Internal Medicine

A 38-year-old woman is diagnosed with a 5-cm right adrenal pheochromocytoma after presenting with episodic palpitations, diaphoresis, and severe headaches. Her clinic blood pressure is 168/102 mmHg, and her heart rate is 105/min. She is scheduled to undergo a laparoscopic adrenalectomy in 3 weeks. Arrange the following perioperative management steps in the correct chronological sequence to appropriately prepare this patient for surgery and minimize the risk of intraoperative hemodynamic instability.

A 54-year-old woman is evaluated in the intensive care unit for worsening respiratory status. She was admitted 24 hours ago for severe community-acquired pneumonia and septic shock. She has been receiving targeted intravenous antibiotics, fluid resuscitation, and a continuous infusion of norepinephrine. Her current blood pressure is 88/58 mm Hg, pulse is 122/min, and respirations are 34/min. Temperature is 38.6°C (101.5°F). Pulse oximetry shows 91% on a high-flow nasal cannula delivering 60% oxygen. Physical examination reveals a lethargic patient with prominent use of accessory muscles of respiration. Lung auscultation reveals diffuse crackles over the right hemithorax.

Laboratory results obtained 15 minutes ago:

Arterial blood gas analysis on current oxygen settings:

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

A $62$-year-old man with a history of alcohol-associated cirrhosis and hepatic encephalopathy is evaluated on hospital day $4$. He was initially admitted for fever, worsening confusion, and diffuse abdominal pain. On admission, diagnostic paracentesis revealed an ascitic fluid absolute neutrophil count of $750/\text{mm}^3$, consistent with spontaneous bacterial peritonitis (SBP). Because the patient had been hospitalized three weeks prior for a variceal bleed, empiric therapy was initiated with intravenous piperacillin-tazobactam, and he was given intravenous albumin. Today, his temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $112/68\text{ mm Hg}$, and pulse is $78/\text{min}$. He is alert, oriented, and reports that his abdominal pain has completely resolved. Ascitic fluid cultures drawn on admission have grown *Escherichia coli*. Susceptibility testing demonstrates that the organism is susceptible to ceftriaxone, cefotaxime, ciprofloxacin, and piperacillin-tazobactam; it is resistant to ampicillin. Which of the following is the most appropriate next step in the pharmacologic management of this patient's infection?

A $48$-year-old man comes to the emergency department due to a $5$-day history of fever, right-sided chest pain that worsens with deep breathing, and a productive cough with foul-smelling sputum. He has a history of alcohol use disorder. Temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $110/70$ mm Hg, pulse is $112$/min, and respiratory rate is $24$/min. Pulse oximetry is $94\%$ on room air.

Physical examination reveals poor dentition. Lung auscultation demonstrates decreased breath sounds, dullness to percussion, and decreased tactile fremitus over the lower right lung field.

Chest radiograph shows a large right-sided pleural effusion with loculations.

Diagnostic thoracentesis yields turbid pleural fluid with the following analysis:

Gram stain of the fluid shows many polymorphonuclear leukocytes but no organisms are seen. The patient is promptly started on intravenous ampicillin-sulbactam.

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

Match each clinical and neuroradiological presentation of central nervous system (CNS) disease in a patient with advanced HIV to the most likely etiologic pathogen.

A 31-year-old woman comes to the office due to a 5-day history of palpitations, excessive sweating, and severe anterior neck pain that radiates to her ears. She reports having a mild sore throat and a runny nose about 3 weeks ago, which resolved without treatment. Her temperature is 38.0°C (100.4°F), pulse is 112/min, and blood pressure is 135/75 mm Hg. Physical examination shows a diffusely enlarged, exquisitely tender thyroid gland. No cervical lymphadenopathy is appreciated. Laboratory results are as follows:

Thyroid-stimulating hormone (TSH): 0.02 mU/L
Free thyroxine (T4): 2.9 ng/dL (Normal: 0.9-1.7 ng/dL)
Erythrocyte sedimentation rate: 95 mm/h

A 24-hour radioactive iodine uptake scan demonstrates 2% uptake (Normal: 15-30%). Which of the following is the most appropriate next step in management for this patient?

Emergency medical personnel transport a 19-year-old female university student to the emergency department after her roommate found her profoundly lethargic. The roommate reports that the patient had been complaining of severe nausea, subjective fever, and a persistent ringing in her ears for the past 24 hours. Vital signs on arrival include a temperature of 38.3°C (100.9°F), pulse of 118/min, respiratory rate of 30/min, and blood pressure of 105/65 mmHg. Physical examination reveals deep, rapid respirations and dry mucous membranes. A basic metabolic panel and room air arterial blood gas are obtained:

Based on these laboratory results, which of the following best characterizes this patient's acid-base status?

A 65-year-old male is reevaluated during bedside rounds on his third day of hospitalization. He originally presented to the emergency department with high fever, left-sided costovertebral angle tenderness, and dysuria. Due to a history of recurrent urinary tract infections and a recent skilled nursing facility admission, he was empirically started on intravenous vancomycin and piperacillin-tazobactam. His clinical condition has markedly improved; he has been afebrile for 24 hours, and his flank pain has resolved. Blood and urine cultures drawn on admission now demonstrate growth of Enterococcus faecalis. The isolate is susceptible to ampicillin, vancomycin, linezolid, and daptomycin. Which of the following is the most appropriate next step in pharmacotherapy?

Match each esophageal motility disorder with its characteristic finding on high-resolution esophageal manometry.

A medical student is reviewing characteristic jugular venous pressure (JVP) waveform abnormalities during a cardiology rotation. Match each specific JVP finding with its most likely underlying cardiovascular pathology.

A 58-year-old female patient is receiving mechanical ventilation in the medical intensive care unit due to severe community-acquired pneumonia. On hospital day 5, her clinical status has markedly improved. She is hemodynamically stable without the need for vasopressor support, and her oxygen requirements have decreased substantially. She is currently receiving continuous intravenous sedation with propofol. The critical care team plans to begin the ventilator liberation process.

Arrange the following interventions in the standard chronological sequence for assessing and executing liberation from mechanical ventilation.

A 38-year-old man is evaluated in the hospital on day 3 of admission for high fever, chills, and progressive shortness of breath. He has a history of bipolar disorder, asthma, and intravenous drug use. On admission, blood cultures were drawn, and empirical intravenous vancomycin and cefepime were initiated. Today, the patient reports feeling persistently fatigued and depressed, stating he has been in a 'down state' for the past month. He is currently taking lithium. Temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $110/70\text{ mm Hg}$, pulse is $105/\text{min}$, and respirations are $22/\text{min}$. Physical examination reveals a grade 3/6 holosystolic murmur at the left lower sternal border that increases in intensity with inspiration. Scattered bilateral lung crackles are present. Laboratory studies show:

An echocardiogram demonstrates a 1.5-cm mobile vegetation on the tricuspid valve with severe tricuspid regurgitation. Blood cultures from admission have grown methicillin-susceptible *Staphylococcus aureus* (MSSA). Which of the following is the most appropriate next step in management?

A $32$-year-old female patient is assessed on hospital day $4$. She was initially admitted for high fevers, rigors, and pleuritic chest pain. Her past medical history is significant for major depressive disorder managed with citalopram, and severe opioid use disorder. On the day of admission, physical examination revealed a pan-systolic murmur at the left lower sternal border that augmented during inspiration. Blood cultures from admission grew methicillin-susceptible *Staphylococcus aureus* (MSSA). A transthoracic echocardiogram showed a $1.6$-cm oscillating mass on the tricuspid valve. She was appropriately started on targeted therapy with continuous intravenous nafcillin.

Currently, she reports mild improvement in her chest pain but notes a persistent cough. Her temperature is $37.9^\circ \text{C}$ ($100.2^\circ \text{F}$), blood pressure is $114/70$ mmHg, pulse is $92$/min, and respiratory rate is $18$/min. Pulse oximetry shows $95\%$ on room air. Auscultation of the lungs reveals coarse crackles in the periphery of both lung fields. The cardiac examination is unchanged from admission. There is no jugular venous distention and no peripheral edema.

Laboratory tests reveal:
Leukocyte count: $12,200$/mm $^3$
Thyroid-stimulating hormone (TSH): $1.4\ \mu\text{U/mL}$ (Normal: $0.5 - 5.0\ \mu\text{U/mL}$)
Free thyroxine (T4): $1.1\ \text{ng/dL}$ (Normal: $0.9 - 1.7\ \text{ng/dL}$)
Total triiodothyronine (T3): $62\ \text{ng/dL}$ (Normal: $80 - 200\ \text{ng/dL}$)

A repeat chest radiograph demonstrates several new, small cavitary lesions scattered throughout the peripheral lung fields bilaterally.

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

A 4th-year medical student is reviewing the endocrine laboratory profiles of four distinct patients being evaluated for suspected adrenal pathology. Match each patient's serum laboratory and dynamic testing profile to the most likely underlying etiology.

A 56-year-old man with a history of alcohol-associated cirrhosis presents to the hepatology clinic with new-onset, moderate abdominal distension and early satiety. He reports no fever, abdominal pain, or confusion. Physical examination reveals shifting dullness, spider angiomas, and palmar erythema. Ultrasound confirms the presence of moderate ascites without portal vein thrombosis or hepatocellular carcinoma.

Arrange the following interventions in the most appropriate chronological sequence for the longitudinal management of this patient's ascites, starting from the immediate next step in the current presentation to the management of highly refractory disease:

An internal medicine resident is evaluating a patient recently admitted to the progressive care unit. The patient has a long-standing history of restrictive eating patterns and admits to consuming large quantities of over-the-counter stimulant laxatives over the past month to lose weight. Today, she developed profound, diffuse muscle weakness to the point of being unable to lift her arms from her sides, prompting her roommate to call emergency services.

Current vital signs include a blood pressure of 92/58 mm Hg, heart rate of 112/min, and respiratory rate of 10/min with shallow excursions.

Laboratory evaluation shows the following:

Based on these findings, which of the following best characterizes this patient's acid-base status?

A $68$-year-old woman is rapidly assessed in the cardiac telemetry unit due to sudden-onset severe dyspnea and progressive confusion. She was admitted $3$ days ago for an ST-segment elevation myocardial infarction involving the inferior leads, which was treated with percutaneous coronary intervention of the right coronary artery.

Current vital signs include a temperature of $36.7^\circ\text{C}$ ($98.1^\circ\text{F}$), blood pressure of $78/48\text{ mmHg}$, heart rate of $122/\text{min}$, and respiratory rate of $32/\text{min}$. Oxygen saturation is $84\%$ on high-flow supplemental oxygen.

Physical examination reveals cold, clammy extremities and significant jugular venous distention. Lung auscultation demonstrates diffuse bilateral crackles and prominent expiratory wheezes. Cardiac auscultation reveals a new, harsh, grade $4/6$ holosystolic murmur heard best at the apex with radiation to the axilla.

Point-of-care testing shows a serum lactate of $5.1\text{ mmol/L}$. A thyroid panel drawn earlier as part of an altered mental status workup shows a thyroid-stimulating hormone (TSH) level of $1.1\text{ \mu U/mL}$ (normal: $0.5-5.0\text{ \mu U/mL}$) and a free T4 of $0.9\text{ ng/dL}$ (normal: $0.9-2.4\text{ ng/dL}$).

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

A 48-year-old man is brought to the emergency department by emergency medical services after his neighbor found him unresponsive in his garage. An open, empty container of automotive antifreeze was found nearby. On examination, he is deeply lethargic and responds only to painful stimuli. His vital signs show a blood pressure of $110/70 \text{ mmHg}$, heart rate of $105/\text{min}$, and respiratory rate of $24/\text{min}$.

Laboratory testing reveals the following:

Based on the laboratory findings, what is the patient's calculated serum osmolar gap?

A 64-year-old man comes to the primary care clinic for a routine evaluation of worsening shortness of breath and a dry, hacking cough over the past 3 months. He reports that the cough is particularly bothersome at night and often wakes him from sleep, forcing him to prop himself up with three pillows. His medical history is significant for hypertension, type 2 diabetes mellitus, and a 35-pack-year smoking history, though he quit smoking a decade ago. Current medications include lisinopril, amlodipine, and metformin. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 158/92 mm Hg, pulse of 88/min, and respirations of 18/min. BMI is 29 kg/m². Pulse oximetry is 96% on room air. On physical examination, the lungs are clear to auscultation bilaterally. Cardiac examination reveals a regular rate and rhythm, but the point of maximal impulse is palpated at the anterior axillary line in the sixth intercostal space. A grade 2/6 holosystolic murmur is heard best at the cardiac apex. There is 1+ pitting edema in the bilateral ankles. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient's condition?

A 71-year-old man presents to the pulmonary clinic reporting a 9-month history of progressively worsening shortness of breath and a dry, hacking cough. He denies fever, chills, orthopnea, paroxysmal nocturnal dyspnea, or chest pain. His past medical history is significant for hypertension and a 35-pack-year smoking history, having quit 10 years ago. Current medications include lisinopril and amlodipine.

Vital signs show a pulse of 86/min, respiratory rate of 22/min, blood pressure of 128/78 mm Hg, and oxygen saturation of 91% on room air. Physical examination reveals digital clubbing. Pulmonary auscultation demonstrates fine, end-inspiratory "Velcro-like" crackles predominantly at the lung bases bilaterally. Cardiac examination is normal with no murmurs, gallops, or jugular venous distention. There is no lower extremity edema.

Pulmonary function testing (PFT) reveals the following:

High-resolution computed tomography (HRCT) of the chest shows bilateral, subpleural reticular opacities with traction bronchiectasis and honeycombing.

Based on the clinical presentation and diagnostic findings, which of the following are accurate regarding this patient's condition? (Select all that apply)