Tüm alıştırma soruları

A 72-year-old man is evaluated on postoperative day 3 following a right total hip arthroplasty for a femoral neck fracture. He reports progressive abdominal distention, nausea, and an inability to pass flatus or stool for the past 48 hours. His medical history includes hypertension and benign prostatic hyperplasia. Current medications include lisinopril, tamsulosin, and intravenous morphine for pain control. Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $130/80\text{ mm Hg}$, pulse of $92\text{/min}$, and respiratory rate of $16\text{/min}$. Abdominal examination reveals massive, tympanitic distension with diminished bowel sounds; there is no guarding or rebound tenderness. Laboratory studies show a serum potassium of $3.1\text{ mEq/L}$ and magnesium of $1.3\text{ mg/dL}$. A CT scan of the abdomen confirms diffuse dilation of the colon with a cecal diameter of $10.5\text{ cm}$ and no evidence of mechanical obstruction or perforation. The patient is diagnosed with acute colonic pseudo-obstruction (Ogilvie syndrome).

Arrange the following management interventions in the correct standard sequential order for this condition, progressing from the most appropriate initial action to the final therapeutic option for refractory disease.

A 28-year-old woman with a history of systemic lupus erythematosus presents to the clinic with new-onset bilateral lower extremity edema. Her blood pressure is 150/92 mm Hg. Laboratory studies show a serum creatinine of 1.5 mg/dL (baseline 0.8 mg/dL), positive anti-dsDNA antibodies, and decreased C3 and C4 levels. Urinalysis reveals 3+ protein, 15-20 red blood cells/hpf, and the presence of red blood cell casts.

Arrange the following steps in the standard chronological sequence for the definitive diagnostic evaluation and long-term pharmacologic management of this patient's renal disease.

A 64-year-old man with a 15-year history of type 2 diabetes mellitus is evaluated in the outpatient clinic for a chronic ulcer on the plantar surface of his right great toe. Over the past 3 days, he has noted new-onset redness and mild pain surrounding the ulcer. He has not had fever, chills, or other systemic symptoms. He has no recent hospitalizations and has not received any antibiotics in the past year. Vital signs are temperature 37.0°C (98.6°F), blood pressure 135/85 mm Hg, heart rate 78/min, and respirations 14/min. Physical examination reveals a 1.5-cm, shallow ulcer on the plantar aspect of the right great toe. There is a 1-cm rim of blanching erythema surrounding the ulcer margins. There is no purulent drainage, fluctuance, or crepitus. The ulcer base does not probe to bone, and pedal pulses are palpable bilaterally. A superficial swab culture of the ulcer base obtained by a visiting home nurse 3 days ago shows heavy growth of methicillin-susceptible Staphylococcus aureus (MSSA) and Pseudomonas aeruginosa. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

An urgent bedside evaluation is requested for a $71$-year-old man in the intensive care unit who developed abrupt, severe shortness of breath and altered mental status. He was admitted $5$ days ago after sustaining a comminuted left femoral shaft fracture in a motor vehicle collision, for which he underwent open reduction and internal fixation. Today, he became suddenly agitated and then poorly responsive.

Physical examination shows profound diaphoresis and mottling of the lower extremities. The jugular venous pulsation is visible at the angle of the mandible while sitting at $45^\circ$. Auscultation of the lungs reveals clear breath sounds bilaterally. Cardiac examination shows a tachycardic, regular rhythm with a prominent parasternal heave and a right-sided S3 gallop.

A 12-lead ECG demonstrates sinus tachycardia with new T-wave inversions in leads V1-V4 and a complete right bundle branch block.

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

Match each clinical and laboratory profile of a patient presenting with secondary hypertension to the most likely underlying pathophysiologic diagnosis.

Match each patient's clinical and high-resolution manometry (HRM) presentation with the most accurate underlying pathophysiologic mechanism.

A 48-year-old man comes to the clinic reporting progressive fatigue, muscle weakness, and decreased libido over the past 6 months. He has gained 4 kg (8.8 lb) during this period. The patient has a history of a traumatic brain injury sustained in a motor vehicle collision one year ago, which required a prolonged hospital stay. His vital signs are temperature 36.4°C (97.5°F), blood pressure 105/65 mmHg, and pulse 56/min. Physical examination shows loss of axillary and pubic hair, and delayed relaxation of deep tendon reflexes. Laboratory results are as follows:

Serum sodium: 132 mEq/L
Serum potassium: 4.0 mEq/L
Thyroid-stimulating hormone (TSH): 1.1 µU/mL (Normal: 0.4–4.0 µU/mL)
Free thyroxine (T4): 0.5 ng/dL (Normal: 0.7–1.9 ng/dL)

Which of the following is the most likely underlying mechanism for this patient's current condition?

A 45-year-old man who recently emigrated from an area highly endemic for tuberculosis presents to the emergency department with a 4-week history of productive cough, blood-tinged sputum, drenching night sweats, and unintentional weight loss. Vital signs show a temperature of 38.3°C (100.9°F). A chest radiograph reveals a large cavitary lesion in the apical segment of the right upper lobe. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 62-year-old woman with a history of cirrhosis secondary to metabolic dysfunction-associated steatohepatitis presents to the hospital complaining of generalized abdominal pain and lethargy for the past two days. Her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $102/60 \text{ mm Hg}$, and pulse is $92/\text{min}$. Physical examination shows a noticeably distended abdomen that is diffusely tender to palpation, accompanied by a positive fluid wave test. A diagnostic paracentesis is promptly performed. The ascitic fluid analysis demonstrates an absolute neutrophil count of $450 / \text{mm}^3$. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A $74$-year-old woman is evaluated in the preoperative clinic $5$ days before a scheduled right total knee arthroplasty. She has a history of severe osteoarthritis and chronic urge incontinence, which has been stable on a scheduled voiding regimen. The patient reports no new symptoms and specifically denies dysuria, urinary frequency, suprapubic discomfort, or flank pain. Her current medications include acetaminophen and cholecalciferol. Vital signs are within normal limits, including a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$). Physical examination shows severe right knee crepitus and limited range of motion. There is no costovertebral angle or suprapubic tenderness. Preoperative laboratory results are as follows:

Leukocyte count: $7,800/\mu\text{L}$
Hemoglobin: $12.4$ g/dL
Platelets: $210,000/\mu\text{L}$

Urinalysis:
Color: Yellow
Appearance: Cloudy
Specific gravity: $1.018$
pH: $7.5$
Leukocyte esterase: Positive
Nitrites: Positive
WBC: $30$/hpf
Bacteria: Many

A urine culture grows $>10^5$ CFU/mL of *Proteus mirabilis* that is susceptible to cefazolin, ceftriaxone, and ciprofloxacin. Which of the following is the most appropriate management of this patient's urinary findings prior to surgery?

During a routine health maintenance examination, laboratory testing is performed on a 58-year-old man with a long-standing history of type 2 diabetes mellitus and essential hypertension. The patient reports feeling entirely well and denies any recent illness, changes in urine output, or gastrointestinal symptoms. His current medication regimen consists of metformin, lisinopril, amlodipine, and rosuvastatin. Vital signs show a blood pressure of 134/82 mm Hg and a heart rate of 72/min. There is no peripheral edema on examination. The basic metabolic panel and urinalysis results are as follows:

Serum sodium: $138$ mEq/L
Serum potassium: $5.8$ mEq/L
Serum chloride: $110$ mEq/L
Serum bicarbonate: $18$ mEq/L
Blood urea nitrogen: $26$ mg/dL
Serum creatinine: $1.7$ mg/dL
Fasting glucose: $148$ mg/dL
Urine pH: $5.2$

Which of the following is the most likely primary mechanism for this patient's laboratory abnormalities?

A $64$-year-old man is evaluated on postoperative day $3$ following an uncomplicated partial colectomy for a diverticular stricture. He reports the abrupt onset of excruciating pain, swelling, and redness in his right knee that woke him from sleep. His temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $135/85\text{ mm Hg}$, and heart rate is $98\text{/min}$. Physical examination reveals a markedly swollen, warm, and erythematous right knee. Any range of motion elicits severe pain. Laboratory studies show a serum creatinine of $2.4\text{ mg/dL}$ (baseline $2.2\text{ mg/dL}$) and a serum uric acid level of $5.5\text{ mg/dL}$. Arthrocentesis is performed, yielding cloudy yellow fluid with a leukocyte count of $35,000/\mu\text{L}$ ($85\%$ neutrophils). Polarized light microscopy demonstrates numerous needle-shaped, negatively birefringent crystals. Gram stain shows no organisms. Which of the following is the most appropriate next step in management for this patient's joint symptoms?

A $68$-year-old man with a history of metastatic prostate cancer is brought to the emergency department by his family due to a $2$-day history of progressively worsening mid-back pain. This morning, he developed weakness in both legs and has been unable to void his bladder for the past $10$ hours. His temperature is $37.1^\circ \text{C}$ ($98.8^\circ \text{F}$), blood pressure is $142/88$ \text{mmHg}, and pulse is $92$/\text{min}. Neurologic examination reveals $3/5$ motor strength in the bilateral lower extremities, diminished deep tendon reflexes at the knees and ankles, and decreased sensation to pinprick below the level of the umbilicus. Anal sphincter tone is decreased. Bladder ultrasound reveals $600$ \text{mL} of retained urine.

Based on the clinical presentation, arrange the following steps in the most appropriate chronological order for the acute management and diagnostic workup of this patient.

A 4-year-old boy is brought to the emergency department by his parents due to the sudden onset of severe throat pain, a muffled voice, and difficulty breathing. His parents note that he has not been able to swallow his saliva for the past two hours and has been leaning forward continuously. He has missed several childhood vaccinations. On observation, the patient is toxic-appearing, drooling, and exhibits inspiratory stridor. His temperature is $39.8^\circ\text{C}$ ($103.6^\circ\text{F}$), heart rate is $155/\text{min}$, and respiratory rate is $36/\text{min}$. He becomes highly agitated when a nurse approaches him with a blood pressure cuff. Arrange the following management steps in the most appropriate chronological order for this patient.

An unresponsive 26-year-old woman is admitted to the intensive care unit after being found lethargic in her apartment by a roommate. The roommate notes that the patient has a history of type 1 diabetes mellitus and has been suffering from a severe gastrointestinal illness with copious vomiting for the past four days. The patient stopped all insulin therapy during this time because she could not tolerate oral intake. At presentation, her blood pressure is 92/58 mm Hg, pulse is 122/min, and respiratory rate is 28/min. Physical examination reveals deep, rapid breathing and profoundly dry mucous membranes.

Initial laboratory evaluation reveals the following:
Serum sodium: 142 mEq/L
Serum potassium: 3.2 mEq/L
Serum chloride: 96 mEq/L
Serum bicarbonate: 16 mEq/L
Blood urea nitrogen: 52 mg/dL
Serum creatinine: 1.8 mg/dL
Plasma glucose: 610 mg/dL

Arterial blood gas analysis on room air:
pH: 7.32
pCO2: 32 mm Hg
pO2: 98 mm Hg

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

A 62-year-old man is evaluated on postoperative day 6 following an elective laparoscopic sigmoid colectomy with primary anastomosis for recurrent diverticulitis. He had been recovering well, tolerating a soft diet, and passing flatus. Over the past 12 hours, he has developed severe, diffuse abdominal pain, nausea, and confusion. Vital signs show a temperature of 39.2°C (102.6°F), heart rate of 128/min, blood pressure of 82/50 mmHg, and respiratory rate of 26/min. Pulse oximetry is 94% on room air. Physical examination reveals a distended, rigidly tense abdomen with diffuse guarding and rebound tenderness. Bowel sounds are absent. A surgical drain left in the pelvis during the initial procedure now shows 100 mL of new purulent, feculent output. Two large-bore peripheral intravenous lines are established, and isotonic fluid resuscitation is initiated. Which of the following are the most appropriate next steps in the management of this patient? (Select 2)

Match each patient's clinical presentation and hypothalamic-pituitary-adrenal (HPA) axis laboratory profile to the most likely underlying pathophysiologic mechanism.

A 42-year-old man is admitted to the hospital with a 24-hour history of severe, unrelenting epigastric pain that radiates directly to his mid-back. The pain is accompanied by continuous nausea and several episodes of nonbilious emesis. He admits to consuming a large amount of alcohol over the past weekend. His temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $112/68\text{ mmHg}$, and pulse is $110/\text{min}$. Physical examination reveals marked tenderness to deep palpation in the epigastric region, with decreased bowel sounds but no rigidity or rebound tenderness. Laboratory evaluation shows a leukocyte count of $14,500/\text{mm}^3$, aspartate aminotransferase of $45\text{ U/L}$, alanine aminotransferase of $38\text{ U/L}$, alkaline phosphatase of $90\text{ U/L}$, total bilirubin of $1.0\text{ mg/dL}$, and serum lipase of $2,800\text{ U/L}$ (normal: $10-140\text{ U/L}$). An ultrasound of the right upper quadrant demonstrates an enlarged, hypoechoic pancreas but no evidence of gallstones, sludge, or biliary ductal dilation. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's gastrointestinal presentation with the most appropriate antimicrobial management strategy.

A rheumatology clinic is updating its patient safety protocols to ensure appropriate baseline screening and long-term monitoring for patients on immunomodulatory therapies. Match each pharmacologic agent commonly used in the management of rheumatologic diseases to its most characteristic severe adverse effect.