Title: Usmle Step 1 MCQ’s # 48
Subject: Behavioral Science
Q NO 48: A 56-year-old man visits his primary care physician complaining of difficulty while having sexual relations with his wife. In the past two months, he has often been unable to achieve an erection. When he does achieve an erection, he is unable to maintain it for a sufficient duration to permit intercourse. The patient appears distressed. He has been married for over 30 years and says that he has never encountered this problem before. To further assess this man’s problem, the physician’s next question should be which of the following?
A. Are you afraid that this will not go away by itself?
B. Have you ever heard of something called a ‘snap gauge’?
C. Have you heard about a drug called sildenafil?
D. How much alcohol do you usually consume in the course of the week?
E. Is this the reason that you feel distressed, or is there something else you would like to tell me?
F. What do you know about how sexual functioning changes as you age?
G. What is your wife’s reaction to all of this?
H. Would you like me to make an appointment for you with a specialist with whom you can talk about this?
Explanation:
The correct answer is D. More information is required before a course of action to address this man’s erectile dysfunction can be decided upon. Before more invasive interventions are considered, the physician should first explore the effect that life circumstances may be having on the man’s sexual functioning. In particular the physician should ask about: 1) alcohol use, 2) smoking 3) diabetes 4) marital conflict and 5) work-related stress. It is critical to gain a sense of the etiology of the condition before moving on to a discussion of treatment options.
Drawing attention to the patient’s anxiety (choice A) distracts from gathering information that will help diagnose the patient’s condition. While noticing and even commenting on the patient’s emotional state is good practice, itis unlikely to reassure the patient that the physician is ting to solve the problem that is presented. Discussing the patient’s distress will most likely be more effective once the patient’s condition is better understood.
Discussing diagnostic options before fully exploring the patient’s lifestyle and life circumstances (choice B) is inappropriate. A “snap gauge” is a device used to help determine whether the erectile disorder is primarily physiological or psychological. The device is fitted around the penis before the man goes to sleep at night and responds to any erections the man achieves during REM sleep. If the man does achieve an erection during sleep physiological problems can be ruled out.
Discussing therapeutic options before making a diagnosis is inappropriate. Sildenafil (Viagra; choice C.) is one of the most commonly prescribed mediations for male secondary impotence. However the prescription is inappropriate before the etiology is fully explored.
Choice E suggests that the physician believes that the patient may be hiding something. Such a direct confrontation, at this early point in the interaction, risks offending the patient, and does little to foster sense of support and rapport.
Although the incidence of erectile dysfunction does increase with age (choice F), this degree of sexual dysfunction is not a natural part of the aging process. To ask this question suggests to the patient that that is the case. The physician should seek specific proximate causes, and not hide behind misconceptions of aging. Many individuals will be able to have sexual relations for the lull duration of their life.
The locus should be on the patient, his symptoms, his life and his reactions. Turning the focus onto his wife’s reactions (choice G) is at best premature.
The physician can in all likelihood treat this patient on his/her own. Even if a referral to a specialist (choice H) is ultimately needed a preliminary inquiry’ needs to be completed before this step is considered.
Source: http://www.usmleworldwide.com/blog/?p=1230
Subject: Behavioral Science
Q NO 48: A 56-year-old man visits his primary care physician complaining of difficulty while having sexual relations with his wife. In the past two months, he has often been unable to achieve an erection. When he does achieve an erection, he is unable to maintain it for a sufficient duration to permit intercourse. The patient appears distressed. He has been married for over 30 years and says that he has never encountered this problem before. To further assess this man’s problem, the physician’s next question should be which of the following?
A. Are you afraid that this will not go away by itself?
B. Have you ever heard of something called a ‘snap gauge’?
C. Have you heard about a drug called sildenafil?
D. How much alcohol do you usually consume in the course of the week?
E. Is this the reason that you feel distressed, or is there something else you would like to tell me?
F. What do you know about how sexual functioning changes as you age?
G. What is your wife’s reaction to all of this?
H. Would you like me to make an appointment for you with a specialist with whom you can talk about this?
Explanation:
The correct answer is D. More information is required before a course of action to address this man’s erectile dysfunction can be decided upon. Before more invasive interventions are considered, the physician should first explore the effect that life circumstances may be having on the man’s sexual functioning. In particular the physician should ask about: 1) alcohol use, 2) smoking 3) diabetes 4) marital conflict and 5) work-related stress. It is critical to gain a sense of the etiology of the condition before moving on to a discussion of treatment options.
Drawing attention to the patient’s anxiety (choice A) distracts from gathering information that will help diagnose the patient’s condition. While noticing and even commenting on the patient’s emotional state is good practice, itis unlikely to reassure the patient that the physician is ting to solve the problem that is presented. Discussing the patient’s distress will most likely be more effective once the patient’s condition is better understood.
Discussing diagnostic options before fully exploring the patient’s lifestyle and life circumstances (choice B) is inappropriate. A “snap gauge” is a device used to help determine whether the erectile disorder is primarily physiological or psychological. The device is fitted around the penis before the man goes to sleep at night and responds to any erections the man achieves during REM sleep. If the man does achieve an erection during sleep physiological problems can be ruled out.
Discussing therapeutic options before making a diagnosis is inappropriate. Sildenafil (Viagra; choice C.) is one of the most commonly prescribed mediations for male secondary impotence. However the prescription is inappropriate before the etiology is fully explored.
Choice E suggests that the physician believes that the patient may be hiding something. Such a direct confrontation, at this early point in the interaction, risks offending the patient, and does little to foster sense of support and rapport.
Although the incidence of erectile dysfunction does increase with age (choice F), this degree of sexual dysfunction is not a natural part of the aging process. To ask this question suggests to the patient that that is the case. The physician should seek specific proximate causes, and not hide behind misconceptions of aging. Many individuals will be able to have sexual relations for the lull duration of their life.
The locus should be on the patient, his symptoms, his life and his reactions. Turning the focus onto his wife’s reactions (choice G) is at best premature.
The physician can in all likelihood treat this patient on his/her own. Even if a referral to a specialist (choice H) is ultimately needed a preliminary inquiry’ needs to be completed before this step is considered.
Source: http://www.usmleworldwide.com/blog/?p=1230
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