Tüm alıştırma soruları

A 33-year-old male is transported to the emergency department via ambulance after a high-speed frontal motor vehicle collision. On arrival, he is deeply unresponsive with a Glasgow Coma Scale score of 6. He has gurgling respirations at a rate of 6/min. Blood pressure is 65/40 mm Hg, and heart rate is 142/min. Paramedics have already placed a tourniquet on his right thigh, effectively controlling active hemorrhage from an open femur fracture. Arrange the following management steps in the most appropriate chronological order for this patient.

A 54-year-old man is brought to the intensive care unit with a temperature of $39.2^{\circ} \text{C}$ ($102.6^{\circ} \text{F}$), heart rate of 122/min, and blood pressure of 88/56 mm Hg. He has a history of severe gallstone pancreatitis that required an extended admission 4 weeks ago. He had been steadily improving at a rehabilitation facility until 2 days ago when he developed worsening abdominal pain, lethargy, and fever. On examination, his abdomen is distended and diffusely tender with prominent guarding in the epigastrium. Laboratory studies show a leukocyte count of $22,000/\mu\text{L}$ with 15% bands. You suspect infected walled-off pancreatic necrosis (WON) complicated by septic shock.

Arrange the following procedural and surgical management steps in the correct chronological sequence, reflecting the current evidence-based "step-up" approach for this patient's evolving condition, starting from immediate initial presentation through to the management of refractory disease.

A 42-year-old woman is hospitalized after sustaining severe multisystem trauma in an all-terrain vehicle accident. Her hospital course is complicated by acute respiratory distress syndrome (ARDS), requiring a tracheostomy and prolonged mechanical ventilation. Assuming a steady, uncomplicated clinical recovery trajectory, arrange the following healthcare settings in the most appropriate chronological sequence representing the standard step-down transition of care.

An obstetric patient at 26 weeks gestation presents to the emergency triage area with abrupt-onset right-sided pleuritic chest discomfort and dyspnea. She has no significant past medical history and takes only prenatal vitamins. Vital signs reveal a temperature of 37.1°C (98.8°F), heart rate of 118/min, respiratory rate of 26/min, blood pressure of 112/70 mmHg, and oxygen saturation of 94% on ambient air. Physical examination is notable for an asymmetrically swollen and tender left calf with palpable cord-like induration. Auscultation of the lungs is clear bilaterally, and cardiovascular examination reveals sinus tachycardia without murmurs. Which of the following represent the most appropriate concurrent initial diagnostic studies for this patient? (Select exactly 2 answers)

An unresponsive 42-year-old woman is admitted to the intensive care unit following a rapid decline in mental status at an outpatient clinic. Her family reports she complained of severe right flank pain and rigors for the past day. Current vital signs include a blood pressure of $85/50\text{ mmHg}$, a heart rate of $122\text{ beats/min}$, and a temperature of $39.4^{\circ}\text{C}$ ($102.9^{\circ}\text{F}$). Point-of-care ultrasound demonstrates significant right-sided hydronephrosis. A subsequent non-contrast computed tomography scan confirms an $8\text{-mm}$ radiopaque calculus lodged in the proximal right ureter accompanied by perinephric fluid. Arrange the clinical interventions below in the most appropriate chronological sequence for this patient.

During a routine outpatient visit, a $64$-year-old female patient reports a $2$-month history of recurrent chest tightness. The discomfort reliably emerges after she walks up a flight of stairs and dissipates completely within $5$ minutes of sitting down. Her established diagnoses include type $2$ diabetes mellitus, essential hypertension, and mixed dyslipidemia. She is compliant with a regimen of metformin, lisinopril, and atorvastatin. Today, her blood pressure is $135/85 \text{ mmHg}$ and her heart rate is $76/\text{min}$. Auscultation of the heart and lungs yields no abnormal findings. An in-office $12$-lead electrocardiogram reveals normal sinus rhythm, a prolonged QRS duration of $145 \text{ msec}$, broad, notched R waves in leads I, aVL, V5, and V6, alongside discordant ST-segment depression in the lateral leads. Which of the following is the most appropriate next step in the diagnostic workup?

Emergency medical services arrive at the resuscitation bay with an unresponsive adult found unconscious in an apartment. The roommate reports that multiple empty, unlabeled medication bottles were scattered on the bedside table. Initial vital signs show a blood pressure of 90/50 mmHg, a pulse of 112/min, and a respiratory rate of 6/min. Physical examination reveals miotic pupils, decreased bowel sounds, and generalized hyperreflexia. A 12-lead electrocardiogram is rapidly obtained, demonstrating sinus tachycardia with a QRS complex duration of 145 msec and a prominent terminal R wave in lead aVR. Based on the patient's presentation and diagnostic findings, which of the following pharmacologic interventions are indicated for immediate management? (Select all that apply)

A 48-year-old woman comes to the clinic for a follow-up visit. Four weeks ago, she was diagnosed with Graves disease after presenting with unintentional weight loss, heat intolerance, and palpitations. At that time, she was initiated on methimazole and propranolol. Today, the patient reports feeling significantly better. She has gained 1.5 kg (3.3 lb) and notes complete resolution of her palpitations and tremors. She denies any sore throat, fever, or abdominal discomfort. Her blood pressure is 120/78 mm Hg and pulse is 74/min. Physical examination reveals a mild, diffuse, non-tender goiter but is otherwise unremarkable. Which of the following is the most appropriate next step in monitoring this patient's treatment?

A $68$-year-old man is evaluated in the intensive care unit for new-onset swelling of his right leg. He is currently on hospital day $8$ following a mitral valve replacement and has been receiving subcutaneous unfractionated heparin for deep vein thrombosis prophylaxis. On admission, his baseline platelet count was $240,000/\text{mm}^3$; today, it is $90,000/\text{mm}^3$. A lower extremity venous duplex ultrasound reveals an acute deep vein thrombosis in the right femoral vein. Heparin-induced thrombocytopenia is suspected. All heparin-containing products are immediately discontinued, a continuous intravenous infusion of argatroban is initiated, and a serotonin release assay is sent.

Three days later, the patient's leg swelling has improved. His platelet count has increased to $165,000/\text{mm}^3$, and his activated partial thromboplastin time has remained consistently in the therapeutic range. The serotonin release assay returns positive. The patient is clinically stable, and the critical care team plans to transition him to oral warfarin for long-term anticoagulation.

Which of the following is the most appropriate next step in the monitoring and treatment evaluation of this patient's anticoagulation?

A 23-year-old primigravid woman at 14 weeks of gestation presents to the outpatient obstetric clinic for a routine prenatal visit. She has no current symptoms and reports feeling well. Physical examination reveals no genital lesions, rashes, or lymphadenopathy. Routine prenatal laboratory screening is performed, which shows a rapid plasma reagin (RPR) titer of 1:32. A confirmatory Treponema pallidum particle agglutination (TPPA) test is reactive. Her medical history is notable for a severe anaphylactic reaction to amoxicillin during childhood, which manifested as diffuse urticaria, wheezing, and hypotension. Which of the following is the most appropriate pharmacologic intervention for this patient?

During an evening shift, paramedics transport a 19-year-old female university student to the resuscitation bay. Her dormitory residents initiated the emergency call after finding her profoundly confused and feverish. She is obtunded upon arrival. Vital signs display a temperature of 39.7°C (103.5°F), blood pressure of 76/40 mm Hg, heart rate of 142/min, and respiratory rate of 24/min. Pulse oximetry shows 96% on ambient air. Physical examination reveals marked nuchal rigidity and a widespread non-blanching purpuric eruption across the trunk and bilateral lower extremities. Her Glasgow Coma Scale score is 11.

Which of the following interventions should be ordered SIMULTANEOUSLY for the immediate initial stabilization of this patient? (Select all that apply)

A 74-year-old man with an 8-year history of Parkinson disease is brought to the clinic by his daughter because he has been experiencing distressing visual hallucinations over the past three weeks. He frequently sees strangers standing in his living room, which causes him significant anxiety. His motor symptoms, including bradykinesia and rigidity, are currently well controlled. He has no fever, dysuria, or recent illnesses. A urinalysis and basic metabolic panel performed in the clinic are unremarkable. His current daily medication regimen includes carbidopa-levodopa, ropinirole, selegiline, and trihexyphenidyl. Arrange the following pharmacological interventions in the correct sequential order of implementation for the stepwise management of this patient's psychosis, proceeding from the first step to the final step if symptoms remain refractory.

A 74-year-old woman with a history of heart failure, atrial fibrillation, and diabetes mellitus is being prepared for hospital discharge. She was treated for sepsis secondary to a urinary tract infection, which was complicated by acute kidney injury (now resolving). As part of the disposition planning, the physician is completing the discharge medication reconciliation to ensure a safe transition of care. Arrange the following steps of the medication reconciliation process in the most appropriate chronological order according to standard patient safety guidelines.

A 34-year-old woman with a history of Graves disease is brought to the emergency department by her husband due to severe agitation, palpitations, and confusion. She recently stopped taking her prescribed antithyroid medications. Her temperature is 39.4°C (103°F), blood pressure is 158/72 mmHg, heart rate is 145/min, and respiratory rate is 24/min. Physical examination reveals a staring gaze, a diffusely enlarged and non-tender thyroid gland, and fine resting tremors in both hands. An electrocardiogram shows sinus tachycardia. The physician diagnoses a thyroid storm. Arrange the following pharmacologic interventions in the most appropriate sequential order for the acute management of this patient's condition.

A medical consultation is requested for an inpatient who was admitted earlier today for severe confusion and generalized weakness. The patient was recently diagnosed with a right hilar mass, and a subsequent biopsy confirmed squamous cell carcinoma of the lung. Clinical evaluation reveals profound lethargy, decreased skin turgor, and dry oral mucous membranes.

Laboratory studies demonstrate:
Serum calcium: $14.6$ mg/dL
Serum phosphorus: $2.1$ mg/dL
Blood urea nitrogen: $68$ mg/dL
Serum creatinine: $3.2$ mg/dL (baseline $0.9$ mg/dL two weeks ago)
Intact parathyroid hormone (PTH): $8$ pg/mL (normal: $10-65$ pg/mL)

Aggressive volume resuscitation with intravenous isotonic saline and administration of calcitonin have been initiated. Which of the following is the most appropriate next step in this patient's pharmacologic management?

A 49-year-old man visits a primary care provider for a general health examination. He has not sought medical care since his twenties. He reports feeling perfectly well and exercises regularly. He has never used tobacco products. His body mass index is 23 kg/m². He has no known family history of medical conditions. Vital signs and physical examination findings are within normal limits. Which of the following preventive screening tests are currently indicated for this patient? (Select all that apply)

A gastroenterology consultation is requested for a female in her mid-forties suffering from relentless burning abdominal discomfort and persistent loose, watery stools for the past eight months. The abdominal distress frequently awakens her from sleep. Outpatient medical records indicate that a recent upper endoscopy revealed markedly thickened gastric folds alongside multiple mucosal ulcerations extending deep into the postbulbar duodenum. Biopsy specimens from the gastric antrum showed no evidence of Helicobacter pylori organisms. Her current medications include high-dose esomeprazole, which was initiated two weeks ago following the endoscopy but has provided minimal symptomatic relief. To properly evaluate her condition, the proton pump inhibitor is discontinued and temporarily replaced with an H2-receptor antagonist, which is subsequently stopped $48$ hours prior to laboratory testing. A fasting serum gastrin concentration is then measured at $620$ pg/mL (normal: $< 100$ pg/mL) alongside a simultaneously recorded basal gastric pH of $1.4$. Which of the following is the most appropriate next step in the diagnostic workup?

A 56-year-old man is brought to the emergency department by ambulance after vomiting large amounts of bright red blood at home. His wife reports that he has a history of alcohol-associated cirrhosis and previously diagnosed esophageal varices. On arrival, the patient is obtunded, opens his eyes only to painful stimuli, and is actively vomiting small amounts of blood. His temperature is 36.5°C (97.7°F), blood pressure is 78/40 mm Hg, pulse is 132/min, and respirations are 26/min. Pulse oximetry shows 92% on room air. Physical examination reveals scleral icterus, prominent abdominal distension with a fluid wave, and mottled extremities. Two large-bore intravenous lines have been successfully placed by the nursing staff. Which of the following is the most appropriate immediate next step in management?

A 58-year-old man is hospitalized with an acute deep vein thrombosis in his right leg. He is promptly started on a continuous intravenous infusion of unfractionated heparin. The nursing staff is instructed to draw blood every six hours to adjust the infusion rate according to a standard hospital protocol. Which of the following laboratory parameters is the most appropriate to monitor and titrate this therapy?

While managing a 68-year-old man with refractory septic shock in the intensive care unit, a physician prepares to obtain central venous access for continuous vasopressor administration. The physician decides to place a right internal jugular central venous catheter using the standard Seldinger technique. After donning maximal sterile barriers, prepping and draping the site, and visualizing the target vessel with real-time ultrasound, the physician must perform the catheter insertion. Arrange the following procedural steps of the Seldinger technique in the correct chronological order.