Exam 2: Behavioral Sciences

A 45-year-old man arrives at the clinic complaining of terrible sleeplessness. The patient is having difficulty sleeping because he thinks he has to stay attentive in order to defend himself from workers at a neighboring chemical factory. He claims they poison him by dumping poisonous garbage in his property at night. According to the patient's wife, "He's been this way for the past ten years. When pressed for proof, he becomes enraged, so he plans to install cameras the next week." She has never witnessed any strange activity in the backyard and claims that her husband has never been threatened or suffered physical violence. Over the years, he has ordered multiple soil toxicity tests, all of which have come back negative.   The patient started working as a taxi driver at age 21 and continues to work for the same company.  He has no history of psychiatric treatment.  Which of the following is the most likely diagnosis for this patient?

A 14-year-old girl is brought to the office by her mother due to behavioral changes over the past seven months.  The mother is concerned that her daughter seems overly anxious about eating, and says, "During lunch, she spent 40 minutes cutting vegetables 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?

A 45-year-old man arrives at the emergency room with several hand lacerations from punching his hand through a glass. When the patient returned home from work to find his wife had walked out and taken their two children, he claims he "momentarily lost control." The temperature is 37.2 ° Celsius (99 F), the blood pressure is 150/88 mm Hg, and the pulse rate is 96 bpm. The patient's right hand has many abrasions and cuts, and he is advised that two lacerations will require suturing. "I've been waiting a terribly long time and have to get out of here and put things right with my wife and kids," the patient adds furiously. I no longer have time for stitching. You are all incompetent."  Which of the following questions is most appropriate in determining the best next step in management of this patient?

A 17-year-old boy is brought to the physician by his parents because of a 4-month history of unpredictable behavior. Last week, when his teacher asked him to present his homework in class, he started shouting and cursing and threw a book on the floor. The teacher has reported that similar outbursts occur at least twice weekly for no apparent reason; otherwise, he is usually calm and sits quietly during class. His mother reports that during driving lessons he regularly becomes angry "if other people drive too slowly", and that has led to him almost losing control of the car. After these episodes, he feels embarrassed and apologizes for his actions. When asked about his behavior in these situations, he says, "I feel a sudden rage inside of me, my mind is racing, and I can feel my heart pounding." His mother is concerned that he may not be able to get his driver's license if he cannot control himself. He is otherwise healthy, takes no medications, and does not use illicit drugs. Which of the following is the most likely diagnosis?

A 5-year-old boy is brought to the office by his parents for the annual health 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 friend brings a 65-year-old man to the emergency department after discovering him bewildered at his residence. Chronic obstructive pulmonary disease, hypertension, coronary artery disease, and cigarette use are all part of the patient's medical history. He is single and unmarried. According to the buddy, the patient has a sister who lives nearby but is unclear of when they last spoke. The patient's companion has known him for 5 years and describes them as "excellent mates." He informs the doctor that they have talked about death and that he feels the patient would like to "die gently" and would refuse any heroic measures, including "being hooked up to a ventilator." The temperature is 39 ° Celsius (102.2 degrees F), the blood pressure is 120/80 mm Hg, the pulse rate is 105 beats per minute, and the respirations rate is 24 /minute. On room air, oxygen saturation is 88 percent, and on 2 L of oxygen, it is 93 percent. The patient is drowsy and unable to respond to queries. Bilateral wheeze and reduced breath sounds are seen in the lungs. A right lower lobe infiltration is shown on a chest x-ray. Bronchodilator and antibiotic therapy are started as needed. If the patient does not respond to the initial therapy within the following 2-3 hours, the doctor is concerned about the necessity for intubation. Which of the following is the best course of action?

A 64-year-old man walks in for a check-up six months after having a myocardial infarction. The patient's health has gradually improved, despite a pulmonary embolus and a urinary tract infection complicating his clinical path. During the session, the patient presents the doctor with handmade cookies and a thank-you note with four professional basketball game tickets. He claims, "I'd like to express my gratitude for everything you've done. Please accept these tickets and have a good game." He encourages the doctor not to worry about the cost, stating, "Every year, I get season tickets but haven't been able to attend any games due to illness. You have been a good doctor, and I wanted to thank you by giving you something." Which of the following statements is the most appropriate?

A 62-year-old man arrives at the emergency department with his wife complaining of back discomfort. He has not recently fallen or been injured. Hypertension and hypercholesterolemia are medical histories. While the doctor is taking a history, the patient feels uncomfortable and claims he is having difficulty comprehending since he has hearing loss and his hearing aid batteries expired a few minutes ago. To reduce ambient noise, which of the following techniques, in addition to closing the door, muting the TV, and turning off non-essential medical equipment, is the greatest next step to improve communication with this patient?

A 52-year-old man comes in for a check-up to discuss the findings of his colonoscopy. The doctor informs the patient that a malignant polyp was removed and that the resection margins show no evidence of aggressive malignancy. He is then reassured that his prognosis is favorable. As a result, the patient rants and yells furiously, "Are you saying I should be grateful you discovered cancer in the first place? You have no idea what you're doing!" Which of the following is the best way to deal with the patient?

A 44-year-old man arrives at the office complaining of weariness for the previous six months. He claims, "I've fallen asleep at work a few times, and I had to force myself to focus. I'm having trouble sleeping as well since I keep waking up." The patient feels bad about spending less time with his children because he is fatigued, and he reports that his mood has been poor for the previous week. He is concerned that his wife is irritated with him since he has not been contributing as much to home tasks and keeps her up at night owing to his snoring. The patient consumes three or four beers each week and does not use cigarettes or illegal substances. Medical history is noncontributory.  Blood pressure is 146/94 mm Hg and pulse is 78/min and regular.  BMI is 32 kg/m².  Which of the following is the most likely diagnosis?

A 62-year-old woman visits the office for a check-up on her deteriorating hypertension. The patient admits to not taking her blood pressure medicine as directed. "I always listen to my physiological rhythms when selecting whether to take medicine on a specific day," she explains. The patient claims that her crystal jewelry has therapeutic properties, and she runs an internet forum regarding crystal health advantages. Most people do not trust her, and she believes she can forecast the weather based on the amount of birds in her yard. She is unemployed, lives alone, and has few friends. The patient makes little eye contact and is moderately apprehensive during the assessment. She has no audio hallucinations and no particular delusions. Which of the following is the most likely explanation for this clinical presentation?

A 30-year-old woman visits the gynecologist's clinic for her annual checkup. The patient is in good health and has no complaints. She says she's been researching tubal ligation and would want to have it done since she's weary of using oral contraceptives and doesn't want to have children. She has experienced no negative side effects from oral contraceptives. The patient has been married for ten years and considers his marriage as "extremely secure." Which of the following responses to the patient's desire for tubal ligation is most appropriate?

A 28-year-old woman arrives at the office for a routine pregnancy checkup. Her pregnancy has been progressing well, and the patient is overjoyed to be having a baby after years of trying to conceive. Her and her husband's marriage suffered greatly as they went through many failed reproductive procedures. During the visit, the doctor requests blood testing and administers a 1-hour glucose challenge test. When this is disclosed, the patient feels concerned and begins to inquire about the aim of the tests. When questioned about her worries, she reveals that the fetus is not her husband's kid.   Her husband is also the physician's patient, and she asks the physician not to tell him about this because "it will ruin everything."  Which of the following is the most appropriate response by the physician?

A 50-year-old woman comes to the physician due to concerns about having diabetes mellitus . She has not been to work since yesterday due to mild fatigue and dizziness for the past 2 days. She says she has "very high blood sugar" and has had similar episodes often in the past 2 years, for which she has visited multiple doctors around the city. She has also purchased a home glucose monitoring device, which she uses daily. Since the symptoms began, she has become socially withdrawn and spends much of her time at home researching diabetes on the internet. One week ago, she took a day off work because of her symptoms. She is not on any treatment. She has had three laboratory test reports that all show normal fasting and post-meal blood glucose levels. Her father and brother have type 2 diabetes mellitus. She appears anxious. Vital signs are normal. Physical examination shows no abnormalities. Random serum glucose is 128 mg/dL. Which of the following is the most likely explanation for this patient's symptoms? Which of the following is the most likely diagnosis?

A 46-year-old man arrives at the emergency room complaining of chest discomfort that began 30 minutes earlier. The discomfort is described as a tight, squeezing sensation that radiates to the left arm by the patient. He is also experiencing excessive perspiration and nausea. The ECG reveals multi-lead ST-segment elevation, as well as elevated cardiac troponin levels. The patient has a history of substance misuse, but no history of heart problems. He had an emergency heart catheterization and is doing well in the postanesthetic care unit. A concerned woman approaches the doctor, claiming to be the patient's wife and inquiring about his status. "I am really anxious; please tell me whether my spouse is okay," she begs. Which of the following is the best course of action?

A 19-year-old man is hospitalized for hallucinations, delusions, and disordered conduct. He is diagnosed with schizophrenia, and the doctor issues an order for him to start taking aripiprazole "2.0" mg. The patient is given 20 mg of aripiprazole instead of 2 mg. This order is missed via the pharmacy review procedure, and the nurse fails to query it before giving the patient aripiprazole. Which of the following interventions is the most successful in reducing this sort of error?

A 13-year-old kid is brought to the doctor by his mother for a standard medical examination and type 1 diabetes mellitus follow-up. "Here's the doctor; he's going to tell you how terribly you've been doing," his mother exclaims at the start of the appointment. Laboratory tests reveal a random blood glucose of 350 mg/dL and a hemoglobin A1c of 9% (normal: 6%-7%). When the doctor asks how the patient is doing with his insulin, his mother interrupts and exclaims, "He never remembers to use it!" When asked about the boy's diet, his mother puts her hands on her hips, glares at him, and exclaims, "Pizza, soda, and sweets!" After addressing the mother's worries about diabetes management, which of the following is the most appropriate course of action?

A 54-year-old woman comes in for her annual preventative checkup. She has no particular concerns. The blood pressure is 144/95 mm Hg, and the pulse rate is 86 beats per minute. 50 kg/m² is the BMI. The examination reveals extreme obesity but else is ordinary. The fasting glucose level is 128 mg/dL. When asked about her weight, the patient responds, "My family simply enjoys eating. My mother, father, and children are all overweight. It's pointless to try to reduce weight right now." Which of the following responses to this patient's remark is most appropriate?

Her mother brings a 16-year-old girl to the office with vague stomachaches and pains. She has no previous medical history. Since the start of the school year six months ago, the patient has missed more than ten days of class owing to symptoms. According to the mother, her daughter has always been worried and has a "sensitive stomach," but the symptoms have gotten worse since the patient's best friend moved away a month ago. She has a few more pals, but she likes to stay at home and avoids after-school events. "She worried for weeks about going to a party," the mother adds. She suffered an anxiety attack and began hyperventilating the night before the party. She ended up not going to the party at all."  The patient says she is "just very shy" and is afraid of being embarrassed or "looking stupid" around others.  Physical examination shows no abnormalities.  During the interview, the patient makes little eye contact and gives brief answers to questions.  Which of the following is the most likely diagnosis?

An 18-year-old man returns to the office for a check-up. He was treated in the emergency room three months ago for panic episodes caused by cocaine usage. Following that, the patient quit taking cocaine and has had no recurring anxiety problems. He finished high school, got a new job, and is thinking about applying to community college. At today's appointment, the patient recalls having taken cocaine at a friend's residence over the weekend. He claims, "I really screwed up. I'm feeling defeated." The patient has no medical history. He is not in any bodily pain. Which of the following statements by the physician is the most suitable at this time?