Exam 3: Psychiatry

A 35-year-old man comes to the office due to persistent fatigue and insomnia for the past 3 weeks.  The patient was fired from his job as an insurance salesman a month ago due to poor sales and has since felt increasingly tired.  He has no difficulty falling asleep but, "for no reason," awakens at 4 AM most nights.  The patient's wife has told him he snores occasionally, although he has not awakened short of breath.  He says, "I liked going to the gym with my friends, but now I just don't want to anymore.  I'm at home a lot now, but I don't have the energy to play with my kids."  The patient feels pressured to look for new job opportunities but is so unfocused that he has not been able to complete any applications.  Medical history is significant for hypertension treated with enalapril.  Weight is 81 kg (178.6 lb) and height is 180.3 cm (5 ft 11 in).  Vital signs are within normal limits.  Physical examination and laboratory studies show no abnormalities.  The patient moves slowly and appears withdrawn.  Polysomnography is recommended to assess for sleep abnormalities.  This patient is most likely to have which of the following findings?

A 40-year-old man with a history of hypertension comes to the office for a checkup.  The patient has been under a lot of stress due to work issues and marital problems.  He says, "My wife is always criticizing me, and we fight a lot.  Last weekend, she was angry that I didn't make it to my daughter's basketball game.  I wanted to go but was too tired because I had stayed out late with friends the night before.  A man has to relax sometimes."  The patient consumes 5 or 6 alcoholic drinks a night and more on weekends.  He says that he never gets intoxicated as he is a "big guy with a high tolerance."  Blood pressure is 170/90 mm Hg.  Physical examination is normal.  Laboratory evaluation indicates persistent mild elevation of liver function tests.  The physician previously explained that the patient's hypertension is worsened by alcohol use and that the abnormal liver tests are likely due to alcohol use, but the patient remains unconcerned.  Which of the following responses is most appropriate for initiating a discussion of the patient's alcohol use?

A 27-year-old woman is brought to the emergency department by police after she was found trespassing on a local newscaster's property.  The patient informed police that she has been dating the newscaster for a few months and was surprising him for his birthday.  She reports their relationship started after she met him briefly when they were both eating at the same restaurant.  The patient says, "We've been so busy we haven't met up since then.  But every night, he makes sure to send me a special message when he's presenting the evening news.  I know he is in love with me because he always wears my favorite color.  He's the most amazing man I've ever known."  The patient is completing her final year of graduate school and lives alone.  Medical and psychiatric history are noncontributory.  Family history is significant for schizophrenia in her father.  The patient's thoughts are linear, and she has no hallucinations.  She is irritated that the police spoiled the surprise she had planned and repeatedly asks the staff to call her boyfriend so that he can "clear everything up."  Which of the following is the most likely diagnosis in this patient?

A 72-year-old man with a history of chronic pain and unknown psychiatric history comes for an initial visit due to diminished energy and anxiety for the past 3 months.  He appears very sad and moves slowly.  He has felt terrible since his wife died unexpectedly from a brain aneurysm 4 months ago and is filled with guilt because he did not get her to the hospital sooner.  Since her death, the patient has suffered from disturbed sleep and is unable to focus on his favorite activities, including coin collecting and fishing.  He drinks a bottle of wine nightly to fall asleep and isolates himself from others because he does not feel like socializing anymore.  The patient feels hopeless and wants to end his life, saying, "I cannot carry on without her."  He has contemplated hanging himself and recently drove by a hardware store with thoughts of buying a rope, but ultimately did not.  The patient is advised to enter a psychiatric hospital.  However, he refuses and says, "I promise to try any help you could offer me as an outpatient."  Which of the following is the most appropriate next step in management of this patient?

A 43-year-old woman comes to the office due to a painful and swollen knee sustained when she tripped while walking outside her home.  She blames her injury on "bad energy" that she was getting from her next-door neighbor, whom she believes does not like her.  The patient thinks she "has a sixth sense" to detect "negative people" but does not believe there is any specific plot to harm her.  She has worked for many years sorting items in a used clothing store and lives alone, saying, "I prefer it this way."  Medical history is significant for glucose intolerance and vitamin D insufficiency.  The patient has been prescribed vitamin D supplements but prefers not to take them because "one can never be sure what could be in these things."  Vital signs are normal.  Physical examination is significant for a painful, swollen right knee with normal range of movement.  On mental status examination, it is noted that the patient is dressed in multiple layers of mismatched clothing.  She has flat affect and makes limited eye contact.  Which of the following is the most likely diagnosis?

A 25-year-old woman is brought to the emergency department by her mother due to suicidal ideation.  The patient's mother found her in the bathroom holding a razor blade to her wrist and saying, "I might as well be dead."  Her mother states, "She started a new relationship last week and thought he was her soul mate.  But they got into an argument a few days later and then broke up.  All of her relationships start and end like that."  She adds that the patient has always been quick to anger and insecure about herself.  The patient says that since middle school, she has had periods of sadness lasting 1-2 days in which she goes into "a bottomless black hole."  She has a history of 3 prior suicide attempts.  She had no significant improvement in her depressive symptoms with trials of escitalopram and venlafaxine, and currently takes no medications.  The patient appears anxious and tearful; physical examination is otherwise unremarkable.  Which of the following is the most likely diagnosis?

An 18-year-old woman comes to the office due to hair loss.  The patient says, "I can't even brush or wash my hair because it just falls out.  I've already been so stressed since college started, and losing my hair is making everything worse."  She has felt "overwhelmed" with adjusting to college and is also working part-time at a coffee shop.  The patient says, "I've felt pretty low-my life isn't going as planned, and I don't know how to get back on track."  She says the only thing that makes her feel good is cycling, which she does for 1-2 hours every day.  The patient also adheres to a strict diet to "maintain a good body image."  She has no other medical conditions and does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.1 C (97 F), blood pressure is 100/65 mm Hg, pulse is 60/min, and respirations are 14/min.  BMI is 17.5 kg/m².  Physical examination shows generalized thinning of the hair with no scarring of the scalp.  The skin is dry with no rashes.  The remainder of the examination is unremarkable, and the patient has no suicidal ideation.  Laboratory results are as follows: Which of the following is the most appropriate management for this patient's condition?

A 42-year-old man comes to the office due to persistent sadness, weight gain, and fatigue over the past 4 months.  The patient is a dentist who has had difficulty waking up in the morning for clinic.  He says, "I used to be really efficient, but now I always run 2 hours behind schedule."  He has been eating "lots of fast food" for dinner and feels exhausted every day.  Following a divorce 3 years ago, the patient was diagnosed with major depressive disorder, which improved after a few months of treatment with paroxetine.  The patient has a history of separation anxiety disorder as a child, which resolved with psychotherapy.  Family history is significant for generalized anxiety disorder in his mother.  Physical examination and laboratory evaluation are normal.  After discussion of treatment options, the patient decides to start sertraline.  His symptoms resolve by the follow-up appointment 6 months later.  Which of the following features is an indication for long-term maintenance of antidepressant therapy in this patient?

A 29-year-old man comes to the office because he is "worrying all the time."  The patient has a long history of anxiety and says, "It was manageable when I was allowed to work from home, but since I was promoted and have to come into the office, I'm completely overwhelmed."  He spends hours rehearsing before meetings to find "the right words" to say and repeatedly edits emails until they are "good enough."  The patient also has difficulty leaving the house in the mornings because he spends 1-2 hours making sure all the appliances are unplugged.  He shares, "I know it sounds crazy, but when I'm at work, I constantly worry that there will be an electrical fire at home, and I can't concentrate."  Physical examination shows no abnormalities.  On mental status examination, the patient describes his mood as "really anxious"; he is restless and makes poor eye contact.  Which of the following is the most likely diagnosis?

A 53-year-old man is brought to the emergency department after a witnessed seizure 1 hour prior.  The patient lives in a group home and was observed by the staff to suddenly become stiff and unresponsive during lunch.  He was then noted to have brief jerking movements of his arms and was lowered to the floor.  The patient regained consciousness after 1-2 minutes.  Medical history includes schizoaffective disorder with multiple hospitalizations for psychotic and mood episodes beginning at age 22.  Vital signs are within normal limits.  On physical examination, the patient is awake and alert.  A 1-cm laceration is noted on the right side of the tongue.  Musculoskeletal, cardiopulmonary, and neurologic examinations show no abnormalities.  Serum chemistry is normal.  A CT scan of the head reveals no abnormalities.  Which of the following medications most likely contributed to this patient's presentation?

A 49-year-old woman comes to the office due to low mood.  The patient has a 3-month history of worsening sadness, increased appetite with weight gain, and difficulty falling and staying asleep.  She was dismissed from her part-time sales job 2 months ago due to poor performance and has been "too tired" to look for a new job.  The patient's husband is threatening to leave her, and she has little contact with family or friends.  She says, "My life is a mess, and I'm not sure that my marriage can be saved.  I've had thoughts of taking all of my medications at once."  The patient admits to drinking increased amounts of alcohol "to cope."  She has hypothyroidism treated with levothyroxine; last year she had an episode of major depression for which she is currently on a maintenance dose of sertraline.  Physical examination, including neurologic examination, shows no abnormalities.  The patient is anxious, sad, and physically restless.  She weeps softly throughout the interview, especially when discussing her marriage.  Which of the following is the most appropriate next step in management?

A 60-year-old physician is admitted to the hospital for jaundice and weight loss.  His medical history is noncontributory.  After a detailed workup, advanced pancreatic carcinoma is diagnosed.  Although the patient is advised to slow down and spend more time with his family, he insists on continuing to work, saying, "It's a good distraction to think about other people's medical problems."  Each day after work, he spends several hours reviewing and analyzing his own diagnostic tests and researching experimental chemotherapy regimens for pancreatic cancer.  The patient's family members wish he would take time off to rest, but he insists that would make him feel worse.  Which of the following psychological defense mechanisms is the best explanation for this patient's behavior?

A 10-month-old boy is brought to the office by his mother for a routine well-child visit.  She says, "I'm planning on returning to work next month, but I'm worried about dropping him off at day care.  Whenever someone tries to hold him, he cries and has screaming fits.  He's gotten very clingy with me and my husband."  The patient crawls, pulls to a stand, and says "Ma."  The mother tries to feed him a range of foods, but he often refuses to eat certain vegetables.  She says, "He just seems a bit fussier in general-my 4-year-old daughter was more easygoing at his age."  The family moved from out of town 3 weeks ago for the mother's new job.  During the evaluation, the patient sits quietly on his mother's lap but cries when he is picked up and weighed by the nurse.  When the physician calls the patient's name, he turns his head away from the physician and looks at his mother.  Physical examination is normal, and growth is at the 55th percentile.  Which of the following is the most likely explanation for this patient's behavior?

A 35-year-old woman comes to the office due to anxiety; she is accompanied by her husband.  The patient describes having several panic attacks while driving over a suspension bridge.  She suddenly felt faint and shaky, and had to stop the car in the middle of the bridge and get assistance.  The patient moved to the suburbs 7 months ago, requiring that she now drive to work.  Since having the panic attacks, she has taken an alternate route to work that requires her to drive miles out of her way to avoid bridges.  She avoids traveling to the city when possible and has anxiety for days beforehand if a planned trip necessitates taking a bridge.  The patient has a history of mitral valve prolapse and asthma.  She drinks a glass of wine on weekends and 3 or 4 cups of coffee daily.  Blood pressure is 110/60 mm Hg and pulse is 88/min.  Auscultation reveals a late systolic click and a grade 2/6 late systolic murmur.  Mental status examination shows an anxious mood and tense affect.  Which of the following is the most likely diagnosis?

A 32-year-old woman comes to the office due to feeling down for the past several months.  The patient has had persistent tiredness, lack of motivation, memory impairment, and loss of libido.  She also has had anorexia but reports an unusual craving for foods like salty pretzels or potato chips.  Menses occur at regular intervals.  The patient does not use tobacco, alcohol, or illicit drugs and works as a fashion designer.  Blood pressure is 110/62 mm Hg and pulse is 88/min.  BMI is 19.8 kg/m² with weight of 54 kg (119 lb), which is 15 kg (33 lb) lower than her previous weight.  The lungs are clear on auscultation and heart sounds are normal.  The abdomen is soft and nontender with no organomegaly.  There is decreased axillary and pubic hair.  Mental status examination reveals a restricted affect.  She has no suicidal ideation.  Which of the following is most likely to establish the diagnosis in this patient?

A 26-year-old man is brought to the emergency department due to hallucinations.  The patient's mother reports that he was acting normally until a few hours ago when he started hallucinating that dogs were chasing him.  She states that the patient has a history of schizoaffective disorder that was difficult to treat and is currently taking clozapine and doxepin; however, she is worried about his mental health because he broke up with his partner yesterday.  Temperature is 38.3 C (100.9 F), blood pressure is 140/80 mm Hg, pulse is 145/min, and respirations are 24/min.  Oxygen saturation is 97% on room air.  The patient is delirious and actively hallucinating.  His pupils are 6 mm and nonreactive.  No murmurs or gallops are present on auscultation of the heart.  Muscle tone and reflexes are normal.  What is the best next step in management?

A 76-year-old man comes to the office for follow-up of hypertension.  He says, "I wouldn't be surprised if my blood pressure is up with all the stress I am under.  My wife has been having an ongoing affair with our accountant.  I've known about this for years, and she continues to deny it.  Even my children are in on it.  They tell me that I'm imagining things."  The patient reports that he monitors his wife closely and calls her multiple times a day to check on her whereabouts but admits that he has not found any evidence of the affair.  He reports intermittent insomnia but no change in appetite.  The patient occasionally forgets names and has word-finding difficulty.  He continues to perform household chores and handle finances.  Blood pressure is 132/85 mm Hg, pulse is 82/min, and respirations are 16/min.  Physical examination, including neurologic examination, is unremarkable.  The patient is alert and oriented, and his mood is irritable.  Which of the following is the most likely diagnosis for this patient?

A 16-year-old boy is brought to the emergency department by his friends for severe anxiety.  He became paranoid and unusually withdrawn at a party and began rocking back and forth, saying, "I feel like I can't breathe" and "I'm afraid I'm going to die."  Prior to the party, he was his regular "happy and outgoing" self.  The patient has intermittent back pain from a bicycle accident last year for which he takes oxycodone as needed.  Temperature is 36.1 C (97 F), blood pressure is 140/80 mm Hg, pulse is 110/min, and respirations are 18/min.  Pulse oximetry is 98% on room air.  Examination shows an anxious and withdrawn boy with 3-mm pupils, conjunctival injection, dry oral mucosa, and a healed scar on his right thigh from his bicycle accident.  Which of the following is most consistent with this patient's presentation?

An 18-year-old woman is brought to the emergency department after a suspected drug overdose at 6 AM.  The mother states that she had awakened this morning to find her daughter difficult to rouse and covered in emesis.  The prescription bottle of paroxetine 20 mg containing 30 pills filled the previous day was next to her and was empty.  She does not know when or if her daughter took the medication.  She last saw her daughter the previous evening before going to bed at 10 PM.  Her daughter has a history of major depressive disorder but has no known previous suicide attempts.  Temperature is 36.1 C (97 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 10/min.  Pulse oximetry is 98% on room air.  On examination, the patient's clothes are stained with emesis.  Her eyes are closed, and she does not follow commands but moans and withdraws all the extremities to painful stimuli.  The pupils are normal sized, equal, and reactive.  Muscle tone and reflexes are normal.  Cardiopulmonary and abdominal examinations are normal.  There is no evidence of trauma.  Which of the following is the best next step in management?

A 26-year-old woman comes to the office requesting referral for breast surgery.  She says, "I feel disgusted with how my breasts look," and she describes numerous cosmetic aspects of her breasts that she finds troubling, including their asymmetry, shape, and small size.  The patient says she has stopped going out with her friends because everyone stares at her breasts.  She spends 1-2 hours every morning trying on different outfits to "hide" her chest and has ordered multiple custom bras to make her breasts appear more symmetric.  The patient has no history of medical or psychiatric conditions and takes no medications.  Vital signs are within normal limits.  On physical examination, the breasts appear normal in symmetry, shape, and size.  There are no palpable breast lumps or axillary lymphadenopathy.  The patient says, "I really think cosmetic surgery would help me feel normal again."  Which of the following is the most appropriate initial response to this patient's concerns?