Internal Medicine

A $62$-year-old woman is evaluated in the hospital on hospital day $6$ for new-onset shortness of breath and right-sided pleuritic chest pain. She was initially admitted for a deep venous thrombosis of the left lower extremity and was started on a continuous infusion of unfractionated heparin. Her past medical history is notable for hypertension and type 2 diabetes mellitus. Temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $134/82\text{ mmHg}$, pulse is $112\text{/min}$, and respirations are $22\text{/min}$. Pulse oximetry shows $92\%$ on room air. Physical examination reveals clear lungs bilaterally and swelling of the left leg that is unchanged from admission.

Laboratory studies obtained today show:

On admission, her platelet count was $240,000/\mu\text{L}$. Which of the following is the most appropriate next step in management?

Match each clinical presentation of a gastrointestinal or hepatobiliary disorder to its most appropriate evidence-based next step in management.

Match each clinical presentation of a gastrointestinal or hepatic condition with the most appropriate next step in antimicrobial management, demonstrating evidence-based principles of antibiotic stewardship.

During a routine follow-up appointment, a 29-year-old female reports a six-month history of profound exhaustion, feeling abnormally cold, and an unintentional weight gain of $4.5\ \text{kg}$ ($10\ \text{lb}$). She delivered her first child ten months ago via a vaginal delivery that was complicated by significant uterine atony, requiring massive volume resuscitation and multiple packed red blood cell transfusions. Following the delivery, she was completely unable to produce breast milk. Her menstrual periods have not returned since the pregnancy. Blood pressure is $92/58\ \text{mm Hg}$, and pulse is $54/\text{min}$. Physical examination demonstrates a delayed relaxation phase of the deep tendon reflexes.

Laboratory results are as follows:

Which of the following is the most likely underlying mechanism for this patient's clinical presentation?

A 52-year-old woman presents to the emergency department with a 2-day history of diffuse abdominal pain, polyuria, and severe, intractable vomiting. She has a history of type 1 diabetes mellitus and states she ran out of her insulin three days ago. Her temperature is 37.2°C (99.0°F), blood pressure is 95/60 mmHg, pulse is 118/min, and respirations are 24/min. Physical examination reveals dry mucous membranes and diffuse, mild abdominal tenderness without rebound or guarding. Laboratory studies show:

Arterial blood gas on room air reveals:

Which of the following best describes this patient's acid-base status?

During a routine morning clinic shift, a physician evaluates a 68-year-old male patient who reports worsening breathing difficulties over the past three days. The patient, who has a 40-pack-year smoking history and known systemic hypertension, states that he must sleep propped up on three pillows and recently woke up abruptly feeling starved for air. Vital signs include a blood pressure of 162/94 mm Hg, heart rate of 95/min, and respiratory rate of 22/min. Physical examination reveals elevated jugular venous pressure, a distinct third heart sound (S3), and bibasilar crackles on inspiration. Bilateral 2+ pitting edema is noted in the lower extremities. Which of the following is the most appropriate initial pharmacological intervention for this patient's current condition?

A 62-year-old man presents to the emergency department reporting continuous, crushing left-sided chest pain that began two hours ago. He is diagnosed with an acute ST-segment elevation myocardial infarction (STEMI) and is monitored closely. Arrange the following classic electrocardiographic (ECG) changes in the typical chronological order that they appear during the natural evolution of an untreated transmural myocardial infarction.

A thorough urinalysis is a critical non-invasive tool for localizing the site of renal injury in patients with acute or chronic kidney disease. For each characteristic urinalysis sediment finding presented below, what is the most likely associated renal pathology? Match each finding to its correct etiology.

A $71$-year-old woman is brought to the emergency department by her family due to a $2$-day history of worsening severe right upper quadrant abdominal pain, shaking chills, and yellowing of her skin. Upon arrival, her temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $86/50 \text{ mmHg}$, and heart rate is $118 \text{/min}$. The patient appears severely lethargic and is oriented only to person. Physical examination reveals marked scleral icterus and significant right upper quadrant tenderness without rebound or guarding. Laboratory studies show:

Leukocytes: $19,200/\text{mm}^3$
Total bilirubin: $5.8 \text{ mg/dL}$
Direct bilirubin: $4.5 \text{ mg/dL}$
Alkaline phosphatase: $510 \text{ U/L}$
Aspartate aminotransferase (AST): $142 \text{ U/L}$
Alanine aminotransferase (ALT): $155 \text{ U/L}$

A bedside right upper quadrant ultrasound demonstrates a dilated common bile duct measuring $14 \text{ mm}$ containing an echogenic focus with posterior acoustic shadowing.

Arrange the following steps in the most appropriate chronological sequence for the management of this patient.

A 28-year-old medical resident sustains a deep percutaneous needle-stick injury to her hand while drawing blood from a patient in the emergency department. The source patient has a documented history of poorly controlled HIV with a high viral load. The hollow-bore needle was visibly contaminated with blood. What is the most appropriate chronological sequence of interventions for this occupational exposure?

A ward nurse urgently pages the on-call physician to evaluate a 71-year-old male inpatient for acute clinical deterioration. The patient was admitted two days prior for a presumed mild lower respiratory tract infection. His medical history is significant for a prior anterior myocardial infarction, diet-controlled type 2 diabetes, and a 45-pack-year smoking history. Upon evaluation, the patient is lethargic, diaphoretic, and in profound respiratory distress. Vital signs are temperature 37.0°C (98.6°F), blood pressure 82/54 mm Hg, pulse 124/min, and respirations 28/min. Pulse oximetry displays 84% on room air. Physical examination reveals cool, clammy extremities. Chest auscultation demonstrates diffuse, high-pitched expiratory wheezing bilaterally without focal crackles. Cardiac auscultation reveals tachycardia with a distinct low-frequency sound heard immediately following $S_2$. Sustained pressure over the right upper abdominal quadrant causes the neck veins to visibly engorge and remain elevated. Arterial blood gas analysis on room air reveals a $pH$ of 7.26, $PaCO_2$ of 60 mm Hg, and $HCO_3^-$ of 26 mEq/L. Which of the following is the most appropriate next step in the management of this patient?

During a multidisciplinary ward round, the medical team evaluates a patient who was admitted 72 hours ago. The patient, a 48-year-old male with a long-standing history of alcohol use disorder, is currently being treated for severe acute pancreatitis. Overnight, he developed a new-onset fever of 38.7°C (101.7°F) and mild shortness of breath. His blood pressure is 112/68 mm Hg, heart rate is 118/min, and respiratory rate is 24/min. Pulse oximetry shows 93% on room air. Auscultation of the chest reveals decreased breath sounds bilaterally at the lung bases. The abdomen is diffusely tender and distended, with hypoactive bowel sounds. Current laboratory results demonstrate a leukocyte count of 17,200/mm³. A metabolic panel reveals a serum bicarbonate of 16 mEq/L, and an arterial blood gas on room air shows a pH of 7.34 and a $PaCO_2$ of 31 mm Hg. To investigate the clinical change, a contrast-enhanced abdominal computed tomography (CT) scan is obtained. The imaging reveals non-enhancement of approximately 40% of the pancreatic parenchyma and adjacent fluid collections, with no evidence of extraluminal gas. What is the most appropriate management plan for this patient's current condition?

A $46$-year-old woman is hospitalized for induction chemotherapy for newly diagnosed acute myeloid leukemia. On hospital day $12$, she develops a new-onset fever. She reports feeling chilled and fatigued but has no cough, dysuria, abdominal pain, or skin changes. Her temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $105/65\text{ mm Hg}$, pulse is $115/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination is unremarkable, with clear lungs and no induration around her central venous catheter. Laboratory studies reveal an absolute neutrophil count of $120/\mu\text{L}$.

Arrange the following steps in the most appropriate chronological sequence for the management of this patient's complication.

A 68-year-old man is brought to the emergency department via ambulance with a 30-minute history of sudden-onset, severe, "tearing" chest pain that radiates to his back between his shoulder blades. His blood pressure is 210/115 mm Hg in the right arm and 175/95 mm Hg in the left arm, and his heart rate is 112/min. He appears visibly distressed and diaphoretic. An ECG shows sinus tachycardia with voltage criteria for left ventricular hypertrophy, but no acute ischemic changes. A chest radiograph demonstrates a widened mediastinum. The clinical presentation is highly suspicious for an acute aortic dissection. Arrange the following management steps in the most appropriate sequential order for the optimal care of this patient.

Paramedics arrive at the emergency department bringing a 74-year-old woman who woke up suddenly with severe shortness of breath two hours ago. She reports progressively worsening exertional dyspnea over the preceding three days. Her medical history includes hypertension, hyperlipidemia, osteoarthritis, and a 40-pack-year smoking history. Current medications are amlodipine, atorvastatin, and ibuprofen. Vital signs are temperature 37.1°C (98.8°F), blood pressure 175/95 mmHg, pulse 110/min, and respiratory rate 26/min. Pulse oximetry shows 89% on room air. The patient is sitting upright on the edge of the stretcher, using accessory muscles of respiration. Lung auscultation reveals diffuse, prominent expiratory wheezing bilaterally. Which of the following physical examination findings is most specific for confirming a cardiogenic etiology for this patient's acute symptoms rather than a primary pulmonary exacerbation?

A patient with a significant history of systemic hypertension and extensive tobacco use is evaluated in the outpatient setting for progressive dyspnea, orthopnea, and recent episodes of waking up gasping for air. Vital signs show a blood pressure of 152/94 mm Hg, a heart rate of 98/min, and a respiratory rate of 22/min. Lung auscultation demonstrates bilateral crackles at the lung bases and scattered expiratory wheezes. The clinician suspects acute decompensated heart failure but wants to differentiate it from a chronic obstructive pulmonary disease exacerbation. Which of the following physical examination findings is most specific for identifying decompensated heart failure in this clinical scenario?

An $82$-year-old woman is evaluated in the outpatient clinic for a routine follow-up. She is accompanied by her son, who assists with her activities of daily living. Her medical history is significant for type 2 diabetes mellitus, essential hypertension, and mild neurocognitive disorder. During the visit, the son expresses concern because he has noticed that the patient's urine in her bedside commode has appeared cloudy and distinctly malodorous over the last $72$ hours. He is worried she may have a urinary tract infection, as she was treated for one six months ago. Upon direct questioning, the patient is pleasant and conversant, remaining at her cognitive baseline. She explicitly denies experiencing any dysuria, increased urinary frequency, urinary urgency, flank pain, or subjective fevers. Her vital signs include a temperature of $37.1^{\circ}$ C ($98.8^{\circ}$ F), blood pressure of $135/85$ mmHg, heart rate of $78$/min, and respiratory rate of $14$/min. Abdominal examination is soft and non-tender, with no suprapubic discomfort or costovertebral angle tenderness. A clean-catch urinalysis obtained in the clinic reveals positive leukocyte esterase, positive nitrites, and $35$ white blood cells per high-power field. Which of the following is the most appropriate next step in management?

Paramedics evaluate a 61-year-old male at his residence following an emergency call for sudden-onset, excruciating retrosternal chest pain that radiates to his mid-back. He is immediately transported to the nearest tertiary care center. On arrival, the patient is visibly distressed, diaphoretic, and tachypneic. His medical history is notable for uncontrolled hypertension and a 40-pack-year smoking history. Vital signs demonstrate a temperature of 36.8°C (98.2°F), a heart rate of 122/min, a blood pressure of 78/46 mm Hg in the right arm and 82/48 mm Hg in the left arm, and an oxygen saturation of 88% on room air. Physical examination reveals elevated jugular venous pressure and diffuse bilateral crackles on lung auscultation. A bounding, early diastolic decrescendo murmur is auscultated along the right sternal border. An electrocardiogram reveals sinus tachycardia with left ventricular hypertrophy but no acute ischemic ST-segment changes. Which of the following is the most appropriate next step in the management of this patient?

A 55-year-old man with a history of decompensated alcohol-associated cirrhosis is brought to the emergency department by ambulance after vomiting a large amount of bright red blood. On arrival, he is lethargic and oriented only to his name. His temperature is 36.8°C (98.2°F), blood pressure is 80/50 mmHg, pulse is 128/min, and respiratory rate is 22/min. Physical examination reveals scleral icterus, spider angiomas, and a distended abdomen with a positive fluid wave. Active hematemesis is ongoing. Arrange the following interventions in the correct chronological sequence of escalation for managing this patient's condition, assuming continued need for intervention at each stage:

A $65$-year-old man with a recent diagnosis of small cell lung cancer is admitted to the hospital due to progressive confusion, lethargy, and nausea over the past week. He has a $40$-pack-year smoking history. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $128/82$ mmHg, pulse is $78$/min, and respirations are $14$/min. Physical examination reveals moist mucous membranes, normal skin turgor, no jugular venous distention, and clear lungs. There is no peripheral edema.

Laboratory results are as follows:

While in the emergency department, the patient develops a generalized tonic-clonic seizure that lasts for $2$ minutes and resolves spontaneously. He remains postictal. Which of the following is the most appropriate next step in management?