Tüm alıştırma soruları

Match each high-resolution esophageal manometry (HRM) profile to its corresponding pathophysiologic diagnosis according to the Chicago Classification.

An elderly resident of a skilled nursing facility is transferred to the intensive care unit following the sudden onset of high-volume, painless hematochezia. Initial assessment reveals profound hypotension (blood pressure $78/48 \text{ mm Hg}$) and marked tachycardia (heart rate $128/\text{min}$). Following aggressive intravenous volume expansion with isotonic crystalloids and transfusion of uncrossmatched type O-negative packed red blood cells, the patient's hemodynamic status normalizes. However, the passage of copious maroon-colored stool continues.

Arrange the following diagnostic and therapeutic interventions in the correct algorithmic sequence according to current clinical guidelines for the management of severe hematochezia.

Assume that each successive diagnostic step fails to isolate the source, subsequent non-invasive imaging successfully localizes the lesion but endovascular techniques fail to achieve definitive hemostasis, and open surgical rescue is ultimately mandated.

A 48-year-old man is evaluated for resistant hypertension and muscle cramps. He currently takes maximum tolerated doses of amlodipine, lisinopril, and chlorthalidone. His blood pressure is 168/104 mmHg. Laboratory evaluation reveals a serum potassium of 2.8 mEq/L and a serum sodium of 145 mEq/L. A secondary cause of hypertension is suspected. Assuming the patient's condition is ultimately driven by a unilateral aldosterone-producing adenoma, arrange the following steps in the correct chronological sequence required for the definitive diagnosis and management of this condition.

An inpatient ward physician is paged regarding a $54$-year-old individual with a history of alcohol-related cirrhosis who has developed a new-onset fever. The patient was admitted the previous day for therapeutic drainage of large-volume ascites. Assessment reveals a temperature of $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$). The abdomen is visibly distended, demonstrating shifting dullness and diffuse tenderness upon palpation, though no rebound guarding is present. A timely diagnostic paracentesis yields ascitic fluid with an absolute neutrophil count of $520/\text{mm}^3$. Ascitic fluid and blood cultures are pending. Which of the following is the most appropriate next step in management?

A $59$-year-old man is evaluated in the post-anesthesia care unit $8$ hours after an elective bilateral laparoscopic inguinal hernia repair. He reports significant lower abdominal pressure and a distressing inability to urinate since the procedure. During the surgery, he received intravenous fluid resuscitation and general anesthesia. His postoperative pain is currently being managed with intravenous hydromorphone. Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $135/85$ mm Hg, pulse $88$/min, and respirations $14$/min. Physical examination reveals a palpable, tender mass in the suprapubic region. Arrange the following steps in the most appropriate chronological sequence for the management of this patient's condition, starting with the immediate next step.

Match each patient's clinical presentation with the most likely corresponding finding on a peripheral blood smear.

An evaluation is requested for a $45$-year-old woman suffering from resistant hypertension. Her current daily medication regimen includes maximal tolerated doses of amlodipine, valsartan, and hydrochlorothiazide. In the clinic, her blood pressure is persistently elevated at $172/104\text{ mm Hg}$, with a heart rate of $78\text{ /min}$. A basic metabolic panel reveals a serum potassium concentration of $2.8\text{ mEq/L}$. The physician suspects primary hyperaldosteronism as the underlying etiology. Arrange the following clinical steps in the most appropriate chronological sequence for the definitive workup and management of this patient.

A 72-year-old man with a long-standing history of tobacco use disorder, emphysema, and ischemic cardiomyopathy presents to the emergency department complaining of acutely worsening shortness of breath for the past 24 hours. He appears visibly distressed and is leaning forward in the tripod position. Vital signs show a temperature of 37.2°C (99.0°F), blood pressure of 145/88 mm Hg, pulse of 105/min, and respiratory rate of 28/min. Pulse oximetry reveals an oxygen saturation of 88% on room air. Physical examination demonstrates diffuse expiratory wheezing bilaterally, but auscultation of the heart sounds is difficult due to the noisy lung fields. The patient has mild bilateral pitting edema at the ankles, which he states is chronic. Given the overlapping clinical features of his comorbidities, which of the following laboratory tests is most useful to rapidly determine whether his acute presentation is primarily driven by decompensated heart failure rather than a pulmonary exacerbation?

A 68-year-old man is brought to the emergency department due to acute-onset, severe shortness of breath. He reports a dry cough and diffuse wheezing that began 2 hours prior to arrival. His medical background includes severe chronic obstructive pulmonary disease (COPD), essential hypertension, and a previous anterior myocardial infarction. At home, he used his albuterol inhaler three times with no improvement. Vital signs include a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $178/104\text{ mm Hg}$, heart rate of $114/\text{min}$, and respiratory rate of $28/\text{min}$. Pulse oximetry reveals an oxygen saturation of $86\%$ on room air. Physical examination shows a diaphoretic man in a tripod position, utilizing accessory muscles of respiration. The jugular venous pressure is visually elevated to $11\text{ cm H}_2\text{O}$. Cardiac auscultation reveals a regular tachycardia with a prominent early diastolic extra heart sound. Lung auscultation demonstrates bilateral expiratory wheezing; notably, no crackles are auscultated. A chest radiograph reveals hyperinflated lung fields, an enlarged cardiac silhouette, and cephalization of the pulmonary vasculature, without any focal consolidation. The patient is immediately initiated on noninvasive positive pressure ventilation (NIPPV). Over the next 15 minutes, his work of breathing and oxygen saturation improve significantly. Which of the following mechanisms best explains the primary physiological basis for this patient's rapid clinical improvement?

A $28$-year-old man is brought to the emergency department by ambulance after being struck by a motor vehicle while crossing the street. On arrival, he is moaning in pain. His temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), pulse is $132/\text{min}$, respirations are $22/\text{min}$, and blood pressure is $78/40\text{ mm Hg}$. Pulse oximetry shows $97\%$ on room air. The patient's airway is patent, and breath sounds are equal bilaterally. A rigid cervical collar is in place. Physical examination reveals ecchymosis over the lower abdomen and perineum, as well as blood at the urethral meatus. Gentle anteroposterior compression of the iliac crests reveals mechanical instability of the pelvis. Intravenous access is established, and a massive transfusion protocol is initiated. A pelvic binder is applied in the emergency department, but the patient's blood pressure remains $80/42\text{ mm Hg}$. A focused assessment with sonography for trauma (FAST) examination shows no free fluid in the pericardial, perihepatic, perisplenic, or pelvic spaces. Which of the following is the most appropriate next step in management?

A 76-year-old woman is admitted to the intensive care unit with severe, poorly localized abdominal pain out of proportion to physical examination findings, accompanied by bloody diarrhea. Her medical history is significant for atrial fibrillation. She is hypotensive and tachycardic. Laboratory testing reveals a serum lactate of $8.5$ mmol/L. Arterial blood gas and basic metabolic panel results are as follows:

The physician determines that the patient has a primary high anion gap metabolic acidosis secondary to suspected acute mesenteric ischemia. According to Winter's formula, what is the exact calculated midpoint of the target expected arterial $pCO_2$ (in mmHg) representing appropriate respiratory compensation?

A 62-year-old postmenopausal woman is found to have an incidental elevated serum total calcium of 11.4 mg/dL during a routine health maintenance examination. She has no history of nephrolithiasis, bone pain, or abdominal discomfort. Assuming her clinical evaluation ultimately leads to a diagnosis of primary hyperparathyroidism requiring surgical intervention, arrange the following clinical steps in the most appropriate chronological sequence for her workup and management.

A 40-year-old man is brought to the emergency department after being rescued from a house fire. He has full-thickness burns involving his entire anterior chest, abdomen, and both upper extremities (approximately 36% total body surface area). He is awake but agitated. On primary survey, he has singed nasal hairs, a hoarse voice, and carbonaceous sputum. Vital signs are temperature 37.0°C (98.6°F), blood pressure 110/70 mmHg, heart rate 115/min, and respiratory rate 24/min. Arrange the following management steps in the optimal chronological order according to standard Advanced Trauma Life Support (ATLS) and burn protocols.

A 38-year-old man seeks evaluation at an outpatient clinic for a four-month history of unremitting, voluminous watery diarrhea accompanied by a $12 \text{ kg}$ weight loss, intermittent low-grade fevers, and diffuse abdominal cramping. He has a history of advanced human immunodeficiency virus (HIV) infection but discontinued his antiretroviral therapy two years ago due to medication fatigue. His last known CD4+ T-lymphocyte count was $35/\text{mm}^3$. Vital signs show a temperature of $37.9^\circ\text{C}$, blood pressure of $105/65 \text{ mm Hg}$, and heart rate of $98/\text{min}$. Physical examination is notable for temporal wasting and mild, diffuse abdominal tenderness without rebound or guarding. Laboratory studies reveal a mild normocytic anemia and an elevated serum alkaline phosphatase level. Stool studies are negative for ova, parasites, and *Clostridioides difficile* toxin. An esophagogastroduodenoscopy (EGD) is performed. Biopsy of the descending duodenum reveals blunted villi and a dense infiltration of the lamina propria with enlarged, foamy macrophages. These macrophages stain strongly positive with periodic acid-Schiff (PAS). An acid-fast bacillus (AFB) stain of the tissue is subsequently performed and is positive. Based on these findings, which of the following is the most appropriate targeted pharmacotherapy for this patient's gastrointestinal condition?

A 58-year-old man is evaluated in the hospital on the third day of his admission for acute pyelonephritis. He originally presented with right flank pain, chills, and dysuria. At the time of admission, his temperature was $39.2^\circ \text{C}$ ($102.6^\circ \text{F}$), heart rate was $110/\text{min}$, and blood pressure was $105/65 \text{ mmHg}$. He was empirically started on intravenous piperacillin-tazobactam.

Today, the patient reports significant improvement in his symptoms. His flank pain has resolved, and he has been afebrile for the past 24 hours. Current vital signs are temperature $37.1^\circ \text{C}$ ($98.8^\circ \text{F}$), heart rate $82/\text{min}$, and blood pressure $122/78 \text{ mmHg}$. He is tolerating a regular diet.

Blood cultures drawn on admission show no growth. Urine cultures from admission grow $>100,000 \text{ CFU/mL}$ of *Escherichia coli*. Antimicrobial susceptibility testing results are as follows:

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

Match each clinical and diagnostic presentation to the most likely hepatic or biliary disorder.

An emergency response team brings a 54-year-old male to the resuscitation bay after he experienced sudden, crushing central chest pain while working in his garden. The pain radiates to his jaw and is accompanied by profuse sweating. En route to the hospital, the transport personnel administered 325 mg of chewable aspirin and one dose of sublingual nitroglycerin. Shortly after receiving the nitroglycerin, the patient developed profound lightheadedness.

Currently, his blood pressure is 78/48 mmHg, and his pulse is 52/min. His respiratory rate is 16/min, and oxygen saturation is 96% on room air.

Physical examination reveals clear lung fields bilaterally. The jugular veins are markedly distended while the patient is positioned at a 45-degree angle.

A 12-lead electrocardiogram demonstrates 3-mm ST-segment elevations in leads II, III, and aVF, as well as ST-segment depressions in leads I and aVL.

Which of the following is the most appropriate initial step to manage this patient's hemodynamic instability?

A 45-year-old man is brought to the emergency department after being ejected from a vehicle during a high-speed rollover collision. On arrival, he is unresponsive. His blood pressure is 65/40 mm Hg, heart rate is 142/min, and respiratory rate is 8/min. Examination reveals active, pulsatile arterial bleeding from a severe crush injury to the right thigh. The patient has snoring respirations and significant maxillofacial trauma. Breath sounds are markedly decreased over the left hemithorax, and the trachea is deviated to the right. The pelvis is mechanically unstable on physical examination. Arrange the following steps in the most appropriate chronological sequence of management according to current Advanced Trauma Life Support (ATLS) principles.

A 68-year-old woman is evaluated on the surgical ward on postoperative day 4 following an elective right total knee arthroplasty. She reports new-onset shortness of breath and a mild, nonproductive cough that began this morning. Her medical history is significant for hypertension, heart failure with preserved ejection fraction, and osteoarthritis. Vital signs include a temperature of 37.9°C (100.2°F), blood pressure of 158/92 mmHg, heart rate of 104/min, respiratory rate of 22/min, and oxygen saturation of 91% on room air. Physical examination reveals prominent jugular venous distention when seated at a 45-degree angle. Pulmonary auscultation demonstrates bilateral crackles at the lung bases. Cardiac examination shows a regular tachycardia with a present S4 gallop, but no murmurs. The right knee surgical dressing is clean, and the incision shows mild erythema without purulent drainage, consistent with normal wound healing. Bilateral lower extremities exhibit 1+ pitting edema. A portable chest radiograph is obtained and demonstrates bilateral perihilar alveolar opacities, prominent pulmonary vasculature, and trace pleural effusions without focal consolidation.

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

Match the following Hepatitis B serologic profiles obtained during routine screening or acute evaluation to their most accurate clinical interpretation.