Exam 3: Psychiatry

A 13-year-old boy is brought to the office by his parents due to concerns about his behavior.  His mother says, "A few weeks ago, he got into trouble for forging my signature so he could go on a school trip.  He has been talking back and arguing with us more than he used to.  I also found a cigarette lighter in his pocket, although he swears that he doesn't smoke and just likes to play with it when he's stressed."  The patient maintains a B average in school and spends most of his afternoons playing video games with a new group of friends.  Three months ago, he was accused of being involved in a suspicious fire at the local park.  His father says, "He has always wanted to be a firefighter.  At age 9, he was playing with matches in the backyard and started a fire just to see how long it would take the firefighters to arrive."  The patient says, "I don't know why my parents are so upset.  I do well in school, and I do all my chores.  Why can't they just leave me alone?"  He has no significant medical history.  On mental status examination, the patient is cooperative but sullen.  He has no delusions, hallucinations, or suicidal ideation.  Which of the following is the most likely diagnosis?

A 4-year-old boy is brought to the office for a routine visit.  He is growing well and talking in short sentences.  The patient can hop and copy a square.  He has started to play board games with his brothers and sister but occasionally hits his siblings when he loses a game.  His parents are concerned that he cannot yet tie his shoelaces and ask if it is normal for him to occasionally fondle his genitals in public or try to touch his brother's genitals while bathing.  The mother says, "He has shown me dolls kissing each other's private parts a few times and has asked where babies come from.  I haven't even had that talk with his 6-year-old brother.  Is that a normal question for a 4-year-old to ask?"  The parents are also concerned that the patient still sucks his thumb when anxious and occasionally wets his bed at night.  He will be starting preschool soon.  Which of the following behavior is concerning in this patient?

An 85-year-old man comes to the office accompanied by his daughter due to "memory problems."  The patient is a retired accountant who lives alone and had been managing his finances and housework until a month ago.  He says, "I've had to ask my daughter to shop for me and help around the house.  I kept forgetting to turn off the stove and could have easily burned down the house."  The patient has been more tired than usual and sleeps through his favorite television shows.  He previously maintained a rose garden but now feels "it's not worth the effort."  The patient's daughter says, "He was due for a medication refill last week but still has a few pills left because he sometimes forgets to take them."  Medical history includes hypothyroidism, hypertension, hypercholesterolemia, and a transient ischemic attack 2 years ago.  Temperature is 37.2 C (99 F), blood pressure is 141/87 mm Hg, pulse is 76/min, and respirations are 14/min.  His weight is up 4 kg (8.8 lb) from last month.  TSH is 4.0 µU/mL.  He scores 21/30 on the Montreal Cognitive Assessment (normal: ≥26), with deficits in delayed recall and attention.  Which of the following is the most likely cause of this patient's cognitive impairment?

A 40-year-old man comes to the office due to hand tremors for the past 2 months.  The patient is an art teacher and has had difficulty demonstrating techniques in front of the class due to shaky hands.  When noticing others looking at his hands, he becomes increasingly anxious and self-conscious, which tends to worsen the tremor.  The patient has a history of bipolar disorder with a manic episode 6 months ago.  He currently reports stable mood on the prescribed medication.  The patient drinks alcohol occasionally and has not noticed any tremor changes with alcohol use.  There is no family history of neurologic disorders.  Vital signs are within normal limits.  Physical examination shows fine, bilateral hand tremors that worsen with posture held against gravity.  Muscle tone, strength, and deep tendon reflexes are normal throughout.  Gait is normal.  On mental status examination, he is cooperative and appears mildly anxious.  The remainder of the physical examination shows no abnormalities.  Which of the following is the most likely cause of this patient's current symptoms?

A 24-year-old man is brought to the emergency department by his wife after he attempted to barricade himself in the garage.  Three weeks ago, while working at a construction site, the patient was almost hit by a falling metal beam.  Since the incident, he has become increasingly distressed and believes his supervisor arranged for the beam to deliberately hit him.  Earlier today, the patient received a routine work email and is now convinced it contains a hidden message warning that his life is still in danger.  He used cannabis and cocaine intermittently in college but has not used either drug for the past year.  The patient has no prior medical or psychiatric conditions.  Vital signs are within normal limits, physical examination is unremarkable, and urine drug screen is negative.  The patient appears hypervigilant and becomes agitated when hospital admission is discussed but calms down after having a conversation with his wife.  The patient agrees to hospitalization; however, once admitted, he refuses to take any medications.  His condition improves over the course of several days without any pharmacotherapy.  The patient is discharged and returns to work without issue.  Which of the following is the most likely diagnosis for this patient?

A 26-year-old woman comes to the office for treatment of depression.  She was prescribed fluoxetine a month ago due to symptoms of depressed mood, lack of motivation, poor sleep, fatigue, and poor concentration at work.  The patient reports that she is tolerating the medication without difficulty and began improving 2 days after starting it.  She says, "I've never felt better.  I instantly clicked with this guy I went on a date with yesterday, and I started a second part-time job."  The patient is sleeping 3 or 4 hours a night but reports that her energy is "excellent."  She tells the physician she is figuring out how to invest her savings in the stock market and offers to share her tips.  The patient does not use alcohol or illicit drugs.  Physical examination is normal.  Mental status examination is remarkable for moderately loud and rapid speech.  Which of the following is the most appropriate initial step in management of this patient?

A 74-year-old woman comes to the office accompanied by her husband for a routine checkup.  The patient has a history of hypertension and hypercholesterolemia.  She has no other medical problems or physical limitations.  At today's visit, her blood pressure is elevated and her husband says that she often forgets to take her blood pressure pills.  The patient says, "It's hard to remember to take them every day."  Her husband believes that her speech has changed as she occasionally struggles to find appropriate words and sometimes cannot recall people's names.  Two days ago, she drove to a nearby grocery store and was unable to find her way back.  She naps during the day, has difficulty falling asleep at night, and always wakes up early in the morning.  Her appetite is good.  Physical examination is within normal limits.  On mental status examination, the patient is calm and cooperative.  She says her mood is good and scores 25/30 on the Mini-Mental State Examination.  Which of the following is the most specific indicator of dementia (major neurocognitive disorder) as opposed to normal aging in this patient?

A 4-year-old boy is brought to the office by his parents due to behavioral difficulties at preschool.  The patient's teacher has concerns that his speech is difficult to understand and that he hits other children for no clear reason.  His mother says, "He is generally a happy kid but gets easily upset sometimes.  It takes a long time to calm him down."  The patient was born at term with no complications and has no significant medical history.  Family history includes autism spectrum disorder in his older brother.  Vital signs are within normal limits, and his height and weight track at the 60th percentile.  On physical examination, the patient has deep-set eyes and large ears.  He is highly active, banging a set of toy trains on the floor.  The patient does not make eye contact or answer questions directly and mumbles 1- or 2-word phrases.  Which of the following is most likely to establish an underlying diagnosis?

A woman brings her 19-year-old daughter to the office due to concerns that she is hypersensitive, depressed, and socially isolated.  The mother worries that her daughter is typically withdrawn, has few close friends, and does not date.  The mother says, "Although we're very close, a girl her age should be going out and not spending all her free time with her mother.  She's also very moody and tends to overreact to the slightest criticism."  The patient describes her mood as "unhappy" but has had no change in sleep or appetite.  She works as a filing clerk and recently turned down a higher-paying job as a receptionist because, "I prefer to work alone."  When questioned about her social isolation, she says, "Who would want to be friends with someone ugly and stupid like me anyway?"  Which of the following is the most likely explanation for this patient's behavior?

A 25-year-old woman comes to the office accompanied by her husband.  She is 1 week postpartum and has been sleeping poorly and crying for no reason.  The patient's pregnancy and vaginal delivery were uncomplicated.  She has some anxiety about being a new mother but says that her mother is helping and the baby is doing well.  The patient says, "I was thrilled after giving birth and can't understand why I now feel so tense and unhappy."  Her husband adds that his wife is uncharacteristically irritable and they fight frequently.  Last night she yelled at him for failing to help with the baby's nighttime feeding and later felt remorseful for her behavior.  The patient has a history of a major depressive episode that began after she moved away from home for college but responded well to psychotherapy and fluoxetine.  She has no other medical problems, takes no medication and is not breastfeeding.  Mental status examination shows a visibly tired woman with tense affect.  She has no suicidal or homicidal ideation.  Which of the following is the most appropriate intervention? A)Cognitive-behavioral therapy B)Fluoxetine C)Interpersonal psychotherapy D)Mirtazapine E)Psychiatry consultation F)Reassurance and monitoring G)Sertraline

A 38-year-old woman is brought to the emergency department by her sister after developing acute anxiety, headache, nausea, and vomiting while eating dinner.  The patient has no history of migraine, hypertension, or diabetes.  She has no known food allergies but does have a history of seasonal allergies treated with diphenhydramine.  The patient has a long history of major depressive disorder and panic attacks and has had poor response to several antidepressants.  For the past year, she has been treated with escitalopram, which she discontinued a week ago.  Yesterday, she started taking phenelzine for depressive symptoms.  On arrival, the patient is agitated, disoriented, diaphoretic, and tremulous.  Temperature is 38.9 C (102 F), blood pressure is 170/110 mm Hg, pulse is 115/min, and respirations are 24/min.  Physical examination shows dilated pupils and bilateral tremors.  Deep tendon reflexes are 3+ bilaterally.  Which of the following is the most likely cause of these findings in this patient?

A 43-year-old man is brought to the emergency department by the police after being found walking in the middle of a busy parking lot while talking to himself and shouting at passing cars.  The patient is barefoot and disheveled.  He is oriented to person and place but is unable to give a coherent history.  He says, "I've been in a lot of hospitals, but I won't take any medication."  The patient appears tense and agitated.  When the nurse attempts to take vital signs, he refuses and pulls his arm away.  He glares at the nurse and shouts, "All you do is experiment on people."  Which of the following is the most appropriate next step in management of this patient?

A 68-year-old man is brought to the emergency department by his wife due to "uncharacteristic behavior."  The patient started buying large numbers of lottery tickets and decided to quit his job 2 weeks ago.  He has maxed out multiple credit cards buying expensive jewelry for his wife.  The patient has had difficulty sleeping recently and stays up watching TV into the early morning hours.  He says, "I feel really good and finally like what I'm doing."  The patient has no psychiatric history.  Medical history includes recently diagnosed restless leg syndrome, treated with ropinirole.  Temperature is 37.1 C (98.8 F), blood pressure is 130/80 mm Hg, and pulse is 86/min.  Physical examination is within normal limits.  The patient is restless, appears to be easily distracted, and speaks rapidly.  Complete blood count and basic metabolic panel are within normal limits.  Urine drug screen is negative.  Which of the following is the most appropriate initial step in management?

A 51-year-old man with a long-standing history of schizophrenia is evaluated for agitation and oppositional behavior at a group home.  He was admitted to the group home yesterday after his mother, with whom he previously lived, moved to an assisted care facility.  A staff member reports the patient was cooperative and calm when he arrived and did not talk much, which seems to be his baseline.  He did not sleep well last night, and today he has been pacing around and yelling at other residents and staff.  The patient has no other medical conditions.  Medications include clozapine.  He does not use tobacco or illicit drugs but does use alcohol.  Temperature is 36.7 C (98.1 F), blood pressure is 152/94 mm Hg, and pulse is 114/min.  On physical examination, the patient appears anxious and diaphoretic and is fidgeting in his seat.  Marked hand tremors are present.  He is alert and oriented to person, place, and time.  Which of the following is the best next step in the management of this patient?

A 5-year-old boy is brought to the office by his mother due to "concerning behavior."  The patient's mother says that he is doing well and enjoying first grade, but for the past month she has noticed him talking to himself and insisting that he can see an angel.  Earlier today he told his mother, "Angels can be nice or they can be angry, and if I speak too loudly the angel could sit on my sister's head."  His mother reports no problems with the patient's appetite or sleep.  She mentions that 6 weeks ago he fell off a balance beam during gymnastics class and says, "He bruised his arm but was okay otherwise.  He's more cautious in class now but still seems to enjoy tumbling."  The patient spends time with his cousins and siblings but tends to be shy around strangers.  He tells the physician about his new toy car and a schoolteacher he likes.  The patient has no prior medical conditions; family history is notable for a paternal uncle with schizophrenia.  Vital signs are normal, and the patient's height and weight are tracking on the 60th percentile.  Physical examination reveals no abnormalities.  The patient turns to his left at one point and whispers something under his breath.  He then looks at the physician and says, "Can't you see the angel?  He's waving at you."  Which of the following is the most likely diagnosis in this patient?

A 27-year-old woman is brought to the office by her boyfriend after locking herself in the bathroom and making a superficial cut to her forearm the night before.  The patient states that she has been more down than usual for the past 2 weeks and has been contemplating suicide.  She has been too tired to get out of bed and tends to sleep for hours after her alarm clock rings.  The patient fears that her boyfriend will leave her because she is "completely useless."  Her boyfriend says, "I'm not sure what changed-last month, she was looking forward to our first vacation together.  She skipped work and spent a week straight figuring out all the details.  She barely slept and couldn't stop talking about this trip because she was so excited."  The patient has a history of 2 suicide attempts at age 18 and 21.  She takes no medications.  Temperature is 36.7 C (98.1 F), blood pressure is 119/78 mm Hg, pulse is 72/min, and respirations are 14/min.  There is a 4-cm, superficial laceration on her left forearm.  The patient is tearful and dysphoric.  Which of the following is the most appropriate next step in treatment of this patient?

A 15-year-old boy is brought to the office by his mother due to "odd behavior."  The mother says, "Since moving to a new school 8 months ago, he has started talking to his imaginary friend Henry again.  He hasn't done this since kindergarten-he used to cry a lot when I dropped him off, but Henry was a big comfort to him."  She adds that the patient can get easily overwhelmed by social situations and has always had a hard time making friends.  The mother also notes that her son has been spending more time alone, and when passing by his bedroom she can sometimes hear him laughing and talking to Henry.  His teachers have said that the patient has not been paying attention in class or completing homework.  He no longer spends time with his siblings and says he "would rather play videogames with Henry."  The patient states, "Henry is always with me and likes to comment on what I am doing."  The patient reports no depressed mood; sleep and appetite are normal.  He has tried marijuana in the past but does not drink alcohol or use other drugs.  Medical history is not significant.  Vital signs and physical examination are normal.  On mental status examination, the patient avoids eye contact and has a flat affect.  Which of the following is the most likely explanation for the patient's behavior?

A 68-year-old woman with a 3-year history of idiopathic Parkinson disease comes to the office with her husband for follow-up.  The patient reports adequate control of motor symptoms with levodopa-carbidopa therapy but states that for the past month, she no longer spends time with her friends or participates in her church choir due to difficulty focusing.  She sleeps restlessly most nights, resulting in daytime naps, and skips dinner because she is not hungry.  Medical history is otherwise noncontributory, and the patient takes no other medications.  Vital signs are within normal limits.  Physical examination shows reduced facial expressions and mild slowing on repeated finger tapping but no significant tremors.  Posture and gait are normal.  Which of the following is the best next step in management?

A 32-year-old physician comes to the office due to insomnia for the past 6 weeks.  He says, "I feel restless at night, and I can't get any sleep.  I've tried reading boring books and drinking herbal teas, but nothing seems to help."  The patient feels his lack of sleep has made it difficult to focus and started drinking 2 cups of coffee before his shifts "to get through the day."  He previously worked in the emergency department but switched to doing shifts at an urgent care clinic a month ago.  The patient says, "I was seeing a lot of gunshot wounds at the hospital.  Compared to my old job, this one is much calmer, but I still feel anxious a lot of the time."  He still thinks about patients he treated and what he could have done differently to save them.  The patient says, "The world has just gotten too dangerous, and I feel like medicine can't keep up with it."  He drinks 3-4 beers on the weekends and does not use tobacco or illicit drugs.  Medical history is noncontributory.  Temperature is 37 C (98.6 F), blood pressure is 130/80 mm Hg, pulse is 84/min, and respirations are 16/min.  Physical examination is unremarkable.  The patient appears tired and speaks in a low volume.  Which of the following is the most appropriate next step in management of this patient?

A 35-year-old man with a history of bipolar and substance use disorders comes to the emergency department due to depression, auditory hallucinations, and suicidal ideation.  His medications include lithium and escitalopram.  The patient has a history of 5 psychiatric hospitalizations and 2 past suicide attempts, including overdose on his medications and attempted hanging.  He has a history of alcohol, benzodiazepine, heroin, and cocaine abuse.  The patient has been using "anything I can get my hands on" because his depression is unbearable.  He is hospitalized and placed on suicide precautions.  His dose of escitalopram is increased to target his depression, and risperidone is added to treat the hallucinations.  His lithium level is 1.0 mEq/L.  On the second day of hospitalization, the patient reports muscle pains, abdominal cramping, nausea, and diarrhea.  His temperature is 37.2 C (99 F), blood pressure is 130/85 mm Hg, and pulse is 84/min.  The patient is alert and restless, and his pupils are dilated bilaterally.  Bowel sounds are hyperactive and neurologic examination is normal.  Which of the following is the most likely explanation for his symptoms?