Tüm alıştırma soruları

A 45-year-old man is diagnosed with a first episode of severe, non-psychotic major depressive disorder. He is medically healthy and has no previous psychiatric treatment history. According to standard stepped-care guidelines for major depressive disorder, arrange the following therapeutic management steps in the most appropriate chronological sequence, assuming the patient exhibits only a partial response to each consecutive intervention.

A 78-year-old woman with a 6-year history of Alzheimer disease is brought to the clinic for a routine follow-up. Her family asks the physician about the natural progression of the disease to help them prepare for future care needs. The physician explains the typical chronological decline expected in this condition. Arrange the following clinical features in the correct chronological sequence that they typically appear during the natural course of Alzheimer disease, from earliest to latest.

An emergency department physician evaluates a 31-year-old man who presents with a 4-week history of severe depressed mood, hypersomnia, and a 6-kg (13.2-lb) weight gain. He recently took a leave of absence from his job as an accountant because he "lacks the mental energy to look at spreadsheets." Review of his electronic medical record reveals a prior hospitalization one year ago for acute agitation, pressured speech, and decreased need for sleep lasting 10 days; during that admission, he was convinced he had discovered a secret formula for infinite energy. He currently takes no medications and has no other medical conditions. Vital signs are within normal limits. Laboratory evaluation shows a normal comprehensive metabolic panel, negative urine toxicology screen, and a normal thyroid-stimulating hormone (TSH) level. The physician is formulating a comprehensive management plan. Which of the following statements regarding the diagnosis and management of this patient are correct? (Select all that apply)

A 30-year-old woman is evaluated in the clinic 2 weeks after surviving a severe house fire. She reports experiencing frequent, distressing nightmares about the fire, hypervigilance, and a new inability to experience positive emotions. She actively avoids anything that reminds her of the event, including cooking and candles. Her past psychiatric history is significant for Bipolar I disorder, which is currently stable, and a history of treatment-resistant depression for which she takes phenelzine. She asks what can be done to manage her current distressing symptoms. Which of the following are the most appropriate management steps for this patient? (Select two)

A 46-year-old woman is evaluated in the psychiatric clinic for an acute bipolar depressive episode. She has a history of bipolar I disorder with multiple past hospitalizations for severe mania. Her medical history includes hypertension, chronic lower back pain, and Hashimoto thyroiditis. Her current medications are lisinopril, naproxen (taken daily), and levothyroxine. Laboratory studies show a normal serum creatinine with an estimated glomerular filtration rate (eGFR) of 95 mL/min/1.73m² and a normal thyroid-stimulating hormone (TSH) level. The psychiatrist plans to initiate lithium carbonate for her current depressive episode and for long-term maintenance.

Which of the following are appropriate steps in the management of this patient prior to or during the initiation of lithium therapy? (Select all that apply)

A 29-year-old woman presents to the primary care clinic reporting a 6-week history of depressed mood, profound fatigue, and an inability to concentrate at work. She notes that her appetite has significantly increased, leading to a 4-kg (8.8-lb) weight gain. She often sleeps for 12 hours a night but still wakes up feeling unrefreshed, and states that her arms and legs frequently feel "like lead." Her medical history is unremarkable, and she takes no medications. Her vital signs are within normal limits. She recalls experiencing a similar episode of depression during her first year of college, which eventually resolved without treatment. The physician is considering initiating pharmacotherapy for her symptoms. Which of the following is the most appropriate next step in management?

A 23-year-old woman comes to the clinic reporting profound sadness, low energy, and poor concentration over the past 6 weeks. She sleeps up to 12 hours a day and has lost interest in her usual hobbies. Her medical history is notable for a psychiatric hospitalization three years ago. At that time, she experienced a two-week period of feeling 'invincible,' requiring only 2 to 3 hours of sleep per night, and impulsively spending her entire savings on luxury handbags. Her current vital signs and physical examination are unremarkable. Laboratory results, including a complete blood count, comprehensive metabolic panel, and thyroid-stimulating hormone (TSH) level, are within normal limits. Which of the following is the most appropriate initial medication for this patient's current symptoms?

A 21-year-old male university student is evaluated in the student health center for worsening fatigue, hypersomnia, and feelings of worthlessness over the past month. He states that he is failing his classes and feels "it would be better if I just went to sleep and never woke up." Review of his medical record reveals a prior psychiatric hospitalization at age 19 for a week-long episode of decreased need for sleep, grandiosity, and reckless spending. He currently takes no medications and uses no illicit substances. The physician is formulating a comprehensive management plan. Which of the following statements regarding his diagnosis and pharmacological management are correct? Select all that apply.

During a routine wellness visit, a 28-year-old female patient presents with vague somatic complaints. She arrives wearing a deeply plunging neckline and a theatrical feather boa. Throughout the interview, she is exceptionally flirtatious with the male medical student and refers to the attending physician as her "absolute favorite doctor in the entire universe" despite this being their first meeting. Her speech is impressionistic and lacks detail; when asked to describe her diet, she says it is "glorious and perfectly balanced" without providing any specifics. Her medical history is unremarkable. Which of the following statements regarding this patient's most likely underlying psychiatric condition are true? (Select all that apply)

A 45-year-old man with no prior psychiatric history is diagnosed with Major Depressive Disorder. Over the next two years, his condition proves difficult to manage, requiring escalating interventions based on his varying levels of therapeutic response at each stage. According to evidence-based guidelines for stepped-care psychiatric management, arrange the following clinical interventions in the most appropriate chronological order, progressing from initial presentation to the management of severe treatment-resistant depression.

A 21-year-old college student presents to the student health center seeking help for extreme distress. For the past 4 months, he has experienced intrusive, distressing fears of contracting a fatal pathogen, leading him to wash his hands with bleach up to 30 times a day. He acknowledges that his fears are likely exaggerated but states the anxiety is unbearable unless he washes. His hands are severely excoriated and erythematous. Two days ago, an urgent care physician diagnosed a soft tissue infection on his right hand (confirmed methicillin-resistant Staphylococcus aureus) and prescribed a 10-day course of oral linezolid. During the interview, the patient appears visibly depressed and reports feeling hopeless. Upon further psychiatric history, he reveals that a year ago, he had a distinct one-month period where he slept only 2 hours nightly, spoke so rapidly that friends could not understand him, and engaged in reckless hypersexual behavior. He is not taking any other medications. Which of the following are the most appropriate management steps for his psychiatric symptoms? (Select 2 options)

An evaluation is requested for a 47-year-old female patient who desires reliable contraception. She reports a 9-month history of erratic, heavy menstrual cycles. Menses occur unpredictably every 3 to 6 weeks, lasting up to 12 days, and are accompanied by the passage of large clots. The patient's medical history includes chronic hypertension and tobacco use disorder, smoking approximately 20 cigarettes per day. Current medications include lisinopril. Vital signs show a blood pressure of 144/92 mmHg, pulse of 82/min, and a body mass index of $35\text{ kg/m}^2$. Pelvic examination demonstrates a parous, normal-appearing cervix and a globally enlarged, non-tender uterus. A urine pregnancy test is negative. Laboratory studies indicate a hemoglobin level of 9.8 g/dL. Pelvic ultrasonography reveals a heterogeneous endometrial echo complex measuring $16\text{ mm}$ in thickness with cystic changes. The patient is interested in starting a contraceptive method that will also alleviate her heavy bleeding. Which of the following is the most appropriate next step in the care of this patient?

A pediatrician is evaluating a 4-year-old boy who has developed a progressively unsteady gait over the past twelve months. According to his medical records, he achieved independent ambulation at 15 months of age but has recently begun to stumble frequently. On neurological examination, he demonstrates truncal instability and a wide-based stance. When asked to follow a finger with his eyes, horizontal nystagmus and delayed saccades are observed. The physician also notes the presence of dilated, tortuous superficial vessels on the bulbar conjunctivae of both eyes. A subsequent blood panel shows a markedly elevated alpha-fetoprotein level alongside a quantitative IgA deficiency. Which of the following statements regarding the patient's underlying syndrome are correct? (Select 2 that apply)

An otherwise healthy $30$-year-old woman presents to the clinic complaining of a $3$-day history of worsening dull, bilateral lower abdominal pain and a new onset of malodorous, yellowish vaginal discharge. She reports no fever, chills, nausea, or vomiting. Her medical history is unremarkable. She has a copper intrauterine device (IUD) that was inserted $3$ years ago for contraception. She recently became sexually active with a new male partner. Vital signs include a temperature of $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure of $120/78\text{ mm Hg}$, and pulse of $82/\text{min}$. Pelvic examination reveals a visually normal cervix with visible IUD strings and moderate purulent discharge at the cervical os. Bimanual examination elicits pronounced cervical motion tenderness and bilateral adnexal tenderness without palpable masses or fullness. A urine pregnancy test is negative. Which of the following is the most appropriate next step in the management of this patient?

A $9$-year-old female patient is evaluated in the pediatric acute care unit due to progressive dyspnea that began yesterday. She has a documented history of moderate persistent asthma, currently managed with a daily inhaled corticosteroid and a short-acting beta-agonist as needed. Over the previous $24$ hours, she has required her rescue inhaler every two hours with minimal relief. Vital signs on presentation show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $110/70\text{ mm Hg}$, heart rate of $142/\text{min}$, and respiratory rate of $44/\text{min}$. Oxygen saturation is $91\%$ on ambient air. The patient appears highly anxious, sits leaning forward, and speaks only in two-word phrases. Examination highlights significant intercostal and suprasternal retractions. Auscultation of the chest reveals widespread tight wheezing and notably reduced air entry in all lung fields. Supplemental oxygen is applied, and the patient receives a systemic dose of intravenous methylprednisolone alongside three back-to-back treatments of nebulized albuterol combined with ipratropium bromide. One hour later, reassessment shows a heart rate of $150/\text{min}$ and a respiratory rate of $40/\text{min}$. She remains awake and responsive but continues to exhibit severe accessory muscle use and diminished breath sounds. Which of the following is the most appropriate next step in management?

An oncologist refers a 58-year-old patient to the gynecology clinic after she reports a recent episode of dark red vaginal spotting. She underwent breast-conserving surgery and radiation for early-stage hormone receptor-positive breast cancer three years ago. Since her surgery, she has been maintained on adjuvant tamoxifen therapy. The patient's last menstrual period occurred naturally at age 52. She denies pelvic pain, dysuria, or systemic symptoms. Her body mass index is $26 \text{ kg/m}^2$. Speculum examination demonstrates pale, thinned vaginal walls with a small amount of blood in the vaginal vault. The cervix appears grossly normal without lesions. Which of the following is the most appropriate next step in management?

A 28-year-old G2P1 woman at 36 weeks gestation presents to the labor triage unit complaining of mild, irregular abdominal cramping. Two hours ago, she was given intravenous fentanyl at an outside clinic for severe back pain. Her prenatal course was notable for a second-trimester anatomy ultrasound revealing a bilobed placenta. Shortly after admission, she experiences a sudden rush of clear fluid from her vagina, followed immediately by a gush of bright red blood. She denies any sharp or severe abdominal pain. Maternal vital signs are: blood pressure 118/76 mmHg, heart rate 86/min, and temperature 37.1°C (98.8°F). The abdomen is soft, non-tender, and without guarding. Fetal heart rate monitoring demonstrates a baseline of 150/min. The tracing exhibits a smooth, undulating, sine-wave-like pattern with a frequency of 3 to 4 cycles per minute, completely absent beat-to-beat variability, and no accelerations. This pattern has persisted for 25 minutes. A sterile speculum examination shows active bleeding pooling in the posterior fornix. Which of the following is the most appropriate next step in management?

A 5-month-old female infant is brought to a primary care clinic by her parents due to rapid breathing and poor feeding. She developed nasal congestion and a mild cough three days ago. Over the past 24 hours, the cough has deepened, and she has consumed only one-third of her usual breast milk volume. She was born at term, and her immunizations are up to date. Vital signs show a temperature of $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), a heart rate of $165/\text{min}$, and a respiratory rate of $68/\text{min}$. Room air pulse oximetry demonstrates an oxygen saturation of $88\%$. Physical examination reveals an irritable infant with prominent nasal flaring and significant subcostal retractions. Chest auscultation reveals diffuse fine crackles and scattered expiratory wheezes throughout both lung fields. The physician arranges for immediate transfer to the pediatric emergency department. Which of the following interventions are appropriate in the initial management of this patient? (Select all that apply)

A primigravid patient at $40$ weeks and $3$ days of gestation is admitted to the labor and delivery unit for an elective induction of labor. An induction is currently underway using a continuous intravenous oxytocin infusion. Her epidural analgesia is functioning well and providing adequate pain relief. Her vital signs are within normal limits, with a blood pressure of $118/74$ mm Hg, a heart rate of $82$/min, and a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$). Routine admission laboratory studies reveal a hemoglobin of $10.5$ g/dL and a platelet count of $165,000/\text{mm}^3$. A recent pelvic examination demonstrates cervical dilation of $6$ cm and effacement of $100\%$, with the fetal vertex at $0$ station. External tocodynamometry records uterine contractions occurring every $2$ to $3$ minutes. Cardiotocography displays a baseline fetal heart rate of $128$/min accompanied by minimal variability. The tracing also shows gradual, symmetric drops in the fetal heart rate to a nadir of $115$/min. The onset of each drop consistently begins after the peak of the associated contraction, and the heart rate returns to baseline only after the uterine tone has normalized. These episodes occur with nearly every contraction. Which of the following is the most appropriate next step in management?

An 8-year-old boy is evaluated in the emergency department for severe shortness of breath and wheezing that began four hours ago. He has a history of moderate persistent asthma and ran out of his controller medications a week ago. His respiratory rate is 45/min, and oxygen saturation is 88% on room air. Physical examination reveals severe suprasternal and subcostal retractions. Auscultation demonstrates diminished air entry with faint, high-pitched expiratory wheezes globally. The patient is visibly fatigued and speaking in single words. Arrange the following interventions in the most appropriate step-wise sequence for managing this patient's acute respiratory compromise, from the immediate first-line therapy to advanced refractory management.