Tüm alıştırma soruları

A 71-year-old man is evaluated on the surgical ward on postoperative day 4 after an open distal pancreatectomy. His past medical history is significant for chronic obstructive pulmonary disease and ischemic heart disease. Over the past 12 hours, he has developed progressively worsening shortness of breath and a new cough productive of yellow-green sputum. Temperature is 38.6°C (101.5°F), pulse is 112/min, respirations are 24/min, and blood pressure is 130/82 mm Hg. Oxygen saturation is 91% on room air. Cardiovascular examination reveals a regular rhythm with no murmurs, and the jugular venous pressure is normal. Pulmonary auscultation reveals focal coarse crackles and egophony over the right lower lung field, without wheezing. The abdominal incision is clean and well-approximated. A portable chest radiograph demonstrates a new consolidation in the right lower lobe. Which of the following is the most appropriate next step in the management of this patient's condition?

An urgent evaluation is requested for a $42$-year-old female on the second postoperative day following a laparoscopic Roux-en-Y gastric bypass. Her medical history includes morbid obesity (body mass index $45\text{ kg/m}^2$), obstructive sleep apnea, and mild asthma. The nursing staff reports that the patient developed sudden, severe left shoulder pain and a feeling of impending doom $30$ minutes ago. She also reports vague left-sided chest discomfort. Her temperature is $38.4^\circ \text{C}$ ($101.1^\circ \text{F}$), pulse is $135/\text{min}$, blood pressure is $105/65\text{ mmHg}$, and respirations are $26/\text{min}$. Pulse oximetry shows an oxygen saturation of $94\%$ on room air. Physical examination demonstrates an obese, soft abdomen with moderate tenderness located in the left upper quadrant. The laparoscopic port sites appear clean and intact. Lung auscultation reveals diminished breath sounds over the left base, but no crackles or wheezes. Cardiac examination shows regular tachycardia without murmurs. Which of the following is the most appropriate next step in the management of this patient?

A university student, aged 22, presents to the campus health center complaining of an 8-week history of profound melancholy, excessive sleepiness, and a complete inability to concentrate. She explains that she has stopped attending her lectures and feels devoid of any motivation. Review of her medical records reveals a prior psychiatric admission two years ago; during that time, she remained awake for six consecutive days, exhibited grandiose delusions about leading the university, and engaged in highly disruptive activities on campus before being hospitalized. She is currently not taking any medications. Recent thyroid function tests show a thyroid-stimulating hormone (TSH) level of $2.5 \mu\text{U/mL}$ (normal: $0.4-4.0 \mu\text{U/mL}$) and a free thyroxine ($T_4$) level of $0.9 \text{ ng/dL}$ (normal: $0.8-1.8 \text{ ng/dL}$). She insists on being prescribed a medication to lift her mood so she can return to her studies. Which of the following is the most appropriate management plan for this patient?

A 32-year-old man presents to the clinic with a 4-week history of productive cough, profound fatigue, and unintentional weight loss. Sputum microscopy reveals acid-fast bacilli, and a nucleic acid amplification test confirms the presence of *Mycobacterium tuberculosis*. The physician explains the diagnosis, prescribes a standard four-drug antituberculous regimen, and strongly advises the patient to isolate at home until he is no longer considered infectious. The patient becomes visibly upset and states, "I work as a respiratory therapist at a long-term care facility. I cannot afford to take any time off. I am going to my shift tomorrow, and you cannot tell my boss because of patient privacy laws." Which of the following is the most appropriate next step?

A third-year internal medicine resident notices that their supervising attending physician smells strongly of alcohol, has slurred speech, and is unsteady on their feet right before starting a shift in the intensive care unit. Arrange the following steps in the most appropriate order of action and escalation to manage this professional concern.

A 45-year-old woman initiates a direct-to-consumer telemedicine consultation with a dermatologist for a changing, pigmented skin lesion on her right shoulder. She uploads a close-up photograph of the lesion using her smartphone. The dermatologist reviews the image, diagnoses a benign seborrheic keratosis, and advises routine observation without recommending a biopsy. Eighteen months later, the lesion ulcerates, and an in-person evaluation reveals a thick nodular melanoma. The patient subsequently requires wide local excision and lymph node dissection. She files a medical malpractice lawsuit against the dermatologist, claiming negligence. To establish a successful prima facie claim of medical negligence, the plaintiff must prove that the delay in diagnosis directly caused a worse prognosis (proximate causation) and that she suffered compensable harm (actual damages). Which TWO of the following additional legal elements MUST the plaintiff also prove to establish negligence?

An attending physician is treating a 24-year-old woman in the outpatient clinic for a newly diagnosed sexually transmitted infection. Later that day, the patient's father, who is a respected surgeon on staff at the same hospital, approaches the attending physician in the doctors' lounge. He states, "I saw my daughter on your schedule today. How is she doing? What did her lab results show?" The patient has not signed a release of information form for her father. Which of the following is the most appropriate response by the attending physician?

A 74-year-old woman is admitted to the medical ward for an acute exacerbation of chronic obstructive pulmonary disease. On her second day of hospitalization, the attending physician prescribes a tapering dose of oral prednisone. The patient's assigned nurse, who is working an unexpected double shift due to acute staffing shortages, misinterprets the electronic medication administration record. The nurse mistakenly administers 50 mg of oral dexamethasone instead of the prescribed 50 mg of prednisone. Over the next 24 hours, the patient develops severe hyperglycemia and delirium, necessitating transfer to the intensive care unit for a continuous insulin infusion. An incident report is submitted to the clinical safety department. Which of the following is the most appropriate initial action in response to this event?

A 27-year-old man comes to the outpatient clinic due to a painless sore on his penis that appeared a week ago. He has no other symptoms. Physical examination reveals a 1-cm, indurated, clean-based ulcer on the glans penis. Bilateral inguinal lymphadenopathy is present. Dark-field microscopy of a specimen from the ulcer confirms the presence of Treponema pallidum, and the patient receives a dose of intramuscular benzathine penicillin G. During counseling, the patient mentions he is married and his wife is currently 14 weeks pregnant. The physician advises the patient to inform his wife about the diagnosis so she can be evaluated and treated. The patient vehemently refuses, stating, 'If she finds out I was unfaithful, she will divorce me. I will just make an excuse to avoid having sex with her until I am completely cured.' Which of the following is the most appropriate next step by the physician?

An 82-year-old woman with advanced Alzheimer disease is admitted to the medical intensive care unit with severe aspiration pneumonia and septic shock. She is obtunded, unresponsive to verbal stimuli, and definitively lacks decision-making capacity. Her prognosis is grave, with death anticipated within hours. The patient has a legally executed advance directive specifying her wish for 'comfort measures only' at the end of life and explicitly designating her eldest son as her sole healthcare proxy.

The patient exhibits severe tachypnea and accessory muscle use, indicating significant air hunger. After discussing the prognosis with the attending physician, the eldest son requests the initiation of an intravenous morphine infusion to relieve his mother's respiratory distress. He acknowledges understanding that this intervention may depress her respiratory drive and hasten her death. Shortly after this discussion, the patient's younger daughter, who is a practicing intensive care unit nurse, arrives at the bedside. She vehemently objects to the morphine, arguing that it will cause fatal respiratory depression. She threatens to file a complaint with the state medical board if the opioid is administered and demands an immediate emergency ethics committee consultation to halt the infusion.

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

A 24-year-old man is brought to the emergency department via helicopter following a high-speed motorcycle collision. Upon arrival, his blood pressure is 70/40 mm Hg, heart rate is 142/min, and respiratory rate is 28/min. A focused assessment with sonography for trauma (FAST) reveals a large amount of free fluid in the peritoneal cavity. The patient is lethargic, oriented only to person, and unable to engage in a meaningful discussion regarding his care. While searching his personal belongings for identification, the trauma bay nurse discovers a formally executed, signed, and witnessed advance medical directive in his wallet. The document explicitly states that he refuses all allogeneic blood product transfusions under any circumstances, even if necessary to preserve his life. Shortly thereafter, the patient's parents arrive at the hospital. Upon being informed of the patient's critical condition and his advance directive, they become highly distressed and adamantly insist that the trauma team utilize all available life-saving measures, including blood transfusions, stating, 'He is too young to die, we are his next of kin, and we authorize whatever it takes to save him.' Which of the following is the most appropriate next step in management?

A 29-year-old man is brought to the emergency department by emergency medical services after sustaining severe head trauma in a high-speed motor vehicle collision. He is unresponsive, intubated, and hemodynamically unstable. While the patient undergoes emergency imaging, a woman arrives at the emergency department triage desk in a state of extreme distress. She identifies herself as the patient's live-in girlfriend of three years and asks the physician for an update on his condition and prognosis. The patient has no advance directive on file, and the police are currently attempting to locate his parents, who live in another state. Which of the following is the most appropriate response by the physician?

A 31-year-old G1P0 woman at 39 weeks gestation is admitted to the labor and delivery unit for induction of labor. During the second stage of labor, fetal monitoring reveals recurrent late decelerations, indicating fetal distress. The attending obstetrician informs the patient that an urgent cesarean delivery is necessary to prevent severe fetal hypoxia or death. The patient is fully alert, oriented, and demonstrates a clear understanding of the risks, but she adamantly refuses the surgery because she strongly desires a vaginal birth. Her husband begs the physician to proceed with the surgery to save the baby. After briefly consulting with the hospital's risk management team over a secure network, the physician decides to prioritize the fetal outcome. Relying on the husband's consent, the physician performs the cesarean delivery over the patient's explicit verbal protests. A healthy infant is delivered without maternal or fetal physical complications. Which of the following best describes the physician's legal liability in this situation?

A 16-year-old girl is evaluated in the clinic for a follow-up visit. She recently tested positive for *Chlamydia trachomatis* after presenting with dysuria. During today's appointment, she requests a prescription for birth control because she is sexually active with a new male partner. Upon further discussion, she tearfully reports feeling hopeless, experiencing poor sleep, and having low energy for the past three months. The physician determines she meets the criteria for major depressive disorder. The patient explicitly asks the physician not to tell her parents about her visit, her sexual activity, or her mood symptoms. She is an unemancipated minor who lives at home and is financially supported by her parents. Which of the following interventions can the physician legally perform without parental notification or consent? (Select all that apply)

A 65-year-old woman with a history of heart failure and atrial fibrillation is hospitalized for acute pyelonephritis. She is appropriately started on intravenous ciprofloxacin. Her home medications, including sotalol, are continued upon admission. On hospital day 2, she experiences a syncopal episode, and telemetry demonstrates a brief run of torsades de pointes. A 12-lead electrocardiogram reveals a QTc interval of 560 msec. She is successfully stabilized with intravenous magnesium sulfate. A subsequent review of the event reveals that the electronic health record (EHR) generated a drug-drug interaction warning when the ciprofloxacin was ordered. However, the admitting physician bypassed the warning because similar alerts frequently trigger for clinically insignificant interactions. A multidisciplinary quality improvement committee is convened to perform a root cause analysis and identifies alert fatigue as the primary contributing factor. Based on the hierarchy of intervention reliability, which of the following is the most appropriate action by the committee to prevent similar adverse events?

Match each workplace scenario with the most appropriate professional action based on medical ethics guidelines.

A 48-year-old man is admitted to the intensive care unit following a massive subarachnoid hemorrhage. He is comatose, permanently lacks decision-making capacity, and his prognosis is extremely poor. The medical team is considering transitioning to comfort measures only. The patient has no written advance directive and has never designated a healthcare proxy. Several individuals are present at the hospital and disagree on the plan of care. According to the standard legal hierarchy of surrogate decision-makers, arrange the following individuals in order of their legal priority to make medical decisions on the patient's behalf, from highest priority (first) to lowest priority (last).

Match each clinical scenario describing a patient safety incident or outcome to the most appropriate error classification.

Match each clinical scenario to the legal doctrine or statute that most accurately governs the liability or mandatory standard of care for that situation.

A 55-year-old man is admitted to the orthopedic floor following an uncomplicated right total knee arthroplasty. On postoperative day 2, he experiences sudden-onset dyspnea and pleuritic chest pain. A computed tomography pulmonary angiogram confirms an acute pulmonary embolism. Subsequent review of the patient's medical record reveals that postoperative chemical venous thromboembolism (VTE) prophylaxis was never ordered, despite being standard hospital protocol for this procedure. The orthopedic resident placed the admission orders but was interrupted by a high-priority trauma page and failed to complete the VTE prophylaxis section of the electronic order set. The clinical pharmacist verified the incomplete order set, and the bedside nurse assumed that early ambulation was the only intended prophylactic measure. The hospital's quality improvement committee is tasked with reviewing this adverse event. Which of the following is the most appropriate initial action by the committee?