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
21) Restless legs syndrome • Worse at night and at rest, Relieved by movement • Associated with iron deficiency → this patients fatigue
22) Brief psychotic disorder • Presence of ≥1 psychotic symptom (eg, paranoia, auditory hallucinations) with a sudden onset and full remission in 1 month
23) Administration of morphine
• 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
24) Acute intermittent porphyria
• Presents with the 5 P’s
• Painful abdomen • Port wine colored urine • Polyneuropathy • Psychological disturbances • Precipitated by drugs (eg, alcohol)
25) Separation anxiety disorder • Persistent anxiety with separation and excessive worry about losing major attachment figures for ≥4 weeks
26) Dopamine • Blockade of the nigrostriatal dopamine pathway is responsible for EPS in patients taking antipsychotics
27) Psychotherapy • Psychotherapy is the treatment of choice for adjustment disorder
28) Adjustment disorder • 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)
29) Begin parent management training • Child is behaved in daycare, at the doctors office, and with her grandmother
• Tantrums are most likely due to parental interactions
30) 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
31) Anorexia nervosa • Excessive dieting, exercising, or binge eating/purging with BMI <18.5 (adults) or <5th percentile (children/adolescents)
32) Lewy body dementia
• Parkinsonism, Hallucination, Dementia (LEWY has a PHD)
33) Conversion disorder • Loss of sensory or motor function following an acute stressor • La belle indifference = patient is aware but indifferent toward symptoms
34) Decrease the dosage of carbidopa-levodopa
• 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
35) Panic disorder
• 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
36) Child abuse • Forceful twisting of a limb → spiral fractures = child abuse
• Demineralization occurs with all bony injuries
37) Decreased binding of dopamine at the postsynaptic receptor
• Haloperidol is a typical antipsychotic that blocks dopamine D2 receptors
38) Serotonin
• Fluoxetine (SSRI) → ↑ serotonin in the synoptic cleft
• Tramadol inhibits the re-uptake of NE and serotonin
• Fluoxetine + Tramadol → Serotonin Syndrome
39) Begin escitalopram therapy • 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
40) 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
41) Amphetamine intoxication • Paranoia, tachycardia, hyperreflexia, rapid speech, agitation
42) Hallucinogen intoxication • Perceptual distortion (visual), anxiety, paranoia, negative urine toxicology (LSD isn’t included on a standard drug test)
43) Amenorrhea • Anorexia nervosa → ↓ GnRH → ↓ LH, FSH → ↓ estrogen → amenorrhea, bone loss
44) Ziprasidone
• Antipsychotics are the first-line pharmacotherapy for patients with acute psychosis
• Second-generation is usually preferred due to less EPS side effects
45) Clomipramine • Tx of OCD: CBT + SSRI; clomipramine and venlafaxine are second line
46) Obsessive-compulsive disorder • 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)
47) Caudate atrophy
• 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
48) Dissociative fugue • Dissociative amnesia is an inability to recall important personal information • Dissociative fugue is a subtype of dissociative amnesia characterized by travel or wandering
49) Conduct disorder
• 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...
50) Delusional disorder
• 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)
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