Usmle Step 1 MCQ's # 20

Title: Usmle Step 1 MCQ's # 20
Subject: Behavioral Science

Q NO 20: A 36-year-old married woman complains to her physician that she is having trouble sleeping. A detailed history shows that her insomnia is sporadic and seems to be connected to cyclical stressors related to her working environment. The physician prescribes alprazolam to be taken “as needed.” The next day, the physician receives a distressed call from the patient. With anger in her voice, she tells the physician that the “pharmacist said that taking this medication might cancel out the effects of my birth control pills.” At this point the physician’s next response should be which of the following?

A. “I’m sorry. This is my fault. The problem is not yew likely given the dose level I prescribed and your only occasional use, but I should have discussed this issue with you before.”
B. “It’s not the pharmacist’s job to be tinkering with your medications. I suggest you have the prescription filled somewhere else.”
C. “Its really such a small chance that it is not worth woring about.”
D, “Really, its nothing to worry about. I’ll call the pharmacist and work it out.”
E. “Really, there is no problem here .Pharmacists just like to show what they know.”
F. “The pharmacist is being overly cautious. As long as you take both medications as I prescribed them for you, you will have no problem.”
G. “Well, if you don’t like the drug I prescribed, what would you rather have?”
H. “You seem angry about this. Tell me more about what you are feeling right now.”

Explanation:
The correct answer is A. Always admit a mistake. In this case the physician erred in not discussing the interaction of the new prescription with other drugs the patient was taking. The right answer starts by admitting the mistake, moves on to provide the necessary information to the patient, and closes by admitting the mistake again. Physicians are only human. Mistakes do unfortunately happen. Within the context of a good relationship with the patient, most mistakes can be openly discussed and corrected. By this discussion, the physician-patient relationship is strengthened.
Choices B, E, and F are defensive. Worse, they do not even acknowledge the mistake, and miss the opportunity’ to educate the patient. Denigrating the pharmacist, who is correctly doing his job, seeks to hide the mistake rather than correcting it.
Choice C provides an explanation without admitting any mistake was made. If the physician wants honesty from the patient, he must provide it in turn. Admit the error and then correct it.
Choice D suggests both that there is no problem, and that the physician will talk with the pharmacist and solve it. It is deceitful. No mistake is admitted, and the chance to educate the patient is lost.
In choice G again, no mistake is admitted. FR at her than educating the patient the physician asks the patient to prescribe for herself. The physician is the one with the expertise, and must lay out options from which the patient can choose. Ideally this should have been done before the alprazolam was prescribed.
Discussing the patient’s feelings (choice H) is off the point, and avoids dealing with the mistake. The error not the patient’s feelings about it, should be the first focus of the discussion.

Usmle Step 1 MCQ's # 19

Title: Usmle Step 1 MCQ's # 19
Subject: Behavioral Science

Q NO 19: A 60-year-old male executive with a history of angina pectoris and depression had bypass surgery the previous day. His depression has responded well to selective serotonin reuptake inhibitors (SSRIs) and there is no history of psychosis in the past. He now presents with confusion, agitation, irritability, and tries to remove his IV lines. His level of consciousness fluctuates, and at times he forgets who he is. He is given a neuroleptic drug, and appears much improved. What is the most likely diagnosis?

A. Adjustment disorder
B. Delirium
C. Dementia
D. Exacerbation of depression with suicidal ideation and psychotic features
E. Schizophrenia

Explanation:
The correct answer is B. Delirium is a common complication of general anesthesia and surgery. It is manifested by acute changes in mental status with waxing and waning level of consciousness, agitation, irritability, and psychosis. Patients usually respond to low-dose neuroleptics to achieve sedation. The course is self-limited.
Any psychosocial or biological stressor can lead to adjustment disorder (choice A). This patient’s surgery will restrict his level of functioning, at least in the short term. This will be difficult for a high-functioning individual to accept. Adjustment disorder may present with depressive mood, anxiety, and irritability, but a fluctuating level of consciousness is not a feature of this disorder.
Dementia (choice C) can present with irritability, confusion, and agitation, but usually has an insidious course and affects mainly cognition. In contrast to delirium, it does not have a fluctuating course.
Severe depression can present with irritability, suicidal ideation, and psychotic features (choice D) . The patient has a history of depression that responded well to SSRIs and he has no prior history of psychosis. He was motivated to undergo cardiac surgery, so removing his IV lines is unlikely to be a manifestation of suicidal ideation.
Schizophrenia (choice E) presents with bizarre behavior, hallucinations, and delusions. It usually starts at a younger age than the acute symptoms in this patient, and is characterized by progressive deterioration in functioning. It is unlikely for a schizophrenic to achieve the functional level of an executive.

Usmle Step 1 MCQ's # 18

Title: Usmle Step 1 MCQ's # 18
Subject: Behavioral Science

Q NO 18: A 25-year-old male presents to his family physician with the following statement “Doctor, I can’t urinate in public restrooms. I can if there is no one around, but if I go to the restroom in a movie, an airport, at the ball park or anywhere that someone else comes in, I can’t urinate. Even if I have already started, it just stops and I can’t get it going until the other person leaves. I am so embarrassed. What do they think of me if they see I can’t do what every other man can do?” Which of the following is the most likely diagnosis?

A. Anxiety disorder due to a general medical condition
B. Panic disorder
C. Social phobia
D. Specific phobia
E. Substance-induced anxiety disorder

Explanation:
The correct answer is C. In the condition described, a person is in a social situation and fears that he or she will not be able to perform in the same manner as most everyone else can. The two most common social phobias concern public speaking and restroom performance (sometimes called “shy bladder”.)
Anxiety disorder due to a general medical condition (choice A) is diagnosed when a medical condition precipitates anxiety, e.g., hypoglycemia.
Panic disorder (choice B) is characterized by sudden paroxysms of anxiety. It can strike unexpectedly in uncued situations so it would not occur only when others are present.
Specific phobias (choice D) are unreasonable tears of some identifiable thing, not situation (e.g., elevators).
Substance-induced anxiety disorder (choice E) is diagnosed when anxiety is precipitated by ingestion of a psychoactive substance e.g. hallucinogens.

Usmle Step 1 MCQ's # 17

Title: Usmle Step 1 MCQ's # 17
Subject: Behavioral Science

Q NO 17: A 1 6-year-old girl comes to see her physician for a standard physical examination prior to attending summer camp. The examination is unremarkable. The girl tails within the normal range for height and weight. The physician notes that she has had menses for the past4years.Asthe girl is getting dressed, the physician sits and completes the required forms for the camp. When handed the completed forms, the girl thanks the physician and says, “Just one more thing. Could you also give me a prescription for birth control pills? I’m going to camp with my boyfriend and want to be prepared. And please, please, don’t tell my parents!” The physician’s most appropriate reply would be which of the following?

A. “Before I write you that type of prescription, I’d like to examine your boyfriend first.”
B. “How long have you been having sexual relations with your boyfriend?”
C. “I can only give you a prescription like that if I have your parents’ permission. Let’s set up a time to talk with them.”
D. “I wish you would reconsider. Sex before marriage can be yew complicated.”
E. “I’ll be glad to give you the prescription, but I want you to discuss things with your parents first.”
F. “I’ll be happy to give you a prescription, but let’s talk about some important issues first.”
“I’ll make a decision about the prescription after I have a discussion with you and your boyfriend. When should we schedule that?”
‘H. “I’m pleased that you are responsible enough to be prepared. I’ll be happy to give you the prescription and see no reason to tell your parents.”

Explanation:
The correct answer is F. Core to this question is the contrast between what the laws allow and what the good practice of medicine demands. Simply doing what the law allows is not enough. The physician must act in such a way as to anticipate the needs of the patient even beyond the manifest presentation.
Under the partial emancipation rules any minor between the ages of 15 and 17 can make medical decisions for themselves in four areas without parental involvement or notification. The four areas are: STD treatment substance abuse treatment birth control and prenatal care. Under this rule, the law allows the physician to write this girl the prescription for birth control pills without parental notification. However, the best answer requires more from the physician. The girl is so certain to become sexually active that she asks for birth control pills. Surely she needs something more from the physician than just a prescription. She needs counseling, advice, and information about other birth control methods especially barrier methods. The prescription should not be given without the discussion of these issues first. Note that the physician’s job is not to lecture here, but to find out what the girl already knows and to give her what ever information she is lacking.
The girl is the patient. The boyfriend (choice A) is not. This is not a request that is usually made before giving a birth control prescription and it is inappropriate here.
This question (choice B) maybe asked in the course of a discussion, possibly to determine if the girl should be screened for any sexually transmitted diseases, but it is an inappropriate lead-off comment.
Choice C is not what the law says, and so the physician is lying. However, encouraging the girl to discuss these issues with her parents is a good idea.
This response sets a moralistic scolding tone (choice D) . It is not the physician’s job to tell the girl what her conduct should be. Rather the girl should be provided with information and a listening ear it she has any questions.
The parents (choice E) need not be involved. The idea behind partial emancipation is to encourage behavior important for public health. It every girl had to ask her parents, she might hesitate to do so, and the number of out-of-wedlock births would rise.
Encouraging the girl to discuss important issues with her boy friend is a good idea.Mandating that it must happen, and in the physician’s presence (choice G) is unduly intrusive.
Yes, you can write the prescription, but more is required than is in choice H . Discussion, counseling, advice, and information should also be dispensed.

Usmle Step 1 MCQ's # 16

Title: Usmle Step 1 MCQ's # 16
Subject: Behavioral Science

Q NO 16: In a restaurant, a 3-year-old child screams shrilly as loudly as she can. The mother gives the child a piece of cookie each time she screams. Which of the following types of reinforcement does the mother receive when the child stops screaming?

A. Aversive
B. Fixed interval
C. Negative
D. Positive
E. Variable Ratio

Explanation:
The correct answer is C. When the child takes away the shrill screaming (which was aversive to the mother) it is reinforcing to the mother and guarantees that the mother will continue the behavior (giving a piece of cookie) which will guarantee that the child will continue to scream. Since the reinforcing event is the removal of an aversive stimulus this is called negative reinforcement.
Aversive reinforcement (choice A) involves doing something that the child would not like e.g. giving a spanking.
Fixed interval reinforcement (choice B) implies that a given amount of time goes by before reinforcement is available.
There is no positive reinforcement (choice D) for the mother because nothing that she wants is being given. What is reinforcing to her is the fact that something she does not want is being taken away.
A variable ratio (choice E) reinforcement schedule means that the child would only stop screaming sometimes when given a cookie (on a schedule that the mother could not predict).

Usmle Step 1 MCQ's # 15

Title: Usmle Step 1 MCQ's # 15
Subject: Behavioral Science

Q NO 15: A 22-year-old college student sometimes experiences a yew vivid and detailed hallucination of her room upon waking. She has learned to recognize the experience as a hallucination because often some details will be inappropriate, such as summer clothes on the chair when she knows it is December. This is an example of which of the following types of hallucination?

A. Hypnagogic hallucination
B. Hypnopompic hallucination
C. Second person auditory hallucination
D. Tactile hallucination
E. Third person auditory hallucination

Explanation:
The correct answer is B. This hallucination occurs on waking, making it a hypnopompic hallucination; hypnagogic hallucinations occur on going to sleep. These hallucinations are most often brief and simple, such as hearing a bell ring ora name called. However, they can be complex and of long duration, such as the one in the question stem. They can be accompanied by sleep paralysis (episodes of paralysis on awakening) and can be difficult to get out of , even when recognized. There is also a known cluster of cataplexy (episodic paralysis), sleep paralysis, hypnagogic/hypnopompic hallucinations, and narcolepsy (extreme drowsiness with repeated episodes of falling asleep).
Hypnagogic hallucinations (choice A) occur in going to sleep.
In second person auditory hallucinations (choice C) 1the person is directly addressed by a voice.
Tactile hallucinations (choice D) involve touch.
In third person auditory hallucinations (choice E) voices talk about the person.

Usmle Step 1 MCQ's # 14

Title: Usmle Step 1 MCQ's # 14
Subject: Behavioral Science

Q NO 14: A 78 year-old woman complains to her physician of not feeling rested after a night’s sleep. Physical examination and routine laboratory studies are unremarkable. The physician explains to her that the sleep patterns of normal elderly persons differ from those of younger individuals in which of the following ways?

A. Increased need for sleep

B. Increased REM sleep

C. More arousal and awakening at night

D. More total nighttime sleep

E. Significant sleep disturbances are more common

Explanation:

The correct answer is C. Sleep patterns differ from person to person, however some generalizations can be made regarding age and sleep. Elderly individuals have more awakening and arousal at night, they tend to awaken earlier, and have less total sleep. Multiple factors can contribute to sleep disturbances in the elderly, including primary sleep disorders sleep disorders secondary to other physical and psychiatric conditions, as well as medication-induced sleep problems.

With increased age, the needs for sleep decreases (compare with choice A). A newborn might sleep up to 22 hours daily, but an adult can generally feel rested with 6 to 8 hours of sleep.

The amount of time spent in REM sleep decreases with age (compare with choice B)’ starting at about age 50.

The elderly generally achieve less total nighttime sleep (compare with choice D).

Mild sleep disturbances (compare with choice E ) can be associated with normal aging, however any significant sleep disturbance that impairs daily activity or causes increased daily sleepiness requires further evaluation.