Psychiatry

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 PSYCHIATRY
General Principles 5%−10%
Organ Systems 90%−95%
Mental Disorders 75%−85%
Mental disorders usually first diagnosed in infancy, childhood, or adolescence
Substance-related disorders
Schizophrenia and other psychotic disorders
Mood disorders
Anxiety disorders
Somatoform disorders
Other disorders/conditions
Diseases of the Nervous System and Special Senses 10%−20%

Physician Tasks
Promoting Health and Health Maintenance 1%−5%
Understanding Mechanisms of Disease 10%−15%
Establishing a Diagnosis 55%−65%
Applying Principles of Management 15%−20%

1. A 3-year-old girl is brought to the physician by her parents 2. A 45-year-old man is brought to the physician by his
because they are concerned about her behavior. They spouse. He has been drinking heavily since he was passed
describe their daughter as stubborn and always on the go. over for a job promotion 3 days ago. He stayed in bed over
She can rarely sit still for more than 10 minutes. She often the weekend. He has no personal history of psychiatric
refuses to comply with their requests and sometimes throws disorders and no personal or family history of alcohol
3- to 5-minute temper tantrums. They report that she abuse. He is crying and states, “I can’t believe it,” when
dawdles at bedtime and requires frequent direction and addressed. When asked what he will do, he states, “I don’t
assistance in preparing for bed. Her preschool teacher notes know, but if I don’t go back to work tomorrow, I’ll lose my
that she is active and talkative without being disruptive and job.” Which of the following is the most likely diagnosis?
is beginning to demonstrate more interactive play with her
peers. She generally sleeps through the night and (A) Adjustment disorder with depressed mood
occasionally wets the bed. Her appetite is good. Her first (B) Bipolar disorder
word was at the age of 11 months, and she began walking (C) Dysthymic disorder
without assistance at the age of 14 months. Physical (D) Major depressive disorder
examination shows no abnormalities. On mental status (E) Substance abuse
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% 3. A previously healthy 18-year-old woman is brought to the
intelligible, and her vocabulary is large for her age. Which physician for evaluation because of loss of appetite,
of the following is the most appropriate next step in sleeplessness, and extreme irritability for 3 weeks. After
management? missing many practices, she quit the college softball team
that she previously enjoyed. She often feels tired and has
(A) Reassurance difficulty sitting still and concentrating on schoolwork. Her
(B) Play therapy menses occur at regular intervals. She weighs 50 kg
(C) Speech therapy (110 lb) and is 168 cm (5 ft 6 in) tall; her BMI is 18 kg/m2.
(D) Enuresis alarm Her pulse is 74/min, respirations are 16/min, and blood
(E) Trial of fluoxetine pressure is 110/70 mm Hg. Which of the following is the
(F) Trial of methylphenidate most likely diagnosis?

(A) Adjustment disorder with mixed disturbance

of emotions and conduct
(B) Anorexia nervosa
(C) Attention-deficit/hyperactivity disorder
(D) Dysthymic disorder
(E) Major depressive disorder

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4. A 57-year-old man comes to the physician accompanied by 7. A 32-year-old woman is brought to the emergency
his wife because of a 2-year history of fatigue. He reports department because of fever, hallucinations, agitation, and
waking up tired nearly every morning, often with a confusion for 8 hours. She has a history of alcohol, cocaine,
headache. He naps almost every afternoon. He thinks that and benzodiazepine abuse. Her temperature is 37.8°C
the fatigue is affecting his concentration and performance (100°F), pulse is 110/min, respirations are 16/min, and
at work. His wife says that he snores frequently during the blood pressure is 150/90 mm Hg. Examination shows
night and sometimes wakes up gasping for air. She tremors and telangiectasia. The lungs are clear to
describes him as a restless sleeper. His tonsils and adenoids auscultation. There is a holosystolic murmur; the abdomen
were removed when he was a child. He has no history of is tender, and the liver edge is palpable 3 cm below the
serious illness and takes no medications. He is 178 cm (5 ft right costal margin. Rectal examination shows no
10 in) tall and weighs 115 kg (253 lb); BMI is 36 kg/m2. abnormalities. Her serum alkaline phosphatase activity is
His pulse is 86/min, and blood pressure is 164/88 mm Hg. 200 U/L, serum ALT activity is 60 U/L, and serum AST
The nasal septum is at the midline. Examination shows no activity is 90 U/L. Which of the following is the most
other abnormalities. Which of the following is the most likely cause of this condition?
likely diagnosis?
(A) Acute cocaine toxicity
(A) Chronic fatigue syndrome (B) Alcohol withdrawal
(B) Narcolepsy (C) Benzodiazepine withdrawal
(C) REM sleep behavior disorder (D) Panic disorder
(D) Restless legs syndrome (E) Schizophreniform disorder
(E) Sleep apnea

5. A 52-year-old woman whose husband died 2 months ago 8. A 10-year-old boy is brought to the physician because of
consults a physician because of headaches and feelings of increasing behavior problems in school since starting 5th
uncertainty. She describes the headaches as a band around grade 3 months ago. His teacher states that he is unable to
her head; they occur unpredictably and are not sit quietly through a classroom period and frequently
accompanied by any other symptoms. She has no history of disrupts the class and interrupts other children while they
psychiatric illness. While talking with the physician, the are talking. His parents report that he has always been an
patient begins to cry and talk about her deceased husband; active child and are concerned because he is inattentive
she feels her life is empty now and worries about her when he runs or walks. During examination, he fidgets with
future. Which of the following is most appropriate at this his hands and feet and is easily distracted from completing
point? a task. Which of the following is the most appropriate
pharmacotherapy?
(A) Allow her to express herself
(B) Prescribe an antianxiety drug (A) Amitriptyline
(C) Prescribe an antidepressant drug (B) Fluoxetine
(D) Refer her for psychological testing (C) Haloperidol
(E) Obtain a psychiatric consultation (D) Imipramine
(E) Methylphenidate
6. 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 9. A 27-year-old woman is brought to the emergency
this town and that he is homeless, so he has no money for department 1 hour after a friend found her barely arousable
food. He admits to several psychiatric hospitalizations in in her disorderly apartment with a nearly starving cat. The
the past but says that he no longer needs medication. He patient appears extremely thin. Her pulse is 90/min,
appears dirty and is malodorous. Vital signs are within respirations are 6/min, and blood pressure is 90/60 mm Hg.
normal limits. Physical examination shows no Physical examination shows small pupils, cracked lips, and
abnormalities. On mental status examination, his speech is bruises and scratches over the upper extremities. Mental
clear, but his thought process is disorganized with many status examination shows mild obtundation, blunted affect,
loose associations. At several times during the interview, and slow, incoherent speech. Which of the following is the
he appears to be preoccupied with internal stimuli. He says most appropriate next step in management?
that he hears voices having an ongoing conversation in his
head. Which of the following is the most likely diagnosis? (A) Observation in a quiet darkened room
(B) Oral administration of chlorpromazine
(A) Bipolar disorder (C) Intramuscular administration of naloxone
(B) Brief psychotic disorder (D) Intravenous administration of haloperidol
(C) Delusional disorder (E) Intravenous administration of lorazepam
(D) Major depressive disorder with psychotic
features
(E) Psychotic disorder due to a general medical
condition
(F) Schizophrenia
(G) Schizotypal personality disorder

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10. A healthy 9-year-old boy is brought to the physician by his 12. One day after admission to the hospital for agitation and
parents because they are concerned that he dislikes hallucinations, a 19-year-old man has the onset of severe
attending school. Every morning he cries and begs to stay muscle stiffness that prevents him from rising out of bed.
home. He misses school at least 1 day weekly because his At the time of admission, treatment with haloperidol was
mother is exhausted from fighting with him to attend. His begun. Today, he appears lethargic and diaphoretic. His
teachers report that he is quiet in class and rarely temperature is 39.7°C (103.5°F), pulse is 120/min, and
participates. He has difficulty reading at the level of his blood pressure is 160/110 mm Hg. Physical examination
peers and lacks confidence. At home, he tends to stay in the shows generalized severe rigidity of the upper extremities
same room as his mother and will sometimes follow her bilaterally. On mental status examination, he is not oriented
around the house. When his parents plan an evening out, he to person, place, and time. Which of the following is the
often becomes tearful and asks many questions about when most appropriate next step in management?
they will return. He likes to have friends over to his house
and appears to enjoy being with them. Physical (A) Observation only
examination shows no abnormalities. During the (B) Add fluoxetine
examination, he sits on his mother’s lap and is quiet but (C) Add lithium carbonate
cooperative. He makes brief eye contact and speaks in a (D) Discontinue haloperidol
low volume, becoming tearful when questioned about (E) Increase the dosage of haloperidol
being away from his mother. Which of the following is the
most likely diagnosis?
13. A 32-year-old woman comes to the physician because of a
(A) Dysthymic disorder 3-week history of depressed mood. She works as a local
(B) Mild mental retardation news anchor. She says that she has always had a busy
(C) Oppositional defiant disorder schedule, but lately she has not had her usual amount of
(D) Reading disorder energy and has had difficulty getting up and going to work.
(E) Separation anxiety disorder She describes herself as normally a “hyper” person with
(F) Social phobia 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
11. A 47-year-old woman is brought to the physician by her that makes her feel “slowed down.” The episodes never last
husband because of bizarre behavior for 1 week. Her more than a few weeks. She sometimes goes through
husband says that she makes no sense when she speaks and periods when she feels a surge in energy, sleeps very little,
seems to be seeing things. She also has had difficulty feels at the top of her mental powers, and is able to
sleeping for 2 months and has gained approximately 9 kg generate new ideas for the news station; these episodes
(20 lb) during the past 5 months. During this time, she has never last more than 5 days. She says that she loves feeling
been moody and easily fatigued. He also notes that the this way and wishes the episodes would last longer. She
shape of her face has become increasingly round and out of takes no medications. She does not drink alcohol or use
proportion with the rest of her body despite her weight illicit drugs. Her temperature is 37°C (98.6°F), pulse is
gain. She has no history of psychiatric or medical illness. 70/min, and blood pressure is 125/80 mm Hg. Physical
She is 160 cm (5 ft 3 in) tall and weighs 70 kg (155 lb); examination shows no abnormalities. Mental status
BMI is 28 kg/m2. Her pulse is 98/min, respirations are examination shows a depressed mood and flat affect.
8/min, and blood pressure is 148/92 mm Hg. Physical Which of the following is the most likely diagnosis?
examination shows truncal obesity and ecchymoses over
the upper and lower extremities. Neurologic examination (A) Attention-deficit/hyperactivity disorder
shows no focal findings. Mental status examination shows (B) Cyclothymic disorder
pressured speech and a disorganized thought process. There (C) Dysthymic disorder
is evidence of visual and auditory hallucinations. Urine (D) Major depressive disorder
toxicology screening is negative. Which of the following is (E) Mood disorder due to a general medical
the most likely diagnosis? condition

(A) Brief psychotic disorder

(B) Major depressive disorder with psychotic
features
(C) Psychotic disorder due to a general medical
condition
(D) Schizophrenia
(E) Schizotypal personality disorder

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14. A 77-year-old woman is brought to the emergency 17. A 42-year-old woman is brought to the physician by her
department by her husband because of agitation and husband because of persistent sadness, apathy, and
confusion for 3 hours. He states that she has been tearfulness for the past 2 months. She has a 10-year history
intermittently crying out and does not appear to recognize of systemic lupus erythematosus poorly controlled with
him. A routine health maintenance examination 3 days ago corticosteroid therapy. Physical examination shows 1-cm
showed no abnormalities except for mild memory deficits. erythematous lesions over the upper extremities and neck
Her current temperature is 37.8°C (100°F), pulse is and a malar butterfly rash. On mental status examination,
100/min, respirations are 14/min, and blood pressure is she appears depressed. She says that she would be better
130/60 mm Hg. Physical examination shows no off dead. Which of the following is the most appropriate
abnormalities except for mild tenderness to palpation of the next step in management?
lower abdomen. Mental status examination shows
confusion; she is oriented to person but not to time or (A) Ask the patient about her suicidal thoughts
place. Which of the following is the most appropriate next (B) Reassure the patient that she will get well
step in diagnosis? (C) Recommend psychiatric hospitalization
(D) Begin paroxetine therapy
(A) Determination of erythrocyte sedimentation (E) Increase the dose of corticosteroid
rate
(B) Measurement of serum alkaline phosphatase
activity 18. A 27-year-old man is brought to the emergency department
(C) Measurement of serum folate concentration by police 2 hours after threatening his next door neighbor.
(D) Urinalysis The neighbor called the police after receiving a note
(E) Western blot assay 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
15. A 14-year-old boy is brought to the physician by his has lived in the neighborhood for 8 months. Three months
mother after she found an unsmoked marijuana cigarette in ago, he noticed that his neighbor installed a new satellite
his bedroom. The mother reports that her son has never dish and says that since that time, she has been watching
done anything like this before. His academic performance every move he makes. He reports no personal or family
is excellent. When interviewed alone, the patient reports history of psychiatric illness. He has not had changes in
that his friends heard about smoking marijuana and sleep pattern and performs well in his job as a car
acquired some from their peers to find out what it was like. salesman. He appears neatly dressed. Physical examination
He adds that he has never smoked marijuana before. He shows no abnormalities. On mental status examination, his
requests that his teachers not be informed because they thought process is organized and logical. There is no
would be very disappointed if they found out. Physical evidence of suicidal or homicidal ideation or
examination shows no abnormalities. On mental status hallucinations. He says that he is not suspicious of anyone
examination, he is pleasant and cooperative and appears other than his neighbor. Which of the following is the most
remorseful. Which of the following is the most likely likely diagnosis?
diagnosis?
(A) Bipolar disorder
(A) Conduct disorder (B) Brief psychotic disorder
(B) Marijuana abuse (C) Delusional disorder
(C) Marijuana dependence (D) Major depressive disorder with psychotic
(D) Parent-child relational problem features
(E) Normal adolescence (E) Schizophrenia

16. 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?

(A) Delusional disorder

(B) Generalized anxiety disorder
(C) Hypochondriasis
(D) Panic disorder
(E) Somatization disorder

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19. A 9-year-old girl is brought to the physician by her 20. A 77-year-old man comes to the physician with his
adoptive parents because they are concerned about her daughter for a follow-up examination to learn the results of
increasing difficulty at school since she began third grade 7 neuropsychological testing performed 1 week ago for
weeks ago. Her teachers report that she is easily frustrated evaluation of a recent memory loss. Results of the testing
and has had difficulty reading and paying attention. She indicated cognitive changes consistent with early stages of
also has had increased impulsivity and more difficulty than dementia. Three weeks ago, he was diagnosed with prostate
usual making and keeping friends. Her biologic mother cancer and has shown signs of a depressed mood since
abused multiple substances before and during pregnancy, then. Twenty years ago, he required treatment in a hospital
and the patient was adopted shortly after birth. She is at the for major depressive disorder. His symptoms resolved with
20th percentile for height and 40th percentile for weight. antidepressant therapy, and he has not taken any
Examination shows a flattened nasal bridge and a long psychotropic medication for the past 15 years. The patient’s
philtrum. During the examination, she is cheerful. daughter comes into the examination room before her
Psychoeducational testing shows an IQ of 82. The most father and asks that the physician not tell her father any
likely explanation for these findings is in utero exposure to information that might be upsetting, given his vulnerability
which of the following? to depression. She says she is concerned about what the
results might be and how her father will handle them. The
(A) Alcohol patient enters the room soon after his daughter makes her
(B) Cocaine request. Which of the following is the most appropriate
(C) Ecstasy (3,4-methylenedioxymethamphetamine) initial physician statement to this patient?
(D) Heroin
(E) Marijuana (A) “Because of your history of depression, I
(F) PCP (phencyclidine) would like you to start on an antidepressant
(G) Toluene medication before we talk any further about
your neuropsychological testing.”
(B) “Before going over your test results, I’d like to
hear how you have been doing. You have
been through a difficult time.”
(C) “I would like to talk with your daughter a bit
about your test results, and then I will go
over things with you.”
(D) “Your daughter is concerned about you. I think
you need to see a psychiatrist before we go
any further here.”
(E) “Your tests were inconclusive, and I would
like to have you start on a medication to
help with your memory as a precaution.”

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 Answer Key for Psychiatry Sample Questions

(Questions 1-20)

1. A 11. C
2. A 12. D
3. E 13. B
4. E 14. D
5. A 15. E
6. F 16. D
7. B 17. A
8. E 18. C
9. C 19. A
10. E 20. B