Psychiatry

A 20-year-old man is brought to the university health clinic by his parents due to increasingly concerning behavior. The parents state that for the past 6 weeks, he has barricaded himself in his bedroom, claiming he can hear the voices of "federal agents" plotting to abduct him, and frequently shouting back at these unseen voices. When asked about his prior baseline functioning, his parents note that he was a highly sociable honors student until approximately 8 months ago. At that time, he began to progressively withdraw from his friends, stopped maintaining his personal hygiene, and displayed a markedly blunted affect. Concurrently, he began expressing vague theories about "sensing electromagnetic fields," which coincided with a severe decline in his academic performance leading to academic probation. His vital signs are within normal limits. A comprehensive metabolic panel and urine toxicology screen are unremarkable. Which of the following is the most likely diagnosis?

A 62-year-old man with a long-standing history of severe, untreated schizophrenia is evaluated in the emergency department for a gangrenous right foot. The surgical team recommends an urgent below-the-knee amputation to prevent systemic sepsis, which carries a high risk of mortality if left untreated. The patient refuses the procedure, stating, "The aliens are using this foot as a transmitter; if you cut it off, they will destroy the hospital." His vital signs are stable, but he requires surgical intervention within the next 24 hours to prevent deterioration. Arrange the following steps in the most appropriate legal and ethical sequence to navigate this patient's refusal of life-saving care.

A 28-year-old man with a recent diagnosis of schizophrenia is started on haloperidol. His physician is reviewing the adverse effect profile with the patient and his family. Arrange the following extrapyramidal symptoms associated with high-potency typical antipsychotics in chronological order of their characteristic onset, from earliest to latest.

A 28-year-old man is currently hospitalized on an inpatient psychiatric unit for an acute exacerbation of bipolar I disorder, current episode manic. Over the past hour, he has become increasingly irritable, pacing the hallways rapidly. Suddenly, he begins shouting profanities, claims the nursing staff are 'demons trying to harvest his organs,' and hurls a metal trash can at the nurses' station wall, shattering a plastic clock. He clenches his fists and takes an aggressive combat stance toward an approaching psychiatric technician. Arrange the following interventions in the most appropriate sequence of escalation for managing this patient's acute agitation, according to standard psychiatric emergency protocols.

Match each clinical presentation of psychotic and mood symptoms to the most accurate DSM-5 psychiatric diagnosis based on the symptom timeline and the temporal relationship between the affective and psychotic episodes.

A 45-year-old woman comes to a new primary care clinic to establish care. For the past 12 months, she has experienced chronic, migratory abdominal pain, generalized muscle aches, and perceived shortness of breath. She has been evaluated by a gastroenterologist, a rheumatologist, and a pulmonologist. Extensive diagnostic workups, including endoscopy, autoimmune panels, and pulmonary function tests, have all been completely normal. She states, "I know I have a terrible systemic disease that everyone is missing, and I cannot stop thinking about it." She reports spending at least 3 hours daily researching her symptoms on medical forums, which has led to a recent leave of absence from her job. During today's visit, she becomes acutely anxious and begins to hyperventilate, stating that her "lung disease is flaring up." Her lungs are clear to auscultation bilaterally, and there is no wheezing. An arterial blood gas on room air reveals:

pH: $7.55$
pCO $_2$: $24 \text{ mm Hg}$
pO $_2$: $105 \text{ mm Hg}$
HCO $_3^-$: $21 \text{ mEq/L}$

She urgently requests a referral to a quaternary care pulmonology center.

Based on the clinical presentation and laboratory findings, which of the following is the most accurate interpretation of this patient's acid-base status and the most appropriate next step in management?

Law enforcement officers transport an unidentified young male to the emergency department. He was apprehended while running through a busy intersection, violently striking passing vehicles, and screaming about extraterrestrial entities. In the resuscitation bay, he exhibits extreme combativeness, vertical nystagmus, profuse diaphoresis, and flushed skin. Vital signs reveal a heart rate of $152$/min, blood pressure of $188/112$ mm Hg, and a core temperature of $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$). The patient requires physical restraint by multiple staff members to prevent immediate harm to himself and others.

Arrange the following clinical interventions in the most appropriate chronological order for managing this patient's acute presentation and subsequent care.

A $68$-year-old man is brought to the emergency department by his wife due to severe muscle stiffness, fever, and marked confusion over the past $48$ hours. Over the past $14$ months, the patient has experienced progressive cognitive decline, prominent day-to-day fluctuations in alertness, and vivid, recurrent visual hallucinations of people in his house. His wife notes that he often thrashes and punches his pillows while asleep. His past medical history is significant for major depressive disorder. Current medications include a daily multivitamin and citalopram. Three days ago, a covering physician prescribed haloperidol to manage the patient's distressing hallucinations. On examination, his temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), pulse is $118\text{ /min}$, and blood pressure is $168/102\text{ mm Hg}$. He is diaphoretic and disoriented. Neurologic examination reveals profound "lead-pipe" muscle rigidity in all extremities. Deep tendon reflexes are $1+$ bilaterally, and there is no clonus. Laboratory studies show a creatine kinase of $4,500\text{ U/L}$, a TSH of $3.5\text{ mU/L}$ (normal: $0.5-5.0\text{ mU/L}$), and a free T4 of $1.2\text{ ng/dL}$ (normal: $0.9-1.7\text{ ng/dL}$). Which of the following is the most likely cause of this patient's acute presentation?

A 26-year-old woman, G1P0 at 14 weeks gestation, is evaluated in the outpatient psychiatry clinic. Three weeks ago, she was the victim of an armed robbery in a parking garage. Since the incident, she has experienced severe insomnia, recurrent nightmares about the robbery, and feels emotionally detached from her husband. She completely avoids going near parking garages or driving alone. Vital signs are temperature 37.0°C (98.6°F), blood pressure 110/70 mm Hg, pulse 88/min, and respirations 16/min. Recent routine prenatal laboratory studies are unremarkable except for a mild, compensated respiratory alkalosis. When recounting the robbery during the interview, she becomes tearful and visibly distressed. She has a history of bipolar I disorder but discontinued her mood stabilizer prior to conception. She works as a hospital administrator and explicitly asks the physician not to document the visit in her medical record, fearing her employer will find out and terminate her. Which of the following is the most appropriate next step in management?

For each of the following brief clinical presentations, identify the most accurate DSM-5 diagnosis based on the specific symptom triggers, core fears, and duration thresholds.

Pharmacotherapy for bipolar disorder requires careful baseline and ongoing laboratory monitoring due to the distinct adverse effect profiles of mood stabilizers and second-generation antipsychotics. Match each of the following medications used in the management of bipolar disorder with its most appropriate baseline and ongoing laboratory monitoring requirement.

A 28-year-old woman comes to the outpatient clinic for a follow-up appointment. Three weeks ago, she presented with a 2-month history of pervasive sadness, sleeping 14 hours a day, a significantly increased appetite, and a sensation that her arms and legs were "weighed down by lead." She was diagnosed with major depressive disorder and prescribed sertraline. Today, she reports no improvement in her mood or energy. She states, "I have been taking these pills for three weeks and feel exactly the same; I want to just stop taking them."

Upon further questioning, the patient describes an episode three years ago that lasted for two weeks. During that time, she felt "invincible," slept only 2 hours a night without feeling fatigued, spoke so rapidly that friends could not follow her thoughts, and impulsively bought a luxury car she could not afford, which subsequently led to bankruptcy. She has never been hospitalized for psychiatric reasons. Vital signs and physical examination are normal.

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

An 82-year-old man with a history of mild Alzheimer dementia is hospitalized for a urinary tract infection. On hospital day 2, he becomes acutely agitated, disoriented, and begins pulling at his intravenous lines. He is experiencing visual hallucinations and yelling at the nursing staff. Arrange the following interventions in the most appropriate sequential order of escalation, from initial best practices to interventions of absolute last resort, for the management of this patient's acute delirium with severe agitation.

A 55-year-old woman is evaluated in the hospital for new-onset agitation, sweating, and tremors. She was admitted three days ago for a severe soft tissue infection and was recently transitioned to intravenous linezolid due to bacterial sensitivities. Her past medical history is significant for major depressive disorder, generalized anxiety disorder, hypertension, and hyperlipidemia. Her temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $158/96\text{ mm Hg}$, and pulse is $118/\text{min}$. Physical examination reveals a prominently diaphoretic and agitated woman. Neurologic examination demonstrates inducible clonus in the bilateral ankles and generalized hyperreflexia. An interaction involving linezolid and which of the following home medications is the most likely cause of this patient's current symptoms?

Evaluated in the sleep clinic is a young adult university student reporting a two-year history of debilitating daytime hypersomnolence. The patient frequently falls asleep during interactive seminars despite maintaining a self-reported 8-hour nightly sleep schedule. In addition, the patient describes recent episodes where hearing a funny joke causes transient buckling of the knees and jaw drooping, with preserved consciousness throughout the event. Suspecting a specific central disorder of hypersomnolence, the clinician plans a comprehensive evaluation and treatment strategy. Arrange the following diagnostic and therapeutic steps in the most appropriate, guideline-directed chronological sequence for the management of this patient.

During a specialized memory disorders conference, a panel of neurologists and psychiatrists discusses five complex patient cases to highlight the diverse pathophysiology of neurodegenerative conditions. For each patient vignette described below, identify and match the correct specific neurocognitive disorder diagnosis.

A 15-year-old girl is brought to the emergency department by her school counselor. The counselor reports that the patient confessed to taking "a whole bottle" of her mother's amitriptyline an hour ago in a suicide attempt. On physical examination, the patient is lethargic but arousable. Temperature is 38.2°C (100.8°F), blood pressure is 92/60 mm Hg, pulse is 125/min, and respirations are 14/min. Her pupils are dilated, and her skin is flushed and dry. An electrocardiogram shows sinus tachycardia with a QRS complex duration of 145 ms. When the physician informs the patient that she requires an intravenous medication, she becomes agitated and refuses. She states, "I just want to die. If you call my mother or step-father, he will beat me again. Please just let me be." Which of the following is the most appropriate next step in management?

Paramedics bring a 27-year-old man to the emergency department after he was found unresponsive in an alley. On arrival, his blood pressure is 105/65 mmHg, pulse is 55/min, and respiratory rate is 5/min. Oxygen saturation is 78% on room air. Physical examination reveals pinpoint pupils and cyanosis of the lips. The patient is accompanied by his brother, who reports that the patient has struggled with prescription opioid misuse for years and recently transitioned to injecting street drugs. Following initial acute stabilization, the patient regains consciousness, becomes tearful, and strongly requests to start medication-assisted treatment for his addiction today. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 45-year-old man is evaluated in the emergency department after sustaining deep partial-thickness burns to his right forearm during a grease fire at his home. The patient has a 15-year history of schizophrenia and was brought to the hospital by his brother. The burn surgery team recommends urgent surgical debridement and grafting to prevent severe infection and preserve limb function. When the physician attempts to obtain consent, the patient vehemently refuses, stating, "The flames were a test from the celestial watchers. If you cut away the marked flesh, you will release my life force and I will evaporate into the ether." He is awake, alert, and oriented to person and place, but becomes highly agitated when the surgery is mentioned. Vital signs are within normal limits. The patient's brother, who is his legally designated healthcare proxy, is at the bedside and urgently requests that the surgery proceed. Which of the following is the most appropriate next step in management?

Accompanied by his roommate, a 21-year-old male college student is brought to the university counseling and psychiatric emergency center. Three weeks ago, he was evaluated at a local walk-in clinic for a two-month history of profound low mood, sleeping up to 14 hours a day, intense cravings for sugary foods, and a sensation that his arms were excessively heavy. At that time, he was diagnosed with major depressive disorder and prescribed fluoxetine. Today, the roommate reports a drastic change in the patient's behavior over the past four days. The patient is currently pacing the examination room, speaking rapidly, and excitedly explaining that he has discovered a theoretical formula that will solve global energy shortages. He mentions he has only slept for two hours over the past two days but feels 'more energetic than ever.' Medical history is otherwise unremarkable. Vital signs are within normal limits. Which of the following is the most appropriate next step in the management of this patient?