Tüm alıştırma soruları

A 34-year-old man is brought to the emergency department after a high-speed motorcycle collision. He is hemodynamically stable, and a primary trauma survey reveals no acute intracranial, thoracic, or abdominal life-threatening injuries. Pelvic radiography demonstrates a displaced fracture of the pubic rami. On physical examination, there is prominent blood at the urethral meatus, a severely swollen and ecchymotic scrotum, and the patient reports a strong urge to void but is unable to do so. Digital rectal examination reveals a high-riding, boggy prostate. Arrange the following steps in the most appropriate chronological sequence for the standard diagnostic and surgical management of this patient's urologic injury.

A randomized controlled trial is conducted to evaluate a new selective estrogen receptor modulator (SERM) for the prevention of breast cancer in high-risk postmenopausal women. The study enrolls 1,600 women, who are randomly assigned in a 1:1 ratio to receive either the new SERM or a placebo. The participants are followed for 5 years. During the follow-up period, 56 out of the 800 women receiving the new SERM develop deep vein thrombosis (DVT). In the placebo group, 16 out of the 800 women develop DVT.

Based on these study results, what is the number needed to harm (NNH) for DVT associated with this new SERM?

A 26-year-old man is brought to the emergency department after a severe motor vehicle collision. Primary survey reveals an unstable pelvic fracture. Genitourinary examination shows blood at the urethral meatus, a scrotal hematoma, and a high-riding prostate on digital rectal examination. A transurethral Foley catheter has not been placed. Arrange the following steps in the most appropriate sequential order for the diagnosis and definitive management of this patient's urologic injury.

A 42-year-old woman presents to the clinic with episodic palpitations, severe headaches, and diaphoresis. Her blood pressure is 180/110 mmHg, and her heart rate is 105/min. She is highly suspected of having a pheochromocytoma. Arrange the following steps in the most appropriate chronological order for her diagnostic workup and perioperative surgical management.

A trauma team evaluates a 32-year-old male construction worker who fell 15 feet from a scaffold, striking his head on a concrete slab. On primary survey, he does not open his eyes, makes incomprehensible sounds, and exhibits decorticate posturing to painful stimuli. His right pupil is 8 mm and nonreactive to light. Vital signs show a blood pressure of 190/110 mmHg, a heart rate of 48/min, and a respiratory rate of 8/min with irregular breathing patterns.

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

A 68-year-old woman is evaluated in the hospital for new-onset, severe abdominal pain and distension. She was admitted four days ago for community-acquired pneumonia and has been receiving intravenous ceftriaxone and azithromycin. The patient has not had a bowel movement or passed flatus for the past 24 hours. Her medical history includes type 2 diabetes mellitus, hypertension, and an open total abdominal hysterectomy performed a decade ago. Temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $92/58 \text{ mm Hg}$, and pulse is $118/\text{min}$. Physical examination reveals a markedly distended abdomen with diffuse tympany. Palpation elicits severe diffuse tenderness with involuntary guarding and rebound tenderness. Bowel sounds are absent. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ and a serum bicarbonate of $15 \text{ mEq/L}$. A plain radiograph of the abdomen demonstrates multiple dilated loops of small bowel with air-fluid levels and a paucity of gas in the colon. Which of the following is the most appropriate next step in management?

A $45$-year-old man presents to the clinic to discuss his risk of developing pancreatic cancer. His father was recently diagnosed with the disease, and the patient is concerned about his own long-term occupational exposure to industrial dyes as a textile worker. The physician reviews the medical literature and finds a recent study that selected $200$ individuals with pancreatic cancer and $400$ individuals without the disease. The researchers subsequently analyzed the participants' past occupational records to determine their previous exposure to industrial dyes. Which of the following metrics was most likely reported in the study to quantify the association between dye exposure and pancreatic cancer?

A 54-year-old woman is evaluated in the neurosurgical intensive care unit for worsening somnolence over the past 12 hours. She was admitted 6 days ago with a subarachnoid hemorrhage secondary to a ruptured left middle cerebral artery aneurysm, which was successfully treated with surgical clipping. Over the last 24 hours, her urine output has been 4.5 liters.

Vitals:
- Temperature: $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$)
- Blood pressure: $88/54 \text{ mm Hg}$
- Heart rate: $122/\text{min}$
- Respirations: $16/\text{min}$

Physical examination shows dry mucous membranes and poor skin turgor. Neurologic examination reveals a Glasgow Coma Scale of 13 (E3, V4, M6). She has a right-sided pronator drift and mild right facial droop, which are unchanged from her immediate postoperative baseline.

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

A 25-year-old man is transported to the trauma center after being struck on the right side of the head with a heavy metal wrench during an altercation. He experienced a brief loss of consciousness lasting approximately one minute at the scene, but was subsequently awake, alert, and answering questions appropriately during transport. Three hours after arrival, he becomes acutely lethargic and stops following commands. His blood pressure is 165/95 mmHg, and his heart rate is 55/min. Neurological examination reveals a Glasgow Coma Scale score of 6 and a right pupil that is 7 mm and unresponsive to light. A non-contrast head computed tomography scan demonstrates a hyperdense, lens-shaped collection over the right frontotemporal convexity that does not cross cranial suture lines. Which of the following is the most appropriate next step in management?

A 29-year-old man presents to the emergency department with acute, agonizing pain in his groin. He reports that 2 hours ago, during vigorous sexual intercourse, he heard a distinct "snapping" sound, which was immediately followed by a loss of erection and rapid swelling of his penis. He states that he has felt a strong urge to urinate since the event but has been unable to pass any urine. Vital signs are within normal limits. Physical examination reveals a markedly swollen, ecchymotic penis that is severely deviated to the right. The scrotum is unremarkable, but there is a visible drop of fresh blood at the external urethral meatus. Which of the following is the most appropriate next step in the management of this patient?

A $65$-year-old man comes to the clinic for a follow-up examination $6$ weeks after undergoing a radical cystectomy and urinary diversion via an ileal conduit for muscle-invasive urothelial carcinoma. Over the past two weeks, he has experienced progressive fatigue and generalized muscle weakness. His temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $118/76\text{ mm Hg}$, pulse is $88/\text{min}$, and respirations are $22/\text{min}$. Physical examination shows a well-healed abdominal incision. The stoma is pink and viable, outputting clear yellow urine into the ostomy bag. The lungs are clear to auscultation bilaterally.

Laboratory studies are obtained:

Arterial blood gas analysis on room air shows:
- pH: $7.28$
- pCO $_2$: $28\text{ mm Hg}$
- pO $_2$: $96\text{ mm Hg}$

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

A 58-year-old woman is evaluated in the surgical clinic after routine laboratory testing reveals a serum calcium level of 11.4 mg/dL (normal: 8.4-10.2 mg/dL). She has a history of nephrolithiasis and complains of generalized fatigue. Arrange the following steps in the most appropriate chronological sequence for the evaluation and definitive surgical management of this patient's condition.

A 74-year-old man with a history of atrial fibrillation and congestive heart failure is brought to the emergency department due to sudden-onset, severe abdominal pain. The pain began $4$ hours ago and was initially out of proportion to his physical examination findings. He has rapidly become lethargic. Vital signs show a blood pressure of $80/50 \text{ mm Hg}$, pulse of $130/\text{min}$ and irregularly irregular, and respiratory rate of $24/\text{min}$. Abdominal examination reveals a distended abdomen with diffuse rebound tenderness and involuntary guarding. Laboratory studies show a leukocyte count of $22,000/\text{mm}^3$ and a serum lactate of $8.5 \text{ mmol/L}$. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 49-year-old postmenopausal woman presents to the surgical breast clinic due to a 5-week history of right breast swelling, redness, and a feeling of heaviness. She was initially evaluated by her primary care provider and completed a 10-day course of oral cephalexin for presumed mastitis, but her symptoms have progressively worsened. She has no personal or family history of breast cancer. Her temperature is 37.1°C (98.8°F). Physical examination reveals a diffusely enlarged right breast with prominent erythema covering approximately 60% of the breast surface. The skin demonstrates a pitted, edematous appearance resembling an orange peel (peau d'orange). A poorly defined, firm area is palpated deep within the central quadrant. A 1.5-cm firm, mobile lymph node is palpable in the right axilla. Arrange the following steps in the most appropriate chronological sequence for the optimal evaluation and definitive management of this patient.

A $35$-year-old woman is evaluated in the clinic for a routine follow-up $3$ months after undergoing a total thyroidectomy and central compartment lymph node dissection for classical papillary thyroid carcinoma. Her postoperative course was complicated by permanent hypoparathyroidism due to inadvertent parathyroid gland resection, requiring continuous calcium and active vitamin D supplementation.

The patient currently feels well and reports no muscle cramping, perioral numbness, or tingling. Her medications include levothyroxine $125$ mcg daily, calcium carbonate $1000$ mg three times daily, and calcitriol $0.5$ mcg twice daily.

Vital signs are within normal limits. Physical examination reveals a well-healed Kocher incision and negative Chvostek and Trousseau signs.

Laboratory studies show the following:
Serum calcium: $9.3$ mg/dL (normal $8.4$ - $10.2$ mg/dL)
Serum phosphorus: $4.2$ mg/dL (normal $2.7$ - $4.5$ mg/dL)
Serum albumin: $4.0$ g/dL
Thyroid-stimulating hormone (TSH): $0.3$ $\mu$ U/mL (normal $0.5$ - $5.0$ $\mu$ U/mL)
Intact PTH: $8$ pg/mL (normal $15$ - $65$ pg/mL)
$24$-hour urine calcium: $450$ mg/day (normal < $250$ mg/day)

Renal ultrasound demonstrates no nephrolithiasis.

What is the most appropriate next step in management to prevent long-term complications in this patient?

A 62-year-old male with stage 4 chronic kidney disease secondary to hypertensive nephrosclerosis presents to the emergency department with a 3-day history of progressively worsening shortness of breath, orthopnea, and lower extremity edema. He has a past medical history of chronic obstructive pulmonary disease (COPD) and tobacco use. Four weeks ago, he underwent surgical creation of a left brachiocephalic arteriovenous fistula in anticipation of starting hemodialysis.

Vital signs are temperature 37.0°C (98.6°F), blood pressure 162/65 mm Hg, heart rate 112/min, respiratory rate 24/min, and oxygen saturation 92% on room air.

Physical examination reveals elevated jugular venous pressure at 10 cm H $_2$ O. Pulmonary auscultation demonstrates bilateral basilar crackles and diffuse expiratory wheezing. Cardiac examination reveals a hyperdynamic precordium with a regular tachycardia and a grade 2/6 systolic ejection murmur at the left upper sternal border. The left arm has a prominent, palpable thrill and a loud, continuous bruit over the surgical site. The right arm and bilateral lower extremities are warm with 2+ pitting edema.

Which of the following hemodynamic profiles best explains this patient's acute respiratory presentation?

An ambulance brings a 62-year-old male to the emergency department after he developed sudden, agonizing pain between his shoulder blades. He is visibly uncomfortable and sweating profusely. Vital signs include a heart rate of 118/min and blood pressures of 198/112 mm Hg in the right arm and 148/92 mm Hg in the left arm. Portable chest radiography displays widening of the mediastinal silhouette. The clinical picture strongly points toward an acute aortic syndrome. Arrange the following interventions in the most appropriate sequential order for managing this patient.

Match each clinical study scenario to the epidemiological measure of disease frequency or association it best describes.

A 76-year-old man is brought to the emergency department from a skilled nursing facility due to severe, intractable vomiting and diffuse abdominal pain for the past 48 hours. He has a history of an open appendectomy 40 years ago and atrial fibrillation, for which he takes warfarin. Over the last 4 hours, the nursing staff noted he became progressively lethargic and confused. On arrival, his temperature is 38.8°C (101.8°F), pulse is 138/min, blood pressure is 78/45 mmHg, and respirations are 28/min. Physical examination reveals an altered, diaphoretic man. The abdomen is markedly distended, rigidly board-like, and exquisitely tender with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent. Laboratory studies show a leukocyte count of 24,000/mm³, a serum lactate of 7.8 mmol/L, and an INR of 3.6. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 71-year-old woman with a history of nonvalvular atrial fibrillation is brought to the emergency department due to sudden-onset, severe left leg pain that began 4 hours ago. She admits to running out of her prescribed oral anticoagulant medication two weeks ago. On physical examination, the left leg is pale and cold to the touch from the mid-calf distally. Femoral pulses are 2+ bilaterally, but the left popliteal and pedal pulses are completely absent. The patient has decreased sensation over the dorsum of the left foot and is unable to actively dorsiflex her toes.

Arrange the following interventions in the most appropriate chronological sequence for managing this patient's primary condition and its most likely post-intervention complication.