NBME Psychiatry Test

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A 3-year-old girl is brought to the physician by her parents because they are concerned about her behavior. They describe their daughter as stubborn and always on the go. She can rarely sit still for more than 10 minutes. She often refuses to comply with their requests and sometimes throws 3- to 5-minute temper tantrums. They report that she dawdles at bedtime and requires frequent direction and assistance in preparing for bed. Her preschool teacher notes that she is active and talkative without being disruptive and is beginning to demonstrate more interactive play with her peers. She generally sleeps through the night and occasionally wets the bed. Her appetite is good. Her first word was at the age of 11 months, and she began walking without assistance at the age of 14 months. Physical examination shows no abnormalities. On mental status examination, she initially hides behind her mother but warms to the interviewer after a few minutes and begins playing with toys in the office. Her speech is 90% intelligible, and her vocabulary is large for her age. Which of the following is the most appropriate next step in management?

Correct! Wrong!

A 45-year-old man is brought to the physician by his spouse. He has been drinking heavily since he was passed over for a job promotion 3 days ago. He stayed in bed over the weekend. He has no personal history of psychiatric disorders and no personal or family history of alcohol abuse. He is crying and states, “I can’t believe it,” when addressed. When asked what he will do, he states, “I don’t know, but if I don’t go back to work tomorrow, I’ll lose my job.” Which of the following is the most likely diagnosis?

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A previously healthy 18-year-old woman is brought to the physician for evaluation because of loss of appetite, sleeplessness, and extreme irritability for 3 weeks. After missing many practices, she quit the college softball team that she previously enjoyed. She often feels tired and has difficulty sitting still and concentrating on schoolwork. Her menses occur at regular intervals. She weighs 50 kg (110 lb) and is 168 cm (5 ft 6 in) tall; her BMI is 18 kg/m2 . Her pulse is 74/min, respirations are 16/min, and blood pressure is 110/70 mm Hg. Which of the following is the most likely diagnosis?

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A 57-year-old man comes to the physician accompanied by his wife because of a 2-year history of fatigue. He reports waking up tired nearly every morning, often with a headache. He naps almost every afternoon. He thinks that the fatigue is affecting his concentration and performance at work. His wife says that he snores frequently during the night and sometimes wakes up gasping for air. She describes him as a restless sleeper. His tonsils and adenoids were removed when he was a child. He has no history of serious illness and takes no medications. He is 178 cm (5 ft 10 in) tall and weighs 115 kg (253 lb); BMI is 36 kg/m2 . His pulse is 86/min, and blood pressure is 164/88 mm Hg. The nasal septum is at the midline. Examination shows no other abnormalities. Which of the following is the most likely diagnosis?

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A 52-year-old woman whose husband died 2 months ago consults a physician because of headaches and feelings of uncertainty. She describes the headaches as a band around her head; they occur unpredictably and are not accompanied by any other symptoms. She has no history of psychiatric illness. While talking with the physician, the patient begins to cry and talk about her deceased husband; she feels her life is empty now and worries about her future. Which of the following is most appropriate at this point?

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A 47-year-old man is brought to the emergency department by police after he was found eating garbage from a dumpster behind a restaurant. He says that he just came to this town and that he is homeless, so he has no money for food. He admits to several psychiatric hospitalizations in the past but says that he no longer needs medication. He appears dirty and is malodorous. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, his speech is clear, but his thought process is disorganized with many loose associations. At several times during the interview, he appears to be preoccupied with internal stimuli. He says that he hears voices having an ongoing conversation in his head. Which of the following is the most likely diagnosis?

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A 32-year-old woman is brought to the emergency department because of fever, hallucinations, agitation, and confusion for 8 hours. She has a history of alcohol, cocaine, and benzodiazepine abuse. Her temperature is 37.8°C (100°F), pulse is 110/min, respirations are 16/min, and blood pressure is 150/90 mm Hg. Examination shows tremors and telangiectasia. The lungs are clear to auscultation. There is a holosystolic murmur; the abdomen is tender, and the liver edge is palpable 3 cm below the right costal margin. Rectal examination shows no abnormalities. Her serum alkaline phosphatase activity is 200 U/L, serum ALT activity is 60 U/L, and serum AST activity is 90 U/L. Which of the following is the most likely cause of this condition?

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A 10-year-old boy is brought to the physician because of increasing behavior problems in school since starting 5th grade 3 months ago. His teacher states that he is unable to sit quietly through a classroom period and frequently disrupts the class and interrupts other children while they are talking. His parents report that he has always been an active child and are concerned because he is inattentive when he runs or walks. During examination, he fidgets with his hands and feet and is easily distracted from completing a task. Which of the following is the most appropriate pharmacotherapy?

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A 27-year-old woman is brought to the emergency department 1 hour after a friend found her barely arousable in her disorderly apartment with a nearly starving cat. The patient appears extremely thin. Her pulse is 90/min, respirations are 6/min, and blood pressure is 90/60 mm Hg. Physical examination shows small pupils, cracked lips, and bruises and scratches over the upper extremities. Mental status examination shows mild obtundation, blunted affect, and slow, incoherent speech. Which of the following is the most appropriate next step in management?

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A healthy 9-year-old boy is brought to the physician by his parents because they are concerned that he dislikes attending school. Every morning he cries and begs to stay home. He misses school at least 1 day weekly because his mother is exhausted from fighting with him to attend. His teachers report that he is quiet in class and rarely participates. He has difficulty reading at the level of his peers and lacks confidence. At home, he tends to stay in the same room as his mother and will sometimes follow her around the house. When his parents plan an evening out, he often becomes tearful and asks many questions about when they will return. He likes to have friends over to his house and appears to enjoy being with them. Physical examination shows no abnormalities. During the examination, he sits on his mother’s lap and is quiet but cooperative. He makes brief eye contact and speaks in a low volume, becoming tearful when questioned about being away from his mother. Which of the following is the most likely diagnosis?

Correct! Wrong!

A 47-year-old woman is brought to the physician by her husband because of bizarre behavior for 1 week. Her husband says that she makes no sense when she speaks and seems to be seeing things. She also has had difficulty sleeping for 2 months and has gained approximately 9 kg (20 lb) during the past 5 months. During this time, she has been moody and easily fatigued. He also notes that the shape of her face has become increasingly round and out of proportion with the rest of her body despite her weight gain. She has no history of psychiatric or medical illness. She is 160 cm (5 ft 3 in) tall and weighs 70 kg (155 lb); BMI is 28 kg/m2 . Her pulse is 98/min, respirations are 8/min, and blood pressure is 148/92 mm Hg. Physical examination shows truncal obesity and ecchymoses over the upper and lower extremities. Neurologic examination shows no focal findings. Mental status examination shows pressured speech and a disorganized thought process. There is evidence of visual and auditory hallucinations. Urine toxicology screening is negative. Which of the following is the most likely diagnosis?

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One day after admission to the hospital for agitation and hallucinations, a 19-year-old man has the onset of severe muscle stiffness that prevents him from rising out of bed. At the time of admission, treatment with haloperidol was begun. Today, he appears lethargic and diaphoretic. His temperature is 39.7°C (103.5°F), pulse is 120/min, and blood pressure is 160/110 mm Hg. Physical examination shows generalized severe rigidity of the upper extremities bilaterally. On mental status examination, he is not oriented to person, place, and time. Which of the following is the most appropriate next step in management?

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A 32-year-old woman comes to the physician because of a 3-week history of depressed mood. She works as a local news anchor. She says that she has always had a busy schedule, but lately she has not had her usual amount of energy and has had difficulty getting up and going to work. She describes herself as normally a “hyper” person with energy to perform multiple tasks. During the past 10 years, she has had similar episodes in which she has had depressed mood associated with a decreased energy level that makes her feel “slowed down.” The episodes never last more than a few weeks. She sometimes goes through periods when she feels a surge in energy, sleeps very little, feels at the top of her mental powers, and is able to generate new ideas for the news station; these episodes never last more than 5 days. She says that she loves feeling this way and wishes the episodes would last longer. She takes no medications. She does not drink alcohol or use illicit drugs. Her temperature is 37°C (98.6°F), pulse is 70/min, and blood pressure is 125/80 mm Hg. Physical examination shows no abnormalities. Mental status examination shows a depressed mood and flat affect. Which of the following is the most likely diagnosis?

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A 77-year-old woman is brought to the emergency department by her husband because of agitation and confusion for 3 hours. He states that she has been intermittently crying out and does not appear to recognize him. A routine health maintenance examination 3 days ago showed no abnormalities except for mild memory deficits. Her current temperature is 37.8°C (100°F), pulse is 100/min, respirations are 14/min, and blood pressure is 130/60 mm Hg. Physical examination shows no abnormalities except for mild tenderness to palpation of the lower abdomen. Mental status examination shows confusion; she is oriented to person but not to time or place. Which of the following is the most appropriate next step in diagnosis?

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A 14-year-old boy is brought to the physician by his mother after she found an unsmoked marijuana cigarette in his bedroom. The mother reports that her son has never done anything like this before. His academic performance is excellent. When interviewed alone, the patient reports that his friends heard about smoking marijuana and acquired some from their peers to find out what it was like. He adds that he has never smoked marijuana before. He requests that his teachers not be informed because they would be very disappointed if they found out. Physical examination shows no abnormalities. On mental status examination, he is pleasant and cooperative and appears remorseful. Which of the following is the most likely diagnosis?

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An otherwise healthy 27-year-old man is referred to a cardiologist because of three episodes of severe palpitations, dull chest discomfort, and a choking sensation. The episodes occur suddenly and are associated with nausea, faintness, trembling, sweating, and tingling in the extremities; he feels as if he is dying. Within a few hours of each episode, physical examination and laboratory tests show no abnormalities. He does not abuse drugs or alcohol and has no history of interpersonal problems. Which of the following is the most likely diagnosis?

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A 42-year-old woman is brought to the physician by her husband because of persistent sadness, apathy, and tearfulness for the past 2 months. She has a 10-year history of systemic lupus erythematosus poorly controlled with corticosteroid therapy. Physical examination shows 1-cm erythematous lesions over the upper extremities and neck and a malar butterfly rash. On mental status examination, she appears depressed. She says that she would be better off dead. Which of the following is the most appropriate next step in management?

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A 27-year-old man is brought to the emergency department by police 2 hours after threatening his next door neighbor. The neighbor called the police after receiving a note demanding that she stop videotaping all of the activities in the patient’s home or he would call the police. During the examination, the patient is cooperative. He explains that he has lived in the neighborhood for 8 months. Three months ago, he noticed that his neighbor installed a new satellite dish and says that since that time, she has been watching every move he makes. He reports no personal or family history of psychiatric illness. He has not had changes in sleep pattern and performs well in his job as a car salesman. He appears neatly dressed. Physical examination shows no abnormalities. On mental status examination, his thought process is organized and logical. There is no evidence of suicidal or homicidal ideation or hallucinations. He says that he is not suspicious of anyone other than his neighbor. Which of the following is the most likely diagnosis?

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A 9-year-old girl is brought to the physician by her adoptive parents because they are concerned about her increasing difficulty at school since she began third grade 7 weeks ago. Her teachers report that she is easily frustrated and has had difficulty reading and paying attention. She also has had increased impulsivity and more difficulty than usual making and keeping friends. Her biologic mother abused multiple substances before and during pregnancy, and the patient was adopted shortly after birth. She is at the 20th percentile for height and 40th percentile for weight. Examination shows a flattened nasal bridge and a long philtrum. During the examination, she is cheerful. Psychoeducational testing shows an IQ of 82. The most likely explanation for these findings is in utero exposure to which of the following?

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77-year-old man comes to the physician with his daughter for a follow-up examination to learn the results of neuropsychological testing performed 1 week ago for evaluation of a recent memory loss. Results of the testing indicated cognitive changes consistent with early stages of dementia. Three weeks ago, he was diagnosed with prostate cancer and has shown signs of a depressed mood since then. Twenty years ago, he required treatment in a hospital for major depressive disorder. His symptoms resolved with antidepressant therapy, and he has not taken any psychotropic medication for the past 15 years. The patient’s daughter comes into the examination room before her father and asks that the physician not tell her father any information that might be upsetting, given his vulnerability to depression. She says she is concerned about what the results might be and how her father will handle them. The patient enters the room soon after his daughter makes her request. Which of the following is the most appropriate initial physician statement to this patient?

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