Tuesday, 13 November 2012

Usmle Step 1 MCQ's # 3

Title: Usmle Step 1 MCQ's # 3
Subject: Behavioral Science

Q NO 3: A 67-year-old man presents at his physician complaining of discomfort in his lower abdomen and difficulty with urination. The man is 5 feet 11 inches tall and weighs 220 pounds. Although he used to smoke cigarettes, he was able to quit when he retired at age 65. Physical examination reveals an enlarged prostate. Suspecting the possibility of cancer, the physician orders a PSA test and tells the patient he will be contacted when the results are available. The patient is visibly upset at hearing the word “cancer” and in spite of the physician’s reassurances of the low probability of malignancy, is physically shaking when he leaves the office. Several days latter the results of the test are received. The patient has a PSA of 3.5, elevated, but below the commonly used screening test cutoff. At this point the physician’s best course of action would be to do which of the following?

A. Arrange an appointment to talk with the patient in the next several days and review the results in person
B. Call the patient at once to deliver the news and offer guidance
C. Call the patient to deliver the news and congratulate him on his overall health.
D. Call the patient to deliver the news and schedule the patient for a follow-up appointment to review what he can do to improve his overall health.
E. Have the nurse employed by the practice call the patient to deliver the news and take time to answer any questions he may have.
F. Schedule an appointment to talk to the patient about the results and offer him a referral for counseling
G. Send the patient a letter detailing the test results and suggesting the next course of action.

The correct answer is D. All communication with a patient is best handled face to face. When this is not possible because of the need to deliver news in a timely manner, as in the present case the phone conversation should be followed up by a visit. The follow-up visit is also needed to discuss some of the patient’s other health issues, including his weight. This patient’s body mass index (weight/height) is too high.
The patient is likely to have high anxiety over the next several days as he waits to hear the results (choice A). Alleviate the anxiety by telling him as soon as possible.
The phone call gets the good news to the patient quickly, but does nothing to either further the building of a good long-term relationship with the physician or address the patient’s other health concerns (choice B)
Choice C while getting the patient the news quickly, and in a cheery manner, does not address the patient’s other health condition.
The physician himself should deliver the news not a nurse (choice E) or other member of the office staff. The practice of having the physician call with bad news and a staff member call with good news only heightens patient’s anxiety anytime the physician calls. The physician is in the best position to answer any questions that the patient has, and to talk about the next steps to improve health.
The patient is likely to have anxiety waiting for days to hear the test results. Also the physician himself should do counseling, and not refer to patient to someone else (choice F).
A letter from the physician (choice G) takes time to get to the patient, always creates anxiety and offers no one to discuss meaning of the results.

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