Tüm alıştırma soruları

Match each clinical patient presentation to the most likely vasculitic syndrome.

A $55$-year-old woman is evaluated on the surgical ward for nausea, bilious vomiting, and diffuse abdominal cramping. She is currently on postoperative day $6$ following an open abdominal hysterectomy for uterine fibroids. The patient reports she has not passed flatus or stool since the operation. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $128/78\text{ mmHg}$, pulse is $86/\text{min}$, and respiratory rate is $14/\text{min}$. Physical examination reveals a significantly distended and tympanic abdomen. Auscultation demonstrates high-pitched, hyperactive bowel sounds. There is mild diffuse tenderness to palpation, but no guarding, rigidity, or rebound tenderness. The surgical incision is healing well with no erythema or discharge. Laboratory results show a leukocyte count of $7,500/\text{mm}^3$ and normal serum lactate levels. Upright abdominal radiography reveals multiple dilated loops of small bowel with prominent air-fluid levels and no free intraperitoneal air. Which of the following is the most appropriate next step in management?

Emergency medical services bring a 47-year-old mechanic to the hospital after he was found deeply lethargic in his workshop. His coworkers report that he had been working alone on a vehicle's cooling system and seemed disoriented before collapsing. On presentation, his temperature is $36.8^\circ C$ ($98.2^\circ F$), blood pressure is $105/65$ mmHg, pulse is $112$/min, and respiratory rate is $24$/min. Physical examination reveals an unarousable patient with deep, rapid breathing. Arterial blood gas analysis on room air shows a pH of 7.21, $PaCO_2$ of 24 mmHg, and $PaO_2$ of 95 mmHg.

Based on the provided laboratory results, what is the patient's calculated serum osmolar gap in mOsm/kg $H_2O$?

A 68-year-old man is evaluated in the hospital for decreased urine output. He was admitted 3 days ago for severe community-acquired pneumonia and has been receiving intravenous antibiotics. His blood pressure is 98/60 mm Hg and heart rate is 102/min. Physical examination shows dry mucous membranes and flat jugular veins. Laboratory studies are obtained to evaluate his acute kidney injury:

What is the patient's fractional excretion of sodium (FeNa) expressed as a percentage?

Match each clinical exposure or presentation with the most appropriate empiric antimicrobial therapy or post-exposure prophylaxis.

A 21-year-old woman is brought to the emergency department by her family due to progressively worsening confusion, jaundice, and abdominal swelling over the past 5 days. She has no significant past medical history, takes no medications, and does not consume alcohol. Her temperature is $37.2^\circ\text{C}$ ($99^\circ\text{F}$), blood pressure is $105/60\text{ mmHg}$, pulse is $112/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals severe scleral icterus, palmar erythema, and a distended abdomen with shifting dullness. She is lethargic and oriented only to person. Asterixis is elicited upon wrist extension.

Laboratory results are as follows:

Direct antiglobulin (Coombs) test is negative. Blood and urine cultures are drawn.

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

A 52-year-old man with a history of alcohol-associated cirrhosis is brought to the emergency department after vomiting a large volume of bright red blood. His blood pressure is 88/50 mmHg and pulse is 124/min. Arrange the following steps for the management of this patient in the most appropriate chronological order, from first to last.

A 32-year-old woman, gravida 2, para 1, at 39 weeks gestation is evaluated in the labor and delivery unit. She is in spontaneous active labor and attempting a trial of labor after cesarean (TOLAC), having had a primary low transverse cesarean delivery three years ago. Epidural analgesia was placed two hours ago and has provided excellent pain relief. Over the past 15 minutes, the patient reports the sudden onset of severe, continuous lower abdominal pain that radiates to her shoulder, which she describes as "breaking through" the epidural. Her temperature is 37.0°C (98.6°F), blood pressure is 88/50 mm Hg, and heart rate is 122/min. The fetal heart rate tracing previously demonstrated a baseline of 145/min with moderate variability but now shows profound and persistent bradycardia at 75/min. On vaginal examination, the cervix is 6 cm dilated and 90% effaced. The fetal presenting part is now palpated at -3 station; it was at 0 station on the previous examination an hour ago. Which of the following is the most appropriate next step in management?

Match each clinical and laboratory presentation to the most likely hematologic diagnosis.

A healthcare clinic evaluates several patients for hepatitis B virus (HBV) exposure and immunity. Match each patient's hepatitis B serologic panel to the most accurate clinical interpretation.

A $78$-year-old woman is brought to the emergency department by her daughter due to $3$ days of worsening, diffuse abdominal pain accompanied by nausea and voluminous bilious vomiting. She has not had a bowel movement or passed flatus for the past $48$ hours. Her medical history is significant for diet-controlled type 2 diabetes mellitus, essential hypertension, and recurrent episodic right upper quadrant abdominal pain for which she has previously declined surgery.

Temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $105/65\text{ mm Hg}$, pulse is $112/\text{min}$, respiratory rate is $18/\text{min}$, and oxygen saturation is $96\%$ on room air. The abdomen is significantly distended and tympanic to percussion. It is diffusely tender to palpation without guarding or rebound tenderness. High-pitched, tinkling bowel sounds are auscultated.

Laboratory studies show:
Leukocyte count: $11,000/\text{mm}^3$
Serum creatinine: $1.6\text{ mg/dL}$ (baseline $0.9\text{ mg/dL}$)
Aspartate aminotransferase: $35\text{ U/L}$
Alanine aminotransferase: $40\text{ U/L}$
Alkaline phosphatase: $110\text{ U/L}$
Total bilirubin: $1.0\text{ mg/dL}$

A computed tomography (CT) scan of the abdomen without contrast reveals markedly dilated loops of small bowel with a transition point in the distal ileum, where a $3\text{ cm}$ calcified mass is impacted. There are also tubular radiolucencies in the right upper quadrant conforming to the central biliary tree.

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

Match each clinical presentation with the most appropriate antimicrobial stewardship intervention based on current clinical guidelines.

A 54-year-old man with a history of alcohol-associated cirrhosis is brought to the emergency department by his family after vomiting a large amount of bright red blood. Upon arrival, he appears pale and lethargic but is adequately protecting his airway. His temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure is $85/55$ mmHg, and pulse is 120/min. Physical examination reveals shifting dullness, spider angiomas, and palmar erythema. Arrange the following steps in the optimal chronological sequence for the management of this patient's condition, from most immediate to subsequent.

A 64-year-old woman is brought to the emergency department by her family due to profound weakness and confusion. She has had 5 days of severe, voluminous watery diarrhea. Her medical history includes type 2 diabetes mellitus and hypertension. On examination, blood pressure is 82/50 mm Hg, heart rate is 118/min, and respiratory rate is 24/min. She has dry mucous membranes, flat neck veins, and delayed capillary refill.

Laboratory studies show:
Serum $Na^+$: 140 mEq/L
Serum $K^+$: 3.2 mEq/L
Serum $Cl^-$: 112 mEq/L
Serum $HCO_3^-$: 8 mEq/L
Blood urea nitrogen: 54 mg/dL
Serum creatinine: 2.8 mg/dL (baseline 0.9 mg/dL)
Serum lactate: 5.2 mmol/L (Normal: 0.5-1.0 mmol/L)
Serum albumin: 4.0 g/dL

Assuming a reference anion gap of 12 mEq/L and a normal serum bicarbonate of 24 mEq/L, what is this patient's calculated delta ratio (also known as the $\Delta/\Delta$ ratio)?

A 62-year-old woman is evaluated in the hospital on hospital day 2. She was admitted with right upper quadrant abdominal pain, fever, and jaundice, and was diagnosed with acute ascending cholangitis. She underwent an urgent endoscopic retrograde cholangiopancreatography (ERCP) with successful biliary stone extraction and stent placement. On admission, blood cultures were drawn, and she was started on empiric intravenous piperacillin-tazobactam. Today, her temperature is 37.1°C (98.8°F), blood pressure is 122/78 mm Hg, and pulse is 78/min. She reports significant improvement in her abdominal pain. The admission blood cultures are now growing *Escherichia coli*. The antimicrobial susceptibility report is as follows:

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

A rapid response is called for a patient who is deteriorating in the intensive care unit. The 28-year-old woman was intubated 15 minutes ago for refractory status asthmaticus. She is deeply sedated and chemically paralyzed. Mechanical ventilation is running in volume-assist control mode with a tidal volume of 450 mL (approximately 6 mL/kg ideal body weight), a respiratory rate of 18/min, an inspiratory flow rate of 40 L/min, and a positive end-expiratory pressure (PEEP) of 5 cm H2O. Upon arrival, the high-pressure alarm is sounding continuously. Vital signs show a blood pressure of 72/40 mm Hg (down from 115/75 mm Hg post-intubation), a heart rate of 138/min, and an oxygen saturation of 93% on a fraction of inspired oxygen of 1.0. Physical examination reveals distended jugular veins and a midline trachea. Auscultation demonstrates symmetrically distant breath sounds with faint, prolonged expiratory wheezes bilaterally. Arterial blood gas analysis indicates a pH of 7.21, PaCO2 of 72 mm Hg, and PaO2 of 150 mm Hg. Review of the real-time ventilator waveforms shows that the expiratory flow curve is abruptly interrupted by the next inspiratory breath before reaching the zero baseline. Which of the following is the most appropriate immediate next step in management?

A 35-year-old woman presents to the clinic for evaluation of generalized muscle weakness and fatigue over the past several weeks. She also reports a recent history of passing two kidney stones. Her past medical history is significant for Sjögren syndrome, for which she uses artificial tears and saliva substitutes. Vital signs are within normal limits. Laboratory evaluation reveals the following:

Urinalysis:
- pH: 6.5
- Specific gravity: 1.015
- Protein: Negative
- Blood: Negative
- Glucose: Negative

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

An intensive care unit team is managing a 68-year-old man who was admitted 5 days ago for severe pneumococcal pneumonia complicated by acute respiratory distress syndrome and septic shock. He remains mechanically ventilated. Sedation was discontinued yesterday in an attempt to perform a spontaneous breathing trial, but the patient remains largely unresponsive. His wife mentions that over the past year he has been more fatigued than usual and has gained 4.5 kg (10 lb). His temperature is 36.5°C (97.7°F), blood pressure is 105/65 mmHg on low-dose vasopressin, and heart rate is 82/min. Physical examination shows no focal neurologic deficits, but relaxation of deep tendon reflexes is slightly delayed. To evaluate for potential endocrine causes of his depressed mental status, a thyroid panel is obtained:

Thyroid-stimulating hormone (TSH): 0.2 µU/mL (Normal: 0.5-5.0 µU/mL)
Free thyroxine (T4): 0.6 ng/dL (Normal: 0.9-1.7 ng/dL)
Total triiodothyronine (T3): 42 ng/dL (Normal: 80-200 ng/dL)

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

Match each clinical presentation of acute renal dysfunction with the most characteristic finding expected on microscopic urinalysis.

An evaluation is requested for a 53-year-old woman who presents to the clinic reporting a three-week history of progressively worsening shortness of breath and new-onset lower extremity swelling. She reports waking up frequently during the night gasping for air. The patient has a 12-year history of seropositive rheumatoid arthritis that has been stable for the past two years on a regimen of methotrexate and infliximab. She also takes naproxen as needed for joint pain. Her temperature is 37.0°C (98.6°F), blood pressure is 138/85 mmHg, pulse is 96/min, and respiratory rate is 22/min. Pulse oximetry shows 94% on room air. Physical examination reveals jugular venous distention at 9 cm $H_2O$. Lung auscultation demonstrates bibasilar fine crackles. Cardiac examination shows a regular rate and rhythm with a prominent S3 gallop. The abdomen is soft, and there is 2+ pitting edema of the lower extremities bilaterally. Joint examination shows ulnar deviation of the metacarpophalangeal joints but no acute synovitis or effusions. Laboratory studies reveal a hemoglobin of 11.2 g/dL, a normal comprehensive metabolic panel, a thyroid-stimulating hormone (TSH) level of 1.2 $\mu$ U/mL (normal: 0.5-5.0 $\mu$ U/mL), and a slightly decreased total $T_4$ level. Which of the following is the most appropriate next step in the management of this patient?