Tüm alıştırma soruları

A $12$-year-old girl with a history of cystic fibrosis presents to the emergency department with a $1$-week history of increased cough, purulent sputum production, fatigue, and a $2\text{-kg}$ ($4.4\text{-lb}$) weight loss. She reports a decreased appetite but no fever. Her baseline $\text{FEV}_1$ is $75\%$ of predicted, but today it is $55\%$. Vital signs are temperature $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), heart rate $110/\text{min}$, respiratory rate $24/\text{min}$, and blood pressure $110/70\text{ mm Hg}$. Oxygen saturation is $93\%$ on room air. Physical examination reveals coarse crackles scattered throughout both lung fields. Sputum cultures from a routine clinic visit $1$ month ago grew *Pseudomonas aeruginosa* and *Staphylococcus aureus*. Which of the following are the most appropriate initial steps in the management of this patient's acute pulmonary exacerbation? (Select all that apply)

A 31-year-old woman, gravida 2, para 1, at 28 weeks gestation, presents to the clinic for a routine prenatal visit. She reports feeling well and notes active fetal movement. Her only symptom is mild swelling of her ankles by the end of the day. Blood pressure is 112/68 mm Hg, and pulse is 84/min. Fundal height is 28 cm. Fetal heart rate is 145/min. Laboratory studies are obtained and the results are shown below:

Urinalysis shows trace protein, 1+ glucose, and is negative for leukocyte esterase and nitrites.

Which of the following findings in this patient is pathologic and requires further evaluation?

A 29-year-old G4P3 woman at 39 weeks gestation delivers a 4,200-g (9-lb 4-oz) neonate vaginally following a prolonged labor augmented with oxytocin. Shortly after the spontaneous delivery of an intact placenta, she develops profuse vaginal bleeding. Her blood pressure is 88/50 mm Hg and pulse is 122/min. On examination, the uterus is soft, boggy, and palpated above the umbilicus. A continuous oxytocin infusion is already running through two large-bore intravenous lines.

Assuming each consecutive intervention fails to control the hemorrhage, arrange the following management steps in the correct sequential order from the immediate next step to the definitive final treatment.

During a pediatric gastroenterology case conference, a series of complex patient presentations is reviewed. For each atypical or highly specific clinical vignette described below, identify the correct underlying embryologic or pathophysiologic mechanism.

A $15$-month-old boy is brought to the pediatric clinic by his paternal grandmother for a routine evaluation. She expresses significant concern regarding the child's "curved legs" and insists that he requires immediate corrective casting to prevent permanent deformity. The patient's mother, who has sole legal custody and is accessible via phone, previously discussed this finding with the physician and stated she is comfortable with conservative observation. The child began walking independently at $12$ months of age and is currently acquiring new vocabulary. His diet is well-balanced and includes fortified whole milk and a daily multivitamin. Vital signs are within normal limits. Physical examination reveals a happy, well-appearing toddler with symmetric bilateral genu varum (bowlegs). There is no localized tenderness, erythema, or leg-length discrepancy. His gait is steady without limping. A basic metabolic panel, serum calcium, phosphorus, thyroid-stimulating hormone (TSH), and free T4 are all within normal limits. Which of the following is the most appropriate next step in management?

A 9-year-old boy is evaluated in the pediatric endocrinology clinic for new-onset severe polyuria, polydipsia, and nocturia over the past month. He is otherwise healthy, and a recent comprehensive metabolic panel and hemoglobin A1c were within normal limits, ruling out diabetes mellitus. The physician suspects diabetes insipidus and admits the patient to the hospital for a water deprivation test. Arrange the following steps in the correct chronological sequence for performing this diagnostic test.

During a scheduled wellness visit, the parents of a 4-month-old infant express concern regarding their child's breathing. They describe a high-pitched 'squeaking' sound when the baby inhales, which they first noticed around 4 weeks of age. The noise becomes significantly louder when the infant is crying or placed on his back to sleep. Conversely, the parents note the sound almost completely disappears when the baby is resting on his stomach. He is exclusively breastfed, feeds well without cyanosis or choking, and is tracking along the 50th percentile for both length and weight. His temperature is 37.0°C (98.6°F), pulse is 120/min, and respirations are 30/min. Physical examination reveals an alert, well-nourished infant with prominent inspiratory stridor that worsens in the supine position. Which of the following is the most likely underlying cause of this patient's clinical presentation?

A $10$-month-old male infant is currently hospitalized on the pediatric ward. He was admitted $3$ days ago for severe respiratory syncytial virus (RSV) bronchiolitis requiring heated humidified high-flow nasal cannula. On hospital day $2$, he developed a temperature of $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), worsening hypoxemia, and new focal crackles in the left lower lung field. Chest radiography confirmed a new left lower lobe consolidation. Blood cultures were drawn, and empiric intravenous ceftriaxone was initiated for suspected secondary bacterial pneumonia. Today (hospital day $4$), he has been afebrile for $24$ hours and is weaning off respiratory support. Physical examination reveals scattered expiratory wheezing and mild intercostal retractions. The blood culture drawn on day $2$ is now positive for *Streptococcus pneumoniae*. Antimicrobial susceptibility testing indicates the isolate is susceptible to penicillin, ampicillin, ceftriaxone, and vancomycin. Which of the following is the most appropriate modification to this patient's treatment plan?

A 6-year-old girl is brought to the emergency department by her parents due to a sudden onset of fever. She was diagnosed with acute lymphoblastic leukemia (ALL) six months ago and is currently undergoing maintenance chemotherapy. Her temperature is $39.4^\circ C$ ($102.9^\circ F$), blood pressure is $90/55$ mmHg, and heart rate is $125$/min. Physical examination reveals a pale, fatigued child with a central venous catheter in place. There is no erythema or discharge at the catheter site. Laboratory studies show an absolute neutrophil count (ANC) of $350/mm^3$. Blood cultures are obtained. Which of the following is the most appropriate next step in management?

A 6-week-old female infant is brought to the clinic for a well-child visit. Her parents report that she is exclusively breastfed and feeding well, but they have noticed her skin appearing increasingly yellow over the past two weeks. Additionally, her stools have recently become very pale, resembling the color of clay. Physical examination is notable for scleral icterus, generalized jaundice, and a palpable liver edge 2 cm below the right costal margin. Arrange the following steps in the most appropriate chronological sequence for the standard evaluation and definitive management of this patient's suspected condition.

A 3-year-old girl is brought to the emergency department by her mother due to refusal to use her left arm. The mother reports that an hour ago, they were walking on a slippery sidewalk when the child lost her balance. To prevent her from falling to the ground, the mother instinctively pulled up firmly on the child's left hand. Following this, the child immediately began crying and has since refused to bend her elbow or reach for toys. Vital signs include a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), pulse of $105/\text{min}$, and blood pressure of $90/60\text{ mm Hg}$. On physical examination, the child is calm when left undisturbed but holds her left arm adducted against her side with the elbow slightly flexed and the forearm pronated. There is no erythema, ecchymosis, or focal point tenderness upon palpation of the clavicle, shoulder, humerus, elbow, or wrist. As part of the initial triage protocol, point-of-care laboratory studies are obtained and reveal a leukocyte count of $7,200/\text{mm}^3$, an erythrocyte sedimentation rate of $6\text{ mm/hr}$, and a C-reactive protein of $0.3\text{ mg/dL}$. Which of the following is the most appropriate next step in management?

A 2-week-old male infant is evaluated in the pediatric orthopedic clinic for bilateral foot deformities present since birth. Physical examination reveals marked plantar flexion of the ankles, inversion of the heels, and medial deviation of the forefeet. The deformities are rigid and cannot be passively corrected to a neutral, anatomic position. Neurological examination of the lower extremities is unremarkable, and the spine is normal. A diagnosis of idiopathic congenital talipes equinovarus (clubfoot) is made, and the parents agree to proceed with the gold-standard conservative management approach. Arrange the following steps of this treatment protocol (the Ponseti method) in the most appropriate chronological order, from initial intervention to long-term maintenance.

Match each clinical presentation of a pregnant patient with the most appropriate hypertensive disorder of pregnancy diagnosis.

A nulliparous woman at 40 weeks gestation presents to the maternity triage area with painful uterine contractions occurring every 3 minutes. Her pregnancy has been uncomplicated. Vital signs are within normal limits. On pelvic examination, the cervix is dilated to 8 cm and is fully effaced. The fetal presenting part is at +1 station. External fetal monitoring displays a baseline heart rate of 145/min with moderate variability. Symmetrical, gradual decreases in the fetal heart rate are noted, which precisely mirror the uterine contractions; the onset, nadir, and recovery of each deceleration coincide directly with the beginning, peak, and end of the corresponding contraction. The minimum fetal heart rate during these episodes is 125/min. Which of the following is the most appropriate next step in the care of this patient?

A primigravid client is admitted to the maternity ward in spontaneous active labor at term. A continuous electronic fetal monitor is applied to evaluate fetal well-being. Throughout the observation period, the tracing displays multiple episodes where the fetal heart rate abruptly decreases by 20 to 30 beats per minute from a stable baseline of 145 beats per minute. These abrupt drops reach their nadir within 15 seconds, last for approximately 30 to 40 seconds, and then rapidly return to the baseline. The decreases occur inconsistently, showing no uniform relationship to the onset or peak of the concurrent uterine contractions. Which of the following is the most likely underlying physiological cause of this fetal heart rate pattern?

A 4-week-old girl is brought to the pediatric emergency department for a 3-day history of a progressively weak cry, poor feeding, and decreased spontaneous movement. Her parents report she has not had a bowel movement in 5 days. They mention she has been fussy recently, and they began dipping her pacifier in local honey to soothe her. She has also had a mild cough and rhinorrhea over the past week. On physical examination, her temperature is 37.2°C (99.0°F), pulse is 150/min, and respiratory rate is 42/min. The infant exhibits generalized hypotonia, a prominent head lag, and symmetric ptosis. Gag and deep tendon reflexes are absent. Lung auscultation reveals mild, scattered end-expiratory wheezes. Skin examination shows scattered erythematous macules and papules on her cheeks, which the parents note appeared a week ago. Which of the following is the most appropriate next step in management?

A $7$-year-old boy is admitted to the pediatric intensive care unit for the initiation of chemotherapy for newly diagnosed, advanced-stage Burkitt lymphoma. He has a massive abdominal tumor burden. A central venous port was placed $48$ hours ago. Twelve hours after receiving his first dose of chemotherapy, he becomes lethargic and his urine output drops to $0.2 \text{ mL/kg/hr}$.

Continuous telemetry reveals peaked T waves and a widened QRS complex.

Temperature is $38.6^\circ \text{C}$ ($101.5^\circ \text{F}$), blood pressure is $90/55 \text{ mm Hg}$, pulse is $135/\text{min}$, and respiratory rate is $28/\text{min}$. Initial blood cultures drawn from the port at the time of admission are now growing *Escherichia coli* that is susceptible to ceftriaxone.

Laboratory studies reveal the following:

An arterial blood gas on room air shows a pH of $7.26$, $pCO_2$ of $26 \text{ mm Hg}$, and $pO_2$ of $92 \text{ mm Hg}$. Upon reviewing his chart, the parents note he missed his $4$-year-old immunization boosters and ask if they can be updated while he is hospitalized.

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

Match each clinical vignette with the most likely deficient enzyme.

A 6-hour-old male infant is evaluated in the neonatal intensive care unit for rapidly worsening cyanosis. He was born at 39 weeks gestation via an uncomplicated vaginal delivery to a 26-year-old primigravid woman. Vital signs demonstrate a heart rate of 175/min, a respiratory rate of 70/min, and blood pressures of 65/45 mm Hg in the right upper extremity and 63/45 mm Hg in the right lower extremity. Palpation of the peripheral arteries reveals symmetric, normal upstrokes in all four extremities. Pulse oximetry indicates an oxygen saturation of 62% despite the implementation of mechanical ventilation with a 1.0 fraction of inspired oxygen. Physical examination reveals a profoundly cyanotic, lethargic infant with prominent intercostal retractions. Cardiac auscultation demonstrates a single, loud second heart sound without any audible murmurs. A chest radiograph displays a narrowed superior mediastinum and a cardiac silhouette resembling an egg on a string, alongside mildly increased pulmonary vascular markings. A continuous infusion of a prostaglandin analog is initiated immediately; however, 30 minutes later, the infant's oxygen saturation remains at 64% and an arterial blood gas reveals a pH of 7.21, pCO2 of 42 mm Hg, and pO2 of 26 mm Hg. Which of the following interventions should be prioritized next for this patient?

A 6-month-old male infant is brought to the emergency department by his parents due to repetitive, profuse vomiting and extreme lethargy. The vomiting began approximately 2 hours after he was fed oat cereal for the first time. The parents note that he became remarkably pale and limp shortly after the vomiting started. He was born at term and has previously tolerated breast milk and pureed vegetables without issue. His temperature is 36.5°C (97.7°F), heart rate is 185/min, blood pressure is 60/35 mmHg, and respiratory rate is 45/min. Physical examination reveals a lethargic, mottled infant with delayed capillary refill of 5 seconds. There is no rash, urticaria, or facial swelling. The lungs are clear to auscultation bilaterally without wheezing. The abdomen is soft, non-distended, and non-tender, with hyperactive bowel sounds.

Laboratory studies show:
Leukocyte count: $24,500/\text{mm}^3$ (with 18% bands)
Hemoglobin: $11.5 \text{ g/dL}$
Platelets: $550,000/\text{mm}^3$
Arterial blood gas:
pH: $7.28$
$pCO_2$: $35 \text{ mm Hg}$
$HCO_3^-$: $16 \text{ mEq/L}$

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