Tüm alıştırma soruları

An evaluation is requested for a 32-year-old woman who reports a 6-month history of profound fatigue, abdominal bloating, and loose, malodorous stools. Initial workup reveals a microcytic anemia with a hemoglobin level of $10.2 \text{ g/dL}$, and serologic testing is markedly positive for IgA anti-tissue transglutaminase antibodies. The patient subsequently undergoes an esophagogastroduodenoscopy with mucosal sampling of the distal duodenum. Which of the following histopathologic features are expected to be present on microscopic examination of this patient's biopsy specimens? (Select all that apply)

Match each of the following synoptic pathology descriptions and immunohistochemical profiles from lymph node or bone marrow biopsies to the most appropriate definitive hematolymphoid diagnosis.

A 45-year-old woman is evaluated for progressive weight gain, proximal muscle weakness, and easy bruising. Physical examination reveals facial plethora, supraclavicular fat pads, and wide, purplish abdominal striae. A 24-hour urine free cortisol test and a low-dose dexamethasone suppression test both confirm the presence of endogenous hypercortisolism. Her plasma adrenocorticotropic hormone (ACTH) level is 145 pg/mL (normal: 10-60 pg/mL), establishing a diagnosis of ACTH-dependent Cushing syndrome.

Assuming that each consecutive test in the localization workup yields an equivocal or non-diagnostic result, arrange the following radiologic and imaging procedures in the most appropriate chronological sequence according to current evidence-based guidelines.

A multidisciplinary sarcoma tumor board is reviewing the pathology of several young adult patients presenting with deep soft tissue and bone masses. To establish the definitive diagnosis and guide neoadjuvant therapy, the pathologist correlates the microscopic morphology and immunohistochemical (IHC) profiles with their defining molecular signatures. Match the following complex histopathologic and immunohistochemical biopsy descriptions with their corresponding definitive diagnoses and characteristic chromosomal translocations.

A 48-year-old man presents to the primary care clinic reporting that his wedding ring no longer fits and his shoe size has increased significantly over the past two years. He also notes excessive sweating and a recent onset of heavy snoring. Physical examination reveals coarse facial features, macroglossia, a prominent jaw, and enlarged, doughy hands. The physician strongly suspects an excess of growth hormone. Arrange the following diagnostic steps in the most appropriate sequential order for the workup of this patient's condition, from the initial screening test to final anatomic localization.

A 65-year-old woman is brought to the emergency department after experiencing a first-time generalized tonic-clonic seizure. Her husband reports she has had progressive right-sided weakness and early morning headaches for the past four weeks. Her medical history is significant for a 40-pack-year smoking history. Upon arrival, she is postictal but independently protecting her airway. Vital signs are within normal limits. Neurological examination reveals a subtle right-sided hemiparesis. Routine laboratory studies, including a basic metabolic panel, reveal a serum creatinine of 0.8 mg/dL. She has no known drug allergies and no implanted medical devices.

Arrange the following diagnostic and procedural steps in the most appropriate chronological order for the evaluation and staging of this patient's suspected condition.

A 62-year-old man comes to the emergency department complaining of sudden, severe abdominal pain that began 2 hours ago. His past medical history is significant for osteoarthritis, for which he takes ibuprofen daily. His temperature is 37.8°C (100.0°F), blood pressure is 105/65 mm Hg, and pulse is 112/min. Physical examination shows a rigid, board-like abdomen with diffuse guarding and rebound tenderness. An upright chest radiograph reveals a thin crescent of radiolucent gas between the right hemidiaphragm and the liver. Based on the interpretation of this imaging finding, which of the following is the most appropriate next step in management?

Emergency medical services bring a 19-year-old male to the emergency department after he was involved in a high-speed motorcycle collision. The patient is restless, diaphoretic, and gasping for air. Vital signs show a blood pressure of 76/40 mm Hg, heart rate of 142/min, and respiratory rate of 34/min. Pulse oximetry indicates 82% on room air. Physical examination demonstrates significant bruising over the right hemithorax, markedly decreased breath sounds on the right side, and engorged jugular veins. The trachea appears shifted toward the left side of the neck. Which of the following is the most appropriate next step in the management of this patient?

Match each classic clinical vignette with the most appropriate initial imaging modality to order.

A 62-year-old man with a 35-pack-year smoking history is found to have an incidental 12-mm solitary, non-calcified pulmonary nodule in the right upper lobe on a routine preoperative chest radiograph. He has no previous chest imaging available in the electronic health record for comparison. Arrange the following diagnostic and interventional modalities in the most appropriate, evidence-based sequential order for the evaluation of this patient. Assume each step yields suspicious but non-definitive findings, requiring progression to the next step in the clinical algorithm.

A 28-year-old male is transported to the trauma center after a high-speed motorcycle collision without a helmet. On arrival, he is unresponsive and has pulsatile, bright red blood spurting from a deep right mid-thigh laceration. He is making gurgling respiratory sounds with copious blood in the oropharynx. His respiratory rate is 32/min, heart rate is 145/min, and blood pressure is 68/38 mm Hg. The trachea is deviated to the left, and breath sounds are absent on the right side of the chest. Arrange the following initial stabilization and triage steps in the correct sequential order according to current advanced trauma life support protocols.

During an evaluation for a persistently enlarged right cervical mass, a 62-year-old woman undergoes an excisional lymph node biopsy. She first noticed the swelling four months ago and reports it has been completely painless. Review of systems is notable for the absence of fevers, night sweats, and weight loss. Physical examination confirms a 3.5-cm, rubbery, mobile lymph node in the anterior cervical chain with no other palpable adenopathy or organomegaly. The surgical pathology report details a completely effaced nodal architecture replaced by closely packed, variably sized nodules without distinct mantle zones. High-power microscopic examination of these nodules reveals a mixture of centrocytes and centroblasts, with a notable absence of tangible-body macrophages. Immunohistochemical staining of the atypical cells demonstrates strong positivity for CD20, CD10, and BCL-2, while staining for CD5 and cyclin D1 is negative. Based on the integration of this patient's clinical presentation and histopathologic findings, which of the following is the most likely diagnosis?

A 59-year-old woman is evaluated in the emergency department for severe, colicky left flank pain radiating to the left groin. Her medical history is notable for essential hypertension, for which she takes amlodipine. Her blood pressure is 144/88 mmHg, pulse is 86/min, and temperature is 37.0°C (98.6°F). Laboratory studies show a serum potassium of 4.2 mEq/L and an otherwise normal basic metabolic panel.

A non-contrast CT scan of the abdomen and pelvis demonstrates a 4-mm radiopaque calculus in the left distal ureter. Incidentally, the radiologist notes a 3.2-cm, well-circumscribed, homogeneous mass in the right adrenal gland. The mass has an unenhanced attenuation value of 8 Hounsfield units (HU). The patient's pain is well controlled with intravenous ketorolac, and she is tolerating oral hydration.

Regarding the incidental adrenal finding, which of the following is the most appropriate next step in management?

A 64-year-old woman comes to the clinic for follow-up after an incidental finding on a recent imaging study. Three weeks ago, she presented to the emergency department with a 1-day history of left flank pain and gross hematuria. A non-contrast CT scan of the abdomen and pelvis at that time demonstrated a 4-mm obstructing calculus in the left distal ureter, which she passed spontaneously. The patient currently has no abdominal pain, nausea, vomiting, or weight loss. Her past medical history is unremarkable, and she takes no medications. She does not use tobacco or consume alcohol. Physical examination shows a soft, non-tender abdomen with no palpable masses.

Laboratory studies from today are as follows:

Hemoglobin: 13.8 g/dL
Leukocyte count: 6,500/mm³
Platelet count: 250,000/mm³
Aspartate aminotransferase (AST): 22 U/L
Alanine aminotransferase (ALT): 25 U/L
Alkaline phosphatase: 138 U/L (Normal: 40-120 U/L)
Total bilirubin: 0.8 mg/dL
Lipase: 35 U/L

Review of the emergency department CT scan reveals an incidental 3.8-cm cystic lesion in the body of the pancreas. A dedicated multiphasic, contrast-enhanced abdominal MRI is performed to further characterize the lesion. The MRI demonstrates a well-circumscribed, multilocular cystic mass consisting of numerous small cysts, each measuring less than 1 cm in diameter, creating a "honeycomb" appearance. A prominent central, star-shaped fibrotic scar with central calcification is also visualized. The main pancreatic duct is not dilated, and there is no visible communication between the cysts and the ductal system.

Based on the interpretation of these specific imaging findings, which of the following is the most appropriate next step in management?

Match each clinical presentation of acute or subacute pulmonary disease with the most likely predominant pattern seen on high-resolution computed tomography (HRCT) of the chest.

A 42-year-old woman presents to the clinic with a 6-month history of progressive fatigue and severe, generalized pruritus. She has no significant past medical history and takes no over-the-counter or prescription medications. On physical examination, there is mild hepatomegaly and scattered excoriations on her extremities. Laboratory studies reveal:

Total bilirubin: 1.1 mg/dL
Alkaline phosphatase: 520 U/L
Aspartate aminotransferase (AST): 58 U/L
Alanine aminotransferase (ALT): 64 U/L
Antimitochondrial antibody (AMA): Negative
Antinuclear antibody (ANA): Positive (1:640)
Anti-smooth muscle antibody (ASMA): Positive (1:160)

Given the cholestatic enzyme pattern with complex serologies, a percutaneous liver biopsy is obtained. The pathology report describes portal tracts expanded by a dense mononuclear infiltrate predominantly composed of lymphocytes. There is asymmetric, non-suppurative destruction of interlobular septal bile ducts accompanied by occasional poorly formed granulomas. The limiting plate remains largely intact, and there is no significant interface hepatitis or lobular necroinflammation. Based on the biopsy findings and clinical presentation, which of the following is the most likely diagnosis?

Match each patient's clinical presentation with the most appropriate next step in diagnostic imaging.

Paramedics arrive at the emergency department with a 58-year-old woman experiencing an acute episode of massive pulmonary hemorrhage. Over the past hour, she has coughed up roughly $500 \text{ mL}$ of bright red blood. Her past medical history includes a severe case of pulmonary tuberculosis treated a decade ago, leaving her with residual right upper lobe cavitations.

During the ambulance ride, the patient remained awake but developed severe agitation and rapid breathing. Upon arrival in the resuscitation bay, she is in frank respiratory failure, actively expectorating blood into a basin, and unable to complete full sentences due to continuous coughing and respiratory distress. She is visibly diaphoretic and utilizing accessory respiratory muscles.

Her initial vital signs are:
Temperature: $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$)
Blood pressure: $86/54 \text{ mmHg}$
Heart rate: $138 \text{ /min}$
Respiratory rate: $38 \text{ /min}$
Oxygen saturation: $82\%$ on a high-flow non-rebreather mask

Chest auscultation demonstrates coarse gurgling and prominent rhonchi isolated to the right hemithorax, with diminished but relatively clear breath sounds on the left.

Which of the following represents the single most urgent initial step in the stabilization of this patient?

A 19-year-old male is brought to the emergency department by ambulance after diving headfirst into a shallow swimming pool. On arrival, he is conscious but extremely anxious and speaking in one-word sentences. He reports an inability to move or feel his arms and legs. His respiratory effort is weak, with shallow, paradoxical abdominal breathing. Vital signs show a temperature of 36.5°C (97.7°F), blood pressure of 72/40 mmHg, heart rate of 52/min, and respiratory rate of 28/min with an oxygen saturation of 88% on room air. Arrange the following management steps in the most appropriate sequential order for the initial stabilization and triage of this patient.

A 35-year-old man comes to the emergency department due to a 1-week history of fever, severe fatigue, chills, and diffuse arthralgias. He has a history of intravenous drug use, with his last use being 3 days ago. He also reports noticing painful, raised, red nodules on the pads of his fingers yesterday. His temperature is 38.9°C (102.0°F), blood pressure is 112/68 mmHg, heart rate is 118/min, and respiratory rate is 18/min. Physical examination reveals a new 3/6 blowing holosystolic murmur heard loudest at the cardiac apex with radiation to the left axilla. There are painless, erythematous macules on the palms of both hands. Splenomegaly is appreciated on abdominal palpation. Which of the following are the most appropriate initial diagnostic studies to order for this patient? (Select exactly 2)