Exam 2: Behavioral science

A 48-year-old man begins psychotherapy due to depression and escalating conflicts with his boss.  He makes progress in the therapy sessions and reports feeling less depressed.  The patient has also gained insight into how his father was rarely available to him while growing up and recently told his father, "I am angry that you were never there for me."  The following week, the psychiatrist unexpectedly cancels a session to attend to an emergency.  At the next appointment, the patient says, "I feel as if you are not interested in listening to me, like I am not your priority."  Which of the following is the most likely explanation of this patient's attitude toward his psychiatrist?

A 28-year-old woman, gravida 2 para 1, comes to the emergency department for evaluation of vaginal bleeding.  The patient has had bright red spotting for the past 24 hours but no contractions or leakage of fluid.  She is at 31 weeks gestation by last menstrual period and has not had prenatal care this pregnancy.  Her first pregnancy ended in an uncomplicated spontaneous vaginal delivery at term.  Vital signs and fetal heart rate tracing are normal.  Physical examination shows a nontender uterus consistent in size with 31 weeks gestation.  A pelvic ultrasound reveals a complete placenta previa.  The findings are discussed with the patient, and she states that she would still like to have a vaginal delivery.  The physician says, "Unfortunately, the only safe option for delivery is a cesarean delivery."  The physician's statement is an example of which of the following ethical principles?

A 46-year-old man is hospitalized with diabetic ketoacidosis.  He is administered intravenous fluids and an insulin drip, and laboratory testing is ordered.  In the morning, the on-call physician hands off the patient to the day shift physician, who arrives an hour late due to an emergency at his nighttime moonlighting job.  The handoff information includes the status of the patient and instructions to check electrolytes and calculate his anion gap.  The physician performs inpatient rounds and then sees his usual clinic outpatients in the afternoon, but he neglects to check the patient's anion gap.  The patient subsequently develops worsening acidosis requiring intubation for respiratory distress.  Which of the following is the most likely cause of this adverse outcome?

A 19-year-old man is admitted with delusions, hallucinations, and disorganized behavior.  He is diagnosed with schizophrenia, and the physician writes an order to begin aripiprazole "2.0" mg.  The patient mistakenly receives 20 mg aripiprazole instead of 2 mg.  This order is overlooked during the pharmacy review process, and the nurse fails to question it before administering aripiprazole to the patient.  Which of the following is the most effective intervention to reduce this type of error?

A 2-year-old girl is brought to the office due to concerns about her development.  The girl says approximately 40 words and does not string words together.  She can jump, walk upstairs slowly, build a 6-block tower, and follow short commands.  She feeds and helps to dress herself.  The girl's mother says, "My daughter is such a happy child.  She loves playing with the other kids at day care.  She is affectionate and caring toward us and her dog.  I don't know why she won't speak.  Her sister was using sentences by age 2.  Is there something wrong with her?"  Which of the following is the most appropriate response by the physician?

A 45-year-old woman comes to the office for a routine follow-up.  The patient feels well overall but mentions that climbing the last flight of stairs to her 3rd-floor apartment has become harder.  She says, "Sometimes I have to stop at the landing to catch my breath."  Medical history includes cocaine use disorder in remission for the past 4 years; it is otherwise unremarkable.  The patient does not use alcohol or illicit drugs.  She has a 25-pack-year smoking history and has been counseled to quit smoking in the past.  The patient says, "I've tried to quit several times.  I can cut down to a few cigarettes or half a pack for a day or two, but then it's just too difficult."  Which of the following is the most appropriate response by the physician regarding this patient's smoking?

A 45-year-old woman comes to the office for follow-up of type 2 diabetes mellitus.  Current glycated hemoglobin level is 9%.  The patient was diagnosed with diabetes a few months ago and was started on metformin twice daily.  When the physician asks how she is doing with her medication, she replies, "I use it most of the time, but it's easy to forget when I am feeling good."  Which of the following statements is most appropriate to begin a discussion about this patient's nonadherence to her medication?

A 28-year-old woman comes to the gynecologist, who has provided routine care for the patient over the past 10 years.  The patient has not menstruated for over 2 months and had a positive home pregnancy test last week.  Although she hopes to have children in the future, she has been under a lot of stress lately and says that caring for a child is the last thing she needs right now.  A pelvic ultrasound confirms an intrauterine pregnancy at 7 weeks gestation, and the patient requests that the gynecologist terminate the pregnancy as soon as possible.  The gynecologist does not perform abortions on moral grounds but does have training in the procedure.  Which of the following is the most appropriate course of action?

A 40-year-old woman is brought to the emergency department by her roommate due to significant left leg weakness.  The symptom began 3 days ago after her father had a heart attack.  There is no personal or family history of neurological disease; surgical history includes liposuction of the thighs and varicose vein removal.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 123/81 mm Hg, pulse is 62/min, and respirations are 14/min.  Physical examination reveals symmetric 2+ deep tendon reflexes as well as normal muscle bulk and tone bilaterally in the upper and lower extremities.  Laboratory testing and neurologic imaging reveal no abnormalities.  Which of the following is the most likely diagnosis?

A 35-year-old woman comes to the office for evaluation of anxiety.  The patient works as a mechanical engineer and recently declined a promotion to be a project manager.  Although her salary would have increased significantly, she felt that overseeing other employees and leading team meetings would be too stressful.  She says, "If something were to go wrong, everyone would blame me.  I don't even know why they offered me this position."  The patient enjoys her job but tends to eat lunch by herself because she feels that her coworkers do not like her appearance or sense of humor.  She has never had a long-term romantic partner but fantasizes about getting married someday.  The patient lives alone, rarely socializes with friends, and is close with her mother, whom she describes as "the person I can always rely on no matter what."  Which of the following is the most likely diagnosis?

A physician is approached by a friend who requests a prescription for antidepressant medication.  The physician has been friends with this individual since college and is aware that she has been treated for depression in the past.  The friend explains that she is only "a little depressed" due to work stress and relationship issues and would like to resume sertraline, which she has taken previously.  She has a physician but wants to avoid seeing the provider due to difficulty getting an appointment and her own busy schedule.  Which of the following is the most appropriate response?

A medical intern is working on the inpatient wards at a busy community hospital.  During rounds, the team evaluates a new patient admitted for worsening congestive heart failure.  The patient's past medical history includes atherosclerotic coronary artery disease, diabetes mellitus, and pulmonary hypertension.  Current medications include metformin, aspirin, and enalapril.  On previous admissions, the patient admitted to using cocaine recreationally with friends and admits to the intern that his last use was today.  The attending physician asks the intern to start the patient on propranolol for his heart condition; he will be expected to continue this medication following hospital discharge.  After rounds, the intern recalls that during medical school she learned that beta adrenergic antagonists can interact poorly with cocaine.  Which of the following actions by the intern is most appropriate?

A 28-year-old medical student comes to the office due to anxiety and trouble concentrating.  He has worked part-time as a volunteer firefighter and reports that he has been struggling to concentrate in class ever since witnessing a child who had been badly burnt pulled out of a house fire 3 weeks ago.  On two occasions the patient began to sweat, shake, and have trouble breathing: "I felt like my head was spinning and had to run out of the classroom to catch my breath."  He also reports having trouble sleeping, being irritable with friends and family, and occasionally feeling like he is in a dream.  The patient says, "Sometimes I'll be sitting in class, and I suddenly feel like I am back in the burning house.  I can smell the fire and see the child."  He has missed almost half of his classes to avoid being in crowded classrooms and has recently quit his volunteer job.  Which of the following is the most likely diagnosis?

A 24-year-old man comes to the office for treatment of opioid use disorder.  The patient has a 6-year history of heroin use, which he says has cost him most of his savings.  His boss has spoken to him about his erratic moods and inconsistent work performance, and he is now in danger of losing his job.  The patient asks for help, saying, "I have tried so hard to do this on my own.  My parents have spent a lot of money on counseling.  It helps for a while, but then I go back to using.  They are fed up and refuse to see me anymore.  I don't want to use, but the craving is so strong."  The physician refers the patient to an opioid treatment program where he is started on maintenance therapy with methadone.  During the next followup appointment, he reports a marked reduction in his cravings.  Which of the following properties of the administered drug is most likely responsible for the improvement in this patient's condition?

A 9-year-old girl is brought to the office by her mother for evaluation of frequent stomach aches.  The mother says that her daughter has always had a "sensitive stomach" but that it has gotten worse since she started going to a new school a few months ago.  The girl has been missing class due to being in the nurse's office multiple times per week.  The patient's symptoms improve when her mother comes to get her.  In response to the doctor's questions about the girl's peer relationships, the mother replies, "She has friends but never enjoys sleepovers."  When the patient is at a friend's house, she often complains of stomach pain and nausea.  She occasionally has nightmares about being left alone and wakes up crying.  Although both parents are healthy, the patient says she worries about them "dying of a terrible illness, like cancer."  Abdominal examination shows no abnormalities.  Which of the following is the most likely diagnosis in this patient?

A 26-year-old woman comes to the emergency department to report that her life is in danger.  The patient believes that transmitters inserted in her bedroom walls are broadcasting her thoughts to a central government agency that is now plotting to kill her.  On mental status examination, she is fearful and paces the examining room.  The patient makes poor eye contact with the examiner, and her responses are interrupted by frequent pauses during which she appears to talk back to a person who is not present.  She has no medical history.  The patient smokes a pack of cigarettes daily and does not use illicit drugs.  Physical examination shows a thin, disheveled young woman but no abnormalities.  She is hospitalized, improves with medication over the course of 2 weeks, and is discharged on olanzapine.  At this patient's 3-month checkup, which of the following studies should be obtained?

A 16-year-old woman comes to the office due to malodorous vaginal discharge.  The patient arrives with her mother, who stays in the examination room for the evaluation.  The patient has had increased vaginal discharge for the past 2 days but no abnormal vaginal bleeding or abdominal or pelvic pain.  She is sexually active with a new partner and uses a progestin-releasing subdermal implant for contraception.  Her last menstrual period was 2 weeks ago.  She has no chronic medical conditions and takes no medications.  Vital signs are normal.  The patient appears anxious.  Abdominal examination shows no tenderness or palpable masses.  When the pelvic examination is attempted, the patient says that she is "embarrassed and anxious" and refuses the examination.  Which of the following is the most appropriate course of action?

A 57-year-old man with amyotrophic lateral sclerosis (ALS) is participating in a clinical trial evaluating a novel therapeutic agent.  The patient is accompanied by his wife for the initial session.  The research coordinator provides a description of the study and tells the wife he is optimistic that the medication will help patients like her husband.  He then shares that more participants are needed for the study to be successful and asks if she would like to enroll as a healthy control.  In obtaining consent for the wife's participation, which of the following principles is at risk of being violated by the research coordinator?

A healthy 8-year-old boy is brought to the office by his parents for an annual checkup.  Both parents express concern about their son's behavior.  The mother says, "He never listens and I am always worried that he is going to run out into the street without looking.  He rarely sits still and is always running and jumping on the furniture."  The father adds, "He talks all the time, interrupts me when I'm speaking, and, despite multiple reminders, forgets to do his chores and misplaces or loses his books or sporting equipment.  We thought he would grow out of it as he got older, but it seems to be getting worse."  Physical examination is unremarkable.  Which of the following would be most helpful in establishing the diagnosis?

An 8-year-old boy is brought to the pediatrician for school refusal.  He has not gone to school for a few days, saying that he has a stomachache.  However, when it comes time for soccer practice, he has no physical symptoms.  When the pediatrician asks how things are going at school, the patient says, "kids laughed at me when the teacher said she couldn't read my homework."  His mother brings a recent report from the boy's teacher, which says that he is able to read and do math, but that when writing he fidgets a lot and stares out the window.  His writing is unclear, disorganized, and below the level of his peers.  His mother received a call from his teacher last week after the boy threw his writing book on the floor and began to cry.  Vital signs and physical examination, including abdominal examination, are normal.  At this time, which of the following is the most likely diagnosis in this patient?