Tüm alıştırma soruları

A 2-month-old girl is brought to the pediatrician by her parents for her first routine well-child visit. She was born at 39 weeks gestation via an uncomplicated spontaneous vaginal delivery. Her mother has a history of severe Crohn disease, which has been well controlled with infliximab therapy. The mother received scheduled infliximab infusions throughout her pregnancy, with the final dose administered 3 weeks prior to delivery. The infant is exclusively breastfed and is gaining weight appropriately. Physical examination reveals an alert, active infant with normal vital signs and no abnormalities. In addition to the second dose of the hepatitis B vaccine, the infant is due for her first doses of the diphtheria, tetanus, and acellular pertussis (DTaP), Haemophilus influenzae type b (Hib), inactivated polio (IPV), pneumococcal conjugate (PCV15), and rotavirus vaccines. Which of the following is the most appropriate recommendation regarding this patient's immunizations today?

A 26-year-old woman, G1P0, at 16 weeks gestation is evaluated during a routine prenatal visit. She reports mild fatigue over the past month but is otherwise feeling well. She has no significant past medical history. Current medications include a daily prenatal vitamin.

Vital signs are within normal limits. Physical examination reveals normal conjunctivae, no scleral icterus, and a gravid uterus consistent with gestational age.

Laboratory results are as follows:

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

For each distinct laboratory and clinical profile in patients presenting with bleeding symptoms, match the most accurate underlying diagnosis.

A 65-year-old woman is hospitalized due to a 2-day history of high fever, right-sided flank pain, and altered mental status. She has a history of poorly controlled type 2 diabetes mellitus and recurrent urinary tract infections. On admission, her temperature is 39.2°C (102.6°F), blood pressure is 88/56 mm Hg, pulse is 118/min, and respirations are 22/min. Physical examination is notable for severe right costovertebral angle tenderness. Laboratory studies show a leukocyte count of 18,500/mm³. Urinalysis is positive for leukocyte esterase, nitrites, and numerous leukocytes. Blood and urine cultures are obtained, and the patient is started on empiric intravenous piperacillin-tazobactam. Over the next 48 hours, her fever resolves, and her hemodynamics normalize.

Preliminary results from both blood and urine cultures grow *Enterobacter cloacae*. Antimicrobial susceptibility testing reveals the isolate is susceptible to ceftriaxone, cefepime, piperacillin-tazobactam, meropenem, and gentamicin. It is resistant to ciprofloxacin and trimethoprim-sulfamethoxazole. Which of the following is the most appropriate next step in antimicrobial therapy?

Match each clinical scenario involving the use of a rheumatologic medication to its most critical associated toxicity, pharmacological interaction, or pre-treatment screening requirement.

An internal medicine clinical pathways committee is updating hospital protocols for the acute management of oncologic complications. Match each of the following patient presentations—characterized by specific clinical signs, symptoms, and targeted laboratory data—to the single most appropriate initial therapeutic intervention according to current clinical guidelines.

During a routine follow-up at the nephrology clinic, a 42-year-old woman is evaluated for persistent hypokalemia and mild muscle weakness. She has a history of Sjögren syndrome and has had two episodes of calcium phosphate nephrolithiasis in the past five years. She reports no diarrhea, vomiting, or recent dietary changes. Her blood pressure is 118/76 mm Hg. Laboratory studies show:

Serum sodium: 140 mEq/L
Serum potassium: 2.9 mEq/L
Serum chloride: 115 mEq/L
Serum bicarbonate: 15 mEq/L
Blood urea nitrogen: 12 mg/dL
Serum creatinine: 0.8 mg/dL

Urine studies obtained simultaneously show:
Urine sodium: 55 mEq/L
Urine potassium: 25 mEq/L
Urine chloride: 60 mEq/L

What is this patient's urine anion gap in mEq/L? (Provide your answer as a number only)

Match the following laboratory profiles of calcium, phosphorus, and parathyroid hormone (PTH) to the most likely underlying pathophysiologic diagnosis.

A 24-year-old man is brought to the emergency department by his roommate due to increasing lethargy and confusion over the past 12 hours. The patient has a history of type 1 diabetes mellitus and has not taken his insulin for the past week due to financial constraints. Vital signs show a temperature of $37.1^\circ$ C ($98.8^\circ$ F), heart rate of 115/min, blood pressure of 105/68 mm Hg, and a respiratory rate of 28/min with deep, rapid breaths.

Laboratory studies reveal:

Which of the following arterial $pCO_2$ values would best indicate an appropriate, isolated respiratory compensation for this patient's acid-base disturbance?

A 64-year-old man is evaluated in the intensive care unit for abnormal laboratory findings. He was admitted 2 days ago for severe community-acquired pneumonia complicated by septic shock. He was intubated yesterday for worsening hypoxia and is currently mechanically ventilated. The patient is sedated and receiving a continuous intravenous infusion of norepinephrine. Vital signs show a temperature of $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure of $92/58 \text{ mm Hg}$, heart rate of $118/\text{min}$, and oxygen saturation of $95\%$ on the current ventilator settings.

Laboratory studies:
Serum sodium: $140 \text{ mEq/L}$
Serum potassium: $4.1 \text{ mEq/L}$
Serum chloride: $100 \text{ mEq/L}$
Serum bicarbonate: $16 \text{ mEq/L}$
Blood urea nitrogen: $32 \text{ mg/dL}$
Serum creatinine: $1.9 \text{ mg/dL}$
Serum lactate: $5.2 \text{ mmol/L}$ (Normal: $0.5-1.5 \text{ mmol/L}$)

Arterial blood gas (on mechanical ventilation):
pH: $7.52$
$\text{PaCO}_2$: $20 \text{ mm Hg}$
$\text{PaO}_2$: $78 \text{ mm Hg}$

Which of the following is the most accurate interpretation of this patient's current acid-base status?

A 54-year-old woman comes to the clinic reporting a 2-month history of progressive weakness, particularly when climbing stairs and brushing her hair. She also notes a new rash on her face and hands. Her medical history is unremarkable, and she takes no medications. Physical examination reveals an erythematous, violaceous rash on her upper eyelids and scaling, erythematous plaques over her metacarpophalangeal and proximal interphalangeal joints. Muscle strength is 3/5 in the proximal upper and lower extremities bilaterally, and 5/5 in the distal extremities. Sensation is intact, and deep tendon reflexes are 2+ bilaterally.

The physician diagnoses the patient with dermatomyositis and plans to initiate high-dose oral prednisone. Which of the following is the most appropriate additional step in the management of this patient?

A 65-year-old man is admitted to the hospital for acute decompensated heart failure and is treated with aggressive intravenous furosemide. On hospital day 3, his blood pressure is 105/65 mm Hg and heart rate is 92/min. Over the past 24 hours, his urine output has decreased to 400 mL. His serum creatinine rises from a baseline of 1.1 mg/dL to 2.8 mg/dL.

Laboratory studies are obtained to evaluate his acute kidney injury:

Serum chemistry:
Sodium: 136 mEq/L
Potassium: 3.8 mEq/L
Chloride: 98 mEq/L
Bicarbonate: 28 mEq/L
Blood urea nitrogen (BUN): 84 mg/dL
Creatinine: 2.8 mg/dL

Urine chemistry:
Sodium: 70 mEq/L
Urea nitrogen: 420 mg/dL
Creatinine: 56 mg/dL

Because recent loop diuretic administration impairs tubular sodium reabsorption, the fractional excretion of sodium ($FE_{Na}$) can be misleadingly elevated. Instead, the fractional excretion of urea ($FE_{Urea}$) is preferred to differentiate between prerenal azotemia and intrinsic acute tubular necrosis in this clinical scenario.

Calculate the patient's $FE_{Urea}$. Express your answer as a percentage.

A 36-year-old man with a history of advanced, untreated HIV infection (CD4 count $28 \text{ cells/mm}^3$) is brought to the emergency department due to progressive confusion, severe headaches, and left-sided weakness over the past week. His temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$). Neurologic examination reveals a dense left hemiparesis. MRI of the brain reveals multiple 1- to 2-cm ring-enhancing lesions in the right basal ganglia and frontal lobe with marked surrounding vasogenic edema causing a 4-mm midline shift. Serum *Toxoplasma gondii* IgG antibodies are positive.

Arrange the following clinical actions in the correct chronological sequence according to the standard management algorithm for this patient, assuming a complete lack of clinical or radiographic response to the first-line medical intervention.

Evaluate the following clinical scenarios of infants presenting with hyperbilirubinemia. Pair each clinical description with the most appropriate underlying diagnosis.

Match each of the following patient presentations, which are characterized by specific acid-base and electrolyte derangements (Left), with the precise underlying cellular or transporter defect (Right).

A $32$-year-old woman comes to the clinic due to progressive fatigue, weight loss, lightheadedness, and failure to resume her menses. Ten months ago, she delivered a healthy full-term infant. The delivery was complicated by severe postpartum hemorrhage requiring an emergency blood transfusion and a brief admission to the intensive care unit. Following discharge, she was unable to produce breast milk. Her blood pressure is $88/54$ mmHg, and her pulse is $92$/min. Physical examination shows pale skin without hyperpigmentation and delayed relaxation of deep tendon reflexes. Laboratory studies show:

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

A hospital's antimicrobial stewardship and infectious diseases teams are reviewing several complex cases involving severe adverse drug events. Match each patient's clinical presentation of an antimicrobial-induced complication to the specific pharmacologic agent most likely responsible.

A 45-year-old man with a history of poorly controlled type 2 diabetes mellitus is brought to the emergency department due to confusion, nausea, and abdominal pain for the past 2 days. He has missed his last several doses of insulin. His temperature is 37.1°C (98.8°F), blood pressure is 100/65 mm Hg, pulse is 112/min, and respirations are 24/min. Physical examination shows dry mucous membranes and a fruity breath odor.

Laboratory studies show:

What is this patient's serum anion gap (in mEq/L)?

Match each classic urinalysis sediment finding with its most likely associated renal pathology.

A $54$-year-old woman is evaluated in the ambulatory care clinic for progressive lethargy and generalized weakness over the past six months. She states she feels persistently cold even during warm weather and has been struggling with constipation. Over the same period, she has been involved in several minor motor vehicle collisions, which she attributes to "not seeing cars coming from the side." Physical examination reveals pale, dry skin, puffiness around the eyes, and a delayed relaxation phase of the deep tendon reflexes. Confrontational visual field testing demonstrates decreased peripheral vision bilaterally.

Laboratory studies reveal:
Hemoglobin: $11.2$ g/dL
Thyroid-stimulating hormone (TSH): $1.8$ $\mu$ U/mL (Normal: $0.4$-$4.0$ $\mu$ U/mL)
Free thyroxine (T4): $0.5$ ng/dL (Normal: $0.9$-$1.7$ ng/dL)

Which of the following is the most likely underlying mechanism for this patient's laboratory findings?