A 33-year-old woman who was recently involved in a motor vehicle accident presents to a medical clinic for a follow-up visit. She was in the front passenger seat when the vehicle swerved off the road and struck 2 pedestrians. She was restrained by her seatbelt and did not suffer any significant physical injury. Since then she has had 1 outpatient visit and is recovering well. She is here today upon the request of her family members who insist that she has not come to terms with the incident. They have noted that she has significant distress while riding in her car; however, she does not seem particularly worried and she cannot remember many of the details of the accident. On a mini-mental examination, she scores 27/30. Which of the following best describes this patient’s condition?
Q12
A 36-year-old woman comes to the physician because of an 8-month history of occasional tremor. The tremor is accompanied by sudden restlessness and nausea, which disrupts her daily work as a professional violinist. The symptoms worsen shortly before upcoming concerts but also appear when she goes for a walk in the city. She is concerned that she might have a neurological illness and have to give up her career. The patient experiences difficulty falling asleep because she cannot stop worrying that a burglar might break into her house. Her appetite is good. She drinks one glass of wine before performances "to calm her nerves" and otherwise drinks 2–3 glasses of wine per week. The patient takes daily multivitamins as prescribed. She appears nervous. Her temperature is 36.8°C (98.2°F), pulse is 92/min, and blood pressure is 135/80 mm Hg. Mental status examination shows a full range of affect. On examination, a fine tremor on both hands is noted. She exhibits muscle tension. The remainder of the neurological exam shows no abnormalities. Which of the following is the most likely explanation for this patient's symptoms?
Q13
A 7-year-old boy is brought to the physician because of repetitive, involuntary blinking, shrugging, and grunting for the past year. His mother states that his symptoms improve when he is physically active, while tiredness, boredom, and stress aggravate them. He has felt increasingly embarrassed by his symptoms in school, and his grades have been dropping from average levels. He has met all his developmental milestones. Vital signs are within normal limits. Mental status examination shows intact higher mental functioning and thought processes. Excessive blinking, grunting, and jerking of the shoulders and neck occur while at rest. The remainder of the examination shows no abnormalities. This patient's condition is most likely associated with which of the following findings?
Q14
A 48-year-old male chef presents to the dermatologist complaining of skin problems on his hands. They are itchy, red, and tender, making his work difficult. He has been using the same dish soap, hand soap, and industrial cleaner at work and at home for the past 5 years. There are no significant changes in his life, in his kitchen at work, or at home. He is otherwise healthy with no past medical or psychiatric history. He admits to enjoying his work and his family. He works at a fine dining restaurant with an immaculate kitchen with well-trained staff. He finds himself worrying about contamination. These thoughts are intrusive and upsetting. He admits to finding relief by washing his hands. He admits to washing his hands more than anyone else at the restaurant. Sometimes he takes 20 minutes to wash his hands. Sometimes he can’t get away from the sink to do his job because he is compelled to wash his hands over and over. Which of the following features is most correct regarding the patient’s psychiatric condition?
Q15
An otherwise healthy 55-year-old woman comes to the physician because of a 7-month history of insomnia. She has difficulty initiating sleep, and her sleep onset latency is normally about 1 hour. She takes melatonin most nights. The physician gives the following recommendations: leave the bedroom when unable to fall asleep within 20 minutes to read or listen to music; return only when sleepy; avoid daytime napping. These recommendations are best classified as which of the following?
Q16
A 25-year-old man presents to his primary care physician for recurrent headaches. The patient states that the headaches have been going on for the past week, and he is concerned that he may have cancer. Based on his symptoms, he strongly believes that he needs further diagnostic workup. The patient works as a nurse at the local hospital and is concerned that he is going to lose his job. The patient is also concerned about his sexual performance with his girlfriend, and as a result he has ceased to engage in sexual activities. Finally, the patient is concerned about his relationship with his family. He states that his concerns related to these issues have persisted for the past year. The patient has a past medical history of obesity, diabetes, hypertension, and irritable bowel syndrome. His current medications include metformin, insulin, lisinopril, and hydrochlorothiazide. The patient has a family history of colorectal cancer in his grandfather and father. The patient's neurological exam is within normal limits. The patient denies having a headache currently. Which of the following is the best initial step in management?
Q17
One hour after undergoing an uncomplicated laparoscopic appendectomy, a 22-year-old man develops agitation and restlessness. He also has tremors, diffuse sweating, headache, and nausea with dry heaves. One liter of lactated ringer's was administered during the surgery and he had a blood loss of approximately 100 mL. His urine output was 100 mL. His pain has been controlled with intravenous morphine. He was admitted to the hospital 3 days ago and has not eaten in 18 hours. He has no history of serious illness. He is a junior in college. His mother has Hashimoto's thyroiditis. He has experimented with intravenous illicit drugs. He drinks 3 beers and 2 glasses of whiskey daily during the week and more on the weekends with his fraternity. He appears anxious. His temperature is 37.4°C (99.3°F), pulse is 120/min, respirations are 19/min, and blood pressure is 142/90 mm Hg. He is alert and fully oriented but keeps asking if his father, who is not present, can leave the room. Mucous membranes are moist and the skin is warm. Cardiac examination shows tachycardia and regular rhythm. The lungs are clear to auscultation. His abdomen has three port sites with clean and dry bandages. His hands tremble when his arms are extended with fingers spread apart. Which of the following is the most appropriate next step in management?
Q18
A 21-year-old female presents to her first gynecology visit. She states that six months ago, she tried to have sexual intercourse but experienced severe pain in her genital region when penetration was attempted. This has continued until now, and she has been unable to have intercourse with her partner. The pain is not present at any other times aside from attempts at penetration. The patient is distressed that she will never be able to have sex, even though she wishes to do so. She does not recall ever having a urinary tract infection and has never been sexually active due to her religious upbringing. In addition, she has never tried to use tampons or had a Pap smear before. She denies alcohol, illicit drugs, and smoking. The patient is 5 feet 6 inches and weighs 146 pounds (BMI 23.6 kg/m^2). On pelvic exam, there are no vulvar skin changes, signs of atrophy, or evidence of abnormal discharge. The hymen is not intact. Placement of a lubricated speculum at the introitus elicits intense pain and further exam is deferred for patient comfort. Office urinalysis is negative. Which of the following is a risk factor for this patient’s condition?
Q19
A 23-year-old woman presents to the emergency department with severe abdominal pain. The pain started suddenly several hours ago and has steadily worsened. The patient has a past medical history of anxiety and depression. Her current medications include sertraline, sodium docusate, a multivitamin, and fish oil. The patient is currently sexually active with her boyfriend and uses the "pull-out" method for contraception. A pelvic ultrasound in the emergency room reveals an ectopic pregnancy. The patient is scheduled for surgery and is promptly treated. She is recovering on the surgical floor. The procedure was complicated by a large amount of blood loss. The patient is recovering on IV fluids when her family comes to visit. When her parents find out the diagnosis, yelling ensues and they leave angrily. The patient is scheduled to go home today. Prior to discharge, the patient reports she is unable to use her left hand. Upon examination, she is teary-eyed and she claims that she has “the worst family in the world,” and she does not want to go home. Physical exam reveals no skin or bony abnormalities of the left arm. Strength is 0/5 in the left upper extremity. She does not recoil her left arm to pain. A MRI is obtained and is unremarkable. The rest of the patient’s neurological exam is within normal limits. Which of the following is the most likely diagnosis?
Q20
A 21-year-old woman presents into the clinic worried that she might be pregnant. Her last menstrual period was 4 months ago and recalls that she did have unprotected sex with her boyfriend, despite not having sexual desire. They have since broken up, and she would like to do a pregnancy test. She appears very emaciated but is physically active. She says that she spends a few hours in the gym almost every day but would spend longer if she was to stray from her diet so that she does not gain any weight. Her calculated BMI is 17 kg/m2, and her urine pregnancy test is negative. Which of the following additional findings would most likely be present in this patient?
Anxiety US Medical PG Practice Questions and MCQs
Question 11: A 33-year-old woman who was recently involved in a motor vehicle accident presents to a medical clinic for a follow-up visit. She was in the front passenger seat when the vehicle swerved off the road and struck 2 pedestrians. She was restrained by her seatbelt and did not suffer any significant physical injury. Since then she has had 1 outpatient visit and is recovering well. She is here today upon the request of her family members who insist that she has not come to terms with the incident. They have noted that she has significant distress while riding in her car; however, she does not seem particularly worried and she cannot remember many of the details of the accident. On a mini-mental examination, she scores 27/30. Which of the following best describes this patient’s condition?
A. Patients are more likely to also have bipolar disorder.
B. The condition is the least common form of dissociative disorder.
C. Memory loss is usually self-limiting. (Correct Answer)
D. Patients are unable to recall only minor or obscure details in this condition.
E. Pharmacotherapy is the mainstay of treatment.
Explanation: ***Memory loss is usually self-limiting.***
* This patient is exhibiting symptoms consistent with **dissociative amnesia**, characterized by an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness.
* Dissociative amnesia, particularly **localized amnesia** (inability to recall specific events during a circumscribed period), often has a **spontaneous and complete recovery** of memory.
*Patients are more likely to also have bipolar disorder.*
* While comorbidity is common in psychiatric disorders, **dissociative disorders** are more frequently comorbid with conditions like **post-traumatic stress disorder (PTSD)**, **depression**, **anxiety disorders**, and **personality disorders**, rather than bipolar disorder specifically.
* There is no strong statistical link suggesting a higher likelihood of co-occurring **bipolar disorder** in patients with dissociative amnesia.
*The condition is the least common form of dissociative disorder.*
* **Dissociative amnesia** is actually considered one of the **more common** forms of dissociative disorders, particularly given its association with trauma.
* **Dissociative identity disorder (DID)** is generally considered the *least* common, but also the most severe.
*Patients are unable to recall only minor or obscure details in this condition.*
* In dissociative amnesia, the memory loss typically involves **significant autobiographical information** and **major traumatic events**, not just minor or obscure details.
* The patient's inability to recall "many of the details of the accident" represents **substantial memory loss** of a significant traumatic event, which is characteristic of dissociative amnesia.
*Pharmacotherapy is the mainstay of treatment.*
* **Psychotherapy**, particularly trauma-focused therapy, is considered the **mainstay of treatment** for dissociative amnesia.
* Medications may be used to treat **comorbid conditions** like depression or anxiety, but they do not directly treat the dissociative symptoms or memory loss itself.
Question 12: A 36-year-old woman comes to the physician because of an 8-month history of occasional tremor. The tremor is accompanied by sudden restlessness and nausea, which disrupts her daily work as a professional violinist. The symptoms worsen shortly before upcoming concerts but also appear when she goes for a walk in the city. She is concerned that she might have a neurological illness and have to give up her career. The patient experiences difficulty falling asleep because she cannot stop worrying that a burglar might break into her house. Her appetite is good. She drinks one glass of wine before performances "to calm her nerves" and otherwise drinks 2–3 glasses of wine per week. The patient takes daily multivitamins as prescribed. She appears nervous. Her temperature is 36.8°C (98.2°F), pulse is 92/min, and blood pressure is 135/80 mm Hg. Mental status examination shows a full range of affect. On examination, a fine tremor on both hands is noted. She exhibits muscle tension. The remainder of the neurological exam shows no abnormalities. Which of the following is the most likely explanation for this patient's symptoms?
A. Atypical depressive disorder
B. Adjustment disorder
C. Generalized anxiety disorder (Correct Answer)
D. Panic disorder
E. Essential tremor
Explanation: ***Generalized anxiety disorder***
- The patient exhibits persistent and excessive worry about various life circumstances (performance, burglaries, general anxiety), accompanied by physical symptoms like **restlessness**, muscle tension, and sleep disturbances, which are hallmark features of **Generalized Anxiety Disorder (GAD)**.
- The symptoms have been present for **8 months**, exceed the diagnostic duration for GAD (at least 6 months), and are not clearly tied to a specific stressor or episodic panic attacks.
*Atypical depressive disorder*
- Atypical depression is characterized by mood reactivity, increased appetite/weight gain, hypersomnia, leaden paralysis, and interpersonal rejection sensitivity.
- This patient reports difficulty sleeping (*insomnia*) and primarily presents with anxiety symptoms, not depressive mood.
*Adjustment disorder*
- **Adjustment disorder** involves emotional or behavioral symptoms in response to an identifiable stressor, occurring within 3 months of the stressor's onset, and usually resolving within 6 months after the stressor or its consequences have ceased.
- The patient's symptoms are chronic (8 months), excessive, and not solely linked to *one* identifiable recent stressor, but rather a pervasive pattern of worry.
*Panic disorder*
- **Panic disorder** is characterized by recurrent unexpected **panic attacks** with sudden onset of intense fear and physical symptoms (e.g., palpitations, dyspnea, dizziness).
- While she experiences sudden restlessness and nausea related to performances, these are specific triggers and not unexpected, unprovoked panic attacks. The primary pattern is persistent worry, not recurrent panic attacks.
*Essential tremor*
- **Essential tremor** is a neurological condition causing an *action tremor*, often visible when performing daily tasks, and typically improves with alcohol.
- While she has a tremor that improves with alcohol, the presence of marked and pervasive psychological symptoms like severe worrying, restlessness, and insomnia point to an underlying anxiety disorder, not solely an isolated neurological tremor.
Question 13: A 7-year-old boy is brought to the physician because of repetitive, involuntary blinking, shrugging, and grunting for the past year. His mother states that his symptoms improve when he is physically active, while tiredness, boredom, and stress aggravate them. He has felt increasingly embarrassed by his symptoms in school, and his grades have been dropping from average levels. He has met all his developmental milestones. Vital signs are within normal limits. Mental status examination shows intact higher mental functioning and thought processes. Excessive blinking, grunting, and jerking of the shoulders and neck occur while at rest. The remainder of the examination shows no abnormalities. This patient's condition is most likely associated with which of the following findings?
A. Feelings of persistent sadness and loss of interest
B. Defiant and hostile behavior toward teachers and parents
C. Recurrent episodes of intense fear
D. Chorea and hyperreflexia
E. Excessive impulsivity and inattention (Correct Answer)
Explanation: ***Excessive impulsivity and inattention***
- The patient exhibits features of **Tourette syndrome**, characterized by multiple motor **tics** and at least one vocal tic present for longer than a year, with onset before age 18.
- Tourette syndrome is frequently comorbid with **attention-deficit/hyperactivity disorder (ADHD)**, which presents with symptoms of **inattention** and **hyperactivity-impulsivity**.
*Feelings of persistent sadness and loss of interest*
- These symptoms describe **major depressive disorder**, which is less commonly comorbid with Tourette syndrome in childhood and less directly linked than ADHD.
- While depression can occur, the primary associations with Tourette's during childhood are more behavioral and attention-related.
*Defiant and hostile behavior toward teachers and parents*
- This symptom profile suggests **oppositional defiant disorder (ODD)** or **conduct disorder**, which are less common comorbidities of Tourette syndrome than ADHD.
- While behavioral issues can arise from the distress of tics, ODD is not the most direct or prevalent comorbidity.
*Recurrent episodes of intense fear*
- This symptom describes **panic attacks** or an **anxiety disorder**, which can co-occur with Tourette syndrome, but less frequently than ADHD.
- The primary clinical picture presented (tics and academic decline) points more strongly to an attention-related comorbidity.
*Chorea and hyperreflexia*
- **Chorea** and **hyperreflexia** are neurological signs not typically associated with Tourette syndrome; they are more characteristic of conditions like Huntington's disease or Sydenham chorea.
- Tourette syndrome is a **neurological disorder** of tics, not a progressive degenerative disorder with chorea and hyperreflexia.
Question 14: A 48-year-old male chef presents to the dermatologist complaining of skin problems on his hands. They are itchy, red, and tender, making his work difficult. He has been using the same dish soap, hand soap, and industrial cleaner at work and at home for the past 5 years. There are no significant changes in his life, in his kitchen at work, or at home. He is otherwise healthy with no past medical or psychiatric history. He admits to enjoying his work and his family. He works at a fine dining restaurant with an immaculate kitchen with well-trained staff. He finds himself worrying about contamination. These thoughts are intrusive and upsetting. He admits to finding relief by washing his hands. He admits to washing his hands more than anyone else at the restaurant. Sometimes he takes 20 minutes to wash his hands. Sometimes he can’t get away from the sink to do his job because he is compelled to wash his hands over and over. Which of the following features is most correct regarding the patient’s psychiatric condition?
A. There is no role for deep brain stimulation.
B. Compulsions are logically related to the obsessions.
C. Disturbing thoughts are usually ego-syntonic.
D. Behavioral treatment is not as effective as drug therapy.
E. Patients generally have insight into their condition. (Correct Answer)
Explanation: ***Patients generally have insight into their condition.***
- Patients with **Obsessive-Compulsive Disorder (OCD)** typically recognize that their obsessions and compulsions are **irrational or excessive**, but they feel unable to resist them.
- This **insight** is a defining characteristic, differentiating OCD from psychotic disorders where insight is often lacking.
*There is no role for deep brain stimulation.*
- **Deep Brain Stimulation (DBS)** is an approved treatment for **severe, refractory OCD** that has not responded to conventional pharmacological and behavioral therapies.
- While not first-line, it is a viable option for a small subset of patients.
*Compulsions are logically related to the obsessions.*
- While compulsions are an attempt to reduce distress from obsessions, they are often **not logically or realistically connected** to the obsession.
- For example, repetitive handwashing does not realistically prevent all contamination in the way the patient believes.
*Disturbing thoughts are usually ego-syntonic.*
- The disturbing thoughts (obsessions) in OCD are typically **ego-dystonic**, meaning they are **contrary to the patient's conscious desires and values**, causing significant distress.
- Ego-syntonic thoughts are consistent with one's self-perception and, therefore, usually do not cause distress.
*Behavioral treatment is not as effective as drug therapy.*
- **Exposure and Response Prevention (ERP)**, a form of cognitive-behavioral therapy, is considered the **most effective behavioral treatment** for OCD and often yields better long-term results than medication alone.
- A combination of ERP and **pharmacotherapy (SSRIs)** is often the most effective approach.
Question 15: An otherwise healthy 55-year-old woman comes to the physician because of a 7-month history of insomnia. She has difficulty initiating sleep, and her sleep onset latency is normally about 1 hour. She takes melatonin most nights. The physician gives the following recommendations: leave the bedroom when unable to fall asleep within 20 minutes to read or listen to music; return only when sleepy; avoid daytime napping. These recommendations are best classified as which of the following?
A. Cognitive behavioral therapy
B. Relaxation
C. Improved sleep hygiene
D. Stimulus control therapy (Correct Answer)
E. Sleep restriction
Explanation: ***Stimulus control therapy***
- This therapy focuses on **removing cues** that hinder sleep and **establishing a strong association** between the bed/bedroom and sleep.
- The recommendations (leaving the bedroom when awake, returning only when sleepy, avoiding daytime naps) are classic components of **stimulus control therapy** for insomnia.
*Cognitive behavioral therapy*
- **CBT-I** is a comprehensive approach that includes stimulus control, sleep hygiene, relaxation techniques, and cognitive restructuring.
- While stimulus control is a part of CBT-I, the recommendations provided are specifically designed to address conditioning and are thus best classified as stimulus control therapy.
*Relaxation*
- Relaxation techniques involve methods like **progressive muscle relaxation**, **deep breathing exercises**, or **meditation** to reduce physiological arousal.
- The given recommendations do not directly involve these types of activities but rather focus on changing behaviors around sleep.
*Improved sleep hygiene*
- Sleep hygiene involves practices that promote good sleep, such as maintaining a **regular sleep schedule**, ensuring a **comfortable sleep environment**, and **avoiding caffeine/alcohol** before bed.
- While avoiding daytime naps is related to sleep hygiene, the core recommendations (leaving the bedroom when awake, returning only when sleepy) specifically target conditional associations with the bed, making them more characteristic of stimulus control.
*Sleep restriction*
- Sleep restriction therapy involves **limiting the time spent in bed** to the actual time asleep, with the goal of building up sleep drive and improving sleep efficiency.
- The recommendations given do not specify a fixed reduction in time allowed in bed but rather focus on behavioral responses to wakefulness in bed.
Question 16: A 25-year-old man presents to his primary care physician for recurrent headaches. The patient states that the headaches have been going on for the past week, and he is concerned that he may have cancer. Based on his symptoms, he strongly believes that he needs further diagnostic workup. The patient works as a nurse at the local hospital and is concerned that he is going to lose his job. The patient is also concerned about his sexual performance with his girlfriend, and as a result he has ceased to engage in sexual activities. Finally, the patient is concerned about his relationship with his family. He states that his concerns related to these issues have persisted for the past year. The patient has a past medical history of obesity, diabetes, hypertension, and irritable bowel syndrome. His current medications include metformin, insulin, lisinopril, and hydrochlorothiazide. The patient has a family history of colorectal cancer in his grandfather and father. The patient's neurological exam is within normal limits. The patient denies having a headache currently. Which of the following is the best initial step in management?
A. Buspirone
B. Sumatriptan
C. Fluoxetine (Correct Answer)
D. Clonazepam
E. MRI head
Explanation: ***Fluoxetine***
- The patient exhibits symptoms consistent with **generalized anxiety disorder** (GAD), including excessive worry about multiple areas of life (health, job, relationships, sexual performance) for over a year, and associated physical symptoms (headaches). **SSRIs like fluoxetine** are first-line treatment for GAD.
- The patient's multiple health concerns, despite a normal neurological exam, and his persistent worries suggest an underlying anxiety disorder that would benefit from pharmacological intervention.
*Buspirone*
- Buspirone is an **anxiolytic** that can be used for GAD, but it typically has a **slower onset of action** and is often considered a second-line agent or an add-on therapy rather than the initial monotherapy for severe, pervasive anxiety.
- While it may be suitable, an **SSRI (like fluoxetine)** is generally preferred as the first-line and most effective option for chronic GAD due to its broader efficacy profile.
*Sumatriptan*
- **Sumatriptan is a triptan** used for the acute treatment of **migraines** and cluster headaches.
- The patient's headaches are recurrent but he denies having one currently, and the primary concern appears to be underlying anxiety rather than the acute management of a headache.
*Clonazepam*
- Clonazepam is a **benzodiazepine**, which can provide rapid relief for anxiety symptoms. However, it is typically used for **short-term management** of acute anxiety or as an adjunct due to its potential for **dependence** and withdrawal symptoms.
- It is not recommended as a first-line, long-term monotherapy for chronic GAD, as it does not address the underlying anxious thought patterns as effectively as SSRIs.
*MRI head*
- This patient has a normal neurological exam, making a **diagnostic MRI head** for headaches in the absence of **focal neurological deficits** or "red flag" symptoms (e.g., papilledema, thunderclap headache) unnecessary as an initial step.
- While the patient is concerned about cancer, further imaging is not indicated given the current clinical presentation strongly suggesting an **anxiety disorder**.
Question 17: One hour after undergoing an uncomplicated laparoscopic appendectomy, a 22-year-old man develops agitation and restlessness. He also has tremors, diffuse sweating, headache, and nausea with dry heaves. One liter of lactated ringer's was administered during the surgery and he had a blood loss of approximately 100 mL. His urine output was 100 mL. His pain has been controlled with intravenous morphine. He was admitted to the hospital 3 days ago and has not eaten in 18 hours. He has no history of serious illness. He is a junior in college. His mother has Hashimoto's thyroiditis. He has experimented with intravenous illicit drugs. He drinks 3 beers and 2 glasses of whiskey daily during the week and more on the weekends with his fraternity. He appears anxious. His temperature is 37.4°C (99.3°F), pulse is 120/min, respirations are 19/min, and blood pressure is 142/90 mm Hg. He is alert and fully oriented but keeps asking if his father, who is not present, can leave the room. Mucous membranes are moist and the skin is warm. Cardiac examination shows tachycardia and regular rhythm. The lungs are clear to auscultation. His abdomen has three port sites with clean and dry bandages. His hands tremble when his arms are extended with fingers spread apart. Which of the following is the most appropriate next step in management?
A. Administer intravenous lorazepam (Correct Answer)
B. Administer 5% dextrose in 1/2 normal saline
C. Administer intravenous naloxone
D. Administer intravenous propranolol
E. Administer intravenous dexamethasone
Explanation: ***Administer intravenous lorazepam***
- The patient's symptoms (agitation, restlessness, tremors, sweating, tachycardia, hypertension, and anxiety) occurring post-surgery in a patient with a history of heavy alcohol use are highly suggestive of alcohol withdrawal syndrome.
- Benzodiazepines like lorazepam are the first-line treatment for alcohol withdrawal due to their sedative, anxiolytic, and anticonvulsant properties, which can prevent progression to more severe complications like seizures or delirium tremens.
*Administer 5% dextrose in 1/2 normal saline*
- This solution is primarily used to address dehydration and provide some caloric support, but it does not directly manage the neuroexcitatory symptoms of alcohol withdrawal.
- While supportive care including fluids is important, addressing the underlying alcohol withdrawal is the immediate priority.
*Administer intravenous naloxone*
- Naloxone is an opioid antagonist used to reverse opioid overdose.
- The patient's symptoms are inconsistent with opioid overdose; in fact, he is experiencing agitation and autonomic hyperactivity, which are the opposite of opioid effects.
*Administer intravenous propranolol*
- Propranolol is a beta-blocker that can help control some autonomic symptoms like tachycardia and hypertension, but it does not address the underlying neuroexcitability or prevent seizures associated with alcohol withdrawal.
- It should not be used as monotherapy for alcohol withdrawal and should be given cautiously, often after benzodiazepines, especially in patients with respiratory concerns.
*Administer intravenous dexamethasone*
- Dexamethasone is a potent corticosteroid used for anti-inflammatory or immunosuppressive effects and in conditions like cerebral edema or adrenal insufficiency.
- It has no role in the management of alcohol withdrawal syndrome.
Question 18: A 21-year-old female presents to her first gynecology visit. She states that six months ago, she tried to have sexual intercourse but experienced severe pain in her genital region when penetration was attempted. This has continued until now, and she has been unable to have intercourse with her partner. The pain is not present at any other times aside from attempts at penetration. The patient is distressed that she will never be able to have sex, even though she wishes to do so. She does not recall ever having a urinary tract infection and has never been sexually active due to her religious upbringing. In addition, she has never tried to use tampons or had a Pap smear before. She denies alcohol, illicit drugs, and smoking. The patient is 5 feet 6 inches and weighs 146 pounds (BMI 23.6 kg/m^2). On pelvic exam, there are no vulvar skin changes, signs of atrophy, or evidence of abnormal discharge. The hymen is not intact. Placement of a lubricated speculum at the introitus elicits intense pain and further exam is deferred for patient comfort. Office urinalysis is negative. Which of the following is a risk factor for this patient’s condition?
A. Low estrogen state
B. Generalized anxiety disorder (Correct Answer)
C. Endometriosis
D. Squamous cell carcinoma of the vulva
E. Body dysmorphic disorder
Explanation: ***Generalized anxiety disorder***
- The patient describes **severe pain upon attempted penetration** and significant distress about her inability to have intercourse, consistent with **genito-pelvic pain/penetration disorder (GPPPD)**, formerly known as dyspareunia, vaginismus, and sexual aversion disorder.
- While GPPPD is multi-factorial, **anxiety and psychological distress** are significant risk factors and often exacerbate the condition, leading to muscle guarding and increased pain perception.
*Low estrogen state*
- This patient is a pre-menopausal 21-year-old with a normal BMI, making a **low estrogen state** highly unlikely.
- Low estrogen typically leads to **vulvovaginal atrophy**, dryness, and pain, which would present with objective findings like vulvar skin changes or atrophy, not observed in this case.
*Endometriosis*
- Endometriosis causes **deep dyspareunia** (pain with deep penetration), often accompanied by chronic pelvic pain, dysmenorrhea, and infertility.
- The patient's pain is described as severe with *attempted penetration at the introitus*, which is more superficial than typical endometriosis-related pain.
*Squamous cell carcinoma of the vulva*
- This condition is typically found in older women and associated with a history of **HPV infection** or chronic inflammation.
- It would present with **visible vulvar lesions**, itching, bleeding, or palpable masses, none of which are described in the patient's exam.
*Body dysmorphic disorder*
- Body dysmorphic disorder involves a **preoccupation with perceived flaws** in physical appearance, leading to significant distress or impairment.
- While it can impact sexual intimacy, the primary symptom described is **physical pain during attempted intercourse**, not distress over her genital appearance.
Question 19: A 23-year-old woman presents to the emergency department with severe abdominal pain. The pain started suddenly several hours ago and has steadily worsened. The patient has a past medical history of anxiety and depression. Her current medications include sertraline, sodium docusate, a multivitamin, and fish oil. The patient is currently sexually active with her boyfriend and uses the "pull-out" method for contraception. A pelvic ultrasound in the emergency room reveals an ectopic pregnancy. The patient is scheduled for surgery and is promptly treated. She is recovering on the surgical floor. The procedure was complicated by a large amount of blood loss. The patient is recovering on IV fluids when her family comes to visit. When her parents find out the diagnosis, yelling ensues and they leave angrily. The patient is scheduled to go home today. Prior to discharge, the patient reports she is unable to use her left hand. Upon examination, she is teary-eyed and she claims that she has “the worst family in the world,” and she does not want to go home. Physical exam reveals no skin or bony abnormalities of the left arm. Strength is 0/5 in the left upper extremity. She does not recoil her left arm to pain. A MRI is obtained and is unremarkable. The rest of the patient’s neurological exam is within normal limits. Which of the following is the most likely diagnosis?
A. Ischemic stroke
B. Malingering
C. Borderline personality disorder
D. Factitious disorder
E. Conversion disorder (Correct Answer)
Explanation: ***Conversion disorder***
- This patient presents with **neurological symptoms (left arm paralysis)** that are **inconsistent with anatomical pathways** or known neurological diseases (unremarkable MRI), occurring after a significant psychosocial stressor (ectopic pregnancy, family conflict).
- Her emotional distress, "worst family in the world" comment, and the specific symptom presentation without organic cause are classic features of **conversion disorder**.
*Ischemic stroke*
- A stroke would typically present with **focal neurological deficits consistent with a vascular territory**, and an MRI would show evidence of **infarction**.
- The **normal MRI findings** and the specific context of psychological distress make ischemic stroke very unlikely.
*Malingering*
- **Malingering** involves the intentional production of false or exaggerated symptoms for obvious external incentives, such as avoiding work or obtaining financial compensation.
- In this case, there is **no clear external incentive** for the patient to feign paralysis; her distress seems genuine.
*Borderline personality disorder*
- **Borderline personality disorder** is characterized by unstable relationships, impulsivity, identity disturbance, and chronic feelings of emptiness, often leading to self-harm or suicidal behavior.
- While she has a history of anxiety and depression, and is emotionally distressed, the **sudden onset of specific neurological symptoms without an organic cause** points away from a primary diagnosis of BPD.
*Factitious disorder*
- **Factitious disorder** (previously Munchausen syndrome) involves deliberately faking or inducing illness in oneself for the primary purpose of assuming the "sick role" and gaining attention.
- While there's no clear organic cause for her paralysis, her presentation is more aligned with an **unconscious psychological conflict converting into physical symptoms** rather than a conscious effort to deceive for secondary gain.
Question 20: A 21-year-old woman presents into the clinic worried that she might be pregnant. Her last menstrual period was 4 months ago and recalls that she did have unprotected sex with her boyfriend, despite not having sexual desire. They have since broken up, and she would like to do a pregnancy test. She appears very emaciated but is physically active. She says that she spends a few hours in the gym almost every day but would spend longer if she was to stray from her diet so that she does not gain any weight. Her calculated BMI is 17 kg/m2, and her urine pregnancy test is negative. Which of the following additional findings would most likely be present in this patient?
A. Hypocholesterolemia
B. Orthostasis (Correct Answer)
C. Primary amenorrhea
D. Hypokalemic alkalosis
E. Increased LH and FSH
Explanation: ***Orthostasis***
- This patient's presentation is highly suggestive of **anorexia nervosa** (BMI 17 kg/m2, amenorrhea, excessive exercise, fear of weight gain despite emaciation, and lack of sexual desire). **Orthostasis** (a drop in blood pressure upon standing) is a common finding due to **dehydration** and **volume depletion** often present in patients with anorexia nervosa.
- **Bradycardia** and **hypotension** (which contributes to orthostasis) are frequent cardiovascular complications of anorexia nervosa as the body attempts to conserve energy.
*Hypocholesterolemia*
- Patients with anorexia nervosa more commonly present with **hypercholesterolemia**, not hypocholesterolemia.
- This paradox is thought to be due to **decreased cholesterol degradation** and **impaired metabolism** in the setting of severe caloric restriction.
*Primary amenorrhea*
- The patient's last menstrual period was 4 months ago, indicating she has experienced menstruation in the past. Therefore, her amenorrhea is **secondary** (cessation of menses for 3 consecutive months in a woman who has previously menstruated), not primary (absence of menses by age 15 or within 5 years of thelarche).
- The **hypothalamic-pituitary-gonadal axis dysfunction** due to low body weight and nutritional deficiency leads to secondary amenorrhea in anorexia nervosa.
*Hypokalemic alkalosis*
- **Hypokalemic alkalosis** is typically associated with **purging behaviors** like vomiting or laxative abuse, which are characteristic of the bulimia nervosa subtype or the binge-eating/purging subtype of anorexia nervosa.
- While this patient's exercise is excessive, there is no direct evidence of purging in the provided vignette; her symptoms more strongly point towards the **restrictive subtype** of anorexia nervosa, where metabolic alkalosis is less common unless purging is also occurring.
*Increased LH and FSH*
- In anorexia nervosa, the severe caloric restriction and low body fat lead to **hypothalamic dysfunction**, specifically affecting the release of **gonadotropin-releasing hormone (GnRH)**.
- This results in **decreased production of LH and FSH** from the pituitary gland, leading to hypogonadotropic hypogonadism, which explains the amenorrhea.
