An 82-year-old woman is brought to the emergency department with high-grade fever.  She resides at a local nursing home.  The nursing home staff reports that in the past few days she has been quieter than usual but is otherwise at her baseline mental status.  In the hospital, the patient is calm and cooperative and says that she feels “tired.”  Medical history includes diabetes mellitus, hypothyroidism, atrial fibrillation, chronic obstructive pulmonary disease, and severe, deforming rheumatoid arthritis.  Her history is also significant for severe alcohol use disorder, which is in remission.  The patient’s medications include aspirin, insulin, albuterol inhaler, levothyroxine, warfarin, and low-dose prednisone.  Temperature is 38.9 C (102 F), blood pressure is 126/84 mm Hg, pulse is 92/min, and respirations are 20/min.  Oxygen saturation is 96% on 3 L of oxygen.  The patient is awake and alert but subdued and minimally conversant.  The mucous membranes are extremely dry.  The rest of the physical examination is unremarkable.  Initial laboratory results are as follows:

Other laboratory results are within normal limits.  The patient is admitted to the hospital, and intravenous fluids and antibiotic therapy are administered.  During the night, she becomes very restless, confused, and agitated.  She pulls out her intravenous line, causing significant bleeding.  When the staff arrives, she insists that one of the nurses is her mother, attempts to leave the bed, and pushes an aide aside.  Which of the following is the most appropriate course of action?

A 31-year-old man comes to the office for a routine annual examination.  The patient mentions that he is engaged to be married, but adds that he is not sure he is ready to make a commitment.  He says, “I love my fiancée, but I have recently had some relationships with men.  My fiancée wants to have children as soon as we are married, but I feel ‘boxed in’ by this and want to be absolutely sure that this is what I want.”  The patient feels conflicted, as he enjoys sex with his fiancée but wonders about other options.  He has had sexual intercourse with men in the past and has used condoms most of the time.  The patient does not use illicit drugs, except for MDMA occasionally at parties.  Examination shows oral thrush and generalized lymphadenopathy.  The rest of the physical examination is normal.  When the physician recommends that the patient undergo HIV testing, he refuses.

Item 1 of 2

Which of the following would be the most appropriate response to this patient?

Item 2 of 2

Following an extensive discussion with the physician, the patient agrees to undergo testing for HIV and other sexually transmitted diseases.  Polymerase chain reaction testing results indicate that he is positive for HIV.  The physician discloses these results to the patient during a follow-up appointment later in the week.  After he hears this news, he says, “How could this have happened to me?  I only had unprotected sex once or twice.  Are you sure those are my test results?  I am shocked at this.  I mean, I am such a healthy person.”  The physician supports the patient and educates him about HIV infection and antiretroviral therapy.  He explains the importance of consistent and correct condom use and the importance of informing his fiancée.  The patient begins to cry and says, “I don’t know if I could ever tell her; I am afraid she will leave me.”  Which of the following is the best next step in responding to this patient?

A 22-year-old man comes to the clinic for routine follow-up of his mild asthma.  He has a history of keeping his appointments but has missed the last three.  Today he seems distracted and uninterested, answering various questions with very brief replies.  At one point, the patient says that he would like to hurry the visit along so he can get home sooner.  Following inquiries about his social life, he becomes more animated and describes spending time with new friends who “really know how to party.”  On further questioning, he says, “I have been snorting cocaine sometimes but it’s not a big deal.  I haven’t used any this past week.  I quit school because it was just stupid and I was wasting my money.  I’m working as a waiter now and enjoying it.  At least I can make my own money and not be dependent on my parents.”  The patient says that he has been living with his new friends since his parents asked him to move out 2 weeks ago, but he would “rather not talk about that.”  He denies any symptoms of depression, mania, or psychosis.  Temperature is 37.7 C (99.9 F), blood pressure is 120/82 mm Hg, pulse is 86/min, and respirations are 15/min.  Physical examination shows perforations of the nasal septum.

Item 1 of 2

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

Item 2 of 2

After discussion, the patient agrees to curtail his cocaine use and says that it will not be a problem.  He is receptive to a back-up plan of referrals to 12-step group programs and outpatient substance abuse programs.  The physician asks for permission to speak with his parents, and the patient says he will think about it.  However, he fails to attend his 1-month follow-up appointment.  Six months later, the patient makes an appointment to renew his asthma medications.  When the physician notes multiple track marks on his arms, the patient admits he has been injecting cocaine.  He has lost his job as a waiter and is currently unemployed.  He has not spoken to his parents and is temporarily staying with a friend who also uses drugs.  The patient says he tried a few Narcotics Anonymous meetings but did not attend regularly and has been unable to stop using.  He admits to feeling depressed and has lost 4.5 kg (10 lb).  He has no suicidal ideation.  Which of the following is the most appropriate step in managing the patient’s substance use problem?

A 26-year-old male graduate student under treatment for depression comes to the office for follow-up.  Two weeks earlier, he was evaluated for symptoms of depressed and irritable mood, loss of appetite, low energy, and impaired concentration.  He had no motivation to work on his thesis and was sleeping 12-14 hours a day.  Physical examination and laboratory studies were unremarkable.  The patient was agreeable to a trial of medication and was started on fluoxetine 20 mg.  At today’s visit, he reports feeling irritable and anxious, but notes that his energy is much improved.  He is now staying up almost all night to work on his thesis and says, “I’ve had some fascinating insights into my research that I never thought of before.”  The patient has been adherent with his medication and has no other medical problems.  He denies substance use apart from 2 beers he drank at a party 3 nights ago.  Mental status examination shows mildly pressured speech and tense affect.  The patient interrupts the physician several times to ask inappropriate questions about the physician’s personal life.  No delusions or hallucinations are elicited.  He has no suicidal ideation.

Item 1 of 2

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

Item 2 of 2

Following discontinuation of fluoxetine, the patient continues to experience increased energy and decreased need for sleep.  He is unable to focus on his research due to racing thoughts and stops attending classes because, “There is no need to study when you already know the truth.”  The patient is admitted to a psychiatric unit.  Urine toxicology is negative, and routine laboratory values are within normal range.  Lithium is started and titrated to a level of 1.1 mEq/L (therapeutic window: 0.6-1.2 mEq/L).  Nursing reports indicate that the patient sleeps 2-3 hours a night and laughs inappropriately.  He makes inappropriate sexual and threatening comments to the staff and does not respond to redirection.  On mental status examination, he is pacing; has loud, pressured speech; and claims that he is on the verge of an important breakthrough that will revolutionize the Internet.  Which of the following is the most appropriate next step in management of this patient?

A 28-year-old man with a history of bipolar I disorder is brought to the emergency department after being pulled over by police for erratic driving.  The police report indicates that the patient appeared alcohol-intoxicated and refused to cooperate with questions, stating, “I have the skills of a race car driver and don’t need to stop for anybody.”  The outpatient psychiatrist is contacted and reports that the patient has been treated with lithium for the past year; he had a therapeutic lithium level and appeared stable at his last visit 2 weeks ago.  Medical history is otherwise noncontributory.  The patient is reevaluated when he is sober and states that he felt upset after an argument with his girlfriend a few days ago, so he decided to “get drunk.”  He is apologetic for driving recklessly and says he intends to follow up with his outpatient psychiatrist.  Temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, and pulse is 88/min.  Physical examination is normal.  The patient is alert and fully oriented.  Speech is not pressured, and his thought process is logical and organized.  Serum lithium level is therapeutic.  Urine toxicology screen is negative.

Item 1 of 3

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

Item 2 of 3

On further questioning, the patient acknowledges that he has been feeling low since losing his job recently and has been having difficulties in his relationship.  He states that he has done a lot of “stupid things” in his life and struggles with “making bad decisions” when he is upset.  Which of the following questions is most appropriate to ask the patient at this time?

Item 3 of 3

The patient shares that when he was driving while intoxicated, he was trying to get up the nerve to crash his car and kill himself.  He started to swerve on purpose but then straightened out when he thought of how his suicide would devastate his mother.  The patient says, “When I’m in a dark hole, it seems that nothing will ever get better for me; alcohol numbs the pain, but it feels like suicide is the only way out.”  The patient agrees to hospitalization for further evaluation and treatment.  Which of the following is the most appropriate next step for reducing the risk of suicide in this patient?

A 9-year-old boy and his 5-year-old sister are brought to the office by their mother due to behavioral concerns.  The boy has been sad and has cried frequently since the family dog was euthanized 10 days ago after being hit by a car and sustaining severe injuries.  His mother says, “The other day, he had a stomachache and did not want to go to school, so I let him stay home.  I later learned from his teacher that he was very embarrassed after crying in front of his classmates.  He’s also been asking to sleep in my bed, which he hasn’t done in years.”  In contrast, his sister is cheerful and “acts as though nothing has happened.”  The mother says, “I sat her down and told her the dog had died, but she didn’t seem sad at all and thinks her dog is coming back.  She’s excited about her birthday party this weekend and plans to set a place for the dog at the table.”  Neither child has a history of medical or psychiatric conditions or takes any medications.  Their developmental and growth milestones are normal.  Which of the following is the most appropriate response to the mother’s concerns?

A 43-year-old woman comes to the office for an initial evaluation.  The patient recently moved to the area for a new job and is worried about her poor health.  She explains that she had to call in sick several times this past month because either “I felt too exhausted” or “I was lightheaded and had an upset stomach.”  The patient has a history of hypothyroidism, chronic headaches, insomnia, and dysmenorrhea.  She describes a long history of fatigue, but previous doctors have assured her that her hypothyroidism is well controlled with medication.  She also describes chronic problems with urinary frequency; stomach bloating; and dry, itchy skin.  The patient is worried about her symptoms and wonders if all the doctors she has seen may have “missed something.”  Her medications include levothyroxine, daily multivitamins, and zolpidem and naproxen as needed.  The patient does not smoke or use illicit drugs.  She stopped drinking alcohol a year ago as it made her symptoms worse.  Blood pressure is 110/70 mm Hg, pulse is 84/min, and respirations are 12/min.  Physical examination is normal.  T4 is 10 µg/dL and TSH is 1.3 µU/mL.

Item 1 of 2

Which of the following is the most likely diagnosis in this patient?

Item 2 of 2

The physician assures the patient that her blood tests and physical examination are normal.  She schedules an appointment 2 weeks later and now reports frequent headaches in addition to her ongoing concerns.  The patient says, “These headaches just make me even more tired.”  Her headaches occur 2-3 times a week and are bilateral and nonthrobbing.  She reports, “My neck is sore and my shoulders are so tight I can hardly turn my head without it being painful.”  The patient has no aura and the headaches are relieved by naproxen.  Physical examination is normal apart from some muscle tenderness in the shoulders and neck.  When the physician inquires if moving and starting a new job have been stressful, she replies, “It’s not the job or the move; it’s not feeling well that is stressful.  Maybe I should see a neurologist.”  The patient is very anxious and asks if the physician can order a repeat brain MRI to determine the diagnosis.  Her records indicate that a brain MRI performed last year was normal.  Which of the following is the most appropriate response to the patient?