Tüm alıştırma soruları

During a routine health maintenance examination, a 45-year-old male is noted to have a blood pressure of 158/96 mmHg. A review of his electronic medical record reveals home blood pressure logs consistently in the 150s/90s over the past three months. The patient takes no prescription medications and reports no significant past medical history. He mentions experiencing intermittent muscle cramps in his lower extremities over the last several weeks but otherwise feels well. Physical examination today is unremarkable aside from the elevated blood pressure. Initial laboratory studies show a serum sodium level of 144 mEq/L and a serum potassium level of 3.0 mEq/L. Which of the following is the most appropriate next step in laboratory evaluation?

A 23-year-old woman presents to the outpatient clinic reporting a 3-day history of lower abdominal pain and increased vaginal discharge. She has a new male sexual partner and notes inconsistent condom use. Her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $112/72\text{ mm Hg}$, and pulse is $88\text{/min}$. She denies nausea or vomiting and is tolerating an oral diet well. Pelvic examination reveals a friable cervix with yellow mucopurulent discharge, pronounced cervical motion tenderness, and bilateral adnexal tenderness. A point-of-care urine pregnancy test is negative. Which of the following pharmacologic interventions should be included in the initial empiric treatment regimen for this patient? (Select all that apply)

A 31-year-old primigravida at 36 weeks gestation is brought to the obstetrical triage by her husband due to progressive lethargy, nausea, and severe right upper quadrant abdominal pain over the past 48 hours. She has no significant past medical history, and her prenatal course has been uncomplicated.

Vital signs show a temperature of 37.2°C (99.0°F), blood pressure of 148/92 mm Hg, heart rate of 110/min, and respiratory rate of 18/min. Physical examination reveals scleral icterus and right upper quadrant tenderness without rebound or guarding. The patient is drowsy but arousable and oriented to person and place only.

Laboratory results are as follows:

Based on the interpretation of these laboratory results, which of the following is the most likely diagnosis?

An endocrinology clinic evaluates a 68-year-old individual who complains of a non-healing sore on the bottom of the right foot that has been present for the past month. Medical history is significant for long-standing type 2 diabetes mellitus, severe peripheral neuropathy, and chronic kidney disease stage 4 (estimated glomerular filtration rate of 22 mL/min/1.73 m²). The patient reports noticing increased swelling and a foul-smelling discharge on the dressing over the past three days. Vitals show a temperature of 37.6°C (99.7°F), blood pressure of 138/82 mmHg, and heart rate of 88/min. Inspection of the plantar aspect of the right forefoot reveals a 2.5-cm, deep ulceration with a necrotic base directly overlying the first metatarsophalangeal joint. A sterile blunt probe easily contacts hard, gritty tissue at the depth of the wound. Which of the following is the most appropriate initial radiologic investigation for this patient?

A $65$-year-old man is hospitalized for an acute exacerbation of severe chronic obstructive pulmonary disease (COPD). He has been receiving nebulized bronchodilators, intravenous glucocorticoids, and antibiotics. On hospital day $3$, he experiences a sudden onset of sharp, right-sided chest pain and an acute worsening of dyspnea. Vital signs show a blood pressure of $105/65$ mmHg, heart rate of $128$/min, respiratory rate of $28$/min, and oxygen saturation of $84\%$ on a $4$ L/min nasal cannula (decreased from $92\%$ on $2$ L/min earlier that day). Physical examination reveals hyperresonance to percussion and absent breath sounds over the right lung fields. The trachea is midline. Heart sounds are distant but regular with no murmurs or gallops. There is no jugular venous distention.

Arrange the following differential diagnoses for his sudden clinical deterioration from highest pre-test probability to lowest pre-test probability based on his presentation.

A 28-year-old man is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision. He was the unrestrained driver of a vehicle that struck a concrete barrier. On arrival, he is confused and diaphoretic. His temperature is $36.5^{\circ}\text{C}$ ($97.7^{\circ}\text{F}$), blood pressure is $78/52\text{ mm Hg}$, pulse is $135/\text{min}$, and respirations are $24/\text{min}$. Oxygen saturation is 96% on high-flow oxygen via a non-rebreather mask. The airway is patent. Breath sounds are equal bilaterally. The abdomen is distended and diffusely tender to palpation. The pelvis is stable to anteroposterior and lateral compression. A portable chest radiograph reveals a widened mediastinum with obliteration of the aortic knob but no pneumothorax or hemothorax. A focused assessment with sonography for trauma (FAST) examination demonstrates a large amount of free fluid in the hepatorenal recess (Morison's pouch) and the splenorenal recess. Two large-bore intravenous lines are placed, and balanced blood product transfusion is initiated. Which of the following is the most appropriate next step in the management of this patient?

A 41-year-old woman is evaluated in the oncology clinic to discuss adjuvant endocrine therapy for breast cancer. She recently underwent a lumpectomy and sentinel lymph node biopsy for a stage I, estrogen receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative invasive ductal carcinoma. Radiation therapy was completed two weeks ago. Her medical history is significant for major depressive disorder, which has been well controlled on fluoxetine for the past four years. She also reports experiencing new-onset, disruptive hot flashes that disturb her sleep. Her menstrual cycles are regular, occurring every $28$ days. Her body mass index is $24 \text{ kg/m}^2$. Vital signs and physical examination are within normal limits. The oncologist plans to initiate tamoxifen. Which of the following is the most appropriate pharmacologic adjustment for this patient?

A $68$-year-old man is evaluated in the clinic for a $3$-month history of progressively worsening lower back pain, generalized fatigue, and recent-onset constipation. He has no prior history of malignancy or significant chronic medical conditions. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $138/86\text{ mmHg}$, pulse is $84/\text{min}$, and respiratory rate is $14/\text{min}$. Physical examination reveals midline tenderness over the lower lumbar spine with no focal neurologic deficits. Muscle strength and deep tendon reflexes are symmetric and intact in both lower extremities.

Laboratory studies show:

Based on these findings, which of the following diagnostic studies are the most appropriate concurrent next steps in this patient's evaluation? (Select two)

A 72-year-old man with a history of severe ischemic cardiomyopathy is brought to the emergency department with progressive dyspnea, orthopnea, and worsening confusion over the past 24 hours. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 74/50 mm Hg, heart rate of 118/min, and respiratory rate of 28/min. Physical examination reveals cool, mottled extremities, significant jugular venous distention, and coarse bilateral crackles extending to the mid-lung fields. Urine output since arrival has been minimal. A bedside echocardiogram demonstrates a left ventricular ejection fraction of 20% with severe global hypokinesis and a dilated, non-collapsible inferior vena cava. Arrange the following pharmacologic interventions in the most appropriate sequential order for the management of this patient, starting with the most immediate stabilizing action.

A 27-year-old man is brought to the emergency department by paramedics following a high-speed motorcycle collision without a helmet. Upon arrival, the patient is unresponsive with massive facial crush injuries and copious bleeding into his oropharynx. He exhibits gurgling respiratory efforts. Vital signs reveal a blood pressure of 72/40 mm Hg, a pulse of 135/min, and a respiratory rate of 8/min. Oxygen saturation is 81% on high-flow oxygen. Physical examination is notable for absent breath sounds on the right hemithorax and distended neck veins. His pelvis is stable to palpation, and paramedics have effectively placed a tourniquet on a mangled left lower extremity. Arrange the following steps in the most appropriate sequential order for the initial stabilization and management of this patient.

A gastroenterology consultation is requested for a 42-year-old male who has developed severe, recurrent peptic ulcer disease despite strict adherence to maximal high-dose proton pump inhibitor therapy. He additionally reports a six-month history of high-volume, watery diarrhea that improves only slightly with fasting. A recent esophagogastroduodenoscopy demonstrated markedly hypertrophic gastric folds and multiple atypical ulcerations extending into the distal duodenum and proximal jejunum. Vital signs are stable: temperature 37.0°C (98.6°F), blood pressure 118/76 mmHg, pulse 74/min, and respiratory rate 14/min. Laboratory results reveal a normal basic metabolic panel, intact parathyroid hormone, and a serum calcium level of 9.2 mg/dL. The clinical team strongly suspects a functional neuroendocrine tumor and plans a comprehensive evaluation. Arrange the following diagnostic modalities in the correct, guideline-directed sequence, progressing from initial biochemical screening to precise anatomic localization.

A 72-year-old man is brought to the emergency department from a skilled nursing facility with altered mental status, fever, and a productive cough. His temperature is $39.2^{\circ} \text{C}$ ($102.6^{\circ} \text{F}$), heart rate is $124/\text{min}$, respiratory rate is $26/\text{min}$, and blood pressure is $72/40 \text{ mmHg}$. His oxygen saturation is $88\%$ on room air. The patient is diagnosed with severe community-acquired pneumonia complicated by septic shock. After securing the airway and obtaining appropriate cultures, empirical broad-spectrum antimicrobial therapy is prescribed.

Arrange the following hemodynamic interventions in the correct sequential order according to standard protocolized management of septic shock, starting from the initial intervention to salvage therapy for refractory hypotension.

A 45-year-old patient presents with vague symptoms including fatigue and muscle weakness. During the workup, various acid-base and electrolyte profiles are considered. Match each comprehensive laboratory profile and clinical parameter to its most likely underlying diagnosis.

A 42-year-old man presents to the clinic complaining of worsening headaches and excessive sweating over the past 14 months. He mentions that his wedding ring has become too tight to wear and his shoe size has recently increased. His blood pressure is 148/92 mm Hg, and his heart rate is 78/min. Physical examination reveals coarse facial features, macroglossia, and widened hands with thickened fingers. Visual field testing by confrontation is normal. Due to high clinical suspicion for acromegaly, a serum insulin-like growth factor-1 (IGF-1) level is obtained and returns markedly elevated for his age and sex. Which of the following is the most appropriate next step in the diagnostic workup?

A 64-year-old man comes to the urgent care clinic due to the sudden onset of severe pain, swelling, and redness in his left knee that awoke him from sleep. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of $30\%$, chronic kidney disease with a baseline serum creatinine of $2.7 \text{ mg/dL}$, and a recent diagnosis of atypical community-acquired pneumonia for which he began taking clarithromycin $3$ days ago. His temperature is $37.2^{\circ}\text{C}$ ($99.0^{\circ}\text{F}$), blood pressure is $118/76 \text{ mm Hg}$, and pulse is $82/\text{min}$. Physical examination shows a warm, erythematous, and exquisitely tender left knee with a moderate effusion. Arthrocentesis is performed, yielding synovial fluid with a leukocyte count of $35,000/\mu\text{L}$ ($90\%$ neutrophils). Polarized light microscopy reveals needle-shaped, negatively birefringent crystals. Gram stain shows no organisms. Which of the following is the most appropriate pharmacologic intervention for this patient's current joint condition?

Match each clinical presentation of acute kidney injury (AKI) to the most appropriate primary differential diagnosis based on the history and diagnostic findings.

Emergency medical personnel arrive at the resuscitation bay with a 58-year-old male experiencing high-volume hematemesis. His spouse reports that he has a history of alcohol use disorder and hepatic cirrhosis. During transfer to the hospital bed, the patient has another large episode of vomiting bright red blood. He appears profoundly lethargic, pale, and diaphoretic. Vital signs demonstrate a heart rate of 138/min, blood pressure of 74/42 mm Hg, respiratory rate of 28/min, and oxygen saturation of 88% on ambient air. Physical examination reveals pooled blood in the posterior oropharynx, a diminished gag reflex, and gurgling respirations. Intravenous access is established with two large-bore peripheral catheters. Which of the following is the single most urgent initial step in the management of this patient?

An unresponsive 68-year-old individual is admitted to the intensive care unit for altered mental status and fever. The patient has a known history of severe chronic obstructive pulmonary disease and alcohol use disorder. Family members report that the patient has experienced intractable vomiting multiple times daily for the past week. Upon arrival, vital signs reveal a blood pressure of 90/60 mmHg, a heart rate of 115/min, a respiratory rate of 12/min, and a temperature of 38.6°C (101.5°F). Physical examination demonstrates dry mucous membranes and poor skin turgor.

Laboratory evaluations yield the following results:

An arterial blood gas sample obtained on room air shows:

Based on the provided laboratory data, which of the following best describes the complete combination of acid-base disturbances present in this patient?

Match each patient's clinical presentation with the most likely underlying differential diagnosis.

A $55$-year-old man is evaluated in the surgical ward $3$ hours after undergoing an anterior cervical discectomy and fusion for severe cervical radiculopathy. The nursing staff requested an urgent evaluation because the patient developed sudden-onset severe anterior neck pressure, difficulty swallowing, and shortness of breath. On arrival, the patient is visibly agitated, diaphoretic, and has audible inspiratory stridor. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $165/95\text{ mm Hg}$, pulse is $118/\text{min}$, and respirations are $28/\text{min}$. Pulse oximetry shows an oxygen saturation of $87\%$ on room air. Physical examination reveals a tense, rapidly expanding, and ecchymotic swelling beneath the surgical incision on the anterior neck. Which of the following are the most appropriate immediate steps in management? (Select all that apply)