Psychiatry

Match each pharmacologic agent used in the maintenance treatment of bipolar disorder with its characteristic adverse effect profile and associated monitoring requirements.

A $23$-year-old woman presents to the outpatient psychiatric clinic with a $2$-month history of profound sadness, fatigue, and social withdrawal. She reports sleeping up to $14$ hours a day and experiencing a strong craving for carbohydrate-rich foods, leading to a $5$-kg ($11$-lb) weight gain. She states her arms and legs frequently feel "so heavy, it is as if my bones have turned to solid stone." Despite her depressed mood, she notes that she felt briefly happy and energized last week when she received a good grade on an exam, though the low mood quickly returned. She also reports occasionally hearing a voice calling her name just as she is drifting off to sleep. She has no chronic medical conditions. Vital signs are within normal limits. Laboratory studies reveal a thyroid-stimulating hormone (TSH) level of $1.8 \text{ \mu U/mL}$ (normal $0.5-5.0 \text{ \mu U/mL}$) and free thyroxine (T4) of $1.2 \text{ ng/dL}$ (normal $0.9-1.7 \text{ ng/dL}$). She is currently not taking any medications. She requests an antidepressant to help her focus on her studies. Which of the following is the most appropriate next step in the management of this patient?

Emergency medical services arrive at the hospital with an unresponsive individual found in a public transit station. Initial assessment reveals a respiratory rate of 4 breaths per minute, oxygen saturation of 82% on room air, and miotic pupils. Track marks are visible on the patient's antecubital fossae. The clinical team must manage the patient from acute presentation through stabilization and eventual hospital discharge. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 42-year-old man is evaluated in the psychiatric clinic for a six-week history of pervasive sadness, insomnia, low energy, and feelings of worthlessness. He frequently thinks about death but has no active suicidal plan. Vital signs and physical examination are unremarkable. Routine laboratory studies, including thyroid function tests, are within normal limits. During the interview, the patient mentions that in his late twenties, he had a one-week period where he slept only two hours a night, felt extremely energetic, and took out multiple unapproved bank loans for a 'revolutionary' business idea. He was hospitalized during that episode. He is currently taking no medications. What is the most appropriate next step in pharmacological management for this patient?

A 26-year-old woman presents to the clinic seeking assistance with smoking cessation. She has smoked one pack of cigarettes per day for the past 6 years. The patient also reports feeling "down" and fatigued for the past 6 months. Her BMI is 21 kg/m^2. Vital signs are within normal limits. Physical examination is notable for mild bilateral parotid gland enlargement and calluses on the dorsum of her right hand. Upon further questioning, the patient admits to episodes of eating abnormally large quantities of food followed by self-induced vomiting 3 to 4 times per week over the past year. Laboratory studies show a serum potassium of 3.2 mEq/L and a serum chloride of 94 mEq/L. The physician discusses pharmacological options for smoking cessation and considers prescribing bupropion. Which of the following best explains why bupropion is contraindicated in this patient?

A 31-year-old woman, G1P1, comes to the outpatient clinic 6 weeks after an uncomplicated vaginal delivery. She is accompanied by her husband, who is concerned about her behavior. For the past 4 weeks, she has experienced profound sadness, frequent crying spells, and a pervasive sense of guilt regarding her parenting. She reports waking up at 3 AM daily and being unable to return to sleep, even when her infant is sleeping. She describes her mood as consistently worse in the mornings and notes no improvement in her mood even when playing with her newborn or when her parents visit. She lacks the energy to perform basic household tasks. She denies suicidal ideation or thoughts of harming the infant. She recalls experiencing a period of "severe depression" in her early twenties that lasted for several months but resolved without treatment. She is currently breastfeeding and takes prenatal vitamins. She does not use tobacco, alcohol, or illicit substances. Vital signs are within normal limits. Which of the following is the most appropriate next step in the evaluation or management of this patient?

An occupational health physician is reviewing the records of a 29-year-old woman currently hospitalized for psychiatric stabilization. A detailed collateral history is obtained from her husband. The patient first experienced psychiatric symptoms 5 years ago, characterized by a 2-month period of profound sadness, anhedonia, and severe insomnia, accompanied by auditory hallucinations commanding her to harm herself. She received treatment and was completely asymptomatic for the next two years. Three years ago, she developed a persistent belief that her neighbors were surveilling her and began hearing two voices conversing about her behavior. She has experienced these psychotic symptoms continuously for the last 36 months. However, during this 36-month period, her mood, energy, and sleep were entirely normal until 2 weeks ago. Over the past 2 weeks, she abruptly developed severe euphoria, pressured speech, and a decreased need for sleep, while still experiencing the paranoia and auditory hallucinations. Medical workup and urine toxicology are unremarkable. Which of the following is the most accurate diagnosis?

A 30-month-old boy is brought to the pediatrician by his parents due to concerns regarding his language development. The parents report that he uses approximately 10 single words and does not combine them into phrases. When he desires a snack, he physically guides his father's hand to the pantry rather than pointing or vocalizing his request. He rarely makes eye contact when his name is called. The parents also note that he becomes severely agitated and inconsolable if his daily routine is altered, such as taking a different driving route to the grocery store. On physical examination, the boy is able to jump in place, walk up stairs while holding the handrail, and stack a tower of seven blocks. A comprehensive audiology evaluation performed last week revealed normal hearing bilaterally. Based on the patient's presentation, which of the following statements regarding his developmental status and management are accurate? (Select all that apply)

Evaluate the concise patient vignettes below and link each to the most accurate DSM-5 psychiatric classification.

A psychiatric consult service is reviewing the charts of four newly evaluated patients who present with prominent depressive symptoms. Each patient's presentation requires a distinct pharmacological or procedural approach. Match each patient's clinical profile with the most appropriate next step in management or treatment strategy.

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

Match each patient's clinical presentation of an antipsychotic-associated complication to the most appropriate next step in pharmacological or clinical management.

An emergency department physician evaluates a 29-year-old man who presents with a rapidly spreading, painful dermatologic eruption. The patient has a known psychiatric history of bipolar I disorder, for which he has been maintained on divalproex sodium for the past four years without any manic relapses. Six weeks ago, his outpatient psychiatrist prescribed an additional medication to address a severe, functionally impairing depressive episode. Upon physical examination, the patient's temperature is 39.2°C (102.6°F). There is a widespread, tender, purpuric maculopapular rash exhibiting epidermal detachment when lateral pressure is applied. Erosions are visible on the buccal mucosa and bilateral conjunctivae. Which of the following prescribing oversights is the most likely cause of this patient's current presentation?

A 22-year-old male college student is brought to the psychiatric emergency department by his parents due to severe depression. For the past four weeks, he has isolated himself in his room, slept up to 15 hours a day, eaten very little, and frequently expressed feelings of worthlessness. He admits to having passive thoughts of suicide but denies any active plan. Review of his medical record reveals a prior psychiatric hospitalization three months ago. During that admission, he presented with a 4-week history of sleeping only 2 hours per night, rapid and pressured speech, excessive spending, and experiencing auditory hallucinations of 'angels' telling him he was chosen for a divine mission. His symptoms resolved completely during that hospitalization with the temporary use of haloperidol, and he has not taken any medications since discharge. Vital signs are within normal limits, and the physical examination is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

Paramedics arrive at the emergency department with a $24$-year-old male who was found severely agitated and disoriented outside a music festival. Bystanders reported seeing him consume a crystalline powder they believed to be "Molly" (MDMA) several hours prior. The patient's roommate, who accompanied him in the ambulance, notes that the patient has a history of major depressive disorder and recently began taking a daily medication prescribed through an online telehealth service.

Upon evaluation in the trauma bay, the patient is combative and profoundly confused. Vital signs demonstrate a temperature of $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$), pulse of $142/\text{min}$, respiratory rate of $24/\text{min}$, and blood pressure of $175/105\text{ mm Hg}$. The physical examination is notable for excessive diaphoresis, bilateral pupillary dilation, and extreme muscle rigidity in the lower extremities accompanied by spontaneous ankle clonus.

Which of the following represents the most appropriate next step in patient care?

A 79-year-old hospitalized man with a history of mild vascular dementia develops acute-onset disorientation, visual hallucinations, and severe psychomotor agitation on his third evening following a laparoscopic cholecystectomy. He is shouting at the nursing staff, exhibiting a fluctuating level of consciousness, and repeatedly attempting to remove his peripheral intravenous catheter. Arrange the following management steps in the most appropriate clinical escalation sequence for treating this patient's acute behavioral disturbance.

A busy metropolitan emergency department evaluates four patients presenting with varying signs of acute substance intoxication or withdrawal. Match each patient's clinical presentation with the most likely corresponding toxidrome or substance-related state.

A 26-year-old woman is evaluated in the outpatient clinic for a two-month history of sudden, unpredictable episodes of overwhelming fear, palpitations, and a sensation of impending doom. These episodes reach their peak intensity within minutes and typically resolve after 15 to 20 minutes. Due to an intense fear of experiencing another episode in public, she has stopped using public transportation and avoids going to shopping malls. Her past psychiatric history is significant for a psychiatric hospitalization at age 21 for a severe manic episode involving grandiosity, rapid speech, and a decreased need for sleep. She was treated with a mood stabilizer at that time but discontinued the medication three years ago and has remained euthymic since. She also has a history of opioid use disorder and has been successfully maintained on buprenorphine-naloxone therapy for the past three years. Vital signs are within normal limits, and a recent comprehensive medical workup was unremarkable. Which of the following is the most appropriate next step in management?

A $21$-year-old female university student is evaluated in the emergency department for severe muscle cramps, palpitations, and dizziness when standing. She says she has been overwhelmed by her coursework and admits to having episodes where she eats excessively large quantities of food in a short period. Following these episodes, she induces vomiting because she is terrified of gaining weight. Her body mass index is $22.5 \text{ kg/m}^2$. Blood pressure is $98/60 \text{ mm Hg}$ supine and $82/50 \text{ mm Hg}$ upon standing. Heart rate is $105/\text{min}$. Physical examination reveals bilateral painless swelling of the cheeks and callous formation on the dorsum of her right hand. Laboratory studies reveal the following:

In addition to acute intravenous fluid and electrolyte resuscitation, which of the following is the most appropriate step in the management of this patient's condition?

A 32-year-old woman is evaluated in the outpatient psychiatric clinic for worsening mood. She delivered a healthy full-term infant 2 months ago. For the last 3 weeks, she has experienced profound sadness, anhedonia, loss of appetite resulting in a 3-kg (6.6-lb) weight loss, and extreme guilt about being a "terrible mother." For the past week, she reports hearing a persistent, derogatory voice telling her she should "disappear." Her husband notes that 6 years ago, she had a 3-week period where she abruptly quit her job, slept only 2 hours per night but felt fully energetic, exhibited pressured speech, and maxed out their credit cards. This previous episode required a brief psychiatric hospitalization, but she stopped taking her prescribed medications 5 years ago. She currently takes no medications. Vital signs are within normal limits. On examination, she exhibits a blunted affect and psychomotor retardation. Which of the following is the most appropriate next step in management?