Tüm alıştırma soruları

A 65-year-old man is evaluated on the surgical ward. He is on postoperative day 6 following an emergent exploratory laparotomy for a perforated duodenal ulcer. His medical history is significant for type 2 diabetes mellitus, obesity, and a 40-pack-year smoking history. Over the past 24 hours, he has had several paroxysms of severe coughing. A few minutes ago, while attempting to transition from his bed to a chair, he felt a sudden "tearing" sensation in his abdomen followed by a gush of salmon-colored fluid from his surgical site. On examination, the surgical dressing is saturated. Removal of the dressing reveals complete separation of the fascial edges with loops of small bowel protruding through the abdominal wound. His temperature is 37.2°C (99.0°F), blood pressure is 135/85 mm Hg, pulse is 98/min, and respirations are 20/min.

Arrange the following management steps in the most appropriate chronological order for this patient's acute complication.

A 62-year-old woman is brought to the emergency department with a 24-hour history of severe right upper quadrant abdominal pain, high fever, and confusion. Her blood pressure is 84/52 mmHg, heart rate is 118/min, and temperature is 39.5°C (103.1°F). Physical examination reveals scleral icterus and right upper quadrant guarding. Laboratory studies show a leukocyte count of 22,000/mm³, total bilirubin of 6.1 mg/dL, direct bilirubin of 4.8 mg/dL, and alkaline phosphatase of 510 U/L. Bedside ultrasound demonstrates a dilated common bile duct of 14 mm with echogenic debris and gallstones, but no pericholecystic fluid or gallbladder wall thickening.

Arrange the following clinical interventions in the most appropriate chronological sequence for the optimal management of this patient.

A $28$-year-old male medical resident is evaluated in the occupational health clinic immediately after sustaining a needlestick injury with a hollow-bore needle. The needle was just used to draw blood from a patient. The source patient is known to be positive for hepatitis B surface antigen (HBsAg) and negative for both HIV and hepatitis C virus. The resident is asymptomatic. A review of his employee health records indicates that he completed the standard hepatitis B vaccination series $4$ years ago. Blood is drawn from the resident, and laboratory studies show the following:

Hepatitis B surface antigen (HBsAg): Negative
Hepatitis B surface antibody (Anti-HBs): Positive ($150 \text{ mIU/mL}$)
Hepatitis B core antibody (Anti-HBc): Negative

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

A $65$-year-old man is evaluated in the clinic for severe, progressive fatigue, generalized weakness, and loss of appetite over the past $3$ weeks. He also reports a mild, constant, diffuse headache. The patient has a history of metastatic melanoma and has been receiving combination immunotherapy with nivolumab and ipilimumab for the past $4$ months. Blood pressure is $96/60$ mmHg while supine and $82/50$ mmHg while standing. Heart rate is $92$/min. Physical examination reveals vitiligo over the upper extremities. The thyroid gland is not palpable.

Laboratory studies show the following:

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

A 42-year-old woman comes to the outpatient clinic for evaluation of generalized muscle weakness and fatigue that have progressively worsened over the past three weeks. She also reports a history of recurrent flank pain, and her medical records indicate two previous emergency department visits for "calcium kidney stones." She has a long-standing history of dry eyes and a dry mouth, for which she uses artificial tears daily. She takes no medications other than an oral contraceptive pill. Vital signs are within normal limits. Physical examination reveals dry oral mucosa, bilateral conjunctival injection, and symmetric proximal muscle weakness (4/5 power). Laboratory studies show the following:

Which of the following is the most likely primary pathophysiologic mechanism for this patient's acid-base and electrolyte abnormalities?

A 24-year-old man with type 1 diabetes mellitus is brought to the emergency department by his roommate after a 2-day history of abdominal pain, nausea, vomiting, and profound weakness. The patient admits to missing several doses of his basal insulin due to a recent gastrointestinal illness. He appears lethargic and is using accessory muscles to breathe. Vital signs show a temperature of 37.6°C (99.7°F), blood pressure of 98/62 mm Hg, pulse of 124/min, and respiratory rate of 28/min with shallow breaths. Physical examination reveals dry mucous membranes and diffuse abdominal tenderness without guarding.

Laboratory evaluation shows:

Arterial blood gas analysis on room air:

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

A 34-year-old woman presents to the emergency department with a 3-day history of profound fatigue, intermittent confusion, and easy bruising. Her temperature is 38.2°C (100.8°F), pulse is 105/min, and blood pressure is 110/70 mm Hg. Physical examination reveals scleral icterus and scattered petechiae on the lower extremities. Neurological examination reveals mild disorientation to time and place, but no focal motor or sensory deficits. Laboratory testing reveals the following:

A peripheral blood smear demonstrates numerous fragmented red blood cells and a paucity of platelets. Which of the following is the most appropriate next step in management for this patient?

A 52-year-old woman is evaluated in the emergency department for a fever of 38.8°C (101.8°F) and severe chills that began 2 hours ago. She was diagnosed with acute myeloid leukemia 3 weeks ago and is currently undergoing induction chemotherapy. She has an indwelling central venous catheter. Her blood pressure is 105/65 mm Hg, pulse is 110/min, and respirations are 18/min. Physical examination reveals a well-healed catheter site with no erythema or purulent drainage, and the remainder of the examination shows no obvious source of infection. A complete blood count reveals an absolute neutrophil count of 150/mm³. Arrange the following management steps in the most appropriate chronological order for this patient.

A 31-year-old woman and her husband come to the office to undergo evaluation for primary infertility. They have engaged in regular, unprotected intercourse for the past 15 months without achieving pregnancy. The patient reports that her menstrual periods have always been unpredictable, occurring approximately every 7 to 9 weeks. She has also struggled with persistent acne and the growth of thick hair on her chin and lower abdomen over the last few years. She does not report any deepening of her voice, increased muscle mass, or abnormal bruising. Her body mass index is 32 kg/m². Vital signs are normal. Physical examination reveals moderate facial hirsutism, but no clitoromegaly or purple striae are noted. A urine pregnancy test is negative. The physician suspects polycystic ovary syndrome but notes that a diagnosis requires excluding other conditions with a similar presentation. Along with thyroid-stimulating hormone and prolactin, which of the following laboratory tests is most necessary to definitively exclude a common mimicker of this patient's suspected condition?

A $26$-year-old woman is brought to the emergency department after being found unresponsive. She has a history of type 1 diabetes mellitus. On presentation, she is lethargic and oriented only to person. Temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure is $90/60\text{ mm Hg}$, heart rate is $135/\text{min}$, and respirations are $40/\text{min}$ and deep.

Initial laboratory and arterial blood gas (on room air) results show:

The patient is started on aggressive intravenous fluid resuscitation and an insulin infusion. One hour later, her respiratory effort diminishes significantly, and she becomes completely unresponsive (Glasgow Coma Scale score of 6). She undergoes rapid sequence intubation with etomidate and rocuronium.

Following intubation, she is placed on volume-assist control mechanical ventilation with the following settings:
- Tidal volume: $450\text{ mL}$ ($6\text{ mL/kg}$ ideal body weight)
- Respiratory rate: $14/\text{min}$
- FiO2: $100\%$
- PEEP: $5\text{ cm H}_2\text{O}$

Twenty minutes later, the ventilator alarms for low blood pressure. The patient's blood pressure has dropped precipitously to $62/40\text{ mm Hg}$, and her heart rate is $148/\text{min}$. A repeat arterial blood gas reveals:

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

A 28-year-old woman, gravida 1, para 0, at 14 weeks gestation presents to the emergency department with a 3-day history of shortness of breath, sharp right-sided chest pain that worsens with deep inspiration, and low-grade fever. She was diagnosed with systemic lupus erythematosus (SLE) 4 years ago and is currently taking hydroxychloroquine. Her temperature is $37.9^\circ \text{C}$ ($100.2^\circ \text{F}$), blood pressure is $122/76 \text{ mm Hg}$, pulse is $112/\text{min}$, and respirations are $24/\text{min}$. Pulse oximetry is $96\%$ on room air.

Physical examination reveals an erythematous rash over the cheeks and nasal bridge, as well as swelling, erythema, and tenderness in the metacarpophalangeal joints bilaterally. Lung auscultation reveals decreased breath sounds and dullness to percussion at the right lung base. Jugular venous pressure is $6 \text{ cm H}_2\text{O}$.

Laboratory studies show:
- Leukocytes: $4,200/\text{mm}^3$
- Hemoglobin: $10.5 \text{ g/dL}$
- Platelets: $130,000/\text{mm}^3$
- Creatinine: $0.7 \text{ mg/dL}$
- Urinalysis: Normal

A chest radiograph with abdominal shielding shows a small right-sided pleural effusion without focal airspace opacities. A ventilation-perfusion scan indicates a low probability of pulmonary embolism. An echocardiogram shows normal ventricular function and no pericardial effusion.

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

A 31-year-old female patient presents to the primary care clinic for evaluation of profound exhaustion, persistent constipation, and chronic cold intolerance that has worsened over the past 5 months. She also reports amenorrhea since the delivery of her child 10 months ago. Her obstetric history is significant for a complicated vaginal delivery involving a severe postpartum hemorrhage, which necessitated massive transfusion protocols and intensive care unit admission. Following discharge, she noticed an inability to lactate. Current vital signs show a temperature of 36.4°C (97.5°F), blood pressure of 105/70 mmHg, pulse of 58/min, and respiratory rate of 14/min. Physical examination is notable for coarse, dry skin, delayed relaxation phase of the deep tendon reflexes, and a marked absence of axillary and pubic hair.

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

A physician is called to the surgical ward to evaluate a 59-year-old female patient for a new-onset fever. The patient underwent a laparotomy and small bowel resection for a strangulated ventral hernia six days ago. Over the past 12 hours, she has developed a fever of $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), chills, and worsening abdominal pain. Vital signs show a blood pressure of $105/65\text{ mmHg}$, pulse of $118/\text{min}$, and respirations of $18/\text{min}$. Physical examination reveals a moderately distended abdomen with marked tenderness in the periumbilical region and hypoactive bowel sounds. The surgical incision is completely closed with surgical staples intact; there is no surrounding erythema, warmth, or purulent drainage. An indwelling urinary catheter was removed on postoperative day two, and the patient has been voiding without difficulty. Cardiopulmonary examination is unremarkable, and there is no lower extremity edema or calf tenderness. A complete blood count reveals a leukocyte count of $17,000/\text{mm}^3$. Which of the following is the most appropriate next step in management?

A 19-year-old male collegiate rugby player is evaluated in the emergency department immediately after a severe on-field collision. During the match, he was struck forcefully in the left flank by an opponent's shoulder. En route to the hospital, he received 1 L of intravenous lactated Ringer solution. Upon arrival, he appears pale, diaphoretic, and lethargic. His temperature is 36.5°C (97.7°F), blood pressure is 78/40 mm Hg, and pulse is 138/min. Oxygen saturation is 99% on room air. The trachea is midline, and breath sounds are clear and symmetric bilaterally. Heart sounds are rapid but normal in intensity, with no jugular venous distention. The abdomen is distended, rigid, and diffusely tender, with significant guarding in the left upper quadrant. The patient also reports worsening pain in his left shoulder while lying supine. A focused assessment with sonography for trauma (FAST) examination reveals an anechoic stripe in the splenorenal recess. What is the most appropriate next step in the management of this patient?

A 55-year-old man with a 15-year history of poorly controlled type 2 diabetes mellitus presents to the clinic with a deep, non-healing ulcer on the plantar surface of his right foot. Examination reveals a 2-cm wide ulcer with surrounding erythema, edema, and purulent exudate. The patient is afebrile, but underlying osteomyelitis is highly suspected. Arrange the following steps in the correct sequential order for the diagnostic evaluation of this patient, starting with the most appropriate initial step and concluding with the definitive diagnostic procedure.

A 54-year-old man presents to the emergency department with a 2-hour history of vomiting bright red blood and passing dark, tarry stools. His blood pressure is 90/60 mmHg, and his pulse is 118/min. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 64-year-old man is brought to the emergency department by his family due to a 2-day history of increasing confusion, low-grade fever, and abdominal discomfort. The patient has a history of decompensated cirrhosis secondary to metabolic dysfunction-associated steatotic liver disease (MASLD). He takes furosemide, spironolactone, and lactulose, but his family reports he has been less compliant with his medications over the past week. His temperature is $38.0^\circ\text{C}$ ($100.4^\circ\text{F}$), blood pressure is $105/65\text{ mmHg}$, and heart rate is $98/\text{min}$. Physical examination reveals scleral icterus and a distended abdomen with shifting dullness. There is diffuse, mild abdominal tenderness without rebound or guarding. Asterixis is present.

Laboratory results are as follows:

A diagnostic paracentesis is performed, yielding cloudy yellow fluid. Ascitic fluid analysis reveals:

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

A $32$-year-old woman is evaluated in the outpatient clinic for progressive exertional dyspnea and fatigue over the past $8$ months. She has no prior medical conditions and does not use tobacco. Vital signs are within normal limits, though pulse oximetry shows $94\%$ on ambient air. Physical examination is notable for a prominent right ventricular heave, a loud pulmonic component of the second heart sound ($P_2$), and trace lower extremity pitting edema. The lungs are clear to auscultation. A chest radiograph reveals enlarged central pulmonary arteries with rapid tapering of the peripheral vessels. Electrocardiography shows right axis deviation.

Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for evaluating and managing this patient's suspected condition, from first to last.

A 52-year-old woman is evaluated in the emergency department for severe, watery diarrhea over the past five days. She reports feeling profoundly weak. She has no significant past medical history. Her blood pressure is 105/65 mm Hg, pulse is 112/min, and respiratory rate is 22/min. Physical examination shows dry mucous membranes and delayed capillary refill.

Laboratory results:
- Serum sodium: 138 mEq/L
- Serum potassium: 3.2 mEq/L
- Serum chloride: 114 mEq/L
- Serum bicarbonate: 12 mEq/L
- Arterial blood gas (room air): pH 7.24, PaCO2 24 mm Hg, PaO2 96 mm Hg

Using Winter's formula, calculate the patient's expected PaCO2. (Provide the exact median numerical value in mm Hg, excluding the ±2 range)

A 38-year-old man presents to the emergency department with a 3-day history of bleeding gums, frequent epistaxis, and a diffuse rash. He has no significant past medical history. His temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $112/70$ mm Hg, and pulse is $105$/min. Physical examination reveals widespread petechiae and ecchymoses over his trunk and extremities, as well as active mucosal bleeding in the oral cavity. Laboratory studies show:

A peripheral blood smear demonstrates numerous atypical promyelocytes containing multiple needle-like cytoplasmic inclusions (Auer rods).

Based on the suspected diagnosis, arrange the following management and diagnostic steps in the most appropriate chronological order.