Internal Medicine

An ambulance brings a 71-year-old male to the emergency department due to severe shortness of breath that awoke him from sleep. He has a known medical background of chronic obstructive pulmonary disease and ischemic heart failure with a reduced ejection fraction. Over the past three days, he has noted increasing difficulty breathing when lying flat and has had to sleep in a recliner chair. He denies fever, chills, or changes in sputum production. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $170/95\text{ mm Hg}$, pulse is $115/\text{min}$, and respirations are $28/\text{min}$. Oxygen saturation is $86\%$ on room air. Examination reveals distended jugular veins when sitting at a 45-degree angle. Pulmonary auscultation demonstrates bilateral crackles up to the mid-lung fields without significant wheezing. Cardiac auscultation reveals a regular tachycardia with an S3 gallop. A bedside chest radiograph demonstrates an enlarged cardiac silhouette, prominent pulmonary vasculature, and bilateral pleural effusions. Which of the following is the most appropriate initial pharmacological intervention for this patient?

A ward nurse urgently requests an evaluation of a 71-year-old male who developed severe, sudden-onset shortness of breath 20 minutes ago. The patient is currently on postoperative day 3 following an elective sigmoid resection for recurrent diverticulitis. His medical history is significant for ischemic heart disease, diet-controlled type 2 diabetes mellitus, and a 40-pack-year smoking history. Over the past 24 hours, he received 3 liters of intravenous lactated Ringer's solution for transient oliguria.

Vital signs are:
- Temperature: 37.2°C (99.0°F)
- Blood pressure: 168/94 mm Hg
- Pulse: 112/min
- Respirations: 26/min
- Oxygen saturation: 87% on room air

Physical examination reveals an agitated, diaphoretic man sitting upright and using accessory muscles of respiration. The jugular veins are distended to the angle of the mandible when the patient is seated at a 45-degree angle. Cardiac auscultation reveals a regular tachycardia with a distinct, low-pitched additional heart sound heard in early diastole. Lung auscultation demonstrates prolonged expiration with diffuse polyphonic wheezing and bilateral moist crackles in the lower lung fields.

Arterial blood gas analysis on room air shows:
- pH: $7.28$
- pCO $_2$: $54$ mm Hg
- pO $_2$: $56$ mm Hg
- HCO $_3^-$: $24$ mEq/L

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

A physician is evaluating a 64-year-old male patient who reports the sudden onset of profuse, watery diarrhea and lower abdominal cramps that began three days ago. The patient recently completed a 10-day course of clindamycin for a dental abscess. He currently experiences up to nine bowel movements daily. His temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), pulse is $92/\text{min}$, and blood pressure is $118/76\text{ mm Hg}$. Physical examination of the abdomen reveals mild, diffuse tenderness without rebound or guarding. Laboratory results show a leukocyte count of $15,500/\text{mm}^3$. Stool testing is positive for *Clostridioides difficile* toxin via nucleic acid amplification testing. Which of the following is the most appropriate pharmacologic intervention for this patient's current condition?

A 55-year-old man presents to a rural emergency department reporting severe, crushing, substernal chest pain of 45 minutes duration that radiates to his left jaw. He appears diaphoretic and dyspneic. His blood pressure is 145/90 mm Hg and heart rate is 92/min. A 12-lead electrocardiogram demonstrates 4 mm ST-segment elevations in leads V2 through V5. The facility does not have a cardiac catheterization laboratory. The nearest percutaneous coronary intervention (PCI)-capable center is located 140 minutes away by helicopter transport, and weather conditions are clear for flying. Arrange the following management steps in the most appropriate chronological sequence for this patient.

An emergency department physician is evaluating a patient who was brought in by family members due to severe breathing difficulties that began three days ago. The patient, a retired factory worker, has a known history of severe chronic obstructive pulmonary disease (COPD), heart failure with preserved ejection fraction, and a $40$-pack-year smoking history. According to his daughter, he has been coughing up increased amounts of thick, yellow-green sputum.

On examination, the $72$-year-old patient appears in moderate respiratory distress. His temperature is $37.8^\circ\text{C}$ ($100^\circ\text{F}$), blood pressure is $142/86\text{ mm Hg}$, pulse is $112/\text{min}$, and respiratory rate is $26/\text{min}$. Oxygen saturation is $86\%$ on room air. Physical examination reveals a barrel-shaped chest, diffuse expiratory wheezes, and a prolonged expiratory phase. Jugular venous pressure is $6\text{ cm H}_2\text{O}$, and there is no peripheral edema.

Laboratory and diagnostic data are as follows:

A sputum culture obtained during a routine clinic visit one week ago grew *Streptococcus pneumoniae* that is susceptible to amoxicillin, azithromycin, and levofloxacin. A chest radiograph demonstrates hyperinflated lungs and flattened diaphragms, without focal consolidation, pleural effusion, or pulmonary venous congestion.

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

A 31-year-old G1P0 woman at 38 weeks gestation presents for an urgent evaluation due to severe, worsening shortness of breath over the past week. She reports that her breathing is particularly difficult at night, requiring her to sleep in a recliner chair. She also notes a persistent, dry cough and significant swelling in her legs. She has no significant past medical history, and her pregnancy has been uncomplicated thus far. Her blood pressure is 112/74 mm Hg, pulse is 116/min, and respirations are 24/min. Pulse oximetry shows 92% on ambient air. Physical examination reveals prominent jugular venous distension while sitting at a 45-degree angle. Cardiac auscultation demonstrates a regular tachycardia with a low-pitched, early diastolic sound at the cardiac apex. Lung auscultation reveals crackles in bilateral lung bases. There is 2+ pitting edema in both lower extremities extending to the knees. Which of the following is the most appropriate next step in evaluation?

A $69$-year-old man in the intensive care unit is being evaluated for acute-onset respiratory distress. He was intubated four days ago for hypercapnic respiratory failure secondary to a viral upper respiratory infection. His medical history is notable for severe chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$. Over the past two days, his clinical status improved on a regimen of systemic glucocorticoids, targeted narrow-spectrum antibiotics, and scheduled bronchodilators.

Thirty minutes ago, a spontaneous breathing trial was initiated via a T-piece. At the start of the trial, his vital signs were temperature $37.1^\circ$ C ($98.8^\circ$ F), blood pressure $112/74$ mm Hg, pulse $84$/min, and respirations $16$/min.

The patient now appears highly agitated and profoundly diaphoretic. Vital signs are blood pressure $185/105$ mm Hg, pulse $132$/min, and respirations $34$/min. Oxygen saturation is $85\%$ on $40\%$ FiO $_2$. Physical examination reveals prominent use of accessory muscles of respiration and new-onset jugular venous distention. Lung auscultation demonstrates diffuse wheezing and bilateral basilar crackles.

An arterial blood gas is obtained:
pH: $7.20$
PaCO $_2$: $68$ mm Hg
PaO $_2$: $54$ mm Hg
HCO $_3^-$: $26$ mEq/L

A basic metabolic panel from yesterday showed a serum bicarbonate of $36$ mEq/L.

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

A 26-year-old man presents to the clinic with a 2-day history of frequent, watery stools and mild, diffuse abdominal cramping. He reports up to six loose bowel movements daily without visible blood or mucus. He has experienced mild nausea but no vomiting. The patient recently attended a catered outdoor gathering with several friends who are now experiencing similar symptoms. His temperature is $37.3^\circ\text{C}$ ($99.1^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, and pulse is $84/\text{min}$. The abdomen is soft, non-distended, and mildly tender to deep palpation diffusely, with hyperactive bowel sounds and no rebound tenderness or guarding. He is otherwise healthy and takes no daily medications. Which of the following is the most appropriate next step in the management of this patient?

An established patient at a primary care clinic presents with worsening breathlessness over the past four days. The patient has a longstanding history of tobacco use and severe chronic obstructive pulmonary disease. Over the last week, the patient noticed a significant increase in daily sputum production, which has recently changed in appearance from clear to thick and dark green. Vital signs include a blood pressure of $135/85$ mmHg, a heart rate of $98$/min, a respiratory rate of $22$/min, and an oxygen saturation of $92\%$ on room air. Physical examination demonstrates a barrel-shaped chest, distant heart sounds, and diffuse expiratory wheezing without any crackles. Jugular venous pressure is normal, and there is no dependent peripheral edema. In addition to optimizing short-acting bronchodilator therapy and administering systemic corticosteroids, which of the following is the most appropriate next step in management?

Paramedics bring a $68$-year-old resident of an assisted living facility to the acute care bay due to progressively worsening breathlessness and thick, yellow sputum over the last two days. He is known to have severe chronic obstructive pulmonary disease (COPD) and uses home oxygen at night. Upon assessment, he is utilizing accessory muscles to breathe but remains fully oriented and can follow commands. Arterial blood gas analysis on room air demonstrates a pH of $7.31$, a $PaCO_2$ of $58$ mm Hg, and a $PaO_2$ of $52$ mm Hg. Arrange the following management interventions in the most appropriate sequential order of therapy escalation, starting from initial stabilization to treatments reserved for refractory respiratory failure.

Match each characteristic electrocardiogram (ECG) finding with its most likely underlying clinical condition or pathology.

A 68-year-old man is evaluated in the intensive care unit on day 3 of mechanical ventilation for severe community-acquired pneumonia. He has a history of severe chronic obstructive pulmonary disease (COPD) and heart failure with preserved ejection fraction. He was intubated on admission due to hypercapnic respiratory failure.

His ventilator settings are:
Mode: Volume assist-control
Tidal volume: 450 mL (6 mL/kg ideal body weight)
Respiratory rate: 14/min
PEEP: 5 cm $H_2O$
$FiO_2$: 0.40

Today, the ventilator alarms for high airway pressures. Vital signs are temperature 37.1 °C (98.8 °F), pulse 112/min, and blood pressure 135/85 mmHg.

Ventilator parameters show:
Peak airway pressure: 58 cm $H_2O$ (was 32 cm $H_2O$ yesterday)
Plateau airway pressure: 24 cm $H_2O$ (was 23 cm $H_2O$ yesterday)

Physical examination reveals jugular venous distension 9 cm above the sternal angle. Breath sounds are diminished bilaterally with a notably prolonged expiratory phase. No crackles are heard.

Current arterial blood gas on the above settings:
pH: 7.27
$PaCO_2$: 66 mmHg
$PaO_2$: 70 mmHg
$HCO_3^-$: 30 mEq/L
(A baseline blood gas from 3 months ago showed: pH 7.36, $PaCO_2$ 56 mmHg, $HCO_3^-$ 31 mEq/L)

Blood cultures drawn on admission are now finalizing and grow only *Streptococcus pneumoniae*, which is pan-sensitive, including to ceftriaxone. The patient is currently receiving intravenous vancomycin, piperacillin-tazobactam, and azithromycin.

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

A 28-year-old woman, who is 14 weeks pregnant, is brought to the emergency department after 4 days of intractable nausea, vomiting, and diffuse abdominal pain. She has a history of type 1 diabetes mellitus and has not taken her insulin for the past 48 hours due to her inability to tolerate oral intake. She reports profound weakness and lightheadedness when standing. Her temperature is 37.1°C (98.8°F), blood pressure is 92/58 mm Hg, heart rate is 122/min, and respiratory rate is 26/min. Physical examination shows dry mucous membranes and diminished skin turgor.

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

A 68-year-old man is evaluated in the intensive care unit for persistent lethargy. He was admitted 8 days ago for septic shock secondary to a perforated diverticulum. He underwent an emergency exploratory laparotomy and has been receiving intravenous fluids, mechanical ventilation, and targeted antibiotic therapy based on intraoperative cultures. Over the past 48 hours, his hemodynamics have stabilized, and vasopressors were discontinued. He has a medical history of hypertension and osteoarthritis but no history of endocrine disorders. Vital signs are temperature $37.2^\circ \text{C}$ ($99.0^\circ \text{F}$), blood pressure $118/74 \text{ mm Hg}$, pulse $78/\text{min}$, and respirations $16/\text{min}$. A comprehensive metabolic panel is unremarkable. Thyroid function testing shows the following:

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

During a winter evening shift in the emergency department, a 68-year-old retired teacher arrives complaining of progressively worsening breathlessness over the last 48 hours. She has a history of tobacco use (40 pack-years) and essential hypertension. The patient notes a persistent cough that worsens significantly when she attempts to sleep flat. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 162/95 mmHg, pulse of 108/min, and respirations of 26/min. Pulse oximetry reveals an oxygen saturation of 89% on room air. Physical examination demonstrates an elevated jugular venous pressure of 10 cm H2O above the sternal angle. Auscultation of the chest reveals diffuse, high-pitched expiratory wheezing throughout all lung fields without focal crackles. Cardiac auscultation shows a regular tachycardia with an audible third heart sound (S3) at the apex. Trace bilateral pitting edema is present at the ankles. Which of the following is the most appropriate initial pharmacotherapy for this patient's current condition?

A $54$-year-old man presents to the emergency department with a $5$-day history of high fever, productive cough with rust-colored sputum, and sharp right-sided chest pain that worsens with deep inspiration. He has no significant past medical history other than a $20$-pack-year smoking history.

His temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $122/78\text{ mm Hg}$, pulse is $110/\text{min}$, and respiratory rate is $24/\text{min}$. Pulse oximetry shows $92\%$ on room air.

Physical examination reveals dullness to percussion and decreased breath sounds over the right lower lung field. A chest radiograph demonstrates a right lower lobe consolidation with a moderate-sized, free-flowing right-sided pleural effusion.

A diagnostic thoracentesis is performed, and pleural fluid analysis yields the following results:

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

Complaining of feeling constantly cold and sluggish, a 45-year-old woman presents to her primary care provider. She reports gaining $6 \text{ kg}$ ($13.2 \text{ lbs}$) over the last six months without any dietary changes. On physical examination, her pulse is $56/\text{min}$, her skin is notably dry, and her deep tendon reflexes exhibit delayed relaxation. A comprehensive metabolic panel is within normal limits. Thyroid function testing demonstrates a free T4 concentration of $0.4 \text{ ng/dL}$ (normal: $0.9–1.7 \text{ ng/dL}$) and a TSH concentration of $1.1 \text{ \mu U/mL}$ (normal: $0.5–5.0 \text{ \mu U/mL}$). Which of the following is the most likely underlying cause of this patient's symptoms?

A 58-year-old man is evaluated in the emergency department after abruptly coughing up approximately 600 mL of bright red blood over the past hour. He has a history of treated pulmonary tuberculosis that resulted in permanent cavitary scarring in his right upper lobe. Currently, his blood pressure is 105/65 mm Hg, pulse is 118/min, and respirations are 28/min. Pulse oximetry shows 89% on room air. He is in moderate respiratory distress and continues to actively expectorate large amounts of blood.

Arrange the following interventions in the most appropriate sequential order for managing this patient's massive hemoptysis, proceeding from the most immediate bedside action to the ultimate definitive therapy.

A female patient, aged $68$, presents to the acute care clinic accompanied by her family. She reports progressive abdominal swelling, nausea, vomiting, and exertional shortness of breath over the past $14$ days. Her medical history is notable for asthma, primary hypothyroidism, and Hodgkin lymphoma that was treated with mantle field radiation therapy $25$ years ago. Her home medications include levothyroxine and as-needed albuterol.

Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $98/60\text{ mmHg}$, pulse is $108\text{/min}$, and respirations are $24\text{/min}$. Pulse oximetry is $94\%$ on room air.

Physical examination reveals a chronically ill-appearing woman. The jugular veins are distended to $14\text{ cm } H_2O$, and the distension increases with inspiration. Chest auscultation reveals diminished breath sounds at the bases bilaterally, with no wheezes or crackles. Cardiac examination shows a rapid, regular rhythm with a sharp, early diastolic sound heard best at the left sternal border. The abdomen is markedly distended and tympanitic, with sluggish bowel sounds and shifting dullness. There is $3+$ pitting edema of the lower extremities bilaterally.

Laboratory studies are as follows:

An upright abdominal radiograph shows multiple dilated loops of small bowel with air-fluid levels. Electrocardiography reveals sinus tachycardia with low-voltage QRS complexes.

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

A $68$-year-old woman with a history of chronic obstructive pulmonary disease (COPD) and hypertension is brought to the emergency department due to progressively worsening shortness of breath over the past $3$ days. She reports orthopnea, paroxysmal nocturnal dyspnea, and bilateral leg swelling. Her blood pressure is $165/95$ mm Hg, pulse is $115$/min, and respirations are $28$/min. Pulse oximetry shows an oxygen saturation of $85\%$ on room air. Physical examination reveals jugular venous distention, bilateral crackles extending to the mid-lung fields, and scattered expiratory wheezes. Arterial blood gas analysis on room air shows:

pH: $7.28$
pCO $_2$: $62$ mm Hg
pO $_2$: $56$ mm Hg
HCO $_3^-$: $28$ mEq/L

Chest radiography reveals cardiomegaly, bilateral perihilar alveolar opacities, and blunting of the costophrenic angles. Which of the following are the most appropriate next steps in the management of this patient? (Select exactly 2 answers)