Usmle Step 1 MCQ’s # 26

Title: Usmle Step 1 MCQ’s # 26
Subject: Behavioral Science

Q NO 26: A 41-year-old married woman of Asian decent becomes pregnant with her first child. During the course of routine prenatal care, the women undergoes a series of tests checking on her health and the health of the fetus. The results of the tests suggest the woman is in good health, but strongly indicate that her child will be born with Down syndrome. When informed of this result the woman becomes visibly upset and begins to cry. “How could this happen to me?” she says, “God must be punishing me!” At this point the physician’s best reply would be which of the following?

A. “I don’t think God has anything to do with this. This sort of thing just happens some of the time.”
B. “I know it is hard to heard this kind of news, but let me assure you that you are still young enough to have other children.”
C. “Let’s take a moment to reflect and pray together for guidance.”
D. “Sometimes God works in mysterious ways that we can not understand. We just have to try to keep our faith.”
E. “Take some deep breaths and try to relax. When you collect yourself, we can talk about how you want to proceed.”
F. “Tell me a bit more about why you think God is punishing you.”
G. “The chances for Down syndrome are simply higher when a woman your age becomes pregnant. That’s why we run these tests.”
H. “The real issue before us is, how do you want to proceed? Do you want to carry the child to term or explore other options?”


Explanation:
The correct answer is F. The core issue here is that the physician needs more information. In particular, he needs to find out about the patient’s beliefs about how the world works and why things happen. Simply imposing his own beliefs, rational or scientific as they may be, does not allow an understanding of how the patient perceives the world. Understanding how the patient sees the world is essential for conveying to her the reasons for Down syndrome, and helping her make a thoughtful decision as to what to do next.
This response may state the physician’s views, which may be contradictory to those of the patient. The problem to be solved here is not how to convince the patient to see things as the physician does (choice A), but for the physician to understand how the patient sees the world.
This response seeks to empathize, and reassure the patient. In doing so, however, it makes an unwarranted assumption that the reason for the woman’s distress is a fear of not being able to have more children (choice B). Whether this is the woman’s chief concern or not is unknown. Ask how the patient sees the world first before trying to make the patient feel better about that world.
Whereas facilitating the tree expression of a patient’s religious beliefs (choice C) is always a good idea, the physician does not yet know what this patient’s beliefs are. The physician is inappropriately directing a course of action, rather than first eliciting from the patient what she would consider appropriate.
This response uses Catholic theology to try to provide comfort to the patient (choice D). If the patient shares this belief system, it may well be effective. If the patient has different beliefs, it will be well shy of the mark and may even cause confusion rather than comfort. Ask before assuming.
This response uses behavior techniques to try to calm the patient (choice E) . While a positive end in its own right, this approach does not help the physician understand how to interact with the patient when she is calm. In addition, this type of suggestion, without context, may convey the impression that the physician simply wants the patient to be calm, but not that he wants to understand the reasons for her distress.
This response risks being perceived as blaming the patient (she is too old), and it does nothing to gain an understanding of how the patient sees the world (choice C)
This response ignores the patient’s distress and the religious issues raised (choice H) Yes, some decisions need to be made, but the physician needs to find out about the patient’s beliefs to have the ability to frame the various options.

Source: http://www.usmleworldwide.com/blog/?p=289

Usmle Step 1 MCQ's # 25

Title: Usmle Step 1 MCQ's # 25
Subject: Behavioral Science 

Q NO 25: A 16-year-old girl is brought to emergency room by her parents for severe right toot pain. The patient states that the pain started 1 day prior to presentation. She cannot recall any recent trauma, and denies any past medical or surgical problem. She is active and walks at least 1 hour daily in the nearby forest. She goes to high school and is doing very well. She gets along well with her parents except that they insist she should eat more as her weight has dropped from 130 to 105 pounds over the past year. Which of the following is the most likely diagnosis?

A. Conversion disorder
B. Depression with somatic manifestation
C. Injured medial ankle tendon
D. Metatarsal stress fracture
E. Tick bite 

Explanation: 
The correct answer is D. The patient is not eating well, as mentioned by her parents, and her weight loss (over 15% of baseline) as well as her school performance anil activity level, is consistent with anorexia nervosa. Metatarsal stress fracture is a complication of rigorous prolonged walking or running in this population. While she is malnourished and underweight, she has poor insight and continues to decrease her input and increase her output with prolonged physical activity. The fracture is a complication of increased output beyond the patient’s physical limitation.
Conversion disorder (choice A) is manifested by chronic neurologic pain or deficit without any objective organic cause. This patient’s chief complaint is acute pain without any sign of another neurologic deficit.
Diffuse muscle and joint aches in conjunction with lack of energy and reduced physical activity, is characteristic of depression (choice B). This patient’s pain is localized and she is very active.
Ruptured or injured tendon of the ankle is a common injury, but the patient does not recall any recent injury and localization of the pain is not consistent with medial ankle injury (choice C). 
The girl’s daily walking in the nearby forest raises suspicion for tick bite (choice E) and Lyme disease with secondary joint pain. Arthritis associated with Lyme disease is generally centered around joints, and does not present as acutely as in this patient.

Usmle Step 1 MCQ's # 24

Title: Usmle Step 1 MCQ's # 24
Subject: Behavioral Science

Q NO 24: A 70-year-old woman with a history of diabetes and alcoholism is sent to the emergency department by her chronic care facility. Stewards at her home report she has had “mental status changes.” These changes have evolved acutely but fluctuate widely. On mental status examination, the woman has deficiencies of recent memory, and a diminished level of awareness. During the inter view, her speech becomes nonsensical and she begins to describe visual hallucinations. Physical examination reveals fever and tachycardia. Which of the following best characterizes this patient’s condition?

A. Amnesia
B. Delirium
C. Dementia
D. Normal aging
E. Psychosis secondary to schizophrenia

Explanation:
The correct answer is B. Delirium is characterized by acute onset of mental status changes that wax and wane. It may present as impaired awareness easy distraction, confusion, and disturbances of perception such as illusions misinterpretations, and visual hallucinations. Recent memory is usually impaired, and speech may be rambling, perseverating, nonsensical pressured or incoherent. Patients may also be agitated or obtunded. The degree of awareness of their condition may fluctuate with time. Physical examination or laboratory studies usually reveal some organic cause for the delirium. Common causes of delirium include intoxication occult infection, head trauma seizure, mania, thyrotoxicosis, renal failure, hepatic failure, neoplasm, stroke, and shock.
Amnesia (choice A) may be due to head trauma, Korsakoff syndrome, transient global amnesia, or various other cerebral events. Head trauma produces retrograde as well as anterograde amnesia while post concussive syndrome is associated with mental dullness, poor memory, depressed mood, and headaches. This patient’s fever, isolated memory deficits, and lack of causal pathology makes the diagnosis of amnesia unlikely.
Dementia (choice C) in contrast to delirium, is a chronically progressive condition that produces a steady and lasting decline in short- and long-term memory. It is associated with a decline in social and occupational functioning. The patient’s sensorium remains intact in dementia. This patient has no long-term memory deficits and the course of the disease is fluctuating and acute. In addition, the patient has sensory disturbances (visual hallucinations). Thus, the diagnosis of dementia is incorrect.
Normal aging (choice D) does not produce the profound memory deficits and sensory deficits outlined here. Characterizing the patient’s constellation of symptoms as normal aging is incorrect.
Psychosis secondary to schizophrenia (choice E) does not characterize this patient’s findings. The altered sensorium of delirium tends to affect the visual modalities while the psychosis of schizophrenia typically affects the auditory’ system (auditory’ hallucinations).

Usmle Step 1 MCQ's # 23

Title: Usmle Step 1 MCQ's # 23
Subject: Behavioral Science

Q NO 24: A 35-year-old homeless and unemployed man comes into the emergency department, stating he needs to be in the hospital. He is very vague and makes poor eye contact. He reports being “suicidal, homicidal, and paranoid.” When the psychiatrist insists on more details about the symptoms, he gets irritable and threatens that if he leaves the hospital and kills somebody, the doctor will be blamed. He admits to using marijuana, crack, and cocaine occasionally, but not recently. His physical examination is unremarkable. During his interview, his associations are tight, and there is no evidence of psychotic symptoms. A urine drug screen is negative. Which of the following conditions should probably be ruled out first?

A. Delusional disorder
B. Factitious disorder
C. Malingering
D. Schizophrenia
E. Substance-induced mood disorder

Explanation:
The correct answer is C. Malingering is diagnosed when there is a voluntary production of physical or psychological symptoms to accomplish a specific goal. Patients are usually vague or have poorly localized complaints. They are easily irritated if a doctor is skeptical of the history
Delusional disorder (choice A) is characterized by one fixed and unshakable delusion. The delusion is non-bizarre and has to be present at least a month. A part from the impact of the delusion, the functioning is not markedly impaired in other areas of life.
Factitious disorder (choice B) is diagnosed when there is a deliberate production of symptoms to attain the sick role and meet unconscious needs. It can be present with physical or psychological symptoms and is associated with early parental abuse or rejection.
Schizophrenia (choice D) is defined by the presence of active symptoms of delusions, hallucinations, and disorganized speech or behavior in the past month. The continuous signs must be present longer than 6 months and cause significant impairment in social or occupational functioning.
Substance-induced mood disorder (choice E) refers to the mood induced shortly after the use of substances. Depending on the type of substance, the mood can be depressed or elated.

Usmle Step 1 MCQ's # 22

Title: Usmle Step 1 MCQ's # 22
Subject: Behavioral Science

Q NO 22: A 45-year-old man has been having problems staying asleep for the past year. He typically goes to bed alter watching the news at 11:30 PM and has no trouble tailing asleep, however, he keeps awakening and always feels tired all day while at work. His primary physician refers him to the university’ sleep center where an overnight polysomnogram is performed. During the study, he is found to have decreased stage 1 sleep, and decreased delta and REM sleep. He has frequent awakenings associated with gasping breaths, oxygen desaturations (monitored by pulse oximetry), and bradycardia. The best initial medical therapy for this problem would be which of the following?

A. Behavioral therapy
B. Imipramine
C. Tonsillectomy and adenoidectomy
D. Triazolam
E. Weight loss and use of continuous positive airway pressure (CPAP)

Explanation:
The correct answer is E. This is a classic description of a person with obstructive sleep apnea (OSA) syndrome. The patient is typically a middle-age, obese male who snores loudly during sleep. The problem stems from obstruction from tissues of the nasopharynx and hypopharynx. The obstruction results in significant periods of apnea associated with arterial hypoxemia and bradycardia. The patient may develop both system and pulmonary hypertension and is at a high risk of sudden death during sleep due to severe hypoxemia and arrhythmias. Often the patient will have a long apneic period followed by gasping respirations and awakening. This cycle repeats over the course of the night and therefore, the patient actually gets little sleep resulting in daytime somnolence. On a polysomnogram (multichannel recording of sleep), one sees a decrease in stage 1 sleep. This is the first stage on non-REM (NREM) sleep. Most adults spend most of the sleep cycle in stage 2 NREM sleep. Stage 3 and 4 NREM sleep is deep sleep and together constitutes delta sleep. The time in REM sleep gets longer as the night progresses and therefore occurs mostly during the last halt of the night. In OSAI we also see a decrease in delta sleep and REM sleep is also decreased. The initial medical treatment for OSA is weight loss with a trial of nasal prong or face mask continuous positive airway pressure (CPAP). Many are noncompliant with this therapy because the presence of the CPAP is felt to be uncomfortable and prevents the patient from falling asleep. Ultimately, one of several surgical procedures involving the removal of tissue from the naso- and hypopharynx may be performed.

Usmle Step 1 MCQ's # 21

Title: Usmle Step 1 MCQ's # 21
Subject: Behavioral Science

Q NO 21: A 15-year-old boy dies in an automobile accident. Following the boy’s death, his 12-year-old brother starts wearing the older boy’s leather jacket all of the time, no matter how warm the weather. This would be most likely to be an example of which of the following defense mechanisms?

A. Denial
B. Identification
C. Rationalization
D. Reaction formation
E. Sublimation

Explanation:
The correct answer is B. This is identification, which is the unconscious adoption of the characteristics or activities of not her person. It often is i mechanism for reducing the pain of separation or loss. Another example would be widow who takes over her husband’s voluntary work alter he dies.
Denial (choice A) is when a person behaves as it he does not know something he might reasonably be expected to know.
Rationalization (choice C) is the offering of a false but acceptable explanation for behavior.
Reaction formation (choice D) is the adoption of behavior opposite to that of one’s true feelings.
Sublimation (choice E) is the diversion of unacceptable impulses into acceptable outlets.

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