Psych
8M + prominent jaw + protruding ears + IQ of 65; most likely explanation?
"Fragile site on the X chromosome" à Fragile X (CGG TNR disorder).
• Sense of hopelessness requires further investigation/questioning
"Have you been feeling like just giving up?"
8. A 32-year-old woman comes to the physician because of increasingly severe pain...
"Have you been feeling like just giving up?" Key idea: In patients with chronic disease or chronic pain, important to assess for depressive symptoms and if patient has any signs of psychosocial distress/depression, YOU NEED TO ASK ABOUT SUICIDE!!! (very high yield on NBME exam)
• A suicidal patient should be admitted to a psychiatric unit (ideally voluntarily, but involuntarily if the patient refuses)
"How would you feel about entering the hospital?"
44. A 32-year-old woman comes to the physician because of depressed mood for 2 weeks; she went...
"How would you feel about entering the hospital?" Young depressed woman with suicidal ideation with organized plan and access to means who will need to be hospitalized involuntarily but often in these cases it is best to first ask the patient if they will voluntarily enter the hospital (better for doctor-patient relationship if possible) Key idea: Passive suicidal ideation can be managed as an outpatient, but if patient has an organized plan and access to means then they should be involuntarily hospitalized
Acutely suicidal patient + you need to admit him/her; what do you say?
"how would you feel about entering hospital?"
Vignette where Dx is either MG or LE but it's not listed; answer?
"neuromuscular junction."
-Intracytoplasmic bundles of neurofilaments. -Earlier onset in an individual containing 3 copies of the APP gene (and PS1/PS2 mutations). -ApoE4 mutation increases risk of late onset disease. -Gradual, progressive, memory impairment. -Treatment is with "central acting cholinesterase inhibitors" and Memantine (NMDA receptor antagonist).
-Alzheimer's Dementia (is the most common cause of dementia in the US).
HY Sleep Associations
-Benzos can be used to treat insomnia on a short term basis, they are NOT first line. -GABA agonists like Zolpidem, Zaleplon, and Eszopiclone can be used to treat insomnia. Other meds here include Ramelteon (melatonin receptor agonist) and Suvorexant (orexin receptor antagonist). -Trazodone is one HY psych med that promotes sleep (and priapism). How would priapism be treated? -Sleep has certain HY EEG associations-> Stage N1 (theta waves), N2 (sleep spindles and K complexes, bruxism), N3 (delta waves, enuresis, reduced by Benzos and Imipramine), REM (beta waves, reduced muscle tone, penile tumescence, rapid eye movements controlled by the Paramedian Pontine Reticular Formation).
Schizophrenia
-Excessive DA in the mesolimbic pathway is responsible for the +ve sxs of SCZ. The typical antipsychotics shut this down by blocking DA receptors. -Reduced DA in the mesocortical pathway is responsible for the -ve sxs of SCZ. Blocking DA receptors makes this worse. Atypical antipsychotics are great are shutting this down b/c they increase DA activity in this pathway by blocking serotonin receptors. -Blocking the nigrostriatal pathway is responsible for the parkinsonism and EPS side effects associated with neuroleptics. -DA is also known as Prolactin Inhibiting Factor. Blocking DA receptors (tuberoinfundibular pathway) leads to hyperprolactinemia (very notable with Risperidone) and gynecomastia. -Low potency typical antipsychotics (Chlorpromazine) cause sedation (from H1 blockade), orthostatic hypotension (from a1 blockade), and anticholinergic sxs (muscarinic blockade). -A study was conducted 12 years ago that led the FDA to put out a statement that there is an increased risk of death with atypical antipsychotics in elderly people with dementia.
HY Drugs of Abuse
-If an individual has conjunctival injection and an insatiable appetite for food on the shelf, consider Marijuana intoxication. -If an individual has significant respiratory depression and pinpoint pupils (miosis), consider opioid intoxication. With respiratory depression and a normal pupillary size, think of Benzo intoxication. -It is HY to know that individuals addicted to opioids never get "tolerant" to effects like miosis (meperidine does not cause this->muscarinic antagonist) and constipation. -If you see a question detailing a teen from a party with seizures from hyponatremia, or a descriptor of an individual that has danced for hours on end, consider MDMA as the offending agent (also causes Serotonin Syndrome). -Remember the association b/w substandard heroine and MPTP (Parkinsonism). -Associate LSD with flashbacks.
-Visual hallucinations. -Bradykinesia and cogwheel rigidity. -Intracytoplasmic, eosinophilic inclusions in the cerebral cortex and substantia nigra. -Forgetful, barely talks during an interview. Finds it difficult to "produce words"
-Lewy Body Dementia
A 23 yo med student finds it difficult to sleep during the day. He recently started 2 weeks of nights on the Charcot Medicine Service. He has been caught snoring multiple times by the supervising resident and attending. He had normal sleep patterns before this all started. He has been making mistakes on the job and no longer enjoys activities he previously enjoyed
-Shift Work Sleep Disorder.
A 33 yo G2P1 female at 33 weeks gestation is brought to the ED by her husband after he found her trying to take 10 tablets of fluoxetine with robitussin to "take the edge off". For the past 4 weeks, she has expressed a desire to give up the baby for adoption before leaving the hospital after delivery. Concerned, the physician decides to involuntarily hospitalize the patient. For the next 3 days, the patient strongly refuses all food offered in the hospital. Prior to attempting definitive management, the patient should be warned about? a. The risks of neural tube defects associated with this treatment. b. The risks of memory impairment with this treatment. c. The risks of a seizure disorder with this treatment. d. The risks of severe GI bleeding with this treatment. e. The risks of severe radiation exposure with this treatment.
-The best answer here is B. -This pregnant patient with depression in addition to active suicidal ideation and refusal to eat requires urgent treatment with electroconvulsive therapy. -It is HY to know that one of the most common SEs of ECT is anterograde and/or retrograde amnesia that is often reversible. -Other HY indications for ECT include OCD refractory to conventional treatment, acute schizophrenia unresponsive to medication, catatonia, severe depression in the elderly, depression with a high risk of suicide, and a prior +ve response to ECT.
A 53 yo woman complains of poor appetite, insomnia, decreased interest in activities that she used to enjoy, difficulty concentrating, and loss of energy for much of the past year. She has lost 19 pounds in the last 6 months. She denies ETOH or illicit drug use and does not take any prescribed medications. PE is unremarkable. Lab evaluation reveals a normal TSH and T4. What is the next best step in the management of this patient? a. Tranylcypromine therapy. b. Haloperidol therapy. c. A trial of low dose cyclosporine. d. Sertraline therapy. e. Carbamazepine for 3 weeks followed by a Lorazepam taper
-The best answer here is D, Sertraline therapy. -This patient has the classic sxs of MDD. The patient should have 5 out of 9 SIGECAPS sxs for the past 2 weeks on an almost daily basis which should significantly impair function. Depressed mood or anhedonia must be one of the sxs (makes up the 9 sxs). -SIGECAPS goes with Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor retardation, and Suicidal Ideation. -The monoamine theory states that a deficiency of NE, Dopamine, and Serotonin lead to sxs of depression. -It is very HY to know for many exams and the wards that hypothyroidism has to be r/o before a dx of MDD is made. Don't get this wrong on a test! -There are multiple drugs used to tx MDD. -The first line class includes the SSRIs like Fluoxetine, Sertraline, and Paroxetine. Take note of the sexual dysfunction and GI upset that accompany these agents. They take about 4-6 weeks to kick in and should not be stopped if effects are not seen immediately. Next steps could include dose increases OR switching to a different SSRI. -There's SNRIs like Duloxetine and Venlafaxine. Note that Venlafaxine raises BP and Duloxetine is used for the treatment of neuropathic pain. -There's NDRIs like Bupropion which are notable for the absence of sexual side effects and are particularly useful in depressed individuals with comorbid obesity and tobacco use. Do not give this to people with seizures or a high risk of seizures secondary to electrolyte imbalances (anorexics, bulimics, etc) -There's also MAOIs like Phenelzine/Tranylcypromine/Isocarboxazid that have an association with a hypertensive crisis in the setting of tyramine food consumption. These drugs are good for atypical depression. These drugs ARE NOT FIRST LINE. -There's TCAs that all end in "pramine" and "epin". These drugs have SEs ranging from orthostatic hypotension (from alpha-1 blockade) to dry mouth (from antimuscarinic effects). These drugs are dangerous in overdose (they can stop your heart, cause comas and convulsions) and Na bicarb is the rescue agent. They can be used to treat nocturnal enuresis. Why??? -The TCAs are also used for chronic pain syndromes like the SNRIs. -Finally, there's Electroconvulsive Therapy (ECT) which has the HY SE of anterograde amnesia. It is relatively safe and has a 90% response rate. It is employed in "dangerous" MDD situations where rapid relief is required. It is also safe in pregnancy. -There's weird drugs like Mirtazapine used for depression that are alpha-2 antagonists (how will this increase NE release???). Mirtazapine is good for depression and comorbid anorexia b/c it causes weight gain and stimulates the appetite. -Finally, there's serotonin receptor modulators like Trazodone that are associated with sedation and a HY SE of priapism. Other HY takeaways include: -SSRIs being especially good in men with premature ejaculation. -Serotonin syndrome being a complication of mixing drugs with serotonergic effects (like SSRIs and a mixture of SNRIs or MAOIs or TCAs or Linezolid or MDMA or Sumatriptan, etc). In general, you should wait about 2 weeks for these drugs to washout out of the system before starting another. -MAO-B inhibitors like Selegiline are used to treat Parkinson's disease (kill DA breakdown). -Consider Dysthymia (Persistent Depressive Disorder) with mild depressive sxs that occur over a long time period (2 year timeframe).
A 44 yo F is brought to the ER by her daughter who is worried about the patient "sleeping in" for the past 3 weeks. Prior to this episode, she worked as a personal trainer in a clinic for individuals with movement disorders but quit her job a few days ago after losing one of her patients who had Parkinson's disease. In comparison to the patient's last visit to the hospital 3 months ago for the removal of a neck mass, the patient has gained close to 20 Lbs and during the interview complains of a poor appetite. She now sleeps at home all day. What is the next best step in the management of this patient? a. Sertraline therapy. b. Early morning cortisol and dexamethasone suppression test. c. Amitriptyline therapy. d. Exposure and response prevention therapy. e. Measurement of serum TSH levels.
-The best answer here is E, measurement of serum TSH levels. This patient is most likely hypothyroid. One big clue here is the recent hospitalization for the removal of a neck mass. Do not be surprised on the shelf by an answer that also sounds like "MDD due to a medical condition". -Classic medical causes of depression include hypothyroidism (weight gain, decreased reflexes, cold intolerance), hyperparathyroidism (stones, bones, groans, and psychiatric overtones), drugs like beta blockers/interferon beta (MS), and cancers (especially brain cancers). Stroke patients are also at high risk of depression. If you don't get enough sleep (e.g. 3rd year med student or patient with OSA), you could also get depression.
A 45 yo F is brought to the ED by concerned family members who recently noticed repetitive stereotypical movements of the patient's tongue. She has no other symptoms. She has a long history of schizophrenia that has been well controlled with Haloperidol. What is the next best step in the management of this patient? a. Decrease the dose of haloperidol. b. Change her medication to Clozapine. c. Change her medication to fluphenazine. d. Increase the dose of haloperidol. e. Discontinue haloperidol and try electroconvulsive therapy. f. Change her medication to Aripiprazole.
-The best answer here is F. This patient is experiencing tardive dyskinesia. The next best step in management (NBSIM) is to stop haloperidol (typical antipsychotic, nigrostriatal EPS effects) and introduce an atypical agent (Aripiprazole). -Clozapine is an atypical agent but it has some pretty nasty side effects (agranulocytosis), so it is not the first line atypical agent. It is also HY to know that this is the only antipsychotic shown to decrease the risk of suicide in schizophrenia. -For the atypicals, their blockade of DA receptors helps with treating the +ve sxs of SCZ (mesolimbic pathway blockade). Their antagonism of 5HT receptors increases DA release in the mesocortical pathway which helps treat the -ve sxs of SCZ. -It is HY to know certain key associations wrt to atypical antipsychotic side effects (SEs) for the purpose of your test. They are detailed in a coming slide.
A 56 yo business executive is 1 day out from an uncomplicated cholecystectomy for symptomatic cholelithiasis. The nurse notices a significant variation in his VS compared to what was measured in the PACU. HR is 153 bpm, BP is 170/105. He has tremors and has been feeling nauseous. He is given a beta blocker for symptomatic relief. 24 hrs later he begins to describe a feeling of bugs crawling under his skin, appears delirious, and has a mild fever. He begins to have generalized tonic-clonic movements of his hands and legs. What is the next best step in the management of this patient? a. IV Lorazepam therapy. b. IV Phenobarbital therapy. c. A 4-6 week course of Bupropion. d. Referral for Alcoholics Anonymous counseling.
-The best answer is A, Lorazepam therapy. This patient has gone into delirium tremens. He deserves a benzodiazepine (increases frequency of chloride channel opening which hyperpolarizes neurons, GABA receptor). -You should watch out for this specific scenario on the shelf/Step 2. -Benzos should not be given for long periods of time to prevent "dependence". They are used in the short term to calm down actively seizing individuals (or individuals with acute episodes of anxiety). Essentially all Benzos end in "pam" with the exception of Chlordiazepoxide. Lorazepam is one of the poster child benzos. -Most benzos are eliminated by the liver and metabolized by 3A4 (except Lorazepam, it is cleared by the liver and metabolized by glucuronidation, the same holds true for Oxazepam and Temazepam, give these 3 in liver dysfunction). Give flumazenil (GABA receptor antagonist) in the setting of BZD overdose. -Barbiturates also work like BZDs but have the mechanism of increasing the duration of chloride channel opening. They cause significant respiratory depression and are more lethal than BZDs in overdose. There is no rescue agent. -As an aside, the Z drugs for insomnia (Zolpidem, Zaleplon, and Eszopiclone) can be reversed with flumazenil. -ETOH also works as a GABA receptor agonist. This is why benzos are first line in the tx of delirium tremens
A 45 yo M with a past history of depression, IVDU, HTN, Type 2 diabetes, and hyperlipidemia is admitted to the hospital for surgical drainage and IV antibiotic treatment of an intra-abdominal abscess. He is initially placed on 14 days of IV Vancomycin for S. Aureus coverage with rapid improvements in his symptoms. Prior to discharge, a decision is made to switch the patient to an oral, once a day 14 day regimen of Linezolid. The most likely contraindication to this regimen is? a. The patient's' past history of depression. b. The patient's' past history of hyperlipidemia. c. The patient's' recent surgical procedure. d. The patient's' history of medication non-compliance. e. The patient's' history of HTN. f. Poor antibiotic coverage for S. Aureus.
-The best answer is A, the patient's' past history of depression. -The first line treatment for MDD is an SSRI. Linezolid is a commonly tested antibiotic (50S ribosome inhibitor) that has a strong association with serotonin syndrome so you would want to avoid this combination. Linezolid has excellent S. Aureus coverage. -Other HY drugs associated with serotonin syndrome include SNRIs, MAOIs (remember the other issues with tyramine containing foods), sumatriptan (migraine med), and MDMA (ecstasy).
A 23 yo medical student gunning for plastic surgery reluctantly comes to the university health department in response to constant cajoling by his roommates. During the interview, he states that he has gotten through a lot of reading, vacuumed his home and the entire 10th floor of 929, burnt through 30, 000 anki flashcards which he made individually and wrote 12 papers for upcoming TIME courses. He feels that time felt sleeping is wasted time he could use to get through more "future work". During the interview, he constantly interrupts the physician and speaks at an accelerated rate. He feels on top of the world. He consistently goes off track and regularly needs redirection. His roommates state that he has been irritable recently and has emailed all the physicians in the SC project brochure to explore the possibility of starting new projects. 2 months ago, he felt completely distraught with life and slept at home for more than 2 weeks w/o attending any of his classes. He stopped playing soccer with his friends which he had enjoyed for many years. He had thoughts of taking his life and felt "physically slow". PE, labs, and UA are unremarkable. He has no history of drug use. He had a similar "superman" episode 3 months ago (first occurrence). What is the next best step in management? a. Escitalopram therapy. b. Carbamazepine therapy. c. Lithium therapy. d. Electroconvulsive Therapy.
-The best answer is C, Lithium therapy. This patient has Bipolar 1 disorder. Li is the first line treatment for bipolar disorder. Be wary in the setting of renal failure. -He has manic sxs (DIGFAST for > 1 week) and a hx of depressive sxs. Note that manic sxs are the only requirement needed for the dx of BPD 1. Mood sxs are not necessary. -BPD 2 is characterized by hypomanic sxs (DIGFAST lite for > 4 days) and mood sxs (which are generally required for dx). Hypomanic episodes are generally not associated with derangements in social or occupational functioning. -Li is associated with a fine tremor, hypo/hyperthyroidism, and nephrogenic diabetes insipidus that is treated with drugs like amiloride and triamterene. -Valproate is another good option but has an association with liver toxicity and birth defects in pregnant women taking the drug.
A 64 yo M comes to a neurologist for his routine 3 month follow up appointment. Prior to appropriate pharmacological control, he had a 3 year history of excessive daytime sleepiness. He occasionally has what he describes as "bizarre dreams" upon awakening in the morning. A med student working with the neurologist as a preceptor decides to perform an experiment in rats with the goal of replicating other findings of this disease. This experiment would most likely involve? a. Blockade of alpha-1 adrenergic receptors. b. Activating interactions with the NMDA receptor. c. Administration of an orexin receptor blocking agent. d. Administration of a GABA receptor activating agent. e. Administration of an agent that inhibits norepinephrine reuptake at adrenergic synapses. f. Administration of an agent that inhibits GABA and glycine release from Renshaw cells.
-The best answer is C. This patient has Narcolepsy. Individuals with narcolepsy have a deficiency of orexin (hypocretin). -Blocking orexin receptors should produce similar effects. -A new drug (Suvorexant) actually works by blocking Orexin receptors as a treatment for insomnia. I think about this as insomnia (little sleep) being on the other end of the spectrum from narcolepsy (excessive sleep).
A 23 yo business major (Patient A) who was a previous straight A student has surprised his friends over the last 7 months with consistent Ds in all his classes. He has stopped hanging out with his friends and prefers to live alone in his dorm room free of distractions. He was taken to the ED by some concerned friends. During the H&P, he informs the medical student that he has been given secret messages through a daily podcast regarding plots by some spies to infiltrate the Med19 Special Forces. He believes some aliens from Mars are driving to his apartment with a scheduled arrival 3 days from now. A urine drug screen and brain imaging are negative. What is the next best step in the management of this patient? a. Begin Lorazepam. b. Begin Clozapine. c. Begin Risperidone. d. Begin Escitalopram. e. Cognitive Behavioral Therapy.
-The most likely diagnosis here is schizophrenia. The best answer is C. -Time frames are extremely important in psychiatry. Sxs must have been present for > 6 mo to dx schizophrenia. -Schizophrenia is treated with neuroleptics. -In general, atypical neuroleptics (which present with a reduced risk of EPS) are started first before typical neuroleptics like Haloperidol. Clozapine is an atypical neuroleptic but the risk of agranulocytosis is massive so this is not typically a first line drug. -Schizophrenia is typically characterized by (at least 2 of these sxs) delusions (super irrational beliefs), auditory hallucinations (hearing voices), disorganized speech (all +ve sxs) AND negative sxs like social withdrawal and a flat affect.
A 2.5 yo healthy infant is brought to his pediatrician by his concerned mom. He sits in the corner and keeps to himself during the interview. He is called multiple times by the pediatrician during the interview with no response. He mutters a few noises when he is called by his mom and retains an expressionless face despite multiple attempts to make him smile. He spends the entire interview stacking bricks in the pediatrician's office. What is the most likely diagnosis?
-This child has an autism spectrum disorder. -This disorder is characterized by poor interpersonal communication, lack of responsiveness to others, an absence of a social smile, occasional intellectual disability, poor eye contact, preoccupation with specific objects, regimented patterns of behavior, and the repetitive use of certain phrases. -Manifestation is usually before a child hits 36 mo.
-Stepwise decline in cognitive function. -History of HTN. -Brain MRI shows multiple foci of ischemia. -Left arm weakness, right leg hemiplegia
-Vascular Dementia. Common in individuals with a history of HTN and DM. Is the 2nd most common cause of dementia in the US.
21 yo F presents to the ED with a wrist injury producing copious amounts of blood. During the interview, she admits to recently breaking up with her boyfriend of 2 months after they had a huge quarrel. As the physician calmly listens to her presenting complaints, she describes him as the best physician she has ever had. She feels lonely and has a prior history of attempting suicide
-borderline personality disorder. Tenuous relationships, suicidality, splitting (defense mechanism)
What is the most likely offending agent?; 25 yo college senior is combative and disoriented. Complains that bugs are crawling under his skin. BP is 210/140, HR is 180 bpm, RR is 40. He is sweating profusely, and his pupils are dilated. He is brought to the ED by friends b/c he has been complaining of chest pain.
A-This is cocaine intoxication. Cocaine blocks the reuptake of catecholamines at the adrenergic synapse. Remember that the SNS causes mydriasis and a "sympathetic response". On the psych shelf, look for "eye findings" as the "kind giveaways" to the OD scenarios. This patient deserves a BZD, not a beta-blocker. Cocaine withdrawal is the opposite of all these sxs. If a BZD is not an answer choice, consider answer choices like phenoxybenzamine/phentolamine (alpha blockers) or Carvedilol/Labetalol (alpha/beta blockers)
> 6 mo with > 6 sxs of inattention, hyperactivity, impulsivity in 2 settings, fidgety child, must be present before the age of 12, doesn't wait in line for his turn, does not complete assignments
ADHD
8M + causes frequent disruption at school and at home; Dx?
ADHD; Tx = methylphenidate.
A 34 yo business executive receives a recent diagnosis of schizophrenia. 2 days after discharge from the hospital he is rushed to the ED by family members who are concerned about a new onset of repetitive "circular" motions of his forearm. What is the most likely diagnosis?
Acute Dystonia (benztropine, diphenhydramine).
• Presents with the 5 P's • Painful abdomen • Port wine colored urine • Polyneuropathy • Psychological disturbances • Precipitated by drugs (eg, alcohol)
Acute intermittent porphyria
32. A 42-year-old woman comes to the physician because of suicidal thoughts...
Acute intermittent porphyria Patient with psychosocial symptoms, intermittent abdominal pain exacerbated by alcohol and polyneuropathy with a family history (which should always make you think of a genetic disease), most consistent with acute intermittent porphyria Acute intermittent porphyria: 5 P's: Painful abdomen, Port-wine colored urine, Polyneuropathy, Psychological disturbances, Precipitated by alcohol, starvation and P-450 inducers Key idea: Treated with glucose and hemin
6M + ECG shows miscellaneous arrhythmia + seizure-like episode; Dx?
Adam-Stokes attack à not true seizure disorder as per EEG; arrythmia leads to hypoxia of brainstem à seizure-like fits ensue.
• Buproprion is an atypical antidepressant that has favorable sexual side effects and will help with this patients weight gain
Add bupropion to the medication regimen
8. A 67-year-old man comes to the physician because of a 2-month history of increased...
Add bupropion to the medication regimen Reasons to use bupropion for MDD: (1) Patient with comorbid cigarette use (2) Patient with increased weight (3) Patient who doesn't want sexual side effects Key idea: 3 ways to diagnose diabetes mellitus include (1) Fasting blood glucose >126 (2) Random plasma glucose >200 with history of polyphagia, polydipsia, polyuria (3) HgbA1c > 6.5%
• Onset within 3 months of a non-life threatening stressor • Poor test performance = functional impairment • For bereavement, someone has to have died (according to the DSM-5)
Adjustment disorder
45. A 20-year-old college student comes to student health services because she...
Adjustment disorder Patient who had acute stressor and then within 3 months has developed psychosocial distress and tearfulness that does not meet criteria for major depressive disorder, and therefore has adjustment disorder Key idea: In contrast to MDD, adjustment disorder is treated with CBT without pharmacotherapy (for the most part)
• Distress with functional impairment within 3 months of a stressor • MDD requires symptoms for ≥ 2 weeks
Adjustment disorder with depressed mood
• Identifiable stressor causing marked distress and significant functional impairment with onset within 3 months of stressor
Adjustment disorder with depressed mood
33. A 19-year-old man has had restless sleep and feelings of sadness for 1 week; he has had a 0.9-kg (2-lb) weight loss...
Adjustment disorder with depressed mood Young patient who had a life stressor 2 weeks ago and presents with 1 week of sadness, insomnia and impaired functioning most consistent with adjustment disorder MDD would require >2 weeks of symptoms and would require at least 5 of the following symptoms: Depressed mood and SIGECAPS symptoms Acute stress disorder leads to <1 month of HARD symptoms (Hyperarousal, Avoidant behavior, Reliving experience (often nightmares), Disturbed thinking/mood) often after a life-threatening or dangerous event
42. A 23-year-old graduate student comes to the physician because of depressed mood and feelings of hopelessness...
Adjustment disorder with depressed mood Young woman who experienced a recent stressor and is now presenting with depression symptoms insufficient to meet formal criteria for MDD (need at least 2 weeks with at least 5 symptoms of depressed mood + SIGECAPS), most consistent with adjustment disorder Substance use occurred AFTER the acute stressor and therefore substance-induced mood disorder is not correct Key idea: Pay CLOSE attention to the time course/parameters of psychiatric diseases as they are essential to diagnosing disease and can help you quickly rule out answer choices (>2 weeks for MDD, >6 months for Generalized anxiety disorder, etc.)
• The benefit of preventing death from alcohol withdrawal far outweighs the possible respiratory depression from benzodiazepines, especially since she is already intubated
Administer additional diazepam
30. A 47-year-old woman is admitted to the hospital because of a 12-hour history of...
Administer additional diazepam Patient with a significant alcohol use history who has not had a drink fro 24 hours and has developed tremors, confusion, hypertension, tachycardia and hyperreflexia, most consistent with delirium tremens Key idea: Delirium tremens treated with benzodiazepines that are Okay for Terrible Livers (Oxazepam, Temazepam, Lorazepam) Key idea: Potential manifestations of alcohol withdrawal and time since last drink include (1) Nonspecific symptoms (3-36 hours): Tremors, insomnia, GI upset, agitation, diaphoresis, etc. (2) Withdrawal seizures (6-48 hours) (3) Alcoholic hallucinations (12-48 hours) (4) Delirium tremens: Altered mental status, tremors, autonomic hyperactivity, etc. (48-96 hours)
• Management of acute pain is similar in all patients regardless of substance abuse history • This patient is about to undergo wound debridement and suturing - they require a stronger analgesic than ibuprofen
Administration of morphine
24. A 47-year-old man is admitted to the hospital 20 minutes after he was involved in...
Administration of morphine Key idea: Although opiates should be carefully prescribed to patients with history of dependence, they still play an important role in pain management and should not be with-held when patient cannot be managed with non-opioid meds
• Indications for hospitalization in anorexia nerves include unstable vital signs, cardiac dysrhythmias, electrolyte derangements, and severely low body weight • Cannot start parenteral nutrition without admitting her due to risk of re-feeding syndrome
Admit her to a psychiatric hospital
2. A 17-year-old girl is brought to the physician by her parents because of a 20-kg...
Admit her to a psychiatric hospital Patient with anorexia (BMI < 18.5 with concerns about gaining weight) who also has bradycardia and hypotension, necessitating admission to the hospital Indications for involuntary psych admission: (1) Threat to self (such as this patient whose food restriction and weight loss are threatening her life) (2) Threat to others (3) Grave disability Key idea: Indications for hospitalization in setting of anorexia nervosa include (1) Bradycardia (2) Hypotension or orthostasis (3) Hypothermia (4) Marked dehydration or electrolyte disturbance (5) Organ compromise (6) BMI < 15
When someone is a danger to themselves or others they should be admitted
Admit the patient to the psychiatric unit
7. A 21-year-old woman is brought to the emergency department by police after...
Admit the patient to the psychiatric unit Patient who threatened her boyfriend with a meat cleaver and states that she would kill her boyfriend, meaning that she poses a threat to others and needs to be involuntarily hospitalized Reasons for involuntary psychiatric hospitalization includes patients who as a result of a mental disorder (1) pose a threat to themselves (2) pose a threat to others (3) are gravely disabled
• This patient is actively suicidal (recent attempt) and should be admitted to the psychiatric unit regardless of his refusal
Admit to the psychiatric unit involuntarily
46. A 37-year-old man is brought to the emergency department after the pilot of a boat found him in the river at 2 am with rocks in...
Admit to the psychiatric unit involuntarily Young man with symptoms of depression (weight loss, fatigue, tearful mood, psychomotor slowing) who presented after a failed suicide attempt and therefore should be hospitalized involuntarily Key idea: Patients with passive suicidal ideation do not need to be hospitalized against their will, but if the patient has an organized plan and access to means then they need to be admitted involuntarily Key idea: These patients should first be offered voluntary hospital admission in the name of patient-physician relationship, but even if they don't want to be admitted they need to be forcefully admitted
• The anti-emetic agent prochlorperazine has additional antipsychotic effects (by blocking D2 receptors) and may cause EPS • Tx: β-blockers or benzos
Adverse effect of prochlorperazine
19. A 47-year-old man comes to the physician because of a 2-day history of intense anxiety. He has been receiving...
Adverse effect of prochlorperazine Middle-aged man with recent initiation of a high-potency typical antipsychotic (prochlorperazine) who now presents with pacing, hand wringing and trouble sitting still which is most consistent with the extrapyramidal adverse effect akathisia Key idea: High-potency typical antipsychotics (Haloperidol, Trifluoperazone, Fluphenazine) are most associated with extrapyramidal side effects of antipsychotics (acute dystonia, Parkinsonism, Akathisia, Tardive dyskinesia) Key idea: Extrapyramidal symptoms associated with antipsychotics include (1) Acute dystonia: Sudden, sustained contraction of neck, eye muscles, etc./ tx: benztropine, diphenhydramine (2) Akathisia: Restlessness that worsens with escalating antipsychotic use / tx: benztropine, beta blocker, benzo / (3) Parkinsonism: Resting tremor, rigidity, shuffling gate, etc. / tx: benztropine, amantadine (4) Tardive dyskinesia: Prolonged antipsychotic therapy with dyskinesia of the mouth, face and extremities / tx: Valbenazine and deutetrabenazine
32. A 7-year-old girl is brought to the physician because her parents are concerned about her recent preoccupation...
Age-appropriate behavior Young child who begins to ask about death and has slight worries about her parents dying but who is showing no impaired functioning and therefore falls under the umbrella of age-appropriate behavior Key idea: In order for a psychiatric disorder to be diagnosed, it must lead to impaired functioning Separation anxiety disorder: Same theme of anxiety/worries but it leads to somatic symptoms, apprehension going to school, etc.
Mr. B is a med student. He skips every class and stays home all the time. He is afraid of being stuck alone in elevators, going to music concerts, riding the bus to school, and being in a movie theater
Agoraphobia
Assuming the patient presented with a constant urge to move with consistent pacing around the room, what is the most likely diagnosis?
Akathisia (propranolol).
• Gait disturbance is characteristic of alcohol intoxication • Normal vitals rule out cocaine or amphetamine use
Alcohol
19. A 15-year-old boy is brought to the emergency department by his two friends because of unusual behavior...
Alcohol Adolescent brought in from a party who demonstrated decreased inhibition, agitation and unsteady gait most associated with alcohol use Amphetamine and cocaine -> Hypertension, tachycardia, mydriasis, etc. Heroin -> Respiratory depression, pinpoint pupils, decreased consciousness LSD -> Hallucinations and dilated pupils with normal vitals Marijuana -> Injected conjunctiva, dry mouth, tachycardia, paranoia
• Drinks vodka in the morning, 'eye-opener' = ⊕ CAGE questions • Must rule out any substance or medical related mood disorders before diagnosing a psychiatric condition (eg, Adjustment disorder)
Alcohol dependence
4. A 47-year-old woman comes to the physician because she has had difficulty...
Alcohol dependence Middle-aged man who drinks excessive alcohol (>3 drinks per day -> >21 drinks per week) and presents with sleeping difficulty, frequent heartburn (exacerbated by alcohol due to relaxation of lower esophageal sphincter), and anxiety with lab studies showing macrocytosis and elevated LFTs with AST>ALT Note: For hard alcohol such as vodka, 1.5 oz = 1 standard drink Drink cut-off for excessive drinking: (1) Men < 65 yo: >14 drinks per week or >4 drinks in a day (2) Women and men > 65 yo: >7 drinks per week or >3 drinks in a day Lab findings of unhealthy alcohol use: Macrocytosis (MCV > 100), AST:ALT ratio > 2:1 (toAST to alcohol) with AST/ALT that are elevated but under 300 Clinical findings of unhealthy alcohol use: Often presents with sleep disturbances and/or anxiety symptoms related to mild withdrawal
• This patient drinks 'several' alcoholic beverages before sex and has ↑ GGT • Alcohol is a depressant that can make it difficult to achieve erections or reach an orgasm
Alcohol use
30. A 29-year-old man comes to the physician because of the inability to maintain an erection through completion of...
Alcohol use Young man who has normal noctural erections (meaning there is no physiologic cause of impotence [vascular/neurologic/endocrine]) but situational erectile dysfunction with his wife associated with consumption of several alcoholic beverages before engaging in sexual activity who is found to have an elevated GGT level on labs most consistent with alcohol-induced erectile dysfunction Key idea: Alcohol is highly associated with sexual dysfunction Key idea: Cimetidine (and not ranitidine) is associated with increased estrogen -> sexual dysfunction in a man Key idea: GGT often used to track whether or not a patient has been using alcohol, such as in a patient with a history of alcoholism currently in a substance abuse program
• Anorexia nervosa → ↓ GnRH → ↓ LH, FSH → ↓ estrogen → amenorrhea, bone loss
Amenorrhea
33. A 16-year-old high school student will not eat meals with her family, preferring to...
Amenorrhea High school girl who is not eating meals and has very low weight, most concerning for anorexia nervosa Key idea: Anorexia nervosa -> Functional hypothalamic amenorrhea -> Low estrogen -> Increased risk of osteoporosis Key idea: Dental caries would be more likely if patient had binging-purging form of anorexia nervosa or bulimia nervosa Key idea: Patients with anorexia nervosa can develop bradycardia (indication for hospitalization)
• TCA are contraindicated in the elderly due to anticholinergic and antihistamine effects • Hydrophilic β-blockers don't cross the BBB and therefore don't cause psychosis; Lipophilic β-blockers (eg, propranolol, nadolol) cross the BBB and therefore can cause psychosis and depression
Amitriptyline
10. An 82-year-old man with dementia, Alzheimer type, is brought to the physician because of a 4-day history of visual...
Amitriptyline Elderly patient with Alzheimer's and polypharmacy who presents with acute hallucinations and irritability, concerning for a medication side-effect due to anti-cholinergic effects of amitriptyline Atenolol -> Hypotension, bradycardia Ibuprofen -> Kidney damage Levothyroxine -> Tachycardia, palpitations (atrial fibrillation in elderly), heat intolerance, etc. Rivastigmine -> GI side effects, headache, dizziness, anorexia
• Paranoia, tachycardia, hyperreflexia, rapid speech, agitation
Amphetamine intoxication
28. A 27-year-old man comes to the emergency department after a motor vehicle...
Amphetamine intoxication Young patient with delusions, pressured speech and agitation, most consistent with bipolar disorder or use of stimulant/sympathomimetic drugs (cocaine, methamphetamine, etc.) Hallucinogen intoxication would not lead to pressured speech Opioid withdrawal -> mydriasis, diarrhea/GI complaints, etc.
-21 yo premed cheerleader in her senior year of college. -BMI is 17. "House exam" reveals Dulcolax and Furosemide. -Current GPA is a 4.0. -Has not menstruated in 3 years. Recently had an ischiopubic stress fracture
Anorexia Nervosa. Look for a super low BMI on your exam (in contrast with the normal or slightly elevated BMI in the setting of bulimia). Super HY to know that Bupropion should be avoided in these patients if they give you a history of comorbid depression on the test. Bupropion lowers the seizure threshold and these patients tend to have electrolyte anomalies that may predispose them to having seizures. -Don't be surprised if giving Mirtazapine (antagonizes alpha 2 receptors, which increases NE release) is answer for the treatment of depression on in the anorexic population on your test. This drug has weight gain as an associated SE which will certainly be appreciated in this case. -Olanzapine (atypical antipsychotic) is also a good option in these patients given the desired SE of the metabolic syndrome. -In general, the best treatment for these patients revolve around CBT (psychotherapy) and in some cases family therapy. -Other HY associations with anorexia include osteoporosis (they are hypoestrogenic), amenorrhea (with caloric restriction, the HPG axis stops working). -An anorexic patient with severe sxs may be involuntarily hospitalized against their will in certain specific exam circumstances (like suicide). -If you get a question that describes an anorexic patient who is checked into the hospital, receives a ton of food, and then starts having seizures, consider refeeding syndrome as the diagnosis. The reintroduction of food triggers a hyperinsulinemic state (causes low serum phosphate) that may drive multiple elytes into the cell and tip them over the edge. -As an aside, if you get a question about a patient in hospice or one that is terminally ill but has no appetite, consider administering Megestrol Acetate (a progesterone analog that spruces the appetite).
• Excessive dieting, exercising, or binge eating/purging with BMI <18.5 (adults) or <5th percentile (children/adolescents)
Anorexia nervosa
10. A 17-year-old girl is brought to the physician by her mother because her...
Anorexia nervosa Key idea: Anorexia nervosa characterized by BMI < 18.5 along with distorted body image and fear of weight gain Key idea: Binging-purging can be seen in both anorexia nervosa and bulimia; use BMI as cut-off Key idea: Indications for hospitalization in setting of anorexia nervosa include (1) Bradycardia (2) Hypotension or orthostasis (3) Hypothermia (4) Marked dehydration or electrolyte disturbance (5) Organ compromise (6) BMI < 15
23 yo M is arrested for theft and vandalism. He shows no signs of remorse. He set his neighbor's home ablaze when he was 15 and was occasionally found striking their dog with a stick.
Antisocial PD
crime/lack of remorse after doing really bad things
Antisocial personality disorder
• Violate the rights of others, social norms, and laws • Consistently irresponsible and is deceitful • Truancy (absent from school for no good reason) is characteristic • Borderline and Narcissistic don't have many friends/relationships
Antisocial personality disorder
17. A 30-year-old law school graduate is caught cheating on the bar examination. Further investigation shows previous...
Antisocial personality disorder Young man with chronic history of repeated disregard for rights of others without remorse, most consistent with antisocial personality disorder Key idea: Conduct disorder diagnosed if patient is younger than 15 years old, whereas antisocial personality disorder can only be diagnosed in an adult who ALSO had conduct disorder when they were younger Borderline personality disorder: Unstable relationships, labile mood states that change over span of hours-days, splitting (all nurses are horrible but all doctors are amazing), self-mutilation and feelings of emptiness Narcissistic personality disorder: Grandiosity, sense of entitlement, requires excessive admiration, etc.
Mrs. Y decides to stay home from a 929 pregame. She would love to go but is afraid of seeming awkward to her other colleagues
Avoidant PD
individuals want to live interact with people but are loners as a means of avoiding embarrassment.
Avoidant personality disorder
• This patient has MDD - 5/9 SIG E CAPS: • Not sleeping = insomnia • Avoids social activities = anhedonia • Tired = ↓ energy • Wight loss = appetite/weight changes • Not remembering like he used to = ↓ concentration or psychomotor retardation • SSRI is first line pharmacotherapy for MDD
Begin escitalopram therapy
43. A 27-year-old first-year surgical resident comes to the physician to request a...
Begin escitalopram therapy Overworked surgery resident who presents with sleep disturbances (specifically early morning awakenings!), cognitive disturbance (can't remember as well), loss of interest, irritability, decreased appetite and anxiety/depressed mood, most concerning with major depressive disorder requiring antidepressant therapy
19. A healthy 4-year-old girl is brought to the physician by her father because of...
Begin parent management training Young child who has normal behavior at day care and at grandmother's house with bad behavior at home, most consistent with poor boundary setting by parents necessitating parent management training Key idea: ADHD requires at least 6 months of hyperactive or inattentive symptoms before age 12 that occur in at least 2 settings
• Child is behaved in daycare, at the doctors office, and with her grandmother • Tantrums are most likely due to parental interactions
Benign parent management training
• Grandiosity, pressured speech, excess energy → sleeping 2 hours/night • Schizoaffective disorder must have delusions or hallucinations for ≥ 2 weeks in the absence of prominent mood symptoms; Bipolar or major depression with psychotic features have psychotic symptoms occurring exclusively during mood episodes
Bipolar disorder
• This patients grandiosity, impulsivity, talkativeness, flight of ideas and increased goal directed activity are consistent with a manic episode • Presence of psychotic features ("god is talking to me") makes this a manic (not hypomanic) episode • This patients presentation is episodic (previous similar episodes)
Bipolar disorder
50. A 47-year-old man is brought to the physician by his wife because of "unbearable" behavior during the past 2 weeks...
Bipolar disorder Middle-aged man with signs of mania/hypomania (impulsivity, grandiosity, etc.) and psychosis most consistent with bipolar disorder Mania/Hypomania leads to DIG FAST symptoms (Distractibility, Impulsivity, Grandiosity, Flight of ideas, decreased Appetite, decreased Sleep need, Talkativeness) Key idea: Can sometimes be difficult to differentiate between schizophrenia and bipolar disorder on NBME when patient presents with psychosis, but look for DIG FAST symptoms to differentiate between them Key idea: Cocaine use can also lead to psychosis with signs of mania/hypomania, but this patient had a negative urine toxicology Key idea: 3 key differences that are consistent with Mania rather than hypomania:(1) Causes significant functional impairment or leads to hospitalization(2) Episode lasting >7 days(3) Presence of psychotic features
14. A previously healthy 27-year-old man is brought to the emergency department by his girlfriend because of a 6-week...
Bipolar disorder Young man with 6-week history of auditory hallucinations, decreased sleep, grandiosity, restlessness/agitation, and pressured speech most consistent with bipolar disorder Key idea: To be diagnosed with schizoaffective disorder patients would need to meet criteria for schizophrenia AND mood disorder, and criteria for schizophrenia requires 6 months of symptoms/dysfunction (and this patient has only been symptomatic for 6 weeks) Key idea: Psychosis can be seen with mood disorders, particularly Bipolar disorder
Mrs. Z storms out of the exam room screaming that you are the worst doctor in the world. She was recently treated in the ED for lacerations around her wrist after a recent breakup
Borderline PD
-DBT (dialectical behavioral therapy) is a form of CBT used to treat
Borderline personality disorder
24. A 27-year-old woman is brought to the emergency department 2 hours after...
Borderline personality disorder Young woman with feelings of emptiness, self-injurious behavior, and unstable relationships (personal and job history) which is most consistent with borderline personality disorder Borderline personality disorder: Unstable relationships, labile mood states that change over span of hours-days, splitting (all nurses are horrible but all doctors are amazing), self-mutilation and feelings of emptiness Key idea: Primary treatment of borderline personality disorder is dialectical behavior therapy (high yield!) Key idea: Bipolar disorder has periods of elevated mood lasting weeks-months, whereas in borderline PD the mood changes occur over span of hours-days
• Presence of ≥1 psychotic symptom (eg, paranoia, auditory hallucinations) with a sudden onset and full remission in 1 month
Brief psychotic disorder
4. A 62-year-old woman comes to the physician because of auditory hallucinations...
Brief psychotic disorder Brief psychotic disorder: At least 1 positive symptom (hallucination, delusion, etc.) for less than 1 month that often comes on due to stress Schizophrenia: At least two of the following symptoms (delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, negative symptoms) for at least 1 month with at least 6 months of decline in functioning Schizophreniform disorder: Same as schizophrenia except for 1-6 months Schizoaffective disorder: Meets criteria for schizophrenia and major mood disorder, with at least 2 weeks of psychotic symptoms without major mood disorder Mood disorder with psychotic features: Predominantly MDD or bipolar disorder with psychotic symptoms that are never seen without mood symptoms
Binge eats, compensates by using Miralax, BMI is 25
Bulimia Nervosa.
Promotes weight loss, no sexual dysfunction, smoking cessation
Bupropion
Triggers seizures in people with eating disorders
Bupropion
• Generalized anxiety disorder: excessive and persistent worry about multiple issues for ≥ 6 months • First-line tx: CBT + SSRI/SNRI • Second-line tx: Buspirone and benzodiazepines
Buspirone
50. A 25-year-old woman comes to the physician at her husband's request because of...
Buspirone Young woman with >6 months of worrying about multiple issues (starting family, finances) with irritability, trouble sleeping and sweaty palms, most consistent with generalized anxiety disorder -> Although first-line treatment is often SSRI/SNRI, Buspirone is also a viable option specifically for generalized anxiety disorder Key idea: Hyperthyroidism can also present with increasing anxiety/irritability, but will almost always also be associated with unintentional weight loss, hyper-reflexia, and low TSH Bupropion: First-line antidepressant that helps with smoking cessation and has more favorable side effect profiles related to weight gain and sexual side effects
• Trinucleotide repeat diseases often show anticipation (earlier onset of disease in succeeding generations) - this patients symptoms began when she was 47 years old and it began in her father when he was 56 years old • This patient has Huntington disease which often presents wit chorea, aggression, depression and dementia • Imaging of the brain in Huntington disease will show atrophy of the caudate nucleus and putamen with ex-vacuo ventriculomegaly
Caudate atrophy
• Caudate & Putamen destruction → ↓ ACh and GABA → Huntington disease • Amygdaloid nucleus: Kluver-bucy syndrome • Medial geniculate nucleus: Auditory pathway • Nucleus basalis of Meynert: Alzheimer disease • Red nucleus: mostly vestigial in mammals; crawling in human babies • Substantia nigra: Parkinson disease • Subthalamic nucleus: Hemiballismus
Caudate nucleus
41. A 37-year-old man is brought to the physician because of a change in personality over the past 4 months...
Caudate nucleus Young man with chronic progressive personality changes and jerky movements who had a father who had similar symptoms at a slightly older age most consistent with Huntington's disease (due to dysfunction of Acetylcholine and GABA in the caudate nucleus) Key idea: Classic Huntington's disease symptoms are Depression, Dementia and Chorea (jerky movements) Key idea: Classic disease that shows anticipation (children develop disease sooner than parents), particularly when inherited from father because CAG trinucleotide repeat expansion most often occurs in spermatogenesis
• Forceful twisting of a limb → spiral fractures = child abuse • Demineralization occurs with all bony injuries
Child abuse
15. A 10-month-old boy is brought to the physician because of irritability throughout...
Child abuse Injuries that are consistent with child abuse include spiral fracture, rib fractures, subdural hematoma, and retinal hemorrhages Key idea: If cause of injury does not line up with developmental milestones (ex: saying a 3 month rolled off the changing table), then you should consider child abuse
• Alzheimer disease → ↓ ACh • Tx: AChE inhibitor (eg, donepezil, rivastigmine, galantamine) → ↑ ACh
Cholinergic
11. A 77-year-old man comes to the physician at his wife's insistence because of a 2-year history of progressive memory...
Cholinergic Elderly man with chronic progressive memory problems that have impaired day-to-day functioning (getting lost close to home, forgetting to turn off oven, etc.) with an MMSE less than or equal to 23 most consistent with Alzheimer's disease 2 main treatment options for Alzheimer's disease are:Acetylcholinesterase inhibitors (which lead to increased acetylcholine): Donepezil, Rivastigmine, GalantamineNMDA receptor inhibitor: Memantine Anticholinergic -> Used in Parkinson's disease Antidopaminergic -> Used in Schizophrenia Dopaminergic -> Used in Parkinson's Serotonergic -> Used in MDD, GAD, PTSD, and many other psychiatric diseases (anything treated with SSRIs)
• This patient is unable to sleep and wake at the time required for normal work and social needs • These patients will have normal sleep, energy and functioning when they can set their own sleep cycle
Circadian rhythm sleep disorder
31. A 27-year-old teacher comes to the physician requesting a prescription for sleep...
Circadian rhythm sleep disorder Patient who falls asleep late at night and feels tired during the week when she has to wake up early but feels well-rested on the weekend when she can sleep until later in morning/afternoon, consistent with a circadian rhythm sleep disorder REM sleep behavior disorder: Acting out dreams (often seen in patients with Parkinson's or Lewy Body dementia)
• Tx of OCD: CBT + SSRI; clomipramine and venlafaxine are second line
Clomipramine
38. A 21-year-old college student comes to the physician because of a 3-year history...
Clomipramine Patient with obsessive compulsive disorder (recurrent thoughts of hurting people and performing violent sexual thoughts [obsessions] that cause his distress that he tries to repress through counting [compulsions]) Treatment of OCD: CBT, SSRIs, Clomipramine, Venlafaxine
• For mild agitation and anxiety, give a benzodiazepine • For agitation and psychosis you'd normally give an antipsychotic, but this patient has a prolonged QT interval, so Ziprasidone is contraindicated
Clonazepam
11. A 32-year-old man is brought to the emergency department by his roommate...
Clonazepam Young patient with known history of cocaine use who presents with agitation, fever, hypertension and ECG changes, with the first-line treatment for cocaine-induced HTN being benzodiazepines Key idea: Only differences between treating a cocaine-induced myocardial infarction vs a normal myocardial infarction is that you should NOT use a beta blocker (due to risk of unopposed alpha agonism) and you should give patient a benzodiazepine
• Benzodiazepine for treatment of insomnia
Clonazepam therapy
49. A 57-year-old woman comes to the physician because of difficulty sleeping...
Clonazepam therapy Patient with adjustment disorder (psychosocial stress not meeting criteria for other condition following a traumatic/stressful event) who also has associated insomnia and therefore can receive symptomatic treatment with benzo's or non-benzo drugs (zolpidem, etc.) Key idea: Adjustment disorder is primarily treated with CBT, but patients can receive pharmacologic therapy for specific symptoms (anxiety, insomnia, etc.) Key idea: If a patient on NBME has family/personal history of alcohol use disorder, then they should NOT receive benzodiazepines (similar mechanism of action) Biofeedback: Used for complex pain disorders
WBC plummets to 200 cells 2 weeks after beginning SCZ tx
Clozapine
• "Sometimes she appears withdrawn/lethargic and other times appears energetic" is consistent with substance abuse • Dilated pupils (without nystagmus), impulsivity, delusion = cocaine abuse (she's a financial analyst...)
Cocaine abuse
21. A 32-year-old financial analyst comes to the physician at her employer's request because of bizarre behavior...
Cocaine abuse Young woman with 6 month history of changes in behavior (including long lunch breaks) paranoia, sympathetic hyperactivity (tachycardia, hypertension, mydriasis) and pressured speech most consistent with cocaine abuse/intoxication Key idea: Signs of sympathetic activity and dilated pupils -> Patient does NOT have a pure psychiatric disorder (such as bipolar disorder or schizophrenia) and likely has a non-psychiatric medical condition or is using substances Key idea: PCP abuse would be associated with more violent behavior and nystagmus
• This patient has a specific phobia (heights & elevators) • Tx: CBT with exposure
Cognitive behavior therapy
• This patient has panic disorder • Tx: CBT ± SSRI/SNRI
Cognitive behavioral therapy
22. A 23-year-old man comes to the physician because of anxiety since beginning a second part-time job as a courier...
Cognitive behavioral therapy Young man with specific phobia of elevators which is best treated with exposure-response treatment which is a type of cognitive behavioral therapy
35. Over the past 6 months, a 24-year-old woman has had 12 episodes of sudden apprehension associated...
Cognitive behavioral therapy Young woman with unprovoked panic attacks who does not want pharmacotherapy and therefore can be managed with cognitive behavior therapy Hypnotherapy -> Drug/substance use history Psychodynamic therapy -> Personality disorders primarily Acute panic attack -> Benzodiazepines Chronic panic attacks or panic disorder -> SSRI/SNRI + CBT Key idea: This patient technically does NOT have panic disorder because they do not have anxiety associated with unprovoked panic attacks
• Repetitive and pervasive behavior that violates the basic rights of others or societal norms (eg, aggression to people and animals, destruction of property, theft) • The kid killed his cat with no remorse...
Conduct disorder
• Repetitive and pervasive behavior that violates the basic rights of others or societal norms (eg, destruction of property)
Conduct disorder
46. A 15-year-old boy is brought to the physician by his parents because "he does whatever he wants and comes...
Conduct disorder 15 year old boy with chronic history of repeated disregard for rights of others without remorse (arrests, assaults, drug use, tattoos/piercings), most consistent with conduct disorder Key idea: Conduct disorder diagnosed if patient is younger than 15 years old, whereas antisocial personality disorder can only be diagnosed in an adult who ALSO had conduct disorder when they were younger Intermittent explosive disorder: Bouts of verbal/physical aggression that is out of proportion to the provocation followed by regret, dysphoria or embarrassment
crime/lack of remorse after doing really bad thing but prior to 18
Conduct disorder ODD can be a similarly presenting disorder used to trip up people
44. A 10-year-old boy is brought by his parents for a well-child examination. His...
Conduct disorder Young boy with bad behavior who also demonstrates socially unacceptable behavior (killing family cat, getting in fights and having bruising), most consistent with conduct disorder Key idea: Conduct disorder diagnosed if patient is younger than 15 years old, whereas antisocial personality disorder can only be diagnosed in an adult who ALSO had conduct disorder when they were younger
• Children who are victims of physical abuse often avoid eye contact on physical exam
Contact child protective services
37 yo F comes to the ED complaining of left arm weakness for the past 6 hrs. PE and complete neurological exam including brain imaging is negative.
Conversion Disorder.
• Loss of sensory or motor function following an acute stressor • La belle indifference = patient is aware but indifferent toward symptoms
Conversion disorder
2. A 57-year-old woman comes to the physician because of progressive loss of...
Conversion disorder Woman who experienced a significantly traumatic event and has had persistent mood symptoms and associated, unexplained neurological symptom, most consistent with Conversion disorder
• Glucocorticoids, particularly at high doses, are often implicated in new-onset psychotic symptoms
Corticosteroid-induced psychotic disorder
52F + 8-week Hx of progressive confusion and memory loss + myoclonus; Dx?
Creutzfeldt-Jakob syndrome (prion disease).
• Rapidly progressive dementia (weeks to months) • Periodic sharp waves on EEG • ↑ 14-3-3 protein in CSF
Creutzfeldt-Jakob disease
16. A previously healthy 57-year-old woman comes to the physician with her...
Creutzfeldt-Jakob disease Previously healthy man who has experienced rapidly progressive dementia + neurological symptoms + Startle myoclonus + Periodic sharp waves on EEG, all consistent with Creutzfeldt-Jakob disease (prion disease) Etiologies: Familial/acquired, cannibal behavior, CNS transplant (retinal transplant, etc.) Clinical features: Rapidly progressive dementia, myoclonus (high yield association for NBME), other neurological symptoms Lab findings: Increased 14-3-3 in CSF, Periodic sharp waves on EEG, Caudate/putamen MRI findings, Spongiform changes
42F + 3-month Hx of insomnia + discomfort while lying in bed + serum iron and ferritin are normal; next best step in management?
D2 agonist - i.e., pramipexole or ropinirole, etc.
-Aripiprazole is classically regarded as an antagonist at
DA receptors. However, it's true MOA is as a partial agonist at DA receptors.
• The psychotic symptoms of Parkinson's disease may be treated with dose reduction of antiparkinson agents and/or low potency antipsychotics (eg, quetiapine) • In the elderly (this patient is 87) it is better to remove medications rather than adding more if it will lead to the sam result
Decrease the dosage of carbidopa-levodopa
23. An 87-year-old man who resides in a skilled nursing care facility is brought to...
Decrease the dosage of carbidopa-levodopa Older patient with Parkinson's with a recent increase in carbidopa-levodopa who since then has experienced delusions (staff stealing items) and hallucinations (auditory), most consistent with Carbidopa-levodopa associated psychosis Key idea: Parkinson's disease associated with low dopamine levels whereas schizophrenia/psychosis associated with increased dopamine levels Key idea: If decreasing carbidopa-levodopa dose does not relieve psychosis or if patient's Parkinson's symptoms progress following decrease in dose, then next step would be a low-potency second-generation antipsychotic such as quetiapine
• Narcolepsy sleep changes: ↓ sleep latency, ↓ REM latency, ↓ sleep efficiency
Decreased REM latency
24. A 26-year-old man comes to the physician because of increasing daytime sleepiness over the past 3 years. He has begun...
Decreased REM latency Young man with 3 year history of lapses into sleep during the day with hypnagogic hallucinations most concerning for narcolepsy Narcolepsy diagnosis: Recurrent lapses into sleep at least 3 times for at least 3 months andAT LEAST 1 of the following :Cataplexy [brief loss of muscle tone with laughter or strong emotion]Low hypocretin-1 in CSFShortened REM sleep latency on polysomnography) Key idea: Often associated with sleep paralysis and hypnagogic (while going to sleep) or hypnapompic (upom waking up) hallucinations Key idea: Polysomnography used to evaluate for many sleep disorders, such as narcolepsy, periodic limb movement disorder, REM sleep behavior disorder and sleep apnea
• Haloperidol is a typical antipsychotic that blocks dopamine D2 receptors
Decreased binding of dopamine at the postsynaptic receptor
17. An 8-year-old boy is brought to the physician by his mother because of a...
Decreased binding of dopamine at the postsynaptic receptor Young patient with ADHD and Tourettes who receives haloperidol, which is a dopamine receptor antagonist Key idea: Psychosis associated with increased dopamine binding within the mesocortical/mesolimbic tracts whereas Parkinson's associated with decreased dopamine binding within the nigrostriatal pathway
• The neurotransmitters that are decreased in depression include dopamine, norepinephrine, and serotonin • Delayed REM sleep on nighttime polysomnography is seen in delayed phase sleep disorder • Enlarged lateral ventricles is seen in schizophrenia • Increased sensitivity to lactate infusion is seen in generalized anxiety disorder
Decreased concentration of 5-hydroxyindoleacetic acid in cerebrospinal fluid analysis
34. A 37-year-old woman is admitted to the hospital after a suicide attempt by an...
Decreased concentration of 5-hydroxyindoleacetic acid in cerebrospinal fluid analysis Patient with major depressive disorder who would therefore have decreased 5-HIAA in CSF because 5-HIAA is a breakdown product of serotonin and patients with depression have decreased serotonin levels (reason why SSRIs are first-line medication)
• Anorexia → malnutrition → ↓ albumin → ↓ oncotic pressure → edema • Low albumin denotes low synthetic capacity of the liver secondary to malnourishment
Decreased serum albumin concentration
30. A 20-year-old woman is admitted to the hospital because of severe swelling of the lower extremities...
Decreased serum albumin concentration Young woman with severely diminished BMI (<15) in the setting of anorexia nervosa (still believes she is fat and is working out obsessively +/- using laxatives/diuretics) found to have lower extremity edema likely due to decreased albumin concentration Key idea: Albumin main component of oncotic pressure, which helps to hold fluid in vessels so in a patient who is malnourised -> low protein levels -> low albumin -> low oncotic pressure -> increased gradient for fluid to move from vessels to tissue Key idea: Anorexia nervosa diagnosed by BMI<18.5
A 27 yo F is given a warning letter for the 4th episode of lateness since beginning a new job 4 days ago. She graduated as a mechanical engineer from Insomnia College. She was always able to get bye in college since classes were not mandatory. She denies having daytime sleepiness and gets 8 hrs of sleep every night. Her new job requires her to be at work by 9 AM. She has been getting to work at 11.45 AM
Delayed Sleep Phase Disorder (good sleep, but this person goes to sleep super late at night).
• Certain antiparkinson drugs (eg, benztropine, trihexyphenidyl) curb excess cholinergic activity → side effects of dry mouth, flushed skin, tachycardia, etc.
Delirium due to anticholinergic medication
26. A homeless 27-year-old man who is being treated with antipsychotic and antiparkinsonian drugs comes to the emergency department...
Delirium due to anticholinergic medication Patient receiving antipsychotic and antiparkinsonian drugs who has signs of anticholinergic toxicity (urinary retention, hallucinations, altered mental status, vision problems, dry mouth, tachycardia, flushed skin) WITHOUT rigidity most consistent with anticholinergic toxicity from antiparkinsonian drugs Key idea: Potential treatments for Parkinson's increase dopamine levels (bromocriptine, pramipexole, selegiline etc.), increase L-dopa levels (carbidopa-levodopa, entacapone) or decrease cholinergic activity (benztropine, trihexyphenidyl)
• Fixed, persistent, false belief system lasting >1 month with otherwise normal functioning • Schizophrenia/Schizophreniform requires greater functional impairment and other psychotic symptoms (eg, hallucinations, disorganization, negative symptoms)
Delusional disorder
25. A 55-year-old woman is brought to the emergency department by her parents...
Delusional disorder Woman with multiple delusions for >1 month that have not significantly impaired her normal functioning, most consistent with delusional disorder Delusional disorder = Greater than 1 delusion for at least 1 month WITHOUT other psychotic features or significant impairment Tx: CBT + antipsychotics Key idea: Differentiate from personality disorders, which lead to pervasive patterns demonstrated through multiple features of an individual's behavior and NO delusions
A 27 yo F is found in her dorm room crying hysterically about a recent breakup. She is in distress over how her groceries and yearly taxes will be taken care of now her boyfriend is gone. He always took the "big decisions" at home.
Dependent PD
depend on others for everything
Dependent personality disorder
• Clozapine may lead to agranulocytosis (non-dose related) and seizures (dose related) • This patients leukocyte count is < 3000 and he has flu-like symptoms
Discontinue clozapine therapy
13. A 28-year-old man is brought to the emergency department because of flu-like symptoms and cough productive of...
Discontinue clozapine therapy Young man on clozapine therapy who presents with a respiratory infection but is found to have low WBC count, most concerning for infection secondary to agranulocytosis due to clozapine Indications for clozapine therapy:Treatment-resistant schizophreniaSchizophrenia associated with suicidality Adverse effects:Agranulocytosis (-> sore throat and fever with low WBC count, specifically neutrophils/PMNs)SeizuresMyocarditisMetabolic syndrome Mnemonic: Patients on CLOZapine need to be watched "CLOZ"ely
• TCA may cause prolonged QT • Tx: Stop medication and give NaHCO3 (prevents arrhythmia)
Discontinue desipramine therapy
20. An 8-year-old boy is brought for a school physical examination. He was diagnosed with attention-deficit/hyperactivity disorder...
Discontinue desipramine therapy Young boy with ADHD treated with desipramine (which is a TCA) who is asymptomatic but has ECG changes consistent with TCA toxicity and therefore should have the desipramine discontinued Key idea: Signs of TCA toxicity include:Anti-cholinergic symptoms: Dry mouth, overheated, mydriasis, constipation, etc.Anti-alpha 1 symptoms: Hypotension, tachycardiaAnti-histamine symptoms: Mental status changes Key idea: Serious signs of TCA toxicity include ECG changes (can affect PR interval, QRS interval or QT interval) and patients with QRS widening or ventricular arrhythmias should be treated with IV sodium bicarbonate TCA drugs: Amitriptyline, Nortriptyline, imipramine, desipramine, clomipramine, doxepin, amoxapine
• TCA toxicity → Coma, Convulsions, Cardiotoxicity (arrhythmia), prolonged QT interval • Tx: ECG, NaHCO3
Discontinue doxepin
15. A 62-year-old woman is brought to the emergency department by her husband because of confusion for...
Discontinue doxepin Middle-aged woman on a TCA (doxepin) who is showing signs of anti-histamine toxicity (confusion), anti-cholinergic toxicity (mydriasis, dry skin) and ECG changes (AV block with widened QRS complex), which is consistent with TCA toxicity and should be treated by discontinuing doxepin and starting IV sodium bicarbonate for the ECG changes
45. A 52-year-old woman comes to the physician for a routine follow-up examination. She has received...
Discontinue haloperidol and begin risperidone Middle-aged woman with severe schizophrenia who has been treated with haloperidol for the past 20 years and has developed signs of tardive dyskinesia (smacks her lips and protrudes her tongue) and therefore should discontinue high-potency antipsychotic and start an atypical antipsychotic (such as risperidone) Key idea: Patient's schizophrenia is so severe that we cannot only discontinue haloperidol and not start her on another antipsychotic with lower extrapyramidal risks Chlorpromazine is a low-potency typical antipsychotic which carries more extrapyramidal risk than an atypical antipsychotic such as risperidone Key idea: High-potency typical antipsychotics (Haloperidol, Trifluoperazone, Fluphenazine) are most associated with extrapyramidal side effects of antipsychotics (acute dystonia, Parkinsonism, Akathisia, Tardive dyskinesia)
• This patient is experiencing Tardive dyskinesia • This patient has attempted suicide twice, and therefore is not a candidate for drug cessation • Second generation antipsychotics are less likely to cause EPS than first generation antipsychotics (eg, haloperidol)
Discontinue heloperidol and begin risperidone
• Absence of 2° pubertal development is normal in girls ≤ 14, and boys ≤ 15
Discuss normal pubertal development
5. A 13-year-old girl is brought to the physician by her mother because she has not...
Discuss normal pubertal development 13 year old girl who has not yet menstruated but has secondary sexual characteristics (Tanner Stage 2) and therefore is still within normal development range Key idea: Primary amenorrhea diagnosed if (1) Lack of menses and secondary sexual characteristics by age 13 OR (2) Lack of menses (regardless of secondary sexual characteristics) by age 15
• This patient has depersonalization/derealization disorder • Acute stress (accident at construction site) → detachment from one's own thoughts, actions, or environment; patients often seem like they're in a fog or spaced out and in their own world • Personal information collected from interpreter makes the diagnosis of dissociative amnesia unlikely
Dissociative disorder
8. A 32-year-old Bosnian man is brought to the emergency department by police 30 minutes after they found...
Dissociative disorder Young man who recently experienced a traumatic event who now has trouble answering basic questions most consistent with some form of dissociative disorder, potentially dissociative fugue Adjustment disorder: Often leads to sadness or anxiety in reaction to stressor Catatonia: More severe presentation characterized by waxy flexibility, repeating other people's behaviors or words, negativism, etc. Generalized anxiety disorder: Need symptoms for >6 months Schizotypal PD: Magical thinking and odd behaviors consistently and for a long time
• Dissociative amnesia is an inability to recall important personal information • Dissociative fugue is a subtype of dissociative amnesia characterized by travel or wandering
Dissociative fugue
46. A 37-year-old woman is brought to the emergency department by police...
Dissociative fugue Key idea: Woman is unable to give her name or where she lives, so we know that we are dealing with a dissociative disorder Dissociative fugue: Dissociative amnesia (cannot remember personal information such as name, address, etc.) accompanied by travel/wandering that is often seen following significant traumatic event or stressor
Our test patient is opioid dependent. Given the following responses in a physician conversation, what is the most likely "stage of change"? Doc I don't want to discuss this right now. Doc, I plan to quit after the shelf exam. I have registered for a Suboxone program in the community. Doc, I have been doing pretty well since I completed the Suboxone program. I have severed relationships with all my "druggie" buddies so I don't fall back into old patterns of behavior. I'll visit you monthly to check in on my progress. I recognize I have a heroine problem, I just can't quit right now. Doc, I am currently in a Suboxone program.
Doc I don't want to discuss this right now-Precontemplation. Doc, I plan to quit after the shelf exam. I have registered for a Suboxone program in the community-Preparation. Doc, I have been doing pretty well since I completed the Suboxone program. I have severed relationships with all my "druggie" buddies so I don't fall back into old patterns of behavior. I'll visit you monthly to check in on my progress-Maintenance. I recognize I have a heroine problem, I just can't quit right now-Contemplation. Doc, I am currently in a Suboxone program-Action.
• Blockade of the nigrostriatal dopamine pathway is responsible for EPS in patients taking antipsychotics
Dopamine
14. Fifteen minutes after administration of intramuscular haloperidol, a 21-year-old...
Dopamine Patient recently given haloperidol who develops acute dystonia (antipsychotics inhibit dopamine receptor binding) Key idea: Extrapyramidal symptoms associated with antipsychotics include (1) Acute dystonia: Sudden, sustained contraction of neck, eye muscles, etc./ tx: benztropine, diphenhydramine (2) Akathisia: Restlessness that worsens with escalating antipsychotic use / tx: benztropine, beta blocker, benzo / (3) Parkinsonism: Resting tremor, rigidity, shuffling gate, etc. / tx: benztropine, amantadine (4) Tardive dyskinesia: Prolonged antipsychotic therapy with dyskinesia of the mouth, face and extremities / tx: Valbenazine and deutetrabenazine
• Epicanthal folds, cardiac murmur, developmental delay
Down syndrome
49. A 5-year-old girl is brought to the physician by her parents because of difficulty...
Down syndrome Young child with trouble in school who is playful with epicanthal folds and a heart murmur (most consistent with a VSD), most consistent with down syndrome Key idea: Most common congenital heart defect associated with down syndrome is AV Key idea: In an infant, down syndrome often characterized by hypotonia and poor feeding Fetal alcohol syndrome: Smooth philthrum, microcephaly, thin vermillion border, small palpebral fissures Fragile X syndrome: Long narrow face with large ears, macrocephaly, prominent chin/forehead and macro-orchidism in post-pubertal patient
• Neuroleptic malignant syndrome: Fever, Muscle rigidity, Abnormal vitals, ↑ CK
Drug reaction
25. A 24-year-old man is brought to the emergency department from a psychiatric hospital because of a decreasing level...
Drug reaction Young adult receiving haloperidol who presents with signs most consistent with neuroleptic syndrome Symptoms of neuroleptic malignant syndrome can be remembered with mnemonic Malignant FEVER: Myoglobinuria, Fever, Encephalopathy, Vitals unstable, increased CK Enzymes, Rigidity Note: Patient has normal CSF findings so infectious encephalitis/meningitis ruled out Signs of catatonia: Stupor, waxy flexibility, negativism, etc.
• OTC cold medications (pseudoephedrine, ephedrine, antihistamines, antitussives) should be used cautiously in young children, with recommended doses not exceeded, as they can have unwanted side effects including confusion and hallucinations
Drug toxicity
38. A 5-year-old boy has had temperatures to 38.9 C (102 F), cough, and coryza for 2 days and visual hallucinations of animals...
Drug toxicity Young boy who has been treated with OTC cold medicine who has developed visual hallucinations most consistent with the anti-histamine effects of these cold medications Key idea: Just like elderly patients are particularly sensitive to anti-cholinergic and anti-histamine effects of medications, so are young children
32. A 27-year-old man is brought to the emergency department 30 minutes after his brother found him agitated, tremulous...
Drug-drug interaction Young male patient on a TCA who has recently been switched to a MAO inhibitor (tranylcypromine) from an SSRI without an adequate washout period (often need washout period of at least 14 days) who presents with symptoms concerning for serotonin syndrome (3 A: Autonomic hyperactivity (fever, tachycardia, hypertension, diaphoresis), Agitation, increased Activity (tremulous, increased DTRs)) most likely due to excessive drug effects Key idea: MAO inhibitors and TCA inhibitors are both highly associated with serotonin syndrome especially when given together or with other drugs that can cause serotonin syndrome such as SSRIs, linezolid, triptans, St. Johns Wort, etc. Key idea: Patients on MAO-inhibitors need to avoid high tyramine foods such as cured and processed meats/cheese and alcohol, with peanut butter NOT being a food known for high tyramine levels Key idea: Abrupt discontinuation of fluoxetine can lead to SSRI discontinuation syndrome, but the symptoms would be flu-like illness, anxiety, dysphoria, etc.
• Switching from most antidepressants to a MAOI requires a 2-week washout; Fluoxetine, an SSRI, has a relatively long half-life and requires a 5 week washout • Excess serotonin → serotonin syndrome
Durg-drug interaction
22M + 1mm pupils + RR of 8 + stuporous; Dx + Tx?
Dx = Opioid/heroin overdose; Tx = naloxone.
64M + Parkinson disease + 2-month Hx of paranoid behavior; Dx + Tx?
Dx is Parkinson disease psychosis (PDP); Tx on shelf = quetiapine (can Tx with quetiapine or clonidine).
How to Dx + Tx carcinoid syndrome?
Dx with urinary 5-HIAA (5-hydroxyindole acetic acid); Tx with octreotide, among other agents.
• This child is likely having seizures and should be evaluated with an EEG • "Spit" = drooling, "blood" = from biting tongue, "takes his power" = loss of consciousness
EEG
18. An unconscious 7-year-old boy is brought to the emergency department by his parents. The family emigrated from rural...
EEG 7 year old boy is brought to ED for chronic episodes where he "becomes possessed" and then becomes confused with depressed mental status which is likely related to epilepsy or seizure disorder -> Work-up with EEG given chronic history and potential secondary intellectual disability Contact child protective services: Patients may not have good health literacy, but they don't seem to be actively hurting the child
10M + family comes from rural Asian town + family says child episodes in which he is "possessed" and has episodes of spitting up blood + parents seem well-supportive; next best step in Dx?
EEG is correct; the wrong answer is contacting child protective services; tongue or cheek biting during a seizure can lead to post-ictal blood in saliva; students hate this type of question, but Psych shelf asks Qs assessing sensitivity to cultural beliefs.
43. A 67-year-old woman, whose husband died 18 months ago, is admitted to the...
Elderly woman with depressed mood, low energy, decreased appetite, somatic symptoms and mood-congruent psychosis, most consistent with major depressive disorder with psychotic features Adjustment disorder: Occurs within 3 months of stressor and leads to impairment not on the level of MDD or other psych conditions Delusional disorder: 1+ delusions for >1 month that does not lead to significant impairment
• ECT is appropriate for severely depressed geriatric patients who require rapid intervention • Antidepressants + antipsychotics would take too long to be effective
Electroconvulsive therapy
42. An 87-year-old man is admitted to the hospital because of dehydration and emaciation. He appears catatonic and is...
Electroconvulsive therapy Indications for electroconvulsive therapy:Treatment-resistant depressionDepression with psychotic featuresEmergency conditions (pregnancy, refusal to eat/drink, catatonia, imminent risk for suicide) Key idea: NO absolute contraindications to electroconvulsive therapy and generally well-tolerated
CT scans of patients with schizophrenia often show ventriculomegaly (particularly the lateral cerebral ventricles) and diffuse cortical atrophy
Enlarged lateral and third ventricles on CT scan of the head
44. A 37-year-old man is brought to the emergency department by police after he was found wandering on the street...
Enlarged lateral and third ventricles on CT scan of the head Young man with signs of schizophrenia (delusions, hallucinations, etc.) who would therefore likely have enlarged ventricles in his brain (associated specifically with schizophrenia) Key idea: Patients with psychosis do not have global increased dopamine levels, but rather increased dopamine levels in the mesolimbic and mesocortical tracts of the brain Causes of cerebral edema: Trauma, stroke, infection, DKA, etc. Increased copper levels -> Wilson's disease (psychosis, parkinsonian-movement disorders, liver disease and Kayser-Fleischer rings in the eyes) Temporal spikes on EEG -> Temporal lobe epilepsy -> Minute-long episodes with loss of consciousness with lip smacking, smelling burnt rubber, hearing hissing sounds, etc.
• Ethylene glycol (antifreeze) → glycoaldehyde (toxic) → glycolate (anion gap) → calcium oxalate → kidney stones • Methanol (moonshine) → formaldehyde (toxic) → formate → blindness • Ethanol → acetaldehyde (toxic) → acetate (non-toxic)
Ethylene glycol toxicity
1: A 52-year-old homeless man with alcoholism is brought to the emergency by police after being found...
Ethylene glycol toxicity Middle-aged homeless man with alcohol use disorder who presents with confusion/agitation and oxalate crystals in his urine, most consistent with ethylene glycol toxicity Ethylene glycol can lead to renal pathologies via 2 mechanisms corresponding to the 2 metabolites because when it is metabolized to glycolic acid it can lead to acute tubular necrosis whereas if it is metabolized to oxalic acid it can lead to precipitation of calcium oxalate stones Methanol -> Eye symptoms (blindness, blurred vision, painful eye movements, etc.)
• This patients bipolar disorder has been well controlled with his medication, and the importance of maintaining this should be explained
Explain the risk of illness recurrence without medication
50. A 23-year-old man with a 3-year history of bipolar disorder well controlled with...
Explain the risk of illness recurrence without medication Key idea: In contrast to major depression (in which majority of patients do NOT need lifelong therapy), basically all patients with bipolar disorder require lifelong therapy (risk of recurrence of mania/depression very high!)
22. A 25-year-old primigravid woman at 16 weeks' gestation has had increased...
Explanation of risks and benefits of antidepressant therapy Pregnant woman who has a history of recurrent MDD and presents with symptoms consistent with depression (depressed mood + SIGECAPS) who should be started on psychotherapy + pharmacotherapy Key idea: In pregnant women, first-line antidepressant is SSRI (except paroxetine) as they have been shown to be safe in pregnant women Key idea: Woman is not currently suicidal, and therefore does not need to be involuntarily admitted to the hospital
• This patients depression has returned and she should have the risks and benefits of restarting an antidepressant explained to her • This patient has no suicidal or homicidal ideation; deliberating about an abortion doesn't merit hospitalization
Explanation of the risk and benefits of antidepressant therapy
7M + prominent ears + flattened nasal bridge + long philtrum + low IQ; Dx?
FAS, not Fragile X; the Q mentions the philtrum.
• Epicanthal folds, small palpebral fissures, low nasal bridge, smooth philtrum, thin vermillion border • Single palmar crease is sensitive but not specific for Down syndrome
Fetal alcohol syndrome
• Facial abnormalities in FAS: long smooth philtrum, thin vermillion border, small palpebral fissures
Fetal alcohol syndrome
29. An 8-month-old male infant who was adopted recently is brought to the physician because of poor weight gain...
Fetal alcohol syndrome 8 month old infant brought in for poor weight gain with narrow palpebral fissures, thin upper lip and a smooth/indistinct nasal philtrum which are highly specific for fetal alcohol syndrome Fetal alcohol syndrome -> intellectual disability, behavior problems, smooth philtrum, microcephaly, small patient Celiac disease -> Steatorrhea, weight loss, vesicular rash on extensor surfaces, iron deficiency anemia (due to villous blunting in the duodenum) Down syndrome -> Can also have epicanthal folds and single palmar crease but more associated with intellectual disability (which this patient does not have), hypertonia, enlarged tongue, and low-set ears Psychosocial deprivation -> Global delay in milestones Silver-Russell syndrome:
18. A 7-year-old boy is brought to the physician by his adoptive parents because of ongoing concern...
Fetal alcohol syndrome Young boy born to a mother with known substance abuse who is small with trouble in school, bad behavior and facial features with a long philtrum, most consistent with fetal alcohol syndrome Key idea: Facial features that are most associated with fetal alcohol syndrome are smooth philtrum, thin vermillion border, microcephaly and small palpebral fissures Angelman syndrome: Intellectual disability, seizures, ataxia and inappropriate laughing ("happy puppet") Fragile X syndrome: Long face, large forehead, prominent ears, macrocephaly (in adolescence) Rett disorder: Female toddler who initially has normal development but then begins to display regression of milestones + stereotyped hand movements Shaken baby syndrome: Baby with subdural hematoma due to tearing of bridging veins
Long half life prevents withdrawal with discontinuation
Fluoxetine
• Complex partial seizure most commonly arise from the temporal lobe, which is confirmed by smelling burnt rubber and hissing noise - spikes on EEG localize the seizure activity • Burst suppression pattern = patients with inactivated brain (eg, coma) • Hypsarrhythmia = infantile spasms • Diffuse 3-Hz spike and slow wave activity = absence seizures • Triphasic wave = toxic metabolic encephalopathy
Focal spikes localized to the temporal lobe
48. A 42-year-old man is brought to the physician by his wife because of a 2-month...
Focal spikes localized to the temporal lobe Middle-aged man who recently sustained head trauma who has since developed intermittent episodes that last 1-2 minutes with simple automatisms in which he smells burnt rubber and hears an intense hissing sound, most consistent with temporal lobe epilepsy Key idea: Important to contrast with absence seizures, which more commonly occur in children and lead to frequent episodes <30 seconds with simple automatisms but NO post-ictal confusion
• Intermittent blurred vision, focal neurologic changes, and paresthesia affecting a woman in her 30s is concerning for Multiple sclerosis • Brain imaging would show Periventricular plaques and Multiple white matter lesions disseminated in time & space
Focal white matter lesions
17. A 37-year-old woman comes to the physician with her husband because of a 1-year history of fatigue...
Focal white matter lesions Young woman who presents with neurological symptoms disseminated in time and space (blurry vision, leg numbness, memory problems) most consistent with multiple sclerosis (which is a demyelinating disease that leads to focal white matter lesions) Key idea: Patient's history of leg numbness that worsens with long walks likely consistent with Uhthoff's phenomenon (MS symptoms worsen in heat), which is often tested on NBME by saying that patient's symptoms worsen with exercise or have come on/worsened since moving to Florida, Arizona, etc. Key idea: Neurological symptoms consistent with multiple sclerosis on NBME exam include optic neuritis (unilateral painful eye with blurry vision)
5. An 8-year-old boy is brought to the physician for evaluation of difficulty reading...
Fragile site on the X chromosome Young boy with intellectual disability, signs of autism (hand-flapping), and unique facial features (large forehead, large ears, prominent jaw), most consistent with Fragile X syndrome Key idea: X-linked recessive gene and therefore will only be seen in males on NBME Key idea: Patients with fragile X syndrome often have comorbid autism spectrum disorder
• High forehead, large everted ears, prominent jaw, low IQ = Fragile X syndrome • Fragile sites are discontinuity of staining in the region of the trinucleotide repeat on the long arm of the X chromosome (a diagnostic lab artifact)
Fragile site on the X-chromosome
-Atrophy of frontal and temporal lobes. Spares the posterior ⅔ of the superior temporal gyrus. -Intracytoplasmic and intranuclear inclusions made of hyperphosphorylated tau protein. -6 mo history of personality changes and inappropriate behavior
Frontotemporal Dementia
-Excessive anxiety and worry > 50% of the time over a preceding 7 mo period. -Restlessness, fatigue, declining grades, insomnia. -Agitated at the slightest provocation. -Citalopram is one possible drug choice for this disorder.
GAD
Mrs. X is a med student. She constantly feels irritable and has trouble sleeping. Her friends describe her as a "light fuse" that can pop at any time. She is always fearful and worried about paying tuition, passing board exams, keeping her home safe, paying taxes, keeping her home clean, etc. She has experienced these sxs more than 50% of the time over the last 8 mo
Generalized Anxiety Disorder. Give SSRIs, SNRIs, or Buspirone.
• Excessive and persistent worry about multiple issues for ≥6 months with significant distress or impairment • First-line tx: CBT + SSRI/SNRI
Generalized anxiety disorder
• Excessive anxiety/worry for ≥ 6 months with significant distress or impairment • Muscle tension, sleep disturbance, irritability, difficulty concentrating, and fatigue are common associated symptoms
Generalized anxiety disorder
10. An 8-year-old girl is brought to the physician by her mother because of frequent stomachaches over the past 3...
Generalized anxiety disorder Pediatric patient with >6 month history of worries/anxiety about multiple life stressors with somatization most consistent with generalized anxiety disorder Key idea: Formal diagnosis requires at least 6 months of symptoms with at least 3 of the following symptoms:RestlessnessFatigueDifficulty concentratingIrritabilityMuscle tensionSleep disturbance Separation anxiety disorder: Somatic symptoms, nightmares and difficulty sleeping associated with reluctance to leave parent/guardian due to fear of separation or excessive concern about bad events happening to parent/guardian
3. A 22-year-old woman comes to the physician because of a 3-year history of intermittent...
Generalized anxiety disorder Young patient with years of worries about multiple issues (college, bills, etc.) who also has somatic symptoms (headaches, diarrhea, muscle tension), most consistent with generalized anxiety disorder Key idea: Generalized anxiety disorder characterized by multiple issues for at least 6 months with at least 3 of the following symptoms (restlessness, fatigue, difficulty concentrating, muscle tension, irritability, sleep problems)
-Exposure and response prevention is a
HY treatment for OCD
• Perceptual distortion (visual), anxiety, paranoia, negative urine toxicology (LSD isn't included on a standard drug test)
Hallucinogen intoxication
29. A previously healthy 25-year-old woman is brought to the emergency department...
Hallucinogen intoxication Young woman with hallucinations and mydriasis without other signs of sympathetic overstimulation with a negative urine tox screen, most consistent with LSD intoxication Key idea: Standard urine drug screen picks up on amphetamine, cocaine, cannabis, opioids and PCP
Highest risk of extrapyramidal side effects
Haloperidol
Patient X comes for a doc's appointment. Patient X has been making suggestive remarks to a few of the patients waiting for their own appointments. Patient X is "dressed to kill"
Histrionic PD
25 yo F is the center of attention in the waiting room of a community cardiologists office. She has held conversations with 6 men in the 45 minutes she has spent waiting for her appointment. She is dressed in a sexually suggestive fashion
Histrionic personality disorder. These people are attention seeking. They tend to be overly dramatic and emotional.
46 yo M has a long history of multiple ED visits. During the interview he consistently expresses worry about having colon, gastric, and renal cancer. His PE is normal and he has no history of weight loss or other constitutional symptoms
Hypochondriasis (now Illness Anxiety Disorder, no "real" somatic symptoms vs somatic symptom disorder where there are real somatic sxs that cause the patient extensive worry, tx with regularly scheduled physician visits). Consider Conversion Disorder in the setting of weird "neurological" signs with a recent stressor.
How to Dx MG vs LE?
If both are listed, choose antibodies over Tensilon (edrophonium) test.
• Recurrent vomiting → parodic gland enlargement/inflammation → ↑ Amylase
Increased amylase activity
16. A 27-year-old woman comes to the physician for an examination prior to starting a new job. She has...
Increased amylase activity Young woman with bulimia nervosa (normal weight with history of binge-eating with compensatory behaviors) who would therefore likely have increased amylase activity because recurrent vomiting leads to increased salivary production of amylase Key idea: Both bulimia nervosa and anorexia nervosa can be associated with purging behavior (vomiting, exercise, etc.), with the difference being that anorexia patients will have BMI < 18.5 and bulimia patients will have normal weight and history of binge eating Vomiting -> Loss of hydrogen chloride (HCl) -> Metabolic alkalosis (high serum bicarb) and hypochloremia Vomiting -> Hypovolemia -> Activation of RAAS system -> Increased aldosterone levels (which leads to hypokalemia because aldosterone mediates reabsorption of sodium in exchange for potassium and hydrogen ions at the collecting ducts via ENaC channels) and increased ADH levels (which leads to hyponatremia due to increased reabsorption of free water at the collecting ducts via aquaporin channels)
• Tardive dyskinesia develops in the meeting of prolonged exposure to dopamine-blocking agents, which is thought to result in the up regulation and super- sensitivity of dopamine receptors
Increased sensitivity of the dopamine receptors
9. A 52-year-old man with schizophrenia comes to the physician for a follow-up examination. At his last examination...
Increased sensitivity of the dopamine receptors Patient with chronic history of schizophrenia treated with antipsychotics who presents with abnormal tongue movements and choreoathetoid movements most consistent with tardive dyskinesia, which is due to increased sensitivity of the dopamine receptors In setting of chronic antipsychotic use, patient has had chronic inhibition of dopamine receptors -> Compensatory upregulation of dopamine receptors leading to increased sensitivity of dopamine receptors because more of them are around ready to be bound by dopamine KEY IDEA: The reason patients experience withdrawal symptoms related to drugs/substances often related to up-regulation of receptors (if they are taking a receptor inhibitor) or down-regulation of certain receptors (if they are taking a receptor agonist) Example: Patients with chronic alcoholism -> Chronic stimulation of GABA receptors by alcohol -> Down-regulation of GABA receptors (which are responsible for tempering/calming nervous sytem), such that when patient stops taking alcohol they lose increased GABA related to alcohol, leading to relatively decreased binding of GABA to GABA receptors -> overstimulation of brain -> seizures, delirium tremens, etc.
• MDD is associated with hyperactivity of the HPA axis → ↑ cortisol • MDD patients may have an atypical (failure to suppress) dexamethasone suppression test
Increased serum cortisol concentration
20. A 72-year-old woman comes to the physician because of a 3-month history of fatigue and difficulty sleeping...
Increased serum cortisol concentration Elderly woman with signs of major depressive disorder (fatigue, insomnia, decreased appetite, hopelessness, etc.) which is associated with increased serum cortisol levels Decreased hemoglobin -> Anemia -> Shortness of breath, low energy, etc.In this age demographic, next best step would be colonoscopy Decreased thiamine -> Wernicke-Korsakoff syndrome Increased percentage of bands -> Increased PMNs/Neutrophils -> Acute infection Increased serum prolactin -> Galactorrhea, sexual dysfunction, etc.
Dysfunction of the Suprachiasmatic Nucleus is observed in
Insomnia
22M + hyperoralism + hyperphagia + docility; Dx?
Kluver-Bucy syndrome à bilateral amygdala lesions.
44F + difficulty getting up from chair but is able to after several attempts; Dx?
LE
44F + proximal muscle weakness + able to perform upward gaze without a problem for 60 seconds; Dx?
Lambert-Eaton (LE) syndrome (if cannot perform, answer = MG).
• Parkinsonism, Hallucination, Dementia (LEWY has a PHD)
Lewy body dementia
37. A 77-year-old man is brought to the physician by his wife because of a 6-month...
Lewy body dementia Older patient with dementia + visual hallucinations + parkinsonism (shuffling gait, akinesia) most consistent with Lewy body dementia Key idea: Lewy body dementia diagnosed by (1) Dementia AND (2) At least 2 of the following (visual hallucinations, parkinsonism, fluctuating cognition and REM sleep behavior disorder) Key idea: For NBME exams, if parkinsonism predates cognitive impairment by >1 year, then patient has Parkinson disease, whereas if parkinsonism and dementia occur <1 year apart then patient has Lewy body dementia
65M + visual hallucinations + bradykinesia + gradual cognitive decline; Dx?
Lewy body dementia.
• NSAIDS → ↓ renal clearance → ↑ lithium levels → toxicity
Lithium
49. A 47-year-old woman is brought to the emergency department by her husband because of increasing confusion...
Lithium Middle-aged woman with bipolar disorder (which is almost always treated with lithium > valproate) who has been taking higher amounts of NSAIDs recently who presents with confusion, tremor, and AV block most consistent with lithium toxicity Key idea: Common signs of lithium toxicity are GI symptoms, confusion, tremors/fasciculations and seizures +/- ECG changes Key idea: Common triggers of lithium toxicity are drugs that affect the function of the kidney, most often thiazides, ACE inhibitors, nephrotoxic agents and NSAIDs (which leads to afferent arteriole vasoconstriction) Key idea: Indications for hemodialysis in setting of lithium toxicity is serum lithium level > 4 mEq/L or serum lithium level > 2.5 mEq/L + signs of lithium toxicity (seizures, altered mental status) OR inability to secrete lithium (CKD, CHF, etc.)
UE tremors, cold intolerance, N/V/D, polyuria, polydipsia
Lithium side effects
• Catatonia: immobility, mutism, waxy flexibility • Tx: benzodiazepines (lorazepam), ECT
Lorazepam
• Performance only social anxiety disorder • Tx: β-blockers or benzodiazepines • This patient should receive a Benzo (β-blockers are contraindicated in asthma)
Lorazepam
• This patient has a specific phobia • 1st-line tx: CBT with exposure; short-acting benzodiazepines are helpful if therapy is unavailable or insufficient time
Lorazepam
13. A 46-year-old man is brought to the emergency department following a self-inflicted gunshot wound to the right upper...
Lorazepam Middle-aged man with chronic alcoholism who on hospital day 3 begins to develop anxiety, insomnia and tachycardia likely associated with alcohol withdrawal who should be managed with a short-acting benzodiazepine Key idea: Potential manifestations of alcohol withdrawal and time since last drink include (1) Nonspecific symptoms (3-36 hours): Tremors, insomnia, GI upset, agitation, diaphoresis, etc. (2) Withdrawal seizures (6-48 hours) (3) Alcoholic hallucinations (12-48 hours) (4) Delirium tremens: Altered mental status, tremors, autonomic hyperactivity, etc. (48-96 hours)
28. A 32-year-old man is admitted to the hospital because of refusal to speak or move since he returned home after being...
Lorazepam Young man who experienced a very traumatic event and presents with symptoms consistent with catatonia (mute, negativism, resists commands and being moved) which can be treated with benzodiazepines (lorazepam) or electroconvulsive therapy Signs of catatonia:Mutism and stuporNegativism (resistance to instructions or movements)Waxy flexibility (initial resistance to movement but then maintains position/posture after being moved)Posturing (assuming positions against gravity)Immobility or purposeless activityMimicking speech and movements
28. An otherwise healthy 25-year-old man comes to the physician because he has a severe fear of flying and must...
Lorazepam Young man with no history of alcohol/substance abuse who has a fear of flying and needs to take a flight in a few days, who can be acutely treated with lorazepam during the flight Key idea: Although benzodiazepines should not be used chronically, they do have a role in settings of acute stress/panic and are effective as short-term agents
• Alcohol withdrawal symptoms should be managed with benzodiazepines • Lorazepam, Oxazepam, and Temazepam are the benzos that should be used in those with liver disease (chronic alcoholism) due to minimal first-pass metabolism
Lorazepam (alcoholic can't sleep)
25 yo M having smoked meats and red wine at the Inner Harbor becomes disoriented. BP enroute to the ED is 240/150
MAOI and hypertensive crisis
Hypertensive emergency with aged cheese consumption
MAOIs
• Diagnosis can't be Adjustment disorder because this patient meets 5/9 criteria for MDD • Crying spells, sad mood = depressed • Poor concentration • Fatigue and lethargy = low energy • Not interested in socializing = anhedonia • 20lb weight gain = appetite/weight change
MDD
72M + wife passed away 3 months ago + 5kg weight loss + cries + guilt; Dx?
MDD (weight loss/gain is huge indicator MDD in elderly).
60M + recovering from a recent MI; he is at high risk of which of the following?
MDD à common following major adverse events (e.g., trauma, serious Dx); give sertraline for post-MI MDD.
Mechanism of MG vs LE?
MG = antibodies against postsynaptic acetylcholine receptors; LE = antibodies against presynaptic voltage-gated calcium channels.
MG can sometimes be paraneoplastic syndromes of which cancer?
MG from thymoma (do chest imaging to check for thymoma after Dx of MG; if thymoma present + removed, this cures the MG). Up to 80% of patients with thymoma + MG have anti-MUSK Abs (muscle-specific kinase).
How do MG vs LE perform with edrophonium?
MG improves drastically; LE less change.
• This depressed geriatric patient that recently developed symptoms of dementia likely has pseudo-dementia, however it is imperative to rule out organic causes of dementia with an MMSE due to his old age • Neuropsychiatric testing would be a better choice (MMSE is now proprietary)
MMSE
23M + used synthetic heroin + diffuse stiffness + drooling; Dx?
MPTP-induced Parkinsonian syndrome à affects substantia nigra; MPTP-containing powder is sometimes sold as "synthetic heroin."
• SSRIs take 4-6 weeks to work - if there is no improvement at that time, then the dose can be titrated accordingly • This patient has a mild-moderate risk for suicide - not enough to hospitalize, but they should be monitored closely outpatient (weekly examinations) • Black box warning: patients age 18-24 have a slightly increased risk of becoming suicidal when initiating antidepressant treatment
Maintain the current dosage of sertraline and schedule weekly follow-up examinations for the next month
26. A 24-year-old male college student comes to student health services for a follow...
Maintain the current dosage of sertraline and schedule weekly follow-up examinations for the next month Key idea: Adequate trial for an antidepressant before changing to another first-line medication is 6 weeks Key idea: Patients often have side effects of anti-depressants (anxiety, etc.) before benefits of medications
• MDD has an atypical presentation with physical symptoms (eg, headache) in the elderly • Sadness • Guilt • Weight loss • Fatigue • Psychomotor retardation (slowing of physical and/or emotional reactions, including speech and affect) • Somatization and illness anxiety disorders require 6 months to diagnose (she has only been experiencing her headaches for 4 weeks)
Major depressive disorder
• Patient presents with 5/9 SIG E CAPS • Sleep disturbances • Anhedonia: stopped going out with friends • Guilt: blames self • Fatigue and energy loss • Concentration problems • ↓ appetite and weight loss
Major depressive disorder
• Post-partum depression
Major depressive disorder
• This patient presents with 5/9 SIG E CAPS • "Withdrawn" = anhedonia • "-15lb" = appetite/weight loss • "sad" = depressed mood • "poor energy" = fatigue • "decreased sleep" = insomnia • Common to develop MDD in chronic diseases
Major depressive disorder
47. A 67-year-old man with Parkinson disease is brought to the physician by his wife...
Major depressive disorder Elderly patient with chronic illness who has >2 week history of tearfulness, decreased energy, sleep changes, decreased appetite, flat affect and depressed mood, all consistent with major depressive disorder Key idea: In order to differentiate between pathology and physiology on NBME psych exam, pay strict attention to diagnostic criteria and also the degree of psychosocial distress/impaired function (can they still work, can they still participate in society, etc.)
3. A 30-year-old woman has had frontal headaches, stomach upset, and poor appetite for 4 weeks; she has had...
Major depressive disorder Patient with >2 week history of SIGECAPS symptoms (specifically Sleep changes, Guilt, decreased Energy, Cognitive dysfunction, Appetite changes) and somatic symptoms most consistent with major depressive disorder Adjustment disorder would not have as severe a presentation Borderline -> Chronic time course Dysthymic disorder -> At least 2 years of symptoms Somatization disorder -> Patient has somatic symptoms AND SIGECAPS
35. A previously healthy 27-year-old woman comes to the physician because of a 2...
Major depressive disorder Young patient with 2-month history of depressed mood + impaired cognitive function + low energy + decreased interest in socializing thus meeting criteria for major depressive disorder Formal definition of MDD: At least 2 weeks with at least 5/9 of the following symptoms (1. Depressed mood 2. Sleep changes 3. Decreased interest 4. Guilt 5. Low energy 6. Cognitive changes 7. Appetite change 8. Psychomotor slowing 9. Suicidal ideation) Key idea: Although MDD classically leads to early morning awakenings and weight loss, in atypical scenarios you can see the opposite in MDD Key idea: Adjustment disorder occurs within 3 months of stressful event and does not meet criteria for MDD (less severe version)
47. A 27-year-old woman, gravida 1, para 1, comes to the physician with her husband because of progressive...
Major depressive disorder Young woman who presents 3 weeks postpartum with >2 weeks of depressed mood and SIGECAPS components (Sleep changes, decreased Interest in friends/family, low Energy, Appetite changes, Suicidal thoughts) most consistent with major depressive disorder Key idea: MDD requires at least 2 weeks of at least 5 of the following 9 symptoms (depressed mood, Sleep changes, decreased Interest in activities, Guilt, low Energy, Cognitive changes, Appetite changes, Psychomotor slowing, Suicidal thoughts) Key idea: Important to differentiate from postpartum blues which is mild depressive symptoms that develop 2-3 days after delivery and RESOLVE WITHIN 2 WEEKS (require monitoring without treatment unless it develops into postpartum depression) Generalized anxiety disorder would require at least 6 months of symptoms PTSD requires at least 1 month of symptoms
A 27 yo resident comes to the ED complaining of lightheadedness within 10 minutes of his 30 hr shift. He has never had this episode before. His BP on telemetry is 75/47. His roommate has a history of hypertrophic cardiomyopathy treated with extended release metoprolol
Malingering. N/B-suspect malingering in the presence of factitious disorder with the opportunity for some kind of secondary gain. The "gain" in factitious disorder is a "primary gain".
• Dry oral mucosa, injected conjunctive, tachycardia, HTN • Always rule out substance or medical related disorder before diagnosing a psychiatric condition
Marijuana intoxication
• Injected conjunctive, tachycardia, HTN, slow reaction time, hallucination • Always rule out substance or medical related disorder before diagnosing a psychiatric condition
Marijuana intoxication
6. A 47-year-old woman comes to the physician 2 hours after the onset of heart palpitations. She had a myocardial...
Marijuana intoxication Middle-aged woman with known marijuana use presenting with paranoia, sensation of things slowing down around her, dry mouth, conjunctival injection and sinus tachycardia most consistent with marijuana intoxication Key idea: Symptoms commonly ascribed to marijuana intoxication on NBME exams include conjunctival injection, tachycardia, paranoia and dry mouth Panic disorder: Unprovoked panic attack with at least one month of psychosocial stress related to fears of having another attack
26. A 16-year-old girl is brought to the physician by her father because of unusual behavior since returning...
Marijuana intoxication Young girl who came home after a party (which should equal drug use on NBME) and demonstrates paranoia, tachycardia, and conjunctival injection most consistent with marijuana intoxication Marijuana: Paranoia, conjunctival injection, dry mouth, tachycardia PCP: Nystagmus, violent behavior, dissociative symptoms LSD: Visual hallucinations + Mydriasis Cocaine: Chest pain, mydriasis, agitation/psychosis, hypertension, tachycardia Methamphetamine: Same as cocaine + violent behavior, choreaform movements and tooth decay Heroin: Respiratory depression, pinpoint pupils, depressed mental status, constipation
• Amphetamines → prolonged wakefulness, aggressive behavior, fever, HTN • Cannabis → dry mouth, conjunctival injection • Ecstasy → ↑ sociability, euphoria • Heroin → CNS depression, miosis • LSD → hallucinations (visual, auditory), depersonalization
Methamphetamine
15. A 22-year-old woman is brought to the emergency department because of a 4...
Methamphetamine Young woman with sudden onset of violent, agitated behavior, tachycardia, and hypertension, which would be consistent with stimulant drugs (cocaine, methamphetamine) PCP: Nystagmus, violent behavior, dissociative symptoms LSD: Visual hallucinations + Mydriasis Cocaine: Chest pain, mydriasis, agitation/psychosis, hypertension, tachycardia Methamphetamine: Same as cocaine + violent behavior, choreiform movements and tooth decay Marijuana: Paranoia, conjunctival injection, dry mouth Heroin: Respiratory depression, pinpoint pupils, depressed mental status, constipation
39. A 53-year-old woman is brought to the physician by her husband because of...
Middle-aged woman presenting with progressive personality changes and jerky movements with a family history of similar symptoms in her father, most consistent with Huntington's disease (due to degeneration of the caudate atrophy) Key idea: Huntington's disease classically leads to triad of Dementia, Depression and Chorea Key idea: Huntington's disease classically leads to anticipation (future generations experience disease at younger age due to trinucleotide repeat expansion), especially when inherited from their father
81F + memory decline; next best step after assessing suicide risk?
Mini-Mental State Exam (MMSE).
31. An 82-year-old man is brought to the physician by his daughter because he has been forgetful during the past 6 weeks...
Mini-Mental State Examination Elderly man with 6 week history of forgetfulness that is not entirely consistent with Alzheimer disease based on time course and may be related to depression ("pseudo-depression") and therefore should be worked-up with MMSE Note: If patient has confirmed Alzheimer disease, then you would start donepezil therapy (acetylcholinesterase inhibitor -> increased cholinergic activity) Routine tests in setting of suspected cognitive impairment:Cognitive testsMMSE less than or equal to 23MOCA less then or equal to 25Abnormal 3-word recall and/or clock drawLabsCBCBMPB12 levelTSH level+/- folate, syphilis work-up+/- Imaging (head CT or brain MRI)
• This patient has OSA (obstructive sleep apnea)
Mood disorder due to a general medical condition
41. A previously healthy 37-year-old man comes to the physician because of a 6-month history of depressed mood, fatigue...
Mood disorder due to a general medical condition Young obese man with mood symptoms in the setting of loud snoring + difficulty sleeping, being tired during the day, etc. most consistent with mood disorder secondary to obstructive sleep apnea Risk factors for obstructive sleep apnea can be remembered by STOP-BANG mnemonic (Snoring, Tired, Observed snoring/chocking, Pressure (elevated BP), BMI >35, Age>50, Neck size > 16 cm and Gender (Male > Female)) Key idea: Polysomnography used to diagnose virtually all NBME sleep disturbance questions (obstructive sleep apnea, narcolepsy, REM sleep behavior disorder, etc.)
58M + loses consciousness while shaving + tilt-table test shows no abnormalities; Dx?
NBME wants "carotid sinus hypersensitivity" as answer. If tilt-table test (+), answer = vasovagal syncope.
40F + headaches + abdo pain + mild weight loss + fatigue + 5/9 SIGECAPS not met + no mention of low mood; Dx?
NBME wants somatization disorder, not MDD; this Q is a little challenging, as mere weight loss/gain + low mood will often be MDD, particularly in elderly; somatization disorder Dx is recurring, multiple, current somatic complaints; Tx = CBT.
Rescue agent for AMS, RR of 4, and pupillary miosis
Nalaxone (not naltrexone!)
Mr. Y is waiting in line at Walmart. There are 15 people in front of him. He walks to the front of the line and screams at the cashier for taking too much of his time
Narcissistic PD
A 44 yo businessman presents to the ED with a small bruise on his arm that may need stitches. The ED is packed with other patients waiting to be seen by the triage nurse. After 5 mins in the waiting room, he screams at the security guard wondering why he is not the first person to be seen
Narcissistic personality disorder. Feel entitled and have zero empathy.
56M + alcoholism + acutely intoxicated + B1 is administered; the latter decreases what most significantly?
Neuro shelf wants "anterograde amnesia" as the answer; mnemonic for Wernicke = A COW à Ataxia, Confusion, Ophthalmoplegia, Wernicke.
2 weeks after starting Fluphenazine (a high potency antipsychotic), a 23 yo M presents with tachycardia, T of 106 F, severe muscle rigidity, and a CBC demonstrating an elevated WBC and a creatine kinase of 70, 000. What is your dx?
Neuroleptic Malignant Syndrome (consider Dantrolene, Bromocriptine, and cooling blankets).
HTN, Tachycardia, AMS, fever, muscle rigidity, recent hx of hearing voices
Neuroleptic malignant syndrome (give dantrolene)
A concerned med student runs to his friend's room around 3AM after he heard a loud noise. This friend is sweating profusely and describes a terrifying dream where he was stabbed by a surgeon who pimped him extensively 2 weeks ago
Nightmare disorder. Occurs during REM sleep (the patient remembers). Consider REM sleep behavior disorder as the dx if the Q stem describes a person performing "detailed activity" during sleep
• This patient with normal pulses and DTRs is likely malingering (secondary gain: temporarily leaving jail)
No treatment is indicated
27. A 24-year-old man is brought to the emergency department from jail by police because he has had numbness in his...
No treatment is indicated Young man who was recently imprisoned with a long history of law-breaking (likely associated with antisocial personality disorder) who presents with numbness of the hand from the wrist to the finger tips with normal motor function which is not consistent with any known neurological/nerve disorder and most likely represents malingering -> No treatment indicated
• This teenage boy is developing normally, both physically and socially
Normal, Normal
• Nucleus basalis of Meynert produces acetycholine; destruction → ↓ ACh → Alzheimer disease • Amygdaloid nucleus: Kluver-bucy syndrome • Caudate nucleus: Huntington disease • Medial geniculate nucleus: Auditory pathway • Red nucleus: mostly vestigial in mammals; crawling in human babies • Substantia nigra: Parkinson disease • Subthalamic nucleus: Hemiballismus
Nucleus basalis of Meynert
40. A 47-year-old man with Down syndrome is brought to the physician because of increasing forgetfulness and irritability...
Nucleus basalis of Meynert Middle-aged patient with Down syndrome who presents with chronic forgetfulness and a loss of ADLs, most consistent with Alzheimer disease Key idea: Patients with Alzheimer's will more specifically have brain effects in the hippocampus and nucleus basalis of Meynert Key idea: Patients with Down syndrome often develop early-onset Alzheimer's because they have an extra copy of chromosome 21 which encodes Amyloid precursor protein which is important to the pathogenesis of Alzheimer's disease Caudate nucleus -> Huntington's disease Substantia nigra -> Parkinson disease Subthalamic nucleus -> Hemibalismus (sudden wild flailing of one side of body)
Consistent, intrusive thoughts about germs, hand washing to relieve the anxiety associated with these thoughts
OCD (not OCPD!).
A famous TCA, clomipramine, may be used to treat
OCD (try SSRIs first!)
Different between obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD)?
OCD is ego-dystonic (patient doesn't want/like the thoughts/actions); OCPD is ego-syntonic (patient is content / not looking to modify behavior).
intrusive thoughts and tension relieving actions
Obsessive (intrusive thoughts) Compulsive (tension relieving actions) disorder which is ego-dystonic
perfectionist who finds nothing wrong in his living mannerisms (ego syntonic)
Obsessive Compulsive Personality disorder
A medical student pays meticulous attention to his notes. He handwrites everything with a certain font and makes liberal use of "white-outs" to avoid errors in his work. He spends at least 15 hrs handwriting his notes on a daily basis. He has done really well in school but has no time for outside activities.
Obsessive-Compulsive PD Note that OCD is ego-dystonic (patient realizes that what they are doing is irrational). Contrast with OCPD which is ego-syntonic (patient does not see anything wrong in what they are doing).
• This patients disorder is ego-dystonic (behavior inconsistent with one's own beliefs and attitude) making OCD the most likely diagnosis • Tx: CBT + SSRI (clomipramine and venlafaxine are second line)
Obsessive-Compulsvie disorder
42. A 32-year-old man comes to the physician because he thinks he might be losing...
Obsessive-compulsive diosrder Patient with recurrent thoughts of hurting his son that are causing distress [obsession] that he deals with by praying and reading scriptures [compulsions], most consistent with obsessive-compulsive disorder Key idea: Common way NBME asks about OCD patient is they will be religious and will pray to deal with obsessions
• Ego-dystonic (behavior inconsistent with one's own beliefs and attitude)
Obsessive-compulsive disorder
6. A 37-year-old man comes to the physician because of increasing distress about his...
Obsessive-compulsive disorder Patient who has social stress related to repeated thoughts about completing projects (obsessions) and spends a lot of time trying to deal with those thoughts by completing them in real life and in his mind (compulsions), most consistent with obsessive-compulsive disorder Generalized anxiety disorder: Persistent worries about multiple practical life stressors (finances, work, school, relationships, etc.)
• This patients disorder is ego-syntonic (behavior consistent with own beliefs) • Tx: CBT + SSRI (clomipramine and venlafaxine are second line)
Obsessive-compulsive personality disorder
33. A 42-year-old man comes to the physician for a routine examination. He is accompanied by his wife. During the...
Obsessive-compulsive personality disorder Middle-aged man with a persistent history of being competitive, obsessed with being successful in his job and thinking that his way is the best way that is causing some problems in his relationships, most consistent with obsessive-compulsive personality disorder Key idea: Regular OCD has behaviors that are ego-dystonic (behavior inconsistent with one's beliefs/attitudes) whereas OCPD has behaviors that are ego-syntonic (behavior consistent with one's beliefs/attitudes)
• Temp of 107.6 F raises suspicion for factitious disorder
Obtain a rectal temperature under supervision
31. A 24-year-old woman reports a 3-week history of recurrent fevers. She has a 4...
Obtain a rectal temperature under supervision Key idea: A temperature of 107.6F with otherwise normal vital signs does not make medical sense, and therefore you should be thinking about malingering or factitious disorder Key idea: For NBME exams, young woman who work in healthcare field are almost always the protagonist in vignettes related to factitious disorder
Woman with SCZ goes from a BMI of 18 to 33
Olanzapine (atypical antipsychotic)
• Opioid intoxication → respiratory and CNS depression, pupillary constriction
Opioid
9. A 46-year-old woman is brought to the emergency department in respiratory...
Opioid Opiates lead to pinpoint pupil, respiratory depression, decreased bowel activity and coma/stupor In NBME, TCA overdose almost always associated with anticholinergic side effects (dry mouth, constipation, etc.) and QRS widening Benzo and barbiturate overdose appear similar to alcohol use (slurred speech, impaired gait, altered mental status, etc.)
What is the overdose situation that best matches the following information cluster? -pH 6.9, pCO2 is 80. -Constipation. -Pupillary constriction. -Patient is unresponsive
Opioid overdose. This patient has a respiratory acidosis with miosis and constipation. The reversal agent that will be the right answer on a test is Naloxone (an opioid receptor antagonist). Do not be deceived by the NBME putting Naltrexone as an answer choice in the same Q. It does the same thing but is longer acting. One weird use of Naltrexone is as a means of treating ROH dependence. -Opioid dependence can be treated with Buprenorphine (partial mu receptor agonist) in combination with naloxone (combo is called Suboxone). Methadone can also be used for this purpose (prolongs the QT interval though). -A partial nicotine receptor agonist (Varenicline) can be used in the treatment of dependence on tobacco. -Alcoholism may be associated with; The development of reversible confusion, ophthalmoplegia, and ataxia (Wernicke's, give thiamine) OR Making stuff up (confabulations)/amnesia + Wernicke sxs which are largely not reversible (Korsakoff's psychosis). Differentiate the seizures and autonomic instability associated with Delirium Tremens from the visual hallucinations and relative autonomic stability associated with alcoholic hallucinosis.
disobedience to parents, teachers, etc. They are not really violent.
Oppositional Defiant Disorder
OCD is associated with
Orbitofrontal cortex anomalies
12M + sore throat + new-onset tic; Dx?
PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus); Group A Strep infection can lead to tic, ADHD, OCD; question on student's USMLE asked for "anti-streptolysin O titer" as the answer to help assess etiology in kid with a tic starting after a sore throat.
Extremely combative individual with vertical/horizontal nystagmus
PCP Intoxication
• PCP intoxication presents with violent behavior, dissociation, hallucinations, amnesia, ataxia, and nystagmus • Benzodiazepines treat severe psychomotor agitation
PCP intoxication
39. A previously healthy 23-year-old man is brought to the emergency department by friends 20 minutes after the onset...
PCP intoxication PCP: Nystagmus, violent behavior, dissociative symptoms LSD: Visual hallucinations + Mydriasis Cocaine: Chest pain, mydriasis, agitation/psychosis, hypertension, tachycardia Methamphetamine: Same as cocaine + violent behavior, choreiform movements and tooth decay Marijuana: Paranoia, conjunctival injection, dry mouth Heroin: Respiratory depression, pinpoint pupils, depressed mental status, constipation
• Nightmares, functional impairment, psychological trauma, and detachment for > 1 month • Tx: Trauma focused CBT + SSRI/SNRI
PTSD
30 yo F has the sudden onset of tachycardia, tachypnea, and intense sweating that goes away after 10 mins. Her last menstrual period was 3 weeks ago. She has had similar episodes a few times a month for the past year. She is worried about having these episodes when she begins her new job next month
Panic Disorder
Mrs. A is a med student. 6 weeks ago, she had a "scary episode" on the bus that was characterized by sweating, palpitations, and feeling like "she lost control". She has since avoided the bus, walks 10 miles back and forth to school each day, and is worried about having another episode like this
Panic Disorder (remember that 1 isolated episode < 1 mo w/o the "maladaptive responses" = panic attack). Give SSRIs to these people for "chronic" management. If they are "actively" having autonomic hyperactivity on the test, give a benzodiazepine.
• Recurrent and unexpected attacks + >1 month of preoccupation with the attacks • Preoccupation with unexplained symptoms overlaps with somatic symptom disorder, but the abrupt onset of physical symptoms that resolve quickly is more consistent with panic disorder • Tx: SSRI or SNRI + CBT
Panic disorder
• Recurrent and unexpected attacks with at least 1 month of preoccupations with the attack (eg, persistent concern of additional attacks) • May be misdiagnosed as somatic symptom disorder, but the abrupt onset and characteristic physical symptoms that resolve within minutes can help differentiate the two
Panic disorder
9. A 17-year-old boy is brought to the emergency department by his mother because of a 20-minute episode of severe...
Panic disorder Chest pain with fear of dying in a patient without risk factors or work-up for coronary artery disease -> Panic disorder (at least on the NBME) Panic disorder: UNPROVOKED panic attacks with at least 1 month of psychological distress related to worries about the attack Symptoms of a panic attack can be broad and include abdominal pain, palpitations, pallor, nausea, intense fear of dying, lightheadedness, coughing, choking, chest pain, shortness of breath, sweating and shaking Key idea: Patient presenting with an ACUTE panic attack can be managed with benzodiazepines, but benzodiazepines should not be used for chronic management (instead use SSRI)
41. A 42-year-old woman comes to the physician because of a 2-week history of...
Panic disorder Patient with history of panic disorders (short episodes of dizziness, flushing, fear of dying, and anxiety) WITH NO CLEAR TRIGGER who experiences concern/anxiety related to attacks, most consistent with panic disorder Key idea: Panic disorder requires at least 1 untriggered panic attack with at least 1 month of worry about future attack and/or avoidance behavior
A Med19 student believes his classmates are conspiring to bring him down. He set up cameras around his apartment to "catch classmates in the act". He has so far scored in the 80th percentile on all his med school exams
Paranoid PD
-Bradykinesia, cogwheel rigidity, small handwriting observed first. -Becomes forgetful and talks at a slow speed 2 years later. -Intracytoplasmic eosinophilic inclusions localized primarily to the substantia nigra.
Parkinson's Disease dementia.
What would your diagnosis be if the patient presented with ataxia, bradykinesia, and "stiff extremities" on exam? His temp is 97.8 F.
Parkinsonism (benztropine, DA agonist, amantadine).
21. One month after undergoing liver transplantation, a 47-year-old woman is...
Patient who has received high-dose IV steroids and has developed psychotic symptoms (hallucinations) shortly after, most consistent with corticosteroid-induced psychosis Drugs/substances associated with psychosis: Hallucinogens, serotonin syndrome (tramadol, psych drugs, etc.), corticosteroids, sympathomimetics (cocaine, meth, etc.) Delirium: Old patient often with baseline dementia who has fluctuating cognition (intermittently confused/combative)
• Nocturnal/early morning erections = cause of sexual dysfunction is psychological
Performance anxiety
2. A 42-year-old man comes to the physician because of a 6-month history of sexual problems. He can achieve...
Performance anxiety Key idea: If a patient has normal morning erections = Physiologic causes of erectile dysfunction (vascular, neurologic, endocrine) are RULED OUT and patient most likely has psychological component to ED (and in this question rules out all answer choices except for D) Note: Beta blockers such as metoprolol can also lead to sexual dysfunction, and SSRIs are specifically known for causing delayed/impaired orgasm Note: Alcohol use also often associated with sexual dysfunction in men
• Hypertensive crisis (tyramine displaces neurotransmitters (eg, NE) in the synaptic cleft → ↑ sympathetic stimulation) • Phentolamine is a nonselective α-blocker that is giving to patients on MAO inhibitors that eat tyramine-contains foods
Phentolamine
40. A 37-year-old woman is brought to the emergency department 30 minutes after the onset of a severe occipital...
Phentolamine Patient on a MAO inhibitor (phenelzine) who presents with a hypertensive emergency after eating tyramine-containing foods (mainly the cheese and pepperoni themselves) who should therefore be treated with phentolamine Phentolamine: Reversible alpha blocker used first-line for MAO-induced hypertensive emergency and 2nd-line for cocaine-induced hypertension (benzo's are first line) Phenoxybenzamine: Irreversible alpha blocker used in setting of pheochromocytoma MAO inhibitors can be remembered with First Aid mnemonic that Mao Takes Pride In Shanghai -> Tranylcypromine, Phenelzine, Isocarboxazid, Selegiline Key idea: MAO inhibitors associated with hypertensive crisis after eating tyramine-containing foods (cheese, cured/processed meats, alcohol) and serotonin syndrome (when used with other serotonergic drugs)
5. A 14-year-old boy is brought to the physician for a well-child examination. His mother says her son is self-centered...
Physical/Sexual Development: Normal // Cognitive/Social Development: Normal Adolescent boy with more independent activities, questionable hygiene habits, and mood swings with Tanner Stage 3 development most consistent with normal development Note: Delayed puberty in males defined by lack of testicular enlargement (Tanner Stage 2) by age 14, whereas delayed puberty in females defined by lack of breast development by 13 or lack of menarche by 15
• Polysomnography showing reduced REM sleep latency will diagnosis narcolepsy
Polysomnography
48. A 24-year-old woman comes to the physician with her husband because of an...
Polysomnography Young woman who recurrently falls asleep and is tired during the day who also has features of REM sleep behavior disorders (gets up and not responding to her name) and cataplexy (falls after joking) who should therefore receive polysomnography to look for features of narcolepsy (decreased REM sleep latency) Narcolepsy diagnosis: (1) Recurrent lapses into sleep at least 3 times for at least 3 months + (2) AT LEAST 1 of the following (Cataplexy [brief loss of muscle tone with laughter or strong emotion], Low hypocretin-1 in CSF, or Shortened REM sleep latency on polysomnography) Key idea: Often associated with sleep paralysis and hypnagogic (while going to sleep) or hypnapompic (upom waking up) hallucinations Key idea: Polysomnography used to evaluate for many sleep disorders, such as narcolepsy, periodic limb movement disorder, REM sleep behavior disorder and sleep apnea
29. A 14-year-old girl is brought to the physician by her mother because of poor...
Post-traumatic stress disorder Young girl involved in a fatal car accident who has experienced 6 months of hyperarousal, reliving experience (nightmares) and cognitive disturbances, most consistent with PTSD PTSD leads to HARD symptoms (Hyperarousal, Avoidant behavior, Reliving experience, Disturbed mood/thinking) for >1 month following a stressful/traumatic experience Key idea: Same symptoms for <1 month = Acute stress disorder Key idea: Degree of impairment in this patient is too severe for a diagnosis of adjustment disorder
• Performance only social anxiety disorder • Tx: β-blockers or benzodiazepines • This patient should receive a β-blocker (benzos may cause drowsiness, which isn't ideal when giving a presentation)
Propranolol
• The tremors in this patients hand are of 1 month duration which doesn't indicate any anxiety disorder • This patient likely has essential tremor (patients often self medicate with alcohol which decreases tremor amplitude, hence this patients alcohol abuse) • Nonselective beta-blockers (eg, propranolol) are the treatment of choice
Propranolol
27. A 47-year-old man has had tension and hand tremors for 1 month. He has been treated for bipolar disorder with lithium...
Propranolol Middle-aged man with likely lithium-induced tremors who has a history of alcohol abuse and therefore should be treated with a beta blocker such as propranolol Key idea: If a patient has a history of alcohol use disorder, then they should NOT be given benzodiazepines on a chronic basis Side effects of lithium can be remembered with mnemonic LiTHIUM: Low Thyroid (hypothyroidism), Heart (Ebstein anomaly in fetus), Insipidus (nephrogenic diabetes insipidus) and Unwanted Movements (such as tremor)
• This will help normalize the patient's symptoms as a consequence of the trauma, so that they are more receptive and more likely to seek help if symptoms persist or deteriorate • This approach also respects the patients autonomy of not wanting to talk to anyone regarding the trauma
Provide information about the range of reactions to trauma
23. A 37-year-old male police officer comes to the physician at the request of his superiors 1 week after he witnessed...
Provide information about the range of reactions to trauma Adult officer who recently witnessed a traumatic event who is showing signs of acute stress disorder (HARD: Hyperarousal, Avoidance behavior, Reliving experience, Disturbed mood/thinking) who does not think anything is wrong and is not open to current treatment at this point, and therefore should just receive information about reactions to trauma and options for treatment in the future Key idea: Unless patient is threat to themselves or to others, then they can't be treated against their will and the decision whether to receive treatment or not is up to the patient
Psych NBME form has both vignettes, practically identical, with the same answer choices: 27M + asthma + very anxious about speech he needs to make soon; Tx? 27M + very anxious about speech he needs to make soon; Tx?
Psych NBME wants lorazepam, not propranolol (because asthma patient). Psych NBME wants propranolol, not lorazepam.
Patient with MDD; which hormone is increased in serum?
Psych shelf answer = cortisol.
8M + 1-year Hx of eye-blinking + facial grimacing + throat-clearing; most appropriate pharmacologic therapy?
Psych shelf answer = risperidone; can Tx with antipsychotics, alpha-2 agonists (clonidine), CBT.
29M + temperature of 107.7F + Hx of MDD + normal HR, RR, BP + WBCs; next best step in Mx?
Psych shelf wants "obtain rectal temperature under supervision"; fraudulent temperature / factitious fever is a type of factitious disorder (patient seeks primary gain - i.e., medical attention; willing to undergo invasive procedures); rectal temperature is most accurate way to measure temperature.
• This patient has a normal physical exam and has completed a battery of tests without any abnormalities (possible somatic symptom disorder)
Psychiatric assessment
37. A 42-year-old woman, gravida 1, para 1, comes to the physician because of a 5...
Psychiatric assessment Young woman with chronic abdominal pain following a stressful life event (losing her job) who has undergone extensive work-up and found no organic cause and therefore would be a good candidate for psychological/psychiatric testing to identify a cause Key idea: Patients pattern of pain does NOT correspond with a known syndrome/condition
• Long standing condition (over 7 years) that is situational (exams) → origin of problem is psychiatric • Thyroid disease would present with additional symptoms and would be more pervasive (not just during exams)
Psychiatric evaluation
48. Over the past 7 years, a 25-year-old graduate student has had increasingly severe palpitations, tremulousness, nausea...
Psychiatric evaluation Patient with symptoms of anxiety that is always brought on when he is taking a test most consistent with a psychiatric/anxiety condition Key idea: All of the other diagnostic tests pertain to medical conditions, some of which can lead to similar symptoms but would not be as highly associated with taking tests 24-hour urine collection for 5-HIAA -> Carcinoid syndrome -> Episodic wheezing, flushing, diarrhea, and right-sided valvular problems 24-hour urine catecholamines/metanephrines -> Pheochromoctycoma -> Recurrent episodes of hypertension, sweating, headaches and palpitations
Treatment of choice for adjustment disorder
Psychotherapy
36. A 42-year-old man comes to the physician for a routine health maintenance...
Psychotherapy Patient with signs of adjustment disorder (distressful psychosocial symptoms within 3 months of an explicit stressor who does NOT meet criteria for MDD or other diagnosis) Key idea: Adjustment disorder treated with CBT/Psychotherapy and NOT pharmacotherapy
-Ziprasidone has the strongest association with
QT interval prolongation
• This patient has Parkinson psychosis • Tx: Quetiapine or clozapine (lowest propensity to cause EPS)
Quetiapine
36. A 67-year-old man is brought to the physician by his wife because of a 1-month history of increasingly "paranoid" behavior...
Quetiapine Key idea: Dopamine precursors (levodopa) and dopamine agonists (pramipexole) are associated with increased risk of psychosis in Parkinson disease Key idea: First step in trying to correct psychosis is by reducing dose of Parkinson's drug (which was not effective in our patient), which can then be followed-up with a low-potency, second-generation antipsychotic such as quetiapine
Polysomnography findings in narcolepsy?
REM latency: decreased, sleep latency: decreased
• Paralysis that normally occurs during REM sleep is incomplete pr absent, allowing the person to 'act out' their dreams • In older patients, REM sleep behavior disorder may be a sign of neurodegeneration (eg, Parkinson disease)
REM sleep behavior disorder
34. A 57-year-old man comes to the physician with his wife because of a 1-month history of bizarre behavior at night. His wife says...
REM sleep behavior disorder Middle-aged man who acts out his dreams most consistent with REM sleep behavior disorder Key idea: Normally during REM sleep are muscles are completely paralyzed so that we do not act out dreams, but in this disorder muscles maintain some activity and can lead to acting out dreams Key idea: REM sleep behavior disorder very strongly associated with Parkinson's disease and Lewy body dementia
• Sleep changes in elderly: ↓ REM sleep time, ↑ REM latency, ↓ stage N3 (non-REM sleep) • This patient is experiencing normal age related changes
Reassurance
1: An 82-year-old man comes to the physician with his wife because of difficulty...
Reassurance Patient is displaying normal age-related changes (early morning awakening, falling asleep during day, normal mood, Mini-mental state > 23) Key idea: Early morning awakening with inability to go back to sleep should prompt strong consideration for major depressive disorder (but this patient does not have other components of SIGECAPS mnemonic) Key idea: MMSE of 23 or lower and MOCA of 25 or lower are abnormal
• Enuresis is normal until age 5 • Encopresis is normal until age 4
Reassurance that this is normal behavior
12. A 3 1/2-year-old boy is brought to the physician by his parents because he has...
Reassurance that this is normal behavior Key idea: Most children begin toilet training between 2-4 years of age and bedwetting is NORMAL before age 5
• Weight unchanged from the previous year, normal growth and development
Reassure the father that this is normal development
34. A 13-year-old girl is brought to the physician by her father for a well-child...
Reassure the father that this is normal development Young child who mainly eats snacks and is a vegetarian for clear humanitarian reasons who seems to be excelling in school and extracurriculars (no impaired functioning) who is within normal levels for weight, most consistent with normal behavior Key idea: In order to diagnose a psychiatric condition, it must cause distress or impair normal functioning
• Sleep changes in elderly: ↓ REM sleep time, ↑ REM latency, ↓ N3
Reassure the patient that his sleep pattern is normal for his age
14. A 74-year-old widower comes to the physician because of gradually increasing insomnia over the past 2 years...
Reassure the patient that his sleep pattern is normal for his age Normal changes in sleep patterns observed with aging:Decreased total sleep timePeak sleepiness earlier in eveningNocturnal awakeningsDaytime napping with reduced daytime sleep latency (time it takes to fall asleep)Decreased slow-wave sleepDecreased REM latency
• This patient does not believe he has a drinking problem, but has cut back on the amount he drinks - therefore he's in the action phase, not the pre-contemplation phase • Disulfiram is given to patients who are not actively drinking and are highly motivated to quit • Clonidine is given in alcohol withdrawal, but should not be given to a patient that is actively drinking • This patient has cirrhosis, so the only benzodiazepines that should be used are lorazepam, oxazepam, and temazapam due to minimal first-pass metabolism
Recommend alcohol rehabilitation
18. A 37-year-old man comes to the physician for a follow-up...
Recommend alcohol rehabilitation Patient with severe alcohol use (>14 drinks/week in adult male or >7 drinks/week in adult female or elderly patient >65) who also has severe dysfunction related to drinking (alcoholic cirrhosis, DUI, etc.) who continues to drink with elevated GGT level
• Worse at night and at rest, Relieved by movement • Associated with iron deficiency → this patients fatigue
Restless legs syndrome
35. A 52-year-old woman comes to the physician with her husband because of a 6...
Restless legs syndrome Patient who develops an uncomfortable sensation in her legs while trying to sleep which makes it difficult for her to sleep Key idea: Commonly associated with iron deficiency anemia Key idea: Treated with dopamine agonists (pramipexole, etc.)
• Tourette syndrome - onset before age 18 • Tx: Antipsychotics, Tetrabenazine, Alpha-2-agonists (eg, guanfacine, clonidine)
Risperidone
1: An 8-year-old boy is brought to the physician because of a 1-year history of...
Risperidone Tourette's diagnosis: Onset before 18 years of age of (1) Multiple motor tics AND (2) at least 1 vocal tic Tourette's treatments: Antipsychotics (tetrabenazine, antipsychotics, etc.), Alpha-2 adrenergic receptor agonists (guanfacine, clonidine) Key idea: Tourette's is commonly associated with OCD and ADHD
Man with SCZ develops gynecomastia
Risperidone (hyperprolactinemia)
Criteria for MDD:
SIGECAPS (at least 5 of 9): Sleep disturbance, Interest (loss of), Guilt, Energy (loss of), Concentration (loss of), Appetite (change in), Psychomotor disturbance (e.g., headaches), Suicidal ideation. Bear in mind USMLE vignettes will often not give you 5 out of 9 SIGECAPS in all questions; sometimes the vignette will be as simple as mentioning weight loss/gain in elderly patient who's teary-eyed.
First line treatment for OCD
SSRIs and CBT
First line treatment for an individual that worries about everything
SSRIs or SNRIs (also Buspirone).
• Delusions or hallucinations for ≥ 2 weeks in the absence of prominent mood symptoms
Schizoaffective disorder
7. Five weeks after being discharged from the hospital after treatment for a psychotic episode...
Schizoaffective disorder Young man recently hospitalized for psychotic episode without much detail but most consistent with schizophrenia vs schizophreniform disorder vs schizoaffective disorder Bipolar disorder -> Decreased sleep, Increased talkativeness, decreased appetite, distractibility, etc. Cyclothymic disorder -> 2 year history of fluctuations between mild depression and mild mania/hypomania, which would typically not lead to psychiatric hospitalization Delusional disorder -> Defined as a delusion for at least 1 month that does not significantly impair function (and likely would not lead to hospitalization) Substance-induced mood disorder -> No history of drug use Note: Important to differentiate schizoaffective disorder from mood disorder with psychotic feature, with schizoaffective disorder having at least 2 weeks of psychotic features without mood symptoms
12. A 27-year-old man comes to student health services because of a 6-week history of increasingly severe insomnia and persistent...
Schizoaffective disorder Young man with signs of depression (guilt, emptiness, profound sadness, etc.) who admits to episodes over the past 4 years of isolated psychosis/hallucinations WITHOUT mood symptoms, most consistent with schizoaffective disorder Schizoaffective disorder: Meets criteria for schizophrenia and major mood disorder, with at least 2 weeks of psychotic symptoms without major mood disorder Mood disorder with psychotic features: Predominantly MDD or bipolar disorder with psychotic symptoms that are never seen without mood symptoms Brief psychotic disorder: At least 1 positive symptom (hallucination, delusion, etc.) for less than 1 month that often comes on due to stress Schizophrenia: At least two of the following symptoms (delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, negative symptoms) for at least 1 month with at least 6 months of decline in functioning Schizophreniform disorder: Same as schizophrenia except for 1-6 months
-A 23 yo computer science major loves to work in dark rooms w/o distractions. He lives in a mobile home on a small plot he carved out in the forest. He enjoys working alone in his home and hates having to participate in group projects with his classmates. What is the diagnosis
Schizoid PD.
individuals that work/live alone and do not want to interact with people.
Schizoid Personality Disorder
Delusions, auditory hallucinations, disorganized speech, flat affect for 7 mo
Schizophrenia
• Delusion: Dementors searching for him to turn him into an alien • Hallucination: Dementors look him in the eyes • Disorganized speech/thinking: Thought process not 100% linear • Disorganized behavior: Disheveled appearance • Negative symptoms: Lives alone, no friends, poor eye contact
Schizophrenia
4. A 42-year-old man is brought to the emergency department by police after they found him hiding under a...
Schizophrenia Young man with >6 months of hallucinations, delusions and disorganized behavior most consistent with schizophrenia Schizophrenia > Bipolar disorder with psychotic features because patient does not have other DIG FAST components of mania/hypomania like decreased sleep, increased activity, etc. Key idea: Patients with schizophrenia can also be described as speaking quickly and loudly even though that is more associated with mania/hypomania = bipolar disorder Brief psychotic disorder: At least 1 positive symptom (hallucination, delusion, etc.) for less than 1 month that often comes on due to stress Schizophrenia: At least two of the following symptoms (delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, negative symptoms) for at least 1 month with at least 6 months of decline in functioning Schizophreniform disorder: Same as schizophrenia except for 1-6 months Schizoid personality disorder = Patient who prefers to be alone and not engage in contact with others
What is the best diagnosis that matches the following info cluster? -Fixed, false beliefs despite evidence to the contrary (delusions). -Hearing voices (perception of something that is not there). -Disorganized speech. -Symptoms like social withdrawal, anhedonia, "being speechless", flat affect, avolition (-ve sxs). -Disorganized behavior. -Symptoms lasting > 6 mo.
Schizophrenia. You need 2 of the above 5 sxs for > 6 mo to make the dx. -Schizophreniform disorder is "SCZ like" but the symptoms have to be around for < 6 mo. -Brief Psychotic Disorder is also similar but the sxs have to be around for < 1 mo. -Schizotypal personality disorder is another similar sounding one that should not trip you up on a test. These are individuals that have weird beliefs (like thinking that a crystal ball in their possession controls the rising and setting of the sun). They may also dress in relatively weird ways. -It is also HY to know what constitutes positive and negative sxs of SCZ. They may give you a list of sxs and expect you to pick which is which. -An example of a delusion is believing you are President Obama. An example of a hallucination is hearing President Obama giving you instructions to save the world. -Schizoaffective disorder revolves around having SCZ+. The + here describes the presence of another "mood disorder" like bipolar disorder with concomitant mania, depression, etc. The predominant sx here is SCZ. The "mood" disorder on exams often happens at the exact same time or in very close proximity to the SCZ. As a generalization, the mood disorder should not happen on its own "in isolation".
A 23 yo business major (Patient A) who was a previous straight A student has surprised his friends over the last 7 months with consistent Ds in all his classes. He has stopped hanging out with his friends and prefers to live alone in his dorm room free of distractions. He was taken to the ED by some concerned friends. During the H&P, he informs the medical student that he has been given secret messages through a daily podcast regarding plots by some spies to infiltrate the Med19 Special Forces. He believes some aliens from Mars are driving to his apartment with a scheduled arrival 3 days from now. A urine drug screen and brain imaging are negative. -Assuming Patient 1A had symptoms over the last 3 months, what would the diagnosis be? -What is the diagnosis if Patient 1A had symptoms over the past 7 months and then presented 3 weeks later with sxs consistent with pressured speech, increased goal directed activity, feelings of grandiosity, and a decreased need for sleep? -What is the diagnosis if Patient 1A had symptoms that began over the past 3 weeks?
Schizophreniform disorder (< 6 months of SCZ sxs but > 1 mo). Schizoaffective disorder (mood disorder + SCZ). Brief Psychotic Disorder.
• Cluster A personality disorder; genetic association with schizophrenia • Eccentric appearance, odd thoughts, beliefs, perceptions and behavior
Schizotypal
3. A 23-year-old man is brought to the physician by his mother because of increasing...
Schizotypal Schizotypal PD: Magical thinking, eccentric appearance, abnormal social functioning Schizoid PD: Voluntary social withdrawal Avoidant PD: Involuntary social withdrawal due to fear of rejection/criticism
-A 25 yo art major gets straight As in all his classes. He has worked in the school cafeteria for the past 8 months and has an excellent relationship with his peers. He believes that a crystal ball he purchased at a farmer's market guides the onset of sunrise and sunset. What is your diagnosis
Schizotypal PD.
"What do you mean by anti-H1-histaminergic effects?"
Sedation
21. A 7-year-old boy is brought to the physician by his mother because of difficulty at...
Separation anxiety disorder Child who recently started school and developed somatic symptoms and anxiety when he is separated from his mother/parents
• Persistent anxiety with separation and excessive worry about losing major attachment figures for ≥4 weeks
Sepration anxiety disorder
• Fluoxetine (SSRI) → ↑ serotonin in the synoptic cleft • Tramadol inhibits the re-uptake of NE and serotonin • Fluoxetine + Tramadol → Serotonin Syndrome
Serotonin
27. A 32-year-old man is brought to the physician by his wife because of increasing...
Serotonin Patient who has been chronically treated with an SSRI and recently started on tramadol who has Agitation, Autonomic hyperactivity (febrile, tachycardia, hypertension), and increased Activity (hyperreflexia, muscle rigidity) consistent with serotonin syndrome Drugs associated with serotonin syndrome: Psych drugs (SSRIs, SNRIs, MAO inhibitors, TCAs), tramadol, ondansetron, linezolid, MDMA (ecstasy), meperidine, dextromethorphan, St. John's wort, triptans
A patient with a hx of migraines begins Sertraline and has clonus, hyperreflexia, tachycardia, tachypnea, ocular clonus, muscle rigidity
Serotonin Syndrome
• OCD tx: SSRI and CBT (venlafaxine and clomipramine are second line)
Sertraline
39. A 25-year-old man comes to the physician with his wife because of bizarre behavior for the past 3 months. She reports...
Sertraline Young man with obsessions (cleanliness, bad air quality) that causes him distress most consistent with Obsessive-compulsive disorder which should be treated with (1st-line) SSRIs vs CBT (2nd line) Clomipramine vs SNRIs Common obsessions in OCD: Cleanliness, thoughts of hurting somebody else or conducting sexual behaviors, etc. Buspirone -> Specific for generalized anxiety disorder
• Delusions or hallucinations for ≥ 2 weeks in the absence of prominent mood symptoms • Bipolar or major depression with psychotic features have psychotic symptoms occurring exclusively during mood episodes (this patient is still having psychotic features even though his mania has resolved after hospitalization)
Shizoaffective disorder
• This obese, male teenager snores and breaths through his mouth = ventilation disrupted by physical obstruction of airflow • Tx: nasal continuous positive airway pressure (nCPAP), weight loss
Sleep-related hypoventilation
11. A 16-year-old boy comes to the physician because of a 1-year history of progressive headaches that have caused...
Sleep-related hypoventilation Overweight child with snoring + headaches in the morning -> Obstructive sleep apnea Hydrocephalus -> Headache and nausea/vomiting upon waking in the morning Idiopathic intracranial hypertension -> Overweight woman with headache, blind spots, pulsatile tinnitus, etc. Migraine -> Pulsatile unilateral headache associated with nausea/vomiting, aura, etc.
LE can sometimes be a paraneoplastic syndrome of which cancer?
Small cell lung cancer
Mr. Z is a med student. He avoids going to school parties for fear of being disgraced by members of his class
Social Anxiety Disorder
• Social anxiety disorder, performance type: anxiety restricted to public speaking • Fear of embarrassment or judgement is a classic sign of social phobia
Social phobia
20. A 20-year-old college student comes to the physician because of a 1-year history of...
Social phobia Social phobia = Social anxiety disorder = Exaggerated fear of embarssment in social situations Key idea: Performance-type treated with beta blockers or benzodiazepines (beta-blockers preferred if history of alcohol use disorder and benzo's preferred if patient has asthma or COPD due to beta-blockade -> bronchoconstriction) with CBT or SSRIs for chronic management
Mr. Y is a med student. He has a fear of heights. He avoids seeing any patients that are not on the ground floor of the hospital
Specific Phobia
• Marked anxiety about a specific object or situation for >6 months • Tx: CBT with exposure
Specific phobia
43. A 42-year-old man comes to the physician for advice concerning his fear of flying. One year ago, he was on an airplane that...
Specific phobia Young patient with a fear of flying who also had a previous episode consistent with social anxiety disorder (panic attack while giving a presentation), most consistent with a specific phobia Mitral valve prolapse and caffeine can predispose to anxiety secondary to a general medical condition, but would not lead to anxiety only about specific situations
"What do you mean by anticholinergic effects of meds?"
Start with knowing that DUMBBELSS is a mnemonic for cholinergic effects: Diarrhea, Urination, Miosis (pupillary constriction), Bradycardia, Bronchoconstriction, Excitation (neuromuscular), Lacrimation, Salivation, Sweating à so by anti- cholinergic effects, it's just the opposite of DUMBBELSS: constipation, urinary retention, mydriasis, tachycardia, bronchodilation not seen (M3 agonism can bronchoconstrict, but dilation is sympathetic beta-2-regulated), Flaccidity not seen, xerophthalmia (dry eye), xerostomia (dry mouth), anhidrosis.
• Must rule out any substance or medical related mood disorder before diagnosing a psychiatric condition • Central acting beta-blockers (eg, propranolol, nadolol) can cause depression and psychosis
Substance-induced mood disorder
13. A 47-year-old man comes to the physician because of a 4-week history of...
Substance-induced mood disorder Patient with depressed mood, decreased energy, poor concentration, and sleep changes (consistent with major depressive disorder) following initiation of propranolol, most consistent with medication-induced mood disorder
• This patient is using stimulants (eg, amphetamine, methylphenidate) to study → psychosis
Substance-induced psychotic disorder
12. A 23-year-old man is brought to the emergency department because of progressive paranoia and agitation for...
Substance-induced psychotic disorder Young man with 2 days of paranoia and agitation with normal pupil sizes (2-4 mm normal), dry mouth and tremulousness most associated with marijuana-induced psychosis Key idea: Presence of physiologic signs (dry mouth, etc.) tells us that patient does NOT have pure psychiatric condition and likely has psychiatric symptoms secondary to substance or medical condition (often endocrine disease) Key idea: Signs/symptoms that are associated with marijuana on NBME exams are injected conjunctivae, dry mouth, tachycardia and paranoia Key idea: Rapid speech with increased volume can be seen in both psychosis and mania/hypomania
• MPTP induced Parkinsonism • MPTP (synthetic potent analog of meperidine (demerol)) is toxic to the substantial nigra
Substantia nigra
25. An 18-year-old man is brought to the emergency department by friends 1 hour after they found him on the couch...
Substantia nigra Young patient taking synthetic heroin who presents with stiffness and akinesia most consistent with MPTP-mediated substantia nigra damage leading to Parkinson's like symptoms Key idea: Synthetic heroin can be tainted with MPTP which directly destroys dopaminergic neurons in the substantia nigra and leads to permanent symptoms of Parkinson's disease Mnemonic for Parkinson's disease symptoms is TRAPS: resting Tremor, Rigidity, Akinesia, Postural instability, Shuffling gait
• Oral hypoglycemic agents stimulate production of endogenous insulin (↑ insulin & ↑ C-peptide)
Surreptitious administration of insulin
40. A 20-year-old woman is brought to the emergency department immediately after...
Surreptitious administration of insulin A young woman with access to insulin (mother has T2DM) who presents with severe hypoglycemia and is found to have an increased insulin level but a normal/low C-peptide level, most consistent with surreptitious insulin use Key idea: Normal the body cleaves pro-insulin into insulin + C-peptide, so if increased endogenous amounts of insulin are being produced in the setting of an insulinoma you would expect both insulin and C-peptide levels to be elevated Key idea: In contrast, pharmacological exogenous insulin contains only insulin and no C-peptide, so patients using exogenous insulin will have increased insulin but normal/low C-peptide
• First generation antipsychotics treat positive symptoms only • Second generation antipsychotics treat positive and negative symptoms • Second generation antipsychotics are less likely to cause EPS than 1st generation antipsychotics (eg, haloperidol) • This patients negative symptoms (blunted affect) remain untreated
Switch from haloperidol to aripiprazole
6. A 47-year-old woman with schizophrenia, paranoid type, comes to the physician...
Switch from haloperidol to aripiprazole Switch from high-potency typical antipsychotic -> atypical antipsychotic will decrease risk of developing tardive dyskinesia Key idea: High-potency typical antipsychotics have the highest risk of extrapyramidal symptoms (such as tardive dyskinesia) and include haloperidol, trifluoperazine and fluphenazine
• CT scans of patients with schizophrenia often show ventriculomegaly (particularly the lateral cerebral ventricles) and diffuse cortical atrophy
Symmetric enlargement of the ventricles
16. A 47-year-old man is brought to the emergency department 1 hour after he...
Symmetric enlargement of the ventricles Long-standing schizophrenia -> Symmetric enlargement of the ventricles
Significant anticholinergic side effects
TCAs
Many years after treatment, the same patient consistently has multiple, rapid, rhythmic movements of his tongue. What is the most likely diagnosis?
Tardive Dyskinesia (discontinue the drug or start an atypical or start clozapine which is an atypical).
A 7 yo boy is brought to the physician by his mother for behavioral problems. The mother says that for as long as she can remember he has been much more difficult than his other brothers and sisters. She is also concerned that he has been doing poorly in the second grade and his teacher has complained several times about his disruptive behaviors in class which include excessive talking and inappropriately leaving his classroom seat. He appears distracted and fidgety in the physician's office and answers only 1 of 5 questions posed by the physician in a questionnaire. He does not appear to be listening to the physician. What is the most likely diagnosis? a. Normal behavior. b. Attention Deficit Hyperactivity Disorder. c. Conduct Disorder. d. Oppositional Defiant Disorder.
The best answer here is B, ADHD. -ADHD = hyperactivity, impulsiveness, inattentiveness, and distractibility in 2 or more settings. -ODD is generally associated with kids being disobedient to authority. CD is associated with kids exhibiting ODD characteristics with the added component of violence (usually setting stuff on fire or being cruel to animals). -Give methylphenidate or dextroamphetamine to these kids. They prevent the reuptake of NE and DA at the adrenergic synapse. These drugs decrease sleep, suppress appetite, and could stunt growth in kids. A non-stimulant drug like Atomoxetine can also be used to treat ADHD.
-7 yo M comes for his pediatric well child visit. He keeps jumping all over the room. -His mom complains that he exhibits similar behavior at home. -His teachers have told his mom that he never waits his turn to answer questions and does not seem to concentrate in class.
This is ADHD. Dx must be made prior to age 12 with symptoms observed in at least 2 settings by multiple individuals. Treatment is with amphetamine derivatives, methylphenidate, or atomoxetine (which is not a stimulant). Note the growth stunting, appetite suppressing, and sleep depriving SEs of these medications.
-Patient can't concentrate, buys a boat and a new car, feels like he is the president of the world, talks like a sportsman, feels rested with 90 mins of sleep each night. -First line treatment is Li. -These sxs have lasted for 2 days and required hospitalization.
This is Bipolar 1 Disorder. You need an elevated mood + 3 of the DIGFAST sxs for > 1 week to make the diagnosis (aka mania). If the patient is hospitalized OR is psychotic, the time frame DOES NOT MATTER. In addition, BPD 1 requires only mania (not necessarily an episode of depression). -Other HY associations to be aware of with BPD include the combination of hypomania and an episode of depression for 4 or more days as the diagnostic criteria for BPD 2 (the same # of DIGFAST criteria required for mania apply, however there is no real "life" impairment). -Treatment of BPD (daily treatment) is with Li (avoid with elevated Creatinine, can cause hypo/hyperthyroidism, and nephrogenic diabetes insipidus which can be treated with Amiloride/Triamterene). You should also remember the Ebstein's anomaly association. -A possible substitute to Li is valproate but this drug could nuke the liver and cause NTDs. -It is very HY to know that an "acute" manic episode requires treatment with an antipsychotic/benzodiazepine (usually atypical but can be first gen). -The antipsychotics are also nice drugs for the treatment of bipolar disorder in pregnancy. Choose this over Li if presented as an answer choice. -One other bizarre scenario that could pop up on a test is knowing what to do if Li has been tried with poor control of BPD sxs. Consider adding one of the atypical antipsychotics to the patient's medication regimen (like aripiprazole, quetiapine, ziprasidone, olanzapine, etc)
55 yo comes to see a psychiatrist from a VA referral. He has been bordered by flashbacks of gun duels with warlords from multiple stints as a peacekeeping army officer in a foreign country. He has a "flat affect" as he describes these episodes
This is PTSD. Common exam buzzwords are flashbacks and re-experiencing of prior traumatic experiences. SSRIs are first line. Sxs must be present for > 1 mo. The dx is acute stress disorder if < 1 mo. As an aside, note that prazosin can be used for the nightmares in PTSD while clonidine can be used for Tourette's syndrome.
-6 year old F clears her throat multiple times a day and blinks excessively. -She repeats everything her older brother says. -Haloperidol can be used as treatment.
This is Tourette's Syndrome. Dx is based on the presence of motor tics (point A) and vocal tics (point B, in this case echolalia, if she repeated obscene words, it is described as coprolalia). A drug like guanfacine OR clonidine (alpha 2 agonists) may also be used as treatment. 2nd gen antipsychotics are also used due to their more favorable side effect profile over first generation agents.
What is the diagnosis that best matches the following info cluster? -Acute onset of AMS and fluctuations in levels of consciousness. -Disorganized thoughts and lack of concentration. -Sees a lion in the exam room. -Presented to the ED yesterday with dysuria, urinary frequency, and urgency. -Discharged home 3 days later in perfect health.
This is delirium. Be able to recognize this cluster of sxs. Medications and infections (especially UTIs) are common etiologies on exams
-76 yo F who is alert during an interview. -Presents with a 3 yr history of "forgetfulness" -20/30 on a MMSE. -May be treated with "central" acting acetylcholinesterase inhibitors.
This is dementia (gradual onset, no alteration in consciousness).
A 19 yo cheerleader comes in for an annual physical with the medical director of the local sports team. She has not had menses for the past 12 months. Her BMI is 16. What is the most likely diagnosis?
This lady most likely suffers from anorexia nervosa. Consider this in a young F on your exam who has a super low BMI (usually < 18.5), belongs to a sport/activity associated with having a super nice body image, has dental caries, calluses on the dorsal surface of her hands (Russell's sign), multiple electrolyte anomalies (low K/Cl and a metabolic alkalosis), fine hair on the skin (lanugo), amenorrhea (the body shuts down the HPG axis in the setting of starvation), and stress fractures (from low estrogen). -Consider bulimia in the presence of a similar presentation and a relatively normal/slightly overweight BMI. -Anorexics have a marked, severe fear of weight gain and subject themselves to severe starvation. They are often < 85% of ideal body weight. -Patient with anorexia often respond better to personal/family counseling. You could try antidepressants, but they rarely work. For the NBME, consider Mirtazapine as a good antidepressant for this patient population.
• Trisomy 21 (down syndrome): Epicanthal folds, up slanting palpebral fissures, low-set small ears, flat facial profile, furrowed tongue
Trisomy of an autosomal chromosome
23. A 2-year-old girl who was adopted is brought to the physician because of developmental delay; she does not...
Trisomy of an autosomal chromosome 2 year old child with developmental delay (motor and speech) with epicanthal folds, prominent tongue and small low-set ears consistent with Down syndrome which is due to Trisomy 21 Defect in N-acetylglutamate synthetase -> Urea cycle disorder (severe developmental delay but not the characteristic facial features) Fetal alcohol syndrome -> intellectual disability, behavior problems, smooth philtrum, microcephaly, small patient Phenylalanine hydroxylase deficiency -> Phenylketonuria -> Fair skin, musky body odor, intellectual disability, seizures, eczema
Tx and prophylaxis for cluster headache?
Tx = 100% oxygen; prophylaxis = verapamil.
Tx and prophylaxis for migraine?
Tx = NSAID, followed by triptan (triptans are NOT prophylaxis; they are for abortive therapy only after NSAIDs); prophylaxis = propranolol.
Tx and prophylaxis for trigeminal neuralgia?
Tx = goes away on its own because it lasts only seconds; prophylaxis = carbamazepine.
• Valproic acid block box warning: hepatotoxicity, pancreatitis, fetal abnormalities
Valproic acid
47. A 32-year-old woman with schizoaffective disorder is brought to the emergency...
Valproic acid Patient who recently initiated therapy for psychiatric symptoms and presents with signs of liver injury (RUQ abdominal pain, lower extremity edema, jaundice, increased LFTs), which should prompt concern for valproic-acid induced hepatotoxicity Key idea: Lithium and valproate are the two first-line medications for bipolar disorder, with valproate > lithium in the setting of renal dysfunction (because lithium is excreted in urine)
Raises BP, inhibits NE and Serotonin reuptake
Venlafaxine
• Wernicke-Korsakoff syndrome → confusion, ataxia, nystagmus, ophthalmoplegia, memory loss
Vitamin B1 (thiamine)
36. A 37-year-old man is brought to the emergency department by the police after they found him sitting in an alley
Vitamin B1 (thiamine) Young man with signs of cirrhosis (gynecomastia, palmar erythema, RUQ tenderness, easy bruising) who presents with confusion, ophthalmoplegia and likely ataxia (unable to stand/walk despite normal muscle strength) most consistent with Wernicke encephalopathy due to thiamine deficiency in the setting of alcoholism Key idea: On the NBME, Alcoholism = Nutritional deficiency Folic acid and B12 deficiency both lead to megaloblastic anemia, with B12 deficiency also leading to neurologic symptoms compatible with subacute combined degeneration Niacin deficiency -> Pellagra -> Diarrhea, Dermatitis, Dementia, Death Vitamin B6 deficiency -> Neuropathy, seborrheic dermatitis, glossitis, etc.
37. A 27-year-old man comes to the physician because of anxiety about a major speech that he must deliver in 3 days...
Young man with performance-specific social anxiety disorder (concern about being publicly embarrassed) which is best treated with a beta blocker > benzodiazepine Key idea: Patients with alcohol use disorder or family history of alcohol dependence often should not receive benzodiazepines if they can be avoided (similar mechanism of action)
38. A 27-year-old man comes to the physician because of anxiety about a major speech that he must deliver in 3 days...
Young man with performance-specific social anxiety disorder who also has severe asthma and no personal or family history of alcohol dependence who in this setting should receive benzodiazepine > beta blocker Beta blockers -> Blockade of Beta-2 receptors in smooth muscle of airways -> Bronchoconstriction -> Worsening asthma
45. A 3-year-old girl is brought to the emergency department 1 hour after injuring her...
Young patient with recurrent ED visits who is acting out at daycare and fearful of physician and presents with a humerus fracture which would not be compatible with supposed mechanism of injury, most concerning for child abuse Key idea: Injuries that are consistent with child abuse include spiral fracture, rib fractures, subdural hematoma, and retinal hemorrhages
• Antipsychotics are the first-line pharmacotherapy for patients with acute psychosis • Second-generation is usually preferred due to less EPS side effects
Ziprasidone
22. A 25-year-old woman is brought to the emergency department by police because...
Ziprasidone Young woman (schizophrenia almost always presents in young adult) who presents with delusions of grandeur, hallucinations, and pressured speech, which is most consistent with psychosis necessitating treatment with antipsychotics Key idea: Difficult at times to differentiate between bipolar disorder and psychotic disorders on NBME exam, but know that bipolar exam will almost always include changes in sleep and schizophrenia will have more prominent psychotic symptoms
• Psychotherapy is the first line therapy for Adjustment disorder (SSRIs aren't given) • Nonbenzodiazepine hypnotics (eg, zolpidem) can be given to treat insomnia
Zolpidem
7. A 37-year-old man comes to the physician because of a 3-week history of fatigue, insomnia and anxiety...
Zolpidem Young man with anxiety and stress provoked by a stressful/traumatic experience most consistent with adjustment disorder with the most impairing symptom being insomnia which can be treated with a non-benzo hypnotic (Similar to question 49) Adjustment disorder: Occurs within 3 months of stressor and leads to impairment not on the level of MDD or other psych conditions Key idea: Adjustment disorder is primarily treated with CBT, but patients can receive pharmacologic therapy for specific symptoms (anxiety, insomnia, etc.)
Pharm Tx for Alzheimer?
acetylcholinesterase inhibitors first (donepezil, galantamine, rivastigmine); sometimes Q will ask for mechanism, and answer = "cholinergic"; for more advanced disease try NMDA (glutamate) receptor antagonist (memantine).
Antipsychotic medication started + abnormal eye movements + stiff neck; Dx?
acute dystonia (oculogyric crisis + torticollis).
Antipsychotic medication started + muscle rigidity + no fever; Dx + Tx?
acute dystonia, not neuroleptic malignant syndrome (because no fever); Tx with benztropine (muscarinic receptor antagonist) or diphenhydramine (1st gen H1 blocker, which has strong anti-muscarinic side-effects).
22F + not performing well in classes since breaking up with boyfriend 3 months ago; sleeps well; no weight loss; has low mood; Dx?
adjustment disorder à Dx is socio-occupational dysfunction (school, work, social life) secondary to specific stressor, but patient must not have mood or psychotic disorder, otherwise Dx is, e.g., major depressive disorder (MDD), or bipolar, etc. Some Psych shelf questions will have as answers, e.g., "Adjustment disorder with depressed mood," or "Adjustment disorder with anxious mood," but in these vignettes the patient won't have actual MDD or a true psychotic disorder.
Patient wants to commit suicide; next best step?
admit to hospital involuntarily.
Nocturnal enuresis; when is it pathologic?
after age 5.
-Enuresis cannot be diagnosed prior to
age 5. Treatment options include desmopressin (caution with hyponatremic seizures) and imipramine. Alarms work best. Catatonia can be treated with benzodiazepines and/or ECT.
7F + preoccupation with death + fear of dying + constantly asking parents about dying; Dx?
age- appropriate behavior. Weird, but the NBME will do what it wants.
• Between ages 6-11 (concrete operational stage), kids begin to understand that death is irreversible • This child has no functional impairment (she continues to excel academically and participate in sports)
age-appropriate behavior
5M + talks to imaginary friends; Dx?
age-appropriate behavior.
-Clozapine is associated with
agranulocytosis (decreased WBC)
25M + schizophrenic non-responsive to many meds + started on new drug + mouth ulcers; Dx?
agranulocytosis secondary to clozapine; stop drug immediately; must do granulocyte checks frequently when first commencing this agent.
Antipsychotic med + restlessness; Dx + Tx?
akathisia; Tx with propranolol. Psych shelf has Q where patient says: "I feel as though I am going to jump out of my skin!" à answer = "adverse effect of prochlorperazine."
"What do you mean by anti-alpha-1-adrenergic?"
alpha-1 normally constricts peripheral arterioles à anti-alpha-1 effects can precipitate orthostatic hypotension + fainting.
Other HY factoids about bupropion:
also used for smoking cessation; never give in electrolyte disturbance or eating disorder patients because of seizure risk; does not cause sexual dysfunction (unlike SSRIs which can cause anorgasmia); bupropion is a reuptake inhibitor preferentially for NE and dopamine over serotonin.
-If an elderly patient is acutely delirious, give
an antipsychotic like Haloperidol.
BMI of 16, purging, runs 30 miles a day, consumes 400 calories a day
anorexia nervosa.
18F + repeated purging + BMI 17; Dx?
anorexia, not bulimia à if BMI low, answer is anorexia.
Frontal lobe injury in car accident; NBME asks which deficit is most likely to ensue;
answer = conceptual planning.
14M + cognitive decline over a few months + ataxia; which drug/substance did he do?
answer = glue, not alcohol à 14 is too young to get alcohol-induced cerebellar ataxia.
65M + given IV methylprednisolone for temporal arteritis + develops confusion + visual hallucinations; Dx?
answer = "corticosteroid-induced psychotic disorder"; astute student says, "I thought that happens with high doses over longer periods of time." à response: yeah, but Psych NBME has it occurring after a one-off dose in a patient. Bottom line is: be aware that glucocorticoid psychosis is tested.
Fainting in panic disorder; why?
answer = "decreased cerebral perfusion," or "cerebral hypoperfusion"; hyperventilation à decreased CO2 à causes decreased cerebral blood flow.
Mechanism for incontinence in NPH?
answer = "failure to inhibit the voiding reflex."
35F + chronic pain in arm since MVA last year + says to physician "I'm realizing I'll be like this forever." Question wants most appropriate response;
answer = "have you been feeling like just giving up?" à must assess suicide risk.
59F + metastatic cancer + in pain + crying + "wants to die"; Q asks most likely reason for wanting to die;
answer = "inadequate pain control"; "major depression" is wrong answer; must address pain management in cancer patients.
Patient witnesses terror attack + has felt emotionally numb for two years since + sometimes disturbed sleep; next best step?
answer = "provide information about the ranges of reactions to trauma."
16M + BMI 31 + snores loudly + morning headaches + 3-5 beats of jerk nystagmus with lateral gaze; Dx?
answer = "sleep-related hypoventilation"; nystagmus is weird finding, but it's on the Psych NBME; morning headaches are common in sleep-related hypoventilation; can do polysomnography to diagnose.
75M + episodes of loss of consciousness (LoC) for 2 years + tonic-clonic-like episodes + becomes pale and sweaty + Hx of MI; Dx?
answer = "syncope" on the NBME (convulsive syncope).
26F in Australia picking peaches + pinpoint pupils; Q is "how could this have been prevented?"
answer = "wearing gloves," not "use of facemask." Apparently organophosphate poisoning is acquired through skin, not droplets.
6M + IQ of 60 + small for age + born to female age 41 + no other information given; Q asks: most likely cause of mental retardation?
answer = Down syndrome, not FAS; although FAS is most common cause of MR overall, two points: 1) if they want FAS, they'll mention the philtrum as per above, and 2) most common cause of MR over the age of 40 is Down, not FAS.
22M takes a drug + gets nystagmus + bellicosity (wants to fight)
answer = PCP.
22M takes a drug + gets mutism + has constricted pupils
answer = PCP. ****ing weird but it's on the psych NBME for 2CK. If you don't believe me, you can Google "pcp mutism constricted pupils."
59M + wife says he has bizarre behavior at night where he jumps out of bed and runs back and forth across the room punching the air + says he does not recall such behavior but remembers bad dreams; Dx?
answer = REM sleep behavior disorder à incomplete or absent REM muscle atonia; tends to occur in older adult men; if recurrent, may indicate onset of neurodegenerative disorder like Parkinson disease.
4F + wringing of the hands + putting objects in her mouth + less eye contact; Dx?
answer = Rett syndrome; only seen in girls; hyperoralism may reflect cognitive regression (babies put everything in their mouths).
Tx for premature ejaculation?
answer = SSRI.
Tx for diabetic neuropathic pain?
answer = TCA (i.e., amitriptyline). Second-line is gabapentin
45M + survived plane crash two weeks ago + wakes up screaming in middle of night reliving the event; Dx?
answer = acute stress disorder, not post-traumatic stress disorder (PTSD); acute stress disorder is < 1 month; PTSD is > 1 month. Treatment for both is CBT.
60M + recent MI + asks when he can resume sexual intercourse;
answer = as soon as he feels ready; wrong answer is "wait at least two weeks."
Tx for organophosphate poisoning?
answer = atropine before pralidoxime. Retired NBME 15 or 16 for Step 1 has both as answers, and atropine is correct.
33M + robbed at gunpoint two days ago + now is mute and not responding to questions; Tx?
answer = benzo (lorazepam) à catatonia secondary to adverse stimulus.
16M + found on floor in school bathroom + brought into hospital + sluggish + pupils and vitals normal; which drug/substance did he do?
answer = butane (inhalant toxicity); this is HY!
22M + sluggish patient + has angiogram performed (for some reason) that shows decreased cerebral blood flow; drug that was taken?
answer = cocaine; this question is on USMLE. Cocaine is known to cause vasoconstriction, i.e., placental abruption, coronary vasospasm; apparently that extends to cerebral blood flow on the exam.
Tx of serotonin syndrome?
answer = cyproheptadine (serotonin receptor antagonist).
Anorexia in patient with edema; mechanism for edema?
answer = decreased serum albumin (yes, this is straight from the Psych NBME, no idea why).
Mechanism of narcolepsy?
answer = deficiency of orexin (hypocretin).
33M + witnessed construction accident at work where many people were injured + found by police in bowling alley parking lot talking to himself + unable to respond to questions about his identity; Dx?
answer = dissociative fugue (dissociative disorder); fugue = amnesia for personal identity + travel.
If brain imaging performed in schizophrenic patient, what would be seen?
answer = enlargement of the third and lateral ventricles.
56M + depressed mood + sleep apnea; Dx?
answer = mood disorder due to a general medical condition.
49M + Down syndrome + forgetfulness; which part of brain is affected?
answer = nucleus basalis of Maynert à high-density of cholinergic neurons (basal forebrain) à affected in Alzheimer (early-onset in Down).
Diagnosis of narcolepsy?
answer = polysomnography.
65M + Parkinsonism + axial dystonia; Dx?
answer = progressive supranuclear palsy (student had this on the USMLE).
23M + hearing voices for 6 weeks + staying up all night for 4 weeks; Dx?
answer = schizoaffective disorder à Dx is >2 weeks of psychotic disorder in the absence of mood disorder.
Tx for TCA toxicity?
answer = sodium bicarb à causes dissociation of drug from myocardial sodium channels.
32M + diffuse headache relieved by acetaminophen + sleep; Dx?
answer = tension-type headache; Tx = rest + taper caffeine (if taking it).
Patient eats aged cheese + red wine + slice of pepperoni pizza (**** now I want pizza) + takes phenelzine for atypical depression + gets BP of 220/100; Dx + Tx?
answer = tyramine crisis; MAOi prevent the breakdown of tyramine, a naturally occurring catecholamine in some foods; tyramine prevents the reuptake of endogenous catecholamines; Tx for tyramine crisis on Psych shelf = alpha-1 blocker (phentolamine).
35M + recently divorced + stressed + insomnia; which med to give: answers are SSRI, antipsychotic, and zolpidem;
answer = zolpidem à non-benzo zolpidem may be used short-term for insomnia. Take home point is be aware both benzo + non-benzo can be used acutely for insomnia.
8-month-old boy + 3rd-centile for weight + slanted palpebral fissures + epicanthal folds + single palmar crease + thin upper lip with a "fish mouth" appearance + indistinct nasal philtrum; Dx?
answer on Psych NBME = fetal alcohol syndrome (FAS), not Down syndrome; everyone says wtf about this question, so what I tell my students is: if Q sounds like Down syndrome but they mention anything about the philtrum (i.e., long, smooth, indistinct, etc.), the answer is FAS, not Down.
Patient with restless leg syndrome is at increased risk for what disease later in life?
answer on USMLE = Parkinson disease (if D2 agonist can Tx, then lack of dopamine transmission may be etiology in some patients).
Mechanism for tardive dyskinesia?
answer on Psych NBME = "increased sensitivity of dopamine receptors."
35F + family member Dx with breast cancer + says she can't sleep; Q asks which med to give
answer on Psych NBME = clonazepam à benzo OK for acute Tx of insomnia; never prescribe chronically.
82F + MDD + refuses to eat + catatonia; next best step?
answer on Psych shelf = electroconvulsive therapy (ECT); some ECT indications are: catatonia, pregnancy, refusal to eat or drink, imminently suicidal, treatment resistance, Hx of ECT response, psychotic features present.
Area of the brain affected in Huntington?
answer on shelf = caudate nucleus.
8M + develops visual hallucinations after starting on over-the-counter cold med provided by his mother; Dx?
anticholinergic delirium caused by diphenhydramine or dextromethorphan (anti- tussive opioid).
25M + started on new psych med + is now hot and dry; Dx?
anticholinergic effects of TCA.
27M + cheated on the Bar Exam + fired from job at 23 for stealing + arrested for drunk driving in high school; Dx?
antisocial personality disorder; key detail is: must break the law; must be older than age 18 and must have had conduct disorder prior to age 15 à in other words, just because an adult breaks the law does not mean he or she has ASPD. Another important point is that "anti-social" means "law-breaking," not "not social." Students tend to erroneously define anti-social as avoidant.
81F + cooks own meals since husband passed away + seems depressed + various non-acute neurologic findings; next best step?
assess suicide risk (this answer is basically always correct if it's listed).
Wernicke's encephalopathy is associated with
atrophy of the mammillary bodies
22F + hyperphagia + hypersomnolence + improved mood with pleasurable events; Dx + Tx?
atypical depression; Tx = SSRI, not MAOi; MAOi (e.g., phenelzine) are considered highly efficacious but carry dangerous side-effects, so SSRIs remain first-line.
Major characteristic in psych vignettes that suggests psychotic disorder?
auditory hallucinations; in contrast, visual hallucinations are non-specific and seen frequently in drug use (alcohol, amphetamines, marijuana, etc.).
47F + highly sensitive to rejection + poor self-esteem; Dx?
avoidant personality disorder (ego- dystonic).
You are called to evaluate a 25 yo M prior to discharge after spending 3 days in central booking for driving under the influence. He feels completely dissatisfied with life, is restless, and has not slept for the past 2 days. You wonder how boring you must be as he constantly yawns during the interview. He has a bad runny nose and there's copious amounts of saliva dripping from the lateral side of his mouth. His PE is notable for marked pupil dilation. He runs to use the restroom 3x during the interview. What is the next best step in the management of this patient? a. Dextroamphetamine therapy. b. Supportive care. c. Referral to alcoholics anonymous. d. Naltrexone therapy. e. Flumazenil therapy.
b. Supportive care (opioid withdrawal, not life threatening!)
How to differentiate normal aging from Alzheimer on Psych shelf?
biggest point is that patients who complain or are concerned about their own cognitive decline do not have Alzheimer; classic example is 68F who frequently says she walks into rooms and can't remember why she went in there + says she accidentally left the burner on in the kitchen last week and had an argument with her adult daughter about it à answer = normal aging, not dementia à patient herself is concerned / complaining, so answer is not dementia on USMLE.
What is bipolar I vs II?
bipolar I is worse than II; both will have cycling episodes of mania and depression, but bipolar I will often tell you there's Hx of hospitalization, or losing one's job, friends, or relationships (socio-occupational dysfunction), or spending lots of money; bipolar II will tell you patient keeps stable job and/or family life and has never been hospitalized.
16F + slice marks on wrists and thighs + Hx of two prior broken engagements; Dx + Tx?
borderline personality disorder; parasuicidal behavior common (suicidal gestures, but not true attempts at suicide); Tx = dialectal behavioral therapy (DBT).
• Often have a history of childhood trauma (eg, physical/sexual abuse or neglect) → insecure attachment, unstable relationships, and fear of abandonment • Cluster B personality disorders have a high rate of self-mutilation and suicide
borderline personality disorder
What are the important timeframes for schizophrenia vs schizophreniform vs brief psychotic disorder?
brief psychotic disorder is < 1 month; schizophreniform is 1-6 months; schizophrenia is >6 months of psychosis.
Anti-depressant med causing seizures?
bupropion.
-Quetiapine causes
cataracts (regular slit lamp exams needed)
Huntington's disease is associated with
caudate atrophy
81F + cooks own meals since husband passed away + seems depressed + various non-acute neurologic findings + MMSE is 25/30 + no suicidal ideation; next best step?
check serum B12 à subacute combined degeneration (SCD) = pattern of neurologic dysfunction seen in B12 deficiency.
42F + 3-month Hx of insomnia + discomfort while lying in bed; next best step in management?
check serum iron and ferritin levels; student says wtf? à restless leg syndrome is most often caused by iron deficiency.
Is abuse reportable?
child + elderly abuse: yes. Domestic abuse: no. Answer for latter is to provide supportive care + as much information as possible about what she can do if she feels unsafe.
56M + 3-day Hx of cutting from 12 beers a day down to 4; develops tremulousness; Tx?
chlordiazepoxide (delirium tremens); classic vignette is guy has surgery + two days later has tachycardia, tremulousness, and hallucinations (alcoholic hallucinosis).
How to differentiate cluster headache from trigeminal neuralgia?
cluster will be a male 20s-40s with 11/10 lancinating pain behind the eye waking him up at night (he may pace around the room until it goes away); details such as lacrimation and rhinorrhea are too easy and will likely not show up on the shelf. In contrast, trigeminal neuralgia will be 11/10 lancinating pain behind the eye (or along the cheek / jaw if V2 or V3 branches affected; it's when V1 is affected that this diagnoses are more readily confused) à TN is brought on by a minor stimulus such as brushing one's hair or teeth, or a gust of wind.
Tx of GAD?
cognitive behavioral therapy (CBT) and/or SSRI; second-line pharm agent is buspirone, which is a serotonin receptor agonist; USMLE wants you to know buspirone + its mechanism, but also remember that it's not first-line for GAD; SSRIs are.
16M + disruptive in class + numerous suspensions from school + caught stealing at the mall; Dx?
conduct disorder à pattern of law-breaking + must be under age 18; in contrast, a patient with oppositional defiant disorder does not break the law.
What is cyclothymia vs dysthymia?
cyclothymia is >2 years of swinging low + elevated moods, but never meets the thresholds for bipolar + never has true depressive episode. Dysthymia is >2 years of low moods not ever meeting thresholds for MDD.
Amenorrhea in patient with anorexia; why?
decreased GnRH pulsation à decreased LH + FSH; Q wants " ̄ FHS, ̄ estrogen" as the answer; in contrast, premature ovarian failure, Turner syndrome, and menopause have " FHS, ̄ estrogen" as the answer.
ALZ is associated with
degeneration of the Basal Nucleus of Meynert (site of Ach production)
Parkinson's is associated with
depigmentation of the Substantia Nigra. You should find Lewy bodies (alpha synuclein only in the substantia nigra, contrast with Lewy Body Dementia where Lewy bodies are in the cortex and substantia nigra).
68M + started on various medications 8 weeks ago for low ejection fraction heart failure + now has depressed mood; most likely cause?
depression caused by beta-blocker.
45F + fundoscopy shows hard exudates + cotton wool spots + scattered hemorrhages; Dx?
diabetic retinopathy.
82M + urinary hesitancy + interrupted stream + taking amitriptyline; next best step?
discontinue amitriptyline.
Antipsychotic med + bradykinesia; Dx + Tx?
drug-induced Parkinsonism; Tx with amantadine or propranolol.
18M + enters emergency department; which blood parameter would indicate recent alcohol intoxication?
elevation of serum GGT.
33M + ingested substance + high RR + now has calcium oxalate urolithiasis; Dx?
ethylene glycol toxicity à causes calcium oxalate nephrolithiasis; high RR is due to respiratory compensation for high-anion gap metabolic acidosis (MUDPILES).
A 27 yo nursing student with no relevant PMH comes to the ED complaining of lightheadedness. She has had this episode once every week for the past 6 mo. A fingerstick glucose reading is 27 mg/dl. Plasma insulin levels are elevated but C-peptide is undetectable
factitious disorder (when would this be factitious disorder imposed on another???).
65M + pulls his pants down when guests come over to the house + apathy; Dx?
frontotemporal dementia (Pick disease) à characterized by apathy, disinhibition, personality change.
Tx for herpetic / post-herpetic neuralgia (i.e., from shingles)?
gabapentin
39F + >6-month Hx of multiple worries (i.e., career, marriage, kids going to college, etc.) + no overt mood or psychotic Sx; Dx?
generalized anxiety disorder (GAD) à Dx is >6 months of general worries without lack of specific stressor.
Tx of MG?
give an acetylcholinesterase inhibitor (i.e., pyridostigmine).
22M + schizophrenia + poor adherence to medications; best med to give to Tx?
haloperidol decanoate.
44F + sexual toward doctor + high energy; Dx?
histrionic personality disorder
44M + comes in dressed all in yellow + high energy; Dx?
histrionic personality disorder.
-Risperidone has the strongest association with
hyperprolactinemia (tuberoinfundibular pathway blockade).
18F + anorexia; what electrolyte disturbance is most likely?
hypokalemia.
18F + anorexia + BMI of 14 + reintroduced to foods; what electrolyte must we notably look out for?
hypophosphatemia (refeeding syndrome).
26M + lost in the woods for three weeks + BMI 27 + reintroduced to foods; what electrolyte must we notably look out for?
hypophosphatemia (refeeding syndrome).
48F + BMI 26 + cholesterol elevated + HR 55 + creatine kinase (CK) elevated; Dx?
hypothyroidism à check serum TSH; hypothyroid myopathy can cause proximal muscle weakness + elevated serum CK.
53M + BMI 25 + mostly quiet during interview + total cholesterol 300 mg/dL + hepatic AST slightly elevated + HR 60; Dx + next best step in Mx + Tx?
hypothyroidism à check serum TSH à give levothyroxine (T4); hypothyroidism can cause dysthymia, high cholesterol, and elevated hepatic transaminases.
Other notable causes of reversible cognitive decline?
hypothyroidism, B12 deficiency, neurosyphilis, neuro Lyme.
Serum abnormalities seen in bulimic patient?
increased serum amylase + hypokalemic, hypochloremic metabolic alkalosis.
Schizophrenia is associated with
increased size of laterla ventricles.
What is myoclonic seizure?
jerks in muscle or group of muscles; no LoC.
Which three spinal tracts are involved in SCD?
lateral corticospinal, spinocerebellar, dorsal columns à just remember that the spinothalamic is not involved.
Adverse effects of lithium and valproic acid?
lithium causes Ebstein anomaly in pregnancy (atrialization of right ventricle in fetus); also tremor and thyroid dysfunction; valproic acid notoriously causes neural tube defects.
Tx for bipolar?
lithium or valproic acid to start.
Where in the brain is there high amount of norepinephrine production?
locus coeruleus (pons).
Panic attacks are associated with
locus coeruleus dysfunction/decreased volume of the amygdala (too much NE)
25F + fear of flying + must fly soon; Tx?
lorazepam à specific phobia.
What is cataplexy?
loss of muscle tone usually in response to emotional stimulus (e.g., laughter) à seen in narcolepsy.
42M prisoner + can't feel his foot + pulses and reflexes normal; Dx + Tx?
malingering (secondary gain - i.e., money, drugs, time away from prison; not willing to undergo invasive procedures) à "no treatment indicated."
16F + injected conjunctivae + has paranoia; Dx + Tx?
marijuana intoxication; observation. - Tx for OCD on shelf? à answer = SSRI (i.e., sertraline).
-Olanzapine has a strong association with the
metabolic syndrome (elevated HbA1C, abnormal lipid studies, severe weight gain) in a patient recently placed on an antipsychotic.
Cause of Kluver-Bucy syndrome?
most often due to HSV encephalitis.
44F + diplopia + dysphagia + eyelid ptosis; all worsen throughout the day; Dx?
myasthenia gravis (MG).
Antipsychotic medication started + muscle rigidity + fever; Dx + Tx?
neuroleptic malignant syndrome; give dantrolene (inhibits ryanodine channel).
72M + wife passed away 5 months ago + sometimes hears her voice at night; Dx?
normal bereavement.
65M + wet, wobbly, wacky + Parkinsonism; Dx?
normal pressure hydrocephalus (NPH) à urinary incontinence, ataxia, cognitive dysfunction; key point to make here is the Parkinsonism. Wiki it yourself, you'll see.
6M + nocturnal enuresis; next best step? USMLE / NBME / shelf wants the following order:
o Behavioral answer first; e.g., spend more time with child; decrease overt stressors as much as possible. o If the above not an answer, do star chart (positive reinforcement therapy; i.e., don't wet the bed and get a star; get 5 stars for extra dessert; 100 and we go to Disneyland). o If star chart not listed or already attempted, next answer is enuresis alarm. o Medications like imipramine and desmopressin are always wrong; water deprivation after 5pm is also always wrong. Students mess these Qs up because they'll see enuresis alarm as correct on one form, but on a different form it's star chart, so know the above order.
Other HY uses for propranolol?
o Migraine prophylaxis (FM form gives patient with HTN + migraine; answer = propranolol) o Akathisia (with antipsychotic use) o Thyroid storm (decreases peripheral conversion of T4 to T3) o Essential tremor (bilateral resting tremor in young adult; autosomal dominant; patient will self-medicate with EtOH, which decreases tremor); also the answer on Psych shelf for lithium-induced tremor. o Hypertension + idiopathic tremor (i.e., tremor need not be essential if patient has HTN à answer on FM form is "beta-adrenergic blockade" for the HTN Tx). o Esophageal varices prophylaxis (patients at risk of bleeds) o Hypertrophic obstructive cardiomyopathy (increases preload à decreases murmur) o Social phobia
45M + has repeated thoughts of harming his son + finds the thoughts absolutely outrageous and disturbing + says he would never do such a thing; Dx + Tx?
obsessive-compulsive disorder (OCD) à obsessions are the thoughts; compulsions are the actions; OCD can be just obsessions without actions; Tx is CBT and/or SSRI.
When is delusional disorder the answer?
one, fixed, non-bizarre delusion + no other mood or psychotic Sx; presentation will often be patient with mistrust + suspects coworkers and neighbors are attempting to undermine her work or are stealing from her. If the vignette says anything about "aliens," "the heavens," "the lord," etc., the delusion is bizarre and the Dx is psychosis (i.e., schizophrenia), not delusional disorder.
16F + has mid-systolic click + episode of hyperventilation and chest pain and sense of impending doom; Dx
panic attack = acute episode; recurrent episodes = panic disorder. Psych shelf will often try to make vignette sound cardiac; sometimes "mitral valve prolapse" will be listed as a wrong answer; student will say, "but there's a mid-systolic click," which is true, but the answer is still panic attack/disorder; MVP is most common murmur in population + almost always benign finding.
A 33 yo M believes his wife is cheating on him. He installs cameras all around his house because he thinks the neighbor's kids are stealing from his backyard garden. He recently sued his business partner for paying himself a dollar more than he was paid last month
paranoid personality disorder. These people do not trust anyone. (Multiple weird thoughts = PPD vs a single, prominent thought for delusional disorder)
What is partial vs generalized seizure?
partial = affecting one part of the brain; generalized = involves the wholes of both cerebral hemispheres.
72M + wife passed away 7 months ago + still grieves; Dx?
pathological grief (normal grief is <6 months).
57M + recently divorced + now sleeping with new women + cannot ejaculate during sex + achieves erection during sex with no problem; Dx?
performance anxiety.
74M + MMSE 22/30 + avoids eye contact + weight loss + low mood; DX and Tx?
pseudodementia à Tx = sertraline (SSRI), not donepezil.
Main way to differentiate pseudodementia from dementia?
pseudodementia is depression that presents as cognitive decline; vignette may describe weight loss or gain, avoidance of eye contact, low mood, and/or tearing up during interview; vignette may also mention poor performance on the reverse serial 7s of the MMSE, or the patient is slow drawing a clockface but can rapidly complete it once prompted (apathy); pseudodementia presents as apathy on MMSE; in contrast, patients with true dementia try on the MMSE.
Where in the brain are there high amounts of serotonergic neurons?
raphe nucleus (medial reticular formation).
The PPRF controls
rapid eye movements in REM sleep.
26M + works at plastics factory + quiet/loner; Dx?
schizoid personality disorder (ego-syntonic).
26M + "wild thinking" + no auditory hallucinations; Dx?
schizotypal personality disorder.
57M + trouble with intercourse with his wife + has nocturnal erections; Dx?
secondary erectile dysfunction (psychological) à if nocturnal tumescence is intact, he's physiologically fine.
Cyproheptadine may be used to treat
serotonin syndrome. It is an antihistamine that also has powerful serotonin receptor blocking activity.
Patient with MDD has fluoxetine discontinued + tranylcypromine commenced one week later + patient develops temp of 105F + HR 110 + RR 25; Dx?
serotonin syndrome; will show up on Psych shelf as simply "drug-drug interaction"; can occur when combining SSRIs with St John Wort, or notably when commencing a MAOi too soon after being on another serotonergic medication.
What is edrophonium
short-acting acetylcholinesterase inhibitor.
What is simple vs complex seizure?
simple = no LoC; complex = LoC; patient staring off into space not aware of surroundings = LoC.
-Older individuals
sleep less, take more time to fall asleep (increased sleep latency), and spend less time in REM sleep.
8M + gets out of bed at night and tries to leave the house; when his mom tries to stop him, he violently tries to pull away from her; once he got out of the house and woke up outside while in the middle of an episode; he has no recollection of the episodes; Dx?
sleep terror disorder; tends to occur in pre-adolescent boys.
32M + fear of public speaking (glossophobia); Dx + Tx?
social phobia, not specific phobia; Tx = atenolol (propranolol also OK).
32M + fear of flying; Dx + Tx?
specific phobia; Tx with benzo.
Defense mechanism in borderline personality disorder?
splitting: "all doctors are bad; all nurses are good."
Tx of nacrolepsy
stimulants (i.e., modafinil).
82M diabetic + neuropathic pain + already taking carbamazepine + gabapentin to no avail; next best step?
switch the meds to nortriptyline (a TCA) à student then asks, "Wait, I thought you said TCAs are first-line. Why does this Q have the guy on those two meds then?" à two points: 1) we don't like giving TCAs to elderly because of their anticholinergic and anti-alpha-1 side-effects, so this vignette happen to try other agents first, but if you're asked first-line, always choose TCA; and 2) if we do give a TCA to an elderly patient, we choose nortriptyline because it carries fewer adverse effects.
Antipsychotic med + abnormal tongue movements; Dx + Tx?
tardive dyskinesia; stop antipsychotic + switch to atypical à answer on Psych shelf for one Q is "discontinue haloperidol and switch to risperidone."
Drugs with anticholinergic activity should be avoided in
the elderly (TCAs, antihistamines like diphenhydramine, low potency typical antipsychotics).
A concerned med student runs to his friend's room around 3AM after he heard a loud noise. This friend is barely arousable and goes back to sleep. The med student questions his friend the next morning who flatly denies any sort of screaming episode
this is sleep terror disorder (patient does not remember, occurs during stages N3/4 of sleep which are associated with delta waves. Benzos decrease this stage)
23M + vignette sounds like he has schizophrenia + no mention of mood disorder + answer is schizoaffective; why?
this is snapshot of the patient in the psychosis-only phase of schizoaffective (asked on Psych shelf, where you need to eliminate the other answers, e.g., bipolar, cyclothymia, etc., in order to answer correctly).
82M + confusion + on various meds; Dx?
various answers on NBME are: "discontinuation of anticholinergic medications"; "discontinuation of diphenhydramine" (1st gen H1 blocker); "discontinuation of amitriptyline"; "discontinuation of doxepin"; "discontinuation of desipramine" (all TCAs) à TCAs, 1st generation H1 blockers, and 2nd generation antipsychotics (atypicals) all cause a triad of side-effects: o Anti-cholinergic (anti-muscarinic) o Anti-alpha-1-adrenergic o Anti-H1-histaminergic
One telltale sign of TCA overdose is
wide QRS complexes on an ECG. Give Na Bicarb ASAP.
Medication that can cause tardive dyskinesia that is not an antipsychotic?
à answer = metoclopramide (D2 antagonist); can also prolong QT interval and cause hyperprolactinemia.
7F + facial grimaces past 5 months + no other motor findings or abnormal sounds + mental status normal; next best step in Mx?
à answer = "schedule a follow-up examination in 3 months" à Dx = provisional tic disorder à 1/5 children experience some form of tic disorder; most common ages 7- 12; usually lasts less than a year; "watch and wait" approach recommended. Provisional tic disorder used to be called transient tic disorder; the name was changed because a small % go on to develop chronic tics.
Tx of panic attack vs panic disorder?
à for panic attack, answer = breathe into paper bag (sounds wrong as an answer but is correct if listed); if this is not listed, choose benzo. For panic disorder, Tx = SSRI.
Difference between serotonin syndrome and carcinoid syndrome?
à serotonin syndrome is from drug-drug interactions and notably causes hyperpyrexia (high fever), tachycardia, and tachypnea; carcinoid syndrome is a result of carcinoid tumors (usually small bowel, appendiceal, or bronchial) secreting serotonin and causes flushing, diarrhea, abdominal pain, and bronchoconstriction.