Tüm alıştırma soruları

A 31-year-old woman with severe, treatment-resistant atypical depression has failed multiple antidepressant trials. She is currently taking fluoxetine 60 mg daily but remains profoundly symptomatic. Her psychiatrist decides to transition her to phenelzine.

Arrange the following clinical steps in the correct chronological sequence to safely and effectively execute this medication transition and its long-term management.

A 67-year-old woman is brought to the emergency department by her daughter due to increasing confusion, rapid breathing, and generalized weakness that started yesterday. The daughter notes that the patient has been complaining of a "constant buzzing" in her ears for the past 24 hours. The patient has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of 35%, type 2 diabetes mellitus, and severe bilateral knee osteoarthritis. Her current medications include metoprolol, lisinopril, empagliflozin, and several over-the-counter analgesics that she has been taking frequently due to a recent pain flare.

Vital signs are:
Temperature: 38.3°C (100.9°F)
Heart rate: 118/min
Respiratory rate: 32/min
Blood pressure: 105/65 mm Hg
Oxygen saturation: 97% on room air

Physical examination reveals a disoriented patient taking deep, rapid breaths. Chest auscultation demonstrates scattered bilateral basilar crackles. Cardiac examination shows a regular, rapid rhythm with no murmurs, gallops, or jugular venous distention. Trace bilateral pedal edema is present.

Laboratory results:
Serum sodium: 142 mEq/L
Serum potassium: 3.4 mEq/L
Serum chloride: 100 mEq/L
Serum bicarbonate: 14 mEq/L
Blood urea nitrogen: 32 mg/dL
Serum creatinine: 1.6 mg/dL (baseline 1.1 mg/dL)

Arterial blood gas on room air:
pH: 7.46
PaCO2: 20 mm Hg
PaO2: 88 mm Hg

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

For each of the following acute trauma scenarios, identify the most appropriate and definitive initial management step based on Advanced Trauma Life Support (ATLS) principles.

Match each clinical presentation describing a medication-induced psychiatric emergency or toxidrome with its most appropriate definitive pharmacological treatment.

A 28-year-old man is brought to the emergency department by ambulance after a high-speed motorcycle collision. He was not wearing a helmet. On arrival, he is unresponsive with irregular, shallow respirations. His blood pressure is 185/105 mm Hg, and his pulse is 52/min. Neurologic examination reveals a 7-mm, nonreactive right pupil and a 3-mm, reactive left pupil. He exhibits decerebrate posturing on the left side in response to painful stimuli. Arrange the following steps in the most appropriate sequential order for the acute management of this patient.

A $34$-year-old male construction worker is brought to the emergency department after falling approximately $6\text{ meters}$ ($20\text{ feet}$) from a scaffold. He is fully alert and reports severe lower abdominal and pelvic pain. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $115/78\text{ mm Hg}$, and pulse is $98/\text{min}$. A focused assessment with sonography for trauma (FAST) reveals no free intraperitoneal fluid. Pelvic radiography demonstrates an unstable "open book" pelvic ring disruption with significant diastasis of the pubic symphysis. The orthopedic surgery team is preparing the patient for emergent open reduction and internal fixation (ORIF) of the pelvis. A retrograde urethrogram is performed and confirms an intact urethra. A transurethral Foley catheter is placed and drains frankly bloody urine. A subsequent computed tomography (CT) cystogram demonstrates contrast extravasation confined to the perivesical space in a "flame-shaped" pattern, with no contrast outlining the bowel loops. Which of the following is the most appropriate management of this patient's urologic injury?

A 38-year-old woman is hospitalized for a 1-week history of severe lower back pain, generalized weakness, and recurrent chills. Her medical history is significant for intravenous drug use. Her temperature is $39.2^\circ C$ ($102.6^\circ F$), blood pressure is $112/68 \text{ mm Hg}$, and pulse is $115/\text{min}$. Physical examination reveals a new III/VI holosystolic murmur loudest at the cardiac apex. There is pronounced point tenderness over the lower lumbar spine, but no focal neurologic deficits are present. Laboratory studies show a leukocyte count of $15,200/\mu L$. Magnetic resonance imaging of the spine demonstrates abnormal signal intensity in the L4-L5 intervertebral disc and adjacent vertebral bodies, consistent with discitis and osteomyelitis. Blood cultures are drawn, and empiric therapy with intravenous vancomycin and cefepime is initiated. On hospital day 3, the patient's fever has improved. A transesophageal echocardiogram reveals a 1.4-cm vegetation on the mitral valve. Blood cultures are finalized and grow *Staphylococcus aureus* that is resistant to penicillin but susceptible to oxacillin, cefazolin, daptomycin, and vancomycin. Which of the following is the most appropriate next step in pharmacotherapy?

Paramedics bring an 81-year-old female to the acute care unit from her assisted living facility. Staff members called for help after noticing she was acting confused and breathing rapidly since she woke up. Her medical history is notable for severe osteoarthritis, hypertension, and diet-controlled type 2 diabetes mellitus. According to the facility's notes, she had been complaining of a constant "ringing" sound in her ears for the past 48 hours and self-administering extra over-the-counter analgesics for knee pain.

On arrival, her temperature is 37.1°C (98.8°F), blood pressure is 135/85 mm Hg, pulse is 112/min, and respirations are 28/min. Oxygen saturation is 96% on ambient air.

The patient appears mildly lethargic and is oriented only to person. Her mucous membranes are notably dry. Auscultation of the chest reveals a rapid, regular heart rate with no murmurs, and breath sounds are clear in all lung fields. The abdomen is non-tender. Trace pitting edema is noted at the ankles.

Laboratory evaluation demonstrates:
Sodium: 142 mEq/L
Potassium: 3.9 mEq/L
Chloride: 102 mEq/L
Bicarbonate: 14 mEq/L
Blood urea nitrogen: 24 mg/dL
Creatinine: 1.2 mg/dL
Glucose: 105 mg/dL

Arterial blood gas analysis on ambient air reveals:
pH: 7.42
pCO2: 20 mm Hg
pO2: 92 mm Hg

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

A 24-year-old G1P0 woman at 33 weeks gestation presents to the obstetric triage unit with painful uterine contractions and leakage of clear vaginal fluid that began 8 hours ago. Her prenatal course has been uncomplicated. On admission, her temperature is 39.1°C (102.4°F), blood pressure is 112/72 mm Hg, pulse is 118/min, and respiratory rate is 18/min. Physical examination reveals a diffusely tender uterine fundus. A sterile speculum examination confirms pooling of amniotic fluid in the posterior vaginal fornix. The cervix is visibly 4 cm dilated and 80% effaced. Continuous fetal heart rate monitoring demonstrates a baseline of 170/min, minimal variability, and no decelerations. The patient is fully oriented. When the physician discusses the clinical findings, she states, 'I understand the risks, but I strongly want to have a vaginal delivery. I refuse any surgical intervention unless my baby is in imminent, life-threatening danger.' Which of the following is the most appropriate next step in management?

A 72-year-old man with a history of chronic obstructive pulmonary disease (COPD) and hypertension is brought to the emergency department for severe, worsening shortness of breath over the past 24 hours. He reports that his breathing is especially difficult when he lies down to sleep, forcing him to sleep in a recliner chair. He denies fever, chills, or any change in the volume or color of his sputum. Blood pressure is 155/92 mm Hg, pulse is 108/min, and respirations are 26/min. Pulse oximetry shows 88% on room air. Physical examination reveals distended jugular veins, bilateral crackles at the lung bases, and an S3 gallop. There is 2+ bilateral lower extremity pitting edema.

Arterial blood gas analysis on room air shows:

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

A $65$-year-old man presents to the clinic with a $3$-month history of progressive difficulty swallowing both solids and liquids. He reports frequent regurgitation of undigested food, especially at night, and an unintended weight loss of $8$ kg ($17.6$ lb) during this period. His medical history is significant for hypertension and a $40$-pack-year smoking history. Vital signs are within normal limits. Physical examination is unremarkable. A barium esophagram demonstrates esophageal dilation with symmetric, smooth tapering at the gastroesophageal junction. Upper gastrointestinal endoscopy shows retained food debris in the esophageal body but normal overlying mucosa; the endoscope passes easily into the stomach with gentle pressure. High-resolution esophageal manometry demonstrates absent peristalsis in the esophageal body and a high integrated relaxation pressure, indicating failure of the lower esophageal sphincter to relax upon swallowing. Which of the following is the most appropriate next step in management?

A 54-year-old woman with a long-standing history of severe alcohol use disorder is brought to the emergency department by emergency medical services after vomiting large amounts of bright red blood at home. On arrival, she is lethargic and confused. Her blood pressure is 82/50 mm Hg, and her pulse is 128/min. Physical examination reveals marked scleral icterus, multiple spider angiomas on the chest, and a visibly distended abdomen with shifting dullness. The emergency physician suspects acute variceal hemorrhage as the cause of her instability. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 38-year-old woman comes to the clinic due to a 3-month history of worsening fatigue, generalized weakness, and a 4.5-kg (10-lb) weight gain despite a decreased appetite. She also reports feeling constantly cold and having increasingly irregular menstrual cycles. Her temperature is 36.1°C (97.0°F), blood pressure is 100/65 mm Hg, and pulse is 54/min. Physical examination shows dry skin and delayed relaxation of the deep tendon reflexes. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 0.1 $\mu$ U/mL (normal: 0.5-5.0 $\mu$ U/mL) and a free thyroxine (T4) level of 0.4 ng/dL (normal: 0.9-1.7 ng/dL). Which of the following is the most likely cause of this patient's findings?

A $64$-year-old woman is evaluated in the emergency department for severe shortness of breath and increasing leg swelling over the past week. She has a history of severe chronic obstructive pulmonary disease (COPD) requiring home oxygen therapy. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $105/68\text{ mm Hg}$, pulse is $118\text{ /min}$, and respirations are $28\text{ /min}$. Jugular venous pulsation is visible at $15\text{ cm H}_2\text{O}$. Cardiac examination reveals a prominent parasternal heave and a loud $P_2$. Lung auscultation shows significantly prolonged expiration and diffuse wheezing, with no crackles. The liver edge is palpable $4\text{ cm}$ below the right costal margin and is tender. Moderate pitting edema is present in the lower extremities. Arterial blood gas on $2\text{ L/min}$ supplemental oxygen shows:

pH: $7.31$
$PaCO_2$: $62\text{ mm Hg}$
$PaO_2$: $54\text{ mm Hg}$
$HCO_3^-$: $31\text{ mEq/L}$

A trial of non-invasive positive pressure ventilation (NIPPV) is initiated for acute-on-chronic hypercapnic respiratory failure. Ten minutes later, the patient becomes lethargic and her blood pressure drops precipitously to $70/40\text{ mm Hg}$. Which of the following is the most appropriate immediate next step in management?

Match each clinical scenario with the legally and ethically required reporting action or entity.

A 54-year-old man presents to the clinic with a 3-month history of profound fatigue, intermittent joint pain in his hands, and a recurrent rash on his lower legs. He has a past medical history of a brief period of intravenous drug use in his early twenties. He currently takes no medications. Vital signs are within normal limits. Physical examination reveals a non-blanching, palpable purpuric rash over the bilateral shins and ankles. There is mild symmetric tenderness and swelling of the metacarpophalangeal and proximal interphalangeal joints.

Laboratory evaluation is as follows:

Urinalysis shows 2+ protein, $15-20$ red blood cells/hpf, and occasional red blood cell casts.

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

Match each patient's clinical presentation with the myositis-specific autoantibody that is most strongly associated with their clinical phenotype.

During a busy evening shift at a university-affiliated hospital, a 19-year-old undergraduate student is admitted to the intensive care unit with acute bacterial meningitis. Cerebrospinal fluid cultures rapidly grow *Neisseria meningitidis*. The patient is currently obtunded and unable to communicate. His father, who is the legally documented healthcare proxy, arrives at the hospital shortly after admission. After being informed of the diagnosis and the treatment plan, the father becomes highly distressed about potential social stigma on campus. He explicitly forbids the care team from disclosing the diagnosis to any government agency or university official. Which of the following is the most appropriate next step in management regarding the disclosure of this patient's diagnosis?

A 58-year-old woman is hospitalized for the treatment of infective endocarditis. She initially presented with a 3-week history of low-grade fever, fatigue, and a new heart murmur. Her history is notable for a dental extraction one month prior. Transesophageal echocardiography on admission revealed a 7-mm vegetation on the mitral valve leaflet. Three sets of blood cultures grew *Streptococcus sanguinis* with a penicillin minimum inhibitory concentration (MIC) of 0.05 mcg/mL. She was started on a planned 2-week synergistic regimen of intravenous aqueous penicillin G and intravenous gentamicin. On day 5 of hospitalization, the patient reports feeling clinically improved and has been afebrile for 48 hours. However, laboratory studies show her serum creatinine has increased from a baseline of 0.8 mg/dL to 2.1 mg/dL. Her urine output has mildly decreased over the past 24 hours. Which of the following is the most appropriate modification to her antimicrobial regimen?

A parent brings their 24-month-old son to the pediatric clinic due to concerns about his language development. The parent states that the child says only five words, including 'mama' and 'dada', and primarily uses pointing to request items. He does not put words together to form phrases. The child is able to walk up and down stairs while holding onto the railing, kick a ball, and stack a tower of six blocks. He frequently brings books to his parent to read and engages in pretend play with a toy kitchen. He responds to his name consistently and follows simple commands. A routine screening for autism spectrum disorder performed today shows a low-risk profile. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?