Exam 3: Psychiatry

An 11-year-old boy is brought to the office by his mother due to concerns about his anxiety and adjustment to school.  Six months ago, he started a new school that requires him to change classrooms for different subjects.  This has been stressful for him and has not become easier over time.  He often gets in trouble because he forgets to raise his hand and blurts out answers.  The patient reads at grade level and does well in math, but he has particular difficulty in classes that require oral participation or group projects.  His mother says he has always been shy.  He has no friends at school and can annoy others by talking incessantly about his interest in space exploration.  The patient's behavior outside school causes problems as well.  When morning traffic required departing from routine by taking a different route to school, he became agitated and refused to go.  When interviewed, the patient looks away from the physician and interrupts him to recite the names of planets.  Physical examination is remarkable for a repetitive opening and closing motion of his hands, which becomes more intense when he is asked about school, but is otherwise normal.  Which of the following is the most likely explanation for the patient's behavior?

A 46-year-old man comes to the office with a 2-month history of depressed mood, low energy, and problems concentrating at work.  The patient has gained 4.5 kg (10 lb) and is disgusted with himself for not exercising.  He sleeps 14 hours a day and has difficulty getting out of bed.  He becomes tearful when describing how he loves his children but no longer feels happy to see them.  The patient denies any suicidal ideation, intent, or plan, but acknowledges that he contemplated suicide 4 years ago during his divorce proceedings.  At that time, he did not seek treatment but felt better over the course of the subsequent year.  The patient's physical examination and laboratory studies are within normal limits.  He is diagnosed with major depressive disorder and started on escitalopram.  After 6 weeks, there is no improvement and the patient is switched to sertraline, which is titrated up to the maximum dose.  On a follow-up visit 2 months later, he says that his depressive symptoms are only minimally improved.  The decision is made to discontinue sertraline and start a new medication.  Which of the following medications would be most appropriate for this patient?

A 24-year-old woman is brought to the emergency department after threatening to kill herself.  She says, "I feel very depressed and can't stop crying.  I feel like a piece of garbage that people just throw away."  The patient thinks frequently that she would be better off dead and has thought of overdosing on sleeping pills since her boyfriend left her a week ago.  The patient has had no significant change in sleep pattern, appetite, concentration, or energy level.  She has felt depressed on and off since high school and describes chronic low self-esteem.  She is also frequently angry and occasionally experiences a sense of detachment from her body.  When a previous relationship ended a year ago, she developed severe depression and thought that people on the street were laughing at her, which lasted for several days.  Physical examination is unremarkable except for multiple superficial cuts on her left arm in various stages of healing.  Which of the following features is most likely to be associated with this patient's condition?

A 44-year-old man comes to the office due to depression, loss of interest, impaired concentration, fatigue, and poor sleep.  The patient is not suicidal and has no psychotic symptoms.  He has no psychiatric history.  Physical examination and laboratory evaluation are unremarkable.  Major depressive disorder is diagnosed, and he is treated with 50 mg of sertraline.  After a month of antidepressant treatment, the patient reports improvement in his energy level and sleep, although he continues to struggle with some sadness and low motivation.  The dose of sertraline is increased to 100 mg.  At his 2-month follow-up, the patient has no depressive symptoms and says, "I feel like I'm totally back to normal.  Work is going well and I'm really enjoying life again."  He has no adverse effects from the sertraline.  The patient asks when he can stop taking the medication.  Which of the following is the most appropriate response?

A 28-year-old woman comes to the office for a preventive visit.  She is getting married in a few weeks and has been increasingly anxious due to last-minute details and preparation.  For the past 3 weeks, the patient has had difficulty falling and remaining asleep as she is "too excited about the wedding."  She notes that her dress required alterations and is pleased she "didn't have to go on a diet."  She states that anxiety has not been an issue for her in the past and asks if there is a medication that could help her feel more relaxed and get some sleep.  Medical history is insignificant; the patient takes no medications or supplements.  She drinks alcohol infrequently on social occasions and does not use illicit drugs.  Temperature is 37.2 C (99 F), blood pressure is 120/80 mm Hg, pulse is 100/min and regular, and respirations are 16/min.  Physical examination shows mild hand tremors with sweaty palms and is otherwise normal.  Which of the following is the most appropriate next step in management of this patient?

A 55-year-old woman is brought to the emergency department after being found unconscious in her apartment by her roommate.  First responders found empty bottles of acetaminophen and clonazepam as well as a note on the floor beside the patient.  The patient had been increasingly isolative in recent months and hired a lawyer to help write a will last week.  She has a long history of episodic sadness and despair dating back to her adolescence.  During these periods of sadness, the patient often needs to be reminded to eat, get out of bed, and take care of herself; on 3 occasions, she was hospitalized after attempting to hang herself.  Temperature is 37.2 C (99 F), blood pressure is 108/76 mm Hg, pulse is 88/min, and respirations are 12/min.  She is somnolent but arousable.  The remainder of the examination is within normal limits.  Which of the following abnormalities is most likely to be present in this patient?

A 38-year-old man comes to the office due to disturbed sleep and depressed mood for the past several months.  The patient has difficulty falling and staying asleep and says, "I lie awake at night thinking about all the weight I've gained and how I am too tired to even do anything about it."  He constantly feels exhausted at work, which involves "sitting all day in a cubicle."  The patient has also felt depressed and irritable, which he attributes to his appearance.  He has no previous medical conditions and takes no medications.  Family history is significant for bipolar disorder in his brother.  Temperature is 36.8 C (98.2 F), blood pressure is 148/90 mm Hg, and pulse is 86/min.  BMI is 34 kg/m².  On physical examination, the patient has a flat affect and a ruddy appearance with central obesity.  The thyroid is normal to palpation.  The lungs are clear to auscultation and heart sounds are normal.  The abdomen is soft and nontender.  There is no extremity edema.  Proximal limb muscles are mildly weak with no associated pain or tenderness.  The patient is tearful throughout the evaluation but has no suicidal ideation.  Laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

A 23-year-old primigravida at 32 weeks gestation is brought to the emergency department by her mother due to a seizure that occurred 30 minutes ago.  The mother states her daughter was eating lunch at a restaurant and "suddenly started shaking her arms and legs."  During the 45-second episode, the patient's head moved from side to side and her eyes fluttered.  The patient has no chronic medical conditions, and her pregnancy has been uncomplicated.  Temperature is 37.4 C (99.3 F), blood pressure is 128/84 mm Hg, and pulse is 82/min.  The patient is alert and fully oriented.  Cardiopulmonary examination is normal.  Neurologic examination demonstrates no abnormalities.  When the abdomen is palpated, the patient states she is not feeling well and suddenly starts to have rhythmic, asynchronous movements of the upper and lower extremities.  The jaw is clenched, and the patient does not respond to questions or follow commands.  The episode resolves within 1 minute and the patient is alert and oriented.  Repeat blood pressure is 116/74 mm Hg.  Fetal heart rate tracing has a baseline of 150/min, moderate variability, and no decelerations.  Complete blood count, basic metabolic panel, and urinalysis show no abnormalities.  Urine drug screen is negative.  Which of the following is the best next step in management of this patient?

An 80-year-old woman is brought to the office by her husband due to behavioral disturbances.  The patient has a history of Alzheimer disease.  For the past month, she has been wandering the house at night, looking for a pet cat that died 10 years ago.  The patient has also been excessively agitated and hits her husband when he tries to assist her.  She has had no other symptoms.  Environmental and behavioral interventions have been unsuccessful.  Medical history also includes hypertension.  Medications include amlodipine and donepezil.  There have been no recent changes in medications.  Vital signs are within normal limits, and physical examination shows no new abnormalities.  Blood cell counts, serum electrolytes, and urinalysis are normal.  Caregiver education is provided, and nightly risperidone is started after discussing medication options.  A week later, the husband reports that the patient is less aggressive, but her restlessness and wandering have worsened.  Now, she cannot sit still, even for a few minutes.  Which of the following is the most appropriate next step in management of this patient?

A 27-year-old woman comes to the office due to abdominal pain.  She has had intermittent "aches and cramps" in her abdomen for the past few weeks.  The patient denies nausea, vomiting, or a change in appetite or bowel movements.  Her stress level has been higher than normal since her boyfriend broke off their relationship a month ago.  She says, "We were together for 10 years.  I did everything to please him and make him happy, and he abandoned me.  I don't know how to go on without him."  The patient starts crying when discussing how her boyfriend managed her finances and recently helped her apply for a new job.  She is unsure about switching jobs now and canceled her interviews to "avoid more confusion."  She recently moved in with a friend and hopes this person can help her "sort everything out."  The patient reports feeling "tired and sad" since the breakup and looks down at the ground, speaking softly during the interview.  Medical history is noncontributory.  Physical examination shows minimal discomfort on palpation of the abdomen with no rebound or guarding; the abdomen is soft and nondistended.  Which of the following is the most likely explanation for the patient's behavior?

A young mother brings her 5-year-old daughter to the office due to problems at school.  The patient started kindergarten 2 months ago and appeared to be doing fine.  Last week, the teacher called to say that the child has persistently refused to answer questions or speak to others in class since her arrival.  The teacher did not report it earlier as she thought the child was undergoing an adjustment period.  During playtime, she prefers to play by herself.  In class she remains quiet while the other children sing songs or recite the alphabet.  The mother finds this very surprising as the patient is talkative at home and plays with her siblings and neighborhood friends.  In addition, the patient did not report any issues with school to her mother, saying it was "fine."  She is "a little shy" at social gatherings but interacts with other kids and adults when she gets to know them.  The child is able to tie her shoelaces, jump rope, and dress and feed herself.  She can copy a triangle and is able to count to 10.  Physical examination shows no abnormalities.  Which of the following is the most likely diagnosis in this patient?

A 76-year-old man is brought to the office by his wife for follow-up of recent behavioral changes.  The patient has been much more withdrawn than usual over the past 6 months and often appears sad.  He stopped driving a year earlier after getting lost several times in his own neighborhood.  He now needs help with grocery shopping, meal preparation, and finances.  His wife says, "He has good days and bad days.  Sometimes he's almost like his old self; other times, he seems confused."  She reports that while the patient sleeps, he frequently seems to act out his dreams and has kicked her on occasion.  Medical history includes hypertension and hypercholesterolemia.  Temperature is 37.3 C (99.1 F), blood pressure is 137/78 mm Hg, pulse is 78/min, and respirations are 14/min.  On neurologic examination, there is bilateral resistance to passive movement of the upper extremities, and the patient walks with an unsteady gait.  Montreal cognitive assessment score is 21/30 (normal: ≥26).  The remainder of the examination shows no abnormalities.  Which of the following is the most likely diagnosis in this patient?

A 33-year-old woman comes to the office due to poor sleep for the past 2 months.  The patient says, "Most nights, I wake up around 2 AM in a state of panic-my heart is racing and it's hard to fall back asleep.  I can barely stay awake at work, and it takes me twice as long to finish assignments because I need to reread everything."  The patient lives alone and works as a computer programmer.  She filed for divorce 3 months ago due to her husband's substance use and violent behavior toward her.  The patient drinks a glass of wine at bedtime to help her fall asleep and does not use illicit drugs.  Vital signs are within normal limits.  Physical examination and laboratory evaluation are unremarkable.  On mental status examination, she appears tired and her mood is depressed and anxious.  The patient jumps when a nearby door slams closed.  At one point, she appears to stare into space and does not respond to her name for a few moments.  Which of the following is the most likely diagnosis in this patient?

A 23-year-old man with schizophrenia is hospitalized in a psychiatric facility after barricading himself in his apartment for "self-defense."  The patient hears voices warning about "secret government agents" who are hunting him.  He is certain that a neighbor has been spying on him and listening through the wall on behalf of the government.  The patient's sister reports that he had his first psychotic episode at age 19 and responded well to olanzapine.  At age 21, he stopped taking olanzapine due to weight gain and was hospitalized with a psychotic relapse; he was prescribed risperidone while hospitalized.  The patient has been hospitalized 3 more times in the past 2 years.  Although he improves rapidly when hospitalized and taking risperidone and is then able to live independently, he typically relapses several months after discharge.  On mental status examination, the patient makes poor eye contact and has a flat affect.  He says, "I don't have a mental illness.  Can't you see the conspiracy is real?"  Which of the following is the most appropriate management for this patient?

A 10-year-old girl is brought to the office by her mother for evaluation of behavioral problems.  Her mother says, "She was sent to the principal's office last week after telling another student that she was 'stupid' for ignoring her in class.  She blurts out whatever comes into her head, like telling a kid at soccer practice that her shoes were ugly.  It is no wonder she has no friends."  The mother is also concerned that her daughter's grades are poor: "She is always making excuses for not doing her homework.  She loses the instructions for assignments and never brings home the schoolbooks she needs to do the work."  The girl's school reports over the last year have described her as "a disruptive student who doesn't follow directions and speaks out of turn."  During the evaluation, the patient interrupts her mother to argue that it is not her fault the teacher doesn't explain what to do for homework and that people have "ugly shoes."  She is easily distracted by noises from outside the examination room, and the physician has to repeat questions a number of times.  Which of the following is the most likely diagnosis in this patient?

A 33-year-old woman is brought to the office by her husband due to bizarre and isolative behavior over the past 8 months.  He often finds his wife whispering to the television, even when it is turned off.  The patient says she communicates with dead people and hears the devil telling her that she should be dead.  She has a history of schizoaffective disorder and has failed to respond to multiple antipsychotic medications, some of which caused severe muscle stiffness.  To target psychotic symptoms, the patient is started on a new medication that requires frequent and regular blood draws.  Over the next few weeks, she begins to show gradual improvement.  This patient is likely being monitored for which of the following adverse reactions?

A 24-year-old man comes to the emergency department after injuring his arm.  Following an argument with his girlfriend, the patient broke a vase and used a shard of glass to cut his wrist.  He says, "I wasn't trying to kill myself.  I just don't know how to deal with my anger."  The patient says he has struggled with depression and anger problems since he was a teenager; this has led to difficulties with romantic relationships and has caused him to get fired from jobs.  He was hospitalized at age 17 for a suicide attempt.  The patient's bouts of depression are "too numerous to count," and he explains that his moods shift unpredictably from one minute to the next.  Previous medication trials of fluoxetine and sertraline were ineffective and caused sexual side effects; he does not currently take any medications.  The patient has a 2-cm, superficial laceration on his left forearm; physical examination is otherwise normal.  He has no suicidal ideation, hallucinations, or delusions.  Which of the following is the most appropriate treatment for this patient's condition?

A 76-year-old man is brought to the office by his daughter due to increasing confusion and falls.  The patient was diagnosed with dementia with Lewy bodies 2 weeks ago and started on carbidopa-levodopa, risperidone, and rivastigmine for symptomatic management.  Temperature is 37.2 C (99 F) and respirations are 14/min.  Supine blood pressure and pulse are 129/82 mm Hg and 75/min, respectively; standing blood pressure and pulse are 101/74 mm Hg and 97/min, respectively.  The patient is not oriented to place or time.  Cranial nerves are intact and upper and lower limb deep tendon reflexes are 2+.  Rigidity is present in both the upper and the lower extremities on passive movement and is notably worse compared with the previous examination.  Which of the following is the most likely explanation for this patient's symptoms?

A 58-year-old woman comes to the emergency department after developing a headache following a gourmet meal that included heavy sauces and wine.  On arrival, the patient is anxious and tremulous.  Medical history includes recurrent major depression with psychotic features, generalized anxiety disorder, and osteoarthritis.  Medications include phenelzine and risperidone, which she takes as prescribed.  Her depression has been in remission for the past 5 years.  The patient's other medications include ibuprofen.  She does not use illicit drugs.  Which of the following is the most likely finding on physical examination?

A 25-year-old woman comes to the office due to a 3-week history of depressed mood, low energy, loss of motivation, and oversleeping following the break-up of a relationship.  The patient is sleeping 12 hours each day and describes difficulty getting out of bed and showering and dressing in the morning.  Her concentration is poor at work, and she has difficulty completing everyday tasks.  The patient has no psychotic symptoms or suicidal ideation.  She has a history of major depressive episodes at age 16 and 20.  The patient was treated briefly with fluoxetine at age 20 but stopped the medication after a week as she did not like the way it made her feel.  Following a rape at age 22, she was treated with trauma-focused psychotherapy for 6 months.  The patient has no significant medical history.  She drinks a beer several times a week and uses cannabis approximately once every other month.  Physical examination is normal.  After the physician discusses treatment options for depression, the patient chooses to have combination treatment with psychotherapy and medication.  Which of the following would be most important to obtain prior to initiating pharmacologic treatment for this patient?