Tüm alıştırma soruları

A 62-year-old man is evaluated on postoperative day 8 following an open bilateral inguinal hernia repair. Yesterday, he began experiencing progressive abdominal bloating, nausea, and bilious emesis. He has not passed flatus or stool for the past 48 hours. Two hours ago, his abdominal discomfort abruptly transitioned into severe, constant, and unremitting pain. Current vital signs show a temperature of 38.9°C (102.0°F), pulse of 122/min, respirations of 22/min, and blood pressure of 98/60 mm Hg. Physical examination reveals a markedly distended abdomen with diffuse rigidity, involuntary guarding, and rebound tenderness. Laboratory evaluation demonstrates a leukocyte count of 19,500/mm³ and a serum lactate of 4.5 mmol/L. An upright abdominal radiograph displays multiple dilated loops of small intestine with air-fluid levels and an absence of colonic gas. Which of the following is the most appropriate next step in the management of this patient?

A 25-year-old man is brought to the emergency department by his family due to severely erratic behavior. He is speaking rapidly, pacing the examination room, and claims he has not slept in a week because he is "solving the global energy crisis." He also reports hearing voices praising his supreme intellect. His family notes that he has a 4-year history of recurrent, severe depressive and manic episodes that have required multiple hospitalizations. Notably, 6 months ago, his mood was entirely stable and normal for a 4-week period, but he persistently heard voices and believed his neighbors were spying on him during that entire time. His vital signs and physical examination are unremarkable, and a urine toxicology screen is negative. Which of the following is the most likely diagnosis?

A 76-year-old man is evaluated in the clinic for progressive memory decline. Over the past 9 months, he has been increasingly forgetful, frequently misplacing household items, and recently became lost while driving home from his local grocery store. His son mentions that the patient's wife passed away 12 months ago; initially, the family attributed his forgetfulness to grief. The patient has a medical history of hypertension and bipolar I disorder, for which he has taken valproate for the past 25 years without any recent mood episodes. During the interview, the patient is cheerful, makes good eye contact, and attempts to joke away his memory lapses. When administered a cognitive assessment, he puts forth significant effort but scores 19/30, losing points on orientation, delayed recall, and intersecting pentagons. Which of the following is the most appropriate next step in management?

A $45$-year-old man is evaluated in the surgical intensive care unit on postoperative day $1$ following a $14$-hour complex pelvic exenteration for an advanced rectal malignancy. His surgical history is significant only for this recent procedure. Over the past $6$ hours, his urine output has precipitously declined to $15 \text{ mL/hr}$, and the fluid in the Foley catheter tubing is noted to be dark reddish-brown. Vital signs are blood pressure $110/70 \text{ mmHg}$, heart rate $118 \text{ beats/min}$, respiratory rate $18 \text{ breaths/min}$, and temperature $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$). Physical examination reveals diffuse muscle tenderness in the lower extremities, which were positioned in prolonged lithotomy during the surgery. Stat laboratory testing reveals a serum potassium level of $7.9 \text{ mEq/L}$, serum creatinine of $3.4 \text{ mg/dL}$, and a creatine kinase level of $52,000 \text{ U/L}$. An emergent $12$-lead electrocardiogram demonstrates peaked T waves, a widened QRS complex, and loss of P waves. Arrange the following interventions in the correct chronological sequence for the optimal management of this acute postoperative emergency.

A 64-year-old woman presents to the emergency department with a 6-hour history of sudden, severe, and continuous abdominal pain accompanied by two episodes of bilious vomiting. Her medical history includes hypertension, paroxysmal atrial fibrillation, and an open total abdominal hysterectomy performed 10 years ago. Her current medications are lisinopril and metoprolol; she is not taking anticoagulation. Temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), pulse is $122/\text{min}$ and irregularly irregular, blood pressure is $94/60\text{ mm Hg}$, and respirations are $24/\text{min}$. Physical examination shows a mildly distended abdomen. There is marked focal tenderness in the left lower quadrant with rigidity and rebound tenderness. Bowel sounds are absent. Laboratory studies show a leukocyte count of $17,500/\text{mm}^3$ and a serum lactate level of $4.2\text{ mmol/L}$. Computed tomography of the abdomen and pelvis with intravenous contrast reveals a high-grade small bowel obstruction with a radially distributed, U-shaped cluster of dilated small bowel loops. The mesenteric vessels converge toward a central point, and the wall of the affected bowel loop is thickened with diminished contrast enhancement. Which of the following is the most appropriate next step in management?

An otherwise healthy 22-year-old college student seeks medical advice because of irrepressible daytime sleepiness that has been present for the last six months. She consistently falls asleep during her morning lectures and on the bus commute, despite maintaining a regular schedule of eight hours of sleep per night. She notes that her nighttime sleep is frequently fragmented. When asked about other symptoms, she describes several alarming episodes where her knees suddenly buckled and she experienced transient facial weakness specifically when laughing at a friend's joke, forcing her to sit down immediately. Additionally, she reports occasionally seeing a frightening, shadowy figure in her room just as she is drifting off to sleep. Her medical history is unremarkable, and she takes no medications or illicit substances. Vital signs and physical examination are within normal limits. Which of the following is most likely to be found during further evaluation of this patient?

A 28-year-old woman is accompanied to an initial psychiatric evaluation by her sister. The patient has been experiencing persistent auditory hallucinations of two voices conversing about her behavior, along with the fixed belief that neighbors are using radar to monitor her thoughts. According to the sister, these symptoms began insidiously 9 months ago and have been continuously present since. The sister also notes that 4 months ago, the patient developed a markedly depressed mood, significant fatigue, poor appetite, and passive suicidal ideation. This distinct period of low mood lasted for precisely 4 weeks before completely resolving. However, the patient's hallucinations and paranoid beliefs remained completely unchanged before, during, and after this 4-week period of depression. She currently exhibits a blunted affect but denies any sadness or anhedonia. The patient takes no medications, and her physical examination and basic laboratory studies are unremarkable. Urine toxicology is negative. Which of the following is the most likely diagnosis?

A 21-year-old male university student is rushed to the emergency department after a severe collision during a rugby game, where he was forcefully struck in the left flank by an opponent's shoulder. He reports intense left-sided abdominal pain with radiation to the top of his left shoulder. His temperature is $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$), pulse is $132 \text{ beats/min}$, respirations are $24 \text{ breaths/min}$, and blood pressure is $80/46 \text{ mmHg}$. He is conscious but profusely diaphoretic and pale. Examination shows prominent guarding and rigidity over the left hemi-abdomen. The pelvis is mechanically stable, and chest auscultation is clear bilaterally. A bedside point-of-care ultrasound demonstrates significant free anechoic fluid in the splenorenal and hepatorenal spaces. Resuscitation with uncrossmatched blood products is initiated via two large-bore peripheral catheters. Which of the following is the most appropriate next step in this patient's management?

An 8-year-old boy is brought to the clinic by his parents due to uncontrollable movements. Over the past 14 months, he has been frequently blinking his eyes forcefully, shrugging his shoulders, and occasionally making loud grunting and throat-clearing noises. These behaviors worsen when he is anxious about school assignments. His parents report that he met all early childhood developmental milestones appropriately. Neurological examination is otherwise unremarkable. Which of the following diagnostic criteria MUST be met to formally diagnose this patient's most likely condition? (Select all that apply)

During an afternoon evaluation, the surgical team examines a $54$-year-old woman who underwent a laparoscopic Roux-en-Y gastric bypass $6$ days ago. The patient reports the recent onset of severe, unremitting left upper quadrant abdominal pain that radiates to her left shoulder. She has experienced significant nausea but no vomiting. Her temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $112/70\text{ mmHg}$, pulse is $118/\text{min}$, and respiratory rate is $22/\text{min}$. Oxygen saturation is $96\%$ on room air. Physical examination reveals focal peritonitis in the left upper quadrant with voluntary guarding. The surgical incisions are well-approximated, clean, and dry. Bowel sounds are absent. A urinary catheter is in place, draining clear yellow urine. Which of the following is the most appropriate next step in the management of this patient?

A 58-year-old man is brought to the emergency department via ambulance due to severe, generalized abdominal pain and persistent bilious vomiting for the past 24 hours. He reports no bowel movements or passage of flatus during this time. His surgical history is significant for an open appendectomy performed 20 years ago. Current vital signs show a temperature of 39.2°C (102.6°F), blood pressure of 88/58 mmHg, heart rate of 124/min, and respiratory rate of 22/min. Physical examination demonstrates a markedly distended abdomen. Palpation reveals diffuse rigidity, severe rebound tenderness, and involuntary guarding. Bowel sounds are absent. Laboratory testing indicates a leukocyte count of 19,000/mm³ with a left shift and a serum lactate of 4.5 mmol/L. An upright abdominal radiograph displays multiple dilated loops of small intestine with prominent air-fluid levels. Which of the following is the most appropriate next step in management?

A 68-year-old man is brought to the clinic by his husband. For the past 8 months, the patient has experienced episodes of shouting, thrashing, and kicking during sleep, typically occurring in the early morning hours. During a recent episode, he accidentally struck his husband in the face. When awakened from these events, the patient reports vivid, action-packed dreams in which he is defending himself from intruders. He has no history of head trauma, seizures, or psychiatric illness. Current medications include a daily multivitamin. Vital signs are within normal limits, and the physical examination, including a detailed neurologic assessment, reveals no abnormalities.

Arrange the following steps in the most appropriate chronological sequence for the diagnostic evaluation and longitudinal management of this patient.

Match each acute thoracic trauma clinical presentation with the most appropriate immediate next step in management.

A 23-year-old man is evaluated in the psychiatric outpatient clinic for ongoing management of schizophrenia. His symptoms began seven months ago with persistent auditory hallucinations, persecutory delusions, and severe social withdrawal. He has no significant past medical history, and his initial physical examination, comprehensive metabolic panel, and urine toxicology were unremarkable. The psychiatric care team is establishing a comprehensive, long-term psychopharmacological management plan. Arrange the following clinical steps in the most appropriate standard sequence for the pharmacological management of this patient, assuming he consistently demonstrates an inadequate clinical response to each successive intervention despite appropriate time for titration.

Match each clinical presentation or constellation of chronic medical complications to the most likely primary substance use disorder.

A 72-year-old man is brought to the emergency department from an assisted living facility due to worsening nausea, intense lower abdominal pain, and an inability to pass gas for the last 36 hours. His medical history includes hypertension, hyperlipidemia, and a large right groin bulge that he typically pushes back in himself. However, he states he has been unable to reduce the bulge since yesterday morning. His temperature is 38.8°C (101.8°F), blood pressure is 92/58 mmHg, and pulse is 118/min. Physical examination demonstrates dry oral mucosa. The abdomen is distended with high-pitched, hyperactive bowel sounds. Examination of the right groin reveals a 6-cm, tense, erythematous mass extending into the scrotum that is exquisitely tender to touch. Laboratory results show a leukocyte count of 19,000/mm³ and a venous lactate level of 4.8 mmol/L. Which of the following is the most appropriate next step in the management of this patient?

An 80-year-old female is evaluated in the surgical assessment unit for a 3-day history of intermittent, crampy abdominal pain and progressive nausea with bilious vomiting. She has a history of hypertension, type 2 diabetes mellitus, and symptomatic gallstones for which she declined surgery two years ago. Her temperature is 37.8°C (100.0°F), blood pressure is 112/68 mm Hg, and pulse is 95/min. On physical examination, the abdomen is distended and tympanitic to percussion, with high-pitched bowel sounds. There is mild, diffuse abdominal tenderness but no rebound or guarding. Laboratory studies show a leukocyte count of 11,200/mm³ and a normal serum amylase level. A plain abdominal radiograph reveals multiple dilated loops of small intestine with air-fluid levels, an absence of colonic gas, and branching radiolucencies over the central hepatic shadow. Which of the following is the most appropriate next step in the management of this patient?

An ambulance brings a 27-year-old female to the emergency department after she was thrown from a horse, landing forcefully on her left side. She is fully alert and complains of severe left-sided abdominal pain. Her temperature is 36.8°C (98.2°F), blood pressure is 78/42 mm Hg, pulse is 138/min, and respiratory rate is 22/min. Physical examination reveals guarding and rigidity in the left upper quadrant. Intravenous fluid resuscitation is initiated with 1 liter of warm crystalloid, but a repeat blood pressure reading is 80/45 mm Hg. A focused assessment with sonography for trauma (FAST) demonstrates a large amount of anechoic fluid in the splenorenal recess. Which of the following is the most appropriate next step in management?

A 45-year-old woman is evaluated on her second day of recovery following an uncomplicated open abdominal hysterectomy. Her temperature is $38.3^\circ C$ ($100.9^\circ F$), blood pressure is $122/78$ mmHg, heart rate is $88/min$, and respirations are $18/min$. Oxygen saturation is $95\%$ on room air. Physical examination reveals decreased breath sounds at the bilateral lung bases without crackles or wheezes. The surgical incision is clean, dry, and intact with no surrounding erythema or induration. The patient's calves are soft and non-tender. Which of the following are the most appropriate next steps in management? (Select two)

A 24-year-old woman is newly diagnosed with schizophrenia after presenting with persistent auditory hallucinations and persecutory delusions. The treatment team outlines a comprehensive, stepwise pharmacological management plan for her condition, anticipating the possibility of treatment resistance at each stage. Arrange the following therapeutic steps in the standard sequential order they should be implemented, assuming the patient continues to have severe, unrelenting symptoms despite documented adherence to each prior intervention.