Clinical Vignette III

• Which of the following is the most likely diagnosis?

A 23-year-old male medical student is evaluated by the Best Medical School’s Office of Student Affairs staff psychiatrist for a one-month history of feeling excessively overwhelmed and stressed since failing the first major exam in the first semester of medical school despite spending countless hours day after day studying for it. As a former straight A student during his undergraduate years of college, the patient states that he felt confident about his ability to handle the pressures of medical school and thought he was doing well until the grades for the first major exam were posted online approximately four weeks ago. Since discovering his failing grade, he states that he has been experiencing insomnia, difficulty concentrating, loss of self-esteem, and severe agitation. Furthermore, the first-year medical student admits that he started to skip class several days a week to drink alcohol by himself at his apartment because he continuously worries that he will fail the next major exam and end up flunking out of medical school. He states that he feels completely hopeless, isolated, and confused about what to do and how to go about doing it. The patient states that he has never felt like this before and that he was always a positive and optimistic person who used to be full of energy and confidence. He denies having any suicidal or homicidal thoughts. With the exception of the recent alcohol drinking episodes, he normally does not use alcohol, tobacco, or recreational drugs. He denies any past history of psychiatric disorders and takes no medications. The remainder of his past medical history, family history, and social history are unremarkable. On physical examination, all vital signs are normal. The rest of the physical examination is unremarkable. 

• Which of the following is the most appropriate next step in management of this patient?

• Several months after initiating conservative first-line treatment, the 23-year-old male medical student has demonstrated some improvement in his symptoms. Despite this very modest improvement in overall symptomatology, the patient still suffers from extreme anxiety on the day of every examination administered at medical school. In addition to the current treatment, the psychiatrist is considering adjunctive therapy with a second treatment method for synergistic and targeted symptomatic effect. Which of the following is the most likely mechanism of action of the adjunctive second treatment method to be added to the patient’s current treatment regimen?

• Two major adverse effects which are also listed as Black Box Warnings for the adjunctive second treatment method include respiratory depression and profound sedation due to its central nervous system neuronal inhibitory mechanism of action. Although the safety margin for this particular second treatment method is relatively higher compared to other treatment options which interact and potentiate the same neuron receptors, an overdose is still a possibility. Which of the following is the most appropriate management for an overdose of this particular adjunctive second treatment method?