Tüm alıştırma soruları

A 24-year-old graduate student presents to the clinic reporting that she has felt "down and empty" for the past 6 weeks. She describes poor appetite, waking up multiple times during the night, low energy, and an inability to enjoy her usual hobbies. She feels guilty about her recently declining academic performance. She has no significant past medical history and takes no medications. Her physical examination is unremarkable. The physician determines that she meets the criteria for a major depressive episode and considers initiating pharmacotherapy with an antidepressant. Which of the following is the most appropriate next step in the psychiatric evaluation prior to prescribing this medication?

A 31-year-old male architect visits a new psychiatrist seeking help for severe, debilitating anxiety. He describes being overwhelmed by intrusive, horrific images of his house catching fire. To neutralize these thoughts, he feels driven to check the stove and electrical outlets exactly twelve times before leaving for work. This ritual consumes over two hours daily, threatening his employment. He also reports experiencing a profoundly depressed mood, fatigue, and anhedonia for the past six weeks. His medical record reveals a prior psychiatric admission three years ago for an episode of grandiosity, pressured speech, and zero sleep requirement that lasted 10 days. The patient is currently taking tranylcypromine, prescribed by a previous provider, but finds it ineffective for his checking rituals. He requests to switch to a different class of medication, specifically a selective serotonin reuptake inhibitor (SSRI), starting today.

Which of the following actions represent appropriate steps in the comprehensive management of this patient's psychiatric conditions? (Select all that apply)

A 45-year-old woman presents to the clinic for evaluation of abdominal pain and continuous vaginal discharge. She underwent a total laparoscopic hysterectomy for symptomatic uterine fibroids 14 days ago. Her initial postoperative course was uncomplicated, and she was discharged home on the first postoperative day. Over the past 3 days, she has developed progressive right-sided flank pain, mild nausea, and a continuous, clear, watery vaginal discharge. She reports no dysuria, urgency, or frequency, and she is voiding normally in typical volumes. Her temperature is 38.0°C (100.4°F), blood pressure is 120/78 mm Hg, and pulse is 88/min. Physical examination reveals right costovertebral angle tenderness. The abdomen is soft and non-distended. Speculum examination shows clear fluid pooling in the vaginal vault. A vaginal tampon is placed, and 300 mL of normal saline mixed with methylene blue dye is instilled into the bladder via a Foley catheter. The patient ambulates for 15 minutes, after which the tampon is removed. The tampon is saturated with clear fluid but has no blue staining. Which of the following is the most likely etiology of this patient's current presentation?

Match each clinical vignette with the most likely personality disorder diagnosis.

A 42-year-old male marketing executive presents to the clinic for a two-month history of pervasive anhedonia, early morning awakening, and an unintentional 5-kg (11-lb) weight loss. He reports that his symptoms have severely impaired his concentration, leading to a recent formal reprimand at work. He is seeking pharmacologic treatment. Assuming this patient will eventually develop treatment-resistant depression over the next year, arrange the following clinical management steps in the standard chronological sequence according to evidence-based stepped-care guidelines.

Match each patient's clinical vignette with the most appropriate personality disorder diagnosis.

A 52-year-old woman undergoes a routine screening mammogram, which reveals a new 1.5-cm spiculated density in the upper outer quadrant of the right breast. She is completely asymptomatic and her past medical history is unremarkable. Arrange the following subsequent steps in her evaluation and management in the most appropriate chronological sequence.

A 27-year-old primigravida at 16 weeks gestation is brought to the clinic by her partner due to worsening mood. Over the last four weeks, she has felt profoundly sad, lacks energy, and sleeps up to 14 hours a day. She expresses deep guilt and says she feels "empty." Her partner notes that during her second year of college, she experienced a distinct two-week period where she slept only three hours a night, spoke at an unusually rapid pace, and started three different business ventures that rapidly failed. That prior episode resolved without hospitalization. She currently takes a daily prenatal vitamin and an over-the-counter dextromethorphan syrup for a chronic post-viral cough. Vital signs are within normal limits. Recent laboratory testing shows a thyroid-stimulating hormone (TSH) level of 1.1 mU/L. Which of the following is the most appropriate next step in pharmacologic management?

A 28-year-old man presents to the outpatient psychiatric clinic complaining of severe "panic attacks" and insomnia. For the past 8 months, he has experienced sudden surges of intense fear accompanied by tachycardia, diaphoresis, and a feeling of impending doom. These episodes are frequently triggered by loud noises or when he attempts to fall asleep. During these episodes, he reports "zoning out" and vividly hearing the screeching of tires and feeling the impact of a vehicle, reliving a severe car accident he survived 8 months ago in which his fiancée was killed. He has since refused to ride in any motor vehicles, walking 3 miles to work every day. He notes that 3 years ago, he experienced a distinct 4-week period where he required only 2 hours of sleep per night, believed he had been chosen by God to solve world hunger, and maxed out multiple credit cards to start a charity. This behavior led to a brief psychiatric hospitalization, but he stopped taking his prescribed medications shortly after discharge. He is currently taking no medications. Vital signs, physical examination, and laboratory studies are unremarkable. Which of the following is the most appropriate next step in management?

Match each depressive disorder or specifier with its most characteristic clinical presentation.

A 49-year-old woman is evaluated in the surgical oncology clinic due to rapid changes in her right breast over the past five weeks. She was initially treated at an urgent care clinic with a two-week course of oral clindamycin for presumed cellulitis, but the condition has progressively worsened. She has no personal or family history of breast malignancy and previously had normal screening mammograms. Vital signs are normal. Examination of the right breast reveals diffuse enlargement, marked erythema, and increased warmth. The skin demonstrates prominent pitting edema encompassing most of the breast surface. Palpation reveals diffuse, firm tissue thickening without a discrete localized lump. Hard, enlarged lymph nodes are palpable in the right axillary region.

Arrange the following clinical interventions in the most appropriate chronological order for the diagnosis, staging, and definitive management of this patient.

A 32-year-old woman is evaluated in the outpatient psychiatric clinic for chronic relationship difficulties. She recently separated from her husband of three years. She states, 'I did everything he asked. I moved to a city I hated, quit my job so I could be home when he wanted, and even stopped talking to my friends because he thought they were a bad influence. I just wanted him to make the decisions so I wouldn't mess things up.' Despite her concessions, her husband filed for divorce. Since the separation, she has felt 'lost and completely helpless.' She immediately moved in with her older sister and has been pleading with her sister to help her find a new job, decide what clothes to wear, and manage her finances. When asked how she coped when her husband first mentioned divorce, she says, 'I begged him to stay and promised I would change whatever he wanted. I just panicked and clung to him tighter.' She denies ever making suicide attempts, engaging in self-injurious behavior, or experiencing sudden angry outbursts toward her husband. She has no history of substance use disorder.

Which of the following clinical features most accurately distinguishes this patient's personality pathology from borderline personality disorder?

A 28-year-old male veteran presents to an outpatient clinic reporting a 5-month history of severe sleep disturbances, hypervigilance, and intrusive memories of a combat engagement. He avoids crowded places and frequently scans his environment for threats. During the interview, he appears visibly tense. He also reports a recent onset of profound fatigue, constipation, and feeling cold all the time over the past 4 weeks.

His psychiatric history is significant for a severe episode of grandiosity, pressured speech, and lack of sleep that required inpatient hospitalization at age 22. He is currently taking isocarboxazid, a monoamine oxidase inhibitor (MAOI), prescribed two years ago for treatment-resistant depression, but he reports it is no longer effective and finds the dietary restrictions burdensome.

Vital signs are within normal limits. Laboratory testing reveals:
- Thyroid-stimulating hormone (TSH): $0.1 \text{ \mu U/mL}$ (Normal: $0.5 - 5.0 \text{ \mu U/mL}$)
- Free thyroxine (T4): $0.6 \text{ ng/dL}$ (Normal: $0.9 - 1.7 \text{ ng/dL}$)

The physician decides to restructure his psychiatric and medical management.

Which of the following are the most appropriate next steps in management? (Choose two correct answers)

Match each classic clinical presentation with its most appropriate DSM-5 diagnostic category.

A 28-year-old woman presents to the outpatient clinic 3 months postpartum reporting an overwhelmingly sad mood, profound hypersomnia, hyperphagia, and a sensation of extreme heaviness in her arms and legs. She reports significant functional impairment, noting difficulty getting out of bed to care for her infant. To avoid common clinical pitfalls and ensure standard-of-care management, arrange the following steps in the correct chronological sequence, from the immediate diagnostic evaluation to the management of potential treatment refractoriness.

Match each patient's clinical presentation of major depressive disorder with the most appropriate initial pharmacological treatment based on their specific comorbidities and symptom profiles.

A 45-year-old night-shift security guard is evaluated at a primary care clinic for a routine employment physical. The patient reports that he lives entirely alone and spends his off-hours building intricate model ships. When the physician asks about his social support system, the patient states that he has no close friends and prefers it that way, noting that interacting with others is exhausting and uninteresting to him. He expresses no desire for romantic or sexual relationships. During the interview, he appears indifferent to the physician's attempts to build rapport and displays a flattened, detached affect. He denies experiencing any hallucinations, paranoia, or periods of depressed mood. Which of the following is the most likely diagnosis?

An emergency medical team brings a 20-year-old female university student to the hospital after she fainted during a lecture. Her friends report she has been severely restricting her food intake and exercising excessively for the past 8 months. On arrival, she is lethargic but arousable. Her body mass index is calculated at $13.0\text{ kg/m}^2$. Vital signs indicate profound bradycardia ($38\text{ /min}$) and hypotension ($78/48\text{ mm Hg}$). Arrange the following interventions in the most appropriate chronological sequence for managing this patient's condition, progressing from immediate acute care to definitive long-term therapy.

A 46-year-old woman comes to the clinic to discuss the results of a recent breast biopsy. Two weeks ago, a routine screening mammogram revealed a new, 8-mm cluster of pleomorphic microcalcifications in the upper outer quadrant of her right breast. A stereotactic core needle biopsy was performed. The pathology report indicates atypical ductal hyperplasia and fibrocystic changes containing microcalcifications. The patient has no history of breast disease. Menarche was at age 12, and she is nulliparous. Her mother was diagnosed with breast cancer at age 55. Vital signs are within normal limits. Physical examination reveals symmetrical breasts with no palpable masses, skin changes, nipple discharge, or axillary lymphadenopathy. Which of the following is the most appropriate next step in management?

An established patient presents to the outpatient psychiatry clinic accompanied by her sister. The 29-year-old woman reports feeling profoundly 'empty' and exhausted for the past three weeks. During this time, she has struggled with significant hypersomnia, hyperphagia, and pervasive feelings of guilt. Her sister notes that two years prior, the patient experienced a highly uncharacteristic 10-day period during which she was exceptionally 'wired,' slept merely two hours per night, spoke incessantly, and had grandiose delusions of being a secret government agent. She was subsequently placed on phenelzine for presumed unipolar depression by a different provider, but she independently stopped taking this medication 3 days ago due to a lack of perceived efficacy. Current laboratory results, including a complete thyroid panel (TSH and free T4), are within normal limits. Which of the following is the most appropriate next step in the pharmacologic management of this patient?