Tüm alıştırma soruları

A $65$-year-old man is evaluated on postoperative day $4$ following a right total knee arthroplasty. He has a history of mild chronic obstructive pulmonary disease (COPD) managed with an as-needed albuterol inhaler. The patient reports sudden-onset shortness of breath and right-sided pleuritic chest pain. Vital signs show a temperature of $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure of $128/82\text{ mmHg}$, heart rate of $115/\text{min}$, and respiratory rate of $24/\text{min}$. Pulse oximetry reveals an oxygen saturation of $88\%$ on room air. Physical examination shows a well-healing surgical incision without erythema or purulence, and the right calf appears swollen compared to the left. Auscultation of the lungs reveals clear breath sounds bilaterally without wheezing or crackles. The physician suspects an acute pulmonary embolism.

Arrange the following steps in the most appropriate chronological order for the diagnostic and therapeutic management of this patient.

A 16-year-old girl is brought to the clinic for evaluation of absent menarche. Her medical history is unremarkable. She is at the 10th percentile for height and 50th percentile for weight. Physical examination reveals absent breast development (Tanner stage I) and normal external female genitalia. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for the evaluation and management of this patient.

A $55$-year-old man is evaluated in the step-down unit due to progressively worsening lethargy and tachypnea over the last $4$ hours. He was admitted two days ago for a severe intra-abdominal infection following a perforated appendix and is receiving intravenous broad-spectrum antibiotics. His past medical history is significant for severe chronic obstructive pulmonary disease. Vital signs show a temperature of $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure of $86/50$ mm Hg, pulse of $118$/min, and respiratory rate of $28$/min.

Laboratory and arterial blood gas results on room air are as follows:

Based on these findings, which of the following best describes the patient's primary acid-base disturbances?

A 38-year-old male is brought to the emergency department via ambulance after his compact car was struck on the driver's side by a commercial truck. On arrival, he is pale and lethargic but follows simple commands. Vitals show a temperature of $36.5^{\circ}$ C ($97.7^{\circ}$ F), blood pressure of $82/46$ mm Hg, pulse of $130$/min, and respiratory rate of $28$/min.

Primary survey reveals a patent airway. Breathing assessment demonstrates markedly diminished breath sounds over the left lower hemithorax, and the trachea appears slightly deviated to the right. The abdomen is diffusely tender with involuntary guarding. A focused assessment with sonography for trauma (FAST) reveals an anechoic collection in the splenorenal recess.

An orogastric tube is placed to decompress the stomach. A portable anteroposterior chest radiograph is immediately obtained in the resuscitation bay, which demonstrates the radiopaque tip of the orogastric tube coiled within the left lower thorax and a shift of the mediastinal structures toward the right.

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

Match each clinical description of a benign neonatal skin finding to its most accurate diagnosis. Recognizing these normal variants is critical to prevent unnecessary diagnostic interventions and parental anxiety.

An 8-year-old boy is evaluated in the hospital on hospital day 4. He was originally admitted for acute, severe right thigh pain, limp, and high fever. Magnetic resonance imaging (MRI) of the right lower extremity at admission demonstrated marrow edema and a subperiosteal fluid collection in the distal femur. He was diagnosed with acute hematogenous osteomyelitis and empirically started on intravenous vancomycin and ceftriaxone. Over the last 48 hours, his temperature has normalized, and his thigh pain has significantly decreased.

Blood cultures drawn prior to the administration of antibiotics have grown *Staphylococcus aureus*. The susceptibility report is as follows:

The patient has no known drug allergies. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 67-year-old woman is brought to the emergency department due to worsening abdominal pain. For the past two days, she experienced crampy periumbilical pain accompanied by multiple episodes of green vomitus and an inability to pass flatus. Four hours ago, the pain suddenly became constant and diffuse. Her medical history is notable for a total abdominal hysterectomy ten years ago. Her temperature is 38.9°C (102.0°F), pulse is 122/min, blood pressure is 85/55 mm Hg, and respirations are 22/min. Physical examination reveals a distended and silent abdomen with board-like rigidity, diffuse guarding, and severe rebound tenderness. Laboratory studies show a leukocyte count of 19,500/mm³ and a serum lactate level of 4.2 mmol/L. Which of the following is the most appropriate next step in management?

A 10-week-old boy is brought to the emergency department in mid-January by his parents due to a 3-day history of nasal congestion and a worsening cough. Over the past 12 hours, he has been feeding poorly and breathing rapidly. The family recently immigrated to the United States, and the infant has not received any immunizations. His temperature is 37.9°C (100.2°F), heart rate is 156/min, respiratory rate is 68/min, and oxygen saturation is 89% on room air. On physical examination, the infant appears mildly lethargic and is using accessory respiratory muscles. Copious clear rhinorrhea is present. Lung auscultation reveals diffuse polyphonic wheezing and crackles bilaterally. Skin examination shows multiple scattered erythematous papules and pustules on his cheeks, which the parents state have been present since he was 3 weeks old. Which of the following is the most appropriate next step in the management of this patient?

On her second day of recovery following an elective sigmoidectomy for recurrent diverticulitis, a 59-year-old woman is noted to have a temperature of 38.4°C (101.1°F). She complains of mild incisional pain but denies chills, chest pain, shortness of breath, or dysuria. Her other vital signs include a blood pressure of 130/80 mmHg, a pulse of 92/min, and a respiratory rate of 16/min. Oxygen saturation is 96% on room air. The patient has spent most of her time in bed due to pain. Lung auscultation reveals diminished breath sounds over the lower lung fields bilaterally without wheezes or crackles. The surgical abdomen is soft and mildly tender near the incision, with no redness or purulent discharge. The indwelling urinary catheter was removed yesterday. Which of the following is the most appropriate next step in management?

A 62-year-old man is brought to the emergency department after a motor vehicle collision in which he was an unrestrained driver. Paramedics report significant front-end vehicle damage. The patient's wife arrives and states he has a history of alcoholic cirrhosis and was hospitalized two months ago for abdominal distension requiring paracentesis. On presentation, his temperature is 36.8°C (98.2°F), blood pressure is 80/50 mm Hg, heart rate is 132/min, and respiratory rate is 24/min. He is confused but localizes to pain. His airway is patent and breath sounds are equal bilaterally. Physical examination reveals scleral icterus, spider angiomas on the chest, and a markedly distended abdomen with shifting dullness and a positive fluid wave. There is no overt abdominal guarding or rebound tenderness. The pelvis is stable to anterior-posterior and lateral compression. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal recess (Morison pouch) and the splenorenal recess. Which of the following is the most appropriate next step in the management of this patient?

An 18-year-old college student presents to the emergency department complaining of progressive pelvic heaviness and a sudden exacerbation of sharp right lower abdominal pain that began 12 hours ago. A transabdominal ultrasound demonstrates a 14-cm complex right ovarian mass featuring prominent solid components. Her urine pregnancy test is negative. Arrange the following interventions in the most appropriate chronological sequence for the standard diagnostic workup and definitive management of this patient.

A team of academic cardiologists is investigating a suspected link between a newly released migraine prophylactic medication and the development of early-onset atrial fibrillation. Because this specific arrhythmia is highly uncommon in young adults, the researchers query a national cardiovascular registry to identify 150 patients under the age of 40 who were diagnosed with atrial fibrillation within the past year. They also identify 600 subjects without a history of arrhythmia from a national primary care database, ensuring these individuals have similar age, sex, and body mass index distributions as the registry patients. The investigators then review the comprehensive electronic health records of all 750 participants to determine if they had been prescribed the novel migraine medication prior to the study date. Which of the following statements regarding the design and methodology of this study are correct? (Select all that apply)

During a home renovation project, a 55-year-old contractor falls approximately 4 meters (13 feet) from a scaffold, landing forcefully on his left side. He is rapidly transported to the local trauma center. On primary survey, his airway is patent and breath sounds are clear and equal bilaterally. Cervical spine precautions are maintained. Vital signs show a heart rate of 132/min, blood pressure of 78/48 mmHg, and respiratory rate of 22/min. Peripheral pulses are weak and thready. Physical examination reveals significant ecchymosis over the left lower rib cage. The abdomen is distended, diffusely tender to palpation, and exhibits involuntary guarding. The pelvis is clinically stable to anterior-posterior and lateral compression. Bedside ultrasonography of the left upper quadrant demonstrates a distinct anechoic fluid collection between the spleen and the left kidney. Which of the following is the most appropriate next step in management?

A multiparous patient in her late fifties reports involuntary loss of urine that occurs exclusively when she sneezes, coughs, or participates in high-impact aerobics. Physical examination confirms the diagnosis without evidence of concurrent urgency symptoms or significant pelvic organ prolapse. According to standard urogynecologic protocols for this specific condition, arrange the following therapeutic interventions in the correct order of clinical escalation, starting with the least invasive initial recommendation and progressing to definitive surgical treatments.

A 74-year-old woman is brought to the emergency department due to sudden-onset, severe abdominal pain that began 3 hours ago. She reports nausea and one episode of non-bloody emesis. Her past medical history is significant for heart failure with preserved ejection fraction and paroxysmal atrial fibrillation, for which she recently stopped taking her prescribed direct oral anticoagulant due to financial constraints. Temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $142/85$ mmHg, pulse is $118$/min and irregular, and respirations are $20$/min. Physical examination reveals a soft, non-distended abdomen with diffuse mild tenderness to deep palpation, but no rebound tenderness, guarding, or rigidity. Bowel sounds are hypoactive. Rectal examination shows trace heme-occult positive stool. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$, serum bicarbonate of $16$ mEq/L, and serum lactate of $4.8$ mmol/L. Based on standard surgical guidelines, arrange the following management steps in the most appropriate chronological order for this patient.

Paramedics rush a 68-year-old retired teacher into the resuscitation bay after he collapsed at home. His wife reports that he suddenly grabbed his chest and screamed about an agonizing pain tearing through his back before losing consciousness. His medical records indicate a history of chronic tobacco use, severe hypertension, and a previously documented descending thoracic aortic aneurysm measuring 6.1 cm in diameter. Current vital signs exhibit profound hemodynamic collapse: blood pressure is 68/38 mm Hg and heart rate is 128/min with a weak, thready pulse. Point-of-care ultrasound of the chest reveals a massive collection of fluid in the left pleural space. The patient remains unresponsive. Which of the following is the most appropriate next step in management?

A $68$-year-old man comes to the clinic reporting a $6$-month history of bilateral leg pain, tingling, and cramping. The symptoms consistently begin after walking for about $10$ minutes and radiate from his lower back down the posterior aspect of both thighs to the calves. He notes that the discomfort is significantly relieved when he sits down or leans forward on a shopping cart at the grocery store, but it does not improve when he simply stops walking and stands upright. He has a medical history of hypertension and hyperlipidemia. Vital signs are within normal limits. Physical examination reveals normal muscle strength ($5/5$) and intact deep tendon reflexes in both lower extremities. Dorsalis pedis and posterior tibial pulses are $2+$ bilaterally. The skin on the lower legs is warm with normal hair distribution. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient's condition?

A 71-year-old man is evaluated on the surgical floor for acute-onset dyspnea, orthopnea, and palpitations. He underwent an elective open left radical nephrectomy for localized renal cell carcinoma 48 hours ago. The patient has a history of chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy. His current medications include inhaled umeclidinium, low-dose aspirin, and atorvastatin. Temperature is 37.8°C (100.0°F), blood pressure is 105/65 mm Hg, pulse is 115/min and irregularly irregular, and respirations are 28/min. Pulse oximetry shows 89% on room air. The patient is sitting on the edge of the bed and using accessory muscles of respiration. Neck examination demonstrates distended jugular veins while upright. Pulmonary auscultation reveals bilateral dependent crackles, but no expiratory wheezing is present. Cardiac examination confirms an irregular rhythm with a prominent S3 gallop. The surgical incision is well-approximated with no purulent drainage. Which of the following are the most appropriate immediate steps in the management of this patient? (Select all that apply)

A psychiatric hospital is updating its standardized clinical pathways for medication safety. Match each psychotropic medication with the most appropriate baseline or ongoing screening modality required to monitor its specific adverse effect profile.

A 5-year-old boy recently immigrated to the United States and has an unknown immunization history. He 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 patient appears highly anxious, toxic, and is sitting leaning forward with his neck extended. He is drooling profusely and has a muffled voice, but no cough is noted. Vital signs reveal a temperature of 39.8°C (103.6°F), heart rate of 145/min, respiratory rate of 42/min, and oxygen saturation of 91% on room air. Marked inspiratory stridor and suprasternal retractions are present. Arrange the following management steps in the most appropriate and safest sequence for this patient.