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Question 1 of 26
1. Question
A 27-year-old man is brought to the office by his wife due to her concerns that “he is not himself.” The patient has been very irritable and hyperactive with difficulty sleeping since returning from a family funeral a week ago. His wife reports that he has been very distracted and unproductive at the factory where he works, to the point that his employer has placed him on probation. Two days ago, he nearly sustained a serious injury while performing risky maneuvers with heavy machinery. When asked about his job, the patient says he has had no difficulties and describes his idea to “use special robot prosthetics to make the production line faster than ever and double everyone’s productivity.” The patient adds, “I don’t know what my wife is worried about. If this job doesn’t work out, I’ll start my own company.” His wife reports that he behaved similarly about 2 years ago and embarrassed her at a party by talking incessantly about his idea for a robotic invention. The patient has no history of depression. He drinks 2 or 3 beers on weekends and has been smoking marijuana approximately once a month for the past year. Temperature is 37 C (98.6 F), blood pressure is 110/80 mm Hg, and pulse is 86/min. Urine toxicology screen is positive for tetrahydrocannabinol. Except for marked restlessness and fidgeting, physical examination is unremarkable. Which of the following is the most likely explanation for the patient’s behavior?
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Question 2 of 26
2. Question
A 9-year-old girl is brought to the office by her mother due to behavioral problems at school. The patient was sent home a week ago after she threw a pencil and cried when the teacher criticized her handwriting. Since that time, she has had stomachaches every morning and asks to stay home. Her recent report cards describe her as “having trouble focusing; easily upset when she makes a mistake.” The mother says, “For the past year, she has become increasingly self-conscious and can’t seem to relax. She always thinks that she will say something stupid and that the other kids will laugh at her. When I try to reassure her, she becomes irritable and snaps at me.” At home, the patient completes her homework and chores without prompting, and her appetite is normal. A few nights a week, she struggles to fall asleep due to concerns that someone might break into the house and insists that her mother check the locks. The patient has no significant medical history, but family history is notable for depression in her mother. Physical examination is normal. The patient is easily distracted by noises outside the room and repeatedly fidgets with her clothing. Which of the following is the most likely diagnosis?
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Question 3 of 26
3. Question
A 38-year-old woman comes to the office for follow-up of major depressive disorder. She was first seen 2 weeks ago for low mood and irritability, loss of interest, difficulty falling and staying asleep, decreased appetite, and poor concentration at work. At that time, she was started on a therapeutic dosage of escitalopram and weekly psychotherapy. The patient had mild nausea for several days after starting the medication but is now tolerating it without difficulty. She says, “I’m afraid the medication isn’t working as well anymore. At first my sleep and appetite were better, but for the past few days I feel like I might be slipping back to where I started.” The patient reports that she is stressed because her husband is away on business this week and her father was recently hospitalized for a stroke. Mental status examination shows a mildly depressed mood and sad affect. Which of the following is the most appropriate next step in pharmacological management?
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Question 4 of 26
4. Question
A 20-year-old college student comes to the emergency department accompanied by her roommate after an episode of falling to the ground and “shaking all over.” Her roommate was able to record part of the episode on her phone, which shows the patient lying on the ground, rhythmically shaking all 4 extremities, and tightly closing her eyes. The roommate is heard asking multiple questions but the patient remains nonresponsive. The episode resolves within 1 minute, when the patient gets up and asks her roommate to take her to the emergency department. The patient has been studying for upcoming final exams, has had minimal sleep, and has consumed multiple cups of coffee a day. She has no other medical problems and takes no medications. The patient shares that one of her close relatives has epilepsy and is concerned that she had a seizure. Vital signs are within normal limits and physical examination shows no abnormalities. Which of the following is the most likely diagnosis in this patient?
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Question 5 of 26
5. Question
A 14-year-old boy is brought to the office by his mother for a well-child visit. Before entering the room, the mother takes the physician aside in private and says, “My son does really well in school and helps out at home, but I’m concerned that he doesn’t play sports like other boys and has started wearing makeup. I don’t know whether that’s normal or not.” When interviewed alone, the patient says, “I’d rather spend my time on clothes and makeup than sports, but that doesn’t make me less of a boy. My friends don’t mind, but I think my mom does.” The patient reports no depressed mood, bullying at school, or difficulty at home, other than occasional disagreements with his mother about how he dresses. He is not sexually active. Medical history is noncontributory. Vital signs are within normal limits; the patient’s height and weight are tracking adequately on growth curves. He is dressed in colorful clothes and is wearing eyeliner and nail polish. Tanner stage is 4. The remainder of the physical examination is unremarkable. Which of the following is the most appropriate response to the mother’s concerns?
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Question 6 of 26
6. Question
A 20-year-old woman comes to the office due to “feeling low” for the past 2 months. The patient says, “All I do is sleep and cry. I lost my job last week, and now I have to move in with my parents. I feel like a failure.” She is upset that she has gained weight and says, “My weight was the only positive thing going for me, but now I don’t even have that. My junk food cravings have gotten worse, but I’ve been too tired to go to the gym to make up for it.” The patient does not use alcohol or recreational drugs and takes no medications. Medical history is insignificant. Temperature is 36.7 C (98.1 F), blood pressure is 106/69 mm Hg, pulse is 90/min, and respirations are 16/min. On physical examination, the thyroid gland is normal to palpation. The lungs are clear to auscultation and heart sounds are normal. The abdomen is soft and nontender. Laboratory results are as follows:
Complete blood count
Hemoglobin
14 g/dL
Platelets
200,000/mm3
Leukocytes
8,000/mm3
Serum chemistry
Sodium
136 mEq/L
Potassium
3.2 mEq/L
Chloride
93 mEq/L
Bicarbonate
31 mEq/L
Creatinine
0.8 mg/dL
Endocrine
TSH
3.4 µU/mL
Which of the following medications would be contraindicated in this patient?
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Question 7 of 26
7. Question
A 32-year-old woman with bipolar disorder comes to the office for evaluation of infertility. She says, “I was hospitalized 2 years ago for a manic episode. We found a good combination of medications, and my condition has been stable. Now, I feel ready to start a family, and my husband and I have been trying to get pregnant for the past year. I was hopeful when my period was late but disappointed when the pregnancy test was negative.” The patient’s last menstrual period was 4 months ago; before that, menses were erratic, occurring every 30-60 days and lasting 4-8 days. Medications include lithium and aripiprazole. Vital signs and physical examination are normal, as are serum TSH, creatinine, and hemoglobin A1c levels. Serum prolactin is markedly elevated at 400 ng/mL (normal: <20). In office urine pregnancy test is negative. Which of the following is the best next step in management of this patient’s hyperprolactinemia?
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Question 8 of 26
8. Question
A 60-year-old physician is admitted to the hospital for jaundice and weight loss. His medical history is noncontributory. After a detailed workup, advanced pancreatic carcinoma is diagnosed. Although the patient is advised to slow down and spend more time with his family, he insists on continuing to work, saying, “It’s a good distraction to think about other people’s medical problems.” Each day after work, he spends several hours reviewing and analyzing his own diagnostic tests and researching experimental chemotherapy regimens for pancreatic cancer. The patient’s family members wish he would take time off to rest, but he insists that would make him feel worse. Which of the following psychological defense mechanisms is the best explanation for this patient’s behavior?
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Question 9 of 26
9. Question
A 35-year-old man with a history of bipolar disorder since age 27 comes to the office for follow-up. The patient was hospitalized 2 years ago for a manic episode and was discharged with a therapeutic dose of lithium; he continues to take the same dose and is engaged in weekly psychotherapy. The patient says, “This is the best I’ve felt in years; work is going great, and I’m getting married in a few months. I really don’t want to get hospitalized again, but I also don’t want to keep taking medication if I don’t have to.” Prior medication trials include quetiapine and olanzapine with fluoxetine; both treatments were discontinued due to weight gain. Medical history is noncontributory. Vital signs and physical examination are unremarkable. The patient appears euthymic and has a full range of affect. Complete blood count, basic metabolic panel, and TSH are within normal limits; serum lithium level is within therapeutic range. Which of the following is the most appropriate response to this patient?
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Question 10 of 26
10. Question
A 72-year-old woman comes to the emergency department accompanied by her son due to worsening depression for the past few weeks. She has recurrent major depressive disorder and a prior suicide attempt. The patient was taking venlafaxine with good response until a month ago, when she discontinued it because she felt it was “unnecessary.” Her son, whom she lives with, noticed that she has become more withdrawn, staying in her bedroom and preferring to sit in the dark watching television instead of sleeping. The patient has been refusing meals to “sacrifice” herself for “the greater good” and repeatedly tells her son that she “must die in accordance with the divine plan.” Height is 165 cm (5 ft 5 in), and weight is 49 kg (108 lb). BMI is 18 kg/m2. Physical examination shows decreased skin turgor and dry mucous membranes. On mental status examination, her clothes are stained and malodorous. The patient makes minimal eye contact and looks at the floor for most of the evaluation. She does not respond to most questions, although she correctly states her name, birthdate, and today’s date. Which of the following is the most appropriate treatment for this patient’s condition?
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Question 11 of 26
11. Question
A 57-year-old woman comes to the office with intermittent headaches, shoulder and neck pain, fatigue, and insomnia. The headaches sometimes interfere with the patient’s ability to concentrate at work. The symptoms are not new but have worsened over the past 8 months due to the stress of starting a new job and placing her elderly mother in an assisted living facility. The patient lies awake at night worrying about her mother, her own health problems, and the finances of her 2 adult children, who are having difficulty supporting themselves. During the day, she is tired due to poor sleep and worries about her job performance. The patient has a history of hypertension, irritable bowel syndrome, and tension headaches. She drinks 1 or 2 glasses of wine before bedtime a few times per week to help her relax and fall asleep. Temperature is 36.7 C (98 F), blood pressure is 130/80 mm Hg, pulse is 88/min, and respirations are 16/min. Examination shows sweaty palms and mild, diffuse abdominal tenderness; no other abnormalities are noted. Complete blood count, chemistry panel, TSH, urinalysis, and ECG are normal. Which of the following is the most appropriate next step in management of this patient?
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Question 12 of 26
12. Question
A 68-year-old man is admitted to a rehabilitation unit following a stroke that resulted in right-sided weakness and facial droop. Medical history includes hypertension, coronary artery disease, osteoarthritis, and prostate cancer in remission. Prior to the stroke, the patient had retired to care for his wife, who has early-onset dementia. He has shown little effort over the past 3 weeks and has recently refused rehabilitation services, saying, “What’s the point?” The patient’s son, who comes to visit a few times a week, says, “Ever since last month’s stroke, he seems so resigned and barely talks when I visit. He seems uninterested in hearing about the grandchildren he adores and has asked his friends not to visit.” The patient says he has had low energy, decreased concentration, and difficulty sleeping since the stroke. He says, “Of course I feel sad, with all my medical problems and my wife’s condition. I don’t know how someone wouldn’t feel this way.” He has no suicidal ideation. Which of the following is the most appropriate response to the patient?
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Question 13 of 26
13. Question
A 26-year-old woman is brought to the hospital by her family due to increasingly bizarre behavior. The patient abruptly quit her sales job 8 months ago because she believed that her coworkers and boss were poisoning her coffee and trying to kill her. Shortly thereafter, she stopped going outside the house because she was convinced that black cars were following her. The patient has been hearing multiple voices over the past month and says, “Mostly they mumble and I can’t make out what they’re saying, but sometimes they tell me I’m stupid and should kill myself.” A comprehensive medical evaluation, including drug screen testing, is unrevealing. She is admitted, and aripiprazole is initiated with improvement in her condition. The patient is discharged 1 week later. At her 1-month follow-up, she is no longer hearing voices, is much less paranoid, and is able to go outside the house; however, she still has periods of anxiety and has been reluctant to look for work. She continues to take the medication as prescribed. Which of the following is the most appropriate treatment recommendation for this patient?
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Question 14 of 26
14. Question
An 18-year-old woman comes to the office due to hair loss. The patient says, “I can’t even brush or wash my hair because it just falls out. I’ve already been so stressed since college started, and losing my hair is making everything worse.” She has felt “overwhelmed” with adjusting to college and is also working part-time at a coffee shop. The patient says, “I’ve felt pretty low—my life isn’t going as planned, and I don’t know how to get back on track.” She says the only thing that makes her feel good is cycling, which she does for 1-2 hours every day. The patient also adheres to a strict diet to “maintain a good body image.” She has no other medical conditions and does not use tobacco, alcohol, or illicit drugs. Temperature is 36.1 C (97 F), blood pressure is 100/65 mm Hg, pulse is 60/min, and respirations are 14/min. BMI is 17.5 kg/m2. Physical examination shows generalized thinning of the hair with no scarring of the scalp. The skin is dry with no rashes. The remainder of the examination is unremarkable, and the patient has no suicidal ideation. Laboratory results are as follows:
Complete blood count
Hemoglobin
11.4 g/dL
Platelets
260,000/mm3
Leukocytes
8,200/mm3
Serum chemistry
Sodium
140 mEq/L
Potassium
3.8 mEq/L
Creatinine
0.6 mg/dL
TSH
0.6 µU/mL
Which of the following is the most appropriate management for this patient’s condition?
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Question 15 of 26
15. Question
A 40-year-old man comes to the office due to low mood, decreased energy, and poor sleep for the past month. Although the patient spends up to 12 hours a day in bed, he gets only 4-5 hours of sleep and never feels rested. He is isolating himself from his family and says, “I eat only because I have to.” The patient has previously had several similar periods of low mood but was never diagnosed or treated. He also has had periods lasting 5-6 days in which he gets a burst of energy, has “tons of new ideas in my head,” and feels great. During these times, he works extra-long hours to complete additional projects at work, and he feels well rested despite sleeping 4 hours a night. Now the patient fears that his depression is having a major impact on his work and family life. He has been procrastinating on several projects and is frequently late to work. He has no motivation to spend time with his children or friends. The patient has increased his daily caffeine consumption to 6 cups of coffee and has an energy drink to counteract his fatigue, and he recently started using marijuana at bedtime to help him fall asleep. Mental status examination shows slow speech, a sad affect, and no suicidal ideation. Which of the following is the most likely diagnosis in this patient?
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Question 16 of 26
16. Question
A 68-year-old man comes to the office due to balance problems over the last 2 weeks. He has had muscle stiffness and 3 near-falls recently. The patient has no musculoskeletal pain or visual problems. He has a history of bipolar disorder and anxiety and was started on valproate and risperidone for a manic episode 5 months ago. Other medical issues include hypertension that is controlled with hydrochlorothiazide. Temperature is 37.2 C (99 F) and blood pressure is 122/78 mm Hg supine and 130/80 mm Hg standing. The patient appears slightly anxious but no longer manic. There is an asymmetric resting tremor in both hands. Finger tapping is slow and irregular bilaterally. Which of the following is the most likely cause of this patient’s current condition?
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Question 17 of 26
17. Question
A 33-year-old woman comes to the office due to low mood and anxiety for the past 5 weeks. The patient broke up with her boyfriend 6 weeks ago and was recently passed over for a promotion at work. She says, “Nothing ever works out for me. I’m never going to find anyone at my age, and the people getting promotions are all younger than me.” The patient feels worse about herself after looking at her ex-boyfriend’s social media accounts and has been “stress eating” on the weekends. She has had no weight changes and continues to work out regularly. The patient has difficulty falling asleep and often lies awake at night worrying about her future. She likes having dinner with her friends but says, “All of them are partnered up. I miss having a boyfriend to spend time with.” The patient has no psychiatric history. Vital signs and physical examination are normal. She appears tearful and tends to look at the floor while speaking; she has no suicidal ideation. Which of the following is the most appropriate management for this patient?
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Question 18 of 26
18. Question
A 53-year-old man is brought to the emergency department after a witnessed seizure 1 hour prior. The patient lives in a group home and was observed by the staff to suddenly become stiff and unresponsive during lunch. He was then noted to have brief jerking movements of his arms and was lowered to the floor. The patient regained consciousness after 1-2 minutes. Medical history includes schizoaffective disorder with multiple hospitalizations for psychotic and mood episodes beginning at age 22. Vital signs are within normal limits. On physical examination, the patient is awake and alert. A 1-cm laceration is noted on the right side of the tongue. Musculoskeletal, cardiopulmonary, and neurologic examinations show no abnormalities. Serum chemistry is normal. A CT scan of the head reveals no abnormalities. Which of the following medications most likely contributed to this patient’s presentation?
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Question 19 of 26
19. Question
A 32-year-old man comes to the office for evaluation of attention deficit hyperactivity disorder (ADHD). Although never treated for ADHD, the patient has had behavioral issues since kindergarten—frequently getting into trouble both at school and at home for not listening, talking out of turn, and not sitting still. Many of these difficulties persisted throughout high school and college. The patient continues to struggle with distractibility, forgetfulness, disorganization, and impulsivity. He is concerned that ADHD is affecting his relationships and work performance and mentions that he has been passed over for promotion several times. The patient has a history of alcohol and cocaine use disorder from age 18-24 but does not currently use alcohol or recreational drugs. He says, “I’m not opposed to taking medication, but I do not want to take anything that could be addictive.” Which of the following is the most appropriate next step in management of this patient?
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Question 20 of 26
20. Question
A 35-year-old man is evaluated in the hospital for a tonic-clonic seizure 30 hours after he underwent right inguinal hernia repair. The operation was uneventful, but the patient gradually became restless afterward. Medical history is remarkable for gastritis and a 15-year history of tobacco and alcohol use. The patient lives alone. Medications include omeprazole and morphine for pain control. Temperature is 37.7 C (99.9 F), blood pressure is 155/94 mm Hg, pulse is 114/min, and respirations are 18/min. The patient is not oriented to place or time. He appears diaphoretic and agitated . Neurologic examination shows tremor of the upper and lower extremities; deep tendon reflexes are 3+ bilaterally. The lungs are clear to auscultation. The incision site is dry, intact, and healing well with no evidence of infection. Laboratory results are as follows:
Serum chemistry
Sodium
137 mEq/L
Potassium
3.5 mEq/L
Chloride
101 mEq/L
Bicarbonate
24 mEq/L
Blood urea nitrogen
12 mg/dL
Creatinine
1.0 mg/dL
Glucose
104 mg/dL
Complete blood count
Hemoglobin
14.1 g/dL
Leukocytes
9,000/mm3
Which of the following is the most appropriate next step in management?
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Question 21 of 26
21. Question
A 46-year-old woman with alcohol use disorder comes to the office for follow-up. The patient has a prolonged history of heavy alcohol use and was hospitalized 6 months ago due to alcohol-induced pancreatitis. She stopped drinking after the hospitalization but restarted following a fight with her husband a month ago. Her daughters convinced her to stop again, and she has had no drinks for the past 2 weeks. The patient reports no anxiety or shakiness but has had occasional cravings and is afraid that she may relapse again. She has no other medical conditions, takes no medications, and does not use tobacco or illicit drugs. Vital signs are within normal limits, and physical examination shows no abnormalities. In addition to psychosocial interventions, which of the following is the most appropriate pharmacotherapy for this patient?
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Question 22 of 26
22. Question
A 24-year-old woman is brought to the emergency department by her roommate due to depression and suicidal thoughts. The roommate became alarmed when the patient did not get up for work as usual and reported feeling “so depressed I want to die.” She currently has no suicidal ideation but describes feeling depressed, exhausted, and unable to concentrate. The patient appears distracted and speaks slowly. The roommate says, “We were up for the last 3 nights at parties where there was alcohol and other stuff,” but reports that her friend was energetic and talkative and appeared to be in a great mood. However, the patient subsequently slept for 18 hours, had difficulty getting out of bed, and missed work. She has no medical or psychiatric history but describes brief periods of acute depression over the past several months. These lasted a few days and were characterized by low energy; hypersomnia; vivid, unpleasant dreams; and increased appetite. Temperature is 36.7 C (98.1 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 12/min. Physical examination is normal. Which of the following is the most likely diagnosis for this patient?
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Question 23 of 26
23. Question
Patient Information
Age: 32 years
Gender: M, self-identified
Race/Ethnicity: unspecified
Site of Care: officeHistory
Reason for Visit/Chief Concern: wife states, “My husband is on probation at work because he keeps getting into arguments with everyone.”
History of Present Illness:
-
during a recent staff meeting, the patient accused the company of hacking his personal computer; he had to be restrained from hitting a coworker
-
wife states that his mood has been “up and down every few days” for a few months, switching from irritable and paranoid to quiet and withdrawn
-
patient states that he created “a genius business plan” and is being punished for not letting others take credit for it
Past Medical History:
-
noncontributory
Medications:
-
none
Allergies:
-
no known drug allergies
Family History:
-
noncontributory
Psychosocial History:
-
car salesman
-
drinks 5-6 beers a week
Physical Examination
Temp
Pulse
Resp
BP
O2 Sat
Ht
Wt
BMI
37 C
(98.6 F)
102/min
16/min
160/100
mm Hg
–
–
–
20 kg/m2
-
Appearance: restless and shifting in seat; diaphoretic; mildly tremulous
-
Pulmonary: clear lungs
-
Cardiac: regular rate and rhythm; normal S1 and S2
-
Neurologic: alert and fully oriented; pupils dilated and reactive to light; steady gait
-
Mental status: affect is irritable, tense, and labile; speech is pressured and difficult to interrupt; persecutory delusion that his boss, coworkers, and wife are working together to get him fired; no suicidal or homicidal ideation
Question: Which of the following is the most likely diagnosis?
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Question 24 of 26
24. Question
A 36-year-old woman comes to the office due to difficulty losing weight over the past several months. The patient says, “I typically lose 1 or 2 pounds in the first week of dieting, but by the second week I lose control and start eating bags of cookies and potato chips.” These episodes are followed by a few days of fasting and exercising excessively. The patient is upset about her weight and appearance but has no persistent sadness. She enjoys her work and socializing with friends and family. The patient has no medical conditions, but her menstrual cycle is irregular. Weight is 67 kg (147.7 lb) and height is 160 cm (5 ft 3 in). BMI is 26.2 kg/m2. Blood pressure is 100/70 mm Hg and pulse is 86/min. Physical examination shows dry skin but is otherwise unremarkable. The patient has a full range of affect and no suicidal ideation. Laboratory results are as follows:
Complete blood count
Hemoglobin
13 g/dL
Hematocrit
39%
Mean corpuscular volume
90 µm3
Platelets
180,000/mm3
Leukocytes
7,500/mm3
Serum chemistry
Sodium
136 mEq/L
Potassium
3.2 mEq/L
Creatinine
0.8 mg/dL
Endocrine
TSH
2.4 µU/mL
The diagnosis is discussed, and the patient asks if any medications are available for treatment. Which of the following is the most appropriate recommendation?
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Question 25 of 26
25. Question
A 22-year-old man comes to the office due to difficulty concentrating and sleeping. The patient lost his job and moved in with his parents 2 months ago. Although he has been looking for work and revising his resume, he gets distracted and easily loses focus. The patient has not received any interview invitations and is worried that he will be living with his parents for a long time. He feels that he has “reverted to my high school self,” playing video games most evenings and going out with friends on the weekends. The patient gets annoyed with his parents occasionally but states that he knows they are “just trying to be helpful.” He has been eating more than usual since moving, gaining 3 kg (6.6 lb) and feeling tired during the day. The patient takes 2-3 hours to fall asleep each night and frequently checks the time while in bed. He drinks 3 or 4 beers a week and does not use recreational substances. Vital signs are within normal limits. Physical examination shows no abnormalities. The patient states that his mood is “okay,” and he has a full range of affect. He reports no suicidal ideation. In addition to recommending psychotherapy, which of the following is the most appropriate pharmacotherapy for this patient?
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Question 26 of 26
26. Question
A 47-year-old man with a long history of schizoaffective disorder comes to the clinic with his wife. After a difficult course requiring several psychiatric hospitalizations and poor response to multiple antipsychotics and mood stabilizers, the patient’s condition has been relatively stable for the past 3 years with high doses of lithium and risperidone. Lowering his dose of risperidone resulted in worsening psychotic symptoms, so the dose was subsequently increased. The patient’s wife states that his psychiatric symptoms have improved with the current medications, but they are both concerned about new abnormal movements he has begun to make. He has no other medical conditions and takes no other medications. The patient does not use tobacco, alcohol, or illicit drugs. Blood pressure is 120/70 mm Hg, pulse is 72/min, and respirations are 12/min. Lithium level is 1.2 mEq/L (range: 0.8-1.2). During examination, the patient repeatedly taps his foot, protrudes his tongue, and smacks his lips. The rest of the examination shows no abnormalities. The patient is treated with sequential trials of valbenazine and deutetrabenazine but shows no significant improvement in abnormal movements at follow-up. Which of the following is the most appropriate next step in management of this patient?
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