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159 questions
The patient is a 26-year-old male graduate student presenting to his health maintenance organization. He is having ongoing difficulty completing his thesis. When he is working on the computer, he finds it necessary to print out and save every draft of his paper. Even though he realizes that it is unnecessary to do so, he feels compelled to read and reread all of his versions in case he made a mistake. As a result, he has been unable to move forward with his dissertation. He is consumed with doubts about his thesis, but at the same time he cannot throw away discarded sections. In fact, his apartment contains stacks of paper spread throughout his rooms. He understands that these thoughts and behaviors are "not rational," and he is greatly distressed by them and the problems they have caused. Which of the following would be the most appropriate pharmacotherapy for his condition?
The patient is a 28-year-old divorced female who presents in the emergency room complaining of insomnia. Further history reveals that she has been depressed since the divorce settlement 3 months ago. She also has anergia, poor concentration, decreased appetite with a 15-lb weight loss, anhedonia, and guilt surrounding her "failed marriage." She reluctantly admits to pervasive thoughts of killing herself, with a plan to overdose on two bottles of Tylenol as "I heard it can kill you." She has purchased the medicine and written a suicide note. She asks to leave to go home, and when discussion of admission is brought up, she becomes angry and demands to be discharged from the emergency room. The above decision is based on which of the following ethical principles?
A 36-year-old man complains that he cannot sleep at night. "I just can't settle down; my mind is constantly working." He describes being able to complete a lot of work, being highly energized, and having a lot of fun. He is afraid that without sleep he will "crash." Once before, he took a medication for depression. He requests medication at this time. According to the patient's psychiatric symptoms, select the most appropriate medication. Presume no medical problems other than those mentioned. amitriptyline clozapine divalproex fluoxetine hypericum perforatum
One of your long-time patients, a 17-year-old with cystic fibrosis, after experiencing several hospital admissions in respiratory crisis requiring intubation, requests that she not be intubated again in the event of future respiratory crisis. She requests comfort care only. The patient lives with her mother, who is mildly mentally retarded and unable to understand or participate in her daughter's health decisions. Her father is deceased. After numerous discussions over several visits, you assist her in filling out an outpatient DNR form and request a bracelet with DNR instructions. Several weeks later, the young girl is at a friend's house and stops breathing. She is not wearing the DNR bracelet and the friends know nothing of her wishes. The ambulance is called and she is intubated en route to the hospital. You are called to the emergency room where she is being stabilized for transfer to pediatric intensive care unit (PICU). What is the most ethically justified next step in this case?
A 29-year-old woman presents to the primary care clinic complaining of frequent headaches for several months. During the interview she appears tearful and withdrawn, with minimal eye contact and reluctance to answer questions. With further encouragement and support, she is able to describe intense feelings of sadness, along with significant insomnia, poor concentration, fatigue, anhedonia, and little appetite with a 20-lb weight loss It is decided to begin treatment for her depressive symptoms with pharmacotherapy. Regarding the selection of the specific class of medication, a family history of what would be crucial?
The patient is a 28-year-old divorced female who presents in the emergency room complaining of insomnia. Further history reveals that she has been depressed since the divorce settlement 3 months ago. She also has anergia, poor concentration, decreased appetite with a 15-lb weight loss, anhedonia, and guilt surrounding her "failed marriage." She reluctantly admits to pervasive thoughts of killing herself, with a plan to overdose on two bottles of Tylenol as "I heard it can kill you." She has purchased the medicine and written a suicide note. She asks to leave to go home, and when discussion of admission is brought up, she becomes angry and demands to be discharged from the emergency room. What is the next most appropriate course of action?
A 38-year-old married female is brought in to the primary care clinic by her husband. She is minimally responsive to questioning, head bowed, and staring at the floor. Most of the history is obtained from her spouse. He denies any known personal or family history of mental illness, but he claims for the past several months his wife has become increasingly depressed and withdrawn. Instead of taking part in her usual hobbies, she is lying around the house. "She tosses and turns" throughout the night. Her husband ensures that she eats a limited amount of food, but she has lost a significant amount of weight. She has been ruminating about guilty feelings regarding a number of issues and recently has been speaking about suicide, although she has no plan or intent. She has refused to come in to see a doctor. Her husband insisted that she come today, as she informed him that the devil has possessed her and told her she will "go to hell." What is the most effective pharmacologic treatment for this patient?
A74 year-old widowed man presents for evaluation to his physician. He has a history of several episodes of major depression, with one prior hospitalization many years ago although he cannot remember the medication he was prescribed. He complains of 3 months of depression, crying spells, terminal insomnia, poor appetite with weight loss, anhedonia, and passive suicidal ideation without plan. His medical history is significant for hypertension, peripheral vascular disease, hypercholesterolemia, and unstable angina. He is currently prescribed diltiazem, aspirin, metoprolol, and simvastatin. Which of the following antidepressants would be the most appropriate treatment option?
A 65-year-old woman with a history of cardiac problems complains that she has lost her appetite, she cries frequently, and has lost interest in her grandchildren, her gardening, and her craft making. She thinks maybe it is time to die. According to the patient's psychiatric symptoms, select the most appropriate medication. Presume no medical problems other than those mentioned. amitriptyline clozapine divalproex fluoxetine hypericum perforatum
A 50-year-old woman with a long history of taking trifluoperazine is noted to have repetitive chewing motions, and periodically protrudes her tongue. Her arms and shoulders seem to jerk fairly often, and there is a peculiar twisting movement in her right hand. She tried several of the "newer" medications that are not supposed to cause the movement problems, but then her auditory hallucinations started again. According to the patient's psychiatric symptoms, select the most appropriate medication. Presume no medical problems other than those mentioned. amitriptyline clozapine divalproex fluoxetine hypericum perforatum
A 30-year-old married male with a history of depression presents to the family medicine clinic. He appears embarrassed and somewhat anxious during his appointment. He denies significant sadness or crying spells. He is sleeping adequately and eating well, without recent changes in his weight. His energy and concentration are normal, and he denies any suicidal or homicidal ideation. He claims to be compliant with his citalopram (Celexa), which he is taking for his depression, but he complains of "problems with sex." Consideration is given to switching the patient to another antidepressant in order to minimize his side effects. Which of the following would be the most appropriate medication to choose?
A 29-year-old woman presents to the primary care clinic complaining of frequent headaches for several months. During the interview she appears tearful and withdrawn, with minimal eye contact and reluctance to answer questions. With further encouragement and support, she is able to describe intense feelings of sadness, along with significant insomnia, poor concentration, fatigue, anhedonia, and little appetite with a 20-lb weight loss. Before she leaves the office, what is the most important question to ask her?
The patient is a 52-year-old male presenting to the emergency room with complaints of severe leg pain. The patient states he has had ongoing left knee pain of 6 months' duration, unrelieved by NSAIDs but improved with vicodin. He denies any trauma but claims to have arthritis. His vital signs are stable. Physical examination of his knee demonstrates no significant findings except for decreased range of motion but with little effort. There is no swelling, erythema, or signs of trauma. An x-ray is obtained which is read as "normal," without evidence of arthritis. He asks for narcotic analgesics, but when he is offered a trial of NSAIDs and a referral to a specialty clinic, he becomes angry and walks out of the emergency room. Which of the following is the most likely motivation for this patient's presentation?
The patient is an 18-year-old male brought into the emergency room in the early morning by his friends after attending a dance party. He is agitated, pacing the hallway but unsteady. Despite this, he claims that he feels "wonderful" and states, "Everything will be all right." He also seems focused on seeing many colored flashes and hearing "all conversations at once." He has no known medical problems and is not taking any medication. He does admit to ingesting something early on, which he was told would help him "party all night." On physical examination, he has an elevated BP and pulse, dilated pupils, and significant diaphoresis. Which of the following is the most likely pharmacologic effect of the substance taken?
The patient is a 28-year-old female medical student who is referred to the Office of Student Affairs due to receiving an incomplete on her surgery clerkship. Upon questioning, she admits to "sneaking out" of the operating room in order to avoid participating in surgeries. When confronted with her unprofessional behavior and expectations of the rotation, she claims to have significant anxiety revolving around the operating room. She states, "It's not that I mind the surgery itself, just the blood." She proceeds to reveal numerous instances of feeling dizzy, lightheaded, and even fainting when seeing blood. As a result, she has been unable to donate blood while in college or medical school and has, thus far, been able to "work around" drawing blood in other clerkships. Which of the following treatment modalities would be the most effective for this individual?
A 16-year-old girl is brought into the family practice clinic for her yearly health maintenance examination. Her height is average and her weight is above average. When this is mentioned to her, she blushes and quickly states that she is trying to lose weight. When asked further about her dieting habits, she eventually admits to routinely eating large amounts of food at one sitting, such as two pizzas, a large sandwich, and a gallon of ice cream. She also confides that she frequently will self-induce vomiting in order to compensate but denies laxative use. She realizes that her behavior is unhealthy, but she feels "out of control." After discussion of her condition with her parents, it is decided to begin her on psychotropic medication and refer her to an eating disorder program. What class of pharmacotherapy would be the most efficacious in this patient?
A32-year-old female presents to the outpatient clinic with complaints of ongoing headaches. For the past 8 months, she has had recurrent headaches which she describes as bilateral, occipital, with a tight/squeezing pain, lasting for several hours and relieved with nonsteroidal anti-inflammatory medication (NSAIDs). Further questioning reveals chronic feelings of fatigue and poor concentration. She admits to "constantly worrying" about her job performance as well as issues involving her relationship with a live-in boyfriend. In fact, her focusing on these concerns interferes with her sleep. As a result, she has on more than one occasion awakened with extreme panic, tremors, diaphoresis, nausea, and palpitations. Her medical problems include gastroesophageal reflux disease that is treated with famotidine. She drinks an occasional glass of wine and denies drug use. Which of the following medications would be the most appropriate in the long-term treatment of this patient's symptoms?
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]." What is his likelihood of a complete recovery in1 year if not treated?
A 30-year-old married male with a history of depression presents to the family medicine clinic. He appears embarrassed and somewhat anxious during his appointment. He denies significant sadness or crying spells. He is sleeping adequately and eating well, without recent changes in his weight. His energy and concentration are normal, and he denies any suicidal or homicidal ideation. He claims to be compliant with his citalopram (Celexa), which he is taking for his depression, but he complains of "problems with sex." Which of the following symptoms would this patient most likely exhibit?
A 40-year-old male is returning to the office for a follow-up visit. He is told about his blood work results, which are consistent with leukemia. He is informed that he should receive a bone marrow biopsy for further clarification. While being presented with this information, he remains silent, peering, and staring intensely. When finished, he comments, "Doctors think they are so smart!" He then explains that he has been mistreated by physicians in the past and, in fact, has several malpractice suits pending. He feels that the biopsy was recommended only "because you want to use me in order to publish and further your career." Based on the above, what is his most likely diagnosis?