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Question 1 of 30
1. Question
A 37-year-old woman with a history of recurrent major depressive disorder comes to the office. Her father died last month after a long illness, and she is concerned that her depression is returning. The patient has little appetite, sleeps poorly, and has difficulty concentrating at her job as a teacher. She recently stopped going to the gym and socializing with friends, activities that she used to enjoy. She has been collecting pills from half-empty bottles of old medication and has considered taking all of them at once. The patient has no history of suicide attempts. Her mother completed suicide at age 40. Which of the following is the most important factor in assessing this patient’s suicide risk?
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Question 2 of 30
2. Question
A 34-year-old woman comes to the office accompanied by her husband for an employment physical examination. The patient says, “I’d rather not be here, but my job requires labs every 2 years.” While getting blood drawn, she starts to feel anxious, nauseated, and short of breath, and says, “I feel like the room is spinning.” The patient’s husband explains that she has had similar episodes since childhood, which began following a bike accident during which she cut her knee and bled profusely. Medical history is significant for asthma and type 2 diabetes mellitus. Temperature is 36.7 C (98.1 F), blood pressure is 140/90 mm Hg, pulse is 104/min, and respirations are 20/min. BMI is 36 kg/m2. Physical examination is significant for anxious demeanor but is otherwise unremarkable. Which of the following is the most likely diagnosis?
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Question 3 of 30
3. Question
A 24-year-old woman comes to the office due to recurrent episodes of chest pain, palpitations, and shortness of breath over the past few months. During some episodes, she experiences dizziness, diaphoresis, and paresthesias of the hands. The episodes last 5-10 minutes, and the patient constantly worries about when and where she will have another one. She says, “This keeps happening and no one has been able to tell me why. I’m scared something might be seriously wrong with me.” The patient has been to the emergency department twice in the past month for similar episodes; prior evaluation, including complete metabolic profile, thyroid function tests, arterial blood gas analysis, ECG, cardiac enzymes, and chest x-ray, showed no abnormalities. Vital signs are within normal limits. Physical examination is unremarkable. Which of the following is the most likely diagnosis?
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Question 4 of 30
4. Question
A 32-year-old man with schizophrenia comes to the office for follow-up. The patient has been stable on his antipsychotic medication for many years. He has infrequent auditory hallucinations and says that the medication “has helped a lot to turn down the volume of the voices.” The patient works stocking grocery shelves part-time and lives with his parents, who are supportive. His symptoms first developed gradually at age 14 when he exhibited nonspecific anxiety and became increasingly paranoid that others were talking about him behind his back; he also became preoccupied with finding special meanings in certain numbers. A year later he was hospitalized for a psychotic episode characterized by paranoid delusions and auditory hallucinations that responded rapidly to antipsychotic medication. The patient was able to finish high school. He was hospitalized again briefly at age 22 but has remained out of the hospital since then. Which of the following factors is most predictive of a favorable prognosis for this patient?
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Question 5 of 30
5. Question
A 69-year-old woman comes to the office due to memory concerns. The patient first began having difficulties with her memory a year ago, and her symptoms have steadily worsened. She often forgets the content of conversations she has with her son and frequently walks to another room, only to forget what she went there to do. The patient lives alone and has no difficulty cooking, cleaning, or otherwise caring for herself. She manages her own finances. Medical history is significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus. Temperature is 36.9 C (98.4 F), blood pressure is 132/83 mm Hg, pulse is 72/min, and respirations are 14/min. The patient is alert and oriented. Neurological examination reveals no focal deficits. She scores 22/30 on the Montreal Cognitive Assessment. Which of the following is the most likely diagnosis?
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Question 6 of 30
6. Question
A 39-year-old man is brought to the office by his wife who is concerned about his behavior over the past year. She says, “He used to be outgoing and upbeat, but now he seems uncharacteristically depressed and distant from the family. He has lost interest in his work and has difficulty making decisions.” Over the past month, he has become increasingly paranoid and believes that his business partner is trying to kill him. The patient has no psychiatric history. Both his father and grandfather were hospitalized in long-term care facilities and died in their 50s. Physical examination shows random, abrupt, uncoordinated movements of the left leg. On mental status examination the patient is restless and irritable. He is convinced that not only his business partner but also the government is out to harm him. Which of the following is the most likely diagnosis?
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Question 7 of 30
7. Question
An 82-year-old man is brought to the office by his daughter due to behavioral changes. She reports that over the past year her father has become increasingly paranoid and frequently talks out loud as if in conversation when no one else is present. The daughter says, “During a recent argument, he accused me of being an imposter and stealing his personal items. Also, he used to be very clean, but his personal hygiene has gotten really bad. He also stopped watching baseball, which used to be his favorite hobby.” The patient’s medical history is significant for hypertension, hypercholesterolemia, and type 2 diabetes mellitus. Medications include lisinopril, simvastatin, and metformin. The patient has been unable to live independently for the past 2 years due to increasing forgetfulness and an inability to perform self-care. Vital signs are stable, and physical examination and laboratory evaluation are unremarkable. Which of the following is the most likely explanation for this patient’s behavior?
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Question 8 of 30
8. Question
A 16-year-old boy is brought to the office for a well-child visit. The patient has no medical history but reports that his appetite is low and he has lost 2.3 kg (5 lb). He stopped playing soccer recently due to lack of interest. The patient is also worried about his grades due to difficulty staying focused in class and concentrating on his homework after school. He feels tired despite sleeping 10 hours a night and taking afternoon naps when he gets home. The patient says, “My parents try to be supportive, but everything they say these days gets on my nerves.” He has tried alcohol and marijuana a few times at parties but does not use other drugs. Vital signs are within normal limits. Physical examination is unremarkable. Which of the following is the most appropriate next step in management of this patient?
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Question 9 of 30
9. Question
A 78-year-old man comes to the office for a regularly scheduled review of his chronic medical problems. The patient has hypertension, coronary artery disease, and type 2 diabetes mellitus, for which he takes metformin, atorvastatin, lisinopril, and nitroglycerin as needed for chest pain. He takes his medications as prescribed and follows diet and exercise instructions. During the discussion, he hesitates, laughs nervously, and says, “I can’t get an erection anymore, and my wife says I have to ask you about getting the ‘blue pill.’” Which of the following is the most appropriate response to this patient’s concern?
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Question 10 of 30
10. Question
A 46-year-old woman comes to the office due to sexual difficulties for the past year. The patient rarely thinks about sex anymore and frequently declines sex when her husband tries to initiate. She is attracted to her husband and worries that he assumes she is losing interest in him. Although vaginal lubrication is adequate during sex and the patient can reach orgasm, she finds that her mind wanders during the experience. She is unsure what is causing a decrease in her sex drive, although she notes that she received a promotion 3 months ago and has been working longer hours since then. The patient describes her marriage as stable and loving. She has a history of a depressive episode and currently takes bupropion. Physical examination and laboratory studies, including thyroid function tests, show no abnormalities. Which of the following is the most likely diagnosis?
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Question 11 of 30
11. Question
A 15-year-old boy is brought to the office by his parents due to concern about his development. The patient has had a long-standing interest in fashion and a preference for having girls as friends, and his parents noticed that he recently bought women’s underwear and shoes and went out to meet friends wearing makeup. They worry that he is being bullied since moving to a new high school last year. When interviewed privately the patient says, “I have always wanted to be a girl.” He is distressed that his voice is deepening and that he is developing facial and pubic hair, which he shaves regularly. Which of the following is the most likely explanation of this patient’s behavior?
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Question 12 of 30
12. Question
A 64-year-old man is brought to the office for evaluation of abnormal behaviors during sleep. According to his wife, over the past 3 months the patient has had episodes of repeatedly punching at the pillow and screaming loudly while asleep. When awakened from these episodes, he recalls a disturbing dream in which he is chased by assailants and must defend himself or escape. The episodes usually last less than 1-2 minutes. Vital signs are within normal limits. General physical and mental status examinations show no abnormalities. A formal sleep study (polysomnogram) is ordered. Which of the following is most likely to be identified during this testing?
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Question 13 of 30
13. Question
A 2-day-old infant is evaluated in the newborn nursery due to poor feeding. The infant is irritable, is not sleeping well, and has had several episodes of vomiting and loose stools today. A review of the maternal history reveals that the mother had poor prenatal care and that the pregnancy was complicated by fetal growth restriction. On examination, the infant is diaphoretic and has a high-pitched cry. The infant is also noted to have occasional sneezing and is mildly tachypneic. No dysmorphic features are noted, and the remainder of the examination is unremarkable. This infant’s symptoms are most likely caused by prenatal exposure to which of the following?
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Question 14 of 30
14. Question
A 45-year-old man comes to the emergency department with multiple hand lacerations sustained when he punched his hand through a window. The patient says he “momentarily lost control” when he came home from work to find that his wife had moved out of the home and taken their two children. Temperature is 37.2 C (99 F), blood pressure is 150/88 mm Hg, and pulse is 96/min. The patient has multiple abrasions and cuts on his right hand and is informed that two lacerations will require suturing. The patient is agitated and angrily says, “I’ve been waiting a really long time and have to get out of here and set things straight with my wife and kids. I don’t have time for stitches anymore. You are all incompetent.” Which of the following questions is most appropriate in determining the best next step in management of this patient?
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Question 15 of 30
15. Question
A 38-year-old woman comes to the office due to dissatisfaction with her weight. Although the patient exercises with a personal trainer weekly and tries to eat well-balanced meals, she loses control several times a week, frequently consuming an entire pizza or large bag of chips by herself. The patient says, “I’m not even hungry when it happens, and I feel so guilty afterward. I can’t even look at myself in the mirror anymore because I’m disgusting.” She smokes marijuana once a week and does not use alcohol or other recreational substances. BMI is 23.4 kg/m2. Which of the following is the most likely explanation for this patient’s eating habits?
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Question 16 of 30
16. Question
A 14-year-old girl is brought to the office by her parents for a sports participation examination. The patient is a competitive figure skater and practices before and after school 5 days a week. Her parents are concerned because she recently announced that she will eat only a vegetarian diet, and they are having difficulty providing an adequate variety of meat-free food options around her busy school and athletic training schedule. The patient is otherwise healthy; menarche occurred at age 12 and she has regular menstrual cycles. Vital signs are normal. BMI is 17 kg/m2. Physical examination is normal for age. Which of the following is the most appropriate next step in management of this patient?
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Question 17 of 30
17. Question
A 44-year-old man comes to the office due to fatigue for the past 6 months. He says, “I’ve fallen asleep at work a few times, and I really have to push myself to concentrate. I can’t seem to get a good night’s sleep either because I keep waking up.” The patient feels guilty that he has been spending less time with his kids due to feeling tired and states his mood has been low the past week. He worries that his wife is annoyed with him because he has not been helping with household chores as much and keeps her up at night due to his snoring. The patient drinks 3 or 4 beers a week and does not use tobacco or illicit drugs. Medical history is noncontributory. Blood pressure is 146/94 mm Hg and pulse is 78/min and regular. BMI is 32 kg/m2. Which of the following is the most likely diagnosis?
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Question 18 of 30
18. Question
A 23-year-old woman at 8 weeks gestation comes to the office for an initial prenatal visit. The patient has no vaginal bleeding or pelvic pain. On examination, areas of bruising in different stages of healing are seen on the chest and abdomen. When asked about the bruises, the patient states that her boyfriend used to hit her during arguments and was initially angry about the pregnancy. Over the past 3 weeks, he has been more supportive, buying prenatal vitamins and offering massages. Ultrasound examination confirms an 8-week intrauterine gestation and normal fetal heart rate. Which of the following is the most appropriate next step in management of this patient?
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Question 19 of 30
19. Question
A 38-year-old woman is brought to the emergency department after causing a disturbance in a department store. The patient says that the government was releasing poisonous gas through the air vents of the store and that red-colored clothing items were a signal to evacuate. She was arrested a year ago for a similar incident. The patient dropped out of college at age 20. She lives with her parents and has never worked. She smokes a pack of cigarettes a day but does not use alcohol or drugs. Physical examination is unremarkable. On mental status examination the patient appears distracted and fearful. She reports hearing the voices of two men who criticize her actions continuously and have done so for years. Which of the following abnormalities is most likely associated with this patient’s symptoms?
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Question 20 of 30
20. Question
A 34-year-old man comes to the emergency department for evaluation of abdominal pain. He reports severe pain unrelated to meals that is sharp, stabbing, and 10 out of 10 in severity. The patient has been hospitalized twice in the past year for similar symptoms and states that a diagnosis was never found. He declines when asked to sign a release of information to obtain his prior medical records. Vital signs are within normal limits. On physical examination, heart and lung sounds are normal. Abdomen is soft and nondistended with normoactive bowel sounds. The patient grimaces and moans in pain throughout the evaluation. Laboratory evaluation and abdominal CT scan show no abnormalities. After hearing the results, the patient asks for a note to excuse him from work so that he can recover at home for a few days. Which of the following additional features is most likely to be present in this patient?
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Question 21 of 30
21. Question
A 17-year-old girl is brought to the office by her parents for evaluation following the accidental drowning of her younger sister a week ago. The patient, her sister, and 2 friends had gone swimming in the ocean. When the sister became submerged, the patient attempted to rescue her but was overpowered by strong rip currents and was forced to return to shore. The mother is concerned that her daughter seems to be unaware of her sister’s death and believes she is “in denial.” The patient was unable to answer questions from the police about the drowning and reports she cannot remember any details of what happened that day. Physical examination is unremarkable. On mental status examination, the patient is alert and fully oriented. She becomes upset and confused when the incident is discussed. Which of the following is the most likely diagnosis?
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Question 22 of 30
22. Question
A 48-year-old woman with major depressive disorder is brought to the emergency department by her husband. The patient is severely depressed; she says she wants to die and has a plan to hang herself. She has no energy or appetite and has lost 5.4 kg (12 lb) over the past month. The patient has difficulty falling asleep and awakens at 4:00 AM each morning. Over the past week, she has heard a voice saying that she is evil and doesn’t deserve to live. In the hospital, she seldom speaks and refuses to eat and drink. Which of the following would provide the most rapid improvement of this patient’s symptoms?
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Question 23 of 30
23. Question
A 45-year-old woman comes to the office due to fatigue, weight gain, and insomnia for the past 2 months. The patient has difficulty falling asleep, awakens at 4:00 AM, and stays awake for the rest of the day. She also describes nonspecific muscle aches and pains in her shoulders, neck, and abdomen. She says, “I was always pretty healthy, but now I worry that something is wrong or that I could have cancer.” The patient has stopped exercising due to lack of motivation and has lost nearly all interest in spending time with friends or family. She has a history of hypertension, for which she takes hydrochlorothiazide. Physical examination is normal except that blood pressure is slightly higher than usual at 142/88 mm Hg and there has been a weight gain of 2.7 kg (6 lb). The patient admits that she has been forgetful recently, sometimes neglecting to take her medication. Laboratory evaluation, including thyroid function testing, is within normal range. The patient appears tense and anxious. Which of the following is the most likely diagnosis?
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Question 24 of 30
24. Question
A 24-month-old girl is brought to the office by her mother due to concerns about walking. The mother says, “She seems so unsteady when she walks. She was walking so well until a few weeks ago, and now she keeps tripping over things.” On examination, the patient is sitting on the floor and clapping her hands. She does not answer questions and instead makes babbling sounds. When her mother encourages her to walk, the patient pulls to stand using a chair and has an unsteady gait. The remainder of the examination is normal apart from abrasions on both knees, which her mother explains are from frequent falls. Height and weight track at the 50th percentile. At a checkup 6 months ago, the patient had been saying 1- or 2-word phrases and walking without aid. Which of the following neuropathic changes most likely underlies this patient’s presentation?
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Question 25 of 30
25. Question
A 19-year-old college student comes to the office with new-onset fatigue. The patient has had difficulty getting up in the morning for the past week and states he would sleep 10-12 hours if his schedule allowed. He also reports vivid dreams. The patient was diagnosed with attention-deficit hyperactivity disorder at age 10 and has been treated with dextroamphetamine since then. However, his prescription ran out early recently after he doubled the dosage to help him study during exams. Which of the following findings is most likely to be present in this patient?
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Question 26 of 30
26. Question
An 18-year-old woman comes to the office to discuss her pain medication. Five months ago, the patient fractured her vertebrae in a ski accident, requiring surgery and prolonged postsurgical rehabilitation. Since the accident, she has been prescribed hydrocodone/acetaminophen 4 times a day for pain. The patient’s pain is adequately controlled and does not interfere with day-to-day activities. Over the past month, she has tried to stop the medication, but each time, she develops rhinorrhea, lacrimation, and vomiting, requiring her to take it to relieve the discomfort. The patient has reduced hydrocodone/acetaminophen intake from 4 to 3 times daily and cannot reduce it further due to these symptoms. She is anxious and frustrated about not being able to discontinue it. Urine drug screen is positive for hydrocodone only. A review of the state prescription drug monitoring database reveals no other controlled substances or irregularities. Which of the following best describes this patient’s condition?
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Question 27 of 30
27. Question
A 28-year-old woman, gravida 1 para 1, comes to the office for a 6-week postpartum checkup following an uncomplicated delivery. The patient reports feeling increasingly fatigued and having little energy for the past few weeks. She feels very anxious about being a new mother and has been getting up multiple times at night to check on the baby when he is sleeping. She tends to skip meals and says, “I don’t have time to sit and eat—I can’t even find the time to shower.” Although the baby is healthy and doing well, the patient berates herself for being a “terrible mother.” She becomes tearful during the interview and says, “I don’t know why I keep crying when I should be so happy.” Physical examination is normal. The patient has no suicidal ideation or thoughts of harming the baby. Which of the following is the most likely diagnosis?
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Question 28 of 30
28. Question
An 11-month-old boy is brought to the office by his mother for a well-child visit. The mother reports that he has been crying and screaming when other people approach him. She is concerned that it has been occurring for the past few months and that it seems to be worsening. She says, “He used to love being held by everyone but now wants to be with only me. He won’t even let his grandma hold him anymore.” The patient is crawling and can stand only with assistance. He babbles but does not say any clear words and uses hand gestures to communicate. Growth curves are tracking adequately. On physical examination, the patient clings to his mother and begins crying, turning his head away from the physician when he attempts to interact with him. Which of the following is the most likely explanation for this patient’s behavior?
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Question 29 of 30
29. Question
A 16-year-old boy is brought to the office by his father after he was found smoking marijuana in his room. The patient has no medical conditions and takes no medications. The father states that although the patient “swears this was the first time,” he cannot trust him. In school, he receives average grades and plays violin in the orchestra. The patient is interviewed in private. He says that his father “has always had high expectations” and frequently compares him to his older sister, who was valedictorian of her class. When asked about substance use, the patient says, “No matter what I say, I know you’re going to judge me. I’m not like your other patients who do everything right.” Which of the following terms best describes this patient’s response to the physician?
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Question 30 of 30
30. Question
A 27-year-old woman is admitted to the hospital for evaluation of abdominal pain that has intensified over the past 3 months. She describes the pain as severe and has been unable to work due to her symptoms. Medical history includes lower back pain, irregular menstrual cycle, depression, and borderline personality disorder. The admitting senior resident physician obtains a detailed history, after which the patient remarks, “You’re a great doctor, and I can tell you really understand what I’m going through.” Vital signs are stable. Physical examination shows mild, diffuse abdominal tenderness and is otherwise unremarkable. The next day, the patient is seen by the first-year resident physician who explains her role on the treatment team. She performs a brief physical examination, explains that an abdominal CT scan and laboratory tests have been ordered, and offers to answer any questions. The patient refuses to undergo testing and angrily says, “You’re not good at your job. I know a good doctor when I see one. You just order tests without even knowing anything about me.” Which of the following is the most appropriate response by the resident?
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