A 50-year-old woman presents with sudden onset right upper quadrant abdominal pain. She says her symptoms started 6 hours ago after she had dinner. She describes the pain as cramping, radiating to her shoulders. She had similar episodes in the past, but they were less severe and resolved with over-the-counter analgesics. Her medical history is significant for hypertension and coronary artery disease. Her current medications include warfarin, hydrochlorothiazide, and fibrates. Her temperature is 37.7°C (99.9°F), blood pressure is 110/80 mm Hg, pulse is 80/min, and respirations are 15/min. Abdominal exam reveals severe right upper quadrant tenderness, and she catches her breath when palpated deeply just below the right costal margin. Surgical consult determines her to be surgically unfit for any intervention due to her high risk of bleeding. After treating her pain with appropriate analgesics, which of the following is the next best step in the management of this patient?
AAntispasmodic therapy (hyoscine butylbromide)
BRe-evaluate after few hours and perform laparoscopic cholecystectomy
CDiscontinue fibrates
DInitiate stronger analgesic medications such as morphine
ENo need for further treatment
A 25-year-old man comes to the physician for severe back pain. He describes the pain as shooting and stabbing. On a 10-point scale, he rates the pain as a 9 to 10. The pain started after he lifted a heavy box at work; he works at a supermarket and recently switched from being a cashier to a storekeeper. The patient appears to be in severe distress. Vital signs are within normal limits. On physical examination, the spine is nontender without paravertebral muscle spasms. Range of motion is normal. A straight-leg raise test is negative. After the physical examination has been completed, the patient asks for a letter to his employer attesting to his inability to work as a storekeeper. Which of the following is the most appropriate response?
A“Yes. Since work may worsen your condition, I would prefer that you stay home a few days. I will write a letter to your employer to explain the situation.”
BYou say you are in severe pain. However, the physical examination findings do not suggest a physical problem that can be addressed with medications or surgery. I'd like to meet on a regular basis to see how you're doing.
CI understand that you are uncomfortable, but the findings do not match the severity of your symptoms. Let's talk about the recent changes at your job.
DThe physical exam findings do not match your symptoms, which suggests a psychological problem. I would be happy to refer you to a mental health professional.
EThe physical exam findings suggest a psychological rather than a physical problem. But there is a good chance that we can address it with cognitive-behavioral therapy.
A 52-year-old man comes to the physician because of a 3-week history of a cough and hoarseness. He reports that the cough is worse when he lies down after lunch. His temperature is 37.5°C (99.5°F); the remainder of his vital signs are within normal limits. Because the physician has recently been seeing several patients with the common cold, the diagnosis of a viral upper respiratory tract infection readily comes to mind. The physician fails to consider the diagnosis of gastroesophageal reflux disease, which the patient is later found to have. Which of the following most accurately describes the cognitive bias that the physician had?
AFraming
BAnchoring
CVisceral
DConfirmation
EAvailability
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