HippoEd: Behavioral Health

increases dopamine levels

A 12-year-old boy is brought to the clinic by his parents for routine follow-up examination. Medical history includes attention-deficit/hyperactivity disorder that has been well-controlled of the past five years with dextroamphetamine/amphetamine therapy. His parents say that he has straight As in school, and they are pleased with his behavior at home. Although his growth is mildly restricted during the school year, it rebounds during the summer when he is not taking the medication. Which of the following best describes the mechanism of action of this pharmacotherapy that this patient is taking? A. Decreases acetylcholine levels B. Decreases norepinephrine levels C. Decreases serotonin levels D. Increases dopamine levels E. Increases gamma-aminobutyric acid levels

serotonin

A 13-year-old boy is brought to the clinic by his mother because he has had fatigue for the past 3 months. He says he has decreased energy and is not interested in playing on the school soccer team as he had for several years. His mother says that he sleeps for 14 hours per day and has not been eating his regular portions at meals. On further questions, the patient admits that he has been having trouble making decisions. Vital signs are within normal limits. Physical examination shows no abnormalities. Dysfunction of which of the following neurotransmitter is the most significant in this disorder? A. Acetylcholine B. Gamma-aminobutyric acid C. Histamine D. Nitric oxide E. Serotonin

factitious disorder imposed on another

A 14-year-old boy is brought to the primary care office by his mother to establish care, obtain refills, and request a surgical referral regarding recurrent abdominal pain for the past eight years. The boy cannot describe his abdominal pain but defers to his mother, who says that the boy cries in pain randomly throughout the day and she is really worried about him. The pain is not associated with meals, flatus, or bowel movements, and it rarely occurs in the same place. The mother brings a large folder of medical records, explaining that her son has many disorders and requires constant monitoring. She says he has a seizure disorder for which he takes four different antiepileptic medications, each prescribed by a different medical provider. His other diagnoses include irritable bowel syndrome with alternating diarrhea and constipation, cyclothymia, gluten intolerance, Frey syndrome, and aphthous stomatitis. The son appears drowsy but otherwise interacts in an age-appropriate manner. He defers detailed medical questions to his mother because he "cannot keep it all straight." The patient is homeschooled; his mother stays with him full-time to care for his many medical diagnoses and administer his medications. On physical examination of the patient, bowel sounds are active in all four quadrants. No tenderness to palpation, rigidity, or guarding is noted. He has multiple surgical scars on his abdomen, which his mother says are from exploratory surgery for his undiagnosed recurrent abdominal pain. Which of the following is the most likely diagnosis? A. Conversion disorder B. Factitious disorder imposed on another C. Illness anxiety disorder D. Malingering by proxy E. Somatic symptom disorder

autism spectrum disorder

A 15-month-old girl is brought to the clinic by her mother for routine well-child examination. The patient was born at 39 weeks' gestation via normal spontaneous vaginal delivery and is currently up-to-date with all immunizations. The mother says that the patient does not seem interested in other family members and does not look up if her mother points at something or tries to get her attention. She is still crawling and does not appear to be learning new words. The patient enjoys playing with doorstops but is not interested in any of her toys. Physical examination shows no abnormalities except for poor eye contact. Which of the following is the most likely diagnosis? A. Attachment disorder B. Autism spectrum disorder C. Congenital rubella syndrome D. Obsessive-compulsive disorder E. Rett syndrome

you are allowed to receive diagnosis and treatment for sexually transmitted infections without us having to notify your parents

A 15-year-old boy comes to the public health department because he has had dysuria and mucopurulent discharge from his urethral meatus for the past two days. He says that he had intercourse with a new partner two weeks ago. Physical examination shows an uncircumcised penis without erythema, vesicles, ulceration, or induration. Significant mucopurulent discharge is noted at the urethral meatus. No inguinal lymphadenopathy or scrotal masses are noted on palpation. Mild right testicular and epididymal tenderness is noted. Gram stain of the urethral discharge shows polymorphonuclear leukocytes with intracellular Gram-negative diplococci. The patient expresses concern about his parents finding out that he has a sexually transmitted infection. Which of the following is the most appropriate response? A. Because you are younger than 18 years of age and this is a reportable disease, we are required to notify your parents of the diagnosis for which you are being treated, as well as the parents of your sexual partner. B. Because you are younger than 18 years of age, we will have to notify your parents that you came to our clinic, but we will not have to notify them of your diagnosis. C. Because you are younger than 18 years of age, we will need permission from your parents to officially diagnose and treat you because your condition is a reportable disease. D. Because you are younger than 18 years of age, we will need your parents' consent to treat you for any condition. E. You are allowed to receive diagnosis and treatment for sexually transmitted infections without us having to notify your parents.

complete blood count

A 15-year-old girl is brought to the clinic because she has had almost daily irritability over the past month. She denies any inciting event, suicidal ideations, or homicidal ideations. The patient says she has new fatigue, loss of interest in usual activities, insomnia, and decreased concentration. Family history is significant for major depressive disorder on the maternal side and bipolar disorder on the paternal side. Blood pressure is 120/68 mmHg, and pulse rate is 96/min. Physical examination shows no abnormalities. Which of the following studies is the most appropriate next step? A. Complete blood cell count B. Erythrocyte sedimentation rate C. Hepatitis panel D. Iron studies E. Prolactin level

bright light therapy

A 15-year-old girl is brought to the clinic by her father because she has had mood issues beginning at the end of summer and resolving at the end of winter during the past three years. She says she has feelings of sadness, desire to sleep much more than usual, fatigue, and low motivation to do things she normally enjoys during these episodes. The patient says she frequently feels worthless and that she gains at least 15 lb during these episodes because she craves pasta daily. Which of the following is the most appropriate initial treatment? A. Bright light therapy B. Buproprion therapy C. Dialectical behavior therapy D. Duloxetine therapy E. Melatonin therapy

urgent referral to psychiatry

A 15-year-old girl is brought to the clinic by her mother for follow-up of asthma. She is currently using her rescue inhaler seven times daily and twice at night, and her triggers are pollen and dander. When discussing the black box warning associated with montelukast, the patient reluctantly admits that she has had depressed mood and frequent suicidal ideation over the past two years. She has not had any homicidal ideation, plan, or intention. Vital signs are within normal limits, and physical examination shows no abnormalities. Which of the following is the most appropriate initial intervention? A. Evaluation in an emergency department B. Family therapy C. Involuntary hospitalization D. Prescription for amitriptyline E. Urgent referral to psychiatry

marijuana

A 15-year-old patient who identifies as genderqueer is brought to the emergency department because of changes in behavior. During the interview, the patient says that they feel like time is going by very slowly, and they hear voices saying their name. The patient is worried that they might be dead. They report no history of injury or trauma. Pulse rate is 90/min, and blood pressure is 124/78 mmHg. The patient appears mildly confused and anxious. On physical examination, the conjunctiva are injected, but pupils are equal, round, and reactive to light. Which of the following substances is most likely responsible for the symptoms in this patient? A. Amphetamines B. Cocaine C. Heroin D. Marijuana E. Psilocybin

major depressive disorder

A 16-year-old girl is brought to the clinic by her mother because she has been irritable and withdrawn for the past month. The patient prefers to go to sleep after getting home from school instead of participating in her usual hobbies of drawing or reading. She says she always feels tired, and she is concerned that she is responsible for her parents' divorce a few years ago as well as her recent breakup with her boyfriend. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. Physical examination shows no abnormalities. CBC and TSH are normal. Which of the following is the most likely diagnosis? A. Adolescent angst B. Bipolar II disorder C. Dysthymic disorder D. Major depressive disorder E. Substance use disorder

agonism at GABA receptors

A 16-year-old girl is brought to the emergency department because she has had altered mental status since she was arrested for underage drinking 30 minutes ago. The patient is ataxic and sedated but responds to verbal commands. Her speech is slurred. Pulse rate is 80/min, and blood pressure is 120/70 mmHg. Which of the following is the most likely explanation for these findings? A. Agonism at gamma-aminobutyric acid receptors B. Agonism at N-methyl-D-aspartate receptors C. Antagonism at opioid receptors D. Decreased levels of dopamine E. Decreased levels of serotonin

hypochloremia **anorexia nervosa binge-eating/purging type

A 16-year-old girl is brought to the emergency department by her mother because she passed out during her dance class 20 minutes ago. The mother says she that she is worried about her daughter's recent weight loss, but the daughter argues that "a dancer's body has to be perfect." During the interview, the patient says that her arms and stomach are "hideously fat," so she exercises to keep the weight off. She says: "I just get so hungry, I can't control myself." A typical overeating episode will occur over an hour and consists of consuming a loaf of bread, a jar of peanut butter, a liter of soda, and several bags of candy. Afterward, she says she feels guilty and remorseful and either increases her exercise or induces vomiting; usually both. Her current BMI is 17 kg/m². Which of the following laboratory abnormalities is most likely in this patient? A. Decreased serum cholesterol level B. Decreased serum urea nitrogen level C. Hyperkalemia D. Hypochloremia E. Metabolic acidosis

hypophosphatemia **refeeding syndrome

A 16-year-old girl is brought to the office by her mother because she has had fatigue and a 25-lb weight loss over the past six months. The patient has had amenorrhea for the past three months and constipation for the past month. Until last week, she ran four miles a day. She says she is scared of becoming fat and has limited herself to one meal per day. She denies vomiting, which her mother confirms. Menarche occurred at 13 years of age. Pulse rate is 50/min, respirations are 12/min, and blood pressure is 85/40 mmHg. Based on these findings, the patient is admitted to the hospital and started on nutritional rehabilitation that provides 1,600 kcal per day. Which of the following complications is this patient at most risk of developing when nutritional rehabilitation is initiated? A. Hyperkalemia B. Hypermagnesemia C. Hypochloremia D. Hyponatremia E. Hypophosphatemia

bipolar I disorder

A 17-year-old boy is brought to the clinic because he has had depression over the past month. He says he has had feelings of sadness and worthlessness, fatigue, and insomnia. He has also had some suicidal ideations without plan or intention. The patient has not had homicidal ideations, previous manic episodes, or current symptoms of mania. Therapy with escitalopram 10 mg daily is initiated. During a follow-up visit two weeks later, the patient says that he has felt "absolutely fantastic" over the past week. He says he has so much energy that he has not needed much sleep for the past week, and he is convinced that he plays the piano better than Elton John. He rapidly moves from one topic to the next during the interview. He does mention he got sent to the principal's office this week for being disruptive in class and says "they have no idea how great I am; I'm way smarter than that whole school". Which of the following is the most likely diagnosis? A. Bipolar I disorder B. Bipolar II disorder C. Major depressive disorder with psychotic features D. Medication-induced bipolar disorder E. Schizophreniform disorder

anorexia nervosa, binge-eating/purging type

A 17-year-old girl is brought to the office by her mother, who is concerned about the patient's decrease in weight over the past three months. The mother says that her daughter weighs herself multiple times per day and has a significant obsession with not weighing over 90 lbs. When the mother encourages the patient to gain weight, the patient says that her hips are already too wide. The mother has recently heard the patient vomiting in the bathroom after meals. The patient admits to purging with self-induced vomiting and laxative use. She denies any binge-eating episodes. The patient is upset with her mother for bringing her to the office because she says this is normal young adult behavior, and all of her friends engage in the same kinds of activities. Height is 5 ft, and weight is 78 lbs with clothing and shoes. Body mass index is 15 kg/m². Pulse rate is 54/min, and blood pressure is 110/60 mmHg. The patient has an overall cachectic appearance. On physical examination, erosion on the lingual side of the teeth is noted. Fine hair is present over the thoracic spine. Significant muscle wasting is noted over the shoulders, buttocks, and thighs. Which of the following is the most likely diagnosis? A. Anorexia nervosa, binge-eating/purging type B. Avoidant/restrictive food intake disorder C. Bulimia nervosa D. Oppositional defiant disorder E. Pica

adjustment disorder

A 19-year-old college student comes to the campus health center requesting medication to help him sleep. He says that his parents, who live 200 miles from campus, are divorcing and are selling his childhood home and many of the possessions from the home. Both parents want to remain involved in the patient's life, but now that he is out of the house, they see no reason to remain married. All of this came on suddenly as he has only been away from home for 3 months. The patient is tremulous and tearful, stating that he has not been able to eat or attend classes because he cannot stop thinking about not living together as one family under the same roof. He has removed all pictures of his family from his room and thrown them away. The patient has difficulty falling asleep, and when he does, he often wakes with an inability to fall back asleep. Medical history does not include mental illness. Which of the following is the most likely diagnosis? A. Acute stress disorder B. Adjustment disorder C. Generalized anxiety disorder D. Panic disorder E. Separation anxiety disorder

a diagnosis of ADHD

A 19-year-old man comes to the psychiatric emergency department on a cold winter night because he has had suicidal ideations for the past day. The patient is charming and pleasant. He says that he will go run in front of a car outside the hospital tonight if he is not kept for observation. The patient's medical record indicates that he has an extensive criminal history and has been institutionalized most of his life. When asked about one incident in which he was arrested for stealing a car, he says that it was the owner's fault for keeping a nice car in his driveway. Pulse rate is 60/min, and blood pressure is 128/84 mmHg. Which of the following findings is most likely in this patient's history? A. A diagnosis of attention-deficit/hyperactivity disorder B. A diagnosis of autism spectrum disorder C. A high level of education D. A high level of intelligence E. Avoidance of illicit substances

report the patient's threat to the roommate

A 19-year-old man who is a college sophomore comes to the primary care office because he has had persistent irritability, unstable relationships, and a sense of emptiness for the past five years. He says that he has had four roommates during the past year. Though he gets along with them at first, when conflict arises, he loses his temper. Subsequently, his roommates have all moved out except his current roommate, who insists that the patient should be the one to move out since he has a problem getting along with other people. Screaming matches have become a daily occurrence, and the patient says: "Sometimes I feel like I should just slit his throat with my hunting knife and be done with it." The patient is seeking help to manage his anger and impulsive thoughts. Which of the following is most appropriate next step? A. Contact the college to request that the patient's roommate be relocated to a safe location B. Contact the patient's parents to see if they can help C. Continue to follow up closely with the patient to encourage him to process his feelings in a constructive way D. Do not report the patient's threats to outside parties because it violates rules of confidentiality E. Report the patient's threat to the roommate

fluoxetine therapy **OCD

A 19-year-old man, who is a full-time college student, comes to the clinic because he has had worsening anxiety over the past two years. He says he frequently is bothered by the sounds his classmates make during class when someone clicks or taps their pen or taps their foot repeatedly. He finds these sounds to be very bothersome and irritating, to the point of getting upset when it occurs. He spends a significant amount of time during every class period thinking about what his classmates are doing and anticipating someone to start making these sounds. When the pen tapping or foot tapping starts, he repeats a saying over and over in his head to try to block out these sounds instead of lashing out at these individuals. He finds it very difficult to concentrate during his college courses and his grades are starting to slip. His pulse rate is 90/min and his blood pressure is 128/84 mmHg. Which of the following is the most appropriate initial step? A. Anterior cingulotomy B. Clomipramine therapy C. Fluoxetine therapy D. Psychodynamic therapy E. Reassurance

family history of schizophrenia

A 19-year-old woman comes to the clinic at the request of her mother because she does not have friends and believes that people will only be friends with her because she is telepathic. The patient avoids people because she feels like they subtly hint about stealing her powers. She does not have hallucinations and has never had legal trouble. The patient appears to have a constricted affect. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. Physical examination shows no abnormalities. Which of the following additional findings on history taking is most likely? A. Born in the summer B. Family history of schizophrenia C. High birth weight D. Upper middle class upbringing E. Use of cocaine

increase in total brain volume

A 2-year-old girl is brought to the clinic by her mother because she has had behavioral changes that have worsened over the past two months. The mother says that the patient has become nonverbal and has habitually begun to avoid direct eye contact. She says that the patient does not look up to see what her mother is pointing to and does not appear interested in playing with other children at daycare. The patient will spin the wheels on a toy car, but she does not use the car itself. Birth was uncomplicated, and she met all developmental milestones up until two months ago. Pulse rate is 120/min, and respirations are 30/min. Which of the following is the most likely explanation for the findings in this patient? A. Decreased extra-axial fluid B. Decreased volume of the amygdala C. Decreased volume of the corpus callosum D. Increase in total brain volume E. Increased volume of the cerebellum

inhibition of serotonin reuptake

A 20-year-old man comes to the office for follow-up six weeks after he initiated first-line therapy for generalized anxiety disorder. The patient says he had headaches, nausea, and diarrhea for the first few days after taking the medication, but these symptoms lessened over time. He is otherwise healthy and takes no other medications. During the interview, he says he feels like his anxiety is well-controlled, and he has not had any thoughts of suicide or homicide. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. Physical examination shows no abnormalities. Based on these findings, which of the following is the primary mechanism of action of the drug that was prescribed to this patient? A. Agonism of gamma-aminobutyric acid receptors B. Antagonism of beta-adrenergic receptors C. Antagonism of dopamine receptors D. Inhibition of monoamine oxidase E. Inhibition of serotonin reuptake

frotteuristic disorder

A 20-year-old man is referred to the primary care office by court mandate after he is arrested for sexually inappropriate behavior. Several complaints about the patient's behavior have been made by several passengers on the local bus route during the past 10 months. The passengers experienced the patient rubbing up against them when the bus was crowded and rubbing his groin against the gluteal regions of other passengers who were strangers to this patient. Which of the following is the most likely diagnosis? A. Exhibitionist disorder B. Fetishistic disorder C. Frotteuristic disorder D. Klismaphilia E. Voyeurism

PHQ-9

A 21-year-old man comes to the office because he has felt sad and hopeless for the past month. He says he has had occasional suicidal ideations. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. Physical examination shows no abnormalities. Which of the following is the most appropriate screening test for major depressive disorder in this patient? A. McMaster Family Functioning Scale B. Montreal Cognitive Assessment C. Mood Disorder Questionnaire D. Patient Health Questionnaire-9 E. Strengths and Difficulties Questionnaire

schizophrenia

A 22-year-old college student comes to the campus clinic requesting a rabies vaccination because he says a family of raccoons has moved to his campus apartment and the mother raccoon bit him on the arm one week ago. He says that campus maintenance has been called, but they never find the raccoons when they come to the apartment. Though he started college on a full academic scholarship, he is currently failing most of his classes and may not be able to graduate on time. The patient says this is because his advisor is sabotaging his work, and he suspects his advisor put the raccoons in his apartment for that purpose nine months ago. He says he has not had fever, chills, headaches, weakness, or malaise. He has not had any depression or anxiety. The patient's need for sleep has not decreased, and he says he avoids social contact when possible. He has not had any alcohol or used illicit drugs during the past two years. The patient's affect is flat, his appearance is unkempt, and he is wearing three coats despite the temperature being in the 80s. His speech is disorganized. Physical examination of the "bite mark" on his left arm is actually a benign nevus, but the patient insists that it is a bite from a raccoon. Which of the following is the most likely diagnosis? A. Delusional disorder B. Encephalitic rabies C. Schizoaffective disorder D. Schizophrenia E. Schizophreniform disorder

caloric acid and risperidone

A 22-year-old man comes to the clinic because he has been significantly late to his job over the past two weeks and is on the verge of getting fired. He also says that he has had more arguments with his partner over his spending, and he had an affair three days ago. The patient believes that his behavior is acceptable since he is the son of God. He says he feels like he could conquer the world and brags that he has been more productive than ever on one hour of sleep nightly. He does not have suicidal or homicidal ideations. Medical history includes similar, less intense symptoms in the past. Which of the following is the most appropriate initial treatment? A. Clozapine and fluoxetine B. Lamotrigine and diazepam C. Lithium and haloperidol D. Topiramate and gabapentin E. Valproic acid and risperidone

acetylcholine receptor agonist

A 22-year-old patient comes to the clinic because they want to quit smoking cigarettes. They have been smoking one half a pack of cigarettes daily for the past five years and would like to quit because their new partner has asthma. However, they say that their mind gets sharper, and they feel happier and more energetic after smoking a cigarette. The patient has tried to quit in the past, but he has had trouble with the resulting irritability and anxiety. Which of the following best describes the mechanism of action of nicotine that this patient is experiencing when smoking cigarettes? A. Acetylcholine receptor agonist B. Cannabinoid receptor agonist C. Dopamine receptor antagonist D. N-methyl-D-aspartate receptor antagonist E. Opioid receptor antagonist

bipolar I disorder

A 22-year-old woman is brought to the emergency department by her roommate because she has had changes in her behavior during the past two months. The roommate says that the patient has stayed up all night shopping online for the past two weeks. The patient has skipped going to class, saying that she is "too smart for college-level courses" and is failing several of her classes from failing to complete her required course work. The roommate also says that last month the patient did not get out of bed for a week, and was continually crying and overeating. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. During the interview, the patient says that she is working on "grand projects to save the world." She has pressured speech and has difficulty keeping still for the physical examination. Based on these findings, this patient most likely has which of the following mood disorders? A. Bipolar I disorder B. Bipolar II disorder C. Cyclothymic disorder D. Major depressive disorder E. Persistent depressive disorder

anorexia nervosa

A 22-year-old woman who is a college senior comes to the campus clinic to obtain a refill prescription for depression medication. She says that bupropion has been working well for her, and she has not had depressed mood, feelings of worthlessness, psychomotor agitation or retardation, or suicidal ideation. The patient says that she wants to stay on the medication even though she is no longer having symptoms because it has helped her watch her weight. She has always been thin and hopes to never weigh over 100 lb because "my rear end is already big enough." She estimates her waist to be larger than 95% of other people. The patient says she eats a wide variety of foods, and limits herself to 500 calories a day. She will be graduating this year with a 4.0 grade point average in a triple major: electrical engineering, music performance, and ancient languages. Her most recent menstrual period was two years ago, and she takes no medications or oral contraceptives. Height is 5 ft 5 in, and weight is 98 lb with clothing and shoes. Body mass index is 15.81 kg/m². Pulse rate is 80/min, respirations are 16/min, and blood pressure is 110/60 mmHg. The patient's mood is anxious, and her affect is bright. Physical examination shows good dentition. No skin abnormalities are noted on the face, torso, or extremities. The abdomen is scaphoid with decreased bowel sounds in all four quadrants. Muscle mass is decreased, and the ribs are apparent. Which of the following is the most likely diagnosis? A. Anorexia nervosa B. Avoidant/restrictive food intake disorder C. Bulimia nervosa D. Obsessive-compulsive disorder E. Pica

lorazepam **cocaine

A 23-year-old man comes to the emergency department because he has had nausea and shakiness for the past five minutes. He says his heart is "beating funny," and he feels anxious. He has a history of illicit drug use. Temperature is 37.5°C (99.5°F), pulse rate is 120/min, and blood pressure is 160/90 mmHg. The patient is angry and agitated. Physical examination shows mydriasis. Deep tendon reflexes are 2+ bilaterally. Which of the following is the most appropriate treatment? A. Diphenhydramine B. Lorazepam C. Metoprolol D. Nifedipine E. Nitroglycerin

amygdala

A 23-year-old transgender woman comes to the clinic because of difficulty managing her fear of snakes. She recently graduated with a college degree in wildlife biology and was hired by a local zoo. The patient was assigned to the reptile house, where she is responsible for caring for the snakes. She says she has always had a discomfort with snakes, but after nearly being bitten twice, her fear intensified. Now, when she sees a snake, she feels a rush of fear that is keeping her from performing her job well. Which of the following areas of the brain is most closely associated with the rush of fear that is felt by this patient? A. Amygdala B. Caudate nucleus C. Hippocampus D. Nucleus accumbens E. Orbitofrontal cortex

the principle of autonomy dictates that the patient's decision should be respected and she should be allowed to forgo treatment

A 23-year-old woman who works as a model is diagnosed with a stage IIIA melanoma on her left cheek. She has met with oncology, plastic surgery, and a psychotherapist to discuss treatment options and coping mechanisms. However, because of the extent and invasiveness of the lesion, treatment will involve a fair amount of disfigurement. The patient will lose function of the facial nerve on the left side of her face. She has decided that she does not want to pursue any treatment that will affect her appearance, including surgery and radiation. Her psychotherapist has determined that she understands her disease and treatment options, understands the consequences of her decisions, and can communicate her wishes consistently. She feels that life with a disfigured face is not worth living and understands that if she does not pursue treatment that she will likely die within five years. Which of the following represents the most ethical position regarding the patient's wishes? A. The principle of autonomy dictates that the patient's decision should be respected and she should be allowed to forgo treatment B. The principle of beneficence requires that the provider maintain monthly appointments with the patient to review and reassess her decision C. The principle of capacity requires that the patient undergo a legal evaluation to determine competency D. The principle of justice calls for a referral to the ethics committee for review of her case E. The principle of nonmaleficence mandates that the patient be referred to hospice care

dextroamphetamine/amphetamine

A 24-year-old man comes to the clinic because he has had difficulty with organization, distractibility, and inattention since he was a young child. He is currently experiencing difficulties at work because he is forgetful, inattentive to details, and makes careless mistakes. His birth was uncomplicated, he met all developmental milestones, and he has no history of chronic medical conditions. He says he uses marijuana recreationally and admits to using cocaine one time at a party this year. Which of the following is the most appropriate treatment? A. Atomextine B. Bupropion C. Dextroamphetamine/amphetamine D. Guanfacine E. Modafinil

haloperidol

A 24-year-old man comes to the clinic because he has had worsening trouble with unusual movements in his face over the past 14 days. The movements are causing trouble for him in his job in customer service, because the customers believe that he is mocking them or sticking his tongue out at them. At first the movements were subtle enough that others thought he was chewing gum. Now the movements are severe enough to prevent him from speaking normally. Medical history includes schizophrenia, generalized anxiety disorder, asthma, and hypertension. Which of the following medications is most likely causing the symptoms in this patient? A. Citalopram B. Divalproex sodium C. Haloperidol D. Levalbuterol E. Lorazepam

fluphenazine

A 24-year-old man who is being treated in the psychiatric unit has had unusual muscle movements for the past two hours. He received his first dose of a new medication three hours ago and is now experiencing uncontrolled muscle contractions of his neck, which are causing his mouth to gape open and his head to bend forward. He has significant pain with an inability to control his neck movements. Which of the following drugs is the most likely cause of this patient's symptoms? A. Clozapine B. Fluphenazine C. Lithium D. Olanzapine E. Quetiapine

have you ever had episodes of irritability or elation with increased goal-directed activity? **major depressive disorder

A 24-year-old woman comes to the clinic because she has felt overwhelmed and fatigued during the past two months. She says she also has had difficulty focusing and sleeping. The patient is not interested in being with friends or engaging in hobbies. She says she feels worthless but does not have suicidal or homicidal ideations. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. Physical examination shows no abnormalities. Which of the following is the most important question to ask this patient? A. Do you have family members with similar symptoms? B. Does your mood improve with pleasant events? C. Have you been in counseling? D. Have you ever had episodes of irritability or elation with increased goal-directed activity? E. Have you tried to be happier?

panic disorder

A 24-year-old woman comes to the emergency department because she has had chest discomfort, palpitations, diaphoresis, dizziness, and nausea for the past twenty minutes. Her symptoms began when she was watching a documentary on television about the arctic tundra. She says she feels like she is going crazy. The patient says she has had several milder episodes during the past three months that occurred at random times, including while at work at her job as a web developer, while eating a pear and reading a book in bed, and while playing with her dog in her backyard. Though she is persistently concerned about having a recurrence of symptoms, she has not specifically avoided circumstances that cause her symptoms because there is no particular stimulus that predictably causes them. If she knew what caused them, she would avoid that circumstance. Family medical history does not include mental illness. She says she recently moved out of her parents' home and moved into her own apartment close by. Electrocardiography shows sinus tachycardia with a rate of 112/min; no other abnormalities are noted. Cardiac enzyme levels, thyroid-stimulating hormone level, and results of complete blood cell count and comprehensive metabolic panel are all within normal limits. Which of the following is the most likely diagnosis? A. Adjustment disorder B. Agoraphobia C. Panic disorder D. Social phobia E. Somatic symptom disorder

Genito-pelvic pain/penetration disorder

A 24-year-old woman comes to the primary care office because she has been unable to consummate her marriage even though she has been married for eight months. She says that any vaginal penetration is painful, to the point that she cannot wear tampons during her menses. While she has sexual desires and wants to please her spouse, any vaginal sexual activity has been so uncomfortable that she quickly loses interest. Though she can reach climax through clitoral stimulation, she can feel her vaginal muscles tightening during sexual intimacy which prevents penetration. This has led her to avoid intimate encounters with her spouse, who is frustrated. He has threatened divorce if the marriage cannot be consummated. The patient declines pelvic examination because she is afraid of pain. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), which of the following is the most likely diagnosis? A. Dyspareunia B. Female orgasmic disorder C. Female sexual arousal disorder D. Genito-Pelvic pain/penetration disorder E. Vaginismus

increased activity in serotonin receptors **LSD

A 25-year-old man comes to the emergency department for evaluation after he was involved in a motor vehicle collision after he drove through a stop sign. The patient appears anxious and is looking around the examination room furtively. He says that the collision occurred because he did not think he was moving. The patient says he feels like "all this isn't real," and that everything looks like he is in a kaleidoscope. On further questioning, he admits to ingesting a substance. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. Results of urine drug screen are pending. Which of the following is the most likely explanation for the findings in this patient? A. Decrease in dopamine levels B. Decreased activity in the paralimbic structures C. Increased activity in serotonin receptors D. Increased activity in the anterior cingulate cortex E. Increased inhibition in the prefrontal cortex

lamotrigine **cyclothymic disorder

A 25-year-old woman comes to the clinic because she has struggled with episodes of feeling tired and sad as well as episodes of increased drive, energy, and irritability over the past five years. She has never experienced legal or professional issues due to her symptoms. Current medications include metformin, pioglitazone, and sitagliptin. The patient says that she is going to begin trying to conceive next month. Body mass index is 35 kg/m². Which of the following is the most appropriate initial treatment? A. Electroconvulsive therapy B. Lamotrigine C. Lithium D. Olanzapine E. Valproic acid

elevated creatinine kinase **cocaine toxicity

A 26-year-old man comes to the emergency department because he has had chest pain for the past 90 minutes. Pulse rate is 150/min, and blood pressure is 180/130 mmHg. The patient appears agitated and is hostile toward staff. Physical examination shows mydriasis as well as perforations in the nasal septum. Laboratory studies show elevated initial troponin level. Results of urine drug screen are pending. Which of the following additional laboratory findings is most likely? A. Decreased hemoglobin level B. Elevated creatine kinase C. Increased estimated glomerular filtration rate D. Leukocytosis E. Metabolic alkalosis

Aripiprazole

A 27-year-old man is brought to the emergency department by his sister because he has been responding to auditory hallucinations during the past seven months. She says that he has become increasingly reclusive over the past six years. The sister lost contact with the patient until she was contacted by police two months ago. At that time, the patient was arrested for disorderly conduct after he was found in a bus station shouting at passengers that there was a bomb on the bus. Since that time, the sister has been trying to find mental health treatment for the patient, but he has been resistant to receiving any care. Which of the following agents is an appropriate initial treatment for this patient's condition? A. Aripiprazole B. Buspirone C. Clozapine D. Lithium E. Sertraline

cortisol **PTSD

A 27-year-old patient who identifies as non-binary comes to the clinic five weeks after they were involved in a motor vehicle collision. The patient's airbags successfully deployed when their car was hit head-on in the accident. Although the patient was not physically injured, they have been having persistent anxiety about driving since the event, to the point that their partner now drives them to and from work. The patient is easily startled and is having poor sleep because of frequent dreams about the collision. Which of the following hormones is most likely involved in this patient's symptoms? A. Cortisol B. Dopamine C. Oxytocin D. Somatostatin E. Vasopressin

history of substance abuse **soamtic symptom disorder

A 27-year-old woman comes to the primary care office for a follow-up visit one week after she was evaluated for discomfort in the right ear, which has been recurring during the past six years. The patient says that she continues to have otalgia and a sense of fullness in her right ear. She has tinnitus, excessive cerumen, intermittent hearing loss, temporomandibular joint popping, dizziness, nausea, and diarrhea associated with her ear pain. Though the left ear is functioning as expected, the patient says she worries that she will lose her job as a cashier because of the disruptive symptoms in her right ear. Physical examination shows a pearly gray tympanic membrane with a good cone of light. Hearing is intact to whispered voice. No bulging or retraction is noted. MRI obtained one month ago showed no abnormalities. Which of the following findings on history and physical examination is most likely to increase the risk of the suspected disorder in this patient? A. Decreased access to medical care B. Heightened self-expression C. History of substance abuse D. Riboflavin deficiency E. Stable family background

borderline

A 27-year-old woman is brought to the emergency department by her partner because she threatened to kill herself after he attempted to break up with her. A chart review reveals a long history of self-injurious and reckless behavior. She has been released from several psychiatric practices for inappropriate behavior, including calling the clinician in the middle of the night while drunk to engage in sexual activity. Which of the following personality disorders has this patient most likely been diagnosed with in the past? A. Antisocial B. Borderline C. Narcissistic D. Paranoid E. Schizoid

dialectical behavior therapy **borderline personality disorder

A 28-year-old woman comes to the emergency department immediately after she cut her wrists in a suicide attempt that was precipitated by her partner trying to break up with her. This patient is well known to the psychiatric service for a long history of self-injurious, reckless behavior. She has been released from several psychiatric practices for inappropriate behavior, including calling the clinician in the middle of the night while drunk to engage in sexual activity. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. Physcial examination show no abnormalities. Which of the following is the most appropriate treatment? A. Cognitive behavioral therapy B. Dialectical behavior therapy C. Haloperidol therapy D. Lithium therapy E. Ziprasidone therapy

empathize with the patient, and work together to manage the symptoms **somatic symptom disorder

A 28-year-old woman comes to the primary care office because she has had several concerning symptoms during the past year. The first symptom that she noticed was sensitivity to bright light first thing in the morning, followed by transient headaches. A few weeks later, the patient noticed that she was having difficulty sleeping due to migrating extremity pain, and she began to feel tired throughout the day. Bowel movements have been irregular, and she is increasingly gassy. Last week, she went to the emergency department after she noticed that her heart was racing and she was having shortness of breath. Extensive workup showed no abnormalities, and the patient says that this was frustrating. She has no history of depression, changes in weight, anhedonia, hallucinations, or suicidal or homicidal ideation. Which of the following is the most appropriate approach to the management of this patient's condition? A. Empathize with the patient, and work together to manage the symptoms B. Encourage the patient to make an appointment every time she experiences a new symptom C. Refer the patient to a mental health provider D. Tell the patient not to worry and that her diagnosis is common E. Tell the patient that these symptoms are easily treated and to disregard the abnormal bodily sensations

bupropion

A 30-year-old man comes to the clinic for routine physical examination. He takes rosuvastatin 10 mg daily for treatment of hyperlipidemia and lisinopril 10 mg daily for treatment of hypertension. The patient has smoked one and one-half packs of cigarettes daily for the past seven years. He says he is interested in quitting to obtain a better financial position with his health insurance. Pulse rate is 89/min, and blood pressure is 134/80 mmHg. Physical examination shows no abnormalities. Which of the following medications is most appropriate to prescribe to this patient to help with smoking cessation? A. Bupropion B. Gabapentin C. Selegiline D. Sertraline E. Venlafaxine

avoidant personality disorder

A 30-year-old woman comes to the clinic because she has had anxiety since childhood. She says she is very shy and constantly concerned about people criticizing her. She is frustrated because she wants intimate relationships, but she is worried she will be rejected. She drinks alcoholic beverages in social situations to decrease her social anxiety, and this has provided some relief. Which of the following is the most likely diagnosis? A. Avoidant personality disorder B. Borderline personality disorder C. Narcissistic personality disorder D. Obsessive-compulsive personality disorder E. Schizoid personality disorder

sertraline

A 30-year-old woman who is at 12 weeks' gestation comes to the clinic for routine prenatal follow-up. The pregnancy is progressing appropriately, vital signs are within normal limits, and physical examination shows no abnormalities. During the interview, the patient says she feels stressed and has noticed that she has felt unusually tired over the past three weeks despite an increase in dietary intake and sleep pattern. She says she has trouble experiencing happiness and feels worthless. The patient is amenable to initiating pharmacotherapy but wants something she can continue to take when breastfeeding, since she is concerned this change in mood will persist after delivery. Which of the following medications is most appropriate to prescribe to this patient? A. Buproprion B. Paroxetine C. Phenelzine D. Sertraline E. Venlafaxine

haloperidol

A 32-year-old woman who is developmentally disabled and lives in an adult care home is brought to the emergency department via ambulance because she has had confusion, agitation, and fever to 39.7°C (103.5°F) for the past day. The fever has not responded to treatment with acetaminophen or ibuprofen. The patient has not had any nausea, vomiting, or diarrhea. Medical history does not include recent surgeries or anesthesia. The care staff is not aware of any new medications, but she did just see her regular provider who may have changed doses and the patient says that she does not use illicit drugs. Vital signs have been unstable, ranging from a blood pressure of 120/60 to 160/100 mmHg, with tachycardia from 110 to 150/min. Physical examination shows excessive rigidity of the extremities with resistance to all passive range of motion. Profuse diaphoresis is noted. Urinalysis shows increased myoglobinuria but is negative for red blood cells. Which of the following drugs is the most likely cause of the symptoms in this patient? A. Cocaine B. Fluoxetine C. Haloperidol D. Oxybutynin E. Succinylcholine

complete blood count with absolute neutrophil count **clozapine

A 33-year-old man comes to the clinic for follow-up of schizophrenia. He says he continues to have disruptive auditory hallucinations, which interfere with his ability to maintain employment. He has tried taking risperidone, haloperidol, and cariprazine therapy, but his symptoms persisted, and he had development of tardive dyskinesia with each of these medications. Which of the following laboratory studies is most important to order before prescribing the next medication for this patient? A. Complete blood cell count with absolute neutrophil count B. Fasting lipid panel with triglycerides C. Liver and renal function tests D. Measurement of hemoglobin A1c level E. Measurement of thyroid-stimulating hormone and free thyroxine levels

propranolol

A 34-year-old man comes to the primary care office because he has had anxiety in specific situations since he was a teenager. His anxiety occurs primarily when he is in social settings, especially when he is giving presentations. He has recently been promoted to manager of the bank branch where he works and is expected to give very technical but motivational speeches on a monthly basis. The patient is concerned that he will make an error, embarrassing himself or causing the business harm. He also is concerned that if he takes medication, he may forget the details of his presentation. Pulse rate is 92/min, and blood pressure is 138/86 mmHg. Which of the following medications is most appropriate for this patient to take prior to his presentations? A. Amitriptyline B. Bupropion C. Buspirone D. Clonazepam E. Propranolol

decrease the dosage of sertraline to 25 mg

A 34-year-old woman comes to the primary care office for follow-up of excessive worry, which has persisted for the past three years. The worry is difficult to control and is related to a range of subjects, from her relationship with her partner, to her employment, and to her vacation plans. She finds it difficult to relax, and is often easily distracted and irritable. The patient started taking sertraline 50 mg six weeks ago. She says that while her anxiety has significantly improved, her sexual desire and arousal have decreased to the point that it is causing difficulty in her marriage. Which of the following is the most appropriate next step in management? A. Add St. John's wort to her current regimen B. Decrease the dose of sertraline to 25 mg C. Stop the sertraline and refer the patient for cognitive behavioral therapy D. Switch to buspirone E. Switch to temazepam

avoidance of events that remind her of the event

A 34-year-old woman comes to the primary care office three months after she experienced the loss of her partner and home in a tornado. When her home was destroyed, she was hiding in the basement bathroom. Unfortunately, her partner was struck and killed by flying debris while protecting her. Since that time, she has experienced recurrent vivid memories of the event in which she experiences palpitations, diaphoresis, and a sense that she is watching herself from outside her body. The patient has also become increasingly withdrawn and distrustful of the world, as she believes that there is little hope for her to ever rebuild her life. She has lost motivation to return to work. The patient finds that she is tense and irritable most of the time and has a hard time sleeping because she cannot relax. Post-traumatic stress disorder (PTSD) is suspected. Which of the following additional symptoms is required to make a full diagnosis of PTSD in this patient? A. Avoidance of events that remind her of the event B. Recurrent panic attacks C. Recurring nightmares D. Significant decrease in appetite and/or weight E. Suicidal ideation

assess for suicidal ideations regularly

A 35-year-old man comes to the clinic for follow-up of depression that he has had for the past six months. Therapy with escitalopram 10 mg daily was initiated two weeks ago, and the patient says that his mood has not improved, and he feels like his anxiety is worse since he began taking the medication. He also has had dry mouth and headache. Which of the following recommendations to this patient is most appropriate at this time? A. Assess for suicidal ideations regularly B. Discontinue taking the medication immediately C. Drink alcoholic beverages to cope with the breakthrough symptoms D. Establishing a good support system is superfluous E. Screening for other comorbidities is unnecessary

schizophrenia **catatonia

A 35-year-old man is brought to the emergency department by his partner because of his unusual behavior. The patient's partner says he stopped speaking and eating at breakfast, and now he has taken on an unusual rigid posture with his one arm extending superiorly above his head and the other reaching toward the floor. The patient is firmly resistant to any changes in this posture. He is conscious but not responding to instruction. Which of the following disorders is most likely in this patient's medical history? A. Body dysmorphic disorder B. Disruptive mood dysregulation disorder C. Dissociative disorder D. Panic disorder E. Schizophrenia

CAGE questionnaire

A 35-year-old patient comes to the clinic because of insomnia during the past two years. They have difficulty falling and staying asleep, but do not have nightmares or restless legs. The patient drinks five to six beers every night to help them fall asleep, and they cannot fall asleep without drinking alcohol. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. Which of the following assessment tools is most appropriate to use to obtain additional history from this patient? A. CAGE questionnaire B. Clinical Institute Withdrawal Assessment for Alcohol Scale C. DIRE score D. Patient Health Questionnaire-9 E. Stanford Sleepiness Scale

blood pressure

A 36-year-old woman comes to the office because she has had persistent anxiety for the past three years. She says she finds it difficult to relax, control her worry, and avoid becoming irritated and annoyed with others. Treatment with trials of escitalopram and sertraline for three months each did not relieve her symptoms. After tapering off of sertraline, the patient begins taking venlafaxine and titrates the dosage upward to response. Which of the following will now need to be monitored in this patient? A blood pressure B cardiac function via ECG C therapeutic drug levels D serum potassium levels E white blood cell count

clozapine

A 37-year-old man who is in the state mental hospital is undergoing initial examination in his secure unit. The patient was recently admitted to the hospital after he attempted suicide by jumping off of a five-story building at the urging of auditory hallucinations. He has been undergoing treatment for the past 10 years for auditory hallucinations, disorganized behavior, flat affect, and multiple suicide attempts. Previous medications included maximum doses of risperidone, olanzapine, and haloperidol, but they were not sufficient in controlling the auditory hallucinations and suicidal ideations. Treatment with the next most appropriate drug for this condition is planned. Which of the following is the most serious side effect of the medication to be given? A. Agranulocytosis B. Hypoglycemia C. Increased risk of bleeding D. Nephrotoxicity E. Pulmonary fibrosis

pseudocyesis **somatic symptom disorder false belief of being pregnant

A 37-year-old woman comes to the emergency department with her partner stating that she is in labor. She indicates that her contractions are approximately five minutes apart. The patient says that she has not received any prenatal care because she just emigrated from a Central American country three months ago and has not established care with a care provider. She has had amenorrhea for the past eight months, regularly feels fetal movement, and believes she is approximately 37 weeks' gestation. Her pregnancy has been uneventful other than mild nausea early on. The patient has no history of previous pregnancies and says that they tried for months to conceive before becoming pregnant. Medical history includes no chronic disease conditions and no surgical or psychiatric history. Family medical history is unremarkable. Physical examination shows abdominal distension to the xiphoid process and engorged breasts. No fetal heart tones are appreciated on auscultation. Abdominal ultrasonography shows an intact but empty uterus. Serum beta-human chorionic gonadotropin level is <5 mIU/mL. Which of the following is the most likely diagnosis? A. Cryptic pregnancy B. Delusion of pregnancy C. Feigned pregnancy D. Gestational trophoblastic disease E. Pseudocyesis

somatic symptom disorder **physical symptoms result in disruption of normal life

A 37-year-old woman comes to the primary care office because she has had persistent sensations in her abdomen for the past 10 months. The sensations are most prominent after eating and migrate around her abdomen. Most often they feel like fluttering sensations, but occasionally they are painful and come in waves. She has created a symptom diary, outlining the state of her symptoms every 30 minutes while awake for the past two months. She says she has been unable to concentrate at her work as a waitress due to the distressing persistence of her symptoms, and she is concerned that she might have a terminal illness. After initial physical examination eight months ago showed no abnormalities, the patient was referred to a gastroenterologist. Though she has tried bismuth subsalicylate, proton pump inhibitors, probiotics, metoclopramide, hyoscyamine, increased fiber, low FODMAP diet, and laxatives, she continues to have the symptoms, which have become increasingly distressing. Colonoscopy, esophagogastroduodenoscopy, and abdominal ultrasonography showed no abnormalities, and the patient was reassured and released from the gastroenterologist. Which of the following is the most likely diagnosis? A. Conversion disorder B. Factitious disorder C. Illness anxiety disorder D. Malingering E. Somatic symptom disorder

applied behavioral analysis

A 4-year-old boy is brought to the clinic by his parents because they are concerned about his aggressive behavior and uncontrollable tantrums. His birth was uncomplicated, and the patient met all development milestones until about 2 years of age when he began to regress. He does not play with other children, but he enjoys watching water and will flush the toilet until he is made to stop. His mother says he is very sensitive to light and noise but that he has difficulty communicating his needs. He appears to have a high pain tolerance and will not seek care from a parent when injured. Which of the following is the most appropriate next step? A. Applied behavioral analysis B. Aripiprazole therapy C. Group therapy D. Secretin therapy E. Trazodone therapy

disinhibited social engagement disorder

A 4-year-old girl is brought to the pediatric office by her mother who is concerned about the child's recent behavior. The previous day, the mother and daughter were at the park, and while the mother chatted with friends, the daughter watched a men's collegiate soccer team practice. At one point, the mother became distracted and failed to notice that the patient got on the bus with the men from the soccer team and left the park. The mother was unaware of the patient's absence until the soccer coach brought the patient back to the park. The patient was not upset at the incident and begged the mother to go with the college team. The mother says that she has not noticed any other behavioral issues. During the interview, the patient speaks excitedly of her adventure the previous day and says that the men were kind to her. She is uninterested in the neatly arranged toys and coloring books in the backpack she brought with her to the office. However, she climbs into the practitioner's lap and asks if she can go home with them. She also asks the medical assistant the same question and follows him out the door when he leaves the room. The patient is pleasant and interactive during the visit, makes good eye contact, has appropriate dress, and is neatly groomed. On physical examination, no abnormal facial features are noted, and cardiopulmonary examination shows no abnormalities. The medical record indicates that the patient was adopted out of foster care at 24 months of age. She had been in multiple foster homes before her adoption. Which of the following is the most likely diagnosis? A. Attention-deficit/hyperactivity disorder B. Autistic spectrum disorder C. Disinhibited social engagement disorder D. Reactive attachment disorder E. Williams syndrome

chlordiazepoxide

A 40-year-old man comes to the clinic because he has had worsening tremor over the past day. He says he feels irritable and restless, and he has not been able to sleep well. The patient says that he has been drinking 750 mL of gin daily for the past three months, but he quit drinking yesterday. Pulse rate is 110/min, and blood pressure is 142/94 mmHg. The patient is tremulous and appears anxious. Which of the following is the most appropriate initial treatment? A. Chlordiazepoxide B. Disulfiram C. Enrollment in Alcoholics Anonymous D. Naltrexone E. Phenytoin

cyclothymic disorder

A 40-year-old patient comes to the clinic because of intermittent episodes of fatigue over the past three years. The episodes are associated with hypersomnia, anhedonia, and racing thoughts lasting three to four days. The patient also reports episodes of "feeling on top of the world" and irritability that lasts two to three days. The patient experiences one of these two episodes monthly. Although these symptoms are bothersome, the patient has never had any difficulty with the law or employment. There are no hallucinations or delusions. Medical history includes well-controlled hypertension on amlodipine. Physical examination shows no abnormalities. Laboratory studies, including urine drug screening, complete blood cell count, complete metabolic panel, and thyroid-stimulating hormone level, are within normal limits. Which of the following is the most likely diagnosis? A. Bipolar II disorder B. Cyclothymic disorder C. Major depressive disorder with atypical features D. Medication-induced bipolar disorder E. Schizoaffective disorder

duration of symptoms

A 42-year-old man comes to the primary care office because he has been experiencing distressing symptoms for the past three weeks since he returned home from a business trip to a developing country. He says that while on the trip, he was taken hostage by a group of armed men who bound and gagged him and held him at gunpoint. While his release was secured after less than 24 hours of captivity, and he was able to travel home without further incident, he has been having recurrent memories of being captured, especially at night, when he feels that he is re-experiencing the events. He says he has been avoiding his family and has had increasing trouble concentrating at work. The patient says that he was in a store yesterday and heard a family speaking a foreign language, which triggered symptoms of feeling that he was back in captivity. He became irritable with the family and began shouting at them, at which time store security asked him to leave. He does not drink alcoholic beverages or use illicit drugs. Which of the following aspects of this patient's history is most important for differentiating between acute stress disorder and post-traumatic stress disorder? A. Difficulty concentrating B. Duration of symptoms C. Flashbacks D. Irritability E. Sleep disturbance

mood disorder questionnaire

A 43-year-old man comes to the clinic because he has had intermittent irritability throughout most of his life. He says he has long episodes of depression as well as short episodes of irritability with an increased desire to engage in activities. The patient says that relationships with his family and spouse are severely damaged, and his spouse is contemplating filing for divorce because of this unpredictable behavior. Bipolar disorder is suspected. Which of the following is the most appropriate screening test? A. Buss-Perry Aggression Questionnaire B. Mood Disorder Questionnaire C. Patient Health Questionnaire-9 D. Post-traumatic Stress Diagnostic Scale E. Short Mood and Feelings Questionnaire

switch to fluoxetine, then taper fluoxetine over the next month

A 43-year-old woman comes to the office for follow-up of panic disorder, which she has had for the past three years. Treatment for the past two years has consisted of paroxetine 10 mg and cognitive behavioral therapy. She says she now feels that she is able to effectively use the skills she learned in cognitive behavioral therapy, and it has been six months since her most recent panic attack. She tried to taper off of paroxetine but developed dizziness, fatigue, nausea, and dizziness within days. Then the patient tried tapering more slowly, but the symptoms recurred again. Which of the following is the most appropriate next step? A administer intramuscular fluphenazine decanoate, and then stop paroxetine B switch to bus-irons, then taper bus-irons over the next month C switch to diazepam, then taper diazepam over the next month D switch to fluoxetine, then taper fluoxetine over the next month E switch to propranolol, then taper propranolol over the next month

mechanical ventilation

A 43-year-old woman is brought to the emergency department via ambulance 20 minutes after her partner found her unconscious with empty bottles of alprazolam and a half-full bottle of vodka next to her. Her medical history includes panic attacks and major depressive disorder for the past 20 years. Respirations are 8/min, and blood pressure is 110/70 mmHg. The patient is unconscious but responds to painful stimuli. Which of the following is the most appropriate intervention? A. Administration of activated charcoal B. Administration of flumazenil C. Hemodialysis D. Mechanical ventilation E. Whole bowel irrigation

sertraline

A 44-year-old man comes to the primary care office with his spouse because he has had problems with sexual intercourse during the past three years. The difficulty started shortly after the couple was married, which was a happy event. While the patient's sexual function was normal early in their relationship, he began to orgasm increasingly early in intercourse, leaving his spouse sexually dissatisfied. This has caused the patient to feel more and more inept and disinterested, not only in sex but in other previously enjoyable activities such as hiking, reading, and fishing. The patient has had worsening difficulty concentrating and sleeping as well as progressive sadness, withdrawal, and guilt. He has lost 10 lb unintentionally over the past six months. He says the sexual difficulty has become a barrier in his relationship with his spouse, and they have sought couples counseling. Physical examination shows no abnormalities. Prolactin, thyroid-stimulating hormone, and testosterone levels are within normal limits. Which of the following is the most appropriate treatment? A. Alprostadil B. Levodopa/carbidopa C. Methylphenidate D. Risperidone E. Sertraline

PDE-5 inhibitors are contraindicated in patients who take nitrates

A 45-year-old man comes to the office because he cannot achieve or maintain an erection for the past three years. The difficulty has been worsening over time, and his spouse has asked him to seek treatment. He has no history of depression, anxiety, or significant difficulty with his spouse. Medical history includes type 2 diabetes mellitus, acute angina, mixed hyperlipidemia, and hypertension. Medications include metformin, sublingual nitroglycerin, simvastatin, and lisinopril. He does not smoke cigarettes, drink alcoholic beverages, or use illicit drugs. Body mass index is 35 kg/m². On laboratory studies, testosterone level, complete blood cell count, and complete metabolic panel are within normal limits. Hemoglobin A1c is 6.9. The patient requests a prescription for a phosphodiesterase-5 (PDE-5) inhibitor. Which of the following is most appropriate to tell this patient about this therapy? A. If chest pain develops after taking a PDE-5 inhibitor, lay down prior to taking a nitrate for the chest pain B. PDE-5 inhibitors are contraindicated in patients who take nitrates C. PDE-5 inhibitors can only be prescribed to patients with a body mass index <30 kg/m² D. Sildenafil is the only appropriate PDE-5 inhibitor to use E. Wait at least four hours between the use of a PDE-5 inhibitor and taking a nitrate for chest pain

medication should be continued for at least 12 months after symptoms are relieved **generalized anxiety disorder

A 45-year-old man who is a business executive comes to the primary care office because he has had insomnia for the past seven months. He has difficulty falling asleep and staying asleep, which leaves him restless and easily fatigued during the day. During the interview, the patient says that he is often irritable with his spouse and children. He works in a high-pressure environment on commission, so he feels stress because he cannot control his income yet he is the primary wage earner in the family. The patient also says that he is concerned for the welfare of his children with him working such long hours; however, because he has been so irritable with them, they avoid him. The patient has significant concerns about how political decisions will affect both his personal and occupational success. Meditation, exercise, and having a drink each night before bed have not relieved his symptoms. He requests medication for treatment, and appropriate therapy is prescribed. When the patient wants to know how long he will need to take this medication, which of the following is the most appropriate response? A. Medication should be continued for approximately the same time that symptoms have been experienced B. Medication should be continued for at least 12 months after symptoms are relieved C. Medication should be continued until symptoms have resolved, and then it should be tapered D. Medication will likely need to be continued indefinitely E. Medication will only need to be taken on an as-needed basis

the patient's spouse

A 46-year-old man sustained a traumatic brain injury in a motorcycle collision one week ago. He is currently in the ICU on mechanical ventilation. Neurologic examination and testing shows a grim prognosis. The patient will need prolonged round-the-clock care and will likely remain in a persistent vegetative state for the remainder of his life. His loved ones have gathered to clarify the patient's wishes for end-of-life care. The patient has no living will or durable power of attorney, and he has never had a discussion of his wishes regarding end-of-life care with any of those present. Which of the following is the most appropriate person to choose the course of care for this patient? A. The patient's 22-year-old daughter B. The patient's childhood best friend C. The patient's parents D. The patient's spouse E. The patient's twin brother

avolition

A 49-year-old man with chronic schizophrenia comes to the primary care clinic for routine follow-up. He says he has not been able to maintain a job or manage his own finances due to lack of motivation. The patient expresses deep sadness over his inability to maintain employment and relationships and feels guilty that he cannot fit in with the rest of his family or society at large. He is convinced that there is going to be a biological warfare attack on the city, but when he tries to explain his concerns to others, the evidence he has read about is removed from his brain by an unknown outside force. The patient's inability to warn others of the upcoming crisis increases his guilt to the point of hopelessness, but he denies suicidal ideation. He also admits to having visions of his family standing over his bed while he is falling asleep, which wakes him. At that time, he realizes they are not present. Which of the following findings in this patient is an example of a negative symptom? A. Avolition B. Depression C. Hypnagogic hallucinations D. Nihilistic delusion E. Thought withdrawal

risperidone

A 5-year-old boy is brought to the clinic by his parents because they are concerned about his behavior. The parents say that the patient does not initiate conversations or use eye contact, and he does not seem comforted by warm interactions with his parents. He frequently flaps his hands and becomes very distressed if he is prevented from engaging in activities related to his toy dinosaurs. His parents are particularly upset that the patient will bang his head against the wall until it bleeds when he is prevented from adhering to his routine. Which of the following is the most appropriate treatment for the irritability in this patient? A. Clonazepam B. Fluvoxamine C. Haloperidol D. Methylphenidate E. Risperidone

insight

A 52-year-old man comes to the clinic because he has had interpersonal problems during the past several years. He is a lawyer at a prestigious firm, and he has been having difficulty with his partners because he feels that they are trying to hold him back. Although he is competent at his job, he is unable to point out instances that would merit a promotion. He is also frustrated with his spouse because he feels that he deserves better, despite the fact she has always been very loving and supportive. Based on these findings, which of the following personality characteristics is most likely to be lacking in this patient? A. Affect B. Cognition C. Effective communication D. Impulsiveness E. Insight

increases the inhibitory effect of GABA **benzodiazepine

A 52-year-old woman comes to the primary care office because she has had excessive worry about many different areas of her life during the past eight months. Her children are at college, and she worries about their safety. Her employer has recently sold the company to a large corporation, and she is concerned about the changes to her office culture. Her neighbors are also not as sociable with her as they have been in the past, and while she cannot think of anything she has done to offend them, she cannot help but wonder what she has done wrong. These thoughts are keeping her awake at night, causing excess fatigue and muscle tension during the day. She feels irritable and edgy with her spouse, who has asked her to seek a medication that might help with her symptoms, especially her insomnia. The medication that is most appropriate to prescribe during the acute phase of this disease has which of the following mechanisms of action? A. Increases brain-derived neurotrophic factor functions as a neurotransmitter modulator to upregulate glutaminergic receptors B. Increases cortisol at the synaptic cleft C. Increases serotonin release at the synaptic cleft D. Increases the inhibitory effect of gamma-aminobutyric acid E. Inhibits the release of norepinephrine at the synaptic cleft

diabetes mellitus

A 54-year-old man comes to the medical provider because he has had an increasing problems sustaining an erection during sexual activity over the past six months. He has been married to his current spouse for 30 years and has a very good relationship with her. However, after having encountered the inability to maintain an erection during several intimate encounters, he has begun to avoid sexual activity because of fear of failure. This has put a strain on his marital relationship in many ways. Which of the following medical conditions is most appropriate to rule out as a potential cause of the erectile dysfunction in this patient? A. Diabetes mellitus B. G6PD deficiency C. Prostate cancer D. Turner syndrome E. Urinary tract infection

cognitive behavioral therapy that includes exposure therapy

A 54-year-old man comes to the primary care office because he has had a fear of heights for the past 50 years. When he was a toddler, he fell off a top bunk bed and broke his arm. Since that time, he has been afraid of heights greater than three feet. The patient has no history of intrusive memories, hypervigilance, or chronic negative affect. He has recently been promoted to a construction supervisor of a 110-story building and needs to conduct daily on-site inspections, which exposes him to great heights. Despite using a safety harnesses that prevents him from falling, the patient says he becomes nauseous and dizzy with fear when on the job site. Which of the following is the most appropriate treatment? A. Alprazolam taken as needed B. Cognitive behavioral therapy that includes exposure therapy C. Electroconvulsive therapy D. Escitalopram taken daily E. Propranolol taken as needed

piloerection **opioid withdrawal

A 54-year-old woman comes to the emergency department because she has had worsening body aches, nausea, and diarrhea over the past two days. Medical history includes hepatitis C infection. She says that she always gets sick when she runs out of medication, and her last dose was about three days ago. She has not had any exposure to a viral illness or sick contacts. Temperature is 37.0°C (98.6°F) and blood pressure is 146/86 mmHg. The patient appears disheveled. Physical examination shows multiple areas of scarring on both antecubital areas and hands. Which of the following additional findings on physical examination is most likely? A. Bradycardia B. Hallucinations C. Miosis D. Piloerection E. Seizures

decreased volume in prefrontal cortex

A 55-year-old man comes to the clinic for follow-up evaluation for major depressive disorder. He was diagnosed with this disorder at 25 years of age, and his symptoms have been moderately controlled with fluoxetine 40 mg daily. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. Complete blood count, complete metabolic panel, and thyroid-stimulating hormone level are within normal limits as well. Which of the following findings is most likely on MRI of the brain? A. Decreased volume in the prefrontal cortex B. Decreased volume of the lateral ventricles C. Increased volume of the amygdala D. Increased volume of the basal ganglia E. Increased volume of the hippocampus

decreased size of temporal lobe

A 56-year-old man comes to the primary care office because he has had worsening auditory hallucinations over the past six months. Medical history includes a diagnosis of schizophrenia at 21 years of age, but his hallucinations have been well-controlled by second-generation antipsychotic drugs for more than 10 years. He says the hallucinations are only auditory and not visual, and they consist of voices telling him to jump off the top of a tall building. The voices are not frightening but are annoying. He is able to maintain his sleep schedule but is having increasing difficulty concentrating at work. Medical history also includes metabolic syndrome with elevated blood pressure and increased cholesterol level, both of which are treated with medication. Family medical history includes premature cardiovascular disease in his father who died from a myocardial infarction at 47 years of age. The patient smokes one pack of cigarettes per day, and he does not drink alcoholic beverages or use illicit drugs. He does not exercise, and basal metabolic rate is 42.3. Which of the following findings is most likely on MRI of the brain? A. Decreased activity of the suprachiasmatic nucleus B. Decreased size of the temporal lobe C. Enlargement of the prefrontal cortex D. Increased activity of the amygdala E. Infarct of the superior occipital lobe

prazosin

A 57-year-old man comes to the office because he has had recurrent nightmares for the past seven months. He says the nightmares started after he was the victim of a burglary with assault in his own home in the middle of the night. He was beaten severely and held at gunpoint while his home was ransacked. Since that time, he has had difficulty falling asleep because his bedroom reminds him of the attack. When he does fall asleep, he has vivid nightmares about the event. The patient says that he is easily startled by any sudden noise and finds it increasingly difficult to concentrate at work due to fatigue, intrusive memories, and self-blame. He feels that if he had better sleep without nightmares, he would have a better ability to function. Which of the following drugs is most appropriate to prescribe to this patient? A. Clonazepam B. Doxylamine C. Lithium D. Prazosin E. Zolpidem

erotomaniac type

A 57-year-old woman comes to the office for follow-up evaluation of depression, for which she is on Social Security Disability. She says that she no longer can afford groceries because she has been financially supporting her fiancé, a 23-year-old prince of a Middle Eastern country who has had his assets frozen because of his love for her. Therefore, the patient has been sending her Social Security income to him so that he can save the money to buy a plane ticket to come to America to marry her. Her family members have all cautioned her against this man, but she insists that his letters are sincere. The patient says the limited number of times she has been able to video chat with him have been wonderful. She has started to distance herself from her family for fear of their criticism. Which of the following types of delusion is this patient experiencing? A. Delusional jealousy type B. Erotomanic type C. Grandiose type D. Persecutory type E. Somatic type

ADHD

A 6-year-old boy is brought to the clinic by his grandmother because he has demonstrated a pattern of aggressive behavior over the past 18 months. The patient has gotten caught shoplifting, swears and pushes his teachers, and was caught bringing a knife to school. The patient recently lit the laundry room on fire. He appears to demonstrate remorse in attempts to avoid punishment but is belligerent if he is punished. The grandmother says that the patient's mother smoked cigarettes while pregnant with him, and he has struggled academically. Which of the following additional findings on history taking is most likely? A. Ability to self-soothe B. Attention-deficit/hyperactivity disorder C. Consistent parenting D. Mild intermittent asthma E. Small family size

psychologically traumatizing event

A 64-year-old man comes to the primary care office for evaluation of the loss of use of his right arm for the past two weeks. He is accompanied by his spouse. Up to this point, the patient has been reluctant to seek care. Evaluation in the ED two weeks ago showed no abnormalities on initial and repeat imaging. The patient's spouse says that he can move his right arm in his sleep but not while he is awake. The patient insists that his spouse is overreacting and that his paralysis does not bother him. He has no history of injury to his head, neck, or upper extremities, and denies recent fever, chills, or weight loss. Physical examination shows symmetrical reflexes, pulses, and temperature. Muscle strength in the right upper extremity is 0/5 in all muscle groups but 5/5 in the left upper extremity. Muscle tone, bulk, and sensation are intact and equal in both extremities. Cranial nerves are intact. Which of the following is the most likely etiology of the symptoms in this patient? A. Cervical radiculopathy B. Encephalomyelitis C. Ischemic stroke D. Psychologically traumatizing event E. Thoracic outlet syndrome

schizoaffective disorder

A 64-year-old man who is disheveled and combative is brought to the emergency department by police who say that the patient had been shouting at customers outside of a shopping mall, telling them that capitalism was the opioid of the masses and that they would die of an overdose if they did not surrender their worldly goods. He also stole several shopping bags and destroyed their contents. The police were able to locate the patient's sister by phone, and she says that this patient's hallucinations and delusions started in his late 20s, are present nearly all the time, and have been difficult to control. She says he has been really up and down his whole adult life. At times, he has periods of not sleeping, calling her at all hours of the day with a new idea he has to revolutionize life, and spending beyond his means. Then he will go weeks without calling stating he is too tired to do anything and just finds no pleasure in anything. He has been unable to hold a job not only because of his paranoid delusions, but also because of lack of motivation and low mood. She loves her brother but it has been hard to be supportive and understanding of all his different moods. The patient's speech and thoughts are disorganized, but he is oriented to person, time, and place. He appears to be responding to internal stimuli though he denies hallucinations. Which of the following is the most likely diagnosis? A. Bipolar disorder with psychotic features B. Major depressive disorder with psychotic features C. Schizoaffective disorder D. Schizophrenia E. Schizophreniform disorder

screen all women of reproductive Aage for intimate partner violence

A 67-year-old woman comes to the office for routine annual physical examination, which encompasses the screening tests for which she is due. She divorced her spouse six months ago, is sexually active, and has had a new sexual partner within the past four months. She seems happy about the relationship and is using condoms to prevent sexually transmitted diseases. During the interview, she says that her new partner is very protective, and she is not sure if that is a positive or negative aspect of the relationship. Which of the following is the screening recommendation for intimate partner violence? A. Screen all women and girls ≥10 years of age for intimate partner violence B. Screen all women of reproductive age for intimate partner violence C. Screen all women who are in a heterosexual relationship for intimate partner violence D. Screen all women who are married or cohabiting with another adult for intimate partner violence E. Screen women who are in a sexual relationship for intimate partner violence

normal childhood development

A 7-year-old girl is brought to the pediatric office by her mother in order to discuss the patient's gender expression. Since the patient was a toddler, she has wanted to dress like a boy, not play with dolls and other traditionally female toys, and prefers to keep her hair short. She has more male friends than female and prefers the company of male peers during recess, lunch, and group work at school. The patient says that she does not want to be a boy or have male anatomy, but she prefers their company because they are more active, athletic, and free than her more reserved female peers. The patient identifies as a girl and is happy with her peer and activity choices. She gets along well with her classmates and is doing well at home and school. Which of the following best defines this patient's condition? A. Body dysmorphic disorder B. Gender dysphoria C. Normal childhood development D. Transgender E. Transvestic disorder

major depressive disorder

A 72-year-old man comes to the clinic for follow-up three weeks after he was hospitalized for treatment of his first myocardial infarction. He says he has been tired all the time and is constantly questioning previous life choices that contributed to his heart attack. The patient says he feels sad and excessively guilty despite the support of his family, and he finds himself losing sleep and not having his usual appetite. He has not had similar episodes of these symptoms in the past. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. Complete blood cell count, complete metabolic panel, and thyroid-stimulating hormone level are within normal limits. Which of the following is the most likely diagnosis? A. Adjustment disorder with depressed mood B. Depressive disorder due to another medical condition C. Major depressive disorder D. Persistent depressive disorder E. Post-traumatic stress disorder

the patient lacks capacity because she cannot understand the consequences of her decision

A 73-year-old woman comes to the emergency department three hours after she fell in her home, where she lives alone. She has a displaced fracture of the right femoral neck, and surgical repair is strongly recommended. The patient's daughter says that her mother has become increasingly confused over the past six months. When the daughter looked for the patient's prescriptions to bring them to the hospital, the daughter says that she noticed that her mother has not been taking her prescriptions for lisinopril, levothyroxine, and metformin. The patient shouts, "I don't know what you are talking about. I don't take any medications. Let me out of here! I don't want any surgery even if my hip is broken! You all are just trying to steal my money. I want to go home!" The daughter does not have durable power of attorney authority for her mother's health care. Which of the following best describes the patient's decision-making capacity? A. The patient has capacity because she has not designated anyone to make health care decisions for her by executing a durable power of attorney for health care. B. The patient has capacity because she is able to articulate the reasons for not wanting surgery. C. The patient has capacity because she understands the nature of her injury and has the right to determine if she wants to undergo surgery. D. The patient lacks capacity because she cannot understand the consequences of her decision. E. The patient lacks capacity because she does not understand the nature of her injury.

Haloperidol

A 75-year-old man is brought to the emergency department by police because he was noted to be exhibiting self-injurious and bizarre behavior in a public park. The police say that he was wearing only his undergarments, cutting himself with a piece of a beer can, and appeared to be responding to internal stimuli. Currently in the emergency department, the patient is combative, shouting profanity, and striking staff. He smells of alcohol and cannabis. Previous medical records indicate that he has had three psychiatric hospitalizations. Which of the following medications is the best choice for the acute management of this patient's condition? A Diphenhydramine B Droperidol C Eszopiclone D Haloperidol E Lorazepam

parent management training

A 9-year-old boy is brought to the clinic by his parents because his behavior has deteriorated over the past two years. The patient is now regularly skipping school, assaulting other children in his class, and lying about his activities and whereabouts. He was caught shoplifting last week, and his parents are demanding that something be done to "fix" him. The patient does not demonstrate any remorse or guilt for his actions. Which of the following is the most appropriate initial management? A. Military style boot camp B. Parent management training C. Therapy with olanzapine D. Therapy with quetiapine E. Therapy with valproic acid

recent streptococcal infection **OCD

A 9-year-old girl is brought to the clinic by her mother because she had an abrupt change in behavior two weeks ago. The mother says that the patient has started worrying about the home doors being locked. She checks the doors repeatedly because she is concerned they will be unlocked and the house will get robbed. The patient has never demonstrated this behavior in the past. Birth was uncomplicated, and she has met all developmental milestones. Pulse rate is 100/min, and blood pressure is 100/60 mmHg. Which of the following findings is most likely on history taking? A. Harsh, inconsistent style in upbringing B. High socioeconomic status C. Positive temperament D. Recent life stressor E. Recent streptococcal infection

slowed speech

A well-groomed 40-year-old woman comes to the clinic because she has had depression for the past three months. She had been effectively treated with sertraline two years ago, but she discontinued the medication on her own six months ago. She says she feels sad, has fatigue, and has an increase in her dietary intake and desire for sleep. The patient says her focus is poor and she has received several written warnings from her employer. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. Which of the following findings on physical examination is most likely? A. Absent deep tendon reflexes in the lower extremities B. Clonus C. Disorganized speech D. Rapid, pressured speech E. Slowed speech

parent management training

An 11-year-old boy is brought to the clinic by his parents because he has had changes in his behavior at home and at school during the past few years. The parents say that the patient is irritable and confrontational, particularly with authority figures but also with his peers. He refuses to follow instructions or obey commands, and he appears to find great joy in going out of his way to be spiteful or to be a nuisance. He has never been physically aggressive or damaged property. The patient's birth was uncomplicated, and he has met all developmental milestones. Pulse rate is 110/min, and respirations are 22/min. Which of the following is the most appropriate next step? A. Lithium therapy B. Parent management training C. Quetiapine therapy D. Regular detention in school E. Risperidone therapy

ecstasy

An 18-year-old patient who identifies as genderqueer is brought to the emergency department by ambulance immediately after they collapsed and had a seizure at a music festival. The patient is unconscious but arousable. Their partner says that the patient had ingested a substance at the festival and had been drinking significant amounts of water prior to the seizure. Temperature is 37.5°C (99.5°F), pulse rate is 120/min, and blood pressure is 140/90 mmHg. Based on these findings, this patient most likely has intoxication with which of the following illicit drugs? A. Ecstasy B. Heroin C. Inhalant D. Marijuana E. Phencyclidine

decreased appetite

An 8-year-old boy is brought to the clinic by his parents because he has been struggling with paying attention at home and at school for the past year. His teachers have given him several warnings about talking in class, and he does not follow through on his work. He is very talkative and fidgets frequently. His birth was uncomplicated, and he has met all developmental milestones. If this patient is prescribed a stimulant for treatment for his presumed diagnosis, which of the following adverse effects of this therapy is most likely? A. Accidents B. Cardiovascular events C. Decreased appetite D. Seizures E. Substance abuse later in life

a pattern of spitefulness

An 8-year-old boy is brought to the clinic by his parents because he has had worsening behavior over the past year. The parents say the patient has become increasingly irritable and argues with his parents and teachers over minute details. He is rude to his peers and deliberately tries to pester them. Development and growth are within normal limits. If this patient has oppositional defiant disorder, which of the following findings on history taking is most likely? A. A history of physical violence toward his pets B. A pattern of spitefulness C. Feelings of guilt D. Frequent episodes of hyperactivity E. Substance use