Tüm alıştırma soruları

Assess the following clinical scenarios. For each patient—all of whom have a negative serum beta-hCG today and seek reliable contraception—select the most appropriate and safest method according to the World Health Organization Medical Eligibility Criteria (WHO MEC).

A 2-year-old boy is brought to the emergency department at 11:00 PM by his parents due to a harsh, 'seal-like' barking cough and noisy breathing. The parents report he has had a low-grade fever and rhinorrhea for the past two days. On examination, the child is visibly anxious, has prominent inspiratory stridor while sitting quietly on his mother's lap, and exhibits marked suprasternal and subcostal retractions. Oxygen saturation is 94% on room air. Arrange the following management steps in the most appropriate sequential order for this patient.

Match each clinical presentation of an intrapartum or postpartum complication with its most likely underlying etiology.

A $5$-week-old male infant is brought to the pediatric evaluation center by his mother due to a $5$-day history of progressively forceful vomiting. The mother reports that the infant vomits large amounts of milk immediately after feeding but remains eager to eat again shortly afterward. The vomitus does not contain bile or blood. The infant has had fewer wet diapers over the last $2$ days. Vital signs are temperature $37.0^{\circ}\text{C}$ ($98.6^{\circ}\text{F}$), heart rate $178/\text{min}$, respiratory rate $42/\text{min}$, and blood pressure $70/40\text{ mm Hg}$. On physical examination, the infant appears lethargic with a sunken anterior fontanelle, dry mucous membranes, and delayed capillary refill. Palpation of the abdomen reveals a $2$-cm, firm, mobile mass in the right upper quadrant. Laboratory studies demonstrate:

Sodium: $131\text{ mEq/L}$
Potassium: $2.7\text{ mEq/L}$
Chloride: $85\text{ mEq/L}$
Bicarbonate: $36\text{ mEq/L}$
Blood urea nitrogen: $32\text{ mg/dL}$
Creatinine: $0.9\text{ mg/dL}$

Based on the patient's presentation and laboratory findings, which of the following is the most appropriate initial step in management?

Match the following classic clinical presentations and laboratory findings of lower genital tract infections to their correct diagnosis and corresponding optimal pharmacotherapy.

An otherwise healthy neonate, delivered at term 4 days ago, presents to the emergency room after developing green-colored emesis. The parents report three episodes of vomiting since this morning. On triage, the patient appears lethargic but maintains normal perfusion, blood pressure, and heart rate for his age. Abdominal examination demonstrates a non-distended, soft abdomen with no signs of peritonitis. Arrange the following steps in the most appropriate sequential order for the evaluation and management of this patient.

A 67-year-old woman, gravida 1, para 1, presents to her gynecologist with a recent episode of painless vaginal bleeding. She reached menopause at age 53. Her past medical history is significant for type 2 diabetes mellitus, chronic hypertension, and obesity (BMI $41 \text{ kg/m}^2$). Pelvic examination is unremarkable, and there is no active bleeding from the cervical os. Transvaginal ultrasonography is performed and demonstrates a $14\text{-mm}$ thickened, heterogeneous endometrial stripe. Arrange the following steps in the most appropriate chronological order for her comprehensive evaluation and definitive management.

A 32-year-old woman, gravida 2, para 1, presents to the clinic at 8 weeks of gestation for her initial prenatal visit. Her blood type is O-negative. Her previous pregnancy was complicated by severe preeclampsia requiring an indicated preterm delivery at 31 weeks of gestation. Her vital signs today are within normal limits, and a viable intrauterine pregnancy is confirmed by ultrasound. Assuming the current pregnancy progresses normally without acute complications, arrange the following recommended maternal screening and prophylactic interventions in the correct chronological order from earliest to latest in gestation.

Match each clinical vignette describing an intrapartum or postpartum complication to the most appropriate immediate intervention.

An emergency response team brings a $22$-year-old primigravida at $11$ weeks gestation to the hospital due to severe, intractable nausea and vomiting that has persisted for three weeks. She has lost $10\%$ of her pre-pregnancy body weight and has been entirely unable to tolerate oral intake for the past four days. Prior to arrival, paramedics established intravenous access and administered $2$ liters of $5\%$ dextrose in $0.9\%$ saline to treat suspected dehydration and hypoglycemia.

Upon arrival, the patient is lethargic, confused, and disoriented to time and place. Neurologic examination reveals prominent horizontal nystagmus, bilateral sixth cranial nerve palsies, and an unsteady, wide-based gait.

Laboratory studies show:
- Sodium: $134$ mEq/L
- Potassium: $3.2$ mEq/L
- Chloride: $96$ mEq/L
- Bicarbonate: $29$ mEq/L
- Glucose: $125$ mg/dL
- Aspartate aminotransferase (AST): $65$ U/L

Which of the following is the most likely pathophysiologic mechanism for this patient's acute neurologic presentation?

During a scheduled initial prenatal evaluation, a pregnant patient at $9$ weeks of gestation undergoes routine laboratory screening. The patient is $26$ years old, has never been pregnant before, and reports only mild early morning nausea. Her medical history is unremarkable, and she denies any palpitations, tremors, weight loss, or heat intolerance. On physical examination, her vital signs are blood pressure $112/68 \text{ mm Hg}$, pulse $78/\text{min}$, and respiratory rate $14/\text{min}$. The thyroid gland is normal in size without palpable nodules or tenderness. A thyroid function panel reveals a thyroid-stimulating hormone (TSH) level of $0.2 \text{ \mu U/mL}$ (non-pregnant reference range: $0.4-4.0 \text{ \mu U/mL}$) and an elevated total thyroxine (T4) level. Her free T4 level is within normal limits. Which of the following is the most appropriate next step in the management of this patient's thyroid findings?

A 23-year-old female collegiate cross-country runner comes to the university health center because she has not had a menstrual period for 8 months. Her body mass index (BMI) is 17.8 kg/m². She mentions intense training for an upcoming national competition and strict caloric restriction. Arrange the following diagnostic and management steps in the most appropriate sequential order for evaluating and managing this patient.

A 29-year-old woman, gravida 2, para 1, at 40 weeks gestation is in the second stage of labor. She chose not to receive regional anesthesia and is laboring with intermittent nitrous oxide. Following a prolonged second stage, the fetal head delivers but immediately retracts tightly against the maternal perineum. Routine gentle downward traction fails to deliver the anterior shoulder.

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

A 2-day-old full-term male newborn is evaluated in the nursery for failure to pass meconium since birth. He has developed abdominal distension and is refusing to feed. Physical examination reveals a markedly distended, tympanitic abdomen and a tight anal sphincter. A digital rectal examination results in an explosive expulsion of gas and stool.

Arrange the following steps in the most appropriate chronological order for the diagnosis and definitive management of this patient's condition.

Match each routine prenatal screening or evaluation milestone to its optimal gestational age window in an uncomplicated pregnancy, according to standard obstetric guidelines.

Match each clinical presentation of a gynecologic malignancy with its most likely specific diagnosis.

A 32-year-old multiparous woman at 40 weeks gestation with diet-controlled gestational diabetes is in the second stage of labor. Following the delivery of the fetal head, the head rapidly retracts tightly against the maternal perineum. Gentle downward traction fails to deliver the anterior shoulder. Arrange the following management steps in the correct sequential order according to standard stepwise escalation protocols for this obstetric emergency, proceeding from the initial response to maneuvers of last resort.

Accompanied by her sister, a $68$-year-old female comes to the outpatient clinic to establish care. While reviewing her symptoms, she casually notes seeing a pinkish discharge on her toilet tissue twice over the past month. She denies pelvic pain, weight loss, or dysuria. She reached natural menopause $16$ years ago and had no vaginal bleeding until this recent episode. Her medical history includes hypertension, type 2 diabetes mellitus, and osteoarthritis. Current medications include lisinopril and metformin. Vital signs are within normal limits, and her body mass index is $34\text{ kg/m}^2$. Pelvic examination reveals atrophic external genitalia and a pale vaginal vault with no gross lesions. A bedside transvaginal ultrasound reveals an endometrial thickness of $7\text{ mm}$. Which of the following is the most appropriate next step in the management of this patient?

Maternal physiology undergoes profound systemic adaptations during an uncomplicated pregnancy to support fetal development and prepare for childbirth. These changes frequently manifest as altered clinical exam findings or shifted laboratory reference ranges that might closely mimic pathological states in a non-pregnant individual. Evaluate the following physiological findings commonly encountered during routine prenatal care and match each to its primary underlying maternal or placental mechanism.

A patient at 40 weeks gestation (G1P0) is admitted to the labor and delivery unit for labor augmentation with intravenous oxytocin. She is 28 years old, and her prenatal course has been uncomplicated. She is utilizing epidural anesthesia for pain management. Her cervix is currently 5 cm dilated, 90% effaced, and at -1 station. Over the past 30 minutes, the fetal heart rate monitor displays a baseline of 150/min. The amplitude of the peak-to-trough fetal heart rate fluctuations is 3 to 5 beats per minute. There are recurrent, gradual decreases in the fetal heart rate that begin after the peak of each uterine contraction and return to baseline after the contraction ends. Tocodynamometry reveals 7 contractions per 10-minute period, averaged over the last 30 minutes, with each contraction lasting 60 to 80 seconds. In response to these findings, the oxytocin infusion is promptly discontinued, the patient is placed in the left lateral decubitus position, and a 500-mL intravenous bolus of lactated Ringer solution is administered. Fifteen minutes later, the contraction frequency remains unchanged, and the fetal heart rate tracing continues to demonstrate the same pattern of recurrent decelerations with minimal fluctuations. Maternal vital signs are blood pressure 118/76 mmHg, pulse 88/min, and temperature 37.1°C (98.8°F). Which of the following is the most appropriate next step in management?