Tüm alıştırma soruları

An expectant mother, age 30, is brought to the emergency department at 28 weeks gestation following a minor traffic accident. She reports no abdominal pain, vaginal bleeding, or shortness of breath. She has no significant medical history and takes only a daily prenatal vitamin. Vital signs show a blood pressure of $110/70$ mm Hg, pulse of $88$/min, and respiratory rate of $16$/min. Continuous fetal heart rate monitoring is reassuring. As part of a standard trauma protocol, an arterial blood gas is obtained on room air. Compared to a healthy nonpregnant state, which of the following acid-base profiles is an expected physiological finding in this patient?

A 24-year-old primigravida presents to the clinic for her first prenatal visit at 8 weeks gestation. She has an uncomplicated medical history and wishes to understand the schedule for her upcoming evaluations. As part of routine prenatal care, various screening tests and imaging studies are recommended at specific gestational ages. Arrange the following routine prenatal evaluations in the correct chronological sequence from earliest to latest in a normal, uncomplicated pregnancy.

A variety of pediatric musculoskeletal conditions present with distinct physical examination signs or characteristic resting postures. Match each specific clinical examination finding with the most appropriate underlying diagnosis.

Correlate the following pediatric hematology and oncology conditions with their characteristic microscopic, histologic, or laboratory hallmarks.

A $25$-year-old woman with a $4$-year history of ileocolonic Crohn disease is evaluated in the hospital on day $4$ of her admission. She originally presented with fever, right lower quadrant abdominal pain, and leukocytosis. A computed tomography scan of the abdomen on admission revealed acute terminal ileitis complicated by a $4.5\text{-cm}$ adjacent fluid collection. She was empirically started on intravenous piperacillin-tazobactam, and a percutaneous drain was successfully placed by interventional radiology on hospital day $1$.

Today, the patient feels much better. She is tolerating a low-residue diet and her abdominal pain has largely resolved. Her temperature is $37.3^\circ\text{C} (99.1^\circ\text{F})$, pulse is $82/\text{min}$, and blood pressure is $118/76\text{ mm Hg}$. Her leukocyte count has decreased from $16,000/\text{mm}^3$ to $8,200/\text{mm}^3$. The percutaneous drain has output only $5\text{ mL}$ of serous fluid over the past $24$ hours. Abscess fluid cultures have finalized, growing *Escherichia coli* and *Bacteroides fragilis*. Susceptibility testing demonstrates that both organisms are susceptible to amoxicillin-clavulanate. The *E. coli* isolate is susceptible to ciprofloxacin and ceftriaxone, and the *B. fragilis* isolate is susceptible to metronidazole.

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

During prenatal care, recognizing normal physiologic adaptations of pregnancy is critical to avoid unnecessary interventions for findings that would otherwise be considered pathologic in non-pregnant patients. Match the following underlying physiologic mechanisms of normal pregnancy to their corresponding clinical or laboratory manifestations.

A 32-year-old G2P1 woman at 39 weeks gestation is in the second stage of active labor. Suddenly, she gasps for air, becomes profoundly cyanotic, and loses consciousness. The fetal monitor shows an acute, prolonged deceleration to 60/min. The patient is apneic and has no palpable carotid pulse. Arrange the following management steps in the most appropriate sequential order for this catastrophic obstetric emergency.

An 11-year-old boy is brought to the emergency department by his parents after he fainted during a soccer game. Over the past three months, he has experienced worsening fatigue, unexplained weight loss, and recurrent episodes of vague abdominal pain and nausea. His parents mention that he has developed an intense craving for salty foods. On physical examination, his temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $82/50\text{ mmHg}$ while supine and drops to $68/40\text{ mmHg}$ upon standing, and pulse is $115\text{/min}$. He appears lethargic. There is noticeable darkening of the skin, particularly over the palmar creases, elbows, knees, and buccal mucosa.

Initial laboratory evaluation reveals:
Serum sodium: $128\text{ mEq/L}$
Serum potassium: $6.1\text{ mEq/L}$
Serum chloride: $95\text{ mEq/L}$
Serum bicarbonate: $16\text{ mEq/L}$
Blood urea nitrogen: $26\text{ mg/dL}$
Serum creatinine: $0.9\text{ mg/dL}$
Serum glucose: $58\text{ mg/dL}$

Which of the following pairs of baseline hormone levels is most likely to be present in this patient prior to any intervention?

An expectant mother at 38 weeks gestation presents to the obstetric triage unit in active labor. She has a history of a low transverse cesarean delivery three years ago and has opted for a trial of labor for her current pregnancy. Upon admission, her vital signs are stable, and contractions are occurring regularly every 3 minutes. Three hours later, she experiences a sudden, agonizing, tearing pain in her lower abdomen that does not resolve between contractions. Simultaneously, the fetal heart rate tracing demonstrates a prolonged deceleration to 70 beats per minute. A prompt cervical examination demonstrates that dilation is unchanged at 6 cm, but the fetal head has receded from 0 station to -3 station. What is the most appropriate next intervention for this patient?

A 12-month-old boy is brought to the pediatric emergency department by his parents after a witnessed episode of generalized tonic-clonic movements lasting for 2 minutes. The episode occurred 45 minutes ago, and the child is now sleepy but easily arousable. He has no history of fever, trauma, or previous seizures. Vital signs are temperature 37.1°C (98.8°F), heart rate 110/min, respiratory rate 24/min, and blood pressure 90/55 mmHg. Physical examination reveals seven well-demarcated, flat, hyperpigmented macules measuring between 8 and 12 mm across his trunk and extremities, as well as distinct freckling in the bilateral axillary regions. Neurologic examination shows a drowsy child with normal muscle bulk and tone, moving all extremities equally. The parents mention they have been worried about his development recently because he only cruises along furniture and says "mama" and "dada" specifically, though he uses a mature pincer grasp.

Based on this patient's clinical presentation, which of the following statements regarding his evaluation and management are correct? (Select all that apply)

During a routine assessment in the newborn nursery, a 2-day-old female infant is found to have central cyanosis that worsens when she cries. She was delivered vaginally at 39 weeks gestation following an uncomplicated pregnancy. Vital signs include a heart rate of 158/min, respiratory rate of 55/min, and blood pressure of 68/40 mm Hg in the right arm. Pulse oximetry indicates an oxygen saturation of 76% on room air. After administration of 100% supplemental oxygen for 10 minutes, her saturation marginally improves to 78%. Physical examination confirms bluish discoloration of the perioral area and mucous membranes. Cardiac auscultation reveals a normal S1, a loud and single S2, and a grade 3/6 holosystolic murmur at the left lower sternal border. An electrocardiogram demonstrates left axis deviation, small R waves in the right precordial leads, and tall P waves in lead II. Chest radiography reveals a normal cardiac size with diminished pulmonary vascular markings. Which of the following is the most likely diagnosis?

A 7-month-old boy is brought to the emergency department in mid-January with a 3-day history of worsening respiratory distress. He was born at 39 weeks gestation and has no significant past medical history. The illness began with rhinorrhea, low-grade fever, and a mild cough. The patient's mother has a history of severe persistent asthma and wonders if he needs her 'breathing treatments.'

Upon arrival, vital signs show:
* Temperature: $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$)
* Heart rate: $182/\text{min}$
* Respiratory rate: $74/\text{min}$
* Oxygen saturation: $86\%$ on room air

Physical examination reveals an anxious, tachypneic infant with marked head bobbing, severe subcostal retractions, and nasal flaring. Lung auscultation demonstrates diffuse polyphonic wheezing, a markedly prolonged expiratory phase, and scattered bibasilar crackles.

Laboratory and radiographic findings:
* Leukocyte count: $11,800/\text{mm}^3$ ($68\%$ lymphocytes, $25\%$ neutrophils)
* Capillary blood gas (room air): $\text{pH} = 7.30$, $\text{pCO}_2 = 60\text{ mm Hg}$
* Chest radiograph: Bilateral pulmonary hyperinflation, flattened hemidiaphragms, and extensive peribronchial thickening without distinct lobar consolidation.

Which of the following interventions MUST be included in the evidence-based acute management bundle for this patient? (Select exactly 2 interventions)

A $5$-day-old male neonate is brought to the pediatric emergency department by his parents due to extreme lethargy, poor feeding, and rapid, labored breathing that has worsened over the past $12$ hours. The infant was born at $39$ weeks gestation via an uncomplicated vaginal delivery and was discharged home on day two of life. On physical examination, the infant appears mottled and pale. His temperature is $36.4^\circ\text{C}$ ($97.5^\circ\text{F}$), heart rate is $192/\text{min}$, respiratory rate is $75/\text{min}$, and blood pressure is $68/40 \text{ mm Hg}$ in the right arm and $45/25 \text{ mm Hg}$ in the left leg. Capillary refill time is $6$ seconds. Palpation of the extremities reveals bounding right brachial pulses, but the femoral and dorsalis pedis pulses are barely palpable. Pulse oximetry on room air is $96\%$ on the right hand and $86\%$ on the right foot. Lung auscultation reveals bilateral crackles. Hepatomegaly is noted $3\text{ cm}$ below the right costal margin. An arterial blood gas analysis demonstrates a $pH$ of $7.12$, $pCO_2$ of $29 \text{ mm Hg}$, and $HCO_3^-$ of $10 \text{ mEq/L}$. Which of the following is the most appropriate initial step in the management of this patient?

A 35-year-old woman, gravida 2, para 1, at 38 weeks gestation is evaluated in the obstetric triage unit for the onset of active labor. Her surgical history is significant for an open myomectomy two years ago for a 10-cm intramural fibroid, during which the surgeon noted that the uterine cavity was entered. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is 112/70 mm Hg, pulse is 108/min, and respirations are 22/min. Arterial blood gas analysis on room air shows a pH of 7.44, $\text{PaCO}_2$ of 28 mm Hg, and $\text{HCO}_3^-$ of 20 mEq/L. The fetal heart rate tracing initially shows a baseline of 145/min with moderate variability and no decelerations. Tocodynamometry shows contractions every 3 to 4 minutes. A cervical examination reveals the cervix is 5 cm dilated and 90% effaced, with the fetal presenting part at -1 station.

Thirty minutes later, the patient suddenly reports a sharp, tearing, and continuous lower abdominal pain that does not remit between contractions. The fetal heart rate tracing abruptly demonstrates a baseline drop to 80/min that persists for 4 minutes without recovery. A repeat cervical examination reveals that the fetal head is no longer palpable.

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

An anxious mother brings her 5-week-old firstborn son to the pediatrician's office because he has been vomiting for the past five days. She notes that the vomiting occurs immediately after every feeding, is very forceful, and consists of curdled breast milk without any green or yellow discoloration. Despite the vomiting, the infant cries continuously and appears ravenously hungry, eagerly demanding to be fed again. On physical examination, the infant has slightly dry mucous membranes and a sunken anterior fontanelle. Palpation of the abdomen reveals a firm, mobile, 2-cm ovoid mass in the right upper quadrant. Which of the following is the most appropriate initial diagnostic test to confirm this patient's underlying condition?

A 7-year-old girl is brought to the emergency department with severe respiratory distress. She has a history of moderate persistent asthma and has been using her albuterol inhaler every 2 hours at home without relief. On presentation, she is alert but anxious, speaking in single words. Vital signs show a respiratory rate of 42/min, heart rate of 150/min, and oxygen saturation of 88% on room air. Examination reveals diffuse inspiratory and expiratory wheezes with prominent suprasternal retractions. Arrange the following interventions in the most appropriate sequential order of escalation for managing this patient's acute severe asthma exacerbation, from initial presentation to refractory respiratory failure.

An 8-month-old infant, recently immigrated from a rural region without a universal newborn screening program, is brought to the pediatric clinic for evaluation of developmental delay. The parents report that the infant has not yet started to sit unsupported, roll over, or babble. On physical examination, the infant has noticeably lighter skin and hair pigmentation compared to both biological parents, a diffuse eczematous rash on the flexor surfaces, and a distinct 'musty' body odor. A presumptive diagnosis of a metabolic disorder is made. Arrange the following steps in the most appropriate chronological sequence for the comprehensive evaluation and lifespan management of this patient's condition, from the immediate next diagnostic step to adulthood.

Emergency medical services arrive with a 7-year-old male who has homozygous sickle cell disease (HbSS). His parents report that he abruptly developed right arm paralysis and lost the ability to speak approximately 45 minutes ago. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $112/72 \text{ mm Hg}$, pulse is $118\text{/min}$, and respirations are $22\text{/min}$. Oxygen saturation is $98\%$ on room air. Neurological examination reveals a right-sided facial droop, expressive aphasia, and $2/5$ muscle strength in the right upper and lower extremities. Laboratory studies show a hemoglobin of $7.5 \text{ g/dL}$, hematocrit of $22\%$, and a reticulocyte count of $12\%$. Arrange the following steps in the most appropriate chronological sequence for the comprehensive immediate and long-term management of this patient.

A 28-year-old G1P0 woman at 38 weeks gestation is brought to the emergency department after experiencing a generalized tonic-clonic seizure at home. Her blood pressure is 168/112 mm Hg. She is currently postictal and breathing spontaneously. Continuous fetal monitoring shows a baseline heart rate of 135/min with moderate variability and no decelerations. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 3-week-old boy is admitted to the neonatal intensive care unit after experiencing two episodes of rhythmic twitching of his right arm and leg, each lasting approximately one minute. He was born at term via uncomplicated spontaneous vaginal delivery to a 28-year-old primigravida. His prenatal course was unremarkable. On physical examination, the neonate is afebrile and vital signs are stable. He alerts to loud sounds and briefly tracks his mother's face. Examination of the skin reveals scattered erythematous macules with central 1-2 mm yellowish pustules over his trunk and face. A magnetic resonance imaging (MRI) scan of the brain demonstrates restricted diffusion in the left middle cerebral artery territory, consistent with an acute ischemic stroke. When discussing the patient's condition and expected care plan with the parents, which of the following statements are correct? (Select all that apply)