Tüm alıştırma soruları

Emergency medical services bring a 58-year-old woman to the hospital after she experienced a sudden onset of severe lower abdominal pain and a sensation of a "bulge" in her vagina. The symptoms began abruptly one hour ago while she was straining to pass stool. Four weeks prior to presentation, she underwent a total laparoscopic hysterectomy for recurrent, heavy uterine bleeding. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, pulse is 102/min, and respirations are 18/min. On physical examination, the lower abdomen is tender to palpation. Pelvic examination demonstrates a separation at the vaginal apex. A hyperemic segment of small bowel is visible protruding through the defect into the vaginal canal. Which of the following is the most appropriate next step in the management of this patient?

An assessment is requested for a patient recovering in the surgical unit. The patient is a 58-year-old female who underwent an open abdominal hysterectomy six days ago for symptomatic uterine leiomyomas. Over the past 12 hours, she has developed new-onset chills and worsening pain at her incision site. Her medical history includes diet-controlled type 2 diabetes mellitus and heart failure with preserved ejection fraction. Current vital signs reveal a temperature of 38.9°C (102.0°F), blood pressure of 130/80 mmHg, heart rate of 96/min, and respiratory rate of 16/min. Pulse oximetry is 96% on room air. Upon physical examination, the lungs exhibit faint, scattered basilar crackles that clear completely with a cough. Abdominal examination demonstrates a 4-cm area of significant erythema, induration, and point tenderness at the inferior aspect of the midline surgical incision. Gentle palpation of this area produces a small amount of thick, purulent exudate between the surgical staples. Bowel sounds are active, and there is no rebound tenderness or guarding in the remaining abdominal quadrants. Which of the following is the most appropriate next step in management?

A $19$-year-old college student is brought to the emergency department by his friends due to intractable vomiting, diffuse abdominal pain, and profound lethargy for the past two days. His friends note that he has been extremely thirsty and has been urinating frequently for the past three weeks. He has no known past medical history and takes no medications.

Vital signs are temperature $37.0^\circ$ C ($98.6^\circ$ F), blood pressure $95/60$ mm Hg, pulse $125$/min, and respiratory rate $28$/min. Physical examination shows dry mucous membranes, decreased skin turgor, and deep, rapid respirations. The abdomen is diffusely tender without guarding or rebound.

Laboratory values are as follows:
Sodium: $136$ mEq/L
Potassium: $5.1$ mEq/L
Chloride: $98$ mEq/L
Bicarbonate: $10$ mEq/L
Blood glucose: $520$ mg/dL
Blood urea nitrogen: $32$ mg/dL
Creatinine: $1.4$ mg/dL
Leukocyte count: $16,500$/mm $^3$

Arterial blood gas (room air):
$pH$: $7.24$
$PaCO_2$: $23$ mm Hg
$PaO_2$: $96$ mm Hg

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

Match each clinical vignette describing a patient's therapeutic intervention to the most appropriate psychological therapy modality.

During a routine morning nursery round, a physician evaluates a newborn male at 48 hours of life. The infant was delivered vaginally at 39 weeks gestation to a 22-year-old primigravida who received limited prenatal care. Maternal admission laboratory screening for HIV, hepatitis B, and syphilis were negative, but her Group B Streptococcus status was unknown. The newborn is breastfeeding vigorously and has had appropriate wet diapers and meconium passage. Vital signs show a temperature of 37.1 °C (98.8 °F), heart rate of 142/min, and respiratory rate of 42/min. Physical examination reveals an alert, well-appearing infant. There is a diffuse cutaneous eruption consisting of multiple 2- to 3-mm firm, yellowish pustules, each surrounded by a prominent erythematous macular base. The lesions are scattered across the chest, abdomen, and proximal thighs, but the palms and soles are completely clear. Mucous membranes are moist without lesions. Which of the following is the most appropriate next step in the management of this patient?

A 26-year-old woman is referred to the emergency department by her university health clinic due to a 3-day history of escalating pelvic pain and high fever. Upon arrival, her temperature is 39.3°C (102.7°F), heart rate is 112/min, and blood pressure is 108/65 mmHg. Speculum examination demonstrates copious, yellow-green cervical exudate. Bimanual examination elicits exquisite pain on cervical manipulation and identifies a boggy, 8-cm mass in the right adnexal region. Arrange the following clinical steps in the most appropriate chronological sequence for managing this patient's condition.

A 4-day-old full-term boy is brought to the neonatal intensive care unit with progressive lethargy, poor feeding, and vomiting. He was previously healthy and discharged home at 48 hours of life. Physical examination reveals a somnolent, tachypneic infant with no dysmorphic features. Sepsis evaluation is initiated. The clinical picture is highly suspicious for an inborn error of metabolism, specifically a urea cycle disorder.

Arrange the following diagnostic steps in the most appropriate sequential order to accurately identify the specific enzymatic defect in this patient.

A 55-year-old woman is evaluated on postoperative day 1 following an anterior colporrhaphy and a vaginal hysterectomy for pelvic organ prolapse. She reports lower abdominal discomfort and a strong urge to urinate, but she is unable to pass urine despite multiple attempts over the last six hours. Her vital signs are stable. Physical examination reveals a palpable, tender, suprapubic mass. Arrange the following steps in the most appropriate chronological order for managing this patient's suspected postoperative urinary retention.

A 7-year-old boy is brought to the emergency department by his parents due to a 24-hour history of high fever, severe headache, and recurrent vomiting. He is fully immunized. On physical examination, his temperature is 39.5°C (103.1°F), blood pressure is 105/65 mm Hg, heart rate is 118/min, and respiratory rate is 22/min. He appears acutely ill and lethargic. Marked nuchal rigidity is present on flexion of the neck. Neurologic examination reveals an inability to abduct the right eye. The remainder of the examination is unremarkable. Intravenous access is rapidly established. Arrange the following next steps in the most appropriate sequential order for managing this patient.

A 20-year-old man is brought to the emergency department by the police after he was found wandering on a busy highway, shouting at passing vehicles. In the emergency department, he is highly agitated, pacing the room, and stating that the cars are emitting radio waves to control his mind. His speech is disorganized, and he frequently pauses as if responding to unseen stimuli. The patient's parents are contacted and arrive at the hospital. They report that these severe, bizarre behaviors began only 2 weeks ago. However, they note that for the past 9 months, he has undergone a significant change. Previously a sociable and high-achieving college student, he gradually stopped seeing his friends, dropped out of his classes, and spent most of his days sitting in his darkened bedroom showing very little emotion. His medical history is unremarkable, and a urine toxicology screen is negative. Which of the following is the most likely diagnosis?

During a routine oncology follow-up, a 52-year-old female patient reports an eight-week history of persistently low mood, loss of interest in activities she previously enjoyed, early morning awakenings, and severe fatigue. She has a history of estrogen receptor-positive breast cancer that was treated with surgical resection and radiation therapy two years ago. She is currently maintained on daily tamoxifen to prevent cancer recurrence. Vital signs include a blood pressure of $124/78 \text{ mm Hg}$, pulse of $72/\text{min}$, and temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$). Mental status examination reveals a tearful, blunted affect and psychomotor retardation, with no evidence of psychosis or suicidal ideation. A diagnosis of major depressive disorder is established, and pharmacotherapy is considered. Which of the following antidepressants should be strictly avoided in this patient to prevent a reduction in the efficacy of her antineoplastic therapy?

A 16-month-old boy is brought to the emergency department by his parents with a 3-day history of a persistent, harsh cough. The parents note that the cough started abruptly while the child was playing unsupervised in the living room, where his older siblings had been eating popcorn. He has no fever, rhinorrhea, or history of reactive airway disease. On physical examination, the child is alert and in mild respiratory distress. His temperature is 37.0°C (98.6°F), pulse is 120/min, respirations are 38/min, and oxygen saturation is 96% on room air. Lung auscultation reveals diminished breath sounds over the right hemithorax and a focal, monophonic expiratory wheeze on the right side. An expiratory chest radiograph shows increased radiolucency of the right lung field and a leftward shift of the mediastinum. Which of the following is the most appropriate next step in management?

A 4-year-old boy is brought to the emergency department by his parents due to the sudden onset of high fever, severe sore throat, and difficulty breathing over the past 4 hours. The family recently immigrated, and the child's immunization history is unknown. On examination, the temperature is 39.4°C (103.0°F), heart rate is 140/min, and respiratory rate is 40/min. The child appears highly anxious and toxic, and he is actively drooling. He insists on sitting upright, leaning forward with his neck extended. Inspiratory stridor and marked suprasternal retractions are present. Arrange the following steps in the most appropriate chronological order for the management of this patient.

An obstetrician is called to the labor unit to evaluate a fetal heart rate tracing for a 28-year-old patient. The patient is a gravida 3, para 2 at $40$ weeks gestation. She was admitted $4$ hours ago in spontaneous labor and was subsequently started on an intravenous oxytocin infusion for labor augmentation due to a secondary arrest of dilation. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $115/75\text{ mmHg}$, and pulse is $88/\text{min}$. The tocodynamometer demonstrates $7$ uterine contractions in a $10$-minute period. The fetal heart rate tracing reveals a baseline of $135/\text{min}$, minimal variability, and visually apparent, gradual decreases in the fetal heart rate that begin after the peak of each contraction and return to baseline after the contraction ends. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old woman, gravida 1, para 1, comes to the office 3 weeks after a difficult vaginal delivery. Her delivery was complicated by a prolonged second stage of labor and required forceps assistance. For the past 5 days, she has experienced a continuous leakage of clear fluid from her vagina. She has no dysuria, fever, abdominal pain, or fecal incontinence. Her voiding frequency is normal, but she feels constantly damp and must wear a sanitary pad at all times. Physical examination shows normal vital signs. The abdomen is soft and non-tender. A cotton swab test reveals a straining angle of $25^\circ$ (normal is $<30^\circ$). Speculum examination reveals a small pool of clear fluid in the posterior vaginal fornix. The fluid has a slight ammonia-like odor. Which of the following is the most appropriate next step in diagnosis?

For each of the following pediatric clinical vignettes describing a characteristic infectious exanthem or dermatologic manifestation, identify the most likely causative pathogen and the most appropriate next step in management.

A 62-year-old man is evaluated on postoperative day 5 following an elective sigmoid colectomy with primary anastomosis for recurrent diverticulitis. He reports the acute onset of severe, localized left lower quadrant abdominal pain. His temperature is 38.8°C (101.8°F), blood pressure is 105/65 mmHg, heart rate is 112/min, and respiratory rate is 20/min. Physical examination reveals focal tenderness and guarding in the left lower quadrant, but no diffuse abdominal rigidity. Laboratory studies show a leukocyte count of 16,500/mm³ with a left shift. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A $12$-month-old boy is evaluated in the pediatric emergency department for profound lethargy, frequent episodes of non-bilious vomiting, and rapid breathing over the past $24$ hours. His parents report that he had a mild runny nose and cough for three days prior to this acute deterioration. During the medical history, the parents mention that he has not yet begun to stand while holding onto furniture and cannot pick up small pieces of food using his thumb and index finger. Vital signs show a temperature of $37.8^\circ\text{C}$ ($100^\circ\text{F}$), pulse of $158/\text{min}$, respirations of $48/\text{min}$, and blood pressure of $86/52\text{ mm Hg}$. Physical examination reveals a somnolent infant with generalized hypotonia. The liver is palpated $3\text{ cm}$ below the right costal margin.

Laboratory evaluation reveals the following:

Serum sodium: $140\text{ mEq/L}$
Serum potassium: $4.2\text{ mEq/L}$
Serum chloride: $102\text{ mEq/L}$
Serum bicarbonate: $12\text{ mEq/L}$
Blood urea nitrogen: $18\text{ mg/dL}$
Serum creatinine: $0.4\text{ mg/dL}$
Blood glucose: $48\text{ mg/dL}$
Serum ammonia: $145\text{ }\mu\text{mol/L}$ (Normal: $15-50\text{ }\mu\text{mol/L}$)

Arterial blood gas (room air):
pH: $7.26$
$\text{PaCO}_2$: $26\text{ mm Hg}$
$\text{PaO}_2$: $96\text{ mm Hg}$

Urinalysis is strongly positive for ketones.

Based on the clinical presentation and laboratory findings, which of the following statements is most accurate regarding this patient's condition?

A 37-year-old male is brought to the emergency department by ambulance after falling approximately 20 feet (6 meters) from scaffolding. He is immobilized on a backboard with a cervical collar. Upon arrival, his temperature is $36.1^{\circ}\text{C}$ ($97.0^{\circ}\text{F}$), blood pressure is $78/45\text{ mmHg}$, heart rate is $138\text{ /min}$, and respiratory rate is $26\text{ /min}$. Oxygen saturation is $97\%$ on room air. Two large-bore intravenous lines are established, and aggressive crystalloid fluid resuscitation is initiated. The airway is patent, and breath sounds are present and equal bilaterally. The abdomen is distended and diffusely tender. The pelvis is stable to anteroposterior compression. Focused assessment with sonography for trauma (FAST) reveals a significant anechoic fluid collection in the splenorenal recess. His blood pressure remains $80/48\text{ mmHg}$ after $1\text{ L}$ of crystalloid infusion. Which of the following is the most appropriate next step in management?

Shortly after delivery via scheduled cesarean section, an infant develops progressively worsening tachypnea and expiratory grunting. The infant was born at $39$ weeks of gestation to a $34$-year-old mother whose pregnancy was complicated by poorly controlled gestational diabetes mellitus. Birth weight is $4.6\text{ kg}$ ($10\text{ lb } 2\text{ oz}$). Vital signs include a temperature of $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), heart rate of $155\text{/min}$, and respiratory rate of $78\text{/min}$. Pulse oximetry shows $87\%$ on room air. Physical examination reveals marked intercostal retractions and decreased air entry bilaterally. Skin examination shows a diffuse rash consisting of $2\text{-mm}$ pale pustules on an erythematous base across the chest and abdomen. A chest radiograph demonstrates decreased lung volumes, diffuse fine reticulogranular opacities, and prominent air bronchograms. Which of the following is the most appropriate next step in the management of this patient?