PCL 1 - Case 4: Session 1
Sean O’Malley
Jason Pier in DC. (2009). Mother and Father [electronic image]. Retrieved from:
http://www.flickr.com/photos/jasonpier/3545398901/
1
Sean O’Malley
Interview between Sean and his
physician, Dr. Abani Mehta
Sean O’Malley (SO) visits his physician at the MFA, Dr. Abani Mehta (MD)
MD: Good morning Mr. O’Malley – haven’t seen you in a long time.
SO: Hi Doc.
MD: Please Have a seat over there and we can chat.
SO: Thanks.
MD: So, I see that you haven’t been to the office for several years. You know I see your wife,
Alice, every year for her physical. She mentioned that she was going to try to get you to come
in. So what brings you in today?
Sean & Alice
SO: Oh, not much really. Alice thought it was about time I got
a checkup.
MD: Did she have any specific concerns?
SO: Alice is a worry-wart. Are you married? You know what
it’s like. She says I’m pushing myself too hard . . .
MD: Oh?
Jason Pier in DC. (2009). Mother and Father [electronic image].
Retrieved from:
http://www.flickr.com/photos/jasonpier/3545398901/
WomensHealth.gov (2011). Publications for Health Professionals [Online image}.
Retrieved from http://womenshealth.gov/publications/health-professionals/
Sean O’Malley
Interview between Sean and his
physician, Dr. Abani Mehta
SO: Yeah, the usual aggravations once you hit your fifties – the job,
paying endless bills, and dealing with the kids – especially that boy.
MD: So it hasn’t been easy for you lately . . .
SO: It’s been no piece of cake – but nothing I can’t handle, just like I
always have.
MD: You’ve got two kids, don’t you? How old are they now?
SO: Julie’s 20 and a junior at Maryland, no problem, great kid. Carl,
he’s eighteen now and just started at Maryland as a freshman this
past fall. Still a bit wild, that one – doesn’t listen much. Paying bills
for both of them has sure turned up the pressure. All this
aggravation I’ve gotta put up with – maybe that’s what’s eating at
me and making me feel bad . . .
MD: Please go on.
Sean’s Son, Carl
SO: It’s no big deal. When I get aggravated it just makes me feel
crummy – no energy, tired all over, nagging heartburn sort of – but I
guess laying out two tuitions is enough to do that to anyone.
Graves, Stephanie. (2007). Keg Stand [electronic image]. Retrieved from:
http://www.flickr.com/photos/the8rgrl/955839104/
eyewash. (2009). Delta Something-or-Other House [electronic image]. Retrieved from:
http://www.flickr.com/photos/eyewash/3899769246/
Julicath (2008) Ma douce Filleule Deli-cat [electronic image]. Retrieved from:
http://www.flickr.com/photos/9221141@N02/2977860978/
Sean O’Malley
Interview between Sean and his
physician, Dr. Abani Mehta
MD: Anything else?
SO: Isn’t that enough, doc ?!
MD: So let me be sure I have this straight. Your wife has been concerned about you. Also,
you’re feeling a lot of pressure. Sometimes when you get aggravated you feel bad – tired and
you feel some nagging heartburn pain . . .
SO: Yeah, that’s about right, but it’s not pain in the chest, it’s just that sometimes I notice, well,
this nagging burning feeling.
MD: Can you tell me more about this nagging, burning feeling.
SO: Well, it doesn’t seem to be related to anything I eat. I’ve got an iron stomach you might
say. The more spice the better.
MD: How about after meals or late at night in bed. Does the burning act up then?
SO: Not really, I guess I notice it mostly during the day. When I hit the
sack at night, I’m out like a light.
Sean’s Daughter, Julie
MD: OK, does this discomfort get very
intense?
Robert the Noid. (2007). A Good Place to Study [electronic image].
Retrieved from:
http://www.flickr.com/photos/herbarium_gnome/1992013924/in/pho
tostream/
Sean O’Malley
Interview between Sean and his
physician, Dr. Abani Mehta
SO: Nah, nothing I can’t put up with.
MD: I see, so when do you notice this pain?
SO: I said before I don’t get no pain.
MD: I’m sorry, I meant the nagging and burning. When does it seem to act up?
SO: Well, as I said, the never-ending money problems usually get it going. Like when I gotta do
those monthly bills late at night. That’s one big aggravation.
MD: There’s nothing like kids at college to keep you in the hole. Anything else?
SO: You mean that causes the nagging?
MD: Uh huh.
SO: Well I guess I’m probably getting old. In the morning I gotta walk the dog before heading
off to the garage. This time of year is still pitch black, cold, and the wind’s coming right up the
block. By the time I get to the end of the driveway I usually get the nagging but I usually ignore
it and get on to the job.
MD: I see. Where exactly do you feel this discomfort?
Sean O’Malley
Interview between Sean and his
physician, Dr. Abani Mehta
SO: Oh, sort of here in the throat.
MD: Do you notice it anywhere else?
SO: What do ya mean?
MD: Does the pain, I mean the nagging, move anywhere else?
SO: Well sometimes when it gets a bit intense, it might move up under my jaw.
MD: How long does it usually last?
SO: Maybe a few minutes, I guess. I usually ignore it and it disappears before I know it.
MD: OK, well do you notice that feeling any other times during the day?
SO: Not too much, Sometimes when I’m driving the train, maybe. Between the tight schedule
and the people trying to jam on the train at rush hour, that’ll get me steamed and all the
aggravation is enough to give anyone heartburn. That’s why I keep a roll of TUMS handy. One
or two and it’s gone.
MD: Has anyone in the past ever told you that you have any stomach or gastrointestinal
problems? Or needed liquid antacids?
Sean O’Malley
Interview between Sean and his
physician, Dr. Abani Mehta
SO: Oh, sort of here in the throat.
MD: Do you notice it anywhere else?
SO: What do ya mean?
MD: Does the pain, I mean the nagging, move anywhere else?
SO: Well sometimes when it gets a bit intense, it might move up under my jaw.
MD: How long does it usually last?
SO: Maybe a few minutes, I guess. I usually ignore it and it disappears before I know it.
MD: OK, well do you notice that feeling any other times during the day?
SO: Not too much, Sometimes when I’m driving the train, maybe. Between the tight schedule
and the people trying to jam on the train at rush hour, that’ll get me steamed and all the
aggravation is enough to give anyone heartburn. That’s why I keep a roll of TUMS handy. One
or two and it’s gone.
MD: Has anyone in the past ever told you that you have any stomach or gastrointestinal
problems? Or needed liquid antacids?
Sean O’Malley
Interview between Sean and his
physician, Dr. Abani Mehta
SO: Nah, but some years back when I had a check up for the job, a doc told me I might have
some kinda hernia problem.
MD: Did he say a hiatal hernia?
SO: Yeah, maybe. He said I might want to get one of those x-ray tests where you drink that
liquid stuff or something. Since I felt okay, especially after cutting back on my drinking, I never
bothered to do anything about it again.
MD: How about alcohol? Are you much of a drinker nowadays?
SO: Naw, nothing like the old days. Just a few beers on the weekend. Never during the week
and never when I’m on the job – have to be alert when I’m on the train.
MD: Good enough then. You were talking about your work before. How long have you been
working for Metro?
SO: Seems like forever. This spring will make 27 years. It’s the only place I’ve worked since I
got out of the army in ‘84. Driving that train everyday has worn me out. And then there are
those rush hour shifts with everyone trying to cram themselves unto the train. I was hoping
there might be an opening in the office for a supervisor position but they’ve cut back and
there’s no opening in sight. Looks like I’m stuck driving the train . . .
Sean O’Malley
Interview between Sean and his
physician, Dr. Abani Mehta
MD: Sounds like that train must give you a lot of stress.
SO: You’re telling me! Sometimes if I drive a long stretch and I have to deal with those pushy
rush-hour commuters, I can get a doozy of a headache. Seems to happen more in winter –
maybe cause everyone is crabbier in the cold. Then there’s that damned water cooler - that’s
always a royal pain!
MD: What’s that about?
SO: You see we have this water cooler in our break room and every week I have to lug in a new
bottle and those things weigh about 40 pounds. I’m outta shape so lifting that thing
sometimes makes me feel that nag in my throat, but it doesn’t last long.
MD: Mm. Anything else bring it on? Like exercise? Do you have any time for leisure activities?
SO: Exercise? Me?! Does watching the Redskins count? I’m mostly into spectator sports. As I
said before, I walk the dog most mornings but that only takes five or ten minutes. On the
weekends, I’ll mow the lawn, but nowadays I gotta take my time. Lately I got this arthritis
condition in my left shoulder probably from an old high school football injury. Just another part
of me falling apart with getting older. When I try to lift my left arm I can barely reach above my
head. Then when I push the mower sometimes the shoulder really acts up and I might even
notice that heartburn. If I rest a moment, the shoulder must loosen up or something, (cont.)
Sean O’Malley
Interview between Sean and his
physician, Dr. Abani Mehta
SO (cont.): and I can finish the job without any problem. Of course, that college boy of mine is
supposed to take care of the lawn. But come the weekends in the summer, he sleeps all
morning and then disappears with his buddies. Anyway, as you can see I’m not an exercise nut.
MD: I got the picture – does that shoulder of yours act up any other time?
SO: Once in a while. Just when I overdo it. It’s sensitive to the cold weather and sometimes
when I’m at work I’ll notice it. By the end of the day, when I’m doing the brakes and
accelerator, the old shoulder will start to ache. A couple aspirin, and I’m okay.
MD: How often do you try aspirin?
SO: Well, I keep a bottle on the train with me, as well as back at the house. On a bad day,
maybe I’ll take 6 to 8 pills.
MD: Are you taking any medications, other than the aspirin?
SO: Just some Ben Gay, but I can’t tell if that does much.
MD: OK. Now, do you have a history of any other medical problems?
SO: No, I’ve been pretty healthy so far. Only went to the hospital when I was a kid to get my
tonsils out. I’ve been able to avoid doctors these past years.
Sean O’Malley
Interview between Sean and his
physician, Dr. Abani Mehta
MD: Nothing else, like diabetes or high blood pressure?
SO: In me? Nope.
MD: How about in your family? Your parents?
SO: Oh yeah, my mother, she had a sugar problem I think when she was in her seventies. And
my dad, he wasn’t diabetic but he had high blood pressure as long as I can remember. Not
much they could do about it in those days.
MD: Are either of your parents still alive?
SO: Nope, my father died a long while back when he was about 53. My mother just passed on
two years ago when she was almost 80.
MD: Do you know what happened to your dad?
SO: Not really. I just remember he went off to work one day and collapsed in the middle of the
shop. He never knew what hit him.
MD: Did the doctors tell you what they thought happened?
SO: They weren’t sure.
Sean O’Malley
Interview between Sean and his
physician, Dr. Abani Mehta
MD: Did they say it might be a heart problem?
SO: Well, I guess they did say my dad might have had a weak heart, maybe because of his
smoking, but otherwise no one else in my family had any heart problems as far as I heard.
MD: Do you smoke cigarettes?
SO: I used to smoke 2-3 packs a day but the coughing would rack my chest. So I quit for good
about 2 years ago.
MD: That’s great! Do you still cough at times?
SO: Oh yeah, but not the coughing fits I had in the past.
MD: Do you have a history of any lung illnesses, like pneumonia, tuberculosis, coughing up
blood?
SO: Nope, nothing like that.
MD: Has anyone ever told you that you have high cholesterol?
SO: Nope, I don’t think I ever got it checked.
Sean O’Malley
Interview between Sean and his
physician, Dr. Abani Mehta
MD: Now I noticed your weight on the scale today is 224 pounds. Is that your usual weight?
SO: Pretty much. Years ago, before I got married, I was around 180, 185. But you know, you
get older, new responsibilities, and so forth – I’ve sort of expanded a bit, doc.
MD: Have you tried to lose a few pounds?
SO: Well both my wife and I are a bit on the heavy side as you know. She is always saying that
the both of us gotta lose 20 pounds, so she is always trying us on some new fad diet. Once in a
while I lose 5 pounds but it always comes right back. The big problem was when I quit smoking
– I started eating everything in sight and after 4 weeks I had put on 15 pounds. Never was able
to lose that again.
MD: What kind of diet do you have now?
SO: Nothing special, I’m your typical meat and potatoes kind of guy.
MD: Do you try to avoid fat in your diet?
SO: Nah, the wife and I, we don’t have time for any fancy cooking – unless she’s on one of her
diet kicks, but those don’t last too long.
MD: How are you and Alice doing? She seemed concerned about you when I saw her.
Sean O’Malley
Interview between Sean and his
physician, Dr. Abani Mehta
SO: Well doc, I guess with work, the kids, expenses – I can be a pain sometimes when I’m
home. I’m sure I give Alice more trouble than she deserves.
MD: So you two are doing OK as you head into your 50s?
SO: Well, I guess we’re both going through the change in life. She misses the kids, especially
Carl – that ‘empty nest syndrome’ I guess. But she’s volunteering at the YMCA, teaching
swimming to some handicapped kids. She’s thinking about working to help out with the bills,
but I’d rather she just did the stuff at the ‘Y’. I’ve always provided for us and I don’t see why
that should change now.
MD: How about your sexual relations?
SO: Our sex life? That’s okay I guess – we both like to ‘get busy’ once in a while, if you know
what I mean. But I gotta take it slow nowadays. I’m not in as good of shape – get short of
breath sometimes, maybe even a little heartburn, but I don’t let her know.
MD: I understand. Well, maybe we can figure out a way to get you back in shape. Let’s go into
the examining room next door where I can take your blood pressure and do a thorough physical
exam. Then, maybe I can give you some suggestions.
Sean O’Malley
Background
Go to Clinical Notes and Fill Out the
History That You Have Learnt Thus Far.
Go to Clinical Notes
Go to Problem List
15
Sean O’Malley
Background
Distribute and Read Handout 1:
Background
Go to Clinical Notes
Go to Problem List
16
Sean O’Malley
Background
Handout 1: Background – Take Away Points
• Middle-aged, working class male.
• Father died suddenly at 53.
• Wife makes a lot of the health-care decisions.
• He and Alice have traditional roles at home.
• Ex-smoker / minimal exercise.
• Complicated relationship with children – wants to create
opportunities for his children that he never had.
Go to Clinical Notes
Go to Problem List
17
Sean O’Malley
EKG and Results of the Exercise Treadmill Test
Mr. O’Malley underwent a screening study for CAD with an exercise treadmill test .
He was shown this video prior to consenting for the test . . .
Stress Test Video
Sean O’Malley
EKG and Results of the Exercise Treadmill Test
N.A. (N.D.) Stress induced Electrocardiogram in a
patient of Angina Pectoris[electronic image].
Retrieved from: http://manbironline.com/cardiac/ecg_stress-test-2.htm
Lead V4 at rest (top) and after 6 METS of exercise (bottom). He has a burning sensation in his throat and 3 mm (0.3 mV) of
horizontal ST-segment depression, at a heart rate of 145 beats per min and systolic BP 150 mmHg. His test is "positive" for
ischemia.
LIPID RESULTS:
The patient had a lipid profile drawn at the end of the first office visit as an addition to his CAD risk
profile. The total cholesterol is high (275mg%) with a high LDL subfraction (195mg%) but normal HDL
(45mg%) and triglycerides (195mg%).
Sean O’Malley
Review of Case History (Part 2)
Distribute and Read Handout 2:
Review of Case History (Part 2)
Sean O’Malley
Review of Case History (Part 2)
Handout 2: Review of Case History (Part 2) – Take Away Points:
• Positive exercise test.
• Worried about job security.
• Taking Atenolol, baby Aspirin, Nitroglycerin.
• Receives dietary advice.
• Coronary angiogram recommended.
Sean O’Malley
Review of Case History (Part 2)
Cardiac Cath Video
Go to Session 1: Wrap up
Go to Session 2:
Management
Go to Session 3:
Management
Go to Session 2: Wrap up
Go to Session 3: Wrap up
Learning Objectives
23
Sean O’Malley
Session 1 Wrap Up
NEXT SESSION:
Student Presentations:
• Students will prepare presentations based on the outcomes/problems that were
identified during class.
• Also assign psychosocial roles to be covered during the third session (each of these
will be given a handout to guide their research):
• Health Psychologist
• Consultation Psychiatrist (personality and athersclerotic cardiovascular
disease)
• Consultation Psychiatrist (stress and coping)
• Primary Care Physician/Nutritionist
Go to Problem List
Go to Clinical Notes
24
Sean O’Malley
Session 1 Wrap Up
NEXT SESSION:
Required Reading (available on Blackboard)
 Fortunato, D.J. & Ferri, F. F. (2012). Angina Pectoris. In: Ferri’s Clinical Advisor (1st
ed). Elsevier.
Supplemental Reading: (available on Blackboard)
 Boden, William. (2011). Chapter 71: Angina Pectoris and Stable Ischemic Heart
Disease. In: Cecil’s Medicine (24th ed). Elsevier.
.
Go to Problem List
Go to Clinical Notes
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26
PCL 1 - Case 4: Session 2
Sean O’Malley
27
Sean O’Malley
Management of Session 2
 Presentations: Learning objectives identified by the group
 Review of Case History (Part 3)
 Phone Conversation between Dr. Mehta and Mr. O’Malley
Go to Problem List
Go to Clinical Notes
28
Sean O’Malley
Review of Case History (Part 3)
Distribute and Read Handout 3:
Review of Case History (Part 3)
Sean O’Malley
Review of Case History (Part 3)
Handout 3: Review of Case History (Part 3) – Take Away Points:
• Chest pain symptoms resolved.
• Unhappy with dietary changes.
• Worried about job security.
• Experiencing sexual dysfunction.
• Minimizing severity of condition.
Sean O’Malley
Phone conversation between Sean and Dr. Mehta
•
Alice, worried about Sean’s decision to stop taking his medication, calls Dr. Mehta to tell her
what’s going on. At first Dr. Mehta is angry (“Doesn’t he know that this is a serious
situation? How can he just stop his meds? Doesn’t he think I’m serious?”) Alice says that
Sean is just scared, and that he is just really worried about work. She asks if Dr. Mehta
would call her husband and talk to him – she does . . .
Dr. Mehta (MD) and Sean O’Malley (SO) talk on the phone
MD: Hello, Mr. O’Malley?
SO: Hello doc. You found me out – I suppose Alice told you?
MD: Well, I did talk to her yesterday, but I was already aware that you had cancelled your
follow-up appointments with me – plus Alice told me that you stopped taking your
medications. Is that really true?! (incredulous and accusatory)
SO: Yeah doc, I did – those pills were making me ‘limp’ – if you know what I mean!
MD: Yes, but did they help the chest burning?
SO: I think so, at least it seemed to go away after I started taking them.
Sean O’Malley
Phone conversation between Sean and Dr. Mehta
MD: And you still stopped them anyway?! You know that could be pretty dangerous for you,
Mr. O’Malley?
SO: Well, they were messing up my sleep and with driving the train and all, I didn’t think that
was too safe either, doc!
MD: Well, maybe you’re right. Would you be willing to try another type of pill, one that might
do the same positive things but without the side-effects you seemed to be experiencing?
SO: I might, if you think it’s really necessary.
MD: What about the cardiac rehab program and coming back to see me?
SO: I don’t know about all that – I don’t want the folks at work to think I’m really sick.
MD: Why’s that, Mr. O’Malley?
SO: Because this might be the excuse they need to replace me with some younger, cheaper
driver!
MD: Mr. O’Malley, you don’t need to worry about that, I already spoke to your supervisor. He
called to see if you were alright after he got my note. I told him you would continue to work as
long as you were on medication and doing alright. He didn’t seem to have any problem with
that.
Sean O’Malley
Phone conversation between Sean and Dr. Mehta
SO: (relieved) Is that right, doc? Well, OK then. I’ll come over and see what else you got to
keep me going. And thanks – Alice was right about you, she said you were the best!
MD: See you tomorrow at 3pm, OK?
SO: Sounds good – see you then.
Sean O’Malley
Overview of Learning
Objectives for Students
(These Will Not Be Tested as Part of PCL)
Clinical Problem Solving
 Practice using a differential diagnosis for chest pain, keeping in mind both
common but also more serious “do not miss” conditions.
 Identify appropriate and cost-effective use of medical resources.
Basic and Clinical Sciences
 Recognize normal physiology of the heart, ischemia, and how it occurs, and how
ischemia effects heart function.
 List the factors producing atherosclerosis?
 Interpret the abnormalities of cholesterol tests and lipid profile.
 Identify therapeutic (tertiary prevention) strategies for angina and list effects and
side-effects of anti-anginal medication.
Go to Problem List
Go to Clinical Notes
34
Sean O’Malley
Overview of Learning
Objectives for Students
(These Will Be Tested as Part of PCL)
Psychosocial, Behavioral, and Developmental Issues
 List the normal middle-adulthood developmental tasks
 Discuss stress and coping responses to illness—ways in which people react to
illness and the contributors to such behaviors.
 Describe the theories of motivating behavior change with application to obesity
(motivational interviewing).
Informatics
 Practice selection and evaluation of information resources to support PCL
research.
 Identify resources available to locate drug information.
 Locate and utilize clinical calculators to compute body mass index and
Framingham score.
Go to Problem List
Go to Clinical Notes
35
Sean O’Malley
Session 2 Wrap Up
NEXT SESSION:
 Psychosocial Presentations (Distribute Handouts 7-10)
• Health Psychologist
• Consultation Psychiatrist (personality and atherosclerotic cardiovascular
disease)
• Consultation Psychiatrist (stress and coping)
• Primary Care Physician/Nutritionist
 Distribute handout 6: Biopsychosocial All Students Guide (ALL)
 Distribute handouts 4 & 5: Food Diary and Exercise Diary (ALL)
 Volunteer to make healthy snack for next week
 Presentations:
 Practice USMLE Questions
 Feedback & Discussion
Go to Problem List
Go to Clinical Notes
36
Sean O’Malley
Session 2 Wrap Up
NEXT SESSION:
 Required Psychosocial Readings:
Sahler and Carr – Behavioral Sciences and Healthcare:
• Motivational Interviewing (pp. 70-71)
• Defense Mechanisms (pp. 76-77)
• Adult Years (chap. 13; pp.101-108)
• Obesity (chap. 20; pp. 159-162)
Go to Problem List
Go to Clinical Notes
37
38
PCL 1 - Case 4: Session 3
Sean O’Malley
39
Sean O’Malley
Management of Session 3
 Psychosocial Presentations
• Health Psychologist
• Consultation Psychiatrist (personality and atherosclerotic cardiovascular
disease)
• Consultation Psychiatrist (stress and coping)
• Primary Care Physician/Nutritionist
 Discuss Food Diary and Exercise Diary
 Healthy snack
 Practice USMLE Questions
 Feedback & Review Case Objectives: Were all of the learning objectives covered?
Go to Problem List
Go to Clinical Notes
40
Sean O’Malley
Sample Questions from USMLE
Step 1 Review
1.
A 62-year old African American man presents with exercise-induced angina. His
serum cholesterol is 277 mg/dL (normal <200), LDL is 157 (normal <157), HDL is 43
(normal > 35) and triglycerides are 170 (normal <150). His BMI is 34 and his
coronary risk ratio is 6.84 (normal <5). On cardiac catheterization there is
occlusion of the left anterior descending and the origin of the right coronary
artery. The disease process is initiated by which of the following:
A.
B.
C.
D.
E.
Proliferation of smooth muscle cells
Formation of an intimal plaque
Attraction of platelets to collagen microfibrils
Adventitial proliferation
Injury to the endothelium
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Sean O’Malley
Sample Questions from USMLE
Step 1 Review
E. Injury to the Endothelium
The site at which coronary arteries become occluded are : first, at the left anterior descending
(thus affecting both ventricles anteriorly); second, at the origin of the right coronary artery
affecting both the right atrium and ventricle and disrupting cardiac rhythm; and third, the
circumflex branch (affecting both left atria and ventricle). Atherosclerosis is initiated by
damage to the endothelial cells, which exposes the subjacent connective tissue
(subendothelium). The loss of the antithrombogenic endothelium results in aggregation of
platelets. Atherosclerosis is one form of arteriosclerosis (hardening of the arteries) that
involves deposition of fatty material primarily in the walls of the conducting arteries. The
intimate and media become infiltrated with lipid. Intimal thickening occurs through the
addition f collagen and elastin with an abnormal pattern of elastin cross-linking. Platelets
release mitogenic substances that stimulate proliferation of smooth muscle cells. The
thickening of the intima is also called an atheromatous plaque and worsens with repeated
damage to the endothelium. It is most dangerous in small vessels, particularly the coronary
arteries, where occlusion can result in a myocardial infarction. Atherosclerotic plaques also
lead to thrombi and aneurysms.
(2008) . Clinical vignettes for the USMLE Step I. New York: McGraw-Hill.
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Sean O’Malley
Sample Questions from USMLE
Step 1 Review
2. A 56 year old male was admitted to the hospital with angina and diaphoresis. A
myocardial infarction is suspected, and a 12-lead electrocardiogram (ECG) is ordered.
The ECG is most effective in detecting disease in which of the following?
A.
B.
C.
D.
E.
Ventricular contractility
Mean blood pressure
Total peripheral resistance
Ejection fraction
Coronary blood flow
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Sean O’Malley
Sample Questions from USMLE
Step 1 Review
E. Coronary Blood Flow
Abnormalities in coronary blood flow resulting in ischemia of the ventricular muscle
will lead to a current of injury, which is reflected as an upward or downward shift in
the ST segment of the ECG recording. The electrical activity of the heart does not
reflect changes in ventricular contractility, blood pressure, ejection fraction, or total
peripheral resistance, although all of these can be altered by changes in coronary
blood flow.
(2008) . Clinical vignettes for the USMLE Step I. New York: McGraw-Hill.
44
Sean O’Malley
Sample Questions from USMLE
Step 1 Review
3. Mr. D has been non-adherent with his treatment regime. His physician decides to
make use of goal-setting to increase his patient’s adherence in the future. Published
guidelines and clinical experience in the use of “goal-setting” to increase patient
adherence suggests that the technique will be most effective when:
A.
B.
C.
D.
E.
Goals are defined by the physician to insure appropriate priorities
Goals are graduated to maximize success experiences
Goals are maintained consistently and may not be altered
Goals are sufficiently broad to allow the patient leeway in meeting them
Patients seek to “shoot for the moon” and achieve maximal results
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Sean O’Malley
Sample Questions from USMLE
Step 1 Review
B. Goals are graduated to maximize success experiences.
No one likes failure. Success in reaching a goal can, by itself, be reinforcing. Making
goals incremental makes each step more attainable and helps to keep the patient
motivated and on track. Goals that are too broad are ambiguous. Goals set by the
provider without patient input may ignore difficulties of which the physician is
unaware and typically do not have the level of “buy in” from the patient needed for
success. “Shooting for the moon” may feel great if the moon is actually hit, but the
chances of failure are too great, and the goal just looks unattainable (and, therefore,
non-motivating) to the patient. Goals must be flexible so they can be altered as
circumstances change.
Sahler, O.J.Z. and Carr, J.E. (2007). The Behavioral Sciences and Health Care. Cambridge, Massachusetts: Hogrefe.
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Sean O’Malley
Session 3 Wrap Up
Feedback:
o Give feedback to the Student Case Leader
o Did students accomplish all of the objectives?
 Teamwork?
 What worked? What did not work?
 Distribute Entire BioPsychoSocial Packet to all Students
 Next Time: the case of Jason Goodman!
 Choose a Student to be the Case Leader for Case V
Go to Problem List
Go to Clinical Notes
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CC: (Chief Complaint/Concern):
PMH: (Past Medical History):
HPI: (History of Present Illness):
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Past Medical History:
Medications:
Allergies:
Past Surgical History:
FH: (Family History):
Labs:
Review of Systems:
Physical Exam:
Assessment & Plan: