NBME 3 - Latest 2023/2024

NBME 3 - Latest 2023/2024 Previously healthy 23yo M brought to ER by friends 20 minutes after bizzare behavior at a party. He became paranoid, started threatening his friends. He has a temp of 100.9, agitation, diaphoresis, horizontal nystagmus, and occasional myoclonus. Has dysarthric speech and combativeness. His thoughts are disorganized and he is unable to give a coherent history. He believes that the physician is trying to kill him. 30 mins later, he becomes somnolent. Administration of naloxone does not help. What is the most likely diagnosis? -- PCP intoxication. Key words here - horizontal nystagmus, combativeness, was at a party 42 yo F, G1P1, has a 5 month hx of increasingly severe episodes of lower abdominal pain. Pain is worse during bowel movements, sex, and menses. Treatment with several analgesics has not helped. Had a laparoscopy 4 years ago and a second laparoscopy 2 years ago showed nothing abnormal. She is sexually active with 1 male and they use condoms. She is a single parent and lost her job 6 months ago. Now has difficulty sleeping because she worries about finding a job. Abdominal exam shows tenderness in both lower quadrants, pelvic exam shows nontender uterus and adnexa. A CBC, ESR, pap smear, urine, and cervical cultures are all normal. Next step to determine cause of pain? -- Psychiatric assessment. Can't find a medical cause for her pain, she lost her job and is stressed out about that. 87 yo M admitted for dehydration and emaciation. He is catatonic and unresponsive to questions. 1 month ago, he began withdrawing from relatives and talking constantly about death. He gradually stopped eating and drinking and has had a 9 kg weight loss during this time. He has a 35 year hx of MDD and has attempted suicide twice. He has no chronic medical conditions and currently takes no meds. He appears cachectic and is staring into space. He does not respond to verbal stimuli. BMI is 18. Exam shows temporal wasting. Which is the most appropriate next step in management? -- ECT. He won't eat or drink, so oral meds are not feasible. He has a really long history of depression, ECT is used for severe and refractory cases. 67 yo F whose husband died 18 months ago, is admitted to the hospital because of severe headaches for 4 weeks. She is quiet and seems sad. She believes that she has brain cancer, deserves to be punished for her sins, and is being punished by God for past misdeeds. She has had fatigue and a 15 lb weight loss over the past 4 months. Physical and neurologic exam shows nothing abnormal. Most likely diagnosis? -- Major Depressive Disorder. Has a lot of guilt, weight loss over the past 4 months. "seems sad," - depressed mood which is one of the required symptoms 27 yo M is brought to the ER 30 mins after his brother found him agitated, tremulous, and complaining of a headache. He had eaten a peanut butter sandwich 12 hours before symptoms began. He has a 10 yr hx of severe MDD. During this period, he has attempted suicide 3 times despite tx with both SSRIs and TCAs. 8 days ago, he went to a new physician because of increasing despondency. This physician immediately