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A 41-year-old man has developed increasing anxiety over his job performance as a manager of an international corporation. He is Caucasian, holds a master’s of business administration degree, and has a long track record of professional success. Which therapeutic intervention for anxiety is this patient particularly suited for? Cognitive behavioral therapy A 26-year-old woman has developed generalized anxiety disorder over the last year, and she has not benefited from cognitive behavioral therapy. At the time of presentation she is in good physical health and has no psychiatric comorbidities. You decide to treat her with medication. Which of the following would be most appropriate? SSRI or SNRI A 48-year-old man complains of extreme anxiety whenever he visits his parents, and over the last several years he has tried to avoid contact with them. He also fears that he could act in a way that would make his family disapprove of him. Going on actual visits over the last several years has provoked extreme anxiety on each occasion. He realizes the fear is irrational and it impairs his quality of life. He has no history of substance abuse or mental disorder, and no other medical condition that could explain his physiologic symptoms of anxiety. Which of the following is the most likely diagnosis for this patient? Nongeneralized social anxiety disorder A 35-year-old man complains of extreme shyness in social situations that go along with blushing, sweating, and, oftentimes, increased heart rate. He has started to avoid social contact largely because of this anxiety. He also reports missing interactions with friends and family. He shows symptoms of depression and assumes the depression arises from social isolation. Which of the following is the most likely diagnosis for this patient? Generalized social anxiety disorder
A 25-year-old woman who was raped is receiving cognitive behavioral therapy for symptoms of acute stress disorder. Which of the following medication classes may be prescribed to further reduce her symptoms and reduce her risk of developing post-traumatic stress disorder? SSRI A 28-year-old woman has experienced a series of episodes of intense anxiety that were accompanied by trembling, sweating, nausea, and feelings of being detached from herself. The episodes have been occurring over the last 6 weeks and are always unexpected. The patient had developed a fear that attacks could occur while she was in the company of other people, and she has invented various strategies to spend the majority of her time by herself both at home and at work. Which of the following is the most likely diagnosis for this patient? Panic disorder A patient on methadone maintenance therapy is experiencing acute anxiety and is being treated with alprazolam. Which potential effect of this drug combination should be considered? higher peak methadone levels A 44-year-old woman has been treated for 4 weeks with diazepam for the initial management of generalized anxiety disorder. Paroxetine was prescribed for maintenance treatment and is now taking effect. How should the termination of benzodiazepine treatment be managed? taper diazepam over several weeks A 26 - year-old woman presents with generalized anxiety that leaves her unable to go about her daily activities. Which of the following strategies is the most promising to quickly control these symptoms? benzodiazepines in combination with serotonin–norepinephrine reuptake inhibitors (SNRIs) or selective serotonin reuptake inhibitors (SSRIs)
the desire to have a child. Which gynecologic and reproductive complications should you be aware of in this scenario? amenorrhea, complications of pregnancy, neonatal complications A 26-year-old woman with anorexia nervosa has a body mass index of 14. kg/m^2 and amenorrhea for the last 8 months. Suspected osteoporosis was confirmed by dual-energy x-ray absorptiometry. How should this patient's osteoporosis be treated? weight gain, resumption of menstrual function A 21-year-old woman with anorexia nervosa is treated with nutritional rehabilitation in an inpatient setting. She has an initial body mass index of 16 kg/m^2 and has been amenorrheic for 5 months. Which of the following is NOT an effect of early recovery? Acute inffections A 30-year-old woman with an initial body mass index of 16.5 is treated in an inpatient setting with nutritional rehabilitation. As refeeding is started, the patient may be at risk for refeeding syndrome. Which are the characteristics of refeeding syndrome? hypophosphatemia; hypokalemia; hypomagnesemia; vitamin and trace mineral deficiencies; volume overload; edema A 33-year-old woman is being treated for anorexia nervosa on an inpatient basis, but she continues to lose weight despite the use of maximal intensive care. Pharmacologic treatment is considered. Which medication is contraindicated for this patient? Bupropion A 26-year-old woman has had episodes of binge eating and subsequent purging. She was recently diagnosed with bulimia nervosa. At presentation, her body mass index is 3 8 kg/m^2. What is the treatment of choice for this patient? cognitive behavioral therapy
A 54-year-old man presents with a complaint of tightness in the chest and shortness of breath. He has a history of prior symptoms suggestive of coronary heart disease. However, his description of his symptoms is inconsistent. Coronary angiography and electrocardiography yielded no evidence of coronary artery disease. An assessment of the patient's financial and legal situation gave no reason to suspect he stood to benefit materially from the diagnosis. What should the diagnosis be? factitious angina A 44-year-old man presents with acute onset left arm and leg hemiparesis and fluctuating weakness. He is morbidly obese, and his blood sugar is within normal limits. Aside from the leg and arm hemiparesis, the neurological exam is intact. Which of the following aspects of his presentation should alert you to a factitious stroke? absence of facial weakness A 54-year-old Caucasian woman has produced a seizure suggestive of an epileptic attack in the waiting room of a physician's office. She is resisting antiepileptic drugs and claims her seizure was triggered by stress. Which of the following best describes the method that can be used to diagnose the seizure as psychogenic? video/electroencephalography (EEG) monitoring A 24-year-old Caucasian woman presents with a complaint of intermittent weakness in her arms, involuntary contractions of her hands, sensory disturbances, and well as poor bowel control. The patient's account appears grandiose, and the results of the initial neurologic assessment are inconsistent with complaints of weakness and involuntary movement. Subsequent urine testing for laxatives is positive. Upon confrontation with these findings, the patient admits her symptoms were feigned to provoke hospitalization. The diagnosis of a factitious disorder is therefore confirmed. Which of the following best describes the risks that the confirmation of this diagnosis carries for the patient?
weight loss. He recently stopped coaching a little league soccer team. During the interview he appears increasingly irritated by the questions, and further questioning reveals that he has been increasingly irritable at home and at work. Which of the following is the most likely diagnosis? Major depression A 34-year-old man presents with complaints of sleeplessness and loss of appetite. An interview reveals symptoms sufficient for the diagnosis of major depression. As part of the diagnostic workup, the patient completes the Patient Health Questionnaire-9. His score is indicative of moderate depression. Which of the following best describes what this patient’s initial treatment should be? psychotherapy or pharmacotherapy with a second-generation antidepressant A 37-year-old man with a previous history of two episodes of major depression presents with new complaints of low mood and marked irritability. He also complains about marital difficulties. A quick screening test reveals that he is likely depressed, and a subsequent interview establishes that he meets the diagnostic criteria for major depression. In particular, his sleeping patterns have changed so that he now sleeps more, rather than less, and his appetite and weight have increased. The diagnostic interview takes place in mid- December, and his medical records reveal that previous depressive episodes also had their onset in the fall, and then reached remission in February or March. Which of the following represents the most appropriate diagnosis for this patient? major depressive disorder with seasonal pattern A 37-year-old man was diagnosed with fall-onset seasonal depression. At the time of diagnosis and at the 6-week follow-up visit, he showed no signs of psychosis or suicidal ideation. However, a 12-week medication trial with citalopram 20 mg/day has not led to any improvement in his depressive symptoms; instead, it has appeared to increase somnolence. The patient is dissatisfied with this therapeutic regimen, so he requests to try light therapy. Which of the following indicates how his treatment should proceed? taper the citalopram and add light therapy
A 24-year-old woman presents with complaints of sleeplessness and an inability to concentrate on her work. A subsequent interview reveals that the symptoms are sufficient for a diagnosis of major depression. Upon further questioning, the patient reveals that she has had previous episodes of sleeplessness, lasting less than 1 week each. During these episodes, she never felt tired, nor did she experience the concentration deficit that is bothering her now; rather, she has felt an increase in energy and self-esteem. She has never felt impaired by her previous episodes, but she points out that she has accomplished extraordinary amounts of schoolwork. She has never been hospitalized for any reason. Which of the following is the most appropriate diagnosis? Bipolar disorder II A 53 - year-old man has been treated for bipolar disorder I for about 6 months with varying combinations of mood stabilizers and second-generation antipsychotics, but he has not shown any improvement. For the last 3 weeks he has been hospitalized after making threats to coworkers. During the hospitalization, he has refused food and has lost weight. He has repeatedly stated that "they are out to get him," and that he is carrying a secret of national importance. How best should this patient’s treatment proceed? electroconvulsive therapy (ECT) may be considered A 76-year-old woman has developed a sudden elevated mood and extensively quotes from the Bible while giving indications of racing thoughts and pressed speech. In a clinical interview, she does not remember any preceding mood episodes at any time in her life, other than postpartum blues. Interviews of family members confirm that she has never appeared hypomanic or depressed. Which conditions are the most common causes of secondary mania in the elderly and should be ruled out before a diagnosis of new-onset bipolar disorder? brain tumor and stroke A 58-year-old man has been diagnosed with and treated for bipolar depression. His symptoms have gradually subsided, and he is now mostly
does not smoke cigarettes, drink alcohol, or use illicit substances. She does not take any medications. Blood pressure is 110/80 mmHg, pulse 80, respirations 14, oxygen saturation 100% on room air, temperature 99F. General physical examination is within normal limits. Complete blood count, serum chemistries, liver enzymes, and thyroid function tests are within normal limits. Urine drug screen is negative. She asks which of the following medications have been shown to prevent suicide? Lithium A 31-year-old man presents with rash, night sweats, weight loss, and fatigue. He describes the rash as starting 1 day ago and is located on his fingers and toes. The rash is painful. The weight loss began 1 week ago, around the same time the fatigue and night sweats began. He’s not sure how much weight he has lost, but says his jeans are now too big. Social history includes intravenous heroin abuse, and he smokes 1 pack of cigarettes a day. His vital signs are: temperature 102.2 °F (39 ° C), pulse 126 beats/minute, blood pressure 105/56 mm Hg, respiratory rate 15 breaths/minute, and oxygen saturation 97 % on room air. His body mass index is 19 .1 kg/m^2. There are multiple, tender erythematous and violaceous papules along the ventral surface of his fingers and toes. Fingernails bilaterally have erythematous, vertical streaks within the nail beds. A regurgitant murmur is heard in the aortic position, and there are subconjunctival petechiae noted bilaterally. His hemoglobin level is 9.1 g/dL (normal range, 11 - 14 g/dL), and his hematocrit level is 27% (range, 32%-42%). What is the most likely diagnosis? Infectious endocardiatis A 26-year-old woman is brought to you because of an acute panic attack she had at a dance party. She feels warm to the touch, acts restless, and is pacing the room. There is no past medical history of illnesses. Social history includes alcohol consumption of 5 to 6 drinks per night on the weekends. Friends with the patient reveal she was "maybe trying some stuff" while she was at the dance party.
Her vital signs are: temperature 103.8 °F (40 °C), pulse 120 beats/minute, blood pressure 160/90 mm Hg, respiratory rate 25 breaths/minute, and oxygen saturation 100% on room air. Her body mass index is 19.1 kg/m2. The patient is salivating and sweating profusely, and she has pressured speech. Laboratory studies are as follows: Glucose: 89 mg/dL (normal range, 70-100 mg/dL) Sodium: 138 mmol/L (normal range, 136-145 mmol/L) Potassium: 4.2 mmol/L (normal range, 3.5-5.4 mmol/L) Creatinine: 0.8 mg/dL (normal range, 0.6-1.1 mg/dL) Urea nitrogen: 12 mg/dL (normal range, 7-18 mg/dL) Hemoglobin: 12.7 g/dL (normal range, 11-14 g/dL) Hematocrit: 35% (normal range, 32%-42%) Urine drug screen is positive for methylenedioxymethamphetamine (MDMA), also known as ecstasy. How best should the immediate MDMA toxicity be managed? urgent fluid replacement, benzodiazepines, labetalol and, if necessary, haloperidol or, consider induced paralysis A 63-year-old woman presents for preoperative clearance for a displaced fracture of the distal tibia, which occurred from a fall 3 days ago. Social history is significant for consuming 12 to 15 beers/day for the past 3 months, and smoking 1 pack of cigarettes per day. Past medical history is negative. She reports that her surgeon has insisted she quit smoking and drinking before the surgery to help improve healing. Physical examination includes a thin, poorly groomed woman who is sweating profusely. Her vitals are: temperature 100.8 °F (38 °C), pulse 115 beats/minute, blood pressure 152/97 mm Hg, respiratory rate 25 breaths/minute, and oxygen saturation 100% on room air. Her body mass index is 17.3 kg/m2. She has a strong tremor when moving her hands. Other physical examination findings are unremarkable. Laboratory test results are as follows: Glucose: 96 mg/dL (normal range, 70-100 mg/dL) Sodium: 140 mmol/L (normal range, 136-145 mmol/L) Potassium: 4.4 mmol/L (normal range, 3.5-5.4 mmol/L) Creatinine: 0.8 mg/dL (normal range, 0.6-1.1 mg/dL) Urea nitrogen: 10 mg/dL (normal range, 7- 18 mg/dL) Alanine aminotransferase: 12.0 U/L (normal range, 0 - 55 U/L)
Her vital signs are: temperature 98.6 °F (37 ° C), pulse 78 beats/minute, blood pressure 105/56 mm Hg, respiratory rate 12 breaths/minute, and oxygen saturation 100% on room air. Her body mass index is 23.4 kg/m2. Laboratory studies are as follows: Glucose: 83 mg/dL (normal range, 70-100 mg/dL) Sodium: 143 mmol/L (normal range, 136-145 mmol/L) Potassium: 3.9 mmol/L (normal range, 3.5-5.4 mmol/L) Creatinine: 0.9 mg/dL (normal range, 0.6-1.1 mg/dL) Urea nitrogen: 13 mg/dL (normal range, 7- 18 mg/dL) Alanine aminotransferase: 17.0 U/L (normal range, 0-55 U/L) Aspartate aminotransferase: 18.0 U/L (normal range, 5 - 34 U/L) Alkaline phosphatase: 58.0 U/L (normal range, 40-150 U/L) Hemoglobin: 11.9 g/dL (normal range, 11 - 14 g/dL) Hematocrit: 34% (normal range, 32%-42%) Urine drug screen is positive for opiates. Urine pregnancy test is positive. What is the preferred method of managing this patient’s substance use disorders during her pregnancy? maintenance therapy with methadone, smoking cessation counseling, alcohol withdrawal treatment using long-acting benzodiazepines A 47-year-old former construction worker presents to you with low back pain. She reports it began 3 years ago and has progressively worsened, making it difficult for her to continue to work. She describes the pain as dull, nonradiating, and worse with bending, twisting, or lifting more than 10 pounds. There is no numbness or tingling. Past medical history includes hypertension, prediabetes and obesity. Current medications are amlodipine 10 mg daily, ibuprofen 800 mg every 8 hours as needed for pain, metformin 500 mg twice daily, and valsartan 40 mg daily. vital signs are: temperature 98.6 °F (37 °C), pulse 67 beats/minute, blood pressure 132/84 mm Hg, respiratory rate 12 breaths/minute, and oxygen saturation 100% on room air. Her body mass index is 37.1 kg/m2. Decreased range of motion of the lumbar spine due to pain is noted on physical examination. Deep tendon patellar reflexes are equal and normal bilaterally. Paraspinal muscle spasms are noted at levels L3 to L5.
Laboratory studies are as follows: Glucose: 106 mg/dL (normal range, 70-100 mg/dL) Sodium: 142 mmol/L (normal range, 136 - 145 mmol/L) Potassium: 3.9 mmol/L (normal range, 3.5-5.4 mmol/L) Creatinine: 0.8 mg/dL (normal range, 0.6-1.1 mg/dL) Urea nitrogen: 12 mg/dL (normal range, 7-18 mg/dL) Hemoglobin: 13.3 g/dL (normal range, 11-14 g/dL) Hematocrit: 35% (normal range, 32%-42%) X-ray of the lumbar spine is normal. Which of the following is the most appropriate treatment option?
- Begin nonpharmacologic interventions such as exercise, weight loss, yoga, electromyography biofeedback, or acupuncture. A 59-year-old retail worker presents with long-term low back pain. He reports it began 10 years ago, has been on and off, and seems to have progressively worsened over the past year. He describes the pain as dull and nonradiating. He began to notice it more after lifting boxes in the attic this weekend. Bending is also uncomfortable. There is no numbness or tingling. He denies any history of trauma or injury. He was previously referred to physical therapy, tried yoga, and has had spinal manipulation. Past medical history includes hypertension and hyperlipidemia. Current medications are pravastatin 40 mg daily, meloxicam 15 mg daily as needed for pain, baclofen 10 mg every 12 hours as needed, and valsartan 40 mg daily. His vital signs are: temperature 98.6 °F (37 °C), pulse 87 beats/minute, blood pressure 126/79 mm Hg, respiratory rate 12 breaths/minute, and oxygen saturation 100% on room air. His body mass index is 23.8 kg/m2. Decreased range of motion of the lumbar spine due to pain is noted on physical examination. Deep tendon patellar reflexes are equal and normal bilaterally. Laboratory studies are as follows: Glucose: 90 mg/dL (normal range, 70-100 mg/dL) Sodium: 142 mmol/L (normal range, 136-145 mmol/L) Potassium: 4.2 mmol/L (normal range, 3.5-5.4 mmol/L) Creatinine: 0.6 mg/dL (normal range, 0.6-1.1 mg/dL) Urea nitrogen: 12 mg/dL (normal range, 7- 18 mg/dL)
Urea nitrogen: 15 mg/dL (normal range, 7 - 18 mg/dL) Hemoglobin: 11.6 g/dL (normal range, 11-14 g/dL) Hematocrit: 38% (normal range, 32%-42%) X-ray of the lumbar spine shows diffuse, severe arthritis, and degenerative disc disease at level L4 to L5. What is the most appropriate next treatment option?
- Stop gabapentin and recommend another medication for pain control such as duloxetine. A 63-year-old woman presents to you with low back pain that she says is a 7 on a 10-point scale for 1 day following a "mud run." She reports her entire family was participating in the event. Her symptoms began yesterday after she tried to lift a large log on the course. She reports throbbing with radiation to the right posterior thigh with changing positions. She cannot recall any previous issues with her back. She denies leg weakness or numbness. Past medical history is negative for any long-term disease. She is not on any medications. Vital signs are: temperature 98.5 °F (37 °C), pulse 61 beats/minute, blood pressure 122/74 mm Hg, respiratory rate 12 breaths/minute, and oxygen saturation 100% on room air. Her body mass index is 20.8 kg/m2. Decreased range of motion of the lumbar spine due to pain is noted on physical examination. Deep tendon patellar reflexes are equal and normal bilaterally. Laboratory studies are as follows: Glucose: 86 mg/dL (normal range, 70-100 mg/dL) Sodium: 137 mmol/L (normal range, 136-145 mmol/L) Potassium: 3.8 mmol/L (normal range, 3.5-5.4 mmol/L) Creatinine: 0.9 mg/dL (normal range, 0.6-1.1 mg/dL) Urea nitrogen: 14 mg/dL (normal range, 7-18 mg/dL) Hemoglobin: 12.5 g/dL (normal range, 11-14 g/dL) Hematocrit: 37% (normal range, 32%-42%) X-ray of the lumbar spine shows mild and diffuse arthritis. Which duration of immediate opioid therapy would be the most appropriate for this patient?
3 days A 59-year-old man presents to you severe low back pain that he says he has had for 8 years. He initially injured his back while working on his home. He has just completed 8 weeks of physical therapy, and he has been receiving chiropractic care for 1 year. He had been evaluated by a neurosurgeon and has declines any surgical interventions. He elects medical management of his pain. He has attempted multiple nonpharmacologic therapies, including tai chi, cognitive behavioral therapy, acupuncture, exercise, low-level laser therapy, and electromyography biofeedback. However, none of these modalities have reduced his pain. Past medical history includes heroin use disorder, which is in remission. Current medications include baclofen 10 mg every 8 hours as needed for spasms and meloxicam 15 mg daily. He has tried duloxetine, tramadol, carbamazepine, gabapentin, nortriptyline, and amitriptyline for pain management, but he has had no success. He has also tried multiple skeletal muscle relaxants, but they have only minimally reduced his pain. His vital signs are: 98.6 °F (37 °C), pulse 84 beats/minute, blood pressure 136/81 mm Hg, respiratory rate 12 breaths/minute, and oxygen saturation 100% on room air. His body mass index is 25.3 kg/m2. He rates his pain as a 9 on a 10 - point scale. Laboratory studies are as follows: Glucose: 96 mg/dL (normal range, 70 - 100 mg/dL) Sodium: 143 mmol/L (normal range, 136-145 mmol/L) Potassium: 4.4 mmol/L (normal range, 3.5-5.4 mmol/L) Creatinine: 0.9 mg/dL (normal range, 0.6-1.1 mg/dL) Urea nitrogen: 14 mg/dL (normal range, 7-18 mg/dL) Hemoglobin: 13.6 g/dL (normal range, 11 - 14 g/dL) Hematocrit: 41% (normal range, 32%-42%) X-ray of the lumbar spine shows diffuse, severe arthritis and degenerative disc disease at L4 to L5. Which of the following is the most appropriate next treatment option?
Hemoglobin: 11.6 g/dL (normal range, 11 - 14 g/dL) Hematocrit: 38% (normal range, 32%-42%) X-ray of the lumbar spine shows diffuse, severe arthritis and degenerative disc disease at L4 to L5. What is the most appropriate next treatment option?
- Evaluate risk factors for opioid-related harms and, if the benefit outweighs the risk, begin immediate-release opioid therapy (≤ 50 morphine milligram equivalents [MMEs]/day). In the course of routine medical treatments, it becomes apparent that a 34- year-old man is subject to frequent anxiety and mood swings and tends toward angry outbursts, which are also evident during other medical visits. With few variations, this behavior pattern has been present since the patient's late teens. Further assessment also reveals that he abuses multiple drugs. The patient also admits to several traffic tickets for speeding. Which of the following conditions should be suggested on the basis of these symptoms? Personality disorder A 28-year-old man presents after a suicide attempt. His medical records reveal that this is the third attempt he has made over the course of 3 years. He states that his motivation was concern over the relationship with his girlfriend, fearing that she might be leaving him. His girlfriend describes the patient as extremely clingy and jealous. The relationship has gone through phases where the patient has idolized his girlfriend alternating with periods where he is cold and distant and his behavior demeaning. Further questioning reveals that the patient is sexually promiscuous, and he frequently overspends on items he does not really need. At times his behavior can be grandiose, and he frequently has angry outbursts with little or no provocation. He also states that the world seems to be out to get him and that he does not really feel safe. However, he says this feeling of being threatened is not always present and he goes through long periods without feeling this way. Which of the following represents the most likely diagnosis for this patient? Borderline personality disorder
A 23-year-old man presents after he has been arrested for speeding on his motorcycle in rush hour traffic. He has engaged in similar bouts of speeding several times before. He also has a criminal record, reaching back several years, mostly for theft. He abruptly left his job 2 days before the speeding incident, and he did not have steady employment before the incident. His behavior problems started when he was 12 years of age and have been continued ever since. He was diagnosed with conduct disorder at the age of
- Which of the following represents the most likely diagnosis for this patient? Antisocial personality disorder A 51-year-old woman with a longstanding diagnosis of borderline personality disorder is assessed in the course of planning the management of her condition. Which of the following best describes an area that is NOT required routinely in the initial assessment? Drug screen A 49-year-old woman with an established diagnosis of borderline personality disorder presents in a highly agitated state and says she will likely hurt herself in some way. Which of the following best describes the considerations that apply to a short-term prescription of benzodiazepine to manage this crisis? ensure consensus among prescribers, identify the primary prescriber, assess risks, consider the impact of drug prescribing on the therapeutic relationship, avoid polypharmacy A 31-year-old man has been diagnosed with antisocial personality disorder after a number of arrests for theft and drug dealing as well as a history of fights. When providing an intervention for this patient, which of the following is most likely to apply? motivate the patient to attend and engage with treatment Which of the following criteria can be best used to identify children at risk for conduct disorder?
