Tüm alıştırma soruları

Paramedics deliver a 68-year-old nursing home resident to the acute care bay after staff found him profoundly lethargic amid multiple episodes of bilious emesis over the preceding 48 hours. Medical history is significant for heart failure with preserved ejection fraction, severe osteoarthritis, and recently diagnosed type 2 diabetes mellitus. On initial assessment, he is obtunded but protects his airway.

Assuming a normal reference anion gap of 12 mEq/L and a normal reference serum bicarbonate of 24 mEq/L, what is this patient's delta ratio ($\Delta AG / \Delta HCO_3^-$)?

A $62$-year-old man comes to the clinic for a routine follow-up. Eight weeks ago, he was hospitalized for new-onset atrial fibrillation and was successfully converted to normal sinus rhythm. He was discharged on a regimen of amiodarone and apixaban. Today, the patient reports feeling well with no palpitations, shortness of breath, heat intolerance, weight changes, fatigue, or constipation. His pulse is $68$/min and regular, and his blood pressure is $124/78$ mm Hg. Physical examination shows a normal-sized, non-tender thyroid gland with no palpable nodules. There is no resting tremor.

Laboratory studies show the following:
Thyroid-stimulating hormone (TSH): $7.8$ $\mu$ U/mL (Normal: $0.5-5.0$ $\mu$ U/mL)
Free thyroxine (T4): $2.1$ ng/dL (Normal: $0.9-1.7$ ng/dL)
Free triiodothyronine (T3): $1.6$ pg/mL (Normal: $2.3-4.1$ pg/mL)

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

A $28$-year-old man comes to the clinic with a $5$-day history of right knee pain and swelling, accompanied by bilateral eye redness and a burning sensation during urination. He has a medical history of major depressive disorder, for which he takes daily fluoxetine. Four weeks ago, he traveled to Southeast Asia and experienced a self-limited episode of severe watery diarrhea. His temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $122/78\text{ mm Hg}$, and pulse is $88/\text{min}$. Physical examination shows bilateral conjunctival injection with no purulent discharge. The right knee is markedly swollen, warm, and tender to palpation. There is also tenderness over the posterior aspect of the left heel. Arthrocentesis of the right knee yields yellow, translucent synovial fluid with a leukocyte count of $15,000/\text{mm}^3$ ($50\%$ neutrophils). Gram stain and cultures of the synovial fluid are negative. Polarized light microscopy reveals no crystals.

Laboratory studies show:
Leukocyte count: $11,500/\text{mm}^3$
Hemoglobin: $13.8\text{ g/dL}$
Thyroid-stimulating hormone (TSH): $0.3\text{ \mu U/mL}$ (N: $0.5$–$5.0\text{ \mu U/mL}$)
Free T4: $0.7\text{ ng/dL}$ (N: $0.9$–$1.7\text{ ng/dL}$)

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

Routine rounding in the normal newborn nursery involves the examination of a 48-hour-old full-term neonate. The pregnancy was uncomplicated, and maternal group B Streptococcus screening was negative. The neonate is feeding well and has not had any documented fevers. However, the parents are highly anxious about a new, widespread skin eruption that appeared earlier this morning. Physical examination reveals multiple 2- to 3-mm pale yellow pustules surrounded by a prominent erythematous base, distributed over the chest, abdomen, and proximal extremities. The palms and soles are completely spared. Vital signs, including temperature, are within normal physiological limits for age. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation in a patient with advanced HIV infection to the most likely central nervous system etiology.

Match each clinical presentation of a zoonotic or vector-borne infectious disease with the most appropriate targeted antimicrobial therapy.

A 32-year-old G3P3 woman experiences severe vaginal bleeding immediately following the vaginal delivery of a 4,300 g neonate. Her pulse is 122/min, and blood pressure is 85/50 mm Hg. Abdominal examination reveals a soft, poorly contracted uterus palpated above the umbilicus. Two large-bore intravenous lines are placed, and fluid resuscitation is initiated.

Arrange the following management steps for this patient's condition in the correct sequential order, from the most appropriate initial intervention to the definitive final procedure for refractory hemorrhage.

A medical student on a psychiatry clerkship is reviewing the adverse effect profiles of commonly prescribed psychiatric medications. Match each of the following psychotropic medications to the clinical vignette that best describes its characteristic adverse effect or toxicity.

Match each clinical presentation of pneumonia or febrile respiratory illness to its most likely causative pathogen based on the provided epidemiological clues and distinct clinical findings.

During morning rounds in the intensive care unit, the medical team evaluates a patient recovering from a catheter-associated bloodstream infection. Empiric therapy with intravenous vancomycin and cefepime was initiated three days ago for suspected sepsis. The patient is currently afebrile and hemodynamically stable, and the offending central venous catheter has been removed. Final blood culture results from admission now reveal growth of *Enterococcus faecalis* in two out of two sets. The isolate demonstrates susceptibility to ampicillin, vancomycin, linezolid, and daptomycin. Which of the following is the most appropriate modification to this patient's antimicrobial regimen?

An outpatient evaluation is conducted for a $35$-year-old female patient who reports severe fatigue and feeling constantly cold. Over the past $6$ months, she has noticed a $5\text{-kg}$ ($11\text{-lb}$) weight gain despite a poor appetite, and her menstrual cycles have completely stopped. She has no chronic medical conditions and takes no medications. Vital signs show a temperature of $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$), blood pressure of $108/68 \text{ mm Hg}$, and pulse of $52/\text{min}$. Physical examination reveals dry skin, delayed relaxation of the deep tendon reflexes, and no palpable thyroid enlargement. Visual fields are full to confrontation. Laboratory results are as follows:

Thyroid-stimulating hormone (TSH): $0.1 \text{ mU/L}$ (Normal: $0.4 - 4.0 \text{ mU/L}$)
Free thyroxine (T4): $0.4 \text{ ng/dL}$ (Normal: $0.9 - 1.7 \text{ ng/dL}$)

Which of the following is the most likely underlying cause of this patient's clinical presentation?

A 32-year-old woman is evaluated in the clinic for progressive generalized muscle weakness and fatigue over the past three weeks. She has a past medical history of two episodes of nephrolithiasis in the last three years but takes no daily medications. She reports no recent history of diarrhea, vomiting, or dietary changes. Her temperature is $37.0°\text{C}$ ($98.6°\text{F}$), blood pressure is $112/72 \text{ mm Hg}$, pulse is $82/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals decreased deep tendon reflexes globally but is otherwise unremarkable.

Laboratory results are as follows:

Arterial blood gas (room air):

Urinalysis reveals a pH of 6.5, specific gravity of 1.015, and is negative for protein, blood, and glucose.

Based on the clinical presentation and laboratory findings, which of the following best describes this patient's underlying condition and acid-base status?

A 34-year-old G4P3 patient at 37 weeks of gestation is brought to the emergency department by her husband due to sudden-onset, severe, and continuous lower abdominal pain accompanied by dark red vaginal bleeding. Her previous pregnancies were delivered vaginally at term without complications. She has a history of chronic hypertension. Her current blood pressure is 165/100 mm Hg, pulse is 115/min, and respirations are 20/min. Physical examination reveals a rigid, hypertonic, and diffusely tender uterus. Speculum examination confirms a moderate amount of dark blood in the vaginal vault with no active cervical lesions. The cervix is 2 cm dilated and 50% effaced. Fetal heart rate monitoring demonstrates a baseline of 90/min, minimal variability, and recurrent late decelerations. Which of the following is the most appropriate next step in management?

A $38$-year-old man is brought to the emergency department due to a severe nosebleed that has not stopped for $2$ hours, along with bleeding gums and profound fatigue over the past week. His temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $110/70$ mm Hg, and heart rate is $112$/min. Physical examination reveals diffuse petechiae across his chest and large ecchymoses on his extremities. Laboratory studies show:

A peripheral blood smear reveals pancytopenia and several large, atypical promyelocytes containing multiple needle-like intracytoplasmic inclusions.

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

A 61-year-old man is evaluated in the surgical ward for new-onset right-sided back pain. He is currently on postoperative day $7$ following an open radical retropubic prostatectomy for localized prostate adenocarcinoma. His early postoperative recovery was routine, and he is tolerating a regular diet. Over the past $12$ hours, he has developed a fever and constant, dull pain in his right flank. He has a suprapubic catheter in place that is draining clear yellow urine. His temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $130/82$ mmHg, pulse is $105$/min, and respiratory rate is $16$/min. Physical examination demonstrates a soft, non-tender abdomen and a clean lower midline incision. There is pronounced right-sided costovertebral angle tenderness. Laboratory evaluation reveals a leukocyte count of $14,800/\text{mm}^3$. Analysis of the urine from the suprapubic catheter is negative for leukocyte esterase and nitrites, and shows $1$-$2$ leukocytes/hpf. Which of the following is the most appropriate next step in management?

Match each clinical trauma presentation with the most appropriate immediate diagnostic modality or therapeutic intervention.

Match each clinical presentation occurring in the third trimester to the most likely obstetric or pregnancy-related diagnosis.

An endocrinologist is reviewing the results of 72-hour fasting tests for five adult patients who developed neuroglycopenic symptoms with concurrent plasma glucose levels < 50 mg/dL. Match each patient's specific plasma laboratory profile, drawn at the precise time of symptomatic hypoglycemia, to the most likely underlying pathophysiologic etiology.

Match each patient's clinical presentation with the most appropriate confirmatory diagnostic test.

A 27-year-old woman presents to the gynecology clinic due to the absence of menses for nine months accompanied by spontaneous milky bilateral nipple discharge. She and her husband are hoping to have a child and have been having regular, unprotected intercourse for a year. A point-of-care urine pregnancy test is negative.

Arrange the following steps in the most appropriate chronological order for the evaluation and management of this patient to facilitate a safe pregnancy.