Warning signs review with patients — MCQs

7 questions

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?

A 66-year-old man is brought to the emergency department after a motor vehicle accident. The patient was a restrained passenger in a car that was struck on the passenger side while crossing an intersection. In the emergency department, he is alert and complaining of abdominal pain. He has a history of hyperlipidemia, gastroesophageal reflux disease, chronic kidney disease, and perforated appendicitis for which he received an interval appendectomy four years ago. His home medications include rosuvastatin and lansoprazole. His temperature is 99.2°F (37.3°C), blood pressure is 120/87 mmHg, pulse is 96/min, and respirations are 20/min. He has full breath sounds bilaterally. He is tender to palpation over the left 9th rib and the epigastrium. He is moving all four extremities. His FAST exam reveals fluid in Morrison's pouch. This patient is most likely to have which of the following additional signs or symptoms?

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?

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?

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?

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?

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?

Warning signs review with patients US Medical PG Practice Questions and MCQs

Question 1: 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?

A. Breach patient confidentiality, as this patient's care should be discussed with the daughter as she is his primary caregiver
B. See the patient back in 2 weeks and assess whether the patient's condition has improved, as his condition is not severe
C. Do not break patient confidentiality, as elder abuse reporting is not mandatory
D. Do not break patient confidentiality, as this would potentially worsen the situation
E. Breach patient confidentiality, as this patient is a potential victim of elder abuse and reporting is mandated in most states (Correct Answer)

Explanation: ***Breach patient confidentiality, as this patient is a potential victim of elder abuse and reporting is mandated in most states*** - As a physician, there is a **legal and ethical obligation** to report suspected elder abuse in most US states, even when the patient denies it and requests confidentiality. - Physicians are typically **mandatory reporters** under state law, and must report to Adult Protective Services or law enforcement when elder abuse is suspected. - The patient's safety and legal requirements outweigh the right to confidentiality in jurisdictions with mandatory reporting laws. *Breach patient confidentiality, as this patient's care should be discussed with the daughter as she is his primary caregiver* - Breaching confidentiality to discuss this with the daughter would be inappropriate, especially since the daughter and son-in-law are the **suspected abusers**. - Discussing with the primary caregiver is only appropriate if the patient has given **explicit consent** and there are no suspicions of abuse from that caregiver. *See the patient back in 2 weeks and assess whether the patient's condition has improved, as his condition is not severe* - This option is inappropriate because it delays intervention in a potentially **dangerous situation**. - Suspected abuse warrants **immediate action** to ensure the patient's safety, regardless of the perceived severity of current injuries. *Do not break patient confidentiality, as elder abuse reporting is not mandatory* - In **most states**, physicians have **mandatory reporting laws** for elder abuse, making this statement generally incorrect. - Physicians are typically considered "mandated reporters" and are legally required to report suspected abuse to the appropriate authorities in their jurisdiction. *Do not break patient confidentiality, as this would potentially worsen the situation* - While this is a valid concern in some situations, the **primary responsibility** of a physician is to protect vulnerable patients from harm. - Reporting suspected abuse initiates protective measures and is legally required in most states, as the potential benefit of intervention outweighs the risk of worsening the situation.

Question 2: A 66-year-old man is brought to the emergency department after a motor vehicle accident. The patient was a restrained passenger in a car that was struck on the passenger side while crossing an intersection. In the emergency department, he is alert and complaining of abdominal pain. He has a history of hyperlipidemia, gastroesophageal reflux disease, chronic kidney disease, and perforated appendicitis for which he received an interval appendectomy four years ago. His home medications include rosuvastatin and lansoprazole. His temperature is 99.2°F (37.3°C), blood pressure is 120/87 mmHg, pulse is 96/min, and respirations are 20/min. He has full breath sounds bilaterally. He is tender to palpation over the left 9th rib and the epigastrium. He is moving all four extremities. His FAST exam reveals fluid in Morrison's pouch. This patient is most likely to have which of the following additional signs or symptoms?

A. Pain radiating to the back
B. Gross hematuria
C. Muffled heart sounds
D. Free air on chest radiograph
E. Shoulder pain (Correct Answer)

Explanation: ***Shoulder pain*** - The presence of **fluid in Morrison's pouch** (hepatorenal recess) on FAST exam indicates **intra-abdominal bleeding**, likely from a liver or spleen injury. - **Diaphragmatic irritation** due to intra-abdominal hemorrhage often manifests as referred **shoulder pain** (Kehr's sign), especially on the left side with splenic injury or right side with liver injury. *Pain radiating to the back* - While pancreatic injury can cause pain radiating to the back, the primary finding of **fluid in Morrison's pouch** points towards hemoperitoneum, less specifically to pancreatic trauma. - Significant pancreatic injury would likely involve more severe abdominal tenderness and potentially elevated **amylase/lipase**, which are not mentioned here. *Gross hematuria* - **Gross hematuria** would suggest a **renal or urologic injury**, but the patient's primary finding is intra-abdominal fluid in Morrison's pouch, which is more indicative of solid organ injury like the liver or spleen. - Though concurrent injuries are possible in trauma, hepatorenal fluid points specifically to **hemoperitoneum**, not necessarily kidney damage. *Muffled heart sounds* - **Muffled heart sounds** are a component of **Beck's triad** (along with hypotension and jugular venous distension), indicative of **cardiac tamponade** due to fluid around the heart. - There is no clinical information in the stem suggestive of cardiac injury or tamponade; the fluid is specifically mentioned in the abdomen. *Free air on chest radiograph* - **Free air on chest radiograph** (pneumoperitoneum) indicates a **perforated hollow viscus**, such as the bowel or stomach. - The FAST exam finding of fluid in Morrison's pouch is characteristic of **hemoperitoneum** from a solid organ injury, not free air from a perforation.

Question 3: 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?

A. Malignant hyperthermia
B. Drug-induced fever
C. Multiple organ dysfunction syndrome
D. Sepsis (Correct Answer)
E. Non-infectious systemic inflammatory response syndrome (SIRS)

Explanation: ***Sepsis*** - The patient exhibits several signs of **systemic inflammatory response syndrome (SIRS)** (fever, tachycardia, tachypnea) coupled with evidence of infection (coarse crackles in the lung base suggests **pneumonia**). - The combination of **SIRS criteria** and a likely infection source in a postoperative patient strongly points to sepsis, a life-threatening organ dysfunction caused by a dysregulated host response to infection. *Malignant hyperthermia* - This is a rare, life-threatening condition typically triggered by **volatile anesthetic agents** or **succinylcholine** during surgery. - It usually presents **intraoperatively or immediately postoperatively** with rapid onset of hyperthermia, muscle rigidity, and metabolic acidosis, which is not consistent with a presentation on post-op day 5. *Drug-induced fever* - While drug-induced fever is possible, particularly in polymedicated patients, it would be a **diagnosis of exclusion** when other more likely causes of fever, such as infection, are present. - There are no specific clinical features in this case that strongly suggest a drug as the singular cause of fever and the systemic inflammatory response. *Multiple organ dysfunction syndrome* - **MODS** is the progressive failure of two or more organ systems and is often a **complication of severe sepsis or septic shock**, rather than an initial diagnosis. - While the patient is unwell, her current presentation describes a potential precursor (sepsis) rather than established multi-organ dysfunction. *Non-infectious systemic inflammatory response syndrome (SIRS)* - SIRS caused by non-infectious etiologies (e.g., pancreatitis, trauma, burns) can occur, but the presence of **localized lung crackles** and a **postoperative fever** makes an infectious etiology much more likely. - Postoperative SIRS can occur due to surgical stress, but the signs of infection (especially respiratory) shift the diagnosis towards sepsis.

Question 4: 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?

A. Herpes simplex virus encephalitis
B. Septic emboli (Correct Answer)
C. Intracranial hemorrhage
D. Thromboembolic stroke
E. Bacterial meningitis

Explanation: ***Septic emboli*** - The patient's history of **intravenous drug use** (inferred from antecubital scars and homelessness), fever, hypotension, tachycardia, and a new murmur strongly suggest **infective endocarditis**. - **Septic emboli** from an infected heart valve can dislodge and travel to the brain, causing a **stroke-like presentation** with focal neurological deficits such as right-sided weakness and dysarthria. - This is the **most specific etiology** as it identifies both the embolic mechanism AND the infectious source. *Herpes simplex virus encephalitis* - While encephalitis can cause focal neurological deficits, it typically presents with **altered mental status, seizures**, and a distinct pattern on MRI (temporal lobe involvement), which is not the primary presentation here. - The context of infective endocarditis makes **embolic events** a more direct and likely cause of acute focal deficits. *Intracranial hemorrhage* - Intracranial hemorrhage would typically cause a **sudden onset** of neurological deficits, often accompanied by severe headache, altered consciousness, and signs of increased intracranial pressure. - Although endocarditis can rarely lead to mycotic aneurysms that rupture, **ischemic stroke** due to emboli is far more common than hemorrhage in this setting. *Thromboembolic stroke* - While septic emboli do cause an embolic stroke, **"thromboembolic stroke"** is a broader, less specific term that doesn't identify the **infectious etiology**. - The term typically refers to sterile emboli from sources like atrial fibrillation, left ventricular thrombus, or atherosclerotic plaques. - **"Septic emboli"** is the most precise answer as it specifically indicates emboli containing infected material from the endocarditis, which has important implications for treatment and prognosis. *Bacterial meningitis* - Meningitis typically presents with classic symptoms like **fever, headache, nuchal rigidity**, and altered mental status. - While it can cause neurological complications, acute focal deficits like hemiparesis and dysarthria are more characteristic of a stroke or mass lesion, not diffuse meningeal inflammation.

Question 5: 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?

A. Transfuse blood products
B. Intubation (Correct Answer)
C. Emergency surgery
D. IV fluids and fresh frozen plasma
E. Emergency variceal banding

Explanation: ***Intubation*** - The patient exhibits signs of **airway compromise** and hypoxemic respiratory failure due to continuous vomiting and worsening mental status, indicated by a GCS score consistent with severe neurological impairment (GCS < 8). - **Securing the airway via intubation** is the priority to prevent aspiration and ensure adequate ventilation and oxygenation in a patient with active hematemesis and altered mental status. *Transfuse blood products* - While transfusion is often necessary for significant bleeding in variceal hemorrhage, the immediate priority in this deteriorating patient is **airway protection and stabilization**. - Transfusion alone will not address the immediate risk of **aspiration** or progressive respiratory compromise. *Emergency surgery* - Emergency surgery (e.g., portosystemic shunt) for variceal bleeding is typically considered only after **endoscopic and pharmacological therapies have failed** to control hemorrhage. - It is a **more invasive** and higher-risk procedure that is not the immediate first-line intervention for acute variceal bleeding. *IV fluids and fresh frozen plasma* - **IV fluids** are crucial for initial resuscitation in hypovolemic shock, and **fresh frozen plasma (FFP)** can help correct coagulopathy in cirrhotic patients. - However, these interventions do not address the immediate and critical need for **airway protection** in a patient with active vomiting and declining mental status. *Emergency variceal banding* - **Endoscopic variceal banding** is a primary treatment for acute variceal bleeding but requires a **secured airway** and patient cooperation. - Given the patient's deteriorating mental status and ongoing hematemesis, performing endoscopy immediately without prior intubation carries a high risk of **aspiration**.

Question 6: 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?

A. "Does the diarrhea typically precede the constipation, or vice-versa?"
B. "Is the diarrhea foul-smelling?"
C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
D. "Are the symptoms worse in the morning or at night?"
E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)

Explanation: ***Can you tell me more about the symptoms you have been experiencing?*** - This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis. - In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions. *Does the diarrhea typically precede the constipation, or vice-versa?* - While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience. - It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture. *Is the diarrhea foul-smelling?* - Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions. - However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed. *Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life* - Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time. - However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially. *Are the symptoms worse in the morning or at night?* - Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related. - This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.

Question 7: 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?

A. I would like to refer you to a psychiatric specialist to start behavioral psychotherapy.
B. Your symptoms are suggestive of a condition called somatic symptom disorder.
C. I would like to investigate your shortness of breath by performing coronary artery catheterization.
D. Your desire for pain medication is suggestive of a medication dependence disorder.
E. I would like to assess your symptoms causing you the most distress and schedule monthly follow-up appointments. (Correct Answer)

Explanation: ***"I would like to assess your symptoms causing you the most distress and schedule monthly follow-up appointments."*** - This response demonstrates **empathy** and a commitment to ongoing care, which is crucial for patients with **somatic symptoms** who often feel dismissed. - Establishing a consistent relationship with a primary care physician can help manage chronic, unexplained symptoms and build **trust**, potentially reducing the need for extensive, often fruitless, investigations. *"Your desire for pain medication is suggestive of a medication dependence disorder."* - This statement is **judgmental** and incorrect, as the patient has not shown any signs of drug-seeking behavior beyond requesting medication for pain. - It would likely damage the **doctor-patient relationship** and discourage the patient from seeking further help from this physician. *"I would like to refer you to a psychiatric specialist to start behavioral psychotherapy."* - While psychotherapy may be beneficial, immediately referring to a **psychologist** without first validating the patient's physical symptoms can make them feel dismissed. - It's often more effective to integrate mental health support after a continued period of medical evaluation and relationship building. *"Your symptoms are suggestive of a condition called somatic symptom disorder."* - While the patient's symptoms are consistent with **somatic symptom disorder**, directly labeling the condition at the initial interaction might be perceived as diagnostic and **invalidating** to the patient, who believes their symptoms are purely physical. - A more gradual approach, focusing on symptom management and observation, is usually preferred before introducing a psychiatric diagnosis. *"I would like to investigate your shortness of breath by performing coronary artery catheterization."* - The patient has already undergone an extensive cardiac stress test with **no abnormalities**, making an invasive procedure like catheterization unnecessary and potentially harmful. - This approach ignores the previous negative workup and the chronic, unexplained nature of the symptoms, contributing to over-medicalization.

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