USMLE Step 2 > Psych incorrects > Flashcards

Psych incorrects Flashcards

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1
Q

antidepressants should be trialled for at least 4-6 weeks before considering effectiveness and switching to another/augumenting with another

A
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2
Q

psych can ask you what is diagnosis eg GAD

A
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3
Q

how to distinguish delusional disorder from paranoid personality disorder or other conditions

A

delusional = grandiose, erotomanic, jealous, somatic, persecutory. no psychotic symptoms like hallucination and disorganization

paranoid = distrust and suspicion of MANY people, not just directed at a single person

note* patients with alzheimers may develop psychosis including delusions of jealousy but this is in late stage of disease where other signs present

abnormal neurological exam -> can point to psychotic disorder due to other medical condition

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4
Q

how to differentiate dependent disorder from adjustment disorder

A

dependent disorder = submissive behaviour!! (eg getting a cat for gf when you are allergic), needs to be taken care of (eg gf used to prepare all meetings for), struggle to make decisions alone, fear of being alone. patients can often have anxiety/panic attacks or depression in context of relationship ending

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5
Q

Social anxiety disorder treatment?

A

performance only = beta blocker (preferred) OR benzodiazepines

SSRIs/SNRIs = if generalised anxiety or depression present

VS panic disorder which is treated with SSRIs and SNRIs and in short term lorazepam

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6
Q

cause of tardive dyskinesia?

A

dopamine receptor upregulation and supersensitivity

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7
Q

in obsessive compulsive disorder, obsession with work for instance may make people neglect hobbies and social relationships

A
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8
Q

what are symptoms of gambling disorder?

triggers?

A

preoccupation with gambling, tendency to jeopardize relationships and work for gambling, relying on others when in debt

mood symptoms - irritability, feeling down

triggers for gambling - distressed, anxious, depressed

distinguish from bipolar manic epsiode as mania is episodic and unlikely to last greater than a year, increased energy, flight of ideas and pressured speech also seen in mania

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9
Q

Give an example of a depressive disorder due to another medical condition

A

Obstructive sleep apnoea -> can cause depressive symptoms like fatigue, difficulty concentrating, irritability, low mood.

excessive snoring, daytime sleepiness, male sex, BMI >35, HTN, age>50

cant diagnose MDD without excluding medical or substance use causes

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10
Q

what drug is used to treat depression in children?

A

fluuoxetine

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11
Q

how to differentiate language disorder from autism or specific learning disorder

A

specific learning disorder -> difficulties in reading, written expression or maths. requires testing. language disorders may be a precursor

in a language disorder patient will make multiple attempts to communicate unlike autism.

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12
Q

antidepressant of choice in patients with depression and comorbid neuropathic pain eg diabetic neuropathy?

A

SNRIs - eg duoloxetine, venlafaxine

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13
Q

Ropinirole and other dopamine agonists can induce impulse control disorders similar to manic symptoms - compulsive shopping, gambling, eating.

Another example is pramiprexole

A
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14
Q

Lithium toxicity symptoms?
management?

A

altered mental status, siezures, fasciculations, tremor, GI (vomiting diarrhea)

hydration. Hemodialysis!! if severe

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15
Q

Sleep terror features?
management?

A
  • occur in children aged 2-12. peak incidence 5
  • occur EARLY on when falling asleep
  • child inconsolable and cant be woken up
  • NO MEMORY of event compared to nightmares
  • reassurance
  • low dose benzodiazepine only if frequent epsiodes with marked functional impairment
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16
Q

management for anxiety related nightmares?

A

CBT

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17
Q

investigation for restless leg syndrome?

A

serum ferritin levels

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18
Q

nocturnal enuresis managment?

A

imipramine or desmopressin

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19
Q

key way to distinguish adjustment disorder from MDD

A
  • symptoms must be present for AT LEAST 2 weeks for MDD diagnosis and a certain number of symptoms must be present
  • indentifiable stressor must be present in Adjustment disorder
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20
Q

when would you suspect phaechromocytoma rather than panic attack diagnosis?

how to differentiate from hyperthyroidsm and

A
  • episodic headaches!! HTN!1
  • palpitations diaphoresis
    (anxiety and panic attacks can occur with phaeos)

palpitations in hyperthyroidism are not episodic. headaches are not seen. and other symptoms of hyperthyroidism eg weight loss, heat intolerance, diarrhea typically present

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21
Q

man with depression!!, gaining a lot of weight. central obesity. raised glucose.

next step in management?

A

urinary free cortisol
(or low dose dex test)

patient has cushings syndrome!!

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22
Q

changes in behaviour, dementia,
pmh htn and diabetes

most likely cause

A

frontotemporal dementia!!

not vascular because that would cause memory impairment + focal neurological deficits

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23
Q

patient presenting with muscle tension(headaches, shoulder neck and back pain), fatigue and insomnia. (core symptoms!)

worried about a few things.

next best step in management?

A

begin escitalopram (SSRI) and recommend CBT

-muscle aches and tension common in GAD

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24
Q

premature ejaculation treatment?

A

SSRI

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25
CJD cerebrospinal fluid findings?
high 14-3-3 protein titres contrast to anti-hu antibodies seen in antihu encephalitis seen in small cell lung cancer
26
hoarding disorder treatment?
CBT
27
how to differentiate schizoid vs avoidant personality disorder?
when avoidant - you prefer to be alone due to fear of criticism and rejection "who would want to be friends with someone ugly and stupid like me anyway"
28
distinguish between bulimia and binge eating disorder
both have binge eating bulimia only -> compensatory behaviours to prevent weight gain = laxatives, fasting, exercise, vomiting, diuretics, diet pills SSRI plays a role in treatment of both no binge eating in anorexia and in anorexia, you can vomit etc but your weight is low unlike bulimia
29
NMS is different from malignant hyperthermia. the latter is caused by anaesthetic use
30
differentiate acute stress disorder and ptsd. treatment for acute stress disorder
PTSD =>1 month symptoms treatment for both = CBT (Trauma focused)
31
patient with sleep difficulties, stopped spending time with friends, discontinued hobbies (anhedonia) feeling tired (fatigue) weight gain missed deadlines, mistakes at work (impaired concentration) increasingly anxious and restless (psychomotor agitation) next best step in management?
Escitalopram and CBT for depression SIG-E-CAPS Sleep, interest, guilt, energy, concentration, appetite, psychomotor changes, suicidality
32
SSRIs and what else are the first line treatment for GAD?
SNRIs eg Venlafaxine
33
in dementia with lewy bodies, what are the possible side effects from treatment with antipsychotics
worsening confusion parkinsonism autonomic dysfunction -> eg postural htn
34
psychotic! man temp 38 ataxia NYSTAGMUS (Clinches diagnosis!) muscle rigidity history of substance abuse most likely diagnosis? how to manage?
Phencyclidine intoxication (PCP) lorazepam! (benzodiazepines)
35
to distinguish a person with major depression with psychotic features from schizophrenia, in MD there will be lots of depressive features like sleep and appetite
36
when assessing suicidal risk, keep to open questions, ask what prompted to feel scared
37
most likely physical finding in patient taking phenelzine (MAOI) experiencing headaches, after eating heavy sauces and wines?
hypertension (hypertensive crises = key side effect)
38
how do you diagnose pesistent depressive disorder (dysthmia)
depressed/low mood for at least 2 years: plus at least two depressive symptoms eg: - low self esteem - believing you are unattractive - patient was not avoidant because she still tried to have a relationship - fatigue - concentration - feelings of hopelessness - etc
39
how do you manage pyschosis in parkinsons disease? ps reduction of PD medications failed
specific antispychotics - quietapine!!! clozapine!!, Pimavanserin!! - low dopamine receptor antagonism
40
postpartum woman with fatigue + unsteady gait + assymmetric lower extremity weakness + hyperreflexia (UMN sign). what is the next step in managment?
obtain MRI of brain and spinal cord Multiple sclerosis can often present or worsen in post partum period
41
patient with schizophrenia, on antipsychotics. inner restlessness (pacing, inability to sit still so walking all around neighbourhood), agitation(seen in severe cases) management options?
reducing dosage switch to antipsychotic with less of this eps or add on Propanolol!!!! (or less commonly a benzodiazepine or benztropine)
41
agitation, restless behaviour, irritability, insomnia, and signs of psychosis in a 16 year old who has been staying up studying for exams. history of adhd. family history of BAD next best step in management?
lorazepam!! (benzodiazepine) patient misused adhd stimulants
42
psychosis, mood changes/ anxiety. when you suspect acute intermittent porphyria as the cause, what other symptoms would you expect?
abdominal pain acute onset sensory and motor neuropathies
43
how would you manage a child that has a specific phobia about when it rains and thunderstorms?
read stories that depict storms to the patient - exposure therapy (a type of CBT) is first line
44
hallucinations can occur in both parkinsons disease and dementia w lewy bodies. in PD, typically minor hallucinations (eg presence/passage) but can be major if on dopaminergic therapy. thus how do you distinguish both conditions?
in PD, dementia is late onset >1 year after symptoms in DWLB <1 year
45
delirum tremens does not present until 48 hours after the last drink and is marked by htn, hyperthermia and tachychardia. so if alcoholic has hallucinations that resolve by 48 hours, what is the most likely diagnosis?
alcoholic hallucinosis
46
psychotic symptoms, paranoid delusions(plotting your murder), hallucinations including tactile hallucinations, multiple sores on body due to skin picking!!!!!, tooth decay, decreased need for sleep. all point to what diagnosis?
methamphetamine use disorder
47
management of acute agitation?
benzodiazepine or antisphycotic eg haloperidol
48
depression, worsened junk food cravings (binge eating symptom) and hypokalemia and hypochloremia on bloods. which antidepressant is contraindicated?
buproprion -> signs of eating disorder including electrolytes hintig to vomiting buproprion contraindicated in patients with bulimia, anorexia and epilepsy as it lowers siezure threshold!
49
what to say to someone with a motivation of 2/5 to stop drinking?
what makes your rating a 2 rather than a 0 evoke their reasons for change
50
insomina and anxiety. divorce a year ago. no longer attending exercise clases, showing up to work late. reports taking alcohol to help fall asleep each night. macrocytic anemia on bloods most likely diagnosis?
alcohol use disorder = patients with this often seek help for insomnia and anxiety which are withdrawal symptoms
51
usually 6 months following remission of depression you can taper meds. but in which patients is lifelong medication required?
patients with severe episodes (suicide attempts) at least at least 3 lifetime depressive episodes episodes lasting at least 2 years NOTE for maintenance treatments (antidepressants for 1-3 years), you need at least 2 depressive episodes
52
19 feels cold all time feels constipatied family history of graves BP 80/50 BMI 15 exercises 5 times a week pulse is 38 labs show hypokalemia, hypophsophotaemia and low T3 and T4 next step in management?
admit patient!! -> anorexia unstable vitals, cardiac arrythmias, electrolyte derangement and severe low body weight are indications for admission NOT hypothyroidism, however euthyroid sick syndrome can occur in anorexia
53
siezure, tightly closing eyes, no post ictal confusion most likley diagnosis?
psychogenic non epileptic siezure!!! other signs = side to side head body movements, memory recall of the event diagnose using video-eeg of the event - demonstrates no epileptiform activity caffein in severe cases can cause siezure but symptoms more in keeping with PNES
54
most important follow up test on olanzapine?
fasting glucose and lipids!
55
thinks doctors are always trying to find something wrong so they can bill feels if she marries partner might just be trying to get her inheritance what type of personality disorder?
paranoid personality disorder!!! -> makes doctor patient relationship hard NOT schizoid disorder = social detachment and restricted emotional expression. dont have pervasive suspicion of others NOT schizotypal personality dosorder = odd beliefs and exxentric behaviour eg belief in telepathy, idosyncratic speech
56
signs of adjustment disorder, difficulty falling asleep, taking 2-3. hours. most appropriate pharmacotherapy?
Zolpidem!! helps with insomnia
57
14 YO girl tremor of hands with aprubt onset and cessation stops during exam (so stops with distraction) most likely dignosis?
functional tremor!!! may also have changeable features NOT essential tremor as more seen in adults, worsens with outstretched hands or at the end of a goal directed movement. also improves with rest not orthostatic tremor as affects legs and trunks and occurs when standing
58
uncharacteristic aggressive and sexual behaviour in young woman and then also regressive behaviour (speaking like a child) memory loss of past events. sexually abused as a child!! (trauma) chronic auditory hallucinations most likely diagnosis?
dissociative identity disorder!! - switching into at least 2 personalities that take over a persons behaviour + cant recall personal information treatment = trauma focused psychotherapy
59
18 yo. been studing for final exams. hypoglycemic episode. serum insulin and c peptide elevated. father has diabetes. most likely diagnosis?
surreptitious sulfonylurea use NOT exogenous insulin as c peptide would be low
60
depressed mood/ loss of interest in activities eg meeting up with friends, helps tease out MDD in cancer patients
61
stressful work situation - low mood, moor sleep fatigue no marked impairment on functioning most likely diagnosis?
normal stress response
62
patient sad she has to care for father that was never present, but when father is with her she is ecxtremley nice to father. what defense mechanism is she using?
reaction formation!!!
63
bipolar on lithium experiencing fatigue, constipation, myalgia and bradycardia also takes atorvastatin most likely cause?
lithium!! lithium induced hypothyroidism - treated with T4 supplementation not lithium discontinuation
64
what is the mechanism by which antipsychotics cause sexual dysfunction?
decreased dopamine activity in the tuberoinfundibular pathway
65
patient on opiod pain medication. what do you have to give in addition?
naloxone!!! -> to help prevent overdose never give clonazapam with opiods due to risk of resp depression
66
treatment for specific phobia?
exposure therapy!!! - a specific form of CBT NOT SSRIs
67
PTSD treatment is CBT!! (trauma focused)
68
on SSRI and having a partially good result, but is experiencing fatigue, weight gain. what can you add on?
Buproprion!!! - also helps with sexual side effects if patient didint respond to SSRI at all. just discontinue and start buproprion NOT mirtazapine becauses weight gain!! and sedation and fatigue
69
quetiapine mechanism of action?
serotonin 2A and dopamine D2 receptor blockade
70
borderline personality disorder treatment?
dialectical behavioural therapy!!
71
schizophrenic on clozapine. moved to care home normal. but following day becomes agitated yelling at people. sweating, hand tremors, elevated BP next step in management?
administer benzodiazepine!!! - alcohol withdrawal alcohol use disorder often goes missed in patients with schizophrenia
72
4 day post up increased tone in limbs, fever, mental status changes recent haloperidol use most likely explanation?
decreased central dopaminergic activity!!! due to antipsychotic use Neuroleptic malignant syndrome!!! NOT malignant hyperthermia as it arises shortly after induction of anaesthesia not 4 days later
73
first line treatment where a patient just broke up with boyfriend and didnt get a promotion?
psychotherapy!! = adjustment disorder
74
Fragile X syndrome is diagnosed via?
FMR1 DNA analysis
75
fatigue, anorexia, memory impairment, lack of motivation, loss of libido but also salt craving and reduced pubic hair next step to establish the diagnosis?
cosyntrophin stimulation testing!!! salt craving and reduced pubic hair are suggestive of primary adrenal insufficiency/adddisons disease
76
patient experiencing bradykinesia, tremor, masked like facies which is hard to distinguish from depression, and decreased arm swing after starting risperidone. next step in management?
continue risperidone and add benztropine!!! or add amantadine other options = reduce dose, switch to other antipsychotic with lower eps potential patient has eps symptoms
77
what group of medications can be prescribed for pTSD?
SSRIS and SNRis like paroxetine!! but trauma focused CBT is 1st line
78
79 yo lady, wakes up in middle of night and wakes up earlier. by one hour at 5:30. increased naps during day but No day time impairment next step?
reassurance and sleep education!! normal age related sleep changes
79
acute dystonia treatment = dipenhydramine!!! or benztropine parkinsonism = amantadine or benztropine!!! tardive dyskinesia = Valbenazine, deutetrabenazine. also discontinue causative medication eg risperidone!!
80
having a professional sitter at bedside!!!/ observation/family helps with delirium and helps prevent need for restraints
81
schizoaffective disorder now presents with RUQ pain, elevated liver enzymes, nausea and malaise. bilateral hand tremor most likely medication cause?
sodium valproate - may cause liver failure NOT lithium as excreted through the kidneys
82
periods of low and high moods. no history of major depressive disorder or psychosis. most likely diagnosis?
cyclothymic disorder!!! not bipolar 2 = MDD + hypomanic episodes
83
patients with schizophrenia frequently have anxiety. psychological approaches eg CBT are preferred initial approaches due to risk of dependency with benzodiazepines. antipsychotic medications should be maintained indefinitley in patients with schizophrenia
84
treatment or neuroleptic malignant syndrome?
bromocriptine!!! or amantadine (dopamine agonists) dantrolene benzodiazepine
85
i cant confirm if he is a patient at this clinci is the correct answer NOT i cant disclose his health information
86
patient started on fluoxetine for social anxiety 2 weeks ago but has been feeling very jittery since next step in management?
decrease fluoxetine dose early side effect of ssris = anxiety
87
17 year old girl. picky eater, weight loss and mood changes. sleeping less have lots of energy exam shows thin body and ERYTHEMA of nasal mucosa!!!!
cocaine abuse!!! causes increased energy, decreased appetite, decreased need for sleep
88
person trying to turn water to wine, believes he has the power to save souls avoids direct contact, monotonous voice (flat affect) speech is difficult to follow (disorganised speech) smiling intermittently for no apparent reason (responding to external stimuli) + functional decline as cant keep job most likley diagnosis?
schizophrenia!!! at least 2 of following to diagnose - Delusions!! - hallucinations - disorganised speech - negative symptoms - apathy, flat affect - disorganised or catatonic behaviour NOT delusional disorder!! as no disorganization of flat affect, and usually functioning is normal
89
patient on opiod treatment has a postitive urine drug screen for PCP. next step in management?
repeat drug tests -> false positives and false negatives can occur, unexpected results need to be repeated
90
anxiety and nightmares 2 weeks after an attack. most likely diagnosis?
acute stress disorder!!! NOT ptsd because needs to be present for at least 1 month!!!
91
chldren often prefer certain foods, doesnt mean they have autism. if picky eating is accompanied by behavioural rigidity, poor growth, weight loss and developmental delays, then further evaluation eg for autism
92
drug overdose ams, siezures anticholinergic signs (dilated pupils , flushed dry skin, intestinal ileus) prolong qrs best predictor of complications from overdose?
QRS duration!!! tricyclic antidepressant overdose QRS> 100 = risk arrhythmias and siezures, treat with sodium bicarbonate
93
cant get a word in = pressured speech punching wall = impulsivity cant shut my mind off = racing thoughts signs of bipolar disorder
94
for spearation anxiety to be diagnsoed - you need hedaches, stomach aches, nightmares, not just not wanting to be dropped at school
95
when hyperactivity and impulsivity aree limited to parent setting only, ineffective parenting methods should be considered
96
ADHD in adult but history of substance abuse. wants treatment but nothing addictive 1st line?
ATOMEXETINE (A non stimulant)! avoid stimulants like methylphenidate
97
acute stress disorder first line management?
review common physical and emotional responses to trauma!!! trauma focused CBT if severe or persistent
98
84 yo man daughter reports isolation calls less frequently asks to repeat things a lot moca test 26/30 next step in management?
hearing evaluation!!! symptoms in keeping with age related hearing loss not MRI as MOCA
99
in addition to acamproasate, what is first line to control cravings in alcohol use disorder?
naltrexone!! not disulfiram + it cant even be used in patients who are actively drinking, only those abstinent
100
cocaine use might be similar to bipolar disorder but pupil dilation, diaphoresis tremors tachy help point to cocaine use
101
narcolepsy. worried will lose job as falling asleep during the day
modafinil - promotes wakefulness!!! NOT clonazepam. sedating drugs should be avoided in narcolepsy
102
depression, anxiety, weight loss. new diagnosis of diabetes mellitus. next step in management?
CT abdomen -> rule out pancreatic cancer
103
nause and vomiting in pregnancy. 8 weeks pregnant. electrolytes and ketones normal. feels shes fat but has acutlly lost 2 kg. unpredictable meals next step in management
evaluate for underlying eating disorder weight loss, distoreted body image, distorted eating behaviours
104
patient is depressed and states shes had thoughts of taking all her medications at once next step in management?
hospital admission!!! she has a plan and a means of access
105
treatment for catatonia?
benzos eg lorazepam!! or ect
106
cocaine - chest pain, siezure, mydriasis PCP - nystagmus LSD - visual hallucinations marijuana - conjuctival injection heroin - depressed mental status, respiratory depression metamphtamine - violent behaviour, psychosis.
107
anorexia treatment - psychotherpy - nutritional rehab - olanzapine if severe/refractory - note one of the key presenting signs of anorexia can be hair loss
108
doctor siagnosed with pancreatic cancer. always wnats to stay at work to focus on other peopeles problems and research treatments for pancreatic cancer rather than take time off what type of reaction is this?
intellectuallization!!! = focusing on non emotional aspects to avoid discomfort.
109
11 year old deciding to become a vegetarian. not concerned babout body weight but about animal rights. weight is notmral next step in management?
reassure the mother that the childs behaviour is normal!! not nutritional counselling or CBT as no evidence of eating disorder eg restrictive diet, distorted body image, low bmi
110
first line medication combination treatment for bipolar disorder?
Lithium + Quietapine!!! essentially lithium OR sodium valproate !!! + second generation antipsychotic
111
episode of psychosis management?
second gen antispychotics eg aripiprazole!!!!! preferred to first gen eg haloperidol due to EPS also long acting injectables only used after evidence of medication non-adherence.
112
patient with schizoaffective disorder having siezures, which drug increases risk of this the most?
clozapine!!
113
patient with anxiety like symtoms. stopped medicationfor 2 days and had a siezure. name a medication likely to cause this.
alprazolam!!! abrupt cessation of a short acting benzo carries risk of this and of confusion
114
active substance use including other peoples drugs eg using mothers clonazepam to fall asleep!!! is associated with increased suicide risk. alcohol, substance intoxication included!!
115
best way to check for opoid misuse in patient?
query the prescription drug monitoring database!!! = can check if patient is getting medication from multiple prescribers NOT scheduled urine visits, as best done randomly
116
question on kleptomania
117
12 yo doesnt want to to leave mother because concerned that something bad will happened to mother stomachaches(somatic symptoms), nightmares and trouble sleeping may also be present difficulty concentrating in class (functional impairment) started middle school 6 months most likely diagnosis?
separation anxiety disorder can happen in transition periods
118
antiparkinsonsim medication can cause psychosis, reducing the dose of the medication eg carbidopa-levodopa can help
119
even if a patient denies a suicide attempt and makes plausible reasons eg for a fall, as a clinician you should still hospitalize the patient if it could have been a likely attempt and risk for further attempts is high
120
adjustment disorder treatmetn?
psychotherapy
121
new onset psychosis in a child what conditions must you rule out first?
SLE!!!!!! Thyroiditis metabolic or electrolyte disorders CNS infection epilepsy
122
what is seen in the CSF of patients with depression?
low concentration of 5-hydroxindoleceatic acid in the CSF 5HIA a metabolite of serotonin
123
maximum dose of fluoxetine for 8 weeks. still feels its not working enought (note, an adequate trial is 6 weeks!!) history of bulimia next step in management?
switch to venlafaxine!!! options are switch to SSNRI, Buproprion, mirtazapine, serotonin modulators, or another SSRI NOT buproprion in this case due to history of bulimia!!! -> risk elecrolyte disturbances
124
which illegal drug carries a risk of serotonin syndrome?
ectsasy!!! (mdma) - its a synthetic amphetamine.
125
depression with psychotic features treatment
antidepressant PLUS antipsychotic OR ECT!! Answer in this case was ECT because other choice was antispychotic only! in elderly depressed patient who are unable to eat, drink or actively suicidal, ECT is typically used to achieve faster response
126
overeating, sleeping too much, poor self esteem about weight chonic fatigue, only remembers a few times since high school where he felt truly happy drinks 4 cups of coffee to maintain energy level most likley diagnosis?
persistent depressive disorder, dysthymia chronic fatigue syndrome is less likely as patient has chronic sadness and low self esteem
127
Depressed mood PLUS schizophrenia symptoms a period where no mood symptoms but experiencing delusions/hallucinations most likely diagnosis?
schizoaffective disorder!!!! mania or depression + schizophrenia schizophreniform and schizophrenia are same but symptoms must be present for at least 6 months to be schizophrenia
128
patient treated with a drug for acute mania. now has high serum calcium levels. most likely drug?
lithium!!! causes hyperparathyroidism with hypercalcemia can also cause NDI and CKD
129
what medication can be used for treatment in serotonin syndrome?
lorazepam!!! benzodiazepines = decrease agitation and muscle contractions cryoheptadine can also decrease central serotonergic activity
130
40 yo fine tremor, worsens with posture against gravity does not improve with alcohol history of bipolar disorder on medication most likely cause?
medication adverse effect!!! - lithium produces an action tremor essential tremors improve with alcohol, patients are typically older or have a family history
131
PTSD, on sertraline and CBT but still having nightmares next step in management?
Prazosin!!! NOT paroxetine as no evidence that it is more effective at treating nightmares than other ssris. switching antidepressants may worsen other PTSD symptoms.
132
alcohol withdrawal syndrome -> agitation/restlessness progressing to HTN, tachycardia, diaphoresis, tremor, siezures. often occurs in patients admitted to hospital for medical treatment management?
IV benzodiazepines
133
major depressive disorder with seasonal pattern AKA seasonal affective disorder. already on antidepressant but not showing sufficient response. what to add?
bright light therapy!!!! in combination = 1st line for SAD
134
patients with somatic symptom disorder benefit from regularly scheduled visits = everything looks good but lets schedule a visit in a month to see how you are doing
135
saying it is normal to feel concerned but your skin is normal wont reassure someone with body dysmorphic disorder rather explore perceptions of how others see them = if you were to ask other people about your nose, what would they say?
136
aggresive patient -> interview with door open and have security on standby
137
if patient is on fluoxetin for 2 weeks and already showing signs of imporvement but not completley improved you continue for up to 6 weeks. you dont increase fluoxetine dose as already showing signs of improvement and increase can cause toxicity
138
tourettes treatmetnt?
tetrabenzine (dopamine blocker) or antipsychotics = risperidone!!!!! and aripiprazole!! or alpha adrenergic receptor agonists
139
severe acute depression with suicidal ideation after going out partying previous episodes in past with hypersomnia, vivid dreaming, hyperphagia most likely diagnosis?
cocaine withdrawal
140
overuse of nasal decongestants can cause hallucinations encephalitis unlikely if no history of siezures and if respiratory signs are predoinant (cough, runny nose) rather than brain signs
141
in contrast to nightmare disorder, for sleep terrors, you dont wake up fully, dont respond to comfort, and dont recall the dreams
142
patient has been trying to quit smoking but keeps having relapses. what can help?
inquire about patients activities whilsts smoking first cigarrette of the day!!! not listing benefits and drawbacks as used for people who are only just contemplating quitting
143
common side effects of SSRIs?
headache insomnia nausea!!!! also anxiety also long term = sexual dysfunction and weight gain
144
moved to attend college lives alone in an appartment anxious someone will break in checks doors are secured every night and locks bedroom door tense when walking alone on campus most likely diagnosis
adjustment disorder!!! OCD less likely - not intrusive thoughts, locks doors once not repeatedly
145
binge eating + exercising (compensatory behaviour) labs show hypokalemia (evidence of vomiting) first step in management?
fluoxetine!! (SSRI first line) paitent has bulimia contrast binge eating with no compensatory behaviour = SSRIs but also lisdexamfetamine contrast anorexia BMI <18.5 = CBT and olanzapine if no response. no role for SSRI!
146
psychotic episode but in past developed EPS when treated with haloperidol. so next step in management?
Zaprasidone!!! a specific 2nd gen with lower risk of metabolic effects than olanzapine and clozapine so zaprasidone, aripiprazole and lusaridone
147
somone presents with depression after break up with girlfriend. manic episode in past. diagnosis?
bipolar 1
148
inappropriate joking and laughter, quits job (impulsitvity), believes only she can save the animals (grandiosity) interrupts conversation with physician to yell at patients walking into hospital (distractibility) most likely diagnosis?
bipolar
149
schizophreniform disorder schizophrenia but less than 6 months if someone is talking to themselves, that is a sign of hallucinations and not seen in schizotypal disorder
150
during sleep. kicking bedmaate, pushing furniture or pushing the nightstand. but when he wakes up he is not confused and remembers the dream. most likely diagnosis?
REM sleep behaviour disorder NOT sleep walking because youre confused on waking and dont recall the dream
151
ptsd = hypervigilance (Jumpy), nightmares, avoidance (school friends) may also experience dissociation/depersonalisation where you might hear voices
152
Varenicline is most effective at smoking cessation!! but if a patient doesnt tolerate this, next most effective is?
Nictone replacement patch PLUS nicotine gum Essentially, Combination NRT burproprion also 1st line but not as effective as combination NRT
153
when a patient loses baby, first step is to say loss was not your fault. this comes before discussing any further medical management
154
1 year of unilateral blindness after breaking up with boyfriend last year now has sudden onset blurry vision intermittnent numbness and tingling in legs mri shows multifocal white matter hyperintense lesions in corpus callosum and periventricular area what MH condition is patient at risk of?
depression!! patient has MS
155
13 yo, irritability abdominal cramps perioral eczema invoolving nasolabial folds (glue sniffers rash)!!! weight loss hand tremors and reduced reflexes (neurologic dysfunction) most likely cause?
inhalant use!!! NOT AIP because manifest 20-40 and doesnt cause perioral dermatitis NOT lead poisioning as would cause myalgia/athralgia AND not cause perioral dermatitis
156
new onset psychosis in 17 yo. dilated pupils, sweating, HTN, tachycardia irritability most likely cause?
amphetamine use!!! Not anticholinergic poisoning as you would also see: dry skin and mucous membranes, motor symptoms (jerks, tremors), ileus and urinary retention
157
if a patient has failed 2 antidepressants of the same class eg escitalopram and sertraline it would make sense to switch to a new class eg buproprion not fluoxetine in a ddition, buproprion helpful if evidence of wight gain, insomnia
158
yes first line maitenance treatment for panic disorder is SSRIs/SNRis and CBT but what do you give first in acute episode?
Lorazepam!!! - a benzo NOT propanolol
159
prolactin levels >100 are unlikely due to medication adverse effect -> MRI of brain
160
Child with history of abuse and neglect trying best to let him know he is loved but to no avail. does not react to praise in school setting. (does not react to comfort) hit classmate after being asked to share book he was reading. gets upset sometimes and tarts throwing and breaking things (emotional outburst) does not participate in group activities (socially withdrawn) essentially unexplained, irritability, fear or aggression. most likely diagnosis?
Reactive attachment disorder!!! disinhibited social engagement disorder can occur from abuse but causes overfamiliarity.
161
energy drinks contain caffeine and can cause caffiene intoxiacation and signs can include pressured speech differentiate from hypomania which should have elevated mood, increased energy, grandiosity
162
psychosis, agitation pupils normal but nystagmus!!!! present and ataxia present attempts to life equipment cart in hospital (aggressions with delusions of enhanced strength!!) throws BP cuff (hypertension, hyperthermia) most likely diagnosis?
Phencyclidine intoxication!!! NOT alcohol withdrawal as symptoms take a stepwise development. also absence of tremors in patient!! = hallmark
163
tardive dyskinesia, cant reduce antipsychotic dose, hals already tried valbenazine etc nt working. next step?
switch to clozapine
164
providing conflicting information to different examiners = confabulation. in setting of good long term recall but poor short term. and alcohol use disorder most likely diagnosis?
koraskoff syndrome!!
165
if there might be language delay but this is clearly in setting of ssupected autism, then you need to do an evaluation asap
166
Wernickes encephalopathy (opthalmoplegia/nystagmus, ataxia and AMS) is due to deficiency of which vitamin? Seen in alcoholics
B1 = thiamine
167
In a patient with psychosis, the most important thing is to remove any weapons from the patients home. Not administer aripiprazole as this begins to address psychosis within days to weeks
168
At a party with drugs. Loses consciousness and begins to slur words. Respirations are 9/min. BP90/60. Pupils 1-2mm and minimally reactive to light. Most likely diagnosis?
Heroin intoxication!!! Opioids are CNS depressants!!! NOT alcohol or clonazepam because although can cause slurred speech. Does not account for miosis!!!! (Pupils less than 2 mm. Mydriasis will be greater than 4)
169
Meperidine and tramadol are opioids that can cause delirium
170
Sexual dysfunction in man. History of T2DM and OCD. Medications are sertraline, clomipramine, risperidone and metformin. Mild gynaecomastia on exam. Most likely cause of patients symptoms?
Risperidone therapy!!!! Used in refractory OCD. Hyperprolactinemia -> suppressing sexual hormones Other options eg diabetic neuropathy, metformin, sertraline less likely as won’t cause gynaecomastia
171
Benzodiazepines act on gamma-aminobutyric acid
172
dipenhydramine is antihistamine with anticholinergic activity thus can cause constipation. Used off label for anxiety and insomnia
173
Schizophrenia been doing well but recently been hearing more voices and having more stress at home with family. Next step in management?
Begin family therapy!!! - stressor correlating with psychosis exacerbation and needs to be addressed first. Following this, physician should consider increasing dose or frequency of haloperidol
174
Man has a son as his lasting power of attorney. But in his right mind and decided he doesn’t want treatment. Next step?
Discontinue treatment. LPAs are only contacted if patient has lost decision making capacity
175
50 Yo. Speech difficulty. Inability to walk. On lithium for BPD and recently began complaining of increased thirst and urination. Muscle weakness. Labs show hypernatremia. Most likely diagnosis?
Lithium-induced diabetes insipidus!!!!
176
35 YO man, speaking nonsense and holding his abdomen. Not aloriented. Rambling speech. Visual hallucination. AMS. Abdominal exam shows RUQ tenderness. Most likely diagnosis?
Delirium!! Acute medical illnesses can be a trigger. Like in this case with likely acute cholecytitis or cholangitis.
177
Patient had NPH but the discractor was things like walking slowly and then stop moving all together over the last year -> NPH can have gait apraxia. No rigidity or resting tremor makes Parkinson’s less likely to
178
Normal BMI, 13 yo dissatisfied with body shape = normal adolescence!!
179
Patient discontinúed sertraline as trying to Concieve. Previously drank 6 glasees of alcohol a week. 1 day history of headache anxiety náusea muscle aches diarrhea, tremor in both hands. Most likely diagnosis?
SSRI withdrawal!!! NOT alcohol use disorder
180
45 yo man. Tired during the day and difficulty concentra ring. Sleeping off during the day. Sometimes hears music whilst falling asleep. Sleep studies shows patient enters REM sleep withing 5 minutes of two naps. Most likely diagnosis?
Narcolepsy!!! Classic description
181
5-mm pupils after taking something and dry mucosa. Signs of delirium as responding to internal stimuli and screaming ar soneine not in the room. Intermitent somnolence. Most likely cause?
Cholinergic blockade!!! Causes delirium and hallucinarions + dry mouth and mydriasis. Can also cause constipation urinary retención etc
182
In normal aging, you can repeatedly forget where you park your car, and also recall 1/3 words and then recall the last one later
183
Most important thing to monitor for when on alprazolam?
Rebound anxiety!!
184
End of life if a patient wants comfort care —> you can periodically offer semi-solid food by mouth. Even if they have infection and not eating, you can’t give IV fluids and antibiotics.
185
Patient on lithium has developed symptomatic NDI but no hypernatremia. Next step in management?
Encourage continued drinking of water!!! You don’t need to discontinue lithium!!!
186
In an acute psychologicsl disturbances in a 61 yo woman for 4 days, unspecified DELIRIUM is more likely than brief psychotic disorder!!!
187
Avoidang personality disorder described. Difficulry making new friends because of shyness, can’t assert himself even when hes right. Next step in management?
CBT!!!
188
16 yo boy, drug intoxication, found break ING mirrors and windows. Erythema surrounding mouth, fruity odor on breath. Movements slow and gait unsteady. Intoxication with which substance is most likely?
Toulene!!! Inhalant abuse - Perioral findings, cerebellar dysfunction!! Toulene classicslly causes agitation
189
Ñame a psych medication that can cause acute pancreatitis!!!
Valproic acid!!!! NBME subject PPQ
190
Woman 6 months inability to reach orgasm. Bad sexual experience in the past. Most likely diagnosis?
Female orgasmic disorder
191
Not moving or speaking, resisting passive movements of extremeties. Not looked for a Job since graduation from high school 2 years ago (apathy) and unkempt. Most likely diagnosis?
Schizophrenia!!!! Patient is presenting with signs of catatonia seen in psychiatric disorder s like schizophrenia and bipolar disorder NOT selective mutism = failure to speak in specific social situations secondary to anxiety
192
Psychotic symptoms 1 week after family member dies most likely diagnosis?
Brief psychotic disorder!! = can be triggered by stressful life events, such as loss of loved ones NOT adjustmenr disorder as psychotic symptoms like delusions and hallucinations not expected
193
15 year old with schizophreniform disorder/schizophrenia. He is most at risk of? -> decline in working memory!!! Most likely thing you’ll see on examination
194
With an eating disorder eg bulimia with progressive generalized weakness and muscle cramps. The next step in work up is?
Serum electrolyte concentrations!!! NOT CBC
195
deficiency of what neurotransmitrer is implicated in antisocial personality disorder?
Serotonin
196
If a child has conduct issues in the setting of an identificable stressor eg parents arguing a lot = adjustment disorder NOT conduct disorder Can also have anxiety symptoms eg difficulting concentratikg or difficulty sleeping, in the abscence of GAD
197
Policíe office has not used drugs in past month. But random urine drug test is positive. Most likely cause?
Marijuana!!! Long half life, positive up to 50 days
198
Metoprolol and other beta blockers are contra-indicated in patients who use cocaine -> increases coronary vasopspasm risk!! NBME practice Question, question
199
Opiod use disorder but had operation and in server Pain. Management?
Patients usual Methadone maintenance + PCA not maintenence + analgesia on set schedule -> not effectively control pain
200
Dementia involves acumulación of which proteins?
Tau!!!! And amyloid NOT alpha synuclein = parkinsons
201
47 yo man. Has appendectomy. Now has moderately Severe diffuse headache. Has not ingested food or drink for 2 days. Most likely cause?
Caffeine withdrawal!!!
202
Restless leg syndrome is treated with?
Ropinirole!! R for R!!! NOT modafinil = narcolepsy
203
Acute dystonia can be treated with dipenhydramine!!
204
Patient wants to write an advanced directive as old. But she comes in with memory impairment symptoms. Next step in management?
Discusión of her preferences for care!!! It is only through discussing that you will be able to assess her capacity
205
Post surgery. Sweating and increasing confusion. On many drugs + haloperidol for night time agitation. High temperature!!! Leukocystosis!!! Muscle tone is increased High glucose Most likely cause of condition?
Adverse effect to haloperidol!!! Patient has NMS Not poor glucose control which could cause HHS or DKa as you would not expect diaphoresis or muscle rigidity
USMLE Step 2
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