Tüm alıştırma soruları

A 26-year-old female software engineer is evaluated in the outpatient clinic for an 8-month history of excessive, uncontrollable worry. She reports being constantly anxious about her job performance, personal finances, and the health of her parents. This worry is accompanied by severe muscle tension, easily fatiguing, and difficulty falling asleep. During the psychiatric review of systems, the patient mentions that two years ago she experienced a distinct one-week period where she felt "on top of the world," slept only two hours a night without feeling tired, talked more rapidly than usual, and accumulated significant debt from impulsive online shopping. She currently takes no medications other than an oral contraceptive pill. Vital signs are within normal limits. Physical examination reveals mild trapezius muscle tenderness but is otherwise unremarkable. Which of the following statements regarding the evaluation and management of this patient are correct? (Select all that apply)

A 64-year-old man is evaluated on the surgical ward due to a change in his clinical status. He was admitted 24 hours ago for a small bowel obstruction secondary to adhesions from a prior open sigmoidectomy. On admission, he reported intermittent, crampy abdominal pain. He was placed on nil per os (NPO) status, and treatment with intravenous fluid resuscitation and nasogastric tube decompression was initiated. Over the past 4 hours, the patient reports that his abdominal pain has worsened, becoming severe and continuous rather than colicky. His temperature is 38.6°C (101.5°F), blood pressure is 105/65 mm Hg, and pulse is 118/min. Physical examination reveals a distended abdomen with focal rigidity, guarding, and marked rebound tenderness in the periumbilical region. Bowel sounds are absent. Laboratory studies show a leukocyte count of $17,500/mm^3$ with 15% bands, and a serum lactate level of $4.2 \text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient?

During bedside rounds in the surgical intensive care unit, a 68-year-old female patient suddenly develops severe shortness of breath and lightheadedness. Her surgical history is significant for a frontotemporal craniotomy performed three days ago to resect a large meningioma. Current vital signs show a temperature of 37.2°C, blood pressure of 76/44 mmHg, pulse of 132/min, and respirations of 28/min. Oxygen saturation is 85% on room air. Physical examination reveals clear lung fields bilaterally and an elevated jugular venous pressure. A stat electrocardiogram demonstrates sinus tachycardia with new-onset T-wave inversions in leads $V_1-V_4$. Arrange the following management steps in the most appropriate chronological order.

A 34-year-old man is newly diagnosed with severe major depressive disorder without psychotic features. Over the course of 18 months, his symptoms prove to be highly refractory to standard treatments despite confirmed medication adherence. Arrange the following clinical management steps in the most appropriate chronological sequence, reflecting the standard escalating algorithm for treatment-resistant depression.

A 34-year-old man presents to a new primary care physician complaining of severe fatigue, sleeping 12 to 14 hours a day, significant weight gain, and an inability to experience pleasure in his usual hobbies for the past two months. He states that his depressive symptoms are significantly impairing his daily functioning and requests a specific prescription for an antidepressant. Upon detailed psychiatric review, he mentions that four years ago, he experienced a one-month period where he abruptly quit his job, maxed out several credit cards to start a speculative business venture, and felt "like a superhuman" despite resting for only an hour each night. He was involuntarily hospitalized during that period due to aggressive behavior but subsequently declined long-term medication. He has no other medical conditions and his physical examination is unremarkable. Which of the following is the most appropriate pharmacological therapy for this patient's current symptoms?

A 31-year-old woman is evaluated in the emergency department after a paragliding collision with a mountain ridge. Upon arrival, she is lethargic and diaphoretic. Her temperature is 36.4°C (97.5°F), blood pressure is 78/42 mm Hg, pulse is 134/min, and respiratory rate is 24/min. Oxygen saturation is 96% on 15 L/min via non-rebreather mask. The airway is unobstructed, and breath sounds are clear and symmetric bilaterally. There is no active external bleeding. Physical examination reveals a large ecchymosis over the left flank. The abdomen is markedly distended, rigid, and diffusely tender with guarding. A focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal space (Morison pouch) and splenorenal recess. Intravenous access is rapidly secured and fluid resuscitation is initiated. Which of the following is the most appropriate next step in the management of this patient?

A 25-year-old man is brought to the psychiatry clinic by his brother. The brother reports that for the past 3 months, the patient has been barricading himself in his apartment because he believes federal agents are monitoring his thoughts. During the interview, the patient maintains poor eye contact, speaks with a flat affect, and occasionally turns his head to whisper to seemingly empty space, stating that he is answering "the voices." The brother notes that the patient was functioning well and working as a software engineer until 3 months ago when these symptoms abruptly began. The patient has had no periods of depressed mood, increased energy, or decreased need for sleep. Medical workup and urine toxicology screening are unremarkable. Which of the following is the most likely diagnosis?

A 13-year-old boy is brought to the pediatric orthopedic clinic by his parents due to a two-month history of a persistent left-sided limp and intermittent, dull pain in his left knee. The pain is worse after walking long distances and improves with rest. He denies any history of trauma, recent illnesses, fevers, or night sweats. He is at the 95th percentile for weight and 60th percentile for height. Vital signs are within normal limits.

On physical examination, the patient has an antalgic gait. Inspection of the left knee reveals no swelling, erythema, or deformity. Palpation of the left knee and thigh elicits no tenderness, and knee range of motion is full and painless. However, when the examiner passively flexes the patient's left hip to 90 degrees, the thigh obligatorily rotates outward. Internal rotation of the left hip is limited compared to the right and elicits mild discomfort. Distal pulses are 2+ bilaterally, and sensation is intact throughout both lower extremities.

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

A $13$-year-old boy is brought to the pediatric clinic by his mother due to a $4$-week history of a right-sided limp and intermittent dull pain in his right anterior thigh and knee. He denies any recent trauma, fever, or prior episodes of similar pain. His medical history is unremarkable. His height is at the $50^{\text{th}}$ percentile and weight is at the $97^{\text{th}}$ percentile for his age. Vital signs are within normal limits. Physical examination reveals a waddling, antalgic gait. The right knee examination shows no effusions, joint line tenderness, or ligamentous laxity. On examination of the right hip, internal rotation is significantly restricted compared to the left. When the clinician passively flexes the right hip to $90^\circ$, the right thigh obligatorily rotates externally. Radiographs of the pelvis demonstrate posterior and inferior displacement of the right proximal femoral epiphysis. Which of the following is the most appropriate next step in the management of this patient?

A 38-year-old male is brought to the emergency department after a high-speed collision in which his snowmobile struck a tree. Upon arrival, he is in severe respiratory distress. Vital signs are blood pressure 80/50 mm Hg, heart rate 138/min, and respiratory rate 32/min. Oxygen saturation is 86% on a non-rebreather mask. Physical examination reveals absent breath sounds over the left hemithorax and dullness to percussion. The trachea is deviated to the right. The abdomen is noticeably scaphoid and diffusely tender to palpation. A needle thoracostomy is immediately performed in the left second intercostal space, yielding a small rush of air but no significant clinical improvement. A subsequent tube thoracostomy in the left fifth intercostal space returns 200 mL of dark blood mixed with particulate matter resembling partially digested food. Which of the following is the most appropriate next step in management?

Emergency medical services bring a $28$-year-old male to the trauma bay following a high-speed motorcycle collision. He was found unresponsive at the scene. Currently, the patient is obtunded but his airway remains patent with equal bilateral breath sounds. Initial vital signs include a blood pressure of $70/40\text{ mmHg}$ and a heart rate of $142\text{ beats/min}$. Abdominal examination shows severe distension and a rigid contour with prominent ecchymosis over the lower quadrants. A bedside focused assessment with sonography for trauma (FAST) reveals a large volume of anechoic fluid in the hepatorenal recess and pelvis. Peripheral intravenous access is secured and crystalloid fluid administration is started. Which of the following is the most appropriate next step in management?

A 72-year-old man is brought to the emergency department from a skilled nursing facility due to severe abdominal pain and intractable vomiting over the past $24\text{ hours}$. The accompanying documentation notes he has not had a bowel movement or passed flatus since yesterday. His medical history is significant for hypertension and benign prostatic hyperplasia. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), pulse is $118/\text{min}$, and blood pressure is $96/58\text{ mmHg}$. Physical examination reveals a significantly distended and tympanic abdomen. Examination of the groin shows a $5\text{-cm}$, tense, erythematous bulge in the right inguinal region that is exquisitely tender to palpation. Attempts to gently reduce the mass are unsuccessful. Laboratory studies show a leukocyte count of $17,500/\text{mm}^3$ and a serum lactate level of $4.1\text{ mmol/L}$ (normal: $0.5-2.2\text{ mmol/L}$). Which of the following is the most appropriate next step in management?

A 56-year-old man is brought to the emergency department after a high-speed motor vehicle collision. He was the restrained driver in a head-on impact with a concrete pillar. His airway is secure, and breath sounds are equal bilaterally. Vital signs show a heart rate of 118/min and a blood pressure of 165/92 mmHg. He is alert but complains of severe interscapular back pain. Secondary survey reveals a seatbelt sign across the chest. A portable anteroposterior chest radiograph obtained in the trauma bay demonstrates a widened mediastinum and loss of the aortic knob contour. The patient remains hemodynamically stable. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for the optimal management of this patient.

A 35-year-old man is brought to the emergency department after a structural fire. He weighs $80 \text{ kg}$. The burn injury occurred exactly 2 hours prior to his arrival at the emergency department. Physical examination reveals deep partial-thickness and full-thickness burns involving the entire anterior surface of his torso, his entire right arm, and the entire anterior surface of his right leg. No other burn injuries are identified. Using the traditional Parkland formula ($4 \text{ mL/kg}$ per percentage of total body surface area), what should be the target intravenous fluid administration rate (in $\text{mL/hr}$) for this patient for the remainder of the first 8-hour post-injury period?

A 33-year-old female paramedic presents to the occupational health clinic reporting severe insomnia, emotional numbness, and being constantly "on edge" for the past 6 months. She states her symptoms began after she responded to a mass casualty incident. She reports recurrent, distressing nightmares about the scene and goes out of her way to avoid driving near the location of the incident. Her medical history includes bipolar II disorder, for which she stopped taking medication three years ago, and a recent skin infection for which she is currently taking linezolid. Laboratory results show a TSH of 1.5 mU/L (Normal: 0.4-4.0) and a free T4 of 0.6 ng/dL (Normal: 0.8-1.8). She requests medication to help her sleep and improve her mood. Her father, who drove her to the clinic, approaches the physician in the hallway and asks for an update on her condition because he is worried about her recent anger outbursts. Which of the following is the most appropriate next step in management?

A 72-year-old man is evaluated in the emergency department for severe, sudden-onset abdominal pain that began $4$ hours ago. His medical history is significant for a large anterior wall myocardial infarction $4$ weeks ago, hypertension, and hyperlipidemia. He has not adhered to his prescribed medication regimen since discharge. The patient was initially writhing in agony, but over the past hour, he has become progressively lethargic. His temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), pulse is $135/\text{min}$ and irregularly irregular, blood pressure is $78/50\text{ mmHg}$, and respirations are $28/\text{min}$. Physical examination reveals a mottled appearance of the lower extremities. The abdomen is moderately distended and diffusely rigid, with marked involuntary guarding and rebound tenderness in all four quadrants. Bowel sounds are absent. Laboratory studies show:

Leukocyte count: $26,000/\text{mm}^3$
Hemoglobin: $14.2\text{ g/dL}$
Bicarbonate: $12\text{ mEq/L}$
Lactate: $7.8\text{ mmol/L}$

An electrocardiogram shows atrial fibrillation with a rapid ventricular response and deep Q waves in the anterior leads. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation and physical examination findings to the underlying surgical pathology or pathophysiologic mechanism that best explains their condition.

During a routine health maintenance visit, the parents of a 24-month-old boy express deep concern that their son might have a neurodevelopmental disorder. They report reading online that toddlers should speak in complete sentences by age 2 and are worried because he only uses two-word phrases, such as "want juice" or "go out". His current vocabulary consists of approximately 60 words. The parents also mention that he occasionally has temper tantrums when transitioning from playtime to bedtime, during which he cries and drops to the floor. These episodes typically resolve within five minutes after redirection. On examination, the child makes appropriate eye contact, points to pictures in a book when named, and engages in pretend play with a toy telephone. He can run, kick a ball, and build a tower of six blocks. Which of the following is the most appropriate next step in management?

A 47-year-old man is evaluated in the emergency department for altered mental status, fever, and severe agitation that started a few hours ago. His wife reports that he had been recovering from a minor ankle sprain sustained over the weekend. His medical history is significant for treatment-resistant major depressive disorder, for which he has been taking tranylcypromine for the past two years. His temperature is 39.4°C (102.9°F), blood pressure is 168/105 mm Hg, and pulse is 128/min. On physical examination, the patient is visibly diaphoretic. Neurological examination reveals spontaneous clonus in the lower extremities and horizontal ocular clonus. He recently started taking a new medication prescribed for his ankle sprain. Which of the following medications was most likely prescribed?

A 31-year-old accountant visits the family medicine clinic accompanied by his partner. He reports a 5-week history of profound sadness, decreased energy, and difficulty concentrating. He states that he sleeps up to 14 hours a day and has gained 6 kg (13 lbs) over the past month. He describes a persistent sensation that his arms and legs are "weighed down by lead." His partner notes that his mood occasionally brightens for a few hours when they go out to his favorite restaurant, but he quickly reverts to feeling depressed. He has missed several days of work. He has no significant past medical history. Family history is notable for a mother who was hospitalized multiple times for erratic behavior and severe mood swings. Physical examination and basic laboratory studies, including thyroid function tests, are within normal limits. The physician determines that the patient is experiencing a major depressive episode. Which of the following is the most critical next step in management prior to initiating pharmacotherapy?