Tüm alıştırma soruları

A $68$-year-old man is evaluated in the outpatient cardiology clinic for ongoing symptoms of heart failure. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of $25\%$. He currently reports dyspnea when walking up a single flight of stairs (New York Heart Association class III). His daily medications include sacubitril-valsartan, carvedilol, and empagliflozin. He is adherent to a low-sodium diet. Vital signs show a blood pressure of $112/74$ mmHg and a pulse of $68$/min. Physical examination reveals clear lungs and trace bilateral lower extremity edema. Recent laboratory studies show:

To further reduce mortality and hospitalizations, the physician decides to initiate spironolactone at a dose of $12.5$ mg daily.

Which of the following represents the most appropriate monitoring or management strategy for this patient's new therapeutic regimen?

A primary care physician is reviewing the chart of a patient with treatment-resistant hypertension. The patient has consistently elevated blood pressure readings over 160/100 mmHg despite documented compliance with maximal doses of amlodipine, lisinopril, and chlorthalidone. Recent laboratory analysis highlights a persistent unprovoked hypokalemia (potassium 3.0 mEq/L). Suspecting an autonomous mineralocorticoid production disorder, the clinical team plans a comprehensive diagnostic workup. Arrange the following evaluations in the standard evidence-based sequence, from initial screening to final pre-surgical planning.

A 29-year-old male is brought to the trauma bay after a high-speed motorcycle collision. Upon arrival, his blood pressure is $78/40 \text{ mm Hg}$, heart rate is $142/\text{min}$, and respiratory rate is $28/\text{min}$. Intravenous crystalloid and a massive transfusion protocol are initiated. A focused assessment with sonography for trauma (FAST) reveals a large amount of free intraperitoneal fluid. The patient is immediately transported to the operating room for an exploratory laparotomy, which reveals a massive Grade V liver laceration with brisk, ongoing hemorrhage. The anesthesia team reports that the patient's core temperature has dropped to $34.1^\circ\text{C}$ ($93.4^\circ\text{F}$), and an arterial blood gas shows a pH of $7.12$ with a base deficit of $14 \text{ mEq/L}$. Diffuse microvascular bleeding is noted from all surgical surfaces. Which of the following is the most appropriate next step in surgical management?

A 19-year-old woman presents to the emergency department exactly $4$ hours after a suspected intentional ingestion of an unknown quantity of extra-strength acetaminophen tablets. She is currently asymptomatic, with stable vital signs and an unremarkable physical examination. The physician plans a comprehensive management and monitoring strategy to prevent irreversible hepatotoxicity. Arrange the following steps in the correct chronological sequence for the guideline-concordant diagnostic evaluation, clinical monitoring, and therapeutic progression for this patient.

A 78-year-old man is evaluated for hospital discharge following a 3-day admission for acute decompensated heart failure. He has severe ischemic cardiomyopathy with a documented left ventricular ejection fraction of 15%. This marks his fourth hospitalization for severe volume overload in the past six months, despite maximum tolerated guideline-directed medical therapy. The patient is currently euvolemic, resting comfortably in bed, and breathing easily on room air. During bedside rounds, he tells the physician, "I am completely exhausted from these constant hospital visits. I know my heart is failing, and I just want to go back to my house and be kept comfortable without any more aggressive treatments or readmissions." His family is highly supportive of his wishes and is continuously available to assist with his daily needs. Which of the following is the most appropriate disposition for this patient?

An endocrinology consultation is requested for a 38-year-old woman presenting with progressive central weight gain, severe fatigue, and easy bruising over the past year. Her blood pressure is 162/98 mmHg. Physical examination reveals significant central adiposity, violaceous striae on her abdomen, and pronounced weakness when rising from a chair. Initial investigations confirm hypercortisolism, demonstrating an elevated 24-hour urine free cortisol level and a failure to suppress serum cortisol during a low-dose dexamethasone suppression test. Subsequent biochemical evaluation reveals a plasma adrenocorticotropic hormone (ACTH) concentration of 95 pg/mL (normal: 10 to 60 pg/mL). To identify the source of her condition, a dedicated gadolinium-enhanced magnetic resonance imaging (MRI) scan of the pituitary gland is performed, which shows a symmetrically normal-appearing gland with no evidence of a focal adenoma. Which of the following is the most appropriate next step in the diagnostic workup for this patient?

A 42-year-old woman is evaluated in the intensive care unit on hospital day 3. She was initially admitted with septic shock secondary to a perforated appendix and underwent an emergency exploratory laparotomy. Her medical history is significant for generalized epilepsy, which has been well-controlled on oral valproic acid for the past 5 years. Upon admission, she was resuscitated with intravenous fluids and norepinephrine, and empiric therapy with intravenous meropenem and vancomycin was initiated. Her home dose of valproic acid was continued. Today, her hemodynamics have improved, and vasopressors have been discontinued. However, she experiences a 2-minute generalized tonic-clonic seizure that resolves spontaneously. Her vital signs are temperature 37.6°C (99.7°F), blood pressure 118/72 mm Hg, pulse 88/min, and respirations 16/min. Laboratory studies reveal a serum valproic acid level of 12 mcg/mL (therapeutic range: 50-100 mcg/mL), which is markedly decreased from a level of 65 mcg/mL drawn on admission. Renal and hepatic function panels are within normal limits. Based on the patient's current presentation, which of the following are the most appropriate immediate pharmacologic interventions? (Select all that apply)

A 68-year-old man presents to the emergency department with a 2-day history of worsening shortness of breath, increased cough, and purulent sputum. He has a history of severe chronic obstructive pulmonary disease (COPD) and uses home oxygen at $2 \text{ L/min}$ continuously. On presentation, he appears in moderate respiratory distress. Vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $145/85 \text{ mm Hg}$, pulse $112/\text{min}$, and respirations $28/\text{min}$. Oxygen saturation is $84\%$ on his home $2 \text{ L/min}$ nasal cannula.

Vital signs are now blood pressure $130/80 \text{ mm Hg}$, pulse $90/\text{min}$, and respirations $18/\text{min}$. Oxygen saturation is $92\%$. He is conversing comfortably with his wife, who states she is fully capable of assisting him at home.

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

A 58-year-old man is treated in the intensive care unit for refractory septic shock secondary to a perforated viscus. Following initial resuscitation with $4\text{ L}$ of intravenous lactated Ringer solution, he requires escalating doses of vasoactive agents. His current infusions include norepinephrine at $0.6\ \mu\text{g/kg/min}$ and vasopressin at $0.04\text{ units/min}$. Despite these measures, his blood pressure is $76/40\text{ mm Hg}$ (mean arterial pressure $52\text{ mm Hg}$). His heart rate is $142/\text{min}$ and regular. Peripheral pulses are bounding. Point-of-care echocardiography demonstrates an underfilled left ventricular cavity, a hyperdynamic left ventricle with an estimated ejection fraction of $80\%$, and systolic anterior motion of the mitral valve creating a dynamic left ventricular outflow tract gradient. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 58-year-old man with metastatic melanoma is hospitalized due to severe abdominal cramping and 9 to 10 watery, non-bloody bowel movements daily. He recently received his second cycle of combination immunotherapy with nivolumab and ipilimumab. The patient is hemodynamically stable. Stool testing for Clostridioides difficile toxin and a multiplex enteric pathogen panel are negative. Flexible sigmoidoscopy demonstrates diffuse severe mucosal ulceration and erythema, consistent with grade 3 immune checkpoint inhibitor-related colitis. The treating oncologist permanently discontinues the immunotherapy regimen.

Assuming this patient's condition eventually proves to be refractory to the initial first-line immunosuppression, arrange the following management and monitoring steps in the correct chronological sequence according to standard clinical guidelines.

A 78-year-old woman is admitted to the hospital with acute decompensated heart failure. She responds well to intravenous diuresis and is now hemodynamically stable, transitioning to oral diuretics. The interdisciplinary team is preparing for her discharge to home. To minimize the risk of a 30-day readmission and ensure a safe transition of care, arrange the following discharge planning and transitional care steps in the most appropriate chronological sequence.

A 54-year-old woman is admitted to the hospital with an acute pulmonary embolism and is started on a continuous intravenous unfractionated heparin infusion. On day 5 of therapy, her platelet count drops from a baseline of $240,000/\text{mm}^3$ to $95,000/\text{mm}^3$. She has no active bleeding, but she reports new-onset pain and swelling in her right lower extremity. Suspecting heparin-induced thrombocytopenia (HIT), the physician calculates a 4T score of 6 (high probability). Which of the following are the most appropriate immediate steps in the monitoring and management of this patient? (Select all that apply)

A 42-year-old man is brought to the emergency department by paramedics due to a continuous generalized tonic-clonic seizure. His wife states the seizure began approximately 25 minutes ago at home, and he has not regained consciousness. He has a history of traumatic brain injury from a motor vehicle collision three years ago. Upon arrival, the patient is actively seizing with rhythmic jerking of all four extremities. Vital signs are temperature $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure $165/95\text{ mm Hg}$, pulse $132/\text{min}$, and respirations $18/\text{min}$. Oxygen saturation is $88\%$ on room air. Capillary blood glucose is $110\text{ mg/dL}$. Arrange the following management steps in the most appropriate chronological sequence for stabilizing and triaging this patient.

Emergency personnel transport a 24-year-old female to the resuscitation bay following accidental ingestion of a walnut-containing dessert at a local bakery. Symptom onset was precipitous, featuring diffuse urticaria, marked facial angioedema, and severe respiratory distress within 10 minutes of exposure. Upon arrival, the patient exhibits gasping respirations. Vital signs include a heart rate of 132/min, a blood pressure of 82/50 mm Hg, and an oxygen saturation of 88% on ambient air. Physical assessment confirms inspiratory stridor and widespread expiratory wheezing. Arrange the following pharmacologic interventions in the most appropriate chronological sequence for this patient's acute stabilization and management.

A 55-year-old woman is evaluated on postoperative day 6 following an open sigmoid colectomy for complicated diverticulitis. Her postoperative course was previously uncomplicated. This morning, after a severe bout of coughing, she felt a sudden 'popping' sensation in her abdomen followed by a rush of serosanguineous fluid. Her temperature is 37.1°C (98.8°F), blood pressure is 130/80 mmHg, pulse is 88/min, and respirations are 16/min. Physical examination of the abdomen reveals that the surgical staples are partially separated, and a loop of pink, viable-appearing small intestine is protruding through the incision onto the abdominal wall. Which of the following interventions are immediately indicated? (Select all that apply)

A 64-year-old man is brought to the emergency department due to coughing up a large amount of bright red blood. He estimates he has coughed up approximately 500 mL of blood over the past 2 hours. His past medical history is significant for pulmonary tuberculosis treated 15 years ago, leaving residual scarring and a cavitary lesion in the right upper lobe. On presentation, he is visibly distressed, diaphoretic, and actively coughing up fresh blood. His temperature is 37.1°C (98.8°F), blood pressure is 105/65 mmHg, pulse is 118/min, and respiratory rate is 30/min. Pulse oximetry shows an oxygen saturation of 85% on room air. Auscultation of the lungs reveals coarse rhonchi and gurgling over the right hemithorax, while the left lung fields are relatively clear.

Arrange the following procedural and management interventions in the most appropriate chronological sequence of escalation for this patient, from the immediate first step to the definitive therapy of last resort.

A 34-year-old nulliparous woman is evaluated for a 15-kg (33-lb) weight gain over the past eight months. She also reports new-onset facial hair growth and severe proximal muscle weakness that makes climbing stairs difficult. Vital signs show a blood pressure of 158/96 mm Hg. Physical examination reveals central adiposity, violaceous abdominal striae, and facial plethora. She takes no medications and has no history of exogenous glucocorticoid use. Arrange the following diagnostic steps in the most appropriate chronological order for the workup of this patient's condition.

A $78$-year-old woman is evaluated in the outpatient clinic for a $3$-week history of increased confusion and two recent falls. She lives alone, and her daughter reports that the patient has been forgetting recent conversations and appearing unusually unsteady on her feet. Her past medical history includes hypertension, type 2 diabetes mellitus, overactive bladder, and insomnia. Her current daily medications are metformin, lisinopril, amlodipine, oxybutynin, and amitriptyline. Her blood pressure is $135/80$ mm Hg lying down and $110/65$ mm Hg standing. Her pulse is $82$/min lying down and $96$/min standing. Physical examination is notable for a dry oral mucosa and delayed cognitive recall. Laboratory results, including a comprehensive metabolic panel and urinalysis, are within normal limits. Which of the following are appropriate pharmacologic interventions for this patient? (Select all that apply)

A 62-year-old man is brought to the triage desk of the emergency department by his spouse. He is clutching his chest and reports that severe, crushing chest pain began abruptly 90 minutes ago while he was watching television. He also notes profound weakness, dizziness, and nausea. His past medical history is significant for essential hypertension and type 2 diabetes mellitus.

Upon evaluation in the resuscitation bay, he is pale, diaphoretic, and lethargic. Vital signs are:
Temperature: 36.6°C (97.9°F)
Blood pressure: 78/48 mmHg
Pulse: 52/min
Respirations: 20/min
Oxygen saturation: 96% on room air.

Physical examination reveals distended neck veins up to the angle of the mandible while sitting at a 45-degree angle. Auscultation of the lungs reveals clear breath sounds bilaterally without crackles or wheezes. Heart sounds are distant, and a regular bradycardia is appreciated with no murmurs, rubs, or gallops. The extremities are cool with delayed capillary refill.

A 12-lead electrocardiogram is rapidly obtained, demonstrating 3-mm ST-segment elevations in leads II, III, and aVF, as well as 1.5-mm ST-segment depressions in leads I and aVL.

Which of the following is the single most appropriate initial step in the hemodynamic stabilization of this patient?

A 34-year-old woman is referred to the endocrinology clinic for evaluation of a $14$-kg weight gain over the past year, accompanied by proximal muscle weakness and new-onset facial hair growth. Her blood pressure is $156/94$ mmHg. Physical examination reveals central adiposity, facial plethora, and wide, violaceous abdominal striae. Laboratory testing confirms hypercortisolism with significantly elevated $24$-hour urine free cortisol levels on two separate collections and failure to suppress morning serum cortisol following a low-dose ($1$-mg) overnight dexamethasone suppression test. Subsequent biochemical evaluation shows a morning plasma adrenocorticotropic hormone (ACTH) level of $95$ pg/mL (normal: $9$ to $52$ pg/mL). Magnetic resonance imaging (MRI) of the sella turcica with gadolinium demonstrates a $3$-mm hypoenhancing lesion in the right anterior pituitary gland. Which of the following is the most appropriate next step in the diagnostic workup?