Tüm alıştırma soruları

A cohort of healthy female patients is observed longitudinally in a primary care setting to track the normative progression of adolescent physical maturation. Arrange the following hallmark physiological events in the most typical chronological sequence of their onset, from earliest to latest.

A pediatric clinic is reviewing its protocols for vaccine safety and administration. Match each pediatric patient's clinical history to the corresponding vaccine contraindication or appropriate management step.

During a pre-scheduled visit for health maintenance, a physician evaluates a 1-year-old male infant. Medical history is notable for severe atopic dermatitis, which recently necessitated a prolonged course of systemic corticosteroids. Specifically, he has been taking oral prednisone (2 mg/kg daily) for the past 28 days. His skin flare has now largely resolved, and the physician plans a gradual taper of the medication. The infant is clinically stable, afebrile, and behaving normally. According to his medical records, he received all indicated immunizations during his first 6 months of life. As the physician prepares orders for today's routine immunizations, which of the following preparations is strictly contraindicated at this time?

A 55-year-old man comes to the urgent care clinic with sudden, severe pain and swelling in his right big toe that awoke him from sleep. He has a history of hypertension and recently recovered from a mild respiratory illness. Vital signs are within normal limits. Physical examination reveals a markedly erythematous, warm, and exquisitely tender right first metatarsophalangeal joint. Synovial fluid analysis shows a leukocyte count of 18,000/µL. Polarized light microscopy of the fluid reveals needle-shaped, negatively birefringent crystals, and the Gram stain is negative. Which of the following is the most appropriate initial management for this patient's current condition?

A 32-year-old woman comes to the clinic due to progressive fatigue and decreased exercise tolerance over the past 4 months. She has no significant past medical history and takes no medications. The patient reports having heavy menstrual periods, often soaking a pad every 2 hours during the first 3 days of her cycle. Vital signs are within normal limits. Physical examination shows mild conjunctival pallor but no jaundice or organomegaly. Laboratory studies show:

Hemoglobin: 9.8 g/dL
Mean corpuscular volume (MCV): 74 fL
White blood cell count: 6,500/mm³
Platelet count: 410,000/mm³

Which of the following is the most appropriate initial diagnostic test for this patient?

An emergency medical services team brings a 68-year-old woman to the resuscitation bay in January due to progressive lethargy and generalized swelling over the past 48 hours. Two weeks ago, she experienced a mild upper respiratory tract infection. Her past medical history is notable for hypertension, hyperlipidemia, and a severe postpartum hemorrhage requiring multiple blood transfusions 38 years ago. Current medications include amlodipine and atorvastatin. Vital signs show a temperature of 34.2°C (93.6°F), blood pressure of 88/56 mm Hg, heart rate of 48/min, and respiratory rate of 8/min. Pulse oximetry is 90% on room air. Physical examination reveals a somnolent patient who only awakens to painful stimuli. Her face appears puffy with marked periorbital edema, and deep tendon reflexes exhibit significantly delayed relaxation. Lung fields are clear to auscultation.

Initial laboratory testing reveals the following:
Sodium: 124 mEq/L
Potassium: 4.1 mEq/L
Chloride: 92 mEq/L
Bicarbonate: 26 mEq/L

Arterial blood gas (room air):
pH: 7.24
PaCO2: 68 mm Hg
PaO2: 62 mm Hg

Thyroid-stimulating hormone (TSH): 1.5 mU/L (Normal: 0.5–5.0 mU/L)
Free T4: 0.3 ng/dL (Normal: 0.9–1.7 ng/dL)

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

Match each classic physical examination finding with the most likely rheumatologic diagnosis.

A medical student is reviewing common adverse effects of antihypertensive medications frequently prescribed in the primary care setting. Match each patient's clinical presentation to the antihypertensive medication most likely responsible for their symptoms.

A 62-year-old man is evaluated in the hematology-oncology unit for persistent daily fevers. He was admitted 14 days ago to undergo induction chemotherapy for acute myeloid leukemia. Four days ago, he developed a fever of 38.9°C (102.0°F) when his absolute neutrophil count (ANC) was 200/mm³. After blood cultures were obtained, empiric intravenous cefepime was initiated. Today, his temperature is 38.8°C (101.8°F), blood pressure is 118/76 mmHg, pulse is 98/min, and respiratory rate is 18/min. His current ANC is 100/mm³. The initial blood cultures have shown no growth after 96 hours. The patient now reports the onset of mild, right-sided pleuritic chest pain. Physical examination reveals normal heart sounds and clear lung fields bilaterally. His tunneled central venous catheter site appears clean with no surrounding erythema or induration. A non-contrast chest CT demonstrates a 2.5-cm dense nodule in the right upper lobe surrounded by a distinct rim of ground-glass opacity. Serum galactomannan and beta-D-glucan assays are drawn and pending. Which of the following is the most appropriate next step in management?

A 54-year-old woman is brought to the emergency department by her daughter after experiencing a witnessed generalized tonic-clonic seizure. The patient has a history of severe systemic lupus erythematosus and is currently managed with chronic cyclophosphamide and high-dose prednisone. Her temperature is 39.3°C (102.7°F), blood pressure is 142/88 mm Hg, and heart rate is 114/min. She is postictal and difficult to arouse. Neurologic examination is limited by her somnolence but reveals profound nuchal rigidity. Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for the immediate management of this patient.

A 72-year-old retired mechanic presents to the emergency department with a 3-day history of progressively worsening shortness of breath. He reports needing to sleep propped up on three pillows and has developed a new nocturnal cough producing frothy white sputum. His medical history includes severe chronic obstructive pulmonary disease (COPD), a myocardial infarction three years ago, and chronic fatigue. His only home medications are a tiotropium inhaler and aspirin.

Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 160/90 mm Hg, heart rate of 110/min, and respiratory rate of 26/min. Pulse oximetry is 88% on room air.

Physical examination reveals an anxious man using accessory muscles of respiration. Jugular venous pressure is measured at 10 cm $H_2O$. Chest auscultation reveals diffuse bilateral expiratory wheezes and fine bibasilar crackles. An S3 gallop is heard at the cardiac apex. The lower extremities show bilateral 2+ pitting edema.

Initial laboratory studies show:
Leukocyte count: 8,500/$mm^3$
Brain natriuretic peptide (BNP): 920 pg/mL (normal < 100)
Thyroid-stimulating hormone (TSH): 1.5 $\mu U/mL$ (normal: 0.5-5.0)
Free T4: 0.6 ng/dL (normal: 0.9-1.7)

Arterial blood gas on room air:
pH: 7.28
$PaCO_2$: 58 mm Hg
$PaO_2$: 54 mm Hg
$HCO_3^-$: 26 mEq/L

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

Match each classic clinical presentation to the most likely hematologic diagnosis.

A 48-year-old woman with a history of limited cutaneous systemic sclerosis presents to the clinic with worsening episodes of painful blanching and cyanosis in her fingers upon cold exposure. She states that these episodes are becoming more frequent and severe despite wearing insulated gloves and strictly avoiding cold temperatures. Her physical examination is notable for sclerodactyly and multiple telangiectasias on her face and hands. No digital ulcers are currently present, but capillary refill is delayed during an episode in the clinic. Arrange the following therapeutic interventions in the correct order of escalation for the management of this patient's Raynaud phenomenon, starting from the most appropriate initial pharmacologic treatment to the therapy of last resort for critical digital ischemia.

A 65-year-old man presents to the clinic with a 3-week history of progressively worsening shortness of breath and swelling in his legs. He reports waking up in the middle of the night gasping for air and now requires three pillows to sleep comfortably. His medical history is significant for severe, erosive rheumatoid arthritis, chronic obstructive pulmonary disease, and hypertension. His medications include methotrexate, lisinopril, tiotropium, and acetaminophen. Three months ago, his rheumatologist added etanercept due to inadequately controlled joint symptoms. He has a 40-pack-year smoking history but quit 5 years ago. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 145/85 mmHg, pulse of 96/min, and respiratory rate of 22/min. Pulse oximetry shows 94% on room air. Physical examination reveals distended jugular veins, bibasilar lung crackles, and 3+ bilateral pitting edema up to the knees. Cardiac auscultation reveals a regular rhythm with an S3 gallop. Joint examination shows chronic deformities but no acute inflammation. Which of the following is the most likely cause of this patient's current presentation?

A 65-year-old woman is brought to the emergency department due to progressive confusion, generalized weakness, and recurrent vomiting over the past 4 days. Her medical history is significant for breast cancer treated with a lumpectomy, radiation, and chemotherapy 6 years ago. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 100/60 mm Hg, heart rate of 112/min, and respiratory rate of 14/min. Physical examination is notable for dry mucous membranes, delayed capillary refill, and lethargy.

Laboratory evaluation reveals the following:

An electrocardiogram demonstrates a shortened QT interval.

Arrange the following management steps in the most appropriate temporal sequence for the acute stabilization and definitive therapy of this patient, from initial action to long-term management.

A 19-year-old college student is admitted to the hospital with a two-day history of fever, severe headache, photophobia, and neck stiffness. On physical examination, the patient is alert but uncomfortable. Temperature is 38.6°C (101.5°F), blood pressure is 118/76 mm Hg, and pulse is 98/min. Nuchal rigidity is present. A lumbar puncture is performed, and empiric intravenous ceftriaxone and vancomycin are initiated. Cerebrospinal fluid (CSF) analysis reveals a leukocyte count of 140/mm³ with 92% lymphocytes, a glucose level of 65 mg/dL (serum glucose 90 mg/dL), and a protein level of 40 mg/dL. Gram stain reveals no organisms. A multiplex polymerase chain reaction (PCR) assay of the CSF is positive for enterovirus and negative for all common bacterial pathogens. Which of the following is the most appropriate next step in this patient's pharmacologic management?

A 34-year-old woman is brought to the emergency department by her husband due to progressive confusion and severe fatigue over the past 48 hours. Her temperature is $37.8^\circ\text{C}$, blood pressure is $142/88 \text{ mmHg}$, and pulse is $108/\text{min}$. Physical examination reveals scleral icterus and scattered petechiae on the lower extremities. Neurological examination shows mild disorientation but no focal motor deficits.

Laboratory studies show:

Arrange the following clinical steps in the most appropriate sequential order for the evidence-based diagnosis and management of this patient.

Following a deceased-donor renal allograft transplantation eight months ago, a 58-year-old woman is admitted to the hospital due to a three-week history of productive cough, night sweats, and new-onset left-sided hemiparesis. Her immunosuppressive regimen includes tacrolimus, mycophenolate mofetil, and prednisone. Routine post-transplant antimicrobial prophylaxis was discontinued two months ago. Vital signs show a temperature of 38.2°C (100.8°F). Neurological examination reveals 3/5 strength in the left upper and lower extremities. A chest radiograph demonstrates a large cavitary lesion in the right upper lobe. Subsequent magnetic resonance imaging of the brain reveals a 2.5-cm ring-enhancing lesion in the right frontal lobe with surrounding vasogenic edema. Bronchoscopy with bronchoalveolar lavage is performed, and cytological analysis reveals branching, filamentous, Gram-positive rods that stain weakly positive with a modified acid-fast stain. Which of the following is the most appropriate initial targeted pharmacotherapy for this patient's underlying infection?

Match each clinical presentation of a chemotherapy-induced adverse effect to the specific antineoplastic agent responsible for the toxicity.

Match each patient's clinical presentation with the autoantibody or immunologic marker most strongly associated with their underlying disease process.