Tüm alıştırma soruları

An obese 13-year-old adolescent is brought to the clinic by his parents due to a four-week history of a right-sided limp and intermittent right knee pain. The pain is exacerbated by physical activity and relieved by rest. There is no history of trauma, fever, or weight loss. His body mass index is $33 \text{ kg/m}^2$. Vital signs are within normal limits. On physical examination, there is no swelling, erythema, or localized tenderness over the right knee. Ligamentous testing of the knee is normal. However, when the patient's right hip is passively flexed, the thigh obligately deviates into external rotation. Internal rotation of the right hip is significantly limited compared to the left. Which of the following is the most appropriate next step in management?

A 62-year-old man is evaluated in the intensive care unit due to fever and lethargy. He underwent a coronary artery bypass grafting procedure 5 days ago. Yesterday, he developed a fever, and blood cultures were drawn which are currently growing methicillin-susceptible Staphylococcus aureus (MSSA). Today, his temperature is 39.2°C (102.6°F), blood pressure is 85/50 mm Hg, and heart rate is 128/min. Physical examination reveals a sternal wound with copious purulent discharge and palpable clicking of the sternal halves during respiration. Lung auscultation reveals clear breath sounds bilaterally. Electrocardiogram shows sinus tachycardia. Which of the following is the most appropriate next step in management?

Physicians at an occupational health clinic are investigating a potential link between a specific industrial solvent and the development of peripheral neuropathy. They access the electronic medical and employment records of 2,500 workers at a large manufacturing plant between 2018 and 2025. The investigators first categorize the workers into two distinct groups based on their historical employment records: those who were stationed in departments utilizing the industrial solvent and those who were not. They then review the subsequent medical records of both groups over their remaining years of employment to determine the incidence rate of newly diagnosed peripheral neuropathy in each group. Which of the following best describes the epidemiologic study design used by these investigators?

A 42-year-old male is brought to the trauma bay after a high-speed motor vehicle collision. On arrival, he is unresponsive. He has audible gurgling respirations with pooling of blood in his oropharynx. His blood pressure is 75/40 mmHg, heart rate is 142/min, and respiratory rate is 32/min. Physical examination reveals tracheal deviation to the left and absent breath sounds over the right hemithorax. His pelvis is mechanically unstable on anterior-posterior compression. Arrange the following management steps in the correct chronological order according to standard trauma resuscitation protocols.

A 64-year-old male is recovering in the surgical ward after undergoing an emergency partial small bowel resection for mesenteric ischemia six days ago. He has a history of severe chronic obstructive pulmonary disease and type 2 diabetes. During a severe coughing fit, he feels a sudden 'giving way' sensation in his lower abdomen. Examination of the surgical site reveals complete separation of the surgical incision with a loop of viable-appearing small intestine protruding onto the skin surface. He is alert, with a heart rate of 98/min and blood pressure of 130/80 mmHg. Arrange the following management steps in the most appropriate chronological sequence for this complication.

A 42-year-old man weighing 90 kg is brought to the emergency department via ambulance after being involved in an industrial boiler explosion and fire. The incident occurred exactly 3 hours prior to arrival. He has a patent airway and his respirations are unlabored. Physical examination reveals erythema, blistering, and severe pain over the entire anterior torso and the entire posterior torso. The entire right lower extremity demonstrates leathery, charred, and insensate skin. Both upper extremities exhibit painful, blanching erythema with no blistering. During transport, emergency medical services established peripheral intravenous access and administered exactly 1260 mL of lactated Ringer solution.

Based on current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what should the infusion rate (in mL/hour) of lactated Ringer solution be set to for the remainder of the first 8 hours post-injury?

Match each clinical presentation to the most appropriate biliary tract diagnosis.

A 31-year-old gravida 4, para 3 at 39 weeks of gestation delivers a 4300-g neonate via spontaneous vaginal delivery. Five minutes after the delivery of an intact placenta, she develops profuse vaginal bleeding. The uterus is palpated as soft and boggy at the level of the umbilicus. Her blood pressure is 95/55 mm Hg, and her pulse is 115/min. Bimanual uterine massage is performed, and a rapid intravenous infusion of oxytocin is started, but the hemorrhage persists. Assuming each subsequent step fails to arrest the bleeding, arrange the following management interventions in the correct chronological sequence from first to last.

Match each clinical presentation of anorectal disease with the most appropriate definitive surgical or procedural management.

A 58-year-old man presents to the emergency department with 3 days of progressive left lower quadrant abdominal pain and a subjective fever. His temperature is 38.1°C (100.6°F), blood pressure is 130/80 mm Hg, and heart rate is 88/min. Abdominal examination reveals localized tenderness in the left lower quadrant but no rigidity, rebound, or guarding. Laboratory studies show a leukocyte count of 13,000/mm³. Arrange the following management steps in the most appropriate chronological order for this patient.

Pair the following maternal and fetal clinical presentations with the correct obstetric complication.

A 28-year-old man is brought to the emergency department with acute-onset confusion, severe diaphoresis, and shivering. He recently started taking tramadol for a back injury while on a maintenance dose of citalopram. Vital signs include temperature 39.2°C (102.6°F), blood pressure 168/98 mmHg, and heart rate 124/min. Physical examination reveals generalized hyperreflexia and inducible ankle clonus. Arrange the following steps in the correct sequential order for the evidence-based management of this patient's condition.

Match each of the following clinical presentations of trauma patients with the most appropriate definitive next step in diagnosis or management.

A 32-year-old pregnant patient, gravida 2, para 1, presents to the obstetric triage unit at 38 weeks gestation reporting painful uterine contractions. The pregnancy has been notable for an anatomy ultrasound at 20 weeks showing a succenturiate placental lobe. Her temperature is 37.0 C (98.6 F), blood pressure is 112/70 mm Hg, and pulse is 86/min. The initial fetal heart rate baseline is 145/min with moderate variability and no decelerations. Cervical examination shows 5 cm dilation and intact membranes. Three hours into her admission, the patient experiences spontaneous rupture of membranes, accompanied by a moderate amount of bright red vaginal bleeding. Immediately following this event, the fetal heart rate tracing demonstrates a prolonged deceleration that evolves into a sinusoidal pattern with a baseline of 90/min. Uterine resting tone is normal, and contractions are occurring every 3 minutes. Which of the following is the most appropriate next step in management of this patient?

Match the following classic mechanisms of knee injury with their most characteristic diagnostic physical examination finding.

A 48-year-old woman comes to the clinic reporting a 3-week history of constant, small-volume urine leakage. She states that she never experiences a sudden urge to void, nor does the leakage worsen exclusively with coughing or laughing. However, she frequently feels that her bladder is full and reports a weak, hesitant urinary stream. The patient was diagnosed with multiple sclerosis five years ago and has had two prior exacerbations involving lower extremity weakness. Vital signs are within normal limits. Abdominal examination reveals a palpable, non-tender suprapubic mass. Neurologic examination shows symmetrically increased deep tendon reflexes in the lower extremities. Urinalysis is negative for leukocyte esterase and nitrites. A bladder ultrasound demonstrates a post-void residual volume of 450 mL.

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

A 68-year-old woman is brought to the clinic for evaluation of blood-tinged vaginal discharge that started 3 weeks ago. She attained menopause at age 52. Her medical history is significant for hypertension, obesity, and estrogen receptor-positive breast cancer diagnosed 3 years ago, for which she was treated with a lumpectomy and radiation therapy. She is currently taking tamoxifen. Pelvic examination reveals a small amount of dark blood in the vaginal vault. The cervix appears flush with the vagina and is severely stenotic. A transvaginal ultrasound shows an endometrial thickness of 14 mm with multiple small cystic spaces. An attempt to perform an in-office endometrial biopsy is unsuccessful because the sampling device cannot pass through the external cervical os, despite the use of a tenaculum and misoprostol preparation. Which of the following is the most appropriate next step in management?

Match each pediatric clinical presentation with the most likely causative pathogen.

A 26-year-old woman is evaluated in the emergency department for a painful rash, fever, and generalized malaise that began two days ago. She has a history of bipolar I disorder that has been stable for two years on a maintenance regimen of divalproex sodium. Six weeks ago, she experienced a major depressive episode, and her psychiatrist initiated an additional mood-stabilizing medication. The new medication was started at a standard dose of 25 mg daily for two weeks, followed by an increase to 50 mg daily. On physical examination, her temperature is 38.6°C (101.5°F). There is a widespread, erythematous, maculopapular eruption on her face, trunk, and extremities, with scattered areas of epidermal sloughing. Painful erosions are present on her buccal mucosa. Which of the following pharmacokinetic effects of the patient's maintenance medication on the newly added drug most likely precipitated this patient's current condition?

A 55-year-old woman is evaluated in the emergency department due to a 2-day history of diffuse, crampy abdominal pain, accompanied by multiple episodes of green-tinged vomiting and an inability to pass flatus or stool. Her surgical history includes a total abdominal hysterectomy performed 10 years ago. Her temperature is 37.1°C (98.8°F), pulse is 90/min, blood pressure is 128/82 mm Hg, and respirations are 14/min. Physical examination shows a protuberant, tympanitic abdomen with high-pitched, tinkling bowel sounds. There is mild diffuse tenderness to palpation, but no guarding, rigidity, or rebound tenderness. Laboratory studies show a leukocyte count of 8,400/mm³, serum sodium of 137 mEq/L, potassium of 3.4 mEq/L, and normal serum lactate. An upright abdominal plain radiograph reveals multiple dilated loops of small intestine with prominent air-fluid levels and a lack of gas in the colon. What is the most appropriate initial management for this patient?