A 75-year-old man with severe chronic obstructive pulmonary disease (COPD) presents with an acute exacerbation. He is currently receiving supplemental oxygen via nasal cannula at 4 L/min, maintaining an SpO2 of 98%. On reassessment, he is noted to be increasingly somnolent and lethargic. What is the most appropriate immediate management?

Reduce inspired oxygen concentration

Increase the frequency of nebulized salbutamol

A 33-year-old male with a history of successfully treated gonococcal urethritis 10 years prior presents to the emergency department with a 2-day history of complete anuria and signs of urinary obstruction. Physical examination reveals a distended lower abdomen with a palpable bladder. Point-of-care ultrasound demonstrates a markedly dilated bladder without evidence of hydronephrosis or other upper urinary tract abnormalities. An attempt at urethral catheterization was unsuccessful, meeting firm resistance within the urethra, suggesting a complete urethral obstruction. What is the most appropriate management?

Repeat the urethral catheterization

A 30-year-old patient presents with resistant hypertension despite a two-drug antihypertensive regimen. Initial laboratory evaluation reveals unprovoked hypokalemia and metabolic alkalosis. What is the most appropriate next step to identify the underlying cause of hypertension?

Renal artery Doppler ultrasound

A 14-year-old female presents with a several-week history of photosensitivity, an erythematous malar rash, and migratory polyarthralgias. Urinalysis reveals microscopic hematuria. What is the most likely diagnosis?

Thrombotic thrombocytopenic purpura

A 25-year-old primigravida at 36 weeks gestation presents in active labor. Fetal heart rate (FHR) tracing reveals recurrent late decelerations with a baseline of 130 bpm and moderate variability. She reports feeling somewhat dizzy while lying supine. Uterine contractions occur every 3-4 minutes, lasting 60-70 seconds. Which of the following is the most appropriate next step?

Hydrate, reposition, and review in 20 minutes

A 1-day-old neonate presents with ambiguous genitalia. Laboratory analysis reveals a markedly elevated serum 17-hydroxyprogesterone level, hyponatremia (sodium 128 mEq/L), hyperkalemia (potassium 6.8 mEq/L), metabolic acidosis (bicarbonate 16 mEq/L), and hypoglycemia (glucose 45 mg/dL). Which of the following is the most likely diagnosis?

3-beta-hydroxysteroid dehydrogenase deficiency

An 85-year-old man, admitted to the ICU following a massive ischemic stroke, experiences acute neurological deterioration marked by a rapidly declining Glasgow Coma Scale, worsening focal deficits, and the development of an ipsilateral dilated and unreactive pupil. An emergency computed tomography scan reveals significant hemorrhagic transformation with notable mass effect and midline shift. What is the most definitive treatment?

Administering high-frequency ventilation

A 68-year-old man with a history of severe chronic obstructive pulmonary disease (COPD) presents to the emergency department experiencing an acute exacerbation, with acutely worsening dyspnea and diffuse expiratory wheezing. He is notably alert, oriented, and able to fully follow commands. Vital signs include a respiratory rate of 28 breaths/min and an oxygen saturation of 86% on 2 L/min via nasal cannula. Arterial blood gas analysis reveals pH 7.28, PaCO₂ 60 mmHg, and PaO₂ 52 mmHg. A chest X-ray demonstrates no evidence of focal consolidation. What is the best next step?

Start noninvasive positive-pressure ventilation (BiPAP)

Immediate endotracheal intubation and mechanical ventilation

Increase oxygen to 15 L/min via non-rebreather mask

An 82-year-old woman is evaluated two days following an uncomplicated hip-fracture repair. Her baseline cognitive function was unremarkable. Overnight, her family noted an acute change in mental status; she became disoriented to place and time, exhibited psychomotor agitation by attempting to climb out of bed, and was easily distractible during conversation. These symptoms characteristically fluctuate throughout the day, often worsening at night. On examination, her temperature is 38.3 °C, and she exhibits suprapubic tenderness. Her current medications include as-needed oxycodone and diphenhydramine, which was administered the previous evening. What is the most likely diagnosis?

Acute confusional state (delirium)

Major neurocognitive disorder (dementia) with sundowning

Major depressive episode ("pseudodementia")

A 68-year-old man with advanced Alzheimer's disease, who for the past year has been unable to recognize close family members or engage in meaningful communication, is admitted with aspiration pneumonia. He lacks decision-making capacity. His chart contains a signed, witnessed advance directive, completed 3 years ago while fully competent, specifically disallowing artificial nutrition or hydration via feeding tubes if he could no longer recognize family or interact meaningfully. His daughter, who is the appointed healthcare surrogate, insists on placing a PEG tube, stating, "Dad would want everything done now that he's sick." What is the most ethical next step?

Honor the advance directive and focus on comfort-oriented care

Place the PEG tube because the daughter is the legal surrogate

Seek an immediate court order to invalidate the directive

Start temporary tube feeds while the ethics committee reviews the case

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A 76-year-old man with a history of diabetes mellitus and hypertension presents with progressively worsening exertional dyspnea, limiting his ambulation to approximately 10 meters. On physical examination, a forceful apex beat is noted along with a harsh crescendo-decrescendo ejection systolic murmur, loudest at the right upper sternal border and radiating to the carotid arteries. What is the most likely diagnosis?

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