Tüm alıştırma soruları

A $39$-year-old man comes to the clinic reporting a $6$-month history of profound fatigue, decreased libido, and a $5\text{-kg}$ ($11\text{-lb}$) weight gain. He has no prior medical history but was involved in a severe motorcycle collision $18$ months ago, sustaining a basilar skull fracture that required a $3$-week intensive care unit stay. His blood pressure is $100/65\text{ mmHg}$ and heart rate is $56\text{/min}$. Physical examination shows pale, dry skin, loss of axillary and pubic hair, and a delayed relaxation phase of the deep tendon reflexes. Laboratory results are as follows:

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

A 58-year-old man is evaluated in the intensive care unit for ongoing antibiotic management. He was admitted 10 days ago following a severe traumatic brain injury that required mechanical ventilation. Five days ago, he developed a new fever of 38.9°C (102.0°F), increased purulent endotracheal secretions, and worsening oxygenation. A portable chest radiograph revealed a new right lower lobe infiltrate. He was empirically started on intravenous vancomycin and piperacillin-tazobactam for presumed ventilator-associated pneumonia. Today, the patient's temperature is 37.2°C (99.0°F), and his oxygen requirements have steadily decreased. A bronchoalveolar lavage culture obtained 48 hours ago has finalized, growing >$10^5$ CFU/mL of methicillin-susceptible *Staphylococcus aureus* (MSSA). Blood cultures drawn at the time of the fever remain sterile. Which of the following is the most appropriate next step in pharmacotherapy?

A 34-year-old woman comes to the outpatient clinic due to profound fatigue, weight gain, cold intolerance, and constipation that have progressively worsened over the last 6 months. She also notes that her menstrual cycles, which were previously regular, have been absent for the past 8 months. She takes no medications and has no other medical conditions. Her blood pressure is 98/60 mm Hg and pulse is 54/min. Physical examination demonstrates dry skin, brittle hair, and delayed relaxation phase of the deep tendon reflexes. Visual fields are full to confrontation.

Laboratory results are as follows:

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

A 34-year-old woman is evaluated for progressive weight gain, profound fatigue, and easy bruising over the past 8 months. Physical examination reveals facial plethora, marked central adiposity, supraclavicular fat pads, and wide violaceous abdominal striae. Her blood pressure is 158/96 mmHg. She takes no medications and has not used any exogenous glucocorticoids. Endogenous Cushing syndrome is suspected.

Arrange the following interventions in the most appropriate chronological sequence for the diagnostic workup and definitive management of this patient. Assume that the patient is ultimately proven to have Cushing disease caused by a biochemically active but radiologically equivocal (4-mm) pituitary microadenoma.

A 27-year-old woman is brought to the emergency department by her roommate due to persistent nausea, vomiting, and diffuse abdominal pain for the past 24 hours. She has a history of type 1 diabetes mellitus and reports that she ran out of her insulin prescription two days ago. On physical examination, she appears lethargic but is easily arousable. Her respiratory rate is $26/\text{min}$ and breaths are deep and rapid.

Laboratory testing reveals the following:

Which of the following most accurately describes this patient's primary acid-base disturbance?

A 24-year-old man with type 1 diabetes mellitus is brought to the emergency department due to altered mental status, generalized weakness, and abdominal pain for the past 24 hours. He recently had an upper respiratory infection and stopped taking his insulin due to poor oral intake. His blood pressure is 90/60 mm Hg, heart rate is 118/min, and respiratory rate is 24/min with deep, rapid breaths. Laboratory results show a blood glucose of 580 mg/dL, arterial pH of 7.12, serum bicarbonate of 10 mEq/L, and strongly positive serum ketones. Arrange the following management steps in the most appropriate chronological order for the optimal acute management of this patient's condition.

An unvaccinated $7$-month-old boy is evaluated in the pediatric clinic for a relentless cough. According to his parents, the illness started approximately $14$ days ago with mild nasal congestion and a low-grade fever. Over the past week, his cough has dramatically worsened into intense, rapid spasms. During these coughing fits, the infant becomes cyanotic around the mouth and frequently vomits his formula afterward. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate is $142/\text{min}$, respiratory rate is $38/\text{min}$, and oxygen saturation is $97\%$ on room air. On physical examination, the child appears well-nourished but has bilateral subconjunctival hemorrhages. Auscultation of the lungs reveals clear breath sounds bilaterally with no wheezing or crackles between coughing episodes. A complete blood count reveals a leukocyte count of $24,000/\text{mm}^3$ with $75\%$ lymphocytes. Which of the following is the most appropriate next step in management?

Neonatal respiratory distress can result from a variety of pulmonary and extrapulmonary conditions. Differentiating these conditions often relies heavily on the initial radiographic evaluation. Match each neonatal respiratory condition below to its most characteristic initial chest radiograph presentation.

A $74$-year-old man is evaluated on postoperative day $3$ following an uncomplicated laparoscopic cholecystectomy. Over the past $12$ hours, he has developed a fever and severe pain in his right knee. He states the pain is so intense that he cannot bear weight or tolerate the bedsheets touching his leg. His medical history is significant for essential hypertension, diet-controlled type 2 diabetes mellitus, and hypothyroidism. Current medications include lisinopril and levothyroxine. His temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is $138/86\text{ mmHg}$, and pulse is $98/\text{min}$. Cardiopulmonary examination is unremarkable. His abdomen is soft and non-tender, and the surgical incisions are clean and intact. Examination of the right knee reveals marked erythema, warmth, and a large effusion. The joint is exquisitely tender to palpation and passive range of motion. Laboratory studies show a leukocyte count of $13,500/\text{mm}^3$ and a thyroid-stimulating hormone (TSH) level of $5.5\text{ mIU/L}$. Arthrocentesis of the right knee yields $3\text{ mL}$ of cloudy synovial fluid. Analysis of the fluid reveals a leukocyte count of $28,000/\text{mm}^3$ with $80\%$ neutrophils. Polarized light microscopy demonstrates rhomboid-shaped crystals with weak positive birefringence. Gram stain of the synovial fluid reveals no organisms. Which of the following is the most appropriate next step in the management of this patient?

A 22-year-old man with type 1 diabetes mellitus is brought to the emergency department with abdominal pain, vomiting, and deep, rapid breathing. Laboratory studies confirm severe diabetic ketoacidosis (DKA) with a blood glucose of 540 mg/dL and a serum potassium of 4.8 mEq/L. Arrange the following management steps in the most appropriate chronological sequence.

A 61-year-old man is evaluated in the intensive care unit to optimize his medication regimen. He was admitted a week ago after sustaining multiple severe injuries in a high-speed motorcycle collision. He required immediate intubation and has remained mechanically ventilated. Three days ago, he developed a temperature of $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), a heart rate of $112/\text{min}$, thick purulent airway secretions, and a leukocytosis of $18,500/\mu\text{L}$. A portable chest radiograph demonstrated a new dense consolidation in the right lower lobe. He was promptly started on a broad-spectrum empiric antimicrobial regimen consisting of intravenous vancomycin, cefepime, and tobramycin.

Today, his clinical trajectory has improved; his temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), his heart rate is $85/\text{min}$, and his fraction of inspired oxygen ($\text{FiO}_2$) has been successfully titrated down. Blood cultures drawn three days ago show no growth. A quantitative culture of an endotracheal aspirate obtained at the onset of his fever grew $>10^5\text{ colony-forming units/mL}$ of *Pseudomonas aeruginosa*. The isolate's susceptibility profile is as follows:

Amikacin: Susceptible
Cefepime: Susceptible
Ciprofloxacin: Susceptible
Meropenem: Susceptible
Tobramycin: Susceptible

Routine morning laboratory results reveal a serum creatinine level of $2.2 \text{ mg/dL}$, which has climbed from a baseline of $1.0 \text{ mg/dL}$ on admission.

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

Match each clinical scenario with its most likely primary acid-base disorder.

Match each commonly prescribed medication with its primary mechanism of inducing acute kidney injury (AKI).

Match each patient's clinical presentation with the most accurate underlying pathophysiologic description.

A 16-month-old male toddler is carried into the acute care clinic by his father because he has been completely unwilling to stand or bear weight on his legs since yesterday evening. The father states that the child was previously healthy and recently started attending a new daycare center. Over the past 24 hours, the toddler has become increasingly irritable, refuses to eat, and feels very warm to the touch. Vital signs show a heart rate of 138/min, respiratory rate of 26/min, and a temperature of 39.3°C (102.7°F). On physical examination, the child cries inconsolably when the physician attempts passive range of motion of the right lower extremity. The right hip is held in a rigidly flexed, abducted, and externally rotated position. Laboratory testing reveals a leukocyte count of 17,200/mm³ and an erythrocyte sedimentation rate of 72 mm/hr. Which of the following represents the most appropriate immediate management for this patient?

Emergency medical services bring an unvaccinated 4-year-old male to the resuscitation bay due to sudden-onset respiratory distress and high fever. The parents report he has been drooling excessively and refusing to swallow. On observation, the child is extremely anxious, leaning forward with his neck hyperextended and resting his hands on his knees. Loud inspiratory stridor is heard. Arrange the following acute management steps in the most appropriate chronological sequence for this patient.

A 61-year-old man comes to the emergency department due to severe right knee pain and swelling that began abruptly overnight. He reports that the pain is excruciating, and he is unable to bear weight on the right leg. His medical history includes type 2 diabetes mellitus, chronic kidney disease (stage 3a), and a recent hospitalization two weeks ago for a chronic obstructive pulmonary disease exacerbation. His temperature is 38.2°C (100.8°F), blood pressure is 142/88 mm Hg, and pulse is 98/min. Physical examination reveals a markedly swollen, erythematous, and warm right knee. Range of motion is severely limited by pain. There are no skin breaks or ulcerations around the joint. Which of the following is the most appropriate next step in management?

A 65-year-old man is evaluated during a routine follow-up appointment. He reports feeling unusually tired over the past few months, along with new-onset constipation and dry skin. His medical history is notable for the transsphenoidal resection of a nonfunctioning pituitary macroadenoma two years ago. He currently takes no medications. Vital signs are normal except for a heart rate of 58/min. Physical examination reveals delayed relaxation of the deep tendon reflexes. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $1.8 \text{ \mu U/mL}$ (normal: $0.5\text{-}5.0 \text{ \mu U/mL}$) and a free T4 level of $0.5 \text{ ng/dL}$ (normal: $0.9\text{-}1.7 \text{ ng/dL}$). Which of the following is the most likely diagnosis?

A $62$-year-old man with a history of osteoarthritis and type $2$ diabetes mellitus presents to the emergency department with acute onset of severe right knee pain, swelling, and a fever of $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$). He is unable to bear weight on the right leg. Physical examination reveals a warm, erythematous, and markedly swollen right knee with a severely restricted range of motion due to pain. Arrange the following steps in the most appropriate chronological sequence for the management of this patient's condition.

A 25-year-old man presents to the clinic for a routine health maintenance examination. He has no past medical history and takes no medications. The patient reports having unprotected receptive anal intercourse with a new male partner 4 weeks ago. He is currently asymptomatic. Physical examination reveals normal vital signs and no lymphadenopathy, rash, or mucosal lesions. The patient requests screening for sexually transmitted infections, including HIV.

Arrange the following steps in the most appropriate chronological order for the diagnosis and initial management of this patient's suspected HIV infection, in accordance with current guidelines.