Tüm alıştırma soruları

During a routine follow-up at the outpatient clinic, a 47-year-old male reports a 9-month history of progressive fatigue, generalized weakness, and decreased libido. He mentions feeling constantly cold despite wearing heavy clothing. His medical history includes a diagnosis of pulmonary sarcoidosis 6 years prior, which was managed with oral glucocorticoids until remission was achieved 2 years ago. He is currently not taking any medications. Vital signs show a blood pressure of $102/64 \text{ mmHg}$ and a pulse of $56/\text{min}$. Physical examination is notable for delayed relaxation phase of the deep tendon reflexes and bilaterally small, soft testes. Visual fields are full to confrontation. Laboratory results are as follows:

Based on the clinical presentation and laboratory findings, which of the following is the most appropriate next step in the management of this patient?

A 54-year-old man is hospitalized for the management of severe pneumonia complicated by sepsis. On hospital day 3, his urine output drops to $200$ mL over a 12-hour period. To evaluate the etiology of his oliguric acute kidney injury, the following laboratory studies are obtained:

Serum sodium: $140$ mEq/L
Serum creatinine: $2.0$ mg/dL
Urine sodium: $56$ mEq/L
Urine creatinine: $40$ mg/dL

What is this patient's fractional excretion of sodium (FENa)? Give your answer as a percentage.

A 68-year-old man is evaluated in the hospital for acute, severe right knee pain. He was admitted 3 days ago for progressive dyspnea, orthopnea, and lower extremity edema. He was diagnosed with acute decompensated heart failure and treated with intravenous furosemide, which significantly improved his respiratory symptoms. His temperature is 38.1°C (100.6°F) and blood pressure is 135/85 mm Hg. Medical history includes ischemic cardiomyopathy and chronic kidney disease. Laboratory studies show a serum creatinine of 2.6 mg/dL (baseline 2.5 mg/dL). Physical examination of the right knee reveals marked erythema, warmth, and a tense joint effusion. Range of motion is severely restricted due to pain. Arthrocentesis yields cloudy yellow synovial fluid containing 55,000 leukocytes/µL (85% neutrophils). Gram stain shows no organisms. Polarized light microscopy demonstrates intracellular, negatively birefringent, needle-shaped crystals. Which of the following is the most appropriate next step in management of this patient's joint pain?

A 24-month-old boy is brought to the clinic for a routine well-child visit. His mother is concerned that his development is lagging behind his older sister's development at the same age. She notes that the patient walks up and down the stairs by placing both feet on each step before moving to the next. He enjoys kicking a ball but cannot yet pedal a tricycle. When playing with blocks, he successfully builds a tower of 6 cubes. His vocabulary consists of approximately 60 words, and he frequently uses 2-word phrases such as "want milk." His mother reports that strangers can understand about half of what he says. During a playdate, he plays next to other children but does not engage in cooperative play with them. He is not yet toilet trained. Physical examination is unremarkable. Which of the following is the most appropriate next step in management?

A 62-year-old woman comes to the emergency department due to a 1-day history of fever, chills, and a productive cough. She was diagnosed with diffuse large B-cell lymphoma 3 weeks ago and completed her first cycle of R-CHOP chemotherapy 10 days ago. A central venous port was placed 4 days ago. Temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), pulse is 112/min, respirations are 22/min, and blood pressure is 92/58 mm Hg. Pulse oximetry on room air shows 94%. Physical examination reveals right lower lobe crackles and a normal-appearing central port site with no surrounding erythema or induration.

Laboratory results are as follows:
Hemoglobin: 9.2 g/dL
Leukocyte count: $600/\text{mm}^3$
Neutrophils: 15%
Lymphocytes: 80%
Platelet count: $75,000/\text{mm}^3$
Serum creatinine: 1.1 mg/dL

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

A 42-year-old man presents to the emergency department with a 6-week history of chronic cough productive of blood-tinged sputum, drenching night sweats, fatigue, and an unintentional 6-kg (13-lb) weight loss. He recently immigrated to the United States from a country with a high incidence of tuberculosis. His temperature is 38.2°C (100.8°F), blood pressure is 118/76 mm Hg, pulse is 98/min, and respirations are 18/min. A portable chest radiograph performed in the triage area reveals a 3-cm cavitary lesion in the apical segment of the right upper lobe.

Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 45-year-old man is hospitalized for the treatment of severe cellulitis of the right lower extremity. On admission, blood cultures were drawn, and he was started on empiric intravenous vancomycin and ceftriaxone. On hospital day 3, the patient is afebrile, and the erythema has significantly decreased. The blood cultures return positive for Staphylococcus aureus. Susceptibility testing shows the organism is resistant to penicillin but susceptible to oxacillin, cefazolin, and vancomycin. Which of the following is the most appropriate next step in antibiotic therapy?

A 65-year-old man develops severe right knee pain, swelling, and a temperature of 38.2°C (100.8°F) on postoperative day 3 following an uncomplicated inguinal hernia repair. His medical history is significant for hypertension and stage 3 chronic kidney disease. Examination reveals a markedly swollen, erythematous, and exquisitely tender right knee. Arthrocentesis yields cloudy yellow synovial fluid. Analysis shows a leukocyte count of 35,000/mm³ with 85% neutrophils. Polarized light microscopy reveals needle-shaped, negatively birefringent crystals. Gram stain shows no organisms. Which of the following is the most appropriate next step in management?

A 62-year-old man is brought to the emergency department by his daughter due to progressive lethargy, confusion, and generalized swelling over the past week. He has a history of hypertension, chronic obstructive pulmonary disease (COPD), and a pituitary macroadenoma treated with transsphenoidal resection two years ago. His medications include amlodipine and a fluticasone-vilanterol inhaler. On arrival, he is difficult to arouse. Temperature is 35.1°C (95.2°F), pulse is 48/min, respirations are 10/min, and blood pressure is 95/60 mm Hg. Pulse oximetry shows 92% on room air. Physical examination reveals periorbital puffiness, non-pitting edema of the lower extremities, and delayed relaxation phase of deep tendon reflexes. Pulmonary auscultation reveals diminished breath sounds bilaterally but no crackles. Laboratory results are as follows:

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

A 54-year-old man is hospitalized for a 3-day history of high fever, severe back pain, and chills. He has a history of type 2 diabetes mellitus and intravenous drug use. Temperature is 39.2°C (102.6°F), blood pressure is 110/70 mm Hg, and pulse is 112/min. Physical examination reveals point tenderness over the L3-L4 vertebrae and a new soft systolic murmur heard at the left lower sternal border. Blood cultures are drawn, and he is started empirically on intravenous vancomycin and piperacillin-tazobactam. Magnetic resonance imaging of the spine reveals L3-L4 osteomyelitis with an associated anterior epidural abscess. On day 3 of hospitalization, blood cultures grow Staphylococcus aureus. Susceptibility testing shows the organism is resistant to penicillin and susceptible to oxacillin, cefazolin, and vancomycin. Which of the following is the most appropriate next step in the patient's pharmacotherapy?

A 42-year-old woman is brought to the emergency department by her husband due to progressive confusion and lethargy over the past 2 days. She has also reported generalized weakness and dark urine. Her temperature is 38.1°C (100.6°F), blood pressure is 142/88 mmHg, pulse is 112/min, and respirations are 18/min. Physical examination reveals scleral icterus and scattered petechiae over her bilateral lower extremities. Neurologic examination shows a lethargic patient who is oriented to person only, with no focal motor or sensory deficits. Laboratory studies show the following:

A peripheral blood smear demonstrates numerous fragmented red blood cells (schistocytes). Which of the following is the most appropriate next step in management?

A 55-year-old man is evaluated in the hospital for a new-onset headache. He was admitted 5 days ago for a deep venous thrombosis of the right lower extremity and was started on intravenous unfractionated heparin. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $128/82\text{ mm Hg}$, pulse is $88/\text{min}$, and respirations are $16/\text{min}$. Physical examination is unremarkable, with no signs of active bleeding. Laboratory studies on admission showed a platelet count of $240,000/\mu\text{L}$. Today, his laboratory studies show a hemoglobin of $13.5\text{ g/dL}$, a leukocyte count of $7,500/\mu\text{L}$, and a platelet count of $105,000/\mu\text{L}$. Which of the following is the most appropriate next step in management?

Match each common respiratory pathogen causing community-acquired pneumonia with its classic clinical presentation, laboratory finding, or associated risk factor.

A young boy recently adopted from an international orphanage is brought to the clinic for a comprehensive initial evaluation. The adoptive parents do not possess his birth certificate, but the adoption agency estimated his age to be "around 2 years old." The parents are anxious to know if his development is appropriate for his estimated age.

During the assessment, the physician observes the child exploring the exam room. He runs stiffly and falls occasionally. He is able to walk up the clinic's step-stool when holding the physician's hand. When given wooden blocks, he successfully builds a tower of exactly 4 cubes before it topples. He is also given a crayon and spontaneously scribbles on the exam paper. His parents report that he uses a spoon to feed himself, though he often spills.

Based on the child's demonstrated motor and adaptive skills, which of the following communication or social milestones is most consistent with his current developmental age?

Match each of the following specific orthopedic injuries with its most commonly associated acute neurovascular deficit as assessed on physical examination.

Match each clinical vignette describing a patient's presentation to the most likely systemic vasculitis diagnosis.

An 81-year-old woman is urgently evaluated on the medical-surgical unit for acute respiratory distress. She was admitted two days prior for treatment of pyelonephritis and bacteremia, initially receiving 3.5 liters of crystalloid resuscitation along with empiric intravenous piperacillin-tazobactam and vancomycin. Her past medical history includes heart failure with preserved ejection fraction, severe chronic obstructive pulmonary disease (COPD), and hypertension. Today, her blood cultures from admission are finalized, showing growth of Escherichia coli that is susceptible to ceftriaxone but resistant to ampicillin. Currently, she appears anxious and is breathing rapidly. Vital signs are temperature 37.0°C (98.6°F), blood pressure 152/88 mm Hg, heart rate 106/min, and respiratory rate 26/min. Oxygen saturation is 89% on room air. Examination shows jugular venous distention to 12 cm H2O. Auscultation reveals dullness to percussion at the bases with crackles extending halfway up the lung fields. Trace wheezing is also noted. Bilateral lower extremities exhibit 2+ pitting edema.

Laboratory studies drawn an hour ago show:
Leukocyte count: 11,200/mm³
Thyroid-stimulating hormone (TSH): 7.2 mU/L (normal: 0.5–5.0 mU/L)
Free thyroxine (T4): 1.1 ng/dL (normal: 0.9–1.7 ng/dL)

Arterial blood gas (room air):
pH: 7.22
PaCO2: 42 mm Hg
PaO2: 58 mm Hg
HCO3−: 17 mEq/L

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

An 82-year-old woman with a history of vascular dementia is evaluated on the surgical ward for acute confusion. She underwent a right total hip arthroplasty $24$ hours ago. Over the past $6$ hours, she has become highly agitated, disoriented, and reports seeing insects on the ceiling. She is currently receiving intravenous morphine as needed for postoperative pain. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $132/78$ mmHg, pulse is $82$/min, and respirations are $14$/min. Physical examination reveals no suprapubic or costovertebral angle tenderness. The surgical incision is clean and intact. Laboratory studies show a leukocyte count of $8,400/\text{mm}^3$. A routine urinalysis obtained in the emergency department prior to surgery showed $25$ leukocytes/hpf, positive leukocyte esterase, and positive nitrites. The admission urine culture now grows $>10^5 \text{ CFU/mL}$ of *Escherichia coli* susceptible to ceftriaxone, ciprofloxacin, and trimethoprim-sulfamethoxazole. Which of the following is the most appropriate management of this patient's bacteriuria?

A 66-year-old man is brought to the emergency department by his family due to a severe, generalized headache, high fever, and progressive confusion over the past 24 hours. His medical history is significant for multiple myeloma, for which he is currently receiving maintenance chemotherapy. On arrival, his temperature is 39.4°C (102.9°F), blood pressure is 88/54 mmHg, pulse is 122/min, and respirations are 22/min. Physical examination reveals prominent nuchal rigidity and a new-onset right pronator drift. He is oriented only to his name. Arrange the following management steps in the most appropriate chronological order for this patient.

A 34-year-old man is brought to the emergency department for severe right shoulder pain. Thirty minutes ago, he experienced a witnessed generalized tonic-clonic seizure that lasted 2 minutes. On physical examination, the right arm is held firmly in adduction and internal rotation. The patient actively resists any attempt at passive external rotation due to severe pain. The radial pulse is 2+ and sensation is intact to light touch over the deltoid and distal fingers. An initial anteroposterior (AP) radiograph of the right shoulder reveals a symmetric, rounded appearance of the humeral head with no obvious fracture lines. Which of the following is the most appropriate next step in the management of this patient?