Tüm alıştırma soruları

A 62-year-old man is brought to the emergency department by emergency medical services due to severe confusion and lethargy. His family reports that he has been increasingly difficult to arouse since yesterday morning. The patient has end-stage renal disease secondary to hypertensive nephrosclerosis and normally receives hemodialysis three days a week. However, he missed his last two scheduled treatments due to transportation issues. His past medical history is also significant for severe chronic obstructive pulmonary disease, for which he requires continuous home oxygen therapy.

Upon arrival, his temperature is $36.8^\circ C$ ($98.2^\circ F$), blood pressure is $158/92$ mm Hg, heart rate is $105$/min, and respiratory rate is $12$/min and shallow. He is somnolent and oriented only to person. Pulmonary examination reveals a prolonged expiratory phase with diffuse expiratory wheezing.

Arterial blood gas and serum laboratory analysis reveal the following:

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

Match each clinical presentation and coagulation laboratory profile to the most likely underlying hematologic diagnosis.

A 29-year-old woman is brought to the emergency department by her husband due to severe left-sided back pain, nausea, and shaking chills that began $48$ hours ago. Her temperature is $39.2^{\circ}C$ ($102.6^{\circ}F$), blood pressure is $86/50$ mmHg, pulse is $128$/min, and respiratory rate is $28$/min. Physical examination reveals flushed skin, dry mucous membranes, and marked left costovertebral angle tenderness. Laboratory testing reveals the following:

Based on the laboratory results, which of the following best characterizes this patient's acid-base status?

Match each clinical presentation of infective endocarditis with the most likely causative microorganism.

A couple with severe male-factor infertility due to oligozoospermia is preparing for their first treatment cycle using assisted reproductive technology. During the informed consent process, the reproductive endocrinologist details the timeline of the procedure to ensure the patients understand the clinical commitment required. Arrange the following clinical and laboratory steps of an in vitro fertilization (IVF) cycle in their correct chronological sequence, from the initiation of the treatment cycle to its completion.

A 52-year-old man comes to the primary care clinic reporting a 7-month history of progressive fatigue, feeling constantly cold, and worsening constipation. He also mentions a reduced libido and difficulty achieving erections over the same period. His only significant medical history is essential hypertension treated with amlodipine. His vital signs show a temperature of $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$), blood pressure of 108/68 mm Hg, and heart rate of 50/min. Physical examination reveals dry skin, thinning of the lateral eyebrows, and delayed relaxation of the ankle reflexes. His testes are soft and bilaterally decreased in volume.

Initial laboratory studies reveal:

Which of the following is the most likely pathophysiologic mechanism for this patient's thyroid laboratory profile?

A 31-year-old man is diagnosed with active ankylosing spondylitis. His symptoms are currently confined to the axial skeleton, presenting as severe inflammatory back pain and profound morning stiffness. Arrange the following pharmacologic management steps in the correct chronological sequence for escalating his therapy, assuming he experiences inadequate clinical responses at each preceding stage.

A $27$-year-old gravida $3$, para $2$ at $38$ weeks and $4$ days of gestation is in the labor unit undergoing induction for gestational diabetes. Uterine contractions are being augmented with a continuous infusion of a synthetic nonapeptide hormone. The continuous electronic fetal monitor demonstrates a baseline heart rate of $145$ /min with absent variability. Over the last $30$ minutes, the patient has experienced $16$ contractions. During this same timeframe, the fetal tracing displays recurrent, gradual decreases in heart rate that reach their nadir strictly after the peak of the corresponding contraction. The nursing staff immediately places the patient in the left lateral decubitus position, administers a $500$ mL intravenous bolus of lactated Ringer solution, and halts the uterotonic infusion. Ten minutes later, the patient continues to experience contractions every $90$ to $120$ seconds, and the fetal heart rate pattern remains unchanged. The patient's blood pressure is $118/76$ mm Hg and pulse is $88$ /min. Cervical examination reveals $5$ cm dilation, $90\%$ effacement, and $-1$ station. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old female is brought to the emergency department by emergency medical services after a high-speed motorcycle collision. She was found approximately 30 feet from her vehicle. On arrival, her temperature is 36.5°C (97.7°F), blood pressure is 76/40 mm Hg, pulse is 138/min, and respirations are 28/min. The patient is lethargic and pale. The airway is intact, and breath sounds are present and equal bilaterally. A rigid cervical collar is in place. Abdominal examination reveals diffuse tenderness and guarding. The patient receives 1 L of warmed intravenous crystalloid solution and 1 unit of uncrossmatched packed red blood cells, but her blood pressure only improves to 82/45 mm Hg. A portable chest radiograph shows a widened mediastinum but no evidence of pneumothorax or hemothorax. A focused assessment with sonography for trauma (FAST) examination reveals a large anechoic fluid collection in the hepatorenal recess (Morison's pouch). An anteroposterior pelvic radiograph shows no fractures. Which of the following is the most appropriate next step in management?

A 24-year-old woman comes to the clinic for a routine follow-up evaluation. Three months ago, she was prescribed a combined oral contraceptive pill for primary dysmenorrhea and mild facial acne. She reports that her menstrual cramps have significantly improved and she is satisfied with the medication. She has no other medical conditions and takes no other medications. She denies any fatigue, weight changes, palpitations, heat or cold intolerance, or changes in bowel habits.

Her blood pressure is 112/72 mm Hg, and pulse is 70/min. Physical examination reveals a normal-sized, non-tender thyroid gland with no palpable nodules. Her skin is warm and dry, and there is mild residual acne on her chin.

Laboratory studies are obtained as part of a routine health screening:
Thyroid-stimulating hormone (TSH): $1.7 \text{ \mu U/mL}$ (Normal: $0.4-4.0 \text{ \mu U/mL}$)
Free thyroxine (Free T4): $1.3 \text{ ng/dL}$ (Normal: $0.8-1.8 \text{ ng/dL}$)
Total thyroxine (Total T4): $14.2 \text{ \mu g/dL}$ (Normal: $4.5-10.9 \text{ \mu g/dL}$)

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

A 64-year-old man is evaluated in the intensive care unit on hospital day 3. He was admitted with septic shock secondary to an obstructing right ureteral calculus. A percutaneous nephrostomy tube was placed shortly after admission. Empiric therapy with intravenous vancomycin and meropenem was initiated. Today, his temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $118/74\text{ mmHg}$, and pulse is $82/\text{min}$. Vasopressors were weaned off yesterday. Blood and urine cultures obtained at admission both grow *Enterobacter cloacae*. Susceptibility testing results for both isolates are as follows:

Based on these results and the patient's clinical improvement, which of the following is the most appropriate next step in pharmacotherapy?

A 58-year-old man is hospitalized for acute ascending cholangitis. On admission, he presented with fever, jaundice, and right upper quadrant abdominal pain. He was started on empiric intravenous piperacillin-tazobactam, and an endoscopic retrograde cholangiopancreatography (ERCP) was performed, successfully removing a common bile duct stone and establishing biliary drainage. Forty-eight hours later, the patient is afebrile, his vital signs are stable, and his abdominal pain has significantly improved. Both blood and bile cultures grow Escherichia coli. Susceptibility testing indicates the organism is susceptible to ceftriaxone, ciprofloxacin, and piperacillin-tazobactam. Which of the following is the most appropriate next step in antibiotic management?

Match each of the following clinical vignettes and laboratory profiles to the most accurate underlying pathophysiologic mechanism.

Following the primary survey and initial resuscitation in the trauma bay, the next steps in management diverge significantly based on the patient's hemodynamic status, mechanism of injury, and bedside diagnostic findings. Match each clinical presentation below with the most appropriate immediate diagnostic or therapeutic next step.

A $58$-year-old man comes to the clinic reporting a $4$-month history of difficulty swallowing. He initially noticed a sensation of food "getting stuck" in his lower chest when eating solid foods such as meat and bread. Over the past few weeks, this sensation has progressed to involve softer foods. The patient also reports an unintentional $6\text{-kg}$ ($13.2\text{-lb}$) weight loss during this period. His past medical history is significant for frequent episodes of burning substernal chest pain over the last $15$ years, which he has managed intermittently with over-the-counter calcium carbonate antacids. He has a $30$-pack-year smoking history. Vital signs are within normal limits. Physical examination reveals a thin, well-appearing man with an unremarkable abdominal exam. Laboratory studies show a hemoglobin of $11.2\text{ g/dL}$ and a mean corpuscular volume of $78\text{ fL}$. Which of the following is the most appropriate next step in management?

A 28-year-old carpenter is brought to the emergency department after accidentally severing his right index finger with a table saw. The amputated digit was recovered at the scene and brought to the hospital by coworkers in a dry tissue paper. The patient is hemodynamically stable, and a trauma primary survey reveals no other injuries. The emergency department team is preparing the amputated digit for transport with the patient to a specialized microsurgery center. Arrange the following steps for the proper preservation and transport of the amputated digit in the correct chronological sequence.

A 45-year-old man is evaluated during hospital rounds. He was admitted 3 days ago for fever, productive cough, and pleuritic chest pain. A chest radiograph on admission showed a right lower lobe consolidation, and he was diagnosed with community-acquired pneumonia. Empiric therapy with intravenous ceftriaxone and oral azithromycin was initiated. He has no significant past medical history and takes no daily medications. He has no known drug allergies. Today, the patient reports feeling significantly better. His temperature is 37.1°C (98.8°F), blood pressure is 120/80 mmHg, pulse is 78/min, and respiratory rate is 16/min. Oxygen saturation is 98% on room air. Blood cultures obtained on admission are now growing *Streptococcus pneumoniae*. Susceptibility testing indicates the isolate is highly susceptible to penicillin, ceftriaxone, and levofloxacin, but resistant to macrolides. The patient is tolerating a regular diet without difficulty. Which of the following is the most appropriate next step in pharmacotherapy?

A $42$-year-old man is brought to the emergency department due to severe, generalized abdominal pain and recurrent, bilious vomiting for the past $24$ hours. He has a $10$-year history of stricturing Crohn's disease, for which he takes adalimumab. The patient reports that he has not passed flatus or had a bowel movement for the last two days. Two days prior to symptom onset, he sustained a blunt abdominal trauma after tripping and falling against a low wall, but he did not seek medical care at that time.

His temperature is $39.2^\circ \text{C}$ ($102.6^\circ \text{F}$), heart rate is $128$/min, blood pressure is $82/50$ mm Hg, and respiratory rate is $24$/min. Physical examination reveals a distended, rigid abdomen with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent.

Laboratory studies show:
Leukocyte count: $22,000/\mu \text{L}$
Hemoglobin: $11.2 \text{ g/dL}$
Platelet count: $350,000/\mu \text{L}$
Serum lactate: $5.8 \text{ mmol/L}$

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

Paramedics bring a $54$-year-old woman to the emergency department due to acute, unremitting abdominal pain and persistent bilious vomiting that began $8$ hours ago. Her medical history is notable for a total abdominal hysterectomy for uterine fibroids performed $4$ weeks ago. She reports that the pain initially started as intermittent cramps but rapidly progressed to become constant and excruciating over the last $2$ hours. Her temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $86/52\text{ mm Hg}$, pulse is $128/\text{min}$, and respirations are $24/\text{min}$. The patient appears diaphoretic, toxic, and lies completely still on the gurney. Physical examination reveals a markedly distended abdomen with involuntary guarding, board-like rigidity, and severe rebound tenderness in all four quadrants. Auscultation yields absent bowel sounds. Laboratory analysis demonstrates a leukocyte count of $21,500/\text{mm}^3$ and a serum lactate level of $5.2\text{ mmol/L}$. An upright abdominal radiograph displays multiple dilated loops of small intestine with prominent air-fluid levels and an absence of colonic gas. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old woman is evaluated in the surgical ward for sudden-onset left-sided shoulder pain, nausea, and severe anxiety. She is currently on her third postoperative day following a laparoscopic Roux-en-Y gastric bypass for morbid obesity. She has a history of obstructive sleep apnea, hypertension, and osteoarthritis. Current medications include subcutaneous enoxaparin, intravenous fluids, and a patient-controlled analgesia pump with morphine.

Vital signs reveal a temperature of $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure of $112/68\text{ mmHg}$, pulse of $132/\text{min}$, and respiratory rate of $22/\text{min}$. Pulse oximetry shows $95\%$ on room air.

Physical examination demonstrates a restless, anxious patient. The lungs are clear to auscultation bilaterally. Cardiac auscultation reveals a rapid, regular rhythm with no murmurs. The abdomen is obese, soft, and mildly tender diffusely, with no rebound tenderness or guarding. The laparoscopic port sites show no erythema or discharge. An electrocardiogram shows sinus tachycardia.

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