Internal Medicine

A 34-year-old woman comes to the emergency department reporting sudden-onset, severe right upper quadrant abdominal pain and rapid abdominal swelling over the past 4 days. She has a history of an unprovoked deep vein thrombosis 2 years ago, for which she took an anticoagulant for 6 months but then self-discontinued. She currently takes oral contraceptives. Her temperature is 37.1°C (98.8°F), blood pressure is 128/82 mm Hg, and pulse is 98/min. Examination shows mild scleral icterus. The jugular veins are flat and not distended. The abdomen is tense and distended with shifting dullness. The liver edge is tender and palpable 6 cm below the right costal margin. Laboratory studies show:

Serum:
Total bilirubin: 3.5 mg/dL
Direct bilirubin: 1.9 mg/dL
Aspartate aminotransferase (AST): 420 U/L
Alanine aminotransferase (ALT): 460 U/L
Albumin: 3.9 g/dL

Diagnostic paracentesis yields clear, yellow fluid. Ascitic fluid analysis shows:
Total protein: 3.4 g/dL
Albumin: 1.5 g/dL
Leukocyte count: 120/mm $^3$ (70% mononuclear)

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

A 72-year-old man with a history of severe chronic obstructive pulmonary disease (COPD) and heart failure with preserved ejection fraction is brought to the emergency department with worsening shortness of breath and lower extremity edema over the past week. Three days ago, his outpatient physician doubled his daily dose of oral furosemide. On examination, the patient is alert but in mild respiratory distress. Vital signs are: temperature $37.1^\circ\text{C}$, blood pressure $110/70 \text{ mmHg}$, heart rate $95/\text{min}$, and respiratory rate $22/\text{min}$. Pulse oximetry is $89\%$ on room air.

Initial laboratory studies on room air show:

Which of the following is the most accurate assessment of this patient's current acid-base status?

A 28-year-old surgical resident sustains a deep, bleeding puncture wound to her left index finger from a hollow-bore needle immediately after drawing arterial blood. The source patient is known to be HIV-positive with a high viral load and is concurrently infected with hepatitis C. The resident has previously received the complete hepatitis B vaccine series and has a documented positive surface antibody titer. Arrange the following steps in the most appropriate chronological order for managing this healthcare worker's occupational exposure.

A $64$-year-old woman is evaluated in the hospital on the third day of her admission. She originally presented to the emergency department with a $2$-day history of severe right upper quadrant abdominal pain, jaundice, and a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$). She was diagnosed with acute ascending cholangitis and promptly started on empirical intravenous piperacillin-tazobactam. An emergent endoscopic retrograde cholangiopancreatography (ERCP) was performed, which successfully cleared a $1.2\text{ cm}$ stone from the common bile duct. Today, the patient is completely asymptomatic, afebrile for the past $24\text{ hours}$, and tolerating a regular diet. Blood cultures drawn on admission are now positive for *Escherichia coli*. Susceptibility testing reveals the organism is susceptible to ceftriaxone, ciprofloxacin, and piperacillin-tazobactam, and is resistant to ampicillin. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A $65$-year-old man is brought to the emergency department for severe shortness of breath. He has a history of advanced chronic obstructive pulmonary disease (COPD). On arrival, he is in severe respiratory distress with a respiratory rate of $34\text{/min}$ and paradoxical abdominal movement. Arterial blood gas on room air shows a $\text{pH}$ of $7.18$, $\text{PaCO}_2$ of $76\text{ mm Hg}$, and $\text{PaO}_2$ of $48\text{ mm Hg}$. He is urgently intubated and placed on mechanical ventilation. Initial settings are volume assist-control, tidal volume of $450\text{ mL}$, respiratory rate of $18\text{/min}$, $\text{FiO}_2$ of $1.0$, and positive end-expiratory pressure (PEEP) of $5\text{ cm H}_2\text{O}$.

Ten minutes after intubation, the ventilator's high-pressure alarm sounds continuously, and the patient's blood pressure drops precipitously to $70/40\text{ mm Hg}$. His heart rate is $132\text{/min}$. Physical examination reveals prominent jugular venous distention. The trachea is midline, and breath sounds are symmetrically diminished bilaterally with a notably prolonged expiratory phase. Bedside echocardiography demonstrates right ventricular dilation with leftward bowing of the interventricular septum, and a small, underfilled left ventricle.

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

Evaluate the following patient presentations describing varying symptoms of dysphagia and esophageal discomfort. Match each clinical vignette to the most appropriate esophageal diagnosis.

Review the varied clinical presentations and histopathologic findings described below. Match each clinical vignette to the most accurate underlying hereditary gastrointestinal syndrome.

A 55-year-old woman with a history of alcohol-associated cirrhosis presents to the emergency department with a 1-day history of fever, diffuse abdominal pain, and confusion. Her temperature is 38.2°C (100.8°F), blood pressure is 90/60 mmHg, and pulse is 110/min. Physical examination reveals a distended abdomen with shifting dullness and diffuse tenderness to palpation without rebound or guarding. Asterixis is present. Laboratory studies show a serum creatinine of 1.6 mg/dL, blood urea nitrogen of 32 mg/dL, and total bilirubin of 4.5 mg/dL. You suspect spontaneous bacterial peritonitis (SBP).

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

During a routine workplace health screening, an occupational physician evaluates a veteran mechanic who has been struggling to walk across the garage floor without stopping to catch his breath over the past month. The patient reports waking up multiple times at night feeling suffocated, a sensation that improves after sitting on the edge of his bed for several minutes. He has smoked a pack of cigarettes daily for thirty years. Blood pressure is 142/88 mm Hg, heart rate is 98/min, and respiratory rate is 20/min. Physical examination reveals an apical impulse palpated in the sixth intercostal space, anterior to the midaxillary line. Auscultation identifies an extra low-frequency heart sound occurring just after S2. Lung auscultation demonstrates fine inspiratory crackles in the dependent zones bilaterally without wheezing or prolonged expiration. Which of the following is the most appropriate initial diagnostic test to establish the underlying cause of this patient's symptoms?

Match each clinical presentation of a suspected or confirmed systemic fungal infection with its most appropriate first-line targeted therapy or initial empiric management strategy.

A 45-year-old woman with a history of diffuse cutaneous systemic sclerosis is evaluated in the hospital for acute-onset shortness of breath and a severe headache. She is currently on postoperative day 3 following an uncomplicated laparoscopic cholecystectomy. Her temperature is 37.8°C (100.0°F), blood pressure is 215/115 mm Hg, pulse is 108/min, and respirations are 24/min. Physical examination reveals taut, thickened skin over her face and fingers. Lung auscultation reveals bilateral basilar crackles.

A peripheral blood smear demonstrates numerous schistocytes.

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

A 64-year-old woman with a known history of severe emphysema presents to her primary care physician due to progressive swelling in both her legs over the past three weeks. She notes a mild increase in exertional fatigue but denies any recent fever, chills, chest pain, or changes in her baseline chronic daily cough. Her temperature is 37.0°C (98.6°F), blood pressure is 128/78 mmHg, pulse is 96/min, and respiratory rate is 18/min. Pulse oximetry shows an oxygen saturation of 88% on room air. Physical examination reveals a barrel-shaped chest and distant heart sounds. A prominent right ventricular heave is palpated along the left sternal border. When the patient is positioned at 45 degrees, her jugular venous pulsations are visible 6 cm above the sternal angle. Lung auscultation demonstrates globally diminished breath sounds with a prolonged expiratory phase, but no crackles or wheezes are heard. There is 2+ pitting edema in both lower extremities extending to the mid-calves. Which of the following is the most likely underlying pathophysiological mechanism responsible for this patient's new physical examination findings?

A 58-year-old man is brought to the emergency department by his roommate due to progressive confusion and lethargy over the past 3 days. The patient has a history of alcohol-associated cirrhosis, chronic obstructive pulmonary disease (COPD), and hypertension. The roommate reports that the patient recently doubled his daily dose of furosemide because his leg swelling was worsening, assuming it was due to his "heart acting up." The patient is lethargic but arousable and is oriented only to person. Temperature is 37.1°C (98.8°F), blood pressure is 105/65 mm Hg, pulse is 110/min, and respiratory rate is 12/min. Physical examination reveals scleral icterus, spider angiomata, and marked ascites. A coarse, flapping tremor of the hands is observed upon wrist extension. Jugular venous pressure is 5 cm $H_2O$. Breath sounds are slightly decreased bilaterally with prolonged expiration. Laboratory studies show:

Sodium: 132 mEq/L
Potassium: 2.6 mEq/L
Chloride: 85 mEq/L
Bicarbonate: 36 mEq/L
Blood urea nitrogen: 48 mg/dL
Creatinine: 1.7 mg/dL (baseline 0.9 mg/dL)

Arterial blood gas analysis on room air shows a pH of 7.53, $pCO_2$ of 47 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?

Match each characteristic colonoscopic finding with the most likely corresponding clinical diagnosis.

Paramedics bring a lethargic 45-year-old male patient to the acute care unit. According to his brother, the patient has consumed heavy amounts of alcohol daily for the past two weeks while completely abstaining from solid foods. Over the last 96 hours, he has suffered from intractable emesis. Physical examination reveals a deeply furrowed tongue, delayed capillary refill, and a loss of skin elasticity.

Laboratory evaluations reveal the following:

Urinalysis is strongly positive for ketones.

Assume a baseline normal serum anion gap of 12 mEq/L and a normal serum bicarbonate of 24 mEq/L. What is the calculated delta ratio ($\frac{\Delta AG}{\Delta HCO_3^-}$) for this patient?

A 42-year-old man presents to his primary care provider reporting a gradual onset of profound sluggishness, increased sensitivity to cold, and worsening constipation over the past five months. He also mentions a decreased interest in sexual activity. He has no significant past medical history and takes no medications. Vital signs show a temperature of 36.4°C (97.5°F), blood pressure of 105/70 mm Hg, and a pulse of 54/min. Physical examination reveals a puffy facial appearance, dry skin, and a delayed relaxation phase of the deep tendon reflexes. Visual field testing is intact to confrontation. Laboratory evaluation yields the following results:

Which of the following is the most likely underlying mechanism for this patient's laboratory findings?

A 55-year-old hospitalized man collapses while walking in the telemetry unit hallway. He is unresponsive, and no carotid pulse is palpable. A code blue is activated, and high-quality cardiopulmonary resuscitation (CPR) is initiated. The defibrillator pads are applied, and the monitor displays coarse ventricular fibrillation.

Arrange the following critical management steps in the chronological order they should be performed according to advanced cardiovascular life support (ACLS) protocols, assuming the patient remains in refractory ventricular fibrillation throughout the resuscitation.

A 71-year-old man is evaluated in the clinic for increasing fatigue, muscle cramps, and intermittent confusion over the past week. He has a long-standing history of severe chronic obstructive pulmonary disease (COPD) and cor pulmonale. Three weeks ago, his primary care physician significantly increased his daily dose of oral furosemide to manage worsening lower extremity edema. On physical examination, the patient has a barrel-shaped chest, prolonged expiratory phase, and diminished breath sounds bilaterally. Trace pitting edema is present in the lower extremities.

Arterial blood gas on room air reveals:
pH: $7.39$
$p\text{CO}_2$: $60$ mmHg
$p\text{O}_2$: $58$ mmHg

Serum chemistry panel shows:
$\text{Na}^+$: $139$ mEq/L
$\text{K}^+$: $2.8$ mEq/L
$\text{Cl}^-$: $92$ mEq/L
$\text{HCO}_3^-$: $36$ mEq/L
Blood urea nitrogen: $32$ mg/dL
Creatinine: $1.4$ mg/dL

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

A $72$-year-old man comes to the clinic reporting a $6$-week history of progressively worsening shortness of breath, a dry cough, and generalized fatigue. He has a history of paroxysmal atrial fibrillation and a myocardial infarction $3$ years ago. His daily medications include apixaban, amiodarone, metoprolol succinate, and atorvastatin. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $128/78\text{ mm Hg}$, and pulse of $64\text{/min}$. Oxygen saturation is $92\%$ on room air. Jugular venous pressure is $6\text{ cm H}_2\text{O}$. Cardiac auscultation reveals a regular rate and rhythm with no murmurs, rubs, or gallops. Pulmonary examination reveals fine bilateral inspiratory crackles but no wheezing. Laboratory studies reveal:

- Leukocyte count: $7,200/\text{mm}^3$
- Brain natriuretic peptide (BNP): $85\text{ pg/mL}$ (normal $< 100\text{ pg/mL}$)
- Thyroid-stimulating hormone (TSH): $7.2\text{ }\mu\text{U/mL}$ (normal: $0.4\text{--}4.0\text{ }\mu\text{U/mL}$)
- Free $T_4$: $1.8\text{ ng/dL}$ (normal: $0.9\text{--}1.7\text{ ng/dL}$)

High-resolution computed tomography of the chest demonstrates bilateral ground-glass opacities and focal areas of consolidation. Which of the following is the most appropriate next step in management?

A medical student is reviewing thyroid laboratory panels in the endocrine clinic. Match the following thyroid function test and radioactive iodine uptake (RAIU) laboratory profiles with the most accurate underlying clinical diagnosis.