Exam 3: Psychiatry

A 33-year-old woman comes to the office due to weight gain and low self-confidence.  She says, "I've always had trouble with my weight and mood swings.  I've gained 11 pounds [5 kg] in the last 2 years and feel horrible about myself.  I go through this cycle in which I feel good, stick to a diet, and exercise for a couple of weeks, but then my mood gets really down.  I start eating junk food and feel bloated until I get my period."  The patient is also upset about a recent fight with her best friend, saying "I blame myself because I am much more irritable before my period, and I lashed out at her for no reason.  The following week I felt much better, but the damage was done."  The patient has struggled with moodiness and being overweight for most of her adult life.  She says, "I hate when I feel this way because, generally, I'm a pretty upbeat person."  Physical examination and laboratory evaluation are unremarkable.  BMI is 29 kg/m².  Which of the following is the most likely diagnosis?

A 15-year-old girl comes to the office with her mother for follow-up 1 week after a prolonged hospitalization for an acute asthma exacerbation.  The patient is taking inhaled albuterol and an oral corticosteroid, and her respiratory symptoms have improved significantly.  Her mother states that since hospital discharge, the girl has been acting strangely.  She is "talking over people instead of listening" and is unable to sit still.  The patient also has started to ignore requests to complete her daily chores and has been refusing dinner because she is "too busy" with organizing a school club for environmental protection.  She says she has been under a lot of pressure due to upcoming final exams but now feels "better than ever," explaining how she will have more time to "save the oceans and Mother Earth" after she is done studying.  The patient has a history of depression and takes sertraline.  She has used marijuana occasionally but does not use tobacco, alcohol, or other illicit drugs.  Vital signs are within normal limits, and cardiopulmonary examination shows no abnormalities.  The patient appears impatient and checks her watch frequently throughout the evaluation.  Which of the following is the most likely diagnosis?

A 58-year-old woman comes to the office due to abdominal pain.  The patient describes a long-standing history of abdominal discomfort characterized by intermittent episodes of cramping, bloating, and nausea.  She describes the pain as severe and disabling but has difficulty describing its quality or location.  There is no clear relationship to eating or specific foods.  Neither rectal bleeding nor melena is present.  The patient has seen 2 other physicians over the past year for similar symptoms but felt that her concerns were not taken seriously.  During review of systems, she reports headaches, fatigue, muscle weakness, joint pain, urinary frequency, anxiety, and insomnia.  She also reports losing 2.3 kg (5.1 lb) over the past year by following a low-calorie diet.  The patient does not use alcohol or drugs.  Vitals signs are stable.  Abdominal examination shows mild, diffuse abdominal tenderness to palpation that improves when she is distracted.  Physical examination is otherwise unremarkable.  Laboratory testing, including complete blood count, comprehensive metabolic panel, lipase, Helicobacter pylori testing, TSH, and a CT scan of the abdomen, is negative.  When discussing the test results with the patient, which of the following is the most appropriate initial statement by the physician?

A 5-year-old boy is brought to the office by his aunt for evaluation of behavioral concerns.  The patient was placed with the aunt 4 months ago due to physical abuse and neglect by his parents.  His teacher is concerned that he does not follow directions, rarely participates during group activities, and does not respond to praise.  Last week, the patient hit a classmate after being asked to share the book he was reading.  The aunt says, "He seems to get upset for no reason at times and usually starts throwing and breaking things.  I'm trying my best and want him to know he's loved, but it feels like nothing I do helps."  Vital signs are within normal limits; growth curves are tracking adequately and consistently.  The patient is sitting on the floor playing with various toys.  Physical examination shows no abnormalities.  He makes eye contact and answers questions briefly before turning away to play by himself.  Affect is indifferent with constricted range.  Which of the following is the most likely diagnosis?

A 33-year-old woman comes to the office for "help losing weight."  She says, "I'm really trying, but I haven't seen any results."  The patient has been on restrictive diets that cut out various food groups but gained 5 pounds in the past month.  She feels "defeated" and says, "Nothing I try works.  I end up feeling sorry for myself, and before I know it, I've eaten an entire cake.  Even though I feel disgusting afterward, I still do it a few times a week."  She reports no difficulty with sleep, energy, or concentration.  The patient has been avoiding meals with friends and family because of embarrassment about overeating.  Medical history is insignificant.  Mental status examination reveals an overweight woman wearing loose clothing.  She is cooperative and has a reactive affect.  Treatment options are discussed, and the patient prefers to start medication.  Which of the following medications would be most appropriate for this patient?

A 22-year-old man is brought to the emergency department by his girlfriend after sustaining a hand injury.  The two were waiting for a table at a crowded bar when the hostess inadvertently seated another couple that was behind them in line.  The patient suddenly became enraged, started pacing back and forth, shouted at the hostess that she was "stupid and incompetent," and threw a nearby chair against the wall, causing damage to the wall and injuring his own hand.  He is remorseful about his behavior, but his girlfriend says, "He can be moody, frequently gets defensive, and loses his temper with the slightest provocation."  They have had several heated arguments during which he has thrown and broken objects.  The patient has no medical history.  Physical examination is unremarkable except for swelling and lacerations of the hand.  Which of the following is the most likely diagnosis in this patient?

A 22-year-old man is brought to the emergency department by his roommate for evaluation of "weird behavior."  Eight days ago, the patient's father died in a car accident.  Since then, the patient has been sleeping poorly and eating minimally.  His roommate says, "He's been keeping all the lights off in the apartment.  Yesterday when I walked in, he was sitting alone in the dark and whispering as if someone else was there.  When I switched on the lights, he immediately closed his eyes and covered his ears."  The roommate reports that the patient is studying computer science and has been on the honor roll every semester, but for the past week, he has not gone to class or spent time with friends.  As an adolescent, the patient was treated for a depressive episode shortly after his parents divorced.  He has no significant medical history and does not take any medications.  Vital signs are normal and physical examination is unremarkable.  On mental status examination, he appears unkempt and hypervigilant.  His responses are short and unrelated to the questions being asked.  Which of the following is the most likely diagnosis?

An 11-year-old girl is brought to the office by her mother after getting suspended from her new school for pushing a peer while waiting in line at the cafeteria.  The patient has had a history of behavioral concerns since first grade and was suspended once before for talking back to her teacher.  Her mother reports that the patient has always had a lot of energy and "needs to be active to stay out of trouble."  The patient requires frequent prompting to complete homework assignments and forgets to do her chores.  The mother states, "My daughter doesn't think before she speaks or acts, but this is the first really bad thing she has done this year.  Her dog died last month, and she's been pretty upset.  I have bipolar disorder, and I know what it's like to be down."  Vital signs are within normal limits.  Height and weight are consistently tracking at the 70th percentile.  On examination, the patient is cooperative, mildly restless, and talkative.  She says her mood is "fine" and that she "hates school because it's so boring."  In further discussion of this patient's diagnosis and treatment options, which of the following responses by the physician is most appropriate?

A 27-year-old man comes to the office due to daily anxiety and poor sleep that have been worsening over the last year.  He has particular difficulty sleeping on the nights leading up to his weekly staff meeting due to worry that he will say something stupid or embarrassing.  He says, "It's just so difficult for me to relax at those meetings even though I am always well prepared.  I'm also worried about having to attend a family reunion next month."  Although the patient's work performance is good, he recently turned down a promotion that would have required him to interact more regularly with clients.  He is experiencing no depression, difficulty concentrating, or appetite disturbance.  The patient formerly used alcohol daily to calm his nerves but now drinks once a week.  Medical history is insignificant.  Blood pressure is 110/70 mm Hg, pulse is 82/min, and respirations are 18/min.  On mental status examination, the patient sighs frequently and has a tense appearance and poor eye contact.  He is reluctant to consider psychotherapy and requests medication to help him relax.  Which of the following is the most appropriate pharmacotherapy?

A 23-year-old man is brought to the office by his parents due to concerns that he has become increasingly depressed and withdrawn over the past year.  The patient dropped out of college in his senior year because of failing grades.  Since returning to live with his parents, he broke up with his girlfriend and stopped going out with his friends.  His father says, "It's frustrating because he refuses to go back to school and just seems to be wasting time.  He sits in his room all day."  His mother reports that for the past few months, he has been watching the same videos over and over, telling her multiple times that he is "checking for signals and listening for messages from secret channels."  The patient says, "I'm fine.  I don't know why everyone's upset."  His appetite, sleep, and energy level are normal.  He does not use alcohol or illicit drugs.  Physical examination and laboratory evaluation are unremarkable.  On mental status examination, the patient is cooperative and appears anxious.  He avoids eye contact and shows little emotion.  His answers are very brief, and he asks if the interview is being secretly recorded.  The patient has no suicidal ideation or hallucinations.  Which of the following is the most likely diagnosis?

A 32-year-old man comes to the office for evaluation of attention-deficit hyperactivity disorder (ADHD).  Although never treated, he had behavioral problems starting in kindergarten, frequently getting into trouble both at school and at home for not listening, talking out of turn, and inability to sit still.  Many of these difficulties persisted throughout high school and college.  The patient continues to struggle with distractibility, forgetfulness, disorganization, and impulsivity.  He is concerned that ADHD is affecting his relationships and work performance and mentions that he has been passed over for promotion several times.  The patient has a history of alcohol and cocaine use disorder from age 18-24 and a family history of alcohol and opioid abuse in his father and paternal uncle.  The patient does not use alcohol or any illicit drugs.  He hopes that medication can help but is concerned about taking anything addictive.  Which of the following is the most appropriate next step in management of this patient?

A 7-year-old boy is brought to the office by his mother for a routine checkup.  Medical history is significant for 2 upper respiratory tract infections this past year but is otherwise normal.  Family history includes hypertension in his father and bipolar disorder in a maternal aunt.  Physical examination is normal, but the mother says that her son's behavior has been difficult to manage over the past year.  "He is always running around (even during dinner), does not listen, and keeps his room a mess.  He is always bothering his younger brother, interrupting him when he talks, and taking his toys without asking.  He is unable to follow a morning routine to get ready for school, and he frequently misses the bus as a result."  The mother also reports difficulty at school.  The boy's second-grade teacher has reported that he cannot sit still, answers questions impulsively and out of turn, and becomes irritable when she redirects him.  The physician recommends a trial of methylphenidate.  Which of the following side effects is the patient most likely to experience while taking this medication?

A 23-year-old woman comes to the office for follow-up after a recent hospitalization.  The patient had no known psychiatric history prior to being arrested by police 2 months ago after breaking into city hall to "find evidence of a secret organization plotting to take over the world."  When police officers took her into custody, she was speaking so rapidly that they had difficulty understanding her.  She was subsequently hospitalized and prescribed appropriate treatment; symptoms improved, and she was discharged 2 weeks later.  Since then, the patient has been taking medications as prescribed.  She is "doing much better" and has no symptoms.  Vital signs are within normal limits and physical examination is unremarkable.  The patient's speech is regular in rhythm and rate and she appears calm.  She is fully oriented and does not appear distracted.  Laboratory studies are unremarkable except for serum calcium of 13.4 mg/dL.  This patient is most likely taking which of the following medications?

A 39-year-old woman comes to the emergency department with sudden right leg weakness.  The patient's medical history is significant for gastroesophageal reflux disease, which provokes occasional heartburn after meals despite medication therapy.  She does not use tobacco, alcohol, or illicit drugs.  The patient's husband of 20 years recently died suddenly in a car accident.  Blood pressure is 120/70 mm Hg, pulse is 82/min, and respirations are 12/min.  She has mild epigastric discomfort on palpation, but the rest of the abdominal examination is within normal limits.  Neurological examination shows normal muscle tone, normal deep-tendon reflexes, and no Babinski sign in the extremities.  The patient cannot lift her right leg off the bed while supine and is very worried that something is wrong.  She is able to stand without assistance from a sitting position and her gait is without abnormalities.  Which of the following is the most likely diagnosis?

A 42-year-old man is brought to the emergency department by police officers after he was found wandering aimlessly at an airport.  The man is alert and answers questions appropriately; however, he appears to be confused about his identity and does not recognize the name on his Nevada driver's license in his wallet.  Extensive inquiry fails to reveal any helpful information as the patient is perplexed and does not remember where he lives, how he got to the airport, his family members, or his profession.  His cognitive function is otherwise intact.  A search of his personal belongings reveals an airline ticket from Las Vegas to Arlington, Virginia.  An emergency contact on the patient's phone leads to his wife in Nevada, who reports that her husband "just disappeared" after he found out that his father had passed away that morning.  Physical examination, routine laboratory values, and brain CT scan are unremarkable, and a urine toxicology screen is negative.  Which of the following is the most likely diagnosis?

A 52-year-old man comes to the office because of increasing fatigue and poor concentration at work over the past month.  The patient is a biology professor at a local university.  He reports that he has been through a "tough year" because his 19-year-old son died of a heroin overdose 6 months ago and his book was recently rejected for publication.  He sleeps 12-14 hours a day but does not feel well rested.  He is frequently late for his morning office hours because it is difficult for him to get out of bed.  He says, "I'm so distracted at work I forget what I've already lectured on and end up repeating myself."  The patient has stopped exercising and socializing with friends, saying, "After work, all I want to do is go straight home and get back into bed."  Physical examination shows no abnormalities.  Mental status examination shows a tired, strained appearance and sad mood.  He has no suicidal ideation.  Which of the following is the most likely diagnosis?

A 35-year-old man comes to the office due to sexual symptoms.  The patient has normal libido and erectile function but has uncontrollable orgasm within a minute of vaginal penetration during intercourse.  His symptoms started 6 months ago after his wife gave birth to their second child.  The patient says his symptoms are distressing and are leading to considerable frustration in his relationship with his wife.  Medical history and examination are unremarkable.  Which of the following is the most appropriate next step in management of this patient's sexual symptoms?

A 20-year-old college student comes to the office due to anxiety.  She is very worried because she has an important presentation coming up in a few weeks and is afraid that "everyone will see how anxious I am."  The patient reports that she had to leave in the middle of her last presentation because her heart suddenly began racing, her voice started to crack, and her face turned bright red.  The patient says school has been stressful due to a heavy class load.  She recently ended a relationship with her boyfriend of 6 months but feels supported by her friends.  She drinks alcohol and uses marijuana socially.  Family history is significant for anxiety, depression, and alcohol dependence in her mother.  Blood pressure is 134/82 mm Hg, pulse is 86/min, and respirations are 12/min.  Physical examination is unremarkable.  Mental status examination shows an initially tense patient who relaxes as the interview progresses.  The patient requests medication to help with her symptoms.  Which of the following is the most appropriate pharmacotherapy for this patient?

A 37-year-old man comes to the emergency department for evaluation of back pain.  The patient was seen 2 days ago in the emergency department for similar pain symptoms and was discharged on naproxen.  Medical history is significant for asthma, hepatitis C, and opioid use disorder.  Temperature is 37.2 C (99 F), blood pressure is 138/92 mm Hg, and pulse is 104/min.  The patient is irritable while his vital signs are being taken and angrily says to the nurse, "That medication I got was useless.  My pain is now 10 times worse."  His speech is very loud, filled with expletives, and disruptive to patients in adjacent rooms.  His fists are clenched.  Which of the following is the most appropriate next step in management of the patient interview?

A 33-year-old man comes to the office with his wife due to marital difficulties.  His wife says, "I came back from a work trip last week, and now my husband is convinced I'm having an affair with my coworker."  She says that he is constantly demanding to look at her phone and has grabbed it from her several times.  The husband says that he has always struggled with his temper, that he shouts with little provocation and his moods go up and down throughout the day.  His wife asks if medication would help "balance him out."  She describes how he binges on alcohol "every few months" when he feels low.  He has had 2 minor car crashes while intoxicated and bought expensive cars after each one, which resulted in significant debt.  Prior to their marriage 2 years ago, the patient had multiple short-lived relationships, each of which ended abruptly.  He says, "My ex-girlfriends were terrible-they never cared about me."  The patient expresses remorse for upsetting his wife and begs her not to leave him.  Which of the following is the most likely diagnosis?