Tüm alıştırma soruları

A 28-year-old woman is admitted to the intensive care unit with severe shortness of breath and profound fatigue. Laboratory studies show a hemoglobin level of 4.2 g/dL, and further workup confirms a diagnosis of acute severe autoimmune hemolytic anemia. The attending physician strongly recommends an urgent packed red blood cell transfusion to prevent cardiovascular collapse. The patient is fully alert, oriented, and calmly demonstrates a clear understanding that without the transfusion, she is at imminent risk of cardiac arrest and death. Nevertheless, she adamantly refuses the blood products, citing her core beliefs as a Jehovah's Witness, but she agrees to receive intravenous iron and erythropoietin. The patient's mother, who is her legally designated healthcare proxy, is present at the bedside. The mother is highly distraught and tells the physician, "I am her proxy and I authorize the transfusion. Please do whatever it takes to save her life." Which of the following is the most appropriate next step in management?

A 58-year-old man with chronic limb-threatening ischemia is advised to undergo urgent revascularization. He refuses the procedure, stating he does not want surgery. The physician decides to formally assess the patient's decision-making capacity. Arrange the following components of the capacity evaluation in the hierarchical order they must be demonstrated, progressing from the most basic foundational requirement to the most complex cognitive task.

An intensive care unit team is conducting morning rounds. The patient is a 68-year-old female who was admitted one week ago following an out-of-hospital cardiac arrest. She was successfully resuscitated and placed on mechanical ventilation. Three days ago, her condition became complicated with a new fever of 39.2°C (102.6°F), worsening hypoxemia, and purulent endotracheal secretions. A chest radiograph demonstrated a new right lower lobe consolidation. Empiric intravenous vancomycin and cefepime were initiated for a presumed ventilator-associated pneumonia.

Today, she exhibits significant clinical improvement. She is afebrile with a temperature of 37.1°C (98.8°F), blood pressure of 128/78 mm Hg, and heart rate of 82/min. Her ventilator settings have been successfully weaned. An endotracheal aspirate culture obtained at the onset of fever demonstrates heavy growth of Pseudomonas aeruginosa. Susceptibility testing shows the organism is susceptible to cefepime, piperacillin-tazobactam, and meropenem, but resistant to levofloxacin. No other organisms are isolated. A nasal swab polymerase chain reaction (PCR) screen for methicillin-resistant Staphylococcus aureus (MRSA) obtained three days ago is negative.

Based on the culture and susceptibility results, which of the following is the most appropriate next step in the pharmacologic management of this patient?

A hospitalised 68-year-old female is evaluated on postoperative day 6 following an elective right total knee arthroplasty. She reports new-onset pain and tightness in her right calf. She has been receiving subcutaneous unfractionated heparin for chemical thromboprophylaxis since her surgery. Vital signs are within normal limits. Physical examination reveals an erythematous, swollen right lower extremity with tenderness to palpation over the popliteal fossa. A venous duplex ultrasonography confirms an acute occlusive thrombus in the right popliteal vein. Laboratory studies show a current platelet count of $55,000/\text{mm}^3$. Her preoperative baseline platelet count was $250,000/\text{mm}^3$. The patient has no history of liver disease or other bleeding disorders. Based on the calculated clinical probability score, arrange the following management steps in the correct chronological sequence for this patient.

Match each clinical presentation of a neonatal gastrointestinal emergency to the most appropriate next step in diagnosis or management.

An endocrinology consultation is requested for a 48-year-old male who has been experiencing progressive sluggishness, unexplained weight gain, and persistent chilliness for the past six months. Upon further questioning, he reports bothersome headaches and difficulty maintaining an erection. He has no significant past medical history and takes no medications. Vital signs are within normal limits, except for a pulse of $54/\text{min}$. Physical examination reveals dry, coarse skin and a notable delay in the relaxation phase of the Achilles tendon reflex. A confrontation visual field test detects bilateral peripheral vision deficits.

Laboratory evaluation reveals:
Serum thyroid-stimulating hormone (TSH): $1.4 \text{ mIU/L}$ (normal: $0.5-5.0 \text{ mIU/L}$)
Serum free thyroxine (T4): $0.4 \text{ ng/dL}$ (normal: $0.9-1.7 \text{ ng/dL}$)

Which of the following is the most likely etiology of this patient's thyroid laboratory abnormalities?

A 29-year-old female graduate student presents to the university health clinic complaining of burning with urination and increased urinary frequency for the past $48$ hours. She denies any back pain, nausea, vomiting, or vaginal discharge. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $110/70\text{ mm Hg}$, and pulse is $78\text{/min}$. Physical examination demonstrates mild suprapubic discomfort on deep palpation but no costovertebral angle tenderness. A urine sample collected at an outside urgent care facility three days ago has just returned positive for *Klebsiella pneumoniae*. The microbiology report flags the isolate as an extended-spectrum beta-lactamase (ESBL) producer. Susceptibility testing reveals resistance to ceftriaxone, cefepime, and ciprofloxacin, but confirms susceptibility to nitrofurantoin, fosfomycin, and meropenem. Which of the following is the most appropriate next step in management?

A 42-year-old woman arrives at the emergency department reporting a severe, throbbing headache and blurred vision that began this morning. She also notes new-onset shortness of breath over the past two days. Her medical history includes diffuse cutaneous systemic sclerosis, which was diagnosed four years ago. She currently takes mycophenolate mofetil. Vital signs show a blood pressure of 230/125 mmHg, a heart rate of 110/min, and a respiratory rate of 22/min. Physical examination reveals thickened, tight skin over the face and proximal extremities, as well as bilateral basilar crackles on lung auscultation. Laboratory studies show:

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

Match each patient's presenting clinical and laboratory profile with the most likely underlying pathophysiologic condition.

Match each pediatric clinical vignette describing a severe infection with the most likely causative pathogen based on the specific diagnostic or microbiological clues provided.

A 62-year-old man with a history of end-stage renal disease comes to the emergency department due to severe muscle weakness and palpitations. He reports missing his last two scheduled hemodialysis sessions because of transportation issues. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $112/68\text{ mmHg}$, pulse is $52\text{/min}$, and respiratory rate is $16\text{/min}$. Physical examination reveals diminished deep tendon reflexes in both lower extremities. An electrocardiogram demonstrates widened QRS complexes and tall, peaked T waves. A point-of-care basic metabolic panel reveals a serum potassium level of $7.9\text{ mEq/L}$. Arrange the following therapeutic interventions in the most appropriate sequential order of execution, from the most immediate priority to the definitive management step.

Correlate the following clinical presentations of central nervous system and disseminated infections in immunocompromised hosts with their most appropriate primary targeted management.

A $31$-year-old woman, gravida $0$, presents to the clinic for evaluation of a $14$-month history of inability to conceive. The patient and her partner have been engaging in regular, unprotected intercourse. Menarche occurred at age $12$. Her menses were previously regular, occurring every $28$ days, but over the past year, they have become irregular, occurring every $45$ to $60$ days. The patient has also noticed new, coarse dark hairs on her chin and upper lip. She reports feeling unusually fatigued recently, which she attributes to stress at her job, and has gained $6 \text{ kg}$ ($13.2 \text{ lbs}$) over the past $6$ months despite no changes in her diet.

Vital signs show a temperature of $36.6^\circ\text{C}$ ($97.9^\circ\text{F}$), blood pressure of $112/74 \text{ mmHg}$, and heart rate of $58\text{/min}$. Her body mass index (BMI) is $32 \text{ kg/m}^2$. Physical examination reveals coarse facial hair and dry skin. Pelvic examination is unremarkable.

Laboratory evaluation reveals the following:

Follicle-stimulating hormone (FSH): $5 \text{ mIU/mL}$
Luteinizing hormone (LH): $6 \text{ mIU/mL}$
Prolactin: $48 \text{ ng/mL}$ (Normal: $<20 \text{ ng/mL}$)
Thyroid-stimulating hormone (TSH): $14.5 \text{ \mu IU/mL}$ (Normal: $0.4-4.0 \text{ \mu IU/mL}$)
Free thyroxine (T4): $0.6 \text{ ng/dL}$ (Normal: $0.8-1.8 \text{ ng/dL}$)

A urine pregnancy test is negative.

Which of the following is the most appropriate initial management for this patient's inability to conceive?

A 26-year-old woman is brought to the emergency department by her roommate due to severe anxiety, shortness of breath, and tingling around her mouth and hands. Her symptoms began 30 minutes ago following an argument. Her past medical history is significant for migraine headaches and a seizure disorder, which are managed with a daily medication she started 6 months ago. On physical examination, she appears anxious and is hyperventilating. Her lungs are clear to auscultation bilaterally. Inflation of a blood pressure cuff above her systolic pressure for 3 minutes elicits carpopedal spasm.

Vital signs are:
Temperature: 37.0°C (98.6°F)
Blood pressure: 115/75 mm Hg
Heart rate: 112/min
Respiratory rate: 32/min
Oxygen saturation: 99% on room air

Arterial blood gas (room air):
pH: 7.53
$pCO_2$: 18 mm Hg
$pO_2$: 102 mm Hg

Serum chemistries:
Sodium: 139 mEq/L
Potassium: 3.7 mEq/L
Chloride: 114 mEq/L
Bicarbonate: 14 mEq/L

Which of the following best describes this patient's current acid-base status?

A $28$-year-old woman comes to the clinic complaining of palpitations, excessive sweating, and a $5\text{ kg}$ ($11\text{ lb}$) weight loss over the past $6$ weeks despite an increased appetite. She has a history of major depressive disorder, for which she takes fluoxetine. She is a competitive bodybuilder and reports feeling immense pressure for an upcoming competition. Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $145/75\ \text{mmHg}$, and a pulse of $112\text{/min}$. Physical examination reveals a fine resting tremor, brisk deep tendon reflexes, and warm, moist skin. The thyroid gland is nonpalpable, and there is no exophthalmos.

Laboratory results are as follows:

* Thyroid-stimulating hormone (TSH): $<0.01 \ \mu\text{U/mL}$ (Normal: $0.4-4.0 \ \mu\text{U/mL}$)
* Free T4: $0.3 \ \text{ng/dL}$ (Normal: $0.9-2.4 \ \text{ng/dL}$)
* Free T3: $8.5 \ \text{pg/mL}$ (Normal: $2.0-4.4 \ \text{pg/mL}$)
* Radioactive iodine uptake ($24$-hour): $1\%$ (Normal: $10\%-30\%$)

Which of the following additional findings is most likely present in this patient?

A 22-year-old woman is brought to the emergency department by her roommate due to agitation, nausea, and ringing in her ears. The roommate reports finding several empty over-the-counter medication bottles in their bathroom. On physical examination, the patient appears distressed and is breathing rapidly.

Temperature is $38.1^\circ$ C ($100.6^\circ$ F), blood pressure is 112/68 mm Hg, pulse is 118/min, and respiratory rate is 26/min. Laboratory studies show:

Arterial blood gas on room air:

Which of the following best characterizes this patient's underlying acid-base disturbance?

A 68-year-old man presents to the clinic with a 2-year history of progressive right knee pain. The pain typically worsens at the end of the day or after prolonged walking, and it improves with rest. He reports about 10 to 15 minutes of joint stiffness in the morning. His medical history is significant for hypertension. Physical examination reveals bony enlargement, decreased range of motion, and crepitus of the right knee without significant effusion, erythema, or warmth. Radiographs show medial joint space narrowing, subchondral sclerosis, and osteophyte formation. Arrange the following interventions in the generally recommended, step-wise sequence for the management of this patient's condition, assuming an inadequate response to each preceding step.

A $48$-hour-old male neonate is evaluated in the nursery for worsening jaundice. He was born at $39$ weeks of gestation via spontaneous vaginal delivery to a $26$-year-old primigravid mother. His birth weight was $3400\text{ g}$. APGAR scores were $8$ and $9$ at $1$ and $5$ minutes, respectively. The mother's blood type is O, Rh-positive, and the infant's blood type is A, Rh-positive. The direct antiglobulin test (Coombs test) is positive. The infant is exclusively breastfed and latching well.

Vital signs are:
Temperature: $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$)
Heart rate: $138\text{/min}$
Respiratory rate: $38\text{/min}$
Blood pressure: $68/42\text{ mmHg}$
Oxygen saturation: $99\%$ on room air

Physical examination reveals marked scleral icterus and jaundice extending to the lower abdomen. The infant is alert and active with normal tone. Additionally, there is a prominent, blotchy erythematous rash with scattered $1\text{-to-}2\text{ mm}$ pale-yellow pustules over the trunk and proximal extremities.

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

A $2$-year-old girl is evaluated in the emergency department at 11:00 PM for a worsening cough and noisy breathing. Two days ago, she developed a mild fever, nasal congestion, and clear rhinorrhea. This evening, her cough became harsh and sounds similar to a barking seal. Her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), heart rate is $130/\text{min}$, respiratory rate is $40/\text{min}$, and oxygen saturation is $96\%$ on room air. The patient is sitting in her mother's lap and appears anxious. There is noticeable inspiratory stridor even when the child is resting quietly. Chest auscultation reveals transmitted upper airway sounds but no lower airway wheezing or crackles. Which of the following is the most appropriate next step in management?

Congenital infections often present with distinct clinical syndromes in the neonatal period. Identify the correct causative pathogen for each of the described neonatal clinical presentations.