Exam 2: Behavioral science

A 22-year-old man comes to the emergency department due to sudden-onset pain and stiffness on one side of his neck.  He was diagnosed with a psychiatric disorder 2 days ago and has been adherent with his newly prescribed medication.  For the past few months, the patient has heard voices telling him to quit his job, and he believes that his girlfriend's parents are monitoring his sexual thoughts with a special device.  He has been socially withdrawn and has difficulty showering regularly.  Vital signs are within normal limits.  The head is tilted to one side and cannot be straightened without considerable pain.  The most likely cause of this patient's symptoms is antagonism of which of the following receptors?

A 46-year-old woman comes to the office due to sexual difficulties for the past year.  The patient rarely thinks about sex anymore and frequently declines sex when her husband tries to initiate.  She is attracted to her husband and worries that he assumes she is losing interest in him.  Although vaginal lubrication is adequate during sex and the patient can reach orgasm, she finds that her mind wanders during the experience.  She is unsure what is causing a decrease in her sex drive, although she notes that she received a promotion 3 months ago and has been working longer hours since then.  The patient describes her marriage as stable and loving.  She has a history of a depressive episode and currently takes bupropion.  Physical examination and laboratory studies, including thyroid function tests, show no abnormalities.  Which of the following is the most likely diagnosis?

A 45-year-old man comes to the office due to chronic insomnia.  The patient has trouble sleeping because he claims he must remain alert to protect himself from workers at a nearby chemical plant.  He says they are poisoning him by secretly dumping toxic waste in his backyard at night.  The patient's wife says, "He's been like this for the past 10 years.  He gets very upset when asked for proof, so he's going to install cameras next week."  She has never seen any unusual activity in the backyard and says that her husband has never received an actual threat or endured actual harm.  He has ordered numerous soil toxicity tests over the years, all of which have been negative.  The patient started working as a taxi driver at age 21 and continues to work for the same company.  He has no history of psychiatric treatment.  Which of the following is the most likely diagnosis for this patient?

A 52-year-old man diagnosed with advanced pancreatic cancer comes to the oncologist for follow-up.  His cancer is unresectable, and he has been receiving palliative treatment for the past 3 months.  The patient has had multiple previous discussions about his prognosis.  He has lost 22.6 kg (50 lb) and now feels too weak to play with his children.  During the visit, he says, "I am a survivor and know I can beat this.  I'm going to do whatever I can to be around for my kids."  Which of the following is the most appropriate response to this patient at this time?

A 13-year-old boy is brought to the office by his parents after being involved in a fight with another student at school.  His parents say, "He has never gotten into fights before, and we are getting worried because his grades have been declining as well.  He seems irritable and moody, stays in his room for hours at a time, and no longer invites friends home."  When interviewed alone about the incident, the patient says, "The wall people warned me that he was trying to poison my lunch."  The patient has no significant medical history; there is a family history of bipolar disorder in a paternal aunt.  Temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, pulse is 98/min, and respirations are 14/min.  Physical examination shows a postural tremor on extension of the arms and a broad-based gait.  Mental status examination is significant for slurred speech, sad mood, and distractibility.  Laboratory studies reveal elevated serum transaminases.  Which of the following is the most likely diagnosis?

An 80-year-old woman is brought to the office for follow-up of hypertension.  The patient is prescribed lisinopril but has not taken any in the past 2 weeks because she ran out of medication.  She has tried to contact her son to pick up a refill but has been unable to reach him.  The patient moved in with her son 2 months ago after he arranged for her house to be sold.  She says he stays at his girlfriend's house during the week, so she must find neighbors who are able to drive her places.  Medical history includes a cerebrovascular accident with mild residual weakness on the left side.  Temperature is 37 C (98.6 F), blood pressure is 156/88 mm Hg, and pulse is 80/min.  The patient is fully oriented.  Cardiopulmonary examination shows no abnormalities.  Gait and voluntary movements are normal.  On mental status examination, she appears tired and is wearing tattered clothing.  Which of the following is the most appropriate next step in management of this patient?

A 27-year-old man comes to the office for follow-up regarding a herniated disc.  He first injured the disc 3 months ago while at work.  Nonsurgical treatment options, including physical therapy and as-needed NSAIDs and tramadol, were recommended.  The patient has completed physical therapy, and follow-up MRI indicates that the herniated disc has regressed.  He reports a significant amount of ongoing pain and asks for a dose increase and refill of his pain medication.  In the past month, the patient has been to the emergency department on 2 occasions to request pain medication due to running out before his next scheduled refill.  Vital signs are within normal limits, and physical examination is unremarkable.  Which of the following statements by the physician would be most appropriate at this time?

A 5-year-old boy is brought to the office by his mother for a checkup.  He is healthy and about to start kindergarten.  His mother is concerned about his recent reaction to her brother's death.  "Although I told him that Uncle John died and can't be with us anymore, he insists that he is coming for his birthday and will take him to a ballgame.  He died over 3 months ago, but my son repeatedly asks me when he is coming back.  When I try to explain, he starts crying that his stomach hurts."  Physical examination is normal.  During the examination he tells the physician, "I try to clean up my toys before bedtime so mommy won't cry."  Which of the following is the most likely explanation for the patient's behavior?

A 13-year-old girl is brought to the office for a routine visit.  Although the patient is doing well in school and has friends, her mother is concerned about a change in her behavior over the past several months.  They had previously enjoyed spending time together, but now the patient is frequently moody and spends most of her time on the computer in her locked bedroom.  The mother also observes that her daughter gets upset for no reason and has used swear words on occasion.  When the mother recently complimented her party outfit, the girl screamed, "I look hideous and I'm not going," and stormed out of the room.  Later that day, she seemed fine and went to the party.  On examination, the patient is pleasant and cooperative but makes little eye contact and asks if she can keep her tank top on during the examination.  Which of the following is the most likely explanation for this girl's behavior?

A 64-year-old man comes to the office for follow-up after a myocardial infarction 6 months ago.  The patient's condition has slowly improved, although his clinical course was complicated by a pulmonary embolus and urinary tract infection.  During the appointment, the patient gives the physician homemade cookies and a thank-you card containing 4 tickets to a professional basketball game.  He says, "I would like to thank you for everything that you've done.  Please accept these tickets and enjoy the game."  He tells the physician not to worry about the expense, saying, "I get season tickets every year but haven't felt well enough to make it to the games.  You have been such a wonderful doctor, and I wanted to give you something to express my gratitude."  Which of the following statements is the most appropriate?

A 19-year-old Hispanic woman comes to the clinic due to nausea and abdominal pain.  She struggles to describe the pain and frequently points to her lower abdomen.  The patient shakes her head no when asked if she could be pregnant or is sexually active.  When she is asked about her last menstrual period, she nods affirmatively and says "now."  She is single and immigrated to the United States several months ago.  Physical examination shows moderate abdominal tenderness with no rebound or guarding and vital signs are stable.  The patient is discharged home with a diagnosis of food poisoning.  Later that day, she is taken by ambulance to the emergency department after experiencing severe abdominal pain followed by loss of consciousness.  A diagnosis of ruptured ectopic pregnancy is made.  Which of the following interventions would most likely have prevented the delay in diagnosis?

A 23-year-old woman comes to the emergency department due to right wrist pain after a fall.  The patient fell onto her outstretched hand while walking across the floor at a gym where she exercises regularly.  She has no significant medical history and takes no medications.  The patient says she has tried several diets to lose weight and is currently consuming a vegan diet.  Her last menstrual period was 3 months ago.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.1 C (97 F), blood pressure is 90/58 mm Hg, and pulse is 50/min.  BMI is 18.3 kg/m².  Weight is 50 kg (110.2 lb) and height is 165 cm (5 ft 5 in).  Physical examination shows tenderness and swelling over the distal radius.  The parotid glands are enlarged and there are fine, soft hairs on her extremities.  Urine pregnancy test is negative.  X-rays reveal a nondisplaced fracture of the right distal radius and generalized radiolucency of the bone.  Which of the following is the most likely diagnosis?

A 44-year-old man comes to the office due to fatigue for the past 6 months.  He says, "I've fallen asleep at work a few times, and I really have to push myself to concentrate.  I can't seem to get a good night's sleep either because I keep waking up."  The patient feels guilty that he has been spending less time with his kids due to feeling tired and states his mood has been low the past week.  He worries that his wife is annoyed with him because he has not been helping with household chores as much and keeps her up at night due to his snoring.  The patient drinks 3 or 4 beers a week and does not use tobacco or illicit drugs.  Medical history is noncontributory.  Blood pressure is 146/94 mm Hg and pulse is 78/min and regular.  BMI is 32 kg/m².  Which of the following is the most likely diagnosis?

A 29-year-old woman comes to the emergency department due to abdominal pain and fever.  This morning, while crossing a street, she was struck in the stomach by a motorcyclist.  On arrival, the patient tells the triage nurse that she does not have medical insurance.  She has no chronic medical conditions.  Temperature is 38 C (100.4 F), blood pressure is 109/82 mm Hg, and pulse is 88/min.  The abdomen is distended with bruising, rebound tenderness, and guarding.  The patient is told she needs exploratory surgery to treat her condition.  She refuses and states angrily, "I'm suffering and I'm not going to be a guinea pig for this system.  If I had insurance, you'd give me something that would actually cure me."  In addition to clarifying the details of the surgical procedure with the patient, which of the following is the most appropriate response by the physician?

A 40-year-old man comes to the office for evaluation of difficulty with concentration.  After reading a book on adult attention deficit hyperactivity disorder (ADHD), he thinks that he has ADHD and requests treatment with stimulants.  The patient has no history of childhood ADHD but states that his parents were unaware of the disorder and never had him evaluated.  He currently does not experience hyperactivity or impulsivity but says, "I just get easily distracted some days and know I could be more productive at work."  The patient does not use alcohol or use recreational substances.  Medical history is noncontributory.  Vital signs and physical examination are normal.  The physician shares that the patient's symptoms are not consistent with a diagnosis of ADHD.  The patient insists that he will benefit from stimulants.  Which of the following is the most appropriate statement?

A 13-month-old girl is brought to the office by her mother.  She is worried that there is something wrong and explains, "My daughter used to sit on her own and loved babbling and clapping her hands.  She still plays with her sisters and likes snuggles, but for the past 3 months she hasn't babbled as much, and can no longer sit without my help.  She twists her hands together and I cannot get her to stop.  I am worried that the skin on her hands is getting red, dry, and painful."  Weight and height are in the 60th percentile.  The patient's head growth, however, has decreased from the 50th to the 40th percentile in 3 months.  On examination, the child is globally hypotonic and unable to sit upright without being held.  She makes no sound apart from an occasional grunt.  She shows interest in toys the doctor provides her but does not reach out for them, wringing her hands repeatedly.  Which of the following best explains this patient's condition?

A 28-year-old man is hospitalized due to the acute onset of severe depression and suicidal ideation for several days.  He was recently thrown out of his mother's home after stealing her money to support his drug habit.  The patient reports fatigue and vivid, disturbing dreams.  The nursing staff note that he is irritable, withdrawn, hypersomnolent, and hyperphagic.  The patient has an extensive history of substance abuse and has been hospitalized previously for alcohol detoxification.  Blood pressure is 110/80 mm Hg and pulse is 64/min.  Physical examination shows old injuries from a motorcycle accident but no other abnormalities.  On mental status examination, he appears lethargic and dysphoric.  This patient's current symptoms are most likely the result of which of the following conditions?

A 16-year-old boy is brought to the office for a well-child visit.  The patient has no medical history but reports that his appetite is low and he has lost 2.3 kg (5 lb).  He stopped playing soccer recently due to lack of interest.  The patient is also worried about his grades due to difficulty staying focused in class and concentrating on his homework after school.  He feels tired despite sleeping 10 hours a night and taking afternoon naps when he gets home.  The patient says, "My parents try to be supportive, but everything they say these days gets on my nerves."  He has tried alcohol and marijuana a few times at parties but does not use other drugs.  Vital signs are within normal limits.  Physical examination is unremarkable.  Which of the following is the most appropriate next step in management of this patient?

A 66-year-old woman comes to the clinic for follow-up of sarcoidosis.  Over the past year, her lung function has worsened significantly, and her probability of survival at 12 months is below 50%.  When discussions regarding advance care planning and appointment of a surrogate decision maker are initiated, the patient replies, "Why would I want to sign away my life on a piece of paper?  The Lord will take me when the time is right."  Which of the following is the best response?

A 15-year-old boy is brought to the office by his parents due to concern about his development.  The patient has had a long-standing interest in fashion and a preference for having girls as friends, and his parents noticed that he recently bought women's underwear and shoes and went out to meet friends wearing makeup.  They worry that he is being bullied since moving to a new high school last year.  When interviewed privately the patient says, "I have always wanted to be a girl."  He is distressed that his voice is deepening and that he is developing facial and pubic hair, which he shaves regularly.  Which of the following is the most likely explanation of this patient's behavior?