Transition to adult care US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Transition to adult care. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Transition to adult care US Medical PG Question 1: A 5-year-old girl is brought to the physician because her mother has found her to be inattentive at home and has received multiple complaints from her teachers at school. She does not complete her assignments and does not listen to her teachers' instructions. She refuses to talk to her parents or peers. Her mother says, “She ignores everything I say to her!” She prefers playing alone, and her mother reports that she likes playing with 5 red toy cars, repeatedly arranging them in a straight line. She avoids eye contact with her mother and the physician throughout the visit. Physical and neurological examination shows no abnormalities. Which of the following is the most likely diagnosis?
- A. Rett syndrome
- B. Conduct disorder
- C. Oppositional defiant disorder
- D. Attention deficit hyperactivity disorder
- E. Autism spectrum disorder (Correct Answer)
Transition to adult care Explanation: ***Autism spectrum disorder***
- The child exhibits core features of **autism spectrum disorder (ASD)**, including **social communication deficits** (refuses to talk, ignores parents, avoids eye contact) and **restricted, repetitive patterns of behavior** (playing with 5 red toy cars, repeatedly arranging them in a straight line).
- Her inattention and difficulty following instructions are also common in ASD, often related to focus on their specific interests rather than external demands, and **sensory processing differences** or **executive dysfunction**.
*Rett syndrome*
- This is a neurodevelopmental disorder almost exclusively affecting **females** and typically presents with a period of normal development followed by **regression of acquired skills**, especially **language and motor skills**.
- Key features include **stereotypic hand movements** (hand-wringing, squeezing), **gait abnormalities**, and **deceleration of head growth**, none of which are described in the patient.
*Conduct disorder*
- Characterized by a **persistent pattern of behavior** in which the basic rights of others or major age-appropriate societal norms or rules are violated, such as **aggression to people and animals**, **destruction of property**, deceitfulness or theft, and serious rule violations.
- The presented symptoms of social communication deficits and repetitive behaviors are not indicative of conduct disorder.
*Oppositional defiant disorder*
- Involves a pattern of **angry/irritable mood, argumentative/defiant behavior**, or **vindictiveness** lasting at least 6 months, often directed at authority figures.
- While the child may appear defiant by not listening, the broader constellation of **social communication deficits** and **repetitive behaviors** points away from ODD as the primary diagnosis.
*Attention deficit hyperactivity disorder*
- Presents with a persistent pattern of **inattention and/or hyperactivity-impulsivity** that interferes with functioning or development.
- Although the child is inattentive, the presence of **social communication difficulties** and **restricted, repetitive behaviors** are not characteristic of ADHD and are better explained by ASD.
Transition to adult care US Medical PG Question 2: A mother brings her 3-year-old son to the doctor because she is worried that he might be harming himself by constantly banging his head on the wall. He has been exhibiting this behavior for a few months. She is also worried because he has started to speak less than he used to and does not respond when his name is called. He seems aloof during playtime with other children and seems to have lost interest in most of his toys. What is the most likely diagnosis?
- A. Autism spectrum disorder (Correct Answer)
- B. Attention deficit hyperactivity disorder
- C. Generalized anxiety disorder
- D. Bipolar disorder
- E. Obsessive-compulsive disorder
Transition to adult care Explanation: ***Autism spectrum disorder***
- The child's symptoms of **head banging** (a repetitive, self-stimulatory behavior), **decreased speech**, **lack of response to his name**, **social aloofness**, and **loss of interest in toys** are classic indicators of **Autism Spectrum Disorder (ASD)**.
- ASD involves persistent deficits in **social communication and interaction** across multiple contexts, as well as **restricted, repetitive patterns of behavior, interests, or activities**.
*Attention deficit hyperactivity disorder*
- **ADHD** is characterized primarily by **inattention, hyperactivity, and impulsivity**, which are not the prominent or primary concerns described in this case.
- While children with ADHD may have social difficulties, their core symptoms do not typically include severe **social aloofness, communication regression**, or **self-injurious repetitive behaviors** like head banging.
*Generalized anxiety disorder*
- **Generalized anxiety disorder (GAD)** in children typically presents with excessive worry about multiple events or activities, often accompanied by **physical symptoms of anxiety** such as restlessness, fatigue, and difficulty concentrating.
- It does not explain the **communication regression, social deficits**, or **stereotypical behaviors** like head banging observed in this child.
*Bipolar disorder*
- **Bipolar disorder** in children often manifests with severe mood dysregulation, including distinct periods of **elevated or irritable mood (mania/hypomania)** and depression.
- The symptoms described, such as social withdrawal and communication difficulties, are not characteristic of the primary presentations of bipolar disorder.
*Obsessive-compulsive disorder*
- **OCD** is characterized by the presence of **obsessions (recurrent, persistent thoughts, urges, or images)** and/or **compulsions (repetitive behaviors or mental acts)**.
- While head banging can be a repetitive behavior, the broader constellation of symptoms, including social and communication deficits, is not typical of primary OCD in young children.
Transition to adult care US Medical PG Question 3: A 16-year-old girl comes to the physician for a regular health visit. She feels healthy. She lives with her parents at home. She says that the relationship with her parents has been strained lately because they ""do not approve"" of her new boyfriend. She recently became sexually active with her boyfriend and requests a prescription for an oral contraception. She does not want her parents to know. She smokes half-a-pack of cigarettes per day and does not drink alcohol. She appears well-nourished. Physical examination shows no abnormalities. Urine pregnancy test is negative. Which of the following is the most appropriate next step in management?
- A. Recommend an oral contraceptive pill
- B. Discuss all effective contraceptive options (Correct Answer)
- C. Conduct HIV screening
- D. Inform patient that her smoking history disqualifies her for oral contraceptives
- E. Ask patient to obtain parental consent before discussing any contraceptive options
Transition to adult care Explanation: ***Discuss all effective contraceptive options***
- It is crucial to discuss all available and **effective contraceptive options** with the patient, including their benefits, risks, and suitability for her lifestyle, before recommending a specific method.
- This ensures **informed consent** and shared decision-making, empowering the patient to choose the best method for her needs.
*Recommend an oral contraceptive pill*
- Recommending only one method without discussing alternatives limits the patient's choices and does not provide a **comprehensive approach** to contraception.
- While oral contraceptives are effective, other methods like **long-acting reversible contraceptives (LARCs)** may be more suitable or preferred by the patient.
*Conduct HIV screening*
- While **HIV screening** is important for sexually active individuals, it is not the immediate next step in management when the patient's primary concern is contraception.
- Addressing the patient's immediate request for contraception takes precedence, though **STI/HIV counseling** should be part of comprehensive sexual health discussions.
*Inform patient that her smoking history disqualifies her for oral contraceptives*
- A smoking history in adolescent patients **does not automatically disqualify** them from all types of oral contraceptives, especially progestin-only pills.
- The risk of **thromboembolism** with combined oral contraceptives is increased in smokers over 35, but a 16-year-old's risk needs careful assessment and discussion, not an outright disqualification.
*Ask patient to obtain parental consent before discussing any contraceptive options*
- In many jurisdictions, including the US, minors have the right to **confidential reproductive healthcare services**, including contraception, without parental consent.
- Requiring parental consent would violate her **confidentiality rights** and could deter her from seeking necessary care, potentially leading to unintended pregnancy.
Transition to adult care US Medical PG Question 4: A 17-year-old white female with a history of depression is brought to your office by her parents because they are concerned that she is acting differently. She is quiet and denies any changes in her personality or drug use. After the parents step out so that you can speak alone, she begins crying. She states that school has been very difficult and has been very depressed for the past 2 months. She feels a lot of pressure from her parents and coaches and says she cannot handle it anymore. She says that she has been cutting her wrists for the past week and is planning to commit suicide. She instantly regrets telling you and begs you not to tell her parents. What is the most appropriate course of action?
- A. Prescribe an anti-depressant medication and allow her to return home
- B. Refer her to a psychiatrist
- C. Explain to her that she will have to be hospitalized as she is an acute threat to herself (Correct Answer)
- D. Tell her parents about the situation and allow them to handle it as a family
- E. Prescribe an anti-psychotic medication
Transition to adult care Explanation: ***Explain to her that she will have to be hospitalized as she is an acute threat to herself***
- This patient is actively suicidal and engaging in **self-harm (cutting)**, which represents an immediate and serious risk to her life, necessitating **involuntary hospitalization** for her safety.
- In cases of acute suicidality, the ethical principle of **beneficence** (acting in the patient's best interest) and **non-maleficence** (avoiding harm) overrides confidentiality to ensure the patient's immediate safety.
*Prescribe an anti-depressant medication and allow her to return home*
- While an antidepressant may be part of long-term management, simply prescribing medication and sending her home is **inappropriate and dangerous** given her active suicidal ideation and self-harm.
- Antidepressants can have a delayed onset of action (2-4 weeks) and, in some adolescents, may initially increase the risk of **suicidal thoughts**, making close monitoring essential.
*Refer her to a psychiatrist*
- A referral to a psychiatrist is crucial for comprehensive evaluation and long-term treatment, but it does **not address the immediate danger** presented by her active suicidal plans and self-harm.
- An urgent psychiatric consultation or hospitalization is needed first, with a referral following stabilization.
*Tell her parents about the situation and allow them to handle it as a family*
- While parents must be informed, simply delegating the responsibility to them is **insufficient and potentially negligent** given the patient's acute suicidal risk.
- **Medical professionals** have a duty to ensure the safety of a suicidal minor, which often requires a higher level of intervention than parental supervision alone.
*Prescribe an anti-psychotic medication*
- There is **no indication of psychosis** in this patient's presentation; her symptoms are consistent with severe depression and acute suicidality.
- Prescribing an antipsychotic would be **inappropriate** and could cause unnecessary side effects without addressing the underlying depressive disorder or acute suicidal crisis.
Transition to adult care US Medical PG Question 5: A 4-year-old boy is brought to the physician by his parents because of concerns about his behavior during the past year. His parents report that he often fails to answer when they call him and has regular unprovoked episodes of crying and screaming. At kindergarten, he can follow and participate in group activities, but does not follow his teacher's instructions when these are given to him directly. He is otherwise cheerful and maintains eye contact when spoken to but does not respond when engaged in play. He gets along well with friends and family. He started walking at the age of 11 months and can speak in two-to-three-word phrases. He often mispronounces words. Which of the following is the most likely diagnosis?
- A. Selective mutism
- B. Hearing impairment (Correct Answer)
- C. Conduct disorder
- D. Specific-learning disorder
- E. Autistic spectrum disorder
Transition to adult care Explanation: ***Hearing impairment***
- The child's inconsistent response to being called, failure to follow direct instructions, and unprovoked crying and screaming, despite maintaining eye contact and having normal social interactions, are all suggestive of a **hearing impairment**.
- His delayed and unusual speech patterns (two-to-three-word phrases, mispronouncing words) for his age further points to **auditory processing difficulties** due to hearing loss.
*Selective mutism*
- This condition involves a consistent failure to speak in specific social situations where speaking is expected, despite speaking in other situations. The child's issue is with comprehending and responding to speech, not with speaking itself.
- The behavior observed (not responding to calls or direct instructions) is more indicative of an inability to hear rather than a choice not to speak.
*Conduct disorder*
- Conduct disorder is characterized by a persistent pattern of behavior that violates the rights of others and major societal norms appropriate for the individual's age.
- The child's symptoms do not include aggression, destruction of property, deceitfulness, or serious rule violations and he gets along well with friends and family.
*Specific-learning disorder*
- A specific learning disorder involves difficulties with academic skills, despite normal intelligence. While he has speech difficulties, he can participate in group activities, and there is no information about his academic performance.
- The primary concern here is his inability to respond to auditory input, which precedes and likely causes any potential learning difficulties rather than being a learning disorder itself.
*Autistic spectrum disorder*
- Autism spectrum disorder is characterized by persistent deficits in social communication and social interaction across multiple contexts, and restricted, repetitive patterns of behavior, interests, or activities.
- This child maintains eye contact, is cheerful, gets along well with friends and family, and can participate in group activities, which argues against significant **social communication deficits** typical of autism.
Transition to adult care US Medical PG Question 6: A 3-year-old boy is brought in by his mother because she is concerned that he has been “acting differently recently”. She says he no longer seems interested in playing with his friends from preschool, and she has noticed that he has stopped making eye contact with others. In addition, she says he flaps his hands when excited or angry and only seems to enjoy playing with objects that he can place in rows or rigid patterns. Despite these behaviors, he is meeting his language goals for his age (single word use). The patient has no significant past medical history. He is at the 90th percentile for height and weight for his age. He is afebrile and his vital signs are within normal limits. A physical examination is unremarkable. Which of the following is the most likely diagnosis in this patient?
- A. Pervasive developmental disorder, not otherwise specified
- B. Autism spectrum disorder (Correct Answer)
- C. Rett’s disorder
- D. Childhood disintegrative disorder
- E. Asperger’s disorder
Transition to adult care Explanation: ***Autism spectrum disorder***
- This patient exhibits **persistent deficits in social communication and social interaction** (e.g., lack of interest in friends, poor eye contact) and **restricted, repetitive patterns of behavior, interests, or activities** (e.g., hand flapping, lining up objects). These are the core diagnostic criteria for **autism spectrum disorder (ASD)**.
- The symptoms are presenting in **early childhood** (age 3) and are causing **clinically significant impairment** in social, occupational, or other important areas of current functioning, consistent with an ASD diagnosis.
*Pervasive developmental disorder, not otherwise specified*
- This diagnosis was previously used when a child met some, but not all, criteria for autistic disorder or when there was atypical presentation. However, under **DSM-5**, these conditions are now unified under the single diagnosis of **Autism Spectrum Disorder**.
- Its usage has been largely superseded by the broader diagnosis of **Autism Spectrum Disorder** in the DSM-5.
*Rett’s disorder*
- **Rett's disorder** primarily affects **females** and is characterized by a period of normal development followed by a loss of acquired hand skills, severe intellectual disability, and characteristic hand-wringing movements. This patient is a male and does not exhibit these specific features.
- Patients typically experience **regression** in language and motor skills after normal early development, which is not described in this case, and they develop **microcephaly**.
*Childhood disintegrative disorder*
- This diagnosis involves a **marked regression** in multiple areas of functioning (social, communication, motor) after at least **2 years of normal development**.
- The patient's mother notes recent changes, but there is no indication of previous normal development followed by significant loss of skills across multiple domains after age 2, which differentiates it from the insidious onset of ASD symptoms.
*Asperger’s disorder*
- **Asperger’s disorder** was characterized by **significant difficulties in social interaction** and **restricted, repetitive patterns of behavior**, but with **no clinically significant delay in language or cognitive development**.
- In **DSM-5**, Asperger's disorder is no longer a distinct diagnosis and is now subsumed under the umbrella of **Autism Spectrum Disorder**, which better reflects the spectrum of symptom severity.
Transition to adult care US Medical PG Question 7: A 16-year-old boy comes to the physician for the evaluation of fatigue over the past month. He reports that his energy levels are low and that he spends most of his time in his room. He also states that he is not in the mood for meeting friends. He used to enjoy playing soccer and going to the shooting range with his father, but recently stopped showing interest in these activities. He has been having difficulties at school due to concentration problems. His appetite is low. He has problems falling asleep. He states that he has thought about ending his life, but he has no specific plan. He lives with his parents, who frequently fight due to financial problems. He does not smoke. He drinks 2–3 cans of beer on the weekends. He does not use illicit drugs. He takes no medications. His vital signs are within normal limits. On mental status examination, he is oriented to person, place, and time. Physical examination shows no abnormalities. In addition to the administration of an appropriate medication, which of the following is the most appropriate next step in management?
- A. Hospitalization
- B. Recommend alcohol cessation
- C. Recommend family therapy
- D. Instruct parents to remove guns from the house (Correct Answer)
- E. Contact child protective services
Transition to adult care Explanation: ***Instruct parents to remove guns from the house***
- The patient has **suicidal ideation** and access to a firearm, which is a significant risk factor for suicide attempts. Removing access to lethal means is a crucial and immediate safety measure.
- While other interventions are important, securing the environment by removing firearms directly addresses an immediate and modifiable **suicide risk factor**, especially in an adolescent with depression.
*Hospitalization*
- Although the patient expresses suicidal thoughts, he states he has **no specific plan**, which suggests he may not require immediate inpatient psychiatric hospitalization.
- Hospitalization is typically reserved for individuals with a **specific suicide plan**, intent, and significant risk that cannot be managed in an outpatient setting.
*Recommend alcohol cessation*
- While **alcohol use** is a concern and can exacerbate depression or suicidal ideation, addressing this is not the most immediate next step in managing acute suicide risk.
- Alcohol cessation is a valuable long-term goal but does not directly mitigate the immediate danger posed by access to lethal means.
*Recommend family therapy*
- **Family therapy** could be beneficial in addressing family conflicts and improving communication, which might contribute to the patient's stress.
- However, addressing family dynamics is a long-term intervention and does not take precedence over immediately securing the patient's safety concerning lethal means.
*Contact child protective services*
- There is no information in the vignette to suggest **child abuse or neglect** by the parents.
- Financial problems and parental fighting, while disruptive, do not automatically constitute grounds for involving child protective services.
Transition to adult care US Medical PG Question 8: An 11-year-old boy is brought to a pediatrician by his parents with the complaint of progressive behavioral problems for the last 2 years. His parents report that he always looks restless at home and is never quiet. His school teachers frequently complain that he cannot remain seated for long during class, often leaving his seat to move around the classroom. A detailed history of his symptoms suggests a diagnosis of attention-deficit/hyperactivity disorder. The parents report that he has taken advantage of behavioral counseling several times without improvement. The pediatrician considers pharmacotherapy and plans to start methylphenidate at a low dose, followed by regular follow-up. Based on the side effect profile of the medication, which of the following components of the patient’s medical history should the pediatrician obtain before starting the drug?
- A. Past history of recurrent wheezing
- B. Past history of idiopathic thrombocytopenic purpura
- C. Past history of recurrent fractures
- D. Past history of Kawasaki disease (Correct Answer)
- E. Past history of Guillain-Barré syndrome
Transition to adult care Explanation: ***Past history of Kawasaki disease***
- Methylphenidate, a stimulant, can cause **cardiovascular side effects** such as increased heart rate and blood pressure.
- A history of Kawasaki disease, which can lead to **coronary artery aneurysms** and other cardiac complications, necessitates a thorough cardiac evaluation before initiating stimulant therapy to prevent potentially serious cardiovascular events.
*Past history of recurrent wheezing*
- **Recurrent wheezing** primarily involves the respiratory system and is not typically a contraindication or concern with methylphenidate use.
- While general health is important, there is no direct interaction or exacerbation of asthma/wheezing expected from methylphenidate.
*Past history of idiopathic thrombocytopenic purpura*
- **Idiopathic thrombocytopenic purpura (ITP)** is a hematological disorder affecting platelet count and clotting.
- There is no known direct interaction or significant risk of exacerbation of ITP with methylphenidate.
*Past history of recurrent fractures*
- **Recurrent fractures** may suggest underlying bone density issues or other musculoskeletal conditions.
- Methylphenidate does not directly impact bone health or fracture risk, making this history less relevant for its initiation.
*Past history of Guillain-Barré syndrome*
- **Guillain-Barré syndrome** is an autoimmune disorder affecting the peripheral nervous system, leading to muscle weakness and paralysis.
- While neurological history is generally important, there is no specific contraindication or heightened risk for patients with a history of Guillain-Barré syndrome taking methylphenidate.
Transition to adult care US Medical PG Question 9: A 4-year-old boy presents with language delay, toe-walking, hand-flapping, and intense interest in trains. He makes poor eye contact but occasionally engages in joint attention with his mother when looking at trains. He has sensory sensitivities to loud noises. He can identify all letters and numbers but cannot have reciprocal conversations. His Childhood Autism Rating Scale (CARS) score is borderline. His parents request your opinion on diagnosis and intervention priorities given diagnostic uncertainty and limited early intervention resources in their area.
- A. Presume autism spectrum disorder and implement evidence-based early interventions while monitoring (Correct Answer)
- B. Diagnose autism spectrum disorder and begin comprehensive ABA therapy immediately
- C. Diagnose language disorder and focus resources on communication training
- D. Refer to genetics for testing before committing to diagnosis or intervention
- E. Delay diagnosis pending further developmental assessment and prioritize speech therapy
Transition to adult care Explanation: ***Presume autism spectrum disorder and implement evidence-based early interventions while monitoring***
- The clinical presentation of **stereotyped behaviors** (hand-flapping, toe-walking), **restricted interests** (trains), and **social communication deficits** warrants early intervention during the critical **neuroplastic window** (ages 2-5).
- Given the diagnostic uncertainty and limited resources, a **provisional diagnosis** ensures the child receives broad-based support for functional deficits while longitudinal monitoring clarifies the diagnosis.
*Diagnose autism spectrum disorder and begin comprehensive ABA therapy immediately*
- While ASD is highly likely, a definitive diagnosis may be premature given the **borderline CARS score** and elements of **joint attention** that require further assessment.
- Immediate **comprehensive ABA therapy** might be resource-intensive and may not be the only or most appropriate option in an area with limited early intervention resources.
*Diagnose language disorder and focus resources on communication training*
- A **language disorder** diagnosis ignores the significant **repetitive behaviors**, **sensory sensitivities**, and **restricted interests** characteristic of ASD.
- Focusing solely on communication training fails to address the child's **social-emotional** and **behavioral needs**, which are central to his presentation.
*Refer to genetics for testing before committing to diagnosis or intervention*
- While **genetic testing** (e.g., chromosomal microarray) is recommended for ASD workups, it should not cause a **delay in starting intervention**.
- Genetic results rarely change the immediate **behavioral or developmental management** plan required for the child's daily functioning.
*Delay diagnosis pending further developmental assessment and prioritize speech therapy*
- Delaying diagnosis and intervention until further assessment can lead to the loss of valuable time during a peak period of **brain development**.
- Prioritizing **speech therapy** alone is insufficient because it does not address the **social reciprocity** and **sensory processing issues** evident in this patient.
Transition to adult care US Medical PG Question 10: A 15-year-old girl with ADHD-predominantly inattentive type has tried methylphenidate, amphetamine salts, and atomoxetine with partial response or intolerable side effects. She has comorbid anxiety disorder and mild depression. She is motivated for treatment and has good family support. Her psychiatrist considers guanfacine as next-line therapy. Evaluate the appropriateness of this choice given her clinical profile.
- A. Appropriate - guanfacine is superior to stimulants in adolescent females
- B. Appropriate - alpha-2 agonist may help both ADHD and anxiety (Correct Answer)
- C. Inappropriate - should try combination stimulant therapy first
- D. Inappropriate - should address anxiety and depression first before ADHD
- E. Inappropriate - guanfacine is only for hyperactive-impulsive ADHD symptoms
Transition to adult care Explanation: ***Appropriate - alpha-2 agonist may help both ADHD and anxiety***
- **Guanfacine** is an **alpha-2a adrenergic agonist** that is FDA-approved for ADHD and is particularly useful when stimulants or atomoxetine have failed or caused intolerable side effects.
- For patients with **comorbid anxiety**, guanfacine is a suitable choice as it lacks the sympathomimetic effects of stimulants that can often exacerbate **anxiety symptoms**.
*Appropriate - guanfacine is superior to stimulants in adolescent females*
- There is no clinical evidence to support the claim that **alpha-2 agonists** are superior to **stimulants** based on gender or age in adolescents.
- **Stimulants** (methylphenidate and amphetamines) remain the first-line and most efficacious pharmacological treatment for ADHD across all demographics.
*Inappropriate - should try combination stimulant therapy first*
- **Combination stimulant therapy** (using two different stimulants) is not a standard evidence-based practice and increases the risk of **cardiovascular side effects** and toxicity.
- Since the patient already failed trials of both **methylphenidate** and **amphetamines**, switching to a different class like **alpha-2 agonists** is the more appropriate next step.
*Inappropriate - should address anxiety and depression first before ADHD*
- In many cases, untreated **ADHD** can contribute to secondary **anxiety** and **depressive symptoms** due to chronic academic or social struggles.
- While severe mood disorders require priority, in this stable patient, managing the **ADHD** with a non-stimulant may concurrently improve her **comorbid profile**.
*Inappropriate - guanfacine is only for hyperactive-impulsive ADHD symptoms*
- While **alpha-2 agonists** are well-known for reducing hyperactivity, they are also effective for the **inattentive subtype** by strengthening prefrontal cortex regulation.
- Clinical studies demonstrate that extended-release **guanfacine** significantly improves overall ADHD scores, including those related to **concentration and focus**.
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