Tüm alıştırma soruları

A 56-year-old man is brought to the emergency department by his daughter due to increasing confusion and abdominal swelling over the past 3 days. He has a history of alcohol use disorder. His temperature is 37.9°C (100.2°F), blood pressure is 105/65 mm Hg, and pulse is 98/min. Physical examination reveals scleral icterus, spider angiomas on the chest, a distended abdomen with a positive fluid wave, and bilateral pitting pedal edema. When the patient extends his arms and dorsiflexes his wrists, a flapping tremor is observed.

Laboratory studies show:

A diagnostic paracentesis is performed, yielding cloudy yellow fluid. Ascitic fluid analysis reveals:

Based on these laboratory results, which of the following is the most accurate diagnostic interpretation?

A 28-year-old woman comes to the clinic reporting a 4-month history of progressively worsening fatigue, intermittent abdominal bloating, and loose, foul-smelling stools. She has a past medical history of type 1 diabetes mellitus, which is well managed with a basal-bolus insulin regimen. Her vital signs are within normal limits. Physical examination reveals conjunctival pallor and mild abdominal distension without focal tenderness. Laboratory studies show a hemoglobin of 10.2 g/dL, a mean corpuscular volume of 74 fL, and a serum ferritin of 8 ng/mL. Which of the following is the most appropriate next step in laboratory evaluation?

A $71$-year-old man is brought to the primary care clinic by his son, who reports that his father has become increasingly forgetful and fatigued over the past $6$ months. The patient also describes a new "pins and needles" sensation in both of his feet. His medical history is notable for type 2 diabetes mellitus, essential hypertension, and hyperlipidemia. Current medications include metformin, lisinopril, and atorvastatin. Vital signs are within normal limits. Physical examination reveals a wide-based, unsteady gait and decreased vibratory sensation in the bilateral toes and ankles.

Laboratory studies reveal the following:

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

A 22-year-old college student is brought to the emergency department by his roommates due to severe agitation, confusion, and muscle twitching that started 4 hours ago. His past medical history is significant for major depressive disorder, for which he takes daily citalopram. Vital signs include a temperature of 39.1°C (102.4°F), heart rate of 128/min, blood pressure of 165/95 mm Hg, and respiratory rate of 22/min. Physical examination reveals profuse diaphoresis, dilated pupils, bilateral ocular clonus, and marked hyperreflexia in the lower extremities with inducible ankle clonus. The physician suspects a specific toxidrome and performs a targeted medical history evaluation.

Which of the following elements in the patient's recent history would directly account for the development of this clinical presentation? (Select all that apply)

A 65-year-old woman with a history of atrial fibrillation is evaluated for sudden-onset right-sided hemiparesis and expressive aphasia. The neurology team discusses the expected neuroimaging evolution of a large middle cerebral artery territory infarction.

Arrange the following expected magnetic resonance imaging (MRI) head findings in chronological order of their appearance, from earliest (hyperacute phase) to latest (chronic phase).

Evaluating a 41-year-old individual during a new-patient intake visit, the physician notes an asymptomatic but severely elevated blood pressure of $172/105$ mmHg. The patient reports experiencing recent, uncharacteristic muscle cramping and profound weakness over the past month. They have not seen a healthcare provider in ten years, deny any vomiting or diarrhea, and take no prescription medications. Initial laboratory analysis reveals a serum potassium level of $2.4$ mEq/L and a serum bicarbonate level of $32$ mEq/L. Before initiating an extensive biochemical workup for an endogenous endocrine disorder, the physician conducts a targeted dietary and habit history to rule out an exogenous mimic. Eliciting a history of heavy, daily consumption of which of the following items is most critical for establishing the underlying diagnosis?

Match each clinical scenario involving a newly discovered intra-abdominal lesion to the single most appropriate next step in diagnostic imaging or workup. Consider patient-specific risk factors and evidence-based society guidelines.

A female patient, aged 61, presents to her primary care physician reporting a progressive decline in her exercise tolerance over the past three months. She notes shortness of breath after climbing a single flight of stairs, alongside generalized fatigue. Her past medical history is significant for a severe febrile illness accompanied by migratory joint pains during adolescence. Current vital signs include a blood pressure of 158/52 mmHg and a regular pulse of 92/min. Careful inspection of the hands reveals alternating blanching and flushing of the nail beds when gentle pressure is applied to the tip of the nails. Auscultation over the femoral arteries detects a to-and-fro bruit with both systolic and diastolic components upon partial compression. Which of the following additional physical examination findings is most likely to be present in this patient?

A 62-year-old man presents to the outpatient clinic with a 6-month history of progressive difficulty walking and tingling in his feet. He describes his legs as feeling 'stiff and heavy.' He also reports increased fatigue over the same period. His past medical history includes hypertension, benign prostatic hyperplasia, and complete edentulism. He takes amlodipine and tamsulosin. He does not use tobacco, alcohol, or illicit substances. Neurological examination reveals a spastic, wide-based gait, bilateral lower extremity hyperreflexia, positive Babinski signs, and markedly decreased vibratory and position sense in the toes. Laboratory studies reveal a hemoglobin of $9.2 \text{ g/dL}$ with a mean corpuscular volume of $74 \text{ fL}$, and an absolute neutrophil count of $900/\text{mm}^3$. Serum vitamin B12, folate, and methylmalonic acid levels are within normal limits. Which of the following questions during the medical history evaluation is most likely to reveal the etiology of this patient's condition?

A 62-year-old woman with a history of poorly controlled type 2 diabetes mellitus, hyperlipidemia, and a 35-pack-year smoking history presents to the vascular surgery clinic. She reports severe, cramping pain in her bilateral calves that predictably occurs after walking approximately 50 meters and is promptly relieved by 5 minutes of rest. Her physical examination reveals shiny, hairless skin over the distal lower extremities, delayed capillary refill, and non-palpable dorsalis pedis pulses bilaterally. The patient states these symptoms have progressively worsened over the past six months and now significantly impair her ability to work. The clinical team determines that she is a candidate for revascularization. Arrange the following diagnostic and imaging modalities in the standard, step-wise chronological sequence utilized to evaluate her condition, map the disease, and perform the intervention.

Emergency medical services arrive at the resuscitation bay with a gravid patient (estimated 34 weeks of gestation) in severe respiratory distress. The 31-year-old patient suddenly developed generalized pruritus, shortness of breath, and a feeling of impending doom while dining at a local seafood restaurant 30 minutes ago. On initial evaluation, she is lethargic. Physical examination reveals prominent periorbital swelling, diffuse raised erythematous plaques across her trunk, and loud inspiratory stridor. She is utilizing accessory muscles to breathe. Initial vital signs indicate a temperature of 37.0°C (98.6°F), profound hypotension at 70/40 mm Hg, marked tachycardia at 145/min, a respiratory rate of 30/min, and an oxygen saturation of 85% on room air. Concurrent with rapid intravenous fluid administration, which of the following are the most appropriate immediate steps in the stabilization of this patient? (Select 3)

A 29-year-old professional graphic designer is evaluated in the occupational medicine clinic due to worsening right forearm discomfort and clumsiness in her hand over the past four months. She describes an aching sensation in the anterior forearm that occasionally radiates distally. On physical examination, there is diminished light touch and pinprick sensation over the volar aspect of the right thumb, index, and middle fingers. During further detailed sensory mapping, the physician notes that this sensory deficit clearly extends to include the skin overlying the thenar eminence. Motor examination demonstrates weakness during thumb abduction and opposition. Flexion of the interphalangeal joints is fully intact. The Phalen maneuver and Tinel sign at the wrist elicit no symptoms. Which of the following physical examination findings in this patient specifically differentiates her condition from compression of the nerve beneath the transverse carpal ligament?

A 39-year-old previously healthy woman is brought to the emergency department after her roommates found her lethargic and confused. Empty bottles of an unknown liquid were found in her room. On arrival, she is difficult to rouse and responds poorly to stimuli. Vital signs show a temperature of $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure of $115/75\text{ mm Hg}$, pulse of $110/\text{min}$, and respiratory rate of $28/\text{min}$ with deep, rapid breaths. Laboratory studies report the following:

Additional laboratory analysis:
* Measured serum osmolality: $340\text{ mOsm/kg } H_2O$
* Arterial blood gas (room air) pH: $7.15$
* Arterial PaCO2: $20\text{ mm Hg}$

Based on these laboratory results, what is this patient's osmolar gap? (Express the result in $\text{mOsm/kg } H_2O$.)

A 47-year-old man with a history of intravenous drug use is admitted to the inpatient medical ward with a 2-week history of spiking fevers, generalized myalgias, and progressive fatigue. His temperature is 39.2°C (102.6°F), blood pressure is 110/65 mm Hg, and pulse is 112/min. Cardiac auscultation reveals a new high-pitched holosystolic murmur at the apex radiating to the axilla. Transesophageal echocardiography visualizes a large, mobile vegetation on the mitral valve leaflets. The physician conducts a thorough physical examination to identify peripheral stigmata of infective endocarditis. Among the classic peripheral manifestations of this disease, which of the following physical examination findings are pathophysiologically mediated by immune complex deposition rather than direct septic microembolization? (Select all that apply)

A 28-year-old man presents to the primary care clinic for evaluation of a penile sore. He noticed the lesion approximately one week ago. He reports that it is completely painless and has not changed in size. The patient is sexually active with new male partners and reports inconsistent condom use. He has no other medical conditions and takes no medications. Vital signs are within normal limits. Physical examination reveals a 1.2-cm, well-demarcated, indurated ulcer with a clean base on the glans penis. Bilateral non-tender inguinal lymphadenopathy is also present. The physician suspects primary syphilis. The clinic laboratory utilizes the reverse sequence screening algorithm for serologic evaluation.

Arrange the following laboratory tests in the correct chronological sequence as they are performed in the reverse sequence diagnostic algorithm for this patient's suspected condition.

A 74-year-old man is brought to the emergency department due to a 4-hour history of agonizing, diffuse abdominal pain. He recently survived an anterior myocardial infarction and has a known left ventricular apical aneurysm. Vital signs show a temperature of 37.2°C (99.0°F), blood pressure of 160/95 mmHg, pulse of 115/min, and respirations of 22/min. On physical examination, the patient is writhing in discomfort, but his abdomen is soft, non-distended, and exhibits only mild diffuse tenderness to deep palpation with no rebound or guarding. A contrast-enhanced computed tomography (CT) scan of the abdomen reveals an abrupt cutoff in a major mesenteric vessel and diminished mural enhancement of several distal jejunal loops. The radiologist also notes distinct, linear, branching radiolucencies located strictly within the substance of the bowel wall. Which of the following is the most accurate interpretation of these linear radiolucencies?

A $58$-year-old man with a history of hypertension undergoes an abdominal ultrasound for mild right upper quadrant pain. The ultrasound incidentally identifies a $3.2$-cm solid mass in the right adrenal gland. Subsequent biochemical screening for hypercortisolism, primary aldosteronism, and pheochromocytoma is entirely normal. Arrange the following diagnostic modalities in the correct evidence-based sequence for characterizing this adrenal incidentaloma, starting with the initial preferred imaging study and ending with the most invasive diagnostic step of last resort.

A 26-year-old man presents to the primary care clinic for evaluation of recurrent transient loss of consciousness. He reports having three distinct episodes over the past six months. Each episode was brief, with rapid and complete spontaneous recovery. He has no known past medical history and takes no medications or supplements. His physical examination, including orthostatic vital signs, cardiopulmonary auscultation, and a detailed neurologic exam, is unremarkable. A resting 12-lead electrocardiogram (ECG) shows normal sinus rhythm with no interval prolongation, ST-T wave abnormalities, or evidence of pre-excitation. An echocardiogram reveals normal biventricular size and systolic function with no valvular pathology.

Given the unremarkable initial objective workup, comprehensive medical history evaluation is paramount to risk-stratify this patient and prioritize subsequent diagnostic testing.

Which of the following historical elements, if elicited, would most strongly indicate a high-risk primary arrhythmogenic or structural cardiac etiology requiring urgent evaluation? (Select all that apply)

A 31-year-old nulliparous woman is evaluated in the emergency department for acute-onset right lower quadrant abdominal pain and nausea. Her only daily medication is a combined oral contraceptive pill, which she has taken for the past 10 years. Vital signs are within normal limits. Physical examination reveals localized tenderness in the right lower quadrant. A contrast-enhanced multiphasic CT scan of the abdomen and pelvis confirms early, uncomplicated acute appendicitis. Additionally, the radiologist reports an incidental 4.2-cm, well-demarcated, solid mass in the right hepatic lobe. On the arterial phase, the mass demonstrates intense, homogeneous enhancement, except for a central, star-shaped hypodense region. On the delayed portal venous phase, the bulk of the mass becomes isodense relative to the surrounding normal liver parenchyma, while the central star-shaped region demonstrates prominent contrast enhancement. Following appropriate surgical management of her appendicitis, which of the following is the most appropriate next step in the management of her incidental hepatic finding?

Match the following classic high-resolution computed tomography (HRCT) findings of the chest with their most likely underlying pulmonary diagnosis.