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An otherwise healthy $52$-year-old male seeks immediate medical attention for sudden-onset shortness of breath and a sharp, right-sided chest pain that worsens with deep inspiration. His vitals show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), a blood pressure of $130/80$ mm Hg, a heart rate of $102$/min, and a respiratory rate of $20$/min. Pulse oximetry indicates an oxygen saturation of $96\%$ on room air. Cardiopulmonary auscultation is unremarkable. The evaluating physician calculates a Wells score of $1.5$, which places him in the low clinical probability category for a pulmonary embolism. Arrange the following diagnostic and therapeutic steps in the correct chronological sequence for the standard management of this patient.

A precise understanding of electrocardiographic lead localization is essential for identifying the specific coronary artery involved in an acute myocardial infarction. Match each presentation of characteristic 12-lead (and extended) ECG findings with the most likely culprit coronary artery and corresponding region of myocardial infarction.

An otherwise healthy 48-year-old male presents to the triage desk reporting a two-day history of worsening, crampy periumbilical pain. He notes several episodes of vomiting green, foul-smelling fluid since this morning and has not had a bowel movement or passed gas for the last 36 hours. Ten years prior, he underwent an open appendectomy for a perforated appendix.

Currently, his temperature is 37.9°C (100.2°F), heart rate is 115/min, respirations are 18/min, and blood pressure is 105/65 mm Hg.

Physical examination shows significant abdominal distension with tympany to percussion. Auscultation reveals a lack of bowel sounds. The abdomen is tender to deep palpation diffusely, but there is no involuntary guarding or rigidity.

Laboratory results are significant for a leukocyte count of 16,000/mm³ and a serum lactate level of 3.8 mmol/L.

A contrast-enhanced CT scan of the abdomen and pelvis displays dilated loops of small intestine with a distinct transition zone in the right lower quadrant. Additionally, there is thickening of the bowel wall, decreased enhancement of the mucosa at the transition point, and adjacent mesenteric fluid.

Based on these findings, what is the most appropriate next step in the patient's care?

A $74$-year-old woman presents to the acute care clinic with a $2$-day history of progressively worsening shortness of breath. She has a medical history significant for coronary artery disease, for which she underwent percutaneous coronary intervention $5$ years ago, and chronic obstructive pulmonary disease due to a $45$-pack-year smoking history. Over the past two nights, she has been unable to sleep flat in her bed, requiring multiple pillows to breathe comfortably. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $162/90\text{ mmHg}$, pulse is $115/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows $88\%$ on room air. Physical examination reveals distended jugular veins when the patient is seated upright. Pulmonary auscultation reveals bilateral expiratory wheezes and dullness to percussion at the bases. Cardiac auscultation demonstrates a regular tachycardia and an early diastolic, low-frequency sound. Which of the following is the most appropriate initial therapy for this patient?

A 34-year-old woman comes to the clinic reporting a persistent cough for the past 10 days. The cough is frequently productive of yellowish-green sputum. She states that she initially had a runny nose, mild sore throat, and low-grade fever that resolved after a few days, but the cough has persisted and occasionally interrupts her sleep. She has no past medical history, takes no medications, and does not smoke. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mmHg, pulse is 78/min, and respiratory rate is 14/min. Pulse oximetry is 99% on room air. Pulmonary examination reveals normal vesicular breath sounds bilaterally with no wheezes, crackles, or rhonchi. Cardiac examination shows a regular rate and rhythm with no murmurs. There is no jugular venous distention or lower extremity edema. Which of the following is the most appropriate next step in management?

Match each clinical presentation of a suspected chemotherapy-induced adverse effect with the most likely responsible antineoplastic agent.

A 45-year-old woman is brought to the emergency department by her husband due to progressive lethargy over the past 12 hours. The patient has a history of Crohn disease and has been experiencing severe, watery diarrhea for the past five days. Yesterday, she took multiple doses of a friend's prescription oxycodone to help manage her severe abdominal cramping. On physical examination, her temperature is 37.1°C (98.8°F), blood pressure is 105/65 mmHg, heart rate is 110/min, and respiratory rate is 8/min. She is somnolent but arouses to verbal stimuli. Mucous membranes are dry.

Laboratory studies show the following:

Based on the provided laboratory data, which of the following best characterizes this patient's acid-base status?

A $28$-year-old man is brought to the emergency department with a $4$-day history of progressively worsening right-sided abdominal pain, nausea, and multiple episodes of bilious vomiting. He reports an inability to pass flatus or stool for the past $24$ hours. The patient was diagnosed with Crohn's disease $6$ years ago, which had been previously well-controlled on adalimumab. However, he discontinued all medications $1$ year ago due to a loss of insurance coverage.

Vital signs show a temperature of $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), heart rate of $118/\text{min}$, blood pressure of $105/65\text{ mm Hg}$, and respiratory rate of $18/\text{min}$. Physical examination reveals dry mucous membranes. The abdomen is moderately distended with high-pitched, tinkling bowel sounds. There is marked tenderness and a palpable, tender fullness in the right lower quadrant. No diffuse rebound tenderness or abdominal rigidity is appreciated.

Laboratory studies show:
Leukocyte count: $16,500/\text{mm}^3$ (with $85\%$ neutrophils)
Hemoglobin: $11.2\text{ g/dL}$
Platelets: $450,000/\text{mm}^3$
C-reactive protein: $145\text{ mg/L}$ (Normal: $<5\text{ mg/L}$)
Lactate: $1.4\text{ mmol/L}$ (Normal: $0.5 - 2.2\text{ mmol/L}$)

Computed tomography (CT) of the abdomen and pelvis with intravenous contrast reveals dilated loops of small bowel measuring up to $4.5\text{ cm}$ in diameter. A distinct transition point is seen in the terminal ileum, which exhibits severe transmural wall thickening and mucosal hyperenhancement. Immediately adjacent to this strictured segment, there is a $5.5\text{ cm}$ well-circumscribed, rim-enhancing fluid collection containing several small locules of gas. There is no evidence of free intraperitoneal air.

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

A 62-year-old man presents to the emergency department with a 3-day history of progressive exertional dyspnea, chest tightness, and a near-syncopal episode while climbing stairs. He has a 40-pack-year smoking history and does not take any daily medications. His temperature is 37.1°C (98.8°F), blood pressure is 112/68 mmHg, pulse is 88/min, and respirations are 20/min. Pulse oximetry shows 95% on room air. Pulmonary auscultation reveals mild, bilateral end-expiratory wheezing. Cardiac examination demonstrates a prominent apical impulse and a grade 3/6 harsh systolic crescendo-decrescendo murmur heard best at the left lower sternal border. An electrocardiogram shows left ventricular hypertrophy and deep, narrow Q waves in leads I, aVL, V5, and V6. Suspecting an acute exacerbation of chronic obstructive pulmonary disease and possible cardiac ischemia, the physician administers nebulized albuterol and sublingual nitroglycerin. Twenty minutes later, the patient becomes lightheaded and lethargic. His blood pressure drops to 76/42 mmHg, and his heart rate increases to 128/min. Cardiac auscultation now reveals a significantly louder and longer systolic murmur. Which of the following is the most appropriate next step in the management of this patient's acute deterioration?

A 78-year-old woman is evaluated for sudden-onset severe shortness of breath. She was admitted to the hospital two days ago for symptomatic anemia secondary to a bleeding duodenal ulcer, which was successfully treated with endoscopic clipping. Two hours ago, she completed a transfusion of two units of packed red blood cells. She has a medical history of hypertension and chronic kidney disease. Her temperature is $37.1^\circ \text{C}$ ($98.8^\circ \text{F}$), blood pressure is $182/98\text{ mm Hg}$, pulse is $112/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows an oxygen saturation of $86\%$ on room air. Physical examination reveals elevated jugular venous pressure and a prominent $S_3$ gallop. Pulmonary auscultation reveals bilateral crackles extending to the mid-lung fields.

Relevant laboratory results are shown below:

Arterial blood gas analysis on room air shows:

A portable chest radiograph demonstrates bilateral perihilar alveolar opacities and an enlarged cardiac silhouette.

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

Emergency medical services bring a 70-year-old female resident of an assisted living facility to the acute care unit with acute-onset lethargy and severe shivering. The patient's caregivers noted she was complaining of right-sided abdominal pain earlier in the day. Vital signs on arrival are: temperature 39.6°C (103.3°F), heart rate 128/min, respirations 22/min, and blood pressure 82/46 mm Hg. The patient is stuporous. Abdominal palpation elicits grimacing when the right subcostal region is pressed. Her skin and mucous membranes appear visibly jaundiced. Initial point-of-care testing reveals a marked leukocytosis of 22,000/mm³ and severe hyperbilirubinemia with a predominant conjugated fraction.

Arrange the following clinical interventions in the correct chronological order for managing this patient's condition.

A 68-year-old man presents to the clinic with a 3-month history of difficulty swallowing. Initially, he had trouble only with solid foods such as meat and bread, but recently he has also developed difficulty swallowing liquids. He reports an unintentional weight loss of 9 kg (20 lb) over this period. Medical history is significant for gastroesophageal reflux disease (GERD) and hypertension. He has a 40-pack-year smoking history. Vital signs are within normal limits. Physical examination reveals temporal wasting but is otherwise unremarkable.

Arrange the following steps in the most appropriate sequential order for the diagnostic evaluation, staging, and management of this patient's condition.

A 28-year-old woman, G2P1, at 20 weeks gestation presents to the emergency department with a 12-hour history of worsening right lower quadrant abdominal pain, nausea, and anorexia. Her temperature is 38.1°C (100.6°F), heart rate is 108/min, and blood pressure is 112/72 mm Hg. Physical examination reveals tenderness superior and lateral to McBurney's point with localized guarding. Fetal heart tones are 145/min. Laboratory studies show a leukocyte count of 16,500/mm³ with 85% neutrophils. Assuming each diagnostic study is sequentially indicated due to inconclusive prior results, arrange the following steps in the most appropriate chronological order for evaluating and managing this patient.

A 27-year-old man is brought to the emergency department by ambulance 20 minutes after sustaining a stab wound to the abdomen during an altercation. On arrival, he is lethargic and confused. His temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), blood pressure is $80/45\text{ mmHg}$, pulse is $135/\text{min}$, and respiratory rate is $22/\text{min}$. Pulse oximetry is $97\%$ on room air. Two large-bore intravenous lines are established, and a bolus of warmed isotonic crystalloid is initiated. The airway is patent, and breath sounds are clear and equal bilaterally. Physical examination reveals a 4-cm transverse laceration in the left lower quadrant of the abdomen. The abdomen is distended, and there is generalized guarding and rebound tenderness across all four quadrants. Which of the following is the most appropriate next step in management?

A 38-year-old woman comes to the office due to a 4-month history of worsening fatigue, generalized weakness, and a $5$-kg ($11$-lb) weight gain. She reports that her menstrual periods ceased 6 months ago; previously, her cycles were regular. She also complains of occasional dull, non-throbbing headaches. Her medical history is unremarkable, and she takes no medications. Vital signs show a temperature of $36.4^\circ$ C ($97.5^\circ$ F), blood pressure of $105/65$ mm Hg, and pulse of $56$/min. Physical examination reveals delayed relaxation of deep tendon reflexes, and pale, dry skin. There is no goiter. Visual fields are full to confrontation. A urine pregnancy test is negative.

Laboratory results show:

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

A 34-year-old woman, G1P0, at 30 weeks gestation is brought to the emergency department due to the sudden onset of severe shortness of breath, orthopnea, and a cough productive of pink, frothy sputum. She recently emigrated from Southeast Asia and has not received routine prenatal care. Her vital signs are temperature 37.0°C (98.6°F), blood pressure 105/65 mm Hg, heart rate 138/min and irregularly irregular, and respiratory rate 32/min. Pulse oximetry shows 87% on room air.

Physical examination reveals a distressed woman using accessory muscles of respiration. Lung auscultation demonstrates diffuse bilateral crackles extending to the apices and prominent expiratory wheezes. Cardiac auscultation reveals a loud $S_1$, a high-frequency sound shortly after $S_2$, and a low-pitched, rumbling mid-diastolic murmur heard best at the cardiac apex.

Laboratory results show:
Hemoglobin: 10.8 g/dL
Leukocyte count: 8,500/mm $^3$

Arterial blood gas on room air:
pH: 7.51
$PaCO_2$: 26 mm Hg
$PaO_2$: 54 mm Hg
$HCO_3^-$: 20 mEq/L

Which of the following is the most important primary pathophysiologic mechanism precipitating this patient's acute respiratory failure?

Approximately $36$ hours after undergoing an elective abdominal hysterectomy for symptomatic uterine fibroids, a $55$-year-old patient develops an elevated temperature of $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$). She reports mild pain at the surgical site but denies shortness of breath, cough, dysuria, or calf pain. Her current medications include scheduled acetaminophen and as-needed intravenous morphine. Her pulse is $88/\text{min}$, blood pressure is $128/82\text{ mm Hg}$, and respiratory rate is $14/\text{min}$. Oxygen saturation is $95\%$ on room air. Physical examination reveals decreased breath sounds at the bilateral lung bases without crackles or wheezes. The abdominal incision is well-approximated with no erythema, induration, or discharge. The urinary catheter placed during surgery was removed on postoperative day zero. Which of the following is the most appropriate next step in management?

A 42-year-old woman is admitted to the hospital with a 1-day history of severe, unrelenting epigastric pain that radiates to her back. She also reports nausea and multiple episodes of nonbilious vomiting. Her temperature is 37.8°C (100°F), blood pressure is 110/70 mm Hg, pulse is 112/min, and respirations are 18/min. Physical examination shows marked epigastric tenderness with guarding but no rebound tenderness. Bowel sounds are decreased. Laboratory studies show:

Right upper quadrant ultrasound shows a distended gallbladder with multiple small echogenic foci and posterior acoustic shadowing. The common bile duct measures 4 mm in diameter, and no choledocholithiasis is visualized. Which of the following is the most appropriate next step in management?

Paramedics rush a 58-year-old man to the resuscitation bay after he experienced a sudden, agonizing, 'tearing' chest pain that radiated directly to his interscapular region. The patient is visibly distressed, diaphoretic, and clutching his chest. His spouse reports that he has a long history of medication nonadherence for hypertension. Initial vital signs reveal a temperature of 37.2°C (99.0°F), a right arm blood pressure of 220/125 mm Hg, a left arm blood pressure of 180/100 mm Hg, a heart rate of 124/min, and a respiratory rate of 24/min. Cardiac auscultation identifies a loud, early diastolic decrescendo murmur best heard at the right second intercostal space. A bedside portable chest radiograph displays significant widening of the superior mediastinum. Large-bore intravenous access is immediately established. Arrange the following critical interventions in the exact sequential order required for the optimal management of this patient, from immediate initial stabilization to definitive treatment.

During morning rounds, the internal medicine team evaluates a 58-year-old man who was admitted three days ago for management of tense ascites. He has a known history of alcohol-associated cirrhosis. On admission, he underwent a 7-liter therapeutic paracentesis.

Current vital signs include a blood pressure of 96/60 mm Hg, heart rate of 92/min, and temperature of 36.9°C (98.4°F).

Over the past 24 hours, his urine output has decreased to 320 mL. Laboratory studies show a progressive rise in serum creatinine from 1.1 mg/dL on admission to 2.8 mg/dL today. Blood urea nitrogen is 48 mg/dL. Urinalysis reveals no red blood cells, white blood cells, or cellular casts. The spot urinary sodium concentration is $< 10$ mEq/L.

Following these results, diuretic therapy was discontinued, and the patient received a 48-hour volume expansion challenge with intravenous albumin. However, a repeat serum creatinine this morning remains elevated at 2.9 mg/dL. A renal ultrasound demonstrates normal kidney size with no evidence of hydronephrosis.

Which of the following is the most appropriate next step in the pharmacologic management of this patient's acute kidney injury?