Psychiatry

A 34-year-old man with a 5-year history of severe heroin use disorder presents to an outpatient addiction clinic seeking treatment. He reports that his last heroin use was 2 hours ago. He is highly motivated to stop using illicit opioids and requests to start buprenorphine/naloxone therapy immediately. To appropriately initiate and maintain his treatment while avoiding iatrogenic complications, arrange the following management steps in the correct chronological sequence.

A 15-year-old girl is admitted to the inpatient pediatric unit for severe anorexia nervosa, restricting type. She has a body mass index (BMI) of 13.2 kg/m², a heart rate of 42/min, and blood pressure of 88/55 mm Hg. Physical examination shows lanugo, temporal wasting, and acrocyanosis. Arrange the following interventions in the most appropriate clinical sequence for the management of this patient, from initial inpatient evaluation to definitive post-hospitalization care.

A 24-year-old man with a recent diagnosis of schizophrenia is admitted to the inpatient psychiatric unit due to worsening paranoia and auditory hallucinations. He is started on high-dose oral haloperidol. As part of patient education, the attending physician discusses the potential adverse extrapyramidal symptoms (EPS) associated with this medication. Arrange the following clinical presentations of EPS in chronological order according to their typical peak onset after initiating the antipsychotic, from earliest (hours/days) to latest (months/years).

A 28-year-old man presents to a primary care clinic with a 2-month history of worsening mood, severe fatigue, and lack of motivation. He reports sleeping up to 12 hours a day but still feeling exhausted upon waking. Additionally, he has experienced a significant increase in appetite, resulting in a 6 kg (13.2 lb) weight gain over the past month. He describes a pervasive sensation of extreme heaviness in his arms and legs, making it difficult to get out of bed. His past medical history is notable for a severe depressive episode at age 20. At that time, he was prescribed a medication that he discontinued after 3 weeks because it made him feel "too wired and agitated." He is currently not taking any medications. Vital signs and physical examination are unremarkable. The physician is considering starting an antidepressant. Which of the following is the most appropriate next step in the management of this patient?

A 19-year-old male college student is brought to the psychiatric clinic by his parents. Eight weeks ago, he was admitted to the emergency department with severe agitation, paranoia, and auditory hallucinations after using synthetic cathinones at a party. He was hospitalized, and his acute intoxication resolved over 3 days. However, his parents report that since his discharge 7 weeks ago, he has continued to hear voices and firmly believes that his professors have planted listening devices in his dormitory. For the past 7 weeks, he has been living at home under strict parental supervision with no access to drugs or alcohol, and weekly random urine toxicology screens have been consistently negative. Over the last two weeks, he has also developed a markedly blunted affect and speaks only in short, one-word answers. Which of the following is the most likely diagnosis?

A 20-year-old man is brought to the emergency department by his roommates due to severe agitation and paranoia. Over the past 4 days, he has barricaded himself in his dorm room, claiming that the university administration has installed hidden cameras to steal his thoughts. He frequently yells at voices that no one else can hear. His roommates report that he has no prior psychiatric history but has been extremely stressed about upcoming final exams. Vital signs show a temperature of 37.9°C (100.2°F), blood pressure of 162/98 mm Hg, and pulse of 118/min. Physical examination reveals pronounced diaphoresis, bilateral mydriasis, and mild fine hand tremors. He is hypervigilant, oriented to person, place, and time, and admits to recently using a 'study aid' given to him by a friend to help him stay awake. Which of the following is the most likely diagnosis?

A 48-year-old male postal worker is brought to the outpatient clinic by his sister due to a one-month history of profound sadness, severe lack of energy, and sleeping up to 14 hours a day. The patient states he feels constantly sluggish, has gained 5 kg (11 lbs) over the last month, and struggles to maintain concentration while sorting mail at work. He has no significant past medical history and takes no medications. Vital signs are within normal limits. Physical examination reveals no abnormalities. On mental status examination, the patient exhibits notable psychomotor retardation, a depressed mood, and a restricted affect. He denies suicidal ideation as well as auditory or visual hallucinations. When specifically asked about his past psychiatric history, his sister notes that three years ago, he experienced a three-week period where he was unusually talkative, slept only 2 to 3 hours a night without feeling tired, and relentlessly painted both his entire house and the neighbor's fence, claiming to possess "limitless energy." This previous episode resolved without medical intervention. Which of the following is the most appropriate next step in pharmacotherapy?

A 58-year-old man presents to the clinic for evaluation of progressive fatigue and poor concentration over the past 6 months. He states that he sleeps 8 hours each night but frequently awakens feeling unrefreshed and with a diffuse morning headache. His wife reports that he snores loudly and occasionally appears to stop breathing for short periods, often waking up with a sudden gasp. He consumes 2 to 3 alcoholic beverages nightly. His medical history includes type 2 diabetes mellitus and hypertension. Current medications are metformin and lisinopril. BMI is $34 \text{ kg/m}^2$. Blood pressure is $152/94 \text{ mmHg}$, pulse is $78 \text{/min}$, and respirations are $14 \text{/min}$. Cardiopulmonary examination reveals clear lungs bilaterally, regular heart rhythm without murmurs, and no jugular venous distention. Laboratory studies show a normal serum thyroid-stimulating hormone concentration. Which of the following is the most appropriate next step in management?

A 62-year-old retired architect with a long-standing history of bipolar I disorder is evaluated in the emergency department for worsening confusion, sluggishness, and an unsteady gait over the past three days. He has been psychiatrically stable on a fixed dose of lithium carbonate for eight years without any recent dosage adjustments. His husband reports that the patient recently started taking an over-the-counter analgesic multiple times a day for a severe flare-up of knee osteoarthritis. Vital signs are within normal limits. Physical examination reveals a coarse, irregular tremor in both upper extremities and pronounced dysarthria. The patient is unable to perform tandem walking without losing his balance. Which of the following mechanisms best explains how the newly initiated analgesic precipitated this patient's current symptoms?

Match each patient's clinical presentation to the most appropriate psychiatric diagnosis.

Match the following neurocognitive or related psychiatric conditions with their most appropriate initial pharmacological management strategy or critical therapeutic constraint.

Match each clinical scenario involving a patient with an anxiety, obsessive-compulsive, or trauma-related disorder to the most appropriate next step in pharmacological management.

A 45-year-old woman is evaluated on the medical ward by the psychiatric consultation-liaison service due to acute-onset agitation and confusion. The patient has a history of major depressive disorder, which has been well controlled on sertraline 150 mg daily for the past two years, and poorly controlled type 2 diabetes mellitus. She was admitted three days ago for a severe diabetic foot infection. Deep tissue cultures grew Vancomycin-resistant Enterococcus faecium (VRE). Yesterday, her intravenous antibiotics were discontinued, and she was transitioned to a targeted oral antibiotic therapy to facilitate hospital discharge. This morning, she became rapidly disoriented and restless. Temperature is 38.6°C (101.5°F), blood pressure is 165/95 mm Hg, pulse is 128/min, and respirations are 20/min. Physical examination reveals a diaphoretic, flushed woman who is unable to answer questions coherently. Her pupils are dilated (6 mm bilaterally). Neurologic examination is notable for 4+ deep tendon reflexes in the lower extremities, spontaneous myoclonus, and sustained bilateral ankle clonus. Which of the following pharmacologic actions of the newly initiated antibiotic is most directly responsible for this patient's current clinical state?

A 32-year-old man is brought to the emergency department by emergency medical services after he was found violently striking parked cars and yelling that "aliens are trying to abduct me." The patient's medical records indicate a history of bipolar I disorder and opioid use disorder. He is currently prescribed lithium and phenelzine. Vital signs are temperature 38.3°C (101.0°F), pulse 132/min, respirations 22/min, and blood pressure 165/100 mm Hg. Physical examination reveals prominent horizontal and vertical nystagmus, diaphoresis, and a lack of pain response when minor lacerations on his hands are examined. The patient is physically restrained for staff safety but continues to struggle aggressively. Which of the following is the most appropriate next step in the management of this patient?

A 25-year-old man is brought to the emergency department by his family due to severely erratic behavior. He is speaking rapidly, pacing the examination room, and claims he has not slept in a week because he is "solving the global energy crisis." He also reports hearing voices praising his supreme intellect. His family notes that he has a 4-year history of recurrent, severe depressive and manic episodes that have required multiple hospitalizations. Notably, 6 months ago, his mood was entirely stable and normal for a 4-week period, but he persistently heard voices and believed his neighbors were spying on him during that entire time. His vital signs and physical examination are unremarkable, and a urine toxicology screen is negative. Which of the following is the most likely diagnosis?

A 76-year-old man is evaluated in the clinic for progressive memory decline. Over the past 9 months, he has been increasingly forgetful, frequently misplacing household items, and recently became lost while driving home from his local grocery store. His son mentions that the patient's wife passed away 12 months ago; initially, the family attributed his forgetfulness to grief. The patient has a medical history of hypertension and bipolar I disorder, for which he has taken valproate for the past 25 years without any recent mood episodes. During the interview, the patient is cheerful, makes good eye contact, and attempts to joke away his memory lapses. When administered a cognitive assessment, he puts forth significant effort but scores 19/30, losing points on orientation, delayed recall, and intersecting pentagons. Which of the following is the most appropriate next step in management?

An otherwise healthy 22-year-old college student seeks medical advice because of irrepressible daytime sleepiness that has been present for the last six months. She consistently falls asleep during her morning lectures and on the bus commute, despite maintaining a regular schedule of eight hours of sleep per night. She notes that her nighttime sleep is frequently fragmented. When asked about other symptoms, she describes several alarming episodes where her knees suddenly buckled and she experienced transient facial weakness specifically when laughing at a friend's joke, forcing her to sit down immediately. Additionally, she reports occasionally seeing a frightening, shadowy figure in her room just as she is drifting off to sleep. Her medical history is unremarkable, and she takes no medications or illicit substances. Vital signs and physical examination are within normal limits. Which of the following is most likely to be found during further evaluation of this patient?

A 28-year-old woman is accompanied to an initial psychiatric evaluation by her sister. The patient has been experiencing persistent auditory hallucinations of two voices conversing about her behavior, along with the fixed belief that neighbors are using radar to monitor her thoughts. According to the sister, these symptoms began insidiously 9 months ago and have been continuously present since. The sister also notes that 4 months ago, the patient developed a markedly depressed mood, significant fatigue, poor appetite, and passive suicidal ideation. This distinct period of low mood lasted for precisely 4 weeks before completely resolving. However, the patient's hallucinations and paranoid beliefs remained completely unchanged before, during, and after this 4-week period of depression. She currently exhibits a blunted affect but denies any sadness or anhedonia. The patient takes no medications, and her physical examination and basic laboratory studies are unremarkable. Urine toxicology is negative. Which of the following is the most likely diagnosis?

An 8-year-old boy is brought to the clinic by his parents due to uncontrollable movements. Over the past 14 months, he has been frequently blinking his eyes forcefully, shrugging his shoulders, and occasionally making loud grunting and throat-clearing noises. These behaviors worsen when he is anxious about school assignments. His parents report that he met all early childhood developmental milestones appropriately. Neurological examination is otherwise unremarkable. Which of the following diagnostic criteria MUST be met to formally diagnose this patient's most likely condition? (Select all that apply)

A 68-year-old man is brought to the clinic by his husband. For the past 8 months, the patient has experienced episodes of shouting, thrashing, and kicking during sleep, typically occurring in the early morning hours. During a recent episode, he accidentally struck his husband in the face. When awakened from these events, the patient reports vivid, action-packed dreams in which he is defending himself from intruders. He has no history of head trauma, seizures, or psychiatric illness. Current medications include a daily multivitamin. Vital signs are within normal limits, and the physical examination, including a detailed neurologic assessment, reveals no abnormalities.

Arrange the following steps in the most appropriate chronological sequence for the diagnostic evaluation and longitudinal management of this patient.