CASE STUDY 1: A 45-year-old man comes to see his primary care physician with a

chief complaint of fatigue lasting for the past 9 months. The man says he goes to sleep
easily enough but then wakes up repeatedly throughout the night. He has had this
problem since he was injured on the job 9 months ago. On questioning, he reports low
mood, especially regarding not being able to do his job.
He states that his alcohol consumption is 6 to 12 beers a day, as well as several ounces of
hard liquor to “take the edge off the pain.” He says that it takes more alcohol than it used
to “get me relaxed.” The patient claims he has experienced several blackouts caused by
drinking during the past 2 months.
He admits that he often has a drink of alcohol first thing in the morning to keep him from
feeling shaky. Despite receiving several reprimands at work for tardiness and poor
performance, and his wife threatening to leave him, he has been unable to stop drinking.
On his mental status examination, the patient is alert and oriented to person, place, and
time. He appears rather haggard, but his hygiene is good. His speech is of normal rate and
tone, and he is cooperative with the physician. His mood is noted to be depressed, and his
affect is congruent, although full range. Otherwise, no abnormalities are noted.
1. What is the most likely diagnosis for this patient?

2. What are some of the medical complications resulting from this disorder? 

CASE STUDY 2:
Twelve hours after a surgical admission because of broken arm, a
42-year-old woman begins to complain of feeling jittery and shaky.
Six hours later, she tells staff members that she is hearing the voice
of a dead relative shouting at her, although on admission she
denied ever having heard voices previously.
She complains of an upset stomach, irritability, and sweatiness.
Her vital signs are: blood pressure 150/95 mm Hg, pulse rate
120/min, respirations 20/min, and temperature 100.0°F (37.8°C).
The patient reports no prior, significant medical problems and says
that she takes no medications.
She has not had prior complications due to general anesthesia.
1　What is the most likely diagnosis?

2　What is the next step in the treatment of this disorder?

Case study3:
A 42-year-old woman presents to a primary care physician with a
chief complaint of back pain for the past 6 months that began after
she was knocked down by a man attempting to elude the police.
She states that she has extreme pain on the right side of her lower
back, near L4 and L5. The pain does not radiate, and nothing
makes it better or worse. She says that since the injury she has
been unable to function and spends most of her days lying in bed
or sitting up, immobile, in a chair. Immediately after the accident,
she was taken to an emergency department where a workup
revealed back strain but no fractures. Since then, the patient has
repeatedly sought help from a variety of specialists, but the
ongoing pain has been neither adequately explained nor relieved.
She denies other medical problems, although she mentions a past
history of domestic violence that resulted in several visits to the
emergency department for treatment of bruises and lacerations.
On mental status examination, the patient is alert and oriented to
person, place, and time. She is cooperative and maintains good eye
contact. She holds herself absolutely still, sitting rigidly in her
chair and grimacing when she has to move even the smallest
amount. Her mood is depressed, and her affect is congruent. Her
thought processes are log- ical, and her thought content is negative
for suicidal or homicidal ideation, delusions, or hallucinations.
I．What is the most likely diagnosis for this patient?
 II．What is the best approach for this patient?
CASE STUDY 4:
A 41-year-old nurse presents to the emergency department with
concerns that she has hypoglycemia from an insulinoma. She
reports repeated episodes of headache, sweating, tremor, and
palpitations. She denies any past medical problems and only takes
nonsteroidal anti-inflammatory medications for menstrual cramps.
On physical examination, she is a well-dressed woman who is
intelligent, polite, and cooperative. Her vital signs are stable except
for slight tachycardia.
The examination is remarkable for diaphoresis, tachycardia, and
numerous scars on her abdomen, as well as needle marks on her
arms. When asked about this, she says that she feels confused
because of her hypoglycemia.
The patient is subsequently admitted to the medical service.
Laboratory evaluations demonstrate a decreased fasting blood
sugar level and an increased insulin level, but a decreased level of
plasma C-peptide, which indicates exogenous insulin injection.
When she is confronted with this information, she quickly becomes
angry, claims the hospital staff is incompetent, and requests that
she be discharged against medical advice.
1. What is the most likely diagnosis?

2. How should you best approach this patient?

Case study 5:
A 28-year-old woman presents to her primary care physician with
a chief complaint of a headache that “will not go away.” The
patient states that she had a headache every day for the past month
and that she obtained relief only by lying down in a darkened
room. The pain radiates through her head to the back. Tylenol with
codeine helps somewhat but does not completely alleviate the pain.
The patient notes that she had these headaches for “at least a
decade,” along with frequent chest pains, back pains, and
abdominal pains. She reports vomiting and diarrhea, most
commonly occurring with the abdominal pain but sometimes in
isolation. She notes that she vomited throughout her one and only
pregnancy at age 24. The patient states that along with the
headaches and abdominal pains she sometimes experiences
numbness and tingling in her upper arms. She has been to see
neurologists, obstetricians, and other primary care physicians, but
no one has found the cause of any of her problems. The patient
underwent one prior surgery, for a ruptured appendix at age 18.
She has one 4-year-old child. She has been unable to work for the
past 5 years because of her symptoms and claims that they have
“destroyed her life.” A mental status examination is notable for the
patient’s depressed mood and affect.
1. What is the most likely diagnosis for this patient?

2. What is the best treatment?

3. What is the most likely prognosis?

Case study 6: An 18-year-old adolescent male presents to a
psychiatrist insisting, “I have schizophrenia and need to be
admitted.” For the past several days, he has heard voices telling
him to kill himself. He says that he is possessed by the devil.
The patient denies feeling depressed, but thinks he will hurt
himself if he is not admitted to a hospital immediately. However,
he denies having any specific suicide plan.
He has no prior history of psychiatric treatment or complaints, no
medical problems, and is not taking any medication. He drinks one
or two beers a week and denies using drugs. At the end of the
interview, he again requests hospitalization. He then adds that he is
currently on leave from the Navy and is due back on his ship,
which is leaving in 2 days.
On a mental status examination, the patient is initially cooperative
and forthcoming but becomes increasingly irritated when asked to
give more details about his symptoms. His mood and affect are
euthymic and full-range. His thought processes are logical, without
looseness of association or thought blocking, and his thought
content has suicidal ideation but no homicidal ideation. He reports
having delusions and auditory hallucinations. His insight seems
good considering the severity of his symptoms.
1　What is the most likely diagnosis?

2　How would you approach this patient?

Case study 7: A 45-year-old man is brought to the emergency

department after a fight in the bar where he has been employed for
the past 3 weeks. The patient says that his name is “Roger Nelson,”
but he has no identification. He states that he does not know where
he lived or worked prior to 3 weeks ago, although he does not
seem upset by this. He says that the fight broke out in the bar
because one of the customers attempted to steal money from the
cash register.
On a mental status examination, the patient is seen to be alert and
oriented to person, place, and time. The results of all other aspects
of the examination are normal. A physical examination shows a 3-
in-long laceration on the patient’s right forearm, which requires
suturing. There is no head trauma or any other abnormalities.
When the police run a description check on the patient, they find
that he fits the description of a missing person, Charles Johnson,
who disappeared from a town 50 miles away 1 month prior to his
emergency department admission. Mrs. Johnson is able to identify
Roger Nelson as her husband, Charles. The patient claims not to
recognize her, however, Mrs. Johnson explains that in the months
prior to his disappearance, her husband was under increasing work
pressures and was afraid that he was going to be fired. She says
that the day before his sudden disappearance, her husband had a
huge fight with his boss. He came home and had a fight with her as
well, culminating in her calling him a “loser.” She woke up the
next morning to find him gone. She states that the patient has no
psychiatric history or problems and denies that he uses drugs or
alcohol. He has no medical problems.
1. What is the most likely diagnosis for this patient?
2. What are the course of and the prognosis for this disorder?

Case study 8:
A 54-year-old woman is seen in her family doctor’s office. She has
seen her doctor more than 20 times over the last year. She believes
that she has some kind of serious medical disease because she “just
doesn’t feel right.” The patient complains of vague stomach
rumblings, aches and pains in her ankles and wrists, and occasional
headaches.
She scours the Internet for articles about serious, life-threatening
diseases and brings these articles in when she visits her physician,
convinced that she has a variety of the diseases listed. She states
that she feels relieved and “safe” for a short period of time after
every negative test result but then becomes convinced that she is ill
again and makes another doctor’s appointment.
In the past year, she took off so much time from work for doctors’
visits that she was put on probation. Other than noting that she is
very concerned about having a serious disease, the results of her
mental status examination are unremarkable.
She has no symptoms suggesting a severe depression and there is
no evidence of thought disorder or psychosis. She becomes
insulted when the primary care physician suggests she sees a
psychiatrist and refuses a referral.
1　What is the most likely diagnosis for this patient?
 2　 What should the primary care practitioner do for this
patient?

Case study 9:
A 24-year-old man was admitted to the neurology service with
new- onset blindness. The man awoke one morning totally unable
to see. A workup by the neurology service revealed no physical
reason for this abnormality—the patient was found to be otherwise
healthy. A psychiatric consultation was then called. The patient
tells the psychiatrist that he does not know why he is blind.
He says that he emigrated from Mexico several years ago, coming
to the United States to make some money to support his sick
mother. She was ill for several years, but he was not able to send
her much money because he became addicted to heroin after
arriving in the United States and used all his money to purchase
drugs. She died recently, and he became despondent because he
would never see her again.
On a mental status examination, the patient is alert and oriented to
person, place, and time. His appearance and hygiene are good, and
he does not seem to be overly concerned with his blindness. His
mood is described as “Okay,” and his affect is congruent and full-
range. He has normal thought processes and denies having suicidal
or homicidal ideation, delusions, or hallucinations.

1. What is the most likely diagnosis for this patient?

2. What is the best therapy for this patient?