Tüm alıştırma soruları

For each of the following patient vignettes, select the most accurate personality disorder diagnosis.

A 56-year-old menopausal patient is evaluated in the clinic after noticing a hard, painless nodule in her left breast. On clinical examination, there is a 1.5-cm, immobile, firm mass located in the upper outer quadrant. No skin dimpling, nipple discharge, or axillary lymphadenopathy is present. Arrange the following steps in the most appropriate chronological sequence for the complete evaluation and standard management of this patient's condition.

Match each atypical patient clinical presentation with the most likely substance intoxication syndrome.

Match each patient's core clinical presentation and disease progression pattern to the most likely neurocognitive disorder diagnosis.

Following an uncomplicated total abdominal hysterectomy for symptomatic leiomyomas, a $42$-year-old female presents to the acute care clinic on postoperative day $6$ for evaluation of new-onset abdominal pain. For the past $48$ hours, she has experienced steadily worsening left lower quadrant pain that radiates to the left groin. The pain makes it difficult for her to lift her left leg when walking. She reports normal flatus, bowel movements, and urination. She has not had chills or vomiting. Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $118/76\text{ mm Hg}$, pulse $92/\text{min}$, and respirations $14/\text{min}$. The surgical incision is clean, dry, and intact. Abdominal examination reveals a soft abdomen with deep tenderness in the left lower quadrant, lacking rebound tenderness or rigidity. When the examiner places a hand on the patient's left distal thigh and asks her to flex her hip against resistance while supine, the patient winces in severe pain. Laboratory evaluation reveals a leukocyte count of $8,500/\text{mm}^3$ and a hemoglobin concentration of $9.2\text{ g/dL}$ (down from $12.1\text{ g/dL}$ on postoperative day $1$). Which of the following is the most likely explanation for this patient's presentation?

A 35-year-old male business executive presents to a new primary care physician to establish care. Upon entering the examination room, he immediately complains that the clinic's waiting area is "substandard for someone of my caliber" and insists he should not have been required to wait. During the interview, he boasts extensively about his "unmatched genius" in corporate strategy and demands referrals only to "top-tier, world-renowned specialists" for his mild lower back pain. He expresses intense envy toward a rival executive who recently received a prestigious industry award. The patient notes that yesterday, upon hearing about his rival's award, he felt a deep sense of emptiness and experienced a 2-hour episode of intense paranoia, believing his colleagues were conspiring to ruin his career. This paranoia completely resolved after he successfully led a board meeting later that afternoon. His medical history is notable for occasional low mood, for which he takes fluoxetine. Vital signs are within normal limits. Laboratory results show a thyroid-stimulating hormone (TSH) level of 1.8 µU/mL and a normal free T4. Which of the following is the most likely diagnosis?

Police officers escort a 27-year-old man to the acute care triage desk after he was found highly agitated outside a nightclub. Witnesses reported seeing him ingest an unknown substance earlier in the evening. He is uncooperative, heavily diaphoretic, and clenching his jaw. Vital signs show a temperature of 37.7°C (99.9°F), pulse of 142/min, respirations of 24/min, and blood pressure of 188/110 mmHg. His pupils are dilated but reactive to light. Cardiopulmonary examination reveals rapid, regular heart sounds and clear lungs. He exhibits no focal motor deficits. A 12-lead electrocardiogram demonstrates sinus tachycardia. Which of the following is the best initial step in managing this patient's condition?

During a routine primary care visit, a 31-year-old architect describes feeling 'drained of all energy' for the past month. She reports sleeping up to 13 hours daily, a 4-kg (8.8-lb) weight gain, and profound sadness. She states, 'I cannot concentrate on my blueprints anymore.' The patient has no prior medical conditions and takes no daily medications. Upon further questioning, she recalls a period in her early 20s when she felt 'on top of the world' for about a week. During that time, she slept only 2 hours a night, spent her entire savings on luxury clothes, and felt her thoughts were racing, which ultimately led to a brief inpatient admission. Currently, she appears lethargic and speaks with a flat affect. She reports that for the past 2 days, she has occasionally heard a voice calling her name when she is alone in her apartment. Laboratory studies show a TSH of $1.5 \mu U/mL$ (normal: $0.5-5.0 \mu U/mL$) and free T4 of $1.2 ng/dL$ (normal: $0.9-1.7 ng/dL$). Which of the following is the most appropriate next step in pharmacologic management?

Match each patient's presentation of a depressive disorder or related mood disturbance with the most appropriate therapeutic intervention.

A 33-year-old woman comes to the clinic reporting sudden-onset episodes of chest tightness, palpitations, and sweating. These episodes started 3 weeks ago after she survived a severe multi-car collision. The episodes are triggered whenever she attempts to get into a vehicle. She reports having recurrent nightmares about the crash, avoids driving completely, and feels detached from her husband and children. Physical examination and an electrocardiogram are unremarkable. Which of the following is the most likely diagnosis?

A 38-year-old woman presents to the outpatient psychiatry clinic seeking help for severe distress. Ten months ago, she was the victim of a violent home invasion. Since then, she experiences recurrent, intrusive nightmares of the event, avoids being alone in her house, and feels constantly "on guard." She states she feels emotionally detached from her husband. Her past psychiatric history includes a hospitalization at age 22 for a week-long period of decreased need for sleep, rapid speech, and grandiose delusions, followed by a severe depressive crash. Three weeks ago, a primary care physician started her on phenelzine for her low mood. She read online that paroxetine is effective for trauma survivors and asks if she can start taking it today to help with her nightmares. Which of the following are the most appropriate actions in the management of this patient's current presentation? (Select 2)

A 38-year-old woman with no prior medical or psychiatric history is evaluated in the outpatient clinic after her employer mandated a medical leave of absence. According to her husband, the patient has spent the last 4 months obsessively dismantling the home smoke detectors and covering all the windows with heavy blankets. She claims that a coordinated surveillance team is transmitting voices directly into her ears, warning her of an impending abduction. The husband notes that her personal hygiene has deteriorated significantly during this timeframe, and she rarely leaves her bedroom. Physical examination, routine laboratory studies, and a comprehensive urine toxicology screen are all within normal limits. Which of the following is the most appropriate diagnosis?

A 34-year-old woman is admitted to the hospital for intravenous antibiotic treatment of acute pyelonephritis. Over the past 48 hours, she has been exceptionally demanding and critical of the nursing staff. She frequently states that she is a "VIP in the corporate world" and insists that only the attending physician is qualified to draw her blood or assess her vital signs. She threatens to sue the hospital over a 15-minute delay in her meal delivery, claiming that her time is "far more valuable than anyone else's in this mediocre facility." When the attending physician explains that her serum creatinine is slightly elevated, she becomes furious, accusing the medical team of incompetence and demanding an immediate transfer to a "world-class hospital." She displays no signs of hallucinations or disorganized thought, and her mood is euthymic as long as her demands are accommodated. Her past medical history is notable for multiple cosmetic surgeries. Which of the following is the most appropriate approach for the physician to take in managing this patient?

A 45-year-old man is brought to the emergency department with severe agitation, diaphoresis, visual hallucinations, and tachycardia. His last alcoholic drink was 48 hours ago. He expresses a strong desire to stop drinking permanently. Arrange the following management steps in the most appropriate chronological order, from immediate emergency care to long-term maintenance.

Match each clinical vignette describing a patient with a bipolar spectrum illness to the most appropriate next best step in management or pharmacologic rationale.

Review the clinical vignettes below and match each patient presentation to the most accurate subtype of delusional disorder.

A 71-year-old retired architect is brought to the neurologist by his daughter due to a 9-month history of progressive cognitive decline. Initially, he began having difficulty organizing his finances and interpreting architectural blueprints. Six months ago, he started experiencing vivid episodes during sleep where he thrashes around and shouts, sometimes injuring his wife. Over the last 3 months, he has reported seeing silent, unfamiliar children playing in his living room, though he is generally not distressed by them. He has a history of major depressive disorder treated with sertraline. Two weeks ago, his primary care physician suspected an underlying bipolar diathesis but ultimately only increased his sertraline dose. A few days later, he was prescribed linezolid at an urgent care clinic for a suspected skin infection. A thyroid panel obtained last week showed a TSH of 0.1 μU/mL (normal: 0.4-4.0 μU/mL) and a free T4 of 0.6 ng/dL (normal: 0.9-1.7 ng/dL). On physical examination today, his temperature is 37.1°C (98.8°F), blood pressure is 128/82 mmHg, and heart rate is 76/min. He has a mask-like facies and increased resting muscle tone with a catch-and-release pattern in both arms. Deep tendon reflexes are 2+ bilaterally without clonus. His Mini-Mental State Examination score is 21/30. Which of the following is the most likely diagnosis?

A 32-year-old man is brought to the outpatient psychiatry clinic by his parents due to chronic behavioral changes. They report that their son has been behaving abnormally for the past 3 years. It began when he started claiming that national television news anchors were communicating with him through coded hand gestures. He also frequently converses with voices that no one else can hear. According to the parents, these beliefs and hallucinations have been continuously present since their onset. During this 3-year period, the patient experienced three distinct episodes of profound sadness, anhedonia, hypersomnia, and feelings of worthlessness. Each of these episodes lasted approximately 2 months and resolved spontaneously, with him returning to a normal mood. He is currently displaying a flat affect and reports that the news anchors are still sending him messages, but he denies any current sadness or changes in sleep, appetite, or energy. His medical history is unremarkable, and a urine toxicology screen is negative. Which of the following is the most likely diagnosis?

During a routine prenatal visit, a 34-year-old primigravida at 16 weeks gestation reports a newly discovered lump in her left breast. She states she noticed the abnormality approximately three weeks ago while showering. She has no significant past medical history and no family history of breast or ovarian cancer. Vital signs are within normal limits. Physical examination reveals a 2.5-cm, hard, fixed mass in the upper outer quadrant of the left breast. There is no nipple retraction, skin dimpling, or palpable axillary adenopathy. A targeted ultrasound of the breast is performed and demonstrates a 2.6-cm solid, hypoechoic lesion with irregular, spiculated margins and posterior acoustic shadowing. Which of the following is the most appropriate next step in management?

A 42-year-old woman comes to the physician because she found a hard lump in her right breast 3 weeks ago. She has not noticed any pain, nipple discharge, or skin changes elsewhere. Four months ago, she fell from a stepladder and bruised the right side of her chest. She has no personal or family history of breast disease. Her last menstrual period was 2 weeks ago. She takes no medications. On physical examination, her temperature is 37.0°C (98.6°F), blood pressure is 120/78 mm Hg, and pulse is 72/min. Breast examination reveals a 2.5-cm, firm, nonmobile mass in the upper outer quadrant of the right breast with mild overlying skin dimpling. There is no axillary lymphadenopathy. Which of the following is the most appropriate next step in management?