Tüm alıştırma soruları

A 28-year-old man with a known history of schizophrenia is brought to the emergency department by police due to severe agitation. He is pacing rapidly in the evaluation room, shouting at unseen stimuli, and intermittently clenching his fists. When nursing staff approach, he yells, 'Stay away from me, you are trying to poison me!' Arrange the following management steps in the most appropriate, evidence-based escalating sequence for addressing this patient's acute agitation, from the initial preferred approach to the intervention of last resort.

A 7-year-old girl is brought to the pediatric clinic by her parents at the recommendation of her second-grade teacher. Over the past four months, the teacher has noted that the patient frequently "zones out" during reading and math groups. During these episodes, she stares blankly at the wall for several minutes and fails to complete her assignments. Her desk is highly disorganized, and she frequently loses her school supplies. When the teacher loudly calls her name during one of these staring episodes, she startles, immediately apologizes, and asks for the instructions to be repeated. At home, she takes hours to complete brief homework assignments, frequently misplaces her jacket, and struggles to follow multi-step commands such as "brush your teeth, put on your pajamas, and pick out a book." There is no history of lip smacking, eyelid fluttering, or sudden loss of postural tone. Her physical and neurologic examinations are unremarkable. Which of the following clinical features is most specific for distinguishing this patient's most likely underlying disorder from childhood absence epilepsy?

A 45-year-old man is brought to the emergency department after a propane tank explosion at his home. He is awake, alert, and complaining of severe pain. Physical examination reveals deep partial-thickness (second-degree) and full-thickness (third-degree) burns involving his entire posterior trunk and both of his entire upper extremities. There are also superficial (first-degree) burns involving his entire face and neck. The remainder of his body is unaffected. Based on the Rule of Nines, what is the estimated total body surface area (TBSA) percentage that should be used to calculate his initial fluid resuscitation requirements?

Match each patient's clinical presentation of a psychotropic medication adverse effect to the primary pharmacodynamic or pathophysiologic mechanism responsible for the finding.

A metropolitan toxicology service is evaluating several patients with suspected substance use disorders. Correlate the following distinct clinical manifestations with their correct underlying etiology.

A $51$-year-old male is evaluated in the surgical oncology clinic for a newly discovered neck mass. Two weeks ago, he underwent a carotid duplex ultrasound as part of a workup for transient visual changes, which incidentally revealed a $2.6\text{ cm}$ solid nodule in the right thyroid lobe. The patient reports an $8$-month history of progressive fatigue, decreased libido, and feeling cold constantly. He has no personal or family history of head and neck irradiation or thyroid malignancy. His blood pressure is $108/68\text{ mmHg}$ and pulse is $54\text{/min}$. Physical examination shows a firm, non-tender nodule palpable in the right anterior neck. No cervical lymphadenopathy is present. Testicular examination reveals bilaterally small, soft testes. Laboratory studies show:

Thyroid-stimulating hormone (TSH): $0.12\text{ \mu U/mL}$ (normal: $0.4-4.0\text{ \mu U/mL}$)
Free thyroxine (T4): $0.5\text{ ng/dL}$ (normal: $0.9-1.7\text{ ng/dL}$)

Which of the following is the most appropriate next step in the diagnostic evaluation of this patient's thyroid nodule?

A 52-year-old woman comes to the primary care clinic for evaluation of sleep disturbance and leg discomfort over the past 3 months. She describes a deep, "crawling" sensation in her calves and thighs that begins almost exclusively when she lies down in bed or relaxes on the couch in the evening. The sensation is accompanied by an irresistible urge to move her legs, and she must pace the hallway for several minutes to find temporary relief. She has no symptoms during the day and sits calmly throughout the examination. Her medical history is significant for bipolar I disorder, hyperlipidemia, and uterine leiomyomas causing heavy menstrual bleeding. Current medications include lithium, lurasidone, and atorvastatin. Vital signs are normal. Neurological examination shows no resting tremor, rigidity, or focal deficits. Laboratory testing reveals a hemoglobin of $11.2 \text{ g/dL}$, mean corpuscular volume of $76 \text{ fL}$, and serum ferritin of $18 \text{ ng/mL}$ (Normal: $15-200 \text{ ng/mL}$). Which of the following is the most appropriate next step in the management of this patient's sleep-related symptoms?

A $22$-year-old man is brought to the emergency department by ambulance $15$ minutes after sustaining a stab wound to the left side of his chest during an altercation. On arrival, the patient is agitated and diaphoretic. His temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure is $82/40 \text{ mmHg}$, pulse is $132/\text{min}$, and respiratory rate is $26/\text{min}$. Pulse oximetry shows $94\%$ on room air. Primary survey reveals a $3 \text{ cm}$ linear laceration in the left $6^{\text{th}}$ intercostal space at the midaxillary line. The trachea is midline. Breath sounds are markedly diminished on the left side of the chest. The abdomen is slightly distended and diffusely tender to palpation. A left-sided tube thoracostomy is placed, draining $400 \text{ mL}$ of gross blood and a small amount of bubbling air. Five minutes after chest tube placement, breath sounds are equal bilaterally, and oxygen saturation improves to $99\%$. However, his blood pressure remains $80/42 \text{ mmHg}$ and pulse is $135/\text{min}$ despite rapid intravenous infusion of $1 \text{ L}$ of warmed crystalloid solution. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large anechoic fluid collection in the splenorenal recess, with no pericardial effusion identified. Which of the following is the most appropriate next step in management?

A 35-year-old man is brought to the emergency department after being rescued from a closed-space house fire. He is coughing up carbonaceous sputum and has a hoarse voice. He has sustained deep partial-thickness and full-thickness burns covering his entire anterior trunk and bilateral upper extremities. According to standard trauma and burn management principles, arrange the following clinical interventions in the most appropriate chronological sequence.

Match each pharmacologic agent used in the maintenance treatment of bipolar disorder with its characteristic adverse effect profile and associated monitoring requirements.

A $23$-year-old woman presents to the outpatient psychiatric clinic with a $2$-month history of profound sadness, fatigue, and social withdrawal. She reports sleeping up to $14$ hours a day and experiencing a strong craving for carbohydrate-rich foods, leading to a $5$-kg ($11$-lb) weight gain. She states her arms and legs frequently feel "so heavy, it is as if my bones have turned to solid stone." Despite her depressed mood, she notes that she felt briefly happy and energized last week when she received a good grade on an exam, though the low mood quickly returned. She also reports occasionally hearing a voice calling her name just as she is drifting off to sleep. She has no chronic medical conditions. Vital signs are within normal limits. Laboratory studies reveal a thyroid-stimulating hormone (TSH) level of $1.8 \text{ \mu U/mL}$ (normal $0.5-5.0 \text{ \mu U/mL}$) and free thyroxine (T4) of $1.2 \text{ ng/dL}$ (normal $0.9-1.7 \text{ ng/dL}$). She is currently not taking any medications. She requests an antidepressant to help her focus on her studies. Which of the following is the most appropriate next step in the management of this patient?

Emergency medical services arrive at the hospital with an unresponsive individual found in a public transit station. Initial assessment reveals a respiratory rate of 4 breaths per minute, oxygen saturation of 82% on room air, and miotic pupils. Track marks are visible on the patient's antecubital fossae. The clinical team must manage the patient from acute presentation through stabilization and eventual hospital discharge. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 42-year-old man is evaluated in the psychiatric clinic for a six-week history of pervasive sadness, insomnia, low energy, and feelings of worthlessness. He frequently thinks about death but has no active suicidal plan. Vital signs and physical examination are unremarkable. Routine laboratory studies, including thyroid function tests, are within normal limits. During the interview, the patient mentions that in his late twenties, he had a one-week period where he slept only two hours a night, felt extremely energetic, and took out multiple unapproved bank loans for a 'revolutionary' business idea. He was hospitalized during that episode. He is currently taking no medications. What is the most appropriate next step in pharmacological management for this patient?

A 26-year-old woman presents to the clinic seeking assistance with smoking cessation. She has smoked one pack of cigarettes per day for the past 6 years. The patient also reports feeling "down" and fatigued for the past 6 months. Her BMI is 21 kg/m^2. Vital signs are within normal limits. Physical examination is notable for mild bilateral parotid gland enlargement and calluses on the dorsum of her right hand. Upon further questioning, the patient admits to episodes of eating abnormally large quantities of food followed by self-induced vomiting 3 to 4 times per week over the past year. Laboratory studies show a serum potassium of 3.2 mEq/L and a serum chloride of 94 mEq/L. The physician discusses pharmacological options for smoking cessation and considers prescribing bupropion. Which of the following best explains why bupropion is contraindicated in this patient?

Twenty-four hours after undergoing an elective open inguinal hernia repair, a 29-year-old man is found to have a temperature of $38.3^\circ\text{C}$ ($101.0^\circ\text{F}$). His other vital signs include a pulse of $84/\text{min}$, respirations of $14/\text{min}$, and blood pressure of $126/82 \text{ mm Hg}$. The patient is currently tolerating a liquid diet but complains of moderate pain around his groin when moving or taking deep breaths. Auscultation of the chest reveals decreased breath sounds at the lung bases bilaterally without crackles or wheezes. The surgical dressing is clean and intact, with no surrounding erythema or induration. Which of the following is the most appropriate next step in management?

A 31-year-old woman, G1P1, comes to the outpatient clinic 6 weeks after an uncomplicated vaginal delivery. She is accompanied by her husband, who is concerned about her behavior. For the past 4 weeks, she has experienced profound sadness, frequent crying spells, and a pervasive sense of guilt regarding her parenting. She reports waking up at 3 AM daily and being unable to return to sleep, even when her infant is sleeping. She describes her mood as consistently worse in the mornings and notes no improvement in her mood even when playing with her newborn or when her parents visit. She lacks the energy to perform basic household tasks. She denies suicidal ideation or thoughts of harming the infant. She recalls experiencing a period of "severe depression" in her early twenties that lasted for several months but resolved without treatment. She is currently breastfeeding and takes prenatal vitamins. She does not use tobacco, alcohol, or illicit substances. Vital signs are within normal limits. Which of the following is the most appropriate next step in the evaluation or management of this patient?

A 48-year-old woman is evaluated in the post-anesthesia care unit two hours after an elective laparoscopic cholecystectomy for symptomatic cholelithiasis. Her medical history is significant for major depressive disorder and Graves disease. Her home medications include sertraline 100 mg daily and methimazole 5 mg daily, though she admits to missing several doses of methimazole over the past month. Anesthesia was induced with propofol and succinylcholine, and maintained with sevoflurane. Fentanyl and ondansetron were administered during the procedure.

The patient is now severely agitated and disoriented. Her temperature is 39.4°C (102.9°F), heart rate is 148/min, blood pressure is 172/95 mmHg, and respiratory rate is 24/min. Physical examination reveals a profusely diaphoretic and flushed woman. Her pupils are dilated. Neurological examination demonstrates spontaneous ocular clonus. Deep tendon reflexes are 4+ in both the upper and lower extremities, with sustained ankle clonus present bilaterally. Her abdomen is soft with hyperactive bowel sounds. No muscle rigidity is noted.

Which of the following are the most appropriate immediate steps in the management of this patient? (Select 2)

An occupational health physician is reviewing the records of a 29-year-old woman currently hospitalized for psychiatric stabilization. A detailed collateral history is obtained from her husband. The patient first experienced psychiatric symptoms 5 years ago, characterized by a 2-month period of profound sadness, anhedonia, and severe insomnia, accompanied by auditory hallucinations commanding her to harm herself. She received treatment and was completely asymptomatic for the next two years. Three years ago, she developed a persistent belief that her neighbors were surveilling her and began hearing two voices conversing about her behavior. She has experienced these psychotic symptoms continuously for the last 36 months. However, during this 36-month period, her mood, energy, and sleep were entirely normal until 2 weeks ago. Over the past 2 weeks, she abruptly developed severe euphoria, pressured speech, and a decreased need for sleep, while still experiencing the paranoia and auditory hallucinations. Medical workup and urine toxicology are unremarkable. Which of the following is the most accurate diagnosis?

A 30-month-old boy is brought to the pediatrician by his parents due to concerns regarding his language development. The parents report that he uses approximately 10 single words and does not combine them into phrases. When he desires a snack, he physically guides his father's hand to the pantry rather than pointing or vocalizing his request. He rarely makes eye contact when his name is called. The parents also note that he becomes severely agitated and inconsolable if his daily routine is altered, such as taking a different driving route to the grocery store. On physical examination, the boy is able to jump in place, walk up stairs while holding the handrail, and stack a tower of seven blocks. A comprehensive audiology evaluation performed last week revealed normal hearing bilaterally. Based on the patient's presentation, which of the following statements regarding his developmental status and management are accurate? (Select all that apply)

Evaluate the concise patient vignettes below and link each to the most accurate DSM-5 psychiatric classification.