Exam 3: Psychiatry

A 68-year-old man is brought to the primary care physician's office by his wife.  She reports that the patient has been flailing in his sleep, particularly during the early morning hours.  She is worried that he will hurt himself or her with these movements.  The episodes started several months ago with infrequent nighttime movements but now occur almost nightly.  The patient's wife says, "It's like he can't control himself.  I have seen him kicking in bed, pushing over the nightstand, and moving furniture out of the way.  He has also tried to push me from behind with his whole body, all while appearing to be asleep."  She is able to wake him from these episodes, and he doesn't appear disoriented or confused on awakening.  The patient is unaware of his nighttime movements but describes a recurrent dream in which he feels lost and trapped in the woods and tries to escape.  He has had no behavioral symptoms while awake during the day.  His only other symptom is constipation.  The patient's medical history includes well-controlled hypertension.  Vital signs are within normal limits, and physical examination is normal except for slight slowness of gait.  Which of the following is the most likely diagnosis?

An 18-year-old student is brought to the emergency department due to dizziness and weakness.  The patient was studying for final exams with her friends when she suddenly felt dizzy and started having palpitations.  She tried to get up but felt weak and had to sit back down.  The patient has had several similar episodes in the past 2 months.  She lives with her parents and commutes to a nearby college.  She has no prior medical conditions.  Family history includes diabetes mellitus in her father.  The patient reports occasional alcohol use.  Temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 90/min, and respirations are 16/min.  There are no orthostatic changes.  BMI is 19 kg/m².  Physical examination shows no abnormalities.  Finger-stick glucose is 48 mg/dL.  Symptoms promptly resolve with intravenous dextrose.  Serum insulin and C-peptide levels, drawn prior to dextrose administration, are elevated.  Which of the following best explains this patient's symptoms?

A 37-year-old man is brought to the emergency department by police officers.  He was found naked at a traffic signal, cursing at drivers and assaulting nearby pedestrians.  The patient has a long history of abusing multiple substances and has been admitted to the hospital several times with a similar presentation.  He has epilepsy and type 2 diabetes mellitus.  Attempts to elicit a history from the patient prove unsuccessful because he is highly agitated and combative.  He keeps repeating, "They are all out to get me.  They are coming through the walls, ready to kill me."  The patient alternates between screaming and pounding on the walls.  Temperature is 38.3 C (100.9 F), blood pressure is 148/100 mm Hg, pulse is 98/min, and respirations are 16/min.  Physical examination shows ataxia, nystagmus, and muscle rigidity.  Which of the following is the most appropriate next step in management of this patient?

A 22-year-old man is brought to the emergency department by the police due to agitated behavior and hearing voices.  The patient's mother called the police after he locked himself in his bedroom while shouting, "The voices won't leave me alone.  They have taken over my brain."  The patient had a previous psychotic episode a year ago while attending college out-of-state and was treated in a psychiatric hospital.  After being discharged, he moved in with his parents and younger sister but did not take any medications or attend follow-up appointments.  His mother says the patient is unemployed, and she must frequently remind him to tend to personal hygiene.  She has also noticed him laughing to himself on several occasions.  A comprehensive medical evaluation is within normal limits.  The patient is treated with quetiapine in the hospital and is discharged 5 days later.  At his 1-week outpatient follow-up, the patient feels "okay" and notes that the voices are quieter since starting medication.  His mother says, "He is much calmer, but I'm worried because he just stays in his room and seems unmotivated to do anything."  In addition to continuing pharmacotherapy, which of the following would be most effective in reducing this patient's risk of relapse?

A 62-year-old woman comes to the office accompanied by her daughter, who is concerned that her mother is depressed.  The daughter says that since her father's unexpected death from a heart attack 2 years ago, her mother seems withdrawn and socially isolated.  The patient reports that she still misses her husband terribly and thinks about him constantly.  She says, "I can't believe he is gone."  She feels guilty that she did not recognize his heart condition and blames herself for not insisting that he get medical care earlier.  The patient does not have sleep or appetite disturbance, but sleeps on the couch because she can't bear to lie in the bed that she and her husband shared.  She has stopped playing golf and attending concerts--activities that they had enjoyed together.  The patient has no suicidal ideation.  She continues to work at her part-time job and help her daughter with the grandchildren.  Which of the following is the most likely explanation for this patient's symptoms?

A 56-year-old man is brought to the emergency department by police after being found walking down the middle of a busy highway saying he is "blessed with the power to save all souls."  The patient believes he is "the reincarnation of the Savior" and was sent to "spread peace on Earth."  He recently moved to the city and is renting a room at a boarding house where he says he has been "turning water into wine."  The patient has been unable to hold down a steady job for most of his adult life but works intermittently in construction.  Blood pressure is 168/94 mm Hg and pulse is 90/min.  The patient appears thin and has stained clothing and unwashed hair.  He avoids direct eye contact, mostly looking at the ceiling and smiling intermittently for no apparent reason.  His speech is difficult to follow, and he repeatedly says in a monotone voice, "I am blessed."  Neurological examination is otherwise unremarkable.  Routine laboratory studies are within normal range, and blood alcohol level is undetectable.  Which of the following is the most likely diagnosis in this patient?

A 26-year-old man is brought to the emergency department after an attempted suicide by medication overdose.  He has had 2 seizures in the past hour.  Temperature is 38.8 C (102 F), blood pressure is 90/60 mm Hg, pulse is 110/min, and respirations are 22/min.  The patient is not oriented to time, place, and person.  Pupils are dilated and respond poorly to light; the skin is flushed and dry.  Abdominal examination shows reduced bowel sounds.  ECG shows prolonged QRS complexes (0.19 sec).  Toxicology studies are pending.  Which of the following is the best predictor of complications due to overdose of the suspected drug?

A 31-year-old woman comes to the office due to fatigue and weight gain.  She has felt tired over the past 2 months and is upset that she has been craving junk food and has gained 8 pounds.  She says, "I have been under some stress at work lately, and I guess I've been eating and sleeping more as a way to cope and escape.  I know I've gained weight but I feel slow-like my legs are in cement blocks."  The patient sleeps 10-12 hours a day but still feels tired throughout the day.  She is feeling "down" and stopped socializing with friends "because I feel that I look awful and don't want to be around anybody."  However, she was able to enjoy a recent family reunion and was excited to meet her newborn nephew for the first time.  The patient has no medical or psychiatric history.  She has 1-2 glasses of wine 3 times a week and uses cannabis approximately once a month.  Physical examination is normal.  On mental status examination the patient appears sad and tired but is able to smile when appropriate.  Laboratory evaluation, including complete blood count and thyroid function tests, is within normal range.  Which of the following is the most likely diagnosis?

A 42-year-old man comes to the office accompanied by his wife for evaluation of mood changes.  The patient's wife states that he has been restless and irritable since returning from a work trip.  While staying in a hotel 2 weeks ago, the patient was unable to leave his room on the 8th floor after an earthquake caused debris to block the door.  He had no cell phone or internet access during this time and remained in his room for 8 hours before the arrival of first responders.  His wife says he refuses to talk about the earthquake and has started sleeping in the living room to have access to multiple exit routes "in case something happens."  The patient has been working from home since he returned and is scheduled to leave for another work trip next week.  He says, "I keep waking up from nightmares, but I'm sure I'll get over this on my own.  I don't feel the need to talk about what happened because I know that getting back to my usual routine will help take my mind off of it."  On mental status examination, the patient is cooperative and provides brief responses to questions.  Although he states that his mood is "okay," he appears withdrawn.  Which of the following is the most appropriate initial step in management of this patient?

A 19-year-old woman who is struggling academically comes to the university health clinic.  The patient is assessed by a counselor and referred to the clinic's physician for symptoms of anxiety, insomnia, and fatigue.  For the past year, the patient has worried excessively about whether her door is locked and the stove is turned off, so she checks the door and stove multiple times during the day and night.  Although she knows she has locked the door and turned off the stove and that her fears "don't make sense," she is unable to stop thinking about them until she checks.  She also is concerned that spending so much time on these thoughts does not allow her time to complete assignments or get enough sleep.  When the patient does complete assignments, she spends a great deal of time checking her work repeatedly.  Her medications include daily oral contraceptives.  She has no significant medical or psychiatric history.  The patient does not use illicit drugs and has no feelings of depression or hopelessness.  Physical examination is unremarkable.  Which of the following would be the most appropriate treatment for this patient?

A 13-year-old boy is brought to the office by his mother due to behavioral problems at school.  The patient started at a new school 2 months ago after his family moved to the area for his father's job.  His teachers report that he is fidgety in the classroom and has difficulty completing assignments on time.  His mother states that he has always been a good student, but his grades have been declining over the past year, despite spending 3-4 hours on homework every night.  The patient states that assignments have been taking longer to complete because he must rewrite them until his handwriting is "just right."  He worries that if he does not achieve this, his father will lose his job and the family will have to move again.  The patient has had no change in sleep or appetite.  He does not feel sad or depressed but describes feeling anxious.  Physical examination shows no abnormalities, and results of routine laboratory evaluation are within normal range.  Which of the following is the most appropriate management for this patient's condition?

A 53-year-old man comes to the office due to persistent fatigue.  The patient started a therapeutic dose of fluoxetine 2 months ago after being diagnosed with major depressive disorder.  He says, "Since I last saw you, I still feel like I'm dragging pretty much every day and have to force myself to go to work in the mornings.  I haven't even wanted to have sex with my wife.  That's been going on for almost a month, and it's really bothering me."  The patient works as a high school English teacher and notes, "It takes me so long to grade my students' essays because I am so easily distracted."  Medical history includes hypertension treated with enalapril.  He had a 4-kg (9-lb) weight gain over the past 2 months.  Blood pressure is 130/84 mm Hg and pulse is 76/min.  Physical examination shows no abnormalities.  The patient appears depressed and speaks softly throughout the interview.  Which of the following is the most appropriate next step in pharmacotherapy?

A 57-year-old woman comes to the office with intermittent headaches, shoulder and neck pain, fatigue, and insomnia.  The headaches sometimes interfere with the patient's ability to concentrate at work.  The symptoms are not new but have worsened over the past 8 months due to the stress of starting a new job and placing her elderly mother in an assisted living facility.  The patient lies awake at night worrying about her mother, her own health problems, and the finances of her 2 adult children, who are having difficulty supporting themselves.  During the day, she is tired due to poor sleep and worries about her job performance.  The patient has a history of hypertension, irritable bowel syndrome, and tension headaches.  She drinks 1 or 2 glasses of wine before bedtime a few times per week to help her relax and fall asleep.  Temperature is 36.7 C (98 F), blood pressure is 130/80 mm Hg, pulse is 88/min, and respirations are 16/min.  Examination shows sweaty palms and mild, diffuse abdominal tenderness; no other abnormalities are noted.  Complete blood count, chemistry panel, TSH, urinalysis, and ECG are normal.  Which of the following is the most appropriate next step in management of this patient?

A 4-year-old boy is brought to the emergency department by his parents due to fever, runny nose, cough, and unusual behavior.  The boy has been at home for the past 3 days since his fever started; his parents note that he has become increasingly restless over the past 2 days, and yesterday he began making odd comments about his dog being in the room when the dog was clearly not there.  Since he has been at home, the parents have treated his cold symptoms with over-the-counter nasal decongestants and antihistamines and humidified the air in his bedroom, without much benefit.  Temperature is 38.3 C (101 F), blood pressure is 110/60 mm Hg, pulse is 100/min, and respirations are 26/min.  Physical examination shows a slightly erythematous oropharynx with no exudate, clear nasal discharge, clear lung fields, and normal S1 and S2.  The abdomen is soft and nontender.  Neurologic examination is within normal limits.  During the examination, the patient starts talking to something in the room, saying that he can see a "bunny sitting on the bed" with him and that "the animals have followed us to the hospital."  Which of the following is the most likely explanation for this boy's visual hallucinations?

A 35-year-old man comes to the office due to poor sleep and feeling "worthless."  His insomnia and poor self-esteem began 2 months ago when he discovered that his girlfriend was romantically involved with one of her co-workers.  The patient was very disappointed by this news as he thought he and his girlfriend were close and had a good sexual relationship.  He immediately ended the relationship and has since stopped socializing, preferring instead to stay home alone.  He admits to having little interest in dating women now, even when they seem to be a good match.  Although the patient continues to meet his deadlines and fulfill all his professional responsibilities, he feels less motivated at work.  He continues to go to the gym regularly, as exercising helps him "escape from feelings" he still has for his former girlfriend.  He reluctantly admits to occasionally using marijuana to help him sleep.  The patient has no psychiatric history.  There is a family history of depression in his older sister, who was successfully treated with venlafaxine.  Which of the following treatments is the most appropriate management for this patient?

A 26-year-old primigravida at 38 weeks gestation is admitted to the hospital due to preeclampsia with severe features.  She undergoes an emergency cesarean delivery of a healthy newborn.  After delivery, the patient continues to have uncontrolled hypertension and suffers an ischemic stroke.  She is intubated and placed on full ventilator support.  On day 3 of hospitalization, the patient remains minimally responsive to most stimuli.  She has no advance directive.  The physician explains the clinical findings and options for care to the patient's husband and parents.  The husband says he met his wife 2 years ago and does not recall discussing life-sustaining medical treatment with her.  The patient's parents state that it would be best to continue life support because the patient just became a mother.  In further discussion with the family, which of the following would be most important for the physician to address?

A 75-year-old hospitalized woman with a history of Alzheimer dementia is evaluated due to labile blood pressure and worsening agitation.  The patient was admitted 4 days ago for right hip replacement after a traumatic fall and hip fracture.  Her immediate postoperative course was complicated by agitation, and she was treated with haloperidol.  Despite treatment, the patient continues to be agitated and confused.  Today, her systolic blood pressure has measured between 120 and 170 mm Hg.  Temperature is 38.7 C (101.6 F), pulse is 120/min, and respirations are 22/min.  Pulse oximetry is 97% on room air.  On mental status examination, the patient is not oriented to place or person.  She is drooling and diaphoretic.  Heart and lungs are normal.  The abdomen is soft and nontender.  The operative site is clean and dry.  Muscle tone is increased in both the upper and the lower extremities.  Tremor is present.  Deep tendon reflexes are 2+.  Babinski sign is absent.  Laboratory results are as follows: Which of the following is the most likely explanation for this patient's symptoms?

A 30-month-old girl is brought to the office after her teacher recommended an evaluation for behavioral and speech problems.  Her mother says, "I have gotten several reports from the school that she hits other children."  The teacher's report indicates that the girl does not respond to her name being called, says only 1-word phrases, and prefers to play by herself with her favorite toy bunny.  The mother acknowledges that the girl's language development has been slow but adds, "Her hearing test was normal, and her sister began speaking late and is perfectly fine; I'm hoping it just runs in the family.  She has always been shy, and I can understand why she hits when it's hard for her to communicate."  The patient is able to walk upstairs, draw a circle, and feed herself.  Her height, weight, and head circumference for age are tracking above the 60th percentile.  On examination, the pediatrician notes that she says 1 or 2 unintelligible words.  The patient does not look up and continues to play with her bunny when he tries to engage her.  Which of the following is the most appropriate response by the physician?

A 30-year-old woman is brought to the office by her husband.  He says that over the past 2 months, the patient has become increasingly depressed to the point that she rarely gets out of bed.  She has called in sick to work, does not answer the phone when her friends call, and has lost 4.5 kg (10 lb).  The patient has a history of 2 psychiatric hospitalizations.  She was first hospitalized at age 27 for a period of extreme irritability and agitation that lasted a week.  At that time, she spoke so rapidly that she was difficult to understand and stayed up for nights dictating letters to government officials about her solution to world hunger.  Last year, the patient was hospitalized for severe depression and a suicide attempt.  She responded within days to venlafaxine but discontinued the medication shortly after discharge because she "felt fine."  On mental status examination, the patient shows a depressed and tearful affect.  She admits to "hearing the devil saying I'm a useless waste of time."  Which of the following medications would be most appropriate for the long-term treatment of this patient's condition?

A 32-year-old man is brought to the emergency department after falling from a fourth-floor balcony of his apartment building.  A witness at the scene reported that the patient stood on the balcony ledge for several minutes beforehand, looking down toward the street.  His fall was broken by a tree, and he sustained multiple minor injuries, including abrasions and lacerations to his face and the extremities.  The patient explains that he had a couple of beers and lost his balance while he was birdwatching.  He has no medical history but reports that he has lost some weight and feels tired because he cannot sleep due to the loud street noise in his neighborhood.  He lives alone and is worried about not being able to pay the rent if he does not find work soon.  The patient drinks 3 beers on most weekdays and 4 or 5 beers on weekends but does not use illicit drugs.  His vital signs, complete blood count, and comprehensive metabolic panel are within normal limits.  Blood alcohol concentration is 0.005%.  The patient's lacerations are sutured, and he is medically cleared.  Mental status examination shows a thin, anxious man who is cooperative and oriented to person, place, and time.  The patient makes poor eye contact and gives brief responses, repeatedly insisting, "Everything's fine, I'm okay.  I just want to go home."  He says he is not suicidal.  Which of the following is the most appropriate next step in management of this patient?