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NBME Psych Form 3

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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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