Dx & Rx
A patient presents to the office with the complaint of having had what she describes as anxiety attacks with shortness of breath, palpitations, dizziness, sweating, and shaking for which she has gone to the ER twice. She reports that over the past 6 weeks, she has fretted over having another anxiety attack and has noted a fear of going out of her home even for something "as simple as grocery shopping". After further discussion and a thorough physical examination, you diagnose her with this condition and decide to treat her with this class of medications.
What is Panic disorder ?
What is an SSRI ?
A 70-year-old female is brought to the office by her daughter for evaluation of increasing memory loss over the past year and an inability to manage her finances alone. She is diagnosed with early Alzheimer disease.
The most appropriate initial treatment for this patient
What is donepezil (Aricept) ?
A 56-year-old female with depression with a BMI of 37 kg/m2 seeks your advice regarding antidepressant medications and weight loss.
This antidepressant is most likely to contribute to weight gain? weight loss?
What is mirtazapine (Remeron) ?
What is bupropion (Wellbutrin) ?
This medication should be considered for patients taking more than 50 morphine milligram equivalents (MMEs) daily for chronic pain?
What is naloxone ?
Your practice is starting a screening program for depression.
1. The U.S. Preventive Services Task Force recommends screening for depression for these people.
2. These are two cardinal symptoms of depression included in the Patient Health Questionnaire–2 (PHQ-2) screening instrument?
1. What is all adults (including pregnant and postpartum and adolescents age 12-18 ?
2. What is little interest or pleasure in doing things and feeling down, depressed or hopeless ?
A 26-year-old female presents to your office after surviving a tornado that destroyed her home 3 months ago. She reports continued intense fear and anxiety when there is a storm.
You diagnose her with this condition.
This form of treatment has the best evidence of effectiveness.
What is Post Traumatic Stress Disorder (PTSD) ?
What is Cognitive Behavioral Therapy (CBT) ?
You are caring for an 84-year-old female with Alzheimer’s dementia. She is disoriented to time but usually oriented to person and place. She is homebound but is frequently visited by family. The patient’s daughter feels conflicted but wants her mother to go to a skilled care facility. The patient is adamant that she does not want to leave her home. During a recent home visit you noted that she smelled of urine and had a severe intertriginous rash suspicious for Candida. Herbedside Mini-Mental State Examination score was 24/30.
This ethical principle should be the primary consideration when determining whether this patient should continue to live at home.
What is autonomy ?
(others are beneficence, nonmaleficence, justice)
A 34-year-old female comes to your office for follow-up after an emergency department visit because of anxiety. She notes persistent anxiety, poor focus, and palpitations. She also reports that she is not hungry and has lost several pounds. She reports “odd things happening” such as sudden weakness in her legs, falling, and getting lost. On exam, the patient is hyperverbal and displays tangential speech. Temperature is 37.4°C (99.3°F), heart rate 134 beats/min, respiratory rate 20/min, and blood pressure 117/69 mm Hg. A physical examination is remarkable for an anxious-appearing female who is tremulous at rest, exophthalmos but no thyromegaly, tachycardia, faint bibasilar crackles and EKG shows sinus tachycardia. Laboratory results are remarkable for TSH <0.08 (L), free T4 4.51(H) and free T3 >19.0 (H).
This is the most likely cause of her anxiety.
What is hyperthyroidism ?
A 30-year-old male presents for a health maintenance examination. He reports that he works full-time and "hangs out" with his "drinking buddies" after work and on weekends. He consumes a six-pack of beer every night and consumes several shots of alcohol on the weekends with his friends. His wife encouraged him to speak to you regarding drugs. He states that he does not consider beer a "drug" and does not think he has a drinking problem because he is able to maintain a job.
1. He is currently at this stage of change.
2. This statement would be the most appropriate response.
What is precontemplative ?
What is "Would it be okay if we discuss your beer drinking?"
A 24-year old female presents to your office with a 3-month history of difficulty sleeping. She says that she struggles to fall asleep and wakes up multiple times at night at least three times a week. She tries to go to bed at 10:00 p.m. and wakes up at 6:30 a.m. to start her day. She lies awake for an hour in bed before falling asleep and spends up to 2 hours awake in the middle of the night trying to fall back asleep. Lately she has been feeling fatigued and having difficulty concentrating at work. You conduct a full history and physical examination and tell her to return in 2 weeks with a sleep diary. At this follow-up visit you see from her diary that she is sleeping an average of 5½ hours per night.
This is the most appropriate recommendation?
What is move her bedtime to 12:30 AM ?
A 12-year-old male is brought to your office by his guardian. In the last 12 months he was suspended from school multiple times for bullying and fighting. He kicks the family dog and goes out at night without permission. He ran away from home 2 weeks ago and he lies constantly. He skips school and does not care about his grades. Attention-deficit/hyperactivity disorder was previously ruled out. Two days ago he was grounded and retaliated by destroying his guardian’s computer. During the office visit he says school is “boring and stupid.”
The most likely diagnosis and the most appropriate next step in managing this patient.
What is Conduct Disorder ?
What is psychosocial intervention ?
This type(s) of hallucination are associated with Parkinson’s disease?
What are visual hallucinations ?
An 8-year-old male with a history of attention deficit hyperactivity disorder presents for a six-month follow-up examination. Current medications include methylphenidate (Ritalin®). His mother reports marked improvement in his overall behavior, but is concerned with his frequent nose wrinkling and sniffling. Examination reveals no nasal congestion, rhinorrhea, allergic shiners, or polyps.
This is the most likely diagnosis.
What is Tourette syndrome ?
You have assumed the care of a well established patient in your practice whose medications include chronic alprazolam (Xanax) treatment for anxiety and codeine for chronic back pain following a work accident years earlier. His Prescription Drug Monitoring Program report shows a consistent pattern of filling the medications as prescribed. You order a urine immunoassay for opioids and benzodiazepines. The results are positive for opioids but negative for benzodiazepines.
This would be the most appropriate next step.
What is perform confirmatory testing for alprazolam ?
A 10-year-old male is brought to the office by his mother for a health maintenance examination. On questioning, his mother states that she is concerned that her son does not have many friends at school and gets upset at home if a certain morning routine is not followed. She notes that he met all of his developmental milestones appropriately, and that during a school screening his IQ was 110. The child seems totally disinterested during the interview; however, he perks up when asked about what his likes are and talks incessantly about dinosaurs during the rest of the examination. Physical examination is unremarkable.
This is the most likely diagnosis.
What is Autism spectrum disorder level 1 ?
A 28-year-old new patient answered "yes" to almost every review of systems question. All of these complaints have been present for more than 5 years, and she has great difficulty holding down a job due to these problems. She is concerned about these complaints and is constantly worried and anxious that there is something seriously wrong. Her physical examination reveals completely normal findings.
Name the most likely diagnosis and the most appropriate treatment (3 elements).
What is Somatic Symptom Disorder ?
What are frequent scheduled visits, acknowledge suffering, minimize diagnostic tests and meds, stress reduction, set realistic goals ?
A 65-year-old female comes to your office for her Welcome to Medicare visit. Her current medication regimen includes losartan (Cozaar), 50 mg daily, for hypertension; oxybutynin, 5 mg daily, for overactive bladder; doxepin, 5 mg at night, for depression and insomnia; and atorvastatin (Lipitor), 10 mg daily, for hyperlipidemia. She is doing well on her current medications and is requesting refills today.
You advise her that the benefits of her current regimen for her overactive bladder and depression need to be weighed against her increased risk of this condition.
What is dementia ?
A 21-year-old female sees you for a medical evaluation prior to admission to a treatment program for anorexia nervosa. The effects of anorexia on the hypothalamic-pituitary axis can cause what medical condition?
What is bone loss, amenorrhea/infertility, hypoglycemia, hyothyroidism?
This is the most common symptom of alcohol withdrawal in the elderly.
What is confusion ?
A 32-year-old white female presents to your office for a health maintenance visit required by her employer. The patient lives with her husband and two children. Her hobbies include water skiing and traveling. She does not have any significant past medical history. Her last Papanicolaou (Pap) smear was normal 1 year ago, and all of her previous Pap smears have been normal. A review of systems and a physical examination are unremarkable.
Based on U.S. Preventive Services Task Force recommendations there is good evidence for screening of what.
What is Intimate Partner Violence ?
A 21-year-old male is brought to the office by his girlfriend, because he has not been sleeping, although he believes 3 hours of sleep is more than adequate. He states that he has been working on a team assignment at work. He believes the group will be unsuccessful without him, and he has been staying up to work on the project. He has also been spending time online playing the stock market and has recently lost a significant amount of his savings. It is difficult to get him to answer questions completely, as he is easily distracted and continues to talk excessively. He states that he has been depressed in the past. He denies any illicit drug use. On physical examination, he does not appear to be in any distress. The remainder of the examination is otherwise unremarkable. An in-office urine drug screening test is negative.
The most likely diagnosis and appropriate class of medication.
What is Bipolar mania?
What is a mood stabilizer ?
A 70-year-old female is admitted to the hospital with right upper quadrant pain determined to be secondary to acute cholecystitis. After initial stabilizing treatment the surgeon recommends cholecystectomy but the patient declines. Her family wants her to have the surgery and they tell you they think she has dementia and cannot make this decision.
Determining the patient’s capacity to make a specific medical decision should include assessment of which 4 factors?
What is 1) understanding of the R/B/A, 2) appreciation of the R/B/A, 3) reasoning in decision making and 4) communication of their decision ?
A 66-year-old female with multiple medical and psychiatric problems has routine laboratory work performed during a regularly scheduled clinic visit. All of the laboratory values are normal except for a serum calcium level of 11.0 mg/dL (N 8.5–10.2).
This psychotropic is most likely to cause hypercalcemia.
What is lithium ?
An 18-year-old male is brought to your clinic by his parents. He reports daily use of alcohol and opioids that he has been getting illegally from his friends. This habit started 3 years ago when he started high school.
In addition to counseling, this pharmacologic agents is indicated to treat both of his substance use disorders.
What is naltrexone ?
A 37-year-old male sees you to discuss some mental health concerns. He states that he has recently been unable to meet deadlines at work and has been reprimanded by his boss. He feels he cannot complete the tasks during his work hours and is worried he is going to lose his job.
These elements of your evaluation are important in determining if he might have adult attention-deficit/hyperactivity disorder (ADHD): age of onset, screen for these co-morbidities.
What is
-age of onset before age 12 ?
- mood, anxiety and substance use disorders, OSA, hyperthyroidism, TBI ?