Tüm alıştırma soruları

A 62-year-old woman comes to the clinic reporting intermittent vaginal spotting for the past month. She went through menopause at age 50. Her medical history is notable for estrogen receptor-positive breast cancer diagnosed three years ago, which was treated with lumpectomy, radiation therapy, and ongoing tamoxifen therapy. Vital signs are within normal limits. Pelvic examination demonstrates a normal-appearing vulva, thin vaginal mucosa, and a small amount of dark red blood in the vaginal vault. The cervix has no visible lesions. A transvaginal ultrasound reveals a heterogeneous endometrial stripe of 14 mm. Which of the following is the most appropriate next step in management?

An expectant 34-year-old mother (G3P2) is admitted to the maternity ward at 39 weeks of gestation. She is attempting a vaginal delivery following a previous lower transverse cesarean section. While her labor is progressing, her vital signs show a pulse of 115/min and a blood pressure of 100/60 mm Hg. Suddenly, she cries out, reporting a severe, tearing pain in her lower abdomen. The continuous tocodynamometer, which previously showed regular activity, now indicates a complete cessation of uterine contractions. A rapid bedside pelvic examination reveals that the presenting fetal part, previously palpable at +1 station, has retracted and is no longer easily reached. Simultaneously, the fetal monitor displays a sudden and sustained heart rate deceleration to 80/min. Which of the following is the most likely diagnosis?

A 19-year-old female university student visits the clinic seeking a reliable method of birth control. She reports that her menstrual periods have been unpredictable since menarche at age 13, often occurring every 3 to 4 months. She also notes worsening facial acne and excess dark hair on her upper lip. Her body mass index is $32 \text{ kg/m}^2$. Blood pressure is $118/76 \text{ mmHg}$ and heart rate is $78/\text{min}$. A urine pregnancy test obtained in the clinic today is negative. During the interview, the patient mentions suffering from severe headaches that are consistently preceded by flashing lights and blind spots. The physician strongly suspects an underlying endocrinopathy but must first address her request for contraception and endometrial protection. Which of the following is the most appropriate next step in the management of this patient?

Match the following clinical presentations of gynecologic infections to their most appropriate, guideline-concordant initial management strategies.

A 5-year-old boy is brought to the pediatrician by his parents because he has been limping since yesterday morning. The parents report that he had a mild upper respiratory tract infection about one week ago, which resolved without treatment. He refuses to bear full weight on his right leg but is able to walk with a noticeable limp. His temperature is 37.4°C (99.3°F), blood pressure is 95/60 mm Hg, pulse is 98/min, and respirations are 20/min. Physical examination shows no erythema or swelling of the lower extremities. There is full range of motion of the right knee and ankle. However, internal rotation and abduction of the right hip elicit discomfort. Laboratory studies show:

Leukocyte count: $7,500/\text{mm}^3$
Erythrocyte sedimentation rate: $15 \text{ mm/h}$
C-reactive protein: $0.5 \text{ mg/dL}$

Radiographs of the right hip and pelvis are unremarkable. Which of the following is the most appropriate next step in management for this patient?

A $14$-day-old female neonate, born at $26$ weeks gestation, is evaluated in the neonatal intensive care unit for worsening respiratory distress. She was initially treated with surfactant for respiratory distress syndrome and successfully extubated to noninvasive positive pressure ventilation on day $3$ of life. Over the past $24$ hours, she has required an increasing fraction of inspired oxygen ($FiO_2$) and has experienced three episodes of apnea. Her temperature is $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$), heart rate is $178/\text{min}$, and blood pressure is $50/20\text{ mmHg}$. Physical examination reveals bounding palmar and pedal pulses and a hyperactive precordium. A continuous, machinery-like murmur is heard loudest at the left infraclavicular region. Lung auscultation reveals bilateral crackles. An echocardiogram confirms a left-to-right shunt through a vascular structure connecting the descending aorta and the left pulmonary artery. The medical team decides to initiate targeted pharmacologic therapy to close this structure. Which of the following is a well-recognized potential adverse effect of the most appropriate medication for this indication?

A full-term male newborn, aged 4 hours, is evaluated in the neonatal care unit due to the sudden onset of a bluish discoloration of the lips and face. The pregnancy and vaginal delivery were entirely uncomplicated, and Apgar scores were normal. Current vital signs include a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), a heart rate of $160/\text{min}$, a respiratory rate of $62/\text{min}$, and an oxygen saturation of $71\%$ on room air. The patient is placed in a headbox with $100\%$ fraction of inspired oxygen; a repeat saturation measurement after 15 minutes is $73\%$. Physical examination reveals a tachypneic infant with profound central cyanosis but no nasal flaring or retractions. Cardiac auscultation identifies a loud, single second heart sound (S2) and a grade 2/6 holosystolic murmur heard best at the left lower sternal border. Palpation of the brachial and femoral pulses reveals symmetric, 2+ intensity with no pulse discrepancies. A portable chest radiograph displays a narrow mediastinal silhouette resembling an egg on a string, alongside normal pulmonary vascular markings. Which of the following is the most appropriate next step in the management of this patient?

Evaluate the following acute obstetric presentations and match each clinical scenario with its most specific underlying pathophysiologic mechanism.

A 4-year-old boy is brought to the emergency department by his parents because he has been refusing to walk since he woke up this morning. The parents note that he complains of pain in his right anterior thigh and knee. He had a mild upper respiratory tract infection two weeks ago but has otherwise been healthy. His temperature is $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), blood pressure is $90/60\text{ mm Hg}$, pulse is $118/\text{min}$, and respirations are $22/\text{min}$. On physical examination, the child appears uncomfortable and refuses to stand or bear any weight on his right leg. The right hip is held in slight flexion, abduction, and external rotation. There is no visible erythema or swelling of the hip, thigh, or knee. Range of motion of the right knee is full and painless, but any attempt to internally rotate the right hip elicits severe pain and crying. Laboratory studies show:

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

A newborn male, delivered at 38 weeks of gestation following an uncomplicated pregnancy, develops profound perioral and truncal cyanosis at 4 hours of life. His peripheral oxygen saturation is 58% on room air and increases to only 62% after 15 minutes of 100% fraction of inspired oxygen ($FiO_2$) via headbox. His respiratory rate is 65/min with minimal work of breathing. Cardiac auscultation reveals a single, loud second heart sound ($S_2$) and a faint, non-radiating systolic murmur at the left mid-sternal border. Urgent echocardiography confirms the aorta arising anteriorly from the right ventricle and the pulmonary trunk arising posteriorly from the left ventricle. The ventricular septum is intact, and color Doppler demonstrates a highly restrictive patent foramen ovale ($PFO$) with minimal bidirectional flow. Arrange the following interventions in the most appropriate chronological sequence for the management of this patient, from immediate life-saving stabilization to definitive treatment.

A 30-month-old male toddler presents to the emergency department with a persistent cough and noisy breathing. The symptoms began abruptly 3 hours ago during a family picnic while the child was eating trail mix. The parents witnessed a brief, severe choking episode that resolved spontaneously, but the child has had a mild cough and increased work of breathing since. His temperature is 37.0°C (98.6°F), blood pressure is 92/58 mm Hg, pulse is 124/min, and respirations are 34/min. Pulse oximetry is 95% on room air. On physical examination, the child is alert but appears mildly anxious. Lung auscultation reveals decreased breath sounds and a monophonic expiratory wheeze exclusively over the right hemithorax. A right lateral decubitus chest radiograph demonstrates hyperlucency of the right lung, with a failure of the dependent lung to deflate, and a leftward mediastinal shift. Which of the following is the most appropriate next step in management?

An 18-year-old nulliparous woman is admitted to the labor ward at 41 weeks of gestation for a scheduled labor induction. She is currently receiving a continuous intravenous infusion of oxytocin. A cervical examination reveals 6 cm of dilation and 80% effacement. The continuous external fetal monitor displays a baseline heart rate of 140/min with moderate variability. Over the last 20 minutes, the monitor reveals symmetric, gradual decreases in the fetal heart rate that begin after the peak of the uterine contractions and slowly return to baseline only after the contractions have completely ended. Maternal vital signs are temperature 37.1°C (98.8°F), blood pressure 118/76 mm Hg, pulse 88/min, and respirations 16/min. Which of the following is the most appropriate next step in management?

A female adolescent seeks evaluation at the outpatient endocrinology clinic due to distressing changes in her physical appearance. Over the preceding year, she has developed coarse, dark hair on her chin and upper lip, along with persistent nodulocystic acne that has not responded to topical therapies. She achieved menarche at $12$ years of age, but her menstrual cycles have become increasingly erratic, currently occurring at intervals of $3$ to $5$ months. Blood pressure is $112/72 \text{ mmHg}$ and body mass index is $23 \text{ kg/m}^2$. Physical examination reveals a Ferriman-Gallwey score of $11$, with normal breast and female external genital development. There is no clitoromegaly.

Early morning serum analyses yield the following results:
Total testosterone: $92 \text{ ng/dL}$ (Normal: $15-70 \text{ ng/dL}$)
Dehydroepiandrosterone sulfate (DHEA-S): $580 \text{ } \mu\text{g/dL}$ (Normal: $65-380 \text{ } \mu\text{g/dL}$)
$17$-hydroxyprogesterone: $3,800 \text{ ng/dL}$ (Normal: $< 200 \text{ ng/dL}$)
Thyroid-stimulating hormone (TSH): $1.6 \text{ mU/L}$ (Normal: $0.5-5.0 \text{ mU/L}$)
Free thyroxine (T4): $1.1 \text{ ng/dL}$ (Normal: $0.8-2.0 \text{ ng/dL}$)

Transabdominal ultrasonography reveals normal-appearing ovaries with no evidence of cysts.

Which of the following best describes the fundamental pathophysiologic mechanism responsible for this patient's condition?

A 28-day-old male infant is urgently evaluated in the emergency department after his parents noted a sudden onset of inconsolable crying and repeated episodes of vomiting over the past 5 hours. The vomitus was initially composed of digested breast milk but has recently become dark green. He was born at 38 weeks gestation without complications and had been feeding well until this morning. On physical examination, the infant appears mottled and lethargic. Vital signs reveal a temperature of 38.1°C (100.6°F), heart rate of 192/min, respiratory rate of 65/min with intercostal retractions, and blood pressure of 54/32 mm Hg. Capillary refill time is prolonged at 6 seconds. The abdomen is distended, markedly rigid, and exquisitely tender to palpation, with a faint erythematous discoloration of the periumbilical skin. Bowel sounds are absent. A portable plain radiograph of the abdomen demonstrates a paucity of distal bowel gas with no evidence of pneumoperitoneum. Which of the following is the most appropriate next step in the management of this patient?

A 26-year-old primigravida at 39 weeks gestation is admitted to the hospital in spontaneous labor. Her pregnancy has been uncomplicated. Her cervix is 6 cm dilated and 90% effaced. The patient is receiving continuous external fetal monitoring. Over the last 30 minutes, the fetal heart rate baseline is 135/min with moderate variability. However, there are recurrent, symmetric decreases in the fetal heart rate that begin after the peak of each uterine contraction and return to baseline only after the contraction has completely finished. The patient's blood pressure is 120/80 mm Hg and her pulse is 85/min. Which of the following is the most appropriate initial step in the management of this patient?

A $74$-year-old woman is brought to the emergency department from a skilled nursing facility due to sudden-onset, severe abdominal pain and altered mental status. Staff report that she had several episodes of bloody diarrhea earlier in the day. Her medical history includes hypertension, type 2 diabetes mellitus, and paroxysmal atrial fibrillation for which she frequently misses her doses of apixaban. Her temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is $82/50\text{ mmHg}$, heart rate is $128/\text{min}$ and irregular, and respiratory rate is $24/\text{min}$. On physical examination, she appears lethargic. The abdomen is rigid with diffuse involuntary guarding and severe rebound tenderness. Bowel sounds are absent.

Laboratory results:
Leukocytes: $22,500/\mu\text{L}$
Hemoglobin: $11.2\text{ g/dL}$
Platelets: $210,000/\mu\text{L}$
Lactic acid: $8.4\text{ mmol/L}$
Bicarbonate: $12\text{ mEq/L}$

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

A 24-year-old woman presents to the emergency department with a 2-day history of progressively worsening shortness of breath, chest tightness, and a nonproductive cough. She has a history of asthma and normally uses an albuterol inhaler as needed, but she ran out of medication two weeks ago. Her temperature is 37.1 C (98.8 F), blood pressure is 128/82 mm Hg, pulse is 118/min, and respiratory rate is 28/min. Oxygen saturation is 93% on room air. Physical examination reveals diffuse bilateral expiratory wheezing with a prolonged expiratory phase. She is speaking in short phrases, using accessory muscles of respiration, and appears anxious. Which of the following are appropriate initial pharmacological interventions for this patient? (Select all that apply)

An on-call physician is asked to assess a 59-year-old female patient on the surgical ward. She is currently on her seventh day of recovery after undergoing an open resection of a perforated appendix. The nursing staff reports that she has developed excruciating, unremitting abdominal pain over the last few hours, accompanied by three episodes of vomiting dark green fluid. She confirms she has not passed gas or had a bowel movement since yesterday morning.

Vital signs show a temperature of 39.1°C (102.4°F), blood pressure of 92/58 mm Hg, heart rate of 128/min, and respiratory rate of 24/min. On physical examination, the patient appears acutely ill and lies completely still in bed. Her abdomen is significantly distended. Palpation elicits diffuse rigidity, involuntary guarding, and severe tenderness with sudden release of pressure. Auscultation reveals a complete absence of bowel sounds. Blood tests reveal a white blood cell count of 21,000/mm³ and an elevated venous lactate concentration. Plain abdominal radiographs display multiple loops of dilated small intestine containing prominent air-fluid levels, alongside an absence of distal colonic gas.

Which of the following are appropriate next steps in managing this patient's current condition? (Select all that apply)

During rounds in the intensive care unit, the telemetry alarm sounds for a 55-year-old female patient who was admitted for atypical chest pain. Upon entering the room, the medical team finds her unresponsive, apneic, and without a palpable pulse. The bedside monitor reveals chaotic, highly irregular waveform deflections of varying amplitudes with no discernible P waves, QRS complexes, or T waves. A manual defibrillator is immediately available at the bedside. Assuming her rhythm remains refractory to all interventions, arrange the following management steps in the correct chronological sequence according to the standard adult Advanced Cardiac Life Support (ACLS) algorithm.

A 3-year-old unimmunized boy is brought to the emergency department with a rapid onset of high fever, severe sore throat, and drooling. He is sitting upright, leaning forward with his neck extended, and appears highly anxious. He has significant inspiratory stridor and suprasternal retractions. Arrange the following management steps in the most appropriate sequential order for this patient.