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A 28-year-old woman comes to the clinic for a routine follow-up. She has a 5-year history of bipolar I disorder. Six months ago, she experienced a severe manic episode, and her psychiatric medication regimen was changed due to inadequate symptom control on lithium therapy. At that time, she was transitioned to a different mood stabilizer, and her mood symptoms have remained well-controlled since. She has no other medical conditions. Her only other medication is a combined oral contraceptive pill (ethinyl estradiol and levonorgestrel), which she has taken consistently at the same time every day for the past 3 years without any missed doses. Today, the patient reports a 6-week history of amenorrhea, breast tenderness, and morning nausea. A urine pregnancy test in the clinic is positive. Which of the following psychiatric medications was most likely initiated six months ago?

A son brings his 68-year-old mother to the geriatric psychiatry clinic due to a 6-week history of profound lethargy, worsening sadness, and uncharacteristic behavior. He reports that she now spends most of her day in bed and has lost 4.5 kg (10 lb) due to a near-total loss of appetite. During the interview, the patient repeatedly states that her internal organs are 'turning to dust' as a punishment for her past sins, and she mentions hearing a male voice that agrees with her. Her medical history includes severe osteoarthritis, for which she takes scheduled tramadol and acetaminophen. A review of her past psychiatric history reveals that at age 40, she experienced a 3-week episode characterized by a severely decreased need for sleep, rapid and pressured speech, and grandiose plans to start a nationwide business, which resulted in an involuntary psychiatric hospitalization. She was treated with medication at the time but discontinued it shortly after discharge and has not taken any psychiatric medications since. Vital signs are within normal limits. Physical examination is unremarkable. Which of the following is the most appropriate next step in management?

A 31-year-old woman is brought to the emergency department after a high-speed motor vehicle collision. She was an unrestrained front-seat passenger, and her knees forcibly struck the dashboard during the impact. She is in severe distress and complains of excruciating right hip pain. Vital signs are temperature 37.1°C (98.8°F), pulse 105/min, blood pressure 122/78 mm Hg, and respirations 18/min. On physical examination, the right lower extremity is shortened, adducted, and internally rotated. Peripheral pulses are 2+ and symmetric. Neurologic examination reveals decreased sensation to pinprick over the dorsum of the right foot and an inability to actively dorsiflex the right ankle. Anteroposterior radiographs of the pelvis demonstrate a posterior dislocation of the right femoral head with no obvious displaced acetabular or femoral neck fractures. Which of the following is the most appropriate next step in management?

During morning rounds, a 74-year-old male is evaluated in the surgical intensive care unit due to progressive dyspnea and mild confusion. The patient is 72 hours status post an uncomplicated Billroth II subtotal gastrectomy for a refractory peptic ulcer. His past medical history is significant for essential hypertension and osteoarthritis. He has received a total of $7.5\text{ L}$ of isotonic crystalloid since the operation and has had a cumulative urine output of $1.8\text{ L}$. Vital signs demonstrate a temperature of $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), blood pressure of $162/94\text{ mm Hg}$, pulse of $118/\text{min}$, and respiratory rate of $28/\text{min}$. Pulse oximetry shows an oxygen saturation of $87\%$ on room air. Physical examination reveals elevated jugular venous pressure. Lung auscultation demonstrates bilateral basilar crackles and diffuse expiratory wheezing. The abdomen is soft, mildly tender at the incision site, and non-distended, with intact surgical dressings and no erythema. Which of the following are the most appropriate immediate steps in the management of this patient? (Select exactly two options)

A 45-year-old woman is brought to the emergency department due to progressively worsening abdominal pain. Two days ago, she developed diffuse, crampy abdominal pain associated with nausea and bilious vomiting. Over the past 4 hours, the pain has become severe and constant. She has not passed flatus or stool for 24 hours. Her past medical history is notable for an open abdominal hysterectomy performed four years ago. Her temperature is 38.9°C (102°F), blood pressure is 85/50 mmHg, pulse is 125/min, and respirations are 22/min. Physical examination reveals a distended abdomen that is rigid, with diffuse rebound tenderness and involuntary guarding. Laboratory studies show a leukocyte count of 19,500/mm³ and a serum lactate level of 4.8 mmol/L. Which of the following is the most appropriate next step in management?

Three weeks after surviving an armed robbery at his workplace, a 35-year-old bank teller is brought to the psychiatry clinic by his husband. The patient was held at gunpoint for several minutes during the incident. Since that day, he reports experiencing intense, distressing flashbacks of the weapon being pointed at his face, which often cause him to wake up sweating in the middle of the night. He strongly refuses to return to the bank, avoids watching any media that might depict crime, and states that he feels completely detached from his family. His husband notes that the patient is constantly "on edge" and becomes easily startled by sudden, normal noises like a door closing. He has no significant past medical or psychiatric history and takes no medications. The patient requests a daily medication to suppress his memories and reduce his hyperarousal. Which of the following is the most appropriate next step in management?

A 20-year-old male university student is brought to the emergency department by his roommate due to severe agitation and confusion. The roommate reports that the patient has been acting increasingly bizarre over the last six hours. When questioned, the roommate admits the patient ingested multiple bottles of over-the-counter dextromethorphan-containing cough syrup earlier today in an attempt to experience hallucinations. The patient has a history of major depressive disorder, for which he takes daily fluoxetine. Vital signs show a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), pulse of $134/\text{min}$, blood pressure of $172/105\text{ mmHg}$, and respiratory rate of $22/\text{min}$. Physical examination reveals a diaphoretic, flushed young man who is disoriented to time and place. He exhibits spontaneous muscle twitching and a coarse bilateral tremor. Neurologic examination is notable for marked hyperreflexia in the lower extremities and sustained ocular clonus. In addition to providing intravenous fluids and supportive care, which of the following is the most appropriate next step in management?

Match each clinical trauma presentation with the most appropriate next step in definitive diagnosis or management.

In the emergency trauma setting, acute musculoskeletal injuries frequently compromise adjacent anatomical structures. Match each acute orthopedic injury pattern with its most commonly associated critical neurovascular consequence or expected physical examination finding.

A 25-year-old male is brought to the emergency department after falling 20 feet from a roof. He is unconscious, hypotensive, and has obvious facial trauma. Arrange the following steps of his initial assessment and management in the correct chronological order according to Advanced Trauma Life Support (ATLS) protocols.

A 34-year-old woman is brought to the emergency department after falling approximately 15 feet from a roof. Upon arrival, she is lethargic but responsive to painful stimuli. Her blood pressure is 78/45 mmHg, and her heart rate is 132/min. Oxygen saturation is 96% on room air. Her airway is clear, and breath sounds are present and equal bilaterally. The abdomen appears distended and is tense on palpation. A bedside focused assessment with sonography in trauma (FAST) reveals a significant amount of anechoic fluid surrounding the spleen and liver. Which of the following is the most appropriate next step in management?

Emergency medical services bring a 26-year-old woman to the hospital due to severe agitation and confusion that began abruptly this morning. According to her roommate, the patient has been recovering from an upper respiratory tract infection over the past few days and recently started taking a new over-the-counter syrup for a persistent, dry cough. Her only daily prescription medication is citalopram for major depressive disorder. Upon arrival, the patient appears profoundly restless and disoriented. Vital signs show a temperature of 38.9°C (102.0°F), blood pressure of 162/94 mm Hg, heart rate of 128/min, and respiratory rate of 22/min. Physical examination reveals warm, diaphoretic skin and visibly dilated pupils. She has continuous rhythmic muscle twitching in her lower extremities, brisk patellar reflexes (4+ bilaterally), and sustained ankle clonus. Which of the following active ingredients is most likely present in the cough medication this patient consumed?

A 32-year-old woman is evaluated in the psychiatry clinic for ongoing management of major depressive disorder. She initially presented two years ago with a 3-month history of pervasive sadness, anhedonia, significant weight loss, and severe insomnia leading to functional impairment at work. Over the course of her illness, she has required progressive escalation of her treatment regimen due to inadequate responses. Arrange the following therapeutic interventions in the generally accepted chronological sequence that her physician would have followed, from initial diagnosis to the management of severe, treatment-resistant symptoms.

A 31-year-old man with a known diagnosis of schizophrenia is brought to the emergency department by police due to severe agitation and threatening behavior. He is pacing rapidly in the examination room, yelling at staff, actively responding to internal stimuli, and clenching his fists. Arrange the following management steps in the most appropriate sequential order for this patient, from the initial approach to the intervention of absolute last resort.

Match each acute medication-induced psychiatric emergency or toxidrome with its most appropriate specific therapeutic intervention.

A 41-year-old man is evaluated on the surgical floor due to a new-onset fever and abdominal discomfort. He is currently on postoperative day 7 following an emergency laparoscopic appendectomy for ruptured appendicitis. The patient was tolerating a regular diet until yesterday, when he developed anorexia, nausea, and a progressively worsening ache in his right lower quadrant. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), pulse is $112/\text{min}$, respirations are $18/\text{min}$, and blood pressure is $118/76\text{ mm Hg}$. Physical examination reveals a mildly distended abdomen with focal deep tenderness in the right lower quadrant. There is no rebound tenderness or guarding. Bowel sounds are hypoactive. The laparoscopic port incisions are clean, dry, and intact with no surrounding erythema, induration, or purulent drainage. Laboratory studies show a leukocyte count of $17,500/\text{mm}^3$ with $85\%$ neutrophils. Which of the following is the most appropriate next step in management?

Match the following complex trauma patient presentations with the most appropriate definitive next step in their diagnostic or therapeutic management. Assume all patients have established, secure airways and are receiving appropriate initial fluid resuscitation.

A 62-year-old man presents to the emergency department with a 3-day history of progressively worsening left lower quadrant abdominal pain, subjective fevers, and nausea. He has a history of diet-controlled type 2 diabetes and hypertension. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $128/82\text{ mm Hg}$, pulse is $98/\text{min}$, and respirations are $18/\text{min}$. Physical examination demonstrates marked tenderness to palpation in the left lower quadrant with localized guarding, but no diffuse rigidity or generalized rebound tenderness. Bowel sounds are hypoactive. Laboratory results show a leukocyte count of $16,500/\text{mm}^3$ with a left shift.

Arrange the following management steps in the most appropriate chronological order for this patient's anticipated clinical course.

A 52-year-old male with a surgical history of an open appendectomy 10 years ago presents with severe, colicky abdominal pain, intractable vomiting, and failure to pass flatus for the past 24 hours. Vital signs reveal a heart rate of 105/min and blood pressure of 115/75 mmHg. Examination shows a distended, tympanitic abdomen without rebound tenderness or guarding. Arrange the following interventions in the most appropriate chronological order for his initial evaluation and management.

A 41-year-old factory worker is evaluated in the resuscitation bay following an industrial explosion inside an enclosed warehouse. Physical examination reveals singed facial hair, hoarseness, carbonaceous sputum, and extensive blistering over the anterior chest and both upper extremities.

Arrange the following acute management steps in the correct chronological sequence according to standard trauma life support protocols.