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Behavioral Science - USMLE 1, First Aid


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Woman with anxiety about a gynecological exam is told to relax and imagine going through the steps of the exam.

What process does this exemplify?
Systematic desensitization.
65-year old man is diagnosed with incurable metastatic pancreatic adenocarcinoma. His family asks you, the doctor, not to tell the patient.

What do you do?
Assess whether telling the patient will negatively affect his health. If not, tell him.
Man admitted for chest pain is medicated for ventricular tachycardia. The next day he jumps out of bed and does 50 pushups to show the nurses he has not had a heart attack.

What defense mechanism is he using?
You find yourself attracted to your 26-year-old patient.

What do you say?
Nothing! The tone of the interview must be professional ... if you feel your actions may be misinterpreted, have a chaperone in the room.
Large group of people is followed over 10 years. Every 2 years, it is determined who develops heart disease and who does not.

What type of study is this?
Cohort study.
Girl can groom herself, can hop on 1 foot, and has an imaginary friend.

How old is she?
4 years old.
Man has flashbacks about his girlfriend's death 2 months ago following a hit-and-run accident. He often cries and wishes for the death of the culprit.

What is the diagnosis?
Normal bereavement.
36-year old woman with a strong family history of breast cancer refuses mammogram because she heard it hurts.

What do you do?
Discuss the risks and benefits of not having a mammogram. Each patient must give her own informed consent to each procedure. If the patient refuses, you must abide by her wishes.
During a particular stage of sleep, man has variable blood pressure, penile tumescence, and variable EEG

What stage of sleep is he in?
REM sleep.
15 year old girl of normal height and weight for her age has enlarged parotid glands but not other complaints. The mother confides that she found laxitives in the daughter's closet.

What is the diagnosis?
11-year old girl exhibits Tanner stage 4 sexual development (almost full breats and pubic hair).

What is the diagnosis?
Advanced stage, early development.
4 year old girl complains of a burning feeling in her genitalia; otherwise she behaves and sleeps normally. Smear of discharge shows N. gonorrhoeae.

How was she infected?
Sexual abuse.
72 year old man insists on stopping treatment for his heart condition because it makes him feel "funny"

What do you do?
Although you want to encourage the pt to take his meds, the pt has the final say in his own rx regimen. you should investigate the "funny" feeling and determine if there are drugs available that won't elicit this particular side effect.
Person demands only the best and most famous doctor in town.

What is the personality disorder?
Nurse has episodes of hypoglycemia; blood analysis reveals no elevation in C-protein.

What is the diagnosis?
Factitious disorder, self scripted insulin.
55 year old businessman complains of lack of successful sexual contacts with women and an inability to reach a full erection. Two years ago he had a heart attack.

What might be the cause of his problem?
Fear of sudden death during intercourse.
Observational Study. Sample chosen on presence of absence of disease. Information collected about exposure.
Case-control Study.
Observational study. sample chosen based on presence of absence of risk factors. Subjects followed over time for development of disease.
Cohort Study.
Pooling data from several studies (often via a literature searach) to acheive greater statistical power.
Experimental study. compares therapeutic benefit of 2 or more treatments, or treatment and placebo.
clinical trial.
List 4 ways to reduce bias in a study.
1. Blind studies.
2. Placebo responses.
3. Case-crossover design.
4. Randomization
When the subjects choose the groups it may lead to what type of bias?
Selection bias.
When knowledge of the presence of the disease alters recall by the subjects what type of bias is likely?
Recall bias.
When subjects are not representative of the population and results are not generalizable, what type of bias is this?
Sampling bias.
When information gathered on subjects is done so at an inappropriate time, what bias is likely?
Late-look bias.
The total proportion of cases in a population at a given time.
The rate of new cases in a population in a given time.
Incidence x Disease Duration
For chronic diseases, which is larger - prevalence or incidence?
Prevalence > Incidence for Chronic Disease
When does prevalence = incidence?
For acute disease (ie the common cold)
What is sensitivity?
TP/(TP+FN) x 100 = Sensitivity
When is high sensitivity desirable?
In a screening test.
What is 1-sensitivity?
False negative ratio.
What is specificity?
TN/(TN+FP) x 100 = specificity
What is 1-specificity?
False positive ratio.
When is high specificity desirable?
In a confirmatory test.
What is the PPV?
The probability of having a condition given a positive test.

What is NPV?
The probability of not having the condition given a negative test.

Unlike sensitivity and specificity, the predictive values are ....
dependent on the prevalence of disease. The higher the prevalence of disease, the higher the predictive value of the test.
OR - approximates RR if prevalence of disease is not too high.
RR - relative risk
Attributable risk formula?
The consistency and reproducibility of a test is the ....
Absence of random variation in a test ....
The trueness of the test measurements is the ...
Reduced precision means
increase in random error
Reduced accuracy means
increase in systematic error
Number needed to treat
NNT = 1/(Ic-Ie)

The number of pts that need to be treated to prevent 1 additional bad outcome.
Reliability is ...
the reproducibility of a test. a Test is reliable if repeat measurements are the same.
Validity is ...
whether the test truly measures what it purports to measure. A test is valid if it measures what it is supposed to measure.
Gaussian distribution is ...
a normal distribution (bell curve) (mean=median=mode)
A bimodal distribution ...
has 2 humps
A positive skew distribution ...
is asymmetry with the tail to the right, hump on the left (mean>median>mode)
a Negative skew distribution ...
is asymmetry with the tail to the left, hump on the right (mean<median<mode)
A null hypothesis is ...
There is no association (ie between the risk factor and the disease in the popuation.)
The alternative hypothesis is ...
There is some difference (ie between the disease and the risk factor in the population)
Type 1 error (alpha)
Stating there IS an effect or difference where none really exists.
Type II error (beta)
Stating there IS NOT an effect or difference when one really exists.
the probability of rejecting the null hypothesis when it is in fact false.
Power in a study depends on what two things ...
1. total number of endpoints experienced by the population
2. difference in compliance between treatment groups
How do you increase study power
increase the sample size.
Confidence interval
mean +/- 1.96 (SEM)

If the CI includes 0, H0 is accepted.
Normal (Gaussian) distribution has what percentage of the population in each standard deviation?
68% within 1 SD, 95% within 2 SDs, 99.7% within 3 SDs.
what does a t-test measure
the difference between the means of two groups
What does ANOVA measure
the difference between means of 3 or more groups
What does a Chi square measure?
the difference between 2 or more proportions of categorial outcomes (NOT mean values)
Correlation coefficient indicates
the strength of the correlation between two variables. The sign indicates a positive or negative.
What is Primary Disease Prevention?
Prevent the disease from occuring.
What is Secondary Disease Prevention?
Early detection of the disease.
What is Tertiary Disease prevention?
Reduce mobidity from the disease.
What are important preventative measure for patients with DM?
Eye exams, foot exams, urine tests.
What are important preventive measures for pts with drug abuse problems?
HIV test, TB test, Hep immunizations.
What are important prevetive measures for pts with alcoholism?
influenza, pneumococcal immunizations and TB testing
What is an important preventive measure to offer obese pts?
Blood sugar testing for diabetes.
What is an important preventive measure to offer homeless pts or recent immigrants?
TB tests
What tests are important for pts engaging in high risk sexual behavior?
HIV, Hep B, Syphilis, gonorrhea, chlamydia tests.
List the Reportable Diseases
1. Hep B
2. Hep A
3. Salmonella
4. Shigella
5. Syphilis
6. Measles
7. Mumps
9. Rubella
10. TB
11. Chickenpox
12. Gonorrhea
Is HIV reportable?
While AIDS is reportable in all states, HIV reporting laws are state dependent.
What are the leading causes of death for infants in the US?
1. Congenital anomalies
2. Short gestation/LBW
4. Maternal complications of pregnancy
5. RDS
What are the leading causes of death for children age 1-14 in the US?
1. Injuries
2. Cancer
3. Congenital anomalies
4. Homicide
5. Heart disease
What are the leading causes of death for people 15-24 years of age in the US?
1. Injuries
2. Homicide
3. Suicide
4. Cancer
5. Heart disease
What are the leading causes of death for adults 25-64 yo in the US?
1. Cancer
2. Heart disease
3. Injuries
4. Suicide
5. Stroke
What are the leading causes of death for adults over the age of 65 in the US?
1. Heart disease
2. Cancer
3. Stroke
5. Pneumonia
6. Influenza
Define autonomy
The obligation to respect patients as individuals and to honor their preferences in medical care.
Informed consent implies pts must understand the risks, benefits, and alternatives which include no intervention.

What is legally required for IC?
1. discussion of pertinent information
2. patient's agreement to the plan of care
3. freedom from coercion
In what circumstances is there an exception to the mandates of informed consent?
1. Patient lacks decision making capacity.
2. Implied consent is an emergency
3. Therapeutic privledge
4. Waiver - pt waives the right to informed consent
What is Therapeuic Privledge
Withholding information when disclosure would severely harm the patietn or undermine informed decision making capacity.
True or False: A patients family cannot require that a doctor withhold information from the patient.
What are some variables in determining a patients decision making capacity?
1. pt makes and communicates a choice
2. pt is informed
3. decision remains stable in time
4. decision is consistent with pt values and goals
5. decision is not a result of hallucinations or delusions
Define Transference.
When the patient projects feelings stemming from their personal life onto their physician.
Define Countertransference.
When the doctor projects feelings stemming from their personal life onto the pt.
Define classical conditioning.
Leaning where a natural response is elicited by a contitioned stimulus that was previously presented in conjuction with an unconditional natural stimulus.
Define operant conditioning.
learning in which a particular action is elicited because it produces a reward.
Define positive reinforcement.
desired reward produces action
Define negative reinforcement.
removal of averse stimuli incresases the behavior.
True or False: reinforcement schedules determine how quickly a behavior is learned or extinguished.
Describe a continuous reinforcement schedule.
reward received after every response. rapidly extinguished.
Define a variable ratio reinforcement schedule.
reward received after random number of responses. slowly extinguished.
What are Stanfornd-Binet and Wechsler?
Intelligence tests.
How does the Stanford Binet test calculate intelligence?
IQ as (mental age/chronological age) x 100
How does Wechsler (WAIS) measure intelligence?
11 subtests (6 verbal, 5 performance)... Mean is 100, SD - 15.
What is the IQ cuttoff for diagnosis of mental retardation?
IQ < 70 or 2 SD below mean.
True or False: IQ tests are objective test.
True ... but they are NOT projective tests.
Are IQ scores correlated with genetic factors or school achievement?
Yes to both ... but more highly correlated to school achievement.
What is an oral advanced directive?
In an incapacitated state, a pts prior oral statement is commonly used as a guide.
What is a written advanced directive?
a living will.
What is a durable power of attorney?
pt desingnates a surrogate to make a medical decision in the event that the patient loses decision making capacity. pt can specify decisions in certain clinical situations, and can revoke power.
What is nonmaleficence.
"do no harm". However, if benfits of an intervention outweigh the risks, a patient may make an informed decision to proceed.
Define beneficence
The physicians ethical responsibility to act in the patients best interest (as a fiduciary). Can conflict with autonomy.
What should guide the physicans decision to disclose information to family and friends?
What the patient wants, or would want.
In what circumstances can a physician break confidentiality?
1. potential harm to others is serious.
2. liklihood of harm to self is great.
3. no alternative means exist to warn and protect those at risk
What steps may a physician take to prevent harm caused by a patients infectious disease?
Physician may have a duty to warn public health officials (reportable diseases) and identify people at risk.
What is the Tarasoff decision?
A law requiring physician to directly inform and protect a potential victim from harm; may involve a breach of confidentiality.
May a physician break confidentiality if they suspect child or elder abuse?
May a physician break confidentiality if in cases of an automobile accident?
Only if they suspect that the driver was imparied.
How may a physician handle a suicidal or homicidal patient?
The physician may hold the patient involuntarily for a period of time ... or until psychiatric evaluation is completed.
A civil suit under negligence requires what 3 things?
1. Physician breach of duty to patient (Dereliction)
2. patient suffers harm (damage)
3. Breach of duty causes harm (Direct)
What is the most common factor leading to litigation between the physician and pt?
poor communication.
In a criminal suit the burden of proof is "beyond a reasonable doubt" ... in a malpractice suit the burden of proff is ...
"more likely than not"
Define Anosognia
unaware that one is ill
Define Autotopagnosia
unable to locate ones own body parts
Define depersonalization
body seems unreal or dissociated
What is involved in orienting the patient
person, place, and time
What is the order of orientation loss in a disoriented patient?
time goes first, then place, and last person
Define anterograde amnesia
the inability to remember things that occred AFTER an CNS insult ... cannot make new memories
Define retrograde amnesia
inability to remember things that occured before a CNS insult
What is Korsakoff's anmesia
classic anterograde anmesia caused by a thymine deficiency.
A alcoholic patient presents with anterograde amnesia, and confabulations.

What is the likely diagnosis?
Korsakoffs amnesia
List some maladaptive patterns of substance use.
1. Tolerance
2. Withdrawal
3. Substance taken in larger than intended amounts
4. Persistent desire or attempts to cut down
5. lots of energy spent trying to obtain the substance
6. important social, occupational, or recreational activites reduced because of substance abuse
7. continued use in spite of knowing the problems it's causing
How many signs of maladaptive substance abuse must be present in a years time to diagnose substance dependance?
3 or more.
What is the difference between substance dependence and substance abuse?
substance abuse is maladaptive patterns leading to clinicall or socially significant impairment or distress that have not met the criteria for substance dependence.
What are some indications of substance abuse?
1. recurrent use resulting in failure to fulfill major obligations at work, school, or home.
2. recurrent use in physically hazardous situations
3. recurrent substance related legal problem
4. continued use in spite of persistent problems cause by use.
What are Freud's three structures of the mind?
Id, Ego, Superego
Define the Id.
Primal urges, sex and aggression.
Define the Superego.
Moral values and concience.
Define the Ego.
Mediator between unconcious mind and external world.
The Topographic thoery of the mind deals with what three topographys?
Concious, preconcious, and unconcious.
Define Concious.
What you are aware of.
Define preconcious.
What you are able to make consious with effort
Define unconcious
what you are not aware of.
What is an Oedipus complex?
repressed sexual feelings of a child for the opposite sex parent, accompanied by a rivalry with same sex parent.
hallucinations, delusions, strange behavior, and loose associations are positive symptoms of what disorder?
What are some negative symptoms of schizophrenia?
flat affect, social withdrawal, thought blocking, lack of motivation
How long must a patient experience symptoms of schizophrenia for a diagnosis?
Periods of psychosis or disturbed behavior lasting > 6 months.
What are the 5 types of schizophrenia?
1. Disorganized
2. Catatonic
3. paranoid
4. Undifferentiated
5. Residual
What are the 4 A's of schizophrenia described by Bleuler?
1. Ambiavlence
2. Autism
3. Affect (blunted)
4. Associations (loose)
What is schizoaffective disorder?
a combination of schizophrenia and a mood disorder.
What is the lifetime prevalence of schizophrenia?
1.5% (males=females, blacks=whites)
Are genetic or envionmental factors stronger in the etiology of schizophrenia
Genetic factors outweigh environmental factors
In one word, describe Clusters A, B, and C personality disorders.
A = weird
B = wild
C = worried
Describe a pt with a Cluster A personality disorder.
odd or eccentric, cannot develop meaningful social relationships.

No psychosis, but genetic associations with schizophrenia.
What are 3 types of Cluster A personality disorders?
1. Paranoid
2. Schizoid
3. Schizotypal
What is a Paranoid personality disorder?
distrust and suspiciousness, projection is main defense mechanism
What is a Schozoid peronality disorder?
voluntary social withdrawal, limited emotional expression
What is a Schizotypal personality disorder
interpersonal awkwardness, odd thought patterns and appearance
Personality disroders that lead pts to be erratic, emotional, or dramatic and have a genetic association with mood disorders are classified as ...
Cluster B
What are the 4 types of Cluster B personality disorders
1. Antisocial
2. Borderline
3. Histrionic
4. Narcissistic
Describe an antisocial personality disorder.
disregard for and violation of rights of others, crimilatiy, males more often affected than females.
Describe a borderline personality disorder
unstable mood and behavior, impulsiveness, sense of emptiness. women more often affected than men.
Describe a Histrionic personality disorder.
excessive emotionality, somatization, attention seeking, sexually provacative.
Describe a Narcissistic personality disorder.
gradiosity, sense of entitlement, may demand "top" physician, or best health care
Pts with personality disorders that leave them anxious or fearful and have a genetic association with anxiety disorders are classified as ...
Cluster C personality disorders
List 3 types of Cluster C personality disorders
1. Avoidant
2. Obsessive-Compulsive
3. Dependent
Describe an avoidant personality disorder.
sensitive to rejection, socially inhibited, timid, feelings of inadequacy
Describe OCD
preoccupation with order, perfectionism, and control
Describe a dependent personatliy disorder.
submissive and clinging, excessive need to be taken care of, low self confidence
What are Medicare and Medicaid?
federal health care programs that originated from ammendments to the Social Security Act.
Who does MedicarE provide for?
The Elderly
Who does MedicaiD provide for?
The Destitute. Medicaid is federal and state assistance for very poor people.
Ethically, what do you do if your patient is non-compliant?
Work to improve the physician patient relationship.
Ethically, what do you do if your patient has difficulty taking medication?
Provide written instructions, attempt to simplify the treatment regimen.
What do you do if a family member asks for information about a patient's prognosis?
avoid discussing issues with relatives without permission of the patient.
What do you do if a 17 year old girl is pregnant and asks for an abortion.
informthe patient that most states require parental conset for minors for an abortion.
What do you do if a terminallyl ill patient requests assistance in ending his life?
refuse involvement in any form of euthanasia. physician may however prescribe appropriat analgesics that may coicidentally shorten a patient's life.
What do you do if a patient states that he finds you attractive?
ask direct, closed ended questions and use a chaperone if necessary.
What do you do if a patient refuses a necessary procedure or desires and unnecessary one?
attempt to understand why the patient wants/does not want the procedure. address underlying concerns. avoid performing unnecessary procedures.
What do you do if a patiend is angry about the amount of time he spent in the waiting room?
apologize for any inconvenience. stay away from efforts to try to explain the delay.
what do you do if the patietn is upset with the way he was treated by another doctor?
suggest that the patient speak directly to the physician regarding the concerns. if the problem is weith a member of the office staff ... tell the patient you will speak to that individual.
What do you do if a child wishes to know more about his illness?
Ask what the parents have told the child about his illness. Parents of a child decide what information can be relayed about the illness.
What do you do if a patient continues to smoke, believing that cigarettes are good for him?
Ask how the pt feels about his smoking. Offer advice on cessation if the patient seems willing to make an effort to quit.
A child puts everything in their mouth. How old are they?
1st year of life.
An infant sits with support, how old is she?
4 months
An infant stands with help, how old is he?
8 months
A baby is crawling, how old is she?
9 months
A little girl just learned to walk on her own, how old is she?
13 months
A child has just learned to climb the stairs alone, how old is he?
18 months
At what age does an emergence of hand preference first appear?
18 months
A child has lots of energy, can walk backwards, turn doorknobs, unscrew jars, and scribble with crayons. How old is she?
2 years
A child can ride a tricycle, go up the stairs normally, draw recognizable figures and has just started toilet training. How old is he?
3 years.
A child can descend the stairs normally and hop on one foot. How old is she?
4 years
At what age will a child develop complete sphincter control (toilet trained)?
5 years
At 5 years of age, what percentage of the adult brain mass does the child have?
A child has most of her permanent teeth, how old is he?
11 years
True or False: Boys and girls have roughly the same height to weight ratio between ages 6-12 years?
False: boys are heavier than girls.
At what age does the adolescent growth spurt usually kick in?
Around 12 years, earlier for girls than for boys.
A child plays patty cake and peek a boo, how old is she?
10 months
A baby is experiencing stranger anxiety, how old is he?
6 months
A baby has started showing signs of normal separation anxiety, how old is she?
1 year.
The parent is the central figure and issues of trust are key, how old is the child?
1st year of life.
A toddler will engage in parallel play, but "no" is still her favorite word, how old is she?
1 year
A toddler is selfish and self centered, aggresive, and tends to immitate mannerisms and activities, how old is he?
2 years
A baby can follow objects to midline, how old is she?
4 months
A baby is putting his feet in his mouth, how old is he?
5 months
A baby will approach a toy with one hand, and then change hands with the toy, how old is she?
1st year of life
A baby first laughs outloud, how old is she?
4 months
A baby has started saying "ma-ma-ma" and "da-da-da", how old is he?
10 months
Sensation and movement are most important, schemas are being developed, and assimilationand accomidation are priorities at what age in Piaget's development?
1st year of life.
In Piaget's Cognitive Development, at what age does a baby acheive object permanence?
1 year
A baby kicks and throws a ball, how old is he?
1 year
A baby can stack three cubes, how old is she?
18 months.
A todler is using two word sentences and has a vocabulary of about 250 words, how old is he?
1 year
A todler has started using pronouns and shows great variations in timing of language. Her parents seem to understand her better. How old is she?
2 years
A toddler is using complete sentences and has a vocabulary of 900 words, although he appears to understand 4x tht many words. Strangers can understand him. How old is he?
3 years
A child tells stories, uses prepositions, plurals, and has discovered compound sentences, how old is she?
4 years
A child can stand on her tiptoes, how old is she?
30 months
A child is able to aim and throw a ball and stack 6 cubes, how old is he?
2 years
In Piaget's view, a child who can use symbols and has concrete use of objects and use of symbols along with a strong egocentrism is how old?
2 years
At what age is gender identity fixed?
3 years
A child knows her full name and what sex she is, how old is she?
3 years
Two children are observed to be taking turns with a toy, how old are they?
3 years
At what age is a child likely to start grooming themselves and brushing their own teeth?
4 years
A toddler can catch a ball, stack 9 cubes, cut paper with scissors and keeps unbottoning his shirt buttons, how old is he?
3 years
A child can point to and count three objects, repeat four digits, and name colors correctly, how old is she?
4 years
A child has an imaginary friend and this is entirely normal for this age group, how old is she?
4 years
Two children are caught "playing doctor", at what age does this curiosity manifest?
4 years
A child is having terrible nightmares and needs the light left on at night for fear of monsters, how old is he?
4 years
At what age does a child adopt personal speach patterns?
adolescence (12+)
At what age does communication become the focus of friendships?
adolescence (12+)
A child repeatedly asks for the meaning of words, how old is she?
5 years
A child can count 10 objects correctly, how old is she?
5 years
At what age will a child first express romantic feelings towards others, perhaps as an Oedipal phase?
5 years
A child can draw a recognizable man, dress and undress herself, and catch a ball with two hands, how old is she?
5 years
A child can ride a bicycle, print letters, and her father is excited because she is gaining athletic skill and coordination. How old is she?
6-12 years
By age 12, about how many words will a child have in their vocabulary?
About 50,000
A child shows a shift from egocentric to social speech and incomplete sentences decline, how old is he?
6-12 years
Identity is the critical issue in what age range?
adolescence (12+)
Conformity is most important for what age range?
11-12 years
When do cross gender relationships first take off?
adolescence (12+)
A teacher has noticed many of her kids are quitting oragnized sports, how old is her class likely to be?
adolescents (12+)
A teacher has noticed that for her kids, the "rules of the game" are paramount. How old is her class?
6-12 years
At what age range are organized sports first possible?
6-12 years

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