Tüm alıştırma soruları

Emergency medical services bring a 68-year-old retired teacher to the trauma bay following a high-velocity motor vehicle collision. The patient was the restrained driver of a sedan that struck a concrete barrier at highway speeds. He is awake, alert, and oriented, but reports severe posterior neck pain and a "pins and needles" sensation radiating down both arms. Vital signs include a heart rate of 94/min, blood pressure of 142/88 mmHg, respiratory rate of 16/min, and oxygen saturation of 99% on room air. Physical examination reveals midline cervical bony tenderness to palpation. Neurological assessment demonstrates 4/5 motor strength in bilateral elbow flexion and wrist extension, along with diminished sensation to light touch over the lateral forearms and thumbs. Lower extremity neurological findings are unremarkable. Which of the following is the most appropriate initial diagnostic imaging study for this patient?

For each clinical presentation described below, identify the most appropriate specific imaging modality and protocol required to establish the diagnosis.

An attending nephrologist is reviewing renal biopsy synoptic reports for five different patients presenting with various nephritic and nephrotic syndromes. Match each set of light microscopy (LM), immunofluorescence (IF), and electron microscopy (EM) findings with its corresponding definitive pathologic diagnosis.

A public health research consortium is designing a pragmatic, randomized controlled trial to evaluate a novel mobile health intervention for patients with inadequately controlled type 2 diabetes mellitus. The preliminary sample size analysis indicates that with the maximum feasible recruitment of $250$ patients, the trial will have $65\%$ power to detect a clinically meaningful difference in the primary outcome (absolute change in hemoglobin A1c at 6 months). Due to strict grant limitations, the investigators cannot increase the sample size or extend the enrollment period. The principal investigator asks the team to propose methodological modifications that will increase the statistical power of the study to at least $80\%$ without requiring additional participants.

Which of the following study design or analysis modifications are most likely to increase the statistical power of this trial? (Select all that apply.)

An 81-year-old male with metastatic prostate cancer is evaluated on the oncology unit for acute confusion, severe agitation, and sudden jerking movements of his extremities. The patient was admitted earlier today for worsening bone pain. His home medications include extended-release morphine 60 mg twice daily and immediate-release morphine 15 mg every 4 hours as needed. According to his wife, he has been taking the as-needed morphine around the clock for the past week. He has a history of chronic kidney disease with a baseline serum creatinine of 1.5 mg/dL. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 135/85 mmHg, pulse of 92/min, and respirations of 16/min. Physical examination reveals a restless, disoriented patient exhibiting frequent, involuntary, shock-like muscle contractions throughout all four limbs. Recent laboratory studies demonstrate a serum creatinine level of 3.6 mg/dL. Which of the following is the most appropriate next step in the management of this patient?

A 73-year-old man presents to the clinic for a health maintenance visit. He has not seen a healthcare provider in over a decade. His medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of 25%, New York Heart Association class III heart failure, and severe chronic obstructive pulmonary disease requiring continuous home oxygen therapy. He is a current smoker with a 55 pack-year smoking history. The patient spends the majority of his day resting in a recliner due to dyspnea on minimal exertion. His medications include aspirin, metoprolol succinate, sacubitril-valsartan, empagliflozin, furosemide, and a fluticasone-umeclidinium-vilanterol inhaler.

He has never undergone screening for colon, prostate, or lung cancer. He recently read an article about the importance of early cancer detection and asks which screening tests he should undergo today.

Which of the following is the most appropriate recommendation regarding cancer screening for this patient?

A team of clinical epidemiologists is designing an observational cohort study to evaluate the association between a newly approved biologic therapy for severe asthma and the subsequent risk of developing serious respiratory infections. The investigators are concerned about a specific variable: baseline pulmonary function (measured by FEV1). Patients with poorer baseline FEV1 are more likely to be prescribed the new biologic therapy and are also independently at a higher risk of developing serious respiratory infections, regardless of the treatment they receive.

Which of the following methodological techniques, if appropriately implemented during the design or analysis phase of the study, would effectively control for the confounding effect of baseline pulmonary function? (Select all that apply)

Seeking to establish care after recently relocating, a 68-year-old woman presents to a new primary care provider for a wellness visit. Her past medical history is notable for human immunodeficiency virus (HIV) infection, diagnosed two decades ago, which remains well-controlled on a daily antiretroviral regimen. Her most recent CD4 T-lymphocyte count is 680 cells/mm³, and her viral load is undetectable. She smoked one pack of cigarettes daily from age 20 to age 38, completely abstaining since then.

A review of her previous medical records reveals the following preventive care history:
- A screening colonoscopy at age 60 demonstrated no polyps or masses.
- A screening mammogram performed 11 months ago was interpreted as Breast Imaging Reporting and Data System (BI-RADS) category 1.
- A dual-energy x-ray absorptiometry scan at age 65 showed a T-score of -0.8 at the lumbar spine and femoral neck.
- Cervical cancer screening via cytology and high-risk human papillomavirus (hrHPV) co-testing was performed at ages 59, 62, and 65; all results were negative for intraepithelial lesion or malignancy and negative for hrHPV.

The patient currently takes no medications other than her antiretroviral therapy. She is up to date on her recombinant zoster vaccine, pneumococcal vaccination series, and the seasonal influenza vaccine.

Based on current evidence-based guidelines, which of the following screening tests is indicated for this patient today?

A 24-year-old woman comes to the clinic complaining of a 4-day history of painful urination and increased urinary frequency. She has not experienced fever, chills, back pain, or gross hematuria. Her medical history is unremarkable, and she takes no medications other than an oral contraceptive. She reports having a new male sexual partner for the past month. Vital signs are normal. Physical examination shows no costovertebral angle tenderness, and a pelvic examination reveals no vaginal discharge or cervical motion tenderness. Initial urinalysis in the clinic shows 15-20 WBCs/hpf, positive leukocyte esterase, and negative nitrites. She is empirically prescribed a 5-day course of nitrofurantoin for presumed uncomplicated cystitis. Three days later, she reports no improvement in her symptoms. The standard urine culture from her initial visit is finalized as 'no growth' at 48 hours. Which of the following is the most likely diagnosis?

Match each patient's laboratory profile with the most likely diagnosis.

A 54-year-old man is brought to the emergency department due to sudden onset of severe, "tearing" chest pain that radiates to his interscapular region. The pain started 45 minutes ago while he was moving heavy furniture. He has a history of essential hypertension and tobacco use. On presentation, he is anxious and diaphoretic. Vital signs are temperature 37.0°C (98.6°F), blood pressure 210/120 mmHg in the right arm and 170/100 mmHg in the left arm, heart rate 115/min, and respiratory rate 24/min. Pulse oximetry is 96% on room air. Neurologic examination is unremarkable. Electrocardiogram reveals sinus tachycardia with left ventricular hypertrophy but no acute ischemic changes. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation of a paraneoplastic syndrome with its specific underlying pathophysiologic mechanism.

A 75-year-old man is preparing for discharge to a skilled nursing facility (SNF) after a 12-day hospitalization for decompensated heart failure and acute kidney injury. The attending physician is initiating the transition of care. To maximize patient safety and prevent transition-related adverse events, arrange the following steps of the discharge and handoff process in the most appropriate chronological sequence according to best-practice transition of care protocols.

Emergency medical services bring a 64-year-old male to the emergency department following the sudden onset of profound room-spinning dizziness, intractable nausea, and an inability to maintain his balance. His medical records document long-standing hypertension that is refractory to multiple medications. On physical examination, blood pressure is 182/100 mm Hg and heart rate is 88/min. Neurological assessment reveals mild ptosis of the right eyelid, a right pupil that is 2 mm smaller than the left but reactive to light, and an absence of sweating on the right side of his face. Testing of sensory pathways demonstrates a marked loss of pinprick and temperature sensation over the right side of the face, as well as over the entire left side of his trunk and extremities. Motor strength is fully preserved at 5/5 in all muscle groups. Proprioception and vibratory sensation are completely intact bilaterally. Finger-to-nose testing shows pronounced dysmetria of the right upper extremity. The attending physician suspects an acute infarction involving the lateral aspect of the medulla rather than the lateral pons. Which of the following additional physical examination findings would most reliably confirm this specific anatomical diagnosis?

A 35-year-old man comes to the emergency department due to a 2-day history of severe, progressive right upper quadrant abdominal pain and abdominal swelling. He also reports worsening fatigue and passing dark-colored urine in the mornings over the past few months. His temperature is 37.2°C (99.0°F), blood pressure is 135/85 mm Hg, and pulse is 98/min. Physical examination reveals scleral icterus, tender hepatomegaly, and moderate ascites. A Doppler ultrasound of the abdomen demonstrates absent flow in the hepatic veins, consistent with Budd-Chiari syndrome.

Laboratory results are as follows:

Hemoglobin: 10.2 g/dL
Platelets: 125,000/mm³
Leukocytes: 3,800/mm³
Reticulocyte count: 5.5%
Lactate dehydrogenase: 950 U/L
Haptoglobin: <10 mg/dL (N: 41-165 mg/dL)
Total bilirubin: 3.2 mg/dL
Direct bilirubin: 0.5 mg/dL
Direct antiglobulin (Coombs) test: Negative
Urinalysis: Positive for hemoglobin and hemosiderin, negative for intact red blood cells.

Which of the following is the most appropriate next step in laboratory evaluation to establish the underlying diagnosis?

During a routine health maintenance visit, a 58-year-old male with essential hypertension and chronic kidney disease stage 2 is prescribed lisinopril. His blood pressure in the clinic is 152/94 mmHg. Baseline laboratory studies obtained today show a serum creatinine of 1.2 mg/dL and a serum potassium of 4.3 mEq/L. The patient is instructed on how to take the medication and asked to schedule a follow-up visit. Which of the following is the most appropriate next step in monitoring this patient's new therapy?

A 78-year-old man is evaluated in the intensive care unit for right upper quadrant abdominal pain and fever. Three days ago, he was admitted for an acute anterior ST-elevation myocardial infarction complicated by cardiogenic shock. He was treated with primary percutaneous coronary intervention and placement of a drug-eluting stent. His current medications include aspirin, ticagrelor, high-intensity statin, and a continuous intravenous infusion of norepinephrine.

His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $88/54\text{ mm Hg}$, pulse is $112/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals marked right upper quadrant tenderness with guarding. A bedside ultrasound demonstrates a distended gallbladder with a thickened wall measuring $8\text{ mm}$, pericholecystic fluid, and multiple echogenic gallstones. The common bile duct diameter is $5\text{ mm}$ with no stones visualized within it. Laboratory studies show a leukocyte count of $19,500/\mu\text{L}$, total bilirubin of $0.9\text{ mg/dL}$, and alkaline phosphatase of $110\text{ U/L}$. Intravenous fluid resuscitation and broad-spectrum antibiotics have been initiated.

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

Following an open reduction and internal fixation for a comminuted right tibial diaphysis fracture, a young adult patient is evaluated on the surgical ward for intractable lower extremity pain. The operative procedure was completed 14 hours ago. The overnight nursing staff reports that the patient has required multiple breakthrough doses of intravenous hydromorphone with minimal relief.

The patient describes the pain as a severe, deep burning sensation in the right calf that is significantly worse than his preoperative pain. On physical examination, the right leg is markedly swollen, and the anterior compartment feels exceptionally tight and woody to palpation. Passive plantar flexion of the right ankle elicits agonizing pain. Dorsalis pedis and posterior tibial pulses are 2+ and symmetric with the left foot. Capillary refill is less than 2 seconds in the right toes, but the patient reports decreased sensation to light touch in the first dorsal web space. All compressive dressings and bandages have already been completely removed down to the skin, with no improvement in symptoms.

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

A 63-year-old man presents to the clinic for a routine wellness evaluation. His medical history includes type 2 diabetes mellitus, hyperlipidemia, and mild osteoarthritis. He smoked one pack of cigarettes daily for 25 years but successfully quit at age 45. His family history is non-contributory.

Review of his preventive care records reveals the following:
- A screening colonoscopy performed at age 58 showed three 6-mm tubular adenomas, which were completely excised.
- He received the 20-valent pneumococcal conjugate vaccine (PCV20) at age 58 shortly after his diabetes diagnosis.
- He received a 2-dose series of recombinant zoster vaccine at age 50.
- He received a tetanus-diphtheria-acellular pertussis (Tdap) booster 4 years ago.
- He has never undergone abdominal imaging.

He currently has no symptoms, and his diabetes is well-controlled. Which of the following is the most appropriate next step in this patient's preventive care?

A 75-year-old woman is recovering on the medical ward from a severe chronic obstructive pulmonary disease exacerbation. The attending physician writes orders for her to be transferred to a lower-acuity rehabilitation facility this afternoon. The bedside nurse reviews the chart and notes that during a morning mobility assessment, the patient's oxygen saturation dropped to 84% on room air, requiring a prolonged recovery period before returning to baseline. The nurse approaches the physician and states, "I am concerned that this patient may not be stable enough for transfer today given her significant desaturation during physical therapy." The physician replies, "Her resting vital signs are back to baseline and her wheezing has completely resolved. The facility transport team is already en route, so please prepare her for departure."

According to standardized interprofessional conflict resolution and patient safety protocols, which of the following is the most appropriate next step for the nurse?