Final Practice Questions/DocCom Quizzes

Allan Jones comes to the walk-in clinic with a 2-week history of productive cough. He is 38, and when asked about smoking he discloses a 30-pack-year history, and says, "I am quitting. My brother-in-law was just diagnosed with lung cancer and with this cough I haven't had a cigarette for a week anyway." After congratulating the patient on his decision, which is the recommended way to continue? A. "So what thoughts do you have about the steps you will take to continue with your plan to quit?" B. "There are many options for quitting smoking. I have some pamphlets for you." C. "A lot of my patients like nicotine gum. Would you like to try it?" D. "Would it be helpful for me to refer you to a smoke-enders group?" E. "Did your brother-in-law smoke as well?

A. "So what thoughts do you have about the steps you will take to continue with your plan to quit?"

Rhea Aldrich, 65, has diabetes, hypertension and high cholesterol. You explain the risks of high cholesterol to her and advise starting medication to lower cholesterol. The patient says "I don't know about all this medication. My son is a nurse, could you talk to him about this?" Which option is recommended to help you reach agreement with Ms. Aldrich? A. "You are the one who has to take the medication, so let's talk a little more about the options for you." B. "Is your son working in hospital or an office?" C. "No problem, I'll call your son." D. "I'm happy to talk to your son and will check in with you afterwards to make sure that our plan works for you too." E. "Even if your son is very knowledgeable in this area, it is really you who has to be comfortable with the decision."

D. "I'm happy to talk to your son and will check in with you afterwards to make sure that our plan works for you too."

A reserved and dignified 59-year-old bank executive follows-up in your office a week after angioplasty for coronary artery disease. He has attended patient education classes and been advised to take it easy for three weeks, but he tells you he is leaving on a ski trip to Colorado with his new girlfriend. What is the recommended first response? A. "Do you have a complete supply of all of your medications?" B. "What do you know about the risks of physical exertion after angioplasty?" C. "Really..., who's the beneficiary on your life insurance?" D. "Tell me your thoughts about taking this trip at this time." E. "Now, let's review all of the instructions that the cardiologist gave you."

D. "Tell me your thoughts about taking this trip at this time."

"Let's see if I have this right: you'd like to talk about your blood pressure, your biggest worry is side effects of the medicine, and you'd like to talk about alternatives." Which of the following communication skills used in opening the discussion best describes the physician's statement? A. Survey symptoms B. List concerns C. Redirect patient D. Summarize E. Open-ended inquiry

D. Summarize

Jerome Weiss is a 15 year old boy hospitalized for leukemia. He had greatly improved and you are discharging him today. This morning you spent a lot of time discussing the details of his outpatient treatment regimen with him and his parents. The appropriate follow up appointments were scheduled and you made sure that the patient and the parents fully understood and agreed with the discharge plans. As you are shaking hands, Mr. Weiss indicates that he lost his job and is unsure whether his son will have insurance coverage for outpatient care. You are surprised about this last minute revelation, and had you known about this earlier, you would have been able to get more assistance from the unit social worker. How might you have avoided this last minute revelation? A. Provided more written materials about the treatment plan. B. Asked the parents whether they had other questions.. C. Discussed the case in more depth with the rest of the team. D. Stressed the importance of continued treatment. E. Invited more questions from patient and parents about implementing the treatment plan.

E. Invited more questions from patient and parents about implementing the treatment plan.

Gwen Lee, 42 is a divorced Chinese American who works as receptionist. She ended her marriage 3 years ago after discovering that she had HIV infection because her husband had been unfaithful. As you ask her today about how she is doing, she smilingly reports that she is finally enjoying the single scene again, and that she already had several dates. Which approach to HIV prevention and condom use is recommeded? A. "You should not pass the HIV infection to someone else, and should insist on your partner wearing condoms. If your ex-husband had used condoms, you would not have HIV infection." B. "I'm glad that you have developed new relationships. Have any of these relationships led to intimacy or sexual contact? Have you been using condoms?" C. "I'm glad that you have developed new relationships. You do not want to pass HIV infection on to your new friends. Be sure to use condoms whenever you have sexual contact." D. "I'm so unhappy that your husband passed HIV infection on to you. However, you can't pass your distress about this on to others. Please make sure that your partners use condoms whenever you have sexual contact." E. "As a health care provider, I must urge you to use condoms whenever you have sexual contact. We are happy to provide you with information on where you can get low-cost or no-cost condoms."

B. "I'm glad that you have developed new relationships. Have any of these relationships led to intimacy or sexual contact? Have you been using condoms?"

Jennifer Store is 62 and her multiple myeloma is just showing signs of relapse. You begin to discuss salvage chemotherapy but she says, "That last round of chemotherapy was my limit." You respond with empathy, "Sounds like you are saying you do not want to do any more chemotherapy." Ms. Store then says, "You heard correctly. I can't imagine any circumstance where I would do any more chemotherapy." Which response would be recommended to keep open your dialog so that you could reach a fully considered agreement about next steps? A. "I'll support you in whatever decision you make." B. "Since your prior chemotherapy, new treatments have been developed that show great promise." C. "Why not try one of the newer agents - we can always stop if it does not work, or if side effects are intolerable." D. "Your husband and your daughters do not want to lose you when treatment might be very beneficial." E. "Tell me more about why you feel this way."

E. "Tell me more about why you feel this way."

Christine Townsend is 53 and starting menopause, and she reports, "I can't get a good night's rest with the night sweats. I have read so many conflicting things about hormones. What does the medical literature say about the risks?" In order to reach agreement on management of Christine's menopausal symptoms, which option would be recommended? A. "Most experts agree that short-term hormone treatment has acceptable risks in treating your symptoms." B. "Tell me how you are handling this important life transition?" C. "Tell me what you already know about hormone replacement therapy?" D. "Tell me what factors are important to you in making a decision about hormone replacement therapy?" E. "There are small increased risks of heart attacks, breast cancer and blood clots."

E. "There are small increased risks of heart attacks, breast cancer and blood clots."

Which of the following statements about disease and illness is most accurate? A. Disease is a patient's experience of illness. B. Disease is a subjective expression of illness. C. Illness is a patient's experience of disease. D. Illness is an objective expression of disease.

C. Illness is a patient's experience of disease.

James Brown is 73, an African American retired police officer in for follow-up of a prostate nodule. He is recently remarried--his first wife of 43 years died from breast cancer 3 years ago. Now, his PSA test is elevated, and you suggest a biopsy. In talking with him about treatment options he says that he is "unalterably" opposed to a prostate biopsy or treatment. What statement or question is most highly recommended for furthering Mr. Brown's care? A. "I hear what you are saying; I'm wondering if you have concerns about how a biopsy or treatment might affect your sexual functioning or sexual health?" B. "I hear what you are saying; I'm worried about the seriousness of your situation, because untreated prostate cancer can spread to your spine, lung, brain or bowel; become terribly painful, or cause your kidneys to shut down, among other problems." C. "I hear what you are saying; what do you already know about prostate cancer and what it can do to you, what treatment might achieve, and what the side-effects of treatment might be?" D. "I hear what you are saying; would it be helpful to have your wife join us for further discussion, because there is a lot we have not yet discussed?" E. "I hear what you are saying; I'd like to arrange for you to speak with a colleague whom I trust, and who has much more experience with the details than I do."

A. "I hear what you are saying; I'm wondering if you have concerns about how a biopsy or treatment might affect your sexual functioning or sexual health?"

Carlos Rodriguez is 60, Hispanic, owns a neighborhood grocery store, and is in the hospital with a heart attack. His condition has improved and he wants to be released immediately, even contemplating signing out against medical advice. Mr. Rodriguez is in bed, with IV's running. He tells you he is concerned that his store is his wife's responsibility while he is in the hospital, and she is undergoing outpatient treatment for breast cancer. Which of the following responses would best convey Partnership? A. State "Many people in your situation would feel hesitant to stay longer in the hospital. Let's work together to make sure that you are stable enough to return home." B. State "Taking care of yourself is the most important thing for now." C. Lean towards the patient and state "You have a lot on your plate - your wife's cancer, the shop and now your illness. It must be tough." D. State "Do you have any relatives or friends who could step in?" E. Briefly touch the patient's arm in a friendly gesture and state "Are you concerned about the financial impact of your hospitalization?

A. State "Many people in your situation would feel hesitant to stay longer in the hospital. Let's work together to make sure that you are stable enough to return home."

Karen Baker is 46 and comes in with a cough that has been remarkably worse over the last 3 months. She smokes a pack a day, and on exam has mild wheezing and a normal chest x-ray. You tell Karen that asthma is the most likely diagnosis and advise her to try an inhaler. She exclaims, "How could I have asthma at my age? I have never had it before!" Which is the recommended response to move toward agreement on the diagnosis and treatment? A. "Asthma can start at any age." B. "Tell me a bit more about what you know about asthma." C. "Let's just focus on getting you some relief. Try the inhaler because I'm sure it'll provide some relief." D. "Many people have asthma for a long time without realizing it- perhaps this is the situation you are facing." E. "Asthma affects so many people! Pollution and allergies are sometimes culprits, and smoking often contributes as well."

B. "Tell me a bit more about what you know about asthma."

Peter Powers is 51 and has abnormal liver function tests, probably from drinking alcohol. Peter does not think drinking is problematic for him and argues that he does not drink as much as his father did, and that he holds down a job and supports his family. What would be the recommended option for moving toward agreement so that Peter might avoid further problems? A. "It is hard to acknowledge that one has a drinking problem, but it is always good to catch any problem early, before it gets worse." B. "Everyone processes alcohol differently. Just because you don't drink as much as your father does not mean that you don't have an alcohol problem." C. "I am concerned because your blood tests show that whatever amount of alcohol you are drinking, it is having an effect on your liver." D. "Stopping alcohol is a big commitment to good health, and not easy, but others have done it too." E. "There is really no other explanation for your abnormal blood test results."

C. "I am concerned because your blood tests show that whatever amount of alcohol you are drinking, it is having an effect on your liver."

A general rule for asking questions during the history of present illness is? A. Asking 2-3 questions at a time B. Wording the question in a way that limits the patient's response C. Using medical jargon D. Using the patient's own terms once you understand what they mean E. Forming the question to elicit a confirming response to your differential diagnosis

D. Using the patient's own terms once you understand what they mean

5-What screening tool can be used to assist a PA in screening for depression? A: PHQ-9 B: GAD-7 C: Mood disorder questionnaire D: PC-PTSD E: CAGE screening tool

A: PHQ-9

When collecting a PAP smear, cells are removed from which of the following? A. Vaginal cuff B. Cervix C. Uterus D. Labia

B. Cervix

A patient is complaining of "peeing a lot". You next ask the patient, can you tell me how many times on average you are urinating each day? This question is representative of which of the seven factors for HPI? A. Bodily location B. Chronology C. Quality D. Quantity E. Alleviating factor

D. Quantity

This factor of the HPI helps you understand where in the body a patient is experiencing a symptom. A. Setting B. Quality C. Associated symptoms D. Chronology E. Bodily location

E. Bodily location

Which one of the following is not one of the 7 cardinal features of a symptom? (A)Attribution (B)Quality (C)Setting (D)Location

(A)Attribution

Integrated patient-centered and doctor-centered interviewing (A)Is less scientific than isolated doctor-centered interviewing (B)Is unnecessary now that we have advanced diagnostic tests (C)Provides more accurate medical diagnoses than isolated doctor-centered interviewing (D)Will make most patients uncomfortable

(C)Provides more accurate medical diagnoses than isolated doctor-centered interviewing

An empathic response to a patient distraught about a new diagnosis of breast cancer might be (A)It's all part of God's plan. (B)I'm sure everything will turn out OK. (C)My grandmother had breast cancer. (D)I can understand; this news is devastating for you.

(D)I can understand; this news is devastating for you.

After you determine that Ms. Rodriguez' use of "wreck" was not heavily emotionally laden, you go over the treatment and follow up thoroughly and smoothly, responding to occasional clarifying questions from her. As you are finishing, which of the following is recommended? A. Many people have additional questions in this situation, how about you? B. Do you have any additional questions or concerns? C. You seem pretty comfortable. Anything else I can do for you? D. You don't have any additional concerns, do you? E. Are you worried about what your mother will say when she finds out about this?

B. Do you have any additional questions or concerns?

Andrew Wyeth, 45 and married, was hospitalized for a ruptured appendix. He does not have health insurance and postponed medical care until he was critically ill. Luckily surgery and other treatments were successful and he recovered. It is a day before his discharge. Which task is most important for a smooth closure tomorrow? A. Encourage Mr. Wyeth to ask any questions he may have. B. Tell Mr. Wyeth that it was a pleasure working with him. C. Jokingly remind Mr. Wyeth to seek medical attention more swiftly next time. D. Reveal to Mr. Wyeth that you live in the same neighborhood and may run into him some time. E. Tell Mr. Wyeth that his lively demeanor helped cheer up the whole unit.

A. Encourage Mr. Wyeth to ask any questions he may have.

Your patient, Dr. Singh, a 28 year old internal medicine resident, comes in 3 weeks after a trip home to India. She opens by complaining of rigors and fever to 103 degrees F, and then says, "This is exactly how I felt the last time I had malaria!" What is the recommended next statement? A. I understand you're having chills and fever. Have you noticed anything else? B. Were you taking malaria prophylaxis? C. Have you noticed a sore throat, cough, skin abscesses or problems when you urinate? D. How long ago did you have malaria? E. Has anyone else in your family been ill?

A. I understand you're having chills and fever. Have you noticed anything else?

You find a suspicious breast lump during your annual physical examination for a 42-year-old pediatrician. You tell her she will be scheduled to see a breast specialist as soon as possible. While she nods and seems to agree with your plan, she appears distracted. At this point you say, "You seem a bit distracted right now... " Which of the following continuations is recommended to move you forward in partnership? A. "...I wonder what you are thinking about all this?" B. "...Are you ready to move ahead with further evaluation and treatment?" C. "...What do you already know about what such masses might represent?" D. "...While awaiting diagnosis, what kind of support do you have from family or friends?" E. "...I'd like to recheck your pulse and BP before we move on."

A. "...I wonder what you are thinking about all this?"

If a patient reports sudden onset of painless vision loss, which of the following might you suspect is going on? A. Retinal artery occlusion B. Conjunctival infection C. Foreign body D. Glaucoma E. Uveitis

A. Retinal artery occlusion

Mr. J has come to your office for a new patient visit. The process of patient-centered interviewing suggests that early in the interview, after introducing yourself and ensuring that he is comfortable, you should say: A. "I see that you told the nurse you are here for a cough. When did that start?" B. "Tell me about your past medical history." C. "Tell me what is on your mind today. ... What else?" D. "What do I need to know about your family history?" E. "What medicines are you taking?"

C. "Tell me what is on your mind today. ... What else?"

In family practice clinic you are seeing a markedly overweight 62-year-old woman who works as an admitting clerk in another medical clinic. The patient has not been to a doctor in many years. She reports burning pain in her feet for six months. You want to check her blood sugar to rule out diabetes. What is the recommended information-sharing statement/ question before sending her to the lab? A. "How have you explained the burning pain in your feet?" B. "The diseases possibly causing your pain include diabetes, hypothyroidism, and other disorders." " C. "Because your weight increases your risk of diabetes, I think we should test for diabetes." D. "You probably learn a lot by working at a clinic. What do you know about pain in the feet?" E. "You really should not have waited so long to check into these symptoms, as it may be serious.

A. "How have you explained the burning pain in your feet?"

You are about to discharge Carolyn Korn, an 82 year old widow hospitalized for severe pneumonia, which required that she be intubated. Happily, she improved and her daughter will soon pick her up. You have a few minutes before rounds to say good bye to her. What is the recommended approach for reaching a successful closure? A. "I'm glad you are doing so well and are ready to go home. We have a few minutes to say good bye. A follow-up appointment has been made with your primary care physician and he should receive a copy of the discharge report before he meets with you. Are these plans ok with you? It's been a pleasure working with you. Good luck!" B. "Are you ready to go home? You've had a rocky time here, but I'm glad it has all worked out and you can go home now. I bet you already have some plans on what to cook for the holidays! All the best!" C. "I know your daughter will be here shortly and I have to run, but I wish you all the best. Don't forget to keep your follow-up appointment with your primary care physician. It's important!" D. "I'm glad you are doing so well and are ready to go home. Take good care of yourself. It has been a pleasure to work with you. Since I live in your neighborhood I may see you at the supermarket." E. "Well, it's time for you to go home. Are you looking forward to it? It must be a bit scary too, after having been here for so long. How will you get yourself to your primary care physician for the follow-up visit? We'll be sending him the discharge summary. I'm sure your daughter will be glad you are going home."

A. "I'm glad you are doing so well and are ready to go home. We have a few minutes to say good bye. A follow-up appointment has been made with your primary care physician and he should receive a copy of the discharge report before he meets with you. Are these plans ok with you? It's been a pleasure working with you. Good luck!"

Mrs. P. is a 25 year old, 5 months post-partum with her first child, who is in neurology clinic because of a severe headache, and says that she's had painful peri-menstrual right and left sided headaches since age 15. Last night an unusually severe headache associated with nausea, vomiting and some difficulty pronouncing words occurred; subsiding after several hours and multiple doses of Ibuprofen. She says she was very frightened, as she was home alone with the baby. Mrs. P has not experienced palpitations or other neurological symptoms, takes no other medications and does not drink alcohol, smoke tobacco, or use other drugs. On exam her BP is 120/80 and P is regular at 72. Her fundi are normal, and she has no carotid bruits, cardiac murmurs, or neurological deficits. Mrs. P says, "There's been a lot going on lately. It's been tough at home. Maybe this was just a bad migraine. I've had headaches for a long time." Which of the following do you prefer? A. "Migraine is definitely possible You mentioned there's been a lot going on at home lately. Can you tell me more about that?" B. "Migraine is definitely possible. In the past, have you ever had problems speaking during your headaches?" C. "Was this the worst headache you've ever had in your life?" D. "Migraine is definitely possible, and I think we need to be certain nothing new is happening and I'm sending you for an MRI scan of your head." E. "Migraine is definitely possible. Did you take any medications other than the Ibuprofen?"

A. "Migraine is definitely possible You mentioned there's been a lot going on at home lately. Can you tell me more about that?"

Juanita Perez, 21, is a single college student of Hispanic descent. Juanita came in with gastrointestinal symptoms, you suspected pregnancy, and confirmed the diagnosis by lab test. You noticed arm bruises consistent with physical abuse. When you told Juanita she was pregnant, she started to cry. Which of the following responses would best convey Support? A. State: "I can see that being pregnant is very upsetting to you. How can I help you?" B. State: "I can see that being pregnant is very upsetting to you. Did someone force you to have sex?" C. State: "I can see that being pregnant is very upsetting to you. Is your partner abusive to you?' D. State: "I can see that being pregnant is very upsetting to you. Many options are available to deal with this situation." E. State: "I can see that being pregnant is very upsetting to you. I've had other patients in the same situation, and somehow things always work out."

A. State: "I can see that being pregnant is very upsetting to you. How can I help you?"

Frank Caldoni is a 58 year old, married tax attorney of Italian extraction. A week ago he was hospitalized following a heart attack. Once he stabilized he confided in you that the heart attack occurred while he was visiting a prostitute and not a client, and that his wife of 30 years had no idea about his repeated extramarital sexual experiences. You then had a few days off, and are seeing him for the first time again today, when he is about to be discharged. You are a bit taken by surprise when Mr. Caldoni pulls you over in the hallway, and asks you in a whispering tone "do you think my system is still going to work?" You suspect that he is referring to his sexual functioning. What is the recommended way to respond? A. Touch Mr. Caldoni on the arm and say, "Let's step into your room, where we can have some privacy and I'll try to respond to your concerns." B. Touch Mr. Caldoni on the arm and say, "This is a common situation, and after rehabilitation, people rarely have any problems having sex again." C. Touch Mr. Caldoni on the arm and say, "Look, just stick to your wife, because heart attacks occur more frequently during extra-marital affairs." D. Touch Mr. Caldoni on the arm and say, "This is a common situation, and the right thing to do next is to speak with your own primary care physician, who knows you well, as you begin your rehabilitation." E. Put your arm around Mr. Caldoni's shoulders and say, "Let's step into your room, so I can give you a bit more detail about the dangers of heart attacks during extramarital affairs." (When in the room, add, "I think it would help to consider marriage counseling.")

A. Touch Mr. Caldoni on the arm and say, "Let's step into your room, where we can have some privacy and I'll try to respond to your concerns."

Kerry Rand is 52, and on maximum oral medications for her type 2 diabetes. You think it is time to start insulin because her labs earlier this week indicate poor control, and her glucose today is again high. As you enter the room she says, "What are we going to do about this sugar, doc?" Which of the responses below will best help you move toward reaching agreement with Kerry on managing her diabetes? A. "I am concerned because a blood sugar at this level can affect your heart, your kidneys and your eyes." B. "I have some ideas, but I am curious about what you think we should do." C. "I was thinking that we should start you on a single insulin shot at night, how would that be for you?" D. "Tell me what role you would like to play in making a decision about your treatment." E. "Tell me what you know about insulin therapy."

B. "I have some ideas, but I am curious about what you think we should do."

You have just concluded a lengthy visit with 62 year old divorced man, Allan Rhoden, and said goodbye. However, rather than getting up to leave, Mr. Rhoden says, "There is one more thing I wanted to tell you. I've been feeling really depressed lately. I'm having trouble functioning at work and I'm worried I might get fired." What is the recommended response to this new issue at the end of the visit? A. "I'm sorry to hear that. Let's set up an appointment as soon as possible so we can talk more." B. "I'm sorry to hear that. Tell me more about your depressed feelings." C. "I'm sorry to hear that. Let me find out how many patients I have waiting, and let's spend a few minutes talking about this." D. "Perhaps I can arrange an appointment with a psychiatrist to see you." E. "Perhaps a prescription for an antidepressant would be helpful."

B. "I'm sorry to hear that. Tell me more about your depressed feelings."

Christine Porter is 28, a married hair stylist of Anglo American decent who is in today complaining of vaginal discharge. She has been married for 5 years, says she is monogamous and thinks her husband is as well. They have sex frequently because for the last year she has been trying to get pregnant. After the physical and review of a vaginal smear, gonococcal infection is apparent, and immediate treatment of both partners is indicated. What is the recommended statement or question to begin to establish a treatment plan? A. "It is clear that you have gonorrhea. This is an easily treated sexually transmitted infection. You or your husband has been unfaithful, otherwise you would not have gonorrhea." B. "It is clear that you have gonorrhea. This is an easily treated sexually transmitted infection. Your husband needs to go to his doctor to be checked out as well. If you have had sexual contact with anyone else that person (or persons) needs to get evaluated too." C. "It is clear that you have gonorrhea but I'm not sure what else is going on here. I can treat this easily, but your husband will need to go to his doctor (or come in here) so that he can give a specimen for cultures too. Then we can talk some more." D. "It is clear that you have gonorrhea. We will treat it and I advise you to use condoms in the future to prevent sexually transmitted infection." E. "It is clear that you have gonorrhea. We will treat it with antibiotics which should clear it up. I can give you more information, and there are some good Websites about sexually transmitted infections. I'll give you the URLs."

B. "It is clear that you have gonorrhea. This is an easily treated sexually transmitted infection. Your husband needs to go to his doctor to be checked out as well. If you have had sexual contact with anyone else that person (or persons) needs to get evaluated too."

Ms. Dole, 25, an executive assistant, is in Urgent Care with left ankle pain and swelling following a fall 10 days ago. She says she simply lost her footing going downstairs from her apartment, and has not felt dizzy or blacked out. The clinic notes show that she had a right wrist injury following another fall at home a few months ago. Otherwise, she is healthy; takes only an oral contraceptive And her x-rays show no fracture. The waiting room is packed with patients waiting. Which option is recommended as your next action? A. I'm going to give you an air cast, crutches, and Ibuprofen. Elevate your leg as much as possible, and come back for more evaluation if you do not improve in this coming week. B. I'm concerned that you've had two recent falls and I'm wondering if you have any ideas about why this is happening. C. How much alcohol do you drink? D. I'd like to do a more complete physical exam. E. Do you have other symptoms, problems or concerns we have not yet discussed?

B. I'm concerned that you've had two recent falls and I'm wondering if you have any ideas about why this is happening.

Dr. Singh (from prior Question) says she had shaking chills and fever without any other focal symptoms. She had malaria a year ago that was successfully treated and has been asymptomatic since that time. Her trip to India was for a month and she took appropriate chemoprophylaxis before, during and after the trip. She says she is quite concerned about P. falciparum infection, because she knows P. falciparum may carry drug resistance. What is the recommended action now? A. Say, "I'd like to send you to the lab for a malaria smear, as well as blood cultures and other appropriate blood and urine tests." B. Say, "I can understand your concern about P. falciparum infection, given your past history and recent travel." C. Say, "Even though P. falciparum may be resistant, its prevalence is low and you were so conscientious in taking the prophylaxis that it is unlikely you have malaria." D. Say, "Let's complete an appropriate physical, checking carefully for splenomegaly, then decide on next steps." E. Say, "I'm eager to work with you until we get to the bottom of this."

B. Say, "I can understand your concern about P. falciparum infection, given your past history and recent travel."

Elizabeth Cronin is a 30 year old single woman seeing you for a follow-up visit. Because of unpleasant side effects, she stopped the antidepressant she started one month ago, and now says she is interested in psychotherapy rather than medication. You suggest continuing medication as well as starting psychotherapy, but she does not seem willing to use any further medication. Which of the following responses contains the greatest number of behavioral skills recommended for closing a medical encounter? A. So, Ms. Cronin, before we end today, let's review our plan together. I would still like to see you on another anti-depressant medication and there are many more options we could try. However, if you absolutely don't want to take medication and would like a referral for a psychotherapist instead, our office staff will give you a list of names. Our next appointment will be in a month. B. So, Ms. Cronin, before we end today I would like to review our plan together. First, we are discontinuing the antidepressant medication since you are not comfortable taking it. Second, our office will provide you with a list of psychotherapists. Third, we will be meeting again in one month. Is that your understanding as well? Good, feel free to call if you have any further questions. I look forward to seeing you in a month. C. So, Ms. Cronin, before we end today I would like to review our plan together. Do you have any other concerns? Is there anything else you would like to tell me? If not then we'll meet again in a month to see how you feel. See you then. D. So, Ms. Cronin, we will discontinue the medication, get you a referral for psychotherapy, and see you back in a month. Do you have any other concerns or questions before we stop? See you in a month. E. So, Ms Cronin, how are you feeling now? Do you have any other concerns? Are you comfortable with our plan? Our office will provide you with a list of psychotherapists before you leave. What else can I help you with today? If that's all I'll see you in a month.

B. So, Ms. Cronin, before we end today I would like to review our plan together. First, we are discontinuing the antidepressant medication since you are not comfortable taking it. Second, our office will provide you with a list of psychotherapists. Third, we will be meeting again in one month. Is that your understanding as well? Good, feel free to call if you have any further questions. I look forward to seeing you in a month.

Francesca Chen is 35, a Chinese American hairdresser with diabetes. Her glucose and HgbA1C indicate poor control. As you speak, she hesitatingly reveals that since the last visit two months ago, she broke up with her boyfriend of 10 years, started a new job and registered for classes at the local community college. Which of the following statements would show that you understand and empathize with her likely emotional state? A. State "A lot has been happening since I last saw you, and you still seem to be managing well." B. State "As you speak, I get the sense that the many changes in your life are very stressful." C. State "With so many life changes happening all at once it would be difficult for anyone to stay on top of their diabetes." D. State "Let's work on adjusting your diabetes treatment plan." E. State "Why do you think your diabetes is not better controlled?"

B. State "As you speak, I get the sense that the many changes in your life are very stressful."

Renata Bowen, an 80 year old widow and retired antiques dealer was brought to the hospital for a hip fracture. Her rehabilitation is going more slowly than usual, and she will clearly need long-term care for an uncertain period. Ms. Bowen has maintained her independence throughout life, and the idea of going to a nursing home (even temporarily) seems unacceptable. Her mood has been depressed, and her social worker reported that Ms. Bowen cried when he brought up the issue. After greeting her, what statement would best demonstrate Respect , as you begin today's conversation? A. State: "Ms. Bowen, I realize this is a difficult subject, but soon you will no longer require hospitalization and I want to help you make plans for your future." B. State: "I am so impressed with your ability to lead a remarkably independent life until now." C. State: "The idea of longer term care, even temporarily, must be very frightening." D. State: "I've had other patients in this situation, and they are always reluctant to sign up for longer term care." E. State: "This is complicated; given that you can't get around that easily yet. Lets' work together to find the best possible living arrangements."

B. State: "I am so impressed with your ability to lead a remarkably independent life until now."

James King, 70, is a patient of your colleague on vacation and a retired African American postal worker. His daughter brings him in today because of difficulty breathing and a fever. You recommend hospitalization, but Mr. King wants to wait until his regular physician returns in a few days. Which of the following responses would best convey Attentiveness and Warmth? A. State: "There is no need to be afraid about going into the hospital. I'll be here to assist in any way I can." B. State: "I can see that you are anxious about going into hospital without having your regular physician at your side. Please tell me more about your concerns." C. State: "Your daughter understands the urgency of getting hospital treatment now." D. State: "Mr. King, I'm worried that you are quite sick and we need to start antibiotics, fluids and other treatments before you get any sicker." E. State: "I'm sure your doctor would insist that you get hospital treatment right away."

B. State: "I can see that you are anxious about going into hospital without having your regular physician at your side. Please tell me more about your concerns."

You have just moved across country and have started a new staff position when a 14-year-old girl, Jane, is brought to the urgent care clinic by her mother, Ms Jones, for evaluation of dysuria and hematuria. From the mother you learn that the patient's most recent period was two months ago. Without telling the patient or her mother you order a pregnancy test which turns out to be positive. What is the recommended next statement regarding the positive pregnancy test results? A. "Ms Jones, would you please step out to the waiting room while I discuss test results with Jane." B. Step outside and say to the nurse, "please contact the health department and let me know the state law regarding notification of parents when young teens are pregnant." C. You avoid reporting the results by saying, "It may take a few days to obtain some of the results, in the meantime, let's review what we have." D. "Jane and Ms Jones, I obtained a pregnancy test and it is positive." E. Escort Ms Jones outside the room and say, "I obtained a pregnancy test and it is positive."

B. Step outside and say to the nurse, "please contact the health department and let me know the state law regarding notification of parents when young teens are pregnant."

Gwendolyn Arthur, 29 and married, just gave birth to her first child, a healthy boy. The full-term delivery was without complications. Both parents seem quite anxious, perhaps related to the fact that they are first-time parents. This morning you spent quite a bit of time with them, answering questions and providing written information about their specific concerns (e.g., breast feeding, sleep habits, colic). What is the recommended way for you to say goodbye, now that it is time for them to take their new baby home? A) "It is time to say goodbye. Have fun with your new baby. I'm sure he'll bring you lots of joy!" B) "It's time to say goodbye. If you don't have any more questions, I wish you all the best" C) "It's time to say goodbye. Please be sure to keep your appointment with the Pediatrician. Do you know exactly where you have to go? If you have any further questions in the meantime, don't hesitate to call our number here. Keep in mind that there are lots of new parents out there and I'm sure you'll adjust to your new role before long. All the best!" D) It's time to say goodbye. Don't worry--a few weeks into your new parenting role you'll be old pros at it. All the best!" E) It's time to say goodbye. Do you have any further questions? I can help provide you with more information.

C) "It's time to say goodbye. Please be sure to keep your appointment with the Pediatrician. Do you know exactly where you have to go? If you have any further questions in the meantime, don't hesitate to call our number here. Keep in mind that there are lots of new parents out there and I'm sure you'll adjust to your new role before long. All the best!"

Chris Tucker is a 20 year old, single man who sustained severe injuries including the loss of a leg after a motorcycle accident. You have worked with the patient for the final two weeks of a 6 week hospitalization, and are glad he is well enough to move on to rehabilitation, which likely will last many weeks.. He worries that rehab will be depressing because everyone else will be so old there. Which option best matches the approach recommended for a successful closure? A. "It is time for us to say goodbye. Don't worry about the rehab; I'm sure you'll do fine there. It's a good place and you'll get lots of physical and occupational therapy there. Take care!" B. "They should be picking you up soon. After a few weeks in rehab you should be ready to go home. Do you have any more questions?" C. "It's time for us to say goodbye. I know you are nervous about going to rehab, since most other people there are older. However, you got along well with everyone here at the hospital. I'm sure you'll manage well there too. It was a pleasure working with you." D. "It's time for us to say goodbye. It's been a pleasure working with you. Good luck!" E. "They will be here soon to pick you up. I hope it will be a smooth ride, sometimes those ambulance drivers can be rough. I hope you will be recovering quickly!"

C. "It's time for us to say goodbye. I know you are nervous about going to rehab, since most other people there are older. However, you got along well with everyone here at the hospital. I'm sure you'll manage well there too. It was a pleasure working with you."

Nicole Bovary is 30, of French descent. You are a male physician whose spouse recently filed for divorce, complaining that you are married to your work. Ms. Bovary is a very attractive new patient in for a routine check up; however, you have met her before because she is a legal assistant in the same office as your divorce lawyer. Early in the visit, she expresses regret about your upcoming divorce and reveals that she is also in the midst of a divorce. You were surprised to see her, and you definitely feel some attraction to her. As you converse about next steps after her unremarkable history and physical, she asks if you would like to go for coffee after work. What is the recommended strategy for responding to Ms. Bovary's suggestion? A. "What a lovely idea. I'd be pleased to have coffee, and we can continue our discussion outside the office setting." B. "What a lovely idea. I'd be pleased to have coffee, and we can continue our discussion. I'll help you find another physician to care for your medical needs." C. "What a lovely idea. I'm afraid I must decline right now; and I'll initiate conversation with a senior colleague with more experience in this kind of situation." D. "What a lovely idea. I'm afraid I must decline right now--let's set up another check for next year, and of course contact us for any medical issues in the meantime." E. "What a lovely idea. I'm afraid I must decline right now. This seems a little inappropriate and I wonder if you would be willing to speak with your employers, or even a counselor, about limits in professional relationships?"

C. "What a lovely idea. I'm afraid I must decline right now; and I'll initiate conversation with a senior colleague with more experience in this kind of situation."

A 58-year-old fast food worker comes to the emergency room by ambulance after the sudden onset of crushing anterior chest pain. His vital signs are stable but the initial ECG is consistent with an acute myocardial infarction. As soon as you tell the patient and his wife about the ECG results he begins to get up and says, "I have to go home now!" What is the recommended next statement from you? A. "What do you know about heart attacks?" B. Turn to his wife and say, "This heart attack is very serious, and I hope you will persuade him to stay with us." C. "What is the reason you wish to return home at this time?" D. "I cannot let you leave right now; your condition is very serious." E. Show him a text, and say, "Look right here, the arteries in your heart are blocked, and if we do not treat the blockage, you might die."

C. "What is the reason you wish to return home at this time?"

Your patient, a 54 year old woman, returns to your office for a blood pressure follow-up. In response to your opening question, "What concerns do you have today?" the patient mentions back pain and begins to give details about the most recent painful episode. You can best facilitate addressing all of the important concerns for the visit today by which of the following: A. Ask, "Can you tell me more about your back pain?" and facilitate the patient's description, including frequency, precipitating events, quality of pain, neurological symptoms, and alarm features. B. Say, "Let's focus on your pain and blood pressure today." C. Allow the patient to complete her statement about the recent painful episode, then ask "In addition to your back pain, is there anything else?" D. Summarize the patient's description of her back symptoms to check for accuracy and begin the physical examination. E. Say, "Let's talk about your blood pressure and then you can tell me about your back pain."

C. Allow the patient to complete her statement about the recent painful episode, then ask "In addition to your back pain, is there anything else?"

Typically, clinicians begin interviews by inquiring about what concerns brought the patient into the office. On average, clinicians interrupt the patient's opening statement after 18-23 seconds, and seldom return to asking the patient for a complete list of concerns. The most likely result of this pattern of limiting the list of concerns in opening the discussion is to: A. Enhance the efficiency of the time spent in the visit B. Assure that the patient's most important concern is voiced since it was mentioned first C. Increase the frequency of late-arising concerns. D. Obtain the most important information early in the visit E. Enhance diagnostic accuracy

C. Increase the frequency of late-arising concerns.

"You mentioned that your wife is having health problems. Let's get back to how that is affecting you." Which of the following communication skills used in opening the discussion best describes the physician's statement? A. Survey symptoms B. List concerns C. Redirect patient D. Summarize E. Open-ended inquiry

C. Redirect patient

You are seeing 8 year old Darren, whom you know well, for asthma. Darren has been to the Emergency Room several times for asthma in the last few months. On exam you note wheezes, and wonder whether he is not regularly getting his medication because his family cannot afford the medication. Beginning with, "I know that you want Darren to be healthy....," which is the recommended beginning to address this issue? A. "...I have some free samples of Darren's medication that I can give you. B. "...I have asked a social worker to meet with you to help you apply for financial assistance." C. "...If you think about it, Darren's ER visits have cost you more than the medication would have." D. "...Medications for asthma are very expensive. Is paying for them an issue for you?" E. "...Tell me if you are having any problems with Darren's medications."

D. "...Medications for asthma are very expensive. Is paying for them an issue for you?"

When you ask Mr. O'Brien, a 37 year old married auto mechanic whose wife and 6 children you also care for, about his use of alcohol, he says that he drinks 2 six-packs on weekends, and goes on to say, "Alcohol is not a problem for me. I can hold my liquor." You know that this level of alcohol consumption is above national guidelines for safe use of alcohol. You see that he is not inclined to talk more about alcohol (patients who say, "not a problem" usually mean, "subject closed"), and you know that any comment from you may elicit a defensive response. Nonetheless you wish to continue. You begin your next comment with a simple reflection: "You do not see your drinking as a problem..." Which of the following responses is the least judgmental way to complete your turn in the conversation? A. "...Even though you are not getting drunk, alcohol can have harmful effects on your health." B. "...Let me ask you some questions. Have you ever tried to cut down on your drinking?" C. "...I'm concerned that your use of alcohol could be harmful to you. May I give you some information on how to use alcohol safely?" D. "...What would an alcohol problem look like to you?" E. "...What does your family think about your drinking?"

D. "...What would an alcohol problem look like to you?"

Kevin Brown is 48 and has multiple risk factors for atherosclerotic heart disease; his recent low-density cholesterol (LDL or "bad") cholesterol is elevated. In discussion, you inform him that national guidelines recommend that anyone with his profile start a cholesterol lowering medication. The patient responds that he would like to try diet and exercise first. Which option for completing your statement that you begin with "Diet and exercise are an important part of lowering cholesterol...," would most likely help you and Kevin reach agreement? "Diet and exercise are an important part of lowering cholesterol...," A. "...but they probably won't be sufficient to get your cholesterol to target." B. "...however, I would recommend a lipid-lowering drug in addition. But the choice is up to you." C. "...so let's plan for you to start on a low cholesterol diet and regular exercise with a cholesterol lowering medication." D. "...but I'd like to hear your reservations about being on cholesterol lowering medications." E. "...but, in your opinion, what do you see as the goals of your treatment?"

D. "...but I'd like to hear your reservations about being on cholesterol lowering medications."

Sandra Margolis is 50; a clothing store manager of Jewish extraction who had a double mastectomy and opted not to have breast reconstruction because her insurance would not have covered it. As her primary care physician, you are checking in on how she is adapting, a few weeks after she completed her treatments with the oncologist. She offers that she generally feels well, has gone back to work and is getting ready for a long planned vacation to Florida. You know that concerns about body image and sexual functioning are universal after this surgery. What is the recommended statement / question that would gently invite her to explore these issues? A. "After a mastectomy many women have difficulties adjusting to their body changes. Do you plan to put on a bathing suit when you are on vacation? Do you still have intercourse with your husband?" B. "After a mastectomy many women have difficulties adjusting to their body changes. Are you planning to go on the beach in Florida? How has your husband adjusted to your surgery?" C. "After a mastectomy many women have difficulties adjusting to their body changes. How is your sex life? Has your husband already adjusted to the fact that you don't have breasts anymore? It can be very difficult for some men to get used to it." D. "After a mastectomy many women have difficulties adjusting to their body changes. How do you feel about the loss of your breasts now? How does your husband feel about it?" E. "After a mastectomy many women have difficulties adjusting to their body changes. Do you feel strong enough to resume your sex life with your husband? How is he adjusting to the situation? There are Websites with information that can help women in your situation."

D. "After a mastectomy many women have difficulties adjusting to their body changes. How do you feel about the loss of your breasts now? How does your husband feel about it?"

You last saw Ken Baker, a 52 year old divorced man, two years ago for an employment physical-- your office nurse records his chief complaint today as "sleep problems." Which approach early in the interview might best facilitate closure? A. "Good morning, how are you today? What concerns you most about your sleep problems? What have you tried? What would be most helpful to you now? B. "Good morning, I've read your chart and it seems that you are concerned about your sleep. What have you tried so far, and what are you hoping I can do to help? " C. "Good morning. How can I help with your sleep problem? Let's get you started on some medication. I will see you back here in two weeks. Any other questions? D. "Good morning, please tell me what concerns you today. Then let's explore these issues and conclude with a plan. How does that sound? E. "Good morning, I am sorry you are feeling badly. I'd like to see what we can do to help you feel better. What do you think is happening? "

D. "Good morning, please tell me what concerns you today. Then let's explore these issues and conclude with a plan. How does that sound?

Ken Quantas, a 35 year old single teacher of Cuban extraction, came in today because of a persistent cough and weight loss. After completing your history and exam, your differential diagnosis includes HIV-related illness. Which statement is recommended for exploring the HIV hypothesis? A. "I know that you are feeling poorly. I'll prescribe some effective antibiotics and check you again next week. If you don't feel better then we'll also need to talk about the possibility of HIV and I'll need to know more about your sexual activity." B. "I know this is embarrassing, but I need to know if you have risk factors for HIV." C. "I am concerned that you might have HIV infection. Have you considered that this could be the reason for your persistent cough and unexpected weight loss?" D. "I ask all of my patients about their sexual history. In your case, with persistent cough and unexpected weight loss, HIV infection is one possibility and that means we should discuss your sexual activity at this time." E. "I am concerned that you could have HIV. Let's talk about the consent form for HIV testing."

D. "I ask all of my patients about their sexual history. In your case, with persistent cough and unexpected weight loss, HIV infection is one possibility and that means we should discuss your sexual activity at this time."

Ms. S., a 23 year old, returns to your office for an oral contraceptive follow-up visit. She has been having increasingly frequent headaches with nausea and vomiting, and tells you she thinks she has a brain tumor. She also has low back pain. She wants an MRI of her brain and her back, pain medications, a note for her supervisor, a referral to a neurologist at another hospital, and a refill of her oral contraceptives. She indicates her agreement with your summary of her complete list of concerns for this 20 minute office visit. What is your best statement to Ms. S. to help you reach agreement on the agenda for the remainder of the visit? A. "Before we do anything else, let's agree to stop your oral contraceptive pills because they are contraindicated with headaches." B. "Let's focus on what's causing your headaches because they sound like migraines and I'm not worried about a brain tumor. C. "I'd like you to make an appointment with a neurosurgeon to talk about your concerns." D. "Let's start with more discussion about your headache symptoms and an exam so we can decide what tests and referrals might be needed." E. "I can't address all of your requests today. What is your top priority for today's visit?"

D. "Let's start with more discussion about your headache symptoms and an exam so we can decide what tests and referrals might be needed."

Mrs. Muldoon, a 60-year-old Welsh woman with multiple medical problems comes to your office. She is on 7 chronic medications. As usual, her blood pressure is above target at 164/92. Since more than 50% of patients with chronic diseases do not take their medication as prescribed, you suspect that Ms. Muldoon is not taking all her medications. Which comment is the recommended initial strategy to address this issue? A. "Mrs. M, shall I call the pharmacy to find out if you have been filling your blood pressure medicine regularly? B. "Mrs. M, I need to know if you are taking your blood pressure medicine so I can help you." C. "Mrs. M, keeping your blood pressure under control will protect you from having a heart attack. Is that important to you?" D. "Mrs. M, most patients would find it difficult to take so many pills. How is it going for you?" E. "Mrs. M, I will make you a medication list including a schedule of how to take your medicines."

D. "Mrs. M, most patients would find it difficult to take so many pills. How is it going for you?"

Mr. F, a 65-year-old man comes to the Emergency room with a gangrenous foot. He has a history of poorly controlled diabetes and has missed some follow up appointments. He is seen by the surgeon on-call who determines that the foot cannot be saved and needs to be amputated. The surgeon presents this plan to the patient who responds, "I'm not going to be a guinea pig! You are not going to cut off my foot!" What would be the surgeon's best initial response to Mr. F's outburst? A. "I am sorry that you have to lose your foot." B. "I will have a community-liaison come in to act as an advocate on your behalf." C. "If you don't allow me to amputate your foot, you could get a serious blood infection and die." D. "Tell me how you would like me to approach this problem with your foot." E. "There is nothing experimental about amputations. This operation is standard of care for patients' with your problem."

D. "Tell me how you would like me to approach this problem with your foot."

Ms. Avery, 42, a recently divorced unemployed woman whose two teenagers are living with her, is in your office for what turns out to be a community-acquired pneumonia. In association with divorcing her husband of 20 years, the patient recently suffered a moderately severe depression, but the symptoms have responded well to ongoing medication. Ms. Avery is aggravated that her ex-husband has not yet paid child support . For her pneumonia you prescribe a new antibiotic that is very effective. What is the best additional question you need to ask before concluding the treatment plan? A. "Are you still taking your antidepressant?" B. "How are your children adjusting to the divorce?" C. "What do you know about the impact of depression on your immune system?" D. "This antibiotic may be expensive. Will you have difficulty affording it?" E. "How is your job search going?"

D. "This antibiotic may be expensive. Will you have difficulty affording it?"

Jenna Olsen is 36 and smokes cigarettes; she comes to the Women's Health Clinic and requests a prescription for birth control pills. You are eager to help prevent unwanted pregnancies, but you know that women over the age of 35 who smoke have a higher risk for problems like blood clots, heart attacks and strokes when they are on birth control pills. What would be the best next response in order to reach agreement on contraception for this patient? "It is important for me to help you prevent an unwanted pregnancy... A. ...but let us look into better options. Prescribing birth control pills for smokers could be very risky." B. ...but if you smoke, birth control pills are not a good choice. There are various other products that are just as reliable but they don't carry such risks." C. ...but first we need to address the smoking problem, then we can talk about contraceptive pills." D. ...but for women over 35 birth control pills increase the chance for getting blood clots, heart attacks or strokes. Let us also explore some other options that would not carry such risks for you." E. ...but in your case, as a smoker over age 35, the pill is not a good idea. I could fit you with a diaphragm which is pretty reliable and many women are very comfortable with it. Also you should consider condoms since they provide the best protection against STDs such as AIDS. So they can do much more for you than just prevent pregnancy."

D. ...but for women over 35 birth control pills increase the chance for getting blood clots, heart attacks or strokes. Let us also explore some other options that would not carry such risks for you."

Bill, a 22 year old college student comes to emergency at 2AM on a busy Saturday with pain in the left side of his chest. You are the supervising physician tonight, and the resident tells you the history- including that he had an injury to his left calf and left chest during a rugby game 2 weeks ago. Tonight he was awakened with the pain, which increased with inspiration. The resident's exam was normal, except for mild left rib tenderness, and his chest x-ray was normal, and the resident suggests that he sign the patient out with a diagnosis of left sided rib injury, possible occult rib fracture, after you see him. At this point, choose the recommended statement. A. After you examine Bill's heart, lungs and chest wall counter-sign the resident's note and discharge Bill with the diagnosis of rib contusion. B. Review the chest x-ray and then ask the resident to order spot rib films. C. Ask the resident to check on the possibility of transferring Bill to the college infirmary for overnight observation. D. Ask Bill to tell you more about his symptoms and their evolution over time. E. As supervisor, ask the resident to share his thinking about the case with you before you decide on the next step.

D. Ask Bill to tell you more about his symptoms and their evolution over time.

Francine Bacon is a single mother of 3 school-aged children. She is 38, African American, overweight and has hypertension. She is an office manager and some of her supervisees are performing poorly. Balancing home and work demands is difficult. You have discussed weight loss strategies and she agreed to start a medication for her blood pressure. When you tell her that today neither her blood pressure nor her weight has changed, she responds "I have been following your instructions and made a lot of changes. But this plan clearly does not work for me." Which of the following responses would best illustrate Partnership? A. State "Before we explore other treatment options, I need to know whether you gave it a fair chance because we know that it is effective in most people." B. State "Between your job, your children and your health, you have a great deal to do. Perhaps you can get some support for managing all these things." C. State "I appreciate that you have been doing your best. However, I'm guessing that that you have had difficulty following the care plan." D. State "You are coping with a lot of challenges. Let's see if we can devise a new plan that won't add to your stress levels." E. State "I can see that you are frustrated that our initial plan did not work. Most people in your shoes would feel the same way."

D. State "You are coping with a lot of challenges. Let's see if we can devise a new plan that won't add to your stress levels."

A patient whose primary language is Spanish comes in complaining of headaches. The patient speaks some English and you have been taking a medical Spanish course. What is the best way for you to communicate with the patient? A. Ask the desk clerk, who is a native Spanish speaker, to interpret. B. Ask the patient if she needs an interpreter to discuss these issues. C. Ask the patient's daughter to interpret for the patient. D. Use a professional interpreter - for example with the clinic over-the-telephone interpretation service. E. Communicate with the patient directly in Spanish and English.

D. Use a professional interpreter - for example with the clinic over-the-telephone interpretation service.

Kevin Avery is a 24 year old single firefighter of Irish decent. He broke his upper thigh during a motorcycle accident and is currently hospitalized. You are a female surgical resident and he has been assigned to you. Soon after he started to feel better and have less pain you noticed that no matter how well his genitalia are covered when you examine his leg, they always seem to come off exposing him fully. This seems to happen only when you are examining him by yourself, never when others are present. You are beginning to suspect that he is doing this on purpose. His inappropriate smiles and winks throughout your encounters with him further strengthen your suspicions. Which one of the following strategies is recommended? A. Express your anger and tell the patient to stop this behavior. Stress that you are a professional and not interested in his advances. B. Jokingly comment on his constant undressing, telling him that he better waits until he gets back to his girlfriend. C. Try to figure out ways to make it more difficult for him to pull down the drape (e.g., distract him with challenging questions). D. Avoid seeing the patient by yourself. Find medical students or other trainees to accompany you, so that you can "teach them about fractures." E. Avoid seeing the patient by yourself and speak to a trusted colleague or supervisor to better understand what is happening.

E. Avoid seeing the patient by yourself and speak to a trusted colleague or supervisor to better understand what is happening.

Ms Rodriguez is single, 28, a graduate student in a Master's writing program, and has seen you for minor skin complaints over the past couple of years. You've taken a thorough history of the present illness, gone over her social history and reviewed her past history. Today her story and symptoms and recent sexual activity with her boyfriend suggest a simple cystitis, a first-time occurrence for her. No other factors in her history and brief physical exam seem important. You tell her, "I think this is a simple bladder infection, and is easily treated." She responds with, "Is there any chance it could wreck my kidneys?" Which question / statement is recommended next? A. No, the antibiotics should clear it up quickly. B. I see this kind of problem frequently, and healthy young women like you always do well. C. In unusual situations the infection can spread to the kidneys, but it is rare. D. Look at this diagram of the kidneys and bladder with me and I'll explain why that is not likely. E. I wonder what you are thinking as you ask about harming the kidneys?

E. I wonder what you are thinking as you ask about harming the kidneys?

Ms. Renata Fortelli is a 60 year old married woman, seeing you for the first time for a persistent painful cough, worse at night. She cannot get to sleep and over-the-counter cough medicines did not help. You 've both agreed to a plan, and you begin to summarize and finish up. At that moment Ms. Fortelli says, "Oh by the way, for the last year I have had some terrible urges to go to the bathroom. I saw an ad on TV about a medication that prevents bathroom accidents. Do you think I should take it?" What is the recommended strategy for avoiding a prolonged closure? A. Ask, "Besides your concern about incontinence, what else is on your mind?" B. State, "Let's focus on one thing at a time and review the plan to manage the cough." C. Ask, "What have you tried to deal with the incontinence?" D. State "Here is a prescription for the medication you've heard about on TV. There is no harm in trying it. Now let's review the plan to treat your cough." E. State "This is an important issue. Let us set up an appointment for next week to explore that problem in greater depth. Then we can also see how you are doing with your cough."

E. State "This is an important issue. Let us set up an appointment for next week to explore that problem in greater depth. Then we can also see how you are doing with your cough."

Israel Wasserman, a 50 year old Caucasian teacher, was brought to the hospital after experiencing a seizure while shopping. You found that he has a benign brain tumor and recommended that he start treatment immediately to prevent further seizures. Israel has trouble accepting the diagnosis and wants to postpone treatment because he fears that any delay in launching a big project at school may derail the entire project. Which of the following statements best conveys Respect? A. State: "It must be very frustrating to get sick just in the midst of starting an exciting project." B. State: "Given your condition it is really essential to get treatment now; another seizure will only cause more delays." C. State: "There is probably someone else working on this that you could trust to start the project for you." D. State: "I want to get you treated quickly so that you can go back to work as soon as possible." E. State: "I admire your devotion to your work, and I'm sure your students appreciate all you do for them."

E. State: "I admire your devotion to your work, and I'm sure your students appreciate all you do for them."

Enrique Rodriguez, 17 and a high school student of Puerto Rican extraction, comes in for a sports physical. Yesterday his mother called with a request to explore his sexual orientation and activities, complaining that Enrique does not seem to have any interest in girls, and that keeps his hair long. You assured her that you would do a full assessment, but would not be able to share information about sexuality because of confidentiality laws. After you open the conversation with Enrique with this statement: "Because sexuality is an important part of life and health I ask all my patients about their sexual experiences and concerns"...which of the following is recommended for continuing inquiry? A. Your mother asked me to explore sexuality with you. Has she ever talked to you about it directly?" B. Your mother asked me to discuss sexuality with you. Do you have any questions or concerns about the way you feel towards boys and / or girls and your sexual relationships with them?" C. I won't tell anyone anything that you say. What type of sex have you had with boys and what type of sex have you had with girls?" D. Whatever we talk about is confidential, and by law I am not allowed to share any information with your parents unless you want me to do so. Many teens are embarrassed to talk about sex. What type of sexual contact have you had thus far?" E. Whatever we talk about is confidential, and by law I am not allowed to share any information with your parents unless you want me to do so. What type of sexual contact have you had thus far?"

E. Whatever we talk about is confidential, and by law I am not allowed to share any information with your parents unless you want me to do so. What type of sexual contact have you had thus far?"

Heng Chan grew up in rural China and is now in your urban US hospital; he is 70, has new onset seizures and a history of lung cancer. An MRI of the brain shows lesions typical for metastases, and you think he should have radiation therapy. Which option for opening a bedside discussion with Mr. Chan would best help you eventually reach agreement on a plan? A. "The test results are in and I have some news about your health. Do you have a preference about how you would like to hear this information or is there someone else that you would prefer that I talk to? B. "I have some bad news for you. I am sorry to tell you that your cancer has spread." C. "I notice that you have a bible at your bedside. Could you tell me about your spiritual beliefs?" D. "Radiation treatment should prevent further seizures, and I want to recommend that treatment for you." E. "Could you tell me what you know about why you are in the hospital?"

A. "The test results are in and I have some news about your health. Do you have a preference about how you would like to hear this information or is there someone else that you would prefer that I talk to?

"I know that you are concerned about losing weight. I'd like to be sure I know the other things that are on your mind." Which of the following communication skills used in opening the discussion best describes the physician's statement? A. Survey symptoms B. List concerns C. Redirect patient D. Summarize E. Open-ended inquiry

A. Survey symptoms

Ms. Boggs, 88, is brought in by long-term, caring neighbors. Ms. Boggs lives independently and has her own financial resources. According to the record, she is "sharp as a tack" but her neighbors are concerned that she is not taking her prescribed heart medications appropriately. What question or statement might best begin your interview of this patient? A. "Are you taking all of your medications as they are prescribed?" B. "Can you tell me about each of your medical conditions along with the names and doses of each of your medications?" C. "Sometimes, as people get older they have memory difficulties." D. "I'm sorry that your neighbors have intruded into your affairs." E. "Let's make a chart for the time and number of each pill to take each day of the week."

B. "Can you tell me about each of your medical conditions along with the names and doses of each of your medications?"

A new patient in your office, Mr. Smith told you his concerns, and said that his biggest concern is a recent episode of chest pain; he appears quite anxious. Your next best step toward completing the history of present illness is to say A. "When did your chest pain start?" B. "You look worried." C. "Did your parents have heart disease?" D. "You must be under a lot of stress." E. "What goes along with your chest pain?"

B. "You look worried."

Kathleen Baker is a 15-year-old high school student of German extraction. She comes in with her mother for a preventive health appointment. During the interview you ask Kathleen if she is sexually active. She looks toward her mother and denies sexual activity. What is the recommended option for obtaining accurate information about her sexual history? A. Explain the importance of this question for the patient's health. B. Ask about sexual activity again when Kathleen's mother is not in the room. C. Ask what Kathleen is feeling at this point in the interview. D. Explain the meaning of the phrase "sexually active" and ask again. E. Make a note to ask about sexual activity again when Kathleen is older.

B. Ask about sexual activity again when Kathleen's mother is not in the room.

In the Emergency Department, you are directed to see a 30 year old man who will be admitted to assess the presence or absence of a heart attack, then write the admitting orders and page your supervising resident. Bob L. is a 30 year old software engineer who appears concerned but not in distress. Bob reports left sided chest pain intermittently since yesterday, and the nursing notes state that he has an elevated cholesterol and family history of coronary artery disease. What is your preferred next statement? A. Was the pain sharp or dull? B. Can you describe your chest pain? C. Have you ever had this type of pain before? D. On a scale of 0 to 10 with 10 being the worst, how bad was this pain? E. Would you tell me a bit more about your family and your current life situation?

B. Can you describe your chest pain?

You are seeing a 21-year-old female patient at a free community clinic. You learn the patient has been experiencing homelessness for 2 years, she is generally hostile in the encounter and at one point states 'you are all the same, trying to tell me what to do, I should just leave'. You pause and say to her, 'I can see that you are very upset today and I want you to know that I am here to help you as best I can, however, if today is not the best day to discuss your concerns we can reschedule for another time if you would prefer.' This would be an example of which of the following tenants of patient-centered care? A. Exploring patients belief's B. Demonstrating shared power and responsibility C. Adopting the biopsychosocial perspective D. Understanding the provider as a person

B. Demonstrating shared power and responsibility

What physical exam findings might you expect to find with pulmonology exam if a patient has a diagnosis of pneumonia? A. Clear breath sounds bilaterally both anterior and posterior B. Dullness with percussion in one of the lung fields C. Hyperresonance with auscultation D. Regular respirations

B. Dullness with percussion in one of the lung fields

Which area of the history is it most appropriate to ask open-ended questions? A. Past medical history B. History of patient illness (HPI) C. Review of Systems D. Social History E. Family History

B. History of patient illness (HPI)

"Headache, backache, difficulty sleeping, tiredness." Which of the following communication skills used in opening the discussion best describes the physician's statement? A. Survey symptoms B. List concerns C. Redirect patient D. Summarize E. Open-ended inquiry

B. List concerns

For your patient who is concerned about chest pain, which informational statement will be included in the History of Present Illness (HPI)? A. Eating strawberries gives me hives. B. This burning chest pain started after I had a bowl of chili. C. My children and I live with my long-time partner. D. I have had chest pain since last night. E. I haven't had any fevers.

B. This burning chest pain started after I had a bowl of chili.

In Video 2, Dr. Lown talks to Ms. Allen about the impact that her asthma diagnosis has had on her life. What is Dr. Lown's primary purpose in talking about this with the patient? A. To allow the patient to vent her frustrations about having asthma B. To communicate to the patient that she is interested in her as a person C. To discover whether the patient is taking her medications as prescribed D. To discover whether there are ways she could help the patient function better with her asthma E. To understand the patient's disease explanatory model

B. To communicate to the patient that she is interested in her as a person

You are seeing a 23-year-old woman three months post-partum. You are pleased to learn that she is breast-feeding her baby successfully. She hasn't resumed menstruating yet. You ask how she is doing with the oral contraceptive pills prescribed at the six-weeks-postpartum visit. The patient tells you she never filled the prescription. You decide to begin with, "So, you are not taking the pill right now..." what is the best way to conclude this comment? A. "...Do you have any questions about how to take it?" B. "...I would recommend that if you don't want to become pregnant you start on the pill right away. " C. "...Tell me what your thoughts or concerns are about taking the pill." D. "...Would you like to hear about other types of birth control?" E. "...You know that even though you are not menstruating, you can still become pregnant."

C. "...Tell me what your thoughts or concerns are about taking the pill."

A 54-year-old female comes in complaining of headaches that are new. As you take your history, which of the following associated symptom questions should you be asking? A. Are you having any chest pain? B. Do you also have a cough? C. Are you experiencing any visual changes? D. Are the headaches occurring any particular time of day?

C. Are you experiencing any visual changes?

The medical term that describes difficulty swallowing is? A. Macrophagia B. Odynophagia C. Dysphagia D. Dyspepsia E. Eructation

C. Dysphagia

Which setting might alter the order of the diagnostic process? A. Outpatient B. Orthopedic office C. Emergency room D. Pediatric office E. Ophthalmologist office

C. Emergency room

What is the first step in the diagnostic process? A. Labs B. Physical exam C. History D. Patient education E. Patient counseling

C. History

Mr. Jones, age 50, comes to the office and says he is worried about his cough. You ask "Please tell me more about this?" Which of his statements about his situation is likely to emerge earlier than the others? A. I am allergic to penicillin so I hardly ever take antibiotics. B. I was in the hospital for a pneumonia when I was three C. I was treated with antibiotics last month for this cough and it didn't help. D. My father died of lung cancer when he was in his 80s. E. My sister has multiple sclerosis, discovered when she had trouble seeing."

C. I was treated with antibiotics last month for this cough and it didn't help.

When assessing a patient with a traumatic musculoskeletal injury an important element of understanding the onset is to know which of the following? A. Is pain sharp or dull B. Duration of pain C. Mechanism of injury D. Is pain intermittent or constant

C. Mechanism of injury

Ms. Avery (see Q6, above) says that she is angry with her ex-husband, but that she can afford the antibiotic. She asks you, "Are there any important side effects?" Which response is preferred? A. Rarely, it might cause bleeding, because in unusual circumstances it can act like an anticoagulant. B. Rarely, it might cause bleeding, which can be pretty severe. C. Rarely, it might cause bleeding, and you should call me right away if you notice any bleeding. D. Rarely, it might cause bleeding; do you have any other questions? E. Rarely, it might cause bleeding, so you could throw up blood or have bloody stools, or a nosebleed, or cough up blood, so you should call me right away.

C. Rarely, it might cause bleeding, and you should call me right away if you notice any bleeding.

Ms. Dole tells you that she really doesn't know why she's been falling. You then tell her you're happy she's come in to see you, but you're wondering why now, ten days after the injury rather than earlier. She replies, "I couldn't come in until today because it's just been hard to get away from work and home. My husband's out of town today so it was more convenient." At this point, choose the recommended response statement. A. It sounds like your schedules are pretty busy. B. It's best to come in soon after this kind of injury so you can avoid further damage. C. Sometimes when I've heard symptoms or seen problems like yours, I've learned that the patient is being hurt or hit at home. Could that possibly be happening to you? D. I'd like to refer you to a primary care physician for follow-up if you don't already have one. E. Is someone hurting you?

C. Sometimes when I've heard symptoms or seen problems like yours, I've learned that the patient is being hurt or hit at home. Could that possibly be happening to you?

This is your first encounter with Margot Gwen, a 20 year old single Caucasian collegian with Crohn's disease whose previous physician just moved out of town. Her responses to your open-ended questions ("Tell me a little about yourself;" or "I've looked at your medical record, how can I help you today;" etc.) are consistently one or two word answers, and she looks down at her hands and twists her fingers during the interview. Which of the following responses would best illustrate Empathy? A. State: "Before we continue, I'd like to let you know why I am asking you questions about your health." B. Connect non-verbally by moving your chair closer, maintaining good eye contact, and gently touching her shoulder to supply reassurance. C. State: "You seem uncomfortable with our conversation, so far." D. State: "Is there anything in particular that you would like to tell me now? I am here to help you with your health." E. Back up in your chair and state: "It seems that now is not a good time for us to get to know each other. What should we do next?"

C. State: "You seem uncomfortable with our conversation, so far."

Which of the following medical terms describes the perception of spinning? A. Tinnitus B. Diplopia C. Vertigo D. Otalgia E. Rhinnohrea

C. Vertigo

Bob (from previous question) tells you the pain is moderately severe and feels like a stabbing sensation in his left chest, and he reveals that he's worried about a possible diagnosis of heart attack. At this point, which statement below is recommended? A. Can you show me where it's hurting you? B. Go back to the beginning. What were you doing when this began? C. What worries you the most? D. Have you had any shortness of breath with this? E. So, who in your family has had a heart attack?

C. What worries you the most?

Your patient for the past 3 years, Angela Pretorez has diabetes and high blood pressure. She is 69, married, and speaks only Spanish, so you use an interpreter to communicate. In the past her compliance has been poor and she often misses appointments. Early in this visit, you explored why she misses visits, and it appeared that her son who transports her is not always available. You invited her to talk to the social worker, but she declined. What can you say in the last few minutes of the encounter to strengthen rapport and encourage her to come back for the next appointment? A. Please don't miss any further appointments. I look forward to seeing you in a month. B. You know how important it is that we continue to work on your diabetes and blood pressure. I'll see you in a month. C. If you don't come we can't help you. I look forward to seeing you in a month. D. I understand that it is difficult for you to get here. If your son is unavailable, please contact us for alternate arrangements. Do you know what number to call? It was good to see you today. E. Tell you son to shape up - these are important appointments! See you!

D. I understand that it is difficult for you to get here. If your son is unavailable, please contact us for alternate arrangements. Do you know what number to call? It was good to see you today.

Which of the statements below is most accurate about the process of patient-centered interviewing? A. It keeps patients focused on the chief complaint B. It keeps patients from talking about emotion C. It occurs at the beginning of a medical interview D. It prompts patients to offer psychosocial details E. It uses only open-ended questions

D. It prompts patients to offer psychosocial details

Ken Fortek is a 40 year old divorced Caucasian book keeper who complains of persistent headaches. You've done a careful history, physical exam, and ordered laboratory tests. Your exam and lab results are normal. You convey this good news but your patient continues to look worried. He asks, "How can you be sure that these headaches are not related to a brain tumor?" Which of the following responses would best illustrate Attentiveness and Warmth? A. State in a confident tone, after briefly touching the patient's arm: "Let me reassure you once again. There is no evidence of a brain tumor." B. State "Nothing is ever 100% certain, but in your case we can be sure that you do not have a brain tumor. The odds of a brain tumor are very small." C. Lean forward and state "The chances of your having a brain tumor are extremely low. I think we can move on to treating your headache pain, and you will feel a lot better." D. State "I can see that you are still worried about the possibility of a brain tumor. Help me understand why that is the case." E. State "You want to be positive there isn't a brain tumor. While I'm sure there is nothing to worry about, I can arrange a referral to a neurologist for another opinion."

D. State "I can see that you are still worried about the possibility of a brain tumor. Help me understand why that is the case."

Mrs. P.(from previous question) shares additional information, revealing that her husband's job requires travel, so she is left alone frequently with the new baby and little support. She's uncomfortable with how much he drinks when he's at home, although he's not been abusive. She feels "down in the dumps," and cries frequently, has been sleeping poorly, awakening at 4-5AM even when the baby is quiet, and feels fatigued most of the time. She's lost 10 pounds more than the weight she gained while pregnant, and says that taking care of the baby is always effortful rather than pleasurable. Which diagnosis seems the least likely based upon Mrs. P's history? A. Complex migraine B. Post-partum thyroiditis C. Major depressive episode D. Transient ischemic attack

D. Transient ischemic attack

"I'd like to ask a few more questions about your past medical history." Which of the following correctly names the question/ statement above? A. Open question B. Clarification C. Closed question D. Verbalize transitions E. Summarization

D. Verbalize transitions

"Tell me what is on your mind today." Which of the following communication skills used in opening the discussion best describes the physician's statement? A. Survey symptoms B. List concerns C. Redirect patient D. Summarize E. Open-ended inquiry

E. Open-ended inquiry

Peter Erman is 18, a Caucasian high school student admitted to the hospital for internal injuries after driving a car into a tree. He was driving while intoxicated, and luckily no one else was injured. It is your responsibility now to address the drunk driving issue with him. Which of the following responses would best convey Support? A. State: "No more drinking and driving - please!" B. State: "I hope this was a good lesson for you - drinking and driving has horrible consequences. Actually, at your age you should not be drinking at all." C. State: "When I was your age I also liked partying. Of course, you can't drive home when your alcohol level is still elevated." D. State: "Let's brainstorm about how you can stay away from alcohol." E. State: "There are many situations that can result in someone driving while they are drunk. I would like to help you figure out what led to your accident so that you can avoid it in the future."

E. State: "There are many situations that can result in someone driving while they are drunk. I would like to help you figure out what led to your accident so that you can avoid it in the future."

In one video, Dr. Lown opens the discussion of Ms. Jones' blood pressure by asking, "What do you think about your blood pressure today? The clinical assistant told me it was up." Which of the following is the most important reason Dr. Lown chose this opening? A.To bring to the patient's attention that her blood pressure is up, using words that do not convey judgment or evaluation of the patient. B.To discover misconceptions the patient may have about her blood pressure so she can correct them. C.To discover whether the patient will confirm her suspicion that she is not taking her blood pressure medicine. D.To start the interview with an open-ended question. E.To discover how the patient views her blood pressure problem.

E.To discover how the patient views her blood pressure problem.

"What did you notice experiencing when this first began? Which of the following correctly names the question/ statement above? a) Open question b) Clarification c) Closed question d) Verbalize transitions e) Summarization

a) Open question

"What exactly do you mean by shortness of breath?" Which of the following correctly names the question/ statement above? a) Open question b) Clarification c) Closed question d) Verbalize transitions e) Summarization

b) Clarification

"What inhaler did you use?" Which of the following correctly names the question/ statement above? a) Open question b) Clarification c) Closed question d) Verbalize transitions e) Summarization

c) Closed question

"So my understanding so far is that you developed shortness of breath and wheezing yesterday that didn't respond to your usual inhalers." Which of the following correctly names the question/ statement above? a) Open question b) Clarification c) Closed question d) Verbalize transitions e) Summarization

e) Summarization