Balancing disease-specific vs comorbidity management — MCQs

6 questions

A 42-year-old man comes to the physician because of a 2-month history of fatigue and increased urination. The patient reports that he has been drinking more than usual because he is constantly thirsty. He has avoided driving for the past 8 weeks because of intermittent episodes of blurred vision. He had elevated blood pressure at his previous visit but is otherwise healthy. Because of his busy work schedule, his diet consists primarily of fast food. He does not smoke or drink alcohol. He is 178 cm (5 ft 10 in) tall and weighs 109 kg (240 lb); BMI is 34 kg/m2. His pulse is 75/min and his blood pressure is 148/95 mm Hg. Cardiopulmonary examination shows no abnormalities. Laboratory studies show: Hemoglobin A1c 6.8% Serum Glucose 180 mg/dL Creatinine 1.0 mg/dL Total cholesterol 220 mg/dL HDL cholesterol 50 mg/dL Triglycerides 140 mg/dL Urine Blood negative Glucose 2+ Protein 1+ Ketones negative Which of the following is the most appropriate next step in management?

A 16-year-old woman presents to the emergency department for evaluation of acute vomiting and abdominal pain. Onset was roughly 3 hours ago while she was sleeping. She has no known past medical history. Her family history is positive for hypothyroidism and diabetes mellitus in her maternal grandmother. On examination, she is found to have fruity breath and poor skin turgor. She appears fatigued and her consciousness is slightly altered. Laboratory results show a blood glucose level of 691 mg/dL, sodium of 125 mg/dL, and elevated serum ketones. Of the following, which is the next best step in patient management?

A 13-year-old boy is brought to the emergency department after being involved in a motor vehicle accident in which he was a restrained passenger. He is confused and appears anxious. His pulse is 131/min, respirations are 29/min, and blood pressure is 95/49 mm Hg. Physical examination shows ecchymosis over the upper abdomen, with tenderness to palpation over the left upper quadrant. There is no guarding or rigidity. Abdominal ultrasound shows free intraperitoneal fluid and a splenic rupture. Intravenous fluids and vasopressors are administered. A blood transfusion and exploratory laparotomy are scheduled. The patient's mother arrives and insists that her son should not receive a blood transfusion because he is a Jehovah's Witness. The physician proceeds with the blood transfusion regardless of the mother's wishes. The physician's behavior is an example of which of the following principles of medical ethics?

A 67-year-old man presents to the emergency department for squeezing and substernal chest pain. He states that he was at home eating dinner when his symptoms began. The patient has a past medical history of diabetes, hypertension, and dyslipidemia. He is currently taking atorvastatin, lisinopril, insulin, metformin, metoprolol, and aspirin. Six days ago he underwent percutaneous coronary intervention. His temperature is 99.5°F (37.5°C), blood pressure is 197/118 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam reveals an uncomfortable elderly man who is sweating. An ECG is ordered. Which of the following is the best next step in management for this patient?

A 65-year-old man presents to the emergency department for sudden weakness. He was doing mechanical work on his car where he acutely developed right-leg weakness and fell to the ground. He is accompanied by his wife, who said that this has never happened before. He was last seen neurologically normal approximately 2 hours prior to presentation. His past medical history is significant for hypertension and type II diabetes. His temperature is 98.8°F (37.1°C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air. Neurological exam reveals that he is having trouble speaking and has profound weakness of his right upper and lower extremity. Which of the following is the best next step in management?

A 25-year-old woman presents to the emergency department with fatigue and weakness. She states over the past 24 hours she has not felt like herself and has felt like she has no strength. The patient has no significant past medical history other than a single episode of blood-tinged diarrhea 1 week ago which resolved on its own. Her temperature is 99.4°F (37.4°C), blood pressure is 124/62 mmHg, pulse is 95/min, respirations are 29/min, and oxygen saturation is 95% on room air. Physical exam is notable for 2/5 strength of the lower extremities and decreased sensation in the lower extremities and finger tips. Which of the following is the best initial step in management?

Balancing disease-specific vs comorbidity management US Medical PG Practice Questions and MCQs

Question 1: A 42-year-old man comes to the physician because of a 2-month history of fatigue and increased urination. The patient reports that he has been drinking more than usual because he is constantly thirsty. He has avoided driving for the past 8 weeks because of intermittent episodes of blurred vision. He had elevated blood pressure at his previous visit but is otherwise healthy. Because of his busy work schedule, his diet consists primarily of fast food. He does not smoke or drink alcohol. He is 178 cm (5 ft 10 in) tall and weighs 109 kg (240 lb); BMI is 34 kg/m2. His pulse is 75/min and his blood pressure is 148/95 mm Hg. Cardiopulmonary examination shows no abnormalities. Laboratory studies show: Hemoglobin A1c 6.8% Serum Glucose 180 mg/dL Creatinine 1.0 mg/dL Total cholesterol 220 mg/dL HDL cholesterol 50 mg/dL Triglycerides 140 mg/dL Urine Blood negative Glucose 2+ Protein 1+ Ketones negative Which of the following is the most appropriate next step in management?

A. Metformin therapy (Correct Answer)
B. Low-carbohydrate diet
C. Aspirin therapy
D. ACE inhibitor therapy
E. Insulin therapy

Explanation: ***Metformin therapy*** - This patient has **newly diagnosed type 2 diabetes mellitus** with classic symptoms (polyuria, polydipsia, blurred vision) and laboratory confirmation (HbA1c 6.8%, glucose 180 mg/dL, glucosuria). - **Metformin is the first-line pharmacologic therapy** for type 2 diabetes according to current guidelines (ADA, AACE) due to its efficacy, safety profile, cardiovascular benefits, and low risk of hypoglycemia. - The patient's creatinine is normal (1.0 mg/dL), so metformin is not contraindicated. - Addressing the **symptomatic hyperglycemia** is the most appropriate next step in management. *ACE inhibitor therapy* - ACE inhibitors are indicated for diabetic patients with **hypertension and albuminuria** to provide renoprotection and slow progression of diabetic nephropathy. - While this patient has both hypertension (148/95 mm Hg) and proteinuria (1+), ACE inhibitor therapy should be initiated **after or concurrent with diabetes management**, not as the sole initial intervention. - The patient needs **glycemic control first** given symptomatic hyperglycemia, though ACE inhibitor would be an appropriate addition to the treatment regimen. *Low-carbohydrate diet* - **Lifestyle modifications** including medical nutrition therapy and exercise are foundational for managing type 2 diabetes and should be recommended. - However, given the patient's **symptomatic hyperglycemia** (HbA1c 6.8%, glucose 180 mg/dL with classic symptoms), lifestyle changes alone are **insufficient as the initial management**. - Pharmacologic therapy with metformin should be initiated immediately alongside lifestyle counseling. *Insulin therapy* - Insulin therapy is indicated for patients with **very high HbA1c** (typically >9-10%), **severe symptoms of hyperglycemia**, evidence of catabolism, or failure of oral agents. - This patient's HbA1c of 6.8% represents **relatively mild hyperglycemia** that is appropriately managed with metformin as first-line therapy. - Insulin is **not indicated** at this stage of disease. *Aspirin therapy* - **Aspirin for primary prevention** in diabetes is controversial; current guidelines suggest shared decision-making for patients at increased cardiovascular risk without high bleeding risk. - While this patient has cardiovascular risk factors (diabetes, hypertension, obesity, dyslipidemia), aspirin would be a **secondary priority** after addressing the acute metabolic derangements. - **Glycemic control takes precedence** over aspirin initiation in newly diagnosed diabetes.

Question 2: A 16-year-old woman presents to the emergency department for evaluation of acute vomiting and abdominal pain. Onset was roughly 3 hours ago while she was sleeping. She has no known past medical history. Her family history is positive for hypothyroidism and diabetes mellitus in her maternal grandmother. On examination, she is found to have fruity breath and poor skin turgor. She appears fatigued and her consciousness is slightly altered. Laboratory results show a blood glucose level of 691 mg/dL, sodium of 125 mg/dL, and elevated serum ketones. Of the following, which is the next best step in patient management?

A. Administer IV fluids and insulin (Correct Answer)
B. Initiate basal-bolus insulin regimen
C. Initiate insulin glargine 10 units at bedtime only
D. Initiate oral antidiabetic medications
E. Initiate insulin aspart at mealtimes only

Explanation: ***Administer IV fluids and insulin*** - The patient presents with **fruity breath**, **altered consciousness**, **hyperglycemia (691 mg/dL)**, **hyponatremia**, and **elevated serum ketones**, which are classic signs of **diabetic ketoacidosis (DKA)**. - The immediate management for DKA involves aggressive **intravenous fluid resuscitation** to correct dehydration and hypovolemia, followed by a continuous **intravenous insulin infusion** to lower blood glucose and suppress ketogenesis. *Initiate basal-bolus insulin regimen* - A **basal-bolus insulin regimen** is appropriate for long-term management of diabetes but is not the immediate treatment for acute DKA, which requires continuous intravenous insulin. - This approach does not address the severe dehydration and electrolyte imbalances seen in DKA, which need urgent fluid replacement. *Initiate insulin glargine 10 units at bedtime only* - **Insulin glargine** is a long-acting insulin used for basal insulin coverage, typically in the chronic management of diabetes. - This dose is insufficient to manage acute DKA, and it also fails to address the critical need for fluid resuscitation. *Initiate oral antidiabetic medications* - **Oral antidiabetic medications** are suitable for individuals with type 2 diabetes or milder forms of insulin resistance, not for acute DKA. - They are ineffective in severe hyperglycemia and metabolic acidosis characteristic of DKA, and do not address dehydration. *Initiate insulin aspart at mealtimes only* - **Insulin aspart** is a rapid-acting insulin used to cover mealtime glucose excursions. - Administering it only at mealtimes is inadequate for acute DKA, which requires continuous insulin infusion and aggressive fluid management.

Question 3: A 13-year-old boy is brought to the emergency department after being involved in a motor vehicle accident in which he was a restrained passenger. He is confused and appears anxious. His pulse is 131/min, respirations are 29/min, and blood pressure is 95/49 mm Hg. Physical examination shows ecchymosis over the upper abdomen, with tenderness to palpation over the left upper quadrant. There is no guarding or rigidity. Abdominal ultrasound shows free intraperitoneal fluid and a splenic rupture. Intravenous fluids and vasopressors are administered. A blood transfusion and exploratory laparotomy are scheduled. The patient's mother arrives and insists that her son should not receive a blood transfusion because he is a Jehovah's Witness. The physician proceeds with the blood transfusion regardless of the mother's wishes. The physician's behavior is an example of which of the following principles of medical ethics?

A. Autonomy
B. Nonmaleficence
C. Informed consent
D. Justice
E. Beneficence (Correct Answer)

Explanation: ***Beneficence*** - The physician prioritized the patient's immediate survival and well-being, which is the core principle of **beneficence** (acting in the best interest of the patient). - In cases of life-threatening emergencies, especially with minors, the duty to preserve life often outweighs other considerations like parental wishes, particularly when the patient lacks the capacity for **informed refusal**. *Autonomy* - The physician’s action directly overrides the mother's wishes, which would be an infringement of surrogate autonomy for a minor. - While patient autonomy is a fundamental principle, it was superseded by the immediate need to save the patient's life. *Nonmaleficence* - **Nonmaleficence** means "do no harm." While transfusions have risks, refusing one in this critical situation would cause more harm (death) than performing it. - The physician acted to prevent immediate harm (death from hemorrhage), even if it meant overriding a family's wishes regarding the specific treatment method. *Informed consent* - **Informed consent** requires obtaining permission from a capacitated patient (or legal guardian for a minor) after explaining the risks and benefits of a treatment. - In this emergency scenario, the patient is a minor and incapacitated, and the urgent need for a life-saving intervention (blood transfusion for a splenic rupture) did not allow for full informed consent or negotiation with the mother, who was refusing a life-saving measure. *Justice* - **Justice** refers to the fair and equitable distribution of healthcare resources and equal treatment, which is not the primary ethical concern in this personal patient-physician interaction. - The scenario focuses on the individual patient's treatment decision, not broader societal resource allocation or fairness in access to care.

Question 4: A 67-year-old man presents to the emergency department for squeezing and substernal chest pain. He states that he was at home eating dinner when his symptoms began. The patient has a past medical history of diabetes, hypertension, and dyslipidemia. He is currently taking atorvastatin, lisinopril, insulin, metformin, metoprolol, and aspirin. Six days ago he underwent percutaneous coronary intervention. His temperature is 99.5°F (37.5°C), blood pressure is 197/118 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam reveals an uncomfortable elderly man who is sweating. An ECG is ordered. Which of the following is the best next step in management for this patient?

A. Stress testing
B. Angiography (Correct Answer)
C. Cardiac troponins
D. Creatine kinase-MB
E. Myoglobin

Explanation: ***Correct: Angiography*** - This patient presenting with **acute chest pain 6 days post-PCI** is at high risk for **stent thrombosis or acute in-stent restenosis**, which represents a life-threatening emergency. - Given the **clinical instability** (severe hypertension 197/118, tachycardia 120/min, diaphoresis) and classic ACS symptoms in the immediate post-PCI period, **urgent coronary angiography** is the best next step in management. - While ECG and troponins are important diagnostic tools, this patient requires **immediate intervention** to evaluate the recent PCI site and potentially perform emergent revascularization. - In the setting of suspected **acute stent thrombosis**, time to reperfusion is critical, and angiography allows both diagnosis and treatment. *Incorrect: Cardiac troponins* - While troponins are essential biomarkers for myocardial injury and should be obtained, they are a **diagnostic test** rather than definitive management. - Waiting for troponin results would delay definitive management in a patient with clear clinical evidence of ACS. - In this high-risk post-PCI patient with active symptoms, management should not wait for biomarker confirmation. *Incorrect: Stress testing* - Stress testing is **absolutely contraindicated** in patients with active chest pain and suspected acute MI. - It could precipitate further myocardial ischemia, arrhythmias, or cardiac arrest. - Stress testing is reserved for risk stratification in stable patients or after ACS has been ruled out. *Incorrect: Creatine kinase-MB* - CK-MB is less sensitive and specific than troponins for myocardial injury, as it can be elevated in skeletal muscle conditions. - It has a shorter elevation window and has largely been replaced by troponins in modern practice. - Like troponins, it would not change the immediate management need in this clinically unstable patient. *Incorrect: Myoglobin* - Myoglobin lacks cardiac specificity (present in both cardiac and skeletal muscle) and has poor diagnostic accuracy for MI. - Its rapid rise and fall make it unreliable, and it generates many false positives. - It has no role in guiding management decisions in suspected ACS.

Question 5: A 65-year-old man presents to the emergency department for sudden weakness. He was doing mechanical work on his car where he acutely developed right-leg weakness and fell to the ground. He is accompanied by his wife, who said that this has never happened before. He was last seen neurologically normal approximately 2 hours prior to presentation. His past medical history is significant for hypertension and type II diabetes. His temperature is 98.8°F (37.1°C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air. Neurological exam reveals that he is having trouble speaking and has profound weakness of his right upper and lower extremity. Which of the following is the best next step in management?

A. Thrombolytics
B. Noncontrast head CT (Correct Answer)
C. CT angiogram
D. MRI of the head
E. Aspirin

Explanation: ***Noncontrast head CT*** - A **noncontrast head CT** is the most crucial initial step in managing acute stroke symptoms because it can rapidly rule out an **intracranial hemorrhage**. - Distinguishing between ischemic stroke and hemorrhagic stroke is critical, as the management strategies are vastly different and administering thrombolytics in the presence of hemorrhage can be fatal. *Thrombolytics* - **Thrombolytics** can only be administered after an **intracranial hemorrhage** has been excluded via noncontrast head CT. - Administering thrombolytics without imaging could worsen a hemorrhagic stroke, causing significant harm or death. *CT angiogram* - A **CT angiogram** is used to identify large vessel occlusions in ischemic stroke and is typically performed after a noncontrast CT rules out hemorrhage. - This imaging is crucial for determining eligibility for **endovascular thrombectomy** but is not the very first diagnostic step. *MRI of the head* - An **MRI of the head** is more sensitive for detecting acute ischemic changes but takes longer to perform and is often not readily available in the acute emergency setting. - It is not the initial imaging of choice for ruling out hemorrhage due to its longer acquisition time compared to CT. *Aspirin* - **Aspirin** is indicated for acute ischemic stroke but should only be given after an **intracranial hemorrhage** has been ruled out. - Like thrombolytics, aspirin could exacerbate a hemorrhagic stroke and is thus deferred until initial imaging is complete.

Question 6: A 25-year-old woman presents to the emergency department with fatigue and weakness. She states over the past 24 hours she has not felt like herself and has felt like she has no strength. The patient has no significant past medical history other than a single episode of blood-tinged diarrhea 1 week ago which resolved on its own. Her temperature is 99.4°F (37.4°C), blood pressure is 124/62 mmHg, pulse is 95/min, respirations are 29/min, and oxygen saturation is 95% on room air. Physical exam is notable for 2/5 strength of the lower extremities and decreased sensation in the lower extremities and finger tips. Which of the following is the best initial step in management?

A. IV immunoglobulin
B. Dexamethasone
C. Spirometry (Correct Answer)
D. Intubation
E. Pyridostigmine

Explanation: ***Spirometry*** - The patient's symptoms (fatigue, weakness, decreased strength, and sensation in extremities) following a gastrointestinal infection are highly suggestive of **Guillain-Barré Syndrome (GBS)**. - **Spirometry** is the most critical initial step to assess respiratory function, as **respiratory muscle weakness** is the primary cause of morbidity and mortality in GBS. *IV immunoglobulin* - While **intravenous immunoglobulin (IVIG)** is a treatment for GBS, it is not the *initial* management step. - The immediate priority in suspected GBS is to assess and stabilize the patient's respiratory status, not to initiate definitive treatment. *Dexamethasone* - **Corticosteroids** like dexamethasone have **not been shown to be effective** in treating GBS and may even prolong recovery in some cases. - Their use is generally avoided in the management of GBS. *Intubation* - **Intubation** is indicated if spirometry reveals rapidly declining or severely compromised respiratory function, but it is not the *initial* step. - An assessment of respiratory capacity via spirometry should precede intubation unless acute respiratory failure is immediately apparent. *Pyridostigmine* - **Pyridostigmine** is an anticholinesterase inhibitor used primarily for the symptomatic treatment of **myasthenia gravis**. - It is not indicated for the management of GBS, which involves a different pathophysiological mechanism.

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