Tüm alıştırma soruları

Match each clinical presentation of an opportunistic infection in a patient with advanced HIV to the most appropriate initial targeted pharmacotherapy.

An occupational health screening includes spirometry for a 42-year-old male construction worker who reports slowly progressive exertional breathlessness over the past year. He denies chronic cough, sputum production, or wheezing. The patient has a 10-year history of daily lower back stiffness that is worst upon waking and improves after a few hours of physical labor. He does not smoke and has no history of cardiovascular disease. Vital signs are within normal limits. Physical examination reveals a stooped posture and a significantly reduced range of motion of the lumbar spine. Chest expansion during deep inspiration is markedly limited to 1.5 cm (normal is greater than 5 cm). Cardiac auscultation is normal, and breath sounds are clear bilaterally. Pulmonary function testing demonstrates a forced vital capacity (FVC) of 65% of predicted, a forced expiratory volume in 1 second (FEV1) of 70% of predicted, and an FEV1/FVC ratio of 86%. Diffusing capacity of the lung for carbon monoxide (DLCO) is normal. Which of the following is the most likely primary cause of this patient's respiratory symptoms?

Match each patient's clinical presentation and initial diagnostic findings with the most accurate underlying pathophysiologic mechanism or defining etiology.

A 19-year-old woman presents to the emergency department reporting persistent ringing in her ears, nausea, and feeling short of breath for the past 6 hours. She recently had an argument with her family and subsequently ingested an entire bottle of an over-the-counter analgesic. Vital signs include a temperature of 38.1°C (100.6°F), blood pressure of 116/74 mm Hg, pulse of 115/min, and respiratory rate of 28/min. She appears agitated and is taking deep, rapid breaths.

Initial laboratory testing reveals:

Arterial blood gas (room air):

Which of the following is the most accurate description of the acid-base abnormality in this patient?

A 72-year-old woman is brought to the emergency department by ambulance after being found unresponsive in her home. According to her family, she has a history of hypothyroidism but stopped taking her medications a year ago. On arrival, she is unarousable. Vital signs show a temperature of $34.2^\circ\text{C}$ ($93.6^\circ\text{F}$), a heart rate of $46/\text{min}$, a blood pressure of $85/50\text{ mm Hg}$, and a respiratory rate of $6/\text{min}$ with shallow breathing. Her oxygen saturation is $82\%$ on room air. Physical examination reveals periorbital puffiness, generalized non-pitting edema, and cold, dry skin. Arrange the following steps in the most appropriate chronological sequence for the acute evaluation and management of this patient.

A $55$-year-old woman is evaluated in the emergency department for a fever that started earlier today. She is currently undergoing systemic chemotherapy for diffuse large B-cell lymphoma; her most recent treatment cycle was $8$ days ago. The patient reports associated chills and generalized weakness. Temperature is $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), blood pressure is $98/60\text{ mmHg}$, heart rate is $112/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals a chronically ill-appearing woman. Her indwelling central venous port site appears clean, with no erythema, induration, or purulent discharge. The lungs are clear to auscultation, and the remainder of the examination is unremarkable.

Laboratory studies show:
- Hemoglobin: $9.2\text{ g/dL}$
- Platelets: $85,000/\mu\text{L}$
- Leukocytes: $600/\mu\text{L}$
- Absolute neutrophil count: $150/\mu\text{L}$

Blood and urine cultures are obtained. Which of the following is the most appropriate next step in management?

A 7-year-old girl is evaluated in the pediatric ward on hospital day 3. She was admitted with high fever, severe right thigh pain, and refusal to bear weight. Magnetic resonance imaging (MRI) of the right lower extremity at admission demonstrated bone marrow edema and a subperiosteal fluid collection in the distal femur consistent with acute hematogenous osteomyelitis. In the emergency department, she was started on empiric intravenous vancomycin and ceftriaxone. Over the past 48 hours, her temperature has trended down, and she reports decreased pain. Blood cultures drawn on admission are now growing Staphylococcus aureus. Susceptibility testing reveals the isolate is sensitive to oxacillin, cefazolin, and clindamycin, but resistant to penicillin and ampicillin. Vital signs today show a temperature of 37.1°C (98.8°F), blood pressure of 105/65 mm Hg, pulse of 92/min, and respiratory rate of 18/min. Which of the following is the most appropriate modification to her pharmacotherapy?

Following a transfer from a long-term care facility, an 82-year-old female patient is evaluated in the hospital for a two-day history of progressive somnolence. Her medical history is significant for advanced Alzheimer dementia and chronic urinary retention requiring an indwelling urethral catheter. Upon presentation, her blood pressure is $112/64\text{ mmHg}$, heart rate is $96/\text{min}$, and temperature is $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$). Physical examination reveals dry oral mucosa, diminished skin turgor, and no costovertebral angle tenderness. The patient is lethargic but arouses to voice. Laboratory evaluation reveals a serum sodium concentration of $159\text{ mEq/L}$ and a blood urea nitrogen level of $45\text{ mg/dL}$. A urinalysis demonstrates cloudy, malodorous urine with positive leukocyte esterase, positive nitrites, and $45\text{ WBCs/hpf}$. A urine culture is submitted, and she is started on intravenous fluid resuscitation.

By the third day of hospitalization, her serum sodium has corrected to $142\text{ mEq/L}$, and her mental status has returned to her baseline of being pleasantly confused but conversational. She remains hemodynamically stable and afebrile. The admission urine culture now reports $>10^5\text{ CFU/mL}$ of *Escherichia coli* that is susceptible to all tested antimicrobial agents. Which of the following is the most appropriate next step in the management of this patient's urinary findings?

A 45-year-old man presents to the gastroenterology clinic for chronic, watery diarrhea and recurrent abdominal pain. Over the past year, he has been treated for peptic ulcer disease with a high-dose proton pump inhibitor, but his symptoms have persisted and worsened. Upper gastrointestinal endoscopy reveals thickened gastric folds and multiple ulcerations in the stomach, distal duodenum, and proximal jejunum. A diagnosis of Zollinger-Ellison syndrome (gastrinoma) is suspected. Arrange the following steps in the most appropriate diagnostic and therapeutic sequence for this patient.

Match each pediatric patient's clinical vignette with the most likely causative viral pathogen.

A hospital's blood bank and transfusion medicine service is reviewing recent adverse events. Match each patient's clinical presentation following a blood product transfusion with the most likely underlying pathophysiologic mechanism.

A 27-year-old man with a 4-year history of ileocolonic Crohn disease presents to the emergency department with a 2-day history of progressive, colicky abdominal pain, nausea, and bilious vomiting. He reports that his baseline bowel habit is 3 loose stools daily, but he has not passed stool or flatus for the past 24 hours. He admits to being nonadherent to his prescribed infliximab therapy for the last 6 months.

His temperature is 38.3°C (100.9°F), blood pressure is 112/68 mm Hg, pulse is 115/min, and respiratory rate is 22/min. Physical examination shows a distended abdomen with hypoactive bowel sounds. There is significant tenderness in the right lower quadrant with localized involuntary guarding and rebound tenderness.

Laboratory results are as follows:
Leukocyte count: 16,500/mm³
Hemoglobin: 12.1 g/dL
Platelet count: 450,000/mm³
Serum sodium: 136 mEq/L
Serum potassium: 3.2 mEq/L
Serum chloride: 102 mEq/L
Serum bicarbonate: 15 mEq/L
Blood urea nitrogen: 38 mg/dL
Serum creatinine: 1.3 mg/dL

Arterial blood gas (room air):
$pH$: 7.32
$pCO_2$: 30 mm Hg
$pO_2$: 92 mm Hg
Lactate: 4.5 mmol/L (Normal: 0.5-1.5 mmol/L)

An upright abdominal radiograph shows multiple dilated loops of small bowel with air-fluid levels and a paucity of gas in the colon.

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

A 54-year-old male is evaluated on postoperative day 5 following a robotic-assisted partial nephrectomy for a localized renal mass. His past medical history is significant for obesity, hypertension, and type 2 diabetes mellitus. The patient complains of a new-onset dull ache and swelling in his left leg that started this morning. He also reports feeling warm. His temperature is 38.4°C (101.1°F), blood pressure is 142/88 mmHg, pulse is 102/min, and respirations are 18/min. Oxygen saturation is 98% on ambient air. Physical examination reveals pitting edema and erythema of the left calf, which is exquisitely tender to palpation. The surgical incisions are well-approximated, clean, and dry, with no surrounding induration or discharge. The abdomen is soft and non-distended with normal active bowel sounds. Which of the following is the most appropriate next step in management?

Match each esophageal disorder with its most characteristic diagnostic imaging or endoscopic finding.

A 45-year-old woman is evaluated in the post-anesthesia care unit 2 hours after undergoing an uncomplicated total thyroidectomy for a multinodular goiter. The nurse urgently requests an evaluation because the patient has become extremely agitated and is complaining of difficulty breathing. Her blood pressure is 142/88 mmHg, pulse is 115/min, and oxygen saturation is 86% on room air. Physical examination reveals audible inspiratory stridor and a tense, rapidly expanding swelling beneath the cervical incision. Arrange the following management steps in the most appropriate chronological order.

Accurate interpretation of serum hormone levels is a critical first step in evaluating patients presenting with ovulatory dysfunction and infertility. Match each distinct reproductive laboratory profile below with the most likely corresponding etiology.

An infertility evaluation is initiated for a couple who have been unable to achieve a pregnancy despite having regular, unprotected intercourse for the past $18$ months. The female partner is $27$ years of age. She reports that since discontinuing oral contraceptive pills a year and a half ago, she has not experienced a single menstrual period. Prior to starting oral contraceptives at age $18$, her menstrual cycles occurred irregularly every $3$ to $5$ months. She competes in triathlons and maintains a strict vegan diet. Her body mass index is $17.5 \text{ kg/m}^2$. Vital signs show a blood pressure of $90/60 \text{ mmHg}$ and a pulse of $50/min$. Physical examination reveals Tanner stage V breast development and normal pubic hair, with no hirsutism, acne, or thyromegaly. Pelvic ultrasound demonstrates a normal-appearing uterus with a thin endometrial stripe ($3 \text{ mm}$) and small, bilateral ovaries without cysts. Laboratory evaluation shows:

After $6$ months of concerted efforts at nutritional rehabilitation and exercise reduction, her body mass index remains $17.8 \text{ kg/m}^2$ and her amenorrhea persists. Which of the following is the most appropriate next step in medical management to help this patient conceive?

A hospitalized patient is evaluated in the labor unit. She is in her first pregnancy at 38 weeks of gestation and was admitted 3 hours ago in spontaneous active labor. Artificial rupture of membranes was performed shortly after admission, yielding a small amount of clear fluid. Her vital signs are temperature 37.0°C (98.6°F), blood pressure 118/72 mm Hg, and pulse 85/min. Uterine contractions are occurring every 3 to 4 minutes. Continuous electronic monitoring reveals a baseline fetal heart rate of 145/min with moderate variability. Coinciding with the majority of uterine contractions, the tracing shows recurrent, sudden drops in the heart rate to a nadir of 85/min. These decreases last for 30 to 50 seconds before rapidly recovering to the baseline rate. Which of the following is the most appropriate initial management for this patient?

During morning rounds, the surgical team evaluates a 67-year-old man who is recovering from an elective open abdominal aortic aneurysm repair performed 48 hours ago. The overnight nurse reported a single temperature spike. The patient states he feels generally well, though he has mild pain at the surgical site when coughing. His past medical history is significant for chronic obstructive pulmonary disease and hypertension. Current vital signs show a temperature of 38.6°C (101.5°F), blood pressure of 138/86 mm Hg, heart rate of 94/min, and respiratory rate of 18/min. Oxygen saturation is 94% on room air. Auscultation of the chest reveals decreased breath sounds at both lung bases and faint end-expiratory wheezes. The abdomen is soft, and the midline laparotomy incision demonstrates healthy granulation without fluctuance, excessive erythema, or purulence. The indwelling urinary catheter was discontinued yesterday, and the patient reports normal, painless urination. Which of the following is the most appropriate next step in management?

A $62$-year-old man with a history of alcohol-associated cirrhosis is brought to the emergency department by his daughter due to increasing confusion and sleepiness over the past two days. She reports that he has also had a productive cough with yellowish sputum and intermittent chills for the last three days. His medical history includes chronic obstructive pulmonary disease (COPD) and diet-controlled type 2 diabetes mellitus. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $105/65\text{ mmHg}$, pulse is $108/\text{min}$, and respirations are $24/\text{min}$. Pulse oximetry shows $92\%$ on room air. Physical examination reveals scleral icterus and spider angiomas. His breath has a sweet, musty odor. Auscultation of the lungs reveals crackles and bronchial breath sounds in the right lower lung field. Abdominal examination shows distension with shifting dullness but no tenderness or rigidity. Neurological examination reveals lethargy, disorientation to time and place, and a distinct flapping tremor when his arms are extended with wrists dorsiflexed. Laboratory studies show a leukocyte count of $14,500/\text{mm}^3$, hemoglobin of $11.2\text{ g/dL}$, and a platelet count of $85,000/\text{mm}^3$. Comprehensive metabolic panel is notable for a blood urea nitrogen of $22\text{ mg/dL}$, creatinine of $1.0\text{ mg/dL}$, and normal electrolytes. Arterial blood gas on room air shows a pH of $7.48$, pCO $_2$ of $30\text{ mmHg}$, and pO $_2$ of $68\text{ mmHg}$. Diagnostic paracentesis yields ascitic fluid with an absolute neutrophil count of $120/\text{mm}^3$ and negative Gram stain. A chest radiograph demonstrates a right lower lobe infiltrate. In addition to initiating lactulose therapy for his hepatic encephalopathy, which of the following is the most appropriate next step in management?