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Question 1 of 10
1. Question
A 17-year-old girl is brought to the emergency department by a friend an hour after she was observed having a seizure. The patient has no known history of a seizure disorder. Her friend reports she has a history of depression and substance use disorder and was released yesterday from a psychiatric hospital after 3 days of inpatient treatment. The patient’s medications are unknown. Temperature is 38.3 C (100.9 F), blood pressure is 90/50 mm Hg, and pulse is 130/min. On examination, the patient is sedated and disoriented. The pupils are dilated and bowel sounds are decreased. She has 700 mL of urine return when a urinary catheter is placed. ECG reveals sinus tachycardia and a QRS duration of 130 msec. Which of the following is the most likely cause of this patient’s symptoms?
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Question 2 of 10
2. Question
A 39-year-old woman is brought to the emergency department after her husband found her confused. The patient was unable to answer questions about why she did not go to work that day and could not remember the day of the week. She has a history of bipolar disorder and has taken the same dose of lithium for the past 10 years. Over the past week, the patient started taking several daily doses of a new medication following a dental extraction. Yesterday, she felt nauseated and vomited twice, and earlier today, she started having diarrhea. Vital signs are within normal limits. The patient is alert and oriented to self only. The abdomen is soft and nontender with increased bowel sounds. Coarse tremors are noted in the upper extremities. Deep tendon reflexes are 2+ in the bilateral extremities. Gait is mildly ataxic. A drug interaction involving which of the following medications is most likely causing this patient’s symptoms?
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Question 3 of 10
3. Question
A 44-year-old man comes to the office due to paresthesia and pain in his feet. The patient began experiencing tingling and numbness in his toes several months ago, which gradually progressed to the rest of both feet. He has also had burning pain on the soles, which frequently disrupts his sleep at night. The patient has a 6-year history of HIV infection. He was not adherent to treatment initially but now takes antiretroviral therapy regularly. His most recent CD4 cell count was 550/mm3. Vital signs are within normal limits. Foot examination shows decreased pain and touch sensation and loss of ankle reflexes bilaterally. There are no other focal neurologic deficits. Medication review shows no neurotoxic drugs and laboratory studies are within normal limits. Treatment with duloxetine is planned. This medication is most likely to improve this patient’s symptoms via which of the following mechanisms?
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Question 4 of 10
4. Question
A 58-year-old man is seen in the clinic 6 months after undergoing right coronary artery stent placement due to unstable angina. His father died at age 50 from coronary artery disease. The patient follows a healthy diet and exercise plan and is compliant with his current medication regimen. BMI is 29 kg/m2. Physical examination is unremarkable. After extensive discussion with the patient, evolocumab is added to his treatment plan. Which of the following is expected as an immediate result of this treatment?
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Question 5 of 10
5. Question
A 32-year-old man with a history of bipolar disorder is brought to the emergency department by his wife. He has been unable to sleep for more than 3 hours a night for the past week. Over the past several weeks, the patient has been irritable at home and has argued constantly with his wife. He has racing thoughts and speaks rapidly. The patient has stopped going to his job as a plumber, having decided to stay home and “unravel the secrets of the universe.” He has been drawing shapes and equations on the walls, and he has accused his wife of working for the police and trying to steal his secrets. Prior to examination, the patient becomes increasingly agitated and is hospitalized against his will. He has no other medical conditions. Vital signs, physical examination, and laboratory findings are normal. He is prescribed multiple medications to address his symptoms. Five days later, the patient is calm but has difficulty moving spontaneously or getting out of bed. He does not respond appropriately to questions and appears newly disoriented and confused. Temperature is 39.4 C (102.9 F), blood pressure is 162/98 mm Hg, pulse is 98/min, and respirations are 20/min. Dysregulation of which of the following neurotransmitters is most likely to be the primary cause of this patient’s new symptoms?
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Question 6 of 10
6. Question
A 48-year-old man is hospitalized due to severe depression. The patient became increasingly depressed over the past month and stopped going to work last week because he was unmotivated to get out of bed. He sleeps up to 16 hours a day, has no energy, and has gained 4.54 kg (10 lb) over the past month. The patient has had daily thoughts of suicide for the past week but says he will not act on them because of his children. He also describes several weeklong periods when he had extra energy and took on many projects at once. During these times, the patient rarely slept and believed he had superhuman powers to control other people’s minds with his eyes. Physical and laboratory evaluations are unremarkable. Which of the following medications would be most appropriate for long-term management of this patient?
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Question 7 of 10
7. Question
A 22-year-old woman is brought to the emergency department for bizarre behavior over the past week. Her parents state that she has been “talking nonsense” nonstop, laughing for no reason, and has not slept for several days. During triage, the patient attempted to hit a staff member, resulting in administration of haloperidol. While awaiting further evaluation, the parents alert the nurse that the patient is starting to “make weird faces” while sticking out her tongue. Medical history is noncontributory, and the patient takes no medications. Urine drug screen is positive for cannabis and opiates. Which of the following is the most likely explanation for this patient’s motor symptoms?
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Question 8 of 10
8. Question
A 10-year-old boy is brought to the office due to poor grades and behavioral problems. Although the patient is very intelligent, his parents report that he struggles at school and has received failing grades because he is easily distracted, makes careless mistakes, and often loses his homework. His teacher has called several times to report that he repeatedly disrupts the class by getting out of his seat and by blurting out answers when he is not called on. At home, the patient does not listen to his parents, does not clean up after himself, and fails to complete chores despite repeated redirection. He has no other medical conditions. Family history is significant for a substance use disorder in the patient’s 16-year-old brother and depression in his mother. Treatment options are discussed with the parents. They would like to try medication but prefer a nonstimulant option. Which of the following is the most appropriate pharmacotherapy for this patient?
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Question 9 of 10
9. Question
A 35-year-old woman is hospitalized following a high-speed motor vehicle collision in which she was an unrestrained passenger. She sustained multiple deep lacerations on her extremities, rib contusions, and a complex humerus fracture requiring surgical fixation. Over the next 2 days, the patient’s pain is treated with oral morphine every 6 hours and nonsteroidal anti-inflammatory drugs (NSAIDs) every 4 hours. Her pain is controlled with this regimen but recurs if the interval between morphine doses is extended to 8 hours. The patient is otherwise medically stable for discharge. She is concerned about continuing to use narcotics at home to treat her pain because her cousin had a history of opioid use disorder and passed away several years earlier due to an overdose. Which of the following actions by the physician is most appropriate?
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Question 10 of 10
10. Question
A 21-year-old woman is brought to the emergency department by her roommate due to anxiety. The patient has generalized anxiety disorder and takes sertraline but has been increasingly restless for the past 2 days, pacing in her room and startling easily. She has been studying for a graduate school entrance examination for the past month, staying up late and drinking 2 cups of coffee a day. The patient has been taking her roommate’s tramadol for headaches that have become more frequent. She has no other medical or psychiatric history. Temperature is 37.7 C (99.9 F), blood pressure is 140/80 mm Hg, pulse is 100/min, and respirations are 14/min. The patient appears jittery and has perspiration on her forehead. No abnormalities are noted on cardiopulmonary examination. Muscle tone is mildly increased in the upper and lower extremities. Deep tendon reflexes are symmetric and 3+ throughout. The patient says she feels overwhelmed and unprepared for her exam. Which of the following is the most likely diagnosis?
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