Tüm alıştırma soruları

A 31-year-old woman is evaluated in the neurology clinic to discuss escalating her disease-modifying therapy. She has a 4-year history of relapsing-remitting multiple sclerosis. Despite strict adherence to glatiramer acetate, she has experienced three distinct clinical relapses over the past year. A recent magnetic resonance imaging (MRI) scan of the brain and cervical spine reveals multiple new T2-hyperintense and gadolinium-enhancing lesions. The physician decides to transition her to oral fingolimod. She has a remote history of an appendectomy but is otherwise healthy. Vital signs are normal. Which of the following baseline assessments and initiation protocols are strictly required to ensure the safe administration of this specific medication? (Select exactly 2 options)

A 42-year-old woman presents to the ambulatory clinic for a routine wellness examination. She has not seen a physician in four years. The patient has no specific health complaints. Her medical history is significant only for mild allergic rhinitis, for which she takes over-the-counter cetirizine as needed. Menarche occurred at age 12, and she is nulliparous. She currently uses an oral contraceptive pill. Family history is notable for her maternal grandmother being diagnosed with breast cancer at age 78. She drinks one glass of wine on weekends and has never smoked. Vital signs are within normal limits. Physical examination reveals soft, non-tender breasts with no palpable masses, skin dimpling, axillary lymphadenopathy, or nipple discharge. She has never undergone breast imaging. Which of the following is the most appropriate next step in preventive care for this patient?

A $62$-year-old man presents to the outpatient clinic for a follow-up visit. Three days ago, he was evaluated in the emergency department for right calf pain and swelling. A venous compression ultrasound confirmed an acute, unprovoked deep vein thrombosis in the right popliteal vein. He was started on oral apixaban monotherapy and discharged. He has a history of essential hypertension and osteoarthritis. His current medications include apixaban, lisinopril, and acetaminophen. He feels well today, and his right leg swelling has mildly improved. His blood pressure is $128/78$ mmHg, heart rate is $72$/min, and respiratory rate is $14$/min. Which of the following parameters are strictly recommended to obtain at baseline and for periodic monitoring during this patient's ongoing anticoagulant therapy? (Select all that apply)

A 68-year-old man is evaluated in the intensive care unit for decreased urine output. He was admitted 8 days ago for a severe exacerbation of chronic obstructive pulmonary disease requiring endotracheal intubation and mechanical ventilation. On hospital day 5, he developed a fever, increased oxygen requirements, and new infiltrates on chest radiography. Endotracheal aspirate cultures subsequently grew Methicillin-resistant Staphylococcus aureus (MRSA), and he was started on intravenous vancomycin. Today, his urine output over the past 24 hours has been 350 mL. Temperature is 37.8°C (100.0°F), blood pressure is 110/70 mm Hg, and pulse is 92/min. Laboratory studies show a serum blood urea nitrogen of 48 mg/dL and a serum creatinine of 3.2 mg/dL (baseline was 1.1 mg/dL upon admission). The serum vancomycin trough level is 34 mcg/mL (therapeutic range: 15-20 mcg/mL). The physician decides to discontinue vancomycin due to acute kidney injury. Which of the following is the most appropriate alternative pharmacologic intervention to treat this patient's pulmonary infection?

A 54-year-old male is preparing for transfer to a skilled nursing facility (SNF) following a prolonged 28-day hospitalization for necrotizing pancreatitis. His hospital course was complicated by critical illness polyneuropathy and newly insulin-dependent diabetes mellitus. The multidisciplinary team has cleared him for discharge, and the case manager has secured an available bed at the SNF for today.

To ensure a safe care transition and adhere to standardized patient handoff protocols, arrange the following transitional care steps in the most appropriate chronological sequence.

A male patient, aged $42$, presents to his primary care provider with a $3$-month history of excessive urination and an unquenchable thirst, requiring him to consume over $5$ liters of water daily. He has a $10$-year history of bipolar I disorder, which has been well-controlled on lithium carbonate. Two prior attempts by his psychiatrist to taper the lithium and transition to alternative mood stabilizers resulted in severe manic episodes requiring involuntary inpatient hospitalizations. His current blood pressure is $118/76\text{ mmHg}$ and heart rate is $82\text{/min}$. Laboratory evaluation reveals:

Serum sodium: $146\text{ mEq/L}$
Serum potassium: $4.1\text{ mEq/L}$
Serum creatinine: $1.0\text{ mg/dL}$
Serum lithium: $0.8\text{ mEq/L}$ (therapeutic range: $0.6-1.2\text{ mEq/L}$)
Urine specific gravity: $1.003$
Urine osmolality: $140\text{ mOsm/kg H}_2\text{O}$

During the evaluation, the administration of exogenous desmopressin results in a repeat urine osmolality of $145\text{ mOsm/kg H}_2\text{O}$.

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

A 52-year-old man presents to the clinic for a routine follow-up of hypertension that has been difficult to control. Despite adherence to maximum tolerated doses of amlodipine, lisinopril, and doxazosin, his blood pressure today is 162/98 mm Hg. The patient reports no headaches, palpitations, or diaphoresis. Laboratory studies show a serum potassium of 3.9 mEq/L and a serum sodium of 142 mEq/L. Suspecting a secondary cause of hypertension, the physician orders a screening panel which reveals a plasma aldosterone concentration of 22 ng/dL and a plasma renin activity of 0.5 ng/mL/hr (aldosterone-to-renin ratio = 44). Which of the following is the most appropriate next step in the diagnostic workup?

A 27-year-old man is brought to the emergency department after a high-speed motorcycle collision. On arrival, he is obtunded, and his airway is immediately secured via endotracheal intubation. Vital signs are temperature 34.8°C (94.6°F), heart rate 145/min, and blood pressure 65/40 mmHg. Breath sounds are equal bilaterally, and a portable chest radiograph is unremarkable. The pelvis is mechanically stable. An extended focused assessment with sonography for trauma (eFAST) scan shows a large amount of free fluid in the hepatorenal and splenorenal spaces, with no pericardial effusion. A massive transfusion protocol is initiated.

Arrange the following surgical and procedural interventions in the most appropriate chronological order for this patient's definitive management.

A 47-year-old male agricultural worker is brought to the emergency department by his supervisor due to sudden onset of confusion, severe vomiting, and labored breathing. The symptoms began approximately 45 minutes ago while he was spraying pesticides in an enclosed greenhouse. The patient is lethargic, diaphoretic, and drooling copiously. His temperature is 36.8°C (98.2°F), blood pressure is 95/55 mm Hg, pulse is 42/min, and respirations are 28/min. Pulse oximetry shows 86% on room air. Physical examination reveals bilateral miosis, diffuse pulmonary wheezing, and visible muscle fasciculations in the upper extremities. The patient is coughing up large amounts of frothy sputum. Which of the following is the single most urgent initial step in the management of this patient?

A 77-year-old man is evaluated in the emergency department for a 3-day history of worsening cough, subjective fevers, and mild shortness of breath. His medical history includes hypertension, benign prostatic hyperplasia, and mild osteoarthritis.

Vital signs are temperature $38.0^{\circ}\text{C}$ ($100.4^{\circ}\text{F}$), heart rate $88/\text{min}$, blood pressure $130/80 \text{ mmHg}$, respiratory rate $20/\text{min}$, and oxygen saturation $95\%$ on room air. Physical examination reveals an alert and cooperative patient. Lung auscultation reveals crackles in the left lower lung field.

Laboratory results:
Leukocytes: $11,200/\text{mm}^3$
Blood urea nitrogen: $18 \text{ mg/dL}$
Creatinine: $1.0 \text{ mg/dL}$

A chest radiograph demonstrates patchy consolidation in the left lower lobe. He is diagnosed with community-acquired pneumonia. A calculated Pneumonia Severity Index (PSI) places him in Risk Class II, and his CURB-65 score is $1$ (for age $\geq 65$).

During the evaluation, the patient attempts to ambulate to the bathroom but requires the assistance of two nurses due to profound generalized weakness and unsteadiness. He states he has barely eaten or consumed fluids for 3 days because he has been too weak to get out of bed. He lives alone in a second-floor apartment, and his only child lives in another country.

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

A 68-year-old retired teacher is admitted to the cardiac telemetry unit for the elective initiation of dofetilide to maintain normal sinus rhythm after a recent electrical cardioversion for symptomatic atrial fibrillation. He has a history of hypertension and ischemic cardiomyopathy. His home medications include lisinopril, metoprolol succinate, and apixaban. His vital signs are stable, and the physical examination is unremarkable. The care team is planning the mandatory safety protocol for initiating this antiarrhythmic therapy.

Arrange the following clinical steps in the correct chronological sequence for the initiation, monitoring, and evaluation of dofetilide therapy in this patient.

Paramedics arrive at the emergency department with a $72$-year-old gentleman who experienced a sudden syncopal episode at his residence. Upon regaining consciousness in transit, he complained of excruciating, tearing pain radiating from his mid-abdomen to his lower back. His past medical history is significant for hypertension, hyperlipidemia, tobacco use disorder, and a $4.8$-cm infrarenal abdominal aortic aneurysm identified on ultrasound $18$ months ago. Upon arrival, he is lethargic, pale, and profoundly diaphoretic. Vital signs show a temperature of $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), heart rate of $138$/min, respiratory rate of $26$/min, and blood pressure of $72/42$ mm Hg. Cardiopulmonary auscultation is unremarkable. Abdominal examination reveals a tender, pulsatile midline mass. Both lower extremities are cool with barely palpable dorsalis pedis pulses. Intravenous access is secured with two large-bore catheters, and uncrossmatched blood transfusion is initiated. Which of the following is the most appropriate next step in management?

A patient is currently receiving treatment in the cardiovascular step-down unit for a massive pulmonary embolism diagnosed three days ago. She was initially started on an unfractionated heparin infusion. Today, her daily laboratory monitoring reveals a precipitous drop in her platelet count. She has also developed a new, painful, swollen right calf.

A serotonin release assay is sent, and a clinical diagnosis of heparin-induced thrombocytopenia (HIT) with a new deep vein thrombosis is suspected.

Arrange the following management and monitoring steps in the correct chronological sequence to appropriately treat this patient's condition and safely transition her to long-term oral anticoagulation with warfarin.

An established 66-year-old female patient is evaluated in the ambulatory clinic for her annual health maintenance visit. She has no acute complaints and reports feeling well. Her medical history is notable for mild primary hypertension, which is well-controlled on amlodipine. She has never smoked cigarettes and consumes a glass of wine occasionally in social settings. She underwent a normal screening colonoscopy eight years ago and a normal screening mammogram three months ago. A fasting lipid panel performed last year was within normal limits. Her gynecologic history reveals negative cervical cytology and high-risk human papillomavirus (HPV) co-testing at ages 58 and 63, with no history of cervical dysplasia or immunocompromise. Her blood pressure is 124/78 mm Hg, and her body mass index is 23 kg/m². Physical examination is unremarkable. Which of the following is the most appropriate next step in preventive care for this patient?

A 64-year-old woman comes to the primary care clinic reporting two days of dysuria, urinary frequency, and suprapubic discomfort. She has no fever, flank pain, or vaginal discharge. Her medical history is significant for a mechanical mitral valve replacement, for which she takes chronic warfarin therapy. Her last international normalized ratio (INR) was 3.1 one week ago. She has a documented severe anaphylactic allergy to fluoroquinolones. Vital signs are within normal limits. Urinalysis is positive for leukocyte esterase and nitrites. The physician determines she has an uncomplicated urinary tract infection and plans to prescribe a 3-day course of oral trimethoprim-sulfamethoxazole. Which of the following is the most appropriate pharmacologic management strategy for this patient?

During a specialized hematology clinic visit, a 31-year-old female teacher is evaluated for a recent onset of left-sided calf swelling and erythema. A compressive ultrasound confirms an occlusive thrombus in the left femoral vein. Her past medical history is notable for two first-trimester pregnancy losses and a transient ischemic attack four years ago. She currently takes no daily medications. Physical examination is unremarkable except for the left lower extremity edema. Initial laboratory analysis reveals a normal prothrombin time (PT) but an activated partial thromboplastin time (aPTT) of 62 seconds (reference: 25-40 seconds). When the patient's plasma is mixed in a 1:1 ratio with normal pooled plasma, the aPTT remains prolonged at 58 seconds. Which of the following is the most likely diagnosis?

A 31-year-old woman with a history of myasthenia gravis presents to the emergency department with a two-day history of progressively worsening difficulty swallowing and a weak voice. She states that she recently recovered from a mild upper respiratory infection. Upon evaluation, she is visibly anxious and using accessory neck muscles to breathe. She has a weak, ineffective cough and is unable to clear pooling oropharyngeal secretions. Vital signs are temperature 37.4°C (99.3°F), blood pressure 132/86 mm Hg, pulse 118/min, and respirations 34/min. Oxygen saturation is 87% on room air. Arterial blood gas analysis on room air reveals a pH of 7.28, $\text{pCO}_2$ of 58 mm Hg, and $\text{pO}_2$ of 60 mm Hg. Which of the following is the most appropriate initial step in the management of this patient?

A 59-year-old woman is evaluated in the intensive care unit shortly after admission for progressive dyspnea, orthopnea, and confusion over the past 48 hours. She has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of 20%, type 2 diabetes mellitus, and chronic kidney disease stage 3. Her home medications include sacubitril-valsartan, metoprolol succinate, spironolactone, dapagliflozin, and oral torsemide.

Vital signs are temperature 36.8°C (98.2°F), blood pressure 82/54 mm Hg, pulse 114/min, and respirations 26/min. Pulse oximetry shows an oxygen saturation of 88% on room air. Physical examination reveals lethargy and confusion. The jugular venous pressure is estimated at 14 cm H2O. Auscultation of the lungs reveals diffuse bilateral crackles extending to the apices. Cardiac examination shows a regular tachycardia with a prominent S3 gallop. The extremities are cool to the touch and mottled, with a capillary refill time of 5 seconds.

Laboratory studies show:
Serum sodium: 132 mEq/L
Serum potassium: 3.3 mEq/L
Serum creatinine: 2.1 mg/dL (baseline 1.5 mg/dL)
B-type natriuretic peptide (BNP): 1,450 pg/mL
High-sensitivity troponin T: 34 ng/L (normal < 14 ng/L)

Electrocardiogram shows sinus tachycardia with a left bundle branch block, unchanged from prior.

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

Determine the most appropriate care setting transition or disposition for each of the following patients based on their clinical risk stratification, functional status, and acute care needs.

A 73-year-old retired pilot arrives at the emergency department accompanied by his wife, complaining of a sudden, agonizing pain across his entire abdomen that started approximately 90 minutes ago. He has a known medical history of heart failure with preserved ejection fraction and paroxysmal atrial fibrillation, for which he has been poorly compliant with his prescribed anticoagulant therapy. Shortly before leaving his house, he passed a large amount of dark red blood from his rectum. Vital signs show a temperature of 37.2°C (99.0°F), blood pressure of 162/94 mmHg, heart rate of 122/min with an irregularly irregular rhythm, and respiratory rate of 22/min. On physical examination, the patient appears in severe distress, writhing on the stretcher. However, his abdomen is soft, non-distended, and only mildly tender to deep palpation without any rebound tenderness, guarding, or rigidity. Bowel sounds are hypoactive. Arrange the following differential diagnoses from the MOST likely (highest pre-test probability) to the LEAST likely (lowest pre-test probability) based on this patient's clinical presentation.