Tüm alıştırma soruları

Match each esophageal motility disorder with its characteristic finding on high-resolution esophageal manometry.

A medical student is reviewing characteristic jugular venous pressure (JVP) waveform abnormalities during a cardiology rotation. Match each specific JVP finding with its most likely underlying cardiovascular pathology.

A 58-year-old female patient is receiving mechanical ventilation in the medical intensive care unit due to severe community-acquired pneumonia. On hospital day 5, her clinical status has markedly improved. She is hemodynamically stable without the need for vasopressor support, and her oxygen requirements have decreased substantially. She is currently receiving continuous intravenous sedation with propofol. The critical care team plans to begin the ventilator liberation process.

Arrange the following interventions in the standard chronological sequence for assessing and executing liberation from mechanical ventilation.

A 38-year-old man is evaluated in the hospital on day 3 of admission for high fever, chills, and progressive shortness of breath. He has a history of bipolar disorder, asthma, and intravenous drug use. On admission, blood cultures were drawn, and empirical intravenous vancomycin and cefepime were initiated. Today, the patient reports feeling persistently fatigued and depressed, stating he has been in a 'down state' for the past month. He is currently taking lithium. Temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $110/70\text{ mm Hg}$, pulse is $105/\text{min}$, and respirations are $22/\text{min}$. Physical examination reveals a grade 3/6 holosystolic murmur at the left lower sternal border that increases in intensity with inspiration. Scattered bilateral lung crackles are present. Laboratory studies show:

An echocardiogram demonstrates a 1.5-cm mobile vegetation on the tricuspid valve with severe tricuspid regurgitation. Blood cultures from admission have grown methicillin-susceptible *Staphylococcus aureus* (MSSA). Which of the following is the most appropriate next step in management?

A 48-year-old male ski instructor is airlifted to the trauma bay after colliding with a tree at high speed. During transport, he received $1$ L of lactated Ringer solution. Upon arrival, the patient appears pale, diaphoretic, and confused. His temperature is $36.1^\circ\text{C}$ ($97.0^\circ\text{F}$), pulse is $135$/min, respirations are $24$/min, and blood pressure is $78/42$ mm Hg. Pulse oximetry shows $95\%$ on room air. The trachea is midline, and breath sounds are present and equal bilaterally. Heart sounds are rapid but normal in intensity, with no jugular venous distention. The abdomen is tense with significant left upper quadrant tenderness and involuntary guarding. The pelvis is mechanically stable to gentle compression. Bedside focused assessment with sonography for trauma (FAST) demonstrates a well-defined anechoic stripe in the splenorenal recess. Which of the following is the most appropriate next step in the management of this patient?

A $32$-year-old female patient is assessed on hospital day $4$. She was initially admitted for high fevers, rigors, and pleuritic chest pain. Her past medical history is significant for major depressive disorder managed with citalopram, and severe opioid use disorder. On the day of admission, physical examination revealed a pan-systolic murmur at the left lower sternal border that augmented during inspiration. Blood cultures from admission grew methicillin-susceptible *Staphylococcus aureus* (MSSA). A transthoracic echocardiogram showed a $1.6$-cm oscillating mass on the tricuspid valve. She was appropriately started on targeted therapy with continuous intravenous nafcillin.

Currently, she reports mild improvement in her chest pain but notes a persistent cough. Her temperature is $37.9^\circ \text{C}$ ($100.2^\circ \text{F}$), blood pressure is $114/70$ mmHg, pulse is $92$/min, and respiratory rate is $18$/min. Pulse oximetry shows $95\%$ on room air. Auscultation of the lungs reveals coarse crackles in the periphery of both lung fields. The cardiac examination is unchanged from admission. There is no jugular venous distention and no peripheral edema.

Laboratory tests reveal:
Leukocyte count: $12,200$/mm $^3$
Thyroid-stimulating hormone (TSH): $1.4\ \mu\text{U/mL}$ (Normal: $0.5 - 5.0\ \mu\text{U/mL}$)
Free thyroxine (T4): $1.1\ \text{ng/dL}$ (Normal: $0.9 - 1.7\ \text{ng/dL}$)
Total triiodothyronine (T3): $62\ \text{ng/dL}$ (Normal: $80 - 200\ \text{ng/dL}$)

A repeat chest radiograph demonstrates several new, small cavitary lesions scattered throughout the peripheral lung fields bilaterally.

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

A 4th-year medical student is reviewing the endocrine laboratory profiles of four distinct patients being evaluated for suspected adrenal pathology. Match each patient's serum laboratory and dynamic testing profile to the most likely underlying etiology.

A 56-year-old man with a history of alcohol-associated cirrhosis presents to the hepatology clinic with new-onset, moderate abdominal distension and early satiety. He reports no fever, abdominal pain, or confusion. Physical examination reveals shifting dullness, spider angiomas, and palmar erythema. Ultrasound confirms the presence of moderate ascites without portal vein thrombosis or hepatocellular carcinoma.

Arrange the following interventions in the most appropriate chronological sequence for the longitudinal management of this patient's ascites, starting from the immediate next step in the current presentation to the management of highly refractory disease:

An internal medicine resident is evaluating a patient recently admitted to the progressive care unit. The patient has a long-standing history of restrictive eating patterns and admits to consuming large quantities of over-the-counter stimulant laxatives over the past month to lose weight. Today, she developed profound, diffuse muscle weakness to the point of being unable to lift her arms from her sides, prompting her roommate to call emergency services.

Current vital signs include a blood pressure of 92/58 mm Hg, heart rate of 112/min, and respiratory rate of 10/min with shallow excursions.

Laboratory evaluation shows the following:

Based on these findings, which of the following best characterizes this patient's acid-base status?

A $68$-year-old woman is rapidly assessed in the cardiac telemetry unit due to sudden-onset severe dyspnea and progressive confusion. She was admitted $3$ days ago for an ST-segment elevation myocardial infarction involving the inferior leads, which was treated with percutaneous coronary intervention of the right coronary artery.

Current vital signs include a temperature of $36.7^\circ\text{C}$ ($98.1^\circ\text{F}$), blood pressure of $78/48\text{ mmHg}$, heart rate of $122/\text{min}$, and respiratory rate of $32/\text{min}$. Oxygen saturation is $84\%$ on high-flow supplemental oxygen.

Physical examination reveals cold, clammy extremities and significant jugular venous distention. Lung auscultation demonstrates diffuse bilateral crackles and prominent expiratory wheezes. Cardiac auscultation reveals a new, harsh, grade $4/6$ holosystolic murmur heard best at the apex with radiation to the axilla.

Point-of-care testing shows a serum lactate of $5.1\text{ mmol/L}$. A thyroid panel drawn earlier as part of an altered mental status workup shows a thyroid-stimulating hormone (TSH) level of $1.1\text{ \mu U/mL}$ (normal: $0.5-5.0\text{ \mu U/mL}$) and a free T4 of $0.9\text{ ng/dL}$ (normal: $0.9-2.4\text{ ng/dL}$).

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

A 48-year-old man is brought to the emergency department by emergency medical services after his neighbor found him unresponsive in his garage. An open, empty container of automotive antifreeze was found nearby. On examination, he is deeply lethargic and responds only to painful stimuli. His vital signs show a blood pressure of $110/70 \text{ mmHg}$, heart rate of $105/\text{min}$, and respiratory rate of $24/\text{min}$.

Laboratory testing reveals the following:

Based on the laboratory findings, what is the patient's calculated serum osmolar gap?

A 35-year-old man is brought to the emergency department after being rescued from a burning building. The fire department successfully extracted him from the fire 2 hours ago. On examination, the patient is hemodynamically stable and weighs 90 kg ($198.4$ lbs). He has severe deep partial-thickness and full-thickness burns involving his entire anterior trunk, his entire right arm, and the anterior aspect of his left leg. The remainder of his skin, including his face, neck, and posterior surfaces, is unaffected. Large-bore intravenous access is obtained. Using the traditional Parkland formula ($4$ mL/kg/% total body surface area), at what rate (in mL/hr) should intravenous lactated Ringer solution be administered to this patient initially?

A 64-year-old man comes to the primary care clinic for a routine evaluation of worsening shortness of breath and a dry, hacking cough over the past 3 months. He reports that the cough is particularly bothersome at night and often wakes him from sleep, forcing him to prop himself up with three pillows. His medical history is significant for hypertension, type 2 diabetes mellitus, and a 35-pack-year smoking history, though he quit smoking a decade ago. Current medications include lisinopril, amlodipine, and metformin. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 158/92 mm Hg, pulse of 88/min, and respirations of 18/min. BMI is 29 kg/m². Pulse oximetry is 96% on room air. On physical examination, the lungs are clear to auscultation bilaterally. Cardiac examination reveals a regular rate and rhythm, but the point of maximal impulse is palpated at the anterior axillary line in the sixth intercostal space. A grade 2/6 holosystolic murmur is heard best at the cardiac apex. There is 1+ pitting edema in the bilateral ankles. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient's condition?

A 71-year-old man presents to the pulmonary clinic reporting a 9-month history of progressively worsening shortness of breath and a dry, hacking cough. He denies fever, chills, orthopnea, paroxysmal nocturnal dyspnea, or chest pain. His past medical history is significant for hypertension and a 35-pack-year smoking history, having quit 10 years ago. Current medications include lisinopril and amlodipine.

Vital signs show a pulse of 86/min, respiratory rate of 22/min, blood pressure of 128/78 mm Hg, and oxygen saturation of 91% on room air. Physical examination reveals digital clubbing. Pulmonary auscultation demonstrates fine, end-inspiratory "Velcro-like" crackles predominantly at the lung bases bilaterally. Cardiac examination is normal with no murmurs, gallops, or jugular venous distention. There is no lower extremity edema.

Pulmonary function testing (PFT) reveals the following:

High-resolution computed tomography (HRCT) of the chest shows bilateral, subpleural reticular opacities with traction bronchiectasis and honeycombing.

Based on the clinical presentation and diagnostic findings, which of the following are accurate regarding this patient's condition? (Select all that apply)

A 55-year-old woman with a recent diagnosis of advanced non-small cell lung cancer is brought to the emergency department due to worsening shortness of breath, profound weakness, and lightheadedness over the past 48 hours. On physical examination, she is diaphoretic and in moderate respiratory distress. Her blood pressure is 82/60 mmHg, heart rate is 118/min, and respiratory rate is 24/min. Jugular venous pressure is estimated at 14 cm H₂O. Auscultation reveals distant heart sounds and clear lung fields bilaterally. Her systolic blood pressure decreases by 18 mmHg during inspiration.

Arrange the following diagnostic and management steps in the most appropriate chronological order for this patient.

A $47$-year-old man with a history of ulcerative colitis, chronic obstructive pulmonary disease (COPD), and hypothyroidism is evaluated in the intensive care unit. He was admitted $2$ days ago for a severe ulcerative colitis flare characterized by $>10$ bloody bowel movements per day and was started on intravenous methylprednisolone. Over the past $12$ hours, his diarrhea has abruptly ceased, but he has developed severe, diffuse abdominal pain and progressive distension.

Vital signs:
- Temperature: $39.3^\circ\text{C}$ ($102.7^\circ\text{F}$)
- Blood pressure: $84/52 \text{ mm Hg}$
- Heart rate: $136/\text{min}$
- Respiratory rate: $28/\text{min}$

Physical examination reveals a markedly distended abdomen with diffuse rebound tenderness and rigidity. Bowel sounds are absent. Lung auscultation reveals faint, scattered expiratory wheezes bilaterally.

Laboratory studies:
- Leukocytes: $25,500/\text{mm}^3$
- Bicarbonate: $13 \text{ mEq/L}$
- Arterial blood gas (on room air): pH $7.24$, $PaCO_2$ $30 \text{ mm Hg}$, $PaO_2$ $68 \text{ mm Hg}$
- TSH: $0.1 \mu\text{U/mL}$ (Normal: $0.4$-$4.0$)
- Free T4: $0.5 \text{ ng/dL}$ (Normal: $0.9$-$1.7$)
- Lactic acid: $7.2 \text{ mmol/L}$ (Normal: $0.5$-$2.2$)

An upright abdominal radiograph shows a continuous column of gas in the transverse colon measuring $8.5 \text{ cm}$ in diameter with a loss of normal haustral markings. No free air under the diaphragm is visualized.

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

A 34-year-old woman presents to the clinic with progressive weight gain, easy bruising, and new-onset facial hair growth over the past year. Examination reveals facial plethora, central adiposity, proximal muscle weakness, and wide purple striae on her abdomen. Her blood pressure is 155/95 mmHg. Arrange the following diagnostic steps in the correct sequential order for the evaluation of this patient's suspected hypercortisolism.

Match each physical examination finding describing a characteristic cardiac murmur to the most likely underlying cardiovascular condition or pathology.

Match each of the following clinical trauma presentations with the single most appropriate next step in management.

A 60-year-old man is brought to the emergency department due to sudden-onset, severe, diffuse abdominal pain that began 2 hours ago. He has a history of severe osteoarthritis for which he takes high-dose ibuprofen daily. On physical examination, he appears in significant distress and lies completely still on the stretcher. Vital signs show a temperature of 38.2°C (100.8°F), heart rate of 115/min, and blood pressure of 98/60 mm Hg. Abdominal examination reveals a rigid, board-like abdomen with diffuse rebound tenderness and involuntary guarding. Arrange the following steps in the most appropriate chronological order for the management of this patient's condition.