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Question 3421Question →

A 23-year-old male construction worker is evaluated at an occupational health clinic after sustaining a minor ankle sprain. During the evaluation, the physician notes that the patient exhibits psychomotor retardation and a markedly flat affect. The patient admits to feeling overwhelmingly sad and sleeping nearly 15 hours a day for the past six weeks, which has severely impaired his job performance. A thorough psychiatric review of systems reveals that two years ago, he experienced a distinct 6-week period where he worked his construction job all day, drove for a rideshare company all night, slept only 90 minutes per night, and felt "more powerful than ever." He is not currently taking any medications. Which of the following medications are appropriate monotherapy choices for his current clinical presentation? (Select all that apply)

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Answer: Quetiapine; Lurasidone

Answer

Quetiapine and Lurasidone
This patient is presenting with a major depressive episode but has a clear history of a past manic episode (decreased need for sleep, boundless energy, and hyper-productivity lasting six weeks). This establishes a diagnosis of bipolar I disorder, currently depressed. The standard of care for acute bipolar depression includes monotherapy with specific second-generation antipsychotics (e.g., quetiapine, lurasidone, cariprazine) or certain mood stabilizers (e.g., lithium, lamotrigine). Both quetiapine and lurasidone are highly effective, FDA-approved first-line options for acute bipolar depression.

Step-by-Step Solution

1
Evaluate the current symptom profile.
The patient is experiencing a major depressive episode, indicated by psychomotor retardation, severe sadness, and hypersomnia lasting six weeks.
Identifying the current mood state is the first step in determining appropriate pharmacotherapy.
2
Review the patient's past psychiatric history.
There is a clear history of a distinct period of elevated mood, decreased need for sleep, and increased goal-directed activity lasting six weeks.
Past episodes of mania or hypomania fundamentally change the diagnosis and management of current depressive symptoms.
3
Synthesize the findings to establish a diagnosis.
The combination of a current major depressive episode and a past manic episode confirms a diagnosis of bipolar I disorder, currently depressed.
Treatment for bipolar depression differs significantly from unipolar major depressive disorder.
4
Select appropriate pharmacotherapy.
Quetiapine and Lurasidone are both approved and effective monotherapies for bipolar depression. Antidepressant monotherapy (such as Paroxetine, Venlafaxine, or Fluoxetine) must be avoided.
Antidepressant monotherapy in bipolar disorder can precipitate a dangerous manic switch.

Key Concept

Bipolar I depression requires treatment with specific mood stabilizers or atypical antipsychotics; antidepressant monotherapy is contraindicated due to the risk of inducing a manic episode.
Question 3422Question →

Paramedics arrive at the trauma center with a 34-year-old construction worker who fell approximately 20 feet from a roof. The patient is moaning and clutching his abdomen. His temperature is 36.8°C (98.2°F), blood pressure is 82/45 mmHg, pulse is 128/min, and respirations are 22/min. Peripheral intravenous lines are placed, and fluid resuscitation is initiated. His airway is clear, and breath sounds are equal bilaterally. A bedside ultrasound evaluation of the abdomen demonstrates an anechoic fluid collection between the liver and right kidney. Which of the following is the most appropriate next step in the management of this patient?

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Answer: Urgent surgical exploration of the abdomen

Answer

The correct course of action is to proceed with urgent surgical exploration of the abdomen to identify and control the source of bleeding.
The patient presents with blunt abdominal trauma, hemodynamic instability (hypotension, tachycardia), and a positive bedside ultrasound indicating intra-abdominal fluid (likely blood). In this scenario, the standard of care dictates immediate surgical exploration to identify and control the source of hemorrhage. Delaying for any other intervention or imaging is potentially fatal.

Step-by-Step Solution

1
Assess the patient's hemodynamic status based on vital signs.
The patient is hypotensive (blood pressure 82/45 mmHg) and tachycardic (pulse 128/min).
Vital signs indicate the patient is hemodynamically unstable and in hemorrhagic shock.
2
Evaluate the findings of the bedside ultrasound.
The focused ultrasound demonstrates free fluid in Morison's pouch.
A positive focused assessment with sonography for trauma in a hypotensive patient strongly suggests intra-abdominal hemorrhage as the cause of shock.
3
Determine the appropriate definitive management.
The patient requires immediate operative intervention.
Hemodynamically unstable patients with confirmed intra-abdominal bleeding require urgent surgical exploration to control the hemorrhage.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive ultrasound for free intra-abdominal fluid require immediate surgical exploration.
Question 3423Question →

A 45-year-old man presents to a dermatologist for the fifth time in a year. He is convinced that he has a severe parasitic infection of his skin, specifically claiming that microscopic worms are burrowing under his epidermis and multiplying. During the visit, he triumphantly shows the physician a small matchbox containing lint, scabs, and skin flakes, asserting they are "specimens" of the parasites. He reports that this infestation began 7 months ago. He strongly denies any depressed mood, hearing voices, or other unusual experiences. He continues to work successfully as a mechanical engineer and maintains a healthy relationship with his wife, who states he is completely normal except for his "obsession with his skin." Physical examination reveals numerous linear excoriations on his forearms and lower legs from chronic scratching. A comprehensive toxicology screen is negative. Which of the following is the most likely diagnosis?

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Answer: Delusional disorder

Answer

The most likely diagnosis is delusional disorder.
The correct answer is delusional disorder. This patient presents with a classic case of delusional parasitosis (Ekbom syndrome), a specific manifestation of delusional disorder, somatic type. Delusional disorder is characterized by the presence of one or more delusions for at least 1 month. A key distinguishing feature is that, apart from the direct impact of the delusion (e.g., scratching the skin, visiting dermatologists), the patient's overall psychosocial functioning is relatively preserved. Furthermore, the patient does not meet the criteria for schizophrenia (he lacks prominent hallucinations, disorganized speech, disorganized behavior, and negative symptoms). The "matchbox sign"—bringing in lint or skin debris as proof of the infestation—is a pathognomonic clinical clue for this condition.

Step-by-Step Solution

1
Identify the primary psychiatric symptom.
The patient has a fixed, false belief that he is infested with parasites, evidenced by bringing a matchbox of "specimens" (Ekbom syndrome/delusional parasitosis).
Establishing the core symptom as a somatic delusion is the first step in formulating the differential diagnosis.
2
Evaluate the duration of symptoms and the patient's functional status.
The delusion has been present for 7 months. Despite the severity of the belief, his occupational and social functioning remain entirely intact.
Duration is critical for distinguishing between psychotic disorders (e.g., brief psychotic disorder vs. schizophreniform vs. schizophrenia/delusional disorder).
3
Differentiate from related psychiatric conditions based on specific criteria.
The absence of prominent hallucinations, disorganized speech, or negative symptoms rules out schizophrenia. Intact insight rules out OCD and illness anxiety disorder. The 7-month duration rules out brief psychotic disorder and schizophreniform disorder.
Systematic elimination based on DSM-5 criteria confirms the diagnosis of delusional disorder, somatic type.

Key Concept

Patients with delusional disorder exhibit one or more delusions for at least 1 month without meeting the criteria for schizophrenia, and their psychosocial functioning is not markedly impaired outside of the delusion.
Estimated Time:1m 30s
Question 3424Question →

Match each distinct clinical presentation to its most likely substance-related diagnosis.

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Items

Piloerection, excessive yawning, rhinorrhea, and mydriasis in a highly restless patient.
Rotary nystagmus, apparent analgesia, and sudden aggressive outbursts in a trauma bay setting.
Conjunctival injection, significant dry mouth, and tachycardia in a lethargic adolescent.
Profound disorientation, visual hallucinations, and autonomic instability peaking three days post-admission.

Matches

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Answer

Piloerection and yawning map to opioid withdrawal; rotary nystagmus maps to PCP intoxication; conjunctival injection maps to cannabis intoxication; and delayed autonomic instability with hallucinations maps to alcohol withdrawal delirium.
Each clinical presentation contains hallmark signs of specific substance states. Opioid withdrawal is uniquely characterized by yawning, piloerection (goosebumps), rhinorrhea, and mydriasis. Phencyclidine (PCP) intoxication is identifiable by rotary or vertical nystagmus combined with violent behavior and apparent decreased pain perception. Cannabis intoxication typically presents with conjunctival injection (red eyes), dry mouth, and tachycardia. Finally, alcohol withdrawal delirium (delirium tremens) is a medical emergency that typically peaks 48 to 96 hours after the last drink, presenting with altered sensorium, visual hallucinations, and severe autonomic instability.

Step-by-Step Solution

1
Analyze the first presentation featuring piloerection and yawning.
These are classic signs of sympathetic hyperactivity associated specifically with opioid receptor uncoupling and withdrawal.
Identifying the specific toxidrome differentiates opioid withdrawal from other withdrawal syndromes.
2
Analyze the second presentation featuring rotary nystagmus and aggression.
The presence of rotary or vertical nystagmus strongly points to NMDA receptor antagonism caused by phencyclidine.
Nystagmus combined with violent behavior is the pathognomonic sign of PCP over other stimulants.
3
Analyze the third presentation featuring conjunctival injection and dry mouth.
These are mild sympathomimetic and anticholinergic-like effects typical of cannabinoid receptor activation.
Recognizing conjunctival injection helps isolate this specific widely-used substance from pure depressants.
4
Analyze the fourth presentation featuring delayed hallucinations and autonomic instability.
A 72-hour timeline post-admission with severe sympathetic overdrive indicates a life-threatening late-stage withdrawal state.
Timing is critical to differentiate early withdrawal phenomena from late-stage delirium tremens.

Key Concept

Substance-Related Toxidromes and Withdrawal Syndromes
Question 3425Question →

Match each patient's clinical presentation with the most appropriate pharmacological treatment based on their specific comorbidities and side effect profiles.

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Items

A 24-year-old patient with major depressive disorder who is highly motivated to quit smoking and wishes to avoid medication-induced sexual dysfunction.
A 78-year-old patient with severe major depressive disorder, profound weight loss, and chronic insomnia.
A 32-year-old patient with bipolar I disorder requiring maintenance pharmacotherapy who has concurrent severe hepatic disease.
A 28-year-old patient with schizophrenia requiring antipsychotic treatment who previously developed severe galactorrhea and amenorrhea on risperidone.

Matches

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Answer

The clinical presentations match properly to Bupropion (for smoking cessation/no sexual side effects), Mirtazapine (for insomnia/weight loss), Lithium (for hepatic disease), and Aripiprazole (to avoid hyperprolactinemia).
Each correct pairing takes into account the specific mechanism of action and side effect profile of the medication, aligning it with the patient's unique comorbidities and treatment goals.

Step-by-Step Solution

1
Analyze the needs of the 24-year-old patient with depression.
The patient needs an antidepressant that assists with smoking cessation and lacks sexual side effects.
Bupropion uniquely fits this profile as an NDRI.
2
Evaluate the symptoms of the 78-year-old patient.
The patient has depression complicated by weight loss and insomnia.
Mirtazapine provides therapeutic benefits for all three issues due to its noradrenergic and specific serotonergic activity, plus antihistaminic effects.
3
Assess the medical comorbidities of the 32-year-old patient with bipolar disorder.
The patient has severe hepatic disease.
Lithium is renally cleared and thus safe in hepatic impairment, whereas valproate is hepatically metabolized and potentially hepatotoxic.
4
Review the previous adverse effects in the 28-year-old patient with schizophrenia.
The patient developed hyperprolactinemia on risperidone.
Aripiprazole, a D2 partial agonist, minimizes prolactin elevation and can even lower prolactin levels compared to typical agents.

Key Concept

Selection of psychotropic medications based on side effect profiles, comorbidities, and specific therapeutic benefits.
Question 3426Question →

A 22-year-old female college student presents to the university health clinic reporting recurrent, unexpected episodes of intense fear. During these episodes, she experiences palpitations, diaphoresis, shortness of breath, and a profound fear of losing control. The episodes peak within 10 minutes and have occurred four times in the past month. She now actively avoids the campus library, where two of the episodes occurred, fearing she will have another attack and be unable to escape. Her medical history is significant for a hospitalization one year ago for a 3-week period of severely decreased need for sleep, pressured speech, and grandiose delusions involving a belief that she was a prophet chosen to solve world hunger. She was stabilized and discharged but voluntarily discontinued all her psychiatric medications 6 months ago. Vital signs are within normal limits. Physical examination, electrocardiogram, and baseline laboratory studies, including a comprehensive metabolic panel, thyroid-stimulating hormone, and urine toxicology, are unremarkable. Which of the following is the most appropriate next step in management?

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Answer: Initiate cognitive-behavioral therapy

Answer

Initiate cognitive-behavioral therapy
The correct approach is to initiate cognitive-behavioral therapy (CBT). This patient's current presentation of recurrent, unexpected panic attacks followed by avoidance of specific locations (the library) is classic for Panic Disorder with Agoraphobia. Normally, first-line treatments include CBT, SSRIs, or SNRIs. However, this patient's history of a hospitalization for decreased sleep, pressured speech, and grandiose delusions indicates she has Bipolar I Disorder. In patients with bipolar disorder, the use of antidepressant monotherapy (such as an SSRI or SNRI) is contraindicated due to the high risk of precipitating a manic or hypomanic episode (manic switch). Therefore, the safest and most effective initial intervention for her panic disorder is psychotherapy, specifically CBT. If pharmacotherapy were deemed necessary for her anxiety, it would need to include a mood stabilizer or atypical antipsychotic to protect against a manic switch.

Step-by-Step Solution

1
Identify the current psychiatric diagnosis based on the clinical presentation.
The patient has recurrent, unexpected panic attacks with subsequent avoidance behavior (agoraphobia), leading to a diagnosis of Panic Disorder with Agoraphobia.
Accurate diagnosis is required before selecting a management plan.
2
Review the patient's past medical history for comorbid psychiatric conditions.
The history of a 3-week episode characterized by decreased sleep, pressured speech, and grandiose delusions confirms a past manic episode, diagnostic of Bipolar I Disorder.
Past psychiatric history often dictates the safety profile of current treatment options.
3
Determine the safest and most effective initial treatment for panic disorder in the context of Bipolar I Disorder.
Cognitive-behavioral therapy (CBT) is selected over SSRI monotherapy.
SSRI monotherapy carries a significant risk of inducing a manic switch in patients with bipolar disorder. CBT is highly effective for panic disorder and carries no risk of mood destabilization.

Key Concept

Management of anxiety disorders in patients with comorbid bipolar disorder
Question 3427Question →

A 41-year-old man presents to the clinic with persistent low mood, anhedonia, and insomnia that have significantly impaired his ability to perform his job. He is diagnosed with major depressive disorder (MDD). He has no prior psychiatric history, no history of hypomanic or manic episodes, and no acute suicidal ideation. He expresses a preference for pharmacological treatment. Assuming the patient experiences inadequate clinical improvement at each successive stage of treatment, arrange the following management steps in the correct chronological sequence according to standard stepped-care guidelines for MDD.

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Answer

The correct sequence of steps for escalating care in major depressive disorder is: (1) Initiate SSRI monotherapy, (2) Titrate to maximum tolerated dosage, (3) Augment with an atypical antipsychotic or second agent, and (4) Refer for neuromodulation therapies such as ECT.
The correct sequence follows the standard consensus guidelines (such as the APA practice guidelines) for treating major depressive disorder: initiating a well-tolerated first-line agent (SSRI), optimizing the dose if partial response is observed, employing augmentation or switching strategies for treatment-resistant cases failing a maximized trial, and finally utilizing neuromodulation (ECT) for refractory treatment-resistant depression.

Step-by-Step Solution

1
Identify the appropriate initial management for an uncomplicated first episode of MDD.
Initiate SSRI monotherapy.
SSRIs are the preferred first-line pharmacological treatment due to an optimal balance of safety, tolerability, and efficacy.
2
Determine the next step for a patient showing partial response after an initial 4-6 week trial.
Optimize the SSRI dosage.
Dose titration is indicated before switching or augmenting if the patient demonstrates partial improvement and is tolerating the medication well.
3
Select the intervention for a patient failing optimized monotherapy.
Augment with a second agent or switch classes.
Adding an atypical antipsychotic (or switching to an SNRI/TCA) addresses non-response to a maximized first-line agent, utilizing different neurochemical pathways.
4
Identify the management strategy for definitive treatment-resistant depression.
Refer for neuromodulation (ECT or TMS).
ECT and TMS are highly efficacious and indicated after multiple failed adequate medication trials or for urgent, severe presentations.

Key Concept

The stepped-care algorithm for Major Depressive Disorder prioritizes starting with a single, tolerable agent, optimizing its dose, sequentially moving to combinations/switching, and reserving neuromodulation for treatment resistance.
Question 3428Question →

A 28-year-old male is brought to the emergency department immediately after a high-speed motor vehicle collision. He is visibly distressed, tachycardic, and has multiple contusions on his chest and abdomen. According to the Advanced Trauma Life Support (ATLS) protocol, arrange the following initial assessment and management steps in the correct chronological order.

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Answer

The correct sequence follows the ATLS primary survey protocol: Airway, Breathing, Circulation, Disability, and Exposure.
The Advanced Trauma Life Support (ATLS) primary survey dictates a strict chronological sequence to identify and treat the most lethal injuries first: Airway maintenance with cervical spine protection, Breathing and ventilation, Circulation with hemorrhage control, Disability (neurologic evaluation), and Exposure/Environmental control (ABCDE). Adhering to this specific order prevents premature focus on distracting injuries.

Step-by-Step Solution

1
Recall the Advanced Trauma Life Support (ATLS) primary survey algorithm.
The algorithm follows the sequential ABCDE mnemonic.
This standardized, chronological approach ensures that the most immediately life-threatening conditions are identified and treated first.
2
Map the provided clinical actions to their corresponding steps in the ABCDE algorithm.
Airway = establishing patency with c-spine restriction; Breathing = assessing breath sounds; Circulation = evaluating pulses and controlling hemorrhage; Disability = rapid neurological evaluation; Exposure = completely undressing the patient.
Accurate categorization of each clinical action allows for correct sequencing.
3
Order the mapped actions sequentially.
The sequence is established as Airway, followed by Breathing, Circulation, Disability, and finally Exposure.
This strictly follows the prioritization of physiological needs in trauma resuscitation.

Key Concept

Advanced Trauma Life Support (ATLS) Primary Survey (ABCDE)
Estimated Time:45s
Question 3429Question →

For each of the following patients presenting with depressed mood, select the most appropriate initial or next-step intervention based on their specific clinical diagnosis.

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Items

A 24-year-old woman presenting with a 6-week history of severe depressed mood and hypersomnia. Review of systems reveals a distinct 5-day period last year involving decreased sleep and impulsive spending. She currently takes no medications.
A 71-year-old man with major depressive disorder who expresses a fixed delusion that his organs are decaying. He has refused all oral intake for four days, resulting in acute kidney injury and hemodynamic instability.
A 45-year-old woman presenting with a 6-week history of tearfulness and difficulty concentrating that began days after an unexpected divorce. She experiences reactivity of mood and does not meet full criteria for a major depressive episode.
A 60-year-old man presenting with new-onset pervasive sadness, anhedonia, and insomnia. These symptoms began two weeks after starting high-dose prednisone for giant cell arteritis. He has no prior psychiatric history.

Matches

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Answer

The correct matches pair bipolar II depression with quetiapine, life-threatening psychotic depression with urgent ECT, adjustment disorder with psychotherapy, and medication-induced depression with tapering the offending corticosteroid.
Each depressive syndrome requires precise identification to select the optimal intervention. Bipolar depression requires mood stabilization, severe psychotic depression with medical compromise requires ECT, adjustment disorder is treated with psychotherapy, and medication-induced depression is managed by modifying the offending agent.

Step-by-Step Solution

1
Analyze each patient's clinical history to differentiate the specific etiology of their depressed mood.
Patient 1 has bipolar II depression; Patient 2 has unipolar psychotic depression with medical emergency; Patient 3 has an adjustment disorder; Patient 4 has substance/medication-induced depressive disorder.
Accurate diagnosis among the differential for depressed mood is required before selecting an intervention.
2
Match the specific psychiatric diagnosis to its optimal evidence-based management strategy.
Bipolar depression warrants an atypical antipsychotic (quetiapine). Medically compromised psychotic depression requires rapid somatic therapy (ECT). Adjustment disorder is primarily treated with psychotherapy. Medication-induced mood changes are managed by dose reduction.
To ensure the intervention directly targets the underlying pathophysiology while minimizing the risk of adverse outcomes (e.g., manic switch, worsening renal failure).

Key Concept

The management of depressed mood requires differentiating unipolar major depressive disorder from bipolar depression, adjustment disorder, and substance-induced mood disorders, as each has distinct treatment pathways.
Estimated Time:1m 30s
Question 3430Question →

Evaluate the following patient scenarios and match each clinical presentation to its most accurate DSM-5 psychiatric diagnosis within the eating disorder spectrum.

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Items

A 24-year-old graduate student with a BMI\text{BMI} of 16.2 kg/m216.2 \text{ kg/m}^2 is evaluated for severe hypokalemia. She reports recurrent episodes of consuming excessively large amounts of high-calorie foods, immediately followed by self-induced vomiting. Despite her emaciated appearance, she insists she is overweight and needs to lose more fat.
A 22-year-old retail worker with a BMI\text{BMI} of 22.8 kg/m222.8 \text{ kg/m}^2 is evaluated for bilateral parotid gland hypertrophy and dental enamel erosion. She frequently eats excessively large meals and subsequently uses enemas to prevent weight gain. She expresses intense fear of becoming obese.
A 27-year-old accountant with a BMI\text{BMI} of 17.5 kg/m217.5 \text{ kg/m}^2 is evaluated for progressive weight loss. He restricts his diet entirely to liquid nutritional shakes due to a profound fear of vomiting, which began after a severe bout of viral gastroenteritis. He is highly distressed by his weight loss and desires to gain weight.
A 35-year-old teacher with a BMI\text{BMI} of 34.1 kg/m234.1 \text{ kg/m}^2 is evaluated for depression. She describes recurrent episodes of rapidly consuming large quantities of snacks until uncomfortably full, typically when experiencing work-related stress. She feels intense shame and disgust with herself afterward but takes no measures to counteract the caloric intake.

Matches

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Answer

Patient 1 matches Anorexia nervosa (binge-eating/purging type); Patient 2 matches Bulimia nervosa; Patient 3 matches Avoidant/restrictive food intake disorder (ARFID); Patient 4 matches Binge-eating disorder.
Correct matching requires systematic evaluation of weight, behaviors, and cognitions. Patient 1's low BMI (<18.5) and body image distortion classify her as having Anorexia nervosa, despite the bulimic behaviors. Patient 2 exhibits identical compensatory behaviors but maintains a normal weight, correctly diagnosing Bulimia nervosa. Patient 3 has significant weight loss but lacks body image distortion, pointing to ARFID resulting from a fear of vomiting. Patient 4 exhibits binging without compensatory behaviors, which is characteristic of Binge-eating disorder.

Step-by-Step Solution

1
Analyze the patient's body mass index (BMI).
Patients 1 and 3 are significantly underweight (BMI<18.5 kg/m2\text{BMI} < 18.5 \text{ kg/m}^2). Patients 2 and 4 have normal or elevated BMIs.
BMI is the primary metric used to differentiate Anorexia nervosa from Bulimia nervosa.
2
Identify the presence or absence of binge eating episodes and inappropriate compensatory behaviors.
Patients 1 and 2 exhibit both binging and purging/compensatory behaviors. Patient 4 exhibits only binging. Patient 3 exhibits neither.
The presence of compensatory behaviors rules out Binge-eating disorder, while the presence of binging and purging differentiates subtypes of Anorexia nervosa.
3
Assess the patient's core psychopathology regarding body image.
Patients 1 and 2 have severe body image distortion and fear of weight gain. Patient 3 restricts food due to a fear of the aversive consequences of eating (choking/vomiting) and is distressed by his weight loss.
Absence of body image distortion in an underweight patient who restricts intake is the key diagnostic feature of Avoidant/restrictive food intake disorder.

Key Concept

The differentiation of eating disorders relies heavily on objective weight parameters (BMI thresholds), the presence or absence of compensatory behaviors, and the underlying motivation for dietary restriction (body image distortion versus aversive food responses).
Question 3431Question →

Match each psychiatric emergency presentation with its most appropriate specific targeted treatment or intervention.

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Items

A 34-year-old man on maintenance haloperidol presents with profound muscle stiffness, diaphoresis, autonomic instability, and a core temperature of 40.0°C (104.0°F).
A 45-year-old woman taking tranylcypromine reports sudden onset of a severe occipital headache and has a blood pressure of 210/120 mmHg after attending a wine and cheese tasting.
A 28-year-old man prescribed fluoxetine and recently started on linezolid develops agitation, diaphoresis, hyperreflexia, and spontaneous ankle clonus.
A 52-year-old man with bipolar disorder presents with lethargy, coarse tremors, ataxia, and a measured specific serum medication level of 3.8 mEq/L.
A 22-year-old woman taking divalproex sodium presents with acute disorientation and asterixis; laboratories reveal an ammonia level of 120 µmol/L with normal hepatic transaminases.

Matches

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Answer

Match NMS to bromocriptine/dantrolene; MAOI hypertensive crisis to phentolamine; Serotonin Syndrome to cyproheptadine; severe lithium toxicity to hemodialysis; and valproate-induced hyperammonemic encephalopathy to L-carnitine.
Each psychiatric emergency requires precise identification of its underlying etiology to administer the correct targeted intervention. NMS requires dopamine agonism (bromocriptine); a tyramine crisis requires alpha-blockade (phentolamine); Serotonin Syndrome requires serotonin antagonism (cyproheptadine); severe lithium toxicity with neurological compromise requires hemodialysis; and valproate-induced encephalopathy requires L-carnitine to correct depleted stores.

Step-by-Step Solution

1
Analyze the haloperidol case.
Identify Neuroleptic Malignant Syndrome.
Fever, lead-pipe rigidity, and autonomic instability after an antipsychotic point to NMS, which is treated with bromocriptine or dantrolene.
2
Analyze the tranylcypromine case.
Identify Tyramine-induced Hypertensive Crisis.
An MAOI combined with tyramine-rich aged cheese causes a catecholamine surge, requiring alpha-blockade with phentolamine.
3
Analyze the fluoxetine/linezolid case.
Identify Serotonin Syndrome.
An SSRI plus the MAOI-activity of linezolid causes serotonin excess (hyperreflexia, clonus), treated with the serotonin antagonist cyproheptadine.
4
Analyze the bipolar patient with high medication levels.
Identify Severe Lithium Toxicity.
A lithium level > 2.5 mEq/L with pronounced neurological symptoms (ataxia, lethargy) necessitates emergent hemodialysis.
5
Analyze the divalproex sodium case.
Identify Valproate-induced Hyperammonemic Encephalopathy.
Asterixis and hyperammonemia with normal LFTs in a patient on valproic acid are treated with L-carnitine.

Key Concept

Pharmacological and procedural management of acute, life-threatening psychiatric emergencies and medication-induced toxidromes.
Question 3432Question →

Match each clinical presentation of a psychiatric or substance-related emergency to the most appropriate specific pharmacological treatment or reversal agent.

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Items

A 24-year-old man develops severe 'lead-pipe' muscle rigidity, a temperature of 103.5°F (39.7°C), and diaphoresis two days after his haloperidol dose was increased.
A 32-year-old woman presents with myoclonus, hyperreflexia, agitation, and shivering shortly after starting sumatriptan for migraines while maintained on fluoxetine.
A 19-year-old man experiences a sudden, sustained upward deviation of the eyes and painful neck twisting hours after receiving a dose of fluphenazine.
A 28-year-old woman is brought to the emergency department unresponsive, with dry mucous membranes and a widened QRS complex on electrocardiogram after ingesting a bottle of pills.
A 45-year-old man with a history of alcohol use disorder presents with confusion, visual hallucinations, tachycardia, and severe tremors 72 hours after his last drink.

Matches

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Answer

The correct matches pair each psychiatric emergency with its definitive pharmacological treatment: Neuroleptic Malignant Syndrome with Bromocriptine, Serotonin Syndrome with Cyproheptadine, Acute Dystonia with Benztropine, TCA toxicity with Sodium bicarbonate, and Alcohol Withdrawal Delirium with Lorazepam.
Each matching pair correctly identifies the reversal agent or definitive medical treatment for a distinct, life-threatening psychiatric or substance-related emergency based on its underlying receptor mechanism.

Step-by-Step Solution

1
Identify the primary clinical diagnosis for each patient presentation.
The diagnoses are NMS, Serotonin Syndrome, Acute Dystonia, TCA Toxicity, and Alcohol Withdrawal Delirium.
Recognizing the toxidrome or emergency state is the prerequisite to selecting the appropriate antidote.
2
Determine the underlying pathophysiology of each condition.
NMS is caused by dopamine blockade, Serotonin Syndrome by serotonin excess, Acute Dystonia by dopamine-acetylcholine imbalance, TCA toxicity by sodium channel blockade, and Alcohol Withdrawal by GABA down-regulation.
The pharmacological treatment targets the specific pathophysiological mechanism.
3
Select the appropriate reversing agent for each mechanism.
Bromocriptine overcomes dopamine blockade; Cyproheptadine blocks serotonin receptors; Benztropine restores anticholinergic balance; Sodium bicarbonate overcomes sodium channel blockade; Lorazepam enhances GABAergic activity.
Matching the mechanism to the drug ensures correct treatment selection.

Key Concept

Recognition of psychiatric emergencies and acute toxidromes, and their definitive pharmacological management.
Question 3433Question →

Match each of the following major cardiovascular conditions to its most characteristic clinical presentation and appropriate initial clinical context.

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Items

Stanford Type A Aortic Dissection
Stanford Type B Aortic Dissection
Ruptured Abdominal Aortic Aneurysm
Acute Limb Ischemia

Matches

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Answer

Stanford Type A is matched with anterior chest pain and a new diastolic murmur. Stanford Type B is matched with interscapular back pain managed medically. Ruptured Abdominal Aortic Aneurysm is matched with abdominal pain, a pulsatile mass, and hypotension. Acute Limb Ischemia is matched with abrupt limb pain, pallor, and pulselessness.
Each vascular emergency has a distinct classic presentation that dictates its management. Type A dissections involve the ascending aorta, causing anterior chest pain and potential aortic regurgitation. Type B dissections affect the descending aorta, present with back pain, and are managed medically. Ruptured AAAs present with the classic triad of hypotension, back pain, and a pulsatile mass. Acute limb ischemia presents with sudden cessation of blood flow leading to the 6 Ps.

Step-by-Step Solution

1
Analyze the anatomical and clinical hallmarks of Stanford Type A aortic dissection.
Identified as involving the ascending aorta, which can affect the aortic valve (causing a new diastolic murmur) and arch vessels (causing a blood pressure discrepancy).
To correctly map the condition to its classic presentation and distinguish it from descending aortic disease.
2
Analyze the management and presentation of Stanford Type B aortic dissection.
Identified as involving the descending aorta, presenting with interscapular back pain, and generally managed with strict blood pressure and heart rate control.
To differentiate it from ascending aortic involvement, which requires emergent surgery.
3
Identify the classic triad for a ruptured abdominal aortic aneurysm.
Matched with severe abdominal or back pain, a pulsatile mass, and profound hypotension.
To recognize this catastrophic intra-abdominal vascular emergency.
4
Recall the classic signs of acute arterial occlusion.
Matched with abrupt limb pain, pallor, poikilothermia, paresthesias, and pulselessness.
To correctly identify acute limb ischemia.

Key Concept

Distinguishing major vascular emergencies based on their classic clinical presentation and anatomical location is critical for determining appropriate emergent management.
Question 3434Question →

Paramedics bring a 21-year-old university student to the emergency department following a syncopal episode during a ballet class. Her dance instructor notes she has appeared increasingly emaciated over the past six months and frequently complains of being cold. Upon arrival, the patient expresses intense fear of gaining weight despite her visible cachexia. Vital signs show a temperature of 35.6°C (96.1°F), blood pressure of 82/50 mm Hg, heart rate of 38/min, and respiratory rate of 12/min. Her body mass index is calculated at 12.8 kg/m2. Physical assessment reveals lanugo over her back and acrocyanosis. A 12-lead electrocardiogram demonstrates marked sinus bradycardia with a prolonged QTc interval. Laboratory evaluation highlights a serum potassium of 2.9 mEq/L and a serum phosphorus of 2.2 mg/dL. Arrange the following clinical management steps in the most appropriate chronological order from initial acute presentation to long-term maintenance.

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Answer

The correct sequence is: 1. Admit to an inpatient medical unit, 2. Initiate a low-calorie refeeding protocol, 3. Transition to a residential eating disorder program, 4. Engage in long-term outpatient cognitive-behavioral therapy.
The correct chronological management of a patient with life-threatening anorexia nervosa follows a strict hierarchy of needs, beginning with immediate medical stabilization. Patients presenting with extreme bradycardia, QTc prolongation, hemodynamic instability, or a body mass index less than 15 kg/m2 require admission to an inpatient medical unit equipped with continuous cardiac telemetry to prevent and treat fatal arrhythmias. Once the patient is admitted, the next clinical step is careful nutritional rehabilitation; calories must be introduced slowly (e.g., 10-20 kcal/kg/day) while aggressively replacing potassium and phosphorus to avoid refeeding syndrome. After the patient becomes medically stable and baseline electrolytes are normalized, they must transition to a specialized residential or partial hospitalization program designed for supervised psychiatric weight restoration. Finally, once a safe baseline weight is achieved and starvation-induced cognitive deficits improve, long-term outpatient cognitive-behavioral therapy is initiated to address underlying cognitive distortions and prevent relapse.

Step-by-Step Solution

1
Assess the patient's medical stability and determine the appropriate initial triage level.
The patient is medically unstable due to hypotension, extreme bradycardia, QTc prolongation, and severe malnutrition, requiring inpatient medical admission.
Medical emergencies take precedence over psychiatric treatment; mortality in severe anorexia nervosa is most often due to sudden cardiac arrhythmias.
2
Formulate a plan for nutritional rehabilitation in a severely malnourished patient.
Implement a slow, cautious refeeding protocol while replacing depleted intracellular electrolytes, specifically potassium and phosphorus.
Rapid refeeding triggers insulin release, driving phosphorus and potassium into cells, which can precipitate fatal cardiovascular collapse and respiratory failure (refeeding syndrome).
3
Determine the next level of care once acute medical parameters (vital signs, electrocardiogram, electrolytes) have stabilized.
Transfer the patient to a specialized residential eating disorder program.
Continued weight restoration requires intense behavioral supervision (e.g., monitoring meals, preventing purging or excessive exercise) in a structured psychiatric setting.
4
Plan for long-term psychological maintenance and relapse prevention.
Initiate outpatient cognitive-behavioral therapy for eating disorders.
Cognitive restructuring of body image distortions is crucial for long-term recovery but is largely ineffective until a patient is renourished enough to engage in complex cognitive tasks.

Key Concept

In life-threatening anorexia nervosa, the sequence of multidisciplinary care strictly prioritizes acute medical stabilization and safe refeeding before transitioning to psychiatric weight restoration and long-term psychotherapy.
Question 3435Question →

While on call for the surgical ward, you are urgently called to the bedside of a patient who underwent an open exploratory laparotomy six days ago. The patient had a severe coughing fit and reported feeling a sudden 'popping' sensation in the abdomen. On examination, the surgical dressing is saturated with serosanguinous fluid. When you carefully lift the dressing, you observe that the fascial layer has separated and loops of small intestine are protruding onto the abdominal wall. Arrange the following immediate management steps in the most appropriate chronological order.

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Answer

The correct chronological management of wound evisceration is to first reduce abdominal tension by positioning the patient with flexed knees, followed immediately by covering the exposed viscera with sterile, saline-moistened dressings. Next, the surgical team must be notified to prepare the operating room, and finally, the patient is transported for definitive surgical closure.
Wound evisceration is a surgical emergency requiring immediate and systematic intervention. The first goal is to prevent worsening of the condition by reducing intra-abdominal pressure (positioning). The second goal is organ preservation by preventing the exposed bowel from drying out (saline dressings). Once stabilized at the bedside, the team must coordinate definitive care (calling the OR) and then execute it (transporting the patient).

Step-by-Step Solution

1
Position the patient with flexed hips and knees.
Decreased tension on the abdominal wall fascia.
Reduces intra-abdominal pressure to prevent additional bowel from herniating through the defect.
2
Apply warm, sterile, saline-soaked dressings over the evisceration.
The exposed bowel remains moist and protected.
Prevents tissue desiccation, ischemia, and further contamination of the exposed serosa.
3
Notify the operating room and surgical team.
Surgical resources are mobilized.
Evisceration is an absolute surgical emergency requiring definitive operative closure.
4
Transport the patient to the operating room.
Patient arrives in a sterile environment for surgery.
Definitive management involves washing out the abdomen and securely closing the fascial defect under general anesthesia.

Key Concept

Immediate sequential management of postoperative wound evisceration
Question 3436Question →

A 58-year-old man is brought to the physician by his wife due to profound changes in his behavior over the past 12 months. His wife states that he was previously a reserved and empathetic middle school teacher, but he recently began making sexually explicit comments to strangers at the grocery store. He has also developed a habit of eating exclusively sugary cereals and frequently takes food from the plates of other patrons at restaurants. When confronted about these actions, the patient is apathetic and demonstrates no remorse. His medical history is significant for hyperlipidemia. Vital signs are within normal limits. On mental status examination, he is alert and oriented to person, place, and time. He scores 26/30 on the Montreal Cognitive Assessment, primarily losing points on verbal fluency and abstraction. Memory recall is intact. Neurological examination reveals a positive grasp reflex but is otherwise unremarkable. Which of the following is the most likely diagnosis?

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Answer: Frontotemporal dementia

Answer

Frontotemporal dementia
The correct answer is frontotemporal dementia. This patient's presentation of early-onset personality changes, marked disinhibition (making sexually explicit comments), apathy, hyperorality (exclusive diet of sugary cereals, taking food from others), and relative sparing of memory is highly characteristic of the behavioral variant of frontotemporal dementia (bvFTD). The presence of frontal release signs (such as a positive grasp reflex) further supports frontal lobe dysfunction. Memory is classically preserved early in the disease, whereas executive dysfunction (impaired verbal fluency and abstraction) is prominent.

Step-by-Step Solution

1
Identify the primary clinical manifestations in the vignette.
The patient has early-onset personality changes, marked disinhibition, apathy, hyperorality, and frontal release signs.
Recognizing the core symptoms is essential for differentiating neurocognitive disorders.
2
Evaluate the patient's cognitive profile.
The patient has intact memory recall and orientation but exhibits executive dysfunction (poor verbal fluency and abstraction).
The pattern of cognitive deficits helps rule out memory-predominant dementias like Alzheimer disease.
3
Synthesize the behavioral and cognitive findings to determine the diagnosis.
The combination of severe behavioral variant symptoms with executive dysfunction and spared memory strongly indicates frontotemporal dementia.
These findings strictly meet the clinical diagnostic criteria for the behavioral variant of frontotemporal dementia (bvFTD).

Key Concept

The behavioral variant of frontotemporal dementia presents with early and prominent personality changes, disinhibition, apathy, hyperorality, and executive dysfunction, with relative sparing of memory and visuospatial skills.
Question 3437Question →

During a routine wellness visit, the parents of a 4-year-and-10-month-old male express significant distress regarding their son's pervasive hyperactivity. They report that he is perpetually in motion, often climbing atop tall bookshelves and abruptly darting into busy streets if his hand is not firmly held. Furthermore, he was recently dismissed from his second preschool program due to his inability to remain seated during structured activities and his tendency to forcefully snatch items from peers. These behavioral challenges are consistently observed across home, school, and social environments. His vocabulary is expansive for his age, and his gross and fine motor milestones are within expected parameters. Physical examination and sensory screenings are unremarkable. The parents inquire about initiating a trial of stimulant therapy. Which of the following is the most appropriate initial intervention for this patient?

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Answer: Implementation of parent-directed behavioral management

Answer

The most appropriate initial intervention is the implementation of parent-directed behavioral management.
This patient presents with pervasive symptoms of hyperactivity and impulsivity that cause significant functional impairment (e.g., dismissal from two preschools, dangerous behaviors in public), fulfilling the diagnostic criteria for Attention-Deficit/Hyperactivity Disorder (ADHD). According to the American Academy of Pediatrics (AAP) guidelines, the first-line treatment for preschool-aged children (under 6 years of age) with ADHD is parent-directed behavioral management (also known as parent management training). Pharmacotherapy, such as methylphenidate, is only considered in this age group if behavioral interventions have been maximized and the child continues to experience moderate-to-severe functional impairment.

Step-by-Step Solution

1
Analyze the clinical presentation to establish a preliminary diagnosis.
The patient exhibits severe, pervasive symptoms of hyperactivity, impulsivity, and inattention across multiple settings, resulting in marked functional impairment. This presentation is consistent with Attention-Deficit/Hyperactivity Disorder (ADHD).
Establishing the core pathology is required before selecting a treatment algorithm.
2
Evaluate patient demographics, specifically age, against clinical guidelines.
The patient is 4 years and 10 months old (preschool-aged).
Treatment guidelines for ADHD are heavily age-stratified, specifically demarcating algorithms for children under 6 years versus those 6 years and older.
3
Apply the age-appropriate management algorithm.
For children under 6 years of age, pediatric clinical guidelines mandate behavioral interventions (specifically parent training in behavior management) as the definitive first-line treatment before any pharmacological trials.
Preschool-aged children are more vulnerable to the adverse effects of psychostimulants and demonstrate a less predictable therapeutic response compared to older pediatric cohorts.

Key Concept

Management of Attention-Deficit/Hyperactivity Disorder in Preschool-Aged Children
Question 3438Question →

A 28-year-old woman, G1P0 at 30 weeks gestation, presents to the emergency department with sudden-onset shortness of breath, palpitations, sweating, and a feeling of impending doom that began 30 minutes ago while she was reading a book at home. She states, "I feel like I am going to die." This is her third such episode in the past month. She has recently started avoiding grocery stores and movie theaters because she fears she might have another attack and be unable to quickly escape.

Vital signs are temperature 37.1°C (98.8°F), blood pressure 120/70 mm Hg, pulse 115/min, and respirations 22/min. Pulse oximetry is 99% on room air. Physical examination shows a gravid uterus consistent with dates. The lungs are clear to auscultation bilaterally, and heart sounds are normal.

Arterial blood gas on room air reveals:
pH: 7.44
PaO2: 104 mm Hg
PaCO2: 29 mm Hg
HCO3-: 21 mEq/L

Her past medical history is notable for a distinct 2-week episode of auditory hallucinations and persecutory delusions 5 years ago that resolved completely without recurrence. Two years ago, she was diagnosed with bipolar disorder following an episode of euphoric mood, hypersexuality, and decreased need for sleep. The patient's husband is in the waiting room. The patient explicitly tells the physician, "Please do not discuss my psychiatric history with my husband. I have never told him, and he would not understand."

Which of the following is the most appropriate next step in the management of this patient?

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Answer: Recommend cognitive-behavioral therapy and respect her request for medical confidentiality

Answer

Recommend cognitive-behavioral therapy and respect her request for medical confidentiality
The correct answer addresses the patient's acute presentation of panic disorder with agoraphobia using cognitive-behavioral therapy (CBT), a highly effective first-line treatment. CBT is particularly advantageous here because it avoids both the teratogenic risks of medications during pregnancy and the risk of precipitating a manic episode in a patient with a known history of bipolar disorder. Furthermore, it correctly identifies that a competent patient's medical information cannot be disclosed to her husband against her explicit wishes, as there is no imminent danger to a third party that would legally override her right to confidentiality.

Step-by-Step Solution

1
Analyze the patient's current acute presentation.
The patient is experiencing recurrent, unexpected panic attacks and exhibits agoraphobia (avoiding public places like theaters).
Establishing the primary psychiatric diagnosis determines the need for targeted intervention.
2
Evaluate the medical data and psychiatric history for contraindications.
The ABG shows normal pregnancy physiology (chronic respiratory alkalosis). Her history of bipolar disorder makes antidepressant monotherapy unsafe due to the risk of a manic switch.
Identifying comorbidities helps avoid inappropriate or harmful treatments, such as anticoagulation or SSRI monotherapy.
3
Determine the appropriate ethical response regarding her husband.
The physician must honor the patient's request to withhold her medical history.
Competent adult patients retain the right to medical privacy; pregnancy does not negate confidentiality rights unless there is an imminent threat.
4
Synthesize findings to select the best management step.
Cognitive-behavioral therapy is recommended while maintaining confidentiality.
CBT is first-line for panic disorder, avoids pharmacologic risks in bipolar disorder and pregnancy, and respects ethical boundaries.

Key Concept

The management of panic disorder with agoraphobia in a patient with comorbid bipolar disorder requires non-pharmacologic interventions like CBT to prevent SSRI-induced mania. Additionally, a pregnant patient's right to confidentiality must be strictly maintained unless explicit exceptions (e.g., imminent harm) apply.
Estimated Time:1m 30s
Question 3439Question →

A 39-year-old woman is evaluated in the emergency department for worsening lower abdominal pain and fever. Seven days ago, she underwent an uncomplicated total vaginal hysterectomy for symptomatic uterine leiomyomata. Over the past 48 hours, she has developed a throbbing, constant pain deep in her pelvis, accompanied by chills and mild nausea. She has not experienced vomiting, diarrhea, or dysuria. Her past medical history is unremarkable, and she takes no daily medications. Her temperature is 38.9°C (102.0°F), blood pressure is 118/74 mmHg, pulse is 104/min, and respirations are 16/min. Abdominal examination reveals mild suprapubic tenderness without rebound or involuntary guarding. Bowel sounds are normoactive. Speculum examination demonstrates an intact vaginal cuff with mild erythema. Bimanual pelvic examination reveals a 5-cm, exquisitely tender, fluctuant mass located just superior to the vaginal apex. Laboratory studies show a leukocyte count of 16,500/mm³. Which of the following is the most appropriate next step in management?

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Answer: Transvaginal drainage of the mass and initiation of intravenous antibiotics

Answer

Transvaginal drainage of the mass and initiation of intravenous antibiotics
The correct approach is transvaginal drainage of the mass and initiation of intravenous antibiotics. This patient's presentation on postoperative day 7 with fever, pelvic pain, leukocytosis, and a 5-cm fluctuant mass at the vaginal apex is classic for a vaginal cuff abscess. A vaginal cuff abscess is a type of pelvic abscess that typically develops from an infected hematoma following a hysterectomy. The cornerstone of treatment for any large abscess is source control (drainage) combined with broad-spectrum antimicrobial therapy. Because the collection is located directly above the vaginal cuff, it is highly amenable to transvaginal drainage, which is less invasive and carries lower morbidity compared to abdominal or percutaneous approaches.

Step-by-Step Solution

1
Analyze the patient's postoperative timeline and vital signs.
The patient is on postoperative day 7 with fever (38.9°C) and leukocytosis (16,500/mm³).
Identifying the timing of postoperative fever helps narrow the differential diagnosis. Day 7 primarily points to surgical site infections or deep pelvic collections.
2
Evaluate the physical examination findings.
Bimanual exam reveals a 5-cm, tender, fluctuant mass at the vaginal apex.
A fluctuant mass in the setting of fever and recent surgery strongly indicates an abscess (a localized collection of pus).
3
Determine the appropriate management for a pelvic abscess.
Management requires both source control (drainage) and systemic therapy (antibiotics).
Antibiotics alone cannot adequately penetrate a large, walled-off abscess cavity. Because the mass is located just superior to the vaginal apex, it can be safely and effectively drained transvaginally.

Key Concept

Postoperative pelvic abscesses presenting with a fluctuant mass at the vaginal apex require both broad-spectrum intravenous antibiotics and source control, typically achieved via transvaginal drainage.

Alternative Method

In cases where the abscess is located higher in the pelvis (e.g., tubo-ovarian abscess) or cannot be safely accessed vaginally, CT-guided percutaneous drainage is an appropriate alternative method for achieving source control.
Estimated Time:1m 30s
Question 3440Question →

A 29-year-old man comes to the outpatient clinic to establish care following successful completion of a 28-day residential substance use treatment program. He has a long history of severe opioid use disorder and alcohol use disorder. The patient reports that he has maintained complete abstinence from all opioids and alcohol for the past 24 days. He states, 'I am determined to stay clean this time, but my cravings for both heroin and alcohol are overwhelming.' His past psychiatric history is significant for major depressive disorder. During a previous attempt at outpatient treatment two years ago, he exhibited poor medication adherence and was ultimately discharged from the practice after admitting to diverting his prescribed sublingual buprenorphine-naloxone. Liver function tests obtained at the residential facility last week were within normal limits. Vital signs today are within normal limits. Physical examination shows no signs of intoxication or withdrawal. Which of the following is the most appropriate pharmacotherapy to prevent relapse in this patient?

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Answer: Intramuscular extended-release naltrexone

Answer

Intramuscular extended-release naltrexone
Intramuscular extended-release naltrexone is a mu-opioid receptor antagonist that is highly effective for patients with both opioid and alcohol use disorders. Because it is administered monthly, it overcomes the patient's history of poor daily adherence. Furthermore, as an antagonist, it has zero diversion potential, directly addressing his prior history of selling his medication. Finally, the patient is an ideal candidate because he has been fully abstinent from opioids for 24 days, safely surpassing the required 7-14 day opioid-free window, thereby eliminating the risk of precipitated withdrawal.

Step-by-Step Solution

1
Identify the patient's active diagnoses and current abstinence status.
The patient has both severe opioid use disorder (OUD) and alcohol use disorder (AUD), and has been abstinent from all substances for 24 days.
Establishing the specific substance use disorders and the duration of abstinence dictates which pharmacologic agents are safe and indicated.
2
Analyze psychosocial barriers to treatment success based on patient history.
The patient has a documented history of poor daily medication adherence and diversion of prescribed sublingual buprenorphine-naloxone.
Past behavior strongly predicts future behavior; therapies requiring daily compliance or carrying high diversion potential are contraindicated or highly suboptimal here.
3
Evaluate the pharmacologic options against the clinical parameters.
Naltrexone treats both OUD and AUD. The extended-release intramuscular formulation bypasses daily adherence issues and has zero diversion potential. The 24-day abstinence period means naltrexone can be initiated without precipitating withdrawal.
Synthesizing the need for dual-diagnosis coverage, guaranteed delivery (IM), and lack of street value points directly to intramuscular naltrexone as the safest and most effective choice.

Key Concept

Intramuscular extended-release naltrexone is a highly effective, dual-purpose pharmacotherapy for patients with both opioid and alcohol use disorders. It is particularly indicated for patients with a history of medication nonadherence or diversion, provided they have been completely opioid-free for at least 7 to 14 days to avoid precipitated withdrawal.
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