Tüm alıştırma soruları

A 61-year-old man is evaluated in the emergency department for sudden, severe, and generalized abdominal pain that started 3 hours ago. He has a past medical history of chronic knee osteoarthritis, for which he takes naproxen regularly. His temperature is 38.4°C (101.1°F), blood pressure is 92/58 mm Hg, and heart rate is 118/min. On physical examination, the patient is visibly uncomfortable and lying rigidly still on the stretcher. The abdomen is distended, diffusely rigid, and exhibits profound rebound tenderness in all quadrants. An upright chest radiograph reveals a crescent of radiolucency beneath the right hemidiaphragm. Intravenous fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

A 5-year-old boy is brought to the pediatric clinic by his parents due to distressing nighttime episodes that have occurred once or twice a week for the past 3 months. Typically, about 90 to 120 minutes after falling asleep, the child abruptly sits up in bed, screams loudly, and breathes heavily. His parents state that he appears terrified, is dripping with sweat, and thrashes his arms defensively. When they attempt to comfort him, he stares blankly, does not recognize them, and violently resists their attempts to console him. The episodes last 5 to 10 minutes, after which he lies down and peacefully sleeps through the rest of the night. In the morning, he has no memory of the events and acts completely normal. His past medical history is unremarkable, and he is meeting all developmental milestones. The parents are exhausted and extremely worried about a potential underlying psychological or neurological problem. Which of the following is the most appropriate next step in management?

Arriving at the trauma center via helicopter emergency medical services is a 28-year-old male who was involved in a high-speed motorcycle collision. On initial assessment, the patient is lethargic and pale. Vital signs show a temperature of 36.5°C (97.7°F), heart rate of 142/min, blood pressure of 76/40 mm Hg, and respiratory rate of 28/min. The airway is patent, and breath sounds are equal bilaterally. The abdomen is soft and non-distended. Pelvic examination reveals mechanical instability to gentle anteroposterior compression. Blood is noted at the urethral meatus. A focused assessment with sonography for trauma (FAST) demonstrates no free fluid in the peritoneal, pericardial, or pleural spaces. Which of the following is the most appropriate next step in the management of this patient?

A 26-year-old man comes to the clinic seeking treatment for opioid use disorder. He has been injecting heroin daily for the past three years. The patient states, "I am tired of living like this and want to start the medication that stops cravings." He reports his last heroin use was two hours ago. Currently, he appears comfortable and cooperative. Vital signs are temperature 37.0°C (98.6°F), blood pressure 118/76 mm Hg, pulse 72/min, and respiratory rate 14/min. Physical examination reveals pinpoint pupils and track marks on bilateral antecubital fossae. The physician discusses initiating buprenorphine-naloxone therapy. Arrange the following steps for initiating this therapy in the correct chronological order from first to last.

Helicopter emergency medical services arrive at a regional burn center with a 50-year-old male who was extricated from a residential fire. The injury occurred exactly 3 hours prior to arrival. Upon presentation, he is intubated and mechanically ventilated. His estimated body weight is 80 kg. Vital signs show a blood pressure of 115/75 mm Hg and a heart rate of 112/min. Physical examination of the skin reveals blistering, weeping, and exquisitely tender lesions over the entire anterior trunk. The entire right lower extremity is covered in white, leathery, and insensate eschar. The entire left upper extremity exhibits diffuse erythema with intact epidermis, blanching on pressure, and no blistering. A large-bore peripheral intravenous catheter is successfully placed. Based on the most current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what should the initial intravenous crystalloid infusion rate be set to in mL/hr?

Match each clinical presentation of a patient receiving antipsychotic therapy with the most appropriate next step in management.

Following a collision with a tree while skiing, a 21-year-old man is transported to the trauma center by medical helicopter. Upon arrival, his blood pressure is 82/45 mm Hg and his heart rate is 128/min. His respiratory rate is 22/min, and oxygen saturation is 98% on high-flow oxygen. He appears pale and is confused, but localizes to painful stimuli. The airway is patent, and breath sounds are equal bilaterally. Examination reveals significant ecchymosis over the left lower chest wall and left upper quadrant of the abdomen. The abdomen is tender to palpation with involuntary guarding. The pelvis is mechanically stable to lateral and anteroposterior compression. Which of the following is the most appropriate next step in the management of this patient?

A 52-year-old man is evaluated on the surgical ward for a new-onset fever. He is currently on postoperative day 9 following an elective sigmoid colectomy for recurrent diverticulitis. His early postoperative course was complicated by a catheter-associated urinary tract infection diagnosed on postoperative day 2, for which his indwelling catheter was removed and he was started on intravenous piperacillin-tazobactam.

Currently, the patient reports feeling well and has been ambulating independently in the hallways. He has no abdominal pain, nausea, vomiting, dysuria, or shortness of breath. He is tolerating a regular diet.

Vital signs are as follows:

Physical examination reveals a soft, non-tender abdomen with a clean, well-approximated surgical incision. There is no calf tenderness or edema. Lungs are clear to auscultation bilaterally.

Laboratory results:

Urinalysis is clear with no leukocyte esterase or nitrites.

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

A 10-year-old girl is brought to the outpatient pediatric clinic by her parents due to persistent academic difficulties. She is currently in the fourth grade. Her teacher reports that she frequently loses her assignments, makes careless mistakes on tests, and seems to "space out" during reading and math lessons. These behaviors have been consistently noted since she was in the first grade. At home, her parents observe that she struggles to follow multi-step instructions and often leaves her chores half-finished. However, she can spend several hours intensely focused on painting and drawing without any distraction. Her recent hearing and vision screenings were normal. She has no history of behavioral outbursts or defiance. Which of the following statements regarding this patient's likely diagnosis and management are accurate? (Select all that apply)

A 29-year-old male is brought to the emergency department after being crushed between a concrete loading dock and a reversing forklift. On arrival, his airway is patent, and breath sounds are equal bilaterally. Vital signs show a blood pressure of 76/40 mm Hg and a heart rate of 142/min. Physical examination reveals a mechanically unstable pelvis in response to anteroposterior compression. Genitourinary examination demonstrates a scrotal hematoma and a prominent drop of blood at the urethral meatus. A commercial pelvic binder is immediately applied, and a massive transfusion protocol is initiated. Ten minutes later, after the rapid infusion of uncrossmatched packed red blood cells and fresh frozen plasma, his blood pressure remains 78/42 mm Hg. A Focused Assessment with Sonography for Trauma (FAST) examination demonstrates a large stripe of anechoic fluid in the hepatorenal and splenorenal recesses. Which of the following is the most appropriate next step in management?

Paramedics rush a 58-year-old male to the resuscitation bay after he experienced sudden, unbearable epigastric pain followed by a syncopal episode. His past medical history is notable for severe osteoarthritis managed with daily high-dose naproxen. On assessment, the patient is lethargic, diaphoretic, and lies completely motionless on the stretcher. Vital signs are significant for a heart rate of 122/min, blood pressure of 82/50 mmHg, and respiratory rate of 24/min. Abdominal examination reveals diffuse rigidity and exquisite rebound tenderness in all four quadrants. Following administration of 2 Liters of warmed isotonic crystalloid, his blood pressure remains 86/54 mmHg. An upright chest radiograph demonstrates a crescent-shaped radiolucency between the liver shadow and the right hemidiaphragm. Intravenous broad-spectrum antibiotics are initiated. What is the most appropriate next step in the care of this patient?

Paramedics rush a 68-year-old male to the trauma bay following an episode of massive hematemesis at his residence. His wife, who arrived separately, reports to the staff that he experienced a smaller episode of bloody vomiting yesterday but refused medical evaluation at that time. The electronic health record shows a history of hypertension, tobacco use disorder, and an open surgical repair of an infrarenal abdominal aortic aneurysm thirty-six months ago. Currently, the patient is lethargic, diaphoretic, and extremely pale. Vital signs include a temperature of $36.8^\circ \text{C}$ ($98.2^\circ \text{F}$), blood pressure of $70/40 \text{ mm Hg}$, heart rate of $142\text{/min}$, and respiratory rate of $28\text{/min}$. Physical examination reveals a well-healed midline abdominal scar. The abdomen is soft and non-distended without guarding or rebound tenderness. Bilateral femoral pulses are palpable but weak. Arterial blood gas analysis reveals a pH of $7.15$, $\text{pCO}_2$ of $30 \text{ mm Hg}$, and $\text{HCO}_3^-$ of $10 \text{ mEq/L}$. Despite the rapid administration of two units of uncrossmatched O-negative packed red blood cells through two large-bore intravenous lines, his blood pressure remains critically low at $74/42 \text{ mm Hg}$. Which of the following is the most appropriate next step in the management of this patient?

Following a kick to the left flank by a horse, a 45-year-old man arrives at the trauma center. He complains of severe left-sided abdominal pain that radiates to his left shoulder. Upon arrival, he appears in significant distress. Vital signs are temperature 36.8°C (98.2°F), blood pressure 105/65 mm Hg, pulse 112/min, and respirations 18/min. Oxygen saturation is 98% on room air. Two large-bore intravenous lines are established, and he is rapidly infused with 1 L of lactated Ringer solution. Following the fluid resuscitation, his blood pressure improves to 128/76 mm Hg and his pulse decreases to 88/min. Physical examination reveals ecchymosis over the left lower ribs and significant tenderness in the left upper quadrant with voluntary guarding. Breath sounds are clear and equal bilaterally. A bedside focused assessment with sonography for trauma (FAST) reveals a moderate amount of anechoic fluid in the splenorenal recess. Which of the following is the most appropriate next step in management?

A 52-year-old man is transported to the trauma center by helicopter after a high-speed head-on motor vehicle collision. On arrival, he is confused and diaphoretic. His blood pressure is 82/54 mm Hg, heart rate is 128/min, and respiratory rate is 22/min. Oxygen saturation is 97% on a nonrebreather mask. The airway is secure, and breath sounds are present and equal bilaterally. The abdomen is grossly distended and rigid to palpation. Pelvic compression does not elicit instability. Intravenous access is established, and rapid fluid resuscitation with warmed crystalloid is initiated. A focused assessment with sonography for trauma (FAST) examination reveals an anechoic stripe in the hepatorenal recess. Which of the following is the most appropriate next step in management?

A 28-year-old woman is brought to the psychiatry clinic by her husband. He reports that for the past month, she has been experiencing exceptionally low mood, sleeping up to 14 hours a day, eating very little, and expressing pervasive, inappropriate guilt. The husband notes that her psychiatric struggles began three years ago. Over the past three years, she has spent approximately thirty months experiencing either severe depression or acute mania. However, he specifically recalls a distinct four-week period last summer where her mood, energy, and sleep were completely normal, yet she firmly believed the television was broadcasting secret messages directed at her and frequently heard voices conversing about her actions. She takes no medications, and her urine toxicology screen is negative. Which of the following is the most likely diagnosis?

A number of patients present with unique adverse effects after initiating pharmacological treatment for major depressive disorder. For each clinical presentation, select the most likely responsible antidepressant.

A 29-year-old woman is evaluated in the post-anesthesia care unit (PACU) due to severe agitation and a rapidly rising temperature. She just underwent an emergency laparoscopic appendectomy for a perforated appendix. Her medical history is significant for major depressive disorder, for which she takes sertraline daily. Intraoperative medications included propofol, succinylcholine, desflurane, fentanyl, and ondansetron. Reversal of neuromuscular blockade was achieved with sugammadex. Her temperature is $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$), blood pressure is $168/96\text{ mmHg}$, pulse is $138/\text{min}$, and respiratory rate is $24/\text{min}$. On physical examination, she is diaphoretic, flushed, and disoriented. Neurologic examination reveals marked hyperreflexia in the bilateral lower extremities, spontaneous myoclonus, and inducible ocular clonus. Her muscle tone is increased, particularly in the lower extremities, but there is no "lead-pipe" rigidity. An arterial blood gas analysis shows a normal partial pressure of carbon dioxide ($PaCO_2$). Administration of a medication with which of the following mechanisms of action is the most appropriate targeted therapy for this patient's current condition?

A 7-year-old girl is evaluated in the pediatric clinic due to academic difficulties. She is currently in the second grade. Her teacher reports that she has significant trouble reading aloud, frequently mispronounces words, and performs poorly on weekly spelling tests. However, she excels in mathematics and enjoys group art projects. Her parents report that she was a "late talker" but caught up by age 4. She achieved all motor milestones on time and is fully independent with dressing and feeding. She has several close friends at school and enjoys playing collaboratively. Audiology and optometry evaluations performed last week were entirely normal. Which of the following is the most appropriate next step in the management of this patient?

Correlate the following classic clinical findings in blunt trauma patients with their most likely associated underlying injury.

A 78-year-old woman is evaluated in the emergency department for a 3-day history of progressively worsening abdominal distension, nausea, and vomiting of brown, foul-smelling fluid. She has not had a bowel movement or passed flatus for 48 hours. Her medical history includes hypertension, diet-controlled type 2 diabetes mellitus, and multiple episodes of right upper quadrant pain after meals over the past year. Her temperature is 37.8°C (100.0°F), blood pressure is 105/65 mmHg, pulse is 112/min, and respirations are 20/min. Physical examination shows a significantly distended, tympanitic abdomen with high-pitched, tinkling bowel sounds. There is diffuse tenderness to palpation but no guarding or rebound tenderness.

A non-contrast computed tomography scan of the abdomen demonstrates dilated small bowel loops up to the distal ileum, air in the biliary tree, and a 3.5-cm radiopaque structure in the right lower quadrant. Which of the following is the most appropriate next step in management?