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Psychiatry NBME Form 4 Questions And Answers



Exam Section : Item 1 of 50
An 82-year-old man is brought to the physician by his daughter because he has been forgetful during the past 6 weeks. She is particularly concerned because a small fire started recently when he left a pot unattended on the stove. The patient's wife died 1 year ago, and he says he has been distracted recently and cannot stop thinking about her. He lives alone and pays his bills, does routine household chores, and drives short distances for errands. His daughter says he was doing well on his own until recently. He is 168 cm (5 ft 6 in) tall and weighs 63 kg (140 1b); BMI is 23 kg/m2. His temperature is 37 0 C (98.6
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F), pulse is 78/min and regular, respirations are 18/min, and blood pressure is 130/80 mm Hg. Physical examination shows no abnormalities. On mental status examination, he is alert and cooperative.
He becomes very sad when he talks about his wife's death. Which of the following is the most appropriate next step in management?
A) Follow-up examination in 3 months
B) Mini-Mental State Examination
C) Recommend assisted living
D) CT scan of the head
E) Begin donepezil therapy

Answer: (B) Mini-Mental state examination

Exam Section : Item 2 of 50
A 37-year-old man is brought to the emergency department after the pilot of a boat found him in the river at 2 am with rocks in his pockets. He reports that he jumped from the bridge to go for a swim and was not attempting suicide. He insists that the rocks were only to give him ballast when he jumped so that he would not hit the bridge tower. He immigrated to the USA 1 year ago and left most of his family behind. He has been living in a single furnished room and has been working numerous low-paying jobs. Over the past month, he has had a 4.5-kg (10-1b) weight loss. He reports that he always feels tired but has not seen a physician because he has no health insurance. He does not usually drink but had two shots of whiskey earlier that night. He has no history of medical or psychiatric illness. Physical examination shows numerous lacerations and abrasions over the chest and all extremities. On mental status examination, he describes his mood as fine but often appears tearful. His speech is slow with frequent pauses, and he is guarded in his responses. He says that he has not had hallucinations. He is alert and oriented to person, place, and time. The physician recommends voluntary admission to the psychiatric unit, but the patient refuses, saying there is nothing wrong with him. Which of the following is the most appropriate next step in management?
A) Recommend a mental health facility in his neighborhood
B) Recommend a social service agency
C) Observe in the emergency department for 36 hours
D) Begin fluoxetine therapy
E) Begin risperidone therapy
F) Admit to the psychiatric unit involuntarily
 
Answer: F) Admit to the psychiatric unit involuntarily
 
Exam Section : Item 3 of 50
Five weeks after being discharged from the hospital after treatment for a psychotic episode, a 27-year-old man comes to the physician for a follow-up examination. During hospitalization, he claimed that he was instructed by the Lord to found a new religion and that a famous gospel singer was in love with him. Today, he says that he still hears the voices of the Lord and members of the church he attends in his apartment and when he shops in the supermarket. He no longer believes the world needs a new religion because the Lord is no longer instructing him to create one. He states, "My father in heaven tells me that he is at peace, and therefore, so am l." Current medications include risperidone and lorazepam. He drinks one to two beers on weekends. He used marijuana regularly in college but has abstained for the past 5 years. He appears clean and is casually dressed. His temperature is 36.7 oc (980F), pulse is 72/min, respirations are 20/min, and blood pressure is 130/72 mm Hg. Physical examination shows no abnormalities. Mental status examination shows a calm affect. He is cooperative, alert, and oriented to person, place, and time. Based on this information, which of the following is the most likely current diagnosis for this patient?
A) Bipolar disorder
B) Cyclothymic disorder
C) Delusional disorder
D) Schizoaffective disorder
E) Substance-induced mood disorder
 
Answer: C) Delusional disorder
 
Exam Section : Item 4 of 50
The response options for the next 2 items are the same. Select one answer for each item in the set.
For each patient with depressed mood, select the most likely diagnosis.
A) Adjustment disorder with depressed mood
B) Bereavement
C) Bipolar disorder, depressed
D) Cyclothymic disorder
E) Dysthymic disorder
F) Major depressive disorder
G) Mood disorder due to a general medical condition
H) Substance-induced mood disorder
A previously healthy 37-year-old man comes to the physician because of a 6-month history of depressed mood, fatigue, poor concentration, and difficulty sleeping. He works as an accountant and has had difficulty staying awake at work, particularly in the afternoon. He says that his wife sleeps in a separate room because of his loud snoring. He drinks alcohol at social functions only. He is 175 cm (5 ft 9 in) tall and weighs 109 kg (240 1b); BMI is 35 kg/m2. Physical examination shows no other abnormalities. Mental status examination shows a mildly depressed mood.
 
Answer: G) Mood disorder due to a general medical condition
 
Exam Section: Item 5 of 50
A) Adjustment disorder with depressed mood
B) Bereavement
C) Bipolar disorder, depressed
D) Cyclothymic disorder
E) Dysthymic disorder
F) Major depressive disorder
G) Mood disorder due to a general medical condition
H) Substance-induced mood disorder
A 23-year-old graduate student comes to the physician because of depressed mood and feelings of hopelessness since breaking up with her boyfriend 1 week ago. During this period, she has rarely left her apartment, has only eaten a small amount of food, and has isolated herself from her friends and family. She has been drinking more alcohol than normal during this period. Physical examination shows no abnormalities. On mental status examination, she becomes tearful when she describes the breakup. When asked about her mood, she says, "I'm miserable. He was my life!" There is no evidence of suicidal ideation.
 
Answer: A) Adjustment disorder with depressed mood
 
Exam Section : Item 6 of 50
A 37-year-old woman is brought to the emergency department 30 minutes after the onset of a severe occipital headache, palpitations, and tremulousness. Shortly before this episode, she ate several slices of pepperoni pizza. She has a 2-month history of atypical major depressive disorder treated with phenelzine. She is otherwise healthy. She appears anxious and tremulous. Her temperature is 37.80C (IOOF), pulse is 94/min, respirations are 20/min, and blood pressure is 210/110 mm Hg. Physical examination shows no other abnormalities. The most appropriate next step is administration of which of the following?
A) Bromocriptine
B) Diazepam
C) Diphenhydramine
D) Fluvoxamine
E) Haloperidol
F) Naloxone
G) Phentolamine
H) Physostigmine
 
Answer: B) Diazepam

Exam Section : Item 7 of 50
A 20-year-old woman is admitted to the hospital because of severe swelling of the lower extremities for 10 days. She has been amenorrheic for 6 months and has had a 23-kg (50-1b) weight loss over the past year. She has been receiving treatment with fluoxetine for major depressive disorder. She is evasive responding to questions about laxatives or diuretics. She states that she believes she is overweight and therefore she works out twice daily at the health club. She appears emaciated. She is 165 cm (5 ft 5 in) tall and weighs 32 kg (70 1b); BMI is 12 kg/m2. Her pulse is 601min, and blood pressure is 100/60 mm Hg. Examination shows 3+ pitting edema of the lower extremities. Which of the following is the most likely explanation for these findings?
A) Adverse effect of fluoxetine
B) Decreased serum albumin concentration
C) Impaired serotonergic function
D) Increased serum corticotropin-releasing hormone concentration
E) Ipecac-induced cardiomyopathy
 
Answer: B) Decreased serum albumin concentration
 
Exam Section : Item 8 of 50
A 42-year-old man is brought to the emergency department by police after they found him hiding under a parked truck. Police say the patient claimed to be hiding from "dementors" who would look him in the eyes and make him an alien through "viral-spatial worms." During the past 5 years, he has been brought to the emergency department eight times for similar behavior. He has no other history of serious illness and takes no medications. He does not use illicit drugs. He lives alone and does not have friends. He appears disheveled. Physical examination shows no abnormalities. On mental status examination, he is fully oriented. He makes poor eye contact and speaks quickly and loudly. He has an anxious affect. His thought process is predominantly linear. During the examination, he opens his eyes only after he counts out loud to 13 and says that doing so helps him to counteract "evil forces." Which of the following is the most likely diagnosis?
A) Bipolar disorder
B) Delusional disorder
C) Obsessive-compulsive disorder
D) Schizoid personality disorder
E) Schizophrenia
  
Answer: E) Schizophrenia
 
Exam Section : Item 9 of 50
An 8-month-old male infant who was adopted recently is brought to the physician because of poor weight gain. He was born at term and weighed 2410 g (5 1b 5 oz). He was formula fed at birth and has consistently been below the 3rd percentile for weight. Currently, his diet consists of 16 ounces of iron-fortified cow milk formula, juice, cereal, prepared fruit, and pureed green vegetables. There is no history of vomiting. He has one formed stool daily. He is alert and appears well. He currently weighs 7002 g (15 1b 7 oz). On examination, he says "mama" and "bye-bye" while waving. He sits unsupported. He is wary of strangers. There are narrow palpebral fissures, epicanthal folds, a thin upper lip with a "fish mouth" appearance of the oral cavity, and an indistinct nasal philtrum. His ears are normally set, the nasal bridge is flattened, and the tongue is not enlarged. There is a single palmar crease on the left hand. Cardiopulmonary examination shows no abnormalities. There is no hepatosplenomegaly, and no masses are palpated. There is no peripheral edema. Which of the following is the most likely diagnosis?
A) Celiac disease
B) Down syndrome
C) Fetal alcohol syndrome
D) Psychosocial deprivation
E) Silver-Russell syndrome
 
Answer: C) Fetal alcohol syndrome
 
Exam Section : Item 10 of 50
A 57-year-old man comes to the physician with his wife because of a I-month history of bizarre behavior at night. His wife says that most nights he falls asleep at approximately 11 pm and begins kicking and groaning in the bed shortly after 12:30 am. Seven times during this period, he has jumped out of the bed and run back and forth across the room, punching the air. She tries to wake him during these episodes because she is afraid that he might hurt her or himself. She reports that when she succeeds, he seems alert but tells her that he was being attacked and needed to defend himself or escape. The patient tells the physician that he does not recall the behavior his wife is describing but remembers having a recurrent dream in which he is in danger and cannot breathe. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, he has a pleasant and full range of affect. His thought process is rational and goal directed. He says that based on his wife's description of his behavior at night, he is afraid that he might hurt her. Results of laboratory studies are within the reference range. Which of the following is the most likely diagnosis?
A) Central sleep apnea
B) Nocturnal panic disorder
C) Nocturnal paroxysmal dystonia
D) REM sleep behavior disorder
E) Restless legs syndrome
F) Sleep-related complex partial seizure disorder
G) Sleep terror disorder
 
Answer: D) REM sleep behavior disorder
 
Exam Section : Item 11 of 50
A 27-year-old woman, gravida 1, para 1, comes to the physician with her husband because of progressive irritability and anxiety since the birth of her child 3 weeks ago. Pregnancy was complicated by premature labor that was managed with bed rest. Delivery occurred at term with no complications. Examination of her newborn at birth showed no abnormalities. The patient reports that he feeds well and appears healthy, but she has constant worries about his health and her own health. She adds that she has had a decreased appetite and difficulty sleeping. Her husband notes that she has been increasingly withdrawn from family and friends and that she has reported thoughts of suicide. The patient has no history of serious illness or major depressive disorder. Her only medication is a multivitamin. She appears tired. Physical examination shows no abnormalities. On mental status examination, she has an irritable mood and depressed affect. She is oriented to person, place, and time.
Which of the following is the most likely diagnosis?
A) Adjustment disorder
B) Bipolar disorder
C) Generalized anxiety disorder
D) Major depressive disorder
E) Post-traumatic stress disorder
 
Answer: D) Major depressive disorder
 
Exam Section : Item 12 of 50
A 42-year-old man comes to the physician because of a 6-month history of sexual problems. He can achieve and maintain erections but is rarely able to ejaculate during intercourse. He has erections on awakening in the morning and nocturnal emissions approximately once monthly. He has a 2-year history of coronary artery disease well controlled with metoprolol, lisinopril, and aspirin. He and his wife of 12 years divorced 3 years ago. Over the past 6 months, he has been sexually active with two female partners, and they use condoms for contraception. Examination shows a normal-appearing penis and testes. Which of the following is the most likely explanation for this patient's sexual dysfunction?
A) Decreased pituitary production of gonadotropins
B) Disruption of arterial inflow to the penis by metoprolol
C) Obstruction at the bladder neck
D) Performance anxiety
E) Testicular insensitivity to testosterone
 
Answer: D) Performance anxiety
 
Exam Section : Item 13 of 50
A 77-year-old man comes to the physician at his wife's insistence because of a 2-year history of progressive memory problems. His wife notes that he often asks questions that have been answered minutes earlier. On three occasions, he got lost while walking a few blocks from their house, and he has forgotten to turn off the burner several times when making coffee. He has been otherwise healthy.
He takes no medications. He is awake and alert. Physical examination shows no abnormalities. On questioning, he states that he has not been aware of any memory problems. His Mini-Mental State Examination score is 21/30. He recalls one of three objects after 2 minutes. An MRI of the brain shows moderate atrophy. Administration of a medication with which of the following properties is the most appropriate treatment?
A) Anticholinergic
B) Antidopaminergic
C) Antiserotonergic
D) Cholinergic
E) Dopaminergic
F) Serotonergic
 
Answer: D) Cholinergic
 
Exam Section : Item 14 of 50
A 32-year-old man is admitted to the hospital because of refusal to speak or move since he returned home after being robbed at gunpoint yesterday. His wife says that her husband was physically unharmed but seemed to be in acute emotional distress. He stopped talking, would not move from his chair, and began staring into space. His wife reports that he has no history of serious illness and takes no medications. The patient is sitting upright with his eyes closed. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, he is mute, does not follow commands, and resists being moved. His affect is flat. Which of the following is the most appropriate pharmacotherapy?
A) Buspirone
B) Dexamphetamine
C) Haloperidol
D) Lorazepam
E) Sertraline
 
Answer: D) Lorazepam
  
Exam Section : Item 15 of 50

A 23-year-old man comes to the physician because of anxiety since beginning a second part-time job as a courier for a photographer 6 weeks ago. He reports a fear of heights and of riding in elevators. He takes stairs and escalators whenever possible, which prevents him from completing his deliveries on time. He has not had panic attacks. He has no history of serious illness and takes no medications. His temperature is 36.80C (98.2 OF), pulse is 80/min, respirations are 18/min, and blood pressure is 118/73 mm Hg. Physical examination shows no abnormalities. On mental status examination, he has an anxious mood and full range of affect. He reports no symptoms of depression or suicidal ideation. Which of the following is the most appropriate next step in management?
A) Cognitive behavioral therapy
B) Interpersonal therapy
C) a-Adrenergic agonist therapy
D) ß-Adrenergic blocker therapy
E) Selective serotonin reuptake inhibitor therapy
 
Answer: A) Cognitive behavioral therapy
 
Exam Section : Item 15 of 50
A 47-year-old man is brought to the physician by his wife because of "unbearable" behavior during the past 2 weeks. His wife reports that he has been talking about his various inventions constantly and recently bought a new recreational vehicle, even though they do not travel long distances. He repeatedly tells his wife that "the time to make and enjoy money has come." He has been openly critical of their pastor's prayers during church services. He claims that the pastor does not know what he is talking about because "God is talking to me, not him." His wife says that he has had episodes of similar behavior during the past 10 years that have been more tolerable. He has peptic ulcer disease treated with ranitidine and hypertension treated with triamterene. He does not smoke or drink alcohol. He is 170 cm (5 ft 7 in) tall and weighs 82 kg (180 1b); BMI is 28 kg/m2. His pulse is 80/min, and blood pressure is 150/95 mm Hg. Physical examination shows no other abnormalities. On mental status examination, he is relaxed and talkative, jumping from one topic to another. He claims that his wife does not understand him and that she has been plotting with the pastor against him. He denies any problems and says that he feels great and is capable of great things. Laboratory findings are within the reference range. Urine toxicology screening is positive for marijuana. Which of the following is the most likely diagnosis?
A) Bipolar disorder
B) Delusional disorder
C) Mood disorder due to a general medical condition
D) Schizophrenia
E) Substance-induced mood disorder
Answer: E) Substance-induced mood disorder
 
Exam Section : Item 16 of 50
An 18-year-old man is brought to the emergency department by friends 1 hour after they found him on the couch at a party unable to move. Earlier that evening, he had been using synthetic heroin. On arrival, his pulse is 85/min, respirations are 181/min, and blood pressure is 130/80 mm Hg. Examination shows stiffness in all extremities, drooling, and slow response to questions. Which of the following brain regions is most likely affected?
A) Cerebellar vermis
B) Globus pallidus
C) Locus ceruleus
D) Mammillary bodies
E) Nucleus accumbens
F) Substantia nigra
 
Answer: F) Substantia nigra
 
Exam Section : Item 18 of 50
A 72-year-old woman comes to the physician because of a 3-month history of fatigue and difficulty sleeping. She has had a 5.4-kg (12-1b) weight loss during this period because of decreased appetite. Her husband died 18 months ago. She has a 15-year history of hypertension treated with verapamil and a 3-month history of insomnia treated with zolpidem. Laboratory studies 1 week ago showed no abnormalities. She is 170 cm (5 ft 7 in) tall and weighs 60 kg (133 1b); BMI is 21 kg/m2. Her pulse is 74/min, and blood pressure is 131/84 mm Hg. Physical examination shows no abnormalities. Mental status examination shows an irritable and tearful mood. She expresses hopelessness about the future. Which of the following is the most likely finding in this patient?
A) Decreased hemoglobin concentration
B) Decreased serum vitamin Bl (thiamine) concentration
C) Increased percentage of bands on complete blood count
D) Increased serum cortisol concentration
E) Increased serum prolactin concentration
 
Answer: D) Increased serum cortisol concentration
 
Exam Section• Item 19 of 50
A 24-year-old man is brought to the emergency department from jail by police because he has had numbness in his right hand from the wrist extending to the fingers for 4 hours. He has been in jail for 10 days awaiting trial for automobile theft. He has an extensive history of juvenile offenses and was released from state prison 6 months ago. Examination shows equal pulses in all extremities; he can move all extremities. Deep tendon reflexes are normal. He has numbness from the wrist to the tips of the digits of the right hand. His skin is warm to the touch, and he has multiple tattoos. The distal phalanx of the ring finger of the right hand is absent with a well-healed scar. Which of the following is the most appropriate next step in management?
A) Brachial nerve conduction studies
B) CT scan of the head
C) Ultrasound venography
D) Lumbar puncture
E) No treatment is indicated
 
Answer: E) No treatment is indicated

Exam Section : Item 20 of 50
A 62-year-old woman is brought to the emergency department by her husband because of confusion for 4 hours. Her husband says that she has been exhibiting strange behavior for 3 days; she forgets pots on the stove or does not know what day it is. This morning she was completely disoriented and thought that her husband was a burglar. She has been taking fluoxetine (20 mg daily) for 2 weeks for treatment of major depressive disorder. Current medications also include propranolol (40 mg three times daily) for hypertension and doxepin (50 mg at bedtime) for insomnia. She appears to be having visual hallucinations and is unable to give any useful information. Her pulse is 110/min, respirations are 14/min, and blood pressure is 140/95 mm Hg. Examination shows dilated pupils, dry flushed skin,and a mild tremor. She is disoriented to person, place, and time. An ECG shows first-degree atrioventricular block and a widened QRS complex. Urine toxicology screening is negative. Which of the following is the most appropriate next step in management?
A) Measurement of serum doxepin and desmethyldoxepin concentrations
B) Measurement of serum fluoxetine and norfluoxetine concentrations
C) Begin lorazepam (2 mg every 8 hours)
D) Discontinue doxepin
E) Insert temporary pacemaker
 
Answer: D) Discontinue doxepin
 
Exam Section : Item 21 of 50
A 19-year-old man has had restless sleep and feelings of sadness for 1 week; he has had a 0.9-kg (2-1b) weight loss during this period. He also has had tension headaches, difficulty concentrating, and difficulty completing his assignments for college. His first relationship ended 2 weeks ago. He states, "My life is over. My girlfriend meant everything to me." He has no history of similar symptoms. He does not intend to harm himself. Which of the following is the most likely diagnosis?
A) Acute stress disorder
B) Adjustment disorder with depressed mood
C) Generalized anxiety disorder
D) Major depressive disorder
E) Uncomplicated grief reaction

Answer: B) Adjustment disorder with depressed mood

Exam Section : Item 22 of 50
A 25-year-old man comes to the physician with his wife because of bizarre behavior for the past 3 months. She reports that he will only travel to work by taking certain routes and is overly concerned about air quality, routinely inspecting for dust on the furniture and closing the windows when he returns from work. He has organized his office and his home in a particular way and becomes extremely upset when anything is rearranged. He realizes that his demands are unreasonable but says that "l would be very nervous and tense if it were arranged any other way." He has had no changes in sleep pattern.
Physical examination shows no abnormalities. On mental status examination, he reports feeling mildly anxious and depressed "all the time." Results of laboratory studies are within reference ranges. Which of the following is the most appropriate pharmacotherapy?
A) Bupropion
B) Buspirone
C) Clonazepam
D) Haloperidol
E) Sertraline

Answer: E) Sertraline

Exam Section : Item 23 of 50
A 47-year-old woman is brought to the emergency department by her husband because of increasing confusion during the past 2 days. On arrival, she has a generalized tonic-clonic seizure lasting 4 minutes. She has bipolar disorder treated with several medications, but her husband is unsure of their names. He knows that she sometimes takes ibuprofen for mild arthritis pain caused by exercise. He says that she has been active and exercising more lately, but he cannot think of other changes in her routine. She has no history of seizure disorder. She is oriented to person but not to place and time. Her pulse is 90/min, and blood pressure is 140/90 mm Hg. On physical examination, she is tremulous and somnolent. There is bilateral nystagmus. An ECG shows a second-degree atrioventricular block. The most likely cause of this patient's symptoms is an adverse effect of which of the following medications?
A) Bupropion
B) Haloperidol
C) Lithium
D) Risperidone
E) Valproic acid

Answer: C) Lithium

Exam Section : Item 24 of 50
A 2-year-old girl who was adopted is brought to the physician because of developmental delay; she does not walk independently and is not yet talking. She was born at term to a 41-year-old woman, gravida 2, para 1, aborta 1. No information is available about pregnancy and delivery. The patient is at the 40th percentile for length and 80th percentile for weight. Examination shows epicanthal folds, a prominent tongue, small low-set ears, and short extremities. Developmental testing shows a developmental quotient of 60. Which of the following is the most likely cause of this patient's condition?
A) Defect in N-acetylglutamate synthetase
B) Fetal exposure to alcohol
C) 45,X karyotype
D) Phenylalanine hydroxylase deficiency
E) Trisomy of an autosomal chromosome

Answer: E) Trisomy of an autosomal chromosome
 
Exam Section : Item 24 of 50
A 47-year-old woman comes to the physician 2 hours after the onset of heart palpitations. She had a myocardial infarction 6 years ago and is suddenly afraid that she might be having another heart attack. She does not have chest pain. She says that 2 hours ago, she was feeling "extremely good and enjoying how things seemed to be moving slowly around me." An exercise stress test 2 months ago showed no abnormalities. She has been taking alprazolam up to three times daily for 3 years for anxiety and took her last dose 3 hours ago. Her father died of a myocardial infarction at the age of 46 years. She had not used an illicit substance for 20 years, but 2 months ago, she was promoted to a managerial position and began smoking marijuana daily to relax. Her temperature is 37.50C (99.50F), pulse is 120/min, respirations are 20/min, and blood pressure is 150/95 mm Hg. Physical examination shows dry oral mucosa and injected conjunctivae. Neurologic examination shows difficulty with finger-nose testing. On mental status examination, she has an anxious affect, and she repeatedly asks for something to be done. Her speech is staccato and rushed but clear and rational. An ECG shows sinus tachycardia. Which of the following is the most likely cause of this patient's current symptoms?
A) Acute myocardial infarction
B) Anxiolytic intoxication
C) Anxiolytic withdrawal
D) Generalized anxiety disorder
E) Histrionic personality disorder
F) Hypochondriasis
G) Major depressive disorder
H) Marijuana intoxication
l) Panic disorder

Answer: H) Marijuana intoxication
 
Exam Section : Item 26 of 50
A 52-year-old woman comes to the physician for a routine follow-up examination. She has received inpatient psychiatric treatment several times since the age of 25 years for auditory hallucinations and the belief that her thoughts and movements were being controlled by a local television station; her last admission to the hospital was 10 years ago. Treatment with haloperidol for the past 20 years has decreased the occurrence of symptoms. She attempted suicide at the ages of 30 and 38 years. She lives in a supervised residence and does not work. During the examination, she repeatedly smacks her lips and slightly protrudes her tongue. When the physician asks if she is chewing gum, she laughs and opens her mouth to show she is not. She can hold her mouth and tongue still when asked but begins lip smacking when the physician resumes the examination. Which of the following is the most appropriate next step in pharmacotherapy?
A) Continue haloperidol and add alprazolam
B) Continue haloperidol and add propranolol
C) Discontinue haloperidol
D) Discontinue haloperidol and begin chlorpromazine
E) Discontinue haloperidol and begin risperidone

Answer:  E) Discontinue haloperidol and begin risperidone
 
Exam Section : Item 27 of 50
A 7-year-old girl is brought to the physician because her parents are concerned about her recent preoccupation with death. Her dog died 2 months ago, and since that time she has repeatedly asked her parents if they are going to die. When her mother travels, the daughter worries that the plane will crash. She has begun to talk with her friends about the possibility of their parents dying. She continues to excel academically and participate in sports. Her pulse is 86/min, and blood pressure is 110/70 mm Hg. Physical examination shows no abnormalities. Mental status examination shows a neutral mood and an appropriately reactive affect. Which of the following is the most likely explanation for these findings?
A) Bereavement
B) Obsessive-compulsive disorder
C) Post-traumatic stress disorder
D) Separation anxiety disorder
E) Age-appropriate behavior

Answer: E) Age-appropriate behavior
  
Exam Section : Item 28 of 50
A 14-year-old boy is brought to the physician for a well-child examination. His mother says her son is self-centered and shows decreasing interest in his family. He showers twice daily but will not keep his room neat. He frequently shifts from being pleasant and cooperative to being very disagreeable. He has not begun dating. Pubic hair development began at the age of 12 years. Examination shows no facial hair and minimal axillary hair. Pubic hair and genital development are Tanner stage 3. Which of the following is the most accurate assessment of this patient's development?
I)    Normal Normal

Exam Section : Item 29 of 50
A 52-year-old man with schizophrenia comes to the physician for a follow-up examination. At his last examination 1 week ago, the physician noticed that the patient's tongue occasionally protruded. When asked, the patient was unaware of this movement, but he was able to voluntarily prevent it. At that time, physical examination showed normal muscle strength. He had been taking risperidone for 5 years; treatment was discontinued to stop his tongue movements. Today, examination shows worsening tongue movements and writhing choreoathetoid movements of the upper extremities. Which of the following is the most likely underlying cause of this patient's symptoms?
A) Atrophy of the caudate nucleus
B) Increased acetylcholine
C) Increased sensitivity of the dopamine receptors
D) Loss of volume in the basal ganglia
E) Vascular changes in the small vessels
 
Answer: C) Increased sensitivity of the dopamine receptors

Exam Section : Item 30 of 50
A 42-year-old man comes to the physician for advice concerning his fear of flying. One year ago, he was on an airplane that had to abort a takeoff. He was so anxious that he was unable to get back on the plane once the problem was resolved and has been unable to fly since that time. His job requires him to travel, and he is concerned that his fear of flying might jeopardize an anticipated promotion.
Twenty years ago, he had a panic attack while giving an oral presentation in a college class. He has mitral valve prolapse. He drinks three cups of coffee daily. His pulse is 90/min, and blood pressure is 110/70 mm Hg. Cardiac examination shows a late systolic click followed by a grade 2/6 late systolic murmur. Mental status examination shows a neutral mood and intense affect. Which of the following is the most likely diagnosis?
A) Anxiety disorder due to a general medical condition
B) Generalized anxiety disorder
C) Panic disorder with agoraphobia
D) Specific phobia
E) Substance-induced anxiety disorder

Answer: D) Specific phobia

Exam Section : Item 31 of 50
A 26-year-old man comes to the physician because of increasing daytime sleepiness over the past 3 years. He has begun to unexpectedly fall asleep at work and is concerned that he will lose his job if he does not change his behavior. He has stopped driving because of fear that he will fall asleep at the wheel. He generally sleeps well at night. He states that he avoids exercise and caffeine ingestion in the evening and does not read or watch television in bed. His wife states that he does not snore or have restless leg movements while sleeping. He has vivid dream-like images just before falling asleep and on awakening. He describes his mood as generally good despite his worry about his job security. Polysomnography is most likely to show which of the following?
A) Decreased REM density
B) Decreased REM latency
C) Decreased stage 1 sleep
D) Increased sleep efficiency
E) Increased sleep latency

Answer: B) Decreased REM latency

Exam Section : Item 32 of 50
A) Bupropion
B) Buspirone
C) Chlorpromazine
D) Fluoxetine
E) Haloperidol
F) Imipramine
G) Lorazepam
H) perphenazine
l) Propranolol
A 27-year-old man comes to the physician because of anxiety about a major speech that he must deliver in 3 days. He is excited about the opportunity for his career but is concerned that his apprehension and great fear of public speaking will affect his performance. He requests a tranquilizer to help with his anxiety. He has no history of medical problems. He has a family history of alcohol dependence. He does not drink alcohol or use drugs. His pulse is 76/min, respirations are 12/min, and blood pressure is 130/82 mm Hg. Examination shows normal findings.

Answer: l) Propranolol
 
Exam Section : Item 33 of 50
A) Bupropion
B) Buspirone
C) Chlorpromazine
D) Fluoxetine
E) Haloperidol
F) Imipramine
G) Lorazepam
H) perphenazine
l) Propranolol
A 27-year-old man comes to the physician because of anxiety about a major speech that he must deliver in 3 days. He has a great fear of public speaking and is convinced that his apprehension and tremulous delivery will damage his performance. He requests a tranquilizer to help with his anxiety. He takes theophylline and uses corticosteroid and albuterol inhalers for asthma. He has a family history of alcohol dependence. He does not drink alcohol or use drugs. His pulse is 66/min, respirations are 12/min, and blood pressure is 132/80 mm Hg. Examination shows normal findings.

Answer: G) Lorazepam
 
Exam Section : Item 34 of 50
Over the past 7 years, a 25-year-old graduate student has had increasingly severe palpitations, tremulousness, nausea, sweating, and inability to concentrate while taking examinations. He is worried because he recently failed an examination despite being thoroughly prepared. Examination shows normal findings. Which of the following is the most appropriate next step in diagnosis?
A) Ambulatory ECG monitoring
B) 24-Hour urine collection for 5-hydroxyindoleacetic acid
C) 24-Hour urine collection for measurement of catecholamine and metanephrine concentrations
D) Measurement of serum thyroxine (T 4) and thyroid-stimulating hormone concentrations
E) Psychiatric evaluation

Answer: E) Psychiatric evaluation
 
Exam Section : Item 35 of 50
A 32-year-old financial analyst comes to the physician at her employer's request because of bizarre behavior and poor work productivity over the past 6 months. She has been arriving late, leaving early,and frequently taking long breaks. She has had daily mood swings; sometimes she appears withdrawn, lethargic, and belligerent and other times she appears energetic and loquacious. Over the past 2 weeks, she has had several arguments with coworkers in which she accused them of stealing or sabotaging her work. This morning, she threatened to physically assault her supervisor after he questioned her about a 2-hour absence from work. Her temperature is 37oc (98.60F), pulse is 90/min, respirations are 16/min, and blood pressure is 160/100 mm Hg. The pupils are dilated and reactive to light. Deep tendon reflexes are increased. On mental status examination, she is angry but cooperative. She describes her supervisor's unfairness and the unfriendliness of other analysts; she suspects that they are jealous of her. She speaks in a loud, rapid voice, frequently interrupting the physician. She is oriented to person, place, and time. She is able to recall three of three objects after 5 minutes and quickly and accurately performs 2-digit calculations. Which of the following is the most likely diagnosis?
A) Alcohol withdrawal
B) Bipolar disorder
C) Cocaine abuse
D) Delusional disorder, persecutory type
E) Inhalant abuse
F) Paranoid personality disorder
G) PCP abuse
H) Schizophrenia, paranoid type

Answer: C) Cocaine abuse
 
Exam Section : Item 36 of 50
A 47-year-old man comes to the physician because of a 2-day history of intense anxiety. He has been receiving chemotherapy for hepatoma for 5 days. His nausea is well controlled with prochlorperazine. He has no history of similar symptoms or psychiatric illness. His pulse is 104/min, and blood pressure is 142/86 mm Hg. Mental status examination shows an anxious affect. He paces, wrings his hands, and says, "l feel as though I am going to jump out of my skin!" Which of the following is the most likely cause of this patient's symptoms?
A) Acute stress disorder
B) Adjustment disorder with anxiety
C) Adverse effect of prochlorperazine
D) Anxiety disorder due to hepatoma
E) Generalized anxiety disorder
F) Panic disorder

Answer: B) Adjustment disorder with anxiety
 
Exam Section : Item 37 of 50
A 52-year-old homeless man with alcoholism is brought to the emergency department by police after being found agitated and confused. He says he feels nervous and could use a drink. His temperature is 37oc (98.60F), pulse is 120/min, respirations are 20/min, and blood pressure is 138/86 mm Hg. He is trembling. His hematocrit is 30%. Urinalysis shows 7 WBC/hpf and many oxalate crystals. Which of the following is the most likely cause of this patient's symptoms?
A) Ethylene glycol toxicity
B) Lactic acidosis
C) Methanol toxicity
D) Paraldehyde toxicity
E) Sepsis

Answer: A) Ethylene glycol toxicity

Exam Section : Item 37 of 50
A 32-year-old woman comes to the physician because of depressed mood for 2 weeks; she went on a drinking binge over the weekend and has been binge eating for 2 days but has not purged. She has a history of bulimia nervosa. She has been sexually active with multiple partners over the past month; she uses an oral contraceptive, and her partners use condoms. She takes paroxetine for dysthymic disorder. Abdominal examination shows mild tenderness in the right upper quadrant. She has poor eye contact and appears close to tears. She describes many new stressors in her life and has thought about taking a full bottle of aspirin. Which of the following is the most appropriate question to ask this patient?
A) "Do you exercise regularly to relieve stress?"
B) "How do you feel about attending an alcohol treatment program?"
C) "How would you feel about entering the hospital?"
D) "Is there someone I could call to get some support for you?"
E) "What would you like me to do?"

Answer: C) "How would you feel about entering the hospital?"

Exam Section : Item 39 of 50
A 46-year-old man is brought to the emergency department following a self-inflicted gunshot wound to the right upper hemithorax. On the third postoperative day, he states that his wife is divorcing him after 28 years of marriage because of his chronic alcoholism. He is anxious and frightened and is unable to sleep. His temperature is 37.70C (99.80F), pulse is 1 1 0/min, respirations are 20/min, and blood pressure is 140/90 mm Hg. Which of the following is the most appropriate initial pharmacotherapy?
A) Carbamazepine
B) Haloperidol
C) Lorazepam
D) Propranolol
E) Secobarbital

Answer: C) Lorazepam
 
Exam Section : Item 40 of 50
An unconscious 7-year-old boy is brought to the emergency department by his parents. The family emigrated from rural Southeast Asia 4 years ago. An interpreter is used because the parents do not speak English. They say, "Our child has been possessed by a spirit since birth who speaks through his mouth with spit and blood and then takes his powers away." He has had these spells all of his life. He does not attend school. They recently sacrificed a piglet as an offering to the spirit, but there has been no change in the child's condition. The parents seem devoted. He awakens during the physical examination and smiles vacantly at his parents. He appears confused and speaks in monosyllables. No other abnormalities are noted. Which of the following is the most appropriate next step in diagnosis?
A) Contact child protective services
B) Psychoeducational assessment
C) Family therapy
D) Throat culture
E) X-ray of the chest
F) ECG
G) EEG
 
Answer: G) EEG
 
Exam Section : Item 41 of 50
A 23-year-old man is brought to the emergency department because of progressive paranoia and agitation for 48 hours. His roommate reports that the patient has not been sleeping or eating during this period but had been staying up all night studying for examinations for the past 4 days. He adds that last night the patient crouched below their apartment window peering out and insisting that every passing car was occupied by FBI agents. The patient has no history of psychosis. He states that he has been under stress from his new position as a software engineer. Physical examination shows 4-mm pupils, dry mouth, and mild tremulousness. On mental status examination, he is agitated, and his speech is rapid with increased volume. There is evidence of paranoid delusions about persecution by the police.
Which of the following is the most likely diagnosis?
A) Bipolar disorder
B) Delusional disorder
C) Generalized anxiety disorder
D) Schizophrenia
E) Substance-induced psychotic disorder

Answer: E) Substance-induced psychotic disorder

Exam Section : Item 42 of 50
An 8-year-old girl is brought to the physician by her mother because of frequent stomachaches over the past 3 months. She has a I-year history of difficulty falling asleep and poor concentration. She has always been a good student and excels in extracurricular activities. Her parents divorced 6 months ago. Physical examination shows no abnormalities. Mental status examination shows an anxious affect and coherent thought process. She says that she is worried about her classes and about her performance in the school band and on the soccer team. Which of the following is the most likely diagnosis?

A) Generalized anxiety disorder
B) Obsessive-compulsive disorder
C) Panic disorder
D) Post-traumatic stress disorder
E) Separation anxiety disorder

Answer: A) Generalized anxiety disorder
 
Exam Section : Item 43 of 50

A 37-year-old woman comes to the physician with her husband because of a I-year history of fatigue, intermittently blurred vision, and numbness of her legs that is exacerbated by walking long distances. Her husband adds that she has begun to have difficulty remembering where she put things around the house and says that when he points out her memory problem to her, she does not seem to care. She states that she does the best she can but does not have the energy to devote to his concerns. Cardiopulmonary examination shows no abnormalities. Sensation to pinprick is decreased over the lower extremities. Muscle strength in the upper and lower extremities is 3/5. On mental status examination, her mood and affect are incongruously bright. She is oriented to person, place, and time. She recalls two of three objects after 5 minutes. Which of the following abnormalities is most likely to be present in this patient on imaging studies?
A) Arteriovenous malformation
B) Edema of the right cerebral hemisphere
C) Enlarged cortical sulci
D) Focal white matter lesions
E) Left cerebellar atrophy

Answer: B) Edema of the right cerebral hemisphere
 
Exam Section : Item 44 of 50

Over the past 6 months, a 24-year-old woman has had 12 episodes of sudden apprehension associated with a sense of doom, hypervigilance, and tingling and numbness in her extremities. During these episodes, she feels dizzy and has a dry mouth and palpitations. She has been seen in the emergency department several times, and an ECG has shown no abnormalities. In between episodes, she has a minimal amount of anxiety. She is unwilling to take medications. Which of the following is the most appropriate next step in management?
A) Group therapy
B) Cognitive behavior therapy
C) Hypnotherapy
D) Interpersonal therapy
E) Psychodynamic therapy

Answer: B) Cognitive behavior therapy

Exam Section : Item 45 of 50

A 27-year-old woman comes to the physician for an examination prior to starting a new job. She has a 10-year history of binge-eating and self-induced vomiting. She takes no medications. She does not drink alcohol or use illicit drugs. She is 178 cm (5 ft 10 in) tall and weighs 72 kg (160 1b); BMI is 23 kg/m2. Her temperature is 37 oc (98.60F), pulse is 70/min, respirations are 10/min, and blood pressure is 120/70 mm Hg. Physical examination shows yellow dental enamel and abdominal striae. Serum studies are most likely to show which of the following abnormalities?
A) Decreased bicarbonate concentration
B) Increased amylase activity
C) Increased magnesium concentration
D) Increased potassium concentration
E) Increased sodium concentration

Answer: B) Increased amylase activity

Exam Section : Item 46 of 50

A 30-year-old woman has had frontal headaches, stomach upset, and poor appetite for 4 weeks; she has had a 2-kg (5-1b) weight loss during this period. She has pain in the left upper quadrant of the abdomen 1 to 3 hours after eating dinner. Over-the-counter antacids have been ineffective. She blames herself for not taking better care of her body. The headaches occur at night and awaken her. She feels fatigued in the morning and has difficulty getting up and going to work. Over the past month, her supervisor has complained about her recent errors, which she attributes to difficulty concentrating. She says that she is so tired when she comes home that she has stopped going out with her friends and just goes to sleep. Which of the following is the most likely diagnosis?
A) Adjustment disorder with depressed mood
B) Borderline personality disorder
C) Dysthymic disorder
D) Major depressive disorder
E) Somatization disorder
F) Ulcerative colitis

Answer: D) Major depressive disorder

Exam Section : Item 47 of 50

A 16-year-old girl is brought to the physician by her father because of unusual behavior since returning from a party early this morning. Her father reports that when she arrived home, she barricaded herself in her room and refused to respond to his pleas to open the door. When he entered the room 1 hour later, he found her huddled in a corner in the dark, saying that the police wanted to kill her. She has no history of medical or psychiatric illness. Her pulse is 115/min, and blood pressure is 150/90 mm Hg. The pupils are 2 mm, equal, and reactive to light and accommodation. The conjunctivae are injected. On mental status examination, she appears apprehensive but is cooperative. Her speech is slow with a prolonged response latency. She believes that she is being followed by plainclothes police officers who want to assassinate her. She hears a male voice making threatening comments. She is oriented to person and place but not to time. She can perform double-digit money calculations but not serial sevens. Which of the following is the most likely cause of this patient's symptoms?
A) Alcohol intoxication
B) Alcohol withdrawal
C) Cocaine withdrawal
D) Delusional disorder, persecutory type
E) Marijuana intoxication
F) Marijuana withdrawal
G) Panic disorder
H) Paranoid personality disorder
l) Schizophrenia, paranoid type

Answer: E) Marijuana intoxication

Exam Section : Item 48 of 50

A 37-year-old man is brought to the emergency department by the police after they found him sitting in an alley unaware of his surroundings or situation. On arrival, he cannot remember his name, date of birth, or age. Vital signs are within normal limits. Examination shows numerous ecchymoses over the face and extremities. Right lateral gaze is severely restricted. On left lateral gaze, there is bilateral nystagmus. There is mild gynecomastia and palmar erythema. Abdominal examination shows right upper quadrant tenderness. The liver edge is palpated 4 cm below the right costal margin. Muscle strength is normal, but he is unable to stand or walk. Deep tendon reflexes are absent. The most likely cause of these findings is a deficiency of which of the following?
A) Folic acid
B) Niacin
C) Vitamin Bl (thiamine)
D) Vitamin
E) Vitamin (cobalamin)

Answer: C) Vitamin Bl (thiamine)

Exam Section : Item 49 of 50

A 74-year-old widower comes to the physician because of gradually increasing insomnia over the past 2 years. He goes to bed at 11:30 pm and awakens at 5:00 am. He sleeps soundly except for awakening to go to the bathroom once during the night. He is concerned because he used to sleep 8 hours daily. He is active and prepares his own meals. Medications include ranitidine at bedtime for gastroesophageal reflux disease and verapamil for hypertension. His pulse today is 881min, and blood pressure is 160/88 mm Hg. He appears mildly anxious. Examination shows no other abnormalities.
Which of the following is the most appropriate next step in management?
A) Reassure the patient that his sleep pattern is normal for his age
B) Recommend staying up later to avoid getting up so early
C) Recommend warm milk before bedtime
D) Recommend an over-the-counter drug containing diphenhydramine at bedtime
E) Prescribe temazepam at bedtime, as needed

Answer: A) Reassure the patient that his sleep pattern is normal for his age

Exam Section : Item 50 of 50

A 32-year-old Bosnian man is brought to the emergency department by police 30 minutes after they found him sitting in a cemetery and muttering to himself. The police officers report that the patient appeared lost in thought and did not respond to their questions; he then passively accompanied them to the hospital. Identification in the patient's wallet indicates that he is a construction worker. The physician calls the patient's employer and learns that he was part of a crew working on a bridge that morning when a crane collapsed, causing multiple injuries to people working in trailers on the ground. A hospital interpreter says that the patient had been an ambulance driver in a military war zone 10 years ago. The patient sits quietly and stares ahead; he appears unaffected by the bustling activity in the emergency department. His pulse is 721min, and respirations are 14/min. Physical examination shows no abnormalities. Mental status examination shows a reserved demeanor. He speaks in monotone and responds to questions with vague, noncommittal answers. He says he is not depressed or anxious. Which of the following is the most likely diagnosis?
A) Adjustment disorder
B) Catatonia
C) Dissociative disorder
D) Generalized anxiety disorder
E) Schizotypal personality disorder

Answer: C) Dissociative disorder


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