Balancing thoroughness with efficiency — MCQs

7 questions

A 40-year-old woman presents to her physician's home with a headache. She describes it as severe and states that her symptoms have not been improving despite her appointment yesterday at the office. Thus, she came to her physician's house on the weekend for help. The patient has been diagnosed with migraine headaches that have persisted for the past 6 months and states that her current symptoms feel like her previous headaches with a severity of 3/10. She has been prescribed multiple medications but is generally non-compliant with therapy. She is requesting an exam and urgent treatment for her symptoms. Which of the following is the best response from the physician?

A 29-year-old man is admitted to the emergency department following a motorcycle accident. The patient is severely injured and requires life support after splenectomy and evacuation of a subdural hematoma. Past medical history is unremarkable. The patient’s family members, including wife, parents, siblings, and grandparents, are informed about the patient’s condition. The patient has no living will and there is no durable power of attorney. The patient must be put in an induced coma for an undetermined period of time. Which of the following is responsible for making medical decisions for the incapacitated patient?

A 15-year-old boy is brought to the emergency department one hour after sustaining an injury during football practice. He collided head-on into another player while wearing a mouthguard and helmet. Immediately after the collision he was confused but able to use appropriate words. He opened his eyes spontaneously and followed commands. There was no loss of consciousness. He also had a headache with dizziness and nausea. He is no longer confused upon arrival. He feels well. Vital signs are within normal limits. He is fully alert and oriented. His speech is organized and he is able to perform tasks demonstrating full attention, memory, and balance. Neurological examination shows no abnormalities. There is mild tenderness to palpation over the crown of his head but no signs of skin break or fracture. Which of the following is the most appropriate next step?

A 42-year-old woman presents to the emergency department with abdominal pain. Her pain started last night during dinner and has persisted. This morning, the patient felt very ill and her husband called emergency medical services. The patient has a past medical history of obesity, diabetes, and depression. Her temperature is 104°F (40°C), blood pressure is 90/65 mmHg, pulse is 160/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for a very ill appearing woman. Her skin is mildly yellow, and she is in an antalgic position on the stretcher. Laboratory values are ordered as seen below. Hemoglobin: 13 g/dL Hematocrit: 38% Leukocyte count: 14,500 cells/mm^3 with normal differential Platelet count: 257,000/mm^3 Alkaline phosphatase: 227 U/L Bilirubin, total: 11.3 mg/dL Bilirubin, direct: 9.8 mg/dL AST: 42 U/L ALT: 31 U/L The patient is started on antibiotics and IV fluids. Which of the following is the best next step in management?

A 77-year-old woman is brought by ambulance to the emergency department after she developed weakness of her right arm along with a right-sided facial droop. By the time the ambulance arrived, she was having difficulty speaking. Past medical history is significant for hypertension, diabetes mellitus type II, and hyperlipidemia. She takes lisinopril, hydrochlorothiazide, metformin, and atorvastatin. On arrival to the emergency department, her vital signs are within normal limits. On physical examination, she is awake and alert but the right side of her mouth is dropping, making it difficult for her to speak clearly. Her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally. Fingerstick glucose is 85 mg/dL. Her right upper extremity strength is 2/5 and her left upper extremity strength is 5/5. Which of the following is the best next step in management?

A 65-year-old woman presents to her primary care physician for a wellness checkup. She states that she has felt well lately and has no concerns. The patient has a 12-pack-year smoking history and has 3 drinks per week. She is retired and lives at home with her husband. She had a normal colonoscopy 8 years ago and mammography 1 year ago. She can't recall when she last had a Pap smear and believes that it was when she was 62 years of age. Her temperature is 98.1°F (36.7°C), blood pressure is 137/78 mmHg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is within normal limits. Which of the following is the best next step in management?

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?

Balancing thoroughness with efficiency US Medical PG Practice Questions and MCQs

Question 1: A 40-year-old woman presents to her physician's home with a headache. She describes it as severe and states that her symptoms have not been improving despite her appointment yesterday at the office. Thus, she came to her physician's house on the weekend for help. The patient has been diagnosed with migraine headaches that have persisted for the past 6 months and states that her current symptoms feel like her previous headaches with a severity of 3/10. She has been prescribed multiple medications but is generally non-compliant with therapy. She is requesting an exam and urgent treatment for her symptoms. Which of the following is the best response from the physician?

A. It sounds to me like you are in a lot of pain. Let me see how I can help you.
B. Do not come to my house when you have medical problems. You should make an appointment.
C. Your symptoms seem severe. Let me perform a quick exam to see if everything is alright.
D. Unfortunately, I cannot examine and treat you at this time. Please set up an appointment to see me in my office. (Correct Answer)
E. You should go to the emergency department for your symptoms rather than coming here.

Explanation: ***Unfortunately, I cannot examine and treat you at this time. Please set up an appointment to see me in my office.*** - This response appropriately **maintains professional boundaries** by declining an unscheduled visit to the physician's private residence. - While house calls are not inherently unethical, this situation is problematic because: the physician is unprepared, lacks proper medical equipment and documentation resources at home, and the patient's symptoms (3/10 severity, chronic migraine) do not constitute an emergency. - This response is **empathetic yet firm**, redirecting the patient to appropriate care settings where proper examination, documentation, and treatment can occur. - Setting this boundary prevents establishing an inappropriate precedent for future unscheduled home visits. *It sounds to me like you are in a lot of pain. Let me see how I can help you.* - While showing empathy, agreeing to treat the patient at home without preparation creates problems: **lack of proper medical equipment, diagnostic tools, and documentation resources**. - This action **blurs professional boundaries** and sets an inappropriate precedent for future unscheduled patient interactions at the physician's home. - The patient's severity (3/10) and chronic nature of symptoms do not justify an urgent unscheduled home examination. *Do not come to my house when you have medical problems. You should make an appointment.* - This response is **unprofessional and lacks empathy**, potentially damaging the patient-physician relationship. - While the message about boundaries is appropriate, the **harsh tone** fails to provide compassionate guidance for the patient's concerns. *Your symptoms seem severe. Let me perform a quick exam to see if everything is alright.* - Despite acknowledging the patient's concern, performing an unscheduled exam at home is **inappropriate** due to lack of preparation, proper equipment, and resources for thorough assessment. - This decision could lead to **inadequate care and documentation issues**, as the physician would be practicing in an unplanned setting without proper resources. *You should go to the emergency department for your symptoms rather than coming here.* - While this directs the patient to a medical facility, the patient has **3/10 severity** chronic migraine symptoms that do not constitute an emergency, making the ED an **inappropriate over-triage**. - This response may come across as dismissive and could strain the patient-physician relationship, though it does maintain appropriate boundaries.

Question 2: A 29-year-old man is admitted to the emergency department following a motorcycle accident. The patient is severely injured and requires life support after splenectomy and evacuation of a subdural hematoma. Past medical history is unremarkable. The patient’s family members, including wife, parents, siblings, and grandparents, are informed about the patient’s condition. The patient has no living will and there is no durable power of attorney. The patient must be put in an induced coma for an undetermined period of time. Which of the following is responsible for making medical decisions for the incapacitated patient?

A. The spouse (Correct Answer)
B. An older sibling
C. Physician
D. Legal guardian
E. The parents

Explanation: ***The spouse*** - In the absence of a **living will** or **durable power of attorney**, the law typically designates the **spouse** as the primary decision-maker for an incapacitated patient. - This hierarchy is established to ensure decisions are made by the individual most intimately connected and presumed to understand the patient's wishes. *An older sibling* - Siblings are generally further down the **hierarchy of surrogate decision-makers** than a spouse or parents. - They would typically only be considered if higher-priority family members are unavailable or unwilling to make decisions. *Physician* - The physician's role is to provide medical care and guidance, not to make medical decisions for an incapacitated patient when family surrogates are available. - Physicians only make decisions in **emergency situations** when no surrogate is immediately available and treatment is immediately necessary to save the patient's life or prevent serious harm. *Legal guardian* - A legal guardian is usually appointed by a **court** when there is no appropriate family member available or when there is a dispute among family members. - In this scenario, with a spouse and other close family members present, a legal guardian would not be the first choice. *The parents* - While parents are close family members, they are typically considered **secondary to the spouse** in the hierarchy of surrogate decision-makers for an adult patient. - They would usually only be the decision-makers if the patient were unmarried or the spouse were unavailable.

Question 3: A 15-year-old boy is brought to the emergency department one hour after sustaining an injury during football practice. He collided head-on into another player while wearing a mouthguard and helmet. Immediately after the collision he was confused but able to use appropriate words. He opened his eyes spontaneously and followed commands. There was no loss of consciousness. He also had a headache with dizziness and nausea. He is no longer confused upon arrival. He feels well. Vital signs are within normal limits. He is fully alert and oriented. His speech is organized and he is able to perform tasks demonstrating full attention, memory, and balance. Neurological examination shows no abnormalities. There is mild tenderness to palpation over the crown of his head but no signs of skin break or fracture. Which of the following is the most appropriate next step?

A. Discharge without activity restrictions
B. Discharge and refrain from all physical activity for one week
C. Observe for 6 hours in the ED and refrain from contact sports for one week (Correct Answer)
D. Administer prophylactic levetiracetam and observe for 24 hours
E. Administer prophylactic phenytoin and observe for 24 hours

Explanation: ***Observe for 6 hours in the ED and refrain from contact sports for one week*** - This patient experienced a brief period of **confusion, headache, dizziness**, and **nausea** immediately after a head injury, which are symptoms consistent with a **mild traumatic brain injury (mTBI)** or **concussion**. - Although his symptoms have resolved at presentation, observation in the ED for a few hours is prudent to ensure no delayed onset of more severe symptoms, and he should **refrain from contact sports** for at least one week as part of concussion management. *Discharge without activity restrictions* - Discharging without activity restrictions is unsafe given the initial symptoms of **confusion** and the potential for delayed symptom presentation or complications from a concussion. - Concussion management requires a period of **physical and cognitive rest** to allow the brain to heal and prevent **second impact syndrome**. *Discharge and refrain from all physical activity for one week* - While refraining from all physical activity for one week is part of concussion management, discharging immediately without any observation period after initial neurological symptoms could be risky. - An observation period allows for monitoring of any **worsening neurological signs** or symptoms that might indicate a more serious injury. *Administer prophylactic levetiracetam and observe for 24 hours* - **Prophylactic anticonvulsants** like levetiracetam are typically not recommended for routine management of **mild traumatic brain injury** or concussion. - Their use is generally reserved for patients with more severe injuries, evolving conditions, or those who have had **seizures post-trauma**. *Administer prophylactic phenytoin and observe for 24 hours* - Similar to levetiracetam, **phenytoin** is an anticonvulsant and its prophylactic use is not indicated for **mild head injuries** or concussions. - Anticonvulsant prophylaxis is associated with potential side effects and is reserved for specific high-risk scenarios, such as **severe TBI** or **penetrating head trauma**.

Question 4: A 42-year-old woman presents to the emergency department with abdominal pain. Her pain started last night during dinner and has persisted. This morning, the patient felt very ill and her husband called emergency medical services. The patient has a past medical history of obesity, diabetes, and depression. Her temperature is 104°F (40°C), blood pressure is 90/65 mmHg, pulse is 160/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for a very ill appearing woman. Her skin is mildly yellow, and she is in an antalgic position on the stretcher. Laboratory values are ordered as seen below. Hemoglobin: 13 g/dL Hematocrit: 38% Leukocyte count: 14,500 cells/mm^3 with normal differential Platelet count: 257,000/mm^3 Alkaline phosphatase: 227 U/L Bilirubin, total: 11.3 mg/dL Bilirubin, direct: 9.8 mg/dL AST: 42 U/L ALT: 31 U/L The patient is started on antibiotics and IV fluids. Which of the following is the best next step in management?

A. Nasogastric tube and NPO
B. Supportive therapy followed by elective cholecystectomy
C. FAST exam
D. Emergency cholecystectomy
E. Endoscopic retrograde cholangiopancreatography (Correct Answer)

Explanation: ***Endoscopic retrograde cholangiopancreatography*** - The patient's presentation with **fever**, **jaundice**, **abdominal pain**, **hypotension**, and **tachycardia** (Reynolds' pentad) indicates **acute cholangitis**. - **ERCP** is the best next step for **biliary decompression** and stone extraction in severe obstructive cholangitis to reduce morbidity and mortality. *Nasogastric tube and NPO* - While **NPO** (nothing by mouth) is standard for acute abdominal pain, a **nasogastric tube** is not typically indicated as a primary intervention for cholangitis unless there's associated vomiting or gastric distention. - This step addresses symptoms but does not treat the underlying **biliary obstruction** and infection. *Supportive therapy followed by elective cholecystectomy* - **Supportive therapy** with antibiotics and IV fluids is already initiated but is insufficient for severe cholangitis requiring **urgent biliary drainage**. - **Elective cholecystectomy** is performed after the acute infection has resolved, but not as an immediate intervention for an unstable patient with acute cholangitis. *FAST exam* - A **Focused Assessment with Sonography for Trauma (FAST)** exam is primarily used to detect **free fluid** (hemoperitoneum) in trauma patients. - It is not indicated for the diagnosis or management of **biliary obstruction** or cholangitis in a non-trauma setting. *Emergency cholecystectomy* - **Emergency cholecystectomy** is generally reserved for complications like **gangrenous cholecystitis** or perforation, or after initial stabilization in acute cholecystitis. - For **acute cholangitis**, the priority is **biliary decompression** first, which is typically achieved through ERCP, before considering cholecystectomy.

Question 5: A 77-year-old woman is brought by ambulance to the emergency department after she developed weakness of her right arm along with a right-sided facial droop. By the time the ambulance arrived, she was having difficulty speaking. Past medical history is significant for hypertension, diabetes mellitus type II, and hyperlipidemia. She takes lisinopril, hydrochlorothiazide, metformin, and atorvastatin. On arrival to the emergency department, her vital signs are within normal limits. On physical examination, she is awake and alert but the right side of her mouth is dropping, making it difficult for her to speak clearly. Her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally. Fingerstick glucose is 85 mg/dL. Her right upper extremity strength is 2/5 and her left upper extremity strength is 5/5. Which of the following is the best next step in management?

A. Obtain transcranial doppler
B. Start tissue plasminogen activator (tPA)
C. Consult cardiology
D. Intubate the patient
E. Obtain noncontrast CT of the brain (Correct Answer)

Explanation: ***Obtain noncontrast CT of the brain*** - An **urgent noncontrast CT of the brain** is the **most crucial initial step** in managing acute neurological deficits suggestive of stroke. - This imaging is essential to **rule out hemorrhagic stroke** before considering thrombolytic therapy like tPA. *Obtain transcranial doppler* - **Transcranial Doppler (TCD)** can be used to assess cerebral blood flow and identify vascular stenosis but is not the immediate first-line diagnostic imaging for an acute stroke presentation. - TCD is typically performed **after initial imaging** to determine the presence of large vessel occlusion or monitor for vasospasm, not to differentiate between ischemic and hemorrhagic stroke. *Start tissue plasminogen activator (tPA)* - While **tPA** is a treatment for acute ischemic stroke, it is **contraindicated in hemorrhagic stroke**. - Without a **noncontrast CT scan to rule out hemorrhage**, administering tPA can be life-threatening. *Consult cardiology* - Consulting cardiology is important for evaluating potential cardiac sources of emboli (e.g., atrial fibrillation) as a cause of stroke but it is **not the immediate next step** in managing acute stroke symptoms. - The **immediate priority is diagnosing the type of stroke** and determining eligibility for acute interventions. *Intubate the patient* - **Intubation** is reserved for patients with compromise of their **airway, breathing, or circulation (ABCs)**, or a significantly decreased level of consciousness (e.g., GCS < 8). - This patient is described as **awake and alert**, making intubation unnecessary at this stage.

Question 6: A 65-year-old woman presents to her primary care physician for a wellness checkup. She states that she has felt well lately and has no concerns. The patient has a 12-pack-year smoking history and has 3 drinks per week. She is retired and lives at home with her husband. She had a normal colonoscopy 8 years ago and mammography 1 year ago. She can't recall when she last had a Pap smear and believes that it was when she was 62 years of age. Her temperature is 98.1°F (36.7°C), blood pressure is 137/78 mmHg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is within normal limits. Which of the following is the best next step in management?

A. Colonoscopy
B. Mammogram
C. No intervention needed
D. DEXA scan (Correct Answer)
E. Pap smear

Explanation: ***DEXA scan*** - A **DEXA scan** is recommended for all women aged 65 years and older to screen for **osteoporosis**, regardless of risk factors. - While she has several risk factors (female sex, age, smoking history), the age alone warrants screening. *Colonoscopy* - The patient had a normal colonoscopy 8 years ago, and routine screening for average-risk individuals typically occurs every 10 years, so it is **not yet due**. - There are **no new symptoms** to suggest the need for an earlier repeat colonoscopy. *Mammogram* - The patient had a mammogram 1 year ago, and screening is typically recommended every **1 to 2 years** for women in this age group, so it is not immediately due. - There are no new breast concerns to warrant an earlier mammogram. *No intervention needed* - This option is incorrect because the patient is a 65-year-old woman, placing her in a demographic for which a **DEXA scan** is routinely recommended as part of preventive care. - While she feels well, screening interventions are designed to detect conditions before symptoms appear. *Pap smear* - **Cervical cancer screening** with a Pap smear can be discontinued in women over age 65 who have a history of adequate negative screening tests and are not at high risk. - Since she had a Pap smear at 62 and has no known risk factors for cervical cancer, further screening is likely **not indicated**.

Question 7: 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.

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