Tüm alıştırma soruları

Friends hastily transport a 28-year-old male to the trauma and resuscitation bay after he abruptly developed severe respiratory distress and facial swelling during a seafood dinner. Upon arrival, the patient is clutching his throat, phonating only in single words, and exhibiting marked periorbital edema along with swollen lips. He has no known medical conditions and takes no daily medications. Initial vital signs reveal a temperature of 37.0°C (98.6°F), blood pressure of 76/40 mm Hg, heart rate of 142/min, respiratory rate of 32/min, and oxygen saturation of 86% on room air. Auscultation of the neck and chest demonstrates a high-pitched inspiratory sound and widespread expiratory wheezing. His skin is warm, hyperemic, and covered with raised, pruritic plaques. Which of the following interventions must be initiated simultaneously for the immediate stabilization of this patient? (Select all that apply.)

An unresponsive 32-year-old male is wheeled into the resuscitation bay by his coworkers, who drove him directly from their office building across the street. The colleagues state that the patient began experiencing severe throat tightness, a harsh cough, and profound dizziness just minutes after taking a bite of a catered Thai peanut dish.

Initial vital signs on the monitors show:
Blood pressure: 60/40 mmHg
Heart rate: 148/min (sinus tachycardia)
Respiratory rate: 36/min
Oxygen saturation: 81% on room air
Temperature: 36.9°C (98.4°F)

On physical examination, the patient is deeply obtunded. His face and lips are profoundly swollen, and there is audible high-pitched inspiratory stridor. Auscultation of the chest reveals almost silent lung fields with minimal air entry. Widespread erythematous, raised wheals are visible on his chest and arms. Two large-bore peripheral intravenous lines are immediately established.

Which of the following are the most appropriate simultaneous initial management steps? (Select all that apply)

A 62-year-old man with a history of alcohol-associated cirrhosis (Child-Pugh class C) is brought to the emergency department by his daughter due to increased confusion and abdominal pain over the past 2 days. Home medications include furosemide, spironolactone, nadolol, lactulose, and rifaximin.

On physical examination, temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is 88/56 mmHg, and heart rate is 108/min. The patient is lethargic but arousable and oriented only to person. Scleral icterus is present. The abdomen is distended with a positive fluid wave and diffuse mild tenderness to palpation. Asterixis is elicited.

Diagnostic paracentesis is performed. Ascitic fluid analysis reveals a total protein of 1.2 g/dL and a white blood cell count of 850/mm³ with 80% neutrophils.

Which of the following pharmacologic interventions are appropriate for the initial management of this patient? (Select all that apply)

Evaluate the following distinct radiographic descriptions obtained during the diagnostic workup of adult patients presenting with chronic musculoskeletal symptoms. Match each specific imaging pattern to its most accurate underlying pathophysiologic mechanism or systemic clinical association.

A 28-year-old male pedestrian is struck by a commercial truck moving at high speed. He is brought to the emergency resuscitation bay by paramedics on a backboard with a rigid cervical collar in place. Upon arrival, the patient is obtunded and withdraws only to painful stimuli. Vital signs are temperature 36.2°C (97.2°F), heart rate 142/min, blood pressure 72/40 mm Hg, respiratory rate 26/min, and oxygen saturation 93% on a non-rebreather mask. Physical examination reveals an unstable pelvis that rocks easily on gentle anteroposterior compression. There is a rapidly expanding scrotal hematoma and a visible drop of blood at the urethral meatus. The abdomen is visibly distended, tense, and diffusely tender. A bedside Focused Assessment with Sonography for Trauma (FAST) examination reveals an anechoic stripe in the hepatorenal recess (Morison's pouch). Which of the following interventions should be executed simultaneously as part of this patient's immediate stabilization? (Select all that apply)

A 35-year-old male is transported to the resuscitation bay by paramedics following a diving accident in a shallow pool. He struck his head on the bottom of the pool. Upon arrival, he is conscious and communicative but completely unable to move his upper or lower extremities.

Initial vital signs show a temperature of 36.0°C (96.8°F), a blood pressure of 75/40 mm Hg, a heart rate of 48/min, and a respiratory rate of 8/min with shallow effort. Pulse oximetry displays 86% on room air.

Neurologic examination demonstrates flaccid paralysis and absent deep tendon reflexes across all four limbs, with a lack of sensation to pinprick below the clavicular line. His extremities are warm and flushed.

Arrange the following management steps in the most appropriate chronological order for this patient's initial stabilization and triage.

An intensive care unit team is urgently called to the bedside of a patient admitted yesterday for hepatic encephalopathy. The nurse reports that the patient just experienced a sudden, large-volume episode of hematemesis. The patient appears pale, diaphoretic, and minimally responsive. Current vital signs include a blood pressure of 84/46 mmHg, heart rate of 128/min, and respiratory rate of 24/min. While large-bore intravenous access is being secured and fluid resuscitation is underway, the team prepares for endotracheal intubation for airway protection. Pending an emergent esophagogastroduodenoscopy (EGD), which of the following pharmacologic interventions should be ordered immediately? (Select all that apply)

A $38$-year-old man is brought to the emergency department by his partner due to a $3$-week history of progressive clumsiness in his right hand and difficulty finding words. The patient has a history of HIV but has been nonadherent to antiretroviral therapy for the past two years. He has not had fever, headaches, or seizures. Temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), pulse is $82/\text{min}$, and blood pressure is $120/78 \text{ mmHg}$. On physical examination, the patient is alert and oriented but exhibits expressive aphasia. There is right-sided lower facial weakness. Muscle strength is $4/5$ in the right upper and lower extremities. Deep tendon reflexes are $3+$ on the right, and a Babinski sign is present on the right.

Laboratory studies show a CD4 T-lymphocyte count of $32 \text{ cells/mm}^3$. Serum *Toxoplasma gondii* IgG is positive.

MRI of the brain with intravenous gadolinium reveals asymmetric, confluent areas of T2 hyperintensity in the left frontal and parietal white matter. The lesions do not enhance with contrast, and there is no surrounding vasogenic edema or midline shift.

Which of the following is the most likely diagnosis?

A 68-year-old man presents to the pulmonology clinic with a 9-month history of progressively worsening shortness of breath on exertion and a dry, hacking cough. He is a retired construction worker and has a 30-pack-year smoking history, having quit 10 years ago. His only medication is a daily multivitamin. Vital signs include a blood pressure of 130/80 mm Hg, heart rate of 82/min, respiratory rate of 18/min, and oxygen saturation of 94% on room air. Physical examination reveals fine, "Velcro-like" end-inspiratory crackles at the lung bases bilaterally and distinct digital clubbing. Pulmonary function testing demonstrates a restrictive pattern with a moderately reduced diffusion capacity for carbon monoxide (DLCO). High-resolution computed tomography (HRCT) of the chest reveals bilateral, subpleural, and basilar-predominant reticular opacities with extensive honeycombing and traction bronchiectasis. There are no significant ground-glass opacities, micronodules, or pleural effusions. Based on the interpretation of these imaging findings, which of the following is the most appropriate next step in management?

Evaluate the following patient presentations. Match each patient's specific historical profile (including medication, surgical, or occupational history) to the most likely etiology of their peripheral neuropathy.

A 68-year-old man is brought to the emergency department by his wife after he collapsed in their hallway minutes before arrival. His wife reports that for the past three days, he has been having dark, tarry stools, and this morning he vomited a large volume of dark material resembling coffee grounds. His medical history is notable for hypertension, hyperlipidemia, and osteoarthritis, for which he takes high-dose naproxen daily. The patient arrived via private vehicle and is placed directly into a resuscitation bay. No intravenous access has been established.

On physical examination, the patient appears pale, mottled, and diaphoretic. He is confused and oriented only to person. His airway is patent, and breath sounds are clear and equal bilaterally.

Vital signs are:
Temperature: 36.3°C (97.3°F)
Pulse: 142/min
Blood pressure: 72/40 mm Hg
Respiratory rate: 22/min
Oxygen saturation: 97% on room air

The abdomen is soft but mildly tender in the epigastric region.

Which of the following is the single most urgent initial step in the management of this patient?

For each of the following endocrine and neuroendocrine clinical scenarios, select the most appropriate targeted laboratory investigation to confirm the suspected underlying diagnosis.

A $61$-year-old man is evaluated in the emergency department for a $4$-day history of severe diarrhea and abdominal cramping. He reports having $8$ to $9$ large, watery bowel movements daily, compared to a baseline of $1$ formed stool per day. The patient has a history of metastatic non-small cell lung cancer, for which he has been receiving pembrolizumab therapy for the past $6$ months. He has not traveled recently, and he has not taken any recent antibiotics. Temperature is $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), blood pressure is $108/66 \text{ mm Hg}$, and pulse is $108/\text{min}$. The abdomen is non-distended but diffusely tender to palpation without rebound or guarding. Laboratory evaluation shows:

Hemoglobin: $12.4 \text{ g/dL}$
Leukocyte count: $8,500/\text{mm}^3$
Potassium: $3.1 \text{ mEq/L}$
Creatinine: $1.3 \text{ mg/dL}$ (baseline $0.9 \text{ mg/dL}$)

Stool studies for bacterial pathogens and *Clostridioides difficile* have been sent. Which of the following is the most appropriate next step in the management of this patient's symptoms?

A 24-year-old male is brought to the emergency department following an altercation during which he sustained a stab wound to the left side of his neck. The injury is located midway between the cricoid cartilage and the angle of the mandible. On presentation, he appears anxious and diaphoretic. His blood pressure is 82/45 mm Hg, heart rate is 134/min, and respiratory rate is 26/min. Pulse oximetry shows 92% on room air. His voice is noticeably hoarse. Physical examination reveals an actively oozing, 3-cm laceration on the left anterolateral neck, with an adjacent rapidly expanding, pulsatile hematoma. Which of the following procedural interventions are indicated in the immediate management of this patient? (Select all that apply)

A $34$-year-old woman is brought to the emergency department by emergency medical services after collapsing at a local restaurant. Her friends report that she complained of sudden throat tightness, chest discomfort, and severe dizziness shortly after eating a dish containing peanuts. She has a history of mild asthma but no known food allergies. On arrival, she is lethargic but arousable. Vital signs are temperature $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), heart rate $142/\text{min}$, blood pressure $76/40\text{ mm Hg}$, respiratory rate $28/\text{min}$, and oxygen saturation $92\%$ on room air. Physical examination reveals a diffuse, raised, erythematous, and pruritic rash over her trunk and extremities. Lung auscultation demonstrates diffuse bilateral wheezing. Her extremities are cool and clammy. Which of the following are the most appropriate initial steps in the stabilization of this patient? (Select 2 options)

A 34-year-old man is brought to the emergency department following a high-speed skiing collision in which he struck a tree. On arrival, he is alert and oriented. His temperature is 36.8°C (98.2°F), blood pressure is 118/76 mm Hg, heart rate is 92/min, and respiratory rate is 16/min. Primary survey reveals a patent airway and bilateral breath sounds. There is severe bruising and tenderness over the left lower ribs. Abdominal examination demonstrates tenderness in the left upper quadrant with mild guarding. A Focused Assessment with Sonography for Trauma (FAST) examination reveals a moderate amount of free fluid in the splenorenal recess. One liter of intravenous crystalloid is administered, and the patient's vital signs remain stable. A subsequent contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis is performed. It reveals a 2-cm deep splenic parenchymal laceration and moderate hemoperitoneum. Furthermore, the radiologist notes an irregular area of high attenuation within the splenic parenchyma that is visible on the arterial phase and increases in size on the delayed venous phase. Based on the interpretation of these imaging findings, which of the following is the most appropriate next step in patient management?

An internal medicine physician has diagnosed three cases of subarachnoid hemorrhage in the past two weeks, all of which presented with sudden-onset, severe headaches. Today, a 30-year-old man presents to the clinic with a sudden-onset headache. He has a long history of classic migraines with aura and states that this current headache feels exactly like his usual migraines. The patient's vital signs and physical examination are completely normal. Despite the typical presentation of a recurrent migraine, the physician is highly concerned about a ruptured aneurysm and immediately sends the patient to the emergency department for a non-contrast head computed tomography scan and a lumbar puncture. Which of the following cognitive biases most likely influenced the physician's decision?

A $72$-year-old man with a history of nonvalvular atrial fibrillation, hypertension, and type $2$ diabetes mellitus is evaluated in the clinic for a $4$-week history of productive cough, low-grade fevers, night sweats, and a $4.5$-kg ($10$-lb) weight loss. His current medications include rivaroxaban, lisinopril, and metformin. Vital signs are temperature $37.8^\circ \text{C}$ ($100.0^\circ \text{F}$), blood pressure $132/82 \text{ mm Hg}$, heart rate $88/\text{min}$, and respiratory rate $16/\text{min}$. Physical examination reveals bronchial breath sounds and crackles in the right upper lung field. A chest radiograph demonstrates a cavitary lesion in the apical segment of the right upper lobe. Sputum acid-fast bacilli smears are positive, and a nucleic acid amplification test confirms the presence of *Mycobacterium tuberculosis*. The physician plans to initiate a daily regimen of isoniazid, rifampin, pyrazinamide, and ethambutol. Which of the following is the most appropriate management regarding this patient's anticoagulation?

A 44-year-old female neurologist practices in a suburban community. For the past three years, she has managed a 29-year-old male patient with complex partial seizures, which are currently well-controlled on monotherapy. The neurologist has been a member of a local specialized fitness center for several years. One evening, she receives an automated email from the fitness center's management stating that her long-term personal trainer has relocated, and she has been randomly reassigned to a newly hired trainer. The email includes a photo and name, and the neurologist immediately recognizes the new trainer as her epilepsy patient. Her first training session with him is scheduled for the following week. What is the most appropriate initial action for the neurologist to take?

Match each advanced palliative clinical scenario with the most appropriate, highly specific next step in management.