Tüm alıştırma soruları

A $48$-year-old woman comes to the primary care clinic reporting a $3$-month history of progressively worsening weakness. She specifically notes difficulty climbing the stairs to her bedroom and rising from a low chair. Over the past several weeks, she has also experienced mild difficulty swallowing solid foods. She denies any muscle pain, joint swelling, or morning stiffness. Vital signs are within normal limits. Physical examination reveals symmetric $3/5$ strength in the deltoids and hip flexors, with $5/5$ strength in the distal extremities. There is a violaceous periorbital discoloration accompanied by mild edema, as well as erythematous, scaly plaques over the metacarpophalangeal joints. Deep tendon reflexes are $2+$ and symmetric. Laboratory studies show a creatine kinase level of $3,200$ U/L.

Based on this clinical presentation, arrange the following differential diagnoses from the highest pre-test probability (most likely) to the lowest pre-test probability (least likely).

A 32-year-old woman is brought to the emergency department by her husband due to severe confusion, profuse vomiting, and a racing heart over the past 24 hours. She has a known history of Graves disease but discontinued her antithyroid medications three months ago. Her temperature is 40.5°C (104.9°F), blood pressure is 90/55 mm Hg, pulse is 155/min, and respirations are 26/min. The patient is agitated, visibly tremulous, and disoriented to time and place. Cardiopulmonary examination reveals a regular, rapid rhythm and clear lungs. She is warm and profoundly diaphoretic. She is immediately placed on a continuous cardiac monitor and provided supplemental oxygen.

Arrange the following management steps in the most appropriate chronological sequence for the safe initial stabilization and treatment of this patient's acute condition.

A 28-year-old man of Southeast Asian descent presents to the primary care clinic complaining of mild, intermittent fatigue over the past six months. He has no other symptoms, and his past medical history is unremarkable. He follows a strict vegan diet and takes no supplements. Vital signs are within normal limits. Physical examination is notable only for mild conjunctival pallor. The physician suspects an underlying hematologic abnormality and plans a stepwise laboratory evaluation.

Arrange the following diagnostic laboratory tests in the most appropriate chronological sequence to definitively evaluate the etiology of this patient's presentation, from initial screening to definitive confirmation.

A 34-year-old male is brought to the emergency department after a high-speed motorcycle collision. On arrival, his blood pressure is 112/70 mm Hg and heart rate is 108/min. Primary survey reveals a patent airway, bilateral breath sounds, and normal heart sounds. The patient complains of severe lower abdominal and pelvic pain. Examination reveals ecchymosis over the suprapubic and perineal regions. A single drop of blood is noted at the urethral meatus. The prostate cannot be reliably palpated due to severe patient discomfort, and the pelvis is mechanically unstable to gentle compression. Arrange the following imaging modalities in the most appropriate chronological sequence for this patient's diagnostic workup.

A 19-year-old woman is referred to the hematology clinic due to a lifelong history of easy bruising, frequent epistaxis, and heavy menstrual bleeding. She recently underwent a dental extraction complicated by prolonged oozing for 48 hours. She has no family history of known bleeding disorders, though her mother also reports heavy menses. Vital signs are within normal limits, and physical examination reveals scattered ecchymoses on her extremities. To evaluate for von Willebrand disease and determine its specific subtype, arrange the following laboratory investigations in the most appropriate, evidence-based diagnostic sequence.

A 72-year-old man is brought to the emergency department after his family found him with profound right-sided hemiparesis, right facial droop, and severe global aphasia. He was last known to be in his usual state of health 9 hours ago when he went to sleep. Vital signs show a blood pressure of 185/100 mm Hg and a pulse of 88/min that is irregularly irregular. Point-of-care blood glucose is 110 mg/dL. The facility is a comprehensive stroke center. Arrange the following neuroimaging modalities in the most appropriate chronological sequence for guiding the acute management of this patient's condition.

A 24-year-old previously healthy woman presents to the emergency department with a 2-hour history of severe, sudden-onset, right-sided pelvic pain. She reports that her last menstrual period was 6 weeks ago and she noticed light vaginal spotting this morning. Vital signs show a blood pressure of 88/54 mmHg, a heart rate of 122/min, and a respiratory rate of 22/min. Abdominal examination demonstrates right lower quadrant tenderness with voluntary guarding and rebound tenderness. Arrange the following differential diagnoses in order from the highest pre-test probability (most likely and most urgent) to the lowest pre-test probability based on this patient's clinical presentation.

A $32$-year-old woman is brought to the emergency department by emergency medical services after being stung by a bee. She has a history of severe bee sting allergy. On arrival, her blood pressure is $80/50$ mm Hg, heart rate is $125$/min, and respiratory rate is $28$/min. She has diffuse urticaria, facial swelling, and prominent expiratory wheezing. Arrange the following pharmacologic interventions in the correct prioritized sequence of administration for the acute management of this patient.

A 31-year-old woman is brought to the emergency department by paramedics due to continuous seizure activity. Her husband states she has a history of epilepsy but ran out of her medications two days ago. He reports the generalized tonic-clonic movements began approximately 10 minutes prior to EMS arrival and have not ceased. She is actively seizing on the stretcher. Vital signs include a blood pressure of 145/92 mm Hg, heart rate of 122/min, respiratory rate of 22/min, and oxygen saturation of 91% on room air. Point-of-care blood glucose is 98 mg/dL. Two large-bore peripheral intravenous catheters are successfully placed by the nursing staff immediately upon arrival.

Assuming the patient's seizures remain refractory to each successive intervention, arrange the following management steps in the most appropriate chronological sequence for her stabilization and definitive care.

A 65-year-old woman presents to the outpatient clinic with a 3-week history of painless yellowing of her skin and eyes. She also reports a 5-kg (11-lb) unintentional weight loss, dark urine, and pale acholic stools. She has no significant past medical history. Vital signs are within normal limits. Physical examination reveals profound scleral icterus and a palpable, non-tender mass in the right upper quadrant. Laboratory studies show a total bilirubin of 10.2 mg/dL, direct bilirubin of 8.6 mg/dL, and an alkaline phosphatase of 750 U/L. A multidisciplinary tumor board anticipates she will require neoadjuvant chemotherapy followed by surgical resection, but notes that she is currently suffering from severe, intractable pruritus due to hyperbilirubinemia.

Arrange the following diagnostic and interventional modalities in the most appropriate chronological sequence for the evaluation and management of this patient, from the initial diagnostic step to the final therapeutic step.

A 58-year-old man presents to the primary care clinic reporting a 9-month history of progressive fatigue, decreased libido, and erectile dysfunction. He has no headaches, visual changes, or prior testicular trauma. His vital signs show a blood pressure of $128/82 \text{ mmHg}$, heart rate of $74 \text{ /min}$, and respiratory rate of $14 \text{ /min}$. His body mass index (BMI) is $34 \text{ kg/m}^2$. Physical examination reveals normal visual fields, no gynecomastia, and bilaterally descended testes with a slightly soft consistency and a volume of $12 \text{ mL}$ bilaterally (normal: $15-25 \text{ mL}$). The physician suspects male hypogonadism and initiates a stepwise laboratory evaluation.

Based on Endocrine Society guidelines, arrange the following laboratory investigations in the most appropriate chronological sequence for establishing the diagnosis and etiology. Assume each subsequent test is pursued only after the preceding test results confirm the need for further evaluation.

A 48-year-old woman presents to the emergency department with severe, constant right upper quadrant abdominal pain that radiates to her right scapula, accompanied by fever and nausea. The pain began $12\text{ hours}$ ago after she consumed a high-fat meal. Her temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is $135/85\text{ mmHg}$, and heart rate is $105\text{/min}$. Physical examination reveals marked tenderness with inspiratory arrest upon deep palpation of the right upper quadrant.

Arrange the following diagnostic imaging modalities in the appropriate step-wise sequence for evaluating and managing this patient's presentation, from the initial diagnostic test to the evaluation of potential late complications.

Roommates of a $20$-year-old male college student rush him to the triage desk due to a rapidly progressive headache, high fever, and extreme lethargy over the past $12$ hours. His past medical history is notable only for allergic rhinitis, and he takes no daily medications. Triage vital signs demonstrate a temperature of $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), blood pressure of $82/50\text{ mmHg}$, heart rate of $132\text{/min}$, and respiratory rate of $24\text{/min}$. Pulse oximetry is $95\%$ on ambient air. The clinical examination reveals a somnolent patient who localizes to painful stimuli but provides nonsensical answers to questions. Nuchal rigidity is prominent, and multiple non-blanching purpuric lesions are visible on the lower extremities. Arrange the following acute management steps in the most appropriate chronological sequence.

A 34-year-old woman is brought to the emergency department by ambulance. Her husband reports she suddenly fell to the floor and began having full-body convulsions 15 minutes ago. The convulsions have been continuous without any periods of recovery. She has no known past medical history. Upon arrival, her blood pressure is 142/88 mmHg, pulse is 118/min, and oxygen saturation is 94% on a non-rebreather mask. She is unresponsive, diaphoretic, and exhibiting continuous generalized tonic-clonic movements. Point-of-care blood glucose is 98 mg/dL. Two large-bore peripheral intravenous lines are rapidly established. Arrange the following pharmacologic interventions in the correct sequential order for the escalating management of this patient's condition, starting from the initial recommended therapy to treatments for refractory cases.

A $28$-year-old woman, gravida 1 para 0, at $22$ weeks gestation presents to the emergency department with a $12$-hour history of progressively worsening right-sided abdominal pain, accompanied by nausea and two episodes of non-bloody emesis. Her temperature is $38.2^\circ\text{C}$, blood pressure is $110/70$ mmHg, and heart rate is $105$/min. Physical examination reveals focal tenderness to palpation in the right mid-to-lower quadrant with mild voluntary guarding, but no rebound tenderness. Laboratory studies demonstrate a leukocyte count of $16,500/\text{mm}^3$ with a left shift. The patient requires emergent diagnostic evaluation for suspected acute appendicitis.

Arrange the following diagnostic modalities and confirmatory protocols in the correct sequential order for evaluating this patient, proceeding from the initial test of choice to subsequent options if the preceding tests are non-diagnostic, unavailable, or equivocal.

An adult with end-stage renal disease is evaluated in the emergency department for severe generalized weakness after missing three consecutive hemodialysis sessions. A 12-lead electrocardiogram demonstrates widened QRS complexes and tall, peaked T waves. The care team prepares to initiate urgent medical therapy while awaiting emergency hemodialysis.

Arrange the following pharmacologic interventions in the correct chronological sequence of administration, from the most immediate therapeutic priority to the final step in management.

A 65-year-old man with a history of poorly controlled hypertension presents to the emergency department with sudden-onset, severe, 'tearing' chest pain that radiates to his back between his scapulae. His blood pressure is 185/110 mmHg in the right arm and 145/90 mmHg in the left arm. A new decrescendo diastolic murmur is heard at the right upper sternal border. An acute type A aortic dissection is suspected. Arrange the following imaging modalities in the typical chronological order they are indicated for the initial triage, definitive preoperative evaluation, intraoperative management, and long-term outpatient surveillance of this patient.

Emergency medical services arrive at the hospital with a 28-year-old female patient who is highly agitated and delirious. According to her family, she has a documented history of Graves disease but abandoned her prescribed medical therapy three months prior. Her temperature is 39.8°C (103.6°F), heart rate is 155/min, blood pressure is 160/70 mm Hg, and respiratory rate is 24/min. Physical examination reveals a diaphoretic patient with a diffusely enlarged, non-tender thyroid gland and a marked resting tremor. An electrocardiogram shows sinus tachycardia. Arrange the following pharmacologic interventions in the most appropriate chronological sequence for the acute management of this patient's condition.

A 35-year-old woman is referred to the clinic for evaluation of resistant hypertension. Her blood pressure today is 168/105 mmHg despite documented medication adherence to maximum tolerated doses of amlodipine, lisinopril, and hydrochlorothiazide. She reports experiencing frequent, discrete episodes of severe throbbing headaches, profound diaphoresis, and a racing heart over the last three months. Her BMI is 23 kg/m^2. Physical examination is unremarkable, with no abdominal bruits, violaceous striae, or abnormal fat distribution. Laboratory studies reveal a serum potassium of 4.1 mEq/L and a serum creatinine of 0.8 mg/dL.

Arrange the following differential diagnoses for her secondary hypertension from MOST likely to LEAST likely based on her specific clinical presentation.

A 58-year-old postmenopausal woman presents to the clinic for evaluation of a newly identified right breast lump. She noticed the firm, painless mass in the upper outer quadrant 2 weeks ago during self-examination. Physical examination confirms a 2-centimeter, non-tender, relatively mobile mass in the right breast with no overlying skin dimpling, nipple retraction, or axillary lymphadenopathy. Her last screening mammogram was 18 months ago and was reported as normal. Arrange the following diagnostic steps in the most appropriate chronological sequence for the evaluation of this patient's new palpable mass.