Internal Medicine

A 72-year-old woman with a history of recurrent nephrolithiasis presents to the emergency department with acute right flank pain, rigors, and altered mental status. Her temperature is 39.4°C (102.9°F), blood pressure is 85/50 mm Hg, heart rate is 122/min, and respiratory rate is 24/min. Physical examination reveals pronounced right costovertebral angle tenderness. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A $32$-year-old woman comes to the clinic for a routine wellness evaluation. Over the past three months, she noticed increased hair shedding and brittle nails, prompting her to start taking a daily over-the-counter multi-ingredient cosmetic supplement. She reports no palpitations, heat intolerance, weight changes, anxiety, or changes in bowel habits. Her medical history is unremarkable, and she takes no prescription medications.

Vitals:
Temperature: $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$)
Blood pressure: $118/76\text{ mm Hg}$
Pulse: $74/\text{min}$
Respirations: $14/\text{min}$

Physical examination shows a normal-sized, non-tender thyroid gland with no palpable nodules. There is no tremor, and deep tendon reflexes are normal ($2+$) and symmetric. Eye examination shows no proptosis, lid retraction, or periorbital edema.

Laboratory results:

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

A 65-year-old hospitalized patient is evaluated for acute-onset hypotension and signs of poor organ perfusion. The intensive care team places a pulmonary artery (Swan-Ganz) catheter to determine the specific etiology of the shock state. Match each set of central hemodynamic parameters obtained from the catheterization to the most likely underlying clinical condition.

A 48-year-old man is brought to the emergency department via ambulance after coughing up approximately 600 mL of bright red blood over the past hour. He has a history of treated pulmonary tuberculosis. He is in moderate respiratory distress and continues to actively expectorate blood. His temperature is 37.1°C (98.8°F), blood pressure is 110/70 mm Hg, pulse is 118/min, and respirations are 28/min. Pulse oximetry shows an oxygen saturation of 87% on room air. A portable chest radiograph reveals a thin-walled cavity in the right upper lobe with an internal mass, alongside fresh patchy infiltrates in the right middle and lower lung zones. The left lung field is clear. Arrange the following acute management steps in the most appropriate chronological order.

A 48-year-old man comes to the physician due to progressive fatigue, feeling cold all the time, and erectile dysfunction over the past 8 months. He also reports recent difficulty seeing cars in his peripheral vision while driving. He has a history of major depressive disorder, for which he took a selective serotonin reuptake inhibitor in the past, but he discontinued all medications two years ago. He currently takes no medications. Vital signs are within normal limits. Physical examination reveals delayed relaxation phases of the deep tendon reflexes and a lack of axillary hair. Visual field testing confirms bitemporal hemianopsia.

Laboratory studies are as follows:

An MRI of the brain reveals a $2.5\text{ cm}$ sellar mass with suprasellar extension.

Which of the following is the most likely mechanism for the elevated serum prolactin level in this patient?

A 35-year-old man is evaluated in the clinic for right upper quadrant abdominal pain and subjective fevers over the past two weeks. He immigrated to the United States from Central America two months ago. His temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, and heart rate is $94\text{/min}$. Physical examination reveals an enlarged liver with marked tenderness to palpation in the right upper quadrant. Laboratory studies show a leukocyte count of $14,000/\mu\text{L}$ and mildly elevated alkaline phosphatase. An abdominal ultrasound demonstrates a single $7\text{-cm}$ hypoechoic, fluid-filled lesion in the right lobe of the liver. *Entamoeba histolytica* serology is positive. Which of the following is the most appropriate next step in management?

An emergency department physician evaluates a 61-year-old female for rapidly worsening respiratory distress. The patient was awakened from sleep two hours ago with a severe sensation of smothering. Her past medical history is significant for a 45-pack-year smoking habit, hyperlipidemia, and poorly controlled hypertension. Current vital signs include a temperature of $37.1^\circ$ C ($98.8^\circ$ F), blood pressure of $192/110$ mmHg, pulse of $118$/min, and respiratory rate of $30$/min. Pulse oximetry shows an oxygen saturation of $85\%$ on room air.

Physical examination reveals a diaphoretic patient speaking in one-word sentences and using accessory muscles of respiration. Jugular venous pulsation is visible at $10$ cm above the sternal angle. Auscultation of the lungs demonstrates diffuse, bilateral expiratory wheezing with a prolonged expiratory phase, alongside rare basilar crackles. Cardiac auscultation reveals a regular, rapid rhythm with an audible S4 gallop, but no murmurs are appreciated. The lower extremities exhibit trace bilateral pretibial edema.

Bedside arterial blood gas analysis on room air reveals:

A portable chest radiograph displays cephalization of the pulmonary vessels, peribronchial cuffing, and indistinct vascular margins, without lobar consolidation or pleural effusions.

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

For each immunocompromised patient described below, pair their clinical presentation with the most appropriate definitive targeted antimicrobial regimen for their suspected or confirmed opportunistic infection.

Emergency medical services bring a somnolent $74$-year-old female to the resuscitation bay following the abrupt onset of severe respiratory distress and palpitations at her nursing home two hours ago. The patient has a documented medical history of severe chronic obstructive pulmonary disease, hypertension, and osteoarthritis. Upon arrival, her blood pressure is $78/52 \text{ mmHg}$, pulse is $152/\text{min}$ and irregularly irregular, and respiratory rate is $30/\text{min}$. Oxygen saturation is $85\%$ on room air.

Physical examination reveals a diaphoretic, lethargic patient with pale, cool extremities. Jugular venous pressure is markedly elevated up to the angle of the mandible. Auscultation of the lungs demonstrates diffuse expiratory wheezing and coarse bilateral inspiratory crackles up to the mid-lung fields. Cardiac auscultation reveals a rapid, irregular rhythm with no distinct murmurs.

An arterial blood gas on room air shows:
$pH$: $7.21$
$PaCO_2$: $64 \text{ mmHg}$
$PaO_2$: $52 \text{ mmHg}$
$HCO_3^-$: $25 \text{ mEq/L}$

A 12-lead electrocardiogram demonstrates a narrow-complex tachycardia with an irregularly irregular R-R interval and absent P waves.

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

A 34-year-old woman is brought to the emergency department by her husband due to severe agitation, confusion, and a pounding heartbeat over the past 6 hours. She had a self-resolving upper respiratory tract infection three days ago. Her temperature is $39.8^\circ\text{C}$ ($103.6^\circ\text{F}$), blood pressure is $158/68$ mmHg, pulse is $148$/min and irregular, and respirations are $26$/min. Physical examination reveals a diffuse, non-tender goiter, marked exophthalmos, a fine resting tremor, and warm, diaphoretic skin. Electrocardiography demonstrates atrial fibrillation with a rapid ventricular response. Laboratory studies confirm a TSH of $<0.01$ $\mu$ U/mL and a free T4 of $4.8$ ng/dL (normal: $0.7-1.8$ ng/dL). Arrange the following interventions in the correct chronological sequence for the management of this patient's condition.

A 76-year-old man who resides in an assisted living facility is evaluated in the emergency department for altered mental status. Facility staff report that he had a productive cough and low-grade fever over the preceding three days. His medical history includes essential hypertension, diet-controlled type 2 diabetes mellitus, and osteoarthritis. Upon arrival, his temperature is 38.8°C (101.8°F), blood pressure is 78/46 mm Hg, pulse is 122/min, and respirations are 26/min. Pulse oximetry shows 91% on a 2 L/min nasal cannula. Physical examination reveals a lethargic man who arouses to tactile stimuli. Mucous membranes are dry. Auscultation of the chest reveals bronchial breath sounds and egophony over the right lower lung field. The jugular venous pressure is flat. Heart sounds are rapid but regular, with no murmurs. Arterial blood gas analysis on the current oxygen setting shows:

- pH: 7.29
- PaCO2: 25 mm Hg
- PaO2: 68 mm Hg
- HCO3-: 12 mEq/L

Serum lactate is 4.8 mmol/L. Peripheral venous access is obtained. Blood and sputum cultures are drawn, and empiric intravenous antibiotics (ceftriaxone and azithromycin) are initiated. An infusion of 3 L of normal saline is administered over 60 minutes. Reassessment reveals a blood pressure of 80/48 mm Hg and a pulse of 118/min. Urine output has been 10 mL over the past hour. Which of the following is the most appropriate next step in the management of this patient?

During morning rounds on the hematology-oncology unit, a physician evaluates a patient undergoing induction chemotherapy for acute myeloid leukemia. The patient, who is $12$ days into his hospital course, reports the sudden onset of chills overnight. His vital signs include a temperature of $39.1^\circ C$ ($102.4^\circ F$), blood pressure of $112/68$ mm Hg, pulse of $105$/min, and respirations of $18$/min. Pulse oximetry shows $98\%$ on room air. Detailed physical assessment reveals a clean central venous catheter insertion site with no erythema, tenderness, or exudate. The patient has no oral ulcers, his chest is clear to auscultation, and his skin is fully intact without rashes. Laboratory evaluation is notable for a total leukocyte count of $0.4 \times 10^9$/L and an absolute neutrophil count of $80$/mm $^3$. Blood and urine cultures have been drawn. Which of the following is the most appropriate initial empiric pharmacotherapy for this patient?

A $58$-year-old man with a history of hepatitis C-induced liver cirrhosis and chronic obstructive pulmonary disease (COPD) is brought to the emergency department by his daughter due to increasing confusion and diffuse abdominal pain over the past $24$ hours. His current medications include furosemide, spironolactone, tiotropium, and lactulose. His daughter, who provides a document confirming she is his legally appointed healthcare proxy, insists he receives full medical care. However, the patient's estranged son recently arrived and told the staff, "Dad wouldn't want any of this."

On presentation, his temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $96/60$ mm Hg, pulse is $112$/min, and respirations are $26$/min. Pulse oximetry shows $94\%$ on room air. Physical examination reveals scleral icterus and asterixis. Lung auscultation demonstrates decreased breath sounds at the bases but no wheezing. The abdomen is grossly distended, tense, and diffusely tender with shifting dullness.

Arterial blood gas analysis on room air reveals:
- pH: $7.30$
- pCO $_2$: $30$ mm Hg
- pO $_2$: $70$ mm Hg
- HCO $_3^-$: $14$ mEq/L

Serum laboratory studies:
- Creatinine: $1.6$ mg/dL (baseline $0.9$ mg/dL)
- Leukocyte count: $14,000$/mm $^3$

A diagnostic paracentesis yields cloudy fluid. Fluid analysis shows a leukocyte count of $800$/mm $^3$ with $80\%$ neutrophils.

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

An unaccompanied 72-year-old woman is triaged in the acute care unit after experiencing 48 hours of constant chest "fluttering" and progressive exertional breathlessness. She has a known medical history of severe chronic obstructive pulmonary disease (COPD), for which she uses a daily umeclidinium-vilanterol inhaler, and essential hypertension. Upon evaluation, her vital signs are:

- Temperature: $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$)
- Blood pressure: $124/82\text{ mm Hg}$
- Heart rate: $148/\text{min}$ and irregularly irregular
- Respiratory rate: $22/\text{min}$
- Oxygen saturation: $95\%$ on room air

Physical examination reveals a completely irregular cardiac rhythm with absent murmurs, rubs, or gallops. Pulmonary auscultation reveals a prolonged expiratory phase globally, but no focal crackles, rhonchi, or active wheezing are appreciated. There is no jugular venous distension or peripheral edema.

Initial laboratory testing yields the following results:
- Leukocyte count: $7,200/\text{mm}^3$
- Thyroid-stimulating hormone (TSH): $2.8\text{ }\mu\text{U/mL}$ (Normal: $0.4-4.0\text{ }\mu\text{U/mL}$)
- Free T4: $1.1\text{ ng/dL}$ (Normal: $0.9-1.7\text{ ng/dL}$)

Arterial blood gas (room air):
- pH: $7.48$
- PaCO $_2$: $31\text{ mm Hg}$
- PaO $_2$: $76\text{ mm Hg}$

A 12-lead electrocardiogram demonstrates an irregularly irregular rhythm with narrow QRS complexes and an absence of discernible P waves.

Which of the following is the most appropriate initial pharmacologic intervention for this patient's current condition?

A critical care team is evaluating a 68-year-old patient during morning rounds. The patient was admitted to the intensive care unit three days ago for severe community-acquired pneumonia and septic shock, which required endotracheal intubation and vasopressor support. The patient has a medical history of chronic obstructive pulmonary disease (COPD) and hypertension.

Over the past 24 hours, the patient has been afebrile, and vasopressors were successfully discontinued. The patient remains sedated on volume-controlled mechanical ventilation.

Blood and endotracheal aspirate cultures obtained upon admission are now finalized and demonstrate heavy growth of Streptococcus pneumoniae, which is susceptible to penicillin, ceftriaxone, and azithromycin. The patient is currently receiving empiric intravenous vancomycin, cefepime, and levofloxacin.

Physical examination reveals a jugular venous pressure of 5 cm $H_2O$. Lung auscultation demonstrates bilateral expiratory wheezing with scattered rhonchi, but no crackles. Heart sounds are regular without $S_3$ or $S_4$ gallops. There is no peripheral edema.

Arterial blood gas on current ventilator settings:
* pH: 7.33
* $PaCO_2$: 35 mmHg
* $PaO_2$: 72 mmHg

Based on the patient's current clinical status and laboratory findings, which of the following are appropriate components of this patient's management plan today? (Select all that apply)

A 42-year-old man is admitted to the hospital with a 3-day history of high fever, severe chills, and profound fatigue. He has a history of intravenous drug use. His temperature on admission is 39.2°C (102.6°F), blood pressure is 112/68 mm Hg, and pulse is 108/min. Physical examination reveals needle track marks on both antecubital fossae and a new holosystolic murmur at the left lower sternal border that increases in intensity with inspiration. Multiple sets of blood cultures are drawn, and empiric intravenous vancomycin is initiated. A transthoracic echocardiogram confirms a 1.4-cm vegetation on the tricuspid valve. On hospital day 3, the patient is clinically stable, and his temperature has decreased to 37.6°C (99.7°F). Final blood culture reports indicate growth of *Staphylococcus aureus* in 4 out of 4 bottles. Susceptibility testing demonstrates the organism is resistant to penicillin but susceptible to oxacillin, cefazolin, and vancomycin. He has no known drug allergies.

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

A 31-year-old woman comes to the clinic due to profound fatigue, generalized weakness, and a $5$-kg weight loss over the past $5$ months. She also reports prominent dizziness when standing up quickly. Six months ago, she underwent an emergency cesarean delivery complicated by severe postpartum hemorrhage requiring the transfusion of four units of packed red blood cells. Since the delivery, she has been unable to breastfeed her infant and has not resumed menstruation. Her blood pressure is $92/60$ mm Hg while supine and $78/52$ mm Hg upon standing. Physical examination shows a notable loss of axillary and pubic hair.

Laboratory studies show:
Sodium: $131$ mEq/L
Potassium: $4.2$ mEq/L
Thyroid-stimulating hormone (TSH): $0.8$ $\mu$ U/mL (Normal: $0.4$-$4.2$ $\mu$ U/mL)
Free T4: $0.4$ ng/dL (Normal: $0.8$-$2.8$ ng/dL)

Based on these findings, what is the most appropriate next step in management?

A previously healthy individual is currently in the intensive care unit recovering from an episode of severe acute gallstone pancreatitis. On the third week of admission, the patient develops a new-onset fever of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), altered mental status, and hypotension unresponsive to fluid resuscitation. Laboratory results indicate a leukocyte count of $26,000/\mu\text{L}$. A contrast-enhanced computed tomography scan of the abdomen is obtained, displaying extensive necrosis of the pancreatic body and tail, now with prominent retroperitoneal gas bubbles. Based on current evidence-based guidelines for infected pancreatic necrosis, arrange the following therapeutic steps in the most appropriate sequential order, proceeding from initial intervention to ultimate salvage therapy.

A 68-year-old man is brought to the emergency department by his daughter due to a severe, progressive headache, fever, and confusion over the last 24 hours. His temperature is 39.4°C (102.9°F), blood pressure is 110/70 mm Hg, and pulse is 115/min. On physical examination, the patient is lethargic and oriented only to person. Neck stiffness is present with passive flexion. Neurologic examination reveals a new-onset right-sided facial droop and weakness in the right arm. Arrange the following steps in the most appropriate chronological order for the management of this patient.

A $67$-year-old woman is evaluated in the cardiac intensive care unit after a sudden episode of unresponsiveness. She was admitted $4$ days ago for an acute anterior ST-segment elevation myocardial infarction and underwent successful percutaneous coronary intervention of the left anterior descending artery. Her medical history is notable for hypertension, type 2 diabetes mellitus, and a $40$-pack-year smoking history. Following the episode of unresponsiveness, she quickly regains consciousness but reports feeling extremely weak and lightheaded. Her temperature is $36.7^\circ\text{C}$ ($98.1^\circ\text{F}$), blood pressure is $72/40$ mm Hg, pulse is $126$/min and regular, and respirations are $26$/min. Pulse oximetry is $93\%$ on room air. Physical examination reveals cold, clammy extremities and significant jugular venous distention. The apical impulse is not palpable. Lung fields are clear to auscultation bilaterally. Heart sounds are distant, and no murmurs, rubs, or gallops are appreciated. An electrocardiogram shows sinus tachycardia and persistent ST-segment elevations in the anterior leads, unchanged from the post-intervention electrocardiogram. Arterial blood gas analysis on room air reveals a pH of $7.24$, pCO $_2$ of $32$ mm Hg, and pO $_2$ of $68$ mm Hg. Which of the following is the most appropriate next step in the management of this patient?