Tüm alıştırma soruları

A 62-year-old man collapses while walking in the hospital corridor. He is unresponsive, apneic, and has no palpable carotid pulse. A crash cart is immediately brought to the scene, and chest compressions are initiated. The cardiac monitor displays coarse ventricular fibrillation. Arrange the following critical resuscitation steps in the most appropriate chronological order according to standard advanced cardiovascular life support (ACLS) guidelines.

A $71$-year-old man is brought to the emergency department by emergency medical services due to severe shortness of breath and confusion. His wife reports that he has had a productive cough with thick, greenish sputum and subjective fevers for the past three days. His medical history is significant for severe chronic obstructive pulmonary disease (FEV1 $30\%$ of predicted) and ischemic cardiomyopathy (left ventricular ejection fraction $35\%$).

Upon arrival, his temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $82/48\text{ mm Hg}$, pulse is $128/\text{min}$, and respiratory rate is $36/\text{min}$. Oxygen saturation is $81\%$ on room air. Physical examination reveals a lethargic, confused patient using accessory muscles of respiration. The jugular venous pulsation is visible $4\text{ cm}$ above the sternal angle. Lung auscultation reveals diffuse expiratory wheezes and coarse crackles over the right lower lung field. The extremities are exceptionally warm, and peripheral pulses are bounding.

Arterial blood gas analysis on room air reveals:
pH: $7.12$
PaCO $_2$: $58\text{ mm Hg}$
PaO $_2$: $48\text{ mm Hg}$
HCO $_3^-$: $18\text{ mEq/L}$

Which of the following initial interventions are indicated in the management of this patient? (Select all that apply)

A $68$-year-old woman comes to the urgent care clinic complaining of progressive shortness of breath and a cough productive of clear, frothy sputum for the past two days. She reports needing to sleep propped up on three pillows at night. Her past medical history includes hypertension, type 2 diabetes mellitus, and a $35$-pack-year smoking history. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $165/95\text{ mmHg}$, pulse is $105/\text{min}$, and respiratory rate is $22/\text{min}$. Oxygen saturation is $89\%$ on room air. Physical examination reveals distended jugular veins. Pulmonary auscultation shows bilateral crackles at the lung bases and scattered expiratory wheezes. Bilateral $2+$ pitting edema is noted in the lower extremities. Which of the following is the most appropriate initial therapy for this patient?

A 65-year-old man is brought to the emergency department by emergency medical services after collapsing at home. His wife reports that he had been complaining of palpitations and dizziness for the past several hours. He has a history of heart failure with reduced ejection fraction and atrial fibrillation, for which he takes carvedilol, sacubitril-valsartan, and amiodarone. Three days ago, he was evaluated at an urgent care clinic and prescribed oral ciprofloxacin for a suspected urinary tract infection. On arrival, the patient is minimally responsive. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $72/40\text{ mmHg}$, pulse is $185\text{/min}$, and respirations are $22\text{/min}$. Cardiopulmonary examination reveals cold, clammy extremities and faint distal pulses. Continuous cardiac monitoring displays a rapid, irregular, wide-complex tachycardia with cyclic alterations in the QRS axis amplitude, appearing to twist around the isoelectric line. What is the most appropriate initial step in the management of this patient?

A 48-year-old man with a history of alcohol-associated cirrhosis is brought to the emergency department after vomiting a large amount of bright red blood. On arrival, he is lethargic but actively protecting his airway. His blood pressure is 85/50 mm Hg, and his pulse is 120/min. Physical examination reveals scleral icterus, spider angiomas, and a distended abdomen with a positive fluid wave. Arrange the following interventions in the most appropriate chronological sequence for the management of this patient's acute presentation.

A 72-year-old man is evaluated in the intensive care unit for progressive lethargy and worsening shortness of breath over the past 12 hours. The patient was admitted 5 days ago for an acute exacerbation of heart failure. His medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of $25\%$ and severe chronic obstructive pulmonary disease (COPD) with a baseline $\text{FEV}_1$ of $35\%$ of predicted. Since admission, he has been treated with a continuous intravenous furosemide infusion, resulting in a net negative fluid balance of 8 liters and resolution of his peripheral edema. Vital signs currently show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $100/60\text{ mm Hg}$, heart rate of $105/\text{min}$, and respiratory rate of $10/\text{min}$. Oxygen saturation is $89\%$ on a $3\text{ L/min}$ nasal cannula. Physical examination reveals a somnolent but arousable patient. The jugular venous pressure is estimated at $4\text{ cm H}_2\text{O}$. Pulmonary examination shows diminished breath sounds bilaterally with prolonged expiration and scattered end-expiratory wheezes, but no crackles are heard. Cardiovascular examination reveals distant heart sounds with a regular rate and rhythm.

Which of the following is the most appropriate next step in the management of this patient's respiratory status?

A $72$-year-old man presents to the emergency department complaining of severe lightheadedness, generalized weakness, and near-syncope that started one hour ago. His blood pressure is $78/50$ mmHg, heart rate is $32$/min, and respiratory rate is $16$/min. Oxygen saturation is $96\%$ on room air. An electrocardiogram (ECG) reveals sinus bradycardia with a heart rate of $32$/min. The patient remains persistently hypotensive and symptomatic despite initial intravenous fluid resuscitation. Arrange the following interventions in the most appropriate chronological sequence for the management of this patient, from the most immediate initial step to definitive long-term therapy.

A 63-year-old woman is brought to the emergency department from an inpatient rehabilitation facility due to sudden-onset severe shortness of breath and lightheadedness. Two weeks ago, she underwent an uncomplicated right total hip arthroplasty. Her medical history includes chronic obstructive pulmonary disease, essential hypertension, and hypothyroidism. Upon arrival, her blood pressure is 76/45 mmHg, heart rate is 126/min, respiratory rate is 28/min, and oxygen saturation is 84% on room air. She appears diaphoretic, agitated, and is using accessory muscles of respiration. Physical examination reveals jugular venous distention up to the angle of the mandible while seated upright. Auscultation of the lungs demonstrates scattered expiratory wheezes. Cardiac examination shows a prominent right ventricular heave, a loud P2, and a grade 2/6 holosystolic murmur at the left lower sternal border. The right thigh and calf are moderately swollen and tender. An electrocardiogram shows sinus tachycardia, new-onset complete right bundle branch block, and T-wave inversions in leads V1 through V4. Laboratory studies show a serum troponin I of $0.8$ ng/mL (normal $<0.04$), thyroid-stimulating hormone of $1.2$ $\mu U/mL$ (normal $0.4-4.0$), and free T4 of $0.6$ ng/dL (normal $0.9-1.7$). Which of the following is the most appropriate next step in the management of this patient?

A $42$-year-old woman is admitted to the intensive care unit with severe community-acquired pneumonia. Twelve hours after admission, she requires endotracheal intubation and mechanical ventilation due to worsening hypoxemic respiratory failure. Her current medications include intravenous ceftriaxone and azithromycin.

Vital signs are temperature $38.9^\circ\text{C}$ ($102^\circ\text{F}$), blood pressure $105/65\text{ mm Hg}$, and heart rate $118/\text{min}$.

A chest radiograph demonstrates diffuse, bilateral alveolar opacities. A bedside echocardiogram reveals normal left and right ventricular function with an estimated ejection fraction of $65\%$.

Which of the following interventions are appropriate for the ongoing management of this patient? (Select all that apply)

A 69-year-old male is transported to the acute care bay by paramedics following an abrupt onset of severe respiratory distress and profound diaphoresis that commenced one hour prior to arrival. His past medical history includes long-standing essential hypertension, type 2 diabetes mellitus, and a 40-pack-year smoking history. Upon arrival, he is extremely agitated, using accessory muscles of respiration, and cannot speak in full sentences.

Vital signs are temperature $36.8^\circ$ C ($98.2^\circ$ F), blood pressure $235/125$ mm Hg, pulse $122$/min, and respirations $38$/min. Oxygen saturation is $82\%$ on room air.

Physical examination reveals neck veins distended to the angle of the jaw while the patient is sitting upright. Lung auscultation demonstrates diffuse, high-pitched expiratory wheezes bilaterally with a significantly prolonged expiratory phase; no crackles are appreciated. Cardiac auscultation reveals a regular, rapid rhythm with a loud S2, though other heart sounds are obscured by the respiratory noise.

Arterial blood gas analysis on room air shows:
pH: $7.18$
PaCO $_2$: $65$ mm Hg
PaO $_2$: $48$ mm Hg
HCO $_3^-$: $24$ mEq/L

An electrocardiogram reveals sinus tachycardia with voltage criteria for left ventricular hypertrophy and secondary ST-segment repolarization abnormalities.

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

A 55-year-old man with a long-standing history of chronic bronchitis presents to the emergency department reporting a 2-day history of progressively worsening dyspnea. He states that his daily cough has become more frequent and is now producing thick, yellow-green phlegm, which is a change from his baseline clear secretions. Vital signs show a temperature of $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), heart rate of $112\text{ /min}$, respiratory rate of $22\text{ /min}$, and oxygen saturation of $89\%$ on ambient air. Physical examination is notable for diffuse bilateral expiratory wheezing and a prolonged expiratory phase. Cardiac auscultation reveals a regular rhythm with no murmurs or gallops. There is no jugular venous distention, and peripheral edema is absent. Chest radiography demonstrates lung hyperinflation without focal consolidations or pleural effusions.

Which of the following pharmacologic therapies are indicated as part of this patient's immediate acute management? (Select all that apply)

A 54-year-old man collapses in an airport terminal and is unresponsive. Bystanders immediately initiate cardiopulmonary resuscitation (CPR). Emergency medical services (EMS) arrive shortly after and confirm the patient is pulseless and apneic. The cardiac monitor displays coarse ventricular fibrillation. Arrange the following critical interventions in the correct chronological sequence for the management of this patient according to standard cardiac arrest algorithms.

A 68-year-old woman is evaluated in the hospital for new-onset diarrhea. She was admitted seven days ago for the management of community-acquired pneumonia and has been receiving intravenous ceftriaxone and azithromycin. Over the past two days, she has developed frequent, profuse, watery bowel movements accompanied by diffuse abdominal cramping. Her temperature is $38.2^{\circ}\mathrm{C}$ ($100.8^{\circ}\mathrm{F}$), blood pressure is $112/74\;\mathrm{mmHg}$, and pulse is $98/\mathrm{min}$. Physical examination reveals mild lower abdominal tenderness without guarding or rebound. Laboratory studies show a leukocyte count of $15,500/\mathrm{mm}^3$. A stool enzyme immunoassay is positive for *Clostridioides difficile* glutamate dehydrogenase antigen and toxin A/B. Which of the following is the most appropriate targeted pharmacotherapy for this patient's gastrointestinal infection?

Match the following valvular pathologies with their classic auscultatory findings on physical examination.

A 28-year-old woman presents to the clinic with an 8-month history of progressive exertional dyspnea, fatigue, and one episode of syncope while climbing stairs. She has no significant past medical history and takes no medications. Her blood pressure is 110/70 mm Hg, pulse is 88/min, and respirations are 16/min. Pulse oximetry shows 97% on room air. Physical examination reveals clear lungs, a prominent right ventricular heave, and a loud pulmonic component of the second heart sound. There is trace lower extremity edema. A transthoracic echocardiogram demonstrates right ventricular dilation, septal flattening during systole, and an estimated right ventricular systolic pressure of 55 mm Hg. The left ventricular size and systolic function are normal, with no significant valvular abnormalities. Pulmonary function testing and high-resolution computed tomography (HRCT) of the chest are unremarkable.

Arrange the following steps in the most appropriate sequential order for the continued diagnostic evaluation and management of this patient's condition.

A $70$-year-old woman presents to the emergency department with severe shortness of breath and wheezing that began $2$ hours ago. She has a history of poorly controlled hypertension and a $30$-pack-year smoking history. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $170/95\text{ mmHg}$, pulse is $112/\text{min}$, and oxygen saturation is $88\%$ on room air. Physical examination reveals distended jugular veins, a third heart sound (S3) on cardiac auscultation, and bilateral diffuse wheezing intermixed with bibasilar crackles. Which of the following is the most appropriate initial pharmacologic therapy for this patient?

Match the following clinical presentations and auscultatory findings with their most likely underlying structural or valvular pathology.

Match the following characteristic arterial pulse abnormalities identified on physical examination with their most likely underlying cardiovascular pathology.

Match each patient's clinical presentation with the most accurate description of the underlying pathophysiologic mechanism responsible for their condition.

A 58-year-old man was intubated and mechanically ventilated 5 days ago for severe community-acquired pneumonia. Today, his clinical condition has significantly improved. He is afebrile, his oxygen saturation is 96% on a fraction of inspired oxygen (FiO2) of 0.35, and he requires no vasopressor support. The critical care team decides to initiate the process of liberating the patient from mechanical ventilation.

Arrange the following steps in the correct chronological sequence for standard mechanical ventilation liberation.