Tüm alıştırma soruları

A 9-year-old boy is brought to the pediatrics clinic by his father due to a persistent cough for the past two weeks. The cough is dry, nonproductive, and frequently disrupts the patient's sleep. Over the past few days, he has also developed a mild sore throat, malaise, and a low-grade fever. His past medical history is unremarkable, and his immunizations are up to date. His temperature is 37.9°C (100.2°F), blood pressure is 105/65 mm Hg, pulse is 95/min, and respiratory rate is 22/min. Pulse oximetry shows 98% on room air. The patient appears comfortable and is in no acute distress. Physical examination of the chest reveals diffuse, bilateral fine crackles and occasional expiratory wheezes. A chest radiograph demonstrates bilateral, patchy interstitial infiltrates without pleural effusions or focal lobar consolidation. What is the most appropriate next step in management?

A 64-year-old female patient is currently hospitalized for the treatment of acute pyelonephritis. She initially presented to the emergency department three days ago with severe right-sided flank pain, dysuria, and a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$). Blood cultures were drawn, and empiric intravenous ceftriaxone was initiated. The admission blood cultures show no growth to date. However, the urine culture obtained prior to antibiotic administration has grown $>10^5$ colony-forming units/mL of *Escherichia coli*. The susceptibility report is as follows:

Today, the patient reports that her flank pain has nearly resolved. Her current temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $122/78 \text{ mmHg}$, and heart rate is $78/\text{min}$. She is tolerating a regular diet without nausea.

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

A reproductive endocrinology clinic is evaluating four different women, all of whom present with secondary amenorrhea and an inability to conceive. Based on the provided clinical presentations and initial serum laboratory findings, match each patient's profile with the most likely underlying diagnosis and pathophysiologic mechanism.

Match each clinical infectious disease vignette with its most appropriate targeted pharmacotherapy or first-line treatment regimen.

A 45-year-old man presents to the clinic complaining of profound fatigue, a 6-kg (13.2-lb) weight loss, and generalized weakness over the past 4 months. He also notes decreased libido and occasional dizziness when standing. Two years ago, he sustained a severe traumatic brain injury in a motor vehicle collision that required a 3-week stay in the intensive care unit. His blood pressure is 102/62 mm Hg while supine and 84/52 mm Hg upon standing. Heart rate is 86/min. Physical examination reveals loss of axillary and pubic hair, and delayed relaxation of deep tendon reflexes. Laboratory studies show:

* Sodium: $131 \text{ mEq/L}$
* Potassium: $4.0 \text{ mEq/L}$
* Thyroid-stimulating hormone (TSH): $2.2 \text{ } \mu\text{U/mL}$ (Normal: $0.4–4.0 \text{ } \mu\text{U/mL}$)
* Free T4: $0.5 \text{ ng/dL}$ (Normal: $0.9–1.7 \text{ ng/dL}$)

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

Review the clinical vignettes below, which present various mechanisms of renal and systemic acid-base derangements. Which classic arterial blood gas and serum chemistry profile is most strongly associated with each patient's presentation?

Match each of the following patient laboratory profiles to the most likely underlying pathophysiologic mechanism.

(Reference ranges: Serum Calcium: 8.4-10.2 mg/dL; Intact PTH: 10-65 pg/mL; Phosphorus: 2.5-4.5 mg/dL; 24-hour urine calcium: 100-300 mg/day).

A $5$-month-old girl is brought to the outpatient clinic in late December due to a $3$-day history of nasal congestion, copious clear rhinorrhea, and a worsening cough. Her oral intake has decreased slightly, but she continues to have wet diapers. During the visit, her mother expresses concern that the infant is not yet able to sit up without support. The patient was born at full term and has received all age-appropriate vaccinations. Her temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), pulse is $148/\text{min}$, respirations are $58/\text{min}$, and pulse oximetry shows $95\%$ on room air. Physical examination reveals mild subcostal retractions. Auscultation of the lungs demonstrates diffuse bilateral wheezing and scattered crackles. Which of the following is the most appropriate next step in management?

An $8$-year-old boy is brought to the emergency department due to a $2$-day history of worsening headache, high fever, and generalized lethargy. Over the last $12$ hours, he has become increasingly difficult to arouse. His temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, pulse is $125/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals a somnolent child who only opens his eyes to painful stimuli. He has marked nuchal rigidity. Funduscopic examination shows bilateral blurring of the optic disc margins. There are no focal neurologic deficits or purpuric rashes. Arrange the following steps in the most appropriate sequential order for managing this patient's acute presentation.

A university student, aged 21, visits the campus health center complaining of highly irregular menstrual periods and worsening acne. She reports menstruating only three times in the past year. Additionally, she has been troubled by thick, dark hair growing on her chin, chest, and lower abdomen, which she removes frequently. The patient takes no medications and is otherwise healthy. Her blood pressure is $112/72 \text{ mm Hg}$, and her body mass index is $23.5 \text{ kg/m}^2$. Pelvic examination reveals normal female external genitalia without clitoromegaly. A serum pregnancy test is negative.

Laboratory evaluation shows the following results:
Thyroid-stimulating hormone: $1.9 \text{ \mu U/mL}$
Prolactin: $14 \text{ ng/mL}$
Total testosterone: $78 \text{ ng/dL}$ (normal: $15$–$70 \text{ ng/dL}$)
Dehydroepiandrosterone sulfate: $310 \text{ \mu g/dL}$ (normal: $35$–$430 \text{ \mu g/dL}$)
17-hydroxyprogesterone (measured at 8:00 AM): $3,800 \text{ ng/dL}$ (normal: $< 200 \text{ ng/dL}$)

Which of the following is the most likely underlying cause of this patient's clinical presentation?

A 34-year-old G1P0 woman at 35 weeks gestation is admitted to the labor and delivery unit for induction of labor due to preeclampsia with severe features. Upon admission, her blood pressure is 168/112 mm Hg, and laboratory studies reveal a serum creatinine of 1.1 mg/dL, platelet count of 110,000/mm³, and elevated liver transaminases. An intravenous infusion of magnesium sulfate is initiated for seizure prophylaxis, alongside continuous oxytocin for labor induction. A bolus of isotonic intravenous fluids is administered prior to initiating epidural anesthesia.

Fourteen hours later, the patient reports a sudden onset of severe shortness of breath and a cough productive of frothy pink sputum. Her temperature is 37.0°C (98.6°F), blood pressure is 160/105 mm Hg, heart rate is 112/min, and respiratory rate is 28/min. Arterial blood gas analysis on room air reveals a pH of 7.44, PaCO2 of 28 mm Hg, and PaO2 of 55 mm Hg. Physical examination reveals bilateral pitting edema of the lower extremities and diffuse crackles auscultated over the lower lung fields bilaterally. Deep tendon reflexes are 2+ and symmetric. The fetal heart rate tracing demonstrates a baseline of 145/min with moderate variability and no decelerations.

Which of the following is the most appropriate next step in the management of this patient's acute symptoms?

A reproductive endocrinology clinic is evaluating four adolescent patients who each present with primary amenorrhea. Based on the findings from physical examinations, laboratory testing, and karyotype analysis, match each patient's clinical profile with the most likely diagnosis.

An otherwise healthy $26$-year-old male is evaluated in the outpatient clinic due to a $4$-day history of a swollen, painful, and warm right knee. He also reports recent onset of left heel pain that worsens with walking. For the past week, he has experienced bilateral eye redness and a "gritty" sensation. Three weeks prior to this visit, the patient had a self-limited episode of fever, abdominal cramps, and watery diarrhea that resolved after a few days. His current temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $122/78$ mmHg, and pulse is $86$/min. Physical examination shows a large effusion in the right knee with restricted range of motion secondary to pain. There is marked tenderness at the insertion of the left Achilles tendon. Bilateral conjunctival injection is noted without purulent discharge. Arthrocentesis of the right knee yields $40$ mL of cloudy yellow fluid. Synovial fluid analysis reveals a leukocyte count of $35,000/\text{mm}^3$ with $80\%$ neutrophils. Gram stain shows no organisms, and polarized light microscopy demonstrates no crystals. Which of the following is the most appropriate next step in the management of this patient?

A clinical quality committee is reviewing antimicrobial prescribing practices within the gastroenterology and hepatology department. Match the following patient scenarios with the most appropriate, guideline-concordant initial pharmacological management to promote effective care and antimicrobial stewardship.

A 66-year-old retired mechanic is brought to the clinic by his daughter after experiencing difficulty walking over the past 24 hours. He reports a two-week history of dull, continuous pain in his mid-thoracic region that worsens when he lies flat in bed. His past medical history is significant for non-small cell lung cancer treated with radiation and chemotherapy two years ago. On neurologic examination, he demonstrates 3/5 strength in the bilateral lower extremities, diminished sensation to pinprick below the umbilicus, and symmetric hyperreflexia at the patellae and ankles. Rectal examination reveals decreased sphincter tone. Vital signs are within normal limits except for a temperature of 37.8°C (100.0°F). Laboratory results reveal a normal leukocyte count and a serum calcium level of 9.2 mg/dL. Which of the following is the most appropriate initial step in the management of this patient?

A 45-year-old woman is brought to the emergency department due to progressive muscle weakness. Over the past week, she has had difficulty rising from a chair and climbing stairs. She has a 5-year history of primary Sjögren syndrome, for which she uses artificial tears and saliva substitutes. Vital signs are within normal limits. Physical examination shows symmetric 3/5 muscle strength in the proximal upper and lower extremities, with decreased deep tendon reflexes.

Laboratory studies are obtained:

Which of the following best explains this patient's clinical presentation and laboratory findings?

A 27-year-old man is brought to the emergency department by paramedics after sustaining a single stab wound to the left anterior chest during a physical altercation. On arrival, he is restless, diaphoretic, and confused. His temperature is 36.6°C (97.9°F), blood pressure is 64/38 mmHg, pulse is 142/min, and respiratory rate is 28/min. Oxygen saturation is 93% on a non-rebreather mask. Physical examination reveals a 3-cm laceration at the left fourth intercostal space, directly adjacent to the sternal border. His jugular veins are markedly distended. Pulmonary auscultation reveals clear and symmetric breath sounds bilaterally. Cardiac auscultation demonstrates faint and muffled heart sounds. The trachea is midline. A bedside focused assessment with sonography for trauma (FAST) confirms a large anechoic space surrounding the heart with evidence of right ventricular collapse during diastole. Rapid intravenous infusion of 1 liter of warmed crystalloid solution does not improve his blood pressure. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old woman is evaluated during morning rounds on the surgical ward. She was admitted 48 hours ago for management of a small bowel obstruction secondary to adhesions from a prior total abdominal hysterectomy. Initial management included bowel rest, intravenous fluid resuscitation, and nasogastric tube decompression. Over the last few hours, she reports that her previously intermittent, crampy abdominal pain has become unremitting, constant, and more severe. She has not had any bowel movements or passed flatus since admission. Her temperature is 38.3°C (100.9°F), blood pressure is 112/74 mmHg, pulse is 116/min, and respirations are 20/min. Physical examination reveals a distended abdomen with hypoactive bowel sounds. There is focal, severe tenderness with involuntary muscle spasm in the periumbilical region. Laboratory studies show a leukocyte count of 15,400/mm³ and a serum bicarbonate level of 16 mEq/L. Which of the following is the most appropriate next step in management?

A 32-year-old man is evaluated by the surgical team for severe right lower extremity pain. Twelve hours ago, he underwent an uncomplicated open reduction and internal fixation of a comminuted right tibial shaft fracture sustained in a mountain biking accident. The patient reports that over the past two hours, the pain has become agonizing and is no longer relieved by his scheduled doses of intravenous morphine. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $138/86\text{ mmHg}$, and heart rate is $112\text{/min}$. On physical examination, the right anterolateral leg appears tense and significantly swollen compared to the contralateral limb. The overlying skin is shiny. Passive plantar flexion of the right ankle and toes elicits a dramatic increase in pain. Capillary refill time is 2 seconds, and the dorsalis pedis and posterior tibial pulses are palpable bilaterally. Which of the following is the most appropriate next step in management?

A $58$-year-old man presents to the emergency department with a $4$-day history of progressively worsening left lower quadrant abdominal pain, subjective fever, and decreased appetite. He has no prior history of similar episodes. His temperature is $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), blood pressure is $130/80\text{ mmHg}$, and pulse is $98\text{/min}$. Physical examination demonstrates marked focal tenderness and voluntary guarding in the left lower quadrant, but no generalized rigidity. Laboratory evaluation reveals a leukocyte count of $16,500\text{/mm}^3$. Intravenous fluid resuscitation and broad-spectrum antibiotics are initiated.

Assume the patient's clinical course progresses appropriately through standard management. Arrange the following steps in the most appropriate chronological sequence for the optimal diagnosis and long-term management of this patient.