Exam 2: Behavioral science

A 33-year-old man comes to the office due to back pain.  He has a 2-week history of moderate pain in the lumbar area that started after a long day of yard work.  There is no associated fever, motor weakness, or urinary symptoms.  The patient has no history of acute trauma and medical history is unremarkable.  Examination shows normal lower extremity strength, sensation, and reflexes.  Straight-leg raising test is negative.  The patient says, "My brother had similar pain last year and his MRI scan showed a bulging disc.  Can you order that test for me?"  The clinician offers options for symptomatic relief but recommends against performing any imaging studies.  Which of the following is the most likely effect of this recommendation?

A 52-year-old woman comes to the clinic to discuss the results of a recent abdominal CT scan.  The patient says, "I hope the scan can tell me why I've been losing so much weight.  What does it show?"  The physician shares that the imaging is suggestive of pancreatic cancer.  Upon hearing this, the patient begins to cry while holding her head in her hands.  Which of the following is the most appropriate response by the physician?

A 40-year-old woman comes to the emergency department fearing she is having a heart attack.  While clutching her chest and breathing heavily, she says, "I feel like I'm dying."  Temperature is 37.2 C (99 F), blood pressure is 125/86 mm Hg, pulse is 110/min and regular, and respirations are 18/min.  The patient's pulse oximetry shows 98% on room air.  Laboratory evaluation and ECG show no abnormalities.  The pain resolves within 10 minutes without treatment, and the patient reports, "I was taking the bus home from work when my chest started feeling really tight.  I'm lucky my friend was there and able to help me get to the hospital.  What if she's not there next time?"  She describes experiencing similar episodes at random places and times that are characterized by a pounding heart, trembling, dizziness, and sweating.  She drinks alcohol socially and does not use any medications.  This patient is most likely to develop which of the following disorders as a result of her current condition?

A 27-year-old man is brought to the emergency department by his wife.  She says that he has been "acting crazy" for the last 2 weeks.  He has hardly slept for the past 7 days and instead has worked on miscellaneous projects around the house.  The patient spent several thousand dollars on new power tools to accomplish these tasks.  When questioned, his speech is rapid and frenzied.  He feels "spectacular" and is creating an "architectural masterpiece."  The patient has had 2 previous depressive episodes.  Which of the following medications is the most appropriate agent for long-term management of this patient?

A 75-year-old woman is hospitalized for a bowel obstruction related to adhesions from previous uterine cancer surgery and radiation.  She has a history of hypertension, atrial fibrillation, and peripheral vascular disease.  After a prolonged hospital course complicated by a pulmonary embolus, she is discharged on multiple medications, including a higher dose of her warfarin.  The patient is scheduled for follow-up appointments with her internist, gynecologist, cardiologist, and gastroenterologist.  She lives by herself and has been able to successfully manage her care needs in the past.  Her adult daughter is supportive but lives out of state.  Which of the following interventions would be most effective in improving her adherence to outpatient treatment?

A 65-year-old man who recently emigrated from the Dominican Republic is admitted to the hospital for surgery.  He has multiple myeloma and a pathologic fracture of the right humerus.  The surgery is completed without complications.  Afterward, the patient is alert and oriented but grimaces frequently and appears uncomfortable.  He is offered pain medication, but he politely declines.  When asked through an interpreter whether he is in pain, the patient replies, "It hurts a lot, but I can bear it and don't wish to be a burden."  Which of the following is the most appropriate response by the physician?

A 78-year-old man comes to the office for a regularly scheduled review of his chronic medical problems.  The patient has hypertension, coronary artery disease, and type 2 diabetes mellitus, for which he takes metformin, atorvastatin, lisinopril, and nitroglycerin as needed for chest pain.  He takes his medications as prescribed and follows diet and exercise instructions.  During the discussion, he hesitates, laughs nervously, and says, "I can't get an erection anymore, and my wife says I have to ask you about getting the 'blue pill.'"  Which of the following is the most appropriate response to this patient's concern?

A 45-year-old man comes to the emergency department with multiple hand lacerations sustained when he punched his hand through a window.  The patient says he "momentarily lost control" when he came home from work to find that his wife had moved out of the home and taken their two children.  Temperature is 37.2 C (99 F), blood pressure is 150/88 mm Hg, and pulse is 96/min.  The patient has multiple abrasions and cuts on his right hand and is informed that two lacerations will require suturing.  The patient is agitated and angrily says, "I've been waiting a really long time and have to get out of here and set things straight with my wife and kids.  I don't have time for stitches anymore.  You are all incompetent."  Which of the following questions is most appropriate in determining the best next step in management of this patient?

A 57-year-old woman with a history of type 2 diabetes mellitus and asthma comes to the office for a preventive visit during influenza season.  The patient belongs to an ethnic minority group and is accompanied by her daughter.  The patient's medical conditions are well controlled, and she currently has no symptoms.  The provider explains that she is at high risk for complications from seasonal influenza and recommends that she get the seasonal influenza vaccine.  The patient says, "I don't trust that vaccine.  It's from the government, so I don't think it's safe for people like me."  Which of the following actions by the physician is most appropriate?

A 26-year-old woman comes to the emergency department accompanied by her boyfriend for evaluation of a broken nose.  With the boyfriend present, she explains that she tripped and fell in the bathroom, hitting her face on the countertop.  When asked privately if she feels unsafe with her boyfriend, the patient says, "No, everything is fine.  He just gets a little upset when he has too much to drink."  When questioned further about how she sustained her nasal fracture, she says, "He pushed me and I fell, but I'm sure it won't happen again."  After assessing the extent of the injuries, which of the following statements by the physician is the most appropriate?

A 32-year-old woman comes to the office for follow-up of asthma.  The patient reports that her asthma seems to be getting worse and describes increasingly frequent episodes of chest tightness and wheezing over the past several months.  She says, "I find myself reaching for my inhaler more often than I used to, and I wonder if I should try a stronger medication."  The patient has an 8-year history of intermittent asthma managed with an albuterol inhaler.  She smoked marijuana in her 20s for several years and started smoking cigarettes over the past year.  When asked about her tobacco use the patient says, "I'm smoking only half a pack a day or less and I really enjoy it, especially with my morning coffee."  Which of the following is the most appropriate response to the patient?

A 44-year-old man comes to the office due to low mood, impaired concentration, increased sleep and appetite, feelings of heaviness in his arms and legs, and loss of energy.  He is having difficulty at work as he is overly sensitive to criticism.  Although his boss has told him not to worry, the patient is concerned that his job is in jeopardy due to poor performance.  His symptoms started 8 months ago without any clear-cut precipitating event.  The patient received adequate trials of 3 different antidepressants without improvement and has been off of medication for the past several weeks.  His physician is now considering electroconvulsive therapy (ECT).  The patient declines ECT and asks to try another medication.  The physician then considers phenelzine.  The presence of which of the following additional symptoms would make the patient more likely to respond to this medication?

A 25-year-old graduate student with a history of recurrent ear infections as a child feels anxious and sweats when she is in the examination room with her primary care physician.  She recently got a roommate, a nursing student, who leaves her stethoscope on the coffee table after returning from class.  The patient sweats and feels her heart start to race whenever she sees the stethoscope.  This patient's response to her roommate's stethoscope is an example of which of the following phenomena?

A 74-year-old woman is brought to the emergency department by ambulance.  She is accompanied by a friend, who found the patient confused and disoriented lying on the floor in her apartment.  The patient is widowed and lives with her adult daughter.  She was diagnosed with aplastic anemia a year ago.  Her condition has responded poorly to immunosuppressive therapy and has required multiple blood transfusions.  The patient is febrile, disoriented, and unable to respond to questions.  Complete blood count shows severe pancytopenia.  The patient has an advance directive, signed 9 months ago, in which she designated the friend as her health care proxy.  The friend tells the physician that the patient did not want to undergo any further blood transfusions.  The patient's daughter arrives and adamantly insists that the patient receive a blood transfusion, saying, "I discussed it with my mother a few weeks ago, and we decided that she should have everything done to prolong her life."  Which of the following is the most appropriate next step in patient care?

A 62-year-old man comes to the emergency department with his wife due to back pain.  He has had no recent falls or injuries.  Medical history includes hypertension and hypercholesterolemia.  As the physician is trying to obtain additional history, the patient becomes embarrassed and says that he is having trouble understanding because he has hearing loss, and his hearing aid batteries died a few minutes ago.  In addition to closing the door, muting the TV, and turning off nonessential medical equipment to decrease ambient noise, which of the following strategies is the best next step to improve communication with this patient?

An intern attends a local dinner party and recognizes a colleague who works at the same hospital in another department.  During the course of the evening, she observes her colleague responding to a number of routine medical calls from the hospital and consuming several alcoholic drinks.  Later that evening, the physician notices that her colleague is giving medication orders over the phone and appears grossly intoxicated with slurred speech.  The physician confronts her colleague, asking him to transfer on-call responsibilities for the sake of patient care.  He insists that he is fine, is not drunk, and that his duties end in 30 minutes anyway.  Which of the following is the most appropriate course of action?

A 60-year-old man comes to the office for surgical consultation of multivessel coronary artery disease.  After reviewing prior records and completing a thorough evaluation, the surgeon discusses the recommendation for a coronary artery bypass graft, describing the indications for the operation and providing an overview of the surgery, including risks and benefits.  The surgeon then discusses what the patient can expect during the recovery period.  Which of the following additional disclosures is a necessary component of an informed consent discussion by the surgeon?

A 35-year-old man comes to the office due to problems with irritability, anxiety, and low self-esteem.  He was recently fired due to poor work performance at his data entry job and worries about finding a new job and supporting himself.  The patient is currently in a relationship but mentions that his girlfriend is upset by his frequent lateness and forgetfulness and has threatened to leave him.  Further history indicates that his problems are long-standing and date back to childhood when he had behavioral problems in school.  The patient frequently feels overwhelmed due to being disorganized.  He frequently procrastinates, is bored easily at work, and jumps to another project before completing what he is working on.  The patient drinks 3 or 4 beers a week and smokes marijuana twice a month.  On mental status examination, he is cooperative and talkative but appears tense, restless, and easily distracted.  Which of the following is the most likely diagnosis in this patient?

A 28-year-old woman, gravida 1 para 1, comes to the office for a 6-week postpartum checkup following an uncomplicated delivery.  The patient reports feeling increasingly fatigued and having little energy for the past few weeks.  She feels very anxious about being a new mother and has been getting up multiple times at night to check on the baby when he is sleeping.  She tends to skip meals and says, "I don't have time to sit and eat-I can't even find the time to shower."  Although the baby is healthy and doing well, the patient berates herself for being a "terrible mother."  She becomes tearful during the interview and says, "I don't know why I keep crying when I should be so happy."  Physical examination is normal.  The patient has no suicidal ideation or thoughts of harming the baby.  Which of the following is the most likely diagnosis?

A 46-year-old man is admitted to the hospital for atypical chest pain.  His medical history is significant for hypertension controlled with amlodipine and hypercholesterolemia treated with atorvastatin; he has a family history of depression and heart disease.  During review of his substance use history, the patient says that he has been a "regular drinker" for the last 5 years.  He drinks a 6-pack of beer every night and has 2 more beers in the morning to help him "get through the day."  He also admits to smoking marijuana occasionally but does not use tobacco or other illicit drugs.  Which of the following symptoms or signs is most likely to appear earliest during this patient's hospitalization?