A 40-year-old woman on lithium 900 mg/day presents with nausea, coarse tremor, and diarrhea. Her lithium level is 1.7 mmol/L. She is awake, oriented, and without neurological decline. What should you do next?

A 28-year-old man has recurrent panic attacks leading to multiple ER visits. He requests benzodiazepines as his main treatment and fears future attacks. What is the most appropriate long-term management plan?

A 33-year-old patient taking clozapine 350 mg/day develops fever and sore throat. Blood work shows ANC = $$0.8 x10^9/L$$ . What is the most appropriate action?

A 45-year-old patient on valproate presents with abdominal pain, nausea, and vomiting. Lipase levels are significantly elevated. What is the best next step?

A patient with major depressive disorder has been on maximum-dose sertraline for 10 weeks with minimal benefit, and adherence is confirmed. What should you do next?

A patient with known bipolar disorder presents with elevated mood, reduced sleep, irritability, and racing thoughts. He is currently taking fluoxetine. What is the immediate management priority?

A 29-year-old man with schizophrenia has had three relapses this year, each time after forgetting oral medication. He is otherwise cooperative. What is the most appropriate next step?

A 70-year-old postoperative patient becomes acutely confused, with fluctuating attention, fever, and mild dehydration. What is the first priority in management?

A 27-year-old woman treated for GAD with escitalopram has been stable for 9 months. She now wants to discontinue treatment. What is the best recommendation?

A 36-year-old man on sertraline 150 mg/day reports good mood improvement but severe sexual dysfunction. He prefers to continue antidepressant treatment. What is the most appropriate adjustment?

A 54-year-old woman with schizophrenia is severely agitated. Her ECG shows QTc 530 ms. Which is the safest immediate option?

A 48-year-old man with alcohol dependence presents with tremors, agitation, and one withdrawal seizure. What is the most appropriate acute management?

A 62-year-old woman with severe depression and psychomotor retardation relapses after previously responding well to ECT. What is the best treatment now?

A highly aggressive inpatient refuses medication and lacks decision-making capacity, posing risk to staff. What is the immediate appropriate action?

A patient on carbamazepine develops ataxia and slurred speech. A serum level is markedly elevated. What is the next step?

A woman 10 days postpartum presents with paranoia, disorganized thinking, and inability to care for her newborn. What is the most urgent management step?

A chronic pain patient requests early opioid refills and states the medication 'isn't working anymore.' What should you assess next?

A stable methadone maintenance patient is moving to another city. What is the appropriate management plan?

A child with ADHD on methylphenidate has delayed sleep onset despite improved daytime behavior. What is the best adjustment?

A patient on lithium develops elevated TSH but remains psychiatrically stable with a therapeutic lithium level. What is the best approach?

A patient with OCD on maximum-dose SSRI has only partial improvement. What is the next evidence-based step?

A patient with anorexia nervosa (BMI 14) has bradycardia and low electrolytes. What is the immediate priority?

A patient with PTSD has persistent nightmares despite SSRI treatment and trauma-focused psychotherapy. What should be added?

A patient on long-term antipsychotic therapy develops tardive dyskinesia. What is the most appropriate adjustment?

A patient on high-dose SSRI complains of emotional numbness and reduced motivation. What is the next step?

A patient with borderline personality disorder presents with chronic self-harm, instability, and emotional reactivity. What is the most effective long-term treatment?

A depressed patient on venlafaxine reports persistent insomnia that is functionally impairing. What is the best option?

A patient with bipolar disorder experiences recurrent depressive episodes despite mania being controlled. What medication is best for preventing bipolar depression?

A patient on antipsychotic therapy refuses to undergo metabolic monitoring (lipids, glucose). What is the best approach?

A patient develops painful neck stiffness and upward eye deviation one day after IM haloperidol. What is the immediate treatment?

A patient on lithium develops vomiting and diarrhea after a gastrointestinal illness. What is the best next step?

A severely depressed patient with suicidal ideation shows minimal improvement after 3 weeks of SSRI therapy. What is the best next intervention?

A first-episode psychosis patient states he wants to stop all medication because he feels back to normal. What should he be counseled about?

A patient on clozapine reports severe nighttime drooling that disturbs sleep. What is the best management?

A patient with alcohol use disorder has completed detoxification and is committed to staying sober. Which medication best prevents relapse?

A patient with panic disorder avoids exercise because physical sensations trigger panic. What psychotherapy is most suitable?

A patient recently had his aripiprazole dose increased and now reports extreme inner restlessness. What is the best adjustment?

A bipolar patient stabilized on valproate is upset about significant weight gain. What is the most appropriate alternative?

A child on stimulant therapy for ADHD develops worsening motor tics.

A patient with moderate depression refuses medications. What psychotherapy is most evidence-based?

A patient frequently presents with multiple somatic complaints and requests repeated investigations. What is the best physician approach?

A patient in acute manic agitation refuses oral medication and is a danger to staff. What is the preferred pharmacologic intervention?

A patient on risperidone develops hyperprolactinemia and sexual dysfunction. What is the most appropriate adjustment?

A patient newly started on an SSRI complains of nausea and insomnia during the first week. What is the best advice?

A patient with GAD remains anxious before presentations despite stable response to SSRI. What is the best adjunctive option?

A patient on olanzapine gains 12 kg in 5 months and is distressed. What is the next step?

A patient has been taking clonazepam daily for a year and wants to discontinue it. What is the safest approach?

A patient with dementia becomes confused and agitated every evening. What is the first-line approach?

A patient with contamination OCD refuses to touch objects in the room and avoids contact with surfaces. Which intervention is most effective?