Tüm alıştırma soruları

Match each clinical presentation of acute renal impairment to the pharmacological agent most likely responsible for its underlying pathogenesis.

A 54-year-old man presents to the clinic with a 5-day history of fever, severe fatigue, drenching sweats, and dark urine. He recently returned from a 2-week camping trip in Nantucket, Massachusetts. Two days ago, he was evaluated at an urgent care center where a 6-cm expanding erythematous plaque with central clearing was noted on his right thigh. He was prescribed oral doxycycline for presumed early localized Lyme disease. Despite compliance with the medication, his fever and fatigue have persisted and worsened. His temperature is 38.9°C (102.0°F), blood pressure is 116/74 mm Hg, and pulse is 108/min. Physical examination reveals pale conjunctivae, mild scleral icterus, and a fading erythematous patch on the right thigh. There is no respiratory distress. Laboratory studies show:

Hemoglobin: 9.2 g/dL
Platelets: 88,000/mm³
Leukocytes: 4,500/mm³
Total bilirubin: 3.4 mg/dL
Indirect bilirubin: 2.8 mg/dL
Lactate dehydrogenase: 650 U/L

A peripheral blood smear demonstrates pleomorphic intraerythrocytic ring forms and occasional tetrads. Which of the following is the most appropriate pharmacotherapy for this patient's current condition?

A 27-year-old woman is admitted to the hospital with a 4-day history of severe, frequent, watery diarrhea and diffuse abdominal pain. She has a history of ulcerative colitis and takes oral mesalamine. Her temperature is $38.8^\circ C$ ($101.8^\circ F$), blood pressure is $96/60$ mm Hg, pulse is 118/min, and respirations are 26/min. The patient appears acutely ill, diaphoretic, and in moderate distress due to abdominal cramping.

Based on the laboratory results, which of the following best describes this patient's acid-base status?

Match the following calcium and bone metabolism disorders with their characteristic initial laboratory findings for serum calcium, parathyroid hormone (PTH), and phosphorus.

During bedside rounds in the surgical intensive care unit, a critical care team evaluates a 68-year-old individual who underwent an emergency exploratory laparotomy 24 hours ago for acute mesenteric ischemia. The postoperative course has been complicated by massive fluid shifts and a need for continuous nasogastric tube suctioning, which is currently draining approximately 1,500 mL of bilious fluid daily. The patient is intubated and sedated. Vital signs demonstrate a blood pressure of 88/50 mm Hg and a heart rate of 122/min.

Serum laboratory analysis reveals:
$Na^+$: 142 mEq/L
$K^+$: 3.2 mEq/L
$Cl^-$: 88 mEq/L
$HCO_3^-$: 16 mEq/L
BUN: 45 mg/dL
Creatinine: 2.1 mg/dL

Arterial blood gas analysis on 40% $FiO_2$ demonstrates:
pH: 7.28
$P_{CO2}$: 34 mm Hg
$P_{O2}$: 92 mm Hg

Assuming a reference normal anion gap of 12 mEq/L and a reference normal bicarbonate of 24 mEq/L, calculate the patient's corrected bicarbonate level (often used to assess for a tertiary acid-base disorder via the delta-delta gap) in mEq/L.

A 68-year-old man is admitted to the hospital due to a 3-week history of low-grade fevers, progressive fatigue, and dyspnea on exertion. He has a history of hypertension and osteoarthritis. His temperature is 38.2°C (100.8°F), blood pressure is 128/76 mm Hg, pulse is 92/min, and respirations are 16/min. Physical examination reveals a new grade 3/6 holosystolic murmur best heard at the cardiac apex and radiating to the axilla. Splinter hemorrhages are noted on the fingernails. Transesophageal echocardiography demonstrates a 1.2-cm mobile vegetation on the anterior leaflet of the mitral valve with moderate mitral regurgitation. Three sets of blood cultures are obtained, and the patient is started on empiric intravenous vancomycin and cefepime. Forty-eight hours later, all three blood cultures grow *Enterococcus faecalis*. Antimicrobial susceptibility testing results are as follows:

Which of the following is the most appropriate definitive pharmacotherapy for this patient?

A 27-year-old woman, G1P0, is evaluated in the obstetric triage area at 31 weeks gestation. She reports a sudden gush of clear vaginal fluid that occurred 48 hours ago. Since this morning, she has developed chills and diffuse abdominal discomfort. Her temperature is 39.2°C (102.6°F), blood pressure is 110/70 mmHg, and heart rate is 115/min. Physical examination reveals a tender uterine fundus. Speculum examination shows a pool of purulent fluid in the posterior vaginal fornix. Fetal monitoring demonstrates a baseline heart rate of 175/min with moderate variability and no decelerations. Tocodynamometry shows irregular uterine contractions occurring every 8 to 10 minutes. Which of the following is the most appropriate next step in management?

A $59$-year-old man with metastatic melanoma is brought to the emergency department by his wife due to profound fatigue, generalized weakness, and nausea that have progressively worsened over the past two weeks. He has been receiving immunotherapy with ipilimumab and nivolumab for the past four months. His temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure is $88/56\text{ mm Hg}$, and pulse is $98/\text{min}$. When he stands, his blood pressure drops to $76/45\text{ mm Hg}$ and he feels dizzy. Physical examination shows a lethargic man. Mucous membranes are dry, and there is no abnormal skin pigmentation.

Laboratory studies show:

Which of the following additional laboratory findings is most likely to be present in this patient?

A newly admitted 19-year-old male with a history of type 1 diabetes mellitus is evaluated on the medical ward for persistent nausea, recurrent vomiting, and diffuse abdominal pain. The patient admits to missing his insulin doses over the past three days. The following initial serum chemistry panel is obtained:

* Sodium: 138 mEq/L
* Potassium: 5.1 mEq/L
* Chloride: 99 mEq/L
* Bicarbonate: 14 mEq/L
* Blood urea nitrogen: 28 mg/dL
* Creatinine: 1.2 mg/dL
* Glucose: 485 mg/dL

Calculate the patient's serum anion gap in mEq/L.

A 34-year-old woman comes to the clinic reporting progressive fatigue, weight gain, and cold intolerance over the past 4 months. She has not had a menstrual period since giving birth 6 months ago. Her pregnancy was complicated by a severe postpartum hemorrhage requiring emergency fluid resuscitation and multiple blood transfusions. She was unable to breastfeed her infant despite repeated attempts. Her pulse is 58/min, and blood pressure is 90/60 mm Hg. Physical examination shows dry skin and delayed relaxation of the deep tendon reflexes. Laboratory studies show:

* Thyroid-stimulating hormone (TSH): $1.1\text{ mU/L}$ (Reference: $0.4-4.0\text{ mU/L}$)
* Free thyroxine (T4): $0.4\text{ ng/dL}$ (Reference: $0.9-1.7\text{ ng/dL}$)

Which of the following is the most likely underlying mechanism for this patient's clinical and laboratory findings?

Match the following complex thyroid function laboratory profiles to the most accurate underlying pathophysiologic diagnosis.

Match each of the following high-risk infectious exposure scenarios with the most appropriate immediate management or post-exposure prophylaxis (PEP) step.

Match each clinical and laboratory profile of hypokalemic metabolic alkalosis to its most likely underlying etiology.

A 28-year-old daycare worker comes to the urgent care center complaining of severe, watery diarrhea for the past four days. She reports drinking only tap water since her symptoms began and has been unable to keep solid food down. On physical examination, her blood pressure is 105/65 mmHg and her pulse is 112/min. Her mucous membranes are dry. Laboratory studies show:

Which of the following is the expected arterial partial pressure of carbon dioxide ($PaCO_2$) for this patient if appropriate respiratory compensation has occurred?

A married couple visits a fertility specialist to discuss their lack of success in having a second child. They have not used contraception for $18$ months. The $32$-year-old female partner states she has not menstruated since the birth of their son two years ago. She describes chronic lethargy, decreased appetite leading to a $4$-kg ($8.8$-lb) weight loss, and frequently wearing sweaters even in warm weather. A review of her medical records reveals that her previous pregnancy ended in a vaginal delivery complicated by severe uterine atony and life-threatening blood loss, necessitating endotracheal intubation, massive transfusion, and emergency pelvic arterial embolization. She notes that she was never able to produce breast milk for her infant in the postpartum period. Physical examination reveals delayed relaxation of deep tendon reflexes and a blood pressure of $90/60$ mmHg. Which of the following pathophysiologic processes is most directly responsible for this patient's secondary amenorrhea and infertility?

Match each classic urinalysis sediment finding with the renal pathology it most strongly indicates.

A $32$-year-old woman is evaluated in the clinic for a $2$-year history of inability to conceive. She has never been pregnant. She and her partner have been engaging in frequent, unprotected intercourse. Over the past $18$ months, her menstrual cycles have lengthened to $45$ to $60$ days, and she has noticed increased dark hair growth on her upper lip and chin, requiring her to shave twice a week. She also reports a $12\text{-kg}$ ($26\text{-lb}$) weight gain during this period, predominantly in her abdominal area, and says she feels profoundly weak when trying to climb the stairs to her apartment. She takes a daily multivitamin. Vital signs show a blood pressure of $154/96 \text{ mm Hg}$, pulse of $82\text{/min}$, and BMI of $33 \text{ kg/m}^2$. Physical examination reveals a rounded, plethoric face and broad, violaceous stretch marks over the lower abdomen. Pelvic examination is unremarkable. Pelvic ultrasonography demonstrates bilaterally enlarged ovaries with multiple peripherally oriented small cysts. Which of the following is the most appropriate initial diagnostic step to ascertain the underlying cause of this patient's ovulatory dysfunction?

Emergency medical services bring a 61-year-old man to the emergency department after his family found him confused and febrile. His wife reports that he complained of a severe, throbbing headache yesterday before becoming progressively somnolent this morning. His past medical history includes hypertension and type 2 diabetes mellitus. Temperature is $39.4^{\circ}\text{C}$ ($102.9^{\circ}\text{F}$), blood pressure is $138/86\text{ mmHg}$, pulse is $112/\text{min}$, and respirations are $18/\text{min}$. On physical examination, the patient is lethargic and oriented only to person. He strongly resists passive neck flexion. Fundoscopic examination reveals bilateral blurring of the optic disc margins. Neurologic examination demonstrates a left-sided facial droop and decreased strength in the left upper extremity compared to the right. Arrange the following steps in the most appropriate chronological order for managing this patient.

A 28-year-old woman is brought to the emergency department due to a 5-day history of extreme fatigue, easy bruising, and spontaneous gingival bleeding. She has no significant past medical history. Her temperature is 37.9°C (100.2°F), blood pressure is 105/65 mmHg, and pulse is 112/min. Physical examination reveals diffuse petechiae across her trunk and extremities, as well as oozing from a recent venipuncture site. Laboratory studies show:

A peripheral blood smear demonstrates numerous atypical promyelocytes containing abundant azurophilic granules and multiple Auer rods.

Arrange the following steps in the most appropriate chronological sequence for the management of this patient.

A 12-day-old female neonate is evaluated in the neonatal intensive care unit for sudden-onset lethargy and temperature instability. She was born at 28 weeks of gestation via spontaneous vaginal delivery secondary to preterm premature rupture of membranes. Her birth weight was 1,050 g, and Apgar scores were 5 and 7 at 1 and 5 minutes, respectively. Over the past week, she had been tolerating incrementally advanced nasogastric feeds with premature infant formula. Current vital signs show a temperature of $35.4^\circ\text{C}$ ($95.7^\circ\text{F}$), heart rate of 175/min, and respiratory rate of 68/min with occasional apneic pauses. Physical examination reveals an ill-appearing neonate with a tensely distended abdomen and prominent abdominal wall erythema. Bowel sounds are absent. A recent diaper change revealed a grossly bloody stool.

Laboratory studies are as follows:

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