Tüm alıştırma soruları

A 62-year-old man with myelodysplastic syndrome is receiving a transfusion of packed red blood cells for symptomatic anemia (hemoglobin $7.2$ g/dL). Thirty minutes into the infusion, he reports the sudden onset of severe flank pain, chills, and shortness of breath. His temperature is $39.2^\circ \text{C}$ ($102.6^\circ \text{F}$), blood pressure is $85/50$ mm Hg, pulse is $118$/min, and respiratory rate is $24$/min. Physical examination reveals diaphoresis, and dark-colored urine is noted in his Foley catheter bag.

Arrange the following steps in the most appropriate sequential order for the immediate management of this patient's suspected acute hemolytic transfusion reaction.

A clinic focuses on the evaluation and management of severe and resistant hypertension. Match each patient's clinical presentation with the most appropriate initial diagnostic test for their suspected secondary cause of hypertension.

During pre-participation sports physicals for a middle school athletics program, a physician evaluates several male students at various stages of adolescence. Understanding the predictable chronological sequence of pubertal changes is essential for distinguishing normal development from delayed or precocious puberty. Arrange the following physiological milestones in the typical chronological order of their initial onset or occurrence in a healthy male adolescent.

A 65-year-old man is evaluated in the hospital on day 3 of admission for community-acquired pneumonia. He was initially started on empiric intravenous ceftriaxone and azithromycin. His past medical history is notable for hypertension and type 2 diabetes mellitus. Today, he reports feeling much better and has a good appetite. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $128/78\text{ mmHg}$, pulse is $78/\text{min}$, and respiratory rate is $14/\text{min}$. Pulse oximetry shows $96\%$ on room air. Physical examination reveals significantly decreased crackles at the right lower lung base compared to admission. The patient is tolerating an oral diet. Blood cultures obtained on admission show no growth. A sputum culture obtained on admission has grown *Streptococcus pneumoniae*. Susceptibility testing indicates the organism is highly susceptible to penicillin, amoxicillin, ceftriaxone, and levofloxacin, but resistant to azithromycin. Which of the following is the most appropriate next step in the management of this patient?

A medical student is reviewing the chronological progression of social and play milestones during early childhood. Arrange the following developmental behaviors in the typical sequence of their emergence in a neurotypical child, from earliest to latest.

A 55-year-old man who underwent a coronary artery bypass graft surgery five days ago develops acute swelling and pain in his right calf. His platelet count has dropped from $250,000/\text{mm}^3$ postoperatively to $90,000/\text{mm}^3$ today. He has been receiving subcutaneous unfractionated heparin for deep vein thrombosis prophylaxis. A venous duplex ultrasound confirms a new right lower extremity deep vein thrombosis. He is clinically suspected of having heparin-induced thrombocytopenia (HIT). Arrange the following pathophysiologic steps in the correct chronological order detailing the development of this patient's condition.

A pediatric resident is reviewing the developmental history of a healthy 4-year-old boy during a well-child visit. The parents have kept a detailed baby journal recording the exact ages at which their son acquired various skills. To assess the resident's knowledge of normal growth and development, the attending physician asks the resident to sequence the child's past milestones. Arrange the following developmental milestones in the correct chronological order in which they typically emerge in a normally developing child, from earliest to latest.

A 28-year-old female patient with established systemic lupus erythematosus comes to the office reporting recent-onset leg swelling and foamy urine. Her blood pressure is $150/92$ mm Hg. Urinalysis reveals 3+ protein and the presence of red blood cell casts. Arrange the following steps in the most appropriate clinical sequence for the evaluation and management of this patient's new complication.

A 64-year-old man presents to the emergency department due to a 2-week history of progressive dyspnea on exertion, orthopnea, and a persistent dry cough. His medical history includes seropositive rheumatoid arthritis, type 2 diabetes mellitus, and a 35-pack-year smoking history. His joint disease was previously inadequately controlled with methotrexate monotherapy, prompting the addition of adalimumab 6 months ago, which has successfully induced clinical remission.

On physical examination, his temperature is $37.4^\circ C$ ($99.3^\circ F$), blood pressure is $148/90\ mmHg$, heart rate is $108/min$, and respiratory rate is $24/min$. Pulse oximetry shows $91\%$ on room air. Jugular venous distention is prominent up to the angle of the mandible while the patient is seated at a 45-degree angle. Auscultation reveals diffuse bilateral expiratory wheezes and coarse crackles at the lung bases. Bilateral 2+ pitting edema is noted up to the mid-calves.

Laboratory results:
Leukocytes: $8,500/mm^3$
Hemoglobin: $11.2\ g/dL$
Brain natriuretic peptide (BNP): $840\ pg/mL$ (Normal $< 100$)
Thyroid-stimulating hormone (TSH): $3.8\ \mu U/mL$ (Normal $0.5 - 5.0$)

Arterial blood gas (room air):
pH: $7.48$
$PaCO_2$: $31\ mmHg$
$PaO_2$: $64\ mmHg$
$HCO_3^-$: $23\ mEq/L$

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

A $28$-year-old man presents to the clinic with a $3$-month history of a painless, slowly enlarging mass in his right supraclavicular region. He also reports an unintentional weight loss of $6\text{ kg}$ ($13\text{ lbs}$) and drenching night sweats over the past month. Physical examination reveals a $4\text{-cm}$, firm, non-tender, and mobile lymph node in the right supraclavicular fossa. The remainder of the examination, including abdominal palpation, is unremarkable. A complete blood count and comprehensive metabolic panel are within normal limits.

Arrange the following clinical steps in the most appropriate chronological order for the definitive evaluation and management of this patient's suspected condition.

Match each clinical presentation with its corresponding primary acid-base disorder.

A couple brings their healthy 36-month-old son for a routine wellness visit. The parents note that he enjoys riding his tricycle and frequently engages in imaginative make-believe play with his toys. During the interview, the boy speaks in three-word sentences and is easily understood by the physician. When handed a piece of paper and a crayon, he successfully copies a circle. However, the parents express significant worry because he is completely unable to copy a cross or draw a square, despite their attempts to teach him at home. The remainder of his physical examination is unremarkable. Which of the following is the most appropriate next step in management?

A medical student is reviewing serologic markers for various autoimmune diseases. Match each specific autoantibody below to the rheumatologic condition with which it is most strongly associated.

A 64-year-old man comes to the emergency department reporting progressive facial swelling and shortness of breath over the past two weeks. He notes that the swelling is worse in the morning when he wakes up and improves slightly throughout the day. The patient has a 40-pack-year smoking history and has not seen a physician in ten years. Vital signs are temperature 37.1°C (98.8°F), blood pressure 135/85 mmHg, pulse 98/min, and respirations 18/min. Physical examination reveals plethora and edema of the face and neck. Prominent, distended superficial veins are visible across the anterior chest wall. Auscultation of the lungs reveals decreased breath sounds over the right upper lung field. Which of the following is the most likely cause of this patient's presentation?

A 65-year-old man with a history of deceased-donor renal transplantation 2 years ago is brought to the emergency department by his family due to a 24-hour history of high fever, severe generalized headache, and progressive confusion. His current medications include tacrolimus, mycophenolate mofetil, and prednisone. His temperature is 39.2°C (102.6°F), blood pressure is 105/65 mm Hg, pulse is 112/min, and respirations are 20/min. Physical examination is notable for marked nuchal rigidity and a Glasgow Coma Scale score of 11. Neurological examination reveals a new mild left-sided hemiparesis. Arrange the following steps in the most appropriate chronological sequence for the acute diagnostic and therapeutic management of this patient.

A 34-year-old man comes to the psychiatry clinic reporting a 6-week history of worsening depressed mood, anhedonia, and profound fatigue. He states he is sleeping up to 14 hours a day and has gained 6 kg (13.2 lb) during this period. The patient has a history of a seizure disorder that has been well controlled on carbamazepine for the past 8 years. Five years ago, he was prescribed sertraline by his primary care physician for a depressive episode; three weeks later, he developed grandiosity, decreased need for sleep, pressured speech, and reckless spending. This resulted in a psychiatric hospitalization. He required inpatient observation and treatment with antipsychotics for 3 weeks, long after the sertraline was discontinued, before his symptoms fully resolved. He has not taken any psychiatric medications since that time. Vital signs are within normal limits. Physical examination reveals no abnormalities. Serum chemistry panel, complete blood count, and thyroid-stimulating hormone (TSH) levels are within normal reference ranges. Which of the following is the most appropriate next step in the pharmacologic management of this patient's current symptoms?

A 58-year-old woman comes to the clinic for follow-up of fatigue and joint pain. She has a 6-year history of rheumatoid arthritis, currently treated with methotrexate and low-dose prednisone. She reports that her fatigue has progressively worsened over the past three months, limiting her daily activities. Over the same period, she has experienced increased morning stiffness lasting up to 2 hours and worsening swelling in her hands and wrists. She has no history of gastrointestinal bleeding or melena. Vital signs are normal. Physical examination reveals active synovitis with swelling and tenderness in the bilateral metacarpophalangeal and proximal interphalangeal joints.

Laboratory studies show:

Which of the following is the most appropriate next step in the management of this patient's anemia?

A 24-month-old girl is evaluated at a community health center prior to enrolling in a new childcare program. She is accompanied by her grandmother, who expresses concern regarding the child's social and language skills. The grandmother reports that at the local playground, the girl will play alongside other toddlers but refuses to share her toys, frequently pulling them away if another child approaches. Furthermore, the child communicates her needs using short phrases such as "want juice" or "go home." Her total vocabulary consists of approximately 80 words. On physical examination, the child is cooperative, can kick a small ball, and jumps with both feet off the floor. When given wooden cubes, she successfully stacks a tower of 6 cubes. She accurately follows two-step verbal instructions without visual cues. Which of the following is the most appropriate next step in management?

Match the following classic dermatological findings with the infectious disease they most accurately represent.

A healthy 18-month-old child is evaluated at the pediatric clinic for a routine well-child visit. The physician performs a comprehensive developmental assessment to ensure the child is acquiring skills at the expected rate. Which specific skill is expected to be achieved by this age in each of the following developmental domains? Match each developmental domain with its appropriate 18-month milestone.