Exam 2: Behavioral science

A 34-year-old man comes to the emergency department for evaluation of abdominal pain.  He reports severe pain unrelated to meals that is sharp, stabbing, and 10 out of 10 in severity.  The patient has been hospitalized twice in the past year for similar symptoms and states that a diagnosis was never found.  He declines when asked to sign a release of information to obtain his prior medical records.  Vital signs are within normal limits.  On physical examination, heart and lung sounds are normal.  Abdomen is soft and nondistended with normoactive bowel sounds.  The patient grimaces and moans in pain throughout the evaluation.  Laboratory evaluation and abdominal CT scan show no abnormalities.  After hearing the results, the patient asks for a note to excuse him from work so that he can recover at home for a few days.  Which of the following additional features is most likely to be present in this patient?

A 26-year-old woman comes to the office due to recent weight gain.  She has eaten more than usual over the last 5 months, has gained 3.2 kg (7 lb), and feels guilty and depressed about it.  Further questioning reveals that she consumes a large pizza and two large bags of chips in one sitting several times a week.  Afterward, the patient feels ashamed about being unable to control her intake and fasts to make up for it.  She is very distressed about being unable to lose weight despite exercising 2-3 hours a day.  Vital signs are within normal limits.  BMI is 23.7 kg/m².  Despite being told that her BMI is normal, the patient insists that she is overweight.  Which of the following is the most likely diagnosis?

A primary care physician is invited to give a presentation to a local employer.  He is a member of a large multi-specialty medical group, which he joined less than a year ago after completing residency.  During the presentation, the physician discusses the various medical specialties available within the group, as well as the range of ancillary services the group offers at its facilities.  In the ensuing discussion, the physician learns that the employer has been facing financial difficulties.  The employer wishes to continue offering health care coverage to its employees but needs to reduce expenditures.  As a result, the employer would like to negotiate a contract in which the medical group would provide care to all the company's employees in exchange for a set monthly fee per employee.  Which of the following payment methods best describes this type of health care financing arrangement?

A 46-year-old woman is hospitalized due to severe depression and fatigue.  She has no other medical problems.  Routine laboratory tests are ordered and the patient is started on antidepressant medication.  After a week, her depression improves slightly and she is discharged home to continue with outpatient care.  However, the patient remains severely fatigued and is unable to return to her job, forcing her to take a leave of absence.  At her follow-up appointment 2 weeks later, review of the hospital record by the outpatient physician reveals a TSH level of 15.2 µU/mL that was never addressed by the inpatient physician.  Subsequent evaluation and treatment with thyroid hormone result in rapid improvement of her depression and fatigue.  Which of the following is the appropriate categorization for this type of medical error?

An 8-year-old boy is brought to the office due to severe behavioral problems.  The patient has been suspended from school on two occasions over the past year due to running around in the classroom and talking back to his teachers.  His parents report that he is "in constant motion" and are concerned about his poor grades and inability to follow directions or household routines.  The patient has a history of mild asthma and no other medical problems.  There is a family history of schizophrenia in a maternal uncle.  Physical examination shows marked fidgeting and difficulty staying seated but is otherwise normal.  The boy frequently interrupts his mother while she speaks with the physician.  Treatment with methylphenidate is recommended.  The parents should be educated about which of the following regarding this medication?

A male newborn, born at 39 weeks gestation, is evaluated in the labor and delivery unit 2 hours after birth.  Prenatal care was limited due to infrequent follow-up, and there were no complications during the delivery.  Apgar scores were 7 and 9 at 1 and 5 minutes, respectively.  Weight is 2.47 kg (5 lbs, 7 oz) and vital signs are normal.  Physical examination shows upslanting palpebral fissures, transverse palmar creasing, and widening of the space between the first and second toes.  The parents share that they are glad the delivery went well.  Which of the following is the most appropriate statement by the physician at this time?

A 32-year-old man is diagnosed with major depressive disorder and started on the selective serotonin reuptake inhibitor sertraline.  At his 2-week follow-up, the patient reports that his mood is "about the same."  He continues to feel sad and unmotivated most days and is short-tempered with his wife and kids.  He has little interest in food, sleeps poorly, and struggles to stay focused at work.  In the first 2-3 days of taking the medication, the patient experienced some mild nausea and anxiety that has since resolved.  He is now tolerating the medication without difficulty but is considering stopping it because he is discouraged by the lack of clear improvement.  Which of the following is the most likely explanation for this patient's lack of response?

A 31-year-old woman comes to the office for a yearly checkup.  The patient has no medical conditions but expresses dissatisfaction with her appearance and wishes she could lose weight more easily.  She reports occasional constipation and fatigue.  The patient exercises daily and drinks 1 or 2 glasses of wine 2-3 times a week when socializing with friends.  Weight is 58.1 kg (128 lb) and height is 157.5 cm (5 ft 2 in).  BMI is 23.4 kg/m².  Routine laboratory evaluation shows a potassium level of 3.1 mEq/L.  Physical examination is most likely to show which of the following abnormalities?

A 37-year-old woman with a history of recurrent major depressive disorder comes to the office.  Her father died last month after a long illness, and she is concerned that her depression is returning.  The patient has little appetite, sleeps poorly, and has difficulty concentrating at her job as a teacher.  She recently stopped going to the gym and socializing with friends, activities that she used to enjoy.  She has been collecting pills from half-empty bottles of old medication and has considered taking all of them at once.  The patient has no history of suicide attempts.  Her mother completed suicide at age 40.  Which of the following is the most important factor in assessing this patient's suicide risk?

A 38-year-old recently homeless woman and her 35-year-old boyfriend come to a community clinic seeking care for her pregnancy at 27 weeks.  She also brings her 19-year-old son, who has cerebral palsy and has not had consistent medical care.  The patient explains to the social worker that the family was recently evicted from their apartment for failure to pay rent after her boyfriend lost his job.  Which of these individuals is eligible for Medicare coverage?

A 42-year-old man comes to the office for a checkup.  He has no medical symptoms but says, "I'm just feeling stressed and not like myself."  The patient is going through a contentious divorce.  He is outraged that his wife is pursuing full custody of their children and says, "I can't believe she is doing this to me."  His job as a legal researcher had been a welcome distraction from his upsetting personal life until yesterday when he was called to his supervisor's office for yelling at the receptionist when the copy machine ran out of ink.  Which of the following is the best explanation for this patient's behavior toward the receptionist?

A 40-year-old woman with major depression comes to the office for follow-up.  She has been taking paroxetine daily for the past year.  The patient is doing fairly well but is concerned that she experiences periods of low mood on occasion.  When asked how she is taking the medication, she states, "I know the bottle says once a day, but I usually take an extra pill when I feel sad and skip it if I'm having a good day."  Vitals signs are within normal limits.  Physical examination shows no abnormalities.  Which of the following is the most appropriate next step in management?

A 26-year-old man is hospitalized after he was found in the park shouting and laughing to himself.  He insists on wearing a cap lined with several layers of aluminum foil and explains that the hat prevents laser beams from reprogramming his mind.  For the past 3 years, the patient has been hearing the voices of his deceased mother, the devil, and a world-famous singer.  He has had one previous psychiatric hospitalization, during which he responded well to haloperidol.  However, the patient stopped the medication shortly after discharge because he did not like the way it made him feel.  A decision is made to administer a second-generation antipsychotic medication.  Compared with first-generation antipsychotics, this class of medication is associated with which of the following?

A 13-year-old boy is brought to the physician by his mother for a routine physical examination and follow-up of type 1 diabetes mellitus.  The patient appears irritated, and his mother begins the visit by exclaiming, "Here's the doctor; he's going to tell you how badly you've been doing."  Laboratory tests show a random blood glucose of 350 mg/dL and a hemoglobin A1c of 9% (normal: <6%-7%).  When the physician asks the patient how he is doing with his insulin, the mother interrupts and shouts, "He never remembers to use it!"  When the boy is asked about his diet, the mother puts her hands on her hips, glares at her son, and says, "Pizza, soda, and candy!"  After acknowledging the mother's concerns regarding diabetic control, which of the following is the most appropriate course of action?

A 32-year-old woman comes to the office due to overwhelming anxiety and stress.  The patient is an accountant and has been under increasing job-related pressure for the past 6 weeks due to an upcoming tax deadline.  She says, "The worst part is that I get really nervous all of a sudden and then feel shaky, dizzy, and nauseated and start to sweat.  It happened while I spoke to my boss a few weeks ago, and I had to excuse myself."  The patient is especially worried about having an episode during a work meeting, although she notes that her symptoms have also occurred while she was relaxing at home.  She says, "I've stopped going out with my friends because I never know when I'm going to feel this way."  The patient has no significant medical history and does not use alcohol or drugs.  Blood pressure is 120/70 mm Hg, pulse is 72/min, and respirations are 18/min.  Physical examination and laboratory evaluation show no abnormalities.  Which of the following is the most likely diagnosis?

A 34-year-old woman comes to the office accompanied by her husband for an employment physical examination.  The patient says, "I'd rather not be here, but my job requires labs every 2 years."  While getting blood drawn, she starts to feel anxious, nauseated, and short of breath, and says, "I feel like the room is spinning."  The patient's husband explains that she has had similar episodes since childhood, which began following a bike accident during which she cut her knee and bled profusely.  Medical history is significant for asthma and type 2 diabetes mellitus.  Temperature is 36.7 C (98.1 F), blood pressure is 140/90 mm Hg, pulse is 104/min, and respirations are 20/min.  BMI is 36 kg/m².  Physical examination is significant for anxious demeanor but is otherwise unremarkable.  Which of the following is the most likely diagnosis?

A 16-year-old girl is brought to the office by her mother due to nonspecific stomachaches and pains.  She has no other medical history.  The patient has missed more than 10 days of school due to the symptoms since the academic year started 6 months ago.  The mother says that her daughter has always been anxious with a "sensitive stomach," but the symptoms have worsened since the patient's best friend moved away a month ago.  She has a few other friends but prefers to stay home and does not participate in after-school activities.  The mother says, "She worried for weeks about going to a party.  On the night of the party she had an anxiety attack and started hyperventilating.  She ended up not going to the party at all."  The patient says she is "just very shy" and is afraid of being embarrassed or "looking stupid" around others.  Physical examination shows no abnormalities.  During the interview, the patient makes little eye contact and gives brief answers to questions.  Which of the following is the most likely diagnosis?

A 22-year-old woman is brought to the emergency department for bizarre behavior over the past week.  Her parents state that she has been "talking nonsense" nonstop, laughing for no reason, and has not slept for several days.  During triage, the patient attempted to hit a staff member, resulting in administration of haloperidol.  While awaiting further evaluation, the parents alert the nurse that the patient is starting to "make weird faces" while sticking out her tongue.  Medical history is noncontributory, and the patient takes no medications.  Urine drug screen is positive for cannabis and opiates.  Which of the following is the most likely explanation for this patient's motor symptoms?

A 68-year-old woman comes to the office to discuss lipid-lowering therapy.  She was prescribed rosuvastatin 6 months ago following a transient ischemic attack, but her pharmacy sent a notice to the physician a week ago that she has not filled her prescription for the past 3 months.  The patient otherwise feels well and has had no recurrent neurologic symptoms.  When asked why she is not taking her medication, she says, "I feel great without it.  The ministroke was the scariest thing that ever happened to me, and now that I have put it behind me, I don't want the medication to remind me about my problem all over again."  Which of the following is the most appropriate response to this patient's statement?

A 32-year-old woman comes to the emergency department requesting medication for severe back pain.  She has tried multiple over-the-counter agents and says that nothing has relieved her pain except oxycodone.  The patient was seen in a pain clinic a year ago but cannot recall the name of the physician and says that her prescription has run out.  Medical history includes a motor vehicle collision 10 years earlier and obesity.  Temperature is 37.1 C (98.8 F), blood pressure is 130/80 mm Hg, pulse is 76/min, and respirations are 16/min.  Physical examination shows no abnormalities.  A recent MRI was normal.  The patient says that her pain level is 10 on a scale of 0-10 and becomes frustrated when the physician suggests nonprescription pain medication.  Which of the following is the most appropriate next step by the physician?