Drug misuse, intoxication and withdrawal Quiz: Ace Your Exams

A 26-year-old woman comes to her primary care physician’s clinic for evaluation of difficulty sleeping, reduced concentration, and headache. On average, the patient sleeps four hours every night. The patient’s headache is dull and frontal and not associated with nausea, vomiting, photophobia or phonophobia. The patient has a history of bipolar disorder and chronic back pain. Her current medications include escitalopram, a combined estrogen-progesterone oral contraceptive agent, and oxycodone as needed for the back pain. She does not use tobacco. She consumes alcohol with her friends on the weekends. Her last drink was four days ago. Until three weeks ago, she regularly consumed 4-5 cups of coffee daily. Temperature is 98 °F (36.6°C), pulse is 88 bpm, blood pressure is 154/90 mmHg. The patient appears irritable. Oral mucosa appears moist. The patient moves all 4 extremities to commands with normal deep tendon reflexes. Urine toxicology screen is negative. Which of the following is the most likely diagnosis?