Tüm alıştırma soruları

A 16-year-old primigravida at 10 weeks gestation presents to a family medicine clinic for her first prenatal visit. During the encounter, she explicitly requests that her parents not be informed of her pregnancy. The physician agrees and documents the patient's wishes. The next day, the patient's mother, a senior hospital executive and attending surgeon at the same institution, confronts the physician in a crowded hospital hallway. The mother reveals she accessed her daughter's electronic medical record and angrily demands that the physician immediately refer the daughter for a pregnancy termination. She threatens to ensure the physician loses hospital privileges if her demand is not met. Which of the following is the most appropriate next step by the physician?

A 34-year-old woman is brought to the emergency department after a high-speed motor vehicle collision. She has sustained a crushed pelvis and massive intra-abdominal hemorrhage. Her blood pressure is 70/40 mm Hg and heart rate is 142/min. The patient is obtunded, unable to communicate, and lacks decision-making capacity. Her husband arrives shortly after and informs the medical team that he and his wife are devout Jehovah's Witnesses. He emphatically refuses the administration of any blood products on her behalf. While gathering the patient's identification, the trauma nurse discovers a legally valid, signed, and witnessed advance directive in her wallet, dated 4 months ago. The document explicitly states: "I no longer practice the Jehovah's Witness faith. I consent to all necessary life-saving medical treatments, including blood transfusions. My family is unaware of my decision." Which of the following is the most appropriate next step in management?

During a routine pre-kindergarten health assessment, a five-year-old boy is evaluated for his immunization needs. His medical history is notable for an orthotopic liver transplant performed two years ago due to decompensated biliary atresia. The patient has been doing well and takes daily tacrolimus and mycophenolate mofetil to prevent allograft rejection. A review of his immunization registry reveals he received all standard infant and toddler vaccines by his second birthday, but no vaccines since then. His vital signs and physical examination today are within normal limits. Which of the following vaccines should be administered to this patient at today's visit? (Select all that apply)

An obstetrician is called to evaluate a primigravid patient at 32 weeks gestation who was admitted for severe preeclampsia. Her blood pressure is 180/110 mm Hg, and laboratory results reveal a platelet count of 60,000/mm³ along with significantly elevated transaminases. Continuous fetal monitoring demonstrates a nonreassuring pattern with minimal variability and recurrent late decelerations. The maternal-fetal medicine team strongly recommends an emergent cesarean delivery to prevent maternal seizure, hepatic rupture, and fetal demise. The patient is fully awake, alert, and oriented. She accurately repeats her diagnosis and explicitly acknowledges the high risk of death to both herself and the fetus if the surgery is not performed. However, she adamantly declines the cesarean delivery, stating a deeply held personal belief that she must have a natural vaginal birth regardless of the outcome. Her husband, who is present in the room, is extremely distressed and begs the medical team to operate to save his wife and baby. Which of the following is the most appropriate next step in management?

A 15-month-old girl is brought to the clinic for a routine health maintenance visit. Her past medical history is significant for biliary atresia, for which she underwent a successful orthotopic liver transplant at age 9 months. She is currently on a daily maintenance immunosuppressive regimen with tacrolimus and mycophenolate mofetil. She has no acute symptoms, and her vital signs are within normal limits. Her immunization record shows she received all age-appropriate vaccines up until 6 months of age, but she missed subsequent doses due to her transplantation course. During the visit, her mother expresses concern that the child is only saying three words ("mama," "dada," and "cup") and is not yet putting words together into short sentences. Additionally, the mother requests a prescription for a broad-spectrum oral antibiotic to keep at home in case the child develops a fever. Which of the following is the most appropriate management plan for this patient today?

Determine the most appropriate post-exposure prophylaxis for each of the following patients presenting with a recent infectious exposure.

Match each patient scenario involving a special population with the most appropriate next step in their immunization management.

A 19-year-old college student presents to the university health clinic with a 3-day history of high fever, cough, coryza, and conjunctivitis. Today, he developed a maculopapular rash that began on his face and is spreading to his trunk. He is unvaccinated against childhood diseases due to personal beliefs. The physician suspects measles. He lives in a crowded university dormitory.

Which of the following is the most appropriate immediate public health action regarding this patient?

Match each public health scenario with the specific type of disease surveillance system it best describes.

A 67-year-old man comes to the clinic for a pre-travel consultation. He is planning a 3-week trip to rural areas of Ghana and Nigeria. His medical history is notable for hypertension, hyperlipidemia, and a thymectomy performed 10 years ago for a benign thymoma. Current medications include lisinopril and atorvastatin. Vital signs are within normal limits. Physical examination shows a well-healed midline sternotomy scar but is otherwise unremarkable. He has received all routine vaccinations, including an updated tetanus-diphtheria-pertussis (Tdap) vaccine 2 years ago. He asks about the yellow fever vaccine, which is required for entry into his destination countries. Which of the following is the most appropriate next step in management regarding the yellow fever vaccine for this patient?

A physician working in a large group practice observes that a peer colleague is consistently arriving late, resulting in rushed patient encounters and delayed review of critical laboratory results. No adverse patient outcomes have occurred yet, but the pattern of behavior is creating an unsafe clinical environment. Assuming each preceding action fails to change the colleague's behavior, arrange the following steps in the most appropriate sequence for escalating this professionalism concern, from the initial action to the final recourse.

A 12-month-old girl is evaluated during a routine health maintenance visit. She was diagnosed with DiGeorge syndrome (22q11.2 deletion syndrome) in the neonatal period after presenting with hypocalcemic tetany and a truncus arteriosus, which was surgically repaired at 1 month of age. A recent immunological workup revealed severe thymic hypoplasia with profound T-cell lymphopenia, showing an absolute CD3+ T-lymphocyte count of $200 \text{ cells/mm}^3$ (normal for age: $>1500 \text{ cells/mm}^3$). She has no current signs of infection and takes no medications other than daily calcium supplementation. The pediatrician is reviewing her immunization schedule for her 12-month visit. Which of the following immunizations is strictly contraindicated for this patient?

A 72-year-old man with a history of moderate vascular dementia is admitted to the medical ward with a severe diabetic foot infection. The surgical team recommends a below-the-knee amputation to prevent life-threatening sepsis. The patient refuses the procedure, stating, 'My foot is fine, it just needs a good wash.' The attending physician decides to evaluate the situation further, as the patient's refusal poses a high risk to his life. Arrange the following clinical and ethical steps in the most appropriate sequential order for managing this patient's refusal of care, starting from the initial bedside assessment to the final steps of identifying a substitute decision-maker.

A physician is attending a weekend community gathering when approached by a neighbor. The neighbor explains they underwent a pulmonary nodule biopsy two days prior at the hospital where the physician works. The procedure was performed by a different doctor. The neighbor is extremely anxious about the possibility of malignancy and asks the physician to log into the hospital's electronic medical record (EMR) system from their smartphone to check the pathology results. The neighbor explicitly states, "I give you my full permission to look at my medical chart." Which of the following is the most appropriate response by the physician?

Match each clinical behavior described below with the corresponding category of professional or ethical violation.

An initial primary care visit is conducted for a 26-year-old man who recently moved to the area. He has a history of fistulizing Crohn disease diagnosed two years prior. He is currently maintained on infliximab infusions, which have successfully induced and maintained clinical remission. The patient's medical history is otherwise unremarkable. A review of his immunization records indicates completion of standard early childhood vaccine series, with his last set of immunizations administered at 11 years of age. Today's physical examination reveals normal vital signs and no acute findings. In addition to administering an age-appropriate inactivated influenza vaccine, which of the following immunizations are indicated for this patient today? (Select all that apply)

An 82-year-old woman is brought to the emergency department from an assisted living facility with severe diffuse abdominal pain, fever, and confusion. Her blood pressure is 85/50 mm Hg, and her pulse is 115/min. Physical examination reveals a rigid abdomen with severe rebound tenderness. A CT scan of the abdomen shows free air under the diaphragm, consistent with a perforated viscus. The surgical team determines that she requires an emergency exploratory laparotomy. The patient is lethargic, oriented only to her name, and unable to demonstrate understanding of her clinical condition. Her medical chart includes an advance directive that appoints her eldest son as her sole healthcare proxy, but it does not specify her wishes regarding life-sustaining treatments or major surgery. The attending physician contacts the eldest son by phone. The eldest son states, "I cannot handle this responsibility right now, you need to ask my younger brother," and immediately hangs up. The younger brother is present at the bedside and states, "My mother and I talked about this exact scenario last month. She explicitly told me she would never want major surgery or life support if she got severely ill. Please just keep her comfortable." Which of the following is the most appropriate next step in management?

A 47-year-old man with end-stage liver disease due to chronic hepatitis C is brought to the emergency department with massive hematemesis. On arrival, he is lethargic, severely confused, and unable to participate in medical decision-making. The clinical team determines that he requires an emergent upper endoscopy and potentially a transjugular intrahepatic portosystemic shunt (TIPS) procedure to control the life-threatening variceal bleeding. The patient's medical record contains a valid advance directive executed one year ago that explicitly names his domestic partner as his healthcare agent. When contacted by telephone, the domestic partner states, 'He told me he never wanted any more invasive procedures if he got to this point. Please just keep him comfortable.' Shortly after, the patient's parents arrive at the hospital. They are legally married and state they are his biological next of kin. Upon learning of the partner's decision, the parents become angry and demand the medical team proceed with the life-saving procedures immediately. Which of the following is the most appropriate next step in management?

A 5-year-old boy is brought to the pediatric oncology clinic by his parents for a scheduled health maintenance visit in mid-October. The child was diagnosed with standard-risk acute lymphoblastic leukemia two years ago and is presently receiving maintenance chemotherapy consisting of daily oral 6-mercaptopurine and weekly oral methotrexate. He has had no recent fevers, chills, sick contacts, or systemic symptoms. Vital signs are within normal limits, and physical examination shows no abnormalities. A review of his immunization record reveals that he received all standard childhood vaccines up to age 2, but he has not yet received any of the routine immunizations typically administered between 4 and 6 years of age. Which of the following vaccines is absolutely contraindicated for this patient at this time?

Match the following clinical scenarios regarding informed consent and refusal of care to the appropriate ethical or legal principle that guides the physician's required action.