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Microsoft word - psychiatry critiques

Sample Psychiatry Questions & Critiques
The sample NCCPA items and item critiques are provided to help PAs better understand how exam questions are developed and should be answered for NCCPA’s Psychiatry A 50-year-old woman who has had low-grade depression for more than two years comes to the office because she has had weakness, cold intolerance, constipation, and weight gain during the past six months. Physical examination shows dry, coarse skin as well as bradycardia, hypothermia, and swelling of the hands and feet. Which of the following laboratory studies is the most appropriate to determine the diagnosis? (B) Measurement of serum C-reactive protein level (C) Measurement of serum electrolyte levels (E) Measurement of serum thyroid-stimulating hormone level Content Area: Mood Disorders (16%) Area of Interest: Evaluation and diagnosis This question tests the examinee’s ability to determine the laboratory study that is most likely to specify the diagnosis. The correct answer is Option (E), measurement of serum thyroid-stimulating hormone level. Hypothyroidism is suspected on the basis of the patient’s symptoms of depression, weakness, constipation, and weight gain as well as the physical findings of bradycardia, hypothermia, swelling of the hands and feet, and dry, coarse skin. Measurement of serum thyroid-stimulating hormone level is the study that will either confirm or refute this suspected diagnosis. Option (A), liver function testing, is a plausible choice based on the patient’s signs and symptoms of weakness, weight gain, and swelling of the hands and feet. However, liver function testing does not address the remaining findings in the patient and, therefore, is incorrect. Option (B), measurement of serum C-reactive protein level, is incorrect because it is a nonspecific indicator of inflammation in the body and will not specify a diagnosis. Option (C), measurement of serum electrolyte levels, is incorrect because although it is included in general diagnostic testing, this study would not specify a diagnosis considering the patient’s symptoms. Option (D), measurement of serum estrogen level, is a plausible choice considering the patient’s age and the signs and symptoms of dry skin and depression, but it does not address the remaining findings. A 35-year-old man with bipolar disorder, most recent episode mixed, comes to the clinic for routine follow-up examination. His condition has been difficult to control and has required treatment with multiple medications during the past two years. The patient says his mood has been stable with his current regimen, but for the past three months, he has had tremor primarily affecting his hands. Which of the following medications is the most Content Area: Mood Disorders (16%) Area of Interest: Psychopharmacology This question tests the examinee’s ability to recognize the indications for and adverse effects of psychopharmacologic agents. The correct answer is Option (D), lithium carbonate (Eskalith). Lithium carbonate is approved by the Food and Drug Administration for management of bipolar I disorder and is the most commonly used pharmacologic therapy for that condition. Tremor, as noted in the patient’s history, is a common adverse effect of lithium carbonate. Such tremor is seen in the fingers of the outstretched hands, usually at a frequency of 8 to 10 Hz, and is sometimes related to peak serum lithium levels. Dividing the dose of lithium carbonate and decreasing caffeine intake can decrease the tremor. In the case of a severe coarse tremor, lithium carbonate toxicity (serum lithium level greater than 2.5 mEq/L) must be ruled out. Option (A), carbamazepine (Tegretol), Option (C), lamotrigine (Lamictal), and Option (E), topiramate (Topamax), are incorrect because even though they are used off-label for management of bipolar disorder, tremor is not caused by these medications. Option (B), gabapentin (Neurontin), is incorrect because even though tremor may occur as an adverse effect of this medication, it is not prescribed for management of bipolar disorder.
A 19-year-old woman who is a college student is brought to the clinic by her roommate because she has been acting strangely during the past six months. During the past month, the patient has been describing how another person's thoughts have been entering into her mind. The patient's grades have been slipping, and she does not talk as much as she did previously. The roommate says that when the patient does talk, she strays from the topic and is hard to follow. During the interview, the patient says a television reporter told her that the government had a special message for her and she should listen to the radio for further instructions. Which of the following conditions is the most likely cause of this Content Area: Schizophrenia and Other Psychotic Disorders (14%) Area of Interest: Evaluation and diagnosis This question tests the examinee’s ability to discriminate between characteristics of behavior disorders. The correct answer is Option (C), schizophrenia. The patient has had classic symptoms of schizophrenia for at least six months, including hallucinations (voices speaking to her), social dysfunction affecting grades and friendships, and disorganized speech. Although the patient is somewhat young for schizophrenia (peak incidence in women is between 25 and 35 years), her symptoms meet the DSM-IV-TR Option (A), delusional disorder, is incorrect because the patient’s delusions are bizarre in nature (for example, a television reporter telling her to listen to the radio for a message and instructions from the government). However, in patients with delusional disorder, delusions are typically plausible, such as the belief that one is being followed. Option (B), schizoaffective disorder, is plausible but can be ruled out based on the fact that there is no evidence of concurrent manic or depressive symptoms during the schizophrenic episode described. Option (D), schizophreniform disorder, is also plausible but can be ruled out based on the six-month duration of symptoms. To meet criteria for schizophreniform disorder, symptoms must persist for at least one month but fewer than six months. Option (E), stress disorder, is incorrect because there is no evidence that the patient has endured or witnessed a traumatic event or expressed intense fear, helplessness, or horror in response to such an event. A 37-year-old man comes to the office after he experienced what he says was a nervous breakdown. The patient says that after he recently declared bankruptcy, losing his home and his business, he became very depressed. During this time, he began to hear voices telling him that he was useless and should kill himself. The patient says his symptoms stopped after approximately one week. He has had no similar episodes. Medical history includes no psychiatric conditions. Physical examination shows no abnormalities, and results of laboratory studies are within normal limits. Which of the following is the most (C) Major depressive disorder with psychotic features Content Area: Schizophrenia and Other Psychotic Disorders (14%) Area of Interest: Evaluation and diagnosis This question tests the examinee’s ability to distinguish between disorders that may present with psychotic symptoms. The correct answer is Option (B), brief psychotic disorder. Essential features of brief psychotic disorder include sudden onset of one or more of the following symptoms: delusions, hallucinations, disorganized speech, disorganized behavior, and catatonia. Brief psychotic disorder is also characterized by duration of symptoms for at least one day but less than one month followed by return to premorbid level of functioning. The disorder is not associated with a medical condition or the effect of illicit substances such as hallucinogens. Option (A), borderline personality disorder, is incorrect because although it may present with stress-related paranoid ideation, this condition is transient. Option (C), major depressive disorder with psychotic features, is incorrect because a diagnosis of major depressive disorder requires the presence of symptoms meeting diagnostic criteria for most of the day, nearly every day, and for at least two weeks. Option (D), schizophrenia, and Option (E), schizophreniform disorder, are also incorrect because the short duration of the patient’s symptoms (one week) does not meet criteria for these conditions. A 28-year-old man comes to the office because he has had severe restlessness, anxiety, and generalized myalgia during the past three days. The patient says he has not slept for the past two days. Physical examination shows dilation of the pupils, excessive lacrimation, diaphoresis, and piloerection. The most likely cause of this patient's condition is withdrawal of which of the following substances? Content Area: Substance-Related Disorders (13%) Area of Interest: Psychopharmacology This question tests the examinee’s ability to identify history and physical examination findings as well as symptoms related to substance withdrawal. The correct answer is Option (E), opioids. Insomnia, dilation of the pupils, piloerection, diaphoresis, lacrimation or rhinorrhea, and myalgia are classic symptoms of opioid withdrawal. Option (A), cocaine, is incorrect because symptoms of cocaine withdrawal include fatigue, vivid dreams, increased appetite, and psychomotor retardation or agitation. Option (B), inhalants, is incorrect because withdrawal syndrome from inhalants is characterized by disturbed sleep, irritability, hallucinations, and delusions, nausea and vomiting, diaphoresis, and tachycardia. Option (C), methamphetamines, is incorrect because withdrawal from methamphetamines is characterized by any two of the following: lethargy, fatigue, psychomotor retardation or agitation, craving for stimulants, increased appetite, insomnia or hypersomnia, and bizarre or unpleasant dreams. Option (D), modafinil, is incorrect because withdrawal of this medication, which is used to treat narcolepsy, would cause sleepiness (not insomnia). A 48-year-old man comes to the office for annual physical examination. The patient has smoked one pack of cigarettes daily for the past 20 years and says he wants to quit. He has tried to quit several times, but every time he does, he has depressed mood, difficulty sleeping, anxiety, restlessness, and increased appetite. The patient says these symptoms are so severe that he is unable to function well at work. Which of the following is the most appropriate therapy to aid in smoking cessation for this patient? (C) Nicotine transdermal patches (NicoDerm) Content Area: Substance-Related Disorders (13%) Area of Interest: Psychopharmacology This question tests the examinee’s ability to determine the most appropriate pharmaceutical therapy to aid in cessation of cigarette smoking in a patient with potential psychiatric disorders. The correct answer is Option (C), nicotine transdermal patches (NicoDerm). Nicotine transdermal patches used as an aid in smoking cessation are not likely to exacerbate a patient’s symptoms of depression, anxiety, or sleep disturbance. Option (A), alprazolam (Xanax), and Option (B), diazepam (Valium), are incorrect because although they may be plausible therapies for anxiety, these medications are not approved for smoking cessation. Option (D), nicotinic acid, is incorrect because this medication, which is used in conjunction with low-fat diet to manage hypercholesterolemia, is neither approved nor effective for smoking cessation. Option (E), varenicline (Chantix), is a plausible choice because it is approved for smoking cessation. However, therapy with varenicline is not advisable in patients who have psychiatric disorders because it has the potential to exacerbate agitation and depression. A 55-year-old woman comes to the office because she has a 20-year history of repetitive actions and is tired of wasting time by repeating these actions. The patient says she repeatedly checks the doors in her house to make sure they are locked, washes her hands several times per hour, and checks her electrical appliances three times each morning before she leaves for work. Medical history includes second-degree atrioventricular block. Which of the following medications is the most appropriate initial therapy for this Content Area: Anxiety Disorders (15%) Area of Interest: Psychopharmacology This question tests the examinee’s ability to recognize the signs and symptoms of obsessive-compulsive disorder and to choose the most appropriate therapy. The correct answer is Option (E), sertraline (Zoloft). Sertraline is a selective serotonin reuptake inhibitor (SSRI), and all of the SSRIs available in the United States have been approved by the Food and Drug Administration for management of obsessive-compulsive disorder. Although SSRIs may cause transient problems with sleep, gastrointestinal disturbances, headache, restlessness, and anxiety, these adverse effects are less problematic than those associated with other medications, such as clomipramine (Anafranil). Option (A), clomipramine (Anafranil), is incorrect. Even though clomipramine was the first drug approved by the Food and Drug Administration for management of obsessive- compulsive disorder, it is not an appropriate first-line therapy because of its adverse effects of orthostasis, gastrointestinal disturbance, and sedation as well as its anticholinergic effects, which include dry mouth and constipation. Option (B), clonazepam (Klonopin), is incorrect because clonazepam is a benzodiazepine and is not indicated or approved for management of obsessive-compulsive disorder. Option (C), methylphenidate (Concerta), which is indicated for attention-deficit/hyperactivity disorder, and Option (D), quetiapine (Seroquel), which is used in management of schizophrenia and bipolar disorder, are not indicated for obsessive-compulsive disorder. A 20-year-old woman who is a college student comes to the health services center because she has had symptoms of depression for the past three months, since she was a victim of date rape at a party. The patient says she was heavily intoxicated when the incident occurred and has little memory of the event, but she was embarrassed and ashamed when she awoke at the scene and realized what had happened. She did not seek medical care at that time. The patient says she has not told her friends about the incident, and she has continued to attend classes and work part time. However, she says she constantly feels sad and anxious, has become tearful and withdrawn, and has had difficulty sleeping because of frightening nightmares. This patient most likely has which of the following psychiatric conditions? Content Area: Anxiety Disorders (15%) Area of Interest: Psychopharmacology This question tests the examinee’s ability to discriminate between behavior disorders based on the salient points in the patient’s history. The correct answer is Option (E), post- traumatic stress disorder. The patient described meets the criteria for post-traumatic stress disorder, which include the following: involvement in a traumatic event, duration of symptoms for more than one month, and significant effect on daily life due to depression, anxiety, nightmares, and social withdrawal. Option (A), acute stress disorder, is a plausible choice but is incorrect because of the duration of symptoms. Symptoms of acute stress disorder present within four weeks of the event and last from two days to four weeks. Option (B), adjustment disorder, is also a plausible choice but is incorrect because of the onset of symptoms. In patients with adjustment disorder, symptoms must appear within three months of the onset of a stressor. Adjustment disorders usually result from common life events such as loss of a job. Option (C), generalized anxiety disorder, is incorrect because this condition is defined as three or more of the following symptoms occurring more days than not for a period of at least six months: restlessness, being easily fatigued, difficulty concentrating or the mind going blank, irritability, muscle tension, and sleep disturbance. These symptoms also include excessive anxiety and worry about several events or activities. Option (D), major depressive disorder, is incorrect because it is characterized by symptoms not exhibited by the patient described. Characteristic symptoms of major depressive disorder include, but are not limited to, the following: depression, anhedonia, significant weight loss without dieting, weight gain (more than 5% of body weight within one month), insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, loss of energy, recurrent thoughts of death, and suicidal ideation. A 42-year-old man is referred to the office for mental health evaluation. The patient says he has a long-standing fear of criticism and rejection. He also has feelings of inadequacy and refuses to try new activities because of his fear of embarrassment. The patient has held the same entry-level position at his workplace for the past 14 years despite several opportunities for promotion. The patient is unmarried and has only had one intimate relationship, which lasted only a few weeks. He has few friends other than those in his model airplane club. Which of the following personality disorders is the most likely Content Area: Personality Disorders (6%) Area of Interest: Evaluation and diagnosis This question tests the examinee’s ability to recognize the characteristics of and diagnostic criteria for personality disorders. The correct answer is Option (A), avoidant. Avoidant personality disorder is characterized by fears of rejection, disapproval, and/or criticism; unwillingness to be involved with people unless assured of being liked; restraint in intimate relationships; preoccupation with social criticism or rejection; inhibition in new situations because of feelings of inadequacy; and unwillingness to engage in new activities because of possibility of embarrassment. Option (B), dependent, is incorrect because dependent personality disorder is characterized by pervasive and excessive need to be taken care of by others. This need begins in early adulthood and results in fear of separation, submissiveness, and clinging behavior. Option (C), paranoid, is incorrect because paranoid personality disorder is characterized by a pervasive distrust and suspiciousness of others to the extent that their motives are interpreted as malevolent. Symptoms begin in early adulthood and may be accompanied by suspicions that others are exploiting, deceiving, or wishing to harm the patient; preoccupation with unjustified doubts regarding trustworthiness or loyalty of friends and acquaintances; inability to forgive insults or slights; and reading threats into innocuous remarks or situations. Option (D), schizoid, and Option (E), schizotypal, are both incorrect because neither of these personality disorders manifests with fears of A 23-year-old man comes to the office because he has pain in his right hand. The nurse says the patient was irritable and reluctant to answer many intake questions, and he refused to put on an examination gown. On questioning, the patient is initially charming and glib, but after he is assured that the information he shares will not be relayed to his probation officer, he admits that he was involved in a fistfight. He says proudly that "the other guy is in a lot worse shape." This patient most likely has which of the following Content Area: Personality Disorders (6%) Area of Interest: Evaluation and diagnosis This question tests the examinee’s ability to discriminate between behavior disorders based on salient points noted during the patient interview. The correct answer is Option (A), antisocial personality disorder. Although the patient seems charming and ingratiating, he is aggressive and clearly exhibits disregard for social norms and rights of others. These findings are characteristic of antisocial personality disorder. Option (B), bipolar disorder, hypomanic episode, is incorrect because the patient has not had a manic or mixed episode and does not seem depressed or distressed in social situations or other areas of functioning. Option (C), conduct disorder, is a plausible choice but is incorrect because there is no evidence that the patient has violated the basic rights of others or age-appropriate social norms or rules for a duration of at least six months to one year. Option (D), oppositional defiant disorder, is incorrect because this disorder is characterized by an enduring pattern of negativistic, hostile, and defiant behaviors in the absence of serious violations of social norms or rights of others. Option (E), paranoid personality disorder, is incorrect because this condition is characterized by long-standing distrust and suspicion of people in general. Individuals with paranoid personality disorder typically are not aggressive, although they can be pathologically A 46-year-old man is brought to the emergency department by ambulance because he has been having visual hallucinations for the past four hours. The patient's wife says he has had diarrhea, agitation, and confusion for the past two days. Two weeks ago, he was fired from his job because of excessive absences. He has been unable to find a new job and has been asking his friends for money for several days. The patient has a 25-year history of drinking one pint of whiskey daily. Temperature is 38.5°C (101.3°F), pulse rate is 126/min, and blood pressure is 162/102 mmHg. Which of the following is the most appropriate initial management of this patient's condition? (A) Admission to the hospital for monitoring and social services evaluation (B) Discharge and referral to an outpatient alcohol treatment center (C) Intramuscular injection of haloperidol (Haldol) and discharge (D) Intravenous infusion of ethyl alcohol and discharge (E) Oral administration of chlordiazepoxide (Librium) and admission to the hospital Content Area: Cognitive Disorders (11%) Area of Interest: Psychopharmacology This question tests the examinee’s ability to determine the appropriate initial management based on the salient findings in the history and physical examination. The correct answer is Option (E), oral administration of chlordiazepoxide (Librium) and admission to the hospital. The history and physical examination findings in this patient represent delirium tremens due to chronic alcohol abuse. Therefore, oral administration of chlordiazepoxide and admission to the hospital is the most appropriate initial management because of the potential for seizure activity. Option (A), admission to the hospital for monitoring and social services evaluation, is plausible but incorrect because drug therapy for the patient’s withdrawal from alcohol is not addressed. Option (B), discharge and referral to an outpatient alcohol treatment center, is incorrect because the patient is at risk for further physical and neurologic deterioration considering his vital signs and history of hallucinations. Option (C), intramuscular injection of haloperidol (Haldol) and discharge, is incorrect because haloperidol is not indicated for management of delirium tremens and can potentially lower the seizure threshold. Option (D), intravenous infusion of ethyl alcohol and discharge, is incorrect because although infusion of ethyl alcohol may mitigate the patient’s symptoms of delirium tremens, this therapy would prolong his time to detoxification. In addition, ethyl alcohol is not an approved therapy for delirium tremens A 35-year-old woman is brought to the emergency department by ambulance after police were called to her home by a neighbor, who witnessed rape and robbery by two intruders. The patient is fully alert and oriented to person, place, and time. She cannot remember anything about the incident. Which of the following is the most likely cause of this Content Area: Cognitive Disorders (11%) Area of Interest: Evaluation and diagnosis This question tests the examinee’s ability to recognize the characteristics of behavior disorders. The correct answer is Option (B), dissociative amnesia. Dissociative amnesia is characterized by inability to recall important information, usually of a traumatic or stressful nature, that is too extensive to be considered ordinary forgetfulness. Option (A), depersonalization disorder, and Option (C), fugue state, are incorrect because the patient is fully alert and oriented. Depersonalization disorder is characterized by feelings of detachment as though one is in a dream, and fugue state involves confusion regarding personal identity. Option (D), traumatic brain injury, is incorrect because the patient has not sustained a head injury. Option (E), volitional memory loss, is incorrect because the patient’s memory loss is due to her ability to suppress or repress selective memories. In addition, volitional memory loss is not a DSM-IV-TR diagnosis. A 26-year-old man with a history of involuntary eye blinking and snorting comes to the office because he is distressed about increasing frequency of these tics over the past six months. The patient says the episodes currently occur numerous times during the day. Medical history includes development of eye blinking at 12 years of age and development of snorting at 16 years of age. Psychotherapy and exercises initially reduced the frequency of these episodes. Because the patient is embarrassed by his tics, his performance at work has decreased and he now declines most invitations to social gatherings. Which of the following medications is the most appropriate therapy for this Content Area: Disorders of Infancy, Childhood, or Adolescence (4%) Area of Interest: Psychopharmacology This question tests the examinee’s ability to recognize the signs and symptoms of Tourette disorder and to choose the most appropriate therapy. The correct answer is Option (D), risperidone (Risperdal). A tic is a rapid, recurrent, nonrhythmic, stereotyped movement of vocalization. Tourette disorder is characterized by vocal or motor tics, both of which may be present during the course of the illness. Onset of tics occurs before 18 years of age, and symptoms persist for at least one year, occurring many times nearly every day. The tics cause marked distress and impairment in occupational and social functioning. Compelling evidence exists that the dopamine system is involved in tic disorders — pharmacologic agents that antagonize dopamine suppress tics, and agents that increase dopamine, such as methylphenidate, exacerbate tics. Risperidone (Risperdal) is a dopamine antagonist and is, therefore, the most appropriate therapy for Option (A), carbamazepine (Tegretol), is incorrect because it is indicated for neuralgias and seizures, not for Tourette disorder, and it does not affect dopamine transmission. Option (B), fluvoxamine (Luvox), is incorrect because it is a selective serotonin reuptake inhibitor, which increases dopamine levels. Option (C), methylphenidate (Concerta), is incorrect because it is a stimulant, and stimulants have been reported to exacerbate preexisting tics. Option (E), venlafaxine (Effexor), is incorrect because it is a serotonin- norepinephrine reuptake inhibitor and does not decrease dopamine transmission. A 19-year-old college student comes to the health clinic for evaluation because she has been purging food during the past semester. The patient appears well developed and well nourished. Physical examination shows mild enlargement of the parotid glands. In addition to complete blood cell count and urinalysis, measurement of which of the Content Area: Eating Disorders (3%) Area of Interest: Evaluation and diagnosis This question tests the examinee’s ability to determine the most appropriate laboratory study considering the salient points in the patient’s history. The correct answer is Option (C), serum electrolytes. Patients who purge are at increased risk for hypokalemia and/or hypochloremic alkalosis because of vomiting. The most appropriate laboratory study to test for these conditions is measurement of serum electrolyte levels. Option (A), fasting blood glucose, is incorrect because this level is typically within normal limits in patients with bulimia. Option (B), serum amylase, is a plausible choice but is incorrect. Although some patients with bulimia develop hyperamylasemia due to regular purging, measurement of serum amylase level is not a critical test compared with measurement of serum electrolyte levels. Option (D), serum liver enzymes, is incorrect because even though disturbances in liver enzyme levels may exist in patients with bulimia, these findings are neither diagnostic of nor specific to the condition. Option (E), serum thyroid-stimulating hormone, is incorrect because thyroid function remains intact A 5-year-old boy is brought to the clinic by his mother because she is worried about changes in his behavior during the past few months. The patient's mother says he has had episodes that occur sporadically at night during which he sits up in bed screaming, crying incoherently, and intensely frightened. She says it is initially difficult to calm him down, and he is usually sweating, breathing rapidly, and tremulous. The patient eventually calms down after 10 to 15 minutes and then falls asleep. Which of the following questions is most appropriate to confirm the suspected diagnosis of sleep terror disorder (A) Do his arms and legs jerk during sleep? Content Area: Primary Sleep Disorders (4%) Area of Interest: Evaluation and diagnosis This question tests the examinee’s ability to recognize and distinguish the signs and symptoms of sleep arousal disorders and sleep terror disorder. The correct answer is Option (B), Does he have nightmares? Sleep terror disorder is characterized by arousal with screams or crying accompanied by fear and signs of autonomic arousal, such as tachycardia, sweating, and rapid breathing. Patients with sleep terror disorder have no recollection of a dream or the episode, which causes distress or impairment in social or Option (A), Do his arms and legs jerk during sleep?, is incorrect because sleep terrors are not accompanied by myoclonus. Although onset of sleep terror disorder in adolescence may be a first symptom of temporal lobe epilepsy, myoclonus is not associated with this disorder. Option (E), Does he wet the bed?, is incorrect because sleep terrors are not accompanied by bedwetting. Option (C), Does he go to sleep late?, and Option (D), Does he watch violent movies?, are incorrect because these behaviors are not related to sleep

Source: https://www.nccpa.net/PDFs/Psychiatry%20Critiques.pdf

Fall-winter program 2011-2012

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