Tüm alıştırma soruları

A 46-year-old woman, G1P1, presents to the clinic with a 4-week history of heavy, erratic vaginal bleeding. Her previous menstrual cycles were unpredictable, occurring every 2 to 6 months. She has a history of type 2 diabetes mellitus and obesity. She also notes severe fatigue and cold intolerance over the past several months. Her BMI is $42 \text{ kg/m}^2$. Vital signs show a blood pressure of $135/85 \text{ mm Hg}$ and a heart rate of $62/\text{min}$. Pelvic examination reveals a normal-appearing cervix with dark blood in the vaginal vault, and no palpable adnexal masses. A urine beta-hCG test is negative.

Initial laboratory studies show:
Hemoglobin: $9.8 \text{ g/dL}$
Thyroid-stimulating hormone (TSH): $0.8 \text{ mU/L}$ (Normal: $0.5-5.0 \text{ mU/L}$)
Free thyroxine (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?

A hospitalist is caring for a patient admitted with severe, symptomatic hyponatremia. During a break in the hospital cafeteria, the hospitalist encounters a nephrologist colleague. The hospitalist outlines the clinical scenario and laboratory findings without disclosing the patient's name, date of birth, or room number. The hospitalist asks for general advice regarding fluid management. Based on the brief description, the nephrologist recommends a specific infusion rate of hypertonic saline. The hospitalist agrees and formally enters the order into the electronic medical record. Over the next 48 hours, the sodium level corrects too rapidly, and the patient suffers permanent neurologic deficits consistent with osmotic demyelination syndrome. The patient subsequently files a medical negligence lawsuit naming both the hospitalist and the nephrologist as defendants. Based on legal precedents governing medical malpractice, which of the following is the most likely outcome regarding the nephrologist in this litigation?

Match each classic clinical presentation and associated radiographic or sonographic finding with the most appropriate pediatric gastrointestinal diagnosis.

A 32-year-old woman with well-controlled type 2 diabetes mellitus presents to the clinic reporting her fifth episode of thick, white vaginal discharge and severe vulvar pruritus in the past 11 months. Previous episodes were treated empirically with short courses of over-the-counter topical miconazole with only temporary relief. Arrange the following clinical steps in the correct chronological sequence for the definitive, guideline-concordant management of this patient's recurrent vulvovaginal candidiasis.

An $8$-month-old male infant is currently hospitalized for severe viral bronchiolitis. For the past $24$ hours, he has been supported with a heated humidified high-flow nasal cannula to manage his respiratory distress. The on-call physician is urgently summoned to the bedside after the patient's respiratory status abruptly declines. On evaluation, the infant is lethargic and profoundly cyanotic. Current vital signs indicate a heart rate of $190/\text{min}$, a respiratory rate of $72/\text{min}$, and an oxygen saturation of $78\%$ despite maximal supplemental oxygen delivery. Clinical assessment reveals severe generalized retractions. Percussion of the chest yields a hyperresonant note over the right chest cavity, alongside a complete lack of breath sounds in the same area. The cardiac point of maximal impulse is palpated in the left axilla. Which of the following is the most appropriate immediate action for this patient?

A 27-year-old primigravida at 40 weeks gestation is undergoing induction of labor for oligohydramnios. She is currently receiving a continuous oxytocin drip and has a functioning epidural block. Her blood pressure is 118/76 mm Hg, pulse is 88/min, and temperature is 37.2°C (99.0°F). A cervical examination shows 5 cm dilation, 90% effacement, and -1 station. The fetal monitor records 7 uterine contractions per 10-minute window. The fetal heart rate baseline is 135/min with minimal variability and recurrent late decelerations. The oxytocin drip is immediately stopped, the patient is repositioned to her left side, and an intravenous fluid bolus is administered. Fifteen minutes later, the contraction frequency remains 7 per 10-minute window, and the fetal heart rate tracing is unchanged. Which of the following is the most appropriate next step in management?

Match each clinical presentation to the most appropriate diagnosis regarding hypertensive disorders of pregnancy.

An emergency medical team evaluates a $22$-day-old male neonate who was rushed to the hospital after developing forceful, green-tinged emesis. His parents note that he became suddenly lethargic and irritable this morning. Previously, the infant had been breastfeeding adequately and gaining weight appropriately. Vital signs reveal significant tachycardia at $190$/min, tachypnea at $58$/min, and profound hypotension ($58/34$ mm Hg). The patient appears pale, mottled, and diaphoretic. Palpation of the abdomen elicits diffuse rigidity and involuntary guarding, with visually apparent distension. Digital rectal examination yields normal-appearing stool with no gross blood. Venous blood analysis demonstrates a pH of $7.21$, bicarbonate of $12$ mEq/L, and a lactate level of $7.1$ mmol/L. A plain radiograph of the abdomen demonstrates a gasless abdomen with a single prominent gastric bubble. Which of the following is the most appropriate next step in the management of this patient?

During a routine health maintenance visit, the parents of a $4$-year-old girl inquire about her eligibility for required preschool immunizations. The patient was diagnosed with standard-risk acute lymphoblastic leukemia (ALL) two years ago. She successfully completed induction and consolidation therapy and is currently in the maintenance phase of her treatment, taking daily oral mercaptopurine and weekly oral methotrexate. She has been feeling well, with no recent fevers, weight loss, or respiratory symptoms. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $95/60\text{ mmHg}$, and heart rate is $90/\text{min}$. Physical examination reveals a well-appearing, active child with no lymphadenopathy or hepatosplenomegaly.

Laboratory evaluation shows:
Hemoglobin: $11.5\text{ g/dL}$
Leukocyte count: $4,500/\mu\text{L}$
Absolute neutrophil count: $1,800/\mu\text{L}$
Platelet count: $250,000/\mu\text{L}$

A review of her immunization record indicates that she received all scheduled vaccines during her first year of life but has not yet received her $4$- to $6$-year booster series, which includes the diphtheria, tetanus, and acellular pertussis (DTaP), inactivated poliovirus (IPV), measles, mumps, and rubella (MMR), and varicella vaccines.

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

Match each pediatric patient's clinical and laboratory presentation to the most likely hematologic or oncologic diagnosis.

Match each clinical presentation of postpartum febrile morbidity to its most likely underlying diagnosis based on the timing and specific physical exam findings.

Match each clinical presentation and characteristic biomarker profile with the most likely specific gynecologic malignancy.

A 72-year-old man with a history of IgG kappa multiple myeloma, chronic obstructive pulmonary disease (COPD), and heart failure with preserved ejection fraction is admitted for symptomatic anemia. His hemoglobin is 6.8 g/dL, and a transfusion of packed red blood cells is initiated. Two hours later, he develops acute-onset respiratory distress. The transfusion is immediately stopped.

Vital signs are temperature 37.1°C (98.8°F), blood pressure 175/95 mm Hg, pulse 115/min, and respirations 28/min. Pulse oximetry is 85% on room air. Physical examination shows an anxious patient in moderate respiratory distress with prominent jugular venous distension. Chest auscultation reveals bilateral basilar crackles, diffuse end-expiratory wheezing, and a third heart sound (S3).

Laboratory studies from admission show:

A urine culture obtained at admission for routine screening grew >100,000 CFU/mL of *Escherichia coli* that is sensitive to all tested antibiotics, including amoxicillin and cephalexin. The patient denies dysuria.

The patient's daughter, who holds a valid healthcare proxy and previously confirmed the patient's wish for full medical interventions, is en route to the hospital. The patient's estranged son is currently at the bedside and demands that the team withhold all respiratory and fluid management to transition the patient immediately to comfort care.

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

Match each patient's clinical profile with the most appropriate contraceptive method based on the World Health Organization Medical Eligibility Criteria (WHO MEC) and specific non-contraceptive benefits.

A $31$-year-old woman, gravida $2$, para $1$, at $26$ weeks gestation is evaluated in the clinic for right-sided flank discomfort that began $5$ days ago. The pain is described as a dull, constant ache and is not exacerbated by movement. She denies dysuria, hematuria, fever, chills, or vaginal bleeding. Fetal movement is active. Her prior pregnancy was uncomplicated. Temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $112/72\text{ mm Hg}$, and pulse is $82/\text{min}$. Physical examination shows a gravid uterus consistent with gestational age. There is mild right costovertebral angle tenderness, but no abdominal guarding or rebound. Urinalysis reveals no leukocytes, nitrites, or erythrocytes. A right upper quadrant and renal ultrasound demonstrates mild dilation of the right renal pelvis and proximal ureter without evidence of shadowing calculi. The left kidney and ureter are unremarkable. Which of the following is the most appropriate next step in management of this patient?

A 39-year-old woman comes to the clinic reporting heavy, irregular vaginal bleeding for the past 6 months. Prior to the onset of this bleeding, she had not menstruated for 9 months. Menarche was at age 12, and her menses have historically occurred only 3 to 4 times per year. She has a history of severe facial acne and hirsutism. Her medical history is otherwise unremarkable, and she does not take any medications. Her BMI is $42 \text{ kg/m}^2$. Vital signs are within normal limits. Pelvic examination demonstrates normal external genitalia and a normal-appearing cervix. Bimanual examination reveals a normal-sized, mobile uterus and no adnexal masses. A urine pregnancy test is negative. Which of the following is the most appropriate next step in management?

A 28-year-old woman, gravida 3, para 2, at 36 weeks gestation is brought to the emergency department via ambulance following a severe motor vehicle collision. She complains of intense, unremitting abdominal pain and moderate dark red vaginal bleeding. Her temperature is 36.8°C (98.2°F), blood pressure is 88/54 mm Hg, pulse is 126/min, and respirations are 24/min. Physical examination reveals a rigid, exquisitely tender uterus with no palpable relaxation between contractions. Continuous fetal monitoring demonstrates a baseline of 175/min with absent variability and recurrent late decelerations. Initial laboratory evaluation reveals a hemoglobin level of 7.8 g/dL, a platelet count of 65,000/mm³, and an elevated international normalized ratio (INR). During the initial assessment, the nursing staff notes continuous, non-clotting blood oozing from the patient's peripheral intravenous catheter sites. Which of the following is the most appropriate next step in the management of this patient?

A 31-year-old female presents to the physician reporting a lack of menstrual periods for the past 5 months. Prior to this, her menses occurred regularly every 29 to 32 days. Over the same 5-month period, she has noticed rapid growth of thick hair on her chin and chest, a noticeable deepening of her voice, and an increase in muscle mass. She has no significant past medical history and takes no medications. Her vital signs include a blood pressure of $122/76$ mm Hg, heart rate of $74$/min, and respiratory rate of $14$/min. Her BMI is $22 \text{ kg/m}^2$. Physical examination reveals temporal hair thinning, coarse terminal hairs on the face and sternum, and significant clitoral enlargement. A point-of-care urine pregnancy test is negative. Which of the following is the most appropriate next step in the diagnosis of this patient?

Match each prenatal screening test or prophylactic intervention with its appropriate clinical indication and temporal timing during an uncomplicated pregnancy.

A 34-year-old gravida 2, para 2 woman comes to the office for a routine wellness examination. She has no current medical conditions and takes no daily medications. Her only form of contraception is a copper intrauterine device, which was placed three years ago. The patient reports normal, regular menstrual cycles and denies any vaginal discharge, pelvic pain, or dyspareunia. Vital signs are within normal limits. Pelvic examination reveals normal external genitalia and a healthy-appearing cervix. The intrauterine device strings are visible at the external cervical os. Bimanual examination shows a non-tender, anteverted uterus with no adnexal masses. A Papanicolaou test is performed. One week later, the cytology report indicates negative for intraepithelial lesion or malignancy, but notes the presence of Actinomyces-like organisms. Which of the following is the most appropriate next step in management?