Tüm alıştırma soruları

An adolescent girl, aged $17$ years, comes to the outpatient office for a pre-college physical examination. She plans to move into a university dormitory next month. The patient has a history of perinatally acquired human immunodeficiency virus (HIV) infection. Her adherence to antiretroviral therapy has been poor over the past year. She currently feels well and reports no fever, cough, or weight loss. Her temperature is $37.1^{\circ}\text{C}$ ($98.8^{\circ}\text{F}$), blood pressure is $110/70 \text{ mmHg}$, and pulse is $78/\text{min}$. Physical examination is notable for white plaques on the buccal mucosa that can be scraped off with a tongue depressor, as well as generalized non-tender lymphadenopathy. Laboratory studies show a CD4+ T-cell count of $140 \text{ cells/mm}^3$ and an HIV viral load of $150,000 \text{ copies/mL}$. A review of her immunization records shows she received all recommended primary vaccines during infancy but has not received any immunizations since $4$ years of age. Which of the following vaccines is contraindicated for this patient during today's visit?

Match each of the following highly specific autoantibodies to the rheumatologic condition with which they are most classically associated.

A 34-year-old woman is admitted to the intensive care unit with a 2-day history of progressively worsening fatigue, fever, and confusion. Her husband notes she has been difficult to arouse this morning. Temperature is 38.2°C (100.8°F), blood pressure is 142/88 mmHg, pulse is 112/min, and respirations are 18/min. Physical examination reveals scleral icterus, pale conjunctivae, and diffuse petechiae over the lower extremities. Neurologic examination shows altered mental status but no focal motor deficits. Laboratory studies show:

Thrombotic thrombocytopenic purpura (TTP) is strongly suspected. Arrange the following steps in the most appropriate chronological order for the diagnosis and management of this patient.

Seeking preconception counseling, a 26-year-old woman with a history of systemic lupus erythematosus (SLE) and class III lupus nephritis presents to the outpatient clinic. Her disease is currently in clinical and serologic remission without active proteinuria. She is maintained on a daily regimen of mycophenolate mofetil, hydroxychloroquine, and lisinopril. The patient and her husband are eager to conceive as soon as it is medically safe to do so. Arrange the following clinical steps in the optimal chronological sequence to ensure the best maternal and fetal outcomes.

A $62$-year-old man is hospitalized due to a $4$-week history of low-grade fever, progressive fatigue, and generalized myalgias. He has a history of osteoarthritis and underwent a colonoscopy $2$ months ago for routine screening. His temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $122/74\text{ mm Hg}$, and pulse is $92/\text{min}$. Physical examination reveals a grade $3/6$ holosystolic murmur heard best at the cardiac apex that radiates to the axilla. Splinter hemorrhages are noted on the fingernails of both hands. Laboratory studies show a leukocyte count of $14,000/\text{mm}^3$ and an erythrocyte sedimentation rate of $65\text{ mm/hr}$. A transesophageal echocardiogram demonstrates a $1.2\text{-cm}$ mobile vegetation on the mitral valve.

Three sets of blood cultures are drawn, and the patient is empirically started on intravenous vancomycin and ceftriaxone. Forty-eight hours later, all three blood culture sets grow *Enterococcus faecalis*. Antimicrobial susceptibility testing is reported as follows:

The patient's serum creatinine is $0.9\text{ mg/dL}$. He has no known drug allergies. Which of the following is the most appropriate next step in antimicrobial therapy?

A $45$-year-old woman is brought to the emergency department due to sudden-onset, severe weakness in her arms and legs. She reports she could not get out of bed this morning. She has a $3$-year history of a "sand-like" sensation in her eyes, dry mouth requiring frequent sips of water, and intermittent pain in her fingers. She takes no medications. Vital signs are normal. Physical examination shows flaccid paralysis of all four extremities with absent deep tendon reflexes. Sensation is intact.

Laboratory studies show:
Serum sodium: $140 \text{ mEq/L}$
Serum potassium: $1.6 \text{ mEq/L}$
Serum chloride: $116 \text{ mEq/L}$
Serum bicarbonate: $12 \text{ mEq/L}$
BUN: $14 \text{ mg/dL}$
Creatinine: $0.9 \text{ mg/dL}$

Arterial blood gas (room air):
pH: $7.22$
pCO $_2$: $26 \text{ mm Hg}$

Urinalysis:
pH: $6.5$
Specific gravity: $1.015$
Glucose: negative
Protein: negative

Which of the following is the most likely underlying mechanism for this patient's acute presentation?

A $34$-year-old female teacher comes to the primary care office complaining of severe throat pain and a fever that began abruptly yesterday. She notes difficulty swallowing but denies having a cough or rhinorrhea. Her temperature is $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, and pulse is $92/\text{min}$. Physical examination reveals marked pharyngeal erythema, bilateral tonsillar exudates, and tender anterior cervical lymphadenopathy. A rapid antigen detection test is positive for Streptococcus pyogenes (Group A Streptococcus). The patient has no known drug allergies. Which of the following is the most appropriate next step in pharmacologic management?

A 58-year-old man comes to the urgent care clinic complaining of severe left knee pain that awoke him from sleep. He has a medical history of hypertension and heart failure with preserved ejection fraction, for which he takes lisinopril and hydrochlorothiazide. His temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$). Physical examination reveals a swollen, erythematous, and exquisitely tender left knee with limited range of motion. There are no other joint abnormalities. Laboratory testing reveals a serum uric acid level of $5.8 \text{ mg/dL}$ (reference: $4.0-8.5 \text{ mg/dL}$). A diagnostic arthrocentesis is performed; synovial fluid analysis shows a leukocyte count of $42,000/\text{mm}^3$ with $85\%$ neutrophils, and the presence of needle-shaped, negatively birefringent crystals. Gram stain reveals no organisms. Which of the following is the most appropriate next step in management?

Match each classic peripheral blood smear or bone marrow finding to its most likely associated hematologic diagnosis.

A primary care clinic is holding an educational seminar for medical students on pediatric development. During the session on expressive communication, the attending physician asks the students to outline the typical progression of a child's speech. Order the following expressive language achievements chronologically as they would normally emerge in a healthy infant and toddler, beginning with the earliest.

A $34$-year-old woman comes to the outpatient medical clinic reporting a $6$-month history of progressive fatigue, weakness, and a $4.5\ \text{kg}$ ($10\ \text{lb}$) weight gain. She notes that her menstrual periods, which were previously regular, have ceased entirely over the same timeframe. She takes no medications and has no other medical history. Vital signs show a temperature of $36.4^\circ\text{C}$ ($97.5^\circ\text{F}$), pulse of $54/\text{min}$, and blood pressure of $100/65\ \text{mm Hg}$. Physical examination reveals dry skin and a delayed relaxation phase of the deep tendon reflexes. The thyroid gland is not palpable. A urine pregnancy test is negative.

Laboratory results are as follows:

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

A 63-year-old man with a history of metastatic non-small cell lung cancer is brought to the emergency department by his family. Over the past week, he has experienced progressively worsening, severe mid-thoracic back pain that is exacerbated by coughing. This morning, he was unable to stand due to profound weakness in his legs and reports that he has not been able to urinate for the past $12$ hours. On physical examination, his temperature is $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$), blood pressure is $142/88\text{ mmHg}$, and heart rate is $98/\text{min}$. Neurologic examination reveals $2/5$ motor strength in bilateral lower extremities, hyperactive patellar reflexes, positive Babinski signs bilaterally, and diminished sensation to pinprick below the level of the umbilicus. A post-void residual volume measured by bladder ultrasound is $750\text{ mL}$. Suspecting malignant epidural spinal cord compression, arrange the following management steps in the most appropriate sequential order.

Match each atypical clinical presentation of a complex hematologic or coagulopathic disorder to the most appropriate and highly specific targeted management strategy.

A 34-year-old woman presents to the outpatient department due to left-sided chest pain and shortness of breath for the past 3 days. The chest pain is sharp and noticeably worsens when she takes a deep breath or coughs. She also reports feeling persistently fatigued and sad for the past month. Her medical history is significant for systemic lupus erythematosus (SLE) and bipolar disorder. Her current daily medications include hydroxychloroquine, prednisone 5 mg, and quetiapine. Her temperature is 37.8°C (100.0°F), blood pressure is 120/78 mmHg, and heart rate is 88/min. Cardiopulmonary examination reveals a pleural friction rub on the left side, with no murmurs, gallops, or jugular venous distention. A chest radiograph demonstrates a small left-sided pleural effusion without any pulmonary infiltrates. An electrocardiogram is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's clinical presentation and laboratory findings of hyponatremia with the most appropriate targeted initial therapeutic intervention.

A 68-year-old man with a history of atrial fibrillation is brought to the emergency department after vomiting large amounts of bright red blood. He takes warfarin daily. On presentation, he appears pale and lethargic. His temperature is 37.1°C (98.8°F), blood pressure is 88/56 mm Hg, and heart rate is 118/min. Physical examination reveals delayed capillary refill and cool extremities. Laboratory studies show a hemoglobin of 8.2 g/dL and an International Normalized Ratio (INR) of 8.4. Intravenous fluid resuscitation with normal saline is initiated. Which of the following is the most appropriate next step in management?

Match the following common outpatient clinical presentations to their most appropriate first-line oral pharmacological therapy.

Evaluate the following clinical presentations of immunocompromised patients with opportunistic infections. Match each clinical scenario with the most appropriate initial targeted pharmacotherapy.

A 24-month-old girl is brought to the family medicine clinic for a routine well-child examination. Her parents express concern about her social skills and physical abilities compared to her older cousins. They report that at her daycare, she typically sits next to other toddlers playing with her own toys but does not actively engage or share with them. The child's medical history is unremarkable, and she takes no medications. On examination, the child runs smoothly around the exam room. When navigating the clinic step stool, she places both feet on each step before taking the next one. During play, she successfully stacks six wooden blocks but is unable to copy a drawing of a circle. Her vocabulary consists of roughly 60 distinct words, and she frequently combines two words to express needs, such as "more juice." Based on these findings, which of the following is the most appropriate next step in management?

A 55-year-old man with poorly controlled type 2 diabetes mellitus is evaluated in the hospital on day 4 of admission for a severe diabetic foot infection. He initially presented with a deep, purulent ulcer on the plantar aspect of his right foot surrounded by extensive cellulitis. On admission, empiric therapy was initiated with intravenous vancomycin and piperacillin-tazobactam, and he subsequently underwent surgical debridement of necrotic tissue. Today, his temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $128/78\text{ mm Hg}$, and pulse is $78\text{/min}$. The wound appears clean with developing granulation tissue. Deep tissue cultures obtained during surgery yield heavy growth of Staphylococcus aureus. Antimicrobial susceptibility testing demonstrates resistance to penicillin and susceptibility to oxacillin, cefazolin, and vancomycin. Which of the following is the most appropriate next step in pharmacotherapy?