Tüm alıştırma soruları

A 65-year-old woman comes to the clinic for a routine wellness visit. During the interview, she mentions that over the past two months, she has noticed occasional blood stains on her underwear. She attributed this to 'fragile skin' since she was recently diagnosed with vulvar lichen sclerosus and uses a prescribed topical corticosteroid ointment. Her last menstrual period was 14 years ago. She has a history of type 2 diabetes mellitus and hypertension. Her medications include metformin, lisinopril, and the topical steroid. Pelvic examination reveals white, parchment-like changes on the vulvar skin and a small anal fissure, but no active bleeding. Speculum examination demonstrates a normal-appearing cervix and vaginal vault without visible lesions. Bimanual examination is unremarkable. Transvaginal ultrasound shows a homogeneous endometrial echo complex of $9 \text{ mm}$. Which of the following is the most appropriate next step in management?

A 9-month-old male infant is brought to the pediatric clinic by his parents due to severe, chronic constipation and poor weight gain. The parents report that he has a bowel movement only once every 5 to 6 days, often requiring significant straining, and his abdomen frequently appears noticeably swollen. He was born at 39 weeks gestation and passed his first meconium at 50 hours of life. His diet consists of breast milk and age-appropriate pureed solids. His weight has fallen from the 45th percentile at birth to the 10th percentile currently. Vital signs are within normal limits for age. Physical examination reveals a distended, tympanitic abdomen. Upon digital rectal examination, there is increased anal sphincter tone and an empty rectal vault; withdrawal of the examining finger is immediately followed by an explosive expulsion of foul-smelling liquid stool and gas. Which of the following is the most accurate test to confirm the diagnosis in this patient?

A 23-year-old woman is contacted by her physician regarding laboratory results. She was evaluated at the student health center two days ago for a one-week history of increased, yellow-tinged vaginal discharge and spotting after intercourse. At that visit, a pelvic examination revealed a friable cervix with mucopurulent exudate, but no cervical motion, uterine, or adnexal tenderness. A vaginal wet mount showed numerous leukocytes but no clue cells, motile trichomonads, or yeast. Nucleic acid amplification testing (NAAT) of an endocervical swab was sent. The results are now available and are positive for *Neisseria gonorrhoeae* and negative for *Chlamydia trachomatis*. The patient has no known drug allergies. Which of the following is the most appropriate pharmacologic intervention for this patient?

A $26$-year-old nulliparous woman comes to the clinic to discuss contraceptive options. She and her partner are sexually active and wish to avoid pregnancy for at least the next $3$ years. Her menstrual periods occur every $28$ days, last for $7$ to $8$ days, and are associated with heavy bleeding that requires changing a super-absorbent pad every $2$ hours on her heaviest days. Her past medical history is significant for episodic headaches that occur approximately once a month. These headaches are characteristically preceded by bilateral flashing lights and zig-zag lines, followed by throbbing unilateral head pain. She takes sumatriptan as needed with good relief. Her blood pressure is $118/76\text{ mmHg}$, heart rate is $72\text{/min}$, and body mass index is $24\text{ kg/m}^2$. A urine beta-hCG test is negative. Pelvic examination is unremarkable. Which of the following is the most appropriate contraceptive recommendation for this patient?

An asymptomatic patient at $10$ weeks gestation presents for her first prenatal visit. She reports mild nausea and breast tenderness over the past three weeks but no other symptoms. Her family history is significant for maternal Hashimoto thyroiditis, prompting the physician to order a baseline thyroid function panel. Physical examination reveals a normal-appearing, non-tender thyroid gland without palpable nodules. Vital signs show a heart rate of $82/\text{min}$ and blood pressure of $110/70\text{ mm Hg}$.

Laboratory studies reveal the following:
Thyroid-stimulating hormone (TSH): $0.1\text{ \mu U/mL}$ (reference: $0.4-4.0\text{ \mu U/mL}$)
Total thyroxine (Total T4): $14.2\text{ \mu g/dL}$ (reference: $5.0-12.0\text{ \mu g/dL}$)
Free thyroxine (Free T4): $1.4\text{ ng/dL}$ (reference: $0.8-1.8\text{ ng/dL}$)

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

Match each pharmacologic agent used in the treatment of substance use disorders with its corresponding mechanism of action, clinical profile, or key contraindication.

A 24-year-old primigravida at 40 weeks and 3 days gestation is evaluated in the labor and delivery ward. She was admitted in spontaneous active labor 8 hours ago. Her temperature is 37.1°C (98.8°F), blood pressure is 118/74 mm Hg, and pulse is 82/min. The estimated fetal weight is 3300 g. A cervical examination shows 8 cm dilation, 100% effacement, and +1 station. Artificial rupture of membranes was performed 4 hours ago and revealed clear fluid. Uterine contractions are occurring every 2 to 3 minutes. Continuous fetal monitoring demonstrates a baseline heart rate of 145/min with moderate variability. During the last 45 minutes, the fetal heart rate has repeatedly shown abrupt decreases to 85/min that last for 40 to 60 seconds and occur with most contractions. The patient has been repositioned to the left lateral decubitus position, and an intravenous fluid bolus has been completed, but the decelerations persist. Which of the following is the most appropriate next step in management?

A $2$-year-old boy with sickle cell disease (HbSS) is brought to the emergency department by his parents due to profound weakness and a rapidly enlarging abdomen over the past $6$ hours. He has been unusually sleepy and difficult to arouse. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), heart rate is $168/\text{min}$, blood pressure is $70/40\text{ mm Hg}$, and respiratory rate is $32/\text{min}$. Physical examination reveals marked conjunctival pallor. His abdomen is distended, firm, and diffusely tender. The spleen edge is palpable $6\text{ cm}$ below the left costal margin, which is a new finding compared to his baseline. Capillary refill time is $4$ seconds. Laboratory studies reveal:

Hemoglobin: $4.2\text{ g/dL}$ (baseline $8.5\text{ g/dL}$)
Reticulocytes: $14\%$
Platelets: $75,000/\text{mm}^3$
Leukocytes: $12,500/\text{mm}^3$

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

An 8-month-old girl arrives at the local emergency department because of progressive breathing difficulty and decreased oral intake over the last two days. Her illness began earlier in the week with clear nasal discharge and a mild cough. She was born at 39 weeks gestation without perinatal complications. Vital signs currently show a temperature of 38.0°C (100.4°F), heart rate of 148/min, respiratory rate of 62/min, and oxygen saturation of 89% on ambient air. Physical assessment demonstrates prominent nasal flaring, suprasternal retractions, and bilateral fine crackles accompanied by diffuse expiratory wheezing. Capillary refill time is 3 seconds, and the oral mucosa appears dry. According to current evidence-based guidelines for this condition, which of the following interventions are appropriate for this patient? (Select all that apply)

Match each patient's clinical presentation of biopsy-proven cervical carcinoma with the most appropriate primary management strategy.

A $36$-year-old nulligravid woman with a history of polycystic ovary syndrome (PCOS) and obesity (body mass index $41$) presents with frequent, heavy menstrual bleeding occurring every $14$ to $60$ days. She has not responded to an initial trial of combined oral contraceptives. The patient explicitly states a strong desire to have children in the near future.

Arrange the following steps in the most appropriate chronological sequence for the diagnosis, definitive management, and long-term follow-up of this patient.

A 48-hour-old full-term neonate is evaluated in the neonatal intensive care unit for failure to pass meconium since birth. Over the past six hours, the infant has developed progressive abdominal distension and just had an episode of dark green vomiting. Vital signs show a heart rate of 158/min, respiratory rate of 48/min, temperature of 37.1°C (98.8°F), and blood pressure of 65/42 mmHg. Physical examination reveals a tensely distended, tympanitic abdomen with hypoactive bowel sounds, but no abdominal wall erythema or rigidity. Digital rectal examination reveals normal anal tone and an empty rectal vault with no stool expulsion upon withdrawal of the finger. Arrange the following steps in the most appropriate sequence for the evaluation and management of this patient.

A $28$-year-old woman, G1P1, presents to the gynecology clinic reporting an absence of menstrual periods for the past $8$ months. She delivered a healthy infant vaginally $10$ months ago. Her immediate postpartum course was complicated by severe hemorrhage that required emergent dilation and curettage. She formula-feeds her infant and has not experienced any galactorrhea, weight changes, hot flashes, or temperature intolerance. Vital signs are within normal limits. Pelvic examination shows a normal-appearing vagina and cervix with no adnexal masses. Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's secondary amenorrhea.

For each patient presenting with vaginal or cervical symptoms, select the most appropriate management plan regarding antimicrobial therapy and sexual partner evaluation.

A 4-week-old male infant is brought to the pediatric clinic by his parents for persistent jaundice. He was born at 39 weeks gestation via an uncomplicated vaginal delivery and has been exclusively breastfed. His parents note that over the past two weeks, his stools have become pale and clay-colored, and his urine stains the diaper dark yellow. He is feeding well and gaining weight appropriately. Vital signs are within normal limits for age. Physical examination reveals scleral icterus, jaundice, and a soft, non-distended abdomen with a liver edge palpable 3 cm below the right costal margin. Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for the evaluation and management of this patient's most likely condition.

Match each standard prenatal screening test or intervention with the gestational age window during which it is universally indicated for an average-risk, uncomplicated pregnancy.

During a routine prenatal visit, a 30-year-old woman at 34 weeks gestation reports experiencing episodes of lightheadedness, nausea, and a feeling of impending fainting over the past two weeks. She states that these episodes occur exclusively when she is lying flat on her back. The symptoms resolve rapidly when she turns onto her side. Her pregnancy has been uncomplicated. Her blood pressure is 112/68 mm Hg and her heart rate is 85/min while seated in the clinic. Fetal heart monitoring shows a baseline rate of 145/min with moderate variability and no decelerations. Which of the following is the most likely underlying mechanism for this patient's symptoms?

A $6$-year-old boy is brought to the emergency department by his parents due to a new-onset fever and a mild cough that started earlier today. The patient was diagnosed with acute lymphoblastic leukemia (ALL) $4$ months ago and is currently receiving maintenance chemotherapy. His last chemotherapy cycle was $10$ days ago. His temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), pulse is $125/\text{min}$, respirations are $24/\text{min}$, and blood pressure is $95/60 \text{ mmHg}$. On physical examination, the child appears pale and mildly lethargic but is easily rousable. Lung auscultation is clear bilaterally without wheezing or crackles. There is a central venous port in the right upper chest with no surrounding erythema or induration.

Laboratory studies show:
Leukocyte count: $800/\mu\text{L}$
- Neutrophils: $15\%$
- Lymphocytes: $80\%$
- Monocytes: $5\%$
Hemoglobin: $9.2 \text{ g/dL}$
Platelet count: $85,000/\mu\text{L}$

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

A 33-year-old woman, gravida 2, para 1, is evaluated in the birthing center at 39 weeks of gestation. She is undergoing a trial of labor after a previous low transverse cesarean delivery. Her prenatal course was uncomplicated. She is currently in the active phase of the first stage of labor, with contractions previously occurring every 3 minutes. Suddenly, the patient reports a sharp, continuous, tearing lower abdominal pain that is distinctly different from her previous contraction pain. Continuous fetal monitoring shows a sudden, prolonged deceleration with a baseline drop to 75/min for the past 4 minutes, and uterine contractions have ceased on the tocodynamometer. A sterile vaginal examination reveals the cervix is 7 cm dilated, and the fetal presenting part, which was previously at 0 station, is no longer palpable. Maternal blood pressure is 90/50 mm Hg and heart rate is 120/min. Which of the following is the most appropriate next step in management?

A 5-year-old boy is rushed to the emergency department by his parents due to severe, sudden breathing difficulties that began earlier today. The family immigrated to the United States three weeks ago, and the child's vaccination records are unavailable. His parents note that he was completely healthy yesterday but developed a high fever and sore throat this morning. In the triage area, the child is noted to be highly anxious, leaning forward with his hands on his knees, and his chin thrust outward. He is continuously drooling and responds to questions with a quiet, muffled voice. Vital signs show a temperature of $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), heart rate of $148$/min, respiratory rate of $38$/min, and oxygen saturation of $94\%$ on room air. Marked suprasternal retractions are visible, and high-pitched inspiratory stridor is heard. Which of the following is the most appropriate next step in management?