Exam 2: Behavioral science

A 45-year-old woman comes to the office with multiple scratches, small sores, and abscesses on her left arm.  She is worried because the sores have been present for the past month and have not healed.  The patient has no idea how the sores developed and is concerned that they will spread.  She is a nurse who is well known to the staff from a similar presentation 2 years ago.  At that time, she had similar skin lesions, many of which were severely infected and did not respond to usual treatment.  Fecal bacteria were found in one of the sores.  On another occasion, the patient had a spreading infection and cellulitis that required a prolonged hospitalization and intravenous antibiotics.  She has no other medical problems.  Which of the following is the most likely cause of this patient's condition?

A 24-year-old woman calls her obstetrician after giving birth to a healthy boy 5 days earlier.  She reports feeling depressed and irritable: "I thought I would be thrilled to have a baby, but then I felt really disappointed it was not a girl and find myself crying constantly."  The patient gets help from her sister during the day but is exhausted due to getting up at night to feed the baby.  She says, "My sister is so helpful, but I can't help snapping at her for no reason.  I get so worried that I won't be a decent mother."  The patient has no medical or psychiatric history, and the pregnancy and delivery were unremarkable.  She has no suicidal ideation or thoughts of harming the baby.  In addition to providing support, which of the following is the most appropriate response to the patient?

A 52-year-old man comes to the office for a routine follow-up appointment.  The patient has a history of well-controlled hypertension and hyperlipidemia.  He has a 35-pack-year smoking history and reports that he continues to smoke about 10-15 cigarettes daily.  Family history is significant for lung cancer in his mother.  His father died following a stroke at age 65.  When asked about whether he has considered quitting, the patient replies that he is not ready to stop smoking.  He says, "I know I probably should, but I'm just too stressed at work to give up my cigarettes right now.  To be honest, I'm probably smoking closer to a pack a day."  Which of the following is the most appropriate response to the patient?

A 72-year-old man is hospitalized due to a leg injury following a high-speed motor vehicle collision.  Medical history is significant for hypertension, hypercholesterolemia, and hearing loss.  The patient drinks a glass of wine every day.  Examination shows localized swelling and severe tenderness under the right knee; the presence of a tibial fracture is confirmed by imaging.  The patient undergoes open reduction and internal fixation without any perioperative complications.  On the first postoperative night, he describes visual hallucinations of his deceased brother in the hospital room with him and perseverates about people invading his home.  Vital signs are normal.  The patient is disoriented and unable to cooperate with the mental status examination.  He appears to respond to internal stimuli.  Which of the following interventions is most likely indicated to prevent further worsening of his condition?

A 21-year-old man comes to the office due to recurrent ear drainage.  He is accompanied by his girlfriend.  He speaks in English.  On examination, the patient has purulent otorrhea, a tympanic membrane perforation, and a pearly white mass behind the tympanic membrane consistent with a large cholesteatoma.  He is told that he will need an operation on his ear to remove the mass.  After listening to an explanation of the procedure and why it should be done, the patient nods briefly but does not ask questions.  He is also given information sheets with a written description of the procedure and instructions on how to schedule surgery that he immediately hands to his girlfriend, who begins to read them.  Review of the medical records shows he has been to the emergency department several times in the last year with this same concern and has not had a flu shot in the past 5 years.  Which of the following is the most appropriate course of action?

A 67-year-old man is brought to the emergency department by ambulance due to altered mental status.  He was having dinner with his daughter when he suddenly became confused and slumped over.  The patient has a history of atrial fibrillation for which he takes an oral anticoagulant.  He is widowed and lives with his daughter.  Blood pressure is 208/113 mm Hg, pulse is 64/min and irregular, and respirations are 15/min.  Oxygen saturation is 88% on room air.  The patient is obtunded and unable to follow commands.  Pupils are midsized and do not respond to light.  The physician determines that intubation is necessary at this time to protect the patient's airway and asks for consent from the daughter and older son who are at the bedside.  They tell the physician that the patient does not have an advance directive and they are unsure how to proceed.  Which of the following is the most appropriate next step in decision-making for this patient?

A resident physician is finishing up her shift when she receives a page that reads, "Patient in Room 121 asking to leave."  The patient was admitted 2 hours ago for worsening dyspnea.  On entering the room, the resident attempts to engage in a discussion about why the patient is requesting to leave.  In response, the patient pulls out his nasal cannula and breathlessly says, "You don't know anything; you're not even a real doctor!"  The resident is reminded of her father, who has frequently belittled her accomplishments.  She angrily informs the patient, "You can't leave and I'm ordering haloperidol to calm you down."  Which of the following best explains the resident's response to the patient?

A 35-year-old woman comes to the office due to worsening fatigue and tension headaches over the past year.  She describes always feeling "on edge" and lies awake at night worrying about various issues such as whether she is good at her job, whether her grown children like her, if she will get cancer one day, and whether her house will be broken into.  During the day she feels tired and her shoulders and neck ache; she has difficulty concentrating on her work and has become increasingly concerned about losing her job.  The patient has no medical or psychiatric history.  Physical examination and routine laboratory studies, including thyroid function tests, are normal.  The patient's anxiety has never been treated, but she once took a tablet of alprazolam offered by a friend.  This lowered her anxiety, but the effect did not last long.  The patient drinks a glass of wine on rare social occasions and does not use illicit drugs.  Which of the following is the most appropriate pharmacotherapy for this patient?

A 65-year-old man is brought to the emergency department by a friend who found the patient disoriented in his apartment.  The patient's medical history includes chronic obstructive pulmonary disease, hypertension, coronary artery disease, and tobacco use.  He is unmarried and lives alone.  The friend says that the patient has a sister who lives in the area but is unaware of when they last spoke.  The friend has known the patient for 5 years and says that they are "good buddies."  He tells the physician that they have discussed dying and that he believes the patient would prefer to "go naturally" and would refuse any heroic measures, including "being hooked up to a ventilator."  Temperature is 39 C (102.2 F), blood pressure is 120/80 mm Hg, pulse is 105/min, and respirations are 24/min.  Oxygen saturation is 88% on room air and 93% on 2 L of oxygen.  The patient is somnolent and unable to answer questions.  The lungs have bilateral wheezing and decreased breath sounds.  Chest x-ray reveals a right lower lobe infiltrate.  Appropriate bronchodilator and antibiotic therapies are initiated.  The physician is concerned about the need for intubation if the patient does not respond to initial treatment in the next 2-3 hours.  Which of the following is the most appropriate course of action?

A 67-year-old woman comes to the office due to difficulty concentrating.  She reports repeatedly reading the same page of material due to an inability to focus.  She also describes memory problems, stating that it "takes a while to remember another person's name."  The patient's medical history is significant for hypertension and type 2 diabetes mellitus.  These are well controlled through diet, exercise, and oral medications.  She lives alone and describes her mood as "good."  Blood pressure is 127/67 mm Hg and pulse is 65/min.  The physician decides to administer a brief cognitive test to assess her difficulty in concentrating.  Which of the following elements of cognitive testing would best assess for impaired attention and concentration in this patient?

A 54-year-old man comes to the office due to concerns about having pancreatic cancer after a coworker died of the disease 6 months ago.  The patient has no epigastric pain, jaundice, or weight loss.  However, he worries constantly because in researching the illness he read that it may not have obvious symptoms in early stages and can be rapidly fatal.  The patient saw another physician 2 months ago, who performed a physical examination, laboratory evaluation, and abdominal CT scan.  The results were normal and the physician reassured the patient that he did not have cancer.  However, the patient reports that he has noticed occasional stomach noises after eating and would like to have additional testing done.  Which of the following is the most likely diagnosis?

A 65-year-old woman comes to the office accompanied by her husband for follow-up of hypertension.  She has been prescribed a thiazide diuretic, and her dose was increased at the last visit due to poorly controlled blood pressure.  At today's visit, the patient's blood pressure remains elevated.  Her husband says, "I'm trying to do everything I can to get her blood pressure under control.  I cook healthy food and remind her to take the medication, but I'm not sure she's taking it."  The patient says, "Taking the medication is a hassle; I know my pressure has been high but I feel absolutely fine."  Which of the following responses by the physician is the most appropriate?

A 5-year-old girl is brought to the office by her mother, who is concerned after observing her daughter speak to an empty chair in her room on several occasions.  The girl's medical history is significant for preterm birth at 36 weeks gestation but is otherwise noncontributory.  Her family history is significant for cerebrovascular accident and depression in her maternal grandfather and schizoaffective disorder in her father.  When questioned, the patient says she sees her grandmother at night and likes to speak to her before she goes to bed.  The grandmother died 2 months ago and had lived in the family home.  For a few weeks following the death, the girl would become tearful and frequently ask her parents when her grandmother would be coming back.  Which of the following is the most likely diagnosis in this patient?

A 59-year-old man comes to the office for follow-up.  The patient had an acute myocardial infarction 1 month ago, and a drug-eluting stent was placed successfully.  He has no cardiovascular symptoms, but he does have hypertension and hyperlipidemia and a 40-pack-year smoking history.  Blood pressure is 132/86 mm Hg and pulse is 68/min.  BMI is 30.8 kg/m².  Physical examination is unremarkable.  The patient says, "I can't wait to get back to work, but at the same time, I'm concerned about having another heart attack.  I have a high-pressure job, but I need to find time to exercise.  Plus, I know I should stop smoking and lose at least 20 pounds."  Which of the following is the most appropriate response by the physician at this time?

An 80-year-old man is brought to the emergency department by his son due to acute shortness of breath.  The patient reports a chronic cough and a 13.6-kg (30-lb) weight loss over the past 6 months.  Chest x-ray demonstrates a large mass in the right lung and an associated pleural effusion.  The patient is hospitalized and undergoes bronchoscopy with biopsy; the pathology report comes back as bronchogenic carcinoma.  When the physician initiates a private discussion about the biopsy results, the patient says, "I prefer not to be told anything.  You can discuss everything with my son.  I trust his judgment."  The patient is cognitively intact without signs of mental illness.  Which of the following is the most appropriate response by the physician?

A 24-year-old man is brought to the emergency department by police and emergency medical services personnel due to aggressive behavior toward his girlfriend.  She reports that he has no history of medical or psychiatric illness and that this behavior is new.  During transport, the patient was combative and difficult to restrain.  He currently appears agitated, disoriented, and confused and seems to be responding to internal stimuli.  Temperature is 37.2 C (99 F), blood pressure is 170/96 mm Hg, pulse is 118/min, and respirations are 20/min.  Nystagmus and ataxia are present on initial neurologic examination.  The patient does not cooperate with urine toxicology testing.  His symptoms begin to resolve after 8 hours in the emergency department.  He has very poor recollection of the previous night's events.  Which of the following substances is most likely causing the constellation of symptoms seen in this patient?

A 33-year-old man is hospitalized after neighbors called the police to report that he has been singing loudly and playing the piano "nonstop" all day and night for the last month.  The patient says his mood is "terrific," claims he is related to the President, and hears voices telling him he is going to be a famous entertainer.  While in the hospital, he makes inappropriate sexual advances toward some of the female nurses.  He has a history of 9 psychiatric hospitalizations starting at age 22 for mood and psychotic symptoms.  In between hospitalizations, the patient has heard voices commenting on his appearance and has believed that secret cameras have been monitoring him, but he has had no mood symptoms.  Which of the following is the most likely diagnosis in this patient?

A 43-year-old woman comes to the office for an initial appointment due to ongoing abdominal pain, general weakness, decreased appetite, and dizziness.  She says the pain is ruining her life and is worried that her previous physicians may have missed something.  Over the past several years, the patient has been hospitalized 3 times with similar symptoms.  No etiology for the pain has been identified despite extensive workups, including several abdominal CT scans and an exploratory laparotomy.  The patient describes chronic abdominal pain since adolescence and is concerned as the nonprescription analgesics she takes are ineffective.  She has no history of psychiatric diagnoses or substance abuse.  Physical examination, vital signs, and laboratory tests (including chemistry panel, complete blood count, and urinalysis) are within normal limits.  Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old woman comes to the office for a regularly scheduled prenatal appointment.  Her pregnancy has been going well and the patient says that she is thrilled to be having a baby after trying to become pregnant for several years.  She and her husband experienced considerable strain in their marriage as they went through multiple unsuccessful fertility treatments.  During the visit, the physician orders some blood work and performs a 1-hour glucose challenge test.  The patient becomes apprehensive when this is mentioned and begins to ask questions about the purpose of the testing.  When asked about her concern, she confides that the fetus is not her husband's child.  Her husband is also the physician's patient, and she asks the physician not to tell him about this because "it will ruin everything."  Which of the following is the most appropriate response by the physician?

A 26-year-old man is brought to the emergency department by police after assaulting customers in a restaurant.  He explains that he meant no harm and was just trying to talk to people and touch them to "heal their pain."  The patient has been up all night for the past 10 days devising a global strategy to end world hunger and has written a hundred-page manifesto documenting his ideas.  Over this same period, he began hearing a voice telling him that he is "God's true son" and will need to sacrifice his life.  The patient has no psychiatric or medical history.  He drinks alcohol socially but does not use illicit drugs.  Physical examination is normal.  On mental status examination, the patient paces continuously.  His mood is very irritable, and his speech is loud, rapid, and difficult to interrupt.  Which of the following is the most likely diagnosis in this patient?