Tüm alıştırma soruları

Match each clinical presentation of an acute abdominal condition with its most appropriate initial definitive management step.

A 59-year-old woman arrives at the emergency department via ambulance with acute, severe respiratory distress. She awoke from sleep two hours ago gasping for air. Her medical history includes hypertension, diet-controlled type 2 diabetes mellitus, and a 35-pack-year smoking history. She has not seen a physician in three years and does not take any daily medications. On arrival, the patient is diaphoretic, sitting bolt upright, and using accessory muscles of respiration. She is unable to speak in full sentences. Vital signs show a temperature of $37.1^\circ\text{C}$, blood pressure of $220/115$ mm Hg, pulse of $128$/min, and respiratory rate of $34$/min. Pulse oximetry shows an oxygen saturation of $83\%$ on room air. Physical examination reveals an estimated jugular venous pressure of $12$ cm H $_2$ O. Chest auscultation demonstrates loud, diffuse expiratory wheezing bilaterally with a prolonged expiratory phase; no crackles are appreciated. Cardiac examination reveals a regular tachycardia with a prominent S4 gallop. There is no peripheral edema. A portable chest radiograph shows prominent pulmonary vasculature and peribronchial cuffing, without focal consolidation. Arterial blood gas analysis on room air reveals:

pH: $7.14$
PaCO $_2$: $65$ mm Hg
PaO $_2$: $52$ mm Hg
HCO $_3^-$: $21$ mEq/L

The patient is immediately placed on noninvasive positive-pressure ventilation (NIPPV). Which of the following is the most appropriate next step in pharmacologic management?

A 32-year-old woman is brought to the emergency department by her husband due to confusion, severe agitation, and palpitations. She has a history of hyperthyroidism but stopped taking her medications three months ago. On presentation, her temperature is $39.4^\circ\text{C}$ ($103^\circ\text{F}$), blood pressure is $150/70\text{ mm Hg}$, and heart rate is $148/\text{min}$ and irregular. Physical examination reveals a staring gaze, a diffusely enlarged and non-tender thyroid gland, and a fine tremor in both hands. An electrocardiogram shows atrial fibrillation with a rapid ventricular response. A clinical diagnosis of thyroid storm is made. Arrange the following interventions in the most appropriate chronological sequence for the management of this patient, from initial acute stabilization to definitive long-term therapy.

A $28$-year-old man comes to the physician for a new patient evaluation. He has no physical complaints. When asked about medication use, he admits to self-administering intramuscular testosterone for the past $2$ years to assist with bodybuilding. He denies fatigue, heat or cold intolerance, or changes in bowel habits. Vital signs are within normal limits. Physical examination reveals a heavily muscled physique, scattered cystic acne on the shoulders, and bilateral testicular atrophy. The thyroid gland is palpably normal in size without nodules.

Routine laboratory screening is performed, and results show:

Based on the laboratory findings, which of the following is the most appropriate next step in management?

An evaluating physician assesses a 31-year-old female in the urgent care clinic. She reports a two-week duration of severe joint pain affecting her wrists and knees, accompanied by daily fevers. She states her temperature consistently spikes to $39.5^{\circ}\text{C}$ ($103.1^{\circ}\text{F}$) in the late afternoon and returns to normal by the following morning. During these febrile episodes, she notices a faint, salmon-colored rash on her trunk that completely resolves once the fever breaks. Her medical history is notable for bipolar disorder, which is currently managed with lithium and a recently added selective serotonin reuptake inhibitor.

Vital signs are temperature $39.4^{\circ}\text{C}$ ($102.9^{\circ}\text{F}$), blood pressure $118/76\text{ mm Hg}$, pulse $112/\text{min}$, and respirations $18/\text{min}$. Physical examination confirms a macular, salmon-colored rash on the chest and abdomen. The wrists and knees exhibit mild effusions and tenderness to palpation bilaterally.

Laboratory studies show:

Blood and urine cultures obtained 48 hours ago demonstrate no growth.

Which of the following is the most appropriate next step in the management of this patient's current symptoms?

A $75$-year-old man is evaluated in the intensive care unit due to a sudden deterioration in his clinical status. He was admitted $14$ days ago for an open repair of a ruptured abdominal aortic aneurysm. His recovery has been complicated by prolonged mechanical ventilation and reliance on total parenteral nutrition. Over the past $3$ days, he developed progressive abdominal distension and high-volume bilious drainage from a nasogastric tube. He has not had a bowel movement for a week.

This morning, his temperature spiked to $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$). His blood pressure dropped to $82/50 \text{ mmHg}$, and his heart rate is $122/\text{min}$. He is receiving a continuous infusion of norepinephrine, and broad-spectrum intravenous antibiotics (piperacillin-tazobactam) have been initiated.

Physical examination demonstrates a markedly distended and tympanitic abdomen with absent bowel sounds. There is focal tenderness to deep palpation in the right upper quadrant.

Laboratory studies:
Leukocyte count: $25,500/\text{mm}^3$ (with $15\%$ bands)
Hemoglobin: $9.8 \text{ g/dL}$
Total bilirubin: $3.1 \text{ mg/dL}$
Alkaline phosphatase: $340 \text{ U/L}$
Aspartate aminotransferase (AST): $92 \text{ U/L}$
Lactate: $4.8 \text{ mmol/L}$

A portable abdominal radiograph shows diffuse dilation of both the small and large intestines without a discrete transition point. No pneumoperitoneum is present. A bedside right upper quadrant ultrasound reveals a distended gallbladder with a wall thickness of $7 \text{ mm}$, pericholecystic fluid, and no intraluminal echogenic shadowing. The common bile duct diameter is $4 \text{ mm}$.

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

A 48-year-old man is evaluated in the hospital for new-onset chest discomfort and lightheadedness. He was admitted 5 days ago for methicillin-susceptible *Staphylococcus aureus* (MSSA) bacteremia and suspected infective endocarditis. He has a history of intravenous drug use. A transthoracic echocardiogram on admission showed a 1.2-cm vegetation on the right coronary cusp of the aortic valve with mild aortic regurgitation. He was started on targeted therapy with intravenous oxacillin. Today, he reports feeling weak and dizzy when sitting up in bed, along with a vague, substernal tightness. His temperature is 38.4°C (101.1°F), blood pressure is 102/60 mm Hg, and pulse is 58/min. Physical examination reveals an early diastolic decrescendo murmur at the left sternal border. The lungs have fine bibasilar crackles. An electrocardiogram is obtained which shows a sinus rhythm with a PR interval of 0.28 seconds and a new left bundle branch block. Which of the following is the most appropriate next step in management?

A 35-year-old nulliparous woman is brought to the emergency department 5 days after undergoing an uncomplicated laparoscopic left ovarian cystectomy with fulguration of pelvic endometriosis. For the past 24 hours, she has experienced progressive, severe generalized abdominal pain accompanied by nausea and multiple episodes of emesis. Her temperature is 39.2°C (102.6°F), blood pressure is 86/54 mm Hg, and pulse is 128/min. She appears toxic and diaphoretic. Physical examination reveals a rigid, significantly distended abdomen with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent. Laboratory studies show a leukocyte count of 22,000/mm³ with a marked left shift. Which of the following is the most appropriate next step in management?

A $71$-year-old woman comes to the office due to a $4$-month history of urinary dribbling, frequent small voiding, and pelvic pressure. The patient says, 'I feel like a ball is falling out of my vagina.' She also notes occasional faint pink spotting on her underwear after wiping, which she attributes to the bulge rubbing against her clothing. She does not take any medications and has never used hormone therapy. Vital signs are within normal limits. Pelvic examination reveals a large anterior vaginal mass extending $2$ cm beyond the hymenal ring with the Valsalva maneuver. The mucosal surface of the prolapsed tissue is thinned, erythematous, and has a superficial $1$-cm abrasion that is oozing a minute amount of blood. Post-void residual volume is $350$ mL. Urinalysis shows trace leukocyte esterase but is negative for nitrites. Which of the following is the most appropriate initial management for this patient?

A $9$-year-old boy is brought to the pediatric clinic due to facial asymmetry that began yesterday. The patient's mother reports he has been unusually tired and has had a low-grade fever for the past $4$ days. Exactly $3$ weeks ago, the family returned from a camping trip in Connecticut. On physical examination, temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), heart rate is $92\text{/min}$, and blood pressure is $105/65\text{ mm Hg}$. There is pronounced drooping of the right side of his face, involving both the upper and lower facial muscles. He is unable to completely close his right eye. Neurologic examination is otherwise entirely normal; there is no nuchal rigidity, photophobia, or altered mental status. Cardiovascular examination reveals a regular rhythm with no murmurs. Skin examination reveals a $7\text{-cm}$ annular erythematous plaque with central clearing on the posterior left thigh. Which of the following is the most appropriate next step in management?

A 38-year-old woman presents to the urogynecology clinic complaining of an 8-month history of continuous postvoid dribbling, dysuria, and pelvic pressure. She also reports deep dyspareunia. Over the past year, she has visited urgent care clinics on three separate occasions for presumed urinary tract infections; each time, she received a short course of oral antibiotics which provided temporary relief of her dysuria. Her past medical history is notable for a spontaneous vaginal delivery $4$ years ago complicated by a prolonged second stage of labor. Vital signs are within normal limits. Pelvic examination reveals normal external genitalia. Speculum examination demonstrates a $3$ cm, exquisitely tender, fluctuant, cystic mass located on the anterior vaginal wall. Gentle palpation of this mass expresses a small amount of purulent discharge from the urethral meatus. Urinalysis demonstrates $15$-$20$ leukocytes per high-power field, positive leukocyte esterase, and negative nitrites. Which of the following is the most appropriate next step in management?

A 24-year-old man is brought to the outpatient psychiatric clinic by his parents. For the past 10 weeks, he has been isolating himself in his bedroom, claiming that foreign intelligence agents are surveilling him through the electrical outlets. His parents frequently hear him conversing with people when he is alone. During this time, his personal hygiene has significantly deteriorated, and he was fired from his job as a data analyst. He has no prior history of psychiatric illness and does not use alcohol or illicit substances. His medical history is unremarkable, and a recent comprehensive metabolic panel and urine toxicology screen were normal. The physician initiates antipsychotic pharmacotherapy. During a family session, the parents ask for clarification about his exact diagnosis and what to expect for his future. Which of the following is the most accurate statement regarding this patient's diagnosis and long-term prognosis?

A 72-year-old man is evaluated on hospital day 3 for discharge planning. He was initially admitted with fever, productive cough, and left-sided pleuritic chest pain. Chest radiography on admission demonstrated a dense left lower lobe consolidation. He was started on empiric intravenous ceftriaxone and azithromycin. Two sets of blood cultures drawn upon presentation have grown *Streptococcus pneumoniae*. Antimicrobial susceptibility testing is reported as follows:

The patient's clinical status has markedly improved. He has been afebrile for 24 hours, maintains an oxygen saturation of 96% on room air, and is tolerating an oral diet. His medical history includes hypertension and benign prostatic hyperplasia. He has no known drug allergies. The plan is to discharge the patient to complete a total 7-day course of antibiotics at home. Which of the following is the most appropriate oral antibiotic to prescribe for discharge?

A 34-year-old graphic designer comes to the office for a follow-up visit. Four weeks ago, she presented with pervasive sadness, hypersomnia, increased appetite, and a heavy feeling in her limbs. She was diagnosed with a major depressive episode and started on sertraline 50 mg daily. Today, she reports that her mood has not improved and she is frustrated. She says, "I stopped taking the pill three days ago because it wasn't working fast enough. Can we just try something else?" Upon further questioning, the patient mentions that three years ago, she experienced a 10-day period where she felt "incredibly energized," required only 2 hours of sleep per night without feeling tired, and impulsively drained her savings account to start a speculative business venture that quickly failed. She has no history of hallucinations or delusions. Physical examination is unremarkable. Which of the following is the most appropriate next step in management?

A physician is evaluating a menopausal patient who reports a recent onset of unprovoked vaginal spotting. The patient's last menstrual cycle occurred $4$ years ago. Her past medical history is significant for a localized, hormone-receptor-positive invasive ductal carcinoma of the breast, which was treated with a lumpectomy and radiation therapy $3$ years ago. Since completing radiation, she has been maintained on daily tamoxifen therapy. She denies pelvic pain, dyspareunia, and weight loss. Vital signs are within normal limits. On speculum examination, the vaginal mucosa appears pale and thin, and the cervix is grossly normal without visible lesions. A trace amount of dark blood is noted in the vaginal vault. Transvaginal ultrasonography demonstrates a symmetrically thickened endometrial stripe measuring $8$ mm, with scattered subendometrial cystic spaces. Which of the following is the most appropriate next step in the management of this patient?

A medical student is reviewing normal gross motor developmental milestones in preparation for performing routine well-child screening examinations. Arrange the following gross motor milestones in the chronological order they typically appear in a healthy infant.

A 54-year-old man is evaluated in the hospital on the third day of his admission for community-acquired pneumonia. He was initially started on empiric therapy with intravenous ceftriaxone and azithromycin. Today, the patient reports feeling much better and has a good appetite. His temperature is 37.1°C (98.8°F), blood pressure is 124/78 mm Hg, pulse is 76/min, and respiratory rate is 16/min. He is tolerating a regular diet. Blood cultures drawn on admission are negative. Sputum cultures have grown *Streptococcus pneumoniae*. Susceptibility testing indicates the isolate is sensitive to penicillin, amoxicillin, levofloxacin, and vancomycin. Which of the following is the most appropriate next step in this patient's management?

Match each pediatric patient scenario with the most appropriate specific preventive care or immunization recommendation.

A 74-year-old man is evaluated in the hospital for severe, sudden-onset abdominal pain. He was admitted 3 days ago for shortness of breath and lower extremity edema, for which he has been receiving intravenous furosemide. His medical history is significant for ischemic cardiomyopathy, persistent atrial fibrillation, and chronic obstructive pulmonary disease (COPD). On examination today, he appears in acute distress. His temperature is 37.8°C (100°F), blood pressure is 105/65 mm Hg, pulse is 118/min and irregularly irregular, and respirations are 24/min. The abdomen is moderately distended but remarkably soft and non-tender to deep palpation; bowel sounds are hypoactive.

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

During a routine health maintenance visit, the parents of a 2-year-old male toddler report anxiety regarding his speech progression. While his peers are beginning to combine words, he currently relies on a vocabulary of approximately 10 to 12 isolated words. He does not yet link words together. He frequently communicates his desires by pointing and grunting, though he readily responds when his name is called and follows simple verbal instructions like "give me the block."

His birth history and past medical history are unremarkable. A parental autism screening questionnaire administered today is negative for behavioral red flags.

Physical examination reveals an alert, socially engaging child who makes appropriate eye contact. He runs steadily, kicks a small ball without falling, and can build a tower using six wooden blocks. He assists his parents in taking off his jacket. Tympanic membranes are translucent with a normal light reflex bilaterally. Which of the following is the most appropriate next step in the evaluation of this patient?