Tüm alıştırma soruları

During a routine sports physical, a 16-year-old adolescent female complains of persistent right lower thigh pain that has progressively worsened over the last two months. She states the pain initially occurred only after running but now throbs at night and regularly disrupts her sleep. She has experienced no fevers, chills, or unintentional weight loss. On examination, the physician palpates a firm, exquisitely tender mass fixed to the underlying bone near the distal right femur. The overlying skin is slightly warm but not erythematous. Plain radiographs of the right lower extremity exhibit a poorly marginated, destructive lytic lesion in the distal femoral metaphysis accompanied by a sunburst pattern of periosteal reaction and a Codman triangle. Which of the following is the most appropriate next step in the management of this patient?

A 31-year-old woman is brought to the trauma center by emergency medical services after a high-speed head-on motor vehicle collision. At the scene, she was unresponsive and intubated for airway protection. Upon arrival, her temperature is 36.1°C (97.0°F), blood pressure is 76/40 mmHg, and heart rate is 142/min. She is receiving mechanical ventilation. Glasgow Coma Scale score is 3T. Pupillary examination reveals a 7-mm nonreactive right pupil and a 3-mm reactive left pupil. Breath sounds are equal bilaterally. The pelvis is mechanically stable on anteroposterior compression. There are no obvious external sources of bleeding. A focused assessment with sonography for trauma (FAST) examination reveals a large anechoic stripe in the hepatorenal recess. Which of the following is the most appropriate next step in the management of this patient?

An urgent surgical consultation is requested for a $67$-year-old male who was admitted three days ago with a partial small bowel obstruction. He has a history of an exploratory laparotomy for a perforated appendix in his twenties. For the first two days of his current admission, he was managed with intravenous fluids, bowel rest, and nasogastric tube decompression. Over the past six hours, his abdominal pain transitioned from intermittent and crampy to severe and unremitting. Current vital signs include a temperature of $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), a pulse of $124/\text{min}$, a blood pressure of $88/52 \text{ mm Hg}$, and respirations of $24/\text{min}$. On physical examination, the patient lies completely still in bed. His abdomen is tightly distended with diffuse rigidity, involuntary guarding, and marked rebound tenderness. Laboratory analysis demonstrates a leukocyte count of $19,500/\text{mm}^3$ and an arterial lactate concentration of $4.6 \text{ mmol/L}$. Which of the following represents the most appropriate next step in the care of this patient?

A 28-year-old pregnant woman at 34 weeks gestation is evaluated in the trauma center following a high-velocity motor vehicle collision. First responders noted substantial vehicular damage. On arrival, she is alert but anxious. Her airway is patent and breathing is unlabored. Vital signs show a temperature of $36.7^\circ\text{C}$ ($98.1^\circ\text{F}$), blood pressure of $78/48\text{ mm Hg}$, pulse of $134/\text{min}$, and respiratory rate of $24/\text{min}$. The trachea is midline, and breath sounds are symmetric. Her abdomen is distended, gravid, and diffusely tender with rebound. Manual compression of the iliac crests reveals a stable pelvis. Two large-bore peripheral intravenous catheters are placed, and warmed crystalloid infusion is started. A bedside ultrasonographic assessment demonstrates an anechoic fluid collection in the hepatorenal space. Which of the following is the most appropriate next step in the management of this patient?

During afternoon rounds, a physician evaluates a 54-year-old female patient due to an episode of elevated temperature. The patient underwent an uncomplicated laparoscopic cholecystectomy three days ago for recurrent biliary colic. She has been tolerating a regular diet and her pain is well controlled with oral medications. Her current vital signs show a temperature of 38.3°C (100.9°F), heart rate of 92/min, blood pressure of 128/82 mmHg, and respiratory rate of 14/min. Auscultation of the lungs reveals clear breath sounds bilaterally. Her abdomen is soft and non-tender, and the surgical port sites are healing appropriately without signs of infection. Inspection of the right distal forearm, where a peripheral venous catheter has been in place since admission, demonstrates localized tenderness, induration, and a 3-centimeter streak of erythema tracing the course of the vein. There is no fluctuance or purulent discharge. Which of the following is the most appropriate next step in management?

A 47-year-old woman is evaluated in the hospital during the evening shift for a sudden change in her clinical status. She was admitted 48 hours ago for a partial small bowel obstruction, attributed to adhesions from a previous total abdominal hysterectomy. Initial therapy with intravenous fluids and bowel rest resulted in a decrease in her abdominal distention. Over the past 3 hours, however, she reports a sudden onset of excruciating, unremitting abdominal pain. Her temperature is 39.1°C (102.4°F), blood pressure is 88/54 mm Hg, pulse is 122/min, and respirations are 22/min. Physical examination reveals a rigid abdomen with severe diffuse rebound tenderness and involuntary guarding. Laboratory studies show a leukocyte count of 21,000/mm³ with 15% band forms. Arterial blood gas analysis reveals a pH of 7.28, $pCO_2$ of 32 mm Hg, and a bicarbonate ($HCO_3^-$) of 15 mEq/L. Serum lactate is 5.8 mmol/L. Which of the following is the most appropriate next step in the management of this patient?

A male patient, aged 54, is brought to the surgical evaluation unit due to intense, unremitting abdominal pain and bilious vomiting that started 12 hours prior. His past medical history is notable for an open appendectomy performed two decades ago. Current vital signs include a temperature of 39.1°C (102.4°F), heart rate of 124/min, and blood pressure of 92/58 mm Hg. The abdominal examination reveals marked distension, absent bowel sounds, involuntary guarding, and diffuse rebound tenderness. Laboratory assessment is significant for a leukocyte count of 19,500/mm³ and a serum lactate of 4.5 mmol/L. Upright radiographic imaging of the abdomen demonstrates multiple dilated small intestinal loops with air-fluid levels and an absence of distal colonic gas. Which of the following is the most appropriate next step in management?

During surgical rounds, the attending physician discusses the classic timeline of postoperative complications with the medical team. Arrange the following common etiologies of postoperative fever in the chronological order they typically present, from earliest (postoperative day 1) to latest (postoperative day 7).

A 28-year-old construction worker is brought to the emergency department after a heavy concrete beam fell on his pelvis. His blood pressure is 118/76 mmHg and heart rate is 92/min. Primary survey reveals a patent airway and clear lungs. A pelvic binder is applied. Physical examination reveals a scrotal hematoma and blood at the urethral meatus. Arrange the following diagnostic and therapeutic steps in the correct chronological sequence to appropriately evaluate and manage this patient, assuming findings lead to the diagnosis and treatment of an intraperitoneal bladder rupture.

A 54-year-old man arrives at the trauma center via ambulance after falling approximately 20 feet from a roof. En route, emergency medical services placed a cervical collar and secured him to a backboard. Upon arrival, the patient is agitated, pale, and diaphoretic. His temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure is $78/48\text{ mmHg}$, pulse is $132\text{/min}$, and respiratory rate is $22\text{/min}$. Oxygen saturation is $98\%$ on a non-rebreather mask. The airway is patent, and breath sounds are clear and equal bilaterally. The abdomen is notably distended and diffusely tender to palpation, with significant involuntary guarding. The pelvis is mechanically stable to manual compression. Two large-bore intravenous lines are established, and rapid resuscitation with warmed isotonic crystalloids is initiated. Which of the following is the most appropriate next step in the management of this patient?

For the following individuals presenting with psychiatric symptoms, select the most accurate diagnosis by pairing the clinical history with the corresponding condition.

A 52-year-old man is brought to the emergency department by his husband due to severe confusion, agitation, and visual hallucinations. The husband reports that the patient has a history of bipolar disorder and has been hospitalized twice in the past for manic episodes. The patient recently experienced a severe depressive episode and was started on fluoxetine three weeks ago by a new provider. The patient also has a severe alcohol use disorder but abruptly stopped drinking 72 hours ago. On physical examination, the patient is profoundly diaphoretic, tremulous, and continuously picks at his skin, claiming there are "spiders everywhere." His temperature is 38.8°C (101.8°F), blood pressure is 158/96 mm Hg, pulse is 118/min, and respirations are 20/min. Physical examination reveals no nuchal rigidity, clear lungs to auscultation bilaterally, and a benign abdomen. Which of the following is the most appropriate next step in management?

A 64-year-old woman is evaluated in the emergency department 12 days after undergoing a coronary artery bypass grafting (CABG) procedure. She reports a 2-day history of increasing retrosternal pain, fever, and profound fatigue. Her temperature is 38.8°C (101.8°F), heart rate is 112/min, blood pressure is 105/65 mmHg, and respiratory rate is 18/min. Physical examination reveals erythema, induration, and a small amount of purulent drainage from the inferior aspect of the sternotomy incision. A palpable 'click' and abnormal movement are felt over the sternum during respiration. Arrange the following management steps in the most appropriate chronological order.

Match each patient's clinical and radiographic presentation with the most likely orthopedic diagnosis.

A 72-year-old man is evaluated on postoperative day 3 following an open partial gastrectomy for a perforated peptic ulcer. Over the last several hours, he has developed progressive dyspnea, a nonproductive cough, and a sense of chest tightness. His medical history is significant for severe chronic obstructive pulmonary disease and ischemic cardiomyopathy with a baseline left ventricular ejection fraction of 40%. During his surgery, he received 4 liters of isotonic crystalloid resuscitation. His temperature is 37.8°C (100.0°F), blood pressure is 158/92 mmHg, pulse is 112/min, and respirations are 24/min. Pulse oximetry shows 88% on room air. Physical examination reveals elevated jugular venous pressure to 10 cm H2O. Lung auscultation demonstrates bilateral coarse crackles at the bases and scattered expiratory wheezes. The surgical incision is clean, dry, and intact. There is bilateral trace lower extremity edema, which is unchanged from baseline. A chest radiograph demonstrates bilateral perihilar opacities and prominent pulmonary vasculature, with no focal consolidation. Which of the following is the most appropriate next step in management?

A primary care physician evaluates a 29-year-old female patient complaining of unrelenting anxiety regarding her job security, personal finances, and general health that has persisted for the past 9 months. She describes experiencing frequent muscle tension, daytime fatigue, and poor concentration. During the psychiatric history, she mentions that 4 years ago she had a distinct 14-day period where she "felt invincible," required only 90 minutes of sleep per night, and maxed out her credit cards on impulsive purchases. She states her mood is currently euthymic. Her past medical history is notable for a methicillin-resistant Staphylococcus aureus (MRSA) skin infection, for which she was prescribed linezolid 3 days ago. Which of the following are appropriate considerations regarding this patient's diagnosis and management? (Select exactly 2 options)

A 22-year-old man is brought to the trauma bay after being struck by a car while crossing the street. He is moaning in pain and has visible bruising on his chest and abdomen. According to the Advanced Trauma Life Support (ATLS) protocol, arrange the following initial assessment and management steps in the correct chronological order.

A 72-year-old man visits his primary care provider to discuss a 3-month history of a persistent, dry cough and worsening shortness of breath. He reports hearing a "whistling" sound when breathing, which he initially attributed to a respiratory infection. He has a 40-pack-year smoking history. A recent trial of nebulized bronchodilators prescribed at an urgent care clinic provided no relief. Over the past month, his voice has become progressively hoarse. Blood pressure is 162/94 mm Hg in the right arm and 160/92 mm Hg in the left. Pulse is 84/min, and respirations are 20/min. Physical examination reveals a harsh, high-pitched inspiratory sound heard most prominently over the anterior neck and upper sternum. Lung fields are clear to auscultation bilaterally. Cardiac examination reveals a regular rate and rhythm with no murmurs. There is no peripheral edema. A chest radiograph demonstrates a widened mediastinum with deviation of the trachea to the right, but no focal consolidation or pleural effusion. Based on the clinical presentation and imaging findings, which of the following is the most likely underlying mechanism for this patient's respiratory and vocal symptoms?

A 45-year-old man is admitted to the intensive care unit with severe acute gallstone pancreatitis. After initial improvement with aggressive fluid resuscitation and supportive care, he develops a new-onset fever of 39.4°C (102.9°F), leukocytosis of 18,000/mm³, and increasing abdominal pain on hospital day 14. He remains hemodynamically stable. Assuming each intervention is indicated by the findings or clinical failure of the preceding step, arrange the following management steps in the most appropriate 'step-up' sequence for this patient's suspected complication.

A 67-year-old man is evaluated by the consultation-liaison psychiatry team on the medical floor. He was admitted one week ago for a non-ST-elevation myocardial infarction and subsequently developed a complicated soft-tissue infection at the catheter insertion site, for which he is currently receiving intravenous linezolid. The nursing staff reports that the patient has been increasingly withdrawn, tearful, and refusing to participate in physical therapy. During the interview, the patient is fully oriented and demonstrates intact decision-making capacity. He reports a two-month history of a profoundly depressed mood, pervasive anhedonia, early morning awakenings, a 5-kg (11-lb) weight loss, and hearing a voice repeatedly telling him he is a "total failure." He states, "I just have no energy left to fight, but I definitely do not want any sort of shock treatments." His wife, who is present, privately tells the physician, "He doesn't know what he's saying. I give you full permission to do electroconvulsive therapy if it will fix this." Review of his past medical history reveals an episode at age 26 when he was hospitalized for a week after staying awake for five consecutive days and recklessly spending his life savings on an impulsive business venture. Which of the following is the most appropriate next step in the psychiatric management of this patient?