Tüm alıştırma soruları

Match each clinical presentation of a patient with suspected pulmonary embolism (PE) to the most appropriate next step in the diagnostic workup sequence.

A 68-year-old male with a 40-pack-year smoking history is evaluated in the clinic for two episodes of painless, gross hematuria over the past month. He reports no flank pain, dysuria, weight loss, or preceding illness. His medical history is notable for essential hypertension. Physical examination reveals a blood pressure of 148/88 mmHg. The abdomen is soft and non-tender, with no palpable masses. Genitourinary examination reveals a right-sided varicocele that remains distended when the patient assumes a supine position. Based on this patient's clinical presentation, arrange the following diagnoses in order from the HIGHEST pre-test probability to the LOWEST pre-test probability.

A $54$-year-old man comes to the clinic for follow-up of hypertension. Over the past three months, his blood pressure has been consistently elevated despite strict adherence to a daily regimen of amlodipine and lisinopril. He reports new-onset muscle cramps and generalized weakness but otherwise feels well. Physical examination shows a blood pressure of $174/98$ mmHg and a heart rate of $76$/min. The remainder of the examination, including cardiopulmonary and abdominal assessments, is unremarkable, and there is no peripheral edema.

Laboratory studies show:
Serum sodium: $144$ mEq/L
Serum potassium: $2.7$ mEq/L
Serum bicarbonate: $32$ mEq/L

Given the unprovoked hypokalemia, his lisinopril is switched to verapamil, and he is prescribed oral potassium supplementation. Two weeks later, his blood pressure remains $168/96$ mmHg and his serum potassium is $2.9$ mEq/L. Further laboratory evaluation reveals markedly suppressed plasma renin activity and a suppressed serum aldosterone concentration.

Based on the clinical and laboratory findings, which of the following is the most likely diagnosis?

Match each clinical presentation of coagulopathy or thrombocytopenia with the most likely underlying diagnosis.

A $36$-year-old man is brought to the emergency department by emergency medical services after being found obtunded in his garage. Beside him were several unlabeled containers of antifreeze and an empty bottle of vodka. His temperature is $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, pulse is $105/\text{min}$, and respiratory rate is $22/\text{min}$. The patient is responsive only to deep pain.

Laboratory evaluation yields the following results:

Based on these laboratory results, what is the patient's calculated osmolar gap?

(Enter your answer as a whole number).

A 22-year-old man with a history of type 1 diabetes mellitus is brought to the emergency department due to altered mental status, nausea, and diffuse abdominal pain. He has not taken his insulin for the past two days. Vital signs show a heart rate of $118/\text{min}$, blood pressure of $105/65\text{ mmHg}$, and respiratory rate of $28/\text{min}$ with deep, rapid breaths.

Laboratory results are as follows:

Serum sodium: $142\text{ mEq/L}$
Serum potassium: $4.8\text{ mEq/L}$
Serum chloride: $98\text{ mEq/L}$
Serum bicarbonate: $14\text{ mEq/L}$
Blood urea nitrogen: $32\text{ mg/dL}$
Serum creatinine: $1.4\text{ mg/dL}$
Serum glucose: $520\text{ mg/dL}$

Arterial blood gas (room air):
pH: $7.21$
$pCO_2$: $24\text{ mmHg}$
$pO_2$: $98\text{ mmHg}$

Using Winter's formula, what is the mean expected $pCO_2$ (in mmHg) to determine if this patient has an appropriately compensated primary metabolic acidosis?

Match each patient's clinical presentation with the most appropriate targeted laboratory test or panel to order for establishing the diagnosis.

During morning rounds in the intensive care unit, a medical team evaluates a 56-year-old man who was admitted the previous night for altered mental status and significant abdominal distension. The patient's records indicate a history of chronic hepatitis C virus infection and severe, long-term alcohol use disorder. His spouse reports that he has become increasingly disoriented over the past week and his abdomen has rapidly swelled. Vital signs show a temperature of 36.8°C (98.2°F), blood pressure of 102/60 mmHg, heart rate of 94/min, and respiratory rate of 16/min. The attending physician suspects decompensated liver cirrhosis with acute complications. Which of the following physical examination findings are expected in this patient? (Select all that apply)

A $55$-year-old male establishes care for hypertension management. His medical history is significant for bipolar I disorder and mild persistent asthma. His bipolar disorder has been well-controlled on lithium carbonate for the past eight years without recurrent mood episodes. His asthma is managed with an as-needed albuterol inhaler. Blood pressure readings from his past three clinic visits have consistently averaged $154/96$ mmHg, despite strict adherence to a low-sodium diet and a daily exercise regimen. Today, his blood pressure is $156/94$ mmHg, and his pulse is $72$/min. Physical examination reveals clear lungs bilaterally with no wheezing. Laboratory studies show a serum creatinine of $0.9$ mg/dL, serum potassium of $4.2$ mEq/L, and a serum lithium level of $0.8$ mEq/L (therapeutic range: $0.6$ to $1.2$ mEq/L). The physician decides to initiate pharmacologic therapy for his hypertension. Which of the following is the most appropriate medication to prescribe for this patient?

A 58-year-old man presents to the primary care clinic reporting a four-week history of progressively worsening shortness of breath, particularly when climbing stairs. He also notes waking up gasping for air at night and increased swelling in his ankles. He has a history of type 2 diabetes mellitus and hypertension. His current medications include metformin and lisinopril. Vital signs show a blood pressure of 145/90 mm Hg, heart rate of 92/min, and respiratory rate of 18/min. Physical examination reveals elevated jugular venous pressure, a regular rhythm with an S3 gallop, bibasilar lung crackles, and 2+ bilateral pitting edema to the mid-calves. The physician suspects new-onset heart failure. Which of the following diagnostic tests should be ordered concurrently as part of the initial baseline evaluation for this patient? (Select all that apply)

A 54-year-old man is brought to the emergency department after vomiting a large amount of bright red blood. He has a history of alcohol use disorder and decompensated cirrhosis complicated by ascites. Upon arrival, he appears confused and lethargic. His temperature is 36.8°C (98.2°F), pulse is 122/min, respirations are 22/min, and blood pressure is 86/50 mmHg. Oxygen saturation is 96% on room air. Physical examination reveals scleral icterus, spider angiomas, and a distended, non-tender abdomen with shifting dullness. Two large-bore intravenous lines are placed, and rapid fluid resuscitation with crystalloids and packed red blood cells is initiated. The patient is being prepared for an emergent upper endoscopy. Which of the following pharmacologic interventions should be administered immediately? (Select all that apply.)

A 34-year-old woman is evaluated in the emergency department after experiencing palpitations and a near-syncopal episode while resting at home. An electrocardiogram performed upon arrival demonstrates sinus rhythm with a markedly prolonged QTc interval of 530 ms. A previous electrocardiogram from one year ago showed a normal QTc interval of 410 ms. The patient has no known structural heart disease. During the clinical interview, a detailed medical history must be obtained to identify the acquired etiology of her electrocardiographic abnormality. Which of the following historical elements would directly explain her presentation and must be specifically targeted during the interview? (Select all that apply)

A 68-year-old woman presents to the clinic with a 4-week history of progressively worsening mid-back pain. The pain is described as a dull, constant ache that often awakens her at night and is not relieved by lying down or changing positions. She has a history of hormone receptor-positive breast cancer treated with a lumpectomy and radiation therapy 6 years ago. She is currently taking anastrozole. She denies fever, chills, recent trauma, or bowel and bladder incontinence. Physical examination reveals mild tenderness to palpation over the T8-T10 spinous processes. Neurological examination of the lower extremities shows 5/5 strength, intact sensation to light touch and pinprick, and 2+ reflexes bilaterally.

Based on the patient's presentation, arrange the following differential diagnoses in order from highest pre-test probability to lowest pre-test probability.

A 22-year-old male is brought to the emergency department after diving headfirst into a shallow lake. He is conscious but in severe respiratory distress, using accessory muscles to breathe. He reports an inability to feel or move his arms or legs. Vital signs include a temperature of 36.5°C (97.7°F), heart rate of 52/min, blood pressure of 80/40 mmHg, respiratory rate of 34/min with shallow effort, and oxygen saturation of 85% on room air. Physical examination demonstrates prominent diaphragmatic breathing, flaccid paralysis of all four extremities, and absent deep tendon reflexes.

Arrange the following steps in the most appropriate sequential order for the initial stabilization and diagnostic workup of this patient.

A $45$-year-old man comes to the clinic for a follow-up visit for hypertension. He was diagnosed with hypertension $2$ years ago. Despite adherence to a regimen of amlodipine, lisinopril, and hydrochlorothiazide at maximal tolerated doses, his blood pressure remains consistently elevated. He reports occasional episodes of muscle weakness and cramps over the past $3$ months but otherwise feels well. He does not have headaches, palpitations, or sweating. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $168/98 \text{ mm Hg}$, and pulse $78/\text{min}$. Physical examination shows no abdominal bruits, normal peripheral pulses, and no peripheral edema.

Laboratory results from today are as follows:
Sodium: $144 \text{ mEq/L}$
Potassium: $2.9 \text{ mEq/L}$
Chloride: $104 \text{ mEq/L}$
Bicarbonate: $29 \text{ mEq/L}$
Blood urea nitrogen: $14 \text{ mg/dL}$
Creatinine: $0.9 \text{ mg/dL}$

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

A 42-year-old woman is referred to the endocrinology clinic due to treatment-resistant hypertension. She currently takes amlodipine, lisinopril, and hydrochlorothiazide at maximal tolerated doses, but her home blood pressure readings consistently range from 160/95 to 175/105 mmHg. Over the past year, she has also experienced episodic, severe, throbbing headaches accompanied by palpitations and profuse sweating. Her vital signs today show a blood pressure of 168/102 mmHg and a heart rate of 105/min. Physical examination is unremarkable, with no abdominal bruits or striae. Because of her classic symptoms, measurement of plasma free metanephrines is performed, revealing levels that are more than four times the upper limit of normal. Which of the following is the most appropriate next step in this patient's diagnostic workup?

A 32-year-old woman is brought to the emergency department via ambulance for a generalized tonic-clonic seizure. Her husband states the seizure began 15 minutes ago at home, and she has not regained consciousness or ceased convulsing since onset. She has a known history of medication-refractory focal impaired awareness seizures. Upon arrival, she is actively seizing, tachycardic to 128/min, and blood pressure is 142/88 mm Hg. She is maintaining her airway, with an oxygen saturation of 92% on room air. Two large-bore intravenous lines are immediately established.

Assuming the patient's generalized convulsive seizure activity continues unabated despite each successive intervention, arrange the following pharmacologic therapies in the correct guideline-directed escalation sequence, from initial management to treatment of super-refractory status epilepticus.

A 45-year-old woman is evaluated on the surgical ward four hours after undergoing a total thyroidectomy for a large multinodular goiter. The on-call physician is urgently summoned because the patient has become increasingly agitated and is complaining of severe difficulty breathing. She is pointing to her neck and is unable to speak in full sentences. Vital signs are temperature 37.1°C (98.8°F), blood pressure 162/94 mm Hg, pulse 118/min, and respirations 28/min. Pulse oximetry shows an oxygen saturation of 91% on room air. Physical examination reveals a high-pitched inspiratory sound audible from the doorway. The surgical dressing is intact, but there is tense, progressive swelling of the anterior neck beneath the incision line. Which of the following is the most appropriate immediate next step in management?

A $28$-year-old woman, gravida $1$, para $0$, at $26$ weeks gestation, presents to the emergency department with a $12$-hour history of progressively worsening right-sided abdominal pain. She also reports nausea and $2$ episodes of vomiting. Her temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $112/70\text{ mmHg}$, and heart rate is $108/\text{min}$. Physical examination reveals localized tenderness to palpation in the right mid-to-upper quadrant of the abdomen, with mild guarding. Laboratory studies show a leukocyte count of $16,500/\text{mm}^3$. A graded-compression transabdominal ultrasound is performed, which shows a normal right kidney and ovary but fails to visualize the appendix. Clinical suspicion for acute appendicitis remains high. Which of the following is the most appropriate next step in the diagnostic imaging evaluation?

A 55-year-old woman is transported to the triage area by her husband after being found lethargic at home. She has a known history of decompensated cirrhosis due to chronic alcohol use. Over the past several hours, she has vomited large quantities of bright red blood. On arrival, she is somnolent, groans to painful stimuli, and continues to have episodes of active hematemesis. Vital signs show a blood pressure of 75/40 mmHg, a pulse of 135/min, and respirations of 26/min. Pulse oximetry displays 91% on room air. Which of the following is the most appropriate initial step in the management of this patient?