Internal Medicine

A 26-year-old man is evaluated in the emergency department for severe shortness of breath that has progressively worsened over the past 48 hours. He has a lifelong history of asthma and uses a short-acting bronchodilator as needed. Yesterday, he moved into an apartment with a roommate who owns a cat. On arrival, the patient is fully alert but speaks in short, two-word sentences. Initial vital signs include a temperature of 37.1°C ($98.8$°F), blood pressure of 135/82 mmHg, pulse of 122/min, and respiratory rate of 30/min. Pulse oximetry shows an oxygen saturation of 93% on room air. Physical examination demonstrates prominent accessory muscle use and loud, diffuse expiratory wheezing.

He is immediately treated with continuous nebulized albuterol, ipratropium, and intravenous methylprednisolone. Two hours later, the nurse urgently alerts the physician because the patient has become drowsy and is difficult to rouse. Repeat vital signs show a blood pressure of 108/65 mmHg, pulse of 138/min, and a respiratory rate of 12/min. Oxygen saturation is 87% on 4 L/min via nasal cannula. Repeat chest auscultation reveals markedly diminished breath sounds bilaterally with absent wheezing.

An arterial blood gas analysis on the current oxygen setting shows:

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

A 32-year-old woman presents to the outpatient clinic with a 1-day history of right-sided pleuritic chest pain and mild dyspnea. Her vital signs show a temperature of 37.1°C (98.8°F), pulse of 92/min, respiratory rate of 16/min, and blood pressure of 118/76 mm Hg. Oxygen saturation is 99% on room air. She has no history of venous thromboembolism, recent surgery, or immobilization. Her physical examination is unremarkable. Arrange the following diagnostic steps in the most appropriate sequential order for the evaluation of this patient.

A 34-year-old woman presents to the emergency department complaining of a sudden-onset "racing heart" and mild palpitations that began 30 minutes ago. She has no significant past medical history and takes no medications. On evaluation, she is alert, oriented, and conversing comfortably. Her blood pressure is 118/76 mmHg, pulse is 185/min, and respiratory rate is 18/min. Cardiopulmonary examination is otherwise unremarkable, with clear lungs and no murmurs. An electrocardiogram reveals a regular, narrow-complex tachycardia at a rate of 185/min with no discernible P waves. Assuming the patient's hemodynamic status remains stable but the arrhythmia is refractory to each successive intervention, arrange the following management steps in the correct chronological sequence according to standard clinical algorithms.

A 59-year-old woman is evaluated on hospital day 3 for new-onset respiratory distress. She was initially admitted for pyelonephritis complicated by septic shock and received 4 liters of intravenous crystalloid fluids over the first 24 hours. Blood cultures drawn on admission grew *Escherichia coli* that is susceptible to ceftriaxone, ciprofloxacin, and ampicillin. She has a history of type 2 diabetes mellitus and hypertension. Current medications include intravenous piperacillin-tazobactam.

Temperature is 37.2°C (99.0°F), blood pressure is 142/86 mmHg, heart rate is 112/min, and respiratory rate is 28/min. Pulse oximetry is 88% on room air. Physical examination reveals jugular venous distention to 11 cm H2O. Lung auscultation demonstrates bilateral crackles extending to the mid-scapulae and diffuse expiratory wheezes.

Arterial blood gas analysis on room air reveals:
pH: 7.25
PaCO2: 42 mmHg
PaO2: 56 mmHg
HCO3-: 18 mEq/L

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

A 68-year-old male retired teacher comes to the urgent care clinic complaining of a three-day history of increased shortness of breath and a persistent cough. He states his normally clear sputum has become thick and yellow. His medical history includes hypertension and a 45-pack-year smoking habit. He currently takes amlodipine. His temperature is 37.2°C (99.0°F), blood pressure is 134/82 mmHg, heart rate is 94/min, and respiratory rate is 24/min. Pulse oximetry reveals an oxygen saturation of 90% on room air. On auscultation, there is a prolonged expiratory phase with diffuse bilateral wheezing. Jugular venous distention is absent, and there is no dependent edema. A bedside arterial blood gas analysis on room air shows:

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

A 65-year-old man arrives at the emergency department reporting sudden-onset, severe, tearing chest pain that radiates to his back. His blood pressure is 195/110 mm Hg in both arms, and his heart rate is 112/min. A chest radiograph demonstrates a widened mediastinum. A presumptive clinical diagnosis of acute aortic dissection is made. Arrange the following management steps in the correct chronological sequence to safely stabilize and evaluate this patient.

Match each esophageal disorder with its most characteristic diagnostic finding on imaging or endoscopy.

A 72-year-old man is evaluated in the emergency department for progressive shortness of breath, a nocturnal cough, and wheezing that has worsened over the past week. He has a 40-pack-year smoking history and long-standing hypertension. His temperature is 37.0°C (98.6°F), blood pressure is 145/85 mm Hg, and oxygen saturation is 91% on ambient air. Auscultation reveals diffuse bilateral wheezes and fine crackles at the lung bases. To help differentiate the etiology of his symptoms, the physician positions the patient at a 45-degree angle and instructs him to breathe normally through his mouth. Firm, sustained pressure is applied to the patient's periumbilical region for 15 seconds. During this maneuver, the jugular venous column rises by 5 cm and remains elevated until the pressure is released. Which of the following underlying mechanisms is most directly confirmed by this physical examination finding?

Paramedics bring a 26-year-old male to the emergency room following the sudden onset of profound palpitations and dizziness while jogging. The symptoms began approximately $45$ minutes prior to arrival. He has no significant past medical history and takes no medications, though he recalls a prior physician mentioning a "unique heart pattern" during a sports physical years ago. On physical examination, the patient is anxious but fully alert and oriented. His temperature is $36.8^\circ$ C ($98.2^\circ$ F), blood pressure is $118/74$ mm Hg, and respiratory rate is $16$/min. Cardiac auscultation reveals a tachycardic, irregularly irregular rhythm without murmurs. The lungs are clear.

A 12-lead electrocardiogram demonstrates an irregularly irregular rhythm with a ventricular rate varying between $160$ and $210$/min. The QRS complexes are widened ($0.15$ seconds) and exhibit variable morphology from beat to beat. No distinct P waves are observed. A review of his electronic medical record reveals a baseline electrocardiogram from three years ago showing a PR interval of $0.10$ seconds and a slurred, broad upstroke of the QRS complex.

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

A 32-year-old woman presents to the clinic with a 6-month history of progressive exertional dyspnea and fatigue. She has no history of smoking, asthma, or illicit drug use, and takes no medications. Physical examination reveals a prominent right ventricular heave, a loud pulmonic component of the second heart sound ($P_2$), and trace bilateral lower extremity edema. The lungs are clear to auscultation. Electrocardiography demonstrates right axis deviation and right ventricular hypertrophy. Arrange the following steps in the most appropriate sequential order for the comprehensive diagnostic evaluation and initial management of this patient's suspected condition.

A 74-year-old male farmer is brought to the emergency department by his wife due to a 3-day history of progressively worsening shortness of breath, increased cough frequency, and a change in his sputum from clear to thick yellowish-green. He has a 45-pack-year smoking history and uses an albuterol inhaler as needed. Upon arrival, his temperature is $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), blood pressure is $145/88\text{ mmHg}$, pulse is $114/\text{min}$, and respiratory rate is $26/\text{min}$. Pulse oximetry shows an oxygen saturation of $85\%$ on room air. Physical examination reveals an anxious, mildly somnolent patient who is easily arousable and follows commands. He is using accessory muscles of respiration. Auscultation demonstrates globally diminished breath sounds with a prolonged expiratory phase and diffuse expiratory wheezing. Jugular venous pressure is normal, and there is no lower extremity edema. An arterial blood gas drawn on room air reveals:

Which of the following are appropriate initial management steps for this patient? (Select all that apply)

A 78-year-old man with end-stage idiopathic pulmonary fibrosis is admitted to the intensive care unit and intubated for acute respiratory failure. He is currently deeply sedated and unresponsive. His arterial blood gas reveals a pH of $7.21$, $PaCO_2$ of $68$ mmHg, and $HCO_3^-$ of $26$ mEq/L. The medical team determines his fibrotic lung disease is irreversible and he cannot be successfully weaned from mechanical ventilation.

The patient's medical record contains a valid advance directive clearly appointing his daughter as his sole healthcare proxy. The directive states he does not wish to be kept on life support if his condition is irreversible. However, the patient's son has just arrived at the hospital, disagrees with the daughter, and demands the team perform a tracheostomy and immediately start empirical intravenous meropenem and vancomycin to 'prevent any potential infections.' The patient has no fever, normal white blood cell count, and clear tracheal secretions.

Which of the following actions by the critical care physician are appropriate? (Select all that apply)

A 28-year-old man comes to the clinic reporting a 2-day history of watery, non-bloody diarrhea. He reports passing 4 to 5 loose bowel movements per day, accompanied by mild, diffuse abdominal cramping. He denies having any fever, nausea, vomiting, or recent travel history. He has no significant past medical history, takes no medications, and has had no recent sick contacts. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 118/76 mmHg, pulse of 82/min, and respiratory rate of 14/min. Physical examination reveals a soft, non-distended abdomen with mild diffuse tenderness and hyperactive bowel sounds. There is no rebound tenderness or guarding. Which of the following is the most appropriate next step in the management of this patient?

Paramedics bring an 80-year-old woman to the resuscitation bay due to the acute onset of severe breathlessness. Her symptoms began suddenly about an hour ago while she was watching television. The patient has a known medical history of poorly controlled hypertension, hyperlipidemia, and stable angina. On assessment, she is coughing up frothy, pink-tinged sputum and appears highly anxious. Vital signs show a temperature of $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), a blood pressure of $190/110\text{ mmHg}$, a heart rate of $118/\text{min}$, and a respiratory rate of $28/\text{min}$. Her oxygen saturation is $84\%$ on room air. The physical examination is notable for prominent distention of the jugular veins when the patient is sitting upright. Cardiac auscultation reveals a regular tachycardia with a loud S4 gallop and no murmurs. Pulmonary auscultation yields coarse crackles heard throughout all lung fields bilaterally. Which of the following is the most appropriate initial pharmacologic therapy for this patient?

An emergency medical crew brings a 45-year-old man to the hospital due to a one-week history of high fevers, intense chills, and severe fatigue. He has a known history of intravenous heroin use. Upon arrival in the acute care unit, his temperature is 39.1°C (102.4°F), blood pressure is 110/65 mm Hg, and pulse is 112/min. Physical examination reveals a loud III/VI holosystolic murmur best heard at the left lower sternal border that increases in intensity with inspiration. Small, tender, erythematous nodules are noted on the pads of his fingers. Arrange the following steps in the most appropriate chronological sequence for the initial diagnostic evaluation and management of this patient.

During bedside cardiovascular examination, various physical maneuvers and pharmacologic interventions are utilized to differentiate structural heart diseases by altering hemodynamics. Match each of the following maneuvers with its characteristic effect on the intensity of specific cardiac murmurs.

A $68$-year-old male is evaluated in the intensive care unit for altered mental status. He was admitted $4$ days ago for an acute exacerbation of chronic obstructive pulmonary disease (COPD) and acute decompensated heart failure. His initial treatment included noninvasive positive pressure ventilation, intravenous furosemide, and a $5$-day course of azithromycin and ceftriaxone, which he completed yesterday. He has a history of severe COPD, heart failure with preserved ejection fraction, and hypertension.

Over the past $24$ hours, he has become increasingly lethargic and is currently difficult to arouse. He is receiving oxygen at $2 \text{ L/min}$ via nasal cannula. Temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $105/60 \text{ mm Hg}$, pulse is $108/\text{min}$, and respirations are $9/\text{min}$. Physical examination shows flat jugular veins when supine. Mucous membranes are dry. Cardiopulmonary examination reveals distant heart sounds and decreased breath sounds bilaterally without wheezing or crackles. There is no lower extremity edema.

Laboratory results are as follows:

Arterial blood gas analysis on $2 \text{ L/min}$ nasal cannula:

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

Identify the defining serologic or biochemical marker that is most specific for diagnosing each of the following hepatobiliary conditions.

Match each underlying valvular pathology to its classic auscultatory finding.

A 73-year-old woman with a history of severe chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy (left ventricular ejection fraction of $35\%$) is brought to the emergency department by her son due to worsening shortness of breath for the past two days. She states that her cough has increased and her sputum has changed from white to thick green. She denies paroxysmal nocturnal dyspnea, orthopnea, or recent weight gain. Vital signs include temperature $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), blood pressure $135/85\text{ mm Hg}$, pulse $115/\text{min}$, and respiratory rate $26/\text{min}$. Oxygen saturation is $87\%$ on room air. Physical examination reveals use of accessory muscles of respiration. Lung auscultation demonstrates a prolonged expiratory phase with loud, bilateral polyphonic wheezes and no crackles. The jugular venous pressure is $6\text{ cm H}_2\text{O}$ (normal $<8\text{ cm H}_2\text{O}$). There is no peripheral edema. A chest radiograph reveals hyperinflated lungs but no cardiomegaly, pulmonary edema, or focal consolidation. Which of the following medication regimens is most appropriate for the initial management of this patient?