Question 1

An intern attends a neighborhood dinner party and recognizes a colleague who works in another department at the same hospital. Throughout the evening, she notices her colleague responding to a number of routine medical calls from the hospital and drinking many alcoholic beverages. Later that evening, the physician discovers that her colleague is delivering pharmaceutical prescriptions over the phone while slurring her voice. The physician approaches her colleague, requesting that on-call responsibilities be transferred for the benefit of patient care. He argues that he is alright, that he is not inebriated, and that his responsibilities finish in 30 minutes. Which of the following is the best course of action?

Accepted Answer

Eductional Objective: Physicians have an ethical and legal obligation to report impaired colleagues as soon as possible. This doctor is in the uneasy situation of knowing that a colleague is inebriated while on duty. Although it is unknown if this is an isolated incident or part of a larger pattern of impairment, the physician is required to respond quickly since patient safety is jeopardized. The immediate supervisor of the colleague should be notified so that the matter may be resolved as soon as feasible.
The risks of failing to intervene include patient damage and the inability to receive appropriate assessment and therapy for the physician, which can have a detrimental impact on his health, career, and family. Regulations at most institutions and state medical boards require physicians to report impaired colleagues.  This can usually be done anonymously. In a non-emergency situation, a person should contact the designated hospital committee, commonly called a physician health

Question 2

A 40-year-old jobless man with persistent back pain arrives at the office for a consultation with a new doctor. Years ago, the patient damaged his back in a job accident and has not worked since. He acknowledges that he takes marijuana everyday to "calm the agony" and that a percentage of his earnings go toward its purchase. The patient claims that nothing has changed and requests that the doctor sign a disability form so that he can continue to receive disability benefits. When the doctor inquires about his condition and previous treatment, he responds furiously, "I wouldn't be here re-applying for disability if anything had worked," slamming the disability form down on the table. The patient walks normally with no apparent discomfort or limitations.  Which of the following is the most appropriate response by the physician?

Accepted Answer

Eductional Objective: In the United States, disability insurance is provided by commercial insurance companies or the Social Security Administration. It offers financial help to employees who are unable to work due to a medical or psychological problem. These entities normally demand a physician's certification of impairment before granting the award.
The patient's request that the doctor sign a disability paper creates a tricky scenario. Pain is very subjective, and the physician knows very little about this patient at this point in the encounter. Malingering or exaggerating the level of impairment to receive benefits, improperly managed pain, or persistent pain resulting in real disability are all possibilities. This patient may also have had negative interactions with health care providers or a psychiatric condition that contributes to his angry, demanding behavior. The best approach is to politely but firmly explain that determining medical disability requires further assessment of his symptoms, physical examination, and testing if indicated.

Question 3

A 13-year-old kid is brought to the doctor by his mother for a standard medical examination and type 1 diabetes mellitus follow-up. "Here's the doctor; he's going to tell you how terribly you've been doing," his mother exclaims at the start of the appointment. Laboratory tests reveal a random blood glucose of 350 mg/dL and a hemoglobin A1c of 9% (normal: 6%-7%). When the doctor asks how the patient is doing with his insulin, his mother interrupts and exclaims, "He never remembers to use it!" When asked about the boy's diet, his mother puts her hands on her hips, glares at him, and exclaims, "Pizza, soda, and sweets!" After addressing the mother's worries about diabetes management, which of the following is the most appropriate course of action?

Accepted Answer

Eductional Objective: This patient's type 1 diabetes is poorly controlled on his current medication regimen, as evidenced by a random blood glucose level of more than 200 mg/dL and a hemoglobin A1c of 9.0 percent. An irate, critical father confronts the physician and refuses to let the patient speak. Continuing the visit in the presence of the patient's mother would almost certainly result in ineffective confrontation or the patient pacifying his mother by agreeing with her or enabling her to speak for him. The best course of action is to acknowledge the mother's concerns and politely ask her to wait outside while the physician speaks with the patient privately. This will allow the patient to be more open about his difficulty managing his diabetes and to discuss any personal concerns that may be having an impact. All adolescent visits should include an opportunity to interview the patient alone to discuss topics such as drugs, alcohol, tobacco, and sexual activity.

Question 4

A 52-year-old lady arrives at the clinic to discuss the findings of an abdominal CT scan. The patient declares, "I'm hoping the scan will reveal why I've been losing so much weight. What does it demonstrate?" The imaging suggests pancreatic cancer, according to the doctor. When she hears this, the patient begins to scream and clutches her head in her hands. Which of the following is the most suitable medical response?

Accepted Answer

Eductional Objective: Delivering serious news requires allowing the patient time to process the information and express emotions.  Empathic, supportive communication should include acknowledging the patient's distress and being open to answering any questions.

Question 5

A 38-year-old woman arrives at the clinic complaining of severe dysmenorrhea and tension headaches during the last three months. "It is more difficult than I imagined; I sometimes have to stay late to catch up on paperwork and am not sleeping very well," she says of her recent promotion to school principal. The patient is married and does not have any children. She falls into tears when answering inquiries about her sexual past. When the doctor asks what is bothering her, she covers her face and confesses she was sexually molested as a youngster. Which of the following is the best way to deal with the patient?

Accepted Answer

Eductional Objective: Physicians must convey empathy and support in the face of sexual abuse allegations. The most suitable initial response is to express empathy by acknowledging the patient's suffering and being open to listen to the patient's ideas and feelings about the abuse. This empathetic recognition will help the patient feel understood while also strengthening the doctor-patient connection. Once this initial assistance has been established, more resources and referrals can be provided as required.
Patients will differ in their comfort level when addressing earlier trauma, and the physician should follow the patient's lead in investigating this delicate area. Patients should be given the chance to discuss the abuse but should not be forced to do so. Some patients may indicate that they are not ready or willing to talk more about the trauma. In these cases, the physician should acknowledge the trauma and convey willingness to discuss it in the future

Question 6

A 48-year-old deaf man arrives at the office for the first time. The patient has recently relocated to the neighborhood and is accompanied by a buddy with whom he communicates using American Sign Language. The physician is informed by the office staff that the patient has been communicating by reading lips, making gestures, and nodding his head in agreement. The buddy states at the outset of the visit that the patient has asthma and takes an inhaler as needed. The patient writes a note to the doctor saying that he would want to test a longer-acting inhaler. Which of the following is the most suitable next step in this patient's evaluation?

Accepted Answer

Eductional Objective: Subject to patient request and agreement, deaf and hard of hearing patients should be provided the services of an interpreter skilled in medical translation and American Sign Language. Computer-assisted real-time transcription and assistive listening devices are examples of alternative means of communication.

Question 7

A 49-year-old lady is moved from a community hospital to a tertiary care institution for treatment of a chronic obstructive pulmonary disease exacerbation. A hospitalist cares for the patient overnight before transferring care to the teaching service in the morning. During morning rounds, the patient's new medical team meets with her for the first time. The attending physician introduces the team and informs the patient that the intern will interview him. The patient then calls the intern by his first name and says, "You are eerily similar to my kid. He's highly intelligent and looks a lot like you." Which of the following activities by the intern would be the best way to start the interview?

Accepted Answer

Eductional Objective: Developing a therapeutic physician-patient connection necessitates striking the right blend of warmth and professionalism. First impressions matter, and early interactions with new patients can set the tone for the rest of the relationship. Using the patient's chosen manner of address can aid in the development of rapport. Clarifying any doubts regarding pronunciation, titles, or pronouns is also vital. Although younger folks generally prefer to be addressed by their first name, elderly patients may take offense at what they perceive to be excessive familiarity. When in doubt, the doctor should ask the patient about their preferred method of address.
As the physician and patient become more acquainted, many patients will want to be addressed by first name. However, it should be the patient, not the physician, who takes the lead in lowering the level of formality. It is better to ask the patient's preference in an open-ended manner rather than make assumptions.

Question 8

A 52-year-old man comes in for a check-up to discuss the findings of his colonoscopy. The doctor informs the patient that a malignant polyp was removed and that the resection margins show no evidence of aggressive malignancy. He is then reassured that his prognosis is favorable. As a result, the patient rants and yells furiously, "Are you saying I should be grateful you discovered cancer in the first place? You have no idea what you're doing!" Which of the following is the best way to deal with the patient?

Accepted Answer

Eductional Objective: After receiving an unexpected cancer diagnosis, this patient is enraged and verbally hostile. Anxiety and discomfort are likely exacerbating his feeling of entitlement and demanding personality traits, and the physician is faced with the difficult task of reacting to his offensive words. When patients are distressed, they may struggle to adequately digest information. Instead of addressing their own worries, they may get enraged with the doctor.
The easiest way to diffuse the issue is to be nondefensive and acknowledge the patient's emotions. This should be followed by an open-ended approach that probes the patient's comprehension of his illness and encourages him to communicate any concerns or anxieties he has regarding the diagnosis, which are likely to be behind his behavior.

Question 9

A 54-year-old man arrives at the clinic for a first evaluation of lower back discomfort. According to the patient's medical record, he has seen multiple doctors for back pain therapy. He was provided several pain medicines and physical rehabilitation treatments, but he frequently stopped taking them too soon or did not follow through on the instructions. The patient adds at the start of the visit, "I'm sick of living with back pain, and I haven't worked in years. Nothing has helped me-I might as well quit up and go on disability at this point." Which of the following statements best describes your initial response to this patient?

Accepted Answer

Eductional Objective: This doctor is confronted by a patient who has not benefited from past therapy and is losing hope that his condition would improve. Such difficult patients can sometimes make the physician feel defensive, manipulated, or despairing, leading to an unnecessary referral to a specialist.
Although methods to promote treatment adherence are vital for improving results, the ideal first step is to strengthen the physician-patient connection by empathizing with the patient's unhappiness and disappointment with previous therapies. As a result, the patient will feel understood rather than blamed for previous treatment failures, and he will be more inclined to collaborate with the physician to establish a collaborative plan centered on realistic goals.

Question 10

A 34-year-old man arrives at the clinic complaining of nasal congestion and coughing for the past five days. He claims to cough up thick, yellow phlegm on occasion and is concerned about his lack of progress. The patient states that he has previously gotten antibiotics for identical symptoms and that "antibiotics always seem to make me feel better quickly." The temperature is 37.2 degrees Celsius (99 degrees Fahrenheit), the blood pressure is 120/70 mm Hg, the pulse rate is 76 beats per minute, and the respirations rate is 18 beats per minute. The physical examination reveals pharyngeal erythema; the rest of the test, including the cardiovascular evaluation, is normal. Which of the following physician replies is most appropriate?

Accepted Answer

Eductional Objective: This afebrile patient with normal lung function is most likely suffering from a viral upper respiratory infection. The physician is confronted with the usual clinical challenge of responding to an unneeded antibiotic prescription request. Despite the fact that many patients are given antibiotics for upper respiratory infections, antibiotic usage in uncomplicated upper respiratory infections is linked with an increased risk of unpleasant effects, no benefit over placebo, and an increase in antibiotic resistance.
A patient-centered approach that supports the patient's worries, informs the patient on the bad effects of antibiotics and their lack of efficacy in treating viral infections, and gives choices for treating the patient symptomatically is the most appropriate response. This must be done in a compassionate and nonjudgmental manner that contributes to, rather than detracts from, the building process. the physician-patient relationship. The physician should refrain from prescribing antibiotics and advise the patient to return if symptoms persist or worsen.

Question 11

A 65-year-old man is taken to the hospital overnight for stomach discomfort. He has a simple minor bowel blockage, which will necessitate surgery in the morning. The temperature is 37 degrees Celsius (98.6 degrees Fahrenheit), the blood pressure is 130/82 mm Hg, and the pulse rate is 90 beats per minute. To consider surgical intervention, the resident meets with the patient and his adult son, who has accompanied him to the hospital. After introducing herself, the resident discovers that the patient predominantly speaks Vietnamese and has low English competence, despite the fact that his kid speaks both Vietnamese and English. The son introduces himself as a critical care nurse and offers to translate the talk for his father. Which of the following replies to the patient's son is correct?

Accepted Answer

Eductional Objective: This patient requires surgical intervention and must first provide informed permission. He does, however, have limited English proficiency (LEP) and will need linguistic support to make informed health-care decisions. Use an interpreter (or provider) skilled in medical translation in the patient's main language when communicating with a patient who has LEP. Using a qualified medical translator can assist avoid potentially harmful misunderstanding, resulting in fewer clinical mistakes, more patient satisfaction, and improved clinical results. However, using an interpreter or other persons to provide treatment requires the patient's approval.
If a live interpreter is not available, video or telephone remote translation services should be provided. If the situation is urgent and there is no time to wait for interpretation services, communication should be facilitated by any tools available (eg, friends/family, writing/drawing instruments, bilingual hospital staff); however, these options should not be considered standard procedure in nonemergency situations.

Question 12

A 35-year-old man visits the office for normal health maintenance. After divorcing his wife, the patient just relocated to "make a fresh start" and begin a new work. He has no chronic medical issues and has never had surgery. The patient is sexually active and has had six lovers in her lifetime. Which of the following questions should the physician ask to complete the rest of the sexual history?

Accepted Answer

Eductional Objective: Taking a sexual history is an important aspect of providing complete treatment and necessitates an open and nonjudgmental attitude. Avoid making judgments about a patient's sexual history and instead ask open-ended questions regarding all sexual relationships.

Question 13

A 21-year-old man arrives to the office with recurring ear leakage. His girlfriend is accompanying him. He communicates in English. On examination, the patient shows purulent otorrhea, a perforation of the tympanic membrane, and a pearly white mass behind the tympanic membrane, which is consistent with a large cholesteatoma. He is told that removing the tumor from his ear will need surgery. The patient nods momentarily but does not ask questions after hearing an explanation of the process and why it is necessary. He is also given information papers that include a written description of the treatment as well as directions on how to schedule surgery, which he promptly passes to his girlfriend, who begins reading them.  Review of the medical records shows he has been to the emergency department several times in the last year with this same concern and has not had a flu shot in the past 5 years.  Which of the following is the most appropriate course of action?

Accepted Answer

Eductional Objective: Low literacy can be a significant barrier to appropriate treatment and may be difficult to identify. For patients with suspected low literacy, alternative methods of communication (eg, visual resources) should be used to improve understanding.

Question 14

A 29-year-old man visits the urgent care clinic with a sore throat and nasal congestion. He is led to an examining room after 2 hours of waiting. The vital indicators are within normal ranges. When the doctor enters the room, the patient exclaims loudly, "I've been here for several hours and there aren't many people in the waiting room. I'm skipping work to come here." In addition to praising the patient for their patience, which of the following physician answers is most appropriate?

Accepted Answer

Eductional Objective: Recognizing the patient's point of view, demonstrating respect, and being nondefensive and nonjudgmental are all components of patient-centered communication. Long delays are best addressed with an open apology and a focus on the patient's concerns.

Question 15

Due to cellulitis, a 38-year-old lady is taken to the hospital for the night. The next morning, the hospitalist on call presents herself to the patient and inquires as to how she is doing. The patient screams angrily, "It's already midday, and I haven't had my breakfast yet. How am I meant to improve if you're starving me?" A normal diet has been ordered for the patient. Which of the following is the most suitable medical response?

Accepted Answer

Eductional Objective: In this scenario, the physician has a first interaction with an irate patient who is furious about a component of her treatment over which the physician has no direct influence. Nonetheless, it is the physician's obligation to respond to the patient's urgent concerns, alleviate her anger, and strengthen the physician-patient connection. The doctor should acknowledge the source of the patient's suffering (e.g., hunger), stay nondefensive, and offer to get further information that may assist fix the problem (eg, confirming correct diet was ordered; checking with the nursing staff).
The doctor should keep a professional approach and avoid making dismissive, defensive, or sarcastic comments in response to the patient's rage.   Being responsive to the patient's immediate concerns is more likely to build rapport, help the patient feel understood and lay a positive foundation for the physician patient relationship.

Question 16

A 33-year-old man arrives at the office complaining of back discomfort. He has a 2-week history of mild lumbar discomfort that began after a hard day of yard labor. There is no temperature, muscle weakness, or urine symptoms. The patient has no history of severe trauma and a normal medical history. Lower extremity strength, sensibility, and reflexes are all normal, according to the examination. The straight-leg raising test results are negative. The patient declares, "My brother experienced comparable symptoms last year, and an MRI revealed a bulging disc. Could you please order the test for me?" The physician suggests symptomatic relief choices but advises against any imaging investigations. Which of the following is the most likely outcome of this suggestion?

Accepted Answer

Eductional Objective: Overutilization is the provision of superfluous services that are not intended to enhance patient outcomes or affect management in a significant way. Patient-centered health care necessitates that care be administered with consideration for the patients' concerns, preferences, and priorities, but it does not need unnecessary testing or treatment if patient input is properly asked and acknowledged when appropriate. MRI is not advised for patients with simple low back pain because it causes overutilization.

Question 17

A 33-year-old woman is moved from a small community hospital to the university medical center owing to severe pyelonephritis with sepsis. She has a history of recurring urinary tract infections as a result of urine retention caused by a spinal cord injury as a youngster. The patient is febrile and sluggish when he arrives. She offers no more background, and the only information accessible is from the originating hospital's handwritten records, which are illegible. The patient is hospitalized to the critical care unit and given the antibiotics imipenem and vancomycin. The patient gets a rash and significant respiratory distress overnight, necessitating temporary artificial ventilation. The following morning, a transcribed physician note from the originating hospital arrives by fax and indicates that the patient has an allergy to multiple antibiotics, including imipenem.  When discussing events with the patient and her family, which of the following statements is associated with reduced malpractice liability for the treating clinician?

Accepted Answer

Eductional Objective: Most patients who encounter problems, even if they are preventable, do not file a malpractice claim. Patients who sue physicians are often motivated not by financial benefits, but by rage, distrust, or a sense that the clinician is unconcerned about their well-being. Patients frequently complain inadequate communication from providers and pursue lawsuits solely to have a better understanding of what occurred.
When communicating with a patient after a medical error, doctors should disclose the problem clearly and honestly; hiding an error might look dishonest and provoke animosity if the error is subsequently revealed. The patient should be able to ask questions during the dialogue, and responses should be delivered in language that the patient understands. A plan to rectify the error should be provided. The provider should then convey concern for the patient and remain engaged with the patient's care until the issue has been resolved.

Question 18

A 73-year-old lady with congestive heart failure is being readied for hospital release. The patient has heart failure with a low ejection fraction and has been hospitalized twice in the last 60 days. The patient's medical history includes ischemic heart disease, chronic obstructive lung disease, and hypertension. Vital indicators are typical. A pulmonary examination reveals normal breathing effort, no crackles, and no peripheral edema. The patient asks to stay in the hospital for a few additional days and says, "I feel fine right now, but I am worried that if I go home, I might end up back in the hospital again." Which of the following responses to this patient's request is most appropriate?

Accepted Answer

Eductional Objective: Predischarge counseling should begin with an assessment of the patient's comprehension and health literacy. Patients should be able to ask questions and voice concerns about variables at home that may contribute to readmission. A multidisciplinary care team should give education if feasible, and a clear plan for home care and follow-up should be in place.

Question 19

A 25-year-old lady arrives at the office for an initial assessment of her poor mood. The patient has been depressed and unable to sleep since relocating to a new apartment three weeks ago. She states, "My landlord does not let dogs in the building. I really miss my dog. I know my attitude would improve if I received a letter from you stating that my dog is welcome to live with me." The patient's dog is presently being cared for by her parents, who reside a few miles away. Which of the following physician remarks is the most appropriate?

Accepted Answer

Eductional Objective: In this initial patient interaction, the physician is met with a specific request for an emotional support animal letter but has very minimal information. Although physicians should respond to a patient's concerns, they should not feel obligated to give a suggestion before thoroughly assessing the patient. The ideal strategy is to confirm the patient's worries and obtain further facts on which to base a decision.
The physician should begin with an empathic statement noting this patient's distress and then gain a more thorough grasp of the problem. This would entail gaining a more complete description of the patient's mood, evaluating for further depressed symptoms, taking a medical and psychiatric history, as well as assessing other psychosocial stresses and the patient's support system.  Dismissing the patient's request or coming to a premature decision should be avoided.

Question 20

A 29-year-old lady visits the clinic for an examination of vaginal discharge and pruritus that has been bothering her for the previous week. The discharge is thick and yellow, with no odor. The patient engages in sexual activity with several partners. When asked what genders her sexual partners are, the patient responds, "What difference does it make? I'm very sure I have a yeast infection, therefore all I need is some medicine." Which of the following is the best reaction at this time?

Accepted Answer

Eductional Objective: Sexual history is an essential part of gathering a complete medical history.  This topic may be uncomfortable for both patient and physician, so it is important to normalize it as a routine part of a medical evaluation.

Quiz 2: Behavioral Sciences