Red flags in mental health assessment US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Red flags in mental health assessment. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Red flags in mental health assessment US Medical PG Question 1: A 24-year-old man is brought to your emergency department under arrest by the local police. The patient was found naked at a busy intersection jumping up and down on top of a car. Interviewing the patient, you discover that he has not slept in 2 days because he does not feel tired. He reports hearing voices. The patient was previously hospitalized 1 year ago with auditory hallucinations, paranoia, and a normal mood. What is the most likely diagnosis?
- A. Schizophrenia
- B. Bipolar disorder
- C. Brief psychotic disorder
- D. Schizotypal disorder
- E. Schizoaffective disorder (Correct Answer)
Red flags in mental health assessment Explanation: ***Schizoaffective disorder***
- This patient demonstrates the **hallmark feature** of schizoaffective disorder: **psychotic symptoms occurring both during AND independent of mood episodes**.
- **Current presentation**: Clear **manic episode** (decreased need for sleep, grandiose/disinhibited behavior, psychomotor agitation) with psychotic features (auditory hallucinations).
- **Previous hospitalization**: **Psychotic symptoms (hallucinations, paranoia) in the absence of a mood episode** ("normal mood"), requiring hospitalization for at least 2 weeks - this is the **key diagnostic criterion** for schizoaffective disorder.
- The diagnosis requires an **uninterrupted period of illness** with both psychotic symptoms (meeting Criterion A for schizophrenia) and a major mood episode, PLUS psychotic symptoms for **≥2 weeks without prominent mood symptoms**.
*Bipolar disorder*
- In bipolar disorder with psychotic features, psychotic symptoms occur **exclusively during mood episodes** (manic, hypomanic, or depressive).
- This patient's previous hospitalization with psychosis but **"normal mood"** indicates psychotic symptoms independent of mood episodes, which **rules out** bipolar disorder and points to schizoaffective disorder.
- While the current presentation shows mania with psychosis, the longitudinal course is critical for diagnosis.
*Schizophrenia*
- Schizophrenia involves **continuous psychotic symptoms** without prominent mood episodes dominating the clinical picture.
- This patient has **prominent manic symptoms** (decreased sleep, grandiose behavior, agitation) that are central to the current presentation, making schizophrenia less likely.
- The presence of full mood episodes that occupy a **substantial portion** of the illness duration favors schizoaffective disorder over schizophrenia.
*Brief psychotic disorder*
- Brief psychotic disorder involves psychotic symptoms lasting **<1 month** with full return to baseline functioning.
- This patient has a **recurrent course** with hospitalization 1 year ago, indicating a chronic/recurring condition rather than a brief, self-limited episode.
*Schizotypal disorder*
- This is a **personality disorder** characterized by social deficits, cognitive/perceptual distortions, and eccentric behavior, but **NOT overt psychotic episodes**.
- Does not involve acute psychotic breaks with severe symptoms like hallucinations requiring hospitalization or manic episodes.
Red flags in mental health assessment US Medical PG Question 2: An 82-year-old woman comes to the physician because of difficulty sleeping and increasing fatigue. Over the past 3 months she has been waking up early and having trouble falling asleep at night. During this period, she has had a decreased appetite and a 3.2-kg (7-lb) weight loss. Since the death of her husband one year ago, she has been living with her son and his wife. She is worried and feels guilty because she does not want to impose on them. She has stopped going to meetings at the senior center because she does not enjoy them anymore and also because she feels uncomfortable asking her son to give her a ride, especially since her son has had a great deal of stress lately. She is 155 cm (5 ft 1 in) tall and weighs 51 kg (110 lb); BMI is 21 kg/m2. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, she is tired and has a flattened affect. Cognition is intact. Which of the following is the most appropriate initial step in management?
- A. Begin mirtazapine therapy
- B. Begin cognitive-behavioral therapy
- C. Notify adult protective services
- D. Assess for suicidal ideation (Correct Answer)
- E. Recommend relocation to a nursing home
Red flags in mental health assessment Explanation: ***Assess for suicidal ideation***
- The patient exhibits several **risk factors for depression**, including **insomnia**, **early morning awakening**, **anorexia**, **weight loss**, and significant **anhedonia** (lack of enjoyment in activities).
- Given her age, recent loss of her husband, social withdrawal, feelings of guilt, and significant emotional distress, it is crucial to first assess for **suicidal ideation** before initiating other treatments.
- **Elderly patients with depression have elevated suicide risk**, especially with recent bereavement and social isolation. Safety assessment is the **mandatory first step** in managing any patient with major depressive symptoms.
*Begin mirtazapine therapy*
- While **mirtazapine** is an effective antidepressant that could address several of her symptoms (insomnia, poor appetite, depression), it should only be considered after a **thorough safety assessment**, particularly for suicide risk.
- Starting medication without assessing for immediate danger may overlook critical safety concerns.
*Begin cognitive-behavioral therapy*
- **Cognitive-behavioral therapy (CBT)** is an effective treatment for depression and could be beneficial for this patient.
- However, similar to medication, it is a subsequent treatment step. The immediate priority is to rule out **suicidal intent** given the severity of her depressive symptoms.
*Notify adult protective services*
- There is no direct evidence of **abuse or neglect** in the provided information that would warrant involving adult protective services.
- Her feelings of guilt and worry about burdening her family, while contributing to her depression, do not indicate that her son or daughter-in-law are harming her.
*Recommend relocation to a nursing home*
- While the patient is elderly and potentially depressed, there is no medical or social necessity presented that indicates she requires or would benefit from a **nursing home** at this stage.
- This step would be premature and does not address the immediate mental health concerns or potential safety issues.
Red flags in mental health assessment US Medical PG Question 3: A 28-year-old male presents to trauma surgery clinic after undergoing an exploratory laparotomy, femoral intramedullary nail, and femoral artery vascular repair 3 months ago. He suffered multiple gunshot wounds as a victim of a drive-by shooting. He is progressing well with well-healed surgical incisions on examination. He states during his clinic visit that he has been experiencing 6 weeks of nightmares where he "relives the day he was shot." The patient also endorses 6 weeks of flashbacks to "the shooter pointing the gun at him" during the daytime as well. He states that he has had difficulty sleeping and cannot concentrate when performing tasks. Which of the following is the most likely diagnosis?
- A. Schizophrenia
- B. Normal reaction to trauma
- C. Acute stress disorder
- D. Post-traumatic stress disorder (PTSD) (Correct Answer)
- E. Schizophreniform disorder
Red flags in mental health assessment Explanation: ***Post-traumatic stress disorder (PTSD)***
- The patient's symptoms of **nightmares**, **flashbacks** (re-experiencing the trauma), **difficulty sleeping**, and **impaired concentration** following severe trauma are characteristic of PTSD.
- The symptoms have persisted for **6 weeks** (more than 1 month), meeting the duration criterion for PTSD diagnosis.
*Schizophrenia*
- Schizophrenia is characterized by **psychotic symptoms** such as hallucinations, delusions, and disorganized thought/speech, which are not described in this patient.
- While stress can exacerbate schizophrenia, the patient's symptoms are directly tied to a specific traumatic event, not a chronic psychotic disorder.
*Normal reaction to trauma*
- While some distress is expected after trauma, the presence of **persistent re-experiencing symptoms** (nightmares, flashbacks), and hyperarousal symptoms lasting for **over a month** is beyond a normal, transient reaction.
- These symptoms significantly impair the patient's functioning and indicate a clinically significant disorder.
*Acute stress disorder*
- Acute stress disorder presents with similar symptoms to PTSD, including intrusive thoughts, negative mood, dissociation, avoidance, and arousal.
- However, acute stress disorder is diagnosed when symptoms occur **3 days to 1 month** after trauma exposure; this patient's symptoms have lasted **6 weeks**, exceeding the 1-month threshold for ASD and meeting criteria for PTSD.
*Schizophreniform disorder*
- Schizophreniform disorder involves psychotic symptoms like **hallucinations, delusions, or disorganized speech**, lasting between 1 and 6 months.
- The patient's symptoms are primarily related to trauma re-experiencing and hyperarousal, not psychotic features.
Red flags in mental health assessment US Medical PG Question 4: A 22-year-old man is brought to the emergency department by his father because he is having bizarre thoughts. The patient says that he is being haunted by aliens from outer space. The father is worried as his son has had these symptoms for the past 7 months and lately, it seems to be getting worse. He has become more self-obsessed and does not seem to have any interest in his favorite activities. He has no plans to harm himself or others but spends a lot of time and energy building ‘defenses’ in and around his room as he is absolutely sure that aliens will come to get him soon. His blood pressure is 121/79 mm Hg, pulse 86/min, respiratory rate 15/min, temperature 36.8°C (98.2°F). Which of the following is correct regarding the patient’s symptoms?
- A. It would benefit from psychosurgery.
- B. He has a fixed false belief. (Correct Answer)
- C. It is best treated with cognitive behavioral therapy alone.
- D. It is a negative symptom.
- E. It falls under the disorganized thinking domain.
Red flags in mental health assessment Explanation: ***He has a fixed false belief.***
- The patient's conviction that he is being haunted by aliens, despite evidence to the contrary and the distress it causes, constitutes a **delusion**.
- A delusion is by definition a **fixed, false belief** that is not in keeping with the individual's cultural background.
*It would benefit from psychosurgery.*
- Psychosurgery, such as lobotomy, is an extreme and rarely used intervention for **severe, refractory mental disorders**, typically only after all other treatments have failed and with significant ethical considerations.
- While the patient's symptoms are impairing, **first-line treatments** for psychotic disorders involve antipsychotic medications and psychotherapy, not psychosurgery.
*It is best treated with cognitive behavioral therapy alone.*
- While CBT for psychosis (CBTp) can be a useful **adjunct** in managing delusions and reducing distress, it is **not sufficient as monotherapy** for active, severe psychotic symptoms.
- The primary intervention for profound delusions like those described is **antipsychotic medication**, with CBT added as an adjunctive treatment to help improve functioning and coping.
- CBT alone would be inadequate for someone with such fixed, impairing delusions actively building defenses against perceived threats.
*It is a negative symptom.*
- Negative symptoms of psychosis include features like **anhedonia** (lack of pleasure), **alogia** (poverty of speech), **avolition** (lack of motivation), and affective flattening.
- The patient's bizarre belief in aliens is a **positive symptom** as it represents an *addition* to normal experience, rather than a *reduction* or *absence* of normal functions.
- Note: The patient's decreased interest in activities suggests negative symptoms are also present, but the question asks about "the patient's symptoms" in context of the delusion described.
*It falls under the disorganized thinking domain.*
- Disorganized thinking or speech involves patterns like **loose associations, tangentiality, incoherence**, or word salad, where the logical connections between thoughts are lost.
- While the content of the patient's thoughts is bizarre, the core issue described is the *belief itself* (a delusion, which is a **positive symptom**), rather than disordered *thought processes* or the way he expresses them.
Red flags in mental health assessment US Medical PG Question 5: A 6-month-old male presents to the emergency department with his parents after his three-year-old brother hit him on the arm with a toy truck. His parents are concerned that the minor trauma caused an unusual amount of bruising. The patient has otherwise been developing well and meeting all his milestones. His parents report that he sleeps throughout the night and has just started to experiment with solid food. The patient’s older brother is in good health, but the patient’s mother reports that some members of her family have an unknown blood disorder. On physical exam, the patient is agitated and difficult to soothe. He has 2-3 inches of ecchymoses and swelling on the lateral aspect of the left forearm. The patient has a neurological exam within normal limits and pale skin with blue irises. An ophthalmologic evaluation is deferred.
Which of the following is the best initial step?
- A. Genetic testing
- B. Complete blood count and coagulation panel (Correct Answer)
- C. Ensure the child's safety and alert the police
- D. Peripheral blood smear
- E. Hemoglobin electrophoresis
Red flags in mental health assessment Explanation: ***Complete blood count and coagulation panel***
- The unusual amount of **bruising** after minor trauma, along with a family history of an unknown blood disorder, strongly suggests a potential **bleeding disorder**. A **CBC** and a **coagulation panel** (PT, aPTT, fibrinogen) are essential initial steps to evaluate for abnormalities in platelets, clotting factors, or other hematologic conditions.
- These tests can help narrow down the differential diagnosis between **platelet dysfunction**, **coagulopathies** (like hemophilia or von Willebrand disease), or other less common bleeding disorders, guiding further specific investigations.
- **Important consideration:** The presence of **blue sclera** (described as "blue irises") raises concern for **osteogenesis imperfecta (OI)**, a connective tissue disorder causing bone fragility. However, initial hematologic screening is still appropriate given the family history of blood disorder and presentation of excessive bruising. If coagulation studies are normal, imaging and further workup for OI would be indicated.
*Genetic testing*
- While a genetic component is plausible given the patient's family history and clinical presentation (blue sclera may suggest osteogenesis imperfecta), **genetic testing** is typically performed *after* initial laboratory workup has identified a specific type of bleeding or inherited disorder.
- Starting with genetic testing without basic hematologic parameters is not the most efficient or cost-effective initial diagnostic approach.
*Ensure the child's safety and alert the police*
- While child abuse should always be considered in cases of unexplained or excessive bruising, the presence of a **family history of a blood disorder** and the **blue sclera** (suggesting possible osteogenesis imperfecta) make **medical causes** more immediate concerns for initial investigation.
- Pursuing a medical workup first often clarifies whether abuse is the primary explanation, although child protective services should be notified if suspicion remains high after medical evaluation.
*Peripheral blood smear*
- A **peripheral blood smear** provides information on red blood cell morphology, platelet size and number, and white blood cell differential. While useful in assessing for some hematologic conditions, it is often performed *after* a CBC has indicated abnormalities or in conjunction with specialized testing.
- It would not be the *best initial step* as it doesn't directly assess clotting factor function, which is critical in evaluating significant bruising severity.
*Hemoglobin electrophoresis*
- **Hemoglobin electrophoresis** is used to diagnose **hemoglobinopathies** like sickle cell anemia or thalassemia.
- The patient's symptoms (easy bruising) are not characteristic of hemoglobinopathies, and while he has pale skin, this test would not be the initial step to investigate a bleeding disorder.
Red flags in mental health assessment US Medical PG Question 6: A 21-year-old man presents to the emergency room requesting surgery to remove "microchips," which he believes were implanted in his brain by "Russian spies" 6 months ago to control his thoughts. He also reports hearing the "spies" talk to each other through embedded "microspeakers." You notice that his hair appears unwashed and some of his clothes are on backward. Urine toxicology is negative for illicit drugs. Which of the following additional findings are you most likely to see in this patient during the course of his illness?
- A. Anhedonia, guilty rumination, and insomnia
- B. Grandiose delusions, racing thoughts, and pressured speech
- C. Asociality, flat affect, and alogia (Correct Answer)
- D. Amnesia, multiple personality states, and de-realization
- E. Intrusive thoughts, ritualized behaviors, and anxious mood
Red flags in mental health assessment Explanation: ***Asociality, flat affect, and alogia***
- This patient exhibits **delusions (persecutory, control)** and **auditory hallucinations**, classic positive symptoms of **schizophrenia**. The question asks about findings "during the course of his illness," which points to the **typical progression of schizophrenia**: patients initially present with **positive symptoms** (as seen in this case) and **over time develop negative symptoms** such as **asociality** (lack of motivation to engage in social interaction), **flat affect** (reduced emotional expression), and **alogia** (poverty of speech).
- The disorganized appearance (unwashed hair, clothes on backward) already demonstrates **disorganized behavior**, part of the schizophrenia spectrum. Negative symptoms typically emerge or worsen as the illness progresses, representing the most likely additional findings.
*Anhedonia, guilty rumination, and insomnia*
- While **anhedonia** and **insomnia** can be seen in schizophrenia, their presence alongside prominent **guilty rumination** would more strongly suggest a **depressive disorder with psychotic features**, rather than primary schizophrenia, especially with the patient's specific, classic psychotic symptoms.
- The primary symptoms described (delusions of control, auditory hallucinations) are more characteristic of primary psychotic disorders, and guilty rumination is not a typical feature of schizophrenia progression.
*Grandiose delusions, racing thoughts, and pressured speech*
- These symptoms are hallmark features of **mania** or a **manic episode with psychotic features**. While psychotic features can occur in bipolar disorder with mania, the patient's specific delusions of being controlled by spies and hearing voices discussing him are more typical of schizophrenia.
- The absence of information about elevated mood, increased energy, or decreased need for sleep also makes mania less likely compared to schizophrenia.
*Amnesia, multiple personality states, and de-realization*
- These symptoms are characteristic of **dissociative disorders**. **Amnesia** and **multiple personality states** (now known as identity alteration in dissociative identity disorder) involve disturbances in memory and identity.
- **De-realization** involves feelings of unreality regarding one's surroundings. None of these align with the patient's primary presentation of well-formed delusions and hallucinations characteristic of a psychotic disorder.
*Intrusive thoughts, ritualized behaviors, and anxious mood*
- These are core features of **obsessive-compulsive disorder (OCD)**. The patient's symptoms are clearly defined as delusions (fixed false beliefs) and hallucinations (perceptions without external stimuli), which are distinct from the ego-dystonic intrusive thoughts and ritualistic compulsions of OCD.
- While anxiety may be present in psychotic disorders, the primary presentation here is not dominated by OCD-like symptoms, and these would not be expected to develop as part of schizophrenia's natural course.
Red flags in mental health assessment US Medical PG Question 7: A 29-year-old man with post-traumatic stress disorder is admitted to the hospital following an intentional opioid overdose. He is a soldier who returned from a deployment in Afghanistan 3 months ago. He is divorced and lives alone. His mother died by suicide when he was 8 years of age. He states that he intended to end his life as painlessly as possible and has also contemplated using his service firearm to end his life. He asks the physician if assisted suicide is legal in his state. He does not smoke or drink alcohol but uses medical marijuana daily. Mental status examination shows a depressed mood and constricted affect. Which of the following is the strongest risk factor for suicide in this patient?
- A. Male sex
- B. Lack of social support
- C. Attempted drug overdose (Correct Answer)
- D. Use of medical marijuana
- E. Family history of completed suicide
Red flags in mental health assessment Explanation: ***Attempted drug overdose***
- A **prior suicide attempt** is the single strongest predictor of future suicide completions. This patient's recent intentional overdose significantly elevates his risk.
- The fact that the attempt involved a **lethal method** (opioid overdose) indicates high suicidal intent and lethality, further increasing the risk.
*Male sex*
- While men have a **higher rate of completed suicide** than women, male sex alone is not the strongest individual risk factor compared to a prior attempt.
- This is a demographic risk factor that contributes to overall risk but does not carry the same weight as a direct behavioral indicator of suicidality.
*Lack of social support*
- **Social isolation** and lack of support are significant risk factors for suicide. The patient's divorce and living alone contribute to his vulnerability.
- However, while important, research consistently shows that a **previous suicide attempt** is a more potent predictor of future suicide than social isolation.
*Use of medical marijuana*
- While **substance use disorders** (including marijuana use, especially if used to self-medicate) can increase suicide risk by impairing judgment and increasing impulsivity, it is not the strongest factor here.
- There is no direct evidence presented that this patient's medical marijuana use directly triggered his current suicidal intent, unlike his documented overdose attempt.
*Family history of completed suicide*
- A **family history of suicide** (specifically, his mother's suicide) is a recognized risk factor, indicating genetic predisposition, environmental factors, or a learned coping mechanism.
- However, a personal history of a **serious suicide attempt** carries significantly more weight in predicting future suicide completions than a family history alone.
Red flags in mental health assessment US Medical PG Question 8: A 60-year-old Caucasian man is brought to the emergency department by his roommate after he reportedly ingested a bottle of Tylenol. He reports being suddenly sad and very lonely and impulsively overdosed on some pills that he had laying around. He then immediately induced vomiting and regurgitated most of the pills back up and rushed to his roommate for help. The patient has a past medical history significant for hypertension and diabetes. He takes chlorthalidone, methadone, and glimepiride regularly. He lives in a room alone with no family and mostly keeps to himself. The patient’s vital signs are normal. Physical examination is unremarkable. The patient says that he still enjoys his life and regrets trying to overdose on the pills. He says that he will probably be fine for the next few days but has another bottle of pills he can take if he starts to feel sad again. Which of the following is the best predictor of this patient attempting to commit suicide again in the future?
- A. His race
- B. He has a previous attempt (Correct Answer)
- C. He has a plan
- D. His lack of social support
- E. His age
Red flags in mental health assessment Explanation: ***He has a previous attempt***
- A **history of prior suicide attempts** is the strongest predictor of future suicidal behavior. Each attempt increases the risk of subsequent attempts and eventual death by suicide.
- The patient's immediate remorse and reaching out for help, while positive, do not negate the significant risk associated with the actual attempt.
*His race*
- While certain racial and ethnic groups may have varying suicide rates, **race alone is not the most significant independent predictor** in an individual case when compared to direct behavioral risk factors.
- Socioeconomic factors and cultural influences often play a more prominent role than race itself.
*He has a plan*
- The patient had a plan and attempted to act on it, but the question asks for the **best predictor of *future* attempts**, not the immediate risk.
- While having a plan indicates immediate risk, a **previous attempt** is a stronger longitudinal predictor of *repeated* behavior.
*His lack of social support*
- **Social isolation and lack of social support** are significant risk factors for suicide and can contribute to feelings of hopelessness.
- However, the direct behavioral evidence of a **past attempt** is a more potent and immediate predictor of recurrence than a demographic or social factor.
*His age*
- **Older age can be a risk factor** for suicide, especially for white males, due to factors like chronic illness, loss of loved ones, and social isolation.
- Nevertheless, a **previous suicide attempt** is a more powerful and direct indicator of future risk regardless of age.
Red flags in mental health assessment US Medical PG Question 9: A 6-year-old boy presents to the office to establish care after recently being assigned to a shelter run by the local child protective services authority. The nurse who performed the vitals and intake says that, when offered an age-appropriate book to read while waiting for the physician, the patient said that he has never attended a school of any sort and is unable to read. He answers questions with short responses and avoids eye contact for most of the visit. His father suffers from alcoholism and physically abused the patient’s mother. Physical examination is negative for any abnormal findings, including signs of fracture or bruising. Which of the following types of abuse has the child most likely experienced?
- A. Sexual abuse
- B. Child neglect (Correct Answer)
- C. Physical abuse
- D. No abuse
- E. Emotional abuse
Red flags in mental health assessment Explanation: ***Child neglect***
- This child's inability to read and complete lack of schooling at age 6 represents **educational neglect**, a failure to provide for basic developmental and educational needs
- Educational neglect is a specific subtype of child neglect recognized by child protective services and involves failure to enroll a child in school or provide required special education
- The avoidance of eye contact and limited verbal interaction suggest possible **emotional neglect** and lack of appropriate developmental stimulation
- The combination of no schooling, developmental delays in social interaction, and removal by CPS strongly indicates **neglect** as the primary form of maltreatment
*Sexual abuse*
- **Sexual abuse** involves engaging a child in sexual activities, exposure to sexual content, or sexual exploitation
- Nothing in the clinical presentation suggests sexual abuse—no concerning physical findings, no behavioral indicators specific to sexual abuse (such as age-inappropriate sexual knowledge or sexualized behavior)
*Physical abuse*
- **Physical abuse** involves non-accidental physical injury to a child
- While the father physically abused the mother, the physical examination of the child is **negative for signs of physical abuse** (no fractures, bruising, or other injuries)
- The child's presentation is primarily characterized by developmental and educational deficits, not physical trauma
*No abuse*
- A 6-year-old who has never attended school and cannot read has clearly experienced a **failure to meet basic educational needs**, which constitutes neglect
- The child's behavioral presentation (avoidance of eye contact, limited verbal responses) and the family environment (paternal alcoholism, domestic violence) further indicate an unsafe and neglectful home environment
- Removal by child protective services confirms that maltreatment has occurred
*Emotional abuse*
- While witnessing domestic violence can constitute **emotional abuse**, and the child may have experienced some degree of emotional maltreatment, this is not the **most likely** or primary form of abuse
- The most prominent and documentable form of maltreatment is the complete **failure to provide education**, which is specifically categorized as **educational neglect** rather than emotional abuse
- Emotional abuse typically involves patterns of behavior that harm a child's emotional development (terrorizing, rejecting, isolating), which may be present but is less clearly documented than the educational neglect
Red flags in mental health assessment US Medical PG Question 10: A 55-year-old man presents to his primary care physician for trouble swallowing. The patient claims that he used to struggle when eating food if he did not chew it thoroughly, but now he occasionally struggles with liquids as well. He also complains of a retrosternal burning sensation whenever he eats. He also claims that he feels his throat burns when he lays down or goes to bed. Otherwise, the patient has no other complaints. The patient has a past medical history of obesity, diabetes, constipation, and anxiety. His current medications include insulin, metformin, and lisinopril. On review of systems, the patient endorses a 5 pound weight loss recently. The patient has a 22 pack-year smoking history and drinks alcohol with dinner. His temperature is 99.5°F (37.5°C), blood pressure is 177/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, you note an overweight man in no current distress. Abdominal exam is within normal limits. Which of the following is the best next step in management?
- A. Endoscopy (Correct Answer)
- B. Omeprazole trial
- C. Manometry
- D. Barium swallow
- E. CT scan
Red flags in mental health assessment Explanation: ***Endoscopy***
- The patient presents with **dysphagia to solids and liquids**, significant for **recent weight loss**, and a **history of smoking**, all of which are **alarm symptoms** necessitating an upper endoscopy to rule out malignancy.
- While he has **GERD symptoms** as well (retrosternal burning), the presence of alarm features mandates a direct investigation of the upper GI tract rather than empirical treatment.
*Omeprazole trial*
- An empirical trial of **PPIs** like omeprazole is appropriate for classic GERD symptoms without alarm features.
- However, **dysphagia to solids and liquids with associated weight loss**, especially in a patient with a significant **smoking history**, are alarm symptoms that require direct visualization via endoscopy, not just symptom management.
*Manometry*
- **Esophageal manometry** is used to evaluate the motility of the esophagus and diagnose conditions like achalasia or esophageal spasm.
- While the patient has dysphagia, **alarm symptoms (weight loss, smoking history)** raise concern for mechanical obstruction or malignancy, which should be investigated before motility disorders.
*Barium swallow*
- A **barium swallow** can identify structural abnormalities like strictures, masses, or webs, and also assess motility.
- However, in the context of alarm symptoms, a **barium swallow is less sensitive** for detecting subtle mucosal changes or early malignancy compared to endoscopy, and any positive findings would still prompt an endoscopy.
*CT scan*
- A **CT scan of the chest and abdomen** is useful for assessing extraluminal pathology, mediastinal involvement, or distant metastases.
- While it may eventually be part of staging if a malignancy is found, the **initial investigation for esophageal symptoms and alarm features** focuses on direct luminal visualization with endoscopy to identify the primary pathology.
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