Tüm alıştırma soruları

A 5-day-old male infant is brought to the emergency department by his parents due to 24 hours of decreased feeding, progressive lethargy, and recurrent vomiting. He was born full-term via an uncomplicated vaginal delivery and was discharged home on day 2 of life. The infant is exclusively breastfed. Vital signs show a temperature of 36.2°C (97.2°F), heart rate of 175/min, and respiratory rate of 68/min. On physical examination, the infant is somnolent with diffuse hypotonia and deep, rapid breathing. Laboratory results are as follows:

Urinalysis is strongly positive for ketones. Deficient activity of which of the following enzymes is the most likely cause of this patient's condition?

A 32-year-old G2P1 at 39 weeks of gestation is in the second stage of labor. Following a 2-hour active pushing phase, the fetal head delivers but immediately retracts firmly against the maternal perineum. The anterior shoulder does not deliver with gentle downward traction. The obstetrician diagnoses shoulder dystocia and instructs the patient to stop pushing while requesting immediate assistance from anesthesia, pediatrics, and additional nursing staff.

Arrange the following obstetric interventions in the most appropriate sequential order of implementation, proceeding from initial first-line management to maneuvers of last resort.

During a scheduled health maintenance visit, the parents of an $8$-year-old girl express concern about her recent rapid growth and the development of severe facial acne. Over the past eight months, she has required frequent shoe size changes, and her height has crossed from the $50$ th to the $90$ th percentile. The parents also report the onset of adult-type body odor and the appearance of dark, coarse pubic hair. She has not developed any breast tissue and has not had vaginal bleeding. On physical examination, her blood pressure is $102/64 \text{ mm Hg}$ and heart rate is $82/\text{min}$. Genitourinary examination reveals Tanner stage $3$ pubic hair and mild clitoromegaly. There are no palpable abdominal or pelvic masses. A radiograph of the left hand and wrist demonstrates a skeletal bone age of $11$ years. Which of the following is the most appropriate next step in the evaluation of this patient?

A 29-year-old woman, gravida 2, para 1, is evaluated on the labor and delivery unit at 41 weeks gestation during an induction of labor for a postterm pregnancy. She is currently receiving continuous intravenous oxytocin. The most recent cervical examination demonstrates 5 cm dilation, 100% effacement, and -1 station. Uterine contractions are occurring every 3 minutes. Continuous fetal monitoring reveals a baseline heart rate of 135/min with minimal variability. Over the preceding 40 minutes, the fetal heart rate tracing demonstrates recurrent, gradual decreases in heart rate that initiate after the peak of each contraction, with the nadir occurring after the contraction has ceased. These heart rate decreases are present with more than half of the contractions. In response, the patient is repositioned to the left lateral decubitus position and administered an intravenous fluid bolus; however, the fetal monitor tracing remains unchanged following these interventions. Maternal vital signs are within normal limits. Which of the following is the most appropriate next step in management?

A 2-year-old child is brought to the emergency department after passing a massive volume of painless, dark red stool at home. On examination, the patient appears pale, mottled, and lethargic. Vital signs reveal a heart rate of 165/min, respiratory rate of 28/min, and blood pressure of 70/40 mmHg. Capillary refill time is prolonged at 4 seconds. The abdomen is soft, non-distended, and non-tender to palpation. Arrange the following medical interventions in the most appropriate chronological sequence for the evaluation and management of this patient.

Parents of an infant currently aged 6 months bring him to the urgent care clinic. They report that he recently began having clusters of sudden, symmetric forward bending of his head and torso, along with extension of his arms. These spells primarily happen just as he is waking up. During the physical examination, the physician notes the presence of three distinct, ash-leaf shaped hypopigmented macules on the infant's trunk. Arrange the following interventions in the most appropriate chronological sequence for evaluating and managing this patient's condition.

An $18$-month-old boy is brought to the pediatric clinic by his parents due to a persistent cough for the past $3$ weeks. The parents state the cough began suddenly while he was eating mixed nuts at a family gathering. He coughed vigorously for a few minutes, but the choking episode seemingly resolved. Over the following weeks, he developed a daily, harsh cough. He was evaluated at an urgent care center two weeks ago and completed a $10$-day course of high-dose oral amoxicillin for suspected community-acquired pneumonia, but his symptoms have not improved. Today, his temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), pulse is $120/\text{min}$, respirations are $28/\text{min}$, and oxygen saturation is $96\%$ on room air. Physical examination reveals diminished breath sounds and localized, monophonic expiratory wheezing over the right lower lung field. The left lung field is clear to auscultation. A chest radiograph reveals volume loss in the right lower lobe with no radiopaque structures visualized. Which of the following is the most appropriate next step in management?

An $8$-week-old male infant is evaluated in the pediatric clinic for a two-week history of difficulty feeding. His parents report that he takes much longer to finish a bottle, becomes excessively sweaty during feeds, and seems to "breathe fast" constantly. He was born full-term at $39$ weeks gestation weighing $3.2\text{ kg}$. His current weight is $3.6\text{ kg}$. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), heart rate is $165/\text{min}$, respiratory rate is $68/\text{min}$, and blood pressure is $85/50\text{ mmHg}$. Oxygen saturation is $97\%$ on room air. Brachial and femoral pulses are equal and robust. Physical examination reveals a hyperactive precordium. Auscultation demonstrates a grade $4/6$ harsh holosystolic murmur at the left lower sternal border with a palpable thrill, and a faint mid-diastolic rumble at the cardiac apex. Lung examination reveals mild bilateral basilar crackles. The liver edge is palpated $3\text{ cm}$ below the right costal margin. Which of the following is the most appropriate next step in the management of this patient?

A 27-year-old woman, gravida 1, para 1, experiences a sudden onset of severe vaginal bleeding immediately following the delivery of the placenta. Her blood pressure drops to 80/40 mmHg and heart rate increases to 125/min. On pelvic examination, a purplish, fleshy mass is seen protruding through the vaginal introitus, and the uterine fundus cannot be palpated through the anterior abdominal wall. Arrange the following management steps for this complication in the correct chronological sequence.

A 6-year-old boy is brought to the emergency department by his parents due to progressive lethargy, weakness, and severe pallor over the past 2 days. One week ago, he had a low-grade fever, rhinorrhea, and a brightly erythematous rash on both cheeks that spared his nasal bridge. His past medical history is significant for neonatal jaundice requiring 4 days of phototherapy. His father underwent a cholecystectomy at age 22. Vital signs show a temperature of 37.1°C (98.8°F), heart rate of 135/min, and blood pressure of 90/60 mm Hg. Physical examination reveals marked conjunctival pallor and a palpable spleen 4 cm below the left costal margin. Laboratory studies reveal the following:

Which of the following is the most likely primary mechanism for this patient's current severe anemia?

A 9-month-old male infant is brought to the emergency department due to sudden episodes of severe, inconsolable crying during which he draws his legs up to his abdomen. Between episodes, he appears lethargic but calm. The parents report one episode of dark, bloody, mucus-like stool on the way to the hospital. He is tachycardic but normotensive, and the abdomen is soft with a palpable 'sausage-shaped' mass in the right upper quadrant. Arrange the following steps in the correct chronological sequence for the evaluation and management of this patient.

During routine prenatal care, physicians must be able to accurately differentiate normal physiological adaptations of pregnancy from pathological states. Match each normal maternal physiological or anatomical alteration (left) with its primary underlying mechanism or evolutionary rationale (right).

A 24-year-old primigravida at 39 weeks gestation is completely dilated and actively pushing in the second stage of labor. The fetal head is descending through the maternal pelvis. To successfully navigate the pelvic structures, the fetus must undergo a series of specific positional changes. Arrange the following cardinal movements of labor in the correct chronological order from first to last.

A 12-month-old boy is brought to the pediatric genetics clinic for evaluation of global developmental delay and recurrent otitis media. His parents report that he sat independently at 9 months but is not yet crawling or pulling to stand. Vital signs are within normal limits. Physical examination reveals macrocephaly, a prominent forehead, thickened facial features, and a flattened nasal bridge. Ophthalmologic examination shows bilateral corneal clouding. Abdominal examination demonstrates a firm liver edge palpable 4 cm below the right costal margin and a palpable spleen tip. Initial skeletal radiography shows anterior beaking of the lumbar vertebrae and thickened, shortened diaphyses (dysostosis multiplex). The physician suspects a severe metabolic disorder.

Arrange the following diagnostic and management steps in the most appropriate chronological sequence for this patient, from initial evaluation to definitive long-term therapy.

A 3-year-old girl is rushed to the emergency department by her parents due to sudden onset of high fever, severe sore throat, and difficulty breathing. The family recently immigrated, and the child has not received any childhood immunizations. On examination, the patient appears toxic, is leaning forward with her neck extended, and is drooling. Her temperature is 39.4°C (102.9°F), heart rate is 150/min, and respiratory rate is 42/min. She has prominent suprasternal retractions and a muffled, "hot potato" voice. Inspiratory stridor is audible without a stethoscope.

Arrange the following steps in the management of this patient in the most appropriate chronological order from first to last.

During a preconception counseling session, a healthy nulliparous patient inquires about the timeline of physiological changes she should expect during a normal pregnancy. Arrange the following maternal physiological and anatomical milestones in the chronological order in which they typically reach their peak, nadir, or maximum extent during a normal, uncomplicated gestation.

An $8$-day-old male infant is brought to the emergency department via ambulance after several episodes of dark green vomiting. The mother reports that the infant has been increasingly lethargic over the past $12$ hours and has not produced a wet diaper since yesterday. Vital signs include a temperature of $35.4^\circ \text{C}$ ($95.7^\circ \text{F}$), heart rate of $195$/min, respiratory rate of $65$/min, and blood pressure of $52/28$ mm Hg. Physical examination reveals an ill-appearing, mottled infant. The abdomen is markedly distended and exquisitely tender to palpation, demonstrating involuntary guarding. A localized area of cutaneous erythema and edema is noted extending across the right hemiabdomen. The skin over the trunk shows scattered blanching erythematous macules with central yellow papules, which the mother states have been present since hospital discharge. Capillary refill is $5$ seconds. Arterial blood gas analysis on room air shows a pH of $7.20$, $\text{pCO}_2$ of $20$ mm Hg, and $\text{HCO}_3^-$ of $8$ mEq/L. Which of the following is the most appropriate next step in the management of this patient?

Following a spontaneous vaginal delivery of a macrosomic infant, a patient develops profuse vaginal bleeding. The placenta was delivered intact five minutes prior. Abdominal examination reveals a soft, boggy fundus resting at the level of the umbilicus. The care team identifies uterine atony and initiates a management protocol. Assuming the hemorrhage persists despite each successive action, arrange the following interventions in the standard chronological order of escalation.

A pregnant individual in her fourth pregnancy (gravida 4, para 1) is evaluated in the labor suite at 40 weeks and 1 day of gestation. She is currently undergoing a trial of labor after a previous cesarean delivery. Her obstetric history is notable for a primary low transverse surgical delivery three years ago due to a breech presentation. Her prenatal course for the current pregnancy has been uncomplicated. Over the last four hours, her labor has progressed steadily. Her most recent cervical examination revealed $8$ cm of dilation and a fetal station of $+1$. Her contractions have been strong, occurring every 2 to 3 minutes.

Shortly after the examination, the patient suddenly screams in agony, reporting an intense, tearing pain in her lower abdomen that does not resolve between contractions. Concurrently, the intrauterine pressure monitor shows an abrupt cessation of regular uterine contractions, and the continuous fetal heart rate tracing reveals a precipitous drop to a baseline of 75/min for the last four minutes. A rapid bedside physical examination shows moderate vaginal bleeding, and the fetal presenting part is now palpable at the $-2$ station.

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

Match each distinct clinical or laboratory presentation during a normal pregnancy to the primary physiological mechanism responsible for that specific adaptation.