NR547 Final Exam - Advanced Integrative
Differential Diagnosis - Psychiatric-Mental Health
NP - PMHNP Certification Prep
60 items | 100 % high-fidelity complex vignettes | Lifespan emphasis
COMPLEX CASE 1 – GERIATRIC DIAGNOSTIC TRILEMMA
Vignette: 72-year-old man, HTN, mild Parkinson’s on carbidopa-levodopa, brought for
“paranoia & visual hallucinations” 2 wks after ciprofloxacin-treated UTI. Acute onset,
fluctuating course, sees “children & animals” nightly. Alert but disoriented to date.
MMSE 24/30 (recall & orientation impaired). Resting tremor & bradykinesia unchanged.
Wife denies prior psych history.
Q1
Stem: MOST urgent initial diagnostic consideration?
A. Neurocognitive Disorder Due to Lewy Body Dementia
B. Delirium due to Multiple Etiologies
C. Parkinson’s Disease Psychosis
D. Late-onset Schizophrenia
Correct: B
,Rationale (Consult Note): Step 1 – Rule-out medical emergency. Acute temporal onset +
fluctuating cognition + medical precipitants (infection, CNS-active antibiotic) = core
delirium criteria. Delirium is a medical emergency; reversal may abolish all psychiatric
symptoms. Lewy Body Dementia (A) is insidious and would not appear abruptly after
medical stress.
Q2
Stem: Delirium resolves with supportive care & medication adjustment, but complex
visual hallucinations persist without confusion. Leading hypothesis?
A. Schizophrenia
B. Persistent delirium
C. Neurocognitive Disorder with Lewy Bodies
D. Substance-Induced Psychotic Disorder
Correct: C
Rationale: Step 2 – Persistent, well-formed visual hallucinations + spontaneous
parkinsonism fulfill probable Lewy Body criteria; acute onset now excluded.
COMPLEX CASE 2 – ADULT RULE-OUT CASCADE
Vignette: 34-year-old woman, software engineer, 6-week history of “racing heart &
insomnia.” Reports 4-h nightly sleep, 10-lb weight loss, “constant worry about project
deadlines.” HR 104, BP 138/88, restless, moist palms. No prior psych history. No
medical problems. No substances. TSH 2.1, Hb 12.1, glucose 98. Mental status:
cooperative, anxious, ruminative, no perceptual disturbances. Acknowledges “maybe
stressed” but denies sadness.
,Q3
Stem: MOST urgent condition to rule out FIRST?
A. Substance-induced anxiety (caffeine/stimulants)
B. Hyperthyroidism
C. Generalized Anxiety Disorder
D. Bipolar II Disorder, hypomanic phase
Correct: A
Rationale: Step 1 – Hidden “zebra.” High-tech workers often consume
caffeine/stimulants; collateral drug screen & caffeine quantification must precede Axis-I
diagnosis. Normal TSH already rules out overt hyperthyroidism (B).
Q4
Stem: Urine tox negative, caffeine 12 mg/L (very high), patient agrees to taper caffeine
over 1 week. Repeat evaluation: still 4-h sleep, HR 100, describes “mind won’t stop,”
increased goal-directed coding activity, spending ↑, but NO psychosis. Mood “fine.”
Which primary psychiatric diagnosis is BEST supported?
A. GAD
B. Bipolar II Disorder
C. ADHD, predominantly inattentive
D. Panic Disorder
Correct: B
, Rationale: Step 2 – Even after caffeine reduction, ≥ 4-day hypomanic syndrome
(decreased need for sleep, hyperactivity, increased goal-directed behavior) plus no clear
depression history supports Bipolar II; GAD (A) does not explain decreased sleep drive.
COMPLEX CASE 3 – MASKED ADOLESCENT PRESENTATION
Vignette: 15-year-old, straight-A student, refereed by school counselor for “severe test
anxiety & hair-pulling.” Mother notes 2-cm bald patch on occiput. Teen states “I’m just
anxious.” Denies depression, no substances. Exam: patchy alopecia with broken hairs,
no inflammation. Nail biting present. Mental status: anxious, embarrassed, otherwise
euthymic.
Q5
Stem: The TRUE primary diagnosis is BEST captured by:
A. Generalized Anxiety Disorder
B. Trichotillomania (Hair-Pulling Disorder)
C. Obsessive-Compulsive Disorder
D. Body Dysmorphic Disorder
Correct: B
Rationale: Hair-pulling is core behavior; anxiety is secondary. DSM-5-TR places
Trichotillomania under OCRD, not Anxiety Disorders.
COMPLEX CASE 4 – FORMULATION QUESTION
Differential Diagnosis - Psychiatric-Mental Health
NP - PMHNP Certification Prep
60 items | 100 % high-fidelity complex vignettes | Lifespan emphasis
COMPLEX CASE 1 – GERIATRIC DIAGNOSTIC TRILEMMA
Vignette: 72-year-old man, HTN, mild Parkinson’s on carbidopa-levodopa, brought for
“paranoia & visual hallucinations” 2 wks after ciprofloxacin-treated UTI. Acute onset,
fluctuating course, sees “children & animals” nightly. Alert but disoriented to date.
MMSE 24/30 (recall & orientation impaired). Resting tremor & bradykinesia unchanged.
Wife denies prior psych history.
Q1
Stem: MOST urgent initial diagnostic consideration?
A. Neurocognitive Disorder Due to Lewy Body Dementia
B. Delirium due to Multiple Etiologies
C. Parkinson’s Disease Psychosis
D. Late-onset Schizophrenia
Correct: B
,Rationale (Consult Note): Step 1 – Rule-out medical emergency. Acute temporal onset +
fluctuating cognition + medical precipitants (infection, CNS-active antibiotic) = core
delirium criteria. Delirium is a medical emergency; reversal may abolish all psychiatric
symptoms. Lewy Body Dementia (A) is insidious and would not appear abruptly after
medical stress.
Q2
Stem: Delirium resolves with supportive care & medication adjustment, but complex
visual hallucinations persist without confusion. Leading hypothesis?
A. Schizophrenia
B. Persistent delirium
C. Neurocognitive Disorder with Lewy Bodies
D. Substance-Induced Psychotic Disorder
Correct: C
Rationale: Step 2 – Persistent, well-formed visual hallucinations + spontaneous
parkinsonism fulfill probable Lewy Body criteria; acute onset now excluded.
COMPLEX CASE 2 – ADULT RULE-OUT CASCADE
Vignette: 34-year-old woman, software engineer, 6-week history of “racing heart &
insomnia.” Reports 4-h nightly sleep, 10-lb weight loss, “constant worry about project
deadlines.” HR 104, BP 138/88, restless, moist palms. No prior psych history. No
medical problems. No substances. TSH 2.1, Hb 12.1, glucose 98. Mental status:
cooperative, anxious, ruminative, no perceptual disturbances. Acknowledges “maybe
stressed” but denies sadness.
,Q3
Stem: MOST urgent condition to rule out FIRST?
A. Substance-induced anxiety (caffeine/stimulants)
B. Hyperthyroidism
C. Generalized Anxiety Disorder
D. Bipolar II Disorder, hypomanic phase
Correct: A
Rationale: Step 1 – Hidden “zebra.” High-tech workers often consume
caffeine/stimulants; collateral drug screen & caffeine quantification must precede Axis-I
diagnosis. Normal TSH already rules out overt hyperthyroidism (B).
Q4
Stem: Urine tox negative, caffeine 12 mg/L (very high), patient agrees to taper caffeine
over 1 week. Repeat evaluation: still 4-h sleep, HR 100, describes “mind won’t stop,”
increased goal-directed coding activity, spending ↑, but NO psychosis. Mood “fine.”
Which primary psychiatric diagnosis is BEST supported?
A. GAD
B. Bipolar II Disorder
C. ADHD, predominantly inattentive
D. Panic Disorder
Correct: B
, Rationale: Step 2 – Even after caffeine reduction, ≥ 4-day hypomanic syndrome
(decreased need for sleep, hyperactivity, increased goal-directed behavior) plus no clear
depression history supports Bipolar II; GAD (A) does not explain decreased sleep drive.
COMPLEX CASE 3 – MASKED ADOLESCENT PRESENTATION
Vignette: 15-year-old, straight-A student, refereed by school counselor for “severe test
anxiety & hair-pulling.” Mother notes 2-cm bald patch on occiput. Teen states “I’m just
anxious.” Denies depression, no substances. Exam: patchy alopecia with broken hairs,
no inflammation. Nail biting present. Mental status: anxious, embarrassed, otherwise
euthymic.
Q5
Stem: The TRUE primary diagnosis is BEST captured by:
A. Generalized Anxiety Disorder
B. Trichotillomania (Hair-Pulling Disorder)
C. Obsessive-Compulsive Disorder
D. Body Dysmorphic Disorder
Correct: B
Rationale: Hair-pulling is core behavior; anxiety is secondary. DSM-5-TR places
Trichotillomania under OCRD, not Anxiety Disorders.
COMPLEX CASE 4 – FORMULATION QUESTION
