44-year-old man comes to the emergency department with his wife, who states that he has been looking “crazed” for the
past 4-5 days The patient reports anxiety and is sleeping less than usual. He is irritable and moody, snapping at his wife
and children when they approach him. The patient says that at night he is frightened by large shadows that "are coming
from the other wor1d to take me with them." He has stopped going to work. The patient also has abdominal pain,
constipation, and “tingling” in his fingertips. He has no other symptoms Medical history includes major depression and
gastroesophageal reflux disease. The patient is a postal worker. He does not use tobacco, alcohol, or illicit drugs. He has
a family history of schizophrenia. His medications include omeprazole and acetaminophen. In the emergency department,
temperature is 36.7 C (98.1 F), blood pressure is 140180 mm Hg, pulse is 110/min, and respirations are 16/min. The
abdomen is soft and minimally tender. Bowel sounds are decreased. There is no rebound tenderness or rigidity
Neurologic examination is within normal limits except for decreased sensation in the fingertips and mild weakness in the
right arm; physical examination is otherwise normal Which of the following is the most likely diagnosis in this patient?
- Q A Acute intermittent porphyria
- Q B Lyme disease
- Q C Major depressive episode with psychotic features
- Q D Schizophrenia
- Q E Wilson disease
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