Tüm alıştırma soruları

Progressive respiratory distress over the past 72 hours brings a retired teacher to the emergency department. The 72-year-old man reports that he cannot sleep flat in bed due to a suffocating sensation, which is accompanied by a cough producing frothy sputum. He has a 45-pack-year history of smoking, hypertension, and type 2 diabetes mellitus. His daily medications are amlodipine and metformin. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 162/94 mm Hg, heart rate of 108/min, and respiratory rate of 26/min. Pulse oximetry on ambient air indicates an oxygen saturation of 88%. On physical examination, the jugular veins are distended to 10 cm H2O above the sternal angle. Auscultation of the lungs reveals widespread expiratory wheezes and fine crackles at both lung bases. Cardiac examination shows a regular, rapid rhythm with a distinct third heart sound (S3). Examination of the lower extremities shows bilateral 1+ pitting edema. Electrocardiography shows sinus tachycardia without ischemic changes. Chest radiography is pending. Which of the following is the most appropriate next step in management?

A 25-year-old woman with a history of type 1 diabetes mellitus presents to the emergency department with generalized weakness, nausea, and abdominal pain for the past 24 hours. She has been unable to eat and has missed her last two doses of insulin. Her blood pressure is 110/70 mm Hg, pulse is 115/min, and respirations are 24/min. Physical examination shows dry mucous membranes and a fruity odor to her breath.

Laboratory studies show:
Serum sodium: 140 mEq/L
Serum potassium: 4.8 mEq/L
Serum chloride: 104 mEq/L
Serum bicarbonate: 12 mEq/L
Blood urea nitrogen: 28 mg/dL
Serum creatinine: 1.2 mg/dL
Plasma glucose: 450 mg/dL

Arterial blood gas analysis on room air:
pH: 7.25
pCO2: 26 mm Hg
pO2: 95 mm Hg

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

A 10-day-old female neonate is evaluated in the neonatal intensive care unit for sudden clinical deterioration. She was born at 29 weeks of gestation via urgent cesarean delivery due to severe maternal preeclampsia. Birth weight was 1,150 g (2 lb 8 oz). Apgar scores were 5 and 7 at 1 and 5 minutes, respectively. Over the past 8 hours, the neonate has developed temperature instability and frequent episodes of apnea and bradycardia. She is currently supported with continuous positive airway pressure. She had been tolerating advancing volumes of expressed maternal milk via an orogastric tube; however, the most recent feed yielded a large bilious gastric residual. Temperature is 35.8°C (96.4°F), pulse is 175/min, and respirations are 68/min. The abdomen is grossly distended, shiny, and erythematous with absent bowel sounds. Complete blood count shows a leukocyte count of 2,200/mm³ and a platelet count of 82,000/mm³. Arterial blood gas analysis reveals a pH of 7.26, $\text{pCO}_2$ of 38 mm Hg, and $\text{HCO}_3^-$ of 15 mEq/L. An anteroposterior abdominal radiograph demonstrates prominent, dilated bowel loops with linear radiolucencies in the intestinal wall, without free air under the diaphragm. Which of the following is the most appropriate next step in management?

A 72-year-old man is evaluated in the hospital for acute-onset shortness of breath. He is currently on postoperative day 3 following an open partial colectomy for colon cancer. He has a history of hypertension, type 2 diabetes mellitus, and chronic kidney disease. Two hours ago, routine laboratory studies were obtained:

Due to the symptomatic anemia, a transfusion of packed red blood cells was initiated. Forty-five minutes into the transfusion, the patient develops severe dyspnea and a nonproductive cough.

His temperature is $38.1^\circ\text{C} (100.6^\circ\text{F})$, blood pressure is $178/96 \text{ mmHg}$, pulse is $115/\text{min}$, and respirations are $28/\text{min}$. Pulse oximetry is $87\%$ on room air.

Physical examination reveals a patient in acute respiratory distress. The jugular veins are distended to the angle of the mandible while sitting at 45 degrees. Cardiac auscultation reveals a regular tachycardia with a prominent $S_{3}$ gallop. Pulmonary auscultation reveals bilateral basilar crackles.

An arterial blood gas on room air shows:
pH: $7.49$
pCO2: $30 \text{ mmHg}$
pO2: $56 \text{ mmHg}$
HCO3: $23 \text{ mEq/L}$

The blood transfusion is immediately stopped, and supplemental oxygen is provided. Which of the following is the most appropriate next step in management?

A 27-year-old graduate student is brought to the university health clinic by his roommate. The roommate reports that for the past 14 weeks, the patient has been barricading himself in their shared apartment, claiming that rival researchers are trying to steal his thoughts using microwave beams. The patient has been hearing two voices arguing about his research outside his window, even when no one is there. He has not attended classes or bathed regularly during this time. Prior to this, he was a top-performing student with a wide circle of friends and no prior psychiatric history. Medical history is unremarkable. Vital signs and physical examination are within normal limits. A urine toxicology screen is negative. Which of the following is the most likely diagnosis?

During routine morning rounds on postoperative day 3, a 51-year-old man is evaluated after an elective open reduction and internal fixation of a right tibial fracture. He reports feeling mildly fatigued but is participating in early physical therapy. An indwelling urinary catheter was placed intraoperatively and removed on postoperative day 1. His temperature is 38.6°C (101.5°F), blood pressure is 125/80 mmHg, heart rate is 88/min, and respiratory rate is 16/min. Oxygen saturation is 98% on room air. Physical examination reveals clear breath sounds bilaterally. The right lower extremity surgical dressings are intact, with no surrounding erythema, induration, or unusual swelling. Palpation of the left calf is non-tender. When questioned further, he notes increased urinary frequency and mild suprapubic discomfort since the previous evening. Which of the following is the most appropriate next step in management?

A 12-hour-old male neonate is evaluated in the nursery due to rapid breathing. He was born at 38 weeks gestation via scheduled cesarean delivery for a breech presentation. The pregnancy was uncomplicated, and maternal group B Streptococcus screening was negative. Apgar scores were 8 and 9 at 1 and 5 minutes. His temperature is 36.9°C (98.4°F), heart rate is 148/min, respiratory rate is 74/min, and oxygen saturation is 96% on room air. Physical examination shows a vigorous infant with mild subcostal retractions. Breath sounds are clear and equal bilaterally without murmurs. Skin examination reveals multiple scattered 2-mm pustules on a broad erythematous base across the anterior chest, abdomen, and proximal extremities. A chest radiograph demonstrates hyperinflation, prominent perihilar linear densities, and fluid within the interlobar fissures. Which of the following is the most appropriate next step in management?

A $74$-year-old man is evaluated on the postoperative wards on hospital day $5$ following an urgent open reduction and internal fixation of a right femoral neck fracture. For the past $3$ days, he has experienced progressive abdominal distension, nausea, and a failure to pass flatus or stool. $48$ hours ago, all opioid analgesics were discontinued, and he was placed on bowel rest with nasogastric tube decompression and intravenous fluid support. Despite these measures, his symptoms have worsened. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), pulse is $88/\text{min}$, blood pressure is $138/82 \text{ mmHg}$, and respirations are $16/\text{min}$. The abdomen is massively distended and tympanitic to percussion. It is mildly tender diffusely, but there is no guarding, rigidity, or rebound tenderness. Bowel sounds are absent. Laboratory studies show a leukocyte count of $8,000/\text{mm}^3$, potassium of $4.2 \text{ mEq/L}$, and magnesium of $2.1 \text{ mEq/L}$. An electrocardiogram shows normal sinus rhythm. Computed tomography of the abdomen and pelvis with intravenous contrast reveals marked dilation of the colon extending from the cecum to the splenic flexure, with a maximal cecal diameter of $11.8 \text{ cm}$. There is no discrete transition point, obstructing mass, or pneumoperitoneum. Which of the following is the most appropriate next step in management?

A 58-year-old man with a history of chronic alcohol use disorder is brought to the emergency department due to profound weakness and a four-day history of intractable vomiting. He reports being unable to keep any food or fluids down. On physical examination, he appears lethargic and has dry mucous membranes with decreased skin turgor.

Laboratory studies reveal the following:

Serum:
Sodium: 140 mEq/L
Potassium: 3.1 mEq/L
Chloride: 88 mEq/L
Bicarbonate: 14 mEq/L
Blood urea nitrogen: 35 mg/dL
Creatinine: 1.6 mg/dL

Arterial blood gas on room air reveals a pH of 7.32 and a $pCO_2$ of 29 mm Hg. The physician suspects a complex mixed acid-base disorder driven by alcoholic ketoacidosis and protracted emesis.

Assuming a baseline normal anion gap of 12 mEq/L and a baseline normal serum bicarbonate of 24 mEq/L, what is the calculated delta-delta ratio ($\Delta AG / \Delta HCO_3^-$) for this patient?

A 26-year-old woman, gravida 1, para 0, presents to the clinic for a scheduled prenatal evaluation at 26 weeks gestation. She has no complaints other than mild, intermittent fatigue. The patient is taking a daily prenatal vitamin containing iron and folic acid. Her vital signs are temperature 36.8°C (98.2°F), blood pressure 110/70 mm Hg, heart rate 82/min, and respiratory rate 14/min. Fetal heart tones are 145/min.

Laboratory studies obtained today show the following:

At her initial visit at 9 weeks gestation, her hemoglobin was 12.8 g/dL. Which of the following is the most likely primary mechanism responsible for this patient's current hematologic findings?

An oncology consultation is requested for a 34-year-old man admitted to the intensive care unit due to profound pancytopenia and severe watery diarrhea. The patient has a history of classical Hodgkin lymphoma, for which he completed systemic chemotherapy three months ago. Two weeks prior to this admission, he presented to an outpatient clinic with symptomatic anemia and received two units of packed red blood cells donated by his healthy biological brother. Over the last four days, he has developed a diffuse, erythematous maculopapular rash involving the palms and soles, abdominal cramping, and jaundice. Vital signs reveal a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure of 105/65 mmHg, and heart rate of 115/min. Laboratory studies show:

Which of the following pre-transfusion blood product modifications would have most likely prevented this patient's current condition?

During her active phase of labor, a $28$-year-old nulliparous woman at $40$ weeks gestation experiences a change in fetal monitoring patterns. She is currently receiving a continuous oxytocin infusion to augment labor. Her cervix is $6$ cm dilated and $90\%$ effaced. The external fetal monitor shows a baseline heart rate of $135$/min with moderate variability. Following the peak of several recent uterine contractions, the fetal heart rate gradually drops to $110$/min and slowly returns to the baseline after the contractions have completely ended. The maternal blood pressure is $120/75$ mm Hg and temperature is $36.8^{\circ}$ C ($98.2^{\circ}$ F). Which of the following is the most appropriate next step in the management of this patient?

Match each classic physical examination finding or auscultatory feature with the most likely associated pediatric congenital heart defect.

Match the following normal expected clinical findings during pregnancy with their primary physiological mechanism.

During morning rounds in the intensive care unit, a 54-year-old woman experiences a sudden respiratory decompensation. She was intubated and mechanically ventilated three days prior due to acute respiratory distress syndrome (ARDS) secondary to severe influenza pneumonia. Over the past 5 minutes, the ventilator's high peak airway pressure alarm has activated repeatedly. Concurrently, her oxygen saturation has rapidly declined from $94\%$ to $82\%$, and her blood pressure has fallen from $110/70\text{ mmHg}$ to $85/50\text{ mmHg}$. Her heart rate is $128/\text{min}$. Arrange the following steps in the most appropriate sequential order for evaluating and managing this patient's acute deterioration.

A $16$-year-old female high school student presents to an outpatient neurology practice after suffering a generalized convulsion. The event occurred this morning shortly after she woke up. Her mother states that for the past $6$ months, the patient has experienced sudden, brief, symmetric muscle jerks in her upper extremities, predominantly occurring within the first hour of awakening. These jerks have occasionally caused her to drop her hairbrush. Her past medical history is unremarkable. She met all early developmental milestones on time, including sitting without support at $6$ months and walking independently at $12$ months. Neurologic examination today demonstrates normal tone, power, and reflexes. An interictal electroencephalogram shows bursts of bilateral, synchronous $4$- to $6$-Hz polyspike-and-wave discharges on a normal background. Which of the following statements regarding this patient's diagnosis and management are correct? (Select 2)

A 62-year-old woman is evaluated in the hospital for sudden-onset right leg pain and swelling. She was admitted 6 days ago for a pulmonary embolism and has been receiving a continuous intravenous infusion of unfractionated heparin. Today, her platelet count is 65,000/mm³, representing a significant drop from her admission baseline of 240,000/mm³. Lower extremity venous Doppler ultrasound reveals a new acute deep vein thrombosis in the right femoral vein. The 4Ts score is calculated and indicates a high clinical probability of heparin-induced thrombocytopenia (HIT).

Arrange the following steps for the diagnosis and long-term management of this patient in the most appropriate chronological order.

A 67-year-old male is brought to the emergency department by his daughter due to a three-day history of progressively worsening shortness of breath. The patient reports that his typical morning cough has worsened, producing a larger volume of thick, yellowish-green sputum. His past medical history is significant for chronic obstructive pulmonary disease and hypertension. Current vital signs reveal a temperature of 37.3°C (99.1°F), blood pressure of 138/86 mm Hg, heart rate of 98/min, and a respiratory rate of 22/min. Pulse oximetry shows an oxygen saturation of 91% on ambient air. Physical examination demonstrates a prolonged expiratory phase with diffuse bilateral wheezing. There is no jugular venous distention, and the lower extremities are free of edema. Which of the following interventions are indicated in the initial management of this patient's current condition? (Select all that apply.)

Match the following thoracic trauma clinical presentations to their most appropriate immediate next step in management or diagnostic evaluation.

A 9-month-old boy is brought to the pediatric clinic by his parents due to progressive lethargy, poor feeding, and loss of motor milestones over the past two months. Previously, he was able to sit without support, but he now has pronounced head lag and generalized weakness. Physical examination reveals a pale, apathetic infant with generalized hypotonia and a smooth, erythematous tongue. There is no hepatosplenomegaly, and no dysmorphic facial features are noted.

Laboratory studies are obtained and reveal the following:

Which of the following is the most likely primary underlying defect in this patient?