MSN 620 Final Study Guide Questions with 100% correct answers

A 17-year-old boy presents with a sore throat that started yesterday afternoon. He denies any congestion or cough but reports a temperature of 102° F (38.8° C) and generalized fatigue. He has pain with swallowing but can speak normally and manage his saliva. On physical examination, the clinician sees yellow-white plaques on his tonsils and anterior cervical lymphadenopathy that is tender to palpation. What is the most appropriate next step in care? A 17-year-old boy presents to the hospital with a severe sore throat and fatigue that has been ongoing for 3 days. He has a high-grade fever for which he has been taking ibuprofen at home. The pain in his throat has been making it difficult for him to swallow, though he can take cold drinks with care, which helps with the pain. He does not feel throat congestion and does not have a cough. On physical examination, the clinician notes exudates and tender cervical lymphadenopathy. The clinician treats him empirically for strep throat with amoxicillin 500 mg twice daily for 10 days. The patient returns two 2 days later, reporting a full-body, blotchy, bumpy rash and no change in his symptoms. He stopped taking the antibiotics after the rash began. What is the most appropriate next step in care? An 8-year-old girl presents with a 4-day history of fever and sore throat. A review of systems is negative for cough. Her past medical and family history is insignificant. She is allergic to penicillin. Vital signs are temperature 101 °F (38.3 °C), heart rate 88 bpm, and blood pressure 110/70 mm Hg. On physical examination, some exudates are seen on the posterior pharyngeal wall, and tender anterior cervical nodes are palpated. Findings on heart and lung examination are normal. Which of the following is the recommended treatment? A 17-year-old boy presents with a sore throat. Associated symptoms include fever and chills, difficulty in swallowing, referred ear pain, headache, and muscle aches. The vital signs are temperature 39 °C (102.2 °F), heart rate 105 bpm, and respiratory rate 22 breaths/min. The physical examination reveals a dry tongue, erythematous enlarged tonsils, pharyngeal exudate, and tender cervical lymphadenopathy. Which of the following is the diagnostic test of choice? A 17-year-old girl presents with a thick discharge from her eyes that started 5 days ago. Associated symptoms include redness and a feeling of dirt in her eyes. Her eyes are usually matted in the morning. Her medical history is significant for multiple similar episodes. She has been using contact lenses for the past 2 years. Her vital signs are blood pressure 120/80 mm Hg, heart rate 88 bpm, respiratory rate 14 breaths/min, and temperature 37 °C (98.6 °F). An ocular examination reveals hyperemia and elevated yellow-white lesions at the lower cul-de-sac. What is the most appropriate next step in management? A 6-year-old girl is brought in with a 5-day history of sore throat and fever. Other children at school have had similar symptoms. She has not had any cough during this time. Her medical and family history is insignificant. Her vitals are currently within normal limits. On physical examination, her anterior cervical nodes are palpable and tender. There are no exudates seen on the posterior pharyngeal wall. What is the next best step in the management of this patient? A 46-year-old man presents with symptoms consistent with allergic rhinitis. He has a history of depression and is treated with a selective serotonin reuptake inhibitor. He works as a school bus driver. Which of the following should be used to treat his symptoms? A 5-year-old boy is brought for evaluation of a sore throat for the past 5 days. His parents report no cough during this period. His medical and family history is insignificant. Vitals show blood pressure 120/80 mm Hg, temperature of 100.4 °F (38 °C), and heart rate 78 bpm. On physical examination, anterior cervical nodes are palpable and tender. Exudates are seen on the posterior pharyngeal wall. A rapid antigen test was performed, which came back negative. Which of the following is the next best step in management? A 16-year-old male presents with a 2 day history of sore throat, fever, and cough. He has been experiencing difficulty swallowing food for the last two days. He has otherwise been in good health and is up to date with his immunizations. On examinations, he has a temperature of 100.6 F, pulse rate of 100 bpm, blood pressure of 110/80 mmHg. Oral exam reveals bilateral tonsillar exudates and diffuse pharyngeal erythema. Which of the following would be the next best step in the management of this patient? A 27-year-old man presents with fever, sore throat, and a generalized maculopapular erythematous rash. He reports having sexual relations with other men. His rapid antigen test for Group A beta- hemolytic streptococcus is negative. What is the next best step in the management of this patient? A 2-year-old boy presents with a fever of 102 °F (38.9 °C). His physical examination reveals bilateral otitis media with effusion with noted erythema on the right side. His parents state that this is his sixth diagnosis of otitis media in the past 12 months. His parents also note that he only has 2 words that are intelligible to them. Following the treatment of this patient for his acute otitis media, which of the following is an appropriate management strategy? Despite trying to manage a child diagnosed with otitis media with effusion conservatively, it is decided an intervention is necessary. Following consultation with an otolaryngologist, it is decided to proceed with the placement of bilateral ventilation tubes. Informed consent is obtained from the parents. Which of the following is the most likely complication of tympanostomy tube placement? A 35-year-old man with nasal congestion continues to use an over-the-counter intranasal decongestant for four weeks. He complains that he is dependant on the intranasal decongestant spray and that he needs to use it more frequently to obtain relief. Which of the following is the best approach to the management of this patient? A 28-year-old male patient with a history of asthma presents complaining of eye discharge, morning matting, and redness. He denies eye itching, burning, or recent upper respiratory symptoms. On examination, there is a bilateral diffuse conjunctival injection, purulent discharge, and conjunctival papillae. What is the most likely etiological agent for this patient's presentation? A 6-day-old girl presents with significant redness and copious discharge from her eyes. She was born via spontaneous vaginal delivery to a gravida three, para two mother. Thick, purulent discharge is noted from both eyes on examination. Which of the following is the most appropriate treatment? A 17-year-old female presents to the office with a severe sore throat. The symptoms, which began four days ago, have become unilateral and much worse over the last day. She has had fevers of 101-103 F at home and was taking over-the-counter medications but now cannot tolerate swallowing even liquid ibuprofen. She has no trouble breathing, but reports that it is very difficult to open her mouth because of pain in her jaw and the clinician struggles to visualize her throat but notes unilateral tonsillar swelling. The clinician also notes tender cervical lymphadenopathy and some right-sided facial swelling but only minimal tenderness to palpation over the right jaw. What is the most appropriate next step in care? A 10-year-old boy presents to the provider with complaints of left eye tearing. He states that when he woke up this morning, his left eye was crusted with his eyelids glued together. He adds that he has noticed some redness and mild discomfort over the previous 2 days. The patient also reports left ear pain and fullness. On further examination, his visual acuity is 20/25 on the right and 20/90 in the left eye. There is left-sided conjunctival erythema and clear discharge, but there does not appear to be any corneal involvement. On otoscopic examination, the left tympanic membrane is bulging and red. Which of the following factors best indicates the need for an ophthalmologic referral? An 11-year-old girl presents with a 1-day history of sore throat, fatigue, and nausea but no congestion and no cough. Her temperature is 103 °F (39.4 °C), and the clinician palpates tender anterior cervical lymph nodes and observes exudates on her swollen tonsils, but a rapid strep test is negative. What is the most appropriate next step? A 27-year-old man presents to the healthcare provider for regular follow-up but mentions that he has had a severe sore throat with fever, pain with swallowing, and painful lymph nodes on the front of his neck but no cough or congestion. He also asks for a refill of the emtricitabine-tenofovir pill he takes for pre- exposure prophylaxis to prevent HIV. He is reluctant to answer questions about sexual activity. What is the most likely pathogen causing his symptoms? A 38-year-old man complains of chronic nasal allergies. He has used over-the-counter antihistamines without much success. He believes he is allergic to ragweed but has had no testing. His past medical history is remarkable for hypertension, which is controlled by hydrochlorothiazide. He does not drink, smoke, or use illicit drugs. He works in a relatively new office but lives in a 60-year-old house with his family. They have carpets, drapes, and a cat. The exam shows pale and boggy nasal mucosa and cobblestoning of the posterior pharynx. Lungs are clear on auscultation. Skin prick testing shows cat dander, dust mites, ragweed, and tree pollen allergies. Which of the following would be an appropriate step to take? A 65-year-old man presents with postauricular pain, facial weakness, and excessive tearing that started 24 hours ago. He denies a history of these symptoms before this episode. His history is significant for cold sores and asthma. He is not currently taking any medication and has no allergies. Physical examination demonstrates severe but incomplete paralysis of the left side of his face, with normal sensation on both sides of his face. There are no other symptoms or findings. What is the most appropriate next step in management? An 88-year-old man presents with progressive dementia and increasing difficulty in remembering things. He can ambulate with a walker and can swallow without any difficulty. He is unable to express his needs from time to time resulting in decreased oral intake which is associated with progressive weakness. He currently lives by himself. Which of the following is the best option? A 56-year-old woman presents with intermittent, severe, brief episodes of lancinating pain in the right cheek and lips for the past 4 months. She has no relief from over-the-counter pain medications. The pain usually occurs when brushing the teeth or when touching some specific points in the lower side of the right cheek. The pain sometimes increases with chewing. On physical examination, she does not have any neurological deficits. What is the most likely cause of the pain? A 40-year-old man presents with left-sided facial weakness, which started 2 days ago. He has a past medical history of bipolar disorder. Vital signs are heart rate 76 bpm, blood pressure 125/79 mm Hg, temperature 99° F (37.2° C), respiratory rate 16 breaths/min, and oxygen saturation 99% on room air. Physical examination shows paralysis of the left side of his face. No sensory deficits are noted. What motor task will the patient have difficulty completing? A daughter brings her 72-year-old mother to the provider because of a constellation of symptoms that appear to be getting slowly worse over the past year. She tells the clinician that her mother is forgetting any new information she is given, is frequently disoriented, and demonstrates faulty judgment. Her house is no longer kept as clean as it used to be and she is having trouble staying on top of organizing her bills and finances. What is the most likely cause of the patient's condition? A 41-year-old female with a past medical history of diabetes mellitus presents for evaluation of right- sided facial weakness, which started 2 days ago. She reports difficulty closing her right eye, drooling, smile asymmetry, hyperacusis, and dysgeusia. Her vitals are heart rate 75 bpm, temperature 98.5 F (36.9 C), blood pressure 140/70 mmHg, respiratory rate 20 breaths/min, and oxygenation saturation 97% on room air. What is the most appropriate management at this time? A 65-year-old man presents with severe right-sided facial pain lasting several seconds to a few minutes and then resolving spontaneously. A history of present illness reveals that this is happening twice a day, often without warning. Sometimes it is provoked by brushing his teeth. His past medical history is significant for mild chronic obstructive pulmonary disease and benign prostatic hyperplasia that was surgically treated 5 years ago. A physical examination reveals decreased breath sounds bilaterally. A neurologic examination shows no focal deficits. What is the most appropriate next step in management? A 65-year-old man with a history of diabetes, transient ischemic attack, and hypertension presents to the emergency department with right-sided facial weakness which started 3 hours before arrival. The patient reports that he was washing his hands and noticed in the mirror that his smile was crooked. He takes lisinopril and metformin. On physical examination, his heart rate is 80 bpm, his blood pressure is 160/70 mmHg, his temperature is 98.7 °F (37 °C), his pulse oxygenation is 100% on room air, and his respiratory rate is 16 breaths/min. Fingerstick glucose reveals blood glucose levels of 80 mg/dL. An electrocardiogram (EKG) is obtained, which shows normal sinus rhythm. On examination, the patient has significant drooping of the right corner of his mouth. What would be the best next step to determine the etiology of the patient’s symptoms? A 62-year-old woman presents with worsening agitation as well as frequent mood swings. A history of present illness obtained from her daughter reveals that she has been developing progressive forgetfulness and has frequently been getting lost on her way back home while driving on familiar routes. She also has had brief but frequent periods of confusion characterized by nonsensical speech. Other reported symptoms include excessive daytime sleepiness as well as difficulty sleeping during the night. Over the past 12 months, the patient has had increasing visual hallucinations and paranoid behavior accompanied by agitation and restlessness. Her medical history is significant for mild depression, and her only medication is sertraline. Her vital signs are temperature 37 °C (98.6 °F), blood pressure 125/80 mm Hg, heart rate 78 bpm, respiratory rate 18 breaths/min, and oxygen saturation 96% on room air. Her general physical examination findings are unremarkable. Neurologic examination shows an agitated and restless female with masked facies, a soft voice, postural instability, and a slow gait. She scores 24/30 on the mini-mental state examination, where she lost points on orientation to time and place, delayed recall, and figure drawing. A depression screen is negative for depressed mood. The patient receives haloperidol in the emergency department to treat the agitation, which results in the worsening of her symptoms with associated limb and neck stiffness. Which of the following is the most likely diagnosis? An 88-year-old female is brought in for a routine physical examination by her family. She has a history of hypertension, diabetes mellitus, and had a myocardial infarction five years ago. The son confides in the clinician that his mother sometimes forgets the names of her grandchildren. On examination, the patient is awake, alert, and able to follow commands. She is only oriented to place and person. Physical examination reveals normal neurologic testing without any motor or sensory deficits. Babinski sign was negative bilaterally. What is the next best step in the management of this patient? A 65-year-old man with a history of hypertension, diabetes mellitus, and tobacco use presents to the emergency department for evaluation of left-sided facial weakness, which started 2 hours ago. The patient reports waking up around 5 am to get some water, and his face feels normal. He went back to sleep, and when he woke again at 7 am, he noticed weakness on the left side of his face. He reports drooling from the right corner of his mouth when he woke up. He says he was sick and had a cold sore last week, but those symptoms have resolved. His vital signs show heart rate 75 bpm, temperature 37 °C (98.5 °F), blood pressure 175/90 mm Hg, respiration rate 20 breaths/min, and pulse oxygenation 99% on room air. On examination, the patient has drooping of the left corner of his mouth. When asked to smile, the right side of his mouth moves upward, and the left stays depressed. His forehead reveals symmetric forehead creasing with eyebrow elevation. Reflexes are 2+ throughout. Strength and sensation in the upper and lower extremities are normal. What is the next appropriate step in management? A 74-year-old man is recently diagnosed with Alzheimer disease. During the evaluation, the patient asks about the prognosis of this disease and the life expectancy. Which of the following is most likely to explain the progression of the patient's condition in the future? A 79-year-old male is brought to the clinic by his daughter with symptoms of change in behavior, getting lost in familiar neighborhoods, memory loss, mood changes, aggression, social withdrawal, and self- neglect. On further inquiry, she states that her father's condition has progressively worsened, and he has now developed personality changes, difficulty performing tasks, forgetfulness, and difficulty in communication. Given the most likely diagnosis, which of the following is the most appropriate tool to monitor the patient's condition over time? A 47-year-old woman presents to the clinic with a history of severe facial pain. The pain occurs in sudden episodes of a few minutes and only affects her left cheek. It starts with a sharp electric shock, which then becomes an ache before it abruptly disappears. Treatment with carbamazepine was commenced at 100 mg twice daily this week, and this has provided only slight relief. Which of the following is the next best step in the management of this patient? An 88-year-old male presents to the clinic for a follow-up visit. He has a past medical history of two previous ischemic strokes with no neurological deficits. He is accompanied by his daughter, who said he has been having a difficult time with planning or solving complex tasks. His physical assessment is positive for impaired executive functioning. Which of the following sets of findings is most likely to be seen on a brain magnetic resonance imaging (MRI) in this patient? A 69-year-old female is brought in with changes in behavior, getting lost in familiar neighborhoods, short-term memory loss, mood changes, and difficulty performing complex tasks. Her primary care provider rules out any reversible cause of cognitive decline. Which of the following classes of medications is most likely to be beneficial for this patient? A patient presents with complaints of drooling of saliva from the angle of the mouth, difficulty chewing, and difficulty smiling. On examination, paralysis of half of his face and forehead is observed, along with loss of the right nasolabial fold. Which of the following is a treatment option for this condition? A patient is being managed in the medical ward for left-sided facial weakness. Which of the following examination methods can best be used to differentiate between Bell palsy and an ischemic stroke affecting the facial muscles? A 37-year-old male presents with weakness on the right side of his face. He complains of being unable to close his right eye and unable to chew from the right side of his mouth. Examination reveals loss of nasolabial fold on the right side, the inability to raise his right eyebrow, and the inability to close his mouth from the right side. Which of the following can cause this condition to develop? A 73-year-old male client with dementia wanders around the facility every day. An identification bracelet has been provided to the client. Which intervention would be most suitable for the client? A 76-year-old woman presents with some new lesions that suddenly appeared on her back. Her history is significant for hypertension and chronic obstructive pulmonary disease. Physical examination reveals multiple uniform, brown, round skin lesions on her back and shoulders that have a verrucous appearance (see picture). What is the sign associated with the sudden appearance of these lesions? A 41-year-old woman presents with a rash that comes and goes. She states that the rash has been present for most of her life. The rash worsened over the past weekend and is associated with intense itch. The itch makes sleeping very difficult. She does not take any medicine or smoke. On physical examination, her vital signs are normal. Her neck, antecubital fossa, and wrists have thickened, erythematous plaques with crusting and erosions from scratching. There is thick, purulent drainage from several areas of the rash. Which of the following is the most likely cause of acute worsening? A 7-year-old boy with varicella infection presents with a change in the appearance of his rash. His mother states that her son has been eating, drinking, and acting normally. He complains of itching but otherwise feels well. Exam demonstrates an afebrile, well-appearing child with multiple erythematous papules and vesicles. Several lesions are surrounded by honey-colored crusts and erythema without fluctuance. A Gram stain of the fluid obtained from one of the lesions shows gram-positive cocci in chains. What is the best treatment for this child? A 68-year-old woman presents for her routine annual physical. A review of systems is positive for a lesion on her back for several years and has not been changing or causing her any discomfort. Her past medical history includes hypertension and type 2 diabetes mellitus. The physical exam reveals a light brown, flat, verrucous lesion on her back. Which of the following is the most appropriate step in management? A patient presents with gradual onset of itching and pain in her fingers and nails for the past 3 months. Initially, she had only itching but recently developed pain. She has applied several types of topical creams without relief. She denies trauma or recent infection. Examination demonstrates thickened, yellowish nails with multiple pits in all nails. Some of the nails appear to be separated from the distal nailbed. A salmon-colored macular rash with silvery plaques on her left knee is also noted, but she denies any associated symptoms. Nail scrapings rule out a fungal infection. What is the most appropriate for this patient's nail condition? A 16-year-old girl presents with a warm, painful, erythematous area with a vague border on the dorsum of the foot. Her medical history is significant for athlete's foot. What is the most likely diagnosis? A 15-month-old child presents with a 4-day history of fever and facial rash. She has a history of atopic dermatitis, for which her parents occasionally apply 0.1% triamcinolone cream. Two days ago, she developed painful bumps on her cheeks that have increased in number. Her temperature is 100 F (37.8 C), and she is hemodynamically stable. Physical examination demonstrates an uncomfortable-appearing child with erythematous, scaly patches studded with multiple clear vesicles and hemorrhagic-crusted erosions on both cheeks. The initial Gram stain of one of the lesions is negative. What is the most likely etiology of this patient's rash? A 16-year-old female presents with a severely pruritic rash over her scapulae, back, and around her neck for the past 3 weeks. She has a past medical history of seasonal allergies, for which she takes hydroxyzine. She says the itch has become intolerable. She received a cotton dress on her birthday last month, which she has worn several times. She believes her rash started after wearing this dress. The patient denies recent fever or other illness in the past three months. She has used triamcinolone 0.1% cream in the past for a similar rash. Physical examination is notable for lichenified, pink plaques on her wrists and shoulders. What is the most appropriate recommendation for this patient after the acute flare has been adequately treated? A 66-year-old man presents for an annual evaluation. He has noticed several brown and black spots on his skin, but they have been stable for several years. The patient recalls that his father had similar skin lesions later in life. His medical history includes hypertension and hyperlipidemia, which are well- controlled with medication. Examination demonstrates numerous brown-to-black lesions that appear stuck on his back's skin surface. Histology shows hyperkeratosis with epidermis pseudo horn and horn cyst formation. Which gene is associated with the pathogenesis of this lesion? A 17-year-old immunocompetent boy presents with a pruritic rash on his left leg (see image). He reports that it recently developed after starting a weightlifting program at a local gymnasium. What is the most appropriate initial treatment for this patient's condition? A 27-year-old woman presents with a 1-year history of an intermittently pruritic rash. Her past medical history is significant for asthma, for which she uses an albuterol inhaler and an inhaled corticosteroid. Examination demonstrates mild xerosis with erythematous plaques on the bilateral antecubital fossae, volar wrists, and popliteal fossae. Lichenification is present on the dorsal hands, and linear excoriations are found within many of the erythematous plaques on the arms. A total body surface area of approximately 3% is affected. Given the likely diagnosis, which of the following best describes the drug of choice for this patient's condition? A 40-year-old man with no significant past medical history presents with a toenail infection. He notes that over the last 3 months, his left great toe has become more discolored. He denies any pain, swelling, or fevers. He works as a construction manager and wears steel-toed shoes daily. On exam, his left great toenail appears thickened, jagged, and cloudy with yellowish streaks. What is the most likely cause of this patient's presentation? A 65-year-old male with a past medical history of diabetes mellitus presents to the clinic with a complaint of thickening of nails along with yellowish discoloration. On examination, he has a ring-shaped rash on his chest and back. He explains that he has had this rash for many years. He has taken medication for the rash; however, it always reoccurs after a period of remission. He is extremely worried about his nails as they have become very hard and look unpleasant. Which of the following investigations should be performed before beginning treatment for this patient? A patient presents with an intensely pruritic rash on his cheeks and torso. The rash has occurred intermittently, starting in childhood, but it has never been as itchy as it is now. In addition to the intermittent rash, the patient has a history of asthma and allergic rhinitis. His father and brother have similar rashes. The physical examination reveals the rash shown below. Aside from acute medical treatment, which of the following patient actions has been shown to assist in managing the condition? Photodynamic therapy (PDT) to treat actinic keratosis is being considered in a 65-year-old woman. Her past medical history is significant for hypertension and hyperlipidemia, for which she takes hydrochlorothiazide and simvastatin. Also, her 3-year-old grandson lives with her. Which patient factor is a contraindication for using PDT? A 37-year-old male presents with complaints of multiple itchy erythematous annular lesions with central clearance diffusely throughout the torso. Tinea corporis is considered and discharge home on antifungals is considered. Which of the following factors should prompt further evaluation? A 67-year-old man with a past medical history significant for poorly controlled diabetes presents to the emergency department for pain and drainage from his scrotum. He reports a three-day history of a red rash over his scrotum that has progressively worsened and now is having "thick drainage." On examination, he has widespread erythema encompassing all his scrotum and going into his inguinal folds with purulent drainage present as well as crepitus on palpation of the area. Vital signs indicate he is febrile at 39.1 C, heart rate 115/min, blood pressure 84/56 mmHg, and respiratory rate 20/min. Which of the following is the best initial step in the management of this patient? A 6-year-old girl presents with complaints of skin lesions on her antecubital fossas. Her mother states she has had these lesions for the past 3 months. The patient has used over-the-counter topical ointments with minimal relief. The patient has a past medical history significant for asthma. On examination, ill-defined plaques composed of pruritic, crusted papules are noted on both antecubital fossas. The clinician decides to perform a biopsy of these lesions. Which of the following findings is most likely to be seen on the histopathology of these lesions? A 65-year-old man presents to the office for evaluation of multiple skin lesions on his back. The patient noticed these skin lesions when he was taking a shower and felt irregular skin nodules on his back. He has a past medical history of hypertension, diabetes mellitus, and osteoarthritis. On examination, there is the presence of multiple lesions with a dull, waxy, verrucous surface, giving a ''stuck-on'' appearance. A biopsy of one of the lesions is performed and the histopathology is shown in the figure. Which of the following is the most likely cause of the patient's disease? A 45-year-old man presents to the office for evaluation of multiple skin lesions on his back. He states the lesions developed in the past 3 months and have increased in size and number progressively. His past medical history is significant for gastric carcinoma and hypertension. On examination, there is the presence of multiple lesions with a dull, waxy, verrucous surface, and it has a ''stuck-on'' appearance. The lesions are shown in the figure. Which of the following findings is most likely to be seen on the histopathology of the patient's condition? A 27-year-old woman presents to the clinic with a rash on both elbows that has been present for four months. The rash appeared suddenly without any clear trigger or inciting trauma or exposure. The rash is erythematous and itchy, but it is not painful. There is silvery scaling present over the rash. It bleeds if scratched. The patient has tried using several over-the-counter moisturizers without any relief. What is the most likely histologic feature that would be found on a biopsy? A 50-year-old man presents for the evaluation of a painful rash on his right leg. He reports a prodrome of pruritus, tingling, and malaise three days before the eruption of the rash seen in the provided image. Which test has the highest sensitivity for making the suspected diagnosis in this patient? A 20-year-old man presents with a rash and itching. Examination reveals a vesicular rash on the right thoracic region that does not cross the midline. Which of the following is the likely cause of the patient's condition? A 62-year-old presents complaining of a gradual change in the shape of her toenails over the past three weeks. She said she observed a change in color and shape of the left big toenail at first but since then other toenails have started showing similar changes. She has a history of psoriasis for the last ten years and has been taking proper treatment to keep it in check. She has had no recent flare-ups. However, these nail changes are acute in onset. She noticed them after coming back from a family trip where she spent her days trekking in the forest with her son. General physical examination is insignificant other than the changes present in her toenails. A picture of the toenail is given shown. Which of the following is the most common causative organism for her current condition? A 17-year-old presents with pain in her right leg. She says that the pain started 3 days ago after she came back from her camping trip. She reports that an insect bit her during her trip and she applied calamine lotion there to ease the pain. However, the pain only increased in intensity. She does not have any diagnosed co-morbidities. She is, however, overweight according to her height. On examination, there is marked swelling of the leg and the girl winces on superficial palpation. A picture of her leg is shown. Which of the following is the most common causative agent for her clinical condition? A 45-year-old man presents with a 5-day history of low back pain and associated numbness and tingling of his right lower extremity. He also complains of a burning, lightning-like pain into his right foot. He states he heard a pop while lifting boxes at work, and the pain immediately started afterward. He denies bowel or bladder incontinence, constitutional symptoms, or a history of malignancy. On physical examination, muscle strength, sensation, and deep tendon reflexes are intact bilaterally. However, the straight leg raise test is positive on the right. What is the most appropriate management of this patient? A 66-year-old woman presents with 12 months of increasing right shoulder pain. The pain is on the lateral shoulder, does not radiate, and is worse with overhead activity. She has pain at night when trying to sleep on her side, and has tried taking over-the-counter ibuprofen intermittently for pain relief. She denies any history of trauma or injury. She states that her normal activities include gardening, yoga, pickleball, and walking. The patient is right-handed. On physical examination, her symptoms are reproduced with both empty and full can test, and there is no external rotation lag sign. Magnetic resonance imaging shows a <50% supraspinatus tear. Which of the following treatments is recommended? A 30-year-old woman presents with widespread musculoskeletal pain, which is bilateral and involves both upper and lower parts of the body for the past 4 months. She has normal laboratory findings, and imaging studies are unremarkable. Which of the following is a first-line medication used to treat this condition? A 25-year-old man presents with left-sided, non-radiating upper back pain that started the day before after lifting a heavy desk. He tried acetaminophen and naproxen with minimal relief. The patient's strength and sensation are intact. His pain is reproduced on palpation of his left upper back. Which of the following medications is most likely to provide improved relief of his symptoms? A 57-year-old man presents for evaluation of severe right ankle pain and swelling that started last night and has progressively worsened. He denies trauma and states this feels similar to his prior gout episodes. He was diagnosed with gout 1 year ago when he presented with right-sided first metatarsophalangeal joint pain and swelling. An arthrocentesis done at that time was notable for uric acid crystals. He was subsequently started on allopurinol; since then, the dose has been titrated up to 300 mg daily. He has also had gout attacks in his right knee. The uric acid level 2 weeks ago was 7.9 mg/dL. His other medical conditions include obesity, coronary artery disease, and hypertension. He takes losartan, hydrochlorothiazide, atorvastatin, and low-dose aspirin. On physical examination today, his vitals are blood pressure 130/85 mm Hg, heart rate 86 bpm, respiratory rate 14 breaths/min, and temperature 98.6 F (37 C). His right ankle is warm to the touch and is swollen with mild erythema. There is no evidence of synovitis in the hands or feet, and there are no tophi. He is treated with prednisone taper over the next 10 days, which results in complete resolution of the symptoms. His allopurinol dose is increased to 400 mg daily. What is the most appropriate next step in reducing hyperuricemia in this patient? A 66-year-old woman presents with extreme fatigue and muscle pain that has troubled her for the past 9 months. On physical examination, she has many tender points on her upper body. Laboratory tests are normal. Which combination of the following medications is helpful in a patient not responding to initial therapy? A 35-year-old woman presents with constant, bilateral lower back pain over the past week since moving furniture. The pain does not radiate, and she has not tried anything for relief except rest. Vital signs are normal. A physical examination is normal. Which of the following is the first-line non-pharmacological, non-invasive management? A 65-year-old woman presents after a slip and fall onto her left shoulder with severe sharp pain after the event. The pain is in the deltoid region of the left shoulder and radiates down the arm. A rotator cuff injury is suspected. Which of the following is consistent with the suspected diagnosis? A 50-year-old man presents to the emergency department after he slipped and fell. While trying to prevent the fall, he grabbed a handle with his right hand, and as he continued to fall, he felt a pop in his shoulder. He states that he can move his arm but has severe pain in his shoulder. The pain radiates towards his elbow and is exacerbated when attempting to lift his arm overhead. He has to use the opposite arm for elevation to abduct the arm. Which of the following exam findings is most characteristic of a supraspinatus rotator cuff tear in this patient? A 68-year-old woman with a past medical history of hypothyroidism and tobacco use disorder presents with chronic low back pain. The pain is localized to her right buttock and has worsened over the last few months. Walking up and down steps, sitting cross-legged, and prolonged sitting or standing exacerbates her symptoms. She takes ibuprofen as needed and recently finished a home exercise program that did not relieve her symptoms. She denies weakness, sensation changes, and incontinence. On examination, her lower limb strength, sensation, and L4, S1 deep tendon reflexes are intact. There is tenderness along the long dorsal ligament on the left. The Gaenslen test and FABER test are positive on the left. What is the most appropriate next step in managing this patient's condition? A 40-year-old man presents with left shoulder pain for the past month. He is left-handed and plays shortstop at softball once or twice a week. Over the previous month, he reports having increased left shoulder pain and difficulty doing work overhead. Two days ago, he went to make a throw and felt a pop in the shoulder. Since then, he has been unable to elevate or abduct the arm above 90°. Also, when lowering the arm, he cannot hold it up. On physical examination, he has a positive shoulder shrug and external rotation lag sign. What is the best next step in management? A 65-year-old male presents to the clinician with a painful right elbow. He claims that for the past 48 hours, his pain has been excruciating, and he is unable to use his hand. He has a history of hypertension, arthritis, diabetes mellitus, and eczema. His home medications include lisinopril and metformin. He denies any trauma to the elbow. Vital signs are stable with no recorded fever. Examination reveals a swollen elbow with erythema. Needle aspiration of the joint shows the presence of negatively birefringent crystals in the aspirated synovial fluid. Consumption of which of the following beverages is associated with this disorder? An 18-year-old musician presents to the provider with complaints of numbness and tingling sensation in the index and middle finger of the right hand and pain in the right wrist joint, which increases at night. Detailed medical history reveals that paraesthesia is also associated with morning stiffness, loss of delicate movements of the middle finger, and dropping off small objects for 3 days. On examination, the symptoms were reproduced by tapping immediately over the right wrist. Nerve conduction studies show sensory plus motor abnormalities. The healthcare professional advises her to buy a splint to immobilize the wrist joint. What type of splint is recommended? A 65-year-old female data entry clerk presents to the provider with complaints of numbness and tingling sensation in the index and middle finger of the right hand, and pain in the right wrist joint which increases at night. Detailed medical history revealed that paraesthesia is also associated with morning stiffness, loss of delicate movements of the middle finger, and dropping off of small objects for three days. On examination, the symptoms were reproduced by tapping immediately over the right wrist. Nerve conduction studies showed sensory plus motor abnormalities. The health care provider advised the use of cock-up splint to immobilize the wrist joint. What is the approximate angle from horizontal on a cock-up splint of the type used for this condition? A 30-year-old female presents for follow-up. She has been feeling quite low for the past three months. She does not feel like getting involved in any routine activities. She further states that she feels like crying all the time. Her past medical history is significant for fibromyalgia. Which of the following is the most appropriate treatment option for this patient? A 69-year-old man presents to the office with right knee pain. The pain has been present over the past 3 years, and he does not recall any specific trauma that caused it. His pain is localized to the knee and does not radiate. It is exacerbated with activity and relieved with rest. Radiographs demonstrate mild to moderate joint space narrowing throughout the medial and lateral compartments but no acute bony abnormalities. Which of the following describes the mechanism of action of the drug most appropriate for this patient? A 35-year-old woman presents with right shoulder pain that has been gradually getting worse for the past two months. She paints houses for a living and plays tennis as a hobby. She tried non-steroidal anti- inflammatory drugs (NSAIDs), topical treatment, and activity modification without significant improvement. On examination, she has a full range of motion of the shoulder, no rotator cuff weakness, positive Neer impingement sign, positive Hawkins test, negative speed test, and positive tenderness to palpation at the anterior aspect of the acromion. X-ray is unremarkable. What is the most appropriate treatment for this patient's condition? A 40-year-old man presents to the office with acute onset low back pain. His pain started while lifting a heavy box while helping his sister move 3 days ago. The pain has been severe enough that he missed work yesterday. Physical examination elicits no neurologic deficits. What are the chances he will return to work within 6 weeks? 1. 80% to 90% 2. 70% to 80% 3. 60% to 70% 4. 50% to 60% A 65-year-old patient comes to the office complaining of symptomatic right knee pain. He denies any history of injury. X-rays in the office demonstrate moderate tricompartmental osteoarthritis. What medication should be recommended to help with the pain? A 65-year-old patient with a past medical history of a previous extensive laminectomy with medial facetectomy at L4 and L5 levels presents to the office with persistent, localized pain at the operative site. The patient complains of shooting back pain in his lower lumbar region that radiates into his posterior left leg. The patient states his pain worsens with prolonged walking or standing up straight and improves with bending forward. On physical exam, he is tender to palpation over the area of pain and has a decreased sensation in the distribution of the L4 dermatome on the left. Muscle strength is intact bilaterally for his lower extremities, but his deep tendon reflex is 1/4 for L4 on the left and 2/4 bilaterally for S1. Straight leg raise is positive on the left. The dynamic x-ray films degenerative arthritis of the lumbar spine. What is the origin of the characteristic pain in the patient? A 65-year-old man presents with chronic right knee pain. He denies a history of trauma or specific inciting event as the cause of his knee pain. His pain is exacerbated by physical activity and is relieved by rest. Ibuprofen was providing moderate pain relief but was discontinued secondary to the development of a gastric ulcer. His knee joint radiographs demonstrate medial joint space narrowing in the right knee. He expresses a desire for continued medical treatment for his knee pain. What is the mechanism of action of the recommended oral medical treatment in this patient? A 65-year-old woman with a past medical history of hypothyroidism presents with pain in the right wrist along with numbness and tingling sensations in her right hand. Her clinical examination reveals weakness and numbness predominantly in the thumb, index, and middle finger of her right hand. What might be an advantage of an endoscopic approach to treat this disease over the traditional open approach? A 65-year-old man presents to the emergency department with severe pain in his right toe for the past 10 hours. This is the patient's third episode in the past six months. The patient has a past medical history significant for hypertension, diabetes mellitus, and hyperlipidemia. On examination, the hallux is erythematous, swollen, and tender. An X-ray of the right hallux shows the presence of well-defined punched-out erosions with sclerotic margins and effusion around the metatarsophalangeal joint. After initial management, synovial fluid is aspirated and sent for histopathology, which is shown in the exhibit. Which of the following best describes the findings seen in the exhibit? A 32-year-old G1P0 woman presents with worsening pain, numbness, and paresthesia in her right hand extending across the thumb, index, and middle finger with varying involvement of her ring finger. She finds doing her daily tasks difficult because she cannot use her right hand for numerous activities. She admits that the symptoms have worsened during her pregnancy. On examination of the hand, some degree of thenar atrophy is seen, and motor functions of the right hand are reduced. Which of the following tests is most definitive for diagnosing her suspected condition? A 55-year-old male presents to the clinic with a chief complaint of right shoulder pain. A single coronal T2/STIR image is provided. Which of the following represents the most likely etiology for the positioning of the humerus? Which of the following is associated with an increased risk of colorectal cancer in patients with ulcerative colitis? A 74-year-old woman presents with progressive right upper quadrant abdominal pain with bloating, food intolerances (especially greasy and spicy foods), increased gas, nausea, and vomiting. Her history is significant for diabetes mellitus. Vital signs are blood pressure 106/70 mmHg, heart rate 96 bpm, temperature 38.8 C (101.8 F), and respiratory rate 22 breaths/min. Physical examination shows a distended symmetric abdomen, with involuntary guarding in the right upper quadrant. Laboratory results include a blood glucose of 254 mg/dL. What is the next step in management? A 57-year-old man presents with heartburn following meals, burning chest pain at night, and a continuous dry cough. Vital signs are heart rate 78 bpm, blood pressure 120/70 mm Hg, and respiratory rate 14 breaths/min. The physical examination, including chest auscultation, is normal. His hemoglobin level is 14 g/dL, mean corpuscular volume of 95 fL, white blood cell count of 4600/mm3, and platelet count of 340,000/mm3. Initially, the clinician advises certain lifestyle modifications. Which of the following behavioral changes would help provide appropriate symptomatic relief? A 55-year-old woman presents with progressive difficulty swallowing solid foods and epigastric discomfort. Symptoms persist despite the use of proton pump inhibitors. Vital signs are temperature 98.6 °F (37 °C), heart rate 73 bpm, blood pressure 130/80 mm Hg, respiratory rate 18 breaths/min, and BMI 32 kg/m2. The physical examination is normal. The electrocardiogram and chest X-ray do not reveal any pathology. Laboratory results are a Hb level of 12 g/dL, a WBC of 4800/mm3, and a platelet count of 270,000/mm3. The serum amylase level is 50 U/L (normal: 30 to 125 U/L). Which of the following is the most appropriate next step in management? A 44-year-old man presents with progressing right upper quadrant abdominal pain with bloating, food intolerances, especially to greasy and spicy foods, increased gas, nausea, and vomiting. He complains of intermittent pain in the mid back and right shoulder. His history is significant for alcohol use disorder averaging 9 drinks a day. What is the preferred next step in his management? What personality disorder is most likely to be present in a patient with ulcerative colitis? A 45-year-old woman presents with a retrosternal burning sensation. Her symptoms worsen after eating heavy meals. Associated symptoms include hoarseness and persistent dry cough. Vital signs are temperature 98.6° F (37° C), heart rate 70 bpm, blood pressure 130/70 mm Hg, and respiratory rate 18 breaths/min. Her body mass index is 32 kg/m2. The physical examination does not reveal any abnormal findings. Laboratory tests reveal a hemoglobin of 12 g/dL, a WBC of 4100/mm3, and a platelet count of 250,000/mm3. The electrocardiogram shows a normal sinus rhythm. Which of the following is the most appropriate management? A 52-year-old woman presents with an 8-hour history of nausea and right upper quadrant pain. She has no significant past medical history. Her temperature is 100.5 °F (38 °C). Physical examination reveals rebound tenderness in the right upper quadrant. Laboratory testing shows a WBC count of 11,000/mm3, normal transaminase levels, and a negative urine dipstick test. She asks about her management. What is the preferred response to her inquiry? Which type of kidney stone is common in patients with ulcerative colitis? A 40-year-old man presents with recurrent chest discomfort. On the history of present illness, he describes the chest discomfort as retrosternal burning, which radiates to the neck and is usually worse after eating a meal or when he lies down. He reports using over-the-counter antacids, which provide relief of his symptoms. He denies any reproducible pain with exertional activities or associated shortness of breath, dysphagia, odynophagia, hematemesis, weight loss nausea, or vomiting. He has no significant past medical history and denies any history of tobacco, alcohol, or illicit drug use. His vital signs are normal. His BMI is 32 kg/m2. The results of a CBC, CMP, and lipid panel are normal. Which of the following best describes the underlying pathogenesis of this patient's signs and symptoms? A 65-year-old woman is evaluated for nocturnal cough and hoarseness. She has had a troublesome cough for the last 3 years, occasionally waking her up at night. She also states that her voice has become hoarse and sometimes has a foul taste in her mouth. She has hypertension and is on amlodipine. She denies episodes of fever or shortness of breath. On examination, she is a middle-aged woman of heavy build; her vital signs are normal. Her physical examination is unremarkable, and her chest is clear to auscultation. An X-ray shows normal lung fields, and pulmonary function tests demonstrate no evidence of restrictive or obstructive disease. Which investigation is likely to confirm the underlying diagnosis? A 22-year-old woman presents with a long history of abdominal pain, intermittent diarrhea, constipation, rectal bleeding, and weight loss. She has been to many providers without a diagnosis. She undergoes a colonoscopy which reveals that the rectum is inflamed with mucus in the lumen. The biopsy specimen reveals an inflammatory reaction limited to the mucosa and submucosa. Numerous neutrophils and cryptic abscesses are visible. Which of the following would be the most appropriate treatment? A 6-month-old previously healthy female is being evaluated. The mother describes an episode where she put the infant to bed following breastfeeding. She went to check on the infant about an hour later to find the infant arching her back while making choking sounds. The infant appeared conscious, but the episode did not resolve until she had vomited and started to cry. The patient was consolable. She is afebrile, 95% percentile for weight and developmentally appropriate. What treatment is most appropriate? A 57-year-old obese male comes to the emergency department with a complaint of acute chest pain. He describes the pain as a 7/10 substernal, burning sensation that does not radiate. He states he often gets this pain at night and that he has tried taking ibuprofen which has never helped. He has a history significant for hypertension. His vital signs are blood pressure 145/94 mmHg, temperature 98.7 F (37 C), respiratory rate 20 breaths per minute, heart rate 76 beats per minute, and SpO2 98% on room air. On physical exam, there is a soft systolic murmur at the left sternal border. Lungs are clear to auscultation bilaterally. An electrocardiogram shows evidence of left ventricular hypertrophy. A complete blood count and basic metabolic profile are within normal limits. CK(MB) and troponin are negative on three successive draws. Which of the following is the likely mechanism behind this man’s presentation? A 35-year-old man presents to the clinic with complaints of anorexia, mild fatigue, intermittent nausea and vomiting, and low-grade fever. He just recently traveled 2 weeks before to the United States from Nigeria to attend a wedding in the family. Workup is done, and labs return unremarkable. Hepatitis panel is checked and comes back positive for IgM antibodies to the hepatitis A virus. What is the best initial step in the management of this patient? A 52-year-old man with a past medical history significant for hypertension and alcohol use disorder presents to the emergency department with complaints of nausea, vomiting, and right upper quadrant abdominal pain. The patient admits to drinking 6 to 10 drinks of vodka every night and has been drinking for the last 6 months. His last drink was 6 hours ago. On physical examination, the patient has mild tenderness in the right upper quadrant, mild hepatomegaly, and mild icterus. AST and ALT are elevated to 150 IU/L and 80 IU/L, respectively. Bilirubin is elevated to 3 mg/dL. The patient is alert, awake, and oriented to time, place, and person. The rest of the labs are unremarkable. The patient is advised admission but requests discharge against medical advice (AMA). Which of the following is the most appropriate recommendation for this patient now? A 28-year old woman with history of heroin use is brought to the hospital with altered mental status. The patient is not able to provide any history as she is confused. She is found to have injection site track marks on her arms. Due to her drug use history, a hepatitis panel is ordered. It comes back negative for HBsAg but positive for anti-HBs. Further testing for anti-HBc is sent and it comes back negative. What is the most likely explanation for these findings? A 26-year-old woman presents to the office for routine prenatal care. She is 25 weeks pregnant and is planning to travel to Thailand next week, where she is going to stay for 4 weeks. She has a history of hepatitis A infection when she was 15 years old during her travel to Mexico and recovered spontaneously. She was vaccinated for hepatitis B before pregnancy. She is worried about acquiring another hepatitis infection and wants to know the risks. Which of the following is the most appropriate recommendation for this patient? A 65-year-old woman with a past medical history of hepatitis B infection for 25 years presents for routine follow-up. Lab work in the office reveals positive HBsAg, positive anti- HBc assay, negative HBeAg, and HBV DNA 5000 IU/mL. The presence of anti-HBs and anti-HBe is detected. ALT is abnormally high and has now been elevated for more than 6 months. Which of the following is the most accurate interpretation of these findings? A 65-year-old man presents to the clinic with dyspepsia and heartburn. He reports that his heartburn worsens after meals. He has no dysphagia or weight loss. He has a 10-pack-year smoking history but takes no illicit drugs. He drinks alcohol on occasion and weekends. Past medical problems include hypertension and obesity. His BMI is 30 kg/mZ. He takes amlodipine and multivitamins. Family history is significant for sleep apnea in the father and diabetes mellitus in the mother. His manometry findings show mildly decreased peristalsis and a normal barium swallow. The chest x-ray is unremarkable. The basic metabolic panel is within normal limits. What is the underlying cause of this man’s symptoms? A 65-year-old obese white male with a past medical history of hypertension and long- standing history of gastroesophageal reflux disease (GERD) presents to the office after being referred by his primary care provider for evaluation of recurrent reflux symptoms despite being on maximal proton pump inhibitor therapy. The patient denied any associated symptoms of dysphagia, odynophagia, weight loss, hematemesis. History negative for active tobacco, alcohol, or illicit drug use. Physical examination was unremarkable. Routine blood work was unremarkable as well. The patient was evaluated with an esophagogastroduodenoscopy (EGD), which was negative for esophagitis or any other abnormality. Which of the following is the next step in the management of this patient? A 35-year-old man with ulcerative colitis undergoes ileal pouch-anal anastomosis. What are this patient's expected bowel movements daily a few months after his surgery? A 35-year-old man with ulcerative colitis undergoes ileal pouch-anal anastomosis with the formation of a J-pouch. This patient should expect to pass stool how many times daily? A 40-year-old man who underwent an ileal pouch-anal anastomosis due to severe ulcerative colitis develops signs and symptoms of functional outlet obstruction. Which of the following diagnostic investigation can confirm this patient's condition? A 45-year-old man who underwent an ileal pouch-anal anastomosis due to severe ulcerative colitis presents with signs and symptoms of chronic pouchitis. For this patient's condition to be labeled as chronic, symptoms should be for how long? A 22-year-old man presents at his family's behest for insomnia, reporting he has only slept 2 hours per night for the past 10 days. They also report increased activity and irritability. During the visit, he paces back and forth and speaks in a nonsensical and pressured manner. He also says, "I believe I'm not sleeping because of my supernatural abilities." He has no history of substance use disorder and does not take any medication. What is the most appropriate initial treatment for this patient? A 31-year-old woman presents with a 6-month history of bilateral headaches occurring once or twice per week. The headaches are moderate in intensity and improve with oral analgesia. She reports problems concentrating, fatigue, and poor performance at work. The patient also mentions that for the last year, she has been experiencing an overwhelming feeling of being on edge, having sleeping difficulty and that she recently started to drink more alcohol than usual. A urine drug screen is negative. ECG and MRI of the brain are unremarkable. Preventive medication is offered, but she is concerned about possible side effects. She leaves without a prescription but calls numerous times in the next couple of weeks. Which of the following medications is most appropriate for this patient's condition? A primary care provider wishes to incorporate screening for depression into their clinical practice. Which of the following has the highest sensitivity and specificity for screening adults for depression in a primary care setting? A 65-year-old woman presents “feeling run down.” A history of present illness reveals that for the past 2 months, she is feeling tired, unable to concentrate, and has a decreased appetite. A review of systems is positive for feeling guilty, worthless, and hopeless, and she copes with these feelings by sleeping more than 12 hours a day. She has had 3 such episodes, each occurring during the winter and lasting for about 3 months each time. She reports decreased libido, anhedonia, difficulty concentrating, hypersomnia, and increased appetite. She has no significant past medical history and takes no medications. She does not smoke or drink alcohol. Her family history is positive for major depressive disorder in her father. Her vital signs are blood pressure 130/90 mm Hg, heart rate 72 bpm, respiratory rate 12 breaths/min, and temperature 98.6 °F (37 °C). The findings of her physical examination are unremarkable. Laboratory test results of a CBC and CMP are normal. Which of the following is the best management? A patient is admitted to the inpatient psychiatric unit. She needs little sleep, has pressured speech, and tells everyone in the unit that she is a rock star hospitalized for exhaustion. Which of the following would be the best outcome? A 22-year-old man presents with headaches and neck pain. A history of present illness reveals that he has had headaches for many years. He is a college student and says that although he is doing okay, he feels overwhelmed and fatigued. He sleeps very fitfully and frequently worries about his grades, health, and social life. He obsesses about minor comments from his friends and gets depressed, thinking that he is not attractive enough to get a girlfriend. Which of the following is the most likely diagnosis? A 40- year-old woman comes to the office due to worsening fatigue and tension headaches over the past year. She stays awake late at night worrying and feels tired with pain in her shoulder and neck throughout the day. Physical examination and labs are normal. She once took alprazolam for anxiety, which relieved her symptoms for some time. What is the most appropriate pharmacotherapy for this patient? A 40-year-old woman in a locked inpatient psychiatric unit demonstrates pressured speech and flight of ideas. She appears restless and irritable and has not slept in 4 days. She has had multiple similar episodes throughout her life. She is currently on lithium. She is married and does not use birth control. Her medical history is positive for class 2 obesity and hyperlipidemia. Given the likely diagnosis, which of the following medications is best to treat this patient's condition? A 30-year-old woman presents to the clinic with anxiety and an inability to function. She reports being worried about her daily routine and her job responsibilities. She had a history of generalized anxiety disorder in her childhood and was treated with some medication. She does not recall the name of the medication, but she had some improvement. For the last few weeks, she has started having nightmares, increased breathlessness, and feeling restless most of the day with lots of thoughts about financial and household responsibilities. She has been unable to function due to anxiety. Which of the following is the best to reduce her symptoms initially? A 45-year-old man presents to the clinic with low interest along with a decreased appetite for four weeks. He has noticed this problem since the start of the fall and at the same time for the last 3 years. He has seen multiple providers over the years and used multiple medications with no adequate response. What is the best initial therapy for this patient? A 65-year-old man presents with recurring anhedonia, lack of interest, and social withdrawal for many years. His daughter states that her father has had similar symptoms of milder sever