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Question 1 of 36
1. Question
A 12-year-old boy is brought to the office due to behavioral problems. His parents are upset about his poor grades and recent school suspension for setting fires in the locker room and stealing another student’s cell phone. They say that the boy has always been impulsive, had a lot of energy, and become angry and argumentative easily, but over the past year his aggressive behavior “has gotten out of control.” The patient says that the fires were an “accident,” although he admits to being angry at the coach for kicking him off the basketball team. Regarding the theft, he jokingly says, “People deserve to have their phones stolen when they are stupid enough to leave them in plain sight.” The patient has a history of getting into trouble for talking back to teachers, skipping class, and getting into fights since the fourth grade. He has no medical history. There is a family history of bipolar disorder and alcohol dependence. The patient smokes cigarettes occasionally but denies illicit drug or alcohol use. Which of the following is the most likely diagnosis in this patient?
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Question 2 of 36
2. Question
A 45-year-old man is hospitalized due to suicidal ideation. Over the past month, the patient has become increasingly depressed, withdrawn, and physically restless. He has had increasing difficulty concentrating at his job as a computer programmer. The patient’s appetite has been poor, and he has had difficulty falling and staying asleep. He stopped going to work last week and refused to leave the house until his hospitalization. The patient has no medical or psychiatric history. Physical examination is unremarkable apart from a 4.5-kg (10-lb) weight loss. On mental status examination, the patient appears depressed and anxious. He reports that he is responsible for “all the evil in the world” and has heard a voice for the past week telling him that he does not deserve to live. Which of the following is the most likely diagnosis in this patient?
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Question 3 of 36
3. Question
A 72-year-old woman is admitted to the hospital due to abnormal vaginal bleeding. Uterine cancer is diagnosed and the patient is scheduled for a hysterectomy. Following successful surgery, the patient compliments her surgeon, exclaiming that she is “a brilliant doctor who saved my life.” After an uneventful recovery, the patient is ready to return home. On the day of discharge, a nurse informs her that the surgeon is running late due to an emergency. The patient responds angrily that the surgeon is “terrible and doesn’t care about patients.” Which of the following is the most likely explanation for this patient’s behavior?
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Question 4 of 36
4. Question
A 14-year-old girl is brought to the office by her mother due to unusual behavior over the past year. The mother is concerned that her daughter seems overly anxious about eating, and says, “During lunch, she spent 45 minutes cutting the broccoli on her plate until all the pieces were the same size.” The patient recently became a vegetarian and spends hours in the grocery store selecting vegetables and checking nutritional information. She also seems very concerned about her appearance; she brushes her hair 21 times on each side, parts her hair strand by strand, and plucks her eyebrows for an hour daily. The patient says, “If I don’t keep things exactly even I’m afraid something bad might happen.” The patient is medically healthy and has not yet started menstruating. She weighs 45.8 kg (101 lb) and is 157.5 cm (5 ft 2 in) tall. BMI is 18.5 kg/m2. Physical examination is normal with the exception of extremely sparse eyebrows. Which of the following is the most likely primary diagnosis?
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Question 5 of 36
5. Question
A 62-year-old woman comes to the office for a checkup. Her husband died 5 months ago in a biking accident, which she witnessed. She has little appetite, resulting in weight loss of 3.17 kg (7 lb), and tends to wake up two hours before her alarm clock rings. The patient feels overwhelmed at having to manage the household finances, saying, “My husband always took care of the bills so I wouldn’t have to worry.” She avoids cycling, a hobby she shared with her husband, but continues to volunteer at a children’s hospital. The patient has no nightmares or suicidal thoughts. During the visit, she tears up intermittently but smiles when sharing a memory of a vacation she took with her husband. Which of the following is the best explanation for this patient’s condition?
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Question 6 of 36
6. Question
A 65-year-old woman comes to the office accompanied by her husband for follow-up of hypertension. She has been prescribed a thiazide diuretic, and her dose was increased at the last visit due to poorly controlled blood pressure. At today’s visit, the patient’s blood pressure remains elevated. Her husband says, “I’m trying to do everything I can to get her blood pressure under control. I cook healthy food and remind her to take the medication, but I’m not sure she’s taking it.” The patient says, “Taking the medication is a hassle; I know my pressure has been high but I feel absolutely fine.” Which of the following responses by the physician is the most appropriate?
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Question 7 of 36
7. Question
A 40-year-old woman is brought to the emergency department by her roommate due to significant left leg weakness. The symptom began 3 days ago after her father had a heart attack. There is no personal or family history of neurological disease; surgical history includes liposuction of the thighs and varicose vein removal. She does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98.1 F), blood pressure is 123/81 mm Hg, pulse is 62/min, and respirations are 14/min. Physical examination reveals symmetric 2+ deep tendon reflexes as well as normal muscle bulk and tone bilaterally in the upper and lower extremities. Laboratory testing and neurologic imaging reveal no abnormalities. Which of the following is the most likely diagnosis?
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Question 8 of 36
8. Question
A 33-year-old man is hospitalized after neighbors called the police to report that he has been singing loudly and playing the piano “nonstop” all day and night for the last month. The patient says his mood is “terrific,” claims he is related to the President, and hears voices telling him he is going to be a famous entertainer. While in the hospital, he makes inappropriate sexual advances toward some of the female nurses. He has a history of 9 psychiatric hospitalizations starting at age 22 for mood and psychotic symptoms. In between hospitalizations, the patient has heard voices commenting on his appearance and has believed that secret cameras have been monitoring him, but he has had no mood symptoms. Which of the following is the most likely diagnosis in this patient?
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Question 9 of 36
9. Question
A 22-year-old college student comes to the office due to tension headaches and neck pain. He has had these symptoms for many years, but they have increased in frequency over the past 7 months since he started working at a coffee shop. The patient attends college and says that although his grades are passing, he feels overwhelmed and fatigued: “I can’t concentrate on my schoolwork and worry that I will flunk out of school and never get a good job.” He sleeps very fitfully and frequently worries about his grades, health, and social life. He obsesses about minor comments his friends have made about how “serious” he is, and gets depressed thinking that he is not attractive enough to get a girlfriend. Which of the following is the most likely diagnosis in this patient?
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Question 10 of 36
10. Question
A 32-year-old woman comes to the office due to overwhelming anxiety and stress. The patient is an accountant and has been under increasing job-related pressure for the past 6 weeks due to an upcoming tax deadline. She says, “The worst part is that I get really nervous all of a sudden and then feel shaky, dizzy, and nauseated and start to sweat. It happened while I spoke to my boss a few weeks ago, and I had to excuse myself.” The patient is especially worried about having an episode during a work meeting, although she notes that her symptoms have also occurred while she was relaxing at home. She says, “I’ve stopped going out with my friends because I never know when I’m going to feel this way.” The patient has no significant medical history and does not use alcohol or drugs. Blood pressure is 120/70 mm Hg, pulse is 72/min, and respirations are 18/min. Physical examination and laboratory evaluation show no abnormalities. Which of the following is the most likely diagnosis?
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Question 11 of 36
11. Question
A 79-year-old man is brought to the office by his wife for evaluation of memory impairment. The patient is a recently retired professor who began having memory problems a month ago. He has been forgetting to take his medication, has had difficulty remembering the names of his grandchildren, and has neglected to turn off the stove on more than one occasion. The patient used to enjoy reading and playing with his grandchildren but has recently stopped doing both of these activities. He also has difficulty staying asleep, low appetite, and decreased energy. The patient has hypertension and type 2 diabetes, for which he takes medications. He has a family history of Alzheimer disease. The patient says, “I just feel so worthless since retiring.” Temperature is 36.7 C (98.1 F), blood pressure is 119/78 mm Hg, pulse is 74/min, and respirations are 14/min. Neurological examination reveals no focal deficits. Montreal Cognitive Assessment score is 23 (normal: ≥26/30). Which of the following is the most likely diagnosis?
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Question 12 of 36
12. Question
A resident physician is finishing up her shift when she receives a page that reads, “Patient in Room 121 asking to leave.” The patient was admitted 2 hours ago for worsening dyspnea. On entering the room, the resident attempts to engage in a discussion about why the patient is requesting to leave. In response, the patient pulls out his nasal cannula and breathlessly says, “You don’t know anything; you’re not even a real doctor!” The resident is reminded of her father, who has frequently belittled her accomplishments. She angrily informs the patient, “You can’t leave and I’m ordering haloperidol to calm you down.” Which of the following best explains the resident’s response to the patient?
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Question 13 of 36
13. Question
A 52-year-old man comes to the office for follow-up to discuss the results of his colonoscopy. The physician informs the patient that a cancerous polyp was removed and that there is no evidence of invasive cancer at the resection margins. He is then reassured that he has an excellent prognosis. In response, the patient curses and shouts angrily, “Are you telling me I should be happy that you found cancer in the first place? You don’t know what you’re doing!” Which of the following is the most appropriate response to the patient?
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Question 14 of 36
14. Question
A 23-year-old man comes to the physician at his girlfriend’s insistence. She says that the patient’s frequent snoring keeps her up at night and that in the last 4 months he has twice fallen asleep while they were talking. In this same period, the patient says that he has regularly fallen asleep in the afternoon while reading or watching television but typically feels refreshed after a brief nap. When asked whether he experiences any other symptoms, the patient hesitantly reveals that he sometimes hears a voice call his name prior to falling asleep. He also reports uncharacteristic episodes of clumsiness in which he has suddenly dropped objects or fallen to his knees. Examination shows no abnormalities. Which of the following is the most likely diagnosis in this patient?
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Question 15 of 36
15. Question
A 31-year-old man is brought to the emergency department by the police after he assaulted a stranger who he thought was following him. The police report indicates that when the patient was arrested, he was shouting, “You don’t understand, I’m the one who needs protection—the Russians are after my secrets!” In the emergency department, the patient is diaphoretic and tremulous. He is very easily distracted and cannot give a clear history. Temperature is 37 C (98.6 F), blood pressure is 164/102 mm Hg, and pulse is 112/min with a normal rhythm. Extraocular movements are intact, and the pupils are dilated. His speech is loud, rapid, and difficult to interrupt. Which of the following is the most likely diagnosis?
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Question 16 of 36
16. Question
A 45-year-old man comes to the office due to chronic insomnia. The patient has trouble sleeping because he claims he must remain alert to protect himself from workers at a nearby chemical plant. He says they are poisoning him by secretly dumping toxic waste in his backyard at night. The patient’s wife says, “He’s been like this for the past 10 years. He gets very upset when asked for proof, so he’s going to install cameras next week.” She has never seen any unusual activity in the backyard and says that her husband has never received an actual threat or endured actual harm. He has ordered numerous soil toxicity tests over the years, all of which have been negative. The patient started working as a taxi driver at age 21 and continues to work for the same company. He has no history of psychiatric treatment. Which of the following is the most likely diagnosis for this patient?
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Question 17 of 36
17. Question
A 32-year-old woman comes to the office due to long-standing anxiety. She reports being excessively worried about everyday events and constantly feeling tense and unable to relax. The patient is diagnosed with generalized anxiety disorder and treated with a selective serotonin reuptake inhibitor. She returns to the office for a 2-month follow-up and reports that her overall anxiety has improved, but she continues to have periods of increased anxiety before bedtime that keep her awake at night. The patient works as a 911 emergency dispatch operator and would be willing to add a medication at bedtime but needs to be “clearheaded” for work. Which of the following medications is most appropriate for this patient’s condition?
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Question 18 of 36
18. Question
A 67-year-old woman comes to the office due to difficulty concentrating. She reports repeatedly reading the same page of material due to an inability to focus. She also describes memory problems, stating that it “takes a while to remember another person’s name.” The patient’s medical history is significant for hypertension and type 2 diabetes mellitus. These are well controlled through diet, exercise, and oral medications. She lives alone and describes her mood as “good.” Blood pressure is 127/67 mm Hg and pulse is 65/min. The physician decides to administer a brief cognitive test to assess her difficulty in concentrating. Which of the following elements of cognitive testing would best assess for impaired attention and concentration in this patient?
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Question 19 of 36
19. Question
A 26-year-old woman comes to the office due to recent weight gain. She has eaten more than usual over the last 5 months, has gained 3.2 kg (7 lb), and feels guilty and depressed about it. Further questioning reveals that she consumes a large pizza and two large bags of chips in one sitting several times a week. Afterward, the patient feels ashamed about being unable to control her intake and fasts to make up for it. She is very distressed about being unable to lose weight despite exercising 2-3 hours a day. Vital signs are within normal limits. BMI is 23.7 kg/m2. Despite being told that her BMI is normal, the patient insists that she is overweight. Which of the following is the most likely diagnosis?
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Question 20 of 36
20. Question
A 35-year-old man comes to the office due to a lack of sexual interest. He says, “I started seeing this woman 9 months ago and am really attracted to her. We get along well and things are great, but I just don’t want to have sex with her anymore.” On further questioning, the patient reluctantly admits that whenever they have intercourse he has an orgasm in less than a minute and finds this very embarrassing. He does not have the same problem when he masturbates. He says, “I’m worried that my girlfriend will leave me, and it’s really affecting my self-esteem.” The patient has no other concerns. His other medical conditions include type 1 diabetes mellitus, chronic insomnia, and a history of major depression. His medications include insulin glargine, short-acting insulin, and trazodone. He does not use illicit substances. Vital signs are within normal limits. Laboratory results are significant for hemoglobin A1c of 7% and fasting glucose of 130 mg/dL. Which of the following is the most likely diagnosis?
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Question 21 of 36
21. Question
A 45-year-old woman brings her stepson to the office for a well-child visit. She never wanted children due to her unhappy childhood and wishes her marriage did not include being a stepmother to her husband’s 5-year-old son. In the waiting room, the woman seems excessively concerned when the boy accidentally trips and is clearly uninjured. During the visit, she tells the physician that she adores the child and describes her elaborate preparations for his birthday party. Which of the following defense mechanisms best explains this woman’s behavior?
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Question 22 of 36
22. Question
A 32-year-old man comes to the office due to anxiety that has intensified since he was promoted to a managerial position. Whereas he previously worked alone, his new position requires him to interact with a team of five employees and handle customer service complaints. The patient says he is anxious throughout the day and fears that he will say something embarrassing or that his coworkers and customers will notice his anxiety and think he is incompetent. He says he was very quiet and shy growing up and would always get anxious when meeting new people. He has a few friends with whom he socializes, but he typically has three or four alcoholic drinks before going out with them to feel more relaxed. The patient does not feel depressed, and his sleep and appetite are normal. A medication with which of the following mechanisms of action would be most appropriate for this patient?
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Question 23 of 36
23. Question
A 13-year-old girl is brought to the office for a routine visit. Although the patient is doing well in school and has friends, her mother is concerned about a change in her behavior over the past several months. They had previously enjoyed spending time together, but now the patient is frequently moody and spends most of her time on the computer in her locked bedroom. The mother also observes that her daughter gets upset for no reason and has used swear words on occasion. When the mother recently complimented her party outfit, the girl screamed, “I look hideous and I’m not going,” and stormed out of the room. Later that day, she seemed fine and went to the party. On examination, the patient is pleasant and cooperative but makes little eye contact and asks if she can keep her tank top on during the examination. Which of the following is the most likely explanation for this girl’s behavior?
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Question 24 of 36
24. Question
A 35-year-old woman comes to the office for evaluation of anxiety. The patient works as a mechanical engineer and recently declined a promotion to be a project manager. Although her salary would have increased significantly, she felt that overseeing other employees and leading team meetings would be too stressful. She says, “If something were to go wrong, everyone would blame me. I don’t even know why they offered me this position.” The patient enjoys her job but tends to eat lunch by herself because she feels that her coworkers do not like her appearance or sense of humor. She has never had a long-term romantic partner but fantasizes about getting married someday. The patient lives alone, rarely socializes with friends, and is close with her mother, whom she describes as “the person I can always rely on no matter what.” Which of the following is the most likely diagnosis?
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Question 25 of 36
25. Question
A 32-year-old man comes to the office due to disabling anxiety. The patient was recently promoted to his company’s headquarters, requiring him to work on the 48th floor of the building. As soon as he steps on the elevator, he feels panicky and faint, sweats profusely, and has heart palpitations. The patient is worried that he might have to resign if he is unable to control his anxiety. His fear of elevators dates back to childhood. He drinks 1 or 2 beers on weekends but does not use tobacco or illicit drugs. Which of the following is the most effective long-term treatment for this patient’s condition?
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Question 26 of 36
26. Question
A healthy 8-year-old boy is brought to the office by his parents for an annual checkup. Both parents express concern about their son’s behavior. The mother says, “He never listens and I am always worried that he is going to run out into the street without looking. He rarely sits still and is always running and jumping on the furniture.” The father adds, “He talks all the time, interrupts me when I’m speaking, and, despite multiple reminders, forgets to do his chores and misplaces or loses his books or sporting equipment. We thought he would grow out of it as he got older, but it seems to be getting worse.” Physical examination is unremarkable. Which of the following would be most helpful in establishing the diagnosis?
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Question 27 of 36
27. Question
A 5-year-old boy is brought to the office by his mother for a checkup. He is healthy and about to start kindergarten. His mother is concerned about his recent reaction to her brother’s death. “Although I told him that Uncle John died and can’t be with us anymore, he insists that he is coming for his birthday and will take him to a ballgame. He died over 3 months ago, but my son repeatedly asks me when he is coming back. When I try to explain, he starts crying that his stomach hurts.” Physical examination is normal. During the examination he tells the physician, “I try to clean up my toys before bedtime so mommy won’t cry.” Which of the following is the most likely explanation for the patient’s behavior?
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Question 28 of 36
28. Question
A 3-year-old boy is brought to the office for a well-child visit. His mother reports that, apart from an ear infection last year, he is in good health. The child started preschool this year. He plays alongside other children and often copies what they are doing but does not play cooperatively with them. The patient knows his age and gender and speaks in 3-word sentences. He can ride a tricycle. The patient cannot use a spoon or fork but enjoys eating with his hands. He scribbles spontaneously but cannot copy a circle. He weighs 14.5 kg (32 lb) and is 96.5 cm (3 ft 2 in) tall. Head circumference is 50.8 cm (20 in). Which of the following developmental milestones is likely delayed in this patient?
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Question 29 of 36
29. Question
A 23-year-old woman comes to the emergency department due to right wrist pain after a fall. The patient fell on her outstretched hand while walking across the floor at a gym where she exercises regularly. She has no significant medical history and takes no medications. The patient says she avoids eating high-fat or high-carbohydrate foods because she wants to avoid “getting bloated” and “gaining fat.” Her last menstrual period was 7 months ago. She does not use tobacco, alcohol, or recreational drugs. Temperature is 35.9 C (96.6 F), blood pressure is 90/58 mm Hg, and pulse is 48/min. BMI is 18 kg/m2. Tenderness and swelling are present over the right distal radius. The parotid glands are enlarged and there are fine, soft hairs on her extremities. Urine pregnancy test is negative. X-ray reveals a nondisplaced fracture of the right distal radius and generalized radiolucency of the bone. Which of the following is the most likely underlying diagnosis?
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Question 30 of 36
30. Question
A 24-year-old man comes to the emergency department due to a painful erection for the past 6 hours. He has never had this condition before and says it is unrelated to sexual excitement. Medical history is significant for treatment-resistant major depressive disorder, obsessive-compulsive disorder, and insomnia. The patient has smoked a pack of cigarettes a day for 2 years and drinks 1 or 2 cans of beer daily. Examination reveals engorged corpora cavernosa but otherwise shows no abnormalities. Which of the following drugs is the most likely cause of this patient’s condition?
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Question 31 of 36
31. Question
A 27-year-old woman comes to the office due to concerns about her weight. She is frustrated about gaining a few pounds, although she maintains a well-balanced diet and exercises for an hour 3 times a week. The patient has been worried for years that her thighs are “huge” and “covered in cellulite.” She always wears loose-fitting pants and spends hours a day researching leg exercises and measuring the circumference of her thighs. The patient generally stays at home and avoids social activities as she feels people tend to stare at her. She weighs 58 kg (127.9 lb) and is 170 cm (5 ft 7 in) tall. Physical examination is normal. Which of the following is the most likely diagnosis?
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Question 32 of 36
32. Question
A 28-year-old man comes to the office due to occasional anxiety attacks over the past 6 months. The patient describes episodes that “come out of nowhere” in which he feels light-headed, sweaty, shaky, and nauseated. He says, “At first I didn’t really care because the attacks don’t last long, but now I’m worried I’ll have one while I’m at work or when I’m driving.” The patient has no history of cardiac disease and takes no medications. He has 4 or 5 alcoholic drinks 3 times a week and adds, “Having some beers and watching football really help take my mind off of things.” The patient appears calm, and vital signs are within normal limits. Physical examination, ECG, comprehensive metabolic panel, and thyroid function tests show no abnormalities. Which of the following is the most appropriate pharmacotherapy for this patient?
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Question 33 of 36
33. Question
A medical student just finished the USMLE Step 1 exam and is anxious about her performance. She is especially unnerved when fellow students talk about the difficulty of the exam and discuss their answers to certain questions. The student decides not to think about the exam until her score arrives because “worrying isn’t going to change the result.” She is delighted when she receives a very high score several weeks later. Before receiving the result, the student exhibited which of the following defense mechanisms?
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Question 34 of 36
34. Question
A 28-year-old man is hospitalized due to the acute onset of severe depression and suicidal ideation for several days. He was recently thrown out of his mother’s home after stealing her money to support his drug habit. The patient reports fatigue and vivid, disturbing dreams. The nursing staff note that he is irritable, withdrawn, hypersomnolent, and hyperphagic. The patient has an extensive history of substance abuse and has been hospitalized previously for alcohol detoxification. Blood pressure is 110/80 mm Hg and pulse is 64/min. Physical examination shows old injuries from a motorcycle accident but no other abnormalities. On mental status examination, he appears lethargic and dysphoric. This patient’s current symptoms are most likely the result of which of the following conditions?
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Question 35 of 36
35. Question
A 27-year-old man is brought to the emergency department by his wife. She says that he has been “acting crazy” for the last 2 weeks. He has hardly slept for the past 7 days and instead has worked on miscellaneous projects around the house. The patient spent several thousand dollars on new power tools to accomplish these tasks. When questioned, his speech is rapid and frenzied. He feels “spectacular” and is creating an “architectural masterpiece.” The patient has had 2 previous depressive episodes. Which of the following medications is the most appropriate agent for long-term management of this patient?
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Question 36 of 36
36. Question
A 27-year-old man is brought to the emergency department by his roommate, who found the patient barricading himself in a closet at home and saying, “They’re coming to get me. No one can be trusted.” The patient was laid off from his job and broke up with his girlfriend last month. He has heard voices threatening to kill him a few times daily for the past 2 weeks. He has no medical or psychiatric history and does not use alcohol or illicit drugs. Physical examination and laboratory results are unremarkable. On mental status examination, the patient is fearful and tense. He describes being followed by men in black cars who are spying on him. Which of the following is the most likely diagnosis in this patient?
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