A 45-year-old man presents to a psychiatrist by his wife with recent behavioral and emotional changes. The patient’s wife says that her husband’s personality has completely changed over the last year. She also says that he often complains of unpleasant odors when actually there is no discernible odor present. The patient mentions that he is depressed at times while on other occasions, he feels like he is ‘the most powerful man in the world.’ The psychiatrist takes a detailed history from this patient and concludes that he is most likely suffering from a psychotic disorder. However, before prescribing an antipsychotic medication, he recommends that the patient undergoes brain imaging to rule out a brain neoplasm. Based on the presence of which of the following clinical signs or symptoms in this patient is the psychiatrist most likely recommending this imaging test?
Q2
A 24-year-old man is brought to your emergency department under arrest by the local police. The patient was found naked at a busy intersection jumping up and down on top of a car. Interviewing the patient, you discover that he has not slept in 2 days because he does not feel tired. He reports hearing voices. The patient was previously hospitalized 1 year ago with auditory hallucinations, paranoia, and a normal mood. What is the most likely diagnosis?
Q3
A 25-year-old woman presents to the psychiatric emergency department in restraints. She was found trying to break into a deli at midnight. The patient claims that she has an idea that will revolutionize the shipping industry. The patient is not violent but seems highly agitated and is speaking very rapidly about her ideas. She is easily distractible and tells you about many of her other ideas. She has a past medical history of depression and hypertension refractory to treatment. Her current medications include captopril, ibuprofen, and melatonin. A neurological exam is deferred due to the patient's current status. Her pulmonary and cardiovascular exams are within normal limits and mild bilateral bruits are heard over her abdomen. The patient is given haloperidol and diphenhydramine and spends the night in the psychiatric inpatient unit. The patient is started on long-term therapy and is discharged 3 days later. At a follow up visit at her primary care physician, the patient is noted to have a blood pressure of 150/100 mmHg. She is started on chlorthalidone and instructed to return in 3 days. When the patient returns her blood pressure is 135/90 mmHg. She exhibits a fine tremor, and complains of increased urinary frequency. Her pulse is 47/minute, and she is afebrile. Which of the following is the best next step in management?
Q4
A 34-year-old male presents to clinic today complaining that his medication has stopped working. He states despite being able to manage the side effects, a voice has returned again telling him to hurt his Mother. You prescribe him a drug which has shown improved efficacy in treating his disorder but requires frequent followup visits. One week later he returns with the following lab results: WBC : 2500 cells/mcL, Neutrophils : 55% and, Bands : 1%. What drug was this patient prescribed?
Q5
A 24-year-old woman is brought to the emergency department by her roommate because of bizarre behavior and incoherent talkativeness for the past week. Her roommate reports that the patient has been rearranging the furniture in her room at night and has ordered a variety of expensive clothes online. The patient says she feels “better than ever” and has a lot of energy. She had absence seizures as a child and remembers that valproate had to be discontinued because it damaged her liver. She has been otherwise healthy and is not taking any medication. She is sexually active with her boyfriend. She does not smoke, drink alcohol, or use illicit drugs. Physical and neurologic examinations show no abnormalities. Her pulse is 78/min, respirations are 13/min, and blood pressure is 122/60 mm Hg. Mental status examination shows pressured and disorganized speech, flight of ideas, lack of insight, and affective lability. Which of the following is the best initial step before deciding on a therapy for this patient's condition?
Q6
A 24-year-old woman is brought to the hospital by her mother because she has "not been herself" for the past 3 months. The patient says she hears voices in her head. The mother said that when she is talking to her daughter she can’t seem to make out what she is saying; it is as if her thoughts are disorganized. When talking with the patient, you notice a lack of energy and an apathetic affect. Which of the following is the most likely diagnosis for this patient?
Q7
A 50-year-old man is brought to his neurologist by his wife for bizarre behavior. On several occasions over the last several days, he had started to complain about ‘bunnies, tigers, and emus’ in the living room. The patient has a history of multiple sclerosis and was last seen by his primary neurologist 2 weeks ago for complaints of new left upper extremity weakness. On physical exam, his temperature is 37.0°C (98.6°F), the heart rate is 70/min, the blood pressure is 126/78 mm Hg, the respiratory rate is 16/min, and the oxygen saturation is 98% on room air. The exam is disrupted by the patient’s repeated comments about various animals in the exam room. His neurologic exam is unchanged from his neurologist's last documented exam. The basic metabolic panel is as follows:
Na+ 138 mEq/L
K+ 3.9 mEq/L
Cl- 101 mEq/L
HCO3- 24 mEq/L
BUN 10 mg/dL
Cr 0.6 mg/dL
Glucose 356 mg/dL
Which of the following is the most likely etiology of this patient's presentation?
Q8
A 79-year-old woman who lives alone is brought to the emergency department by her neighbor because of worsening confusion over the last 2 days. Due to her level of confusion, she is unable to answer questions appropriately. She has had type 2 diabetes mellitus for 29 years for which she takes metformin. Vital signs include: blood pressure 111/72 mm Hg, temperature 38.5°C (101.3°F), and pulse 100/min. Her fingerstick blood glucose is 210 mg/dL. On physical examination, she is not oriented to time or place and mistakes the nursing assistant for her cousin. Laboratory results are shown:
Hemoglobin 13 g/dL
Leukocyte count 16,000/mm3
Segmented neutrophils 70%
Eosinophils 1%
Basophils 0.3%
Lymphocytes 25%
Monocytes 4%
Which of the following is the most likely diagnosis?
Q9
A 27-year-old woman is brought to the office at the insistence of her fiancé to be evaluated for auditory hallucinations for the past 8 months. The patient’s fiancé tells the physician that the patient often mentions that she can hear her own thoughts speaking aloud to her. The hallucinations have occurred intermittently for at least 1-month periods. Past medical history is significant for hypertension. Her medications include lisinopril and a daily multivitamin both of which she frequently neglects. She lost her security job 7 months ago after failing to report to work on time. The patient’s vital signs include: blood pressure 132/82 mm Hg; pulse 72/min; respiratory rate 18/min, and temperature 36.7°C (98.1°F). On physical examination, the patient has a flat affect and her focus fluctuates from the window to the door. She is disheveled with a foul smell. She has difficulty focusing on the discussion and does not quite understand what is happening around her. A urine toxicology screen is negative. Which of the following is the correct diagnosis for this patient?
Q10
A 23-year-old man presents to the emergency department with a chief complaint of being assaulted on the street. The patient claims that he has been followed by the government for quite some time and that he was assaulted by a government agent but was able to escape. He often hears voices telling him to hide. The patient has an unknown past medical history and admits to smoking marijuana frequently. On physical exam, the patient has no signs of trauma. When interviewing the patient, he is seen conversing with an external party that is not apparent to you. The patient states that he is afraid for his life and that agents are currently pursuing him. What is the best initial response to this patient’s statement?
Psychosis due to medical conditions US Medical PG Practice Questions and MCQs
Question 1: A 45-year-old man presents to a psychiatrist by his wife with recent behavioral and emotional changes. The patient’s wife says that her husband’s personality has completely changed over the last year. She also says that he often complains of unpleasant odors when actually there is no discernible odor present. The patient mentions that he is depressed at times while on other occasions, he feels like he is ‘the most powerful man in the world.’ The psychiatrist takes a detailed history from this patient and concludes that he is most likely suffering from a psychotic disorder. However, before prescribing an antipsychotic medication, he recommends that the patient undergoes brain imaging to rule out a brain neoplasm. Based on the presence of which of the following clinical signs or symptoms in this patient is the psychiatrist most likely recommending this imaging test?
A. Olfactory hallucinations (Correct Answer)
B. Echolalia
C. Anhedonia
D. Delusions of grandeur
E. Thought broadcasting
Explanation: ***Olfactory hallucinations***
- The presence of **olfactory hallucinations** ("unpleasant odors when actually there is no discernible odor present") in the context of new-onset psychotic symptoms and personality changes, particularly in a middle-aged adult, raises suspicion for an underlying **structural brain lesion**, such as a **frontal or temporal lobe tumor**.
- Brain neoplasms in these regions can irritate cortical areas, leading to atypical psychotic symptoms and these specific types of hallucinations, making imaging crucial before initiating antipsychotic therapy.
*Echolalia*
- **Echolalia** is the involuntary repetition of words or phrases spoken by another person, often associated with conditions like **autism spectrum disorder**, **Tourette's syndrome**, or severe **psychotic disorders**, particularly **schizophrenia**.
- While it can be a feature of psychiatric illness, it is not a red flag for structural brain pathology in the same manner as new-onset olfactory hallucinations.
*Anhedonia*
- **Anhedonia** is the inability to experience pleasure from activities usually found enjoyable, a prominent symptom of **major depressive disorder** and other mood disorders, as well as some psychotic disorders.
- Although the patient reports feeling "depressed at times," anhedonia is a common psychiatric symptom and does not specifically point to a need for urgent brain imaging in the absence of other alarming features.
*Delusions of grandeur*
- **Delusions of grandeur** are false beliefs that one is much greater or more powerful than they truly are, as described by the patient feeling like "the most powerful man in the world." This symptom is characteristic of **bipolar disorder (manic episodes)** or some **psychotic disorders**.
- While present in this patient, grandiose delusions are part of the core symptomatology of many psychiatric conditions and, by themselves, do not typically necessitate brain imaging to rule out a tumor.
*Thought broadcasting*
- **Thought broadcasting** is the belief that one's thoughts are being transmitted into the minds of others, a classic **first-rank symptom of schizophrenia**.
- This symptom is indicative of a severe thought disorder within the spectrum of psychotic illnesses but does not specifically raise the suspicion of an underlying brain lesion requiring neuroimaging.
Question 2: A 24-year-old man is brought to your emergency department under arrest by the local police. The patient was found naked at a busy intersection jumping up and down on top of a car. Interviewing the patient, you discover that he has not slept in 2 days because he does not feel tired. He reports hearing voices. The patient was previously hospitalized 1 year ago with auditory hallucinations, paranoia, and a normal mood. What is the most likely diagnosis?
A. Schizophrenia
B. Bipolar disorder
C. Brief psychotic disorder
D. Schizotypal disorder
E. Schizoaffective disorder (Correct Answer)
Explanation: ***Schizoaffective disorder***
- This patient demonstrates the **hallmark feature** of schizoaffective disorder: **psychotic symptoms occurring both during AND independent of mood episodes**.
- **Current presentation**: Clear **manic episode** (decreased need for sleep, grandiose/disinhibited behavior, psychomotor agitation) with psychotic features (auditory hallucinations).
- **Previous hospitalization**: **Psychotic symptoms (hallucinations, paranoia) in the absence of a mood episode** ("normal mood"), requiring hospitalization for at least 2 weeks - this is the **key diagnostic criterion** for schizoaffective disorder.
- The diagnosis requires an **uninterrupted period of illness** with both psychotic symptoms (meeting Criterion A for schizophrenia) and a major mood episode, PLUS psychotic symptoms for **≥2 weeks without prominent mood symptoms**.
*Bipolar disorder*
- In bipolar disorder with psychotic features, psychotic symptoms occur **exclusively during mood episodes** (manic, hypomanic, or depressive).
- This patient's previous hospitalization with psychosis but **"normal mood"** indicates psychotic symptoms independent of mood episodes, which **rules out** bipolar disorder and points to schizoaffective disorder.
- While the current presentation shows mania with psychosis, the longitudinal course is critical for diagnosis.
*Schizophrenia*
- Schizophrenia involves **continuous psychotic symptoms** without prominent mood episodes dominating the clinical picture.
- This patient has **prominent manic symptoms** (decreased sleep, grandiose behavior, agitation) that are central to the current presentation, making schizophrenia less likely.
- The presence of full mood episodes that occupy a **substantial portion** of the illness duration favors schizoaffective disorder over schizophrenia.
*Brief psychotic disorder*
- Brief psychotic disorder involves psychotic symptoms lasting **<1 month** with full return to baseline functioning.
- This patient has a **recurrent course** with hospitalization 1 year ago, indicating a chronic/recurring condition rather than a brief, self-limited episode.
*Schizotypal disorder*
- This is a **personality disorder** characterized by social deficits, cognitive/perceptual distortions, and eccentric behavior, but **NOT overt psychotic episodes**.
- Does not involve acute psychotic breaks with severe symptoms like hallucinations requiring hospitalization or manic episodes.
Question 3: A 25-year-old woman presents to the psychiatric emergency department in restraints. She was found trying to break into a deli at midnight. The patient claims that she has an idea that will revolutionize the shipping industry. The patient is not violent but seems highly agitated and is speaking very rapidly about her ideas. She is easily distractible and tells you about many of her other ideas. She has a past medical history of depression and hypertension refractory to treatment. Her current medications include captopril, ibuprofen, and melatonin. A neurological exam is deferred due to the patient's current status. Her pulmonary and cardiovascular exams are within normal limits and mild bilateral bruits are heard over her abdomen. The patient is given haloperidol and diphenhydramine and spends the night in the psychiatric inpatient unit. The patient is started on long-term therapy and is discharged 3 days later. At a follow up visit at her primary care physician, the patient is noted to have a blood pressure of 150/100 mmHg. She is started on chlorthalidone and instructed to return in 3 days. When the patient returns her blood pressure is 135/90 mmHg. She exhibits a fine tremor, and complains of increased urinary frequency. Her pulse is 47/minute, and she is afebrile. Which of the following is the best next step in management?
A. Ultrasound of the renal arteries (Correct Answer)
B. Maintain current medication regimen
C. Increase captopril dose
D. Change diuretics
E. Increase chlorthalidone dose
Explanation: ***Ultrasound of the renal arteries***
- The presence of **bilateral abdominal bruits** and **refractory hypertension** in a young woman despite multiple medications (captopril, chlorthalidone) strongly suggests **renovascular hypertension**, likely due to **fibromuscular dysplasia**.
- **Renal artery stenosis** is an important cause of secondary hypertension that requires investigation. Ultrasound of the renal arteries is the appropriate first-line non-invasive investigation to assess for renal artery stenosis.
- While the new symptoms (tremor, bradycardia, polyuria) are concerning for **lithium side effects** or toxicity (likely the "long-term therapy" started for bipolar disorder), potentially exacerbated by the thiazide diuretic chlorthalidone, the underlying **secondary hypertension must still be evaluated** to optimize long-term management.
- Among the available options, investigating the cause of refractory hypertension is the priority.
*Maintain current medication regimen*
- The patient's blood pressure remains suboptimally controlled at 135/90 mmHg.
- Furthermore, the new symptoms (tremor, bradycardia, increased urinary frequency) suggest possible medication side effects that require investigation, not simply maintenance of the current regimen.
*Increase captopril dose*
- Increasing the dose of an **ACE inhibitor** (captopril) in a patient with suspected **bilateral renal artery stenosis** can lead to acute kidney injury due to critical reduction in glomerular filtration pressure.
- This would not address the underlying cause of secondary hypertension or the new symptoms.
*Change diuretics*
- While simply changing diuretics does not address the strong clinical suspicion for **renovascular hypertension** indicated by bilateral abdominal bruits in a young patient with refractory hypertension.
- The underlying secondary cause must be investigated first before making empiric medication changes.
*Increase chlorthalidone dose*
- Increasing the thiazide dose might marginally lower blood pressure but does not address the potential underlying **renovascular hypertension**.
- Additionally, thiazide diuretics can **increase lithium levels** by reducing renal clearance, and increasing the dose could worsen potential lithium toxicity (explaining the tremor, bradycardia, and polyuria).
Question 4: A 34-year-old male presents to clinic today complaining that his medication has stopped working. He states despite being able to manage the side effects, a voice has returned again telling him to hurt his Mother. You prescribe him a drug which has shown improved efficacy in treating his disorder but requires frequent followup visits. One week later he returns with the following lab results: WBC : 2500 cells/mcL, Neutrophils : 55% and, Bands : 1%. What drug was this patient prescribed?
A. Clozapine (Correct Answer)
B. Lurasidone
C. Olanzapine
D. Chlorpromazine
E. Haloperidol
Explanation: ***Clozapine***
- **Clozapine** is an atypical antipsychotic known for its superior efficacy in **treatment-resistant schizophrenia**, which fits the patient's presentation of a recurrence of symptoms despite prior medication.
- The given lab results (WBC 2500 cells/mcL, Neutrophils 55%, Bands 1%) show signs of **neutropenia**, a severe side effect of clozapine that necessitates frequent monitoring of complete blood counts (CBCs).
*Lurasidone*
- **Lurasidone** is an atypical antipsychotic, but it is not typically considered a first-line treatment for treatment-resistant cases and does not carry the same risk of agranulocytosis requiring frequent CBC monitoring as clozapine.
- It would not explain the **observed neutropenia** and the need for frequent follow-up for blood work.
*Olanzapine*
- While **olanzapine** is an effective atypical antipsychotic, it is not uniquely indicated for treatment-resistant cases in the same way clozapine is, nor does it typically require the intensive hematological monitoring.
- Its main severe side effects are metabolic (e.g., weight gain, dyslipidemia), not **neutropenia** that would manifest in these lab results.
*Chlorpromazine*
- **Chlorpromazine** is a first-generation antipsychotic and, while effective, is not known for superior efficacy in treatment-resistant cases compared to clozapine and has a different side effect profile.
- It can cause **agranulocytosis** but is not the drug of choice for treatment-resistant schizophrenia and its side effect profile does not align.
*Haloperidol*
- **Haloperidol** is a potent first-generation antipsychotic, effective for acute psychosis, but less effective for negative symptoms and carries a high risk of extrapyramidal side effects.
- It is not typically chosen for treatment-resistant cases and does not cause the specific hematological issues seen in the lab results that would necessitate weekly follow-up for blood counts.
Question 5: A 24-year-old woman is brought to the emergency department by her roommate because of bizarre behavior and incoherent talkativeness for the past week. Her roommate reports that the patient has been rearranging the furniture in her room at night and has ordered a variety of expensive clothes online. The patient says she feels “better than ever” and has a lot of energy. She had absence seizures as a child and remembers that valproate had to be discontinued because it damaged her liver. She has been otherwise healthy and is not taking any medication. She is sexually active with her boyfriend. She does not smoke, drink alcohol, or use illicit drugs. Physical and neurologic examinations show no abnormalities. Her pulse is 78/min, respirations are 13/min, and blood pressure is 122/60 mm Hg. Mental status examination shows pressured and disorganized speech, flight of ideas, lack of insight, and affective lability. Which of the following is the best initial step before deciding on a therapy for this patient's condition?
A. Obtain CBC, liver function studies, and beta-HCG
B. Obtain TSH, β-hCG, and serum creatinine concentration (Correct Answer)
C. Obtain BMI, HbA1c, lipid levels, and prolactin levels
D. Perform urine drug testing and begin cognitive behavior therapy
E. Assess for suicidal ideation and obtain echocardiography
Explanation: ***Obtain TSH, β-hCG, and serum creatinine concentration***
- This patient presents with symptoms highly suggestive of **mania** (bizarre behavior, incoherent talkativeness, grandiosity, increased energy, pressured speech, flight of ideas). Before initiating treatment, it's crucial to rule out other medical conditions that can **mimic mania**, such as **hyperthyroidism** (TSH), **pregnancy** (β-hCG), or **kidney dysfunction** (creatinine), which can impact medication choice and dosage.
- TSH levels are essential as **hyperthyroidism** can cause symptoms like agitation, rapid speech, and increased energy, mimicking mania. A **pregnancy test (β-hCG)** is critical for women of childbearing age to ensure that any potential psychiatric medications are safe for both the mother and fetus. **Serum creatinine** helps assess kidney function, which is important for dosing many psychotropic medications eliminated by the kidneys.
*Obtain CBC, liver function studies, and beta-HCG*
- While a **β-hCG** is appropriate, **CBC** and **liver function studies (LFTs)** are typically obtained if there are specific concerns for anemia, infection, or liver damage (which the patient mentions about valproate in childhood, but there's no immediate indication for current LFTs before diagnosis confirmation).
- Although LFTs are important for certain antidepressant or mood stabilizer monitoring (e.g., valproate, carbamazepine), they are not the most immediate initial screen for ruling out medical mimics of mania in this context as **TSH** and **renal function** are more critical.
*Obtain BMI, HbA1c, lipid levels, and prolactin levels*
- These tests are important for **monitoring long-term metabolic side effects** of certain antipsychotics and mood stabilizers, but they are not the best initial steps for ruling out acute medical causes of manic symptoms.
- **BMI, HbA1c, and lipid levels** are typically assessed *after* diagnosis and initiation of treatment to establish a baseline for future metabolic monitoring. **Prolactin levels** might be checked if there is concern for hyperprolactinemia, which is a side effect of some antipsychotics, but not usually a cause of acute mania.
*Perform urine drug testing and begin cognitive behavior therapy*
- While **urine drug testing** is often performed in acute psychiatric presentations to rule out substance-induced mania, it is not listed as the *best initial step* alone, as other medical conditions also need to be ruled out concurrently.
- **Cognitive behavioral therapy (CBT)** is not an appropriate initial treatment for acute mania due to the patient's severe symptoms, lack of insight, and disorganized thought processes. **Pharmacotherapy** is the cornerstone of acute mania management.
*Assess for suicidal ideation and obtain echocardiography*
- Assessing for **suicidal ideation** is crucial in every psychiatric evaluation, but it is a mental status component rather than a diagnostic lab test. While important for patient safety, it doesn't rule out medical mimics of mania.
- **Echocardiography** is not indicated in the initial work-up of acute mania unless there are specific cardiac symptoms or a history that suggests underlying heart disease.
Question 6: A 24-year-old woman is brought to the hospital by her mother because she has "not been herself" for the past 3 months. The patient says she hears voices in her head. The mother said that when she is talking to her daughter she can’t seem to make out what she is saying; it is as if her thoughts are disorganized. When talking with the patient, you notice a lack of energy and an apathetic affect. Which of the following is the most likely diagnosis for this patient?
A. Major depressive disorder
B. Schizophrenia
C. Brief psychotic disorder
D. Schizotypal disorder
E. Schizophreniform disorder (Correct Answer)
Explanation: ***Schizophreniform disorder***
- The patient exhibits core **psychotic symptoms** (hearing voices, disorganized thoughts) for a duration of **3 months**, which is characteristic of schizophreniform disorder (symptoms lasting **1 to 6 months**).
- Her **lack of energy** and **apathetic affect** align with the negative symptoms commonly seen in psychotic disorders.
*Major depressive disorder*
- While **lack of energy** and **apathetic affect** can be present, the prominent **hallucinations** (hearing voices) and **disorganized thoughts** are not primary features of major depressive disorder.
- A diagnosis of depression alone would not fully account for her psychotic symptoms.
*Schizophrenia*
- Schizophrenia requires symptoms to be present for **at least 6 months**, including at least one month of **active phase symptoms**. This patient's symptoms have only been present for 3 months.
- While the symptoms are consistent with schizophrenia, the **duration criterion** has not yet been met.
*Brief psychotic disorder*
- Brief psychotic disorder is characterized by psychotic symptoms lasting **less than 1 month**. This patient's symptoms have been ongoing for 3 months.
- The chronicity of symptoms makes this diagnosis unlikely.
*Schizotypal disorder*
- Schizotypal disorder is a **personality disorder** characterized by peculiar thoughts and behaviors, but typically **without overt psychotic episodes** or pronounced disorganized speech/hallucinations as described.
- While there may be odd beliefs or ideas of reference, the clear **auditory hallucinations** and **thought disorder** in this case point to a more severe psychotic condition.
Question 7: A 50-year-old man is brought to his neurologist by his wife for bizarre behavior. On several occasions over the last several days, he had started to complain about ‘bunnies, tigers, and emus’ in the living room. The patient has a history of multiple sclerosis and was last seen by his primary neurologist 2 weeks ago for complaints of new left upper extremity weakness. On physical exam, his temperature is 37.0°C (98.6°F), the heart rate is 70/min, the blood pressure is 126/78 mm Hg, the respiratory rate is 16/min, and the oxygen saturation is 98% on room air. The exam is disrupted by the patient’s repeated comments about various animals in the exam room. His neurologic exam is unchanged from his neurologist's last documented exam. The basic metabolic panel is as follows:
Na+ 138 mEq/L
K+ 3.9 mEq/L
Cl- 101 mEq/L
HCO3- 24 mEq/L
BUN 10 mg/dL
Cr 0.6 mg/dL
Glucose 356 mg/dL
Which of the following is the most likely etiology of this patient's presentation?
A. Medication side effect
B. Metabolic abnormality (Correct Answer)
C. Recreational drug intoxication
D. Progression of neurologic disease
E. Primary psychiatric illness
Explanation: ***Metabolic abnormality***
- The patient's **blood glucose of 356 mg/dL** indicates significant hyperglycemia, a common cause of acute mental status changes, including **delirium** and **hallucinations**.
- This **metabolic derangement** is the most likely driver of his "bizarre behavior" and visual hallucinations of animals, especially given the acuteness of the presentation.
*Medication side effect*
- While many medications, including those for MS symptoms, can cause mental status changes, there is **no specific medication mentioned** or recent change in regimen to support this as the primary cause.
- The **elevated glucose** provides a more direct and evident cause for the observed symptoms compared to an unstated medication side effect.
*Recreational drug intoxication*
- There is **no information or clinical sign** in the vignette suggesting recreational drug use.
- While drug intoxication can cause hallucinations, the presence of **severe hyperglycemia** points to a clear alternative etiology.
*Progression of neurologic disease*
- Although the patient has MS and new weakness, his **neurologic exam is noted as unchanged** from two weeks prior, and his bizarre behavior is not typical for an MS exacerbation or progression.
- MS progression usually presents with **worsening focal neurological deficits** rather than isolated, acute psychiatric symptoms like visual hallucinations without other corresponding neurological changes.
*Primary psychiatric illness*
- The **acute onset** of symptoms, described as "bizarre behavior" and visual hallucinations, in a patient with no prior psychiatric history, makes a primary psychiatric illness less likely.
- The presence of a significant **metabolic abnormality (hyperglycemia)** provides a more plausible organic cause for the symptoms.
Question 8: A 79-year-old woman who lives alone is brought to the emergency department by her neighbor because of worsening confusion over the last 2 days. Due to her level of confusion, she is unable to answer questions appropriately. She has had type 2 diabetes mellitus for 29 years for which she takes metformin. Vital signs include: blood pressure 111/72 mm Hg, temperature 38.5°C (101.3°F), and pulse 100/min. Her fingerstick blood glucose is 210 mg/dL. On physical examination, she is not oriented to time or place and mistakes the nursing assistant for her cousin. Laboratory results are shown:
Hemoglobin 13 g/dL
Leukocyte count 16,000/mm3
Segmented neutrophils 70%
Eosinophils 1%
Basophils 0.3%
Lymphocytes 25%
Monocytes 4%
Which of the following is the most likely diagnosis?
A. Brief psychotic disorder
B. Alzheimer's dementia
C. Delirium (Correct Answer)
D. Depression
E. Delusional disorder
Explanation: **Delirium**
- The patient presents with **acute-onset confusion**, **disorientation** to time and place, and **misidentification of individuals**, all fluctuating symptoms characteristic of delirium.
- The presence of **fever** (38.5°C), **leukocytosis** (16,000/mm³ with neutrophilia), and **hyperglycemia** (210 mg/dL) suggests an underlying acute medical condition (e.g., infection) as a precipitating factor for delirium in a vulnerable elderly patient with diabetes.
*Brief psychotic disorder*
- This disorder is characterized by the sudden onset of **psychotic symptoms** (e.g., delusions, hallucinations, disorganized speech) lasting less than 1 month, but it is not typically associated with an acute medical illness or systemic signs like fever and leukocytosis.
- While the patient exhibits confusion, the clinical picture points more strongly to an acute organic cause rather than a primary psychiatric disorder.
*Alzheimer's dementia*
- Alzheimer's dementia typically manifests as a **gradual, progressive decline** in cognitive function over months to years, not an acute change in mental status over 2 days.
- Although advanced dementia can present with confusion and disorientation, the acute onset, fluctuating nature, and signs of an underlying infection make delirium more likely.
*Depression*
- Depression in the elderly can sometimes cause **cognitive slowing** or **"pseudodementia,"** but it does not typically present with acute disorientation, fever, or leukocytosis.
- The patient's presentation is more consistent with an acute confusional state rather than altered mood or anhedonia associated with depression.
*Delusional disorder*
- Delusional disorder involves **persistent, non-bizarre delusions** without other prominent psychotic symptoms or significant impairment in functioning, typically developing over a longer period.
- The patient's global confusion, disorientation, and acute medical signs are inconsistent with a primary delusional disorder.
Question 9: A 27-year-old woman is brought to the office at the insistence of her fiancé to be evaluated for auditory hallucinations for the past 8 months. The patient’s fiancé tells the physician that the patient often mentions that she can hear her own thoughts speaking aloud to her. The hallucinations have occurred intermittently for at least 1-month periods. Past medical history is significant for hypertension. Her medications include lisinopril and a daily multivitamin both of which she frequently neglects. She lost her security job 7 months ago after failing to report to work on time. The patient’s vital signs include: blood pressure 132/82 mm Hg; pulse 72/min; respiratory rate 18/min, and temperature 36.7°C (98.1°F). On physical examination, the patient has a flat affect and her focus fluctuates from the window to the door. She is disheveled with a foul smell. She has difficulty focusing on the discussion and does not quite understand what is happening around her. A urine toxicology screen is negative. Which of the following is the correct diagnosis for this patient?
A. Schizoaffective disorder
B. Schizophrenia (Correct Answer)
C. Schizoid personality disorder
D. Schizophreniform disorder
E. Schizotypal personality disorder
Explanation: ***Schizophrenia***
- The patient exhibits core symptoms of schizophrenia, including **auditory hallucinations** (hearing thoughts speaking aloud), **disorganized thinking** (difficulty focusing, fluctuating focus), and **negative symptoms** (flat affect, disheveled, foul smell, loss of job due to poor function). These symptoms have been present for **at least 6 months** (8 months of hallucinations, 7 months of job loss), which meets the diagnostic criteria.
- The duration of symptoms (over 6 months) differentiates it from schizophreniform disorder, and the absence of prominent mood episodes rules out schizoaffective disorder.
*Schizoaffective disorder*
- This diagnosis requires a **major mood episode** (depressive or manic) concurrent with Criterion A of schizophrenia, along with a period of **at least 2 weeks of delusions or hallucinations in the absence of prominent mood symptoms**.
- While the patient has some signs of distress (lost job, disorganized), a full major mood episode is not described, and the primary symptoms are clearly psychotic.
*Schizoid personality disorder*
- This is characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression, often appearing indifferent to praise or criticism.
- The patient's symptoms are primarily psychotic (hallucinations, disorganized thought), not just social withdrawal or emotional flatness. She doesn't necessarily avoid social contact, but her psychosis interferes with it.
*Schizophreniform disorder*
- This disorder presents with symptoms identical to schizophrenia but with a **duration of at least 1 month but less than 6 months**.
- The patient's symptoms, particularly the auditory hallucinations, have been present for 8 months and are therefore outside the timeframe for schizophreniform disorder.
*Schizotypal personality disorder*
- This disorder involves a pervasive pattern of **social and interpersonal deficits** marked by acute discomfort with, and reduced capacity for, close relationships, as well as **cognitive or perceptual distortions** and eccentric behaviors.
- While there may be some odd beliefs or magical thinking, **full-blown psychotic symptoms like prominent auditory hallucinations** (hearing thoughts speaking aloud) are generally not present as consistently or severely as seen in this patient, who meets criteria for a major psychotic disorder.
Question 10: A 23-year-old man presents to the emergency department with a chief complaint of being assaulted on the street. The patient claims that he has been followed by the government for quite some time and that he was assaulted by a government agent but was able to escape. He often hears voices telling him to hide. The patient has an unknown past medical history and admits to smoking marijuana frequently. On physical exam, the patient has no signs of trauma. When interviewing the patient, he is seen conversing with an external party that is not apparent to you. The patient states that he is afraid for his life and that agents are currently pursuing him. What is the best initial response to this patient’s statement?
A. I think you are safe from the agents here.
B. You have a mental disorder but don’t worry we will help you.
C. I don’t think any agents are pursuing you.
D. What medications are you currently taking?
E. It sounds like you have been going through some tough experiences lately. (Correct Answer)
Explanation: ***It sounds like you have been going through some tough experiences lately.***
- This response **acknowledges the patient's distress** and experience without validating or refuting their delusional beliefs.
- It helps establish **rapport** and encourages the patient to share more about their symptoms, which is crucial for assessment in a psychiatric emergency.
*I think you are safe from the agents here.*
- While intended to reassure, directly addressing the delusion can be perceived as dismissive and may **escalate the patient's paranoia** or agitation.
- It does not validate their *feelings* of fear, which are real to them, even if the source is delusional.
*You have a mental disorder but don’t worry we will help you.*
- This statement is **confrontational** and judgmental, labeling the patient immediately with a diagnosis.
- This approach can cause the patient to become defensive, shut down, or feel stigmatized, making further assessment and trust-building very difficult in the **initial interaction**.
*I don’t think any agents are pursuing you.*
- Directly **challenging a patient's delusion** is generally unhelpful in acute settings and can lead to increased agitation.
- It invalidates their subjective reality and can make them feel misunderstood or distrustful of the healthcare provider.
*What medications are you currently taking?*
- While important information, asking about medications is too premature as an *initial response* to a patient expressing severe paranoia and fear.
- This question comes across as dismissive of their current emotional state and **prioritizes medical history over emotional support** and rapport-building.
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