Internal Medicine

A 45-year-old female with a history of primary biliary cholangitis is brought to the emergency department by paramedics after vomiting a large volume of bright red blood at home. Upon arrival, the patient is lethargic but arousable. Vital signs show a blood pressure of $82/50 \text{ mmHg}$, heart rate of $132 \text{ /min}$, respiratory rate of $22 \text{ /min}$, and oxygen saturation of $96\%$ on room air. Physical examination reveals scleral icterus, palmar erythema, shifting dullness to percussion, and prominent superficial abdominal veins. Considering the patient's presentation and likely diagnosis of acute variceal hemorrhage, arrange the following management steps in the most appropriate sequential order, starting from the immediate priority to definitive rescue intervention for refractory bleeding.

Emergency medical services transport a $62$-year-old male patient to the acute care unit due to two hours of unrelenting, oppressive chest discomfort that radiates to his jaw. He also reports profound diaphoresis and severe lightheadedness. His medical background includes type 2 diabetes mellitus, hyperlipidemia, and a $40$-pack-year smoking history. Upon arrival, his temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), his blood pressure is remarkably low at $82/52\text{ mm Hg}$, pulse is $52\text{ beats/min}$, and respirations are $18\text{ breaths/min}$. Pulse oximetry reveals an oxygen saturation of $96\%$ on room air. Physical evaluation shows prominent jugular venous pulsations at $10\text{ cm}$ above the sternal angle while seated at $45$ degrees. Pulmonary auscultation indicates completely clear breath sounds bilaterally without any wheezes or crackles. The cardiac exam reveals a regular bradycardic rhythm with a right-sided S3 gallop, but no significant murmurs. An electrocardiogram is rapidly acquired and demonstrates $3\text{ mm}$ ST-segment elevations in leads II, III, and aVF, along with reciprocal ST-segment depressions in leads I and aVL. Which of the following is the most appropriate next step in the management of this patient?

A 65-year-old woman is evaluated in the intensive care unit on hospital day 4. She was initially admitted for severe pneumococcal pneumonia and rapidly developed acute respiratory distress syndrome requiring mechanical ventilation and vasopressor support. Her past medical history is significant for hypertension and type 2 diabetes mellitus. She has no known history of thyroid disease. Her current temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $102/64\text{ mm Hg}$ on a norepinephrine infusion, and heart rate is $112\text{/min}$. To evaluate for additional causes of her ongoing hemodynamic instability, a comprehensive metabolic panel and thyroid function tests are obtained.

The laboratory results are as follows:
- Thyroid-stimulating hormone (TSH): $0.2\text{ \mu U/mL}$ (Normal: $0.5-5.0\text{ \mu U/mL}$)
- Free T4: $1.2\text{ ng/dL}$ (Normal: $0.9-1.7\text{ ng/dL}$)
- Total T3: $40\text{ ng/dL}$ (Normal: $80-200\text{ ng/dL}$)

Which of the following is the most appropriate next step in management regarding this patient's thyroid laboratory findings?

Match each clinical presentation and characteristic high-resolution esophageal manometry finding to the most appropriate esophageal motility disorder.

A $32$-year-old man comes to the emergency department because of a $5$-day history of high fever, profound fatigue, and severe joint pains. His past medical history is significant for severe opioid use disorder, and he reports injecting heroin daily. His temperature is $39.4^{\circ}\text{C}$ ($102.9^{\circ}\text{F}$), blood pressure is $114/68 \text{ mm Hg}$, pulse is $118/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination shows multiple needle track marks in both antecubital fossae. Cardiovascular auscultation reveals a regular tachycardia and a grade $3/6$ holosystolic murmur at the left lower sternal border; the murmur's intensity increases with inspiration. The lungs are clear to auscultation bilaterally. Small, linear, dark-red hemorrhages are noted beneath the nail beds of his right hand. Three sets of blood cultures are obtained. Which of the following is the most appropriate next step in management?

Match the following clinical vignettes of central nervous system infections with their most appropriate targeted or empiric antimicrobial therapy.

A $62$-year-old man presents to the emergency department with a $2$-week history of worsening nausea, early satiety, and frequent vomiting. He notes that the vomitus often contains undigested food eaten several hours earlier. He reports a $5$-kg ($11$-lb) weight loss over the past month. His past medical history is notable for severe osteoarthritis of the knees, for which he takes high-dose ibuprofen daily. Temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $105/65\text{ mmHg}$, pulse is $108/\text{min}$, and respiratory rate is $14/\text{min}$. Physical examination reveals dry mucous membranes and decreased skin turgor. The abdomen is distended in the epigastric region, and a splashing sound is heard over the upper abdomen when the patient is gently rocked back and forth. There is no rebound tenderness or guarding. Laboratory studies are as follows:

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

A 47-year-old man presents to the emergency department with a 4-day history of high fever, severe headache, profound myalgias, and chills. He recently returned from a week-long hiking trip in the Ozark Mountains of Arkansas, where he reports sustaining multiple tick bites. His temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, and pulse is $105/\text{min}$. Physical examination reveals a non-toxic appearing man with no focal neurological deficits, no lymphadenopathy, and no skin rash. Laboratory studies show:

Hemoglobin: $13.8\text{ g/dL}$
Leukocyte count: $2,400/\text{mm}^3$
Platelet count: $82,000/\text{mm}^3$
Aspartate aminotransferase (AST): $145\text{ U/L}$
Alanine aminotransferase (ALT): $152\text{ U/L}$

Which of the following is the most appropriate empiric pharmacotherapy for this patient?

A $54$-year-old male visitor suddenly collapses in the main hospital concourse. He is unresponsive, apneic, and pulseless. The rapid response team arrives within two minutes, initiates high-quality cardiopulmonary resuscitation (CPR), and attaches a manual defibrillator. The monitor reveals coarse ventricular fibrillation. No vascular access is currently in place. Place the following resuscitative actions in the correct chronological order of execution as dictated by the Advanced Cardiac Life Support (ACLS) pulseless arrest algorithm. Assume the patient remains in refractory ventricular fibrillation throughout the entire resuscitation effort.

During an outpatient evaluation, a $42$-year-old male describes a one-year history of chronic watery diarrhea and burning epigastric pain that routinely awakens him from sleep. He has a history of multiple hospitalizations for complicated duodenal ulcers despite strict adherence to daily high-dose pantoprazole. Recent upper endoscopy revealed prominent hypertrophic gastric folds and multiple ulcerations extending into the distal duodenum and proximal jejunum. Histopathology from gastric biopsies was negative for *Helicobacter pylori* organisms. The clinician highly suspects an underlying neuroendocrine etiology.

Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for the evaluation and management of this patient's suspected condition.

A 68-year-old woman is evaluated in the surgical telemetry unit on postoperative day 3 following an uncomplicated partial colectomy for early-stage colon cancer. Over the last 4 hours, she has developed severe shortness of breath and a cough productive of pink, frothy sputum. During her surgery and the immediate postoperative period, she received a total of 6 liters of intravenous crystalloids. Her medical history includes hypertension, osteoarthritis, and a 40-pack-year smoking history.

Her temperature is 37.7°C (99.9°F), blood pressure is 180/100 mmHg, pulse is 115/min, and respirations are 28/min. Pulse oximetry is 86% on room air.

Physical examination reveals a patient in moderate respiratory distress, using accessory muscles of respiration. Jugular venous distention is present to the angle of the mandible while the patient is sitting at a 45-degree angle. Lung auscultation reveals diffuse bilateral expiratory wheezes and crackles extending halfway up both lung fields. Cardiac auscultation reveals a regular tachycardia with a prominent third heart sound ($S_3$).

Arterial blood gas analysis on room air shows:
pH: 7.28
$PaCO_2$: 56 mmHg
$PaO_2$: 54 mmHg
$HCO_3^-$: 25 mEq/L

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

A 28-year-old man is referred to a gastroenterology genetics clinic for evaluation of early-onset colon polyps. A detailed family history reveals multiple relatives affected by various gastrointestinal and extraintestinal malignancies across several generations. Recognizing the specific extraintestinal manifestations is essential for identifying the underlying genetic disorder and initiating appropriate multisystem cancer screening. Match each hereditary gastrointestinal syndrome with its most characteristic extraintestinal manifestation or associated malignancy.

A 21-year-old woman is brought to the emergency department by her college roommate due to confusion and rapid breathing. The roommate reports that the patient has been complaining of severe ear ringing, nausea, and vomiting since last night after taking 'an entire bottle' of an over-the-counter pain reliever for a severe headache. On physical examination, the patient is agitated, diaphoretic, and tachypneic. Temperature is 38.2°C (100.8°F), blood pressure is 112/68 mm Hg, heart rate is 122/min, and respiratory rate is 34/min. Pulse oximetry is 99% on room air. Lungs are clear to auscultation bilaterally. Cardiac examination shows tachycardia with a regular rhythm and no murmurs.

Laboratory results are as follows:

Arterial blood gas analysis on room air:

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

Following a recent admission for a community-acquired lower respiratory tract infection, a hospitalized adult becomes abruptly less responsive to verbal commands. The clinical record confirms Streptococcus pneumoniae bacteremia, which has been managed with targeted intravenous ceftriaxone for the past 36 hours. Vital signs reveal a temperature of 38.2°C (100.8°F), a pulse of 122/min, a blood pressure of 85/52 mm Hg, and a respiratory rate of 28/min. Pulse oximetry shows an oxygen saturation of 88% on high-flow nasal oxygen. Physical examination demonstrates bronchial breath sounds over the left lung base, warm extremities, and absent jugular venous distention. The patient appears lethargic and only moans in response to pain.

An arterial blood gas analysis reveals:

Concurrent serum chemistries show a sodium of 140 mEq/L and a chloride of 103 mEq/L.

Based on these findings, which of the following is the most appropriate next step in management?

A 75-year-old man is brought to the emergency department after a syncopal episode at home. On arrival, he is lethargic and complains of lightheadedness and mild chest heaviness. His blood pressure is 82/50 mm Hg, and his pulse is 32/min. An electrocardiogram reveals sinus bradycardia with no evidence of acute ischemia. The patient is immediately placed on a continuous cardiac monitor and receives supplemental oxygen. Arrange the following interventions in the correct sequential order for the stepwise management of this hemodynamically unstable patient, from immediate acute stabilization to definitive long-term therapy.

A 55-year-old woman is evaluated in the intensive care unit on postoperative day 3 following an emergency laparotomy for a perforated diverticulum. She has been receiving intravenous piperacillin-tazobactam. Over the last 12 hours, she has developed worsening hypoxemia and increased work of breathing. Temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), heart rate is $112/\text{min}$, respiratory rate was $28/\text{min}$ prior to intubation, and blood pressure is $110/68 \text{ mm Hg}$. Chest radiograph reveals new-onset bilateral alveolar opacities. Echocardiogram shows a normal left ventricular ejection fraction and no significant valvular disease. She is subsequently intubated and placed on mechanical ventilation.

Current ventilator settings are:
Mode: Assist-control volume
Tidal volume: $8 \text{ mL/kg}$ of actual body weight
PEEP: $5 \text{ cm H}_2\text{O}$
$\text{FiO}_2$: $0.8$

Arterial blood gas analysis reveals:
pH: $7.31$
$\text{PaCO}_2$: $48 \text{ mm Hg}$
$\text{PaO}_2$: $58 \text{ mm Hg}$

Which of the following are appropriate management strategies for this patient's respiratory condition? (Select all that apply)

During an evaluation at an urgent care clinic, a 48-year-old man describes a two-day history of worsening left lower quadrant abdominal pain. The pain is constant and described as an aching sensation. He reports having a mild decrease in appetite but denies nausea, vomiting, melena, or hematochezia. His medical history is unremarkable, and he takes no daily medications. Vital signs are temperature $37.3^\circ\text{C}$ ($99.1^\circ\text{F}$), heart rate $82/\text{min}$, blood pressure $128/82\text{ mmHg}$, and respiratory rate $14/\text{min}$. Physical examination reveals a non-distended abdomen with focal tenderness to deep palpation in the left lower quadrant. There is no rebound tenderness, guarding, or rigidity. Laboratory studies show a leukocyte count of $10,200/\text{mm}^3$ with a normal differential. A computed tomography scan of the abdomen and pelvis with intravenous contrast demonstrates scattered diverticula in the sigmoid colon, localized colonic wall thickening, and mild pericolonic fat stranding. There is no evidence of an abscess, fistula, stricture, or free intraperitoneal air. The patient easily tolerates drinking a glass of water during the evaluation. Which of the following is the most appropriate next step in management?

Transported via emergency medical services with severe, acute-onset respiratory distress, a 71-year-old individual is evaluated in the resuscitation bay. The patient has a history of a remote myocardial infarction and a 35-pack-year smoking history. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 172/98 mm Hg, heart rate of 118/min, and respiratory rate of 28/min. Oxygen saturation is 85% on room air.

Physical examination reveals a patient sitting upright and using accessory muscles of respiration. The jugular venous pressure is elevated to 11 cm $H_2O$. Cardiac auscultation reveals a regular tachycardia with a prominent S3 gallop. Lung auscultation demonstrates diffuse, bilateral end-expiratory wheezing without focal crackles. Bilateral trace pitting edema is present in the lower extremities.

Arterial blood gas analysis on room air shows:
$pH$: 7.26
$PaCO_2$: 58 mm Hg
$PaO_2$: 52 mm Hg
$HCO_3^-$: 25 mEq/L

Laboratory evaluation reveals a leukocyte count of 8,200/mm³ and a thyroid-stimulating hormone (TSH) level of 5.8 mU/L (normal: 0.4-4.0 mU/L).

Which of the following is the most appropriate initial pharmacological intervention for this patient?

An otherwise healthy 54-year-old man is evaluated in the hospital on the third day of his admission for a severe skin infection. He initially presented to the emergency department with diffuse, non-purulent erythema and warmth extending from his left ankle to his knee, along with a temperature of 38.8°C (101.8°F). He was empirically started on intravenous vancomycin and piperacillin-tazobactam.

Today, his temperature is 37.0°C (98.6°F), heart rate is 76/min, blood pressure is 126/78 mmHg, and respiratory rate is 14/min. The area of erythema has receded significantly, and his pain is markedly improved. The patient is conversing comfortably and tolerating a regular diet. Two sets of blood cultures drawn upon admission have both grown *Streptococcus pyogenes* (Group A Streptococcus).

Which of the following is the most appropriate next step in this patient's pharmacotherapy?

A 73-year-old man presents to the primary care clinic reporting progressively worsening swelling in his legs and an uncomfortable sensation of fullness in his abdomen over the last six weeks. He also notes that he now becomes breathless after walking just one block, which represents a significant decline from his previous baseline. His medical history is significant for chronic bronchitis and a 50-pack-year smoking history. His only current medication is an albuterol inhaler used as needed. His pulse is 95/min, respiratory rate is 20/min, and blood pressure is 120/78 mmHg. Pulse oximetry shows an oxygen saturation of 87% on room air. Physical examination reveals marked jugular venous distention with prominent 'v' waves. Cardiac auscultation demonstrates a prominent right ventricular heave and a grade 3/6 holosystolic murmur at the lower left sternal border that intensifies with deep inspiration. Pulmonary auscultation reveals a prolonged expiratory phase with diffuse rhonchi, but no crackles are heard. The liver is palpated 4 cm below the right costal margin and is tender. There is 3+ pitting edema of the lower extremities extending up to the knees. Which of the following interventions is most likely to prolong this patient's survival?