ECFMG Patient Care & Clinical Skills 4 — Questions and Answers
Question 1: A 45-year-old HIV-positive man with a CD4 count of 80 cells/µL presents with progressive dyspnea, dry cough, and bilateral interstitial infiltrates on chest X-ray. Which organism is the most likely cause?
- Mycobacterium tuberculosis
- Pneumocystis jirovecii (Correct answer)
- Streptococcus pneumoniae
- Aspergillus fumigatus
Correct answer: Pneumocystis jirovecii
PCP (Pneumocystis jirovecii pneumonia) is the most common AIDS-defining pneumonia, typically occurring when CD4 count falls below 200 cells/µL.
Question 2: During a well-child visit, the parents of a 18-month-old ask about normal developmental milestones. Which skill would be expected at this age?
- Speaking in complete 5-word sentences
- Walking up stairs without support
- Building a tower of 2–4 cubes (Correct answer)
- Copying a circle
Correct answer: Building a tower of 2–4 cubes
By 18 months, children typically build a tower of 2–4 cubes as part of normal fine motor development.
Question 3: A 58-year-old woman with rheumatoid arthritis on long-term prednisone undergoes elective hip replacement. Perioperatively, she develops hypotension, tachycardia, and confusion despite adequate fluids. What is the most likely cause?
- Pulmonary embolism
- Septic shock
- Adrenal insufficiency (adrenal crisis) (Correct answer)
- Anaphylaxis to anesthetic agents
Correct answer: Adrenal insufficiency (adrenal crisis)
Chronic steroid use suppresses the HPA axis; surgical stress without stress-dose steroids can precipitate adrenal crisis.
Question 4: A 30-year-old man is brought to the ED after a high-speed motor vehicle collision. He is confused, has a GCS of 10, and CT shows a hyperdense lens-shaped (biconvex) lesion over the temporal lobe. What is the most likely diagnosis?
- Subdural hematoma
- Subarachnoid hemorrhage
- Epidural hematoma (Correct answer)
- Diffuse axonal injury
Correct answer: Epidural hematoma
A biconvex (lens-shaped) hyperdense lesion on CT after head trauma is the classic appearance of an epidural hematoma, typically from middle meningeal artery rupture.
Question 5: A physician is caring for a terminally ill patient who requests a higher dose of morphine for pain, knowing it may hasten death. The patient has decision-making capacity and a terminal prognosis. Which ethical principle supports honoring this request?
- Non-maleficence alone
- Autonomy and the doctrine of double effect (Correct answer)
- Beneficence overriding patient preference
- Justice through resource allocation
Correct answer: Autonomy and the doctrine of double effect
The doctrine of double effect permits administering palliative doses even if they may hasten death, when the intent is relief of suffering and the patient has made an autonomous, informed decision.
Question 6: A 22-year-old woman presents with acute onset of right lower quadrant pain, nausea, and low-grade fever. Her last menstrual period was 6 weeks ago. Which test should be ordered first?
- Appendiceal ultrasound
- Urine beta-hCG (Correct answer)
- Complete blood count
- Pelvic CT scan with contrast
Correct answer: Urine beta-hCG
In a reproductive-age woman with acute abdominal pain, ectopic pregnancy must be excluded first with a urine or serum beta-hCG before further imaging.
Question 7: A 65-year-old man with known coronary artery disease presents with increasing exertional dyspnea and bilateral leg edema over 2 weeks. Exam reveals an S3 gallop and JVD. Which initial treatment is most appropriate?
- IV diuresis with furosemide (Correct answer)
- Beta-blocker initiation
- Angiotensin receptor-neprilysin inhibitor (ARNI) start
- Immediate coronary angiography
Correct answer: IV diuresis with furosemide
Acute decompensated heart failure with volume overload (edema, JVD, S3) is initially managed with IV diuresis to relieve congestion.
ECFMG Patient Care & Clinical Skills 4
A 45-year-old HIV-positive man with a CD4 count of 80 cells/µL presents with progressive dyspnea, dry cough, and bilateral interstitial infiltrates on chest X-ray.
Which organism is the most likely cause?