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Question 1 of 40
1. Question
A 38-year-old man with a history of schizophrenia is brought to the emergency department by police for a court-ordered evaluation. His mother requested that the patient be involuntarily committed after he refused voluntary hospitalization. She says that his illness was controlled with an injectable antipsychotic. She does not remember the name of the medication, but he received it once a month. Four months ago, the patient stopped going to his psychiatrist to receive the injection. His mother has seen a continuous deterioration in his overall functioning, especially within the last few weeks. Temperature is 37 C (98.6 F), blood pressure is 132/80 mm Hg, pulse is 88/min, and respirations are 14/min. Laboratory results are within normal limits, and a urine toxicology screen is negative. During the evaluation, the patient does not respond to any questions. He sits motionless on the edge of the bed, staring at the wall in front of him. During the physical examination, the resident picks up the patient’s arm and places it over his head to evaluate range of motion. When the resident releases the arm, the arm stays in place above the patient’s head. The resident then purposefully moves it down 30 degrees and the arm, once again, stays in the new location. Which of the following would be the most appropriate next step in management of this patient?
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Question 2 of 40
2. Question
A 63-year-old man with Parkinson disease, hypertension, and a history of depression comes to the office with his wife for follow-up. Medications include amantadine and carbidopa-levodopa; the patient has responded well to the latter, in contrast to his insufficient response to previous medications prescribed for Parkinson disease. During his last visit, his dosage of carbidopa-levodopa was increased to target continued shuffling gait, rigidity, and frequent falls. The patient’s wife says that he initially did very well afterward; they participated in more social activities, dined out, and visited with friends, and falls became far less frequent. However, over the past week, she has become increasingly concerned about the patient’s behavior. He has become more withdrawn and started to avoid his friends. The patient falsely accused her of infidelity and suddenly refused to see his son, saying, “All he wants is to get his hands on my money.” He also called the police on several occasions because he reported seeing strangers in his bedroom. The patient is afebrile; blood pressure is 114/76 mm Hg and pulse is 64/min. Physical examination shows mild rigidity and tremor, which have improved since his last visit. The remainder of the examination is unremarkable. He shows no signs of dementia, delirium, or infection. Which of the following medication adjustments would be most appropriate in management of this patient?
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Question 3 of 40
3. Question
A 27-year-old man comes to the office due to depressed mood and low energy for the past several months. He describes sad and irritable mood, sleeping 12-14 hours a day, decreased appetite, and poor concentration at work. The patient has stopped going to the gym and playing his guitar and has withdrawn from his friends and girlfriend. He has no medical problems and physical examination and routine laboratory tests are normal. Major depressive disorder is diagnosed and he is started on fluoxetine 20 mg. At his 2-month follow-up, the patient reports, “I’m feeling just a little better. I am still down on most days but at least I picked up my guitar once this week. The other thing is sex. In the beginning, I was so depressed that I didn’t care whether I had sex. Now, I’m interested and get erections, but it’s taking too long to ejaculate and it sometimes fails to happen altogether.” The patient says that this is creating problems with his girlfriend and he is considering stopping the antidepressant. He drinks a beer a day and does not use illicit drugs. Which of the following is the best management strategy for this patient?
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Question 4 of 40
4. Question
A 19-year-old man is brought to the emergency department by his mother due to behavioral changes. She says that he has been acting strangely for the past 2 months, spending significantly less time with his friends and more time on the computer. Over the past few nights, the mother has observed the patient shouting at the computer. She became alarmed when he suddenly disconnected all electronic devices in the house and warned his family that encrypted messages were being sent over the Internet to control his brain. The patient’s grades at the local community college have recently declined, and he stopped attending classes after he became convinced that other students were laughing at him behind his back. Medical history is noncontributory. The patient does not use tobacco or alcohol but smokes marijuana daily. He has also used cocaine on several occasions. Family history is significant for schizophrenia in a maternal uncle. Vital signs and physical examination are normal. The patient is cooperative, guarded, and anxious during the interview. Blood work and a CT scan of the head are normal. Urine toxicology is positive for tetrahydrocannabinol. The mother asks if her son is going to be okay. After consent is obtained from the patient to speak with his mother, which of the following is the most appropriate response to her at this time?
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Question 5 of 40
5. Question
A 4-year-old boy is brought to the office by his mother for an annual wellness examination. The mother mentions that the boy has recently experienced several thrashing episodes at night in which he awakens screaming and crying about an hour after falling asleep. She says, “It’s baffling because his eyes are open during these episodes, but he does not appear to be aware that I am present. I try to calm him down and comfort him, but it seems to have no effect.” Eventually he falls back asleep and appears to have no recollection of the previous night’s events in the morning. The mother says, “He recently saw a horror movie with his older siblings and I wonder if this upset him.” The only recent change has been moving to a new home within the same city. The patient has no other medical problems. Physical examination is normal, and the boy appears to be meeting all developmental milestones. For advising the mother about the child’s prognosis, which of the following is the most accurate statement?
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Question 6 of 40
6. Question
The following vignette applies to the next 3 items. The items in the set must be answered in sequential order. Once you click Proceed to Next Item, you will not be able to add or change an answer.
A 52-year-old man is brought to the emergency department by his roommate after threatening to kill himself. The patient is angry about being taken to the hospital and says, “I just want to go home and sleep.” Medical history includes recurrent major depression, posttraumatic stress disorder, and alcohol use disorder. He describes an increase in depression since his divorce 5 years ago. He feels hopeless, has difficulty getting out of bed, and eats 1 meal a day. The patient has been thinking a lot about his failed marriage and blames himself for his heavy drinking and losing contact with his 2 adult children. He has always owned a gun, which he usually keeps locked in his bedside table. In the last week, he has taken the gun out a few times “to hold it and know that I have a way out.” The patient has thoughts about ending his life but does not think he will act on them. Medical records indicate that he was hospitalized 3 months ago after taking a handful of sleeping pills and drinking 2 liters of vodka. The patient was seeing a psychiatrist in an outpatient clinic but stopped going to appointments and taking his prescribed medications. He insists that he is not feeling suicidal now and demands to leave the hospital.
Item 1 of 3
Which of the following is the most appropriate next step in management of this patient?
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Question 7 of 40
7. Question
Item 2 of 3
The patient is placed on 1:1 observation and arrangements to hospitalize him are discussed. He is upset and tearful. He says, “You’re trying to keep me against my will. If I wanted to kill myself, I would have done it already. I just want to go home so I can finally get some rest.” Which of the following is the most appropriate statement?
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Question 8 of 40
8. Question
Item 3 of 3
The patient is started on escitalopram in the inpatient psychiatric unit. He is willing to take the medication but remains angry about being hospitalized. He is initially withdrawn and uncommunicative but after several days is more conversant and participates in individual and group therapy sessions. After 2 weeks, the patient is noticeably less depressed and has no suicidal thoughts. His appetite has improved, and he is eating 3 meals a day. Discharge planning is begun, and an outpatient psychiatric appointment is scheduled. Which of the following is the most important prior to discharge?
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Question 9 of 40
9. Question
A 15-year-old boy is brought to the office by his parents due to concern about his behavior. The mother says, “Over the past year, he has become very withdrawn and seems anxious when he is around people or goes outside. He never smiles or seems to have fun anymore. He isn’t motivated to do well in school, and his grades have declined. In the last 2 weeks, he has refused to go to school altogether.” The patient says, “I don’t like to be around people because they can’t be trusted. They know what I am thinking and use it against me. I can tell they are watching me because I hear their voices even when I’m in my room at home.” Although he is shy, the patient has normal developmental milestones and had no behavioral problems until this past year. He has no medical conditions and does not use alcohol or recreational drugs. Sleep and appetite are normal. Temperature is 36.7 C (98.1 F), blood pressure is 110/70 mm Hg, pulse is 84/min, and respirations are 12/min. The patient weighs 80 kg (176.4 lb) and is 170 cm (5 ft 7 in) tall. Physical examination shows a well-developed boy with mild facial acne and no other abnormalities. Laboratory evaluation is noncontributory. On mental status examination, he is quiet and soft-spoken and avoids eye contact. His mood is anxious. Which of the following is the most appropriate treatment for this patient?
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Question 10 of 40
10. Question
A 38-year-old man was brought to the emergency department after nearly being hit by a car that swerved to avoid hitting him as he walked down the middle of a busy city street. On arrival, the patient was ataxic and his speech was slurred. He had evidence of polysubstance use on toxicology testing. He received intravenous fluids and was monitored for several hours in the emergency department. The patient’s vital signs are now stable. He is oriented to time, place, and person, and he feels badly about his behavior. As the patient is about to be discharged, his wife arrives. He informs the staff that he does not wish to see her. Before the staff can intervene, she bursts into his room and they begin a heated argument about his substance use, recent job loss, and neglect of family responsibilities. The nurse asks the patient’s wife to leave, but she says, “I’m not leaving. He is going to hear everything I have to say!” The patient becomes increasingly agitated and starts shouting. His fists are clenched and his loud voice and offensive language disrupt nearby staff and patients. Which of the following is the most appropriate next step in management?
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Question 11 of 40
11. Question
A 79-year-old female nursing home resident is brought to the clinic by a nurse from the facility. Three years ago, the patient was diagnosed with dementia, and her memory and behavior have gradually worsened. Staff members report that she has been exhibiting increased aggression and paranoia over the last few weeks. She has pushed staff members and tried to rush out of the nursing facility. The patient does not recall these episodes. Gabapentin, valproate, citalopram, and trazodone were tried but did not improve her worsening symptoms. She has a history of hypertension and diabetes, which are well controlled with medication. She had a myocardial infarction approximately 10 years ago with no cardiac symptoms since then. The patient’s vital signs are within normal limits, and on examination there are no abnormal findings except for areas of ecchymosis on her upper extremities. ECG is normal, and QTc interval is 430 msecs. The physician recommends low-dose risperidone. The patient’s daughter, who is her guardian, is notified of the treatment plan and is concerned as she heard there is an increased risk of death associated with antipsychotics. She asks the physician about the safety of the medication. Which of the following is the most appropriate response regarding the potential safety risks of this class of medications?
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Question 12 of 40
12. Question
A 63-year-old man with a 2-year history of Parkinson disease comes to the office for follow-up. The patient has been taking carbidopa-levodopa twice daily since he was diagnosed and had a dose increase 3 months ago. He feels “okay”; his tremor has improved, but he shares that, for the past month, his friends have commented that he has slowed down and becomes distracted during conversations. The patient says he knows they look at him differently because his lack of energy is obvious. His daughter previously relied on him to babysit twice a week, but he has been unable to help her due to taking naps during the day. Vital signs are normal. Physical examination shows mild resting tremors of the hands and decreased rigidity of the upper and lower extremities compared to prior evaluations. Gait is slow but steady. Which of the following is the most appropriate next step in management of this patient?
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Question 13 of 40
13. Question
A 35-year-old man comes to the office due to “feeling very stressed” for the past month. He has felt “down” about his relationship with his wife and is currently going through a divorce. The patient has also had difficulty concentrating and fears that his productivity at work has fallen. He says, “I drag myself into work late because I can’t get out of bed. Then I sit and stare at the papers piling up on my desk. I used to enjoy biking and going out with friends, but now I just come straight home from work and lie on the couch. Having a couple of beers with dinner has helped me feel more relaxed.” Over the past month, the patient has wished that he could go to sleep and not wake up and has thought that he would be “better off dead.” These thoughts last for a few minutes when he is lying in bed awake at night. He has no intent or plan to harm or kill himself. The patient has no history of suicide attempt or depression. There is a family history of suicide in a paternal uncle who had depression and substance use disorder. He recently separated from his wife and moved from their house into an apartment. Vital signs and physical examination are normal, with the exception of a 2.3-kg (5-lb) weight loss. Which of the following is the most appropriate next step in management of this patient?
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Question 14 of 40
14. Question
A 33-year-old woman is brought to the outpatient psychiatry clinic by her husband. He says that his wife was fine and working as a store clerk until about 8 months ago, when they relocated to another state for his new job. Soon after, the patient’s behavior abruptly changed. She became fearful of leaving the apartment and was fired from her job 6 months ago due to repeated absences. The patient hears her neighbors whispering disparaging remarks to her and has remained convinced that they are secretly monitoring her with hidden cameras planted outside the apartment. Her mother has been staying at the apartment to keep the patient company and makes sure she eats regular meals. The patient has no history of similar signs or symptoms, and there is no family history of psychiatric illness. Physical examination is unremarkable. Recent results of blood work, urine toxicology, and a brain CT scan are normal. Diagnosis and treatment recommendations are shared, and the husband asks about the patient’s prognosis. Which of the following is the most appropriate response?
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Question 15 of 40
15. Question
A 27-year-old woman comes to the office for a routine medical examination. She reports feeling well since her last appointment a year ago. The patient is sexually active with her boyfriend of 5 years. They are monogamous and use condoms consistently for contraception. She has had no malodorous vaginal discharge or abnormal uterine bleeding. Previous Pap tests were normal. The patient describes her relationship with her boyfriend as stable, although they fight about money and she wishes that he were more supportive. She is unhappy with her job as a waitress and would like to go back to school someday. The patient smokes marijuana about once a week and does not use tobacco or other recreational drugs. She has 2 mixed drinks and a couple of beers when socializing with friends after work. The patient denies depression and has no suicidal ideation. Temperature is 36.9 C (98.4 F), blood pressure is 118/78 mm Hg, pulse is 76/min, and respirations are 14/min. Pelvic examination reveals clear cervical discharge throughout the vaginal vault; a Pap test is obtained. Which of the following is the most appropriate next step in management of this patient?
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Question 16 of 40
16. Question
A 32-year-old woman comes to the office to follow up for bipolar I disorder. The patient was hospitalized for a depressive episode 6 months ago and was prescribed quetiapine. Her condition responded well to the medication, and she decided to discontinue it 2 months ago. The patient says, “The depression lifted after a few months on the medication, which was such a relief. I was so down before and couldn’t enjoy anything, but now I’m doing great. I met a fantastic guy 2 weeks ago, and we just got engaged.” She adds, “The wedding is in a few weeks, and I’m planning the entire thing, so I’ve been very busy. I feel so lucky—we both want the same things in life and are going to start a family right away.” She enjoys her work as a real estate agent and shares that she was recently promoted due to her high volume of sales. On mental status examination, she is neatly dressed and groomed; she has a bright affect. The patient states that she is doing well without medication and would like to “see how things go.” Which of the following is the most appropriate statement?
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Question 17 of 40
17. Question
A 70-year-old woman is brought to the office by her daughter due to behavioral changes for the past few weeks. The patient was diagnosed with Alzheimer disease 6 months ago, and her cognitive impairment has been slowly worsening. She was living with her sister but decided to live with her children a month ago and now alternates between her son’s and daughter’s houses. Her daughter says, “Lately, she has been accusing the family of stealing her belongings every time she can’t find something, but she just misplaces things in her suitcase.” The patient has also required increased supervision at night due to restlessness and wandering but still independently performs most activities of daily living. She does not report any pain or discomfort and has had no fever, nausea, dysuria, or diarrhea. There has been no significant change in mood. Medical history includes hypertension and hyperlipidemia. Medications include simvastatin, lisinopril, and donepezil. Vital signs are within normal limits. Physical examination shows no abnormalities. Mental status examination shows a constricted range of affect. The patient is oriented to person and place but not to time. She is able to recall 1 of 3 objects after 5 minutes. Which of the following is the most appropriate next step in management of this patient?
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Question 18 of 40
18. Question
A 25-year-old woman is brought to the emergency department by her parents for evaluation of agitated and bizarre behavior over the past week. The patient abruptly stopped attending college classes a week ago. She has gotten into several loud arguments with strangers on the street. She has not slept for several days but has “tons of energy.” The patient demands to leave the hospital, explaining that she must work on her novel, which “will be the greatest book of the century.” The patient experienced depression at age 17 and 20 but was never treated. Physical examination is unremarkable, and a urine drug screen is negative. In the emergency department, the patient starts to pace and becomes increasingly agitated when told she cannot leave. She shouts, pounds her fists, and refuses medication. Administration of which of the following medications is the most appropriate next step in management?
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Question 19 of 40
19. Question
A 21-year-old woman comes to the office due to poor sleep and depression. She has been feeling progressively depressed and unmotivated over the past month, and also describes decreased appetite, a 2.2-kg (5-lb) weight loss, poor concentration, and low energy. The patient has no suicidal ideation or manic or psychotic symptoms. She drinks 1 or 2 beers twice a week but does not use illicit drugs. She has never felt like this before and is worried as her symptoms have worsened to the point that she has trouble getting out of bed and attending college. Major depressive disorder is diagnosed, and the patient is started on citalopram 20 mg. One month later, she returns for a follow-up visit. She now reports feeling much better, has improved energy and sleep, and has returned to school. The patient has no side effects from the medication and wonders how long she should continue it. Which of the following is the most appropriate recommendation?
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Question 20 of 40
20. Question
A 32-year-old woman comes to the clinic due to persistent thoughts about killing her 3 children. She says, “This is so upsetting because I love my children and would never harm them. I have had these thoughts for the past 3 months and cannot get them out of my head. It happens when I’m in the kitchen preparing dinner. As I reach for a knife in the drawer, I get this sudden thought about stabbing all three of them. The thoughts are senseless and ridiculous, but I worry that I’m going crazy. I wish I never had these thoughts but can’t make them stop.” The patient is happily married and says that all 3 children are well behaved. Her medical problems include hypothyroidism and microcytic anemia. She has no previous psychiatric history, but recalls being very anxious as a child. The patient says, “I was always worried that something bad was going to happen to my parents if I didn’t do the right thing and would get really upset if anyone touched my possessions.” Current medications include levothyroxine and iron. Temperature is 37 C (98.6 F), blood pressure is 131/78 mm Hg, and pulse is 87/min. On examination, the pupils are equal and reactive to light and mucous membranes are moist. There is no thyromegaly. Auscultation of the lungs reveals normal breath sounds. Heart sounds are normal. Neurologic examination reveals no focal deficits. The patient appears tense and her mood is anxious. Which of the following is the most likely diagnosis?
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Question 21 of 40
21. Question
A 30-year-old woman comes to the office for evaluation and treatment of depression. The patient says, “I have been feeling down for the past 3 months. Sometimes I cry for no reason. My energy is low all day at work. On weekends, all I want to do is stay in bed, and I make excuses for avoiding my friends and family. My sleep and appetite are poor, and the only things I eat are unhealthy snacks.” The patient has a demanding job as a restaurant manager and is worried that she has become less productive at work. She is not interested in dating and says, “Who would want to be with me when I feel so down?” The patient has no medical problems. Her medications include combination estrogen-progestin contraceptives. Physical examination is normal. On mental status examination, the patient has a depressed mood and sad affect. She has no suicidal ideation or psychotic features. She says, “I have heard good things about St. John’s wort and wonder if it would help me. I have read positive reviews for it on the Internet, and my sister takes it and is doing well.” Which of the following would be the most appropriate response to this patient?
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Question 22 of 40
22. Question
A 22-year-old college student is brought to the emergency department by his roommates, who say that he has been acting bizarrely for the last 2 months and “is only getting worse.” He refuses to leave the house and has put aluminum foil over his windows. The only way his friends could get the patient out of the house today was by threatening to call the police if he did not cooperate. They estimate that it has been 2 weeks since his last shower. He will not eat anything that is not prepackaged. The patient has no known medical or psychiatric history. He does not use alcohol or illicit drugs. Physical examination is unremarkable. On mental status examination, the patient is disheveled and malodorous. He sits quietly on the bed, smiles, and periodically laughs inappropriately. He looks down at the floor and avoids eye contact with the physician. During questioning, he says that his professors are trying to prevent him from graduating. He is unsure why they do not want him to graduate but says that they are sending him “telepathic” messages encouraging him not to attend class. The patient now thinks that his professors have convinced his friends to “join in their plot.” He whispers, “The nurse at the front desk is in on it too.” Which of the following would be the most effective approach to forming an initial therapeutic alliance with this patient?
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Question 23 of 40
23. Question
An 8-year-old boy with a history of congenital renal dysplasia is admitted to the hospital for fatigue, nausea, and anorexia over the past few days. He has been monitored since birth for renal dysfunction, which has worsened over the past few years. His glomerular filtration rate is 30 mL/min, creatinine is 5.0 mg/dL, and blood urea nitrogen is 100 mg/dL. On the second hospital day, the patient’s glomerular filtration rate falls to 15 mL/min and he requires emergency dialysis. The attending physician recommends renal allograft transplantation. After consultation with the nephrologist, the mother says that they would prefer a living donor due to superior outcomes; an older son from her previous marriage has been identified as a match. The patient’s half-brother comes to the hospital for a pre-transplant evaluation. He is an 18-year-old high school senior with a history of bipolar disorder treated with lithium in the past, and prior cocaine abuse with 2 years of sustained sobriety following residential substance abuse treatment. He takes no medications. The half-brother appears uninterested in the interview and frequently glances at his watch, but he perks up when discussing a new sports car that his mother has promised him following his donation procedure. He has had a difficult time in school but will be graduating on time and going to college. Which of the following represents a potential contraindication to the half-brother donating his kidney?
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Question 24 of 40
24. Question
A 28-year-old woman is brought to the office by her husband, who is concerned about her behavior. The patient had an uncomplicated vaginal delivery 12 days ago. The husband says, “At first she seemed elated about giving birth, but now she is quiet, withdrawn, and tearful. She eats very little and appears tired and fatigued.” The patient repeatedly comments, “The baby cries and cries and I am just so tired,” but says little else. The patient has a history of depression at age 23 that was treated with fluoxetine and psychotherapy. She has no other medical conditions. Family history is significant for hypothyroidism and breast cancer in her mother and coronary artery disease in her father. Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, pulse is 62/min, and respirations are 12/min. Physical examination is normal. Mental status examination reveals psychomotor slowing and depressed mood and affect. The patient has no suicidal ideation. She says, “I wish I could just go to sleep, but the voices won’t go away. They keep saying the baby is not mine and will grow up to be evil.” Which of the following is the most appropriate next step in management of this patient?
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Question 25 of 40
25. Question
A 72-year-old man comes to the office for follow-up of depression. Six weeks ago, the patient was evaluated for symptoms of depressed mood, loss of interest in activities, weight loss, poor concentration, and wishing he were dead. Physical examination and laboratory tests were unremarkable. He was diagnosed with major depressive disorder and prescribed fluoxetine. At today’s visit, the patient reports feeling 80% better since starting the medication but is having intolerable adverse effects, including difficulty falling asleep and feeling jittery. Medical history is noncontributory, and he takes no other medications. Temperature is 37 C (98.6 F), blood pressure is 112/70 mm Hg, and pulse is 80/min. Heart and lung sounds are normal. The abdomen is soft and nontender. On mental status examination, he is alert, cooperative, and mildly restless. Mood is minimally depressed, and affect is mood congruent. The patient has no suicidal ideation. He asks if he can switch to a different antidepressant. Which of the following medications would be most appropriate for this patient?
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Question 26 of 40
26. Question
A 42-year-old man comes to the office due to insomnia for the past month. He often awakens in the middle of the night anxious about his job performance and is unable to go back to sleep. He says, “I think I’m getting only 5 hours of sleep. All I really need is something to knock me out.” The patient is an accountant for a furniture store; he has been very tired at work and has difficulty concentrating from lack of sleep. He adds, “Last month I made several accounting errors. My boss was really understanding about it, but he isn’t going to be understanding for long if I keep making mistakes.” Further questioning indicates that the patient has not felt like himself for several months. He has been uncharacteristically irritable with his wife and children and has lost interest in going to the gym and socializing with his friends and coworkers. On weekends, he stays in bed until noon and then lies on the couch for the rest of the day. The patient believes it is inevitable that he will lose his job and feels very guilty that he is letting his family down. He has no medical or psychiatric history. There is a family history of Sjögren syndrome in his mother and obesity, hypertension, and heart disease in his father and paternal grandfather. He says, “If I can just get some sleep, maybe things will be better.” Physical examination and laboratory test results are unremarkable. Which of the following is the most appropriate next step in management of this patient?
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Question 27 of 40
27. Question
A 37-year-old man is brought to the emergency department by ambulance 20 minutes after he was hit by a motor vehicle while crossing the street. At the scene of the accident, he was awake, alert, and in considerable distress. On initial assessment, temperature is 36.7 C (98 F), blood pressure is 154/88 mm Hg, pulse is 108/min, and respirations are 31/min. There is an open fracture of the right femur. Chest radiograph shows several fractured ribs. Medical history is significant for opioid use disorder. The patient has undergone a drug rehabilitation program and successfully tapered off all opioids 2 years ago. He is given acetaminophen and ketorolac but continues to rate his pain as 6-7 on a scale of 0-10. Which of the following is the most appropriate next step in management of this patient’s acute pain?
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Question 28 of 40
28. Question
A 9-year-old girl is brought to the office by her father for follow-up of attention deficit hyperactivity disorder (ADHD). The patient was diagnosed 3 months ago due to impulsivity and excessive motor activity at school and home. She is currently engaged in parent-child behavioral therapy and takes methylphenidate, which was increased at her last visit 2 weeks ago. Although the hyperactive symptoms have improved, the father shares that the patient has not been eating as much as usual. He says, “She takes her medication every morning and then eats a handful of cereal for breakfast. Most of the food I pack in her lunchbox comes back untouched—even her favorite foods.” The patient eats snacks after school and usually half of her meal for dinner. She has had no changes in weight. Vital signs are within normal limits; growth curves are tracking consistently. Physical examination shows no abnormalities. Which of the following is the most appropriate statement?
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Question 29 of 40
29. Question
A 34-year-old woman comes to the office for a routine health maintenance evaluation. She says, “I got passed over for a promotion last month and have been in a funk for a few weeks. I guess it’s normal to be disappointed, but I’m pretty down about it.” The patient describes difficulty concentrating on her work assignments and explains that she is tired despite sleeping more than usual. She has gained 1.8 kg (4 lb) in the past month and says, “I used to enjoy cooking, but now I just eat takeout.” The patient lives with her husband and describes him as supportive. She drinks a glass of wine 4 or 5 times a week. The patient does not use tobacco or recreational drugs. She has no psychiatric history. Vital signs are normal. Physical examination and routine laboratory testing are unremarkable. On mental status examination, affect is dysthymic, and the patient has no suicidal ideation. A diagnosis is given and treatment options are discussed. The patient says, “I just want to get better and am open to whatever will work best.” Which of the following is the most appropriate statement to this patient?
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Question 30 of 40
30. Question
A 16-year-old boy is brought to the office by his mother, who is worried that he has been acting “strange” for the past week. She says, “He stays up late because he can’t fall asleep, isn’t eating much, and has been really irritable. He’s picking fights with his brother and arguing a lot, which is not like him. I don’t think he would use drugs, but some of his friends recently got into trouble for smoking marijuana.” Medical history includes a football injury and arthroscopic surgery for an anterior cruciate repair 3 months ago. The patient has no other medical issues. He takes no medications other than diphenhydramine, which his mother has given him over the past week to help with sleep. Family history is significant for attention deficit hyperactivity disorder in his younger brother, who is treated with medication. When interviewed alone, the patient says, “It’s nothing. I was nervous about final exams. I stayed up late studying and then had a hard time sleeping.” Temperature is 36.7 C (98.1 F), blood pressure is 130/90 mm Hg, pulse is 102/min, and respirations are 20/min. Physical examination shows a restless and talkative but otherwise healthy-looking boy. He is slightly diaphoretic and has trouble sitting still. The pupils are dilated and mouth is dry. Examination of the ears and nose is normal. The lungs are clear on auscultation. The patient’s heart is tachycardic with a loud S2. Which of the following is the most likely cause of the patient’s presentation?
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Question 31 of 40
31. Question
A 24-year-old man is brought to the emergency department by police after breaking into the house of a famous singer. The singer was not home at the time, and the patient was found taking a bubble bath when police arrived. During the psychiatric evaluation, he speaks rapidly and says loudly, “I didn’t realize that it was a crime to take a bath! I’m famous, you know!” The patient has not slept for days and says he has heard the singer’s voice telling him that he will be “a star.” He has no medical symptoms or illnesses. He has a 5-pack-year smoking history but does not use alcohol or illicit drugs. The patient takes no prescription medications. Physical examination shows no abnormalities. Laboratory results and vital signs are within normal limits, and toxicology screen is negative. The patient’s mother arrives and reports that her son was fine until 4 years ago when he went into a deep depression after breaking up with his college girlfriend. During that time, he became convinced that the campus police was following him and he heard voices telling him that he was a loser. His mother says he has not been the same since. The patient was unable to return to college and has since been hospitalized at least 5 times for mood and psychotic symptoms. His mother says, “Even when he is out of the hospital and his mood is completely stable, he continues to hear multiple voices.” Which of the following is the most likely diagnosis?
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Question 32 of 40
32. Question
A 32-year-old woman comes to the office accompanied by her sister. The patient says “my sister thinks I’m losing my mind; I don’t know what’s going to happen to me.” Her sister states that for the past few weeks the patient has become convinced that “ballerinas” are visiting her apartment and going through her belongings. The patient says, “At first I wasn’t sure, but now I know they’ve been coming to scare me out of my apartment. I see them sometimes running around at night. The one with the long black hair wants to strangle me. I’m scared for my life.” The patient’s sister has not noted any intruders. The patient does not appear to be otherwise confused. In review of systems, she acknowledges feeling more tired over the past few months and losing 4.5 kg (10 lb) over the same period. She also reports pain in her knuckles and wrists. Medical history is unremarkable except for episodes of recurrent depression in her 20s. She takes no medications. The patient does not use tobacco, alcohol, or illicit drugs. She has a family history of depression. Temperature is 36.7 C (98.1 F), blood pressure is 148/92 mm Hg, pulse is 82/min, and respirations are 16/min. Examination shows mildly swollen wrists bilaterally and mild edema in both lower extremities but is otherwise normal. Laboratory results show a white blood cell count of 3,900/mm3; serum chemistries are within normal limits. Which of the following is the most appropriate next step in diagnostic evaluation of this patient?
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Question 33 of 40
33. Question
A 24-year-old man is brought to the emergency department by a friend due to disorientation and restlessness. The friend says, “He’s been acting crazy for hours. It was really hard for me to get him here. He kept moving from side to side in the car and banging his body against the door. Then he started pushing me while I was driving. I almost ran off the road.” The patient is well known from past emergency department admissions for similar episodes of agitation and polysubstance use; he often becomes coherent in 7-8 hours. Medical history is otherwise noncontributory. Temperature is 37.2 C (99 F), blood pressure is 160/100 mm Hg, pulse is 120/min, and respirations are 12/min. The patient is not oriented to time and place but recalls his name and date of birth. Physical examination shows prominent nystagmus, as well as multiple cuts and abrasions of the shoulders and extremities. The patient paces the room and begins banging his body against the wall, yelling, “They’re pushing a rock on me.” Which of the following is the best next step in management of this patient?
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Question 34 of 40
34. Question
A 43-year-old woman comes to the office for a follow-up appointment. She was diagnosed with major depressive disorder a year ago and was prescribed citalopram, which provided no symptom relief. The patient was then switched to sertraline, and the dose was gradually increased. She is now taking the highest recommended dose, which she tolerates without difficulty. Although the patient has experienced 50% improvement in depression, she still has symptoms. Specifically, she continues to have low energy and sleeps 12 hours a day without feeling rested. She also describes an increased appetite with recent weight gain of 4.5 kg (10 lb) and poor libido. The patient says, “I really hoped I would feel back to my normal self, but my lack of energy drags me down. I’m reluctant to discontinue sertraline because I feel it has helped somewhat.” The patient is married with 2 children and works as a grade school teacher. She describes her marriage as “good” but is concerned that her husband is becoming frustrated with her. She does not smoke or use alcohol. Blood pressure is 128/76 mm Hg and pulse is 64/min. BMI is 28 kg/m2. Physical examination is normal. Which of the following is the most appropriate change in pharmacotherapy?
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Question 35 of 40
35. Question
A 16-year-old girl is brought to the emergency department by her parents after they found razor blades hidden in her room and noted several scratches on her forearms. The girl says, “My parents are always overreacting to stupid things and when I really need them, they’re always busy. It wasn’t like I was trying to kill myself or anything.” The parents note that their daughter is always moody. They have noticed that she frequently wears long sleeves and don’t know how long she has been cutting herself. They are also concerned that she frequently binges on junk food and then starves herself for a few days afterward. They suspect that she may be forcing herself to vomit. The girl has no medical problems and no prior psychiatric history. She has tried alcohol and marijuana at parties but does not use them regularly. When interviewed alone and asked about depression, she says, “I just hate everything in my boring life. I wasn’t trying to kill myself. I just feel like cutting when I am upset about something. I know a lot of kids who do it.” She has no thoughts of suicide currently, although she has previously wished that she were dead after breaking up with her boyfriend and sometimes thinks about how her parents and friends would react if she were dead. Vital signs are stable. Physical examination is normal except for multiple scratches and superficial lacerations in various stages of healing on both forearms. Her parents are very concerned. Which of the following is the most appropriate statement to make to the parents at this time?
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Question 36 of 40
36. Question
A 44-year-old man comes to the office for an annual physical examination. The patient’s history includes hypertension and gastroesophageal reflux disease, for which he takes enalapril and famotidine. The patient also has a history of depression in his early 20s that responded well to sertraline. He currently has no depressive symptoms. The patient works as a real estate agent and has been employed at the same company for many years. He is married with two children ages 17 and 15. He says, “Things are okay at work and at home, but I’m a little worried about paying for college.” The patient has a 15-pack-year smoking history and drinks socially but does not use recreational drugs. There is a family history of hypertension and coronary artery disease, and the patient describes both his father and brother as “recovering alcoholics.” Blood pressure is 130/80 mm Hg, pulse is 72/min, and respirations are 16/min. Examination shows no abnormalities. Which of the following questions is most appropriate to screen this patient for unhealthy alcohol use?
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Question 37 of 40
37. Question
A 42-year-old woman with a recent diagnosis of metastatic breast cancer comes to the office for a follow-up visit. Although the patient is currently stable, she decided to stop working due to the stress of managing her illness and caring for her 7-year-old son, who has multiple behavioral issues and special needs. The patient has a history of depression in her 20s and late 30s. She was previously treated with weekly psychotherapy that she found helpful. She tries to exercise 2 or 3 times per week but often feels too weak. The patient describes her husband as extremely supportive. Her son attends a special school for children with autism. As the physician reviews the chemotherapy regimen, recent imaging, and laboratory results, the patient becomes tearful. She says, “I think I was doing much better when I was distracted by work. Now, I’m so afraid of dying and what’s going to happen after I’m gone that it’s hard to think of anything else. I know I have to be brave for my son.” Which of the following is the most appropriate initial response to the patient’s concerns?
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Question 38 of 40
38. Question
A 22-year-old graduate student comes to the clinic at his mother’s urging due to being very tearful, sad, and irritable. Three weeks earlier, he was in a motor vehicle collision in which the other driver lost control of the vehicle and collided with the patient’s car, killing his father and sister. The patient was unable to extricate either family member from the vehicle, and they both died before emergency personnel arrived. He remains unable to recall most of the event. Since then, he has felt guilty about his failure to save them and has experienced recurrent nightmares about the collision. The patient says, “I feel like I’m in a daze and everything seems unreal. Last week, while leaving a gas station, I was panicked that my car was spinning out of control and heard screams and sirens although no one was around. Since then, I have stopped driving.” The patient insists that his mother avoid the highway where the collision took place. He has been unable to concentrate on his studies and has stopped attending class. His medical history is significant for patellofemoral syndrome and acne vulgaris; family history is significant for depression in a paternal uncle. The patient takes no medications and has no allergies. He does not use alcohol, tobacco, or illicit drugs. Physical examination is unremarkable. Which of the following is the most likely diagnosis?
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Question 39 of 40
39. Question
A 32-year-old man comes to the office for follow-up. Two weeks ago, he was evaluated for depressed mood, low energy, and poor concentration at work. The patient had difficulty getting out of bed in the mornings and called in sick to work 3 days in a row. Routine laboratory testing and physical examination were normal, and he was diagnosed with major depressive disorder. The patient was started on fluoxetine, which he has taken for the past 2 weeks. At today’s follow-up visit, he reports that although still somewhat depressed, he feels more energetic and a little better overall. He says, “I have more energy, and it’s a little easier to get motivated to go to work now.” However, he reports new symptoms of mild nausea and occasional anxiety and restlessness. He also had difficulty sleeping one night, which is unusual for him as he previously was oversleeping. The patient drinks a glass of wine daily but does not use tobacco or illicit drugs. He is a sales representative and reports missing no workdays this past week. Vital signs are stable, and his physical examination is unchanged. Which of the following is the most appropriate next step in management of this patient?
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Question 40 of 40
40. Question
A 16-year-old boy comes to the office for a routine well-child visit. The patient has no health concerns. He makes average grades at school and plays on the basketball team. When asked about substance use, the patient states that he drinks alcohol at parties almost every weekend and usually drinks to the point of intoxication. He says, “Everyone drinks at parties. I’m not addicted or anything—I never drink during basketball season and can stop whenever I want. It’s not a big deal.” Which of the following is the most appropriate statement?
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