standard antipsychotics will severely worsen parkinsonism. Low D2-affinity agents are required to treat hallucinations safely.
5
Escalate to the treatment of last resort
Initiates clozapine
Used only when other safe antipsychotics fail, due to the burdensome requirement for absolute neutrophil count monitoring to prevent agranulocytosis.

Anahtar Kavram

Management algorithm for psychosis and delirium in Major Neurocognitive Disorder due to Parkinson Disease
Soru 478Soru →

A 35-year-old male architect is brought to the outpatient psychiatry clinic by his brother due to worsening depression. For the past 5 weeks, the patient has exhibited profound sadness, anhedonia, and severe fatigue. He struggles to concentrate at work and is sleeping up to 14 hours a day. The brother reports that 3 years ago, the patient had a 3-week period where he slept only 2 hours a night, spoke extremely rapidly, and believed he was receiving direct telepathic messages from aliens instructing him to redesign the city's infrastructure. During that time, he drained his personal savings to fund the project before his symptoms gradually subsided without formal medical treatment. The patient has no other medical conditions and takes no medications. Vital signs are within normal limits. Mental status examination reveals a depressed affect, psychomotor retardation, and tearfulness, but no current suicidal ideation or psychotic symptoms. Which of the following is the most appropriate next step in management?

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Cevap: Initiate lurasidone

Cevap

Initiate lurasidone
This patient is currently experiencing a major depressive episode, but his history of a 3-week episode characterized by decreased sleep, pressured speech, and grandiose delusions confirms a diagnosis of Bipolar I Disorder. First-line pharmacotherapy for acute bipolar depression includes certain second-generation antipsychotics (e.g., lurasidone, quetiapine, cariprazine) or mood stabilizers (e.g., lithium). Lurasidone is highly effective for bipolar depression and has a favorable metabolic profile.

Adım Adım Çözüm

1
Analyze the patient's past psychiatric history.
The patient had a 3-week episode of decreased sleep, pressured speech, severe impulsivity (draining savings), and grandiose delusions.
Identifying past episodes is crucial to differentiating unipolar major depressive disorder from bipolar disorder. The prior episode meets full criteria for a Manic Episode with psychotic features.
2
Assess the current clinical presentation.
The patient is currently experiencing a major depressive episode (depressed mood, anhedonia, hypersomnia, fatigue, psychomotor retardation for 5 weeks).
Combining the past manic episode with the current depressive episode establishes a diagnosis of Bipolar I Disorder, currently in a depressed phase.
3
Evaluate treatment options for acute bipolar depression while ruling out contraindications.
Antidepressant monotherapy must be avoided. An agent approved for bipolar depression, such as lurasidone, is required.
Using traditional antidepressants without a mood stabilizer in Bipolar I disorder can precipitate a manic switch. First-line treatments for acute bipolar depression include lurasidone, quetiapine, cariprazine, or the olanzapine-fluoxetine combination.

Anahtar Kavram

Patients presenting with depressive episodes must be screened for past manic episodes to accurately diagnose Bipolar I Disorder and avoid the administration of antidepressant monotherapy, which can trigger a manic switch.
Tahmini Süre:1m 30s
Soru 479Soru →

A 34-year-old male distance runner is brought to the hospital by his partner due to profound weakness and near-syncope. His body mass index is 13.5 kg/m213.5 \text{ kg/m}^2, heart rate is 38/min38/\text{min}, and blood pressure is 82/50 mm Hg82/50 \text{ mm Hg}. He reports eating fewer than 500 kcal500 \text{ kcal} daily for the past three months to 'improve race times'. He is admitted to the medical intensive care unit for severe anorexia nervosa. Arrange the following steps in the optimal sequence for managing this patient's acute and long-term care to minimize the risk of potentially fatal complications.

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Cevap

The correct sequence requires establishing a metabolic baseline, proactively correcting electrolyte deficits, initiating feeding at a low caloric threshold, slowly advancing calories with close monitoring, and finally initiating formal psychotherapy once the patient is medically and cognitively stable.
The management of severe anorexia nervosa requires a highly orchestrated sequence to prevent refeeding syndrome. Prolonged starvation leads to a total body depletion of phosphorus, potassium, and magnesium, despite potentially normal serum levels due to metabolic adaptation. When carbohydrates are reintroduced, the sudden surge in insulin drives glucose and these electrolytes into the cells. If feeding is started before assessing and repleting these electrolytes, the serum levels crash catastrophically, causing arrhythmias, heart failure, and seizures. Therefore, baseline labs and ECG must be obtained first, followed immediately by fluid and electrolyte repletion. Only after baseline stability is achieved should low-calorie feeding begin (10−15 kcal/kg/day10-15 \text{ kcal/kg/day}). Calories are then cautiously advanced while continuously monitoring for electrolyte shifts and fluid overload. Finally, intensive psychotherapy (CBT) should be delayed until the patient is medically stable and the brain is sufficiently nourished to engage in complex cognitive tasks.

Adım Adım Çözüm

1
Obtain baseline electrocardiogram and electrolytes.
Identifies pre-existing hypophosphatemia, hypokalemia, hypomagnesemia, or prolonged QTc.
Establishing a baseline is critical before any intervention that could trigger fluid shifts or insulin release.
2
Replete electrolytes prior to caloric loading.
Normalizes serum levels of critical intracellular ions.
Introducing carbohydrates causes a surge of insulin, which drives phosphorus, potassium, and magnesium into cells. Pre-repletion prevents fatal depletion.
3
Initiate feeding at 10−15 kcal/kg10-15 \text{ kcal/kg} per day.
Safely reintroduces glucose to a starved metabolic system.
Starting at a low caloric rate minimizes the magnitude of the insulin spike, serving as a primary defense against refeeding syndrome.
4
Gradually advance caloric intake with continuous monitoring.
Achieves nutritional restoration while mitigating risk.
The risk of refeeding syndrome persists for up to two weeks; careful titration and daily monitoring allow for early detection and treatment of electrolyte shifts.
5
Initiate cognitive-behavioral therapy (CBT-E).
Addresses the underlying psychiatric pathology.
Severely malnourished brains lack the cognitive flexibility required for CBT. Psychotherapy is only effective once baseline medical stability and partial weight restoration are achieved.

Anahtar Kavram

Refeeding syndrome pathophysiology and sequential management in severe Anorexia Nervosa.
Soru 480Soru →

A 7575-year-old man is brought to the clinic by his daughter due to a progressive decline in his mobility and memory over the past 88 months. The daughter reports that he has become increasingly forgetful and struggles to manage his finances. Additionally, his walking has become remarkably slow and unsteady; he walks with his feet spread apart and appears as if his shoes are 'stuck to the floor.' In the past month, he has had several episodes of urinary incontinence, which he seems largely unconcerned about. His medical history includes hypertension and osteoarthritis. Neurological examination reveals a wide-based, magnetic gait with short steps. Muscle strength and deep tendon reflexes are normal, and there is no resting tremor or cogwheel rigidity. Montreal Cognitive Assessment score is 21/3021/30. Which of the following is the most appropriate next step in the diagnostic workup?

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Cevap: Magnetic resonance imaging of the brain

Cevap

Magnetic resonance imaging of the brain
The correct answer is magnetic resonance imaging of the brain. This patient's presentation of cognitive impairment, a wide-based 'magnetic' gait, and urinary incontinence constitutes the classic triad of normal pressure hydrocephalus (NPH). The initial diagnostic step for suspected NPH is always structural neuroimaging (MRI or CT of the brain). This is essential to document ventriculomegaly out of proportion to cerebral atrophy and to rule out other structural etiologies before any invasive testing is attempted.

Adım Adım Çözüm

1
Analyze the patient's clinical presentation.
The patient exhibits a progressive triad of cognitive impairment, wide-based magnetic gait, and urinary incontinence.
Identifying symptom clusters is essential for accurate syndromic diagnosis in geriatrics.
2
Formulate a primary differential diagnosis based on the triad.
The combination of 'wacky, wobbly, and wet' is the classic presentation of normal pressure hydrocephalus (NPH).
This specific combination distinguishes NPH from other dementias like Alzheimer disease or vascular dementia.
3
Determine the safest and most appropriate initial diagnostic step.
Structural neuroimaging must be performed first.
Imaging confirms ventriculomegaly and rules out structural lesions, which is a prerequisite before performing invasive testing like a high-volume lumbar puncture.

Anahtar Kavram

Diagnostic evaluation algorithm for Normal Pressure Hydrocephalus
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Psychiatry Alıştırma Soruları — USMLE Step 2 CK — Sayfa 24 | Examkin