Tüm alıştırma soruları

A $38$-year-old woman comes to the clinic to discuss contraceptive options. She is sexually active with a new male partner and does not desire future fertility, but she explicitly declines any form of surgical sterilization. Her medical history is significant for poorly controlled hypertension and heavy menstrual bleeding. She smokes one pack of cigarettes daily. Her current medications include amlodipine. Her last menstrual period was $14$ days ago. Blood pressure is $164/102$ mmHg, heart rate is $78$/min, and body mass index is $24$ kg/m $^2$. Pelvic examination reveals a normal-sized, mobile uterus with no adnexal masses. Urine pregnancy test is negative. Laboratory studies show a hemoglobin level of $10.2$ g/dL. Which of the following is the most appropriate contraceptive method for this patient?

Parents bring their 5-week-old male infant to the outpatient pediatric clinic due to prolonged feeding times and unusual sweating. Over the past week, the mother noticed that the infant takes up to an hour to consume 2 ounces of formula, frequently pausing to catch his breath, and his forehead becomes drenched in sweat. The pregnancy and term delivery were uncomplicated, and neonatal examinations were previously documented as normal. Current vital signs include a temperature of 37.0°C (98.6°F), a heart rate of 168/min, a respiratory rate of 68/min, and an oxygen saturation of 98% on ambient air. Physical examination shows subcostal retractions and a hyperactive precordium. A grade III/VI harsh, blowing holosystolic murmur is best heard at the left lower sternal border. Palpation of the abdomen reveals hepatomegaly, with the liver edge extending 4 cm below the right costal margin. Fine crackles are audible bilaterally. Which of the following best explains the timing of this patient's symptomatic presentation?

A 26-year-old woman presents to the clinic for a routine well-woman examination. She feels healthy and has no complaints. She specifically denies any pelvic pain, abnormal vaginal bleeding, malodorous vaginal discharge, or dyspareunia. Her medical history is unremarkable. She is in a monogamous relationship and has used a copper intrauterine device (IUD) for contraception for the past four years. Vital signs are within normal limits. Pelvic examination reveals normal external genitalia, a visually normal cervix with visible IUD strings, and no cervical motion tenderness or adnexal masses. A cervical cytology (Pap) smear is performed. Two weeks later, the pathology report indicates "negative for intraepithelial lesion or malignancy" but notes the incidental presence of Actinomyces-like organisms. The patient is contacted and confirms she remains completely asymptomatic. Which of the following is the most appropriate next step in management?

A $2$-day-old full-term male neonate is evaluated in the neonatal intensive care unit for abdominal distension and vomiting. The emesis is dark green. The infant was born via uncomplicated vaginal delivery to a $28$-year-old primigravid woman. The prenatal course was unremarkable. The infant has not passed meconium since birth. His temperature is $37.1^\circ$ C ($98.8^\circ$ F), heart rate is $145$/min, respiratory rate is $42$/min, and blood pressure is $65/40$ mmHg. Physical examination reveals a markedly distended and firm abdomen. Bowel sounds are absent, and there is no erythema of the abdominal wall. An anteroposterior abdominal radiograph demonstrates multiple dilated loops of small bowel with a distinct lack of air-fluid levels. A bubbly, granular appearance is noted in the right lower quadrant. There is no free air under the diaphragm.

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

Match each of the following intrapartum or postpartum clinical presentations to the most likely underlying obstetric etiology.

Match each congenital heart defect to its most characteristic physical examination finding.

A 28-year-old primigravida at 40 weeks gestation is admitted to the labor and delivery unit in spontaneous labor. Her prenatal course has been uncomplicated. Her vital signs are within normal limits. Cervical examination reveals dilation to 5 cm, 90% effacement, and 0 station. Epidural analgesia is providing adequate pain relief.

Continuous fetal heart rate monitoring demonstrates a baseline of 140/min, minimal variability, and no spontaneous accelerations. Over the past 45 minutes, there are intermittent decelerations occurring with approximately 30% of contractions. These decelerations begin after the peak of the contraction, take more than 30 seconds to reach their nadir, and slowly return to baseline.

In response, the patient is repositioned to the left lateral decubitus position, administered a 500-mL intravenous fluid bolus, and given supplemental oxygen. Thirty minutes later, her contractions are occurring every 3 to 4 minutes. The fetal heart rate tracing remains unchanged, with persistent minimal variability and intermittent late decelerations.

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

An established patient presents for evaluation at $32$ weeks gestation due to concerns about her heart and breathing. The $26$-year-old gravida $1$ para $0$ reports that over the past month, she has felt easily winded when climbing stairs and noticed her shoes feel tight by the end of the day. She occasionally feels her heart racing when resting. Vital signs are temperature $37.0^\circ$ C ($98.6^\circ$ F), blood pressure $112/68$ mmHg, pulse $98$/min, and respirations $18$/min. Cardiovascular examination reveals a prominent point of maximal impulse displaced slightly to the left, along with a grade II/VI systolic ejection murmur at the left upper sternal border. There is $1+$ bilateral lower extremity pitting edema up to the ankles. Pulmonary auscultation is clear. Urine dipstick yields negative results for protein. Which of the following is the most appropriate action at this time?

A $28$-year-old primigravida at $39$ weeks gestation is admitted to the labor and delivery unit in active labor. Her pregnancy has been uncomplicated. Her vital signs on admission are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $118/76$ mm Hg, and pulse $82$/min. Cervical examination shows $5$ cm dilation, $90\%$ effacement, and $0$ station. Fetal heart rate monitoring demonstrates a baseline of $145$/min with moderate variability, spontaneous accelerations, and no decelerations. Uterine contractions occur every $3$ to $4$ minutes. The patient requests pain management, and a continuous epidural infusion of bupivacaine and fentanyl is initiated. Twenty minutes later, the patient reports feeling lightheaded and nauseated. Her blood pressure is now $84/48$ mm Hg and pulse is $112$/min. Simultaneously, the fetal heart rate baseline drops to $90$/min with minimal variability and has remained at this rate for the past $4$ minutes. Which of the following is the most appropriate next step in the management of this patient?

A $29$-year-old woman, gravida $2$, para $1$, at $32$ weeks gestation comes to the clinic for a scheduled prenatal visit. She reports increased urinary frequency over the last few weeks but denies dysuria, hematuria, or urgency. She feels well, reports active fetal movements, and has no itching or abdominal pain. At $26$ weeks gestation, her $50$-g, $1$-hour oral glucose challenge test result was $110$ mg/dL. Vital signs are within normal limits. Fundal height is $32$ cm, and the fetal heart rate is $145$/min.

Which of the following is the most appropriate next action?

A 6-month-old girl is brought to the pediatric emergency department by her parents due to worsening weakness and poor feeding over the past three days. Her parents report that she previously breastfed vigorously and was able to roll from front to back, but she has progressively lost these abilities. Additionally, she has not passed a stool in five days. The family lives on an older rural property and recently began excavating soil to build a large garden. On physical examination, the infant appears lethargic. Her temperature is 37.1°C (98.8°F), heart rate is 110/min, and respiratory rate is 28/min. Neurological evaluation reveals bilateral ptosis, sluggish pupillary light reflexes, and a weak gag reflex. There is profound generalized hypotonia with marked head lag, and deep tendon reflexes are absent bilaterally. Which of the following is the most appropriate initial treatment for this patient?

An $18$-month-old boy is brought to the emergency department in late January by his parents due to severe difficulty breathing. His parents report a $4$-day history of clear nasal discharge, a mild cough, and a low-grade fever. Over the past $12$ hours, his breathing has become increasingly rapid and labored, and he has been feeding poorly. He was born at full term and has no prior history of wheezing or atopic dermatitis. His $4$-year-old sister recently recovered from a mild 'cold'.

Vital signs are:
- Temperature: $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$)
- Heart rate: $158\text{/min}$
- Respiratory rate: $64\text{/min}$
- Oxygen saturation: $87\%$ on room air

Physical examination reveals an irritable infant with significant nasal flaring and marked subcostal and intercostal retractions. Lung auscultation demonstrates a prolonged expiratory phase with diffuse bilateral wheezing and scattered coarse crackles. A rapid viral panel is positive for respiratory syncytial virus (RSV).

Which of the following interventions are appropriate components of the immediate management bundle for this patient? (Select all that apply)

A 66-year-old postmenopausal woman presents to the clinic with a 2-month history of progressive abdominal bloating, early satiety, and vague pelvic pressure. She has no history of abnormal vaginal bleeding. Physical examination reveals a distended abdomen with shifting dullness, and a palpable, firm, irregular right adnexal mass. Arrange the following steps in the most appropriate sequential order for the evaluation and management of this patient, from the initial step to definitive post-surgical treatment.

A 29-year-old woman presents to the clinic reporting the absence of menses for the past eight months, accompanied by a bilateral milky nipple discharge. She previously had regular 28-day menstrual cycles. She takes no medications and reports no headaches, visual disturbances, or cold intolerance. Vital signs and physical examination are within normal limits, aside from expressible galactorrhea. Arrange the following clinical steps in the most appropriate chronological sequence for the evaluation and management of this patient.

A $33$-year-old G2P1 at $40$ weeks and $5$ days gestation is pushing in the second stage of labor. The fetal head delivers but immediately retracts tightly against the maternal perineum. The attending physician applies gentle downward traction, but the anterior shoulder fails to deliver. The estimated fetal weight by third-trimester ultrasound was $4500$ g.

Arrange the following steps for the management of this obstetric emergency in the most appropriate sequential order, from the initial response to the maneuver of last resort.

Following a prolonged second stage of labor, a multiparous patient at 40 weeks gestation delivers a 4,350-g neonate vaginally. Twelve minutes after the intact placenta is delivered, nursing staff observe a sudden, massive surge of continuous vaginal bleeding. Vital signs demonstrate a maternal heart rate of 128/min and a blood pressure of 82/48 mm Hg. Abdominal examination reveals a soft, poorly contracted uterus extending to the level of the umbilicus. After securing two large-bore intravenous lines, administering tranexamic acid, and initiating aggressive fluid resuscitation, the obstetric team begins sequential interventions for refractory uterine atony. Assuming continuous failure to achieve hemostasis at each consecutive stage, arrange the following management steps in the correct, standardized escalating sequence.

An otherwise healthy nulligravid patient in her late twenties is evaluated in the ambulatory clinic for severe vulvar pain that has worsened over the past three days, making it difficult for her to sit or walk. Vital signs are within normal limits. Pelvic examination reveals a 4-cm, exquisitely tender, erythematous, and fluctuant mass located at the left posterior vestibule near the 5 o'clock position. There is no surrounding cellulitis. The physician decides to perform an office-based procedure to definitively treat the condition and minimize the risk of recurrence.

Arrange the following procedural and management steps in the most appropriate sequential order.

A 9-year-old boy is admitted to the pediatric oncology unit with newly diagnosed T-cell acute lymphoblastic leukemia. He has a 2-week history of worsening fatigue, bone pain, and shortness of breath. Chest radiograph shows a large anterior mediastinal mass. Before the initiation of induction chemotherapy, laboratory studies are obtained:

An electrocardiogram shows normal sinus rhythm with no ST-segment or T-wave abnormalities. The patient does not exhibit tetany or seizures. Vigorous intravenous hydration with normal saline is initiated.

Which of the following is the most appropriate additional pharmacologic intervention for this patient's metabolic derangements?

Match each classic pediatric gastrointestinal clinical presentation with its most appropriate definitive procedural or surgical management.

A 24-year-old healthy nulligravida presents for preconception counseling. She has a regular 28-day menstrual cycle and no significant past medical history. She and her partner are actively trying to conceive and she is curious about the normal progression of pregnancy. The physician discusses the expected physiological changes and clinical milestones she will experience. Arrange the following normal clinical and physiological milestones in the chronological order in which they typically first occur during an uncomplicated primigravid pregnancy, from earliest in gestation to latest.