Tüm alıştırma soruları

An 81-year-old man who resides in an assisted living facility is brought to the emergency department after 3 days of progressive abdominal swelling, obstipation, and bilious emesis. He has a medical history of severe Parkinson disease, hypertension, and chronic constipation. On arrival, his temperature is 38.8°C (101.8°F), blood pressure is 82/50 mmHg, pulse is 128/min, and respirations are 24/min. Physical examination reveals a markedly distended, tympanitic abdomen with diffuse rebound tenderness and involuntary guarding. Laboratory evaluation demonstrates a leukocyte count of 21,000/mm³ and a serum lactate level of 6.1 mmol/L. Following initial intravenous fluid resuscitation, a portable abdominal radiograph is acquired, demonstrating a massive, dilated, inverted U-shaped colonic loop arising from the pelvis and projecting toward the right upper quadrant. There is no pneumoperitoneum visible. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old man is brought to the emergency department with altered mental status, severe agitation, and tremors. He recently started taking linezolid for a methicillin-resistant Staphylococcus aureus skin infection while maintaining his usual daily dose of sertraline. Vital signs are temperature 39.8°C (103.6°F), pulse 132/min, respirations 22/min, and blood pressure 165/95 mm Hg. Physical examination reveals marked diaphoresis, mydriasis, hyperreflexia, and spontaneous ankle clonus. Arrange the following management steps in the correct sequential order for this patient, from the immediate initial action to interventions reserved for progressive or severe refractory symptoms.

Match each clinical presentation of an acute abdomen to its most appropriate initial management or definitive surgical intervention.

A 28-year-old carpenter is brought to the emergency department after accidentally severing his left index finger with an electric table saw 30 minutes ago. His blood pressure is 135/85 mmHg, heart rate is 98/min, and respiratory rate is 16/min. On physical examination, the patient is alert and cooperative. The proximal stump of the left index finger is cleanly amputated at the level of the proximal phalanx. Bleeding is effectively controlled with a sterile compressive dressing. The amputated digit has been brought to the hospital by his coworkers, currently resting on a dry, dirty cloth. Arrange the following steps in the most appropriate chronological order for the optimal preservation and transport of the amputated digit to a microsurgical replantation center.

Match each patient's clinical presentation of an acute surgical abdomen with the most appropriate next step in management.

A 34-year-old plumber weighing 80 kg is brought to the emergency department 30 minutes after a commercial water heater exploded at a job site. He is awake and in significant pain. Vital signs show a heart rate of 110/min, blood pressure of 130/85 mm Hg, and respiratory rate of 20/min. Physical examination reveals second- and third-degree thermal burns involving his entire anterior trunk, his entire right arm, and the anterior surface of his right leg. There is no facial involvement or singed nasal hairs. The remainder of his skin is unaffected. Using the Rule of Nines for adults, what is the estimated total body surface area (TBSA) percentage affected by these burns?

An industrial worker is rushed to the trauma bay after a forklift accident caused a direct crush injury to his left shin. The primary trauma survey is completed, and his airway, breathing, and circulation are stable. The secondary survey reveals an obvious gross deformity of the left tibia with a 5-centimeter anterior laceration. Fractured bone segments are protruding through the skin, and the wound is heavily contaminated with grease and debris. Arrange the following acute management steps for this patient's extremity injury in the most appropriate chronological sequence, from first to last.

A 28-year-old unrestrained driver is extricated from a crushed vehicle after a prolonged entrapment. On arrival at the trauma center, his systolic blood pressure is 65 mm Hg, heart rate is 142/min, and core temperature is 34.0°C (93.2°F). Focused assessment with sonography in trauma (FAST) demonstrates massive intraperitoneal free fluid. Initial arterial blood gas analysis reveals a pH of 7.12, and coagulation studies show an international normalized ratio (INR) of 1.9. Arrange the following management steps in the most appropriate chronological sequence according to established damage control principles for this patient.

Match each patient's core clinical presentation to the most accurate definitive DSM-5 diagnosis.

Match each clinical presentation following the initiation of antipsychotic therapy (left) with the underlying receptor mechanism or affected neuroanatomical pathway (right).

During a weekend visit with her family, a 62-year-old woman experiences progressively worsening shortness of breath and a 'racing heart' over a 48-hour period. She is evaluated in the acute care clinic, where she frantically states, 'I feel like I am having a severe panic attack; I just cannot catch my breath.' The patient's medical history includes chronic obstructive pulmonary disease (COPD), bipolar disorder (for which she currently takes no medications), and hypothyroidism (managed with levothyroxine). Her most recent echocardiogram from three months prior showed normal left ventricular systolic function with an ejection fraction of $60\%$.

Vital signs are temperature $37.2^{\circ}\text{C}$ ($99.0^{\circ}\text{F}$), blood pressure $136/84 \text{ mmHg}$, pulse $152\text{/min}$, and respirations $26\text{/min}$. Pulse oximetry shows $91\%$ on room air.

Physical examination reveals an irregularly irregular pulse. Lung auscultation demonstrates bilateral basilar crackles and diffuse expiratory wheezes. Trace bilateral lower extremity edema is present.

An electrocardiogram (ECG) reveals an irregularly irregular rhythm with absent P waves, narrow QRS complexes, and a ventricular rate of $152\text{/min}$.

Laboratory testing shows:
- Brain natriuretic peptide (BNP): $720 \text{ pg/mL}$ (Normal: $<100 \text{ pg/mL}$)
- Thyroid-stimulating hormone (TSH): $0.2 \mu\text{U/mL}$ (Normal: $0.4-4.0 \mu\text{U/mL}$)
- Free $T_4$: $0.7 \text{ ng/dL}$ (Normal: $0.8-1.8 \text{ ng/dL}$)

Arterial blood gas on room air reveals:
- $pH = 7.52$
- $pCO_2 = 26 \text{ mmHg}$
- $pO_2 = 62 \text{ mmHg}$
- $HCO_3^- = 20 \text{ mEq/L}$

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

A 29-year-old male utility worker is brought to the emergency department after sustaining a high-voltage electrical injury while working on a power line. The injury occurred exactly 3 hours ago. On presentation, he has full-thickness burns involving his entire anterior trunk, entire right arm, entire left arm, and the anterior surface of his right leg. The remainder of his skin is uninjured. He weighs 90 kg. During transport, emergency medical services established intravenous access and administered 1,100 mL of lactated Ringer solution. According to the Advanced Trauma Life Support (ATLS) guidelines for electrical burns, what should be the intravenous fluid infusion rate (in mL/hr) for the remainder of the first 8-hour resuscitation period?

Evaluate the following distinct patient scenarios and pair each clinical description with the most accurate psychiatric diagnosis.

A physician is called to review a patient who has suddenly become short of breath. The patient is a 73-year-old retired teacher who underwent an open radical cystectomy and formation of an ileal conduit three days ago for urothelial carcinoma. His past medical records indicate a long history of tobacco use with associated chronic bronchitis, as well as a prior myocardial infarction. During the surgery, he received substantial crystalloid resuscitation due to significant blood loss. Current vital signs include a temperature of 38.5°C (101.3°F), a heart rate of 122/min, a blood pressure of 158/92 mm Hg, and a respiratory rate of 28 breaths per minute. Pulse oximetry indicates an oxygen saturation of 87% on room air. Clinical examination highlights elevated neck veins and a positive hepatojugular reflux. Lung auscultation demonstrates bilateral expiratory wheezes and dependent fine crackles. The surgical incision shows no signs of erythema or discharge, and the ostomy is viable with clear urine output. Which of the following is the most appropriate next step in the management of this patient?

Match each psychotropic medication used during pregnancy with its most characteristic associated fetal or neonatal adverse effect.

A 23-year-old female college student presents to the university health center complaining of intense sadness, exhaustion, and an inability to enjoy her usual activities over the last 96 hours. Upon further questioning, she admits to participating in a three-day period of continuous cocaine consumption to celebrate the end of her final exams. Her drug use ceased four days prior to this visit. Since that time, she notes that she sleeps approximately 15 hours daily, has an insatiable appetite, and experiences disturbing nightmares. She has no previous history of mental health disorders. Her vital signs are within normal limits, and physical evaluation shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?

Twelve days ago, a 72-year-old man underwent an emergency exploratory laparotomy with bowel resection for acute mesenteric ischemia. He remains in the intensive care unit on mechanical ventilation and receives total parenteral nutrition. Over the past 24 hours, his body temperature has increased to $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$). His blood pressure is $92/62\text{ mmHg}$ and his pulse is $116/\text{min}$. The abdominal incision is clean and intact. Physical examination reveals localized guarding in the right upper abdominal quadrant when palpated. Laboratory results demonstrate a leukocyte count of $19,500/\text{mm}^3$, total bilirubin of $2.9\text{ mg/dL}$, and alkaline phosphatase of $350\text{ U/L}$. A bedside abdominal ultrasound shows a gallbladder wall thickness of $6\text{ mm}$, pericholecystic fluid, and no visible gallstones or biliary ductal dilation. Which of the following is the most appropriate next step in management?

A 42-year-old male construction worker is evaluated in the trauma center after a 15-foot fall from scaffolding. On arrival, his blood pressure is $75/40 \text{ mmHg}$ and heart rate is $132 \text{ /min}$. His airway is patent, and breath sounds are present and equal bilaterally. A chest radiograph shows no abnormalities. The abdomen is soft and non-distended without guarding or rigidity. A focused assessment with sonography for trauma (FAST) reveals no free intraperitoneal or pericardial fluid. Gentle compression of the iliac crests reveals mechanical instability and crepitus. Which of the following is the most appropriate next step in management?

A 28-year-old man is brought to the emergency department by paramedics after a high-speed motorcycle collision. On arrival, he is in severe respiratory distress and appears pale and diaphoretic. Vital signs are temperature 36.5°C (97.7°F), blood pressure 75/40 mm Hg, pulse 138/min, and respirations 32/min. Physical examination reveals rightward tracheal deviation. The left hemithorax is dull to percussion with absent breath sounds. Intravenous access is established, and a bolus of warmed crystalloid is initiated. A tube thoracostomy is placed in the left fifth intercostal space, which immediately returns 1,600 mL of bright red blood. Over the next 5 minutes, an additional 250 mL of blood drains into the collection unit. A repeat blood pressure is 68/35 mm Hg. Which of the following is the most appropriate next step in management?

A 22-year-old woman is brought to the emergency department by paramedics after falling from a horse. The horse reportedly stepped directly on her mid-abdomen. She is groaning in pain and appears confused. Her temperature is 36.5°C (97.7°F), heart rate is 134/min, blood pressure is 82/50 mm Hg, and respiratory rate is 24/min. Pulse oximetry is 97% on room air. The patient is lethargic but is actively protecting her airway. Breath sounds are clear and equal bilaterally. The abdomen is visibly distended, tense, and diffusely tender to palpation with guarding. The pelvis is stable to gentle compression. Two large-bore intravenous lines are established, and a 1-liter bolus of warm crystalloid is rapidly administered. Reassessment reveals a heart rate of 128/min and a blood pressure of 84/52 mm Hg. Which of the following is the most appropriate next step in management?