Tüm alıştırma soruları

A 48-year-old woman is admitted to the hospital with a 2-day history of fever, chills, and progressive right lower extremity swelling and redness. Her past medical history is unremarkable. On admission, her temperature is 38.6°C (101.5°F), blood pressure is 110/70 mmHg, and pulse is 108/min. Physical examination reveals a $10 \times 8$ cm area of well-demarcated erythema, warmth, and exquisite tenderness over the right calf. Two sets of peripheral blood cultures are obtained, and the patient is started on empiric intravenous vancomycin and piperacillin-tazobactam.

By hospital day 3, her temperature has normalized, and the erythema has significantly receded. The admission blood cultures grow *Staphylococcus aureus* in all four bottles. Antimicrobial susceptibility testing reveals the following:

A subsequent transthoracic echocardiogram shows no valvular vegetations. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 42-year-old woman is evaluated in the psychiatric clinic and diagnosed with a moderate major depressive episode without psychotic features. Over the next 18 months, she requires multiple adjustments to her treatment plan due to inadequate symptom relief. Ultimately, her condition deteriorates, and she develops severe psychotic depression with delusions of guilt and total refusal to consume food or fluids. According to standard clinical guidelines for the stepped-care management of major depressive disorder, arrange the following therapeutic interventions in the most appropriate chronological sequence of escalation.

A male patient, aged $55$, arrives at the acute care clinic complaining of worsening shortness of breath and chest discomfort over the past two days. He recently recovered from a severe viral respiratory infection. He describes the chest pain as sharp and states that it lessens significantly when he sits up and leans forward. Within the last two hours, he has felt increasingly dizzy. Vital signs show a temperature of $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), a blood pressure of $88/72$ mm Hg, a heart rate of $118$/min, and a respiratory rate of $22$/min. Physical examination reveals prominent distention of the neck veins and heart sounds that are noticeably faint on auscultation. An exaggerated drop in systolic blood pressure during inspiration is observed. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 45-year-old man comes to the clinic reporting a 4-month history of progressive fatigue, cold intolerance, and decreased libido. He says he feels sluggish and lacks the energy to perform his job as an accountant. His medical history is unremarkable, and he takes no medications. Vital signs show a blood pressure of 105/70 mm Hg and a heart rate of 56/min. Physical examination reveals delayed relaxation of the deep tendon reflexes and somewhat soft, small testes. Laboratory studies show:

Serum thyroid-stimulating hormone (TSH): 1.6 $\mu$ U/mL (Normal: 0.4–4.0 $\mu$ U/mL)
Serum free thyroxine (T4): 0.6 ng/dL (Normal: 0.9–1.7 ng/dL)

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

Match the following specific cardiovascular physical examination findings with their most likely underlying structural or pathophysiological etiology.

Match each clinical presentation of a central nervous system infection (or related exposure) to the most appropriate targeted antimicrobial therapy or prophylaxis regimen.

A team of internal medicine residents is reviewing the post-infarction clinical course of several patients admitted to the cardiac intensive care unit. Match each described clinical presentation with the most likely underlying mechanical or structural complication of acute myocardial infarction.

A 38-year-old man arrives at the emergency department accompanied by his spouse, reporting excruciating abdominal pain that began 6 hours ago. He states that he has had a painless "bulge" in his right groin for two years, which typically disappears when he lies down. Earlier today, the bulge became noticeably larger, highly painful, and could no longer be pushed back in. Over the past 3 hours, the pain has generalized across his entire abdomen, and he has vomited dark, bilious fluid three times. He has not passed flatus since yesterday. His temperature is 38.6°C (101.5°F), blood pressure is 98/60 mm Hg, pulse is 118/min, and respirations are 22/min. On physical examination, the patient is diaphoretic and lying completely still. Abdominal examination reveals board-like rigidity, diffuse involuntary guarding, and severe rebound tenderness in all quadrants. Examination of the right groin demonstrates a 6-cm, tense, erythematous mass protruding into the scrotum that is exquisitely tender to palpation. Laboratory results show a leukocyte count of 17,500/mm³ and a serum lactate of 4.1 mmol/L. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation with the most likely corresponding auscultatory finding and its characteristic response to dynamic maneuvers.

A 38-year-old man with a history of schizophrenia is brought to the emergency department by police due to erratic behavior in public. In the triage area, he becomes increasingly agitated, pacing rapidly, clenching his fists, and shouting that the hospital staff are 'government spies trying to poison him.' He has not physically assaulted anyone but is blocking the exit and refusing to sit down. Arrange the following interventions for managing this patient's acute agitation in the most appropriate sequential order, applying the psychiatric principle of the least restrictive alternative.

A $16$-year-old boy is brought to the emergency department by his parents due to progressive muscle weakness over the past $24$ hours. He is currently unable to stand without assistance. His parents note that he has been increasingly irritable and performing poorly in school for the past $4$ months. Two weeks ago, his primary care provider prescribed fluoxetine for suspected depression, but his behavior has not improved. A routine thyroid panel obtained at that clinic visit showed a thyroid-stimulating hormone (TSH) level of $4.5$ $\mu$ U/mL (normal: $0.4-4.0$ $\mu$ U/mL) and a normal free T4. On physical examination, temperature is $37.1^\circ$ C ($98.8^\circ$ F), blood pressure is $110/70$ mmHg, pulse is $92$/min, and respirations are $22$/min. He appears lethargic. There is an erythematous, scaling rash localized around his mouth and nose. Neurologic examination reveals symmetrical proximal and distal muscle weakness in all extremities, with diminished deep tendon reflexes. Laboratory studies show:

Serum sodium: $140$ mEq/L
Serum potassium: $2.1$ mEq/L
Serum chloride: $115$ mEq/L
Serum bicarbonate: $14$ mEq/L

Arterial blood gas (room air):
pH: $7.28$
pCO $_2$: $30$ mmHg

Which of the following is the most likely diagnosis?

A 15-month-old male toddler is evaluated in the pediatric emergency center due to worsening respiratory effort and poor oral intake over the last 24 hours. The parents note that he developed a profuse runny nose, mild fever, and a paroxysmal cough three days ago. His birth history is notable for delivery at 34 weeks gestation. He has no history of atopy or prior wheezing episodes. On physical examination, the patient's temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), heart rate is $165/\text{min}$, respiratory rate is $72/\text{min}$, and oxygen saturation is $87\%$ on room air. The child appears lethargic but is easily arousable. He exhibits pronounced nasal flaring, intercostal retractions, and expiratory grunting. Auscultation of the chest reveals widespread coarse crackles and high-pitched expiratory polyphonic wheezing. Which of the following interventions are indicated as part of the most appropriate management bundle for this patient? (Select all that apply)

Paramedics arrive at the emergency department with an $80$-year-old male who developed sudden, severe shortness of breath one hour ago while watching television. The patient has a medical history significant for poorly controlled hypertension, type 2 diabetes mellitus, and a $45$-pack-year history of smoking. Upon arrival, he is in acute respiratory distress, utilizing accessory muscles to breathe, and cannot speak more than a few words at a time. Vital signs include a blood pressure of $225/115 \text{ mm Hg}$, a heart rate of $115/\text{min}$, and a respiratory rate of $30/\text{min}$. Oxygen saturation is $86\%$ on ambient air. Physical examination shows profound diaphoresis. Pulmonary auscultation reveals prominent expiratory wheezing diffusely, along with fine crackles at both lung bases. Cardiovascular examination is notable for a rapid, regular rhythm and a distinct fourth heart sound (S4). Evaluation of the neck shows flat jugular veins, and there is no peripheral edema. Which of the following is the most appropriate initial pharmacologic therapy for this patient?

A 62-year-old woman with a history of chronic obstructive pulmonary disease (COPD) presents to the emergency department complaining of progressive shortness of breath over the past three days. She reports an increased frequency of cough and a change in her sputum from clear to thick and yellow-green. She denies chest pain, orthopnea, or paroxysmal nocturnal dyspnea. Her daily medications include a long-acting muscarinic antagonist and a short-acting beta-agonist as needed. Vital signs are temperature $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure $135/85\text{ mmHg}$, heart rate $108\text{/min}$, and respiratory rate $26\text{/min}$. Oxygen saturation is $86\%$ on room air.

Physical examination reveals a patient in moderate respiratory distress, using accessory muscles of respiration. Auscultation demonstrates a prolonged expiratory phase and diffuse end-expiratory wheezing bilaterally. Cardiac examination shows a rapid, regular rhythm with no murmurs, gallops, or jugular venous distention. There is no peripheral edema.

Chest radiograph shows hyperinflated lung fields with flattened diaphragms, but no focal consolidations or pleural effusions.

Arterial blood gas on room air reveals:
pH: $7.28$
$\text{PaCO}_2$: $66\text{ mmHg}$
$\text{PaO}_2$: $54\text{ mmHg}$
$\text{HCO}_3^-$: $30\text{ mEq/L}$

Which of the following are appropriate next steps in the management of this patient? (Select all that apply)

Complaints of a racing heart, persistent heat intolerance, and frequent loose stools have brought a 31-year-old medical assistant to the clinic. She reports unintentionally losing $4$ kg ($8.8$ lb) over the past month. She denies any neck pain, dysphagia, or recent viral illnesses. Her past medical history is unremarkable, and she denies taking any prescribed medications or over-the-counter supplements. Vital signs show a blood pressure of $138/78$ mm Hg and a regular pulse of $112$/min. Physical examination reveals an anxious-appearing woman with a fine, symmetric resting tremor in her outstretched fingers. The neck is supple, and the thyroid gland is not palpable. No proptosis or localized pretibial edema is noted.

Laboratory studies yield the following results:
- Thyroid-stimulating hormone (TSH): $0.02$ $\mu$ U/mL (Normal: $0.4-4.2$ $\mu$ U/mL)
- Free T4: $3.4$ ng/dL (Normal: $0.8-1.8$ ng/dL)
- Free T3: $6.2$ pg/mL (Normal: $2.3-4.2$ pg/mL)

A 24-hour radioactive iodine uptake scan demonstrates an uptake of $1\%$ (Normal: $15\%-30\%$).

Which of the following laboratory findings is most likely present in this patient?

Evaluate the following ethical dilemmas involving pediatric patients and pregnant individuals. Match each clinical situation with the most appropriate ethical or legal course of action.

Match each clinical scenario with the most appropriate legal or ethical action required by the physician regarding confidentiality and mandatory reporting.

A 55-year-old man with a history of decompensated alcohol-related cirrhosis is brought to the emergency department after vomiting a large amount of bright red blood. On arrival, his blood pressure is 85/50 mmHg, and his heart rate is 122/min. He appears pale and lethargic but is maintaining his airway.

Arrange the following management steps in the most appropriate chronological sequence for this patient's acute condition.

Emergency medical services arrive at the trauma bay with a 22-year-old college student who crashed his mountain bike at high speed, striking his torso against the handlebars. He is awake but lethargic, complaining of severe pain in his left upper abdomen and left shoulder.

Vital signs include a heart rate of 135/min, blood pressure of 82/48 mm Hg, and respiratory rate of 22/min. Oxygen saturation is 96% on room air.

Physical examination reveals a large contusion over the left lower rib cage with marked tenderness and guarding in the left upper quadrant.

Intravenous access is established, and a bolus of warmed isotonic crystalloid is initiated. A focused assessment with sonography for trauma (FAST) demonstrates a large anechoic stripe between the spleen and the left kidney.

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

A 54-year-old man arrives at the emergency department due to the sudden onset of left-sided chest pain and shortness of breath that began $2$ hours ago. The chest pain worsens with deep inspiration. Over the past $6$ months, he has experienced worsening fatigue, frequent headaches, and intense generalized pruritus that is particularly severe after taking hot showers. He also describes a burning sensation in his palms and soles. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $142/88\text{ mm Hg}$, pulse is $112\text{/min}$, and respirations are $24\text{/min}$. Pulse oximetry shows an oxygen saturation of $90\%$ on room air. Physical examination reveals a plethoric face and engorged retinal veins. The spleen is palpated $4\text{ cm}$ below the left costal margin. The lungs are clear to auscultation bilaterally. The right calf is visibly swollen, erythematous, and tender to palpation.

Laboratory studies reveal:
Hemoglobin: $19.2\text{ g/dL}$
Hematocrit: $59\%$
Leukocyte count: $15,200\text{ /mm}^3$
Platelet count: $620,000\text{ /mm}^3$

Arterial blood gas analysis (room air):
pH: $7.51$
PaCO $_2$: $29\text{ mm Hg}$
PaO $_2$: $60\text{ mm Hg}$

Which of the following is the most appropriate initial step in the management of this patient's acute presentation?