Tüm alıştırma soruları

Match each classic clinical presentation of an acute surgical abdomen to the most likely diagnosis.

A 62-year-old male patient is evaluated in the emergency department for three days of progressively worsening left lower quadrant abdominal pain accompanied by chills. His vital signs show a temperature of 38.6°C (101.5°F), blood pressure of 128/78 mmHg, and heart rate of 92/min. On physical examination, there is focal tenderness and voluntary guarding in the left lower quadrant, but the abdomen is not rigid and there is no diffuse rebound tenderness. Laboratory evaluation reveals a leukocyte count of 16,500/mm³. A contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis confirms severe sigmoid diverticulitis complicated by a 5.5-cm, well-defined peri-colonic fluid collection.

Arrange the following management steps in the most appropriate chronological sequence for this patient, from immediate acute care to definitive long-term management.

An emergency medical services team transports a 71-year-old man to the acute care bay after he suddenly collapsed at a grocery store. Prior to collapsing, he complained of severe, tearing pain in his lower back and abdomen. His past medical history includes hypertension, hyperlipidemia, and a 45-pack-year smoking history. Upon arrival, he is lethargic but arousable. His temperature is 36.5°C (97.7°F), blood pressure is 74/42 mm Hg, pulse is 128/min, and respirations are 24/min. The patient's skin is pale, cold, and clammy. Physical examination of the abdomen reveals a prominent, expansile, pulsatile mass measuring approximately 7 cm in width. The abdomen is otherwise soft without peritoneal signs. Which of the following is the most appropriate next step in management?

An emergency department physician evaluates a 29-year-old female patient after police found her wandering in traffic. The patient is highly agitated and states, "The angels are speaking to me, they say the end is coming!" Her sister arrives at the hospital and explains that the patient had been functioning perfectly normally until two weeks ago. At that time, the patient's house was destroyed in a severe fire, and she immediately began exhibiting disorganized speech and reporting auditory hallucinations. She has no prior history of mental illness, and she does not use alcohol or recreational drugs. Vital signs are within normal limits. A thorough medical workup reveals no metabolic, infectious, or neurologic abnormalities. Which of the following is the most likely diagnosis?

Match each trauma patient presentation with the most appropriate definitive next step in management. Assume airway and breathing have been secured in all patients.

A 35-year-old man is brought to the emergency department after a motor vehicle collision. On initial evaluation, he opens his eyes only when the physician loudly calls his name. When asked what happened, he responds with single, random words that do not form coherent sentences. When pressure is applied to his right fingernail bed, he briskly flexes his elbow to pull his right arm away from the stimulus, but does not reach toward the examiner's hand. What is this patient's Glasgow Coma Scale (GCS) score?

An occupational health physician is evaluating a 49-year-old male warehouse manager due to unintended sleep episodes at work over the past 7 months. The patient states, 'No matter how early I go to bed, I wake up with a morning headache and feel exhausted.' His bed partner recently moved to a separate bedroom due to his disruptive, loud snoring and intermittent gasping sounds during the night. Medical history is notable for essential hypertension and bipolar II disorder, which has been stable on lamotrigine for five years. Current medications include lisinopril and lamotrigine. His body mass index is $36 \text{ kg/m}^2$. Vital signs are within normal limits. Physical examination reveals a crowded oropharynx and 1+ bilateral pitting edema in the lower extremities. Laboratory studies reveal a normal thyroid-stimulating hormone level of $1.9 \text{ \mu U/mL}$ and a normal free T4 level. The patient expresses concern because a previous physician mentioned a 'borderline low thyroid hormone' level years ago. Which of the following is the most appropriate next step in the management of this patient?

Match each classic thoracic trauma clinical presentation with its most appropriate definitive diagnostic modality or immediate intervention.

An 82-year-old man is brought to the emergency department from a long-term care facility due to progressive abdominal swelling and a lack of bowel movements for the past three days. He has a history of Parkinson disease, hypertension, and chronic constipation. His medications include carbidopa-levodopa, amlodipine, and a daily multivitamin. On arrival, his temperature is 37.1°C (98.8°F), blood pressure is 138/82 mm Hg, pulse is 86/min, and respiratory rate is 16/min. Physical examination reveals a markedly distended, tympanitic abdomen. There is mild diffuse tenderness to palpation, but no guarding, rigidity, or rebound tenderness. Digital rectal examination demonstrates an empty rectal vault. Laboratory studies reveal a leukocyte count of 8,200/mm³ and normal serum electrolytes. A plain abdominal radiograph demonstrates a massively dilated large bowel loop resembling an inverted U-shape extending from the pelvis toward the right upper quadrant, with a loss of haustral markings. Which of the following is the most appropriate next step in management?

A 62-year-old man presents to the emergency department with a 2-day history of constant, worsening left lower quadrant abdominal pain. He also reports fever, mild nausea, and no bowel movements for the past 48 hours. His medical history is significant for hypertension and chronic constipation. His temperature is 38.6°C (101.5°F), blood pressure is 135/85 mm Hg, pulse is 92/min, and respirations are 16/min. Physical examination reveals focal tenderness to palpation in the left lower quadrant with voluntary guarding, but no rebound tenderness or diffuse rigidity. Laboratory studies show a leukocyte count of 14,000/mm³. Which of the following is the most appropriate next step in evaluation?

A 28-year-old woman is brought to the emergency department by her sister due to severe agitation and paranoia. The sister reports that the patient has been awake for three days, pacing her apartment, and claiming that government agents are watching her through the smoke detectors. The patient has a past psychiatric history of bipolar I disorder. The sister suspects the patient recently began using "meth" (methamphetamine). The patient's medical record indicates that her father is her legally appointed healthcare proxy. Vital signs are temperature 38.2°C (100.8°F), blood pressure 165/100 mm Hg, pulse 122/min, and respirations 22/min. Physical examination shows diaphoresis, mydriasis, and extensive excoriations on her face and arms. She is highly combative, actively attempting to strike the nursing staff, and screaming, "I won't let you poison me!" Which of the following is the most appropriate next step in the management of this patient?

An 81-year-old woman is brought to the emergency department from a long-term care facility due to severe, unrelenting abdominal pain and recurrent bilious vomiting for the past 24 hours. She has not had a bowel movement or passed flatus for 2 days. Her medical history includes atrial fibrillation, hypertension, and osteoarthritis. She has no history of previous abdominal surgeries. Her temperature is 38.6°C (101.5°F), pulse is 122/min, and blood pressure is 94/56 mm Hg. Physical examination reveals a markedly distended and tympanic abdomen with diffuse guarding and rebound tenderness. Bowel sounds are absent. A firm, exquisitely tender, 4-cm mass is palpable in the right groin, located inferior to the inguinal ligament and medial to the femoral artery pulsation. The skin overlying the mass is erythematous and dusky. Laboratory studies show a leukocyte count of 19,500/mm³ and a serum lactate of 4.2 mmol/L. Which of the following is the most appropriate next step in management?

A 62-year-old man is evaluated in the surgical intensive care unit for a new-onset fever. He was admitted 12 days ago after sustaining severe blunt abdominal trauma in a motor vehicle collision. He underwent an emergency exploratory laparotomy with splenectomy and repair of multiple small bowel lacerations. His postoperative course has been complicated by acute respiratory distress syndrome requiring prolonged mechanical ventilation, and he has been receiving total parenteral nutrition via a right internal jugular central venous catheter for the past 10 days.

Today, his temperature has spiked to 39.4°C (102.9°F). Blood pressure is 100/65 mm Hg, pulse is 118/min, and respirations are 22/min on the ventilator. He is sedated but grimaces when the right upper quadrant of his abdomen is palpated. The laparotomy incision is clean and intact. The central venous catheter site shows no erythema, induration, or purulent exudate.

Blood and urine cultures are drawn, and empiric broad-spectrum intravenous antibiotics are initiated.

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

A 42-year-old male is transported to the emergency department via helicopter after a high-speed motorcycle collision. Upon arrival, his airway is patent, and breath sounds are vesicular and equal bilaterally. His blood pressure is 75/40 mmHg, and his heart rate is 132/min. The abdomen is soft, non-distended, and without rebound tenderness. Examination of the lower half of the body reveals a shortened and externally rotated right lower extremity, as well as significant ecchymosis over the scrotum and perineum. Gentle palpation of the iliac crests reveals abnormal mobility. A focused assessment with sonography for trauma (FAST) examination demonstrates no free intraperitoneal or pericardial fluid. Intravenous access is established, and administration of uncrossmatched blood is initiated. Which of the following is the most appropriate next step in management?

A 32-year-old man with a 10-year history of treatment-resistant schizophrenia is evaluated on the inpatient psychiatric unit. Over the past several years, he has continued to experience severe, commanding auditory hallucinations despite adequate therapeutic trials of risperidone, olanzapine, and haloperidol. Four weeks ago, he was transitioned to clozapine, which was gradually titrated to 600 mg daily. The nursing staff notes that his psychotic symptoms have dramatically improved, and he is interacting appropriately with peers for the first time in years. However, earlier today, the patient experienced a new-onset generalized tonic-clonic seizure that lasted 90 seconds and spontaneously resolved. He has no prior history of seizures, and a non-contrast head CT is unremarkable. His current absolute neutrophil count is 4,500/mm³. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 26-year-old man with a recent diagnosis of schizophrenia is initiated on oral haloperidol therapy to manage severe psychotic symptoms. Arrange the following potential medication-induced movement disorders in the standard chronological order of their expected onset, from the earliest to appear to the latest.

A 22-year-old male is brought to the emergency department via ambulance after being struck by a motor vehicle while riding his bicycle. He was reportedly thrown over the handlebars. On arrival, he is confused and diaphoretic. His temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), blood pressure is $78/40\text{ mmHg}$, pulse is $135\text{/min}$, and respirations are $24\text{/min}$. Oxygen saturation is $97\%$ on room air. The airway is clear, and breath sounds are equal bilaterally. Primary survey reveals marked abdominal distension with diffuse guarding and rebound tenderness. A focused assessment with sonography for trauma (FAST) demonstrates a large amount of free fluid in the hepatorenal recess (Morison's pouch). Intravenous fluid resuscitation is initiated with $1\text{ L}$ of warmed crystalloid, but his repeat blood pressure is $80/42\text{ mmHg}$. Which of the following is the most appropriate next step in management?

Match each anatomic description or clinical presentation with the correct type of abdominal or pelvic hernia.

A 32-year-old woman with a history of severe, treatment-resistant major depressive disorder is evaluated in the psychiatry clinic. She has experienced minimal clinical improvement on an optimized dose of fluoxetine over the past 12 weeks. The psychiatrist decides to discontinue fluoxetine and initiate phenelzine. To prevent life-threatening complications such as serotonin syndrome and hypertensive crisis, strict guidelines must be followed during this transition and in the event of future medication changes. Arrange the following clinical management steps in the correct chronological sequence required to safely execute this treatment plan.

Lower extremity injuries frequently involve concurrent vascular, neurologic, or systemic complications that require distinct, time-sensitive interventions. Match each specific lower extremity trauma presentation with its most appropriate next step in management or definitive intervention.