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1: An 82-year-old man comes to the physician with his wife because of difficulty…
Reassurance
- Patient is displaying normal age-related changes (early morning awakening, falling asleep during day, normal mood, Mini-mental state > 23)
- Key idea: Early morning awakening with inability to go back to sleep should prompt strong consideration for major depressive disorder (but this patient does not have other components of SIGECAPS mnemonic)
- Key idea: MMSE of 23 or lower and MOCA of 25 or lower are abnormal
2. A 57-year-old woman comes to the physician because of progressive loss of…
Conversion disorder
- Woman who experienced a significantly traumatic event and has had persistent mood symptoms and associated, unexplained neurological symptom, most consistent with Conversion disorder
3. A 22-year-old woman comes to the physician because of a 3-year history of intermittent…
Generalized anxiety disorder
- Young patient with years of worries about multiple issues (college, bills, etc.) who also has somatic symptoms (headaches, diarrhea, muscle tension), most consistent with generalized anxiety disorder
- Key idea: Generalized anxiety disorder characterized by multiple issues for at least 6 months with at least 3 of the following symptoms (restlessness, fatigue, difficulty concentrating, muscle tension, irritability, sleep problems)
4. A 62-year-old woman comes to the physician because of auditory hallucinations…
Brief psychotic 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
- 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
5. A 13-year-old girl is brought to the physician by her mother because she has not…
Discuss normal pubertal development
- 13 year old girl who has not yet menstruated but has secondary sexual characteristics (Tanner Stage 2) and therefore is still within normal development range
- Key idea: Primary amenorrhea diagnosed if (1) Lack of menses and secondary sexual characteristics by age 13 OR (2) Lack of menses (regardless of secondary sexual characteristics) by age 15
6. A 47-year-old woman with schizophrenia, paranoid type, comes to the physician…
Switch from haloperidol to aripiprazole
- Switch from high-potency typical antipsychotic –> atypical antipsychotic will decrease risk of developing tardive dyskinesia
- Key idea: High-potency typical antipsychotics have the highest risk of extrapyramidal symptoms (such as tardive dyskinesia) and include haloperidol, trifluoperazine and fluphenazine
7. A 21-year-old woman is brought to the emergency department by police after…
Admit the patient to the psychiatric unit
- Patient who threatened her boyfriend with a meat cleaver and states that she would kill her boyfriend, meaning that she poses a threat to others and needs to be involuntarily hospitalized
- Reasons for involuntary psychiatric hospitalization includes patients who as a result of a mental disorder (1) pose a threat to themselves (2) pose a threat to others (3) are gravely disabled
8. A 67-year-old man comes to the physician because of a 2-month history of increased…
Add bupropion to the medication regimen
- Reasons to use bupropion for MDD: (1) Patient with comorbid cigarette use (2) Patient with increased weight (3) Patient who doesn’t want sexual side effects
- Key idea: 3 ways to diagnose diabetes mellitus include (1) Fasting blood glucose >126 (2) Random plasma glucose >200 with history of polyphagia, polydipsia, polyuria (3) HgbA1c > 6.5%
9. A 46-year-old woman is brought to the emergency department in respiratory…
Opioid
- Opiates lead to pinpoint pupil, respiratory depression, decreased bowel activity and coma/stupor
- In NBME, TCA overdose almost always associated with anticholinergic side effects (dry mouth, constipation, etc.) and QRS widening
- Benzo and barbiturate overdose appear similar to alcohol use (slurred speech, impaired gait, altered mental status, etc.)
10. A 17-year-old girl is brought to the physician by her mother because her…
Anorexia nervosa
- Key idea: Anorexia nervosa characterized by BMI < 18.5 along with distorted body image and fear of weight gain
- Key idea: Binging-purging can be seen in both anorexia nervosa and bulimia; use BMI as cut-off
- 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
11. A 32-year-old man is brought to the emergency department by his roommate…
Clonazepam
- Young patient with known history of cocaine use who presents with agitation, fever, hypertension and ECG changes, with the first-line treatment for cocaine-induced HTN being benzodiazepines
- Key idea: Only differences between treating a cocaine-induced myocardial infarction vs a normal myocardial infarction is that you should NOT use a beta blocker (due to risk of unopposed alpha agonism) and you should give patient a benzodiazepine
12. A 3 1/2-year-old boy is brought to the physician by his parents because he has…
Reassurance that this is normal behavior
- Key idea: Most children begin toilet training between 2-4 years of age and bedwetting is NORMAL before age 5
13. A 47-year-old man comes to the physician because of a 4-week history of…
Substance-induced mood disorder
- Patient with depressed mood, decreased energy, poor concentration, and sleep changes (consistent with major depressive disorder) following initiation of propranolol, most consistent with medication-induced mood disorder
14. Fifteen minutes after administration of intramuscular haloperidol, a 21-year-old…
Dopamine
- Patient recently given haloperidol who develops acute dystonia (antipsychotics inhibit dopamine receptor binding)
- 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
15. A 10-month-old boy is brought to the physician because of irritability throughout…
Child abuse
- Injuries that are consistent with child abuse include spiral fracture, rib fractures, subdural hematoma, and retinal hemorrhages
- Key idea: If cause of injury does not line up with developmental milestones (ex: saying a 3 month rolled off the changing table), then you should consider child abuse
16. A 47-year-old man is brought to the emergency department 1 hour after he…
Symmetric enlargement of the ventricles
- Long-standing schizophrenia –> Symmetric enlargement of the ventricles
17. An 8-year-old boy is brought to the physician by his mother because of a…
Decreased binding of dopamine at the postsynaptic receptor
- Young patient with ADHD and Tourettes who receives haloperidol, which is a dopamine receptor antagonist
- Key idea: Psychosis associated with increased dopamine binding within the mesocortical/mesolimbic tracts whereas Parkinson’s associated with decreased dopamine binding within the nigrostriatal pathway
18. A 37-year-old man comes to the physician for a follow-up examination 3 months…
Recommend alcohol rehabilitation
- Patient with severe alcohol use (>14 drinks/week in adult male or >7 drinks/week in adult female or elderly patient >65) who also has severe dysfunction related to drinking (alcoholic cirrhosis, DUI, etc.) who continues to drink with elevated GGT level
19. A healthy 4-year-old girl is brought to the physician by her father because of…
Begin parent management training
- Young child who has normal behavior at day care and at grandmother’s house with bad behavior at home, most consistent with poor boundary setting by parents necessitating parent management training
- Key idea: ADHD requires at least 6 months of hyperactive or inattentive symptoms before age 12 that occur in at least 2 settings
20. A 20-year-old college student comes to the physician because of a 1-year history of…
Social phobia
- Social phobia = Social anxiety disorder = Exaggerated fear of embarssment in social situations
- Key idea: Performance-type treated with beta blockers or benzodiazepines (beta-blockers preferred if history of alcohol use disorder and benzo’s preferred if patient has asthma or COPD due to beta-blockade –> bronchoconstriction) with CBT or SSRIs for chronic management
21. A 7-year-old boy is brought to the physician by his mother because of difficulty at…
Separation anxiety disorder
- Child who recently started school and developed somatic symptoms and anxiety when he is separated from his mother/parents
22. A 25-year-old woman is brought to the emergency department by police because…
Ziprasidone
- Young woman (schizophrenia almost always presents in young adult) who presents with delusions of grandeur, hallucinations, and pressured speech, which is most consistent with psychosis necessitating treatment with antipsychotics
- Key idea: Difficult at times to differentiate between bipolar disorder and psychotic disorders on NBME exam, but know that bipolar exam will almost always include changes in sleep and schizophrenia will have more prominent psychotic symptoms
23. An 87-year-old man who resides in a skilled nursing care facility is brought to…
Decrease the dosage of carbidopa-levodopa
- Older patient with Parkinson’s with a recent increase in carbidopa-levodopa who since then has experienced delusions (staff stealing items) and hallucinations (auditory), most consistent with Carbidopa-levodopa associated psychosis
- Key idea: Parkinson’s disease associated with low dopamine levels whereas schizophrenia/psychosis associated with increased dopamine levels
- Key idea: If decreasing carbidopa-levodopa dose does not relieve psychosis or if patient’s Parkinson’s symptoms progress following decrease in dose, then next step would be a low-potency second-generation antipsychotic such as quetiapine
24. A 47-year-old man is admitted to the hospital 20 minutes after he was involved in…
Administration of morphine
- Key idea: Although opiates should be carefully prescribed to patients with history of dependence, they still play an important role in pain management and should not be with-held when patient cannot be managed with non-opioid meds
25. A 55-year-old woman is brought to the emergency department by her parents…
Delusional disorder
- Woman with multiple delusions for >1 month that have not significantly impaired her normal functioning, most consistent with delusional disorder
- Delusional disorder = Greater than 1 delusion for at least 1 month WITHOUT other psychotic features or significant impairment
- Tx: CBT + antipsychotics
- Key idea: Differentiate from personality disorders, which lead to pervasive patterns demonstrated through multiple features of an individual’s behavior and NO delusions
26. A 24-year-old male college student comes to student health services for a follow…
Maintain the current dosage of sertraline and schedule weekly follow-up examinations for the next month
- Key idea: Adequate trial for an antidepressant before changing to another first-line medication is 6 weeks
- Key idea: Patients often have side effects of anti-depressants (anxiety, etc.) before benefits of medications
27. A 32-year-old man is brought to the physician by his wife because of increasing…
Serotonin
- Patient who has been chronically treated with an SSRI and recently started on tramadol who has Agitation, Autonomic hyperactivity (febrile, tachycardia, hypertension), and increased Activity (hyperreflexia, muscle rigidity) consistent with serotonin syndrome
- Drugs associated with serotonin syndrome: Psych drugs (SSRIs, SNRIs, MAO inhibitors, TCAs), tramadol, ondansetron, linezolid, MDMA (ecstasy), meperidine, dextromethorphan, St. John’s wort, triptans
28. A 27-year-old man comes to the emergency department after a motor vehicle…
Amphetamine intoxication
- Young patient with delusions, pressured speech and agitation, most consistent with bipolar disorder or use of stimulant/sympathomimetic drugs (cocaine, methamphetamine, etc.)
- Hallucinogen intoxication would not lead to pressured speech
- Opioid withdrawal –> mydriasis, diarrhea/GI complaints, etc.
29. A previously healthy 25-year-old woman is brought to the emergency department…
Hallucinogen intoxication
- Young woman with hallucinations and mydriasis without other signs of sympathetic overstimulation with a negative urine tox screen, most consistent with LSD intoxication
- Key idea: Standard urine drug screen picks up on amphetamine, cocaine, cannabis, opioids and PCP
30. A 47-year-old woman is admitted to the hospital because of a 12-hour history of…
Administer additional diazepam
- Patient with a significant alcohol use history who has not had a drink fro 24 hours and has developed tremors, confusion, hypertension, tachycardia and hyperreflexia, most consistent with delirium tremens
- Key idea: Delirium tremens treated with benzodiazepines that are Okay for Terrible Livers (Oxazepam, Temazepam, Lorazepam)
- 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)
31. A 27-year-old teacher comes to the physician requesting a prescription for sleep…
Circadian rhythm sleep disorder
- Patient who falls asleep late at night and feels tired during the week when she has to wake up early but feels well-rested on the weekend when she can sleep until later in morning/afternoon, consistent with a circadian rhythm sleep disorder
- REM sleep behavior disorder: Acting out dreams (often seen in patients with Parkinson’s or Lewy Body dementia)
32. A 42-year-old woman comes to the physician because of suicidal thoughts…
Acute intermittent porphyria
- Patient with psychosocial symptoms, intermittent abdominal pain exacerbated by alcohol and polyneuropathy with a family history (which should always make you think of a genetic disease), most consistent with acute intermittent porphyria
- Acute intermittent porphyria: 5 P’s: Painful abdomen, Port-wine colored urine, Polyneuropathy, Psychological disturbances, Precipitated by alcohol, starvation and P-450 inducers
- Key idea: Treated with glucose and hemin
33. A 16-year-old high school student will not eat meals with her family, preferring to…
Amenorrhea
- High school girl who is not eating meals and has very low weight, most concerning for anorexia nervosa
- Key idea: Anorexia nervosa –> Functional hypothalamic amenorrhea –> Low estrogen –> Increased risk of osteoporosis
- Key idea: Dental caries would be more likely if patient had binging-purging form of anorexia nervosa or bulimia nervosa
- Key idea: Patients with anorexia nervosa can develop bradycardia (indication for hospitalization)
34. A 37-year-old woman is admitted to the hospital after a suicide attempt by an…
Decreased concentration of 5-hydroxyindoleacetic acid in cerebrospinal fluid analysis
- Patient with major depressive disorder who would therefore have decreased 5-HIAA in CSF because 5-HIAA is a breakdown product of serotonin and patients with depression have decreased serotonin levels (reason why SSRIs are first-line medication)
35. A 52-year-old woman comes to the physician with her husband because of a 6…
Restless legs syndrome
- Patient who develops an uncomfortable sensation in her legs while trying to sleep which makes it difficult for her to sleep
- Key idea: Commonly associated with iron deficiency anemia
- Key idea: Treated with dopamine agonists (pramipexole, etc.)
36. A 42-year-old man comes to the physician for a routine health maintenance…
Psychotherapy
- Patient with signs of adjustment disorder (distressful psychosocial symptoms within 3 months of an explicit stressor who does NOT meet criteria for MDD or other diagnosis)
- Key idea: Adjustment disorder treated with CBT/Psychotherapy and NOT pharmacotherapy
37. A 77-year-old man is brought to the physician by his wife because of a 6-month…
Lewy body dementia
- Older patient with dementia + visual hallucinations + parkinsonism (shuffling gait, akinesia) most consistent with Lewy body dementia
- Key idea: Lewy body dementia diagnosed by (1) Dementia AND (2) At least 2 of the following (visual hallucinations, parkinsonism, fluctuating cognition and REM sleep behavior disorder)
- Key idea: For NBME exams, if parkinsonism predates cognitive impairment by >1 year, then patient has Parkinson disease, whereas if parkinsonism and dementia occur <1 year apart then patient has Lewy body dementia
38. A 21-year-old college student comes to the physician because of a 3-year history…
Clomipramine
- Patient with obsessive compulsive disorder (recurrent thoughts of hurting people and performing violent sexual thoughts [obsessions] that cause his distress that he tries to repress through counting [compulsions])
- Treatment of OCD: CBT, SSRIs, Clomipramine, Venlafaxine
39. A 53-year-old woman is brought to the physician by her husband because of…
- Middle-aged woman presenting with progressive personality changes and jerky movements with a family history of similar symptoms in her father, most consistent with Huntington’s disease (due to degeneration of the caudate atrophy)
- Key idea: Huntington’s disease classically leads to triad of Dementia, Depression and Chorea
- Key idea: Huntington’s disease classically leads to anticipation (future generations experience disease at younger age due to trinucleotide repeat expansion), especially when inherited from their father
40. A 20-year-old woman is brought to the emergency department immediately after…
Surreptitious administration of insulin
- A young woman with access to insulin (mother has T2DM) who presents with severe hypoglycemia and is found to have an increased insulin level but a normal/low C-peptide level, most consistent with surreptitious insulin use
- Key idea: Normal the body cleaves pro-insulin into insulin + C-peptide, so if increased endogenous amounts of insulin are being produced in the setting of an insulinoma you would expect both insulin and C-peptide levels to be elevated
- Key idea: In contrast, pharmacological exogenous insulin contains only insulin and no C-peptide, so patients using exogenous insulin will have increased insulin but normal/low C-peptide
41. A 42-year-old woman comes to the physician because of a 2-week history of…
Panic disorder
- Patient with history of panic disorders (short episodes of dizziness, flushing, fear of dying, and anxiety) WITH NO CLEAR TRIGGER who experiences concern/anxiety related to attacks, most consistent with panic disorder
- Key idea: Panic disorder requires at least 1 untriggered panic attack with at least 1 month of worry about future attack and/or avoidance behavior
42. A 32-year-old man comes to the physician because he thinks he might be losing…
Obsessive-compulsive diosrder
- Patient with recurrent thoughts of hurting his son that are causing distress [obsession] that he deals with by praying and reading scriptures [compulsions], most consistent with obsessive-compulsive disorder
- Key idea: Common way NBME asks about OCD patient is they will be religious and will pray to deal with obsessions
43. A 27-year-old first-year surgical resident comes to the physician to request a…
Begin escitalopram therapy
- Overworked surgery resident who presents with sleep disturbances (specifically early morning awakenings!), cognitive disturbance (can’t remember as well), loss of interest, irritability, decreased appetite and anxiety/depressed mood, most concerning with major depressive disorder requiring antidepressant therapy
44. A 10-year-old boy is brought by his parents for a well-child examination. His…
Conduct disorder
- Young boy with bad behavior who also demonstrates socially unacceptable behavior (killing family cat, getting in fights and having bruising), 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
45. A 20-year-old college student comes to student health services because she…
Adjustment disorder
- Patient who had acute stressor and then within 3 months has developed psychosocial distress and tearfulness that does not meet criteria for major depressive disorder, and therefore has adjustment disorder
- Key idea: In contrast to MDD, adjustment disorder is treated with CBT without pharmacotherapy (for the most part)
46. A 37-year-old woman is brought to the emergency department by police…
Dissociative fugue
- Key idea: Woman is unable to give her name or where she lives, so we know that we are dealing with a dissociative disorder
- Dissociative fugue: Dissociative amnesia (cannot remember personal information such as name, address, etc.) accompanied by travel/wandering that is often seen following significant traumatic event or stressor
47. A 67-year-old man with Parkinson disease is brought to the physician by his wife…
Major depressive disorder
- Elderly patient with chronic illness who has >2 week history of tearfulness, decreased energy, sleep changes, decreased appetite, flat affect and depressed mood, all consistent with major depressive disorder
- Key idea: In order to differentiate between pathology and physiology on NBME psych exam, pay strict attention to diagnostic criteria and also the degree of psychosocial distress/impaired function (can they still work, can they still participate in society, etc.)
48. A 42-year-old man is brought to the physician by his wife because of a 2-month…
Focal spikes localized to the temporal lobe
- Middle-aged man who recently sustained head trauma who has since developed intermittent episodes that last 1-2 minutes with simple automatisms in which he smells burnt rubber and hears an intense hissing sound, most consistent with temporal lobe epilepsy
- Key idea: Important to contrast with absence seizures, which more commonly occur in children and lead to frequent episodes <30 seconds with simple automatisms but NO post-ictal confusion
49. A 5-year-old girl is brought to the physician by her parents because of difficulty…
Down syndrome
- Young child with trouble in school who is playful with epicanthal folds and a heart murmur (most consistent with a VSD), most consistent with down syndrome
- Key idea: Most common congenital heart defect associated with down syndrome is AV
- Key idea: In an infant, down syndrome often characterized by hypotonia and poor feeding
- Fetal alcohol syndrome: Smooth philthrum, microcephaly, thin vermillion border, small palpebral fissures
- Fragile X syndrome: Long narrow face with large ears, macrocephaly, prominent chin/forehead and macro-orchidism in post-pubertal patient
50. A 23-year-old man with a 3-year history of bipolar disorder well controlled with…
Explain the risk of illness recurrence without medication
- Key idea: In contrast to major depression (in which majority of patients do NOT need lifelong therapy), basically all patients with bipolar disorder require lifelong therapy (risk of recurrence of mania/depression very high!)
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