A 13-year-old boy is brought to the office by his parents due to their concern about his behavior and academic performance.  The patient is failing several classes in junior high school and has few friends.  His mother reports, “His teachers complain that he doesn’t pay attention and disrupts the class.  One teacher says that he clears his throat repeatedly, distracting the other kids and making it difficult for her to teach.  She has asked him to stop but he keeps doing it.”  The boy says, “I try in school but the kids are mean and make fun of me because they think I am weird or something.”  Over the past year, his father has observed frequent repeated blinking, which he found unusual but assumed was a sign of fatigue.  His mother adds that several months ago the boy was grimacing frequently, but this seems to have passed.  In the office, the boy shrugs his left shoulder repeatedly.  Medical history is unremarkable.  A Stanford-Binet test administered 2 years ago measured the boy’s intelligence quotient as 95.  Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, pulse is 88/min, and respirations are 14/min.  Weight is 45 kg (99.2 lb) and height is 155 cm (5 ft 1 in).  Physical examination, including neurological examination, is normal.

Item 1 of 2

Which of the following is the most likely diagnosis?

Item 2 of 2

The diagnosis of Tourette syndrome is made.  The physician educates the patient and his parents about the disorder and provides counseling on behavioral techniques to suppress tics.  Six months later, the patient returns with his mother for a follow-up visit.  She reports that the tics are worse and very distressing.  Although his grades have improved somewhat, he is miserable at school and refuses to attend any afterschool activities.  Examination shows grunting, facial grimacing, and writhing of the left side of the body.  Which of the following medications would be most effective in reducing tics in this patient?

A 15-year-old girl is brought to the office after falling in the shower.  Her mother was outside of the bathroom when she heard a thud, and went in and found her daughter trying to get back up.  The patient insists, “I just slipped.  It’s no big deal.  I am fine.”  She reports that she had no loss of consciousness, tongue biting, incontinence, or confusion.  Her parents are concerned that she lost her balance because she is thin and eats poorly.  They also note that she seems depressed and has not been interested in seeing any friends.  The patient admits, “I have been a little down since my boyfriend broke up with me, but I don’t blame him because I am so fat.”  She takes no medications, has no allergies, and does not use tobacco, alcohol, or illicit drugs.  Temperature is 35.6 C (96 F), blood pressure is 100/60 mm Hg sitting and 80/48 mm Hg standing, pulse is 50/min, and respirations are 14/min.  BMI is 16 kg/m².  Examination shows an alert and cooperative girl with dry mucous membranes and emaciation.  Calluses are present over the knuckles.  The abdomen is soft, nontender, and nondistended.  Urine hCG is negative.  Laboratory results are as follows:

Item 1 of 2

Which of the following is the most appropriate next step in management of this patient?

Item 2 of 2

The patient is admitted to the hospital.  Thiamine is administered prior to initiation of a supervised diet.  On the third day of hospitalization, the patient develops progressive dyspnea and orthopnea.  Temperature is 35.6 C (96 F), blood pressure is 100/60 mm Hg sitting and standing, pulse is 78/min, and respirations are 24/min.  Examination reveals an anxious girl with bibasilar crackles, dullness to percussion of the lung bases, and pretibial pitting edema.  Laboratory results are as follows:

Which of the following therapies should be administered immediately?

A 65-year-old woman is brought to the emergency department by her son.  The patient lives alone and works as a librarian.  The son became concerned 2 days ago when “she didn’t sound right and seemed somewhat confused over the phone.”  When he arrived at her home this morning, the patient was disoriented and her speech was slurred.  Medical history is significant for diabetes mellitus controlled with metformin.  The son says that a “mood disorder” runs in the family and that she has taken lithium, escitalopram, and risperidone for the past several years.  A month ago, the patient was diagnosed with hypertension and arthritis, and treatment with chlorthalidone and acetaminophen was initiated.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.1 C (97 F), blood pressure is 150/90 mm Hg, pulse is 52/min, and respirations are 16/min.  Physical examination shows coarse hand tremor and an unstable gait.  The patient is oriented to person but not to time or place.

Item 1 of 2

Which of the following is the most likely cause of this patient’s symptoms?

Item 2 of 2

The patient’s lithium level was found to be 4.2 mEq/L (normal: <1.5 mEq/L).  Which of the following is the most effective management strategy?

A 72-year-old woman is brought to the emergency department after a fall.  The patient landed on her side and has extensive bruising over the right hip area.  She was able to reach her phone and call an ambulance to bring her to the hospital.  She says, “I lost my balance on the way to the bathroom.  I usually have to get up to go to the bathroom once or twice a night.”  The patient has no history of lightheadedness, dizziness, or syncope.  She leads an active lifestyle and walks 2 miles every day.  Her medical problems include type 2 diabetes mellitus, urge incontinence, chronic insomnia, transient ischemic attacks, and osteoarthritis.  Her daily medications include aspirin, glyburide, lorazepam, and naproxen.  The patient lives alone.  She does not use tobacco, alcohol, or illicit drugs.  Vital signs are within normal limits.  Physical examination and subsequent x-rays reveal a right-sided femoral neck fracture.  Neurological examination is normal.

Item 1 of 2

Which of the following is the most appropriate intervention to reduce this patient’s risk of falls?

Item 2 of 2

The patient is admitted to the hospital and undergoes a hemiarthroplasty of her right hip.  Her medications in the hospital include aspirin, insulin, calcium, vitamin D, subcutaneous heparin for deep venous thrombosis prevention, and oxycodone for pain control.  Lorazepam was discontinued as it was thought to have contributed to her fall.  Following surgery, the patient appears to be recovering well.  On day 3 of hospital admission, however, she becomes very restless and agitated.  She is oriented to person only and insists that she is in her own home.  The patient demands to know “who stole my clothes and jewelry” and is verbally abusive toward the nursing staff.  She is observed to be talking to her herself and says she sees her deceased father and hears his voice.  Temperature is 37.8 C (100 F), blood pressure is 160/90 mm Hg, pulse is 106/min, and respirations are 24/min.  Pulse oximetry is 98% on room air.  Physical examination shows generalized tremors and is otherwise unchanged.  All laboratory studies are normal.  Which of the following is the most appropriate next step in management of this patient?

A 31-year-old man comes to the office with his wife, who is threatening to leave him if he does not get help.  The patient was recently fired from his job as a computer programmer due to frequent lateness and absences caused by his elaborate morning showering ritual.  He feels compelled to clean each part of his body in a specific order while counting to 27.  If he misses a body part or makes a mistake in counting, he must start over.  His wife adds that he often takes 3 showers in a row because “he won’t accept that the towels I give him were just cleaned.  It has become extremely difficult to live with him.”  Once dressed, the patient must go out of his way to take a certain route to work to avoid “dirty” street corners that may soil or contaminate his clothes.  He says, “I know it makes no sense, but I can’t get rid of the thought that my clothes are splattered with urine.  Once this idea takes hold, I have to go home and change.”  The patient became concerned with cleanliness as a young teen and wonders whether this was inherited from his mother, whom he describes as “a control freak.”  He says, “I know I need help but prefer not to take medication if possible.”

Item 1 of 2

Which of the following nonpharmacologic approaches would be most effective for this patient?

Item 2 of 2

After 12 weeks of twice-weekly therapy, the patient has made some improvement but still has significant anxiety and difficulty changing his rituals.  Although he is better able to resist counting, he continues to shower excessively and still changes his clothes several times a day.  The patient was offered a new job but turned it down when he learned that it would require him to share a computer keyboard with coworkers.  He and his wife are frustrated that he has not made more progress.  The patient is now more receptive to the idea of taking medication.  His other medical problems include obesity and premature ejaculation.  He takes no medication other than acetaminophen as needed.  Physical examination is normal.  Which of the following medications is the most appropriate next step in management of this patient?

A 27-year-old woman with no medical history comes to the office due to recent-onset chest pain.  She gives a dramatic, vague, and nonspecific description of the pain, which she continues even when pressed for details.  The patient is dressed in revealing clothing and mentions having seen the physician several times at a nearby grocery store.  Physical examination, including vital signs, is unremarkable.  Laboratory evaluation and an ECG are normal and suggest no medical etiology for chest pain.  Despite reassurance that more serious causes of chest pain are highly unlikely, the patient insists on scheduling a follow-up appointment.  On the day of the second appointment, she arrives as the office is closing and intercepts the physician in the parking lot.  The patient reports that the chest pain has disappeared; however, she is very concerned about feeling fatigued.  She says, “I frequently have insomnia, but it’s been worse than usual lately and I am so tired.”  The patient insists on calling the physician by first name, apologizes profusely for being late, and requests an after-hours appointment.

Item 1 of 3

Which of the following is the most appropriate response to the patient’s request?

Item 2 of 3

At the next scheduled appointment, the patient does not mention the chest pain or fatigue but reports that she has “bad headaches and feels horribly depressed and in a black hole” following a romantic breakup a week ago.  She adds, “I was sure this was the person for me, but to be honest, I am thrilled to be free again.  You’re also single, aren’t you?”  The patient has difficulty describing the nature of the depression but reports that her moods go “up and down” during the day.  She denies current suicidal ideation or significant disturbances in sleep and appetite.  As the appointment is ending, the patient shows the physician a photograph from a recent beach vacation and then expresses disappointment when no compliments are offered.  This patient’s behavior is most consistent with which of the following disorders?

Item 3 of 3

Later that day, the physician discovers that the patient has questioned an office staff member about the physician’s marital status.  The following week, the patient calls and invites the physician to have dinner at a nearby restaurant.  Which of the following is the most appropriate response?

A 25-year-old woman is brought to the emergency department after her boyfriend called police and reported that she had thoughts of killing herself.  The patient states that they had been arguing when she told her boyfriend that she wanted to die.  The patient says, “I didn’t mean what I said.  This is all a big misunderstanding.  I don’t know why my boyfriend overreacted.  We both had a little too much to drink tonight.  I got upset when we were arguing, and I just said something stupid.  I had no intention of killing myself.”  The patient has no psychiatric treatment history.  She drinks 4 or 5 glasses of wine a week and smokes marijuana twice a week.  Vital signs are within normal limits.  Examination shows a mildly unsteady gait but is otherwise within normal limits.  On mental status examination, the patient is alert with slightly slurred speech.  She says her mood is “fine,” and she currently has no suicidal ideation, intent, or plan.

Item 1 of 2

Which of the following is the most appropriate next step in management of this patient?

Item 2 of 2

The physician reassesses the patient a few hours later.  She says, “I am so embarrassed.  I lose control of myself when I am drunk.”  The patient reaffirms that she has never received any psychiatric treatment; however, she took an intentional overdose of sleeping pills at the age of 20 and expressed a desire to die after her boyfriend broke up with her.  Family history is significant for depression and a maternal uncle who completed suicide.  The patient has been feeling depressed and describes difficulties with sleep and concentration.  Her appetite has decreased, and she has lost 3.17 kg (7 lb) over the past month.  The patient works at a coffee shop and is a part-time student at a local community college.  She is considering dropping out of school because she has no interest in her classes and her grades are poor.  She is afraid her boyfriend will break up with her and shares that she has few friends and is estranged from her family.  Which of the following is this patient’s strongest risk factor for suicide?

A 4-year-old boy is brought to the office by his parents due to behavioral problems.  The parents recently decided to take him out of preschool after receiving numerous complaints from the staff about his hyperactive behavior (running and climbing in the classroom, interrupting the teacher) and inability to listen and follow directions.  This is the second school he has attended this year.  He was asked to leave the first school for similar behavior.  The patient’s mother says that at home, he “runs wild” and fights with his older siblings all the time.  She says, “He is always bothering or interrupting his older sister and brother.  Another difficulty is that we are always running late for school because I can’t get him to follow through with getting dressed and eating breakfast.”  The father had a history of attention-deficit hyperactivity disorder as an adolescent and was treated with amphetamines.  He says, “I think I never would have graduated from high school without them.”  The boy has no medical problems and developmental milestones are within normal range.  The parents are reluctant to have their son take medication and are particularly concerned about the risk of weight loss because he is already very thin.

Item 1 of 3

Which of the following is the most appropriate next step in management of this patient?

Item 2 of 3

The parents participate in a program on attention-deficit hyperactivity disorder (ADHD) and see some improvement in their son’s response to their directions and ability to follow household rules.  However, he remains hyperactive, easily distractible, and impulsive.  They return 2 years later after receiving multiple phone calls from their son’s first grade teacher.  The patient has difficulty sitting still for more than a few minutes and frequently disrupts the class by blurting out answers or talking to classmates instead of listening to the teacher.  If his behavior does not improve, he may have to repeat first grade.  The patient undergoes a comprehensive evaluation for ADHD and no comorbid psychiatric or learning disorder is identified.  The parents are now receptive to starting medication.  Which of the following is most important to obtain prior to starting stimulant medication?

Item 3 of 3

Treatment with methylphenidate is initiated at a low dose and gradually titrated to a maximum dose over 4 weeks.  The patient is seen for a follow-up visit an additional 2 months later.  The mother reports mild improvement in the boy’s behavior at home (less talking back and fighting with siblings) but continued difficulty following the morning routine.  She is concerned that the patient’s recent headaches and moodiness may be due to the medication.  Teacher feedback indicates some improvement with sitting in his chair but continued talking out of turn and distractibility.  There has been no improvement in his academic performance, and he is in danger of having to repeat first grade.  Which of the following is the most appropriate next step in management of this patient?

A 75-year-old man with a recent diagnosis of metastatic pancreatic cancer is admitted to the hospital due to dehydration.  The patient admits that he was trying to hasten his death by refusing food and water despite his family’s disagreement with this plan.  He is a documentary filmmaker who has made multiple films on the subject of bravery, frequently interviewing firemen and wartime pilots.  He says that “being brave means not being afraid of death and leaving this suffering behind.”  The patient’s wife recently filed for divorce.  She says that she is an observant Buddhist and has been “fed up with his atheism for a long time; it’s just so negative.  He doesn’t believe that anything has a point, when really everything is purposeful if he would only just look.  He can’t even see the people around him who love and support him.”  The patient occasionally has pain despite taking morphine regularly.  He has experienced severe constipation as a result of the pain medication and has received minimal relief from stool softeners.  His wife says that prior to his hunger strike his appetite was poor and that he frequently spends much of the day doing nothing other than lying on the couch watching television due to fatigue.  After his wife leaves the room, the patient pleads with the physician to “give me something to end my life in peace with dignity.”

Item 1 of 2

Which of the following factors is most closely associated with this type of request?

Item 2 of 2

While his wife is out of the room, the patient repeatedly asks the physician for assistance in ending his life.  The patient says that his wife and adult children from a previous marriage have been very opposed to this idea, but he has been reading on the Internet about places “where doctors will honor and fulfill my wish to die with dignity and to end this suffering.”  Which of the following would be the most appropriate response to the patient’s request for assistance in ending his life?

A 22-year-old woman is brought to the emergency department after overdosing on benzodiazepines.  On presentation, her speech is slurred and her gait is unsteady.  She is admitted to the hospital and improves with supportive care.  When questioned later, she states that she had wanted to die because her boyfriend of 4 months ended their relationship a week ago.  Currently she is less depressed and no longer suicidal, and feels that “he was the worst person for me.”  The patient describes “mood swings” since she was a teenager characterized by feelings of severe depression lasting from a few hours to several days.  She has a history of 2 suicide attempts involving medication overdose.  The patient has been treated with fluoxetine but stopped taking it 6 months ago because “it didn’t seem to make a difference in how low I was feeling.”

Item 1 of 2

Which of the following is the most likely diagnosis?

Item 2 of 2

Which of the following is the most effective treatment for this patient’s condition?

A 22-year-old man is found unresponsive on his bedroom floor.  His girlfriend calls emergency medical services, and paramedics arrive within 10 minutes.  She says that the patient has been using heroin and points to track marks on his right arm.  Temperature is 37.8 C (100 F), blood pressure is 90/40 mm Hg, pulse is 65/min, and respirations are 6/min.  The paramedics provide supportive care and administer naloxone on the way to the hospital.  The patient’s condition stabilizes in the emergency department.  The toxicology screen is positive for opiates and cannabis.  Once he becomes more alert, additional information, including a substance abuse history, is obtained.  The patient says, “I’ve been using heroin for the last 9 months and drinking since I was 16.  I like to use pretty much any drug I can get my hands on; I don’t see what the big deal is.”  He has never tried to stop using and has never been to a drug-detoxification or drug-rehabilitation program.  He recently lost his construction job as he was “too high to show up.”  His girlfriend is considering leaving him if he does not get help.

Item 1 of 2

Which of the following statements or questions is the most appropriate for initiating a discussion about the patient’s substance use?

At 1-month follow-up, the patient says that he was recently arrested and charged with driving under the influence.  His court date is set for later in the month.  The patient confirms that he was intoxicated at the time and is worried about sentencing.  He tells the physician that his girlfriend has left him and that it has been a struggle finding work.  He says, “I can’t blame her for leaving.  I stopped for a week but started using again after getting fired from yet another job.  I’m a pretty good worker, but I think the boss could tell I was using.  It’s the people I hang out with; it’s hard to stop when they’re all getting high.”

Item 2 of 2

Which of the following is the best indicator of this patient’s motivation to change his behavior?

A 14-year-old boy is brought to the office by his mother, who is concerned about his academic performance.  The patient has a history of attention-deficit hyperactivity disorder (ADHD) diagnosed at age 6.  He responded well to methylphenidate and continued stimulant medication through age 11.  Currently, he takes no medication.  His mother says, “He is less hyperactive at home and I no longer get phone calls from the school about his behavior, but adjusting to high school has been a challenge.  Even though he is very bright, he has difficulty keeping up with his schoolwork.  He often hands assignments in late and his work is sloppy.  Now that he is in high school and grades are important, I worry that his poor grades will limit his options for college.”  The boy feels fine but says that “the teachers are boring and treat me unfairly.  I know the answer, but then get in trouble for not raising my hand.”  The patient struggles, particularly in math, and is getting mostly Cs and Ds in his other classes.  He has several friends and was excited when he made the soccer team.  However, he decided to quit after receiving several warnings for being late to practice and forgetting his equipment.  His mother says that he is much less hyperactive at home and hopes that he has “outgrown” his ADHD by now.

Item 1 of 2

Which of the following is the most appropriate statement in response to the mother’s concerns?

Item 2 of 2

The physician meets with the boy alone to obtain additional history.  The patient says, “I hate high school.  The work really isn’t that hard; I just always put off my homework until the last minute or hand in assignments late.  I know I would have gotten better test grades if I had just caught some stupid mistakes.  I’m always the one who gets in trouble for talking, when it’s really the kid next to me who gets me started.  I also got in trouble with the soccer team for forgetting my uniform and talking back and not listening to the coach.  My friends think I’m funny, but when it comes to getting together outside of school, they always say they’re busy and can’t make it.”  The boy has tried alcohol and marijuana on 2 occasions, but does not use these regularly.  There is a family history of alcohol abuse in the patient’s father and grandfather.  The boy is interested in restarting medication for attention-deficit hyperactivity disorder.  Which of the following is the most appropriate statement regarding treatment for this patient?