Psychiatry Linked-item Set (Vignette)

Part 1
The 44-year-old, wealthy, married businessman shown in the video exhibit is referred for psychiatric evaluation by his couples therapist (James) because of a recent change in behavior. For the past several months, he has been buying expensive artwork, his attendance at work has become increasingly erratic, and he is sleeping only one to two hours each night. Nineteen years ago, he was hospitalized for a serious manic episode involving the police. He was stabilized on lithium carbonate for the next 18 years. About one year prior to this visit, laboratory tests showed that his creatinine clearance had fallen to less than 50% of normal. The lithium carbonate was discontinued, and the patient, now very distrustful of all medications, reluctantly agreed to take divalproex, 1000 mg per day.

Sample Questions

Answers are in bold below.

1. The patient demonstrates which of the following phenomena? (Choose three)

Flight of ideas
Paranoid delusions
Inflated self-esteem
Interpersonal connectedness
Pressured speech
Ruminative thinking

2. Which of the following disorders are most likely in the differential diagnosis? (Choose two)

Schizophrenia
Substance abuse disorder
Obsessive-compulsive disorder
Brief psychotic disorder
Bipolar disorder

3. Which of the following steps should the psychiatrist consider next? (Choose two)

Offer the patient an appointment for the next month
Obtain consent for collateral history
Contact the referring colleague for collateral history
Refer the patient for drug rehabilitation
Refer the patient for group therapy

4. After a medical evaluation, which of the following medications are appropriate for the patient at this time? (Choose two)

Fluoxetine
Olanzapine
Alprazolam
Gabapentin
Carbamazepine

Please read Part 2

Part 1 (repeat)
The 44-year-old, wealthy, married businessman shown in the video exhibit is referred for psychiatric evaluation by his couples therapist (James) because of a recent change in behavior. For the past several months, he has been buying expensive artwork, his attendance at work has become increasingly erratic, and he is sleeping only one to two hours each night. Nineteen years ago, he was hospitalized for a serious manic episode involving the police. He was stabilized on lithium carbonate for the next 18 years. About one year prior to this visit, laboratory tests showed that his creatinine clearance had fallen to less than 50% of normal. The lithium carbonate was discontinued, and the patient, now very distrustful of all medications, reluctantly agreed to take divalproex, 1000 mg per day.

Part 2
After initial evaluation, he is placed on carbamazepine. The patient also agrees to add treatment with 10 mg olanzapine and has significant improvement with sleep and overall functioning.

After the patient’s mania has become well managed with the combination of carbamazepine and olanzapine, he continues to be followed on a weekly basis and is gradually moved to monthly follow-up visits following a return to baseline. Three months after he has returned to baseline euthymia, he returns to the clinic.

5. At 12 weeks, the patient requests to stop medication, reporting a lack of creativity and cognitive slowing. Which of the following interventions are clinically appropriate? (Choose two)

Hospitalize the patient
Stop olanzapine
Transition the patient back to divalproex
Check carbamazepine levels
Suggest a medication-free period

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