Exam 3: Psychiatry

A 52-year-old woman with a history of schizoaffective disorder, depressive type, is brought to the office by her husband for follow-up.  The patient was hospitalized last month due to worsening auditory hallucinations that were telling her to kill herself.  She responded to an increased dose of risperidone and was discharged a week later.  The patient reports feeling relieved that the voices telling her to kill herself have gone away since her antipsychotic dose was increased.  Her husband also reports that she is much less agitated since the voices have subsided, but he is concerned that she smiles less and seems slowed down.  He is worried that she is becoming depressed.  On examination the patient is alert, calm, and cooperative.  She has a mild tremor and does not swing her arms when she walks.  Her affect appears sad.  She denies any auditory hallucinations or thoughts of wanting to die.  Which of the following is the most appropriate pharmacological management for this patient's condition?

A 6-year-old girl is brought to the office by her parents for evaluation of odd behaviors.  For the past year, the patient has had brief episodes of repetitive blinking.  Her father says, "We thought she had dry eyes, but giving her artificial tears didn't help."  He says the blinking gets worse when she is excited and seems to subside when she is watching television.  Due to the episodes, the patient has difficulty paying attention in class and plays alone because other children make fun of her.  She is meeting appropriate developmental milestones and tracking adequately on growth curves.  Medical history is unremarkable apart from an upper respiratory infection a month ago.  Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, pulse is 80/min, and respirations are 14/min.  During the evaluation, the patient intermittently squeaks and scrunches her nose; when asked about this, she says she cannot stop pretending to be a bunny.  Her parents share that she has been "acting like a rabbit" every day for the past month.  Physical examination, including ocular examination, is unremarkable.  Which of the following is the most likely diagnosis?

A 22-year-old man comes to the office due to irregular sleep for the past 3 months.  The patient says, "School has become more stressful, and I have been feeling more fatigued since my girlfriend broke off our relationship last month."  He is often sleepy during the day and sometimes falls asleep unintentionally during classes.  The patient goes to bed at 1 AM and awakens at 9 AM.  After classes, he avoids socializing and frequently returns straight to his dorm room to nap.  The patient also describes "weird things happening as I fall asleep, like hearing whispering voices and seeing colorful animals."  He describes another unusual experience last week when he suddenly felt weak in his face and knees following an upsetting phone call with his ex-girlfriend.  The patient drinks beer socially but does not use illicit drugs.  He has a history of depression as a teenager that responded to psychotherapy.  Height is 170.2 cm (5 ft 7 in), and weight is 83.9 kg (185 lb).  BMI is 29 kg/m².  Physical examination is normal.  Which of the following is the most likely diagnosis for this patient?

A 22-year-old man comes to the office due to fatigue, poor appetite, and weakness.  The patient recently emigrated from India and has few social supports.  He feels tired throughout the day despite sleeping 8-9 hours every night.  He is worried about his new job and thinks that his coworkers don't like him.  The patient reports no significant medical history but is very worried that he is losing semen when he urinates.  Temperature is 36.7 C (98 F), blood pressure is 110/78 mm Hg, pulse is 62/min, and respirations are 14/min.  BMI is 24 kg/m².  Physical examination is unremarkable.  The patient is alert and oriented.  His thought process is organized, linear, and coherent.  He does not appear to be responding to internal stimuli.  Which of the following would be the most appropriate initial response to the patient's concerns?

A 16-year-old boy is brought to the office for a routine health maintenance examination.  The mother discloses concerns about his recent irritability and "moodiness."  He was recently bullied at school, got into a fistfight, and was suspended for 10 days.  The patient has also been caught using marijuana and alcohol.  Last month he was assaulted by a group of teenagers while walking home late at night.  He is learning to box and also takes his mother's gun to a shooting range to practice so he can protect himself and her if needed.  The patient spends his spare time in the evenings playing violent video games.  Family history is significant for an uncle with schizophrenia and an aunt with bipolar disorder.  His father used physical punishment to discipline him as a child.  Which of the following factors is most concerning for this patient's future risk of committing homicide?

A 25-year-old woman is brought to the office by her husband, who is concerned about her intense mood swings and unusual behavior.  The patient has rapid mood shifts that last for a few hours.  Although she is typically quiet and reserved, the husband reports that she can suddenly become enraged without provocation.  The patient does not remember these episodes.  The husband was also alarmed when he found her at a local bar dressed in a seductive outfit; when he called her name she did not respond to him and just walked away.  When he confronted her at home she denied having been at the bar and hid behind a chair crying.  When she was finally convinced to come out she was speaking in a childlike voice, saying, "leave me alone."  The patient has experienced depression and anxiety since childhood but has never received psychiatric evaluation or treatment.  She was physically and sexually abused at age 5-16.  She is medically healthy and does not use alcohol or illicit drugs.  When interviewed alone, the patient has difficulty giving a detailed history and has many gaps in her memory.  Her mood is anxious and she hears voices that she describes as coming from inside her head.  Which of the following is the most likely diagnosis?

A 24-year-old woman comes to the emergency department due to sudden-onset blurry vision.  She also describes intermittent numbness and tingling in the legs for the past several weeks.  The patient has been under stress at school and is struggling to complete assignments on time.  She is worried about her mother, who was recently diagnosed with breast cancer, and feels too distracted to concentrate.  The patient's medical history is significant for 2 episodes of urinary incontinence that occurred 8 months apart and 1 episode of unilateral blindness that occurred after breaking up with her boyfriend last year.  In each instance, her symptoms resolved spontaneously over several weeks without treatment.  The patient has no other medical or psychiatric history.  Brain MRI shows multifocal, white matter, hyperintense T2 lesions in the corpus callosum and periventricular area.  This patient is most likely to develop which of the following conditions?

An 85-year-old man comes to the office for a routine health evaluation.  The patient lives independently but is accompanied by his daughter who does his grocery shopping and visits him weekly.  The daughter is concerned that her father seems increasingly withdrawn and forgetful over the past year.  She reports that he does not socialize with his neighborhood friends as much as he used to and calls her less frequently.  "When we do speak, he often seems to forget what I just told him and repeats the same question that I've just answered."  The patient admits that he sometimes forgets names but attributes this to "old age."  He denies any changes in mood, sleep, or appetite.  Medical history includes hypertension and osteoarthritis of the knees.  Current medications include hydrochlorothiazide and ibuprofen.  Vital signs are within normal limits, and physical examination is unremarkable.  The patient is pleasant and cooperative and speaks loudly.  Montreal Cognitive Assessment score is 26/30.  Which of the following is the most appropriate next step in management of this patient?

A 35-year-old woman comes to the urgent care clinic due to fatigue and muscle aches for 2 days.  She says, "I rarely have to use a sick day but today I had to because I feel horrible-my nose won't stop running, and I've got a bad headache.  I think I'm coming down with the flu."  The patient also reports having chills and difficulty sleeping through the night.  She took acetaminophen but has had no symptom relief.  The patient has a 2-year history of depression treated with paroxetine, which she has not taken for the past few days.  She is visiting New York from Chicago for work and forgot to pack her medication.  She takes no other medications.  The patient drinks a glass of wine on most evenings and does not use tobacco.  Temperature is 37 C (98.6 F), blood pressure is 134/86 mm Hg, and pulse is 92/min.  On physical examination, the patient appears restless.  There is clear nasal discharge, but nasopharyngeal mucosa appears normal.  Lungs are clear on auscultation, and heart sounds are normal.  The abdomen is soft and nontender.  There is a mild tremor in both hands, but no other focal neurological deficits are present.  Which of the following is the most appropriate next step in management of this patient?

A 22-year-old woman is brought to the emergency department by her father due to "strange behavior."  Earlier that day, the patient insisted that a television newscaster was talking directly to her about the risks of "poison rays" from the moon.  Her father says that she has "not been herself" for the past year.  He is upset about her declining grades, along with increasing conflicts with her younger siblings and social isolation from her friends.  A month ago, the patient abruptly quit the part-time job that she had previously enjoyed because she believed that her coworkers were spying on her.  In the emergency department, she is agitated and the decision is made to admit her to the psychiatric unit.  After a comprehensive evaluation, the patient is diagnosed with schizophrenia.  She is stabilized on risperidone over a period of 3 weeks, and discharge plans to return home are discussed.  Her father asks what can be done to decrease the likelihood of rehospitalization.  In addition to maintaining risperidone, which of the following measures would be most helpful for this patient?

A 61-year-old attorney comes to the office with his wife for follow-up.  Two months ago, the patient experienced an acute myocardial infarction while presenting a case in court and went into cardiac arrest.  He was resuscitated in the emergency department, and a drug-eluting stent was placed.  The patient recovered without complications and was discharged.  He recently returned to work part-time, although his wife thinks he needs more time to rest.  She states that he has been very stressed for the past month and worries that he is overworking.  The patient has been sleeping restlessly and frequently wakes up startled and diaphoretic.  While practicing a case presentation a few days ago, he had to stop and sit down because he felt overwhelmed.  The patient plans to "take things slowly" and has asked his partner to cover upcoming court appearances.  He has had no chest pain, palpitations, shortness of breath, or syncope.  Medications include metoprolol, simvastatin, aspirin, and ticagrelor.  Vital signs are within normal limits.  Physical examination shows no abnormalities.  ECG reveals no acute changes.  Which of the following is the best next step in management of this patient?

A 46-year-old man with a history of medication-controlled hypertension comes to the office for a routine checkup.  Blood pressure is 115/80 mm Hg and physical examination findings are normal.  The physician notes that the patient's mood seems low.  The patient admits that he has been "stressed out" for the past 2 months as a few people at work recently quit and he has had to take on more responsibility while management finds replacements.  He has not been able to exercise or eat right as he is so busy.  The patient feels irritable and tense at work and has had neck and shoulder pain.  He is also worried about not being able to spend time with his wife, who complains that he works too much.  The patient has occasional difficulty falling asleep at night after working long hours and feels tired during the day.  Although he doesn't enjoy his job, he has no choice but to stay.  He continues to get his work done and enjoys social activities, including playing golf on weekends.  The patient drinks 2-3 cans of beer on weekends and smokes marijuana twice a month.  Which of the following is the most likely diagnosis?

A 19-year-old woman is brought to the emergency department by the police after she was found trespassing at an animal shelter.  The patient had keys to a rental van, as well as numerous collars and leashes.  She says, "The shelter is going to sell the animals to labs, where they'll do horrible experiments on them.  I'm the only one who can save them!"  The patient quit her retail job a week ago to spend more time researching escape routes for the animals.  Throughout the evaluation, she interrupts the physician to yell at other patients and hospital staff walking by the room.  She repeatedly refers to herself as a "cat burglar" and then laughs loudly for a few minutes.  Physical examination is unremarkable and urine drug screening is negative.  Which of the following additional features is most likely in this patient?

A 27-year-old woman comes to the office due to headaches and neck and back pain.  She has been coping with pain symptoms for several years but notes that they have increased since she was recently let go from her job as an administrative assistant.  The patient worries about finding another job but says, "Most days I am just too tired to even look for work."  She is also concerned about gaining weight but has no motivation to go to the gym or leave the house.  The patient has been to the office twice in the past year for similar symptoms and is worried that something is wrong.  At her last visit 4 months ago, laboratory testing, including a basic chemistry panel, thyroid function tests, and complete blood count, were within normal range.  The patient says, "I doubt that anything will ever improve for me."  Medications include ibuprofen for pain as needed.  The patient drinks 1 or 2 glasses of wine 3 times a week.  She has increased her use of marijuana to 3 or 4 times a week at bedtime to help her relax and fall asleep and has started smoking cigarettes after a 2-year abstinence.  Family history includes hypertension and colon cancer in her father and hypothyroidism and anxiety in her mother.  Vital signs and physical examination are normal except for a 2.27-kg (5-lb) weight gain since her last visit.  Which of the following is the most appropriate next step in management of this patient?

A 23-year-old woman comes to the office due to skin concerns.  The patient states, "I have pockmarks on my nose from having acne as a teenager."  She has tried high-dose retinol creams and skin-resurfacing procedures with no improvement.  The patient applies concealer to her nose every morning and has been late to work multiple times due to her routine.  She touches up her makeup throughout the day and is concerned that her supervisor has started to notice her frequent trips to the bathroom.  Vital signs are within normal limits.  Skin examination shows pores of minimal size, if any, on the nose and forehead; no acne or scarring is visible.  The remainder of the examination shows no abnormalities.  Which of the following is the most appropriate statement?

A 43-year-old man comes to the office due to worsening insomnia, dysphoria, and anxiety.  Symptoms began yesterday and have steadily worsened.  The patient has felt restless and on edge throughout the day and has had difficulty concentrating at work.  He has a history of major depressive disorder and generalized anxiety disorder successfully treated with fluoxetine and lorazepam for the last 2 years.  The patient's other medical issues include asthma treated with an albuterol inhaler, which he uses twice a week, and osteoarthritis of his left knee joint, for which he takes ibuprofen.  Two days ago, he discontinued fluoxetine and lorazepam after his boss was critical of his "tired" appearance during a presentation to important clients.  The patient does not use alcohol or illicit drugs.  Examination shows an alert and oriented man with a tense, strained affect and an anxious, irritable mood.  He is tremulous and shifts uneasily in his seat.  He is worried about his ability to perform at work and receiving further criticism from his boss.  Which of the following is the most likely explanation for this patient's new symptoms?

A 6-year-old boy is brought to the office by his mother due to learning difficulties at school.  The patient was adopted from an overseas orphanage at age 5 and stayed home until beginning kindergarten 6 months ago.  His birth and developmental history are unknown.  Since beginning school, he has struggled to keep up with reading and writing.  Educational testing was completed and showed an intelligence quotient (IQ) of 68.  Audiology revealed a mild conductive hearing loss in his right ear.  The patient's mother says, "He is a really happy kid and enjoys playing with his older siblings.  I know he doesn't talk as much as other kids his age, but I thought that would improve with time."  Vital signs are within normal limits; weight and height curves are at the 70th and 10th percentiles, respectively.  The patient is sitting on the floor playing with a range of toys.  Physical examination is significant for a flat nasal bridge and a grade 3 holosystolic murmur at the lower left sternal border.  He makes eye contact, has a friendly demeanor, and responds to questions with 3- to 4-word phrases.  Which of the following tests is most likely to reveal the diagnosis?

A 4-year-old girl is brought to the office by her adoptive mother due to concerns about her adjustment to preschool.  She was placed in foster care at age 2 due to parental substance use disorder and was adopted by her current family 6 months ago.  Prenatal history is unknown.  At school, the patient does not interact with classmates and prefers to play by herself.  She speaks infrequently at home and stays in her room; the mother has discovered that she hoards toys and food under the bed.  The mother says, "She doesn't like being hugged or picked up; nothing I do seems to comfort her."  The patient can dress herself, copy a triangle, write the letters of her name, and walk down the stairs without aid.  Vital signs are within normal limits; weight and height curves are at the 50th and 60th percentiles, respectively.  On examination, the patient is sitting quietly, playing with various toys in the room.  She interacts with the physician and makes occasional eye contact.  Responses are brief and said with little facial expression, but speech is otherwise normal.  Physical examination shows no other abnormalities.  Which of the following is the most likely diagnosis in this patient?

A 59-year-old woman comes to the office due to upper respiratory symptoms for 3 days. She arrives an hour late for her appointment and lies about the reason, blaming it on an emergency at work.  The patient is angry that the physician refused to prescribe antibiotics for her over the phone, and she paces at the reception desk, insisting that the office staff work her into the schedule because "I'm very busy and must be seen immediately."  She mentions that her previous physician always made time for her.  The patient is a successful businesswoman and is recently divorced.  During the visit, she expresses irritation at having to take time out of her busy day to come to the appointment and admits to being "under stress" at work.  The patient then talks at length about feeling depressed because her children no longer want to see her even though she is a "great mother."  She is upset that her daughter recently canceled plans to visit in order to help a friend who was in a near-fatal motor vehicle collision.  The patient has no significant medical history, and family history is notable for major depressive disorder in her mother.  Which of the following is the best explanation for this patient's behavior?

A 26-year-old graduate student comes to the campus medical clinic with a report that she was raped after a dinner date 5 weeks ago.  The patient tearfully describes details of the incident and acknowledges that she did not report it to the police because she was concerned that her parents would pull her out of college.  She recently confided in a friend, who encouraged her to seek medical care.  The patient is now concerned that she might be pregnant or have a sexually transmitted disease.  Since the assault, she has had recurring nightmares of the rape and takes the long way to class so that she does not walk past the man's apartment where the rape occurred.  Occasionally, she will hear her assailant's voice or feel his breath on her face.  It takes the patient almost an hour to fall asleep, and she is afraid to be alone.  In addition, she has extreme difficulty concentrating in class and would rather not attend at all despite previously enjoying school.  This patient is at greatest risk for developing which of the following?