Exam 2: Behavioral Sciences

A 27-year-old man comes to the office for follow-up regarding a herniated disc.  He first injured the disc 3 months ago while at work.  Nonsurgical treatment options, including physical therapy and as-needed NSAIDs and tramadol, were recommended.  The patient has completed physical therapy, and follow-up MRI indicates that the herniated disc has regressed.  He reports a significant amount of ongoing pain and asks for a dose increase and refill of his pain medication.  In the past month, the patient has been to the emergency department on 2 occasions to request pain medication due to running out before his next scheduled refill.  Vital signs are within normal limits, and physical examination is unremarkable.  Which of the following statements by the physician would be most appropriate at this time?

At a busy community hospital, a medical intern works on the inpatient wards. The team analyzes a new patient hospitalized for increasing congestive heart failure during rounds. Past medical history of the patient includes atherosclerotic coronary artery disease, diabetes mellitus, and pulmonary hypertension. Metformin, aspirin, and enalapril are among the current drugs. The patient previously acknowledged to taking cocaine recreationally with pals and admits to the intern that his most recent usage was today. The attending physician instructs the intern to begin the patient on propranolol for his heart issue; he will be expected to maintain this medication after being discharged from the hospital. After rounds, the intern recalls learning in medical school that beta adrenergic antagonists had a bad interaction with cocaine.

A 29-year-old man visits the urgent care clinic with a sore throat and nasal congestion. He is led to an examining room after 2 hours of waiting. The vital indicators are within normal ranges. When the doctor enters the room, the patient exclaims loudly, "I've been here for several hours and there aren't many people in the waiting room. I'm skipping work to come here." In addition to praising the patient for their patience, which of the following physician answers is most appropriate?

A 28-year-old woman visits her gynecologist, who has been providing routine treatment to her for the previous ten years. The patient received a positive home pregnancy test last week despite not having menstruated in over two months. Despite her desire to have children in the future, she has been experiencing a lot of stress recently and believes that caring for a child is the last thing she needs right now. At 7 weeks gestation, a pelvic scan reveals an intrauterine pregnancy, and the patient requests that the gynecologist terminate the pregnancy as soon as feasible. On moral grounds, the gynecologist does not conduct abortions, yet she is trained in the technique. Which of the following is the best course of action?

A 75-year-old lady is admitted to the hospital with a bowel blockage caused by adhesions from earlier uterine cancer surgery and radiation. She has had hypertension, atrial fibrillation, and peripheral vascular disease in the past. She is discharged on many drugs, including a greater dose of her warfarin, after a lengthy hospital stay complicated by a pulmonary embolus. The patient has appointments with her internist, gynecologist, cardiologist, and gastroenterologist. She lives on her own and has previously managed her care requirements satisfactorily. Her adult daughter is helpful, although she lives out of state. Which of the following strategies would be most successful in increasing her outpatient treatment adherence?

A 56-year-old lady with a history of schizophrenia is admitted to the hospital with right upper quadrant stomach discomfort and is later diagnosed with cholecystitis. She is being treated with antibiotics first, then a cholecystectomy is scheduled. The patient reported feeling significantly better on day two of her stay. The patient does not want surgery and would rather take oral antibiotics at home. "I believe God is on my side and will take care of me," she adds. The patient lives in a group home and attends a day treatment program where she receives risperidone on a regular basis. During the examination, the patient is attentive and aware of person, place, and time. She claims to have heard voices many times a day for many years, but they no longer affect her as much as they once did. The patient has no suicidal ideation.  Which of the following is the best next step in management of this patient?

Due to changed mental condition, a 67-year-old man is sent to the emergency room via ambulance. He was eating supper with his daughter when he grew disoriented and collapsed over. The patient has a history of atrial fibrillation and is taking an anticoagulant. He is a widower living with his daughter. The blood pressure is 208/113 mm Hg, the pulse is 64 beats per minute and irregular, and the respirations are 15/minute. On room air, oxygen saturation is 88 percent. The patient is dazed and unable to respond to directions. Pupils are medium in size and do not react to light. The physician concludes that intubation is required at this time to preserve the patient's airway and obtains approval from the patient's daughter and elder son who are present at the bedside. They tell the physician that the patient does not have an advance directive and they are unsure how to proceed.  Which of the following is the most appropriate next step in decision-making for this patient?

A 70-year-old woman comes to the office due to progressive memory impairment.  This symptom was satrarted a year ago and her symptoms have steadily worsened.  She often forgets the content of conversations she has with her son and frequently walks to another room, only to forget what she went there to do.  The patient lives alone and has no difficulty cooking, cleaning, or otherwise caring for herself.  She manages her own finances.  Medical history is significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus.  Temperature is 36.9 C (98.4 F), blood pressure is 132/83 mm Hg, pulse is 72/min, and respirations are 14/min.  The patient is alert and oriented.  Neurological examination reveals no focal deficits.  She scores 22/30 on the Montreal Cognitive Assessment.  Which of the following is the most likely diagnosis?

A 28-year-old man arrives at the office after experiencing regular anxiety episodes for several months. He claims, "I dismissed it at first since the attacks are brief, but now I'm concerned that it may happen again when I'm at work or driving. I suddenly feel weak, begin to tremble and sweat, and my heart begins to race. My heart felt like it was ready to leap out of my chest." The patient has no history of heart disease and is not on any medications. He had an alcohol use issue in his early twenties and occasionally smokes marijuana. The patient looks to be in good spirits, and his vital signs are within normal ranges. There are no abnormalities on physical examination or ECG. Which of the following is the most appropriate pharmacotherapy?

A 24-year-old lady arrives at the clinic after experiencing repeated episodes of chest discomfort, palpitations, and shortness of breath in recent months. She has dizziness, diaphoresis, and hand paresthesias during certain bouts. The episodes last 5-10 minutes, and the patient is continuously concerned about when and where next one may occur. She states, "This continues happening, and no one can explain why. I'm afraid something is really wrong with me." The patient had visited the emergency room twice in the previous month for similar episodes; earlier assessment, which included a thorough metabolic profile, thyroid function tests, arterial blood gas analysis, ECG, cardiac enzymes, and a chest x-ray, revealed no abnormalities. The vital indicators are within normal ranges. Examination of the body. Which of the following is the most likely diagnosis?

A 29-year-old lady visits the clinic for an examination of vaginal discharge and pruritus that has been bothering her for the previous week. The discharge is thick and yellow, with no odor. The patient engages in sexual activity with several partners. When asked what genders her sexual partners are, the patient responds, "What difference does it make? I'm very sure I have a yeast infection, therefore all I need is some medicine." Which of the following is the best reaction at this time?

A woman brings her 11-month-old son to the office for a well-child visit. When other people approach him, he screams and cries, according to his mother. She is concerned since it has been happening for a few months and appears to be getting worse. She states, "He used to like being held by everyone, but now he only wants to be with me. He won't even let his grandmother hold him." The sufferer is crawling and can only stand with help. He babbles but does not speak well and communicates through hand gestures. Growth curves are tracking well. During the physical examination, the patient clings to his mother and begins to weep, turning his head away from the physician when he tries to connect with him. Which of the following explanations is most likely for this patient's behavior?

A 27-year-old man is taken to the emergency hospital by his roommate, who discovered him barricaded in a closet at home and stating, "They're on their way to get me. Nobody can be relied on." Last month, the patient was laid off from his work and split up with his girlfriend. For the past two weeks, he has heard voices threatening to murder him on a regular basis. He has no medical or mental background, and he does not drink or use illegal substances. The findings of the physical examination and laboratory tests are ordinary. The patient feels anxious and tense throughout the mental status evaluation. He claims that persons in black automobiles are tailing him and spying on him. Which of the following is the most likely diagnosis in this patient?

After becoming involved in a dispute with another kid at school, a 13-year-old boy is escorted to the office by his parents. According to his parents, "He has never been in a fight before, and we are concerned because his grades have also been falling. He appears irritated and grumpy, spends extended periods of time in his room, and no longer welcomes guests to his house." When asked about the event by himself, the patient answers, "The wall people told me that he was trying to poison my food." The patient has no substantial medical history; nevertheless, a paternal aunt has a family history of bipolar illness. The temperature is 37.2 degrees Celsius (99 degrees Fahrenheit), the blood pressure is 130/80 mm Hg, the pulse rate is 98 bpm, and the respirations rate is 14/minute. Physical examination shows a postural tremor on extension of the arms and a broad-based gait.  Mental status examination is significant for slurred speech, sad mood, and distractibility.  Laboratory studies reveal elevated serum transaminases.  Which of the following is the most likely diagnosis?

A 52-year-old man is on a week-long cruise vacation with his family to celebrate his mother's 80th birthday. He has a very important presentation at work to give in one month, which will in part determine whether he receives a promotion. He decides to focus on enjoying the vacation and not to worry about the presentation until the cruise is over. Which of the following psychological defense mechanisms is he demonstrating?

A 33-year-old woman is moved from a small community hospital to the university medical center owing to severe pyelonephritis with sepsis. She has a history of recurring urinary tract infections as a result of urine retention caused by a spinal cord injury as a youngster. The patient is febrile and sluggish when he arrives. She offers no more background, and the only information accessible is from the originating hospital's handwritten records, which are illegible. The patient is hospitalized to the critical care unit and given the antibiotics imipenem and vancomycin. The patient gets a rash and significant respiratory distress overnight, necessitating temporary artificial ventilation. The following morning, a transcribed physician note from the originating hospital arrives by fax and indicates that the patient has an allergy to multiple antibiotics, including imipenem.  When discussing events with the patient and her family, which of the following statements is associated with reduced malpractice liability for the treating clinician?

A 3-year-old girl is brought to the physician for a well-child examination. She was born at term and has been healthy since. She can climb up and down the stairs and can pedal a tricycle. She has difficulty using a spoon to feed herself but can copy a line. She speaks in two- to three-word sentences that can be understood by most people. She does not play cooperatively with children of her age and often throws tantrums. The patient cannot use a spoon or fork but enjoys eating with her hands.  She scribbles spontaneously but cannot copy a circle.  She weighs 14.5 kg (32 lb) and is 96.5 cm (3 ft 2 in) tall.  Head circumference is 50.8 cm (20 in).  Which of the following developmental milestones is likely delayed in this patient?

A physician is having dinner with a colleague when he observes one of his patients seated at a nearby table with her spouse. When the patient leaves the restaurant, he approaches the table and exchanges a few pleasantries with the physician's colleague. She then gives the physician a short nod but says nothing to him. The doctor smiles as he accepts the gift. Following that, the physician's colleague inquires, "Is she one of your patients? She is a family member who has recently been diagnosed with breast cancer. I've been worried about her and have been wondering how she's doing." Which of the following is the physician's most suitable reaction to his colleague?

A 14-year-old girl is brought to the physician by her parents for evaluation of fatigue for the past 6 months. Her parents are concerned because she eats only a vegetarian diet. During this period, she has had a 5-kg (11-lbs) weight loss. She states that she has no friends. When she is not in school, she spends most of her time in bed. She has no history of serious illness. She appears pale. She is at 25th percentile for height, 15th percentile for weight, and 20th percentile for BMI; her BMI is 17 kg/m2. Her temperature is 37.0°C (98.6°F), pulse is 65/min, and blood pressure is 110/70 mm Hg. Examination shows dry skin, brittle nails, and calluses on the knuckles. Which of the following is the most appropriate next step in management of this patient?

A 52-year-old man with advanced pancreatic cancer visits an oncologist for a check-up. His cancer is incurable, and he has been on palliative care for the past three months. The patient and I had already discussed his prognosis. He's dropped 22.6 kg (50 lb) and is now too weak to play with his kids. He claims that during the visit, "I am a survivor, and I know I can overcome this. I'm going to do everything I can to be there for my kids." Which of the following is the best way to respond to this patient right now?