Tüm alıştırma soruları

A 12-month-old boy is evaluated in the primary care clinic for a routine health maintenance examination. His mother reports he has been doing well since a hospital admission 10 weeks ago. During that hospitalization, he was treated for 6 days of high fever, bilateral nonexudative conjunctivitis, mucosal changes, and cervical lymphadenopathy. His treatment included an infusion of intravenous immunoglobulin (IVIG) and high-dose oral aspirin. His immunizations were fully up to date prior to the illness. Growth parameters are normal. Physical examination today shows a healthy, active child with no significant findings. Which of the following is the most appropriate immunization strategy for this patient today?

A 65-year-old woman is evaluated in the emergency department for three days of worsening right-sided flank pain, subjective fever, and profound weakness. Her past medical history is significant for hypertension and type 2 diabetes mellitus. On physical examination, her temperature is $38.9^\circ C$ ($102.0^\circ F$), blood pressure is $88/55$ mmHg, pulse is $118$/min, and respiratory rate is $26$/min. The patient appears lethargic but is arousable. Mucous membranes are dry, and there is marked tenderness to percussion over the right costovertebral angle.

Laboratory studies reveal the following:

Arterial blood gas analysis on room air shows:

Based on the provided laboratory data, which of the following combinations best characterizes this patient's current acid-base status?

Match each clinical scenario regarding medical decision-making and refusal of care to the ethical principle or legal standard that best justifies honoring the decision.

A travel and tropical medicine clinic evaluates several individuals presenting for pre-travel consultation and occupational health screening. Identify the most appropriate immunization recommendation for each individual described below.

A 74-year-old man is evaluated in the hospital for worsening right foot pain and fever. He has a history of type 2 diabetes mellitus, peripheral artery disease, and mild major neurocognitive disorder. Evaluation reveals a gangrenous right foot ulcer complicated by osteomyelitis. The surgical team recommends an urgent below-the-knee amputation to prevent overwhelming sepsis. During the preoperative discussion, the patient is alert and oriented, demonstrates a clear understanding of the risks and benefits of the procedure, and correctly states that without surgery, he will likely die. He signs the informed consent form.

The following morning, as the patient is being prepared for the operating room, he becomes tearful and tells the medical team, "I have changed my mind. I cannot live without my leg. I would rather let the infection take its course." The attending physician evaluates the patient; he remains alert, oriented, and calmly reiterates his understanding that refusing the surgery will likely lead to his death. The patient's son, who is his legally appointed healthcare proxy, arrives and insists that the surgery proceed. The son states, "He has dementia and he already signed the papers yesterday. He is just scared. As his proxy, I authorize the surgery."

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

Review the following clinical scenarios involving challenges to medical decision-making and consent. Match each patient presentation with the legal or ethical principle that most appropriately dictates the physician's required course of action.

A 24-year-old primigravid woman at 28 weeks gestation presents to the obstetric clinic in mid-October for a routine prenatal visit. She has no significant past medical history and her pregnancy has been uncomplicated to date. Her vaccination records from childhood are unavailable, and she states she has not received any immunizations since graduating high school. Physical examination shows a fundal height consistent with dates and normal fetal heart tones. Which of the following immunizations should be administered to this patient today? (Select all that apply)

A 68-year-old woman is admitted to the intensive care unit with severe septic shock secondary to ischemic bowel disease. She is intubated, mechanically ventilated, and deeply sedated, rendering her without decision-making capacity. The surgical team determines that an emergent exploratory laparotomy is required to improve her chances of survival. The patient does not have an advance directive, and there is no record of a legally appointed healthcare proxy or durable power of attorney for healthcare in her medical file. The clinical social worker locates several family members in the waiting room who all wish to be involved in her care. According to the standard statutory hierarchy of surrogate decision-makers in most US jurisdictions, arrange the following family members in the correct order of priority to provide informed consent for the surgery, from highest priority to lowest priority.

A 29-year-old primigravida at 40 weeks gestation is admitted to the labor and delivery unit in active labor. Continuous fetal heart rate monitoring reveals recurrent late decelerations with absent beat-to-beat variability, indicating severe fetal distress. The attending physician informs the patient that an emergency cesarean delivery is immediately necessary to prevent fetal asphyxia and potential demise. The patient is fully alert, oriented to person, place, and time. She clearly articulates an understanding of the clinical situation and the high likelihood of fetal death if surgery is not performed. However, she adamantly refuses the cesarean delivery, stating, "I firmly believe that surgery violates my body, and I will only accept a natural vaginal birth." Her husband, who is present at the bedside, is extremely distressed and tells the physician, "Please save our baby. I am the father and I give you full permission to do the surgery." Which of the following is the most appropriate next step in management?

A 68-year-old man is admitted to the hospital for community-acquired pneumonia. The internal medicine resident prescribes a daily dose of levofloxacin. However, due to a calculation error, the resident orders a dose that is twice the recommended maximum. The medication is dispensed by the pharmacy and administered by the nurse. The patient experiences mild, self-limiting nausea but remains hemodynamically stable with a normal electrocardiogram. The resident discovers the error the following morning during chart review. When the resident discusses the event with the attending physician, the attending says, "Since the patient suffered no serious harm and is clinically stable, let's just adjust the dose for today. There is no need to mention this to the patient, as it will only cause unnecessary anxiety." Which of the following is the most appropriate next step for the resident?

An 18-month-old girl is brought to the clinic by her adoptive parents to establish care. The family recently immigrated to the United States. The child was diagnosed with perinatally acquired HIV infection in her country of origin and was started on an antiretroviral therapy regimen 3 months ago. She appears active and playful today, with no signs of acute illness. Medical records show she received all recommended childhood immunizations up to 6 months of age, but none thereafter. Recent laboratory studies show a CD4 $^+$ T-lymphocyte count of $400$ cells/mm $^3$ and a CD4 $^+$ T-lymphocyte percentage of $12\%$. Which of the following is the most appropriate approach to this patient's immunizations today?

A 28-year-old man presents to the clinic complaining of a painless, enlarging lump in his right neck that he noticed two months ago. He also reports drenching night sweats and a 5-kg (11-lb) weight loss over the past six weeks. On physical examination, a 3.5-cm, firm, rubbery, mobile lymph node is palpated in the right anterior cervical chain. The remainder of the examination is unremarkable. Basic laboratory studies reveal a normocytic anemia and an elevated erythrocyte sedimentation rate. The physician suspects a hematologic malignancy.

Arrange the following steps in the most appropriate clinical sequence for the definitive diagnosis, staging, and initial management of this patient.

An anesthesiologist is observed pocketing partial vials of fentanyl during surgery and later appears drowsy and uncoordinated in the staff lounge. Arrange the following steps in the correct chronological sequence for addressing and managing this suspected physician impairment according to professional and ethical guidelines.

Match each adult patient clinical profile to the specific indicated vaccine or vaccine series based on their underlying medical condition according to current immunization guidelines.

A couple visits the pediatric clinic seeking advice regarding their 9-month-old son. They are planning to travel to Southeast Asia for a month-long family visit, departing in 2 weeks. The region they are visiting is currently experiencing a large, ongoing measles outbreak. The infant was born at term, has no significant past medical history, and is up to date on all routine childhood immunizations. His physical examination today is unremarkable. Which of the following is the most appropriate recommendation regarding measles prophylaxis for this patient?

A 14-year-old boy is brought to the emergency department by his 24-year-old cousin after falling from a tree. The patient is in agonizing pain and is cradling his left arm. Physical examination reveals a grossly deformed left elbow. The left hand is noticeably pale, cold to the touch, and pulseless. Plain radiographs demonstrate a severely displaced supracondylar humerus fracture. The on-call orthopedic surgeon evaluates the patient and determines that immediate surgical reduction is required to prevent permanent ischemic loss of the limb. The hospital staff attempts to contact the patient's parents, but they are currently on a cruise ship in a remote location and cannot be reached despite multiple efforts. The young patient is distressed, crying, and begs the physician to fix his arm. Which of the following is the most appropriate next step in obtaining consent for the surgery?

A 72-year-old man is admitted to the intensive care unit with severe septic shock and acute respiratory distress syndrome. He is intubated, sedated, and lacks decision-making capacity. The critical care team must make immediate decisions regarding the initiation of renal replacement therapy. The medical record contains no advance directive or designated healthcare proxy. Several individuals who care about the patient are present in the family meeting room, but they disagree on the goals of care. According to the standard statutory hierarchy of surrogate decision-makers in most US jurisdictions, arrange the following individuals in the correct legal order of priority to act as the primary decision-maker, from highest priority (first) to lowest priority (last).

A 62-year-old woman is admitted to the hospital after suffering a massive left middle cerebral artery ischemic stroke. She is stabilized medically but has severe global aphasia and profound right hemiplegia. Repeated assessments show she is entirely unable to comprehend medical information, communicate her wishes, or demonstrate decision-making capacity. A formal swallowing evaluation reveals severe oropharyngeal dysphagia with a high risk of aspiration, and the medical team determines that placement of a percutaneous endoscopic gastrostomy (PEG) tube is indicated for long-term nutritional support. The patient has a legally executed advance directive from two years ago that specifically appoints her longtime neighbor and close friend as her durable power of attorney for healthcare. The document does not explicitly mention preferences regarding artificial nutrition. When approached by the medical team, the friend requests that the PEG tube be placed. Shortly after, the patient's biological adult daughter, who lives out of state and visits annually, arrives at the hospital and adamantly demands that the PEG tube not be placed. The daughter insists that as the patient's closest living blood relative, she is the rightful decision-maker. Which of the following is the most appropriate next step in management?

A 5-year-old boy presents to the outpatient clinic for a pre-kindergarten health maintenance examination. His mother states he is doing well overall, though he recently had a flare-up of his underlying minimal change disease. Four weeks ago, he was started on oral prednisone at a dose of $2\text{ mg/kg}$ daily. He is currently on day $28$ of this regimen, with plans to begin tapering next week. His other daily medications include an age-appropriate dose of calcium and vitamin D supplementation. Review of his immunization registry reveals that he is up to date with all vaccines recommended through $18$ months of age, but he has not yet received his preschool vaccine boosters. He is currently due for his $5$ th dose of DTaP, $4$ th dose of IPV, $2$ nd dose of MMR, and $2$ nd dose of varicella vaccines. Vital signs today are within normal limits for his age, and physical examination is unremarkable. Which of the following is the most appropriate recommendation regarding his immunizations today?

A 15-month-old girl is evaluated in the pediatric transplant clinic for a routine follow-up visit. Three months ago, she underwent a deceased-donor renal transplantation for congenital nephrotic syndrome. She is currently maintained on an immunosuppressive regimen of tacrolimus and mycophenolate mofetil. Her medical records indicate that she received all standard routine immunizations at 2, 4, and 6 months of age, but she missed her 12-month well-child visit due to her hospitalization and surgery. Which of the following vaccines are indicated and safe to administer at this visit? (Select all that apply)