Tüm alıştırma soruları

Match each common pediatric congenital cardiovascular disorder with its classic physical examination finding.

Match each characteristic peripheral blood smear or microscopic finding with the most likely corresponding pediatric hematologic or oncologic diagnosis.

Match the following clinical presentations of pediatric limp and lower extremity pain with their most accurate underlying pathophysiologic description.

A healthy 24-year-old primigravida presents for her initial prenatal visit at 8 weeks gestation. She asks about the timeline of standard prenatal assessments and screenings she will undergo throughout her pregnancy. Arrange the following routine prenatal evaluations in the correct chronological order as they are typically recommended from the first trimester to term.

A 14-day-old term male infant is brought to the emergency department due to acute onset of irritability and three episodes of bright green emesis over the past 4 hours. The infant was born at 39 weeks gestation without complications and had been feeding well until today. Vital signs are within normal limits for age. Physical examination reveals a soft, non-distended abdomen without palpable masses, guarding, or erythema. There is no hemodynamic instability. Assuming this patient proceeds through standard evaluation and requires surgical intervention for the most likely underlying etiology without evidence of bowel perforation at any stage, arrange the following diagnostic and therapeutic steps in the correct chronological sequence.

A primigravid patient at $39$ weeks gestation arrives at the labor and delivery unit in active labor. Her prenatal course was uncomplicated. Uterine contractions are occurring every $3$ minutes. Initial examination reveals a blood pressure of $120/75 \text{ mm Hg}$, a heart rate of $98/\text{min}$, and a respiratory rate of $20/\text{min}$. Routine admission laboratory results show a hemoglobin level of $10.8 \text{ g/dL}$ and a hematocrit of $32\%$. Because the patient reports feeling mildly short of breath during contractions, an arterial blood gas analysis is obtained, which reveals a pH of $7.44$, $\text{PaCO}_2$ of $28 \text{ mm Hg}$, and $\text{PaO}_2$ of $104 \text{ mm Hg}$. The patient subsequently requests neuraxial analgesia, and an epidural block is administered without technical difficulty. Twenty minutes later, she reports feeling dizzy and nauseated. Her blood pressure is now $86/50 \text{ mm Hg}$. Concurrent electronic fetal monitoring demonstrates a baseline heart rate of $140/\text{min}$, minimal variability, and symmetric, gradual decreases in the heart rate that reach their nadir after the peak of each uterine contraction. Which of the following is the most appropriate initial step in management?

Match each pediatric patient's clinical presentation with the most likely congenital cardiac anomaly.

A 4-week-old boy is brought to the emergency department by his parents due to a 3-day history of worsening vomiting. The parents report that he forcefully vomits a large amount of milk immediately after almost every feed. The vomitus does not contain bile. Despite the vomiting, the infant appears hungry and eagerly accepts feeds right after an episode. He has had only one wet diaper in the past 12 hours. Vital signs are temperature 37.0°C (98.6°F), heart rate 165/min, blood pressure 70/40 mm Hg, and respiratory rate 40/min. Physical examination reveals a sunken anterior fontanelle, dry mucous membranes, and markedly decreased skin turgor. Palpation of the abdomen reveals a firm, mobile, olive-shaped mass in the right upper quadrant. Laboratory studies are obtained and show the following:

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

An obstetric evaluation is requested for a 32-year-old woman, currently at $34$ weeks gestation, who visits the clinic with concerns of progressive breathlessness over the past three weeks. She notes that the shortness of breath is most pronounced when climbing the stairs to her apartment. Additionally, she reports an occasional "fluttering" sensation in her chest and mild ankle swelling that worsens by the evening. This is her first pregnancy, which has been uncomplicated thus far; her $1$-hour oral glucose tolerance test at $26$ weeks was within normal limits.

Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), heart rate of $98/\text{min}$, respiratory rate of $18/\text{min}$, and blood pressure of $105/65 \text{ mm Hg}$.

Cardiac auscultation reveals a prominent point of maximal impulse shifted to the fourth intercostal space at the midclavicular line. A grade $2/6$ early systolic ejection murmur is best heard at the left upper sternal border, and a distinct $S_3$ gallop is audible. Pulmonary auscultation is clear in all fields. Lower extremities exhibit $1+$ bilateral pitting edema up to the ankles.

An electrocardiogram demonstrates normal sinus rhythm with left axis deviation and inverted T waves in lead III. Due to her respiratory complaints, an arterial blood gas analysis on room air is obtained by the triage nurse.

Laboratory studies reveal the following:
* Hemoglobin: $11.2 \text{ g/dL}$
* Platelets: $130,000/\text{mm}^3$
* Serum creatinine: $0.5 \text{ mg/dL}$
* Arterial blood gas (room air): $pH$ $7.44$, $PaO_2$ $102 \text{ mm Hg}$, $PaCO_2$ $28 \text{ mm Hg}$, $HCO_3^-$ $18 \text{ mEq/L}$
* Urinalysis: trace protein, $1+$ glucose, negative for leukocyte esterase and nitrites

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

An 8-year-old boy with a known history of moderate persistent asthma presents to the emergency department with acute, severe shortness of breath. He is visibly distressed, using accessory muscles to breathe, and speaking in fragmented sentences. Vital signs reveal a respiratory rate of 42 breaths/min and an oxygen saturation of 88% on room air. Auscultation demonstrates markedly diminished breath sounds with faint expiratory wheezing bilaterally. Arrange the following acute management steps in the most appropriate sequential order for this patient, from first to last.

A 3-year-old boy is brought to the pediatric neurology clinic by his mother and 14-year-old sister for a routine follow-up of his seizure disorder. He has a history of infantile spasms that have now evolved into focal impaired awareness seizures. Examination of the boy reveals erythematous, papular facial lesions clustered around the nose and a thickened, elevated plaque on his lumbosacral region.

During the developmental assessment, the mother expresses concern about the boy's progress. He can walk up steps with assistance and build a tower of six blocks, but he is unable to copy a cross or hop on one foot.

During the visit, the 14-year-old sister asks to speak to the physician privately. She requests a prescription for oral contraceptives, explicitly asking that her mother not be informed. Additionally, the sister complains of a mild cough, rhinorrhea, and sore throat that began 48 hours ago; her physical exam is consistent with an uncomplicated viral upper respiratory infection, yet she asks for a strong antibiotic to "knock it out quickly."

Which of the following statements regarding the management and clinical evaluation of these patients are correct? (Select all that apply)

During a routine kindergarten physical, the physician notes that a 5-year-old boy has grown significantly faster than his peers. His parents report that he has developed axillary hair and adult-like body odor over the last six months. He is otherwise healthy and takes no medications. Vital signs show a blood pressure of $134/86\text{ mm Hg}$ (greater than the 99th percentile for his age and height). Physical examination reveals a muscular habitus and moderate facial acne. Genitourinary examination demonstrates Tanner stage III pubic hair, an enlarged phallus, and bilateral testicular volumes of $2\text{ mL}$. Radiographic imaging of the left wrist indicates a bone age of 9 years, and his serum testosterone is markedly elevated. Which of the following laboratory abnormalities is most likely to be found in this patient?

A 27-year-old G1P0 at 28 weeks gestation arrives at the obstetric clinic for a scheduled prenatal visit. She works as a teacher and mentions mild fatigue by the late afternoon, but otherwise feels healthy. She is fully compliant with her daily prenatal vitamin. Vital signs demonstrate a blood pressure of 112/68 mm Hg and a heart rate of 84/min. Physical examination confirms a fundal height of 28 cm, and the fetal heart rate is reassuring at 150/min. A routine complete blood count is obtained and shows the following results:

Hemoglobin: 10.8 g/dL
Hematocrit: 33%
Mean corpuscular volume (MCV): 88 fL
Platelet count: 215,000/mm³

Which of the following physiologic mechanisms best explains this patient's hematologic profile?

A 4-year-old boy is brought to the pediatrician's office by his parents after they noticed a red, pinpoint rash on his legs and arms this morning. The patient had a mild upper respiratory tract infection two weeks ago but has completely recovered. He is currently active and well-appearing. His temperature is 37.0°C (98.6°F), blood pressure is 95/60 mmHg, pulse is 90/min, and respirations are 20/min. Physical examination reveals scattered petechiae and purpura over the lower extremities. There is no hepatosplenomegaly, lymphadenopathy, or joint swelling. Laboratory evaluation shows:

Hemoglobin: 12.2 g/dL
Leukocyte count: 7,500/mm³
Platelet count: 15,000/mm³
Prothrombin time: 11 seconds (normal: 11-15 seconds)
Activated partial thromboplastin time: 30 seconds (normal: 25-40 seconds)

Which of the following is the most likely diagnosis?

A 2-year-old boy is brought to the emergency department due to refusal to walk for the past 12 hours. His parents note he was well yesterday but awoke crying and pointing to his right leg. His current temperature is $39.5^{\circ}C$ ($103.1^{\circ}F$). On examination, the child is irritable, and the right hip is held rigidly in flexion, abduction, and external rotation. Any attempt to move the joint elicits severe distress. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for managing this patient's condition.

A 9-month-old girl is brought to the emergency department due to intermittent episodes of severe crying. During these episodes, she draws her legs up to her chest and appears to be in significant pain. Between episodes, she is calm and plays with her toys. Her parents report one episode of nonbilious emesis and note that her most recent diaper contained dark red, mucus-like stool. Her vital signs are stable, and abdominal examination reveals a palpable sausage-shaped mass in the right upper quadrant without guarding or rebound tenderness. Arrange the following steps in the standard chronological order of management for this patient.

A 24-year-old primigravida at 38 weeks and 4 days gestation is admitted to the labor and delivery unit in active labor. Her cervical dilation is 6 cm. She requests and receives epidural analgesia for pain relief. Fifteen minutes later, the patient reports feeling lightheaded. Her blood pressure is 85/45 mm Hg and heart rate is 110/min. Physical examination reveals mild bilateral lower extremity edema. Continuous fetal heart rate monitoring demonstrates a baseline of 145/min, minimal variability, and 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. Which of the following is the most appropriate next step in management?

A $27$-year-old woman, gravida $2$, para $1$, at $31$ weeks gestation is evaluated in the labor and delivery unit for chills and a rapid heart rate. She was admitted $48$ hours ago after presenting with a sudden gush of clear vaginal fluid. Ferning and nitrazine tests were positive at that time. Upon admission, she received her first dose of intramuscular betamethasone and was started on prophylactic intravenous ampicillin and oral azithromycin. Her temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $112/72$ mmHg, pulse is $118$/min, and respirations are $18$/min. Continuous fetal monitoring shows a baseline heart rate of $175$/min with moderate variability and no decelerations. Physical examination reveals a tender uterine fundus and malodorous fluid pooling in the posterior vaginal fornix. The cervix is $2$ cm dilated and $50\%$ effaced, with the fetal vertex at $-2$ station. Which of the following is the most appropriate next step in management?

An 8-year-old girl is admitted to the pediatric ward with a 6-day history of worsening productive cough, low-grade fever, and increasing shortness of breath. She has a past medical history of recurrent sinopulmonary infections, nasal polyps, and chronic malabsorption requiring daily pancreatic enzyme supplementation. Her immunizations, including the annual influenza vaccine, are up to date. On admission, her temperature is 38.5°C (101.3°F), blood pressure is 105/65 mmHg, heart rate is 118/min, and respiratory rate is 28/min. Pulse oximetry shows 92% on room air. Physical examination reveals digital clubbing, an increased anteroposterior chest diameter, and coarse crackles over the bilateral upper lung fields. Sputum analysis is performed, and the Gram stain demonstrates abundant neutrophils and Gram-negative bacilli that are oxidase-positive and non-lactose fermenting. Which of the following is the most appropriate antimicrobial regimen for this patient's acute respiratory exacerbation?

A $10$-month-old girl is admitted to the pediatric intensive care unit due to rapidly worsening work of breathing. She was born prematurely at $32$ weeks gestation and is fully immunized according to the standard schedule. Her current illness began $3$ days ago with nasal congestion and a low-grade temperature. The patient's father has severe persistent asthma, and she has a history of mild atopic dermatitis. Vital signs show a temperature of $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), heart rate of $175$/min, and respiratory rate of $68$/min. Oxygen saturation is $87\%$ on ambient air. Physical examination reveals an exhausted infant with marked suprasternal retractions, head bobbing, and diffuse bilateral expiratory wheezing mixed with coarse crackles. A chest radiograph demonstrates hyperinflation, flattened hemidiaphragms, and patchy atelectasis. Based on current pediatric guidelines, which of the following interventions are indicated in the immediate management of this patient? (Select all that apply)