Exam 2: Behavioral science

A 38-year-old woman is brought to the emergency department after causing a disturbance in a department store.  The patient says that the government was releasing poisonous gas through the air vents of the store and that red-colored clothing items were a signal to evacuate.  She was arrested a year ago for a similar incident.  The patient dropped out of college at age 20.  She lives with her parents and has never worked.  She smokes a pack of cigarettes a day but does not use alcohol or drugs.  Physical examination is unremarkable.  On mental status examination the patient appears distracted and fearful.  She reports hearing the voices of two men who criticize her actions continuously and have done so for years.  Which of the following abnormalities is most likely associated with this patient's symptoms?

A 10-year-old boy is brought to the pediatric clinic due to unusual classroom behavior for the past year, which has worsened over the last few weeks.  Although the patient is generally quiet, he intermittently disrupts the class with sniffling, repetitive throat clearing, and grunting sounds.  His teacher states that the boy distracts other students and that his focus in class is poor.  The behaviors worsen when he is tired, stressed, or excited.  The patient's parents are also concerned because he has only a few friends and his classmates make fun of him.  Medical history is significant for recurrent otitis media as a toddler, atopic dermatitis, and an influenza infection 9 months ago.  Family history is significant for rheumatoid arthritis and anxiety in his mother.  Temperature is 36.7 C (98 F), pulse is 78/min, blood pressure is 110/72 mm Hg, and respirations are 14/min.  Physical examination shows frequent eye blinking and shoulder shrugging but is otherwise normal.  Which of the following is the most likely diagnosis?

A 55-year-old man is scheduled to have electrode implantation surgery for the treatment of advanced Parkinson disease.  Three days before the procedure, the surgeon discusses the details of the operation, including associated risks and benefits, as well as alternate treatment options.  The patient expresses understanding of the discussion and signs the consent form.  In the preoperative room on the day of the procedure, however, he becomes anxious and nervously says, "I can't do this, doctor.  I'm sorry.  I don't want to have the surgery anymore."  Which of the following is the most appropriate course of action?

A 20-year-old college student is brought to the emergency department by his roommate.  The patient is frightened and claims that campus police are following him and plotting to kill him.  His roommate says that the patient seemed "totally normal" until a few days ago, when he began to stay up all night to prepare for final exams.  The patient has no known medical or psychiatric history, but his father has schizophrenia.  Blood pressure is 150/95 mm Hg and pulse is 110/min.  Examination shows clear lungs and tachycardia with normal S1 and S2.  The abdomen is soft and nontender.  Extraocular movements are intact, and the pupils are dilated.  The patient is diaphoretic.  He appears hypervigilant, paces during the examination, and has mildly pressured speech.  Which of the following is the most likely diagnosis in this patient?

A 36-year-old woman with well-controlled asthma and hypothyroidism comes to the office to review recent thyroid function tests with her primary care physician.  She has been his patient for the past 8 years.  During the visit, she mentions that she is recently divorced and has had difficulty meeting "smart and interesting" men.  The patient, noticing the physician is not wearing a wedding ring, asks if he is single.  The physician responds, "Yes, why do you ask?"  The patient replies that she was wondering whether he would consider going out for dinner now that they are both single.  The physician has always found the patient attractive and would like to accept the invitation.  Which of the following is the most appropriate response to the patient's request?

A 17-year-old girl comes to the office for evaluation of worsening vaginal irritation and discharge.  She has had multiple sexual partners in the past few months.  The patient is adherent with oral contraceptives and inconsistently uses condoms.  She has no prior medical conditions and takes no other medications.  Urine pregnancy test is negative and urine gonorrhea test is positive.  The patient does not want her parents to find out she is having sex and asks if the physician will tell her parents about today's visit.  Which of the following is the most appropriate response to this patient?

A 27-year-old man is brought to the emergency department by his roommate, who found the patient barricading himself in a closet at home and saying, "They're coming to get me.  No one can be trusted."  The patient was laid off from his job and broke up with his girlfriend last month.  He has heard voices threatening to kill him a few times daily for the past 2 weeks.  He has no medical or psychiatric history and does not use alcohol or illicit drugs.  Physical examination and laboratory results are unremarkable.  On mental status examination, the patient is fearful and tense.  He describes being followed by men in black cars who are spying on him.  Which of the following is the most likely diagnosis in this patient?

A 61-year old woman comes to the office due to insomnia.  She has had difficulty falling asleep since her divorce was finalized 2 months ago and she relocated to a new state to be closer to her daughter and grandchildren.  The patient's sleep is restless and she is frequently awakened by household noises.  During this time, she has also felt anxious and tense.  The patient is overwhelmed by financial worries and the responsibilities of living on her own.  Although previously outgoing, she now avoids opportunities to meet new people and socializes only with her daughter.  The patient has no psychiatric history but does have a history of hypothyroidism treated with levothyroxine.  Physical examination is unremarkable.  TSH is 1.6 µU/mL.  Which of the following is the most likely diagnosis?

A frail, 93-year-old woman with mild dementia enters a nursing home due to difficulty managing on her own.  She has recently had several falls, including one during the night while getting out of bed to use the bathroom.  The patient attributes this fall to "clumsiness."  Syncope workup is unremarkable for any abnormalities.  She has a medical history of hypertension, osteoarthritis, depression, and anxiety.  Her medications include amlodipine, sertraline, aripiprazole, and amitriptyline.  Which of the following is the most effective strategy for decreasing this patient's fall risk?

A 13-year-old boy is brought to the office due to anxiety and behavioral problems at school.  Although he has good grades, he frequently feels overwhelmed at school and his mother worries that he is socially awkward and has no friends.  The patient often appears anxious and uncomfortable in new social situations.  He insists on sitting in the same row and seat in every class and has had several inappropriate outbursts when told by teachers that this was not possible.  After school, the patient prefers to spend time at home.  His mother observes that he is obsessed with dates and comparing solar and lunar calendars and can discuss this for hours, but has difficulty shifting to other topics of conversation.  The patient was born at full term, and developmental milestones were within normal range.  Physical examination is unremarkable.  Which of the following is the most likely explanation of this patient's behavior?

A 32-year-old man comes to the office due to disabling anxiety.  The patient was recently promoted to his company's headquarters, requiring him to work on the 48th floor of the building.  As soon as he steps on the elevator, he feels panicky and faint, sweats profusely, and has heart palpitations.  The patient is worried that he might have to resign if he is unable to control his anxiety.  His fear of elevators dates back to childhood.  He drinks 1 or 2 beers on weekends but does not use tobacco or illicit drugs.  Which of the following is the most effective long-term treatment for this patient's condition?

A 3-year-old boy is brought to the office by his parents due to behavioral difficulties.  His mother says, "He is physically healthy and affectionate but has become more defiant and often resists our instructions about getting ready for bed.  He plays roughly with his 6-year-old brother and throws tantrums when he has to share his toys or put them away."  His preschool teacher describes him as an "active child" who sometimes talks out loud to classmates while the teacher is speaking.  He is easily distracted and often gets up to walk around the classroom.  The patient is able to draw circles, speak 3-word sentences, go up stairs with alternating feet, and use the toilet but cannot wipe himself.  His parents express concern about his inability to dress himself and about his bed-wetting that occurs approximately twice a week.  Physical examination is unremarkable.  Which of the following is the most likely explanation for the child's behavior?

A 24-year-old woman comes to the office due to recurrent episodes of chest pain, palpitations, and shortness of breath over the past few months.  During some episodes, she experiences dizziness, diaphoresis, and paresthesias of the hands.  The episodes last 5-10 minutes, and the patient constantly worries about when and where she will have another one.  She says, "This keeps happening and no one has been able to tell me why.  I'm scared something might be seriously wrong with me."  The patient has been to the emergency department twice in the past month for similar episodes; prior evaluation, including complete metabolic profile, thyroid function tests, arterial blood gas analysis, ECG, cardiac enzymes, and chest x-ray, showed no abnormalities.  Vital signs are within normal limits.  Physical examination is unremarkable.  Which of the following is the most likely diagnosis?

A 17-year-old girl is brought to the office by her parents due to recurrent episodes where "she seems to be lost in her own world."  The parents say that the episodes began about 2 years ago, but seem to be occurring more frequently since a difficult breakup with her boyfriend several months ago.  The patient acknowledges that she seems to "space out" easily.  She says, "I often feel numb, like I'm in a fog or a dream.  Sometimes, I feel as if I'm not myself, as if things are happening to someone else."  The patient uses nonsteroidal anti-inflammatory drugs for menstrual cramps.  She has no other medical conditions.  She smokes cigarettes but does not use alcohol or illicit drugs.  Physical and neurologic examinations are normal.  On mental status examination, the patient is cooperative with a mildly anxious mood and flat affect.  Which of the following is the most likely diagnosis?

An 18-year-old woman comes to the office to discuss test results.  She was evaluated one week ago for recurrent vulvovaginal discharge and reported being sexually active with two partners, using oral contraceptives sometimes.  The patient was counseled on safe sexual practices and tested for sexually transmitted diseases.  The results have returned as positive for HIV.  She has no significant medical history and takes no medications other than oral contraceptives.  The patient's family history is significant for a mother with schizophrenia and a paternal uncle with alcohol use disorder who lives in the home with them.  On hearing her test results and the recommendation to start antiretroviral therapy, she is visibly upset.  Which of the following is the most important intervention to promote adherence to treatment in this patient?

A 39-year-old right-handed man is brought to the office by his wife due to concerns about his behavior.  Two months ago, the patient was robbed and hit in the head and knees with a baseball bat when he resisted.  He initially had difficulty walking, but his injuries have since healed.  His wife and other family members say that his overall demeanor has changed significantly since the attack.  Prior to the assault, the patient was kind, considerate, and extremely polite.  However, since the attack, he has been very irritable and rude, and was recently fired from his job for insulting customers and making socially insensitive comments to coworkers.  Damage to which anatomical region of the brain is the most likely explanation for this patient's symptoms?

A 72-year-old, previously healthy man is brought to the office by his wife due to unusual movements and behavior during sleep that have occurred with increasing frequency over the past 3 months.  She says, "Lately, he's been waking me up in the middle of the night, moaning and thrashing around like he's having a bad dream.  Sometimes, he becomes so violent in his sleep that he'll kick and punch me.  I can easily wake him up, but he's often confused for a few seconds.  Then he usually describes a dream in which he was defending himself from an attack."  Physical examination is unremarkable.  Neurodegeneration due to accumulation of which of the following is the most likely etiology of this patient's condition?

A 34-year-old man comes to the office with a 5-day history of nasal congestion and cough.  He says that he occasionally coughs up thick, yellow sputum and is worried about the lack of improvement.  The patient mentions that he has received antibiotics for similar symptoms in the past and says, "Antibiotics always seem to help me feel better fast."  Temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, pulse is 76/min, and respirations are 18/min.  Physical examination shows pharyngeal erythema; the remainder of the examination, including cardiopulmonary evaluation, is normal.  Which of the following responses by the physician is most appropriate?

A 24-month-old girl is brought to the office by her mother due to concerns about walking.  The mother says, "She seems so unsteady when she walks.  She was walking so well until a few weeks ago, and now she keeps tripping over things."  On examination, the patient is sitting on the floor and clapping her hands.  She does not answer questions and instead makes babbling sounds.  When her mother encourages her to walk, the patient pulls to stand using a chair and has an unsteady gait.  The remainder of the examination is normal apart from abrasions on both knees, which her mother explains are from frequent falls.  Height and weight track at the 50th percentile.  At a checkup 6 months ago, the patient had been saying 1- or 2-word phrases and walking without aid.  Which of the following neuropathic changes most likely underlies this patient's presentation?

A 14-year-old boy is brought to the office by his parents, who are worried about his reaction to their recent decision to divorce.  Despite their efforts to be supportive and engage him, he has not expressed any feelings directly about the divorce.  When the patient is evaluated alone, he shares that he feels his parents are angry with him, although he cannot think of any instances when they expressed any anger toward him.  On examination, the patient appears sullen and reports his mood is "fine."  This patient is most likely using which of the following defense mechanisms?