Tüm alıştırma soruları

A 32-year-old man is brought to the emergency department by paramedics after being found unresponsive in his apartment. Bystanders report that he may have used heroin and had been lying in the same position for an unknown duration. On arrival, his temperature is 36.8°C (98.2°F), blood pressure is 105/65 mm Hg, pulse is 88/min, and respiratory rate is 10/min. Physical examination reveals pinpoint pupils and marked swelling and induration of the right lower extremity.

Laboratory studies show the following:

Arterial blood gas analysis on room air reveals:

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

Match each patient's clinical presentation with the most likely predominant finding on a peripheral blood smear.

During a winter clinic visit, a 34-year-old female with known limited cutaneous systemic sclerosis reports increasingly painful episodes where her fingers turn stark white, then blue, when exposed to the cold. Physical examination reveals taut skin over the digits but no active ulceration. She is currently not taking any medications for this specific symptom. Arrange the following management steps in the standard escalating sequence for this condition, starting from initial baseline interventions and progressing to therapies reserved for severe, refractory digital ischemia.

A 42-year-old man presents to a gastroenterology clinic with a 1-year history of severe, burning epigastric pain and chronic high-volume watery diarrhea. The abdominal pain frequently awakens him at night and is only minimally relieved by high-dose pantoprazole, which he has taken reliably for the past 6 months. He has no personal or family history of nephrolithiasis, hypercalcemia, or pituitary disease. An upper endoscopy performed prior to referral revealed remarkably prominent gastric folds and multiple deep ulcerations in the duodenal bulb and the descending duodenum. The physician highly suspects Zollinger-Ellison syndrome (ZES) and plans to initiate a comprehensive diagnostic and management algorithm.

Arrange the following steps in the strictly correct chronological order for the evaluation and definitive management of this patient's condition.

A 29-year-old woman is brought to the emergency department by her husband due to progressive lethargy and profound weakness. For the past 4 days, she has had severe, voluminous watery diarrhea and poor oral intake following a sick contact. Her medical history is significant for idiopathic intracranial hypertension, for which she takes acetazolamide. Her temperature is 37.2°C (99.0°F), blood pressure is 98/60 mmHg, pulse is 112/min, and respiratory rate is 16/min. Physical examination shows dry mucous membranes, decreased skin turgor, and generalized diminished muscle strength in all extremities.

Laboratory studies show the following:
Serum sodium: 136 mEq/L
Serum potassium: 2.2 mEq/L
Serum chloride: 116 mEq/L
Serum bicarbonate: 10 mEq/L
Blood urea nitrogen: 42 mg/dL
Serum creatinine: 1.6 mg/dL

Arterial blood gas (room air):
pH: 7.11
$pCO_2$: 32 mmHg
$pO_2$: 88 mmHg

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

A $33$-year-old woman comes to the clinic due to a $14$-month history of inability to conceive. She and her husband have regular, unprotected intercourse. Menarche was at age $12$. Her menstrual cycles were previously regular, but they became irregular $2$ years ago. For the past $6$ months, she has had no menses. She reports intermittent episodes of sudden warmth and sweating, particularly at night. She has no significant past medical history and takes no medications. Vital signs are within normal limits. BMI is $22 \text{ kg/m}^2$. Pelvic examination shows pale, thin vaginal mucosa with loss of rugae. The uterus is of normal size and adnexa are nonpalpable.

Laboratory studies show the following:

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

A 68-year-old man is admitted to the hospital with acute decompensated heart failure. He is started on an intravenous bumetanide infusion. On hospital day 3, his urine output decreases to 300 mL over the last 24 hours. Physical examination shows jugular venous distention, bibasilar crackles, and bilateral lower extremity pitting edema.

Laboratory studies are obtained:
Serum sodium: $140 \text{ mEq/L}$
Serum potassium: $3.5 \text{ mEq/L}$
Serum chloride: $98 \text{ mEq/L}$
Serum bicarbonate: $26 \text{ mEq/L}$
Serum blood urea nitrogen (BUN): $60 \text{ mg/dL}$
Serum creatinine: $2.0 \text{ mg/dL}$

A spot urine sample is analyzed:
Urine sodium: $105 \text{ mEq/L}$
Urine blood urea nitrogen (BUN): $600 \text{ mg/dL}$
Urine creatinine: $100 \text{ mg/dL}$

Based on these findings, what is the patient's fractional excretion of urea nitrogen (expressed as a percentage)?

A 29-year-old woman with a body mass index of $34 \text{ kg/m}^2$ and a known diagnosis of polycystic ovary syndrome (PCOS) presents for an infertility evaluation. She and her partner have been unable to conceive after 18 months of regular, unprotected intercourse. Her partner's semen analysis is normal, and a hysterosalpingogram confirms patent fallopian tubes bilaterally. Arrange the following management steps in the correct sequential order from the most appropriate initial intervention to the most advanced therapy.

A $52$-year-old man comes to the physician due to progressive fatigue, unintentional weight loss, and a feeling of early satiety over the past $3$ months. He has no other medical conditions and takes no medications. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $128/78\text{ mmHg}$, and pulse is $82/\text{min}$. Physical examination reveals a palpable spleen edge $8\text{ cm}$ below the left costal margin. There is no palpable cervical, axillary, or inguinal lymphadenopathy. Laboratory studies show the following:

A peripheral blood smear demonstrates a full spectrum of granulocytic cells, including $5\%$ myeloblasts, $10\%$ promyelocytes, $15\%$ myelocytes, $10\%$ metamyelocytes, $15\%$ bands, $35\%$ neutrophils, $6\%$ eosinophils, and $4\%$ basophils. The leukocyte alkaline phosphatase score is markedly decreased. Which of the following is the most appropriate next step in the evaluation or management of this patient?

A 62-year-old woman is evaluated on postoperative day 6 following an elective open sigmoid colectomy for recurrent diverticulitis. She reports new-onset chills and increasing incisional pain over the past 24 hours. Her temperature is 39.1°C (102.4°F), heart rate is 112/min, and blood pressure is 110/70 mmHg. Examination of the surgical site reveals marked erythema, induration, and purulent drainage seeping from between the surgical staples. The patient is admitted to the progressive care unit for close monitoring.

Arrange the following management steps in the most appropriate chronological sequence for the care of this postoperative complication.

A 42-year-old man with a history of poorly controlled HIV infection presents to the emergency department with a 2-day history of worsening headache, severe photophobia, and confusion. On presentation, his temperature is 39.4°C (102.9°F), blood pressure is 115/75 mm Hg, pulse is 118/min, and respirations are 18/min. Physical examination reveals marked nuchal rigidity. He is oriented only to his name. Funduscopic examination shows blurring of the optic disc margins bilaterally.

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

A 68-year-old man is evaluated in the hospital on the third day of admission for acute ascending cholangitis. He initially presented with a 2-day history of right upper quadrant abdominal pain, fever, and jaundice. On admission, his temperature was 39.2°C (102.6°F) and blood pressure was 98/60 mm Hg. Laboratory studies showed a leukocyte count of 16,500/mm³, total bilirubin of 4.2 mg/dL, and alkaline phosphatase of 450 U/L.

He was empirically started on intravenous piperacillin-tazobactam and received aggressive fluid resuscitation. Within 12 hours of admission, he underwent urgent endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and extraction of a common bile duct stone.

Today, the patient feels much better. His temperature is 37.1°C (98.8°F), blood pressure is 122/78 mm Hg, and pulse is 78/min. His abdominal examination shows mild right upper quadrant tenderness without rebound or guarding.

Blood cultures drawn on admission are now growing *Escherichia coli*. The susceptibility report is as follows:

Based on these results, which of the following is the most appropriate next step in the management of this patient's antibiotic therapy?

A 4-year-old boy is brought to the emergency department by his parents for a 1-day history of high fever, severe right hip pain, and an inability to bear weight. His temperature is 39.2°C (102.6°F), heart rate is 130/min, respiratory rate is 24/min, and blood pressure is 95/60 mm Hg. Examination reveals the right hip is held in flexion, abduction, and external rotation. Passive movement of the joint elicits severe pain and guarding. There is no history of trauma. Assuming the patient remains hemodynamically stable, arrange the following steps in the most appropriate sequential order for the diagnostic and therapeutic management of this patient.

A 26-year-old female medical student presents to the student health clinic reporting a two-day history of frequent, watery bowel movements. She notes having four to five loose stools daily, accompanied by mild, diffuse abdominal cramping. She has not noticed any visible blood or mucus in the toilet. The patient denies any recent international travel, new medications, or known exposure to sick individuals. Her only regular medication is a daily oral contraceptive. Her temperature is 37.1°C (98.8°F), blood pressure is 116/74 mm Hg, and pulse is 80/min. Abdominal examination reveals a soft, non-distended abdomen with hyperactive bowel sounds. There is mild, generalized tenderness to deep palpation, but no guarding, rigidity, or rebound tenderness.

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

During morning rounds, the surgical team evaluates a 60-year-old man who is 36 hours status post an uncomplicated elective open right inguinal hernia repair. The patient reports mild discomfort at the incision site but otherwise feels well. He has been ambulating in the hallways with minimal assistance and is tolerating a regular diet. The nursing staff requested this evaluation because his latest temperature measurement was 38.4°C (101.1°F). His blood pressure is 130/80 mm Hg, pulse is 82/min, and respiratory rate is 14/min. Pulse oximetry shows 98% on room air. Physical examination reveals clear lungs bilaterally and normal heart sounds. The abdomen is soft and non-distended. The right groin incision is clean, dry, and intact without erythema, fluctuance, or induration. The calves are soft and non-tender bilaterally, with no lower extremity edema. Which of the following is the most appropriate next step in management?

A 28-year-old woman is brought to the emergency department by her family due to severe agitation, confusion, and palpitations that have progressively worsened over the past 24 hours. She has a history of Graves disease but stopped taking her medications three months ago. On physical examination, her temperature is 39.8°C (103.6°F), blood pressure is 160/90 mm Hg, heart rate is 148/min and irregular, and respiratory rate is 24/min. She is delirious, diaphoretic, and has a noticeable fine tremor. Neck examination reveals a diffusely enlarged, non-tender thyroid gland with a bruit. ECG shows atrial fibrillation with rapid ventricular response. Laboratory studies confirm a TSH level of < 0.01 µU/mL and a free T4 of 5.8 ng/dL. Arrange the following interventions in the most appropriate chronological order for the comprehensive management of this patient, from initial acute stabilization to long-term definitive care.

A 52-year-old woman presents to the emergency department with severe, sudden-onset epigastric pain radiating to her back, accompanied by intractable nausea. Her heart rate is 112/min and blood pressure is 105/65 mm Hg. Laboratory studies reveal a serum lipase level of 1,250 U/L and an alanine aminotransferase (ALT) level of 185 U/L. She is diagnosed with acute gallstone pancreatitis. Assuming her clinical course is complicated by new-onset fever and worsening jaundice on hospital day 2, arrange the following interventions in the most appropriate chronological sequence for her overall management.

A 61-year-old man is evaluated on postoperative day 2 following an elective open hepatic resection for a solitary colorectal metastasis. He reports moderate pain at the surgical site but denies shortness of breath, chest pain, cough, or dysuria. His medical history is significant for chronic obstructive pulmonary disease and heart failure with preserved ejection fraction. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $134/82\text{ mmHg}$, pulse is $102/\text{min}$, and respirations are $16/\text{min}$. Pulse oximetry is $96\%$ on room air. Physical examination reveals an intact abdominal incision without erythema, induration, or purulent drainage. Lung auscultation demonstrates fine bibasilar crackles that completely disappear after the patient coughs forcefully. Cardiac examination shows a regular rhythm with no murmurs or gallops. The abdomen is soft, and bowel sounds are hypoactive. There is trace bilateral lower extremity edema that is unchanged from his preoperative baseline. Laboratory studies show a leukocyte count of $11,500/\text{mm}^3$. Which of the following is the most appropriate next step in management?

A 38-year-old man comes to the clinic complaining of a 3-week history of right upper quadrant abdominal pain, low-grade fevers, and profound fatigue. He emigrated from an endemic region of Central America 4 months ago. He does not use tobacco, alcohol, or illicit drugs. His temperature is 38.3°C (100.9°F), blood pressure is 122/78 mm Hg, and pulse is 88/min. Physical examination shows a liver edge that is palpable 3 cm below the right costal margin with marked point tenderness over the lower right rib cage. A complete blood count reveals a leukocyte count of 13,500/mm³ with 75% neutrophils. An abdominal ultrasound reveals a solitary, hypoechoic, 5-cm fluid collection in the right hepatic lobe. Enzyme immunoassay for *Entamoeba histolytica* antibodies is positive. Which of the following is the most appropriate next step in management?

Paramedics transport a 45-year-old male to the hospital after his wife discovered him confused and stumbling inside their garage. The patient reports severe bilateral flank pain and appears visibly intoxicated, though his wife states he has not consumed alcohol. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 145/90 mm Hg, heart rate of 98/min, and respiratory rate of 22/min.

Based on the provided laboratory data, determine this patient's serum osmolar gap in mOsm/kg H₂O.