Tüm alıştırma soruları

A 31-year-old G1P0 woman at 34 weeks gestation is admitted to the labor and delivery unit for management of preeclampsia with severe features. Upon admission, her blood pressure is 175/115 mmHg, and laboratory evaluation reveals a platelet count of 90,000/mm $^3$, aspartate aminotransferase of 110 U/L, and alanine aminotransferase of 125 U/L. A continuous intravenous infusion of magnesium sulfate is initiated for seizure prophylaxis, along with intravenous hydralazine.

Over the subsequent 12 hours, the patient receives 3 liters of intravenous lactated Ringer solution because her urine output has been consistently 15 mL/hour. She now complains of new-onset, severe shortness of breath, a persistent cough, and the inability to lie flat.

Current vital signs are:
Temperature: 37.0°C (98.6°F)
Blood pressure: 160/100 mmHg
Pulse: 115/min
Respiratory rate: 28/min
Oxygen saturation: 86% on room air

Physical examination reveals 3+ pitting edema of the lower extremities extending to the knees and bilateral basilar crackles on lung auscultation. Deep tendon reflexes are 2+ and symmetric globally.

Arterial blood gas analysis on room air shows:
pH: 7.46
PaO $_2$: 55 mmHg
PaCO $_2$: 28 mmHg
HCO $_3^-$: 19 mEq/L

The fetal heart rate tracing demonstrates a baseline of 145/min, minimal variability, and recurrent late decelerations.

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

A 31-year-old female patient presents to the outpatient gynecology office reporting the absence of menstruation for the past 9 months. She experienced menarche at age 12, and her menses were consistently regular until this past year. Her medical history is notable for an incomplete spontaneous abortion 11 months ago, which was managed with a dilation and curettage. She currently denies nipple discharge, headaches, visual field deficits, or vasomotor symptoms. Her blood pressure is 112/72 mm Hg, pulse is 76/min, and body mass index is 22 kg/m^2. Physical examination demonstrates Tanner stage 5 breast development and normal-appearing female external genitalia. Arrange the following diagnostic steps in the classical sequential order to properly evaluate the etiology of this patient's secondary amenorrhea.

Match each patient's clinical presentation and examination findings to the most likely etiologic pathogen responsible for their symptoms.

A 4-year-old boy is evaluated in the pediatric clinic due to a 4-week history of increasing unsteadiness and frequent falls. His parents note that he was previously running and climbing without difficulty but has recently begun walking with his feet wide apart. He also complains of head pain upon waking in the mornings, accompanied by two recent episodes of non-bilious emesis. His developmental history was previously normal. On physical examination, his temperature is 37.0°C (98.6°F), blood pressure is 115/75 mm Hg, pulse is 80/min, and respirations are 20/min. Fundoscopic examination reveals blurred optic disc margins bilaterally. He exhibits truncal ataxia and nystagmus on lateral gaze. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation of a pediatric genetic syndrome to its most strongly associated congenital heart defect.

Congenital bone marrow failure syndromes and inherited cytopenias in pediatric oncology often present with characteristic combinations of hematologic laboratory abnormalities and physical exam findings. Match each of the following patient clinical vignettes with the most likely underlying syndromic diagnosis.

A fundamental understanding of developmental biology and neonatal pathophysiology is essential when evaluating surgical and medical abdominal emergencies in the pediatric population. Match each specific embryologic defect or pathophysiologic mechanism with the corresponding pediatric gastrointestinal disorder.

A nulliparous woman presents to the labor ward at 40 weeks of gestation complaining of regular, painful contractions. Upon admission, her vital signs are within normal limits. Her cervix is dilated to 5 cm and is 90% effaced. Artificial rupture of membranes is performed, yielding a moderate amount of clear amniotic fluid. Two hours later, her cervix is 7 cm dilated. The continuous fetal heart rate tracing demonstrates a baseline of 140/min and moderate variability. However, the tracing also reveals recurrent, abrupt drops in the heart rate to 90/min that last for 40 seconds before rapidly returning to the baseline. These drops are not consistently related to the peak of the uterine contractions, which are occurring every 3 minutes. The patient is immediately placed in the left lateral decubitus position and given an intravenous fluid bolus, but the fetal heart rate pattern remains unchanged. Which of the following is the most appropriate next step in management?

A $14$-month-old girl is brought to the emergency department by her parents due to a generalized tonic-clonic seizure and subsequent unresponsiveness. The parents report that she has had a mild upper respiratory tract infection for the past $48$ hours and has refused to eat or drink anything since yesterday evening. Prior to this illness, she had no medical issues and her growth and development were appropriate for her age. On physical examination, the patient is obtunded. Her temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), heart rate is $150/\text{min}$, respiratory rate is $26/\text{min}$, and blood pressure is $82/50\text{ mmHg}$. The liver edge is palpable $4\text{ cm}$ below the right costal margin.

Laboratory results are as follows:

Urinalysis is negative for ketones.

Which of the following is the most likely underlying biochemical defect in this patient?

An obstetric team is managing a multiparous patient at 36 weeks gestation who is admitted to the labor unit for induction of labor due to poorly controlled gestational diabetes. Her prenatal care was delayed, and she had only a single second-trimester ultrasound which was reportedly normal. Following artificial rupture of membranes at 5 centimeters of cervical dilation to place an internal fetal scalp electrode, the patient immediately develops moderate, bright red vaginal bleeding. Her blood pressure is 118/76 mm Hg, and pulse is 84/min. The electronic fetal monitor subsequently demonstrates a visually smooth, undulating baseline heart rate that fluctuates evenly between 130 and 150/min. This pattern repeats 4 times per minute and exhibits an absolute lack of short-term beat-to-beat variability. The fetal heart rate does not change in response to vibroacoustic stimulation. Uterine contractions remain regular every 4 minutes. Which of the following is the most appropriate next step in the management of this patient?

A 16-month-old boy is rushed to the pediatric emergency department after sudden-onset choking while eating grapes at home. Upon arrival, the child is cyanotic, diaphoretic, and making high-pitched inspiratory sounds. While the triage nurse is rapidly evaluating the patient, the child abruptly loses consciousness and becomes limp.

Arrange the following next steps in the most appropriate sequence according to pediatric basic life support guidelines for an unresponsive choking child.

A 34-year-old G3P3 woman with a history of poorly controlled asthma and gestational hypertension experiences a massive postpartum hemorrhage immediately following a spontaneous vaginal delivery of a 4200-g neonate. The placenta delivered intact. The uterus is soft, boggy, and palpated 3 cm above the umbilicus. Arrange the following therapeutic interventions in the most appropriate sequential order to manage this patient's hemorrhage, assuming each consecutive measure fails to achieve hemostasis.

A $15$-month-old boy is brought to the emergency department via ambulance after experiencing a generalized tonic-clonic seizure. His parents report that he has had a low-grade fever, vomiting, and poor oral intake for the past $48$ hours. On physical examination, the child is lethargic, hypotonic, and pale. Hepatomegaly is noted on abdominal palpation. Point-of-care testing reveals a blood glucose level of $28$ mg/dL ($1.5$ mmol/L). A urinalysis is notably negative for ketones. A metabolic crisis secondary to a fatty acid oxidation defect (such as medium-chain acyl-CoA dehydrogenase deficiency) is suspected. Arrange the following steps in the most appropriate chronological sequence for the immediate management, diagnostic workup, and long-term care of this patient.

Match each clinical scenario describing an acute intrapartum or puerperal emergency with its most appropriate immediate definitive management step.

Evaluate the following complex laboratory and clinical profiles of pregnant patients presenting with hepatic or hematologic dysfunction. Pair each patient presentation with its most precise underlying pathophysiologic mechanism.

An otherwise healthy 29-year-old woman is evaluated in the outpatient clinic for a 7-month history of absent menses. Menarche occurred at age 12, and her menstrual cycles were previously regular, occurring every 28 to 30 days. She runs 15 miles per week and consumes a balanced diet. Her body mass index is 22 kg/m². She takes no daily medications and has no history of chronic medical conditions. A urine human chorionic gonadotropin test is negative. Physical examination reveals normal breast development without galactorrhea. There is no evidence of hirsutism, acne, or clitoromegaly. Pelvic examination is unremarkable. Which of the following is the most appropriate next step in the evaluation of this patient?

A 4-year-old boy is brought to the emergency department by his parents due to severe difficulty breathing. Over the past three days, he has had nasal congestion, a low-grade fever, and a harsh, barking cough. This morning, his fever spiked and he became increasingly lethargic. His immunizations are up to date. His temperature is 39.8°C (103.6°F), pulse is 155/min, respirations are 48/min, and blood pressure is 100/65 mm Hg. Pulse oximetry shows 92% on room air. On examination, the child appears toxic, anxious, and is leaning forward slightly, but there is no drooling. He has marked inspiratory stridor at rest and severe suprasternal retractions. The patient is administered nebulized racemic epinephrine and intravenous dexamethasone; however, reassessment 30 minutes later reveals no improvement in his work of breathing or stridor. Which of the following is the most appropriate next step in management?

A $28$-year-old woman, gravida $2$, para $1$, presents to the clinic for her initial prenatal evaluation at $9$ weeks gestation based on her last menstrual period. Her only complaints are mild fatigue and intermittent morning nausea, which improve with small meals. She has no significant past medical history and takes a daily prenatal vitamin. Her vital signs are within normal limits. Physical examination reveals a normal-appearing thyroid gland with no palpable enlargement or nodules. Pelvic examination is consistent with her gestational age. Because of her fatigue, a primary care physician previously ordered laboratory tests prior to this obstetric visit. The results are as follows:

Thyroid-stimulating hormone (TSH): $0.1$ $\mu$ U/mL (Reference: $0.5$–$5.0$ $\mu$ U/mL)
Total thyroxine (Total T4): $14.2$ $\mu$ g/dL (Reference: $5.0$–$12.0$ $\mu$ g/dL)
Free thyroxine (Free T4): $1.4$ ng/dL (Reference: $0.8$–$2.0$ ng/dL)

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

A $28$-year-old primigravida at $10$ weeks gestation comes to the clinic for her initial prenatal visit. She reports mild nausea, breast tenderness, occasional palpitations, and feeling warmer than usual over the past few weeks. She has no significant past medical history and takes a daily prenatal vitamin. Vital signs include a heart rate of $92$/min and a blood pressure of $110/70$ mmHg. Physical examination reveals a normal-sized, non-tender thyroid gland without palpable nodules. Deep tendon reflexes are normal.

Laboratory evaluation shows the following:

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

Match each normal obstetrical finding or clinical milestone to the earliest gestational age at which it is typically expected during a normal, uncomplicated pregnancy.