Exam 2: Behavioral science

A 62-year-old woman comes to the office for follow-up of worsening hypertension.  The patient admits to not taking her antihypertension medication as prescribed.  She says she feels fine and adds, "I always listen to my bodily rhythms when deciding whether to take medication on a particular day."  The patient explains that her crystal jewelry has healing powers, and she maintains an online forum about the health benefits of crystals.  The patient does not trust most people and believes that she can predict the weather based on the number of birds in her yard.  She lives alone, has few friends, and is unemployed.  On examination, the patient makes limited eye contact and appears mildly anxious.  She has no auditory hallucinations, and no specific delusions are elicited.  Which of the following is the most likely explanation for this clinical presentation?

A medical student just finished the USMLE Step 1 exam and is anxious about her performance.  She is especially unnerved when fellow students talk about the difficulty of the exam and discuss their answers to certain questions.  The student decides not to think about the exam until her score arrives because "worrying isn't going to change the result."  She is delighted when she receives a very high score several weeks later.  Before receiving the result, the student exhibited which of the following defense mechanisms?

An 82-year-old man with a history of advanced Alzheimer dementia is brought to the hospital by his daughter, who is his power of attorney and caregiver.  She says that her father is increasingly confused and verbally aggressive.  He is admitted to the hospital and found to have a urinary tract infection.  Intravenous antibiotics are initiated and he appears less disoriented and agitated but remains unable to recall nursing instructions throughout the day and is fairly nonverbal.  Three days into his treatment, the antibiotic order expires and is missed by the physician, nurses, and pharmacy staff.  The patient receives no medication for 2 days before the error is noted and corrected.  There are no consequences to this error other than extension of his hospital stay by 2 days.  Which of the following is the most appropriate course of action?

A 27-year-old woman is brought to the emergency department by her employer due to increasingly paranoid and disorganized behavior over the past year.  The patient works as a housekeeper and has had progressive difficulty performing her work responsibilities.  She has become increasingly secretive over the past 6 months and recently started talking in a whisper because she believes that listening devices are planted in the walls.  Over the past month, she started hiding food and personal possessions in closets and under beds.  The patient does not use alcohol or illicit drugs.  Vital signs are stable, and physical examination is unremarkable.  During the interview, she changes topics frequently and rambles about voices harassing her.  Which of the following additional mental status findings is most likely in this patient?

A 45-year-old woman with type 2 diabetes mellitus, obesity, and hypertension comes to the office for a routine follow-up visit.  Her medications include a sulfonylurea and ACE inhibitor.  The patient has lost 2.3 kg (5 lb) and credits a new energy and weight loss supplement.  She purchased the supplement over the Internet on the recommendation of a friend and believes that it contains caffeine and several herbs that promote weight loss.  The patient has had no problems tolerating the supplement.  Blood pressure is 140/90 mm Hg and pulse is 88/min.  Which of the following is the most appropriate response by the physician?

An 11-year-old girl is brought to the office due to disruptive behavior at home and at school.  Her parents report that she gets in trouble for talking during class and not following instructions.  Although the patient is of above-average intelligence, her grades are poor.  Teachers note that she makes careless mistakes while rushing through tests and frequently forgets to hand in assignments.  At home, she is easily distracted while trying to focus on her homework.  The patient has frequent conflicts with her mother, who says, "Getting her ready for school in the morning is impossible.  We're frequently late because she always misplaces her cell phone and books."  The patient has no other medical history, and developmental milestones are within normal range.  Physical examination shows no abnormalities.  The girl and her parents are willing to consider medication if it will help.  A drug with which of the following mechanisms of action is most appropriate for this patient?

A 38-year-old man comes to the office for evaluation of discomfort in his wrists.  He thinks his symptoms may be related to "typing all day, every day."  The patient is a software engineer and prefers to work remotely from home to "avoid wasting time talking and interacting with coworkers."  He rarely leaves his apartment and spends his spare time on his computer, reading online forums about space exploration and the possibility of alien life.  When asked about relationships he says, "I've always liked being on my own."  He spent a large portion of his childhood disassembling and rebuilding electronic devices and had few friends.  His affect appears constricted and his responses to questions are limited.  Which of the following is the most likely personality disorder in this patient?

A 22-year-old college student comes to the office due to tension headaches and neck pain.  He has had these symptoms for many years, but they have increased in frequency over the past 7 months since he started working at a coffee shop. The patient attends college and says that although his grades are passing, he feels overwhelmed and fatigued: "I can't concentrate on my schoolwork and worry that I will flunk out of school and never get a good job."  He sleeps very fitfully and frequently worries about his grades, health, and social life.  He obsesses about minor comments his friends have made about how "serious" he is, and gets depressed thinking that he is not attractive enough to get a girlfriend.  Which of the following is the most likely diagnosis in this patient?

While having dinner at a restaurant with a colleague, a physician notices one of his patients sitting at a neighboring table with her husband.  When exiting the restaurant, the patient approaches the table and exchanges some brief pleasantries with the physician's colleague.  She then nods briefly in the physician's direction but says nothing to him.  The physician acknowledges the gesture with a smile.  Afterward, the physician's colleague asks, "Is she your patient?  She's a family friend who was recently diagnosed with breast cancer.  I have been worried about her and wonder how she's doing."  Which of the following is the most appropriate response by the physician to his colleague?

A 38-year-old man is brought to the emergency department by ambulance due to severe abdominal pain and undergoes an emergency appendectomy.  Following a successful operation and recovery, the patient questions whether the appendectomy was absolutely necessary.  He doubts the surgeon's explanation that the surgery was potentially lifesaving, angrily suggests that the hospital is taking advantage of his excellent medical insurance, and makes vague threats to sue the hospital.  He asks to be discharged immediately, and explains, "I've earned everything I have on my own, and this hospital isn't getting any of it."  When asked if he has any relatives or friends the team can speak with, he says, "I haven't talked to my family in 20 years, and I wouldn't call anyone my friend.  Even if I did, that's none of your business."  Which of the following is the most likely explanation of this patient's behavior?

A 28-year-old man comes to the office due to frequent anxiety attacks over the past several months.  He says, "At first I shook it off because the attacks subside rapidly, but now I'm worried it will happen again while I'm at work or driving.  All of a sudden I feel faint, start to shake and sweat, and my heart starts racing.  I thought my heart was going to jump out of my chest."  The patient has no history of cardiac disease and takes no medication.  He has a history of alcohol use disorder in his early twenties and smokes marijuana occasionally.  The patient appears calm and his vital signs are within normal limits.  Physical examination and ECG show no abnormalities.  Which of the following is the most appropriate pharmacotherapy?

A 29-year-old woman comes to the office due to depression.  Since breaking up with her boyfriend last month, she has been extremely sad and has difficulty getting out of bed.  She describes sleeping 16 hours a day, increased appetite, a 4.5-kg (10-lb) weight gain, low energy, decreased concentration, and loss of interest in socializing with her friends and family.  The patient had 2 similar episodes at age 23 and 27.  She also describes brief periods in the past, lasting several days, when she was uncharacteristically confident and optimistic, successfully juggled 3 part-time jobs, and felt well rested and energetic despite sleeping only 3-4 hours a night.  The patient drinks a glass of wine several times a week but does not use tobacco or illicit drugs.  Which of the following is the most likely diagnosis?

A 79-year-old man is undergoing evaluation for hospital admission due to an exacerbation of chronic obstructive pulmonary disease.  His wife expresses concern about his health due to multiple hospitalizations over the last year for various complications related to his comorbidities.  The patient has smoked cigarettes daily for more than 50 years.  Medical history includes coronary artery disease, type 2 diabetes mellitus, and obesity.  After performing a thorough history and physical examination, the physician prepares to admit the patient and decides to continue his existing medications for diabetes and heart disease.  Admission orders also include supplemental oxygen, bronchodilators, antibiotics, and systemic corticosteroids.  Which of the following additional components is most critical to include during the admission process?

A 17-year-old girl is brought to the office by her parents for evaluation following the accidental drowning of her younger sister a week ago.  The patient, her sister, and 2 friends had gone swimming in the ocean.  When the sister became submerged, the patient attempted to rescue her but was overpowered by strong rip currents and was forced to return to shore.  The mother is concerned that her daughter seems to be unaware of her sister's death and believes she is "in denial."  The patient was unable to answer questions from the police about the drowning and reports she cannot remember any details of what happened that day.  Physical examination is unremarkable.  On mental status examination, the patient is alert and fully oriented.  She becomes upset and confused when the incident is discussed.  Which of the following is the most likely diagnosis?

A 71-year-old woman is brought to the emergency department with suicidal ideation.  Medical history includes major depressive disorder as well as chronic knee and back pain due to injuries sustained in a motor vehicle collision.  Developmental history is significant for physical abuse as a child.  Family history is significant for bipolar disorder and completed suicide in her father.  The patient reports increasing depression since losing her job a year ago and separating from her husband of 40 years 6 months ago.  She has a history of 2 prior hospitalizations for depression and a previous suicide attempt.  The patient is recovering from alcohol use disorder and attends weekly Alcoholics Anonymous meetings at her church.  Although she lives alone, she is close to her daughter, who lives nearby.  The patient reports that she owns a firearm that is kept in a locked cabinet.  Which of the following is the strongest risk factor for completed suicide in this patient?

An 18-year-old woman comes to the office due to low energy, decreased appetite, insomnia, poor concentration, and decreased interest in her daily activities.  She has lost 3.6 kg (8 lb) over the last month.  The patient has no psychiatric history and has no current or significant medical illnesses.  Physical examination and laboratory evaluation are unremarkable.  Treatment with medication is initiated.  Three weeks later, the patient is brought to the emergency department by her mother for not sleeping at all for 3 nights.  The patient reports that she does not feel tired despite lack of sleep.  She spent a large amount of money on plane tickets and plans to travel around the world to promote world peace.  Her mother adds that she herself has suffered from severe mood swings in the past.  This patient was most likely started on which of the following medications 3 weeks ago?

A 33-year-old woman is transferred to the university medical center from a small community hospital due to acute pyelonephritis with sepsis.  She has a history of recurrent urinary tract infections due to urinary retention related to a spinal cord injury in childhood.  On arrival, the patient is febrile and lethargic.  She provides no additional history, and the only information available is from poorly legible handwritten notes from the originating hospital.  The patient is admitted to the intensive care unit with orders to give imipenem and vancomycin.  Overnight, the patient develops a rash and severe respiratory distress requiring brief mechanical ventilation.  The following morning, a transcribed physician note from the originating hospital arrives by fax and indicates that the patient has an allergy to multiple antibiotics, including imipenem.  When discussing events with the patient and her family, which of the following statements is associated with reduced malpractice liability for the treating clinician?

A 3-year-old boy is brought to the office for a well-child visit.  His mother reports that, apart from an ear infection last year, he is in good health.  The child started preschool this year.  He plays alongside other children and often copies what they are doing but does not play cooperatively with them.  The patient knows his age and gender and speaks in 3-word sentences.  He can ride a tricycle.  The patient cannot use a spoon or fork but enjoys eating with his hands.  He scribbles spontaneously but cannot copy a circle.  He weighs 14.5 kg (32 lb) and is 96.5 cm (3 ft 2 in) tall.  Head circumference is 50.8 cm (20 in).  Which of the following developmental milestones is likely delayed in this patient?

A 25-year-old man is brought to the emergency department by his wife after vomiting at a party.  The patient admits to drinking 4 glasses of wine and some vodka and says he feels better now.  Temperature is 37.8 C (100 F), blood pressure is 100/50 mm Hg, pulse is 106/min, and respirations are 14/min.  Physical examination is remarkable for blood-tinged vomitus on the patient's shirt and shoes.  Abdominal examination reveals epigastric tenderness on palpation.  On mental status examination, the patient is alert, cooperative, and fully oriented.  Blood alcohol level is 70 mg/dL (0.07% blood alcohol content).  The physician recommends laboratory evaluation, including complete blood count, comprehensive metabolic panel, amylase, and lipase.  The patient insists that he is fine and wants to go home.  Which of the following is the most appropriate course of action?

An 18-year-old boy is brought to the emergency department by his mother due to his strange behavior.  The mother says that he laughs inappropriately and seems sluggish.  The boy has recently been hanging out with a new group of friends that he describes as "really cool."  He has also stopped attending family events and appears apathetic about his schoolwork.  When asked in private, the boy admits smoking marijuana.  Which of the following physiologic effects is most likely to be observed in this patient?