Psychiatry

Match each clinical presentation of a patient with a depressive disorder to the most appropriate next step in clinical management.

Evaluate the following clinical scenarios detailing distinct neurocognitive or acute neuropsychiatric presentations. Pair each patient vignette with the single most appropriate next step in management or definitive therapeutic intervention.

Evaluate the following distinct patient presentations encountered in an outpatient clinic and pair each with its most accurate diagnostic classification based on DSM-5 criteria.

Match each clinical scenario describing an adverse pharmacological event in a patient being treated for bipolar disorder to the most accurate underlying mechanism of the interaction.

A 48-year-old man is brought to the clinic by his sister due to a 5-month history of progressive forgetfulness, social withdrawal, and difficulty concentrating. The sister reports that he takes an unusually long time to answer simple questions and that his walking has become slow and uncoordinated. His medical history is significant for HIV infection, diagnosed 12 years ago. He admits to poor adherence to his antiretroviral therapy over the past 18 months. His most recent CD4+ T-cell count was 145/mm³. Vital signs are within normal limits. Neurological examination reveals marked psychomotor slowing, saccadic pursuit eye movements, and brisk deep tendon reflexes in the bilateral lower extremities. His Montreal Cognitive Assessment score is 19/30. Magnetic resonance imaging of the brain demonstrates diffuse cortical atrophy and symmetric, bilateral periventricular white matter hyperintensities without contrast enhancement or mass effect. Which of the following is the most likely diagnosis?

A 32-year-old man presents to the outpatient clinic with a 2-month history of persistent sadness, profound fatigue, early morning awakening, and difficulty concentrating at work. He reports that his symptoms have led to a recent poor performance review. He denies suicidal ideation, psychotic symptoms, or active medical problems. Physical examination and baseline laboratory studies are unremarkable. You suspect major depressive disorder (MDD) and plan to initiate treatment. Arrange the following clinical management steps in the most appropriate chronological sequence, assuming the patient eventually requires treatment escalation due to an initial inadequate response.

A 61-year-old retired engineer is brought to the physician by his daughter for a psychiatric evaluation. Over the past five weeks, he has become increasingly withdrawn, spending most of the day in bed. He reports waking up at 3:00 AM daily and being unable to return to sleep. His daughter notes he has lost approximately 5.5 kg (12 lb) during this period and no longer shows interest in his usual hobbies, such as gardening. Two weeks ago, the patient's primary care provider diagnosed him with a major depressive episode and prescribed fluoxetine. The patient states he feels no better and wants to discontinue the medication. Upon further questioning, the daughter recalls that when her father was in his late thirties, he was briefly given a different antidepressant for sadness. Within days of starting that medication, he became excessively talkative, slept only two hours a night for a week, and impulsively bought three luxury vehicles, leading to a brief psychiatric hospitalization. Medical history is otherwise unremarkable, and he takes no other medications. Vital signs are within normal limits. Which of the following is the most appropriate next step in management?

A $27$-year-old man with a history of schizophrenia is brought to the emergency department by his family because he has been standing completely still in the corner of his room for the past $12$ hours. He does not respond to questions, maintains his arm in a raised position when the physician moves it there, and has not eaten or drank anything all day. His current medications include haloperidol and benztropine. Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $120/80\text{ mm Hg}$, pulse $82/\text{min}$, and respirations $14/\text{min}$. Arrange the following management steps in the most appropriate chronological order for this patient's current condition.

During a routine psychiatric intake at a community mental health center, an architect presents voluntarily, seeking help for what he describes as "constant emotional whiplash." The patient reports a long-standing history of intense, tumultuous romantic involvements that invariably end abruptly. He struggles with chronic feelings of inner emptiness and admits to frequent episodes of binge drinking and reckless driving whenever he perceives his partner is withdrawing. Last week, following his therapist's announcement of an upcoming vacation, the patient superficially lacerated his own thighs. Throughout today's interview, his demeanor shifts dramatically; he initially praises the evaluating physician as a "brilliant lifesaver," but later becomes overtly hostile, shouting that the physician is "just as dismissive and useless as the rest of them" after being asked to clarify a timeline. The patient has never experienced distinct manic episodes. He notes occasional feelings of being "detached from reality" during extreme stress, which rapidly resolve once the stressor passes.

Which of the following statements regarding the diagnosis and optimal evidence-based management of this patient's condition are correct? (Select exactly 2 answers)

Match each patient's clinical presentation with the most appropriate next step in pharmacological or procedural management.

A patient with a recent history of ischemic heart disease is evaluated at an outpatient psychiatry practice. The $58$-year-old male suffered a myocardial infarction $3$ months prior, for which he takes aspirin, ticagrelor, rosuvastatin, and metoprolol. He now describes a $6$-week history of unremitting dysphoria, anhedonia, insomnia, and feelings of worthlessness, without any thoughts of self-harm. His physical examination and vital signs are unremarkable at this visit. A diagnosis of major depressive disorder is established, and pharmacotherapy is initiated. Eight days following this appointment, the patient arrives at the urgent care clinic complaining of severe dizziness and near-fainting episodes. Triage vital signs demonstrate a pulse of $40\text{/min}$ and a blood pressure of $88/54\text{ mm Hg}$. A $12$-lead electrocardiogram confirms pronounced sinus bradycardia. Which of the following psychiatric medications is most likely responsible for precipitating this patient's acute presentation?

A psychiatric clinical pharmacist is reviewing the pharmacotherapy regimens of six patients being treated for various phases of bipolar disorder. Each scenario involves a critical drug-drug interaction, a specific administration requirement, or a major prescribing pitfall. Match each clinical scenario with the precise pharmacokinetic or pharmacodynamic rationale that governs its clinical management.

A 74-year-old retired teacher is brought to her primary care physician by her daughter due to progressive forgetfulness and difficulty managing her finances over the past two years. Her medical history includes well-controlled hypertension and hyperlipidemia. The physician suspects a major neurocognitive disorder. Arrange the following diagnostic steps in the most appropriate sequential clinical workflow, from the initial encounter to advanced diagnostic testing.

A 31-year-old woman with severe, treatment-resistant atypical depression has failed multiple antidepressant trials. She is currently taking fluoxetine 60 mg daily but remains profoundly symptomatic. Her psychiatrist decides to transition her to phenelzine.

Arrange the following clinical steps in the correct chronological sequence to safely and effectively execute this medication transition and its long-term management.

Match each clinical presentation describing a medication-induced psychiatric emergency or toxidrome with its most appropriate definitive pharmacological treatment.

A 19-year-old college sophomore is evaluated at the university counseling center for a 6-month history of severe anxiety. She reports experiencing frequent, distressing images of herself being covered in deadly bacteria. To relieve this distress, she spends up to 4 hours a day washing her hands and disinfecting her belongings, causing her to fail two classes this semester. Three weeks ago, she visited a community clinic for low mood and was prescribed phenelzine, which she has been taking daily. She is now seeking treatment specifically for her intrusive thoughts and repetitive behaviors. Which of the following are appropriate management steps? (Select 2)

Match the following patient clinical profiles with the most appropriate next step in management.

Diagnostic boundaries in psychiatry often hinge on precise symptom duration and the exact nature of the triggering event. For each of the following patient encounters, determine the single most appropriate DSM-5 diagnosis by differentiating between overlapping clinical features.

A 75-year-old man is brought to the clinic by his daughter for a cognitive evaluation. Over the past 5 months, he has stopped managing his finances, spends most of the day sitting in a recliner, and frequently complains that his memory is 'completely gone.' When the physician asks him to perform serial sevens and recall three objects, he sighs loudly, states 'I just cannot do this anymore,' and refuses to try. Five months ago, he was forced to surrender his driver's license due to worsening macular degeneration. His daughter notes that he has lost 4.5 kg (10 lb) during this period. Neurologic examination is nonfocal. Which of the following is the most likely diagnosis?

A 25-year-old primigravida at 14 weeks gestation is evaluated in the emergency department for sudden-onset palpitations, chest tightness, trembling, and a feeling of impending doom that awoke her from sleep. The episode peaked within 10 minutes and has now resolved. She has had three similar unexpected episodes over the past month. She now refuses to leave her house unless accompanied by her husband, fearing she will have an attack in public. Medical history is notable for a hospitalization at age 19 for a manic episode with psychotic features; she had been stable on lithium but discontinued it 6 months prior to conception.

Her temperature is 37.0°C (98.6°F), blood pressure is 112/70 mm Hg, pulse is 92/min, and respirations are 18/min. Pulse oximetry is 99% on room air. She mentions a chronic, mild sensation of breathlessness over the last few weeks. Physical examination is unremarkable.

Laboratory results:
- TSH: 0.2 $\mu$ IU/mL (normal: 0.4-4.0 $\mu$ IU/mL)
- Free T $_4$: 1.3 ng/dL (normal: 0.8-1.8 ng/dL)

Arterial blood gas analysis on room air:
- pH: 7.45
- PaCO $_2$: 30 mm Hg
- PaO $_2$: 102 mm Hg

The patient's husband is distressed by her avoidance behaviors and demands she be given an intravenous sedative immediately. However, the patient explicitly declines any pharmacotherapy due to fear of teratogenicity. Which of the following is the most appropriate next step in management?