Tüm alıştırma soruları

A 4-day-old male neonate is evaluated in the neonatal intensive care unit. He was delivered vaginally at 39 weeks of gestation to a 26-year-old primigravida. Birth weight was $3400\text{ g}$. APGAR scores were 8 and 9 at 1 and 5 minutes, respectively. At $48\text{ hours}$ of life, he developed temperature instability, poor feeding, and lethargy. A full sepsis evaluation was performed, and empiric intravenous ampicillin and gentamicin were initiated. Current vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate $140/\text{min}$, and respiratory rate $42/\text{min}$ on room air.

Blood cultures obtained at symptom onset now demonstrate robust growth of *Streptococcus agalactiae* (Group B Streptococcus) that is exquisitely sensitive to penicillin G. Cerebrospinal fluid analysis is unrevealing. Physical examination today reveals an alert infant with a new scattering of erythematous macules containing central tiny yellow papules on the anterior chest, lacking any surrounding induration.

Laboratory studies drawn this morning show:

During bedside rounds, the mother expresses profound anger upon learning that her positive maternal Group B Streptococcus screening results were not transmitted from her outpatient clinic to the hospital during admission. She demands that the specific administrative staff member responsible for the omission face immediate disciplinary action.

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

Match each patient's clinical presentation with the most likely predominant finding on their peripheral blood smear.

A $68$-year-old man is hospitalized due to a $4$-week history of fatigue, intermittent fevers, and unintentional weight loss. Two months ago, he underwent a cystoscopy for evaluation of hematuria. His temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), pulse is $92/\text{min}$, and blood pressure is $118/74\text{ mm Hg}$. Physical examination reveals small, linear, dark red streaks in the nail beds of both hands and a new grade $3/6$ holosystolic murmur heard best at the cardiac apex.

Echocardiography demonstrates a $1.2\text{-cm}$ mobile vegetation on the mitral valve with moderate mitral regurgitation.

Laboratory studies show:
Leukocyte count: $14,500/\text{mm}^3$
Serum creatinine: $2.2\text{ mg/dL}$ (baseline: $1.0\text{ mg/dL}$)

Three sets of blood cultures are drawn, and the patient is started empirically on intravenous vancomycin and piperacillin-tazobactam. Forty-eight hours later, all blood culture bottles grow *Enterococcus faecalis*. Susceptibility testing reveals:

Ampicillin: Susceptible
Vancomycin: Susceptible
Piperacillin-tazobactam: Susceptible
Gentamicin: High-level resistance

Which of the following is the most appropriate targeted pharmacotherapy for this patient?

A 34-year-old woman comes to the office seeking evaluation for infertility. She and her husband have been having unprotected intercourse for the past $14$ months. Her only pregnancy resulted in a spontaneous abortion at $9$ weeks of gestation $18$ months ago, which was complicated by retained products of conception requiring a suction dilation and curettage. Prior to this event, her menstrual cycles occurred at regular 28-day intervals. Since the procedure, she has had complete cessation of menses. She reports no cyclical pelvic pain, headaches, visual changes, or galactorrhea. Her temperature is $36.8^\circ$ C ($98.2^\circ$ F), blood pressure is $115/75$ mm Hg, pulse is $72$/min, and BMI is $29$ kg/m $^2$. She has mild facial acne that she has had since her teenage years. Pelvic examination reveals a normal-appearing cervix with no adnexal masses.

Laboratory testing shows:
$\beta$-hCG: $< 5$ mIU/mL
Thyroid-stimulating hormone: $1.8$ $\mu$ U/mL
Prolactin: $14$ ng/mL
Follicle-stimulating hormone: $7$ mIU/mL
Luteinizing hormone: $6$ mIU/mL
Estradiol: $80$ pg/mL

Following a 10-day course of oral medroxyprogesterone acetate, the patient experiences no withdrawal bleeding. Which of the following is the most likely underlying cause of this patient's current condition?

An evaluation is requested for a 32-year-old woman who reports profound fatigue, cold intolerance, and a $5$-kg ($11$-lb) weight gain over the past six months. She also notes that her menstrual cycles have not resumed since the vaginal delivery of her first child 10 months ago. The patient's medical records indicate that her delivery was complicated by uterine atony and severe postpartum hemorrhage requiring the transfusion of four units of packed red blood cells. Following the birth, she was unable to breastfeed despite multiple attempts.

Vital signs include a blood pressure of $88/56$ mm Hg and a heart rate of $58$/min. Physical examination demonstrates pale, dry skin and a noticeable loss of axillary and pubic hair. Deep tendon reflexes show delayed relaxation.

Laboratory studies reveal:
Thyroid-stimulating hormone (TSH): $1.3$ $\mu$ U/mL (Normal: $0.5$-$5.0$ $\mu$ U/mL)
Free thyroxine (T4): $0.4$ ng/dL (Normal: $0.9$-$1.7$ ng/dL)

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

A $6$-year-old girl is evaluated in the pediatric rheumatology clinic for a routine follow-up. Six months ago, she was diagnosed with systemic juvenile idiopathic arthritis. She is currently maintained on high-dose daily oral prednisone ($2$ mg/kg/day) and methotrexate. Her disease has been well-controlled on this regimen. Review of her medical chart shows that she received all recommended immunizations during her first two years of life, but she has not attended any preventive care visits since then. It is mid-October. Vital signs and physical examination today are unremarkable. Which of the following vaccines can be safely administered to this patient today? (Select all that apply)

Researchers at a medical center are investigating a potential association between the use of a newly introduced class of weight-loss medications and the development of acute pancreatitis. To conduct the study, they review electronic health records to identify 150 patients who were admitted to the hospital with a confirmed diagnosis of acute pancreatitis over the past three years. They also randomly select 600 patients from the same hospital system who have never been diagnosed with acute pancreatitis, ensuring they are matched by age, sex, and body mass index. The research team then analyzes the past pharmacy dispensing records for all 750 individuals to determine how many had been prescribed the new weight-loss medication prior to the index date. Which of the following is the most appropriate statistical measure to report the strength of the association in this study?

Match each of the following public health and clinical research scenarios with the most appropriate epidemiologic study design.

Sports medicine physicians aim to determine if early sports specialization increases the risk of ulnar collateral ligament (UCL) tears. They query a regional network database spanning the last decade. The physicians identify $200$ adolescent baseball pitchers who underwent surgical reconstruction for a UCL tear. For a comparison group, they randomly select $600$ adolescent baseball pitchers from the same database who were treated for acute, non-throwing contact injuries during the same period. The physicians then review the patients' initial intake questionnaires and conduct structured telephone interviews to determine how many athletes in each group specialized exclusively in pitching before the age of $12$. Which of the following is the most appropriate measure of association to report for this investigation?

For each patient presentation below, select the most appropriate legal or ethical guideline that dictates the physician's next action regarding informed consent or treatment.

A 26-year-old man is hospitalized after sustaining a closed mid-shaft fracture of the right femur in a motor vehicle collision. Due to multiple life-threatening cases in the operating room, his fracture is temporarily managed with skeletal traction. On the second day of hospitalization, he becomes acutely confused and agitated. His temperature is 38.3°C (100.9°F), blood pressure is 118/76 mmHg, heart rate is 122/min, and respiratory rate is 28/min. Pulse oximetry shows an oxygen saturation of 86% on room air. Physical examination reveals a non-blanching petechial rash over the anterior chest, axillae, and conjunctivae. Lung auscultation demonstrates bilateral scattered crackles. Which of the following interventions during the initial 24 hours of admission would have most effectively decreased the risk of this patient's current complication?

Match each clinical scenario with the corresponding ethical or legal exception to the standard requirement for informed consent.

A $54$-year-old woman arrives at the emergency department with severe, sudden-onset breathing difficulty that started one hour ago. The patient has a history of long-standing hypertension but has not taken her prescribed medications for several months.

On evaluation, she is sitting upright, diaphoretic, and in significant respiratory distress.

Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $220/115\text{ mm Hg}$, heart rate of $118/\text{min}$, and respiratory rate of $28/\text{min}$. Oxygen saturation is $88\%$ on room air.

Physical examination reveals prominent jugular venous distention. Pulmonary auscultation demonstrates bilateral crackles extending to the apices and widespread expiratory wheezing.

Cardiac auscultation reveals a regular tachycardia and a prominent fourth heart sound (S4). There is no peripheral edema.

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

Match each physical examination finding and its corresponding response to dynamic auscultatory maneuvers with the most likely underlying structural or valvular pathology.

A 34-year-old man with a history of intravenous opioid use disorder is hospitalized for a 1-week history of fever, chills, and pleuritic chest pain. On admission, multiple sets of blood cultures are drawn, and empiric intravenous vancomycin and cefepime are initiated. A transthoracic echocardiogram reveals a $1.4\text{-cm}$ mobile vegetation on the tricuspid valve with moderate tricuspid regurgitation. Two days later, all blood culture bottles grow *Staphylococcus aureus*. Susceptibility testing indicates the isolate is resistant to penicillin G, but susceptible to oxacillin, cefazolin, and vancomycin. The patient's medical record notes a history of a diffuse maculopapular rash after taking amoxicillin for a respiratory infection 5 years ago; he specifically denies any history of facial swelling, difficulty breathing, or anaphylaxis associated with medications. His temperature is currently $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $122/76\text{ mm Hg}$, and heart rate is $82/\text{min}$. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A patient with a fifty-pack-year smoking history and severe chronic obstructive pulmonary disease comes to the clinic for a routine follow-up. He is seventy-two years old and reports progressively worsening fatigue, bilateral leg swelling, and right upper quadrant abdominal discomfort over the past few months. His current medications include a long-acting muscarinic antagonist and an inhaled corticosteroid. Vital signs show a respiratory rate of $22$/min and an oxygen saturation of $87\%$ on room air. Physical examination reveals elevated jugular venous pressure, a right ventricular heave, and $2+$ pitting edema of the lower extremities up to the knees. Auscultation of the heart reveals a loud $P_2$. Lung auscultation shows decreased breath sounds globally without wheezes. Which of the following interventions is most likely to improve long-term survival in this patient?

A 72-year-old woman is brought to the emergency department due to severe dizziness, confusion, and near-syncope. Her heart rate is 32/min, and blood pressure is 75/40 mm Hg. The 12-lead electrocardiogram reveals third-degree atrioventricular block. Arrange the following interventions in the optimal chronological sequence for managing this patient's symptomatic bradycardia, from initial emergency stabilization to definitive treatment.

A 72-year-old man is brought to the emergency department by emergency medical services due to severe, rapidly progressive shortness of breath that awoke him from sleep 2 hours ago. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of 30%, chronic obstructive pulmonary disease (COPD), and chronic kidney disease. His home medications include lisinopril, metoprolol succinate, tiotropium, and as-needed albuterol. On arrival, he is in marked respiratory distress, speaking in short phrases and using accessory muscles of respiration. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $178/96\text{ mmHg}$, heart rate $112/\text{min}$, respiratory rate $30/\text{min}$, and oxygen saturation 85% on room air. Physical examination reveals an elevated jugular venous pressure at 12 cm $H_2O$. Lung auscultation demonstrates diffuse expiratory wheezing and bilateral crackles extending to the mid-lung fields. Cardiac auscultation reveals a normal $S_1$ and $S_2$ with a prominent $S_3$ gallop. Bilateral 2+ pitting lower extremity edema is present.

Laboratory results:
Leukocyte count: $9,500/\text{mm}^3$
Thyroid-stimulating hormone (TSH): $1.1\ \mu\text{U/mL}$ (normal: $0.4-4.0\ \mu\text{U/mL}$)
Free thyroxine ($T_4$): $0.5\ \text{ng/dL}$ (normal: $0.9-1.7\ \text{ng/dL}$)

Arterial blood gas (room air):
pH: $7.22$
$PaCO_2$: $35\text{ mmHg}$
$PaO_2$: $55\text{ mmHg}$
$HCO_3^-$: $14\text{ mEq/L}$

Chest radiography reveals an enlarged cardiac silhouette, bilateral perihilar alveolar opacities, and prominent interlobular septal lines. Which of the following is the most appropriate initial step in the management of this patient?

A 57-year-old man visits his primary care provider due to a 3-day history of progressively worsening shortness of breath and a change in his chronic cough. He states that his usual mild morning cough is now occurring throughout the day and is producing thick, dark yellow sputum. He also feels unusually fatigued. His past medical history is significant for essential hypertension and a 35-pack-year history of smoking; he successfully quit smoking two years ago. His temperature is 37.9°C (100.2°F), blood pressure is 128/82 mm Hg, pulse is 96/min, and respiratory rate is 22/min. Oxygen saturation is 92% on room air. Physical examination reveals an augmented anteroposterior chest diameter and bilateral prolonged expiratory phases with diffuse wheezing. Evaluation of the neck shows flat jugular veins, and there is no trace of lower extremity edema. Cardiac auscultation reveals a regular rate and rhythm with no murmurs or gallops. In addition to inhaled bronchodilators and oral corticosteroids, which of the following is the most appropriate next step in pharmacologic management?

A primary care physician is evaluating a 68-year-old man who presents to an urgent care clinic with progressively worsening shortness of breath over the past 48 hours. The patient states he has been waking up in the middle of the night feeling as though he is suffocating and has required sleeping in a recliner chair. His past medical history is notable for essential hypertension, ischemic heart disease, and a 40-pack-year history of cigarette smoking. Current medications include daily aspirin, lisinopril, and atorvastatin. Vital signs show a temperature of 37.1 C (98.8 F), blood pressure of 158/92 mm Hg, heart rate of 108/min, and respiratory rate of 24/min. Oxygen saturation is 91% on ambient air. Physical examination reveals distended jugular veins when sitting upright. Cardiac auscultation demonstrates a regular tachycardia with a distinct third heart sound (S3). Lung auscultation yields bilateral crackles at the posterior lung bases without any audible wheezing. Palpation of the lower extremities reveals bilateral pitting edema extending to the knees. Which of the following is the most appropriate next step in the management of this patient?