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194) A 23-year-old man is seen in the emergency department for sudden onset, right-sided pleuritic chest pain that developed 30 minutes ago while he was watching television. The patient also complains of difficulty breathing. He has no prior medical history, denies smoking and intravenous drug use, and does not take any medications. His temperature is 37.3°C (99.1°F), blood pressure is 130/82 mm Hg, pulse is 92/ min and regular, respiratory rate is 20/min and shallow, and oxygen saturation is 98% on room air. His body mass index is 18 kg/m². Diminished breath sounds, hyperresonance, and decreased tactile fremitus are prominent in the right lung field. The trachea is midline. X-ray of the chest shows a 10% pneumothorax on the right. Which of the following is the most appropriate initial management?

195) A 57-year-old Caucasian man presents complaining of "feeling overwhelmed by life." He has felt depressed for the past six months, and states that he has difficulty focusing on daily activities. His sleep is poor and he wakes frequently at night. Further inquiry reveals that he is a Vietnam War veteran and that he experiences flashbacks and nightmares about his combat experiences. He notes that the flashbacks began prior to his feelings of depression. He avoids watching war movies and refuses to discuss with anyone his time spent in Vietnam. This is his first visit to a psychiatrist and he asks to be started on some medication. Which of the following should be avoided in this patient?

196) A 58-year-old woman has a history of major depressive disorder that has been in remission for the past ten years. She takes phenelzine daily and sees her psychiatrist every other month. While on vacation, the patient and her husband indulge in a gourmet meal. Afterward, the patient becomes concerned as she believes one of the dishes may have contained aged cheese, which her psychiatrist had warned her about eating. She comes to the emergency department of the local hospital to express her concerns. Which of the following is most appropriate to monitor?

197) While working as the attending pediatrician in the neonatai ICU, you are called by nursing to examine a two-day-old male child who has recently begun vomiting. The child has failed to pass meconium since birth. Physical examination demonstrates significant abdominal distention. A rectal examination reveals no stool in the vault. You strongly suspect Hirschsprung disease and inform the child's mother that an abdominal radiograph and barium enema are necessary. The mother forbids you from proceeding with any further testing or procedures because she does not believe "there is anything wrong." What is the most appropriate next step?

198) A 24-year-old female veterinary assistant is referred to a psychiatrist for the presumptive diagnosis of dysthymia. She reports having a three-year history of low energy levels and gradual worsening in her ability to focus on her work. She feels "sad, hopeless," and experiences little pleasure. She denies any suicidal thoughts. She has never been on any psychotropic medications before, and denies any family history of psychiatric illness. She has gastroesophageal reflux disease, for which she takes omeprazole. She has no known allergies, and does not drink alcohol or smoke cigarettes. The psychiatrist decides to treat her dysthymia with bupropion. Which of the following is a contraindication to the use of bupropion?

199) A 35-year-old woman has chronic auditory hallucinations in which she hears her father's voice. His voice said encouraging things to her in the past, but it has recently been scolding her and saying derogatory things about her. The woman is started on risperidone, and she returns two weeks later for a follow-up visit. Although she states that the hallucinations are much better, you notice that she is walking much slower than usual and is not swinging her arms. Also, the patient's facial expressions are rather flat and unchanging, and she admits that her writing has become smaller since starting the medication. Which of the following pharmacologic changes would be most appropriate?

200) A 29-year-old gravida 1, para 0 Caucasian female with a history of bipolar disorder presents at eight weeks of gestation for prenatal counseling. She has been taking a stable dose of lithium for the past year. Her last depressive episode was 16 months ago. Her family history is significant for bipolar disorder in her mother, which was successfully controlled with lithium. She does not smoke cigarettes or consume alcohol. She asks whether her baby will have any congenital abnormalities. Which of the following complications is her fetus at increased risk for?

201) A 22-year-old woman is brought to the emergency department by her father because she is demonstrating "strange, disorganized behavior." Earlier that day, she had insisted that the television news anchorman was talking directly to her about the risks of "poison rays" from the moon. She was also apparently attempting to re-organize her bedroom closet when her father found her mumbling incoherently and counting the same pair of socks over and over. She is agitated when examined in the emergency department and the decision is made to admit her to the psychiatric ward. There, after a detailed interview, the diagnosis of schizophrenia is made. She is stabilized with antipsychotics and then discharged home. Her father asks what can be done to ease her return to everyday life and to decrease the likelihood of re-hospitalization. Which of the following measures would be most helpful in this regard?

202) A middle-aged Asian American married couple comes to clinic for a routine examination. Both the husband and wife have been known patients of yours for many years. The husband is being treated for coronary artery disease and tension headaches. Today, he mentions that he "cannot get an erection" even when he feels sexual desire. He adds that he still finds his wife physically attractive and that they are mutually compatible in every respect. This recent development has been causing him significant anxiety and has been a source of concern for his wife. After ruling out medical and psychological causes for his erectile dysfunction by taking a detailed history and pursuing a thorough workup, you agree to his request that he be started on sildenafil. One week later, his wife places an urgent call to your office, reporting that her husband developed severe chest pain "after taking the new medication you prescribed." An EKG done in the emergency department reveals new inferior wall ischemia. You immediately realize that you should not have written him the prescription for sildenafil because he was already using a nitroglycerin patch for his coronary artery disease. What is the most appropriate next step?

203) A 38-year-old male with a chronic history of schizophrenia is admitted to the hospital for deterioration in his condition. He is a known patient and was stable on risperidone for the past few years. Today, the patient does not respond when spoken to and he sits motionlessly. He makes no eye contact and his face remains expressionless. Vital signs include temperature of 37.0°C (98.6°F), blood pressure of 132/80 mm Hg, pulse of 88/min, and respirations of 14/min. Physical examination demonstrates diffuse muscle rigidity but is otherwise unremarkable. Which of the following would be the most appropriate next step?

204) A 7-year-old boy is brought to the pediatrician by his mother for a routine check-up. Physical examination is normal, but during the exam the mother reveals that her son's behavior has been poor. She says that he is always running around (even during dinner), doesn't listen, and keeps his room a mess. She hopes he will grow out of this soon. Upon further questioning, the pediatrician learns that the patient's second-grade teacher has reported that he answers questions impulsively and out of turn, and that he cannot sit at his desk for a very long time without fidgeting. He also frequently forgets to bring in his homework. The mother states that her son has had these symptoms for about a year, and that his grades have been falling over the past six months. The diagnosis of attention deficit hyperactivity disorder is made and the boy is started on methylphenidate. Which of the following side effects is most likely to occur in patients who take methylphenidate?

205) A 16-year-old boy presents to his pediatrician with scattered petechiae and a three-week history of fatigue. Laboratory evaluation and a bone marrow biopsy confirm the diagnosis of acute lymphoblastic leukemia. The boy's parents are divorced and have joint custody of him. His mother consents to the proposed chemotherapy and blood transfusion and requests that his treatment be started immediately. The father, however, refuses to agree to the treatment because of his religious beliefs. What is the most appropriate means of handling this situation?

206) A middle-aged married couple brings their 10-year-old daughter to the pediatrician because "she just is too tired to play nowadays and sleeps all the time." The parents say that their daughter is winded with minimal exertion. Further inquiry reveals that for the past two weeks, the girl has had bleeding gums when she brushes her teeth. Physical examination demonstrates pallor and hepatosplenomegaly. An extensive workup indicates that the girl is suffering from acute lymphoblastic leukemia, and her parents are informed that chemotherapy will be necessary. The parents firmly refuse to comply with this treatment plan, however, because they are convinced that the side effects will be too severe. Despite a lengthy discussion about the benefits of treatment and the likely consequences for their daughter if therapy is withheld, the girl’s parents insist upon taking her home. What is the most appropriate next step?

207) A 72-year-old man presents for a follow-up visit regarding his depressed mood after his wife's death seven months ago. The patient complains of lethargy and episodes of tearfulness. He has attended three sessions of supportive psychotherapy so far and expresses appreciation for the referral because he likes the therapist. However, he continues to feel depressed and is now experiencing insomnia. He is also feeling very guilty about his wife's death and feels that he should have somehow done more for her in her final months. He admits that during a particularly dark moment last month he briefly contemplated committing suicide so that he could "join her," although he is adamant that he does not feel suicidal at this time and will readily contract for safety. Physical examination reveals the patient has lost 13 lbs (5.9 kg) since his wife's death. What is the most appropriate next step?

208) A 60-year-old Caucasian man presents to his family physician complaining of weight loss and fatigue. A review of systems is positive for a change in bowel habits. He says that in the past several weeks, he has developed pencil-thin stools. Further evaluation reveals the presence of colon carcinoma. The patient is told the diagnosis, and his treatment options and prognosis are discussed. He refuses any treatment and says he wants to die peacefully at home without any medical intervention. What would be the most appropriate means of handling the situation?

209) A 20-year-old female college student is brought to the emergency department by police at 2:30 am after she was caught attempting to enter the White House. She is highly agitated and is pacing around the examination room. Upon further questioning, she states that she just flew in from Texas to meet with the president because she has a "foolproof plan for eliminating terrorism worldwide in just seven days." She adds that she has barely slept for the past ten nights because she has been working intensively on this plan. She speaks very quickly, but periodically stops to angrily shout, "I'm going to sue all of you for interfering with my right to meet with the president." The evaluation has to be stopped because she demands that she be allowed to leave. Family history is significant for major depression in her mother. Vital signs are temperature 37.0°C (98.6°F), blood pressure 148/84 mmHg, pulse 98/min, and respiratory rate 22/min. Which of the following medications should be administered to this patient immediately?

210) A 52-year-old obese male presents with complaints of episodes of daytime sleepiness that prove irresistible. He reports feeling very refreshed and energized upon awakening from these "naps." A detailed history reveals he also frequently experiences a complete loss of muscle tone, especially when he laughs suddenly or feels a surge of intense emotion. Of particular concern to this patient is that he occasionally finds himself unable to move upon waking, and says he feels temporarily "frozen." His previous diagnoses include gout and external hemorrhoids. His family history is noncontributory. He does not smoke cigarettes or drink alcohol and denies recreational drug use. Physical examination reveals no abnormalities. Which of the following is the most appropriate treatment for this patient?

211) A 28-year-old woman is brought to the emergency department by her sister after she experiences a generalized tonic-clonic seizure. The patient appears confused and is unable to answer any questions. The sister says the patient has never had a seizure before. The patient's medical history is unremarkable except for a long history of panic disorder for which she has been taking high doses of "some medication." The sister adds that the patient missed a few doses recently because they were staying at a friend's house, but she is sure that the patient was otherwise regular in taking her medication. Which of the following medications was the patient most likely taking?

212) A 27-year-old man is brought to his primary care physician by his wife because he has not been himself for the past ten days. His wife says that her formerly reserved, quiet husband has been staying up all night lately gambling their savings away while playing poker with friends that he recently met. He is also not concerned about having missed work for the past week. When asked about this recent change in behavior, the man smiles and replies proudly that he no longer needs to work because he has invested a large sum of money in a company that will soon make him rich. He speaks very quickly and it is difficult for him to focus his attention at times. Which one of the following medications would be most appropriate in the treatment of this patient?

213) A 27-year-old man presents to his primary care physician complaining of feelings of inadequacy and hopelessness. In a quavering voice, he reports that he gets "extremely anxious" when he has to speak before a group of people at business meetings or other social events. He is unable to "just relax," even at small parties with friends or family, and he isolates himself as a result. He feels his social seclusion is limiting his career advancement, which bothers him greatly. Which of the following treatment combinations would be the most appropriate choice for this patient?

214) A 33-year-old businessman with an unremarkable past medical history presents to you complaining of fatigue and some weight loss over the past three months. He awakens at 4:00 am each morning and is unable to fall back asleep. He also mentions that he used to enjoy playing golf twice per week, but now has little interest. Although he used to excel at work, he now finds himself losing interest and "spacing out" at times. He denies considering suicide. His TSH is normal. He is diagnosed with major depression and prescribed fluoxetine, and is asked to return for a follow-up appointment in two weeks. At the return visit, he states that his symptoms have not worsened, but have not improved either. He says, "I don't feel like the medication is doing anything." What is the most appropriate next step in the management of this patient's condition?

215) A 22-year-old woman presents to the emergency department in an agitated state, certain that she is "about to die." Fifteen minutes ago, she developed heart palpitations and a severe "viselike" tightness in her chest. She experienced a similar episode last week, which resolved in twenty minutes. She denies using any drugs and her medical history is unremarkable. Her father has a history of heart disease and her mother has diabetes mellitus. She takes no medications. Vital signs are temperature 37.0°C (98.6°F), blood pressure 132/74 mmHg, pulse 118/min, and respiratory rate 30/min. She is sweating profusely. EKG reveals sinus tachycardia. The most appropriate next step is administration of which of the following?

216) As the on-call surgery resident, you are paged to see a patient on the ward who is having seizures. The patient is a 35-year-old male who underwent a cholecystectomy yesterday. His surgery was uneventful and the man appeared to be doing well until an hour ago when he developed altered sensorium. Upon arriving on the floor, you discover the patient to be confused and agitated. His vital signs include a temperature of 38°C (100.4°F), blood pressure of 134/86 mm Hg, pulse of 110/min, and respirations of 18/min. The man is diaphoretic and has tremors. His wound incisions show no evidence of inflammation, and biliary drainage appears adequate. A review of his medical record indicates his medical history to be unremarkable except for mild esophagitis. He smokes a pack of cigarettes per day and drinks 6-10 beers per night. His medications include folic acid, thiamine, and omepra zole. Laboratory results include the following: CBC: Hb 14.1 g/dL, Leukocyte count 7,100/cmm. Serum Chemistry: Sodium 137 mEq/L, Potassium 4.0 mEq/L, Chloride 101 mEq/L, Bicarbonates 24 mEq/L, BUN 12 mg/dL, Creatinine 1.0 mg/dL, Glucose 104 mg/dL. Arterial Blood Gas: PH 7.40, PO2 94 mm Hg, PCO2 40 mm Hg. Which of the following should be initiated immediately in this patient?

217) A 35-year-old Caucasian male with a chronic history of paranoid schizophrenia presents to the mental health clinic. He strongly believes that his wife recently stole his pill bottle of risperidone, which he feels caused him to start experiencing more frequent and intense auditory hallucinations. He says that the "voices" tell him to kill his wife because she cannot be trusted. He admits to having homicidal thoughts about his wife but denies any specific plan for harming her. He requests a refill of his risperidone. What is the most appropriate next step?

218) A 37-year-old obese man returns to his doctor for a follow-up visit. One month ago, he was diagnosed with type II diabetes mellitus and was started on metformin. His fasting glucose is 122 mg/dl, and his blood pressure is 145/85 mm Hg. The patient looks rather dejected and admits it has been difficult to come to terms with his diagnosis. He has tried to exercise, watch his diet, and quit smoking as was suggested, but lately he has been feeling unmotivated and without energy. He admits to feeling sad and guilty about his weight, but is not sure he will be able to do anything about it. He continues to smoke despite attempts to cut back, and has been spending much of the day in bed watching television or sleeping. He has withdrawn from friends and family and took the last two weeks off from work, as he did not feel "up to going." Which of the following would be the best medication to prescribe at this time?

219) A 28-year-old attorney presents complaining of a six-month history of extreme nervousness, irritability, and restlessness. He is "plagued" by recurrent thoughts of not being able to properly carry out his responsibilities at the office. He dreads the possibility of not being offered a position as partner in the law firm. As a result, he finds himself unable to concentrate well or perform his duties efficiently. He is also engaged to be married, and spends sleepless nights thinking about the responsibilities of married life. He worries that he will not be a good husband or father. He denies any history of alcohol intake, but has recently begun drinking two bottles of beer every night for the past month as a means of escaping from his distressing thoughts. Which of the following is the treatment of choice for this patient?

220) A 16-year-old female presents to her pediatrician's office for a routine examination. She is wearing a sweater despite the warm weather, and admits she often feels cold. She states that she has otherwise been feeling fine, except for having difficulty losing weight. She wants to lose about 10 lbs (4.5 kg) because she believes she is "too fat." She has been on a strict diet and exercises two hours daily. She is also requesting a pregnancy test because she has not had a menstrual period for the past three months. Past medical history is significant for a supracondylar fracture of her right humerus at the age of seven. She is alert, cooperative, and in no apparent distress. Vital signs are temperature 36.2°C (97.2°F), blood pressure 88/58 mmHg, pulse 56/min, and respiratory rate 16/min. Her height is 5'5" (165 cm) and weight is 90 lbs (40.9 kg). What is the most appropriate next step in the management of her symptoms?

221) A 21-year-old male is admitted to the intensive care unit after attempting to commit suicide by overdosing on some pills he found in the medicine cabinet at home. A psychiatry consult is ordered. While interviewing the patient, the psychiatrist observes that the patient has a "blank" expression on his face and is minimally responsive. He refuses to make eye contact and speaks in monosyllables. An attempt is made to obtain a more detailed history from the patient's father. He describes his son as very aloof, having avoided the other children in the neighborhood and participated in few activities as a child. His son dropped out of school in ninth grade and has not been able to maintain jobs throughout the years because of his social difficulties. He adds that his son has been increasingly isolated this past year and that he has complained his deceased mother frequently asks him to "join her in heaven." Which of the following medications would provide the greatest benefit to this patient?

222) A 26-year-old graduate student presents at her husband's urging, complaining of severe pain during sexual intercourse. She says that she was a virgin when she married her husband two years ago, and that she has been experiencing severe "genital pain" during sex since then. As a result, she avoids sexual intimacy with her husband, which is placing a strain upon their marriage. She also complains of intense pain with her menses and when passing stool. She admits to sporadic pelvic pain that waxes and wanes with no discernible trigger. What would be the most appropriate treatment given this woman's condition?

223) A 28-year-old male presents for a follow-up visit regarding his bipolar disorder, which has been managed with valproic acid for several years. He is accompanied by his mother who is very concerned because her son has been behaving strangely for the past two weeks, saying that he can hear the voice of his long-deceased father telling him to "come to me." The patient insists that he is able to ignore his father's voice and that he is not considering suicide at this time. The decision is made to start risperidone to treat the auditory hallucinations. This medication predominantly produces its antipsychotic effect by blocking which of the following receptors?

224) A 59-year-old man well known to his primary care physician presents complaining of excessive fatigue during the daytime. He is accompanied by his wife, who says that he wakes frequently during the night and snores loudly. She worries because sometimes it sounds like he is gasping for breath at night. The only finding on physical examination is morbid obesity. The diagnosis of obstructive sleep apnea is made. Which of the following is not true about this disorder?

225) A 19-year-old college student presents for a first visit because she is concerned about her "abnormal behavior." She says that she worries excessively about her door being locked and that she wakes several times throughout the night to confirm that the door is properly locked. She finds these thoughts distressing. Although she agrees that her fears are not rational, she feels unable to stop from acting on them. This frequent waking grossly impairs her sleep and as a result, she is finding it increasingly difficult to perform well academically. She has no history of psychiatric conditions, but her mother was recently diagnosed with trichotillomania. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 118/84rnrnHg, pulse of 76/min, and respirations of 12/min. Physical examination is unremarkable. Which of the following medications would be the most appropriate treatment for her condition?

226) A 68-year-old woman with a history of well-managed sick sinus syndrome and osteoporosis is brought to the physician by her daughter. According to the daughter, her mother has become increasingly forgetful and irritable over the past two years. She adds that she felt less concerned about her mother's forgetfulness as "it just comes with aging," but that the "mood swings have become a problem in terms of her getting along with family members." A Folstein Mini-Mental Status Examination is performed and suggests significant cognitive decline. Dementia is strongly suspected. After potentially causative medical or psychiatric conditions have been ruled out, the diagnosis of Alzheimer's dementia is made. Which of the following medications would be most appropriate in the treatment of this woman's condition?

227) A 34-year-old male calls his primary care physician's office, requesting an urgent appointment to discuss a personal problem. The receptionist informs him that the physician is preparing to leave as it is near closing time, but that an appointment is available for early the next morning. The patient declines the offer of an appointment and hangs up. Fifteen minutes later, as the physician is locking the office up, the patient arrives and insists on being seen immediately. He breathlessly says that he has "some kind of red rash" on his penis, which has him very worried. He asks again to be examined now. What is the most appropriate response?

228) A 19-year-old known patient with bipolar disorder presents to her psychiatrist for a follow-up visit. She experienced her first manic episode three years ago and was then immediately placed on lithium. She has had no relapses and remains asymptomatic. Today she inquires about the possibility of discontinuing her medication. Her mother is apprehensive, however, about the prospect and asks the psychiatrist to continue the medication for a longer period. Which of the following is the most appropriate management of this patient's condition?

229) A fourth-year medical student develops a new onset headache that he describes as "excruciating." He denies any fever or vomiting. He requests the emergency department physician to order a CT scan of his head, as he is certain that he has developed an intracranial hemorrhage. A complete workup, including an ophthalmologic evaluation, is negative. In spite of reassurance from the physician, the student continues to be excessively worried and is unable to focus on his studies due to persistent thoughts about having a "brain bleed." Which of these would be the most effective step in resolving this patient's symptoms?

230) A 44-year-old woman presents for a follow-up visit regarding her severe depression. She has taken numerous antidepressants over the years with little symptomatic relief, and continues to spend the majority of her time in seclusion, experiencing intense feelings of worthlessness and despair. Her husband is deeply concerned about the impact her depression has had on their marriage and their two teenage children. He requests information about "all available options" to improve his wife's symptoms. The prospect of electroconvulsive therapy (ECT) is discussed, and the husband inquires about potential drawbacks to the procedure. Which of the following is a common side effect of electroconvulsive therapy?

231) A 42-year-old Caucasian man presents to the emergency department complaining of a two-day history of fever to 40°C (104°F), headache, and vomiting. Physical examination reveals petechiae and purpura on his trunk and lower extremities. Examination of his cerebrospinal fluid is consistent with bacterial meningitis. The patient is told of his diagnosis and the need for antibiotics and hospitalization is discussed. The patient refuses to be admitted to the hospital, however, and insists upon being treated at home. What is the most appropriate next step?

232) A 28-year-old married nurse who works with you in clinic comes to you privately, saying that she "missed a period" this month. An over-the-counter urine pregnancy test confirms that she is pregnant. The first-trimester laboratory testing is performed, and she is found also to be HIV-positive. When you reveal the news of her HIV status to her, she is devastated. She hesitantly reveals that she had unprotected sexual intercourse with a former boyfriend several months ago. You explain that her husband's HIV status must be evaluated. Upon hearing this, the nurse is horrified and says. "No, I cannot tell him about this. He would never forgive me!" What is the most appropriate next step?

233) You are seeing a 41-year-old woman and her 19-year-old daughter in the emergency room because they think that they have been poisoned. The woman states that they have not been getting along with their landlord lately because they have been late on their last few rent payments. They say that the landlord is harassing them by banging on their floor at all hours of the night, turning down their heat, and asking the other tenants to spy on them. Last month, the woman thinks the landlord tried to spy on them by installing video cameras in her living room while they were out. Today, she tasted something odd in her food, and is convinced that she and her daughter have been poisoned in an attempt to get them out of the apartment once and for all. She came immediately to the hospital for treatment and to collect evidence of the poisoning. The mother is very protective of her daughter, who seems rather submissive and passive. She completely agrees with her mother's description of the events. Which of the following is the best course of action?

234) A 24-year-old man with chronic schizophrenia is brought to the emergency room after his parents found him in his bed and were unable to communicate with him. On examination, the man is confused and disoriented. He has severe muscle rigidity and a temperature of 39.4°C (103°F). His blood pressure is elevated, and he has a leucocytosis. Which of the following is the best first step in the pharmacologic treatment of this man?

235) A 30-year-old man is brought to the emergency room after he was found wandering on the streets with no shoes on in the middle of winter. He is admitted to the inpatient psychiatric unit and stabilized on antipsychotic medication. Looking at past records, his psychiatrist notes that he is repeatedly noncompliant with his medication postdischarge, and each time he relapses within 6 months. Which of the following medications is the best one for this patient to be maintained on?

236) A 23-year-old woman was diagnosed with schizophrenia after a single episode of psychosis (hallucinations and delusions) that lasted 7 months. She was started on a small dose of olanzapine at the time of diagnosis, which resulted in the disappearance of all her psychotic symptoms. She has now been symptom free for the past 3 years. Which of the following treatment changes should be made first?

237) A 28-year-old woman is diagnosed with bipolar disorder, manic type, when she was hospitalized after becoming psychotic, hypersexual, severely agitated, and unable to sleep. She is started on a medication in the acute phase of her illness. Which of the following medications, recommended for acute use in manic patients, is recommended to be continued on into maintenance therapy?

238) A 30-year-old man comes to the psychiatrist for the evaluation of a depressed mood. He states that at least since his mid-20s he has felt depressed. He notes poor self-esteem and low energy, and feels hopeless about his situation, though he denies suicidal ideation. He states he does not use drugs or alcohol, and has no medical problems. His last physical examination by his physician 1 month ago was entirely normal. Which of the following treatment options should be tried first?

239) A 22-year-old college student calls his psychiatrist because for the past week, after cramming hard for finals, his thoughts have been racing and he is irritable. The psychiatrist notes that the patient’s speech is pressured as well. The patient has been stable for the past 6 months on 500 mg of valproate twice a day. Which of the following is the most appropriate first step in the management of this patient’s symptoms?

240) A 38-year-old woman with bipolar disorder has been stable on lithium for the past 2 years. She comes to her psychiatrist’s office in tears after a 2-week history of a depressed mood, poor concentration, loss of appetite, and passive suicidal ideation. Which of the following is the most appropriate next step in the management of this patient?

241) A 42-year-old woman sees her physician because she has been depressed for the past 4 months. She also notes that she has gained 20 lb without trying to. She notes that she does not take pleasure in the activities that she once enjoyed and seems fatigued most of the time. These symptoms have caused the patient to withdraw from many of the social functions that she once enjoyed. The physician diagnoses the patient with hypothyroidism and starts her on thyroid supplementation. Six weeks later, the patient’s thyroid hormone levels have normalized, but she still reports feeling depressed. Which of the following is the most appropriate next step in the management of this patient?

242) A 54-year-old man sees a physician complaining of a depressed mood and inability to sleep for the past 3 weeks. He tells the physician that in the past when he has had similar episodes, he was placed on a monoamine oxidase inhibitor, which proved effective. The physician diagnoses the patient with major depression and agrees to use an MAOI. Which of the following foods must be completely avoided by this patient while on this medication?

243) A 10-year-old boy is brought to the psychiatrist by his mother. She states that for the past 2 months he has been increasingly irritable, withdrawn, and apathetic. He has been refusing to do his homework, and his grades have dropped. Which of the following is the best next step in management?

244) A 35-year-old woman is seeing a psychiatrist for treatment of her major depression. After 4 weeks on fluoxetine at 40 mg/day, her psychiatrist decides to try augmentation. Which of the following is the most appropriate medication?

245) While working as the medical resident on call, you are paged to see a 72-year-old woman who complains of a headache. Upon seeing you, she snaps, "You look young and foolish. I hope you're more efficient than you seem." While you are performing a basic physical examination on her, she says, "I'm going to complain to the hospital administrators about you because you have no idea how to properly deal with a patient." Which of the following is the best response to her threat?

246) A colleague who works as a pediatrician in your group practice comes to your office to inquire about a patient you examined earlier this morning. The colleague says that he recognized the patient as a former neighbor of his who is also a good friend of the family. The patient was recently diagnosed as HIV-positive and is now on antiretroviral medication. Your colleague asks what the patient is being treated for. What is the most appropriate response to such an inquiry?

247) A 35-year-old female presents to your office complaining of knee pain. She has a long history of rheumatoid arthritis affecting her hand and knee joints. The stiffness and pain has persisted over the last several months and has responded poorly to NSAIDs. Over the last two days the pain in her right knee has been interfering with her sleep. She had an episode of chills this morning. Her blood pressure is 120/70 mmHg, pulse is 90/min, temperature is 38.7°C (102°F) and respiratory rate is 18/min. Physical examination reveals swelling in the joints of her hand and wrist. The right knee is red and swollen; active and passive range of motion at the right knee is limited due to pain. This patient's current condition can be best treated with which of the following?

248) A 68-year-old African-American woman presents to the ER in acute distress. She complains of a sudden onset of complete visual loss in her right eye. Her vision had been blurry for the past few days and acutely worsened one hour ago. She also describes right-sided headaches of two months duration for which she has taken ibuprofen without relief. She has no nausea or vomiting. She has diabetes, hypertension, and degenerative joint disease. Her temperature is 37.2°C (98.9°F) and blood pressure is 146/86 mmHg. Examination reveals complete loss of vision in the right eye. Her pupils are 4 mm bilaterally. Fundoscopy shows a swollen pale disc with blurred margins. A bruit is heard in the right subclavicular area. Motor and sensory examination is within normal limits. Which of the following is the most appropriate next step in management?

249) A 45-year-old woman presents to your office complaining of one week of fatigue and weakness in her shoulders and hips. She reports difficulty performing household tasks, climbing the stairs, or rising from a chair. She denies any facial weakness or blurry vision. She has a history of gastroesophageal reflux disease and takes over the counter ranitidine. Her family history is positive for breast cancer in her mother. Her vital signs are within normal limits and examination shows normal sensation and deep tendon reflexes. Strength is 4 out of 5 in the proximal muscles groups of the arms and legs, and there is no limitation in the range of motion. Other physical examination is within normal limits. The ESR is 80 mm/hour and her serum creatine kinase is elevated. The TSH is within normal limits. Which of the following is the best initial treatment for this patient?

250) A 55-year-old man presents to his physician with 6 months of mild intermittent pain in both knees. The pain is aggravated by walking and weight bearing, and is partially relieved by rest. He also complains of morning stiffness that lasts for 10 minutes. He does not smoke but drinks alcohol occasionally. His BMI is 25 Kg/m2, temperature is 37°C (98.6°F), pulse is 75/min, and blood pressure is 130/80 mmHg. Examination reveals crepitus over both knee joints. Which of the following is the most appropriate initial treatment for this patient?

251) A 38-year-old woman complains of chronic aching pain and stiffness around the neck, shoulders, low back and hips. She fatigues easily and has been having problems with sleep. Even minor exertion worsens her pain. She has no muscle weakness, fever, malaise, weight loss or rash. She has a history of irritable bowel syndrome. Her vital signs are within normal limits. Examination shows multiple tender spots over specific points on her body. Power is 5/5 in all extremities and deep tendon reflexes are 2+. No sensory abnormalities are noted. Labs show: ESR 9 mm/hr, Hematocrit 43%, WBC count 7,000/microL, Platelet count 200,000/microL, TSH 3 microU/L, CPK 100 IU/L. Which of the following is the most appropriate pharmacotherapy for this patient?

252) A 35-year-old man presents to your office with severe back pain. The pain started three days ago when the patient was carrying a heavy pack. The pain radiates to the posterior surface of the right thigh. The straightleg raise test is positive. There is no bladder or bowel incontinence. Pain and temperature perception is preserved in the affected extremity, as well as in the perineal area. Anal reflex is normal. Which of the following is the best next step in the management of this patient?

253) A 31-year-old Caucasian male complains of joint pains. He describes right knee pain, right heel pain and lowback pain. He was recently treated for urethral discharge at an outside clinic. He has no history of trauma or illicit drug use. He is afebrile, and his vital signs are stable. His right knee is swollen, tender and warm to touch; tenderness is also present over the Achilles tendon. Oral examination shows mouth ulcers. Synovial fluid analysis from the right knee shows a white blood cell count of 10,000/mm3 with many polymorphonuclear leukocytes but a negative Gram stain. Which of the following is the most appropriate initial pharmacotherapy for this patient?

254) A 70-year-old male presents with malaise, pain and stiffness of his neck, shoulders and hips for the last 3 months. His stiffness is worse in the morning and lasts about 30-40 minutes. He also complains of a recent weight loss of 7 1bs and mild fevers. He has no headache, scalp tenderness, visual symptoms or jaw claudication. Examination shows no swelling or tenderness of the involved joints with normal range of motion on active and passive movement. The arteries of the scalp, neck and extremities are normally palpable without any tenderness. Labs show a hematocrit of 31% and an ESR of 65 mm/hr. Blood cultures are negative. Which of the following is the most appropriate next step in management of this patient?

255) A 43-year-old construction worker presents to your office 2 weeks after an episode of acute back pain. The pain started after lifting a heavy box, was localized to the lower back with little radiation to the buttocks, and quickly responded to conservative treatment. His past medical history is insignificant. He smokes 2 packs a day and consumes alcohol occasionally. He is concerned about the possibility of recurrence of the pain. Which of the following would be most helpful in preventing another episode of back pain in this patient?

256) A 54-year-old woman comes to the physician's office complaining of chronic, bilateral knee and hip pain. The pain increases with activity and is relieved by rest. She denies fever, chills or weight loss. The review of systems is unremarkable. She currently weighs 80 kg (180 lb) and is 146 cm (59 in) tall. Her knee joints are tender but there is no warmth, erythema or effusion. X-rays show narrow joint space, subchondral bone cysts, and bony spurs in both knees. Which of the following interventions would provide the greatest long-term benefit to this patient?

257) A 45-year-old man complains of sudden pain and swelling in his left first metatarsophalangeal joint. He is undergoing high dose induction chemotherapy for acute leukemia. Joint fluid aspiration reveals negative birefringent crystals and elevated white cell count. Which of the following prophylactic measures would most likely have prevented this condition?

258) A 30-year-old Caucasian female patient is seen at the rheumatology clinic. She has a 4-year history of rheumatoid arthritis. Over the past year, she has noticed an improvement in her symptoms. Examination of her joints reveals less swelling and erythema than on the previous visit Laboratory studies show: CBC: Hb 10.8 g/dL, Ht 32%, MCV 104 fl, Platelet count 226,000/cmm, Leukocyte count 7,500/cmm, Neutrophils 65%, Eosinophils 1%, Lymphocytes 28%, Monocytes 6%. Serum: Serum Na 140 mEq/L, Serum K 3.9 mEq/L, Chloride 100 mEq/L, Bicarbonate 18 mEq/L, BUN 16 mg/dL, Serum Creatinine 1.1 mg/dL, Calcium 9.8 mg/dL, Blood Glucose 98 mg/dL. Which of the following medications is this patient most likely taking?

259) A 46-year-old woman suffering from systemic lupus erythematosus (SLE) develops hematuria and proteinuria. She was diagnosed with SLE four years ago and has been treated with hydroxychloroquine. A renal biopsy is performed and shows diffuse proliferative glomerulonephritis. She is started on cyclophosphamide and prednisone and hydroxychloroquine is stopped. She continues these two medications for several weeks because of the low therapeutic response. This new therapeutic regimen puts her at an increased risk for which of the following conditions?

260) A 35-year-old white female presents with pain and stiffness of her wrist and hand joints for the last several months. Her morning stiffness lasts for more than an hour. She also complains of redness and joint swelling. Her past medical history is significant only for a similar episode one year ago. That episode resolved with over the counter ibuprofen. Examination of her joints shows redness, warmth, swelling and tenderness of proximal interphalangeal joints, metacarpophalangeal joints and wrists. X-ray shows periarticular osteopenia and erosions of the proximal interphalangeal and metacarpophalangeal joints. She started taking indomethacin with good relief. Which of the following is the most appropriate next step in the management of this patient?

261) A 40-year-old man complains of exquisite pain and tenderness in the left ankle. There is no history of trauma. The patient is taking hydrochlorothiazide for hypertension. On examination, the ankle is very swollen and tender. There are no other physical examination abnormalities. Which of the following is the best next step in management?

262) A 48-year-old woman complains of joint pain and morning stiffness for 4 months. Examination reveals swelling of the wrists and MCPs as well as tenderness and joint effusion in both knees. The rheumatoid factor is positive, antibodies to cyclic citrullinated protein are present, and subcutaneous nodules are noted on the extensor surfaces of the forearm. Which of the following statements is correct?

263) A 60-year-old man complains of pain in both knees coming on gradually over the past 2 years. The pain is relieved by rest and worsened by movement. The patient is 5ft 9 in. Tall and weighs 210 lb. There is bony enlargement of the knees with mild warmth and small effusions. Crepitation is noted on motion of the knee joint bilaterally. There are no other findings except for bony enlargement at the distal interphalangeal joint. Which of the following is the best way to prevent disease progression?

264) A 20-year-old woman has developed low-grade fever, a malar rash, and arthralgias of the hands over several months. High titers of anti-DNA antibodies are noted, and complement levels are low. The patient’s white blood cell count is 3000/µL, and platelet count is 90,000/µL. The patient is on no medications and has no signs of active infection. Which of the following statements is correct?

265) A 75-year-old man complains of headache. On one occasion he transiently lost vision in his right eye. He also complains of aching in the shoulders and neck. There are no focal neurologic findings. Carotid pulses are normal without bruits. Laboratory data show a mild anemia. Erythrocyte sedimentation rate (ESR) is 85. Which of the following is the best approach to management?

266) A 55-year-old man with psoriasis has been troubled by long-standing destructive arthritis involving the hands, wrists, shoulders, knees, and ankles. Hand films demonstrate pencil-in-cup deformities. He has been treated with naproxen 500 mg bid, sulfasalazine 1 g bid, prednisone 5 mg qd, and methotrexate 17.5 mg once a week without substantive improvement. Which of the following treatments is most likely to provide long-term benefit?

267) A 35-year-old woman complains of aching all over. She says she sleeps poorly and all her muscles and joints hurt. Her symptoms have progressed over several years. She reports she is desperate because pain and weakness often cause her to drop things. Physical examination shows multiple points of tenderness over the neck, shoulders, elbows, and wrists. There is no joint swelling or deformity. A complete blood count and erythrocyte sedimentation rate are normal. Rheumatoid factor is negative. Which of the following is the best therapeutic option in this patient?

1) A 32-year-old Caucasian female comes to the physician because of a one-week history of fatigue, progressive worsening of shortness of breath and swelling of feet. She denies any chest pain. She has no other medical problems except a recent cold two weeks ago. She is not taking any medication. Her temperature is 36.7°C (98°F), blood pressure is 110/65 mmHg, pulse is 90/min, and respirations are 20/min. Bilateral basal crackles, elevated jugular venous pressure, and 2+ bilateral pitting edema of the ankles are noted. Complete blood count is unremarkable. Transthoracic echocardiogram of her heat will most likely show?

2) A 35-year-old Caucasian male is being evaluated for poor exercise tolerance and muscle weakness. He has no past medical history. His blood pressure ranges from 175-185 mmHg systolic and 105-115 mmHg diastolic on repeat measurement. His heat rate is 78-95/min His serum chemistry is significant for blood glucose of 95 mg/dL serum creatinine of 0.7mg/dL serum Na of 146 mEq/L and serum K of 2.4 mEq/L. CT scan of the abdomen reveals a 3 cm mass in the left adrenal gland. Which of the following additional findings would you expect in this patient? ( Plasma renin activity, Serum aldosterone, Serum bicarbonate

4) A 20-year-old female presents to your office for a routine. She has no complaints and her past medical history is insignificant. She is not taking any medications and denies drug abuse. Her blood pressure is 125/65 mmHg and heat rate is 80/min. Cardiac auscultation reveals early diastolic murmur at the left sternal border. What is the next best step in the management of this patient?

5) A 68-year-old man is brought to the emergency room after he passed out for one minute during an early morning jog. He was not confused after the episode and did not have bowel or bladder incontinence. He has been having exertional chest pain and shortness of breath for the past few months. He has never had any resting chest pain. He has been healthy except for hypertension, for which he takes hydrochlorothiazide. He has a 20 pack year smoking history and occasionally drinks a glass of wine. His blood pressure is 142/90 mm Hg, pulse is 80/min, and respirations are 16/min. Carotid pulse is delayed S2 is weak and an S4 is present. A grade 3/6 systolic ejection murmur is in the right 2nd intercostal space, radiating to the carotids. Neurological examination reveals no focal findings, and there are no signs of head trauma. An EKG shows left ventricular hypertrophy. The first set of cardiac enzymes is negative. Which of the following is the most appropriate next step in management?

6) A 61-year-old woman with a history of diabetes and hypertension is brought to the ED by her daughter. The patient states that she started feeling short of breath approximately 12 hours ago and then noticed a tingling sensation in the middle of her chest and became diaphoretic. An ECG reveals ST depression in leads II, III, and aVF. You believe that the patient had a non–ST-elevation MI (NSTEMI). Which of the following cardiac markers begins to rise within 3 to 6 hours of chest pain onset, peaks at 12 to 24 hours, and returns to baseline in 7 to 10 days?

7) A 71-year-old man is playing cards with some friends when he starts to feel a pain in the left side of his chest. His fingers in the left hand become numb and he feels short of breath. His wife calls the ambulance and he is brought to the hospital. In the ED, an ECG is performed. Which of the following best describes the order of ECG changes seen in an MI?

8) While playing a match of tennis, a 56-year-old man with a medical history significant only for acid reflux disease starts to feel substernal chest pain that radiates into his left arm and shortness of breath. His pain feels better after drinking antacid, but since it is not completely resolved, his partner calls 911. Upon arrival, EMS administers aspirin and sublingual nitroglycerin. After 20 minutes, the man’s symptoms resolve. He is brought to the ED for further evaluation where his ECG shows sinus rhythm without any ischemic abnormalities. You order a chest radiograph and send his blood work to the laboratory for analysis. Which of the following statements regarding the diagnosis of acute MI is most accurate?

9) During a routine office visit, a 62-year-old male is found to have a pulsatile non-tender mass above his umbilicus. His medical history is significant for hypertension, chronic renal insufficiency, myocardial infarction, and peripheral vascular disease. He quit smoking 10 years ago. On physical examination, his blood pressure is 160/90 mmHg and pulse is 76/min. Laboratory analyses reveal a serum creatinine of 2.0 mg/dl. Which of the following is the most appropriate next step in evaluating this patient's abdominal mass?

11) A 35-year-old male complains of substernal chest pain aggravated by inspiration and relieved by sitting up. Lung fields are clear to auscultation, and heart sounds are somewhat distant. Chest x-ray shows an enlarged cardiac silhouette. Which of the following is the best next step in evaluation?

12) A 32-year-old male presents to your office with concern about progressive fatigue and lower extremity edema. He has experienced decreased exercise tolerance over the past few months, and occasionally awakens coughing at night. Past medical history is significant for sickle cell anemia and diabetes mellitus. He has had multiple admissions to the hospital secondary to vasoocclusive crises since the age of three. Physical examination reveals a displaced PMI, but is otherwise unremarkable. ECG shows a first degree AV block and low voltage. Chest x-ray shows an enlarged cardiac silhouette with clear lung fields. Which of the following would be the best initial diagnostic approach? .

13) A 64-year-old diabetic with a long history of uncontrolled hypertension is admitted for chest pain. ECG reveals elevated ST segments in the anterior wall leads. Cardiac enzymes are elevated and the patient is admitted to the ICU for supportive care. He receives low molecular weight heparin and is placed on a nitroglycerin drip. He continues to have chest pain and requires intravenous morphine. Three days later, the patient is transferred to the floor and he remains on bed rest. During the night the nurse on call informs you that the patient has a cold leg. On examination, the left leg is cold and there are no distal pulses. There is minimal swelling and the leg appears mottled. Emergency vascular surgery consult was placed and the appropriate treatment was given. Which of the following should also be considered in this patient?

14) A 36-year-old man presents to your office for a routine pre-employment physical. He has no complaints except for occasional morning headaches. His father died suddenly at the age of 54. The patient's blood pressure is 175/103 mmHg in the right arm and 180/105 mmHg in the left arm. His heart rate is 82/min. His lungs are clear bilaterally and his heart sounds are normal. Bilateral, non-tender, upper abdominal masses are palpated on exam. His hemoglobin level is 15.2 g/dL and creatinine concentration is 0.8 mg/dL. Which of the following is most likely to diagnose this patient's condition?

15) A 56-year-old male is hospitalized following an acute anterior wall myocardial infarction that was treated with thrombolytic therapy 4 days ago. On day 4 of his hospitalization, he develops recurrent chest pain, similar in quality and severity to his previous pain. Sublingual nitroglycerin is administered but does not help. His blood pressure is now 140/90 mmHg and his heart rate is 82/min. S1 and S2 are normal, and there are no cardiac murmurs or rubs. Lungs are clear to auscultation. Which of the following laboratory tests would be most useful to send in this setting?

17) A 60-year-old Caucasian man presents to the office with a 2-week history of worsening shortness of breath and decreased exercise tolerance. His breathlessness is worse at night. He thinks his legs are swelling up. He has hypertension, coronary artery disease and chronic obstructive pulmonary disease. He used to drink heavily and smoke 1 pack of cigarettes daily but has quit recently, although he still reports occasionally drinking a "few beers." He currently denies any chest pain, palpitations or cough. His temperature is 37.5°C (99.5°F), blood pressure is 110/70 mm Hg, pulse is 96/min and respirations are 22/min. The pertinent physical findings are an S3, bibasilar crackles, JVP 10 cm above the sternal angle, mild hepatomegaly, and 4+ pitting lower extremity edema. The patient is immediately treated with oxygen, intravenous furosemide, and nitrates. Which of the following markers is most likely elevated in this patient?

18) A 68-year-old Caucasian male presents to the emergency room with a three-week history of progressive dyspnea, orthopnea, and lower extremity edema. His past medical history is significant for hypertension, type 2 diabetes mellitus, myocardial infarction experienced eight years ago, and congestive heart failure. His current medications include metoprolol, digoxin, enalapril, furosemide, spironolactone, and aspirin. His blood pressure is 145/90 mmHg, and heart rate is 75/min. Symmetric 2+ pitting edema of the lower extremities is present. Point of maximal impulse is displaced to the left and soft holosystolic murmur is heard on the apex. Bilateral crackles are present over the lower lobes. His laboratory values are: Hemoglobin 11.0 g/dl, Leukocyte count 7 ,500/cmm, Platelets 300,000/cmm, Serum sodium 128 mEq/L, Serum potassium 5.3 mEq/L, Serum calcium 9.0 mg/dl, Serum phosphorus 4.0 mg/dl, Serum creatinine 1.9 mg/dl. ECG does not reveal acute ischemic changes. Which of the following is most likely correct concerning this patient's condition?

19) A 70-year-old male is brought to the ER, by his wife, because he lost consciousness while getting up in the morning. The syncopal episode lasted for several minutes, and the patient rapidly recovered consciousness. He had diarrhea and a decreased appetite one day earlier, which resolved spontaneously. His past medical history is significant for hypertension that is effectively controlled with the combination of hydrochlorothiazide/amiloride. His blood pressure is 120/70 mmHg, while supine, and 98/50 mmHg, while standing. The physical examination revealed a mucosal dryness. The EKG is normal. Which of the following laboratory values is the most sensitive indicator of the patient's underlying condition?

22) A 74-year-old woman presents to your office complaining of diarrhea and decreased appetite over the past week as well as increasing fatigue and occasional palpitations over the last few days. Her past medical history is significant for chronic atrial fibrillation for which she takes metoprolol, digoxin and warfarin. She smokes cigarettes and has for the past several years. On physical examination, her blood pressure is 140/90 mmHg and her heart rate is 70/min and irregular. Lung auscultation reveals scattered wheezes. Her abdomen is soft and non-tender. The liver span is 8 cm and the spleen is not palpable. There is no ankle edema. Her last measured INR was 2.3 two weeks ago. Which of the following is the best initial test in this patient?

23) A 43-year-old male complains of frequent epigastric burning not relieved by antacids. The sensation is typically brought on by heavy lifting at work and takes 10-15 minutes to go away. He denies having associated arm or neck pain, cough, shortness of breath or difficulty swallowing. His past medical history is significant for systemic lupus erythematosus (SLE) diagnosed five years ago, for which he takes lowdose prednisone daily. On physical examination, his blood pressure is 140/90 mmHg and pulse is 80/min and regular. Heart, lung, and abdomen exams are unremarkable. EKG is normal. Which of the following is the best next step in managing this patient?

24) An 84-year-old Caucasian male is brought to the ER with severe chest pain, dyspnea and diaphoresis. His past medical history is significant for a long history of hypertension and diabetes mellitus, type 2. He experienced a severe myocardial infarction 6 months ago. His current medications are enalapril, metoprolol, aspirin, furosemide, potassium, glyburide and pravastatin, but he says that he has not been taking some of his medications recently. Physical examination reveals acrocyanosis and symmetric 3+ lower extremity edema. Point of maximal apical impulse is displaced to the left, and a holosystolic II/VI apical murmur is heard at the apex. Non-specific ST segment and T wave changes are present on ECG. The initial set of cardiac enzymes are positive. The patient continues to deteriorate, despite aggressive diuretic and vasodilator therapy. You perform an echocardiographic evaluation of left ventricular function and decide to proceed with pulmonary artery catheterization. Cardiac index (CI), total peripheral resistance (TPR) and left ventricular enddiastolic volume (LVEDV) are determined. Which of the following is most likely to present in this patient?

26) A 36-year-old male patient, who has a history of Marfan's syndrome, presents with sudden onset of severe central tearing chest pain radiating to his back. The pain is 9/10 in severity and is unrelated to exertion. He denies any history of alcohol or tobacco use. Measurement of his BP shows a difference of 35 mmHg between his two arms. Chest auscultation reveals clear lung sounds and a mid-systolic click. What is the most appropriate next diagnostic step in the management of this patient?