Tüm alıştırma soruları

Currently admitted to the intensive care unit, a $76$-year-old man with ischemic cardiomyopathy (left ventricular ejection fraction $20\%$) is being managed for a severe heart failure exacerbation. He has been receiving continuous intravenous furosemide for the past four days. Over the last $48$ hours, his net fluid balance is negative $6$ liters. Today, he develops an insidious onset of severe, diffuse abdominal pain. He is grimacing in bed and requesting intravenous analgesia.

Vital signs include a temperature of $37.1^\circ\text{C}$, heart rate of $112$/min (irregularly irregular), blood pressure of $85/55$ mmHg, and respiratory rate of $22$/min. Physical examination reveals a flat, soft abdomen that is surprisingly non-tender to deep palpation. There is no guarding, rigidity, or rebound tenderness. Bowel sounds are diminished.

Laboratory studies are significant for:
Leukocyte count: $16,500/\text{mm}^3$
Blood urea nitrogen: $55 \text{ mg/dL}$
Creatinine: $2.1 \text{ mg/dL}$ (baseline $1.0 \text{ mg/dL}$)
Lactate: $4.8 \text{ mmol/L}$ (Normal: $0.5-2.2 \text{ mmol/L}$)

CT angiography of the abdomen and pelvis demonstrates diffuse, smooth narrowing of the superior mesenteric artery and its primary branches with an alternating pattern of spasm and dilation. No distinct endoluminal filling defects or abrupt vascular cutoffs are visualized. The bowel wall appears mildly thickened, but no pneumatosis intestinalis or free intraperitoneal air is present.

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

A $3$-week-old male infant is evaluated in the emergency department for a $12$-hour history of decreased feeding and increased somnolence. The parents report that he has been difficult to rouse for his usual feedings. He was born at term via an uncomplicated vaginal delivery to a mother who received standard prenatal care. Vital signs reveal a rectal temperature of $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), heart rate of $168/\text{min}$, respiratory rate of $54/\text{min}$, and blood pressure of $70/45\text{ mmHg}$. Physical examination shows a lethargic infant who awakens only briefly to stimulation. The anterior fontanelle is soft and flat. Cardiopulmonary examination is unremarkable, with no wheezing or retractions. Skin examination reveals scattered $1$ to $2\text{ mm}$ yellow-white pustules on a splotchy erythematous base distributed over the anterior chest and back. Which of the following is the most appropriate next step in management?

Match each distinct clinical presentation of acute third-trimester or intrapartum bleeding with its most likely underlying obstetric complication.

Match each of the following clinical presentations with the most likely diagnosis.

Match each clinical presentation with its underlying pathophysiologic mechanism or characteristic pathologic finding.

A $48$-year-old man is evaluated in the hospital on day $5$ of an admission for severe acute pancreatitis. He originally presented with severe, radiating epigastric pain, nausea, and a serum lipase level of $3,200\text{ U/L}$. The patient has a $10$-year history of heavy alcohol consumption. He has been strictly nil per os (NPO) and is receiving intravenous crystalloid fluids and opioid analgesics. Today, his temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is $118/74\text{ mmHg}$, pulse is $108/\text{min}$, and respirations are $18/\text{min}$. Physical examination reveals persistent epigastric tenderness to deep palpation without rebound tenderness or guarding. Bowel sounds are hypoactive. Laboratory studies show:

Leukocyte count: $16,500/\text{mm}^3$
Total calcium: $7.8\text{ mg/dL}$
Albumin: $2.0\text{ g/dL}$
Liver function tests: Within normal limits

A repeat computed tomography (CT) scan of the abdomen with intravenous contrast demonstrates an area of non-enhancement involving approximately $40\%$ of the pancreatic body and tail, consistent with pancreatic necrosis. There is no visible gas within the peripancreatic fluid collection. Which of the following is the most appropriate next step in management?

A $78$-year-old man is brought to the clinic by his son for a routine follow-up. The patient has a history of advanced Parkinson disease and neurogenic bladder, which is managed with a chronic indwelling urethral catheter. The son reports that over the past week, the urine in the collection bag has become notably turbid and foul-smelling. The patient is otherwise acting at his baseline; he has had no fevers, chills, abdominal pain, or changes in oral intake. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $132/82\text{ mm Hg}$, pulse $74\text{/min}$, and respirations $14\text{/min}$. Physical examination demonstrates a soft, non-tender abdomen and no costovertebral angle tenderness. There is no leakage or erythema around the urethral meatus.

A urine culture grows $>100,000\text{ CFU/mL}$ of *Klebsiella pneumoniae*. Which of the following is the most appropriate next step in management?

Following a one-week vacation in a tropical resort, a 32-year-old female presents to the outpatient clinic reporting 48 hours of frequent, watery bowel movements. She describes having three to four loose stools per day accompanied by mild abdominal cramping. She denies seeing blood or mucus in the stool and has not experienced fever, chills, nausea, or vomiting. Her medical history is unremarkable, and she takes no daily medications. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 118/76 mmHg, and heart rate of 78/min. On physical examination, the abdomen is soft and non-tender with active bowel sounds. The patient requests an antibiotic prescription to ensure she can return to work tomorrow. Which of the following is the most appropriate management plan for this patient?

A 72-year-old man is evaluated on postoperative day 2 following an elective open sigmoid colectomy for recurrent diverticulitis. He reports mild incisional pain but denies dyspnea, cough, or dysuria. His temperature is 38.6°C (101.5°F), blood pressure is 132/84 mmHg, pulse is 98/min, and respirations are 18/min. Pulse oximetry shows 95% on room air. Physical examination reveals decreased breath sounds at the lung bases bilaterally without wheezes or crackles. The surgical incision is clean, dry, and intact with no erythema, induration, or purulent drainage. The abdomen is mildly distended with hypoactive bowel sounds. His indwelling urinary catheter was removed on postoperative day 1, and he is voiding without difficulty. Which of the following are appropriate next steps in the management of this patient's current condition? (Select 2 answers)

A 52-year-old woman with a history of type 1 diabetes mellitus is brought to the emergency department after $3$ days of intractable vomiting and generalized abdominal pain. She ran out of her prescribed insulin $4$ days ago. On physical examination, she appears lethargic with dry mucous membranes and decreased skin turgor. Temperature is $37.2^\circ$ C ($99.0^\circ$ F), blood pressure is $95/60$ mm Hg, pulse is $118$/min, and respirations are $26$/min and deep.

Laboratory studies reveal:

Assume a normal anion gap of $12$ mEq/L and a normal serum bicarbonate of $24$ mEq/L.

What is the patient's calculated delta ratio (also known as the $\Delta$ AG / $\Delta$ HCO $_3^-$ ratio)?

On the fourth day after undergoing an uncomplicated sigmoid colectomy for recurrent diverticulitis, a 68-year-old man is assessed for new-onset breathing difficulties. Over the past 12 hours, he has developed progressive shortness of breath accompanied by a cough producing thick, yellow sputum. His medical history includes chronic obstructive pulmonary disease (COPD) and heart failure with preserved ejection fraction.

Vital signs are:
Temperature: $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$)
Blood pressure: $135/85\text{ mmHg}$
Heart rate: $108/\text{min}$
Respiratory rate: $24/\text{min}$
Oxygen saturation: $88\%$ on room air

Physical examination reveals a patient in mild respiratory distress using accessory muscles of respiration. Auscultation of the lungs demonstrates a prolonged expiratory phase with diffuse, bilateral wheezing. Jugular venous pressure is normal, and there are no crackles or lower extremity edema. The abdomen is soft, non-distended, and mildly tender around the surgical incision, but lacks guarding or rebound tenderness. The incision is intact with no erythema or purulent drainage.

Laboratory and imaging results:
Leukocyte count: $11,500/\text{mm}^3$
Brain natriuretic peptide (BNP): $85\text{ pg/mL}$ (Normal: $<100\text{ pg/mL}$)
Procalcitonin: $0.05\text{ ng/mL}$ (Normal: $<0.15\text{ ng/mL}$)
Chest radiograph: Hyperinflated lungs and flattened hemidiaphragms; no focal consolidations, pleural effusions, or vascular congestion

Which of the following are the most appropriate next steps in the management of this patient? (Select 2)

Match the following clinical presentations of acute trauma to the most appropriate initial diagnostic or therapeutic intervention according to standard trauma protocols.

Evaluate the following four clinical scenarios describing patients with symptomatic thyrotoxicosis. Match each clinical vignette to the specific histopathologic or molecular etiology driving the patient's condition.

A 29-year-old nulligravid woman comes to the office due to a 6-month history of absent menstrual periods. Menarche occurred at age 12, and her menses were previously regular, occurring every 28 to 30 days. For the past several months, she has also noticed a bilateral milky nipple discharge that stains her undergarments. The patient reports feeling unusually sluggish, experiencing generalized muscle aches, and having difficulty concentrating at her desk job. She has gained 5 kg (11 lb) over the past year despite no change in her dietary habits. She has no chronic medical conditions and takes no medications. Vital signs include a blood pressure of 110/70 mm Hg, a pulse of 58/min, and a respiratory rate of 14/min. Her body mass index (BMI) is 26 kg/m². Physical examination reveals pale, cool skin and delayed relaxation of the deep tendon reflexes. A urine pregnancy test is negative.

Laboratory results are as follows:

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

A patient is hospitalized for the management of an acute, swollen, and exquisitely tender left knee. Diagnostic arthrocentesis performed at admission yielded opaque, purulent synovial fluid, prompting the immediate initiation of empiric antimicrobial therapy with intravenous vancomycin and intravenous ceftriaxone. Over the past 48 hours, the patient has demonstrated marked clinical improvement, with complete resolution of fever and a significant decrease in joint effusion. The microbiology laboratory subsequently contacts the team to report that the admission synovial fluid culture is growing *Streptococcus pyogenes* (Group A Streptococcus). The isolate demonstrates standard susceptibility patterns to all tested beta-lactams, macrolides, and fluoroquinolones. In accordance with the principles of antimicrobial stewardship, which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 72-year-old man is evaluated for severe shortness of breath on postoperative day 3 following a right hemicolectomy for colon cancer. Yesterday, his hemoglobin was 6.5 g/dL, and he was prescribed 2 units of packed red blood cells. The infusion of the second unit was completed 30 minutes ago. He has a history of essential hypertension, diet-controlled type 2 diabetes mellitus, and osteoarthritis. His temperature is 37.1°C (98.8°F), blood pressure is 168/94 mm Hg, pulse is 112/min, and respirations are 24/min. Pulse oximetry shows 88% on room air. Physical examination reveals distended jugular veins evaluated at 9 cm above the sternal angle. Cardiac auscultation shows a regular tachycardia with a prominent S3 gallop. Lung auscultation reveals bilateral crackles at the lung bases. Trace bilateral pedal edema is present. What is the most appropriate next step in management?

A 68-year-old man with a history of severe chronic obstructive pulmonary disease and hypertension is brought to the emergency department by his daughter due to worsening confusion and decreased urine output over the past 48 hours. He recently had a gastrointestinal illness with severe nausea and poor oral intake, leading to profound dehydration. His current medications include lisinopril and tiotropium. Temperature is 37.1°C (98.8°F), blood pressure is 88/52 mm Hg, pulse is 112/min, and respirations are 26/min. Physical examination shows dry mucous membranes, diminished breath sounds bilaterally with a prolonged expiratory phase, and delayed capillary refill.

Laboratory studies reveal the following:
Sodium: $136\text{ mEq/L}$
Potassium: $5.1\text{ mEq/L}$
Chloride: $95\text{ mEq/L}$
Bicarbonate: $12\text{ mEq/L}$
Blood urea nitrogen: $72\text{ mg/dL}$
Creatinine: $4.1\text{ mg/dL}$ (baseline $1.1\text{ mg/dL}$)

Arterial blood gas (on room air):
pH: $7.18$
pCO2: $34\text{ mm Hg}$
pO2: $62\text{ mm Hg}$

Which of the following best characterizes this patient's acid-base status?

An obstetrics triage nurse evaluates a primigravid patient at 40 weeks and 2 days gestation. The patient was admitted earlier in the day for an elective labor induction and is currently receiving an intravenous infusion of oxytocin. She reports severe, sharp pain with each contraction, and monitoring shows contractions occurring every 2.5 minutes on average. Vital signs include a blood pressure of 118/76 mm Hg, heart rate of 88/min, and respiratory rate of 18/min. To investigate a complaint of mild shortness of breath, an arterial blood gas on room air is drawn, demonstrating a pH of 7.44, PaCO₂ of 28 mm Hg, and PaO₂ of 102 mm Hg.

A continuous fetal heart rate monitor displays a baseline rate of 140/min accompanied by moderate variability. However, the tracing also reveals recurrent, symmetric decreases in the heart rate to a nadir of 120/min. The onset of each decrease is gradual, taking roughly 40 seconds to reach its lowest point. Notably, the nadir of each deceleration occurs consistently after the peak of the corresponding uterine contraction, returning to baseline only after the contraction ends. These specific decelerations are present following 60% of the recorded contractions. Pelvic examination confirms the cervix is 5 cm dilated and 90% effaced, with the fetal head at 0 station.

Based on these findings, which of the following is the most appropriate next step in management?

Review the following clinical scenarios involving patients with diverticular disease. Correlate each specific presentation with its most appropriate next step in management based on current clinical guidelines.

Match each clinical presentation of glomerular disease with its most characteristic renal biopsy or immunofluorescence finding.