Tüm alıştırma soruları

A 28-year-old woman is rushed into the emergency department by her husband. She is gasping for air and clutching her anterior neck. Her husband states they were eating at a seafood restaurant 15 minutes ago when she suddenly developed severe shortness of breath, lightheadedness, and a diffuse rash. She has no known past medical history and takes no medications. Vital signs show a temperature of 37.1 C (98.8 F), blood pressure of 76/40 mm Hg, heart rate of 132/min, and respiratory rate of 28/min. Oxygen saturation is 88% on room air. Physical examination reveals marked periorbital edema, swollen lips, and loud inspiratory stridor. Which of the following are the most appropriate immediate steps in the stabilization of this patient? (Select all that apply)

A 52-year-old man presents for evaluation of a new, irregularly pigmented 8-mm macule on his left shoulder. An excisional biopsy with 2-mm margins is performed. The synoptic pathology report reveals an asymmetric, poorly circumscribed proliferation of atypical melanocytes present as single cells and in variable-sized nests. These cells exhibit prominent upward pagetoid scatter throughout the full thickness of the epidermis. Atypical melanocytes are also noted invading the papillary and superficial reticular dermis to a measured depth of 1.1 mm from the epidermal granular layer. There is no evidence of surface ulceration, and the dermal mitotic rate is 2 mitoses per square millimeter. Deep and peripheral margins are free of tumor. Based on the interpretation of this pathology report, which of the following statements are correct? (Select all that apply)

Emergency medical services arrive at the resuscitation bay with a 26-year-old male found obtunded in his apartment. Paramedics report finding empty bottles of amitriptyline and diphenhydramine at the scene. En route, the patient had a 3-minute generalized tonic-clonic seizure that terminated after intramuscular midazolam administration. Upon transfer to the stretcher, he remains unresponsive to deep pain. Vital signs demonstrate a temperature of 38.2°C (100.8°F), blood pressure of 65/35 mmHg, heart rate of 155/min, and a respiratory rate of 6/min with shallow effort. Pulse oximetry displays 88% on room air. Physical examination reveals widely dilated pupils with sluggish reactivity, and markedly warm, dry, and flushed skin. The cardiac monitor displays a regular, wide-complex tachycardia with a QRS duration of 170 msec and a prominent terminal R wave in lead aVR.

Which of the following interventions must be ordered simultaneously as the immediate priorities in stabilizing this patient? (Select 2 options)

A 35-year-old woman is brought to the emergency department by her husband due to a sudden onset of severe shortness of breath, facial swelling, and a diffuse rash. The symptoms began abruptly while they were eating at a seafood restaurant 20 minutes ago. On arrival, the patient is lethargic, extremely restless, and gasping for air. Blood pressure is 70/40 mmHg, heart rate is 138/min, and respiratory rate is 32/min. Oxygen saturation is 86% on room air. Physical examination reveals marked angioedema of the lips and tongue, prominent inspiratory stridor, and diffuse bilateral wheezing. Her skin is warm and erythematous with widespread urticaria. Which of the following are the most appropriate immediate steps in the stabilization of this patient? (Select all that apply)

A 34-year-old industrial worker is brought to the emergency department by paramedics after being rescued from a chemical warehouse fire. The patient was trapped in an enclosed storage room for an unknown duration. En route, emergency medical services administered high-flow oxygen via a non-rebreather mask. On arrival, the patient is visibly agitated and confused. Temperature is 37.2°C (99.0°F), blood pressure is 84/50 mmHg, pulse is 138/min, and respiratory rate is 28/min. Oxygen saturation is 94% on 15 L/min of oxygen. Physical examination reveals significant soot accumulation in the oropharynx, singed facial hair, and noticeable hoarseness when the patient attempts to speak. There are widespread circumferential full-thickness burns involving both lower extremities, and partial-thickness burns extending across the anterior torso. Distal pulses in all extremities are palpable and symmetric. Which of the following are the most appropriate immediate steps in management? (Select two)

Emergency medical services arrive at the trauma bay with a 27-year-old male warehouse worker who was crushed between a loading dock and a reversing forklift. On arrival, the patient is obtunded, extremely pale, and diaphoretic. Vital signs include a temperature of 36.1°C (97.0°F), blood pressure of 62/30 mm Hg, heart rate of 152/min, respiratory rate of 38/min, and oxygen saturation of 82% on a 15-L non-rebreather mask. Physical examination reveals tracheal deviation to the left and severely distended neck veins. There are absent breath sounds and hyperresonance to percussion over the right hemithorax. The abdomen is grossly distended, rigid, and diffusely tender to palpation. The pelvis is mechanically stable. Two large-bore intravenous lines are rapidly established. Which TWO of the following are the most appropriate immediate next steps in the stabilization of this patient?

A 28-year-old male is brought to the emergency department by paramedics after being struck by a motor vehicle at highway speeds. He is unresponsive upon arrival. Vital signs are temperature 35.8°C (96.4°F), heart rate 142/min, blood pressure 68/40 mm Hg, and respiratory rate 36/min. Oxygen saturation is 82% on a high-flow non-rebreather mask. Physical examination reveals a Glasgow Coma Scale score of 6 (E1, V1, M4). The right hemithorax is hyperresonant to percussion with absent breath sounds. The trachea is palpably deviated to the left. The patient has pale, cool, and diaphoretic extremities with thready peripheral pulses. Which of the following are the most appropriate immediate next steps in the management of this patient? (Select 2 options)

A 54-year-old man is diagnosed with moderate-to-severe rheumatoid arthritis following an extensive evaluation for symmetric small joint pain and prolonged morning stiffness. His rheumatologist initiates disease-modifying treatment with weekly oral methotrexate and daily folic acid supplementation. The patient has a past medical history of essential hypertension, which is well-controlled with amlodipine. He is a non-smoker and does not consume alcohol. Baseline laboratory studies, including a comprehensive metabolic panel, complete blood count, hepatitis serologies, and a chest radiograph, were all within normal limits prior to starting the new medication.

Which of the following parameters are required for routine, ongoing monitoring of this patient's new pharmacotherapy? (Select all that apply)

A 72-year-old man with chronic kidney disease (baseline creatinine 2.4 mg/dL) and atrial fibrillation is admitted to the general medical floor for community-acquired pneumonia. The resident physician uses the electronic health record (EHR) to prescribe medications. While entering an order for apixaban, the resident receives three consecutive pop-up alerts regarding minor drug interactions with the patient's home supplements and overrides all of them rapidly. A fourth alert warning about the need for renal dose adjustment of apixaban is also inadvertently dismissed. The hospital's EHR does not require a specific justification to override renal dose alerts, and new anticoagulant orders do not require pharmacist verification before dispensing. The patient receives the unadjusted dose of apixaban and two days later experiences a severe gastrointestinal hemorrhage requiring transfer to the intensive care unit. Which of the following represent latent system vulnerabilities that contributed to this adverse event? (Select all that apply.)

A 72-year-old woman is evaluated in the ambulatory care clinic for a routine follow-up. She has a history of type 2 diabetes mellitus, osteoarthritis, hypertension, and recurrent uncomplicated urinary tract infections. Her current medications include metformin 1000 mg twice daily, sitagliptin 100 mg daily, meloxicam 15 mg daily, nitrofurantoin 100 mg daily, and amlodipine 10 mg daily. The patient reports feeling well overall, though she mentions mild fatigue over the past few weeks. Blood pressure is 132/82 mmHg, and pulse is 76/min. Physical examination is unremarkable, with no peripheral edema.

Laboratory results from today are compared to those from six months ago:

Based on the patient's current laboratory results, which of the following medications must be entirely DISCONTINUED? (Select all that apply)

A 26-year-old man comes to the clinic for treatment of a painless penile chancre. Darkfield microscopy confirms the presence of Treponema pallidum, and his baseline rapid plasma reagin (RPR) titer is 1:64. He is administered a single dose of intramuscular benzathine penicillin G for primary syphilis. He is otherwise healthy, has no allergies, and tests negative for HIV. The patient asks the physician how they will know if the infection has been successfully cured. Which of the following statements represent the appropriate monitoring and evaluation plan for this patient? (Select all that apply)

Emergency medical services bring a 72-year-old male resident of a skilled nursing facility to the acute care setting following a two-day history of worsening confusion, fever, and purulent sputum production. Upon triage, he appears lethargic and is in mild respiratory distress. Vital signs reveal a temperature of 38.9°C (102.0°F), a blood pressure of 88/56 mmHg, a heart rate of 112/min, and a respiratory rate of 26/min. Room air pulse oximetry indicates an oxygen saturation of 89%. Auscultation of the lungs demonstrates dense, coarse crackles localized to the right lower lung base. A portable chest radiograph confirms a new dense consolidation in the right lower lobe. A review of his electronic medical record reveals a prior ischemic stroke complicated by oropharyngeal dysphagia. Notably, he was discharged from the hospital one month ago after being treated for complicated pyelonephritis with a 10-day course of intravenous levofloxacin. Blood and sputum cultures are sent to the laboratory.

Which of the following antimicrobial agents should be included in his initial empiric pharmacologic regimen? (Select all that apply)

During morning rounds in the intensive care unit, the medical team evaluates a patient receiving treatment for an acute massive pulmonary embolism. The 58-year-old male, who has a documented history of advanced chronic kidney disease (stage G4), was started on a continuous intravenous unfractionated heparin infusion upon admission. Which of the following laboratory parameters must be routinely monitored to ensure the efficacy and safety of this specific anticoagulant therapy? (Select all that apply)

A 58-year-old man is brought to the emergency department by his wife due to fever, severe headache, and confusion that started 12 hours ago. He has a past medical history of alcohol use disorder, type 2 diabetes mellitus, and hypertension. His temperature is 39.2°C (102.6°F), blood pressure is 110/70 mmHg, and heart rate is 115/min. On physical examination, he is lethargic but arousable. There is significant resistance to passive neck flexion. Funduscopic examination shows no papilledema. Lumbar puncture is performed, and cerebrospinal fluid (CSF) analysis reveals a leukocyte count of 2,400/mm³ (90% neutrophils), a glucose level of 30 mg/dL, and a protein level of 150 mg/dL. Gram stain of the CSF is pending.

Which of the following pharmacologic agents should be included in his immediate empiric regimen? (Select all that apply)

A 42-year-old woman with a history of bipolar I disorder is admitted to the inpatient psychiatric unit with an acute manic episode. She has previously been nonadherent to medications but now agrees to initiate treatment with lithium carbonate. She has no other medical conditions and takes no other medications. Her physical examination is unremarkable. In addition to monitoring serum drug concentrations, which of the following laboratory parameters are necessary to evaluate at baseline and periodically during long-term maintenance therapy with this medication? (Select all that apply)

A 48-year-old man presents to the emergency department with an 8-hour history of severe, unremitting epigastric pain that radiates to his mid-back. He reports that the pain is exacerbated by lying supine and is partially relieved by leaning forward. He has had two episodes of non-bloody, non-bilious emesis since the pain began. His medical history is notable for hypertension treated with amlodipine. He does not use tobacco but drinks 3-4 alcoholic beverages daily. His temperature is $37.8^\circ\text{C}$ ($100^\circ\text{F}$), blood pressure is $138/86\text{ mmHg}$, pulse is $105/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination shows a distressed patient with marked epigastric tenderness to palpation, but no rebound tenderness or guarding. Bowel sounds are hypoactive. Which of the following diagnostic tests should be included in the initial diagnostic workup of this patient? (Select all that apply)

A 28-year-old woman arrives at the emergency department due to severe, progressive right lower quadrant abdominal pain over the past 12 hours, accompanied by nausea and vomiting. Vital signs show a temperature of 38.3°C (100.9°F), blood pressure of 112/72 mmHg, and pulse of 105/min. Physical examination demonstrates localized rigidity and rebound tenderness in the right lower quadrant. A complete blood count reveals a leukocyte count of 16,000/mm³. Cross-sectional imaging of the abdomen and pelvis confirms acute, uncomplicated appendicitis. The surgical team schedules an urgent laparoscopic appendectomy. Which of the following interventions are appropriate in the immediate preoperative management of this patient? (Select all that apply)

A 67-year-old man comes to the cardiology clinic for a follow-up evaluation. Over the past 6 months, he has experienced four episodes of severe palpitations, shortness of breath, and fatigue, each lasting up to 12 hours. He has a history of hypertension, type 2 diabetes mellitus, and paroxysmal atrial fibrillation. Current medications include metoprolol succinate, apixaban, rosuvastatin, and lisinopril. His blood pressure is $132/82$ mmHg, and his pulse is $78$/min and irregularly irregular. An electrocardiogram confirms atrial fibrillation with a ventricular rate of $76$/min. The patient is highly symptomatic during his episodes, and after discussing the risks and benefits, the physician decides to initiate oral amiodarone for rhythm control. Which of the following parameters should be evaluated prior to initiating this therapy? (Select all that apply)

A 72-year-old man comes to the clinic to establish care. He was recently diagnosed with paroxysmal atrial fibrillation and was started on apixaban for stroke prophylaxis. Due to highly symptomatic palpitations despite maximum tolerated beta-blocker therapy, the decision is made today to initiate oral amiodarone for rhythm control. He has a history of essential hypertension but no other major medical conditions. Which of the following tests are indicated for baseline and routine ongoing monitoring of this new antiarrhythmic therapy? (Select all that apply)

A 56-year-old man is brought to the emergency department by ambulance after vomiting a large amount of bright red blood. He has a history of alcohol use disorder and compensated cirrhosis. On arrival, he is lethargic but localizes to pain and maintains his airway. Blood pressure is 88/55 mm Hg, and pulse is 118/min. Physical examination reveals scleral icterus, palmar erythema, and a distended abdomen with shifting dullness. Two large-bore peripheral intravenous lines are placed, and fluid resuscitation with isotonic crystalloid is initiated. Laboratory studies show:

Which of the following pharmacologic interventions are most appropriate for this patient at this time? (Select all that apply)