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A 52-year-old woman is brought to the emergency department due to sudden-onset, severe abdominal pain and bilious vomiting that started 12 hours ago. She reports no bowel movements or flatus during this time. Her medical history is unremarkable, and she has had no prior abdominal surgeries. Her temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $115/75\text{ mmHg}$, and heart rate is $110/\text{min}$. Physical examination reveals an asymmetric, tympanic, and markedly distended abdomen. There is diffuse tenderness to palpation but no guarding or rigidity. Laboratory results are notable for a leukocyte count of $12,500/\text{mm}^3$ and a normal serum lactate level. A CT scan of the abdomen with intravenous contrast demonstrates a severely dilated cecum measuring $10.5\text{ cm}$ in diameter displaced into the left upper quadrant, with a "whirl pattern" of the mesenteric vessels and collapsed distal bowel. Which of the following is the most appropriate next step in management?

An asymptomatic 68-year-old retired teacher presents for an annual wellness assessment. He reports feeling well with no active complaints. His past medical history includes well-controlled essential hypertension and hyperlipidemia. He has a 40 pack-year smoking history but successfully quit 8 years ago. He consumes alcohol occasionally and walks briskly for 30 minutes three times a week.

His immunization history shows a tetanus, diphtheria, and acellular pertussis (Tdap) booster 3 years ago, completion of the two-dose recombinant zoster vaccine series at age 65, and a recent annual influenza vaccination. He has no history of receiving any pneumococcal vaccines. A screening colonoscopy performed 5 years ago was entirely normal. Physical examination today reveals a blood pressure of 126/78 mmHg, a heart rate of 72/min, and a body mass index of 27 kg/m².

Which of the following interventions are indicated for this patient at this visit? (Select all that apply)

A $62$-year-old woman is evaluated in the hospital for new-onset right leg swelling and pain. She was admitted $6$ days ago for an acute pulmonary embolism and was subsequently started on a continuous unfractionated heparin infusion. On admission, her platelet count was $260,000/\text{mm}^3$. Today, her vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $130/80\text{ mmHg}$, pulse $92/\text{min}$, and respirations $16/\text{min}$. Physical examination reveals a visibly swollen right calf that is tender to palpation. A venous Doppler ultrasound of the right lower extremity demonstrates an acute deep venous thrombosis in the right femoral vein. Laboratory studies from this morning show a platelet count of $110,000/\text{mm}^3$ and an activated partial thromboplastin time (aPTT) of $65\text{ seconds}$ (therapeutic range: $60-80\text{ seconds}$). Which of the following is the most appropriate next step in the management of this patient?

A $45$-year-old man presents to the clinic for a routine $4$-week follow-up visit. One month ago, he was diagnosed with active pulmonary tuberculosis and was started on a daily regimen of isoniazid, rifampin, pyrazinamide, and ethambutol, supplemented with pyridoxine. Today, he reports significant improvement in his symptoms; his cough has nearly resolved, and his night sweats have ceased. He has a good appetite and explicitly denies any nausea, vomiting, abdominal pain, fatigue, or dark urine. Physical examination reveals normal vital signs, no scleral icterus, and a non-tender abdomen without hepatomegaly.

Laboratory studies obtained today show the following:

Total bilirubin: $0.8 \text{ mg/dL}$ (Reference: $0.1-1.2 \text{ mg/dL}$)
Alkaline phosphatase: $85 \text{ U/L}$ (Reference: $40-120 \text{ U/L}$)
Aspartate aminotransferase (AST): $165 \text{ U/L}$ (Reference: $10-40 \text{ U/L}$)
Alanine aminotransferase (ALT): $175 \text{ U/L}$ (Reference: $10-40 \text{ U/L}$)

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

A 79-year-old man is admitted to the intensive care unit with severe septic shock and multiorgan failure. He is currently intubated, sedated, and lacks clinical decision-making capacity. The medical team concludes that further aggressive interventions are futile and wishes to discuss transitioning to comfort-focused care. A chart review reveals no advance directive, living will, or designated durable power of attorney for healthcare. The patient is a widower and his parents are deceased. He is survived by an adult son who lives in another state, a brother who visits him daily, and a devoted neighbor who has served as his primary caregiver for the past three years. Which of the following individuals is the most appropriate legally recognized primary surrogate decision-maker for this patient?

A 64-year-old man is evaluated in the outpatient clinic for a routine health maintenance visit. He has a history of primary hypertension and hyperlipidemia. His current medications include lisinopril and atorvastatin. He has a 30-pack-year smoking history but successfully quit 5 years ago. The patient is active, walks 2 miles daily without any chest pain, dyspnea, palpitations, or claudication, and has no history of cardiovascular disease. Vital signs include a blood pressure of 124/78 mm Hg, a heart rate of 72/min, and a BMI of 27 kg/m². Cardiovascular and pulmonary examinations are unremarkable. Recent laboratory results show a low-density lipoprotein (LDL) cholesterol level of 85 mg/dL and a hemoglobin A1c of 5.6%. During the visit, the patient mentions he recently read a news article about 'silent heart attacks' and requests a cardiac stress test to 'make sure my heart is in good shape.' In the context of high-value, cost-conscious care, which of the following is the most appropriate next step in management?

A surgical resident is transitioning the care of a 55-year-old man who is 2 days post-operative from an exploratory laparotomy to the night coverage team. The departing resident provides the following verbal sign-out: 'The patient is doing well overall. He had some tachycardia earlier today, but it resolved after a 500 mL normal saline bolus. His abdomen is mildly tender but soft. I have placed all the routine overnight orders. I will leave it to you to manage any new issues that arise.' Which of the following essential components of a standardized handoff protocol is notably absent from this communication, representing the greatest risk to patient safety?

A fundamental professional responsibility of physicians is to self-regulate and ensure patient safety when colleagues exhibit signs of impairment or unprofessional conduct. For each of the following peer-observation scenarios, select the most appropriate initial ethical and administrative action.

A 74-year-old man is admitted with a severe diabetic foot ulcer complicated by osteomyelitis. The surgical team recommends a below-the-knee amputation to prevent life-threatening sepsis. The patient refuses the surgery, stating he prefers to use 'natural herbal soaks' at home. The primary care team is concerned about his decision-making capacity regarding this refusal. Arrange the following steps in the most appropriate clinical and ethical sequence for evaluating and managing this patient's decision-making capacity.

A 32-year-old nulliparous woman arrives at the outpatient clinic to establish primary care. She reports excellent overall health and exercises regularly. She has no gastrointestinal complaints, unexplained weight changes, or evidence of bleeding. Her medical background is notable only for an appendectomy during childhood. Family history is significant for her mother, who was diagnosed with an early-stage colonic adenocarcinoma at the age of 46 and underwent a curative hemicolectomy. Medical records confirm the mother's tumor underwent mismatch repair protein analysis, demonstrating no loss of nuclear expression. Her maternal grandfather developed a similar intestinal malignancy at the age of 72. The patient expresses anxiety regarding her familial susceptibility and inquires about the optimal timing and modality for her own surveillance. Based on current evidence-based guidelines, which of the following is the most appropriate strategy for this patient?

A 48-year-old anesthesiologist is assigned to provide care for a patient undergoing an elective exploratory laparotomy. A circulating nurse observes the anesthesiologist stumbling in the hallway, slurring his words, and having profound difficulty drawing up intravenous medications. The nurse immediately notifies the hospital's Chief Medical Officer (CMO). The CMO approaches the anesthesiologist and notes the strong odor of alcohol on his breath, severe ataxia, and delayed cognitive responses. The patient is already in the operating room, awake, and has not yet received any preoperative sedation. Which of the following is the most appropriate next step in management by the Chief Medical Officer?

A 42-year-old man comes to the clinic for a routine follow-up visit. He was diagnosed with hypertension and type 2 diabetes mellitus three months ago, at which time he was prescribed amlodipine and metformin. Today, his blood pressure is 154/92 mmHg and his hemoglobin A1c is 8.5%. Upon inquiry, the patient admits he stopped taking both medications after one week. He explains, "A coworker warned me that these blood pressure pills will eventually destroy my kidneys. I started taking a daily herbal detox supplement instead. I feel perfectly fine, so I do not want to put unnatural chemicals into my body." Which of the following is the most appropriate initial response by the physician?

A $55$-year-old woman is evaluated in the hospital on postoperative day $6$ following an abdominal hysterectomy. She was admitted to the general medical ward and started on an intravenous unfractionated heparin infusion $5$ days ago for a right lower extremity deep vein thrombosis. Today, she reports new pain and swelling at the site of a peripheral intravenous catheter in her left arm. Her temperature is $37.2^\circ \text{C}$ ($99.0^\circ \text{F}$), blood pressure is $128/82$ mmHg, and pulse is $88$/min. Physical examination shows induration, erythema, and tenderness along the left cephalic vein, consistent with superficial thrombophlebitis. There is no active bleeding, and no petechiae are noted.

Laboratory results are as follows:
- Hemoglobin: $12.2$ g/dL
- Platelet count: $110,000/\text{mm}^3$ (Baseline $5$ days ago: $320,000/\text{mm}^3$)
- Partial thromboplastin time (PTT): $68$ seconds

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

During a medication management visit, a 58-year-old woman asks about her current health maintenance requirements. She takes methotrexate and daily prednisone ($10 \text{ mg}$) for rheumatoid arthritis, which was diagnosed five years ago. She has never smoked cigarettes. Her body mass index is $21 \text{ kg/m}^2$. A review of her preventive care history shows a normal screening colonoscopy three years ago, a negative primary human papillomavirus test two years ago, and a normal bilateral mammogram six months ago. She completed the recombinant zoster and 20-valent pneumococcal conjugate vaccine series last year. Which of the following is the most appropriate indicated preventive service for this patient at this time?

During a comprehensive annual evaluation, a 62-year-old man is assessed at the primary care clinic. He has a past medical history of diet-controlled type 2 diabetes mellitus and essential hypertension. His current medications include amlodipine and atorvastatin. He reports feeling well overall, though he notes intermittent, mild lower back pain after heavy yard work; the pain lacks radiation and resolves rapidly with rest and acetaminophen. He denies any bowel or bladder incontinence, saddle anesthesia, or lower extremity weakness.

His substance use history reveals that he began smoking cigarettes at age 20, consuming 1.5 packs daily until he quit on his 50th birthday. He consumes alcohol occasionally but denies illicit drug use. He has been in a monogamous marriage for 35 years.

A review of his preventive health record demonstrates:
- A screening colonoscopy performed 4 years ago at age 58 revealed no polyps or abnormalities.
- Routine screening for HIV, hepatitis B, and hepatitis C conducted at age 55 was negative.
- Following his diabetes diagnosis at age 59, he received a dose of the 20-valent pneumococcal conjugate vaccine (PCV20).
- He completed the two-dose recombinant zoster vaccine series at age 56.
- He received a tetanus, diphtheria, and acellular pertussis (Tdap) booster 3 years ago.
- He received the seasonal influenza vaccine two weeks ago.

Recent laboratory studies from a separate visit two weeks ago show a hemoglobin A1c of 6.2% and an in-range lipid profile. His physical examination today, including a detailed neurologic assessment of the lower extremities, is entirely within normal limits.

Based on current clinical guidelines, which of the following is the most appropriate next step in the management of this patient?

Review the following interprofessional clinical scenarios. Match each scenario with the most appropriate high-reliability communication or conflict resolution tool that should be utilized to ensure patient safety and team function.

A 62-year-old man comes to the clinic for a routine health maintenance evaluation. He recently went through a divorce and reports being sexually active with multiple new male partners over the past 6 months. He admits to inconsistent condom use. His medical history is significant for essential hypertension, for which he takes amlodipine. He smoked 1.5 packs of cigarettes daily for 20 years but quit 8 years ago. His most recent cancer screening was a colonoscopy at age 54, which was normal. His vaccination history includes the complete hepatitis B series, a tetanus-diphtheria-acellular pertussis (Tdap) booster at age 58, and an influenza vaccine 2 weeks ago. He has never received pneumococcal or zoster vaccines. Vital signs and physical examination are unremarkable. Basic metabolic panel and hepatic function panel are within normal limits. Point-of-care HIV testing is negative, and comprehensive sexually transmitted infection testing is sent to the laboratory. Assuming the pending tests are negative, which of the following is the most appropriate next step in comprehensive preventive care?

A 59-year-old man is hospitalized with a severe traumatic brain injury following a high-speed motorcycle collision. He is comatose, ventilator-dependent, and lacks decision-making capacity. The trauma team recommends an open reduction and internal fixation of a complex pelvic fracture to stabilize the pelvis and prevent long-term functional morbidity. The patient is divorced and has no written advance directives. His live-in girlfriend of five years arrives and presents a legally executed 'General Durable Power of Attorney for Financial Affairs' naming her as the principal agent. She insists the surgery be performed. Shortly after, the medical team contacts the patient's 35-year-old daughter, who lives in another state. The daughter states, 'My dad told me clearly last year that he would never want any major surgeries to keep him alive if his brain was severely and permanently damaged,' and she refuses consent for the procedure. Which of the following is the most appropriate action regarding the patient's care?

A clinical investigator is studying the effect of a newly developed ACE inhibitor on serum potassium levels. The study enrolls 50 adult patients with essential hypertension. Each patient has their baseline serum potassium level measured prior to starting the medication. After four weeks of daily therapy, a second serum potassium measurement is obtained for each patient. The investigator wants to evaluate if there is a statistically significant change in serum potassium levels from baseline. Depending on whether the data follows a normal distribution, which of the following statistical tests are appropriate for analyzing the results of this study? Select all that apply.

A 31-year-old woman, gravida 1, para 0, presents to the clinic for a routine prenatal visit at 13 weeks of gestation. She has a medical history of chronic hypertension that is currently well controlled. She has never smoked and consumes no alcohol. Her daily medication is nifedipine. Vital signs today demonstrate a blood pressure of $126/82 \text{ mm Hg}$, a heart rate of 78/min, and a body mass index of $28 \text{ kg/m}^2$. A urine dipstick is negative for protein. Fetal heart tones are audible via Doppler ultrasound. Which of the following is the most appropriate preventive intervention to add to this patient's management plan at this time?