Tüm alıştırma soruları

A 26-day-old male infant, born at 28 weeks gestation, is evaluated in the neonatal intensive care unit due to an acute clinical decline. The infant had been successfully advancing on enteral feedings with fortified maternal breast milk. Over the past 8 hours, he has developed temperature instability, marked abdominal distension, and bilious emesis. Vital signs reveal a temperature of $35.4^\circ\text{C}$ ($95.7^\circ\text{F}$), heart rate of $190\text{ /min}$, respiratory rate of $68\text{ /min}$, and blood pressure of $38/20\text{ mm Hg}$. Physical examination demonstrates a tense, erythematous abdomen with absent bowel sounds. Capillary refill time is 5 seconds.

Laboratory results are as follows:

An anteroposterior abdominal radiograph demonstrates widespread pneumatosis intestinalis and a continuous band of radiolucency across the upper abdomen clearly outlining the falciform ligament.

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

A 32-year-old man is brought to the psychiatric clinic by his sister for a follow-up evaluation. The patient has a 10-month history of continuous psychiatric symptoms. According to the sister, the illness began with a 7-month period during which the patient experienced severe sadness, loss of appetite, hypersomnia, and intense feelings of worthlessness. During this same 7-month period, he also began hearing voices plotting to harm him and firmly believed his neighbors were attempting to poison his water supply. Following a medication adjustment 3 months ago, the patient's mood, appetite, and sleep completely returned to normal, and he no longer feels sad or worthless. However, over the past 3 months of euthymia, he has continued to hear voices and remains convinced that his water is poisoned. He does not use illicit substances, and a urine drug screen is negative. Which of the following is the most likely diagnosis?

A 60-hour-old male neonate is evaluated in the maternity ward prior to planned hospital discharge. He was born at 38 weeks of gestation via an uncomplicated spontaneous vaginal delivery to a 27-year-old primigravid woman. The mother's prenatal laboratory screening was unremarkable, including negative serologies for syphilis, hepatitis B, and HIV, and she received adequate prenatal care. The neonate has been breastfeeding vigorously every 2 to 3 hours and has had normal urine and meconium output. His temperature is 36.9°C (98.4°F), heart rate is 142/min, and respiratory rate is 40/min. Physical examination reveals a well-appearing, active infant with a widespread skin eruption consisting of scattered 1- to 3-mm yellowish pustules situated on irregular, splotchy, erythematous macular bases. The lesions are prominent on the thorax, abdomen, and proximal extremities, but completely spare the palms and soles. The remainder of the physical examination, including neurologic tone and reflexes, is unremarkable. Which of the following is the most appropriate next step in management?

An internal medicine rapid response team is called to evaluate a 25-year-old hospitalized man for acute-onset severe agitation and chest discomfort. The patient was admitted yesterday for a soft tissue infection of the right arm and has been receiving intravenous cefazolin. When the physician arrives, the patient is pacing the room, visibly sweating, and shouting at the nursing staff. Vital signs are temperature 37.9°C (100.2°F), blood pressure 178/112 mm Hg, pulse 132/min, and respirations 24/min. Physical examination reveals bilateral mydriasis and significant diaphoresis. A friend who was visiting the patient abruptly left the room right before the episode started. An ECG demonstrates sinus tachycardia with no ST-segment changes. Which of the following is the most appropriate initial step in the pharmacologic management of this patient?

Match each of the following clinical presentations of patients experiencing secondary amenorrhea or oligomenorrhea with the primary pathophysiological mechanism responsible for their reproductive endocrine dysfunction.

A 14-month-old girl is evaluated during morning rounds on hospital day 3. She was initially admitted due to a high fever, irritability, and an inability to bear weight on her right leg. Her medical history is significant for acute lymphoblastic leukemia, and she is currently in the maintenance phase of chemotherapy with daily oral 6-mercaptopurine and weekly oral methotrexate. Upon initial evaluation, her temperature was $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$). Physical examination revealed an exquisitely tender, swollen, and erythematous right knee. Initial laboratory studies showed a leukocyte count of $4,500/\text{mm}^3$ with an absolute neutrophil count of $1,350/\text{mm}^3$. Arthrocentesis yielded visibly purulent synovial fluid, and she was promptly started on empiric intravenous vancomycin and cefepime.

Today, her temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$) and she is clinically improving with decreased knee swelling. Synovial fluid and blood cultures obtained on admission both grow Staphylococcus aureus. Susceptibility testing demonstrates resistance to penicillin and ampicillin, but susceptibility to oxacillin, cefazolin, clindamycin, and vancomycin.

During the evaluation, the parents express concern about a recent local measles outbreak. They note that their daughter missed her 12-month well-child visit due to her cancer treatments and ask if she can receive her measles, mumps, and rubella (MMR) and varicella vaccines before discharge.

Which of the following is the most appropriate management plan regarding her antimicrobial therapy and requested immunizations?

A rapid response is called for a $74$-year-old man who develops acute shortness of breath and agitation $48$ hours after undergoing a right femoral-popliteal bypass. His past medical history is significant for type 2 diabetes mellitus, hypertension, hyperlipidemia, and a $40$-pack-year smoking history. The operative report notes a brief $15$-minute episode of hypotension that resolved with intravenous fluid administration. He currently denies any chest pain. His temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), pulse is $116$/min, blood pressure is $100/60$ mmHg, respirations are $26$/min, and oxygen saturation is $91\%$ on room air. Physical examination reveals jugular venous distention. Pulmonary auscultation demonstrates fine bibasilar crackles. Cardiac auscultation reveals a regular, rapid rhythm with an $S_4$ gallop. The surgical incisions are intact, and distal pulses are palpable. Which of the following is the most appropriate next step in management?

A 44-year-old female presents to the physician 14 days after an uncomplicated total abdominal hysterectomy for symptomatic uterine leiomyomas. She reports a new onset of constant, clear, watery fluid leaking from her vagina that requires her to wear adult diapers. She maintains a normal sensation of bladder filling and is voiding normal volumes of urine voluntarily in the toilet. To evaluate the source of the leakage, she is given oral phenazopyridine. Two hours later, a cotton tampon is placed in the vaginal canal, and her bladder is filled with a solution of methylene blue via a transurethral catheter. The patient is asked to walk around for 20 minutes. Upon removal, the tampon shows prominent orange staining near its apex, with absolutely no blue discoloration. Which of the following is the most likely diagnosis?

A $29$-year-old woman, gravida $2$, para $1$, at $22$ weeks gestation presents to the clinic with severe vulvovaginal itching and a thick, white vaginal discharge for the past $5$ days. She reports no abdominal pain, fever, or urinary symptoms. Her pregnancy has been uncomplicated. One month ago, she had a similar episode of vaginal itching that she self-treated with an over-the-counter $3$-day course of intravaginal miconazole. Her symptoms temporarily improved but have now returned and are more severe. Vital signs are within normal limits. Pelvic examination reveals significant vulvar erythema, excoriations, and a thick, adherent, "cottage cheese-like" vaginal discharge. The cervix is closed, and there is no cervical motion tenderness. Vaginal pH is $4.2$. Wet mount examination with potassium hydroxide (KOH) preparation reveals branching pseudohyphae and budding yeast. Which of the following is the most appropriate next step in management?

A 52-year-old man with a known history of severe alcohol use disorder is brought to the emergency department by emergency medical services after being found confused and wandering in a park. On examination, he is disoriented to time and place, has horizontal nystagmus, and exhibits a wide-based, unsteady gait. He appears malnourished. Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for the acute management of this patient.

An evaluation is requested for a female patient experiencing persistent, unpredictable vaginal spotting over the last 8 weeks. The patient is 38 years of age and has never been pregnant. Her gynecologic history is notable for oligomenorrhea since adolescence, with menses occurring only two to three times per year. She also reports long-standing struggles with excess facial hair and obesity; her current body mass index is 37 kg/m². Pelvic examination reveals no active bleeding from the cervical os and normal-appearing vaginal mucosa. Transvaginal ultrasonography is performed and demonstrates an endometrial stripe measuring 17 mm in thickness, alongside bilaterally enlarged ovaries containing numerous small peripheral follicles. Which of the following is the most appropriate next step in the management of this patient's condition?

Identify the most appropriate next step in management for each of the following burn-related clinical scenarios.

A 31-year-old man is brought to the emergency department by ambulance after sustaining a stab wound to the abdomen during a physical altercation. On arrival, he is lethargic and pale. Vital signs are temperature $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure $78/42\text{ mmHg}$, pulse $142/\text{min}$, and respirations $24/\text{min}$. Pulse oximetry is $97\%$ on high-flow oxygen. Primary survey reveals a patent airway and equal bilateral breath sounds. There is a single $4\text{ cm}$ laceration in the left upper quadrant, just below the costal margin. The patient's abdomen is markedly distended, rigid, and exhibits diffuse rebound tenderness. Peripheral pulses are thready. Two large-bore intravenous lines are established, and isotonic fluid resuscitation is initiated. Which of the following is the most appropriate next step in the management of this patient?

A term infant is delivered vaginally. Immediately after birth, the infant is noted to be apneic and limp with a heart rate of 70/min. Arrange the following neonatal resuscitation interventions in the correct chronological sequence for this patient, assuming the infant's condition fails to improve after each consecutive step.

A 61-year-old man is evaluated on postoperative day 2 following an open repair of a large ventral hernia. He reports mild shortness of breath and states that it is extremely painful to take a deep breath or cough. His temperature is $38.3^\circ\text{C}$ ($101.0^\circ\text{F}$), blood pressure is $135/85\text{ mmHg}$, pulse is $92/\text{min}$, and respiratory rate is $20/\text{min}$. Pulse oximetry shows an oxygen saturation of $93\%$ on room air. On physical examination, the abdominal dressing is clean, dry, and intact with no surrounding erythema. Pulmonary auscultation reveals decreased breath sounds at the lung bases bilaterally, but no crackles, rhonchi, or wheezing are heard. Cardiac examination shows a regular rate and rhythm without murmurs. The calves are soft and non-tender. Laboratory studies show a leukocyte count of $12,200/\text{mm}^3$. Which of the following are the most appropriate management steps for this patient's current condition? (Select 2)

An 82-year-old woman is brought to the emergency department from a skilled nursing facility due to a 3-day history of progressive abdominal distension, colicky abdominal pain, and intractable vomiting. The nursing facility staff reports that her vomit has a dark green, bilious appearance and she has not had a bowel movement or passed flatus for the last 4 days. Her medical history is significant for moderate dementia, hypertension, and recurrent episodes of postprandial right upper quadrant pain for which she previously declined surgical intervention.

Vital signs are:
Temperature: 37.4°C (99.3°F)
Heart rate: 105/min
Blood pressure: 110/70 mm Hg
Respiratory rate: 18/min

Physical examination reveals a markedly distended abdomen with high-pitched, hyperactive bowel sounds. There is mild, diffuse tenderness to palpation, but no guarding, rigidity, or rebound tenderness. Laboratory studies show a leukocyte count of 11,000/mm³ and mild hypokalemia.

A computed tomography (CT) scan of the abdomen and pelvis reveals dilated loops of small bowel with a distinct transition point in the right lower quadrant, air within the biliary tree, and a 3-cm radio-opaque, calcified mass impacted in the terminal ileum.

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

A 32-year-old gravida 2, para 1 at 39 weeks gestation is admitted to the labor and delivery unit in active labor. Her prenatal course has been uncomplicated. On admission, her cervical examination shows 6 cm dilation, 100% effacement, and the fetal presenting part is at -2 station. Thirty minutes later, the patient experiences spontaneous rupture of membranes with a large gush of clear fluid. The continuous fetal heart rate monitor immediately shows a prolonged deceleration to 70/min that does not resolve. A subsequent sterile vaginal examination reveals a pulsating, smooth, rope-like structure in the vaginal canal ahead of the fetal head. Which of the following is the most appropriate initial next step in management?

Match each clinical presentation of hyponatremia to the most appropriate initial management step.

Match each clinical presentation of a gynecologic neoplasm with its most likely diagnosis.

A 10-year-old girl is evaluated in the hospital on day 3 of her admission for acute hematogenous osteomyelitis of the left proximal tibia. Upon admission, her temperature was 39.2°C (102.6°F), blood pressure was 110/70 mm Hg, and heart rate was 118/min. She had severe left leg pain, localized swelling over the proximal tibia, and an inability to bear weight. Magnetic resonance imaging of the left lower extremity demonstrated marrow edema and a small subperiosteal abscess. She was empirically started on intravenous vancomycin and ceftriaxone. Today, she is clinically improved, her pain has decreased, and she has been afebrile for the past 24 hours. Blood cultures drawn on admission are now growing Staphylococcus aureus. Susceptibility testing shows the organism is resistant to penicillin, but susceptible to oxacillin, cefazolin, clindamycin, and vancomycin. Which of the following is the most appropriate next step in this patient's pharmacotherapy?