Tüm alıştırma soruları

A $52$-year-old man comes to the clinic reporting a $5$-month history of worsening fatigue, generalized weakness, and decreased libido. He has also been experiencing intermittent, dull headaches and occasional blurry vision, especially when driving. He does not take any medications. Vital signs are within normal limits. Physical examination reveals delayed relaxation phase of the deep tendon reflexes. Visual field testing by confrontation demonstrates decreased peripheral vision bilaterally.

Laboratory results are as follows:

Thyroid-stimulating hormone (TSH): $1.8$ $\mu$ U/mL (Normal: $0.4-4.2$ $\mu$ U/mL)
Free thyroxine (T4): $0.5$ ng/dL (Normal: $0.9-1.7$ ng/dL)
Testosterone, total: $140$ ng/dL (Normal: $300-1000$ ng/dL)
Luteinizing hormone (LH): $1.2$ mIU/mL (Normal: $1.5-9.3$ mIU/mL)

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

A 54-year-old male is currently hospitalized for a right lower lobe community-acquired pneumonia. On hospital day 4, he develops worsening pleuritic chest pain and a persistent fever of $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$). A repeat chest radiograph demonstrates a new, moderate-sized right pleural effusion. Over the subsequent two weeks, his pleural disease becomes increasingly complex, requiring a step-wise escalation of therapy. Arrange the following interventions in the correct chronological order of standard management for an evolving parapneumonic effusion, from initial evaluation to the definitive treatment of refractory multi-loculated empyema.

Following a severe pedestrian-vehicle collision, a young adult female is delivered to the trauma bay by paramedics. She was struck directly by a commercial truck that lost control on an icy road. On arrival, the patient is agitated, pale, and sweating profusely. The airway is clear, and bilateral breath sounds are symmetric and unlabored. Vital signs show a heart rate of 135/min and a blood pressure of 78/42 mm Hg, which remain unchanged after the rapid intravenous infusion of one liter of crystalloid solution. The abdomen is diffusely tender and mildly distended with a large ecchymosis across the periumbilical region. The pelvis is mechanically stable to anteroposterior and lateral compression. Which of the following is the most appropriate next step in management?

A $62$-year-old woman who has been mechanically ventilated for $6$ days due to severe acute respiratory distress syndrome (ARDS) following a viral infection develops a new fever of $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), leukocytosis, and increased purulent endotracheal secretions. A portable chest radiograph reveals a new right lower lobe alveolar infiltrate. The patient is hemodynamically stable. Arrange the following steps in the correct chronological order for the standard diagnostic and therapeutic management of suspected ventilator-associated pneumonia (VAP) in this patient.

A $29$-year-old primigravida at $30$ weeks gestation is brought to the emergency department due to rapidly progressive shortness of breath, palpitations, and hemoptysis that began $24$ hours ago. She reports a sense of overwhelming anxiety and impending doom. She has a history of bipolar I disorder, currently well-controlled on lamotrigine, and mild intermittent asthma since childhood. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $112/68$ mmHg, pulse is $135$ /min and irregularly irregular, and respiratory rate is $28$ /min. Oxygen saturation is $88\%$ on room air and improves to $94\%$ on supplemental oxygen.

Physical examination reveals prominent jugular venous pulsations with absent 'a' waves. Pulmonary auscultation reveals bilateral crackles up to the mid-scapulae with scattered expiratory wheezes. Cardiac auscultation reveals a loud first heart sound, a high-frequency sound in early diastole, and a low-pitched mid-diastolic sound best heard at the apex in the left lateral decubitus position.

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

Match each patient's clinical presentation of chronic diarrhea and malabsorption with the most likely corresponding diagnostic finding or histologic feature.

A 72-year-old retired teacher presents to the urgent care clinic with progressively worsening breathing difficulty over the past three days. He reports a sensation of chest tightness and a new cough that produces clear, frothy sputum. His medical history includes hypertension, coronary artery disease, and a 35-pack-year smoking history, though he quit five years ago. Over the last two nights, he has frequently awakened gasping for air and has resorted to sleeping upright in a recliner chair. His current home medications are aspirin, metoprolol, and lisinopril. Vital signs are temperature 36.8°C (98.2°F), blood pressure 168/94 mm Hg, pulse 110/min, and respiratory rate 24/min. Pulse oximetry is 88% on room air. Physical examination reveals prominent jugular venous distention. Lung auscultation demonstrates widespread expiratory wheezing and fine crackles extending to the mid-lung fields bilaterally. Cardiac examination reveals tachycardia with a regular rhythm and an extra low-frequency heart sound occurring just after S2. There is 2+ bilateral pitting edema extending to the mid-calf. Which of the following is the most appropriate initial pharmacologic management for this patient?

A 35-year-old man comes to the clinic due to a 3-week history of right upper quadrant abdominal pain, low-grade fevers, and a 4-kg (8.8-lb) weight loss. He returned from a 6-week backpacking trip across Southeast Asia one month ago. During his trip, he had a self-limited episode of bloody diarrhea that resolved after a few days without medical intervention. His temperature is 38.3°C (100.9°F), blood pressure is 120/80 mmHg, and pulse is 95/min. Physical examination reveals tenderness to palpation in the right upper quadrant and moderate hepatomegaly. Laboratory studies show a leukocyte count of 14,500/mm³ and an alkaline phosphatase level of 340 U/L. An abdominal ultrasound demonstrates a solitary, 6-cm, well-demarcated, hypoechoic mass in the right lobe of the liver. Enzyme-linked immunosorbent assay (ELISA) is positive for Entamoeba histolytica antibodies. Which of the following is the most appropriate next step in management?

Calcium and phosphorus homeostasis is tightly regulated by parathyroid hormone (PTH), vitamin D, and renal function. Disruptions in this balance yield distinct laboratory patterns. Match each of the following serum laboratory profiles to its most likely underlying pathophysiologic diagnosis.

Match each patient's clinical presentation with the most appropriate definitive or initial procedural management.

A 27-year-old man visits the emergency department complaining of sudden, intense shortness of breath and chest tightness that began one hour ago. He has a known history of mild persistent asthma but has not used his maintenance inhaler for the past month. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $138/82\text{ mmHg}$, pulse is $115/\text{min}$, and respiratory rate is $26/\text{min}$. Pulse oximetry shows an oxygen saturation of $93\%$ on room air. Physical examination reveals an anxious patient sitting upright. Diffuse expiratory wheezes are heard bilaterally with a prolonged expiratory phase. There is no lower extremity edema or jugular venous distention. A point-of-care arterial blood gas analysis on room air shows a pH of $7.50$, $\text{PaCO}_2$ of $27\text{ mmHg}$, and $\text{PaO}_2$ of $68\text{ mmHg}$. A portable chest radiograph displays hyperinflation of both lungs but no focal opacities. Which of the following is the most appropriate next step in the management of this patient?

A 66-year-old man is evaluated on postoperative day 2 following an elective open ventral hernia repair with mesh placement. The nursing staff notes that he has developed new-onset tachypnea and a low-grade fever. His medical history is significant for ischemic cardiomyopathy, chronic obstructive pulmonary disease, and tobacco use disorder. Vital signs include a temperature of 38.2°C (100.8°F), blood pressure of 132/84 mmHg, heart rate of 94/min, and respiratory rate of 22/min. Oxygen saturation is 93% on room air. Physical examination reveals decreased breath sounds at the bilateral lung bases. There are no pulmonary crackles, expiratory wheezing, or jugular venous distention. The abdominal dressing is clean, dry, and intact. Which of the following are the most appropriate next steps in management? (Select two)

Match the following specific clinical trauma and burn presentations with their most appropriate immediate next step in management.

A 65-year-old man presents to the emergency department with sudden-onset, severe, tearing chest pain that radiates to his back. His blood pressure is 190/110 mmHg in the right arm and 140/80 mmHg in the left arm. His heart rate is 112/min. A bedside chest radiograph shows a widened mediastinum. Suspecting an acute aortic dissection, arrange the following management steps in the most appropriate chronological order.

A 39-year-old woman is evaluated for progressive weight gain, proximal muscle weakness, and new-onset facial hair growth over the past year. Physical examination reveals central adiposity, facial plethora, a dorsocervical fat pad, and wide violaceous abdominal striae. Her blood pressure is 158/96 mm Hg. Initial screening with two separate 24-hour urine free cortisol measurements and an overnight low-dose dexamethasone suppression test confirm the diagnosis of endogenous hypercortisolism.

Arrange the following diagnostic steps in the most appropriate chronological sequence to determine the specific etiology of her condition. Assume each test is performed sequentially and its result dictates the necessity of the immediate next step in this patient's diagnostic pathway.

A 62-year-old man is evaluated on postoperative day 2 following an elective low anterior resection for rectal cancer. He reports severe, continuous pain at the abdominal incision site that has worsened over the past 6 hours and is disproportionate to his previous postoperative pain. His temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $88/58 \text{ mmHg}$, pulse is $122/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals significant edema and violaceous discoloration of the skin surrounding the midline incision. Removal of the dressing reveals a thin, grayish fluid leaking from the wound edges. Palpation around the incision elicits exquisite tenderness, though sensation to light touch is decreased near the wound margins. Which of the following is the most appropriate next step in the management of this patient?

A 58-year-old man with a history of type 2 diabetes mellitus is evaluated in the inpatient ward. He was admitted two days ago with a three-day history of high fever, chills, and severe right upper quadrant abdominal pain. At admission, his temperature was 39.4°C (102.9°F). A contrast-enhanced abdominal CT scan revealed a 6.5-cm fluid-filled collection with peripheral enhancement in the right hepatic lobe.

The patient underwent prompt ultrasound-guided percutaneous drain placement. Empiric antimicrobial therapy with intravenous piperacillin-tazobactam was initiated.

Currently, on hospital day 3, the patient reports significant symptomatic improvement. His temperature is 37.2°C (99.0°F), and his vital signs are stable. The percutaneous drain is producing minimal serosanguinous output.

Microbiology results for both blood and abscess fluid cultures have returned, as shown below:

Based on these results, which of the following is the most appropriate next step in the pharmacologic management of this patient?

Nurses urgently call the physician to evaluate a 62-year-old woman in the step-down unit due to progressive somnolence and respiratory distress. She was admitted 48 hours ago for community-acquired pneumonia and is currently receiving intravenous ceftriaxone and azithromycin. Temperature is 38.6°C (101.5°F), blood pressure is 85/54 mm Hg, pulse is 122/min, and respirations are 30/min. Pulse oximetry shows 89% on a 6 L/min simple face mask. Physical examination reveals a lethargic patient who only briefly opens her eyes to painful stimuli. She has marked intercostal retractions and diminished breath sounds with crackles at the right lung base.

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

A 65-year-old man is admitted to the cardiac intensive care unit following a myocardial infarction. While he is resting in bed, the telemetry monitor suddenly alarms, showing a wide-complex tachycardia at a rate of 180/min. The nurse rushes into the room and finds the patient completely unresponsive. Arrange the following critical next steps in the correct chronological sequence according to standard Advanced Cardiovascular Life Support (ACLS) protocols.

A 24-year-old man with a history of type 1 diabetes mellitus is evaluated in the intensive care unit. He was admitted 12 hours ago for the management of diabetic ketoacidosis. Initial therapy included a continuous intravenous regular insulin infusion and aggressive volume resuscitation with a total of 6 liters of 0.9% sodium chloride. He is now alert and reports feeling much better. Vital signs are temperature 37.0°C (98.6°F), blood pressure 118/76 mm Hg, heart rate 88/min, and respiratory rate 20/min.

Laboratory results are as follows:
Serum sodium: 142 mEq/L
Serum potassium: 4.1 mEq/L
Serum chloride: 112 mEq/L
Serum bicarbonate: 10 mEq/L
Blood glucose: 190 mg/dL

Arterial blood gas on room air:
pH: 7.26
PaCO2: 23 mm Hg
PaO2: 95 mm Hg

Which of the following best describes this patient's current acid-base status?