Tüm alıştırma soruları

A 2-day-old full-term neonate is evaluated in the nursery for failure to pass meconium and progressive abdominal distension. Physical examination reveals a remarkably tight anal sphincter. Upon withdrawal of the examiner's finger during a digital rectal examination, there is an explosive release of gas and foul-smelling stool. Arrange the following steps in the optimal diagnostic and therapeutic sequence for this patient's suspected condition.

A 10-year-old boy is currently admitted to the pediatric intensive care unit following a severe traumatic brain injury. He is intubated, mechanically ventilated, sedated, and has an external ventricular drain in place. Over the last five minutes, his intracranial pressure monitor indicates a sudden and sustained spike to 40 mm Hg (normal is less than 15 mm Hg). Simultaneously, his heart rate drops to 45/min, and his blood pressure rises to 160/90 mm Hg. Arrange the following acute management steps for suspected impending brain herniation in the most appropriate escalating sequence, proceeding from basic initial maneuvers to advanced refractory therapies.

A $15$-month-old boy is brought to the pediatric clinic for a routine well-child visit. His mother is concerned because he is not yet walking independently and his vocabulary consists of only a single word. He was born at $39$ weeks gestation without perinatal complications, and newborn screening was reported as normal. A review of his growth chart demonstrates that his length has decreased from the $50$ th percentile at $6$ months of age to the $5$ th percentile currently, while his weight has remained steady along the $45$ th percentile. Vital signs include a temperature of $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), heart rate of $88$/min, and respiratory rate of $22$/min. Physical examination reveals an infant with a persistently open and large anterior fontanelle, generalized hypotonia, and delayed relaxation of the deep tendon reflexes. Laboratory evaluation shows:

Thyroid-stimulating hormone (TSH): $2.1\ \mu\text{U/mL}$ (Normal: $0.5-5.0\ \mu\text{U/mL}$)
Free thyroxine (T4): $0.4\ \text{ng/dL}$ (Normal: $0.9-2.4\ \text{ng/dL}$)

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

A 14-month-old girl is rushed to the pediatric emergency center by her parents because she suddenly became severely cyanotic and limp after a prolonged crying episode at home. On arrival, she is highly agitated, inconsolable, and instinctively drawing her legs toward her abdomen. Vital signs show a heart rate of 178/min, respiratory rate of 52/min, and oxygen saturation of 62% on room air. Auscultation reveals a harsh, grade 3/6 systolic ejection murmur at the left mid-to-upper sternal border, which the parents note is much softer than what was described during her last pediatric visit. She is diagnosed with a hypercyanotic spell secondary to an underlying congenital heart defect. Arrange the following interventions in the most appropriate sequential order for the acute escalation of management for this patient, starting with the immediate first step and progressing to treatments for medically refractory symptoms.

A 7-year-old girl is rushed to the pediatric emergency department with continuous rhythmic jerking of her arms and legs that began 12 minutes ago while at school. She has no prior history of seizures. On arrival, she is unresponsive, her pulse oximetry reads 89% on room air, and she has active generalized tonic-clonic movements. A peripheral intravenous line is rapidly established by the nursing staff. Arrange the following management steps in the correct chronological sequence for the optimal acute algorithmic management of this patient's condition, from immediate priority to late-stage refractory care.

Match each maternal clinical presentation occurring during the third trimester with the most accurate obstetric diagnosis.

A $6$-week-old boy is brought to the emergency department by his parents after a witnessed $15$-second episode of absent breathing associated with perioral cyanosis at home. The parents report he has had progressive nasal congestion, clear rhinorrhea, and decreased feeding over the past three days. He was born at $39$ weeks gestation with no perinatal complications. His rectal temperature is $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), pulse is $165/\text{min}$, and respirations are $70/\text{min}$. Pulse oximetry shows an oxygen saturation of $90\%$ on room air. Physical examination reveals an appropriately grown infant with copious nasal secretions, marked subcostal and intercostal retractions, and diffuse fine crackles with scattered expiratory wheezes on auscultation. Which of the following are the most appropriate immediate steps in the management of this patient? (Select exactly two)

A 9-year-old boy with a known history of sickle cell anemia is brought to the emergency department by his parents due to fever, cough, and severe chest pain that started yesterday. His temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), heart rate is $120/\text{min}$, blood pressure is $105/65\text{ mmHg}$, and respiratory rate is $30/\text{min}$. Oxygen saturation is $89\%$ on room air. Physical examination reveals crackles and decreased breath sounds in the right lower lung field. A chest radiograph demonstrates a new right lower lobe infiltrate. Which of the following is the most appropriate next step in management?

A healthy 24-year-old nulliparous woman is admitted to the labor suite at 40 weeks gestation. She is in active labor with an epidural catheter in place for analgesia. Her blood pressure is 118/74 mm Hg and her heart rate is 84/min. Pelvic examination reveals a cervix that is 7 cm dilated and fully effaced, with the fetal vertex at -1 station. Thirty minutes ago, an amniotomy was performed to augment labor progression, yielding clear amniotic fluid. Currently, the continuous fetal heart rate monitor displays a baseline of 145/min with moderate variability. The tracing also demonstrates multiple abrupt drops in the fetal heart rate down to 85/min, lasting approximately 45 seconds before returning sharply to baseline. These drops vary in their timing relative to the onset of uterine contractions. The nursing staff has already repositioned the patient to the left lateral decubitus position and administered a bolus of intravenous lactated Ringer solution, but the heart rate pattern remains unchanged. Which of the following is the most appropriate next step in management?

A 28-year-old G2P1 presents to the clinic to establish prenatal care. She has a history of irregular menstrual cycles and is unsure of her last menstrual period. She will undergo serial transvaginal and transabdominal obstetric ultrasounds to confirm intrauterine pregnancy, verify gestational age, and assess early fetal development. Arrange the following normal sonographic landmarks in the typical chronological order of their initial appearance during a developing intrauterine pregnancy, from earliest to latest.

The parents of a $14$-month-old female infant bring her to the emergency department in mid-winter because of a worsening cough and rapid breathing. The infant had a $3$-day history of mild nasal congestion and clear rhinorrhea, but over the past $24$ hours, she developed a high fever and became increasingly lethargic. She was born at full term and is up-to-date on all routine childhood immunizations, including the Haemophilus influenzae type b and pneumococcal conjugate vaccines. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), heart rate is $155/\text{min}$, respiratory rate is $58/\text{min}$, and oxygen saturation is $91\%$ on room air. On physical examination, the infant is lethargic but arousable. Nasal flaring and moderate intercostal retractions are present. Auscultation of the lungs reveals decreased breath sounds and fine crackles localized over the right lower lobe. The left lung fields are clear, and no wheezing is appreciated. Chest radiography shows a dense consolidation in the right lower lobe with no pleural effusion. She is admitted to the pediatric ward and placed on supplemental oxygen via nasal cannula. Which of the following is the most appropriate initial pharmacotherapy for this patient?

A 6-week-old boy is brought to the pediatrician by his mother due to a 7-day history of a worsening, repetitive cough. The mother describes the cough as occurring in rapid, short bursts, occasionally causing the infant's face to turn red, though without a distinct "whoop" sound or post-tussive emesis. The infant is exclusively breastfed and has been afebrile. He received his first hepatitis B vaccination at birth and is not yet due for his 2-month immunizations. Medical history is notable for bilateral mucopurulent eye discharge at 10 days of life, which resolved after a 7-day course of topical erythromycin ointment.

Vital signs are temperature 37.1°C (98.8°F), heart rate 145/min, respiratory rate 58/min, and oxygen saturation 95% on room air. Lung auscultation reveals bilateral scattered crackles and occasional expiratory wheezes without prominent intercostal retractions.

Laboratory testing shows a leukocyte count of $14,500/\text{mm}^3$ with $35\%$ neutrophils, $45\%$ lymphocytes, and $15\%$ eosinophils. A chest radiograph demonstrates bilateral symmetric interstitial infiltrates and hyperinflation.

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

A full-term female infant is delivered vaginally from a breech presentation. The mother has a positive family history of developmental dysplasia of the hip (DDH). The pediatrician is discussing the long-term evaluation and potential treatment plan for this condition with the parents. Assuming the patient will require the complete spectrum of standard medical intervention due to progressive or refractory disease, arrange the following steps in the chronological sequence they would be appropriately performed, starting from birth and progressing through late infancy.

A $27$-year-old G1P0 at $35$ weeks gestation is evaluated in the obstetric triage unit for a $2$-day history of progressively worsening right upper quadrant pain, nausea, and profound fatigue. She reports normal fetal movement and denies any vaginal bleeding or leakage of fluid. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $156/102$ mm Hg, and heart rate is $92$/min. Physical examination reveals tenderness to deep palpation in the right upper quadrant and $2+$ pitting edema of the bilateral lower extremities. Laboratory studies show:

A continuous fetal heart rate monitor shows a baseline of $145$/min, moderate variability, and frequent early decelerations coincident with mild, irregular uterine contractions. Which of the following is the most appropriate next step in management?

In mid-January, a distressed father arrives at the emergency department with his $15$-month-old toddler. The child has been experiencing rapidly worsening respiratory distress over the past $12$ hours. The father reports that the illness began $4$ days ago with a runny nose, mild cough, and decreased appetite. The child's medical history is significant for atopic dermatitis, and his $6$-year-old sister recently missed school due to a severe asthma exacerbation.

Temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), pulse is $172$/min, and respirations are $68$/min. Pulse oximetry shows an oxygen saturation of $87\%$ on room air. The child appears lethargic but becomes irritable when handled. Physical examination reveals marked nasal flaring, grunting, and deep subcostal retractions. Auscultation of the chest demonstrates a prolonged expiratory phase with diffuse polyphonic wheezes, as well as fine inspiratory crackles at both lung bases. Cardiac examination reveals a regular tachycardia without murmurs. The liver edge is palpable $3$ cm below the right costal margin.

Capillary blood gas analysis on room air reveals the following:

Which of the following is the most appropriate initial management for this patient?

A 4-week-old boy is brought to the pediatric emergency department with a 12-hour history of high fever, progressive lethargy, and explosive, foul-smelling, bloody diarrhea. His parents report that his abdomen has become massively swollen over the past day. His neonatal history is notable for passage of meconium at 50 hours of life and chronic constipation requiring glycerin suppositories. Vital signs show a temperature of 39.1°C (102.4°F), heart rate of 185/min, respiratory rate of 60/min, and blood pressure of 65/35 mm Hg. Physical examination reveals a lethargic, mottled infant with a markedly distended and tympanic abdomen. Digital rectal examination results in a forceful expulsion of foul-smelling stool and gas. Arrange the following management steps in the most appropriate chronological sequence for this patient.

Evaluate the following clinical profiles of pediatric patients presenting with cytopenias. Assign each patient to the fundamental pathophysiologic mechanism or genetic defect that best explains their constellation of clinical and laboratory findings.

An 8-month-old infant is rapidly triaged in the emergency department following a syncopal event at home. According to the parents, the child was crying vigorously during a diaper change when he suddenly became deeply blue around the lips and face, followed by a brief loss of consciousness. The mother notes he has had similar, though milder, episodes of blueness when agitated over the past few weeks. The infant was born at a rural clinic and has not received subsequent medical care. On physical examination, the infant is awake but severely agitated. Vital signs demonstrate a heart rate of 180/min, respiratory rate of 55/min, and oxygen saturation of 74% on room air. Auscultation reveals a prominent right ventricular impulse and a harsh, crescendo-decrescendo systolic murmur at the left upper sternal border. Lung fields are clear to auscultation. Which of the following is the most appropriate initial step in the management of this patient?

A 32-year-old woman, gravida 3, para 2, at 39 weeks gestation is admitted to the labor and delivery unit in spontaneous active labor. Her pregnancy is complicated by polyhydramnios. Her vital signs are within normal limits. Cervical examination reveals 5 cm dilation, 80% effacement, and the fetal presenting part at -2 station. Thirty minutes later, the patient experiences a spontaneous rupture of membranes with a large gush of clear fluid. The continuous electronic fetal heart rate monitor immediately shows a sudden, prolonged deceleration to 70/min that persists for 3 minutes. The nurse performs a sterile vaginal examination and palpates a pulsating, rope-like mass protruding through the cervical os ahead of the fetal presenting part. Which of the following is the most appropriate next step in the management of this patient?

Match each classic clinical presentation of an obstetric complication with its most likely diagnosis.