Tüm alıştırma soruları

During a routine ambulatory visit, a 58-year-old male is evaluated for ongoing management of type 2 diabetes mellitus and hypertension. Eight weeks prior, his primary care provider initiated high-intensity cardiovascular risk reduction therapy with rosuvastatin. The patient states he feels well and specifically denies experiencing new-onset muscle pain, weakness, dark urine, or abdominal discomfort. His current medication regimen includes metformin, lisinopril, and rosuvastatin. His blood pressure is $128/78 \text{ mmHg}$, and his heart rate is $72\text{/min}$. Physical examination reveals no scleral icterus, right upper quadrant tenderness, or muscle weakness.

Laboratory studies obtained today show the following:

Baseline liver function tests prior to starting rosuvastatin were within normal limits.

Which of the following is the most appropriate next step in the management of this patient's medication regimen?

A 52-year-old woman is evaluated in the emergency department for left lower quadrant abdominal pain and fever that began 24 hours ago. The pain is constant and severe. Her past medical history is significant for obesity and chronic constipation. Her temperature is 38.3°C (100.9°F), blood pressure is 128/82 mm Hg, pulse is 98/min, and respirations are 16/min. Physical examination reveals focal tenderness to palpation in the left lower quadrant with voluntary guarding, but no rebound tenderness or rigidity. Laboratory studies show a leukocyte count of 16,500/mm³. A computed tomography (CT) scan of the abdomen and pelvis with intravenous and oral contrast demonstrates focal wall thickening of the sigmoid colon, prominent pericolic fat stranding, and an adjacent 4.5-cm well-circumscribed, rim-enhancing fluid collection. No free intraperitoneal air is observed. Based on these imaging findings, which of the following is the most appropriate next step in management?

A 32-year-old woman, G2P1, at 18 weeks gestation is brought to the emergency department by emergency medical services. Her husband reports that she suddenly lost the ability to speak and developed severe weakness on her right side approximately 45 minutes ago. Upon arrival, her blood pressure is 145/88 mmHg, heart rate is 92/min, and respiratory rate is 16/min. Neurological examination reveals a dense right-sided hemiplegia, right lower facial droop, and global aphasia. Her National Institutes of Health Stroke Scale (NIHSS) score is 18. The patient is otherwise healthy, and her pregnancy has been uncomplicated. Suspecting an acute ischemic stroke with a possible large vessel occlusion (LVO), the clinical team prepares for immediate neuroimaging to determine her candidacy for reperfusion therapy.

Which of the following is the most appropriate initial sequence of imaging studies for this patient?

A 58-year-old woman is evaluated in the emergency department for sudden-onset severe dyspnea, lightheadedness, and right-sided pleuritic chest pain that began 2 hours ago. Two months ago, she underwent an uncomplicated total abdominal hysterectomy for uterine fibroids. On arrival, her temperature is 37.1°C (98.8°F), blood pressure is 108/68 mmHg, pulse is 112/min, and respirations are 24/min. Pulse oximetry shows 88% on room air. A computed tomography (CT) pulmonary angiogram reveals a large, occlusive filling defect in the main pulmonary artery extending into the right and left lobar branches. Additional review of the axial CT slices demonstrates a right ventricular to left ventricular (RV/LV) diameter ratio of 1.4, with leftward bowing of the interventricular septum, and reflux of contrast into the inferior vena cava. Immediately upon returning from the radiology suite, she becomes confused and diaphoretic; her blood pressure drops to 78/50 mmHg, and her pulse increases to 132/min. What is the most appropriate next step in patient management?

An $8$-year-old boy is brought to the emergency department by his parents due to abdominal pain for the past $24$ hours. The pain initially began around his umbilicus but has now migrated to the right lower quadrant. He has had one episode of non-bilious vomiting and reports a complete loss of appetite. His temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), pulse is $105/\text{min}$, and blood pressure is $100/65\text{ mmHg}$. Physical examination reveals a patient who lies very still on the stretcher. Abdominal examination demonstrates significant tenderness to palpation in the right lower quadrant, particularly one-third of the distance from the anterior superior iliac spine to the umbilicus. Rebound tenderness is present. Laboratory studies show a leukocyte count of $14,500/\text{mm}^3$ with a neutrophilic predominance. Which of the following is the most appropriate initial step in diagnostic imaging?

A 48-year-old man is evaluated for refractory hypertension. Despite adherence to an optimal regimen of amlodipine, lisinopril, and chlorthalidone, his blood pressure remains consistently elevated, typically around 165/100 mm Hg. He reports occasional muscle cramps and generalized weakness. Laboratory studies reveal a serum potassium level of 2.9 mEq/L. Subsequent screening demonstrates a plasma aldosterone concentration (PAC) of 26 ng/dL and a plasma renin activity (PRA) of 0.4 ng/mL/hr. He then undergoes an intravenous saline infusion test, which shows a post-infusion serum aldosterone level of 16 ng/dL (normal suppression < 5 ng/dL). A high-resolution contrast-enhanced computed tomography (CT) scan of the abdomen reveals a 1.4-cm hypodense, lipid-rich nodule in the right adrenal gland, with a normal-appearing left adrenal gland. The patient has no significant comorbidities and expresses a strong preference for a definitive surgical cure if possible. Which of the following is the most appropriate next step in the diagnostic workup?

A 68-year-old man comes to the clinic for evaluation of a 2-month history of episodic retrosternal chest pressure. The discomfort occurs reliably when he jogs or climbs more than two flights of stairs and resolves within 5 minutes of rest. He has a history of type 2 diabetes mellitus, hypertension, and mild knee osteoarthritis. His medications include metformin, amlodipine, and lisinopril. He is physically active and states that his joint pain does not limit his ability to exercise. Vital signs are within normal limits. Cardiopulmonary examination is unremarkable. A resting 12-lead electrocardiogram demonstrates normal sinus rhythm with a QRS duration of 140 milliseconds, broad notched R waves in leads I, aVL, V5, and V6, and deep S waves with ST-segment elevation in leads V1 and V2. Which of the following is the most appropriate next step in the diagnostic workup of this patient?

A 28-year-old woman presents to the ambulatory care clinic for evaluation of vague, intermittent right upper quadrant abdominal discomfort that has been present for the past three months. She has no significant past medical history other than a 10-year history of taking combined oral contraceptive pills. Vital signs are within normal limits, and physical examination reveals a soft, non-tender abdomen with no palpable hepatomegaly. Laboratory studies, including liver function tests, basic metabolic panel, alpha-fetoprotein, and CA 19-9, are all within normal limits. Given her persistent symptoms, a multiphasic contrast-enhanced magnetic resonance imaging (MRI) of the liver is performed. The MRI reveals a solitary, 6-cm, well-demarcated lesion in the right hepatic lobe. During the arterial phase, the lesion demonstrates robust, homogeneous hyperenhancement. On the portal venous and delayed phases, the lesion becomes isointense to the surrounding normal liver parenchyma. A central stellate structure is identified within the lesion; this structure is hyperintense on T2-weighted sequences and demonstrates progressive contrast enhancement on the delayed phase. Based on the precise interpretation of these imaging findings, which of the following is the most appropriate next step in management?

Coworkers rush a $45$-year-old butcher into the trauma bay following an occupational accident. While cutting meat, he accidentally struck his right forearm with a large cleaver. On arrival, the patient is lethargic, extremely pale, and diaphoretic. Bright red blood is actively spurting from a deep laceration on the volar aspect of his forearm, soaking rapidly through the towel wrapped around his arm.

Vital signs are:
Temperature: $36.6^\circ\text{C}$ ($97.9^\circ\text{F}$)
Blood pressure: $82/50$ mm Hg
Heart rate: $132$/min
Respiratory rate: $20$/min
Oxygen saturation: $97\%$ on room air

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

A 34-year-old man presents to the emergency department with a 2-day history of sharp, constant right lower quadrant abdominal pain. He reports no nausea, vomiting, or changes in bowel habits. His temperature is 37.2°C (99.0°F), blood pressure is 128/78 mmHg, and pulse is 82/min. Physical examination reveals localized tenderness to palpation in the right lower quadrant without rebound or guarding. Laboratory studies show a leukocyte count of 11,500/mm³. A contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis is performed. The scan reveals a 2.5-cm, oval-shaped, fat-density lesion located anterior to the ascending colon, featuring a hyperdense rim and a central high-attenuation dot. There is mild surrounding inflammatory fat stranding. The colonic wall demonstrates normal thickness, and the appendix measures 5 mm in diameter with no surrounding fluid. Based on these imaging findings, which of the following is the most likely diagnosis?

An 76-year-old woman arrives at the emergency department accompanied by her daughter. The patient reports the abrupt onset of excruciating, generalized abdominal pain that started approximately $2$ hours ago. The pain is severe, constant, and associated with one episode of non-bilious emesis and an urgent need to defecate. Her medical history includes long-standing hypertension, type 2 diabetes mellitus, chronic kidney disease stage 4, and paroxysmal atrial fibrillation. She states she has not taken her prescribed apixaban for the past three weeks due to an insurance coverage issue.

Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $158/92 \text{ mmHg}$, a heart rate of $115/\text{min}$ with an irregularly irregular rhythm, and a respiratory rate of $22/\text{min}$. On physical examination, the patient appears in significant distress, writhing on the stretcher. Her abdomen is soft and non-distended. There is mild, diffuse tenderness to palpation, but no guarding, rigidity, or rebound tenderness is elicited. Bowel sounds are diminished.

Which of the following is the most appropriate next step in diagnostic imaging for this patient?

A 28-year-old woman, G1P0 at 16 weeks gestation, presents to the emergency department with a 12-hour history of progressively worsening right lower quadrant abdominal pain, nausea, and vomiting. Her temperature is 38.0°C (100.4°F), blood pressure is 112/72 mmHg, and heart rate is 105/min. Physical examination reveals focal tenderness in the right lower quadrant with guarding, but no rebound tenderness. Laboratory studies show a leukocyte count of 14,500/mm³. Which of the following is the most appropriate initial imaging study to establish the diagnosis?

A 55-year-old woman is evaluated in the breast clinic after a routine screening mammogram demonstrated a new cluster of fine, linear, and branching microcalcifications in the upper outer quadrant of her right breast. She has no palpable breast masses, skin dimpling, or nipple discharge. A stereotactic core needle biopsy of the calcifications is performed.

Histopathologic examination of the biopsy specimens reveals enlarged terminal duct lobular units completely expanded by a monomorphic population of atypical epithelial cells forming rigid, punched-out secondary lumens. The central portions of these involved spaces contain abundant eosinophilic amorphous debris with karyorrhectic nuclei. Associated microcalcifications are present within this central debris.

Immunohistochemical staining is performed and demonstrates a continuous, intact rim of p63 and smooth muscle myosin heavy chain (SMMHC) positive cells surrounding the involved spaces. The neoplastic cells exhibit strong, diffuse membranous staining for E-cadherin.

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

A 48-year-old woman comes to the clinic for a routine wellness examination. Her medical history is significant for severe persistent asthma, for which she uses a fluticasone-salmeterol inhaler, and an unprovoked deep vein thrombosis diagnosed six months ago, for which she currently takes rivaroxaban.

During the encounter, she mentions several self-initiated changes to her health routine. She states, 'I have been feeling sad lately, so I started taking an over-the-counter St. John's wort supplement. I also occasionally take my husband's propranolol when I feel anxious about my breathing. Furthermore, I read online that I should get a bone density scan to check for osteoporosis, so I want to schedule that today.'

When the physician gently expresses concern regarding her unprescribed medication use, the patient crosses her arms and says, 'I am an adult, and as a doctor, you cannot just declare me legally incompetent to make my own health choices!'

Which of the following is the most appropriate counseling response by the physician?

A 62-year-old woman is evaluated in the clinic for follow-up of abnormal laboratory findings. Two weeks ago, she underwent routine blood work for a wellness exam, which showed an elevated serum calcium level. She is completely asymptomatic and specifically denies fatigue, bone pain, abdominal pain, nausea, or a history of nephrolithiasis. She has no significant past medical history and takes no medications. She has no known family history of endocrine disorders.

Vital signs are within normal limits. Physical examination reveals a well-appearing woman with a normal thyroid gland on palpation and no palpable neck masses.

Repeat laboratory studies obtained today are as follows:

A dual-energy x-ray absorptiometry (DEXA) scan demonstrates a T-score of -2.6 at the distal third of the radius and -1.8 at the lumbar spine. Because the patient meets the criteria for surgical intervention due to osteoporosis, her physician is considering a referral for parathyroidectomy.

Which of the following is the most appropriate next step in the diagnostic workup prior to surgical planning?

A 72-year-old man who is recovering from a right total hip arthroplasty performed 3 days ago develops progressive abdominal distension, mild diffuse abdominal pain, and nausea. He has not had a bowel movement since surgery, though he reports passing flatus. His medications include oxycodone, enoxaparin, and scheduled acetaminophen. Vital signs are temperature 37.1°C (98.8°F), blood pressure 130/80 mmHg, heart rate 88/min, and respiratory rate 16/min. Physical examination shows a massively distended, tympanic abdomen with hypoactive bowel sounds. There is no guarding, rigidity, or rebound tenderness. Laboratory results are unremarkable. A supine plain abdominal radiograph demonstrates diffuse dilation of the cecum, ascending colon, and transverse colon, with a maximum cecal diameter of 9 cm. There is a continuous column of gas extending down to the rectum with no discrete transition point. No free intraperitoneal air is visualized. Based on the interpretation of these imaging findings, which of the following is the most appropriate next step in management?

A $62$-year-old man with a $4$-year history of untreated, asymptomatic, low-grade follicular lymphoma presents with rapid enlargement of a right cervical lymph node, new-onset fevers, and a $10\%$ body weight loss over the past $6$ weeks. An excisional biopsy of the rapidly enlarging node is performed.

Histopathologic and molecular evaluation reveals the following:
- Complete architectural effacement by a diffuse infiltrate of large lymphoid cells.
- The atypical cells display vesicular chromatin, prominent nucleoli, and moderate basophilic cytoplasm.
- No residual nodular or follicular architecture is identified.
- Immunohistochemistry: The large cells are strongly positive for $CD20$, $CD10$, $BCL-2$, and $BCL-6$.
- The Ki-67 proliferation index is estimated at $85\%$.
- Fluorescence in situ hybridization (FISH) confirms the persistence of a $t(14;18)(q32;q21)$ translocation and identifies a newly acquired $MYC$ gene rearrangement at $8q24$.

Which of the following is the most accurate diagnostic interpretation of this lymph node biopsy?

A 59-year-old male presents to the outpatient clinic reporting a three-week history of episodic right upper quadrant abdominal pain. The pain typically occurs following large meals, lasts for approximately an hour, and then resolves completely. He is currently asymptomatic. His vital signs are temperature 37.1°C (98.8°F), blood pressure 128/82 mmHg, heart rate 76/min, and respiratory rate 14/min. Physical examination reveals a soft, non-distended abdomen with mild deep palpation tenderness in the right upper quadrant, but no Murphy sign or peritoneal signs are present.

Laboratory studies are obtained and shown below:

An abdominal ultrasound demonstrates multiple echogenic foci with posterior acoustic shadowing in the gallbladder. The gallbladder wall is not thickened. The common bile duct measures 9 mm in diameter, but no obstructing calculus is directly visualized.

Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

A 72-year-old man is brought to the emergency department by emergency medical services after collapsing at home. His wife reports that he complained of a sudden, tearing pain in his abdomen and lower back shortly before losing consciousness. His past medical history is significant for hypertension, hyperlipidemia, and a 50-pack-year smoking history. Upon arrival, he is lethargic, pale, and diaphoretic. Vital signs are temperature $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), heart rate 132/min, blood pressure 68/40 mmHg, and respiratory rate 24/min. Physical examination reveals a large, pulsatile midline abdominal mass and cold, mottled lower extremities. Two large-bore peripheral intravenous catheters have been successfully inserted. Which of the following is the most appropriate next step in management?

A 58-year-old woman presents to the ambulatory clinic complaining of a swollen and painful right calf that started two days ago. She is currently receiving chemotherapy for active ovarian cancer and reports spending most of the past week in bed due to profound fatigue. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 128/82 mmHg, heart rate of 88/min, and respiratory rate of 14/min. Physical examination reveals pitting edema extending to the right knee, mild erythema, and localized tenderness along the popliteal vein. The right calf circumference is measured to be 4.5 cm larger than the left calf. Which of the following is the most appropriate next step in evaluating this patient's condition?