Exam 2: Behavioral science

A 14-year-old boy is brought to the emergency department by a teacher after being found staggering and falling on the ground in the school parking lot between classes.  When she found him, the patient seemed lethargic and disoriented and his speech was slurred.  His condition slowly improved over the next 30 minutes; when the patient is evaluated in the emergency department an hour after the teacher found him, he is alert, oriented, and able to speak clearly.  Temperature is 36.7 C (98.1 F), blood pressure is 102/65 mm Hg, and pulse is 62/min.  On physical examination, there are abrasions on the right forearm and shin and a rash around the nostrils and mouth.  The patient has no known medical history.  Which of the following substances is the most likely cause of this patient's symptoms?

A 35-year-old woman comes to the office due to insomnia and fatigue over the past month.  She has felt increasingly depressed, irritable, and worthless since being let go from her job 5 weeks ago.  The week prior to her last menstrual period was particularly difficult, and she stayed in bed most of the day.  Over the last month, the patient has lost 3.6 kg (8 lb) and has felt unmotivated and unable to concentrate on looking for new work.  Other medical conditions include hypothyroidism and migraine headaches.  The patient drinks 1 or 2 glasses of wine a few times a week and smokes marijuana once a month.  Medications include levothyroxine and naproxen.  Physical examination is normal.  TSH level is 0.9 µU/mL.  Which of the following is the most likely diagnosis in this patient?

A 20-year-old college student comes to the office due to fatigue and decreased exercise tolerance.  She says, "I used to run 5 miles every day, but for the past month I get out of breath after running 3 miles.  I need to keep running so I don't get any fatter than I already am."  The patient also reports difficulty concentrating in class, depressed mood, constipation, and abdominal bloating.  Her appetite is normal, but she admits to occasionally forcing herself to vomit to prevent weight gain.  Physical examination is significant for dry skin, painless bilateral parotid swelling, pharyngeal erythema, and hypoactive bowel sounds.  Temperature is 36.2 C (97.2 F), blood pressure is 100/60 mm Hg, pulse is 62/min, and respirations are 16/min.  BMI is 17.5 kg/m².  Which of the following is the most likely diagnosis?

A 62-year-old man comes to the office with his wife for evaluation of episodic chest pain.  The physician introduces herself to the patient and his wife and confirms that he is comfortable and not experiencing any current pain.  The patient's wife begins the conversation by saying, "He brought a list of his medications for you to review, but I'm not sure he takes all of them regularly."  After thanking them for bringing the list, which of the following is the most appropriate way for the physician to initiate the medical interview?

A 40-year-old woman comes to the office due to worsening anxiety and insomnia over the past 3 months.  She says, "I'm really worried that something is wrong with me.  I was never a particularly anxious person, but now I feel anxious all the time.  Sometimes I feel panicky for no reason; my heart races and I break out in a sweat.  The only benefit is that I have lost 5 pounds (2.3 kg) without even trying."  The patient has no significant medical or psychiatric history.  She drinks 2-3 glasses of wine per week and does not smoke or use illicit drugs.  Blood pressure is 130/90 mm Hg and pulse is 112/min.  On physical examination, the patient is restless and has warm, moist skin and mild hand tremor bilaterally.  Mental status examination is notable for a frightened stare, anxious mood, and rapid speech.  Which of the following is the most likely diagnosis?

A 49-year-old woman comes to the office due to worsening hot flashes and night sweats over the past year.  The patient's menstrual periods have been irregular for the past 2 years, and her last menstrual cycle was a year ago.  She has no chronic medical conditions and has had no surgeries.  BMI is 23 kg/m².  Vital signs are normal.  The neck is supple and without thyromegaly.  The remainder of the examination is normal.  The patient says, "This is awful.  I turn red and sweat in the middle of work meetings and then have to leave to cool down.  I'm wondering if hormones could help."  Which of the following is the most appropriate response to this patient?

A 25-year-old woman comes to the office for an initial evaluation of low mood.  Since moving to a new apartment 3 weeks ago, the patient has felt sad and has not been sleeping well.  She says, "My landlord won't allow pets in the building.  I miss my dog so much.  I know my mood would improve if I could get a letter from you saying my dog can live with me."  The patient's dog is currently staying with her parents, who live a few miles away from her.  Which of the following statements by the physician is the most appropriate?

A 45-year-old woman brings her stepson to the office for a well-child visit.  She never wanted children due to her unhappy childhood and wishes her marriage did not include being a stepmother to her husband's 5-year-old son.  In the waiting room, the woman seems excessively concerned when the boy accidentally trips and is clearly uninjured.  During the visit, she tells the physician that she adores the child and describes her elaborate preparations for his birthday party.  Which of the following defense mechanisms best explains this woman's behavior?

A 23-year-old woman at 8 weeks gestation comes to the office for an initial prenatal visit.  The patient has no vaginal bleeding or pelvic pain.  On examination, areas of bruising in different stages of healing are seen on the chest and abdomen.  When asked about the bruises, the patient states that her boyfriend used to hit her during arguments and was initially angry about the pregnancy.  Over the past 3 weeks, he has been more supportive, buying prenatal vitamins and offering massages.  Ultrasound examination confirms an 8-week intrauterine gestation and normal fetal heart rate.  Which of the following is the most appropriate next step in management of this patient?

A 54-year-old woman comes to the office for a yearly preventive examination.  She has no specific concerns.  Blood pressure is 144/95 mm Hg and pulse is 86/min.  BMI is 50 kg/m².  Examination shows severe obesity but is otherwise unremarkable.  Fasting glucose is 128 mg/dL.  When the subject of her weight is mentioned, the patient says, "In my family, we just like to eat.  My mother is heavy, my father is heavy, and my kids are heavy.  There's no point in trying to lose weight now."  Which of the following is the most appropriate response to this patient's statement?

A 40-year-old woman comes to the office due to new-onset genital lesions.  On examination, she is found to have several genital warts in her vaginal area.  Testing for sexually transmitted infections is otherwise negative.  The patient admits to having a brief extramarital affair while traveling for business.  The following week, the physician receives a phone call from the patient's husband, who is not a patient in the practice.  He knows his wife was recently seen and would like information regarding her health as he is concerned about his physical symptoms.  Which of the following would be the most appropriate response by the physician?

A 24-year-old man comes to the office because of mood changes.  He has felt depressed, irritable, and anxious nearly every day for 2 months.  The patient has difficulty getting out of bed in the mornings and staying focused at work.  He has no medical conditions and takes no medications.  The patient drinks 3 or 4 beers daily and more on weekends.  The physician provides education about the link between alcohol and mood changes.  The patient responds, "But it really helps me to unwind and relax after a long workday and makes it easier to fall asleep.  It's also how I hang out with my friends on weekends.  I can't see quitting." Which of the following is the most appropriate statement by the physician at this time?

A 19-year-old man comes to the office for evaluation of a hand injury.  He says, "I was just minding my own business at work when this dog bit me."  The patient recently started operating a dog-fighting club and adds that his "entrepreneurial skills" have made him "richer than a doctor."  He has been fired from multiple jobs, most recently while working as a car salesman, due to getting into arguments with coworkers and being repeatedly late to shifts.  The patient says, "I was only late a few times.  Haven't you ever been late before, doc?"  During middle school, he was recurrently truant and spent time at a juvenile detention center for tampering with his teacher's car brakes after failing a class.  Which of the following is the most likely diagnosis?

A 63-year-old man comes to the office for follow-up of hypertension.  At his last appointment, he revealed that he had increased his intake of 12-oz cans of beer from 3 to 6 cans daily due to stress at work.  The physician advised him to seek help for his alcohol use because it could be causing his elevated blood pressure and has many negative health risks.  The patient now tells the physician, "I thought about what you said.  I know my alcohol use has gotten out of hand and is affecting my health.  My wife and daughter also say that I need to quit.  I have made an appointment with a counselor to talk about my options."  Which of the following best describes this patient's stage of behavioral change?

A 32-year-old man comes to the office due to anxiety that has intensified since he was promoted to a managerial position.  Whereas he previously worked alone, his new position requires him to interact with a team of five employees and handle customer service complaints.  The patient says he is anxious throughout the day and fears that he will say something embarrassing or that his coworkers and customers will notice his anxiety and think he is incompetent.  He says he was very quiet and shy growing up and would always get anxious when meeting new people.  He has a few friends with whom he socializes, but he typically has three or four alcoholic drinks before going out with them to feel more relaxed.  The patient does not feel depressed, and his sleep and appetite are normal.  A medication with which of the following mechanisms of action would be most appropriate for this patient?

A 21-year-old woman comes to the office at her mother's urging due to irritability and low mood.  Two months ago, the patient was sexually assaulted in the parking lot of her workplace.  Since then, she has felt that "the world is not a safe place" and is reluctant to go back to work, preferring to stay home.  In the middle of the day she will "space out" and hear the voice of her assailant, "as if I am right there in the parking lot."  At other times, she feels a sense of unreality as if she is outside her body and cannot recall the exact details about what happened, and says that, "I feel like I am going crazy."  The patient has become withdrawn and either avoids her friends or becomes "snappy" when they visit her.  She has lost interest in her hobbies of writing poetry and exercising.  There is a family history of major depression in the patient's mother and schizoaffective disorder in her maternal grandmother.  Which of the following is the most likely diagnosis?

A 30-year-old woman comes to the office due to depressed mood.  The patient has felt "disappointed and sad" since she was passed over for promotion 3 weeks ago.  She has trouble falling asleep because she thinks about what she could have done differently at work.  The patient's appetite, energy, and concentration are not affected, and she still enjoys going out with friends and attending choir group.  She has no significant medical or psychiatric history.  Vital signs and physical examination are within normal limits.  A course of psychotherapy is recommended, to which she responds, "Have you ever had depression or been in therapy, doctor?"  Which of the following is the best response to this patient?

A 29-year-old woman comes to the office for evaluation of vaginal discharge and pruritus for the past week.  The discharge is thick and yellow with no associated odor.  The patient is sexually active with multiple partners.  When asked about the genders of her sexual partners, the patient says, "Why does it matter?  I'm pretty sure this is a yeast infection, so I just need some medication."  Which of the following is the most appropriate response at this time?

A 79-year-old man is brought to the office by his wife for evaluation of memory impairment.  The patient is a recently retired professor who began having memory problems a month ago.  He has been forgetting to take his medication, has had difficulty remembering the names of his grandchildren, and has neglected to turn off the stove on more than one occasion.  The patient used to enjoy reading and playing with his grandchildren but has recently stopped doing both of these activities.  He also has difficulty staying asleep, low appetite, and decreased energy.  The patient has hypertension and type 2 diabetes, for which he takes medications.  He has a family history of Alzheimer disease.  The patient says, "I just feel so worthless since retiring."  Temperature is 36.7 C (98.1 F), blood pressure is 119/78 mm Hg, pulse is 74/min, and respirations are 14/min.  Neurological examination reveals no focal deficits.  Montreal Cognitive Assessment score is 23 (normal: ≥26/30).  Which of the following is the most likely diagnosis?

A 65-year-old man is admitted to the inpatient unit of a busy community hospital for worsening shortness of breath over the last few days.  He has a 40-pack-year smoking history and was initially diagnosed with chronic obstructive pulmonary disease exacerbation and treated accordingly.  Chest x-ray on admission shows a large hilar opacity, and CT scan confirms the presence of a 4-cm mass in the right hilum.  During the process of obtaining informed consent for bronchoscopy with biopsy, the patient says, "Doc, please don't tell me what they find, because if it's cancer, I don't want to know."  Which of the following is the most appropriate response to this patient's request?