Psychiatry NBME Form 4 Questions And Answers

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Psychiatry NBME Form 4 Questions And Answers
Psychiatry NBME Form 4 Questions and Answers pejo Psychiatry NBME Form 4 Questions and Answers 2018-03-30 7308

Exam Section : Item 1 of 50
An 82-year-old man is brought to the physician by his daughter because he has been forgetful during the past 6 weeks. She is particularly concerned because a small fire started recently when he left a pot unattended on the stove. The patient’s wife died 1 year ago, and he says he has been distracted recently and cannot stop thinking about her. He lives alone and pays his bills, does routine household chores, and drives short distances for errands. His daughter says he was doing well on his own until recently. He is 168 cm (5 ft 6 in) tall and weighs 63 kg (140 1b); BMI is 23 kg/m2. His temperature is 370C (98.60F), pulse is 78/min and regular, respirations are 18/min, and blood pressure is 130/80 mm Hg. Physical examination shows no abnormalities. On mental status examination, he is alert and cooperative.
He becomes very sad when he talks about his wife’s death. Which of the following is the most appropriate next step in management?

• A) Follow-up examination in 3 months
• B) Mini-Mental State Examination
• C) Recommend assisted living
• D) CT scan of the head
• E) Begin donepezil therapy

Answer: (B) Mini-Mental state examination

Exam Section : Item 2 of 50
A 37-year-old man is brought to the emergency department after the pilot of a boat found him in the river at 2 am with rocks in his pockets. He reports that he jumped from the bridge to go for a swim and was not attempting suicide. He insists that the rocks were only to give him ballast when he jumped so that he would not hit the bridge tower. He immigrated to the USA 1 year ago and left most of his family behind. He has been living in a single furnished room and has been working numerous low-paying jobs. Over the past month, he has had a 4.5-kg (10-1b) weight loss. He reports that he always feels tired but has not seen a physician because he has no health insurance. He does not usually drink but had two shots of whiskey earlier that night. He has no history of medical or psychiatric illness. Physical examination shows numerous lacerations and abrasions over the chest and all extremities. On mental status examination, he describes his mood as fine but often appears tearful. His speech is slow with frequent pauses, and he is guarded in his responses. He says that he has not had hallucinations. He is alert and oriented to person, place, and time. The physician recommends voluntary admission to the psychiatric unit, but the patient refuses, saying there is nothing wrong with him. Which of the following is the most appropriate next step in management?

• A) Recommend a mental health facility in his neighborhood
• B) Recommend a social service agency
• C) Observe in the emergency department for 36 hours
• D) Begin fluoxetine therapy
• E) Begin risperidone therapy
• F) Admit to the psychiatric unit involuntarily

Answer: F) Admit to the psychiatric unit involuntarily

Exam Section : Item 3 of 50
Five weeks after being discharged from the hospital after treatment for a psychotic episode, a 27-year-old man comes to the physician for a follow-up examination. During hospitalization, he claimed that he was instructed by the Lord to found a new religion and that a famous gospel singer was in love with him. Today, he says that he still hears the voices of the Lord and members of the church he attends in his apartment and when he shops in the supermarket. He no longer believes the world needs a new religion because the Lord is no longer instructing him to create one. He states, “My father in heaven tells me that he is at peace, and therefore, so am l.” Current medications include risperidone and lorazepam. He drinks one to two beers on weekends. He used marijuana regularly in college but has abstained for the past 5 years. He appears clean and is casually dressed. His temperature is 36.7 oc (980F), pulse is 72/min, respirations are 20/min, and blood pressure is 130/72 mm Hg. Physical examination shows no abnormalities. Mental status examination shows a calm affect. He is cooperative, alert, and oriented to person, place, and time. Based on this information, which of the following is the most likely current diagnosis for this patient?

• A) Bipolar disorder
• B) Cyclothymic disorder
• C) Delusional disorder
• D) Schizoaffective disorder
• E) Substance-induced mood disorder

Answer: C) Delusional disorder

Exam Section : Item 4 of 50
The response options for the next 2 items are the same. Select one answer for each item in the set.
For each patient with depressed mood, select the most likely diagnosis.

• A) Adjustment disorder with depressed mood
• B) Bereavement
• C) Bipolar disorder, depressed
• D) Cyclothymic disorder
• E) Dysthymic disorder
• F) Major depressive disorder
• G) Mood disorder due to a general medical condition
• H) Substance-induced mood disorder

A previously healthy 37-year-old man comes to the physician because of a 6-month history of depressed mood, fatigue, poor concentration, and difficulty sleeping. He works as an accountant and has had difficulty staying awake at work, particularly in the afternoon. He says that his wife sleeps in a separate room because of his loud snoring. He drinks alcohol at social functions only. He is 175 cm (5 ft 9 in) tall and weighs 109 kg (240 1b); BMI is 35 kg/m2. Physical examination shows no other abnormalities. Mental status examination shows a mildly depressed mood.

Answer: G) Mood disorder due to a general medical condition

Exam Section: Item 5 of 50

• A) Adjustment disorder with depressed mood
• B) Bereavement
• C) Bipolar disorder, depressed
• D) Cyclothymic disorder
• E) Dysthymic disorder
• F) Major depressive disorder
• G) Mood disorder due to a general medical condition
• H) Substance-induced mood disorder

A 23-year-old graduate student comes to the physician because of depressed mood and feelings of hopelessness since breaking up with her boyfriend 1 week ago. During this period, she has rarely left her apartment, has only eaten a small amount of food, and has isolated herself from her friends and family. She has been drinking more alcohol than normal during this period. Physical examination shows no abnormalities. On mental status examination, she becomes tearful when she describes the breakup. When asked about her mood, she says, “I’m miserable. He was my life!” There is no evidence of suicidal ideation.

Answer: A) Adjustment disorder with depressed mood

Exam Section : Item 6 of 50
A 37-year-old woman is brought to the emergency department 30 minutes after the onset of a severe occipital headache, palpitations, and tremulousness. Shortly before this episode, she ate several slices of pepperoni pizza. She has a 2-month history of atypical major depressive disorder treated with phenelzine. She is otherwise healthy. She appears anxious and tremulous. Her temperature is 37.80C (IOOF), pulse is 94/min, respirations are 20/min, and blood pressure is 210/110 mm Hg. Physical examination shows no other abnormalities. The most appropriate next step is administration of which of the following?

• A) Bromocriptine
• B) Diazepam
• C) Diphenhydramine
• D) Fluvoxamine
• E) Haloperidol
• F) Naloxone
• G) Phentolamine
• H) Physostigmine

Answer: B) Diazepam

Exam Section : Item 7 of 50
A 20-year-old woman is admitted to the hospital because of severe swelling of the lower extremities for 10 days. She has been amenorrheic for 6 months and has had a 23-kg (50-1b) weight loss over the past year. She has been receiving treatment with fluoxetine for major depressive disorder. She is evasive responding to questions about laxatives or diuretics. She states that she believes she is overweight and therefore she works out twice daily at the health club. She appears emaciated. She is 165 cm (5 ft 5 in) tall and weighs 32 kg (70 1b); BMI is 12 kg/m2. Her pulse is 601min, and blood pressure is 100/60 mm Hg. Examination shows 3+ pitting edema of the lower extremities. Which of the following is the most likely explanation for these findings?

• A) Adverse effect of fluoxetine
• B) Decreased serum albumin concentration
• C) Impaired serotonergic function
• D) Increased serum corticotropin-releasing hormone concentration
• E) Ipecac-induced cardiomyopathy

Answer: B) Decreased serum albumin concentration

Exam Section : Item 8 of 50
A 42-year-old man is brought to the emergency department by police after they found him hiding under a parked truck. Police say the patient claimed to be hiding from “dementors” who would look him in the eyes and make him an alien through “viral-spatial worms.” During the past 5 years, he has been brought to the emergency department eight times for similar behavior. He has no other history of serious illness and takes no medications. He does not use illicit drugs. He lives alone and does not have friends. He appears disheveled. Physical examination shows no abnormalities. On mental status examination, he is fully oriented. He makes poor eye contact and speaks quickly and loudly. He has an anxious affect. His thought process is predominantly linear. During the examination, he opens his eyes only after he counts out loud to 13 and says that doing so helps him to counteract “evil forces.” Which of the following is the most likely diagnosis?

• A) Bipolar disorder
• B) Delusional disorder
• C) Obsessive-compulsive disorder
• D) Schizoid personality disorder
• E) Schizophrenia

Answer: E) Schizophrenia

Exam Section : Item 9 of 50
An 8-month-old male infant who was adopted recently is brought to the physician because of poor weight gain. He was born at term and weighed 2410 g (5 1b 5 oz). He was formula fed at birth and has consistently been below the 3rd percentile for weight. Currently, his diet consists of 16 ounces of iron-fortified cow milk formula, juice, cereal, prepared fruit, and pureed green vegetables. There is no history of vomiting. He has one formed stool daily. He is alert and appears well. He currently weighs 7002 g (15 1b 7 oz). On examination, he says “mama” and “bye-bye” while waving. He sits unsupported. He is wary of strangers. There are narrow palpebral fissures, epicanthal folds, a thin upper lip with a “fish mouth” appearance of the oral cavity, and an indistinct nasal philtrum. His ears are normally set, the nasal bridge is flattened, and the tongue is not enlarged. There is a single palmar crease on the left hand. Cardiopulmonary examination shows no abnormalities. There is no hepatosplenomegaly, and no masses are palpated. There is no peripheral edema. Which of the following is the most likely diagnosis?

• A) Celiac disease
• B) Down syndrome
• C) Fetal alcohol syndrome
• D) Psychosocial deprivation
• E) Silver-Russell syndrome

Answer: C) Fetal alcohol syndrome

Exam Section : Item 10 of 50
A 57-year-old man comes to the physician with his wife because of a I-month history of bizarre behavior at night. His wife says that most nights he falls asleep at approximately 11 pm and begins kicking and groaning in the bed shortly after 12:30 am. Seven times during this period, he has jumped out of the bed and run back and forth across the room, punching the air. She tries to wake him during these episodes because she is afraid that he might hurt her or himself. She reports that when she succeeds, he seems alert but tells her that he was being attacked and needed to defend himself or escape. The patient tells the physician that he does not recall the behavior his wife is describing but remembers having a recurrent dream in which he is in danger and cannot breathe. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, he has a pleasant and full range of affect. His thought process is rational and goal directed. He says that based on his wife’s description of his behavior at night, he is afraid that he might hurt her. Results of laboratory studies are within the reference range. Which of the following is the most likely diagnosis?

• A) Central sleep apnea
• B) Nocturnal panic disorder
• C) Nocturnal paroxysmal dystonia
• D) REM sleep behavior disorder
• E) Restless legs syndrome
• F) Sleep-related complex partial seizure disorder
• G) Sleep terror disorder

Answer: D) REM sleep behavior disorder

Exam Section : Item 11 of 50
A 27-year-old woman, gravida 1, para 1, comes to the physician with her husband because of progressive irritability and anxiety since the birth of her child 3 weeks ago. Pregnancy was complicated by premature labor that was managed with bed rest. Delivery occurred at term with no complications. Examination of her newborn at birth showed no abnormalities. The patient reports that he feeds well and appears healthy, but she has constant worries about his health and her own health. She adds that she has had a decreased appetite and difficulty sleeping. Her husband notes that she has been increasingly withdrawn from family and friends and that she has reported thoughts of suicide. The patient has no history of serious illness or major depressive disorder. Her only medication is a multivitamin. She appears tired. Physical examination shows no abnormalities. On mental status examination, she has an irritable mood and depressed affect. She is oriented to person, place, and time.
Which of the following is the most likely diagnosis?

• A) Adjustment disorder
• B) Bipolar disorder
• C) Generalized anxiety disorder
• D) Major depressive disorder
• E) Post-traumatic stress disorder

Answer: D) Major depressive disorder

Exam Section : Item 12 of 50
A 42-year-old man comes to the physician because of a 6-month history of sexual problems. He can achieve and maintain erections but is rarely able to ejaculate during intercourse. He has erections on awakening in the morning and nocturnal emissions approximately once monthly. He has a 2-year history of coronary artery disease well controlled with metoprolol, lisinopril, and aspirin. He and his wife of 12 years divorced 3 years ago. Over the past 6 months, he has been sexually active with two female partners, and they use condoms for contraception. Examination shows a normal-appearing penis and testes. Which of the following is the most likely explanation for this patient’s sexual dysfunction?

• A) Decreased pituitary production of gonadotropins
• B) Disruption of arterial inflow to the penis by metoprolol
• C) Obstruction at the bladder neck
• D) Performance anxiety
• E) Testicular insensitivity to testosterone

Answer: D) Performance anxiety

Exam Section : Item 13 of 50
A 77-year-old man comes to the physician at his wife’s insistence because of a 2-year history of progressive memory problems. His wife notes that he often asks questions that have been answered minutes earlier. On three occasions, he got lost while walking a few blocks from their house, and he has forgotten to turn off the burner several times when making coffee. He has been otherwise healthy.
He takes no medications. He is awake and alert. Physical examination shows no abnormalities. On questioning, he states that he has not been aware of any memory problems. His Mini-Mental State Examination score is 21/30. He recalls one of three objects after 2 minutes. An MRI of the brain shows moderate atrophy. Administration of a medication with which of the following properties is the most appropriate treatment?

• A) Anticholinergic
• B) Antidopaminergic
• C) Antiserotonergic
• D) Cholinergic
• E) Dopaminergic
• F) Serotonergic

Answer: D) Cholinergic

Exam Section : Item 14 of 50
A 32-year-old man is admitted to the hospital because of refusal to speak or move since he returned home after being robbed at gunpoint yesterday. His wife says that her husband was physically unharmed but seemed to be in acute emotional distress. He stopped talking, would not move from his chair, and began staring into space. His wife reports that he has no history of serious illness and takes no medications. The patient is sitting upright with his eyes closed. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, he is mute, does not follow commands, and resists being moved. His affect is flat. Which of the following is the most appropriate pharmacotherapy?

• A) Buspirone
• B) Dexamphetamine
• C) Haloperidol
• D) Lorazepam
• E) Sertraline

Answer: D) Lorazepam

Exam Section : Item 15 of 50

A 23-year-old man comes to the physician because of anxiety since beginning a second part-time job as a courier for a photographer 6 weeks ago. He reports a fear of heights and of riding in elevators. He takes stairs and escalators whenever possible, which prevents him from completing his deliveries on time. He has not had panic attacks. He has no history of serious illness and takes no medications. His temperature is 36.80C (98.2 OF), pulse is 80/min, respirations are 18/min, and blood pressure is 118/73 mm Hg. Physical examination shows no abnormalities. On mental status examination, he has an anxious mood and full range of affect. He reports no symptoms of depression or suicidal ideation. Which of the following is the most appropriate next step in management?

• A) Cognitive behavioral therapy
• B) Interpersonal therapy
• C) a-Adrenergic agonist therapy
• D) ß-Adrenergic blocker therapy
• E) Selective serotonin reuptake inhibitor therapy

Answer: A) Cognitive behavioral therapy

Exam Section : Item 15 of 50
A 47-year-old man is brought to the physician by his wife because of “unbearable” behavior during the past 2 weeks. His wife reports that he has been talking about his various inventions constantly and recently bought a new recreational vehicle, even though they do not travel long distances. He repeatedly tells his wife that “the time to make and enjoy money has come.” He has been openly critical of their pastor’s prayers during church services. He claims that the pastor does not know what he is talking about because “God is talking to me, not him.” His wife says that he has had episodes of similar behavior during the past 10 years that have been more tolerable. He has peptic ulcer disease treated with ranitidine and hypertension treated with triamterene. He does not smoke or drink alcohol. He is 170 cm (5 ft 7 in) tall and weighs 82 kg (180 1b); BMI is 28 kg/m2. His pulse is 80/min, and blood pressure is 150/95 mm Hg. Physical examination shows no other abnormalities. On mental status examination, he is relaxed and talkative, jumping from one topic to another. He claims that his wife does not understand him and that she has been plotting with the pastor against him. He denies any problems and says that he feels great and is capable of great things. Laboratory findings are within the reference range. Urine toxicology screening is positive for marijuana. Which of the following is the most likely diagnosis?

• A) Bipolar disorder
• B) Delusional disorder
• C) Mood disorder due to a general medical condition
• D) Schizophrenia
• E) Substance-induced mood disorder