Psychiatry

A 20-year-old male university student is brought to the emergency department by his roommate due to severe agitation and confusion. The roommate reports that the patient has been acting increasingly bizarre over the last six hours. When questioned, the roommate admits the patient ingested multiple bottles of over-the-counter dextromethorphan-containing cough syrup earlier today in an attempt to experience hallucinations. The patient has a history of major depressive disorder, for which he takes daily fluoxetine. Vital signs show a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), pulse of $134/\text{min}$, blood pressure of $172/105\text{ mmHg}$, and respiratory rate of $22/\text{min}$. Physical examination reveals a diaphoretic, flushed young man who is disoriented to time and place. He exhibits spontaneous muscle twitching and a coarse bilateral tremor. Neurologic examination is notable for marked hyperreflexia in the lower extremities and sustained ocular clonus. In addition to providing intravenous fluids and supportive care, which of the following is the most appropriate next step in management?

Emergency medical services bring a 26-year-old woman to the hospital due to severe agitation and confusion that began abruptly this morning. According to her roommate, the patient has been recovering from an upper respiratory tract infection over the past few days and recently started taking a new over-the-counter syrup for a persistent, dry cough. Her only daily prescription medication is citalopram for major depressive disorder. Upon arrival, the patient appears profoundly restless and disoriented. Vital signs show a temperature of 38.9°C (102.0°F), blood pressure of 162/94 mm Hg, heart rate of 128/min, and respiratory rate of 22/min. Physical examination reveals warm, diaphoretic skin and visibly dilated pupils. She has continuous rhythmic muscle twitching in her lower extremities, brisk patellar reflexes (4+ bilaterally), and sustained ankle clonus. Which of the following active ingredients is most likely present in the cough medication this patient consumed?

A 32-year-old woman is evaluated in the psychiatry clinic for ongoing management of major depressive disorder. She initially presented two years ago with a 3-month history of pervasive sadness, anhedonia, significant weight loss, and severe insomnia leading to functional impairment at work. Over the course of her illness, she has required progressive escalation of her treatment regimen due to inadequate responses. Arrange the following therapeutic interventions in the generally accepted chronological sequence that her physician would have followed, from initial diagnosis to the management of severe, treatment-resistant symptoms.

A 31-year-old man with a known diagnosis of schizophrenia is brought to the emergency department by police due to severe agitation and threatening behavior. He is pacing rapidly in the examination room, yelling at staff, actively responding to internal stimuli, and clenching his fists. Arrange the following management steps in the most appropriate sequential order for this patient, from the initial approach to the intervention of absolute last resort.

Match each acute medication-induced psychiatric emergency or toxidrome with its most appropriate specific therapeutic intervention.

A 26-year-old female software engineer is evaluated in the outpatient clinic for an 8-month history of excessive, uncontrollable worry. She reports being constantly anxious about her job performance, personal finances, and the health of her parents. This worry is accompanied by severe muscle tension, easily fatiguing, and difficulty falling asleep. During the psychiatric review of systems, the patient mentions that two years ago she experienced a distinct one-week period where she felt "on top of the world," slept only two hours a night without feeling tired, talked more rapidly than usual, and accumulated significant debt from impulsive online shopping. She currently takes no medications other than an oral contraceptive pill. Vital signs are within normal limits. Physical examination reveals mild trapezius muscle tenderness but is otherwise unremarkable. Which of the following statements regarding the evaluation and management of this patient are correct? (Select all that apply)

A 34-year-old man is newly diagnosed with severe major depressive disorder without psychotic features. Over the course of 18 months, his symptoms prove to be highly refractory to standard treatments despite confirmed medication adherence. Arrange the following clinical management steps in the most appropriate chronological sequence, reflecting the standard escalating algorithm for treatment-resistant depression.

A 34-year-old man presents to a new primary care physician complaining of severe fatigue, sleeping 12 to 14 hours a day, significant weight gain, and an inability to experience pleasure in his usual hobbies for the past two months. He states that his depressive symptoms are significantly impairing his daily functioning and requests a specific prescription for an antidepressant. Upon detailed psychiatric review, he mentions that four years ago, he experienced a one-month period where he abruptly quit his job, maxed out several credit cards to start a speculative business venture, and felt "like a superhuman" despite resting for only an hour each night. He was involuntarily hospitalized during that period due to aggressive behavior but subsequently declined long-term medication. He has no other medical conditions and his physical examination is unremarkable. Which of the following is the most appropriate pharmacological therapy for this patient's current symptoms?

A 25-year-old man is brought to the psychiatry clinic by his brother. The brother reports that for the past 3 months, the patient has been barricading himself in his apartment because he believes federal agents are monitoring his thoughts. During the interview, the patient maintains poor eye contact, speaks with a flat affect, and occasionally turns his head to whisper to seemingly empty space, stating that he is answering "the voices." The brother notes that the patient was functioning well and working as a software engineer until 3 months ago when these symptoms abruptly began. The patient has had no periods of depressed mood, increased energy, or decreased need for sleep. Medical workup and urine toxicology screening are unremarkable. Which of the following is the most likely diagnosis?

A 33-year-old female paramedic presents to the occupational health clinic reporting severe insomnia, emotional numbness, and being constantly "on edge" for the past 6 months. She states her symptoms began after she responded to a mass casualty incident. She reports recurrent, distressing nightmares about the scene and goes out of her way to avoid driving near the location of the incident. Her medical history includes bipolar II disorder, for which she stopped taking medication three years ago, and a recent skin infection for which she is currently taking linezolid. Laboratory results show a TSH of 1.5 mU/L (Normal: 0.4-4.0) and a free T4 of 0.6 ng/dL (Normal: 0.8-1.8). She requests medication to help her sleep and improve her mood. Her father, who drove her to the clinic, approaches the physician in the hallway and asks for an update on her condition because he is worried about her recent anger outbursts. Which of the following is the most appropriate next step in management?

During a routine health maintenance visit, the parents of a 24-month-old boy express deep concern that their son might have a neurodevelopmental disorder. They report reading online that toddlers should speak in complete sentences by age 2 and are worried because he only uses two-word phrases, such as "want juice" or "go out". His current vocabulary consists of approximately 60 words. The parents also mention that he occasionally has temper tantrums when transitioning from playtime to bedtime, during which he cries and drops to the floor. These episodes typically resolve within five minutes after redirection. On examination, the child makes appropriate eye contact, points to pictures in a book when named, and engages in pretend play with a toy telephone. He can run, kick a ball, and build a tower of six blocks. Which of the following is the most appropriate next step in management?

A 47-year-old man is evaluated in the emergency department for altered mental status, fever, and severe agitation that started a few hours ago. His wife reports that he had been recovering from a minor ankle sprain sustained over the weekend. His medical history is significant for treatment-resistant major depressive disorder, for which he has been taking tranylcypromine for the past two years. His temperature is 39.4°C (102.9°F), blood pressure is 168/105 mm Hg, and pulse is 128/min. On physical examination, the patient is visibly diaphoretic. Neurological examination reveals spontaneous clonus in the lower extremities and horizontal ocular clonus. He recently started taking a new medication prescribed for his ankle sprain. Which of the following medications was most likely prescribed?

A 31-year-old accountant visits the family medicine clinic accompanied by his partner. He reports a 5-week history of profound sadness, decreased energy, and difficulty concentrating. He states that he sleeps up to 14 hours a day and has gained 6 kg (13 lbs) over the past month. He describes a persistent sensation that his arms and legs are "weighed down by lead." His partner notes that his mood occasionally brightens for a few hours when they go out to his favorite restaurant, but he quickly reverts to feeling depressed. He has missed several days of work. He has no significant past medical history. Family history is notable for a mother who was hospitalized multiple times for erratic behavior and severe mood swings. Physical examination and basic laboratory studies, including thyroid function tests, are within normal limits. The physician determines that the patient is experiencing a major depressive episode. Which of the following is the most critical next step in management prior to initiating pharmacotherapy?

A 28-year-old man is brought to the emergency department with altered mental status, severe agitation, and tremors. He recently started taking linezolid for a methicillin-resistant Staphylococcus aureus skin infection while maintaining his usual daily dose of sertraline. Vital signs are temperature 39.8°C (103.6°F), pulse 132/min, respirations 22/min, and blood pressure 165/95 mm Hg. Physical examination reveals marked diaphoresis, mydriasis, hyperreflexia, and spontaneous ankle clonus. Arrange the following management steps in the correct sequential order for this patient, from the immediate initial action to interventions reserved for progressive or severe refractory symptoms.

Match each patient's core clinical presentation to the most accurate definitive DSM-5 diagnosis.

Match each clinical presentation following the initiation of antipsychotic therapy (left) with the underlying receptor mechanism or affected neuroanatomical pathway (right).

Evaluate the following distinct patient scenarios and pair each clinical description with the most accurate psychiatric diagnosis.

Match each psychotropic medication used during pregnancy with its most characteristic associated fetal or neonatal adverse effect.

A 23-year-old female college student presents to the university health center complaining of intense sadness, exhaustion, and an inability to enjoy her usual activities over the last 96 hours. Upon further questioning, she admits to participating in a three-day period of continuous cocaine consumption to celebrate the end of her final exams. Her drug use ceased four days prior to this visit. Since that time, she notes that she sleeps approximately 15 hours daily, has an insatiable appetite, and experiences disturbing nightmares. She has no previous history of mental health disorders. Her vital signs are within normal limits, and physical evaluation shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?

A 31-year-old man comes to the outpatient psychiatry clinic reporting a 2-month history of sudden, terrifying episodes of "feeling like I am going to die." During these episodes, which peak within 10 minutes, he experiences intense palpitations, diaphoresis, shortness of breath, and chest tightness. He has had six of these episodes in the past month. Recently, he has stopped taking the subway to work because he fears being unable to escape if an episode occurs. The patient has no significant past medical history and his physical examination, including an electrocardiogram, is normal. Upon further psychiatric history, the patient describes a 3-week period in his mid-twenties when he felt "invincible," slept only 2 hours a night, spoke incessantly, and aggressively invested his life savings into a fraudulent scheme. He was hospitalized during that time but currently takes no medications. Which of the following is the most appropriate next step in management for this patient?