Tüm alıştırma soruları

Match each central hemodynamic profile obtained via pulmonary artery (Swan-Ganz) catheterization to its most likely underlying pathophysiological etiology.

A 71-year-old man is brought to the emergency department by his wife due to progressively worsening shortness of breath and a persistent, dry cough over the past 48 hours. He states that the breathlessness is most severe when he lies down, forcing him to sleep in a recliner chair. His medical history includes hypertension, osteoarthritis, and severe chronic obstructive pulmonary disease (COPD) for which he uses a daily tiotropium inhaler. Two weeks ago, he was prescribed daily high-dose naproxen for severe bilateral knee pain. His temperature is 37.1°C (98.8°F), blood pressure is 172/96 mmHg, pulse is 112/min, and respirations are 26/min. Pulse oximetry shows 88% on room air. Physical examination reveals a patient in moderate respiratory distress using accessory muscles of respiration. Lung auscultation demonstrates diffuse, high-pitched expiratory wheezes and a prolonged expiratory phase. Cardiac auscultation reveals a regular tachycardia without murmurs; no extra heart sounds are audible. Jugular venous pressure is estimated at 12 cm H2O. Chest radiography reveals baseline hyperinflation with new, bilateral, hazy interstitial opacities and thickening of the interlobular septa. Arterial blood gas on room air shows a pH of 7.47, PaCO2 of 32 mmHg, and PaO2 of 56 mmHg. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

Match each set of laboratory findings from the evaluation of the hypothalamic-pituitary-adrenal (HPA) axis to the most likely underlying pathophysiologic diagnosis.

A $58$-year-old man presents to the oncology clinic complaining of worsening fatigue, generalized weakness, and cold intolerance for the past month. He also reports intermittent nausea and a $3$-kg ($6.6$-lb) weight loss during this time. The patient has a history of advanced renal cell carcinoma, for which he has been receiving nivolumab therapy for the past six months. Blood pressure is $96/60$ mm Hg, and pulse is $54$/min. Physical examination reveals dry skin and a delayed relaxation phase of the deep tendon reflexes.

Laboratory studies show:
Thyroid-stimulating hormone (TSH): $1.1$ $\mu$ U/mL (Normal: $0.5 - 5.0$ $\mu$ U/mL)
Free thyroxine (T4): $0.4$ ng/dL (Normal: $0.9 - 2.4$ ng/dL)
Sodium: $131$ mEq/L
Potassium: $4.1$ mEq/L

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

Determine the most appropriate definitive surgical or procedural management for each of the following gastrointestinal and colorectal pathologies.

Emergency medical services transport a 41-year-old male to the hospital after his spouse discovered him unresponsive in their garage. Beside him was an open, partially consumed jug of automotive antifreeze. Upon arrival, vital signs demonstrate a temperature of 36.5°C (97.7°F), blood pressure of 105/65 mm Hg, heart rate of 92/min, and a depressed respiratory rate of 10/min. The physical examination is notable for profound lethargy, with the patient only groaning in response to painful stimuli.

Initial laboratory evaluation reveals the following:

Which of the following best characterizes this patient's underlying acid-base disorder?

A 25-year-old man presents to the clinic complaining of abdominal cramping and diarrhea that began 4 days ago. He reports that the diarrhea was initially watery but has become frankly bloody over the past 24 hours. He does not recall having a fever. Five days prior to symptom onset, he attended a neighborhood barbecue where he consumed hamburgers. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, and heart rate is $88/\text{min}$. Abdominal examination reveals hyperactive bowel sounds and diffuse, mild tenderness without guarding or rebound. Laboratory studies show a leukocyte count of $10,500/\text{mm}^3$, hemoglobin of $14.2\text{ g/dL}$, platelet count of $220,000/\text{mm}^3$, and serum creatinine of $0.9\text{ mg/dL}$. Rapid stool enzyme immunoassay is positive for Shiga toxin. Which of the following is the most appropriate next step in management?

A 58-year-old man is found unresponsive on the floor of his hospital room. He has no palpable pulse and is not breathing. The emergency response team arrives with a crash cart. Arrange the following actions in the correct sequential order for managing this patient's cardiac arrest, assuming the initial rhythm identified on the monitor is ventricular fibrillation.

A 49-year-old man with a history of untreated hepatitis B viral infection and known hepatic cirrhosis is brought to the emergency department via ambulance due to the abrupt onset of excruciating, diffuse abdominal pain that began 4 hours ago. He is lethargic and confused. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $72/45\text{ mmHg}$, pulse is $130/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows $92\%$ on room air. Physical examination reveals a markedly distended abdomen with board-like rigidity, severe diffuse tenderness, and rebound tenderness. Bowel sounds are absent. Skin examination shows numerous spider telangiectasias. Laboratory studies reveal a leukocyte count of $18,500/\text{mm}^3$, hemoglobin of $10.8\text{ g/dL}$, platelet count of $72,000/\text{mm}^3$, and creatinine of $2.4\text{ mg/dL}$. Arterial blood gas on room air shows a pH of $7.22$, pCO2 of $30\text{ mmHg}$, and pO2 of $68\text{ mmHg}$. A bedside diagnostic paracentesis yields cloudy ascitic fluid with a leukocyte count of $8,200/\text{mm}^3$ ($90\%$ neutrophils), total protein of $2.8\text{ g/dL}$, glucose of $22\text{ mg/dL}$, and lactate dehydrogenase (LDH) of $640\text{ U/L}$ (Serum LDH upper limit: $220\text{ U/L}$). Gram stain shows many polymorphonuclear leukocytes, abundant gram-negative bacilli, and gram-positive cocci. Which of the following is the most appropriate next step in management?

During a clinical skills workshop, a group of medical students is reviewing characteristic peripheral pulse findings in various cardiovascular disorders. Match each described arterial pulse abnormality with the underlying cardiac pathology it most classically represents.

Emergency medical services bring a 31-year-old female equestrian to the trauma center after her horse tripped and rolled over her torso during a jumping event. The patient is pale, diaphoretic, and lethargic. Vital signs are temperature 36.8°C (98.2°F), blood pressure 82/45 mm Hg, pulse 128/min, and respirations 22/min. Pulse oximetry shows 96% on high-flow oxygen. Primary survey reveals a patent airway and equal bilateral breath sounds. The abdomen is markedly distended with diffuse guarding and rebound tenderness. Bedside ultrasound evaluation of the abdomen demonstrates a significant amount of anechoic fluid in Morison pouch. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old man with a 40-pack-year smoking history presents to the emergency department with a 2-week history of progressive facial swelling, a dry cough, and a feeling of "fullness" in his head that worsens when he leans forward. On physical examination, his temperature is 37.1°C (98.8°F), blood pressure is 134/82 mmHg, heart rate is 98/min, and respiratory rate is 18/min. Oxygen saturation is 96% on room air. He has plethora of the face and marked distension of the jugular veins that do not collapse with inspiration. The patient is conversant, has no stridor, and is in no acute respiratory distress. Arrange the following steps in the most appropriate chronological order for the management of this patient's condition.

During morning rounds, the surgical team examines a 41-year-old male patient who underwent an emergency appendectomy for a perforated appendix six days ago. Over the last 24 hours, he has developed lower abdominal discomfort, tenesmus, and the passage of several small-volume, loose stools. His temperature is $38.9^\circ\text{C}$ ($102^\circ\text{F}$), blood pressure is 118/76 mmHg, pulse is 105/min, and respirations are 18/min. Cardiopulmonary examination is unremarkable. The midline abdominal incision is clean, dry, and intact with no surrounding erythema, fluctuance, or induration. Deep palpation of the lower abdomen elicits moderate tenderness, but no rebound or guarding is appreciated. Digital rectal examination reveals a markedly tender, boggy mass positioned anteriorly. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$. Which of the following is the most appropriate next step in the management of this patient?

A $72$-year-old woman is evaluated in the intensive care unit for sudden clinical deterioration. She was admitted $10$ days ago for a severe chronic obstructive pulmonary disease exacerbation, which was treated with systemic glucocorticoids and levofloxacin. Three days ago, she developed profuse, watery diarrhea. This morning, her diarrhea abruptly ceased, but she became increasingly lethargic and developed severe abdominal pain. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), pulse is $132\text{/min}$, blood pressure is $78/45\text{ mm Hg}$, and respirations are $24\text{/min}$. Physical examination reveals a lethargic patient. The abdomen is markedly distended and tympanic with absent bowel sounds. Diffuse rigidity, guarding, and rebound tenderness are present.

Laboratory studies show:
Leukocyte count: $38,000/\text{mm}^3$ ($90\%$ neutrophils, $5\%$ bands)
Serum lactate: $5.2\text{ mmol/L}$

Arterial blood gas (room air):
pH: $7.22$
$\text{PaCO}_2$: $30\text{ mm Hg}$
$\text{HCO}_3^-$: $12\text{ mEq/L}$

An upright chest and abdominal radiograph demonstrates a $10\text{-cm}$ dilation of the transverse colon, loss of colonic haustrations, and a prominent crescent of radiolucency beneath the right hemidiaphragm.

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

Match each classic valvular abnormality to its most characteristic physical examination finding on cardiac auscultation.

A 62-year-old male is brought to the emergency department by his family due to a severe headache, confusion, and a high fever that began 18 hours ago. His temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $138/82\text{ mmHg}$, heart rate is $112\text{/min}$, and respiratory rate is $20\text{/min}$. Physical examination reveals nuchal rigidity and a positive Brudzinski sign. Neurologic examination is notable for a left-sided hemiparesis and bilateral papilledema on fundoscopy. The physician suspects acute bacterial meningitis and prepares to manage the patient.

Arrange the following management steps in the most appropriate chronological sequence for this patient.

Match each clinical presentation with its most likely corresponding arterial blood gas and serum electrolyte panel.

A 62-year-old male with a history of chronic obstructive pulmonary disease and ischemic heart disease is brought to the trauma center after being struck by a forklift. He is lethargic and complains of severe abdominal pain. Vital signs show a temperature of $36.5^\circ$ C ($97.7^\circ$ F), a blood pressure of $76/40$ mm Hg, a pulse of $128$/min, and a respiratory rate of $26$/min. Examination reveals large ecchymoses over the left lower ribs and severe diffuse abdominal tenderness with involuntary guarding. A focused assessment with sonography for trauma (FAST) demonstrates a substantial anechoic fluid collection in the splenorenal recess. A portable chest radiograph shows fractures of the left eighth, ninth, and tenth ribs with no pneumothorax. Which of the following is the most appropriate next step in the management of this patient?

Helicopter transport arrives at a regional burn center carrying a 30-year-old female who was trapped in a residential fire. She currently weighs $70\text{ kg}$. The injury occurred exactly $2\text{ hours}$ prior to her arrival. Physical examination reveals full-thickness burns involving her entire anterior trunk, her entire right lower extremity, and her entire left upper extremity. The trauma team confirms this accounts for exactly $45\%$ of her total body surface area (TBSA). Large-bore intravenous access is established. Utilizing the classic Parkland formula ($4\text{ mL/kg/\%TBSA}$), what is the targeted fluid administration rate in $\text{mL/hr}$ for the remainder of the first 8-hour post-burn period?

A 67-year-old male with a 40-pack-year smoking history and known chronic obstructive pulmonary disease (COPD) presents to the emergency department reporting three days of progressively worsening shortness of breath. He also notes increased cough frequency and a change in his sputum from clear to thick, yellow-green. He denies orthopnea, paroxysmal nocturnal dyspnea, and lower extremity swelling. Vital signs include a temperature of 37.1 C (98.8 F), heart rate of 102/min, respiratory rate of 24/min, blood pressure of 134/82 mmHg, and oxygen saturation of 90% on room air. Chest auscultation reveals diffuse expiratory wheezing with prolonged expiration, but no crackles. A chest radiograph demonstrates hyperinflation without focal consolidation, pleural effusion, or pulmonary edema. Which of the following are appropriate initial pharmacologic interventions for this patient? (Select exactly 3)