Psychiatry

A 29-year-old woman is brought to the psychiatrist by her sister due to worsening isolation and profound sadness over the past $5$ weeks. The patient sleeps $14$ hours daily and frequently hears voices stating, "You are a vessel of sin." Three years ago, she experienced a $10$-day period during which she slept only $3$ hours per night, spoke incessantly, and aggressively attempted to start a new company despite having no related experience. She has a history of primary hypothyroidism, for which she takes daily levothyroxine. Vital signs are normal. Laboratory results demonstrate a TSH of $2.2$ $\mu$ U/mL (normal: $0.4$-$4.0$ $\mu$ U/mL) and a free T4 of $1.3$ ng/dL (normal: $0.9$-$1.7$ ng/dL). Which of the following is the most appropriate next step in the management of this patient?

A 38-year-old woman comes to the clinic reporting persistent daytime fatigue and sleepiness for the past 14 months. She works as a software engineer and frequently dozes off at her desk during the mid-afternoon, occasionally making embarrassing errors in her code. She goes to bed at 10:30 PM and wakes up at 6:30 AM daily, feeling relatively refreshed initially, but severe sleepiness returns by midday. She reports that occasionally, right before drifting off to sleep at night, she hears unfamiliar voices calling her name in the room, though she lives alone. She has no episodes of sudden muscle weakness when laughing or angry. Her medical history is unremarkable, and she takes no medications. Physical examination is within normal limits. An overnight polysomnogram (PSG) reveals a total sleep time of 7.9 hours, an apnea-hypopnea index of 1.5 events/hour, and a rapid eye movement (REM) sleep latency of 10 minutes. The next day, a multiple sleep latency test (MSLT) demonstrates a mean sleep latency of 5.5 minutes and 1 sleep-onset REM period (SOREMP). Which of the following is the most appropriate next step in the management of this patient?

A quality improvement committee in a community mental health clinic is reviewing the longitudinal care of a 34-year-old man with a 10-year history of schizophrenia. His clinical course was initially complicated by frequent relapses due to medication nonadherence, and later by severe, persistent auditory hallucinations despite continuous, verified medication delivery. The committee is evaluating whether the sequence of psychopharmacological interventions followed current consensus guidelines for the stepwise management of schizophrenia and treatment-refractory psychosis. Assuming the clinical team followed standard evidence-based algorithms at each stage of his illness, arrange the following interventions in the correct chronological sequence from earliest to latest.

A 28-year-old woman at 34 weeks gestation is brought to the emergency department by paramedics following a high-speed motor vehicle collision. She has a history of schizophrenia, which had been well-controlled until she discontinued her medications one month ago. On arrival, her blood pressure is 78/40 mm Hg and her heart rate is 142/min. She is combative, actively hallucinating, and screaming, "The government is trying to steal my organs!" A Focused Assessment with Sonography for Trauma (FAST) examination reveals a large amount of free intraperitoneal fluid. Continuous fetal monitoring demonstrates recurrent late decelerations. The patient is unable to demonstrate an understanding of her medical condition or the risks of refusing treatment. Her husband arrives and immediately provides consent for an emergency exploratory laparotomy, cesarean delivery, and any necessary blood transfusions. However, a review of the patient's electronic medical record reveals a valid Advance Directive executed two years ago when she was psychiatrically stable. The document appoints her mother as her healthcare proxy and explicitly refuses the administration of all blood products under any circumstances due to religious beliefs. The mother is contacted by telephone; she confirms the Advance Directive and insists that blood products must be withheld, even if it results in the death of the patient and the fetus. Which of the following is the most appropriate next step in management?

A 27-year-old man is evaluated in an outpatient psychiatry clinic for worsening irritability. He has a history of major depressive disorder and was started on fluoxetine three weeks ago. During the interview, he becomes highly agitated and states, "My former supervisor ruined my career when he fired me last week. I bought a handgun yesterday, and I am going to his house tonight to shoot him." When the psychiatrist attempts to explore this further and suggests voluntary hospitalization, the patient abruptly stands up, refuses any further discussion, and runs out of the clinic. The psychiatrist confirms the supervisor's identity and home address in the patient's occupational history records. Which of the following is the most appropriate next step in management?

A 24-year-old male medical student presents to the university counseling center seeking help for severe anxiety regarding medical procedures. During his recent surgical clerkship, he experienced intense lightheadedness, nausea, and diaphoresis, ultimately fainting while observing a routine venipuncture. He reports having an intense fear of blood and needles since early childhood, which led him to avoid medical settings until his clinical rotations began. His physical examination and recent electrocardiogram are unremarkable. He is highly motivated to overcome this fear to successfully complete his medical training. Which of the following are the most appropriate steps in the evaluation and management of this patient? (Select 2 that apply)

A 25-year-old male fitness instructor presents to a primary care clinic reporting a 6-week history of feeling 'completely drained of energy.' He states that he has lost interest in his usual workout routines, struggles to concentrate on his business, and has been sleeping up to 13 hours a day. His medical history is unremarkable, and he currently takes no medications. Upon further questioning about his past psychiatric history, he recalls a 5-week period approximately two years ago when he felt 'invincible.' During that time, he slept only 3 hours per night, spoke incredibly fast, and spontaneously purchased extremely expensive gym equipment that led to bankruptcy. He also harbored an intense belief that he possessed a telepathic ability to communicate with elite athletes worldwide; this belief entirely resolved when his energy levels returned to baseline. His vital signs are within normal limits. Mental status examination today reveals a blunted affect and psychomotor retardation, with no current delusional thought processes or suicidal ideation. Which of the following is the most appropriate next step in pharmacologic management?

A 35-year-old man with a history of schizophrenia is brought to the emergency department from a residential psychiatric facility due to high fever, severe muscle rigidity, and progressive confusion over the past 24 hours. His current medication regimen includes high-dose fluphenazine. His temperature is 39.8°C (103.6°F), blood pressure is 168/104 mm Hg, and pulse is 122/min. Physical examination reveals generalized lead-pipe rigidity and profuse diaphoresis. Laboratory studies show a markedly elevated creatine kinase level. Arrange the following interventions in the most appropriate sequential order for the standard step-wise management of this patient's condition, from the initial immediate action to the last-resort treatment.

An attending physician is evaluating a 31-year-old female patient admitted to the telemetry unit for investigation of recurrent, severe hypoglycemic episodes. The patient, who works as a neonatal intensive care nurse at another facility, has had three syncopal events accompanied by diaphoresis over the past month. During the current admission, a fasting laboratory workup during a symptomatic episode (blood glucose of $38 \text{ mg/dL}$) reveals a serum insulin level of $72 \text{ \mu U/mL}$ (normal: $< 10 \text{ \mu U/mL}$) and a C-peptide level of $0.1 \text{ ng/mL}$ (normal: $0.5 - 2.0 \text{ ng/mL}$). A plasma sulfonylurea screen is negative. Later that evening, the nursing staff discovers several used insulin syringes and empty vials of short-acting insulin concealed inside the lining of the patient's cosmetic bag. The patient has no documented history of diabetes mellitus and is currently resting comfortably in her room.

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

A 16-year-old girl is evaluated in the outpatient clinic for primary amenorrhea. She has never had a menstrual period. Over the past year, she has become increasingly focused on maintaining a 'clean' lifestyle, strictly eliminating fats and carbohydrates from her diet, and exercising for at least two hours daily. Her mother reports that the patient often complains of feeling cold and fatigued but continues to excel academically. The patient takes no medications and denies sexual activity. Her temperature is 35.8°C (96.4°F), blood pressure is 92/58 mm Hg, and pulse is 48/min. Her BMI is 15.2 kg/m². Physical examination reveals fine, soft hair on her back and abdomen, as well as dry skin. Pelvic examination is normal. Laboratory testing reveals:

Which of the following is the most likely diagnosis?

A 45-year-old man with a 10-year history of schizoaffective disorder, bipolar type, is admitted to the inpatient psychiatric unit due to a severe manic episode with psychotic features. For the past week, he has slept only two hours per night, exhibits pressured speech, and holds the grandiose delusion that he is the chief executive officer of a multinational corporation. On evaluation, he is highly agitated, pacing the halls, and refusing to take any oral medications. The treating psychiatrist determines that the patient currently lacks decision-making capacity. His brother, who is his designated healthcare proxy, arrives at the hospital and tells the physician, "He is completely out of control. When this happened three years ago, electroconvulsive therapy and haloperidol worked perfectly to bring him back. Please administer those treatments right away before he gets worse."

A review of the patient's medical record reveals a legally valid psychiatric advance directive created two years ago when the patient was euthymic and possessed full decision-making capacity. The directive explicitly states: "Under no circumstances do I consent to the administration of electroconvulsive therapy or any first-generation antipsychotics, including haloperidol, due to severe adverse reactions I experienced in the past."

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

A 64-year-old man is brought to the neurologist by his wife due to a 3-month history of rapidly progressive cognitive decline and unusual involuntary movements. The wife notes that he initially had trouble concentrating at work and seemed unusually anxious. Over the past month, he has become profoundly disoriented, struggles to walk independently due to poor coordination, and frequently exhibits sudden, brief, shock-like muscle jerks, particularly when startled by a loud noise. He has no significant past medical history and takes no medications. Vital signs are normal. Neurological examination reveals marked gait ataxia, widespread myoclonus, and severe expressive aphasia. Magnetic resonance imaging (MRI) of the brain demonstrates hyperintensity in the basal ganglia and cerebral cortex on diffusion-weighted imaging. Which of the following best describes the underlying pathophysiology of this patient's condition?

A 29-year-old man presents to the outpatient clinic reporting a 6-week history of feeling "down and hopeless." He states that he has lost interest in his usual hobbies, has very low energy, and is sleeping up to 12 hours a day. His appetite has increased, leading to a 4-kg (8.8-lb) weight gain. He was recently reprimanded at work for excessive absences because he could not find the motivation to get out of bed. He has no significant past medical history and takes no medications. He does not use tobacco, alcohol, or illicit substances. He mentions that occasionally, just as he is falling asleep, he hears a voice calling his name. Physical examination reveals a flat affect and psychomotor retardation, but no other abnormalities. He requests to be started on an antidepressant medication. Which of the following is the most appropriate next step in the management of this patient?

Carefully analyze the timeline and symptom profile of each clinical presentation below. Match each patient's presentation to the most accurate DSM-5 psychiatric diagnosis.

A 24-year-old woman is brought to the emergency department by her roommate due to profound muscle weakness and an inability to walk. The patient is a professional ballet dancer. The roommate reports that the patient has been highly distressed about her body image and frequently complains of "feeling huge," despite having a body mass index of 20.1 kg/m². The patient admits to occasional episodes where she consumes unusually large amounts of high-calorie foods in secret, followed by taking undisclosed over-the-counter medications to "flush it all out." She vehemently denies self-induced vomiting.

Vital signs show a blood pressure of 98/60 mmHg, a heart rate of 110/min, and a respiratory rate of 18/min. Physical examination reveals dry mucous membranes, delayed capillary refill, and symmetric 2/5 muscle strength in the bilateral lower extremities. There are no dental erosions or parotid gland swelling.

Initial laboratory studies show:
Sodium: 136 mEq/L
Potassium: 2.1 mEq/L
Chloride: 114 mEq/L
Bicarbonate: 12 mEq/L
Blood urea nitrogen: 34 mg/dL
Creatinine: 1.4 mg/dL

Arterial blood gas on room air reveals:
pH: 7.26
pCO2: 26 mmHg
pO2: 95 mmHg

Which of the following statements is most accurate regarding this patient's condition or appropriate management?

A 29-year-old male presents to the outpatient clinic reporting a 4-week history of persistently depressed mood, anhedonia, severe fatigue, sleeping 12 to 14 hours a day, and a 4-kg (9-lb) weight gain. He states that he is struggling to concentrate at his job as a data analyst. He denies any suicidal ideation. His past medical history is notable for an episode three years ago during which he experienced a 10-day period of decreased need for sleep (sleeping only 2 hours per night), remarkably elevated mood, grandiosity, and impulsive behavior that resulted in significant credit card debt. He did not seek medical attention at that time, and the symptoms eventually resolved. Vital signs are normal. Physical examination is unremarkable. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 1.4 mU/L and a free thyroxine (T4) level of 1.2 ng/dL. Which of the following is the most appropriate next step in management?

A 74-year-old woman is brought to the emergency department from her home by her daughter due to severe confusion and agitation that began yesterday. The daughter reports that the patient was previously able to manage her daily activities but has been 'talking to people who aren't there' and pacing the house incessantly over the past 24 hours. The patient has a history of major depressive disorder and mild cognitive impairment. Two days ago, she developed a runny nose and began taking an over-the-counter cold and allergy medication. Her prescribed medications include daily citalopram. Routine laboratory results from a clinic visit one week ago showed a decreased free thyroxine (T4) level with a normal thyroid-stimulating hormone (TSH) level. On physical examination, her temperature is 37.8°C (100.0°F), pulse is 112/min, and blood pressure is 142/86 mm Hg. She is disoriented to place and time. Her skin is warm, flushed, and dry. Her pupils are 7 mm bilaterally and sluggishly reactive to light. Bladder ultrasound reveals 600 mL of retained urine. Which of the following is the most likely cause of this patient's acute presentation?

A $21$-year-old man is brought to the emergency department by his roommates because he has been acting increasingly erratic and paranoid over the last $48$ hours. He barricaded himself in his bedroom, claiming that foreign spies are broadcasting signals into his brain through the smoke detector. His roommates report that he has no prior psychiatric history but has been staying awake for the past three nights studying for final exams, consuming large amounts of a "study aid" powder he bought from an unverified website. On examination, the patient is highly agitated, pacing the room, and sweating profusely. Vital signs are temperature $37.8^\circ \text{C}$ ($100.0^\circ \text{F}$), blood pressure $162/98$ mmHg, pulse $124$/min, and respirations $20$/min. Pupillary examination reveals bilateral mydriasis. Which of the following is the most likely diagnosis?

A 28-year-old woman, G1P0, at 14 weeks gestation presents to the outpatient clinic reporting severe anxiety, insomnia, and a persistently depressed mood. Eight weeks ago, she was the victim of a violent armed mugging. Since the event, she has experienced recurrent, distressing nightmares about the attack and feels intensely fearful when leaving her home, constantly scanning her surroundings for threats. She actively avoids the street where the mugging occurred. Her psychiatric history is significant for Bipolar I disorder, with her last manic episode occurring at age 22. She was previously stabilized on lithium but successfully tapered off the medication under medical supervision six months prior to conception. She is currently taking only prenatal vitamins. Vital signs are within normal limits. Recent routine laboratory studies show a normal complete blood count, a free T4 of $1.2$ ng/dL (normal: $0.8-1.5$ ng/dL), and a TSH of $0.2$ $\mu$ U/mL (normal: $0.4-4.0$ $\mu$ U/mL). The patient is desperate for relief and asks for 'anything that will make this stop.' Which of the following is the most appropriate next step in the management of this patient?

A 31-year-old man presents to the outpatient psychiatric clinic accompanied by his sister. He describes a 3-month history of severe anxiety, hypervigilance, and recurrent nightmares following a violent mugging. He actively avoids the neighborhood where the incident occurred and feels detached from his family. His past psychiatric history is significant for bipolar I disorder; however, he stopped taking his prescribed valproate a year ago. He currently describes his mood as 'very low' and states he has no energy or appetite. During the interview, the patient's sister steps out to take a phone call. Privately, the patient confesses that for the past two weeks, he has been hearing a voice telling him he is worthless. He explicitly requests that his condition and medical records be kept strictly private from his family. Later, when the sister returns, she asks the physician to share the details of the psychiatric evaluation so she can help arrange a medical leave of absence at his workplace.

Which of the following are appropriate actions by the physician? (Select all that apply)