The correct answer is choice 3. In this patient there is a clear cut finding on physical exam that points to a neurological problem. In an African -American patient, one must suspect the presence of Sarcoidosis. A chest X-ray and basic labs are called for.

CT of chest is not indicated yet but if the X-ray is abnormal, one may consider it according to an algorithm.

Even if she has a history of drug abuse, one will still be obliged to do the CXR. Before one makes a psychiatric diagnosis on any patient, one must rule out an organic cause.

I once remember making a diagnosis of depression on a patient. Routine labs ordered the same day revealed a leukemia in blast crisis. Always order basic routine labs before making psychiatric diagnoses.

For organic brain syndrome, watch out for visual hallucinations as opposed to auditory hallucination in psychiatric disorders.