1. A 28-year-old man with a history of new-onset schizophrenia is brought by his mother to the health center for recent confusion and high fever. She states that his psychiatric symptoms had worsened recently until she took him to see a psychiatrist who started him on quetiapine (Seroquel) 2 weeks ago. On interview, the patient is confused about where he is and how he got there. His vitals are Temp 104.2°F, HR 106, RR 24, BP 150/88. What is the most likely diagnosis?

A. Akasthisia.
B. Tardive dyskinesia.
C. Dystonia.
D. Neuroleptic malignant syndrome.
E. Typical anticholinergic syndrome.

2. What investigation below should be ordered as part of the initial workup?

A. Electrolytes.
B. CPK.
C. Arterial blood gas.
D. Lumbar puncture.
E. Calcium level.

Answers. 1. D. The symptoms present in this patient that are characteristic of neuroleptic malignant syndrome (NMS) are fever and change in mental status in the setting of new neuroleptic medication. This strongly suggests medication-induced NMS.

2. B. Key labs in the workup of NMS include CBC, CPK, and transaminase levels.

3. You are seeing a patient in continuity whom you've previously placed on sertraline (Zoloft) for major depression. The patient has been on this medication for 6 weeks, and believes it is not working since he is still having suicidal thoughts. What treatment below is a poor choice for therapy?

A. Amitriptyline (Elavil).
B. Citalopram (Celexa).
C. Cenlafaxine (Effexor).
D. Escitalopram (Lexapro).
E. Electroconvulsive therapy.

Answer. 3. A. Amitriptyline (Elavil) is the worst choice listed due to its being a tricyclic antidepressant with fatal side effects on overdose including cardiovascular compromise. Since this patient has been suicidal in the past, prescription of this medication, with its relatively low lethal dose profile, would not be advisable.

4. A 32-year-old man comes to the mental health clinic stating he has had an excessively depressed mood for the past 6 months after switching jobs and moving to a new area. He states he has tended to stay in his home, does not know the neighbors, and reports sleeping and eating excessively. He states he has gained 30 lbs since the onset of symptoms and has no desire to wake in the morning, spending whole weekends in bed. What is the most likely diagnosis?

A. Adjustment disorder.
B. Major depression with catatonic symptoms.
C. Major depression with atypical features.
D. Major depression with melancholic features.
E. Bipolar II disorder.

Answer. 4. C. The patient describes depressed mood and anhedonia, which suggest a depressive disorder. He also describes weight gain from excessive caloric intake and hypersomnia, which are atypical features. Also, the time course of 6 months makes adjustment disorder less likely.

5. A 21-year-old man comes to the clinic after being started on quetiapine (Seroquel) for a new diagnosis of schizophrenia. He has since not been in contact with his prescriber but complains of new onset restlessness and states he now paces most of the day, which he's never done before. What is the next step in management of this patient?

A. Stopping his medication immediately.
B. Addition of sertraline (Zoloft).
C. Addition of amitriptyline (Elavil).
D. Change to clomipramine (Anafranil).
E. Addition of benztropine (Cogentin).

Answer. 5. E. The side effects described are typical of akasthisia and may be treated by temporary addition of benztropine (Cogentin) to the regimen. After approximately 1?2 weeks, this medication may be stopped and a trial of the neuroleptic alone may be attempted.

6. A 32-year-old female comes to the health center for a repeat evaluation for anorexia nervosa. She has been through extensive counseling and psychotherapy and now her family is pushing her to start medication. You review her history and assess her to be a candidate for medication. Which treatment below is contraindicated in this patient?

A. Sertraline (Zoloft).
B. Fluoxetine (Prozac).
C. Venlafaxine (Effexor).
D. Clomipramine (Anafranil).
E. Bupropion (Wellbutrin).

Answer. 6. E. The patient above has anorexia nervosa, which may be treated by many psychotropic medications except for bupropion (Wellbutrin) because of the possibility of lowering the seizure threshold.

7. A 23-year-old female is admitted to the hospital for cellulitis of the right arm. Soon after admission, she tells you that you're her favorite doctor and she feels a close bond with you. The more you talk she describes how certain nurses are horrible people and states that some nurses don't even follow orders when you're gone. This is an example of what psychiatric diagnosis?

A. Conduct disorder.
B. Histrionic personality disorder.
C. Antisocial personality disorder.
D. Borderline personality disorder.
E. Dependant personality disorder.

Answer. 7. D. The patient is demonstrating a very clingy disposition and, while she seems to love you, she hates some of the nursing staff, which is called "splitting." Borderline personality disorder patients also tend to be overly dramatic and threaten suicide regularly although few serious attempts are made. Purposeful cutting and self-mutilation also fit this personality type.

8. A 2-year-old boy is brought to you by his mother who has recently moved to the area and requests treatment for her son's autism. She states that her last physician had diagnosed him but recommended she seek treatment after the move. You search the child's medical records and confirm a neuropsychologic testing panel lending evidence to the diagnosis of autism. What is the next step in management of this child?

A. Start an SSRI as soon as possible.
B. Start bupropion as soon as possible.
C. Refer to an autistic therapy educational program at 4 years of age.
D. Refer to an autistic therapy educational program as soon as possible.
E. Watchful waiting for development and use of medications for any specific symptoms.

Answer. 8. D. Autism is a treatable disease although the earlier the treatment is begun, the better the outcome. Treatment is behavioral and educational in nature and is comprised of special classes and environments aimed at external stimulation. Medications may be helpful but very rarely used early on and only helpful to treat specific features such as depression.

9. A 37-year-old male comes to the mental health clinic reporting recent depressed mood and "flashbacks" to a mountain-climbing trip with his wife during which she was killed. He states he was present when her line broke and she fell to her death. For the last 3 weeks after the accident, he has felt horribly guilty, had thoughts of suicide, and can't seem to function in his daily life anymore. His nightmares of the incident prevent him from sleeping and when he is awake, he can't think of anything but the accident. What is the most likely diagnosis?

A. Posttraumatic stress disorder.
B. Acute stress disorder.
C. Major depressive episode.
D. Adjustment disorder.
E. Major depression.

10. What is the next step in management of this patient?

A. Screen for an active plan for suicide, assess means for suicide, and consider admission to the hospital.
B. Contract for safety with the patient, refer him to a mental health provider as an outpatient, and consider starting an SSRI.
C. Contract for safety with the patient and start an SSRI.
D. Contract for safety with the patient, call his closest family member and report your concerns and arrange close supervision, and start an SSRI.
E. Consider admission to the hospital, start an SSRI or electroconvulsive therapy, and initiate a court order for involuntary hold status since this patient is in danger of hurting himself.

Answers. 9. B. This patient is experiencing symptoms of acute stress disorder as indicated by the symptoms of posttraumatic stress disorder within 1 month of the event. Pervasive feelings of guilt, depression, impairment in life activities, and re-experiencing the event predominate. If these persist for greater than 1 month from the event, the diagnosis would change to PTSD.

10. A. The patient has stated he has thoughts of suicide and thus is a danger to himself. Screening him for a plan, assessing his means (availability of a gun at home, etc), and consideration of admission to the hospital are appropriate. Contracts for safety may or may not be helpful, depending on the patient but should never be relied upon for effect. SSRIs and many other psychotropic medications may take weeks for effect and should not be relied upon for short-term suicide prevention.