Tüm alıştırma soruları

A 22-year-old woman is brought to the emergency department due to progressive confusion, nausea, and severe abdominal pain over the past 24 hours. She was diagnosed with type 1 diabetes mellitus during childhood. Vital signs show a blood pressure of 90/60 mm Hg, pulse of 124/min, and deep, rapid respirations at 26/min. Laboratory evaluation reveals a serum glucose of 560 mg/dL, arterial pH of 7.12, serum bicarbonate of 10 mEq/L, and significantly elevated serum ketones. Arrange the following interventions in the most appropriate chronological order for the acute management of this patient's condition.

Match each complication of decompensated cirrhosis to its most appropriate initial pharmacological or procedural management.

A 68-year-old man presents to a rural clinic with severe substernal chest pain. He is diagnosed with an acute ST-segment elevation myocardial infarction (STEMI). Due to limited resources and transport delays, definitive revascularization is significantly delayed, allowing the infarction to follow its natural clinical course. Arrange the following electrocardiographic (ECG) changes in the typical chronological order in which they appear during the evolution of an untreated acute transmural myocardial infarction.

A $76$-year-old woman is brought to the emergency department from her assisted living facility due to a $4$-day history of worsening, colicky abdominal pain, nausea, and frequent bilious vomiting. She has not passed flatus or stool for the past $2$ days. Her medical history includes type 2 diabetes mellitus, hypertension, and episodic right upper quadrant abdominal pain for which she declined surgery several years ago.

Her temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), pulse is $102/\text{min}$, respirations are $18/\text{min}$, and blood pressure is $110/70\text{ mm Hg}$. On physical examination, the abdomen is distended and tympanitic with high-pitched, hyperactive bowel sounds. There is mild, diffuse tenderness without guarding or rebound.

An abdominal computed tomography scan with intravenous contrast reveals dilated loops of small bowel with a transition point in the right lower quadrant. Air is visible within the biliary tree, and a $3.5\text{-cm}$ calcified intraluminal mass is identified near the ileocecal valve.

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

A 57-year-old woman is admitted to the hospital due to a two-day history of diffuse abdominal pain, generalized weakness, and subjective fevers. Her past medical history is significant for alcohol-associated cirrhosis and esophageal varices. On physical examination, her temperature is 38.3°C (100.9°F), blood pressure is 105/65 mmHg, and heart rate is 102/min. Her abdomen is distended, tense, and diffusely tender to palpation, with shifting dullness present. Due to initial hypotension and concern for sepsis, she was empirically started on broad-spectrum coverage with intravenous piperacillin-tazobactam and daptomycin in the emergency department. A diagnostic paracentesis was also promptly performed, yielding cloudy fluid with an absolute neutrophil count of $750/mm^3$. It is now hospital day 3. The patient's fever has resolved and her abdominal pain has significantly improved. The ascitic fluid culture from admission now grows *Klebsiella pneumoniae*. Antimicrobial susceptibility testing indicates that the isolate is sensitive to ceftriaxone, cefepime, piperacillin-tazobactam, and meropenem. Which of the following is the most appropriate management of this patient's pharmacotherapy?

During a routine afternoon check, nursing staff requests an evaluation for a patient experiencing new-onset right arm discomfort. The patient is a $48$-year-old female recovering on the surgical ward on postoperative day $3$ following an uncomplicated laparoscopic myomectomy for symptomatic uterine fibroids. Her temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $122/76\text{ mm Hg}$, pulse is $88\text{/min}$, and respirations are $14\text{/min}$. The abdomen is soft, non-tender, and the laparoscopic port sites are clean and dry. Lung fields are clear to auscultation bilaterally. Examination of the right forearm reveals a $4\text{-cm}$ area of localized erythema, mild induration, and tenderness tracking proximally from an intact peripheral intravenous catheter. A palpable, tender cord is present along the course of the vein. There is no fluctuance, purulent drainage, or surrounding generalized limb edema. Which of the following are the most appropriate next steps in management? (Select two)

An endocrine evaluation is requested for a female patient aged $62$ who has been experiencing progressive, deep skeletal aching and difficulty rising from a seated position over the last half-year. Five years prior, the patient underwent bariatric surgery (Roux-en-Y bypass) to manage severe obesity, resulting in a weight loss of $45$ kg ($99$ lb). She admits to poor adherence with her prescribed postoperative vitamin regimen. Physical examination demonstrates a distinct waddling gait and marked tenderness upon palpation of the sternum, ribs, and anterior tibia. Proximal muscle strength is symmetrically reduced in the bilateral lower extremities.

Initial laboratory investigations reveal the following results:

Based on the patient's clinical presentation and laboratory findings, which of the following describes the most probable underlying histologic abnormality in this patient's skeletal system?

A 45-year-old man with a history of alcohol use disorder is admitted to the hospital with acute-onset, severe epigastric pain radiating to his back. His serum lipase is markedly elevated at $4,500 \text{ U/L}$. Over the next four weeks, his hospital course is complicated by the development of infected necrotizing pancreatitis. Based on the current standard of care and the evidence-based 'step-up approach' for necrotizing pancreatitis, arrange the following interventions in the most appropriate chronological sequence from his initial presentation to his definitive management.

A $68$-year-old male is evaluated in the intensive care unit for abrupt-onset severe respiratory distress and hypotension. Four days ago, he was admitted with an acute ST-segment elevation myocardial infarction involving the inferior leads; he subsequently received a drug-eluting stent to the right coronary artery. His medical history includes hypertension and a $40$-pack-year smoking habit. Vital signs are temperature $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$), blood pressure $82/54\text{ mm Hg}$, heart rate $118\text{/min}$, and respirations $28\text{/min}$. Oxygen saturation is $84\%$ on a non-rebreather mask. Physical examination reveals cool, diaphoretic extremities and elevated jugular venous pressure. Auscultation of the chest demonstrates bilateral crackles extending halfway up the lung fields with scattered expiratory wheezes. A new, loud holosystolic murmur is heard best at the cardiac apex with radiation to the left axilla. Which of the following is the most likely cause of this patient's current clinical deterioration?

An $68$-year-old man is evaluated in the intensive care unit on hospital day $5$. He was originally admitted for severe sepsis secondary to a complicated intra-abdominal infection and underwent an emergency exploratory laparotomy. He remains on mechanical ventilation but his vasopressor requirements have resolved over the past $24$ hours. The medical team notes that he exhibits generalized edema and remains profoundly lethargic when sedation is paused. To evaluate his metabolic state, a thyroid panel is obtained, which reveals:

Thyroid-stimulating hormone (TSH): $0.2\text{ \mu U/mL}$ (Normal: $0.4-4.0\text{ \mu U/mL}$)
Free thyroxine (T4): $1.0\text{ ng/dL}$ (Normal: $0.8-2.7\text{ ng/dL}$)
Total triiodothyronine (T3): $45\text{ ng/dL}$ (Normal: $70-204\text{ ng/dL}$)

Which of the following is the most appropriate action regarding this patient's thyroid laboratory findings?

A 38-year-old male is brought to the emergency department after a high-speed head-on motor vehicle collision. He was an unrestrained driver and was ejected from the vehicle. Upon arrival, his blood pressure is 76/40 mmHg and his heart rate is 135/min. He is unresponsive with a Glasgow Coma Scale score of 3. The airway is secured with an endotracheal tube, and breath sounds are clear and equal bilaterally. The trachea is midline, and jugular veins are flat. Examination of the abdomen reveals mild distension and a transverse band of ecchymosis across the lower abdomen. The pelvis is mechanically stable to anteroposterior and lateral compression. Intravenous access is rapidly established, and a massive transfusion protocol is initiated. Which of the following is the most appropriate next step in management?

A 71-year-old man presents to the emergency department with rapidly worsening respiratory failure secondary to severe bilateral pneumonia. Despite a trial of non-invasive ventilation, his oxygenation continues to decline, and the decision is made to secure his airway. Arrange the following steps of rapid sequence intubation (RSI) in the correct chronological order.

A $58$-year-old man is brought to the emergency department after coughing up approximately $600 \text{ mL}$ of bright red blood over the past two hours. He has a history of treated pulmonary tuberculosis with known residual cavitary disease in the right upper lobe. On arrival, he is in severe respiratory distress, coughing continuously, and expectorating fresh blood. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $105/65 \text{ mmHg}$, pulse is $118/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows an oxygen saturation of $86\%$ on room air. Physical examination reveals coarse crackles over the right hemithorax, while the left lung field is relatively clear. The patient is unable to speak in full sentences due to the ongoing hemoptysis.

Arrange the following interventions in the most appropriate sequential order for managing this patient's condition.

Match the following classic arterial pulse abnormalities with their most likely underlying cardiovascular pathology.

A 24-year-old man is brought to the emergency department after being involved in a high-speed motor vehicle collision. He is in severe respiratory distress and complains of right-sided chest pain. His blood pressure is 80/50 mm Hg, heart rate is 135/min, and respiratory rate is 32/min. Oxygen saturation is 86% on room air. Physical examination reveals significantly decreased breath sounds over the right hemithorax, hyperresonance to percussion on the right, and distended neck veins. The trachea is deviated to the left. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A $72$-year-old man is brought to the emergency department by his daughter due to a $2$-day history of progressively worsening shortness of breath, a cough productive of yellow sputum, and palpitations. His medical history is significant for hypertension, hyperlipidemia, and chronic obstructive pulmonary disease (COPD). He has a $50$-pack-year smoking history. Current medications include inhaled tiotropium, inhaled fluticasone, and oral amlodipine. His temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $138/86$ mmHg, pulse is $134$/min and irregular, and respirations are $26$/min. Pulse oximetry is $87\%$ on room air. Physical examination reveals a barrel chest with prominent use of accessory muscles of respiration. Lung auscultation demonstrates a prolonged expiratory phase and diffuse wheezing bilaterally. There is no jugular venous distention or peripheral edema. An electrocardiogram reveals an irregular rhythm with narrow QRS complexes, absent flutter waves, and $3$ distinct P wave morphologies in lead II. Which of the following is the most appropriate initial management for this patient?

A $61$-year-old man with known liver cirrhosis secondary to chronic hepatitis C infection is hospitalized due to an acute onset of fever, diffuse abdominal discomfort, and confusion. Diagnostic paracentesis performed on the day of admission yielded ascitic fluid with an absolute neutrophil count of $550$ cells/mm $^3$. Consequently, he was initiated on an empiric antimicrobial regimen of intravenous piperacillin-tazobactam and vancomycin.

Now, on his third day in the hospital, his clinical status has markedly improved. He is fully oriented, his temperature is $37.0^\circ$ C ($98.6^\circ$ F), and his abdominal pain has subsided. The ascitic fluid cultures from admission demonstrate the growth of *Escherichia coli*. The susceptibility report indicates that this organism is resistant to ampicillin but highly susceptible to ceftriaxone, cefotaxime, and ciprofloxacin.

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

A $48$-year-old man is brought to the emergency department via ambulance due to a severe episode of coughing up blood. The patient has a history of treated pulmonary tuberculosis $10$ years ago, which left residual cavitary lesions in his right upper lobe. Over the last $4$ hours, he estimates coughing up approximately $600$ mL of bright red blood. Upon arrival, he has another paroxysm of coughing, producing an additional $250$ mL of fresh blood. He appears distressed and diaphoretic. Vital signs show a blood pressure of $105/65$ mm Hg, heart rate of $122$/min, respiratory rate of $28$/min, and oxygen saturation of $88\%$ on room air. Auscultation reveals coarse rhonchi and gurgling sounds predominantly over the right hemithorax, with relatively clear breath sounds on the left. The patient is immediately placed on high-flow supplemental oxygen.

Arrange the following subsequent interventions in the most appropriate sequential order for managing this patient's life-threatening condition.

A $74$-year-old man presents to the emergency department with a $2$-day history of worsening shortness of breath and a nonproductive cough. He has a past medical history of hypertension, ischemic cardiomyopathy, and chronic obstructive pulmonary disease (COPD). His daily medications include lisinopril, metoprolol, low-dose aspirin, and a tiotropium inhaler. He has a $40$-pack-year smoking history but quit $5$ years ago. He reports waking up several times last night gasping for air. His temperature is $37.0^\circ\text{C} (98.6^\circ\text{F})$, blood pressure is $158/92 \text{ mmHg}$, pulse is $112/\text{min}$, and respiratory rate is $26/\text{min}$. Pulse oximetry on room air is $88\%$. Physical examination shows jugular venous distention $8 \text{ cm}$ above the sternal angle. Lung auscultation reveals diffuse expiratory wheezes bilaterally; no crackles are heard. Cardiac auscultation demonstrates a regular tachycardia with a prominent $S_3$ gallop. There is $2+$ pitting edema in the bilateral lower extremities. A bedside portable chest radiograph shows prominent perihilar vasculature and indistinct vascular margins without focal opacities. Arterial blood gas analysis on room air shows:

pH: $7.47$
$\text{PaCO}_2$: $30 \text{ mmHg}$
$\text{PaO}_2$: $58 \text{ mmHg}$
$\text{HCO}_3^-$: $22 \text{ mEq/L}$

Which of the following is the most appropriate initial therapy for this patient?

During a routine outpatient evaluation, a physician examines a patient with a long-standing history of severe chronic obstructive pulmonary disease. The patient reports a three-month history of progressive bilateral leg swelling and a noticeable decline in exercise tolerance. Vital signs are stable. On physical examination, the physician notes prominent jugular venous distention and a palpable parasternal heave. Auscultation reveals globally decreased breath sounds without inspiratory crackles. A subsequent point-of-care echocardiogram demonstrates marked right ventricular dilation alongside a completely normal left ventricular ejection fraction. Which of the following underlying pathophysiologic mechanisms most likely initiated this patient's cardiac findings?