Tüm alıştırma soruları

Match the described hallmark gastrointestinal radiographic findings to their most likely diagnostic conditions.

During an evaluation in the obstetric triage unit, a physician examines a woman at 29 weeks gestation who complains of the sudden onset of difficulty breathing and sharp right-sided chest pain that worsens with deep inspiration. Her pregnancy has been uncomplicated to date, and she has no significant past medical history. Vital signs reveal a heart rate of 118/min, a respiratory rate of 22/min, a blood pressure of 112/68 mmHg, and an oxygen saturation of 94% on room air. Physical examination demonstrates clear breath sounds bilaterally and normal cardiac auscultation. Evaluation of the lower extremities reveals asymmetric pitting edema and localized tenderness in the right calf. Which of the following is the most appropriate next step in evaluating this patient's condition?

Paramedics transport a 68-year-old male to the emergency room due to progressive, profound weakness over the past 24 hours. The patient has a background of ischemic cardiomyopathy and stage IV chronic kidney disease. Current outpatient medications comprise lisinopril, spironolactone, and carvedilol. Initial triage vital signs demonstrate a pulse of 42/min and a blood pressure of 105/60 mmHg. A 12-lead electrocardiogram displays a sine wave pattern with widened QRS complexes and prominently peaked T waves. A point-of-care basic metabolic panel is notable for a potassium concentration of 8.2 mEq/L. Arrange the following pharmacologic therapies in the correct chronological order for the acute management of this presentation.

A 32-year-old man is brought to the trauma bay via ambulance after losing control of his motorcycle at highway speeds. He was wearing a helmet. On arrival, he is pale and diaphoretic. He is groaning and protecting his airway. His temperature is 36.2°C (97.2°F), blood pressure is 74/40 mm Hg, heart rate is 142/min, and respiratory rate is 24/min. Oxygen saturation is 96% on room air. Breath sounds are equal and clear bilaterally. His abdomen is visibly distended, tense, and diffusely tender with guarding. The pelvis is mechanically stable to anteroposterior and lateral compression. A focused assessment with sonography for trauma (FAST) demonstrates a large amount of anechoic fluid in the hepatorenal and splenorenal recesses. Two large-bore peripheral intravenous catheters have been established. Which of the following are the most appropriate immediate next steps in the management of this patient? (Select all that apply)

A 61-year-old female patient is evaluated in the intensive care unit due to deteriorating hemodynamics. She underwent a complex open ventral hernia repair with myofascial advancement flaps 24 hours ago. Over the past four hours, her urine output has steadily declined to a total of 15 mL. She is currently intubated and mechanically ventilated. Her temperature is 37.2°C (99.0°F), blood pressure is 82/48 mmHg, and pulse is 126/min. The patient is receiving a continuous infusion of norepinephrine, and her blood pressure remains low despite two 1-L boluses of intravenous lactated Ringer solution. The respiratory therapist reports that the peak airway pressures have gradually increased from 22 cm H2O to 45 cm H2O over the same time period. Physical examination reveals an extremely tense and distended abdomen with diffuse firmness to palpation. A transducer attached to the indwelling urinary catheter displays a pressure of 26 mmHg. Laboratory studies obtained 30 minutes ago show a hemoglobin of 10.4 g/dL and a lactate of 4.2 mmol/L. Which of the following is the most appropriate next step in the management of this patient?

A 72-year-old woman comes to the clinic reporting a 4-week history of worsening insomnia, profound fatigue, and a 4.5-kg (10-lb) weight loss despite a normal appetite. Her past medical history is significant for hypertension and recurrent highly symptomatic atrial fibrillation. Her current medications include amiodarone, apixaban, and lisinopril. She has been taking amiodarone for the past three years with good control of her arrhythmias. Her blood pressure is 138/85 mm Hg and heart rate is 108/min and irregular. Physical examination reveals a fine tremor of the outstretched hands, warm and moist skin, and a normal-sized, non-tender thyroid gland without palpable nodules.

Laboratory results are as follows:

Which of the following is the most appropriate next step in the evaluation to guide treatment for this patient's current condition?

A $72$-year-old female is evaluated for discharge on hospital day $8$. She was originally admitted for ischemic colitis complicated by bowel perforation, requiring an emergent laparotomy and the creation of a temporary colostomy. Her postoperative course was initially complicated by acute kidney injury that required $2$ sessions of hemodialysis. However, her renal function has steadily improved, and hemodialysis was discontinued $4$ days ago. Her current serum creatinine is $1.4$ mg/dL (baseline $1.1$ mg/dL). She is hemodynamically stable, afebrile, and tolerating a soft diet.

The patient is eager to return home. Prior to admission, she was fully independent with her activities of daily living and enjoyed gardening. She lives in a single-story home with her $75$-year-old husband, who has severe macular degeneration and is legally blind.

A physical therapy evaluation reveals she requires moderate assistance to transfer from the bed to a chair and can ambulate $15$ feet with a walker before requiring a seated rest. She reports severe fatigue after $30$ minutes of physical exertion. A nursing assessment notes that while the patient understands the steps of ostomy care, she currently lacks the manual dexterity and stamina to independently empty or change the appliance.

Which of the following is the most appropriate disposition for this patient?

A 54-year-old male presents to the emergency department with severe right groin pain that began 8 hours ago. He has a known right inguinal hernia that he usually pushes back in manually, but he has been unable to do so today. He reports nausea and two episodes of bilious emesis. Temperature is 38.4°C (101.1°F), blood pressure is 105/65 mm Hg, pulse is 118/min, and respirations are 18/min. Physical examination reveals a 6-cm bulge in the right inguinal region that is exquisitely tender to palpation, erythematous, and warm to the touch. The overlying skin is tense, and bowel sounds are absent over the mass. Laboratory studies show a leukocyte count of 16,500/mm³. Which of the following is the most appropriate next step in the management of this patient?

During a follow-up visit for a minor motor vehicle collision, an otherwise healthy 58-year-old woman asks about a finding on her recent imaging. She was evaluated in the local trauma center two weeks ago, where a noncontrast computed tomography (CT) scan of the chest was performed to assess for rib fractures. The radiologist's report notes an incidental 14-mm solitary pulmonary nodule in the right lower lobe. The nodule is described as having well-defined, smooth margins with macroscopic, central "popcorn-like" calcifications. The patient smoked cigarettes occasionally in her twenties but has not smoked for over 30 years. She has no chronic medical conditions and reports no respiratory symptoms, weight loss, or night sweats. Vital signs are within normal limits. Physical examination of the chest is unremarkable. Which of the following is the most appropriate next step in the management of this patient's pulmonary finding?

A 72-year-old man comes to the clinic for a routine follow-up visit. He was recently diagnosed with highly symptomatic paroxysmal atrial fibrillation. Attempts to control his rhythm with metoprolol and flecainide were unsuccessful due to poor tolerance, and he was transitioned to amiodarone 4 weeks ago. His other medical conditions include hypertension and hyperlipidemia. His current medications are metoprolol, apixaban, atorvastatin, and amiodarone. The patient feels well and reports no further palpitations, shortness of breath, or muscle aches. His pulse is 62/min and regular, and blood pressure is 128/78 mm Hg. Physical examination reveals clear lungs, a regular cardiac rhythm, and no peripheral edema. Which of the following diagnostic tests are indicated for the routine periodic surveillance of this patient's new antiarrhythmic therapy? (Select all that apply)

A $74$-year-old female is evaluated in the emergency department for severe shortness of breath, confusion, and lethargy that has progressively worsened over the past $48$ hours. The patient has a known medical history of ischemic cardiomyopathy with a left ventricular ejection fraction of $20\%$, chronic kidney disease stage $3$, and type $2$ diabetes mellitus. Her home medications include sacubitril-valsartan, carvedilol, spironolactone, empagliflozin, and aspirin.

Upon arrival, she is difficult to arouse but oriented to person only. Her extremities are cool and mottled, with weak distal pulses and delayed capillary refill. Jugular venous distention is prominent, estimated at $12$ cm $H_2O$. Auscultation of the lungs reveals diffuse bilateral crackles extending to the apices. Cardiac examination reveals tachycardia with a regular rhythm and a distinct $S_3$ gallop.

Initial vital signs are:
Blood pressure: $78/52$ mm Hg
Heart rate: $118$/min
Respiratory rate: $28$/min
Oxygen saturation: $84\%$ on room air

Point-of-care laboratory testing reveals:
Serum creatinine: $3.4$ mg/dL (baseline $1.6$ mg/dL)
Serum potassium: $5.4$ mEq/L
Venous lactate: $5.2$ mmol/L

The patient is immediately placed on noninvasive positive pressure ventilation. The physician is preparing the initial pharmacologic management plan.

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

A 24-year-old man with type 1 diabetes mellitus is admitted to the intensive care unit for the management of diabetic ketoacidosis precipitated by viral gastroenteritis. He has been receiving aggressive intravenous fluid resuscitation, potassium supplementation, and a continuous regular insulin infusion. Eighteen hours after admission, he is alert, reports feeling hungry, and has no nausea. Current laboratory studies show a serum glucose of $165 \text{ mg/dL}$, a serum bicarbonate of $18 \text{ mEq/L}$, an anion gap of $10 \text{ mEq/L}$, and a venous pH of $7.34$. The physician determines the patient is ready to transition to a subcutaneous insulin regimen. Arrange the following steps in the correct chronological sequence to safely de-escalate therapy and establish ongoing monitoring.

A 75-year-old woman is evaluated on hospital day 6 for discharge planning following an emergency exploratory laparotomy for a perforated diverticulum. On admission, she presented with septic shock; her Sequential Organ Failure Assessment (SOFA) score was 7, and she required mechanical ventilation and vasopressor support in the intensive care unit (ICU) for 48 hours.

Currently, she is on a general surgical floor and is medically stable. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $122/76\text{ mmHg}$, pulse $78/\text{min}$, and respiratory rate $16/\text{min}$. Her bowel function has returned, she is tolerating a soft diet, and her surgical incision is clean and intact. She has been transitioned to oral antibiotics.

A physical therapy evaluation reveals profound ICU-acquired weakness. She requires maximum assistance for bed-to-chair transfers and is currently unable to ambulate. She is highly motivated to recover but experiences severe fatigue, tolerating a maximum of 30 to 45 minutes of physical and occupational therapy daily. Prior to admission, she was fully independent with all activities of daily living. She lives with her 77-year-old husband in a single-level home; he works part-time during the day and has a history of severe osteoarthritis.

Based on her clinical severity history and current functional capacity, which of the following is the most appropriate discharge disposition?

A 65-year-old man is hospitalized for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia secondary to an infected central venous catheter. The catheter was removed, and he was started on intravenous vancomycin 4 days ago. His clinical status has significantly improved, with resolution of fever and two consecutive sets of negative blood cultures. Today, routine laboratory studies show a serum creatinine level of 2.1 mg/dL, representing a significant increase from his baseline of 1.0 mg/dL on admission. His urine output over the past 24 hours has been 600 mL. A serum vancomycin trough level obtained 30 minutes before the next scheduled dose is 29 mcg/mL (therapeutic target for severe infections: 15-20 mcg/mL). Which of the following is the most appropriate next step in the management of this patient's pharmacotherapy?

You are evaluating several patients in an outpatient primary care setting to update their preventive care plans. Based on current United States Preventive Services Task Force (USPSTF) guidelines, match each patient profile to the most appropriate evidence-based screening intervention that is newly indicated or essential for their specific clinical scenario.

A 78-year-old woman is brought to the geriatrics clinic by her daughter due to a 2-week history of worsening confusion, daytime lethargy, and a recent mechanical fall at home. The daughter reports that the patient has been increasingly forgetful, occasionally experiencing visual hallucinations, and complaining of a severely dry mouth. Her medical history is significant for painful diabetic neuropathy, overactive bladder, type 2 diabetes mellitus, hypertension, and osteoarthritis of the knees.

Her current medications include:
- Amitriptyline 50 mg daily
- Oxybutynin 5 mg three times daily
- Zolpidem 5 mg at bedtime
- Metformin 1000 mg twice daily
- Lisinopril 10 mg daily

Vital signs:
- Temperature: 37.0°C (98.6°F)
- Blood pressure: 138/84 mmHg (supine), 125/78 mmHg (standing)
- Heart rate: 82/min
- Respiratory rate: 14/min

Laboratory results:
- Sodium: 139 mEq/L
- Potassium: 4.7 mEq/L
- Blood urea nitrogen: 24 mg/dL
- Creatinine: 1.2 mg/dL (baseline 1.1 mg/dL)
- Glucose: 145 mg/dL

Physical examination reveals a frail woman who is disoriented to time and date. Mucous membranes are exceedingly dry. There are no focal neurologic deficits.

Which of the following medications should be immediately discontinued to resolve this patient's current presentation? (Select 3)

A $73$-year-old woman is brought to the emergency department by her daughter after suddenly developing agonizing abdominal pain $4$ hours ago. The patient has a history of ischemic cardiomyopathy, atrial fibrillation, and hypertension. She was prescribed warfarin but stopped taking it two weeks ago due to financial difficulties.

Vital signs are temperature $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure $82/50\text{ mm Hg}$, pulse $135/\text{min}$ and irregularly irregular, and respirations $26/\text{min}$. Physical examination reveals a distended abdomen with diffuse, severe tenderness, involuntary guarding, and rebound tenderness. Bowel sounds are absent.

Laboratory studies show a leukocyte count of $22,000/\text{mm}^3$ and a serum lactate level of $8.1\text{ mmol/L}$. Computed tomography angiography (CTA) of the abdomen reveals a complete occlusion of the proximal superior mesenteric artery. Air is visible within the bowel wall (pneumatosis intestinalis) and in the portal venous system.

Intravenous fluid resuscitation, broad-spectrum antibiotics, and an unfractionated heparin infusion are immediately initiated.

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

A 52-year-old female presents to the emergency department with a subjective fever and mild fatigue that started 12 hours ago. She is currently undergoing adjuvant chemotherapy (docetaxel and cyclophosphamide) for early-stage breast cancer, with her last cycle administered 10 days ago. Her temperature is $38.5^\circ\text{C}$ ($101.3^\circ\text{F}$), blood pressure is $122/78\text{ mmHg}$, pulse is $86/\text{min}$, and respirations are $14/\text{min}$. Pulse oximetry is $99\%$ on room air. Physical examination reveals a well-appearing woman who is alert and oriented. There is no focal source of infection; her lungs are clear, and there is no erythema at her port-a-cath site or signs of mucositis. Laboratory results show a white blood cell count of $800/\text{mm}^3$ with an absolute neutrophil count (ANC) of $350/\text{mm}^3$. Her hemoglobin is $10.5\text{ g/dL}$, platelets are $110,000/\text{mm}^3$, and creatinine is $0.8\text{ mg/dL}$. Blood cultures are drawn. Her Multinational Association for Supportive Care in Cancer (MASCC) risk index score is calculated to be 25. The patient is functionally independent, tolerates oral intake without nausea, and lives with her highly supportive husband in a home located 15 minutes from the hospital with reliable transportation. Based on her clinical status and objective severity scoring, which of the following is the most appropriate disposition and initial management plan?

A 24-year-old male is evaluated in the orthopedic unit for severe left lower leg pain 12 hours after undergoing open reduction and internal fixation of a comminuted midshaft tibia fracture. He describes the pain as a "10/10" burning sensation that is significantly worse than his preoperative pain. The pain is not relieved by escalating doses of intravenous hydromorphone. On physical examination, the left lower leg is visibly swollen, and the skin is tense and shiny. Passive dorsiflexion of the toes elicits excruciating pain. Sensation to light touch is decreased over the first dorsal web space. Dorsalis pedis and posterior tibial pulses are equal and brisk. Which of the following are the most appropriate next steps in the management of this patient? (Select all that apply)

A 61-year-old man presents to the primary care clinic for a follow-up visit. Three weeks ago, he was diagnosed with active pulmonary tuberculosis and started on a regimen of rifampin, isoniazid, pyrazinamide, and ethambutol. Two days ago, he presented to an urgent care clinic with palpitations and was diagnosed with new-onset atrial fibrillation. His past medical history is significant for hypertension, type 2 diabetes mellitus, and heart failure with preserved ejection fraction. Based on a CHA2DS2-VASc score of 4, the urgent care physician initiated apixaban and metoprolol. The patient reports that his palpitations have resolved, and he has not experienced any bleeding, bruising, or neurologic symptoms. His temperature is 37.1°C (98.8°F), blood pressure is 126/78 mmHg, and pulse is 76/min and irregularly irregular. Cardiopulmonary examination is otherwise unremarkable. Which of the following is the most appropriate modification to this patient's pharmacotherapy?