Category: Psych Forms

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1: An 8-year-old boy is brought to the physician because of a 1-year history of…

Risperidone

• Tourette’s diagnosis: Onset before 18 years of age of (1) Multiple motor tics AND (2) at least 1 vocal tic
• Tourette’s treatments: Antipsychotics (tetrabenazine, antipsychotics, etc.), Alpha-2 adrenergic receptor agonists (guanfacine, clonidine)
• Key idea: Tourette’s is commonly associated with OCD and ADHD

2. A 17-year-old girl is brought to the physician by her parents because of a 20-kg…

Admit her to a psychiatric hospital

• Patient with anorexia (BMI < 18.5 with concerns about gaining weight) who also has bradycardia and hypotension, necessitating admission to the hospital
• Indications for involuntary psych admission: (1) Threat to self (such as this patient whose food restriction and weight loss are threatening her life) (2) Threat to others (3) Grave disability
• Key idea: Indications for hospitalization in setting of anorexia nervosa include (1) Bradycardia (2) Hypotension or orthostasis (3) Hypothermia (4) Marked dehydration or electrolyte disturbance (5) Organ compromise (6) BMI < 15

3. A 23-year-old man is brought to the physician by his mother because of increasing…

Schizotypal

• Schizotypal PD: Magical thinking, eccentric appearance, abnormal social functioning
• Schizoid PD: Voluntary social withdrawal
• Avoidant PD: Involuntary social withdrawal due to fear of rejection/criticism

4. A 47-year-old woman comes to the physician because she has had difficulty…

Alcohol dependence

• Middle-aged man who drinks excessive alcohol (>3 drinks per day –> >21 drinks per week) and presents with sleeping difficulty, frequent heartburn (exacerbated by alcohol due to relaxation of lower esophageal sphincter), and anxiety with lab studies showing macrocytosis and elevated LFTs with AST>ALT
• Note: For hard alcohol such as vodka, 1.5 oz = 1 standard drink
• Drink cut-off for excessive drinking: (1) Men < 65 yo: >14 drinks per week or >4 drinks in a day (2) Women and men > 65 yo: >7 drinks per week or >3 drinks in a day
• Lab findings of unhealthy alcohol use: Macrocytosis (MCV > 100), AST:ALT ratio > 2:1 (toAST to alcohol) with AST/ALT that are elevated but under 300
• Clinical findings of unhealthy alcohol use: Often presents with sleep disturbances and/or anxiety symptoms related to mild withdrawal

5. An 8-year-old boy is brought to the physician for evaluation of difficulty reading…

Fragile site on the X chromosome

• Young boy with intellectual disability, signs of autism (hand-flapping), and unique facial features (large forehead, large ears, prominent jaw), most consistent with Fragile X syndrome
• Key idea: X-linked recessive gene and therefore will only be seen in males on NBME
• Key idea: Patients with fragile X syndrome often have comorbid autism spectrum disorder

6. A 37-year-old man comes to the physician because of increasing distress about his…

Obsessive-compulsive disorder

• Patient who has social stress related to repeated thoughts about completing projects (obsessions) and spends a lot of time trying to deal with those thoughts by completing them in real life and in his mind (compulsions), most consistent with obsessive-compulsive disorder
• Generalized anxiety disorder: Persistent worries about multiple practical life stressors (finances, work, school, relationships, etc.)

7. A 37-year-old man comes to the physician because of a 3-week history of fatigue, insomnia and anxiety…

Zolpidem

• Young man with anxiety and stress provoked by a stressful/traumatic experience most consistent with adjustment disorder with the most impairing symptom being insomnia which can be treated with a non-benzo hypnotic (Similar to question 49)
• Adjustment disorder: Occurs within 3 months of stressor and leads to impairment not on the level of MDD or other psych conditions
• Key idea: Adjustment disorder is primarily treated with CBT, but patients can receive pharmacologic therapy for specific symptoms (anxiety, insomnia, etc.)

8. A 32-year-old woman comes to the physician because of increasingly severe pain…

“Have you been feeling like just giving up?”

• Key idea: In patients with chronic disease or chronic pain, important to assess for depressive symptoms and if patient has any signs of psychosocial distress/depression, YOU NEED TO ASK ABOUT SUICIDE!!! (very high yield on NBME exam)

9. A 17-year-old boy is brought to the emergency department by his mother because of a 20-minute episode of severe…

Panic disorder

• Chest pain with fear of dying in a patient without risk factors or work-up for coronary artery disease –> Panic disorder (at least on the NBME)
• Panic disorder: UNPROVOKED panic attacks with at least 1 month of psychological distress related to worries about the attack
• Symptoms of a panic attack can be broad and include abdominal pain, palpitations, pallor, nausea, intense fear of dying, lightheadedness, coughing, choking, chest pain, shortness of breath, sweating and shaking
• Key idea: Patient presenting with an ACUTE panic attack can be managed with benzodiazepines, but benzodiazepines should not be used for chronic management (instead use SSRI)

10. An 82-year-old man with dementia, Alzheimer type, is brought to the physician because of a 4-day history of visual…

Amitriptyline

• Elderly patient with Alzheimer’s and polypharmacy who presents with acute hallucinations and irritability, concerning for a medication side-effect due to anti-cholinergic effects of amitriptyline
• Atenolol –> Hypotension, bradycardia
• Ibuprofen –> Kidney damage
• Levothyroxine –> Tachycardia, palpitations (atrial fibrillation in elderly), heat intolerance, etc.
• Rivastigmine –> GI side effects, headache, dizziness, anorexia
• https://qioprogram.org/sites/default/files/2019BeersCriteria_JAGS.pdf

11. A 16-year-old boy comes to the physician because of a 1-year history of progressive headaches that have caused…

Sleep-related hypoventilation

• Overweight child with snoring + headaches in the morning –> Obstructive sleep apnea
• Hydrocephalus –> Headache and nausea/vomiting upon waking in the morning
• Idiopathic intracranial hypertension –> Overweight woman with headache, blind spots, pulsatile tinnitus, etc.
• Migraine –> Pulsatile unilateral headache associated with nausea/vomiting, aura, etc.

12. A 27-year-old man comes to student health services because of a 6-week history of increasingly severe insomnia and persistent…

Schizoaffective disorder

• Young man with signs of depression (guilt, emptiness, profound sadness, etc.) who admits to episodes over the past 4 years of isolated psychosis/hallucinations WITHOUT mood symptoms, most consistent with schizoaffective disorder
• Schizoaffective disorder: Meets criteria for schizophrenia and major mood disorder, with at least 2 weeks of psychotic symptoms without major mood disorder
• Mood disorder with psychotic features: Predominantly MDD or bipolar disorder with psychotic symptoms that are never seen without mood symptoms
• Brief psychotic disorder: At least 1 positive symptom (hallucination, delusion, etc.) for less than 1 month that often comes on due to stress
• Schizophrenia: At least two of the following symptoms (delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, negative symptoms) for at least 1 month with at least 6 months of decline in functioning
• Schizophreniform disorder: Same as schizophrenia except for 1-6 months

13. A 28-year-old man is brought to the emergency department because of flu-like symptoms and cough productive of…

Discontinue clozapine therapy

• Young man on clozapine therapy who presents with a respiratory infection but is found to have low WBC count, most concerning for infection secondary to agranulocytosis due to clozapine
• Indications for clozapine therapy:
  • Treatment-resistant schizophrenia
  • Schizophrenia associated with suicidality
• Adverse effects:
  • Agranulocytosis (–> sore throat and fever with low WBC count, specifically neutrophils/PMNs)
  • Seizures
  • Myocarditis
  • Metabolic syndrome
• Mnemonic: Patients on CLOZapine need to be watched “CLOZ”ely

14. A previously healthy 27-year-old man is brought to the emergency department by his girlfriend because of a 6-week…

Bipolar disorder

• Young man with 6-week history of auditory hallucinations, decreased sleep, grandiosity, restlessness/agitation, and pressured speech most consistent with bipolar disorder
• Key idea: To be diagnosed with schizoaffective disorder patients would need to meet criteria for schizophrenia AND mood disorder, and criteria for schizophrenia requires 6 months of symptoms/dysfunction (and this patient has only been symptomatic for 6 weeks)
• Key idea: Psychosis can be seen with mood disorders, particularly Bipolar disorder

15. A 22-year-old woman is brought to the emergency department because of a 4…

Methamphetamine

• Young woman with sudden onset of violent, agitated behavior, tachycardia, and hypertension, which would be consistent with stimulant drugs (cocaine, methamphetamine)
• PCP: Nystagmus, violent behavior, dissociative symptoms
• LSD: Visual hallucinations + Mydriasis
• Cocaine: Chest pain, mydriasis, agitation/psychosis, hypertension, tachycardia
• Methamphetamine: Same as cocaine + violent behavior, choreiform movements and tooth decay
• Marijuana: Paranoia, conjunctival injection, dry mouth
• Heroin: Respiratory depression, pinpoint pupils, depressed mental status, constipation

16. A previously healthy 57-year-old woman comes to the physician with her…

Creutzfeldt-Jakob disease

• Previously healthy man who has experienced rapidly progressive dementia + neurological symptoms + Startle myoclonus + Periodic sharp waves on EEG, all consistent with Creutzfeldt-Jakob disease (prion disease)
• Etiologies: Familial/acquired, cannibal behavior, CNS transplant (retinal transplant, etc.)
• Clinical features: Rapidly progressive dementia, myoclonus (high yield association for NBME), other neurological symptoms
• Lab findings: Increased 14-3-3 in CSF, Periodic sharp waves on EEG, Caudate/putamen MRI findings, Spongiform changes

17. A 30-year-old law school graduate is caught cheating on the bar examination. Further investigation shows previous…

Antisocial personality disorder

• Young man with chronic history of repeated disregard for rights of others without remorse, most consistent with antisocial personality disorder
• Key idea: Conduct disorder diagnosed if patient is younger than 15 years old, whereas antisocial personality disorder can only be diagnosed in an adult who ALSO had conduct disorder when they were younger
• Borderline personality disorder: Unstable relationships, labile mood states that change over span of hours-days, splitting (all nurses are horrible but all doctors are amazing), self-mutilation and feelings of emptiness
• Narcissistic personality disorder: Grandiosity, sense of entitlement, requires excessive admiration, etc.

18. A 7-year-old boy is brought to the physician by his adoptive parents because of ongoing concern…

Fetal alcohol syndrome

• Young boy born to a mother with known substance abuse who is small with trouble in school, bad behavior and facial features with a long philtrum, most consistent with fetal alcohol syndrome
• Key idea: Facial features that are most associated with fetal alcohol syndrome are smooth philtrum, thin vermillion border, microcephaly and small palpebral fissures
• Angelman syndrome: Intellectual disability, seizures, ataxia and inappropriate laughing (“happy puppet”)
• Fragile X syndrome: Long face, large forehead, prominent ears, macrocephaly (in adolescence)
• Rett disorder: Female toddler who initially has normal development but then begins to display regression of milestones + stereotyped hand movements
• Shaken baby syndrome: Baby with subdural hematoma due to tearing of bridging veins

19. A 15-year-old boy is brought to the emergency department by his two friends because of unusual behavior…

Alcohol

• Adolescent brought in from a party who demonstrated decreased inhibition, agitation and unsteady gait most associated with alcohol use
• Amphetamine and cocaine –> Hypertension, tachycardia, mydriasis, etc.
• Heroin –> Respiratory depression, pinpoint pupils, decreased consciousness
• LSD –> Hallucinations and dilated pupils with normal vitals
• Marijuana –> Injected conjunctiva, dry mouth, tachycardia, paranoia

20. An 8-year-old boy is brought for a school physical examination. He was diagnosed with attention-deficit/hyperactivity disorder…

Discontinue desipramine therapy

• Young boy with ADHD treated with desipramine (which is a TCA) who is asymptomatic but has ECG changes consistent with TCA toxicity and therefore should have the desipramine discontinued
• Key idea: Signs of TCA toxicity include:
  • Anti-cholinergic symptoms: Dry mouth, overheated, mydriasis, constipation, etc.
  • Anti-alpha 1 symptoms: Hypotension, tachycardia
  • Anti-histamine symptoms: Mental status changes
• Key idea: Serious signs of TCA toxicity include ECG changes (can affect PR interval, QRS interval or QT interval) and patients with QRS widening or ventricular arrhythmias should be treated with IV sodium bicarbonate
• TCA drugs: Amitriptyline, Nortriptyline, imipramine, desipramine, clomipramine, doxepin, amoxapine

21. One month after undergoing liver transplantation, a 47-year-old woman is…

• Patient who has received high-dose IV steroids and has developed psychotic symptoms (hallucinations) shortly after, most consistent with corticosteroid-induced psychosis
• Drugs/substances associated with psychosis: Hallucinogens, serotonin syndrome (tramadol, psych drugs, etc.), corticosteroids, sympathomimetics (cocaine, meth, etc.)
• Delirium: Old patient often with baseline dementia who has fluctuating cognition (intermittently confused/combative)

22. A 25-year-old primigravid woman at 16 weeks’ gestation has had increased…

Explanation of risks and benefits of antidepressant therapy

• Pregnant woman who has a history of recurrent MDD and presents with symptoms consistent with depression (depressed mood + SIGECAPS) who should be started on psychotherapy + pharmacotherapy
• Key idea: In pregnant women, first-line antidepressant is SSRI (except paroxetine) as they have been shown to be safe in pregnant women
• Key idea: Woman is not currently suicidal, and therefore does not need to be involuntarily admitted to the hospital

23. A 37-year-old male police officer comes to the physician at the request of his superiors 1 week after he witnessed…

Provide information about the range of reactions to trauma

• Adult officer who recently witnessed a traumatic event who is showing signs of acute stress disorder (HARD: Hyperarousal, Avoidance behavior, Reliving experience, Disturbed mood/thinking) who does not think anything is wrong and is not open to current treatment at this point, and therefore should just receive information about reactions to trauma and options for treatment in the future
• Key idea: Unless patient is threat to themselves or to others, then they can’t be treated against their will and the decision whether to receive treatment or not is up to the patient

24. A 27-year-old woman is brought to the emergency department 2 hours after…

Borderline personality disorder

• Young woman with feelings of emptiness, self-injurious behavior, and unstable relationships (personal and job history) which is most consistent with borderline personality disorder
• Borderline personality disorder: Unstable relationships, labile mood states that change over span of hours-days, splitting (all nurses are horrible but all doctors are amazing), self-mutilation and feelings of emptiness
• Key idea: Primary treatment of borderline personality disorder is dialectical behavior therapy (high yield!)
• Key idea: Bipolar disorder has periods of elevated mood lasting weeks-months, whereas in borderline PD the mood changes occur over span of hours-days

25. A 24-year-old man is brought to the emergency department from a psychiatric hospital because of a decreasing level…

Drug reaction

• Young adult receiving haloperidol who presents with signs most consistent with neuroleptic syndrome
• Symptoms of neuroleptic malignant syndrome can be remembered with mnemonic Malignant FEVER: Myoglobinuria, Fever, Encephalopathy, Vitals unstable, increased CK Enzymes, Rigidity
• Note: Patient has normal CSF findings so infectious encephalitis/meningitis ruled out
• Signs of catatonia: Stupor, waxy flexibility, negativism, etc.

26. A homeless 27-year-old man who is being treated with antipsychotic and antiparkinsonian drugs comes to the emergency department…

Delirium due to anticholinergic medication

• Patient receiving antipsychotic and antiparkinsonian drugs who has signs of anticholinergic toxicity (urinary retention, hallucinations, altered mental status, vision problems, dry mouth, tachycardia, flushed skin) WITHOUT rigidity most consistent with anticholinergic toxicity from antiparkinsonian drugs
• Key idea: Potential treatments for Parkinson’s increase dopamine levels (bromocriptine, pramipexole, selegiline etc.), increase L-dopa levels (carbidopa-levodopa, entacapone) or decrease cholinergic activity (benztropine, trihexyphenidyl)

27. A 47-year-old man has had tension and hand tremors for 1 month. He has been treated for bipolar disorder with lithium…

Propranolol

• Middle-aged man with likely lithium-induced tremors who has a history of alcohol abuse and therefore should be treated with a beta blocker such as propranolol
• Key idea: If a patient has a history of alcohol use disorder, then they should NOT be given benzodiazepines on a chronic basis
• Side effects of lithium can be remembered with mnemonic LiTHIUM: Low Thyroid (hypothyroidism), Heart (Ebstein anomaly in fetus), Insipidus (nephrogenic diabetes insipidus) and Unwanted Movements (such as tremor)

28. An otherwise healthy 25-year-old man comes to the physician because he has a severe fear of flying and must…

Lorazepam

• Young man with no history of alcohol/substance abuse who has a fear of flying and needs to take a flight in a few days, who can be acutely treated with lorazepam during the flight
• Key idea: Although benzodiazepines should not be used chronically, they do have a role in settings of acute stress/panic and are effective as short-term agents

29. A 14-year-old girl is brought to the physician by her mother because of poor…

Post-traumatic stress disorder

• Young girl involved in a fatal car accident who has experienced 6 months of hyperarousal, reliving experience (nightmares) and cognitive disturbances, most consistent with PTSD
• PTSD leads to HARD symptoms (Hyperarousal, Avoidant behavior, Reliving experience, Disturbed mood/thinking) for >1 month following a stressful/traumatic experience
• Key idea: Same symptoms for <1 month = Acute stress disorder
• Key idea: Degree of impairment in this patient is too severe for a diagnosis of adjustment disorder

30. A 29-year-old man comes to the physician because of the inability to maintain an erection through completion of…

Alcohol use

• Young man who has normal noctural erections (meaning there is no physiologic cause of impotence [vascular/neurologic/endocrine]) but situational erectile dysfunction with his wife associated with consumption of several alcoholic beverages before engaging in sexual activity who is found to have an elevated GGT level on labs most consistent with alcohol-induced erectile dysfunction
• Key idea: Alcohol is highly associated with sexual dysfunction
• Key idea: Cimetidine (and not ranitidine) is associated with increased estrogen –> sexual dysfunction in a man
• Key idea: GGT often used to track whether or not a patient has been using alcohol, such as in a patient with a history of alcoholism currently in a substance abuse program

31. A 24-year-old woman reports a 3-week history of recurrent fevers. She has a 4…

Obtain a rectal temperature under supervision

• Key idea: A temperature of 107.6F with otherwise normal vital signs does not make medical sense, and therefore you should be thinking about malingering or factitious disorder
• Key idea: For NBME exams, young woman who work in healthcare field are almost always the protagonist in vignettes related to factitious disorder

32. A 27-year-old man is brought to the emergency department 30 minutes after his brother found him agitated, tremulous…

Drug-drug interaction

• Young male patient on a TCA who has recently been switched to a MAO inhibitor (tranylcypromine) from an SSRI without an adequate washout period (often need washout period of at least 14 days) who presents with symptoms concerning for serotonin syndrome (3 A: Autonomic hyperactivity (fever, tachycardia, hypertension, diaphoresis), Agitation, increased Activity (tremulous, increased DTRs)) most likely due to excessive drug effects
• Key idea: MAO inhibitors and TCA inhibitors are both highly associated with serotonin syndrome especially when given together or with other drugs that can cause serotonin syndrome such as SSRIs, linezolid, triptans, St. Johns Wort, etc.
• Key idea: Patients on MAO-inhibitors need to avoid high tyramine foods such as cured and processed meats/cheese and alcohol, with peanut butter NOT being a food known for high tyramine levels
• Key idea: Abrupt discontinuation of fluoxetine can lead to SSRI discontinuation syndrome, but the symptoms would be flu-like illness, anxiety, dysphoria, etc.

33. A 42-year-old man comes to the physician for a routine examination. He is accompanied by his wife. During the…

Obsessive-compulsive personality disorder

• Middle-aged man with a persistent history of being competitive, obsessed with being successful in his job and thinking that his way is the best way that is causing some problems in his relationships, most consistent with obsessive-compulsive personality disorder
• Key idea: Regular OCD has behaviors that are ego-dystonic (behavior inconsistent with one’s beliefs/attitudes) whereas OCPD has behaviors that are ego-syntonic (behavior consistent with one’s beliefs/attitudes)

34. A 13-year-old girl is brought to the physician by her father for a well-child…

Reassure the father that this is normal development

• Young child who mainly eats snacks and is a vegetarian for clear humanitarian reasons who seems to be excelling in school and extracurriculars (no impaired functioning) who is within normal levels for weight, most consistent with normal behavior
• Key idea: In order to diagnose a psychiatric condition, it must cause distress or impair normal functioning

35. A previously healthy 27-year-old woman comes to the physician because of a 2…

Major depressive disorder

• Young patient with 2-month history of depressed mood + impaired cognitive function + low energy + decreased interest in socializing thus meeting criteria for major depressive disorder
• Formal definition of MDD: At least 2 weeks with at least 5/9 of the following symptoms (1. Depressed mood 2. Sleep changes 3. Decreased interest 4. Guilt 5. Low energy 6. Cognitive changes 7. Appetite change 8. Psychomotor slowing 9. Suicidal ideation)
• Key idea: Although MDD classically leads to early morning awakenings and weight loss, in atypical scenarios you can see the opposite in MDD
• Key idea: Adjustment disorder occurs within 3 months of stressful event and does not meet criteria for MDD (less severe version)

36. A 67-year-old man is brought to the physician by his wife because of a 1-month history of increasingly “paranoid” behavior…

Quetiapine

• Key idea: Dopamine precursors (levodopa) and dopamine agonists (pramipexole) are associated with increased risk of psychosis in Parkinson disease
• Key idea: First step in trying to correct psychosis is by reducing dose of Parkinson’s drug (which was not effective in our patient), which can then be followed-up with a low-potency, second-generation antipsychotic such as quetiapine

37. A 42-year-old woman, gravida 1, para 1, comes to the physician because of a 5…

Psychiatric assessment

• Young woman with chronic abdominal pain following a stressful life event (losing her job) who has undergone extensive work-up and found no organic cause and therefore would be a good candidate for psychological/psychiatric testing to identify a cause
• Key idea: Patients pattern of pain does NOT correspond with a known syndrome/condition

38. A 5-year-old boy has had temperatures to 38.9 C (102 F), cough, and coryza for 2 days and visual hallucinations of animals…

Drug toxicity

• Young boy who has been treated with OTC cold medicine who has developed visual hallucinations most consistent with the anti-histamine effects of these cold medications
• Key idea: Just like elderly patients are particularly sensitive to anti-cholinergic and anti-histamine effects of medications, so are young children

39. A previously healthy 23-year-old man is brought to the emergency department by friends 20 minutes after the onset…

PCP intoxication

• PCP: Nystagmus, violent behavior, dissociative symptoms
• LSD: Visual hallucinations + Mydriasis
• Cocaine: Chest pain, mydriasis, agitation/psychosis, hypertension, tachycardia
• Methamphetamine: Same as cocaine + violent behavior, choreiform movements and tooth decay
• Marijuana: Paranoia, conjunctival injection, dry mouth
• Heroin: Respiratory depression, pinpoint pupils, depressed mental status, constipation

40. A 47-year-old man with Down syndrome is brought to the physician because of increasing forgetfulness and irritability…

Nucleus basalis of Meynert

• Middle-aged patient with Down syndrome who presents with chronic forgetfulness and a loss of ADLs, most consistent with Alzheimer disease
• Key idea: Patients with Alzheimer’s will more specifically have brain effects in the hippocampus and nucleus basalis of Meynert
• Key idea: Patients with Down syndrome often develop early-onset Alzheimer’s because they have an extra copy of chromosome 21 which encodes Amyloid precursor protein which is important to the pathogenesis of Alzheimer’s disease
• Caudate nucleus –> Huntington’s disease
• Substantia nigra –> Parkinson disease
• Subthalamic nucleus –> Hemibalismus (sudden wild flailing of one side of body)

41. A 37-year-old man is brought to the physician because of a change in personality over the past 4 months…

Caudate nucleus

• Young man with chronic progressive personality changes and jerky movements who had a father who had similar symptoms at a slightly older age most consistent with Huntington’s disease (due to dysfunction of Acetylcholine and GABA in the caudate nucleus)
• Key idea: Classic Huntington’s disease symptoms are Depression, Dementia and Chorea (jerky movements)
• Key idea: Classic disease that shows anticipation (children develop disease sooner than parents), particularly when inherited from father because CAG trinucleotide repeat expansion most often occurs in spermatogenesis

42. An 87-year-old man is admitted to the hospital because of dehydration and emaciation. He appears catatonic and is…

Electroconvulsive therapy

• Indications for electroconvulsive therapy:
  • Treatment-resistant depression
  • Depression with psychotic features
  • Emergency conditions (pregnancy, refusal to eat/drink, catatonia, imminent risk for suicide)
• Key idea: NO absolute contraindications to electroconvulsive therapy and generally well-tolerated

43. A 67-year-old woman, whose husband died 18 months ago, is admitted to the…

• Elderly woman with depressed mood, low energy, decreased appetite, somatic symptoms and mood-congruent psychosis, most consistent with major depressive disorder with psychotic features
• Adjustment disorder: Occurs within 3 months of stressor and leads to impairment not on the level of MDD or other psych conditions
• Delusional disorder: 1+ delusions for >1 month that does not lead to significant impairment

44. A 37-year-old man is brought to the emergency department by police after he was found wandering on the street…

Enlarged lateral and third ventricles on CT scan of the head

• Young man with signs of schizophrenia (delusions, hallucinations, etc.) who would therefore likely have enlarged ventricles in his brain (associated specifically with schizophrenia)
• Key idea: Patients with psychosis do not have global increased dopamine levels, but rather increased dopamine levels in the mesolimbic and mesocortical tracts of the brain
• Causes of cerebral edema: Trauma, stroke, infection, DKA, etc.
• Increased copper levels –> Wilson’s disease (psychosis, parkinsonian-movement disorders, liver disease and Kayser-Fleischer rings in the eyes)
• Temporal spikes on EEG –> Temporal lobe epilepsy –> Minute-long episodes with loss of consciousness with lip smacking, smelling burnt rubber, hearing hissing sounds, etc.

45. A 3-year-old girl is brought to the emergency department 1 hour after injuring her…

• Young patient with recurrent ED visits who is acting out at daycare and fearful of physician and presents with a humerus fracture which would not be compatible with supposed mechanism of injury, most concerning for child abuse
• Key idea: Injuries that are consistent with child abuse include spiral fracture, rib fractures, subdural hematoma, and retinal hemorrhages

46. A 15-year-old boy is brought to the physician by his parents because “he does whatever he wants and comes…

Conduct disorder

• 15 year old boy with chronic history of repeated disregard for rights of others without remorse (arrests, assaults, drug use, tattoos/piercings), most consistent with conduct disorder
• Key idea: Conduct disorder diagnosed if patient is younger than 15 years old, whereas antisocial personality disorder can only be diagnosed in an adult who ALSO had conduct disorder when they were younger
• Intermittent explosive disorder: Bouts of verbal/physical aggression that is out of proportion to the provocation followed by regret, dysphoria or embarrassment

47. A 32-year-old woman with schizoaffective disorder is brought to the emergency…

Valproic acid

• Patient who recently initiated therapy for psychiatric symptoms and presents with signs of liver injury (RUQ abdominal pain, lower extremity edema, jaundice, increased LFTs), which should prompt concern for valproic-acid induced hepatotoxicity
• Key idea: Lithium and valproate are the two first-line medications for bipolar disorder, with valproate > lithium in the setting of renal dysfunction (because lithium is excreted in urine)

48. A 24-year-old woman comes to the physician with her husband because of an…

Polysomnography

• Young woman who recurrently falls asleep and is tired during the day who also has features of REM sleep behavior disorders (gets up and not responding to her name) and cataplexy (falls after joking) who should therefore receive polysomnography to look for features of narcolepsy (decreased REM sleep latency)
• Narcolepsy diagnosis: (1) Recurrent lapses into sleep at least 3 times for at least 3 months + (2) AT LEAST 1 of the following (Cataplexy [brief loss of muscle tone with laughter or strong emotion], Low hypocretin-1 in CSF, or Shortened REM sleep latency on polysomnography)
• Key idea: Often associated with sleep paralysis and hypnagogic (while going to sleep) or hypnapompic (upom waking up) hallucinations
• Key idea: Polysomnography used to evaluate for many sleep disorders, such as narcolepsy, periodic limb movement disorder, REM sleep behavior disorder and sleep apnea

49. A 57-year-old woman comes to the physician because of difficulty sleeping…

Clonazepam therapy

• Patient with adjustment disorder (psychosocial stress not meeting criteria for other condition following a traumatic/stressful event) who also has associated insomnia and therefore can receive symptomatic treatment with benzo’s or non-benzo drugs (zolpidem, etc.)
• Key idea: Adjustment disorder is primarily treated with CBT, but patients can receive pharmacologic therapy for specific symptoms (anxiety, insomnia, etc.)
• Key idea: If a patient on NBME has family/personal history of alcohol use disorder, then they should NOT receive benzodiazepines (similar mechanism of action)
• Biofeedback: Used for complex pain disorders

50. A 25-year-old woman comes to the physician at her husband’s request because of…

Buspirone

• Young woman with >6 months of worrying about multiple issues (starting family, finances) with irritability, trouble sleeping and sweaty palms, most consistent with generalized anxiety disorder –> Although first-line treatment is often SSRI/SNRI, Buspirone is also a viable option specifically for generalized anxiety disorder
• Key idea: Hyperthyroidism can also present with increasing anxiety/irritability, but will almost always also be associated with unintentional weight loss, hyper-reflexia, and low TSH
• Bupropion: First-line antidepressant that helps with smoking cessation and has more favorable side effect profiles related to weight gain and sexual side effects

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1: A 52-year-old homeless man with alcoholism is brought to the emergency by police after being found…

Ethylene glycol toxicity

• Middle-aged homeless man with alcohol use disorder who presents with confusion/agitation and oxalate crystals in his urine, most consistent with ethylene glycol toxicity
• Ethylene glycol can lead to renal pathologies via 2 mechanisms corresponding to the 2 metabolites because when it is metabolized to glycolic acid it can lead to acute tubular necrosis whereas if it is metabolized to oxalic acid it can lead to precipitation of calcium oxalate stones
• Methanol –> Eye symptoms (blindness, blurred vision, painful eye movements, etc.)

2. A 42-year-old man comes to the physician because of a 6-month history of sexual problems. He can achieve…

Performance anxiety

• Key idea: If a patient has normal morning erections = Physiologic causes of erectile dysfunction (vascular, neurologic, endocrine) are RULED OUT and patient most likely has psychological component to ED (and in this question rules out all answer choices except for D)
• Note: Beta blockers such as metoprolol can also lead to sexual dysfunction, and SSRIs are specifically known for causing delayed/impaired orgasm
• Note: Alcohol use also often associated with sexual dysfunction in men

3. A 30-year-old woman has had frontal headaches, stomach upset, and poor appetite for 4 weeks; she has had…

Major depressive disorder

• Patient with >2 week history of SIGECAPS symptoms (specifically Sleep changes, Guilt, decreased Energy, Cognitive dysfunction, Appetite changes) and somatic symptoms most consistent with major depressive disorder
• Adjustment disorder would not have as severe a presentation
• Borderline –> Chronic time course
• Dysthymic disorder –> At least 2 years of symptoms
• Somatization disorder –> Patient has somatic symptoms AND SIGECAPS

4. A 42-year-old man is brought to the emergency department by police after they found him hiding under a…

Schizophrenia

• Young man with >6 months of hallucinations, delusions and disorganized behavior most consistent with schizophrenia
• Schizophrenia > Bipolar disorder with psychotic features because patient does not have other DIG FAST components of mania/hypomania like decreased sleep, increased activity, etc.
• Key idea: Patients with schizophrenia can also be described as speaking quickly and loudly even though that is more associated with mania/hypomania = bipolar disorder
• Brief psychotic disorder: At least 1 positive symptom (hallucination, delusion, etc.) for less than 1 month that often comes on due to stress
• Schizophrenia: At least two of the following symptoms (delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, negative symptoms) for at least 1 month with at least 6 months of decline in functioning
• Schizophreniform disorder: Same as schizophrenia except for 1-6 months
• Schizoid personality disorder = Patient who prefers to be alone and not engage in contact with others

5. A 14-year-old boy is brought to the physician for a well-child examination. His mother says her son is self-centered…

Physical/Sexual Development: Normal // Cognitive/Social Development: Normal

• Adolescent boy with more independent activities, questionable hygiene habits, and mood swings with Tanner Stage 3 development most consistent with normal development
• Note: Delayed puberty in males defined by lack of testicular enlargement (Tanner Stage 2) by age 14, whereas delayed puberty in females defined by lack of breast development by 13 or lack of menarche by 15

6. A 47-year-old woman comes to the physician 2 hours after the onset of heart palpitations. She had a myocardial…

Marijuana intoxication

• Middle-aged woman with known marijuana use presenting with paranoia, sensation of things slowing down around her, dry mouth, conjunctival injection and sinus tachycardia most consistent with marijuana intoxication
• Key idea: Symptoms commonly ascribed to marijuana intoxication on NBME exams include conjunctival injection, tachycardia, paranoia and dry mouth
• Panic disorder: Unprovoked panic attack with at least one month of psychosocial stress related to fears of having another attack

7. Five weeks after being discharged from the hospital after treatment for a psychotic episode…

Schizoaffective disorder

• Young man recently hospitalized for psychotic episode without much detail but most consistent with schizophrenia vs schizophreniform disorder vs schizoaffective disorder
• Bipolar disorder –> Decreased sleep, Increased talkativeness, decreased appetite, distractibility, etc.
• Cyclothymic disorder –> 2 year history of fluctuations between mild depression and mild mania/hypomania, which would typically not lead to psychiatric hospitalization
• Delusional disorder –> Defined as a delusion for at least 1 month that does not significantly impair function (and likely would not lead to hospitalization)
• Substance-induced mood disorder –> No history of drug use
• Note: Important to differentiate schizoaffective disorder from mood disorder with psychotic feature, with schizoaffective disorder having at least 2 weeks of psychotic features without mood symptoms

8. A 32-year-old Bosnian man is brought to the emergency department by police 30 minutes after they found…

Dissociative disorder

• Young man who recently experienced a traumatic event who now has trouble answering basic questions most consistent with some form of dissociative disorder, potentially dissociative fugue
• Adjustment disorder: Often leads to sadness or anxiety in reaction to stressor
• Catatonia: More severe presentation characterized by waxy flexibility, repeating other people’s behaviors or words, negativism, etc.
• Generalized anxiety disorder: Need symptoms for >6 months
• Schizotypal PD: Magical thinking and odd behaviors consistently and for a long time

9. A 52-year-old man with schizophrenia comes to the physician for a follow-up examination. At his last examination…

Increased sensitivity of the dopamine receptors

• Patient with chronic history of schizophrenia treated with antipsychotics who presents with abnormal tongue movements and choreoathetoid movements most consistent with tardive dyskinesia, which is due to increased sensitivity of the dopamine receptors
• In setting of chronic antipsychotic use, patient has had chronic inhibition of dopamine receptors –> Compensatory upregulation of dopamine receptors leading to increased sensitivity of dopamine receptors because more of them are around ready to be bound by dopamine
• KEY IDEA: The reason patients experience withdrawal symptoms related to drugs/substances often related to up-regulation of receptors (if they are taking a receptor inhibitor) or down-regulation of certain receptors (if they are taking a receptor agonist)
• Example: Patients with chronic alcoholism –> Chronic stimulation of GABA receptors by alcohol –> Down-regulation of GABA receptors (which are responsible for tempering/calming nervous sytem), such that when patient stops taking alcohol they lose increased GABA related to alcohol, leading to relatively decreased binding of GABA to GABA receptors –> overstimulation of brain –> seizures, delirium tremens, etc.

10. An 8-year-old girl is brought to the physician by her mother because of frequent stomachaches over the past 3…

Generalized anxiety disorder

• Pediatric patient with >6 month history of worries/anxiety about multiple life stressors with somatization most consistent with generalized anxiety disorder
• Key idea: Formal diagnosis requires at least 6 months of symptoms with at least 3 of the following symptoms:
  • Restlessness
  • Fatigue
  • Difficulty concentrating
  • Irritability
  • Muscle tension
  • Sleep disturbance
• Separation anxiety disorder: Somatic symptoms, nightmares and difficulty sleeping associated with reluctance to leave parent/guardian due to fear of separation or excessive concern about bad events happening to parent/guardian

11. A 77-year-old man comes to the physician at his wife’s insistence because of a 2-year history of progressive memory…

Cholinergic

• Elderly man with chronic progressive memory problems that have impaired day-to-day functioning (getting lost close to home, forgetting to turn off oven, etc.) with an MMSE less than or equal to 23 most consistent with Alzheimer’s disease
• 2 main treatment options for Alzheimer’s disease are:
  • Acetylcholinesterase inhibitors (which lead to increased acetylcholine): Donepezil, Rivastigmine, Galantamine
  • NMDA receptor inhibitor: Memantine
• Anticholinergic –> Used in Parkinson’s disease
• Antidopaminergic –> Used in Schizophrenia
• Dopaminergic –> Used in Parkinson’s
• Serotonergic –> Used in MDD, GAD, PTSD, and many other psychiatric diseases (anything treated with SSRIs)

12. A 23-year-old man is brought to the emergency department because of progressive paranoia and agitation for…

Substance-induced psychotic disorder

• Young man with 2 days of paranoia and agitation with normal pupil sizes (2-4 mm normal), dry mouth and tremulousness most associated with marijuana-induced psychosis
• Key idea: Presence of physiologic signs (dry mouth, etc.) tells us that patient does NOT have pure psychiatric condition and likely has psychiatric symptoms secondary to substance or medical condition (often endocrine disease)
• Key idea: Signs/symptoms that are associated with marijuana on NBME exams are injected conjunctivae, dry mouth, tachycardia and paranoia
• Key idea: Rapid speech with increased volume can be seen in both psychosis and mania/hypomania

13. A 46-year-old man is brought to the emergency department following a self-inflicted gunshot wound to the right upper…

Lorazepam

• Middle-aged man with chronic alcoholism who on hospital day 3 begins to develop anxiety, insomnia and tachycardia likely associated with alcohol withdrawal who should be managed with a short-acting benzodiazepine
• Key idea: Potential manifestations of alcohol withdrawal and time since last drink include (1) Nonspecific symptoms (3-36 hours): Tremors, insomnia, GI upset, agitation, diaphoresis, etc. (2) Withdrawal seizures (6-48 hours) (3) Alcoholic hallucinations (12-48 hours) (4) Delirium tremens: Altered mental status, tremors, autonomic hyperactivity, etc. (48-96 hours)

14. A 74-year-old widower comes to the physician because of gradually increasing insomnia over the past 2 years…

Reassure the patient that his sleep pattern is normal for his age

• Normal changes in sleep patterns observed with aging:
  • Decreased total sleep time
  • Peak sleepiness earlier in evening
  • Nocturnal awakenings
  • Daytime napping with reduced daytime sleep latency (time it takes to fall asleep)
  • Decreased slow-wave sleep
  • Decreased REM latency

15. A 62-year-old woman is brought to the emergency department by her husband because of confusion for…

Discontinue doxepin

• Middle-aged woman on a TCA (doxepin) who is showing signs of anti-histamine toxicity (confusion), anti-cholinergic toxicity (mydriasis, dry skin) and ECG changes (AV block with widened QRS complex), which is consistent with TCA toxicity and should be treated by discontinuing doxepin and starting IV sodium bicarbonate for the ECG changes

16. A 27-year-old woman comes to the physician for an examination prior to starting a new job. She has…

Increased amylase activity

• Young woman with bulimia nervosa (normal weight with history of binge-eating with compensatory behaviors) who would therefore likely have increased amylase activity because recurrent vomiting leads to increased salivary production of amylase
• Key idea: Both bulimia nervosa and anorexia nervosa can be associated with purging behavior (vomiting, exercise, etc.), with the difference being that anorexia patients will have BMI < 18.5 and bulimia patients will have normal weight and history of binge eating
• Vomiting –> Loss of hydrogen chloride (HCl) –> Metabolic alkalosis (high serum bicarb) and hypochloremia
• Vomiting –> Hypovolemia –> Activation of RAAS system –> Increased aldosterone levels (which leads to hypokalemia because aldosterone mediates reabsorption of sodium in exchange for potassium and hydrogen ions at the collecting ducts via ENaC channels) and increased ADH levels (which leads to hyponatremia due to increased reabsorption of free water at the collecting ducts via aquaporin channels)
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3204380/

17. A 37-year-old woman comes to the physician with her husband because of a 1-year history of fatigue…

Focal white matter lesions

• Young woman who presents with neurological symptoms disseminated in time and space (blurry vision, leg numbness, memory problems) most consistent with multiple sclerosis (which is a demyelinating disease that leads to focal white matter lesions)
• Key idea: Patient’s history of leg numbness that worsens with long walks likely consistent with Uhthoff’s phenomenon (MS symptoms worsen in heat), which is often tested on NBME by saying that patient’s symptoms worsen with exercise or have come on/worsened since moving to Florida, Arizona, etc.
• Key idea: Neurological symptoms consistent with multiple sclerosis on NBME exam include optic neuritis (unilateral painful eye with blurry vision)

18. An unconscious 7-year-old boy is brought to the emergency department by his parents. The family emigrated from rural…

EEG

• 7 year old boy is brought to ED for chronic episodes where he “becomes possessed” and then becomes confused with depressed mental status which is likely related to epilepsy or seizure disorder –> Work-up with EEG given chronic history and potential secondary intellectual disability
• Contact child protective services: Patients may not have good health literacy, but they don’t seem to be actively hurting the child

19. A 47-year-old man comes to the physician because of a 2-day history of intense anxiety. He has been receiving…

Adverse effect of prochlorperazine

• Middle-aged man with recent initiation of a high-potency typical antipsychotic (prochlorperazine) who now presents with pacing, hand wringing and trouble sitting still which is most consistent with the extrapyramidal adverse effect akathisia
• Key idea: High-potency typical antipsychotics (Haloperidol, Trifluoperazone, Fluphenazine) are most associated with extrapyramidal side effects of antipsychotics (acute dystonia, Parkinsonism, Akathisia, Tardive dyskinesia)
• Key idea: Extrapyramidal symptoms associated with antipsychotics include (1) Acute dystonia: Sudden, sustained contraction of neck, eye muscles, etc./ tx: benztropine, diphenhydramine (2) Akathisia: Restlessness that worsens with escalating antipsychotic use / tx: benztropine, beta blocker, benzo / (3) Parkinsonism: Resting tremor, rigidity, shuffling gate, etc. / tx: benztropine, amantadine (4) Tardive dyskinesia: Prolonged antipsychotic therapy with dyskinesia of the mouth, face and extremities / tx: Valbenazine and deutetrabenazine

20. A 72-year-old woman comes to the physician because of a 3-month history of fatigue and difficulty sleeping…

Increased serum cortisol concentration

• Elderly woman with signs of major depressive disorder (fatigue, insomnia, decreased appetite, hopelessness, etc.) which is associated with increased serum cortisol levels
• Decreased hemoglobin –> Anemia –> Shortness of breath, low energy, etc.
  • In this age demographic, next best step would be colonoscopy
• Decreased thiamine –> Wernicke-Korsakoff syndrome
• Increased percentage of bands –> Increased PMNs/Neutrophils –> Acute infection
• Increased serum prolactin –> Galactorrhea, sexual dysfunction, etc.
• http://www.aamj.eg.net/journals/pdf/2394.pdf

21. A 32-year-old financial analyst comes to the physician at her employer’s request because of bizarre behavior…

Cocaine abuse

• Young woman with 6 month history of changes in behavior (including long lunch breaks) paranoia, sympathetic hyperactivity (tachycardia, hypertension, mydriasis) and pressured speech most consistent with cocaine abuse/intoxication
• Key idea: Signs of sympathetic activity and dilated pupils –> Patient does NOT have a pure psychiatric disorder (such as bipolar disorder or schizophrenia) and likely has a non-psychiatric medical condition or is using substances
• Key idea: PCP abuse would be associated with more violent behavior and nystagmus

22. A 23-year-old man comes to the physician because of anxiety since beginning a second part-time job as a courier…

Cognitive behavioral therapy

• Young man with specific phobia of elevators which is best treated with exposure-response treatment which is a type of cognitive behavioral therapy
• https://en.wikipedia.org/wiki/Exposure_therapy

23. A 2-year-old girl who was adopted is brought to the physician because of developmental delay; she does not…

Trisomy of an autosomal chromosome

• 2 year old child with developmental delay (motor and speech) with epicanthal folds, prominent tongue and small low-set ears consistent with Down syndrome which is due to Trisomy 21
• Defect in N-acetylglutamate synthetase –> Urea cycle disorder (severe developmental delay but not the characteristic facial features)
• Fetal alcohol syndrome –> intellectual disability, behavior problems, smooth philtrum, microcephaly, small patient
• Phenylalanine hydroxylase deficiency –> Phenylketonuria –> Fair skin, musky body odor, intellectual disability, seizures, eczema

24. A 26-year-old man comes to the physician because of increasing daytime sleepiness over the past 3 years. He has begun…

Decreased REM latency

• Young man with 3 year history of lapses into sleep during the day with hypnagogic hallucinations most concerning for narcolepsy
• Narcolepsy diagnosis: 
  • Recurrent lapses into sleep at least 3 times for at least 3 months and
  • AT LEAST 1 of the following :
    • Cataplexy [brief loss of muscle tone with laughter or strong emotion]
    • Low hypocretin-1 in CSF
    • Shortened REM sleep latency on polysomnography)
• Key idea: Often associated with sleep paralysis and hypnagogic (while going to sleep) or hypnapompic (upom waking up) hallucinations
• Key idea: Polysomnography used to evaluate for many sleep disorders, such as narcolepsy, periodic limb movement disorder, REM sleep behavior disorder and sleep apnea

25. An 18-year-old man is brought to the emergency department by friends 1 hour after they found him on the couch…

Substantia nigra

• Young patient taking synthetic heroin who presents with stiffness and akinesia most consistent with MPTP-mediated substantia nigra damage leading to Parkinson’s like symptoms
• Key idea: Synthetic heroin can be tainted with MPTP which directly destroys dopaminergic neurons in the substantia nigra and leads to permanent symptoms of Parkinson’s disease
• Mnemonic for Parkinson’s disease symptoms is TRAPS: resting Tremor, Rigidity, Akinesia, Postural instability, Shuffling gait

26. A 16-year-old girl is brought to the physician by her father because of unusual behavior since returning…

Marijuana intoxication

• Young girl who came home after a party (which should equal drug use on NBME) and demonstrates paranoia, tachycardia, and conjunctival injection most consistent with marijuana intoxication
• Marijuana: Paranoia, conjunctival injection, dry mouth, tachycardia
• PCP: Nystagmus, violent behavior, dissociative symptoms
• LSD: Visual hallucinations + Mydriasis
• Cocaine: Chest pain, mydriasis, agitation/psychosis, hypertension, tachycardia
• Methamphetamine: Same as cocaine + violent behavior, choreaform movements and tooth decay
• Heroin: Respiratory depression, pinpoint pupils, depressed mental status, constipation

27. A 24-year-old man is brought to the emergency department from jail by police because he has had numbness in his…

No treatment is indicated

• Young man who was recently imprisoned with a long history of law-breaking (likely associated with antisocial personality disorder) who presents with numbness of the hand from the wrist to the finger tips with normal motor function which is not consistent with any known neurological/nerve disorder and most likely represents malingering –> No treatment indicated

28. A 32-year-old man is admitted to the hospital because of refusal to speak or move since he returned home after being…

Lorazepam

• Young man who experienced a very traumatic event and presents with symptoms consistent with catatonia (mute, negativism, resists commands and being moved) which can be treated with benzodiazepines (lorazepam) or electroconvulsive therapy
• Signs of catatonia:
  • Mutism and stupor
  • Negativism (resistance to instructions or movements)
  • Waxy flexibility (initial resistance to movement but then maintains position/posture after being moved)
  • Posturing (assuming positions against gravity)
  • Immobility or purposeless activity
  • Mimicking speech and movements

29. An 8-month-old male infant who was adopted recently is brought to the physician because of poor weight gain…

Fetal alcohol syndrome

• 8 month old infant brought in for poor weight gain with narrow palpebral fissures, thin upper lip and a smooth/indistinct nasal philtrum which are highly specific for fetal alcohol syndrome
• Fetal alcohol syndrome –> intellectual disability, behavior problems, smooth philtrum, microcephaly, small patient
• Celiac disease –> Steatorrhea, weight loss, vesicular rash on extensor surfaces, iron deficiency anemia (due to villous blunting in the duodenum)
• Down syndrome –> Can also have epicanthal folds and single palmar crease but more associated with intellectual disability (which this patient does not have), hypertonia, enlarged tongue, and low-set ears
• Psychosocial deprivation –> Global delay in milestones
• Silver-Russell syndrome: https://rarediseases.org/rare-diseases/russell-silver-syndrome/#:~:text=Russell%2DSilver%20syndrome%20(RSS),asymmetry%20and%20significant%20feeding%20difficulties.

30. A 20-year-old woman is admitted to the hospital because of severe swelling of the lower extremities…

Decreased serum albumin concentration

• Young woman with severely diminished BMI (<15) in the setting of anorexia nervosa (still believes she is fat and is working out obsessively +/- using laxatives/diuretics) found to have lower extremity edema likely due to decreased albumin concentration
• Key idea: Albumin main component of oncotic pressure, which helps to hold fluid in vessels so in a patient who is malnourised –> low protein levels –> low albumin –> low oncotic pressure –> increased gradient for fluid to move from vessels to tissue
• Key idea: Anorexia nervosa diagnosed by BMI<18.5

31. An 82-year-old man is brought to the physician by his daughter because he has been forgetful during the past 6 weeks…

Mini-Mental State Examination

• Elderly man with 6 week history of forgetfulness that is not entirely consistent with Alzheimer disease based on time course and may be related to depression (“pseudo-depression”) and therefore should be worked-up with MMSE
• Note: If patient has confirmed Alzheimer disease, then you would start donepezil therapy (acetylcholinesterase inhibitor –> increased cholinergic activity)
• Routine tests in setting of suspected cognitive impairment:
  • Cognitive tests
    • MMSE less than or equal to 23
    • MOCA less then or equal to 25
    • Abnormal 3-word recall and/or clock draw
  • Labs
    • CBC
    • BMP
    • B12 level
    • TSH level
    • +/- folate, syphilis work-up
  • +/- Imaging (head CT or brain MRI)

32. A 7-year-old girl is brought to the physician because her parents are concerned about her recent preoccupation…

Age-appropriate behavior

• Young child who begins to ask about death and has slight worries about her parents dying but who is showing no impaired functioning and therefore falls under the umbrella of age-appropriate behavior
• Key idea: In order for a psychiatric disorder to be diagnosed, it must lead to impaired functioning
• Separation anxiety disorder: Same theme of anxiety/worries but it leads to somatic symptoms, apprehension going to school, etc.

33. A 19-year-old man has had restless sleep and feelings of sadness for 1 week; he has had a 0.9-kg (2-lb) weight loss…

Adjustment disorder with depressed mood

• Young patient who had a life stressor 2 weeks ago and presents with 1 week of sadness, insomnia and impaired functioning most consistent with adjustment disorder
• MDD would require >2 weeks of symptoms and would require at least 5 of the following symptoms: Depressed mood and SIGECAPS symptoms
• Acute stress disorder leads to <1 month of HARD symptoms (Hyperarousal, Avoidant behavior, Reliving experience (often nightmares), Disturbed thinking/mood) often after a life-threatening or dangerous event

34. A 57-year-old man comes to the physician with his wife because of a 1-month history of bizarre behavior at night. His wife says…

REM sleep behavior disorder

• Middle-aged man who acts out his dreams most consistent with REM sleep behavior disorder
• Key idea: Normally during REM sleep are muscles are completely paralyzed so that we do not act out dreams, but in this disorder muscles maintain some activity and can lead to acting out dreams
• Key idea: REM sleep behavior disorder very strongly associated with Parkinson’s disease and Lewy body dementia

35. Over the past 6 months, a 24-year-old woman has had 12 episodes of sudden apprehension associated…

Cognitive behavioral therapy

• Young woman with unprovoked panic attacks who does not want pharmacotherapy and therefore can be managed with cognitive behavior therapy
• Hypnotherapy –> Drug/substance use history
• Psychodynamic therapy –> Personality disorders primarily
• Acute panic attack –> Benzodiazepines
• Chronic panic attacks or panic disorder –> SSRI/SNRI + CBT
• Key idea: This patient technically does NOT have panic disorder because they do not have anxiety associated with unprovoked panic attacks

36. A 37-year-old man is brought to the emergency department by the police after they found him sitting in an alley

Vitamin B1 (thiamine)

• Young man with signs of cirrhosis (gynecomastia, palmar erythema, RUQ tenderness, easy bruising) who presents with confusion, ophthalmoplegia and likely ataxia (unable to stand/walk despite normal muscle strength) most consistent with Wernicke encephalopathy due to thiamine deficiency in the setting of alcoholism
• Key idea: On the NBME, Alcoholism = Nutritional deficiency
• Folic acid and B12 deficiency both lead to megaloblastic anemia, with B12 deficiency also leading to neurologic symptoms compatible with subacute combined degeneration
• Niacin deficiency –> Pellagra –> Diarrhea, Dermatitis, Dementia, Death
• Vitamin B6 deficiency –> Neuropathy, seborrheic dermatitis, glossitis, etc.

37. A 27-year-old man comes to the physician because of anxiety about a major speech that he must deliver in 3 days…

• Young man with performance-specific social anxiety disorder (concern about being publicly embarrassed) which is best treated with a beta blocker > benzodiazepine
• Key idea: Patients with alcohol use disorder or family history of alcohol dependence often should not receive benzodiazepines if they can be avoided (similar mechanism of action)

38. A 27-year-old man comes to the physician because of anxiety about a major speech that he must deliver in 3 days…

• Young man with performance-specific social anxiety disorder who also has severe asthma and no personal or family history of alcohol dependence who in this setting should receive benzodiazepine > beta blocker
• Beta blockers –> Blockade of Beta-2 receptors in smooth muscle of airways –> Bronchoconstriction –> Worsening asthma

39. A 25-year-old man comes to the physician with his wife because of bizarre behavior for the past 3 months. She reports…

Sertraline

• Young man with obsessions (cleanliness, bad air quality) that causes him distress most consistent with Obsessive-compulsive disorder which should be treated with (1st-line) SSRIs vs CBT (2nd line) Clomipramine vs SNRIs
• Common obsessions in OCD: Cleanliness, thoughts of hurting somebody else or conducting sexual behaviors, etc.
• Buspirone –> Specific for generalized anxiety disorder

40. A 37-year-old woman is brought to the emergency department 30 minutes after the onset of a severe occipital…

Phentolamine

• Patient on a MAO inhibitor (phenelzine) who presents with a hypertensive emergency after eating tyramine-containing foods (mainly the cheese and pepperoni themselves) who should therefore be treated with phentolamine
• Phentolamine: Reversible alpha blocker used first-line for MAO-induced hypertensive emergency and 2nd-line for cocaine-induced hypertension (benzo’s are first line)
• Phenoxybenzamine: Irreversible alpha blocker used in setting of pheochromocytoma
• MAO inhibitors can be remembered with First Aid mnemonic that Mao Takes Pride In Shanghai –> Tranylcypromine, Phenelzine, Isocarboxazid, Selegiline
• Key idea: MAO inhibitors associated with hypertensive crisis after eating tyramine-containing foods (cheese, cured/processed meats, alcohol) and serotonin syndrome (when used with other serotonergic drugs)

41. A previously healthy 37-year-old man comes to the physician because of a 6-month history of depressed mood, fatigue…

Mood disorder due to a general medical condition

• Young obese man with mood symptoms in the setting of loud snoring + difficulty sleeping, being tired during the day, etc. most consistent with mood disorder secondary to obstructive sleep apnea
• Risk factors for obstructive sleep apnea can be remembered by STOP-BANG mnemonic (Snoring, Tired, Observed snoring/chocking, Pressure (elevated BP), BMI >35, Age>50, Neck size > 16 cm and Gender (Male > Female))
• Key idea: Polysomnography used to diagnose virtually all NBME sleep disturbance questions (obstructive sleep apnea, narcolepsy, REM sleep behavior disorder, etc.)

42. A 23-year-old graduate student comes to the physician because of depressed mood and feelings of hopelessness…

Adjustment disorder with depressed mood

• Young woman who experienced a recent stressor and is now presenting with depression symptoms insufficient to meet formal criteria for MDD (need at least 2 weeks with at least 5 symptoms of depressed mood + SIGECAPS), most consistent with adjustment disorder
• Substance use occurred AFTER the acute stressor and therefore substance-induced mood disorder is not correct
• Key idea: Pay CLOSE attention to the time course/parameters of psychiatric diseases as they are essential to diagnosing disease and can help you quickly rule out answer choices (>2 weeks for MDD, >6 months for Generalized anxiety disorder, etc.)

43. 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…

Specific phobia

• Young patient with a fear of flying who also had a previous episode consistent with social anxiety disorder (panic attack while giving a presentation), most consistent with a specific phobia
• Mitral valve prolapse and caffeine can predispose to anxiety secondary to a general medical condition, but would not lead to anxiety only about specific situations

44. A 32-year-old woman comes to the physician because of depressed mood for 2 weeks; she went…

“How would you feel about entering the hospital?”

• Young depressed woman with suicidal ideation with organized plan and access to means who will need to be hospitalized involuntarily but often in these cases it is best to first ask the patient if they will voluntarily enter the hospital (better for doctor-patient relationship if possible)
• Key idea: Passive suicidal ideation can be managed as an outpatient, but if patient has an organized plan and access to means then they should be involuntarily hospitalized

45. A 52-year-old woman comes to the physician for a routine follow-up examination. She has received…

Discontinue haloperidol and begin risperidone

• Middle-aged woman with severe schizophrenia who has been treated with haloperidol for the past 20 years and has developed signs of tardive dyskinesia (smacks her lips and protrudes her tongue) and therefore should discontinue high-potency antipsychotic and start an atypical antipsychotic (such as risperidone)
• Key idea: Patient’s schizophrenia is so severe that we cannot only discontinue haloperidol and not start her on another antipsychotic with lower extrapyramidal risks
• Chlorpromazine is a low-potency typical antipsychotic which carries more extrapyramidal risk than an atypical antipsychotic such as risperidone
• Key idea: High-potency typical antipsychotics (Haloperidol, Trifluoperazone, Fluphenazine) are most associated with extrapyramidal side effects of antipsychotics (acute dystonia, Parkinsonism, Akathisia, Tardive dyskinesia)

46. 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…

Admit to the psychiatric unit involuntarily

• Young man with symptoms of depression (weight loss, fatigue, tearful mood, psychomotor slowing) who presented after a failed suicide attempt and therefore should be hospitalized involuntarily
• Key idea: Patients with passive suicidal ideation do not need to be hospitalized against their will, but if the patient has an organized plan and access to means then they need to be admitted involuntarily
• Key idea: These patients should first be offered voluntary hospital admission in the name of patient-physician relationship, but even if they don’t want to be admitted they need to be forcefully admitted

47. A 27-year-old woman, gravida 1, para 1, comes to the physician with her husband because of progressive…

Major depressive disorder

• Young woman who presents 3 weeks postpartum with >2 weeks of depressed mood and SIGECAPS components (Sleep changes, decreased Interest in friends/family, low Energy, Appetite changes, Suicidal thoughts) most consistent with major depressive disorder
• Key idea: MDD requires at least 2 weeks of at least 5 of the following 9 symptoms (depressed mood, Sleep changes, decreased Interest in activities, Guilt, low Energy, Cognitive changes, Appetite changes, Psychomotor slowing, Suicidal thoughts)
• Key idea: Important to differentiate from postpartum blues which is mild depressive symptoms that develop 2-3 days after delivery and RESOLVE WITHIN 2 WEEKS (require monitoring without treatment unless it develops into postpartum depression)
• Generalized anxiety disorder would require at least 6 months of symptoms
• PTSD requires at least 1 month of symptoms

48. Over the past 7 years, a 25-year-old graduate student has had increasingly severe palpitations, tremulousness, nausea…

Psychiatric evaluation

• Patient with symptoms of anxiety that is always brought on when he is taking a test most consistent with a psychiatric/anxiety condition
• Key idea: All of the other diagnostic tests pertain to medical conditions, some of which can lead to similar symptoms but would not be as highly associated with taking tests
• 24-hour urine collection for 5-HIAA –> Carcinoid syndrome –> Episodic wheezing, flushing, diarrhea, and right-sided valvular problems
• 24-hour urine catecholamines/metanephrines –> Pheochromoctycoma –> Recurrent episodes of hypertension, sweating, headaches and palpitations

49. A 47-year-old woman is brought to the emergency department by her husband because of increasing confusion…

Lithium

• Middle-aged woman with bipolar disorder (which is almost always treated with lithium > valproate) who has been taking higher amounts of NSAIDs recently who presents with confusion, tremor, and AV block most consistent with lithium toxicity
• Key idea: Common signs of lithium toxicity are GI symptoms, confusion, tremors/fasciculations and seizures +/- ECG changes
• Key idea: Common triggers of lithium toxicity are drugs that affect the function of the kidney, most often thiazides, ACE inhibitors, nephrotoxic agents and NSAIDs (which leads to afferent arteriole vasoconstriction)
• Key idea: Indications for hemodialysis in setting of lithium toxicity is serum lithium level > 4 mEq/L or serum lithium level > 2.5 mEq/L + signs of lithium toxicity (seizures, altered mental status) OR inability to secrete lithium (CKD, CHF, etc.)

50. A 47-year-old man is brought to the physician by his wife because of “unbearable” behavior during the past 2 weeks…

Bipolar disorder

• Middle-aged man with signs of mania/hypomania (impulsivity, grandiosity, etc.) and psychosis most consistent with bipolar disorder
• Mania/Hypomania leads to DIG FAST symptoms (Distractibility, Impulsivity, Grandiosity, Flight of ideas, decreased Appetite, decreased Sleep need, Talkativeness)
• Key idea: Can sometimes be difficult to differentiate between schizophrenia and bipolar disorder on NBME when patient presents with psychosis, but look for DIG FAST symptoms to differentiate between them
• Key idea: Cocaine use can also lead to psychosis with signs of mania/hypomania, but this patient had a negative urine toxicology
• Key idea: 3 key differences that are consistent with Mania rather than hypomania:
  • (1) Causes significant functional impairment or leads to hospitalization
  • (2) Episode lasting >7 days
  • (3) Presence of psychotic features

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