Tüm alıştırma soruları

A 26-year-old woman is evaluated in the office alongside her husband due to primary infertility. The couple has engaged in regular, unprotected vaginal intercourse for the past 16 months without achieving pregnancy. The patient reports that her menstrual periods are highly unpredictable, typically occurring at 60- to 90-day intervals. Over the last three years, she has noticed the gradual onset of coarse, dark hair growing on her upper lip and chin, which she manages by daily plucking. She has no chronic medical conditions and takes no medications other than a prenatal vitamin. Vital signs are within normal limits. Her body mass index is $29 \text{ kg/m}^2$. Physical examination demonstrates a female escutcheon and normal external genitalia without clitoromegaly. A bimanual pelvic examination is unremarkable. The partner's semen analysis parameters are within normal reference ranges. A transvaginal ultrasound reveals bilaterally enlarged ovaries, each containing 15 to 20 small, peripherally oriented follicles. Serum concentrations of prolactin and thyroid-stimulating hormone are normal. The clinician suspects polycystic ovary syndrome (PCOS). To definitively establish this diagnosis, which of the following is the most appropriate next step in the laboratory evaluation?

A 38-year-old man is brought to the trauma bay following a high-speed motorcycle collision. He is confused and agitated. His blood pressure is 75/40 mm Hg, and his heart rate is 142/min. His airway is patent, and breath sounds are clear and equal bilaterally. The pelvis is clinically stable on examination, and there are no obvious sources of external hemorrhage. Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient's condition.

A 68-year-old man is evaluated on postoperative day 1 following an open partial gastrectomy for a perforated gastric ulcer. His past medical history is significant for hypertension and type 2 diabetes mellitus. The nursing staff reports that his urine output over the last 2 hours has been a total of $25$ mL. His temperature is $37.2^{\circ}\text{C}$ ($99.0^{\circ}\text{F}$), blood pressure is $105/65$ mmHg, pulse is $108/\text{min}$, and respiratory rate is $16/\text{min}$. The patient is currently receiving intravenous normal saline at $100$ mL/hr and has an indwelling Foley catheter in place. The abdomen is tender near the surgical incision with no rebound or guarding. Arrange the following steps in the most appropriate chronological order for the evaluation and management of this patient's postoperative oliguria.

An 82-year-old woman is brought to the clinic by her daughter due to a 3-month history of urinary incontinence. The patient experiences a sudden, overwhelming urge to urinate and frequently leaks urine before reaching the bathroom. She has a history of hypertension, Alzheimer dementia, and narrow-angle glaucoma. Her current medications include lisinopril, donepezil, and timolol ophthalmic drops. Vital signs are within normal limits. Abdominal examination reveals no suprapubic tenderness. Pelvic examination shows normal postmenopausal vaginal mucosa and no evidence of pelvic organ prolapse. A post-void residual volume is 40 mL. Urinalysis is negative for leukocyte esterase and nitrites. The patient has attempted timed voiding and pelvic floor muscle exercises for the past 6 weeks without significant improvement. Which of the following is the most appropriate pharmacotherapy for this patient's urinary symptoms?

A term infant is delivered at 41 weeks gestation via emergent cesarean delivery for non-reassuring fetal heart tones. The delivery is complicated by thick meconium-stained amniotic fluid. Immediately after birth, the infant is limp, apneic, and has a heart rate of 80/min. Arrange the following steps of neonatal resuscitation in the correct chronological order, assuming the infant's clinical status persistently fails to improve with each preceding intervention.

Following three days of progressive obstipation and bilious vomiting, a 48-year-old man arrives at the emergency department. He states that his abdominal pain, which was initially intermittent and crampy, has abruptly become constant and excruciating within the last few hours. His surgical history includes a midline laparotomy for a ruptured appendix a decade ago. Vital signs show a temperature of 38.6°C (101.5°F), a pulse of 118/min, and a blood pressure of 96/60 mm Hg. The abdominal examination demonstrates widespread rigidity, diffuse rebound tenderness, and absent bowel sounds. Blood tests indicate a leukocyte count of 18,500/mm³ and an elevated serum lactate. Upright abdominal radiographs reveal prominent dilated loops of small bowel with multiple air-fluid levels and no free air. Which of the following is the most appropriate next step in the management of this patient?

A 23-year-old man is diagnosed with schizophrenia after presenting with a 7-month history of auditory hallucinations and disorganized behavior. His physician discusses the long-term management plan, noting that many patients require medication adjustments over their lifetime to achieve and maintain symptom remission. Arrange the following pharmacological interventions in the standard step-wise treatment algorithm for schizophrenia, from initial treatment of a first episode to the management of severe, treatment-refractory disease.

Match each acute obstetric emergency vignette to the most appropriate immediate next step in management.

Match each patient's clinical presentation with the most likely surgical diagnosis.

An 11-month-old girl is brought to the pediatric emergency department by her adoptive parents after experiencing a generalized tonic-clonic seizure that lasted 3 minutes. She was adopted internationally at age 4 months, and her neonatal medical records and newborn screening results are unavailable. The parents report that over the past several months, she has become increasingly lethargic and hypotonic, and she has not started crawling or babbling. On physical examination, her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate is $120/\text{min}$, and respiratory rate is $32/\text{min}$. The patient is lethargic with absent deep tendon reflexes. She has diffuse thinning of her scalp hair and an erythematous, scaly eruption around her mouth and diaper area.

Laboratory studies show:
Serum sodium: $140\text{ mEq/L}$
Serum chloride: $104\text{ mEq/L}$
Serum bicarbonate: $14\text{ mEq/L}$

Arterial blood gas on room air reveals:
pH: $7.28$
$\text{pCO}_2$: $29\text{ mmHg}$

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

A 42-year-old woman is brought to the emergency department by ambulance following an all-terrain vehicle (ATV) rollover. She was thrown from the vehicle and struck her abdomen against a large rock. She reports severe diffuse abdominal pain. On presentation, her temperature is 36.6°C (97.9°F), blood pressure is 82/50 mmHg, pulse is 132/min, and respirations are 24/min. Intravenous fluid resuscitation with lactated Ringer's is initiated. Primary survey demonstrates an intact airway and clear, equal breath sounds bilaterally. The abdomen is visibly distended with diffuse involuntary guarding and rebound tenderness. Compression of the iliac crests reveals a stable pelvis. A bedside focused assessment with sonography for trauma (FAST) is performed and demonstrates an anechoic fluid collection in the hepatorenal recess (Morison pouch). Which of the following is the most appropriate next step in management?

Match each patient presenting with major depressive disorder to the most appropriate first-line pharmacologic treatment based on their specific comorbidities and symptom profile.

A $3$-year-old unimmunized boy is brought to the pediatric emergency department with a $6$-hour history of high fever, severe sore throat, and progressive difficulty breathing. On presentation, he is sitting on his mother's lap, leaning forward with his neck extended. He is drooling continuously and appears highly anxious. Inspiratory stridor and moderate suprasternal retractions are visible. His temperature is $39.5^{\circ}\text{C}$ ($103.1^{\circ}\text{F}$), heart rate is $145\text{/min}$, and respiratory rate is $38\text{/min}$. Arrange the following management steps in the most appropriate sequential order for this patient.

Emergency medical services bring a 24-year-old male to the trauma center following a high-velocity motorcycle collision. He was found approximately 30 meters from his vehicle without a helmet. Due to a severely depressed level of consciousness (Glasgow Coma Scale score of 5), he was intubated at the scene. Upon arrival, he is receiving mechanical ventilation. Vital signs show a blood pressure of $76/40 \text{ mmHg}$ and a heart rate of $142 \text{ /min}$. Physical examination reveals a right pupil that is $7 \text{ mm}$ and unresponsive to light, while the left pupil is $3 \text{ mm}$ and reactive. Breath sounds are clear and symmetric bilaterally. A portable chest radiograph shows clear lung fields without pneumothorax. A portable pelvic radiograph demonstrates intact pelvic ring structures. Bedside ultrasonography of the abdomen demonstrates a significant anechoic fluid collection between the liver and the right kidney. Two large-bore intravenous lines are present, and the massive transfusion protocol is actively running. What is the most appropriate next step in the management of this patient?

Match each neonatal clinical presentation (left) with the most likely causative pathogen and its appropriate diagnostic and management strategy (right).

A 19-year-old male collegiate rugby player collapses on the field after being tackled forcefully around the midsection by an opposing player. He is rushed to the emergency department. En route, emergency medical services administer 2 L of intravenous crystalloid solution. On arrival, he is restless and complaining of severe abdominal pain. His temperature is 36.1°C (97.0°F), pulse is 142/min, blood pressure is 76/40 mm Hg, and respiratory rate is 26/min. Oxygen saturation is 98% on high-flow oxygen. Physical examination reveals an exquisitely tender, board-like abdomen with severe rebound tenderness across all four quadrants. There is early ecchymosis developing over the periumbilical area. The pelvis is mechanically stable to anteroposterior and lateral compression. Cardiopulmonary auscultation reveals clear breath sounds bilaterally. Which of the following interventions should be prioritized next for this patient?

A 31-year-old woman presents to the clinic with a 6-month history of absent menses and new-onset, spontaneous bilateral milky nipple discharge. She has no headaches or visual changes and takes no medications. Physical examination confirms bilateral galactorrhea but is otherwise unremarkable. Visual fields are full to confrontation.

Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient, starting with the initial diagnostic test and progressing to the management of a refractory condition.

A 74-year-old man is brought to the emergency department from a long-term care facility due to progressive abdominal distension, severe pain, and recurrent vomiting for the past 48 hours. He has not had a bowel movement or passed flatus for 3 days. His medical history is significant for an open ventral hernia repair 8 years ago. On arrival, his temperature is 39.4°C (102.9°F), blood pressure is 85/50 mm Hg, pulse is 128/min, and respirations are 24/min. Physical examination reveals a markedly distended abdomen with diffuse rigidity, severe rebound tenderness, and absent bowel sounds. Laboratory studies show a leukocyte count of 24,000/mm³ and a serum lactate level of 6.8 mmol/L. An upright abdominal radiograph demonstrates multiple dilated loops of small bowel with prominent air-fluid levels and a paucity of colonic gas. Which of the following is the most appropriate next step in the management of this patient?

A 48-year-old woman is evaluated in the outpatient psychiatry clinic at the insistence of her husband. For the past 9 months, she has been absolutely convinced that her neighbors are piping toxic gases into her home through the ventilation system to force her to move out. She has sealed all the vents in her house with duct tape and frequently sleeps in her car to "escape the fumes." She denies hearing voices, and her thoughts are otherwise logical and goal-directed. She continues to work successfully as a freelance graphic designer and maintains her close friendships, provided she does not discuss her neighbors. Her husband reports her mood has been generally stable, though she is understandably frustrated by the "gas attacks." Physical examination, neurological evaluation, and laboratory studies are unremarkable. Which of the following is the most accurate diagnosis for this patient?

An individual in his late sixties is evaluated in the surgical assessment unit due to persistent crampy abdominal pain and multiple episodes of bilious vomiting over the past 48 hours. He reports no passage of stool or flatus since the symptoms began. The patient has a surgical history significant for an open partial colectomy performed a decade ago. Vital signs demonstrate a temperature of 38.5°C (101.3°F), pulse of 118/min, and blood pressure of 96/60 mmHg. Physical examination reveals a markedly distended abdomen with absent bowel sounds. Palpation elicits diffuse guarding and pronounced rebound tenderness, particularly in the periumbilical area. Laboratory investigations show a leukocyte count of 18,200/mm³ with 85% neutrophils and a serum lactate concentration of 4.1 mmol/L. Upright radiograph displays dilated small intestinal loops with prominent air-fluid levels and a complete lack of colonic gas. Which of the following is the most appropriate next step in management?