ECFMG Patient Care & Clinical Skills 3 — Questions and Answers
Question 1: A 35-year-old man presents with three weeks of productive cough, night sweats, and a 10-lb weight loss. He emigrated from Southeast Asia two years ago. Which diagnostic test is most important?
- Chest X-ray alone
- Sputum acid-fast bacilli smear and culture (Correct answer)
- Complete blood count with differential
- Serology for Epstein-Barr virus
Correct answer: Sputum acid-fast bacilli smear and culture
The clinical picture strongly suggests pulmonary tuberculosis; sputum AFB smear and culture are essential for diagnosis and to guide infection control.
Question 2: An 8-year-old child is brought in by her mother for a routine visit. During the exam, you notice multiple bruises in various stages of healing on the child's back and buttocks. The mother states the child 'falls a lot.' What is the most appropriate next step?
- Accept the explanation and schedule a follow-up
- Ask the child privately about how the injuries occurred
- Report suspicion of child abuse to child protective services (Correct answer)
- Order a coagulation panel before taking any action
Correct answer: Report suspicion of child abuse to child protective services
Patterned bruises in unusual locations at different healing stages are sentinel signs of abuse; mandatory reporting to child protective services is required by law.
Question 3: A patient taking warfarin for atrial fibrillation presents with a supratherapeutic INR of 8.5 and active GI bleeding. Which treatment is most urgently indicated?
- Hold the next warfarin dose only
- Administer vitamin K orally
- Give 4-factor prothrombin complex concentrate (4F-PCC) plus IV vitamin K (Correct answer)
- Transfuse packed red blood cells and observe
Correct answer: Give 4-factor prothrombin complex concentrate (4F-PCC) plus IV vitamin K
Life-threatening bleeding with supratherapeutic INR requires immediate reversal with 4F-PCC (rapid onset) plus IV vitamin K (sustained reversal).
Question 4: A 60-year-old woman presents with crushing substernal chest pain radiating to her left arm, diaphoresis, and nausea for 45 minutes. ECG shows ST elevation in leads II, III, and aVF. What is the target time for reperfusion?
- Within 60 minutes (door-to-balloon time)
- Within 90 minutes (door-to-balloon time) (Correct answer)
- Within 120 minutes of first medical contact
- Within 3 hours of symptom onset
Correct answer: Within 90 minutes (door-to-balloon time)
Current ACC/AHA guidelines recommend primary PCI with a door-to-balloon time of ≤90 minutes for STEMI.
Question 5: A physician notices that a patient's electronic health record contains a billing code that does not match the services actually rendered. The physician suspects insurance fraud by a colleague. What is the most appropriate action?
- Correct the code without reporting the discrepancy
- Report the concern through appropriate institutional channels or compliance office (Correct answer)
- Confront the colleague directly in the clinic
- Ignore it as it does not affect patient care
Correct answer: Report the concern through appropriate institutional channels or compliance office
Suspected fraud must be reported through proper institutional compliance channels to protect patients, the institution, and the integrity of the health care system.
Question 6: A 50-year-old man presents after being found unconscious. His blood glucose is 35 mg/dL and he has no IV access. What is the most appropriate immediate treatment?
- Administer oral glucose gel under the tongue
- Give glucagon 1 mg intramuscularly (Correct answer)
- Establish IV access and infuse D50W
- Administer insulin to stabilize glucose
Correct answer: Give glucagon 1 mg intramuscularly
In an unconscious hypoglycemic patient without IV access, IM glucagon rapidly raises blood glucose by stimulating hepatic glycogenolysis.
Question 7: A 25-year-old medical student on her third clinical rotation asks you to sign off on a procedure she has not yet performed. She says she has 'watched it many times.' What should you do?
- Sign the form to help her advance in her training
- Decline and explain that documentation must accurately reflect actual performance (Correct answer)
- Ask her to perform the procedure now under close supervision and then sign
- Report her to the program director immediately
Correct answer: Decline and explain that documentation must accurately reflect actual performance
Falsifying medical records or competency documentation is a serious ethical and legal violation; the physician must decline and explain why accurate documentation is mandatory.
ECFMG Patient Care & Clinical Skills 3
A 35-year-old man presents with three weeks of productive cough, night sweats, and a 10-lb weight loss.
He emigrated from Southeast Asia two years ago.
Which diagnostic test is most important?