Tüm alıştırma soruları

Match the following thyroid nodule presentations and cytology findings with the most appropriate initial surgical or medical management.

An urgent evaluation is requested for a 65-year-old male patient in the cardiovascular intensive care unit due to an acute decline in mental status and worsening dyspnea. The patient is currently on postoperative day 2 following a surgical aortic valve replacement and ascending aortic aneurysm repair. Until this morning, his recovery was progressing as expected. Current vital signs show a temperature of $37.5^\circ\text{C}$ ($99.5^\circ\text{F}$), heart rate of $128/\text{min}$, respiratory rate of $26/\text{min}$, and a blood pressure of $78/48\text{ mm Hg}$. When the patient takes a deep breath, his systolic blood pressure drops to $64\text{ mm Hg}$. Telemetry demonstrates marked sinus tachycardia accompanied by alternating heights of the QRS complexes. On physical assessment, the neck veins are severely distended despite the head of the bed being elevated. Auscultation reveals clear lung fields bilaterally, but the cardiac sounds are notably faint. The nursing staff reports that while the mediastinal drain produced $150\text{ mL}$ of bloody output yesterday, it has yielded only $5\text{ mL}$ over the last 4 hours. Which of the following is the most appropriate next step in management?

During a routine wellness examination, a $54$-year-old woman is found to have an asymmetric thyroid gland. She reports feeling generally well, though she notes a mild increase in anxiety and occasional loose stools over the past two months. Her heart rate is $92/min$ and blood pressure is $128/78$ $mmHg$. Physical examination reveals a non-tender, mobile, $2.8$ cm nodule in the right lobe of the thyroid gland. There is no palpable cervical lymphadenopathy. Laboratory testing reveals:

Thyroid-stimulating hormone (TSH): $0.04$ $\mu U/mL$ (normal: $0.4-4.0$ $\mu U/mL$)
Free thyroxine (T4): $2.1$ $ng/dL$ (normal: $0.9-1.7$ $ng/dL$)

A neck ultrasound confirms a $2.8$ cm solid, hypoechoic right-sided thyroid nodule with increased internal vascularity. Which of the following is the most appropriate next step in the management of this patient?

Investigators at a university hospital are evaluating the relationship between severe obstructive sleep apnea (OSA) and the subsequent development of atrial fibrillation. In January 2026, the team queries a comprehensive national electronic health registry. They define an exposed group by identifying 15,000 adult patients who received a new polysomnography-confirmed diagnosis of severe OSA between January 2012 and December 2015. They simultaneously identify an unexposed group of 30,000 patients without an OSA diagnosis during the same time frame, matched for age, biologic sex, and body mass index. The researchers then extract longitudinal data, reviewing each patient's medical records from their index date through December 2025 to calculate the incidence of newly diagnosed atrial fibrillation in both groups. Which of the following is the most appropriate primary statistical measure of association for this study?

A 22-year-old man is brought to the emergency department via ambulance 45 minutes after being struck on the right side of his head with a baseball bat during an altercation. Witnesses report that he briefly lost consciousness for about one minute but then awoke and was conversing normally. During transport, he became increasingly somnolent and is now unarousable with a Glasgow Coma Scale (GCS) score of 5 (Eyes: 1, Verbal: 1, Motor: 3). His temperature is 37.0°C (98.6°F), blood pressure is 165/95 mm Hg, pulse is 52/min, and respirations are 10/min and irregular. Physical examination reveals a right-sided fixed and dilated pupil, and he exhibits decorticate posturing on the left side in response to painful stimuli. A non-contrast computed tomography (CT) scan of the head demonstrates a 3.5-cm biconvex, hyperdense collection in the right temporal region with 11 mm of midline shift. Which of the following is the next best step in management?

An 80-year-old male resident of an assisted living facility is brought to the urgent care clinic complaining of excruciating right knee pain that started abruptly 24 hours ago. His medical history is significant for generalized osteoarthritis and well-controlled heart failure. His current temperature is $37.8^\circ C$ ($100.0^\circ F$), blood pressure is $135/82$ mmHg, and heart rate is $88$/min. Examination of the right knee demonstrates prominent swelling, marked warmth, and erythema, with passive range of motion severely limited by pain. Synovial fluid aspirated from the joint reveals a leukocyte count of $32,000/\mu L$ (88% segmented neutrophils). Polarized light microscopy identifies numerous rhomboid-shaped crystals exhibiting weak positive birefringence. Gram stain is negative for bacteria. Plain films of the affected joint exhibit linear calcification of the meniscal cartilage. Which of the following is the most appropriate next step in management?

A 34-year-old female presents to the emergency department with a sudden onset of intense, unrelenting periumbilical pain that began 4 hours ago. The pain radiates to her mid-back and is accompanied by several episodes of nonbilious vomiting. Her past medical history is notable for a laparoscopic Roux-en-Y gastric bypass performed two years ago for morbid obesity, resulting in a 45-kg (99-lb) weight loss. Vital signs show a temperature of 37.2°C (99.0°F), a heart rate of 115/min, and a blood pressure of 108/65 mm Hg. On physical examination, the patient appears deeply uncomfortable and is constantly shifting positions in bed to find relief. Her abdomen is soft and non-distended; there is moderate periumbilical tenderness to deep palpation, but no guarding, rigidity, or rebound tenderness. Bowel sounds are hyperactive. Laboratory studies reveal a leukocyte count of 11,500/mm³ and a serum lactate of 1.4 mmol/L (normal: 0.5-2.2 mmol/L). A CT scan of the abdomen and pelvis with intravenous contrast reveals a cluster of dilated small bowel loops in the left upper quadrant, vascular engorgement of the mesentery, and a 'whirl' appearance of the mesenteric root. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's clinical presentation with the underlying pathophysiology that best explains their bleeding disorder.

A reproductive endocrinology clinic utilizes various pharmacotherapy regimens to treat patients with anovulatory and anatomical infertility. For each clinical scenario describing a patient receiving an infertility treatment, match the appropriate intervention with its primary pathophysiological mechanism of action.

A $34$-year-old woman comes to the clinic for evaluation of a $4$-week history of palpitations, anxiety, sweating, and a $3$-kg ($6.6$-lb) weight loss. She works as a medical assistant and reports high stress levels. She has no neck pain, dysphagia, or recent viral illnesses. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $135/85\text{ mm Hg}$, and pulse is $112\text{/min}$. Physical examination reveals warm, moist skin and a fine resting tremor. The eyes appear normal without proptosis. The thyroid gland is normal in size, non-palpable, and non-tender.

Laboratory studies show:
Thyroid-stimulating hormone (TSH): $<0.01\text{ }\mu\text{U/mL}$
Free thyroxine (T4): $2.9\text{ ng/dL}$ (Normal: $0.9-1.7\text{ ng/dL}$)

A radioactive iodine uptake (RAIU) scan reveals $1\%$ uptake at $24$ hours (Normal: $15\%-30\%$).

Which of the following is the most appropriate next step in evaluating this patient's condition?

An oncologist evaluates a $45$-year-old hospitalized male patient for persistent fever and new respiratory symptoms. The patient is currently on day $15$ of induction chemotherapy for acute lymphoblastic leukemia. His hospital course has been complicated by profound neutropenia. Three days prior, after recording a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), he was started on empiric intravenous piperacillin-tazobactam. Despite this intervention, his fevers have remained unremitting. This morning, he developed right-sided pleuritic chest pain and experienced an episode of hemoptysis. Current vital signs include a temperature of $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure of $112/72 \text{ mm Hg}$, pulse of $110/\text{min}$, and respiratory rate of $20/\text{min}$. Pulse oximetry shows $94\%$ on room air. Pulmonary auscultation reveals focal crackles and decreased breath sounds in the right upper lung zone. Laboratory analysis demonstrates a leukocyte count of $200/\text{mm}^3$ with an absolute neutrophil count of $40/\text{mm}^3$. A high-resolution non-contrast computed tomography scan of the chest reveals a $2.5\text{-cm}$ right upper lobe dense macroscopic nodule surrounded by a peripheral zone of ground-glass attenuation. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 65-year-old man is evaluated on postoperative day 3 for acute-onset right knee pain and swelling. The patient underwent an uncomplicated laparoscopic cholecystectomy for acute calculous cholecystitis. His medical history is significant for hypertension, type 2 diabetes mellitus, and chronic kidney disease. His home medications include amlodipine, insulin glargine, and atorvastatin. His temperature is 38.2°C (100.8°F), blood pressure is 145/85 mm Hg, pulse is 95/min, and respiratory rate is 16/min.

Physical examination shows a swollen, erythematous, and exquisitely tender right knee with a large effusion. Range of motion is severely limited due to pain. The surgical incisions are clean, dry, and intact.

Arthrocentesis of the right knee is performed. Synovial fluid analysis shows a leukocyte count of 45,000/mm³ with 85% neutrophils. Polarized light microscopy reveals negatively birefringent, needle-shaped crystals. Gram stain of the synovial fluid shows no organisms.

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

Match each patient's clinical scenario with the most appropriate next step in management.

A 58-year-old man with a 15-year history of type 2 diabetes mellitus and peripheral neuropathy presents to the outpatient clinic with a 3-week history of a nonhealing ulcer on the plantar surface of his left hallux. He reports no fever, chills, or systemic symptoms. Vital signs are within normal limits. Physical examination reveals a 2-cm, deep ulceration with a hyperkeratotic border and mild surrounding erythema. There is no fluctuance or gross purulence. The physician suspects underlying osteomyelitis. Arrange the following steps in the most appropriate sequential order for the optimal diagnostic workup and management of this patient's condition.

A 16-year-old girl comes to the outpatient clinic requesting a prescription for oral contraceptives. She reports that she recently started dating and plans to become sexually active. She is accompanied by her 20-year-old sister, who is waiting in the reception area. During the private consultation, the patient explicitly asks the physician not to inform her parents about the visit or the prescription, stating, 'They are very strict and would kick me out of the house if they knew.' The patient is physically healthy, has no medical contraindications to hormonal contraception, and demonstrates a clear understanding of the medication's risks, benefits, and instructions for use. Which of the following is the most appropriate next step in management?

A 32-year-old man is brought to the emergency department after a high-speed motorcycle collision. His airway is patent, breathing is unlabored, and he is hemodynamically stable. Examination reveals a grossly deformed right lower leg with a 4-cm anteromedial laceration through which fractured bone fragments are visible. The wound is oozing dark blood, but there is no pulsatile bleeding.

Arrange the following steps in the most appropriate sequential order for the acute management of this patient's orthopedic injury.

A 9-year-old boy is brought to the emergency department by his parents due to a 3-day history of worsening left leg pain and fever. The parents report that he initially started limping but now refuses to bear any weight on the left leg. There is no history of recent trauma, tick bites, or travel. His temperature is 38.8°C (101.8°F), blood pressure is 105/65 mmHg, heart rate is 115/min, and respiratory rate is 18/min. On physical examination, the child is ill-appearing. There is exquisite point tenderness, localized warmth, and mild swelling over the proximal anterior aspect of the left tibia. Range of motion of the left knee and ankle is fully preserved and does not elicit pain. Laboratory studies reveal a leukocyte count of 15,500/mm³ (85% neutrophils), an erythrocyte sedimentation rate (ESR) of 65 mm/hr, and a C-reactive protein (CRP) level of 82 mg/L. Plain radiographs of the left tibia and knee show no obvious abnormalities. Which of the following is the most appropriate next step in management?

Match each clinical vignette describing an orthopedic injury with the most appropriate definitive management step.

For each of the following patients presenting with symptoms following a specific occupational or environmental exposure, select the most appropriate targeted pharmacologic therapy.

A 45-year-old man comes to the clinic to review the results of recent genetic testing. Over the past year, he has developed mild choreiform movements, irritability, and subtle cognitive decline. His father died of a similar undiagnosed neurological condition at age 55. Testing reveals an abnormal CAG trinucleotide repeat expansion on chromosome 4, confirming a diagnosis of Huntington disease. The patient is devastated by the news. He mentions that his two younger sisters, ages 35 and 32, are both actively trying to conceive their first children. He says, "This news is a death sentence. You absolutely cannot tell my sisters about this. I refuse to ruin their lives right now while they are trying to start their families." Which of the following is the most appropriate next step by the physician?