Psychiatry

A 34-year-old man is brought to the emergency department by paramedics after being found confused and severely agitated in his apartment. Beside him are empty bottles of tranylcypromine and fluoxetine. In the emergency department, he is delirious and thrashing violently. His temperature is 39.5°C (103.1°F), blood pressure is 170/105 mm Hg, and pulse is 135/min. Physical examination reveals pronounced diaphoresis, hyperreflexia, and sustained ankle clonus bilaterally. Shortly after the initial assessment, the patient develops a generalized tonic-clonic seizure.

The patient's electronic health record contains a legally executed medical power of attorney designating his long-term partner as his sole healthcare proxy. The partner is currently on an international flight and cannot be reached. The patient's biological parents, who were notified of the emergency by the landlord, arrive at the hospital. They declare themselves as his legal next-of-kin and demand that all medications be withheld, insisting he 'just needs to sleep it off without chemical interference.'

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

A 28-year-old pregnant woman at 14 weeks gestation is brought to the emergency department by her husband. Over the past week, she has been sleeping for only one to two hours a night, exhibiting rapid and pressured speech, and making impulsive, large financial investments that they cannot afford. Three weeks ago, she visited a different clinic reporting severe sadness, hypersomnia, and anhedonia, at which time fluoxetine monotherapy was initiated. She is currently taking fluoxetine and prenatal vitamins. When approached by the physician, she refuses any new medications or hospital admission, stating her high energy is a "divine gift for the baby" and demands to leave immediately. Which of the following are the most appropriate next steps in the management of this patient? (Select all that apply)

A 31-year-old man comes to the clinic accompanied by his husband due to daytime sleep attacks and episodes of sudden muscle weakness. Over the last 5 months, he has been sleeping 9 to 10 hours per night but still struggles to stay awake during his work as a financial analyst. He reports that when he laughs heartily at a joke, his knees buckle and he occasionally drops his briefcase, though he remains fully conscious. Last month, while falling asleep, he saw a terrifying shadowy figure in his room and was unable to move his limbs for approximately a minute. His medical history is notable for a manic episode at age 22, leading to a diagnosis of bipolar I disorder. He was previously taking valproate but discontinued it a year ago due to weight gain. He is currently taking only tranylcypromine, which was prescribed 2 months ago for an acute depressive episode. Vital signs are within normal limits. Physical examination is unremarkable. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 7.2 µU/mL (normal: 0.5-5.0 µU/mL) and a free thyroxine (T4) level of 1.2 ng/dL (normal: 0.9-1.7 ng/dL).

Which of the following is the most appropriate pharmacotherapy for this patient's sleep-related symptoms?

On postoperative day 3 following an open reduction and internal fixation of a right tibial fracture, a 51-year-old male is evaluated by the on-call physician for acute, severe agitation and confusion. The fracture was sustained during a motor vehicle collision. The patient lives alone and a comprehensive medical history is unavailable. Current temperature is 38.7°C (101.7°F), pulse is 126/min, blood pressure is 168/102 mm Hg, and respirations are 22/min. On examination, the patient is profoundly diaphoretic and continuously attempts to pull out his intravenous catheter. When approached, he points frantically toward the ceiling and claims that swarms of insects are dropping onto his bed. Neurological examination reveals a coarse, bilateral resting tremor of the upper extremities. The surgical incision is clean, intact, and without erythema. Cardiopulmonary auscultation is unremarkable. Which of the following is the most appropriate next step in management?

A 68-year-old man is brought to the clinic by his son for evaluation of cognitive decline. The son reports that his father's memory has worsened significantly over the past 4 months, which coincided with the unexpected death of his wife. The patient frequently misplaces his glasses and forgets the names of acquaintances. During the interview, the patient appears visibly distressed about his memory, stating, "My brain is completely useless now. I can't remember a single thing." When asked orientation questions and to perform a three-word delayed recall, he frequently answers "I don't know" with little initial effort. However, with gentle encouragement and extra time, he is able to correctly recall two of the three words. The patient also reports early morning awakenings, poor appetite, and a 5-kg (11-lb) weight loss over the past 3 months. His medical history includes hypertension well-controlled on lisinopril. Vital signs are within normal limits. Physical and neurological examinations reveal no abnormalities. Which of the following is the most appropriate next step in management?

A 28-year-old pregnant woman, G2P1, at 32 weeks gestation presents to the emergency department complaining of severe muscle aches, abdominal cramps, nausea, and diarrhea for the past 24 hours. She has a history of opioid use disorder and admits to using intranasal heroin daily, but reports she ran out yesterday. She also states she has been feeling profoundly sad, having low energy, and sleeping excessively over the past 3 weeks. Her medical records indicate two previous psychiatric hospitalizations for manic episodes characterized by grandiosity and a decreased need for sleep. Vital signs are temperature 37.2°C (99.0°F), blood pressure 140/90 mm Hg, heart rate 110/min, and respiratory rate 18/min. Physical examination reveals dilated pupils, frequent yawning, rhinorrhea, and piloerection. Fetal heart rate monitoring reveals a baseline of 150/min, moderate variability, positive accelerations, and no decelerations.

The physician counsels the patient on the risks of untreated opioid withdrawal during pregnancy, including preterm labor and fetal demise. The patient demonstrates a clear understanding of these risks but states, "I need to leave right now to take care of my 3-year-old at home. I refuse to be admitted, but I want to get better. I will come to the outpatient clinic tomorrow morning."

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

A 28-year-old male with a 5-year history of schizophrenia is evaluated in the inpatient psychiatric unit for severe, persistent commanding auditory hallucinations and paranoid delusions. He is currently prescribed olanzapine 20 mg daily. His psychiatric history reveals a prior 8-week trial of risperidone 6 mg daily, which was discontinued due to a lack of efficacy. The patient insists he takes his medication every day as prescribed. The treatment team is evaluating him for treatment-resistant schizophrenia. Arrange the following management steps in the most appropriate chronological sequence for this patient.

Review the clinical vignettes below, representing adult patients currently undergoing psychiatric evaluation for mood symptoms. Map each individual's unique presentation to the most appropriate initial pharmacological or procedural intervention.

Match each pharmacologic agent used in the treatment of substance use disorders with its corresponding mechanism of action, clinical profile, or key contraindication.

A 31-year-old male architect is evaluated via a telehealth consultation. Over the past 14 weeks, he has refused to leave his apartment, citing a firm belief that a competing architecture firm has deployed microscopic drones to monitor his thoughts. He frequently hears a male voice criticizing his design choices. The patient's mother reports that roughly coinciding with the onset of the paranoia, the patient experienced a 6-day period where he slept only 3 hours per night, exhibited pressured speech, and impulsively bought $8,000 worth of computer equipment. This hyperactive period spontaneously resolved within a week. Since that time, his paranoid beliefs and auditory hallucinations have remained constant, and his mood has been euthymic. His medical history is unremarkable. A recent urine toxicology screen was negative. Which of the following is the most likely diagnosis?

Accompanied by her husband, a 31-year-old architect presents to her primary care physician with complaints of overwhelming fatigue and persistent low mood that began a month ago. She reports spending most of her days in bed, missing work deadlines, and feeling intensely guilty about her lack of productivity. She states, "I just don't see the point in trying anymore." Upon further questioning, her husband recalls an unusual period two years prior. Over a span of 15 days, the patient barely slept, talked continuously about redesigning their entire city, and impulsively purchased $15,000 worth of construction materials. That episode led to severe financial distress and a brief psychiatric hospitalization, after which she returned to her baseline. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 1.1 mU/L (normal: 0.5–5.0 mU/L) and a free T4 level of 0.9 ng/dL (normal: 0.9–1.7 ng/dL). She currently takes no medications. Which of the following is the most appropriate pharmacotherapy to initiate for this patient?

A $14$-year-old boy is brought to the pediatric clinic by his mother due to a $3$-month history of declining academic performance, irritability, and social withdrawal. She reports that he frequently locks himself in his room and sometimes appears clumsy and disoriented when she enters abruptly. Physical examination reveals an erythematous, eczematous rash around his mouth and nose. Neurologic examination is significant for a broad-based, unsteady gait, dysarthria, and diminished deep tendon reflexes in the lower extremities. Laboratory studies show:

Which of the following is the most likely diagnosis?

A 29-year-old woman, G1P0 at 16 weeks gestation, is evaluated in the emergency department. She was brought in by her sister after expressing a detailed plan to end her life by carbon monoxide poisoning in her garage. The patient has a 5-year history of bipolar disorder but discontinued all medications 6 months ago. Over the past three weeks, she has exhibited profoundly depressed mood, anhedonia, and hypersomnia. In the emergency department, she is irritable, refuses further psychiatric evaluation, and states, "I have the right to leave. If you try to stop me, I will sue this hospital." The patient's sister presents legally binding documentation designating herself as the patient's healthcare proxy. Which of the following is the most appropriate next step in management?

A 66-year-old retired accountant is evaluated in the clinic for a 12-month history of progressive memory impairment. His husband reports that the patient frequently forgets recent conversations, struggles to manage their household finances, and occasionally gets lost in familiar neighborhoods. His past medical history is significant for well-controlled hypertension and hyperlipidemia. Vital signs are within normal limits, and a general physical examination shows no acute abnormalities. The physician suspects a major neurocognitive disorder and plans a comprehensive diagnostic evaluation. Arrange the following diagnostic and evaluative steps in the most appropriate, standard chronological sequence for the workup of this patient.

A 34-year-old male architect is accompanied to the primary care physician by his spouse. The patient survived a severe structural collapse at a building site exactly twenty-four days ago. Since the event, he has experienced recurrent, intrusive nightmares about the collapse and profound distress when exposed to loud noises. He actively avoids visiting any construction zones. The spouse notes that the patient has been highly irritable, jumpy, and disconnected from his family. During the psychiatric review of systems, the physician discovers that six years ago, the patient had a discrete four-week episode characterized by a severely decreased need for sleep, pressured speech, and grandiose delusions that required inpatient psychiatric hospitalization. Current laboratory studies reveal a serum thyroid-stimulating hormone level of 1.8 µU/mL (normal: 0.4-4.5 µU/mL) and a free thyroxine level 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's condition?

An addiction psychiatry clinic evaluates a 29-year-old male patient who is seeking pharmacological support to maintain abstinence from heroin. The patient states he was discharged from a short-term inpatient detoxification facility 10 days ago and has not used any illicit substances since. Physical examination reveals normal pupillary size, absence of piloerection, and a resting heart rate of 72/min. The physician and patient agree to proceed with an opioid antagonist therapy to reduce the risk of relapse. Arrange the following steps in the most appropriate chronological sequence for safely initiating this patient on long-acting injectable naltrexone.

An emergency physician evaluates a 24-year-old man who collapsed during gymnastics practice. He reports profound weakness and muscle cramps over the past three days. His body mass index is $19.5 \text{ kg/m}^2$. The patient is heavily preoccupied with his body image and fears gaining weight. He admits to consuming massive amounts of food in short periods, followed immediately by self-induced vomiting, a pattern he repeats several times a day. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $100/60 \text{ mmHg}$, pulse $105/\text{min}$, and respirations $10/\text{min}$. Physical examination reveals enlarged parotid glands and calluses on the dorsum of his right hand.

Laboratory results are as follows:

Arterial blood gas (room air):

Which of the following best describes this patient's current acid-base status?

A 50-year-old woman is diagnosed with major depressive disorder following a period of persistent low mood and anhedonia. Over the next year, her condition progressively worsens despite various treatment attempts, culminating in a state of severe melancholia characterized by a life-threatening refusal to eat and drink. Arrange the following clinical management steps in the correct chronological sequence, representing a standard stepped-care escalation for this patient's evolving clinical condition.

A young adult male is brought to the inpatient psychiatric unit by his family due to a profound decline in functioning over the past two weeks. The patient has been entirely mute, persistently holds his arms in rigid, unnatural postures for hours, and refuses all oral intake. His current daily medication regimen includes risperidone and fluoxetine. Vital signs show a heart rate of $105/\text{min}$ and blood pressure of $130/85\text{ mm Hg}$; he is afebrile. The psychiatry team suspects catatonia. Arrange the following management steps in the most appropriate sequential order for evaluating and treating this patient's current condition.

A 34-year-old man presents to the clinic with his partner due to a 1-month history of worsening sadness, anhedonia, and sleeping 12 to 14 hours a day. His partner reports that the patient has stopped going to his job as a software developer, barely eats, and has expressed feelings of worthlessness. Medical history is significant for a hospital admission 5 years ago when the patient was found wandering the streets, claiming he was a "prophet" who did not need to sleep, and talking so rapidly that he was difficult to understand. This previous episode resolved after a 2-week inpatient stay, and he eventually stopped taking his prescribed medications. The patient currently exhibits a flat affect and psychomotor retardation. Vital signs are within normal limits, and physical examination shows no abnormalities. Basic metabolic panel and thyroid-stimulating hormone levels are unremarkable. Which of the following pharmacologic therapies are appropriate for this patient's current episode? (Select all that apply)