Psychiatry

A 38-year-old woman comes to the clinic seeking help to stop drinking alcohol. She reports consuming approximately half a bottle of wine every evening but expresses a strong desire to achieve total abstinence. She has been attending group counseling for the past month and feels motivated, but she requests medication to help manage her daily alcohol cravings. Her medical history is notable for opioid use disorder, which has been in sustained remission for the past 4 years on a stable dose of methadone. She has no other medical conditions. Vital signs are normal. Laboratory studies, including a comprehensive metabolic panel and complete blood count, are within normal limits. Which of the following is the most appropriate pharmacotherapy to promote alcohol abstinence in this patient?

A 68-year-old retired mechanic is brought to the clinic by his wife due to excessive daytime sleepiness and frequent nighttime awakenings over the past two months. His wife reports that he sleeps restlessly and has episodes where he completely stops breathing for about 20 seconds at a time. The patient has a history of a myocardial infarction four years ago, type 2 diabetes mellitus, and hypertension. His current medications include metformin, low-dose aspirin, and amlodipine. Vital signs are temperature 37.0°C (98.6°F), blood pressure 118/76 mmHg, heart rate 92/min, and respiratory rate 18/min. BMI is $26 \text{ kg/m}^2$. Physical examination reveals a laterally displaced point of maximal impulse, a faint third heart sound (S3), and trace bilateral lower extremity pitting edema. A polysomnography study demonstrates recurrent episodes of apnea without associated chest or abdominal wall movement, occurring between periods of a crescendo-decrescendo breathing pattern. Which of the following is the most appropriate initial step in the management of this patient's sleep disorder?

A 26-year-old woman is admitted to the medical ward for treatment of a localized methicillin-sensitive Staphylococcus aureus (MSSA) cutaneous abscess on her left forearm, which developed after a superficial self-inflicted laceration. She is currently receiving intravenous vancomycin. Her home medications include fluoxetine. Over the past 48 hours, she has been highly demanding, frequently yelling at nurses for 'ignoring' her, while praising the attending physician as her 'savior.' She has a long-standing history of intense, unstable relationships, chronic feelings of emptiness, and frequent, rapid mood shifts from extreme euphoria to deep dysphoria that last for a few hours, typically triggered by interpersonal conflicts. She reports that after a recent breakup, she heard voices telling her she was worthless for 2 days; this resolved without psychiatric intervention. Today, when told the attending physician is off duty, she becomes enraged, states she is being abandoned, and demands to be discharged immediately. She denies active suicidal ideation. Which of the following is the most appropriate next step in the management of this patient?

A 32-year-old male is evaluated at the behavioral health center for profound distress. Five months prior, he witnessed a catastrophic scaffolding collapse at his construction site. Since the incident, he suffers from severe hyperarousal, nightly harrowing dreams about the collapse, and active avoidance of any construction zones. He feels emotionally estranged from his spouse. Over the previous six weeks, he has also manifested a severely depressed affect, extreme fatigue, and complete loss of interest in his usual recreational activities.

Review of his psychiatric history reveals an involuntary psychiatric admission at age 23. During that 18-day admission, he exhibited expansive mood, pressured speech, a perceived lack of need for sleep, and auditory hallucinations of a voice declaring him 'the chosen architect.' These hallucinations ceased entirely within days of mood stabilization.

Five days ago, the patient abruptly stopped taking phenelzine—prescribed by a different provider for his low mood—due to his inability to maintain the required dietary restrictions. He is currently taking no medications.

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

You are evaluating five different patients who have recently initiated psychotropic medications. Each patient is now presenting with a specific adverse effect based on their history and examination findings. Which primary pharmacological mechanism best corresponds to the responsible medication for each patient's clinical presentation?

A 25-year-old woman is brought to the outpatient psychiatric clinic by her sister due to a 4-week history of profound sadness, lack of motivation, and sleeping up to 14 hours daily. For the past week, the patient has been hearing an unfamiliar voice repeatedly telling her she is "hopeless and already dead." Her past psychiatric history is notable for a 3-week hospitalization two years ago when she exhibited extremely rapid speech, required only two hours of sleep per night, and harbored grandiose delusions about being a spiritual prophet. Following her discharge from that hospitalization, she returned to her baseline functioning and experienced no mood or psychotic symptoms until the current episode. The patient currently takes no medications. Vital signs are within normal limits. Laboratory evaluation reveals a thyroid-stimulating hormone (TSH) level of $1.4 \mu U/mL$ (normal: $0.5-5.0 \mu U/mL$) and a free thyroxine (T4) level of $0.8 ng/dL$ (normal: $0.9-1.7 ng/dL$). Which of the following is the most appropriate next step in management?

During morning rounds on a surgical ward, an internal medicine consultant is asked to evaluate a patient recovering from a right femoral neck fracture repair performed 48 hours ago. The nursing staff reports that the patient was awake, alert, and conversational yesterday, but overnight she became highly agitated, attempted to remove her urinary catheter, and claimed that insects were crawling on her bed sheets. The patient's daughter confirms her mother lived independently and had no history of memory issues or psychiatric illness prior to the fall. Physical examination reveals an inattentive patient who drifts off to sleep during questioning. Vital signs are stable, and a basic metabolic panel is unremarkable. Which of the following is the most likely diagnosis for this patient's acute presentation?

A 22-year-old college student presents to the university outpatient clinic reporting a 5-week history of feeling profoundly sad, crying frequently, and lacking the motivation to attend her classes. She reports sleeping up to 12 hours a day and eating significantly more than usual, resulting in a 4 kg (8.8 lb) weight gain. She has no significant past medical history, and her vital signs are within normal limits. Laboratory tests, including a complete blood count and thyroid-stimulating hormone (TSH) level, are normal. She currently takes no medications or illicit substances. The physician suspects a major depressive episode and plans to prescribe fluoxetine. Which of the following is the most appropriate next step in the clinical evaluation and management of this patient?

An unmarried 29-year-old accountant is referred for a psychiatric evaluation by his corporate human resources department due to ongoing interpersonal difficulties. For the past seven years, he has worked in an isolated cubicle and consistently refuses to attend team meetings or company events. During the clinical interview, the patient sits rigidly, avoids eye contact, and appears visibly apprehensive. He explains that he avoids his colleagues because he is convinced they are harboring malicious intentions and secretly sabotaging his energy fields. He notes that this intense anxiety persists even with colleagues he has known for years. He describes his mind as being 'tuned to a specialized frequency that intercepts cosmic warnings.' His speech is markedly abstract and circumstantial, yet it remains goal-directed without derailment or neologisms. He firmly denies ever experiencing auditory or visual hallucinations. A review of his medical history reveals that these eccentric behaviors and beliefs have been present continuously since his late teens, without distinct episodes of clinical deterioration or full recovery. He denies any periods of pervasive sadness or elevated mood. Which of the following is the most likely diagnosis?

A 35-year-old teacher visits her primary care physician due to chronic fatigue and neck pain. During the interview, she reveals that she feels constantly 'on edge' and struggles to control her worries. Over the last 7 months, she has experienced relentless anxiety concerning her family's health, financial stability, and school responsibilities, despite no recent changes in her life circumstances. She notes that these thoughts frequently prevent her from falling asleep. Physical examination is unremarkable, and recent laboratory studies, including thyroid-stimulating hormone levels, are within normal limits. Which of the following is the most likely diagnosis?

A 26-year-old woman is brought to the clinic by her sister due to a 5-week history of severe depression. The patient describes her mood as "bottomless" and complains that her arms and legs constantly feel "heavy as lead." She reports sleeping 14 to 16 hours daily and has gained 6 kg (13.2 lb) over the past month, which she attributes to intense carbohydrate cravings. Despite her profound sadness, the sister notes that the patient's mood brightened considerably yesterday when she was presented with a surprise gift, though she relapsed into despondency hours later. The patient has experienced two similar depressive episodes in the past. The sister confidentially shares that during the patient's sophomore year of college, there was a distinct 10-day period where she seemed "like a completely different person." During that time, she slept only 3 hours a night without feeling fatigued, rapidly repainted her entire apartment, and abruptly spent her tuition money on a business venture that never materialized. She has no significant past medical history. Physical examination is unremarkable. Which of the following is the most appropriate next step in pharmacotherapy for this patient?

A 29-year-old woman presents to the clinic 4 weeks postpartum for a follow-up evaluation. She reports feeling profoundly sad, tearful, and unable to enjoy time with her newborn. She states, "I feel completely overwhelmed and guilty for being a terrible mother." She wakes up at 3:00 AM every day and is unable to fall back asleep, despite her husband handling the nighttime feedings. She has a poor appetite and has lost 4.5 kg (10 lb) since her delivery. She denies any thoughts of harming herself or her infant. She had an uncomplicated vaginal delivery but required a second-degree perineal laceration repair; she takes tramadol occasionally for residual pain. When reviewing her psychiatric history, she mentions that during her sophomore year of college, she experienced a distinct 5-day period where she felt "invincible," required only 2 hours of sleep per night, and started three different student organizations while speaking so rapidly her friends could hardly understand her. This college episode resolved spontaneously without hospitalization. Which of the following is the most appropriate next step in management?

A $26$-year-old woman comes to the psychiatric clinic for a follow-up evaluation regarding persistent low mood, hypersomnia, and severe fatigue. She has an established diagnosis of bipolar II disorder. Six weeks ago, she began taking lamotrigine for a major depressive episode. Her dosage was gradually increased according to standard protocols to a maintenance dose of $200 \text{ mg}$ daily, which she has been taking consistently for the past $2$ weeks. Despite medication adherence, the patient states she feels "just as depressed as before" and struggles to complete basic daily tasks. Her medical history is notable for polycystic ovary syndrome, which is well-controlled with a combined ethinyl estradiol and norgestimate oral contraceptive pill. Vital signs are within normal limits. Laboratory testing reveals a serum lamotrigine concentration of $1.2 \mu\text{g/mL}$ (therapeutic reference range: $3-15 \mu\text{g/mL}$).

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

A 22-year-old man is brought to the psychiatrist by his parents due to ongoing behavioral changes. Six weeks ago, the patient was hospitalized in the psychiatric unit for 4 days after presenting with severe agitation, auditory hallucinations, and paranoid delusions about being monitored by the government. At that time, his urine toxicology screen was markedly positive for amphetamines. He was discharged after brief treatment with haloperidol. His parents report that since discharge, he has lived at home and has been completely abstinent from all illicit drugs, a claim corroborated by weekly negative urine toxicology screens over the past 5 weeks. Despite his abstinence, the patient continues to experience daily auditory hallucinations of voices conversing about him and firmly believes his neighbors are tracking his movements. He has no prior psychiatric history, and there is no family history of psychiatric illness. His mood is described as 'fine,' and he exhibits no depressive or manic symptoms. Vital signs and physical examination are unremarkable. Which of the following is the most likely diagnosis?

A 28-year-old man is brought to the psychiatric clinic by his spouse. Over the past 3 weeks, the patient has slept only 2 hours per night, spoken at an unusually rapid pace, and claimed he is on the verge of single-handedly solving the global energy crisis. He also reports hearing the voices of angels who provide him with daily guidance. The spouse confirms this is his third episode of this nature in the past five years. Crucially, the spouse notes that even between these highly energetic episodes, during periods when the patient's mood is completely stable and normal for several months at a time, he continues to hear the angels' voices and firmly believes he possesses supernatural powers. A comprehensive medical and toxicological workup is negative. Which of the following is the most likely diagnosis?

A 47-year-old male executive seeks psychiatric evaluation for profound sadness, early morning awakening, and severe anhedonia that have progressively worsened over the past four months. His past medical history is unremarkable, and he is currently taking no medications. Arrange the following therapeutic steps in the exact sequence recommended by standard clinical guidelines for the progressive pharmacological and procedural management of major depressive disorder. Assume that each step is implemented sequentially only after the preceding intervention has yielded an inadequate clinical response (either non-response or insufficient partial response) despite optimal dosing and duration.

A 73-year-old retired architect is evaluated in the hospital for severe agitation. He was admitted 24 hours ago for cellulitis of the right lower extremity, for which wound cultures grew methicillin-resistant *Staphylococcus aureus* (MRSA). His medical history is significant for bipolar I disorder (not currently taking mood stabilizers), severe osteoarthritis (managed with scheduled tramadol), and a 3-year history of progressive cognitive decline, prominent visual hallucinations of small animals, and a resting tremor. He has a documented diagnosis of major neurocognitive disorder with Lewy bodies.

Currently, he is severely agitated, attempting to pull out his intravenous line, and striking at the nursing staff. He is unable to cooperate with a medical examination or verbal de-escalation. His husband, who is his legally appointed healthcare proxy, requests that the medical team administer medication to calm him down. However, the patient's daughter, who just arrived, demands that no mind-altering medications be given and suggests using physical restraints instead.

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

A 72-year-old woman is brought to the clinic by her son due to a 6-month history of progressive memory impairment, apathy, and severe psychomotor slowing. She frequently forgets conversations and has stopped participating in her usual social activities. She also reports worsening fatigue, constipation, and feeling cold constantly. Her medical history is significant for bipolar I disorder, which has been well-controlled on lithium monotherapy for 15 years, and hypertension. Current medications are lithium and lisinopril. Vital signs show a blood pressure of 130/80 mm Hg and a heart rate of 52/min. Physical examination reveals delayed relaxation of the deep tendon reflexes, dry skin, and a slightly puffy face. Cognitive assessment yields a Montreal Cognitive Assessment (MoCA) score of 19/30.

Laboratory results are as follows:

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

A $31$-year-old woman is evaluated in the emergency department for severe nausea, vomiting, diffuse muscle aches, and profound restlessness. She has a history of severe opioid use disorder. For the past three years, she has been maintained on a daily dose of $80\text{ mg}$ of methadone. Two days ago, her physician decided to transition her to sublingual buprenorphine-naloxone to provide more flexible outpatient management. She was instructed to wait until she felt withdrawal symptoms before taking her first dose. She took her last dose of methadone approximately $36$ hours ago. One hour ago, she took her first prescribed dose of sublingual buprenorphine-naloxone. Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $158/96\text{ mm Hg}$, pulse of $118\text{/min}$, and respirations of $18\text{/min}$. Physical examination reveals dilated pupils, excessive lacrimation, rhinorrhea, and piloerection. The patient's skin is clammy, and she is visibly shivering. She reports, "I thought this new medication was supposed to help, but I feel worse than I ever have." Which of the following is the most likely primary mechanism responsible for this patient's acute symptom presentation?

A 19-year-old female sophomore college student presents to the university health clinic seeking help for worsening sadness, low energy, and difficulty focusing on her coursework over the past four months. During the interview, she tearfully admits to intense dissatisfaction with her body weight. She describes periods where she consumes unusually large amounts of food in secret, immediately followed by the use of laxatives and self-induced vomiting. This cycle occurs almost daily. Her current body mass index is 22.1 $kg/m^2$. Vital signs reveal a blood pressure of 105/65 mm Hg and a heart rate of 88/min. Physical examination notes bilateral parotid gland enlargement and abrasions on the dorsal aspect of her hands.

The patient asks about starting a medication to help with her mood and eating patterns. Which of the following is the most accurate statement regarding this patient's clinical picture and pharmacological management?