Psychiatry

Match each clinical presentation with the most likely sleep-wake disorder diagnosis.

A 52-year-old woman presents to the outpatient clinic accompanied by her husband. For the past 10 months, she has complained of alternating episodes of shortness of breath, severe fatigue, and lower extremity heaviness. She states, "I know my heart or lungs are failing, but no one will listen to me." She brings a detailed log of her symptoms, daily resting heart rates, and oxygen saturation readings. Over the past month, she has visited the emergency department three times for these symptoms. Review of her medical records reveals a recent normal echocardiogram, clear chest radiograph, and normal pulmonary function tests. Laboratory studies from two weeks ago showed a normal thyroid-stimulating hormone (TSH) level but a borderline low total T4 level. The patient spends six hours a day researching her symptoms on medical forums and has taken a leave of absence from her job due to severe distress. Her physical examination today is unremarkable. Which of the following is the most appropriate next step in management?

A 29-year-old woman comes to the psychiatry clinic seeking help for severe, distressing thoughts. For the past 6 months, she has experienced recurrent, intrusive images of accidentally leaving the stove on and burning down her house. These thoughts cause intense anxiety. To relieve this anxiety, she feels compelled to check the stove exactly seven times before leaving the house, often making her late for work. She recognizes that these thoughts and behaviors are excessive but feels unable to stop them. A review of her psychiatric history reveals a hospitalization 5 years ago for a 10-day episode of persistently elevated mood, grandiosity, decreased need for sleep, and pressured speech. She is currently prescribed phenelzine for depression, but she states it is not helping her checking behaviors. She is open to both psychological and new pharmacological interventions.

Which of the following statements regarding the diagnosis and management of this patient are correct? (Select all that apply)

A 28-year-old woman is brought to the clinic by her husband due to severe anxiety, poor sleep, and behavioral changes. Three weeks ago, she was the victim of a violent home invasion. Since the event, she has experienced frequent, distressing flashbacks, severe insomnia, and an exaggerated startle response. She refuses to be left alone in the house, feels detached from her family, and is unable to return to work. Her medical history is notable for bipolar I disorder, which has been well-controlled on lithium for 5 years. She is also taking phenelzine, prescribed by a previous physician for treatment-resistant depression prior to her bipolar diagnosis. She is requesting medication to help alleviate her current distress. Which of the following are appropriate next steps in the management of this patient? (Select exactly 2)

A 32-year-old woman presents to an outpatient addiction medicine clinic seeking treatment for severe opioid use disorder. She reports using intravenous heroin daily for the past 3 years and expresses a strong desire to stop. She is currently not intoxicated and shows no signs of opioid withdrawal, having last used heroin 2 hours ago. She and the physician agree to initiate buprenorphine/naloxone therapy. Arrange the following clinical steps in the correct chronological sequence required to safely and effectively initiate and maintain this pharmacotherapy.

A 45-year-old man presents to the clinic with a 6-week history of persistently depressed mood, profound anhedonia, terminal insomnia, 5-kg (11-lb) weight loss, and difficulty concentrating. He denies any suicidal ideation and exhibits no psychotic features. He has no prior psychiatric or medical history and is currently treatment-naive. Based on standard clinical guidelines, arrange the following management steps in the most appropriate chronological sequence for this patient. Assume that at each subsequent step, the patient experiences an inadequate clinical response despite adequate trial duration, documented medication adherence, and good tolerability.

Match each acute psychiatric emergency or adverse medication effect with its most appropriate definitive pharmacological management.

An internal medicine physician is evaluating a 76-year-old male patient who presents with his daughter due to concerns about his worsening memory and unusual behavior over the past 14 months. The daughter reports that his cognitive abilities fluctuate drastically; on some days he is highly conversational and independent, while on other days he stares blankly for hours and requires help with dressing. He frequently reports seeing "small animals" hiding in the corners of his room. His medical history includes hypertension, benign prostatic hyperplasia, and Bipolar I disorder. He discontinued his mood stabilizer 5 years ago against medical advice but has remained euthymic since. Current medications include amlodipine, tamsulosin, and carbidopa-levodopa, which was initiated two months ago by a neurologist for a newly developed resting tremor and bradykinesia.

The patient's daughter is his legally appointed healthcare proxy via a verified advance directive. However, his estranged son is also present at the visit and demands that the physician immediately prescribe a strong medication to "stop the crazy visions," explicitly overriding his sister's request for a cautious approach.

On mental status examination, the patient is alert but oriented only to person. He scores $19/30$ on the Montreal Cognitive Assessment, with pronounced deficits in visuospatial function and executive tasks. Physical examination reveals bilateral cogwheel rigidity in the upper extremities.

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

Match each patient's clinical presentation with the most appropriate next step in management or specific therapeutic intervention.

Match each clinical vignette to the most accurate DSM-5 diagnosis.

A 38-year-old female presents to the clinic with an 8-week history of depressed mood, significant weight loss, early morning awakenings, and severe anhedonia, causing her to take a leave of absence from work. Over the subsequent 14 months, her clinical condition progresses through multiple phases of treatment resistance, eventually culminating in a psychiatric admission for active suicidal ideation with a specific plan. Arrange the following clinical actions in the correct chronological sequence according to evidence-based management guidelines for this patient's evolving condition, from her initial presentation through her eventual inpatient admission.

A 78-year-old man is hospitalized for community-acquired pneumonia. On the evening of hospital day 3, he becomes acutely confused, agitated, and combative towards nursing staff. He attempts to pull out his intravenous line, claiming that "snakes are biting his arm." His baseline cognitive function is intact. Arrange the following interventions for managing this patient's acute agitation in the correct escalating sequence, from the initial preferred approach to the absolute last resort.

A 24-year-old female graphic designer comes to the outpatient clinic reporting a 4-week history of feeling 'completely drained.' She states that she struggles to get out of bed, sleeps up to 14 hours daily, and has lost interest in her hobbies. She has gained 4 kg (8.8 lb) during this time. Her past psychiatric history is significant for a period during her sophomore year of college when she felt 'supercharged' for two weeks, requiring only 2 to 3 hours of sleep per night, talking rapidly, and aggressively confronting her professors, which ultimately led to a brief academic suspension. She is currently sexually active with a male partner and relies on the withdrawal method for contraception. Medical history is unremarkable, and she currently takes no medications. Which of the following are appropriate next steps or considerations in the management of this patient? (Select all that apply)

A 21-year-old college student presents to the student health clinic reporting a 4-week history of low mood, fatigue, poor concentration, and insomnia. Temperature is 37.0°C (98.6°F), blood pressure is 118/76 mm Hg, and pulse is 72/min. Physical examination reveals a well-groomed young man with no acute distress. On mental status examination, he has a depressed affect and slightly delayed speech, but his thought process is linear. When specifically asked about self-harm, he admits to occasional thoughts of suicide but adds, "I could never actually do it. My religion strictly forbids it, and it would destroy my parents." He denies having any specific plan, intent, or past suicide attempts. During the evaluation, the patient explicitly requests that his parents not be told about his clinic visit or his depressive symptoms, stating he does not want to burden them. The physician determines the patient has the capacity to make medical decisions. Which of the following is the most appropriate next step regarding the patient's privacy?

A 19-year-old woman is admitted to the hospital with severe anorexia nervosa, restricting type. She presents with a BMI of 13.2 kg/m^2, a heart rate of 38/min, and a blood pressure of 82/50 mm Hg. The patient reports consuming only small amounts of water and black tea for the past two weeks. The multidisciplinary team is formulating a comprehensive treatment plan to ensure medical stabilization and long-term recovery while minimizing the risk of fatal complications. Arrange the following clinical management steps in the most appropriate sequential order, from immediate admission priorities to long-term management.

An 82-year-old retired pilot is currently admitted to the surgical ward on post-operative day three following an open reduction and internal fixation of a right femoral neck fracture. The on-call physician is paged urgently by the nursing staff because the patient has suddenly become highly disoriented, verbally aggressive, and is actively attempting to remove his peripheral intravenous catheter and surgical dressings. His baseline cognitive status prior to admission was completely intact.

Arrange the following clinical actions in the most appropriate sequential order for the evaluation and management of this patient's acute behavioral decompensation.

A 16-year-old girl is brought to the emergency department by her parents after she fainted during gymnastics practice. She has a 9-month history of severe dietary restriction and intense fear of gaining weight. Her current body mass index (BMI) is $13.2 \text{ kg/m}^2$. Vital signs show a temperature of $35.2^\circ\text{C}$ ($95.4^\circ\text{F}$), blood pressure of 82/50 mm Hg, and a heart rate of 34/min. Physical examination reveals diffuse muscle wasting, lanugo, and delayed capillary refill. Initial laboratory studies show:

An electrocardiogram (ECG) reveals sinus bradycardia with a QTcF of 510 ms.

Arrange the following management steps in the most appropriate chronological order to safely stabilize and treat this patient.

A 20-year-old collegiate gymnast is evaluated at the university clinic after reporting several weeks of profound muscle weakness, generalized fatigue, and intermittent muscle cramps. Her vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), heart rate 94/min, blood pressure 105/65 mm Hg, and respiratory rate 18/min. BMI is 19.5 kg/m $^2$. Physical examination reveals dry mucous membranes and diminished deep tendon reflexes bilaterally. Her dental enamel is completely intact, and there are no calloused lesions on the dorsal aspects of her hands. The parotid glands are not enlarged.

Laboratory studies are obtained and show the following:

Which of the following compensatory behaviors is most likely responsible for this patient's clinical and laboratory findings?

During a routine follow-up at a community health clinic, a $29$-year-old male construction worker describes experiencing severe restlessness, diffuse muscle aches, abdominal cramping, and insomnia over the previous $36$ hours. The patient discloses that he had been illicitly purchasing oxycodone to self-medicate for chronic lower back pain. However, he abruptly discontinued its use $2$ days ago to 'get clean.' He is highly motivated to remain abstinent and emphatically declines any opioid-based substitution therapy, emphasizing his desire for a non-addictive treatment option. Vital signs reveal a temperature of $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure of $156/98\text{ mm Hg}$, heart rate of $118\text{ /min}$, and respiratory rate of $18\text{ /min}$. Physical examination demonstrates an anxious, diaphoretic patient with prominent piloerection, frequent yawning, and mydriasis. To specifically target this patient's acute autonomic hyperarousal, the physician prescribes a non-opioid medication. Which of the following neuropharmacological mechanisms best describes the action of the most appropriate drug for this indication?

A 24-year-old woman presents to the outpatient psychiatry clinic complaining of persistent sadness, fatigue, and lack of motivation for the past month. She reports sleeping up to 14 hours a day, an increased appetite with a 4 kg (8.8 lb) weight gain, and difficulty concentrating at work. Medical history is unremarkable, and she does not use illicit substances. During the interview, she mentions that two years ago, she experienced a distinct 6-day period where she felt exceptionally energetic and creative. During that time, she slept only 2 hours a night without feeling tired, spoke much faster than usual, and impulsively booked an expensive vacation she could not afford. Her symptoms during that period did not require hospitalization and resolved spontaneously. If initiated as monotherapy for her current presentation, which of the following medications is most likely to precipitate an adverse psychiatric outcome?