A 23-year-old woman is admitted to the inpatient psychiatry unit after her boyfriend reported she was “acting funny and refusing to talk.” The patient’s boyfriend states that he came home from work and found the patient sitting up in bed staring at the wall. When he said her name or waved his hand in front of her, she did not respond. When he tried to move her, she would remain in whatever position she was placed. The patient’s temperature is 99°F (37.2°C), blood pressure is 122/79 mmHg, pulse is 68/min, and respirations are 12/min with an oxygen saturation of 98% O2 on room air. During the physical exam, the patient is lying on the bed with her left arm raised and pointing at the ceiling. She resists any attempt to change her position. The patient remains mute and ignores any external stimuli. The patient’s medical history is significant for depression. She was recently switched from phenelzine to fluoxetine. Which of the following is the best initial therapy?
Q92
A 29-year-old woman is hospitalized due to depression and suicidal ideation. She has a 5-year history of chaotic relationships that last only a few short weeks or months. Each relationship has left her feeling abandoned, empty, and extremely upset. During these periods, the patient confesses to shopping and making big purchases on impulse. She says she gets bored easily and moves on to the next adventure. The patient denies any changes in appetite, energy level, or concentration. On examination, multiple linear lacerations of varying phases of healing were noted on her forearms and trunk. Following consultation, she praises physicians to be ‘the best people on the planet’, but when the nurse came in to take her blood, she furiously stated that ‘all nurses are incompetent and cruel’. Which of the following is the most likely diagnosis?
Q93
A 14-year-old boy is brought to a child psychiatry office by his father, who is concerned about his grades and teachers’ comments that he has “problems focusing.” He has a B- average. The boy's teachers in math, social studies, and English say that he often appears to not be listening in class, instead talking to classmates, making jokes, and blurting out incorrect answers. He typically turns in his homework late or not at all. During other classes (band and science, which he enjoys), none of these behaviors are observed. At home, he enjoys playing chess and reads comic and fiction books for hours without pause. His father describes him as calm and organized at home. Formal testing reveals an intelligence quotient (IQ) of 102. Which of the following is the most likely explanation for this patient’s grades?
Q94
An 18-year-old male is seen for a routine physical prior to starting college. He will be moving from Ohio to California, away from his family for the first time. His temperature is 36.8 deg C (98.2 deg F), pulse is 74/min, and blood pressure is 122/68 mmHg. BMI is 24. On questioning, he reveals that he has a habit of binge eating during times of stress, particularly during exams. He then feels guilty about his behavior and attempts to compensate by going to the gym, sometimes for 4+ hours per day. He is disturbed by this behavior and feels out of control. He denies ever vomiting as a means of losing weight. What is the most likely diagnosis?
Q95
A 78-year-old man is brought to the physician by his daughter for a follow-up examination. The daughter noticed that he has gradually become more forgetful and withdrawn over the last year. He frequently misplaces his car keys and forgets the names of his neighbors, whom he has known for 30 years. He has difficulty recalling his address and telephone number. He recently had an episode of urinary and fecal incontinence. Last week, his neighbor found him wandering the parking lot of the grocery store. He has hypertension and hyperlipidemia. He had smoked one pack of cigarettes daily for 40 years but quit 18 years ago. His current medications include hydrochlorothiazide and atorvastatin. He appears healthy; BMI is 23 kg/m2. His temperature is 37.2°C (99.0°F), pulse is 86/min, respirations are 14/min, and blood pressure is 136/84 mm Hg. Mini-mental state examination score is 19/30. He is not bothered by his forgetfulness. Cranial nerves II–XII are intact. He has 5/5 strength and full sensation to light touch in all extremities. His patellar, Achilles, and biceps reflexes are 2+ bilaterally. His gait is steady. MRI scan of the brain shows ventriculomegaly and prominent cerebral sulci. Which of the following is the most appropriate pharmacotherapy?
Q96
A 31-year-old male comedian presents to your mental health clinic for a psychotherapy appointment. He is undergoing psychodynamic psychotherapy for depressive symptoms. During the therapy session, you discuss his job as a successful comedian and identify ways that he channels his emotions about his abusive childhood into comedy routines. Though he enjoys his job overall and idolizes some of his coworkers, he complains about most of them being "totally incompetent." When you attempt to shift the discussion back to his childhood, he avoids eye contact and he tells you he "doesn't want to talk about it anymore." Which of the following is a primitive defense mechanism exhibited by this patient?
Q97
A 61-year-old woman presents to her primary care doctor with her son who reports that his mother is not acting like herself. She has gotten lost while driving several times in the past 2 months and appears to be talking to herself frequently. Of note, the patient’s husband died from a stroke 4 months ago. The patient reports feeling sad and guilty for causing so much trouble for her son. Her appetite has decreased since her husband died. On examination, she is oriented to person, place, and time. She is inattentive, and her speech is disorganized. She shakes her hand throughout the exam without realizing it. Her gait is slow and appears unstable. This patient’s condition would most likely benefit from which of the following medications?
Q98
A 15-year-old girl is brought into her pediatrician's office by her mother because the mother thinks her daughter has attention issues. The mother explains that her daughter started high school four months ago and had lackluster grades in a recent progress report despite having earned consistent top marks in middle school. The mother complains that her daughter never talks to her at home anymore. The patient yells at her mother in the exam room, and the mother is escorted out of the room. The patient scoffs that her mother is so overbearing, ruining her good days with criticism. She begins to chew gum and states that she hates hanging out with the girls on the cheerleading squad. She denies experiencing physical abuse from anyone or having a sexual partner. She has seen kids smoke marijuana underneath the football field bleachers, but does not go near them and denies smoking cigarettes. She denies any intention to harm herself or others, thinks her grades went down because her teachers are not as good as her middle school teachers, and states she thinks she learns best by watching explanations through online videos. What is the most likely diagnosis?
Q99
A 55-year-old man is brought to the physician because of inappropriate behavior for the past 6 months. He has been making inappropriate comments and jokes while talking to friends and family members. He was arrested 3 weeks ago while trying to kiss strangers on the street. He has no interest in talking to his daughter or playing with his grandchildren. During this period, he has developed a strong desire for chocolate pudding and potato chips and has gained 10 kg (22 lb). He appears unkempt. Vital signs are within normal limits. Physical examination is unremarkable. Mental status examination shows apathy and a blunt affect. He avoids answering questions and instead comments on the individuals he saw in the waiting room. Mini-Mental State Examination score is 28/30. A complete blood count and serum concentrations of glucose, creatinine, and electrolytes are within the reference range. Which of the following is the most likely diagnosis?
Q100
A 15-year-old girl presents to her primary care physician, accompanied by her mother, for 4 days of abdominal pain. She describes the pain as diffuse, dull, and constant. She also endorses constipation over this time. The patient's mother says the patient has become increasingly self-conscious of her appearance since starting high school this year and has increasingly isolated herself to her room, rarely spending time with or eating meals with the rest of the family. Her temperature is 98.0°F (36.7°C), blood pressure is 100/70 mmHg, pulse is 55/min, and respirations are 19/min. Body mass index (BMI) is at the 4th percentile for age and gender. Physical exam reveals dental caries, mild abdominal distension, and diffuse, fine body hair. Basic labs are most likely to reveal which of the following?
Mood Disorders US Medical PG Practice Questions and MCQs
Question 91: A 23-year-old woman is admitted to the inpatient psychiatry unit after her boyfriend reported she was “acting funny and refusing to talk.” The patient’s boyfriend states that he came home from work and found the patient sitting up in bed staring at the wall. When he said her name or waved his hand in front of her, she did not respond. When he tried to move her, she would remain in whatever position she was placed. The patient’s temperature is 99°F (37.2°C), blood pressure is 122/79 mmHg, pulse is 68/min, and respirations are 12/min with an oxygen saturation of 98% O2 on room air. During the physical exam, the patient is lying on the bed with her left arm raised and pointing at the ceiling. She resists any attempt to change her position. The patient remains mute and ignores any external stimuli. The patient’s medical history is significant for depression. She was recently switched from phenelzine to fluoxetine. Which of the following is the best initial therapy?
A. Electroconvulsive therapy
B. Lorazepam (Correct Answer)
C. Haloperidol
D. Cyproheptadine
E. Benztropine
Explanation: **Lorazepam**
- The patient presents with classic symptoms of **catatonia**, including **mutism**, **waxy flexibility**, and **posturing**, following a medication change from phenelzine (MAOI) to fluoxetine (SSRI), which could potentially precipitate catatonia or serotonin syndrome.
- **Benzodiazepines**, particularly lorazepam, are the **first-line treatment** for catatonia, often showing a rapid and dramatic response.
*Electroconvulsive therapy*
- While **ECT** is a highly effective treatment for severe catatonia, especially when unresponsive to benzodiazepines, it is typically considered a **second-line intervention** or for cases involving medical instability.
- Given the strong initial efficacy and safety profile of benzodiazepines, they are preferred as the first step before proceeding to ECT.
*Haloperidol*
- **Antipsychotics** like haloperidol are generally **contraindicated** in catatonia, as they can sometimes worsen the symptoms or even induce **neuroleptic malignant syndrome (NMS)**, which shares some features with severe catatonia.
- NMS is a serious condition with high mortality, and introducing an antipsychotic in a catatonic patient could be dangerous.
*Cyproheptadine*
- **Cyproheptadine** is a **serotonin antagonist** used primarily in the treatment of **serotonin syndrome**, which involves symptoms like hyperthermia, agitation, and hyperreflexia.
- While the medication change could raise suspicion for serotonin syndrome, the clinical picture of **waxy flexibility, mutism, and posturing** is much more indicative of catatonia, for which cyproheptadine is not an effective treatment.
*Benztropine*
- **Benztropine** is an **anticholinergic medication** primarily used to treat **extrapyramidal symptoms (EPS)** caused by antipsychotics, such as **dystonia** or **parkinsonism**.
- The patient's symptoms are not indicative of EPS, and benztropine has no role in the treatment of catatonia.
Question 92: A 29-year-old woman is hospitalized due to depression and suicidal ideation. She has a 5-year history of chaotic relationships that last only a few short weeks or months. Each relationship has left her feeling abandoned, empty, and extremely upset. During these periods, the patient confesses to shopping and making big purchases on impulse. She says she gets bored easily and moves on to the next adventure. The patient denies any changes in appetite, energy level, or concentration. On examination, multiple linear lacerations of varying phases of healing were noted on her forearms and trunk. Following consultation, she praises physicians to be ‘the best people on the planet’, but when the nurse came in to take her blood, she furiously stated that ‘all nurses are incompetent and cruel’. Which of the following is the most likely diagnosis?
A. Borderline personality disorder (Correct Answer)
B. Histrionic personality disorder
C. Major depressive disorder (MDD)
D. Bipolar I disorder
E. Factitious disorder
Explanation: ***Borderline personality disorder***
- This condition is characterized by a pervasive pattern of **instability in interpersonal relationships**, **self-image**, and **affects**, along with marked impulsivity, as evidenced by chaotic relationships, feelings of abandonment, and impulsive shopping.
- The patient's rapid shift from idealizing physicians to devaluing nurses (the "best people" to "incompetent and cruel") is characteristic of **splitting**, a common defense mechanism in borderline personality disorder, and the self-inflicted lacerations indicate **self-harm**, another hallmark feature.
*Histrionic personality disorder*
- Characterized by **excessive emotionality** and **attention-seeking behavior**, often through dramatic and sexually provocative means.
- While there may be some superficial overlap in relationship instability, the primary symptoms of splitting, impulsivity (shopping), and self-harm are less prominent here than in borderline personality disorder.
*Major depressive disorder (MDD)*
- While the patient exhibits **depression and suicidal ideation**, MDD typically involves core symptoms like persistent sadness, anhedonia, and changes in appetite, sleep, and energy, which the patient denies ("denies any changes in appetite, energy level, or concentration").
- The long-standing pattern of chaotic relationships, impulsivity, and splitting points away from MDD as the primary diagnosis, suggesting a more pervasive personality difficulty.
*Bipolar I disorder*
- This disorder is characterized by distinct periods of **mania or hypomania** alternating with depressive episodes.
- While impulsivity can be seen in hypomanic/manic states, the patient's symptoms are described as persistent emotional instability and chaotic relationships present for five years, rather than episodic changes in mood and energy, and she denies changes in appetite or energy.
*Factitious disorder*
- Involves **falsification of physical or psychological signs or symptoms**, or induction of injury or disease, associated with identified deception, to assume the sick role.
- Although the patient has self-inflicted lacerations, this behavior is more consistent with **self-harm** seen in borderline personality disorder as a coping mechanism for emotional distress, rather than a deliberate attempt to deceive medical professionals for secondary gain.
Question 93: A 14-year-old boy is brought to a child psychiatry office by his father, who is concerned about his grades and teachers’ comments that he has “problems focusing.” He has a B- average. The boy's teachers in math, social studies, and English say that he often appears to not be listening in class, instead talking to classmates, making jokes, and blurting out incorrect answers. He typically turns in his homework late or not at all. During other classes (band and science, which he enjoys), none of these behaviors are observed. At home, he enjoys playing chess and reads comic and fiction books for hours without pause. His father describes him as calm and organized at home. Formal testing reveals an intelligence quotient (IQ) of 102. Which of the following is the most likely explanation for this patient’s grades?
A. Mood disorder
B. Attention deficit hyperactivity disorder (ADHD)
C. Absence seizures
D. Intellectual disability
E. Specific Learning Disorder (Correct Answer)
Explanation: ***Specific Learning Disorder***
- This patient demonstrates **selective academic difficulties** in math, social studies, and English, while performing well in band and science (subjects he enjoys).
- The key feature is that his problems are **context-dependent and motivation-based** rather than representing a true learning disorder, but among the given options, this is the most fitting explanation for his grades.
- His **normal IQ (102)** and ability to focus for extended periods on preferred activities (chess, reading) suggest this is more likely **underachievement due to lack of interest** rather than a true pathological condition.
- True specific learning disorders typically show persistent difficulties in specific academic skills regardless of interest level, making this diagnosis imperfect but the best option available.
*Intellectual disability*
- A diagnosis of intellectual disability requires an **IQ below 70-75**, which is not present here as the patient's IQ is 102 (normal range).
- Additionally, significant deficits in **adaptive functioning across multiple domains** (conceptual, social, practical) during the developmental period are necessary for diagnosis.
- This patient shows **normal functioning at home** and in preferred activities, ruling out intellectual disability.
*Mood disorder*
- While mood disorders can affect concentration and academic performance, the patient's **selective inattentiveness** (present only in certain classes) and ability to focus for hours on enjoyable activities make this unlikely.
- There are **no reported symptoms** of depression (persistent sadness, anhedonia, sleep/appetite changes) or mania (elevated mood, grandiosity, decreased need for sleep).
*Attention deficit hyperactivity disorder (ADHD)*
- ADHD symptoms are typically **pervasive across settings** and are not dependent on whether the activity is enjoyable.
- The patient's ability to **focus for hours on chess and reading**, and his calm, organized behavior at home, **contradict the diagnostic criteria** for ADHD.
- ADHD requires significant impairment in multiple domains, which is not observed here.
*Absence seizures*
- Absence seizures are characterized by **brief episodes of staring spells** with impaired consciousness, typically lasting only seconds.
- These episodes involve **sudden cessation of activity** and are **not associated with purposeful behaviors** like talking to classmates, making jokes, or blurting out answers.
Question 94: An 18-year-old male is seen for a routine physical prior to starting college. He will be moving from Ohio to California, away from his family for the first time. His temperature is 36.8 deg C (98.2 deg F), pulse is 74/min, and blood pressure is 122/68 mmHg. BMI is 24. On questioning, he reveals that he has a habit of binge eating during times of stress, particularly during exams. He then feels guilty about his behavior and attempts to compensate by going to the gym, sometimes for 4+ hours per day. He is disturbed by this behavior and feels out of control. He denies ever vomiting as a means of losing weight. What is the most likely diagnosis?
A. Normal behavior variant
B. Hypomania
C. Body dysmorphic disorder
D. Anorexia nervosa
E. Bulimia nervosa (Correct Answer)
Explanation: ***Bulimia nervosa***
- This patient exhibits characteristic symptoms of **bulimia nervosa**, including recurrent episodes of **binge eating** followed by inappropriate compensatory behaviors (excessive exercise) to prevent weight gain.
- While he denies vomiting, other compensatory behaviors like **excessive exercise** are common and validate the diagnosis, coupled with feelings of lack of control and guilt.
*Normal behavior variant*
- The described pattern of recurrent binge eating, lack of control, and extreme compensatory behaviors is **not within the range of normal eating behavior** or coping mechanisms.
- The distress and impairment associated with these behaviors differentiate it from typical stress-related eating patterns.
*Hypomania*
- **Hypomania** involves elevated mood, increased energy, decreased need for sleep, and impulsivity, but it does not typically involve specific patterns of binge eating and compensatory behaviors.
- The patient's reported distress about his eating habits also contradicts the usually euphoric or irritable mood seen in hypomania.
*Body dysmorphic disorder*
- **Body dysmorphic disorder** is characterized by preoccupation with perceived flaws in physical appearance, leading to repetitive behaviors like mirror checking or excessive grooming.
- While body image concerns can co-occur with eating disorders, the primary issue described here is the cycle of binge eating and compensatory behaviors, not preoccupation with a specific physical defect.
*Anorexia nervosa*
- **Anorexia nervosa** is characterized by a significant **restriction of energy intake** leading to a significantly low body weight, intense fear of gaining weight, and disturbance in the way one's body weight or shape is experienced.
- This patient's **BMI is normal**, and he does not show evidence of being underweight, which is a core diagnostic criterion for anorexia nervosa.
Question 95: A 78-year-old man is brought to the physician by his daughter for a follow-up examination. The daughter noticed that he has gradually become more forgetful and withdrawn over the last year. He frequently misplaces his car keys and forgets the names of his neighbors, whom he has known for 30 years. He has difficulty recalling his address and telephone number. He recently had an episode of urinary and fecal incontinence. Last week, his neighbor found him wandering the parking lot of the grocery store. He has hypertension and hyperlipidemia. He had smoked one pack of cigarettes daily for 40 years but quit 18 years ago. His current medications include hydrochlorothiazide and atorvastatin. He appears healthy; BMI is 23 kg/m2. His temperature is 37.2°C (99.0°F), pulse is 86/min, respirations are 14/min, and blood pressure is 136/84 mm Hg. Mini-mental state examination score is 19/30. He is not bothered by his forgetfulness. Cranial nerves II–XII are intact. He has 5/5 strength and full sensation to light touch in all extremities. His patellar, Achilles, and biceps reflexes are 2+ bilaterally. His gait is steady. MRI scan of the brain shows ventriculomegaly and prominent cerebral sulci. Which of the following is the most appropriate pharmacotherapy?
A. Acetazolamide
B. Sertraline
C. Memantine
D. Thiamine
E. Donepezil (Correct Answer)
Explanation: ***Donepezil***
- The patient exhibits features consistent with **Alzheimer's disease**, including gradual memory loss, difficulty with daily tasks, episodes of incontinence, and a Mini-Mental State Examination (MMSE) score of 19/30. Donepezil, a **cholinesterase inhibitor**, is a first-line treatment for mild to moderate Alzheimer's to slow cognitive decline.
- The MRI findings of **ventriculomegaly and prominent cerebral sulci** are consistent with general cerebral atrophy often seen in Alzheimer's disease, not hydrocephalus requiring shunting or other specific brain pathologies (normal pressure hydrocephalus would have gait disturbance as a prominent feature, which is absent here).
*Acetazolamide*
- **Acetazolamide** is a **carbonic anhydrase inhibitor** used to treat conditions like glaucoma, altitude sickness, and idiopathic intracranial hypertension.
- There is no indication of elevated intracranial pressure or hydrocephalus that would warrant the use of acetazolamide in this patient.
*Sertraline*
- **Sertraline** is a **selective serotonin reuptake inhibitor (SSRI)** primarily used to treat depression, anxiety disorders, and obsessive-compulsive disorder.
- While depression can coexist with dementia, the primary cognitive symptoms described here are not primarily depressive; therefore, an antidepressant is not the most appropriate initial pharmacotherapy for cognitive decline.
*Memantine*
- **Memantine** is an **NMDA receptor antagonist** used in moderate to severe Alzheimer's disease, often in combination with cholinesterase inhibitors or when cholinesterase inhibitors are not tolerated.
- While appropriate for moderate to severe Alzheimer's, **cholinesterase inhibitors** are typically the initial treatment for mild to moderate stages, and the patient's MMSE score of 19/30 often falls into the mild-moderate category where donepezil is usually favored first.
*Thiamine*
- **Thiamine** (vitamin B1) supplementation is primarily used to treat **Wernicke-Korsakoff syndrome**, which is associated with chronic alcohol abuse and presents with ataxia, ophthalmoplegia, and confusion, none of which are the primary presenting symptoms here.
- There is no evidence of **nutritional deficiency** or alcohol abuse in this patient to suggest thiamine deficiency as the cause of his cognitive decline.
Question 96: A 31-year-old male comedian presents to your mental health clinic for a psychotherapy appointment. He is undergoing psychodynamic psychotherapy for depressive symptoms. During the therapy session, you discuss his job as a successful comedian and identify ways that he channels his emotions about his abusive childhood into comedy routines. Though he enjoys his job overall and idolizes some of his coworkers, he complains about most of them being "totally incompetent." When you attempt to shift the discussion back to his childhood, he avoids eye contact and he tells you he "doesn't want to talk about it anymore." Which of the following is a primitive defense mechanism exhibited by this patient?
A. Humor
B. Denial
C. Suppression
D. Splitting (Correct Answer)
E. Reaction formation
Explanation: ***Splitting***
- The patient exhibits **splitting** by describing coworkers as "totally incompetent" while simultaneously idealizing others, demonstrating an inability to integrate positive and negative qualities of himself or others.
- This defense mechanism leads to black-and-white thinking, where individuals or situations are perceived as either all good or all bad.
*Humor*
- **Humor** is typically considered a mature defense mechanism used to express uncomfortable feelings or thoughts in a socially acceptable way, as seen with his comedy routines.
- While he channels emotions into comedy, this specific act of avoiding deep discussion and categorizing coworkers is not humor.
*Denial*
- **Denial** involves refusing to acknowledge a painful reality, which isn't explicitly demonstrated by his statement "doesn't want to talk about it anymore" regarding his childhood, but rather an avoidance of the topic itself.
- Although he avoids the topic, it does not mean he denies the reality of his childhood.
*Suppression*
- **Suppression** is a conscious decision to delay paying attention to an emotion or need, which differs from his outright refusal to discuss his childhood further.
- He explicitly states he "doesn't want to talk about it anymore," indicating a more forceful push away than merely postponing.
*Reaction formation*
- **Reaction formation** involves transforming an unacceptable impulse or feeling into its opposite, which is not evident in his complaints about incompetent coworkers or avoidance of discussing his childhood.
- There is no indication that his complaints or avoidance are actually masked versions of opposite feelings or thoughts.
Question 97: A 61-year-old woman presents to her primary care doctor with her son who reports that his mother is not acting like herself. She has gotten lost while driving several times in the past 2 months and appears to be talking to herself frequently. Of note, the patient’s husband died from a stroke 4 months ago. The patient reports feeling sad and guilty for causing so much trouble for her son. Her appetite has decreased since her husband died. On examination, she is oriented to person, place, and time. She is inattentive, and her speech is disorganized. She shakes her hand throughout the exam without realizing it. Her gait is slow and appears unstable. This patient’s condition would most likely benefit from which of the following medications?
A. Bromocriptine
B. Rivastigmine (Correct Answer)
C. Reserpine
D. Selegiline
E. Levodopa
Explanation: ***Rivastigmine***
- The patient's symptoms of progressive cognitive decline (getting lost while driving, talking to herself), inattention, disorganized speech, and motor symptoms (hand tremor, unstable gait) suggest **Dementia with Lewy Bodies (DLB)**.
- Key features supporting DLB over depression with pseudodementia: **involuntary hand tremor**, **unstable gait**, **visual hallucinations** (talking to herself), and **disorganized speech** occurring with cognitive decline.
- **Rivastigmine**, a cholinesterase inhibitor, is a first-line treatment for the cognitive and behavioral symptoms in DLB and is FDA-approved for this indication.
- While bereavement-related depression is present, the prominent motor and cognitive features indicate an underlying neurodegenerative process.
*Bromocriptine*
- This is a **dopamine agonist** typically used for Parkinson's disease, hyperprolactinemia, and acromegaly.
- While Parkinsonian features are present in DLB, dopamine agonists can worsen **psychotic symptoms** (hallucinations) common in DLB, making them unsuitable as first-line treatment.
*Reserpine*
- **Reserpine** depletes catecholamines and serotonin and is primarily used as an antihypertensive.
- Its use in dementia is not indicated and could exacerbate mood, cognitive issues, and Parkinsonian symptoms due to its dopamine-depleting effects.
- This medication is rarely used in modern practice.
*Selegiline*
- **Selegiline** is a **monoamine oxidase-B (MAO-B) inhibitor** used in Parkinson's disease to reduce dopamine breakdown.
- While it may help with motor symptoms, its benefit in DLB is less established compared to cholinesterase inhibitors.
- The prominent **cognitive and behavioral symptoms** in this patient make cholinesterase inhibition the priority.
*Levodopa*
- **Levodopa** is a dopamine precursor and the most effective medication for motor symptoms of Parkinson's disease.
- In DLB, while it can improve motor symptoms, it can significantly worsen **psychotic symptoms** (hallucinations, delusions) and cognitive fluctuations.
- Given the prominent non-motor symptoms and existing hallucinations, levodopa is not first-line therapy for this patient.
Question 98: A 15-year-old girl is brought into her pediatrician's office by her mother because the mother thinks her daughter has attention issues. The mother explains that her daughter started high school four months ago and had lackluster grades in a recent progress report despite having earned consistent top marks in middle school. The mother complains that her daughter never talks to her at home anymore. The patient yells at her mother in the exam room, and the mother is escorted out of the room. The patient scoffs that her mother is so overbearing, ruining her good days with criticism. She begins to chew gum and states that she hates hanging out with the girls on the cheerleading squad. She denies experiencing physical abuse from anyone or having a sexual partner. She has seen kids smoke marijuana underneath the football field bleachers, but does not go near them and denies smoking cigarettes. She denies any intention to harm herself or others, thinks her grades went down because her teachers are not as good as her middle school teachers, and states she thinks she learns best by watching explanations through online videos. What is the most likely diagnosis?
A. Attention deficit hyperactivity disorder
B. Conduct disorder
C. Oppositional defiant disorder
D. Antisocial personality disorder
E. Normal behavior (Correct Answer)
Explanation: ***Normal behavior***
- The patient exhibits behaviors typical of **adolescent development**, including increased desire for independence, conflicts with parents, and shifting social interests.
- While academic performance has declined, her explanation about learning preferences and criticisms of school staff is consistent with a normal rebellious phase and does not indicate a mental health disorder.
*Attention deficit hyperactivity disorder*
- ADHD is characterized by persistent patterns of **inattention**, **hyperactivity**, and **impulsivity** that interfere with functioning or development.
- The patient's explanation for poor grades and lack of other ADHD symptoms makes this diagnosis less likely; her academic decline is recent and attributed to external factors.
*Conduct disorder*
- Conduct disorder involves a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, such as **aggression to people and animals**, **destruction of property**, **deceitfulness or theft**, or **serious violation of rules**.
- The patient's behaviors, while defiant, do not meet criteria for significant rule-breaking, aggression, or deceit.
*Oppositional defiant disorder*
- This disorder involves a pattern of **angry/irritable mood**, **argumentative/defiant behavior**, or **vindictiveness** lasting at least 6 months, often directed at an authority figure.
- While the patient shows some defiant behavior towards her mother, it is limited to this particular interaction, and not a pervasive pattern that meets the frequency and severity for ODD, especially considering her age and developmental stage.
*Antisocial personality disorder*
- Antisocial personality disorder cannot be diagnosed before age 18 and requires a history of **conduct disorder** symptoms before age 15.
- The patient does not display the pervasive disregard for the rights of others, deceit, or criminal behavior characteristic of antisocial personality disorder.
Question 99: A 55-year-old man is brought to the physician because of inappropriate behavior for the past 6 months. He has been making inappropriate comments and jokes while talking to friends and family members. He was arrested 3 weeks ago while trying to kiss strangers on the street. He has no interest in talking to his daughter or playing with his grandchildren. During this period, he has developed a strong desire for chocolate pudding and potato chips and has gained 10 kg (22 lb). He appears unkempt. Vital signs are within normal limits. Physical examination is unremarkable. Mental status examination shows apathy and a blunt affect. He avoids answering questions and instead comments on the individuals he saw in the waiting room. Mini-Mental State Examination score is 28/30. A complete blood count and serum concentrations of glucose, creatinine, and electrolytes are within the reference range. Which of the following is the most likely diagnosis?
A. Parkinson disease
B. Normal pressure hydrocephalus
C. Amyotrophic lateral sclerosis
D. Wilson disease
E. Frontotemporal dementia (Correct Answer)
Explanation: ***Frontotemporal dementia***
- This patient's presentation with **inappropriate behavior**, **disinhibition**, **apathy**, **dietary changes** (sweet cravings, weight gain), and **lack of insight** are classic features of the **behavioral variant of frontotemporal dementia (bvFTD)**.
- The **Mini-Mental State Examination (MMSE) score of 28/30** indicates relatively preserved memory and visuospatial skills, which is typical in early bvFTD as cognitive deficits often appear later.
*Parkinson disease*
- While Parkinson's can present with **cognitive and behavioral changes** in later stages (Parkinson's disease dementia), the *initial* presentation is typically dominated by **motor symptoms** such as **bradykinesia, tremor, and rigidity**, which are absent here.
- The prominent behavioral disinhibition and early dietary changes are less characteristic of Parkinson's disease.
*Normal pressure hydrocephalus*
- Characterized by the classic triad of **gait disturbance**, **urinary incontinence**, and **dementia (subcortical)**.
- While some behavioral changes can occur, the prominent disinhibition, hyperorality, and specific dietary cravings seen here are not typical primary symptoms.
*Amyotrophic lateral sclerosis*
- This is a **motor neuron disease** characterized by progressive **muscle weakness, atrophy, and fasciculations**, affecting both upper and lower motor neurons.
- While approximately 15% of ALS patients can develop FTD, the primary presentation is invariably motor, and there are no motor symptoms described in this patient.
*Wilson disease*
- A **rare genetic disorder** leading to **copper accumulation**, affecting the **liver** and **brain**.
- Presents with a combination of **hepatic symptoms** (e.g., cirrhosis), **neurological symptoms** (e.g., tremor, dystonia, dysarthria), and **psychiatric symptoms** (e.g., depression, psychosis), often with **Kayser-Fleischer rings** in the cornea. The patient has none of these characteristic findings.
Question 100: A 15-year-old girl presents to her primary care physician, accompanied by her mother, for 4 days of abdominal pain. She describes the pain as diffuse, dull, and constant. She also endorses constipation over this time. The patient's mother says the patient has become increasingly self-conscious of her appearance since starting high school this year and has increasingly isolated herself to her room, rarely spending time with or eating meals with the rest of the family. Her temperature is 98.0°F (36.7°C), blood pressure is 100/70 mmHg, pulse is 55/min, and respirations are 19/min. Body mass index (BMI) is at the 4th percentile for age and gender. Physical exam reveals dental caries, mild abdominal distension, and diffuse, fine body hair. Basic labs are most likely to reveal which of the following?
A. Hyperkalemia
B. Hyperphosphatemia
C. Hypocalcemia
D. Hypokalemia (Correct Answer)
E. Hypercalcemia
Explanation: ***Hypokalemia***
- The patient's clinical presentation, including low BMI, dental caries, abdominal pain, constipation, diffuse fine body hair (**lanugo**), and **bradycardia**, is highly suggestive of **anorexia nervosa** with possible **bulimic features** (dental caries suggest purging).
- **Hypokalemia** is a common electrolyte abnormality in patients with bulimia nervosa or anorexia nervosa with purging behaviors due to **vomiting** (loss of gastric acid and subsequent renal potassium wasting) or **laxative abuse**.
*Hyperkalemia*
- **Hyperkalemia** is unlikely given the history of suspected purging behavior (vomiting/laxative abuse), which typically leads to potassium loss.
- While some conditions affecting renal function can cause hyperkalemia, there is no information to suggest such issues in this patient.
*Hyperphosphatemia*
- **Hyperphosphatemia** is not a typical finding in eating disorders; rather, **hypophosphatemia** can occur, especially during refeeding syndrome.
- There are no clinical signs or symptoms in this patient's presentation that would suggest hyperphosphatemia.
*Hypocalcemia*
- **Hypocalcemia** is not a primary or common electrolyte disturbance directly related to the purging behaviors seen in anorexia or bulimia nervosa.
- While chronic malnutrition might affect calcium balance over time, it's not the most immediate or characteristic electrolyte imbalance in this acute presentation.
*Hypercalcemia*
- **Hypercalcemia** is rare in eating disorders and is usually associated with conditions like **hyperparathyroidism** or certain malignancies, which are not indicated here.
- There are no symptoms presented that would point towards this electrolyte imbalance.
