NBME Psychiatry 2 — Questions and Answers
Question 1: A 34-year-old woman presents with a 2-week history of depressed mood, insomnia, anhedonia, and passive suicidal ideation. She has had two similar episodes in the past. Which medication is first-line for acute treatment?
- Lithium carbonate
- Sertraline (Correct answer)
- Haloperidol
- Clonazepam
Correct answer: Sertraline
SSRIs such as sertraline are first-line pharmacotherapy for major depressive disorder.
Question 2: A 28-year-old man is brought to the ED after being found agitated and confused. He has dilated pupils, tachycardia, diaphoresis, and clonus. Which substance is most likely responsible?
- PCP
- Cocaine
- MDMA combined with an SSRI (Correct answer)
- Methamphetamine
Correct answer: MDMA combined with an SSRI
The combination of MDMA with an SSRI can precipitate serotonin syndrome, characterized by the triad of altered mental status, autonomic instability, and neuromuscular abnormalities including clonus.
Question 3: A 45-year-old woman with schizophrenia on haloperidol develops involuntary chewing movements and tongue protrusion that persist even after dose reduction. What is the most likely diagnosis?
- Acute dystonia
- Tardive dyskinesia (Correct answer)
- Akathisia
- Neuroleptic malignant syndrome
Correct answer: Tardive dyskinesia
Tardive dyskinesia is a late-onset movement disorder caused by long-term dopamine antagonist use, classically presenting with orofacial dyskinesias.
Question 4: A 22-year-old college student reports months of persistent worry about academic performance, restlessness, muscle tension, and difficulty concentrating. Symptoms cause significant impairment. What is the most likely diagnosis?
- Panic disorder
- Social anxiety disorder
- Generalized anxiety disorder (Correct answer)
- Adjustment disorder
Correct answer: Generalized anxiety disorder
Generalized anxiety disorder is characterized by excessive, difficult-to-control worry about multiple domains lasting at least 6 months with associated somatic symptoms.
Question 5: A 55-year-old man with bipolar I disorder on lithium develops coarse tremor, polyuria, and confusion. His lithium level is 2.8 mEq/L. What is the most appropriate next step?
- Switch to valproate immediately
- Reduce lithium dose by half
- Discontinue lithium and provide supportive care (Correct answer)
- Add benzodiazepine for tremor control
Correct answer: Discontinue lithium and provide supportive care
Lithium toxicity at levels above 2.0 mEq/L requires immediate discontinuation; severe toxicity may require hemodialysis.
Question 6: A 19-year-old woman describes recurrent episodes of binge eating followed by self-induced vomiting. Exam shows parotid enlargement and dental enamel erosion. What electrolyte abnormality is most expected?
- Hypernatremia
- Hypokalemia (Correct answer)
- Hyperkalemia
- Hyperchloremia
Correct answer: Hypokalemia
Repeated purging causes loss of hydrochloric acid and potassium, leading to hypokalemic metabolic alkalosis.
Question 7: A 68-year-old man with Alzheimer dementia becomes agitated and physically aggressive toward nursing staff at night. Nonpharmacologic measures have failed. Which agent carries the lowest risk of extrapyramidal side effects?
- Haloperidol
- Quetiapine (Correct answer)
- Fluphenazine
- Chlorpromazine
Correct answer: Quetiapine
Quetiapine has very low D2 receptor affinity and is preferred in elderly or Parkinson-like patients due to minimal extrapyramidal side effects.
NBME Psychiatry 2
A 34-year-old woman presents with a 2-week history of depressed mood, insomnia, anhedonia, and passive suicidal ideation.
She has had two similar episodes in the past.
Which medication is first-line for acute treatment?