Tüm alıştırma soruları

Match each patient's clinical presentation with the most appropriate initial or definitive diagnostic imaging modality based on safety, diagnostic yield, and clinical guidelines.

During a routine telehealth visit, a 67-year-old woman reports a two-day history of dysuria, suprapubic discomfort, and feeling the urge to urinate frequently. She feels otherwise well, with no fevers, chills, or flank pain. The patient's past medical history includes paroxysmal atrial fibrillation managed with daily warfarin. Her last international normalized ratio (INR) was therapeutic at 2.5. A urine dipstick performed at a local laboratory is positive for nitrites and leukocyte esterase. Her baseline estimated glomerular filtration rate is $88 \text{ mL/min/1.73 m}^2$. The local resistance rate of *Escherichia coli* to trimethoprim-sulfamethoxazole is approximately $10\%$. To safely treat her suspected uncomplicated cystitis without disrupting her anticoagulation status, which of the following empiric regimens are most appropriate? (Select all that apply)

A 32-year-old man is brought to the emergency department with a severe head injury and a Glasgow Coma Scale score of 6 following a motorcycle collision. He is spontaneously breathing but unable to protect his airway. His blood pressure is 110/70 mm Hg and heart rate is 115/min. The trauma team decides to proceed with rapid sequence intubation (RSI).

Arrange the following pharmacologic interventions in the correct chronological sequence of administration for this patient's airway management, from earliest to latest.

An otherwise healthy $34$-year-old woman is brought to the emergency department due to the sudden onset of severe, right-sided pelvic pain that began abruptly while she was exercising $3$ hours ago. She reports two episodes of non-bilious emesis since the pain started. Her last menstrual period was $2$ weeks ago, and she has regular $28$-day cycles. She has no history of sexually transmitted infections or prior abdominal surgeries. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $132/82\text{ mm Hg}$, pulse is $108/\text{min}$, and respiratory rate is $16/\text{min}$. Physical examination reveals a non-distended abdomen with marked tenderness to palpation in the right lower quadrant. Voluntary guarding is present, but there is no rebound tenderness. Pelvic examination demonstrates a tender fullness in the right adnexa. A urine pregnancy test is negative. Laboratory studies show a leukocyte count of $11,500/\mu\text{L}$. A transvaginal ultrasound with color Doppler is performed. The right ovary measures $6.5\text{ cm} \times 5.0\text{ cm} \times 4.5\text{ cm}$ and exhibits a heterogeneous stroma with multiple peripherally displaced follicles. Color Doppler evaluation demonstrates the presence of arterial blood flow, but venous flow is entirely absent. The left ovary is normal in size and appearance. A small volume of anechoic free fluid is noted in the rectouterine pouch (cul-de-sac). Based on the imaging findings, which of the following is the most appropriate next step in management?

A 28-year-old woman is brought to the emergency department by her sister after collapsing at home. The sister reports that the patient complained of sudden, severe lower abdominal pain right before losing consciousness. The patient's last menstrual period was approximately 7 weeks ago. On arrival, she is lethargic, diaphoretic, and extremely pale. Vital signs are temperature 36.6°C (97.9°F), heart rate 145/min, blood pressure 68/38 mm Hg, respiratory rate 24/min, and oxygen saturation 98% on ambient air. Physical examination reveals a rigid, distended abdomen with diffuse guarding and rebound tenderness. Capillary refill is delayed at 5 seconds. Which of the following interventions should be ordered simultaneously as the most appropriate initial stabilization steps? (Select all that apply)

A 42-year-old man with known nephrotic syndrome is brought to the emergency department due to altered mental status and fever. His family reports he developed a spreading, painful, erythematous rash on his right lower extremity over the past three days. Vital signs reveal a temperature of $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), heart rate of $118/\text{min}$, blood pressure of $88/54\text{ mmHg}$, and respiratory rate of $26/\text{min}$.

Initial laboratory studies show:

What is the patient's albumin-corrected serum anion gap in mEq/L? (Assume a normal serum albumin concentration of $4.0\text{ g/dL}$).

A $62$-year-old man comes to the clinic to establish care. His past medical history is significant for essential hypertension, hyperlipidemia, and a $30$-pack-year smoking history; he quit smoking $10$ years ago. He currently has no respiratory complaints, weight loss, night sweats, or hemoptysis. Vital signs are within normal limits. Physical examination reveals clear lung fields bilaterally and no palpable cervical or supraclavicular lymphadenopathy. A chest radiograph obtained during a recent health fair revealed a small opacity in the right mid-lung zone. He is referred for a high-resolution, non-contrast computed tomography (CT) scan of the chest, which reveals a $13$-mm solid, non-calcified pulmonary nodule with smooth margins in the right middle lobe. No hilar or mediastinal lymphadenopathy is identified. Medical records from his previous provider are requested, but no prior imaging studies are available for comparison. Which of the following is the most appropriate next step in the diagnostic workup?

A 58-year-old man presents to his primary care physician to discuss recent difficulties with erectile dysfunction. He reports an inability to maintain an erection sufficient for sexual intercourse over the past four months. His past medical history is significant for stable angina pectoris, hypertension, and hyperlipidemia. His daily medication regimen includes several drugs for his cardiovascular conditions. His blood pressure is 128/82 mmHg and heart rate is 72/min. Physical examination is unremarkable. The physician considers prescribing sildenafil. Concurrent use of which of the following medications is an absolute contraindication to initiating this therapy?

A $64$-year-old man with a history of advanced squamous cell carcinoma of the lung is brought to the emergency department by his family due to progressive lethargy, confusion, and generalized weakness over the past $3$ days. He has also been experiencing severe nausea, vomiting, and polyuria. Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), heart rate of $112/\text{min}$, blood pressure of $88/58\text{ mmHg}$, and respiratory rate of $16/\text{min}$. Physical examination reveals dry mucous membranes, flat jugular veins, and delayed capillary refill. He is disoriented to time and place. Laboratory results are as follows:

Serum calcium: $14.8\text{ mg/dL}$
Serum albumin: $3.5\text{ g/dL}$
Blood urea nitrogen (BUN): $42\text{ mg/dL}$
Serum creatinine: $1.4\text{ mg/dL}$ (baseline $0.9\text{ mg/dL}$)

Electrocardiogram shows a shortened QT interval. Which of the following pharmacologic interventions are indicated in the initial management of this patient's acute metabolic derangement? (Select all that apply)

Campus security brings a 21-year-old female university student to the emergency department due to extreme agitation, paranoia, and auditory hallucinations that began three days ago. Her roommate reports that two weeks prior, the patient experienced a mild febrile illness with a headache and rhinorrhea, which resolved with supportive care. Medical history is significant for generalized anxiety disorder and migraine headaches. Home medications include citalopram and sumatriptan. In the emergency department, she is administered a dose of intramuscular haloperidol for severe agitation. Vital signs show a temperature of 38.4°C (101.1°F), pulse of 126/min, and blood pressure of 148/92 mmHg. Physical examination reveals a diaphoretic, restless patient who intermittently exhibits repetitive lip-smacking and facial grimacing movements. Tone is slightly increased in the upper extremities, and deep tendon reflexes are 3+ bilaterally without sustained clonus. Laboratory studies show a leukocyte count of 11,500/mm³ and an antinuclear antibody (ANA) titer of 1:40. A urine toxicology screen is negative. Which of the following is the most likely diagnosis?

A 32-year-old woman is evaluated in the preoperative clinic prior to an elective laparoscopic cholecystectomy. She has no significant past medical history and takes no medications. She reports normal menstrual periods and denies any history of easy bruising, epistaxis, or prolonged bleeding after minor cuts or prior dental extractions. Routine preoperative laboratory testing reveals a normal prothrombin time (PT) of 11.5 seconds and an isolated, significantly prolonged activated partial thromboplastin time (aPTT) of 62 seconds (reference range: 25-35 seconds). Her platelet count is $210,000/\mu L$.

Arrange the following laboratory tests in the most appropriate sequential order to establish the etiology of this patient's isolated prolonged aPTT, from the initial evaluation step to the final diagnostic confirmation.

A 48-year-old man presents to the emergency department with a 3-day history of progressively worsening left lower quadrant abdominal pain, subjective fevers, and mild nausea. He has no significant past medical history and takes no medications. Vital signs include a temperature of 38.1°C (100.6°F), blood pressure of 130/80 mmHg, pulse of 88/min, and respiratory rate of 16/min. Physical examination reveals focal tenderness to palpation in the left lower quadrant. There is no guarding, rigidity, or rebound tenderness. Laboratory studies show a leukocyte count of 13,500/mm³. A contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis is performed. The radiologist's report describes multiple mucosal outpouchings in the sigmoid colon accompanied by marked pericolic fat stranding and localized thickening of the bowel wall. The report specifically notes the absence of free intraperitoneal air, extravasation of oral contrast, and discrete organized fluid collections. Based on the interpretation of these imaging findings, which of the following is the most appropriate next step in patient management?

Match each physical examination maneuver of the shoulder with the specific underlying pathology or pathophysiological mechanism it is primarily designed to assess.

A 41-year-old man presents to the primary care clinic for evaluation of elevated blood pressure. He has a 3-year history of hypertension that has been difficult to control despite strict adherence to a regimen of maximum tolerated doses of lisinopril, amlodipine, and hydrochlorothiazide. The patient notes occasional episodes of muscle cramping and generalized weakness but denies headaches, palpitations, or diaphoresis. His blood pressure is 168/102 mm Hg, and his pulse is 76/min. The physical examination is unremarkable, with no abdominal bruits or peripheral edema.

Initial laboratory studies reveal the following:

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

A $55$-year-old man is evaluated in the post-anesthesia care unit due to altered mental status, tachypnea, and hypotension. Two hours ago, he underwent an elective laparoscopic cholecystectomy for symptomatic cholelithiasis. His past medical history includes type 2 diabetes mellitus, hypertension, and a pulmonary embolism $4$ months ago. Home medications include metformin, empagliflozin, lisinopril, and rivaroxaban. He was instructed to hold all oral medications on the morning of surgery.

Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $78/48\text{ mmHg}$, heart rate of $128\text{/min}$, and respiratory rate of $28\text{/min}$. Physical examination reveals dry mucous membranes, clear lungs, and delayed capillary refill. The abdomen has appropriately placed, dry surgical dressings. A Foley catheter has drained $30\text{ mL}$ of urine over the last $2$ hours.

Laboratory results are as follows:

An arterial blood gas on room air reveals a pH of $7.18$, pCO $_2$ of $24\text{ mmHg}$, and pO $_2$ of $92\text{ mmHg}$.

Aggressive intravenous fluid resuscitation with isotonic crystalloid is initiated. Which of the following is the most appropriate targeted pharmacologic intervention for this patient's underlying condition?

Emergency medical services bring a 26-year-old female to the resuscitation bay after she was found obtunded in her apartment. Several empty medication bottles, including one prescribed for amitriptyline, were discovered nearby. Upon transfer to the stretcher, she exhibits generalized tonic-clonic motor activity. Her skin is warm and exceptionally dry, and her pupils measure $7$ mm bilaterally. Current vital signs are blood pressure $78/42$ mmHg, heart rate $148$/min, respiratory rate $6$/min, and oxygen saturation $84\%$ on ambient air. Cardiac monitoring reveals a regular, wide-complex tachycardia with a QRS interval of $170$ ms. Which of the following interventions must be initiated simultaneously as the immediate next steps in management? (Select all that apply)

Match each patient's unique clinical presentation and initial laboratory profile of hyperandrogenism with the most probable underlying diagnosis in order to formulate an accurate differential diagnosis.

A $48$-year-old woman is referred to the endocrinology clinic due to refractory hypertension. Her blood pressure has remained uncontrolled despite documented adherence to maximal tolerated doses of amlodipine, valsartan, and hydralazine. She reports occasional muscle weakness and severe leg cramps. Her vital signs today show a blood pressure of $165/102$ mm Hg. A basic metabolic panel reveals a serum sodium of $144$ mEq/L, a serum potassium of $2.9$ mEq/L, and a serum bicarbonate of $30$ mEq/L. The clinician strongly suspects primary hyperaldosteronism as the etiology of her presentation. Arrange the following diagnostic steps in the most appropriate sequential order to establish the diagnosis, confirm the etiology, and determine surgical candidacy.

A $31$-year-old man is rushed to the emergency department by his coworkers after developing sudden, severe respiratory distress while eating at a company luncheon. He is clutching his throat, visibly agitated, and speaking in one-word gasps. His past medical history is significant for mild intermittent asthma and an undocumented food allergy. Vital signs reveal a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), pulse of $134/\text{min}$, blood pressure of $82/45\text{ mmHg}$, and respiratory rate of $32/\text{min}$. Oxygen saturation is $88\%$ on room air. Physical examination demonstrates prominent perioral swelling, diffuse wheezing in all lung fields, and a widespread erythematous rash on his chest and arms. Which of the following is the single most urgent initial step in the stabilization of this patient?

Match each distinctive pediatric gastrointestinal imaging description to its corresponding pathognomonic clinical diagnosis.