Exam 3: Psychiatry

A 21-year-old woman comes to the office for a routine health maintenance evaluation.  The patient shares that looking in the mirror has been increasingly difficult due to feeling upset about "how my breasts look."  The patient frequently imagines what it would be like to not have breasts and wears a chest binder to make them appear flatter.  The patient says, "I've always wanted to change how I look but didn't want to upset my parents.  I don't want people to see me as a woman anymore because I've never felt like one."  The patient recently moved to the area a month ago due to "overbearing parents" and "feeling too confined."  Medical history is noncontributory.  Vital signs are within normal limits.  The patient appears somewhat anxious and is wearing trousers and a loose T-shirt.  Which of the following is the most likely explanation for this patient's condition?

A 28-year-old man comes to the office saying, "I'm just not feeling like myself."  This change began soon after his older brother died of cancer 3 months ago.  The patient feels sad and has lost interest in work and going out with friends on weekends.  He falls asleep relatively easily at night but awakens very early in the morning and is unable to fall back asleep.  The patient feels "very down," especially when he first wakes up, but says that his mood improves a little during the day when he is busy.  His poor energy and concentration have started to affect his performance at work, and he frequently thinks that, "I should just quit because I am bringing everyone down."  He has been eating less and has lost 5.4 kg (12 lb) over the past few weeks.  The patient has had no suicidal thoughts.  He has no psychiatric history other than counseling as a teenager when his parents divorced.  The patient mentions that he had been close to his brother when they were growing up, but they drifted apart as adults.  Which of the following is the most likely diagnosis for this patient?

A 32-year-old man comes to the office for a routine annual examination and is accompanied by his wife.  He has no new medical problems, and the physical examination is unremarkable.  At the end of the visit, the patient's wife asks to speak with the physician and expresses concern that her husband was recently placed on probation for poor work performance.  Over the past few years, the patient has become increasingly irritable and less interested in his work as an insurance agent.  She says, "He misses work at least once a week because he stays up all night playing poker online and then sleeps in during the day.  He talks nonstop about his betting strategies and how clever they are."  The patient has lost a lot of money, and they have started borrowing from her parents to pay the bills.  The patient denies that he has any problems and says, "I've just been a little down these past few weeks.  I know I can be on top again if I just get out of this slump.  I'm one of the best poker players around."  Which of the following is the best explanation for this patient's behavior?

A 27-year-old woman is brought to the office by her husband due to anxiety.  The patient had an uncomplicated vaginal delivery a week ago and was discharged on postpartum day 2.  Her husband notes that she was "really nervous" after returning home.  The patient would watch the infant overnight to check for respirations and followed a strict feeding regimen.  At the first well-child visit, she expressed concerns about the newborn's weight but was told he had surpassed his birth weight and was healthy and doing well.  Despite this reassurance, the patient has continued to worry.  For the past 2 days, she has been pacing around the house, sleeping poorly, and eating minimally.  This morning, the husband found the patient mixing protein powder with formula due to concern that the infant was "shrinking."  The patient says, "I know my baby is sick, but the doctors won't tell me the truth.  They're trying to hurt my baby."  She has no psychiatric history.  Vital signs and physical examination are within normal limits.  The patient appears tearful and exhausted.  Which of the following is the most likely diagnosis?

A 76-year-old man is brought to the office by his daughter due to disruptive behavior.  Last night he behaved normally, took his regular medications, and retired to his bedroom shortly after dinner.  When the patient emerged an hour later, he was agitated, irritable, and confused.  When asked what was wrong, he became belligerent and seemed unable to recognize some family members.  The daughter describes similar episodes over the past 3 evenings.  Although the patient seems calmer and less confused this morning, the daughter worries that he will have another episode.  His medical history is significant for essential hypertension, benign prostatic hyperplasia, mild neurocognitive disorder, insomnia, and a recent increase in anxiety related to stock market losses.  Medications include terazosin and alprazolam.  A thorough physical examination is unremarkable, with no focal neurologic findings.  Laboratory evaluation, including complete blood count and serum electrolytes, is normal.  Which of the following is the most appropriate next step in management of this patient?

A 38-year-old woman is brought to the emergency department by her husband due to depression and difficulty caring for their 3-week-old son.  The husband came home from work and found the patient staring at the television and mumbling to herself while the baby cried in his crib in a soiled diaper.  He says that she has already lost all her pregnancy weight and frequently cries for no apparent reason.  The patient is exhausted because the baby keeps her up all night.  She admits to hearing voices sometimes but insists on going home and says, "Everything will be okay if I just get some sleep."  The patient has a history of bipolar disorder; she did not take medication during the pregnancy due to concerns about effects on the fetus.  On mental status examination, the patient is alert and speaks slowly and softly.  Her mood is depressed and her affect is blunted.  At one point, she stares into space and mumbles something before turning to the doctor and saying, "I am a terrible mother; I should not have brought a baby into this world."  The patient does not have suicidal ideation or intent.  Which of the following is the most appropriate course of action?

A 76-year-old woman comes to the office for a routine checkup.  Her medical history is significant for hypertension, type 2 diabetes mellitus, and hypothyroidism that are treated with oral agents.  The patient had a stroke a year ago and has mild residual weakness in the right arm.  Otherwise, she has no physical symptoms but is concerned about becoming more forgetful, especially because her mother died of Alzheimer disease.  She says, "Sometimes I can't remember people's names, and occasionally during conversations, I can't seem to find the right word."  The patient is widowed and lives alone.  She drives herself to the grocery store weekly and manages her own finances.  She describes her mood as "just okay," misses her husband, and regrets that she lives far from her children and grandchildren.  The patient plays cards with her close friends regularly and is looking forward to a trip to visit her family.  Her appetite is good, but she falls asleep earlier in the evening than before, awakening earlier in the morning and having less energy during the day.  Blood pressure is 135/76 mm Hg and pulse is 65/min.  Finger-stick glucose is 94 mg/dL and TSH is 2.4 µU/mL.  She scores 26/30 on the Montreal Cognitive Assessment.  Which of the following is the most likely diagnosis in this patient?

A 42-year-old woman is brought to the office by her husband due to worsening depression.  The husband reports that the patient has become increasingly withdrawn over the past month.  He says, "She abruptly quit her part-time job, stopped answering the phone, and rarely leaves the house now.  Over the past week, she stopped showering and wears the same t-shirt and sweatpants every day."  The patient has difficulty falling asleep and wakes up at 4:30 AM and is up for the rest of the day.  She has a history of 2 depressive episodes previously treated with fluoxetine and venlafaxine but currently takes no psychiatric medications.  Physical examination is remarkable for 4.53 kg (10 lb) weight loss.  Laboratory results are within normal limits.  On mental status examination, the patient whispers and is slow to respond.  She says, "My body is infected with worms."  She has no suicidal ideation but says, "I deserve to die; my body is decaying from the inside anyway."  Which of the following is the most appropriate treatment for this patient?

A 22-year-old man comes to the office for follow-up regarding anxiety.  The patient was referred for treatment by the student health service due to severe anxiety accompanied by sweaty palms and shaky voice, as well as blushing when meeting new people and giving oral presentations.  He was diagnosed with social anxiety disorder and started on fluoxetine 2 weeks ago.  Today, the patient reports that his anxiety in social situations has not improved and that he has started to feel uncharacteristically tense and jittery, "like I've had too much coffee."  He says, "If anything, my anxiety is worse than before, and I feel anxious most of the time."  The patient now has difficulty falling asleep.  He has no significant medical history.  The patient does not use illicit drugs.  Vital signs are stable, and physical examination is unchanged from the initial presentation.  Which of the following is the most appropriate next step in management of this patient?

A 27-year-old woman at 8 weeks gestation comes to the office for her first prenatal visit.  This is her first pregnancy; it was unplanned.  The patient lives alone and works part-time as a restaurant server.  She has a 5-year history of intravenous heroin use and says, "I've tried to quit before, but it was so hard.  I know drugs are bad for the baby, so I want to try again."  The patient uses heroin daily.  Her last injection was 6 hours ago.  She has no other chronic medical conditions and no known drug allergies.  Temperature is 37.2 C (99 F), blood pressure is 126/80 mm Hg, and pulse is 88/min.  Physical examination is notable only for needle marks on the patient's extremities.  Transvaginal ultrasonography reveals an intrauterine gestation and a heart rate of 150/min.  Which of the following is the best next step in management of this patient?

A 32-year-old man comes to the office due to erectile dysfunction and decreased libido for the past month.  The patient has never experienced these symptoms before and finds them to be very upsetting.  He has no problems with urination.  The patient has a history of schizophrenia and was discharged from a psychiatric hospital 3 months ago on risperidone.  He has no current delusions, and his auditory hallucinations have decreased in frequency and intensity.  His thoughts are well organized.  Review of systems is negative except for a recent 3-kg (6.6-lb) weight gain.  Physical examination shows bilateral breast enlargement.  Which of the following is the most likely mechanism responsible for this patient's decreased libido?

A 24-year-old woman is brought to the emergency department due to sudden-onset difficulty breathing.  She is preparing to defend her graduate school thesis at the end of the week.  The patient feels that she "can't get enough air" into her lungs.  Her fingertips have started tingling.  She has no pain.  Medical history includes allergic rhinitis and childhood eczema.  Medications include nasal fluticasone.  Temperature is 36.7 C (98 F), blood pressure is 110/76 mm Hg, pulse is 100/min, respirations are 20/min, and pulse oximetry is 99%.  On examination, she is taking deep breaths with occasional audible deep sighs.  The lungs are clear to auscultation.  Cardiac auscultation is normal.  Which of the following is the most appropriate treatment for this patient's condition?

A 63-year-old man is brought to the emergency department due to restlessness and altered mental status.  His wife reports that the patient awakened at 6:00 AM agitated and slightly confused.  Over the past 2 hours, his symptoms have worsened.  She states that he was well the previous day but went to his primary care doctor due to a persistent, dry cough for 3 weeks following an upper respiratory tract infection.  The patient was prescribed dextromethorphan and an albuterol inhaler.  He has a history of major depressive disorder that is well controlled with fluoxetine.  Temperature is 38.3 C (101 F), blood pressure is 160/90 mm Hg, pulse is 112/min, and respirations are 22/min.  Pulse oximetry is 100% on room air.  The patient is agitated and confused.  Pupils are dilated, and lungs are clear to auscultation bilaterally.  Hyperreflexia and ankle clonus are noted on neurological examination.  Which of the following is the most appropriate initial therapy for this patient?

A 15-year-old boy is brought to the office by his parents after he was caught shoplifting from an art supply store.  The patient's father says, "For the past 2 weeks, my son has been impossible to manage.  He has become loud, obnoxious, and rude.  He skips doing household chores and stays up all night drawing in his room."  The boy's mother received a phone call from his school last week after he told his teacher that she was "incompetent" and that he intended to drop out.  The patient tells the physician that he lives in "the most boring place in the world" and that his parents are jealous that he is "making a masterpiece that will be famous."  He has a history of a specific learning disorder with impairment in reading.  Family history is significant for depression in a cousin and alcohol abuse in a paternal aunt.  On mental status examination, the patient is easily distracted and struggles to sit still.  He speaks quickly and becomes irritable when the physician attempts to clarify what he is saying.  Routine laboratory tests are within normal range, and urine drug screen is negative.  Which of the following is the most likely explanation for this patient's behavior?

A 35-year-old man with a history of bipolar disorder since age 27 comes to the office for follow-up.  The patient was hospitalized 2 years ago for a manic episode and was discharged with a therapeutic dose of lithium; he continues to take the same dose and is engaged in weekly psychotherapy.  The patient says, "This is the best I've felt in years; work is going great, and I'm getting married in a few months.  I really don't want to get hospitalized again, but I also don't want to keep taking medication if I don't have to."  Prior medication trials include quetiapine and olanzapine with fluoxetine; both treatments were discontinued due to weight gain.  Medical history is noncontributory.  Vital signs and physical examination are unremarkable.  The patient appears euthymic and has a full range of affect.  Complete blood count, basic metabolic panel, and TSH are within normal limits; serum lithium level is within therapeutic range.  Which of the following is the most appropriate response to this patient?

A 55-year-old man is brought by ambulance to the emergency department due to acute-onset agitation.  While at work, the patient became angry during a meeting, throwing his laptop against a wall and accusing his coworkers of conspiring against him.  On arrival, he is diaphoretic with flushed skin and dilated pupils.  Temperature is 37.6 C (99.7 F), blood pressure is 150/90 mm Hg, pulse is 118/min, and respirations are 18/min.  Physical examination shows no other abnormalities.  ECG reveals sinus tachycardia and a prolonged QT interval.  The patient refuses to provide a urine specimen.  His voice becomes increasingly loud, and he is convinced that other patients are stealing money from him.  Administration of a medication with which of the following properties is the most appropriate initial treatment?

A 29-year-old man is brought to the emergency department by police after he broke into a radio station and started yelling about being a "child of nature destined to reverse global warming and save the planet."  He is initially cooperative with the nurse taking his vital signs but then starts pacing around the room and raising his arms with clenched fists, motioning toward the hospital staff.  His speech is rapid, loud, and difficult to interrupt.  Medical records indicate a history of depression treated with antidepressants and a hospitalization 2 years ago following a suicide attempt.  Temperature is 37 C (98.6 F), blood pressure is 142/85 mm Hg, pulse is 96/min, and respirations are 20/min.  Administering which of the following medications is the most appropriate initial step in pharmacological management of this patient?

A 55-year-old man is brought to the office due to unusual movements of his face and extremities.  He lives in a group home and was noted to be sticking out his tongue, smacking his lips, and twisting his body from side to side, actions that were disruptive to the other residents.  The patient has a history of schizoaffective disorder that has been treated with risperidone, fluoxetine, and clonazepam for more than 20 years.  Examination shows protruding and twisting movements of the tongue, dystonic postures of the neck, and squirming movements of the torso.  Which of the following is the most likely underlying cause of this patient's symptoms?

A 16-year-old boy comes to the office for an annual checkup before starting at a new school.  Vital signs, physical examination, and growth curves are within normal limits.  When asked if he is looking forward to starting school, the patient hesitates and says, "Doc, I really want to talk to you about something.  I've never really felt right being a boy.  I don't even like having a boy's body.  I wish I had been born a girl because I feel and think like girls do; I always have."  Last school year, the patient started skipping gym class due to feeling uncomfortable about changing in the boys' locker room.  The patient says, "I heard there might be ways to change my appearance, but I haven't discussed this with anyone yet."  In addition to providing support, which of the following is the best next step in management of this patient?

A 59-year-old man comes to the office due to worsening depression and insomnia since his wife died 7 months ago from cancer.  The patient is frequently tearful and is no longer interested in socializing with his married friends.  He has attended 3 sessions of supportive psychotherapy and expresses appreciation for the referral because he likes the therapist.  However, he continues to feel depressed and is now experiencing severe insomnia.  The patient has difficulty falling and staying asleep, frequently lying awake at night thinking about his wife.  He feels very guilty about her death and believes that he should have done more for her during her final months.  His appetite is poor and he says it is easier to buy prepared foods than cook for himself.  Last week, the patient experienced a moment of severe depression in which he briefly thought that he would be better off dead.  However, he insists that he would never act on these thoughts.  Vital signs are normal.  Physical examination is unremarkable aside from a 3.6-kg (8-lb) weight loss since his wife's death.  Which of the following is the most appropriate next step in management of this patient?