Tüm alıştırma soruları

A 28-year-old female, currently at 14 weeks gestation, presents to the emergency department complaining of sudden-onset shortness of breath and right-sided pleuritic chest pain that began two hours ago. Her temperature is 37.2°C (99.0°F), blood pressure is 110/70 mm Hg, pulse is 115/min, and respiratory rate is 22/min. Oxygen saturation is 94% on room air. Physical examination reveals clear lungs to auscultation bilaterally. Her right calf is noticeably swollen, warm, and tender to palpation compared to the left. Which of the following is the most appropriate initial imaging study for this patient?

A 22-year-old man is brought to the emergency department via ambulance after sustaining a stab wound to the right anterior chest. He is in severe respiratory distress and appears agitated. His temperature is 37.0°C (98.6°F), blood pressure is 80/40 mmHg, heart rate is 135/min, and respiratory rate is 32/min. Pulse oximetry shows an oxygen saturation of 86% on room air. Physical examination reveals absent breath sounds over the right hemithorax, hyperresonance to percussion on the right side, and distended neck veins. Which of the following is the most appropriate immediate next step in the management of this patient?

A 54-year-old man presents to the emergency department with a 3-day history of severe, progressive mid-back pain, fevers, and new-onset weakness in his legs. His medical history is significant for poorly controlled type 2 diabetes mellitus, intravenous heroin use, and a non-MRI-conditional permanent pacemaker placed 12 years ago for sick sinus syndrome. His temperature is 38.8°C (101.8°F), blood pressure is 115/75 mmHg, pulse is 88/min, and respiratory rate is 16/min. Physical examination reveals focal tenderness to palpation over the T8 spinous process. Neurologic examination shows 3/5 motor strength in the bilateral lower extremities, decreased sensation to pinprick below the umbilicus, and upgoing plantar reflexes bilaterally. Initial laboratory studies show a leukocyte count of 18,000/mm³ and an erythrocyte sedimentation rate of 92 mm/h. Blood cultures are drawn, and empiric intravenous vancomycin and ceftriaxone are initiated. Which of the following is the most appropriate imaging study to order next?

A 28-year-old man is brought to the emergency department via ambulance after being involved in a high-speed motor vehicle collision. The paramedics report he was the unrestrained driver of the vehicle. He is highly agitated, confused, and in severe respiratory distress. His past medical history is unknown. Vital signs are temperature 36.9°C (98.4°F), blood pressure 75/40 mmHg, pulse 142/min, and respirations 36/min. Pulse oximetry shows 84% on a 15 L/min non-rebreather mask. Physical examination reveals a large contusion over the right anterior chest wall. The neck veins are markedly distended. Lung auscultation demonstrates completely absent breath sounds over the right hemithorax. The trachea is visibly deviated to the left. Which of the following is the most appropriate next step in the management of this patient?

A 64-year-old man with a 15-year history of poorly controlled gastroesophageal reflux disease undergoes a screening upper endoscopy. Irregular, salmon-colored mucosa is noted extending 4 cm proximal to the gastroesophageal junction. Four-quadrant biopsies are obtained. The synoptic pathology report describes gastric-type and intestinal-type mucosa with prominent goblet cells. The glandular epithelium demonstrates marked architectural distortion, loss of nuclear polarity, marked nuclear pleomorphism, and atypical mitotic figures that extend to the luminal surface. The basement membrane remains entirely intact without single-cell infiltration into the adjacent tissue.

Based on these histopathologic findings, which of the following is the most accurate diagnostic interpretation?

A 54-year-old man presents to the clinic with a 6-month history of epigastric pain, early satiety, and occasional nausea. He has no history of nonsteroidal anti-inflammatory drug use. Vital signs are within normal limits. Physical examination reveals mild epigastric tenderness but is otherwise unremarkable. Laboratory studies show a hemoglobin of 11.2 g/dL and a mean corpuscular volume of 78 fL. An upper gastrointestinal endoscopy reveals thickened, erythematous gastric folds in the antrum without frank ulceration. Multiple forceps biopsies are obtained. The histopathology report describes a dense, monomorphic infiltrate of small-to-medium-sized atypical lymphocytes in the lamina propria. These cells are seen infiltrating and destroying the adjacent gastric mucosal glands, forming lymphoepithelial lesions.

Immunohistochemical analysis of the lymphocytic infiltrate reveals the following profile:
- CD20: Positive
- CD3: Negative
- CD5: Negative
- CD10: Negative
- Cyclin D1: Negative

A Warthin-Starry silver stain demonstrates sparse, curved bacilli along the surface epithelium.

Based on these histopathologic and immunohistochemical findings, which of the following is the most accurate diagnosis?

A 24-year-old male college student undergoes an excisional lymph node biopsy for a painless, progressively enlarging cervical mass accompanied by night sweats and unexplained fever. The pathology report describes an effaced nodal architecture with a mixed inflammatory background composed of small lymphocytes, eosinophils, and macrophages. Scattered throughout this background are large, atypical, binucleated cells with prominent, eosinophilic nucleoli resembling owl eyes. Based on this histopathologic description, which of the following immunohistochemical markers are typically positive in these atypical neoplastic cells? (Select all that apply)

A 72-year-old woman presents to the gynecology clinic complaining of severe, persistent vulvar pruritus and a burning sensation for the past 8 months. She notes that the symptoms have not improved despite applying an over-the-counter topical hydrocortisone cream. On physical examination, there is a well-demarcated, erythematous, crusted, and slightly weeping plaque measuring 3.5 cm on the right labium majus. A punch biopsy of the lesion is performed. Light microscopy of the hematoxylin and eosin (H&E) stained section reveals an intact basement membrane with a proliferation of large, atypical cells containing abundant pale-staining cytoplasm and prominent nucleoli. These cells are scattered singly and in small clusters throughout the epidermis, predominantly in the basal and suprabasal layers. Immunohistochemical staining demonstrates that the atypical cells are strongly reactive for cytokeratin 7 (CK7) and carcinoembryonic antigen (CEA), but are completely negative for S100 protein, Melan-A, and p63. Which of the following is the most definitive diagnosis established by these histopathologic and immunohistochemical findings?

Match each patient's clinical presentation and specific risk factors with the most appropriate next step in diagnostic imaging.

A 68-year-old woman is brought to the emergency department 45 minutes after the sudden onset of left-sided weakness and slurred speech. The clinical team initiates the acute stroke protocol. Arrange the following imaging modalities in the chronological order their results must be interpreted to rapidly diagnose the condition, determine eligibility for reperfusion therapies, and ultimately confirm the extent of the injury.

Match each patient's clinical presentation to the single most appropriate initial or definitive imaging modality.

A 38-year-old man presents to the emergency department complaining of sudden-onset, severe right flank pain that started two hours ago. The pain radiates to his right groin and is associated with nausea and two episodes of vomiting. He is unable to find a comfortable position and is pacing around the examination room. His temperature is 37.1°C (98.8°F), blood pressure is 155/92 mmHg, pulse is 112/min, and respiratory rate is 18/min. Physical examination reveals right costovertebral angle tenderness but no abdominal rebound or guarding. Laboratory studies show a serum creatinine of 0.9 mg/dL. Urinalysis is positive for gross blood, but negative for leukocyte esterase and nitrites. Which of the following is the most appropriate initial imaging study for this patient?

A 45-year-old agricultural worker is brought to the emergency department by emergency medical services after being found unresponsive in a pesticide storage facility. His past medical history is notable for hypertension. On arrival, the patient exhibits generalized tonic-clonic movements, is incontinent of urine, and has profuse, frothy secretions emanating from his mouth and nose. The emergency medical services personnel report a strong garlic-like odor on his clothing. Vital signs are temperature 37.1°C (98.8°F), blood pressure 70/40 mmHg, heart rate 38/min, respiratory rate 10/min, and oxygen saturation 82% on a 15-L non-rebreather mask. Physical examination reveals pinpoint pupils, generalized muscle fasciculations, and diffuse wheezing with coarse rhonchi in all lung fields. Intravenous access has been established, and the healthcare team has donned appropriate personal protective equipment. Which of the following is the single most urgent initial step in the stabilization of this patient?

A 62-year-old retired agricultural worker visits his primary care physician after his spouse noticed an enlarging, irregularly bordered skin lesion on his upper back over the past eight months. Examination reveals a 1.2-cm asymmetric plaque with variegated colors of black, brown, and blue. An excisional biopsy with 2-mm margins is performed. The preliminary pathologic diagnosis confirms invasive cutaneous melanoma. The physician is reviewing the synoptic pathology report to determine the appropriate clinical staging and definitive surgical management plan. Which of the following histopathologic features reported in the biopsy are the primary determinants of the tumor (T) category for staging this patient's melanoma according to current guidelines? (Select all that apply)

A 24-year-old man is brought to the emergency department by paramedics after being ejected from a motorcycle during a high-speed collision. He was not wearing a helmet. On arrival, he is unresponsive. The paramedics report that his Glasgow Coma Scale score was initially 9 at the scene but has progressively declined to 6 (Eye opening: 1, Verbal response: 2, Motor response: 3) during transport. Vital signs are temperature 36.2°C (97.1°F), blood pressure 185/105 mm Hg, heart rate 48/min, and respiratory rate 8/min with an irregular pattern. Physical examination reveals a large right temporoparietal scalp hematoma. The right pupil is 7 mm and nonreactive to light, while the left pupil is 3 mm and briskly reactive. There is no active external hemorrhage, and the pelvis is stable to palpation. Breath sounds are equal bilaterally. Which of the following is the most appropriate initial step in the management of this patient?

A 48-year-old woman is referred to an endocrinologist after her primary care physician palpated a lump in her neck during a routine physical examination. She is asymptomatic and denies dysphagia, hoarseness, or weight changes. Her thyroid-stimulating hormone (TSH) level is within normal limits. A neck ultrasound demonstrates a 2.5-cm, solid, hypoechoic nodule with irregular margins and microcalcifications in the right lobe of the thyroid gland. A fine-needle aspiration (FNA) biopsy of the nodule is performed. The cytopathology report describes 'high cellularity with large, overlapping epithelial cells demonstrating optically clear nucleoplasm, prominent nuclear grooves, intranuclear pseudoinclusions, and scattered concentric laminated calcifications.'

Which of the following is the most likely diagnosis based on this cytopathologic interpretation?

Evaluate the following complex clinical presentations and match each patient with the most appropriate next imaging or diagnostic study, taking into consideration their specific comorbidities and absolute or relative contraindications.

A 62-year-old woman is brought to the emergency department by her daughter after vomiting a large volume of bright red blood at home. The patient has a history of alcohol use disorder and was diagnosed with decompensated liver cirrhosis six months ago. Upon arrival, the patient is lethargic, opening her eyes only to painful stimuli, and producing incomprehensible sounds. She withdraws her extremities from painful stimuli. Vital signs include a temperature of 36.4°C (97.5°F), blood pressure of 68/38 mm Hg, pulse of 142/min, and respiratory rate of 28/min. Pulse oximetry shows an oxygen saturation of 91% on room air. Physical examination reveals cool, clammy skin, scleral icterus, and a distended abdomen with a positive fluid wave. Which of the following are the most appropriate simultaneous initial steps in the management of this patient? (Select two)

Match the following clinical quality and safety scenarios with the most appropriate quality improvement (QI) tool or methodology.

A 45-year-old man with a documented severe anaphylactic allergy to penicillin is admitted to the medical ward from the emergency department for bacterial pneumonia. During the verbal transition of care, the emergency physician is distracted and forgets to mention the patient's allergy. Furthermore, the hospital's electronic medical record (EMR) system recently underwent an update that inadvertently disabled prominent allergy pop-up alerts. Unaware of the allergy, the admitting ward physician prescribes intravenous piperacillin-tazobactam. A clinical pharmacist reviewing the orders discovers the allergy in a scanned historical document and intercepts the medication before it is dispensed.

Based on the classification of medical errors and adverse events, which of the following statements about this incident are correct? (Select all that apply)