Tüm alıştırma soruları

A 28-year-old woman with a known history of systemic lupus erythematosus (SLE) presents to the nephrology clinic with new-onset hypertension, progressive lower extremity edema, and foamy urine. Laboratory evaluation reveals a serum creatinine of 1.7 mg/dL, a serum albumin level of 2.6 g/dL, and a urine protein-to-creatinine ratio of 3.8 g/g. Urinalysis demonstrates dysmorphic red blood cells and red blood cell casts.

Assuming the patient initially follows a standard favorable clinical trajectory but eventually experiences a severe, treatment-resistant flare several years later, arrange the following clinical interventions in the correct chronological sequence of her long-term management.

A 68-year-old man with a history of castration-resistant metastatic prostate cancer is brought to the emergency department by his family. He reports a 5-day history of progressively worsening, severe thoracic back pain that is exacerbated by coughing and laying flat. Over the past 12 hours, he has developed profound weakness in both legs and an inability to urinate. His temperature is 37.2°C (99.0°F), blood pressure is 142/86 mmHg, and pulse is 92/min. Neurological examination reveals 2/5 motor strength in the bilateral lower extremities, decreased pinprick sensation below the umbilicus, and absent patellar and Achilles reflexes. Anal sphincter tone is markedly diminished. Post-void residual bladder volume is 600 mL.

Arrange the following management steps in the most appropriate chronological sequence for this patient:

A $34$-year-old woman is brought to the emergency department by her partner due to confusion and difficulty speaking that began this morning. Over the past three days, she has experienced fatigue, generalized weakness, and subjective fever. She has no significant past medical history and takes no medications. Her temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is $145/88\text{ mmHg}$, pulse is $112/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals scleral icterus and scattered petechiae over the lower extremities. Neurological examination is notable for fluctuating lethargy and expressive aphasia.

Laboratory studies show the following:

A peripheral blood smear demonstrates numerous fragmented red blood cells. Which of the following is the most critical initial intervention for this patient?

A 26-year-old man presents to the clinic with a 4-day history of a severely swollen, painful right knee, bilateral conjunctival injection, and pain at the left posterior heel. He reports having had a severe diarrheal illness three weeks ago after a camping trip. The patient's vital signs are within normal limits. Arrange the following diagnostic and therapeutic steps in the optimal chronological sequence for managing this patient's condition.

Match each clinical presentation with its most characteristic peripheral blood smear finding.

A $52$-year-old man is evaluated for persistent fever. He was admitted $20$ days ago for acute myeloid leukemia induction chemotherapy, which resulted in profound bone marrow suppression. Ten days ago, his absolute neutrophil count dropped to $50/\text{mm}^3$ and he developed a fever of $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$). Blood cultures were drawn, and empiric intravenous cefepime was initiated. He remained febrile, and $5$ days ago, intravenous vancomycin was added.

Today, his temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$). He reports new-onset right-sided pleuritic chest pain. His absolute neutrophil count remains at $50/\text{mm}^3$. Repeated blood cultures drawn prior to the initiation of antibiotics and $5$ days ago have shown no growth. A non-contrast computed tomography scan of the chest reveals a $3\text{ cm}$ dense macronodule surrounded by a halo of ground-glass attenuation in the right upper lobe. Serum galactomannan testing is strongly positive, and intravenous voriconazole is initiated.

Which of the following is the most appropriate next step regarding this patient's antibacterial regimen?

Parents bring their 4-year-old boy to the clinic for a routine annual check-up. They report that he can successfully hop on one foot, copy a cross on a piece of paper, and play cooperatively in a group with other children. His speech is entirely understandable to strangers. However, the parents are worried because he cannot yet tie his own shoelaces and is unable to draw a person with six body parts. His physical examination is entirely unremarkable. Based on normal developmental milestones, which of the following is the most appropriate next step in management?

Match each pediatric patient's clinical presentation with the most appropriate next step in management.

A 62-year-old woman is evaluated in the emergency department for a 24-hour history of confusion and fever. She was brought from a skilled nursing facility where she is recovering from an ischemic stroke. Her medical history includes chronic obstructive pulmonary disease (COPD) and diet-controlled type 2 diabetes mellitus. Medications include aspirin and inhaled tiotropium.

Vital signs are temperature 38.6°C (101.5°F), blood pressure 82/50 mm Hg, pulse 122/min, and respirations 24/min. Pulse oximetry is 94% on room air.

Physical examination reveals a lethargic and disoriented patient. Mucous membranes are dry. Lung auscultation reveals mild, diffuse end-expiratory wheezing without crackles. Cardiac examination shows tachycardia with a regular rhythm. The abdomen is soft, but right costovertebral angle tenderness is present.

Laboratory results are as follows:
Leukocytes: 16,500/mm³ (15% bands)
Sodium: 138 mEq/L
Potassium: 4.8 mEq/L
Bicarbonate: 16 mEq/L
Creatinine: 2.1 mg/dL (baseline 0.9 mg/dL)
Lactate: 4.2 mmol/L
TSH: 0.1 mU/L (Normal 0.4-4.0 mU/L)
Free T4: 0.6 ng/dL (Normal 0.9-1.7 ng/dL)

Arterial blood gas on room air:
pH: 7.30
PaCO2: 32 mm Hg
PaO2: 78 mm Hg

A urine culture collected 2 days ago at the nursing facility for dysuria has just resulted, showing >100,000 CFU/mL of *Escherichia coli* sensitive to ceftriaxone, ciprofloxacin, and nitrofurantoin.

A chest radiograph shows hyperinflated lungs and flattened diaphragms with no focal consolidations or pulmonary venous congestion.

The patient is immediately started on intravenous ceftriaxone. Over the next 2 hours, she receives 3 liters of intravenous normal saline. Reassessment shows a blood pressure of 78/48 mm Hg and a pulse of 118/min.

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

A physician is asked to evaluate a hospitalized $72$-year-old male on postoperative day $4$ following an emergency exploratory laparotomy and small bowel resection for a strangulated hernia. Overnight, he developed an acute fever of $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$) and excruciating pain in his right knee.

The patient has a history of hypertension and chronic kidney disease, with a baseline serum creatinine of $2.1\text{ mg/dL}$. He is currently receiving continuous intravenous fluids and is transitioning to a clear liquid diet.

On physical examination, his vital signs are stable aside from the fever. The right knee is markedly swollen, uniformly erythematous, warm, and exquisitely tender to light palpation. He refuses to range the joint. The surgical incision site is clean, dry, and intact with no surrounding erythema or induration.

Arthrocentesis of the right knee is performed, yielding $5\text{ mL}$ of cloudy yellow fluid. Synovial fluid analysis reveals:

- Leukocyte count: $45,000/\text{mm}^3$ ($85\%$ neutrophils)
- Gram stain: No organisms seen
- Crystal analysis: Negatively birefringent, needle-shaped crystals

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

A 24-year-old man comes to the clinic complaining of lower back pain that has progressively worsened over the past 7 months. He states that the pain is most severe when he wakes up in the morning and is associated with profound stiffness that lasts for about 2 hours. The discomfort noticeably improves after he goes for a jog or stretches, but it does not improve with rest. He has no history of trauma or recent infections. Vital signs are within normal limits. Physical examination reveals reduced forward flexion of the lumbar spine. An anteroposterior radiograph of the pelvis demonstrates bilateral sclerosis and joint space narrowing of the sacroiliac joints. Which of the following is the most appropriate initial pharmacotherapy for this patient's condition?

Emergency medical services arrive with a $22$-year-old university student who intentionally ingested a large quantity of analgesic medication following a dispute. According to her roommate, she swallowed approximately $30$ tablets of $500$-mg acetaminophen exactly $45$ minutes ago. The patient is visibly distressed and reports mild nausea, but denies vomiting, abdominal pain, or other symptoms. Vital signs include a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $118/75$ mm Hg, pulse of $88$/min, and respiratory rate of $16$/min. The physical examination is notable only for a flat, non-tender abdomen and no focal neurologic deficits. Arrange the clinical interventions below in the correct chronological sequence to appropriately evaluate and manage this patient's toxic exposure.

A $65$-year-old man comes to the clinic reporting progressive fatigue, weakness, and a "pins and needles" sensation in his feet for the past $4$ months. His past medical history is significant for type $2$ diabetes mellitus, for which he has been taking metformin for $10$ years. Vital signs are within normal limits. Physical examination reveals pale conjunctivae and decreased vibratory sensation in the bilateral toes and ankles.

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

A 52-year-old restaurant manager comes to the clinic due to sudden, excruciating pain and swelling in his left big toe that woke him up from sleep. He reports having two similar episodes over the past twelve months that eventually resolved after taking various over-the-counter pain relievers. His past medical history is notable for hypertension and obesity. Vital signs are stable and within normal limits. Physical examination reveals a markedly erythematous, warm, swollen, and exquisitely tender left first metatarsophalangeal joint. Arrange the following clinical steps in the most appropriate chronological sequence for the optimal evaluation and long-term management of this patient's condition.

A 42-year-old woman is brought to the emergency department by her husband due to sudden-onset, severe weakness in her legs that rapidly progressed over the last 12 hours. She is now unable to stand or bear weight. She also reports feeling intensely "short of breath." Her medical history is significant for a 5-year history of primary Sjögren syndrome, for which she takes artificial tears and cevimeline. Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), pulse 105/min, blood pressure 115/75 mm Hg, and respirations 26/min. Oxygen saturation is 98% on room air.

Physical examination reveals a tachypneic woman taking deep, rapid breaths. Lungs are clear to auscultation bilaterally. Neurologic examination shows 1/5 motor strength in the bilateral lower extremities and 3/5 in the upper extremities. Deep tendon reflexes are absent globally. Sensation is intact.

Laboratory results are as follows:

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

A 72-year-old man is evaluated on postoperative day 2 following a partial colectomy for recurrent diverticulitis. His postoperative course was complicated by surgical site oozing, resulting in a hemoglobin drop to 6.8 g/dL. His past medical history is significant for chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy with a left ventricular ejection fraction of 35%. He is currently receiving his second unit of packed red blood cells when he develops sudden-onset severe dyspnea and a dry cough. Temperature is 37.8°C (100.0°F), blood pressure is 175/95 mm Hg, pulse is 115/min, and respirations are 26/min. Pulse oximetry shows 88% on room air. Physical examination reveals an elevated jugular venous pressure of 12 cm H2O. Lung auscultation demonstrates bilateral basilar crackles with scattered expiratory wheezing. Cardiac auscultation reveals a regular tachycardia with a prominent S3 gallop. The transfusion is immediately stopped. Which of the following is the most appropriate next step in management?

A 55-year-old man develops sudden-onset generalized urticaria, wheezing, and a blood pressure of $80/50$ mm Hg shortly after receiving a dose of intravenous ceftriaxone on the medical ward. Arrange the following management steps in the correct chronological sequence, prioritizing immediate life-saving interventions first.

Match each clinical presentation of an immunocompromised patient with the most appropriate targeted pharmacotherapy.

Match each classic physical examination or imaging finding to its most likely rheumatologic diagnosis.

A 52-year-old woman undergoing induction chemotherapy for acute myeloid leukemia presents to the emergency department with chills and a temperature of 39.2°C (102.6°F). Laboratory studies reveal an absolute neutrophil count of 250/mm³. Arrange the following steps for the management of this patient in the most appropriate chronological order.