Internal Medicine

A 64-year-old man is brought to the emergency department via ambulance due to the sudden onset of severe, "tearing" chest pain that radiates to his interscapular region. He has a history of poorly controlled hypertension. On arrival, he appears diaphoretic and in severe distress. Blood pressure is 210/115 mm Hg in the right arm and 160/90 mm Hg in the left arm, with a heart rate of 112/min. Physical examination reveals a new early diastolic decrescendo murmur heard best at the right upper sternal border. An electrocardiogram shows sinus tachycardia with left ventricular hypertrophy, but no acute ischemic changes. A portable chest radiograph reveals a widened mediastinum. Intravenous access and continuous hemodynamic monitoring have been established.

Arrange the following management steps in the most appropriate sequential order for this patient's acute presentation.

A 59-year-old man with a known history of alcohol-related cirrhosis is brought to the emergency department by his family due to increasing confusion, lethargy, and diffuse abdominal discomfort over the past $48$ hours. His home medications include nadolol, spironolactone, and furosemide. His temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), pulse is $92/\text{min}$, blood pressure is $105/65\text{ mmHg}$, and respirations are $16/\text{min}$. Physical examination reveals scleral icterus and spider angiomas. The abdomen is distended with shifting dullness and diffuse, mild tenderness to palpation without rebound or guarding. Asterixis is present on neurologic examination.

A diagnostic paracentesis is performed, and ascitic fluid analysis reveals a total protein of $1.1\text{ g/dL}$ and a leukocyte count of $650/\text{mm}^3$ with $75\%$ neutrophils.

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

Match each Hepatitis B (HBV) serologic and virologic profile to its corresponding clinical disease state.

A 42-year-old man presents to the emergency department with a 4-week history of productive cough, low-grade fever, drenching night sweats, and a 5-kg (11-lb) weight loss. He emigrated from a country with a high incidence of tuberculosis two years ago. Vital signs show a temperature of 38.1°C (100.6°F), heart rate of 92/min, blood pressure of 120/78 mm Hg, respiratory rate of 18/min, and oxygen saturation of 97% on room air. Physical examination reveals bronchial breath sounds and crackles in the right upper lung field. He is currently waiting in the general triage area. Arrange the following management steps in the most appropriate chronological order.

A 42-year-old woman comes to the clinic reporting a 5-month history of worsening fatigue, a $4\text{ kg}$ ($8.8\text{ lb}$) weight gain, and generalized weakness. She also notes that her menstrual periods have been absent for the past 6 months. Her last menstrual period was 7 months ago, and prior to this, her cycles were regular. She has no prior medical history and takes no medications. Vital signs show a pulse of $54 \text{ /min}$ and blood pressure of $100/60 \text{ mmHg}$. Physical examination reveals pale, dry skin and delayed relaxation of the deep tendon reflexes. Visual field testing by confrontation is normal.

Laboratory studies show the following:

Which of the following is the most likely explanation for this patient's clinical and laboratory findings?

Progressive respiratory distress and a persistent nighttime cough prompt a $68$-year-old woman to seek medical evaluation at a local urgent care clinic. She states that over the past $4$ days, she has been unable to sleep lying flat and has needed to prop herself up with three pillows. Her medical history includes hypertension, type 2 diabetes mellitus, a myocardial infarction three years prior, and a $30$-pack-year smoking history. She currently uses an as-needed albuterol inhaler. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $156/94 \text{ mm Hg}$, heart rate of $110/\text{min}$, and respiratory rate of $26/\text{min}$. Pulse oximetry reveals an oxygen saturation of $91\%$ on room air. Physical examination demonstrates prominent jugular venous distention when the patient is seated at a $45^\circ$ angle. Auscultation of the lungs reveals diffuse expiratory wheezes bilaterally and dullness to percussion at the bases. Cardiac auscultation identifies a regular tachycardia and a third heart sound (S3) gallop. A point-of-care arterial blood gas demonstrates a pH of $7.48$, $\text{PaCO}_2$ of $30 \text{ mm Hg}$, and $\text{PaO}_2$ of $64 \text{ mm Hg}$. Which of the following is the most appropriate initial step in management for this patient?

A $68$-year-old man is evaluated on postoperative day $5$ following a partial colectomy for recurrent uncomplicated diverticulitis. Over the past $24$ hours, he has developed a fever, tachycardia, and new-onset copious, watery diarrhea. He reports mild, diffuse abdominal cramping but no nausea or vomiting. His current medications include intravenous fluids, prophylactic subcutaneous enoxaparin, and patient-controlled analgesia. He received a standard course of perioperative intravenous cefoxitin. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $118/74 \text{ mm Hg}$, and pulse is $112/\text{min}$. On physical examination, the abdomen is mildly distended and diffusely tender to deep palpation, without rigidity or rebound tenderness. The surgical incision is clean, dry, and intact.

Laboratory studies show:
Leukocyte count: $18,500/\text{mm}^3$

Arterial blood gas (room air):
pH: $7.32$
pCO $_2$: $30 \text{ mm Hg}$
HCO $_3^-$: $15 \text{ mEq/L}$

A stool enzyme immunoassay (EIA) is positive for *Clostridioides difficile* toxins A and B.

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

An intensive care unit team is reviewing pulmonary artery catheterization data for several critically ill patients. Match each patient's clinical presentation with their expected central hemodynamic profile. (Note: Arrows indicate relative changes: $\uparrow$ increased, $\downarrow$ decreased, $\leftrightarrow$ normal or unchanged).

During morning multidisciplinary rounds in the intensive care unit, the team evaluates a 73-year-old male who has been mechanically ventilated for the past $48$ hours. His initial presentation involved profound hypoxemia due to community-acquired pneumonia. The patient's medical history includes ischemic cardiomyopathy (left ventricular ejection fraction of $25\%$) and severe emphysema.

He was empirically started on intravenous vancomycin and piperacillin-tazobactam. The microbiology laboratory has just finalized the results of blood and bronchoalveolar lavage fluid cultures obtained at admission; both demonstrate heavy growth of *Streptococcus pneumoniae*. The susceptibility report confirms the isolate is sensitive to all tested antibiotics, including ceftriaxone and penicillin.

Vital signs reveal a heart rate of $112$/min and a blood pressure of $118/72$ mm Hg. He is afebrile. Physical examination shows engorged neck veins when the head of the bed is elevated. Cardiac auscultation identifies a third heart sound (S3). Lung examination yields diffuse bilateral crepitations that extend to the mid-apices, accompanied by prolonged expiratory wheezing.

An arterial blood gas analysis on current ventilator settings reveals:
- pH: $7.18$
- pCO $_2$: $56$ mm Hg
- pO $_2$: $82$ mm Hg
- HCO $_3^-$: $20$ mEq/L

Which of the following interventions are appropriate for this patient at this time? (Select all that apply)

A 27-year-old woman, G1P0, at 7 weeks gestation presents to the clinic for her first prenatal visit. She reports mild morning nausea and breast tenderness but otherwise feels well. She was diagnosed with primary hypothyroidism secondary to Hashimoto thyroiditis 4 years ago and has been taking levothyroxine $100 \mu\text{g}$ daily since that time. Her pre-pregnancy thyroid function tests were consistently within normal limits. Her vital signs are stable, and physical examination shows a normal-sized, non-tender thyroid gland without nodules.

Laboratory evaluation reveals the following:

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

Match each clinical presentation of genital ulcer disease to the most appropriate first-line pharmacotherapy.

Correlate the following specific jugular venous pulse (JVP) waveform abnormalities with the underlying cardiovascular pathology that most classically produces them.

A 65-year-old woman is evaluated in the hospital on postoperative day 2 following an elective total right knee arthroplasty due to sudden-onset palpitations, severe shortness of breath, and lightheadedness. Her medical history includes hypertension, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. Her temperature is 37.9°C (100.2°F), blood pressure is 82/50 mm Hg, heart rate is 148/min, and respiratory rate is 26/min. Pulse oximetry is 91% on 2 L/min of oxygen via nasal cannula. On physical examination, the patient appears distressed and diaphoretic. Her extremities are cool to the touch with delayed capillary refill. Jugular venous distension is present. Lung auscultation reveals bibasilar crackles and scattered expiratory wheezes. Cardiac examination shows an irregularly irregular rhythm with a rapid rate and no distinct murmurs. The right knee surgical site is intact with expected mild swelling and no purulent drainage. An electrocardiogram demonstrates an irregularly irregular rhythm with narrow QRS complexes and absent P waves. Which of the following is the most appropriate immediate next step in management?

An 82-year-old woman residing in a skilled nursing facility is evaluated during a routine monthly check-up. Her medical history includes Alzheimer dementia, hypertension, and type 2 diabetes mellitus. The facility staff requested a urinalysis today because they noted her urine has appeared cloudy and malodorous over the past three days. The patient has no complaints and denies any pain. Temperature is 37.0°C (98.6°F), blood pressure is 138/82 mm Hg, pulse is 76/min, and respirations are 14/min. The patient is alert, pleasant, and oriented to her own name, which is consistent with her baseline mental status. Abdominal examination reveals a soft, non-distended abdomen with no suprapubic or costovertebral angle tenderness. A clean-catch urinalysis shows a specific gravity of 1.015, pH 6.5, positive leukocyte esterase, positive nitrites, and 45 white blood cells/hpf. Which of the following is the most appropriate next step in management?

A 52-year-old man is brought to the emergency department by his wife due to a 24-hour history of high fever, severe generalized headache, and progressive confusion. On physical examination, his temperature is 39.2°C (102.6°F), blood pressure is 110/70 mmHg, heart rate is 115/min, and respiratory rate is 18/min. He is lethargic but arousable. Neurologic examination reveals marked nuchal rigidity and a new, mild right-sided hemiparesis. Fundoscopic examination shows early papilledema. The physician suspects acute bacterial meningitis. Arrange the following steps in the most appropriate chronological order for the initial management of this patient.

Match each patient's clinical presentation and response to dynamic auscultatory maneuvers with the corresponding underlying hemodynamic mechanism.

During bedside rounds on the medical-surgical ward, a clinical team evaluates a patient on hospital day $4$. The patient was initially admitted for severe acute pancreatitis secondary to cholelithiasis. Despite adequate initial volume resuscitation, the patient has required continuous nasojejunal enteral nutrition and aggressive pain management for unremitting epigastric discomfort.

Vital signs demonstrate a temperature of $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), a heart rate of $112\text{/min}$, respirations of $18\text{/min}$, and a blood pressure of $116/72\text{ mm Hg}$.

Physical examination reveals a distended abdomen with marked epigastric tenderness. Bowel sounds are hypoactive. No scleral icterus is present.

Laboratory analysis shows:
Leukocyte count: $15,800\text{/mm}^3$
Hemoglobin: $14.2\text{ g/dL}$
Blood urea nitrogen: $28\text{ mg/dL}$
Total bilirubin: $0.9\text{ mg/dL}$ (decreased from $3.2\text{ mg/dL}$ on admission)
Alkaline phosphatase: $110\text{ U/L}$ (decreased from $340\text{ U/L}$ on admission)
Alanine aminotransferase (ALT): $45\text{ U/L}$ (decreased from $450\text{ U/L}$ on admission)

Due to the persistent systemic inflammatory response syndrome (SIRS) and severe pain, a contrast-enhanced computed tomography (CT) scan of the abdomen is obtained. The imaging demonstrates diffuse pancreatic enlargement with interstitial edema and $>30\%$ non-enhancement of the pancreatic parenchyma, consistent with acute necrotizing pancreatitis. Several acute peripancreatic fluid collections are noted. There is no evidence of retroperitoneal gas or pneumobilia.

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

An unresponsive 22-year-old male is brought to the emergency department by his parents. He has a history of type 1 diabetes mellitus but lost his insurance and ran out of his medication a week ago. Capillary blood glucose is $540\text{ mg/dL}$. Vital signs show a blood pressure of $85/50\text{ mm Hg}$, pulse of $128\text{/min}$, and respirations of $28\text{/min}$ with deep, sighing breaths. Laboratory results reveal an arterial pH of $7.15$, serum bicarbonate of $10\text{ mEq/L}$, and serum potassium of $4.8\text{ mEq/L}$. Urinalysis is strongly positive for ketones. Arrange the following management steps in the correct chronological sequence for the optimal treatment of this patient's acute condition.

A $68$-year-old man is evaluated in the intensive care unit for a new-onset fever and increased respiratory secretions. He has been receiving mechanical ventilation for $7$ days following a severe cerebrovascular accident. His temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, and pulse is $105/\text{min}$. Physical examination reveals coarse crackles in the right lower lung field. A chest radiograph demonstrates a new right lower lobe infiltrate. Endotracheal aspiration is performed, and empiric intravenous therapy with cefepime, tobramycin, and vancomycin is initiated.

Forty-eight hours later, the patient's temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$) and his oxygenation has steadily improved. The endotracheal aspirate culture grows $10^6\text{ CFU/mL}$ of *Pseudomonas aeruginosa*. Antimicrobial susceptibility testing indicates the organism is susceptible to cefepime, meropenem, and tobramycin, but resistant to levofloxacin. No other organisms are isolated. Which of the following is the most appropriate next step in the management of this patient's pharmacotherapy?

A 72-year-old man is evaluated in the intensive care unit for progressive lethargy and labored breathing. He was admitted 3 days ago for presumed urosepsis and is receiving broad-spectrum intravenous antibiotics. His temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is 82/50 mm Hg, pulse is 122/min, and respirations are 28/min. Physical examination shows a somnolent patient using accessory muscles of respiration.

Laboratory studies show the following:

Which of the following best describes this patient's acid-base disorder?