Tüm alıştırma soruları

A 31-year-old woman comes to the reproductive endocrinology clinic due to an inability to conceive for the past 14 months. Her menstrual periods were regular until two years ago, when they became irregular, and she has had no menses for the past 8 months. During this time, she has gained 8 kg (17.6 lb) and reports progressive fatigue, cold intolerance, and constipation. She also reports occasional clear, milky discharge from both nipples. Her BMI is 28.5 kg/m². Vital signs show a pulse of 54/min and a blood pressure of 105/65 mmHg. Physical examination reveals delayed relaxation of the deep tendon reflexes and bilateral galactorrhea. Pelvic examination is normal. A urine pregnancy test is negative.

Laboratory evaluation shows:
Follicle-stimulating hormone: 2.2 mIU/mL
Luteinizing hormone: 1.8 mIU/mL
Prolactin: 78 ng/mL (normal: 4-23 ng/mL)
Thyroid-stimulating hormone (TSH): 0.2 mU/L (normal: 0.5-5.0 mU/L)
Free thyroxine (T4): 0.4 ng/dL (normal: 0.9-1.7 ng/dL)

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

A 7-month-old female infant is brought to the pediatric acute care clinic by her parents due to a three-day history of poor feeding, increased work of breathing, and a prominent runny nose. She was born at term and has an unrepaired moderate ventricular septal defect that is followed by cardiology. Her current temperature is 38.2°C (100.8°F), heart rate is 168/min, respiratory rate is 66/min, and oxygen saturation is 88% on room air. Physical examination reveals an infant in moderate-to-severe respiratory distress with marked subcostal and intercostal retractions, nasal flaring, and copious clear nasal secretions. Cardiopulmonary auscultation demonstrates a harsh holosystolic murmur at the left lower sternal border, diffuse bilateral polyphonic expiratory wheezes, and scattered fine crackles. Which of the following is the most appropriate initial step in the management of this patient's acute respiratory condition?

A 65-year-old man with a history of stage 4 chronic kidney disease and heart failure with reduced ejection fraction is brought to the emergency department due to profound muscle weakness and palpitations. His home medications include lisinopril, spironolactone, and carvedilol. Vital signs show a blood pressure of $110/70 \text{ mmHg}$ and a heart rate of $52/\text{min}$. An electrocardiogram reveals sinus bradycardia with peaked T waves and widened QRS complexes. Laboratory studies demonstrate a serum potassium level of $7.6 \text{ mEq/L}$ and a serum creatinine of $3.4 \text{ mg/dL}$ (baseline $2.2 \text{ mg/dL}$). Arrange the following pharmacological interventions in the most appropriate chronological order for this patient's acute management.

A female neonate is delivered at 32 weeks and 4 days of gestation to a 24-year-old primigravida due to preterm labor and rupture of membranes 12 hours prior to delivery. Her birth weight is 1750 g. Apgar scores are 6 and 7 at 1 and 5 minutes, respectively. In the delivery room, the infant exhibits mild grunting and tachypnea, and is subsequently transferred to the neonatal intensive care unit on nasal continuous positive airway pressure (CPAP) at $5 \text{ cm H}_2\text{O}$ with a fractional inspired oxygen ($\text{FiO}_2$) of $0.30$.

At 6 hours of life, the infant's work of breathing markedly increases. Vital signs show a temperature of 36.8°C, heart rate of 175/min, respiratory rate of 88/min, and oxygen saturation of 86% despite escalating the $\text{FiO}_2$ to $0.70$. Physical examination reveals severe subcostal retractions, expiratory grunting, and a scattered rash consisting of 1- to 2-mm pustules on an erythematous base on the chest and back. A chest radiograph demonstrates low lung volumes with diffuse, bilateral reticulogranular opacities and air bronchograms.

An arterial blood gas analysis on current respiratory settings reveals:

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

A 22-year-old woman presents to the emergency department with acute-onset, severe bilateral lower abdominal pain and a fever of 38.8°C (101.8°F). She is sexually active with a new partner and states her last menstrual period was 6 weeks ago. Her blood pressure is 110/70 mm Hg, and pulse is 108/min.

Arrange the following steps in the most appropriate chronological order for evaluating and managing this patient's condition, from first to last.

A 39-week gestation neonate is delivered via emergency cesarean section due to a severe placental abruption. At birth, the infant is profoundly limp, cyanotic, and exhibits no spontaneous respiratory effort. Arrange the following steps of neonatal resuscitation in the correct chronological sequence, assuming the infant exhibits no clinical improvement and the heart rate persistently remains below 60/min despite an adequate duration of each successive intervention.

A 32-year-old woman with a history of bipolar I disorder comes to the outpatient psychiatry clinic due to a 4-week history of depressed mood, profound fatigue, and sleeping up to 14 hours a day. Her last manic episode occurred two years ago, and she has been maintained on a stable dose of valproate since that time. Vital signs include a heart rate of 72/min, blood pressure of 118/76 mm Hg, and respiratory rate of 14/min. Mental status examination reveals psychomotor retardation, a blunted affect, and a sad mood. She denies any suicidal ideation. The physician decides to add lamotrigine to her current regimen to target the depressive symptoms. To minimize the risk of a life-threatening dermatologic complication, which of the following pharmacokinetic principles must be applied to the management of this patient?

A 3-year-old boy is brought to the emergency department by his parents with a 24-hour history of high fever and a new-onset limp. Today, he completely refuses to bear weight on his right leg. His temperature is 39.2°C (102.6°F), blood pressure is 95/60 mmHg, heart rate is 135/min, and respiratory rate is 26/min. On physical examination, the right hip is held in a position of flexion, abduction, and external rotation. Any attempted passive movement of the right hip elicits severe pain and inconsolable crying. Laboratory results reveal a leukocyte count of 19,500/mm³ and an erythrocyte sedimentation rate of 65 mm/h. Arrange the following acute management steps in the most appropriate sequential order.

A 28-year-old woman is brought to the emergency department by ambulance after being found unresponsive with a syringe nearby. On arrival, her respiratory rate is 6/min, oxygen saturation is 82% on room air, and she has pinpoint pupils. She is cyanotic and unarousable to painful stimuli. The medical team is preparing a comprehensive care plan encompassing acute resuscitation and subsequent addiction management.

Arrange the following management steps in the most appropriate chronological sequence for this patient.

An 8-month-old girl is evaluated in the pediatric clinic in January due to increased work of breathing. She has had a runny nose, mild cough, and low-grade fever for the past three days. The patient was born full-term and is up to date on immunizations. Vital signs show a temperature of 37.6°C (99.7°F), a heart rate of 138/min, a respiratory rate of 56/min, and an oxygen saturation of 95% on room air. Physical examination demonstrates clear rhinorrhea, mild intercostal retractions, and bilateral expiratory wheezing with scattered crackles. The child is consolable and is feeding adequately. Which of the following is the most appropriate next step in management?

A 76-year-old woman comes to the clinic reporting a 6-month history of a vaginal bulge and pelvic pressure. She notes significant difficulty with bowel movements, frequently needing to press on the skin between her vagina and rectum to completely empty her bowels. Today, she noticed a few spots of blood on her undergarments. Her medical history is significant for severe chronic obstructive pulmonary disease requiring continuous home oxygen therapy, and a myocardial infarction 3 months ago. Her current medications include aspirin, metoprolol, atorvastatin, and a tiotropium inhaler. On pelvic examination, there is a prominent bulge of the posterior vaginal wall that extends 3 cm beyond the hymenal ring with the Valsalva maneuver. The cervix is flush with the vaginal vault and has no active bleeding or lesions. There is a superficial 3-mm mucosal ulceration on the dependent portion of the prolapsed posterior vaginal wall that oozes a small amount of blood when touched. Which of the following is the most appropriate next step in management?

A $34$-year-old gravida $3$, para $2$ at $37$ weeks gestation is brought to the labor and delivery triage complaining of a sudden onset of intense, constant abdominal pain accompanied by a moderate amount of dark red vaginal bleeding. Her medical history is significant for chronic hypertension. Her vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $168/105\text{ mmHg}$, heart rate of $112/\text{min}$, and respiratory rate of $18/\text{min}$. Physical examination reveals a uniformly rigid and exquisitely tender uterus. A bedside ultrasound confirms a live fetus in cephalic presentation but does not visualize a retroplacental hematoma. Laboratory studies display a hemoglobin level of $10.6\text{ g/dL}$ and a platelet count of $140,000/\text{mm}^3$. The continuous fetal monitor indicates a baseline heart rate of $105/\text{min}$, absent variability, and recurrent late decelerations. Which of the following is the most appropriate next step in the management of this patient?

A 2-year-old boy is brought to the emergency department at night with a harsh, barking cough and noisy breathing. On examination, he is agitated, has loud inspiratory stridor at rest, and displays significant suprasternal and subcostal retractions. His temperature is 38.0°C (100.4°F) and oxygen saturation is 95% on room air. Arrange the following management steps in the most appropriate chronological sequence for this patient.

During a routine health maintenance visit, a 61-year-old G2P2 complains of a three-month history of progressive abdominal bloating, early satiety, and pelvic heaviness. Her last menstrual period was 10 years ago, and she has never used hormone replacement therapy. Vital signs are within normal limits. Abdominal examination reveals fullness in the lower quadrants. Bimanual pelvic examination identifies a palpable, firm, irregular, and fixed mass in the right adnexa. Arrange the following steps in the most appropriate chronological sequence for the diagnostic workup and therapeutic management of this patient.

A 16-year-old adolescent boy with a history of cystic fibrosis complicated by severe bronchiectasis is brought to the emergency department after coughing up copious amounts of bright red blood at home. In the triage room, he expectorates approximately 250 mL of blood into an emesis basin over 15 minutes. He appears pale, anxious, and is in moderate respiratory distress. Vital signs are temperature 37.1°C (98.8°F), heart rate 138/min, blood pressure 92/58 mmHg, respiratory rate 30/min, and oxygen saturation 86% on room air. Lung auscultation reveals coarse crackles and gurgling sounds predominantly over the right hemithorax, with relatively clear breath sounds on the left. Arrange the following acute management steps in the most appropriate sequential order.

A 74-year-old woman is brought to the clinic by her son for evaluation of urinary incontinence that has worsened over the past 6 months. The patient experiences sudden, overwhelming urges to urinate and frequently leaks large amounts of urine before she can reach the bathroom. These episodes occur during both the day and night. She has attempted pelvic floor muscle exercises and timed voiding for the last 3 months with minimal benefit. The patient denies dysuria, hematuria, or abdominal pain. Her medical history is significant for hypertension, hyperlipidemia, and mild Alzheimer dementia. Her current medications are amlodipine, atorvastatin, and donepezil. Vital signs are within normal limits. Pelvic examination demonstrates healthy, well-estrogenized vaginal mucosa without evidence of pelvic organ prolapse. A bladder scan shows a post-void residual volume of 30 mL. Urinalysis is negative for leukocyte esterase, nitrites, and blood. Which of the following is the most appropriate next step in management?

A $68$-year-old nulliparous woman comes to the clinic for a $1$-month history of intermittent vaginal spotting. She went through menopause at age $52$. Her medical history is significant for obesity (BMI $36 \text{ kg/m}^2$), type 2 diabetes mellitus, and essential hypertension. She takes metformin and lisinopril. Vital signs are within normal limits. Pelvic examination reveals normal external genitalia and a small amount of dark blood at the cervical os. Bimanual examination is limited by body habitus. A transvaginal ultrasound demonstrates an endometrial stripe thickness of $14 \text{ mm}$ with a heterogeneous appearance. No adnexal masses are noted. An office endometrial biopsy is attempted, but the sampling catheter cannot be advanced past the internal cervical os due to severe cervical stenosis. The patient reports significant discomfort, and the procedure is aborted. Which of the following is the most appropriate next step in management?

The parents of a 14-day-old boy bring him to the emergency department in mid-winter due to a progressively worsening cough, nasal congestion, and a rectal temperature of 38.3°C (100.9°F) at home. He was born full-term following an uncomplicated pregnancy. His state newborn screening report recently returned flagged for undetectable T-cell receptor excision circles (TRECs), and an immunology consultation is scheduled for next week. In the emergency department, his temperature is 38.4°C (101.1°F), heart rate is 175/min, and respiratory rate is 72/min. Physical examination demonstrates nasal flaring, subcostal retractions, and bilateral diffuse wheezing and crackles. The physician notes scattered erythematous macules with 1- to 2-mm central yellow pustules on his trunk and proximal extremities, which the parents state have waxed and waned since his second day of life. A rapid multiplex viral polymerase chain reaction assay of nasopharyngeal secretions is positive for respiratory syncytial virus. The parents ask if he can receive his first dose of the oral rotavirus vaccine today since they missed their primary care appointment. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical vignette describing a patient with major depressive disorder to the most appropriate first-line antidepressant based on their specific comorbidities and symptom profile.

Match each clinical presentation of a urogynecologic condition with the most appropriate therapeutic intervention, taking into account the patient's specific comorbidities.