USMLE

1. A 35-year-old homeless and unemployed man comes into the
emergency department, stating he needs to be in the hospital. He is
very vague and makes poor eye contact. He reports being "suicidal,
homicidal, and paranoid."When the psychiatrist insists on more details
about the symptoms, he gets irritable and threatens that if he leaves the
hospital and kills somebody, the doctor will be blamed. He admits to
using marijuana, crack, and cocaine occasionally, but not recently. His
physical examination is unremarkable. During his interview, his
associations are tight, and there is no evidence of psychotic symptoms.
A urine drug screen is negative. Which of the following conditions
should probably be ruled out first?






A. Delusional disorder
B. Factitious disorder
C. Malingering
D. Schizophrenia
E. Substance-induced mood disorder





The correct answer is C. Malingering is diagnosed when there is a
voluntary production of physical or psychological symptoms to
accomplish a specific goal. Patients are usually vague or have
poorly localized complaints. They are easily irritated if a doctor is
skeptical of the history.
Delusional disorder (choice A) is characterized by one fixed and
unshakable delusion. The delusion is non-bizarre and has to be
present at least a month. Apart from the impact of the delusion,
the functioning is not markedly impaired in other areas of life.
Factitious disorder (choice B) is diagnosed when there is a
deliberate production of symptoms to attain the sick role and meet
unconscious needs. It can be present with physical or
psychological symptoms and is associated with early parental
abuse or rejection.
Schizophrenia (choice D) is defined by the presence of active
symptoms of delusions, hallucinations, and disorganized speech
or behavior in the past month.The continuous signs must be
present longer than 6 months and cause significant impairment in
social or occupational functioning.
Substance-induced mood disorder (choice E) refers to the mood
induced shortly after the use of substances.Depending on the type
of substance, the mood can be depressed or elated.

2. 35-year-old patient is given a battery of
neuropsychological tests. He scores 85 on the
Wechsler Adult Intelligence Scale (WAIS) Verbal
IQ, 135 on the Performance IQ test, and 125 on
the Wechsler Memory Scale test. Which of the
following is the most likely site of his brain
dysfunction?






A. Bilateral frontal lobes
B. Bilateral hippocampal gyri
C. Bilateral occipital lobes
D. Left hemisphere
E. Right hemisphere






The correct answer is D. The pattern presented suggests this
person is having difficulties with verbal material (WAIS
verbal IQ of 85) but not with visual-spatial tasks
(performance IQ) or memory (Wechsler memory scale).Since
the left hemisphere is dominant for speech and verbal
material in the majority of individuals, the lesion is most
likely in the left hemisphere.
Choice A is incorrect since the frontal lobes control socially
appropriate behavior, sequencing, and future planning.
There is no indication that these are deficient in this person.
Since memory is intact, a lesion in the bilateral hippocampal
gyri (choice B) is unlikely.
Bilateral occipital lesions (choice C) would produce
problems with visual recognition, which are not apparent in
this person.
The right hemisphere (choice E) is related to control of
visual-spatial functions (e.g., map reading, locating oneself
in space, etc.), rather than verbal ability.

3. A 67-year-old woman who has been in very good health is
brought to her physician's office by her husband. He states that
over the course of the last 5 years she has had difficulty
recognizing her grandchildren, he must do all the planning for
their daily activities, she forgets that she has things cooking on
the stove, and at night he sometimes finds her wandering
through the house with an "absent" look on her face. She is
beginning to demonstrate difficulty in recalling the names of
common objects, and her speech is limited to simple two- or
three-word sentences. Which of the following is the most likely
diagnosis?






A. Alzheimer's disease
B. Amnestic disorder
C. Pseudodementia
D. Substance-induced persisting dementia
E. Vascular dementia





The correct answer is A. This woman is suffering from dementia
of the Alzheimer's type. A gradual onset of symptoms, general
pervasive memory deficit, difficulties with language, and inability
to plan, leading to severe impairment of daily functioning are all
characteristic of dementia of the Alzheimer's type.
Amnestic disorder (choice B) is limited to memory problems and
this woman is demonstrating cognitive dysfunction, such as
alterations in language and the loss of the ability to plan.
Pseudodementia (choice C) is incorrect since it is a major
depressive disorder rather than a dementing condition. There is
no evidence for a depressive syndrome in this patient's
presentation.
The diagnosis of substance-induced persisting dementia (choice
D) requires evidence of a history of substance abuse. However, it
is the second most likely diagnosis and should be carefully
explored with the husband and other close relatives and friends.
Vascular dementia (choice E) is generally characterized by a stepwise deterioration, not the gradual presentation of this case.

4. A patient complains to her family physician that "When
it's time to go to work, I just can't seem to get out of the
house. I have a lot of windows, and I need to check them
all three times. Then, I can never be sure the door is
locked, so I check it 3 times. I've been late for work a few
times, but this is the only way I can be sure the house is
safe. Sometimes I think I'm going to go crazy." Which of
the following is the most likely diagnosis?






A. Adjustment disorder with anxiety
B. Agoraphobia without history of panic disorder
C. Generalized anxiety disorder
D. Obsessive compulsive disorder
E. Panic disorder with agoraphobia





The correct answer is D. This patient expresses feelings of
anxiety which are only relieved by compulsive ritual
behavior (checking the doors and windows excessively).
Adjustment disorder with anxiety (choice A) generally
occurs in response to an identifiable stressor.
Agoraphobia without a history of panic disorder (choice B)
is characterized by a fear of all large enclosed or open spaces
when alone.
In generalized anxiety disorder (choice C), excessive worry
or anxiety is present most of the time the person is awake,
not just in a specific situation.
In panic disorder with agoraphobia (choice E), panic attacks
occur in uncued situations. This patient's symptoms appear
consistently when she leaves for work in the morning.

5. A 47-year-old man comes to the physician 1 year after his wife
died in an automobile accident. Ever since the accident, he has
had feelings of worthlessness, self-blame, insomnia, and
fatigue. He does not go out with friends and never goes to
football games anymore, formerly his favorite pastime. He is
"sad all the time," has lost 15 pounds, frequently spends nights
and weekends crying on the couch, and finds it difficult to
move. Sometimes he cannot even get up to go to work. He says
that his symptoms have been worsening over time. He is not so
sure that wants to "be around" without his wife anymore. Which
of the following is the most likely diagnosis?






A. Conversion disorder
B. Dysthymic disorder
C. Major depressive disorder
D. Normal grief
E. Separation anxiety disorder


The correct answer is C. This patient most likely has major
depressive disorder. He has had depressed mood, insomnia,
fatigue, weight loss, anhedonia, psychomotor retardation, feelings
of worthlessness, and suicidal ideation for a year. These
symptoms are causing severe distress and functional impairment.
They are severe enough to meet the criteria for a major depressive
episode and are not better accounted for by normal grief and
bereavement. Normal grief (choice D) is usually characterized by a
depressed mood, feelings of loss, crying spells, and decreased
enjoyment in life. Dysfunction may occur, however, after several
months the individual should feel less sad and become more
functional with time. Suicidal ideation, psychomotor retardation,
and marked functional impairment are consistent with depression,
and not normal grief.
Conversion disorder (choice A) is characterized by the sudden
onset of motor or sensory symptoms and dysfunction that are
without an identifiable physical cause. The symptoms are
temporally related to a psychological stressor, however the deficit
is not intentionally produced. This patient does not have motor or
sensory symptoms.

6. A 35-year-old woman consults a family practitioner because
she is worried about her health. Physical examination and
routine screening yield no significant abnormal results. On
further questioning, the patient states that she is also very
worried about her family's health, her job, her husband's job,
her car, her children's school performance, the plants in her
yard, and her pets. In no case does her level of anxiety appear
appropriate to what she states to be the factual basis of the
anxiety. When asked whether she has been worried for a long
time, she replies "ever since high school." Which of the
following is the most likely diagnosis?






A. Acute stress disorder
B. Generalized anxiety disorder
C. Panic attack
D. Panic disorder
E. Posttraumatic stress disorder



The correct answer is B. This patient has generalized anxiety
disorder. This term is reserved for patients who have had
excessive, virtually daily, anxiety about many activities and
events for more than 6 months. This condition affects 3% to
5% of the general population, and often begins in childhood
or adolescence. The condition is also characterized by
restlessness, unusual fatigability, concentration difficulties,
irritability, and difficulty sleeping. The level of anxiety is
often exhausting, and these patients may do poorly in their
environment because of difficulties with concentration and
fatigue. Behavioral therapy is usually ineffective.
Many physicians who treat these patients start them on
benzodiazepines (that act quickly) and then switch them to
buspirone (which does not cause dependency but takes
about 2 weeks to work).
Acute stress disorder (choice A) occurs within a month of a
traumatic event and lasts for 2-4 weeks.

7. A 29-year-old single man seeks psychiatric treatment to
help him deal with difficulties in his personal life.
Although the man is a successful computer programmer,
he feels unsatisfied with his interpersonal relationships.
He reports being attracted to several of his female
coworkers, but is "too shy" to talk to them about anything
other than superficial subjects such as the weather. He
would like to ask one of the women out on a date, but is
afraid of being rejected. Which of the following diagnoses
is most appropriate?






A. Avoidant personality disorder
B. Borderline personality disorder
C. Dependent personality disorder
D. Narcissistic personality disorder
E. Schizotypal personality disorder





The correct answer is A. The man described is probably suffering
from avoidant personality disorder, characterized by feelings of
inadequacy and extreme sensitivity to criticism, leading to social
inhibition and withdrawal. These individuals often avoid
interpersonal relationships entirely rather than subject themselves
to the potential risk of criticism or rejection, although they may
yearn for a more satisfying personal life.
Borderline personality disorder (choice B) is characterized by
unstable interpersonal relationships, instability of affect,
impulsivity, feelings of emptiness or anger and, in some cases,
paranoid or dissociative symptoms.
Dependent personality disorder (choice C) is characterized by the
need for constant support and reassurance, with unrealistic
anxieties over being forced to fend for oneself.
Narcissistic personality disorder (choice D) is characterized by
excessive grandiosity and an exaggerated sense of selfimportance, accompanied by a feeling of entitlement and a need
for attention or admiration.
Schizotypal personality disorder (choice E) is characterized by
eccentricities of behavior, odd beliefs or magical thinking, and
difficulties with social and interpersonal relationships.

8.A 43-year-old physicist consults a physician about his heart.
The man brings along a folder containing a literature search he
has done on the Internet on atherosclerosis. He is very pleased
when the physician complements him on the material he has
collected. The physician then examines the man and identifies
no significant abnormalities that suggest the presence of
ischemic disease. The physician tells the man that he will be
ordering a few blood tests to evaluate lipid status. The patient
challenges the physician's selection of tests as being "not the
best available" and offends the physician by implying that he
does not know what he is doing. The physician replies mildly
that he personally finds these particular tests quite helpful. The
physicist then appears crushed by what he interprets as
criticism. Which of the following is the most likely diagnosis?







A. Antisocial personality disorder
B. Narcissistic personality disorder
C. Obsessive-compulsive personality disorder
D. Paranoid personality disorder
E. Passive-aggressive personality disorder





The correct answer is B. Narcissistic personality disorder is characterized
by an exaggerated sense of self-importance. These individuals have a
strong need to be admired and are often extremely sensitive to criticism,
failure, or defeat. They may be perceived as obnoxious by medical staff,
as they often project an impression of entitlement because they believe
that satisfaction of their needs is more important than satisfaction of other
people's needs. Although many of these people are, in fact, high
achievers, persons with few accomplishments may also share these
personality traits.
Individuals with antisocial personality disorder (choice A) are
characterized by exploitation of others for materialistic gain or personal
gratification. Unlike people with narcissistic personality disorder, people
with antisocial personality disorder usually do not particularly care what
others think of them.
Individuals with obsessive-compulsive personality (choice C) tend to be
conscientious but inflexible in their decisions. They tend to worry a great
deal about their decisions.
People with paranoid personality disorder (choice D) believe others are
out to harm them. They tend to be secretive in their thoughts, fearing that
others will use information against them, and they are concerned with
fidelity in intimate relations with others.
Individuals with passive-aggressive personality disorder (choice E) tend
to appear superficially agreeable, but often engage in passive behavior
that is actually designed to covertly control or punish others.

A 20 year old lady shows acute psychotic
behavior. At times she rests in a unusual &
uncomfortable body position (waxy flexibility)
What type of schizophrenia she suffers from?





Disorganized
Catatonic
Paranoid
Schizoaffective disorder
Brief psychotic disorder

Correct ans B Catatonic