Tüm alıştırma soruları

An emergency medical team brings a female in her early thirties to the resuscitation bay following a brief loss of consciousness at her workplace. Upon arrival, the patient is lethargic and complains of profound weakness, lightheadedness, and difficulty breathing. She reports recovering from a severe viral upper respiratory tract infection two weeks ago but otherwise has no chronic medical conditions.

Her temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), pulse is $128$/min, respirations are $26$/min, and blood pressure is $78/48$ mmHg. When assessed during normal inhalation, her systolic blood pressure drops to $62$ mmHg.

Physical evaluation reveals marked distension of the external jugular veins while she is positioned at a $45$-degree angle. Auscultation of the chest demonstrates clear lung fields bilaterally without rhonchi or crepitations. Cardiac auscultation reveals a regular, rapid rhythm with significantly distant and muffled heart sounds. An electrocardiogram shows sinus tachycardia with low-voltage QRS complexes and beat-to-beat variation in QRS amplitude.

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

A $71$-year-old woman who resides in a skilled nursing facility is evaluated for the sudden onset of severe, foul-smelling, watery diarrhea. She reports having up to eight bowel movements per day for the last $48$ hours, accompanied by mild abdominal cramping. Three weeks prior, she completed a $10$-day course of oral clindamycin for a tooth abscess. Her temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $112/70\text{ mmHg}$, and pulse is $98/\text{min}$. Abdominal examination reveals hyperactive bowel sounds and diffuse mild tenderness, but the abdomen is soft and non-distended. Laboratory testing shows a serum leukocyte count of $18,500/\text{mm}^3$. Stool polymerase chain reaction testing is positive for *Clostridioides difficile* toxin genes. Which of the following is the most appropriate initial pharmacotherapy for this patient?

Match each structural or valvular heart pathology with its most characteristic physical examination or auscultatory finding.

Identify the correct inherited gastrointestinal syndrome that corresponds to each set of clinical findings.

Match the following physical examination findings of cardiac murmurs with their most likely underlying pathophysiology or structural etiology.

A 24-year-old man is brought to the emergency department after a severe motor vehicle collision. He is in profound respiratory distress. Vital signs show a heart rate of 135/min, blood pressure of 75/40 mm Hg, and oxygen saturation of 82% on room air. Physical examination reveals distended neck veins, marked tracheal deviation to the left, and completely absent breath sounds over the right hemithorax. The clinical diagnosis of a right-sided tension pneumothorax is made. Arrange the following management steps in the correct chronological sequence for this patient.

A $75$-year-old retired teacher arrives at the outpatient clinic reporting a one-week history of worsening shortness of breath. He states that he has been waking up gasping for air in the middle of the night and now must sleep propped up on three pillows. He has a $40$-pack-year smoking history and suffered an anterior myocardial infarction $4$ years ago. Vital signs show a blood pressure of $150/90$ mmHg, heart rate of $105$/min, respiratory rate of $24$/min, and oxygen saturation of $91\%$ on ambient air. Pulmonary auscultation reveals dependent, coarse crackles in both lower lung fields with absent wheezing and a normal expiratory phase. Cardiovascular examination is notable for an S3 gallop and jugular venous distention to $12$ cm $H_2O$. Which of the following is the most appropriate initial pharmacological intervention?

A 68-year-old man is evaluated in the hospital prior to planned discharge. He was admitted 5 days ago for an acute exacerbation of heart failure. His medical history is notable for ischemic cardiomyopathy with a left ventricular ejection fraction of 30%, type 2 diabetes mellitus, and mild chronic obstructive pulmonary disease (COPD).

During this hospitalization, he has received aggressive diuresis with intravenous furosemide, achieving a net negative fluid balance of $6.5 \text{ L}$. He currently feels well and denies shortness of breath.

Vital signs are temperature $37.0^\circ\text{C} (98.6^\circ\text{F})$, blood pressure $118/74 \text{ mm Hg}$, pulse $78/\text{min}$, and respiratory rate $14/\text{min}$. Oxygen saturation is 96% on room air.

Physical examination reveals absent jugular venous distension and no lower extremity edema. Auscultation of the lungs reveals decreased breath sounds at the right lung base.

A chest radiograph demonstrates a small-to-moderate right-sided pleural effusion, which is unchanged from admission. Because the effusion has not resolved with diuresis, a diagnostic thoracentesis is performed to rule out other etiologies.

Pleural fluid analysis also shows a leukocyte count of $150/\text{mm}^3$ (predominantly mononuclear) and a glucose level of $98 \text{ mg/dL}$.

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

During morning rounds in the intensive care unit, a physician evaluates a patient who was admitted $24$ hours ago for severe right lower lobe pneumonia complicated by septic shock. The patient is a $72$-year-old retired mechanic with a past medical history of ischemic cardiomyopathy (ejection fraction $35\%$) and type 2 diabetes mellitus. He is currently receiving targeted intravenous antibiotics based on rapid polymerase chain reaction testing, intravenous lactated Ringer's solution, and a continuous norepinephrine infusion.

Over the last hour, the patient has become increasingly agitated and diaphoretic. His temperature is $38.8^\circ$ C ($101.8^\circ$ F), blood pressure is $86/52$ mm Hg, pulse is $118$/min, and respiratory rate is $32$/min. Physical examination demonstrates prominent use of the sternocleidomastoid and scalene muscles. Lung auscultation reveals coarse crackles at the right lung base.

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

Match each classic electrocardiographic (ECG) description to its corresponding cardiac condition.

A nephrologist is evaluating laboratory data and urinalysis findings from several patients. Match each clinical laboratory presentation with its most likely underlying etiology.

An evaluation for secondary amenorrhea and spontaneous bilateral galactorrhea is initiated for a 29-year-old female. She reports her last menstrual period occurred 8 months ago, prior to which her cycles were regular every 28 days. Over the past several months, the patient has also noted worsening constipation, generalized sluggishness, and increased sensitivity to cold environments. She takes no daily medications, and a urine pregnancy test is negative. Vital signs show a temperature of 36.2 °C (97.1 °F), blood pressure of 114/72 mm Hg, and a pulse of 54/min. Physical examination demonstrates delayed relaxation of the Achilles tendon reflexes.

Laboratory studies reveal:
Thyroid-stimulating hormone (TSH): $58.0 \ \mu\text{U/mL}$ (Normal: $0.4-4.0 \ \mu\text{U/mL}$)
Free thyroxine (T4): $0.4 \ \text{ng/dL}$ (Normal: $0.9-2.4 \ \text{ng/dL}$)
Prolactin: $82 \ \text{ng/mL}$ (Normal: $< 25 \ \text{ng/mL}$)

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

A 38-year-old woman presents to the emergency department with a 1-week history of worsening fatigue, spontaneous gum bleeding, and easy bruising. Her temperature is 37.8°C (100°F), blood pressure is 110/70 mm Hg, and pulse is 105/min. Physical examination is notable for diffuse petechiae across her chest and extremities, as well as oozing from her intravenous catheter site.

Laboratory studies show:

A peripheral blood smear demonstrates numerous atypical promyelocytes with multiple needle-like cytoplasmic inclusions.

Arrange the following steps in the most appropriate chronological sequence for the management of this patient's condition.

During morning rounds, a surgical team evaluates a 68-year-old male inpatient whose clinical status has acutely worsened. He was admitted two days prior for management of an adhesive small bowel obstruction. Initial treatment consisted of intravenous fluid resuscitation, bowel rest, and placement of a nasogastric tube for gastric decompression. Over the last three hours, the patient reports that his previously intermittent, crampy abdominal pain has become constant and severe. His temperature is 38.9°C (102.0°F), blood pressure is 102/64 mmHg, pulse is 118/min, and respirations are 22/min. Physical examination reveals a distended abdomen with marked focal tenderness, involuntary guarding, and rebound tenderness in the periumbilical region. Laboratory studies show a leukocyte count of 16,500/mm³ and a serum lactate level of 3.4 mmol/L. Which of the following is the most appropriate next step in the management of this patient?

A 27-year-old male pedestrian is brought to the emergency department after being struck by a motor vehicle. He complains of severe pelvic and lower abdominal pain. On arrival, his temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure is 80/50 mmHg, heart rate is 132/min, and respiratory rate is 22/min. Oxygen saturation is 98% on room air. The patient's airway is patent, and breath sounds are equal bilaterally. A focused assessment with sonography for trauma (FAST) exam is negative for intraperitoneal fluid. Chest radiography reveals no abnormalities. Pelvic radiography demonstrates widening of the pubic symphysis and sacroiliac joints. An external pelvic binder is applied, and an institutional massive transfusion protocol is initiated. Reassessment 15 minutes later shows a blood pressure of 82/52 mmHg and a heart rate of 128/min. Which of the following is the most appropriate next step in management?

Correlate the following clinical scenarios involving suspected central nervous system infections with the most appropriate empiric or targeted pharmacotherapy.

A 34-year-old woman is evaluated in the emergency department for sudden-onset, severe, and cramping mid-abdominal pain that began 8 hours ago. The pain is continuous but worsens in waves. She has had three episodes of vomiting, which recently became bilious. Her past medical history is significant for a laparoscopic Roux-en-Y gastric bypass performed 2 years ago for class III obesity, resulting in a 45-kg (99-lb) weight loss. Her temperature is 37.8°C (100.0°F), pulse is 115/min, blood pressure is 108/68 mm Hg, and respirations are 18/min. Physical examination reveals an anxious patient in obvious distress. The abdomen is mildly distended with focal tenderness in the mid-abdomen, but there is no rebound tenderness or rigidity. Bowel sounds are high-pitched.

Laboratory results:
Leukocyte count: 14,500/mm³
Hemoglobin: 13.2 g/dL
Serum sodium: 138 mEq/L
Serum potassium: 3.6 mEq/L
Blood urea nitrogen: 24 mg/dL
Serum creatinine: 1.1 mg/dL
Serum lactate: 3.2 mmol/L (Normal: 0.5 - 2.2 mmol/L)

A computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast reveals dilated loops of small bowel with a transition point. The mesenteric vessels appear rotated around a central axis, and there is mild adjacent mesenteric edema. There is no free intraperitoneal air.

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

A $61$-year-old man with decompensated cirrhosis secondary to metabolic dysfunction-associated steatohepatitis (MASH) is evaluated in the progressive care unit for acute kidney injury. He was admitted four days prior for tense ascites, at which time he underwent an uncomplicated $6$-liter therapeutic paracentesis. Currently, he reports feeling fatigued but denies abdominal pain, fever, or shortness of breath. His daily urine output has declined to $350$ mL over the past $24$ hours. Spironolactone and furosemide were discontinued two days ago when an initial rise in creatinine was noted.

A urine culture collected on admission grew $>100,000$ CFU/mL of *Escherichia coli* pan-susceptible to all tested agents, and he has been receiving targeted oral amoxicillin.

Vital signs are temperature $37.1^\circ$ C ($98.8^\circ$ F), blood pressure $96/58$ mmHg, and pulse $86$/min. Physical examination reveals scleral icterus, a protuberant abdomen with a positive fluid wave, and bilateral pitting edema up to the mid-calves.

Laboratory findings:
Hemoglobin: $10.2$ g/dL
Leukocyte count: $6,800/\mu$ L
Serum sodium: $131$ mEq/L
Blood urea nitrogen: $68$ mg/dL
Serum creatinine: $2.8$ mg/dL (baseline at admission: $1.1$ mg/dL)
Urine sodium: $8$ mEq/L
Urinalysis: occasional hyaline casts, no red blood cells, negative for protein

A repeat diagnostic paracentesis performed this morning yields fluid with a total leukocyte count of $120/\mu$ L and $15\%$ neutrophils. An ultrasound of the kidneys shows normal cortical echogenicity without hydronephrosis. Over the preceding $24$ hours, the patient received a continuous infusion of intravenous isotonic crystalloid totaling $2.5$ liters, but his repeat serum creatinine today remains unchanged at $2.8$ mg/dL.

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

A 68-year-old woman is evaluated on postoperative day 4 following an elective open cholecystectomy. Her medical history includes heart failure with preserved ejection fraction, essential hypertension, and diet-controlled type 2 diabetes mellitus. A Foley catheter placed during surgery was removed on postoperative day 2.

Yesterday, she reported new-onset dysuria and urinary frequency. A urinalysis and urine culture were obtained.

Today, she reports a mild, non-productive cough but denies shortness of breath. She has developed a new fever. Her temperature is 38.6°C (101.5°F), blood pressure is 130/80 mm Hg, pulse is 88/min, and respiratory rate is 16/min. Oxygen saturation is 96% on room air.

Physical examination shows a comfortable patient. Lung auscultation reveals decreased breath sounds and mild crackles at the bases bilaterally, which clear completely after she takes a deep breath and coughs. The abdomen is soft, and the right subcostal incision is intact without erythema or discharge. There is mild suprapubic tenderness. Bilateral lower extremities exhibit no edema, erythema, or calf tenderness.

The urine culture from yesterday returns positive for >100,000 CFU/mL of *Escherichia coli*. Susceptibility testing shows the organism is sensitive to cephalexin, nitrofurantoin, and ceftriaxone, but resistant to ampicillin.

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

A 32-year-old man presents to the emergency department with a 4-week history of productive cough, occasional hemoptysis, low-grade fevers, and night sweats. He has experienced a 5-kg (11-lb) unintentional weight loss during this time. The patient immigrated to the United States from a region highly endemic for tuberculosis two months ago. His temperature is 37.8°C (100.0°F), blood pressure is 120/78 mm Hg, pulse is 88/min, and respiratory rate is 16/min. Physical examination reveals bronchial breath sounds and crackles in the right upper lung field. The clinical presentation is highly suspicious for active pulmonary tuberculosis. Arrange the following management steps in the most appropriate chronological order.