Tüm alıştırma soruları

A 15-year-old girl is brought to the clinic by her parents due to the absence of menarche. She reports no cyclical lower abdominal pain. A urine beta-hCG test obtained in the clinic is negative. Her height is at the 5th percentile for her age, and her weight is at the 40th percentile. Vital signs are within normal limits. Physical examination reveals Tanner stage 1 breast development and Tanner stage 1 pubic hair. She has a broad chest with widely spaced nipples and a low posterior hairline. Arrange the following diagnostic steps in the most appropriate sequential order to evaluate and manage this patient's condition.

A 19-year-old male is brought to the emergency department after colliding with a tree while snowboarding. On arrival, he complains of severe left upper quadrant abdominal pain and left shoulder pain. Initial vital signs include a blood pressure of 115/70 mm Hg, heart rate of 105/min, and respiratory rate of 18/min. A Focused Assessment with Sonography for Trauma (FAST) exam shows a moderate amount of free fluid in the splenorenal recess. Because the patient is hemodynamically stable, a computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast is performed, which reveals a deep splenic laceration with active contrast extravasation. Shortly after returning to the trauma bay, the patient becomes confused and diaphoretic. Repeat vital signs show a blood pressure of 82/45 mm Hg and a heart rate of 138/min. The patient is rapidly transfused with 1 unit of uncrossmatched packed red blood cells, but his blood pressure remains 84/48 mm Hg. Which of the following is the most appropriate next step in management?

A $26$-year-old woman, gravida $1$, para $0$, presents to the obstetrics clinic to establish prenatal care. Her vital signs are within normal limits, and her medical history is unremarkable. She reports irregular menstrual cycles and is uncertain of her last menstrual period. Her physician explains how pregnancy progression is tracked using early ultrasound findings followed by standardized physical examination landmarks. Arrange the following expected clinical and sonographic milestones for this patient in the correct chronological sequence from the earliest gestational age to the latest.

A 68-year-old female is evaluated on postoperative day 5 following a robotic-assisted hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer. She reports a 2-hour history of sudden-onset shortness of breath and right-sided chest pain that worsens when she takes a deep breath. She has a history of type 2 diabetes mellitus, hypertension, and obesity. Her current medications include subcutaneous enoxaparin and oral oxycodone as needed. Temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is 118/76 mmHg, pulse is 114/min, and respirations are 24/min. Pulse oximetry shows 92% on room air. Physical examination reveals clear breath sounds bilaterally and a regular, rapid heart rhythm. The abdomen is soft and non-tender, and the surgical incisions are well-approximated with no erythema. There is no lower extremity edema or calf tenderness. Electrocardiogram shows sinus tachycardia. Which of the following is the most appropriate next step in management?

A 58-year-old woman is recovering on the surgical ward on postoperative day 7 following an open abdominal hysterectomy. She experiences a severe coughing fit, after which she reports a sudden 'giving way' sensation in her abdomen. Examination reveals complete separation of the surgical incision with loops of small bowel protruding through the wound. Arrange the following steps for the immediate management of this complication in the most appropriate chronological order.

A 35-year-old previously healthy gentleman arrives at the triage desk reporting severe, unremitting abdominal pain accompanied by multiple episodes of bilious vomiting over the past 12 hours. He has not had a bowel movement or passed flatus since the pain began. His temperature is 38.6°C (101.5°F), pulse is 118/min, and blood pressure is 98/60 mm Hg. Physical examination reveals a markedly distended abdomen with absent bowel sounds. Palpation of the groin demonstrates a 4-cm, firm, erythematous, and exquisitely tender bulge in the right inguinal region. Laboratory studies show a leukocyte count of 19,000/mm³ with 85% neutrophils and a serum lactate level of 4.2 mmol/L. Which of the following is the most appropriate next step in the management of this patient?

A 31-year-old male architect is evaluated via a telehealth consultation. Over the past 14 weeks, he has refused to leave his apartment, citing a firm belief that a competing architecture firm has deployed microscopic drones to monitor his thoughts. He frequently hears a male voice criticizing his design choices. The patient's mother reports that roughly coinciding with the onset of the paranoia, the patient experienced a 6-day period where he slept only 3 hours per night, exhibited pressured speech, and impulsively bought $8,000 worth of computer equipment. This hyperactive period spontaneously resolved within a week. Since that time, his paranoid beliefs and auditory hallucinations have remained constant, and his mood has been euthymic. His medical history is unremarkable. A recent urine toxicology screen was negative. Which of the following is the most likely diagnosis?

A 48-year-old woman is assessed in the intensive care unit due to persistent hypotension. Five hours ago, she underwent an uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis. Her medical history includes severe rheumatoid arthritis, for which she has taken daily oral prednisone for the past three years. She reports that she abruptly stopped all her medications five days before the procedure to "clear her system for anesthesia."

Upon admission to the unit, her blood pressure was 82/44 mmHg and her pulse was 118/min. She was administered 3 L of intravenous normal saline, but her repeat blood pressure remains 78/42 mmHg. Current temperature is 38.1°C (100.6°F), pulse is 124/min, and respirations are 20/min. Physical examination shows a lethargic patient who arouses to voice. The abdomen is soft and mildly tender at the surgical port sites, with no guarding or rigidity.

Laboratory studies show:
- Sodium: 130 mEq/L
- Potassium: 4.1 mEq/L
- Chloride: 97 mEq/L
- Bicarbonate: 22 mEq/L
- Blood urea nitrogen: 18 mg/dL
- Serum creatinine: 0.9 mg/dL
- Glucose: 58 mg/dL
- Leukocyte count: 10,500/mm³

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

Accompanied by her husband, a 31-year-old architect presents to her primary care physician with complaints of overwhelming fatigue and persistent low mood that began a month ago. She reports spending most of her days in bed, missing work deadlines, and feeling intensely guilty about her lack of productivity. She states, "I just don't see the point in trying anymore." Upon further questioning, her husband recalls an unusual period two years prior. Over a span of 15 days, the patient barely slept, talked continuously about redesigning their entire city, and impulsively purchased $15,000 worth of construction materials. That episode led to severe financial distress and a brief psychiatric hospitalization, after which she returned to her baseline. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 1.1 mU/L (normal: 0.5–5.0 mU/L) and a free T4 level of 0.9 ng/dL (normal: 0.9–1.7 ng/dL). She currently takes no medications. Which of the following is the most appropriate pharmacotherapy to initiate for this patient?

A $14$-year-old boy is brought to the pediatric clinic by his mother due to a $3$-month history of declining academic performance, irritability, and social withdrawal. She reports that he frequently locks himself in his room and sometimes appears clumsy and disoriented when she enters abruptly. Physical examination reveals an erythematous, eczematous rash around his mouth and nose. Neurologic examination is significant for a broad-based, unsteady gait, dysarthria, and diminished deep tendon reflexes in the lower extremities. Laboratory studies show:

Which of the following is the most likely diagnosis?

A 38-year-old female is evaluated in the emergency department after a low-speed collision in which her bicycle was struck by a turning vehicle. She was wearing a helmet and reports no loss of consciousness. She complains primarily of left-sided abdominal pain and left shoulder pain. Upon arrival, her blood pressure is 122/78 mm Hg, heart rate is 88/min, and respiratory rate is 16/min. Oxygen saturation is 99% on room air. The primary survey is unremarkable. Physical examination reveals bruising over the left lower ribs. Abdominal examination demonstrates mild left upper quadrant tenderness but no rebound or guarding. A bedside focused assessment with sonography for trauma (FAST) demonstrates a distinct rim of anechoic fluid surrounding the spleen. Which of the following is the most appropriate next step in management?

A 29-year-old woman, G1P0 at 16 weeks gestation, is evaluated in the emergency department. She was brought in by her sister after expressing a detailed plan to end her life by carbon monoxide poisoning in her garage. The patient has a 5-year history of bipolar disorder but discontinued all medications 6 months ago. Over the past three weeks, she has exhibited profoundly depressed mood, anhedonia, and hypersomnia. In the emergency department, she is irritable, refuses further psychiatric evaluation, and states, "I have the right to leave. If you try to stop me, I will sue this hospital." The patient's sister presents legally binding documentation designating herself as the patient's healthcare proxy. Which of the following is the most appropriate next step in management?

A 66-year-old retired accountant is evaluated in the clinic for a 12-month history of progressive memory impairment. His husband reports that the patient frequently forgets recent conversations, struggles to manage their household finances, and occasionally gets lost in familiar neighborhoods. His past medical history is significant for well-controlled hypertension and hyperlipidemia. Vital signs are within normal limits, and a general physical examination shows no acute abnormalities. The physician suspects a major neurocognitive disorder and plans a comprehensive diagnostic evaluation. Arrange the following diagnostic and evaluative steps in the most appropriate, standard chronological sequence for the workup of this patient.

As a trauma and burn unit leader, you are tasked with managing multiple complex clinical scenarios simultaneously. Match each specific patient presentation to the most appropriate immediate diagnostic or therapeutic intervention.

A 34-year-old male architect is accompanied to the primary care physician by his spouse. The patient survived a severe structural collapse at a building site exactly twenty-four days ago. Since the event, he has experienced recurrent, intrusive nightmares about the collapse and profound distress when exposed to loud noises. He actively avoids visiting any construction zones. The spouse notes that the patient has been highly irritable, jumpy, and disconnected from his family. During the psychiatric review of systems, the physician discovers that six years ago, the patient had a discrete four-week episode characterized by a severely decreased need for sleep, pressured speech, and grandiose delusions that required inpatient psychiatric hospitalization. Current laboratory studies reveal a serum thyroid-stimulating hormone level of 1.8 µU/mL (normal: 0.4-4.5 µU/mL) and a free thyroxine level of 1.2 ng/dL (normal: 0.8-1.8 ng/dL). Which of the following is the most appropriate next step in the management of this patient's condition?

A $48$-year-old man is brought to the emergency department by his wife due to sudden-onset, agonizing abdominal pain that began $2$ hours ago. He reports no prior episodes of similar pain but has a history of chronic knee osteoarthritis, for which he takes high-dose naproxen daily. His temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), pulse is $118/\text{min}$, blood pressure is $90/58\text{ mm Hg}$, and respirations are $22/\text{min}$. The patient appears distressed and lies completely still on the examination table, refusing to move. Physical examination reveals a rigid, board-like abdomen with diffuse guarding and rebound tenderness. Bowel sounds are absent. An upright chest radiograph demonstrates a crescent of free air under the right hemidiaphragm. Which of the following is the most appropriate next step in management?

Match each classic trauma or burn presentation to its most appropriate definitive intervention or next step in management.

An addiction psychiatry clinic evaluates a 29-year-old male patient who is seeking pharmacological support to maintain abstinence from heroin. The patient states he was discharged from a short-term inpatient detoxification facility 10 days ago and has not used any illicit substances since. Physical examination reveals normal pupillary size, absence of piloerection, and a resting heart rate of 72/min. The physician and patient agree to proceed with an opioid antagonist therapy to reduce the risk of relapse. Arrange the following steps in the most appropriate chronological sequence for safely initiating this patient on long-acting injectable naltrexone.

A 54-year-old man undergoes an exploratory laparotomy for bowel ischemia. Three days postoperatively, he develops a high fever, severe abdominal pain, and leukocytosis. An abdominal computed tomography scan reveals a retained surgical sponge, necessitating an emergent reoperation for removal. The hospital's risk management department declares this a sentinel event and initiates a formal Root Cause Analysis (RCA) to prevent future occurrences. Arrange the following steps of the RCA process in the correct chronological sequence that the hospital committee should follow.

An emergency physician evaluates a 24-year-old man who collapsed during gymnastics practice. He reports profound weakness and muscle cramps over the past three days. His body mass index is $19.5 \text{ kg/m}^2$. The patient is heavily preoccupied with his body image and fears gaining weight. He admits to consuming massive amounts of food in short periods, followed immediately by self-induced vomiting, a pattern he repeats several times a day. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $100/60 \text{ mmHg}$, pulse $105/\text{min}$, and respirations $10/\text{min}$. Physical examination reveals enlarged parotid glands and calluses on the dorsum of his right hand.

Laboratory results are as follows:

Arterial blood gas (room air):

Which of the following best describes this patient's current acid-base status?