Exam 2: Behavioral science

A 35-year-old man is admitted to the hospital after sustaining multiple injuries in a motor vehicle accident.  He undergoes surgery for an open fracture of the tibia and a spiral fracture of the humerus.  The tibial repair is successful, but the surgeon operates on the wrong arm.  Which of the following procedures would be most effective in preventing a similar error?

A 38-year-old woman is admitted to the hospital overnight due to cellulitis.  The next morning, the hospitalist on service introduces herself to the patient and asks how she is feeling.  The patient angrily says, "It's almost lunchtime, and I still haven't gotten my breakfast.  How am I supposed to get better when you're starving me?"  The patient has an order to receive a regular diet.  Which of the following is the most appropriate response by the physician?

A 62-year-old woman comes to the office for a checkup.  Her husband died 5 months ago in a biking accident, which she witnessed.  She has little appetite, resulting in weight loss of 3.17 kg (7 lb), and tends to wake up two hours before her alarm clock rings.  The patient feels overwhelmed at having to manage the household finances, saying, "My husband always took care of the bills so I wouldn't have to worry."  She avoids cycling, a hobby she shared with her husband, but continues to volunteer at a children's hospital.  The patient has no nightmares or suicidal thoughts.  During the visit, she tears up intermittently but smiles when sharing a memory of a vacation she took with her husband.  Which of the following is the best explanation for this patient's condition?

A 27-year-old woman comes to the office due to concerns about her weight.  She is frustrated about gaining a few pounds, although she maintains a well-balanced diet and exercises for an hour 3 times a week.  The patient has been worried for years that her thighs are "huge" and "covered in cellulite."  She always wears loose-fitting pants and spends hours a day researching leg exercises and measuring the circumference of her thighs.  The patient generally stays at home and avoids social activities as she feels people tend to stare at her.  She weighs 58 kg (127.9 lb) and is 170 cm (5 ft 7 in) tall.  Physical examination is normal.  Which of the following is the most likely diagnosis?

An 86-year-old woman with Alzheimer disease is brought to the emergency department by her son due to worsening cough and fatigue; she is found to have pneumonia.  The physician explains the diagnosis and treatment plan, including hospitalization for intravenous antibiotics.  The patient replies, "I'd prefer to leave.  I'm more comfortable at home."  She asks to be discharged with oral antibiotics.  The physician explains that intravenous antibiotics are preferred and that the risks of worsening infection may include sepsis and death.  The patient appreciates the risks involved and says, "I will come back to the hospital if I feel worse; I just don't like to stay in the hospital."  The patient is widowed and lives with her son, who insists that she stay in the hospital for treatment.  He reports that his mother has been increasingly forgetful and has gotten lost several times while walking in the neighborhood.  On mental status examination, the patient is alert and oriented.  Mini-Mental State Examination score is 24, indicating mild cognitive impairment.  Which of the following is the most appropriate next step in the managment of this patient?

A 28-year-old man comes to the office due to persistent fatigue.  For the past several weeks, he has been having trouble sleeping and is frequently late for work as he has difficulty getting out of bed.  At work, his mind wanders, and his supervisor has commented that the quality of his work has deteriorated.  The patient says, "I've been feeling down and don't feel like doing anything.  My appetite is poor.  I no longer go out with my friends and haven't gone to the gym in weeks."  The patient has no significant medical or psychiatric history.  He has 1 or 2 alcoholic drinks several days a week but does not use illicit drugs.  Routine laboratory evaluation, including thyroid function tests and serum B₁₂ level, is normal.  Physical examination is unremarkable.  Mental status examination shows a cooperative man with sad affect.  No delusions are elicited.  The patient says he sometimes wishes he could "go to sleep and not wake up," but has no suicidal intent or plan.  First-line pharmacotherapy for this patient most likely involves a drug with which of the following mechanisms of action?

A 49-year-old woman is transferred from a community hospital to a tertiary care center for management of an acute exacerbation of chronic obstructive pulmonary disease.  The patient receives care overnight from a hospitalist, who transfers care to the teaching service in the morning.  The medical team now responsible for the patient meets with her for the first time during morning rounds.  The attending physician introduces the team and explains that the patient will be interviewed by the intern.  The patient then addresses the intern by his first name and mentions, "You remind me so much of my son.  He's very smart and looks a lot like you."  Which of the following actions by the intern would be most appropriate to begin the interview?

A 21-year-old woman, gravida 1 para 0, comes to the office for a prenatal visit at 16 weeks gestation.  The patient, who has not gained weight since her last visit 4 weeks ago, has occasional nausea with vomiting twice a week.  She has little appetite, which she attributes to mild indigestion, and her food consumption has decreased.  However, the patient craves ice and has been consuming it throughout the day for the last few months.  Medications include daily prenatal vitamins.  The patient was prescribed twice-daily iron for anemia but does not take it because it causes constipation.  She has no diarrhea, dysuria, chills, or fever.  She does not use tobacco.  Uterine fundus is consistent with a 16-week pregnancy.  Fetal heart tone is 140-149/min.  The patient's vital signs are within normal limits.  Which of the following is the most likely diagnosis?

A 48-year-old deaf man comes to the office for a new patient visit.  The patient recently moved to the area and is accompanied by a friend with whom he communicates using American Sign Language.  The office staff informs the physician that the patient has also been communicating by reading lips, using gestures, and nodding his head in agreement.  At the start of the appointment, the friend says that the patient has asthma and uses an inhaler as needed.  The patient gives the physician a handwritten note indicating that he would like to try a longer-acting inhaler.  Which of the following is the most appropriate next step in evaluation of this patient?

A 35-year-old man comes to the office due to a lack of sexual interest.  He says, "I started seeing this woman 9 months ago and am really attracted to her.  We get along well and things are great, but I just don't want to have sex with her anymore."  On further questioning, the patient reluctantly admits that whenever they have intercourse he has an orgasm in less than a minute and finds this very embarrassing.  He does not have the same problem when he masturbates.  He says, "I'm worried that my girlfriend will leave me, and it's really affecting my self-esteem."  The patient has no other concerns.  His other medical conditions include type 1 diabetes mellitus, chronic insomnia, and a history of major depression.  His medications include insulin glargine, short-acting insulin, and trazodone.  He does not use illicit substances.  Vital signs are within normal limits.  Laboratory results are significant for hemoglobin A1c of 7% and fasting glucose of 130 mg/dL.  Which of the following is the most likely diagnosis?

A 37-year-old man is admitted to the hospital for right lower-lobe pneumonia.  He is given antibiotics, and his shortness of breath and fever improve by the second hospital day.  However, he now has new-onset abdominal pain, diarrhea, and severe muscle aches.  The patient has no history of gastrointestinal conditions or prior surgeries but does admit to recreational drug use.  Temperature is 36.8 C (98.2 F), blood pressure is 124/80 mm Hg, and pulse is 88/min.  On examination, the patient appears uncomfortable and anxious.  Pupils are dilated and there is prominent lacrimation.  Abdominal examination reveals hyperactive bowel sounds without tenderness or distension.  Which of the following is the most likely diagnosis?

A 56-year-old woman with a history of schizophrenia is hospitalized for right upper quadrant abdominal pain and diagnosed with cholecystitis.  She is initially treated with antibiotics, and a scheduled cholecystectomy is planned.  On day 2 of hospitalization, the patient reports that she feels much better.  The patient doesn't want surgery and prefers to go home on oral antibiotics.  She says, "I know that God is on my side and will take care of me."  The patient lives in a group home and takes risperidone daily at her day treatment program.  On examination, the patient is alert and oriented to person, place, and time.  She reports hearing voices several times a day for many years, but they don't bother her as much as they used to.  The patient has no suicidal ideation.  Which of the following is the best next step in management of this patient?

A 4-year-old girl is sent to the emergency department from her day care center due to fever, right ear pain, and repeated vomiting.  Examination shows a bulging, cloudy tympanic membrane associated with erythema, swelling, and tenderness over the right mastoid.  CT scan reveals opacification of the mastoid air cells with destruction of bony septa.  When the patient's parents arrive, they report that the patient has had recurrent episodes of otitis media.  However, the parents decline antibiotic therapy, stating, "In our family, we believe that natural healing techniques are better than shooting up our children with chemicals."  Which of the following is the most appropriate response to the parents' statement?

A 9-year-old boy is brought to the pediatrician due to poor school performance and difficulty making friends.  His parents say he always had "very high energy," but they noticed that this got worse after they moved 8 months ago, which they attributed to a normal adjustment period.  Over the past several months, however, the parents have received repeated phone calls from his teachers, reporting that he does not listen in class, has difficulty staying in his seat, turns in assignments late without his name, and frequently disrupts the class by talking out of turn.  At home the boy forgets to do his daily chores, regularly loses his books and homework, and delays the family by taking too long getting ready for school in the morning.  When his older brother teases him about this, the patient becomes irritable, and on a few occasions has shouted profanities and tried to hit his brother.  Which of the following is the most likely explanation for this patient's behavior?

A 73-year-old woman with congestive heart failure is being prepared for discharge from the hospital.  The patient has heart failure with reduced ejection fraction and has been admitted to the hospital twice in the past 60 days.  Medical history is notable for ischemic heart disease, chronic obstructive pulmonary disease, and hypertension.  Vital signs are normal.  Pulmonary examination shows normal respiratory effort and no crackles, and there is no peripheral edema.  The patient asks to stay in the hospital for a few additional days and says, "I feel fine right now, but I am worried that if I go home, I might end up back in the hospital again."  Which of the following is the most appropriate response to this patient's request?

An 18-year-old man is brought to the clinic by his mother due to increasingly bizarre behavior over the past 2 months.  The patient is in his first semester at an out-of-state college and has had difficulty adjusting to being away from home.  For the past few weeks, he has not been attending classes, and he no longer socializes with friends.  The patient spends most of his time alone in his dorm room and eats very little because he believes the cafeteria food is poisoned.  He has no significant medical or psychiatric history and does not use alcohol or illicit drugs.  Physical examination is unremarkable.  On mental status examination, he appears disheveled with unwashed hair, makes poor eye contact, and shouts "leave me alone" in response to unseen people.  Which of the following is the most likely diagnosis in this patient?

A 65-year-old man is admitted overnight to the hospital with abdominal pain.  It is determined that he has an uncomplicated small bowel obstruction that will require surgery in the morning.  Temperature is 37 C (98.6 F), blood pressure is 130/82 mm Hg, and pulse is 90/min.  The resident meets with the patient and his adult son, who has accompanied him to the hospital, to discuss surgical intervention.  After introducing herself, the resident learns that the patient speaks primarily Vietnamese and has limited English proficiency, although his son speaks both Vietnamese and English.  The son shares that he is a critical care nurse and offers to interpret the conversation for his father.  Which of the following responses to the patient's son is the most appropriate?

A 31-year-old man is brought to the emergency department by the police after he assaulted a stranger who he thought was following him.  The police report indicates that when the patient was arrested, he was shouting, "You don't understand, I'm the one who needs protection-the Russians are after my secrets!"  In the emergency department, the patient is diaphoretic and tremulous.  He is very easily distracted and cannot give a clear history.  Temperature is 37 C (98.6 F), blood pressure is 164/102 mm Hg, and pulse is 112/min with a normal rhythm.  Extraocular movements are intact, and the pupils are dilated.  His speech is loud, rapid, and difficult to interrupt.  Which of the following is the most likely diagnosis?

A 54-year-old man arrives for an appointment with a new physician.  At the front desk, the receptionist tells him that the physician is running behind schedule and gives him several forms to complete regarding his personal and family medical history.  The patient politely agrees to fill them out and has a seat in the waiting area.  However, when his paperwork is reviewed by the physician, it contains only the patient's signature.  The patient says, "I'm sure a doctor with your education can take a good history."  When asked if anything is wrong he says, "Oh, nothing, I'm fine."  Which of the following best describes this patient's behavior?

A 14-year-old girl is brought to the office by her mother due to unusual behavior over the past year.  The mother is concerned that her daughter seems overly anxious about eating, and says, "During lunch, she spent 45 minutes cutting the broccoli on her plate until all the pieces were the same size."  The patient recently became a vegetarian and spends hours in the grocery store selecting vegetables and checking nutritional information.  She also seems very concerned about her appearance; she brushes her hair 21 times on each side, parts her hair strand by strand, and plucks her eyebrows for an hour daily.  The patient says, "If I don't keep things exactly even I'm afraid something bad might happen."  The patient is medically healthy and has not yet started menstruating.  She weighs 45.8 kg (101 lb) and is 157.5 cm (5 ft 2 in) tall.  BMI is 18.5 kg/m².  Physical examination is normal with the exception of extremely sparse eyebrows.  Which of the following is the most likely primary diagnosis?