Tüm alıştırma soruları

Match each clinical presentation and high-resolution manometry (HRM) profile with the most likely esophageal motility disorder diagnosis based on the Chicago Classification.

A $32$-year-old woman is brought to the emergency department by her husband due to severe confusion, agitation, and repeated vomiting over the past $12$ hours. She had an uncomplicated spontaneous vaginal delivery $3$ days ago. Her past medical history is notable for Graves disease, for which she discontinued her antithyroid medications during the third trimester. Her temperature is $39.8^\circ\text{C}$ ($103.6^\circ\text{F}$), blood pressure is $165/75\text{ mmHg}$, pulse is $152/\text{min}$ and irregular, and respirations are $28/\text{min}$. Physical examination reveals a staring gaze, diaphoresis, marked fine tremor, and a diffusely enlarged, non-tender thyroid gland. An electrocardiogram shows atrial fibrillation with a rapid ventricular response. A clinical diagnosis of thyroid storm is made, and the patient is admitted to the intensive care unit.

Arrange the following interventions in the most appropriate chronological sequence for the management of this patient's condition.

A 74-year-old woman presents to the emergency department with a 3-day history of severe right-sided headache and jaw pain while chewing. She reports that 2 hours ago, she experienced sudden, painless vision loss in her right eye. Physical examination reveals a tender, nonpulsatile right temporal artery. Laboratory studies show an erythrocyte sedimentation rate of $110$ mm/h. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for the management of this patient's condition, from immediate (first) to long-term (last).

Match each clinical presentation of hypercalcemia and its associated laboratory profile with the most likely underlying pathophysiologic mechanism.

A 36-year-old woman comes to the clinic for evaluation of a neck mass. She noticed a lump on the right side of her neck 3 weeks ago while applying lotion. She feels occasionally warm and has had mild palpitations recently, but she attributes these symptoms to stress at work. Her menstrual cycles are regular. Vital signs show a heart rate of $98/\text{min}$ and blood pressure of $128/78\text{ mmHg}$. Physical examination reveals a firm, mobile, $2.4\text{-cm}$ nodule in the right lobe of the thyroid gland. No cervical lymphadenopathy is appreciated.

Laboratory studies reveal the following:

Ultrasound of the neck shows a $2.4\text{-cm}$ solid, hypoechoic nodule in the right lobe with smooth margins and no microcalcifications.

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

A $62$-year-old man comes to the emergency department complaining of severe, worsening lower back pain for the past $3$ weeks. The pain is constant, wakes him up at night, and is not relieved by rest or over-the-counter analgesics. He reports feeling warm at times but denies any leg weakness, numbness, or loss of bowel and bladder control. His medical history is significant for type 2 diabetes mellitus and end-stage renal disease, for which he receives hemodialysis via a right internal jugular venous catheter. Temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), blood pressure is $135/85 \text{ mm Hg}$, and pulse is $88/\text{min}$. Physical examination reveals exquisite tenderness to percussion over the L3 and L4 spinous processes. Neurologic examination of the lower extremities shows $5/5$ strength, normal sensation to pinprick and light touch, and $2+$ deep tendon reflexes symmetrically. Anal sphincter tone is normal. Laboratory studies show a leukocyte count of $9,500/\text{mm}^3$, an erythrocyte sedimentation rate of $88 \text{ mm/hr}$, and a C-reactive protein of $65 \text{ mg/L}$. Two sets of blood cultures are drawn. Magnetic resonance imaging of the lumbar spine reveals increased fluid signal in the L3-L4 intervertebral disc space with adjacent vertebral body marrow edema, consistent with pyogenic spondylodiscitis. There is no evidence of an epidural abscess or spinal cord compression. Which of the following is the most appropriate next step in the management of this patient?

A 37-year-old woman presents to the clinic with an 8-month history of progressive shortness of breath. She reports initially feeling winded only during heavy exertion, but her dyspnea now occurs when walking short distances on flat ground. Last week, she experienced a syncopal episode while climbing stairs. She has no significant past medical history, takes no medications, and has never smoked. Vital signs show temperature 37.0°C (98.6°F), blood pressure 110/72 mm Hg, pulse 94/min, and respirations 18/min. Oxygen saturation is 96% on room air. Physical examination reveals clear breath sounds bilaterally. Cardiovascular examination is notable for a palpable left parasternal heave and a prominently accentuated pulmonic component of the second heart sound (P2). Jugular venous pressure is estimated at 9 cm H2O. There is trace bilateral lower extremity edema.

Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's condition, starting from the initial evaluation step to the final confirmatory assessment.

During morning rounds on the general medical ward, a physician evaluates a $68$-year-old man undergoing treatment for severe community-acquired pneumonia. The patient was admitted $3$ days ago with acute respiratory distress, fever, and a dense right lower lobe consolidation on chest radiography. Due to a history of a recent hospitalization $6$ weeks prior, he was started on empiric intravenous vancomycin and piperacillin-tazobactam.

The patient's condition has markedly improved over the past $48$ hours. He is now breathing comfortably on room air, and his cough is producing only minimal clear sputum. His temperature is $37.2^\circ$ C ($99.0^\circ$ F), blood pressure is $130/82$ mmHg, pulse is $78$/min, and respirations are $16$/min. Blood cultures drawn at the time of admission are now positive for *Streptococcus pneumoniae* in two out of two bottles. Antimicrobial susceptibility testing demonstrates that the isolate is sensitive to penicillin, amoxicillin, ceftriaxone, and linezolid, but resistant to azithromycin.

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

A 32-year-old woman with a history of severe pelvic inflammatory disease and bilateral tubal occlusion is preparing to undergo in vitro fertilization (IVF). She and her partner are reviewing the upcoming treatment protocol with their reproductive endocrinologist. Arrange the following steps of a standard IVF cycle in the correct chronological order from first to last.

A $58$-year-old man is brought to the emergency department by his wife due to severe headache, high fever, and confusion that started $12$ hours ago. On examination, his temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, and heart rate is $112\text{/min}$. The patient is lethargic and oriented only to his name. Nuchal rigidity is present. There are no focal neurologic deficits. The physician suspects acute bacterial meningitis.

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

A 32-year-old woman comes to the clinic for a routine follow-up. She has a history of Graves disease that was treated with radioactive iodine ablation 5 years ago, resulting in primary hypothyroidism. She has been well-maintained on a stable daily dose of $112 \mu g$ of levothyroxine. Eight weeks ago, she began taking combined oral contraceptive pills for dysmenorrhea. She currently reports feeling well, with no palpitations, fatigue, or weight changes. Her vital signs are within normal limits. Physical examination reveals a well-healed neck, no palpable goiter, and normal deep tendon reflexes.

Laboratory studies show:

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

A 5-month-old boy is brought to the clinic in late January with a 3-day history of worsening nasal congestion, clear rhinorrhea, and a mild cough. Over the past 12 hours, his parents have noticed that he is breathing more rapidly than usual and appears fussy. He was born at 39 weeks gestation and has no underlying medical conditions. He has received all recommended age-appropriate vaccinations. His temperature is 37.8°C (100.0°F), pulse is 148/min, and respiratory rate is 64/min. Pulse oximetry shows 94% on room air. Physical examination reveals flaring of the nasal alae, mild subcostal retractions, and prolonged expiration. Lung auscultation demonstrates diffuse bilateral wheezing and scattered fine crackles. The remainder of the examination is unremarkable. Which of the following is the most appropriate next step in management?

A 52-year-old man with a history of obesity hypoventilation syndrome and type 2 diabetes mellitus is brought to the emergency department by his wife due to profound weakness and confusion. For the past 4 days, he has had severe, watery diarrhea with up to 10 bowel movements daily, accompanied by abdominal cramping. He has not been able to tolerate oral intake. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $90/60\text{ mm Hg}$, pulse is $112\text{/min}$, and respirations are $14\text{/min}$. Physical examination shows dry mucous membranes and decreased skin turgor. The patient appears somnolent but is arousable.

Laboratory studies show:
Serum sodium: $135\text{ mEq/L}$
Serum potassium: $3.2\text{ mEq/L}$
Serum chloride: $113\text{ mEq/L}$
Serum bicarbonate: $12\text{ mEq/L}$
Blood urea nitrogen: $42\text{ mg/dL}$
Serum creatinine: $1.6\text{ mg/dL}$
Serum albumin: $4.0\text{ g/dL}$

Arterial blood gas analysis on room air:
pH: $7.08$
$\text{PaCO}_2$: $42\text{ mm Hg}$
$\text{PaO}_2$: $65\text{ mm Hg}$

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

A 67-year-old woman is brought to the emergency department complaining of severe, unremitting abdominal pain and vomiting for the past 8 hours. Her medical history is notable for a total abdominal hysterectomy performed 10 years ago. She describes the pain as initially colicky but now constant and diffusely located across the lower abdomen. Her temperature is 39.1°C (102.4°F), blood pressure is 92/58 mm Hg, and pulse is 114/min. On physical examination, the abdomen is markedly distended and tympanic. There is severe, diffuse tenderness to palpation with involuntary guarding and rebound tenderness. Bowel sounds are absent. Laboratory studies reveal a leukocyte count of 19,500/mm³. An upright abdominal radiograph demonstrates multiple dilated small bowel loops with air-fluid levels and a paucity of gas in the colon.

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

An 82-year-old man is brought to the emergency department due to sudden-onset, severe abdominal pain. He has a history of hypertension, type 2 diabetes mellitus, and atrial fibrillation for which he takes apixaban; however, he admits to missing several doses over the past week. During transport, paramedics administered intravenous morphine for pain control. On arrival, he appears drowsy but is arousable. Temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $102/60\text{ mmHg}$, pulse is $118/\text{min}$ and irregular, and respiratory rate is $14/\text{min}$. The abdomen is slightly distended with absent bowel sounds, and there is minimal tenderness to palpation.

Laboratory results are as follows:

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

A 5-year-old girl is brought to the emergency department by her parents due to a severe headache, high fever, and worsening lethargy over the past 12 hours. She has not received any childhood vaccinations. On examination, her temperature is 39.8°C (103.6°F), heart rate is 150/min, respiratory rate is 28/min, and blood pressure is 85/50 mm Hg. She is somnolent, responding only to painful stimuli. Physical examination reveals nuchal rigidity and a rapidly expanding, non-blanching purpuric rash on her lower extremities. Fundoscopic examination demonstrates bilateral papilledema. Arrange the following steps in the most appropriate sequential order for the acute management of this patient.

Match each clinical scenario describing a patient with newly detected hyponatremia to the most accurate expected pattern of laboratory findings, focusing on serum and urine osmolar characteristics.

A $48$-year-old man comes to the clinic due to worsening fatigue, feeling constantly cold, and a $6\text{-kg}$ ($13.2\text{-lb}$) weight gain over the past $5$ months. He also reports decreased libido and recent onset of erectile dysfunction. He has no significant past medical history and takes no medications. Blood pressure is $102/68 \text{ mm Hg}$, and pulse is $55/\text{min}$. Physical examination shows dry, pale skin and delayed relaxation of the deep tendon reflexes. Visual fields are full to confrontation. Laboratory studies show:

Serum sodium: $132 \text{ mEq/L}$
Thyroid-stimulating hormone (TSH): $1.6 \text{ mIU/L}$ (Normal: $0.5$ - $5.0 \text{ mIU/L}$)
Free thyroxine (T4): $0.4 \text{ ng/dL}$ (Normal: $0.9$ - $1.7 \text{ ng/dL}$)

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

A 68-year-old man is brought to the emergency department by his family due to a 24-hour history of high fever, severe generalized headache, and progressive confusion. His medical history is significant for type 2 diabetes mellitus and hypertension. On presentation, his temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, heart rate is $115/\text{min}$, and respiratory rate is $22/\text{min}$. The patient is somnolent and oriented only to person. Neurologic examination reveals marked nuchal rigidity. Fundoscopic examination demonstrates bilateral blurring of the optic disc margins.

Arrange the following steps in the most appropriate chronological order for managing this patient.

During morning rounds, the clinical team reviews the status of a patient who was hospitalized four days ago due to massive ascites and lower extremity edema. The patient has long-standing cirrhosis secondary to chronic hepatitis C virus infection. Despite medication compliance prior to admission, his weight had increased significantly over the preceding month. Current vital signs include a temperature of $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$), blood pressure of $92/56\text{ mmHg}$, and heart rate of $94/\text{min}$. Physical examination reveals a tensely distended abdomen with a positive fluid wave and bilateral pitting edema extending to the thighs. The lungs are clear to auscultation. Recent laboratory values show a serum sodium of $131\text{ mEq/L}$, serum potassium of $4.2\text{ mEq/L}$, serum bicarbonate of $17\text{ mEq/L}$, blood urea nitrogen of $55\text{ mg/dL}$, and serum creatinine of $2.8\text{ mg/dL}$ (baseline was $1.0\text{ mg/dL}$ three weeks prior). A diagnostic paracentesis performed upon admission showed an absolute neutrophil count of $110/\text{mm}^3$. Urinalysis demonstrates no red blood cells, white blood cells, or casts, and the urine sodium concentration is $8\text{ mEq/L}$. Renal ultrasonography reveals normal renal architecture without obstruction. Over the past 48 hours, all diuretic therapy was withheld, and the patient was administered intravenous albumin at $1\text{ g/kg}$ per day. Today, his serum creatinine remains elevated at $2.9\text{ mg/dL}$. Which of the following is the most appropriate next step in management?