Internal Medicine

Match each central hemodynamic profile obtained via pulmonary artery (Swan-Ganz) catheterization to its most likely underlying pathophysiological etiology.

A 71-year-old man is brought to the emergency department by his wife due to progressively worsening shortness of breath and a persistent, dry cough over the past 48 hours. He states that the breathlessness is most severe when he lies down, forcing him to sleep in a recliner chair. His medical history includes hypertension, osteoarthritis, and severe chronic obstructive pulmonary disease (COPD) for which he uses a daily tiotropium inhaler. Two weeks ago, he was prescribed daily high-dose naproxen for severe bilateral knee pain. His temperature is 37.1°C (98.8°F), blood pressure is 172/96 mmHg, pulse is 112/min, and respirations are 26/min. Pulse oximetry shows 88% on room air. Physical examination reveals a patient in moderate respiratory distress using accessory muscles of respiration. Lung auscultation demonstrates diffuse, high-pitched expiratory wheezes and a prolonged expiratory phase. Cardiac auscultation reveals a regular tachycardia without murmurs; no extra heart sounds are audible. Jugular venous pressure is estimated at 12 cm H2O. Chest radiography reveals baseline hyperinflation with new, bilateral, hazy interstitial opacities and thickening of the interlobular septa. Arterial blood gas on room air shows a pH of 7.47, PaCO2 of 32 mmHg, and PaO2 of 56 mmHg. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

Match each set of laboratory findings from the evaluation of the hypothalamic-pituitary-adrenal (HPA) axis to the most likely underlying pathophysiologic diagnosis.

A $58$-year-old man presents to the oncology clinic complaining of worsening fatigue, generalized weakness, and cold intolerance for the past month. He also reports intermittent nausea and a $3$-kg ($6.6$-lb) weight loss during this time. The patient has a history of advanced renal cell carcinoma, for which he has been receiving nivolumab therapy for the past six months. Blood pressure is $96/60$ mm Hg, and pulse is $54$/min. Physical examination reveals dry skin and a delayed relaxation phase of the deep tendon reflexes.

Laboratory studies show:
Thyroid-stimulating hormone (TSH): $1.1$ $\mu$ U/mL (Normal: $0.5 - 5.0$ $\mu$ U/mL)
Free thyroxine (T4): $0.4$ ng/dL (Normal: $0.9 - 2.4$ ng/dL)
Sodium: $131$ mEq/L
Potassium: $4.1$ mEq/L

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

Emergency medical services transport a 41-year-old male to the hospital after his spouse discovered him unresponsive in their garage. Beside him was an open, partially consumed jug of automotive antifreeze. Upon arrival, vital signs demonstrate a temperature of 36.5°C (97.7°F), blood pressure of 105/65 mm Hg, heart rate of 92/min, and a depressed respiratory rate of 10/min. The physical examination is notable for profound lethargy, with the patient only groaning in response to painful stimuli.

Initial laboratory evaluation reveals the following:

Which of the following best characterizes this patient's underlying acid-base disorder?

A 25-year-old man presents to the clinic complaining of abdominal cramping and diarrhea that began 4 days ago. He reports that the diarrhea was initially watery but has become frankly bloody over the past 24 hours. He does not recall having a fever. Five days prior to symptom onset, he attended a neighborhood barbecue where he consumed hamburgers. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, and heart rate is $88/\text{min}$. Abdominal examination reveals hyperactive bowel sounds and diffuse, mild tenderness without guarding or rebound. Laboratory studies show a leukocyte count of $10,500/\text{mm}^3$, hemoglobin of $14.2\text{ g/dL}$, platelet count of $220,000/\text{mm}^3$, and serum creatinine of $0.9\text{ mg/dL}$. Rapid stool enzyme immunoassay is positive for Shiga toxin. Which of the following is the most appropriate next step in management?

A 58-year-old man is found unresponsive on the floor of his hospital room. He has no palpable pulse and is not breathing. The emergency response team arrives with a crash cart. Arrange the following actions in the correct sequential order for managing this patient's cardiac arrest, assuming the initial rhythm identified on the monitor is ventricular fibrillation.

A 49-year-old man with a history of untreated hepatitis B viral infection and known hepatic cirrhosis is brought to the emergency department via ambulance due to the abrupt onset of excruciating, diffuse abdominal pain that began 4 hours ago. He is lethargic and confused. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $72/45\text{ mmHg}$, pulse is $130/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows $92\%$ on room air. Physical examination reveals a markedly distended abdomen with board-like rigidity, severe diffuse tenderness, and rebound tenderness. Bowel sounds are absent. Skin examination shows numerous spider telangiectasias. Laboratory studies reveal a leukocyte count of $18,500/\text{mm}^3$, hemoglobin of $10.8\text{ g/dL}$, platelet count of $72,000/\text{mm}^3$, and creatinine of $2.4\text{ mg/dL}$. Arterial blood gas on room air shows a pH of $7.22$, pCO2 of $30\text{ mmHg}$, and pO2 of $68\text{ mmHg}$. A bedside diagnostic paracentesis yields cloudy ascitic fluid with a leukocyte count of $8,200/\text{mm}^3$ ($90\%$ neutrophils), total protein of $2.8\text{ g/dL}$, glucose of $22\text{ mg/dL}$, and lactate dehydrogenase (LDH) of $640\text{ U/L}$ (Serum LDH upper limit: $220\text{ U/L}$). Gram stain shows many polymorphonuclear leukocytes, abundant gram-negative bacilli, and gram-positive cocci. Which of the following is the most appropriate next step in management?

During a clinical skills workshop, a group of medical students is reviewing characteristic peripheral pulse findings in various cardiovascular disorders. Match each described arterial pulse abnormality with the underlying cardiac pathology it most classically represents.

A 62-year-old man with a 40-pack-year smoking history presents to the emergency department with a 2-week history of progressive facial swelling, a dry cough, and a feeling of "fullness" in his head that worsens when he leans forward. On physical examination, his temperature is 37.1°C (98.8°F), blood pressure is 134/82 mmHg, heart rate is 98/min, and respiratory rate is 18/min. Oxygen saturation is 96% on room air. He has plethora of the face and marked distension of the jugular veins that do not collapse with inspiration. The patient is conversant, has no stridor, and is in no acute respiratory distress. Arrange the following steps in the most appropriate chronological order for the management of this patient's condition.

A $72$-year-old woman is evaluated in the intensive care unit for sudden clinical deterioration. She was admitted $10$ days ago for a severe chronic obstructive pulmonary disease exacerbation, which was treated with systemic glucocorticoids and levofloxacin. Three days ago, she developed profuse, watery diarrhea. This morning, her diarrhea abruptly ceased, but she became increasingly lethargic and developed severe abdominal pain. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), pulse is $132\text{/min}$, blood pressure is $78/45\text{ mm Hg}$, and respirations are $24\text{/min}$. Physical examination reveals a lethargic patient. The abdomen is markedly distended and tympanic with absent bowel sounds. Diffuse rigidity, guarding, and rebound tenderness are present.

Laboratory studies show:
Leukocyte count: $38,000/\text{mm}^3$ ($90\%$ neutrophils, $5\%$ bands)
Serum lactate: $5.2\text{ mmol/L}$

Arterial blood gas (room air):
pH: $7.22$
$\text{PaCO}_2$: $30\text{ mm Hg}$
$\text{HCO}_3^-$: $12\text{ mEq/L}$

An upright chest and abdominal radiograph demonstrates a $10\text{-cm}$ dilation of the transverse colon, loss of colonic haustrations, and a prominent crescent of radiolucency beneath the right hemidiaphragm.

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

Match each classic valvular abnormality to its most characteristic physical examination finding on cardiac auscultation.

A 62-year-old male is brought to the emergency department by his family due to a severe headache, confusion, and a high fever that began 18 hours ago. His temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $138/82\text{ mmHg}$, heart rate is $112\text{/min}$, and respiratory rate is $20\text{/min}$. Physical examination reveals nuchal rigidity and a positive Brudzinski sign. Neurologic examination is notable for a left-sided hemiparesis and bilateral papilledema on fundoscopy. The physician suspects acute bacterial meningitis and prepares to manage the patient.

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

Match each clinical presentation with its most likely corresponding arterial blood gas and serum electrolyte panel.

A 67-year-old male with a 40-pack-year smoking history and known chronic obstructive pulmonary disease (COPD) presents to the emergency department reporting three days of progressively worsening shortness of breath. He also notes increased cough frequency and a change in his sputum from clear to thick, yellow-green. He denies orthopnea, paroxysmal nocturnal dyspnea, and lower extremity swelling. Vital signs include a temperature of 37.1 C (98.8 F), heart rate of 102/min, respiratory rate of 24/min, blood pressure of 134/82 mmHg, and oxygen saturation of 90% on room air. Chest auscultation reveals diffuse expiratory wheezing with prolonged expiration, but no crackles. A chest radiograph demonstrates hyperinflation without focal consolidation, pleural effusion, or pulmonary edema. Which of the following are appropriate initial pharmacologic interventions for this patient? (Select exactly 3)

An otherwise healthy $52$-year-old male seeks immediate medical attention for sudden-onset shortness of breath and a sharp, right-sided chest pain that worsens with deep inspiration. His vitals show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), a blood pressure of $130/80$ mm Hg, a heart rate of $102$/min, and a respiratory rate of $20$/min. Pulse oximetry indicates an oxygen saturation of $96\%$ on room air. Cardiopulmonary auscultation is unremarkable. The evaluating physician calculates a Wells score of $1.5$, which places him in the low clinical probability category for a pulmonary embolism. Arrange the following diagnostic and therapeutic steps in the correct chronological sequence for the standard management of this patient.

A precise understanding of electrocardiographic lead localization is essential for identifying the specific coronary artery involved in an acute myocardial infarction. Match each presentation of characteristic 12-lead (and extended) ECG findings with the most likely culprit coronary artery and corresponding region of myocardial infarction.

A $74$-year-old woman presents to the acute care clinic with a $2$-day history of progressively worsening shortness of breath. She has a medical history significant for coronary artery disease, for which she underwent percutaneous coronary intervention $5$ years ago, and chronic obstructive pulmonary disease due to a $45$-pack-year smoking history. Over the past two nights, she has been unable to sleep flat in her bed, requiring multiple pillows to breathe comfortably. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $162/90\text{ mmHg}$, pulse is $115/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows $88\%$ on room air. Physical examination reveals distended jugular veins when the patient is seated upright. Pulmonary auscultation reveals bilateral expiratory wheezes and dullness to percussion at the bases. Cardiac auscultation demonstrates a regular tachycardia and an early diastolic, low-frequency sound. Which of the following is the most appropriate initial therapy for this patient?

A 34-year-old woman comes to the clinic reporting a persistent cough for the past 10 days. The cough is frequently productive of yellowish-green sputum. She states that she initially had a runny nose, mild sore throat, and low-grade fever that resolved after a few days, but the cough has persisted and occasionally interrupts her sleep. She has no past medical history, takes no medications, and does not smoke. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mmHg, pulse is 78/min, and respiratory rate is 14/min. Pulse oximetry is 99% on room air. Pulmonary examination reveals normal vesicular breath sounds bilaterally with no wheezes, crackles, or rhonchi. Cardiac examination shows a regular rate and rhythm with no murmurs. There is no jugular venous distention or lower extremity edema. Which of the following is the most appropriate next step in management?

Match each clinical presentation of a suspected chemotherapy-induced adverse effect with the most likely responsible antineoplastic agent.