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Question 1 of 40
1. Question
A 5-year-old girl is brought to the office by her mother, who is concerned after observing her daughter speak to an empty chair in her room on several occasions. The girl’s medical history is significant for preterm birth at 36 weeks gestation but is otherwise noncontributory. Her family history is significant for cerebrovascular accident and depression in her maternal grandfather and schizoaffective disorder in her father. When questioned, the patient says she sees her grandmother at night and likes to speak to her before she goes to bed. The grandmother died 2 months ago and had lived in the family home. For a few weeks following the death, the girl would become tearful and frequently ask her parents when her grandmother would be coming back. Which of the following is the most likely diagnosis in this patient?
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Question 2 of 40
2. Question
A 13-month-old girl is brought to the office by her mother. She is worried that there is something wrong and explains, “My daughter used to sit on her own and loved babbling and clapping her hands. She still plays with her sisters and likes snuggles, but for the past 3 months she hasn’t babbled as much, and can no longer sit without my help. She twists her hands together and I cannot get her to stop. I am worried that the skin on her hands is getting red, dry, and painful.” Weight and height are in the 60th percentile. The patient’s head growth, however, has decreased from the 50th to the 40th percentile in 3 months. On examination, the child is globally hypotonic and unable to sit upright without being held. She makes no sound apart from an occasional grunt. She shows interest in toys the doctor provides her but does not reach out for them, wringing her hands repeatedly. Which of the following best explains this patient’s condition?
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Question 3 of 40
3. Question
An 8-year-old boy is brought to the office due to severe behavioral problems. The patient has been suspended from school on two occasions over the past year due to running around in the classroom and talking back to his teachers. His parents report that he is “in constant motion” and are concerned about his poor grades and inability to follow directions or household routines. The patient has a history of mild asthma and no other medical problems. There is a family history of schizophrenia in a maternal uncle. Physical examination shows marked fidgeting and difficulty staying seated but is otherwise normal. The boy frequently interrupts his mother while she speaks with the physician. Treatment with methylphenidate is recommended. The parents should be educated about which of the following regarding this medication?
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Question 4 of 40
4. Question
A 37-year-old man is admitted to the hospital for right lower-lobe pneumonia. He is given antibiotics, and his shortness of breath and fever improve by the second hospital day. However, he now has new-onset abdominal pain, diarrhea, and severe muscle aches. The patient has no history of gastrointestinal conditions or prior surgeries but does admit to recreational drug use. Temperature is 36.8 C (98.2 F), blood pressure is 124/80 mm Hg, and pulse is 88/min. On examination, the patient appears uncomfortable and anxious. Pupils are dilated and there is prominent lacrimation. Abdominal examination reveals hyperactive bowel sounds without tenderness or distension. Which of the following is the most likely diagnosis?
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Question 5 of 40
5. Question
A 28-year-old man comes to the office due to persistent fatigue. For the past several weeks, he has been having trouble sleeping and is frequently late for work as he has difficulty getting out of bed. At work, his mind wanders, and his supervisor has commented that the quality of his work has deteriorated. The patient says, “I’ve been feeling down and don’t feel like doing anything. My appetite is poor. I no longer go out with my friends and haven’t gone to the gym in weeks.” The patient has no significant medical or psychiatric history. He has 1 or 2 alcoholic drinks several days a week but does not use illicit drugs. Routine laboratory evaluation, including thyroid function tests and serum B12 level, is normal. Physical examination is unremarkable. Mental status examination shows a cooperative man with sad affect. No delusions are elicited. The patient says he sometimes wishes he could “go to sleep and not wake up,” but has no suicidal intent or plan. First-line pharmacotherapy for this patient most likely involves a drug with which of the following mechanisms of action?
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Question 6 of 40
6. Question
A 20-year-old college student comes to the office due to persistent fatigue, irregular menstrual periods, and difficulty losing weight despite intensive exercise. Several times a week, the patient has episodes where she uncontrollably consumes large amounts of cookies, bread, and potato chips. She feels disgusted with herself afterward and subsequently does additional exercise. Although the patient hates her appearance and constantly compares herself to her slimmer friends, she denies feeling persistently depressed. She has no other medical problems. Weight is 70 kg (154.3 lb) and height is 160 cm (5 ft 3 in). Blood pressure is 100/60 mm Hg and pulse is 92/min. Examination shows pharyngeal erythema and minimal parotid enlargement bilaterally. Potassium level is 3.4 mEq/L and amylase is 140 U/L. Pregnancy test is negative. Which of the following medications would be most effective in treating this patient?
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Question 7 of 40
7. Question
An 8-year-old boy is brought to the pediatrician for school refusal. He has not gone to school for a few days, saying that he has a stomachache. However, when it comes time for soccer practice, he has no physical symptoms. When the pediatrician asks how things are going at school, the patient says, “kids laughed at me when the teacher said she couldn’t read my homework.” His mother brings a recent report from the boy’s teacher, which says that he is able to read and do math, but that when writing he fidgets a lot and stares out the window. His writing is unclear, disorganized, and below the level of his peers. His mother received a call from his teacher last week after the boy threw his writing book on the floor and began to cry. Vital signs and physical examination, including abdominal examination, are normal. At this time, which of the following is the most likely diagnosis in this patient?
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Question 8 of 40
8. Question
A 21-year-old woman comes to the office at her mother’s urging due to irritability and low mood. Two months ago, the patient was sexually assaulted in the parking lot of her workplace. Since then, she has felt that “the world is not a safe place” and is reluctant to go back to work, preferring to stay home. In the middle of the day she will “space out” and hear the voice of her assailant, “as if I am right there in the parking lot.” At other times, she feels a sense of unreality as if she is outside her body and cannot recall the exact details about what happened, and says that, “I feel like I am going crazy.” The patient has become withdrawn and either avoids her friends or becomes “snappy” when they visit her. She has lost interest in her hobbies of writing poetry and exercising. There is a family history of major depression in the patient’s mother and schizoaffective disorder in her maternal grandmother. Which of the following is the most likely diagnosis?
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Question 9 of 40
9. Question
A 2-week-old girl is brought to the office for a weight check. She was born at 36 weeks gestation due to preterm labor. The patient has been gaining weight appropriately, and her parents have no concerns. When questioned about the home environment, the mother says that she started smoking cigarettes after delivery due to the stress of sleep deprivation. The mother did not smoke during pregnancy, and the father is a nonsmoker. Support is provided, and the mother is counseled regarding the risks of secondhand smoke exposure. Which of the following conditions is the patient at increased risk for developing due to this exposure?
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Question 10 of 40
10. Question
A 22-year-old man comes to the emergency department due to sudden-onset pain and stiffness on one side of his neck. He was diagnosed with a psychiatric disorder 2 days ago and has been adherent with his newly prescribed medication. For the past few months, the patient has heard voices telling him to quit his job, and he believes that his girlfriend’s parents are monitoring his sexual thoughts with a special device. He has been socially withdrawn and has difficulty showering regularly. Vital signs are within normal limits. The head is tilted to one side and cannot be straightened without considerable pain. The most likely cause of this patient’s symptoms is antagonism of which of the following receptors?
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Question 11 of 40
11. Question
A 62-year-old man comes to the office with his wife for evaluation of episodic chest pain. The physician introduces herself to the patient and his wife and confirms that he is comfortable and not experiencing any current pain. The patient’s wife begins the conversation by saying, “He brought a list of his medications for you to review, but I’m not sure he takes all of them regularly.” After thanking them for bringing the list, which of the following is the most appropriate way for the physician to initiate the medical interview?
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Question 12 of 40
12. Question
A 9-year-old girl is brought to the office by her mother for evaluation of frequent stomach aches. The mother says that her daughter has always had a “sensitive stomach” but that it has gotten worse since she started going to a new school a few months ago. The girl has been missing class due to being in the nurse’s office multiple times per week. The patient’s symptoms improve when her mother comes to get her. In response to the doctor’s questions about the girl’s peer relationships, the mother replies, “She has friends but never enjoys sleepovers.” When the patient is at a friend’s house, she often complains of stomach pain and nausea. She occasionally has nightmares about being left alone and wakes up crying. Although both parents are healthy, the patient says she worries about them “dying of a terrible illness, like cancer.” Abdominal examination shows no abnormalities. Which of the following is the most likely diagnosis in this patient?
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Question 13 of 40
13. Question
An 11-year-old girl is brought to the office due to disruptive behavior at home and at school. Her parents report that she gets in trouble for talking during class and not following instructions. Although the patient is of above-average intelligence, her grades are poor. Teachers note that she makes careless mistakes while rushing through tests and frequently forgets to hand in assignments. At home, she is easily distracted while trying to focus on her homework. The patient has frequent conflicts with her mother, who says, “Getting her ready for school in the morning is impossible. We’re frequently late because she always misplaces her cell phone and books.” The patient has no other medical history, and developmental milestones are within normal range. Physical examination shows no abnormalities. The girl and her parents are willing to consider medication if it will help. A drug with which of the following mechanisms of action is most appropriate for this patient?
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Question 14 of 40
14. Question
A 38-year-old recently homeless woman and her 35-year-old boyfriend come to a community clinic seeking care for her pregnancy at 27 weeks. She also brings her 19-year-old son, who has cerebral palsy and has not had consistent medical care. The patient explains to the social worker that the family was recently evicted from their apartment for failure to pay rent after her boyfriend lost his job. Which of these individuals is eligible for Medicare coverage?
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Question 15 of 40
15. Question
A 46-year-old woman is hospitalized due to severe depression and fatigue. She has no other medical problems. Routine laboratory tests are ordered and the patient is started on antidepressant medication. After a week, her depression improves slightly and she is discharged home to continue with outpatient care. However, the patient remains severely fatigued and is unable to return to her job, forcing her to take a leave of absence. At her follow-up appointment 2 weeks later, review of the hospital record by the outpatient physician reveals a TSH level of 15.2 µU/mL that was never addressed by the inpatient physician. Subsequent evaluation and treatment with thyroid hormone result in rapid improvement of her depression and fatigue. Which of the following is the appropriate categorization for this type of medical error?
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Question 16 of 40
16. Question
A 46-year-old man is hospitalized with diabetic ketoacidosis. He is administered intravenous fluids and an insulin drip, and laboratory testing is ordered. In the morning, the on-call physician hands off the patient to the day shift physician, who arrives an hour late due to an emergency at his nighttime moonlighting job. The handoff information includes the status of the patient and instructions to check electrolytes and calculate his anion gap. The physician performs inpatient rounds and then sees his usual clinic outpatients in the afternoon, but he neglects to check the patient’s anion gap. The patient subsequently develops worsening acidosis requiring intubation for respiratory distress. Which of the following is the most likely cause of this adverse outcome?
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Question 17 of 40
17. Question
A 75-year-old woman is hospitalized for a bowel obstruction related to adhesions from previous uterine cancer surgery and radiation. She has a history of hypertension, atrial fibrillation, and peripheral vascular disease. After a prolonged hospital course complicated by a pulmonary embolus, she is discharged on multiple medications, including a higher dose of her warfarin. The patient is scheduled for follow-up appointments with her internist, gynecologist, cardiologist, and gastroenterologist. She lives by herself and has been able to successfully manage her care needs in the past. Her adult daughter is supportive but lives out of state. Which of the following interventions would be most effective in improving her adherence to outpatient treatment?
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Question 18 of 40
18. Question
A 31-year-old woman comes to the office for a yearly checkup. The patient has no medical conditions but expresses dissatisfaction with her appearance and wishes she could lose weight more easily. She reports occasional constipation and fatigue. The patient exercises daily and drinks 1 or 2 glasses of wine 2-3 times a week when socializing with friends. Weight is 58.1 kg (128 lb) and height is 157.5 cm (5 ft 2 in). BMI is 23.4 kg/m2. Routine laboratory evaluation shows a potassium level of 3.1 mEq/L. Physical examination is most likely to show which of the following abnormalities?
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Question 19 of 40
19. Question
An 82-year-old woman is hospitalized in a busy tertiary care hospital due to fever and shortness of breath. The patient has a history of chronic obstructive pulmonary disease. She is diagnosed with pneumonia and started on empiric antibiotic therapy overnight by the admitting physician. After several days of treatment, the patient’s condition deteriorates, and she is transferred to the intensive care unit. Sputum cultures were obtained on admission, but the results were not checked by the daytime team, resulting in a delay in initiating more specific antibiotic treatment. Which of the following interventions would be most effective to prevent this type of medical error?
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Question 20 of 40
20. Question
A 40-year-old woman with major depression comes to the office for follow-up. She has been taking paroxetine daily for the past year. The patient is doing fairly well but is concerned that she experiences periods of low mood on occasion. When asked how she is taking the medication, she states, “I know the bottle says once a day, but I usually take an extra pill when I feel sad and skip it if I’m having a good day.” Vitals signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?
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Question 21 of 40
21. Question
A 70-year-old woman comes to the physician for a new patient visit. She reports intermittent headaches and poor sleep. During review of systems, she also describes a sensation of incomplete emptying of the bladder and constipation. The patient has a history of migraines and chronic insomnia. Her other medical problems include hypercholesterolemia and osteoarthritis. Her medications include amitriptyline prescribed for migraines, simvastatin, diclofenac, and over-the-counter diphenhydramine for insomnia. Which of the following is the most appropriate next step in management of this patient?
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Question 22 of 40
22. Question
A 19-year-old man is admitted with delusions, hallucinations, and disorganized behavior. He is diagnosed with schizophrenia, and the physician writes an order to begin aripiprazole “2.0” mg. The patient mistakenly receives 20 mg aripiprazole instead of 2 mg. This order is overlooked during the pharmacy review process, and the nurse fails to question it before administering aripiprazole to the patient. Which of the following is the most effective intervention to reduce this type of error?
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Question 23 of 40
23. Question
A 45-year-old woman comes to the office for follow-up of type 2 diabetes mellitus. Current glycated hemoglobin level is 9%. The patient was diagnosed with diabetes a few months ago and was started on metformin twice daily. When the physician asks how she is doing with her medication, she replies, “I use it most of the time, but it’s easy to forget when I am feeling good.” Which of the following statements is most appropriate to begin a discussion about this patient’s nonadherence to her medication?
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Question 24 of 40
24. Question
A 28-year-old man comes to the office at his wife’s insistence. He reports severe insomnia but otherwise feels physically healthy. His wife is concerned that the patient is having a difficult time since returning from military duty. She says, “He used to be so upbeat and easygoing. Now his moods fluctuate between really tense and on edge to detached and numb.” The patient cannot fall asleep at night because, as soon as he closes his eyes, he sees the horrific scene of his friend being blown up after stepping on a landmine. During the day, he is hypersensitive to loud sounds such as firecrackers or a car backfiring. The patient says, “Sometimes I feel as if I’m back in combat and have to duck and take cover.” Vital signs are within normal limits, and physical examination shows no abnormalities. On mental status examination, the patient has an anxious mood and blunted affect. Which of the following is the most appropriate pharmacotherapy?
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Question 25 of 40
25. Question
A frail, 93-year-old woman with mild dementia enters a nursing home due to difficulty managing on her own. She has recently had several falls, including one during the night while getting out of bed to use the bathroom. The patient attributes this fall to “clumsiness.” Syncope workup is unremarkable for any abnormalities. She has a medical history of hypertension, osteoarthritis, depression, and anxiety. Her medications include amlodipine, sertraline, aripiprazole, and amitriptyline. Which of the following is the most effective strategy for decreasing this patient’s fall risk?
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Question 26 of 40
26. Question
A 12-year-old girl is brought to the office for an annual checkup. The mother expresses concern about her daughter’s behavior and poor grades, and says, “She is stubborn, irritable, overly emotional, and doesn’t listen. She also seems resentful of her twin brother and deliberately annoys or upsets him. I can’t get her to do chores or her homework, or go to bed on time.” Over the past year, the mother has been called several times by the school guidance counselor about her daughter talking back to teachers and skipping classes. The patient says that school is “boring” and blames her behavior on “pointless rules and unreasonable demands,” saying that her teachers are all “stupid.” Which of the following is the most likely diagnosis in this patient?
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Question 27 of 40
27. Question
A 40-year-old woman comes to the office due to worsening anxiety and insomnia over the past 3 months. She says, “I’m really worried that something is wrong with me. I was never a particularly anxious person, but now I feel anxious all the time. Sometimes I feel panicky for no reason; my heart races and I break out in a sweat. The only benefit is that I have lost 5 pounds (2.3 kg) without even trying.” The patient has no significant medical or psychiatric history. She drinks 2-3 glasses of wine per week and does not smoke or use illicit drugs. Blood pressure is 130/90 mm Hg and pulse is 112/min. On physical examination, the patient is restless and has warm, moist skin and mild hand tremor bilaterally. Mental status examination is notable for a frightened stare, anxious mood, and rapid speech. Which of the following is the most likely diagnosis?
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Question 28 of 40
28. Question
A 39-year-old right-handed man is brought to the office by his wife due to concerns about his behavior. Two months ago, the patient was robbed and hit in the head and knees with a baseball bat when he resisted. He initially had difficulty walking, but his injuries have since healed. His wife and other family members say that his overall demeanor has changed significantly since the attack. Prior to the assault, the patient was kind, considerate, and extremely polite. However, since the attack, he has been very irritable and rude, and was recently fired from his job for insulting customers and making socially insensitive comments to coworkers. Damage to which anatomical region of the brain is the most likely explanation for this patient’s symptoms?
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Question 29 of 40
29. Question
A 35-year-old man is admitted to the hospital after sustaining multiple injuries in a motor vehicle accident. He undergoes surgery for an open fracture of the tibia and a spiral fracture of the humerus. The tibial repair is successful, but the surgeon operates on the wrong arm. Which of the following procedures would be most effective in preventing a similar error?
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Question 30 of 40
30. Question
A 44-year-old man comes to the office due to low mood, impaired concentration, increased sleep and appetite, feelings of heaviness in his arms and legs, and loss of energy. He is having difficulty at work as he is overly sensitive to criticism. Although his boss has told him not to worry, the patient is concerned that his job is in jeopardy due to poor performance. His symptoms started 8 months ago without any clear-cut precipitating event. The patient received adequate trials of 3 different antidepressants without improvement and has been off of medication for the past several weeks. His physician is now considering electroconvulsive therapy (ECT). The patient declines ECT and asks to try another medication. The physician then considers phenelzine. The presence of which of the following additional symptoms would make the patient more likely to respond to this medication?
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Question 31 of 40
31. Question
An 18-year-old woman comes to the office due to low energy, decreased appetite, insomnia, poor concentration, and decreased interest in her daily activities. She has lost 3.6 kg (8 lb) over the last month. The patient has no psychiatric history and has no current or significant medical illnesses. Physical examination and laboratory evaluation are unremarkable. Treatment with medication is initiated. Three weeks later, the patient is brought to the emergency department by her mother for not sleeping at all for 3 nights. The patient reports that she does not feel tired despite lack of sleep. She spent a large amount of money on plane tickets and plans to travel around the world to promote world peace. Her mother adds that she herself has suffered from severe mood swings in the past. This patient was most likely started on which of the following medications 3 weeks ago?
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Question 32 of 40
32. Question
A 72-year-old retired man with end-stage renal disease becomes agitated during dialysis and attempts to abruptly leave in the middle of the procedure. The patient accuses the staff of violating his rights and stealing his belongings but then appears to fall asleep. Fifteen minutes later, he becomes violent and requires restraints. Medical history is significant for hypertension, type 2 diabetes mellitus, hyperlipidemia, and peripheral vascular disease. The patient has a history of major depression that has been in remission for 15 years. His wife says that he has experienced mild memory and word-finding difficulties over the last year and that he often needs to make lists to remind himself of errands; however, she has never witnessed this type of agitated behavior. Temperature is 38.3 C (100.9 F), blood pressure is 112/63 mm Hg, pulse is 93/min, and respirations are 18/min. The patient has a left carotid bruit, and a dialysis catheter is present in the right internal jugular vein. Bronchial breath sounds are heard at the right lung base. During neurologic evaluation, he is confused but cooperative with no focal findings. Which of the following is the most likely explanation for this patient’s current behavior?
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Question 33 of 40
33. Question
A 45-year-old woman with type 2 diabetes mellitus, obesity, and hypertension comes to the office for a routine follow-up visit. Her medications include a sulfonylurea and ACE inhibitor. The patient has lost 2.3 kg (5 lb) and credits a new energy and weight loss supplement. She purchased the supplement over the Internet on the recommendation of a friend and believes that it contains caffeine and several herbs that promote weight loss. The patient has had no problems tolerating the supplement. Blood pressure is 140/90 mm Hg and pulse is 88/min. Which of the following is the most appropriate response by the physician?
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Question 34 of 40
34. Question
A 27-year-old man comes to the office for follow-up regarding a herniated disc. He first injured the disc 3 months ago while at work. Nonsurgical treatment options, including physical therapy and as-needed NSAIDs and tramadol, were recommended. The patient has completed physical therapy, and follow-up MRI indicates that the herniated disc has regressed. He reports a significant amount of ongoing pain and asks for a dose increase and refill of his pain medication. In the past month, the patient has been to the emergency department on 2 occasions to request pain medication due to running out before his next scheduled refill. Vital signs are within normal limits, and physical examination is unremarkable. Which of the following statements by the physician would be most appropriate at this time?
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Question 35 of 40
35. Question
A 48-year-old man comes to the office due to concern that his skin is excessively dry, red, and cracked. The patient explains that he washes his hands each time he touches something due to fear of contamination. He spends 3-4 hours a day washing his hands and showers multiple times daily. He was recently fired from his job after refusing to touch keyboards shared by coworkers and is worried that he will be unable to find employment. On physical examination, the palms are erythematous with peeling skin. Treatment of this patient’s disorder is most likely to involve a medication affecting which of the following neurotransmitters?
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Question 36 of 40
36. Question
A 29-year-old woman comes to the office due to persistent fatigue over the last 4 years. She has also felt unhappy during this period, ever since being let go from her previous job. The patient describes her fatigue as “having little energy to do things.” When asked what she enjoys, she replies that “everything in life is a chore” and that she feels hopeless that her life will improve. The patient has no suicidal thoughts, problems with concentration, or changes in appetite or sleeping patterns. She used marijuana as a teenager and drinks 1 or 2 glasses of wine on weekends. Detailed workup, including urine toxicology screen, is negative. Which of the following is the most likely diagnosis?
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Question 37 of 40
37. Question
A 35-year-old woman comes to the office due to insomnia and fatigue over the past month. She has felt increasingly depressed, irritable, and worthless since being let go from her job 5 weeks ago. The week prior to her last menstrual period was particularly difficult, and she stayed in bed most of the day. Over the last month, the patient has lost 3.6 kg (8 lb) and has felt unmotivated and unable to concentrate on looking for new work. Other medical conditions include hypothyroidism and migraine headaches. The patient drinks 1 or 2 glasses of wine a few times a week and smokes marijuana once a month. Medications include levothyroxine and naproxen. Physical examination is normal. TSH level is 0.9 µU/mL. Which of the following is the most likely diagnosis in this patient?
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Question 38 of 40
38. Question
A 35-year-old man comes to the office due to problems with irritability, anxiety, and low self-esteem. He was recently fired due to poor work performance at his data entry job and worries about finding a new job and supporting himself. The patient is currently in a relationship but mentions that his girlfriend is upset by his frequent lateness and forgetfulness and has threatened to leave him. Further history indicates that his problems are long-standing and date back to childhood when he had behavioral problems in school. The patient frequently feels overwhelmed due to being disorganized. He frequently procrastinates, is bored easily at work, and jumps to another project before completing what he is working on. The patient drinks 3 or 4 beers a week and smokes marijuana twice a month. On mental status examination, he is cooperative and talkative but appears tense, restless, and easily distracted. Which of the following is the most likely diagnosis in this patient?
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Question 39 of 40
39. Question
An 83-year-old woman is sent to the emergency department from the nursing home where she resides for evaluation of mental status changes. At baseline, she has mild memory impairment but is otherwise cognitively intact, calm, and cooperative with the nursing home staff. Over the past 24 hours, she has become increasingly combative and agitated and stayed up all night. Behavioral interventions and environmental modifications have not been helpful. The patient’s medical conditions include hypertension and a history of anxiety and depression. Temperature is 37.2 C (99 F), blood pressure is 110/80 mm Hg, pulse is 84/min, and respirations are 18/min. Neurological examination is normal, but the patient is unable to attend to the conversation, is mildly disoriented, and cannot state the days of the week backwards. Without provocation, she strikes out at a nurse’s aide standing next to her. Laboratory results are normal except for urinalysis, which shows an increased presence of white blood cells and is positive for nitrites. Head CT scan is negative. In addition to starting antibiotic therapy, which of the following medications is most appropriate to treat this patient’s behavioral symptoms?
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Question 40 of 40
40. Question
A 43-year-old woman comes to the office for an initial appointment due to ongoing abdominal pain, general weakness, decreased appetite, and dizziness. She says the pain is ruining her life and is worried that her previous physicians may have missed something. Over the past several years, the patient has been hospitalized 3 times with similar symptoms. No etiology for the pain has been identified despite extensive workups, including several abdominal CT scans and an exploratory laparotomy. The patient describes chronic abdominal pain since adolescence and is concerned as the nonprescription analgesics she takes are ineffective. She has no history of psychiatric diagnoses or substance abuse. Physical examination, vital signs, and laboratory tests (including chemistry panel, complete blood count, and urinalysis) are within normal limits. Which of the following is the most appropriate next step in the management of this patient?
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