Tüm alıştırma soruları

A 28-year-old woman, gravida 1, para 0, at 28 weeks gestation is brought to the emergency department due to the sudden onset of severe shortness of breath, orthopnea, and a cough productive of pink, frothy sputum. She recently immigrated to the United States and has had limited prenatal care. Over the past month, she noticed progressive fatigue and palpitations, which she attributed to normal pregnancy. Temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $110/70\text{ mm Hg}$, heart rate is $142\text{/min}$ and irregularly irregular, and respiratory rate is $32\text{/min}$. Pulse oximetry is $86\%$ on room air. Jugular venous distension is prominent. Lung auscultation reveals diffuse bilateral crackles and prolonged expiratory wheezes. Cardiac auscultation demonstrates a loud S1, an early diastolic sound, and a low-pitched, mid-diastolic rumble best heard at the cardiac apex. Arterial blood gas analysis on room air reveals:

$\text{pH}$: $7.30$
$\text{pCO}_2$: $55\text{ mm Hg}$
$\text{pO}_2$: $55\text{ mm Hg}$
$\text{HCO}_3^-$: $26\text{ mEq/L}$

In addition to noninvasive positive pressure ventilation, which of the following is the most appropriate next step in pharmacologic management for this patient?

A $31$-year-old woman comes to the outpatient clinic due to profound fatigue, generalized weakness, and amenorrhea for the past six months. Ten months ago, she delivered a healthy neonate via vaginal delivery. Her delivery was complicated by severe postpartum hemorrhage requiring a massive transfusion protocol and a brief intensive care unit stay. Since the delivery, she has been unable to produce breast milk. Her current blood pressure is $94/58$ mm Hg, and her pulse is $58$/min. Physical examination shows delayed relaxation of deep tendon reflexes and loss of pubic hair.

Laboratory results are as follows:
Serum sodium: $133$ mEq/L
Serum potassium: $4.2$ mEq/L
Thyroid-stimulating hormone (TSH): $1.1$ $\mu$ U/mL (Normal: $0.4$–$4.0$ $\mu$ U/mL)
Free thyroxine (T4): $0.5$ ng/dL (Normal: $0.9$–$1.7$ ng/dL)

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

A 65-year-old man suddenly collapses while walking in the hospital hallway. A physician is the first to arrive and finds the patient unresponsive, with no normal breathing and no palpable carotid pulse. The physician immediately calls for help and requests a resuscitation cart. Arrange the following subsequent steps in the most appropriate chronological sequence for managing this patient's cardiac arrest, assuming the underlying rhythm is ventricular fibrillation.

Match each patient's clinical vignette with the most likely corresponding coagulation profile and mixing study result.

During morning rounds, a 74-year-old male patient is assessed for mild respiratory distress and a low-grade fever. He underwent a primary right total hip arthroplasty 48 hours ago. The patient has a medical history significant for hypertension, diet-controlled type 2 diabetes mellitus, and mild chronic obstructive pulmonary disease. He reports a new, mild cough producing scant white sputum, but denies chest pain, calf pain, or dysuria.

His temperature is 38.2°C (100.8°F), blood pressure is 146/84 mmHg, pulse is 94/min, and respiratory rate is 20/min. Pulse oximetry shows 93% on room air. Cardiac auscultation is unremarkable with no murmurs or gallops. Pulmonary examination reveals decreased breath sounds and fine crackles at both lung bases. The surgical incision is intact without drainage, and there is no lower extremity edema. A portable chest radiograph displays bilateral basilar linear opacities consistent with subsegmental atelectasis, without any focal consolidation or pleural effusion.

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

Match the following hereditary gastrointestinal polyposis and cancer syndromes with their defining genetic, clinical, or phenotypic characteristics.

A clinician is reviewing laboratory results for four different patients being evaluated for mineral and bone disorders. Match each laboratory profile with its most likely underlying pathophysiologic diagnosis.

A 38-year-old woman is evaluated in the emergency department for severe, progressive muscle weakness over the past two days. She reports feeling so weak today that she had difficulty standing up from a chair. Her medical history is significant for a 2-year history of dry eyes and dry mouth, for which she uses artificial tears and saliva substitutes. She takes no other medications. Her temperature is 37.0°C (98.6°F), blood pressure is 110/70 mmHg, pulse is 88/min, and respirations are 18/min. Physical examination reveals dry oral mucosa and 4/5 motor strength in the proximal muscles of the upper and lower extremities. Sensation and deep tendon reflexes are intact.

Based on these findings, which of the following is most likely to be found on further evaluation of this patient?

A $65$-year-old man with a $15$-year history of structuring Crohn's disease, chronic obstructive pulmonary disease (COPD), and heart failure with preserved ejection fraction is currently hospitalized. He was admitted two days ago with colicky abdominal pain, obstipation, and bilious vomiting due to a mechanical small bowel obstruction. Initial management included bowel rest, intravenous fluids, and nasogastric decompression.

Over the past four hours, the patient reports a sudden transition from intermittent colicky pain to severe, unremitting diffuse abdominal pain. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $88/54\text{ mm Hg}$, heart rate is $128/\text{min}$, and respiratory rate is $28/\text{min}$. Physical examination reveals a rigid, silent abdomen with exquisite diffuse rebound tenderness and involuntary guarding.

Blood cultures drawn upon admission are currently growing *Escherichia coli* that is susceptible to ceftriaxone, ciprofloxacin, and metronidazole, but resistant to ampicillin.

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

During the evening shift, a physician is called to review the status of a $45$-year-old female admitted two days ago with a partial small bowel obstruction following a recent laparoscopic hysterectomy. Her initial management included intravenous fluids and continuous nasogastric suction. Recently, she reports a rapid exacerbation of her abdominal pain, which has become unremitting and localized. Vital signs indicate a temperature of $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure of $85/50 \text{ mmHg}$, heart rate of $130/\text{min}$, and respiratory rate of $28/\text{min}$. Physical examination reveals a markedly distended abdomen with diffuse rigidity and severe rebound tenderness. Recent laboratory analysis displays a leukocyte count of $21,000/\text{mm}^3$ and a serum lactate of $6.2 \text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical vignette describing a patient with a normal anion gap metabolic acidosis to the most likely corresponding serum and urine laboratory profile.

A 19-year-old college student is brought to the emergency department by his roommates. They report that he ingested a large amount of a sweet-tasting, brightly colored liquid he found in a garage, believing it was a sports drink. On presentation, he is disoriented and slurring his words. His blood pressure is 120/75 mm Hg and his pulse is 100/min.

Laboratory studies:
- Serum sodium: 142 mEq/L
- Serum chloride: 105 mEq/L
- Serum bicarbonate: 14 mEq/L
- Blood urea nitrogen: 14 mg/dL
- Blood glucose: 90 mg/dL
- Measured serum osmolality: 345 mOsm/kg $H_2O$

What is this patient's serum osmolar gap in mOsm/kg $H_2O$?

A $34$-year-old woman presents to the clinic with a $6$-month history of worsening fatigue, cold intolerance, and constipation. She also reports frequent dizziness upon standing, intermittent nausea, and a $4$-kg ($8.8$-lb) weight loss. Her medical history is notable for a complicated vaginal delivery $2$ years ago that was followed by massive postpartum hemorrhage requiring multiple blood transfusions. She has been amenorrheic since the delivery and was unable to lactate.

Her blood pressure is $102/68$ mm Hg while supine and $84/56$ mm Hg while standing. Her heart rate is $82$/min. Physical examination shows delayed relaxation of deep tendon reflexes and loss of pubic and axillary hair.

Laboratory results are as follows:

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

A 29-year-old man comes to the clinic for a follow-up examination. Over the past 4 months, he has experienced profound fatigue, cold intolerance, a 6-kg (13.2-lb) weight gain, and decreased libido. Eight months ago, he was involved in a severe motorcycle collision that resulted in a traumatic brain injury. He spent 3 weeks in the intensive care unit but has since been participating in a physical rehabilitation program. His current medications include ibuprofen as needed for occasional headache. Blood pressure is 106/68 mm Hg and pulse is 56/min. Physical examination reveals dry skin, loss of axillary and pubic hair, and a delayed relaxation phase of the deep tendon reflexes. Laboratory studies show:

Which of the following is the most likely explanation for this patient's clinical and laboratory findings?

A 52-year-old man presents to the emergency department with a 48-hour history of severe, colicky abdominal pain accompanied by nausea and multiple episodes of bilious vomiting. He reports no passage of flatus or stool for the past 24 hours. His surgical history is significant for an open appendectomy performed 15 years ago. On initial evaluation, his temperature is 37.1°C (98.8°F), heart rate is 88/min, blood pressure is 130/80 mm Hg, and respiratory rate is 16/min. The abdomen is markedly distended and tympanic, with high-pitched, tinkling bowel sounds and mild diffuse tenderness, but no rebound tenderness or guarding.

Arrange the following interventions in the correct sequential order for the management of this patient, from initial presentation to ultimate definitive care.

Match the following clinical presentations and corresponding high-resolution manometry (HRM) metrics to the most appropriate esophageal motility disorder.

Following treatment for a newly diagnosed deep venous thrombosis, a $45$-year-old woman develops severe, worsening pain over her abdomen and left thigh. She sought care at an urgent care clinic $3$ days prior for left leg swelling and was immediately prescribed oral warfarin monotherapy. Her past medical history is significant for obesity and type $2$ diabetes mellitus. Current medications include metformin and warfarin. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $134/82\text{ mmHg}$, and pulse is $88/\text{min}$. Physical examination reveals well-demarcated, exquisitely tender, purpuric lesions with central black eschars over her abdomen and thighs. The remainder of the examination is unremarkable. Laboratory studies show:

Hemoglobin: $13.2\text{ g/dL}$
Platelets: $210,000/\text{mm}^3$
Leukocytes: $7,500/\text{mm}^3$
Prothrombin time: $24\text{ seconds}$ (INR: $2.2$)
Activated partial thromboplastin time: $32\text{ seconds}$

Which of the following is the most likely underlying mechanism for this patient's current skin findings?

Match each valvular heart disease with its most characteristic auscultatory physical exam finding.

A physician is evaluating four patients who present with pronounced polyuria and polydipsia. Match each patient's clinical vignette with the most likely corresponding laboratory profile observed during a diagnostic water deprivation test and subsequent administration of exogenous desmopressin.

A $48$-year-old man presents for a follow-up visit regarding his hypertension. He is currently taking maximum tolerated doses of lisinopril, amlodipine, and hydrochlorothiazide. His blood pressure is $168/102$ mmHg. Laboratory studies reveal a serum sodium of $143$ mEq/L and a serum potassium of $2.8$ mEq/L. The patient is suspected to have a secondary cause of hypertension. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for the evaluation and definitive management of this patient's suspected condition.