Diagnosis Schmiagnosis
9 yo F presents with various somatic complaints for the past 3-4 weeks, including mild headaches and stomachaches; however, no underlying medical cause for her symptoms have been identified. She has had periods of low mood and anxiety ever since her father was deployed overseas 2 months ago. She has been refusing to get up in the morning to attend school during the past week. She is experiencing this condition.
adjustment disorder
67 yo M was started on an as-needed anti-anxiety medication by his PCP. He found it helpful for anxiety but had side effects of dry mouth, urinary retention, and constipation. This receptor is likely being affected.
muscarinic acetylcholine receptor
14 yo M is brought to the ED after being found by his parents in his closet with his belt wrapped around his neck unconscious. He is tearful and remorseful about what happened. He does not have any past suicide attempts and promises “I’ll never do it again!” The physician in the ED decides that this is the appropriate disposition/level of care for the patient.
involuntary inpatient psychiatric hospitalization (aka IPLOC)
12 yo M presents to clinic with a broken arm and scrapes on his arms and knees. Initially he attributes these to an injury he sustained while playing sports. Later when speaking with you alone, he shares that when he misbehaves his mother physically punishes him and his siblings, and that this is how he actually broke his arm. He asks that you do not disclose that he shared this information, as he fears this will result in more harm to his siblings. As his physician, you recognize it your duty to this.
report to the proper authorities (file a 51A in MA)
47 yo F is brought to the ED by family after being found down at home. The pt struggles to remember what she was doing earlier today. On exam, she seems confused and has a broad-based gait and horizontal nystagmus. Her sister says they frequently bring her to the ED for issues related to her alcohol consumption, “but it’s never been this bad before!” Treating the patient with this medication may help reverse some of the symptoms she’s experiencing.
thiamine for Wernicke's encephalopathy
26 yo F reports monthly episodes of 4-5 days of lower abdominal cramping, vaginal bleeding, poor concentration, and increased appetite. She is able to go to work and fulfill her obligations but is not thrilled about it. She has a similar presentation at around the same time every month. These episodes most likely represent
normal menses (PMS also acceptable)
36 yo M is presents with several weeks of low mood, poor appetite, insomnia, low energy, and poor concentration. He’s interested in starting a medication for his symptoms, and he specifically asks that this medication help with putting him to sleep. You prescribe this medication that has a minimal risk for decreased libido.
mirtazapine, trazodone, or nefazodone
29 yo M is brought to the ED a witnessed seizure at home thought to be 2/2 alcohol withdrawal. His family asks that he be kept in the hospital on a section 12 because “he’ll kill himself drinking.” Pt denies depressed mood, SI, or any past suicide attempts. He wants to resume drinking but is otherwise future oriented and describes how he will seek help if feeling unwell or unsafe. Regarding a section 12, you make this decision.
not section 12'ing the patient
25 yo F presents to the ED for SI. You are the attending psychiatrist interviewing the pt in her room when suddenly she says, “if you don’t stop me, I’m going to walk out of this ED and then into the street to kill myself.” You try to verbally de-escalate the situation, but then she gets up out of her bed and starts walking toward the door. You make it a point to NOT do this.
laying hands on the patient or trying to physically keep the patient there yourself
27 yo M presents to the ED right leg paralysis, sudden onset a few hours ago. Medical work-up and imaging is unrevealing for any specific medical etiology that would explain his symptom. He reveals that a few nights ago, he was sexually assaulted outside of a bar. He says he feels that this is happening him because he failed to stand up for himself, and that God is punishing him for his sins. His symptoms are best explained by this diagnosis.
functional neurological disorder (aka conversion disorder)
32 yo F presents with difficulties completing tasks in a timely fashion due to her obsessive attention to detail. She can spend all day making lists and organizing her tasks but without making much progress on her projects. Her co-workers complain about her rigid and inflexible approach, but she feels how she does things is important for doing things “the right way.” She likely struggles with this disorder.
obsessive compulsive personality disorder (OCPD)
42 yo F has a history of many long episodes of depressed mood as well as a few episodes in her life in which she had elevated mood, increased interest in hobbies, rapid speech, and somewhat irresponsible spending habits, typically lasting 4-5 days. She was recommended this medication to help with her depressed mood but was told it needed to be titrated very slowly in order to reduce risk of this potentially life-threatening side effect.
lamotrigine and Stevens-Johnson Syndrome (SJS)
19 yo F BIB EMS after being found down by an empty bottle of her medications. Exam notable for confusion, dry mucous membranes, non-purposeful limb movements, and tremors. Her EKG shows tachycardia and widened QRS and prolonged QTc. She most likely overdosed on this medication.
tricyclic antidepressant (TCA)
A woman calls the inpatient psychiatric unit you’re working at and says her son is admitted to your unit. She provides his full legal name and date of birth, which matches up with a patient who is on your service. However, you look in his chart and there is no release of information (ROI) form signed for his mother. You decide to respond in this way.
Don't provide any patient information without an ROI
7 yo M brought by parents for evaluation of his eyes. Parents reports that the pt blinks them repeatedly. Pt cannot control the blinking, and that it appears worse at some times of the day compared to others. Pt also appears to clear his throat frequently. These behaviors occur several times per day and are getting worse over time. Nose and throat appear normal on exam. Pt is doing well at school but sometimes struggles with completing his homework due to his symptoms. He likely has this disorder.
Tourette syndrome
58 yo M comes to see his PCP. He refuses any vaccinations or medications that you recommend due to concerns about big pharma. He shares that throughout his life he has struggled to maintain long-term relationships or jobs because others have “betrayed or exploited him.” He recently has had trouble sleeping due to hearing tapping noises from his ceiling and is convinced that his upstairs neighbors are intentionally trying to keep him awake. He can also faintly hear them speaking and fears they are speaking ill of him. He most likely has this disorder.
paranoid personality disorder
28 yo F w/ past history of a 2 week-long episode of impulsive spending, staying up all night reading scripture, and thinking that she is the 2nd coming of Christ. She has been stable on a medication but is concerned because she is interested in having a baby. Her doctor made sure to check her kidney function and thyroid hormones and counseled her about this potential birth defect.
Ebstein anomaly
35 yo M presents to the ED with flushing, sweating, tremor, and myoclonic jerk. He has a history of severe MDD that has not gotten better despite a few different medication trials. His psychiatrist recently had him switch to a new antidepressant. This issue could have potentially been avoided if the psychiatrist had done this.
waiting at least 2 weeks before starting the MAOI (aka washout period)
24 yo M presents with 3 weeks of low mood, low energy, poor appetite, insomnia, hopelessness, and voices telling him he’s worthless. He’s interested in pharmacotherapy for his symptoms. Before you prescribe anything, you make sure to counsel the patient about these 4 things to get informed consent.
reason for treatment, risks and benefits, reasonable alternatives, risks of refusing treatment
27 yo F is hospitalized due to severe hypokalemia of unknown etiology. She reports extreme fatigue, diffuse body pains, and depressed mood. She expresses that she is very distressed and concerned about an undiagnosed chronic medical issue. This is her 4th admission this year for a similar presentation. During her hospitalization, a staff member walked in on her biting into her IV line that was providing K+ repletion. She lives with her boyfriend. He provides collateral that she works as a nurse and was recently disciplined for pocketing HCTZ that was meant for a patient. Her presentation is most consistent with this disorder.
factitious disorder
54 yo M frequently gets hospitalized for episodes of euphoric mood, high energy, rapid speech, decreased need for sleep, grandiose delusions, and command auditory hallucinations. Today, he presents to the ED with auditory hallucinations but otherwise reports a normal mood and has a euthymic affect. His urine tox screen is pan-negative. He likely has this diagnosis.
schizoaffective disorder, bipolar type
27 yo F seen in clinic after recent hospitalization for increase in AH, paranoia, and delusions. She is stable on a new medication but reports significant weight gain and sedation. Her psychiatrist considers switching to this medication with lower risk of weight gain but greater risk for QTc prolongation.
ziprasidone
72 yo F presents to the ED due to confusion and agitation at her senior home. She’s found to be febrile and hypotensive, and her UA shows presence of bacteria, WBC’s, and LE’s. While admitted, she continues to be very confused, agitated, and is starting to get violent with nursing staff. You order this treatment that is most vital to improving her cognition and shortening her hospital stay.
antibiotics for her likely UTI (i.e. treat the underlying cause of delirium)
68 yo M admitted to the hospital for chest pain is offered a CABG for his cardiac ischemia. His team consults psych for a capacity evaluation because the pt “has a flat affect.” You evaluate and make sure that the patient meets these 4 criteria for having capacity to make his own medical decisions.
Communication of a clear/consistent choice, relevant information regarding treatment is understood, appreciate the appropriate weight and impact of the decision, and manipulation of information a rationale manner
60 yo M presents with a few years of gradually worsening inattention, impulsivity, and ability to start and complete tasks. His daughter says his memory seems fine, but he seems to struggle with word finding and understanding when she’s speaking to him. She also feels he has been colder and more apathetic lately. The patient recalls that his father had experienced something similar at around the same age. He is likely suffering from this disease.
frontotemporal dementia (FTD)