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Question 1 of 6
1. Question
A 75-year-old man comes to the office due to difficulty sleeping for the past several months. The patient says, “I think I would be fine if I could just get some sleep.” He describes taking at least 45 minutes to an hour to fall asleep at night. He also awakens 2-3 times in the middle of the night and has difficulty falling back asleep, often staying up for an hour or more at a time. He wakes up naturally at his usual time of 6:30 AM but then feels tired throughout the day. The patient lives in a retirement community. His wife died last year and he lives alone. He misses his wife but has no other psychosocial stressors and enjoys playing golf and socializing with a group of friends. He does not feel anxious or depressed and is not sure what keeps him awake or why he is waking up so often. His medical history is significant for aortic stenosis, well-controlled hypertension, osteoporosis, benign prostatic hyperplasia, and constipation. His current medications include terazosin, alendronate, and over-the-counter fiber supplements and multivitamins. The patient does not smoke or use illicit drugs. He drinks alcohol rarely on social occasions. Physical examination is noncontributory. Which of the following is the most appropriate management of this patient’s condition?
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Question 2 of 6
2. Question
A 12-year-old girl is brought to the office by her mother due to declining grades and depressed mood. The mother says, “My daughter is normally a good student, but for the past 3 months, she has been getting Cs and Ds. It’s as if she just doesn’t care anymore. She goes to sleep as soon as she comes home from school and has no interest in seeing her friends. I’m afraid she has depression, like me.” The patient does not use alcohol or recreational drugs. Family history is significant for depression in the mother, who tried many medications but whose condition finally responded to phenelzine, as well as bipolar disorder in a maternal aunt. Physical examination and laboratory evaluation show no abnormalities. Major depressive disorder is diagnosed, and the patient is referred for cognitive-behavioral psychotherapy. At a 3-month follow-up, she shows no improvement. She says, “I like talking to my therapist, but I still feel bad.” Her mother observes, “She is moody and still doesn’t want to go out or do anything.” The patient reports increased appetite and has gained 2.3 kg (5.1 lb). She remains socially isolated and continues to struggle in school. On mental status examination, she is dysphoric and irritable. She has no suicidal ideation. Which of the following is the most appropriate pharmacotherapy for this patient?
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Question 3 of 6
3. Question
A 39-year-old woman recently diagnosed with systemic lupus erythematosis comes to the office for follow-up accompanied by her husband. The husband says, “I can understand that she’s been depressed about having lupus, but for the past week she seems really upset even though her pain is better. She keeps picking fights with me, gets angry, and yells at me. A few minutes later she calms down and starts bawling her eyes out.” The patient states “I’m not myself” and reports that for the past week her mood has been “up and down, but mostly depressed.” She is able to sleep only 5 hours each night. During the day her energy and motivation are low and she spends most of the time lying on the couch. Her appetite, which was low before, has declined further. Medications include hydroxychloroquine, ibuprofen, and multivitamins. Two weeks ago she began taking prednisone 40 mg daily due to a flare-up with worsening joint pain and fatigue. The patient does not use alcohol or illicit drugs. She has no psychiatric history. There is a family history of bipolar disorder. Temperature is 36.7 C (98 F), blood pressure is 126/80 mm Hg, pulse is 82/min, and respirations are 16/min. Physical examination is unchanged from her last visit. On mental status examination, the patient’s mood is “down” and her affect is mildly reactive. Her speech is not pressured and she has no flight of ideas, hallucinations, or delusions. Laboratory results indicate no renal insufficiency or cytopenias, and there is no evidence of nephritis. Which of the following is the most appropriate next step in management of this patient?
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Question 4 of 6
4. Question
A 55-year-old woman comes to the physician for a follow-up appointment due to problems with low energy, difficulty losing weight, and joint pain. She works in sales and says that it is difficult to be on her feet all day. She has a 10-year history of hypertension, type 2 diabetes mellitus, and hypercholesterolemia. Her current medications include metformin, atorvastatin, lisinopril, and naproxen. The patient has no polyuria, polydipsia, or blurred vision. She has gained 4.5 kg (10 lb) over the past year despite a diabetic diet and repeated counseling about the importance of weight loss and exercise from her physician. She says, “I start off the day eating healthy, but by the afternoon I am so tired and ravenous that I just have to have a snack. No matter what I do, I just can’t lose weight. It’s depressing.” When the importance of exercise is discussed, she says, “I want to exercise, but it’s hard when I have pain in my knees and ankles.” The patient drinks a glass of wine daily and does not use illicit drugs. She binge eats (a box of cookies or a whole pizza) once a month when stressed. Her blood pressure is 140/90 mm Hg and pulse is 84/min. She weighs 145 kg (319.7 lb). Finger-stick glucose is 210 mg/dL, and she admits that she stopped off at a donut shop prior to this morning’s visit. Which of the following is the most appropriate response by the physician?
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Question 5 of 6
5. Question
The following vignette applies to the next 2 items. The items in the set must be answered in sequential order. Once you click Proceed to Next Item, you will not be able to add or change an answer.
A 74-year-old man comes to the office due to memory problems over the past several months. He is accompanied by his wife. The patient says, “I am worried about my memory. I feel like I am losing my mind. I can’t remember what I’ve read in the newspaper, and I even have difficulty following the plot on TV shows.” His wife says, “He frequently misplaces things like his keys and wallet and can’t recall names of individuals he should know. She adds, “He used to like to cook and watch TV, but he doesn’t seem to enjoy these things anymore. When he attempted to make a favorite dish recently, he left out half the ingredients and burned the meal.” Over the past 2 months, the patient has been involved in 2 minor car accidents in which he was “not paying attention.” He recently told his wife that they are “ruined and going bankrupt,” despite her multiple assurances that this is not so. She says, “I show him the bank statements, but a few days later, it’s as if he doesn’t remember and he asks to see them again.” They went through a difficult time over the past year due to his suspicions that she had an affair, which were recently confirmed. The patient’s medical history is significant for gastroesophageal reflux disease, rheumatoid arthritis, and hypertension. He has increased soreness and pain in his joints and neck that he attributes to “my body breaking down.” The patient has a history of thyroid cancer that was successfully treated 15 years earlier. His medications include lisinopril, levothyroxine, hydrochlorothiazide, aspirin, and antacids. Physical examination is unremarkable. Laboratory studies, including vitamin B12 and thyroid function, are normal.
Item 1 of 2
Which of the following is the best response to this patient’s concerns?
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Question 6 of 6
6. Question
Item 2 of 2
The patient is diagnosed with major depressive disorder, and antidepressant medication is started. Three months later, his condition has significantly improved. Examination of memory and concentration demonstrates clear improvement. The patient’s wife says that he is “back to his normal self and sharp as a whistle.” He has been driving without accidents. They have started socializing again and have attended couples counseling to address issues with infidelity. At a recent clinic visit, the patient and his wife ask about his prognosis, as they are planning their advance directive documents. Which of the following disorders is the patient at increased risk of developing?
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