Tüm alıştırma soruları

A 60-year-old woman is evaluated on postoperative day 6 following a robotic-assisted total hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer. Her recovery had been uncomplicated until this morning, when she developed a mild fever and sudden-onset shortness of breath. Her temperature is 38.2°C (100.8°F), blood pressure is 110/70 mm Hg, pulse is 112/min, and respirations are 24/min. Pulse oximetry shows an oxygen saturation of 92% on room air. Physical examination reveals clear breath sounds bilaterally. The abdominal surgical incisions are clean, dry, and intact with no surrounding erythema. Her right calf appears mildly swollen and is tender to palpation compared to the left. Which of the following are the most appropriate next steps in the management of this patient? (Select two)

A 38-year-old female is brought to the emergency department after a snowmobile collision in which she struck a tree at high speed. On arrival, she is lethargic and pale. Her temperature is 36.1°C (97.0°F), blood pressure is 74/42 mmHg, heart rate is 136/min, and respiratory rate is 24/min. Oxygen saturation is 96% on a non-rebreather mask. Two large-bore intravenous lines are established, and she receives 1 L of warmed lactated Ringer solution and 1 unit of uncrossmatched type O-negative packed red blood cells. Reassessment reveals a blood pressure of 76/40 mmHg and a heart rate of 132/min. Primary survey shows a patent airway and equal breath sounds bilaterally. A portable chest radiograph demonstrates a widened mediastinum and blurring of the aortic knob but no pneumothorax or hemothorax. A focused assessment with sonography for trauma (FAST) examination reveals a large amount of anechoic fluid in the hepatorenal recess (Morison pouch). An anteroposterior pelvic radiograph shows an intact pelvic ring with no fractures. Which of the following is the most appropriate next step in management?

A 72-year-old man is evaluated on postoperative day 4 following an elective right hemicolectomy for colon cancer. He has a history of chronic obstructive pulmonary disease (COPD). Yesterday, he developed a fever of 38.6°C (101.5°F). At that time, blood, urine, and sputum cultures were obtained, and empiric intravenous piperacillin-tazobactam was initiated. Today, his temperature is 38.2°C (100.8°F), blood pressure is 120/78 mmHg, and heart rate is 88/min. Lung auscultation reveals mild expiratory wheezing consistent with his baseline COPD, but no crackles or signs of respiratory distress. His surgical incision is clean, dry, and intact with no erythema. The indwelling urinary catheter, placed just before surgery, is still present. Urine culture results have just returned, showing greater than $10^5$ CFU/mL of Escherichia coli. The isolate is susceptible to ceftriaxone, ciprofloxacin, and trimethoprim-sulfamethoxazole, but resistant to ampicillin. Blood and sputum cultures show no growth so far. Which of the following are appropriate next steps in the management of this patient? (Select all that apply.)

A 34-year-old woman is evaluated on the surgical ward 30 hours after undergoing an elective laparoscopic myomectomy for symptomatic uterine fibroids. The nursing staff notifies the physician because the patient's temperature has increased to 38.4°C (101.1°F). She is resting comfortably in bed and reports mild soreness at the surgical port sites. Her blood pressure is 118/76 mm Hg, pulse is 82/min, and respirations are 16/min. Pulse oximetry shows 98% on room air. Physical examination reveals clear lungs bilaterally, normal active bowel sounds, and non-erythematous incisions without any discharge or induration. Which of the following are the most appropriate next steps in managing this patient? (Select exactly 2 options)

A 24-year-old male is brought to the emergency department via ambulance following a high-speed motorcycle collision. He was found approximately 30 feet from his motorcycle. On arrival, he is moaning but not following commands. His blood pressure is 80/40 mmHg, and his heart rate is 132/min. Arrange the following steps of his initial trauma evaluation and management in the most appropriate chronological order.

A 35-year-old woman presents to the clinic after noticing a lump in her neck while applying lotion. She denies weight changes, palpitations, heat or cold intolerance, or changes in bowel habits. She has no family history of thyroid disease or head and neck irradiation. Vital signs are within normal limits. Physical examination reveals a 1.5-cm, firm, mobile nodule in the left lobe of the thyroid gland. There is no cervical lymphadenopathy. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 2.8 µU/mL (normal: 0.4–4.0 µU/mL) and a free T4 of 1.2 ng/dL (normal: 0.9–2.4 ng/dL). An ultrasound of the neck demonstrates a 1.6-cm solid, hypoechoic nodule with irregular margins and microcalcifications in the left thyroid lobe. Which of the following is the most appropriate next step in management?

A 73-year-old man presents to the emergency department with severe, progressively worsening shortness of breath over the past 48 hours. His medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of 35%, severe chronic obstructive pulmonary disease, and stage 3 chronic kidney disease. The patient reports having to sleep upright in a chair to breathe. Temperature is 37.0°C (98.6°F), blood pressure is 168/94 mm Hg, pulse is 112/min, and respirations are 26/min. Pulse oximetry shows 86% on room air. Physical examination reveals use of accessory muscles of respiration. Jugular venous pressure is estimated at 10 cm $H_2O$. Chest auscultation reveals bilateral basilar crackles extending to the mid-lung fields and prolonged expiration with diffuse end-expiratory wheezes. Lower extremities show 2+ pitting edema.

Laboratory results are as follows:
Sodium: 138 mEq/L
Potassium: 4.8 mEq/L
Chloride: 104 mEq/L
Bicarbonate: 16 mEq/L
Blood urea nitrogen: 42 mg/dL
Creatinine: 2.1 mg/dL (baseline 1.8 mg/dL)
Lactic acid: 3.8 mmol/L
Thyroid-stimulating hormone (TSH): 0.9 $\mu$ U/mL (Normal: 0.4-4.0 $\mu$ U/mL)
Free T4: 0.6 ng/dL (Normal: 0.9-1.7 ng/dL)

Arterial blood gas on room air:
pH: 7.30
$PaCO_2$: 31 mm Hg
$PaO_2$: 54 mm Hg

Chest radiograph demonstrates cardiomegaly, bilateral hazy perihilar opacities, and cephalization of the pulmonary vessels without focal consolidation. Which of the following is the most appropriate next step in management?

A 72-year-old woman is brought to the emergency department due to severe, worsening abdominal pain, nausea, and bilious vomiting for the past 2 days. She has not had a bowel movement or passed flatus for 48 hours. Her medical history is significant for an open total abdominal hysterectomy 15 years ago. Her temperature is 38.6°C (101.5°F), pulse is 118/min, respirations are 22/min, and blood pressure is 96/60 mm Hg. Physical examination reveals a distended abdomen with absent bowel sounds. There is severe, diffuse abdominal tenderness with guarding and rebound tenderness. Laboratory studies show:

Leukocyte count: 18,500/mm³
Lactate: 4.2 mmol/L
Bicarbonate: 14 mEq/L

An upright abdominal radiograph reveals multiple dilated loops of small bowel with air-fluid levels and a paucity of gas in the colon. No pneumoperitoneum is observed. Which of the following is the most appropriate next step in the management of this patient?

A neurosurgical team is evaluating several patients with elevated intracranial pressure and deteriorating neurologic status following severe traumatic brain injury. Match each specific brain herniation syndrome with its corresponding characteristic neuroimaging findings and clinical signs.

An emergency medical crew brings a 61-year-old woman to the hospital after she developed severe left flank pain, nausea, and acute confusion over the past 48 hours. Her medical history is notable for type 2 diabetes mellitus and recurrent cystitis. Vital signs include a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure of $84/52 \text{ mmHg}$, pulse of $122/\text{min}$, and respirations of $24/\text{min}$. Physical examination reveals marked left costovertebral angle tenderness and a lethargic affect. Laboratory testing demonstrates a leukocyte count of $22,000/\text{mm}^3$. An unenhanced computed tomography (CT) scan of the abdomen and pelvis reveals a $9\text{-mm}$ calculus lodged in the left proximal ureter, accompanied by severe hydroureteronephrosis and perinephric fat stranding. She is immediately given aggressive intravenous fluid resuscitation and broad-spectrum antibiotics (piperacillin-tazobactam). Two hours later, her blood pressure remains $86/54 \text{ mmHg}$ and her urine output is only $10 \text{ mL/hr}$. Which of the following is the most appropriate next step in management?

A $31$-year-old woman is evaluated in the emergency department for severe nausea, vomiting, diffuse muscle aches, and profound restlessness. She has a history of severe opioid use disorder. For the past three years, she has been maintained on a daily dose of $80\text{ mg}$ of methadone. Two days ago, her physician decided to transition her to sublingual buprenorphine-naloxone to provide more flexible outpatient management. She was instructed to wait until she felt withdrawal symptoms before taking her first dose. She took her last dose of methadone approximately $36$ hours ago. One hour ago, she took her first prescribed dose of sublingual buprenorphine-naloxone. Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $158/96\text{ mm Hg}$, pulse of $118\text{/min}$, and respirations of $18\text{/min}$. Physical examination reveals dilated pupils, excessive lacrimation, rhinorrhea, and piloerection. The patient's skin is clammy, and she is visibly shivering. She reports, "I thought this new medication was supposed to help, but I feel worse than I ever have." Which of the following is the most likely primary mechanism responsible for this patient's acute symptom presentation?

A 19-year-old female sophomore college student presents to the university health clinic seeking help for worsening sadness, low energy, and difficulty focusing on her coursework over the past four months. During the interview, she tearfully admits to intense dissatisfaction with her body weight. She describes periods where she consumes unusually large amounts of food in secret, immediately followed by the use of laxatives and self-induced vomiting. This cycle occurs almost daily. Her current body mass index is 22.1 $kg/m^2$. Vital signs reveal a blood pressure of 105/65 mm Hg and a heart rate of 88/min. Physical examination notes bilateral parotid gland enlargement and abrasions on the dorsal aspect of her hands.

The patient asks about starting a medication to help with her mood and eating patterns. Which of the following is the most accurate statement regarding this patient's clinical picture and pharmacological management?

A 29-year-old woman is brought to the psychiatrist by her sister due to worsening isolation and profound sadness over the past $5$ weeks. The patient sleeps $14$ hours daily and frequently hears voices stating, "You are a vessel of sin." Three years ago, she experienced a $10$-day period during which she slept only $3$ hours per night, spoke incessantly, and aggressively attempted to start a new company despite having no related experience. She has a history of primary hypothyroidism, for which she takes daily levothyroxine. Vital signs are normal. Laboratory results demonstrate a TSH of $2.2$ $\mu$ U/mL (normal: $0.4$-$4.0$ $\mu$ U/mL) and a free T4 of $1.3$ ng/dL (normal: $0.9$-$1.7$ ng/dL). Which of the following is the most appropriate next step in the management of this patient?

A 38-year-old woman comes to the clinic reporting persistent daytime fatigue and sleepiness for the past 14 months. She works as a software engineer and frequently dozes off at her desk during the mid-afternoon, occasionally making embarrassing errors in her code. She goes to bed at 10:30 PM and wakes up at 6:30 AM daily, feeling relatively refreshed initially, but severe sleepiness returns by midday. She reports that occasionally, right before drifting off to sleep at night, she hears unfamiliar voices calling her name in the room, though she lives alone. She has no episodes of sudden muscle weakness when laughing or angry. Her medical history is unremarkable, and she takes no medications. Physical examination is within normal limits. An overnight polysomnogram (PSG) reveals a total sleep time of 7.9 hours, an apnea-hypopnea index of 1.5 events/hour, and a rapid eye movement (REM) sleep latency of 10 minutes. The next day, a multiple sleep latency test (MSLT) demonstrates a mean sleep latency of 5.5 minutes and 1 sleep-onset REM period (SOREMP). Which of the following is the most appropriate next step in the management of this patient?

A quality improvement committee in a community mental health clinic is reviewing the longitudinal care of a 34-year-old man with a 10-year history of schizophrenia. His clinical course was initially complicated by frequent relapses due to medication nonadherence, and later by severe, persistent auditory hallucinations despite continuous, verified medication delivery. The committee is evaluating whether the sequence of psychopharmacological interventions followed current consensus guidelines for the stepwise management of schizophrenia and treatment-refractory psychosis. Assuming the clinical team followed standard evidence-based algorithms at each stage of his illness, arrange the following interventions in the correct chronological sequence from earliest to latest.

A 28-year-old woman at 34 weeks gestation is brought to the emergency department by paramedics following a high-speed motor vehicle collision. She has a history of schizophrenia, which had been well-controlled until she discontinued her medications one month ago. On arrival, her blood pressure is 78/40 mm Hg and her heart rate is 142/min. She is combative, actively hallucinating, and screaming, "The government is trying to steal my organs!" A Focused Assessment with Sonography for Trauma (FAST) examination reveals a large amount of free intraperitoneal fluid. Continuous fetal monitoring demonstrates recurrent late decelerations. The patient is unable to demonstrate an understanding of her medical condition or the risks of refusing treatment. Her husband arrives and immediately provides consent for an emergency exploratory laparotomy, cesarean delivery, and any necessary blood transfusions. However, a review of the patient's electronic medical record reveals a valid Advance Directive executed two years ago when she was psychiatrically stable. The document appoints her mother as her healthcare proxy and explicitly refuses the administration of all blood products under any circumstances due to religious beliefs. The mother is contacted by telephone; she confirms the Advance Directive and insists that blood products must be withheld, even if it results in the death of the patient and the fetus. Which of the following is the most appropriate next step in management?

A 27-year-old man is evaluated in an outpatient psychiatry clinic for worsening irritability. He has a history of major depressive disorder and was started on fluoxetine three weeks ago. During the interview, he becomes highly agitated and states, "My former supervisor ruined my career when he fired me last week. I bought a handgun yesterday, and I am going to his house tonight to shoot him." When the psychiatrist attempts to explore this further and suggests voluntary hospitalization, the patient abruptly stands up, refuses any further discussion, and runs out of the clinic. The psychiatrist confirms the supervisor's identity and home address in the patient's occupational history records. Which of the following is the most appropriate next step in management?

A 24-year-old male medical student presents to the university counseling center seeking help for severe anxiety regarding medical procedures. During his recent surgical clerkship, he experienced intense lightheadedness, nausea, and diaphoresis, ultimately fainting while observing a routine venipuncture. He reports having an intense fear of blood and needles since early childhood, which led him to avoid medical settings until his clinical rotations began. His physical examination and recent electrocardiogram are unremarkable. He is highly motivated to overcome this fear to successfully complete his medical training. Which of the following are the most appropriate steps in the evaluation and management of this patient? (Select 2 that apply)

A 25-year-old male fitness instructor presents to a primary care clinic reporting a 6-week history of feeling 'completely drained of energy.' He states that he has lost interest in his usual workout routines, struggles to concentrate on his business, and has been sleeping up to 13 hours a day. His medical history is unremarkable, and he currently takes no medications. Upon further questioning about his past psychiatric history, he recalls a 5-week period approximately two years ago when he felt 'invincible.' During that time, he slept only 3 hours per night, spoke incredibly fast, and spontaneously purchased extremely expensive gym equipment that led to bankruptcy. He also harbored an intense belief that he possessed a telepathic ability to communicate with elite athletes worldwide; this belief entirely resolved when his energy levels returned to baseline. His vital signs are within normal limits. Mental status examination today reveals a blunted affect and psychomotor retardation, with no current delusional thought processes or suicidal ideation. Which of the following is the most appropriate next step in pharmacologic management?

Nine days after undergoing an open right partial nephrectomy for localized renal cell carcinoma, a 58-year-old man is assessed by the surgical team prior to planned discharge. His postoperative course was notable for a urinary tract infection diagnosed on postoperative day 2, which was effectively treated with oral trimethoprim-sulfamethoxazole based on susceptibility testing. Today, the patient reports that he feels completely well, has a robust appetite, and is eager to return home. However, his vital signs show a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure of $128/82\text{ mm Hg}$, pulse of $82\text{/min}$, and respirations of $14\text{/min}$. Oxygen saturation is $98\%$ on room air. Physical examination reveals a clean, well-approximated flank incision with no erythema, induration, or drainage. The lungs are clear to auscultation bilaterally. There is no costovertebral angle tenderness. The lower extremities show no edema or calf tenderness.

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