Question 1

A 13-year-old boy is brought to the office by his parents after being involved in a fight with another student at school.  His parents say, "He has never gotten into fights before, and we are getting worried because his grades have been declining as well.  He seems irritable and moody, stays in his room for hours at a time, and no longer invites friends home."  When interviewed alone about the incident, the patient says, "The wall people warned me that he was trying to poison my lunch."  The patient has no significant medical history; there is a family history of bipolar disorder in a paternal aunt.  Temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, pulse is 98/min, and respirations are 14/min.  Physical examination shows a postural tremor on extension of the arms and a broad-based gait.  Mental status examination is significant for slurred speech, sad mood, and distractibility.  Laboratory studies reveal elevated serum transaminases.  Which of the following is the most likely diagnosis?

Accepted Answer

11ec160b_364f_e676_9249_b398b3b29677_MD0001_00 This patient's auditory hallucinations, mood and personality changes associated with neurologic features (slurred speech, tremor, gait instability), and abnormal liver function tests suggest a diagnosis of Wilson disease. Wilson disease is an autosomal recessive condition marked by copper accumulation in the liver, brain, and cornea, which most commonly manifests in childhood, adolescence, or early adulthood with hepatic involvement and/or neuropsychiatric symptoms. Psychiatric symptoms range from subtle personality changes to depression, mania, and/or psychosis. These symptoms may predate hepatic or neurologic manifestations and be mistaken for normal adolescence or primary psychiatric illness. Evaluation includes a ceruloplasmin level, 24-hour urinary copper excretion, and slit-lamp examination for copper deposition in the cornea (Kayser-Fleischer rings). (Choice A) Acute intermittent porphyria (AIP) can present with psychiatric symptoms; however, these are episodic in nature and normally associated with abdominal pain and peripheral neuropathy. AIP commonly manifests in midlife rather than childhood. (Choice B) Heavy alcohol use can result in elevated transaminases and psychiatric symptoms, and acute intoxication can present with slurred speech and unsteady gait. However, acute intoxication would likely present with stupor or disinhibition, alcohol on the breath, and additional findings such as abnormal vital signs (eg, hypotension, tachycardia), or other metabolic abnormalities (eg, hypoglycemia, hyperlactatemia). Tremors would be expected in alcohol withdrawal, not intoxication. (Choices C and E) Although this patient has mood and psychotic symptoms, these primary psychiatric disorders would not explain his neurologic findings and abnormal liver function tests. Major depressive and bipolar disorders are not diagnosed when symptoms are attributable to another medical condition. (Choice D) In hemochromatosis, there is an abnormal buildup of iron, which particularly affects the liver, heart, and pancreas. It may present with abnormal liver function tests, diabetes, arthralgia, and/or cardiomegaly. Hemochromatosis tends to present in later life (eg, age ≥ 40). Neurologic findings and psychosis are uncommon. (Choice F) Prodromal schizophrenia often presents with personality changes and social withdrawal prior to the onset of overt psychosis. However, because primary psychotic disorders in children and adolescents are rare, a thorough workup of substance-induced and other etiologies is necessary. This patient's psychiatric symptoms are better explained as a manifestation of Wilson disease. Educational objective: Wilson disease is associated with copper accumulation in the liver, brain, and cornea. It can present in childhood or adolescence with abnormal liver function tests and/or neuropsychiatric symptoms. Psychiatric symptoms may predate other manifestations and include personality changes, depression, mania, and/or psychosis. __________ References: Wilson disease in children. (http://www.ncbi.nlm.nih.gov/pubmed/28433098) Psychiatric aspects of Wilson disease: a review. (http://www.ncbi.nlm.nih.gov/pubmed/24120023) Psychiatric manifestations in Wilson's disease: possibilities and difficulties for treatment. (http://www.ncbi.nlm.nih.gov/pubmed/29977520)

Question 2

A 43-year-old woman comes to the office for an initial appointment due to ongoing abdominal pain, general weakness, decreased appetite, and dizziness.  She says the pain is ruining her life and is worried that her previous physicians may have missed something.  Over the past several years, the patient has been hospitalized 3 times with similar symptoms.  No etiology for the pain has been identified despite extensive workups, including several abdominal CT scans and an exploratory laparotomy.  The patient describes chronic abdominal pain since adolescence and is concerned as the nonprescription analgesics she takes are ineffective.  She has no history of psychiatric diagnoses or substance abuse.  Physical examination, vital signs, and laboratory tests (including chemistry panel, complete blood count, and urinalysis) are within normal limits.  Which of the following is the most appropriate next step in the management of this patient?

Accepted Answer

11ec160b_3647_0cce_9249_77a68876e12e_MD0001_00 This patient's preoccupation with unexplained medical symptoms and excessive health care use are characteristic of somatic symptom disorder. The best approach is to schedule regular visits with her primary care provider, who can monitor her condition and avoid unnecessary diagnostic testing and specialist referrals (Choices B and C). In contrast to symptom-driven visits, regular visits provide patients with an opportunity to discuss their concerns without the need to have new or worsening symptoms. This may decrease the use of emergency services and encourage formation of a therapeutic alliance. Rather than focusing on symptom elimination, office visits should emphasize a return to occupational and social activities (functional improvement) and promotion of stress reduction and healthy behaviors (eg, diet, exercise). (Choices A and F) This patient currently has no insight into the psychological nature of her disorder and would likely feel invalidated and unreceptive to being told that her condition is psychogenic and/or by getting referred to a psychiatrist for treatment. Once a physician-patient relationship is established, she may be able to accept that psychological distress plays a role in her condition and be more receptive to psychiatric referral. (Choice D) Use of potentially addictive pain medication should be avoided. (Choice E) Reassurance alone is rarely effective in managing somatic symptom disorder. Optimal management consists of regularly scheduled visits so that the patient does not need to have active symptoms to justify a visit. Educational objective: Somatic symptom disorder is best managed with regularly scheduled medical visits that are not contingent on having active symptoms. Unnecessary diagnostic testing and specialist referrals should be avoided. __________ References: Approach to the patient with multiple somatic symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/25134874) Medically unexplained symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/24758967) Somatic symptom disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26760840)

Question 3

A 20-year-old college student is brought to the emergency department by his roommate.  The patient is frightened and claims that campus police are following him and plotting to kill him.  His roommate says that the patient seemed "totally normal" until a few days ago, when he began to stay up all night to prepare for final exams.  The patient has no known medical or psychiatric history, but his father has schizophrenia.  Blood pressure is 150/95 mm Hg and pulse is 110/min.  Examination shows clear lungs and tachycardia with normal S1 and S2.  The abdomen is soft and nontender.  Extraocular movements are intact, and the pupils are dilated.  The patient is diaphoretic.  He appears hypervigilant, paces during the examination, and has mildly pressured speech.  Which of the following is the most likely diagnosis in this patient?

Accepted Answer

The misuse of stimulants by college students to enhance academic performance is prevalent. This patient's acute onset of paranoia, restlessness, and hypervigilance, and physical signs of mydriasis, tachycardia, hypertension, and diaphoresis, are most likely due to stimulant intoxication. Transient paranoid psychosis can develop in intoxication with all major stimulants, including prescription medications for attention-deficit hyperactivity disorder (eg, amphetamines, methylphenidate). Substance-induced psychotic disorder is diagnosed when stimulant intoxication presents with prominent psychotic symptoms. Substance-induced psychotic disorders must be differentiated from primary psychiatric disorders such as bipolar manic episodes and psychotic disorders. This student's prominent physical signs and lack of psychiatric history, combined with the temporal association between staying up to study and acute onset of psychosis, make a stimulant-induced psychotic disorder more likely. (Choice A) Patients experiencing a bipolar manic episode can also have decreased sleep, pressured speech, physical restlessness, and psychotic features. However, the temporal association of studying for exams and the patient's abnormal vital signs, mydriasis, and diaphoresis make substance intoxication more likely. (Choice B) Primary psychotic disorders are diagnoses of exclusion that require ruling out substance use and medical etiologies. Brief psychotic disorder is a rare condition characterized by acute onset of ≥1 psychotic symptoms (eg, delusions, hallucinations, disorganized speech or behavior) lasting ≥1 days but <1 month, with eventual complete resolution. This patient's physical findings (ie, mydriasis, tachycardia, hypertension, diaphoresis), the prevalence of stimulant misuse on college campuses, and the temporal association between intense studying and symptom onset make substance-induced psychosis much more likely than brief psychotic disorder. (Choices C and D) These diagnoses would not be considered at this point due to insufficient duration of psychotic symptoms. The essential feature of delusional disorder is ≥1 delusions lasting ≥1 months without other psychotic symptoms. Schizophreniform disorder involves ≥2 psychotic symptoms lasting ≥1 months but <6 months. Educational objective: Stimulant intoxication can present with paranoid ideation and must be differentiated from primary psychiatric disorders. Physical signs of stimulant intoxication include mydriasis, tachycardia, hypertension, and diaphoresis. __________ References: Toxicity of amphetamines: an update. (http://www.ncbi.nlm.nih.gov/pubmed/22392347) Misuse of stimulant medication among college students: a comprehensive review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/25575768)

Question 4

A 28-year-old woman comes to the gynecologist, who has provided routine care for the patient over the past 10 years.  The patient has not menstruated for over 2 months and had a positive home pregnancy test last week.  Although she hopes to have children in the future, she has been under a lot of stress lately and says that caring for a child is the last thing she needs right now.  A pelvic ultrasound confirms an intrauterine pregnancy at 7 weeks gestation, and the patient requests that the gynecologist terminate the pregnancy as soon as possible.  The gynecologist does not perform abortions on moral grounds but does have training in the procedure.  Which of the following is the most appropriate course of action?

Accepted Answer

Conscientious refusal occurs when a provider refuses to provide care because doing so would conflict with the provider's beliefs. Although following one's conscience-the part of the self that judges actions as right or wrong-can lead to ethical and appropriate care, it also can conflict with professional obligations. Provider conscience does not take precedence over other ethical principles (eg, autonomy, justice, beneficence, nonmaleficence). As with any procedure or treatment, the physician should have a neutral discussion regarding the procedure and alternatives. The physician should be nonjudgmental, refrain from imposing moral values, and convey respect for the patient's autonomy. If the patient decides to undergo the procedure after neutral education, she should be provided with resources that will assist in obtaining the desired service. Providers who are unable to provide care in good conscience are professionally and ethically obligated to refer patients in a timely fashion to other providers who can provide care. (Choices A and D) The physician is not required to perform the procedure but is obligated to provide resources to help the patient find another provider who will perform it in a timely manner to respect the patient's autonomy. (Choice B) Encouraging the patient to reconsider her decision is inappropriate because it imposes the physician's own judgment and values. Discussing age-related infertility risks in this situation can inadvertently place guilt or shame on the patient and should be avoided. (Choice C) Encouraging the patient to take additional time to make a decision is not advisable because this could place her past the first trimester and increase complexity/risk to the procedure. Educational objective: Conscientious refusal of treatment occurs when a provider refuses to provide care due to moral conflict. Providers who cannot, in good conscience, provide treatment that a patient requests, are obligated to refer the patient in a timely fashion to another provider who can. This respects the patient's autonomy.

Question 5

A 10-year-old boy is brought to the pediatric clinic due to unusual classroom behavior for the past year, which has worsened over the last few weeks.  Although the patient is generally quiet, he intermittently disrupts the class with sniffling, repetitive throat clearing, and grunting sounds.  His teacher states that the boy distracts other students and that his focus in class is poor.  The behaviors worsen when he is tired, stressed, or excited.  The patient's parents are also concerned because he has only a few friends and his classmates make fun of him.  Medical history is significant for recurrent otitis media as a toddler, atopic dermatitis, and an influenza infection 9 months ago.  Family history is significant for rheumatoid arthritis and anxiety in his mother.  Temperature is 36.7 C (98 F), pulse is 78/min, blood pressure is 110/72 mm Hg, and respirations are 14/min.  Physical examination shows frequent eye blinking and shoulder shrugging but is otherwise normal.  Which of the following is the most likely diagnosis?

Accepted Answer

11ec160b_364e_11b5_9249_8facfae72b88_MD0001_00 This patient is experiencing both vocal and multiple motor tics (sudden, intermittent, nonrhythmic motor movements and vocalizations) consistent with a diagnosis of Tourette syndrome. Vocal tics can range from simple sounds (eg, coughing, grunting, throat clearing) to blurting out inappropriate comments and obscenities (coprolalia). They are typically preceded by irresistible urges and followed by feelings of relief. Tics have a waxing and waning course and are typically exacerbated by stress or fatigue, but they can be suppressed voluntarily for brief periods. Tourette syndrome is more common in boys and typically presents at age 6-15. Comorbid psychiatric conditions such as attention-deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder are common. (Choice A) Although ADHD is a common comorbidity, this patient does not exhibit sufficient symptoms of inattention and hyperactivity/impulsivity required for this diagnosis. (Choice B) Stereotypic movement disorder is characterized by simple repetitive movements (eg, rocking, head banging), which are voluntary in nature and seemingly purposeless. They are often seen in children with autism spectrum disorders and intellectual disability and are a common form of self-soothing. (Choice C) Sydenham chorea is a manifestation of rheumatic fever (related to group A streptococcal infection) characterized by choreiform movements (brief, random, irregular contractions of the limbs and face), emotional lability, and hypotonia. Tics can be differentiated from chorea by their patterned, repetitive appearance; ability to be temporarily suppressed; and association with premonitory urges. (Choice E) Wilson disease is caused by copper accumulation and can present in children and adolescents. It is characterized by liver dysfunction, neurological signs (eg, dysarthria, dystonia, ataxia) rather than tics, and psychiatric abnormalities (eg, depression, psychosis). Educational objective: Tourette syndrome is a common childhood neuropsychiatric disorder characterized by both vocal and multiple motor tics. These tics characteristically wax and wane, can be suppressed temporarily, and are preceded by a premonitory urge. __________ References: Tourette syndrome: update. (http://www.ncbi.nlm.nih.gov/pubmed/25604739) Clinical assessment of Tourette syndrome and tic disorders. (http://www.ncbi.nlm.nih.gov/pubmed/23206664) Tourette syndrome and chronic tic disorders: the clinical spectrum beyond tics. (http://www.ncbi.nlm.nih.gov/pubmed/28805580)

Question 6

A 32-year-old man comes to the office due to disabling anxiety.  The patient was recently promoted to his company's headquarters, requiring him to work on the 48th floor of the building.  As soon as he steps on the elevator, he feels panicky and faint, sweats profusely, and has heart palpitations.  The patient is worried that he might have to resign if he is unable to control his anxiety.  His fear of elevators dates back to childhood.  He drinks 1 or 2 beers on weekends but does not use tobacco or illicit drugs.  Which of the following is the most effective long-term treatment for this patient's condition?

Accepted Answer

11ec160b_3647_81ff_9249_a5a7ca1883bc_MD0001_00 This patient's marked and immediate fear in a specific situation (ie, elevator as phobic stimulus) is consistent with a specific phobia. Although he feels panicky when confronted with the phobic stimulus, he does not have unexpected panic attacks as in panic disorder. Cognitive-behavioral therapy, involving systematic, repeated exposure to the phobic stimulus, is the treatment of choice for specific phobia. Exposure is typically performed in a gradual, step-wise manner, resulting in decreased anxiety over time as habituation and extinction occur. Confrontation with the phobic stimulus in a safe and controlled manner can be accomplished through in vivo (most effective), imaginal, and virtual reality exposure techniques. (Choice A) Benzodiazepines (eg, alprazolam) can be used in the acute treatment of specific phobia when there is lack of time, no available therapist, or infrequent encounters. It could be considered in the short-term treatment of this patient's anxiety while cognitive-behavioral therapy takes effect. Benzodiazepines, however, carry the risks of dependence, rebound anxiety, and cognitive impairment and would not be the appropriate long-term choice for this patient who must encounter the phobic stimulus at work on a daily basis. (Choices C and G) Escitalopram (a selective serotonin reuptake inhibitor), and venlafaxine (a serotonin-norepinephrine reuptake inhibitor) are used to treat depression in addition to panic disorder, generalized anxiety disorder, and social anxiety disorder. They are not first-line treatments for specific phobia. (Choice D) The beta blocker propranolol has been used to treat performance anxiety (a subtype of social anxiety disorder) but is not useful for specific phobia. (Choices E and F) These forms of psychotherapy would not address this patient's specific phobia directly. Psychodynamic psychotherapy focuses on developing insight into unresolved conflicts and the influence of past relationships on current life situations. Supportive psychotherapy is aimed at bolstering adaptive psychological defenses to help individuals cope with acute crises or chronic psychiatric illness. Educational objective: Exposure-based cognitive-behavioral therapy, in which patients are systematically confronted with their feared objects or situations, is the most effective long-term treatment for specific phobia. __________ References: Specific phobias. (http://www.ncbi.nlm.nih.gov/pubmed/19716991) Specific phobia. (http://www.ncbi.nlm.nih.gov/pubmed/29763098)

Question 7

A 32-year-old man comes to the office due to anxiety that has intensified since he was promoted to a managerial position.  Whereas he previously worked alone, his new position requires him to interact with a team of five employees and handle customer service complaints.  The patient says he is anxious throughout the day and fears that he will say something embarrassing or that his coworkers and customers will notice his anxiety and think he is incompetent.  He says he was very quiet and shy growing up and would always get anxious when meeting new people.  He has a few friends with whom he socializes, but he typically has three or four alcoholic drinks before going out with them to feel more relaxed.  The patient does not feel depressed, and his sleep and appetite are normal.  A medication with which of the following mechanisms of action would be most appropriate for this patient?

Accepted Answer

11ec160b_3646_708d_9249_534a0e911f53_MD0001_00 This patient's marked anxiety in social situations is consistent with social anxiety disorder (SAD). His fears of saying something embarrassing and negative evaluation by others are characteristic of the disorder. SAD is a common anxiety disorder with typical onset in childhood or adolescence. If untreated, the disorder can cause major impairment in social and occupational functioning and is often complicated by depression and self-medication with alcohol. Drugs that inhibit the reuptake of serotonin are first-line medications for social anxiety disorder. Patients are commonly started on a selective serotonin reuptake inhibitor (SSRI) although there is also good evidence for the efficacy of serotonin-norepinephrine reuptake inhibitors (SNRIs). These medications work by blocking the serotonin transporter, causing an increase in the availability of serotonin in the synaptic cleft. (Choice A) Beta blockers have been used to treat performance-only social anxiety disorder. They are taken on an as-needed basis and are most useful for patients with prominent physiological symptoms such as tachycardia or tremor. A beta blocker would not be appropriate for this patient who is generally socially anxious (ie, anxiety not limited to performance situations) and who experiences impairing anxiety on a daily basis. (Choice B) Dopamine and serotonin receptor antagonism are the mechanisms of action of second-generation antipsychotics. These drugs are not indicated for SAD. (Choice C) GABA A receptor agonism is the mechanism of action of benzodiazepines. Benzodiazepines are effective in SAD but are generally used as second-line agents due to their potential for tolerance, abuse, and dependence. They should be avoided in this patient who has a history of self-medication with alcohol. (Choice D) Histamine receptor antagonism is the mechanism of action of antihistamines (eg, diphenhydramine). Although they have sedative effects, they are not effective in treating anxiety. (Choice E) Monoamine oxidase inhibitors are effective for SAD but are not used as a first-line treatment due to their side effect profile and dietary restrictions. Educational objective: Social anxiety disorder is characterized by anxiety and fear of scrutiny in social situations and can result in marked social-occupational impairment. Preferred pharmacotherapy is medication that inhibits serotonin reuptake (eg, SSRIs or SNRIs). __________ References: The evidence-based pharmacotherapy of social anxiety disorder. (http://www.ncbi.nlm.nih.gov/pubmed/22436306) Pharmacotherapy for social anxiety disorder (SAnD). (http://www.ncbi.nlm.nih.gov/pubmed/29048739)

Question 8

A 16-year-old girl is brought to the office by her mother due to nonspecific stomachaches and pains.  She has no other medical history.  The patient has missed more than 10 days of school due to the symptoms since the academic year started 6 months ago.  The mother says that her daughter has always been anxious with a "sensitive stomach," but the symptoms have worsened since the patient's best friend moved away a month ago.  She has a few other friends but prefers to stay home and does not participate in after-school activities.  The mother says, "She worried for weeks about going to a party.  On the night of the party she had an anxiety attack and started hyperventilating.  She ended up not going to the party at all."  The patient says she is "just very shy" and is afraid of being embarrassed or "looking stupid" around others.  Physical examination shows no abnormalities.  During the interview, the patient makes little eye contact and gives brief answers to questions.  Which of the following is the most likely diagnosis?

Accepted Answer

11ec160b_3645_d44c_9249_ff4de911e32d_MD0001_00 This patient's intense social anxiety, in which she fears embarrassment and scrutiny by others, is characteristic of social anxiety disorder (social phobia). It is a common psychiatric disorder with typical onset in adolescence that can result in significant impairment in functioning and quality of life. Social interactions with peers and meeting new people cause significant distress. Anticipatory anxiety weeks before a social event and avoidance (not going to parties, school refusal) are common. Patients with social anxiety disorder frequently appear ill at ease during the interview, avoid eye contact, give overly brief responses, and may exhibit physical manifestations of anxiety (eg, blushing, sweating, trembling, tachycardia). The specifier "performance-only" is given to patients who have symptoms only in performance situations (eg, speaking or performing in public). (Choice A) This patient's social anxiety predates the stressor of her friend moving away. Stressors often exacerbate symptoms of other disorders. Adjustment disorder is not diagnosed when symptoms meet criteria for another disorder. (Choice B) Individuals with agoraphobia avoid public situations (eg, movie theaters) as escape might be difficult or help might not be available if they are incapacitated or have panic like symptoms. Although individuals with social anxiety disorder may avoid leaving the house, this is primarily due to fear of embarrassment and scrutiny by others. (Choice C) This patient's anxiety is restricted to social situations, whereas generalized anxiety is characterized by multiple worries. (Choice D) Shyness is a common nonpathological personality trait. However, this patient's severe and pervasive anxiety is out of proportion to the actual threat posed by social situations. It is causing significant distress and functional impairment in both academic and social contexts. (Choice E) Patients with social anxiety disorder may have panic attacks related to social situations. In panic disorder, however, attacks are unexpected and there is no clear trigger. (Choice G) Patients with anxiety disorders often present with somatic symptoms. This patient's stomachaches are a physical manifestation of her anxiety. She does not exhibit the excessive preoccupation with physical symptoms that characterizes somatic symptom disorder. Educational objective: Social anxiety disorder involves excessive fear of scrutiny or embarrassment in social or performance situations, resulting in significant distress and functional impairment. __________ References: Social anxiety disorder in adolescence: how developmental cognitive neuroscience findings may shape understanding and interventions for psychopathology. (http://www.ncbi.nlm.nih.gov/pubmed/25818181) Social anxiety disorder in DSM-5. (http://www.ncbi.nlm.nih.gov/pubmed/24395386)

Question 9

A 66-year-old woman comes to the clinic for follow-up of sarcoidosis.  Over the past year, her lung function has worsened significantly, and her probability of survival at 12 months is below 50%.  When discussions regarding advance care planning and appointment of a surrogate decision maker are initiated, the patient replies, "Why would I want to sign away my life on a piece of paper?  The Lord will take me when the time is right."  Which of the following is the best response?

Accepted Answer

Advance care planning (ACP) identifies a patient's personal preferences for health care in case of chronic, serious illness. ACP is a flexible, patient-centered process (ie, prioritizing patient values); it may include (but does not necessitate) creation of legal documents, such as appointment of surrogate decision makers who act on the patient's behalf if the patient is incapacitated. ACP often begins with informal conversations with patients (and trusted family members, if appropriate) exploring beliefs about illness, death, and health care interventions. ACP is meant to promote patient empowerment by ensuring patients receive care aligned with expressed values. However, patient participation in ACP remains low (<11% of patients), and occurs even less frequently for patients belonging to ethnic minorities (eg, Hispanic, Black, Asian). Ethnic disparities in ACP initiation and completion may result from distrust of health care systems, cultural norms, misconceptions, and suboptimal physician communication. This patient's statement indicates that she has a misconception about ACP (eg, she must "sign away" her life with legally binding documents), and values ownership over her health care decisions - a value which is in fact supported by ACP. Therefore, the physician should respond by explaining the ACP's shared goal of patient empowerment (eg, of allowing her voice to be heard) in simple, nonjudgmental terms. Expressing this patient-centered goal can increase trust, acceptability, and likelihood of patient engagement in subsequent discussions. (Choice A) Given the patient's low probability of 12-month survival, realistic conversations about end of life are important. However, this statement does not focus on the patient's expressed values, may be perceived as judgmental or patronizing (it assumes the patient has not otherwise been preparing for end of life), and does not emphasize the goal of patient empowerment through ACP. (Choice B) The patient has not expressed fear, so this statement is less likely to engage her and may appear condescending. (Choice D) This statement describes only one aspect of ACP (ie, appointment of a surrogate decision maker); furthermore, it is premature to assume that the patient values or prefers family involvement. (Choice E) If the patient continues to decline engagement, her wishes should be respected; however, the physician should first clarify potential misconceptions about ACP (eg, "sign my life away") and attempt to find common ground by highlighting the shared, patient-centered goal of ACP. Educational objective: Patient participation in advance care planning (ACP), the process of identifying a patient's health care goals in case of serious illness, is low, especially for ethnic minorities (eg, due to mistrust or suboptimal physician communication). Physicians should engage patients in ACP by first explaining its primary purpose of patient empowerment (eg, allowing the patient's voice to be heard).

Question 10

A 79-year-old man is undergoing evaluation for hospital admission due to an exacerbation of chronic obstructive pulmonary disease.  His wife expresses concern about his health due to multiple hospitalizations over the last year for various complications related to his comorbidities.  The patient has smoked cigarettes daily for more than 50 years.  Medical history includes coronary artery disease, type 2 diabetes mellitus, and obesity.  After performing a thorough history and physical examination, the physician prepares to admit the patient and decides to continue his existing medications for diabetes and heart disease.  Admission orders also include supplemental oxygen, bronchodilators, antibiotics, and systemic corticosteroids.  Which of the following additional components is most critical to include during the admission process?

Accepted Answer

Advance directives record a patient's personal preferences for health care and treatment if the patient lacks decision-making capacity. During hospital admissions, all patients admitted to the hospital must be asked about resuscitation preferences (eg, full code, Do-Not-Resuscitate [DNR]) and whether advance directives are in place because serious clinical deterioration can happen unexpectedly. Advance directives include the following types of documents: Living will, which specifies the patient's end-of-life wishes and often includes instructions regarding intubation, cardiopulmonary resuscitation, enteral feeding, and other life-prolonging interventions. Given the breadth of medical scenarios that can arise, not all decisions can be accounted for in a living will. A health care proxy, which designates a specific individual (the surrogate decision-maker) to make health care decisions and interpret instructions in the living will on the patient's behalf if the patient is incapacitated, using the principle of substituted judgment (ie, considering what the patient would want). Ideally, advance care planning should take place through a series of open-ended conversations early in a patient's serious illness (eg, chronic obstructive pulmonary disease) in the context of a longitudinal patient-physician relationship. Patients without advance directives at the time of hospital admission should be provided with information and venues for learning about and completing this process. (Choices A, C, D, and E) Each of these components should be addressed during the patient's hospitalization course and discharge planning process. However, they do not need to be completed during admission. In contrast, discussion and documentation of a patient's advance care status must be completed during admission because unexpected clinical deterioration can occur at any time. Educational objective: The admission process must include discussion of whether the patient has advance directives, along with code status, to ensure that medical personnel adhere to the patient's specific wishes should the patient become incapacitated.

Question 11

A 39-year-old right-handed man is brought to the office by his wife due to concerns about his behavior.  Two months ago, the patient was robbed and hit in the head and knees with a baseball bat when he resisted.  He initially had difficulty walking, but his injuries have since healed.  His wife and other family members say that his overall demeanor has changed significantly since the attack.  Prior to the assault, the patient was kind, considerate, and extremely polite.  However, since the attack, he has been very irritable and rude, and was recently fired from his job for insulting customers and making socially insensitive comments to coworkers.  Damage to which anatomical region of the brain is the most likely explanation for this patient's symptoms?

Accepted Answer

This patient's personality change, disinhibition, and irritability are most likely due to damage affecting the orbitofrontal cortex (OFC). The OFC is located in the frontal lobe and has strong modulatory connections to the limbic system (ie, the brain's primary emotional system); it is involved in behavioral and emotional regulation. Pathological behavioral and emotional changes are more commonly seen with bilateral, rather than unilateral, injury to the OFC. Disinhibition may be associated with significant impulsivity and loss of social etiquette, whereas increased irritability in the context of disinhibition may lead to frank, aggressive behavior. Diagnostic workup includes obtaining information from family and friends about personality changes, neuropsychological testing, and structural brain imaging. (Choice A) Damage to the corpus callosum can result in the "split-brain" syndrome. Although these patients may appear normal in general social situations, further evaluation can demonstrate lack of interhemispheric transfer of information (eg, patient unable use one hand to retrieve an object palpated with the other hand). (Choices B and E) The parietal cortex processes and interprets visual, auditory, and motor signals received from other brain areas. Parietal cortex damage results in difficulties with spatial and visual perception. Dominant lesions (>95% of right-handed and >50% of left-handed patients are left hemisphere dominant) result in Gerstmann syndrome with right-left confusion and difficulty with writing and mathematics. Nondominant parietal cortex lesions (most commonly right-sided) can result in hemi-neglect, constructional apraxia, and denial of the problem. (Choices C and F) Temporal cortex injury can cause disturbances in language, sensory interpretation, and impaired memory. These patients can also exhibit behavioral changes, such as apathy, hyperorality, hypersexuality, and visual agnosia as seen in Klüver-Bucy syndrome. Nondominant (usually right-sided) lesions can affect nonverbal memory, including musical ability; dominant left-sided lesions can affect verbal memory, such as word recognition. This patient's symptoms are most characteristic of an OFC injury. (Choice D) The lateral prefrontal cortex is involved in executive functioning, which includes motivation, organization, planning, and purposeful action. Damage to the lateral prefrontal cortex may result in dysexecutive syndrome, a syndrome characterized by significant difficulties performing these functions. Educational objective: Patients with orbitofrontal cortex injury often experience personality changes, disinhibition, and irritability secondary to impairment of the behavioral and emotional modulatory systems. __________ References: A review of social disinhibition after traumatic brain injury. (http://www.ncbi.nlm.nih.gov/pubmed/27696753) The role of the orbitofrontal cortex in cognition and behavior. (http://www.ncbi.nlm.nih.gov/pubmed/25252749) Traumatic brain injury: relation to executive dysfunction and the frontal lobes. (http://www.ncbi.nlm.nih.gov/pubmed/21968550)

Question 12

A 9-year-old girl is brought to the office by her mother for evaluation of frequent stomach aches.  The mother says that her daughter has always had a "sensitive stomach" but that it has gotten worse since she started going to a new school a few months ago.  The girl has been missing class due to being in the nurse's office multiple times per week.  The patient's symptoms improve when her mother comes to get her.  In response to the doctor's questions about the girl's peer relationships, the mother replies, "She has friends but never enjoys sleepovers."  When the patient is at a friend's house, she often complains of stomach pain and nausea.  She occasionally has nightmares about being left alone and wakes up crying.  Although both parents are healthy, the patient says she worries about them "dying of a terrible illness, like cancer."  Abdominal examination shows no abnormalities.  Which of the following is the most likely diagnosis in this patient?

Accepted Answer

Although separation anxiety is common in young children and in older children at times of change or stress, this patient's distress is excessive and impairing when she is separated from her mother. Her inability to sleep away from home, abdominal pain when separated from her mother, worries about losing her parents, and nightmares about being left alone are consistent with separation anxiety disorder. Children with this disorder commonly experience physical symptoms (eg, headaches, stomach aches, nausea) when separation occurs or is anticipated, and have repeated nightmares involving the theme of separation. According to DSM-5, symptoms must be present for ≥4 weeks in children and ≥6 months in adults. (Choice A) This girl's symptoms predate the stressor of starting a new school. In addition, adjustment disorders are not diagnosed when symptoms better meet the criteria for another disorder. As in this patient, stressful events often exacerbate symptoms of another disorder. (Choice B) Patients with dependent personality disorder fear being left alone and seek out others to support and assume responsibility for them. However, personality disorders are not diagnosed in children as their personalities are still developing. (Choice C) Generalized anxiety disorder involves chronic anxiety regarding multiple issues. This patient's symptoms occur in the context of separation, making separation anxiety disorder the appropriate diagnosis. (Choice D) This child's fears focus on her parents becoming ill, causing her to be left alone. Illness anxiety disorder is diagnosed in individuals who excessively worry about having a specific illness themselves. (Choice F) Social anxiety disorder is considered when anxiety and avoidance of social settings are due to worry about being viewed negatively by others. This child fears separation from her parents, not social rejection. (Choice G) Patients with somatic symptom disorder have an ongoing preoccupation with physical symptoms; their anxiety is primarily related to their physical symptoms and health. This child's somatic symptoms are an expression of anxiety due to separation from attachment figures. Educational objective: Separation anxiety disorder consists of excessive and distressing anxiety (≥4 weeks in children, ≥6 months in adults) due to separation from attachment figures. Children with this disorder often experience physical symptoms and nightmares. __________ References: Pediatric-onset and adult-onset separation anxiety disorder across countries in the World Mental Health Survey. (http://www.ncbi.nlm.nih.gov/pubmed/26046337) Assessment and treatment of anxiety disorders in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/25980507)

Question 13

A 37-year-old woman with a history of recurrent major depressive disorder comes to the office.  Her father died last month after a long illness, and she is concerned that her depression is returning.  The patient has little appetite, sleeps poorly, and has difficulty concentrating at her job as a teacher.  She recently stopped going to the gym and socializing with friends, activities that she used to enjoy.  She has been collecting pills from half-empty bottles of old medication and has considered taking all of them at once.  The patient has no history of suicide attempts.  Her mother completed suicide at age 40.  Which of the following is the most important factor in assessing this patient's suicide risk?

Accepted Answer

11ec160b_364d_9c84_9249_f9ee500e1158_MD0001_00 Assessment of suicide risk requires detailed questioning to determine the presence of suicidal thoughts and plans. Suicidal thoughts can be differentiated as passive (wish to be dead or not wake up) versus active suicidal ideation (actual thoughts of killing oneself). Patients who have active suicidal ideation should be further questioned about whether they have thought about specific methods of killing themselves and whether they have made any preparations and plans for suicide. Finally, the strength of the patient's intention to carry out the suicide plan should be assessed. Although this patient has several risk factors, it is her recent preparation for suicide (ie, collecting old medication with a plan of taking an overdose) that is the most concerning. Patients with active suicidal ideation and intent who have made preparations to carry out a specific method of suicide are at highest risk. Hospitalization may be necessary to ensure their safety. (Choices A and F) This patient's other risk factors for suicide include her family history of suicide (considered a static risk factor) and recurrent episodes of major depressive disorder. They are not as important as her recent active suicidal ideation associated with a specific method and preparatory behavior. (Choices B and C) Social isolation and insomnia are common symptoms of major depression that occur in patients with and without suicidality. Although they increase the risk for suicide, they are not as critical as this patient's active suicidal ideation and preparations. (Choice E) Although suicide risk increases in patients who have lost a loved one, this is not as strong a risk factor as having active suicidal ideation with a plan. Educational objective: Patients with suicidal thoughts should be assessed for intent and plan. Patients with active suicidal ideation and intent who have made preparations to carry out a specific method of suicide are at highest risk.

Question 14

A 19-year-old college student comes to the office with new-onset fatigue.  The patient has had difficulty getting up in the morning for the past week and states he would sleep 10-12 hours if his schedule allowed.  He also reports vivid dreams.  The patient was diagnosed with attention-deficit hyperactivity disorder at age 10 and has been treated with dextroamphetamine since then.  However, his prescription ran out early recently after he doubled the dosage to help him study during exams.  Which of the following findings is most likely to be present in this patient?

Accepted Answer

11ec160b_364a_6831_9249_c723b1bcf40c_MD0001_00 This patient's new-onset fatigue, hypersomnia, and vivid dreams following abrupt cessation of prolonged stimulant (eg, dextroamphetamine) use is most likely due to stimulant withdrawal. Decreased appetite and insomnia are the most common adverse effects of stimulant medications used to treat attention-deficit hyperactivity disorder, and abrupt stimulant withdrawal is associated with the opposite symptoms of fatigue, hypersomnia, and hyperphagia. Dysphoric mood may also occur. Use of supratherapeutic doses of prescribed stimulants or use that deviates from prescription instructions (eg, insufflation to attain a euphoric effect) increases the risk for withdrawal and adverse effects. Depending on the half-life of the agent used, symptoms of stimulant withdrawal typically present within hours to days of cessation or reduction of heavy or prolonged use and resolve without treatment. In contrast to withdrawal from alcohol, benzodiazepines, and opiates, physical symptoms in stimulant withdrawal are minor. (Choices A and C) Dilated pupils and rhinorrhea are classic symptoms of opioid withdrawal. Pupillary dilation may be seen during acute intoxication with stimulants but not during withdrawal. (Choices D, E, and F) Seizures, tachycardia, and tremors are features of alcohol and benzodiazepine withdrawal syndromes. These features may be seen in stimulant overdose but not in stimulant withdrawal. Educational objective: Stimulant withdrawal is characterized by dysphoric mood, fatigue, hypersomnia, hyperphagia, and vivid dreams. In contrast to many other withdrawal syndromes, stimulant withdrawal is not associated with significant findings on physical examination. __________ References: Food consumption and weight gain after cessation of chronic amphetamine administration. (http://www.ncbi.nlm.nih.gov/pubmed/24667154)

Question 15

A 16-year-old boy is brought to the office for a well-child visit.  The patient has no medical history but reports that his appetite is low and he has lost 2.3 kg (5 lb).  He stopped playing soccer recently due to lack of interest.  The patient is also worried about his grades due to difficulty staying focused in class and concentrating on his homework after school.  He feels tired despite sleeping 10 hours a night and taking afternoon naps when he gets home.  The patient says, "My parents try to be supportive, but everything they say these days gets on my nerves."  He has tried alcohol and marijuana a few times at parties but does not use other drugs.  Vital signs are within normal limits.  Physical examination is unremarkable.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

11ec160b_364d_2753_9249_a37ab3b1f213_MD0001_00 This patient's loss of interest, weight loss, hypersomnia, low energy level, and impaired concentration are concerning for major depressive disorder (MDD). Depressed adolescents may experience feelings of annoyance and irritability rather than sadness. Other common signs are loss of interest in previously enjoyed activities, changes in academic functioning and relationships with peers and family, feelings of worthlessness/inappropriate guilt, and suicidal thoughts. Suicide is the third leading cause of death in adolescents age 15-19 years. Any adolescent with behavioral changes should be assessed for suicidal ideation, which has an immediate impact on safety and acute management (eg, an actively suicidal patient may require hospitalization). Therefore, the most appropriate next step is to assess this patient for suicidal thoughts. (Choice A) This patient's recent difficulty concentrating is one of multiple symptoms characteristic of depression. In attention deficit hyperactivity disorder, concentration difficulties are chronic, with typical onset prior to adolescence. (Choice B) It would be inappropriate to involve the parents prior to fully assessing the patient and his safety. (Choices C and D) A complete blood count and thyroid function testing may be included as part of a workup to rule out medical causes of depressive symptoms (eg, anemia, hypothyroidism or hyperthyroidism). However, these conditions are unlikely to be contributory in a patient with no medical history and a normal physical examination. In addition, the results of these tests take time, whereas suicidality and safety are immediate concerns. (Choice F) This patient appears to be forthcoming about his substance use and has no signs of intoxication or abuse. Screening the urine for drugs is unlikely to yield helpful information and may damage the trusting relationship with the patient. Educational objective: Depressed adolescents may display irritable rather than depressed mood, declining academic performance, and withdrawal from social activities. Initial evaluation of all children and adolescents with suspected depression should include a careful suicide risk assessment.

Question 16

A 32-year-old woman comes to the emergency department requesting medication for severe back pain.  She has tried multiple over-the-counter agents and says that nothing has relieved her pain except oxycodone.  The patient was seen in a pain clinic a year ago but cannot recall the name of the physician and says that her prescription has run out.  Medical history includes a motor vehicle collision 10 years earlier and obesity.  Temperature is 37.1 C (98.8 F), blood pressure is 130/80 mm Hg, pulse is 76/min, and respirations are 16/min.  Physical examination shows no abnormalities.  A recent MRI was normal.  The patient says that her pain level is 10 on a scale of 0-10 and becomes frustrated when the physician suggests nonprescription pain medication.  Which of the following is the most appropriate next step by the physician?

Accepted Answer

Back pain accompanied by a request for opioid medication is a relatively common occurrence in the emergency department that requires differentiating inadequate pain management from drug-seeking behavior. This patient exhibits many features concerning for drug-seeking behavior, including requesting a specific medication by name, running out of medication, and claiming pain out of proportion to the physical examination. Reporting lost or stolen medication and obtaining multiple opioid prescriptions from different providers are other red flags indicating misuse or diversion. The best initial approach is to clarify the patient's medication history to determine which drugs have been prescribed, by whom, and at what frequency. State-based, online, prescription drug-monitoring programs are increasingly used in emergency departments to check for undisclosed prescriptions, clarify prescription patterns, and identify patients who obtain prescriptions from multiple providers. By identifying potential opioid misuse, physicians can make more informed decisions regarding pain prescriptions. (Choice A) It would be inappropriate to challenge the patient prior to clarifying her pattern of medication use. (Choice C) Repeating an MRI of the spine would not be the next step in a patient with a normal physical examination and recent normal MRI. (Choices D and F) These are options that can be considered once the patient's history is clarified. If the patient has received opioid prescriptions for a documented diagnosis at appropriately spaced intervals, a limited prescription would be reasonable. If there is evidence of misuse, refusing to prescribe opioid medication would be more appropriate. (Choice E) This patient does not perceive her opioid use as problematic and would likely be unreceptive to discussing referral to a substance abuse rehabilitation program. Educational objective: Physicians have a responsibility to identify signs of potential drug-seeking behavior and prescription drug misuse. This involves being alert to red flags (eg, lost or stolen medication, pain inconsistent with physical examination) and attempting to clarify medication history by using prescription drug-monitoring programs or other information sources. __________ References: Prescription drug monitoring programs, nonmedical use of prescription drugs, and heroin use: evidence from the National Survey of Drug Use and Health. (http://www.ncbi.nlm.nih.gov/pubmed/28152391) Impact of prescription drug monitoring programs (PDMPs) on opioid utilization among Medicare beneficiaries in 10 US states. (http://www.ncbi.nlm.nih.gov/pubmed/28498498)

Question 17

A 16-year-old boy with suicidal thoughts is brought to the office by his parents.  He has been in constant conflict with his parents since refusing to stop drinking alcohol, which he does on a daily basis.  The patient is the oldest of 6 children; his mother suffers from lower back pain and relies on him for child care, which he finds overwhelming.  His father works 2 jobs and is often not around to help with the children.  His mother keeps a firearm by her bedside for protection when she is alone with the children at night.  The patient dropped out of high school last year after getting dumped by his girlfriend.  He recently contracted Lyme disease with resultant symptoms of fatigue and myalgia.  Which of the following interventions is the best next step to decrease this patient's risk of completed suicide?

Accepted Answer

11ec160b_364c_8b12_9249_c7b5e7156c29_MD0001_00 Suicide is a major public health issue that is linked to approximately 1 million deaths worldwide each year. It is the second leading cause of death, after accidents, in those aged 15-24. Suicide risk management involves controlling modifiable factors that decrease the risk of suicide, such as decreasing stress, improving psychosocial support, treating psychiatric illness and substance abuse, managing pain, and limiting access to firearms or other means of self-harm. Other risk factors are static and cannot be modified. These include age (teenagers and the elderly), male sex, family history of suicide, and history of previous attempts. Individuals with access to firearms have 3 times the risk of suicide completion, as suicide by firearm is associated with a higher fatality rate compared to other methods. Due to the impulsivity often associated with suicide in teenagers, limiting this patient's access to firearms is the most important next step to decrease his risk. (Choice B) Treatment for this patient's depression should be offered. However, the next step is to advise his mother to lock away her firearm, so that the risk of completed suicide is decreased while treatment takes effect. (Choice C) Providing the mother with assistance could decrease the patient's burden in the long term but is not an immediate intervention. (Choice D) Although alcohol use increases the risk for suicide by impairing judgment, this teenager does not acknowledge that he has an alcohol problem and may not be willing to start counseling at this time. Removing access to weapons is a more immediate measure. (Choice E) Although decreasing this patient's isolation and improving his future prospects by helping him return to school is important in the long term, limiting access to firearms is the most pressing concern. (Choice F) Chronic illness involving pain is a strong risk factor for attempted suicide. Although the patient's Lyme disease should be treated to prevent further disability, removal of access to firearms is more likely to prevent a completed suicide at this stage. Educational objective: Access to firearms greatly increases the risk of completed suicide. Evaluation of a patient's access to guns is a key part of suicide risk assessment. Other interventions to reduce suicide risk include decreasing stress, increasing psychosocial support, treating psychiatric illness and substance use, and managing pain. __________ References: Firearm storage in gun-owning households with children: results of a 2015 national survey. (http://www.ncbi.nlm.nih.gov/pubmed/29748766) The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/24592495)

Question 18

A 74-year-old woman is brought to the emergency department by ambulance.  She is accompanied by a friend, who found the patient confused and disoriented lying on the floor in her apartment.  The patient is widowed and lives with her adult daughter.  She was diagnosed with aplastic anemia a year ago.  Her condition has responded poorly to immunosuppressive therapy and has required multiple blood transfusions.  The patient is febrile, disoriented, and unable to respond to questions.  Complete blood count shows severe pancytopenia.  The patient has an advance directive, signed 9 months ago, in which she designated the friend as her health care proxy.  The friend tells the physician that the patient did not want to undergo any further blood transfusions.  The patient's daughter arrives and adamantly insists that the patient receive a blood transfusion, saying, "I discussed it with my mother a few weeks ago, and we decided that she should have everything done to prolong her life."  Which of the following is the most appropriate next step in patient care?

Accepted Answer

11ec160b_3651_9427_9249_cf59c33ea14f_MD0001_00 A health care proxy (eg, durable power of attorney for health care) is a surrogate decision-maker who has been designated by a patient and is legally enabled to make health care decisions on that patient's behalf. A health care proxy is obligated to make decisions in accordance with what he or she believes the patient would have wanted (ie, substituted judgment) and the patient's best interest. As with all forms of advance directive, a health care proxy must be designated when the patient is competent and is used only when the patient is presently unable to make health care decisions. A designated health care proxy takes legal priority over all other decision-makers, regardless of family relationship. In this case, the patient's friend is the designated proxy and has had clear instruction from the patient regarding her wish not to receive additional blood transfusions. Therefore, the patient should not receive a transfusion regardless of the family's preferences. (Choice A) A facility ethics committee is typically convened when no suitable surrogate decision-maker can be identified or there is disagreement among equal surrogates (eg, adult children). In this case, the patient has a single, properly designated surrogate decision-maker, whose decisions should be considered determinative. (Choices B and C) A next-of-kin surrogate does not take priority over a designated health care proxy. If there is no designated surrogate decision-maker, decisions typically fall to the next of kin as a default surrogate. A patient's spouse is usually considered the next of kin, although in the absence of a spouse, decisions may be made by other family members (eg, adult children, parents) in the order of relationship proximity. (Choice E) A physician should always make recommendations based on the best interests of the patient. However, with limited exception, the physician may not intervene over a patient's explicit refusal when given either directly by the patient or indirectly via an appropriate surrogate. Educational objective: A health care proxy is a person legally designated to make medical decisions if the patient loses decision-making capacity. The proxy takes priority over all other surrogate decision-makers, including family members. __________ References: Advance care planning: contemporary issues and future directions. (http://www.ncbi.nlm.nih.gov/pubmed/30480109)

Question 19

A 14-year-old boy is brought to the office by his mother for a 6-month checkup for asthma.  Although the patient's asthma is generally well controlled with long-acting agents, he has episodes of exercise-induced bronchoconstriction for which he was prescribed a short-acting beta agonist.  His mother became concerned after the physical education teacher called from school saying that her son was refusing to participate in class.  When asked about this, the patient said that it was easier to avoid exercising than to use an inhaler at school.  Family history is significant for chronic obstructive pulmonary disease (COPD) in his maternal grandfather, heart disease in his father, and generalized anxiety disorder in his mother.  Vital signs and physical examination are within normal limits.  Which of the following factors would most likely increase this patient's adherence with bronchodilator administration?

Accepted Answer

Adolescence involves the developmental tasks of separating from parental figures and finding one's own place in society, which includes beginning to take responsibility for one's physical health. This exploration is often accompanied by rebelling, pushing limits, and having a strong need to fit in with a peer group, all factors that may contribute to low treatment adherence rates. In particular, adolescents with chronic medical conditions may hide their illness due to feeling self-conscious and different from their peers. Factors associated with better treatment adherence rates include close peers with complementary behavioral practices, positive family functioning, school involvement, physician empathy, and immediate benefits of treatment. Another factor affecting adolescent treatment adherence is that the prefrontal cortex (center of executive function) does not fully develop until the third decade of life. Compared to adults, adolescents are less able to weigh the risks and benefits of their decisions or to anticipate that negative consequences may occur. (Choices A and D) Although education and written instruction are important in increasing adherence, adolescents struggle to conceive of possibilities outside their immediate experience and do not anticipate negative consequences happening to them. The desire to improve long-term asthma symptoms or to prevent chronic obstructive pulmonary disease is unlikely to be a major motivating factor. (Choice B) Although learning about role models (eg, famous athletes) with asthma might be helpful, similar peer behavior is more likely to decrease this patient's embarrassment about using an inhaler in the school setting. (Choice C) Physician education about the patient's illness is unlikely to be as strong a factor in adherence as peer acceptance. As adolescents strive to become more independent, they may rebel against authority figures, including physicians. (Choice F) Although parental attitudes and support are important in helping adolescents maintain adherence, making the patient feel responsible for causing his mother's concern is inappropriate and unlikely to facilitate adherence. Educational objective: Adolescents have low treatment adherence rates due to issues with autonomy, rebellion against authority, increased self-consciousness, and a lack of understanding of potential risks. Peer behavior has a strong influence on adherence due to adolescents' desire to fit in with their social groups. __________ References: [Adolescence and asthma management: the perspective of adolescents receiving primary health care]. (http://www.ncbi.nlm.nih.gov/pubmed/25479845) The adolescent with asthma. (http://www.ncbi.nlm.nih.gov/pubmed/23972334)

Question 20

A 34-year-old woman comes to the office accompanied by her husband for an employment physical examination. The patient says, "I'd rather not be here, but my job requires labs every 2 years." While getting blood drawn, she starts to feel anxious, nauseated, and short of breath, and says, "I feel like the room is spinning." The patient's husband explains that she has had similar episodes since childhood, which began following a bike accident during which she cut her knee and bled profusely. Medical history is significant for asthma and type 2 diabetes mellitus. Temperature is 36.7 C (98.1 F), blood pressure is 140/90 mm Hg, pulse is 104/min, and respirations are 20/min. BMI is 36 kg/m². Physical examination is significant for anxious demeanor but is otherwise unremarkable. Which of the following is the most likely diagnosis?

Accepted Answer

11ec160b_3649_f300_9249_d92a5ad9b11c_MD0001_00 This patient's marked anxiety response and fear regarding blood drawing (a specific phobic stimulus) with a history of avoidance behavior is consistent with specific phobia, one of the most common anxiety disorders. The blood-injection-injury type (ie, fear of blood, injections, and injury) is often accompanied by a vasovagal fainting response, and severe cases may be associated with avoidance of necessary medical procedures. Other subtypes of specific phobia, based on the type of phobic stimulus, include animals (eg, insects, snakes, dogs), natural environment (eg, heights, storms, water), and situations (eg, elevators, enclosed places, airplanes). The treatment of choice of specific phobia is cognitive-behavioral therapy with repetitive, graded exposure to the fear-inducing stimulus. (Choice A) Although medical conditions such as asthma or hypoglycemia can result in anxiety, it is more likely that this patient's longstanding and specific fear of blood is triggering her current symptoms. (Choice B) Illness anxiety disorder involves persistent preoccupation with having or developing a serious medical condition. (Choice C) Patients with specific phobia may experience anxiety that reaches the level of a panic attack when exposed to the phobic stimulus. However, panic attacks in specific phobia are always triggered by the phobic stimulus; diagnosis of panic disorder requires that patients experience recurrent, unexpected panic attacks with no trigger. (Choice D) Both specific phobia and posttraumatic stress disorder (PTSD) may be associated with anxiety and avoidance of situations related to a traumatic event. However, PTSD also involves intrusive symptoms of reexperiencing (eg, flashbacks, nightmares) that are not present in this patient. Educational objective: Specific phobia is a common anxiety disorder characterized by high levels of anxiety and panic attacks triggered by exposure, or anticipation of exposure, to a feared stimulus. As a result, these patients try to avoid the phobic stimulus whenever possible. __________ References: Specific phobia. (http://www.ncbi.nlm.nih.gov/pubmed/29763098)

Exam 2: Behavioral science