Exam 3: Psychiatry

A 37-year-old man with a history of depression, alcohol, and polysubstance use comes to the emergency department saying, "I feel awful; I need help."  The patient says he was feeling fine until last night, when he developed abdominal cramps that were initially mild but gradually worsened in intensity.  Since this morning, he has had 4 loose stools with no blood or mucus.  The patient has also had persistent nausea but no vomiting.  He has had no fever.  His medications include paroxetine, clonazepam, and diphenhydramine.  Temperature is 36.6 C (97.8 F), blood pressure is 144/98 mm Hg, pulse is 88/min, and respirations are 16/min.  Physical examination shows a diaphoretic, thin man in considerable distress.  His pupils are dilated.  This patient's clinical presentation is most consistent with withdrawal from which of the following drugs?

A 16-year-old girl is brought to the emergency department by her parents for evaluation of bizarre behavior.  The patient was found in her bedroom surrounded by broken lamps and ripped-up notebooks.  Her father says, "She's been a bit irritable for the past few days, probably because she's been studying for final exams nonstop.  We heard some noises in the middle of the night and found her wide awake and unable to sit still."  The patient has no medical conditions and no psychiatric history; she takes diphenhydramine as needed when she cannot sleep.  Family history is significant for bipolar disorder in the patient's older sister.  Temperature is 37.6 C (99.7 F), blood pressure is 150/90 mm Hg, pulse is 120/min, and respirations are 18/min.  On physical examination, the patient appears diaphoretic and restless.  During the cardiovascular examination, the patient removes the physician's stethoscope and says, "I need to get home and finish my paper.  It's due in a few hours."  Which of the following is the most appropriate pharmacotherapy for this patient?

A 37-year-old man comes to the office for a follow-up visit.  One month ago, he was diagnosed with type 2 diabetes mellitus and was started on metformin.  Blood pressure is 130/80 mm Hg, fasting glucose is 122 mg/dL, and BMI is 29.1 kg/m².  The patient looks rather dejected and admits that it has been difficult to come to terms with his diagnosis.  He has tried to exercise, watch his oral intake, and quit smoking as was suggested, but lately he has felt unmotivated and without energy.  The patient admits to feeling sad and guilty about his weight and smoking but is not sure he can do anything about it.  He has been oversleeping and then spending much of the day in bed watching television or sleeping due to lack of energy.  He has withdrawn from friends and family and took the last 2 weeks off from work because he did not "feel up to going."  The patient's ability to concentrate and pay attention to daily tasks is significantly impaired.  Which of the following is the most appropriate pharmacotherapy?

A 24-year-old woman is brought to the office by her roommate due to behavioral changes.  After taking a few days off work to recover from flu-like symptoms a month ago, the patient started to feel anxious about getting fired.  Despite repeated reassurance from her boss, she continued to fixate on losing her job and had difficulty sleeping.  More recently, she became convinced that her employer was trying to harm her and stopped going to work.  The patient has been increasingly forgetful over the past week and was briefly unable to recognize well-known friends that came to visit her.  Earlier today, her roommate noticed the patient staring blankly and smacking her lips rhythmically for about a minute while they watched television.  An incidental, 2-cm, right-sided ovarian teratoma was visualized on ultrasound 2 months ago; the patient is scheduled for surgical resection next month.  She has no other medical or psychiatric history.  Temperature is 38 C (100.4 F), blood pressure is 167/86 mm Hg, pulse is 122/min, and respirations are 14/min.  The patient is fully oriented, although easily distracted.  The left hand is clenched, and the left wrist is held in sustained flexion.  Mild rigidity is noted in the upper extremities.  Deep tendon reflexes are 3+ throughout, and her gait is normal.  She appears to be responding to internal stimuli and mumbles to herself during the examination.  Which of the following is the most likely diagnosis?

A 73-year-old woman is seen in the hospital following emergent left transmetatarsal amputation.  The patient has a history of chronic, nonhealing foot ulcers due to poorly controlled diabetes mellitus and peripheral artery disease and was admitted 2 days ago with wet gangrene and cellulitis.  At the time of admission, she had fever, hypotension, and altered mental status, and consent for amputation was provided by her son who is her designated surrogate decision maker.  Following surgery, the patient has been stabilized with intravenous antibiotics, opioid pain medications, and appropriate thromboembolism prophylaxis.  When the vascular surgeon explains his recommendation for left lower extremity angiography and possible revascularization to prevent further amputation, the patient refuses the procedures.  She says, "I'm too old for another operation.  I didn't want surgery the first time, and I don't want it now."  Which of the following is the most appropriate next step in management of this patient?

A 28-year-old woman comes to the office due to panic attacks.  She was promoted at work 7 months ago and has experienced severe anxiety, trembling, sweating, chest tightness, and shortness of breath when giving presentations or meeting new clients.  The patient says, "I have been anxious around people since I was a teenager, but it is getting worse.  It's very embarrassing.  I know everyone can see that I'm extremely nervous in meetings and will think I'm incompetent.  I'm afraid I'll make a fool of myself.  The last time I had to speak, I became so anxious that I couldn't breathe and almost passed out."  The patient is becoming increasingly concerned that she will lose her job, which is resulting in poor sleep.  She drinks 2-3 glasses of wine on weekends and does not use illicit substances.  Physical examination is unremarkable.  On mental status examination, she is visibly anxious throughout the interview and avoids eye contact with the physician.  Which of the following is the most likely diagnosis in this patient?

A 43-year-old woman presents to the emergency department complaining of feeling "horrible."  She has not been sleeping through the night, has been losing weight, and has crying fits throughout the day.  These symptoms began about 3 months ago when she discovered that her husband was having an affair.  She feels betrayed and foolish for having failed to recognize it sooner.  She states that she has been doubting her abilities as a wife and mother.  She has also stopped participating in her weekly book club and has not returned phone calls from friends and family recently, preferring to keep to herself instead.  She says she "just can't take the embarrassment" and has been having frequent thoughts of suicide.  The patient has been drinking 2-3 glasses of wine to help her fall asleep at night and using marijuana several times a month.  She has no psychiatric history.  Physical examination is unremarkable.  Which of the following is the most appropriate next step in management of this patient?

A 46-year-old woman comes to the office for a follow-up visit a week after hospitalization due to a second episode of acute pancreatitis.  The patient describes mild epigastric pain that is gradually subsiding.  She has no nausea or vomiting.  Medical history is significant for type 2 diabetes mellitus, hypertension, and alcohol use disorder.  The patient drinks 1 pint of vodka daily.  The physician asks the patient, "On a scale of 0 to 5, with 5 as the highest rating, how ready are you right now to make a change in your drinking?"  The patient rates her readiness as "about a 2."  According to principles of motivational interviewing, which of the following responses by the physician will be the most helpful at this time?

A 16-year-old girl comes to the office for psychiatric follow-up accompanied by her mother.  The patient has a history of depression and was started on fluoxetine 2 weeks ago.  Her energy and appetite have improved, but she still struggles with feelings of sadness and low self-esteem.  She has difficulty fitting in with social groups at school and tends to keep to herself.  The patient's depression was diagnosed at age 14 after she attempted suicide by an overdose of 15 acetaminophen tablets.  At that time, she was being sexually abused by a friend of the family; the abuse has since stopped.  She also has a history of cutting behavior and self-induced vomiting.  The patient uses marijuana and alcohol and has tried cocaine twice but did not like it.  Family history is significant for depression in her mother and suicide in her father.  The patient has had fleeting thoughts that she would be "better off dead" and "wonders how people would feel if I were gone," but she has had no suicidal intent or suicide plan.  Which of the following is the strongest risk factor for suicide in this patient?

A 39-year-old woman is hospitalized for appendicitis and undergoes an appendectomy on hospital day 1.  The patient has an uncomplicated postoperative course until the morning of hospital day 3, when she suddenly becomes acutely agitated.  She tries to get out of bed and shouts, "Get your hands off me!  God is watching!" when the nurses try to redirect her back into bed.  The patient has a history of schizophrenia, hypertension, multiple substance use disorders, and homelessness.  Medical records indicate that she was treated for a heroin and cocaine overdose last year and has had multiple admissions related to her substance use.  Temperature is 39 C (102.2 F), blood pressure is 171/95 mm Hg, pulse is 102/min, and respirations are 18/min.  The patient is oriented only to person.  She is diaphoretic, but the remainder of the examination is limited due to agitation.  Which of the following is the most likely cause of this patient's condition?

A 5-year-old girl is brought to the office due to behavioral changes.  The mother says, "We took her to a magic show a few months ago and bought a toy wand from the gift shop.  Now she thinks she has special powers."  The patient brings the wand to school each morning so that "bad things don't happen."  A week ago, she forgot to bring her wand home, and that night, her father was in a motor vehicle collision that resulted in a fractured wrist.  The patient says, "Dad got hurt because of me.  It was my fault."  She has become more protective of the wand and no longer shares it with her classmates because "it will lose its power."  Each night before falling asleep, the patient closes her eyes and taps her wand in the air 3 times to make sure she and her family stay safe.  Vital signs are within normal limits; growth curves are tracking consistently.  Physical examination shows no abnormalities.  Which of the following is the most likely diagnosis?

During bedside rounds, a medical student is asked by the senior resident to describe the differential diagnosis of hematuria.  After listing several diagnostic possibilities, but neglecting to mention nephrolithiasis, the resident sarcastically says, "What year of medical school are you in?  When I was a student, I could recite this in my sleep."  The student is upset by this comment and speaks to the resident privately later in the day, saying, "I am open to feedback on my performance but would hope that you would not belittle me in public."  Earlier that day the resident was reprimanded by the chief of service for mismanaging the care of a private patient.  The resident did not agree with the attending's assessment but said nothing.  Which of the following defense mechanisms is exhibited by the resident's behavior toward the student?

A 68-year-old man comes to the office due to headaches and unexplained weight loss.  The patient says, "Something is definitely wrong with my brain."  Over the past month, he has become convinced that he has brain cancer despite reassurance by another physician that his laboratory and brain MRI results are normal.  The patient reports low energy and little appetite for the last 3 months.  He stopped cooking when his wife died 6 months ago and has lost 9 kg (19.8 lb).  The patient also quit his volunteer job due to headaches and an inability to concentrate, explaining, "I no longer enjoy the work anyway."  Medical history includes hypertension and osteoarthritis.  Physical and neurologic examinations are unremarkable.  On mental status examination, the patient moves and speaks slowly with frequent pauses.  He says, "Cancer is my punishment for sins I committed as a young child."  He denies suicidal ideation but says, "It doesn't matter because I am dying of cancer anyway."  Which of the following is the most likely diagnosis in this patient?

A 32-year-old man is brought by his wife to the emergency department with a hand injury.  The patient "flew into a rage" and punched a mirror when his wife was late coming home from work.  The wife says, "He is generally not like this, but for the past couple of weeks, he's been extremely irritable.  Everything seems to set him off on a long rant, and I can't get a word in.  I'd be cranky too if I were getting as little sleep as he is-he's been working around the clock."  The patient has a history of behavioral conditions as a child and had a depressive episode in his twenties.  He drinks alcohol socially and does not use drugs.  Physical examination shows multiple lacerations on his right hand but is otherwise normal.  On mental status examination, he is tense and restless.  The patient has no delusions or hallucinations but says, "I can't shut my mind off."  Which of the following is the most likely diagnosis?

A 32-year-old woman comes to the office due to "feeling anxious and down" for the past 2 weeks.  The patient cries frequently and has been making mistakes in her accounting job due to poor concentration.  She feels tense throughout the day and has difficulty staying asleep most nights because she is awakened by episodes of palpitations, shortness of breath, and sweating.  The patient was mugged 3 weeks ago while walking home from work but is reluctant to discuss what happened.  She does not use alcohol or illicit drugs and takes no medication.  Temperature is 36.9 C (98.4 F), blood pressure is 125/70 mm Hg, pulse is 88/min, and respirations are 14/min.  Physical examination shows no abnormalities.  On mental status examination, the patient makes minimal eye contact, looks down at the floor, and wrings her hands repeatedly.  She tearfully says, "I feel like I'm in a daze, and I can't snap out of it."  Which of the following is the most likely diagnosis?

A 28-year-old primigravida at 16 weeks gestation comes to the office for a routine prenatal visit.  The patient has had muscle aches for the past 3 months.  She did not think much of her soreness early in the pregnancy, but her symptoms have become more bothersome.  The patient reports feeling fatigued and sleeping restlessly even before becoming pregnant and takes short naps most days.  Throughout the past year, she has spent much of her time thinking about whether she can tolerate the pain of labor and if her marriage and health will be affected by having a baby.  The patient usually feels comforted after talking to her mother but becomes overwhelmed again soon after.  She has no chronic medical conditions and takes a prenatal vitamin.  Vital signs are within normal limits.  Physical examination shows no abnormalities, and fetal heart tones are normal.  Complete blood count, comprehensive metabolic panel, and TSH are normal.  Which of the following is the most appropriate statement in response to this patient's condition?

A 52-year-old man with schizophrenia is brought to the emergency department by his group home staff due to agitation.  Staff report that for the past 2 weeks, the patient has been leaving the group home in the mornings and walking all day in the neighborhood.  Today, he became very angry and started shouting when asked to remain in the home.  A month ago, his antipsychotic was switched from quetiapine to risperidone for increasing auditory hallucinations.  Although the intensity of his voices significantly improved after 2 weeks, the patient has since become increasingly agitated, and dosage escalations to target his agitation do not appear to be calming him.  On mental status examination, he is cooperative but seems on edge, getting up to pace.  No localized abnormal movements are seen.  The patient makes limited eye contact and fidgets with his clothes.  He is oriented to time, place, person, and circumstance.  He does not have auditory hallucinations.  Which of the following is the most appropriate next step in pharmacotherapy for this patient?

A 28-year old woman comes to the office for follow-up.  She was seen a month earlier for evaluation of a year-long history of fatigue and leg pain.  The patient described "feeling tired all the time" and a sensation of heaviness and aching in both legs, unrelated to exertion.  Laboratory test results, including complete blood count, iron level, comprehensive metabolic panel, erythrocyte sedimentation rate, and TSH are normal, and she says, "my other doctor also said all my tests showed nothing abnormal."  The patient has a history of childhood attention deficit hyperactivity disorder, treated with methylphenidate but has not required any medication since high school.  During college, she received supportive counseling for 2 months after being raped.  The patient does not smoke.  She drinks 1 or 2 glasses of wine or smokes marijuana most evenings to "relax after work."  Family history is significant for bipolar disorder in her maternal grandmother.  Vital signs are stable, and physical examination is unremarkable.  The patient describes her mood as "fine" and has a full range of affect.  Which of the following historical risk factors is most consistent with this patient's diagnosis?

A 66-year-old man comes to the office to follow up on his prostate cancer treatment.  The patient has painful, bony metastasis in the pelvis and is being treated with hormonal therapy and radiotherapy.  He has been receiving long-acting and as-needed short-acting morphine, but he continues to have significant pain.  In the past 2 weeks, the patient has also experienced insomnia due to the pain, leading to worsening fatigue.  He has no nausea, constipation, drowsiness, or suicidal ideation.  Urine drug screen is positive for opioids and negative for other substances.  A review of the state prescription drug monitoring program database reveals no irregularities.  In addition to titration of opioid therapy to improve pain control, which of the following responses is the most appropriate recommendation for this patient?

A 44-year-old woman requests a same-day appointment due to poor sleep.  The patient says that when she goes to bed, her "brain can't shut off" and she feels "too wired" to fall asleep.  She has been spending hours playing online games and buying things from the Internet.  The patient is well known to the physician and has a long history of bipolar disorder.  Her medications include valproate and ziprasidone.  Physical examination is normal.  On mental status examination, the patient is very animated, laughs frequently, and speaks very rapidly.  She has no hallucinations, and no delusions are elicited.  The physician increases the patient's valproate dosage and prescribes a 1-week supply of zolpidem for sleep, with a planned follow-up in a week.  At the close of the visit, the patient thanks the physician profusely and presents a gift of a sterling silver pen, saying she is so appreciative that her visit could be scheduled on such short notice.  Which of the following is the most appropriate response by the physician?