Tüm alıştırma soruları

A 71-year-old multiparous woman is evaluated in the urogynecology clinic for a persistent vaginal bulge and pelvic pressure that has progressively worsened over the past year. She also reports a single episode of scant, bright red vaginal spotting three weeks ago, which she attributed to the bulge rubbing against her clothing. She went through menopause at age 52 and has not seen a physician in over a decade. Her medical history includes well-controlled hypertension. On physical examination, there is stage III pelvic organ prolapse with the cervix protruding past the hymenal ring. A 1.5-cm superficial, non-bleeding erosion is noted on the dependent portion of the prolapsed cervix. A transvaginal ultrasound reveals a homogeneous endometrial stripe of 8 mm and normal-appearing adnexa. Which of the following is the most appropriate next step in the management of this patient?

A 31-year-old man presents to the clinic to discuss starting medication for newly diagnosed major depressive disorder. He is prescribed escitalopram 10 mg daily. The physician provides psychoeducation regarding what to expect during the course of treatment. Arrange the following clinical events in the most likely chronological sequence of their typical onset or occurrence after initiating this selective serotonin reuptake inhibitor (SSRI).

A 48-hour-old female newborn is evaluated in the nursery for a new skin eruption. She was delivered vaginally at 40 weeks of gestation following an uncomplicated pregnancy. Maternal prenatal laboratory results, including a rectovaginal swab for group B Streptococcus, were negative. The patient's temperature is 37.0°C (98.6°F), heart rate is 140/min, and respiratory rate is 42/min. Physical examination reveals an alert, vigorous infant who is feeding adequately at the breast. Skin examination shows numerous 2-mm pale yellow pustules, each surrounded by a prominent, blotchy erythematous macular base. The lesions are scattered widely over the infant's trunk, face, and proximal arms, but the palms, soles, and mucous membranes are completely spared. Which of the following is the most appropriate next step in management for this patient?

During a severe winter outbreak, parents bring their 6-month-old male infant to the pediatric acute care center. The mother expresses concern that her son has been unusually lethargic and has refused his formula for the past 14 hours, resulting in a single mildly wet diaper. The illness began four days ago with clear nasal discharge and a mild cough. The mother notes she has a strong personal history of childhood asthma. Vital signs on presentation demonstrate a temperature of $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), a heart rate of $168\text{/min}$, a respiratory rate of $76\text{/min}$, and an oxygen saturation of $86\%$ while breathing room air. Examination shows a lethargic infant with prominent nasal flaring, grunting, and deep suprasternal retractions. Thoracic auscultation reveals diffuse, high-pitched expiratory wheezes and scattered inspiratory crackles. A chest radiograph demonstrates bilateral hyperinflation, peribronchial cuffing, and a small area of patchy atelectasis in the right upper lobe. Based on the most likely diagnosis, which of the following interventions are indicated for the initial management of this patient? (Select all that apply)

An emergency department physician is evaluating several patients presenting with acute psychiatric and physiologic changes related to substance use. Correlate each clinical vignette with the most appropriate diagnosis.

An otherwise healthy 39-year-old woman presents to the reproductive endocrinology clinic to discuss her difficulty becoming pregnant. For the last 10 months, she and her male partner have engaged in regular, unprotected coitus targeting her fertile window. Her menstrual cycles occur regularly every 24 to 25 days, with menses lasting 4 days. She notes that in her early twenties, her cycles were consistently 28 days long. She reports mild, intermittent facial acne that she has had since her teenage years, as well as occasional night sweats occurring a few days prior to the onset of her period. Medical and surgical history are unremarkable. She takes a daily prenatal vitamin. Vital signs are within normal limits, and her body mass index is $22 \text{ kg/m}^2$. Bimanual pelvic examination reveals a normal-sized, mobile uterus with no adnexal masses. Her partner's semen analysis shows normal volume, concentration, and motility. Initial laboratory testing on the third day of her menstrual cycle reveals the following:

Which of the following is the most likely primary underlying mechanism for this patient's difficulty conceiving?

Match each clinical presentation of a birth-related head injury or finding in a neonate to the most likely diagnosis.

During morning rounds, a 65-year-old woman is evaluated on postoperative day 4 following an elective right hemicolectomy for a large adenomatous polyp. Her medical history includes heart failure with preserved ejection fraction, type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD). An indwelling urinary catheter, placed prior to surgery, remains in situ to monitor urine output. Today, she reports feeling feverish and having mild chills but denies cough, shortness of breath, dysuria, or calf pain. Her temperature is 38.6°C (101.5°F), blood pressure is 132/80 mmHg, pulse is 104/min, and respirations are 16/min. Pulse oximetry is 96% on room air. Cardiopulmonary examination reveals distant breath sounds and scattered end-expiratory wheezes that are unchanged from her preoperative baseline. There is no jugular venous distention or peripheral edema. The abdomen is soft and mildly tender near the surgical site. The midline abdominal incision is clean, dry, and intact without surrounding erythema or drainage. Which of the following is the most appropriate next step in management?

A 61-year-old woman is evaluated for a 1-year history of sudden, overwhelming urges to urinate accompanied by frequent, large-volume urinary leakage. She has no neurologic deficits, and a recent urinalysis was unremarkable. Post-void residual volume is 25 mL. Evaluation confirms non-neurogenic urgency urinary incontinence. According to standard clinical guidelines, arrange the following therapeutic interventions in the correct escalating sequence, starting from the initial first-line approach to the treatment of last resort for severely refractory symptoms.

A 35-year-old woman is evaluated in the outpatient clinic due to a 4-month history of profound fatigue, a 6-kg (13-lb) weight loss, and generalized weakness. She also reports feeling lightheaded when standing up quickly. She has not had a menstrual period since giving birth 18 months ago. Her delivery was complicated by severe postpartum hemorrhage requiring intensive care admission and multiple blood transfusions. She was unable to breastfeed her infant. She occasionally has a mild, nonproductive cough but no fever or chills. She does not use tobacco.

Her temperature is 37.2°C (99.0°F), blood pressure is 92/58 mm Hg sitting and 78/48 mm Hg standing, pulse is 102/min, and respirations are 16/min. Physical examination shows pale skin with no abnormal hyperpigmentation, and notably sparse axillary and pubic hair. Lung fields are clear to auscultation, and there is no jugular venous distention or peripheral edema.

Laboratory studies show the following:

Based on the clinical presentation and laboratory findings, which of the following is the most appropriate next step in the management of this patient?

A 28-year-old man with a recent diagnosis of schizophrenia is started on a high-potency first-generation antipsychotic. He is monitored closely for adverse effects. Arrange the following antipsychotic-induced movement disorders in expected chronological order based on their typical timeline of onset, from earliest to latest.

During a routine well-child visit, the parents of a $5$-month-old boy report that he has become increasingly irritable over the past two weeks. The mother notes this is most pronounced in the early mornings, which coincides with him finally "sleeping through the night." She also reports he has been taking rapid, deep breaths during these fussy episodes. Additionally, he had a mild upper respiratory infection last week with rhinorrhea and diffuse wheezing; she requests a rescue inhaler, noting her older child has asthma. On examination, the infant has a "doll-like" facial appearance with prominent, rounded cheeks. His weight is at the $35$ th percentile and length is at the $20$ th percentile. He appropriately tracks objects, smiles socially, and rolls from front to back, but cannot sit unsupported. Abdominal examination reveals a massively enlarged, smooth liver palpable $6$ cm below the right costal margin.

Laboratory tests obtained after a $4$-hour fast reveal:

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

A 55-year-old man is evaluated in the surgical intensive care unit on postoperative day 3 following an extensive bowel resection. He just underwent right internal jugular central venous catheter placement for the administration of total parenteral nutrition. Ten minutes after the procedure, he develops sudden, severe dyspnea and right-sided chest pain. Vital signs show a temperature of 37.1°C (98.8°F), heart rate of 132/min, blood pressure of 85/50 mmHg, and oxygen saturation of 87% on room air. Physical examination reveals absent breath sounds on the right hemithorax and distended neck veins. Arrange the following steps in the most appropriate chronological sequence for the immediate management of this patient.

A 26-year-old woman is undergoing a suction dilation and curettage for a missed abortion. During the procedure, the physician notes a sudden loss of resistance while advancing the suction curette. Upon withdrawing the instrument, yellow, fatty tissue is seen within the cannula. The patient is under monitored anesthesia care. Her blood pressure is 105/65 mm Hg and heart rate is 102/min.

Arrange the following management steps in the most appropriate chronological sequence for this patient's acute complication.

A 22-year-old university student is evaluated in the psychiatry clinic accompanied by his mother. For the past 9 months, he has become increasingly isolated, claims that his professors are inserting thoughts into his mind, and frequently talks to unseen individuals in his room. His academic performance has significantly declined, leading to academic probation. The mother notes that 4 months ago, he experienced a 3-week period during which he felt profoundly sad, slept up to 16 hours a day, had markedly low energy, experienced poor appetite with a 5-pound weight loss, and expressed excessive guilt over failing his classes. This depressive period resolved spontaneously, and his mood has been completely stable since. However, his bizarre beliefs and auditory hallucinations have continued unchanged without interruption for the entire 9 months. He does not use any illicit substances, and his medical history is unremarkable. Which of the following is the most likely diagnosis?

A $6$-year-old boy is brought to the clinic by his father due to a $24$-hour history of left eye redness and swelling. The father reports that the child sustained a mosquito bite near his left eyebrow $3$ days ago. Yesterday, the area became red, and this morning his eye was swollen shut. The boy has been eating and drinking normally and has had no rhinorrhea or sinus pain. Temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), heart rate is $98/\text{min}$, respiratory rate is $20/\text{min}$, and blood pressure is $100/65\text{ mmHg}$. On physical examination, the left upper and lower eyelids are severely edematous, warm, and erythematous, preventing the patient from opening the eye spontaneously. With gentle manual retraction of the eyelids, the sclera and conjunctiva appear clear without chemosis. The pupils are equal, round, and reactive to light. Visual acuity is $20/20$ in both eyes. Extraocular movements are fully intact in all directions, and the patient denies pain with eye movement. There is no proptosis. Which of the following is the most appropriate next step in the management of this patient?

A family practitioner evaluates a 7-month-old male infant during an urgent clinic visit. The parents mention he has had a runny nose and a mild temperature elevation for the past 48 hours. Today, they noticed he is breathing faster than usual and his chest appears to sink in slightly when he inhales. Vital signs reveal a respiratory rate of 52/min, heart rate of 130/min, and an oxygen saturation of 95% on room air. Lung auscultation demonstrates diffuse polyphonic expiratory wheezes and coarse crackles bilaterally. He is still producing normal wet diapers and taking his bottle adequately. Based on current pediatric guidelines for this presentation, which of the following management strategies are appropriate? (Select 2 that apply)

A 17-year-old boy is brought to the emergency department by his parents after experiencing a generalized tonic-clonic seizure at home. The seizure lasted approximately 2 minutes. His parents report that he has become increasingly irritable, secretive, and academically withdrawn over the past month. Earlier today, they heard a loud noise and found him convulsing on his bedroom floor next to an electronic vaping device and an unlabeled vial of liquid. On current evaluation, the patient is highly agitated, diaphoretic, and pacing around the room. He expresses intense paranoia, claiming that the medical staff are trying to harvest his organs. Vital signs show a temperature of 37.7°C (99.9°F), blood pressure of 160/100 mmHg, and heart rate of 128/min. Physical examination is notable for prominent bilateral conjunctival injection. Horizontal and vertical gaze nystagmus are absent. A standard comprehensive urine toxicology screen is negative for all tested substances. Which of the following is the most likely cause of this patient's clinical presentation?

A 23-year-old nulliparous woman comes to the clinic because she found a lump in her right breast 2 weeks ago. She has no family history of breast cancer or other malignancies. Menarche was at age 12, and her menses are regular, occurring every 28 days. She takes no medications. On physical examination, her temperature is 37.0°C (98.6°F), blood pressure is 110/70 mm Hg, and pulse is 72/min. Breast examination reveals a 2-cm, firm, mobile, rubbery, well-circumscribed, non-tender mass in the upper outer quadrant of the right breast. There is no overlying skin erythema, dimpling, nipple retraction, or abnormal discharge. Examination of the axillae reveals no palpable lymphadenopathy. Which of the following is the most appropriate next step in evaluation?

A physician evaluates a $24$-day-old neonate in the emergency department who presents with progressive respiratory distress and a truncal eruption. The parents note that the symptoms began two days ago with nasal congestion and reduced breast milk intake, following close contact with a sick preschool-aged sibling. The neonate was delivered at term without complications. Current vital signs include a temperature of $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), pulse of $158/\text{min}$, respirations of $66/\text{min}$, and oxygen saturation of $93\%$ on room air. Cardiopulmonary auscultation reveals prolonged expiration, diffuse polyphonic wheezing, and bilateral fine crackles, accompanied by visible subcostal retractions. Dermatologic evaluation shows scattered erythematous macules on the anterior chest and back; several macules have small, central, yellow-white pustules. A rapid microscopic evaluation of the pustular fluid reveals a dense infiltration of eosinophils. Which of the following is the most appropriate clinical intervention?