Tüm alıştırma soruları

A 5-month-old male infant is brought to the pediatric neurology clinic by his parents due to concerns about his motor development. The parents report that he "feels like a rag doll" when lifted and has never rolled over or been able to support his head. He was born at 39 weeks gestation via uncomplicated vaginal delivery and has been exclusively breastfed. On physical examination, the infant appears alert and tracks the examiner's face with normal extraocular movements. He exhibits severe generalized hypotonia and assumes a "frog-leg" posture when placed in the supine position. Deep tendon reflexes are absent bilaterally in both the upper and lower extremities. Examination of the oral cavity reveals fine, rapid, continuous twitching movements of the resting tongue. Which of the following is the most appropriate next step in the evaluation of this patient?

A $7$-month-old boy is brought to the pediatric emergency department for extreme lethargy, diaphoresis, and recurrent vomiting. The parents state that he was completely healthy and exclusively breastfed until one month ago, when they began introducing fruit purees and juices. He frequently vomits shortly after these meals. The parents also mention they are worried about his development; although he can roll over in both directions and passes toys from one hand to the other, he is not yet able to pull himself up to a standing position. Physical examination reveals a lethargic and mildly jaundiced infant. The liver edge is palpable $4$ cm below the right costal margin.

Laboratory studies show:
Sodium: $140$ mEq/L
Potassium: $3.5$ mEq/L
Chloride: $104$ mEq/L
Bicarbonate: $14$ mEq/L
Glucose: $45$ mg/dL
Aspartate aminotransferase (AST): $180$ U/L
Alanine aminotransferase (ALT): $210$ U/L

Arterial blood gas on room air:
pH: $7.29$
PaCO2: $29$ mm Hg

Which of the following is the most accurate statement regarding this patient's presentation?

A healthy pregnant patient at $28$ weeks of gestation comes to the obstetric clinic for a scheduled evaluation. She is $24$ years old and this is her first pregnancy. The patient mentions occasionally feeling as though she cannot take in a full breath, especially when resting. She confirms she has no chest pain, cough, or difficulty speaking in full sentences, and she continues to walk her dog daily without limitation. Vital signs reveal a heart rate of $85$/min, respiratory rate of $16$/min, blood pressure of $112/68$ mmHg, and an oxygen saturation of $99\%$ on room air. Pulmonary auscultation reveals clear breath sounds bilaterally. A comprehensive metabolic panel and arterial blood gas analysis are drawn as part of a voluntary physiologic study she enrolled in. Which of the following profiles most accurately reflects the expected acid-base status in this patient?

A 24-year-old woman comes to the clinic for evaluation of a newly identified right breast lump. She first noticed the mass 2 weeks ago while showering. The patient is otherwise healthy, takes no medications, and has no family history of breast cancer. Her menstrual cycles are regular, and her last menstrual period was 3 weeks ago. Vital signs are normal. On physical examination, there is a 2-cm, firm, mobile, and non-tender mass in the upper outer quadrant of the right breast. There is no overlying skin dimpling, nipple retraction, or axillary lymphadenopathy. Which of the following is the most appropriate next step in management of this patient?

A 3-year-old boy is brought to the emergency department by his parents after vomiting a large amount of bright red blood. He has a past medical history of biliary atresia, for which he underwent a Kasai hepatoportoenterostomy during infancy, and subsequent portal hypertension. On presentation, the child appears lethargic and pale. His temperature is 37.1°C (98.8°F), heart rate is 165/min, blood pressure is 70/40 mm Hg, and respiratory rate is 28/min. He has another episode of voluminous hematemesis while in the resuscitation bay. Arrange the following management steps in the most appropriate chronological order for this patient.

A 15-year-old boy, who recently immigrated, presents to the clinic with progressive shortness of breath, generalized cyanosis, and digital clubbing. His parents report that he was diagnosed with a "hole in his heart" as an infant but never received surgical treatment due to limited medical access. Physical examination reveals a loud P2 but no significant murmur. He is diagnosed with Eisenmenger syndrome secondary to a large, unrestrictive ventricular septal defect (VSD). Arrange the following pathophysiological events in the correct chronological sequence that led to this patient's current clinical presentation, starting from the neonatal period.

A $25$-year-old primigravida at $41$ weeks gestation is admitted to the labor and delivery unit for induction of labor due to postterm pregnancy. A continuous intravenous oxytocin infusion is initiated. Her cervix is $5\text{ cm}$ dilated and $80\%$ effaced. Uterine contractions are occurring every $3$ to $4$ minutes. The fetal heart rate baseline is $135/\text{min}$ with moderate variability. Over the past $30$ minutes, the fetal heart rate tracing demonstrates recurrent, symmetric decreases in the heart rate that begin after the peak of each contraction, reach their nadir after the contraction ends, and then gradually return to baseline. Maternal vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $118/76\text{ mmHg}$, and heart rate $84/\text{min}$. Laboratory studies show a leukocyte count of $14,500/\text{mm}^3$ and hemoglobin of $10.8\text{ g/dL}$. Which of the following is the most appropriate next step in management?

A physician is evaluating a 62-year-old patient who reports highly distressing urinary symptoms that have persisted for the past eight months. She states that she frequently experiences an abrupt, overwhelming need to urinate, which is often followed by a large volume of urine loss before she can reach the bathroom. These episodes occur 4 to 5 times daily. There is no history of leakage associated with physical exertion, sneezing, or coughing. Her medical history includes well-controlled hypertension, narrow-angle glaucoma, and severe chronic idiopathic constipation that requires daily osmotic laxatives. Pelvic examination reveals normal vaginal rugae without erythema or atrophy, and there is no evidence of pelvic organ prolapse. The cough stress test is negative. Postvoid residual volume is 25 mL. Urinalysis shows no abnormalities. The patient has diligently completed an 8-week behavioral therapy program, including timed voiding and pelvic floor muscle training, with minimal improvement. Which of the following pharmacologic mechanisms is most appropriate to target for symptom relief in this patient?

An $8$-year-old boy is evaluated on the pediatric ward for sudden onset of respiratory distress. He has a medical history significant for homozygous hemoglobin S disease. He was admitted $2$ days ago for a severe vaso-occlusive pain episode affecting his bilateral lower extremities, which has been managed with intravenous hydration and morphine. Today, he developed a new-onset fever with a temperature of $39.2^\circ\text{C}$, a respiratory rate of $32/\text{min}$, and sharp right-sided chest pain. Pulse oximetry shows an oxygen saturation of $87\%$ on room air. Physical examination reveals decreased breath sounds and crackles in the right lower lung field. Laboratory studies show that his hemoglobin level has dropped from a baseline of $8.2\text{ g/dL}$ to $6.1\text{ g/dL}$, and his leukocyte count is $18,500/\text{\mu L}$. A chest radiograph demonstrates a new right lower lobe consolidation. Which of the following is the most appropriate next step in the management of this patient?

A 65-year-old G3P3 patient is evaluated in the urogynecology clinic prior to a scheduled surgical procedure. She has a symptomatic, advanced anterior vaginal wall prolapse that causes daily pelvic pressure and a bothersome vaginal bulge. The patient explicitly denies any current involuntary loss of urine, urinary urgency, or dysuria, stating that her bladder control is completely normal. Her medical history includes obesity, well-controlled hypertension, and a total abdominal hysterectomy for benign fibroids 12 years ago. Pelvic examination confirms a large cystocele protruding 4 cm beyond the hymenal ring during a Valsalva maneuver. The posterior vaginal wall and vaginal apex are well supported. Urinalysis is unremarkable, and postvoid residual volume is 25 mL. The patient is scheduled to undergo an anterior colporrhaphy next week. To prevent a common postoperative complication, which of the following is the most appropriate next diagnostic step to guide this patient's surgical plan?

A worried couple arrives at the urgent care clinic with their 18-month-old son shortly after he experienced a full-body convulsion. According to the parents, the episode involved rhythmic shaking of all four extremities, lasted approximately 2 minutes, and stopped on its own. The child has been irritable for the past 24 hours with a prominent runny nose and a rectal temperature of 39.6°C (103.3°F). His immunizations are up to date. Vital signs are stable. On physical examination, the boy is postictal but arousable, demonstrating normal tone and no focal neurological deficits. During the interview, the parents express significant anxiety, stating they fear the seizure was caused by an underlying neurological problem. They point out that his development seems 'slow' because he 'can barely run stiffly' and only says about 15 to 20 single words. Which of the following statements are accurate regarding this patient's current status and management? (Select 2 answers)

A 31-year-old G3P3 woman experiences massive postpartum hemorrhage immediately following a spontaneous vaginal delivery of a 4200g neonate. Physical examination reveals a soft, enlarged, and boggy uterus. Initial management with continuous bimanual uterine massage, aggressive intravenous fluid resuscitation, and high-dose intravenous oxytocin has failed to arrest the bleeding. Her past medical history is significant for chronic hypertension and poorly controlled asthma. Arrange the following interventions in the most appropriate stepwise order of escalation for managing this patient's ongoing hemorrhage.

A worried mother brings her $9$-month-old daughter to an urgent care center in late November due to rapid breathing. The infant has had a runny nose and a prominent, mucousy cough for the past $4$ days. The mother mentions that several other children at the patient's daycare have been out sick recently. The infant’s temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), pulse is $132/\text{min}$, respirations are $54/\text{min}$, and oxygen saturation is $94\%$ on room air. While the child has mild intercostal retractions, she remains playful, is tracking the physician across the room, and is feeding normally according to the mother. Physical examination reveals profuse clear rhinorrhea, diffuse expiratory wheezing, and scattered coarse crackles bilaterally. What is the most appropriate next step in managing this patient's condition?

A 31-year-old woman, gravida 2 para 1, at 37 weeks and 4 days gestation, presents to the emergency department reporting unremitting lower back pain for the past three hours. She has not experienced any vaginal bleeding, leakage of fluid, or recent trauma. Her medical history is significant for chronic hypertension managed with oral labetalol. Vital signs are temperature 37.1°C, pulse 115/min, blood pressure 152/92 mm Hg, and respirations 18/min. Physical examination reveals a firm, tense uterus that is tender to deep palpation. There is no visible blood in the vaginal vault on speculum examination, and the cervix is closed. Continuous electronic fetal monitoring demonstrates a baseline heart rate of 165/min, absent baseline variability, and repetitive late decelerations. The tocodynamometer shows high-frequency, low-amplitude uterine contractions occurring every 1 to 2 minutes with an elevated resting tone. Initial laboratory studies show a hemoglobin of 10.4 g/dL, platelet count of 105,000/mm³, and fibrinogen of 190 mg/dL. Which of the following is the most appropriate next step in management?

A $72$-year-old woman, gravida $2$, para $2$, comes to the gynecologist reporting a vulvar lesion that she first noticed $4$ months ago. She states that the area is occasionally pruritic and bleeds slightly when wiped. Her past medical history is notable for lichen sclerosus, which was diagnosed $10$ years ago and is managed with intermittent topical clobetasol. Menopause occurred at age $51$. On physical examination, the vagina and cervix appear atrophic. On the right labium majus, approximately $4$ cm lateral to the midline, there is a $2.5$ cm, firm, ulcerated, unifocal nodule. There are no palpable inguinal lymph nodes. A punch biopsy of the nodule confirms invasive squamous cell carcinoma with a depth of invasion of $3.5$ mm. Which of the following is the most appropriate next step in management?

A 58-year-old woman presents to the clinic with a 3-week history of continuous, thin, watery vaginal discharge that occasionally leaves pink stains on her undergarments. She reached menopause at age 51. Her medical history is notable for estrogen receptor-positive breast cancer diagnosed 4 years ago, which was treated with a lumpectomy and radiation therapy. She has been taking anastrozole for the past 3 years. Since starting the medication, she reports significant vaginal dryness and dyspareunia. Her vital signs are within normal limits. Speculum examination reveals pale, thin, and dry vaginal mucosa with a loss of rugation. There are no lacerations in the vaginal vault, but a small amount of dark red fluid is noted pooling at the external cervical os. Bimanual examination demonstrates a small, mobile, non-tender uterus without adnexal masses. Which of the following is the most appropriate next step in the management of this patient?

A clinic nurse is preparing an educational timeline chart for patients beginning their prenatal care. Match each routine obstetrical screening test or intervention to the precise gestational age window during which it is standardly recommended for an uncomplicated pregnancy.

A 26-year-old primigravida presents to the obstetrics clinic for her initial prenatal visit at 8 weeks gestation. She has no significant past medical history and takes a daily prenatal vitamin. Vital signs are normal. A transvaginal ultrasound confirms a viable singleton intrauterine pregnancy. The patient is eager to ensure she receives all standard prenatal care and asks about the schedule of upcoming tests. Assuming a continuous, uncomplicated pregnancy course, arrange the following routine prenatal screening and diagnostic evaluations in the correct chronological order from the earliest to the latest gestational age at which they are optimally performed.

A $29$-year-old woman, G2P1, at $32$ weeks gestation is brought to the emergency department via ambulance following a motor vehicle collision. She was the restrained driver of a sedan that was struck on the driver's side by a commercial truck. On arrival, she is immobilized on a backboard with a cervical collar. She appears confused and is diaphoretic. Temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), blood pressure is $78/45\text{ mmHg}$, heart rate is $132\text{/min}$, and respiratory rate is $24\text{/min}$. Pulse oximetry is $96\%$ on $15\text{ L/min}$ oxygen via a nonrebreather mask. The airway is patent, and breath sounds are equal bilaterally. The uterus is palpated above the umbilicus. The abdomen is diffusely tender to palpation with involuntary guarding. There is no external vaginal bleeding. A focused assessment with sonography for trauma (FAST) reveals a large amount of free fluid in the hepatorenal space (Morison's pouch). Fetal heart tones are $140\text{/min}$. Two large-bore intravenous lines are established, and administration of warmed crystalloid fluids is initiated. Which of the following is the best next step in management?

Match each pediatric patient's clinical presentation and associated diagnostic findings with the most likely central nervous system tumor.