Psychiatry

A 75-year-old man is brought to the neurology clinic by his son. Over the past 8 months, the patient has developed a progressively unsteady gait. The son describes his father's walking as feeling "glued to the ground" with very short steps. For the past 4 months, the patient has had difficulty managing his finances, exhibits new-onset apathy, and struggles with short-term memory. Over the last month, he has had multiple episodes of urinary incontinence, toward which he appears indifferent. His medical history includes hypertension and type 2 diabetes mellitus. Neurological examination reveals a broad-based, magnetic gait, but muscle strength and deep tendon reflexes are normal. A magnetic resonance imaging (MRI) scan of the brain is obtained and is shown below, demonstrating enlarged lateral and third ventricles with relatively normal, uncrowded cortical sulci. What is the most appropriate next step in the management of this patient?

A 30-year-old male chef is brought to the emergency department by his husband due to worsening suicidal ideation. For the past month, the patient has experienced profound sadness, a 7-kg (15-lb) weight gain, hypersomnia, and a complete lack of energy. He has a history of major depressive disorder diagnosed in his early twenties. His husband reports that three years ago, the patient had a 3-week period where he slept only two hours per night, spoke so rapidly he was difficult to interrupt, and developed grandiose delusions that he had discovered the cure for aging. These delusions completely resolved when his mood returned to baseline. The patient is currently not taking any prescribed medications but consumes a high-dose St. John's wort supplement daily. Vital signs are within normal limits. Mental status examination reveals a cooperative patient with depressed mood, flattened affect, and psychomotor retardation. He denies current hallucinations or delusions. Which of the following is the most appropriate next step in management?

A 28-year-old man comes to the outpatient clinic for a routine psychiatric follow-up. He has a history of major depressive disorder, for which he takes sertraline. During the session, the patient appears visibly agitated, pacing the room and speaking loudly about his recent job termination. He states, "My former boss is completely ruining my life. Sometimes I get so furious that I just want to kill him." The physician immediately asks if the patient has any specific plan or true intent to harm his former boss. The patient sits down, shakes his head, and says, "No, of course not. I am just venting because I am so frustrated. I would never actually hurt anyone or risk going to jail." Further assessment reveals he has no access to firearms and no prior history of violent behavior. He denies any current suicidal ideation. Vital signs are within normal limits. Which of the following is the most appropriate next step in management?

A 58-year-old man is brought to the clinic by his wife due to an $8$-month history of progressive behavioral changes. His wife reports that he has become increasingly apathetic and socially withdrawn, frequently neglecting his personal hygiene. He recently began compulsively hoarding empty glass bottles and has made sexually explicit remarks to neighbors, which is entirely out of character. The patient has a history of bipolar I disorder following a single manic episode at age 22, but he has been euthymic and off psychiatric medications for over $30$ years. Mental status examination reveals an alert and oriented patient with a blunted affect. He displays poor insight and disinhibition during the interview. Memory recall is 3/3 after $5$ minutes, but he exhibits significant impairment on the Trail Making Test Part B. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $0.2 \mu U/mL$ (Normal: $0.4-4.0 \mu U/mL$) and a free thyroxine (T4) level of $0.6 ng/dL$ (Normal: $0.9-1.7 ng/dL$). The patient has a legally executed advance directive designating his eldest daughter as his sole healthcare proxy. However, the daughter is not present, and the wife vehemently demands the physician immediately start an antidepressant, believing his symptoms represent a severe depressive relapse. Which of the following is the most appropriate next step in management?

A 32-year-old man is brought to the emergency department by emergency medical services after his roommate found him lethargic with empty pill bottles nearby. The patient states he intentionally ingested "a handful" of his prescribed phenelzine and his roommate's fluoxetine two hours ago because he "wanted to sleep forever." Vital signs are temperature 39.1°C (102.4°F), blood pressure 165/100 mmHg, heart rate 122/min, and respiratory rate 20/min. Physical examination reveals profuse diaphoresis, bilateral ocular clonus, and hyperreflexia most prominent in the lower extremities. As the physician prepares to initiate treatment, the patient becomes agitated, states he has changed his mind about wanting to die, and demands to leave the hospital immediately. He explicitly forbids the physician from contacting his wife, stating, "If she finds out about this, she will take my kids away." Which of the following is the most appropriate next step in management?

A 26-year-old female graduate student is brought to the emergency department by her roommate. For the past month, the patient has exhibited profound sadness, a 4.5-kg (10-lb) weight loss, and severe psychomotor retardation. She sleeps 14 hours a day and refuses to attend her classes. During the interview, she stares blankly and admits she has been hearing a persistent voice saying she is "a fraud who deserves to die." The roommate reports that two years ago, the patient had a distinct 3-week period where she barely slept, spoke incredibly fast, bought thousands of dollars of unneeded laboratory equipment on credit, and claimed she had independently deciphered the human genome. That prior episode culminated in a 5-day psychiatric hospitalization. Her urine toxicology screen is negative. Which of the following is the most accurate diagnosis and most appropriate initial pharmacotherapy for this patient?

A 34-year-old woman presents to the clinic with a 6-week history of profound sadness, anhedonia, and terminal insomnia. She reports significant functional impairment, having recently taken a leave of absence from her job due to a severe inability to concentrate. Review of systems is notable for a 4.5-kg (10-lb) weight loss and mild psychomotor agitation. Thorough psychiatric screening confirms the absence of any past manic or hypomanic episodes, ruling out bipolar disorder. Over the next 14 months, her major depressive disorder exhibits a complex trajectory, requiring a progressive, stepped-care escalation of her management plan according to standard psychiatric guidelines. Arrange the following clinical interventions in the most appropriate chronological sequence, beginning with her initial presentation and escalating to the management of life-threatening psychiatric complications.

A $72$-year-old woman is brought to the geriatrics clinic by her husband due to progressive memory loss and confusion over the past $3$ months. Her husband states she spends most of her day in bed, has stopped cooking, and has lost $5$ kg ($11$ lb). Over the last $3$ weeks, she has been repeatedly stating that "the government is coming to arrest me for tax fraud," which is completely unfounded.

Past medical history is significant for Parkinson disease, treated with selegiline, and bipolar I disorder. She previously took lithium but discontinued it a year ago of her own volition.

On mental status examination, she exhibits marked psychomotor retardation and poor eye contact. When asked to perform serial sevens or spell "WORLD" backwards, she gives minimal effort, frequently stating, "I don't know, my mind is completely gone."

Her daughter, who is her legally appointed healthcare proxy, lives in another state. Her husband is frustrated with the patient's decline and demands that the physician immediately authorize her placement in a local nursing home.

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

A 54-year-old software developer with no prior psychiatric history is evaluated for Major Depressive Disorder (MDD). Arrange the following pharmacological and somatic management steps in the correct chronological sequence according to standard stepped-care escalation protocols, starting from the initial presentation to the eventual management of a severe, life-threatening refractory state.

A 34-year-old man with a history of treatment-resistant depression is brought to the emergency department by his partner. The patient was doing well on a newly prescribed psychiatric medication until this morning, when he took an over-the-counter nasal decongestant for a severe cold. Within an hour of taking the cold medication, he developed a severe, throbbing headache, blurred vision, and neck stiffness. On triage, his temperature is 37.1°C (98.8°F), pulse is 115/min, and blood pressure is 220/125 mm Hg. Physical examination shows diaphoresis and normal deep tendon reflexes without clonus. Which of the following psychiatric medications is this patient most likely taking?

For each clinical presentation described below, select the most appropriate personality disorder diagnosis.

A 31-year-old woman is evaluated in the clinic for severe mood changes. She delivered her first child 5 months ago without complications. Over the past 8 weeks, she has experienced profound sadness, anhedonia, and a 5-kg (11-lb) weight loss. She awakens at 3:00 AM daily and cannot return to sleep. She notes her depressed mood is worst in the mornings and is completely unreactive to positive events, including playing with her infant. Two weeks ago, her primary care physician prescribed escitalopram; however, she discontinued it 4 days ago, stating it was ineffective. Her husband reports that five years ago, she had a 7-day episode where she slept only 2 hours per night, spoke incessantly, and compulsively purchased thousands of dollars of baby clothes despite not being pregnant. She has no other medical conditions and does not use illicit substances. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in the management of this patient?

A $22$-year-old college student is brought to the emergency department by his roommate due to severe agitation and bizarre behavior. The roommate reports that for the past $2$ weeks, the patient has barely slept, paced the room continuously, and claimed that government agents are monitoring his thoughts. The roommate found empty plastic baggies containing residual white powder on the patient's desk. The patient has a history of major depressive episodes and is currently prescribed sertraline. His family history is notable for a mother with bipolar disorder. In the emergency department, the patient is combative, diaphoretic, and uncooperative. Temperature is $38.2^\circ \text{C}$ ($100.8^\circ \text{F}$), blood pressure is $165/100 \text{ mmHg}$, pulse is $128/\text{min}$, and respirations are $22/\text{min}$. Physical examination reveals bilaterally dilated pupils and a fine resting tremor. Which of the following is the most appropriate next step in the management of this patient?

Emergency medical responders bring a $32$-year-old woman, who is at $28$ weeks gestation, to the emergency department after she was found wandering in traffic. The patient has a history of schizoaffective disorder and stopped taking her medications $3$ months ago. On arrival, she is actively vomiting large amounts of bright red blood. Vital signs are temperature $37.1^\circ\text{C}$, pulse $135/\text{min}$, respirations $24/\text{min}$, and blood pressure $80/50\text{ mmHg}$. She is extremely agitated, striking at the nursing staff, and screaming, "The doctors are vampires trying to steal my baby's soul!" She physically resists all attempts at medical intervention. The physician determines she lacks the capacity to make medical decisions due to acute psychosis.

The patient's sister, who is her legally appointed healthcare proxy, arrives at the emergency department. The sister provides a signed, notarized advance directive that the patient completed $5$ years ago during a period of psychiatric stability. The document explicitly states: "I refuse the administration of any blood products under all circumstances due to my religious convictions." The sister states, "I know what the document says, but she is pregnant and bleeding to death. As her proxy, I am authorizing you to give her the blood transfusion to save her and the baby."

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

A 42-year-old woman is brought to the emergency department by her husband due to worsening confusion, severe nausea, vomiting, and a prominent hand tremor. Her husband reports that she has been unusually unsteady on her feet for the past three days. Her medical history is significant for bipolar disorder, which has been well-controlled on a stable dose of lithium for the past five years. Three weeks ago, she was diagnosed with essential hypertension by her primary care provider and was started on a new daily medication. On physical examination, the patient is lethargic and exhibits a coarse resting tremor, hyperreflexia, and ataxia. Her serum lithium level is 2.1 mEq/L (therapeutic range: 0.6-1.2 mEq/L). Which of the following antihypertensive medications was most likely prescribed to this patient?

A physician at a community health clinic evaluates a 34-year-old man who reports feeling "constantly tense and detached" for the past half-year. Seven months ago, the patient survived a severe factory explosion in which two of his colleagues died. Since the incident, he experiences recurrent, vivid nightmares about the explosion and becomes visibly diaphoretic and tachycardic whenever he hears loud metallic noises. He has completely stopped driving near the industrial park where he used to work and mentions that he feels entirely disconnected from his wife and children. His medical history is significant for treatment-resistant major depressive disorder, for which his psychiatrist prescribed tranylcypromine three weeks ago after multiple other medication trials failed. His blood pressure is 128/82 mm Hg, and his pulse is 76/min. The patient expresses a strong desire for immediate relief from his hyperarousal and intrusive memories. Which of the following is the most appropriate next step in the management of this patient?

A 48-year-old man is evaluated in the outpatient clinic for a 6-week history of persistently low mood, severe fatigue, anhedonia, and waking up at 3:00 AM every day without being able to return to sleep. He reports feeling "completely empty" and has unintentionally lost $4.5\text{ kg}$ ($10\text{ lb}$) over this period. His past medical history is significant for chronic lumbar radiculopathy, for which he takes daily tramadol. His past psychiatric history reveals a psychiatric hospitalization at age 32 for a 3-week episode of abnormally euphoric mood, hypersexuality, decreased need for sleep, and impulsive spending that led to significant debt. Vital signs are within normal limits. Physical examination is unremarkable. Mental status examination reveals a disheveled man with psychomotor retardation, restricted affect, and depressed mood. He denies active suicidal ideation. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $1.8\text{ }\mu\text{U/mL}$ and a free thyroxine (T4) level of $1.2\text{ ng/dL}$. Which of the following is the most appropriate next step in management?

A 78-year-old man residing in an assisted living facility is evaluated for a decline in his cognitive abilities over the past 3 months. The nursing staff report that he has stopped participating in social activities, frequently stays in his room with the blinds drawn, and has lost 4.5 kg (10 lb) during this period. When asked about his memory, the patient becomes distressed and repeatedly states, "My mind is completely gone; I cannot remember anything anymore." On cognitive testing, he makes poor eye contact and frequently responds to questions with "I don't know," exhibiting minimal effort. However, when strongly encouraged by the examiner, he successfully performs complex attention tasks. His neurological examination shows no focal deficits. A non-contrast head CT performed 2 months ago after a mechanical fall was unremarkable. Laboratory studies, including thyroid-stimulating hormone and vitamin B12, are within normal limits. Which of the following is the most appropriate initial management for this patient?

Match each patient's clinical presentation with the most appropriate first-line management strategy or pharmacological principle.

A 42-year-old male is admitted for an acute exacerbation of schizophrenia and is started on intramuscular haloperidol. Three days later, he develops severe, generalized muscle rigidity, profound diaphoresis, and mutism. His temperature is 103.8°F (39.9°C), pulse is 122/min, respirations are 24/min, and blood pressure is 178/104 mm Hg. Physical examination reveals "lead-pipe" rigidity in all extremities. Laboratory studies reveal a serum creatine kinase level of 5,500 U/L. Based on standard clinical guidelines, arrange the following management steps in the correct sequential order from the most immediate initial intervention to the most advanced treatment reserved for refractory cases.