Psychiatry

A 38-year-old woman with a history of severe social anxiety disorder and treatment-resistant panic disorder is brought to the emergency department by her roommate due to severe agitation, shivering, and confusion. She has been maintained on phenelzine for the past year. Three days ago, her primary care physician prescribed a new daily medication to better manage her ongoing anxiety symptoms, instructing her to stop the phenelzine immediately and start the new drug. Vital signs show a temperature of 39.2°C (102.5°F), blood pressure of 165/100 mm Hg, and pulse of 118/min. Physical examination reveals diaphoresis, dilated pupils, and prominent bilateral clonus in the lower extremities. Which of the following medications was most likely prescribed by the primary care physician?

A 61-year-old man, currently in remission from colon cancer, is evaluated in the oncology survivorship clinic for a 2-month history of pervasive low mood, anhedonia, severe fatigue, and feelings of worthlessness. He is not currently taking any psychiatric medications and has no prior psychiatric history. Based on standard psychiatric guidelines for the stepped-care management of Major Depressive Disorder (MDD), arrange the following clinical steps in the most appropriate chronological sequence, assuming the patient exhibits inadequate responses to initial treatments and eventually develops life-threatening clinical features.

Match each clinical presentation of an adverse drug reaction in a patient treated for bipolar disorder to the most likely responsible psychotropic medication.

A 52-year-old man with a 20-year history of severe alcohol use disorder is admitted to the medical ward for treatment of community-acquired pneumonia. He reports that his last alcoholic beverage was consumed just prior to arriving at the emergency department. To anticipate his clinical course, arrange the following classic manifestations of alcohol withdrawal syndrome in the chronological order in which they most typically first appear, from earliest to latest.

A 28-year-old woman presents to her primary care physician reporting a 6-week history of pervasive sadness, loss of interest in her usual hobbies, significant fatigue, and difficulty concentrating at work. She has no past medical history and takes no medications. Physical examination and initial laboratory studies, including a thyroid-stimulating hormone level, are unremarkable. The physician determines she meets the criteria for a major depressive episode and considers initiating a selective serotonin reuptake inhibitor. Which of the following is the most critical historical information to obtain before prescribing this medication?

A 27-year-old man presents to the clinic reporting sudden, unexpected episodes of intense fear, heart palpitations, diaphoresis, and shortness of breath occurring over the past month. The episodes peak within 10 minutes and resolve after approximately an hour. Between episodes, he constantly worries about having another attack. He has no known medical history. Upon taking a detailed psychiatric history, he reports a past episode where he felt "on top of the world," had a decreased need for sleep (3 hours per night), and engaged in reckless spending for two weeks, which resolved spontaneously. Vital signs and physical examination are unremarkable. An electrocardiogram shows normal sinus rhythm. Which of the following are the most appropriate initial steps in the evaluation and management of this patient? (Select all that apply)

A 54-year-old man is admitted to the hospital with acute pancreatitis. He has a 15-year history of heavy daily alcohol consumption, and his last drink was 24 hours ago. On examination, he is agitated, diaphoretic, and tremulous. Vital signs show a temperature of 37.8°C (100.0°F), blood pressure of 165/95 mm Hg, and heart rate of 118/min. Laboratory studies reveal a blood glucose of 68 mg/dL, aspartate aminotransferase (AST) of 185 U/L, alanine aminotransferase (ALT) of 82 U/L, and total bilirubin of 3.2 mg/dL. He has temporal muscle wasting and a scaphoid abdomen. The patient expresses a strong desire to achieve long-term sobriety after this hospitalization. Arrange the following steps in the most appropriate chronological order for the comprehensive management of this patient, from immediate acute stabilization to long-term relapse prevention.

Assess the following diverse clinical presentations of patients experiencing fear-based or stress-related psychiatric symptoms. Select the most appropriate diagnosis for each patient presentation based on symptom duration and clinical characteristics.

An 81-year-old man is brought to the primary care clinic by his son due to a 9-month history of gradual memory decline. The son reports that the patient frequently repeats questions, has stopped managing his own finances, and recently got lost while walking in his familiar neighborhood. The patient has a history of hypertension and osteoarthritis. Vital signs are within normal limits, and the physical examination is unremarkable. After completing a thorough clinical history and medication review, arrange the following steps in the diagnostic evaluation of this patient's suspected neurocognitive disorder in the most appropriate chronological order, from the immediate next step to advanced workup.

For each patient vignette describing a mood-related presentation, select the most appropriate primary treatment modality or specific medication.

A 26-year-old male graduate student presents to the student health clinic complaining of severe exhaustion and low mood for the past month. He states he has no energy to attend lectures, sleeps 12 hours a day, and has lost interest in playing the guitar, which is his favorite hobby. He describes feeling immensely guilty over his lack of productivity. Upon further questioning, he reveals that two years ago he experienced a distinct 3-week period where he required only 2 hours of sleep per night, felt 'full of brilliant ideas,' and maxed out his credit cards buying equipment to start a music production company. That episode resolved without medical intervention. He currently takes no medications and has no history of substance use. The physician is planning to initiate pharmacological therapy for his current presentation.

Which of the following are appropriate pharmacological interventions for this patient's current episode? (Select all that apply)

A 24-year-old man is brought to the clinic by his sister due to bizarre behavior. For the past 3 months, he has been hearing voices telling him that he is on a special mission, and he believes that the government is monitoring his thoughts. His sister notes that he has stopped going to work and spends most of his time in his room. He has no history of medical illnesses, and a urine toxicology screening is negative. He does not display any symptoms of depression or mania. Which of the following is the most likely diagnosis?

An accompanied 71-year-old male patient presents to the geriatrics clinic for the evaluation of distressing 'visions' that have worsened over the past 11 months. According to his daughter, who lives with him, the patient frequently sees unfamiliar people sitting in their living room. These detailed visual hallucinations cause him severe agitation. Over the same timeframe, his cognitive abilities have declined, characterized by pronounced day-to-day fluctuations in attention and alertness. The daughter also reports that he often shouts and thrashes during sleep. Physical examination reveals an expressionless face, right-sided resting tremor, and cogwheel rigidity in the upper extremities. Initial non-pharmacological management, including environmental modifications, has failed to alleviate his distress. Which of the following is the most appropriate initial pharmacological therapy for this patient's visual hallucinations?

Paramedics bring a 24-year-old female university student to the acute care clinic after her roommates found her unresponsive on the couch. Her temperature is 36.5°C (97.7°F), blood pressure is 105/62 mm Hg, pulse is 55/min, and respiratory rate is 6/min. Pulse oximetry shows an oxygen saturation of 86% on room air. On physical examination, the patient is somnolent and minimally responsive to sternal rub. Cardiopulmonary auscultation reveals shallow but clear breath sounds bilaterally and a bradycardic but regular heart rhythm. Pupillary examination demonstrates 1.5-mm pupils bilaterally that are sluggishly reactive to light. Bowel sounds are diminished. Which of the following is the most appropriate next step in management?

Match each clinical presentation to the most appropriate psychiatric diagnosis based on symptom duration and characteristics.

A 34-year-old male combat veteran presents to the psychiatric outpatient clinic seeking help for severe irritability, insomnia, and intrusive memories. He returned from a combat deployment 14 months ago and has since struggled to reintegrate into civilian life. He avoids crowded places, refuses to watch war movies, and describes feeling "constantly on guard." His wife reports that he frequently wakes up thrashing and sweating. A review of his past medical records reveals a psychiatric hospitalization at age 23 for a 2-week episode of euphoric mood, flight of ideas, and severely decreased need for sleep, which resulted in significant financial debt. He is currently not taking any medications and denies any illicit substance use, though he admits to drinking 4-5 beers nightly to help him sleep.

Which of the following is the most appropriate initial pharmacologic step in the management of this patient's symptoms?

A 23-year-old female law student is evaluated at the university student health clinic for a 4-week history of depressed mood, sleeping up to 14 hours a day, significant weight gain, leaden paralysis, and an inability to concentrate on her coursework. Her medical history is unremarkable. A detailed psychiatric history reveals that one year ago, she experienced a 3-week period where she felt 'invincible,' required only 2 hours of sleep per night, exhibited hypersexuality, and spent thousands of dollars on luxury items, which ultimately resulted in a brief psychiatric hospitalization. She is currently medically stable and taking no medications. The physician is planning the next steps in her management. Which of the following interventions are appropriate for this patient? (Select all that apply)

An 82-year-old female is currently hospitalized on the medical ward for treatment of community-acquired pneumonia. On hospital day 3, the nursing staff urgently reports that the patient has become acutely agitated, is forcefully pulling at her intravenous lines, and claims she sees insects crawling on the ceiling. According to her family, she lives independently and her baseline cognitive status is fully intact. Arrange the following steps in the evaluation and management of this patient's acute change in mental status in the most appropriate chronological sequence, from the initial, most immediate action to the intervention of last resort.

Match each classic clinical presentation with the most likely corresponding substance intoxication.

A 31-year-old man visits the outpatient psychiatry clinic seeking help for career stagnation. Despite receiving excellent performance reviews as an independent data analyst, he recently declined a lucrative promotion that required him to oversee a small team. He admits, "I am terrified they will criticize my management style and realize I am inadequate." He expresses a deep desire for close friendships and a romantic partner but spends his weekends entirely alone, stating, "I can't interact with people unless I am 100% sure they already like me." He denies any history of hallucinations, delusions, or manic episodes. He occasionally feels depressed about his isolation but does not meet the criteria for a major depressive episode. Which of the following is the most accurate statement regarding this patient's presentation and management?