Psychiatry EOR practice questions

Why Trauma-focused cognitive behavioral therapy is correct

• This patient meets criteria for acute stress disorder: characteristic intrusion, negative mood, dissociative, avoidance, and arousal symptoms occurring 3 days to 1 month after exposure to a traumatic event
• First-line management is trauma-focused cognitive behavioral therapy, which reduces symptom severity and lowers the risk of progression to PTSD

Why the others are wrong

• Brief psychological debriefing session — single-session critical incident debriefing does not prevent PTSD and has been associated with worse outcomes, so it is not recommended after trauma
• Scheduled low-dose risperidone at bedtime — antipsychotics such as risperidone are not first-line treatment for acute stress disorder in a patient without psychosis or refractory severe symptoms
• Supportive counseling with sleep hygiene — non-trauma-focused supportive therapy lacks the exposure and cognitive restructuring components that drive symptom reduction and is less effective at preventing progression to PTSD

Why Fibromyalgia is correct

• Fibromyalgia presents with widespread musculoskeletal pain, fatigue, unrefreshing sleep, and cognitive symptoms ("fibro fog") for at least 3 months with no underlying disease.
• 2016 diagnostic criteria: widespread pain index (WPI) at least 7 + symptom severity scale (SSS) at least 5, or WPI 4–6 + SSS at least 9.

Why the others are wrong

• Obstructive sleep apnea — causes unrefreshing sleep, daytime fatigue, and cognitive complaints, but it does not produce chronic widespread pain above and below the waist.
• Late Lyme disease — causes intermittent oligoarticular arthritis with objective joint swelling (most often the knee), not diffuse pain with an entirely normal joint examination.
• Chronic fatigue syndrome — defined by post-exertional malaise as the hallmark feature; the predominant symptom cluster here fits fibromyalgia.

Additional high-yield points

• Treatment: aerobic exercise has the most evidence.
• Cognitive behavioral therapy (CBT) is also first-line.
• FDA-approved pharmacotherapy: duloxetine (serotonin-norepinephrine reuptake inhibitor, SNRI), pregabalin, and milnacipran.
• Avoid opioids and NSAIDs (limited benefit, high harm).
• Sleep hygiene is an important component of management.

Why Postictal state is correct

• Postictal state is a period of confusion, drowsiness, and disorientation that follows a generalized tonic-clonic seizure
• The patient's epilepsy medical alert bracelet is a critical clue to the underlying diagnosis
• Mechanism: neuronal exhaustion, surges in inhibitory neurotransmitters (gamma-aminobutyric acid (GABA)), and transient metabolic dysfunction following excessive neuronal firing
• Duration is typically 5–30 minutes but may last hours in patients with structural epilepsy, prolonged seizures, or cumulative seizure burden
• Features include confusion, amnesia for the event, gradual recovery toward baseline, possible focal weakness (Todd paralysis) if the seizure was focal, and incontinence

Why the others are wrong

• Acute alcohol intoxication — excluded by the undetectable serum ethanol level; the epilepsy medical alert bracelet and gradual recovery toward baseline point to a postictal state instead
• First episode psychosis — typically includes hallucinations or delusions and does not explain the spontaneous gradual recovery toward baseline
• Malingering — does not explain the spontaneous gradual recovery observed over 45 minutes

Additional high-yield points

• Management: maintain airway, supportive care, check glucose, allow recovery, and evaluate for seizure trigger (missed medications, alcohol, metabolic disturbance, fever, head trauma)
• Electroencephalogram (EEG) in the postictal state may show diffuse slowing

Why Dental caries is correct

• Caries develops when cariogenic bacteria (Streptococcus mutans, Lactobacillus) ferment dietary sugars into acids that demineralize enamel
• Frequent juice exposure and poor oral hygiene are classic risk factors
• The characteristic progression is chalky white demineralized spot lesion → brown discoloration → cavitation detectable on visual and tactile probing

Why the others are wrong

• Dental fluorosis — presents with symmetric, diffuse white striations or mottling from excess fluoride during enamel development, not focal cavitation
• Enamel hypoplasia — a developmental defect producing pits or grooves in enamel, typically symmetric and present from eruption, without active demineralization
• Pulpitis — would cause spontaneous or thermal pain and is a complication of untreated caries reaching the pulp, not the initial clinical finding here

Additional high-yield points

• Definitive diagnosis is made by clinical inspection with probing; bitewing radiographs assess depth
• Management: referral to dentistry for restoration and caries-prevention counseling

Why Explain the reporting duty and submit the required protective-services report is correct

• The clinician practices under a state mandated-reporting statute, and examination plus collateral information establish reasonable suspicion, the threshold that triggers a report.
• The clinician should explain the confidentiality limit and report through the required channel while continuing supportive care and safety planning.
• National Institute on Aging Elder Abuse guidance (2023) notes reporting obligations and that clinicians do not need to personally prove abuse before an investigation.

Why the others are wrong

• Promise secrecy and defer reporting until the patient authorizes the disclosure - Ordinary confidentiality does not override the mandated-reporting duty that applies in this case.
• Delay reporting until the clinician independently proves each allegation of mistreatment - The reporting threshold is reasonable suspicion, not proof. Investigation is the responsibility of the designated authorities.
• Notify his primary care clinician and ask them to follow up on the allegations - Handing the concern to another clinician generally does not satisfy a mandated reporter's own duty. The report must go to adult protective services or the designated agency; informing the primary care clinician can supplement it but not replace it.
• Refer him to a legal-aid attorney and document the allegations in detail - Legal help and careful documentation are useful supports, but neither is the report the statute requires. Protective services must still be notified so the neglect and exploitation can be investigated.

Additional high-yield points

• Reporting requirements vary by jurisdiction and by the patient's circumstances.
• Explain next steps transparently and document objective findings and the patient's statements.
• HIPAA permits disclosures about victims of abuse or neglect to the authority designated by law to receive such reports (45 CFR 164.512(c)).

Why Repeat fasting early-morning total testosterone is correct

• Testosterone varies with time of day and other physiologic factors. A low afternoon result should be reassessed with an accurate fasting morning measurement and appropriate confirmation of consistently low values.
• The Endocrine Society 2018 guideline requires compatible symptoms plus unequivocally and consistently low testosterone, and recommends repeat morning fasting testing.

Why the others are wrong

• Serum luteinizing and follicle-stimulating hormones - Gonadotropins distinguish primary from secondary hypogonadism, but they are interpreted after low testosterone is confirmed on repeat morning testing; they cannot establish deficiency from a single afternoon value.
• Pituitary magnetic resonance imaging with contrast - Pituitary imaging can be indicated after biochemical classification and additional findings, but is premature before confirming a low morning concentration.
• Overnight penile tumescence monitoring in a laboratory - Tumescence testing concerns erectile physiology and does not confirm the hormonal explanation for reduced desire.
• Serum prostate-specific antigen measured today - Prostate-specific antigen may enter a later treatment discussion; it does not diagnose testosterone deficiency.

Additional high-yield points

• If the morning result is low, establish persistence before labeling hypogonadism; do not treat this afternoon sample as two confirmed morning results.
• Luteinizing hormone and follicle-stimulating hormone help classify primary versus secondary hypogonadism after deficiency is established.