Exam 2: Behavioral science

A 30-year-old woman comes to the gynecologist's office for an annual physical examination.  The patient is in good health and does not report any symptoms.  She shares that she has been reading about tubal ligation and would like to undergo the procedure because she is tired of using oral contraceptives and does not want to have children.  She has had no adverse effects to oral contraceptives.  The patient has been married for 10 years and describes the relationship as very stable.  Which of the following is the most appropriate response to the patient's request for tubal ligation?

A 14-year-old girl is brought to the office by her parents for a sports participation examination.  The patient is a competitive figure skater and practices before and after school 5 days a week.  Her parents are concerned because she recently announced that she will eat only a vegetarian diet, and they are having difficulty providing an adequate variety of meat-free food options around her busy school and athletic training schedule.  The patient is otherwise healthy; menarche occurred at age 12 and she has regular menstrual cycles.  Vital signs are normal.  BMI is 17 kg/m².  Physical examination is normal for age.  Which of the following is the most appropriate next step in management of this patient?

A 19-year-old college student comes to the office with new-onset fatigue.  The patient has had difficulty getting up in the morning for the past week and states he would sleep 10-12 hours if his schedule allowed.  He also reports vivid dreams.  The patient was diagnosed with attention-deficit hyperactivity disorder at age 10 and has been treated with dextroamphetamine since then.  However, his prescription ran out early recently after he doubled the dosage to help him study during exams.  Which of the following findings is most likely to be present in this patient?

A 48-year-old man comes to the office with his wife for follow-up of major depressive disorder.  The patient has been taking sertraline for 2 years, and due to a recurrence of depression, he started bupropion and weekly cognitive behavioral therapy 3 weeks ago.  Since then, his energy level has improved, and he is working on communicating more with his wife about his emotions.  The patient has no suicidal ideation and is hopeful that he will feel better with continued treatment.  A week later, his wife calls the office and states that her husband died by suicide a few days ago.  She is tearful on the phone and says, "I thought that he was doing better.  I don't understand how this happened."  Which of the following is the most appropriate response?

A 60-year-old woman comes to the office due to uncontrollable movements that have worsened.  Medical history is significant for hypertension, hyperlipidemia, osteoarthritis, and schizophrenia, and she has been on a stable medication regimen for years.  Throughout the interview, she exhibits facial grimacing, lip smacking, and twisting movements of her hands and feet.  The patient has lived in a group home for many years and worries that her housemates are avoiding her because her symptoms make her look "strange."  On mental status examination, the patient makes poor eye contact and is generally distrustful but has no specific delusions or hallucinations.  Which of the following is the most likely diagnosis?

A 72-year-old retired man with end-stage renal disease becomes agitated during dialysis and attempts to abruptly leave in the middle of the procedure.  The patient accuses the staff of violating his rights and stealing his belongings but then appears to fall asleep.  Fifteen minutes later, he becomes violent and requires restraints.  Medical history is significant for hypertension, type 2 diabetes mellitus, hyperlipidemia, and peripheral vascular disease.  The patient has a history of major depression that has been in remission for 15 years.  His wife says that he has experienced mild memory and word-finding difficulties over the last year and that he often needs to make lists to remind himself of errands; however, she has never witnessed this type of agitated behavior.  Temperature is 38.3 C (100.9 F), blood pressure is 112/63 mm Hg, pulse is 93/min, and respirations are 18/min.  The patient has a left carotid bruit, and a dialysis catheter is present in the right internal jugular vein.  Bronchial breath sounds are heard at the right lung base.  During neurologic evaluation, he is confused but cooperative with no focal findings.  Which of the following is the most likely explanation for this patient's current behavior?

An 18-year-old man comes to the office for a follow-up visit.  He was seen in the emergency department 3 months ago because of panic attacks related to cocaine use.  The patient subsequently stopped using cocaine and has had no recurrent anxiety symptoms.  He graduated from high school, started a new job, and has been considering applying to community college.  At today's visit, the patient reports that he used cocaine at a friend's house this past weekend.  He says, "I really messed up.  I feel like a failure."  The patient has no history of illness.  He is in no physical discomfort.  Which of the following is the most appropriate statement by the physician at this time?

An 11-month-old boy is brought to the office by his mother for a well-child visit.  The mother reports that he has been crying and screaming when other people approach him.  She is concerned that it has been occurring for the past few months and that it seems to be worsening.  She says, "He used to love being held by everyone but now wants to be with only me.  He won't even let his grandma hold him anymore."  The patient is crawling and can stand only with assistance.  He babbles but does not say any clear words and uses hand gestures to communicate.  Growth curves are tracking adequately.  On physical examination, the patient clings to his mother and begins crying, turning his head away from the physician when he attempts to interact with him.  Which of the following is the most likely explanation for this patient's behavior?

Over the next several months, there are more cases in which expired medications fail to be renewed.  Finally, a patient on intravenous dobutamine for decompensated heart failure does not receive the medication for 6 hours and experiences worsening of her condition, with resulting hypotensive shock.  Hospital administration convenes a committee to address this incident.  Which of the following is the most appropriate next step in addressing this problem?

A 33-year-old man comes to the office for a routine health maintenance visit.  The patient states he wants to make sure he is taking care of his health after his father had a myocardial infarction a few months ago at the age of 61.  He has been eating healthy and exercising 3 to 4 times a week.  Past medical history is noncontributory, and the patient takes no medications.  He shares that his aunt is an herbalist and recently gave him a supplement that is supposed to help prevent cardiovascular disease.  The patient asks whether it is okay to start taking the supplement and provides a list of the ingredients, which includes herbs unfamiliar to the physician.  Which of the following is the most appropriate response?

A 28-year-old man is brought to the emergency department by his roommate, who is concerned about his change in behavior over the past 2 weeks.  The roommate describes the patient as "a regular guy who is usually very responsible."  Last week, the patient abruptly quit his job as a computer programmer and started placing large bets on an online gambling site because he was "sure to make millions."  The roommate says that the patient has been staying up most nights scribbling notes for his autobiography on small scraps of paper.  The patient says, "My new mission is to spread understanding."  He denies any alcohol or drug use, which his roommate affirms.  This patient is most likely to exhibit which of the following additional findings?

A 39-year-old man is brought to the office by his wife who is concerned about his behavior over the past year.  She says, "He used to be outgoing and upbeat, but now he seems uncharacteristically depressed and distant from the family.  He has lost interest in his work and has difficulty making decisions."  Over the past month, he has become increasingly paranoid and believes that his business partner is trying to kill him.  The patient has no psychiatric history.  Both his father and grandfather were hospitalized in long-term care facilities and died in their 50s.  Physical examination shows random, abrupt, uncoordinated movements of the left leg.  On mental status examination the patient is restless and irritable.  He is convinced that not only his business partner but also the government is out to harm him.  Which of the following is the most likely diagnosis?

A 78-year-old man with end-stage esophageal cancer is admitted to the hospital with severe malnutrition and failure to thrive.  The patient's caretaker says that he has not been able to eat or drink for the last 3 weeks.  His weight dropped from 72.6 kg (160 lb) to 63.5 kg (140 lb) during that time.  The cancer has spread to his lungs and liver.  The patient does not wish to receive any further treatment for the cancer and specifies that he wants no heroic measures or interventions to keep him alive.  His physician considers referral to hospice care.  Which of the following is a requirement for referring a patient for hospice care?

A 38-year-old woman comes to the office due to worsening dysmenorrhea and tension headaches for the past 3 months.  She was recently promoted to school principal and says, "It is more stressful than I anticipated; I often have to work late to catch up on paperwork and am not sleeping very well."  The patient is married and has no children.  While answering questions regarding her sexual history, she bursts into tears.  When the physician asks the patient what is upsetting her, she covers her face and says she was sexually abused as a child.  Which of the following is the most appropriate response to the patient?

A 39-year-old disheveled homeless woman walks into the emergency department complaining of abdominal pain.  The woman smells strongly of alcohol and seems disoriented.  She describes the abdominal pain as "real bad" but cannot specify when the pain first started, where it is localized, or what factors exacerbate or relieve the pain.  She then adds that she does not have health insurance and has no money to pay for her care.  What is the next best step in handling this situation?

A 36-year-old man is brought to the hospital after being found wandering the streets barefoot and shouting to himself.  Although he takes antipsychotic medication daily, his parents are having difficulty managing him at home.  The patient believes he is fighting a conspiracy and that his thoughts are directly controlled by a device that was implanted in his brain during a prior hospitalization.  Previous trials of haloperidol, quetiapine, and risperidone resulted in minimal improvement.  He has no other medical problems.  On mental status examination, the patient is alert, and restless with poor grooming, disheveled clothing, and flat affect.  He refuses to answer most questions, accuses his parents of being part of the conspiracy, and mumbles nonsensical words.  Which of the following medications would be most effective for this patient's illness?

A 69-year-old woman comes to the office due to memory concerns.  The patient first began having difficulties with her memory a year ago, and her symptoms have steadily worsened.  She often forgets the content of conversations she has with her son and frequently walks to another room, only to forget what she went there to do.  The patient lives alone and has no difficulty cooking, cleaning, or otherwise caring for herself.  She manages her own finances.  Medical history is significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus.  Temperature is 36.9 C (98.4 F), blood pressure is 132/83 mm Hg, pulse is 72/min, and respirations are 14/min.  The patient is alert and oriented.  Neurological examination reveals no focal deficits.  She scores 22/30 on the Montreal Cognitive Assessment.  Which of the following is the most likely diagnosis?

A resident physician is on her way to morning signout after her overnight shift and gets into an elevator crowded with nurses and other hospital staff members.  The medical student on the team gets on the elevator and asks the resident how her shift went.  During the conversation, the student is careful not to mention the patient's name, asking, "Did the patient in Room 232 get her CT scan?"  Which of the following is the most appropriate response to the student?

A 55-year-old, previously healthy man is brought to the office by his wife after being forced into early retirement due to poor work performance.  The patient was a financial planner but began missing important deadlines and mismanaging his client's accounts 6 months ago.  He became more irritable during this time and started to curse at and insult his coworkers when they expressed concern about his performance.  The patient has also become verbally abusive toward his wife but appears indifferent to the hurt he causes.  She has had to take over the finances and grocery shopping.  She adds, "My husband has developed quite the sweet tooth.  He eats almost two boxes of cookies a day now."  Physical examination is unremarkable.  This patient is most likely to have which of the following neuropathologic findings?

A 72-year-old woman is admitted to the hospital due to abnormal vaginal bleeding.  Uterine cancer is diagnosed and the patient is scheduled for a hysterectomy.  Following successful surgery, the patient compliments her surgeon, exclaiming that she is "a brilliant doctor who saved my life."  After an uneventful recovery, the patient is ready to return home.  On the day of discharge, a nurse informs her that the surgeon is running late due to an emergency.  The patient responds angrily that the surgeon is "terrible and doesn't care about patients."  Which of the following is the most likely explanation for this patient's behavior?