Tüm alıştırma soruları

A 58-year-old man is evaluated in the hospital for worsening abdominal distension and diffuse abdominal discomfort over the past 48 hours. He has a history of alcohol-associated cirrhosis. His temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), blood pressure is $105/65\text{ mm Hg}$, and pulse is $92/\text{min}$. Physical examination shows a protuberant abdomen with shifting dullness and mild, diffuse tenderness to palpation without rebound or guarding. Neurologic examination shows a fully oriented patient with no asterixis.

Diagnostic paracentesis yields ascitic fluid with a total leukocyte count of $800/\text{mm}^3$ and $85\%$ neutrophils. Intravenous cefotaxime is initiated. Which of the following is the most appropriate additional intervention for this patient?

Match each characteristic electrocardiogram (ECG) description with its corresponding cardiovascular diagnosis.

A 38-year-old woman is newly diagnosed with Raynaud phenomenon secondary to limited cutaneous systemic sclerosis. She is concerned about the progression of her condition and asks her physician about the treatment options available if her symptoms worsen over time. Arrange the following interventions in the correct sequential step-up escalation order for the management of Raynaud phenomenon, from the initial first-line approach to treatments reserved for severe, refractory disease with threatened digital ischemia.

A 28-year-old woman presents to the outpatient clinic reporting a painless swelling in her neck that has progressively enlarged over the past two months. She also describes experiencing drenching night sweats that require her to change her sleepwear, along with an unintended 5-kg (11-lb) weight loss during this time frame. Vital signs reveal a temperature of $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$). Physical examination identifies a 3.5-cm, firm, rubbery, mobile, and non-tender lymph node in the left supraclavicular fossa. The remainder of the examination shows no other palpable adenopathy or hepatosplenomegaly. Arrange the following steps in the most appropriate clinical sequence for the evaluation and management of this patient's condition.

A 59-year-old man is evaluated in the intensive care unit on postoperative day 5 following a partial gastrectomy with Billroth II reconstruction for a perforated peptic ulcer. Over the past 3 hours, he has become increasingly confused and agitated. His temperature is $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), blood pressure is $76/42\text{ mmHg}$, pulse is $134/\text{min}$, and respirations are $26/\text{min}$. Pulse oximetry shows $94\%$ on room air. Central venous pressure is $3\text{ cm H}_2\text{O}$. Physical examination reveals a rigid, diffusely tender abdomen with involuntary guarding and generalized rebound tenderness. The surgical dressing is saturated with bilious fluid. Laboratory studies show a leukocyte count of $24,000/\text{mm}^3$ with $18\%$ bands. Arterial blood gas analysis on room air reveals a pH of $7.22$, $\text{pCO}_2$ of $32\text{ mmHg}$, and $\text{pO}_2$ of $78\text{ mmHg}$. Which of the following are the most appropriate immediate steps in the management of this patient? (Select 2 answers)

Match each clinical and neuroimaging presentation of a central nervous system disorder in patients with advanced HIV infection to its most appropriate definitive or empiric management.

Evaluate the following clinical vignettes describing patients who developed acute kidney injury (AKI) in various clinical settings. Match each patient's clinical presentation to the most accurate pathophysiological diagnosis.

A 62-year-old woman is receiving care on the inpatient ward for a catheter-associated bloodstream infection. She was admitted 3 days ago with high fever, chills, and localized erythema around a peripheral intravenous catheter site. The catheter was promptly removed, and she was started on empiric intravenous vancomycin and piperacillin-tazobactam. Today, she reports feeling much better. Her temperature is 37.1°C (98.8°F), blood pressure is 128/82 mmHg, pulse is 76/min, and respirations are 14/min. The erythema at the prior catheter site has significantly improved. Blood cultures obtained on admission are now finalized and grow *Staphylococcus aureus*. Susceptibility testing demonstrates resistance to penicillin G and susceptibility to oxacillin, cefazolin, vancomycin, and daptomycin. Which of the following is the most appropriate next step in pharmacotherapy?

A 62-year-old woman is evaluated on postoperative day 1 following an open total abdominal hysterectomy for symptomatic uterine fibroids. Over the last $6$ hours, her recorded urine output has been a total of $70\text{ mL}$. Her temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), blood pressure is $100/65\text{ mmHg}$, pulse is $98\text{/min}$, and respiratory rate is $16\text{/min}$. Her oxygen saturation is $98\%$ on room air. She has been receiving maintenance intravenous normal saline at $75\text{ mL/hr}$. Physical examination reveals dry oral mucosa and a soft abdomen with mild incisional tenderness. Breath sounds are clear bilaterally. A Foley catheter is in place. Which of the following are appropriate initial actions in the management of this patient? (Select all that apply)

Paramedics transport a 68-year-old male resident of a skilled nursing facility to the acute care clinic due to profound lethargy and weakness over the past 24 hours. According to the accompanying transfer paperwork, the patient has experienced large-volume, watery stools for five consecutive days following a treatment course of clindamycin for cellulitis. His daily medications include a transdermal fentanyl patch for severe osteoarthritis and oral acetaminophen. Initial triage vital signs show a temperature of 37.1 C (98.8 F), blood pressure of 88/58 mm Hg, heart rate of 114/min, and a respiratory rate of 9/min. Physical assessment is notable for somnolence, a delayed capillary refill of 4 seconds, and dry oral mucosa. Blood is drawn for an arterial blood gas and serum chemistry panels with the following results:

Which of the following is the most accurate interpretation of this patient's current acid-base status?

A 10-year-old boy is brought to the emergency department via ambulance after falling forcefully onto the handlebars of his bicycle. He is pale and intermittently responsive. Heart rate is $155\text{ /min}$, and blood pressure is $72/40\text{ mm Hg}$. Capillary refill time is $4\text{ seconds}$. Intravenous access is rapidly obtained, and an initial bolus of $20\text{ mL/kg}$ of warm isotonic crystalloid is administered, but his vital signs do not improve. Primary survey reveals equal breath sounds bilaterally and no external bleeding. His abdomen is tightly distended with diffuse tenderness. Bedside focused assessment with sonography for trauma (FAST) demonstrates significant free fluid in the splenorenal and hepatorenal recesses.

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

A 52-year-old woman is evaluated in the emergency department after a severe motor vehicle collision. She was the restrained driver of a vehicle that struck a concrete retaining wall at highway speeds. Upon arrival, she is lethargic but her airway is patent. She appears pale and diaphoretic. Vital signs are a temperature of 36.6°C (97.9°F), a pulse of 135/min, a blood pressure of 78/48 mmHg, and a respiratory rate of 28/min. Oxygen saturation is 96% on supplemental oxygen.

Breath sounds are clear and equal bilaterally, and the trachea is midline. Heart sounds are normal. The abdomen is soft, nondistended, and mildly tender to deep palpation in the lower quadrants. There is marked ecchymosis over the suprapubic region. Anteroposterior pelvic radiography performed in the trauma bay demonstrates a symphyseal diastasis of $4 \text{ cm}$ and a displaced fracture of the left sacroiliac joint. A pelvic binder is immediately applied, and she receives rapid intravenous transfusion of uncrossmatched blood products and crystalloid.

Following initial resuscitation, her blood pressure is 82/50 mmHg and pulse is 128/min. A bedside focused assessment with sonography for trauma (FAST) exam demonstrates no pericardial effusion and no intraperitoneal free fluid.

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

An 81-year-old female resident of an assisted living facility is evaluated in the emergency department for severe, diffuse abdominal pain and intractable vomiting that began abruptly 5 hours ago. Her medical history includes hypertension and paroxysmal atrial fibrillation, for which she frequently misses her apixaban doses. On examination, the patient is agitated, diaphoretic, and writhing in pain. Abdominal examination reveals mild diffuse tenderness without guarding or rebound, which appears surprisingly benign given her reported level of pain.

Vitals:
* Temperature: $37.2^{\circ}\text{C} (99.0^{\circ}\text{F})$
* Pulse: $122/\text{min}$, irregularly irregular
* Respirations: $32/\text{min}$
* Blood pressure: $148/85 \text{ mm Hg}$

Laboratory analysis reveals the following:

What is the most accurate interpretation of this patient's acid-base status?

A 64-year-old woman is brought to the emergency department due to a 2-day history of high fever, severe right upper quadrant abdominal pain, and confusion. She has a medical history of morbid obesity, for which she underwent a Roux-en-Y gastric bypass 5 years ago. She has not had a cholecystectomy. Her temperature is 39.5°C (103.1°F), blood pressure is 80/50 mmHg, pulse is 125/min, and respiratory rate is 24/min. Physical examination reveals profound scleral icterus and significant right upper quadrant tenderness with guarding.

Intravenous fluids and broad-spectrum antibiotics (piperacillin-tazobactam) are immediately initiated. An abdominal ultrasound demonstrates a dilated common bile duct measuring 14 mm with echogenic material consistent with a stone, and a gallbladder containing multiple stones but without wall thickening. Despite aggressive fluid resuscitation, she requires vasopressor support.

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

A 65-year-old man comes to the clinic reporting a 3-month history of right calf cramping. The discomfort consistently begins after walking approximately three blocks and resolves completely within a few minutes of rest. He has a history of type 2 diabetes mellitus, hypertension, and a 40-pack-year smoking history. His current medications include metformin and lisinopril. Vital signs are within normal limits. On physical examination, the skin of the right lower extremity appears thin and shiny with decreased hair growth. The right dorsalis pedis pulse is diminished compared to the left. Which of the following is the most appropriate initial diagnostic test to evaluate this patient's condition?

A 64-year-old man presents to the emergency department with a 2-day history of progressive shortness of breath, orthopnea, and a dry cough. His medical history is significant for chronic obstructive pulmonary disease (COPD) and severe seropositive rheumatoid arthritis. Four months ago, his rheumatologist added infliximab to his regimen of methotrexate due to persistent joint erosions. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 158/94 mmHg, pulse of 112/min, and respiratory rate of 26/min. Pulse oximetry is 88% on room air. Physical examination reveals elevated jugular venous pressure, a third heart sound (S3) gallop, and bilateral basilar crackles with mild expiratory wheezing. Chest radiography shows an enlarged cardiac silhouette, bilateral interstitial opacities, and blunting of the costophrenic angles. Which of the following is the most appropriate next step in management?

Match each patient's hepatitis B (HBV) serology profile with the most appropriate clinical diagnosis.

High-resolution manometry (HRM) is the gold standard for diagnosing esophageal motility disorders. According to the Chicago Classification v4.0, match the following esophageal motility disorders with their precise defining manometric criteria.

A 65-year-old man with a history of an open appendectomy presents to the emergency department with severe crampy abdominal pain, bilious vomiting, and obstipation for the past 24 hours. His vital signs show a heart rate of 110/min and blood pressure of 115/75 mm Hg. Physical examination reveals a distended, tympanic abdomen with high-pitched "tinkling" bowel sounds, but no rebound tenderness or guarding. Arrange the following management steps in the most appropriate sequential order.

An independent, community-dwelling 71-year-old male schedules a clinic appointment due to persistent lumbar back pain that began spontaneously 6 weeks ago. The pain is described as a deep ache that does not improve with rest or ibuprofen. Over the past month, he has also experienced unusual fatigue and new-onset constipation. He has a history of mild essential hypertension controlled with amlodipine. Vital signs are within normal limits. Physical examination reveals point tenderness over the L4 spinous process.

Laboratory results are as follows:

Which of the following is the most appropriate initial diagnostic step to evaluate this patient's condition?