BH Study Guide.pdf

1. For a patient who overdosed on a tricyclic antidepressant, which of the following is the most appropriate initial diagnostic study? a. Urine toxicology screen b. Electrocardiography c. Electroencephalography d. TSH e. CBC 2. Which of the following meds is most likely to be used to diminish compulsive behaviors identified in patients with exhibitionistic disorder? a. Fluoxetine (Prozac) b. Trazadone (Desyrel) c. Lithium (Lithobid) d. Valproic acid (depakote) 3. Which of the following is a risk factor for attention-deficit/hyperactivity disorder? a. Obesity b. Lead exposure c. Secondhand smoke exposure after birth d. Birth order 4. Which of the following is recommended as an adjunct to the pharmacologic treatment for a patient with a diagnosis of GAD? a. Increased caffeine intake b. Mindfulness meditation c. Acupuncture d. Riboflavin supplementation 5. A 28-year-old woman comes to the office due to difficulty sleeping and recurrent nightmares after she was attacked by a dog 3 months ago. She has difficulty concentrating at work and avoids areas where she may come into contact with dogs. Which of the following is the most likely diagnosis? a. Panic disorder b. Adjustment disorder c. Agoraphobia d. GAD e. PTSD 6. More than half of all patients with a depressive disorder have an increase in levels of which of the following chemical mediators? a. Dopamine b. Serotonin c. Cortisol d. Norepinephrine 7. Which of the following is a risk factor for the development of an anxiety disorder? a. Poor school performance b. History of childhood abuse c. High SES d. Older age e. Male gender 8. Which of the following meds has the greatest risk of fetal abnormalities when used during pregnancy? a. Aripiprazole (abilify) b. Lithium (lithobid) c. Levetiracetam (keppra) d. Fluphenazine (prolixin) 9. A 22 yo woman comes to the office for evaluation. She states that she exercises frequently and eats only one meal a day because she is concerned about gaining weight. The patient reports that in addition to her weight, she worries about losing her job and her husband having an affair, though she has no evidence to support those concerns. Height is 167.64cm (66in) and weight is 45.36 kg (100 lb). On examination she appears to be tense, often wringing her hands as she speaks. This patient is at risk for which of the following comorbid conditions? a. Borderline personality disorder b. Body dysmorphic disorder c. GAD d. Social anxiety disorder 10. A 22 yo college student comes to the office reporting persistent sadness, decreased appetite, the inability to sleep, and difficulty concentrating on her coursework. The symptoms began 3 months ago when her boyfriend of 1 year broke off their relationship. She denies having these types of symptoms in the past. Which of the following is the most appropriate intervention? a. Referral to the eating disorders clinic b. Consumption of energy drinks c. Zolpidem (ambien) d. CBT 11. A 5 yo boy is brought to the clinic by his parents for treatment of behavioral problems at school and at home. Symptoms include pervasive hyperactivity, impulsivity, and inattention. He has no other medical problems and does not take any medications. Which of the following interventions should be recommended to the parents for management of their child’s condition? a. Disciplinary action in public for misbehavior b. Charts and checklists to remember tasks c. Frequent changes in the daily schedule d. Essential fatty acid supplementation 12. Which of the following statements is most characteristic of persons with tobacco use disorder? a. Cigarette smoking enhances nicotine delivery to the brain with levels peaking within 20 seconds of inhalation b. The average cigarette smoker takes in 3 to 5 mg of nicotine per cigarette c. More than 85% of smokers who try and quit smoking on their own relapse d. Nicotine activates the brain’s reward centers, increasing serotonin levels 13. Which of the following neurotransmitters is most involved in the etiology of anxiety disorders? a. Acetylcholine b. Histamine c. Serotonin d. Glycine 14. Which of the following is recommended for the treatment of a patient with antisocial personality disorder with no comorbidities? a. Typical antipsychotic b. No medication c. Mood stabilizer d. Atypical antipsychotic e. SSRI 15. A 12 yo boy is brought to the ED by his mother. The mother states that her son is becoming aggressive, acting irritated, and having angry outbursts. On many occasions, the child has kicked the family dog. He has also started fires at home for no reason. Which of the following is most likely contributory for this patient’s condition? a. Obesity b. Genetic predisposition c. High SES d. Illicit drug use 16. Which of the following physical examination findings is expected for a patient who has a history of alcohol use disorder? a. Alopecia, ptosis, and decreased hearing b. Neuropathy, hepatosplenomegaly, and rhinophyma c. Miosis, bradypnea, and spider angioma d. CVA tenderness, Murphy sign, and decreased bowel sounds e. Clubbing, splinter hemorrhages, and coarse skin 17. A 8 yo boy is brought to the office by his mother for evaluation of disruptive behavior that has worsened over the past year. His PMH is negative. His developmental milestones are normal and his current academic performance is average for his age. Which of the following diagnostic studies is indicated in the initial evaluation for ADHD? a. CBC b. MRI c. Evaluate for learning disorder d. Electroencephalography 18. A 22 yo woman is brought to the clinic by her mother for evaluation of unusual behavior. She has been making dozens of phone calls in the middle of the night to friends and family and boasting of her plans to bring peace to the Middle East. She spent several hundred dollars during a recent shopping spree. During the interview, she is difficult to interrupt when speaking. Which of the following is the most likely diagnosis? a. Bipolar I disorder b. OCD c. Schizophrenia d. Narcissistic personality disorder 19. A 49 yo woman comes to the office with difficulty making routine daily decisions without reassurance. She also experiences hopelessness, and has difficulty expressing herself due to fear of being ridiculed. Which of the following personality disorders is the most likely diagnosis? a. Dependent personality disorder b. Antisocial personality disorder c. Avoidant personality disorder d. Paranoid personality disorder 20. A 17 yo boy is brought to the office by his mother who reports that his academic performance has declined and he has lost interest in previously enjoyed baseball and music. When interviewed alone, the boy admits to marijuana use for 4 years, with daily use for the past 3 months. When trying to stop using, he has bad dreams and feels jittery. Which of the following is the most appropriate next step in management of this patient? a. Inform mother and monitor patient b. Inpatient treatment c. Pharmacologic treatment d. Counseling and behavioral interventions 21. A 28 yo woman comes to the office for a f/u visit. She has had abdominal pain for over a year and worries that she has cancer. Previous workup has been negative. Height is 160 cm (63 in), weight is 59 kg (130 lb), and BMI is 23 kg/m2. Temperature is 36.7 C (98 F), pulse rate is 78/min and regular, respirations are 12/min and unlabored, and BP is 110/60 mmHg. Physical exam reveals an anxious patient, but otherwise shows no abnormalities. Which of the following is most likely to be present in this patient’s history? a. Self-harming behavior b. Eating disorder c. Childhood trauma d. Multiple sexual partners 22. A woman comes to the office for evaluation of depressed mood, suicidality, anhedonia, and hypersomnia for one month. She has a 3-year history of psychosis. Which of the following is the most likely diagnosis? a. Schizotypical disorder b. Brief psychotic disorder c. Acute mania with psychotic features d. Schizoaffective disorder e. Borderline personality disorder 23. Which of the following is most likely found in the history of a high school patient with anorexia nervosa? a. Male gender b. Unwanted facial hair c. Competitive gymnastics d. Metromenorrhagia 24. A 30 yo man comes to the Inpatient Psychiatric Unit for evaluation after being involuntarily admitted through the ED. He was arrested for a physical altercation, stealing a car, and using an unregistered firearm. He has a history of multiple incarcerations since age 15 and an inability to conform to societal norms. Which of the following diagnostic studies is most useful in assessing for comorbid disorders? a. Thyroid antibodies b. Cortisol level c. Random drug screens d. Heavy metal screen 25. A 12 yo boy is brought by his parents for evaluation after he was suspended from school for frequent bullying, fighting, and destruction of school property. They also report that at home he has been hostile, verbally abusive, and caught lying several times. Which of the following is the most likely diagnosis? a. ADHD b. Conduct disorder c. Bipolar I disorder d. Oppositional defiant disorder 26. Which of the following medications is the treatment of choice for a patient with an initial presentation of hypomania? a. Lithium b. Fluoxetine c. Alprazolam d. Clonidine 27. A 22 yo man is brought to the clinic due to an acute onset of restlessness and bizarre behavior as described by his father. His symptoms began early that morning and have progressed. The patient paces back and forth and is unable to sit for more than a few seconds. He has a history of unemployment and use of multiple drugs. Temperature is 39.4 C (103 F), pulse rate is 112/min, respirations are 26/min, and BP is 180/100 mmHg. He is diaphoretic, has dilated pupils, and is disoriented in all 3 spheres. Which of the following is the most likely cause of his signs and symptoms? a. Alcohol intoxication b. Marijuana intoxication c. Heroin overdose d. Opioid withdrawal e. Amphetamine intoxication 28. A patient comes to the clinic with a stiff and painful neck after recently starting haloperidol (Haldol) for psychotic symptoms. On physical examination, he appears distressed, with a protruding tongue. His neck and jaw muscles are contracted to one side. Which of the following is the most appropriate intervention for this patient? a. Diphenhydramine (benadryl) orally b. Ketorolac (toradol) intramuscularly c. Olanzapine orally d. Benztropine intramuscularly e. Clozapine intramuscularly 29. A 28 yo woman comes to the clinic to discuss chronic abdominal pain, headaches, left knee pain, and dizziness. She has seen multiple physicians over the past 4 years and feels frustrated that none have helped her, despite various laboratory and imaging studies. In addition to psychotherapy, which of the following medications may benefit this patient? a. Gabapentin b. Topiramate c. Midazolam d. Fluoxetine e. Risperidone 30. A 16 yo girl seeks evaluation for fever, abdominal pain, and nausea. She reports vomiting and blood-tinged diarrhea for several days. Vital signs are within normal limits. Physical examination reveals several well-healed scars on the abdomen. Rectal examination and guaiac test are negative. Previous records show several office visits with no significant physical findings and normal laboratory results. Which of the following is the most appropriate pharmacologic treatment for this patient? a. Antipsychotics b. No pharmacologic therapy c. Anxiolytics d. Antidepressants 31. A 23 yo man is brought to the clinic by his girlfriend who is concerned about his behavior. His graduate-school grades and self care have declined during the last month. She suspects he is hearing voices because he frequently talks to himself. He recently began refusing meals because he thinks they are poisoned. What is the most likely diagnosis? a. Schizophrenia b. Schizoid personality disorder c. Schizophreniform disorder d. Schizoaffective disorder 32. A 60 yo man is hospitalized for evaluation of headache, palpitations, and agitation. He has a 30 yr history of heavy alcohol use. Pulse rate is 130/min, respirations are 28/min, and BP is 190/92 mmHg. Physical examination shows a flushed, anxious, and diaphoretic man in moderate distress. Hands are tremulous. Remainder of physical examination is within normal limits. Which of the following medications is most appropriate for treating the patient? a. Alprazolam b. Clonazepam c. Naloxone d. Lorazepam 33. Which of the following should be included in patient education regarding atypical antipsychotics? a. Monitor weight b. Undergo routine thyroid screening c. Schedule screening colonoscopy d. Avoid tyramine-containing foods 34. A 19 yo woman is brought to the college health center by her roommate. The patient has not left her room in 2 days for fear of being killed. She was notified 2 weeks ago that her sister died in a MVA. Physical exam shows waxy flexibility, no eye contact, and verbal preservation. Which of the following is the most likely diagnosis? a. Agoraphobia b. Schizophrenia c. Brief psychotic disorder d. PTSD 35. Which of the following diagnostic tests is indicated to evaluate a patient with symptoms of an undiagnosed anxiety disorder? a. Urinalysis b. Liver function c. Serum cortisol d. TSH 36. Functional neurologic symptoms of vision loss, paralysis, seizures, or abnormal movements are most consistent with which of the following? a. Malingering b. Illness anxiety disorder c. Body dysmorphic disorder d. Conversion disorder (functional neurological symptoms disorder) 37. A 28 yo man comes to the urgent care center because of increased agitation, restlessness, irritability, and palpitations for the past 4 hours. The symptoms started after he consumed an energy drink to keep him alert during an 8 hr drive. Temperature is 36.7 (98 F), pulse rate is 124/min, and respirations are 24/min. He is anxious, unkempt, and his skin is diaphoretic. He is cooperative but agitated, and demands a prescription medication so he can continue to drive the remainder of the trip. Which of the following is the most appropriate initial diagnostic study? a. Urine for vanillylmandelic acid b. CBC c. TSH d. Urine toxicology e. Serum electrolytes 38. Which of the following neurotransmitters is associated with positive symptoms in patients with a diagnosis of schizophrenia? a. Gamma-aminobutyric acid b. Serotonin c. Dopamine d. Norepinephrine 39. A 16 year old girl is brought to the clinic by her father for evaluation of weight loss. The father states the patient exercises 4 hours a day and barely eats anything except salads. The patient’s body mass index is 16 kg/m2 and she states that she is fat. Her symptoms began a year ago when she says that some boys teased her about her weight. She likes to cook food for her family, but often sweeps her own meal into a napkin when no one is looking. She plans to try out for the varsity track team and claims that only “thin girls” make the team. There is no history of purging. Laboratory results are shown. What is the most likely diagnosis? a. Body dysmorphic disorder b. Adjustment disorder with depressed mood c. Bulimia nervosa d. Anorexia nervosa restricting type 40. The leading hypothesis for the etiology of schizophrenia focuses on which of the following physiological processes? a. Coagulation disorders resulting in brain micro embolisms b. Exposure to viruses in utero c. Gastrointestinal malabsorption d. Excess or deficiency of specific neurotransmitters e. Thyroid dysfunction 41. An increase in which of the following neurotransmitters has been implicated in the etiology of manic disorders? a. Glutamate b. Gamma-aminobutyric acid c. Oxytocin d. Substance P 42. In a patient with obsessive-compulsive personality disorder, which of the following is most likely to be revealed as part of the patient’s history? a. Lack of empathy b. Difficulty delegating tasks c. Inflated self-esteem d. Hypersensitivity to criticism 43. Which of the following laboratory studies is most appropriate to order when evaluating a patient with depression? a. ESR b. Serum B12 and folate c. Fasting glucose d. CMP e. TSH 44. A 25 yo woman returns to the ED with a 2 month history of believing she is pregnant despite negative pregnancy tests and ultrasounds. She is still functioning appropriately but has had a significant amount of stress lately. Her medical workup is negative. What is the most likely diagnosis? a. Borderline personality disorder b. Schizophrenia c. Bipolar disorder d. Delusional disorder 45. Children with separation anxiety disorder are at increased risk for which of the following? a. Oppositional defiant disorder b. Social anxiety disorder c. Histrionic personality disorder d. Bipolar I disorder 46. Which of the following disorders is characterized by a history of sexual pleasure occurring as a result of physical or mental abuse to self? a. Sexual masochism disorder b. Exhibitionistic disorder c. Sexual sadism disorder d. Voyeuristic disorder e. Fetishistic disorder 47. Which of the following is a risk factor for the development of ADHD? a. Positive family history b. High-sugar diet c. Advanced maternal age d. Female gender 48. During the active phase of schizophrenia, first-line medications are used to reduce which of the following symptoms? a. Loss of appetite, insomnia, tardive dyskinesia b. Anhedonia, flat affect, alogia, avolition, social withdrawal c. Suicidal and homicidal ideation, disordered cognition, impulsivity d. Hallucinations, delusions, disorganized speech, agitation 49. Which of the following parental recommendations has been found to reduce the risk of feeding or eating disorders for high-risk individuals? a. Monitor and direct peer group selection b. Limit media with inappropriate body images c. Maintain family meals including breakfast d. Closely monitor the child’s weight 50. An 8 yo old boy is brought to the office for evaluation at his teacher’s request because of difficulty at school. The child is easily distracted and will not sit still in class. His teacher last year noted similar symptoms; however, his grades are now being impacted. Which of the following is likely on history of this patient? a. Avoids completing math homework at home b. Quiet in school c. Enjoys building complex Lego sets d. Completes chores at home 51. What is the expected disease course for a 32 yo man diagnosed with bipolar II disorder? a. Diagnosis reversion to depressive disorder b. Complete remission of bipolar disorder c. Loss of short-term memory d. More frequent depression episodes e. Episode of increased severity of mania 52. A 37 yo man is evaluated for occasional palpitations, agitation, and a depressed mood that started recently. He reports that his wife filed for divorce 2 months ago and he did not receive an expected promotion at work. He has no history of psychiatric illness and says that he knows he will eventually feel better. He is particularly concerned, however, because he feels that his work has suffered due to his depression and agitation. Which of the following is the most likely diagnosis? a. GAD b. MDD c. Cyclothymic disorder d. Adjustment disorder 53. Which of the following is the most appropriate initial intervention for a patient with a disorder characterized by a paralyzing fear of being embarrassed by one’s actions in social situations? a. Exposure therapy b. Benzodiazepines c. SNRI d. CBT 54. A 40 yo woman comes to the office for a routine physical examination. Social history is significant for intense, unstable relationships and an inability to maintain a full-time job despite a graduate education. She has seen a therapist biweekly for the past 10 years, but still experiences feelings of emptiness. Two suicide attempts in the same time frame resulted in hospitalization. The patient most likely has a history of which of the following? a. Recurrent nightmares b. Substance use c. Repetitive hand washing d. Fear of closed spaces 55. A patient with bulimia nervosa is at risk of developing which of the following complications? a. Crohn disease b. Seizure disorder c. Hypertension d. Diabetes mellitus 56. A 56 yo man comes to the ED with concerns that his heart is racing and he cannot sleep. Physical examination is significant for anxious and diaphoretic appearance, tachycardia, tremor, and hyperreflexia. When questioned about substance use disorder he says he has not had “anything in a day or 2.” While waiting to be admitted he experiences tonic-clonic seizure activity. He is likely experiencing withdrawal from which of the following substances? a. Stimulants b. Opioids c. Benzodiazepines d. Alcohol 57. A 40 yo woman presents for an evaluation at the request of her mother. Her mother is concerned because the patient insists that she can read other people’s minds. The patient lives alone and only keeps in contact with her mother. Her appearance is disheveled and she is wearing multiple pairs of earrings on each ear, and several rings on each finger of both hands. While you are interviewing her, she makes several attempts to try to tell you what you are thinking about. What type of medication may benefit this patient? a. TCAs b. SSRIs c. Anxiolytic d. Antipsychotic e. MAOI 58. A 48 yo woman is seen by her primary care clinician for increasing restlessness, agitation, disturbed sleep, and weight loss during the past year. She was diagnosed with generalized anxiety disorder in an urgent care clinic 2 months ago, and prescribed a trial of fluoxetine (Prozac) without improvement in her symptoms. Physical examination reveals mild tachycardia, fine tremor, and a 3.6 kg (8 lb) weight loss since her physical one year ago. Which of the following diagnostic studies is most beneficial for evaluating an alternate source for her anxiety? a. Antinuclear antibodies b. CBC with differential c. TSH d. CMP e. FSH 59. A 34 yo woman comes to the clinic for evaluation of a new onset of blurred vision and numbness of her right hand in the setting of chronic fatigue and weakness. She had an episode of tongue numbness and increased nocturia 4 months ago, and has a history of somatic symptom disorder. The patient has has extensive workups in the past that showed no abnormalities. Physical examination shows visual acuity decreased from baseline and a decreased sensitivity to painful stimuli over the skin of the right hand. Which of the following is the most appropriate diagnostic study for this patient? a. MRI of the brain b. CSF analysis c. Urine toxicology screen d. Lyme panel 60. A 50 yo woman who is a widow comes to the office with the belief that she has cancer despite multiple medical evaluations that have been within normal limits. She unintentionally lost 15 lb in the last 6 months, is unable to find pleasure in anything in her life, and is too fatigued to do daily housework. Which of the following is the most likely diagnosis? a. Illness anxiety disorder b. Factitious disorder c. Conversion disorder d. MDD 61. Which of the following treatments is most effective for the secondary prevention of drug use in high-risk adolescents? a. Rehabilitation efforts that include physical exercise b. Prescription of psychotherapeutic medications c. Nondirective counseling with a 12 month outpatient program d. Motivational interviewing within a harm-reduction setting 62. A 28 yo man is brought to the clinic by his wife for treatment of his hands, which appear to be irritated, red, and raw. The patient’s wife reports that he washes his hands at least 20 times/day for more than 10 minutes each time, and that their marriage is suffering due to his preoccupation with cleanliness. He acknowledges that his thoughts about contamination are unwanted and that he washes his hands when these thoughts occur to lessen his distress. He has requested disability from his work because of fear of being contaminated by other people’s germs. He has no scars on his hands, arms, or face. Which of the following is the most likely diagnosis for this patient? a. Body dysmorphic disorder b. Delusional disorder c. Obsessive-compulsive personality disorder d. OCD e. Excorations (skin-picking) disorder 63. A 37 yo woman comes to the ED with hallucinations. The patient has associated dry mouth, tachycardia, and urinary retention. Examination reveals dilated pupils and photophobia. Which of the following is the most likely diagnosis? a. Amphetamine withdrawal b. Alcohol withdrawal c. Cannabis intoxication d. Anticholinergic intoxication 64. A 21 yo man seeks evaluation for a 1 week history of elevated mood, grandiose thinking, and decreased need for sleep. Which of the following is most likely to be observed on this patient’s mental status examination? a. Blunted affect b. Pressured speech c. Depressed mood d. Paranoid delusions e. Thought blocking 65. Which of the following symptoms is most likely to be present in a patient who is in the withdrawal phase after heavy cocaine use? a. Anorexia b. Dysphoria c. Impaired cognition d. Altered time perception 66. A 16 yo boy is brought to the office by his parents after being caught at a party smoking marijuana. He admits to frequent use most days of the week. Which of the following elements in his history would suggest his use may be an attempt to self-medicate? a. Increased creativity with use b. Feeling more normal with use c. Social rejection if not using d. Desire to lose weight 67. Which of the following is the most appropriate initial intervention for a patient with acrophobia? a. Eye movement desensitization therapy b. Psychodynamic therapy c. Dialectical behavior therapy d. Exposure therapy 68. A 16 yo girl is assessed at an annual physical. The patient reports difficulty getting out of bed to go to school for the past few weeks. She admits irritability, difficulty concentrating on school work, fatigue, and increased appetite. She has talked to a school counselor about these concerns over the past year; however, she feels that these issues have worsened. In addition to psychotherapy, which of the following pharmaceutical therapies is most appropriate? a. Fluoxetine b. Bupropion c. Amitriptyline d. Imipramine 69. A 45 yo woman comes to the office to be evaluated for fatigue, insomnia, loss of interest in her usual activities, and feelings of hopelessness. History is positive for narcissistic personality disorder. Which of the following medications is most likely to be helpful at this time? a. Citalopram b. Risperidone c. Zolpidem (ambien) d. Valproic acid 70. A patient with a 3 year history of schizophrenia still experiences symptoms after several medication trials. Clozapine is prescribed. Which of the following laboratory tests should be routinely monitored in this patient? a. TSH b. CBC c. Cholesterol panel d. Chemistry panel 71. A 39 yo woman is evaluated for acute loss of consciousness following a drug overdose. Tempature is 36.7 C (98 F), pulse rate is 56/min and regular, respirations are 8/min and unlabored, and BP is 98/62 mmHg. Her pupils are 1 mm bilaterally. Physical examination reveals no other abnormalities. Intoxication with which of the following substances is the most likely? a. Cannabinoids b. Amphetamines c. Barbituates d. Ethanol e. Opioids 72. A 20 yo woman comes to the office with her boyfriend to discuss her weight. Her boyfriend is concerned that she has lost 20 lb over the last 6 months. The patient insists she needed to lose the weight and wants to lose at least 5 lb more. Height is 65 in, weight 96 lb, and BMI is 16 kg/m2. Temperature is 96.6 F, pulse rate is 54/min and regular, respirations are 20/min and unlabored, and BP is 84/60 mmHg. For which of the following is the patient at increased risk when starting on the first-line medication? a. Hypokalemia b. Suicidal thoughts c. Prolonged QT interval d. Seizures 73. A 20 yo man is brought to the clinic by his mother for evaluation of bizarre behaviors that began 8 months ago. He is often found talking to himself. When his mother questions this, he becomes defensive stating he is talking to his dead grandfather. He no longer attends social functions because he feels people are talking about him and tracking his whereabouts. He is an accounting major at a local university and was previously doing well, but his grades this semester have dropped considerably, which of the following is the most likely diagnosis? a. Delusional disorder b. Paranoid personality disorder c. Bipolar I disorder d. Schizophrenia 74. A 29 yo woman is being evaluated for an 8 month history of abdominal pain. She states that the pain is getting worse and that she is persistently worried about the pain. She rarely leaves her house because of it. She was raised in an orphanage, so family history is not obtainable. She has been seen by 6 other clinicians, and a diagnosis for her pain was never made. Which of the following is the most likely diagnosis? a. GAD b. Illness anxiety disorder c. Persistent depressive disorder d. Somatic symptom disorder 75. Which of the following limits the use of benzodiazepines in panic disorder? a. Anticholinergic side effects b. Dependence c. Serotonin syndrome d. Weight gain 76. A 35 yo man is evaluated for constant lower back pain after falling at work. He states the pain has prevented him from working since he fell 3 months ago. He consulted another clinician approximately 1 month ago, who found no physical abnormalities. He insists on treatment but refuses any diagnostic tests. Which of the following is the best next step in management? a. Neurological consult b. Individual psychotherapy c. Opioids d. Direct conversation 77. A 23 yo woman comes to the clinic with her boyfriend. He is concerned by her recent eating habits. The patient is noted to consume large amounts of food at times, frequently ice cream and cake. She is then noted to be vomiting a short time later. The patient states that she just thinks she is “lactose intolerant.” Which of the following is the most likely diagnosis? a. Anorexia nervosa b. Bulimia nervosa c. Binge-eating disorder d. Body dysmorphic disorder 78. The most pronounced long-term deleterious effects on neurocognition in adolescents has been associated with the use of which of the following substances? a. Opioids b. Alcohol c. Tobacco d. Stimulants e. Marijuana 79. A patient with schizophrenia states that, when he is watching the weather report on television and the forecast calls for significant rainfall, there is a message within the report meant only for him that says he must build an ark to save humankind. Which of the following best describes this patient’s symptoms? a. Tangentiality b. Auditory hallucinations c. Ideas of reference d. Loose associations e. Visual hallucinations 80. A 58 yo man comes to the office with his wife for headaches and dizziness over the past month. He previously was very laid back but recently has become irrational and aggressive. He is no longer interested in his hobbies and has been sleeping more than usual. Which of the following diagnostic studies is most likely to reveal the cause of his symptoms? a. MRI of the brain b. ESR c. Electroencephalogram d. BMP 81. Which of the following is required to meet diagnostic criteria for ADHD? a. Medical history of CNS injury b. Inappropriate behavior confined to the social situations in school c. Onset of symptoms before age 12 years d. Symptoms for at least 12 months e. Hyperactivity must be accompanied by inattentiveness 82. Pharmacotherapy is most effective for decreasing the symptomatology of illness anxiety disorder in which of the following settings? a. Comorbid diagnosis of a depressive disorder b. Behavioral stability c. Older age at time of diagnosis d. Ineffective group therapy 83. A patient taking which of the following medications requires monitoring of renal function? a. Lithium b. Valproic acid c. Lamotrigine d. Fluphenazine 84. A 26 yo graduate student comes to the office with a headache and difficulty sleeping. She has spent the past 10 months researching and writing her doctoral thesis. Prior to that she had “done just fine” during the 24 months of classes. Now she feels as though she worries about everything, and has not been able to concentrate enough to complete any work over the last few weeks. Which of the following physical examination findings would be consistent with her most likely diagnosis? a. Urticaria b. Amnesia c. Tics d. Tachycardia 85. A 29 yo woman comes to the office because of a 4 month history of feeling fatigued, spontaneous tearfulness, a depressed mood, and increased irritability. The symptoms have persisted and she denies having more than one to two days when the symptoms were not present. She denies ever having these symptoms in the past. Which of the following additional symptoms is this patient most likely to have? a. Diminished ability to concentrate b. Exaggerated startle response c. Inability to recall autobiographical information d. Preoccupation with acquiring a serious illness 86. A comprehensive diagnostic evaluation for autism spectrum disorder in a 4 yo boy must include which of the following assessments? a. Serum lead level b. Montreal Cognitive Assessment c. Electroencephalogram d. Hearing and vision 87. A 17 yo girl comes to the office weighing 5 lb less than her last visit 1 month ago. She has a history of anorexia nervosa. BMI is 15 kg/m. Temperature is 96.8F, pulse rate is 40/min, and BP is 88/60 mmHg. What is the most appropriate intervention for this patient? a. Begin paroxetine b. Admission to the hospital c. Referral to a psychiatrist d. Referral to a nutritionist 88. Which of the following shares susceptibility genes and inheritance patterns with bipolar disorder? a. GAD b. Schizophrenia c. Agoraphobia d. Eating disorder 89. A 42 yo man who takes a second-generation antipsychotic for schizophrenia has experienced a 15 lb weight gain since his last visit 6 months ago. His BMI is 36 kg/m, and his waistline circumference is 41 in. BP is 160/100 mmHg. Fasting blood glucose is 145 mg/dL. Which of the following is the best initial intervention at this time? a. Education regarding diet and exercise b. Begin insulin therapy c. Stop antipsychotic medication d. Begin a stimulant medication 90. A 23 yo woman is brought to the clinic by her boyfriend who is concerned after she impulsively bought a car. He reports that she has been sleeping for 2 weeks and that she has been clearing the apartment in the middle of the night. At the clinic, the patient is unable to sit in her seat and frequently interrupts the examiner, making it difficult to elicit information. The examiner reports to the consultant psychiatrist that the patient has so much energy that she “blows you out of the room!” The patient talks rapidly about how she should be running the company where she works. She reports no hallucinations, but frequently uses rhymes and repeats words that start with the same letter such as house, hill, help, and home. She admits to having a glass of wine at night to slow down her thinking. She has no prior history of impairing mood symptoms. The toxicology screen is negative. Which of the following is the most likely diagnosis? a. Bipolar I disorder b. Bipolar II disorder c. Schizoaffective disorder d. ADHD combined presentation 91. A 32 yo woman comes to the office because of chest pain and palpitations that last less than 10 mins and are associated with a feeling that she is “going crazy”. She reports having similar episodes in the past with associated nausea, diaphoresis, tremulousness, and a sense of smothering. She was seen in the ED 1 month ago for 2 similar episodes. She has become increasingly afraid to leave her house. Physical exam shows no abnormalities. Which of the following laboratory studies is most appropriate to rule out a nonpsychiatric cause for this patient’s symptoms? a. Serum amylase b. Thyroid function tests c. Vitamin B6 level d. Serum albumin e. Liver function tests 92. A 22 yo woman comes to the clinic with sudden onset of stuttering that began 2 days ago during a class in which she is studying to be a paralegal. She reports that she began to stutter when it was her turn to comment on a sexual harassment case study, which reminded her of being sexually assaulted 10 years ago. Which of the following disorders is most likely? a. Conversion b. Illness anxiety c. Somatic symptom d. Language 93. A 52 yo man is brought to the clinic by his husband with acute agitation, restlessness, headache, and tremors. He makes poor eye contact throughout the interview. He is unemployed and reports hard liquor consumption of 2 pints/day for the past 4 years. His last alcoholic drink was 2 days ago. Temperature is 100 F, pulse rate is 110/min, respirations are 24/min, and BP is 160/100 mmHg. On physical examination, he is diaphoretic, in acute distress, and oriented to person only. During assessment, he loses consciousness and experiences a generalized tonic-clonic seizure. Which of the following is the most appropriate treatment for this patient’s acute symptoms? a. Baclofen b. Phenytoin c. Propranolol d. Vitamin B6 e. Lorazepam 94. A 49 yo man comes to the office for an employment physical. He describes a 6 year history of IV drug use but states that he has been clean for almost a year. He has been feeling well and denies any symptoms. Which of the following is the most appropriate measure to ensure his continued good health? a. Vaccination against HPV b. Initiation of buprenorphine (suboxone) therapy c. Echocardiogram d. Hepatitis C testing 95. A 40 yo woman is brought to the ED by her family for evaluation of increasing paranoia. They report she is fearful that there are people in the house who will kill her and her family. Her sister states that the patient has been superstitious and has believed she is clairvoyant since she was a teenager. The patient’s husband states his wife has had odd behaviors for the past 15 years and has few friends. Mental status examination shows an angry, articulate female who insists she is fine and her family is lying. Physical examination is otherwise unremarkable and toxicology screen is negative. Which of the following meds is indicated at this time? a. Venlafaxine b. Lithium c. Risperidone d. Nefazodone 96. In which of the following is the vast majority of serotonin found in the human body? a. Raphe nuclei b. Somatotroph cells c. Enterochromaffin cells d. Locus ceruleus 97. Children with separation anxiety disorder are at increased risk for which of the following? a. Oppositional defiant disorder b. Social anxiety disorder c. Histrionic personality disorder d. Bipolar I disorder 98. A 4 yo boy develops tachycardia after beginning short-acting methylphenidate (Ritalin) therapy for ADHD. His parents are also concerned about weight loss. What is the most appropriate next step in management? a. Add propranolol b. Change to a long-acting methylphenidate c. Reassurance that side effects will abate d. Change to atomoxetine 99. A 25 yo woman comes to her psychiatrist’s office with concerns that therapy is not working for her. She has been seeing her psychiatrist for the past 4 years. During the interview, she states that she has difficulty sleeping, has trouble concentrating, feels numb and feels disconnected from others. She also states that she has been having recurrent nightmares related to having been raped in the past. Which of the following is the most appropriate next step in the management of this patient? a. Fluoxetine b. Chlorodiazepoxide c. Clonazepam d. Midazolam 100. Which of the following is the best explanation of the mechanism of action of methylphenidate (Concerta)? a. Norepinephrine and serotonin reuptake inhibitor b. Dopamine and norepinephrine activity antagonist c. Dopamine and serotonin receptors agonist d. CNS stimulant 101. Which of the following is most likely to contribute to the occurrence of narcissistic personality disorder? a. Substance use b. History of conduct disorder c. History of sexual abuse d. Genetic factors 102. A 28 yo G1P1 woman who had an uncomplicated vaginal delivery of a full-term healthy infant 2 weeks ago comes to the office with her husband and infant. She is concerned that the baby is “dying from cancer, and maybe should return to heaven.” The husband explains that the mother refuses to feed the infant and stays away from the infant as much as possible. PMH includes a brief depressive episode in high school. Physical exam reveals an anxious-appearing woman who is alert and oriented in all spheres, displays poor eye contact and keeps her head down during the interview. Her thought processes are disorganized and her thought content is delusional and paranoid. She has poor judgment and insight. Which of the following is the most appropriate question to ask the patient? a. “Does your baby make you angry?” b. “Do you feel guilty that you are not feeding your child?” c. “How do you think your husband feels about your behavior?” d. “Do you think you are being punished?” e. “Do you hear voices that no one else hears?” 103. A 32 yo woman comes to the ED because of anxiety, a racing pulse, and clammy, sweaty hands. She reports that she stopped going to therapy 3 months ago. She has a history of a car accident 2 years ago and has vivid dreams about the accident. Temperature is 98.7 F, pulse rate is 130/min and regular, respirations are 25/min and unlabored, and BP is 110/70 mmHg. Lorazepam (Ativan) is given. Which of the following is the most appropriate next step in the management of this patient? a. Prescribe escitalopram b. Admit to psychiatric unit c. Prescribe clonazepam d. Recommend resuming psychotherapy 104. Which of the following is an important counseling point for a patient who is undergoing treatment for GAD? a. Reassure that occasional hallucinations are normal b. Advise to decrease caffeine intake c. Recommend use of ginseng extract d. Advise to avoid large crowds 105. A 68 yo man comes to the urgent care center because of anxiety, headache, and nausea. He reports abruptly stopping the consumption of 12 beers daily. Height is 61 in, weight is 130 lb, and BMI is 25.4 kg/m. Temperature is 98 F, pulse rate is 108/min and regular, respirations are 12/min and unlabored, and BP is 138/92 mmHg. His skin is moist and warm. Examination shows no other abnormalities. Which of the following is the most likely diagnosis? a. Alcohol intoxication b. Delirium tremens c. Alcoholic liver disease d. Alcohol withdrawal e. Binge drinking 106. A 35 yo man seeks evaluation due to a several month history of nightmares, irritability, and hypervigilance following a motor vehicle accident in which his son was injured. Which of the following medication classes is most appropriate for this patient? a. TCA b. Antihistamines c. Atypical antipsychotics d. SSRIs 107. A 27 yo woman returns to the clinic for re-evaluation of continued vague symptoms of abdominal pain and the presence of blood in her stools. Palpation of the abdomen elicits a severe pain response, but without guarding or rebound tenderness. Physical exam is otherwise within normal limits. Stool guaiac remains negative. She is not seeking any obvious external reward. Which of the following is consistent with this presentation? a. Factitious disorder b. GAD c. Conversion disorder d. OCD 108. A 16 yo girl is brought to the office to discuss unusual eating habits that her father has observed for the past 6 months. Her father has found numerous cookie and candy wrappers hidden under the girl’s mattress. The patient becomes very tearful when confronted and states she eats when she is stressed but then feels very guilty. She feels she is out of shape and has started running at least 2 hours/day 4 days/week. Which of the following is the treatment of choice? a. Citalopram b. Bupropion c. Fluoxetine d. Paroxetine 109. A 24 yo man comes to the ED with a noticeable elevated, expansive mood for the past 9 days. His girlfriend states that according to his psychiatrist, he has been suffering from a major depression over the past month. The depressive episode ended about a week ago. Which of the following is the most likely diagnosis? a. Bipolar II disorder b. MDD c. Bipolar I disorder d. Substance-induced bipolar disorder 110. An 8 yo girl is brought to the clinic by her parents because of extreme irritability, anger, and frequent, intense temper outbursts over the past 2 months. Physical exam shows no abnormalities and Vanderbilt questionnaires filled out by both parents and teachers are not suggestive of pathology. Which of the following is the most appropriate therapy? a. Psychotherapy b. Pharmacotherapy c. Deity modification d. Acupuncture 111. A 15 yo boy is brought to the ED by his mother who states that her son is becoming progressively irritated and having angry outbursts. She states that he has been a master at lying for the past 2 years. He has kicked his dog in the belly on many occasions. Which of the following is the most appropriate treatment for this patient? a. Paroxetine hydrochloride b. Home schooling c. Valproic acid d. Reinforced positive behavior 112. Which of the following is most important to screen for when evaluating a patient with depression? a. Suicidal ideation b. Family history c. Sleep disturbance d. Anhedonia 113. Which of the following has been most closely associated with borderline personality disorder? a. Abnormal cholinergic activity b. Decreased brain glucose utilization c. Frontal lobe dysregulation d. Increased adrenal enterochromaffin activity 114. A 26 yo woman comes to the office experiencing signs and symptoms of depression 2 weeks postpartum. She is at greatest risk of which of the following with a future pregnancy? a. Acute psychotic episode b. Major depressive disorder with peripartum onset c. Panic disorder d. Gestational diabetes 115. A 67 yo man is brought to his primary care provider by his wife. Since the patient retired from his career as an accountant, he has become increasingly preoccupied with rearranging everything in the kitchen. His wife, a gourmet cook, can no longer tolerate her husband’s constant attempts to obtain perfect order in the kitchen. Which of the following interventions would be most beneficial for this patient? a. Exposure therapy b. Motivational interviewing c. CBT d. Dialectical behavior therapy 116. A 35 yo man comes to the clinic because of constant fatigue and irritability for 7 months. He cannot attribute this to any trauma or inciting event. He also reports difficulty concentrating at work. He is frustrated that he cannot sleep due to worrying about his job, the health of the neighbor’s older dog, and the possibility of something bad happening to his parents. Pulse rate is 122/min abd BP is 138/88 mmHg. Physical exam is otherwise within normal limits. Which of the following disorders is most consistent with this presentation? a. Somatic symptom b. Panic c. Social anxiety d. Generalized anxiety 117. Which of the following is the most commonly experienced type of hallucination? a. Gustatory b. Auditory c. Tactile d. Olfactory e. Visual 118. Which of the following is a common negative symptom of schizophrenia? a. Diminished capacity to experience pleasure b. Loss of appetite c. Disorganized speech and behavior d. Delusions of reference 119. A 23 yo man comes to the office with a 2 month history of acute, self-limited, recurrent episodes in which he feels like he is having a heart attack. He experiences chest pain, palpitations, SOB, and diaphoresis. Location and situation do not seem to be a factor, and he is worried that one of these episodes may occur while he is at work. The patient denies use of alcohol, nicotine, or other drugs. Physical exam and diagnostic studies reveal no abnormaltieis. Which of the following disorders is the most likely diagnosis? a. Somatic symptom b. Social anxiety c. Generalized anxiety d. Panic 120. A 21 yo woman comes to the office with her mother to discuss her eating habits. Her mother reports that she hears her daughter vomiting in the bathroom after almost every meal and that this behavior has been occurring for the past 4 months. Height is 63 in and weight is 136 lb. Physical exam reveals calluses on the knuckle of her right middle finger. In addition to counseling, which of the following is the pharmacologic treatment of choice? a. Nortriptyline b. Bupropion c. Fluoxetine d. Paroxetine 121. When evaluating a man for frotteuristic disorder, which of the following is most likely present in the patient’s history? a. Frequently rubbing against fully clothed women b. Exposing himself to others c. Wearing women’s clothing d. Stealing women’s underwear 122. A 29 yo woman is brought to the ED by family members, who state that she suffered a seizure within the last hour. They describe symptoms consistent with a tonic-clonic seizure. She was feeling well prior to the episode and has no prior history of seizures. She has a history of factitious disorder. Which of the following is most important in the evaluation of this patient? a. Lumbar puncture b. MRI of the brain c. Lactate dehydrogenase d. Prolactin level - would be normal if had pseudoseizure 123. A 30 yo man comes to the office with symptoms of anxiety 1 week after witnessing a traumatic event. He describes feeling numb and being in dazed dreamlike state with poor concentration. He also has had difficulty sleeping. He has not been able to tell anyone else about the event that occurred and has started having flashbacks. Which of the following is the most likely predisposing factor for this patient’s condition? a. Family history of psychosis b. Education level c. Male gender d. Intensity of the trauma 124. A 34 yo man has been started on clozapine 150 mg twice a day. Which of the following must be monitored weekly? a. Urine drug screen b. Serum clozapine level c. Thyroid profile d. Absolute neutrophil count e. C-reactive protein 125. A 20 yo man is brought to the clinic by his mother for evaluation of bizarre behaviors that began 8 months ago. He is often found talking to himself. When his mother questions this, he becomes defensive stating he is talking to his dead grandfather. He no longer attends social functions because he feels people are talking about him and tracking his whereabouts. He is an accounting major at a local university and was previously doing well, but his grades this semester have dropped considerably. Which of the following is the most likely diagnosis? a. Bipolar I disorder b. Schizophrenia c. Paranoid personality disorder d. Delusional disorder 126. A 7 yo girl is brought to her pediatrician’s office by her mother upon recommendation by her first grade teacher. The girl is withdrawn and unable to interact socially with teachers or peers. She becomes intensely focused on one activity and refuses to be re-directed. Which of the following is the most likely diagnosis? a. Autism spectrum disorder b. Adjustment disorder c. Antisocial personality disorder d. Conduct disorder 127. Which of the following is expected to decrease over time for patients with bipolar II disorder? a. Severity of manic symptoms b. Duration of depression episodes c. Interval between mood episodes d. Severity of depressive symptoms 128. Which of the following factors is most likely to be associated with the onset or exacerbation of obsessive-compulsive personality disorder? a. Tobacco exposure b. Lack of sun exposure c. Postpartum changes d. Sleep disturbance 129. A 19 yo man seeks evaluation because of concern about sexual urges that have occured for the past year toward girls who attend the middle school near his workplace. He has not acted on the urges, but is having an increased number of fantasies. He has not had any relationships during this time. In addition to cognitive-behavioral therapy, which of the following medications is the appropriate treatment? a. Clozapine b. Sertraline c. Valproic acid d. Lorazepam e. Risperidone 130. A 22 yo woman has had difficulty entering the lobby of her apartment for the past 7 months. She reports that the lobby is often crowded, and there are only 2 exit doors. Upon seeing the lobby entrance, she experiences sudden onset of tremor, abdominal pain, dry mouth, and palpitations. She has no previous psychiatric history. Which disorder is most likely? a. Generalized anxiety b. Obesessive-compulsive c. Social anxiety d. Agoraphobia 131. Which of the following screening tests is the most appropriate to perform on a 45 yo man with a 20 year history of alcohol use disorder? a. Liver function studies b. TSH c. Urine toxicology d. Gamma-glutamyl transferase e. Rapid plasma reagin 132. Which of the following findings is most likely in the history of a patient diagnosed with paraphilic disorder? a. Premature birth b. Incarceration c. Multiple atypical sexual urges d. Watching pornography as a teenager 133. A 72 yo woman comes to the office and reports experiencing sadness, insomnia, poor appetite, and weight gain for the past 3 weeks. She has no past psychiatric history but reports becoming a widow 6 months ago. Lab studies reveal serum glucose of 102 mg/dL, sodium of 139 mEq/L, hemoglobin of 12.8 g/dL, and TSH of 8.04 mlU/mL. Which of the following is the most likely diagnosis? a. Persistent depressive disorder b. Depressive disorder due to medical condition c. Major depressive disorder d. Adjustment disorder 134. A 36 yo graduate student comes to the office with a headache and difficulty sleeping. She has spent the past 10 months researching and writing her doctoral thesis. Prior to that she had “done just fine” during the 24 months of classes. Now she feels as though she worries about everything, and has not been able to concentrate enough to complete any work over the last few weeks. Which of the following physical examination findings would be consistent with her most likely diagnosis? a. Amnesia b. Tics c. Tachycardia d. Urticaria 135. Which of the following is the most appropriate treatment for a 6 month history of abdominal pain for a patient diagnosed with somatic symptom disorder? a. Amitriptyline b. Reassurance that the condition is benign c. CBT d. Aripiprazole 136. A 19 yo woman comes to the office with concern about being required to give a presentation in a college course. She reports that for many years she has been getting very nervous about talking in public due to a fear of saying something embarrassing. This fear has also led her to curtail her social interactions, making it difficult to maintain friendships. Which of the following diagnosis is most likely? a. Generalized anxiety disorder b. Social anxiety disorder c. Panic disorder d. Schizoid personality disorder 137. Which of the following medications is contraindicated for the treatment of panic disorder in a woman who is trying to conceive? a. Escitalopram b. Buspirone c. Sertraline d. Paroxetine 138. Voyeuristic disorder is characterized by sexual arousal through which of the following? a. Inflicting pain on their sexual partner b. Dressing like the opposite sex c. Exposing genitalia to innocent strangers d. Watching an unsuspecting person undress 139. A 36 yo woman comes to a telemedicine psychiatric appointment for follow-up. She continues to refuse to come to the office for appointments and works remotely as an office assistant. She shops without anxiety but refuses social interactions due to fear of rejection. Which of the following is most likely to be revealed in her history? a. Difficulty making decisions without excessive advice b. Substance use behaviors c. Periods of sleeplessness and hyperactivity d. Views herself as inept and inferior to others 140. A 30 yo man is brought to the ED by ambulance because his girlfriend was afraid that he might commit suicide after they had an argument. During the interview, the patient states that he is sad because of the passing of his grandmother 4 days ago. He is goal-oriented and works as a graphic designer. The patient denies having suicidal ideation, homicidal ideation, visual hallucinations, or auditory hallucinations, but he admits to inability to sleep, stomachaches associated with nausea, and palpitations. Which of the following is the most appropriate first step in the management of this patient? a. Administer clonazepam b. Give reassurance and arrange follow-up c. Initiate paroxetine d. Refer to psychotherapy 141. A 14-year-old girl is brought to the Emergency Department by her father. He states that his daughter is getting progressively irritable, has angry outbursts, and no longer listens to him. He also states that his daughter has been breaking her curfew rules for the past six months. Which of the following is the most appropriate first step in the management of this patient? a. Cognitive behavioral therapy b. Lithium (Lithobid) c. Parent effectiveness training d. Methylphenidate (Concerta) 142. A 24-year-old woman experiences the abrupt onset of palpitations and diaphoresis when she enters an elevator. Which of the following additional symptoms is most likely present? a. Hyperventilation b. Nausea with vomiting c. Tunnel vision d. Headache 143. Which of the following needs to be closely monitored in a patient taking valproic acid (Depakene)? a. Kidney function b. Potassium c. Hemoglobin d. Liver function 144. Which of the following is consistent with a diagnosis of schizophrenia? a. Cerebral ventricular enlargement b. Absence of the corpus callosum c. Diffuse white matter defects d. Multifocal cortical hemorrhages 145. A 40-year-old woman comes to the office with left shoulder pain and fatigue for the past two weeks. She is very concerned there is something seriously wrong with her. She states she has chest pain, shortness of breath, dizziness, arm weakness, paresthesia, headache, abdominal pain, and nausea. She has been in the Emergency Department at least once per month over the past year. She has also seen a cardiologist, rheumatologist, and neurologist reporting other symptoms. Height is 167.6 cm (66 in), weight is 74.4 kg (164 lb), and body mass index is 26.5 kg/m?. Temperature is 36.2°C (97.2°F), pulse rate is 68/min and regular, respirations are 16/min and labored, and blood pressure is 110/74 mg. Electrocardiogram is within normal limits and her physical examination is unremarkable. Which of the following is the most likely diagnosis? a. Delusional disorder b. Generalized anxiety disorder c. Somatic symptom disorder d. Illness anxiety disorder 146. A 22-month-old boy is brought to the pediatrician by his mother for a routine well child visit. The mother notes that the boy sleeps very little, eats only one or two food items, and has great difficulty transitioning from one activity to another. Length is 86.4 cm (34.0 in), weight is 12.7 kg (28.0 lb), and body mass index is 17.0 kg/m? (63rd percentile). Temperature is 37.2°C (98.9°F), pulse rate is 86/min and regular, respirations are 20/min and unlabored, and blood pressure is 110/75 mg. The boy becomes fixated on the examiner's penlight, switching it off and on dozens of times during the interview. When the examiner attempts to distract the boy in order to retrieve the penlight, the boy screams hysterically and cannot be redirected. Which of the following physical examination findings is most likely to be found? a. Hyperreflexia b. Hearing loss c. Avoidance of eye contact d. Lower extremity weakness 147. A 35-year-old man is brought to the Emergency Department with a gunshot wound to his foot. He reports that he was working in his yard when a snake crawled across his boot. He drew his pistol and tried to shoot the snake, missed, and shot himself in the foot. He reports a lifelong fear of snakes but has never considered therapy since he has managed to avoid encountering snakes prior to this incident. Which of the following is the most likely diagnosis? a. Panic disorder b. Postraumatic stress disorder c. Specific phobia d. Delusional disorder 148. A 35-year-old man is being evaluated for increasing anxiety, restlessness, and concern about losing his job due to decreased productivity. Symptoms began about six months ago. He believes that his co-workers are trying to get him fired. He sleeps on his office couch because he is worried that his co-workers will access files to use against him. He no longer socializes with them outside work. He denies using alcohol or illicit drugs. He is unkempt and appears agitated. Which of the following personality disorders is the most likely diagnosis? a. Antisocial b. Schizoid c. Narcissistic d. Schizotypal e. Paranoid 149. For which of the following is there greatest evidence of positive correlation to antisocial personality disorder? a. Microglial dysfunction b. Heritability c. Overactivity of central inhibitory pathways d. Increased catecholamine levels 150. A 13-year-old girl is brought to her pediatrician by her mother. Her mother reports that her daughter's hair is falling out. Her hair is shoulder length, but she wears it in a ponytail to disguise the thin areas. She reports no scalp pruritus. Height is 152.4 cm (60.0 in), weight is 52.2 kg (115.0 lb), and body mass index is 22.5 kg/m2 (85th percentile). Temperature is 37.2°C (98.9°F), pulse rate is 80/min and regular, respirations are 20/min and unlabored, and blood pressure is 110/75 mg. Physical examination reveals noticeable thinning of the hair at the crown of the head, no erythema, no flaking, and regrowth evident in some areas. Her fingernails are short and ragged. Laboratory testing reveals thyroid hormone levels within normal limits. Punch biopsy is negative for tinea capitis. Which of the following is the most likely additional finding on physical examination? a. Pallor b. Geographic tongue c. Thinning eyebrows d. Obesity 151. A 49-year-old woman comes to the office because she has been having difficulty completing occupational and daily living tasks due to experiencing frequent periods of tearfulness, increased fatigue, need for increased sleep, feelings of hopelessness, and loss of appetite since her fiance broke off their engagement three months ago. She does not have any psychiatric or medical history. Which of the following is the most likely diagnosis? a. Normative reactions to life stressors b. Adjustment disorder c. Major depressive disorder d. Acute stress disorder 152. A 47-year-old man comes to the office because of sudden, renewed onset of psychotic symptoms. Medical history includes compliance with medication and well-controlled schizophrenia. Which of the following diagnostic studies would distinguish an exacerbation of schizophrenia from an organic etiology for the psychosis? a. Electroencephalogram b. Serum protein electrophoresis c. Human immunodeficiency virus screening d. Positron emission tomography scan e. Polysomnography 153. Due to which of the following personality disorders will the patient most likely refuse immunizations? a. Paranoid b. Schizoid c. Histrionic d. Avoidant 154. Which of the following characterizes CBT in the treatment of alcohol use disorder? a. Utilizes a 12-step facilitation process b. Helps patient identify triggers and develop refusal skills c. Less effective than discussing the health risks of alcohol d. Needs to be implemented on a life-long basis 155. A 28-year-old man comes to his primary care provider requesting a referral to see a psychiatrist. He reports that he has become progressively irritated and very anxious over the past seven months. During the interview, the patient states that he is having difficulty sleeping and trouble concentrating. Which of the following is the most likely pathophysiology of this patient's symptoms? a. Increased norepinephrine b. Decreased corticotropin-releasing factor c. Increased gamma-aminobutyric acid d. Decreased serotonin 156. Which of the following is most likely to be found on ultrasound in a patient taking lithium? a. Goiter b. Biliary sludge c. Hepatomegaly d. Nephrolithiasis 157. A 22-year-old woman comes to the office for evaluation of a rash that started two days ago. Medical history is significant for bipolar I disorder. Height is 170.2 cm (67 in), weight is 68.0 kg (150 lb), and body mass index is 23.5 kg/m?. Temperature is 36.9°C (98.4°F), pulse rate is 88/min and regular, respirations are 16/min and unlabored, and blood pressure is 112/60 mmH. Physical examination reveals tender, ill-defined, coalescing, erythematous macules with purpuric centers on the face and thorax. Multiple ulcerations are also seen on the lips and buccal surfaces. Which of the following medications is most likely causing these symptoms? a. Divalproex sodium (Depakote) b. Lithium (Lithobid) c. Lamotrigine (Lamictal) d. Quetiapine (Serosiel) 158. After correction of caloric deficiencies in a patient with anorexia nervosa, which of the following is indicated to stimulate bone anabolism? a. Estrogen b. Parathyroid hormone c. Vitamin D d. Bisphosphonate 159. A 34-year-old woman comes to the family practice office for evaluation of a left breast mass. She states she felt the mass last night and came to the office today because she is convinced she has breast cancer. The patient has been concerned about breast cancer for the past two years. She no longer uses antiperspirant for fear that it causes cancer and performs self-breast examinations at least twice per day. She has had a mammogram and breast ultrasound in the past six months. Family history is significant for breast cancer in her maternal grandmother who was diagnosed at age 76. Height is 172.7 cm (68 in), weight is 65.3 kg (144 lb), and body mass index is 21.9 kg/m. Temperature is 36.6°C (97.8°F), pulse rate is 72/min and regular, respirations are 14/min and unlabored, and blood pressure is 106/68 mmH. Physical examination shows no breast mass. Which of the following is the most likely diagnosis? a. Illness anxiety disorder b. Factitious disorder c. Delusional disorder d. Body dysmorphic disorder 160. Which of the following meds is an anxiolytic but is not a benzodiazepine? a. Lorazepam b. Clorazepate c. Alprazolam d. Buspirone e. Midazolam 161. A 53 yo F comes to the clinic following 2 episodes of palpitations, SOB, and cold sweaty palms. Each time, these symptoms were associated with giving a presentation to a large number of peers in her new job. She had uneventfully done similar public speaking at her previous job. She does not want to take a medication “all the time”, but is willing to accept a referral to a counselor. At present, she feels fine. Pulse rate is 86/min, respirations are 14/min, and BP is 130/76 mmHg. After clearing her of organic disease, which of the following meds is the most appropriate for treating this condition on an as needed basis? a. Haloperidol b. Propranolol c. Methylphenidate d. Valsartan e. Diphenhydramine 162. A 26 yo F comes to the office for evaluation of decreased sleep at night due to initial insomnia. She has persistent worries about burglars and leaving the oven on, and gets up multiple times to check the locks on her doors and windows and be sure the oven is turned off. Her total sleep time has been reduced by 2 hours each night, causing her to restrict work and social activities. Which of the following is the most likely diagnosis? a. Alcohol use disorder b. Agoraphobia c. Panic disorder d. OCD 163. A patient with previous 20/20 vision and current history of conversion disorder comes to the clinic with new onset left eye blindness. Which of the following is the expected result of a Snellen Test? a. Left 20/200; right 20/20 b. Left 20/10; right 20/20 c. Left 20/20; right 20/200 d. Left 20/20; right 20/20 164. Which of the following is the most likely side effect of the recommended pharmacologic therapy for ADHD disorder? a. Decreased appetite b. Precocious puberty c. Restless leg syndrome d. Sedation 165. Which of the following is most likely to play a role in the etiology of autism spectrum disorder? a. Deficiency of dopamine b. Genetics c. SES d. Vaccinations 166. A 17 yo girl is seen in the clinic for follow-up evaluation of suspected anorexia nervosa. Her last visit was 8 months ago, and she failed to return for her next scheduled appointment. Current BMI is 15.7 kg/m2, which is decreased from 16 kg/m2 at the previous visit. Her last menstrual period was 6 months ago. She denies sexual activity. For which of the following is this patient of greatest risk? a. IBD b. Cervical cancer c. PCOS d. Osteoporosis e. Endometrial hyperplasia 167. A 23 yo M comes to the office for a court-ordered evaluation. He was recently arrested for exposing his genitals to passersby on the city streets. He admits that this behavior has occurred for several years and results in his sexual arousal. Which of the following is the most likely diagnosis? a. Voyeuristic disorder b. Transvestic disorder c. Exhibitionistic disorder d. Sexual masochism disorder 168. A 6 yo girl is brought to the office by her mother for evaluation of recurrent nightmares after she witnessed her father collapse from a massive MI 2 weeks ago. The child wakes up several times per night and refuses to sleep alone. Which of the following is most likely on history of this patient? a. Frequent temper tantrums b. Physical abuse c. Increased appetite d. Hyperactivity 169. A 48 yo M with no prior psychiatric history is brought to the ED by police officers after physically assaulting his wife. His wife reports that the patient has been anxious and accusing her of having an affair. On exam, he is guarded, agitated, and paranoid. He states that he wants his wife and neighbor dead for their betrayal of his trust. He refuses admission to the hospital and insists on signing out against medical advice. Which of the following is the most appropriate intervention? a. Allow the patient to leave against medical advice b. Outpatient psychiatric referral c. Involuntary hospitalization d. Electroconvulsive therapy e. Arrest the patient 170. Which of the following meds requires an electrocardiogram prior to initiating high-dose therapy? a. Paroxetine b. Sertraline c. Fluvoxamine d. Citalopram - associated with QT prolongation 171. A 15 yo boy is brought to the clinic by his father with dysarthria, nystagmus, lethargy, bilateral hand tremor, and confusion. Temperature is 98.8 F, pulse rate is 70/min, respirations are 10/min, and BP is 100/60 mmHg. An unusual odor is detected on the patient’s clothes. Physical exam reveals an erythematous rash over his nasolabial area. Which substance is most likely responsible for the patient’s intoxication? a. Phencyclidine b. Alcohol c. Cannabis d. Inhalant e. Methamphetamine 172. A 30 yo woman comes to the office for evaluation for breast augmentation surgery. She reports that her breasts are much too small and that this deficit affects her social life. Surgical history is positive for 2 breast augmentation procedures over 5 years. She states that she wears baggy clothing to avoid drawing attention to the problem. Which of the following is the most appropriate next steps in the management of this patient? a. Densensitization therapy b. Pharmacologic therapy c. Biofeedback d. Psychotherapy

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