Psychiatry

A 24-year-old woman is admitted to the inpatient medical-surgical ward for intravenous antibiotic treatment of a complicated lower extremity cellulitis. Over the past 48 hours, her behavior has become increasingly disruptive. During morning rounds, she tells the daytime attending physician, "You are the only brilliant doctor in this hospital. The night shift nurses and doctors are completely incompetent, and I think they are trying to ruin my recovery on purpose." She is pleasant and cooperative with the daytime medical team. However, later that evening, the night charge nurse reports that the patient was screaming at the staff, calling the daytime doctors "clueless," and demanding that the night team ignore the morning care plan. The patient has a history of multiple brief, intense relationships and recurrent suicidal gestures, though she currently denies suicidal ideation. This situation has caused significant arguments between the day and night shift staff regarding her care. Which of the following is the most appropriate next step in management?

Match each highly specific clinical presentation and diagnostic finding to the most likely corresponding substance-related etiology.

A 32-year-old female high school teacher presents to the clinic reporting a 4-week history of severely depressed mood, profound fatigue, and sleeping up to 14 hours a day. She says she can no longer concentrate on grading her students' assignments and feels completely worthless. The patient mentions she had a similar period of depression in her mid-twenties. When asked about periods of unusually elevated mood, she recalls an episode three years ago that lasted for 12 days. During that time, she felt "invincible," slept only 2 hours a night without feeling tired, spoke so rapidly that friends could not understand her, and impulsively spent her life savings on a high-risk investment. Her vital signs are within normal limits. Physical examination is unremarkable. Laboratory tests reveal a thyroid-stimulating hormone (TSH) level of 2.1 µU/mL (normal: 0.4-4.0 µU/mL) and free thyroxine (T4) of 1.2 ng/dL (normal: 0.8-1.8 ng/dL). Which of the following is the most appropriate next step in the management of this patient?

A 24-year-old woman with a 3-year history of schizophrenia is admitted to the inpatient psychiatric unit. For the past four days, she has been entirely mute, refuses all food and fluids, and maintains rigid postures for hours. When the examiner attempts to reposition her arm, it remains exactly where placed. Her current medication is oral risperidone 4 mg daily, which her parents state she took consistently until three days ago. Her vital signs are within normal limits. Arrange the following management steps in the most appropriate chronological sequence for this patient's episode of care, assuming sequential escalation is required due to refractory symptoms before eventual resolution.

Emergency medical services transport an unidentified adult male to the resuscitation bay after bystanders found him comatose on a park bench. Beside him, responders noted drug paraphernalia, including a burnt spoon and an empty syringe. Initial assessment reveals marked respiratory depression with a breathing rate of 4/min, accompanied by a heart rate of 45/min. Physical examination demonstrates cyanosis of the perioral area and symmetric 1-mm pupils. Which of the following pharmacologic agents should be administered immediately?

A 34-year-old woman is brought to the emergency department by her sister due to increasingly bizarre behavior. The sister reports that for the past 10 weeks, the patient has been locking herself in her room, claiming that foreign intelligence agents are monitoring her thoughts through the television. During the psychiatric interview, the patient is observed responding to unseen stimuli and her speech is frequently derailed. She has no prior psychiatric or medical history and takes no medications. A urine toxicology screen is negative. Which of the following is the most likely diagnosis?

Match each patient's clinical vignette to the most accurate psychiatric diagnosis.

An emergency department physician is evaluating four patients who were brought in overnight with suspected substance intoxication. Match each patient's predominant physical examination findings to the most likely intoxicating substance.

A 22-year-old man is brought to the clinic by his family and is subsequently diagnosed with schizophrenia. He has not received any previous psychiatric care. Arrange the following steps in the correct sequential order for the long-term psychopharmacologic management of this patient, starting with the initial therapy and progressing to the management of highly refractory disease.

A 28-year-old man presents to the psychiatry clinic complaining of severe sadness, fatigue, and loss of interest in his usual hobbies for the past 3 weeks. He reports sleeping up to 14 hours a day and experiencing a significant decline in his appetite. Medical history is notable for an episode two years ago during which he felt "unstoppable," slept only 2 hours per night without feeling tired, and maxed out multiple credit cards on unnecessary purchases. That episode lasted for 10 days and resulted in a brief psychiatric hospitalization. Temperature is 37.0°C (98.6°F), blood pressure is 120/78 mmHg, pulse is 72/min, and respirations are 14/min. On mental status examination, the patient appears disheveled, makes poor eye contact, and exhibits psychomotor retardation. His mood is described as "miserable" and his affect is constricted. He denies suicidal ideation. Which of the following is the most appropriate initial pharmacotherapy for this patient's current symptoms?

Match each clinical vignette describing a patient with progressive cognitive decline to the most likely underlying neurocognitive disorder diagnosis.

A $28$-year-old man is brought to the emergency department by his husband due to increasingly erratic behavior and paranoia. The husband reports that the patient's symptoms began approximately $8$ weeks ago, when he started claiming that his internet service provider was intercepting his thoughts and transmitting them to a dark web forum. He also began hearing two distinct voices commenting on his daily actions. The husband emphasizes that during the first $5$ weeks of these symptoms, the patient maintained a completely normal mood, slept his usual $7$ hours per night, and continued to attend his job as a software engineer.

However, over the past $3$ weeks, the patient abruptly developed an intensely elevated mood and boundless energy. He began sleeping only $1$ to $2$ hours per night without feeling fatigued, spoke so rapidly that he was difficult to interrupt, and confidently stated he was on the verge of "solving the universe's ultimate algorithm." The auditory hallucinations and paranoid delusions have persisted unchanged throughout this entire $8$-week period. The patient has no prior psychiatric or medical history and takes no medications. Vital signs are within normal limits, and a comprehensive urine toxicology screen is negative. Which of the following is the most likely diagnosis?

Evaluate the following distinct patient presentations and pair each with the single most accurate psychiatric diagnosis.

A 21-year-old man is brought to the emergency department by university police due to severe, unrelenting agitation and bizarre behavior. He was found barricaded in his dormitory room, shouting that government drones were attempting to abduct him. His roommate reports that the patient attended a rave 3 days ago where he ingested an unknown powder. Since then, the patient has not slept, has been pacing continuously, and has become increasingly aggressive. He has no prior psychiatric or medical history. Vital signs show a temperature of 38.6°C (101.5°F), pulse of 132/min, respirations of 22/min, and blood pressure of 170/105 mm Hg. Physical examination reveals mydriasis, profuse diaphoresis, and generalized muscle rigidity without clonus. Horizontal and vertical nystagmus are absent. Routine urine toxicology screening is negative for amphetamines, cocaine, opioids, cannabis, and phencyclidine. Which of the following is the most likely diagnosis?

A 26-year-old man is brought to the primary care clinic by his mother, who expresses deep concern about his lack of a social life. The patient lives in his mother's basement and works entirely from home as a freelance computer programmer. His mother insists the physician evaluate him for a 'chemical imbalance' and explicitly requests to be informed of the treatment plan. During a private interview, the patient makes poor eye contact and displays a markedly restricted affect. He states, 'I am only here to get her off my back. I have no desire to make friends or find a romantic partner; I find interacting with people to be tedious and I prefer my own company.' He denies feeling sad, hopeless, or anxious. He also firmly denies experiencing auditory hallucinations, paranoid thoughts, or holding bizarre beliefs. He explicitly requests that his mother not be told anything about the details of his visit. Which of the following is the most appropriate action by the physician?

A 29-year-old woman presents to the psychiatry clinic seeking treatment for new-onset severe anxiety, frequent panic attacks, and irritability that began 2 months ago. She has a history of bipolar II disorder; she was previously treated with valproate but discontinued all medications two years ago and has been stable since. The patient works as a fitness model and notes a 5-kg (11-lb) weight loss over the last 2 months, which she attributes to "burning nervous energy." She feels constantly "on edge" and has been struggling with insomnia. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 135/85 mm Hg, and a heart rate of 112/min. Physical examination reveals a fine tremor of the outstretched hands, brisk deep tendon reflexes, and no palpable thyroid enlargement. An initial laboratory workup is obtained to rule out medical causes of her anxiety:

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

A 26-year-old woman comes to the clinic due to feeling "constantly on edge" for the past 8 months. During this time, she has experienced excessive, uncontrollable worry about her job performance, finances, and relationships. She reports associated muscle tension, poor concentration, and feeling easily fatigued. She denies any depressed mood, suicidal ideation, or hallucinations. Two years ago, she was hospitalized for a 3-week episode characterized by a severely decreased need for sleep, euphoric mood, pressured speech, and hypersexuality. She was treated with a medication that she stopped taking 6 months ago. Her current medications include a daily multivitamin. Vital signs are within normal limits. Physical examination shows mild trapezius muscle tenderness but is otherwise unremarkable. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 2.1 µU/mL (normal: 0.5-5.0 µU/mL). Which of the following is the most appropriate next step in management for this patient?

A $28$-year-old graphic designer is evaluated at an outpatient clinic following a referral from her gastroenterologist. For the past $14$ months, she has experienced persistent, daily pelvic discomfort and generalized muscle aches. She describes these sensations as severely distressing and states that they significantly impair her ability to focus on her job. She spends roughly $3$ to $4$ hours each evening researching her physical symptoms on medical forums, firmly believing she suffers from an undetected, rare autoimmune pathology. Extensive laboratory tests, pelvic ultrasounds, and endoscopic evaluations have repeatedly shown no organic abnormalities. She does not intentionally produce or feign these symptoms. Which of the following is the most likely diagnosis?

A 32-year-old man is brought to the emergency department by his roommate. The patient has a known history of bipolar I disorder but stopped taking his prescribed lithium six months ago. Over the past three weeks, he has become increasingly withdrawn, sleeping up to 14 hours a day, and feeling profoundly depressed. Today, he told his roommate, "I cannot take this pain anymore. I am going to jump off the city bridge tonight." In the emergency department, the patient is tearful, confirms his intent and plan, and demands to be discharged immediately. He states, "You cannot keep me here against my will. I want to leave right now." Vital signs are within normal limits. Which of the following is the most appropriate next step in management?

Evaluate the following distinct adverse clinical outcomes observed in patients receiving pharmacotherapy for bipolar disorder. Match each clinical presentation to the specific psychotropic medication most strongly associated with its development.