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A 72-year-old resident of an assisted living facility is brought to the emergency department due to worsening confusion and a productive cough over the past forty-eight hours. Medical history is notable for hypertension, type 2 diabetes mellitus, and benign prostatic hyperplasia. The facility staff noted that the patient has been increasingly difficult to arouse since the morning. Upon arrival in the resuscitation bay, the patient is obtunded and responds only to deep painful stimuli. Vital signs demonstrate a temperature of 35.4°C (95.7°F), blood pressure of 72/38 mm Hg, heart rate of 128/min, and respiratory rate of 26/min. Oxygen saturation is 91% on room air. Physical examination reveals cool, mottled extremities with a prolonged capillary refill time of five seconds. Pulmonary auscultation reveals coarse rhonchi predominantly in the right lower lung field. Which of the following is the most appropriate initial step in the management of this patient?

A 28-year-old female is brought to the emergency department by her roommate due to severe agitation, palpitations, and confusion over the past 24 hours. She has a history of Graves disease but admits to discontinuing her prescribed medications three months ago. Her temperature is $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$), blood pressure is $160/70$ mm Hg, pulse is $152$/min and irregular, and respirations are $24$/min. Physical examination reveals marked diaphoresis, a diffusely enlarged and non-tender thyroid gland, and a fine bilateral hand tremor. The patient is delirious and unable to cooperate with a detailed neurologic examination. An electrocardiogram demonstrates atrial fibrillation with rapid ventricular response. Which of the following pharmacologic interventions are indicated in the initial management of this patient's condition? (Select all that apply)

A 52-year-old woman is evaluated in the surgical telemetry unit 6 hours after undergoing an uncomplicated total thyroidectomy for a large multinodular goiter. Over the past 15 minutes, she has become increasingly restless and reports progressive difficulty breathing. Her voice is muffled. Temperature is 37.1°C (98.8°F), blood pressure is 155/95 mmHg, pulse is 115/min, and respirations are 26/min. Oxygen saturation is 89% on room air. Physical examination reveals audible inspiratory stridor. There is a tense, expanding, ecchymotic swelling beneath the cervical surgical incision. The lungs are clear to auscultation bilaterally. Which of the following is the most appropriate next step in management?

A series of patients present with new-onset abdominal distension and fluid waves on physical examination. Diagnostic paracentesis is performed for each. Match each set of serum and ascitic fluid laboratory findings to the most likely underlying etiology.

A 55-year-old female presents to the pulmonary clinic for evaluation of progressive exertional dyspnea and a dry cough. Her physician is reviewing various characteristic high-resolution computed tomography (HRCT) findings to establish a differential diagnosis for diffuse parenchymal lung diseases. Match each distinctive HRCT of the chest imaging description to its corresponding pathognomonic interstitial lung disease.

Match each cerebrospinal fluid (CSF) laboratory profile to its most likely corresponding clinical diagnosis. Assume a baseline normal serum glucose of $100 \text{ mg/dL}$ for all patients.

Match the following patient clinical presentations to the most appropriate targeted laboratory autoantibody evaluation.

A 55-year-old female presents to the emergency department complaining of sudden-onset, severe epigastric pain that radiates directly to her back. The pain began abruptly two hours ago and is accompanied by multiple episodes of intractable, non-bilious emesis. She has no history of alcohol consumption and takes no routine medications. Her temperature is 37.8°C (100.0°F), pulse is 112/min, and blood pressure is 138/86 mmHg. Abdominal examination demonstrates marked epigastric tenderness with voluntary guarding, but no rebound or rigidity. Bowel sounds are hypoactive. Which of the following diagnostic investigations are the most appropriate NEXT steps in the evaluation of this patient? (Select exactly 2 options)

A 35-year-old man presents to the clinic with a 3-month history of progressive fatigue, unintentional weight loss, and diffuse arthralgias. He also reports intermittent low-grade fevers and night sweats. Physical examination reveals generalized, non-tender lymphadenopathy and a newly auscultated grade 3/6 holosystolic murmur at the cardiac apex. Laboratory studies show a normocytic, normochromic anemia, an elevated erythrocyte sedimentation rate, and a positive rheumatoid factor. Arrange the following differential diagnoses in order from most likely to least likely based on the patient's clinical presentation.

An established patient, a 72-year-old male with a 6-year history of Parkinson disease, presents to the outpatient neurology clinic accompanied by his wife. Over the past three weeks, he has experienced new-onset visual hallucinations, frequently reporting that strangers are standing in their living room. These episodes cause him significant distress. His motor symptoms remain well-controlled. His current daily medication regimen consists of carbidopa-levodopa, pramipexole, selegiline, and trihexyphenidyl. He takes no other medications. Vital signs include a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $134/76\text{ mmHg}$, pulse of $72\text{/min}$, and respiratory rate of $16\text{/min}$. Physical examination is remarkable for a mild resting pill-rolling tremor and slight bradykinesia, unchanged from previous visits. Laboratory results, including a complete blood count, comprehensive metabolic panel, and urinalysis, show no abnormalities.

Arrange the following pharmacologic interventions in the chronological sequence they should be implemented (from first step to last step) to appropriately manage this patient's new-onset psychosis.

Match each patient presenting with suspected stable ischemic heart disease to the most appropriate next step in their diagnostic workup.

A 24-year-old nulliparous woman is brought to the emergency department by her partner due to the sudden onset of severe, right-sided lower abdominal pain that began 2 hours ago. She reports one episode of vomiting and scant, dark vaginal spotting. Her last menstrual period was 6 weeks ago, although she notes her cycles are occasionally irregular. Her medical history is notable for a Chlamydia trachomatis infection complicated by pelvic inflammatory disease 3 years ago. On presentation, her temperature is 37.1°C (98.8°F), blood pressure is 88/54 mmHg, pulse is 122/min, and respirations are 22/min. Physical examination reveals a pale, diaphoretic patient in acute distress. Abdominal examination demonstrates marked right lower quadrant tenderness with involuntary guarding and rebound tenderness. Pelvic examination reveals significant cervical motion tenderness and a palpable, exquisitely tender, 5-cm right adnexal mass. Serum human chorionic gonadotropin (hCG) results are pending.

Arrange the following differential diagnoses in order from the MOST likely to the LEAST likely to explain this patient's acute clinical presentation.

An independent 68-year-old male is evaluated in the outpatient clinic for progressive mid-to-lower back pain and generalized fatigue that has worsened over the past three months. He describes the pain as a deep, constant ache exacerbated by ambulation and poorly responsive to ibuprofen. He also reports a recent onset of constipation. His medical history is significant for essential hypertension treated with amlodipine. His temperature is 37.1°C (98.8°F), blood pressure is 134/84 mmHg, pulse is 82/min, and respiratory rate is 14/min. Physical examination reveals pale conjunctivae and point tenderness to palpation over the L3 and L4 spinous processes. Neurological examination of the lower extremities shows 5/5 strength, intact sensation to light touch and pinprick, and normal symmetric deep tendon reflexes. The prostate is smooth and mildly enlarged without nodules.

Initial laboratory studies show:

Hemoglobin: 10.1 g/dL
Mean corpuscular volume: 88 fL
Leukocyte count: 5,400/mm³
Platelet count: 210,000/mm³
Serum calcium: 11.4 mg/dL
Serum creatinine: 1.7 mg/dL
Blood urea nitrogen: 32 mg/dL
Total protein: 8.9 g/dL
Albumin: 3.8 g/dL

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

An $82$-year-old man is evaluated in the intensive care unit for persistent fever and clinical deterioration. He was admitted $8$ days ago for severe community-acquired pneumonia and respiratory failure requiring intubation and mechanical ventilation. His hospital course has been complicated by septic shock, for which he is currently receiving continuous infusions of norepinephrine and vasopressin. Today, his temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $86/52\text{ mmHg}$, pulse is $122/\text{min}$, and respiratory rate is $18/\text{min}$ (ventilator set). Physical examination reveals a distended abdomen with guarding in the right upper quadrant upon deep palpation. Laboratory studies show a leukocyte count of $24,000/\text{mm}^3$ (up from $14,000/\text{mm}^3$ yesterday). Liver function tests reveal a total bilirubin of $1.4\text{ mg/dL}$, alkaline phosphatase of $130\text{ U/L}$, aspartate aminotransferase of $45\text{ U/L}$, and alanine aminotransferase of $40\text{ U/L}$. A bedside right upper quadrant ultrasound demonstrates a markedly distended gallbladder with a thickened wall, pericholecystic fluid, and no stones or sludge. The common bile duct measures $4\text{ mm}$ in diameter. Intravenous meropenem is initiated. Which of the following is the most appropriate next step in the management of this patient?

A 32-year-old woman with persistent asthma comes to the clinic for a preconception counseling visit. She currently uses a medium-dose fluticasone-formoterol inhaler twice daily, which provides excellent control of her symptoms. She and her husband are planning to conceive in the next few months. The patient expresses significant anxiety regarding the use of medications during pregnancy. She states, "I read on a natural parenting blog that asthma inhalers can cause severe birth defects. I have decided to stop using my inhaler immediately and will manage my asthma with breathing exercises alone." Which of the following is the most appropriate initial response by the physician?

A retired teacher visits the ambulatory care clinic for a routine wellness check. The patient's medical history includes osteoarthritis, essential hypertension, and chronic insomnia. A medication review reveals the daily use of clonazepam at bedtime, which the patient has been taking for the past two decades. The physician explains the increased risk of falls, motor vehicle accidents, and cognitive impairment associated with this medication in older adults, and recommends initiating a gradual taper. The patient becomes visibly upset, crosses their arms, and states, 'That pill is the only thing keeping me sane. If I do not get my sleep, my blood pressure goes up and my joints ache worse the next day. I am not stopping it.' Which of the following is the most appropriate initial response by the physician?

A 66-year-old female presents to the outpatient clinic for a routine wellness examination. She has no acute symptoms and feels well. Her past medical history is significant for primary hypertension, for which she takes amlodipine. She has never smoked, does not consume alcohol, and exercises by walking 30 minutes daily. Her last screening mammogram was performed 6 months ago and was unremarkable. A screening colonoscopy performed at age 61 was normal. Her medical records indicate she had negative cervical human papillomavirus (HPV) co-testing at ages 55, 60, and 64. She has never undergone bone mineral density testing. Vital signs today are within normal limits, and physical examination shows no abnormalities. Which of the following is the most appropriate next step in preventive screening for this patient?

A 66-year-old woman is admitted to the hospital with intractable nausea, vomiting, and diffuse, crampy abdominal pain. She has a history of advanced ovarian cancer with extensive peritoneal carcinomatosis. Her last bowel movement was 5 days ago. Temperature is 37.1°C (98.8°F), blood pressure is 105/65 mm Hg, pulse is 110/min, and respirations are 18/min. The abdomen is markedly distended and tympanic, with high-pitched bowel sounds. A CT scan of the abdomen reveals multifocal complete small bowel obstructions with several transition points.

The surgical and oncology services evaluate the patient and determine she is not a candidate for surgical intervention or further chemotherapy. Following a goals-of-care discussion, the patient and her family elect to transition to a comfort-focused palliative approach. A nasogastric tube was placed in the emergency department, which currently drains 800 mL of bilious fluid daily. The patient is experiencing severe distress from the nasogastric tube and explicitly requests its removal. She is currently receiving a transdermal fentanyl patch and as-needed intravenous morphine, which provide partial relief of her pain.

After the nasogastric tube is removed, which of the following is the most appropriate next step in the pharmacologic management of this patient's symptoms?

A 66-year-old male presents to his primary care physician for an annual wellness visit. He has a history of essential hypertension that is well-controlled with amlodipine. He reports feeling well and has no acute complaints. His social history is notable for smoking 1 pack of cigarettes per day from age 18 to 30, after which he completely quit. He drinks alcohol occasionally and exercises three times a week.

Review of his preventive care records reveals the following:
- Screening colonoscopy at age 60 was normal.
- Fasting lipid panel and plasma glucose levels obtained last year were within normal limits.
- He received the 20-valent pneumococcal conjugate vaccine (PCV20) at age 65.
- He completed the two-dose recombinant zoster vaccine series at age 50.
- He received a Tdap booster 3 years ago and his annual influenza vaccine 2 weeks ago.

The patient has never had any abdominal imaging. Vital signs today show a blood pressure of $122/78 \text{ mm Hg}$, heart rate of $72/\text{min}$, and a body mass index of $24 \text{ kg/m}^2$. Physical examination is unremarkable.

Which of the following is the most appropriate next step in this patient's preventive care?

During a scheduled visit to the anticoagulation clinic, a 67-year-old man with a mechanical mitral valve replacement undergoes point-of-care testing, which reveals an International Normalized Ratio (INR) of 7.4. He takes warfarin 5 mg daily, and his past INR results have consistently been well-controlled between 2.5 and 3.5. Four days ago, an urgent care physician prescribed a course of trimethoprim-sulfamethoxazole for acute cystitis. The patient notes that his dysuria has resolved. He explicitly denies experiencing hematuria, epistaxis, gingival bleeding, black tarry stools, or new bruising. Vital signs include a blood pressure of 128/78 mmHg and a heart rate of 76/min. Physical examination shows no evidence of petechiae, ecchymoses, or focal neurologic deficits.

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