Tüm alıştırma soruları

A 28-year-old woman, gravida 2, para 1, at 34 weeks gestation presents to the clinic for a routine scheduled visit. She reports that her shoes have felt increasingly tight over the past two weeks and she has noticed swelling in both of her ankles. The swelling progressively worsens throughout the day but improves significantly after she sleeps at night. She denies any headaches, visual changes, right upper quadrant pain, chest pain, or shortness of breath. Vital signs include a blood pressure of 116/74 mm Hg, a heart rate of 82/min, and a respiratory rate of 14/min. Physical examination reveals 1+ pitting edema of the bilateral lower extremities extending up to the ankles. Deep tendon reflexes are 2+ and symmetric. Urinalysis is negative for protein and glucose. Which of the following is the most appropriate next step in management for this patient's symptoms?

Match each clinical presentation of a pediatric patient with the most likely underlying endocrine condition.

A female patient in her first pregnancy presents to the obstetric triage unit at term ($39$ weeks of gestation). She reports the continuous leakage of clear vaginal fluid that began approximately $22$ hours prior to arrival. Currently, she is experiencing mild, irregular uterine contractions. Evaluation reveals a maternal core temperature of $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), a blood pressure of $110/70$ mm Hg, and a pulse of $115$/min. Fetal monitoring demonstrates a baseline heart rate of $175$/min with moderate variability and an absence of periodic decelerations. Abdominal examination is notable for diffuse fundal tenderness. Pelvic examination shows the cervix is $4$ cm dilated and $80\%$ effaced. What is the most appropriate next step in the management of this patient?

During normal pregnancy, profound maternal physiological adaptations occur that can mimic pathological disease states. Match each isolated clinical or laboratory finding observed in a healthy pregnant patient (Left) to its precise driving pathophysiologic mechanism (Right).

A 7-year-old boy with a history of meconium ileus in infancy presents to the pulmonary clinic for a routine follow-up. He has a chronic daily cough producing thick, purulent sputum and has required multiple hospitalizations for respiratory exacerbations. He is currently in the 10th percentile for weight and 15th percentile for height. Sweat chloride testing reveals a concentration of $95 \text{ mmol/L}$ (normal $<39 \text{ mmol/L}$). The patient's progressive pulmonary disease is driven by a well-described pathophysiologic cascade.

Arrange the following pathophysiologic events in the chronological sequence that leads to this patient's chronic lung disease, starting with the primary cellular defect.

A 20-year-old woman comes to the clinic because of irregular menstrual periods and increased facial hair. Her menarche occurred at age 13. Her periods were initially regular but have become increasingly irregular over the past two years, now occurring every 3 to 4 months. She has also noticed coarse, dark hair growing on her chin and chest, and she has struggled with severe acne that has not responded to over-the-counter topical treatments. She takes no medications and has no other medical conditions. Vital signs show a blood pressure of 122/78 mmHg, pulse of 76/min, and a BMI of 31 kg/m². Physical examination reveals hirsutism on the face and chest and moderate inflammatory acne on the back. There is no clitoromegaly or deepening of the voice. Pelvic examination is unremarkable. A urine pregnancy test is negative. Initial laboratory studies show a normal serum thyroid-stimulating hormone (TSH) level and a normal serum prolactin level. Which of the following is the most appropriate next step in the evaluation of this patient?

A 2-year-old boy is brought to the pediatric emergency department with a 6-day history of high fever, bilateral non-exudative conjunctivitis, cracked red lips, and a polymorphous maculopapular rash on his trunk. Physical examination reveals cervical lymphadenopathy and erythema of the palms and soles. A clinical diagnosis of Kawasaki disease is made. Arrange the following steps in the correct chronological sequence for the standard management and follow-up of this patient.

A $9$-month-old boy is evaluated in the pediatric neurology clinic for a rapidly increasing head circumference. At his $6$-month well-child visit, his head circumference was at the $85^{\text{th}}$ percentile, but it has now crossed lines to the $99^{\text{th}}$ percentile. His weight and length continue to track along the $50^{\text{th}}$ percentile. The parents are extremely anxious; they have been reading about hydrocephalus and are concerned that he has a severe neurological delay because he only babbles, can pull himself to a stand, but cannot walk independently. On physical examination, the infant is playful and alert. The anterior fontanelle is open, soft, and flat. There is no sunsetting of the eyes, and muscle tone and deep tendon reflexes are normal. An ultrasound of the head reveals normal ventricular size and prominent subarachnoid spaces. Which of the following statements regarding this patient's presentation and management are true? (Select all that apply)

A 14-year-old boy is evaluated in the emergency department for a 3-day history of progressively worsening headache, blurred vision, and shortness of breath. Physical examination reveals pale conjunctivae, scattered petechiae, and bilateral retinal hemorrhages. Vital signs are temperature 37.8°C (100.0°F), heart rate 132/min, respiratory rate 28/min, and blood pressure 110/65 mmHg. Pulse oximetry shows 92% on room air.

Laboratory studies show:
Leukocytes: 380,000/mm³ (90% myeloblasts)
Hemoglobin: 5.2 g/dL
Platelets: 22,000/mm³
Uric acid: 9.8 mg/dL
Potassium: 4.8 mEq/L
Creatinine: 1.1 mg/dL

Arrange the following interventions in the most appropriate chronological sequence to safely manage this patient's acute presentation.

A 2-year-old boy is brought to the pediatric clinic by his parents after they noticed a large amount of dark red blood in his diaper this morning. The parents report the child has been entirely asymptomatic otherwise; he has had no fever, vomiting, abdominal pain, diarrhea, or changes in his appetite. His medical history is unremarkable, and he has reached all developmental milestones appropriately. Vital signs are within normal limits for his age. Physical examination reveals a soft, non-tender abdomen with normal active bowel sounds. Rectal examination shows dark blood in the vault but no anal fissures, skin tags, or palpable masses. Which of the following is the most appropriate next diagnostic test for this patient?

A young patient with an intrauterine pregnancy confirmed by home testing presents for initial obstetric care. She is currently at 8 weeks gestation based on her last menstrual period. She has no chronic medical conditions. Throughout the course of a normal, low-risk pregnancy, arrange the following standard prenatal evaluations in the correct chronological sequence from earliest to latest.

A 5-month-old boy is brought to the emergency department by his parents due to a persistent fever for the past 6 days. His mother reports he has been extremely irritable, feeding poorly, and has a mild, dry cough. A transient erythematous macular rash was noted on his trunk 3 days ago but has since resolved. His temperature is 39.8°C (103.6°F), heart rate is 175/min, blood pressure is 85/50 mmHg, and respiratory rate is 45/min. On physical examination, the infant is fussy but consolable. He has bilateral non-exudative conjunctival injection and erythematous, cracked lips. There is no cervical lymphadenopathy, and his hands and feet appear normal without edema or peeling. Breath sounds are clear bilaterally. Cardiac examination reveals a tachycardic, regular rhythm with no murmurs. Laboratory studies reveal:

Urinalysis demonstrates 25 leukocytes/hpf, negative nitrites, and no bacteria. Which of the following is the most appropriate next step in the management of this patient?

A 7-year-old girl is brought to the pediatrician by her father, who recently noticed that she is developing breasts and has experienced a rapid increase in height over the past year. Vital signs are within normal limits for her age. Physical examination reveals Tanner stage 3 breast development and Tanner stage 2 pubic hair. No axillary hair or acne is noted, and the neurological examination is unremarkable. The physician suspects an early onset of puberty. Arrange the following steps in the most appropriate chronological sequence for the diagnostic evaluation and management of this patient's condition.

A 3-year-old boy is evaluated in the pediatric neurology clinic for progressive unsteadiness. According to his parents, he achieved independent walking at 15 months of age, but his gait has always been 'clumsy.' Over the past year, his balance has deteriorated; he now sways continuously when standing and falls frequently. His medical history is significant for three prior hospitalizations for severe sinopulmonary infections presenting with wheezing and respiratory distress. Vital signs today are: temperature 37.1°C (98.8°F), blood pressure 95/60 mmHg, pulse 105/min, and respirations 22/min. On physical examination, the child exhibits a wide-based, truncal ataxia. Extraocular movement testing reveals impaired smooth pursuit and frequent saccadic intrusions. Close inspection of the eyes reveals prominent, dilated superficial blood vessels on the bulbar conjunctivae bilaterally. Deep tendon reflexes are absent in the lower extremities. The parents mention that he is due for his scheduled childhood immunizations today. Based on the most likely underlying diagnosis, which of the following is the most appropriate recommendation regarding this patient's care?

A 4-month-old boy is brought to the emergency department in January with a 3-day history of rapid breathing, poor feeding, and excessive diaphoresis during feeds. He was noted to have a 'heart murmur' at birth but has not been evaluated by a cardiologist. On physical examination, his temperature is 37.2°C (99.0°F), heart rate is 168/min, respiratory rate is 65/min, and blood pressure is 85/50 mm Hg in the right arm. Oxygen saturation is 94% on room air. Femoral pulses are 2+ and equal bilaterally, with no brachial-femoral delay. Lung auscultation reveals diffuse bilateral expiratory wheezes and fine basilar crackles. Cardiac examination demonstrates a hyperactive precordium, a 4/6 holosystolic murmur heard best at the left lower sternal border, and a prominent S3 gallop. The liver edge is palpable 4 cm below the right costal margin. Suspecting a severe respiratory infection, a resident physician administers nebulized albuterol and oral dexamethasone. Thirty minutes later, the infant becomes increasingly lethargic, his heart rate rises to 215/min, and his respiratory distress significantly worsens. Which of the following best describes the underlying pathophysiology of this patient's initial presentation, and why did the administered pharmacotherapy exacerbate his clinical deterioration?

During an ongoing labor induction for post-term pregnancy, a $31$-year-old nulliparous woman at $41$ weeks gestation is evaluated for abnormal fetal monitoring. She is receiving a continuous intravenous oxytocin infusion. Her most recent laboratory results demonstrate a hemoglobin concentration of $10.4\text{ g/dL}$ and a normal basic metabolic panel. On continuous electronic fetal monitoring, the baseline heart rate is $145\text{/min}$ with moderate variability. The tracing reveals symmetric, gradual decreases in the fetal heart rate that nadir after the peak of uterine contractions and return to baseline after the contractions end. Simultaneously, the tocodynamometer records $7$ contractions every $10$ minutes. In response, the clinical team stops the oxytocin infusion, alters her position to the left lateral decubitus, and provides an intravenous fluid bolus. Reassessment $15$ minutes later reveals ongoing uterine activity with $6$ contractions per $10$-minute period and persistence of the fetal heart rate decelerations. Her cervix is $4\text{ cm}$ dilated.

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

An infant delivered at full term is admitted to the neonatal intensive care unit at 48 hours of life due to progressive lethargy, hypotonia, and Kussmaul respirations. Initial laboratory evaluation reveals a severe high anion gap metabolic acidosis ($pH\ 7.12$, $HCO_3^{-}\ 7\ mEq/L$), hypoglycemia ($34\ mg/dL$), and moderate hyperammonemia ($420\ \mu mol/L$). The clinical presentation is highly suspicious for an acute metabolic crisis secondary to an inborn error of metabolism, such as an organic acidemia. Arrange the following acute management and diagnostic steps in the most appropriate sequential order of priority for this patient.

An 18-month-old girl is brought to the pediatric clinic by her parents in late January due to fast breathing and a whistling sound from her chest. Over the past 48 hours, she has had copious clear rhinorrhea, a low-grade fever, and a slight decrease in oral intake. There is no family history of asthma or atopy, and she has had no previous episodes of similar symptoms. Her immunizations are up to date. Her temperature is 37.9°C (100.2°F), heart rate is 138/min, respiratory rate is 48/min, and oxygen saturation is 94% on room air. The patient appears alert but has mild subcostal retractions. Lung auscultation reveals diffuse polyphonic expiratory wheezing and coarse crackles bilaterally. Which of the following are the most appropriate management steps for this patient? (Select all that apply)

A $22$-month-old toddler is evaluated in the emergency department for a persistent cough and noisy breathing that started abruptly while he was eating a snack mix containing peanuts at a family gathering the previous day. Initially, he had a vigorous coughing fit that resolved after several minutes, prompting the parents to monitor him at home. Today, he developed a mild fever of $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$) and ongoing tachypnea. He has no history of atopy, prior wheezing, or recent upper respiratory infections. Current vital signs show a heart rate of $128\text{/min}$, respiratory rate of $46\text{/min}$, and oxygen saturation of $93\%$ on room air. Physical examination reveals asymmetric chest expansion. Auscultation demonstrates prolonged expiration with a high-pitched wheeze exclusively over the right hemithorax. The left lung field has normal vesicular breath sounds. Which of the following is the most appropriate next step in management?

A term patient in active labor reaches complete cervical dilation and begins the pushing phase. After several contractions, the fetal head emerges but then abruptly retracts against the vulva, and the fetal cheeks begin to bulge. Standard gentle downward traction does not yield delivery of the body. Arrange the following interventions in the correct sequential order for managing this clinical scenario, from initial response to maneuvers of last resort.