Exam 3: Psychiatry

A 34-year-old woman comes to the emergency department due to sudden onset of tingling and numbness in her left hand.  She is an assistant chef at a nearby restaurant and was lifting a box earlier in the day when she heard a "pop" and her left hand went numb.  The patient's numbness is in a glove distribution:  Her fingers, entire left hand, and wrist are numb, with normal sensation above her wrist.  The patient describes her numbness as feeling like "pins and needles."  Medical history is insignificant.  The patient allows the nurse to take her vital signs but refuses any further physical examination, insisting that it will worsen her discomfort.  Temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, pulse is 72/min, and respirations are 16/min.  The patient asks for a doctor's note to excuse her from work, fearing that her condition will worsen if she does not take some time off to heal.  Which of the following is the most likely diagnosis?

A 58-year-old man is brought to the office by his daughter for evaluation of "abnormal behavior."  The patient has been anxious and irritable for the past several days, and over the past 2 days, he has repeatedly said that "bad men" are following him.  He has no history of psychiatric illness but was diagnosed with polymyositis 2 weeks ago.  The patient has been taking high-dose prednisone with improvement in muscle weakness.  He has no other medical conditions and takes no other medications.  Vital signs are within normal limits.  Physical examination shows mild symmetric, proximal muscle weakness.  During the examination, the patient frequently looks around the room and startles easily when the nurse knocks on the door.  He reports no suicidal ideation or hallucinations.  Based on the patient's responses to questions, his memory and recall are intact.  Which of the following is the most appropriate first step in the management of this patient's current symptoms?

A 32-year-old man comes to the office due to recurrent episodes of chest pain, dizziness, and numbness.  The patient says, "Suddenly, my heart starts pounding and I have trouble breathing.  Then my whole body shakes, I start to sweat, and I feel like I'm going to faint.  Many times I also notice numbness and tingling in both arms.  It only lasts for a few minutes, but it feels like hours."  The episodes occur 3 or 4 times a week.  He is very worried that similar episodes will occur at work and that he will pass out.  The patient has a history of occasional insomnia and hypertension treated with enalapril.  His mood is good, and he enjoys his work and spending time with family and friends.  The patient both smokes marijuana and drinks 2 or 3 glasses of wine daily.  Family history is significant for hypertension, coronary artery disease, and seizure disorder.  Physical examination is unremarkable, and laboratory results and ECG are normal.  Which of the following is the most appropriate pharmacotherapy for this patient?

A 24-year-old woman is brought to the emergency department by her roommate due to depression and suicidal thoughts.  The roommate became alarmed when the patient did not get up for work as usual and reported feeling "so depressed I want to die."  She currently has no suicidal ideation but describes feeling depressed, exhausted, and unable to concentrate.  The patient appears distracted and speaks slowly.  The roommate says, "We were up for the last 3 nights at parties where there was alcohol and other stuff," but reports that her friend was energetic and talkative and appeared to be in a great mood.  However, the patient subsequently slept for 18 hours, had difficulty getting out of bed, and missed work.  She has no medical or psychiatric history but describes brief periods of acute depression over the past several months.  These lasted a few days and were characterized by low energy; hypersomnia; vivid, unpleasant dreams; and increased appetite.  Temperature is 36.7 C (98.1 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 12/min.  Physical examination is normal.  Which of the following is the most likely diagnosis for this patient?

A 4-year-old girl is brought to the office due to "picky eating."  Her mother says, "She insists on eating the same thing for dinner every night.  First it was fish sticks for a few weeks, and now she's switched to pasta with cheese.  She starts crying if I suggest trying something different."  The patient eats yogurt for breakfast and takes peanut butter sandwiches and apple wedges to preschool for lunch; she refuses to eat unless the sandwich is cut into triangles and the apple skin is peeled.  The patient's teacher has reported that she interacts with other children for group activities but tends to play with one specific girl during free time.  She is toilet-trained and able to tie a knot but cannot tie her shoelaces or dress herself.  The patient can draw a square and catch a ball.  Vital signs and physical examination are normal.  She is tracking on the 70th percentile for weight and 60th percentile for height.  The patient makes intermittent eye contact with the physician, and when asked about her favorite foods, she smiles and tells a story about how owls are the smartest animals in the forest.  What is the most likely explanation for this patient's behavior?

A 22-year-old man comes to the office due to difficulty concentrating and sleeping.  The patient lost his job and moved in with his parents 2 months ago.  Although he has been looking for work and revising his resume, he gets distracted and easily loses focus.  The patient has not received any interview invitations and is worried that he will be living with his parents for a long time.  He feels that he has "reverted to my high school self," playing video games most evenings and going out with friends on the weekends.  The patient gets annoyed with his parents occasionally but states that he knows they are "just trying to be helpful."  He has been eating more than usual since moving, gaining 3 kg (6.6 lb) and feeling tired during the day.  The patient takes 2-3 hours to fall asleep each night and frequently checks the time while in bed.  He drinks 3 or 4 beers a week and does not use recreational substances.  Vital signs are within normal limits.  Physical examination shows no abnormalities.  The patient states that his mood is "okay," and he has a full range of affect.  He reports no suicidal ideation.  In addition to recommending psychotherapy, which of the following is the most appropriate pharmacotherapy for this patient?

A 47-year-old man with a long history of schizoaffective disorder comes to the clinic with his wife.  After a difficult course requiring several psychiatric hospitalizations and poor response to multiple antipsychotics and mood stabilizers, the patient's condition has been relatively stable for the past 3 years with high doses of lithium and risperidone.  Lowering his dose of risperidone resulted in worsening psychotic symptoms, so the dose was subsequently increased.  The patient's wife states that his psychiatric symptoms have improved with the current medications, but they are both concerned about new abnormal movements he has begun to make.  He has no other medical conditions and takes no other medications.  The patient does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 120/70 mm Hg, pulse is 72/min, and respirations are 12/min.  Lithium level is 1.2 mEq/L (range: 0.8-1.2).  During examination, the patient repeatedly taps his foot, protrudes his tongue, and smacks his lips.  The rest of the examination shows no abnormalities.  The patient is treated with sequential trials of valbenazine and deutetrabenazine but shows no significant improvement in abnormal movements at follow-up.  Which of the following is the most appropriate next step in management of this patient?

A 42-year-old woman, gravida 1 para 1, comes to the office for evaluation of insomnia following the birth of her son 5 weeks ago.  The patient says she wakes up each night to breastfeed him but is unable to go back to sleep.  She stays up most of the night thinking, "Why did I have a child so late in life? I'm already failing as a mother."  The patient has a decreased appetite and no interest in seeing friends or family members other than her mother.  She has no medical history and the delivery was uncomplicated.  Physical examination shows no abnormalities.  On mental status examination, the patient appears restless and is tearful.  Which of the following is the most likely diagnosis? A)Adjustment disorder B)Anxiety due to a general medical condition C)Generalized anxiety disorder D)Major depressive episode E)Postpartum blues

A 5-year-old girl is brought to the office for evaluation of night awakenings.  The patient has awakened screaming 1 or 2 times a month over the past few months shortly after going to sleep.  When her parents go to her room during these episodes, she is short of breath, crying, and sweating, and her face is flushed.  The patient appears frightened, does not respond to her parents' attempts at comforting her, and continues to cry.  She eventually goes back to sleep on her own and does not recall the incident the next morning.  Until starting kindergarten 2 months ago, the patient stayed at home with her mother, and she no longer takes a nap during the day.  Although the patient reports that she is happy and enjoys making friends, her mother wonders if she is having nightmares due to underlying anxiety about starting school.  Developmental milestones are normal.  Temperature is 36.7 C (98 F), blood pressure is 100/60 mm Hg, pulse is 96/min, and respirations are 20/min.  A complete physical examination is unremarkable.  Which of the following is the best next step in management of this patient?

A 21-year-old man comes to the emergency department due to injuries sustained during a fight.  He has a broken nose and requires stitches for scalp and arm lacerations.  His girlfriend says, "We were having a beer when he got angry and paranoid about the way a guy was looking at me.  We're not allowed to go back to that bar again because he's started so many fights there."  The patient says, "The other guy looks much worse than I do, but he had it coming."  The patient has had multiple jobs in the past year and was recently fired from his sales job for repeated absences.  He states, "That job was beneath me-I can easily make more money doing something else."  Starting in middle school, the patient has had repeated suspensions for truancy and fighting; he blames his failure to be accepted into college on the teachers who reported this.  He uses alcohol, marijuana, and crack cocaine "for fun" but had only 1 beer at the time of the fight.  Which of the following is the most likely diagnosis?

A 32-year-old woman with bipolar disorder comes to the office for follow-up.  The patient was diagnosed and treated for a manic episode at age 29 and has been stable on a combination of lithium and risperidone.  Her mood has been "fine" overall, but she has been stressed about work.  After a staff meeting a few weeks ago, her supervisor said she appeared angry because she was repeatedly frowning while others were presenting.  Since then, the patient has been increasingly self-conscious and has started eating lunch alone at her desk.  Temperature is 37.0 C (98.6 F), blood pressure is 132/78 mm Hg, pulse is 72/min, and respirations are 14/min.  Physical examination is unremarkable except for occasional grimacing and slow inversion and tapping movements of her right foot.  Lithium level is 0.9 mEq/L (normal: 0.6-1.2).  Which of the following is the most appropriate next step in pharmacological management?

A 69-year-old man is brought to the emergency department after he was found by police trying to break into the back office of a grocery store, claiming that he worked there and that he had left his keys in the office.  The owner of the grocery denied that the patient was employed there but thought that she recognized him as a regular patron.  The patient's medical problems include hypertension, hyperlipidemia, major depressive disorder, alcohol use disorder, and type 2 diabetes mellitus.  Family history is significant for Alzheimer disease on both sides of the family.  Temperature is 37 C (98.6 F), blood pressure is 135/86 mm Hg, pulse is 82/min, and respirations are 12/min.  The patient answers questions without difficulty but provides conflicting information to different examiners.  He is unable to account for how he ended up in the grocery store; however, he does provide detailed accounts of his previous job as an English professor, even reciting Shakespeare's Macbeth at length.  He does not appear troubled by his inability to recall events accurately.  The remainder of the examination is within normal limits.  Which of the following is the most likely explanation for this patient's symptoms?

A 44-year-old man is brought to the emergency department after he was found talking to himself in a park.  When authorities asked him to leave, he became agitated and combative, saying he was "destined to lead" and has to "wait in the park for the sign."  The patient admits to not sleeping for the past week.  His thoughts jump from topic to topic, and he appears distractible, disorganized, and unable to care for himself.  The patient is admitted to the hospital and prescribed daily haloperidol and valproate.  Over the next week, he becomes significantly calmer.  Although he continues to believe that he will "lead a spiritual revolution," he sleeps 6 hours a night and is better able to focus.  Ten days after admission, nursing staff members find him lying in bed, confused, sweating, and stiff.  Temperature is 39.2 C (102.6 F), blood pressure is 164/98 mm Hg, pulse is 122/min, and respirations are 28/min.  As a precaution, all medications are stopped.  If the patient's condition fails to improve with supportive measures, which of the following medications would be most appropriate to administer at this time?

A 27-year-old man is brought to the office by his wife due to her concerns that "he is not himself."  The patient has been very irritable and hyperactive with difficulty sleeping since returning from a family funeral a week ago.  His wife reports that he has been very distracted and unproductive at the factory where he works, to the point that his employer has placed him on probation.  Two days ago, he nearly sustained a serious injury while performing risky maneuvers with heavy machinery.  When asked about his job, the patient says he has had no difficulties and describes his idea to "use special robot prosthetics to make the production line faster than ever and double everyone's productivity."  The patient adds, "I don't know what my wife is worried about.  If this job doesn't work out, I'll start my own company."  His wife reports that he behaved similarly about 2 years ago and embarrassed her at a party by talking incessantly about his idea for a robotic invention.  The patient has no history of depression.  He drinks 2 or 3 beers on weekends and has been smoking marijuana approximately once a month for the past year.  Temperature is 37 C (98.6 F), blood pressure is 110/80 mm Hg, and pulse is 86/min.  Urine toxicology screen is positive for tetrahydrocannabinol.  Except for marked restlessness and fidgeting, physical examination is unremarkable.  Which of the following is the most likely explanation for the patient's behavior?

A 32-year-old man with no significant medical history comes to the office with concerns about recurrent episodes of sudden heart pounding, shortness of breath, chest pain, dizziness, shaking, and tingling in his extremities over the past several months.  The episodes last about 10 minutes and are associated with feelings of unreality and detachment from his body.  The patient fears having episodes while at work or driving and worries that he may have a heart condition or a serious undiagnosed disease.  He has seen other physicians, who performed extensive medical workups but found nothing wrong.  His worry has progressively worsened, and he now feels anxious all the time.  The patient does not use alcohol or illicit drugs.  Routine laboratory testing, ECG, and physical examination show no abnormalities.  Which of the following is the most likely diagnosis?

A 62-year-old man is brought to the office by his wife due to recent personality changes and cognitive impairment.  The symptoms began 4 months ago with abrupt-onset depression and profound sleepiness.  Soon after, the patient began having difficulty remembering names and events.  He now cannot prepare his own meals or care for himself.  The patient has a history of herpes simplex virus type 1 and takes acyclovir occasionally for recurrent symptoms; medical history is otherwise unremarkable.  He has no history of psychiatric disease but has a family history of dementia from his father.  The patient has a 40-pack-year smoking history.  Temperature is 37.7 C (99.9 F), blood pressure is 118/79 mm Hg, pulse is 72/min, and respirations are 14/min.  The patient is oriented only to self.  Montreal Cognitive Assessment score is 10/30 (normal: ≥26).  Near the end of the examination, the patient startles and jerks his arms when a door closes loudly.  Lumbar puncture is recommended.  Which of the following findings would be expected in this patient's cerebrospinal fluid?

A 27-year-old woman is brought to the emergency department after fainting at home.  The patient is an avid runner and follows a strict diet and exercise regimen.  She has been on a special juice fast and is training for a marathon with her husband.  The patient describes feeling "out of control" and has periods during which she craves sweet foods and eats "everything in sight"; afterward, she feels depressed and guilty and tries to compensate by fasting and running an additional 5 miles the next day.  She breaks down in tears and says she is afraid that her husband will leave her because of her "disgusting body."  Review of systems is unremarkable except for menstrual irregularity.  Temperature is 37 C (98.6 F), blood pressure is 98/62 mm Hg, pulse is 96/min, and respirations are 14/min.  BMI is 20 kg/m².  Physical examination is unremarkable.  Which of the following is the most likely diagnosis for this patient?

A 15-year-old girl is brought to the office by her mother, who is concerned about her moodiness and poor grades.  For the past 3 months, the patient has been uncharacteristically irritable and withdrawn.  The mother says, "She snaps at everyone for no reason and then slams the door to hide in her room."  The patient was previously active socially with several close friends and was an A student but now has stopped attending after-school activities, has no friends, and struggles to maintain a C average.  On weekends, she spends most of her time sleeping.  When seen alone, the patient tearfully describes herself as a failure and says, "I'm stupid and ugly."  She can no longer concentrate to complete her homework or school projects and failed a recent math test.  She has no suicidal ideation or medical conditions.  Physical examination is normal apart from weight gain of 2 kg (4.4 lb) since her annual checkup 3 months previously.  On mental status examination, the patient is fidgety, makes poor eye contact, and picks at her fingernails.  Laboratory values, including TSH, are within normal range, and urine drug screen is negative.  The patient and her mother ask if medication is a treatment option.  In addition to psychotherapy, which of the following is the most appropriate recommendation?

A 38-year-old man is evaluated for a 2-month history of depressed mood.  He explains, "I'm just exhausted all the time.  I can't sleep.  I can't think.  I just feel worn out."  During further discussion, the patient tearfully admits to thoughts of suicide but has no plan or intent to act on these thoughts.  He has no medical conditions.  Family history is significant for type 2 diabetes mellitus and hypertension in his father and hyperthyroidism in his mother.  After physical examination and laboratory workup, major depressive disorder is diagnosed and antidepressant therapy is initiated.  The patient's symptoms do not respond to monotherapy, so an antipsychotic medication is added.  Over the course of several months, the patient's antidepressant dose is increased to the maximal therapeutic dose.  At his 6-month follow-up, the patient's mood is improved and his depression is in remission.  Temperature is 36.7 C (98.1 F), blood pressure is 148/91 mm Hg, pulse is 72/min, and respirations are 14/min.  Compared to his most recent visit, he has lost 0.5 kg (1.1 lb); he has also new-onset hypertension.  Which of the following medications is the most likely cause of this adverse effect?

A 42-year-old man comes to the office with his brother due to depressed mood following the breakup of a relationship 6 weeks prior.  The patient says, "I feel hopeless.  Nothing will ever work out for me.  My girlfriend left me for no reason and now I'm on probation at work for missing too many days."  He has been sleeping 15 hours a day and has had difficulty completing daily activities like showering and getting dressed.  The patient is unable to concentrate on anything and spends time flipping through television channels to distract himself from feeling sad.  He had episodes of depression in his 20s and 30s, and he was hospitalized 3 years ago after a psychotic episode in which he believed he was a world-renowned sea captain.  During that episode, the patient spent all his savings buying a boat and did not sleep for days while he tried to recruit people to "join his expedition."  His symptoms fully resolved with treatment in the hospital, but he did not follow up after discharge.  The patient's brother says, "He was doing so well after leaving the hospital-no symptoms at all.  This breakup has been really hard on him though."  The patient has no history of substance abuse.  Mental status examination shows slow rate of speech with mild response latency, psychomotor retardation, and depressed mood.  He has no suicidal ideation.  Which of the following is the most likely diagnosis?