Tüm alıştırma soruları

During routine prenatal care, various screening tests and clinical evaluations are utilized to monitor maternal and fetal well-being. Match each specific clinical presentation or screening result with its most appropriate next step in management or physiological interpretation.

A $68$-year-old woman is evaluated in the hospital on postoperative day $7$ following an elective right total hip arthroplasty. Since the surgery, she has been receiving subcutaneous enoxaparin for deep venous thrombosis prophylaxis. She now reports new-onset right leg pain and swelling that began this morning. Temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $132/82\text{ mm Hg}$, pulse is $92/\text{min}$, and respirations are $16/\text{min}$. Physical examination shows a swollen, erythematous right lower extremity with tenderness to palpation over the calf and thigh.

Laboratory studies:
Hemoglobin: $11.2\text{ g/dL}$
Leukocyte count: $7,800/\text{mm}^3$
Platelet count: $52,000/\text{mm}^3$ (Preoperative platelet count was $260,000/\text{mm}^3$)

A lower extremity venous duplex ultrasound reveals a noncompressible segment in the right femoral vein consistent with an acute deep venous thrombosis. Which of the following is the most appropriate next step in management?

Paramedics arrive at the emergency room with a 52-year-old man who was discovered unresponsive in a public park. The patient has a documented medical history of severe alcohol use disorder. Upon initial evaluation, his body temperature is $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$), pulse is $102/\text{min}$, blood pressure is $110/70\text{ mm Hg}$, and respirations are $24/\text{min}$. He is unarousable to painful stimuli. Cardiopulmonary examination is unremarkable. Initial laboratory studies show the following:

Arterial blood gas (room air) shows a pH of $7.22$ and a $\text{PaCO}_2$ of $26\text{ mm Hg}$.

Based on the provided laboratory results, what is the patient's serum osmolar gap in $\text{mOsm/kg}$?

A preterm neonate, born at 27 weeks gestation, is currently on day 18 of life in the neonatal intensive care unit. The nursing staff reports a sudden clinical deterioration characterized by temperature instability (hypothermia to 35.6°C [96.1°F]), recurrent prolonged apneic spells, and marked hypotonia. On assessment, the infant is poorly responsive with a heart rate of 195/min, respiratory rate of 20/min with irregular shallow breaths, and a mean arterial pressure of 22 mm Hg. Capillary refill is delayed at 5 seconds. Late-onset neonatal sepsis is suspected. Arrange the following steps in the most appropriate chronological sequence for managing this critically ill patient.

Match each patient's clinical and histopathologic presentation with the corresponding defining cytogenetic abnormality and characteristic therapeutic approach.

A 41-year-old woman is evaluated in the clinic for progressive fatigue, cold intolerance, and a 6-kg (13-lb) weight gain over the past eight months. She has also experienced diffuse muscle aches and secondary amenorrhea during this time. A urine pregnancy test is negative. She takes no medications and has no significant past medical history. Vital signs show a blood pressure of $102/64$ mmHg and a pulse of $54$/min. Physical examination reveals dry skin, a pale appearance, and delayed relaxation of the Achilles tendon reflexes. Palpation of the anterior neck reveals no thyromegaly or nodules.

Laboratory results are as follows:

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

An electrocardiogram previously documented ventricular tachycardia in a $68$-year-old man. He now visits the physician complaining of severe palpitations, unintended weight loss, and profound fatigue persisting for the last $3$ weeks. His medical history includes ischemic cardiomyopathy and placement on a rhythm-control medication approximately $14$ months ago. Current medications include lisinopril, carvedilol, and aspirin. The patient's temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $142/86$ mm Hg, and pulse is $115$/min and irregularly irregular. Physical examination demonstrates brisk deep tendon reflexes and a prominent bilateral hand tremor. Palpation of the neck reveals a diffusely firm, slightly enlarged thyroid gland with no distinct nodules.

Laboratory studies reveal:
Thyroid-stimulating hormone (TSH): $<0.01 \ \mu\text{U/mL}$
Free thyroxine (T4): $4.1 \text{ ng/dL}$
Total triiodothyronine (T3): $195 \text{ ng/dL}$

A $24$-hour radioactive iodine uptake scan demonstrates $1\%$ uptake. Subsequent color Doppler ultrasonography of the thyroid shows a diffusely enlarged gland with markedly diminished internal vascularity. Which of the following is the most appropriate next step in the management of this patient's current condition?

A 19-year-old college student presents to the student health clinic complaining of severe, watery diarrhea for the past 3 days after returning from a camping trip. He reports feeling profoundly weak and lightheaded when standing. His temperature is 37.2°C (99.0°F), blood pressure is 98/60 mm Hg while supine and 82/50 mm Hg while standing, and pulse is 115/min. Physical examination shows dry mucous membranes and delayed capillary refill. Laboratory results reveal:

Serum sodium: $138 \text{ mEq/L}$
Serum potassium: $3.1 \text{ mEq/L}$
Serum chloride: $112 \text{ mEq/L}$
Serum bicarbonate: $14 \text{ mEq/L}$

Arterial blood gas on room air:
pH: 7.28
$pCO_2$: 29 mm Hg
$pO_2$: 95 mm Hg

Based on the laboratory findings, which of the following best characterizes this patient's acid-base status?

A 5-year-old girl is admitted to the pediatric ward with severe right thigh pain, fever, and an inability to bear weight. Magnetic resonance imaging confirms acute hematogenous osteomyelitis of the right femur. She is empirically started on a regimen of intravenous vancomycin and ceftriaxone. On hospital day 3, her clinical condition has significantly improved, and she has been afebrile for 24 hours. Blood cultures and a deep tissue aspirate obtained on admission both grow *Staphylococcus aureus*. Antimicrobial susceptibility testing reveals the isolate is resistant to penicillin, but susceptible to oxacillin, cefazolin, and clindamycin. The patient has no known drug allergies. Which of the following is the most appropriate antimicrobial regimen for this patient at this time?

A 31-year-old woman is evaluated in the outpatient clinic for progressive fatigue, cold intolerance, and generalized weakness over the past 5 months. She also reports a complete cessation of menses since the birth of her son 6 months ago. The patient's pregnancy was complicated by placental abruption, which resulted in significant blood loss requiring emergency cesarean delivery and transfusion of packed red blood cells. She was unable to breastfeed despite multiple attempts. Vital signs show a blood pressure of 90/60 mmHg and a pulse of 58/min. Physical examination reveals pale, dry skin and a delay in the relaxation phase of the deep tendon reflexes.

Laboratory results are as follows:
Sodium: 134 mEq/L
Potassium: 4.1 mEq/L
Thyroid-stimulating hormone (TSH): 2.1 $\mu$ U/mL (normal: 0.5-5.0 $\mu$ U/mL)
Free thyroxine (T4): 0.3 ng/dL (normal: 0.9-1.7 ng/dL)

Which of the following best describes the underlying pathogenesis of this patient's current condition?

A 42-year-old woman is evaluated in the rheumatology clinic for worsening episodes of painful blanching and cyanosis in her fingers upon exposure to cold air. She has a known history of diffuse cutaneous systemic sclerosis and currently takes no medications for her vascular symptoms. Arrange the following therapeutic interventions for secondary Raynaud phenomenon in the correct sequential order of escalation, from initial management to salvage therapy for critical ischemia.

A physician is evaluating four different patients in the outpatient clinic who present with varying signs of adrenal dysfunction. Match each patient's clinical presentation and characteristic laboratory profile to the most likely underlying adrenal disorder.

Match each patient's clinical presentation of chronic cough with the most appropriate initial pharmacological intervention or management step.

A 72-hour fasting test is conducted to evaluate adult patients presenting with recurrent episodes of spontaneous fasting hypoglycemia. Match each of the following biochemical profiles (all obtained at the time of symptomatic hypoglycemia with plasma glucose < 45 mg/dL) with the most likely underlying etiology.

A $21$-day-old male infant born at $34$ weeks gestation is evaluated in the pediatric clinic for a spreading rash in the diaper area that has worsened over the past $4$ days. He was discharged from the neonatal intensive care unit one week ago after a $14$-day stay for prematurity and suspected early-onset neonatal sepsis, for which he received a $7$-day course of intravenous ampicillin and gentamicin. Currently, he is breastfeeding well and gaining weight appropriately. Vital signs include a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate of $140$/min, and respiratory rate of $38$/min. Physical examination of the perineal region reveals sharply demarcated, beefy-red plaques that prominently involve the inguinal creases. Several pinpoint erythematous papules and pustules are scattered on the lower abdomen and upper thighs, distinct from the primary confluent rash. Which of the following is the most appropriate next step in management for this patient's skin condition?

Evaluation of an uncommunicative $76$-year-old male takes place in the emergency department after his family found him severely short of breath and somnolent. Medical history includes ischemic cardiomyopathy, chronic obstructive pulmonary disease (COPD), and osteoarthritis. Vital signs include a blood pressure of $165/95 \text{ mm Hg}$, pulse of $112/\text{min}$, respirations of $28/\text{min}$, and oxygen saturation of $85\%$ on room air. He is afebrile. Physical examination reveals labored breathing with use of accessory muscles. Auscultation of the lungs demonstrates diffuse wheezing and bilateral crackles extending to the mid-lung fields. Jugular venous distention is present at $12 \text{ cm H}_2\text{O}$. There is $2+$ pitting edema of the lower extremities.

Laboratory results are as follows:
Leukocyte count: $8,500/\mu \text{L}$ (Normal: $4,500-11,000/\mu \text{L}$)
Brain natriuretic peptide (BNP): $850 \text{ pg/mL}$ (Normal: $< 100 \text{ pg/mL}$)
Free T4: $0.7 \text{ ng/dL}$ (Normal: $0.9-2.4 \text{ ng/dL}$)
Thyroid-stimulating hormone (TSH): $1.0 \text{ mU/L}$ (Normal: $0.4-4.0 \text{ mU/L}$)

Arterial blood gas (room air):
pH: $7.24$
PaCO $_2$: $62 \text{ mm Hg}$
PaO $_2$: $54 \text{ mm Hg}$
HCO $_3^-$: $26 \text{ mEq/L}$

Chest radiography shows cardiomegaly, bilateral perihilar alveolar opacities, and prominent interlobular septal thickening. Which of the following is the most appropriate initial step in the management of this patient?

A $31$-year-old pregnant patient (G2P1) presents to the obstetric triage unit at $31$ weeks gestation after experiencing a sudden gush of clear vaginal fluid. The fluid loss occurred approximately $2$ hours ago, and she reports continuous vaginal leaking since that time. The patient notes normal fetal movement and denies painful uterine contractions or vaginal bleeding. Her previous pregnancy resulted in an uncomplicated term vaginal delivery. She takes a daily prenatal vitamin and has no known drug allergies.

Her temperature is $37.1^{\circ}$ C ($98.8^{\circ}$ F), blood pressure is $112/72$ mm Hg, pulse is $84$/min, and respiratory rate is $16$/min. Speculum examination reveals a visually closed cervical os with a pool of clear fluid in the posterior vaginal fornix. The fluid turns nitrazine paper blue and demonstrates an arborization pattern on microscopic evaluation.

Continuous external fetal monitoring shows a baseline heart rate of $145$/min with moderate variability, presence of spontaneous accelerations, and no decelerations. Tocodynamometry confirms the absence of uterine contractions. Laboratory evaluation reveals:

Hemoglobin: $10.8$ g/dL
Leukocyte count: $14,200$/mm $^3$
Platelet count: $185,000$/mm $^3$

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

Match each classic pediatric clinical presentation with its most likely causative pathogen.

Match the following clinical presentations and laboratory profiles with their most likely underlying pathophysiologic diagnosis.

A 47-year-old woman with a history of type 2 diabetes mellitus is evaluated on hospital day 4 for ongoing management of a left foot infection. She initially presented to the emergency department with a deep, purulent ulcer on the plantar surface of her foot, surrounded by a 6-cm area of erythema and induration. On admission, she was febrile and had leukocytosis. She was started on empiric intravenous vancomycin and piperacillin-tazobactam and underwent prompt surgical debridement. The surgeon noted no evidence of bone involvement, which was confirmed by a negative MRI of the foot. Today, her temperature is 37.0°C (98.6°F), blood pressure is 122/78 mm Hg, and pulse is 76/min. The surgical wound is clean with healthy granulation tissue, and the surrounding erythema has nearly resolved. Intraoperative deep tissue cultures now show heavy growth of methicillin-susceptible Staphylococcus aureus (MSSA) and Streptococcus agalactiae. Susceptibility testing indicates both isolates are susceptible to cefazolin, cephalexin, and ampicillin. The MSSA isolate is resistant to clindamycin. Which of the following is the most appropriate next step in pharmacotherapy?