Tüm alıştırma soruları

A 36-year-old man comes to the clinic for a follow-up visit. Two weeks ago, he was diagnosed with HIV infection during an evaluation for generalized lymphadenopathy and chronic fatigue. His CD4 count is 310 cells/mm³ and his HIV viral load is 45,000 copies/mL. He was subsequently started on antiretroviral therapy. The patient is married and states that his wife is his only sexual partner. When asked if he has discussed the diagnosis with his wife, he becomes visibly anxious and says, 'I can't tell her. She will leave me and take our children. I promise I will always use condoms from now on, so she won't be at risk. Please don't tell her.' The physician spends considerable time counseling the patient about the critical importance of partner notification, the limitations of barrier contraception, and offers to be present to help facilitate the conversation. The patient adamantly refuses and explicitly forbids the physician from contacting his wife. Which of the following is the most appropriate next step by the physician?

A hospital quality improvement committee is reviewing a series of adverse events in the emergency department. Several elderly patients who presented with acute confusion were quickly diagnosed with urinary tract infections (UTIs) based on mildly abnormal urinalysis results. The treating physicians subsequently stopped their diagnostic workup, resulting in delayed diagnoses of more serious conditions such as subdural hematoma and occult sepsis. The committee identifies premature closure and anchoring bias as the primary drivers of these errors. To mitigate these cognitive biases, the committee wants to implement human factors engineering solutions that utilize strong, system-level constraints and automation, rather than relying on human memory or vigilance. Which of the following interventions best meet these criteria? (Select all that apply)

A 55-year-old man is admitted to the inpatient ward following a single-vehicle collision. In the emergency department, his blood alcohol concentration was notably elevated. Routine screening during his admission returns a positive test for HIV. During a consultation with the psychiatric service for depressed mood, the patient reveals a detailed, credible plan to shoot his former business partner, whom he blames for his recent financial collapse. The patient is medically stable, alert, oriented, and demonstrates intact decision-making capacity. He explicitly demands that the medical team "keep everything about this hospitalization completely confidential from everyone." Which of the following disclosures of protected health information are legally and ethically appropriate to make WITHOUT the patient's authorization? (Select all that apply)

A 62-year-old man with metastatic prostate cancer is being evaluated in the palliative care clinic. He is currently experiencing poorly controlled bone pain and dose-limiting neurotoxicity, manifesting as myoclonus and hyperalgesia, on his high-dose oral morphine regimen. The physician decides to transition the patient to oral hydromorphone to improve pain control and resolve the neurotoxicity. Arrange the following steps of opioid rotation in the correct clinical sequence to safely and effectively transition the patient to the new regimen.

A 22-year-old university student is treated in an urgent care center for a minor laceration on his forearm. During the social history, he discloses that he has been struggling with heroin addiction and requests help finding an outpatient rehabilitation program. He emphatically asks that his parents, who are sitting in the waiting room and who hold the family health insurance policy, not be informed about his substance use. As the patient is getting dressed, his mother approaches the physician in the hallway and asks, "Did he tell you anything about using drugs? We've been very worried about him." Which of the following is the most appropriate response by the physician?

A 65-year-old man with end-stage renal disease and poorly controlled schizophrenia is admitted for a severe, non-healing diabetic foot ulcer complicated by osteomyelitis. The orthopedic surgery team recommends a below-knee amputation to prevent systemic sepsis. The patient refuses the surgery, stating, 'The government planted a tracking chip in my leg, and they just want to take it back.' The surgical team asks you, the attending physician, to manage the patient's refusal of this necessary but non-emergent intervention. Order the following steps in the most appropriate ethical and legal sequence for addressing this situation.

A 55-year-old woman is admitted to the hospital for management of a severe diabetic foot infection complicated by gangrene. Despite the administration of broad-spectrum intravenous antibiotics, the infection is rapidly spreading. The surgical team strongly recommends a below-the-knee amputation to prevent overwhelming sepsis and death. The patient is awake, alert, and fully oriented to person, place, and time. During the discussion, she clearly articulates that she understands the high risk of death without the surgery but steadfastly refuses to undergo the amputation, stating she prefers to be buried with her body intact. A resident on the team insists that they must intervene immediately to save her life. Which of the following is the most appropriate next step in management?

A 70-year-old man is recovering in the surgical ward on post-operative day 2 following a total knee arthroplasty. The cross-covering night physician is called by the nursing staff because the patient has developed sudden-onset tachycardia and tachypnea. The electronic sign-out note from the day team states, 'Patient is highly anxious about pain; expect tachycardia and treat with PRN opioids.' The night physician reads this note and immediately attributes the new vital sign abnormalities solely to pain-related anxiety. The physician administers a dose of morphine without conducting further evaluation, failing to consider other critical postoperative complications such as a pulmonary embolism. By fixating on the first piece of information provided (the day team's label) to guide the diagnostic approach, which of the following cognitive biases is the night physician primarily demonstrating?

Match each clinical scenario to the most appropriate legal or ethical action regarding patient confidentiality.

Mr. Henderson, a 58-year-old patient with long-standing diabetes mellitus, is admitted for a rapidly spreading necrotizing soft tissue infection of his right lower extremity. The vascular surgery team evaluates the patient and determines that an urgent below-knee amputation is necessary to prevent fatal septic shock. However, upon hearing the recommendation, Mr. Henderson becomes highly distressed and declares, "No one is taking my leg. I absolutely refuse the surgery. I would rather die whole." He is currently hemodynamically stable, awake, and conversant. The attending physician must address this high-stakes treatment refusal.

Arrange the following clinical and ethical steps in the most appropriate sequence to manage this patient's refusal of life-saving treatment.

Match each clinical scenario involving a question of informed consent or treatment refusal to the most appropriate legal or ethical doctrine that governs the physician's required approach.

A 38-year-old male physician is evaluating a 24-year-old female patient in an outpatient clinic for chronic pelvic pain. The patient's past medical history is significant for borderline personality disorder. Over the past three months, the patient has exhibited escalating boundary-testing behaviors, including calling the physician's personal cell phone after hours for non-urgent matters. During today's visit, as the physician enters the closed examination room, the patient immediately makes explicit sexual advances. When the physician politely declines and attempts to redirect the conversation to her medical care, the patient becomes visibly angry and states, 'If you do not sleep with me right now, I will tell the state medical board and the police that you sexually assaulted me during this examination.' Which of the following actions are appropriate for the physician to take? (Select all that apply)

During a night shift on the surgical ward, an on-call physician is asked to evaluate a patient on postoperative day 2 following an open hemicolectomy. The bedside nurse reports that the patient has developed sudden-onset dyspnea, hypoxemia, and tachycardia. Over the preceding five days, this same physician has been involved in the emergent resuscitation and intensive care transfer of three different patients who suffered massive, life-threatening pulmonary embolisms on this specific ward. Upon evaluating the new patient, the physician immediately orders a computed tomography pulmonary angiogram and initiates a therapeutic heparin infusion without performing a comprehensive physical examination or considering other etiologies. The imaging study ultimately shows no evidence of a pulmonary embolism. Subsequent thorough evaluation reveals diminished breath sounds at the lung bases, and a portable chest radiograph confirms substantial bibasilar atelectasis as the underlying cause of the patient's symptoms. Which of the following cognitive phenomena best explains the physician's initial diagnostic and management approach?

A 42-year-old man is evaluated in the ambulatory clinic for persistent fatigue, unintentional weight loss, and occasional palpitations over the past three months. Upon entering the examination room, the physician notices the patient appears remarkably anxious and has a fine resting tremor of the hands. The physician immediately forms a leading hypothesis of hyperthyroidism. A comprehensive metabolic panel and a complete blood count are ordered, but the physician specifically adds a thyroid-stimulating hormone (TSH) level and free T4. The TSH and free T4 results return entirely within normal limits.

Despite these reassuring laboratory findings, the physician believes the results might represent early or fluctuating thyroid disease. The physician refers the patient to an endocrinologist for a radioactive iodine uptake scan, while completely omitting an evaluation of the patient's newly mentioned symptoms of excessive thirst and frequent urination. A fasting blood glucose is not ordered, delaying the ultimate diagnosis of new-onset diabetes mellitus.

Which of the following cognitive biases best describes the physician's selective interpretation of the data and persistence in pursuing the initial hypothesis?

A 42-year-old internal medicine physician attends a parent-teacher conference for her 10-year-old daughter. The teacher is a 38-year-old man who is also an established patient in the physician's private practice. At the end of the academic meeting, the teacher closes the classroom door, confides that he has been experiencing worsening lower back pain with intermittent right leg tingling over the past week, and asks if the physician could order a lumbar spine MRI or prescribe a muscle relaxant to save him a trip to the clinic. Which of the following is the most appropriate response by the physician?

A 28-year-old woman comes to the emergency department for the evaluation of a bruised right eye and a laceration on her lower lip. She initially states that she fell down a flight of stairs, but her affect is withdrawn and she avoids eye contact. Upon interviewing the patient alone in a private room, she tearfully discloses that her boyfriend punched her in the face during an argument. The patient is fully alert, oriented, and exhibits intact decision-making capacity. When the physician gently asks if she would like to contact the police, she adamantly refuses and begs the physician not to tell anyone, stating, 'He will kill me if he finds out I told you.' She is medically stable and requires no acute interventions other than lip laceration repair. Which of the following is the most appropriate next step in management?

An 82-year-old man is admitted to the medical ward for treatment of community-acquired pneumonia. He is receiving intravenous ceftriaxone and azithromycin. On his second day of hospitalization, his fever resolves, but he continues to require supplemental oxygen and intravenous antibiotics. The patient informs the primary team that he intends to leave the hospital immediately to return home and care for his elderly dog. The attending physician evaluates the patient and explains that leaving prematurely could result in worsening respiratory failure, sepsis, and potentially death. The patient accurately repeats these risks, stating, "I know I could die without the antibiotics, but my dog is my only family, and he will starve without me. I am willing to take that risk." He is alert, oriented to person, place, and time, and displays no signs of delirium or psychosis. The patient's daughter, who is his legally designated healthcare proxy, is contacted by telephone. She insists that the medical team keep her father in the hospital, stating, "He is not in his right mind if he is choosing a dog over his own life. As his proxy, I forbid you from discharging him."

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

Match each clinical scenario to the most appropriate legal or ethical doctrine regarding informed consent.

A 42-year-old family physician is the medical director of a busy outpatient practice. At the end of the workday, the clinic's 38-year-old office manager approaches him in his private office. She states that she has been experiencing severe stress, palpitations, and difficulty sleeping over the past month due to a sudden illness in her family. She asks if he could write a quick prescription for a short course of an anxiolytic medication, explaining that her regular primary care provider has no available appointments for the next three weeks and she is struggling to function at work. She has no known past medical history and is not an established patient at the practice. Which of the following is the most appropriate response by the physician?

A 28-year-old woman is evaluated in the emergency department for acute right lower quadrant abdominal pain. The emergency physician suspects appendicitis, orders laboratory tests including a urine pregnancy test, and verbally signs out the patient to the oncoming night shift physician at the end of the shift. During the transition of care, the departing physician forgets to mention that the pregnancy test result is still pending. Assuming the patient is not pregnant, the night physician immediately orders an abdominopelvic computed tomography (CT) scan. The scan confirms appendicitis, but the urine pregnancy test subsequently returns positive, indicating a 7-week intrauterine pregnancy. The patient is highly distressed about the fetal radiation exposure. The hospital's patient safety committee is tasked with addressing this incident. Which of the following is the most appropriate next step in evaluating and preventing future occurrences of this type of event?