Tüm alıştırma soruları

An obstetrician-gynecologist is evaluating a 54-year-old female who reports a single episode of bright red blood on her toilet tissue the previous morning. She attained menopause four years ago and has not experienced any vaginal bleeding since that time. Her medical history includes polycystic ovary syndrome (PCOS), essential hypertension, and type 2 diabetes mellitus. Her body mass index is 36 kg/m². Vital signs are within normal limits. Pelvic examination demonstrates normal external genitalia and a parous cervix without visible lesions. Bimanual examination reveals a mobile, non-tender uterus of normal size. Office-based transvaginal ultrasonography demonstrates a heterogeneous endometrial stripe measuring 8 mm in thickness. Which of the following is the most appropriate next step in management?

An obstetrician is evaluating a $24$-year-old woman during her first prenatal visit. She is gravida $1$, para $0$. She reports having irregular menstrual cycles and states that her last menstrual period began exactly $16$ weeks ago. She has no significant past medical history and takes no medications other than a daily prenatal vitamin. Vital signs are within normal limits. A pelvic ultrasound is performed in the office and demonstrates a single viable fetus with biometric measurements consistent with a gestational age of $14$ weeks and $3$ days. The patient expresses a strong desire for non-invasive screening for fetal aneuploidy and asks what testing options can be performed at today's visit.

Which of the following is the most appropriate screening test to offer this patient today?

Match each clinical and histopathological vignette with the most likely gynecologic neoplasm.

A 10-day-old male neonate is brought to the emergency department by his parents due to extreme lethargy, poor feeding, and rapid breathing over the past 12 hours. Physical examination reveals a mottled, pale infant with marked intercostal retractions and grunting. Vital signs are temperature 36.5°C (97.7°F), heart rate 185/min, respiratory rate 75/min, blood pressure 55/35 mm Hg in the right arm, and unobtainable in the lower extremities. Brachial pulses are 2+, but femoral pulses are absent. Capillary refill is 6 seconds. The infant is unresponsive to peripheral venous cannulation. Arrange the following interventions in the most appropriate sequential order for managing this patient's condition.

An infant boy born at $27$ weeks of gestation is currently $14$ days old and recovering in the neonatal intensive care unit. Over the past $8$ hours, the nursing staff has reported increased episodes of apnea, bradycardia, and a drop in body temperature. The patient had previously been tolerating slowly advancing orogastric feeds, but a large bilious residual was aspirated prior to his last scheduled feed. On evaluation, his temperature is $36.0^\circ\text{C}$ ($96.8^\circ\text{F}$), blood pressure is $45/28\text{ mm Hg}$, pulse is $182/\text{min}$, and respirations are $62/\text{min}$. Physical examination reveals a lethargic and mottled neonate. His abdomen is markedly distended, firm, and diffusely tender, with prominent erythema spreading across the abdominal wall. Laboratory analysis demonstrates a leukocyte count of $3,200/\text{mm}^3$ with $25\%$ band forms, a platelet count of $55,000/\text{mm}^3$, and a serum lactate level of $4.8\text{ mmol/L}$. A supine abdominal radiograph shows diffusely dilated loops of bowel, branching linear lucencies overlying the right upper quadrant, and a prominent radiolucent outline of the falciform ligament. Intravenous fluid resuscitation, broad-spectrum antimicrobial therapy, and bowel rest (NPO) are promptly initiated. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's clinical presentation with the most appropriate next step in surgical or interventional management.

A $4$-year-old girl is brought to the pediatric clinic by her father due to a $2$-day history of high fever, productive cough, and decreased appetite. The father notes that she occasionally holds her right side when she coughs. Her medical history is unremarkable, and she has received all scheduled childhood vaccinations. Her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), pulse is $125/\text{min}$, and respirations are $42/\text{min}$. Oxygen saturation is $95\%$ on room air. The patient appears fatigued but is interactive and does not have intercostal retractions or nasal flaring. Lung auscultation reveals focal fine crackles and decreased breath sounds in the right lower lung field. No wheezing or stridor is present. Which of the following is the most appropriate next step in management?

A 32-year-old woman, gravida 2 para 1, at 36 weeks gestation is admitted to the labor and delivery unit for management of severe preeclampsia. Upon admission, her blood pressure is $165/110$ mmHg. She is started on a continuous intravenous magnesium sulfate infusion. Initial laboratory studies reveal a platelet count of $75,000/\text{mm}^3$, an aspartate aminotransferase (AST) level of $620$ U/L, and an alanine aminotransferase (ALT) level of $650$ U/L. Four hours after admission, the patient suddenly reports acute, excruciating right upper quadrant abdominal pain that radiates to her right shoulder. She also complains of severe lightheadedness and nausea. Her blood pressure is now $82/45$ mmHg, and her heart rate is $135$/min. Physical examination demonstrates a rigid, distended abdomen with diffuse tenderness. Continuous fetal heart rate monitoring shows a baseline of $160$/min, absent variability, and recurrent late decelerations. Which of the following is the most appropriate next step in management?

A 14-year-old boy is brought to the emergency department by his parents due to a 1-week history of progressively worsening shortness of breath, a barking cough, and facial swelling. On physical examination, the patient is anxious, diaphoretic, and leaning forward in a seated position. He is using accessory muscles of respiration. Vital signs show a temperature of 37.8°C (100.0°F), heart rate of 135/min, respiratory rate of 32/min, and oxygen saturation of 91% on room air. Inspection reveals distended neck veins and facial plethora. A portable chest radiograph demonstrates a massive anterior mediastinal mass causing significant tracheal deviation and compression. You are concerned for superior mediastinal syndrome with severe airway compromise.

Arrange the following management steps in the most appropriate sequential order to safely stabilize and diagnose this patient.

A 12-year-old boy is brought to the pediatric emergency department after a high-speed motor vehicle collision. On arrival, he is unresponsive, withdraws from painful stimuli, makes no verbal sounds, and does not open his eyes (Glasgow Coma Scale score of 6). Physical examination reveals that his right pupil is 7 mm and nonreactive to light, while the left is 3 mm and reactive. Vital signs demonstrate a heart rate of 48/min, blood pressure of 165/95 mmHg, and irregular, shallow respirations.

Assuming each step represents the standard progression of care from initial emergency resuscitation to the intensive care management of refractory intracranial hypertension, arrange the following interventions in the most appropriate chronological order.

A 29-year-old G1P0 at 38 weeks gestation presents to the labor and delivery ward with painful uterine contractions. Her prenatal course was uncomplicated. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, and pulse is $82/\text{min}$. She is currently positioned in the left lateral decubitus position and receiving a continuous intravenous infusion of lactated Ringer solution. Cervical examination reveals dilation to $6\text{ cm}$, $100\%$ effacement, and $+1$ station. The amniotic membranes ruptured spontaneously 3 hours ago, and the fluid was clear. Tocodynamometry shows uterine contractions occurring every 3 minutes and lasting 50 seconds. Fetal heart rate monitoring demonstrates a baseline of $145/\text{min}$ with moderate variability. Over the past 30 minutes, there have been recurrent, abrupt decreases in the fetal heart rate to $80/\text{min}$ that last for 40 seconds before rapidly returning to the baseline. These decelerations occur with most contractions but have a varied onset relative to the contraction peak. Which of the following is the most appropriate next step in the management of this patient?

A $7$-month-old male infant is brought to the emergency department due to intermittent episodes of inconsolable crying over the past $6$ hours. During these episodes, the infant intensely draws his knees to his chest and appears visibly distressed. Between episodes, he becomes uncharacteristically lethargic. His parents report one instance of non-bilious emesis and note that his last diaper contained dark red, mucoid stool. Vital signs reveal a heart rate of $165$/min, respiratory rate of $40$/min, temperature of $37.8$°C ($100$°F), and blood pressure of $85/50$ mm Hg. Physical examination is notable for dry mucous membranes and a palpable, slightly tender, sausage-shaped mass in the right upper quadrant. The abdomen is otherwise soft without involuntary guarding.

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

A 26-year-old woman, gravida 1 para 0, is evaluated in the labor and delivery unit at 40 weeks and 2 days of gestation. She was admitted 6 hours ago in active labor. Her prenatal course was uncomplicated. Admission laboratory values demonstrated a hemoglobin concentration of $10.4\text{ g/dL}$ and a leukocyte count of $11,500/\mu\text{L}$. Epidural analgesia was administered, and an artificial rupture of membranes was performed at 5 centimeters of cervical dilation, yielding clear fluid.

Currently, the patient's blood pressure is $118/76\text{ mmHg}$, pulse is $84/\text{min}$, and temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$). Uterine contractions occur every 3 to 4 minutes, lasting 50 seconds, with normal intensity upon palpation. Cervical examination reveals 8 centimeters of dilation, 100% effacement, and the fetal vertex at 0 station. Fetal monitoring demonstrates a baseline heart rate of $150/\text{min}$ with moderate variability and no accelerations. Over the last 40 minutes, the cardiotocograph has shown abrupt decreases in the fetal heart rate to $80/\text{min}$, lasting 45 to 60 seconds before rapidly returning to baseline. These decreases are noted during approximately 60% of the uterine contractions. Maternal repositioning to the left lateral decubitus position, an intravenous normal saline bolus, and supplemental oxygen administration have been implemented, but the fetal heart rate pattern remains unchanged.

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

A 7-month-old boy is brought to the emergency department by his parents because of a sudden episode of deep blue discoloration of his lips and face. The parents report that he was crying vigorously when he suddenly became intensely cyanotic, tachypneic, and irritable. He has a known history of a congenital cardiac defect for which he is awaiting surgical repair. On arrival, the infant is agitated and visibly cyanotic. Vital signs show a heart rate of $165 \text{ /min}$, respiratory rate of $55 \text{ /min}$, and oxygen saturation of $68\%$ on room air. Auscultation reveals a harsh, crescendo-decrescendo systolic murmur over the left mid-to-upper sternal border. The physician immediately places the infant in a knee-chest position and administers $100\%$ oxygen via a non-rebreather mask, but the infant's agitation and cyanosis persist. Which of the following is the most appropriate next step in pharmacologic management?

A 4-year-old boy is brought to the pediatric clinic by his parents due to concerns about his frequent falls and difficulty climbing stairs. The parents report that he tires more easily than his peers when playing at the local park. When getting up from a sitting position on the floor, he uses his hands to push himself up his thighs to stand upright. His developmental history is significant for walking independently at 16 months, and he currently speaks in short sentences. His temperature is 37.0°C (98.6°F), pulse is 95/min, respirations are 20/min, and blood pressure is 95/60 mm Hg. Physical examination reveals bilaterally enlarged, firm calf muscles and a waddling gait. Which of the following is the most appropriate next step in evaluation?

Match each patient's clinical profile with the most appropriate contraceptive method based on the Medical Eligibility Criteria for Contraceptive Use.

Match the following clinical presentations of healthy pregnant patients with the primary underlying physiologic mechanism responsible for their findings.

An adolescent primigravida at 15 weeks gestation is evaluated in the outpatient clinic for a 3-day history of thick, yellow vaginal discharge and mild burning during urination. She denies lower abdominal discomfort, nausea, vomiting, or fever. Her vital signs are within normal limits. Speculum examination reveals a grossly erythematous cervix that bleeds easily upon contact with a swab. Copious mucopurulent exudate is visible at the external cervical os. Bimanual palpation elicits no cervical motion tenderness, and the adnexa are non-tender. Fetal heart tones are reassuring. A point-of-care urinalysis is unremarkable. The clinician prepares to send an endocervical sample for nucleic acid amplification testing. Which of the following is the most appropriate empiric management for this patient?

A $37$-year-old G3P3 woman presents to the clinic to discuss long-term contraception. She and her partner state that their family is complete, but they prefer a non-surgical option. Her menstrual periods occur every $28$ days, last for $7$ to $8$ days, and are exceptionally heavy, requiring her to change super-absorbent pads every $2$ hours during the first three days of menses. Her past medical history is significant for migraines that are consistently preceded by visual scintillating scotomas. She smokes $15$ to $20$ cigarettes per day. Vital signs show a blood pressure of $124/78 \text{ mmHg}$ and a heart rate of $72$/min. Body mass index is $28 \text{ kg/m}^2$. Pelvic examination is unremarkable. A urine pregnancy test is negative. Laboratory studies reveal a hemoglobin level of $10.2 \text{ g/dL}$. Which of the following is the most appropriate contraceptive method for this patient?

A 26-year-old woman comes to the physician due to a 5-month history of absent menstrual periods and increased facial hair growth. She also reports a recent deepening of her voice and increased muscle mass. Her menstrual cycles had previously occurred every 28 to 30 days and lasted 5 days. Her blood pressure is 112/72 mmHg, pulse is 78/min, and body mass index is 23 kg/m². Physical examination reveals severe acne on the face and back, coarse terminal hair growth on the upper lip and chin, temporal balding, and clitoromegaly. Pelvic examination shows no palpable adnexal masses. A urine pregnancy test is negative. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?