Exam 3: Psychiatry

A 68-year-old man is admitted to a rehabilitation unit following a stroke that resulted in right-sided weakness and facial droop.  He has a history of hypertension, coronary artery disease, osteoarthritis, and prostate cancer in remission.  Prior to the stroke, the patient had retired to care for his wife, who has early-onset dementia.  The physical therapist informs the physician that the patient has shown little effort over the past 3 weeks and has recently refused rehabilitation services, saying, "What's the point?"  The physician speaks with the patient's family members, who say, "Ever since last month's stroke, he seems so resigned and barely talks when we visit.  He seems uninterested in hearing about the grandchildren he adores and has asked his friends not to visit."  When interviewed by the physician, the patient says he has had low energy, decreased concentration, and difficulty sleeping since the stroke.  He says, "Of course I'm depressed, with all my medical problems and my wife's condition.  Wouldn't anyone in my situation be depressed?"  He has no suicidal ideation.  Which of the following is the most appropriate response to the patient by the physician?

A 13-year-old girl is brought to the office by her mother due to concerns about her adjustment to a new school.  Her mother says, "She has always been shy and somewhat awkward.  I was hoping that her new school's emphasis on group projects would help her to be more social, but instead it has made her extremely anxious.  She is pleading with me to consider home schooling so she can work by herself."  The patient is bright but has always been an underachiever at school and has few friends.  She has an obsessive interest in horses.  The patient was born at full term, and developmental milestones were within normal range.  During the interview, the girl appears anxious and makes poor eye contact.  She interrupts the physician's questions by changing topics and mentioning facts about different horse breeds.  When her vital signs are checked, she touches the blood pressure cuff repeatedly.  Physical examination is unremarkable.  Which of the following is the most likely explanation for this patient's behavior?

A 23-year-old woman is brought to the emergency department by her roommate due to bizarre behavior.  The roommate reports that, over the past few days, the patient has become increasingly paranoid.  She stays up almost all night and believes the apartment is bugged.  The roommate became alarmed when the patient did not go to work yesterday and started speaking in a whisper.  When interviewed, the patient does not respond verbally to questions but calmly writes on a piece of paper, "I've been warned not to say anything."  Her parents are contacted and report a history of depression treated with bupropion.  They have never observed the behavior their daughter is exhibiting.  The parents report that the patient drinks alcohol socially but do not believe she uses illicit drugs.  Vital signs and physical examination are unremarkable.  Family history is significant for bipolar disorder in a maternal uncle.  Which of the following is the most appropriate next step in management of this patient?

A 28-year-old woman, gravida 1 para 1, comes for a routine 4-week postpartum visit following an uncomplicated vaginal delivery.  The patient describes some mild vaginal soreness and breast tenderness but has no other physical problems.  She says, "The baby is adorable, but I worry about being a good mother."  She tearfully describes feeling exhausted and unable to return to sleep after getting up in the middle of the night to feed the baby.  She says, "The baby cries all the time and nothing I do helps.  I tried to breastfeed, but I gave it up because she was fussy and I was afraid she wasn't getting enough to eat.  My husband tries to be supportive and has offered to help with nighttime feedings, but I am up at night anyway because I can't sleep."  The patient has little time to care for herself and has been eating poorly.  She feels increasingly depressed and has little energy.  The patient says, "Everyone expects me to be happy, but it has been so hard.  I don't deserve to be a mother."  The patient has no psychiatric history and no thoughts of hurting herself or the baby.  Physical examination is normal.  Routine laboratory tests, including hemoglobin and TSH levels, are within normal range.  Which of the following is the most appropriate next step in management of this patient?

A 45-year-old man comes to the office for a routine maintenance evaluation.  The patient has no prior medical or surgical history and takes no medication.  He moved to the area 3 weeks ago to work as a newscaster at a local television station.  He says, "I quit my last job while we were on-air.  I had my own show before, but then the station hired a coanchor.  There was no room for me there."  He became "extremely upset" last week when he saw an unflattering photograph of himself still featured on the station's website.  The patient then crosses his arms dramatically and describes how he had previously quit another television job abruptly after his boss told him that he was difficult to work with because he was always trying to take over meetings.  He bursts into tears and says, "I thought that he was my friend, but real friends don't stab you in the back like that."  On mental status examination, speech is loud and not pressured; facial expressions and hand gestures appear exaggerated.  Which of the following is the most likely diagnosis in this patient?

A 19-year-old woman is brought to the emergency department by her father due to bizarre behavior.  When the patient did not come down for breakfast this morning, her father went to her room and found her sitting up in bed, staring at the wall.  The patient did not respond to questions and was very stiff when her father tried to help her stand.  The patient was diagnosed with bipolar disorder last year.  She takes lithium, risperidone, and fluoxetine.  Her dosages of risperidone and fluoxetine were both increased recently to target residual depressive symptoms.  Temperature is 36.6 C (97.9 F), blood pressure is 121/78 mm Hg, pulse is 68/min, and respirations are 14/min.  When asked what today's date is, the patient repeats, "Date, date, date," repeatedly.  She resists the examiner's movement of her arms, increasing her resistance in proportion to the applied force.  Which of the following is the most likely diagnosis for this patient?

A 22-year-old man comes to the emergency department with his roommate due to depression and thoughts of killing himself.  The patient says, "I've been struggling for weeks, but my roommate convinced me to finally get help."  The patient has not attended classes the past 2 weeks because he feels exhausted and has been sleeping throughout the day.  He has no appetite and must force himself to eat at least 1 meal a day.  The roommate says, "The whole week before he got depressed, he was doing great.  He was reading ahead for class and working in the lab with almost no sleep.  He was so excited about his research and would talk about it nonstop to anyone who would listen."  The patient takes no medication.  Physical examination and laboratory studies are unremarkable; urine drug screen is negative.  He appears tearful and has suicidal ideation.  The patient is admitted for inpatient psychiatric treatment.  Which of the following is the most appropriate pharmacotherapy at present?

A 72-year-old woman is admitted to the hospital because of worsening suicidal ideation for the past month.  The patient has been refusing meals in order to "sacrifice" herself for "the greater good."  She has stopped communicating with her family and spends most of her days sleeping or staring at the television.  The patient has been treated with multiple antidepressants in the past for recurrent major depressive disorder.  Two weeks ago, she discontinued taking venlafaxine because she felt it "interfered" with her plan to kill herself.  The patient is 165 cm (5 ft 5 in) tall and weighs 48 kg (105 lb).  BMI is 17.5 kg/m2.  Physical examination shows decreased skin turgor and dry mucous membranes.  Which of the following is the best next step in management?

A 12-year-old girl is brought to the office by her mother, who is upset over her daughter's poor grades.  The mother says, "Although she has always been scatterbrained, she is a really smart kid.  Her grades have been poor throughout middle school, but I feel she could do so much better."  On her most recent report card, the girl received Cs and Ds in most academic subjects.  Typical teacher comments have included, "Mind seems elsewhere," "Frequently misses important details," and "Work is handed in late and is messy, incomplete, and disorganized."  At home, the girl is occasionally moody and easily frustrated.  Her mother says, "She gets upset when reminded of her chores, when the problem is usually that she simply forgot or wasn't listening in the first place."  Apart from the issue of her grades, the girl enjoys school and is sleeping and eating well.  The mother adds that the girl recently felt sad and rejected when she was not invited to a friend's party, but the girl says it was "no big deal."  The patient has no medical conditions.  On mental status examination, she makes good eye contact.  She is responsive to the physician's questions but is occasionally distracted, requiring redirection.  In addition to psychosocial interventions, which of the following medications would be most effective for this patient?

A 22-year-old man comes to the office for evaluation of acne.  The patient has seen several doctors over the past few years for his "huge pimples" and has tried multiple nonprescription acne preparations without benefit.  He spends hours a day checking his skin in the mirror for new pimples and scars and researching the latest acne treatments.  He avoids socializing and dating due to fears of being rejected based on his appearance.  The patient purposely styles his hair to conceal his forehead and cheeks.  He has no medical history.  Vital signs are within normal limits.  The patient is wearing a baseball cap and hesitantly removes it.  Physical examination shows a small papule on his forehead and a few closed comedones on his nose that are noticeable only on close inspection.  His skin is otherwise clear without scarring or hyperpigmentation.  Which of the following is the most appropriate management for this patient?

A 16-year-old boy comes to the office due to crippling anxiety.  The patient recently quit his job at a local convenience store due to the anxiety.  He was responsible for closing the store at the end of his shifts but was overwhelmed by an uncontrollable urge to take keychains from one of the displays.  One evening, as the patient was closing the store, he acted on this impulse and felt better.  However, he then felt guilty and could not sleep; the next morning, he returned the keychain before anyone noticed.  Over the next few weeks, the patient felt increasingly restless during his shifts and scared about being left alone with the merchandise at the end of the day.  After 3 more instances of taking keychains and returning them, he stopped going to work because he liked the manager and was afraid of getting caught.  The patient has otherwise been attending high school classes regularly.  He has no medical conditions.  He smokes marijuana on weekends.  Physical examination is unremarkable.  TSH is within normal limits.  Which of the following is the most likely diagnosis?

A 51-year-old man comes to the office for a follow-up appointment.  The patient was recently diagnosed with amyotrophic lateral sclerosis (ALS), and his condition has deteriorated rapidly.  Physical examination shows progressive muscle weakness and atrophy.  The patient says, "I need to know that, when things get really bad and I can't take care of myself, you will help me end my life.  I haven't discussed this with my wife yet, but I think she would agree that it would be better to end my suffering when the time comes."  The patient has no psychiatric history and is not currently suicidal.  Which of the following is the most appropriate response to the patient's request or concern?

A 25-year-old homeless man with a history of schizophrenia is brought to the hospital by local police.  He destroyed a television set at a local electronics store and then became extremely agitated and violent when employees attempted to intervene.  The patient's speech is difficult to follow, and he is distracted, seemingly listening to voices that only he can hear.  He is admitted to the psychiatric ward and given haloperidol, which calms him down.  Later that evening, however, he walks to the nurses' station and says, "What's happening to me?"  The patient is upset and refuses to sit down, pointing to his neck.  Physical examination shows a sustained contraction of his neck to the right side.  Which of the following is the most appropriate next step in management?

A 23-year-old man comes to the emergency department declaring that police helicopters have followed him for the past year.  The patient is convinced that their surveillance lasers are damaging his sperm.  He says that the lasers have caused burns on his stomach and a low sperm count.  As evidence, the patient points to an area of slight discoloration that looks like a birthmark on his lower abdomen.  He has contacted an officer in charge of internal affairs who is investigating his charge of police brutality.  The patient has a history of 2 prior psychiatric hospitalizations.  His psychosis rapidly improves during hospitalization, but following discharge he stops taking his medication.  The patient says, "I used to have schizophrenia, but now I'm cured."  He is highly anxious and frequently gets up to pace and look out the window.  After describing his fears, he asks if the physician believes him.  Which of the following is the best response to the patient?

A 49-year-old woman comes to the office due to depression.  She quit her retail sales job 6 months ago as she could no longer stand all day due to increasing numbness, tingling, and painful, burning sensations in her feet.  The patient has since become increasingly depressed, withdrawn, and preoccupied with feelings of low self-esteem.  She is unable to concentrate to read or watch television and has lost interest in her family and friends.  The patient also describes severe insomnia and extremely low energy.  Medical history is significant for obesity, hypercholesterolemia, and type 2 diabetes mellitus.  Medications include glipizide and lisinopril.  She has no prior psychiatric history.  After medical evaluation, major depressive disorder is diagnosed.  Which of the following is the most appropriate pharmacotherapy to treat this patient's condition?

A 75-year-old-man is admitted to hospice care for end-stage multiple myeloma.  He has severe pain due to pathologic vertebral compression fractures and osteolytic rib lesions.  The pain remains uncontrolled despite a continuous intravenous morphine infusion; the infusion rate has been increased several times, most recently 2 days ago.  Temperature is 37 C (98.6 F), blood pressure is 140/75, pulse is 95/min, and respirations are 10/min.  Pulse oximetry is 89% on room air.  On examination, the patient is drowsy but constantly moans in pain and opens his eyes when his name is called.  Which of the following is the most appropriate next step in the management of this patient?

A 30-year-old man comes to the office due to chronic fatigue.  When he is not working, the patient is often at home sleeping; he estimates that he sleeps approximately 12 hours a day.  He has felt down since being passed over for a promotion last month and copes by overeating.  The patient says he has never had a lot of energy and can remember only a few times since high school when he felt happy-a month he spent with his grandparents in Florida and a brief period when he felt really good after starting his first job.  He has worked as a computer programmer since graduating from college.  The patient socializes with friends but avoids dating due to his weight, saying, "I just know I will be rejected because I'm fat."  Apart from obesity, the patient has no other medical conditions.  He smokes marijuana 3 times a week, which he began doing in his mid-20s, to "help me relax and feel better about myself."  He also drinks 4 cups of coffee before going to work on weekdays, which he says helps with his energy level.  There is a family history of bipolar disorder in a maternal uncle.  Vital signs and physical examination are unremarkable.  Which of the following is the most likely diagnosis?

A 28-year-old woman is brought to the emergency department by her sister after a generalized tonic-clonic seizure.  The patient appears confused and is unable to answer questions.  Her sister says that the patient has never had a seizure before and does not use alcohol or illicit drugs.  The sister is unaware of any medical or psychiatric history but reports that sometimes the patient feels anxious and sad and has trouble sleeping.  For the past 6 months the patient has been taking medication, prescribed by her primary care doctor, to help with these issues.  The sister says that the patient had not taken any of the medication in 2 days, as they were on their way to a concert in another state.  There is no family history of seizure disorder.  Which of the following medications was this patient most likely taking?

A 26-year-old woman is brought to the hospital by her family due to increasingly bizarre behavior.  The patient abruptly quit her sales job 8 months ago because she believed that her coworkers and boss were poisoning her coffee and trying to kill her.  Shortly thereafter, she stopped going outside the house because she was convinced that black cars were following her.  The patient has been hearing multiple voices over the past month and says, "Mostly they mumble and I can't make out what they're saying, but sometimes they tell me I'm stupid and should kill myself."  A comprehensive medical evaluation, including drug screen testing, is unrevealing.  She is admitted, and aripiprazole is initiated with improvement in her condition.  The patient is discharged 1 week later.  At her 1-month follow-up, she is no longer hearing voices, is much less paranoid, and is able to go outside the house; however, she still has periods of anxiety and has been reluctant to look for work.  She continues to take the medication as prescribed.  Which of the following is the most appropriate treatment recommendation for this patient?

A 19-year-old man is brought to the office by his mother due to sad mood and declining grades at college.  Previously a straight-A student, he is now getting Cs and Ds, and his mother worries he will not complete his freshman year.  The patient says, "I feel depressed and hopeless about the future."  He has little interest in his classes, has difficulty concentrating on assignments, and abruptly decided to quit the soccer team.  He refuses to answer any phone calls from his friends and keeps himself isolated at home.  The patient feels that there is little point in living but has no suicidal intent or plan.  He has tried alcohol at parties on 2 occasions but does not use illicit drugs.  There is no history of mania.  There is a family history of untreated depression in his mother and grandmother.  Physical examination and laboratory values are normal.  Major depressive disorder is diagnosed, and treatment is discussed.  The patient is willing to take medication, but his mother is concerned that antidepressants can cause people to become suicidal.  Which of the following is the most appropriate response to the mother?