Thursday 13 September 2012

Usmle Step 1 MCQ's # 4

Title: Usmle Step 1 MCQ's # 4
Subject: Behavioral Science

Q NO 4: A 49-year-old patient is evaluated for suicidal ideation after he is found laying on train tracks by police. The man is disheveled and malodorous and states that he has “reached the end” and would rather die. He admits to depressed mood, anhedonia, poor energy and appetite; he feels miserable and regrets what he has done with his life and wants to put an end to it. He states he has felt this way since age 26, alter he was discharged from the military. The man indicates that his life was “great” until he increased his drinking, which caused a divorce at age 30. He has had two arrests for driving under the influence. He was in jail for 6 months alter he had an accident while drunk that resulted in public property damage. He remembers that he initially felt sick in jail, with sweating, vomiting, shaking, and he experienced a seizure. He then improved alter a few days and felt better during the rest of his imprisonment without any depression. Which of the following criteria most strongly suggests alcohol abuse?

A. Desire to cut down
B. Recurrent drunk driving
C. Seizure alter withdrawal
D. Suicidal ideation
E. Tolerance

Explanation:
The correct answer is B. The DSM criteria for alcohol abuse are recurrent use resulting in failure to fulfill obligations, recurrent use in hazardous situations, recurrent legal problems related to use, and continued use despite negative consequences.
A persistent desire or unsuccessful efforts to cut down (choice A) is also a symptom of dependence.
Seizures (choice C) are a symptom of severe withdrawal in chronic alcoholics. When the patient develops withdrawal symptoms and tolerance, requiring larger amount to achieve the desired effect, he or she has met the criteria for dependence.
Suicidal ideation (choice D) in this patient is a consequence of his depression, which in turn, is secondary to alcohol use. Continued use of a substance despite knowledge of persistent or recurrent physical or psychological problems is also a criterion for dependence.
Tolerance (choice E) is defined as the need to increase substance use to achieve the desired effect, or diminished effect with continuous use of the same amount. Tolerance is a major criterion of dependence.

Thursday 6 September 2012

Usmle Step 1 MCQ's # 3


Title: Usmle Step 1 MCQ's # 3
Subject: Behavioral Science

Q NO 3: A 67-year-old man presents at his physician complaining of discomfort in his lower abdomen and difficulty with urination. The man is 5 feet 11 inches tall and weighs 220 pounds. Although he used to smoke cigarettes, he was able to quit when he retired at age 65. Physical examination reveals an enlarged prostate. Suspecting the possibility of cancer, the physician orders a PSA test and tells the patient he will be contacted when the results are available. The patient is visibly upset at hearing the word “cancer” and in spite of the physician’s reassurances of the low probability of malignancy, is physically shaking when he leaves the office. Several days latter the results of the test are received. The patient has a PSA of 3.5, elevated, but below the commonly used screening test cutoff. At this point the physician’s best course of action would be to do which of the following?

A. Arrange an appointment to talk with the patient in the next several days and review the results in person
B. Call the patient at once to deliver the news and offer guidance
C. Call the patient to deliver the news and congratulate him on his overall health.
D. Call the patient to deliver the news and schedule the patient for a follow-up appointment to review what he can do to improve his overall health.
E. Have the nurse employed by the practice call the patient to deliver the news and take time to answer any questions he may have.
F. Schedule an appointment to talk to the patient about the results and offer him a referral for counseling
G. Send the patient a letter detailing the test results and suggesting the next course of action.

Explanation:
The correct answer is D. All communication with a patient is best handled face to face. When this is not possible because of the need to deliver news in a timely manner, as in the present case the phone conversation should be followed up by a visit. The follow-up visit is also needed to discuss some of the patient’s other health issues, including his weight. This patient’s body mass index (weight/height) is too high.
The patient is likely to have high anxiety over the next several days as he waits to hear the results (choice A). Alleviate the anxiety by telling him as soon as possible.
The phone call gets the good news to the patient quickly, but does nothing to either further the building of a good long-term relationship with the physician or address the patient’s other health concerns (choice B)
Choice C while getting the patient the news quickly, and in a cheery manner, does not address the patient’s other health condition.
The physician himself should deliver the news not a nurse (choice E) or other member of the office staff. The practice of having the physician call with bad news and a staff member call with good news only heightens patients anxiety anytime the physician calls. The physician is in the best position to answer any questions that the patient has, and to talk about the next steps to improve health.
The patient is likely to have anxiety waiting for days to hear the test results. Also the physician himself should do counseling, and not refer to patient to someone else (choice F).
A letter from the physician (choice G) takes time to get to the patient, always creates anxiety and offers no one to discuss meaning of the results.

Saturday 1 September 2012

Usmle Step 1 MCQ's # 2


Title: Usmle Step 1 MCQ's # 2
Subject: Behavioral Science

Q NO 2: A 25-year-old woman is brought to the hospital by her husband. The patient complains of severe pain and tenderness in her lower left abdomen. She is diagnosed with appendicitis and scheduled for an emergency appendectomy under general anesthesia. A 2nd year resident performs her surgery. Surgery reveals that the appendix is normal and without inflammation. However, the resident notices a large tumor attached to the patient’s left ovary At this point the resident’s best next course of action would be to do which of the following?

A. Biopsy the tumor and terminate the surgery
B. Excise as much of the tumor as possible without coming into contact with the ovary?
C. Exercising common standards of care, remove the patient’s ovary to eliminate the tumor
D. Seek permission to excise the tumor from the patient’s husband, who is sitting in the waiting room
E. Seek the advice of the supervising surgeon
F. Talk with the patient’s husband, who is in the waiting room, about how his wife would probably want to proceed

Explanation:
The correct answer is A. A competent patient has the right to make all treatment decisions for themselves, including refusal of treatment. If you can access the patient’s wishes by direct conversation, then this must be done. After woman recovers from the anesthesia, she is entitled to full informed consent including descriptions of the: 1) nature of the procedure, 2) the purpose or rationale, 3) the benefits, 4) the risks, and 5) the availability of alternatives. With this information presented, the patient herself can make what ever treatment decision seems best to her.
Excising the tumor (choice B) is treatment without the patient’s consent and permission.
Patient’s wishes, not” common standards of care” (choice C), are what guide treatment decisions. Only if we could not access the patient’s wishes in any way, AND the situation was critical, would we act using judgment as to what would be reasonable care.
Choices D and F are incorrect, because the woman has primary say over her own body. If she were in a coma of some duration, then we might ask the husband under the doctrine of substituted judgment. But here, we can wake her up and ask her directly.
The resident has all of the information required to know the correct actions to take without consulting a superior (choice E). In general, consulting a superior will be the wrong answer on the Step 1 exam.