Usmle Step 1 MCQ's # 13

Title: Usmle Step 1 MCQ's # 13
Subject: Behavioral Science

Q NO 13: Over the past 10 years, a 15-year-old boy has been taking medication that has successfully controlled his severe asthma. He has had no exacerbations in the past two years. His parents come to see the boy’s physician seeking her advice. The boy has recently declared that he does not want to take his asthma medication any longer. Instead, he believes that changing his diet to one that is tree of all “toxins” is all that is required to limit his exacerbations. The parents want to know what they should do. What action should the physician take next?

A. Arrange to speak with the boy and ask him the reasons for his decision
B. Arrange to speak with the boy and convince him that he must stay on his medication
C. Have the boy evaluated by a pulmonologist and follow the recommendations of the specialist
D. Take the boy off his medication and monitor him closely in case there are any adverse reactions
E. Tell parents that you will switch the boy to a newly available medication
F. Tell the parents that it is essential that their son stay on his medications and that they must convince him to do so

Explanation:
The correct answer is A. Before reaching any treatment recommendation or encouraging either the parents or the boy to take any particular course of action, the physician needs more information. All he knows is the boy’s views as represented by the parents. The boy is old enough to express himself and articulate his reasons, so the physician should go directly to the source. Getting enough information before you act is a good rule for the exam, and a good rule for medical practice.
Speaking with the boy is the right idea. But walking into the conversation with an agenda of selling a particular course of action (choice B) is likely to lead to confrontation, not communication. Be open-minded and hear what the boy’s experience and reasons have been.
This is your patient, and you should make the required decisions. The rule:” Never pass off,” applies here. Giving your patient to someone else (choice C) will yew rarely be a right answer on the Step 1 exam.
Taking the boy off his medication (choice D) is premature. Talk to the boy and get his views before deciding on any course of action.
Choices E and F not only force a solution before all the relevant information is known, they force the parents to do the work of the physician, namely, talking directly with the patient. Yes, the parents, at this age, have the final say regarding treatment choices, but cooperation of the patient is essential for adequate treatment of asthma.

Usmle Step 1 MCQ's # 12

Title: Usmle Step 1 MCQ's # 12
Subject: Behavioral Science 

Q NO 12: A 15-year-old boy has been treated on an ongoing basis by his physician for type 1 diabetes. During a regularly scheduled evaluation, the patient appears sullen and non-responsive. He slouches in his chair and will not make eye contact with the physician. When questioned about how he is feeling, the boy mumbles something unintelligible and stares at the floor. When told that he was not understood, the boy blurts out, “This treatment is not working. It’s such a pain. I don’t want to come here anymore. I don’t think you know what you are doing.” In response to this out burst the physician’s best reply would be which of the following?

A. "Are you having trouble with the other kids at school?"

B. "I know this is a bother, but your parents have decided on this course of action and they know what is best for you."

C. "If you would be more comfortable with a different doctor, I’ll try to arrange it for you."

D. "I’ll make a deal with you. Keep on with your treatment for six more months, and we’ll see where you are at that point."

e. "In what way is the treatment not working?"

F. "Tell me a little bit about what life has been like for you lately."

G. "When I was younger, I had to do a lot of things that I did not want to, but looking back, I’m glad I did."

H. "When you are old enough, you will get to make these decisions. Until that time, I’m going to do as your parents request."

I. "Without this treatment you will die. Do you understand that?"

Explanation:

The correct answer is E. The key issue here is that the physician does not know exactly what is bothering the boy when he says the treatment is not working. Does he think he should be cured? Does he find the monitoring and treatment regimen to be onerous? Is he subject to criticism from his peers? Or is he just tired of having a medical problem? The physician does not know, and so should ask. When you don’t know exactly what the patient is talking about, ask!

Choice A is not directly responsive to the boy’s outburst and leaps to an assumption about the reason he is upset. Guessing correctly may make the physician seem omniscient, but guessing wrong simply makes him seem foolish. Don’t assume, ask.

Choice B brings the parents, and their authority to make medical decisions for the boy into the discussion. It complicates the gathering of information from the boy, and stresses the authority relations, something that is likely to heighten, not soothe the boy’s anger.

Choice C is incorrect. The physician must form a relationship and solve the presented problem. Getting rid of the problem by getting rid of the patient is nothing more than a dereliction of duty.

Choice D is not a bad tactic for negotiating adherence. Often, seeing treatment stretching out interminably makes patients despair. Breaking it into a bounded time frame makes it seem more manageable. The problem here is that this discussion is premature. The physician is negotiating the solution before having a clear sense what the problem is.

Choice F is a great way to get a sense of how the disease and treatment might be affecting the boy and his relationship with others. But, again, this is premature. Find out what the problem really is before talking about how it has affected the boy’s life.

Choice 0 is meant as fatherly advice, but risks being perceived as condescending and un empathetic. At the very least, find out what the problem is before regaling the boy with what life was like when you were young!

Choice H tells the boy that he has no say, and that the physician is not interested in what he has to say. True, the parents are the ones making the decisions, but there are other reasons to talk to the boy. Only he knows how the treatment makes him feel, and what impact it has on his life. And he is likely to be the first one that knows if something is truly wrong. Don’t lecture ask.

Choice I is a bit harsh, but statements like this can be excellent motivators to foster adherence with treatment. The Health belief model tells us that engendering fear, and then providing a simple solution is empirically a very good way to motivate adherence. But here again, we need to know what the problem is before we seek to work on adherence issues.

Usmle Step 1 MCQ's # 11

Title: Usmle Step 1 MCQ's # 11
Subject: Behavioral Science

Q NO 11: A 29-year-old man comes to see his physician for treatment of a sinus infection. From previous medical history, the physician knows the patient often has sexual relations with other men. In the course of the physical examination, the patient tells the physician that he has “had a difficult time lately” since the death of his “life partner” due to AIDS several months ago. He reports difficultly sleeping, waking time anxiety, and a weight loss of 10 to 15 pounds. His appearance is gaunt and his face is strained. When asked it he had ever been tested for HIV, the patient becomes angry and says,” No, and I’m never going to get tested. Don’t tell me you’re one of those doctors who think that all gay men have AIDS!”. At this point the physician’s best reply would be which of the following?

A. ”Don’t be so sensitive. It just seemed like the obvious question to ask given your circumstances 11
0B.1 have quite a few gay patients and i get a long well with allot them. I’m sorry that l upset you.”
C. “I’m going to prescribe an antibiotic for your sinus infection and something else to help you feel a little better.”
D. “l’ m sorry if I upset you. I want to make surely give you the best care possible and with currently available medications, early detection for AIDS is essential.”
E. “I’m sorry that you feel that way about me. Would you rather I refer you to another physician?”
F. “If you want me to help you, I have to ask these types of questions.”
G. “OK, sounds like that is a sensitive subject. Sorry that I bought it up.”
H. “You seem to be distressed at the loss of your partner.”
I. “You seem upset. Let’s talk a little bit about how things have been going for you in the past several weeks.”

Explanation:
The correct answer is D. The issue of testing is a legitimate, and even necessary one. The anger of the patient should be defused, and the reasons for the question explained, but the matter should not be left to drop just because of the patient’s emotional response. The physician first takes responsibility, and acknowledges that he is the cause of the patient being upset by apologizing. Alter addressing the emotional issue, the physician proceeds to explain the reason for the question. This answer keeps the lines of discussion open, and focused on the health matter at hand. This answer is best because it deals with the patient’s anger AND keeps the discussion on the health issue of concern.
This response is defensive--the physician feels attacked and defends himself by justifying his actions (choice A) . Un fortunately, this response is likely to heighten, not reduce, the patient’s anger. Further, the discussion now centers on the patient’s response with the focus on the need for testing and treatment lost. Note that in this response, no reason for raising the testing issue is given. It is merely asserted.
This is also defensive and opens up a discussion about how the physician feels about and deals with homosexual men (choice B), not the core health issue, which needs to be addressed. The issue is the patient’s HIV status, not how the physician feds about gay men.
This may be a reasonable treatment for the sinus infection (choice C); however, it is not responsive to either the patient’s expressed anger or the health need of testing. Note that the veiled offer of antidepressant medication is also incorrect. yew likely the patient is grieving. Correct response to grief is listening, support, and allowing the patient to go through the grieving process.
The rule” never pass off H applies here. The physician can and should, resolve this issue with his patient. There is simply no reason for a referral (choice E)
This is not bad answer, just not best. The tone is sufficiently non-confrontative. However, the physician takes no responsibility for the patient’s response and provides no rationale for raising the topic of testing (choice F).
This response backs away from the subject because of the patient’s response. The apology is correct, but the subject raised is important, one might even say central to the ongoing health of the patient, and cannot be dropped just because the patient is uncomfortable with it (choice G)
Acknowledging the patient’s emotional state is a good idea (choice H). Leaping to an interpretation as to why he is distressed is not. This statement is an interpretation. Physicians should remember that interpretations are almost always perceived as hostile, even if correct. This response is likely to escalate the patient’s anger and detracts from the health issue at hand, the need for testing.
This option reflects back to the patient that he is upset (choice I), a good technique. However, the discussion is then turned to the patient’s life in general, and the focus on testing as the important health issue is lost. Allowing a grieving patient to talk about what they have been doing with their day is good and appropriate, but should be pursued after the discussion about HIV testing is concluded. By raising these issues now, the physician is avoiding the main topic at hand.

Usmle Step 1 MCQ's # 10

Title: Usmle Step 1 MCQ's # 10

Subject: Behavioral Science

Q NO 10: For the past 3 years, a physician has been treating a 55-year-old man for peripheral neuropathy of undetermined cause. Extensive tests have ruled out both diabetes and multiple sclerosis. The patient is in considerable pain that is only controlled by a multiple drug regimen that includes amitriptyline. The physician is approached by the local representative of a pharmaceutical company who is seeking subjects to be included in a Phase Ill clinical trial of a drug that treats peripheral neuropathy. The representative says that the company is willing to pay a $500 administrative fee for any referral to the study. In addition, the physician is offered the chance of becoming in author when the results re published it he refers 20 or more patients to the study. Phase II results for this new drug have been very promising. The physician feels that this patient is an excellent candidate for the study, and that the clinical trial offers the best chance of the patient achieving real relief from his symptoms in the long term. Based on this belief, the physician’s best course of action would be to do which of the following?

A. Allow the pharmaceutical representative to meet with the patient and explain the details of the clinical trial

B. Decline to enroll the patient to receive an untested treatment

C. Discuss the clinical trial with the patient and disclose fully the financial arrangement agreed to with the pharmaceutical company

D. Discuss the clinical trial with the patient and offer to rebate the administrative fee to him as an incentive to participate

Discuss the clinical trial with the patient, disclose the offer of an administrative fee, but tell the patient that the physician will decline the fee

F. Refer the patient to the clinical trial, accept the administrative fee, and donate it to the scholarship fund at a local medical school

G. Refer the patient to the study and accept the administrative fee as offered

OH. Refer the patient to the study but decline the administrative fee offered

Explanation:

The correct answer is E. Payment for referrals, even for a study, even when the referral is appropriate even when the payment is disclosed is a breach of ethics. Period. Professional judgment must not be clouded by other considerations including financial incentive. The clinical trial is right for the patient, so he should be referred, but the “administrative fee” is a disguised bribe and must be refused. In addition the patient must be fully informed about the circumstances surrounding the referral, including the otter of the administrative fee.

The physician must deal directly with his or her own patient. Communication about the study must come from the physician and not be passed off to the pharmaceutical representative (choice A) . Who knows what pressure the representative might place, however unwittingly, on the patient to consent to enroll in the clinical trial?

Choice B is incorrect. All of the indications are that this treatment may be the patient’s best hope. Remember that the treatment is not completely unknown. Phase II data are available and, although not definitive, certainly give an indication of this drug as a reasonable option.

Choice C is incorrect. Disclosure is not enough. The fee must be refused.

Bribing the patient to accept a presented treatment option (choice D) is not appropriate either. True, the physician does not benefit, so the money does not cloud his or her judgment. The problem is that it may cloud the patient’s judgment when rendering consent.

The administrative fee is tainted money. Laundering it by donating it to a scholarship fund (choice F) does not prevent it from influencing the physician’s judgment. In the worst-case scenario, a medical school might pressure faculty to institute this procedure as away to fund the medical school. Just say,” No!” to the money.

Choice 0 is wrong on three counts. The patient is not told about the fee. The physician accepts the fee. The patient is referred, but is not given the chance to understand the circumstances and consent.

Choice H is incorrect. The referral and the decline of the fee are appropriate. However, the physician must also explain all the circumstances to the patient so that the patient can make a fully informed decision.

Usmle Step 1 MCQ's # 9

Title: Usmle Step 1 MCQ's # 9

Subject: Behavioral Science

  

Q NO 9: Two young boys are playing at a daycare center. One holds a ball on top of some

blocks that the other child has placed on the floor. The second child helps steady the blocks 1 then the first child lets go of the ball, knocking the blocks down to the floor. They both watch and then repeat the process. These children are most likely which of the following ages?

A. 10 months old
B. 16 months old
C. 18 months old
D. 24 months old
E. 48 months old

Explanation:
The correct answer is E. The capacity for cooperative play generally does not begin much before the age of 4. Prior to this time (24-30 months) children may play in a parallel fashion, but without real interaction.

Usmle Step 1 MCQ's # 8

Title: Usmle Step 1 MCQ's # 8
Subject: Behavioral Science

Q NO 8: A 29-year-old woman is admitted to the outpatient surge department for an elective operation. She undergoes general anesthesia and, because of an intraoperative complication requires additional hospital days on the inpatient unit. Two days after surgery, she becomes agitated and starts developing tremors. She says she beds as it insects are crawling on her. A history of which of the following is most relevant in determining this patient’s current medical management?

A. Alcoholism
B. Depression
C. Past LSD use
D. Schizophrenia
E. Traumatic childhood

Explanation: The correct answer is A. The patient’s hallucinations, agitation, and tremor point to the diagnosis of delirium tremens (DT5), which should always be considered in cases in which a patient does not have access to alcohol as they did before admission. Depression (choice B) is nota cause of tremor, although it can be associated with agitation in depression with psychotic features.
Past LSD use (choice C) can lead to flash back visual hallucinations but it would not cause the DT5 that this patient is experiencing.
Schizophrenia (choice D) is a disorder of thought associated with auditory hallucinations. It is not associated with formication the feeling that insects are crawling on one’s skin.
Childhood trauma (choice E) has no demonstrated link to autonomic instability alter a surgical procedure, as in this patient.

Usmle Step 1 MCQ's # 7

Title: Usmle Step 1 MCQ's # 7
Subject: Behavioral Science

Q NO 7: A 28-year-old woman visits a cosmetic surgeon for evaluation for surgery to modify the shape of her nose. She has had two other minor surgeries on her nose in the past for cosmetic reasons. During this evaluation, she is accompanied by her mother, who demanded to come to the appointment with her daughter. Her mother asks the surgeon not to perform further cosmetic surgery on the patients nose because she believes that it looks just fine, Instead, she claims that her daughter has been obsessed with the appearance of her nose and spends much of her of time looking at her nose in the mirror. Which of the following is a feature of this disorder?

A. Agoraphobia
B. Disruption of day-to-day functions
C. Pain symptoms
D. Panic attacks
E. Search for secondary gain

Explanation:
The correct answer is B. The patient is most likely suffering from body dysmorphic disorder, a preoccupation with an imagined bodily defect or an exaggerated distortion of a minimal or minor defect. To be considered a mental disorder, the concern must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Patients with this disorder are more likely to go to dermatologists and plastic surgeons than psychiatrists. Additionally, patients with this disorder have a high lifetime prevalence of depressive and anxiety disorders. This patient’s presentation is typical for body dimorphic disorder. The cosmetic surgeon should seek psychiatric consultation.
Agoraphobia (choice A) is a fear of public/open places. It is a specific type of phobia that causes the patient to become introverted and avoid being seen in public.
Pain symptoms (choice C) are associated with somatoform pain disorder, in which a complaint of pain is unsupported by any physiologic process that can be identified by lab tests or physical examination.
Panic attacks (choice D) are a major feature of panic disorder, which is characterized by discrete periods of intense fear and discomfort with palpitations, abdominal distress, nausea, increased perspiration, chest pain, chills, and a choking sensation.
Secondary gain (choice E) is an unconscious drive for medical attention, often accompanying somatoform pain disorders, somatization disorders, or conversion disorders.

Usmle Step 1 MCQ's # 6

 Title: Usmle Step 1 MCQ's # 6
 Subject: Behavioral Science

Q NO 6: A 67-year-old man is admitted to the hospital for a biopsy to confirm suspected lung cancer. The results of the biopsy, sent to his physician the next day, confirm the presence of cancer in an advanced stage. Although a number of treatments are available, life expectancy for patients with this type of cancer is less than 6 months. The physician decides to tell the patient the results of the biopsy immediately. After checking in at the nurse’s station, he walks down the hall towards the patient’s room. Outside the patient’s door, he is met by the man’s adult daughter, who is visibly upset, and asks to speak with the physician in private. “If it is cancer,” she says, “please don’t tell him!” At this point what should the physician reply?

A. “I do need to tell him what we know. Would you like to come in with me while I tell him?”
B. “I know you are concerned, but I have to ask you not to interfere.”
C. “I’d be happy to wait a little bit it you can tell me why I should.”
D. “I’m sorry, but I am required to tell my patient everything, even the bad news.”
“Talk with me about why you don’t want me to tell him.”
F. “Why don’t we go into a quiet room over here and talk about your father a bit.”
G. “Would you have me lie to my patient?”
H. “You seem upset. Please try to compose yourself and then we can talk about it.”

Explanation:
The correct answer is E. The patient needs to be told what the doctor knows, and told in a timely fashion, but something else has occurred that must be dealt with first. Confronted with the daughter’s pleading, the correct response is to seek some information from the daughter to discover if she has any information the physician should know. Be clear that there is nothing the daughter can say that will stop the physician from going into the room and telling the patient what he knows. Rather she may have information that changes they way that he approaches the patient or the method he will use to break this bad news. Notice that with this question the physician is asking for, but not giving information.
Along with these specifics, there is i more general rule here. Don’t get carried away by momentum. The doctor was on his way to talk to the patient. But when new events occur he must change his tack in order to deal with them.
The patient, not the physician should be the one to decide it the daughter should be present. Confidentiality is absolute and should not be violated by inviting the daughter into the discussion (choice A)
Choice B chides the daughter. At best, it misses the chance to seek information from her. At worst it sets up a confrontation that could escalate right outside the patient’s door.
The physician wants to know what the daughter thinks, but should not delay telling the patient (choice C) . The patient has the right to know the results of the test. The physician has no right to tell the daughter he will delay the necessary conversation.
The physician must tell the patient everything, but should take the opportunity to gain additional information about the patient from the daughter. Simply bypassing her (choice D) misses the opportunity.
The physician must respect the patient’s confidentiality. This means not discussing the patient’s health, even with family members, without the patient’s explicit permission. It’s OK to ask the daughter what she knows, but not to tell her about her father (choice F)
Choice C is very challenging and confrontative. It is more likely to lead to an emotional exchange than any useful conversation.
Choice H also misses the opportunity to find out what the daughter knows. In addition, it could be perceived as condescending, that is, treating the daughter like a child, rather than an adult.

Usmle Step 1 MCQ's # 5

Title: Usmle Step 1 MCQ's # 5
Subject: Behavioral Science
  
Q NO 5: A 19-year-old woman is brought to the emergency department by the police. She had run away from home alter another battle with her mother. She has been hospitalized several times for overdoses, and she has numerous scars on her wrists. The psychiatrist notes that all of her relationships have been stormy, and that she seems to regard people as either “all good” or “all bad.” She is admitted with a diagnosis of major depression because of the apparent depth of her depression, however, by the next morning, she is completely recovered and is “well” with no vegetative symptoms. Which of the following is the most likely diagnosis?

A. Antisocial personality disorder
B. Borderline personality disorder
C. Histrionic personality disorder
D. Narcissistic personality disorder
E. Passive-aggressive personality disorder

Explanation:
The correct answer is B. Borderline personality disorder is characterized by short term psychotic episodes (e.g., the depression noted in this case), self mutilation, “splitting” persons into the “good-bad” extremes on a continuum and markedly unstable interpersonal relationships.
The person with antisocial personality disorder (choice A) operates in opposition to society’s rule and customs. Criminal behavior is common.
The person with histrionic personality disorder (choice C) is flamboyant and seductive.
The person with narcissistic personality disorder (choice D) is impressed with himself and operates from a position of entitlement.
The person with passive-aggressive personality disorder (choice E) expresses his anger by passive means such as procrastination, chronic tardiness, and sabotaging productivity.