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ABPN C-L Psychiatry study materials
ABPN C-L Psychiatry study resources

ABPN C-L Psychiatry practice questions

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Question 1Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Which combination of features is required to meet the Confusion Assessment Method (CAM) threshold for delirium?

  1. Stable low mood with psychomotor slowing
  2. Acute fluctuating course with inattention Correct answer.
  3. Gradual memory decline over several months
  4. Preserved attention with isolated hallucinations

Explanation

The CAM requires an acute onset with a fluctuating course plus inattention, accompanied by either disorganized thinking or an altered level of consciousness. Requiring both core features keeps the instrument specific in medically ill populations.

Question 2Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

The Montreal Cognitive Assessment is generally preferred over the Mini-Mental State Examination for which purpose?

  1. Diagnosing delirium immediately after surgery
  2. Identifying mild cognitive impairment in educated adults Correct answer.
  3. Detecting late-stage dementia with severe aphasia
  4. Documenting lifelong intellectual disability

Explanation

The MoCA samples executive function, visuospatial ability, abstraction, and delayed recall, and it uses a higher cutoff, which makes it more sensitive to mild deficits than the MMSE. The MMSE has strong ceiling effects in highly educated patients and is less sensitive to executive dysfunction.

Question 3Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Which neuromuscular finding is most characteristic of serotonin syndrome?

  1. Hyporeflexia with markedly raised creatine kinase
  2. Pinpoint pupils with depressed respiration
  3. Lead-pipe rigidity with bradyreflexia
  4. Clonus and hyperreflexia with agitation Correct answer.

Explanation

Serotonin syndrome is driven by excess serotonergic activity and produces neuromuscular excitability: inducible, ocular, or spontaneous clonus, hyperreflexia, tremor, agitation, and autonomic instability. Onset is typically rapid, within hours of a new or increased serotonergic agent.

Question 4Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Which set of abilities is assessed when determining a patient's decision-making capacity for a medical treatment?

  1. Orientation, attention, recall, and verbal fluency
  2. Understanding, appreciation, reasoning, and expressing a choice Correct answer.
  3. Insight, judgment, abstract reasoning, and memory
  4. Insight, planning, self-monitoring, and frustration tolerance

Explanation

Capacity rests on four functional abilities: communicating a choice, understanding the relevant information, appreciating how that information applies to oneself, and reasoning about the options. Capacity is decision-specific, so a patient may be capable for one decision and not another.

Question 5Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

A quiet, withdrawn, slowed older inpatient with poor oral intake is most likely to have hypoactive delirium mistaken for which condition?

  1. Generalized anxiety disorder
  2. Major depression with psychomotor retardation Correct answer.
  3. Conversion disorder with motor symptoms
  4. Bipolar disorder with mixed features

Explanation

Hypoactive delirium presents with reduced motor activity, sparse speech, and withdrawal, which closely resembles depression with retardation. The distinguishing features are acute onset, fluctuating severity, inattention, and an identifiable medical or pharmacologic trigger.

Question 6Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Delirium tremens most typically begins at which point after the last drink?

  1. Between 48 and 96 hours Correct answer.
  2. Only after 4 weeks of abstinence
  3. Between 10 and 14 days
  4. Within 2 to 4 hours

Explanation

Alcohol withdrawal follows a predictable progression: tremor and autonomic hyperactivity within 6 to 24 hours, seizures typically at 12 to 48 hours, and delirium tremens at roughly 48 to 96 hours. The delayed onset of delirium tremens makes prolonged monitoring important in high-risk patients.

Question 7Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

A 34-year-old presents with palpitations, tremor, heat intolerance, and weight loss. Which diagnosis best explains the anxiety symptoms?

  1. Adjustment disorder with anxiety
  2. Panic disorder
  3. Hyperthyroidism Correct answer.
  4. Generalized anxiety disorder

Explanation

Palpitations, tremor, heat intolerance, and weight loss form a thyrotoxic picture, and thyrotoxicosis commonly mimics an anxiety disorder. Screening thyroid function is indicated before attributing such symptoms to a primary anxiety disorder.

Question 8Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Why must depression screening scores be interpreted cautiously in medically hospitalized patients?

  1. Somatic items inflate scores in the medically ill Correct answer.
  2. Somatic items should always be weighted more heavily
  3. A positive screen alone confirms major depression
  4. Total scores are unaffected by concurrent medical illness

Explanation

Neurovegetative items such as fatigue, appetite change, weight loss, insomnia, and poor concentration are often caused by the medical illness itself, inflating total scores. Screening instruments flag possible cases; diagnosis still requires a clinical interview using an inclusive or etiologic approach.

Question 9Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Which examination finding most strongly supports catatonia in a medically hospitalized patient?

  1. Flaccid paralysis with areflexia
  2. Resting tremor with cogwheel rigidity
  3. Waxy flexibility and posturing Correct answer.
  4. Choreiform movements of the limbs

Explanation

Catatonia is a motor syndrome with signs such as stupor, mutism, negativism, posturing, waxy flexibility, staring, and grimacing, and it is rated with instruments such as the Bush-Francis Catatonia Rating Scale. A lorazepam challenge can support the diagnosis and guide treatment.

Question 10Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Which feature best distinguishes neuroleptic malignant syndrome from serotonin syndrome?

  1. Altered mental status with agitation
  2. Autonomic instability with diaphoresis
  3. Presence of fever above 38.5 degrees Celsius
  4. Lead-pipe rigidity and hyporeflexia Correct answer.

Explanation

Neuroleptic malignant syndrome follows dopamine blockade and produces lead-pipe rigidity, hyporeflexia or bradyreflexia, marked creatine kinase elevation, and a slower onset over days. Serotonin syndrome instead shows clonus and hyperreflexia with a rapid onset after serotonergic exposure.

Question 11Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Which pharmacologic agent is approved for pseudobulbar affect?

  1. Dextromethorphan-quinidine Correct answer.
  2. Sertraline combined with buspirone
  3. Lithium with valproate
  4. Haloperidol with benztropine

Explanation

Pseudobulbar affect consists of involuntary, incongruent episodes of laughing or crying in patients with neurologic disease and is rated with the Center for Neurologic Study-Lability Scale. A fixed combination of dextromethorphan and quinidine is FDA-approved, while SSRIs are used off-label.

Question 12Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Which medication property most strongly increases delirium risk in older hospitalized patients?

  1. Serotonin reuptake inhibition
  2. Strongly anticholinergic drugs Correct answer.
  3. Proton pump inhibition
  4. Beta-blockade

Explanation

Anticholinergic burden, benzodiazepines, opioids, corticosteroids, and polypharmacy are leading modifiable precipitants of delirium in older adults. Anticholinergic burden scales help quantify cumulative risk and guide medication review.

Question 13Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

A patient with limited English proficiency needs a detailed diagnostic interview. What is the most appropriate approach?

  1. Postpone the interview until the patient learns English
  2. Rely on written translated questionnaires only
  3. Use a trained medical interpreter Correct answer.
  4. Ask the patient's adult child to interpret

Explanation

Professional interpreters improve accuracy and preserve confidentiality, and they are particularly important for sensitive content such as trauma, suicidality, and substance use. Family members should not interpret because of altered accuracy, role conflicts, and privacy concerns.

Question 14Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Which feature most suggests malingering rather than factitious disorder?

  1. Production of symptoms for an external incentive Correct answer.
  2. The patient seems unaware of creating symptoms
  3. Symptoms persist across multiple hospitalizations
  4. The patient reports a long history of unexplained illness

Explanation

Malingering is the intentional production of symptoms for an identifiable external gain, such as money, medications, or avoiding work or legal duty. Factitious disorder involves intentional symptom production driven by an internal need for the sick role, without external incentive.

Question 15Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

A patient with cirrhosis develops confusion, asterixis, and reversal of the sleep-wake cycle. Which test best supports hepatic encephalopathy?

  1. Serum ammonia Correct answer.
  2. Lumbar puncture with opening pressure
  3. Serum ceruloplasmin
  4. Noncontrast head CT

Explanation

An elevated ammonia level supports the diagnosis of hepatic encephalopathy, although the diagnosis is clinical and ammonia correlates poorly with severity. Management includes lactulose and rifaximin while searching for precipitants such as infection, bleeding, or electrolyte disturbance.

Question 16Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

A litigating patient's neuropsychological scores are far below expectation while daily functioning appears preserved. What is the most appropriate next step?

  1. Interpret the low scores as brain injury
  2. Administer standalone and embedded effort tests Correct answer.
  3. Repeat the same battery until scores improve
  4. Add a depression rating scale to the battery

Explanation

Performance validity tests such as the Test of Memory Malingering and embedded validity indices estimate whether adequate effort was exerted. Low scores cannot be attributed to brain dysfunction unless validity has been established.

Question 17Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Which cognitive pattern is most typical of HIV-associated neurocognitive disorder in the antiretroviral era?

  1. Stepwise decline after repeated strokes
  2. Subcortical attention and executive slowing Correct answer.
  3. Cortical dementia with early fluent aphasia
  4. Rapidly progressive aphasia with preserved memory

Explanation

HIV-associated neurocognitive disorder spans asymptomatic impairment, mild neurocognitive disorder, and HIV-associated dementia, with a predominantly subcortical profile of slowed processing, inattention, and executive dysfunction. Brief screens such as the MoCA or the International HIV Dementia Scale are commonly used.

Question 18Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

A patient started on high-dose prednisone two weeks ago develops insomnia, pressured speech, agitation, and grandiosity. What is the most likely explanation?

  1. Corticosteroid-induced mania Correct answer.
  2. Acute dystonia from dopamine blockade
  3. Serotonin syndrome from prednisone
  4. Alcohol withdrawal delirium

Explanation

Corticosteroids can produce mood lability, insomnia, irritability, mania, and psychosis, typically early in treatment and in a dose-related fashion. Symptoms usually resolve with dose reduction or discontinuation, and antipsychotics or mood stabilizers may be needed temporarily.

Question 19Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Before starting an antipsychotic in a patient with known cardiac disease, which baseline study is most appropriate?

  1. Carotid duplex ultrasound
  2. 12-lead ECG with QTc measurement Correct answer.
  3. Serum lithium level
  4. Overnight electroencephalogram recording

Explanation

Many antipsychotics prolong the QTc interval, so a baseline ECG plus electrolyte assessment helps identify patients at risk of torsades de pointes. Risk is compounded when QT-prolonging drugs are combined, so monitoring should continue after initiation.

Question 20Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Which finding warrants medical optimization before proceeding with electroconvulsive therapy?

  1. Acute decompensated heart failure Correct answer.
  2. Controlled hypertension on two agents
  3. Heart rate of 70 beats per minute
  4. Stable atrial fibrillation on anticoagulation

Explanation

ECT produces a brief parasympathetic then sympathetic surge with transient bradycardia, hypertension, and tachycardia, which can destabilize patients with severe cardiac disease. Unstable conditions such as decompensated heart failure, recent myocardial infarction, or severe untreated hypertension require optimization first.

Question 21Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

A malnourished patient with alcohol use disorder receives intravenous glucose in the emergency department and then develops ophthalmoplegia, ataxia, and confusion. What is the most appropriate immediate treatment?

  1. Intravenous haloperidol
  2. Oral disulfiram
  3. Intravenous thiamine Correct answer.
  4. Intravenous lorazepam

Explanation

The triad of ophthalmoplegia, ataxia, and confusion indicates Wernicke encephalopathy, and thiamine must be given promptly, ideally before or alongside glucose. Untreated Wernicke encephalopathy can progress to irreversible Korsakoff syndrome with persistent amnesia.

Question 22Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

A young woman presents with new psychosis, seizures, orofacial dyskinesias, and autonomic instability. Which test is most specific for the likely diagnosis?

  1. 24-hour urinary copper excretion
  2. CSF anti-NMDA receptor antibodies Correct answer.
  3. Serum ceruloplasmin and slit-lamp examination
  4. Serum ammonia level

Explanation

Anti-NMDA receptor encephalitis often begins with psychiatric symptoms in young women and evolves into seizures, movement disorders, autonomic instability, and hypoventilation. CSF testing for anti-NMDA receptor antibodies is specific, and evaluation for an ovarian teratoma plus immunotherapy is standard.

Question 23Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Which cerebrospinal fluid result best supports neurosyphilis in a patient with reactive serum treponemal testing?

  1. Positive CSF bacterial culture
  2. Elevated protein with normal cell count
  3. CSF VDRL reactivity Correct answer.
  4. Normal glucose with elevated lactate

Explanation

CSF VDRL is highly specific for neurosyphilis, though it is insensitive and a negative result does not exclude the diagnosis. CSF pleocytosis and elevated protein support the diagnosis, while CSF treponemal tests are sensitive but may reflect antibody transfer from serum.

Question 24Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

A patient with severe hypertension develops headache, visual loss, and seizures, and MRI shows bilateral parieto-occipital edema. What is the most likely diagnosis?

  1. Herpes simplex encephalitis
  2. Posterior reversible encephalopathy Correct answer.
  3. Acute disseminated encephalomyelitis
  4. Progressive multifocal leukoencephalopathy with JC virus

Explanation

Posterior reversible encephalopathy syndrome presents with headache, visual disturbance, seizures, and encephalopathy in the setting of severe hypertension or offending drugs, with vasogenic edema in the parieto-occipital regions. Treatment is blood pressure control and removal of the precipitant.

Question 25Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

A hospitalized patient remains confused with fluctuating responsiveness despite correction of metabolic abnormalities. Which next test is most likely to identify the cause?

  1. Lumbar puncture
  2. Continuous EEG monitoring Correct answer.
  3. Repeat head CT with contrast
  4. Serum thyroid function tests

Explanation

Nonconvulsive status epilepticus can present as unexplained altered mental status with subtle or fluctuating signs and is detected only by electroencephalography. Continuous monitoring is indicated when confusion persists without a clear cause, especially after sedative withdrawal or in patients with epilepsy.

Question 26Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Which bedside cognitive screening instrument is most sensitive for detecting mild cognitive impairment in a medically stable older adult?

  1. Mini-Cog
  2. Clock drawing test used alone
  3. Montreal Cognitive Assessment (MoCA) Correct answer.
  4. Mini-Mental State Examination (MMSE)

Explanation

The MoCA was designed to sample executive function, visuospatial ability, and delayed recall more thoroughly than the MMSE, which has a prominent ceiling effect and misses mild deficits. In medically stable patients with subjective or informant-reported decline, the MoCA is the preferred brief screen. Abnormal MoCA results should be followed by formal neuropsychological testing rather than being treated as diagnostic.

Question 27Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Which instrument uses a structured bedside algorithm based on acute onset, inattention, and either disorganized thinking or altered consciousness to identify delirium in hospitalized patients?

  1. Confusion Assessment Method (CAM) Correct answer.
  2. Mini-Mental State Examination (MMSE)
  3. Generalized Anxiety Disorder-7 (GAD-7)
  4. Patient Health Questionnaire-9 (PHQ-9)

Explanation

The CAM operationalizes the core delirium criteria into a short algorithm and can be administered reliably by trained non-psychiatrists, including nurses. Its key features are acute onset or fluctuation, inattention, and either disorganized thinking or altered level of consciousness. The CAM is a screening tool and does not by itself identify the cause of delirium.

Question 28Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

During a capacity evaluation, a patient accurately restates the risks and benefits of a proposed procedure but states, 'That might be true for other people, but it does not apply to me.' Which of the four decisional abilities is most impaired?

  1. Rational reasoning
  2. Expressing a choice
  3. Appreciation Correct answer.
  4. Understanding

Explanation

Appreciation refers to the patient's ability to apply the disclosed information to his or her own situation and acknowledge that the consequences could happen personally. This patient demonstrates intact understanding by restating the facts, but fails to connect them to the self, which is a deficit in appreciation. Capacity is decision-specific, so the assessment must remain focused on the particular intervention being proposed.

Question 29Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Which feature most reliably distinguishes delirium from a progressive dementia at the bedside?

  1. Presence of visual hallucinations
  2. Acute onset with fluctuating attention Correct answer.
  3. Impaired free recall on formal testing
  4. Age older than 75 years

Explanation

Delirium is defined by an acute disturbance in attention and awareness that develops over hours to days and tends to fluctuate, whereas dementia has an insidious, progressive course with initially preserved attention. When delirium is superimposed on dementia, the acute change from the patient's baseline is the discriminating feature. Serial bedside assessment and collateral history are essential to make that determination.

Question 30Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

A patient with three months of apathy, sparse speech, and poor grooming is thought to be depressed. Which bedside observation most suggests a frontal lobe syndrome rather than a primary mood disorder?

  1. Psychomotor retardation with guilt
  2. Early morning awakening
  3. Diurnal variation of mood
  4. Utilization behavior Correct answer.

Explanation

Utilization behavior, in which the patient automatically reaches for and uses objects without being asked, reflects environmental dependency from frontal lobe dysfunction and is not a feature of depression. Other frontal release or environmental dependency signs, such as imitation behavior and grasp reflexes, carry similar significance. Classic depressive features support a mood disorder but do not localize to the frontal lobes.

Question 31Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

An older hospitalized patient with suspected major neurocognitive disorder gives a fragmented and unreliable history. Which approach best establishes baseline daily functioning?

  1. Review of nursing notes from the current admission
  2. Serial Mini-Mental State Examinations on the same day
  3. A self-report depression scale completed by the patient
  4. Structured informant interview about daily function Correct answer.

Explanation

Diagnosis of a neurocognitive disorder requires evidence that cognitive decline interferes with independence in everyday activities, and the patient's own report is often unreliable. A structured interview with a knowledgeable informant about instrumental and basic activities of daily living provides the most valid estimate of baseline function. Informant-based measures also help distinguish longstanding decline from an acute change due to delirium.

Question 32Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

A hospitalized patient with a known seizure disorder remains unresponsive with subtle facial and eyelid twitching after a generalized convulsion. Which study is most likely to establish the diagnosis?

  1. Serum ammonia and liver panel
  2. Noncontrast head CT
  3. Continuous video-EEG monitoring Correct answer.
  4. Lumbar puncture with opening pressure

Explanation

Persistent unconsciousness with subtle motor signs after a convulsion suggests nonconvulsive status epilepticus, which can only be confirmed by demonstrating ongoing electrographic seizure activity. Continuous EEG is required because the clinical signs are easily missed and may mimic delirium or coma. Identifying the pattern promptly matters because prolonged seizures cause additional neuronal injury.

Question 33Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Which test has the highest diagnostic accuracy for sporadic Creutzfeldt-Jakob disease in a patient with rapidly progressive dementia?

  1. CSF RT-QuIC assay Correct answer.
  2. CSF 14-3-3 protein
  3. EEG showing periodic sharp wave complexes
  4. Diffusion-weighted MRI

Explanation

Real-time quaking-induced conversion detects prion seeding activity in CSF with near-perfect specificity and high sensitivity, making it the most accurate antemortem test for sporadic Creutzfeldt-Jakob disease. EEG periodic sharp wave complexes appear in only a minority of patients and are not specific, and 14-3-3 is a marker of rapid neuronal injury that is elevated in many conditions. Diffusion-weighted MRI is supportive but less accurate than RT-QuIC.

Question 34Foundations and Psychiatric Assessment in the Medically Ill (interviewing, differential diagnosis, neuropsychiatric and cognitive assessment, diagnostic testing)

Which historical feature most strongly favors psychogenic nonepileptic seizures over epileptic seizures?

  1. Lateral tongue biting during the event
  2. Closed eyes and asynchronous limb movements Correct answer.
  3. Prolonged postictal confusion
  4. Urinary incontinence during the event

Explanation

Events with sustained eye closure, asynchronous or fluctuating limb movements, and prolonged duration without a stereotyped sequence suggest psychogenic nonepileptic seizures. Features such as lateral tongue biting, incontinence, and a clear postictal state favor an epileptic mechanism. Definitive classification requires capture of a typical event with video-EEG, since history alone is imperfect.

Question 35Consultation and Liaison Practice (consultation request triage, communication with medical/surgical teams, care coordination, systems and administrative issues)

You are the on-call consultation-liaison psychiatrist and four requests arrive at the same time. Which patient should be evaluated first?

  1. A 78-year-old two days after hip repair who is newly agitated and pulling at intravenous lines Correct answer.
  2. A 45-year-old admitted with cellulitis who asks for adjustment of a long-standing antidepressant
  3. A 30-year-old scheduled for elective hernia repair in three days who needs a preoperative letter
  4. A 60-year-old with chronic low back pain who wants help coping with a long admission

Explanation

Consultation triage is driven by acuity and immediate safety risk rather than by order of arrival. New agitation after surgery suggests delirium with a potentially reversible medical cause, and line-pulling endangers the patient and staff. Requests for medication adjustment, preoperative letters, and coping support are important but can be scheduled.

Question 36Consultation and Liaison Practice (consultation request triage, communication with medical/surgical teams, care coordination, systems and administrative issues)

A hospitalist pages you: "I have a patient with mild anxiety about an upcoming MRI. Should I give lorazepam?" What is the most appropriate response?

  1. Decline to answer anything by phone until a full consultation has been completed and billed
  2. Ask the hospitalist to document that you prescribed the medication before you answer
  3. Offer brief phone guidance and suggest a formal consult if the case is more complex Correct answer.
  4. Answer the question and document a full consultation note without seeing the patient

Explanation

Brief curbside guidance is acceptable and helpful, provided the limitations of an informal opinion are recognized and the colleague is invited to request a full consultation if the situation is more complicated than described. A curbside exchange does not substitute for a documented evaluation of a patient who is actually seen.

Question 37Consultation and Liaison Practice (consultation request triage, communication with medical/surgical teams, care coordination, systems and administrative issues)

You are asked to assess decision-making capacity in a patient who speaks only Spanish. What is the most appropriate approach?

  1. Ask the patient's adult son to interpret to save time
  2. Use a qualified medical interpreter, in person or by video or phone Correct answer.
  3. Use a bilingual nurse who happens to speak some Spanish
  4. Postpone the assessment until an interpreter is available the next business day

Explanation

A valid capacity assessment requires accurate communication, which in turn requires a qualified medical interpreter. Untrained family members and ad hoc bilingual staff may mistranslate, alter the patient's responses, or introduce confidentiality and role conflicts. Telephone or video interpretation is acceptable when in-person interpretation is unavailable.

Question 38Consultation and Liaison Practice (consultation request triage, communication with medical/surgical teams, care coordination, systems and administrative issues)

Which documentation is most appropriate after a psychiatric consultation on a medical inpatient?

  1. Write a private note and bill for the consultation without a chart entry
  2. Record only the final disposition so that other clinicians' notes stay brief
  3. Document the question, findings, formulation, risk assessment, and recommendations Correct answer.
  4. Keep the clinical assessment out of the chart to protect the patient's privacy

Explanation

The consultation note is the principal means of communicating with the referring team and must state the clinical question, relevant findings, formulation, risk assessment, and actionable recommendations. Omitting the assessment or keeping a parallel private record leaves the treating team without the information needed to act and is not defensible.

Question 39Consultation and Liaison Practice (consultation request triage, communication with medical/surgical teams, care coordination, systems and administrative issues)

A team requests "evaluation for depression" in a 70-year-old who has refused physical therapy for three days after hip fracture. What is the best first step?

  1. Initiate an antidepressant based on the request alone
  2. Complete a capacity evaluation covering all treatment decisions
  3. Recommend that the consult be canceled until the patient consents to physical therapy
  4. Clarify the clinical question with the referring team before seeing the patient Correct answer.

Explanation

Consultation requests are often framed as a diagnosis when the real question is behavioral, such as why the patient is refusing rehabilitation. Clarifying the question and reviewing the record prevents the consultant from answering the wrong question and helps set agreed goals for the consultation.

Question 40Consultation and Liaison Practice (consultation request triage, communication with medical/surgical teams, care coordination, systems and administrative issues)

A patient with moderate dementia lacks capacity for a current decision. His involved adult daughter, who is visiting, asks the team about his diagnosis and plan. What is the proper approach?

  1. Refer the daughter to the hospital's attorney for all questions
  2. Disclose nothing, because privacy rules forbid all discussion with family members
  3. Require a court order before any discussion can occur
  4. Share information relevant to the daughter's role in his care and document the discussion Correct answer.

Explanation

When a patient lacks capacity and has not objected to family involvement, clinicians may share the information necessary for family members to participate in care and support the patient. The scope of disclosure should be limited to what is relevant, and the conversation should be documented.

Question 41Consultation and Liaison Practice (consultation request triage, communication with medical/surgical teams, care coordination, systems and administrative issues)

In the emergency department, a patient describes active suicidal ideation with a specific plan and intent. The emergency physician asks whether the patient can be discharged. What is the most appropriate action?

  1. Ask the ED to place the patient on a medical hold pending a court hearing
  2. Recommend continuous observation with contraband removed while arranging psychiatric admission Correct answer.
  3. Document that the patient is at low risk because there have been no prior attempts
  4. Recommend discharge with outpatient follow-up scheduled within one week

Explanation

Active ideation with a plan and intent constitutes high acute risk requiring observation in a secure setting and prompt arrangement of psychiatric admission. The consultant communicates this recommendation directly to the treating team and documents the risk assessment and rationale.

Question 42Consultation and Liaison Practice (consultation request triage, communication with medical/surgical teams, care coordination, systems and administrative issues)

An intubated patient with severe anoxic brain injury has no advance directive and never discussed treatment preferences. His wife must decide about tracheostomy placement. Which standard should guide the decision?

  1. The hospital's written policy on allocation of scarce resources
  2. The preference of the patient's eldest child as next of kin
  3. The treating physician's judgment that further treatment is futile
  4. Best interests, weighing benefits and burdens as the patient would likely view them Correct answer.

Explanation

When a patient's prior wishes are unknown, the surrogate decides using the best-interests standard, weighing the benefits and burdens of treatment as the patient would likely have viewed them. Substituted judgment applies when the patient's values or statements are known. The clinical team informs but does not supplant the surrogate.

Question 43Consultation and Liaison Practice (consultation request triage, communication with medical/surgical teams, care coordination, systems and administrative issues)

A 74-year-old with mild cognitive impairment refuses dialysis. She states her choice clearly and says she does not want to be "hooked to a machine," but she cannot describe the consequences of refusing. The team asks whether she "has capacity." Which approach is most accurate?

  1. Assess capacity for this specific decision using the four functional abilities Correct answer.
  2. Conclude that a diagnosis of cognitive impairment precludes capacity
  3. Determine capacity once and apply the finding to all future decisions
  4. Use the Mini-Mental State Examination score to determine global capacity

Explanation

Capacity is decision-specific and assessed through the functional abilities to understand, appreciate, reason, and express a choice regarding the particular decision. A cognitive diagnosis or a screening score informs but does not determine the outcome, and capacity can change over time.

Question 44Consultation and Liaison Practice (consultation request triage, communication with medical/surgical teams, care coordination, systems and administrative issues)

A patient with a progressive neurologic illness, now minimally communicative, has no written advance directive but repeatedly told his brother, his health care agent, that he would never want prolonged ventilation. Which standard should guide the brother's decision?

  1. Substituted judgment based on the patient's previously expressed values and wishes Correct answer.
  2. A court-appointed guardian's independent choice
  3. The treatment team's assessment of the patient's best medical interests
  4. The majority preference of the extended family

Explanation

When a patient's values and prior statements are known, the surrogate should apply substituted judgment and decide as the patient would have decided. Best interests serves as a fallback when prior wishes are unknown, and the clinical team's view does not override a documented patient preference.

Question 45Consultation and Liaison Practice (consultation request triage, communication with medical/surgical teams, care coordination, systems and administrative issues)

A surgical team asks you to "talk the patient into" an elective amputation that the patient has refused after a documented informed consent discussion. What is the consultant's most appropriate role?

  1. Persuade the patient to consent because the surgeons consider the procedure indicated
  2. Decline the consultation because it involves a disagreement
  3. Clarify the concern, explore the patient's reasoning, and document without advocating a set outcome Correct answer.
  4. Declare the patient incompetent so that the team can proceed

Explanation

The consultant's task is to clarify the team's underlying concern, assess the patient's reasoning and decision-making, and document findings neutrally. Advocating a predetermined outcome compromises the assessment, and a competent refusal remains authoritative regardless of the team's recommendation.

Question 46Consultation and Liaison Practice (consultation request triage, communication with medical/surgical teams, care coordination, systems and administrative issues)

During an afternoon consultation you learn that an inpatient has new command auditory hallucinations telling him to harm his roommate. What is the most appropriate immediate action?

  1. Document the statement as a known chronic symptom and continue the current plan
  2. Ask the unit clerk to relay the findings to the attending physician
  3. Call the primary team and nursing directly, arrange safety measures, and then document Correct answer.
  4. Write the recommendations in the chart and sign off for the team to read tomorrow

Explanation

Findings that pose imminent risk require direct verbal communication with the responsible clinicians and nursing staff so that protective measures can be implemented immediately. Documentation follows but never substitutes for real-time communication of urgent risk.

Question 47Consultation and Liaison Practice (consultation request triage, communication with medical/surgical teams, care coordination, systems and administrative issues)

A 68-year-old with pneumonia becomes agitated and tries to climb out of bed. He has received two doses of lorazepam from the covering team with worsening confusion. What is the most appropriate recommendation?

  1. Start a standing antipsychotic for the remainder of the admission
  2. Increase the lorazepam dose to achieve deeper sedation
  3. Apply physical restraints and reassess the patient in the morning
  4. Stop the benzodiazepine, treat precipitants, and use nonpharmacologic measures first Correct answer.

Explanation

Benzodiazepines frequently worsen delirium, especially in older adults, and agitation is best managed by identifying and treating the underlying cause with environmental and behavioral measures first. Restraints and standing sedatives increase morbidity and are reserved for narrowly defined situations after less restrictive measures fail.

Question 48Consultation and Liaison Practice (consultation request triage, communication with medical/surgical teams, care coordination, systems and administrative issues)

A 28-year-old with borderline personality disorder, admitted for a medical illness, has superficial self-cuts and repeatedly requests extra opioids. Nurses report that the patient is "splitting" the team. Which approach is best?

  1. Help the team create a consistent behavioral plan with one contact person and clear limits Correct answer.
  2. Transfer the patient to a psychiatric unit because medical needs are secondary
  3. Ask the team to ignore the self-harm so that it is not reinforced
  4. Request continuous sitter observation to prevent all self-harm for the whole admission

Explanation

Inconsistent responses across shifts reinforce escalating behavior, so a written plan with a single point of contact, predictable limits, and agreed responses to requests reduces splitting. The consultant supports the medical team in implementing the plan rather than taking over care.

Question 49Consultation and Liaison Practice (consultation request triage, communication with medical/surgical teams, care coordination, systems and administrative issues)

After a workplace injury, a patient's employer calls the consultation service asking about the patient's psychiatric diagnosis. The patient is awake, has capacity, and has not authorized any release of information. What should you do?

  1. Provide the information because the injury occurred at work
  2. Refer the employer to the patient's outpatient psychiatrist
  3. Decline to disclose and explain that written authorization is required Correct answer.
  4. Confirm the diagnosis but withhold treatment details

Explanation

Protected health information cannot be disclosed to an employer without the patient's written authorization, even when the injury is work related. Confirming a diagnosis is itself a disclosure, and referring the employer to another clinician simply moves the improper request elsewhere.

Question 50Consultation and Liaison Practice (consultation request triage, communication with medical/surgical teams, care coordination, systems and administrative issues)

An inpatient tells you he plans to shoot his former partner after discharge. Which action is most appropriate?

  1. Notify the team, follow the jurisdiction's duty-to-protect procedures, and document Correct answer.
  2. Invite the former partner to the hospital to discuss the threats
  3. Obtain a promise from the patient that he will not act on the threat
  4. Maintain confidentiality and only document the statement in the chart

Explanation

A serious threat toward an identifiable person triggers duties that vary by jurisdiction, typically involving warning or protective notification, notification of law enforcement where required, and consideration of hospitalization. Consultation with risk management and careful documentation support compliance with the applicable standard.