Tüm alıştırma soruları

Match each clinical presentation of a patient with a depressive disorder to the most appropriate next step in clinical management.

Match each postoperative clinical presentation following cardiothoracic or vascular surgery with its corresponding pathophysiological mechanism or definitive diagnosis.

Evaluate the following clinical scenarios detailing distinct neurocognitive or acute neuropsychiatric presentations. Pair each patient vignette with the single most appropriate next step in management or definitive therapeutic intervention.

Evaluate the following distinct patient presentations encountered in an outpatient clinic and pair each with its most accurate diagnostic classification based on DSM-5 criteria.

Match each clinical scenario describing an adverse pharmacological event in a patient being treated for bipolar disorder to the most accurate underlying mechanism of the interaction.

A 54-year-old man is evaluated in the intensive care unit on hospital day 3. He was initially admitted for community-acquired pneumonia and septic shock, requiring endotracheal intubation, mechanical ventilation, and vasopressor support. His empiric antibiotic regimen was de-escalated to intravenous ceftriaxone and oral azithromycin two days ago based on sputum cultures confirming *Streptococcus pneumoniae*.

Today, his blood pressure has improved to $115/75\text{ mm Hg}$ on a minimal weaning dose of norepinephrine, and his temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$). He remains deeply sedated and is not initiating spontaneous breaths.

Current ventilator settings (Volume Assist-Control):
Tidal Volume: $450\text{ mL}$
Respiratory Rate: $12/\text{min}$
$\text{FiO}_2$: $0.35$
PEEP: $5\text{ cm H}_2\text{O}$

Which of the following are appropriate management steps for this patient? (Select all that apply)

A 48-year-old woman comes to the emergency department due to a 24-hour history of severe, colicky abdominal pain, nausea, and bilious vomiting. She has not passed flatus or stool since the pain began. Her medical history is notable for a laparoscopic appendectomy 10 years ago. She takes no daily medications. Her temperature is 37.3°C (99.1°F), blood pressure is 114/76 mm Hg, pulse is 106/min, and respirations are 18/min. Physical examination reveals an asymmetrically distended abdomen. It is highly tympanitic to percussion and moderately tender diffusely, but there is no guarding or rebound tenderness. Bowel sounds are high-pitched and hyperactive. A plain radiograph of the abdomen demonstrates a markedly dilated, comma-shaped loop of bowel originating in the right lower quadrant and projecting toward the left upper quadrant. There is a single air-fluid level within the loop and a paucity of gas in the distal colon. Which of the following is the most appropriate next step in management?

A 25-year-old man is brought to the emergency department by police after being found running dangerously through traffic. He is highly agitated, speaks rapidly, exhibits grandiose delusions, and is diagnosed with an acute manic episode. Psychiatric evaluation determines that he currently lacks medical decision-making capacity. The patient's electronic medical record contains a valid advance directive legally appointing his older sister as his healthcare proxy. The sister arrives shortly after, is fully briefed on the situation, and provides informed consent to initiate treatment with haloperidol and valproate. Meanwhile, the patient actively yells that he refuses all medications. Just as the medications are being prepared, the patient's father arrives, demands that no drugs be given, and threatens to sue the physician for medical battery and malpractice. The physician declines the father's demands and administers the medications as authorized by the sister. Which of the following statements regarding the legal and ethical aspects of this scenario are correct? (Select all that apply)

A 62-year-old male is evaluated in the surgical intensive care unit on postoperative day 8 following an open appendectomy for a perforated appendix. After an initially uncomplicated recovery with return of bowel function on day 4, he developed severe, constant abdominal pain, nausea, and bilious vomiting over the past 24 hours. He has not passed flatus since the onset of these symptoms.

His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), heart rate is $125/\text{min}$, respiratory rate is $24/\text{min}$, and blood pressure is $88/55\text{ mmHg}$.

Physical examination reveals a distended, rigid abdomen with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent.

Laboratory studies show a leukocyte count of $19,500/\text{mm}^3$ with $85\%$ neutrophils, and a serum lactate of $4.6 \text{ mmol/L}$.

Supine and upright abdominal radiographs demonstrate multiple dilated loops of small bowel with prominent air-fluid levels and a paucity of colonic gas.

Which of the following is the most appropriate next step in management?

A 67-year-old man is evaluated on hospital day 3. He was initially admitted for fever, chills, and left flank pain. His past medical history is significant for a T10 spinal cord injury resulting in neurogenic bladder, managed with intermittent clean catheterization. On presentation to the emergency department, his temperature was $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure was $92/58\text{ mmHg}$, and heart rate was $114/\text{min}$. Laboratory testing demonstrated a leukocyte count of $16,500/\text{mm}^3$. He was aggressively resuscitated with intravenous fluids and empirically started on intravenous piperacillin-tazobactam and vancomycin for presumed urosepsis.

Today, the patient's temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $122/78\text{ mmHg}$, and heart rate is $82/\text{min}$. He has been afebrile for the last 36 hours and is tolerating a normal oral diet. His flank pain has resolved. The urine culture collected on admission has finalized, growing $>10^5\text{ CFU/mL}$ of *Enterococcus faecalis*. Susceptibility testing results are as follows:

Blood cultures drawn on admission show no growth after 48 hours. Which of the following is the most appropriate next step in the patient's antimicrobial management?

A $68$-year-old woman is evaluated on hospital day $3$. She was initially admitted to the intensive care unit with fever, right upper quadrant pain, jaundice, and hypotension. On admission, her temperature was $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure was $88/54\text{ mmHg}$, and heart rate was $118\text{/min}$. Laboratory studies showed a leukocyte count of $18,500/\mu\text{L}$, total bilirubin of $6.2\text{ mg/dL}$, and alkaline phosphatase of $450\text{ U/L}$. She was resuscitated with intravenous fluids, started on empiric intravenous piperacillin-tazobactam, and underwent emergent endoscopic retrograde cholangiopancreatography (ERCP), which revealed purulent bile and a common bile duct stone. A biliary sphincterotomy with stone extraction was performed successfully.

Today, she is transferred to the general medical floor. She is afebrile and hemodynamically stable, and her abdominal pain has resolved. Blood cultures drawn on admission now grow *Escherichia coli*. Susceptibility testing demonstrates that the organism is resistant to ampicillin but susceptible to ceftriaxone, cefepime, ciprofloxacin, meropenem, and piperacillin-tazobactam.

Which of the following is the most appropriate next step in the pharmacotherapy of this patient?

A 32-year-old female, gravida 1, para 0, at 35 weeks gestation, is brought to the trauma center following a high-speed motor vehicle collision. She was a restrained passenger. On arrival, she is lethargic, confused, and oriented only to her name. Her husband, who was driving and sustained minor injuries, is present in the trauma bay and demands that the medical team focus exclusively on saving the fetus. A card discovered in the patient's wallet legally designates her sister as her healthcare proxy.

Evaluation reveals a patent airway and symmetric vesicular breath sounds bilaterally. Vital signs include a heart rate of 142/min, respiratory rate of 26/min, and blood pressure of 76/40 mm Hg. Pulse oximetry is 98% on room air. The patient is placed on a backboard with manual left uterine displacement. An initial fluid bolus is administered with minimal hemodynamic improvement.

Extended focused assessment with sonography for trauma (E-FAST) demonstrates a large anechoic collection in the splenorenal recess. There is no evidence of pneumothorax. Fetal heart rate monitoring demonstrates a baseline of 105/min with minimal variability and recurrent late decelerations.

Which of the following is the most appropriate next step in the management of this patient?

A 48-year-old man is brought to the clinic by his sister due to a 5-month history of progressive forgetfulness, social withdrawal, and difficulty concentrating. The sister reports that he takes an unusually long time to answer simple questions and that his walking has become slow and uncoordinated. His medical history is significant for HIV infection, diagnosed 12 years ago. He admits to poor adherence to his antiretroviral therapy over the past 18 months. His most recent CD4+ T-cell count was 145/mm³. Vital signs are within normal limits. Neurological examination reveals marked psychomotor slowing, saccadic pursuit eye movements, and brisk deep tendon reflexes in the bilateral lower extremities. His Montreal Cognitive Assessment score is 19/30. Magnetic resonance imaging of the brain demonstrates diffuse cortical atrophy and symmetric, bilateral periventricular white matter hyperintensities without contrast enhancement or mass effect. Which of the following is the most likely diagnosis?

A 74-year-old man is evaluated on postoperative day 3 following an open partial colectomy for colon cancer. He reports new-onset shortness of breath and a cough productive of yellowish sputum that started this morning. His medical history is significant for ischemic cardiomyopathy with an ejection fraction of 40% and chronic obstructive pulmonary disease. His temperature is 38.9°C (102.0°F), blood pressure is 118/74 mmHg, heart rate is 112/min, and respiratory rate is 24/min. Oxygen saturation is 90% on room air. Physical examination reveals a patient in mild respiratory distress. Jugular venous pressure is not elevated. Auscultation of the lungs reveals bronchial breath sounds and crackles over the right lower lung field. The surgical incision is clean, dry, and intact. There is no lower extremity edema. Based on the most likely diagnosis, which of the following are the most appropriate next steps in this patient's management? (Select 2)

A 45-year-old female weighing 70 kg is brought to the emergency department after being rescued from a house fire. She sustained deep partial-thickness and full-thickness thermal burns over 40% of her total body surface area (TBSA). The injury occurred approximately 1 hour prior to arrival. Upon initial evaluation, her blood pressure is 110/70 mm Hg, heart rate is 115/min, and oxygen saturation is 96% on room air. She is speaking in a hoarse voice, has singed nasal hair, and carbonaceous sputum is noted. Arrange the following management steps in the correct chronological sequence for this patient's acute and subacute burn care.

Following an assault, a 29-year-old woman is evaluated in the emergency department for a deep stab wound to the right side of her neck. On arrival, she is confused and diaphoretic. Her blood pressure is 80/40 mmHg and her pulse is 130/min. Physical examination reveals an actively expanding, pulsatile hematoma in the right anterior cervical triangle. There is a continuous stream of bright red blood oozing through the applied pressure dressing. The patient's airway remains patent and breath sounds are bilateral. Which of the following is the most appropriate next step in management?

A 28-year-old woman is brought to the emergency department after falling from a fourth-story balcony. She was intubated at the scene due to a depressed level of consciousness. Upon arrival, her temperature is 36.1°C (97.0°F), blood pressure is 72/40 mm Hg, and pulse is 138/min. Physical examination reveals a 7-mm, nonreactive right pupil and a 3-mm, briskly reactive left pupil. The trachea is midline, and breath sounds are present and equal bilaterally. The pelvis is stable to anteroposterior and lateral compression. The left thigh is visibly swollen and deformed. Focused assessment with sonography for trauma (FAST) demonstrates an anechoic stripe in the hepatorenal recess. A peripheral intravenous line is established, and 1 L of warmed lactated Ringer solution is rapidly infused; her blood pressure remains 70/40 mm Hg. Which of the following is the most appropriate next step in the management of this patient?

A 32-year-old man presents to the outpatient clinic with a 2-month history of persistent sadness, profound fatigue, early morning awakening, and difficulty concentrating at work. He reports that his symptoms have led to a recent poor performance review. He denies suicidal ideation, psychotic symptoms, or active medical problems. Physical examination and baseline laboratory studies are unremarkable. You suspect major depressive disorder (MDD) and plan to initiate treatment. Arrange the following clinical management steps in the most appropriate chronological sequence, assuming the patient eventually requires treatment escalation due to an initial inadequate response.

A 39-year-old woman comes to the emergency department due to a 24-hour history of high fever, chills, and right-sided back pain. She also reports a constant sensation of vaginal wetness that requires her to change her sanitary pad multiple times a day. Ten days ago, the patient underwent an uncomplicated total abdominal hysterectomy for severe endometriosis. Her temperature is 39.0°C (102.2°F), blood pressure is 110/65 mmHg, and pulse is 112/min. She has no pain with urination and voids normally. Physical examination shows pronounced tenderness to percussion over the right costovertebral angle. On speculum examination, a pool of clear fluid is visualized in the vaginal vault. The vaginal cuff appears well-approximated without erythema. A transurethral catheter is placed, and a retrograde instillation of a dilute methylene blue solution into the bladder is performed. A sterile tampon placed in the vagina for 15 minutes is subsequently removed; it is saturated with clear, yellowish fluid but shows no evidence of blue discoloration. Which of the following is the most appropriate next step in management?

A 61-year-old retired engineer is brought to the physician by his daughter for a psychiatric evaluation. Over the past five weeks, he has become increasingly withdrawn, spending most of the day in bed. He reports waking up at 3:00 AM daily and being unable to return to sleep. His daughter notes he has lost approximately 5.5 kg (12 lb) during this period and no longer shows interest in his usual hobbies, such as gardening. Two weeks ago, the patient's primary care provider diagnosed him with a major depressive episode and prescribed fluoxetine. The patient states he feels no better and wants to discontinue the medication. Upon further questioning, the daughter recalls that when her father was in his late thirties, he was briefly given a different antidepressant for sadness. Within days of starting that medication, he became excessively talkative, slept only two hours a night for a week, and impulsively bought three luxury vehicles, leading to a brief psychiatric hospitalization. Medical history is otherwise unremarkable, and he takes no other medications. Vital signs are within normal limits. Which of the following is the most appropriate next step in management?