Tüm alıştırma soruları

A 58-year-old woman is brought to the emergency department by her husband due to a 3-day history of increasing confusion, sluggishness, and tremors. Her husband reports that she has been sleeping more than usual and has had difficulty holding a glass of water without spilling it. Her medical history is significant for bipolar I disorder, for which she has been stable on lithium carbonate 900 mg daily for the past 5 years. She also has osteoarthritis and began taking naproxen 500 mg twice daily two weeks ago for worsening knee pain.

On physical examination, temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, pulse is 88/min, and respirations are 14/min. She appears lethargic but is easily arousable. Neurologic examination reveals a prominent coarse, irregular tremor in her upper extremities bilaterally, as well as hyperreflexia in all four extremities. No nuchal rigidity is noted.

Serial laboratory studies are shown below:

An electrocardiogram shows normal sinus rhythm with no ST-segment or T-wave abnormalities.

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

A 68-year-old man comes to the clinic for a 1-week follow-up after an adjustment to his heart failure medications. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of 25%. One week ago, spironolactone 25 mg daily was added to his guideline-directed medical therapy regimen to further reduce morbidity and mortality. He is also taking sacubitril-valsartan, carvedilol, and dapagliflozin. The patient reports feeling well and has no shortness of breath, orthopnea, or lower extremity edema. His blood pressure is 114/72 mm Hg, and his pulse is 62/min. Physical examination reveals clear lungs and no jugular venous distention. Laboratory studies obtained today, compared to his baseline from one week ago, are shown in the table below:

Which of the following is the most appropriate next step in the monitoring and treatment evaluation of this patient?

A 52-year-old man visits the clinic due to sudden, severe pain and swelling in his right big toe that began overnight. He is unable to bear weight on the affected foot. His medical history is significant for a deceased-donor renal allograft performed three years ago for end-stage renal disease secondary to hypertensive nephrosclerosis. His current medications include tacrolimus, mycophenolate mofetil, and low-dose prednisone. Vital signs are within normal limits. Physical examination reveals a swollen, erythematous, and exquisitely tender right first metatarsophalangeal joint. Joint aspiration is performed, and synovial fluid analysis reveals negatively birefringent, needle-shaped crystals under polarized light microscopy. His serum creatinine today is 1.6 mg/dL, which is unchanged from his baseline over the past year. Which of the following is the most appropriate pharmacologic intervention for this patient's acute joint condition?

A hospitalist is evaluating the arterial blood gas (ABG) and metabolic panel profiles for several adult patients upon admission. Match each laboratory profile to its most likely clinical etiology. Assume a normal serum anion gap is $8$-$12$ mEq/L.

A 27-year-old woman, gravida 1 para 0, presents to the emergency department with two days of mild, intermittent left lower quadrant abdominal pain and light vaginal spotting. Her last menstrual period was six weeks ago. She has no significant past medical history and takes only prenatal vitamins. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 118/74 mm Hg, heart rate of 82/min, and respiratory rate of 14/min. Physical examination reveals mild left adnexal tenderness on palpation but no cervical motion tenderness or palpable masses. The cervical os is closed, and there is no active bleeding in the vaginal vault. A serum quantitative $\beta$-human chorionic gonadotropin ($\beta$-hCG) level is $950$ mIU/mL. Transvaginal ultrasonography demonstrates a thickened endometrial stripe of 12 mm without a visible intrauterine gestational sac, no adnexal masses, and no free pelvic fluid. Which of the following is the most appropriate next step in evaluating this patient's condition?

Emergency medical services transport a 24-year-old male with a known history of severe persistent asthma to the acute care bay. According to his roommate, the patient experienced progressively worsening shortness of breath over the past 24 hours and had been using his albuterol inhaler continuously with no clinical improvement. Upon evaluation, the patient is obtunded, profoundly diaphoretic, and cannot answer questions or follow commands. His vital signs show a temperature of 37.1°C, heart rate of 145/min, blood pressure of 112/68 mmHg, and a decreasing respiratory rate of 8/min with shallow excursions. Pulse oximetry reads 85% despite high-flow supplemental oxygen via a non-rebreather mask. Auscultation of the lungs reveals a 'silent chest' with markedly diminished air movement and no audible wheezing bilaterally. Which of the following is the most appropriate immediate next step in the stabilization of this patient?

An emergency medical services team brings a 64-year-old man to the resuscitation bay due to sudden-onset, agonizing chest pain that he describes as 'ripping' and radiating directly to his shoulder blades. The pain started abruptly one hour ago while he was carrying groceries. He has a known history of tobacco use and medication nonadherence for hypertension. The patient is visibly distressed, sweating profusely, and unable to find a comfortable position on the stretcher.

Vital signs:
Temperature: 37.1°C (98.8°F)
Blood pressure: 220/120 mm Hg in the right arm, 175/90 mm Hg in the left arm
Heart rate: 118/min
Respiratory rate: 24/min
Oxygen saturation: 97% on room air

An electrocardiogram demonstrates sinus tachycardia with left ventricular hypertrophy but no ST-segment or T-wave abnormalities. A stat portable chest radiograph shows a widened mediastinum.

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

A $71$-year-old female presents to the cardiology clinic for an urgent consultation regarding worsening shortness of breath and ankle swelling over the past $6$ weeks. She reports needing three pillows to sleep at night and becomes breathless after walking just one block. Her past medical history is notable for seropositive rheumatoid arthritis, type 2 diabetes mellitus, essential hypertension, and stage 4 chronic kidney disease. Her medication regimen includes oral methotrexate, subcutaneous adalimumab, metformin, sitagliptin, and lisinopril.

Vital signs show a blood pressure of $134/82 \text{ mmHg}$ and a heart rate of $88\text{ /min}$. Physical examination reveals distended jugular veins, crackles in the lower third of both lung fields, and bilateral $2+$ pitting edema up to the mid-calves.

A transthoracic echocardiogram reveals global hypokinesis with an estimated left ventricular ejection fraction of $25\%$.

Current laboratory values:
Serum potassium: $4.6 \text{ mEq/L}$
Serum creatinine: $2.5 \text{ mg/dL}$ (estimated GFR: $22 \text{ mL/min/}1.73 \text{ m}^2$; baseline $3$ months ago: $2.4 \text{ mg/dL}$)
Hemoglobin A1c: $7.2\%$

Which of the following sets of modifications to this patient's current medications is most appropriate?

A $32$-year-old female fitness instructor is evaluated for a $4$-week history of heart palpitations, severe anxiety, heat intolerance, and excessive sweating. She reports strict adherence to a new competition diet and taking various over-the-counter supplements for "cutting weight." Blood pressure is $145/88$ mm Hg, and pulse is $118$/min. Physical examination shows a fine resting tremor in both hands and hyperreflexia. The thyroid gland is non-palpable and non-tender. There is no proptosis, periorbital edema, or pretibial myxedema.

Laboratory evaluation shows the following:

Which of the following is the most likely diagnosis?

A $34$-year-old man arrives at the trauma bay via helicopter emergency medical services after a high-speed motorcycle collision. He is agitated, pale, and diaphoretic. Vital signs show a blood pressure of $74/40$ mm Hg, a heart rate of $145$/min, and a respiratory rate of $36$/min. His oxygen saturation is $86\%$ despite receiving high-flow oxygen via a nonrebreather mask. Clinical evaluation demonstrates rightward tracheal deviation and absent breath sounds over the left hemithorax, which is hyperresonant to percussion. An anteroposterior compression force on the iliac crests reveals marked pelvic instability. Peripheral intravenous access has just been established. Which of the following simultaneous interventions are the most appropriate immediate next steps in management? (Select all that apply)

A 34-year-old male patient presents for an initial primary care evaluation to establish care. He reports feeling entirely well and has no specific health concerns. He denies headaches, palpitations, diaphoresis, or muscle weakness. He takes no medications and does not use tobacco or illicit drugs. Family history is notable for type 2 diabetes in his father, but no early-onset cardiovascular disease. His blood pressure is 166/104 mmHg. A repeat measurement after 15 minutes of rest is 164/102 mmHg. Physical examination reveals a body mass index (BMI) of 23.5 kg/m $^2$. The abdomen is soft without bruits, and there are no abnormal skin findings or fat redistribution.

Laboratory studies are obtained with the following results:

Arrange the following differential diagnoses in order from HIGHEST pre-test probability to LOWEST pre-test probability based on this patient's clinical presentation.

A 38-year-old man is admitted to the hospital for intravenous antibiotic therapy for right lower extremity cellulitis. His past medical history is significant for treatment-resistant schizophrenia, which has been well-controlled for three years on a stable dose of clozapine (500 mg daily). He smokes two packs of cigarettes per day. Because the hospital is a smoke-free facility, he is prescribed a 21-mg nicotine transdermal patch upon admission to prevent withdrawal symptoms. His admission laboratory studies, including a serum creatinine of 0.8 mg/dL and normal liver enzymes, are unremarkable. He is started on intravenous daptomycin. On hospital day 4, the patient experiences a first-time generalized tonic-clonic seizure. Vital signs immediately following the event are temperature 37.0°C (98.6°F), blood pressure 132/82 mmHg, heart rate 94/min, and respiratory rate 16/min. Neurologic examination demonstrates post-ictal confusion but no focal deficits.

Which of the following medication management strategies upon admission would have most likely prevented this patient's new-onset neurologic complication?

For each of the following patient encounters, identify the specific ethical doctrine or decision-making standard that appropriately justifies the clinical action taken.

A 45-year-old man comes to the clinic for a follow-up visit after being diagnosed with active pulmonary tuberculosis. Sputum acid-fast bacilli smear and culture were positive for Mycobacterium tuberculosis, and he has been started on appropriate four-drug therapy. During the visit, the patient expresses significant anxiety about his diagnosis. He explicitly requests that his medical information not be shared with anyone, particularly government or local authorities, because he fears it will negatively impact his employment. Which of the following is the most appropriate response to this patient's request?

A retired $68$-year-old teacher presents to the emergency department reporting two days of profound fatigue and noticeably reduced urine volume. Four days ago, he underwent an urgent percutaneous coronary intervention with stent placement for a non-ST-segment elevation myocardial infarction. He was discharged the following day in stable condition. His medical history is notable for hypertension, type 2 diabetes mellitus, and hyperlipidemia. Current medications are aspirin, clopidogrel, atorvastatin, and metoprolol.

His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $158/92\text{ mmHg}$, and pulse is $84/\text{min}$. Physical examination reveals a lacy, purplish discoloration in a reticular pattern over his bilateral thighs and lower legs that does not blanch with pressure. The toes on his right foot appear cyanotic, although bilateral dorsalis pedis and posterior tibial pulses are strong and symmetric.

Laboratory studies show:
- Hemoglobin: $13.2\text{ g/dL}$
- Platelet count: $210,000/\mu\text{L}$
- Leukocyte count: $10,500/\mu\text{L}$ (Neutrophils $65\%$, Lymphocytes $25\%$, Eosinophils $10\%$)
- Blood urea nitrogen: $48\text{ mg/dL}$
- Serum creatinine: $2.9\text{ mg/dL}$ (baseline prior to the procedure was $1.1\text{ mg/dL}$)
- Urinalysis: $1-2\text{ RBCs/hpf}$, trace protein, and positive for urinary eosinophils.

Based on these clinical and laboratory findings, which of the following is the most likely diagnosis?

Match each patient's clinical presentation with the most likely underlying neurologic diagnosis.

During multidisciplinary rounds, the care team is planning the next steps for a patient who recently underwent an emergent colectomy for perforated diverticulitis. The patient, a retired teacher, has been hospitalized for two weeks. Acute infectious processes have resolved, and intravenous antibiotics were discontinued yesterday. Vital signs are currently within normal limits.

The physical therapy team notes that the patient experiences significant fatigue, tolerating only 40 minutes of low-intensity mobilization exercises before needing to rest for the remainder of the day. Prior to admission, the patient lived independently with a spouse. Currently, the patient requires moderate physical assistance for bed-to-chair transfers and is unable to safely ambulate. Additionally, the patient has a newly formed stoma; the spouse is eager to assist but has not yet demonstrated competency in ostomy appliance changes despite repetitive nursing instruction.

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

A 55-year-old man is hospitalized for the treatment of community-acquired pneumonia. The attending physician orders intravenous ceftriaxone. The following morning, the physician is notified by the charge nurse that the patient mistakenly received an intravenous infusion of cefazolin instead of ceftriaxone due to a mislabeled intravenous bag delivered from the hospital pharmacy. The patient has no known drug allergies, remains hemodynamically stable, and shows no adverse clinical signs or symptoms from the incorrect medication administration. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old man is evaluated in the surgical step-down unit due to tachycardia. He was transferred from the intensive care unit (ICU) earlier this morning, which is postoperative day 3 following an open abdominal aortic aneurysm repair. During the morning verbal handoff, the night-shift intensivist told the receiving physician, "The patient had some mild tachycardia overnight, but it is just expected postoperative incisional pain; we plan to optimize his epidural." Upon evaluation 3 hours later, the patient's heart rate is 125/min and blood pressure is 88/58 mmHg. He complains of vague, diffuse abdominal discomfort and back pain. The receiving physician documents, "Tachycardia secondary to inadequately controlled pain," and immediately orders an epidural local anesthetic bolus without reviewing the patient's recent hemoglobin level or ordering new laboratory studies. Later that evening, the patient develops profound hemorrhagic shock due to a retroperitoneal bleed. Which of the following cognitive biases best explains the receiving physician's initial decision-making process?

A 68-year-old man is hospitalized for a severe exacerbation of chronic obstructive pulmonary disease and newly diagnosed heart failure with preserved ejection fraction. He has stabilized after 4 days of intravenous diuresis and systemic corticosteroids. The medical team is preparing for his transition out of the acute care hospital. He lives with his daughter, who works during the day. He requires new supplemental oxygen and close monitoring of his fluid status. To minimize the risk of readmission and ensure a safe transition of care, arrange the following discharge planning steps in the most appropriate chronological sequence.