Tüm alıştırma soruları

A 15-month-old boy is brought to the clinic for a health maintenance visit. At 12 months of age, he was hospitalized for 5 days due to a prolonged fever, bilateral nonexudative conjunctivitis, mucosal changes, and unilateral cervical lymphadenopathy. He was diagnosed with Kawasaki disease and received high-dose aspirin and intravenous immunoglobulin (IVIG). He has fully recovered, and his most recent echocardiogram was normal. His last immunizations were administered at age 6 months. His development is age-appropriate. His vital signs and physical examination today are within normal limits. Which of the following is the most appropriate immunization plan for this patient today?

A 28-year-old woman comes to the clinic for evaluation of chronic fatigue, poor sleep, and diffuse muscle aches over the past 4 months. She describes the pain as "aching all over" and notes that she often wakes up feeling unrefreshed. She has no history of joint swelling, facial rashes, oral ulcers, or fever. Her medical history is notable for atypical depression, for which she currently takes phenelzine. Physical examination reveals normal range of motion in all joints with no effusions, erythema, or synovitis. However, there is symmetric point tenderness to palpation over the neck, shoulders, and greater trochanters.

Because she was worried about having systemic lupus erythematosus (SLE), she recently obtained laboratory tests at an independent clinic. The results are as follows:

Based on the patient's clinical presentation and laboratory findings, which of the following is the most appropriate next step in management?

Accurate assessment of developmental domains is critical for identifying delays that warrant early intervention. Match each of the following documented developmental profiles to the chronological age at which a typically developing child is expected to achieve these specific milestones.

An otherwise healthy 45-year-old man presents to the primary care clinic for evaluation of an expanding red rash on his right lower extremity. He first noticed the redness 48 hours ago, and it has since become increasingly tender and warm. His medical history is notable only for recurrent tinea pedis, for which he sporadically uses an over-the-counter antifungal cream. His temperature is 37.2°C (99.0°F), pulse is 78/min, respirations are 14/min, and blood pressure is 126/82 mm Hg. Physical examination of the right lower leg demonstrates a poorly demarcated, erythematous, edematous, and warm plaque extending from the lateral ankle to the mid-calf. There are no fluctuant nodules, purulent exudates, or overlying ulcers. Bilateral pedal pulses are palpable and symmetric. Which of the following is the most appropriate empiric pharmacotherapy for this patient?

During a community pediatric developmental screening initiative, a physician evaluates several healthy children. Match each child's observed clinical milestone constellation with their most likely chronological age.

A clinical director at a pediatric outpatient center is developing an electronic medical record algorithm for routine well-child preventive care. The system must prompt clinicians for age-appropriate immunizations for a healthy, full-term child born to a Hepatitis B surface antigen-negative mother. Arrange the administration of the following specific vaccine doses in the correct chronological order of their routine initial administration, from the earliest age to the oldest age.

A 35-year-old woman is evaluated in the clinic for progressive fatigue, cold intolerance, and a 5-kg (11-lb) weight gain over the past 4 months. She also reports that she has not had a menstrual period for the last 6 months, despite having previously regular 28-day cycles. She is not taking any medications. Her temperature is 36.4°C (97.5°F), blood pressure is 100/60 mm Hg, and pulse is 58/min. Physical examination reveals dry skin and a delayed relaxation phase of the deep tendon reflexes. A urine pregnancy test is negative.

Laboratory results are as follows:
Thyroid-stimulating hormone (TSH): $1.8$ mU/L (Reference: $0.5 - 5.0$ mU/L)
Free thyroxine (T4): $0.4$ ng/dL (Reference: $0.9 - 1.7$ ng/dL)

Which of the following is the most likely diagnosis?

Match each clinical presentation of a common infectious disease with the most appropriate first-line pharmacotherapy.

A 67-year-old man is brought to the emergency department by his family due to a 1-day history of high fever, severe headache, and worsening confusion. His medical history is significant for hypertension and type 2 diabetes mellitus. His temperature is 39.4°C (102.9°F), blood pressure is 145/85 mm Hg, and pulse is 115/min. He is lethargic, mumbling incomprehensibly, and unable to follow complex commands. Neurologic examination shows a right-sided facial droop and right upper extremity weakness. Nuchal rigidity is present. Arrange the following steps in the most appropriate chronological sequence for the management of this patient.

A 36-year-old woman comes to the outpatient clinic reporting a 4-month history of profound fatigue, a 5-kg (11-lb) weight gain, and persistent constipation. She also mentions that her menstrual periods have stopped completely for the past 3 months. She has no prior medical conditions and takes no daily medications.

Her temperature is 36.6°C (97.8°F), blood pressure is 102/64 mmHg, and pulse is 54/min. Physical examination reveals dry, cool skin and a delayed relaxation phase of the deep tendon reflexes. The thyroid gland is nonpalpable and non-tender. During cranial nerve evaluation, the patient has difficulty seeing fingers presented in the lateral aspects of her visual fields bilaterally.

Initial laboratory testing reveals the following:
TSH: 2.1 $\mu$ U/mL (Normal: 0.5-5.0 $\mu$ U/mL)
Free $T_4$: 0.4 ng/dL (Normal: 0.9-1.7 ng/dL)

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

A 62-year-old woman comes to the clinic for a routine follow-up. She has a 10-year history of rheumatoid arthritis that has been poorly controlled due to medication nonadherence. She reports feeling increasingly tired over the past several months but denies black stools, blood in her urine, or heavy menses. Vital signs are within normal limits. Physical examination reveals swelling and tenderness in the metacarpophalangeal joints of both hands. Laboratory studies show the following:

Which of the following best describes the primary pathophysiology of this patient's hematologic findings?

A 26-year-old woman presents to the physician to discuss recent laboratory results. She specifically requested an antinuclear antibody (ANA) screening after reading a health blog about autoimmune disorders, despite having no physical complaints. She explicitly denies any history of joint stiffness, photosensitive skin rashes, oral ulcers, profound fatigue, or weight changes. Her past medical history is unremarkable. Vital signs and a comprehensive physical examination are entirely within normal limits. The laboratory report reveals a positive ANA at a titer of $1:40$ in a speckled pattern. The patient is highly distressed and wants to know her treatment options for systemic lupus erythematosus. Which of the following is the most appropriate next step in management?

A community health clinic is preparing an educational brochure for first-time parents regarding what to expect during their infant's first year of life. As part of the anticipatory guidance on normal neurodevelopment, the nursing staff is outlining key social, language, and cognitive milestones. Arrange the following developmental milestones in the typical chronological order of their expected emergence, from earliest to latest.

For each of the following outpatient clinical scenarios, select the most appropriate initial targeted pharmacotherapy.

A 45-year-old woman presents to the clinic with a 3-month history of symmetric pain, swelling, and morning stiffness in her metacarpophalangeal and proximal interphalangeal joints lasting up to 2 hours daily. Physical examination reveals active synovitis in multiple small joints of the hands. Laboratory evaluation is strongly positive for rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies. The patient is diagnosed with moderate-to-severe rheumatoid arthritis. Arrange the following steps in the most appropriate chronological sequence for the standard diagnostic workup and long-term pharmacologic management of this patient, according to current clinical guidelines.

A 45-year-old man is evaluated in the intensive care unit on day 8 of hospitalization. He was admitted after a motor vehicle collision that caused a severe traumatic brain injury and bilateral pulmonary contusions, requiring immediate intubation and mechanical ventilation. Over the past 24 hours, the nursing staff has noted an increase in the volume of thick, yellowish endotracheal secretions. The patient remains sedated. His temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $128/78\text{ mmHg}$, heart rate is $86/\text{min}$, and respiratory rate is $16/\text{min}$. Physical examination reveals coarse rhonchi over both lung fields. Laboratory studies show a leukocyte count of $8,500/\text{mm}^3$. A portable chest radiograph demonstrates stable, resolving bilateral opacities with no new focal consolidations compared to imaging from three days prior. An endotracheal aspirate culture obtained yesterday grows $>10^5\text{ CFU/mL}$ of Pseudomonas aeruginosa. Which of the following is the most appropriate next step in the management of this patient?

Parents bring their $4$-week-old infant boy to the pediatric clinic out of concern for his worsening yellow skin tone. The child was born at $38$ weeks of gestation following an uncomplicated pregnancy and delivery. He is exclusively fed with commercial infant formula and has demonstrated appropriate weight gain. However, over the past $14$ days, the parents have observed that his diapers contain pale, chalk-colored stools and unusually dark urine. The infant has remained afebrile and active without episodes of emesis. Vital signs are normal. On physical examination, diffuse cutaneous jaundice and prominent scleral icterus are evident. The forehead and cheeks display a scattering of tiny erythematous papules and pustules. Abdominal palpation reveals a soft abdomen, but the liver edge extends $3\text{ cm}$ below the right costal margin. Initial laboratory analysis demonstrates:

Total bilirubin: $10.5\text{ mg/dL}$
Direct bilirubin: $6.2\text{ mg/dL}$
Aspartate aminotransferase (AST): $110\text{ U/L}$
Alanine aminotransferase (ALT): $95\text{ U/L}$

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

Rheumatology consultation is requested for a 74-year-old man who developed sudden, excruciating pain and swelling in his right knee overnight. The patient is currently recovering on the surgical ward on postoperative day 4 following an open cholecystectomy for acute cholecystitis. His medical background is significant for long-standing hypertension, diet-controlled type 2 diabetes, and stage 3b chronic kidney disease. He is receiving prophylactic subcutaneous enoxaparin. Temperature is 37.9°C (100.2°F). The right knee is markedly erythematous, warm to the touch, and held in slight flexion; any attempted movement elicits severe distress. Laboratory evaluation reveals a serum creatinine of 2.3 mg/dL. An ultrasound-guided diagnostic arthrocentesis yields 35,000 leukocytes/mm³ (85% neutrophils). Microscopic examination under polarized light demonstrates multiple rhomboid-shaped crystals with weak positive birefringence. Gram stain of the synovial fluid is negative for microorganisms. Which of the following is the most appropriate next step in management?

Parents bring their 8-week-old daughter to the clinic for a well-child examination. The infant was born at full term without any peripartum complications. However, her newborn screening panel returned positive for severe combined immunodeficiency (SCID), which was subsequently confirmed by flow cytometry. She is currently receiving prophylactic antimicrobials and is scheduled for a hematopoietic stem cell transplant in the near future. Vital signs today are within normal limits, and physical examination is unremarkable. The pediatrician and the parents review the infant's immunization schedule. Which of the following vaccines must be withheld from this patient's regimen today?

A concerned father schedules a well-child examination for his 4-year-old son to discuss the boy's developmental progress. The father reports that the child is unable to tie his own shoelaces, cannot accurately draw a picture of a triangle, and has not yet learned how to skip. The father notes that his older daughter had easily mastered these skills by the time she was four, which has caused him significant anxiety. The boy was born full-term without complications and has received all standard immunizations. During the clinic visit, the physician observes the boy easily hopping on one foot and using safety scissors to cut a piece of paper. When asked to draw a picture, the boy draws a stick figure consisting of a head, a body, and legs. He speaks in completely intelligible sentences and excitedly tells a story about his recent trip to a local park. The father also mentions that the child occasionally wets the bed at night but is fully toilet trained during the day. Based on these findings, which of the following is the most appropriate next step in management?