Tüm alıştırma soruları

A 67-year-old retired mechanic is evaluated in the emergency department for severe shortness of breath that has progressively worsened over the past 48 hours. He has a medical history of heart failure with reduced ejection fraction (ejection fraction 40%), atrial fibrillation, and severe chronic obstructive pulmonary disease (COPD) due to a 50 pack-year smoking history. Upon arrival, his temperature is $36.4^\circ\text{C}$ ($97.5^\circ\text{F}$), blood pressure is $148/86\text{ mm Hg}$, heart rate is $102/\text{min}$, respiratory rate is $28/\text{min}$, and oxygen saturation is $85\%$ on room air. The patient is lethargic but arousable and is using accessory muscles of respiration. Physical examination reveals a prolonged expiratory phase with diffuse polyphonic wheezing bilaterally. There are no crackles. The jugular venous pressure is $6\text{ cm H}_2\text{O}$. Cardiac examination shows an irregularly irregular rhythm without murmurs. Bilateral lower extremities have trace pitting edema that the patient states is his baseline. A portable chest radiograph shows hyperinflated lung fields and flattened diaphragms, without focal opacities or pleural effusions. Arterial blood gas analysis on room air reveals:

$pH$: $7.24$
$PaCO_2$: $68\text{ mm Hg}$
$PaO_2$: $54\text{ mm Hg}$
$HCO_3^-$: $28\text{ mEq/L}$

Recent outpatient laboratories from one week ago showed a thyroid-stimulating hormone (TSH) of $1.1\text{ }\mu\text{U/mL}$ (normal: 0.5-5.0) and a free T4 of $0.6\text{ ng/dL}$ (normal: 0.9-1.7). Which of the following is the most appropriate initial step in the management of this patient's acute respiratory distress?

A 28-year-old man comes to the physician because of a 5-day history of right knee swelling, left heel pain, and redness in both eyes. He reports no recent trauma. Four weeks ago, he had a diarrheal illness that resolved spontaneously after $3$ days. His temperature is $37.2^{\circ}\text{C}$ ($99.0^{\circ}\text{F}$), blood pressure is $122/78$ mmHg, and pulse is 84/min. Physical examination shows a moderately effused, warm, and tender right knee. There is marked tenderness to palpation at the insertion of the left Achilles tendon. The conjunctivae are injected bilaterally. Arthrocentesis of the right knee yields synovial fluid with a leukocyte count of $22,000/\text{mm}^3$ ($75\%$ neutrophils). Gram stain of the fluid shows no organisms, and polarized light microscopy reveals no crystals. Which of the following is the most appropriate initial pharmacotherapy for this patient's current symptoms?

A 32-year-old man comes to the emergency department due to severe right upper quadrant abdominal pain and progressive fatigue over the past week. He also reports that his urine has occasionally appeared unusually dark, particularly in the morning. He has no significant past medical history and takes no medications. His temperature is 37.2°C (99.0°F), blood pressure is 128/82 mm Hg, and pulse is 98/min. Physical examination reveals scleral icterus, pale conjunctivae, and right upper quadrant abdominal tenderness with hepatomegaly.

Laboratory studies show:

Doppler ultrasound of the abdomen demonstrates absent blood flow in the hepatic veins.

Which of the following is the most appropriate next step to confirm the underlying cause of this patient's findings?

A $38$-year-old man is evaluated in the emergency department for progressive fatigue, severe epistaxis, and bleeding from his gums over the past two days. He has no significant past medical history and takes no medications. Vital signs are: Temperature $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), Blood pressure $100/60 \text{ mm Hg}$, Heart rate $112/\text{min}$, Respiratory rate $18/\text{min}$. Physical examination reveals marked mucosal pallor, continuous gingival oozing, and extensive coalescing petechiae and purpura over the trunk and bilateral lower extremities. Laboratory studies show:

Leukocyte count: $2,800/\text{mm}^3$
- Neutrophils: $15\%$
- Lymphocytes: $25\%$
- Atypical cells: $60\%$
Hemoglobin: $7.4 \text{ g/dL}$
Platelet count: $15,000/\text{mm}^3$
Prothrombin time: $24 \text{ seconds}$
Partial thromboplastin time: $54 \text{ seconds}$
Fibrinogen: $65 \text{ mg/dL}$ (Normal: $150-400 \text{ mg/dL}$)
D-dimer: $8,500 \text{ ng/mL}$ (Normal: $< 500 \text{ ng/mL}$)

Peripheral blood smear demonstrates predominant cells with bilobed nuclei and dense, coarse azurophilic granules. Several of these cells contain bundles of red-staining, needle-like cytoplasmic inclusions. Which of the following is the most appropriate initial step in the management of this patient?

An essential skill in hematology is interpreting coagulation panels to diagnose bleeding disorders. Match each underlying hematologic disorder with its most characteristic laboratory profile.

A 32-year-old man presents to the emergency department triage desk with a 4-week history of severe cough, low-grade fevers, and drenching night sweats. He recently returned from a prolonged trip to a region where tuberculosis is highly endemic. He is currently sitting in the crowded main waiting room. Arrange the following steps in the correct chronological order for managing this patient's suspected infection.

Match each clinical presentation of developmental milestones to the expected chronological age at which a typical child demonstrates these specific skills.

A 64-year-old man with a 15-year history of poorly controlled type 2 diabetes mellitus is evaluated in the outpatient clinic for a chronic ulcer on the plantar surface of his right foot. He first noticed the ulcer 8 weeks ago. He has established peripheral neuropathy and reports no pain at the site. His temperature is 37.1°C (98.8°F), blood pressure is 135/82 mmHg, and pulse is 78/min. Physical examination reveals a 2.5-cm, full-thickness ulcer under the first metatarsal head. The ulcer base is composed of pale granulation tissue. There is no surrounding erythema, warmth, fluctuance, or purulent discharge. A sterile, blunt stainless-steel probe easily reaches the underlying bone. Pedal pulses are palpable bilaterally. Laboratory studies show a leukocyte count of $7,500/\mu L$ and an erythrocyte sedimentation rate of $65 \text{ mm/h}$. A plain radiograph of the right foot demonstrates cortical erosion and periosteal elevation at the first metatarsal head. Which of the following is the most appropriate next step in management?

A clinical informatics team is updating a pediatric electronic health record system to generate automated clinical decision support alerts for routine well-child visits. The alerts are designed to remind clinicians to perform age-appropriate universal screenings and immunizations based on current Bright Futures and CDC guidelines. Arrange the following universal pediatric preventive care interventions in chronological order, from the earliest routinely recommended age of onset to the latest.

Match each peripheral blood smear description or characteristic laboratory finding with the most likely underlying hematologic disorder.

A 54-year-old man is reviewed by the medical team during his inpatient hospitalization. He was admitted 72 hours ago after presenting to the emergency department with an acutely painful, erythematous, and swollen right knee accompanied by shaking chills. Initial arthrocentesis yielded turbid synovial fluid containing $85,000 \text{ leukocytes}/\mu L$ with $92\%$ neutrophils. Following the procedure, he was empirically started on intravenous vancomycin and piperacillin-tazobactam. Today, his temperature has improved to $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $128/82 \text{ mmHg}$, and pulse is $84/\text{min}$. The right knee shows decreased swelling and erythema. Blood cultures and synovial fluid cultures obtained on admission are both positive for *Staphylococcus aureus*. Antimicrobial susceptibility testing reveals the following:

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

A $14$-day-old female neonate is brought to the emergency department by her parents due to fever and decreased oral intake for the past $24$ hours. The patient was born at $39$ weeks of gestation via vaginal delivery complicated by fetal heart rate decelerations, which required the application of a fetal scalp electrode. The mother is a $22$-year-old primigravida who received limited prenatal care. At presentation, the neonate's temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), heart rate is $172/\text{min}$, and respiratory rate is $48/\text{min}$. Physical examination reveals a lethargic but arousable infant. The anterior fontanelle is full. Examination of the scalp reveals a $2\text{ cm}$ cluster of erythematous vesicles with clear fluid overlying the vertex. The remainder of the physical examination is unremarkable.

Laboratory evaluation reveals:

A lumbar puncture is performed, and cerebrospinal fluid (CSF) analysis reveals:

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

A $61$-year-old male landscape architect presents to the emergency department in coastal Connecticut during early September. His wife reports that he has had $4$ days of high-grade fever, drenching sweats, profound fatigue, and progressive confusion. His medical history is significant for a splenectomy at age $25$ following blunt abdominal trauma, and essential hypertension. Vital signs show a temperature of $39.8^\circ\text{C}$ ($103.6^\circ\text{F}$), blood pressure of $88/54 \text{ mm Hg}$, heart rate of $126/\text{min}$, and respiratory rate of $28/\text{min}$. Oxygen saturation is $88\%$ on room air. Physical examination reveals marked scleral icterus and pale conjunctivae. Auscultation of the lungs reveals bibasilar crackles.

Laboratory evaluation shows the following:

A peripheral blood smear demonstrates numerous intraerythrocytic pleomorphic ring forms and occasional tetrad structures. Quantitative analysis reveals a parasitemia level of $16\%$.

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

A mother brings her male infant to the office for a health supervision visit. The child is chronologically 15 months old. He was delivered at 28 weeks gestation due to severe maternal preeclampsia. He spent 8 weeks in the neonatal intensive care unit but was discharged without major complications. His immunizations were current up until his 6-month visit. Due to a temporary out-of-state relocation, he missed his subsequent well-child checks. At 11 months of chronological age, he was hospitalized for 6 days with prolonged high fever, bilateral nonexudative conjunctivitis, oral mucosal changes, and cervical lymphadenopathy. He received treatment with high-dose intravenous immunoglobulin (IVIG) and high-dose aspirin, which led to rapid clinical improvement. He currently takes no medications.

During today's visit, the mother expresses deep concern because the child is not yet walking without support, whereas his older sister walked at 11 months. The patient is able to pull himself to a standing position and walk along the couch. He accurately picks up small cereal pieces using his thumb and index finger. He points to his toys when he wants them and calls his parents 'mama' and 'dada' appropriately. Vital signs and physical examination are unremarkable.

Which of the following is the most appropriate management for this patient today?

A 42-year-old woman is evaluated on the medical floor for ongoing management of a bloodstream infection. She was admitted three days ago with a high fever and localized erythema surrounding a peripheral intravenous catheter site. Blood cultures were drawn, the catheter was removed, and she was started on empiric intravenous vancomycin and intravenous cefepime. The patient is currently afebrile and her localized erythema has resolved. Today, the initial blood cultures are finalized, showing growth of Staphylococcus aureus. Susceptibility testing reveals the organism is resistant to penicillin but susceptible to oxacillin, cefazolin, and vancomycin. Repeat blood cultures drawn 48 hours after admission show no growth. Which of the following is the most appropriate next step in the antibiotic management of this patient?

Match each specific autoantibody profile with its most strongly associated clinical presentation or syndrome.

A term neonate born at 39 weeks gestation is diagnosed with alloimmune hemolytic disease secondary to ABO incompatibility. The infant's unconjugated total serum bilirubin levels are monitored closely. Management of neonatal hyperbilirubinemia follows a specific escalation protocol based on neurotoxicity risk factors and bilirubin levels to prevent kernicterus. Arrange the following therapeutic interventions in the correct standard sequence of clinical escalation, starting from the most basic baseline management to the most invasive rescue therapy.

A $62$-year-old man is hospitalized on the general medical ward for a severe exacerbation of chronic obstructive pulmonary disease and suspected superimposed pneumonia. He is prescribed a new regimen of intravenous piperacillin-tazobactam. $10$ minutes into the first infusion, the rapid response team is called because the patient suddenly develops diffuse urticaria, facial swelling, a high-pitched inspiratory noise, and profound shortness of breath. His vital signs reveal a blood pressure of $80/45$ mm Hg, a heart rate of $128$/min, and an oxygen saturation of $88\%$ on room air. Arrange the following acute management steps in the most appropriate chronological sequence according to established life-support guidelines.

A 52-year-old man is recovering on the surgical ward following an extensive bowel resection for ischemic colitis. On postoperative day 2, his hemoglobin is found to be 6.5 g/dL, and a transfusion of packed red blood cells is initiated. Approximately 25 minutes after the transfusion begins, the patient suddenly develops severe chills, a temperature of 39.2°C (102.6°F), and worsening right flank pain. His blood pressure drops to 90/60 mm Hg, and his heart rate increases to 118/min. A Foley catheter placed in the operating room now drains dark, reddish-brown urine. Which of the following is the most appropriate initial step in management?

A 62-year-old man is evaluated in the intensive care unit for antimicrobial management. He was admitted 8 days ago after a severe motor vehicle collision resulting in multiple rib fractures and a pulmonary contusion. He has required mechanical ventilation since admission. On hospital day 6, he developed a new fever, increased purulent endotracheal secretions, and a right lower lobe consolidation on chest radiography. He was empirically started on intravenous vancomycin and piperacillin-tazobactam for suspected ventilator-associated pneumonia.

Today (hospital day 8), his temperature is 37.6°C (99.7°F), blood pressure is 122/78 mmHg, and heart rate is 84/min. Endotracheal aspirate cultures obtained on day 6 now show $>10^5$ CFU/mL of *Enterobacter cloacae*. Blood cultures remain sterile. Antimicrobial susceptibility testing for the *E. cloacae* isolate is reported below:

Which of the following is the most appropriate modification to this patient's pharmacotherapy?