Tüm alıştırma soruları

A pediatrician is reviewing normal child development principles to prepare for upcoming well-child examinations. To properly screen for developmental delays, clinicians must understand the normal sequencing of skills across various domains. Arrange the following pediatric developmental milestones in chronological order from earliest to latest based on the typical age of acquisition in a healthy, full-term child.

Match each biologic disease-modifying antirheumatic drug (bDMARD) with its specific mechanism of action and the most characteristic clinical caveat or adverse effect associated with its use.

A 74-year-old man is admitted to the intensive care unit with septic shock secondary to a severe complicated urinary tract infection. He has a history of neurogenic bladder managed with clean intermittent catheterization. On admission, his temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $82/50\text{ mmHg}$, and heart rate is $118/\text{min}$. He receives aggressive fluid resuscitation and is started on empiric intravenous piperacillin-tazobactam and vancomycin. By hospital day 3, his condition has significantly improved; he is afebrile, hemodynamically stable off vasopressors, and transferred to the general medical floor. Blood cultures and a urine culture obtained on admission both yield *Enterococcus faecalis*. Susceptibility testing indicates the organism is sensitive to ampicillin, vancomycin, linezolid, and daptomycin, but intrinsically resistant to cephalosporins. Which of the following is the most appropriate next step in pharmacotherapy?

A 54-year-old man develops severe pain, redness, and swelling of his right big toe on postoperative day 3 following an uncomplicated laparoscopic cholecystectomy. He cannot bear weight on the affected foot. His temperature is 37.6°C (99.7°F), blood pressure is 135/85 mm Hg, and pulse is 88/min. Examination shows an exquisitely tender, erythematous, and swollen right first metatarsophalangeal joint. Synovial fluid analysis reveals a leukocyte count of 22,000/mm³ and numerous negatively birefringent, needle-shaped crystals. Which of the following is the most appropriate next step in management?

A 58-year-old female patient visits the outpatient clinic to discuss a two-month history of progressively worsening shortness of breath. Initially, she noticed breathlessness only when climbing stairs, but she now experiences it after walking short distances on level ground. The patient's medical background is notable for limited cutaneous systemic sclerosis, characterized by diffuse calcinosis cutis, severe esophageal dysmotility, and tightening of the skin over her fingers. She also has a history of primary hypothyroidism and severe digital vasospasm triggered by cold exposure.

Her daily medications include amlodipine, omeprazole, levothyroxine, and sildenafil.

Vital signs are as follows:
- Temperature: $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$)
- Blood pressure: $126/78\text{ mm Hg}$
- Heart rate: $94/\text{min}$
- Respiratory rate: $22/\text{min}$
- Pulse oximetry: $94\%$ on room air

Physical examination reveals clear lung fields bilaterally with no crackles or wheezes. Cardiovascular assessment demonstrates a prominent parasternal impulse and a markedly accentuated pulmonic component of the second heart sound. Examination of the lower extremities shows mild bilateral pitting edema.

Recent laboratory and diagnostic results:

An electrocardiogram reveals right axis deviation and signs of right ventricular hypertrophy. A chest radiograph demonstrates prominent central pulmonary arteries with rapid peripheral tapering and completely clear lung parenchyma. A transthoracic echocardiogram obtained yesterday estimates a right ventricular systolic pressure of $55\text{ mm Hg}$ with normal left ventricular ejection fraction.

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

An otherwise healthy 45-year-old woman receives treatment in the inpatient ward for an acute complicated urinary tract infection with associated bacteremia. At the time of admission two days ago, she presented with fever, chills, and costovertebral angle tenderness, prompting the initiation of empiric intravenous piperacillin-tazobactam. Today, she has been afebrile for the past 24 hours, her flank pain has nearly resolved, and she is tolerating a regular diet. Final culture results from both blood and urine demonstrate growth of *Escherichia coli*. The susceptibility report indicates resistance to ampicillin, but susceptibility to ceftriaxone, trimethoprim-sulfamethoxazole, levofloxacin, and piperacillin-tazobactam. Based on the culture results and the patient's clinical improvement, what is the most appropriate next step in management?

Emergency medical personnel transport an elderly resident from an assisted living facility to the acute medical unit. The staff reported a three-day decline in functional status, noting increased thirst, frequent urination, and an escalating, non-productive cough. Medical records indicate long-standing insulin-requiring diabetes mellitus and severe chronic obstructive pulmonary disease.

Upon arrival, the patient is somnolent but appropriately follows simple commands. Vital signs reveal a temperature of 37.0°C (98.6°F), heart rate of 118/min, blood pressure of 105/62 mm Hg, and a respiratory rate of 28/min with shallow, labored breathing. Oxygen saturation is 90% on ambient air. Physical examination demonstrates poor skin turgor, prominent use of accessory muscles of respiration, and diffuse expiratory wheezing with a prolonged expiratory phase. Jugular venous pressure is estimated at 4 cm H2O.

Initial laboratory studies are obtained:

Arterial blood gas analysis on ambient air:

In addition to intravenous fluid resuscitation and a continuous regular insulin infusion, which of the following is the most appropriate next step in the management of this patient?

A $25$-year-old man presents to the clinic with a diffuse maculopapular rash on his trunk, palms, and soles, along with generalized lymphadenopathy. He reports having a painless penile ulcer $2$ months ago that resolved on its own. Assuming the traditional testing algorithm is used, arrange the following steps in the most appropriate chronological sequence for the diagnosis and management of this patient's condition.

A 55-year-old man receiving systemic chemotherapy for diffuse large B-cell lymphoma presents to the emergency department with chills and a temperature of 38.8°C (101.8°F). His laboratory evaluation reveals an absolute neutrophil count of 400/mm³. Arrange the following clinical interventions in the correct chronological sequence for the standard initial management of this patient's neutropenic fever.

During a routine follow-up evaluation, a 32-year-old woman with diffuse cutaneous systemic sclerosis reports severe pain and discoloration in her digits. She notes that exposure to cold temperatures triggers her fingers to turn sharply white, then blue, and finally red. Arrange the following therapeutic interventions in the correct step-wise sequence for the management of this patient's Raynaud phenomenon, proceeding from initial conservative measures to therapies reserved for severe, refractory, or tissue-threatening disease.

A daughter brings her 75-year-old father to the emergency department due to his profound sleepiness and labored breathing over the preceding 72 hours. The patient has developed a worsening cough productive of yellow sputum and subjective fevers during this time. His medical history includes chronic obstructive pulmonary disease (COPD), benign prostatic hyperplasia, and essential hypertension. His home medications are a tiotropium inhaler, as-needed albuterol, and amlodipine.

Vital signs show a temperature of $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), blood pressure of $118/74\text{ mm Hg}$, pulse of $108/\text{min}$, and respiratory rate of $26/\text{min}$. Pulse oximetry reveals an oxygen saturation of $85\%$ on room air.

Physical examination demonstrates a somnolent patient who awakens easily to verbal stimuli and follows simple commands. The anteroposterior chest diameter is increased. Auscultation reveals a prolonged expiratory phase with diffuse wheezing bilaterally, as well as coarse crackles localized to the right lower lung field. Cardiac examination shows a regular tachycardia with distant heart sounds and no murmurs. Trace bilateral ankle edema is present.

Laboratory results are as follows:

An arterial blood gas analysis obtained on room air demonstrates:

A portable chest radiograph displays hyperinflated lung fields, flattened hemidiaphragms, and a dense alveolar opacity in the right lower lobe. The cardiac silhouette is normal in size.

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

A 41-year-old woman is brought to the emergency department by her husband due to a 4-day history of profound fatigue, easy bruising, and recurrent nosebleeds. She has no significant past medical history and takes no medications. Vital signs show a temperature of $37.6^\circ \text{C}$ ($99.7^\circ \text{F}$), pulse of $110$/min, respirations of $18$/min, and blood pressure of $105/65$ mm Hg. Physical examination reveals pale mucous membranes, diffuse petechiae over the trunk and extremities, and continuous oozing of blood from a peripheral intravenous catheter site.

Laboratory studies reveal the following:

* Hemoglobin: $7.6$ g/dL
* Leukocyte count: $3,200/\mu\text{L}$
* Platelet count: $18,000/\mu\text{L}$
* Prothrombin time: $22$ seconds
* Activated partial thromboplastin time: $48$ seconds
* Fibrinogen: $80$ mg/dL (Normal: $200$–$400$ mg/dL)
* D-dimer: $8,500$ ng/mL (Normal: $< 500$ ng/mL)

Peripheral blood smear demonstrates large mononuclear cells with bilobed nuclei and abundant azurophilic granules; several of these cells contain multiple, needle-like eosinophilic inclusion bodies.

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

Correlate each complex clinical scenario with the specific autoantibody marker that best corresponds to the patient's underlying rheumatologic diagnosis.

Concerned about their son's lack of progress, a young couple schedules an evaluation for their firstborn child who just celebrated his fourth birthday. According to the parents, the child appears "clumsy" and struggles with fine motor tasks, specifically noting his inability to tie his shoelaces and his failure to draw a triangle when instructed by his preschool teacher. During the clinical observation, the boy successfully hops on one foot, independently buttons his shirt, copies a cross, and plays a board game cooperatively with his mother. His speech is fully intelligible, though he occasionally repeats the first syllables of words when enthusiastically describing his favorite toy. No facial tics or signs of physical struggle accompany these speech repetitions. Which of the following is the most appropriate next step in management?

A 54-year-old woman presents to the outpatient clinic reporting a three-week history of progressively worsening exertional dyspnea, fatigue, and bilateral lower extremity swelling. She states that she now requires three pillows to sleep comfortably at night without waking up short of breath. Her medical history is significant for estrogen-receptor-negative, HER2-positive breast cancer, for which she underwent surgical resection and completed a chemotherapy regimen containing doxorubicin and cyclophosphamide six months ago. She is currently receiving maintenance therapy with trastuzumab. Vital signs show a temperature of $37.1^\circ C$ ($98.8^\circ F$), heart rate of $105\text{ /min}$, respiratory rate of $22\text{ /min}$, and blood pressure of $114/74\text{ mmHg}$. Pulse oximetry is $94\%$ on room air. Physical examination reveals an elevated jugular venous pressure of $9\text{ cm H}_2\text{O}$, fine bibasilar crackles, and a distinct third heart sound ($S_3$). Pitting edema is present to the mid-calves bilaterally.

Recent laboratory studies are as follows:

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

A 24-year-old woman is brought to the emergency department by her roommate 2 hours after intentionally ingesting a large, unknown quantity of immediate-release acetaminophen tablets. She reports mild nausea but is otherwise asymptomatic. Her temperature is 37.0°C (98.6°F), blood pressure is 118/76 mm Hg, pulse is 88/min, and respirations are 14/min. She is alert, fully oriented, and cooperative. Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient.

A family physician is reviewing the timeline for universal screening tests recommended during routine well-child care. Arrange the following universal screening evaluations in chronological order based on the earliest age they are routinely indicated for healthy children.

Progressive shortness of breath over the past 48 hours prompts a 62-year-old man to seek evaluation at the emergency department. He has a 45-pack-year smoking history, type 2 diabetes mellitus, and essential hypertension. The patient notes that his breathing worsens significantly when he lies flat, forcing him to sleep in a recliner chair. His temperature is 37.2°C (99.0°F), blood pressure is 162/94 mm Hg, pulse is 108/min, and respiratory rate is 24/min. Pulse oximetry shows an oxygen saturation of 90% on room air. Physical examination reveals distended neck veins while sitting at a 45-degree angle. Lung auscultation demonstrates bilateral basilar crackles without wheezing. Cardiac examination reveals a regular tachycardia with a prominent S3 gallop. A chest radiograph demonstrates cardiomegaly and cephalization of pulmonary vessels. Which of the following is the most likely diagnosis?

A 65-year-old woman with a body mass index (BMI) of $32\text{ kg/m}^2$ is diagnosed with osteoarthritis of the right knee after presenting with chronic, progressive knee pain that worsens with activity. Radiographs show joint space narrowing and osteophyte formation. Arrange the following management strategies in the standard chronological order of escalation, from initial conservative therapy to definitive treatment.

A pediatric clinic evaluates several patients presenting for routine health maintenance or parent concerns regarding growth and development. Match each patient's clinical presentation with the most accurate clinical interpretation and next best step in management.