Exam 3: Psychiatry

A 28-year-old woman comes to the office for follow-up of an 8-month history of anxiety, nightmares, and flashbacks after returning from a military deployment.  She has been taking sertraline for the past 6 months and completed a course of cognitive-behavioral therapy recently.  The patient reports her symptoms have mostly improved, and she no longer has intrusive thoughts or flashbacks related to her time in a combat zone.  She says, "My mood feels lighter, and I've started spending more time with friends and family.  I can't seem to sleep through the night though.  I'm still having scary dreams about my time in the army."  She drinks a glass of wine twice a week and does not use tobacco or illicit drugs.  Medical history is noncontributory.  Vital signs are within normal limits.  Physical examination shows no abnormalities.  Which of the following is the best next step in management of this patient?

A 28-year-old man comes to the office with a 6-month history of extreme nervousness, irritability, restlessness, muscle tension, and insomnia.  He fears making mistakes in his job as an attorney and often worries that he has said something wrong.  The patient dreads the possibility of not being offered a position as partner in the law firm despite being reassured many times by his superiors.  As a result, he finds himself unable to concentrate well or perform his duties efficiently.  He is also engaged to be married and spends sleepless nights thinking about the responsibilities of married life.  He worries that he will not be a good husband or father.  The patient says that he has no previous history of alcohol intake but has been drinking 2 beers on weekends for the past month to escape his distressing thoughts.  He is reluctant to start psychotherapy due to his busy schedule.  Which of the following medications is most appropriate for this patient?

A 72-year-old man is brought to the office due to visual disturbances that are causing significant distress.  The patient describes seeing prowlers in the bushes outside of his windows at night that disappear when he tries to move in for a closer look.  He asked his daughter over to see if she could also see these people, and she could not.  The patient says, "I am really worried because I've never experienced anything like this before."  He has Parkinson disease, for which he takes carbidopa-levodopa, and generalized anxiety disorder, for which he takes sertraline.  Temperature is 36.9 C (98.4 F), blood pressure is 127/77 mm Hg, pulse is 68/min, and respirations are 14/min.  The patient is alert and oriented.  He has a mild resting tremor but very minimal rigidity.  His movements are slightly slowed.  Which of the following is the most appropriate next step in management?

A 68-year-old man comes to the office due to balance problems over the last 2 weeks.  He has had muscle stiffness and 3 near-falls recently.  The patient has no musculoskeletal pain or visual problems.  He has a history of bipolar disorder and anxiety and was started on valproate and risperidone for a manic episode 5 months ago.  Other medical issues include hypertension that is controlled with hydrochlorothiazide.  Temperature is 37.2 C (99 F) and blood pressure is 122/78 mm Hg supine and 130/80 mm Hg standing.  The patient appears slightly anxious but no longer manic.  There is an asymmetric resting tremor in both hands.  Finger tapping is slow and irregular bilaterally.  Which of the following is the most likely cause of this patient's current condition?

A 28-year-old woman is evaluated for the recent onset of paranoid thinking.  For the past 4 months, she has thought that coworkers have been spying on her and talking behind her back.  She is afraid to go to work and worries that she might lose her job.  She has no hallucinations or depression and no significant medical history.  Her father has coronary artery disease and hypertension, and her mother has a history of depression and hypothyroidism.  The patient has a 9-pack-year smoking history and drinks alcohol socially.  Physical examination is unremarkable.  ECG, complete blood count, comprehensive metabolic panel, and urine toxicology screen are normal.  The patient is started on olanzapine.  Which of the following tests would be most important to obtain at the patient's 3-month follow-up visit?

A 53-year-old man comes to the office due to depressed mood, low energy, and poor sleep for the past 2 months.  Although he spends up to 12 hours a day lying in bed, he gets only 4-5 hours of sleep and never feels rested.  He is isolating himself from his family and says, "I eat only because I have to."  The patient has had several previous periods of depression but was never diagnosed or treated.  He also has had periods lasting 5-6 days at a time in which he gets a burst of energy, has "tons of new ideas in my head," and feels great.  During these times, he likes to work extra-long hours to take on additional projects at work, and he feels well rested despite sleeping only 4 hours a night.  Now the patient fears that his depression is having a major impact on his work and family life.  He has been uncharacteristically procrastinating on several projects and is frequently late to work.  He has no motivation to spend time with his children or friends.  The patient has increased his daily caffeine consumption to 6 cups of coffee and has an energy drink to counteract his fatigue, and he recently started using marijuana at bedtime to escape from his depression and help him fall asleep.  Mental status examination shows slow speech, a sad affect, and no suicidal ideation.  Which of the following is the most likely diagnosis?

A 33-year-old man is hospitalized after he was found by his mother rocking back and forth on the floor of his room, repeatedly saying, "I deserve to die."  The patient has a history of schizophrenia since his early twenties and lives with his parents.  His antipsychotic medication was recently switched to aripiprazole due to poor response to quetiapine.  The patient has no other medical history.  He does not use alcohol or illicit drugs.  Physical examination is unremarkable.  On mental status examination, the patient is fearful and agitated.  He appears to be responding to internal stimuli and says the devil's voice is saying, "Why don't you kill yourself."  The patient asks the physician, "Don't you hear the devil?"  Which of the following is the most appropriate response to this patient?

A 72-year-old woman with breast cancer comes to the office for follow-up accompanied by her daughter.  The patient has undergone surgery and completed chemotherapy over the last 7 months; she was informed at her appointment last month that her cancer was in remission.  The daughter says that "despite the news of remission, Mother isn't any happier.  She eats very little, does not sleep more than 2 or 3 hours at a time, and cries frequently.  She also doesn't seem to enjoy visits from the family, reading, or watching her favorite television programs."  The patient says, "Wouldn't anyone who has been through this be depressed?"  She reports that her energy is still low following chemotherapy but that she is not in any pain.  She has stopped reading as she has difficulty concentrating and remembering.  The patient has lost 4.5 kg (10 lb) since her appointment a month ago.  She has no suicidal thoughts.  There are no changes on physical examination, and her laboratory results remain stable.  In addition to providing support, which of the following is the most appropriate next step in management of this patient?

A 12-year-old girl is brought to the office by her mother due to worsening grades and repeated absences from school associated with frequent stomachaches.  Her mother says, "She never had a problem before starting middle school 6 months ago.  She used to walk to elementary school, but the middle school is farther away.  Now, I have to take her to school myself because she refuses to get on the bus.  As soon as we get close to the school, her stomach hurts and she says she's going to vomit.  If she goes to school, she calls during every break to see if I'm okay.  I keep telling her that I'm fine."  The patient is worried that her mother will have an accident and not be able to pick her up from school and says, "I won't know what happened to her."  The patient denies problems with her appetite or energy levels but has trouble concentrating in class because she is worried about getting to the phone in her locker.  She denies being bullied or having other issues at school.  Family history is significant for cardiovascular disease and anxiety in her father and obsessive-compulsive disorder in her maternal aunt.  Physical examination is normal.  Which of the following is the most likely diagnosis?

A 24-year-old man is brought to the emergency department by his wife after he began threatening her at home.  She reports that he has been increasingly irritable and abusive over the last several months and becomes angry for no clear reason.  He was recently involved in a fist fight at work.  His wife also adds that they have been unsuccessful in their attempts to conceive over the past 2 years.  The husband states that there is nothing wrong.  He is otherwise healthy and exercises frequently.  The patient reports occasional alcohol use and past marijuana use.  On examination, blood pressure is 148/92 mm Hg and pulse is 102/min; he has a receding hairline.  There is palpable tissue underneath his nipples bilaterally.  Heart and lung examinations are normal.  Which of the following substances most likely explains the patient's symptoms and findings?

A 31-year-old woman comes to the office for a 6-week postpartum visit.  The patient is accompanied by her husband who says, "We haven't been getting much sleep since the baby was born, but he's healthy and doing well.  My wife is doing a great job-I'm just worried she's too overwhelmed."  Her husband shares that she spends hours every night reading about breastfeeding and baby formula instead of sleeping.  The patient says, "Lots of things get passed on to the baby in breast milk.  I don't want him to get exposed to something bad or hurt him in some way."  She wears sterile surgical gloves when preparing formula and showers every time before breastfeeding.  The patient washes fruits and vegetables 3 times to "get all the pesticides out" and does not eat at restaurants anymore from fear of getting food poisoning.  She does not drink alcohol or use illicit drugs.  Medical history is insignificant.  Physical examination is within normal limits.  The patient appears tired and anxious; she has no suicidal ideation.  Which of the following is the most likely diagnosis?

A 4-year-old boy is brought to the office by his father for a well-child visit.  The father says, "He gets frustrated so easily when I can't understand what he's saying.  He'll throw himself on the floor, screaming and crying.  I thought he would have outgrown this by now."  The father also reports that the patient is having trouble at preschool.  His teacher has mentioned that he does not speak much in class, is difficult to understand, and cries loudly when upset.  The patient can balance on one foot, catch a ball, cut with scissors, and draw a square.  He speaks in 2- or 3-word phrases and is unable to name colors or letters.  On interview, the patient's speech is clear but difficult to understand.  He says, "School open Monday; not dog today."  When the physician asks, "You are not going to school today?" the patient starts crying and throws his toys on the floor.  Physical examination, audiologic testing, and laboratory evaluation are normal.  Which of the following is the most likely diagnosis in this patient?

A 22-year-old woman comes to student health services for evaluation of low mood and anxiety.  The patient received a rejection letter a week ago from her top choice for graduate school.  Although she has received multiple acceptance letters from other programs, she feels like a "failure" and has not spoken to any of her friends or family for the past few days because she is too ashamed.  The patient angrily states, "I have classmates that got much worse grades and have no publications, but they all got into better schools than I did."  She has been staying in bed instead of attending classes and has been eating large amounts of junk food.  The patient says that her life is now "pointless" and that she would be "better off dead."  She has no medical or psychiatric history.  Vital signs are within normal limits.  Physical examination shows no abnormalities.  Which of the following is the most likely diagnosis?

A 48-year-old man comes to the office for a follow-up appointment.  He has a history of type 2 diabetes, hypertension, and major depression.  Over the past year, the patient has been treated with fluoxetine 20 mg for depression, which was subsequently increased to 40 mg.  He says, "I feel about 50% better.  I'm definitely less sad, and I'm somewhat more interested in my work and spending time with family.  However, I still feel like my energy is low.  I used to go to the gym or attend my son's soccer games on weekends, but now all I want to do is rest in bed or on the couch.  I'm frustrated because I'm eating too much and haven't been able to lose any weight."  Physical examination and routine laboratory tests are unremarkable.  Which of the following medications would be most appropriate to augment this patient's antidepressant therapy?

A 66-year-old woman comes to the office with her daughter for evaluation of behavioral changes.  The daughter says, "My mother was living with a friend but moved into a one-bedroom apartment 3 months ago to be closer to the family.  She was okay the first month but then started getting scared about living on her own.  It's gotten so bad, she asked to move in with me last week."  The patient has felt tense and appears distracted when spending time with family.  She sleeps restlessly through the night due to nightmares and takes early-morning drives around town to "clear my mind."  The patient has had no appetite changes or fatigue.  The daughter says that the patient was hospitalized a year ago for surgical repair of a hip fracture after slipping in the bathroom.  She was unable to move or call 911 and was found 8 hours later by a friend.  The patient says she cannot remember details of the fall.  Medical history includes hypertension and type 2 diabetes mellitus.  Temperature is 37.1 C (98.8 F), blood pressure is 140/80 mm Hg, and pulse is 86/min.  The patient is fully oriented.  Physical examination shows no abnormalities.  Speech is normal.  She has no delusions, hallucinations, or suicidal ideation.  Which of the following is the most appropriate next step in management of this patient?

A 38-year-old woman comes to the office due to anxiety and poor sleep.  A week ago, the patient went on a family hiking trip, which ended when her brother slipped and fell 30 ft down the mountainside.  Although his condition is now stable and improving, the patient worries about his recovery and awakens multiple times a night in a profuse sweat.  She is unable to take naps because she feels "too wound up."  The patient tearfully says, "I keep reliving the moment he fell, and I can't block it out."  Medical history is noncontributory.  She has started drinking 3 glasses of wine at bedtime to "calm down" but does not use recreational drugs.  Vital signs and physical examination are within normal limits.  On mental status examination, the patient appears tense and nervously taps her foot; she describes her mood as "numb."  Which of the following is the most appropriate management of this patient?

A 16-year-old girl is brought to the office by her mother due to concern about her behavior and grades.  Her mother says, "She used to be a good student, but over the past few months, her grades have dropped, and she doesn't seem to care."  The patient has been in the annual school play since first grade but recently quit the drama club because "I am not into it anymore; I can't even remember the lines anyway."  She avoids her friends and spends a great deal of time in her room with the door locked.  She goes to bed early, wakes up late, and takes naps of 1-2 hours when she gets home from school because she feels tired.  Her mother reports that the patient has been more irritable, fighting frequently with her younger siblings.  The patient responds, "I'm the oldest and my brothers annoy me all the time.  I just don't have any privacy at home!"  She has no medical conditions and does not use tobacco, alcohol, or illicit drugs.  Physical examination shows no abnormalities.  The patient is cooperative but appears distracted at times and asks for several questions to be repeated.  She appears fidgety and restless, frequently shifting in her seat and shaking her right leg.  Which of the following is the most likely diagnosis?

A 59-year-old woman comes to the office to follow up for chronic back pain caused by a motor vehicle collision.  A month ago, the patient was given scheduled-dose oral morphine.  Her pain level has decreased from 8 to 3 on a scale of 0-10, and pain no longer interferes with activities of daily living.  There has been no drowsiness, constipation, or nausea.  Other medications include naproxen, acetaminophen, and a lidocaine patch as needed.  Temperature is 37 C (98.6 F), blood pressure is 114/76 mm Hg, pulse is 64/min, and respirations are 12/min.  On examination, the back has greater range of motion than it did during the last visit.  Which of the following would be most helpful in the early detection of prescription opioid misuse in this patient?

A 31-year-old woman comes to the office for follow-up treatment of major depressive disorder.  Five months ago, the patient attempted suicide by hanging after learning that her husband had filed for divorce.  She was admitted to a psychiatric unit, where she was treated with fluoxetine 20 mg and discharged 2 months later.  A month following discharge, the fluoxetine dosage was increased.  The patient now says that her suicide attempt was "stupid" and denies suicidal ideation.  However, despite taking maximum doses of fluoxetine for 8 weeks, she still feels very depressed and reports minimal improvement in her energy level, motivation, and concentration.  The patient has ongoing feelings of guilt regarding the impact of her suicide attempt on her mother and young children.  Other medical conditions include a history of bulimia nervosa and allergic rhinitis.  Family history is significant for bipolar disorder in her mother.  Mental status examination reveals poor eye contact, constricted affect, and soft speech.  Which of the following is the most appropriate next step in the pharmacologic management of this patient's depression?

A 26-year-old man is brought to the emergency department by police after he was found disoriented and wandering on the street.  No medical history is available.  The patient is agitated and violent but calms down after several doses of lorazepam and haloperidol.  Physical examination reveals confusion and bilateral horizontal nystagmus but no other focal neurologic findings.  There are abrasions on the lower extremities.  Urine drug screen is positive for phencyclidine.  The patient is hospitalized for observation.  Several hours later, his agitation and confusion have improved, but he reports difficulty with his vision.  Temperature is 37.1 C (98.8 F), blood pressure is 134/84 mm Hg, pulse is 88/min, and respirations are 16/min.  On examination, both eyes are deviated superiorly, and extraocular movement is restricted.  There is rigidity of the neck and upper extremities.  Noncontrast CT scan of the head shows no intracranial hemorrhage.  Which of the following is most appropriate pharmacotherapy for this patient's current condition?