Tüm alıştırma soruları

A $71$-year-old man is evaluated in the emergency department for severe, progressive shortness of breath over the past two days. He has a complex medical history that includes ischemic cardiomyopathy and chronic obstructive pulmonary disease. On physical examination, he is tachypneic and sitting upright in bed. Auscultation of the lungs reveals diffuse bilateral expiratory wheezing with faint crackles at the bases. To help distinguish between a pulmonary and a cardiovascular etiology for his acute presentation, the physician orders a rapid serum laboratory test that measures a specific endogenous polypeptide. The test results show a markedly elevated concentration of this polypeptide, supporting acute decompensated heart failure as the primary cause of his symptoms.

What is the primary physiologic stimulus for the secretion of the polypeptide measured in this patient?

Match each classic radiographic finding with its most likely surgical gastrointestinal diagnosis.

A 62-year-old man is brought to the emergency department via ambulance due to the sudden onset of severe, tearing chest pain that radiates to his interscapular region. His blood pressure is 195/115 mm Hg in the right arm and 170/100 mm Hg in the left arm. Heart rate is 110/min. Physical examination reveals a new diastolic decrescendo murmur at the right upper sternal border. Arrange the following steps in the most appropriate chronological order for the initial evaluation and management of this patient.

A 34-year-old woman comes to the clinic reporting a 6-month history of severe fatigue, a 5-kg (11-lb) weight gain, and generalized weakness. She also reports cold intolerance and irregular menstrual periods, with her last menses occurring 4 months ago. She has no significant past medical history and takes no medications. Blood pressure is 100/60 mmHg and pulse is 55/min. Physical examination shows a tired-appearing woman with dry skin. Deep tendon reflexes exhibit a delayed relaxation phase. Laboratory results are as follows:

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

Match each clinical presentation of a trauma patient with the most appropriate next step in definitive management or diagnostic workup.

A $28$-year-old man with no significant past medical history is undergoing an elective open reduction and internal fixation of a right femur fracture. Anesthesia is induced with propofol and succinylcholine, and maintained with sevoflurane. Approximately $45$ minutes into the surgery, the anesthesiologist notes a sudden, unexplained rise in end-tidal carbon dioxide (ETCO2) from $35$ mmHg to $68$ mmHg. The patient's heart rate increases to $142$/min, and generalized masseter muscle rigidity is observed. His core body temperature begins to rise rapidly and is currently $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$). Arrange the following steps in the most appropriate chronological sequence for the immediate management of this patient's suspected complication.

A $54$-year-old woman is brought to the emergency department due to severe, generalized abdominal pain and persistent bilious vomiting for the past $12$ hours. She has not passed flatus or stool since yesterday. Her surgical history is significant for a total abdominal hysterectomy $5$ years ago. Temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $90/60\text{ mmHg}$, and pulse is $122/\text{min}$. Physical examination reveals a markedly distended abdomen with diffuse guarding, severe rebound tenderness, and absent bowel sounds. Laboratory studies show a leukocyte count of $22,000/\text{mm}^3$ and a serum lactate of $5.1\text{ mmol/L}$. An upright abdominal radiograph shows multiple dilated loops of small bowel with air-fluid levels and no free air under the diaphragm. Which of the following is the most appropriate next step in management?

A $48$-year-old male arrives at the emergency department reporting an abrupt onset of severe, constant epigastric pain that radiates to his back. The pain began $4$ hours ago after he consumed a heavy meal. He has experienced two episodes of nonbilious emesis since symptom onset. He has a history of hyperlipidemia and takes rosuvastatin. His temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), heart rate is $115/\text{min}$, blood pressure is $128/82\text{ mmHg}$, and respiratory rate is $18/\text{min}$. Cardiopulmonary examination is unremarkable. Abdominal examination reveals decreased bowel sounds and significant epigastric tenderness without rebound or guarding.

Laboratory studies show:

A right upper quadrant ultrasound reveals multiple mobile gallstones within the gallbladder. The common bile duct measures $4\text{ mm}$ in diameter, and there is no intrahepatic biliary dilation.

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

An emergency department evaluation is requested for a 58-year-old male presenting with progressively worsening shortness of breath and a cough producing frothy sputum over the past 48 hours. His medical history is significant for a 30-pack-year smoking habit and type 2 diabetes mellitus complicated by diabetic nephropathy. Upon arrival, he is in moderate respiratory distress.

Vital signs reveal a blood pressure of $185/110 \text{ mm Hg}$, pulse of $112/\text{min}$, and respiratory rate of $28/\text{min}$. Oxygen saturation is 88% on room air. Pulmonary auscultation reveals bilateral crackles extending to the mid-lung fields along with diffuse expiratory wheezing. Examination of the lower extremities shows 2+ bilateral pitting edema.

Laboratory evaluation reveals the following:
Serum sodium: $138 \text{ mEq/L}$
Serum potassium: $5.9 \text{ mEq/L}$
Serum chloride: $102 \text{ mEq/L}$
Serum bicarbonate: $12 \text{ mEq/L}$
Blood urea nitrogen: $92 \text{ mg/dL}$
Serum creatinine: $7.4 \text{ mg/dL}$

Arterial blood gas (room air):
pH: $7.22$
$p\text{CO}_2$: $36 \text{ mm Hg}$
$p\text{O}_2$: $58 \text{ mm Hg}$

Based on the clinical and laboratory findings, which of the following best describes this patient's current acid-base disorder and the primary cause of his respiratory distress?

A 28-year-old man presents to the emergency department with a 3-week history of daily spiking fevers, reaching up to 39.6°C (103.3°F), typically occurring in the late afternoon. He reports a severe sore throat, profound fatigue, and worsening pain and swelling in his bilateral wrists and knees. He notes a faint, salmon-colored rash on his trunk that seems to appear only during his febrile episodes and resolves when his temperature normalizes. He had an uncomplicated appendectomy 4 weeks ago. He is also stressed because his employer is demanding his specific medical diagnosis to approve his prolonged sick leave.

Vital signs show a temperature of 39.5°C (103.1°F), blood pressure of 120/78 mm Hg, heart rate of 110/min, and respiratory rate of 16/min. Physical examination reveals swollen, tender wrists and a macular erythematous rash on the chest. The lungs are clear to auscultation. Laboratory studies reveal:

Rheumatoid factor and antinuclear antibody (ANA) tests are negative. Blood cultures drawn 3 days ago in the outpatient clinic are sterile. Which of the following is the most appropriate next step in the management of this patient?

An ambulance brings a 60-year-old female to the emergency department due to severe, unrelenting abdominal pain and repeated bilious vomiting that started 24 hours ago. Her past medical history is notable for an open appendectomy performed 15 years prior. She reports that the pain was initially colicky, but over the last 3 hours, it has become constant and generalized. Her temperature is 38.7°C (101.7°F), pulse is 125/min, respirations are 22/min, and blood pressure is 85/50 mm Hg. Physical evaluation reveals a distended and rigid abdomen with marked diffuse tenderness, involuntary guarding, and rebound tenderness. Bowel sounds are absent. Laboratory studies demonstrate a leukocyte count of 19,500/mm³ and a serum lactate of 5.1 mmol/L. A plain upright abdominal radiograph displays multiple distended small bowel loops with air-fluid levels and no free intraperitoneal gas. Which of the following is the most appropriate next step in the care of this patient?

A 45-year-old individual is evaluated in the emergency department for severe, progressive abdominal pain and persistent vomiting of greenish fluid over the past 24 hours. The patient reports an inability to pass flatus since the symptoms began. Past medical history is notable for a Roux-en-Y gastric bypass performed three years ago for severe obesity. Vital signs are temperature $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure $88/58\text{ mmHg}$, heart rate $122\text{ /min}$, and respiratory rate $22\text{ /min}$. The patient appears acutely ill and diaphoretic. Abdominal examination reveals significant distension, diffuse tenderness to palpation, and involuntary guarding. Bowel sounds are absent. Laboratory studies demonstrate a leukocyte count of $19,000/\text{mm}^3$ and a serum lactate level of $4.2\text{ mmol/L}$. Upright abdominal radiography shows multiple dilated loops of small bowel with prominent air-fluid levels and no gas in the rectum. Which of the following is the most appropriate next step in management?

For each of the following hospitalized patients presenting with severe, confirmed, or highly suspected infections, select the most appropriate definitive or targeted empiric intravenous antimicrobial therapy from the options provided.

Match each patient's clinical presentation with the autoantibody most specific to or characteristic of their underlying diagnosis.

A 55-year-old man presents to the clinic with a 4-month history of worsening fatigue, generalized weakness, and cold intolerance. He also reports a significant decrease in libido and difficulty achieving erections over the same period. The patient occasionally experiences mild, dull headaches but denies any changes in his vision. His blood pressure is $112/72 \text{ mm Hg}$ and pulse is $56/\text{min}$. Physical examination is notable for dry skin, sparse body hair, and delayed relaxation of the deep tendon reflexes. Visual field testing is full to confrontation. Laboratory evaluation is performed, with the following results:

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

A 55-year-old man presents to the emergency department with a 4-day history of profuse watery diarrhea. He reports orthostatic dizziness, generalized weakness, and a significantly reduced urine output over the past 24 hours. He has no significant past medical history and takes no medications. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $88/55\text{ mm Hg}$, and a heart rate of $122/\text{min}$. Physical examination reveals dry mucous membranes, decreased skin turgor, and flat jugular veins.

Laboratory studies are as follows:

Serum
Sodium: $140\text{ mEq/L}$
Potassium: $3.2\text{ mEq/L}$
Chloride: $110\text{ mEq/L}$
Bicarbonate: $18\text{ mEq/L}$
Blood urea nitrogen (BUN): $60\text{ mg/dL}$
Creatinine: $2.5\text{ mg/dL}$

Urine
Sodium: $14\text{ mEq/L}$
Creatinine: $50\text{ mg/dL}$

What is this patient's fractional excretion of sodium ($Fe_{Na}$) in percentage?

Match each clinical and laboratory presentation with the most likely underlying nephrological etiology.

A $71$-year-old woman is evaluated in the hospital for new-onset diarrhea. She was admitted $8$ days ago for a severe chronic obstructive pulmonary disease exacerbation, for which she was treated with intravenous methylprednisolone, nebulized bronchodilators, and a $5$-day course of oral levofloxacin. Over the past $48$ hours, she has developed crampy abdominal pain and $6$ to $8$ watery bowel movements daily. Her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $112/74\text{ mmHg}$, and pulse is $98/\text{min}$. Physical examination shows mild, diffuse abdominal tenderness without guarding or rebound. Laboratory studies reveal a leukocyte count of $18,500/\text{mm}^3$ and a serum creatinine of $1.4\text{ mg/dL}$ (baseline $0.9\text{ mg/dL}$). Stool enzyme immunoassay is positive for *Clostridioides difficile* glutamate dehydrogenase antigen and toxins A and B. Which of the following is the most appropriate targeted pharmacotherapy for this patient?

A 21-year-old female university student is evaluated in the urgent care clinic after her roommates noticed her acting increasingly confused and breathing rapidly over the past $4\text{ hours}$. She has a history of major depressive disorder and recently failed an important exam. She complains of a constant "buzzing" sound in her ears. Her temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), pulse is $118\text{/min}$, respirations are $30\text{/min}$, and blood pressure is $112/68\text{ mm Hg}$. Physical examination reveals an agitated, tachypneic patient with clear lung fields and no focal neurologic deficits.

Laboratory studies reveal the following:

Which of the following best describes this patient's underlying acid-base derangement?

Match each clinical presentation of a nephrologic or urologic emergency with its most appropriate targeted intervention.