Psychiatry

A 41-year-old chef is brought to the outpatient clinic by his business partner due to a severe decline in functioning over the past six weeks. The patient describes a pervasive feeling of emptiness, increased appetite, and sleeping up to 12 hours daily. He also reports occasionally hearing a voice telling him he is a 'complete failure.' He has stopped going to the restaurant and avoids social contact. The business partner notes that four years ago, the patient had a distinctly different episode lasting three weeks during which he slept only three hours a night, talked incessantly, and maxed out multiple credit cards to launch an ill-advised catering business. The patient takes no medications and has no other medical conditions. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in management?

A 28-year-old woman presents to the psychiatry clinic with a 4-month history of recurrent, unexpected episodes of intense fear. These episodes are accompanied by palpitations, sweating, shortness of breath, and a feeling of impending doom. She constantly worries about having another episode and has started avoiding public transportation as a result. Her past medical history is significant for bipolar I disorder, but she discontinued all her psychiatric medications 2 years ago against medical advice and currently takes no medications. The physician and patient are discussing treatment options for her current symptoms. Which of the following is the most appropriate next step in management?

For each of the following patient scenarios involving depressive symptoms or related disorders, select the most appropriate targeted pharmacotherapy or management step.

Match each clinical vignette with the most appropriate personality disorder diagnosis.

A 55-year-old man is recovering on the telemetry floor following a myocardial infarction. Throughout his hospitalization, he has been meticulously recording his vital signs, fluid intake, and medication administration times in a personal notebook. He frequently argues with the nursing staff, insisting that his medications be given at the exact minute they are scheduled, rather than within the hospital's standard 30-minute administration window. When the attending physician suggests a minor adjustment to his cardiac rehabilitation plan, the patient becomes visibly anxious, stating that they must stick to the 'original protocol,' and demands to read the primary research articles supporting the change. His wife notes that his need for order and perfectionism has caused significant strain in their marriage, as he insists household tasks be done 'exactly his way.' Which of the following represent appropriate management strategies for this patient's underlying personality structure while he is hospitalized? (Select all that apply)

A 32-year-old woman is evaluated in the outpatient clinic for a 1-month history of severe depressed mood, hypersomnia, profound fatigue, and passive suicidal ideation. She has no formal psychiatric history. However, upon further questioning, the patient's husband reports that during her college years, she had a distinct 3-week period where she slept only $3$ hours per night, spoke so rapidly she was difficult to understand, claimed she was "chosen by God to solve world hunger," and drained her savings account. Her medical history is significant for essential hypertension and obesity. Current medications include hydrochlorothiazide and a multivitamin. Her BMI is $34 \text{ kg/m}^2$. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $128/82 \text{ mm Hg}$, and heart rate $78\text{/min}$. Physical examination is unremarkable. Recent fasting laboratory results show a blood glucose of $124 \text{ mg/dL}$ and hemoglobin A1c of $6.2\%$. Mental status examination reveals psychomotor retardation, blunted affect, and a depressed mood. Which of the following is the most appropriate pharmacotherapy for this patient's current episode?

A 28-year-old woman presents to the outpatient clinic seeking treatment for heroin addiction. She states that her last heroin use was approximately 18 hours ago. She currently complains of severe muscle aches, abdominal cramps, and anxiety. On physical examination, she exhibits rhinorrhea, piloerection, and pupillary dilation. The physician plans to initiate treatment with buprenorphine-naloxone. Arrange the following steps in the most appropriate sequential order for the comprehensive management of this patient's opioid use disorder, from immediate acute presentation to long-term care.

A 30-year-old man presents to the clinic reporting a 4-week history of persistent sadness, sleeping 12 hours a day, and lacking energy to do his usual activities. He mentions having a history of a distinct 10-day period during his college years when he felt "on top of the world," had racing thoughts, and stayed awake for days working on multiple projects without feeling tired. His only current medication is lisinopril for mild hypertension. A thyroid panel performed last week showed a TSH of 2.1 µU/mL (normal: 0.5-5.0 µU/mL) and a normal free T4. The physician is evaluating pharmacological treatment options. Which of the following statements regarding the management of this patient is most accurate?

A 34-year-old architect is brought to the emergency department by his spouse due to increasingly erratic behavior. For the past week, he has slept only two hours per night, stating he feels "more energized than ever." He has maxed out multiple credit cards purchasing expensive aviation parts to build a "revolutionary flying vehicle" in his garage. On examination, he paces around the room continuously, and his speech is so rapid and pressured that it is difficult to interrupt. His spouse reports that three weeks ago, the patient visited his primary care provider for profound sadness, hypersomnia, and anhedonia that had persisted for a month. At that visit, he was diagnosed with a psychiatric condition and started on a new daily medication. Which of the following actions by the primary care provider prior to initiating this medication would most likely have prevented the patient's current presentation?

A 28-year-old male is evaluated in an ambulatory clinic for a 4-week history of persistent sadness, hypersomnia, profound fatigue, and poor concentration. He reports struggling to get out of bed in the morning and has missed multiple days of work as an accountant. His medical history is significant for occasional migraines, for which he takes sumatriptan as needed. Vital signs are within normal limits. Physical examination shows no abnormalities. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 2.1 µU/mL (normal: 0.5-5.0 µU/mL). Upon further questioning, the patient describes a distinct two-week period three years ago when he felt "on top of the world," required only two hours of sleep per night, spoke very rapidly, and successfully renovated his entire house by himself without feeling tired. He was not hospitalized during that time. Which of the following is the most appropriate pharmacotherapy for this patient's current condition?

A 3-year-old boy is brought to the clinic by his parents due to concerns about his speech and behavior. He has a vocabulary of only 5 to 10 words and does not use two-word phrases. The parents report that he rarely makes eye contact and does not point to objects to share interest. He prefers to play alone and spends hours lining up his toy cars in a specific order. If the cars are moved by someone else, he becomes extremely agitated and cries inconsolably. His motor development is age-appropriate; he runs well, walks up stairs, and feeds himself with a spoon. A recent audiometry evaluation showed normal hearing. Which of the following is the most likely diagnosis?

A medical student on a psychiatry clerkship is reviewing the adverse effect profiles and monitoring requirements for various psychotropic medications used in the treatment of bipolar disorder. Match each medication below with its most characteristic adverse effect profile and required monitoring parameters.

Evaluate the following concise clinical presentations and match each patient's symptom profile with the most accurate DSM-5 psychiatric diagnosis.

Match each pediatric clinical vignette with the most likely neurodevelopmental diagnosis.

Match each mood stabilizer commonly used in the management of bipolar disorder with its most characteristic adverse effect profile.

A 42-year-old accountant is evaluated for a two-month history of pervasive sad mood, anhedonia, and poor concentration. He is seeking treatment for the first time. Arrange the following clinical steps in the standard chronological order they should be considered, starting with the initial evaluation and progressing through the escalation of care for increasingly treatment-resistant depression.

A 42-year-old executive is diagnosed with severe Major Depressive Disorder (MDD) without psychotic features. Despite excellent medication adherence, the patient's symptoms prove progressively difficult to treat over several months. Arrange the following steps in the standard evidence-based sequence for the management and escalation of care for MDD, from initial presentation through to the management of severe treatment-resistant depression.

A 24-year-old man is brought to the emergency department by his parents due to bizarre and erratic behavior over the past 3 weeks. He has barricaded himself in his bedroom, claiming that foreign intelligence agents have implanted a device in his head and are monitoring his thoughts. His parents report that he has slept less than 2 hours per night over this period and has been continuously pacing and speaking at a rapid pace. The patient has a history of major depressive disorder, for which he was started on citalopram 6 weeks ago. Vital signs are temperature 37.8°C (100.0°F), pulse 122/min, respirations 18/min, and blood pressure 162/98 mmHg. Physical examination reveals bilateral pupillary dilation, marked diaphoresis, and multiple linear excoriations on his face and forearms. Neurologic examination reveals normal muscle tone and absent clonus. Routine urine toxicology screen results are pending. Which of the following is the most likely diagnosis?

A 42-year-old man presents to the clinic reporting persistent, overwhelming anxiety. For the past 8 months, he has worried excessively about his job security, finances, and family health. He describes feeling constantly 'on edge,' tires easily, and has severe muscle tension in his neck and shoulders. His medical history is significant for treatment-resistant major depressive disorder, for which he has been taking the monoamine oxidase inhibitor (MAOI) tranylcypromine for the past year with excellent symptom control. Vital signs are within normal limits. The physician diagnoses generalized anxiety disorder (GAD) and discusses pharmacological treatment options. Which of the following medications can be safely initiated for his GAD without precipitating a life-threatening drug-drug interaction? (Select all that apply)

A $42$-year-old male construction manager presents to the clinic accompanied by his wife. He reports a $6$-week history of feeling "completely hollow," sleeping up to $14$ hours a day, having a ravenous appetite, and experiencing severe heavy feelings in his arms and legs. He has gained $7$ kg ($15.4$ lbs) during this period. Review of his medical history reveals an incident four years ago where he went $8$ days sleeping only $2$ hours a night, became convinced he was chosen by a deity to build a new city, and spent $40,000$ dollars of his savings on barren land. This episode resulted in an involuntary psychiatric hospitalization. He stopped taking all prescribed medications three years ago. His vital signs are normal, and a recent comprehensive metabolic panel and thyroid-stimulating hormone (TSH) level of $2.2$ $\mu$ U/mL (normal: $0.4$-$4.0$ $\mu$ U/mL) are unremarkable. Which of the following is the most appropriate next step in pharmacotherapy for this patient's current presentation?