Tüm alıştırma soruları

A 26-year-old woman is evaluated in the sleep clinic for a 1-year history of irresistible daytime sleep attacks. She reports frequently falling asleep during meetings and while driving. Additionally, she experiences vivid, frightening hallucinations just as she is falling asleep, and transient periods of bilateral leg weakness triggered by sudden laughter. She takes no medications and her physical examination is unremarkable. Arrange the following steps in the most appropriate chronological sequence for the diagnostic evaluation and step-wise pharmacological management of this patient.

Match the following clinical presentations of abdominal pathology with their most appropriate definitive surgical or procedural management.

A mother schedules a pediatric consultation for her four-and-a-half-year-old son because she feels overwhelmed by his constant need to move. The mother describes the child as being 'driven by a motor,' noting that he routinely climbs on top of the refrigerator, sprints down the hallways, and constantly interrupts her conversations. She is convinced he has a medical condition and wants a prescription to calm him. Developmentally, the child can hop on one foot, copy a cross on paper, and speak in completely intelligible sentences. A behavior rating scale completed by his preschool teacher reveals that the child participates cooperatively in group games, sits attentively during fifteen-minute story sessions, and shares toys with peers appropriately. His physical examination, including vision and hearing screens, reveals no abnormalities. Which of the following is the most appropriate management for this patient?

An otherwise healthy 42-year-old male undergoes an uncomplicated open appendectomy for acute appendicitis. Approximately 24 hours after the procedure, the nursing staff notes a new-onset temperature of 38.4°C (101.1°F). The patient reports mild incisional pain but denies dyspnea, cough, dysuria, or calf pain. Blood pressure is 128/76 mm Hg, pulse is 88/min, and respirations are 16/min. The surgical dressing is dry and intact, with no surrounding erythema. Auscultation of the chest reveals diminished breath sounds over both lung bases. Which of the following is the most likely etiology of this patient's elevated temperature?

A 59-year-old man is evaluated in the recovery unit four hours after undergoing a percutaneous coronary intervention via a right common femoral artery approach. He now complains of sudden, intense pain in his right foot and numbness in his toes. His vital signs are within normal limits. On physical examination, the right foot is mottled, pale, and cold to the touch compared to the left. The right femoral pulse is bounding. The right popliteal, dorsalis pedis, and posterior tibial pulses are not palpable and are absent on handheld Doppler ultrasound. He exhibits weakened plantar flexion of the right foot and decreased sensation over the dorsal and plantar surfaces. Which of the following is the most appropriate next step in the management of this patient?

An oncologist is asked to evaluate a 54-year-old man admitted for profound neutropenia following induction chemotherapy for acute myeloid leukemia. For the past 5 days, he has been treated with intravenous cefepime for a temperature of 39.2°C (102.6°F) and an absolute neutrophil count of 150/mm³. Today, his temperature remains elevated at 38.9°C (102.0°F). He reports a new, dry cough and mild right-sided chest pain that worsens with deep inspiration. Blood pressure is 114/72 mm Hg, pulse is 108/min, and respirations are 20/min. Pulse oximetry shows 94% on room air. Physical examination reveals diminished breath sounds in the right upper lung field. Laboratory studies show a white blood cell count of 0.6 x 10^9/L (ANC 100/mm³). Blood cultures obtained on admission have shown no growth. A high-resolution CT scan of the chest reveals a 2-cm macronodule with a surrounding zone of ground-glass attenuation in the right upper lobe. Which of the following is the most appropriate next step in management?

A 31-year-old man is brought to the emergency department by his roommate due to increasingly erratic behavior over the past week. The patient is pacing rapidly, speaking tangentially, and claims he has discovered a mathematical formula that will solve world hunger. He states he has not slept in four days. He also reports hearing the voice of a historical figure giving him constant instructions. Review of his medical record reveals a psychiatric history beginning at age 24. Since that time, he has experienced multiple prolonged episodes of both severe depression and mania, which collectively account for more than half of the total duration of his illness. The records also clearly document a notable 4-month period last year when his mood was entirely stable and euthymic, yet he continued to experience persistent auditory hallucinations and the delusion that foreign agents were monitoring his thoughts. Urine toxicology screen is negative. Which of the following is the most accurate diagnosis?

A 42-year-old man presents to the psychiatric clinic for the management of a newly diagnosed major depressive disorder (MDD). Over the next 18 months, his clinical course is characterized by significant treatment resistance, eventually leading to a severe exacerbation with psychotic features and food refusal. Arrange the following therapeutic interventions in the correct chronological order according to standard stepped-care pharmacologic and somatic treatment guidelines for MDD, starting from his initial presentation to his most severe exacerbation.

A 58-year-old woman is evaluated in the hospital for a fever of 39.2°C (102.6°F), scleral icterus, and severe right upper quadrant abdominal pain. Her blood pressure is 100/60 mmHg and her heart rate is 110/min. Laboratory studies demonstrate a significant leukocytosis, conjugated hyperbilirubinemia, and markedly elevated alkaline phosphatase. Arrange the following steps in the most appropriate chronological sequence for the management of this patient's condition.

A 35-year-old woman is being managed for cocaine use disorder over a period of three years. Her readiness to modify her substance use behavior fluctuates over time. According to the Transtheoretical Model of Change, arrange the following patient statements in the expected chronological progression from the earliest stage of behavior change to the latest.

A 35-year-old man is brought to the emergency department after being rescued from a closed-space house fire. On arrival, he is agitated and in respiratory distress. His vital signs are temperature 37.0°C (98.6°F), blood pressure 110/70 mmHg, heart rate 115/min, and respiratory rate 26/min. Physical examination reveals full-thickness burns involving his anterior trunk and both upper extremities. He has soot in his oropharynx, singed nasal vibrissae, and a hoarse voice. Arrange the following steps in the most appropriate chronological order for the acute management of this patient.

A 29-year-old man is brought to the emergency department by his partner due to a rapidly spreading rash and fever. Over the past 48 hours, he developed flu-like symptoms followed by painful, erythematous macules on his chest and back. Physical examination reveals a temperature of 39.2°C (102.6°F). The macules have coalesced into large areas of blistering, and the epidermis sloughs off with gentle lateral pressure. Ulcerations are visible on his buccal mucosa and vermilion border. The patient has a 4-year history of bipolar I disorder and has been maintained on divalproex sodium. Three weeks ago, he sought treatment for a severe depressive episode, and his psychiatrist added a second medication to his regimen. The new medication was prescribed at a starting dose of 25 mg daily. Which of the following pharmacokinetic or pharmacodynamic mechanisms best explains the pathogenesis of this patient's current dermatologic emergency?

A 36-year-old woman presents to the primary care clinic reporting a 5-week history of profound sadness, early morning awakening, decreased appetite, and difficulty concentrating at work. She states she has never felt this way before and denies any current suicidal ideation, hallucinations, or delusions. Her medical history is unremarkable, and she takes no medications. The physician determines she is experiencing a major depressive episode and considers initiating fluoxetine therapy. Which of the following is the most appropriate next step in the clinical care of this patient?

A 35-year-old male is brought to the emergency department after a high-speed motorcycle collision. He complains of severe lower abdominal and pelvic pain.

Vital signs on arrival are:
Temperature: $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$)
Blood pressure: $76/40\text{ mmHg}$
Heart rate: $135/\text{min}$
Respiratory rate: $24/\text{min}$
Oxygen saturation: $96\%$ on room air

The primary survey reveals a clear airway and bilaterally equal breath sounds. The abdomen is soft and non-distended without guarding or rebound tenderness. Emergency medical services placed a commercial pelvic binder prior to arrival. A portable anteroposterior pelvic radiograph reveals an "open-book" pelvic fracture with a $4\text{ cm}$ diastasis of the pubic symphysis.

A FAST (Focused Assessment with Sonography for Trauma) examination demonstrates no free fluid in the pericardial, perisplenic, perihepatic, or pelvic views.

Two large-bore intravenous lines are established, and he receives $1\text{ L}$ of warmed lactated Ringer solution and $1\text{ unit}$ of uncrossmatched type O-negative blood. A repeat blood pressure is $82/45\text{ mmHg}$ with a heart rate of $128/\text{min}$.

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

Pair the following clinical presentations of acute trauma patients with the corresponding immediate management step.

A 71-year-old man is evaluated on the surgical ward immediately after experiencing a sudden "tearing" sensation in his abdomen during a severe bout of coughing. He is on postoperative day 6 following an open sigmoid resection for complicated diverticulitis. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $112/74\text{ mmHg}$, and pulse is $102/\text{min}$. When the abdominal binder and surgical dressings are removed, a large volume of serosanguineous fluid is noted, and loops of small intestine are visibly protruding through the separated midline fascial defect.

Arrange the following next steps in the most appropriate chronological sequence for managing this patient's acute complication.

A $65$-year-old man is evaluated in the surgical intensive care unit for sudden-onset severe dyspnea, diaphoresis, and right-sided chest pain. He is currently on postoperative day $3$ following an open radical retropubic prostatectomy for localized prostate cancer. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $76/45\text{ mm Hg}$, pulse is $132/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows an oxygen saturation of $82\%$ on room air. Physical examination reveals prominent jugular venous distention and a loud pulmonary component of the second heart sound ($P_2$). Bilateral breath sounds are clear to auscultation. An electrocardiogram shows sinus tachycardia with a new-onset right bundle branch block. The patient remains persistently hypotensive despite the rapid administration of $1\text{ L}$ of intravenous normal saline.

Arrange the following management steps in the most appropriate chronological sequence for this patient.

The rapid response team is called to the surgical ward to assess a patient experiencing sudden respiratory distress. The patient is $48$ hours status-post an elective open ventral hernia repair. His past medical history is significant for severe chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy with a baseline left ventricular ejection fraction of $35\%$. He complains of shortness of breath and a cough producing clear sputum. Vital signs reveal a temperature of $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure of $135/85\text{ mm Hg}$, heart rate of $108\text{/min}$, and respiratory rate of $26\text{/min}$. Pulse oximetry shows an oxygen saturation of $87\%$ on room air. Physical examination demonstrates a prolonged expiratory phase with diffuse bilateral wheezing. Jugular venous pressure is normal, crackles are absent, and there is no lower extremity edema. A bedside lung ultrasound reveals diffuse bilateral A-lines. A portable chest radiograph shows hyperinflated lung fields without focal consolidation or pleural effusion. A sputum culture obtained on the first postoperative day for a mild baseline cough is finalized today and reveals only normal respiratory flora. Based on this clinical presentation, which of the following are the most appropriate next steps in management? (Select all that apply)

A 20-year-old college sophomore presents to the student health clinic reporting intense fear and physical distress regarding an upcoming mandatory oral presentation scheduled in four days. He describes experiencing severe palpitations, visible hand tremors, and a "knot in his stomach" whenever he thinks about standing in front of his classmates. He states, "I know my fear is irrational, but I am terrified they will see me shaking and think I am incompetent." He has no anxiety in social gatherings, on dates, or in other academic settings. His medical history is significant for moderate persistent asthma, which is well-controlled with a daily fluticasone-salmeterol inhaler and albuterol as needed. He does not use illicit substances or alcohol. Vital signs are within normal limits. Which of the following is the most appropriate pharmacological intervention to manage his symptoms for the upcoming presentation?

A kindergarten teacher raises concerns about a 5-year-old boy who recently transferred to her classroom. The child rarely initiates play with peers, often avoids eye contact when addressed, and frequently flaps his hands when excited. The school psychologist and pediatrician collaborate to evaluate him for Autism Spectrum Disorder (ASD). When distinguishing ASD from an isolated speech delay or global developmental delay, which of the following findings would specifically fulfill the core diagnostic criteria for ASD? (Select all that apply)