Tüm alıştırma soruları

A 12-month-old male infant presents to the primary care office for a wellness evaluation. His parents report that he is generally healthy and they have no acute concerns. The patient was born at 40 weeks gestation via an uncomplicated vaginal delivery. Developmentally, he can sit without support, pull himself to a standing position, and cruise along furniture. He says "mama" and "dada" specifically to his parents and can successfully wave "bye-bye." While observing the patient playing on the examination table, the physician notes that he consistently uses a mature pincer grasp with his right hand to pick up small objects. His left hand remains largely clenched in a fist resting on his leg. Furthermore, when a toy is placed on his left side, he crosses his midline with his right hand to retrieve it. His height, weight, and head circumference are tracking consistently at the 60th percentile. Which of the following is the most appropriate next step in management?

A 68-year-old man is admitted to the hospital due to a 4-week history of progressively worsening lower back pain. The pain is localized to the lower lumbar area, is dull and constant, and frequently awakens him from sleep. It is not relieved by rest or over-the-counter ibuprofen. He has a history of type 2 diabetes mellitus and benign prostatic hyperplasia. Six weeks ago, he underwent a transurethral resection of the prostate. His temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $135/85\text{ mmHg}$, pulse is $88/\text{min}$, and respiratory rate is $14/\text{min}$. Physical examination reveals exquisite point tenderness over the L4 and L5 spinous processes. Neurological examination of the lower extremities shows 5/5 motor strength, normal sensation, and 2+ symmetric deep tendon reflexes. Anal sphincter tone is normal. Laboratory studies show a leukocyte count of $11,500/\text{mm}^3$, an erythrocyte sedimentation rate of $85\text{ mm/h}$, and a C-reactive protein level of $72\text{ mg/L}$. Magnetic resonance imaging of the lumbar spine reveals fluid in the L4-L5 intervertebral disc space with T2 hyperintensity and gadolinium enhancement of the adjacent vertebral endplates. Blood cultures are drawn on admission. Forty-eight hours later, the blood cultures show no growth, and the patient's clinical status remains unchanged. Which of the following is the most appropriate next step in management?

An oncologist is evaluating a 67-year-old male who has been receiving chemotherapy for advanced pancreatic adenocarcinoma. The patient reports a two-day history of progressive swelling and a 'heavy, aching sensation' in his right calf. He denies chest pain, shortness of breath, or recent trauma to the area. His temperature is 37.0°C (98.6°F), blood pressure is 128/82 mmHg, heart rate is 92/min, and respiratory rate is 16/min. Physical examination reveals a right lower leg that is visibly enlarged, mildly erythematous, and tender to palpation along the popliteal fossa. The right calf circumference is 5 cm greater than the left calf. Which of the following is the most appropriate initial step in evaluating this patient's symptoms?

During a routine clinic visit, a $71$-year-old woman describes a $6$-week history of profound stiffness in her shoulders, neck, and pelvic girdle. She reports that the stiffness is most severe upon awakening and typically lasts for $2$ to $3$ hours before gradually improving throughout the day. Over the past month, she has also experienced generalized fatigue and a $2$-kg ($4.4$-lb) weight loss. She explicitly denies headaches, visual changes, scalp tenderness, and jaw pain with chewing. Her past medical history is notable for mild essential hypertension. Vital signs are within normal limits.

Physical examination reveals a well-appearing but visibly uncomfortable woman. There is no focal joint effusion, erythema, or warmth. Active range of motion in the shoulders and hips is limited by pain, but passive range of motion is fully preserved. Muscle strength is $5/5$ in the proximal and distal extremities.

Laboratory studies show:

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

A hospital's clinical toxicology service is reviewing protocols for the acute management of various hazardous ingestions and exposures. For each patient presentation described below, match the clinical scenario and associated findings with the most appropriate specific pharmacological intervention.

Match each pediatric patient's clinical presentation with the most accurate developmental assessment or underlying etiology.

Match each of the following patient clinical vignettes to the most likely specific vasculitis diagnosis.

A 47-year-old woman is evaluated on her third day of hospitalization for community-acquired pneumonia. At the time of admission, empiric therapy with intravenous ceftriaxone and oral azithromycin was initiated. She currently feels much better, and her cough has significantly decreased. Vital signs are temperature 37.0°C (98.6°F), blood pressure 124/76 mm Hg, pulse 78/min, and respirations 14/min. Oxygen saturation is 98% on room air. Sputum culture collected prior to antibiotic administration now grows Streptococcus pneumoniae. Susceptibility testing indicates the isolate is highly susceptible to penicillin, ceftriaxone, macrolides, and respiratory fluoroquinolones. The patient is tolerating a regular diet and has adequate gastrointestinal absorption. Which of the following is the most appropriate next step in pharmacotherapy?

A pediatrician is analyzing the growth charts and skeletal maturation data of several patients. Match each described clinical growth trajectory with its most likely underlying etiology.

A 28-year-old woman presents to the clinic for evaluation of fatigue and decreased exercise tolerance over the past 3 months. She reports heavy menstrual periods lasting 7 to 8 days each month. She has no other medical conditions and takes no medications. Vital signs are within normal limits. Physical examination reveals pale conjunctivae.

Which of the following laboratory findings is most likely to be present in this patient?

A 31-year-old woman presents to her primary care clinic reporting persistent fatigue, generalized weakness, and cold intolerance that have progressively worsened over the past several months. She also notes that she has not menstruated since the birth of her daughter 10 months ago. Her pregnancy was uncomplicated, but her delivery was followed by a massive obstetric hemorrhage necessitating a massive transfusion protocol and emergency arterial embolization. Following the delivery, she was unable to produce breast milk.

Vital signs show a blood pressure of 88/54 mm Hg and a heart rate of 52/min. Physical examination reveals dry, pale skin and delayed relaxation of deep tendon reflexes. Visual fields are full to confrontation.

Laboratory studies reveal:

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

During a health maintenance evaluation, a physician sees a 12-month-old infant who was recently diagnosed with profound T-cell lymphopenia secondary to complete DiGeorge syndrome. The patient's parents report that he has not received any immunizations since his 6-month checkup. They are requesting that he receive all age-appropriate vaccines today to protect him from circulating illnesses. Given the patient's underlying genetic condition and immunologic status, which of the following preparations is strictly contraindicated?

A 62-year-old woman is evaluated in the hospital on day 4 of admission. She initially presented to the emergency department with a 2-day history of high fever, chills, and severe right-sided back pain. On admission, her temperature was $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure was $110/70\text{ mmHg}$, and heart rate was $115\text{/min}$. Physical examination revealed pronounced right costovertebral angle tenderness. Laboratory studies showed a leukocyte count of $16,500\text{/mm}^3$. She was started on empiric intravenous ceftriaxone.

On hospital day 2, her fever persisted. Urine culture grew $>10^5\text{ CFU/mL}$ of *Escherichia coli*. The isolate was identified as an extended-spectrum beta-lactamase (ESBL) producer. Antimicrobial susceptibility testing showed the following:

- Ceftriaxone: Resistant
- Cefepime: Resistant
- Piperacillin-tazobactam: Resistant
- Meropenem: Susceptible
- Ertapenem: Susceptible
- Ciprofloxacin: Susceptible
- Nitrofurantoin: Susceptible
- Fosfomycin: Susceptible

Her regimen was subsequently changed to intravenous ertapenem. Today (hospital day 4), the patient is afebrile, her flank pain has resolved, and her leukocyte count has normalized to $8,500\text{/mm}^3$. She is tolerating a regular diet and is eager to be discharged.

Which of the following is the most appropriate antimicrobial regimen for discharge?

Match each patient's clinical presentation and laboratory coagulation profile to the most likely underlying hemostatic disorder.

An otherwise healthy 24-year-old university student presents to the student health center reporting discomfort when urinating. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 118/76 mmHg, and a heart rate of 78/min. She reports that she has been urinating more frequently than usual over the past 48 hours. She has not experienced any fevers, chills, nausea, back pain, or abnormal vaginal discharge. An abdominal examination demonstrates mild tenderness located just above the pubic symphysis, but there is no pain elicited upon percussion of the costovertebral angles bilaterally. A clean-catch urine specimen is analyzed and demonstrates positive results for both leukocyte esterase and nitrites. Which of the following is the most appropriate empiric pharmacotherapy for this patient?

A 26-year-old man comes to the clinic due to a 4-day history of right knee pain and swelling, as well as pain at the back of his left heel. He reports that the knee feels stiff in the morning and improves slightly as he moves around during the day. Four weeks ago, he experienced a brief episode of watery diarrhea, abdominal cramps, and a low-grade fever that resolved spontaneously after 3 days. He has no other medical conditions and takes no medications. He is sexually active with a new female partner and uses condoms inconsistently. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, and pulse is $82/\text{min}$. Physical examination shows a swollen, warm, and tender right knee with a palpable effusion. There is also pronounced tenderness over the insertion of the left Achilles tendon. Arthrocentesis of the right knee yields yellow, slightly cloudy synovial fluid with a leukocyte count of $22,000/\text{mm}^3$ ($75\%$ neutrophils). Gram stain shows no organisms, and polarized light microscopy reveals no crystals. Which of the following is the most appropriate next step in management?

A mother brings her 15-month-old son to the pediatric office for a scheduled health maintenance visit. She expresses concern regarding his speech, noting he only uses four distinct words regularly. Observations in the clinic show the child walking independently, stacking three blocks, and pointing to objects he desires. He follows a simple command to 'give me the ball'. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$) and physical examination is entirely normal. He had a mild viral rhinitis one week ago, but his symptoms have fully resolved. The mother asks about the appropriateness of giving him his scheduled immunizations today given his recent cold and speech development. Which of the following is the most appropriate action?

A $6$-month-old boy is brought to the pediatric clinic by his parents for evaluation of chronic noisy breathing. The parents report the noise started around $2$ months of age and has progressively worsened. It is described as a harsh, high-pitched sound heard during both inspiration and expiration. The parents also report that he frequently regurgitates his formula and has been resisting the recent introduction of pureed solid foods, often coughing when swallowing. They note that the infant's breathing seems to improve when he sleeps with his neck hyper-extended. He is at the $15$ th percentile for weight and $50$ th percentile for length. Vital signs are within normal limits for age. Physical examination reveals a prominent biphasic stridor that does not improve with the administration of nebulized racemic epinephrine. Which of the following is the most likely underlying mechanism of this patient's condition?

A 24-year-old man comes to the clinic with fever, myalgias, and a rash 14 days after high-risk sexual exposure. Acute human immunodeficiency virus (HIV) infection is suspected. Arrange the following steps of the HIV diagnostic and initial management algorithm in the correct chronological sequence, assuming each diagnostic test yields a result consistent with acute HIV infection.

A 35-year-old woman with a history of limited cutaneous systemic sclerosis presents to the clinic complaining of worsening pain and episodic color changes in her fingers. When she is exposed to cold air, her digits turn distinctly white, then blue, and eventually red. She is currently not taking any medications for this specific symptom but wants to know how her condition will be managed if it continues to progress. Arrange the following interventions in the standard step-wise escalating sequence for the management of secondary Raynaud phenomenon, from initial conservative management to treatments reserved for severe, refractory digital ischemia.