Tüm alıştırma soruları

A 62-year-old man is brought to the emergency department complaining of severe abdominal pain. He reports a two-day history of crampy abdominal discomfort, accompanied by multiple episodes of bilious emesis and an inability to pass flatus. His surgical history is significant for an open appendectomy at age 25. Earlier today, the pain acutely transitioned from intermittent cramps to a constant, sharp pain. His temperature is 38.8°C (101.8°F), blood pressure is 92/60 mmHg, and heart rate is 122/min. On physical examination, the abdomen is distended, rigid, and exhibits diffuse rebound tenderness and involuntary guarding. Which of the following is the most appropriate next step in the management of this patient?

A 22-year-old man is evaluated in a dual-diagnosis residential facility. Two months ago, he was hospitalized following an episode of severe agitation where he claimed that government drones were injecting thoughts into his mind. This psychotic episode began immediately after a three-day binge of smoking methamphetamine. He was subsequently transferred to the current facility, where he has been monitored continuously and has had negative urine toxicology screens twice weekly for the past 7 weeks. Despite confirmed abstinence from all illicit substances during this 7-week period, the patient continues to experience daily auditory hallucinations and expresses the belief that the facility staff are government agents. He has not exhibited any significant depressive or manic symptoms. Which of the following is the most likely diagnosis?

A 30-year-old G1P0 woman at 35 weeks gestation is brought to the trauma center after being involved in a high-speed motor vehicle collision as the unrestrained driver. On arrival, she is lethargic but conversant and protecting her airway. She is placed on a backboard with left lateral tilt and receives 2 liters of warmed intravenous crystalloids. Reassessment reveals a blood pressure of 78/42 mm Hg and a heart rate of 135/min. Breath sounds are clear and equal bilaterally. Her abdomen is gravid, rigid, and diffusely tender with rebound and guarding. Bedside focused assessment with sonography for trauma (FAST) demonstrates a large volume of free fluid in the hepatorenal recess. Fetal monitoring shows a baseline heart rate of 115/min with recurrent late decelerations. Arterial blood gas analysis reveals a pH of 7.21, $pCO_2$ of 25 mm Hg, and $HCO_3^-$ of 10 mEq/L. Which of the following is the most appropriate next step in management?

A 26-year-old nulligravid woman comes to the office due to a 6-month history of absent menses. Prior to this, her menses occurred at regular 28-day intervals. She also reports frequent difficulty sleeping and episodic feelings of intense warmth and sweating over the past 3 months. She has no significant past medical history and takes no medications. Her temperature is 37.0°C (98.6°F), blood pressure is 118/76 mm Hg, pulse is 74/min, and respirations are 14/min. Her BMI is 22 kg/m². Pelvic examination shows normal external genitalia and a normal-appearing cervix, but the vaginal mucosa appears pale and thin. A urine pregnancy test in the office is negative. Arrange the following steps in the most appropriate chronological sequence for the diagnostic evaluation and comprehensive management of this patient's condition.

A $28$-year-old female seeks evaluation alongside her partner due to primary infertility. The couple has been engaging in regular, unprotected vaginal intercourse for $14$ months without achieving conception. Her menarche occurred at age $12$. Her menstrual cycles are highly regular, occurring every $28$ days with $5$ days of moderate bleeding. She utilizes a home basal body temperature tracking method, which consistently demonstrates a biphasic monthly pattern. Five years ago, she was treated for a sexually transmitted pelvic infection with a single dose of intramuscular ceftriaxone and a $14$-day course of oral doxycycline. She takes a daily prenatal vitamin. Her body mass index is $23 \text{ kg/m}^2$. Vital signs are within normal limits. Physical examination reveals normal female hair distribution, absent galactorrhea, and no cutaneous manifestations of hyperandrogenism. Pelvic examination is unremarkable, with no cervical motion tenderness or adnexal masses.

Recent laboratory studies reveal:
Thyroid-stimulating hormone: $1.8 \mu\text{U/mL}$
Prolactin: $12 \text{ ng/mL}$
Day $21$ serum progesterone: $14 \text{ ng/mL}$

Her partner's semen analysis shows a volume of $3.2 \text{ mL}$, a sperm concentration of $55 \times 10^6/\text{mL}$, $65\%$ progressive motility, and $8\%$ normal morphology.

Based on the provided clinical data, what is the most appropriate next diagnostic step for this couple?

A $42$-year-old woman is evaluated in the emergency department after her roommate found her confused and breathing rapidly. The roommate reports that the patient has a history of chronic lower back pain and has recently been complaining of a continuous ringing in her ears. Her temperature is $38.2^\circ C$ ($100.8^\circ F$), blood pressure is $112/72$ mm Hg, pulse is $115$/min, and respirations are $28$/min. Physical examination shows a diaphoretic and agitated woman. Cardiopulmonary examination is unremarkable except for tachycardia and tachypnea. The lungs are clear to auscultation bilaterally.

Laboratory results are as follows:

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

A 71-year-old woman presents to the emergency department with 18 hours of worsening, colicky lower abdominal pain and repeated bilious vomiting. She has not had a bowel movement or passed flatus since the symptoms began. Her temperature is 38.6°C (101.5°F), blood pressure is 92/60 mm Hg, and pulse is 118/min. Cardiopulmonary examination is unremarkable. Abdominal examination reveals a distended abdomen with diffuse rebound tenderness and involuntary guarding. A tender, erythematous, non-reducible bulge is palpated in the right groin, located inferior to the inguinal ligament and medial to the femoral artery pulse. Laboratory studies demonstrate a leukocyte count of 18,500/mm³ and a serum lactate level of 4.2 mmol/L. Which of the following is the most appropriate next step in management?

A 68-year-old man is evaluated in the surgical intensive care unit for sudden-onset hypotension and altered mental status. He was admitted 3 days ago after a severe motor vehicle collision. His initial injuries included multiple left-sided rib fractures, bilateral pulmonary contusions, and a grade III liver laceration that was managed nonoperatively. His past medical history includes heart failure with preserved ejection fraction and chronic obstructive pulmonary disease (COPD).

Currently, his blood pressure is 76/45 mm Hg and his heart rate is 135/min. Oxygen saturation is 89% on 4 L/min via nasal cannula. His temperature is 38.3°C (100.9°F). Physical examination reveals a rigid, distended abdomen with involuntary guarding and rebound tenderness. Auscultation of the lungs reveals decreased breath sounds at the bases with scattered wheezes.

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

A 55-year-old female patient presents to the urogynecology clinic seeking evaluation for involuntary urinary leakage. She reports experiencing a sudden, overwhelming need to void that she frequently cannot suppress, resulting in loss of urine before reaching the restroom. These episodes happen 5 to 6 times daily and wake her up twice nightly. She specifically denies any leakage associated with sneezing, coughing, or physical exertion. Her medical history is unremarkable. Pelvic examination demonstrates normal vaginal estrogenization with no evidence of pelvic organ prolapse. Urinalysis is negative for infection, and post-void residual volume is 25 mL. She is highly motivated to undergo treatment. Arrange the following management strategies for this patient's diagnosis in the correct sequential order, starting from the most appropriate initial intervention to the most advanced, last-resort therapy.

A 68-year-old man is evaluated for a new-onset fever on postoperative day 7 following an open anterior resection of the rectum for rectal adenocarcinoma. Over the past 12 hours, he has developed right-sided chest pain that worsens with deep inspiration, along with a mild, dry cough. His temperature is 38.9°C (102.0°F), blood pressure is 132/84 mm Hg, pulse is 114/min, and respirations are 22/min. Oxygen saturation is 93% on room air. His medical history includes heart failure with preserved ejection fraction and diet-controlled type 2 diabetes mellitus. Physical examination shows a normal jugular venous pressure. Lung auscultation is notable for a focal pleural friction rub in the right lower lung field, without crackles or wheezing. The abdomen is soft and non-distended; the midline surgical incision is well-approximated with no erythema, induration, or purulent drainage. The right calf is mildly edematous and tender to palpation compared to the left. Laboratory studies show a white blood cell count of 11,200/mm³. A chest radiograph demonstrates a peripheral, wedge-shaped opacity in the right lower lung zone and a small right-sided pleural effusion. There is no cardiomegaly. Which of the following is the most appropriate next step in management?

A $48$-hour-old term male newborn is evaluated in the nursery for a new skin eruption. The infant was delivered via uncomplicated spontaneous vaginal delivery at $39$ weeks gestation to a $28$-year-old primigravida. Maternal prenatal laboratory studies were unremarkable, and maternal Group B Streptococcus screening was negative. The newborn has been breastfeeding vigorously and has had normal bowel and bladder output. Vital signs show a temperature of $37.0$ °C ($98.6$ °F), a heart rate of $135$/min, and a respiratory rate of $42$/min. Physical examination reveals a well-appearing, alert infant. His skin exhibits a scattered rash on the chest, abdomen, and proximal extremities consisting of $1$- to $3$-cm erythematous macules, many of which contain a central $1$- to $2$-mm yellow-white pustule. The palms, soles, and mucous membranes are entirely clear. Which of the following is the most appropriate next step in management?

Match each acute clinical presentation to the most appropriate initial management step or targeted therapeutic intervention.

A 64-year-old woman with a history of obesity, chronic hypertension, and type 2 diabetes mellitus presents to the clinic reporting two weeks of daily, unprovoked vaginal bleeding. She experienced natural menopause at age 52 and has never used hormone replacement therapy. Pelvic examination is unremarkable, and a transvaginal ultrasound reveals an irregular, heterogeneous endometrial stripe measuring 16 mm. Arrange the following steps in the most appropriate chronological sequence for the diagnostic evaluation and definitive management of this patient.

A 38-year-old woman is evaluated by the surgical team 24 hours after admission for a mechanical small bowel obstruction. Her initial management included intravenous fluid resuscitation, bowel rest, and nasogastric tube decompression. Over the last 3 hours, she has developed severe, constant abdominal pain that is distinctly different from the cramping pain she experienced on admission. She underwent a total abdominal hysterectomy for uterine fibroids 4 years ago. Her temperature is 38.8°C (101.8°F), blood pressure is 96/60 mmHg, pulse is 124/min, and respirations are 22/min. On physical examination, the abdomen is distended. There is marked right lower quadrant tenderness with guarding and rebound. The nasogastric tube has drained 400 mL of bilious fluid since placement. Laboratory results demonstrate a leukocyte count of 18,000/mm³ with 15% bands, and a serum lactate of 3.5 mmol/L. Which of the following is the most appropriate next step in management?

A 28-year-old primigravida presents to the labor and delivery ward in active labor following spontaneous rupture of membranes $22\text{ hours}$ prior. Her prenatal care was limited, and her maternal Group B Streptococcus (GBS) colonization status is unconfirmed. She delivers a female neonate at $36\text{ weeks}$ gestation. The infant's birth weight is $2600\text{ g}$ ($5\text{ lb } 12\text{ oz}$). APGAR scores are $7$ and $8$ at $1$ and $5\text{ minutes}$, respectively.

At $30\text{ hours}$ of life, the newborn develops profound lethargy and poor feeding. Vital signs are:

Physical examination reveals an ill-appearing infant with audible grunting, intercostal retractions, and a capillary refill time of $4\text{ seconds}$.

Laboratory evaluation shows:

Cerebrospinal fluid, blood, and urine specimens are obtained for culture.

Which of the following represents the most appropriate initial empiric pharmacotherapy for this patient?

Match each classic imaging finding described below with its most likely gastrointestinal or surgical diagnosis.

Review the following trauma patient presentations and pair each one with its definitive diagnostic modality or most appropriate immediate intervention.

Match each patient's clinical scenario regarding primary infertility with the most appropriate primary treatment modality or next best step in management to achieve conception.

A $24$-year-old primigravida at $41$ weeks gestation is undergoing induction of labor for a post-term pregnancy. She is currently $5$ cm dilated, $100\%$ effaced, and the fetal presenting part is at $0$ station. Artificial rupture of membranes was performed one hour ago, releasing a small amount of clear fluid. Uterine contractions are occurring every $3$ minutes. The fetal heart rate tracing demonstrates a baseline of $135$/min with moderate variability. However, with nearly every contraction, there is an abrupt decrease in the fetal heart rate to $70$ to $80$/min that lasts for $40$ to $50$ seconds before rapidly returning to the baseline. The patient's vital signs include a blood pressure of $118/76$ mmHg, a heart rate of $92$/min, and a respiratory rate of $22$/min. She reports intense pain during contractions. The nursing staff has already changed the patient's position and administered an intravenous fluid bolus, but the abnormal fetal heart rate pattern persists. Which of the following is the most appropriate next step in the management of this patient?

A 26-year-old woman, G2P1, at 14 weeks gestation, comes to the clinic for an initial prenatal visit. She reports daily intravenous heroin use and states, "I want to stop using to protect my baby." Her last heroin use was 16 hours ago, and she currently exhibits yawning, rhinorrhea, and piloerection. Her medical history includes bipolar I disorder, but she stopped her mood stabilizer prior to conception. Over the past three weeks, she has experienced a pervasive low mood, anhedonia, and fatigue. She is adamant about not being admitted to the hospital, fearing she will be fired from her job if she misses work. Vital signs are within normal limits. Arterial blood gas analysis on room air shows:

- pH: $7.44$
- PaCO $_2$: $30\text{ mm Hg}$
- PaO $_2$: $102\text{ mm Hg}$
- HCO $_3^-$: $20\text{ mEq/L}$

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