Exam 2: Behavioral science

A 45-year-old man is hospitalized due to suicidal ideation.  Over the past month, the patient has become increasingly depressed, withdrawn, and physically restless.  He has had increasing difficulty concentrating at his job as a computer programmer.  The patient's appetite has been poor, and he has had difficulty falling and staying asleep.  He stopped going to work last week and refused to leave the house until his hospitalization.  The patient has no medical or psychiatric history.  Physical examination is unremarkable apart from a 4.5-kg (10-lb) weight loss.  On mental status examination, the patient appears depressed and anxious.  He reports that he is responsible for "all the evil in the world" and has heard a voice for the past week telling him that he does not deserve to live.  Which of the following is the most likely diagnosis in this patient?

A 46-year-old man comes to the emergency department with chest pain that began 30 minutes ago.  The patient describes the pain as a tight, squeezing sensation that radiates to the left arm.  He also has increased sweating and nausea.  ECG shows multi-lead ST-segment elevation, and cardiac troponin levels are high.  The patient has a history of alcohol and cocaine abuse, but no history of cardiac disease.  He undergoes emergency cardiac catheterization and is recovering appropriately in the postanesthetic care unit.  The physician is approached by a distraught woman who says she is the patient's wife and asks about his condition.  She says, "I am so worried; please tell me if my husband is okay."  Which of the following is the most appropriate course of action?

A 27-year-old man leaves the men's room of a bar after smoking an unknown substance.  He soon becomes disoriented and belligerent.  The man displays uncoordinated, jerky movements of his extremities and assaults a bouncer who tries to calm him.  When police and emergency medical services personnel arrive, he fights off 4 officers before being restrained and appears immune to pain.  In the emergency department, the patient has visual hallucinations, cannot cooperate with the interview, and alternates between agitation and sedation.  He is hypertensive and tachycardic, and examination shows vertical nystagmus.  The patient does not cooperate with urine toxicology testing.  Several hours later, during questioning by the emergency physician, he does not remember most of the preceding events.  Which of the following is the primary mechanism of action of the drug most likely used by this patient?

A 16-year-old boy with suicidal thoughts is brought to the office by his parents.  He has been in constant conflict with his parents since refusing to stop drinking alcohol, which he does on a daily basis.  The patient is the oldest of 6 children; his mother suffers from lower back pain and relies on him for child care, which he finds overwhelming.  His father works 2 jobs and is often not around to help with the children.  His mother keeps a firearm by her bedside for protection when she is alone with the children at night.  The patient dropped out of high school last year after getting dumped by his girlfriend.  He recently contracted Lyme disease with resultant symptoms of fatigue and myalgia.  Which of the following interventions is the best next step to decrease this patient's risk of completed suicide?

A 3-year-old boy is brought to the emergency department due to a fever and stiff neck.  The child is hospitalized with a diagnosis of bacterial meningitis and begins treatment with intravenous antibiotics.  On day 2 of hospitalization, the mother requests to take the child home and explains that she intends to treat him with homeopathic remedies.  She has 4 other children at home who have "never needed vaccinations or medications" and are "strong and healthy."  The physician explains the risks of meningitis, including brain damage and death.  After a long discussion, the mother says that she understands the risks but believes that homeopathic remedies will be adequate for treatment and remains unconvinced of the need for hospitalization.  Which of the following is the most appropriate course of action?

A 47-year-old man comes to the office for follow-up of recently diagnosed hypertension.  He was prescribed a generic formulation of lisinopril a month ago.  Inspection of the patient's pill bottle shows 15 tablets remaining of an original 30-tablet supply.  Medical history is otherwise unremarkable, and he is taking no other medications.  Blood pressure measurement shows no significant improvement from his blood pressure a month ago.  Serum chemistry panel, including potassium and creatinine, is also unchanged from prior results.  The patient reports no adverse effects from the medication but often forgets to take it.  Which of the following would be most helpful in improving this patient's medication adherence?

A 56-year-old man comes to the office for follow-up of type 2 diabetes mellitus.  He has an extensive family history of complicated type 2 diabetes, and multiple family members have required lower extremity amputations for nonhealing ulcers.  The patient has tried multiple oral medications and his most recent hemoglobin A1c is 9.6%.  He is now being considered for basal insulin therapy.  After an extended discussion of injection technique, the patient tells the clinician that he does not want to initiate insulin.  He says, "My diabetes is my own fault.  My mother always said I was too fat and was going to get diabetes like my dad.  Maybe if I stop eating too much, I wouldn't have to waste your time giving me insulin."  Which of the following is the most appropriate response to this patient's statement?

A 25-year-old man is brought to the emergency department by ambulance after being found sitting in the street drinking his own urine.  The patient's mother says that a year ago he expressed the belief that he was being watched by an unidentified government agency and subsequently broke up with his girlfriend, quit his job, and disconnected his phone.  The patient's mother has noticed that he no longer seems to care about activities that used to interest him, and last month she found out that he had moved into the family garden shed with his dog.  On examination, the patient is malodorous, disheveled, and laughs for no apparent reason.  He later becomes angry and refuses to sit in a chair for the interview.  The patient switches among unrelated topics and when asked where he lives says, "in the holy buffet of diplomacy."  Temperature is 36.7 C (98 F), blood pressure is 122/79 mm Hg, and pulse is 80/min.  Physical examination and laboratory evaluation, including urine toxicology, are unremarkable.  Which of the following is the most likely diagnosis in this patient?

A 35-year-old man comes to the office for a routine health maintenance evaluation.  After separating from his wife, the patient recently moved to "make a fresh start" and start a new job.  He has no chronic medical conditions and has had no surgeries.  The patient is sexually active and has had 6 lifetime partners.  When completing the rest of the sexual history, which of the following questions is most appropriate for the physician to ask?

An 82-year-old woman is hospitalized in a busy tertiary care hospital due to fever and shortness of breath.  The patient has a history of chronic obstructive pulmonary disease.  She is diagnosed with pneumonia and started on empiric antibiotic therapy overnight by the admitting physician.  After several days of treatment, the patient's condition deteriorates, and she is transferred to the intensive care unit.  Sputum cultures were obtained on admission, but the results were not checked by the daytime team, resulting in a delay in initiating more specific antibiotic treatment.  Which of the following interventions would be most effective to prevent this type of medical error?

A 26-year-old woman, gravida 1 para 0, at 38 weeks gestation is admitted to the hospital in active labor.  Twelve hours after admission, she has a spontaneous vaginal delivery of a baby boy who weighs 3.8 kg (8.4 lb) and has Apgar scores of 8 and 9 at 1 and 5 minutes, respectively.  The patient did not receive routine prenatal care.  She has no chronic medical conditions and no medication allergies.  After delivery, the patient is informed that her son will require erythromycin ointment to prevent an eye infection and possible blindness that can be caused by untreated gonorrhea.  The patient says her son does not need treatment because she has never had a sexually transmitted infection.  Which of the following is the most appropriate response to this patient?

A 40-year-old unemployed man with chronic back pain comes to the office for an appointment with a new physician.  The patient injured his back in a work accident years ago and has not worked since.  He uses marijuana daily to "ease the pain" and admits that a portion of his income goes toward its purchase.  The patient says that nothing has changed and asks the physician to sign a disability form so he can continue to collect disability benefits.  When the physician asks about his disability and previous treatment, he replies angrily, "I wouldn't be here re-applying for disability if anything had worked" and slams the disability form down on the table.  Review of his medical records indicates a normal MRI one year earlier and inconsistent adherence with physical rehabilitation appointments.  The patient walks normally with no apparent discomfort or limitations.  Which of the following is the most appropriate response by the physician?

A 12-year-old boy is brought to the office due to behavioral problems.  His parents are upset about his poor grades and recent school suspension for setting fires in the locker room and stealing another student's cell phone.  They say that the boy has always been impulsive, had a lot of energy, and become angry and argumentative easily, but over the past year his aggressive behavior "has gotten out of control."  The patient says that the fires were an "accident," although he admits to being angry at the coach for kicking him off the basketball team.  Regarding the theft, he jokingly says, "People deserve to have their phones stolen when they are stupid enough to leave them in plain sight."  The patient has a history of getting into trouble for talking back to teachers, skipping class, and getting into fights since the fourth grade.  He has no medical history.  There is a family history of bipolar disorder and alcohol dependence.  The patient smokes cigarettes occasionally but denies illicit drug or alcohol use.  Which of the following is the most likely diagnosis in this patient?

A 5-year-old boy is brought to the office by his parents for a well-child visit.  His mother says, "My son is doing very well.  He is able to read at a first-grade level and knows his name and address.  He loves to sing, dance, and play house with his older sisters.  Everything seems fine with him; we just want to make sure his vaccinations are up to date before our family trip overseas."  The physician administers the appropriate vaccinations.  Just before leaving, the father says, "I think you should know that my son is playing with his sister's dolls and doesn't seem to like cars or trucks like most other boys.  Is that normal?"  Which of the following is the most appropriate response to the father's concerns?

A 28-year-old man comes to the office at his wife's insistence.  He reports severe insomnia but otherwise feels physically healthy.  His wife is concerned that the patient is having a difficult time since returning from military duty.  She says, "He used to be so upbeat and easygoing.  Now his moods fluctuate between really tense and on edge to detached and numb."  The patient cannot fall asleep at night because, as soon as he closes his eyes, he sees the horrific scene of his friend being blown up after stepping on a landmine.  During the day, he is hypersensitive to loud sounds such as firecrackers or a car backfiring.  The patient says, "Sometimes I feel as if I'm back in combat and have to duck and take cover."  Vital signs are within normal limits, and physical examination shows no abnormalities.  On mental status examination, the patient has an anxious mood and blunted affect.  Which of the following is the most appropriate pharmacotherapy?

A 32-year-old woman comes to the office due to long-standing anxiety.  She reports being excessively worried about everyday events and constantly feeling tense and unable to relax.  The patient is diagnosed with generalized anxiety disorder and treated with a selective serotonin reuptake inhibitor.  She returns to the office for a 2-month follow-up and reports that her overall anxiety has improved, but she continues to have periods of increased anxiety before bedtime that keep her awake at night.  The patient works as a 911 emergency dispatch operator and would be willing to add a medication at bedtime but needs to be "clearheaded" for work.  Which of the following medications is most appropriate for this patient's condition?

An 82-year-old man is admitted to the hospital in the middle of the night.  He is noncommunicative and has multiple comorbidities, including end-stage lung cancer.  The patient has neither a designated power of attorney nor an advance directive on file.  His wife of many years, who is at the hospital with him, has an extensive conversation with the physician in charge of his care.  During the conversation, she says that, on several occasions, the patient said not to resuscitate him if he were near death because he did not want to live "attached to machines or brain dead."  She says that he just wants to die in peace when the time comes.  What would be the most appropriate course of action if the patient enters ventricular fibrillation?

A 12-year-old girl is brought to the office for an annual checkup.  The mother expresses concern about her daughter's behavior and poor grades, and says, "She is stubborn, irritable, overly emotional, and doesn't listen.  She also seems resentful of her twin brother and deliberately annoys or upsets him.  I can't get her to do chores or her homework, or go to bed on time."  Over the past year, the mother has been called several times by the school guidance counselor about her daughter talking back to teachers and skipping classes.  The patient says that school is "boring" and blames her behavior on "pointless rules and unreasonable demands," saying that her teachers are all "stupid."  Which of the following is the most likely diagnosis in this patient?

A 64-year-old man is brought to the office for evaluation of abnormal behaviors during sleep.  According to his wife, over the past 3 months the patient has had episodes of repeatedly punching at the pillow and screaming loudly while asleep.  When awakened from these episodes, he recalls a disturbing dream in which he is chased by assailants and must defend himself or escape.  The episodes usually last less than 1-2 minutes.  Vital signs are within normal limits.  General physical and mental status examinations show no abnormalities.  A formal sleep study (polysomnogram) is ordered.  Which of the following is most likely to be identified during this testing?

A 66-year-old woman with rheumatoid arthritis and atrial fibrillation is scheduled for an elective right total knee arthroplasty in a tertiary care hospital.  The patient speaks mostly Spanish and understands limited English.  Informed consent is obtained during a preoperative clinic visit using a certified interpreter.  On the day of the procedure, the operating room is running behind schedule, and the patient's procedure is delayed by 3 hours.  When the surgeon and circulating nurse visit the patient to confirm the site and side of the procedure, the certified interpreter is in the emergency department assisting with another patient and will be unavailable for an hour.  The patient talks rapidly and has several questions for the team.  The surgeon has taken a 3-week course in medical Spanish, and the nurse can speak short sentences in Spanish.  The surgeon converses with the patient in a mixture of Spanish and English.  The patient nods frequently as the surgeon speaks.  Which of the following best describes the patient-provider communication in this encounter?