Tüm alıştırma soruları

Emergency medical services arrive at the trauma bay with a 38-year-old construction worker who sustained a fall from a fourth-story scaffolding. En route, he received 1 liter of intravenous crystalloid. Upon arrival, the patient is obtunded and groaning painfully. Vital signs demonstrate a blood pressure of 78/42 mm Hg, a pulse of 138/min, and a respiratory rate of 28/min. Primary survey reveals profound pallor and diaphoresis. The trachea is midline, and jugular venous distention is absent. Auscultation of the chest demonstrates markedly absent breath sounds over the entire left hemithorax with accompanying dullness to percussion. Heart sounds are distinct and rapid. The pelvis is mechanically stable, and an extended focused assessment with sonography for trauma (eFAST) yields negative results for pericardial and intraperitoneal fluid.

A left-sided tube thoracostomy is rapidly placed, which immediately yields 1,750 mL of bright red blood. Following the administration of two units of uncrossmatched packed red blood cells, his blood pressure marginally improves to 82/48 mm Hg.

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

A 74-year-old man with a history of hypertension and atrial fibrillation treated with apixaban is brought to the emergency department by emergency medical services. His wife reports that he experienced a sudden, severe occipital headache and intractable vomiting 45 minutes ago before collapsing. Upon arrival in the trauma bay, he is unresponsive. His eyes do not open to pain, he makes incomprehensible sounds, and he exhibits abnormal extensor posturing to painful stimuli. His blood pressure is 220/115 mmHg, heart rate is 52/min, and respiratory rate is 10/min with irregular breathing patterns.

Arrange the following clinical interventions in the most appropriate, evidence-based sequential order for the acute management of this patient.

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

Investigators at a regional cardiovascular center analyze data from a prospective study evaluating a new oral anticoagulant compared to standard therapy for stroke prevention. The study followed patients with nonvalvular atrial fibrillation over a two-year period. Among the $1,000$ patients receiving the new anticoagulant, $20$ experienced an ischemic stroke. Among the $1,000$ patients receiving standard therapy, $70$ experienced an ischemic stroke. Based on these findings, what is the number needed to treat with the new anticoagulant to prevent one additional ischemic stroke compared to standard therapy?

Correlate the following nuanced clinical presentations of abdominal pathology with their most appropriate definitive management strategy.

Vascular and cardiothoracic surgery encompasses a wide range of acute and chronic pathologies with distinct clinical presentations. Match the following classic clinical presentations with their most likely corresponding vascular diagnosis.

A 74-year-old woman with a history of atrial fibrillation, noncompliant with her apixaban, presents to the emergency department with sudden-onset, severe periumbilical abdominal pain. Her vital signs show a temperature of 38.4°C (101.1°F), blood pressure of 88/54 mmHg, and heart rate of 122/min. Physical examination reveals a rigid abdomen with diffuse guarding and rebound tenderness. Laboratory studies demonstrate a leukocyte count of 24,500/mm³ and a serum lactate level of 7.2 mmol/L. Arrange the following steps in the most appropriate sequential order for the definitive management of this patient's condition.

Match each clinical presentation of a scrotal or testicular mass to its most appropriate definitive management.

An 82-year-old woman is evaluated in the emergency department for a 4-day history of progressively worsening, colicky abdominal pain accompanied by nausea and feculent vomiting. Her medical history includes hypertension, osteoarthritis, and moderate dementia. She lives with her daughter, who is her legally appointed healthcare proxy. Her estranged son recently arrived at the hospital and has been demanding to direct her medical care.

Vitals:
Temperature: $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$)
Heart rate: $105/\text{min}$
Blood pressure: $110/70 \text{ mm Hg}$

Physical examination reveals a distended and tympanitic abdomen with high-pitched bowel sounds. There is mild, diffuse tenderness to palpation but no guarding, rigidity, or rebound tenderness.

Laboratory studies:
Leukocytes: $11,500/\text{mm}^3$
Lactate: $1.6 \text{ mmol/L}$
Liver function tests: Within normal limits

A computed tomography scan of the abdomen and pelvis without contrast reveals dilated loops of small bowel up to the terminal ileum, air in the biliary tree, and a $3.5\text{-cm}$ radiopaque, calcified mass impacted in the distal ileum. The colon is decompressed.

The son demands that the medical team transition her to comfort care, stating, 'She is too frail for any surgery, and I am the oldest child, so I make the decisions.' The daughter states, 'She has excellent quality of life at home. I want whatever is medically necessary to relieve this blockage.'

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

Investigators are evaluating the efficacy of a newly developed long-acting monoclonal antibody for preventing severe respiratory syncytial virus (RSV) infections in high-risk premature infants. A total of $5,000$ infants are enrolled and randomized in a 1:1 ratio to receive either the monoclonal antibody or a placebo injection at the start of the RSV season. All participants are followed for $150$ days. At the end of the follow-up period, data analysis reveals that $50$ infants in the monoclonal antibody group and $150$ infants in the placebo group required hospitalization for severe RSV infection.

Based on these study results, what is the number needed to treat to prevent one RSV-related hospitalization?

A 31-year-old man presents to the emergency department with a painful, fully rigid erection that has persisted for 18 hours. He admits to recreational cocaine use the previous evening. Physical examination reveals tense, tender corpora cavernosa with a completely flaccid glans penis and corpus spongiosum. Arrange the following diagnostic and therapeutic interventions in the correct escalating sequence for managing this condition, assuming each successive step fails to achieve permanent detumescence.

Match each clinical presentation of an acute abdominal emergency with the most appropriate definitive next step in management.

A resident is reviewing imaging studies and physical examination findings of patients with elevated intracranial pressure in the neurocritical care unit. Match each specific pattern of tissue displacement and associated clinical presentation with the correct brain herniation syndrome.

Match each clinical and diagnostic presentation with the most likely thyroid pathology.

A 74-year-old woman is evaluated in the clinic for a 6-month history of a slow, broad-based, shuffling gait, new-onset urinary incontinence, and mild cognitive decline. The physician suspects normal pressure hydrocephalus (NPH). Arrange the following diagnostic and therapeutic steps in the standard evidence-based sequence for managing this condition, from first to last.

A 68-year-old man comes to the physician because of a 3-month history of progressively worsening shortness of breath, a persistent "brassy" cough, and mild difficulty swallowing solid foods. He has a history of long-standing, poorly controlled hypertension and has smoked a pack of cigarettes daily for 40 years. His temperature is 37.0°C (98.6°F), blood pressure is 165/95 mm Hg, heart rate is 82/min, and respiratory rate is 18/min. Physical examination shows normal jugular venous pressure and no lower extremity edema. The lungs are clear to auscultation except for a faint, high-pitched expiratory sound heard predominantly over the central chest. Chest radiography reveals a significantly widened superior mediastinum and a prominent aortic silhouette. Which of the following is the most likely underlying cause of this patient's symptoms?

A local health department investigates an outbreak of a novel skin rash in an agricultural community. Officials enroll a cohort of $2,000$ residents and follow them over a $3$-month period. Among the $500$ residents who work directly with a newly introduced pesticide, $100$ develop the rash. Among the $1,500$ residents who do not work with the pesticide, $150$ develop the rash. Which of the following is the relative risk of developing the rash associated with pesticide exposure?

A 62-year-old woman is evaluated in the neurosurgical intensive care unit on postoperative day 5 following a right temporal craniotomy for glioblastoma resection. Over the past 12 hours, she has become progressively lethargic. She now only opens her eyes to painful stimuli and mutters incomprehensibly. Her temperature is 38.9°C (102.0°F), blood pressure is 145/88 mmHg, heart rate is 105/min, and respiratory rate is 16/min. Physical examination reveals pronounced nuchal rigidity. The surgical incision is well-approximated, clean, and has no fluctuance or drainage. An indwelling urinary catheter, placed prior to surgery, remains in situ. Which of the following is the most appropriate next step in management?

Match each clinical presentation with its most likely underlying vascular pathology or pathophysiologic mechanism.

A 59-year-old male with untreated hypertension arrives at the emergency department reporting the abrupt onset of a severe, tearing pain in his anterior chest that radiates straight to his interscapular region. His blood pressure is 210/115 mmHg, and his heart rate is 112/min. A portable chest radiograph demonstrates a widened mediastinum. Acute aortic dissection is highly suspected. Arrange the following clinical steps in the most appropriate chronological sequence for the evaluation and management of this patient.