A 79-year-old male presents to your office for his annual flu shot. On physical exam you note several linear bruises on his back. Upon further questioning he denies abuse from his daughter and son-in-law, who live in the same house. The patient states he does not want this information shared with anyone. What is the most appropriate next step, paired with its justification?

Breach patient confidentiality, as this patient is a potential victim of elder abuse and reporting is mandated in most states

Breach patient confidentiality, as this patient's care should be discussed with the daughter as she is his primary caregiver

See the patient back in 2 weeks and assess whether the patient's condition has improved, as his condition is not severe

Do not break patient confidentiality, as elder abuse reporting is not mandatory

Do not break patient confidentiality, as this would potentially worsen the situation

A 68-year-old woman presents to the hospital for an elective right hemicolectomy. She is independently mobile and does her own shopping. She has had type 2 diabetes mellitus for 20 years, essential hypertension for 15 years, and angina on exertion for 6 years. She has a 30-pack-year history of smoking. The operation was uncomplicated. On post-op day 5, she becomes confused. She has a temperature of 38.5°C (101.3°F), respiratory rate of 28/min, and oxygen saturation of 92% on 2 L of oxygen. She is tachycardic at 118/min and her blood pressure is 110/65 mm Hg. On chest auscultation, she has coarse crackles in the right lung base. Her surgical wound appears to be healing well, and her abdomen is soft and nontender. Which of the following is the most likely diagnosis?

Multiple organ dysfunction syndrome

Non-infectious systemic inflammatory response syndrome (SIRS)

Five minutes after arriving in the postoperative care unit following total knee replacement under general anesthesia, a 55-year-old woman is acutely short of breath. The procedure was uncomplicated. Postoperatively, prophylactic treatment with cefazolin was begun and the patient received morphine and ketorolac for pain management. She has generalized anxiety disorder. Her only other medication is escitalopram. She has smoked one pack of cigarettes daily for 25 years. Her temperature is 37°C (98.6°F), pulse is 108/min, respirations are 26/min, and blood pressure is 95/52 mm Hg. A flow-volume loop obtained via pulmonary function testing is shown. Which of the following is the most likely underlying cause of this patient's symptoms?

Type I hypersensitivity reaction

Decreased central respiratory drive

A 29-year-old man presents to the emergency department with chest pain and fatigue for the past week. The patient is homeless and his medical history is not known. His temperature is 103°F (39.4°C), blood pressure is 97/58 mmHg, pulse is 140/min, respirations are 25/min, and oxygen saturation is 95% on room air. Physical exam is notable for scars in the antecubital fossa and a murmur over the left sternal border. The patient is admitted to the intensive care unit and is treated appropriately. On day 3 of his hospital stay, the patient presents with right-sided weakness in his arm and leg and dysarthric speech. Which of the following is the most likely etiology of his current symptoms?

Herpes simplex virus encephalitis

A 55-year-old man presents to the emergency department with hematemesis that started 1 hour ago but has subsided. His past medical history is significant for cirrhosis with known esophageal varices which have been previously banded. His temperature is 97.5°F (36.4°C), blood pressure is 114/64 mmHg, pulse is 130/min, respirations are 12/min, and oxygen saturation is 98% on room air. During the patient's physical exam, he begins vomiting again and his heart rate increases with a worsening blood pressure. He develops mental status changes and on exam he opens his eyes and flexes his arms only to sternal rub and is muttering incoherent words. Which of the following is the most appropriate next step in management?

IV fluids and fresh frozen plasma

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

"Can you tell me more about the symptoms you have been experiencing?"

"Does the diarrhea typically precede the constipation, or vice-versa?"

"Is the diarrhea foul-smelling?"

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

"Are the symptoms worse in the morning or at night?"

A 38-year-old woman comes to the physician for the first time because of a 2-year history of lower back pain and fatigue. She also says that she occasionally feels out of breath. Her symptoms are not associated with physical activity. She has seen multiple physicians over the past year. Extensive workup including blood and urine tests, abdominal ultrasound, MRI of the back, and cardiac stress testing have shown no abnormalities. The patient asks for a medication to alleviate her symptoms. Which of the following is the most appropriate response by the physician?

I would like to assess your symptoms causing you the most distress and schedule monthly follow-up appointments.

I would like to refer you to a psychiatric specialist to start behavioral psychotherapy.

Your symptoms are suggestive of a condition called somatic symptom disorder.

I would like to investigate your shortness of breath by performing coronary artery catheterization.

Your desire for pain medication is suggestive of a medication dependence disorder.

Warning signs review with patients for USMLE Step 2 CK: High-Yield CCS Cases Lessons

Safety Netting - The 'Why' & 'How'

Why? A crucial medicolegal safeguard against diagnostic uncertainty. It empowers patients to co-monitor their condition, reducing risks from delayed diagnosis or atypical presentations. It bridges the gap between consultation and follow-up.
How? Provide explicit, documented advice.
- Explain specific red flag symptoms (e.g., "worsening chest pain," "new-onset weakness").
- Set a clear timeframe for re-evaluation (e.g., "if no improvement in 48 hours," "return immediately if...").
- Provide a concrete action plan: what to do and where to go (e.g., return to this clinic, visit A&E).
- 📌 Mnemonic (3 W's):
  - What to look for (signs).
  - When to worry (timeframe).
  - Where to go (action plan).

⭐ In medicolegal cases, safety netting advice that is not documented is considered advice not given. Always record the specific warnings and timeframe discussed with the patient.

General Red Flags - Universal Alarms

Systemic Symptoms: Unexplained fever (>38°C), night sweats, rigors, or significant unintentional weight loss (>5% of body weight in 6-12 months).
Cardiopulmonary: Acute chest pain (especially with radiation), shortness of breath (dyspnea) at rest or new-onset, palpitations with syncope.
Neurological: Sudden severe headache ("thunderclap"), new-onset seizure, focal weakness or numbness, acute confusion, or changes in vision/speech/gait.
Bleeding: Any unexplained bleeding from any site-rectal (melena/hematochezia), urine (hematuria), or coughing up blood (hemoptysis).
Physical Findings: New or changing lumps, moles (asymmetry, border, color, diameter, evolving), or persistent, painless lymphadenopathy.

⭐ In a patient presenting with vague symptoms, the presence of multiple constitutional symptoms (fever, night sweats, weight loss) significantly raises the suspicion for underlying malignancy (e.g., lymphoma) or chronic infections like tuberculosis.

Specialty Red Flags - Case-Specific Clues

A crucial step in follow-up is educating patients to recognize and report warning signs promptly. This prevents delays in managing serious complications.

Cardiology:
- Chest pain: new onset, crescendo pattern, or at rest.
- Syncope or near-syncope, especially during exertion.
- Palpitations associated with dizziness or dyspnea.
Neurology:
- Headache red flags 📌 SNOOP: Systemic symptoms (fever), Neurologic signs (focal deficit), Onset (sudden/thunderclap), Older age (>50), Pattern change.
- First-ever seizure or a change in seizure pattern; altered sensorium.
Gastroenterology:
- GI Bleeding: Hematemesis, melena, hematochezia.
- Progressive dysphagia, odynophagia, or significant unintentional weight loss.
- Persistent vomiting, severe abdominal pain, or new-onset jaundice.
Surgery (Post-Op):
- Fever >38°C after post-op day 2.
- Wound: increasing erythema, purulent discharge, dehiscence.
- Calf pain/swelling (DVT), sudden dyspnea/chest pain (PE).

⭐ The "5 W's" is a classic mnemonic for post-operative fever causes: Wind (atelectasis/pneumonia, Day 1-2), Water (UTI, Day 3-5), Wound (infection, Day 5-7), Walking (DVT/PE, Day 7+), and Wonder drugs (drug fever).

High‑Yield Points - ⚡ Biggest Takeaways

Always document the discussion of warning signs, including the patient's understanding.

Use the "Teach-Back" method to confirm the patient can recall and explain the key symptoms.

Crucial signs include uncontrolled pain, persistent fever, worsening shortness of breath, or any new neurological deficit.

Provide clear, explicit instructions on when to call, when to return, or when to go to the Emergency Department.

Tailor warnings to the specific diagnosis and potential medication side effects.

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