Tüm alıştırma soruları

Match the following complex nephrologic and acid-base clinical presentations with their most appropriate specific therapeutic interventions.

A 30-month-old boy is brought to the clinic by his parents for a routine health maintenance visit. His parents express concern because his knees touch when he walks, which they fear causes him to be clumsy. They also note that he has a "potbelly" and are worried about his language development, stating that strangers can only understand about half of what he says. He currently combines two words into phrases and has an estimated vocabulary of 60 words. He is able to jump in place with both feet, turn single pages of a book, and build a tower of 6 cubes. He washes and dries his hands independently. Vital signs are within normal limits. His height and weight have consistently tracked along the 50th percentile. Physical examination reveals a protuberant abdomen, exaggerated lumbar lordosis, and symmetric genu valgum with an intermalleolar distance of 5 cm. Which of the following is the most appropriate next step in management?

An emergency department evaluation is requested for a $42$-year-old man who reports severe, diffuse abdominal pain that consistently begins $30\text{ minutes}$ after meals over the past $4\text{ weeks}$. He also reports a $6\text{-kg}$ ($13\text{-lb}$) weight loss during this period, diffuse muscle aches, and intermittent fevers. Two days ago, the patient developed difficulty lifting his right foot while walking. His temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$) and blood pressure is $168/98\text{ mmHg}$. Physical examination shows a mottled, purplish, net-like rash on the lower extremities. Neurologic examination demonstrates $2/5$ motor strength in right foot dorsiflexion and decreased pinprick sensation over the right lateral calf.

Laboratory studies are as follows:

Urinalysis reveals $1+$ protein, $0-2$ red blood cells/hpf, and no cellular casts.

Which of the following is the most appropriate next step in diagnosis?

Match each clinical presentation of systemic vasculitis with the most likely specific diagnosis.

A $55$-year-old man is brought to the emergency department by his wife due to confusion, high fever, and a severe headache that started $12$ hours ago. His medical history is significant for a deceased-donor renal transplant $2$ years ago, for which he takes tacrolimus and mycophenolate mofetil. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $105/65\text{ mm Hg}$, pulse is $115\text{/min}$, and respirations are $22\text{/min}$. On physical examination, the patient is lethargic but arousable. He has pronounced nuchal rigidity. Neurologic examination reveals left-sided pronator drift and a sluggish left pupillary reflex. Fundoscopy shows bilateral blurring of the optic discs. Arrange the following management steps in the most appropriate chronological order for this patient.

A 68-year-old man arrives at the emergency department reporting two days of progressively worsening dyspnea and an inability to lie flat without severe respiratory distress. He has a past medical history of chronic obstructive pulmonary disease (COPD), diet-controlled type 2 diabetes mellitus, and hypertension. Current medications include inhaled tiotropium and oral amlodipine. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $174/96\ \text{mm Hg}$, pulse is $116/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry indicates an oxygen saturation of $87\%$ on room air. Physical examination reveals a patient in moderate respiratory distress using accessory muscles. Jugular venous pressure is elevated to $11\ \text{cm H}_2\text{O}$ above the sternal angle. Pulmonary auscultation reveals a prolonged expiratory phase with diffuse bilateral wheezing and scattered crackles at the lung bases. Cardiac examination shows tachycardia with a regular rhythm and an audible S3 gallop. There is $2+$ pitting edema in the lower extremities bilaterally.

Laboratory results are as follows:
Leukocyte count: $8,200/\text{mm}^3$
Thyroid-stimulating hormone (TSH): $0.2\ \mu\text{IU}/\text{mL}$ (Normal: $0.4\text{-}4.0$)
Free T4: $1.2\ \text{ng}/\text{dL}$ (Normal: $0.9\text{-}1.7$)
N-terminal pro-B-type natriuretic peptide (NT-proBNP): $2,800\ \text{pg}/\text{mL}$

Arterial blood gas analysis on room air reveals:
pH: $7.25$
$\text{PaCO}_2$: $64\ \text{mm Hg}$
$\text{PaO}_2$: $55\ \text{mm Hg}$
$\text{HCO}_3^-$: $27\ \text{mEq}/\text{L}$

A portable chest radiograph displays cardiomegaly, bilateral pleural effusions, prominent upper lobe pulmonary vessels, and hyperinflated lung fields. Which of the following is the most appropriate next step in the management of this patient?

An emergency medical services team brings a 58-year-old male to the emergency department following a new-onset generalized tonic-clonic seizure. His wife reports that he had been complaining of a progressively worsening headache, severe neck stiffness, and subjective fevers for the past 48 hours. His temperature is 39.4°C (102.9°F), blood pressure is 112/68 mmHg, and pulse is 118/min. On physical examination, the patient is obtunded and grimaces upon neck flexion. Funduscopic examination shows no papilledema, but a detailed neurologic exam reveals a new right-sided pronator drift.

Arrange the following interventions in the most appropriate chronological sequence for this patient's management.

A 62-year-old man is evaluated on postoperative day 3 following an uncomplicated laparoscopic inguinal hernia repair. He reports the acute onset of severe pain, swelling, and redness in his right first metatarsophalangeal joint that began overnight. The patient has a history of hypertension and hyperlipidemia. His temperature is 37.8°C (100.0°F), blood pressure is 135/85 mmHg, and pulse is 88/min. Physical examination reveals an exquisitely tender, warm, and erythematous right big toe. Synovial fluid analysis of the affected joint reveals a leukocyte count of 22,000/mm³ and the presence of needle-shaped, negatively birefringent crystals. Gram stain shows no organisms. Which of the following is the most appropriate next step in management?

A $72$-year-old man is evaluated on postoperative day $1$ following an elective total hip arthroplasty due to severe osteoarthritis. Prior to surgery, his hemoglobin was $11.2 \text{ g/dL}$. Postoperatively, his hemoglobin dropped to $6.8 \text{ g/dL}$, and a transfusion of $2$ units of packed red blood cells was ordered. One hour into the transfusion of the second unit, he reports severe shortness of breath and a new-onset dry cough. His medical history is significant for hypertension, type $2$ diabetes mellitus, and coronary artery disease.

Vital signs are:
- Temperature: $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$)
- Blood pressure: $175/95 \text{ mmHg}$
- Heart rate: $112/\text{min}$
- Respiratory rate: $28/\text{min}$
- SpO $_2$: $88\%$ on room air

Physical examination reveals elevated jugular venous pressure to $9 \text{ cm H}_2\text{O}$. Cardiac auscultation reveals a regular tachycardia with a new $S_3$ gallop. Pulmonary examination reveals bibasilar crackles extending midway up the lung fields. There is no rash or stridor.

Laboratory studies obtained one hour prior to the transfusion:

Arterial blood gas (room air, during acute event):
- pH: $7.48$
- pCO $_2$: $30 \text{ mmHg}$
- pO $_2$: $55 \text{ mmHg}$

Which of the following is the most appropriate next step in management?

A 58-year-old man presents to the outpatient clinic with a 2-day history of steady left lower quadrant abdominal pain. The pain is associated with mild nausea and a decreased appetite. He denies vomiting, hematochezia, or melena. He has a history of essential hypertension treated with amlodipine. He underwent a screening colonoscopy three years ago, which revealed scattered diverticula but no polyps or malignancy. Vital signs are temperature 37.6°C (99.7°F), blood pressure 132/82 mmHg, heart rate 84/min, and respiratory rate 16/min. The abdomen is soft and non-distended. There is focal tenderness to deep palpation in the left lower quadrant, but no guarding or rebound tenderness is appreciated. Complete blood count shows a leukocyte count of 11,200/mm³. A CT scan of the abdomen and pelvis with contrast reveals focal thickening of the sigmoid colon wall and adjacent pericolic fat stranding. There are no fluid collections, abscesses, pneumatosis, or free intraperitoneal air. Which of the following is the most appropriate next step in management?

A 26-year-old woman with a 3-year history of systemic lupus erythematosus (SLE) presents to the clinic with 2 weeks of worsening bilateral lower extremity edema and newly frothy urine. Her current medications include hydroxychloroquine and low-dose prednisone. Vital signs show a blood pressure of 152/94 mm Hg. Physical examination reveals 2+ pitting edema up to the mid-calves. You suspect new-onset lupus nephritis. Arrange the following steps in the standard sequential order for the diagnostic evaluation and subsequent therapeutic management of this patient.

A 14-year-old boy is brought to the clinic by his father for a routine sports physical. The father inquires about his son's physical development, noting that some of his son's classmates have already experienced significant growth spurts. The physician explains that male puberty progresses through a predictable sequence of physiological changes, primarily driven by the hypothalamic-pituitary-gonadal axis. Arrange the following clinical milestones of normal male pubertal development in their typical chronological order of onset, from earliest to latest.

A 74-year-old woman is evaluated in the emergency department for a 3-day history of progressively worsening shortness of breath and increased sputum production. She has a medical history of chronic obstructive pulmonary disease (COPD), heart failure with preserved ejection fraction, and type 2 diabetes mellitus. Her current medications include lisinopril, amlodipine, metformin, and a daily tiotropium inhaler. She has a 40-pack-year smoking history. Her temperature is 37.3 °C (99.1 °F), blood pressure is 138/86 mm Hg, pulse is 92/min, and respirations are 24/min. Pulse oximetry shows an oxygen saturation of 89% on room air. The patient is sitting upright and using accessory muscles of respiration. The jugular venous pressure is 6 cm H2O. Chest auscultation reveals a prolonged expiratory phase with diffuse expiratory wheezing bilaterally. Cardiac examination shows a regular rate and rhythm with a normal S1 and S2; there are no murmurs or gallops. There is no peripheral edema. Laboratory studies show:

Leukocyte count: 9,500/mm³
Serum $Na^+$: 139 mEq/L
Serum $K^+$: 4.1 mEq/L
Serum $Cl^-$: 96 mEq/L
Serum $HCO_3^-$: 33 mEq/L
BUN: 18 mg/dL
Creatinine: 0.9 mg/dL
Thyroid-stimulating hormone (TSH): 0.15 µU/mL (Normal: 0.4–4.0 µU/mL)
Free thyroxine (T4): 1.1 ng/dL (Normal: 0.9–2.4 ng/dL)

An arterial blood gas on room air shows:
pH: 7.35
$PaCO_2$: 60 mm Hg
$PaO_2$: 58 mm Hg

A chest radiograph shows hyperinflated lungs and flattened diaphragms, with no focal consolidation, pleural effusion, or pulmonary vascular congestion. Which of the following is the most appropriate next step in management of this patient's current condition?

A 48-year-old man is brought to the emergency department by his wife due to a 2-week history of worsening shortness of breath, fever, and coughing up blood-tinged sputum. He has a past medical history of chronic rhinosinusitis refractory to antibiotics, recurrent epistaxis, and bilateral knee pain over the past year. His only medication is ibuprofen as needed.

His temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $155/95\text{ mm Hg}$, pulse is $112/\text{min}$, and respirations are $26/\text{min}$. Oxygen saturation is $89\%$ on room air.

Physical examination shows ulceration of the nasal septum and a saddle nose deformity. Lung auscultation reveals bilateral fine crackles. Heart sounds are normal. There is no peripheral edema.

Laboratory results are as follows:

Urinalysis shows 3+ protein and large blood; microscopy reveals 25-50 RBCs/hpf and occasional red blood cell casts.

An arterial blood gas on room air shows:
pH: $7.28$
PaO $_2$: $58\text{ mm Hg}$
PaCO $_2$: $25\text{ mm Hg}$
HCO $_3^-$: $11\text{ mEq/L}$

A chest X-ray shows multiple bilateral nodular opacities, several of which are cavitating.

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

During a routine health supervision visit, a pediatrician evaluates a 3-year-old female. She was born full-term with an uncomplicated neonatal course. Observations and parental reports indicate she can pedal a small tricycle, build a tower of nine blocks, and successfully unbutton her coat. She enjoys engaging in pretend play with her older sister and consistently follows two-step verbal instructions. Her parents report that she primarily communicates using two-word phrases, such as "want milk" and "go outside." Additionally, extended family members can only understand approximately half of her spoken words. Physical examination reveals normal tympanic membranes and a clear oropharynx. Which of the following is the most appropriate next step in management?

A $74$-year-old woman presents to the emergency department with a severe, unilateral right-sided headache and jaw pain when chewing. She also reports a transient episode of complete vision loss in her right eye that resolved after $10$ minutes. Laboratory studies show an erythrocyte sedimentation rate of $88\text{ mm/h}$ and a C-reactive protein of $45\text{ mg/L}$. Arrange the following management steps in the most appropriate sequential order for this patient.

An elderly woman is brought to the emergency department by her daughter after developing a sudden high fever, an intense headache, and confusion over the last 12 hours. The patient is a 72-year-old with a history of hypertension. Vital signs reveal a temperature of 39.4°C (102.9°F) and a heart rate of 112/min. Physical examination demonstrates marked nuchal rigidity and a Glasgow Coma Scale score of 12. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 58-year-old man is evaluated in the emergency department for a 2-day history of severe headache, fever, and progressive lethargy. His wife reports that he became disoriented this morning. His temperature is 39.2°C (102.6°F), blood pressure is 110/70 mmHg, heart rate is 115/min, and respiratory rate is 18/min. The patient is stuporous but grimaces to painful stimuli. Neurologic examination reveals marked nuchal rigidity and a new right-sided pronator drift.

Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for the management of this patient.

A 72-year-old man with a history of chronic obstructive pulmonary disease and a mechanical mitral valve replacement is brought to the emergency department due to 5 days of fever, progressive dyspnea, and a cough producing frothy sputum. Temperature is 38.6°C (101.5°F), blood pressure is 105/60 mm Hg, pulse is 115/min, and respirations are 28/min. Oxygen saturation is 86% on room air. Lung auscultation reveals diffuse bilateral crackles. Cardiovascular examination reveals a new, loud holosystolic murmur at the apex radiating to the axilla. Chest radiograph shows cardiomegaly and bilateral perihilar alveolar opacities.

Laboratory studies on admission:
Leukocyte count: $18,500/\text{mm}^3$
Serum creatinine: $1.2\ \text{mg/dL}$
Thyroid-stimulating hormone (TSH): $0.15\ \mu\text{U/mL}$ (Normal: $0.4-4.0\ \mu\text{U/mL}$)
Free T4: $0.8\ \text{ng/dL}$ (Normal: $0.9-2.4\ \text{ng/dL}$)

The patient is intubated for acute respiratory failure. Blood cultures are drawn, and he is empirically started on intravenous vancomycin, cefepime, and furosemide. Transesophageal echocardiography demonstrates severe mitral regurgitation and a $12\text{-mm}$ mobile vegetation on the mechanical mitral valve.

On day 3, four out of four blood culture bottles grow *Enterococcus faecalis*. The isolate is susceptible to ampicillin, vancomycin, and high-level gentamicin. Repeat laboratory studies show a serum creatinine of $2.9\ \text{mg/dL}$ and a blood urea nitrogen of $52\ \text{mg/dL}$.

Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A $45$-year-old man with recently diagnosed Burkitt lymphoma is evaluated in the hospital on the second day of his induction chemotherapy regimen. He reports new-onset nausea, generalized weakness, and severe muscle cramps. Over the past $12$ hours, his urine output has decreased to approximately $200$ mL. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $118/76$ mmHg, pulse is $114$/min, and respirations are $18$/min. Physical examination reveals muscle fasciculations and diffuse weakness. Laboratory studies show the following:

An electrocardiogram is obtained and demonstrates peaked T waves, flattened P waves, and a widened QRS complex. Which of the following is the most appropriate initial step in the management of this patient?