A 76 year-old male comes to your office to discuss his ongoing medical problems. He reports feelings of sadness and hopelessness. He was fired from his job due to his angry outbursts and for showing frustration even over small matters. He has lost interest in watching football, which he used to enjoy a lot. He has difficulty sleeping. He feels a lack of energy even to do small tasks like waking up from his bed. His appetite has never been this low in ‘his entire life’. He was diagnosed with HIV over a decade ago. He can’t stop blaming himself because his life was lost over a one-night stand sexual encounter and he was diagnosed with a deadly disease. Sometimes he entertains thoughts of suicide but they are mostly under control now. He had taken sertraline 50 mg daily for a few months but in his words, ‘it didn’t do a thing for me’. His vital signs are normal. Physical examination is significant for a tearful patient, who looks sad and emaciated. Which of the following medications is the best choice to treat his symptoms?

A 36 year-old male comes to your clinic for the evaluation of his ongoing medical problems. He lost interest in activities that used to give him pleasure. He denies any suicidal thoughts but life feels like he entered into an uncharted territory with no meaning and purpose. He can’t fall asleep easily and has difficulty staying asleep. He feels sleepy early in the morning when it is time to go to work. He feels miserable because the sleep won’t come when he needs it and comes when he does not need it. He thinks his recent divorce drained ‘all life out of me’ and feels he has low energy. He is responsible to pay the full mortgage on his now. And his anxiety is ‘going through the roof’. He does not have a good appetite. Even when he forces himself to eat, he feels early fullness in stomach, excessive bloating, belching and nausea. He had lost 8 pounds during the last 2 months. He used paroxetine for a few months but it did not help him much and caused sexual dysfunction. His past medical history is significant for a 10 years history of tension headaches which come 3-4 times a week. Which of the following is the best medication to treat his symptoms on a long-term basis?

A 72 year-old man is brought to your office by his daughter for evaluation. For the last 3 months, he has been suffering from difficulty falling and staying asleep, severe fatigue, poor appetite, and fatigue. He lost interest in the activities he used to enjoy such as fishing and spending time in the local library. He forces himself to go to the library a few times a week but he lost interest in reading the newspaper and watching television which he used to enjoy until recently. He feels like he has little energy and thinks he is a burden to his daughter’s family. His last hospitalization was four months ago for myocardial infarction. He denies any chest pain, palpitations or shortness of breath. He takes metoprolol 25 mg once daily and hydrochlorothiazide 25 mg once daily. He lost his beloved wife to cancer three years ago. His daughter says, ‘his grandkids love him. There is no reason for him to feel lonely’. Recently, he is having problems remembering details. His vital signs are normal. His physical examination is unremarkable. What is the next best step in the management of this patient?

A 27 year-old male comes to your urgent care center and reports that he has been feeling intense fear that something terrible is about to happen, worrying about losing control of his life, spending sleepless nights fearing he might go crazy, feeling as if he is choking and feeling a sense of impending doom. He insists that his symptoms are not ‘just mental’. He reports he has a pounding heart, upset stomach, diarrhea, shaking, sweating, numbness and tingling in his arms and legs.He has had 5 or 6 episodes of fear attacks in the last two months. He denies any alcohol or substance use. His medical history is unremarkable for medical and mental health histories. Suspecting drug abuse, you ordered a random urine drug screen, which came negative on a 12 panel test. When you ask him to stand during a physical examination, he reports feeling dizzy and lighthearted. When you are planning to order some laboratory tests, he reports that his family doctor checked him for a lot of things to rule out heart disease, gastrointestinal disease and neurological disease and ‘all those tests showed nothing abnormal’. To diagnose this individual with panic disorder, symptoms should be present for how long?

A 26 year-old male comes to your urgent care center and reports that he has been feeling intense fear that something terrible is about to happen, worrying about losing control of his life, spending sleepless nights fearing he might go crazy, feeling as if he is choking and feeling a sense of impending doom. He insists that his symptoms are not ‘just mental’. He reports he has a pounding heart, upset stomach, diarrhea, shaking, sweating, numbness and tingling in his arms and legs.He has had 5 or 6 episodes of fear attacks in the last two months. He denies any alcohol or substance use. His medical history is unremarkable for medical and mental health histories. Suspecting drug abuse, you ordered a random urine drug screen, which came negative on a 12 panel test. When you ask him to stand during a physical examination, he reports feeling dizzy and lighthearted. When you are planning to order some laboratory tests, he reports that his family doctor checked him for a lot of things to rule out heart disease, gastrointestinal disease and neurological disease and ‘all those tests showed nothing abnormal’. Which of the following is the cornerstone of drug therapy for the long term management of this disorder?

A 25 year-old male comes to your urgent care center and reports that he has been feeling intense fear that something terrible is about to happen, worrying about losing control of his life, spending sleepless nights fearing he might go crazy, feeling as if he is choking and feeling a sense of impending doom. He insists that his symptoms are not ‘just mental’. He reports he has a pounding heart, upset stomach, diarrhea, shaking, sweating, numbness and tingling in his arms and legs.He has had 5 or 6 episodes of fear attacks in the last two months. He denies any alcohol or substance use. His medical history is unremarkable for medical and mental health histories. Suspecting drug abuse, you ordered a random urine drug screen, which came negative on a 12 panel test. When you ask him to stand during a physical examination, he reports feeling dizzy and lighthearted. When you are planning to order some laboratory tests, he reports that his family doctor checked him for a lot of things to rule out heart disease, gastrointestinal disease and neurological disease and ‘all those tests showed nothing abnormal’. Which of the following medications indicated in this patient for immediate relief of panic symptoms?

A 24 year-old male comes to your urgent care center and reports that he has been feeling intense fear that something terrible is about to happen, worrying about losing control of his life, spending sleepless nights fearing he might go crazy, feeling as if he is choking and feeling a sense of impending doom. He insists that his symptoms are not ‘just mental’. He reports he has a pounding heart, upset stomach, diarrhea, shaking, sweating, numbness and tingling in his arms and legs.He has had 5 or 6 episodes of fear attacks in the last two months. He denies any alcohol or substance use. His medical history is unremarkable for medical and mental health histories. Suspecting drug abuse, you ordered a random urine drug screen, which came negative on a 12 panel test. When you ask him to stand during a physical examination, he reports feeling dizzy and lighthearted. When you are planning to order some laboratory tests, he reports that his family doctor checked him for a lot of things to rule out heart disease, gastrointestinal disease and neurological disease and ‘all those tests showed nothing abnormal’. What is the most likely diagnosis in this patient?

A 34 year-old female comes to your office for the evaluation of her fears. For a little over a month, she has been feeling intense fear that something terrible is about to happen, worrying about losing control, worrying about dying, going crazy, and having a heart attack. She is also having an upset stomach, diarrhea, shaking, sweating, pounding heart after she experiences these fears. It feels as if she is choking and can’t breathe. As the fears overwhelm her, she feels dizzy, faint, and lightheaded. Her arms and legs go numb with tingling feet. The feelings start suddenly and get very strong, usually within 10 minutes. Then the symptoms usually last from 20 to 30 minutes. The attacks happen when she thinks about being lonely by herself in a dark room. But sometimes they come unexpectedly without a warning. She went to her primary care doctor, who according to the patient, ‘did every test in the world on me and found nothing wrong with me’. She also denies alcohol or drug use. Of the following, which medications are considered first-line in her treatment?