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.129) A 44-year-old woman presents with increased shortness of breath, cough, and sputum production. She has had asthma since childhood and uses her medications as directed. Recently, she noticed that her peak flow readings were decreasing after the symptoms started. On examination, she is in moderate respiratory distress, respirations 25/min, there are bilateral wheezes and oxygen saturation is 90% on room air. On her blood gas, the PCO2 is 50 mm Hg. Which of the following is the most likely mechanism for her carbon dioxide retention?

.130) A 57-year-old man with a 40-pack-per-year history of smoking experiences symptoms of shortness of breath on exertion. He has bilateral wheezes on expiration and increased resonance to percussion of the chest. Pulmonary function tests confirm the diagnosis of chronic obstructive lung disease (COPD). Which of the following is the best definition of this condition?

.132) A 32-year-old man develops symptoms of wheezing, cough, and shortness of breath. He has bilateral expiratory wheezes, and the rest of the examination is normal. Further evaluation with pulmonary function tests reveals a reduced FEV1/FVC ratio that corrects with bronchodilators. Which of the following statements about a diagnosis of idiosyncratic asthma (also called nonatopic) is correct?

.134) A 64-year-old woman is admitted to the hospital with right lobar pneumonia and sepsis syndrome. She becomes progressively more short of breath and hypoxemic requiring intubation and mechanical ventilation. Her repeat CXR in the intensive care unit now shows diffuse pulmonary infiltrates and a diagnosis of acute respiratory distress syndrome (ARDS) is made. Which of the following mechanisms is the most likely cause for the early exudative‖ phase of ARDS?

.136) You are the internist caring for a 26-year-old male who is stricken with alcoholic gastritis. The man has remained absent from his work as a waiter for several days due to his illness. His employer calls you for more information about the illness and the prognosis. He says that he just spoke with his employee on the phone and was granted permission to talk with you. What is the most appropriate response to this request?

.137) A 34-year-old obese female is brought to the emergency department complaining of severe right upper quadrant abdominal pain that began suddenly earlier this morning. She is accompanied by her husband. An ultrasound evaluation is performed and the woman is diagnosed with acute cholecystitis. Because her symptoms worsen with conservative treatment, the decision is made to operate. The patient is discharged home five days after her successful cholecystectomy. Upon discharge, the patient and her husband request all medical records associated with her stay. What is the most appropriate response on the behalf of the physician?

.138) A long-time patient calls your office to speak with you directly. She voices frustration with your receptionist, who has repeatedly refused to allow her to schedule an appointment to see you. The patient says that at her last visit, she had a heated argument with the receptionist about a minor detail regarding her insurance coverage. When she has called since then, the receptionist always responds by saying, "I'm sorry, but there are too many patients waiting ahead of you." Which of the following defense mechanisms is the receptionist demonstrating?

.139) A 34-year-old woman who describes herself as a "holistic healer" brings her two children aged four years and three years to the pediatrician for routine physical examinations. This is a first visit as they have recently moved from another state. The medical records for the children indicate that no immunizations have been given. When the mother is questioned about this, she proudly replies, "My children are wonderfully healthy on their own and have no need for these artificial vaccines." The principles and benefits of immunization are discussed at length, as well as the risks inherent in not being immunized. The physician recommends that the children be given all age-appropriate vaccinations today. The mother remains convinced that immunizations cause more harm than good, and she steadfastly refuses to allow her children to be vaccinated. What is the most appropriate next step?

.140) A 48-year-old woman notices a firm, fixed mass in her right breast but chooses to ignore it. The mass is then detected on her annual physical examination eight months later. By that point, the mass has increased greatly in size. When questioned as to why she did not report the mass when she first noticed it, the woman states that she was not concerned about the mass because she does not have a family history of breast cancer This response is an example of which of the following defense mechanisms?

.141) A 60-year-old physician is admitted to the hospital for jaundice and weight loss. He denies other symptoms, including abdominal pain and alterations in bowel movements. His past medical history is noncontributory. He denies any history of significant alcohol intake but admits to a 30-pack-year smoking history. A detailed work-up eventually reveals the diagnosis of pancreatic carcinoma. Shortly after his discharge, he spends several hours per day on his laptop computer so that he can obtain the latest information on his illness. Which of the following psychological defense mechanisms is this physician most likely employing?

.142) A 54-year-old male with a history of chronic alcoholism is admitted to the hospital with hematemesis and abdominal distension. Upper gastrointestinal endoscopy reveals the presence of esophageal varices. Continued workup of his condition results in a diagnosis of cirrhosis of the liver. He is treated appropriately and strongly counseled about the need to abstain from alcohol. He is then discharged home. After discharge, he begins to work as a full-time volunteer for a non-profit organization that assists patients with alcoholic cirrhosis. Which of the following defense mechanisms is this man using?

.143) A 21-year-old college junior requests an urgent appointment with her family physician to discuss a "personal concern." During her conversation with the doctor, the woman appears tense, speaks very little, and makes minimal eye contact. After gentle questioning, she breaks down and says that her father is taking lithium for a manic episode experienced two years ago. She had not realized this could have any bearing on her own situation until she encountered an article on the Internet that mentioned genetics appears to play a role in the pathogenesis of bipolar disorder. Since then, she has had disturbed sleep and has been very worried that she too will one day develop bipolar disorder. Based on clinical data, what is the likelihood that she will have a manic episode during her lifetime?

.144) A 25-year-old married female is brought to the emergency department by her mother for excruciating right-sided abdominal pain. A urine pregnancy test is positive and a pelvic ultrasound reveals an empty uterus. Ruptured ectopic pregnancy is suspected, and an operating room is reserved for an emergent laparotomy. The patient's medical history is unremarkable except for a psychiatric diagnosis of paranoid schizophrenia. Who should sign the informed consent paperwork for the procedure?

.145) A 31-year-old woman voices her anger at the increasing number of immigrants who compete for job opportunities in her chosen field of computer science. She observes that many of her friends in the local community are also experiencing difficulty in securing appealing employment because of the influx of immigrants. This woman volunteers in her spare time to provide vocational guidance to new immigrant families in the community. Which of the following psychological defense mechanisms is she demonstrating?

146) A 57-year-old Caucasian woman presents for a follow-up visit regarding her lower back pain. She originally presented with this complaint last month and was advised to limit activity and use ibuprofen as needed. When her pain persisted, she was scheduled for an MRI of her back. The MRI report returned today and describes the presence of metastatic deposits in her spine. The source of the primary neoplasm remains undetermined. The patient has not yet been told about the findings and will need to be informed today. Which of the following is the best means of initiating a conversation about her condition?

..148) A 37 year-old man with chronic schizophrenia is brought to see a new psychiatrist for treatment. While taking the history, the psychiatrist finds that the patient functions with a flat affect and circumstantial speech all the time. He has few friends. He is able to hold a menial job at the halfway house where he lives, and his behavior is not influenced by delusions or hallucinations currently. What should the psychiatrist rate the patient on Axis V (global assessment of functioning)?

.149) An 18-year-old man is brought to the emergency room by police after he is found wandering in the street, screaming loudly at passersby. In the emergency room he is placed in an examination room, and paces the floor and pounds his fist against the door repeatedly. Which of the following actions should be taken by the psychiatrist first?

.150) A 24-year-old man returns from Iraq after a 13-month tour of duty. During that tour he was involved in battle situations and saw one of his friends injured by a car bomb. What percentage of American soldiers returning home from Iraq have posttraumatic stress disorder (PTSD)?

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100) A 21 -year-old male has been experiencing severe headaches for the past week. He also describes difficulty grasping objects in his right hand and difficulty getting dressed, which both started today. CT scan of the head shows a ring-enhancing lesion in the left frontal lobe and a fluid collection in the left maxillary sinus. Tissue biopsy of the brain lesion is most likely to demonstrate which of the following?

.101) A 30-year-old Caucasian male comes to the office due to symmetric weakness of his lower extremities. He also has paresthesias in his toes and fingers, and lower back pain. The neurological examination shows symmetric weakness, diminished reflexes, and intact sensation in his lower extremities. Orthostatic hypotension is also noted. Electrophysiological studies show slowed nerve conduction velocities. Lumbar puncture reveals normal opening pressure. CSF examination shows few cells, and a protein concentration of 90 mg/dL. Which of the following organisms is involved in the pathogenesis of this disorder?

.102) A 65-year-old Caucasian male presents to your office complaining of an episode of slurred speech and clumsiness of his right hand. The episode lasted 15 minutes and resolved spontaneously. He had a similar episode one week ago. His past medical history is significant for moderate hypertension, diabetes mellitus (OM) type 2 and osteoarthritis of the right knee. He has smoked one pack of cigarettes daily for 35 years, and drinks 1-2 glasses of wine daily. His current medications include metoprolol, glyburide and naproxen. His blood pressure is 160/95 mmHg, pulse is 65/min, respirations are 16/min, and temperature is 36.7°C (98°F). The physical findings are within normal limits. The lab studies show: Fasting blood glucose 200 mg/dl, Total cholesterol 240 mg/dl, LDL cholesterol 140 mg/dl, HDL cholesterol 76 mg/dl. What is the most important risk factor for a stroke in this patient?

.103) A 65-year-old bedridden woman is brought in with complaints of weight loss, weakness and malaise. Her past medical history includes chronic obstructive pulmonary disease (diagnosed fifteen years ago) and hypertension of ten years' duration. She quit smoking two years ago, but previously smoked three packs of cigarettes daily since she was 20 years of age. Her vital signs are stable. Her physical examination reveals severe weakness in her proximal muscles, and loss of deep tendon reflexes. Chest x-ray shows a right upper lung mass with mediastinal lymphadenopathy. Which of the following is the most likely cause of her weakness?

.104) A 16-year-old female complains of headaches and visual impairment for the past month. She says that the headaches are worst in the morning and are associated with nausea. Her medical history is also significant for severe acne for which she takes oral isotretinoin. On physical examination, her temperature is 36.7°C (98°F), blood pressure is 130/80 mm Hg, pulse is 70/min, and respirations are 15/min. She has papilledema and decreased visual acuity. There is no neck stiffness. Motor examination shows 5/5 power, 2+ deep tendon reflexes, and a normal plantar response. Sensory examination is unremarkable. CT scan of the head is within normal limits. Lumbar puncture reveals the following: Opening pressure 250 cm H20, CSF glucose 40 mg/dL, CSF protein 40 mg/dL, WBC 3/mm3. Which of the following is the most likely cause of her symptoms?

.105) A 26-year-old man comes to the emergency department because he is "suffering from the worst headache of his life." He feels nauseated and is photosensitive. His blood pressure is 160/90 mm Hg, heart rate is 88/min, and temperature is 36.5°C (97.7°F). The physical examination reveals no focal neurological symptoms, except for some meningismus and vertigo, which is not localized to either side. CSF examination reveals the presence of xanthochromia. What is the major cause of morbidity and mortality in a patient with the above condition?

.106) A 53-year-old man comes to the office because of difficulty reading fine print over the last year. He now has to hold books, menus, and magazines at an arm’s length in order to read them. He has never had visual problems before. Which of the following is most likely abnormal in this patient?

.107) A 35-year-old HIV-positive male is complaining of deterioration of his vision over the past week. He initially experienced eye pain and mild conjunctivitis, followed by rapid progressive visual loss. Examination of his eyes reveals marked keratitis. Funduscopy shows widespread, pale, peripheral retinal lesions and central necrosis of the retina. Which of the following is the most likely causative organism of this patient's condition?

.108) A 57-year-old female with a history of type 2 diabetes mellitus complains of fatigue, urinary frequency, increasingly blurred vision and worsening leg cramps over the past week. She reports that the symptoms all began following an upper respiratory infection 7 or 8 days ago. She does not take any medications, but adheres to a diet low in saturated fat and simple carbohydrates to manage her diabetes. On physical examination, her blood pressure is 160/90 mmHg and her heart rate is 90/min. Her mucous membranes are dry. Her urine is positive for glucose but negative for ketones. Which of the following is the most likely cause of this patient's vision impairment?

.109) A 34-year-old obese Caucasian female complains of periodic visual obscurations. She has episodes during which she "goes blind" for several seconds when standing up or stooping forward abruptly. She also describes frequent morning headaches over the last two months for which she has had to take ibuprofen or aspirin almost every morning. She takes no other medications. Past medical history is insignificant aside from one uncomplicated vaginal delivery. She denies use of alcohol, tobacco, or illicit drugs. She is afebrile with a blood pressure of 138/88 mmHg and pulse of 93/min. Visual field testing shows enlarged blind spots. There are no other significant findings on neurologic examination. Which of the following is the most likely cause of this patient's symptoms?

.110) A 30-year-old man is concerned about "floating spots" and blurred vision in his right eye. He had a serious injury of his left eye several weeks ago, which eventually led to vision loss in that eye. Inspection reveals a moderate perilimbal flush. What is the most probable cause of this patient's condition?

.111) A 67-year-old Caucasian male complains of progressive visual loss in his right eye over the past several months. He has a history of hypertension and type 2 diabetes mellitus. Current medications include a daily baby aspirin, hydrochlorothiazide, lisinopril, and metformin. There is no family history of visual problems. He has a 35 pack year smoking history and admits to occasional alcohol use. He is afebrile with a blood pressure of 137/82 mmHg and pulse of 73/min. Cardiac and pulmonary examinations are unremarkable. A neurologic examination demonstrates no focal motor or sensory abnormalities. The patient is asked to cover his left eye and to look at a small spot on a grid made of parallel vertical and horizontal lines. He describes the vertical lines as being bent and wavy. Which of the following is the most likely cause of this patient's complaints?

.112) A 35-year-old white female is complaining of blurry vision and pain with eye movements. She is on no medications and denies any trauma. Last year, she developed bladder incontinence and an episode of leg weakness, which both improved without therapy. Physical examination reveals reduced vision and swollen optic discs. The one diagnosis that may explain her symptoms is:

.113) A 67-year-old male presents with a one-month history of dyspnea on exertion and chest pain. He denies hemoptysis, cough, fever, night sweats or weight loss. His past medical history is significant for hypertension and chronic obstructive pulmonary disease. He has a 48 pack-year smoking history but quit six years ago. He works as a salesman. On physical examination, the patient has a temperature of 38.2°C (100.8°F), blood pressure of 128/72 mm Hg, pulse of 92/minute, and respirations of 20 breaths/minute. His complete blood count, chemistry panel, and hepatic function tests are all within normal limits. A chest x-ray and computed tomography scan of the chest reveal a right-sided pleural effusion and calcified nodules in both upper lobes. The patient undergoes thoracentesis. Characteristics of the pleural fluid are given below: Total protein 5.2 g/dl, Glucose 83 mg/dl, Adenosine deaminase 98.5 U/L. Cytologic examination reveals 600 white blood cells/mm3, 1% macrophages and 99% leukocytes. Of the leukocytes, 45% are neutrophils, 50% are lymphocytes, and 5% are monocytes, with no basophils or eosinophils. No neoplastic cells are found. Which of the following is the most likely mechanism underlying development of this pleural effusion?

.115) A 65-year-old man complains of two years of persistent cough. He says that he coughs up whitish sputum almost every morning on waking, and then continues coughing throughout the day. He also complains of exertional shortness of breath that becomes disabling if he gets an upper respiratory infection. He has smoked one pack of cigarettes daily for the past 40 years. Pulmonary function testing reveals a vital capacity that is 65% of his predicted. Which of the following best explains this finding?

.116) A 71-year-old man is brought to the ER after a witnessed tonic-clonic seizure. He is somnolent and intermittently combative on exam. No past medical history is available. His arterial blood gas (ABG) at room air is given below: pH 7.23, pCO2 69 mmHg, pO2 57 mmHg, HCO3 28 mmHg. Which of the following best explains the acid-base disturbances in this patient?

.117) A 60-year-old white male presents to the Emergency Room with sudden onset of dyspnea. He is a truck driver and just returned from a long trip. His past medical history is insignificant. He is not taking any medications. His blood pressure is 110/70 mmHg and heart rate is 110/min. Physical examination reveals a moderately overweight man with tachypnea. Lungs are clear on auscultation. ECG shows right axis deviation. You order ventilation/perfusion scanning. Which of the following findings will help you the most to confirm the diagnosis?

.118) A 74-year-old nursing home resident is brought to the ER with a low-grade fever, cough and shortness of breath for the last two days. The cough is productive of small amounts of greenish sputum. His past medical history is significant for hypertension, diabetes mellitus type 2, COPD, hypercholesterolemia and mild dementia. His blood pressure is 152/78 mmHg and his heart rate is 89/min, regular. Physical examination reveals decreased breath sounds, coarse rhonchi, and increased fremitus over the lower left lung field. His oxygen saturation is 92% on room air when lying on his right side but drops to 84% when he lies on his left. Which of the following best explains this finding?

..119) A 60-year-old man comes to the office with worsening shortness of breath over the last 5 months. He has had two episodes of bronchitis over the last 12 months. He now has a mild nonproductive cough. He denies any fever, chills, hemoptysis, chest pain, or difficulty breathing while lying on his back. His medications include an ipratropium inhaler, aspirin, and amlodipine. He was hospitalized twice in the last 3 years due to an exacerbation of his chronic obstructive pulmonary disease. He has been smoking 1 pack of cigarettes per day for the last 40 years. His temperature is 99°F (37.2°C), blood pressure is 130/86 mm Hg, pulse is 98/min, and respirations are 18/min. Examination shows a thin man in mild respiratory distress with increased anteroposterior chest diameter, diffuse expiratory wheeze and loud S2. Chest X-ray shows hyperinflation of bilateral lung fields with diaphragm flattening and small heart size. Which of the following is the most effective measure to decrease mortality in this patient?

.120) A 64-year-old man presents to the emergency department with progressive exertional dyspnea that worsened after he contracted an upper respiratory infection. He also complains of bilateral ankle swelling. He has a 40 pack-year history of smoking. Physical examination reveals a mildly overweight patient in mild respiratory distress. Lung auscultation reveals bilateral wheezes and a prolonged expiratory phase. His white blood cell count is 14,500/mm3 and his hemoglobin level is 16 mg/dl. Arterial blood gas analysis reveals the following: pH 7.37, pO2 65mmHg, pCO2 60mmHg. Absence of marked acidosis in this patient is best explained by which of the following?

.121) A 43-year-old woman with congestive heart failure, rheumatoid arthritis and chronic hepatitis C complains of abdominal discomfort and difficulty breathing. Physical examination shows dullness to percussion at the right lung base. Chest x-ray reveals a large right-sided pleural effusion. Thoracentesis yields pleural fluid with a glucose content of 30 mg/dl and an LDH of 192units/L. Which of the following explains the pleural fluid glucose concentration?

.123) A 42-year-old morbidly obese man is being evaluated for poor sleep. He complains of frequent awakenings due to a choking sensation and says that the resulting tiredness severely limits his physical activity. He also complains of chronic leg swelling. He denies cigarette, alcohol, or drug use. On physical examination, his blood pressure is 160/100 mmHg and his heart rate is 110/min. Which of the following additional findings is most likely to be present in this patient?

.125) A 53-year-old homosexual man comes to the ER with shortness of breath and dry cough over the past week. You note that he was hospitalized for Candida esophagitis one month ago, but left against medical advice. On physical examination, his blood pressure is 120/70 mmHg, heart rate is 120/min and regular, oxygen saturation is 89% on 2Umin of oxygen by nasal cannula, and temperature is 38.3°C (101°F). There are extensive white plaques over the oral mucosa and there is a soft 2/6 systolic murmur over the cardiac apex. Lung auscultation is remarkable for faint bilateral crackles. Which of the following is most likely responsible?

.126) A 56-year-old male presents with progressively worsening dyspnea over a 4 month period. He denies fever, chest pain, cough or ankle swelling and does not use tobacco, alcohol or drugs. He works for a home insulation and plumbing company. He has never been abroad and does not own any pets. His only medications are hydrochlorothiazide and metoprolol for blood pressure control. On physical examination, his temperature is 36.8°C (98.2°F), pulse is 76/min, blood pressure is 130/78 mmHg, and respirations are 15/min. Examination shows digital clubbing and fine bibasilar end-inspiratory crackles. Jugular venous pressure is 7 cm and there is no peripheral edema. Which of the following additional findings is most likely in this patient?

.127) An 80-year-old Caucasian female is brought to the emergency room by her son with a three-day history of fever and a foul-smelling, productive cough. Her past medical history is significant for advanced dementia, diabetes, and hypertension. She takes aspirin, metformin, insulin, and atenolol. She was admitted two times with pneumonia during the past two months. Her temperature is 38.3°C (101°F), blood pressure is 100/70mmHg, pulse is 105/min, and respirations are 20/min. The patient is not oriented in time and place. Physical examination reveals dry mucus membranes and decreased skin turgor. Breath sounds are decreased to the right. A chest x-ray revealed right, lower lobe infiltrate. Which of the following is the most important predisposing factor for this condition in this patient?

.129) A 44-year-old woman presents with increased shortness of breath, cough, and sputum production. She has had asthma since childhood and uses her medications as directed. Recently, she noticed that her peak flow readings were decreasing after the symptoms started. On examination, she is in moderate respiratory distress, respirations 25/min, there are bilateral wheezes and oxygen saturation is 90% on room air. On her blood gas, the PCO2 is 50 mm Hg. Which of the following is the most likely mechanism for her carbon dioxide retention?

.130) A 57-year-old man with a 40-pack-per-year history of smoking experiences symptoms of shortness of breath on exertion. He has bilateral wheezes on expiration and increased resonance to percussion of the chest. Pulmonary function tests confirm the diagnosis of chronic obstructive lung disease (COPD). Which of the following is the best definition of this condition?

.131) A 38-year-old man is being seen in his physician’s office after being involved in a car accident. He has a vague pain along his right sternal border, where he crashed into the steering wheel. His temperature is 36.6°C (97.8°F), pulse is 80/min, blood pressure is 123/75 mm Hg, respiratory rate is 14/min, and oxygen saturation is 99% on room air. Physical examination is significant for point tenderness over the right sternal border. X-ray of the chest shows no broken ribs but a single, well-circumscribed pulmonary nodule, 1.5 cm in diameter, located in the left lower lung field. A search through the patient’s electronic medical file reveals that he had an x-ray of the chest taken 2 years ago. The radiology report from that time reveals that the nodule was only 0.75 cm in diameter. To characterize the lesion, CT of the chest is performed and shows dense, flocculated calcification within the lesion. Which of the following risk factors most increases the chances of malignancy in this patient?

.132) A 32-year-old man develops symptoms of wheezing, cough, and shortness of breath. He has bilateral expiratory wheezes, and the rest of the examination is normal. Further evaluation with pulmonary function tests reveals a reduced FEV1/FVC ratio that corrects with bronchodilators. Which of the following statements about a diagnosis of idiosyncratic asthma (also called nonatopic) is correct?

.133) A 25-year-old man is recovering in the hospital from an open repair of his broken femur, which he suffered during an automobile accident. On postoperative day 3 he develops sudden onset shortness of breath and vague chest discomfort. His temperature is 37.6°C (99.6°F), heart rate is 108/min, blood pressure is 95/62 mm Hg, respiratory rate is 42/min, and oxygen saturation is 89% on room air. Physical examination is significant for jugular venous distention to 9 cm and an accentuated pulmonic component of S2. A pulmonary angiogram is shown in the image. Which of the following is most likely to be decreased?

.134) A 64-year-old woman is admitted to the hospital with right lobar pneumonia and sepsis syndrome. She becomes progressively more short of breath and hypoxemic requiring intubation and mechanical ventilation. Her repeat CXR in the intensive care unit now shows diffuse pulmonary infiltrates and a diagnosis of acute respiratory distress syndrome (ARDS) is made. Which of the following mechanisms is the most likely cause for the early exudative‖ phase of ARDS?

.135) A 55-year-old woman is in the intensive care unit on a ventilator for hypoxemia following “flash” pulmonary edema. Her PO2 on the blood gas prior to intubation was 44 mm Hg, and now while breathing 100% oxygen on the ventilator her repeat blood gas reveals a PO2 of 80 mm Hg. Hypoxemia while receiving 100% oxygen indicates which of the following problems?

.136) You are the internist caring for a 26-year-old male who is stricken with alcoholic gastritis. The man has remained absent from his work as a waiter for several days due to his illness. His employer calls you for more information about the illness and the prognosis. He says that he just spoke with his employee on the phone and was granted permission to talk with you. What is the most appropriate response to this request?

.137) A 34-year-old obese female is brought to the emergency department complaining of severe right upper quadrant abdominal pain that began suddenly earlier this morning. She is accompanied by her husband. An ultrasound evaluation is performed and the woman is diagnosed with acute cholecystitis. Because her symptoms worsen with conservative treatment, the decision is made to operate. The patient is discharged home five days after her successful cholecystectomy. Upon discharge, the patient and her husband request all medical records associated with her stay. What is the most appropriate response on the behalf of the physician?

.138) A long-time patient calls your office to speak with you directly. She voices frustration with your receptionist, who has repeatedly refused to allow her to schedule an appointment to see you. The patient says that at her last visit, she had a heated argument with the receptionist about a minor detail regarding her insurance coverage. When she has called since then, the receptionist always responds by saying, "I'm sorry, but there are too many patients waiting ahead of you." Which of the following defense mechanisms is the receptionist demonstrating?

.139) A 34-year-old woman who describes herself as a "holistic healer" brings her two children aged four years and three years to the pediatrician for routine physical examinations. This is a first visit as they have recently moved from another state. The medical records for the children indicate that no immunizations have been given. When the mother is questioned about this, she proudly replies, "My children are wonderfully healthy on their own and have no need for these artificial vaccines." The principles and benefits of immunization are discussed at length, as well as the risks inherent in not being immunized. The physician recommends that the children be given all age-appropriate vaccinations today. The mother remains convinced that immunizations cause more harm than good, and she steadfastly refuses to allow her children to be vaccinated. What is the most appropriate next step?

.140) A 48-year-old woman notices a firm, fixed mass in her right breast but chooses to ignore it. The mass is then detected on her annual physical examination eight months later. By that point, the mass has increased greatly in size. When questioned as to why she did not report the mass when she first noticed it, the woman states that she was not concerned about the mass because she does not have a family history of breast cancer This response is an example of which of the following defense mechanisms?

.141) A 60-year-old physician is admitted to the hospital for jaundice and weight loss. He denies other symptoms, including abdominal pain and alterations in bowel movements. His past medical history is noncontributory. He denies any history of significant alcohol intake but admits to a 30-pack-year smoking history. A detailed work-up eventually reveals the diagnosis of pancreatic carcinoma. Shortly after his discharge, he spends several hours per day on his laptop computer so that he can obtain the latest information on his illness. Which of the following psychological defense mechanisms is this physician most likely employing?

..142) A 54-year-old male with a history of chronic alcoholism is admitted to the hospital with hematemesis and abdominal distension. Upper gastrointestinal endoscopy reveals the presence of esophageal varices. Continued workup of his condition results in a diagnosis of cirrhosis of the liver. He is treated appropriately and strongly counseled about the need to abstain from alcohol. He is then discharged home. After discharge, he begins to work as a full-time volunteer for a non-profit organization that assists patients with alcoholic cirrhosis. Which of the following defense mechanisms is this man using?

.143) A 21-year-old college junior requests an urgent appointment with her family physician to discuss a "personal concern." During her conversation with the doctor, the woman appears tense, speaks very little, and makes minimal eye contact. After gentle questioning, she breaks down and says that her father is taking lithium for a manic episode experienced two years ago. She had not realized this could have any bearing on her own situation until she encountered an article on the Internet that mentioned genetics appears to play a role in the pathogenesis of bipolar disorder. Since then, she has had disturbed sleep and has been very worried that she too will one day develop bipolar disorder. Based on clinical data, what is the likelihood that she will have a manic episode during her lifetime?

.144) A 25-year-old married female is brought to the emergency department by her mother for excruciating right-sided abdominal pain. A urine pregnancy test is positive and a pelvic ultrasound reveals an empty uterus. Ruptured ectopic pregnancy is suspected, and an operating room is reserved for an emergent laparotomy. The patient's medical history is unremarkable except for a psychiatric diagnosis of paranoid schizophrenia. Who should sign the informed consent paperwork for the procedure?

.145) A 31-year-old woman voices her anger at the increasing number of immigrants who compete for job opportunities in her chosen field of computer science. She observes that many of her friends in the local community are also experiencing difficulty in securing appealing employment because of the influx of immigrants. This woman volunteers in her spare time to provide vocational guidance to new immigrant families in the community. Which of the following psychological defense mechanisms is she demonstrating?

.146) A 57-year-old Caucasian woman presents for a follow-up visit regarding her lower back pain. She originally presented with this complaint last month and was advised to limit activity and use ibuprofen as needed. When her pain persisted, she was scheduled for an MRI of her back. The MRI report returned today and describes the presence of metastatic deposits in her spine. The source of the primary neoplasm remains undetermined. The patient has not yet been told about the findings and will need to be informed today. Which of the following is the best means of initiating a conversation about her condition?

.147) A 23-year-old man comes to the psychiatrist with a chief complaint of a depressed mood. He is very anxious and obviously uncomfortable in the physician’s office. Which of the following actions should be used to help develop rapport with this patient?

.148) A 37 year-old man with chronic schizophrenia is brought to see a new psychiatrist for treatment. While taking the history, the psychiatrist finds that the patient functions with a flat affect and circumstantial speech all the time. He has few friends. He is able to hold a menial job at the halfway house where he lives, and his behavior is not influenced by delusions or hallucinations currently. What should the psychiatrist rate the patient on Axis V (global assessment of functioning)?

.149) An 18-year-old man is brought to the emergency room by police after he is found wandering in the street, screaming loudly at passersby. In the emergency room he is placed in an examination room, and paces the floor and pounds his fist against the door repeatedly. Which of the following actions should be taken by the psychiatrist first?

.150) A 24-year-old man returns from Iraq after a 13-month tour of duty. During that tour he was involved in battle situations and saw one of his friends injured by a car bomb. What percentage of American soldiers returning home from Iraq have posttraumatic stress disorder (PTSD)?

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