Tüm alıştırma soruları

A 58-year-old man is evaluated in the emergency department for worsening respiratory distress. He has a history of chronic obstructive pulmonary disease (COPD) and was brought in by ambulance after his wife found him gasping for air. On arrival, his blood pressure is 150/90 mm Hg, heart rate is 122/min, and oxygen saturation is 84% on room air. Physical examination reveals accessory muscle use, diffuse wheezing, and paradoxical abdominal breathing. Despite initiation of noninvasive positive-pressure ventilation and continuous bronchodilator therapy, the patient's mental status rapidly declines. The physician decides to proceed with rapid sequence intubation (RSI). Arrange the following procedural steps for RSI in the most appropriate chronological sequence.

During an afternoon shift at an outpatient clinic, staff hear a loud thud from a restroom and discover a $74$-year-old man collapsed on the floor. He is immediately transported via advanced life support to the adjacent hospital's resuscitation bay. Upon arrival, the patient is diaphoretic, lethargic, and complains of excruciating, tearing pain radiating to his lower back. Vital signs reveal a blood pressure of $65/40$ mm Hg, a heart rate of $128$/min, and a respiratory rate of $24$/min. Physical examination demonstrates a prominent, expansile pulsation in the epigastrium. An immediate bedside focused assessment with sonography for trauma (FAST) reveals a $7.5$ cm dilation of the infrarenal aorta surrounded by hypoechoic free fluid. Which of the following are appropriate immediate steps in the procedural and clinical management of this patient? Select all that apply.

Emergency medical services arrive at the emergency department with a 45-year-old man who has been experiencing a continuous generalized tonic-clonic seizure for the past 15 minutes. Upon evaluation, the patient remains unresponsive with rhythmic motor jerking of all four extremities. His airway is patent with spontaneous respirations, and a point-of-care capillary blood glucose is 98 mg/dL. The nursing staff has successfully secured intravenous access. Arrange the following pharmacologic interventions in the required chronological sequence for the escalating management of this patient's condition.

A 54-year-old man is admitted to the hospital with an acute, unprovoked deep vein thrombosis and a subsequent pulmonary embolism. He is hemodynamically stable and is initiated on a continuous intravenous infusion of unfractionated heparin. Which of the following laboratory parameters are essential to monitor routinely to ensure the therapeutic efficacy and safety of this specific therapy? (Select all that apply)

Emergency medical responders transport a 22-year-old male to the trauma center following a high-speed bicycle collision against a concrete wall. He is gasping for air and profoundly cyanotic. Vital signs show a blood pressure of 76/40 mmHg, pulse of 142/min, and respiratory rate of 34/min. Physical examination reveals tracheal deviation to the left, prominently distended jugular veins, and no audible breath sounds over the right hemithorax. Which of the following is the most appropriate next step in the management of this patient?

A $61$-year-old woman is brought to the emergency department by her husband due to progressive weakness and severe diarrhea. She has a history of metastatic melanoma and began combination immunotherapy with ipilimumab and nivolumab four weeks ago. Over the past three days, she has had up to eight large-volume, watery bowel movements daily, accompanied by diffuse abdominal cramping. Over the last $12$ hours, she has also developed new-onset palpitations, a sensation of a 'racing heart,' and mild shortness of breath at rest.

Her temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $105/65\text{ mmHg}$, pulse is $118\text{/min}$ and irregular, and respiratory rate is $20\text{/min}$. Oxygen saturation is $96\%$ on room air. Physical examination reveals dry mucous membranes and diffuse, mild abdominal tenderness without guarding or rebound. Cardiovascular examination reveals an irregular rhythm with no murmurs, rubs, or gallops.

Which of the following are the most appropriate diagnostic and monitoring steps in the evaluation of this patient? (Select all that apply)

A 68-year-old man is evaluated in the hospital for acute, severe right knee pain and swelling that began 12 hours ago. His medical history is significant for a mechanical aortic valve replacement, chronic kidney disease stage 4 (baseline estimated glomerular filtration rate is 22 mL/min/1.73 m²), type 2 diabetes mellitus with neuropathy, and gout. His last gout flare was 3 years ago. Current medications include warfarin, linagliptin, insulin glargine, and allopurinol 100 mg daily. His temperature is 37.1°C (98.8°F), blood pressure is 138/82 mm Hg, and pulse is 78/min. Physical examination reveals a markedly swollen, erythematous, and warm right knee that is exquisitely tender to palpation. Range of motion is severely limited due to pain. Laboratory studies show an international normalized ratio (INR) of 2.8, hemoglobin of 12.1 g/dL, serum creatinine of 2.9 mg/dL, and a fasting serum glucose of 315 mg/dL with a hemoglobin A1c of 10.2%. Arthrocentesis of the right knee yields 30 mL of cloudy, yellow synovial fluid. Analysis of the fluid shows a leukocyte count of 55,000/mm³ (85% neutrophils). Polarized light microscopy demonstrates abundant negatively birefringent, needle-shaped crystals. Gram stain of the synovial fluid shows no organisms. Synovial fluid bacterial cultures are pending. Which of the following is the most appropriate initial pharmacologic intervention for this patient's acute knee condition?

On hospital day 6, a 58-year-old male requires disposition planning following an admission for an acute exacerbation of relapsing-remitting multiple sclerosis. The patient initially presented with profound lower extremity weakness and urinary retention, which have now stabilized following a course of high-dose intravenous methylprednisolone. Vital signs are within normal limits. Neurologic examination reveals 2/5 strength in the bilateral lower extremities and decreased sensation below the T10 dermatome. He currently requires a Foley catheter, and the team plans to initiate teaching for clean intermittent catheterization. During his hospitalization, physical and occupational therapy evaluations note that although the patient experiences significant fatigue after 45 minutes of active exertion, he recovers quickly with rest and successfully participated in four separate 45-minute therapy blocks yesterday. Prior to this exacerbation, he was fully independent. His residence is a split-level house where the primary bathroom is located up a flight of twelve stairs. His spouse works outside the home during the day. What is the most appropriate next step in care transition for this patient?

A 45-year-old woman is brought to the emergency department by her family due to confusion, high fever, and severe right upper quadrant abdominal pain that began 24 hours ago. Her medical history is significant for hypertension, hyperlipidemia, and a laparoscopic Roux-en-Y gastric bypass performed for severe obesity three years ago. Her temperature is 39.4°C (102.9°F), blood pressure is 86/50 mmHg, pulse is 122/min, and respirations are 24/min. Physical examination reveals scleral icterus and marked tenderness in the right upper quadrant with voluntary guarding. Laboratory studies show:

Leukocyte count: 19,500/mm³
Total bilirubin: 7.2 mg/dL
Direct bilirubin: 5.6 mg/dL
Alkaline phosphatase: 510 U/L
Aspartate aminotransferase (AST): 145 U/L
Alanine aminotransferase (ALT): 160 U/L
Lactate: 4.8 mmol/L

Right upper quadrant ultrasound demonstrates a dilated common bile duct measuring 1.5 cm with an echogenic focus within the distal duct, as well as gallstones in the gallbladder without gallbladder wall thickening. Aggressive intravenous fluid resuscitation and broad-spectrum intravenous antibiotics are initiated. Despite receiving 3 liters of crystalloid, her blood pressure remains 88/54 mmHg, and a norepinephrine infusion is started. Which of the following is the most appropriate next step in management?

Match each of the following clinical scenarios (Patients 1-4) to the most appropriate post-acute care disposition setting.

A 62-year-old female is evaluated for hospital discharge. She was admitted 5 days ago for severe osteomyelitis of the right first metatarsal. During the admission, she underwent surgical debridement and a partial ray amputation. Her vital signs are stable, with a temperature of 37.0°C (98.6°F), heart rate of 78/min, blood pressure of 132/80 mm Hg, and respiratory rate of 14/min. Blood cultures drawn on admission grew Methicillin-resistant Staphylococcus aureus (MRSA), but repeat cultures are now negative. Her discharge plan requires a 6-week course of intravenous vancomycin. The surgical wound was left open to heal by secondary intention and requires wet-to-dry dressing changes twice daily. The patient lives alone in a single-story apartment. She has severe bilateral diabetic retinopathy resulting in legal blindness. She is able to ambulate short distances with a walker but struggles with fine motor tasks. Her only family member lives in another state and cannot assist with her care. Which of the following is the most appropriate disposition for this patient?

A 52-year-old man presents to the emergency department for evaluation of a new-onset fever. He is currently on day 10 of induction chemotherapy with cytarabine and daunorubicin for acute myeloid leukemia. The patient reports feeling fatigued but specifically denies chills, cough, shortness of breath, abdominal pain, or dysuria. He is tolerating a normal diet and oral fluids. He lives in a ground-floor apartment with his wife, who is his primary caregiver, and they have reliable transportation located 15 minutes away from the hospital.

Temperature is 38.6°C (101.5°F), blood pressure is 124/78 mm Hg, pulse is 88/min, and respirations are 14/min. Pulse oximetry is 99% on room air.

Physical examination reveals a well-appearing man in no acute distress. Cardiopulmonary examination is unremarkable. There is a totally implantable venous access device in the right upper chest with no overlying erythema, induration, or tenderness. Skin examination shows no rashes or lesions.

Laboratory studies show:
Hemoglobin: 8.4 g/dL
Platelet count: 42,000/mm³
Leukocyte count: 300/mm³
Neutrophils: 5%
Bands: 0%
Lymphocytes: 85%
Monocytes: 10%
Serum creatinine: 0.9 mg/dL
Total bilirubin: 0.8 mg/dL
Alanine aminotransferase (ALT): 22 U/L

Based on the patient's clinical presentation and risk profile, which of the following is the most appropriate disposition and initial management?

A 22-year-old man is admitted to the intensive care unit for diabetic ketoacidosis. After 14 hours of continuous intravenous regular insulin, aggressive fluid resuscitation, and electrolyte replacement, he is now fully alert, reports no nausea, and is able to tolerate oral intake. The physician orders a reassessment to determine if the patient is ready to transition to a maintenance regimen. Arrange the following treatment evaluation and protocol steps in the correct chronological sequence to safely de-escalate his therapy.

A 62-year-old man is transferred to the intensive care unit due to distributive shock secondary to a severe soft tissue infection. Peripheral intravenous access is insufficient, and the critical care team determines that a central venous catheter is required for continuous vasopressor infusion. The physician opts to cannulate the right internal jugular vein using the ultrasound-guided Seldinger technique. The patient is placed in the Trendelenburg position, the neck is prepped and draped in a sterile fashion, and local anesthetic is infiltrated.

Arrange the subsequent critical steps of the Seldinger technique in the correct chronological order to safely complete the procedure.

Match each patient's gastrointestinal clinical presentation with the most appropriate next step in diagnostic testing according to current clinical guidelines.

In the emergency department and inpatient wards, specific validated clinical scoring systems are used to safely triage patients, optimize resource utilization, and prevent both premature discharges and unnecessary admissions. Match each clinical risk stratification tool to its appropriate application in determining patient disposition and care setting transitions.

A 52-year-old man with a history of decompensated alcoholic cirrhosis presents to the emergency department with a 2-day history of subjective fever, generalized abdominal pain, and worsening lethargy. His home medications include lactulose and furosemide. On physical examination, his temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $98/60\text{ mmHg}$, and heart rate is $102/\text{min}$. The abdomen is distended with shifting dullness and diffuse tenderness to palpation. Arrange the following steps in the most appropriate chronological sequence for the diagnosis, monitoring, and longitudinal treatment evaluation of this patient's suspected spontaneous bacterial peritonitis.

Emergency medical services bring a 35-year-old man to the emergency department after he was rescued from a closed-space house fire. The paramedics report that he was trapped in a smoke-filled room for several minutes before being extricated. Upon arrival, the patient is agitated, has a hoarse voice, and is coughing up carbonaceous sputum. Vital signs are temperature 37.2°C (99.0°F), blood pressure 118/76 mm Hg, pulse 112/min, and respirations 26/min. Pulse oximetry shows 98% on 15 L/min of oxygen via a non-rebreather mask. Physical examination reveals singed nasal hairs and soot in the oropharynx. The lungs are clear to auscultation bilaterally. There are superficial burns on his bilateral forearms, accounting for approximately 9% of his total body surface area. Which of the following is the most appropriate next step in the management of this patient?

A $34$-year-old man presents to the emergency department with a $3$-week history of progressive dyspnea on exertion, a dry, nonproductive cough, and subjective fevers. He was diagnosed with HIV $5$ years ago but has been non-compliant with antiretroviral therapy for the past $2$ years. His last known CD4 count was $85 \text{ cells/mm}^3$. His temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $118/76 \text{ mmHg}$, pulse is $105/\text{min}$, and respiratory rate is $22/\text{min}$. Oxygen saturation is $89\%$ on room air. Physical examination reveals white plaques on the buccal mucosa that can be scraped off. Lung auscultation reveals scattered bilateral fine crackles. Laboratory testing shows a significantly elevated serum lactate dehydrogenase (LDH). A chest radiograph demonstrates bilateral, symmetric, diffuse reticulonodular opacities. The patient is promptly placed on supplemental oxygen, and empiric intravenous trimethoprim-sulfamethoxazole and corticosteroids are initiated. Which of the following is the most appropriate next step in the diagnostic evaluation to establish a definitive etiology?

A $42$-year-old woman presents to the emergency department with a severe, throbbing headache and blurred vision that started earlier today. She has a $3$-year history of diffuse cutaneous systemic sclerosis and Raynaud phenomenon. Two weeks ago, she was evaluated in the rheumatology clinic for worsening joint pain and skin tightness, and a new oral medication was prescribed. Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $218/116\text{ mm Hg}$, heart rate $105/\text{min}$, and respiratory rate $18/\text{min}$. Physical examination reveals diffusely thickened, tight skin over the face, chest, and extremities. Funduscopic examination shows bilateral flame-shaped hemorrhages and papilledema. Laboratory studies show:

Hemoglobin: $9.8\text{ g/dL}$
Platelet count: $110,000/\text{mm}^3$
Serum creatinine: $3.4\text{ mg/dL}$ (baseline $0.8\text{ mg/dL}$)
Blood urea nitrogen: $45\text{ mg/dL}$

A peripheral blood smear reveals $3$ to $5$ schistocytes per high-power field.

Which of the following is the most appropriate initial pharmacologic intervention?