Tüm alıştırma soruları

A 68-year-old man is evaluated in the emergency department for severe right thigh pain and swelling that began 48 hours ago without preceding trauma. He has a history of chronic lymphocytic leukemia (CLL), for which he is currently on observation. His other medical problems include hypertension and type 2 diabetes mellitus. He has no personal or family history of bleeding disorders and has undergone several major surgeries in the past without abnormal bleeding. Vital signs show a heart rate of $112/\text{min}$ and blood pressure of $105/65 \text{ mmHg}$. Physical examination reveals a massive, tense, ecchymotic swelling over the anterior right thigh extending to the knee.

Laboratory studies reveal:
Hemoglobin: $7.4 \text{ g/dL}$
Mean corpuscular volume: $88 \text{ } \mu\text{m}^3$
Platelet count: $310,000/\text{mm}^3$
Prothrombin time (PT): $12.1 \text{ s}$ (Reference: $11-14 \text{ s}$)
Activated partial thromboplastin time (aPTT): $82 \text{ s}$ (Reference: $25-35 \text{ s}$)

A 1:1 mixing study of the patient's plasma with normal pooled plasma is performed. Immediately after mixing, the aPTT is $37 \text{ s}$. After 2 hours of incubation at $37^\circ\text{C}$, the aPTT is $74 \text{ s}$.

Which of the following is the most likely diagnosis?

A 28-year-old man comes to the clinic for the evaluation of a painless penile ulcer. Laboratory testing confirms a diagnosis of primary syphilis. He receives an intramuscular injection of benzathine penicillin G in the office. The patient is highly distressed about the diagnosis and tells the physician, "Please do not tell anyone about this, not even the health department. It would ruin my reputation if this gets out." Which of the following is the most appropriate next step regarding the patient's request?

A 54-year-old man is brought to the emergency department with a massive upper gastrointestinal hemorrhage. His blood pressure is 85/50 mm Hg, and his heart rate is 120/min. His hemoglobin is 6.2 g/dL. The physician recommends an urgent blood transfusion, aggressive fluid resuscitation, and an emergent upper endoscopy. The patient is alert, oriented to person, place, and time, and communicates his wishes clearly. He states that he is a Jehovah's Witness and adamantly refuses the blood transfusion, although he consents to the endoscopy and the administration of intravenous crystalloids. He demonstrates a clear understanding that refusing the blood transfusion will likely result in his death. His wife, who is not a Jehovah's Witness, is at the bedside and pleads with the physician to administer the blood, stating, "He is just confused from losing so much blood. Please do whatever it takes to save him." The patient calmly reiterates his refusal. Which of the following is the most appropriate next step in management?

A 62-year-old woman is evaluated in the ambulatory clinic for progressive fatigue, diffuse muscle aches, and depressed mood over the past month. The physician, having diagnosed three patients with hypothyroidism who presented with identical symptoms earlier that same week, immediately suspects that this patient also has hypothyroidism. The physician orders a thyroid-stimulating hormone (TSH) level and a free T4 level but decides to forgo a comprehensive metabolic panel to save costs. The patient is sent home to await the laboratory results. Two days later, the thyroid function tests are reported as normal. The patient subsequently presents to the emergency department with severe dehydration and confusion, and is found to have severe hypercalcemia secondary to an undiagnosed malignancy. Which of the following cognitive biases most likely contributed to the physician's initial diagnostic error in the clinic?

A 68-year-old man is admitted to the intensive care unit for management of severe pneumonia. During a busy shift change, the outgoing nurse verbally asks the incoming nurse to administer the patient's scheduled antibiotic. The incoming nurse quickly retrieves a vial from the automated dispensing cabinet. Due to a similarity in vial appearance and storage proximity, the nurse accidentally administers a paralytic agent instead of the antibiotic. The error is recognized almost immediately, and the patient is promptly intubated and stabilized without long-term harm. The hospital safety committee is notified of this adverse event.

Which of the following is the most appropriate next step for the safety committee to take?

A 68-year-old woman with a history of heart failure and chronic obstructive pulmonary disease (COPD) is brought to the emergency department with acute dyspnea. The triage nurse evaluates the patient, notes an oxygen saturation of 88% on room air, and enters a chief complaint of "COPD exacerbation" into the electronic health record. The evaluating physician sees this triage note, auscultates bilateral wheezing, and immediately initiates treatment with inhaled bronchodilators and systemic corticosteroids. An hour later, laboratory and imaging results return, revealing a markedly elevated B-type natriuretic peptide (BNP) level of 1,200 pg/mL and a chest radiograph showing cardiomegaly with prominent bilateral interstitial infiltrates. Despite these objective findings strongly indicating acute decompensated heart failure, the physician interprets them as "baseline chronic changes" and continues aggressive COPD management without administering diuretics. Which of the following cognitive biases most likely led to this physician's diagnostic error?

A 78-year-old woman is brought to the emergency department by her daughter after a fall at home. The patient has a history of mild vascular dementia and hypertension. Physical examination reveals a right Colles fracture and several large, distinct ecchymoses on her upper arms and torso in various stages of healing. When the daughter briefly leaves the room, the patient becomes visibly anxious and tearful. She tells the physician, "My daughter gets so overwhelmed caring for me. She sometimes grabs me too hard or pushes me when she is angry. Please, I beg you not to tell anyone. If you do, they will put me in a nursing home and I will never see her again." The patient is fully oriented, demonstrates a clear understanding of her situation, and is deemed to have intact clinical decision-making capacity. Which of the following is the most appropriate next step in management?

A 72-year-old man on warfarin for atrial fibrillation is brought to the emergency department with altered mental status. A non-contrast head CT reveals a large acute subdural hematoma. The emergency department physician appropriately orders intravenous vitamin K and prothrombin complex concentrate. Due to severe department overcrowding and boarding, the patient is rapidly transported to the intensive care unit during a nursing shift change. The emergency department nurse provides a brief verbal report to the receiving nurse but inadvertently omits mentioning the pending medication orders. The intensive care unit team assumes the reversal agents were already administered. Three hours later, the patient's neurologic status acutely worsens, and the omission is discovered. The patient requires emergent surgical decompression and suffers permanent neurologic deficits. A multidisciplinary committee is convened to perform a Root Cause Analysis of this sentinel event. Which of the following represents the most appropriate conclusion and corresponding action plan for this committee?

A 55-year-old oncologist has been treating a 50-year-old woman for stage III breast cancer over the past 3 years. The patient is now in complete remission and is transitioning her routine care back to her primary care provider. During her final clinic visit, the patient expresses profound gratitude and presents the oncologist with a $15,000 personal check made out directly to his specific oncology research laboratory. The patient states, 'Your research gave me my life back, and I want to ensure your lab can stay open to help others.' The physician's laboratory has recently lost significant grant funding and is at risk of laying off staff. Which of the following is the most appropriate course of action for the physician?

A 65-year-old man is admitted to the intensive care unit for management of an acute pulmonary embolism. The attending physician enters an order in the electronic health record (EHR) for a continuous intravenous heparin infusion at 1,000 units/hour. When setting up the infusion, the nurse manually programs the smart pump but accidentally enters 10,000 units/hour due to a double-bounce of the keypad's zero button. Four hours later, the patient develops gross hematuria and epistaxis. Stat laboratory results reveal an unmeasurable partial thromboplastin time (PTT). The infusion is immediately stopped, and the patient is successfully stabilized with protamine sulfate. The hospital risk management team convenes a multidisciplinary committee to evaluate the sentinel event.

Which of the following proposed actions represents the most effective systems-based intervention to prevent a recurrence of this specific error?

A 38-year-old female surgeon presents to a primary care clinic to establish care as a new patient. During the social history interview, she tearfully admits to consuming a bottle of wine every night and occasionally taking unprescribed oxycodone to cope with severe anxiety and burnout. She states that she voluntarily began a 3-month administrative leave of absence from her hospital duties two weeks ago to "sort out her mental health and get better." She explicitly asks the primary care physician to keep her substance use completely confidential, expressing intense fear of permanently losing her medical license and career. She lives alone, denies any suicidal or homicidal ideation, and states she has absolutely no intention of returning to the operating room or seeing any patients until she is fully recovered and her leave is officially over. Which of the following is the most appropriate action by the primary care physician regarding the disclosure of this patient's medical information?

A 42-year-old man is brought to the emergency department by his ex-wife after experiencing two hours of severe, crushing, substernal chest pain. An electrocardiogram reveals prominent ST-segment elevations in leads V1 through V4. The physician informs the patient that he is having an acute anterior myocardial infarction and urgently requires percutaneous coronary intervention (PCI). The patient, who has a documented history of bipolar I disorder, is pacing the room, speaking rapidly, and demonstrating flight of ideas. He states, "I hear you, doc. My heart pipes are clogged and I could drop dead right now. But I am on the verge of discovering a new source of unlimited energy! I have a meeting with the President in two hours. I cannot stay here. I will fix my heart with my mind later." He aggressively attempts to pull out his intravenous lines. His ex-wife, who divorced him five years ago and has no legal medical power of attorney, demands that the medical team let him leave, stating, "He is terrified of hospitals and would never want any procedure done." Which of the following is the most appropriate next step in management?

A 45-year-old primary care physician is managing a busy outpatient clinic. Throughout the day, the physician encounters several situations involving complex confidentiality and privacy issues. In which of the following scenarios is the physician legally required or ethically obligated to disclose patient information to appropriate authorities or third parties without the patient's explicit consent? (Select all that apply)

A 45-year-old internist has been serving as the primary care physician for his 82-year-old mother for the past four years. Her medical history is significant for poorly controlled hypertension, type 2 diabetes mellitus, and mild cognitive impairment. Recently, her condition has deteriorated; she has missed several doses of her medications and frequently cancels follow-up appointments. During a home visit today, the mother insists she feels entirely fine. She explicitly refuses to take any further doses of her diabetes medication, stating, "I am old enough to decide what goes into my own body." The physician is highly frustrated, deeply worried for her safety, and feels overwhelmed by her resistance. Which of the following is the most appropriate next step for the physician?

A hospital quality improvement committee is conducting a root cause analysis following a sentinel event involving a wrong-site surgical procedure. The investigation identifies several contributing factors, and the multidisciplinary team proposes multiple corrective actions. Match each finding or proposed intervention with its appropriate patient safety classification.

A 55-year-old woman presents to the emergency department with a 2-hour history of retrosternal chest pain. The triage nurse documents 'likely severe acid reflux' in the electronic triage note because the patient recently ate a large, spicy meal. The attending physician reads this note prior to evaluating the patient. During the clinical encounter, the physician focuses the history exclusively on gastrointestinal symptoms and performs a brief abdominal exam. The physician confidently diagnoses gastroesophageal reflux disease without considering acute coronary syndrome or ordering an electrocardiogram and cardiac biomarkers. The patient is discharged with a prescription for a proton pump inhibitor but returns the next day with a massive myocardial infarction. Which of the following cognitive biases best characterize the physician's decision-making errors in this scenario? (Select all that apply)

A 14-year-old girl comes to the outpatient clinic requesting a prescription for oral contraceptives. During a confidential interview without her parents present, she reveals that she has been sexually active with her 22-year-old boyfriend for the past three months. She currently complains of increased vaginal discharge and dysuria over the last week. A nucleic acid amplification test is positive for $Neisseria$ $gonorrhoeae$. The patient begs the physician not to tell her parents about her diagnosis, the contraception, or her boyfriend, stating, "My parents will be furious if they find out." Which of the following actions regarding confidentiality and disclosure are appropriate and legally mandated for this physician? (Select all that apply)

A multidisciplinary Root Cause Analysis (RCA) committee is reviewing a sentinel event where a pediatric patient received a severe overdose of a high-alert medication due to an infusion pump programming error. During the investigation, the committee identifies several contributing factors and proposes multiple corrective action plans. Match each identified factor or proposed intervention to its correct classification within the patient safety and human factors engineering framework.

A family medicine physician is attending a weekend family gathering. His sister asks him to write a prescription for a short course of oral antibiotics for her 7-year-old daughter, who has been complaining of a sore throat and subjective fever since the morning. The sister states that the child's regular pediatrician's office is closed for the weekend. The child appears comfortable, is drinking fluids well, and is playing with other children in the yard. Which of the following is the most appropriate action by the physician?

An inpatient pharmacy technician mistakenly stocks an automated dispensing cabinet drawer with concentrated potassium chloride instead of normal saline flush syringes. Several hours later, a floor nurse retrieves a vial, identifies the high-alert label, and averts the error before administration. The hospital's patient safety committee is alerted to this incident. Which of the following represents the most appropriate next step for the committee?