Tüm alıştırma soruları

A 72-year-old man is hospitalized due to 3 weeks of progressive fatigue, low-grade fevers, and shortness of breath with exertion. Six weeks ago, he underwent a transurethral resection of the prostate for benign prostatic hyperplasia. On physical examination, his temperature is 38.2°C (100.8°F), pulse is 94/min, blood pressure is 132/84 mm Hg, and respirations are 18/min. Cardiac auscultation reveals a new grade 3/6 holosystolic murmur loudest at the apex with radiation to the axilla. Examination of the extremities shows splinter hemorrhages under the fingernails of both hands.

Laboratory studies show:
Leukocyte count: 14,500/mm³
Hemoglobin: 10.8 g/dL
Platelets: 130,000/mm³
Blood urea nitrogen: 42 mg/dL
Serum creatinine: 2.1 mg/dL (baseline 1.1 mg/dL)

Transesophageal echocardiography demonstrates a 1.4-cm oscillating vegetation on the anterior leaflet of the mitral valve with moderate-to-severe mitral regurgitation. Empiric therapy with intravenous vancomycin and gentamicin is initiated. Two days later, three sets of blood cultures drawn prior to antibiotic administration are positive for *Enterococcus faecalis*. Antimicrobial susceptibility testing indicates the isolate is susceptible to ampicillin, penicillin, and vancomycin, and exhibits no high-level resistance to gentamicin. The patient remains hemodynamically stable.

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

A $48$-year-old man is evaluated for resistant hypertension. His blood pressure is $168/104 \text{ mm Hg}$ despite strict adherence to maximum-dose amlodipine, lisinopril, and hydrochlorothiazide. He reports recent episodes of muscle cramping and significant fatigue. Laboratory studies reveal a serum potassium level of $2.9 \text{ mEq/L}$ and a serum sodium level of $146 \text{ mEq/L}$. The physician suspects a specific endocrine etiology for his secondary hypertension. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for this patient.

A 28-year-old woman is brought to the emergency department by her husband due to a 1-week history of worsening fatigue, facial rash, and shortness of breath that is exacerbated by deep inspiration. She was diagnosed with systemic lupus erythematosus (SLE) 4 years ago but stopped taking her prescribed mycophenolate mofetil and hydroxychloroquine 8 months ago. Her temperature is 38.6°C (101.5°F), blood pressure is 155/95 mmHg, heart rate is 110/min, and respiratory rate is 24/min. Physical examination reveals an erythematous rash across her cheeks and nasal bridge that spares the nasolabial folds. Lung auscultation demonstrates decreased breath sounds at the bilateral bases and a pleural friction rub. Mild jugular venous distention is present.

Urinalysis shows 3+ protein, 20-30 red blood cells/hpf, and red blood cell casts. A urine culture obtained on admission grows >100,000 CFU/mL of *Escherichia coli* that is sensitive to amoxicillin, ceftriaxone, and nitrofurantoin. Blood cultures are pending.

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

A 38-year-old man is brought to the emergency department by his partner due to severe headache, confusion, and fever for the past 24 hours. His medical history is significant for HIV, but he has not taken antiretroviral therapy for over a year. His last known CD4 cell count was 85/mm $^3$. His temperature is 39.2°C (102.6°F), blood pressure is 110/70 mmHg, and heart rate is 115/min. He is lethargic but arousable to physical stimuli. Neurologic examination reveals marked nuchal rigidity. Funduscopic examination shows blurring of the optic disc margins bilaterally. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for the immediate management of this patient.

A 68-year-old woman is brought to the emergency department by her family due to a 24-hour history of fever, severe headache, and progressively worsening confusion. She has a medical history of rheumatoid arthritis and is currently on chronic immunosuppressive therapy with methotrexate and prednisone. On physical examination, her temperature is 39.2°C (102.6°F), blood pressure is 105/65 mmHg, and heart rate is 118/min. She is lethargic, oriented only to her own name, and exhibits marked nuchal rigidity. There are no clear focal neurologic deficits, but a thorough neurologic examination is limited by her altered mental status. Based on her clinical presentation and risk factors, arrange the following management steps in the most appropriate chronological sequence.

Match each pediatric patient's medical history or underlying condition with the specific vaccine that is absolutely contraindicated for them.

A $68$-year-old man is brought to the emergency department by his daughter due to a $3$-day history of progressively worsening headache, blurred vision, and confusion. He also reports having two episodes of severe epistaxis earlier in the week. Over the past several months, he has experienced fatigue and a $4.5\text{ kg}$ ($10\text{ lb}$) weight loss. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $145/85\text{ mm Hg}$, heart rate is $92/\text{min}$, and respiratory rate is $16/\text{min}$. Physical examination reveals bilateral cervical lymphadenopathy. Funduscopic examination shows dilated, tortuous retinal veins with scattered retinal hemorrhages. Neurologic examination shows an oriented but lethargic patient with no focal motor or sensory deficits. Laboratory studies show the following:

Serum protein electrophoresis demonstrates a prominent monoclonal spike in the gamma-globulin region. Quantitative immunoglobulins reveal a markedly elevated IgM level. Which of the following is the most appropriate next step in management?

A 32-year-old woman comes to the clinic due to profound fatigue, generalized weakness, and amenorrhea. She delivered her first child 6 months ago. The delivery was complicated by a severe postpartum hemorrhage that required an emergent transfusion of $4$ units of packed red blood cells. Since the delivery, she has been unable to breastfeed her infant and her menses have not resumed. She reports frequent dizzy spells, especially when standing. Her blood pressure is $90/60 \text{ mm Hg}$ seated and $78/50 \text{ mm Hg}$ upon standing. Her pulse is $64/\text{min}$. Physical examination shows loss of pubic and axillary hair, and a delayed relaxation phase of the deep tendon reflexes.

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

A 52-year-old man is brought to the emergency department by emergency medical services after his daughter found him lethargic and confused in his apartment. The daughter reports that the patient has a history of severe osteoarthritis, major depressive disorder, and alcohol use disorder. He recently lost his job and has been drinking heavily for the past week. His current medications include fluoxetine and several over-the-counter pain relievers. On physical examination, the patient is difficult to arouse but withdraws from painful stimuli. His mucous membranes are dry.

Vital signs are as follows:
Temperature: 37.4°C (99.3°F)
Blood pressure: 105/65 mmHg
Heart rate: 112/min
Respiratory rate: 26/min
Oxygen saturation: 98% on room air

Laboratory studies reveal the following:

Serum chemistry:
Sodium: 142 mEq/L
Potassium: 3.4 mEq/L
Chloride: 106 mEq/L
Bicarbonate: 12 mEq/L
Blood urea nitrogen: 24 mg/dL
Creatinine: 1.2 mg/dL
Glucose: 88 mg/dL

Arterial blood gas (on room air):
pH: 7.44
PaCO $_2$: 18 mmHg
PaO $_2$: 102 mmHg

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

Match each patient's clinical presentation and laboratory profile, obtained during an episode of documented fasting hypoglycemia, to the most accurate pathophysiologic description of the underlying etiology.

A $22$-year-old man with a history of type 1 diabetes mellitus is brought to the emergency department due to lethargy, abdominal pain, and recurrent vomiting for the past $24$ hours. He recently had a viral respiratory tract infection. Vital signs show a temperature of $37.2^{\circ}\text{C}$ ($99.0^{\circ}\text{F}$), blood pressure of $90/60$ mm Hg, pulse of $122$/min, and respirations of $28$/min with deep, sighing breathing. Point-of-care blood glucose is $520$ mg/dL. Intravenous access is established. Arrange the following acute management steps in the most appropriate chronological order.

A 23-year-old man comes to the office to evaluate a progressively enlarging lump on the right side of his neck that he first noticed 6 weeks ago. He also reports drenching night sweats and a 6-kg (13-lb) unintentional weight loss over the past 2 months. His temperature is 37.8°C (100.0°F), blood pressure is 118/76 mm Hg, pulse is 84/min, and respirations are 14/min. Physical examination reveals a 4.5-cm, firm, non-tender, rubbery lymph node in the right supraclavicular region. There is no other cervical, axillary, or inguinal lymphadenopathy. The liver and spleen are not palpable. Complete blood count and comprehensive metabolic panel are within normal limits. Arrange the following steps in the most appropriate chronological order for the evaluation and initial management of this patient's condition.

A 22-year-old woman with a history of type 1 diabetes mellitus presents to the emergency department with a 1-day history of nausea, vomiting, and diffuse abdominal pain. She missed several doses of her insulin because she was not feeling well. Her temperature is $37.2^\circ C$ ($99.0^\circ F$), blood pressure is $105/65$ mmHg, heart rate is $118/min$, and respiratory rate is $26/min$. Physical examination reveals dry mucous membranes and diffuse abdominal tenderness without rebound or guarding.

Which of the following is the expected arterial partial pressure of carbon dioxide ($pCO_2$) if appropriate respiratory compensation has occurred in this patient?

A 68-year-old man presents to the emergency department with progressively worsening shortness of breath over the past 3 days. He has a history of ischemic cardiomyopathy with a reduced ejection fraction and severe chronic obstructive pulmonary disease. The patient reports waking up in the middle of the night gasping for air and has required three pillows to sleep comfortably. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $155/90$ mm Hg, pulse is $110$/min, and respirations are $24$/min. Oxygen saturation is $91\%$ on room air. Physical examination reveals an elevated jugular venous pressure, an S3 gallop, and diffuse bilateral crackles at the lung bases. There is 3+ bilateral pitting edema up to the mid-calves. Laboratory testing demonstrates a brain natriuretic peptide (BNP) level of $950$ pg/mL (normal: $<100$ pg/mL). Which of the following is the most appropriate next step in management?

A 72-year-old man is brought to the emergency department by emergency medical services due to severe, progressive shortness of breath over the past 48 hours. He also reports a cough productive of clear sputum and difficulty sleeping unless propped up on three pillows. His medical history is significant for severe chronic obstructive pulmonary disease (COPD), ischemic cardiomyopathy with a left ventricular ejection fraction of 35%, and hypothyroidism. He admits to missing his medications for the past two weeks.

Vital signs are temperature 37.1 °C (98.8 °F), blood pressure 162/94 mm Hg, pulse 115/min, and respirations 28/min. Oxygen saturation is 85% on room air.

Physical examination shows a patient in acute respiratory distress, using accessory muscles of respiration. Jugular venous distention is present up to 10 cm H2O. Lung auscultation reveals diffuse, bilateral expiratory wheezing and scattered crackles at the lung bases. Cardiovascular examination demonstrates a regular tachycardia with a prominent S3 gallop. There is 2+ bilateral lower extremity pitting edema.

Laboratory and diagnostic studies show:
Leukocyte count: 8,200/mm³
Thyroid-stimulating hormone (TSH): 0.3 µU/mL (Normal: 0.5–5.0 µU/mL)
Free T4: 0.8 ng/dL (Normal: 0.9–1.7 ng/dL)
Sputum culture (obtained 3 days ago at an outpatient clinic for a mild cough): heavy growth of *Streptococcus pneumoniae*, susceptible to amoxicillin.

Arterial blood gas analysis on room air:
$pH$: $7.29$
$pCO_2$: $56$ mm Hg
$pO_2$: $52$ mm Hg
$HCO_3^-$: $26$ mEq/L

A portable chest radiograph shows cardiomegaly, bilateral perihilar alveolar opacities, and prominent interlobular septa.

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

A $22$-year-old man with type $1$ diabetes mellitus is brought to the emergency department due to nausea, vomiting, and confusion for the past $24$ hours. He has not taken his insulin for $2$ days. Vital signs show blood pressure $90/60$ mm Hg, heart rate $124$/min, and respiratory rate $26$/min with deep, sighing breaths. Laboratory evaluation reveals a serum glucose of $580$ mg/dL, potassium of $4.9$ mEq/L, bicarbonate of $11$ mEq/L, and an arterial pH of $7.18$. Serum ketones are strongly positive. Arrange the following steps in the most appropriate sequence for the acute management and resolution of this patient's condition.

Jugular venous pulse (JVP) analysis provides critical insights into right-sided heart hemodynamics and can distinguish between several life-threatening and chronic cardiovascular pathologies. Match each of the following abnormal JVP waveform findings with the specific clinical condition it most classically represents.

A series of patients present to the primary care clinic for routine health screening and evaluation of liver function. As part of their workup, Hepatitis B serologic testing is performed. Match the following Hepatitis B serologic profiles with their most accurate clinical interpretation.

Match each patient's clinical presentation with the most likely corresponding liver biopsy finding.

A 22-year-old man with type 1 diabetes mellitus is brought to the emergency department due to lethargy, nausea, vomiting, and diffuse abdominal pain for the past 24 hours. He recently had a viral upper respiratory infection. Temperature is 37.2°C (99.0°F), blood pressure is 90/60 mmHg, pulse is 125/min, and respirations are 28/min and deep. Mucous membranes are dry and capillary refill is prolonged. Laboratory studies show:

Urine ketones are strongly positive.

Arrange the following management steps in the correct chronological order of administration for this patient according to standard diabetic ketoacidosis (DKA) protocols.