Tüm alıştırma soruları

While rounding on the labor and delivery unit, an attending physician evaluates a full-term pregnant woman undergoing a trial of labor after a previous low transverse cesarean section. The pregnancy has been entirely uncomplicated to date. Over the last six hours, her labor progressed normally, and the fetal head was documented at a $+1$ station. Suddenly, the patient reports a severe, tearing pain in her lower abdomen that persists between contractions. On physical examination, the fetal presenting part is now palpated at a $-2$ station. The continuous fetal heart rate monitor, which previously showed a category I tracing, now demonstrates a sustained fetal heart rate of $80$ beats per minute lasting for over four minutes. Vaginal bleeding is scant, but the patient's heart rate has increased to $115$ beats per minute and her blood pressure is $90/55$ mmHg. Which of the following is the most appropriate next step in the management of this patient?

A 29-year-old woman is brought to the emergency department by her partner due to worsening confusion, extreme restlessness, and tremors. Her temperature is $39.4^{\circ}\text{C}$ ($102.9^{\circ}\text{F}$), heart rate is $132\text{/min}$, and blood pressure is $164/98\text{ mm Hg}$. Physical examination reveals profuse diaphoresis, mydriasis, hyperreflexia, and sustained clonus in the bilateral lower extremities. Her medical history is significant for major depressive disorder treated with sertraline. Two days ago, she began taking an over-the-counter dextromethorphan syrup for a cough. Arrange the following therapeutic interventions in the most appropriate sequential order for managing this patient's condition, starting from the immediate first step to treatments reserved for progressively severe or refractory toxicity.

An unimmunized 4-year-old male is rushed to the emergency department by emergency medical services after an acute onset of high fever and severe dysphagia. Upon arrival, the patient is observed to be toxic-appearing, drooling, and sitting in a tripod position with a hyperextended neck. Audible inspiratory stridor is present. His temperature is 39.6°C (103.3°F), heart rate is 148/min, and respiratory rate is 38/min. Oxygen saturation is 93% on room air. The clinical presentation is highly suspicious for a life-threatening supraglottic infection. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A $58$-year-old man comes to the physician complaining of profound fatigue, cold intolerance, and decreased libido for the past $6$ months. He also reports recent onset of intermittent headaches and frequently bumping his shoulders into doorframes. Vital signs are within normal limits. Physical examination reveals bitemporal hemianopsia and delayed relaxation phase of deep tendon reflexes. Laboratory studies show the following:

Magnetic resonance imaging of the brain reveals a $2.6 \text{ cm}$ mass in the sella turcica with suprasellar extension compressing the optic chiasm. The physician determines that the patient requires thyroid hormone replacement therapy for symptomatic relief prior to planned transsphenoidal surgery. Which of the following is the most appropriate next step in management before initiating this therapy?

Seeking assistance to achieve sobriety, a 48-year-old male construction worker presents to an addiction medicine clinic. He reports consuming a half-liter of vodka daily and feels unable to quit relying on willpower alone. His medical history is notable for a previous heroin addiction, which has been in stable remission for three years via daily buprenorphine-naloxone therapy. He was also diagnosed with chronic hepatitis C two years ago but has not received antiviral treatment. Vital signs are within normal limits. Physical examination shows a calm, cooperative patient with no tremors, diaphoresis, or autonomic instability.

Laboratory evaluation reveals:

The patient requests a medication to help reduce his alcohol consumption. Which of the following is the most appropriate pharmacotherapy for this patient?

An 8-month-old infant girl is evaluated in the pediatric clinic during mid-winter for a three-day history of nasal congestion and a subjective low-grade fever. Today, her parents noticed that she developed a raspy cough and is breathing faster than usual. She has been feeding slightly less than normal but continues to have an adequate number of wet diapers. Her medical history is unremarkable, and she is up to date on all recommended immunizations. On physical examination, her temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), heart rate is $135/\text{min}$, respiratory rate is $56/\text{min}$, and oxygen saturation is $95\%$ on room air. The infant appears mildly fussy but is easily consolable. Auscultation of the chest reveals diffuse expiratory wheezing and scattered crackles bilaterally, accompanied by mild subcostal retractions. Which of the following is the most appropriate next step in the management of this patient?

An infant boy is evaluated in the neonatal intensive care unit for increased work of breathing. He was born 4 hours ago to a 30-year-old gravida 2, para 2 woman at 38 weeks gestation. Delivery was via elective repeat cesarean section prior to the onset of labor. The mother has a history of diet-controlled gestational diabetes. Her prenatal screening for group B *Streptococcus* was negative.

Upon evaluation, the infant appears tachypneic. Vital signs are temperature 36.9°C (98.4°F), heart rate 155/min, respiratory rate 82/min, and blood pressure 60/40 mm Hg. Oxygen saturation is 89% on room air. Physical examination reveals nasal flaring, subcostal retractions, and a clear chest to auscultation. The skin examination shows multiple 1- to 2-mm firm, pale yellow pustules surrounded by erythematous halos distributed across the trunk and proximal extremities.

Arterial blood gas on room air shows:

A chest radiograph demonstrates prominent perihilar vascular markings, hyperinflation, and a thin line of radiodensity in the right horizontal fissure.

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

During a routine follow-up appointment, a 68-year-old female reports a recent onset of bothersome urinary leakage. Over the past month, she has experienced frequent episodes where a sudden, intense desire to pass urine is immediately followed by incontinence. Additionally, she reports an increase in nighttime awakenings to void. Her past medical history includes poorly controlled type 2 diabetes mellitus, essential hypertension, and painful peripheral neuropathy. Medication adjustments one month ago included the addition of amitriptyline. Current vital signs are within normal limits. On physical examination, there is mild suprapubic fullness but no identifiable anterior or posterior vaginal wall defects. The Q-tip test demonstrates a maximum straining angle of $15^\circ$ from the horizontal. Bedside bladder ultrasonography demonstrates a residual volume of 410 mL immediately after the patient voluntarily voids. Dipstick urinalysis shows no abnormalities. Which of the following is the most appropriate next step in the care of this patient?

Match each pediatric patient's clinical presentation to the most likely causative pathogen.

Match each of the following patient clinical vignettes with the arterial blood gas and basic metabolic panel profile that most accurately reflects their expected mixed acid-base disorder.

A 19-year-old man is brought to the emergency department by his college roommate due to increasingly bizarre behavior. The roommate reports that for the past 21 days, the patient has been highly agitated, refusing to attend classes, and has barricaded himself in their shared dorm room. The patient confidently claims that foreign intelligence agents are tracking his movements through the campus Wi-Fi network. During the interview, the patient appears guarded, frequently pauses to whisper to the empty corner of the room, and his speech frequently derails into unrelated topics. His medical history is unremarkable, and he takes no medications. Vital signs and physical examination are within normal limits. A comprehensive urine toxicology screen is negative. Which of the following is the most likely diagnosis?

A 28-year-old nulliparous woman is evaluated in the hospital for persistent abdominal pain. Two days ago, she was admitted with severe bilateral lower abdominal pain, a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), and purulent cervical discharge. At that time, pelvic examination revealed extreme cervical motion tenderness and a palpable, tender fullness in the left adnexa. A transvaginal ultrasound demonstrated a $6\text{ cm}$ complex, multiloculated cystic mass in the left adnexa with thick walls and internal debris. She was diagnosed with a tubo-ovarian abscess and immediately started on intravenous cefoxitin and doxycycline.

Today ($48\text{ hours}$ after admission), she reports her left lower quadrant pain has progressively worsened. Her temperature is $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), blood pressure is $112/72\text{ mm Hg}$, and pulse is $114\text{ /min}$. Abdominal examination shows hypoactive bowel sounds and significant left lower quadrant tenderness with guarding, but no rebound tenderness. Her leukocyte count has increased from $16,500\text{ /mm}^3$ on admission to $21,000\text{ /mm}^3$ today. Which of the following is the most appropriate next step in management?

Emergency medical services transport a 2-year-old toddler to the pediatric department after the parents found the child unarousable in bed this morning. The parents note that the toddler had been suffering from a mild viral gastroenteritis over the last 48 hours, resulting in complete refusal of solid foods and minimal fluid intake. Medical history is unremarkable, and the child's weight and length have consistently tracked along the 50th percentile.

Upon arrival, the patient is deeply lethargic. Vital signs show a temperature of $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), pulse of 160/min, and respiratory rate of 28/min. Physical assessment demonstrates a soft abdomen with the liver edge palpable 4 cm below the right costal margin. Neurological assessment reveals profound hypotonia without focal deficits.

Initial point-of-care testing and serum chemistry panel demonstrate:

A catheterized urine sample is obtained and is notably completely negative for acetoacetate and beta-hydroxybutyrate.

An impairment in which of the following metabolic pathways best explains this patient's clinical presentation?

A 12-hour-old male neonate is evaluated in the newborn nursery due to respiratory difficulty and a skin eruption. The infant was born at 38 weeks of gestation via uncomplicated vaginal delivery to a 19-year-old primigravida who recently immigrated and received no prenatal care.

Birth weight is 2100 g (4 lb 10 oz). APGAR scores were 7 and 8 at 1 and 5 minutes, respectively. Vital signs show a temperature of 37.3°C (99.1°F), heart rate of 165/min, and respiratory rate of 55/min.

Physical examination reveals a small-for-gestational-age infant with copious, clear nasal discharge. The abdomen is distended, and the liver edge is palpable 4 cm below the right costal margin along with a palpable spleen tip. Skin examination shows a widespread maculopapular rash with prominent desquamation involving the palms and soles.

Initial laboratory evaluation reveals the following:

Which of the following is the most appropriate next step in pharmacologic management for this infant?

A patient with well-controlled depression is evaluated during a same-day appointment for acute-onset agitation, sweating, and muscle spasms. The 45-year-old male states these symptoms began roughly 12 hours ago. His medical history includes major depressive disorder, for which he takes citalopram daily. Two days ago, he strained his lower back while moving heavy boxes and received a prescription from a local urgent care facility. Vital signs show a temperature of 38.6°C (101.5°F), blood pressure of 162/94 mm Hg, and heart rate of 115/min. On physical examination, the patient appears visibly restless and diaphoretic. Neurological assessment reveals bilateral ocular clonus, generalized hyperreflexia, and sustained ankle clonus. Which of the following medications was most likely prescribed for this patient's back injury?

An active 71-year-old woman is evaluated in the clinic to discuss surgical intervention for severe pelvic organ prolapse. She has a history of five vaginal deliveries. Over the past year, she has experienced a bothersome vaginal bulge and a sensation of pelvic heaviness that worsens after prolonged standing. She occasionally has to apply manual pressure to her perineum to initiate voiding. Two months ago, a trial of conservative management with a vaginal ring pessary was attempted but was discontinued because the patient experienced recurrent dislodgment and discomfort. She currently denies any involuntary leakage of urine with coughing, laughing, or physical exertion. Vital signs are within normal limits. Body mass index is $28 \text{ kg/m}^2$. Pelvic examination in the supine position reveals an anterior vaginal wall prolapse that descends $4 \text{ cm}$ beyond the hymen during the Valsalva maneuver. The apical and posterior vaginal compartments are well supported. Post-void residual volume is $45 \text{ mL}$. The patient is eager to proceed with surgical repair. Which of the following is the most appropriate next step in the management of this patient?

During a school field trip, a 9-year-old girl with a history of atopy and reactive airway disease suddenly develops severe shortness of breath. By the time emergency medical services transport her to the hospital, she is lethargic and exhibiting head-bobbing with each breath. Vital signs on presentation include a heart rate of 158/min, respiratory rate of 46/min, and oxygen saturation of 83% on a non-rebreather mask. Auscultation reveals a "silent chest" with no discernible wheezing or air movement bilaterally. While the team prepares equipment for potential endotracheal intubation, which of the following pharmacological therapies must be initiated concurrently as part of the immediate resuscitation bundle? (Select all that apply)

A $32$-year-old parous woman presents for evaluation of a $9$-month history of absent menstruation. She previously experienced regular $30$-day menstrual cycles. Her obstetric history is notable for a difficult vaginal delivery three years ago that was complicated by postpartum hemorrhage and required emergent uterine curettage. She denies hot flashes, visual disturbances, or galactorrhea. Her BMI is $21 \text{ kg/m}^2$. Based on standard diagnostic algorithms for secondary amenorrhea, arrange the following management steps in the correct chronological sequence to definitively confirm her suspected diagnosis. Assume all preliminary laboratory results and withdrawal tests yield non-diagnostic or negative results (e.g., normal hormone levels or absence of withdrawal bleeding), thereby necessitating progression to the next step down the diagnostic pathway.

A 72-year-old multiparous woman presents to the urogynecology clinic with a sensation of pelvic pressure and a vaginal bulge. Examination reveals stage III anterior vaginal wall prolapse. After discussing treatment options, she elects for conservative management with a vaginal pessary. The physician prepares to fit the patient for a ring pessary with support. Arrange the following steps of the pessary fitting and management process in the correct chronological order, from the initial evaluation to the final discharge instructions.

A 62-year-old woman comes to the office reporting a three-week history of breast tenderness, abdominal bloating, and intermittent vaginal spotting. She underwent menopause at age 51 and has not experienced any vaginal bleeding until now. Her past medical history is notable for well-controlled hypertension. She takes amlodipine and has no history of hormone replacement therapy. Vital signs are within normal limits. Pelvic examination reveals a parous cervix with a small amount of dark blood in the vaginal vault. Bimanual examination is notable for a slightly enlarged, mobile uterus and a palpable, firm, 9-cm mass in the left adnexa. Transvaginal ultrasound demonstrates a 9.5-cm complex, solid and cystic left ovarian mass and an endometrial stripe thickness of 16 mm. A urine pregnancy test is negative. Which of the following is the most appropriate next step in the evaluation of this patient?