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A 41-year-old woman is evaluated in the emergency department for severe, diffuse abdominal pain that started two days ago. The pain is continuous, non-radiating, and accompanied by persistent nausea, vomiting, and new-onset generalized weakness. One week ago, she was diagnosed with an uncomplicated lower urinary tract infection and began a course of trimethoprim-sulfamethoxazole. Her past medical history is notable for generalized anxiety disorder. On presentation, her temperature is $37.1^{\circ}\text{C}$ ($98.8^{\circ}\text{F}$), blood pressure is $168/102 \text{ mmHg}$, heart rate is $118/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals a distressed, diaphoretic woman. Her abdomen is diffusely tender to deep palpation, but there is no guarding, rigidity, or rebound tenderness. Neurologic examination demonstrates $4/5$ strength in the proximal upper and lower extremities bilaterally, with diminished deep tendon reflexes. Laboratory studies show a leukocyte count of $8,500/\mu\text{L}$, hemoglobin of $13.8 \text{ g/dL}$, and a serum sodium of $128 \text{ mEq/L}$. Liver function tests and serum lipase are within normal limits. A non-contrast CT scan of the abdomen shows no abnormalities. Urinalysis reveals no red or white blood cells, but the urine appears dark reddish-brown after standing. Which of the following is the most likely diagnosis?

Match each patient's clinical presentation with the single most appropriate initial or definitive diagnostic imaging modality to order.

A 24-year-old man is brought to the emergency department by paramedics after sustaining a stab wound to the right upper chest during an altercation. On arrival, he is stuporous, diaphoretic, and in severe respiratory distress. His temperature is 36.5°C (97.7°F), blood pressure is 74/40 mmHg, pulse is 142/min, respirations are 36/min, and pulse oximetry shows 84% on a non-rebreather mask. Physical examination reveals a 3-cm laceration in the right second intercostal space at the midclavicular line. The trachea is visibly deviated to the left, and the jugular veins are prominently distended. Auscultation demonstrates completely absent breath sounds over the right hemithorax with hyperresonance to percussion. Which of the following simultaneous initial stabilization steps are indicated immediately? (Select two)

An ambulance brings a 58-year-old man to the acute care bay with a chief complaint of unremitting, heavy chest pain radiating to the left jaw that started 45 minutes prior. He appears profoundly weak and is sweating profusely. His medical history includes type 2 diabetes mellitus and hyperlipidemia. Vital signs show a blood pressure of $76/48\text{ mmHg}$, a heart rate of $115\text{ /min}$, a respiratory rate of $24\text{ /min}$, and an oxygen saturation of $95\%$ on ambient air. Physical examination demonstrates distended neck veins while sitting at a $45^{\circ}$ angle. Lung auscultation reveals clear breath sounds in all fields without adventitious sounds. An initial 12-lead electrocardiogram reveals $3\text{ mm}$ ST-segment elevations in leads II, III, and aVF. The patient is lethargic but responds to verbal stimuli. Which of the following is the most appropriate immediate next step in stabilizing this patient?

Accurate interpretation of pulmonary and chest wall physical examination findings requires an understanding of the underlying changes in intrathoracic acoustics and mechanics. Match each clinical respiratory examination finding with its most characteristic pathophysiologic mechanism.

Match each patient presentation of suspected stable ischemic heart disease with the most appropriate guideline-indicated next step in diagnostic test sequencing.

During morning rounds on hospital day 8, a 72-year-old man is assessed for transition of care. He was initially admitted for altered mental status and diagnosed with Listeria monocytogenes meningitis, for which he received a full course of intravenous ampicillin and gentamicin. He has been afebrile for 48 hours, is hemodynamically stable, and his white blood cell count is normal. His delirium has improved, though he remains oriented only to person and place, lacking insight into his current physical limitations. Prior to admission, the patient lived alone and was independent with his activities of daily living. Currently, he requires moderate assistance with feeding, bathing, and bed-to-chair transfers. Physical therapy evaluates the patient and notes that he fatigues after 45 minutes of exertion and cannot currently tolerate prolonged therapy sessions. His daughter, who is his legally designated healthcare proxy, visits daily but works full-time and cannot provide daytime supervision. The patient states, 'I am perfectly fine, I am going back to my own house today,' and demands to leave immediately. Which of the following is the most appropriate disposition plan for this patient?

A 58-year-old male presents to the clinic for routine follow-up. He has a 10-year history of type 2 diabetes mellitus and hypertension. Current medications include glipizide, amlodipine, and a recently initiated angiotensin-receptor blocker (valsartan). He reports feeling generally fatigued but denies any recent illness, nausea, vomiting, or diarrhea. Vital signs are within normal limits.

Laboratory results are as follows:

Based on the interpretation of these laboratory findings, which of the following is the most likely mechanism underlying this patient's acid-base disturbance?

A 48-year-old woman presents to the emergency department with severe, constant right upper quadrant abdominal pain that radiates to her right scapula, accompanied by fever and nausea. The pain began $12\text{ hours}$ ago after she consumed a high-fat meal. Her temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is $135/85\text{ mmHg}$, and heart rate is $105\text{/min}$. Physical examination reveals marked tenderness with inspiratory arrest upon deep palpation of the right upper quadrant.

Arrange the following diagnostic imaging modalities in the appropriate step-wise sequence for evaluating and managing this patient's presentation, from the initial diagnostic test to the evaluation of potential late complications.

An adult male in his early sixties presents to an urgent care clinic with a three-day history of severe, diffuse muscle pain, profound generalized weakness, and passing tea-colored urine. His established medical background includes ischemic heart disease, hypercholesterolemia, and a recently identified supraventricular arrhythmia. His longstanding daily medication regimen consists of simvastatin, low-dose aspirin, and previously, metoprolol. His baseline laboratory records show mild, asymptomatic elevations in serum transaminases, and he is up to date on all age-appropriate cancer screenings. Eighteen days prior to this visit, a consulting specialist transitioned him from metoprolol to diltiazem for optimized chronotropic control. During the clinical interview, the patient also reports initiating a light treadmill walking routine last week. Physical examination reveals marked, diffuse tenderness across major muscle groups of the proximal extremities. During the targeted medical history evaluation for this patient's acute presentation, identifying which of the following details is most crucial for establishing the immediate etiology of his symptoms?

A 24-year-old nulligravid woman comes to the clinic with a 3-day history of lower abdominal pain, new-onset abnormal vaginal discharge, and pain during sexual intercourse. Her temperature is 38.0°C (100.4°F), blood pressure is 110/70 mmHg, and pulse is 88/min. Pelvic examination reveals a friable cervix with mucopurulent discharge, pronounced cervical motion tenderness, and bilateral adnexal fullness with tenderness. A urine pregnancy test is negative. She is able to tolerate oral intake and appears well overall. Which of the following antimicrobial therapies should be included in this patient's initial empiric outpatient regimen? (Select all that apply)

Evaluate the following distinct patient presentations involving peripheral nerve and spinal cord dysfunction. Match each clinical scenario to its most likely underlying pathophysiologic etiology.

Roommates of a $20$-year-old male college student rush him to the triage desk due to a rapidly progressive headache, high fever, and extreme lethargy over the past $12$ hours. His past medical history is notable only for allergic rhinitis, and he takes no daily medications. Triage vital signs demonstrate a temperature of $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), blood pressure of $82/50\text{ mmHg}$, heart rate of $132\text{/min}$, and respiratory rate of $24\text{/min}$. Pulse oximetry is $95\%$ on ambient air. The clinical examination reveals a somnolent patient who localizes to painful stimuli but provides nonsensical answers to questions. Nuchal rigidity is prominent, and multiple non-blanching purpuric lesions are visible on the lower extremities. Arrange the following acute management steps in the most appropriate chronological sequence.

A 34-year-old woman is brought to the emergency department by ambulance. Her husband reports she suddenly fell to the floor and began having full-body convulsions 15 minutes ago. The convulsions have been continuous without any periods of recovery. She has no known past medical history. Upon arrival, her blood pressure is 142/88 mmHg, pulse is 118/min, and oxygen saturation is 94% on a non-rebreather mask. She is unresponsive, diaphoretic, and exhibiting continuous generalized tonic-clonic movements. Point-of-care blood glucose is 98 mg/dL. Two large-bore peripheral intravenous lines are rapidly established. Arrange the following pharmacologic interventions in the correct sequential order for the escalating management of this patient's condition, starting from the initial recommended therapy to treatments for refractory cases.

A 54-year-old man presents to the clinic to discuss his medication regimen. He was diagnosed with active pulmonary tuberculosis earlier today and is scheduled to begin a standard empiric regimen of isoniazid, rifampin, pyrazinamide, and ethambutol. His past medical history is significant for a mechanical mitral valve replacement performed four years ago, for which he takes warfarin. His daily medications also include low-dose aspirin and metoprolol. His vital signs are within normal limits. Physical examination reveals a crisp mechanical click on cardiac auscultation and bronchial breath sounds in the right upper lung field. His international normalized ratio (INR) has been consistently stable at 3.0 for the past year, and today's INR is 2.9. Which of the following is the most appropriate next step in management regarding this patient's pharmacotherapy?

A $28$-year-old woman, gravida 1 para 0, at $22$ weeks gestation presents to the emergency department with a $12$-hour history of progressively worsening right-sided abdominal pain, accompanied by nausea and two episodes of non-bloody emesis. Her temperature is $38.2^\circ\text{C}$, blood pressure is $110/70$ mmHg, and heart rate is $105$/min. Physical examination reveals focal tenderness to palpation in the right mid-to-lower quadrant with mild voluntary guarding, but no rebound tenderness. Laboratory studies demonstrate a leukocyte count of $16,500/\text{mm}^3$ with a left shift. The patient requires emergent diagnostic evaluation for suspected acute appendicitis.

Arrange the following diagnostic modalities and confirmatory protocols in the correct sequential order for evaluating this patient, proceeding from the initial test of choice to subsequent options if the preceding tests are non-diagnostic, unavailable, or equivocal.

A 52-year-old man is evaluated for treatment-resistant hypertension. His current blood pressure is $168/95\text{ mmHg}$ despite adherence to amlodipine, lisinopril, and chlorthalidone. Laboratory studies obtained two weeks ago showed:

- Serum sodium: $144\text{ mEq/L}$
- Serum potassium: $2.9\text{ mEq/L}$
- Plasma aldosterone concentration: $32\text{ ng/dL}$ (Normal: $3-16\text{ ng/dL}$)
- Plasma renin activity: $0.2\text{ ng/mL/h}$ (Normal: $0.6-4.3\text{ ng/mL/h}$)

A dedicated adrenal protocol computed tomography (CT) scan demonstrates a $1.8\text{-cm}$ lipid-rich nodule in the right adrenal gland. The left adrenal gland appears normal.

To guide further management, an adrenal venous sampling (AVS) procedure is performed with continuous cosyntropin (ACTH) infusion. The laboratory results from the procedure are shown in the table below:

Based on these laboratory findings, which of the following is the most accurate interpretation of this patient's underlying condition?

A 42-year-old woman presents to the clinic to establish care. She reports an 18-kg (39.7-lb) weight gain over the past year, accompanied by irregular menses, new-onset facial hair, and difficulty rising from a seated position. Her medical history is significant for generalized anxiety disorder. Her only medication is an estrogen-containing oral contraceptive pill. Blood pressure is 162/98 mmHg, and BMI is 34 kg/m². Physical examination reveals a plethoric face, prominent supraclavicular fat pads, broad violaceous striae on the abdomen, and 4/5 strength in the proximal lower extremities. The physician suspects hypercortisolism. An overnight 1-mg dexamethasone suppression test yields a morning serum cortisol of 14.2 µg/dL (normal: < 1.8 µg/dL). A 24-hour urine free cortisol is 185 µg/24h (normal: 10-50 µg/24h). Which of the following is the most appropriate next step in laboratory evaluation?

A 62-year-old woman presents to the emergency department with a 24-hour history of severe, intermittent right upper quadrant abdominal pain that radiates to her right scapula. She also reports several episodes of nausea and vomiting. She has no prior history of similar pain and has not had any recent illnesses. Her temperature is 37.4°C (99.3°F), blood pressure is 132/84 mmHg, heart rate is 88/min, and respiratory rate is 16/min. On physical examination, the abdomen is non-distended. There is moderate tenderness to deep palpation in the right upper quadrant, but no guarding, rigidity, or rebound tenderness. Murphy sign is negative. There is no scleral icterus or visible jaundice.

Laboratory studies show:
White blood cell count: 8,500/mm³
Total bilirubin: 2.2 mg/dL
Direct bilirubin: 1.6 mg/dL
Alkaline phosphatase: 245 U/L
Aspartate aminotransferase (AST): 140 U/L
Alanine aminotransferase (ALT): 165 U/L
Lipase: 42 U/L

A right upper quadrant transabdominal ultrasound reveals multiple gallstones within the gallbladder. The gallbladder wall thickness is 2 mm, and there is no pericholecystic fluid. The common bile duct measures 9 mm in diameter, but no obstructing stones are visualized within the duct.

Which of the following is the most appropriate next step in the diagnostic workup?

A 66-year-old man comes to the pulmonary clinic complaining of a gradual onset of shortness of breath and a persistent, dry cough over the past seven months. He has no history of fever, chest pain, hemoptysis, or significant weight loss. He is a retired accountant, has no known occupational exposures, and has never smoked. His vital signs are within normal limits. On physical examination, there are bilateral fine end-inspiratory crackles auscultated at the lung bases, and digital clubbing is present. A high-resolution computed tomography (HRCT) scan of the chest is performed, revealing peripheral, subpleural, and bibasilar predominant reticular opacities. Additionally, there are multiple clustered cystic airspaces measuring 3 to 10 mm in diameter with thick walls, arranged in multiple layers at the lung bases. There is no significant ground-glass opacification, micronodules, or hilar lymphadenopathy. Based on these imaging findings, which of the following is the most likely diagnosis?