Tüm alıştırma soruları

Match each clinical scenario with the most appropriate antimicrobial therapy or prophylaxis regimen.

Match each clinical scenario and associated arterial blood gas (ABG) profile with the most accurate description of the primary acid-base disturbance(s). Assume a normal anion gap is $8-12$ mEq/L.

A $24$-year-old man with a history of type 1 diabetes mellitus is brought to the emergency department with abdominal pain, vomiting, and confusion. Laboratory evaluation reveals the following:

He is diagnosed with severe diabetic ketoacidosis (DKA). Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 14-month-old boy is brought to the emergency department due to a 4-day history of high fever, severe respiratory distress, and a progressively worsening rash. His medical history is significant for a conotruncal cardiac anomaly (truncus arteriosus) that was surgically repaired at 1 week of age. His neonatal intensive care course was complicated by recurrent generalized tonic-clonic seizures that resolved after intravenous calcium gluconate infusions. He has had no recent sick contacts and does not attend daycare. Three weeks ago, he received his routine 12-month childhood immunizations at a mobile health clinic.

On physical examination, his temperature is 39.5°C (103.1°F), heart rate is 175/min, and respiratory rate is 55/min. Oxygen saturation is 86% on room air. The patient appears lethargic and toxic. Skin examination reveals a diffuse eruption of umbilicated vesicles on an erythematous base covering his face, trunk, and extremities. Several of the vesicles are hemorrhagic. Chest auscultation reveals diffuse bilateral crackles.

Laboratory evaluation shows:
Leukocyte count: 3,200/mm³
Neutrophils: 80%
Lymphocytes: 15%
Monocytes: 5%
Serum calcium: 8.2 mg/dL (normal: 8.5–10.5 mg/dL)

Chest radiograph demonstrates diffuse, bilateral nodular interstitial infiltrates.

Which of the following is the most appropriate next step in targeted pharmacotherapy for this patient?

A $42$-year-old male is evaluated in the urgent care clinic for persistent nausea and non-bilious emesis that has occurred multiple times daily over the past four days. He reports feeling profoundly weak and dizzy when standing up. His blood pressure is $98/60$ mm Hg while supine and drops to $82/50$ mm Hg upon standing. Heart rate is $112$/min. Physical examination reveals dry oral mucosa and decreased skin turgor. Laboratory studies show:

$Na^+$: $137$ mEq/L
$K^+$: $2.8$ mEq/L
$Cl^-$: $86$ mEq/L
$HCO_3^-$: $36$ mEq/L
$BUN$: $42$ mg/dL
Creatinine: $1.3$ mg/dL

Arterial blood gas reveals a $pH$ of $7.53$ and a $pCO_2$ of $46$ mm Hg.

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

An unresponsive $59$-year-old man is transported to the emergency department by ambulance after his partner noticed profound confusion, severe weakness, and abdominal pain over the past $48$ hours. He has a known history of locally advanced head and neck squamous cell carcinoma. According to his partner, he has been drinking excessive amounts of water and urinating frequently for the past week, and has not had a bowel movement in $5$ days. Vital signs reveal a heart rate of $115/\text{min}$ and blood pressure of $98/60\text{ mmHg}$. The patient is afebrile. Physical examination demonstrates notably dry mucous membranes, delayed capillary refill, and generalized hypotonia.

Laboratory evaluation shows:
Serum sodium: $139\text{ mEq/L}$
Serum potassium: $4.1\text{ mEq/L}$
Serum chloride: $104\text{ mEq/L}$
Serum bicarbonate: $25\text{ mEq/L}$
Blood urea nitrogen: $52\text{ mg/dL}$
Serum creatinine: $2.3\text{ mg/dL}$
Serum total calcium: $12.8\text{ mg/dL}$
Serum albumin: $1.5\text{ g/dL}$
Serum phosphorus: $2.0\text{ mg/dL}$

An electrocardiogram demonstrates sinus tachycardia with a shortened QT interval.

What is the most appropriate initial step in the management of this patient?

An internal medicine resident is reviewing the electronic medical record of a $50$-year-old female patient who recently underwent routine laboratory screening. The patient had mentioned experiencing mild, intermittent fatigue over the last few months but otherwise felt well. She has no significant past medical history and takes no medications. The physical examination documented in the chart is entirely unremarkable, with a normal body mass index and a resting heart rate of $72/\text{min}$. Her thyroid panel reveals a serum thyroid-stimulating hormone (TSH) level of $8.2\text{ mU/L}$ (normal: $0.5 - 5.0\text{ mU/L}$) and a serum free thyroxine (T4) level of $1.3\text{ ng/dL}$ (normal: $0.9 - 1.7\text{ ng/dL}$). Which of the following is the most accurate diagnosis based on these laboratory findings?

A 28-year-old man with a history of HLA-B27 positivity is diagnosed with active ankylosing spondylitis. He presents with worsening inflammatory back pain and morning stiffness. Arrange the following therapeutic steps in the standard chronological sequence of escalation for the management of his condition, assuming an inadequate response or disease progression at each preceding stage.

A 14-day-old male infant is brought to the pediatrician by his mother due to a 3-day history of bilateral eye redness and discharge. The infant was born at 39 weeks gestation via an unassisted home birth to a 22-year-old mother who received no prenatal care. Postnatal care was limited, and the infant did not receive prophylactic eye drops at birth. The infant is breastfeeding well, produces 6 to 8 wet diapers daily, and has no fever or cough. Vital signs are within normal limits for his age. Physical examination shows bilateral eyelid edema, marked conjunctival injection, and moderate mucopurulent discharge. The remainder of the physical examination is unremarkable. Which of the following is the most appropriate next step in management?

A $24$-year-old man with a history of type $1$ diabetes mellitus is brought to the emergency department due to altered mental status, nausea, and vomiting for the past $24$ hours. He recently had an upper respiratory tract infection. Vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $90/60\text{ mm Hg}$, pulse $120\text{/min}$, and respirations $26\text{/min}$ with deep, rapid breaths. Laboratory studies show a serum glucose of $580 \text{ mg/dL}$, arterial pH of $7.12$, serum bicarbonate of $10 \text{ mEq/L}$, and an anion gap of $22 \text{ mEq/L}$. Urine is strongly positive for ketones. Arrange the following interventions in the most appropriate chronological order for the acute management of this patient.

Match each patient's clinical presentation with the most characteristic peripheral blood smear finding associated with their underlying hematologic condition.

Carefully review the following clinical presentations of neonates experiencing respiratory compromise. Match each patient's clinical scenario with the most accurate underlying pathophysiologic mechanism.

Match each pediatric patient presenting with suspected osteoarticular or disseminated infection to the most appropriate initial empiric antimicrobial regimen based on their specific clinical risk factors.

An $11$-month-old female infant presents to the pediatric outpatient clinic during the winter season accompanied by her parents. They report a $4$-day history of copious nasal discharge and a worsening, wet-sounding cough. Over the past $24$ hours, the parents noted an increased work of breathing. During the visit, the parents also mention they are worried because the infant is not yet walking independently, although she pulls herself to a stand and cruises along the furniture. She babbles and says "mama" and "dada" specifically. Her temperature is $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), heart rate is $142/\text{min}$, respiratory rate is $48/\text{min}$, and pulse oximetry is $96\%$ on room air. Physical examination reveals clear nasal secretions and mild subcostal retractions. Lung auscultation demonstrates diffuse bilateral expiratory wheezes and scattered coarse crackles. Cardiovascular examination is normal. Which of the following is the most appropriate next step in the management of this patient?

A 60-year-old man is brought to the emergency department by a neighbor who found him lethargic and confused in his apartment. The neighbor notes that the patient has a history of severe alcohol use disorder and has been drinking heavily for the past week. He has also had multiple episodes of non-bilious vomiting over the last three days. Physical examination reveals dry mucous membranes and decreased skin turgor. Laboratory studies are obtained:

Arterial blood gas on room air reveals a pH of $7.30$ and PaCO $_2$ of $32\text{ mm Hg}$.

Calculate the patient's delta-delta ratio, defined as the change in anion gap divided by the change in serum bicarbonate ($\frac{\Delta \text{AG}}{\Delta \text{HCO}_3^-}$). Assume a normal anion gap of $12\text{ mEq/L}$ (calculated without potassium) and a normal serum bicarbonate of $24\text{ mEq/L}$.

During a late June clinic visit in Massachusetts, a $28$-year-old pregnant woman at $18$ weeks gestation presents for evaluation of an expanding rash. She reports feeling unusually fatigued over the past $4$ days, accompanied by a mild headache. Two weeks ago, the patient spent a weekend camping in a heavily wooded area, though she does not recall any specific insect bites. Her medical history is notable for a childhood episode of anaphylaxis following penicillin administration, which required emergent intubation. Vital signs include a temperature of $37.4^\circ\text{C}$, heart rate of $88\text{/min}$, and blood pressure of $110/70\text{ mm Hg}$. Physical examination reveals a $9\text{-cm}$ annular, erythematous plaque with central clearing on the right posterior thigh. The lesion is warm but non-tender. The remainder of the examination, including a detailed neurological assessment, is unremarkable. Which of the following is the most appropriate pharmacotherapy for this patient?

A 58-year-old man is evaluated on hospital day 3 for persistent fever. He was admitted with fever, severe left flank pain, and dysuria, and was diagnosed with acute complicated pyelonephritis. At that time, empiric therapy with intravenous ceftriaxone was initiated.

Today, he reports continued flank pain and malaise. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, pulse is $102\text{/min}$, and respiratory rate is $18\text{/min}$. Physical examination reveals persistent left costovertebral angle tenderness.

Blood cultures drawn on admission are now positive for *Enterobacter cloacae*. The antimicrobial susceptibility report is as follows:

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

A $76$-year-old woman is brought to the emergency department by her daughter due to worsening confusion and rapid breathing that started earlier today. The daughter notes the patient has severe osteoarthritis and recently started taking a new "over-the-counter powder" for joint pain in addition to her prescribed medications. Temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is $110/70 \text{ mm Hg}$, pulse is $112/\text{min}$, and respiratory rate is $32/\text{min}$. Physical examination shows a confused, elderly woman. Mucous membranes are dry. Cardiopulmonary examination reveals clear lungs bilaterally and tachycardia without murmurs. Laboratory studies show:

Leukocyte count: $14,500/\text{mm}^3$
Serum sodium: $140 \text{ mEq/L}$
Serum potassium: $3.8 \text{ mEq/L}$
Serum chloride: $104 \text{ mEq/L}$
Serum bicarbonate: $12 \text{ mEq/L}$
Blood urea nitrogen: $32 \text{ mg/dL}$
Serum creatinine: $1.5 \text{ mg/dL}$
Thyroid-stimulating hormone (TSH): $0.2 \ \mu\text{U/mL}$ (Normal: $0.5-5.0$)
Free T4: $0.6 \text{ ng/dL}$ (Normal: $0.9-1.7$)

Arterial blood gas analysis on room air:
pH: $7.50$
$pCO_2$: $16 \text{ mm Hg}$
$pO_2$: $98 \text{ mm Hg}$

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

A 41-week gestation male infant is delivered via emergency cesarean section for placental abruption. He is limp and apneic at birth. Following initial warming, drying, and stimulation, his heart rate is 70/min. Positive pressure ventilation (PPV) is started via face mask. After 30 seconds of effective PPV with visible chest rise, his heart rate is 50/min. Assuming the infant's heart rate remains below 60/min despite each subsequent optimized intervention, arrange the following management steps in the correct chronological sequence according to the Neonatal Resuscitation Program (NRP) algorithm.

A 38-year-old woman is evaluated for progressive proximal muscle weakness, easy bruising, and irregular menses over the past 8 months. Physical examination shows central obesity, a dorsocervical fat pad, and wide purple striae on her abdomen. Blood pressure is 162/98 mm Hg. The physician suspects hypercortisolism and plans a stepwise diagnostic evaluation. Assume the results of each test necessitate further investigation to localize an occult source of adrenocorticotropic hormone (ACTH). Arrange the following diagnostic steps in the correct chronological sequence according to standard endocrine guidelines.