Tüm alıştırma soruları

During bedside cardiovascular examination, various physical maneuvers and pharmacologic interventions are utilized to differentiate structural heart diseases by altering hemodynamics. Match each of the following maneuvers with its characteristic effect on the intensity of specific cardiac murmurs.

A $68$-year-old male is evaluated in the intensive care unit for altered mental status. He was admitted $4$ days ago for an acute exacerbation of chronic obstructive pulmonary disease (COPD) and acute decompensated heart failure. His initial treatment included noninvasive positive pressure ventilation, intravenous furosemide, and a $5$-day course of azithromycin and ceftriaxone, which he completed yesterday. He has a history of severe COPD, heart failure with preserved ejection fraction, and hypertension.

Over the past $24$ hours, he has become increasingly lethargic and is currently difficult to arouse. He is receiving oxygen at $2 \text{ L/min}$ via nasal cannula. Temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $105/60 \text{ mm Hg}$, pulse is $108/\text{min}$, and respirations are $9/\text{min}$. Physical examination shows flat jugular veins when supine. Mucous membranes are dry. Cardiopulmonary examination reveals distant heart sounds and decreased breath sounds bilaterally without wheezing or crackles. There is no lower extremity edema.

Laboratory results are as follows:

Arterial blood gas analysis on $2 \text{ L/min}$ nasal cannula:

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

Identify the defining serologic or biochemical marker that is most specific for diagnosing each of the following hepatobiliary conditions.

Match each underlying valvular pathology to its classic auscultatory finding.

A 73-year-old woman with a history of severe chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy (left ventricular ejection fraction of $35\%$) is brought to the emergency department by her son due to worsening shortness of breath for the past two days. She states that her cough has increased and her sputum has changed from white to thick green. She denies paroxysmal nocturnal dyspnea, orthopnea, or recent weight gain. Vital signs include temperature $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), blood pressure $135/85\text{ mm Hg}$, pulse $115/\text{min}$, and respiratory rate $26/\text{min}$. Oxygen saturation is $87\%$ on room air. Physical examination reveals use of accessory muscles of respiration. Lung auscultation demonstrates a prolonged expiratory phase with loud, bilateral polyphonic wheezes and no crackles. The jugular venous pressure is $6\text{ cm H}_2\text{O}$ (normal $<8\text{ cm H}_2\text{O}$). There is no peripheral edema. A chest radiograph reveals hyperinflated lungs but no cardiomegaly, pulmonary edema, or focal consolidation. Which of the following medication regimens is most appropriate for the initial management of this patient?

A 71-year-old man comes to the clinic reporting progressive dyspnea on exertion, fatigue, and bilateral leg swelling for the past 4 months. He has a 45-pack-year smoking history and was previously told he has "smoker's lung." His medical history is significant for hypertension and a gunshot wound to the right thigh 30 years ago. His blood pressure is $162/52$ mm Hg, and his pulse is $104$/min. Physical examination shows an elevated jugular venous pressure of $10$ cm $H_2O$. The carotid upstrokes are brisk, and the apical impulse is hyperdynamic and laterally displaced. Auscultation reveals a $2/6$ systolic flow murmur at the left upper sternal border. Lung fields have faint bibasilar crackles. Examination of the right thigh reveals a well-healed scar with a palpable thrill and a continuous murmur auscultated over the area. Which of the following hemodynamic profiles is most likely present in this patient?

A 62-year-old man is evaluated in the intensive care unit on day 2 of admission. He was admitted for septic shock secondary to a perforated gastric ulcer and underwent an emergent exploratory laparotomy. Postoperatively, he developed severe hypoxemia and bilateral pulmonary infiltrates consistent with acute respiratory distress syndrome (ARDS). He remains intubated and mechanically ventilated.

Current ventilator settings are as follows:

Current vital signs include a temperature of 38.2°C (100.8°F), heart rate of 118/min, and blood pressure of 92/58 mm Hg while receiving a norepinephrine infusion. Pulse oximetry shows an oxygen saturation of 91%.

Arterial blood gas and serum chemistry results are as follows:

Which of the following best characterizes this patient's current acid-base status?

While rounding in the surgical recovery unit, a physician is urgently called to the bedside of a $58$-year-old male who just experienced a sudden cardiovascular collapse. The patient underwent an extensive small bowel resection for acute mesenteric ischemia $5$ days prior. The nurse reports that the patient acutely developed severe breathlessness and profound diaphoresis while being repositioned in bed.

Vital signs are temperature $38.0^{\circ}\text{C}$ ($100.4^{\circ}\text{F}$), blood pressure $76/40$ mm Hg, heart rate $136$/min, and respirations $34$/min. Pulse oximetry displays $82\%$ on room air.

On physical examination, the patient is obtunded with cool, mottled extremities. There is marked jugular venous distension. Lung auscultation is clear bilaterally. Cardiac auscultation reveals a prominent parasternal heave, a loud P2, and a right-sided S3 gallop. The abdominal incision is intact with mild surrounding erythema but no fluctuance or purulent drainage.

Arterial blood gas reveals:
pH: $7.21$
PaCO $_2$: $29$ mm Hg
PaO $_2$: $52$ mm Hg
HCO $_3^-$: $11$ mEq/L

A portable bedside echocardiogram is immediately performed, demonstrating a severely enlarged right ventricle with free-wall hypokinesis and apical sparing, along with leftward bowing of the interventricular septum. Left ventricular systolic function is preserved.

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

A 65-year-old retired factory worker presents to an urgent care center complaining of severe shortness of breath and a persistent cough that has progressively worsened over the past 3 days. He has a 35-pack-year smoking history and was diagnosed with essential hypertension a decade ago. The patient reports that he has been sleeping in a recliner because lying flat in bed causes a sudden choking sensation. His temperature is 37.1°C (98.8°F), blood pressure is 172/96 mm Hg, heart rate is 112/min, and respiratory rate is 26/min. Oxygen saturation is 88% on ambient air. Physical examination reveals markedly distended jugular veins when the patient is seated upright. Lung auscultation demonstrates diffuse expiratory wheezes and fine crackles at both lung bases. Cardiac auscultation reveals a regular, rapid rhythm with a distinct low-frequency sound occurring just after S2. Which of the following is the most appropriate initial pharmacologic therapy for this patient's acute symptoms?

A 52-year-old man is evaluated in the intensive care unit for worsening hypoxemia. He was admitted 48 hours ago with severe right lower lobe pneumonia and was intubated yesterday due to progressive respiratory failure. He is currently receiving continuous intravenous norepinephrine. His temperature is 38.2°C (100.8°F), blood pressure is 94/58 mm Hg, pulse is 112/min, and respirations are 28/min. A bedside echocardiogram shows normal left ventricular systolic function with an estimated ejection fraction of 60%. A portable chest radiograph reveals new diffuse bilateral alveolar opacities. He is deeply sedated and receiving volume-cycled assist-control ventilation.

Current ventilator settings and arterial blood gas (ABG) results are as follows:

The measured plateau pressure is 35 cm $H_2O$. The patient's predicted body weight is calculated to be 65 kg (143 lb).

ABG on current settings:
pH: 7.26
$PaCO_2$: 58 mm Hg
$PaO_2$: 55 mm Hg
$HCO_3^-$: 25 mEq/L

Which of the following are the most appropriate next steps in the management of this patient's respiratory status? (Select all that apply)

A 68-year-old man is hospitalized for community-acquired pneumonia and treated with intravenous ceftriaxone and azithromycin. On day 5 of his admission, he develops new-onset frequent, watery diarrhea, mild diffuse abdominal pain, and a temperature of 38.2°C (100.8°F). His vital signs are otherwise stable, and physical examination reveals mild lower abdominal tenderness without rebound or guarding. The medical team suspects an infectious complication related to his recent pharmacotherapy. Arrange the following management steps in the most appropriate chronological sequence for addressing this new complication.

During the cardiovascular physical examination, distinct abnormalities in the arterial pulse contour and amplitude can provide critical clues to the underlying structural or hemodynamic pathology. Match each abnormal arterial pulse description to the cardiac condition it most classically represents.

An inpatient medical team is evaluating a 62-year-old man with a known history of decompensated alcohol-associated cirrhosis who developed worsening confusion and lethargy over the past 24 hours. He has a past medical history of chronic obstructive pulmonary disease. His wife, who is his legally appointed healthcare proxy, is at the bedside; his estranged son is also present and frequently interrupts the care team to demand interventions. Vital signs are within normal limits. Physical examination reveals scleral icterus, a moderately distended abdomen with shifting dullness, and a coarse, flapping tremor of the hands when the wrists are extended. Laboratory evaluation demonstrates an elevated serum ammonia level, a normal thyroid-stimulating hormone level with a slightly decreased free T4, and a urinalysis showing $>10^5$ colony-forming units/mL of Escherichia coli without leukocyte esterase or nitrites. The patient denies dysuria or urinary frequency. An arterial blood gas reveals a normal partial pressure of carbon dioxide. The son demands that the team immediately insert a feeding tube to provide nutrition. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old woman presents to the emergency department with sudden-onset, severe, tearing chest pain radiating to her upper back. Her blood pressure is 195/110 mm Hg and heart rate is 112/min. A bedside chest radiograph shows a widened mediastinum. The physician suspects an acute aortic dissection. Arrange the following steps in the most appropriate sequential order for the evaluation and management of this patient.

A 62-year-old man is brought to the emergency department complaining of sudden-onset, severe, 'tearing' chest pain that radiates to between his shoulder blades. His blood pressure is 210/115 mm Hg in the right arm and 170/95 mm Hg in the left arm. His heart rate is 112/min. A chest x-ray reveals a widened mediastinum. The clinical suspicion for an acute aortic dissection is very high. Arrange the following steps in the most appropriate sequential order for the acute management of this patient.

A 54-year-old man is admitted to the intensive care unit with severe bilateral pneumonia and subsequently develops acute respiratory distress syndrome (ARDS). The clinical team decides to initiate invasive mechanical ventilation due to worsening hypoxemia and respiratory fatigue. Arrange the following steps in the standard sequential order for the management of severe ARDS, proceeding from the initial ventilator setup to advanced therapies.

Match each systemic disease or infectious etiology with its most characteristic cardiovascular manifestation or pathophysiologic consequence.

A $72$-year-old retired mechanic is evaluated on the medical ward on hospital day $5$. He originally presented with worsening shortness of breath, three-pillow orthopnea, and marked lower extremity swelling. Medical history is notable for ischemic cardiomyopathy with a left ventricular ejection fraction of $25\%$, hypertension, and a $40$-pack-year smoking history. Over the past four days, he has received intravenous bumetanide, resulting in a net negative fluid balance of $6$ liters and significant improvement in his respiratory symptoms. His oxygen saturation is now $96\%$ on room air. A chest radiograph obtained this morning shows a persistent, moderate, right-sided pleural effusion, which is slightly smaller than it was on admission. To evaluate the persistent fluid, a diagnostic thoracentesis is performed.

Simultaneous laboratory studies reveal the following:

The upper limit of normal for serum LDH is $250 \text{ U/L}$. Pleural fluid analysis also shows a leukocyte count of $210/\text{mm}^3$ ($85\%$ lymphocytes), a glucose level of $95 \text{ mg/dL}$, and a pH of $7.46$.

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

A $45$-year-old man is receiving mechanical ventilation in the intensive care unit for acute respiratory distress syndrome (ARDS). The ventilator alarm suddenly sounds for high peak airway pressures. The patient's blood pressure drops abruptly from $110/70$ mm Hg to $70/40$ mm Hg, and his oxygen saturation falls to $82\%$. Physical examination reveals absent breath sounds on the right side, hyperresonance to percussion, and the trachea is deviated to the left. Arrange the following interventions in the most appropriate chronological order to manage this acute life-threatening event.

An emergency medical team brings a 67-year-old male to the acute care unit due to sudden-onset respiratory distress that awakened him from sleep. The patient has a medical history significant for long-standing essential hypertension, diet-controlled type 2 diabetes mellitus, and a 40-pack-year history of cigarette smoking. On physical examination, his blood pressure is $165/92 \text{ mmHg}$, pulse is $112/\text{min}$, and respiratory rate is $26/\text{min}$ with an oxygen saturation of $88\%$ on room air. Jugular venous distention is prominent when sitting at a 45-degree angle. Cardiac auscultation reveals a regular tachycardia with a distinct $S_3$ gallop. Lung auscultation demonstrates bilateral basilar crackles along with scattered expiratory wheezes. Laboratory studies show:

Leukocyte count: $8,200/\text{mm}^3$
Arterial blood gas (room air):
$\text{pH}$: $7.34$
$p\text{CO}_2$: $48 \text{ mmHg}$
$\text{HCO}_3^-$: $25 \text{ mEq/L}$

Thyroid panel:
$\text{TSH}$: $1.2 \text{ } \mu\text{U/mL}$ (Normal: $0.4-4.0 \text{ } \mu\text{U/mL}$)
Free $T_4$: $0.7 \text{ ng/dL}$ (Normal: $0.9-1.7 \text{ ng/dL}$)

Which of the following is the most appropriate initial pharmacological therapy for this patient's respiratory distress?