Tüm alıştırma soruları

A $46$-year-old woman is hospitalized for induction chemotherapy for newly diagnosed acute myeloid leukemia. On hospital day $12$, she develops a new-onset fever. She reports feeling chilled and fatigued but has no cough, dysuria, abdominal pain, or skin changes. Her temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $105/65\text{ mm Hg}$, pulse is $115/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination is unremarkable, with clear lungs and no induration around her central venous catheter. Laboratory studies reveal an absolute neutrophil count of $120/\mu\text{L}$.

Arrange the following steps in the most appropriate chronological sequence for the management of this patient's complication.

A 62-year-old woman is evaluated on postoperative day 6 following an open total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer. She reports the sudden onset of right-sided chest pain that worsens with deep inspiration, accompanied by mild shortness of breath. She has a medical history of chronic obstructive pulmonary disease, hypertension, and type 2 diabetes mellitus. Her current medications include inhaled tiotropium and subcutaneous prophylactic enoxaparin. Vital signs are:

Temperature: 37.8°C (100.0°F)
Blood pressure: 118/76 mmHg
Pulse: 114/min
Respirations: 22/min
Oxygen saturation: 90% on room air

Physical examination reveals a patient in mild respiratory distress. Jugular venous pressure is normal. Lung auscultation reveals clear breath sounds bilaterally without wheezes or crackles. Cardiac examination shows tachycardia with a regular rhythm; no murmurs, rubs, or gallops are heard. The abdominal incision is clean, dry, and well-approximated without erythema. Her right calf is visibly swollen, erythematous, and tender to palpation compared to the left.

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

A 68-year-old man is brought to the emergency department via ambulance with a 30-minute history of sudden-onset, severe, "tearing" chest pain that radiates to his back between his shoulder blades. His blood pressure is 210/115 mm Hg in the right arm and 175/95 mm Hg in the left arm, and his heart rate is 112/min. He appears visibly distressed and diaphoretic. An ECG shows sinus tachycardia with voltage criteria for left ventricular hypertrophy, but no acute ischemic changes. A chest radiograph demonstrates a widened mediastinum. The clinical presentation is highly suspicious for an acute aortic dissection. Arrange the following management steps in the most appropriate sequential order for the optimal care of this patient.

Paramedics arrive at the emergency department bringing a 74-year-old woman who woke up suddenly with severe shortness of breath two hours ago. She reports progressively worsening exertional dyspnea over the preceding three days. Her medical history includes hypertension, hyperlipidemia, osteoarthritis, and a 40-pack-year smoking history. Current medications are amlodipine, atorvastatin, and ibuprofen. Vital signs are temperature 37.1°C (98.8°F), blood pressure 175/95 mmHg, pulse 110/min, and respiratory rate 26/min. Pulse oximetry shows 89% on room air. The patient is sitting upright on the edge of the stretcher, using accessory muscles of respiration. Lung auscultation reveals diffuse, prominent expiratory wheezing bilaterally. Which of the following physical examination findings is most specific for confirming a cardiogenic etiology for this patient's acute symptoms rather than a primary pulmonary exacerbation?

A 56-year-old man is brought to the emergency department due to the sudden onset of severe, diffuse abdominal pain that began 2 hours ago. He has a history of osteoarthritis for which he takes naproxen daily. His temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), pulse is $122/\text{min}$, respirations are $24/\text{min}$, and blood pressure is $88/56\text{ mmHg}$. On physical examination, the patient is lying completely still on the stretcher. The abdomen is diffusely tender to palpation with board-like rigidity and pronounced rebound tenderness. Bowel sounds are absent. Intravenous fluid resuscitation and broad-spectrum antibiotics are initiated. An upright chest radiograph reveals a crescent of radiolucency between the liver and the right hemidiaphragm. Which of the following is the most appropriate next step in management?

A patient with a significant history of systemic hypertension and extensive tobacco use is evaluated in the outpatient setting for progressive dyspnea, orthopnea, and recent episodes of waking up gasping for air. Vital signs show a blood pressure of 152/94 mm Hg, a heart rate of 98/min, and a respiratory rate of 22/min. Lung auscultation demonstrates bilateral crackles at the lung bases and scattered expiratory wheezes. The clinician suspects acute decompensated heart failure but wants to differentiate it from a chronic obstructive pulmonary disease exacerbation. Which of the following physical examination findings is most specific for identifying decompensated heart failure in this clinical scenario?

An $82$-year-old woman is evaluated in the outpatient clinic for a routine follow-up. She is accompanied by her son, who assists with her activities of daily living. Her medical history is significant for type 2 diabetes mellitus, essential hypertension, and mild neurocognitive disorder. During the visit, the son expresses concern because he has noticed that the patient's urine in her bedside commode has appeared cloudy and distinctly malodorous over the last $72$ hours. He is worried she may have a urinary tract infection, as she was treated for one six months ago. Upon direct questioning, the patient is pleasant and conversant, remaining at her cognitive baseline. She explicitly denies experiencing any dysuria, increased urinary frequency, urinary urgency, flank pain, or subjective fevers. Her vital signs include a temperature of $37.1^{\circ}$ C ($98.8^{\circ}$ F), blood pressure of $135/85$ mmHg, heart rate of $78$/min, and respiratory rate of $14$/min. Abdominal examination is soft and non-tender, with no suprapubic discomfort or costovertebral angle tenderness. A clean-catch urinalysis obtained in the clinic reveals positive leukocyte esterase, positive nitrites, and $35$ white blood cells per high-power field. Which of the following is the most appropriate next step in management?

Paramedics evaluate a 61-year-old male at his residence following an emergency call for sudden-onset, excruciating retrosternal chest pain that radiates to his mid-back. He is immediately transported to the nearest tertiary care center. On arrival, the patient is visibly distressed, diaphoretic, and tachypneic. His medical history is notable for uncontrolled hypertension and a 40-pack-year smoking history. Vital signs demonstrate a temperature of 36.8°C (98.2°F), a heart rate of 122/min, a blood pressure of 78/46 mm Hg in the right arm and 82/48 mm Hg in the left arm, and an oxygen saturation of 88% on room air. Physical examination reveals elevated jugular venous pressure and diffuse bilateral crackles on lung auscultation. A bounding, early diastolic decrescendo murmur is auscultated along the right sternal border. An electrocardiogram reveals sinus tachycardia with left ventricular hypertrophy but no acute ischemic ST-segment changes. Which of the following is the most appropriate next step in the management of this patient?

A 55-year-old man with a history of decompensated alcohol-associated cirrhosis is brought to the emergency department by ambulance after vomiting a large amount of bright red blood. On arrival, he is lethargic and oriented only to his name. His temperature is 36.8°C (98.2°F), blood pressure is 80/50 mmHg, pulse is 128/min, and respiratory rate is 22/min. Physical examination reveals scleral icterus, spider angiomas, and a distended abdomen with a positive fluid wave. Active hematemesis is ongoing. Arrange the following interventions in the correct chronological sequence of escalation for managing this patient's condition, assuming continued need for intervention at each stage:

A $65$-year-old man with a recent diagnosis of small cell lung cancer is admitted to the hospital due to progressive confusion, lethargy, and nausea over the past week. He has a $40$-pack-year smoking history. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $128/82$ mmHg, pulse is $78$/min, and respirations are $14$/min. Physical examination reveals moist mucous membranes, normal skin turgor, no jugular venous distention, and clear lungs. There is no peripheral edema.

Laboratory results are as follows:

While in the emergency department, the patient develops a generalized tonic-clonic seizure that lasts for $2$ minutes and resolves spontaneously. He remains postictal. Which of the following is the most appropriate next step in management?

A $56$-year-old male patient is evaluated in the clinic for a $6$-month history of progressive fatigue, cold intolerance, and erectile dysfunction. He also notes that he has recently scraped the side of his car twice while pulling out of his garage, which he attributes to increasing clumsiness. His medical history is unremarkable, and he takes no medications. Blood pressure is $110/70$ mmHg and pulse is $56$/min. Physical examination demonstrates a delayed relaxation phase of the deep tendon reflexes and bilateral loss of peripheral vision in the temporal fields. Laboratory studies show the following:

Sodium: $135$ mEq/L
Thyroid-stimulating hormone (TSH): $2.2$ $\mu$ U/mL (Normal: $0.4-4.2$ $\mu$ U/mL)
Free thyroxine (T4): $0.5$ ng/dL (Normal: $0.9-2.4$ ng/dL)
Total testosterone: $140$ ng/dL (Normal: $300-1000$ ng/dL)

Which of the following best describes the pathogenesis of this patient's thyroid laboratory abnormalities?

A $65$-year-old man with a history of alcohol-associated cirrhosis, chronic obstructive pulmonary disease (COPD), and a recent admission for an upper gastrointestinal bleed one month ago presents to the emergency department with a $2$-day history of progressively worsening shortness of breath, increased abdominal girth, and mild lethargy.

Physical examination reveals an alert but mildly lethargic patient who is oriented to person and place only. Scleral icterus is present. Jugular venous pulsation is $6 \text{ cm H}_2\text{O}$. Lung examination shows decreased breath sounds and dullness to percussion over the right lower two-thirds of the lung field, with scattered end-expiratory wheezes bilaterally. The abdomen is distended, non-tender, and has shifting dullness. Bilateral $2+$ pitting lower extremity edema and asterixis are present.

Laboratory studies reveal the following:

Chest radiograph demonstrates a large right-sided pleural effusion without mediastinal shift or focal consolidations. A diagnostic paracentesis yields clear, yellow fluid with a total protein of $1.1 \text{ g/dL}$ and a neutrophil count of $80/\text{mm}^3$. The patient is currently receiving intravenous piperacillin-tazobactam, which was started empirically by a transferring facility $24$ hours ago for presumed pneumonia.

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

A 22-year-old woman is brought to the emergency department by her roommate due to confusion, nausea, and ringing in her ears for the past several hours. The roommate found an empty bottle of over-the-counter pain relievers in her room. On physical examination, her temperature is 37.8°C (100.0°F), blood pressure is 110/70 mm Hg, pulse is 115/min, and respiratory rate is 28/min. She appears agitated and diaphoretic. Laboratory results are as follows:

Which of the following best describes this patient's acid-base status?

A 62-year-old woman is admitted to the hospital with a 3-day history of severe left lower quadrant abdominal pain, fever, and nausea. Her temperature is $38.7^{\circ}\text{C}$ ($101.7^{\circ}\text{F}$), blood pressure is $118/76\text{ mmHg}$, and heart rate is $92/\text{min}$. Physical examination reveals marked tenderness in the left lower quadrant without diffuse rebound tenderness or guarding. Laboratory studies show a leukocyte count of $16,500/\text{mm}^3$. A computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast reveals acute sigmoid diverticulitis complicated by a $5.5\text{ cm}$ peridiverticular abscess. Arrange the following management steps in the most appropriate chronological sequence for this patient.

Review the following descriptions of patients presenting to the emergency department following various traumatic events. Pair each specific clinical scenario with its unequivocally correct next step in diagnostic evaluation or acute management.

A 48-year-old woman presents to the outpatient clinic with a 5-month history of worsening fatigue, unintentional weight gain, and cold intolerance. She also reports bilateral milky nipple discharge and absence of menses for the past 6 months. She has no significant past medical history and takes no medications. Vital signs show a temperature of $36.2^{\circ}\text{C}$ ($97.2^{\circ}\text{F}$), blood pressure of $105/65\text{ mmHg}$, and pulse of $54\text{/min}$. Physical examination reveals dry skin and a delayed relaxation phase of the deep tendon reflexes. Visual field testing is unremarkable. Laboratory results are as follows:

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

Match each clinical exposure scenario with the most appropriate pharmacological prophylaxis or empiric antimicrobial regimen.

A $72$-year-old man is evaluated on the surgical ward for a new-onset fever. He is currently on postoperative day $3$ following an elective open lower anterior resection for rectal adenocarcinoma. His medical history is significant for hypertension and type $2$ diabetes mellitus. His temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $132/82\text{ mm Hg}$, pulse is $94/\text{min}$, and respirations are $16/\text{min}$. Oxygen saturation is $97\%$ on room air. The patient reports mild, well-controlled pain at his surgical site but notes a new onset of burning with urination and a sensation of incomplete bladder emptying. His indwelling urinary catheter was removed $24$ hours ago. Physical examination shows a soft, non-distended abdomen with normal active bowel sounds. The surgical incision is clean, dry, and intact without erythema, induration, or purulent drainage. Lung fields are clear to auscultation bilaterally. The calves are soft and non-tender. Which of the following is the most appropriate next step in management?

A rapid response is called for a 67-year-old male inpatient recovering from an emergent open sigmoid colectomy performed 5 days ago for perforated diverticulitis. He has a history of severe chronic obstructive pulmonary disease and obesity (BMI $41 \text{ kg/m}^2$). His vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $145/85 \text{ mmHg}$, heart rate $110/\text{min}$, and respiratory rate $22/\text{min}$. The nursing staff reports that while the patient was having a violent coughing fit, his abdominal binder became saturated with copious amounts of a pink, salmon-colored fluid. Upon removal of the binder and surgical dressings, it is immediately apparent that the midline abdominal incision has dehisced and multiple loops of small intestine are protruding outside the abdominal cavity onto the skin.

Arrange the following steps for the definitive management of this patient's surgical complication in the most appropriate chronological order.

A 31-year-old woman comes to the emergency department due to the sudden onset of severe, unremitting mid-abdominal pain that began 6 hours ago. The pain is associated with nausea and multiple episodes of non-bilious vomiting. Two years ago, she underwent a laparoscopic Roux-en-Y gastric bypass for morbid obesity, losing $45\text{ kg}$ ($99\text{ lb}$) since the procedure. Her temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), pulse is $126\text{/min}$, and blood pressure is $90/58\text{ mm Hg}$. Physical examination shows a significantly distended abdomen that is exquisitely tender to palpation, with involuntary guarding and rebound tenderness. Laboratory evaluation reveals a leukocyte count of $17,500\text{/mm}^3$ and a serum lactate level of $4.8\text{ mmol/L}$. A computed tomography scan of the abdomen demonstrates dilated loops of small intestine with a 'swirl sign' of the mesenteric vessels. Which of the following is the most appropriate next step in management?