Tüm alıştırma soruları

A $22$-year-old female college student is evaluated in the emergency department for severe, colicky abdominal pain, intractable nausea, and new-onset weakness in her bilateral upper extremities. She has a history of similar, albeit milder, abdominal pain episodes over the past $2$ years. Her vital signs are notable for a heart rate of $122$/min and a blood pressure of $168/105$ mm Hg. Physical examination demonstrates generalized abdominal tenderness without rigidity or rebound. Initial laboratory workup reveals a serum sodium of $126$ mEq/L, with a normal lipase level, liver transaminases, and complete blood count. An abdominal ultrasound is unremarkable. Upon returning from the radiology suite, the nurse notes that the patient's urine in the bedside collection container has developed a deep red-purple hue after being exposed to ambient light. Arrange the following laboratory investigations in the most evidence-based sequential order for the diagnostic workup of this patient's suspected metabolic disorder.

A 29-year-old woman presents to the clinic with a 6-week history of a painless, enlarging mass in her right supraclavicular region. She also reports experiencing drenching night sweats and a 5-kilogram (11-pound) weight loss over the past two months. Physical examination confirms a 3.5-centimeter, firm, mobile, non-tender right supraclavicular lymph node. Arrange the following steps in the most appropriate clinical sequence for establishing the diagnosis, evaluating the neoplastic process, and determining management, from first to last.

A 24-year-old man with type 1 diabetes mellitus is brought to the emergency department unconscious by his roommate. The roommate found him unresponsive and administered an intramuscular injection of glucagon prior to arrival. Upon evaluation, the patient is regaining consciousness, and his capillary blood glucose is now $85$ mg/dL (reference range: $70$-$99$ mg/dL), up from an unrecorded low value at home.

Arrange the following sequence of molecular events that occurred in this patient's hepatocytes in response to the emergency intramuscular injection, ultimately leading to the restoration of his serum glucose levels.

A 34-year-old man is admitted to the hospital for treatment of severe community-acquired pneumonia. Ten minutes after the initiation of his first dose of intravenous ceftriaxone, he reports sudden-onset throat tightness, severe chest pain, and a feeling of impending doom. Physical examination reveals diffuse urticaria, marked angioedema of the lips and tongue, and audible expiratory wheezing. Vital signs show a temperature of 37.2°C (99.0°F), a heart rate of 138/min, and a blood pressure of 72/40 mm Hg. The physician immediately recognizes a severe, IgE-mediated immunologic emergency.

Arrange the following acute management steps in the most appropriate chronological order for this type I hypersensitivity reaction.

A 45-year-old woman is admitted to the hospital with central diabetes insipidus following a transsphenoidal pituitary adenoma resection. She is administered intravenous desmopressin to manage her profound polyuria and hypernatremia. Arrange the following cellular and biochemical events in the correct chronological sequence that occurs in the principal cells of the renal collecting duct following the administration of this medication.

An adult female patient is referred to the internal medicine clinic for evaluation of rapid, unexplained weight gain, severe proximal muscle weakness, and new-onset easy bruising over the past eight months. The patient is 39 years of age. Physical examination is notable for significant central adiposity, facial plethora, supraclavicular fat pads, and broad violaceous striae across her abdomen. Blood pressure is 158/96 mm Hg. Suspecting an endocrine etiology for her clinical presentation, the physician plans a step-wise diagnostic laboratory workup.

Arrange the following diagnostic laboratory investigations in the most appropriate sequential order for establishing the diagnosis and etiology of this patient's condition, from the initial diagnostic screening step to the final definitive localization step.

A 45-year-old woman is diagnosed with Zollinger-Ellison syndrome after presenting with chronic diarrhea and recurrent, medically refractory peptic ulcers. Her fasting serum gastrin level is 2,400 pg/mL (normal: < 100 pg/mL) while off proton pump inhibitors, and her gastric fluid pH is 1.5. A secretin stimulation test demonstrates a paradoxical rise in serum gastrin of 350 pg/mL. An initial multiphase contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis performed at a community hospital reveals no discrete pancreatic or hepatic masses. She is referred to a tertiary care center for surgical evaluation.

Arrange the following advanced imaging and localization modalities in the most appropriate chronological sequence to pinpoint the location of the primary neuroendocrine tumor.

A 42-year-old man presents to the hospital with a 2-day history of low-grade fever, malaise, decreased urine output, and allograft tenderness. He underwent a deceased-donor kidney transplantation 2 months ago. His current medications include tacrolimus, mycophenolate mofetil, and prednisone. His serum creatinine has abruptly increased from a baseline of $1.3 \text{ mg/dL}$ to $2.9 \text{ mg/dL}$. Initial laboratory studies show a subtherapeutic serum tacrolimus trough level. Urinalysis reveals mild proteinuria but is negative for infection.

Arrange the following steps in the most appropriate sequence for the continued evaluation and management of this patient's allograft dysfunction, from initial structural evaluation to the escalation of therapy for refractory immunologic disease.

A $62$-year-old postmenopausal woman is evaluated in the clinic after a routine comprehensive metabolic panel revealed an incidentally elevated serum total calcium of $11.5 \text{ mg/dL}$. She has a remote history of nephrolithiasis but currently feels well. She takes no medications and does not use over-the-counter supplements. The physician initiates a stepwise diagnostic and pre-operative evaluation pathway.

Arrange the following diagnostic evaluations in the most appropriate, evidence-based sequential order to establish the definitive etiology and complete the pre-operative workup.

A $66$-year-old man presents to the internal medicine clinic for a routine health maintenance visit. He reports a six-month history of mild urinary urgency, frequency, and nocturia, but denies any weight loss, bone pain, hematuria, or dysuria. He has no significant past medical history. Examination reveals a slightly enlarged, firm, and asymmetric prostate. As part of a comprehensive evaluation for a potential neoplastic process of the prostate, the physician considers the appropriate diagnostic and therapeutic algorithm.

Arrange the following diagnostic and management steps in the most appropriate chronological order according to current oncologic guidelines.

A 72-year-old woman is brought to the emergency department by emergency medical services. Her family reports that she was last seen in her normal state of health at 10:00 PM the previous night. She awoke at 6:00 AM today with profound left-sided hemiparesis, rightward gaze deviation, and severe dysarthria. Her current blood pressure is 170/90 mmHg, and point-of-care blood glucose is 110 mg/dL. The institutional acute stroke code is activated. Arrange the following neuroimaging modalities in the standard step-wise sequence to evaluate this patient's eligibility for and to execute endovascular reperfusion therapy.

A 29-year-old woman, G1P0 at 24 weeks gestation, presents to the emergency department with sudden-onset shortness of breath and right-sided pleuritic chest pain. Her pulse is 112/min, respiratory rate is 24/min, and blood pressure is 110/70 mm Hg. Oxygen saturation is 96% on room air. Physical examination reveals clear lungs bilaterally and no asymmetric leg swelling. An electrocardiogram shows sinus tachycardia. You highly suspect an acute pulmonary embolism (PE).

Assuming each test fails to definitively rule in or rule out the diagnosis (i.e., yielding normal or indeterminate results), arrange the following imaging studies in the most appropriate step-by-step diagnostic sequence according to current evidence-based guidelines for suspected PE in pregnancy.

A physician is managing a 45-year-old female patient who presents with resistant hypertension and spontaneous hypokalemia. Diagnostic testing reveals an elevated plasma aldosterone concentration to plasma renin activity ratio, and abdominal imaging confirms a unilateral adrenal adenoma. The patient's condition results in excessive sodium reabsorption in the distal nephron. Arrange the following cellular events in the correct chronological sequence to describe the physiological mechanism of action for the hormone overproduced in this condition.

A 62-year-old man with a 35-pack-year smoking history schedules an appointment at a primary care office. He was recently informed that a baseline chest radiograph, required for a life insurance policy, revealed a 1.4-cm non-calcified opacity in the left upper lobe. He is completely asymptomatic and denies any history of malignancy, weight loss, or hemoptysis. His vital signs and physical examination are unremarkable. A comprehensive review of his electronic medical record reveals no prior chest imaging is available for comparison.

Assuming each successive investigation yields findings highly suspicious for a primary bronchogenic carcinoma, arrange the following imaging and image-guided diagnostic studies in the most appropriate chronological sequence for the comprehensive evaluation and systemic staging of this patient.

During a routine review of laboratory results at a skilled nursing facility, an attending physician is alerted to a resident exhibiting new-onset lethargy and generalized skeletal discomfort. Blood chemistry analysis demonstrates a serum calcium concentration of $14.8 \text{ mg/dL}$, accompanied by a serum creatinine of $2.6 \text{ mg/dL}$ and a notably low serum anion gap of $4 \text{ mEq/L}$. Subsequent endocrinology panels reveal a profoundly suppressed intact parathyroid hormone (PTH) level, an undetectable parathyroid hormone-related peptide (PTHrP), and low-normal levels of $1,25$-dihydroxyvitamin D. Based on this specific pathophysiological profile, arrange the following differential diagnoses in descending order of their probability, from the most likely underlying etiology to the definitively excluded condition.

A 65-year-old man with a history of atrial fibrillation presents to the emergency department with acute onset right-sided hemiparesis and expressive aphasia. If magnetic resonance imaging (MRI) of the brain is obtained over the course of his illness, arrange the following characteristic imaging findings of an ischemic stroke in the correct chronological order of their typical initial appearance, from earliest to latest.

A $34$-year-old woman is referred to the endocrinology clinic due to unexplained weight gain of $15$ kg over the past year, accompanied by easy bruising and new-onset facial hair growth. She reports that her menstrual periods, previously regular, now occur only once every $3$ to $4$ months. Vital signs show a blood pressure of $158/98$ mm Hg. Physical examination is notable for facial plethora, a dorsocervical fat pad, truncal obesity with thin extremities, and wide, purplish striae over the lower abdomen and flanks. The physician suspects hypercortisolism. Assuming the patient ultimately has a pituitary adenoma (Cushing disease) and each successive diagnostic test dictates the need for further localization, arrange the following laboratory tests and diagnostic procedures in the correct sequential order from initial screening to definitive confirmation.

A 52-year-old woman is brought to the emergency department reporting the abrupt onset of an excruciating headache, which she describes as "the worst of my life." The pain began $10$ hours ago and is accompanied by photophobia, severe nausea, and a stiff neck. Her vital signs are stable, and a detailed neurologic examination reveals no focal motor or sensory deficits. A stepwise diagnostic workup for a suspected subarachnoid hemorrhage (SAH) is initiated.

Arrange the following diagnostic modalities in the most appropriate sequential order for evaluating this patient, assuming each preceding step is non-diagnostic or requires further localization.

A 25-year-old man comes to the primary care clinic for routine sexually transmitted infection screening. He is currently asymptomatic and has no history of genital lesions. The clinic's affiliated laboratory recently switched to the 'reverse sequence algorithm' for syphilis screening to handle high testing volumes more efficiently. Assuming the initial screening test is reactive, and the reflex test is non-reactive, arrange the following laboratory assays in the correct chronological order they would be performed to complete the diagnostic workup.

A 48-year-old woman is brought to the emergency department after the sudden onset of an excruciating 'thunderclap' headache, photophobia, and nausea. On physical examination, her blood pressure is 160/90 mm Hg, and her heart rate is 92/min. She exhibits nuchal rigidity but no focal neurological deficits. She is subsequently diagnosed and admitted to the neurological intensive care unit. Arrange the following diagnostic neuroimaging modalities in the standard chronological sequence they should be utilized for her initial diagnosis, etiological workup, and subsequent inpatient complication monitoring.