Tüm alıştırma soruları

A 48-year-old woman is admitted to the medical ward for the management of a partial small bowel obstruction. She initially presented with diffuse, colicky abdominal pain and bilious vomiting. Her surgical history is notable for a total abdominal hysterectomy 5 years ago. Upon admission, she was hemodynamically stable and managed with intravenous fluid resuscitation and nasogastric tube decompression.

Fourteen hours later, the nursing staff requests an urgent physician evaluation because the patient reports a sudden, drastic worsening of her abdominal pain, which has become severe and unremitting.

Vital signs are now:
Temperature: 38.8°C (101.8°F)
Pulse: 124/min
Blood pressure: 86/54 mm Hg

Physical examination reveals a markedly distended abdomen that is rigidly firm. There is severe, diffuse rebound tenderness and involuntary guarding present. Laboratory testing reveals a leukocyte count of 21,000/mm³ and a serum lactate of 4.8 mmol/L.

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

A 4-year-old boy is brought to the pediatric clinic by his foster parents due to behavioral challenges at his preschool. His teacher notes that he frequently wanders the room during group storytime, flaps his hands repeatedly when excited, and avoids interacting with peers. At home, he meticulously sorts his blocks by shape and becomes inconsolable if the arrangement is disrupted. His foster parents report that he uses only two-word phrases to express his needs and rarely makes eye contact. On physical examination, the child successfully hops on one foot and copies a cross on a piece of paper. Which of the following statements regarding this patient are correct? (Select all that apply)

An emergency response team delivers a 69-year-old male to the trauma center following a syncopal episode at his residence. The patient's spouse reports that he complained of sudden, agonizing pain in his left flank radiating to his groin moments before collapsing. His medical records indicate a history of coronary artery disease and a 40-pack-year smoking history. On evaluation, he is lethargic, and his skin is cool, clammy, and mottled. His blood pressure is currently 74/42 mm Hg, heart rate is 128/min, and respiratory rate is 24/min. Palpation of the abdomen reveals a tender, prominently pulsatile central mass. Peripheral pulses in the lower extremities are diminished bilaterally. Two large-bore intravenous lines are placed. Which of the following is the most appropriate next step in the management of this patient?

A 31-year-old man is brought to the trauma center by helicopter after falling approximately 10 meters (33 feet) from a construction scaffold. His airway was secured by paramedics at the scene with an endotracheal tube. Large-bore intravenous access is established, and a massive transfusion protocol is initiated. Current vital signs are temperature 35.6°C (96.1°F), blood pressure 72/40 mm Hg, and heart rate 148/min. Breath sounds are equal bilaterally. The patient does not open his eyes or move his extremities to painful stimuli. His right pupil is 7 mm and nonreactive to light, while his left pupil is 3 mm and reactive. The abdomen is visibly distended and tense. Bedside sonography for trauma demonstrates a large volume of anechoic fluid in the hepatorenal and perisplenic spaces. Which of the following is the most appropriate next step in the management of this patient?

A 29-year-old man presents to a community health center to establish primary care. He currently resides in a supported housing facility. During the clinical interview, the patient displays diminished emotional expression and speaks in a monotonous voice. When asked about his employment history, he states that he cannot hold a job because "foreign agents are constantly broadcasting their plans into my head." He reports that these experiences began shortly after his 22nd birthday and have been continuously present since that time. Upon detailed psychiatric history-taking, the patient mentions that three years ago, he felt profoundly sad, lacked energy, and slept for most of the day for a three-week period. He experienced a similar two-week episode of low mood last year. He has not experienced any other mood changes or periods of elevated energy. Physical examination, routine laboratory studies, and a urine toxicology screen are within normal limits. Based on the patient's history and presentation, which of the following is the most likely diagnosis?

A 24-year-old medical student is diagnosed with a first episode of major depressive disorder. After ruling out any history of mania or hypomania, the physician prescribes a selective serotonin reuptake inhibitor (SSRI). The physician provides comprehensive anticipatory guidance regarding the expected treatment timeline. Arrange the following clinical events in the standard chronological order of their expected occurrence during a successful, uncomplicated course of SSRI therapy.

A 32-year-old man is brought to the emergency department via ambulance after being rescued from a house fire. He weighs 100 kg. The fire started at 13:00, and he was extricated shortly after. He arrives at the emergency department at 16:00. Physical examination reveals deep partial-thickness and full-thickness thermal burns involving his entire back, entire right arm, entire left arm, and the anterior surface of his right leg. During transport, emergency medical services administered 900 mL of intravenous Lactated Ringer's solution. Vital signs are blood pressure 110/70 mmHg, heart rate 115/min, and respiratory rate 22/min. Assuming adherence to the most current Advanced Trauma Life Support (ATLS) recommendations for adult thermal burn fluid resuscitation ($2 \text{ mL} \times \text{weight in kg} \times \%\text{TBSA}$), what should be the intravenous fluid infusion rate (in mL/hr) programmed on the pump for the remainder of the first 8-hour resuscitation window?

A 78-year-old man develops progressive abdominal distention over the past 48 hours. He is currently on postoperative day 4 following a right total knee arthroplasty. His medical history is significant for hypertension and osteoarthritis. Current medications include patient-controlled intravenous morphine. Vital signs are within normal limits. Physical examination reveals a massively distended, tympanitic abdomen with mild diffuse tenderness but no guarding or rebound. Bowel sounds are hypoactive. An upright abdominal radiograph demonstrates diffuse colonic dilation with a cecal diameter of 11.5 cm and no air-fluid levels or free air. The patient is diagnosed with acute colonic pseudo-obstruction (Ogilvie syndrome). Assuming the patient's condition does not resolve with each successive intervention and he remains hemodynamically stable without signs of perforation, arrange the following management options in the correct sequential order from initial step to most definitive last-resort therapy.

An epidemiologic screening program adopts a point-of-care serologic test for a chronic viral infection. The assay operates with a fixed sensitivity of 90% and specificity of 95%. During the first phase, it is utilized exclusively within an urban syringe services program where the target infection is highly prevalent. Six months later, the identical assay is implemented at a suburban university student health center where the infection is exceedingly rare. Which of the following best describes how the predictive values of the test at the university health center will differ from those at the syringe services program?

Match each acute gastrointestinal surgical condition with its most characteristic initial imaging finding.

Following a left total knee arthroplasty $48$ hours ago, a $75$-year-old man develops progressively worsening shortness of breath. His medical history includes severe chronic obstructive pulmonary disease, hypertension, and a myocardial infarction $4$ years prior. During the intraoperative and immediate postoperative periods, he received a total of $3.5$ L of intravenous crystalloid solution. Vital signs reveal a temperature of $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), a blood pressure of $162/94$ mm Hg, a pulse of $114$/min, and a respiratory rate of $26$/min. Pulse oximetry demonstrates an oxygen saturation of $88\%$ on room air. Physical examination shows visible engorgement of the jugular veins while sitting at a $45^\circ$ angle. Lung auscultation is notable for bilateral crackles in the lower and middle lung fields, along with scattered expiratory wheezes. He is coughing up pink-tinged, frothy sputum. The surgical site appears clean and intact without any signs of infection. Which of the following is the most appropriate initial step in management?

A 38-year-old man is brought to the emergency department by his husband due to a sudden, severe, pounding headache, blurred vision, and chest palpitations. The symptoms began approximately 45 minutes ago. The patient has a history of severe, treatment-resistant major depressive disorder. He recently started a new psychiatric medication after trials of several selective serotonin reuptake inhibitors and a serotonin-norepinephrine reuptake inhibitor failed to improve his mood. Earlier this evening, he attended a holiday party where he consumed multiple glasses of tap beer, aged cheddar cheese, and cured sausages. His temperature is 37.2°C (99.0°F), blood pressure is 218/124 mm Hg, pulse is 122/min, and respirations are 18/min. Physical examination reveals a diaphoretic and tremulous man. Neurological examination shows no focal deficits, and an unenhanced head CT scan reveals no abnormalities. Which of the following medications is this patient most likely taking?

Match each clinical presentation of inflammatory bowel disease with the most appropriate definitive or initial surgical intervention.

A regional department of public health identifies an unusual cluster of 15 patients diagnosed with an atypical fungal pneumonia over a two-month period. Given the unexpected nature of this outbreak and the large geographic area involved, investigators decide to recruit these 15 patients and compare them to 45 healthy individuals matched by age and zip code. Both groups are then interviewed extensively about their recent travel history, occupational hazards, and recreational activities over the past year.

Based on the methodology described, which of the following statements are accurate regarding this investigation? (Select all that apply)

A 34-year-old man with treatment-resistant schizophrenia is brought to the emergency department by his partner after experiencing a generalized tonic-clonic seizure lasting approximately 2 minutes. He has no prior history of seizures. His psychotic symptoms have been well controlled on a stable regimen of clozapine 400 mg daily for the past 3 years. Four weeks ago, the patient suffered an uncomplicated myocardial infarction and was discharged on aspirin and atorvastatin. At that time, the patient successfully quit smoking cold turkey after previously smoking 2 packs of cigarettes daily for 15 years. He reports no illicit drug or alcohol use. His temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, pulse is 88/min, and respirations are 16/min. Physical examination reveals a postictal state but is otherwise unremarkable. Laboratory studies show an absolute neutrophil count of $5,200/mm^3$ and normal liver function tests. Which of the following is the most likely mechanism responsible for this patient's new-onset seizure?

Match each patient's clinical presentation to the underlying surgical pathology or pathophysiologic mechanism that best explains their symptoms.

A $32$-year-old man is brought to the trauma bay via ambulance after being ejected from a vehicle during a high-speed rollover collision. On arrival, he is unresponsive. Vital signs show a blood pressure of $75/40$ mm Hg, a heart rate of $142$/min, and a respiratory rate of $6$/min with shallow, gurgling respirations. Paramedics report a large, deep laceration on his left mid-thigh that is actively spurting bright red blood. According to standard trauma resuscitation protocols, arrange the following initial management steps in the correct chronological order.

A regional health authority implements a pilot program to evaluate a strategy for reducing hospital readmission rates among patients with heart failure. Fifty community hospitals are randomized to either utilize a novel telehealth monitoring system or continue with standard discharge protocols. After $12$ months, the data shows a $15\%$ reduction in readmissions in the telehealth group compared to the standard care group. However, the $95\%$ confidence interval (CI) for the relative risk is $0.72$ to $1.05$. Based on these results, the investigators conclude that the telehealth system does not significantly affect readmission rates. Three years later, a comprehensive national registry study involving over $500$ hospitals definitively confirms that the telehealth system genuinely reduces readmission rates by $14\%$. Which of the following best explains why the initial pilot program failed to demonstrate a statistically significant benefit?

A regional health task force is reviewing the performance characteristics of various diagnostic tests and screening protocols used within their clinical network. They are specifically analyzing how modifying test parameters or changing the target population affects test metrics. Match each clinical or administrative adjustment on the left with its corresponding expected impact on the test's performance characteristics on the right.

Match each trauma patient presentation with the most appropriate next step in acute management according to Advanced Trauma Life Support (ATLS) principles.