Internal Medicine

A 45-year-old woman from a developing country presents to the clinic with progressive dyspnea on exertion, orthopnea, and occasional palpitations. Physical examination reveals a loud S1, an opening snap, and a low-pitched mid-diastolic rumble at the cardiac apex. Echocardiography confirms severe mitral stenosis. Arrange the following pathophysiological events in the correct chronological order of this patient's disease progression, from the initial insult to the current hemodynamic state.

Match each precise electrocardiographic (ECG) morphological description with its most strongly associated underlying cardiovascular pathology or clinical condition.

A 67-year-old man comes to the emergency department complaining of progressive shortness of breath, increased cough, and yellow sputum production over the past 48 hours. He has a 45-pack-year smoking history and severe chronic obstructive pulmonary disease (COPD). His temperature is 38.2°C, blood pressure is 140/85 mm Hg, pulse is 112/min, and respirations are 26/min. Pulse oximetry shows an oxygen saturation of 88% on room air. He is using accessory muscles of respiration. Physical examination reveals an expanded barrel chest, diffuse expiratory wheezing bilaterally, and coarse crackles over the left lower lung base. Jugular venous pressure is 7 cm $H_2O$. A chest radiograph demonstrates hyperinflated lung fields, flattened diaphragms, and a new consolidation in the left lower lobe. Sputum Gram stain shows numerous polymorphonuclear leukocytes and frequent Gram-positive diplococci. Arterial blood gas analysis on room air reveals:

Which of the following are the most appropriate next steps in the management of this patient? (Select all that apply)

While rounding in the intensive care unit, a physician evaluates a $68$-year-old woman whose clinical status has acutely deteriorated. She was admitted $10$ days ago for severe community-acquired pneumonia and was treated with a course of intravenous levofloxacin. Five days into her hospitalization, she developed profuse, watery diarrhea and was subsequently diagnosed with a *Clostridioides difficile* infection. She was immediately started on oral vancomycin therapy. Over the past $12$ hours, the patient reports that her diarrhea has completely ceased, but she has developed agonizing abdominal pain and progressive bloating. Her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $82/50\text{ mm Hg}$, and pulse is $132\text{/min}$. Physical examination reveals a markedly distended, tympanic abdomen with diffuse, severe tenderness and absent bowel sounds. Laboratory studies show a leukocyte count of $32,000\text{/mm}^3$ and a serum lactate of $5.2\text{ mmol/L}$. An upright abdominal radiograph demonstrates a transverse colon diameter of $10\text{ cm}$ with a loss of haustral markings and no free air under the diaphragm. Which of the following is the most appropriate next step in the management of this patient?

A $71$-year-old male is evaluated on the surgical ward due to the sudden onset of difficulty breathing. He underwent an uncomplicated right total hip arthroplasty four days ago. His medical history includes essential hypertension, hypercholesterolemia, diet-controlled type 2 diabetes mellitus, and a $35$-pack-year history of smoking. During his hospitalization, he has been receiving continuous intravenous normal saline at $100\text{ mL/hr}$.

This morning, the patient developed worsening dyspnea, particularly when lying flat, along with a persistent dry cough. His temperature is $37.5^\circ\text{C}$ ($99.5^\circ\text{F}$), blood pressure is $162/94\text{ mmHg}$, pulse is $112/\text{min}$, and respiratory rate is $26/\text{min}$. Pulse oximetry indicates an oxygen saturation of $88\%$ on room air.

Physical examination reveals elevated jugular venous pressure. Cardiac auscultation shows a regular tachycardia with a distinct $S_3$ gallop. Pulmonary examination is notable for dullness to percussion at the lung bases, diffuse bilateral crackles, and scattered expiratory wheezing. The surgical incision is healing appropriately. Examination of the lower extremities reveals bilateral, symmetric pitting edema up to the mid-calves.

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

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

A $74$-year-old man is brought to the emergency department due to acute worsening of shortness of breath and severe agitation. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$, severe chronic obstructive pulmonary disease (COPD), and hypothyroidism. Over the last $2$ days, he has had an increased cough productive of white sputum and progressive orthopnea. His current medications include lisinopril, carvedilol, tiotropium, levothyroxine, and as-needed albuterol.

Vital signs:
Temperature: $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$)
Blood pressure: $178/102\text{ mmHg}$
Heart rate: $118/\text{min}$
Respiratory rate: $28/\text{min}$
SpO $_2$: $84\%$ on room air

Physical examination reveals an agitated man in severe respiratory distress, using accessory muscles of respiration. Jugular venous distension is prominent at $12\text{ cm H}_2\text{O}$. Auscultation of the lungs reveals prolonged expiration with loud, diffuse bilateral wheezing, but no crackles are distinctly appreciated. Cardiac auscultation reveals a regular tachycardia; a third heart sound ($S_3$) is present. Trace bilateral lower extremity edema is noted.

Arterial blood gas on room air:
pH: $7.28$
PaCO $_2$: $60\text{ mmHg}$
PaO $_2$: $52\text{ mmHg}$
HCO $_3^-$: $27\text{ mEq/L}$

Thyroid-stimulating hormone (TSH) is $4.5\text{ \mu U/mL}$ (normal: $0.5$-$5.0\text{ \mu U/mL}$), and free T4 is $1.1\text{ ng/dL}$ (normal: $0.9$-$1.7\text{ ng/dL}$). A chest radiograph shows cardiomegaly and prominent interstitial markings without focal consolidation.

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

Match each clinical presentation with its most characteristic echocardiographic finding.

A 52-year-old woman is evaluated in the hospital due to sudden-onset right-sided chest pain and shortness of breath. She is currently on postoperative day 3 following an open abdominal hysterectomy for symptomatic uterine fibroids. Her temperature is 38.0°C (100.4°F), blood pressure is 118/76 mm Hg, pulse is 114/min, and respirations are 26/min. Pulse oximetry is 89% on room air. She appears anxious and is in mild respiratory distress. The chest pain worsens with deep inspiration. Lung auscultation reveals clear breath sounds bilaterally without wheezes or crackles. The surgical incision site is clean and intact. The right calf is mildly swollen and tender to palpation compared to the left. Arterial blood gas on room air shows:

pH: 7.52
PaCO2: 28 mm Hg
PaO2: 56 mm Hg
HCO3-: 23 mEq/L

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

A 62-year-old man is admitted to the cardiac intensive care unit following a large anterior ST-segment elevation myocardial infarction. On hospital day 2, he suddenly becomes unresponsive. The patient is apneic, and no central pulse is palpable. The continuous telemetry monitor demonstrates coarse ventricular fibrillation. A resuscitation team is immediately activated. Arrange the following steps in the most appropriate chronological sequence for the management of this patient's cardiac arrest according to standard advanced cardiovascular life support (ACLS) guidelines.

A 71-year-old male with a known history of severe emphysema is admitted to the medical ward following three days of worsening productive cough, increased sputum purulence, and breathlessness. Assume his clinical condition progressively deteriorates over the course of his hospitalization despite each successive intervention.

Arrange the following management steps in the standard chronological order of escalation for a severe chronic obstructive pulmonary disease (COPD) exacerbation complicated by progressive hypercapnic respiratory failure.

A $48$-year-old man comes to the emergency department due to severe, constant epigastric pain that radiates to his back. The pain began $12$ hours ago and is associated with nausea and $2$ episodes of nonbilious emesis. His medical history is notable for alcohol use disorder, and he reports consuming $4$ to $5$ alcoholic beverages daily. His temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $135/85\text{ mm Hg}$, pulse is $112/\text{min}$, and respirations are $18/\text{min}$. Physical examination reveals a moderately distended abdomen with marked epigastric tenderness, but no rebound or guarding. Bowel sounds are hypoactive.

An abdominal ultrasound demonstrates an enlarged, hypoechoic pancreas with peripancreatic fluid, and no evidence of gallstones or biliary dilation.

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

A 65-year-old man presents to the emergency department with a 24-hour history of progressively worsening shortness of breath and a cough productive of clear sputum. His past medical history is significant for an ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$, as well as severe chronic obstructive pulmonary disease. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $142/88\text{ mmHg}$, pulse is $115\text{/min}$, and respirations are $26\text{/min}$. Pulse oximetry is $89\%$ on room air. Physical examination reveals a patient in moderate respiratory distress using accessory muscles of respiration. Assessment of the jugular venous pressure shows flat neck veins when the patient is seated at a 45-degree angle. Pulmonary auscultation reveals diffuse bilateral expiratory wheezes and a markedly prolonged expiratory phase, with no crackles. Cardiac auscultation reveals a regular tachycardia with a normal $S_1$ and $S_2$; there is no $S_3$ gallop or murmur. The lower extremities show no pitting edema. A portable chest radiograph demonstrates hyperinflated lung fields and flattened hemidiaphragms, with no evidence of pulmonary vascular congestion, focal infiltrates, or pleural effusions. Which of the following is the most appropriate initial management for this patient's acute presentation?

A 34-year-old man is evaluated in the emergency department four hours after experiencing a witnessed generalized tonic-clonic seizure at a local restaurant. Bystanders report that he vomited during the postictal period before paramedics arrived. The patient is now fully awake and oriented but complains of worsening shortness of breath and a dry cough. His medical history is notable for epilepsy, though he has not taken his levetiracetam for the past week.

His temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $118/76\text{ mm Hg}$, pulse is $110/\text{min}$, and respirations are $26/\text{min}$. Pulse oximetry is $89\%$ on room air. Physical examination shows no jugular venous distention. Lung auscultation reveals focal crackles over the right mid-to-lower posterior lung fields. Cardiac examination is normal with no murmurs or gallops.

Laboratory results:
Leukocyte count: $11,500/\text{mm}^3$
Serum lactate: $4.2\text{ mEq/L}$

Arterial blood gas (room air):
pH: $7.28$
PaCO2: $30\text{ mm Hg}$
PaO2: $58\text{ mm Hg}$
HCO3-: $14\text{ mEq/L}$

A chest radiograph shows a new patchy alveolar infiltrate in the superior segment of the right lower lobe.

Which of the following is the most appropriate next step in the management of this patient's respiratory symptoms?

A $34$-year-old female arrives at the emergency department reporting a sudden onset of a racing heartbeat that began while she was sitting at her desk. She feels anxious but denies chest discomfort, dyspnea, or lightheadedness. Her blood pressure is $122/78$ mm Hg, heart rate is $178$/min, and oxygen saturation is $99\%$ on room air. An electrocardiogram demonstrates a regular, narrow-complex tachycardia with no discernible P waves. Assuming each successive step fails to terminate the arrhythmia, arrange the following therapeutic interventions in the correct chronological order recommended by current advanced cardiovascular life support (ACLS) guidelines for a hemodynamically stable patient.

A $29$-year-old G1P0 woman at $32$ weeks gestation is brought to the emergency department due to the acute onset of severe shortness of breath and a cough productive of pink, frothy sputum. She recently emigrated from a developing country and had limited prenatal care. She reports a history of frequent, untreated sore throats during childhood. Her temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $110/68\text{ mmHg}$, pulse is $135/\text{min}$ and irregularly irregular, and respirations are $28/\text{min}$. Pulse oximetry shows $86\%$ on room air. Physical examination reveals elevated jugular venous pressure. Lung auscultation demonstrates bibasilar crackles and diffuse expiratory wheezes. Cardiac examination reveals a loud S1 and a low-pitched, rumbling, mid-diastolic murmur heard best at the apex.

Laboratory results are as follows:

Continuous fetal heart rate monitoring shows a baseline of $150/\text{min}$ with moderate variability and recurrent late decelerations. Which of the following is the most appropriate next step in management?

A $28$-year-old woman comes to the outpatient clinic reporting a $4$-day history of frequent, watery stools, accompanied by intermittent periumbilical cramps and mild nausea. She works as a veterinary technician and recently cleaned several reptile enclosures. She has no significant past medical history and takes no medications. Her temperature is $37.4^\circ \text{C}$ ($99.3^\circ \text{F}$), blood pressure is $118/74 \text{ mmHg}$, and pulse is $84/\text{min}$. Physical examination shows moist mucous membranes and normal skin turgor. The abdomen is soft and non-tender with hyperactive bowel sounds. Laboratory studies show a leukocyte count of $7,800/\text{mm}^3$. A stool culture returns positive for non-typhoidal \textit{Salmonella}. Which of the following is the most appropriate next step in management?

Match each of the following autoimmune gastrointestinal or hepatobiliary disorders with its most highly associated and diagnostically useful autoantibody marker.

An evaluation is requested for a 59-year-old man who comes to the outpatient clinic complaining of a progressive decline in his exercise tolerance over the past six months. He reports having to stop and catch his breath after walking just one block. The patient also notes a persistent dry cough, which frequently wakes him up at night. His medical history includes untreated hypertension and a 35-pack-year smoking history. Vital signs show a blood pressure of 162/98 mm Hg, a heart rate of 88/min, and an oxygen saturation of 94% on room air. On physical examination, the apical impulse is laterally displaced and sustained. Cardiac auscultation reveals a low-frequency diastolic sound just after S2 and a blowing, holosystolic murmur at the cardiac apex. Lung auscultation demonstrates bilateral basilar crackles without wheezing. In-office spirometry reveals a forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) ratio of 0.82. Which of the following is the most likely underlying mechanism for this patient's respiratory symptoms?

Match each clinical vignette describing a patient with a structural heart defect to the expected physiologic response of their cardiac physical exam findings during dynamic auscultation maneuvers.