NBME PSYCH Form 1 - Answers & Explanations

Updated: Feb 19, 2020

1) Circadian rhythm sleep disorder

• 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

2) Down syndrome • Epicanthal folds, cardiac murmur, developmental delay

3) Substance-induced mood disorder • 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

4) Admit the patient to the psychiatric unit • When someone is a danger to themselves or others they should be admitted

5) Focal spikes localized to the temporal lobe • 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

6) Add bupropion to the medication regimen • Buproprion is an atypical antidepressant that has favorable sexual side effects and will help with this patients weight gain

7) Explain the risk of illness recurrence without medication • This patients bipolar disorder has been well controlled with his medication, and the importance of maintaining this should be explained

8) Social phobia • Social anxiety disorder, performance type: anxiety restricted to public speaking

• Fear of embarrassment or judgement is a classic sign of social phobia

9) Decreased concentration of 5-hydroxyindoleacetic acid in cerebrospinal fluid analysis

• 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

10) Clonazepam • 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

11) Reassurance

• Sleep changes in elderly: ↓ REM sleep time, ↑ REM latency, ↓ stage N3 (non-REM sleep)

• This patient is experiencing normal age related changes

12) Reassurance that this is normal behavior

• Enuresis is normal until age 5 • Encopresis is normal until age 4

13) Recommend alcohol rehabilitation

• 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

14) Opioid

• Opioid intoxication → respiratory and CNS depression, pupillary constriction

15) Symmetric enlargement of the ventricles • CT scans of patients with schizophrenia often show ventriculomegaly (particularly the lateral cerebral ventricles) and diffuse cortical atrophy

16) Surreptitious administration of insulin • Oral hypoglycemic agents stimulate production of endogenous insulin (↑ insulin & ↑ C-peptide)

17) Discuss normal pubertal development

• Absence of 2° pubertal development is normal in girls ≤ 14, and boys ≤ 15

18) Switch from haloperidol to aripiprazole

• 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

19) Maintain the current dosage of sertraline and schedule weekly follow-up examinations for the next month

• 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

20) Administer additional diazepam • The benefit of preventing death from alcohol withdrawal far outweighs the possible respiratory depression from benzodiazepines, especially since she is already intubated

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