Psychiatry

Match each patient's clinical presentation and symptom timeline to the most appropriate DSM-5 psychiatric diagnosis.

A 19-year-old woman is brought to the emergency department after intentionally ingesting ten 500-mg acetaminophen tablets following a recent breakup. She is medically stabilized, and her acetaminophen levels remain well below the treatment threshold. During the psychiatric evaluation, she is tearful and states she feels 'completely empty inside' and hates being alone. She describes a history of intense, short-lived relationships and frequently changing her college major because she 'does not know who she is.' When the physician explains that she will be discharged with a psychiatric outpatient follow-up appointment, she becomes suddenly enraged, yelling, 'You doctors do not care about anyone!' Moments later, she apologizes profusely and begs the physician not to abandon her. She reports that under extreme stress, she sometimes feels like she is detached from her body. Which of the following statements regarding this patient's diagnosis and management are accurate? (Select all that apply)

A 16-year-old girl is brought to the emergency department by her parents due to severe fatigue and dizziness. She has lost 15 kg (33 lb) over the last 4 months and restricts her daily intake to under 500 calories. Her temperature is 35.8°C (96.4°F), blood pressure is 85/50 mm Hg, and pulse is 42/min. Her BMI is 14.2 kg/m². Physical examination reveals fine downy body hair and temporal wasting. The patient is admitted to the hospital.

Arrange the following management steps in the most appropriate chronological order from initial acute management to long-term therapy.

A 26-year-old man comes to the clinic for a follow-up visit. Three weeks ago, he was diagnosed with major depressive disorder after presenting with a 6-week history of depressed mood, anhedonia, significant weight loss, and severe fatigue. At his initial evaluation, a comprehensive psychiatric history confirmed the absence of any past episodes of abnormally elevated mood, impulsivity, or decreased need for sleep. He was started on sertraline 50 mg daily. Today, the patient reports that his sleep has improved slightly, but he still feels sad most days and lacks the energy to resume his usual hobbies. He denies suicidal ideation, auditory hallucinations, or racing thoughts. His vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in management?

A 32-year-old male accountant presents to the psychiatric clinic for evaluation of worsening anxiety. For the past 6 months, he has been overwhelmingly preoccupied with the intrusive thought that he might accidentally send confidential client financial data to the wrong email address. To prevent this, he spends 2 to 3 hours every evening repeatedly checking his outbox and reading every sent email multiple times. He recognizes these thoughts are irrational and excessive, but he states he cannot stop the checking behavior. His performance at work has declined significantly, and his manager has recently issued a formal warning. He was diagnosed with atypical depression by another provider and started on phenelzine 2 weeks ago; however, he abruptly stopped taking it 5 days ago due to severe orthostatic hypotension. He asks the physician to provide a medical note explaining his diagnosis to his employer to prevent termination.

Which of the following are the most appropriate next steps in the management of this patient? (Select 2)

Match each clinical scenario to the most appropriate pharmacologic intervention.

A 79-year-old woman is brought to the emergency department from a memory care facility due to a 3-day history of extreme agitation and visual hallucinations. Staff report she has been picking at the air and describing "spiders on the ceiling." The patient has a 4-year history of Major Neurocognitive Disorder due to Alzheimer disease, with a baseline Mini-Mental State Examination score of $17/30$. Five days ago, she was evaluated for new-onset urinary incontinence, and a new medication was prescribed.

Her current daily medications include donepezil and sertraline. Her son, who is visiting from out of state and is not her legally appointed healthcare proxy (her daughter holds this role), is highly distressed and demands the physician immediately administer heavy sedatives to "calm her down."

On examination, the patient's temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), pulse is $110/\text{min}$, and blood pressure is $142/86 \text{ mm Hg}$. She is disoriented, continuously muttering, and unable to participate in cognitive testing. Pupils are $6 \text{ mm}$ bilaterally and minimally reactive to light. Mucous membranes are extremely dry. Abdominal examination reveals absent bowel sounds and a palpable, dull suprapubic mass.

Laboratory results show:
Thyroid-stimulating hormone (TSH): $0.2 \text{ \mu U/mL}$ (Normal: $0.5 - 5.0 \text{ \mu U/mL}$)
Free T4: $1.3 \text{ ng/dL}$ (Normal: $0.9 - 1.7 \text{ ng/dL}$)
Urinalysis: Negative for leukocyte esterase and nitrites.

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

A 74-year-old retired teacher presents to the geriatrics clinic accompanied by her husband. Over the past 6 months, she has become increasingly unsteady on her feet, with her husband describing her walking as if her feet are 'glued to the floor.' Recently, she has also experienced several episodes of urinary incontinence and seems more forgetful than usual. Physical examination reveals a magnetic, broad-based gait with preserved arm swing. There are no focal motor or sensory deficits. To properly evaluate and manage this patient's most likely condition, arrange the following clinical steps in the most appropriate sequential order.

A 24-year-old woman presents to the primary care clinic seeking assistance to quit smoking. She also reports a 4-month history of persistently low mood, decreased energy, and feelings of worthlessness. Her medical history is significant for active bulimia nervosa, characterized by episodes of binge eating followed by self-induced vomiting three times a week. Her vital signs are within normal limits, and her BMI is 22 kg/m². The physician is considering a pharmacological intervention that can simultaneously target her depressive symptoms and aid in smoking cessation. Which of the following medications is absolutely contraindicated in this patient?

A 22-year-old man is diagnosed with schizophrenia. His psychiatrist is planning a long-term pharmacological management strategy and outlining potential next steps depending on his clinical response over time. Arrange the following treatment steps in the correct standard sequential order for the management of schizophrenia, proceeding from initial therapy to the management of severe treatment-resistant disease.

A 42-year-old man is evaluated on the surgical ward due to severe agitation and confusion. He was admitted two days ago after sustaining a right femur fracture in a motor vehicle collision, for which he underwent an uncomplicated open reduction and internal fixation. His medical history is significant for a 15-year history of heavy daily alcohol consumption, but he has had no access to alcohol since his admission. His temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $168/102\text{ mmHg}$, pulse is $124/\text{min}$, and respirations are $22/\text{min}$. On examination, the patient is profusely diaphoretic and tremulous. He is disoriented to time and place and repeatedly swats at the air, claiming that spiders are crawling down the walls. The surgical incision site is clean, dry, and intact. Which of the following is the most appropriate next step in the management of this patient?

A 36-year-old man, who works as a software quality assurance manager, comes to his primary care physician for a routine physical examination. He hands the physician a neatly bound, color-coded 20-page document detailing his daily blood pressure readings, caloric intake, and sleep duration for the past six months. He complains of chronic fatigue, stating that he often stays awake until 3:00 AM reviewing his subordinates' code. He says, "If I do not check every single line myself, they will ruin the product. It is just more efficient if I take over their tasks." He mentions that his wife recently threatened to separate from him because he refuses to let her load the dishwasher, arguing she "never follows the optimal spatial configuration." The patient does not believe his behavior is problematic; rather, he is highly frustrated that others fail to meet his exacting standards. He denies experiencing recurrent intrusive thoughts that cause him distress, and he does not perform repetitive physical rituals to neutralize anxiety. Which of the following is the most likely diagnosis?

During a scheduled appointment at the university health center, the parents of a 20-year-old undergraduate student express deep concern regarding their son's recent behavior. Over the previous 16 weeks, the student has dedicated up to 5 hours every evening to vigorously washing his hands and disinfecting his living space. When questioned about the necessity of this routine, the patient becomes visibly agitated and insists, 'My room is covered in microscopic parasites. If I don't eliminate them completely, they will infest my family and cause a fatal disease.' The evaluating physician probes further, asking if there is any chance this fear might be disproportionate. The patient responds, 'Absolutely not. It is an undeniable reality; I can feel them crawling on my epidermis.' He denies experiencing any auditory or visual hallucinations, and his thought process remains linear and goal-directed. Despite the extensive time consumed by these rituals, he has sustained excellent academic performance. Physical examination is notable only for severe erythema and desquamation on both hands. Urine toxicology is negative.

Which of the following is the most appropriate initial pharmacological therapy for this patient's condition?

A 52-year-old man is evaluated on postoperative day 3 following an emergency exploratory laparotomy and repair of a perforated duodenal ulcer. The nursing staff reports that he has become increasingly combative over the last few hours. The patient is shouting that there are "swarms of insects" crawling on the walls of his room. He has no known psychiatric history. His medical history is significant for hypertension and a 20-pack-year smoking history. Social history is notable for drinking 6 to 8 beers daily, though he stated he was planning to quit while in the hospital. Vital signs are temperature 38.8°C (101.8°F), blood pressure 168/102 mmHg, pulse 122/min, and respirations 22/min. Physical examination reveals a diaphoretic, agitated man. Abdominal exam shows a clean, intact surgical incision with mild tenderness but no rebound or guarding. Neurologic examination shows a coarse, rhythmic tremor of the outstretched hands. Which of the following is the most appropriate next step in the management of this patient?

A 19-year-old female college student is evaluated at the student health clinic after her resident advisor expressed concerns about her behavior. According to the advisor, the patient has isolated herself in her dormitory for the past seven months. During this entire period, she has consistently claimed that the university's Wi-Fi network is transmitting government mind-control signals into her brain. She is frequently observed pacing the hallways at night while mumbling and responding to unseen individuals. The patient's academic performance has dropped significantly, and her emotional expression during the interview is noticeably flat. She has no history of substance use or medical illnesses, and a urine toxicology screen is negative. Which of the following is the most appropriate diagnosis?

A 24-year-old male is evaluated in the outpatient psychiatry clinic for the management of a recently diagnosed bipolar I disorder. The physician discusses various maintenance medication options, their baseline monitoring requirements, and their characteristic adverse effect profiles. Match each psychotropic medication discussed during the consultation to its correct baseline monitoring requirement and specific adverse effect risk.

A 22-year-old woman is admitted to the inpatient psychiatric unit for the management of severe anorexia nervosa, restricting subtype. On admission, her body mass index (BMI) is 13.8 kg/m². Her vital signs show a blood pressure of 88/54 mm Hg, pulse of 44/min, and respiratory rate of 12/min. Physical examination reveals temporal wasting and fine, downy hair on her arms and back. Initial laboratory studies show normal serum electrolytes. A closely monitored nutritional rehabilitation program is initiated with enteral feedings. On the third day of hospitalization, the patient develops acute-onset profound muscle weakness, areflexia, and difficulty breathing. An electrocardiogram demonstrates premature ventricular complexes. Which of the following pathophysiologic mechanisms is the primary cause of this patient's acute clinical deterioration?

A 35-year-old female marketing director is evaluated in the outpatient psychiatry clinic for a 4-week history of severely depressed mood. She reports sleeping up to 14 hours daily, profound fatigue, a 4-kg (8.8-lb) weight gain, and feelings of worthlessness. She states, 'My family would be better off if I were gone,' but she denies an active plan or intent for self-harm. Three years ago, she was brought to the emergency department after a 10-day period of sleeping only 2 hours per night, rapid speech, and impulsive spending that depleted her savings. She is currently medically healthy and takes no medications. Vital signs and physical examination are unremarkable. Following the evaluation, the patient's husband leaves a voicemail for the physician, requesting an update on his wife's condition. Which of the following are appropriate components of this patient's management plan? (Select all that apply)

A 64-year-old man is brought to the clinic by his husband for a 9-month history of progressive memory impairment, worsening apathy, and newly developed difficulty managing their household finances. His husband notes that the patient experienced a severe major depressive episode following an early retirement a year ago, which was partially responsive to a selective serotonin reuptake inhibitor. Physical and neurologic examinations reveal no focal deficits. The physician suspects a neurocognitive disorder but must carefully differentiate this from other etiologies, particularly given the prominent psychiatric history.

Arrange the following diagnostic steps in the most appropriate sequential clinical order, proceeding from the initial baseline evaluation to the most advanced, specialized investigations.

Match each clinical presentation to the most appropriate diagnostic category.