Tüm alıştırma soruları

A 27-year-old female patient seeks medical evaluation because she has been unable to conceive for the past year and a half. She notes that her menses are infrequent, occurring only 5 to 6 times per year. She also reports progressive, unwanted hair growth on her face and abdomen over the last four years. She has no other medical conditions and does not take any prescription medications. Her body mass index is 30 kg/m2 and blood pressure is 118/76 mm Hg. On physical examination, terminal hairs are noted on her chin, upper lip, and lower abdomen. No clitoromegaly or purple striae are observed. Transvaginal ultrasonography reveals polycystic morphology in both ovaries. Serum levels of prolactin and thyroid-stimulating hormone are within normal reference ranges. Which of the following is the most appropriate test to perform next to establish the etiology of her symptoms?

A 38-year-old man presents to the clinic complaining of progressive fatigue, generalized weakness, and cold intolerance over the past 8 months. He also reports a significantly decreased libido. Two years ago, he was involved in a severe motor vehicle collision that resulted in a basilar skull fracture and a prolonged intensive care unit stay. He takes no daily medications. His temperature is $36.4^\circ\text{C}$ ($97.5^\circ\text{F}$), pulse is 55/min, and blood pressure is 102/64 mmHg. Physical examination demonstrates pale, dry skin and a delayed relaxation phase of the ankle reflexes. Visual field testing is normal.

Laboratory results are as follows:

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

A 12-month-old boy is brought to the pediatric clinic for a routine well-child visit. Two weeks ago, he experienced a mild upper respiratory tract infection characterized by clear rhinorrhea, a low-grade fever, and a mild cough. These symptoms have completely resolved. Today, he appears well, active, and playful. His temperature is 37.1°C (98.8°F), pulse is 110/min, and respirations are 24/min. Otoscopic examination of the right ear reveals an amber-colored, retracted tympanic membrane with decreased mobility on pneumatic otoscopy; there is no bulging or erythema. Lung auscultation reveals a few scattered expiratory wheezes that clear completely after the child coughs. The mother expresses concern that her son only says "mama" and "dada" and is not yet speaking in two-word phrases. She asks if he needs antibiotics to "clear up whatever is in his ear." Which of the following is the most appropriate next step in the management of this patient?

Concerned by a complete cessation of her menstrual cycles over the past six months, a female in her late twenties visits a specialist. She and her partner have been having regular, unprotected intercourse for the past 14 months without a pregnancy. The patient expresses significant distress regarding a recent, rapid increase in coarse hair growth on her chin, chest, and lower abdomen, as well as a noticeable deepening of her voice. She has no chronic medical conditions and takes no medications. Her blood pressure is 122/78 mmHg, and her body mass index is 24 kg/m². Physical examination reveals temporal hair thinning, severe nodulocystic acne, and prominent clitoromegaly. Bimanual pelvic examination is unremarkable. Transvaginal ultrasonography reveals normal-sized ovaries lacking any cystic changes or solid masses. A urine pregnancy test is negative. Which of the following is the most appropriate next step in the evaluation of this patient?

Emergency medical services arrive with a 74-year-old woman who became acutely lethargic at her assisted living facility. According to the staff, she had been complaining of severe, diffuse abdominal pain that was out of proportion to her physical exam findings earlier in the morning. Her medical history includes atrial fibrillation, type 2 diabetes mellitus, and severe peripheral vascular disease.

On evaluation, her blood pressure is 78/46 mm Hg, pulse is 132/min and irregularly irregular, and respirations are deep and rapid at 28/min. Physical examination reveals mottled, cool extremities and a rigid, diffusely tender abdomen.

Point-of-care laboratory testing reveals:
Serum $Na^+$: 141 mEq/L
Serum $K^+$: 4.9 mEq/L
Serum $Cl^-$: 105 mEq/L
Serum $HCO_3^-$: 14 mEq/L
Blood urea nitrogen: 32 mg/dL
Creatinine: 1.6 mg/dL
Lactate: 9.4 mmol/L (normal: 0.5-1.0 mmol/L)

Arterial blood gas on room air:
pH: 7.23
$PaO_2$: 88 mm Hg

What is the expected arterial partial pressure of carbon dioxide ($PaCO_2$) in mm Hg that indicates appropriate and isolated respiratory compensation for her primary acid-base disturbance?

Match each patient's clinical presentation and laboratory profile with the most characteristic finding expected on their microscopic urinalysis or urine sediment examination.

Match each clinical and laboratory presentation of secondary amenorrhea to the most likely underlying etiology.

Match each of the following clinical scenarios describing patients presenting for fertility evaluation to the most appropriate primary therapeutic intervention or assisted reproductive technology.

A 29-year-old man is evaluated in the outpatient office due to a one-year history of worsening sluggishness, weight gain, and diminished libido. He reports feeling constantly cold even when others are comfortable. His medical history is notable for a severe closed head injury sustained in a motorcycle collision three years ago, which required a two-week stay in the intensive care unit. He currently takes no medications. Vital signs show a temperature of $36.1^\circ\text{C}$ ($97.0^\circ\text{F}$), blood pressure of $105/65 \text{ mm Hg}$, and heart rate of $56/\text{min}$. Physical examination reveals dry skin and a delayed relaxation phase of the deep tendon reflexes. Testes are soft and measure $12 \text{ mL}$ bilaterally (normal $15-25 \text{ mL}$). Laboratory studies show:

Thyroid-stimulating hormone (TSH): $1.1 \text{ mU/L}$ (Reference: $0.5-5.0 \text{ mU/L}$)
Free thyroxine (T4): $0.5 \text{ ng/dL}$ (Reference: $0.9-2.4 \text{ ng/dL}$)
Total testosterone: $160 \text{ ng/dL}$ (Reference: $300-1000 \text{ ng/dL}$)

Which of the following is the most likely diagnosis?

A 42-year-old man is brought to the emergency department by his husband due to a 2-day history of progressive confusion, fatigue, and fever. The patient had a mild upper respiratory tract infection one week ago but otherwise has no significant past medical history. He takes no medications.

Vital signs are:
Temperature: 38.6°C (101.5°F)
Blood pressure: 142/88 mm Hg
Heart rate: 110/min
Respiratory rate: 18/min
Oxygen saturation: 98% on room air

Physical examination reveals a lethargic man who is oriented to person only. Scleral icterus is present. The skin examination shows widespread pinpoint, non-blanching red macules over the lower extremities and abdomen. There is no nuchal rigidity, and the remainder of the neurologic examination is nonfocal.

Laboratory studies reveal:
Hemoglobin: 7.6 g/dL
Mean corpuscular volume (MCV): 88 fL
Platelets: 18,000/mm³
Leukocytes: 9,200/mm³
Blood urea nitrogen (BUN): 42 mg/dL
Creatinine: 2.3 mg/dL
Total bilirubin: 4.8 mg/dL
Indirect bilirubin: 3.9 mg/dL
Lactate dehydrogenase (LDH): 1,450 U/L
Haptoglobin: 8 mg/dL (Normal: 50–200 mg/dL)
Prothrombin time (PT): 12 seconds
Activated partial thromboplastin time (aPTT): 28 seconds
Direct antiglobulin (Coombs) test: Negative

Peripheral blood smear reveals numerous fragmented red blood cells.

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

During morning rounds, the pediatric team evaluates a $13$-month-old male infant who was admitted $48$ hours ago for a febrile urinary tract infection. He has a past medical history of acute lymphoblastic leukemia and is currently receiving maintenance chemotherapy. Upon admission, he was started on empiric intravenous ceftriaxone. Today, he is afebrile and tolerating a regular diet. Urine cultures from admission have grown \textit{Escherichia coli} ($>100,000 \text{ CFU/mL}$) that is resistant to ampicillin but susceptible to cephalexin, ceftriaxone, and trimethoprim-sulfamethoxazole.

Additionally, since yesterday, the patient has developed copious rhinorrhea and a frequent cough. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate is $110/\text{min}$, and respiratory rate is $36/\text{min}$. Pulse oximetry shows $97\%$ on ambient air. Physical examination reveals clear nasal discharge and diffuse expiratory wheezing bilaterally without intercostal retractions. A viral multiplex polymerase chain reaction panel is positive for respiratory syncytial virus (RSV).

The infant's mother notes he missed his $12$-month wellness visit due to his oncology treatments and requests that all overdue immunizations be administered before he is discharged. She also expresses concern that he is delayed because he only cruises along furniture and cannot yet walk independently without support.

Which of the following is the most appropriate comprehensive management plan for this patient at discharge?

A 38-year-old woman is admitted to the medical ward due to a sudden onset of severe headache, palpitations, and profuse diaphoresis. Her blood pressure is 185/115 mm Hg, and her heart rate is 118/min. She reports experiencing three similar episodes over the past month. The clinical presentation is highly suspicious for a catecholamine-secreting neuroendocrine tumor. Arrange the following steps in the most appropriate chronological sequence for the comprehensive diagnostic evaluation and perioperative management of this patient's suspected condition. Assume each step yields confirmatory findings that warrant progression to the subsequent step.

A 45-year-old male is evaluated in the emergency department for altered mental status. His spouse found him acting confused and stumbling in their basement next to several open containers of antifreeze. Vital signs are temperature $36.7^\circ C$ ($98.1^\circ F$), blood pressure $115/78$ mm Hg, pulse $95$/min, and respirations $26$/min. He appears intoxicated but has no scent of alcohol on his breath. Laboratory results are as follows:

Based on these findings, what is the patient's serum osmolar gap?

A male college student, aged $19$, is brought to the emergency department after his roommate found him confused and vomiting. He has been complaining of abdominal pain for the past day. On physical examination, he appears lethargic and has dry mucous membranes. Vital signs demonstrate a heart rate of $120$ beats per minute and a blood pressure of $90/60$ mmHg. Point-of-care capillary glucose testing shows a level of $480$ mg/dL. An arterial blood gas analysis reveals a pH of $7.12$. A dipstick urinalysis is strongly positive for ketones. The patient is diagnosed with diabetic ketoacidosis. Arrange the following interventions in the most appropriate chronological order for his initial management.

A 24-year-old nulliparous woman at 40 weeks gestation is evaluated in the labor and delivery unit due to painful uterine contractions. She has no significant past medical history, and her prenatal care has been routine. On admission, her blood pressure is 118/76 mm Hg and her pulse is 78/min. Cervical examination shows 5 cm dilation and 90% effacement. The fetal head is engaged. A lumbar epidural is placed for pain control. Twenty minutes later, the patient complains of dizziness and nausea. Repeat maternal vital signs show a blood pressure of 82/45 mm Hg and a pulse of 105/min. The continuous fetal monitor displays a baseline heart rate of 125/min, minimal variability, and symmetric decreases in the fetal heart rate that nadir after the peak of the uterine contractions. Uterine contractions are occurring every 3 to 4 minutes and lasting 60 seconds.

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

While rounding in the surgical intensive care unit, a physician is urgently called to the bedside of a 68-year-old male patient who abruptly developed respiratory distress. The patient underwent a right hemicolectomy for stage III colon cancer two days ago. Two hours prior to the acute event, his hemoglobin level was noted to be $6.8$ g/dL, prompting the initiation of a cross-matched packed red blood cell transfusion. Approximately $30$ minutes after the transfusion began, the patient reported the sudden onset of shaking chills and severe pain in his right flank.

Vital signs reveal a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), heart rate of $122/\text{min}$, blood pressure of $85/50$ mm Hg, and respiratory rate of $24/\text{min}$. Pulse oximetry shows an oxygen saturation of $94\%$ on room air.

Physical examination shows profound diaphoresis and anxiety. Jugular venous pulsations are not elevated. Auscultation of the chest reveals clear breath sounds in all lung fields. The surgical incision is intact without erythema or purulent drainage. Inspection of the Foley catheter drainage system reveals that the previously clear, yellow urine has acutely transitioned to a dark, reddish-brown color.

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

A 35-year-old man with untreated HIV infection is brought to the emergency department by his partner due to a 2-week history of progressively worsening headache, fever, and confusion. His temperature is 38.6°C (101.5°F), blood pressure is 120/78 mmHg, and heart rate is 102/min. Physical examination reveals nuchal rigidity and bilateral sixth cranial nerve palsies. Laboratory studies show a CD4 cell count of 28/mm³. A lumbar puncture is performed, and cerebrospinal fluid (CSF) analysis reveals a leukocyte count of 350/mm³ (85% lymphocytes), glucose of 30 mg/dL, and protein of 150 mg/dL. CSF acid-fast bacilli smear is positive. The patient is admitted to the intensive care unit and started on isoniazid, rifampin, pyrazinamide, ethambutol, and intravenous dexamethasone. Which of the following is the most appropriate timing for initiating antiretroviral therapy in this patient?

A 24-year-old man with a history of type 1 diabetes mellitus is brought to the emergency department with altered mental status, vomiting, and diffuse abdominal pain. His blood pressure is 90/60 mmHg, heart rate is 125/min, and respiratory rate is 28/min with deep, rapid breaths. Laboratory studies reveal a blood glucose of 650 mg/dL, arterial pH of 7.12, serum bicarbonate of 10 mEq/L, and a high anion gap. Urinalysis is strongly positive for ketones. Arrange the following steps in the management of this patient's condition in the most appropriate chronological order.

A 19-year-old man with type 1 diabetes mellitus is brought to the emergency department due to altered mental status, generalized weakness, and recurrent vomiting for the past 24 hours. He recently had a respiratory tract infection. Vital signs show a blood pressure of 90/60 mm Hg, heart rate of 124/min, and respiratory rate of 28/min with deep, sighing breaths. Laboratory results show:

Arrange the following management steps in the most appropriate chronological order from first to last.

A 71-year-old man comes to the clinic for a 4-month history of progressive lower back pain and severe fatigue. He states that the pain is a constant, deep ache that does not improve with rest or over-the-counter ibuprofen. Over the same period, he has developed increasing constipation. He has no prior medical history and takes no daily medications. Vital signs are within normal limits. Physical examination reveals generalized pallor and localized tenderness to palpation over the mid-lumbar spine. Neurologic examination is unremarkable. Laboratory studies show the following:

Which of the following is the most appropriate next step in establishing the diagnosis?