Tüm alıştırma soruları

A $26$-year-old primigravida at $40$ weeks gestation is evaluated in the labor and delivery unit. She is undergoing an induction of labor for gestational diabetes mellitus. She is currently receiving a continuous intravenous oxytocin infusion, and epidural anesthesia is in place. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $122/78\text{ mmHg}$, and pulse is $88/\text{min}$. A recent cervical examination revealed a dilation of $6\text{ cm}$, $90\%$ effacement, and $0$ station. Over the past $20$ minutes, the tocodynamometer records $7$ uterine contractions per $10$-minute window, with each contraction lasting $60$ to $80$ seconds. The fetal heart rate tracing demonstrates a baseline of $145/\text{min}$, minimal variability, and recurrent decelerations that begin after the peak of the contractions and take $\geq 30$ seconds to reach their nadir.

The nurse immediately discontinues the oxytocin infusion, repositions the patient to the left lateral decubitus position, and administers a $500\text{-mL}$ intravenous bolus of lactated Ringer solution. Fifteen minutes later, the contraction frequency remains $6$ to $7$ per $10$ minutes, and the fetal heart rate tracing continues to show recurrent late decelerations with minimal variability.

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

During a routine health maintenance visit, a 23-year-old female college student reports a bothersome change in her vaginal discharge over the past week. She describes the discharge as thin and grayish, accompanied by a noticeable malodor that is particularly prominent after sexual intercourse. She has no abdominal pain, pruritus, or dysuria. The patient has been in a monogamous relationship with a new male partner for the past month. Her temperature is 37.0°C (98.6°F) and blood pressure is 118/76 mm Hg. Abdominal examination is unremarkable. On pelvic examination, the vulva and vagina appear normal with no erythema, but a homogeneous, gray-white fluid smoothly coats the vaginal walls. The cervix appears normal, and there is no cervical motion tenderness. Vaginal pH is measured at 5.5. The addition of potassium hydroxide to the fluid produces a strong amine odor. Microscopic evaluation of a wet mount reveals multiple squamous epithelial cells with stippled appearances and indistinct borders. Which of the following is the most appropriate next step in management for this patient?

A 28-year-old woman, gravida 2, para 2, is evaluated in the outpatient clinic 3 days after an uncomplicated term vaginal delivery. She has chosen to exclusively formula-feed her newborn. The patient reports severe, bilateral breast pain and swelling that began 24 hours ago. Her temperature is 37.4°C (99.3°F), blood pressure is 118/76 mm Hg, pulse is 78/min, and respirations are 14/min. Physical examination reveals bilaterally enlarged, firm, and diffusely tender breasts. There is no focal erythema, fluctuance, or purulent nipple discharge. Which of the following is the most appropriate next step in management?

An obstetrician evaluates a $31$-year-old primiparous female in the outpatient clinic $3$ weeks after childbirth. The patient reports a constant, involuntary trickling of fluid from her vagina. Her labor course was complicated by an arrest of descent in the second stage, ultimately requiring a forceps-assisted vaginal delivery of a macrosomic infant weighing $4.2\text{ kg}$ ($9.2\text{ lbs}$). The patient states her undergarments are persistently wet regardless of her physical activity, position, or whether she is coughing. She explicitly denies pain with urination, a sudden urge to void, or any sensation of incomplete bladder emptying. Vital signs are within normal limits. A speculum examination reveals clear fluid pooling in the posterior vaginal vault, but no discrete lacerations or mucosal defects are immediately visible. Urinalysis shows no leukocyte esterase, nitrites, or abnormal cellular elements. Which of the following is the most appropriate next step in the evaluation of this patient's symptoms?

An expectant mother at $25$ weeks of gestation visits the obstetrician's office for a follow-up assessment. She is $27$ years old, gravida $1$, para $0$. Her pregnancy has been uncomplicated thus far. She reports experiencing occasional mild swelling in her ankles by the end of the day but denies headaches, visual changes, abdominal pain, contractions, or vaginal bleeding. Fetal movements are felt daily. Maternal vital signs show a blood pressure of $112/68$ mm Hg, heart rate of $82$/min, and respiratory rate of $16$/min. Fundal height is $25$ cm, and the fetal heart rate is $145$/min. Laboratory studies obtained earlier this morning yield the following results:

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

Six days following a complex total laparoscopic hysterectomy for deeply infiltrating endometriosis, a patient presents to her physician's office reporting progressive right-sided back pain. She notes that the pain occasionally radiates to her right groin and is associated with nausea and feeling feverish. The operative report indicates that extensive adhesiolysis was required due to significant anatomical distortion in the posterior cul-de-sac and broad ligament. She is currently voiding normally without dysuria. Vital signs show a temperature of $38.2^{\circ}\text{C}$ ($100.8^{\circ}\text{F}$), blood pressure of $118/76\text{ mm Hg}$, and a pulse of $88\text{/min}$. Abdominal examination is notable for a soft, non-distended abdomen with normal bowel sounds. Severe tenderness is present upon percussion of the right costovertebral angle. Laboratory testing demonstrates a leukocyte count of $11,500/\mu\text{L}$ and a serum creatinine level of $0.8\text{ mg/dL}$, which is unchanged from her preoperative baseline. Urinalysis reveals $15$-$20$ red blood cells per high-power field and is negative for leukocyte esterase and nitrites. Which of the following is the most appropriate next step in management?

An 8-week-old infant is evaluated in the pediatric emergency department for poor feeding and excessive sweating during meals. Over the past two weeks, his mother has noticed that he breathes unusually fast and becomes exhausted after consuming only 1 to 2 ounces of formula. A previous evaluation at a local clinic attributed the rapid breathing to a viral respiratory infection, but his symptoms have progressively worsened. Vital signs include a heart rate of 172/min, respiratory rate of 68/min, and blood pressure of 85/45 mmHg. Pulse oximetry is 97% on room air. On physical examination, the infant appears mildly distressed. Auscultation of the lungs reveals bilateral basilar crackles and scattered expiratory wheezes. Cardiovascular examination shows a palpable parasternal heave and a grade 3/6 pansystolic murmur best heard at the left lower sternal border. Abdominal examination demonstrates a firm liver edge palpable 3.5 cm below the right costal margin. Which of the following is the most likely underlying hemodynamic derangement responsible for this patient's presentation?

A primigravid patient at 10 weeks of gestation comes to the office for an initial obstetric evaluation. The patient feels well and has no current medical concerns. She specifically notes an absence of pelvic pain, vaginal pruritus, or malodorous discharge. Her medical history is unremarkable, and she has never had a sexually transmitted infection. Pelvic examination demonstrates a normal-appearing cervix with a minimal amount of thin, grayish fluid in the posterior fornix. A sample of the fluid is evaluated under microscopy, revealing several vaginal epithelial cells with obscured borders and a stippled appearance. The addition of potassium hydroxide to the slide produces a noticeable amine odor. The vaginal pH is measured at 5.5. What is the most appropriate next step in the management of this patient?

Seeking evaluation for severely heavy and unpredictable vaginal bleeding, a $48$-year-old G2P2 patient visits the women's health center. Her symptoms began $6$ months ago, characterized by menses occurring at random $14$- to $45$-day intervals and lasting up to $12$ days, requiring her to change super-absorbent pads every $3$ hours. She also reports feeling persistently cold, profound lethargy, and a documented $6$-kg ($13.2$-lb) weight gain during this timeframe. She notes mild acne and increased facial hair growth since her twenties, for which she was previously told she might have "ovary cysts." Five years ago, she developed an unprovoked deep venous thrombosis in her left lower extremity, which was treated with anticoagulation for $6$ months. She takes no medications currently.

Vital signs reveal a temperature of $36.6^\circ$ C ($97.9^\circ$ F), blood pressure of $132/84$ mmHg, pulse of $56$/min, and respirations of $14$/min. Her BMI is $34$ kg/m $^2$.

Pelvic examination demonstrates an active moderate flow of blood through the cervical os, but no visible vaginal or cervical lesions. The uterus is mobile, non-tender, and of normal size.

Laboratory analysis:
- Urine beta-hCG: negative
- Hemoglobin: $10.4$ g/dL
- Thyroid-stimulating hormone (TSH): $0.1$ $\mu$ U/mL (Normal: $0.4$-$4.0$ $\mu$ U/mL)
- Free thyroxine (T4): $0.5$ ng/dL (Normal: $0.9$-$1.7$ ng/dL)

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

A $26$-year-old healthy primigravida with a blood type of O-negative presents for her first prenatal visit at $7$ weeks gestation. She has an uncomplicated medical history and wishes to follow all standard prenatal care guidelines. Arrange the following routine prenatal screening and prophylactic interventions in the correct chronological order from the earliest gestational age they are indicated to the latest.

A 3-year-old boy is rushed to the emergency department by his parents. The family recently immigrated to the United States, and the child's vaccination history is unknown. Over the past 6 hours, he has developed a high fever, severe difficulty breathing, and a muffled voice. Upon evaluation, the child is sitting upright, leaning forward with his neck extended, and drooling profusely. He appears highly anxious. He has marked inspiratory stridor and moderate intercostal retractions. Oxygen saturation is 92% on room air.

Arrange the following next steps in management in the most appropriate sequential order for this patient.

A family planning clinic provides counseling for various patients with unique medical backgrounds. Match each clinical profile below with the most appropriate contraceptive method based on the standard Medical Eligibility Criteria (MEC) guidelines.

A $10$-month-old female infant is brought to the emergency department by her parents due to severe, episodic abdominal pain and lethargy. The parents report she has been pulling her legs up to her chest and crying inconsolably for the past $24$ hours. In the last $4$ hours, she has become increasingly difficult to arouse. She recently passed a stool described by the parents as looking like "currant jelly."

Physical examination reveals:
Temperature: $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$)
Heart rate: $185/\text{min}$
Respiratory rate: $55/\text{min}$
Blood pressure: $65/40\text{ mmHg}$

The infant appears toxic, mottled, and lethargic. The abdomen is grossly distended, rigid, and exquisitely tender to light palpation. Bowel sounds are absent.

Laboratory results:
pH: $7.24$
PaCO $_2$: $30\text{ mmHg}$
HCO $_3^-$: $12\text{ mEq/L}$
Lactate: $5.8\text{ mmol/L}$ (Normal: $0.5-1.5$)

After initiating airway management and aggressive intravenous fluid resuscitation, which of the following is the most appropriate next step in the management of this patient?

A 31-year-old woman, gravida 1 para 0, at 40 weeks gestation is admitted to the labor and delivery unit for induction of labor due to oligohydramnios. An intravenous oxytocin infusion is initiated. Four hours later, her temperature is 37.0°C (98.6°F), blood pressure is 122/78 mm Hg, and pulse is 88/min. Cervical examination reveals the cervix is 6 cm dilated, 90% effaced, and at 0 station. The external fetal monitor demonstrates a fetal heart rate baseline of 145/min with moderate variability. Over the past 15 minutes, there are recurrent, symmetric, gradual decreases in the fetal heart rate that consistently begin after the peak of the contraction and return to baseline after the contraction ends. Uterine contractions are occurring every 1 to 1.5 minutes and lasting 60 to 70 seconds. The patient is repositioned to the left lateral decubitus position and administered an intravenous fluid bolus, but the fetal heart rate pattern persists. Which of the following is the most appropriate next step in management?

A healthy nulliparous patient at term ($39$ weeks gestation) presents in active labor and subsequently delivers a vigorous male infant vaginally. During the third stage of labor, significant umbilical cord traction is applied. Immediately following the delivery of the placenta, the patient develops catastrophic vaginal hemorrhage. Her vital signs rapidly deteriorate, showing a blood pressure of $75/40$ mm Hg and a pulse of $138$/min. Palpation of the maternal abdomen reveals that the uterine fundus is entirely unpalpable at the umbilicus. A speculum examination identifies a large, smooth, beefy-red mass extending through the dilated cervix. Intravenous fluid resuscitation and massive transfusion protocols are rapidly initiated for acute complete uterine inversion. Arrange the following definitive management steps in the correct chronological sequence.

Presenting with a dull, continuous ache in her right flank, a primigravid patient at $26$ weeks gestation is evaluated in the obstetric triage unit. She first noticed the discomfort yesterday. There is no radiation of the pain to the groin, and she has not experienced any fever, chills, urinary frequency, or dysuria. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $110/68$ mm Hg, and pulse is $82$/min. Physical examination shows a gravid uterus consistent with gestational age and trace tenderness over the right costovertebral angle. Laboratory results are as follows:

Hemoglobin: $11.2$ g/dL
Leukocyte count: $10,500/\text{mm}^3$
Blood urea nitrogen: $7$ mg/dL
Serum creatinine: $0.5$ mg/dL

Urinalysis is negative for blood, nitrites, and leukocyte esterase, showing $1$-$2$ WBCs/hpf. A right upper quadrant and renal ultrasound reveals mild dilation of the right renal pelvis and proximal ureter, without visible echogenic foci or acoustic shadowing. The left kidney appears normal. Which of the following is the most appropriate next step in management?

Parents bring their 5-year-old son to the emergency department because he has developed worsening weakness in his legs over the past two days. According to his mother, he has been stumbling frequently and today refused to get out of bed, complaining that his legs feel "like jelly." Three weeks ago, the boy experienced a self-resolving episode of abdominal cramps and bloody diarrhea. On physical examination, his temperature is $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$), heart rate is $108/\text{min}$, respiratory rate is $20/\text{min}$, and blood pressure is $102/64\text{ mm Hg}$. He is alert and interactive. Cranial nerve examination shows no abnormalities. Motor examination reveals symmetric $3/5$ strength in the proximal and distal lower extremities, and $5/5$ strength in the upper extremities. Deep tendon reflexes are absent at the patellae and Achilles, and $1+$ at the biceps. Sensory examination to light touch and pinprick is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

A 9-year-old boy is hospitalized for the management of acute myeloid leukemia. He recently completed his first cycle of induction chemotherapy. Five days ago, he developed a fever of $39.4^\circ C$ ($102.9^\circ F$) and was found to have an absolute neutrophil count (ANC) of $120/\mu L$. Blood and urine cultures were drawn, and empiric intravenous cefepime was initiated.

Today (hospital day 6 of fever), his temperature remains elevated at $39.2^\circ C$ ($102.6^\circ F$). His blood pressure is 105/65 mmHg, and heart rate is 110/min. Physical examination reveals a clean central venous catheter site with no surrounding erythema or tenderness. The lungs are clear to auscultation, and there are no oral lesions or skin rashes.

Laboratory studies today show:

Blood cultures from admission and from two days ago have shown no growth. A chest radiograph reveals no infiltrates. Which of the following is the most appropriate next step in management?

Correlate the following clinical assessments and microscopic laboratory findings with the correct definitive pharmacotherapy and partner management protocol.

A nulliparous patient at $38$ weeks and $5$ days gestation is monitored on the labor ward after presenting with painful uterine contractions. Her prenatal course was unremarkable. Current maternal vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $122/80$ mm Hg, and pulse $88$/min. Pelvic examination demonstrates a cervix that is $6$ cm dilated and $90\%$ effaced, with the fetal vertex at $0$ station. The amniotic membranes ruptured spontaneously one hour ago. Uterine contractions are palpable every $3$ minutes. The continuous fetal heart rate monitor displays a baseline of $140$/min with moderate variability. Throughout the last $20$ minutes, the tracing reveals recurrent, abrupt decreases in the fetal heart rate to $85$/min that last for approximately $40$ seconds before abruptly returning to the baseline. The nadirs of these decelerations have no consistent temporal relationship to the uterine contractions. Which of the following is the most appropriate initial step in the management of this patient?