Tüm alıştırma soruları

Match each clinical presentation with the single most appropriate evidence-based screening, immunization, or preventive intervention.

A 54-year-old man who underwent an orthotopic heart transplant six months ago is admitted to the hospital with hemoptysis, pleuritic chest pain, and a low-grade fever. His maintenance immunosuppressive regimen consists of tacrolimus, mycophenolate mofetil, and low-dose prednisone. Chest computed tomography reveals a right upper lobe dense consolidation with a surrounding halo of ground-glass opacity. Serum galactomannan testing is markedly positive, establishing a diagnosis of invasive pulmonary aspergillosis. The infectious disease service recommends initiating intravenous posaconazole therapy immediately.

Which of the following treatment modifications and monitoring strategies are indicated for this patient upon starting the antifungal therapy? (Select two)

A 28-year-old woman is brought to the emergency department by paramedics after experiencing sudden-onset, severe lower abdominal pain and a syncopal episode at home. She reports that her last menstrual period was 7 weeks ago. Her past medical history is significant for a lifelong tendency to bruise easily, frequent epistaxis, and heavy menstrual bleeding. For her bleeding issues, she occasionally uses a specific nasal spray prescribed by her hematologist.

Vital signs on arrival are: temperature 37.0°C (98.6°F), blood pressure 85/50 mmHg, heart rate 128/min, and respiratory rate 22/min. Physical examination reveals a pale, diaphoretic patient with a distended abdomen exhibiting diffuse tenderness, guarding, and rebound tenderness.

Laboratory studies are as follows:

The patient is urgently prepped for surgery for a presumed ruptured ectopic pregnancy. In addition to addressing the acute hemorrhage, the surgical team must formulate a care plan for her underlying bleeding diathesis. Which of the following conditions most likely accounts for this patient's underlying hematologic abnormality?

An asymptomatic 37-year-old man presents to the outpatient clinic to establish primary care. He feels well and reports no fatigue, polyuria, or changes in vision. His medical history is unremarkable, and he takes no prescription medications. He works as a software engineer and describes his lifestyle as sedentary. He does not smoke or use illicit drugs and consumes alcohol socially. His father was diagnosed with type 2 diabetes mellitus at age 50.

Records indicate he had a normal fasting lipid panel at age 32 and a negative hepatitis C antibody test three years ago.

Vital signs show a blood pressure of 126/80 mm Hg and a heart rate of 72/min. His body mass index is 29 kg/m^2. Physical examination is unremarkable, with no acanthosis nigricans or peripheral edema.

In accordance with current preventive care guidelines, which of the following is the most appropriate screening test to perform today?

A 70-year-old man presents to the preoperative clinic for evaluation prior to an elective right total hip arthroplasty for severe osteoarthritis. His medical history is significant for hypertension, hyperlipidemia, and a non-ST-segment elevation myocardial infarction (NSTEMI) that occurred 6 weeks ago. At that time, he underwent percutaneous coronary intervention with the placement of a drug-eluting stent (DES) in the left anterior descending artery. His current medications include aspirin, clopidogrel, metoprolol, lisinopril, and atorvastatin. He reports no chest pain or shortness of breath with his current limited daily activities. Vital signs are within normal limits. Physical examination is unremarkable except for decreased range of motion and crepitus in the right hip. Which of the following are the most appropriate recommendations regarding his surgical and perioperative management? (Select all that apply)

A 66-year-old man is evaluated for discharge on hospital day 12. He was admitted for a severe acute exacerbation of chronic obstructive pulmonary disease (COPD) requiring intubation and mechanical ventilation. He was successfully extubated three days ago and is currently stable on 2 L/min of oxygen via nasal cannula. He is hemodynamically stable, afebrile, and his acute respiratory infection has resolved. His comorbidities include heart failure with preserved ejection fraction and type 2 diabetes mellitus. During his intensive care unit stay, he developed a new Stage 3 pressure injury on his sacrum that requires daily skilled wound care. Prior to admission, he was fully ambulatory and independent. Currently, he requires moderate assistance with all transfers and can walk only 15 feet with a walker before becoming severely dyspneic and fatigued. A physical therapy evaluation concludes that he has significant rehabilitation potential but can currently tolerate a total of only 60 to 90 minutes of therapy spread throughout the day due to cardiopulmonary limitations. Laboratory studies show a stable serum creatinine of 1.4 mg/dL (baseline 1.3 mg/dL). He lives with his elderly wife, who has severe osteoarthritis and uses a wheelchair, rendering her unable to assist him with mobility or personal care.

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

A $58$-year-old man is admitted to the hospital with a $2$-day history of diffuse abdominal pain, fever, and confusion. He has a history of decompensated alcohol-associated cirrhosis. His current medications include furosemide, spironolactone, and nadolol. Temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $96/60\text{ mm Hg}$, pulse is $102/\text{min}$, and respirations are $18/\text{min}$. Physical examination reveals scleral icterus, spider angiomata, and a distended, diffusely tender abdomen with shifting dullness. Mild asterixis is present.

Laboratory results:
Hemoglobin: $10.2\text{ g/dL}$
Platelet count: $88,000/\text{mm}^3$
Leukocyte count: $11,500/\text{mm}^3$
Blood urea nitrogen: $36\text{ mg/dL}$
Serum creatinine: $1.8\text{ mg/dL}$ (baseline $1.0\text{ mg/dL}$)
Total bilirubin: $3.4\text{ mg/dL}$
INR: $1.7$

Diagnostic paracentesis yields cloudy ascitic fluid with a polymorphonuclear leukocyte count of $650/\text{mm}^3$. Intravenous cefotaxime is initiated, and his home medications are temporarily withheld. Which of the following is the most appropriate additional pharmacologic intervention at this time?

A 78-year-old woman is evaluated in the intensive care unit for new-onset fever and abdominal pain. She was admitted 5 days ago for a massive anterior ST-segment elevation myocardial infarction complicated by cardiogenic shock. She currently remains on a dobutamine infusion for hemodynamic support. Over the past 12 hours, her temperature has risen to 39.2°C (102.6°F) and she has developed significant right upper quadrant abdominal tenderness. Her blood pressure is 88/56 mm Hg and pulse is 115/min. Laboratory studies show a leukocyte count of 18,500/mm³ with a left shift. Liver function tests reveal normal total bilirubin and alkaline phosphatase levels. A bedside right upper quadrant ultrasound demonstrates gallbladder wall thickening of 6 mm, pericholecystic fluid, and a positive sonographic Murphy sign. No gallstones or common bile duct dilation are visualized. Intravenous broad-spectrum antibiotics are initiated. Which of the following is the most appropriate next step in the management of this patient?

A 45-year-old man is evaluated by the multidisciplinary care team for discharge planning on hospital day 12. He was originally admitted after sustaining a traumatic brain injury and multiple rib fractures in a motor vehicle collision. His hospital course was initially complicated by a brief period of mechanical ventilation, but he was extubated on day 4 and is currently medically stable. Vital signs are within normal limits. On physical examination, the patient is alert and oriented to person, place, and time. He has residual right-sided hemiparesis, with motor strength of 3/5 in the right upper and lower extremities. His swallowing function is intact. A physical therapy evaluation demonstrates that he requires moderate assistance with bed-to-chair transfers and ambulation. The patient is highly motivated and successfully participated in a combined total of 3.5 hours of physical, occupational, and speech therapy yesterday without excessive fatigue. His wife is supportive and plans to take a leave of absence from work to assist him, but they live in a two-story home with bedrooms on the second floor. Which of the following is the most appropriate disposition for this patient?

A 78-year-old man is being prepared for discharge after a 12-day hospitalization for urosepsis. Upon admission, his temperature was 38.9°C (102.0°F), blood pressure was 85/50 mm Hg, and serum creatinine was 3.2 mg/dL. He responded well to intravenous fluids and antibiotics; current vitals are temperature 37.1°C (98.8°F), blood pressure 122/76 mm Hg, and heart rate 78/min. His serum creatinine has improved to 1.8 mg/dL. Despite medical stabilization, his functional status has declined, requiring the assistance of two people for transfers. Furthermore, his cognitive status continues to fluctuate with new-onset delirium, and a formal assessment reveals he currently lacks medical decision-making capacity. The care team is initiating the discharge process. Arrange the following critical steps in this patient's transition of care in the most appropriate chronological order to ensure a safe, legally sound, and comprehensive disposition.

A $34$-year-old female is evaluated in the emergency department after experiencing the abrupt onset of severe, cramping periumbilical pain radiating to her back $6$ hours ago. She has also had multiple episodes of bilious vomiting. Her medical history is significant for morbid obesity, for which she underwent an uncomplicated laparoscopic Roux-en-Y gastric bypass $4$ years ago. Her current body mass index is $26 \text{ kg/m}^2$. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $112/68 \text{ mm Hg}$, pulse is $118/\text{min}$, and respirations are $20/\text{min}$. Physical examination reveals a non-distended but diffusely tender abdomen, particularly in the periumbilical region, with mild voluntary guarding. Bowel sounds are high-pitched and hyperactive. Laboratory studies show a leukocyte count of $14,200/\text{mm}^3$ and a serum lactate level of $3.1 \text{ mmol/L}$. A computed tomography scan of the abdomen and pelvis with intravenous contrast reveals small bowel dilation with a transition point and a 'swirl sign' of the mesenteric vessels. Which of the following is the most appropriate next step in management?

A community health center is initiating a quality improvement protocol to address gaps in age-appropriate and risk-appropriate preventive services. Based on current United States Preventive Services Task Force (USPSTF) guidelines, match each patient profile with the single most urgently indicated screening intervention.

A 42-year-old woman is evaluated in the clinic for a scheduled 4-week follow-up visit. One month ago, she was diagnosed with latent tuberculosis infection after a positive interferon-gamma release assay during a routine occupational health screening. She was started on a 9-month course of daily isoniazid and pyridoxine. Today, the patient reports perfect adherence to her medication regimen. She feels well and specifically denies fatigue, anorexia, nausea, vomiting, right upper quadrant pain, or dark-colored urine. She has no history of liver disease and takes no other medications. She does not consume alcohol.

Vital signs are within normal limits. Physical examination reveals anicteric sclerae and a soft, non-tender abdomen with no palpable hepatomegaly.

Laboratory studies show:
Alanine aminotransferase (ALT): 115 U/L (Reference: 7–52 U/L)
Aspartate aminotransferase (AST): 98 U/L (Reference: 10–40 U/L)
Alkaline phosphatase: 80 U/L (Reference: 40–120 U/L)
Total bilirubin: 0.9 mg/dL (Reference: 0.1–1.2 mg/dL)

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

A 62-year-old man is recovering on the general medical floor after a three-week hospitalization for severe sepsis secondary to ascending cholangitis. He initially required vasopressor support and mechanical ventilation but is now hemodynamically stable, afebrile, and breathing comfortably on room air. Due to significant intensive care unit-acquired weakness, he cannot perform basic activities of daily living independently. The primary internal medicine team determines that he requires transfer to a skilled nursing facility (SNF) for comprehensive physical and occupational therapy prior to returning home.

Arrange the following essential steps of this care transition process in the most appropriate chronological sequence to ensure patient safety and minimize the risk of readmission.

A 71-year-old man presents to the primary care clinic reporting intense pain and swelling in his right big toe that began abruptly overnight. He states the pain is so severe that he cannot bear weight on his foot or tolerate the touch of a bedsheet. His medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of $30\%$, stage 4 chronic kidney disease with a baseline estimated glomerular filtration rate of $24 \text{ mL/min/1.73 m}^2$, and a hospitalized episode of bleeding peptic ulcer disease three years ago. His current daily medications include carvedilol, sacubitril-valsartan, and low-dose aspirin. Vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $118/76\text{ mmHg}$, and heart rate $78\text{/min}$. Physical examination reveals a markedly erythematous, warm, swollen, and exquisitely tender first metatarsophalangeal joint on the right foot. The remainder of the joint examination is unremarkable. Which of the following is the most appropriate initial pharmacologic intervention for this patient's acute joint pain?

A 62-year-old woman is brought to the emergency department after her family noticed sudden-onset difficulty speaking and right-sided facial droop that began 45 minutes ago. Her medical history includes hypertension and type 2 diabetes mellitus. She is not taking any anticoagulant medications. Vital signs show a blood pressure of 165/90 mm Hg, heart rate of 82/min, and respiratory rate of 16/min. Neurological examination reveals expressive aphasia, right-sided facial droop, and right upper extremity weakness. The physician prepares to evaluate the patient for intravenous thrombolysis. Which of the following diagnostic tests MUST be obtained and reviewed prior to the administration of intravenous alteplase? (Select all that apply)

During a scheduled ambulatory clinic visit, a $57$-year-old woman reports a $3$-day history of escalating pain and swelling in her left lower extremity. Her medical history is significant for hypertension, diabetic nephropathy, and morbid obesity. Her current medications include nifedipine, sitagliptin, and subcutaneous insulin detemir. Blood pressure is $142/88$ mmHg, pulse is $82$/min, and respirations are $16$/min. Pulse oximetry shows $98\%$ on room air. Physical examination reveals that the left calf is erythematous, warm, and measures $5$ cm larger in circumference than the right calf. A compressive duplex ultrasonography reveals an acute, noncompressible thrombus in the left popliteal vein. Laboratory studies show:

Hemoglobin: $11.8$ g/dL
Platelet count: $230,000$/mm $^3$
Serum creatinine: $3.1$ mg/dL
Estimated glomerular filtration rate (eGFR): $19$ mL/min/$1.73$ m $^2$

The patient is hemodynamically stable with normal oxygenation. The physician determines she is an appropriate candidate for immediate outpatient management of her deep vein thrombosis.

Which of the following is the most appropriate pharmacologic intervention for this patient?

A 55-year-old man develops abrupt right-sided chest pain and dyspnea while recovering on the surgical ward. He underwent a partial colectomy for perforated diverticulitis $7$ days ago. His postoperative recovery was complicated by severe sepsis and ischemic acute tubular necrosis, for which he currently requires hemodialysis every other day. Since the day of surgery, he has been receiving twice-daily subcutaneous injections of unfractionated heparin for deep vein thrombosis prophylaxis.

Current vital signs include a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $110/70\text{ mm Hg}$, heart rate of $118/\text{min}$, and respiratory rate of $24/\text{min}$. Pulse oximetry shows $92\%$ on $4\text{ L/min}$ supplemental oxygen via nasal cannula.

A CT pulmonary angiogram confirms an acute segmental pulmonary embolism in the right lower lobe.

Today's laboratory results show:
Hemoglobin: $9.8\text{ g/dL}$
Platelet count: $48,000/\text{mm}^3$ (down from $260,000/\text{mm}^3$ on admission)
Blood urea nitrogen: $52\text{ mg/dL}$
Serum creatinine: $5.1\text{ mg/dL}$

The surgical team suspects heparin-induced thrombocytopenia (HIT). In addition to immediately discontinuing all heparin products, which of the following is the most appropriate pharmacologic intervention?

Emergency medical services arrive with an elderly female patient, aged $74$ years, complaining of an abrupt onset of excruciating left lower extremity pain that started $4$ hours prior to arrival. Her medical history is significant for hypertension, type $2$ diabetes mellitus, and paroxysmal atrial fibrillation. She admits she stopped taking her prescribed apixaban two weeks ago due to financial difficulties.

On physical examination, the patient is in obvious distress. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), heart rate is $118/\text{min}$ and irregular, blood pressure is $145/88\text{ mmHg}$, and respiratory rate is $18/\text{min}$. Evaluation of the left lower extremity reveals it is pale, cold to the touch, and exhibits mottled skin distal to the knee. The patient reports profound numbness over the dorsum of the foot and is completely unable to dorsiflex her toes. Palpation of the left femoral pulse is normal, but the popliteal, dorsalis pedis, and posterior tibial pulses are absent. Bedside continuous-wave Doppler evaluation demonstrates absent arterial signals over the distal left leg, while venous signals remain audible.

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

A retired construction worker, 68 years of age, is evaluated in the critical care resuscitation bay shortly after experiencing a sudden, excruciating pain between his shoulder blades that he describes as "ripping." He has a history of poorly controlled hypertension and tobacco use. Vital signs reveal a heart rate of 122/min, a respiratory rate of 22/min, and a blood pressure of 78/40 mm Hg in the right arm. On physical examination, the patient is visibly diaphoretic, pale, and lethargic. Cardiopulmonary auscultation reveals a new, faint early decrescendo diastolic murmur at the right upper sternal border. The lungs are clear to auscultation bilaterally. Electrocardiography demonstrates sinus tachycardia with non-specific ST-segment changes. Intravenous fluid resuscitation is immediately initiated via two large-bore peripheral catheters. Which of the following is the most appropriate next step in the diagnostic workup?