Psychiatry

A 46-year-old female accountant is referred to the outpatient psychiatry clinic due to an 8-month history of excessive, uncontrollable worry regarding her finances, job security, and health. She describes feeling constantly "on edge," suffers from severe muscle tension in her neck and shoulders, and struggles with initial insomnia. These symptoms began shortly after she underwent a lumpectomy and localized radiation for estrogen receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancer. She is currently taking tamoxifen and frequently complains of bothersome, spontaneous hot flashes occurring both during the day and at night. Vital signs are within normal limits. Which of the following is the most appropriate pharmacotherapy for this patient's psychiatric condition?

Evaluate the clinical scenarios below and match each patient to the most appropriate next step in psychiatric management.

A 32-year-old man is evaluated in the psychiatric clinic as part of a court-mandated diversion program following an arrest for assault. During the interview, the patient is superficially charming but shows no remorse for his actions, stating, 'The guy was asking for it.' His medical records show a history of conduct disorder diagnosed at age 14, multiple arrests for theft, and chronic deceitfulness. He is currently prescribed fluoxetine by his primary care physician for mild depressive symptoms. He frequently demands early refills of controlled substances from various providers, although none are currently prescribed. He mentions that during periods of extreme frustration, he occasionally feels 'paranoid that people are out to get me' for a few days, but these feelings quickly resolve. Which of the following are the most appropriate considerations in the evaluation and management of this patient? (Select 2 choices)

Match each clinical presentation of cognitive decline to its most likely underlying pathophysiologic mechanism.

A 58-year-old woman is admitted to the hospital for management of a deep vein thrombosis. A psychiatric consultation is requested because she refuses her prescribed heparin infusion. The patient states she has a "sixth sense" that hospital medications contain micro-crystals designed to negatively alter her aura. She has lived alone in a rural cabin for 30 years, making a living selling energy-infused stones online. During the interview, she speaks in a vague, overly elaborate manner and appears highly anxious around the nursing staff, attributing her fear to their "disruptive energy fields." Collateral history from her visiting sister confirms that the patient has exhibited these eccentric beliefs and a preference for intense isolation since her early 20s. The sister also notes the patient has experienced fatigue and poor sleep over the past two weeks due to leg pain. Frustrated by the situation, the sister demands that the physician administer the heparin regardless of the patient's objections to prevent a pulmonary embolism.

Which of the following statements regarding the diagnosis and management of this patient are correct? (Select all that apply)

Match each clinical vignette describing a medication-specific complication, adverse effect, or pharmacokinetic requirement to the most likely offending psychotropic agent used in the context of bipolar disorder.

Evaluate the clinical scenarios describing older adult patients presenting with progressive cognitive or behavioral changes. Match each distinct clinical presentation with its definitive diagnostic finding or most likely underlying pathophysiological mechanism.

A $31$-year-old man presents via telehealth for an initial psychiatric evaluation. He reports a $7$-week history of persistent low mood, extreme lethargy, and a $6$-kg ($13$-lb) weight gain. He sleeps up to $15$ hours a day and describes his limbs as feeling 'unnaturally heavy.' For the past $2$ weeks, he has also been hearing a distinct, critical voice telling him he is 'toxic and contagious' whenever he is alone in his room. Upon detailed psychiatric history taking, he reveals that $3$ years ago, he was hospitalized for a $10$-day period during which he believed he was a divine messenger, slept only $1$ hour per night, and paced the streets preaching. He was stabilized and discharged but stopped his prescribed medications shortly afterward. He recently began taking a high-dose over-the-counter St. John's wort supplement to improve his mood, but it has provided no relief. A recent primary care blood panel shows a thyroid-stimulating hormone (TSH) level of $2.1$ mU/L (normal: $0.5$-$5.0$) and a free thyroxine (T4) level of $1.1$ ng/dL (normal: $0.8$-$1.8$). Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old man is brought to the emergency department by police due to erratic behavior in public. He is pacing the evaluation room, speaking loudly, and appears acutely agitated. He has not yet committed any acts of physical violence but is becoming increasingly uncooperative and hostile. Arrange the following interventions in the standard stepwise order for managing this acutely agitated patient, from the initial, least restrictive measure to the final, most restrictive measure.

Match each of the following patient clinical vignettes with the most likely personality disorder diagnosis.

Match the following psychiatric legal and ethical concepts with their most appropriate clinical scenario.

Match each psychotropic medication with its most characteristic adverse effect, specific monitoring requirement, or clinical contraindication.

A 28-year-old man is brought to the emergency department by police after he was found running through traffic, shouting that he is "being hunted by assassins." He is highly agitated, uncooperative, and combative. The patient has a history of major depressive disorder. Medical records indicate he takes citalopram. A friend who arrives at the ED reports the patient recently started taking an over-the-counter herbal supplement for mood enhancement and was also prescribed linezolid for a skin infection at an urgent care clinic two days ago. His temperature is $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$), pulse is $134/\text{min}$, respirations are $24/\text{min}$, and blood pressure is $172/98\text{ mm Hg}$. Physical examination reveals severe diaphoresis and mydriasis. Neurological examination is notable for hyperreflexia and sustained bilateral ankle clonus. The patient is delirious, disoriented to time and place, and violently resists examination, screaming, "You're not touching me! I'm leaving!" as he attempts to climb off the stretcher. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old woman comes to the clinic reporting progressive fatigue, mild shortness of breath on exertion, and tingling in her fingertips over the past two weeks. She has a long-standing history of binge-eating disorder characterized by eating large amounts of food with a sense of loss of control, without any compensatory purging behaviors. Three weeks ago, her psychiatrist initiated a new medication that is also indicated for migraine prophylaxis to help manage her binge-eating episodes and promote weight loss. Her body mass index (BMI) is $32.4 \text{ kg/m}^2$. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), pulse is $88/\text{min}$, blood pressure is $118/76\text{ mm Hg}$, and respirations are $18/\text{min}$.

Which of the following best describes the acid-base disturbance in this patient resulting from her new psychiatric medication?

A 50-year-old man is evaluated on the surgical ward on postoperative day 3 following an uncomplicated partial colectomy for recurrent diverticulitis. The cross-cover physician is called because the patient has become acutely disoriented, diaphoretic, and extremely agitated, stating that he sees spiders descending from the ceiling. Vital signs reveal a temperature of $38.5^\circ\mathrm{C}$ ($101.3^\circ\mathrm{F}$), blood pressure of $172/106\text{ mmHg}$, pulse of $128/\text{min}$, and respiratory rate of $24/\text{min}$. Physical examination shows a coarse tremor of the extended hands. His surgical dressings are clean and intact, and the abdomen is nondistended with mild expected incisional tenderness. A review of his preoperative social history indicates he consumes one pint of whiskey daily. Which of the following is the most appropriate next step in management?

Paramedics rush a $34$-year-old woman to the emergency department. Her husband discovered her unresponsive in their bedroom alongside an empty bottle of her recently prescribed antidepressant. According to the husband, she suffers from major depressive disorder and has been enduring a severe relapse over the past month.

Upon arrival, her temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $90/60\text{ mmHg}$, pulse is $128/\text{min}$, and respirations are $6/\text{min}$. Physical examination reveals dilated, minimally reactive pupils, completely dry mucous membranes, and absent bowel sounds. She is deeply obtunded and withdraws only to painful stimuli. An electrocardiogram demonstrates sinus tachycardia with a QRS duration of $150\text{ ms}$.

As the medical team prepares for immediate endotracheal intubation, the husband produces a legally valid, notarized advance directive that the patient completed one year ago. The document explicitly mandates: 'I refuse mechanical ventilation and cardiopulmonary resuscitation under any circumstances.' The husband pleads, 'She has been expressing a desire to end her life for weeks. She meant every word in this document. You must respect her legal rights and not put her on a breathing machine.'

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

For each of the following pediatric patients presenting with behavioral or neurodevelopmental concerns, identify the most appropriate next step in evaluation or management.

Match each patient's clinical presentation with the most likely substance-related toxidrome or diagnosis.

Match the following brief clinical scenarios detailing symptom onset, duration, and core clinical features to their most appropriate DSM-5 psychiatric diagnosis.

A 45-year-old woman is brought to the emergency department by her husband due to a severe, throbbing headache, blurred vision, and chest palpitations that began 45 minutes ago. She has a 10-year history of major depressive disorder that was poorly responsive to multiple trials of selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. Six weeks ago, her psychiatrist started her on tranylcypromine. Vital signs are temperature 37.2°C (99.0°F), blood pressure 228/132 mm Hg, pulse 118/min, and respirations 20/min. Physical examination reveals profuse diaphoresis, facial flushing, and pupillary dilation. Neurological examination shows normal muscle tone, 2+ deep tendon reflexes symmetrically, and absent clonus. Mental status examination reveals an anxious woman who is fully oriented to person, place, and time. Her husband mentions they were celebrating their anniversary at a restaurant earlier this evening, where they shared a large platter of aged cheeses and cured meats. Which of the following is the most appropriate initial pharmacological intervention for this patient's current condition?