Tüm alıştırma soruları

A 42-year-old woman is brought to the emergency department by her husband due to a 24-hour history of severe headache, high fever, and worsening confusion. Her medical history is significant for a recent kidney transplant, for which she takes immunosuppressive medications. Her temperature is 39.2°C (102.6°F). Physical examination demonstrates marked nuchal rigidity and a new left lower extremity weakness. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for managing this patient.

A 24-year-old man is diagnosed with active ankylosing spondylitis characterized by progressive inflammatory back pain, elevated inflammatory markers, and severe morning stiffness. Arrange the following therapeutic interventions in the standard chronological sequence for escalating disease management, from initial first-line therapy to end-stage treatment.

A clinic evaluates a 55-year-old male who developed sudden, severe right knee swelling and pain 48 hours ago. He denies any recent trauma, falls, or prior joint issues. His current temperature is 38.2°C (100.8°F). Examination reveals a visibly enlarged, erythematous right knee that is exquisitely tender to palpation. Range of motion is severely limited by pain. Which of the following is the most appropriate initial step in the evaluation of this patient?

A 64-year-old woman is brought to the emergency department by her son due to worsening confusion, nausea, and ringing in her ears for the past 24 hours. She has a history of chronic obstructive pulmonary disease (COPD), hypertension, and osteoarthritis, for which she frequently takes over-the-counter analgesics. She also underwent transsphenoidal resection of a pituitary macroadenoma 5 years ago.

Vital signs: Temperature 37.1°C (98.8°F), blood pressure 110/70 mmHg, heart rate 112/min, respiratory rate 28/min.

Physical examination reveals dry mucous membranes and lethargy. Lung auscultation reveals clear breath sounds bilaterally. There is no jugular venous distention.

Laboratory results:
Sodium: 141 mEq/L
Potassium: 3.9 mEq/L
Chloride: 105 mEq/L
Bicarbonate: 14 mEq/L
Blood urea nitrogen: 38 mg/dL
Creatinine: 1.8 mg/dL
Thyroid-stimulating hormone (TSH): 1.1 µU/mL (normal: 0.4–4.0 µU/mL)
Free T4: 0.5 ng/dL (normal: 0.9–1.7 ng/dL)

Arterial blood gas on room air:
pH: 7.42
$PaCO_2$: 22 mmHg
$PaO_2$: 96 mmHg

A urine culture sent 3 days ago from an outpatient clinic visit for mild dysuria has returned positive for $>100,000$ CFU/mL of *Escherichia coli*, which is susceptible to cephalexin and nitrofurantoin, but resistant to fluoroquinolones.

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

A $19$-year-old male of Mediterranean descent is admitted to the hospital with newly diagnosed Burkitt lymphoma. He has a massive abdominal tumor burden. Baseline laboratory studies reveal a serum uric acid level of $14.2 \text{ mg/dL}$ and a serum creatinine of $1.9 \text{ mg/dL}$. To mitigate the risk of tumor lysis syndrome, he receives aggressive intravenous hydration and a dose of rasburicase. Forty-eight hours later, the patient acutely develops shortness of breath, fatigue, and bluish discoloration of his lips and fingertips. Vital signs are: temperature $37.1^\circ \text{C}$, heart rate $128$ /min, blood pressure $105/65$ mmHg, and respiratory rate $28$ /min. Pulse oximetry shows an oxygen saturation of $84\%$ on room air, which does not improve following the administration of $100\%$ oxygen via a non-rebreather mask. Arterial blood gas on $100\%$ oxygen shows a PaO $_2$ of $410$ mmHg. Blood drawn from the patient's vein appears chocolate-brown. Laboratory studies show a rapid decline in hemoglobin from $14.5 \text{ g/dL}$ to $8.2 \text{ g/dL}$. A peripheral blood smear reveals numerous bite cells and Heinz bodies. Which of the following is the most appropriate next step in the management of this patient's acute respiratory compromise?

Match each patient scenario describing the initiation of a specific targeted biologic or immunomodulatory therapy with the most appropriate infectious disease screening or prophylactic management step.

Match each advanced biologic or targeted synthetic disease-modifying antirheumatic drug (DMARD) with its most characteristic severe adverse effect or specific clinical contraindication.

A 68-year-old man is evaluated in the hospital on day 4 of admission for persistent low-grade fevers and fatigue. He originally presented with a 2-week history of generalized weakness, night sweats, and shortness of breath. His medical history is significant for hypertension and osteoarthritis. On examination today, temperature is 37.8°C (100.0°F), blood pressure is 128/76 mmHg, and pulse is 88/min. Cardiac auscultation reveals a new grade 3/6 holosystolic murmur heard best at the cardiac apex. Laboratory studies show a leukocyte count of 12,400/mm³ and serum creatinine of 1.4 mg/dL (baseline 0.9 mg/dL). Blood cultures drawn at admission have grown *Enterococcus faecalis* in 4 out of 4 bottles. Susceptibility testing demonstrates the isolate is susceptible to ampicillin, vancomycin, and linezolid, and lacks high-level aminoglycoside resistance. A transesophageal echocardiogram shows a 1.2-cm mobile vegetation on the mitral valve. The patient is currently receiving empiric therapy with intravenous vancomycin and cefepime. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

Match each clinical scenario describing a medication-specific toxicity, mechanism, or required screening protocol to the appropriate disease-modifying medication used in rheumatologic conditions.

A $74$-year-old man is admitted to the hospital with a four-week history of low-grade fevers, progressive fatigue, and an unintentional weight loss of $4\text{ kg}$ ($8.8\text{ lbs}$). His medical history is significant for ischemic cardiomyopathy, type 2 diabetes mellitus, and a surgical aortic valve replacement with a bioprosthetic valve three years ago. His temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $122/76\text{ mmHg}$, and pulse is $92/\text{min}$. Physical examination reveals a grade 3/6 diastolic murmur at the right upper sternal border. Inspection of the hands reveals small, painless, erythematous macules on the palms. A transesophageal echocardiogram shows an oscillating $1.1\text{ cm}$ mass on the bioprosthetic aortic valve. Three sets of blood cultures grow gram-positive cocci in pairs and short chains that are catalase-negative and capable of growing in $6.5\%$ sodium chloride broth. Susceptibility testing indicates that the organism is susceptible to ampicillin, vancomycin, and daptomycin, but it exhibits high-level resistance to gentamicin and streptomycin. His serum creatinine is $1.9\text{ mg/dL}$. Which of the following is the most appropriate targeted intravenous antibiotic regimen for this patient?

Pair each patient's key clinical findings with the most appropriate rheumatologic or vasculitic diagnosis.

During morning rounds on the general medical floor, a resident evaluates a newly admitted patient who presented overnight with chronic cough, progressive fatigue, and hemoptysis. The patient recently emigrated from a country with a high incidence of endemic respiratory pathogens. Vital signs reveal a temperature of $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$). Review of a portable chest radiograph obtained in the emergency department demonstrates a prominent cavitary opacity in the right upper lobe with surrounding consolidation. The clinical team strongly suspects active pulmonary tuberculosis.

Arrange the following clinical and infection control interventions in the most appropriate chronological sequence for this patient.

A 24-year-old primigravid woman at 26 weeks gestation is evaluated during a routine prenatal visit. She has no fatigue, dyspnea, or palpitations. Her pregnancy has been uncomplicated. She takes a daily prenatal multivitamin. Blood pressure is 112/70 mm Hg and pulse is 78/min. Physical examination shows a gravid uterus consistent with gestational age and no peripheral edema.

Laboratory results are as follows:

Which of the following is the most appropriate next step in the management of this patient's hematologic findings?

Review the following clinical presentations of patients who develop complications during or shortly after receiving blood product transfusions. Match each patient's clinical scenario with the primary pathophysiologic mechanism responsible for their reaction.

Match each patient's clinical presentation with the most likely causative pneumonia pathogen.

A 62-year-old woman is evaluated on postoperative day 6 following a right total knee arthroplasty. Since the surgery, she has been receiving subcutaneous unfractionated heparin for deep vein thrombosis prophylaxis. Today, she reports new-onset left calf pain and swelling.

Vital signs are within normal limits. Physical examination reveals left calf tenderness, erythema, and 2+ pitting edema up to the knee.

Laboratory studies on admission:
Hemoglobin: 13.2 g/dL
Leukocyte count: 8,500/mm³
Platelet count: 260,000/mm³

Laboratory studies today:
Hemoglobin: 12.8 g/dL
Leukocyte count: 9,200/mm³
Platelet count: 110,000/mm³

A duplex ultrasonography of the left lower extremity demonstrates a noncompressible popliteal vein. Which of the following is the most appropriate next step in management?

A 12-year-old boy is evaluated in the pediatric office for his annual health maintenance visit. He was born full-term at 39 weeks of gestation following an uncomplicated pregnancy. His vital parameters include a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), heart rate of 82/min, and blood pressure of 108/68 mm Hg. The physical assessment is entirely within normal limits, and he is meeting all expected psychosocial and academic milestones. His immunization record is current. As part of comprehensive preventive care, the attending physician audits the patient's historical medical chart to verify that all age-appropriate universal screening tests were conducted. Place the following universal pediatric screening interventions in the chronological order in which they are routinely recommended to occur, starting with the earliest.

A $28$-year-old primigravida at $32$ weeks gestation presents to the emergency department reporting acute-onset fatigue, shortness of breath, and dark urine for the past $24$ hours. $3$ days ago, she was diagnosed with an uncomplicated urinary tract infection and prescribed nitrofurantoin. Her prenatal course has otherwise been unremarkable.

Temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $110/70$ mmHg, pulse is $112$/min, and respirations are $20$/min. Physical examination reveals conjunctival pallor and mild scleral icterus. The uterine fundus is consistent with gestational age. Continuous fetal heart rate monitoring demonstrates a baseline of $165$/min, minimal variability, and occasional variable decelerations.

Laboratory studies show:

A peripheral blood smear stained with Wright-Giemsa is obtained (see image) and reveals scattered erythrocytes with irregular, semi-circular marginal defects.

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

A group of patients presents to the emergency department with signs and symptoms of lower respiratory tract infection. Based on the unique clinical features described for each patient, match the clinical presentation with the most likely causative pathogen.

Match each pediatric clinical scenario involving an infectious disease exposure or risk with the most appropriate preventive management step.