1/10
A 70-year-old woman comes to the physician for a new patient visit. She reports intermittent headaches and poor sleep. During review of systems, she also describes a sensation of incomplete emptying of the bladder and constipation. The patient has a history of migraines and chronic insomnia. Her other medical problems include hypercholesterolemia and osteoarthritis. Her medications include amitriptyline prescribed for migraines, simvastatin, diclofenac, and over-the-counter diphenhydramine for insomnia. Which of the following is the most appropriate next step in management of this patient?
- Add topiramate for additional migraine prophylaxis
- Add zolpidem to treat insomnia
- Cystography
- Discontinue diphenhydramine
- Head CTscan
- Increase dose of amitriptyline
2/10
A 23-year-old man comes to the physician at his girlfriend's insistence. She complains that one night last week he fell asleep while they were talking and that he frequently snores. He says that he almost always falls asleep in the afternoon while reading or watching television and typically feels refreshed after a brief nap. When asked whether he experiences any other symptoms, the patient hesitantly reveals that he sometimes hears a voice call his name prior to falling asleep. He also reports uncharacteristic episodes of clumsiness in which he has suddenly dropped objects or fallen to his knees. Examination shows no abnormalities. Which of the following is the most likely diagnosis in this patient?
- Brief psychotic disorder
- Hypersomnolence disorder
- Narcolepsy
- Obstructive sleep apnea
- Sleep deprivation
3/10
Two months ago, a 39-year-old male was leaving a local restaurant when a group of young men approached him in the parking lot and attempted to rob him. When he resisted, one of the men struck him on the head with a lead pipe. The injury required twenty-two stitches. The wound has healed well and recent computed tomography of his head was negative. However, the family reports that his overall demeanor has changed significantly since the attack. Prior to the assault, he was considered one of the most hard-working employees at his job and had received numerous awards, including an award for outstanding customer service. Since the attack, he has been demoted and put on probation for making inappropriate and sexual comments to customers and coworkers. In addition, his spouse reports that he has lost his motivation and does not seem to care about providing for his family anymore. He also appears to have difficulty concentrating on simple tasks, such as balancing his checkbook. Damage to which anatomical brain region is the most likely explanation for this patient's symptoms?
- Cerebellum
- Corpus callosum
- Frontal lobe
- Parietal lobe
- Temporal lobe
4/10
A 32-year-old woman comes to the physician because of long-standing anxiety. After taking a thorough history, the physician diagnoses her with generalized anxiety disorder and recurrent panic attacks, and then initiates therapy with paroxetine. She returns to the office two days later and reports that her anxiety has worsened and that she cannot sleep. The physician considers prescribing a benzodiazepine to help her sleep. However, the patient works as a 911 emergency dispatch operator and is concerned about potential side effects such as excessive daytime fatigue and impaired judgment. Which of the following benzodiazepines would be the most appropriate choice for this patient?
- Triazolam
- Chlordiazepoxide
- Flurazepam
- Diazepam
- Lorazepam
5/10
A 43-year-old former heroin abuser has just finished a drug-abuse rehabilitation program. He had used heroin daily for nearly 10 years and underwent an extensive rehabilitation program over a 6-week period. Although he finished the program, he still feels a strong desire to use heroin. He decides to volunteer with Narcotics Anonymous in order to help other addicts recover and visit area schools speaking about the harmful effects of drug abuse. He also begins speaking at public forums, stating that all heroin users should be avoided in society. This is a demonstration of which of the following defense mechanisms?
- Reaction formation
- Projection
- Repression
- Identification
- Suppression
- Displacemen
6/10
You are treating a 35-year-old Caucasian male with psychotherapy. During one of your clinical visits, the patient admits to you that every time he gets into an argument with his wife he feels the need to break something to 'vent his anger.' He has been treated multiple times by orthopedic surgeons for injuries to his hand sustained while 'punching holes in walls.' Which of the following defense mechanisms is the patient exhibiting?
- Sublimation
- Displacement
- Projection
- Reaction formation
- Splitting
7/10
A 52-year-old businessman comes to the physician for follow-up to discuss the results of his colonoscopy. He works on his computer while waiting for his appointment and becomes irritated when the office staff asks him to refrain from using his cell phone. The physIcian mforms the patient that a cancerous polyp was removed and that there is no evidence of invasive cancer at the rese~tlon margins. He reassures the patient that he has an excellent prognosis. In response, the patient curses and shouts angrily, I don't have time for this! You keep me waiting and then tell me ,I, shOl!ld be happy that I have cancer! You don't know what you're doing. What kind of doctor are you? Which of the following is the most appropriate response to the patient?
- 'I know you are upset, but it is inappropriate to attack me.'
- 'I see you are upset; I think we should discuss your concerns and questions.'
- 'I understand your distress but can assure you that you have received the best care.'
- 'If you cannot control your temper, I will have to ask you to leave.'
- 'Let me reassure you that the cancer has been completely removed.'
8/10
A 26-year-old nurse comes to the physician complaining of recent weight gain. She says she has been eating more than usual over the last 5 months and feels guilty and depressed about it. Further questioning reveals that she consumes 'enough food for 2 or 3 people during a single meal' at least a couple of times a week. Afterward, she feels ashamed about being unable to control her intake and eats only minimal amounts of toast and vegetables to try and make up for it. She is very distressed about being 'unable to shed the extra pounds' despite vigorous exercise most days of the week. On examination, the patient's vital signs are within normal limits and her body mass index (BMI) is 23.7 . Despite being told that her BMI is normal, she continues to insist she is overweight. Which of the following is the most likely diagnosis?
- Factitious disorder
- Body dysmorphic disorder
- Anorexia nervosa
- Hypochondriasis
- Malingering
- Bulimia nervosa
9/10
A 27-year-old man sustained a back injury at work 9 months ago. He is a mover for a national relocation company. Magnetic resonance imaging confirmed a herniated disc. The neurosurgeon concluded that surgery was not indicated. His primary care physician recommended physical therapy, and he was prescribed oxycodone with acetaminophen for pain relief during the recovery period. The patient has ~ow completed physical therapy, and follow-up magnetic resonance imaging indicates that the herniated disc .has regressed. Nonetheless, he continues to report a significant amount of pain and is requesting refills on his pain medication with a dose increase. In the last month, he has been to the emergency department on 2 separate occasions requesting pain medication due to 'running out' prior to his next scheduled. refill. The. patient reports that 2 pills per day are no longer effective. Despite having financial difficulty, he is not working as he is in 'too much pain.' He is reapplying for long-term disability, which was already denied once. Which of the following statements by the patient's primary care physician would be most appropriate at this time?
- Additional testing is needed to identify the source of your pain.
- I am concerned about your use of pain medication
- I am concerned that stress and your inability to work are amplifying your pain
- I would like to refer you to a pain specialist
- Right now, the priority is to treat your addiction to pain medication
- You may need stronger medication to control your pain.
10/10
A 62-year-old man is referred to a cardiology clinic at a local teaching hospital that serves as the tertiary care center for the surrounding area. The patient suffered a myocardial infarction 2 months ago, and has been sent by his primary physician for management of his blood pressure. While reviewing his medical record, the physician finds that the patient's hypertension has been treated only with verapamil. The patient also takes a daily 81-mg aspirin tablet and a statin. His high-density lipoprotein and low-density lipoprotein levels are within the desired range. The cardiologist is surprised that the primary physician had not placed him on a beta-blocker and/or angiotensin-converting enzyme inhibitor for control of his blood pressure given his history of myocardial infarction. Which of the following is the most appropriate statement to make to the patient?
- 'It is a good thing you came to us when you did. I am concerned that your blood pressure is not being managed appropriately.'
- 'Sometimes rural physicians aren't able to keep up with the latest medical research, so it's understandable that we need to make some adjustments to your current medications.'
- 'Your primary physician has you taking the wrong blood pressure medications, but we can make some changes now to try and prevent another heart attack.'
- 'Your primary physician sent you to me because he is concerned about your blood pressure given your previous heart attacks. Let's see what we can do to optimize your current treatment.'
- 'Your primary physician has done a great job managing your other risk factors, but I have no idea why he failed to put you on the appropriate blood pressure medications.'
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