Welcome to your 2. 🧩 Psychiatric, Behavioral & Substance Use Disorders with Anxiety and Depression Clinical Long Case Arena — 40 Integrated MCQs
1.
A 68-year-old man with acute ischemic stroke has a blood pressure of 174/96 mmHg. He is within the intravenous thrombolysis treatment window, and initial CT brain excludes hemorrhage. Which approach to blood pressure management is most appropriate?
2.
A 25-year-old man is brought to a primary healthcare centre by his family because of increasing social withdrawal and academic deterioration. He believes his neighbours are monitoring his conversations and occasionally hears voices commenting on his activities. He denies substance use. A brief depression screening questionnaire is negative. Which clinical action is most appropriate?
3.
A 41-year-old woman presents with persistent depressive symptoms, early morning awakening and reduced appetite. Further questioning reveals that she previously experienced a period of unusually elevated mood, reduced need for sleep, excessive spending and increased activity lasting approximately one week. Which clinical decision is most appropriate before prescribing an antidepressant?
4.
A 68-year-old right-handed man with hypertension and diabetes is brought to the emergency department with sudden right-sided weakness and difficulty speaking. His wife reports that he was normal at breakfast before suddenly dropping a cup. He arrived approximately 90 minutes after symptom onset. Which additional historical information is most important for immediate treatment planning?
5.
A 33-year-old woman attends a family medicine clinic complaining of severe anxiety, intermittent palpitations and difficulty sleeping. During the interview, the physician notices that she is fearful when discussing her home circumstances. On gentle questioning, she reveals repeated physical threats from her partner. Which consultation approach is most appropriate?
6.
A 69-year-old man with a recent ischemic stroke is undergoing evaluation for secondary prevention. His initial ECG demonstrates sinus rhythm, but cardiac monitoring later identifies intermittent atrial fibrillation. No intracranial hemorrhage is present. Which long-term prevention strategy should now receive particular consideration?
7.
A 32-year-old man with a history of heroin use presents with severe muscle aches, abdominal cramps, diarrhoea, lacrimation and restlessness. Examination reveals dilated pupils, sweating and tachycardia. He reports that he last used heroin approximately 24 hours earlier. Which interpretation best explains this presentation?
8.
A 71-year-old man with acute ischemic stroke receives intravenous thrombolytic treatment after appropriate assessment. Twenty minutes later, his family asks whether aspirin should be administered immediately to prevent another stroke. Which antithrombotic approach is most appropriate?
9.
A 31-year-old woman attends a family medicine clinic for recurrent anxiety. She reports frequently visiting emergency departments for chest discomfort during stressful situations. Her medical assessment does not suggest an acute cardiovascular disorder. However, she has increasing avoidance behaviour and difficulty attending work. Which approach best distinguishes effective primary care from simple reassurance?
10.
A 69-year-old man is evaluated for suspected acute ischemic stroke. He is alert, follows commands and has right-sided weakness with expressive aphasia. His Glasgow Coma Scale is documented as E4 V4 M6. Which interpretation of the GCS assessment is most appropriate?
11.
A 68-year-old man is attending follow-up after an ischemic stroke. He has hypertension, diabetes and elevated LDL cholesterol. He has completed initial rehabilitation but admits missing medications frequently. His family asks how another stroke can be prevented. Which counselling and follow-up strategy is most appropriate?
12.
A 66-year-old man presents with sudden right arm and leg weakness. Examination reveals right upper limb power of 2/5, right lower limb power of 3/5, a right extensor plantar response and non-fluent speech. The left limbs have normal power. Which interpretation of these neurological findings is most appropriate?
13.
A 54-year-old man with hypertension and type 2 diabetes attends a family medicine clinic because of reduced energy, poor concentration and persistent low mood. He recently stopped taking his antihypertensive medication and has missed several medical appointments. His physician diagnoses depression and develops a management plan. Which approach best addresses his overall healthcare needs?
14.
A 39-year-old man presents to a primary healthcare clinic with two months of low mood, loss of interest and impaired concentration. During consultation, he reports hearing a voice commanding him to harm himself. He appears distressed and admits difficulty resisting the commands. Which feature most strongly supports the need for urgent psychiatric assessment?
15.
A 68-year-old man presents 90 minutes after developing sudden right hemiparesis and expressive aphasia. His blood pressure is 174/96 mmHg, capillary blood glucose is 168 mg/dL, and NIHSS is 9. Which investigation should be prioritized to guide immediate reperfusion treatment decisions?
16.
A 72-year-old man presents with acute right-sided weakness and expressive aphasia. His NIH Stroke Scale score is 9 on admission. During observation, his right arm becomes weaker and his speech deteriorates further. Which is the most appropriate clinical use of repeat NIHSS assessment?
17.
A 44-year-old woman has experienced fatigue, diffuse body pain and intermittent gastrointestinal symptoms for two years. Appropriate clinical evaluation has not identified a disease explaining the degree of distress. She repeatedly requests investigations, remains preoccupied with serious illness and has stopped attending work. Her physician suspects somatic symptom disorder. Which finding most strongly supports this diagnosis?
18.
A 36-year-old woman presents to a primary healthcare clinic with persistent worrying, fatigue and poor sleep. She reports difficulty managing household responsibilities and has begun avoiding social activities. Examination is unremarkable. The physician plans psychological treatment and considers an SSRI because her symptoms are causing significant impairment. Which additional assessment is particularly important before initiating treatment?
19.
A 48-year-old man with a 15-year history of heavy alcohol consumption is admitted after suddenly stopping alcohol intake. On the third hospital day, he develops marked agitation, fever, profuse sweating, disorientation and visual hallucinations. His pulse is 124/min and blood pressure is 165/100 mmHg. Which management approach is most appropriate?
20.
A 70-year-old man is recovering in a stroke unit after an acute left MCA territory infarction. He suddenly develops severe headache, repeated vomiting and reduced consciousness. His right-sided weakness also worsens. Which complication must be urgently considered, particularly if he received reperfusion treatment?
21.
A 37-year-old man has repeatedly failed to stop using heroin despite losing his employment and experiencing family difficulties. Following detoxification, he remains at high risk of returning to opioid use. His physician discusses long-term medication-assisted treatment. Which intervention can reduce opioid craving and lower the risk of illicit opioid use when combined with psychosocial support?
22.
A 29-year-old female nurse survived a violent robbery four months ago. She now experiences recurrent nightmares, avoids the location of the incident, has difficulty concentrating at work and becomes extremely distressed when she hears loud noises. She has no history of substance use or previous psychiatric illness. Following assessment, the physician diagnoses post-traumatic stress disorder. Which intervention is most appropriate for addressing the underlying trauma-related symptoms?
23.
A 70-year-old woman presents with sudden left hemiparesis and severe headache. Non-contrast CT brain demonstrates a hyperdense collection within the right basal ganglia, surrounded by cerebral edema. Which interpretation is most appropriate?
24.
A 67-year-old man develops sudden weakness of his right arm and leg while talking to his family. His speech becomes effortful, although he remains conscious and understands simple commands. The neurological deficits persist after two hours. Which interpretation of the presenting history is most appropriate?
25.
A 68-year-old man presents with sudden right hemiparesis and aphasia. An initial non-contrast CT performed shortly after symptom onset excludes hemorrhage but demonstrates only subtle loss of definition of the left insular cortex. Subsequent MRI shows restricted diffusion in the left frontal-insular region. Which interpretation best integrates these findings?
26.
A 68-year-old man presents 90 minutes after developing disabling right hemiparesis and expressive aphasia. His NIHSS is 9, blood pressure is 174/96 mmHg, and CT brain excludes hemorrhage. He has no known recent surgery, active bleeding or anticoagulant use. Which is the most appropriate immediate management decision?
27.
A 68-year-old patient admitted with acute ischemic stroke has right hemiparesis and expressive aphasia. His wife reports that he coughed repeatedly when attempting to drink water shortly after symptom onset. He is alert and requests oral medication. Which management step is most appropriate?
28.
A 68-year-old man is discharged after a left MCA territory ischemic stroke. He has persistent right-sided weakness and expressive aphasia. He can understand most simple commands but struggles to communicate his needs and requires assistance with dressing and walking. Which rehabilitation approach is most appropriate?
29.
A 27-year-old woman returns to her family physician after four weeks of SSRI treatment for depression. She reports partial improvement in sleep but persistent low mood. She has been taking the medication irregularly because she expected complete improvement within a few days. She denies suicidal thoughts and has no features suggesting mania. What is the most appropriate next management step?
30.
A 69-year-old man presents with disabling hemiparesis and aphasia approximately two hours after symptom onset. Non-contrast CT excludes intracranial hemorrhage. CT angiography reveals an occlusion of the proximal left middle cerebral artery. Which is the most appropriate interpretation of this additional imaging finding?
31.
A 70-year-old man with diabetes presents with sudden facial asymmetry, slurred speech and weakness of his left arm. His family reports that he took his usual diabetes medication but had very little breakfast. He is sweating and appears confused. Which immediate assessment is most important before attributing these findings to an acute stroke?
32.
A 30-month-old boy is referred because of limited social interaction, delayed language development and repetitive hand movements. He rarely initiates shared attention with caregivers and becomes distressed by changes in routine. Hearing assessment is normal. His parents ask whether medication can correct the underlying developmental disorder. Which response best reflects appropriate management?
33.
A 72-year-old man has a large cerebral infarction and is being monitored in the stroke unit. Over the next two days, he develops worsening headache, vomiting, declining consciousness and further neurological deterioration. Repeat imaging demonstrates increasing swelling around the infarct. Which complication best explains his deterioration?
34.
A 68-year-old right-handed man presents with sudden right hemiparesis and difficulty producing speech. Examination reveals right lower facial weakness, reduced power in the right upper and lower limbs, and non-fluent speech with relatively preserved comprehension. Which anatomical location best explains the combined findings?
35.
A 46-year-old man who has consumed large quantities of alcohol daily for several years wishes to stop drinking. He previously experienced a withdrawal-related seizure during an unsuccessful attempt to quit. He requests medication that will allow him to withdraw at home without medical monitoring. What is the most appropriate clinical recommendation?
36.
During a supervised family medicine consultation, a 35-year-old patient presents with anxiety, poor sleep and difficulty functioning at work. The physician obtains a focused psychiatric and psychosocial history, assesses risk, explains possible treatment approaches and invites the patient to express preferences. The patient agrees to psychological treatment and a planned follow-up visit. Which principle best explains the value of this consultation?
37.
A 5-year-old child with autism spectrum disorder attends a follow-up consultation. His parents report increasing irritability, poor sleep and aggressive behaviour. The child has limited expressive language. Before considering medication, the physician evaluates his sleeping pattern, environmental changes, constipation and possible sources of discomfort. Which clinical principle best explains this approach?
38.
A 23-year-old university student presents to the emergency department with extreme agitation, tachycardia, hypertension, dilated pupils and excessive sweating after attending a party. His friends report that he consumed an unidentified recreational drug. He has no history of alcohol dependence. Which substance class is most consistent with this clinical presentation?
39.
A 26-year-old accountant reports recurrent unwanted thoughts that he may have left electrical appliances switched on. He checks them repeatedly before leaving home, sometimes spending more than two hours doing so. He recognizes that his fears are excessive but becomes distressed when prevented from checking. His psychiatrist recommends exposure and response prevention therapy. Which mechanism best explains the therapeutic benefit?
40.
A 51-year-old schoolteacher has chronic widespread musculoskeletal pain associated with fatigue, disturbed sleep and reduced daily functioning. Investigations do not suggest active inflammatory or structural disease. He has gradually stopped exercising because he fears that movement will worsen his condition. Which management strategy is most likely to improve his long-term functional outcome?
