Tüm alıştırma soruları

A 28-year-old woman with a history of Sjögren syndrome is evaluated in the clinic for progressive muscle weakness over the past week. She reports no vomiting, diarrhea, or recent illnesses. Her vital signs are within normal limits. Physical examination reveals 3/5 strength in the proximal muscles of her lower extremities. Laboratory studies show:

Serum:
Na $^+$: 139 mEq/L
K $^+$: 2.8 mEq/L
Cl $^-$: 114 mEq/L
HCO $_3^-$: 14 mEq/L

Arterial blood gas (room air):
pH: 7.28
pCO $_2$: 32 mm Hg

Urine:
Na $^+$: 62 mEq/L
K $^+$: 30 mEq/L
Cl $^-$: 55 mEq/L
pH: 6.0

What is the calculated urine anion gap for this patient in mEq/L?

A 48-year-old male presents to the emergency department after vomiting a large amount of coffee-ground material. He reports feeling lightheaded, dizzy, and fatigued over the past several hours. His blood pressure is 88/55 mm Hg and his heart rate is 118/min. Physical examination shows pale conjunctivae and mild epigastric tenderness. He has a significant history of daily ibuprofen use for chronic lower back pain. Arrange the following management steps in the most appropriate chronological order for this patient.

Identify the most specific diagnostic marker or laboratory finding for the following patients presenting with classic hepatobiliary manifestations.

A 62-year-old man is evaluated on postoperative day 5 after undergoing an elective open cholecystectomy and common bile duct exploration. Over the past 24 hours, he has developed a fever and increasing pain at the surgical site. His temperature is 38.7°C (101.6°F), blood pressure is 128/82 mm Hg, and pulse is 98/min. Examination of the abdomen reveals a 15-cm subcostal incision that is notably erythematous, indurated, and warm to the touch. Palpation elicits significant tenderness, and a moderate amount of thick, whitish-yellow fluid is easily expressed from between the surgical staples. His lungs are clear to auscultation, and bowel sounds are normoactive. Which of the following are the most appropriate next steps in the management of this patient's current condition? (Select all that apply)

A 32-year-old G2P1 woman at 35 weeks gestation is brought to the obstetric triage unit after experiencing a sudden gush of clear fluid from her vagina, followed immediately by moderate, painless vaginal bleeding. She recently immigrated and has not received regular prenatal care, missing her second-trimester anatomy ultrasound. Her temperature is 36.9°C (98.4°F), blood pressure is 112/72 mm Hg, pulse is 90/min, and respirations are 16/min. Speculum examination reveals clear fluid mixed with bright red blood pooling in the posterior vaginal fornix. The fetal heart rate tracing demonstrates a continuous, smooth, undulating baseline of 140/min with a wave frequency of 4 cycles per minute, absent short-term variability, and no accelerations or true decelerations. Which of the following is the most appropriate next step in management?

Match each clinical exposure scenario with the most appropriate targeted post-exposure management or prophylaxis protocol.

A $68$-year-old man is evaluated in the hospital for a new-onset fever. He was admitted $5$ days ago for an acute exacerbation of chronic obstructive pulmonary disease, which has significantly improved with intravenous corticosteroids and bronchodilators. A Foley catheter was placed on admission for strict fluid monitoring but was removed $48$ hours later. Yesterday, he developed a fever of $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), dysuria, and suprapubic tenderness. Urinalysis revealed $50$ leukocytes per high-power field and positive leukocyte esterase. He was empirically started on intravenous piperacillin-tazobactam and vancomycin. Today, the patient's fever has resolved, his urinary symptoms are improving, and he is tolerating an oral diet. Blood cultures drawn concurrently have no growth to date. Cardiac examination reveals a regular rate and rhythm with no murmurs. Urine culture from yesterday grows $>100,000$ CFU/mL of *Enterococcus faecalis*. Susceptibility testing demonstrates that the isolate is susceptible to ampicillin, vancomycin, and linezolid.

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

A 44-year-old man visits the urgent care clinic complaining of a 3-day history of progressive left lower quadrant abdominal pain. He reports mild nausea but has not vomited. His last bowel movement was yesterday and was normal in consistency. He has no significant past medical history and takes no medications. His temperature is $37.3^\circ\text{C}$ ($99.1^\circ\text{F}$), blood pressure is $124/78\text{ mmHg}$, and pulse is $82/\text{min}$. Physical examination reveals focal tenderness to palpation in the left lower quadrant without rigidity, guarding, or rebound tenderness. Laboratory studies show a leukocyte count of $9,800/\text{mm}^3$. A CT scan of the abdomen and pelvis with intravenous contrast demonstrates wall thickening of the sigmoid colon with adjacent pericolonic fat stranding. There is no evidence of an abscess, stricture, fistula, or free intraperitoneal air. He is able to tolerate oral fluids without difficulty. Which of the following is the most appropriate next step in management?

A 58-year-old man with advanced cirrhosis due to nonalcoholic steatohepatitis is evaluated in the hospital on day 3 of his admission. He originally presented from a skilled nursing facility with fever, worsening ascites, and hepatic encephalopathy. On admission, diagnostic paracentesis revealed cloudy fluid with an absolute neutrophil count of 850/mm³. Due to his recent healthcare exposure and a history of urinary tract infections caused by extended-spectrum beta-lactamase (ESBL)-producing organisms, he was empirically started on intravenous meropenem and received appropriate albumin infusions.

Today, the patient is afebrile, alert, and fully oriented. His abdominal pain has resolved. Blood and ascitic fluid cultures obtained on admission have grown *Escherichia coli*. Antimicrobial susceptibility testing demonstrates that the isolate is resistant to ampicillin but susceptible to ceftriaxone, ciprofloxacin, trimethoprim-sulfamethoxazole, and meropenem.

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

During multidisciplinary rounds in the medical intensive care unit, the team evaluates a patient who repeatedly fails spontaneous breathing trials. The patient, a $69$-year-old woman with a history of severe chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy (ejection fraction $25\%$), was admitted $5$ days ago for acute hypercapnic respiratory failure and cardiogenic pulmonary edema.

On admission, she was intubated and placed on mechanical ventilation. She has since received treatment with inhaled bronchodilators, systemic glucocorticoids, and continuous intravenous furosemide, resulting in a net fluid loss of $6.5$ L and complete resolution of pulmonary crackles.

Today, her sedation is paused, and she is alert and following commands. A spontaneous breathing trial is initiated with continuous positive airway pressure (CPAP) of $5$ cm $H_2O$. However, within $10$ minutes, her respiratory rate drops to $6$/min with shallow tidal volumes, triggering an apnea alarm, and she is placed back on full ventilatory support.

Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $112/68$ mm Hg, and heart rate $84$/min. Jugular venous pressure is $7$ cm $H_2O$.

Arterial blood gas (on assist-control ventilation, rate $12$/min, tidal volume $400$ mL, $FiO_2$ $0.30$):
pH: $7.54$
$PaCO_2$: $53$ mm Hg
$PaO_2$: $82$ mm Hg
$HCO_3^-$: $44$ mEq/L

Which of the following is the most appropriate next step in management to facilitate weaning from mechanical ventilation?

A $67$-year-old man presents to the primary care clinic reporting progressively worsening fatigue and dyspnea on exertion over the past $3$ months. He denies any chest pain, orthopnea, or recent cough. He has a past medical history of hypertension and hyperlipidemia. His medications include lisinopril and atorvastatin. Vital signs show a blood pressure of $135/82$ mmHg, pulse of $92$/min, and respiratory rate of $16$/min. Physical examination reveals pale conjunctivae but no jaundice, cyanosis, or peripheral edema. Cardiopulmonary examination is unremarkable. Digital rectal examination reveals brown stool; no palpable masses are present.

Laboratory studies:
Hemoglobin: $8.4$ g/dL
Hematocrit: $26\%$
Mean corpuscular volume: $72$ fL
Leukocyte count: $6,500$/mm $^3$
Platelet count: $410,000$/mm $^3$

Serum iron: $30$ $\mu$ g/dL
Total iron-binding capacity (TIBC): $450$ $\mu$ g/dL
Serum ferritin: $12$ ng/mL

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

Evaluate the following clinical scenarios describing patients with varied presentations of renal dysfunction. Correlate each patient's presentation with the most characteristic predominant finding expected on their urine microscopy.

A 42-year-old man comes to the clinic for evaluation of sudden, severe headaches associated with profuse sweating and heart palpitations. These episodes occur 2 to 3 times a week, typically lasting for 15 to 20 minutes. He has no significant past medical history and takes no medications. His blood pressure during the visit is 172/105 mm Hg, and his pulse is 105/min. The rest of his physical examination is unremarkable. Arrange the following steps in the most appropriate chronological order for the evaluation and management of this patient's suspected condition.

A mother brings her 10-month-old daughter to a pediatric clinic for evaluation of a fever and a new rash. The infant developed a high fever, a persistent cough, and a runny nose four days ago. Since yesterday, her eyes have been markedly red and watering. This morning, the mother noticed a rash starting on the child's face. The infant has not received any vaccinations due to the family's personal beliefs. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), pulse is $155/\text{min}$, and respirations are $38/\text{min}$. Physical examination reveals an ill-appearing infant. There is a blanching, erythematous maculopapular rash prominent on the face and neck, with early spread to the upper trunk. Oral examination shows clustered, $1$- to $2\text{ mm}$ white lesions on an erythematous base on the bilateral buccal mucosa. Lung auscultation reveals transmitted upper airway sounds. Which of the following is the most appropriate next step in management?

A 68-year-old male is evaluated by the surgical team on postoperative day 3 following an open partial gastrectomy for a gastric mass. The patient has a 40-pack-year smoking history and known chronic obstructive pulmonary disease. He now complains of progressive shortness of breath and chest tightness that began earlier this morning. His temperature is 37.8°C (100.0°F), blood pressure is 145/88 mmHg, pulse is 108/min, and respirations are 24/min. Pulse oximetry shows 89% on room air. Physical examination reveals an anxious patient sitting upright. Jugular venous pressure is estimated at 6 cm $H_2O$. Lung auscultation demonstrates diffuse expiratory wheezing and a prolonged expiratory phase; there are no crackles. The surgical incision is intact without drainage. Cardiac examination reveals tachycardia with a regular rhythm and no murmurs or gallops. There is no lower extremity edema. Which of the following is the most appropriate next step in management?

Paramedics bring a pregnant patient to the emergency department after she suffered a witnessed generalized tonic-clonic convulsion at home. The patient's partner reports that she has been experiencing severe headaches and visual changes for the past two days. She is currently at 37 weeks gestation. Upon arrival in the trauma bay, the patient is actively seizing. Her blood pressure is 176/114 mmHg. Oxygen saturation is 96% on room air, and her airway remains patent. Fetal heart rate monitoring is not yet established. Arrange the following acute management steps in the most appropriate chronological sequence for this patient.

A 68-year-old woman is brought to the emergency department from a skilled nursing facility due to altered mental status, fever, and right upper quadrant abdominal pain for the past 24 hours. Her temperature is 39.2°C (102.6°F), blood pressure is 86/52 mm Hg, pulse is 118/min, and respirations are 22/min. Physical examination demonstrates scleral icterus, dry mucous membranes, and significant tenderness to palpation in the right upper quadrant with involuntary guarding. Laboratory studies reveal a leukocyte count of 18,500/mm³, total bilirubin of 5.8 mg/dL, direct bilirubin of 4.2 mg/dL, and alkaline phosphatase of 450 U/L.

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

A $54$-year-old man is admitted to the hospital with a $5$-day history of fever, productive cough, and right-sided pleuritic chest pain. His temperature is $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), pulse is $112/\text{min}$, and respiratory rate is $24/\text{min}$. A portable chest radiograph demonstrates a right lower lobe consolidation and a moderate, free-flowing right-sided pleural effusion. He is initiated on empiric intravenous ceftriaxone and azithromycin. Over the next $48$ hours, he remains persistently febrile and tachycardic, and his oxygen requirement increases.

Assume that the patient's clinical condition requires sequential escalation of interventions due to the failure of each preceding step. Arrange the following management steps in the most appropriate chronological order according to standard treatment guidelines.

An evaluation for secondary amenorrhea and secondary infertility is requested for a 32-year-old woman. She reports that she has not menstruated since the delivery of her first child 14 months ago. The patient's pregnancy was complicated by placental abruption at 37 weeks gestation, which resulted in hemorrhagic shock requiring the transfusion of six units of packed red blood cells. Following delivery, she experienced profound lactational failure despite multiple interventions by a lactation consultant. Over the past six months, she has also noted worsening lethargy, unintentional weight gain, and cold intolerance. Her body mass index is $22 \text{ kg/m}^2$. Vital signs show a blood pressure of $92/60 \text{ mmHg}$ and a heart rate of $56/\text{min}$. Physical examination reveals a loss of axillary and pubic hair, as well as a delayed relaxation phase of the deep tendon reflexes.

Laboratory studies are obtained with the following results:
- Thyroid-stimulating hormone (TSH): $0.1 \text{ \mu U/mL}$ (Normal: $0.4-4.0 \text{ \mu U/mL}$)
- Free thyroxine (T4): $0.5 \text{ ng/dL}$ (Normal: $0.9-1.7 \text{ ng/dL}$)
- Follicle-stimulating hormone (FSH): $2.0 \text{ mIU/mL}$ (Normal for follicular phase: $3-10 \text{ mIU/mL}$)
- Luteinizing hormone (LH): $1.1 \text{ mIU/mL}$ (Normal for follicular phase: $2-12 \text{ mIU/mL}$)
- Prolactin: $1.5 \text{ ng/mL}$ (Normal: $4-25 \text{ ng/mL}$)

Which of the following is the most likely underlying etiology of this patient's reproductive failure?

A $72$-year-old female with a medical history of severe chronic obstructive pulmonary disease and heart failure with reduced ejection fraction ($35\%$) is evaluated in the intensive care unit for worsening hemodynamic instability. She was admitted to the hospital three days ago with a left lower lobe community-acquired pneumonia. Following progressive hypoxemia and increased work of breathing, she was intubated yesterday. She is currently sedated and paralyzed.

Over the past $4$ hours, her blood pressure has steadily declined despite receiving $30$ mL/kg of lactated Ringer solution.

Vital signs:
* Temperature: $38.9^\circ \text{C}$ ($102.0^\circ \text{F}$)
* Heart rate: $118$/min
* Blood pressure: $76/40$ mmHg
* $\text{SpO}_2$: $92\%$

Physical examination reveals a mottled appearance of the lower extremities. Jugular venous pressure is $8$ cm $\text{H}_2\text{O}$. Auscultation demonstrates left basilar crackles and bilateral expiratory wheezing. Bedside echocardiography shows an ejection fraction of $35\%$ without right ventricular enlargement or pericardial effusion.

Sputum cultures obtained on admission are now growing *Streptococcus pneumoniae* susceptible to ceftriaxone, levofloxacin, and vancomycin. The patient is currently receiving empiric therapy with intravenous vancomycin, cefepime, and azithromycin.

Ventilator settings (Volume Control):
* Tidal volume: $380$ mL ($6$ mL/kg predicted body weight)
* Respiratory rate: $12$/min
* $\text{FiO}_2$: $0.60$
* PEEP: $12$ cm $\text{H}_2\text{O}$

Arterial blood gas (drawn $15$ minutes ago):
* pH: $7.18$
* $\text{PaCO}_2$: $44$ mmHg
* $\text{PaO}_2$: $65$ mmHg
* $\text{HCO}_3^-$: $16$ mEq/L

Which of the following are the most appropriate immediate steps in management? (Select all that apply)