Tüm alıştırma soruları

A 31-year-old woman, G1P0 at 35 weeks gestation, is brought to the emergency department via ambulance following a high-speed frontal motor vehicle collision. She was the restrained driver. Upon arrival, her blood pressure is 78/42 mmHg, pulse is 128/min, and respirations are 24/min. She is pale, diaphoretic, and lethargic. Physical examination reveals a transverse ecchymosis across the lower abdomen. The abdomen is diffusely tender with involuntary guarding. The uterus is firm and exquisitely tender to palpation. Fetal heart rate monitoring demonstrates a baseline of 110/min with absent variability and recurrent late decelerations. An extended focused assessment with sonography for trauma (E-FAST) reveals a large volume of anechoic fluid in the hepatorenal space (Morison pouch). Which of the following is the most appropriate next step in the management of this patient?

Paramedics transport a 41-year-old male accountant to the emergency department after his wife found him acutely confused and sweating profusely at home. The patient has a long-standing history of major depressive disorder that has been difficult to manage. Five days ago, his outpatient psychiatrist discontinued his fluoxetine and immediately initiated a prescription for phenelzine to target different neurotransmitter receptors. On examination, the patient is visibly shivering, highly agitated, and disoriented to time and place. Vital signs reveal a temperature of $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), blood pressure of $168/102\text{ mm Hg}$, and a heart rate of $124\text{/min}$. Neurological evaluation demonstrates dilated pupils, marked bilateral hyperreflexia in the lower extremities, and sustained ankle clonus. The medical team promptly discontinues all psychiatric medications and administers intravenous normal saline along with a dose of intravenous lorazepam. Thirty minutes later, the patient remains profoundly agitated, and his hyperthermia and clonus are completely unchanged. Which of the following is the most appropriate next step in management?

A 27-year-old woman is evaluated in the outpatient psychiatry clinic for a 4-week history of profound sadness, excessive sleepiness, increased appetite, and severe difficulty concentrating at work. She states she has missed several days of work because she "cannot muster the energy to get out of bed." Two years ago, she experienced a 10-day period during which she slept only 2 hours per night, spoke very rapidly, spent her entire savings on a risky business venture, and was highly irritable. This past episode resulted in a brief psychiatric hospitalization. She is not currently taking any medications.

Physical examination shows normal vital signs. Mental status examination reveals psychomotor retardation, a blunted affect, and a depressed mood. Her thought process is linear, and she denies any suicidal ideation, delusions, or hallucinations.

Laboratory studies show:
- TSH: 1.8 µU/mL (normal: 0.5-5.0 µU/mL)
- Free T4: 1.2 ng/dL (normal: 0.8-1.8 ng/dL)
- Urine toxicology screen: negative

The physician decides to initiate pharmacotherapy for this patient's current episode. Which of the following medications are appropriate first-line monotherapy options for this patient? (Select all that apply)

A 27-year-old female medical resident presents to the clinic due to overwhelming anxiety. She reports experiencing intense palpitations, sweating, and hand tremors whenever she has to orally present patient cases during morning rounds. She states, 'I am terrified that my attendings will think I am incompetent because I look so nervous.' This anxiety is strictly isolated to public speaking; she has no difficulty interacting with patients, attending social events, or talking to colleagues in casual settings. Her past medical history is notable for asthma, which is currently managed with an albuterol inhaler as needed. Her vital signs are within normal limits. Which of the following is the most appropriate next step in management for this patient's psychiatric symptoms?

A 48-year-old woman with a history of two prior cesarean deliveries is undergoing a total abdominal hysterectomy for severe symptomatic adenomyosis. While sharply dissecting the scarred vesicouterine reflection to mobilize the bladder, the surgeon notes a sudden pooling of clear fluid in the operative field. Careful inspection reveals an inadvertent 2.5-cm laceration at the dome of the bladder.

Arrange the following intraoperative and postoperative management steps in the most appropriate chronological sequence for this patient.

During morning rounds, the surgical team examines a 55-year-old woman on her fourth day of recovery following an elective sigmoid colectomy. She is lethargic and her vital signs show a blood pressure of 80/45 mm Hg, heart rate of 125/min, and temperature of 39.2 C (102.6 F). Physical examination reveals a distended abdomen that is diffusely tender with marked rigidity and involuntary guarding. A diagnosis of acute septic shock secondary to an anastomotic leak is suspected. Arrange the following critical management steps in the most appropriate chronological sequence for this patient.

A 32-year-old woman with a severe opioid use disorder (primarily intravenous heroin) presents to an outpatient addiction clinic. She is highly motivated to achieve long-term abstinence and requests to start extended-release intramuscular naltrexone therapy, as her occupation makes daily medication adherence difficult. She used heroin this morning. Arrange the following clinical steps in the most appropriate chronological order for safely initiating extended-release naltrexone therapy in this patient.

Match each classic burn trauma or post-resuscitation clinical presentation with its most appropriate immediate diagnostic or therapeutic next step in management.

A 42-year-old high school teacher presents for evaluation of a 7-month history of difficulty initiating sleep and frequent, prolonged nocturnal awakenings. The patient reports spending over 9 hours in bed each night in a desperate attempt to feel rested, but estimates achieving only 4 to 5 hours of total sleep. The resulting severe daytime fatigue has begun to impair her teaching performance and daily functioning. She denies snoring, witnessed apneic events, or an urge to move her legs at rest. Physical examination, neurologic assessment, and routine laboratory studies are unremarkable.

Arrange the following clinical interventions in the most appropriate chronological sequence for the evidence-based, stepped-care management of this patient's condition, proceeding from initial assessment to subsequent escalations for refractory symptoms.

A $78$-year-old man is evaluated in the surgical ward on postoperative day $4$ following an open reduction and internal fixation of a comminuted intertrochanteric femur fracture. His medical history includes hypertension, diet-controlled type $2$ diabetes mellitus, and chronic kidney disease stage II. Over the past $48$ hours, he has developed progressive, severe abdominal distension and nausea without vomiting. He has not passed flatus or had a bowel movement since the surgery. His pain is being managed with a patient-controlled intravenous hydromorphone pump.

Vital signs include a temperature of $37.1^\circ\text{C}$, heart rate of $88$/min, blood pressure of $135/85$ mmHg, and respiratory rate of $16$/min. On physical examination, the abdomen is massively distended and tympanitic to percussion throughout, with high-pitched, infrequent bowel sounds. There is diffuse mild tenderness but no rebound guarding or rigidity.

An initial portable supine abdominal radiograph demonstrates severe dilation of the entire colon, with the cecum measuring $10.5$ cm in diameter. A subsequent computed tomography (CT) scan of the abdomen and pelvis with water-soluble enteral contrast confirms marked colonic dilation without any transition point, mechanical obstruction, or signs of bowel ischemia, establishing the diagnosis of acute colonic pseudo-obstruction (Ogilvie syndrome).

Assuming the patient's condition ultimately proves refractory to each successive non-operative therapy without developing signs of peritonitis or perforation, arrange the following therapeutic interventions in the correct algorithmic sequence from first-line to last-resort management.

A 21-year-old man is brought to the psychiatrist by his parents for a follow-up appointment. Eight weeks ago, the patient was a passenger in a severe motor vehicle collision in which he sustained minor physical injuries. One week after the accident (seven weeks ago), he abruptly began hearing unfamiliar voices conversing about his actions and developed the belief that local traffic lights were sending him coded government messages. He exhibited grossly disorganized behavior, prompting hospitalization. He was started on oral risperidone, and his parents report that his hallucinations and delusions completely resolved three weeks ago. However, since his positive symptoms ceased, he has remained socially withdrawn, speaks only in rare monosyllables, and exhibits a strikingly flat affect. He has not returned to his college classes or his part-time job, and spends most of his day staring blankly out the window. His physical examination and vital signs are unremarkable. A urine toxicology screen is negative. Which of the following is the most accurate diagnosis for this patient at this time?

A 42-year-old woman is evaluated in the post-anesthesia care unit three hours after a total thyroidectomy for Graves disease. The nursing staff urgently requests an assessment because the patient has developed severe agitation and difficulty breathing. Vital signs show a heart rate of 118/min, respiratory rate of 28/min, and oxygen saturation of 86% on room air. Physical examination reveals a tense, rapidly expanding swelling of the anterior neck beneath the surgical incision, accompanied by significant inspiratory stridor. Arrange the following management steps in the most appropriate chronological sequence for this acute postoperative emergency.

Match each clinical presentation to the most appropriate psychiatric or behavioral diagnosis on the somatic symptom spectrum.

A $64$-year-old woman is evaluated on postoperative day $5$ following a right total knee arthroplasty. She reports new-onset right calf pain that worsens when she attempts to walk. Her temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $130/80\text{ mm Hg}$, pulse is $88/\text{min}$, and respirations are $16/\text{min}$. Physical examination reveals right calf swelling, warmth, and tenderness to palpation. The surgical incision site is well-approximated, clean, and without purulent discharge or surrounding erythema. Her breath sounds are clear bilaterally. Which of the following is the most appropriate next step in the management of this patient?

A 47-year-old male accountant presents to an outpatient psychiatric clinic with a 3-month history of pervasive sadness, anhedonia, terminal insomnia, profound fatigue, impaired concentration, and a 12-lb (5.4 kg) weight loss. He is diagnosed with a severe episode of major depressive disorder without psychotic features. Over the next 14 months, his condition proves remarkably difficult to treat, eventually culminating in a hospitalization for depressive stupor and mood-congruent delusions.

Arrange the following therapeutic interventions in the most appropriate chronological sequence according to standard stepped-care escalation algorithms for major depressive disorder.

A high school student is transported to the acute care clinic by her family following a fainting spell. She reports eating less than 500 calories daily for several months. Her current body mass index is $13.8 \text{ kg/m}^2$. Triage vitals reveal marked hypotension ($80/50 \text{ mm Hg}$), profound sinus bradycardia ($36/\text{min}$), and hypothermia ($35.4^\circ\text{C}$). Examination shows marked cachexia, temporal wasting, and lanugo. Arrange the following steps in the most appropriate chronological sequence for the comprehensive management of this patient.

A $27$-year-old man is brought to the emergency department by his sister due to increasingly bizarre behavior over the past $6$ weeks. The sister reports that he has been barring the doors to their apartment, claiming that intelligence agencies have placed listening devices in the walls. He has also been talking to himself and appears to be responding to unseen stimuli. Over the past three days, he has not slept. He has no prior psychiatric history. His temperature is $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), pulse is $118/\text{min}$, and blood pressure is $152/94\text{ mm Hg}$. Physical examination reveals a thin, disheveled man. He is diaphoretic and has prominent dental caries along with multiple healing excoriations on his bilateral forearms and face. He is hypervigilant and frequently paces the room. Which of the following is the most likely diagnosis?

A 19-year-old male is brought to the emergency department after a collision during a rugby match. While running, he was struck forcefully in the left upper quadrant of the abdomen by an opposing player's knee. He initially tried to continue playing but collapsed on the sideline due to lightheadedness and severe abdominal pain.

On presentation, his temperature is 36.6°C (97.9°F), blood pressure is 82/48 mm Hg, heart rate is 134/min, and respiratory rate is 22/min. He appears pale and diaphoretic. The airway is intact, and breath sounds are equal bilaterally. Cardiac examination reveals sinus tachycardia. His abdomen is rigid and diffusely tender with guarding and rebound tenderness, most pronounced in the left upper quadrant. The pelvis is stable to compression.

A focused assessment with sonography for trauma (FAST) examination demonstrates anechoic free fluid in the splenorenal recess and the rectovesical pouch. Two large-bore peripheral intravenous lines are established. Despite a 1-liter bolus of warmed isotonic crystalloid and initiation of an uncrossmatched blood transfusion, his blood pressure remains 84/50 mm Hg.

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

Match each gynecologic surgical procedure or step with the specific anatomic complication it is most likely to cause based on its anatomical location.

Pair the following clinical presentations with the most likely corresponding neurocognitive disorder.