Title: Usmle Step 1 MCQ’s # 38
Subject: Behavioral Science
Q NO 38: The mother of a 6-year-old boy brings him to see the local pediatrician complaining that the boy is enuretic from 4 to 5 times a week. She reports that the problem began in the past few months alter she gave birth to a baby girl. Breast4eeding for the new baby has been difficult and has consumed a great deal of her time each day. She says that the boy is very embarrassed about his enuresis and is afraid that the other children where he goes to school will find out and make fun of him. She asks the physician help and advice. The physician’s best course of action would be to do which of the following?
A. Arrange to inter view the boy about his condition
B. Direct her to have a serious discussion with her son about whether anything is bothering him
C. Prescribe a course of imipramine for the boy
D. Refer the mother to a seminar on breastfeeding
E. Send the boy to a child psychologist for counseling
F. Suggest that the mother block out some special time each day and give exclusive attention to her son
G. Tell the mother that the boy’s problem is normal and tempora, and will soon pass if left alone
Explanation:
The correct answer is F. This type of enuresis, the result of the defense mechanism of regression, is very common when new siblings enter the household. The boy feels neglected and returns to response patterns more typical of a younger child either out of anxiety, or as a direct attempt to gain more parental attention. Spending more, separate time with the boy will help to reassure him of the mother’s continued love and affection. With the motive removed, the symptom is likely to dissipate as well.
Having to discuss a problem about which he is already embarrassed with the authority figure of the physician (choice A) is likely to heighten, not reduce, the boy’s discomfort and embarrassment. The issue here is one between mother and child. The physician should encourage that direct relationship and not seek to form an indirect substitute.
The capacity’ of a 6-year-old to articulate the abstract relationship issues which may be bothering him (choice B) will be limited. More likely the child will feel uncertain as to what to say, and may walk away with heightened embarrassment about his enuresis.
This is the correct pharmacology, but the treatment is premature. Imipramine (choice C) will reduce the bed-wetting, but this merely addresses the symptom, not the root cause. Remember that one of the key mechanisms by which imipramine reduces bed-wetting is through the reduction of delta sleep, which is not a long-term solution for the child.
Referring the mother to a breast-feeding seminar (choice D) misses the issue. The core problem presented is that of enuresis, not the mother’s difficulties with breast-feeding. Even if the mother is expert at this skill, the child is still likely to feel slighted by the attention given to the new sibling. The mother must be directed to affirm her relationship to her son on a daily basis, not advised how to bond better with the new baby.
Don’t “pass off” (choice E) the child. You can, and should, deal with this yourself.
Enuresis after age 5 is diagnosable and, therefore, beyond the normal range (choice G). It is distressing to the mother and a cause of embarrassment to the child. The physician can, and should, provide guidance and help.
Source: http://www.usmleworldwide.com/blog/?p=760
Subject: Behavioral Science
Q NO 38: The mother of a 6-year-old boy brings him to see the local pediatrician complaining that the boy is enuretic from 4 to 5 times a week. She reports that the problem began in the past few months alter she gave birth to a baby girl. Breast4eeding for the new baby has been difficult and has consumed a great deal of her time each day. She says that the boy is very embarrassed about his enuresis and is afraid that the other children where he goes to school will find out and make fun of him. She asks the physician help and advice. The physician’s best course of action would be to do which of the following?
A. Arrange to inter view the boy about his condition
B. Direct her to have a serious discussion with her son about whether anything is bothering him
C. Prescribe a course of imipramine for the boy
D. Refer the mother to a seminar on breastfeeding
E. Send the boy to a child psychologist for counseling
F. Suggest that the mother block out some special time each day and give exclusive attention to her son
G. Tell the mother that the boy’s problem is normal and tempora, and will soon pass if left alone
Explanation:
The correct answer is F. This type of enuresis, the result of the defense mechanism of regression, is very common when new siblings enter the household. The boy feels neglected and returns to response patterns more typical of a younger child either out of anxiety, or as a direct attempt to gain more parental attention. Spending more, separate time with the boy will help to reassure him of the mother’s continued love and affection. With the motive removed, the symptom is likely to dissipate as well.
Having to discuss a problem about which he is already embarrassed with the authority figure of the physician (choice A) is likely to heighten, not reduce, the boy’s discomfort and embarrassment. The issue here is one between mother and child. The physician should encourage that direct relationship and not seek to form an indirect substitute.
The capacity’ of a 6-year-old to articulate the abstract relationship issues which may be bothering him (choice B) will be limited. More likely the child will feel uncertain as to what to say, and may walk away with heightened embarrassment about his enuresis.
This is the correct pharmacology, but the treatment is premature. Imipramine (choice C) will reduce the bed-wetting, but this merely addresses the symptom, not the root cause. Remember that one of the key mechanisms by which imipramine reduces bed-wetting is through the reduction of delta sleep, which is not a long-term solution for the child.
Referring the mother to a breast-feeding seminar (choice D) misses the issue. The core problem presented is that of enuresis, not the mother’s difficulties with breast-feeding. Even if the mother is expert at this skill, the child is still likely to feel slighted by the attention given to the new sibling. The mother must be directed to affirm her relationship to her son on a daily basis, not advised how to bond better with the new baby.
Don’t “pass off” (choice E) the child. You can, and should, deal with this yourself.
Enuresis after age 5 is diagnosable and, therefore, beyond the normal range (choice G). It is distressing to the mother and a cause of embarrassment to the child. The physician can, and should, provide guidance and help.
Source: http://www.usmleworldwide.com/blog/?p=760
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