Psychiatry

For each clinical scenario describing an adverse reaction to a psychiatric medication, select the most likely causative antipsychotic agent.

A 45-year-old woman is diagnosed with severe major depressive disorder without psychotic features. Place the following therapeutic interventions in the most appropriate chronological sequence of standard stepped-care escalation, assuming the patient exhibits an inadequate or partial response at each preceding step.

A 19-year-old male college student is currently undergoing psychiatric evaluation following a recent hospitalization for his first psychotic break, during which he experienced severe auditory hallucinations and persecutory delusions. The psychiatrist is reviewing the patient's longitudinal history with his parents to establish a comprehensive, long-term care plan. According to the classic natural history of schizophrenia, arrange the following clinical periods in the correct chronological order from the earliest developmental stage to the late-stage post-acute period.

Emergency medical services personnel bring a 29-year-old man to the emergency department after he was found shouting erratically outside a nightclub. The patient is highly agitated, pacing the room, and repeatedly scratching his forearms, claiming that "insects are trying to burrow into my veins." His medical history includes bipolar I disorder, for which he is prescribed lithium. Vital signs are temperature 38.1°C (100.6°F), blood pressure 172/108 mm Hg, pulse 128/min, and respirations 20/min. Physical examination reveals mydriasis, profuse diaphoresis, and multiple linear excoriations on both upper extremities. The patient is uncooperative with a detailed neurological examination but moves all extremities spontaneously. Which of the following is the most appropriate initial step in the management of this patient?

A 27-year-old woman is brought to the psychiatric clinic by her wife due to concerning behavioral changes. The patient has a history of intermittent profound sadness, anhedonia, and hypersomnia that first began 8 months ago. During these periods of low mood, she frequently reports hearing derogatory voices commenting on her actions. Medical records indicate that she was treated with an antidepressant 4 months ago, which completely resolved her low mood, anhedonia, and sleep disturbances for a period of 5 weeks. However, during that 5-week period of normal, euthymic mood, she continued to hear the same derogatory voices and developed a new fixed belief that her neighbors were planting cameras in her walls. For the past 3 months, her severe low mood and hypersomnia have returned alongside the persistent auditory hallucinations and delusions. A urine toxicology screen is negative, and her physical examination is unremarkable. Which of the following is the most likely diagnosis?

A 52-year-old man with a known history of severe alcohol use disorder is brought to the emergency department by bystanders who found him unresponsive on the street. Initial vital signs show a heart rate of 115/min and blood pressure of 145/90 mm Hg. Point-of-care blood glucose is 42 mg/dL. As he slowly regains consciousness in the emergency department, he becomes visibly tremulous, anxious, and profusely diaphoretic. Arrange the following management steps in the most appropriate chronological order for this patient, proceeding from immediate acute stabilization to long-term outpatient care.

For each of the following clinical scenarios involving a depressive presentation or its treatment, select the most appropriate next step in management.

A 22-year-old male university student is escorted to the urgent care clinic by campus security after he was observed shouting at pedestrians and claiming that invisible drones were tracking his movements. His roommate mentions that the patient attended a rave three days ago and has not slept since. The patient's past medical records show a diagnosis of major depressive disorder, for which he is prescribed daily fluoxetine. Vital signs include a heart rate of 128/min, respiratory rate of 20/min, and blood pressure of 162/98 mm Hg. Physical assessment reveals profuse sweating, bilateral mydriasis, and extensive scratch marks on both arms. The patient states he is trying to remove "parasites" from his skin. Assessment of his reflexes shows 2+ patellar responses bilaterally with no evidence of rigidity or clonus. Which of the following is the most likely diagnosis?

A 54-year-old man is brought to the clinic by his adult daughter. She states that over the last 4 months, her father has been repeatedly filing police reports claiming that local teenagers are entering his garage at night to rearrange his tools. He has installed multiple padlocks and a security system, but he claims the intruders "know how to bypass the sensors." The daughter notes that aside from this specific fixation, his behavior is completely normal. He continues to run his successful landscaping business, maintains his personal hygiene, and enjoys spending time with his grandchildren. He denies hearing voices or seeing things, and his mood has been normal. His medical history is significant only for hypertension, for which he takes lisinopril. A physical examination and medical workup are unremarkable. Which of the following is the most likely diagnosis?

A 62-year-old man is evaluated in the hospital due to rapidly worsening mental status. He was admitted three days ago for complicated cellulitis of the right lower extremity and was started on intravenous linezolid. His past medical history is significant for major depressive disorder, for which he has taken fluoxetine for several years. Today, he developed sudden-onset severe agitation, restlessness, and confusion. His temperature is 39.2°C (102.6°F), blood pressure is 165/100 mmHg, pulse is 124/min, and respirations are 22/min. Physical examination demonstrates excessive diaphoresis and shivering. Neurological examination reveals prominent hyperreflexia and inducible ankle clonus bilaterally in the lower extremities. Initial management with intravenous normal saline, cooling blankets, and intravenous lorazepam does not sufficiently control his severe symptoms. Which of the following is the most appropriate next step in pharmacologic management?

A 31-year-old man presents to the clinic to discuss starting medication for newly diagnosed major depressive disorder. He is prescribed escitalopram 10 mg daily. The physician provides psychoeducation regarding what to expect during the course of treatment. Arrange the following clinical events in the most likely chronological sequence of their typical onset or occurrence after initiating this selective serotonin reuptake inhibitor (SSRI).

An emergency department physician is evaluating several patients presenting with acute psychiatric and physiologic changes related to substance use. Correlate each clinical vignette with the most appropriate diagnosis.

A 28-year-old man with a recent diagnosis of schizophrenia is started on a high-potency first-generation antipsychotic. He is monitored closely for adverse effects. Arrange the following antipsychotic-induced movement disorders in expected chronological order based on their typical timeline of onset, from earliest to latest.

A 22-year-old university student is evaluated in the psychiatry clinic accompanied by his mother. For the past 9 months, he has become increasingly isolated, claims that his professors are inserting thoughts into his mind, and frequently talks to unseen individuals in his room. His academic performance has significantly declined, leading to academic probation. The mother notes that 4 months ago, he experienced a 3-week period during which he felt profoundly sad, slept up to 16 hours a day, had markedly low energy, experienced poor appetite with a 5-pound weight loss, and expressed excessive guilt over failing his classes. This depressive period resolved spontaneously, and his mood has been completely stable since. However, his bizarre beliefs and auditory hallucinations have continued unchanged without interruption for the entire 9 months. He does not use any illicit substances, and his medical history is unremarkable. Which of the following is the most likely diagnosis?

A 17-year-old boy is brought to the emergency department by his parents after experiencing a generalized tonic-clonic seizure at home. The seizure lasted approximately 2 minutes. His parents report that he has become increasingly irritable, secretive, and academically withdrawn over the past month. Earlier today, they heard a loud noise and found him convulsing on his bedroom floor next to an electronic vaping device and an unlabeled vial of liquid. On current evaluation, the patient is highly agitated, diaphoretic, and pacing around the room. He expresses intense paranoia, claiming that the medical staff are trying to harvest his organs. Vital signs show a temperature of 37.7°C (99.9°F), blood pressure of 160/100 mmHg, and heart rate of 128/min. Physical examination is notable for prominent bilateral conjunctival injection. Horizontal and vertical gaze nystagmus are absent. A standard comprehensive urine toxicology screen is negative for all tested substances. Which of the following is the most likely cause of this patient's clinical presentation?

A 32-year-old woman with a history of bipolar I disorder comes to the outpatient psychiatry clinic due to a 4-week history of depressed mood, profound fatigue, and sleeping up to 14 hours a day. Her last manic episode occurred two years ago, and she has been maintained on a stable dose of valproate since that time. Vital signs include a heart rate of 72/min, blood pressure of 118/76 mm Hg, and respiratory rate of 14/min. Mental status examination reveals psychomotor retardation, a blunted affect, and a sad mood. She denies any suicidal ideation. The physician decides to add lamotrigine to her current regimen to target the depressive symptoms. To minimize the risk of a life-threatening dermatologic complication, which of the following pharmacokinetic principles must be applied to the management of this patient?

A 28-year-old woman is brought to the emergency department by ambulance after being found unresponsive with a syringe nearby. On arrival, her respiratory rate is 6/min, oxygen saturation is 82% on room air, and she has pinpoint pupils. She is cyanotic and unarousable to painful stimuli. The medical team is preparing a comprehensive care plan encompassing acute resuscitation and subsequent addiction management.

Arrange the following management steps in the most appropriate chronological sequence for this patient.

Match each clinical vignette describing a patient with major depressive disorder to the most appropriate first-line antidepressant based on their specific comorbidities and symptom profile.

A 34-year-old woman is brought to the outpatient psychiatry clinic by her husband for a follow-up evaluation. He reports that 9 months ago, the patient became increasingly withdrawn, reported feeling profound sadness every day, had significant difficulty sleeping, and lost interest in her usual hobbies. Three months after these initial symptoms began, she started telling her husband that their neighbors were "broadcasting" negative thoughts into her mind and frequently appeared to be responding to unseen voices. She was started on an antidepressant and an antipsychotic medication. Over the past 8 weeks, her mood, energy levels, and sleep have completely returned to normal, and she expresses looking forward to the future. However, she continues to hear the voices daily and insists that the neighbors are still targeting her. She has no history of substance use or medical conditions. Which of the following is the most likely diagnosis?

A 54-year-old man is evaluated on postoperative day 2 following an emergency exploratory laparotomy for a perforated duodenal ulcer. Over the past 6 hours, the nursing staff reports that he has become highly agitated, disoriented, and profusely diaphoretic. He is currently shouting at the staff, claiming that there are "swarms of insects" crawling on the walls and his bedsheets. Medical records show no prior psychiatric history. Upon interview, his wife mentions that he typically drinks a pint of whiskey daily but has not consumed any alcohol since the morning of his admission. His temperature is 38.6°C (101.5°F), blood pressure is 168/104 mm Hg, pulse is 126/min, and respirations are 24/min. Physical examination reveals an oriented to person only, restless patient with a coarse, rhythmic tremor of the outstretched hands. The surgical abdomen is tender but without rebound, and the incision site is clean and intact. Which of the following is the most appropriate next step in management?