Tüm alıştırma soruları

A 29-year-old woman is evaluated in the emergency department for a 5-day history of high fever, a diffuse rash, and right upper quadrant abdominal pain. Her past medical history is significant for bipolar disorder and hypertension. Her home medications include lisinopril, which she has taken for three years, and lamotrigine, the dose of which was increased 5 weeks ago. She reports taking ibuprofen 2 days ago when the fever began. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$). Physical examination reveals prominent facial edema, tender cervical lymphadenopathy, and a diffuse, pruritic, morbilliform eruption that spares the mucosal surfaces. Laboratory studies show a leukocyte count of $16,500/\mu\text{L}$ with $18\%$ eosinophils. Hepatic transaminases are markedly elevated (AST $620\text{ U/L}$, ALT $740\text{ U/L}$). The admitting physician suspects an acute hypersensitivity reaction to ibuprofen, discontinues the NSAID, and plans to admit the patient to the medical ward while continuing her other home medications. Which of the following represents the most critical flaw in the physician's evaluation of this patient's medical history?

A 52-year-old man is evaluated in the hospital for worsening abdominal pain and a new-onset fever. He was admitted three weeks ago for severe acute pancreatitis secondary to alcohol use disorder and has been managed with supportive care. Over the past 24 hours, his temperature has increased to 38.9°C (102.0°F). His blood pressure is 110/70 mmHg, pulse is 112/min, and respirations are 18/min. Physical examination shows marked epigastric tenderness with guarding. Laboratory studies show a leukocyte count of 18,500/mm³. A contrast-enhanced CT scan of the abdomen reveals an 8-cm well-circumscribed collection of fluid and necrotic tissue in the lesser sac. Multiple small pockets of gas are visible within this collection. Intravenous meropenem is initiated. Based on the interpretation of these imaging findings, which of the following is the most appropriate next step in management?

A $45$-year-old woman is evaluated during morning rounds on post-operative day two following a total thyroidectomy for a multinodular goiter. She complains of a new-onset "pins and needles" sensation around her mouth and in both hands. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $122/78$ mm Hg, and pulse is $84$/min. The physician suspects a specific electrolyte abnormality and decides to perform a diagnostic physical examination maneuver by inflating a blood pressure cuff on her arm to $20$ mm Hg above her systolic pressure for three minutes. Which of the following physical examination findings is most likely to be observed in this patient?

A 72-year-old woman is evaluated in the hospital for acute kidney injury. She was admitted 6 days ago for urosepsis and has been treated with intravenous ampicillin, gentamicin, and intravenous fluids. Over the past 24 hours, her urine output has decreased to 400 mL. Her blood pressure is 122/76 mm Hg, and heart rate is 84/min. She appears euvolemic, and her mucous membranes are moist. Laboratory studies show:

Based on these laboratory results, what is the patient's fractional excretion of sodium (FENa) in percent?

A $54$-year-old man presents to the clinic with a $4$-month history of severe fatigue, diffuse muscle weakness, and an $8$-kg ($17.6$-lb) weight loss. He also reports chronic, vague abdominal pain and nausea. Over the past $2$ weeks, he has had worsening constipation. His medical history is significant for type $1$ diabetes mellitus. He notes that he has had to decrease his insulin doses recently due to recurrent episodes of sweating and tremors. Blood pressure is $95/60$ mmHg sitting and $80/50$ mmHg standing. Heart rate is $112$/min. Physical examination shows dry mucous membranes and generalized muscle weakness. Laboratory studies show:

Which of the following is the most likely diagnosis?

Select the single most appropriate diagnostic imaging modality for each patient scenario, taking into account their unique physiologic states, prior test results, and specific contraindications.

A 28-year-old woman, G2P1, at 33 weeks gestation presents to the emergency department with sudden-onset shortness of breath and right-sided pleuritic chest pain that began 4 hours ago. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mmHg, pulse is 112/min, respiratory rate is 24/min, and oxygen saturation is 95% on room air. The patient appears anxious but is in no acute respiratory distress. Lungs are clear to auscultation bilaterally. Cardiac examination reveals regular tachycardia but is otherwise unremarkable. The right calf appears slightly more edematous than the left and is mildly tender to palpation. A plain chest radiograph performed with abdominal shielding shows no abnormalities. An electrocardiogram demonstrates sinus tachycardia with no ischemic changes. Which of the following is the most appropriate next step in the diagnostic workup?

A hospital's internal medicine residency program uses a case-based module to assess competency in diagnosing complex acid-base and electrolyte disorders. Match each isolated laboratory profile (1-5) to the most likely underlying etiology. Assume all patients present with normal renal function (glomerular filtration rate > $90$ mL/min/$1.73$ m²).

A 24-year-old woman presents to the emergency department with sudden-onset, severe, colicky pain in her right lower quadrant that began 4 hours ago. The pain radiates to her right flank and is associated with multiple episodes of nausea and vomiting. She has no significant past medical history and takes no medications. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mmHg, pulse is 102/min, and respiratory rate is 16/min. Physical examination reveals marked tenderness to palpation in the right adnexal region with voluntary guarding. A urine pregnancy test is negative. A transvaginal pelvic ultrasound demonstrates a unilaterally enlarged right ovary measuring 6.5 cm in maximum dimension with multiple small, peripherally displaced follicles. Spectral Doppler interrogation of the right ovary shows continuous arterial waveforms, but no venous flow is detected. A small amount of echogenic free fluid is noted in the rectouterine pouch. Which of the following is the most accurate interpretation of these imaging findings?

Match the following classic radiographic imaging descriptors with their corresponding underlying pathognomonic clinical conditions.

A 68-year-old woman is brought to the emergency department by her daughter due to increasing confusion, an unsteady gait, and urinary incontinence that developed progressively over the past 3 days. Her medical history is significant for type 2 diabetes mellitus, hypertension, and osteoarthritis. Five days ago, she was started on amitriptyline for painful diabetic neuropathy. Her other daily medications include metformin and lisinopril. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 142/85 mmHg, pulse of 102/min, and respirations of 14/min. Physical examination reveals dry oral mucosa, flushed skin, and mildly dilated pupils that are sluggishly reactive to light. Abdominal examination demonstrates a firm, mildly tender suprapubic mass. Neurological examination reveals a broad-based, unsteady gait but no focal motor or sensory deficits. The patient is disoriented to time and place. A bedside bladder scan shows 600 mL of retained urine. Urinalysis reveals no leukocytes, nitrites, or blood. A comprehensive metabolic panel is within normal limits. Which of the following is the most likely diagnosis?

A 26-year-old woman, G2P1, at 16 weeks gestation presents to the clinic for a routine prenatal visit. She recently underwent standard prenatal screening. Her laboratory results show a positive rapid plasma reagin (RPR) test with a titer of 1:32, and a positive fluorescent treponemal antibody absorption (FTA-ABS) test. The patient feels well and has no history of genital ulcers, rashes, or neurologic symptoms. When discussing the treatment plan, she states that she had a severe allergic reaction to penicillin at age 10, which was characterized by widespread hives, facial swelling, and difficulty breathing. Vital signs are within normal limits, and the physical examination is unremarkable. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

During a comprehensive health evaluation, a physician palpates an asymmetric enlargement in the anterior neck of an asymptomatic 45-year-old software architect. The individual denies experiencing weight changes, heat intolerance, tremors, or difficulty swallowing. Vital signs show a heart rate of 82/min and a blood pressure of 124/78 mm Hg. Palpation of the neck reveals a firm, non-tender, mobile $2.2\text{-cm}$ nodule in the right thyroid lobe. There is no palpable cervical lymphadenopathy. Initial laboratory evaluation demonstrates a suppressed thyroid-stimulating hormone (TSH) concentration of $0.02 \text{ mU/L}$ (normal: $0.4-4.0 \text{ mU/L}$) and an elevated free thyroxine (T4) concentration of $2.3 \text{ ng/dL}$ (normal: $0.9-1.7 \text{ ng/dL}$). Dedicated ultrasonography of the neck confirms a $2.4\text{-cm}$ solid, hypoechoic nodule in the right lobe lacking high-risk features such as microcalcifications or irregular margins. Which of the following represents the most appropriate next step in the diagnostic sequence for this individual?

A 42-year-old industrial worker is rushed to the acute care facility following an explosion at a chemical manufacturing plant. His coworkers report he was trapped in a small, smoke-filled room for several minutes before being rescued. He has no significant past medical history. On arrival, he is restless, grasping at his throat, and speaks with a raspy, altered voice. Examination reveals soot around his nares and mouth, along with superficial burns on his neck and lower face. His temperature is 37.1 C (98.8 F), heart rate is 134/min, blood pressure is 118/76 mm Hg, and respiratory rate is 28/min. Oxygen saturation is 93% on a high-flow oxygen mask. Which of the following is the single most critical next step in the immediate management of this patient?

A 49-year-old woman is admitted to the hospital with a one-week history of progressively worsening fatigue, nausea without vomiting, and yellowing of her eyes. She notes her urine has become noticeably dark over the last three days. She denies abdominal pain, fever, or changes in stool color. Her past medical history is significant for type 2 diabetes mellitus, hyperlipidemia, and class II obesity. She had an uncomplicated laparoscopic cholecystectomy ten years ago. Her home medications include metformin and atorvastatin, both of which she has taken at stable doses for over five years. She does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. Physical examination demonstrates pronounced scleral icterus and generalized jaundice. Her abdomen is soft with mild right upper quadrant tenderness, but no hepatosplenomegaly or ascites is noted. Laboratory studies reveal the following:

AST: 1,650 U/L
ALT: 1,920 U/L
Alkaline phosphatase: 125 U/L
Total bilirubin: 6.8 mg/dL
Direct bilirubin: 4.5 mg/dL
INR: 1.2

Viral hepatitis serologies (A, B, C, and E) and antinuclear antibodies are negative. A right upper quadrant ultrasound demonstrates normal intrahepatic and extrahepatic bile ducts with an absent gallbladder. Which of the following previously unelicited elements of the patient's history is the most likely cause of her clinical presentation?

Emergency medical responders bring a 71-year-old female to the resuscitation bay after her daughter found her unable to speak or move her right side this morning at 07:00. The patient and her daughter watched television together until 23:00 last night, at which point the patient went to bed in her usual state of health. Vital signs include a blood pressure of 172/95 mm Hg and a heart rate of 94/min that is irregularly irregular. Neurologic examination reveals global aphasia, a right-sided facial droop, and 1/5 strength in the right upper and lower extremities. Her National Institutes of Health Stroke Scale (NIHSS) score is 18. An initial non-contrast computed tomography of the head reveals a hyperdense left middle cerebral artery sign and subtle loss of gray-white matter differentiation in the left insular ribbon, with no evidence of intracranial hemorrhage. Which of the following is the most appropriate next step in imaging for this patient?

A 72-year-old man is brought to the emergency department after his family found him with profound right-sided hemiparesis, right facial droop, and severe global aphasia. He was last known to be in his usual state of health 9 hours ago when he went to sleep. Vital signs show a blood pressure of 185/100 mm Hg and a pulse of 88/min that is irregularly irregular. Point-of-care blood glucose is 110 mg/dL. The facility is a comprehensive stroke center. Arrange the following neuroimaging modalities in the most appropriate chronological sequence for guiding the acute management of this patient's condition.

A medical resident is reviewing the laboratory results of four adult patients referred to the endocrinology clinic for evaluation of complex mineral metabolism abnormalities.

Match each patient's specific laboratory profile to the most likely underlying diagnosis.

A $65$-year-old man is evaluated in the intensive care unit. He was admitted $5$ days ago for severe community-acquired pneumonia complicated by septic shock. He remains on mechanical ventilation and requires continuous intravenous norepinephrine to maintain an adequate mean arterial pressure. His past medical history is significant for hypertension and type 2 diabetes mellitus, with no known history of thyroid disease. His current medications include broad-spectrum intravenous antibiotics, norepinephrine, and prophylactic subcutaneous heparin. Vital signs are temperature $37.2^\circ C$ ($99.0^\circ F$), blood pressure $102/64$ mm Hg, pulse $98$/min, and respirations $16$/min (ventilator-controlled). Routine laboratory tests prompt the medical team to order a comprehensive thyroid panel, which yields the following results:

Which of the following is the most likely explanation for these laboratory findings?

A $48$-year-old woman is evaluated in the outpatient clinic for incidentally discovered hypercalcemia. She has no acute complaints but reports mild, intermittent fatigue over the past year. She has no history of nephrolithiasis, fragility fractures, or abdominal pain. Her family history is notable for a father who had "some kind of high calcium problem" that did not require surgical intervention. She takes no medications and her vital signs are within normal limits. Physical examination is unremarkable, with no palpable neck masses or thyromegaly. Initial laboratory studies reveal the following:

Serum total calcium: $11.3$ mg/dL
Serum albumin: $4.0$ g/dL
Serum creatinine: $0.9$ mg/dL
Intact parathyroid hormone (PTH): $92$ pg/mL (Normal: $15$–$65$ pg/mL)
$25$-hydroxyvitamin D: $35$ ng/mL (Normal: $20$–$50$ ng/mL)

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