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3,531 questions
A38-year-old married woman presents to her urgent care clinic complaining of "crying spells" for several weeks since the termination of her employment. She admits to feeling "down all the time." She also has difficulty falling asleep, poor energy, decreased appetite, and is "not able to enjoy anything." She fears that her condition will never improve. She has begun to feel that "it wouldn't matter if I died," but she denies any suicidal plan or intent. She drinks one to two mixed drinks per week and denies any drug use. It is decided to begin antidepressant therapy with paroxetine (Paxil) 20 mg at bedtime. Which of the following side effects would be most likely to emerge after several months of treatment?
A 65-year-old man presents to the emergency department with an abrupt onset of excruciating chest pain 1 hour ago. The pain is localized to the anterior chest, but radiates to the back and neck. On examination, the patient is afebrile, with a BP of 210/110 mmHg, pulse rate of 95/min, and a respiratory rate of 12/min. He appears pale and sweaty. Unequal carotid, radial, and femoral pulses are noted. An electrocardiogram (ECG) shows nonspecific ST-T segment changes. Chest x-ray shows a slightly widened mediastinum and normal lung fields. Which of the following is the first step in management of this patient?
A 60-year-old male with a history of chronic schizophrenia and multiple hospitalizations checks into the emergency room with complaints of "funny movements." He has been compliant with risperidone (Risperdal) 3 mg bid, and he has been taking that dose for the last 6 years while living at a group home. He appears overweight but with adequate hygiene. His thoughts are somewhat tangential but not grossly disorganized. He denies any paranoia, ideas of reference, or delusions. He denies perceptual disturbances or suicidal/homicidal ideation. His physical examination is unremarkable except for occasional involuntary blinking and grimacing, as well as rotation of his left ankle. He is greatly distressed about these "habits" and wishes something to be done about them. Which of the following would be the most appropriate management for this patient?
A 14-month-old girl is brought into the primary care clinic by her parents. Her prior wellbaby checks have been normal, but her parents have noticed that while she used to be "outgoing," she has now become shyer and less responsive. Whereas she had been beginning to walk, she has recently been falling more and unable to even stand up. Her mother noticed that she has been flapping her hands and that her sun hats have become too big for her. Which of the following is the most likely diagnosis for this patient?
A 65-year-old man presents to the emergency department with sudden onset of pain and weakness of the left lower extremity of 2-hour duration. Past history reveals chronic atrial fibrillation following a myocardial infarction 12 months ago. On examination, he is found to have a cool, pale left lower extremity with decreased strength and absent popliteal and pedal pulses. The opposite leg has a normal appearance with palpable pulses. Following successful treatment for an embolus to the left femoral artery with no evidence of a reperfusion injury, which of the following long-term treatments would most likely decrease the chance of recurrent embolus?
A 60-year-old male with a history of chronic schizophrenia and multiple hospitalizations checks into the emergency room with complaints of "funny movements." He has been compliant with risperidone (Risperdal) 3 mg bid, and he has been taking that dose for the last 6 years while living at a group home. He appears overweight but with adequate hygiene. His thoughts are somewhat tangential but not grossly disorganized. He denies any paranoia, ideas of reference, or delusions. He denies perceptual disturbances or suicidal/homicidal ideation. His physical examination is unremarkable except for occasional involuntary blinking and grimacing, as well as rotation of his left ankle. He is greatly distressed about these "habits" and wishes something to be done about them. The same patient is brought back to the emergency room via ambulance 1 month later due to "catatonia." According to his chart, he was maintained on his current dose of risperidone by his outpatient psychiatrist. On examination, he is unresponsive to questions. His vital signs demonstrate a temperature of 103.5°F, BP of 180/95, pulse of 105, and respirations of 20. His physical examination is notable for significant diaphoresis, muscular rigidity, and lack of cooperation with much of the examination. Which of the following would be the most appropriate management for this patient?
An 18-month-old boy is brought into the urgent care clinic by his mother who complains that he is "eating weird stuff." For the past few months since being able to walk, he has been found chewing and swallowing odd substances, such as hair, paper, and string. She has been more concerned since she recently noticed him eating clay from around the foundation of their apartment in the projects. His appetite has been affected because of this, and she is worried that he will become sick as a result. Determination of which of the following blood levels would be the most appropriate next step in the workup and management of this patient?
A 65-year-old man presents to the emergency department with sudden onset of pain and weakness of the left lower extremity of 2-hour duration. Past history reveals chronic atrial fibrillation following a myocardial infarction 12 months ago. On examination, he is found to have a cool, pale left lower extremity with decreased strength and absent popliteal and pedal pulses. The opposite leg has a normal appearance with palpable pulses. Which of the following is the treatment of choice for this patient?
A19-year-old male United States Army veteran presents to the outpatient clinic. He recently returned from combat in Iraq where he was assigned to the infantry. While on patrol 1 month ago, he witnessed several friends killed by a road-side bomb. Since that time he has had difficulty sleeping, with frequent awakenings after recurrent nightmares about the event. He finds himself "jumpy" at times, especially with loud noises. He stayed in his parents' house around the July 4th holiday, and he became acutely anxious when hearing firecrackers. He has not spent time with friends or family. He refuses to watch any television or listen to the radio for fear of hearing news of more casualties. He complains of a sense of "numbness" and gets easily distracted. He denies suicidal ideation but sometimes feels that "my life ended over [in Iraq]." Which of the following medications as monotherapy is most likely to be effective in treating his symptoms?
A 65-year-old man presents to the emergency department with sudden onset of pain and weakness of the left lower extremity of 2-hour duration. Past history reveals chronic atrial fibrillation following a myocardial infarction 12 months ago. On examination, he is found to have a cool, pale left lower extremity with decreased strength and absent popliteal and pedal pulses. The opposite leg has a normal appearance with palpable pulses. Which of the following is the most appropriate first step in management of this patient?
A 12-year-old boy is brought into the office by his mother, who states, "I can't deal with this anymore!" She appears exasperated, claiming that her son has been getting into more and more trouble over the past 15 months since the finalization of a particularly long and difficult divorce. He has been leaving the house at night without notifying his mother or telling her of his whereabouts. She suspects that he is responsible for the increased vandalism in the neighborhood. He has recently been caught shoplifting at a nearby store. His grades have always been poor, but he has just been suspended for missing classes and skipping school over the past year. He has often come home with evidence of having been in fights. She suspects that he may be hanging out with gang members. She is afraid of his ending up in jail and "becoming like his father." If untreated, which of the following diagnoses is most likely to transpire in this patient?
A 75-year-old man is brought to the emergency department for severe pain in the left flank and back of 1 hour duration. He has a prior history of a myocardial infarction and coronary artery bypass grafting 8 years ago. On examination, he is found to have a BP of 80/50 mmHg, pulse rate of 110/min, respiratory rate of 15/ min, and a pulsatile, tender abdominal mass. He has had two large-bore IV lines placed by the paramedics. He is alert and oriented, and gives consent for surgery. Which of the following is the most appropriate next step in management of this patient?
A 12-year-old boy is brought into the office by his mother, who states, "I can't deal with this anymore!" She appears exasperated, claiming that her son has been getting into more and more trouble over the past 15 months since the finalization of a particularly long and difficult divorce. He has been leaving the house at night without notifying his mother or telling her of his whereabouts. She suspects that he is responsible for the increased vandalism in the neighborhood. He has recently been caught shoplifting at a nearby store. His grades have always been poor, but he has just been suspended for missing classes and skipping school over the past year. He has often come home with evidence of having been in fights. She suspects that he may be hanging out with gang members. She is afraid of his ending up in jail and "becoming like his father." Ahistory of which of the following premorbid diagnoses would most likely be found in this patient?
A 65-year-old woman presents to the physician's office for her yearly physical examination. She has no complaints except for a recent 10-lb weight loss. Past history is pertinent for a 40 pack-year smoking history, hypertension, asthma, and hypothyroidism. Examination reveals a thin woman with normal vital signs and unremarkable heart and abdominal examinations. Lung examination reveals mild wheezing and a few bibasilar rales. A chest x-ray is obtained and is shown in Figure. Achest x-ray obtained 3 years ago was normal. Yearly laboratory tests including a CBC, electrolytes, and lipid panels are normal. Which of the following is the most appropriate next diagnostic test? percutaneous needle biopsy
The patient is a 70-year-old man brought to the primary care clinic by his family over concerns that he has Alzheimer's disease. They have noticed a worsening of his memory over the past 6 months. He does not seem to want to get out of bed, and he appears to have difficulty providing for his basic needs such as cleaning, dressing, and cooking for himself. He is hesitant when talking, but it is unclear whether he is unable or unmotivated to speak. His family has also noticed that he appears depressed and is often seen crying. A MSE of the patient is performed to help determine whether he is suffering from a dementing illness or a depressive illness (pseudodementia). Further history, cognitive examinations, physical examination, and laboratory/radiographic studies are obtained. The results are consistent with Alzheimer's dementia. While the family had been able to take care of him initially, they have since returned to the clinic stating that they can no longer keep him at home. They feel that he is becoming much more agitated. He is staying up at night. Lately he has been rearranging the furniture, claiming to look for "the little people who are teasing me." They have noticed that he has difficulty walking, often moving slowly and dropping items. The family has pursued nursing home placement, but they wish to have something prescribed in order to help him sleep and keep him calm. Which of the following medications should be avoided in this patient?
A 65-year-old woman presents to the physician's office for her yearly physical examination. She has no complaints except for a recent 10-lb weight loss. Past history is pertinent for a 40 pack-year smoking history, hypertension, asthma, and hypothyroidism. Examination reveals a thin woman with normal vital signs and unremarkable heart and abdominal examinations. Lung examination reveals mild wheezing and a few bibasilar rales. A chest x-ray is obtained and is shown in Figure. Achest x-ray obtained 3 years ago was normal. Yearly laboratory tests including a CBC, electrolytes, and lipid panels are normal. Which of the following is the most likely diagnosis?
The patient is a 70-year-old man brought to the primary care clinic by his family over concerns that he has Alzheimer's disease. They have noticed a worsening of his memory over the past 6 months. He does not seem to want to get out of bed, and he appears to have difficulty providing for his basic needs such as cleaning, dressing, and cooking for himself. He is hesitant when talking, but it is unclear whether he is unable or unmotivated to speak. His family has also noticed that he appears depressed and is often seen crying. A MSE of the patient is performed to help determine whether he is suffering from a dementing illness or a depressive illness (pseudodementia). Which of the following characteristics on MSE is most consistent with pseudodementia?
A30-year-old separated female with borderline personality disorder is brought in by her roommate after she admitted to feeling suicidal and taking several handfuls of "an old prescription" some hours ago. Her vitals demonstrate a slight fever, elevated BP, and tachycardia. On physical examination, her pupils are dilated, she has a tremor, and she complains of "seeing scary faces." She also has noticeably dry mucous membranes. Which of the following medications should be immediately administered in the above case?
A 45-year-old man presents to the physician's office for evaluation of a skin lesion on his abdomen. He states that the lesion has been present for 1 year, but has recently enlarged over the last 2 months. The mass is nontender, and he is otherwise asymptomatic. Past history is unremarkable. Examination reveals a 3-cm, pigmented, irregular skin lesion located in the left lower quadrant of the abdomen, as shown in Figure. Heart, lung, and abdominal examination are normal. There are no palpable cervical, axillary, or inguinal lymph nodes. Chest x-ray and liver function tests are normal. Which of the following is the most appropriate next step in management?
An 8-year-old girl presents for a checkup. She is new to your practice. The mother states that she has always been small for her age; otherwise, she has been well. She is short and has a height age of 4 years, 4 months. You note some abnormalities in her general appearance as shown in the figure. As you continue your physical examination, you remember that congenital heart disease is common in this particular syndrome. Which of the following is the most likely congenital heart defect in patients with this syndrome?