Tüm alıştırma soruları

A 55-year-old man is evaluated 20 hours after undergoing an open partial colectomy for an obstructing colon mass. The surgical team is urgently called because the patient has developed sudden confusion and a high fever. His temperature is 39.8°C (103.6°F), blood pressure is 82/48 mm Hg, pulse is 132/min, and respirations are 28/min. The patient reports agonizing pain around his abdominal incision, which has rapidly worsened over the last few hours despite adequate opioid analgesia. Physical examination shows a confused, diaphoretic man. The abdominal dressing is removed, revealing significant edema, erythema, and purplish discoloration of the skin extending radially from the incision. Palpation of the abdominal wall elicits coarse crepitus. There is a small amount of thin, grayish, foul-smelling discharge at the wound edges. Intravenous fluids and broad-spectrum antibiotics are immediately ordered. Which of the following is the most appropriate next step in the management of this patient?

Match each post-bariatric surgery clinical presentation with the most likely diagnosis or surgical complication.

A 45-year-old man is brought to the emergency department 30 minutes after falling from a 3-story building. He is confused and moaning in pain. His temperature is 36.2°C (97.2°F), blood pressure is 75/40 mm Hg, heart rate is 135/min, and respiratory rate is 24/min. The airway is patent, and breath sounds are clear and equal bilaterally. A portable chest radiograph is unremarkable. A portable pelvic radiograph demonstrates a 4.5-cm diastasis of the pubic symphysis. A pelvic binder is immediately applied and secured appropriately. Focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal and splenorenal recesses. The patient receives 2 units of uncrossmatched packed red blood cells and 2 units of fresh frozen plasma via a rapid infusion device. Following the transfusion, his blood pressure is 78/42 mm Hg and heart rate is 130/min. Which of the following is the most appropriate next step in management?

A 45-year-old woman with a history of severe alcohol use disorder is admitted to the inpatient psychiatric unit for medical detoxification. She reports that her last drink was 12 hours ago. On examination, she exhibits bilateral hand tremors, mild tachycardia, diaphoresis, and anxiety. Arrange the following clinical management steps in the most appropriate chronological sequence for this patient's comprehensive care, proceeding from initial acute stabilization to long-term relapse prevention.

A 28-year-old woman is brought to the emergency department by emergency medical services after she was found severely agitated and combative outside a nightclub. Her friends report that she consumed an unknown "party pill" a few hours ago. The patient has a history of major depressive disorder with past hypomanic episodes, for which she was recently prescribed sertraline by a new primary care physician. She also has a history of opioid use disorder and has been stable on methadone maintenance therapy for two years.

On presentation, she is hallucinating, claiming that "angels are commanding her to fly." Vital signs are temperature 39.4°C (102.9°F), blood pressure 178/108 mm Hg, pulse 142/min, and respirations 24/min. Physical examination reveals marked diaphoresis, mydriasis, and bilateral continuous ankle clonus with generalized hyperreflexia.

Laboratory studies show:
Thyroid-stimulating hormone (TSH): 0.1 µU/mL (normal: 0.4–4.0 µU/mL)
Free thyroxine (T4): 1.3 ng/dL (normal: 0.9–1.7 ng/dL)
Urine toxicology screen is positive for methadone but negative for amphetamines, cocaine, and phencyclidine (PCP).

Which of the following is the most likely diagnosis for this patient's acute presentation?

A 68-year-old woman is recovering in the surgical intensive care unit shortly after undergoing a pancreaticoduodenectomy. Due to poor peripheral venous access, the surgical resident places a right internal jugular central venous catheter. Ten minutes after the procedure, the patient suddenly develops severe shortness of breath. Her temperature is 37.1°C, blood pressure is 76/40 mm Hg, heart rate is 138/min, and respiratory rate is 32/min. Oxygen saturation is 82% on room air. Physical examination reveals distended neck veins, absent breath sounds over the right lung field, and deviation of the trachea to the left side. Arrange the following management steps in the most appropriate chronological sequence for this patient.

Match each postoperative clinical presentation following abdominal surgery to the most likely diagnosis.

A 42-year-old woman presents to the emergency department with steady, severe right upper quadrant abdominal pain that radiates to her right scapula. The pain began 6 hours ago after eating a large, fatty meal. She reports nausea and two episodes of vomiting. Her temperature is 38.2°C (100.8°F), blood pressure is 130/80 mmHg, and heart rate is 92/min. Physical examination reveals tenderness to palpation in the right upper quadrant with inspiratory arrest (positive Murphy sign). Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient.

A 50-year-old construction worker is evacuated by helicopter to the trauma center following a localized industrial explosion. The patient weighs $80\text{ kg}$. Paramedics report the incident occurred exactly $2\text{ hours}$ prior to arrival. Primary survey reveals a patent airway with no signs of inhalation injury, clear breath sounds bilaterally, and a heart rate of $115\text{ beats/min}$. Secondary survey is notable for deep partial-thickness and full-thickness thermal burns covering the entirety of his posterior trunk (including buttocks), his entire left lower extremity, and his entire right upper extremity. Superficial (first-degree) burns are noted on his face but are not blistering. Large-bore intravenous access is established. The trauma team initiates fluid resuscitation using lactated Ringer solution according to current Advanced Trauma Life Support (ATLS) guidelines ($2\text{ mL/kg/\%TBSA}$ for adult thermal burns).

What should be the initial rate of the fluid infusion (in $\text{mL/hr}$) programmed on the intravenous pump for the time remaining in the first 8-hour post-injury window?

A 34-year-old man is brought to the emergency department 20 minutes after a high-speed motor vehicle collision. He was the restrained driver of a vehicle that struck a concrete barrier. On arrival, the patient is confused and diaphoretic. His temperature is 36.5°C (97.7°F), blood pressure is 78/45 mm Hg, pulse is 135/min, and respirations are 24/min. Pulse oximetry shows 97% on room air. The airway is patent, and breath sounds are equal bilaterally. A focused assessment with sonography for trauma (FAST) reveals a large amount of free fluid in the hepatorenal recess (Morison pouch) and splenorenal recess. Which of the following is the most appropriate next step in management?

During a routine visit to an outpatient clinic, a 29-year-old woman reports a 2-month history of persistent sadness, tearfulness, and profound fatigue. She states she has lost interest in reading and hiking, activities she previously enjoyed every weekend. The patient notes she has been waking up at 3 AM daily and is unable to fall back asleep. She has lost 4 kg (8.8 lb) over this period without actively dieting. She denies any substance use or suicidal ideation. She has no significant past medical history and currently takes no medications. Her physical examination is unremarkable. The patient requests to be started on a medication to help her mood, noting that a family member had significant improvement with fluoxetine. Which of the following is the most appropriate next step in the clinical evaluation of this patient?

A $71$-year-old woman is assessed by the rapid response team five days after undergoing an elective sigmoid resection with primary anastomosis for recurrent complicated diverticulitis. The nursing staff activated the response due to acute mental status changes and hypotension. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $78/48\text{ mm Hg}$, pulse is $132/\text{min}$, and respirations are $26/\text{min}$. Pulse oximetry shows $93\%$ on room air. The patient is lethargic and oriented only to person. Abdominal examination reveals a rigid, board-like abdominal wall with severe diffuse tenderness and absent bowel sounds. A closed-suction pelvic drain, which had been outputting minimal clear fluid, has abruptly filled with $200\text{ mL}$ of dark, foul-smelling, turbid liquid. Electrocardiography demonstrates sinus tachycardia alongside $2\text{-mm}$ ST-segment depressions in leads II, III, and aVF. Laboratory studies reveal a leukocyte count of $22,000/\text{mm}^3$, a serum lactate level of $5.4\text{ mmol/L}$, and a serum troponin I concentration of $0.8\text{ ng/mL}$ (normal: $<0.04\text{ ng/mL}$). Intravenous crystalloid resuscitation is initiated. 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 psychiatric clinic for a severe depressive episode characterized by profound sadness, anhedonia, early morning awakening, and significant weight loss. Over the course of the following year, her major depressive disorder proves difficult to manage, requiring a progressive escalation of her treatment plan due to varying degrees of treatment resistance. Her course ultimately culminates in a severe decompensation requiring urgent intervention. Arrange the following therapeutic steps in the most appropriate chronological sequence according to standard evidence-based treatment algorithms for major depressive disorder, from her initial presentation to the management of her final life-threatening deterioration.

A 21-year-old man is brought to the outpatient psychiatric clinic by his mother. For the past 3 weeks, he has been spending up to 6 hours a day repeatedly checking locks, counting backwards from 100, and washing his hands. He states he must perform these actions because he is tormented by intrusive, unwanted thoughts that his family will die in a house fire if he does not. He recognizes that these thoughts are irrational but feels immense, paralyzing anxiety if he attempts to stop the behaviors. His psychiatric history is notable for a hospitalization at age 19 for a 2-week episode characterized by a decreased need for sleep, grandiosity, and pressured speech, which was preceded by a major depressive episode. He is currently unmedicated. At the end of the clinical assessment, the patient explicitly requests that his medical information remain private. His mother, however, demands to be informed of the diagnosis and treatment plan, stating she has a right to know because he lives in her home and is covered under her health insurance. Which of the following is the most appropriate next step in the management of this patient?

A $35$-year-old man weighing $70 \text{ kg}$ is brought to the emergency department $2 \text{ hours}$ after being rescued from a structural fire. On examination, he is hemodynamically stable, and his airway is secure with no evidence of inhalational injury. He has sustained deep partial-thickness and full-thickness burns involving his anterior chest, anterior abdomen, entire right arm, and the anterior aspect of his left leg. The remainder of his skin is intact. Intravenous access is obtained. According to current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what should be the initial rate of intravenous lactated Ringer solution administration for this patient? (Enter the value in $\text{mL/hr}$)

Eighteen hours into resuscitation for severe thermal injuries, a $42$-year-old male patient exhibits acute clinical deterioration in the intensive care unit. He initially presented following an industrial fire with full-thickness burns covering $55\%$ of his total body surface area, localized exclusively to his back and bilateral lower extremities. He was intubated upon arrival, and standard Parkland formula-based crystalloid infusion was initiated.

Current assessment reveals a precipitous drop in urine output to $10 \text{ mL/hr}$. Vital signs show a temperature of $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure of $82/50 \text{ mm Hg}$, and a heart rate of $135\text{/min}$. The central venous pressure is elevated at $18 \text{ mm Hg}$. The mechanical ventilator repeatedly triggers high-pressure alarms, with peak airway pressures rising acutely from $25 \text{ cm H}_2\text{O}$ to $48 \text{ cm H}_2\text{O}$. On physical examination, the abdomen is tensely distended. Transducer measurement via the urinary catheter demonstrates an intravesical pressure of $34 \text{ mm Hg}$. Which of the following is the most appropriate next step in management?

A 31-year-old woman, gravida 2, para 1, at 28 weeks gestation is evaluated in the outpatient clinic for severe insomnia. Over the past month, she has been unable to fall asleep because of an uncomfortable, aching sensation deep within her calves. She states, "I feel an overwhelming urge to move my legs to make the feeling stop." These symptoms occur exclusively when she lies down to rest at night and improve significantly when she gets out of bed and paces around the house. Her medical history includes generalized anxiety disorder, which has been stable on sertraline for the past two years. Her prenatal course has been uncomplicated, and vital signs are normal. Neurological examination reveals normal muscle strength, tone, and deep tendon reflexes in the lower extremities. Which of the following is the most appropriate initial step in the evaluation or management of this patient's sleep complaint?

A 35-year-old man presents to the emergency department complaining of severe, crampy periumbilical pain and worsening abdominal bloating for the past two days. He has had multiple episodes of bilious emesis over the last 12 hours. His last bowel movement was 3 days ago, and he has not passed flatus for 24 hours. His surgical history is significant for an open appendectomy for ruptured appendicitis 8 years ago.

Temperature is 37.8°C (100.0°F), blood pressure is 135/85 mm Hg, pulse is 98/min, and respirations are 18/min. Physical examination reveals a distended and tympanitic abdomen. High-pitched, tinkling bowel sounds are auscultated. There is diffuse, mild tenderness to deep palpation, but no rebound tenderness, rigidity, or involuntary guarding.

Laboratory results:
- Leukocyte count: $11,500/\text{mm}^3$
- Hemoglobin: $15.2 \text{ g/dL}$
- Blood urea nitrogen: $28 \text{ mg/dL}$
- Serum creatinine: $1.2 \text{ mg/dL}$
- Serum lactate: $1.2 \text{ mmol/L}$ (normal: $0.5-2.2 \text{ mmol/L}$)

An abdominal CT scan with oral and intravenous contrast demonstrates dilated proximal small bowel loops measuring up to $4.5 \text{ cm}$ in diameter. A distinct transition point is seen in the distal ileum. Contrast is visualized within the cecum. There is no bowel wall thickening, pneumatosis intestinalis, mesenteric fat stranding, or free intraperitoneal fluid.

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

A 65-year-old man presents to the outpatient surgical clinic 6 days after undergoing an emergency laparotomy and omental patch repair for a perforated duodenal ulcer. He reports worsening, throbbing pain at his surgical site that began yesterday. His temperature is 38.2°C (100.8°F), blood pressure is 128/78 mm Hg, heart rate is 90/min, and respiratory rate is 14/min. Physical examination shows a midline abdominal incision closed with surgical staples. The inferior one-third of the incision is erythematous, indurated, and exquisitely tender to palpation. Thick, yellowish fluid is spontaneously draining from between two of the staples in this area. The remainder of the abdominal examination is unremarkable, with normal bowel sounds and no rebound tenderness. Which of the following is the most appropriate next step in management?

A 34-year-old female with schizoaffective disorder is admitted to the hospital for intravenous antibiotic therapy for a complicated cellulitis. Her psychiatric symptoms have been well controlled for the past three years on a stable dose of clozapine. She typically smokes one and a half packs of cigarettes daily but is currently in a strict smoke-free inpatient unit; a transdermal nicotine patch was prescribed on admission to prevent withdrawal. Her other home medications include a combined oral contraceptive pill and ibuprofen as needed. On hospital day 4, the patient becomes progressively lethargic and develops significant sialorrhea. Later that evening, she experiences a generalized tonic-clonic seizure. Her vital signs are temperature 37.1°C (98.8°F), blood pressure 110/70 mm Hg, pulse 92/min, and respirations 14/min. Laboratory studies show a normal basic metabolic panel, and her white blood cell count is 8,500/mm³. Which of the following is the most likely pharmacological explanation for this patient's acute neurological presentation?