Tüm alıştırma soruları

Concerned parents present to the urgent care clinic with their 15-month-old son due to worsening breathing difficulties. The illness started four days prior with severe nasal congestion, clear rhinorrhea, and low-grade pyrexia. Over the past 24 hours, the parents noticed that his abdomen pulls inward with each breath, prompting the visit. The child was born at full term via an uncomplicated vaginal delivery and has received all age-appropriate immunizations. Vital signs show a temperature of 38.2°C (100.8°F), heart rate of 140/min, respiratory rate of 52/min, and oxygen saturation of 94% on room air. Examination shows an alert toddler in mild respiratory distress with subcostal retractions. Auscultation of the lungs reveals widespread expiratory wheezes and scattered coarse crackles. Which of the following is the most appropriate next step in the management of this patient?

A healthy 26-year-old primigravida presents to the clinic for her first obstetric evaluation at 8 weeks of gestation. Vital signs are within normal limits, with a blood pressure of 108/68 mm Hg, a heart rate of 76/min, and a body mass index (BMI) of 23 kg/m $^2$. Her medical history is unremarkable. During the consultation, she expresses curiosity about the timeline of the physical and internal changes her body will undergo in the coming months. The physician explains the expected progression of normal maternal physiological adaptations. Arrange the following physiological and anatomical milestones of a normal pregnancy in the correct chronological sequence of their occurrence or peak, from earliest in gestation to latest.

A $12$-year-old boy with a known history of Ewing sarcoma is brought to the emergency department due to worsening, severe back pain for the past $48$ hours. This morning, he developed weakness in both legs and has been unable to urinate. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $112/70\text{ mmHg}$, pulse is $98\text{/min}$, and respirations are $20\text{/min}$. Physical examination reveals $2/5$ motor strength in the bilateral lower extremities, exaggerated deep tendon reflexes at the knees and ankles, and a loss of sensation to pinprick below the level of the umbilicus. Anal sphincter tone is markedly decreased. Arrange the following steps in the most appropriate chronological order for the management of this patient's current condition.

Seeking medical advice for the absence of her menstrual periods over the past eight months, an unmarried twenty-six-year-old nulligravida arrives at the outpatient clinic. Her prior menstrual cycles occurred regularly every thirty days. She reports feeling profoundly fatigued and has noticed a $5$-kg ($11$-lb) weight gain over the past year despite maintaining her usual diet. Recently, she began experiencing intermittent morning headaches.

Vital signs are blood pressure $108/70$ mm Hg, pulse $56$/min, and BMI $27$ kg/m $^2$. Physical examination shows delayed relaxation of the deep tendon reflexes and bilateral galactorrhea upon breast expression. There is no facial hirsutism or acne. A point-of-care urine pregnancy test is negative.

Laboratory studies reveal the following:

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

A gravida 1 para 0 at 39 weeks and 5 days of gestation is admitted to the labor and delivery unit in active labor. Her prenatal course was uncomplicated. Her temperature is 37.1°C (98.8°F), blood pressure is 122/78 mm Hg, and pulse is 88/min. The estimated fetal weight is 3,200 g (7 lb 1 oz). Cervical examination shows 6 cm dilation, 90% effacement, and 0 station. Spontaneous rupture of membranes occurred 3 hours ago, revealing clear amniotic fluid. Uterine contractions are occurring every 3 to 4 minutes and palpate as strong. Continuous external fetal monitoring demonstrates a baseline heart rate of 145/min with moderate variability. There are recurrent, abrupt decreases in the fetal heart rate to 90/min that last for 45 to 60 seconds before rapidly returning to baseline; these decreases occur with almost every contraction. Maternal repositioning to the left lateral decubitus position and administration of an intravenous fluid bolus were performed 15 minutes ago, but the fetal heart rate pattern remains unchanged. Which of the following is the most appropriate next step in management?

A $4$-year-old girl is brought to the pediatric clinic by her mother due to a $6$-month history of foul-smelling, bulky stools and poor weight gain. Her mother reports that the child frequently complains of diffuse abdominal discomfort and has become increasingly irritable. The patient's growth chart indicates that her weight has dropped from the $50^{\text{th}}$ percentile to the $10^{\text{th}}$ percentile over the past year, while her height remains tracking at the $40^{\text{th}}$ percentile. Physical examination reveals a visibly distended abdomen and decreased subcutaneous fat in the extremities. Laboratory evaluation demonstrates a hemoglobin of $9.2 \text{ g/dL}$ with a mean corpuscular volume of $72 \text{ fL}$. Which of the following is the most appropriate initial diagnostic step for this patient?

A 48-year-old female presents to the gynecology clinic reporting a 3-month history of postcoital bleeding and foul-smelling vaginal discharge. She has not received regular medical care or cancer screening for over a decade. Pelvic examination reveals a 5-centimeter friable, exophytic mass replacing the cervix and extending into the upper third of the vaginal wall. There is nodularity in the bilateral parametria on rectovaginal examination. Arrange the following steps in the correct chronological order for the optimal diagnosis, staging, and definitive management of this patient's condition.

An otherwise healthy 26-year-old woman presents to the ambulatory care center complaining of pelvic pain and abnormal vaginal discharge that began 3 days ago. She describes the pain as a dull, continuous ache in her lower abdomen that worsens with intercourse. She denies any nausea, vomiting, or subjective fever. Her medical history is unremarkable, and she has been using a levonorgestrel-releasing intrauterine device for contraception over the past two years. Her last menstrual period was three weeks ago. She reports having a new male sexual partner as of two months ago. Vital signs show a temperature of 37.6 C (99.7 F), blood pressure of 112/74 mm Hg, and a heart rate of 84/min. Abdominal palpation elicits mild tenderness in the bilateral lower quadrants but no rebound tenderness or guarding. On pelvic examination, the intrauterine device strings are visible at the cervical os. Purulent material is seen exuding from the endocervical canal. Bimanual examination demonstrates pronounced cervical motion tenderness and bilateral adnexal tenderness without discrete masses. A urine pregnancy test is negative. Which of the following is the most appropriate next step in management?

A 32-year-old woman, gravida 3, para 2, at 36 weeks gestation is evaluated in the clinic for a routine prenatal visit. Her pregnancy has been uncomplicated. While lying flat on the examination table for fundal height measurement, she suddenly complains of dizziness, nausea, and shortness of breath. She appears pale and diaphoretic. Her blood pressure is 82/50 mm Hg, and her heart rate is 115/min. Upon rolling onto her left side, her symptoms resolve within a few minutes. Her repeat blood pressure is 112/70 mm Hg with a heart rate of 82/min. Which of the following is the most likely mechanism responsible for this patient's initial presentation?

Review the following patient clinical histories and epidemiological profiles. Identify the specific gynecologic malignancy that each patient is at the highest statistical risk of developing.

An $8$-year-old girl with a history of homozygous sickle cell anemia (HbSS) is brought to the pediatric emergency department due to a two-day history of progressive shortness of breath, right-sided chest pain, and fever. Her temperature is $38.9^\circ \text{C}$ ($102.0^\circ \text{F}$), blood pressure is $100/60\text{ mmHg}$, heart rate is $128/\text{min}$, and respiratory rate is $34/\text{min}$. Oxygen saturation is $89\%$ on room air. Physical examination reveals shallow breathing and crackles over the right lower posterior lung fields. Laboratory studies show:

* Hemoglobin: $7.1\text{ g/dL}$
* Leukocyte count: $19,500/\mu \text{L}$
* Reticulocytes: $11\%$

Chest radiography demonstrates a new alveolar infiltrate in the right lower lobe. The patient is immediately started on supplemental oxygen, pain control, and intravenous normal saline. Which of the following is the most appropriate additional pharmacologic therapy for this patient?

A 2-hour-old term male newborn is evaluated in the neonatal nursery for excessive drooling, frothy oral secretions, and episodes of choking and coughing accompanied by perioral cyanosis immediately upon his first feeding. The infant is currently breathing comfortably on room air after the feeding was abruptly stopped. Prenatal ultrasound was notable for severe polyhydramnios. Physical examination is unremarkable except for the continuous reaccumulation of copious oral secretions. Arrange the following steps in the most appropriate chronological order for the acute management and evaluation of this patient.

A 56-year-old woman, gravida 2, para 2, comes to the office due to a 1-month history of intermittent vaginal spotting and new-onset breast tenderness. Her last menstrual period was 5 years ago. She has no significant past medical history and takes no medications. Vital signs are within normal limits. Body mass index is $23 \text{ kg/m}^2$. Pelvic examination reveals normal external genitalia and vagina. The cervix appears grossly normal. Bimanual examination is notable for an $8 \text{ cm}$, mobile, non-tender right adnexal mass. The uterus is of normal size and mobility. Transvaginal ultrasound demonstrates an $8.5 \text{ cm}$ complex, multiloculated solid and cystic right ovarian mass. The endometrial stripe thickness is $14 \text{ mm}$. Which of the following is the most appropriate next step in management?

Parents bring their $4$-week-old male infant to the acute care clinic because he has been forcefully vomiting after feeds for the past five days. The nonbilious vomitus frequently shoots across the crib. Despite the recurrent emesis, the infant appears remarkably hungry and demands to feed again immediately. Over the last $48$ hours, his urine output has decreased to only one wet diaper per day. Vital signs show a heart rate of $165\text{/min}$, blood pressure of $68/38\text{ mm Hg}$, and respiratory rate of $32\text{/min}$. Physical examination reveals a lethargic infant with sunken eyes, a depressed anterior fontanelle, and a capillary refill time of $5$ seconds. Abdominal examination is notable for a palpable, firm, olive-shaped mass in the right upper quadrant.

Laboratory studies demonstrate the following:

What is the most appropriate initial step in the management of this patient?

A 26-year-old woman, G1P0, at 40 weeks and 2 days gestation, is currently in the active phase of the first stage of labor. Cervical examination reveals 7 cm dilation, complete effacement, and +1 station. Spontaneous rupture of membranes occurred four hours ago, revealing clear fluid. The patient is receiving an epidural for analgesia and an intravenous oxytocin drip to optimize uterine contractility. Maternal vital signs are within normal limits. The continuous fetal monitor shows a baseline heart rate of 142/min with moderate variability. The tracing also reveals gradual, symmetric drops in the fetal heart rate that consistently start after the peak of each uterine contraction, with the lowest point of the drop occurring after the contraction resolves. These drops are observed with more than half of the contractions. Which of the following is the most appropriate next action in the care of this patient?

A pediatric pathology team is correlating characteristic genetic and microscopic findings with their corresponding childhood malignancies. Match each specific diagnostic description with the most likely pediatric hematologic or oncologic diagnosis.

A 62-year-old female is evaluated in the emergency department for severe, diffuse abdominal pain that worsened abruptly over the last four hours. Her medical history is notable for a total abdominal hysterectomy ten years ago. She has not had a bowel movement or passed flatus in two days. On physical examination, the patient appears diaphoretic and in severe distress. Temperature is 39.2°C (102.6°F), pulse is 130/min, respirations are 24/min, and blood pressure is 80/50 mm Hg. Abdominal examination reveals a rigid, board-like abdomen with severe diffuse guarding and rebound tenderness. Laboratory studies show a leukocyte count of 22,000/mm³ and an elevated serum lactate. Which of the following is the most appropriate next step in the management of this patient?

Routine cervical cancer screening is performed on a 44-year-old patient during her annual health maintenance visit. The patient has a medical history significant for type 2 diabetes mellitus and a body mass index of $33 \text{ kg/m}^2$. She reports that her menstrual cycles occur every 28 days and last for 5 days with moderate flow. She has two children delivered vaginally at term. The laboratory reports the cytology results as atypical glandular cells. Speculum examination reveals a parous cervix with no visible lesions. Bimanual examination demonstrates a normal-sized, mobile uterus and no adnexal tenderness. Which of the following is the most appropriate next step in the management of this patient?

An uncomplicated pregnant patient presents for evaluation at $28$ weeks of gestation for her scheduled obstetric follow-up. The $25$-year-old nulliparous woman reports feeling well, with only mild generalized fatigue and occasional lower back pain. She explicitly denies abdominal pain, nausea, vomiting, or skin itchiness. Her blood pressure is $112/70$ mm Hg, and her pulse is $82$/min. Physical examination reveals a gravid uterus consistent with dates and no right upper quadrant tenderness. The skin shows no excoriations or jaundice.

Routine laboratory results are as follows:

Hemoglobin: $11.2$ $g/dL$
Platelet count: $195,000/\mu L$
Aspartate aminotransferase (AST): $24$ $U/L$
Alanine aminotransferase (ALT): $28$ $U/L$
Alkaline phosphatase: $285$ $U/L$ (Reference: $40-120$ $U/L$)
Total bilirubin: $0.6$ $mg/dL$

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

A preschool-aged male is evaluated in the emergency department due to a new-onset fever of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$) and extreme lethargy. The patient is currently in the consolidation phase of cytotoxic chemotherapy for an underlying high-risk neuroblastoma. Two days prior to arrival, an implanted central venous access port was surgically placed without immediate complications. On evaluation, he is tachycardic at $165/\text{min}$, tachypneic at $32/\text{min}$, and hypotensive with a blood pressure of $72/40\text{ mm Hg}$. Capillary refill time is $4\text{ seconds}$. The surgical site appears clean with no surrounding erythema, and the lungs are clear to auscultation. A complete blood count reveals a total leukocyte count of $400/\text{mm}^3$ with $10\%$ segmented neutrophils and $5\%$ band forms. What is the most appropriate next step in the management of this patient?