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?
Q2
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?
Q3
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?
Q4
You are the team physician for an NBA basketball team. On the morning of an important playoff game, an EKG of a star player, Mr. P, shows findings suspicious for hypertrophic cardiomyopathy (HCM). Mr. P is an otherwise healthy, fit, professional athlete.
The playoff game that night is the most important of Mr. P's career. When you inform the coach that you are thinking of restricting Mr. P's participation, he threatens to fire you. Later that day you receive a phone call from the owner of the team threatening a lawsuit should you restrict Mr. P's ability to play. Mr. P states that he will be playing in the game "if it's the last thing I do."
Which of the following is the most appropriate next step?
Q5
A 67-year-old woman is brought by ambulance from home to the emergency department after she developed weakness of her left arm and left face droop. According to her husband, she has a history of COPD, hypertension, and hyperlipidemia. She takes hydrochlorothiazide, albuterol, and atorvastatin. She is not on oxygen at home. She is an active smoker and has smoked a pack a day for 20 years. Her mother died of a heart attack at age 60 and her father died of prostate cancer at age 55. By the time the ambulance arrived, she was having difficulty speaking. Once in the emergency department, she is no longer responsive. Her blood pressure is 125/85 mm Hg, the temperature is 37.2°C (99°F), the heart rate is 77/min, and her breathing is irregular, and she is taking progressively deeper inspirations interrupted with periods of apnea. Of the following, what is the next best step?
Q6
A 27-year-old man is brought to the emergency department by emergency medical services. The patient was an unrestrained passenger in a head-on collision that occurred 15 minutes ago and is currently unresponsive. His temperature is 99.5°F (37.5°C), blood pressure is 60/33 mmHg, pulse is 180/min, respirations are 17/min, and oxygen saturation is 95% on room air. A FAST exam demonstrates fluid in Morrison’s pouch. Laboratory values are drawn upon presentation to the ED and sent off. The patient is started on IV fluids and an initial trauma survey is started. Twenty minutes later, his blood pressure is 95/65 mmHg, and his pulse is 110/min. The patient is further stabilized and is scheduled for emergency surgery. Which of the following best represents this patient’s most likely initial laboratory values?
Q7
A female presents with a 1 × 1 cm thyroid swelling. What is the next best step in management?
Managing multiple patient issues simultaneously 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 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 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: You are the team physician for an NBA basketball team. On the morning of an important playoff game, an EKG of a star player, Mr. P, shows findings suspicious for hypertrophic cardiomyopathy (HCM). Mr. P is an otherwise healthy, fit, professional athlete.
The playoff game that night is the most important of Mr. P's career. When you inform the coach that you are thinking of restricting Mr. P's participation, he threatens to fire you. Later that day you receive a phone call from the owner of the team threatening a lawsuit should you restrict Mr. P's ability to play. Mr. P states that he will be playing in the game "if it's the last thing I do."
Which of the following is the most appropriate next step?
A. Allow Mr. P to play against medical advice
B. Consult with a psychiatrist to have Mr. P committed
C. Call the police and have Mr. P arrested
D. Schedule a repeat EKG for the following morning
E. Educate Mr. P about the risks of HCM and restrict him from playing pending cardiology evaluation (Correct Answer)
Explanation: ***Educate Mr. P about the risks of HCM and restrict him from playing pending cardiology evaluation***
- The physician's primary ethical duty is to **protect the patient's well-being** (beneficence and non-maleficence), especially when there is a significant risk of sudden cardiac death associated with **hypertrophic cardiomyopathy (HCM)** during strenuous activity.
- While navigating external pressures, the physician must uphold professional standards by **educating the patient** about the risks and **restricting high-risk activities** until a definitive diagnosis and management plan from a cardiologist can be established.
*Allow Mr. P to play against medical advice*
- Allowing Mr. P to play against medical advice would be a **breach of the physician's ethical duty** to prevent harm, especially given the high risk of **sudden cardiac death** associated with HCM in athletes.
- This action could also expose the physician to **legal liability** should Mr. P suffer an adverse cardiac event during the game.
*Consult with a psychiatrist to have Mr. P committed*
- There is no indication that Mr. P is a danger to himself or others due to a **mental health crisis** requiring commitment; his desire to play is driven by external pressures and personal ambition, not a psychiatric condition.
- Committing Mr. P against his will would be an **unwarranted and extreme measure**, infringing on his autonomy without appropriate medical justification.
*Call the police and have Mr. P arrested*
- Calling the police to arrest Mr. P is an **inappropriate and disproportionate response** to a medical disagreement, as it does not address the medical issue or the ethical obligations of the physician.
- This action would severely damage the **physician-patient relationship** and would not be a valid legal or ethical approach to managing the situation.
*Schedule a repeat EKG for the following morning*
- Delaying further diagnostic evaluation until the following morning keeps Mr. P’s participation in the immediate playoff game an option, despite the **urgent suspicion of HCM**, which carries a high risk of **sudden cardiac death during exertion**.
- A repeat EKG alone is insufficient; **immediate cardiac evaluation** (e.g., echocardiogram) is necessary to confirm or rule out HCM before allowing him to play.
Question 5: A 67-year-old woman is brought by ambulance from home to the emergency department after she developed weakness of her left arm and left face droop. According to her husband, she has a history of COPD, hypertension, and hyperlipidemia. She takes hydrochlorothiazide, albuterol, and atorvastatin. She is not on oxygen at home. She is an active smoker and has smoked a pack a day for 20 years. Her mother died of a heart attack at age 60 and her father died of prostate cancer at age 55. By the time the ambulance arrived, she was having difficulty speaking. Once in the emergency department, she is no longer responsive. Her blood pressure is 125/85 mm Hg, the temperature is 37.2°C (99°F), the heart rate is 77/min, and her breathing is irregular, and she is taking progressively deeper inspirations interrupted with periods of apnea. Of the following, what is the next best step?
A. Start tissue plasminogen activator (tPA)
B. Intubate the patient (Correct Answer)
C. Consult a cardiologist
D. Obtain an MRI of brain
E. Obtain non-contrast enhanced CT of brain
Explanation: ***Intubate the patient***
- The patient's **irregular breathing pattern with progressively deeper inspirations interrupted by periods of apnea** (known as **Cheyne-Stokes respiration**) combined with unresponsiveness due to probable acute stroke indicates imminent respiratory failure and the need for **airway protection**.
- **Intubation** secures the airway, ensures adequate ventilation, and prevents aspiration during a neurological emergency.
*Start tissue plasminogen activator (tPA)*
- Although this patient likely has an **acute ischemic stroke**, the first priority is managing the **compromised airway and breathing**.
- **tPA** administration is time-sensitive but requires stabilization of vital signs and exclusion of hemorrhage via neuroimaging, which hasn't occurred yet.
*Consult a cardiologist*
- While the patient has significant **cardiovascular risk factors** (**hypertension, hyperlipidemia, smoking, COPD, family history**), an acute cardiac event is not the immediate concern.
- The pressing issue is **acute neurological deterioration with respiratory compromise**.
*Obtain an MRI of brain*
- An **MRI** offers detailed imaging for stroke but is **time-consuming** and **less accessible** in an emergency compared to CT.
- The patient's critical respiratory status requires immediate intervention before non-urgent diagnostic imaging.
*Obtain non-contrast enhanced CT of brain*
- A **non-contrast CT scan of the brain** is crucial for differentiating between **ischemic** and **hemorrhagic stroke** and guiding treatment, specifically for tPA administration.
- However, ensuring a **patent airway and stable ventilation** takes precedence over imaging in a patient with impending respiratory arrest.
Question 6: A 27-year-old man is brought to the emergency department by emergency medical services. The patient was an unrestrained passenger in a head-on collision that occurred 15 minutes ago and is currently unresponsive. His temperature is 99.5°F (37.5°C), blood pressure is 60/33 mmHg, pulse is 180/min, respirations are 17/min, and oxygen saturation is 95% on room air. A FAST exam demonstrates fluid in Morrison’s pouch. Laboratory values are drawn upon presentation to the ED and sent off. The patient is started on IV fluids and an initial trauma survey is started. Twenty minutes later, his blood pressure is 95/65 mmHg, and his pulse is 110/min. The patient is further stabilized and is scheduled for emergency surgery. Which of the following best represents this patient’s most likely initial laboratory values?
A. Hemoglobin: 10 g/dL, Hematocrit: 30%, MCV: 110 µm^3
B. Hemoglobin: 19 g/dL, Hematocrit: 55%, MCV: 95 µm^3
C. Hemoglobin: 7 g/dL, Hematocrit: 21%, MCV: 75 µm^3
E. Hemoglobin: 15 g/dL, Hematocrit: 45%, MCV: 90 µm^3
Explanation: ***Hemoglobin: 11 g/dL, Hematocrit: 33%, MCV: 88 µm^3***
- The patient experienced significant trauma and is experiencing **hemorrhagic shock**, as evidenced by his initial **hypotension** (BP 60/33 mmHg), **tachycardia** (pulse 180/min), and positive **FAST exam** for fluid in Morrison's pouch, indicating intra-abdominal bleeding.
- The initial hemoglobin and hematocrit could be mildly decreased due to acute blood loss, but significant drops are often *not immediately apparent* as plasma volume has not yet moved into the intravascular compartment to dilute the remaining red blood cells. A hemoglobin of 11 g/dL and hematocrit of 33% are consistent with **acute blood loss** before significant hemodilution occurs. MCV of 88 µm^3 is within the normal range for **normocytic anemia** seen in acute hemorrhage.
*Hemoglobin: 10 g/dL, Hematocrit: 30%, MCV: 110 µm^3*
- While a hemoglobin of 10 g/dL and hematocrit of 30% are consistent with anemia due to blood loss, an **MCV of 110 µm^3** (macrocytic) is not typically seen in acute hemorrhage.
- Macrocytic anemia usually results from conditions like **B12 or folate deficiency**, alcoholism, or liver disease, which are not suggested by the acute traumatic scenario.
*Hemoglobin: 19 g/dL, Hematocrit: 55%, MCV: 95 µm^3*
- This indicates **polycythemia** (abnormally high red blood cell count), which is the opposite of what would be expected in a patient experiencing acute hemorrhagic shock.
- These values would suggest conditions like **polycythemia vera** or severe dehydration, which are not relevant in this acute trauma setting.
*Hemoglobin: 7 g/dL, Hematocrit: 21%, MCV: 75 µm^3*
- While a hemoglobin of 7 g/dL and hematocrit of 21% represent significant anemia consistent with major blood loss, these values are typically seen *later* as **hemodilution** occurs, or in cases of chronic blood loss.
- An **MCV of 75 µm^3** (microcytic) is generally indicative of **iron deficiency anemia** or thalassemia, which develops over time and is not characteristic of acute traumatic blood loss.
*Hemoglobin: 15 g/dL, Hematocrit: 45%, MCV: 90 µm^3*
- These values are within the **normal range** for hemoglobin and hematocrit, which would not be expected in a patient presenting with signs of **hemorrhagic shock** and a positive FAST exam indicating significant internal bleeding.
- This would suggest either very minor blood loss or that the values were taken before any bleeding had occurred or before hemodilution had a chance to manifest.
Question 7: A female presents with a 1 × 1 cm thyroid swelling. What is the next best step in management?
A. I-131
B. TSH (Correct Answer)
C. TSH & T4
D. T3 & T4
E. FNAC
Explanation: ***Correct Option: TSH***
- **Thyroid-stimulating hormone (TSH)** is the most sensitive initial test to assess thyroid function when a thyroid nodule is discovered.
- An abnormal TSH level (either high or low) can guide further investigation into whether the nodule is associated with a functional thyroid disorder.
- **TSH should be the first test** according to American Thyroid Association guidelines for thyroid nodule evaluation.
*Incorrect Option: I-131*
- **I-131 (radioactive iodine therapy)** is a treatment modality for hyperthyroidism or thyroid cancer, not a diagnostic step for initial thyroid swelling evaluation.
- Administering I-131 before assessing thyroid function would be inappropriate and could lead to unnecessary or harmful intervention.
*Incorrect Option: TSH & T4*
- While TSH is crucial, adding **T4 (thyroxine)** as an initial step is often not necessary if TSH is normal, as TSH alone effectively screens for primary thyroid dysfunction.
- Measuring both TSH and T4 is typically reserved for situations where TSH is abnormal or when central hypothyroidism is suspected.
*Incorrect Option: T3 & T4*
- Measuring **T3 (triiodothyronine)** along with T4 as an initial screening for a thyroid nodule is generally not recommended.
- T3 levels are primarily used to diagnose **hyperthyroidism** or to evaluate the severity of thyrotoxicosis after an abnormal TSH and T4 have been identified.
*Incorrect Option: FNAC*
- While **Fine Needle Aspiration Cytology (FNAC)** is an essential diagnostic tool for thyroid nodules, it is typically performed after TSH assessment.
- FNAC is indicated for nodules >1 cm with suspicious ultrasound features, but **functional assessment with TSH comes first** to rule out hyperfunctioning nodules.
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