Tüm alıştırma soruları

Match each patient's clinical presentation with the autoantibody most specifically associated with their underlying immunologic pathology.

Review the following patient encounters. Which targeted laboratory evaluation is the most appropriate next step for each clinical presentation? Match each patient's scenario to the correct diagnostic test.

A 48-year-old man presents to the emergency department with a $3$-day history of high fever and severe right upper quadrant abdominal pain. He was initially evaluated at an urgent care clinic yesterday, where he was told he likely had a "gallbladder infection" and was referred to the hospital. His past medical history is notable for type 2 diabetes mellitus and hypertension. He emigrated from rural Peru $6$ months ago. Temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $110/70$ mmHg, and heart rate is $108$/min. Physical examination reveals significant tenderness to palpation in the right upper quadrant, with marked hepatomegaly. No scleral icterus is noted. Laboratory studies show a leukocyte count of $18,000$/mm $^3$, total bilirubin of $1.4$ mg/dL, and alkaline phosphatase of $350$ U/L. Right upper quadrant ultrasound demonstrates a single, $8$ cm hypoechoic mass in the right hepatic lobe with well-defined margins; there are no visible gallstones or biliary ductal dilation. Upon further historical questioning, the patient reports having a chronic, nonproductive cough that recently changed; he is now coughing up dark, reddish-brown material that he describes as resembling "anchovy paste." Based on a comprehensive evaluation of the patient's history and diagnostic findings, which of the following is the most likely etiology of his presentation?

A 59-year-old man is brought to the emergency department complaining of severe, worsening lower back pain and an inability to urinate for the past 14 hours. He also reports numbness in his groin area and bilateral leg weakness. His past medical history is significant for hypertension and a history of a metallic intraocular foreign body from a welding accident 20 years ago. At the time, the metal fragment was deemed too deeply embedded to be safely removed and has remained in his left eye. Vital signs are within normal limits. Neurologic examination reveals decreased sensation over the perineum, absent anal wink reflex, and 3/5 motor strength in the bilateral lower extremities. A bedside bladder ultrasound shows a post-void residual volume of 650 mL. Which of the following is the most appropriate next step in imaging for this patient?

A $31$-year-old woman is evaluated in the outpatient clinic prior to an elective laparoscopic cholecystectomy for symptomatic cholelithiasis. She has a past medical history of a left lower extremity deep vein thrombosis $3$ years ago following a long-haul flight, for which she was treated with oral anticoagulation for $6$ months. She currently takes no medications. She reports no history of abnormal bleeding with previous dental extractions or menses. Physical examination is unremarkable.

Preoperative laboratory studies show:

A $1:1$ mixing study with normal pooled plasma is performed. The patient's aPTT immediately after mixing is $58$ seconds, and after a $2$-hour incubation, it remains $60$ seconds.

Which of the following is the most likely explanation for this patient's laboratory findings?

A 48-year-old woman is evaluated in the outpatient clinic after discovering a painless lump in her neck while applying lotion. She reports feeling somewhat "jittery" over the past month and has experienced a 2-kg (4.4-lb) weight loss despite maintaining her normal appetite. She has no prior medical history and takes no medications. Vital signs are normal except for a heart rate of 102/min. Physical examination reveals a smooth, firm, mobile, 1.8-cm nodule in the left lobe of the thyroid gland. No cervical lymphadenopathy is appreciated. A targeted bedside ultrasound confirms a 1.8-cm solid, circumscribed, hypoechoic nodule in the left thyroid lobe. Laboratory studies reveal:

Thyroid-stimulating hormone (TSH): 0.08 $\mu$ U/mL (Normal: 0.5–5.0 $\mu$ U/mL)
Free thyroxine (T4): 2.4 ng/dL (Normal: 0.9–1.7 ng/dL)

Which of the following is the most appropriate next imaging study?

A 74-year-old woman presents to the clinic with a 2-week history of severe, unilateral right-sided temporal headache and generalized fatigue. She also reports pain in her jaw muscles when chewing meat, which resolves shortly after she stops eating. Yesterday, she experienced a transient episode of vision loss in her right eye that lasted for 10 minutes before fully resolving. Her temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$). Physical examination reveals a tender, nodular, and non-pulsatile right temporal artery. Laboratory studies show an erythrocyte sedimentation rate (ESR) of $85\text{ mm/h}$ (normal: $<20\text{ mm/h}$). A biopsy of the symptomatic temporal artery is scheduled to confirm the diagnosis. Which of the following histopathologic findings are most likely to be present in this patient's biopsy specimen? (Select all that apply)

A 72-year-old man is admitted to the hospital with a 3-day history of severe diarrhea and decreased oral intake. His past medical history is significant for heart failure with preserved ejection fraction, for which he takes furosemide and lisinopril daily. On physical examination, his blood pressure is $90/60\text{ mm Hg}$ and heart rate is $112/\text{min}$. Mucous membranes are dry, and capillary refill time is prolonged.

Initial laboratory studies are obtained:

The patient's baseline serum creatinine is $1.0\text{ mg/dL}$. The physician suspects prerenal acute kidney injury secondary to volume depletion. Given the patient's active loop diuretic use, the fractional excretion of sodium (FENa) may be artifactually elevated and unreliable.

What is the calculated value (expressed as a percentage) of the alternative fractional excretion index that should be used to confirm the etiology of his kidney injury?

Match each endocrine or renal diagnostic entity with its characteristic laboratory profile involving calcium, phosphorus, and parathyroid hormone (PTH). Assume standard laboratory reference ranges unless otherwise specified.

A 58-year-old man presents to the urgent care clinic complaining of left elbow pain and swelling that began 3 days ago. He works as a carpet installer and reports frequently leaning on his elbows during his work shifts. He denies any recent falls, skin abrasions, tick bites, or fevers. Vital signs are temperature 37.1°C (98.8°F), blood pressure 128/82 mmHg, heart rate 76/min, and respiratory rate 14/min. On physical examination, there is a discrete, fluctuant, 4-cm swelling over the posterior aspect of the left elbow with mild overlying erythema. The patient has full, painless passive range of motion of the elbow joint. Active range of motion is completely intact but elicits mild discomfort at the posterior elbow during maximum flexion. Palpation of the medial and lateral epicondyles reveals no tenderness. Which of the following is the most likely diagnosis based on these physical examination findings?

A 54-year-old woman presents to the emergency department with a 2-day history of intense burning pain in her hands and feet. Four days ago, she developed abrupt-onset nausea, vomiting, and non-bloody diarrhea that resolved after 48 hours. Yesterday, she noticed severe tingling around her mouth. She specifically reports that when she stepped on the cold bathroom tile this morning, it felt like she was stepping on hot coals. Medical history includes type 2 diabetes mellitus, fibromyalgia, and essential hypertension. Surgical history is notable for a cholecystectomy 5 years ago. She returned 3 days ago from a 10-day vacation in the Caribbean, where she participated in scuba diving and ate at local seafood restaurants. She does not use tobacco or illicit drugs and drinks wine occasionally. Medications include metformin, duloxetine, and amlodipine, which was started 3 weeks ago. Vital signs are within normal limits. Neurologic examination shows intact cranial nerves and normal strength. There is marked allodynia and dysesthesia to cold stimuli over the distal extremities. Deep tendon reflexes are 2+ and symmetric. Laboratory studies show a random serum glucose of 142 mg/dL. Which of the following elements from this patient's history is most critical for establishing the correct diagnosis?

Match each clinical presentation with the single most appropriate initial or subsequent diagnostic imaging modality. Consider patient-specific contraindications and hemodynamic stability when making your selections.

During comprehensive neurological assessments on the inpatient medical ward, a physician observes various distinct pupillary and extraocular movement abnormalities across multiple patients. Match each specific physical examination finding to its exact neuroanatomic localization or underlying pathophysiologic mechanism.

A 68-year-old man is brought to the emergency department with sudden-onset right-sided hemiparesis, facial droop, and global aphasia. His symptoms were first noticed by his wife 8 hours ago, and he was last known to be at his baseline 10 hours ago. His blood pressure is 165/90 mmHg, and his pulse is 88/min and irregularly irregular. Suspecting an acute ischemic stroke, the stroke team is activated to evaluate the patient for potential mechanical thrombectomy.

Arrange the following neuroimaging modalities in the most appropriate chronological sequence for the evaluation and management of this patient, from initial emergency department presentation to definitive subacute post-treatment follow-up.

A $58$-year-old man is evaluated in the emergency department for severe, acute-onset pain, swelling, and redness of his right knee. He is a renal transplant recipient and his current immunosuppressive regimen includes azathioprine, tacrolimus, and low-dose prednisone. He also has a history of peptic ulcer disease with a recent gastrointestinal hemorrhage. His temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$). Serum laboratory studies show a creatinine level of $2.9\text{ mg/dL}$ and a uric acid level of $5.8\text{ mg/dL}$ (normal: $4.0-8.5\text{ mg/dL}$). Joint aspiration yields cloudy synovial fluid with a leukocyte count of $55,000/\mu\text{L}$ ($85\%$ neutrophils) and negatively birefringent, needle-shaped crystals. Due to the patient's medical history, several standard therapies are deemed high-risk. The physician decides to administer a targeted biologic agent appropriate for the acute management of this condition. Inhibition or neutralization of which of the following is the primary mechanism of action of the most appropriate therapy for this patient's current symptoms?

A 65-year-old man presents to a gastroenterology clinic with a 4-week history of painless jaundice, significant pruritus, dark urine, and a 6-kg (13-lb) unintentional weight loss. His medical history is significant for type 2 diabetes mellitus diagnosed 6 months ago. He has a 40-pack-year smoking history. Vital signs are within normal limits. Physical examination reveals profound scleral icterus and a palpable, non-tender mass in the right upper quadrant of the abdomen. Laboratory studies demonstrate:

Total bilirubin: 14.2 mg/dL
Direct bilirubin: 11.5 mg/dL
Alkaline phosphatase: 720 U/L
Aspartate aminotransferase (AST): 85 U/L
Alanine aminotransferase (ALT): 92 U/L

A contrast-enhanced multiphasic computed tomography (CT) scan of the abdomen is obtained. The radiologist's report describes a 3.5-cm hypoattenuating mass in the head of the pancreas. There is marked dilation of both the common bile duct and the main pancreatic duct. Furthermore, the mass encases the superior mesenteric artery (SMA) for approximately 270 degrees of its circumference and causes short-segment occlusion of the superior mesenteric vein (SMV). No hepatic or pulmonary lesions are identified.

Based on the interpretation of these imaging results, which of the following is the most accurate conclusion regarding this patient's diagnosis and management?

A $31$-year-old primigravid woman at $26$ weeks gestation is evaluated in the emergency department for a $24$-hour history of progressively worsening right-sided abdominal pain. The pain initially began in the periumbilical region but has since localized to the right mid-to-upper abdomen. She reports nausea and one episode of vomiting. Her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $112/70\text{ mmHg}$, pulse is $105/\text{min}$, and respirations are $16/\text{min}$. Physical examination reveals focal tenderness over the right lateral abdomen without rebound or guarding. Fetal heart tones are $145/\text{min}$ and reactive. Laboratory studies show a leukocyte count of $15,200/\text{mm}^3$ with $82\%$ neutrophils. Which of the following is the most appropriate initial imaging study to evaluate this patient's condition?

A 68-year-old man is brought to the emergency department by his daughter. She reports that he has a long history of severe alcohol use disorder and was found at his apartment with a 3-day history of high fever, productive cough with thick, foul-smelling sputum, and progressive shortness of breath. Temperature is $38.9^\circ\text{C}$, blood pressure is $110/70$ mmHg, heart rate is $108$/min, and respiratory rate is $24$/min. Pulse oximetry shows $92\%$ on room air. Dental examination reveals poor dentition with severe gingivitis. Chest radiography demonstrates a $4$ cm cavitary lesion with a prominent air-fluid level located in the superior segment of the right lower lobe. Based on this patient's clinical presentation, arrange the following differential diagnoses for his cavitary lung lesion in order of their pre-test probability, from highest (most likely) to lowest (least likely).

A 45-year-old male construction worker presents to the primary care clinic complaining of right shoulder pain that has progressively worsened over the past three months. He denies any acute trauma but notes deep pain with overhead activities and a sense of weakness when lifting heavy materials at work. As part of his clinical evaluation, the physician performs various provocative maneuvers of the shoulder. Match the following physical examination maneuvers with the corresponding anatomical structure or pathology they are designed to evaluate.

An adult rheumatology clinic is evaluating a 48-year-old woman who reports a six-month history of profound generalized muscle weakness and fatigue. During the review of systems, she mentions requiring frequent sips of water to swallow dry foods and a constant gritty sensation in her eyes. Physical examination reveals bilateral parotid gland enlargement and dry oral mucosa.

Laboratory evaluation shows the following:

Based on the interpretation of these laboratory results, which of the following additional findings is most likely to be present in this patient?