Internal Medicine

Match each clinical presentation of a systemic autoimmune condition with its most highly associated specific autoantibody.

A 45-year-old man is brought to the emergency department by his wife due to acute-onset confusion, slurred speech, and an unsteady gait. His symptoms began earlier in the day and have progressively worsened. The patient has a history of severe Crohn's disease that necessitated multiple extensive small bowel resections three years ago, leaving him with short bowel syndrome. He does not consume alcohol and has no history of substance use. His temperature is 37.1°C (98.8°F), blood pressure is 110/70 mm Hg, heart rate is 88/min, and respiratory rate is 22/min. Physical examination reveals a confused man with an ataxic gait. His lungs are clear to auscultation. The abdomen is soft with well-healed surgical scars.

Laboratory studies show:

Arterial blood gas analysis on room air:

Which of the following best describes the primary underlying mechanism for this patient's current condition?

A 22-year-old woman with a history of type 1 diabetes mellitus is admitted to the intensive care unit with a two-day history of high fever, productive cough, and progressive lethargy. She has been unable to tolerate oral intake and missed her last four doses of insulin. On arrival, her temperature is $38.9^\circ\text{C}$ ($102^\circ\text{F}$), pulse is $132\text{/min}$, respiratory rate is $36\text{/min}$, and blood pressure is $88/54\text{ mm Hg}$. Oxygen saturation is $89\%$ on ambient air. Physical examination reveals deep, rapid breathing and bronchial breath sounds with crackles in the right lower lung field. Laboratory studies show a serum glucose of $510\text{ mg/dL}$, sodium of $134\text{ mEq/L}$, potassium of $4.9\text{ mEq/L}$, chloride of $98\text{ mEq/L}$, and bicarbonate of $10\text{ mEq/L}$. A chest radiograph confirms a right lower lobe consolidation. The patient is resuscitated with intravenous normal saline, started on a continuous insulin infusion, and administered intravenous ceftriaxone and azithromycin. Two hours later, her respiratory effort wanes and she becomes severely hypoxemic, necessitating endotracheal intubation. She is placed on volume assist-control mechanical ventilation with a tidal volume of $400\text{ mL}$, a respiratory rate of $14\text{/min}$, $FiO_2$ of $0.70$, and positive end-expiratory pressure (PEEP) of $5\text{ cm }H_2O$. Thirty minutes later, arterial blood gas analysis reveals:

$pH$: $7.15$
$PaCO_2$: $38\text{ mm Hg}$
$PaO_2$: $72\text{ mm Hg}$
$HCO_3^-$: $10\text{ mEq/L}$

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

A $68$-year-old woman arrives at the urgent care clinic reporting severe, progressively worsening difficulty breathing over the last $48$ hours. She notes that she has been waking up gasping for air in the middle of the night and now requires sleeping in her recliner to breathe comfortably. Her past medical history includes long-standing high blood pressure and diet-controlled type $2$ diabetes mellitus. She smoked cigarettes for $30$ years but quit a decade ago. Vital signs show a blood pressure of $162/96$ mm Hg, heart rate of $105$/min, and respiratory rate of $24$/min. Pulse oximetry indicates $92\%$ oxygen saturation on ambient air. Physical examination demonstrates noticeable distension of the neck veins while sitting upright. Lung auscultation reveals bilateral crackles at the bases. Cardiac auscultation detects an extra low-pitched sound occurring just after the second heart sound. Moderate pitting edema is present in both lower legs. Which of the following is the most appropriate initial pharmacological intervention to relieve this patient's respiratory distress?

A 34-year-old woman with no significant past medical history is evaluated in the clinic for a 6-month history of progressively worsening exertional dyspnea and fatigue. She has no cough, wheezing, orthopnea, or leg swelling. She does not smoke. Vital signs are within normal limits. Physical examination reveals a prominent right ventricular heave, a loud pulmonic component of the second heart sound (P2), and a faint holosystolic murmur at the left lower sternal border that increases in intensity with inspiration. The lungs are clear to auscultation bilaterally. Electrocardiogram shows right axis deviation and right ventricular hypertrophy. Suspecting a primary pulmonary vascular disorder, the physician plans a comprehensive diagnostic workup.

Arrange the following diagnostic and management steps in the correct chronological sequence according to consensus guidelines for unexplained pulmonary hypertension, moving from initial screening to definitive management:

Match the following classic physical examination auscultation findings with the most likely underlying valvular pathology.

A $34$-year-old primigravida at $37$ weeks gestation is evaluated in the obstetric triage unit for worsening difficulty breathing over the past week. She states that she becomes excessively winded when walking up a single flight of stairs and has recently started using three pillows to sleep comfortably at night. She has a past medical history of mild persistent asthma, for which she occasionally uses an inhaled corticosteroid. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $118/78\text{ mmHg}$, pulse of $110/\text{min}$, and respiratory rate of $22/\text{min}$. Pulse oximetry is $94\%$ on room air. Physical examination reveals prominent distension of the neck veins while sitting at a $45$-degree incline. Chest auscultation reveals fine crackles at the bilateral lung bases. Cardiac auscultation reveals a regular tachycardia and an extra, low-pitched sound in early diastole. There is $2+$ pitting edema extending to the mid-shins bilaterally. Which of the following is the most appropriate next step in patient care?

Match each of the following classic arterial pulse abnormalities with the cardiovascular pathology most commonly associated with its presentation.

A 55-year-old male comes to the outpatient clinic reporting a 3-week history of swelling in both of his ankles. He mentions that his shoes feel uncomfortably tight by the end of the day. One month ago, he was diagnosed with primary hypertension and was started on amlodipine monotherapy. He denies any difficulty breathing, waking up at night gasping for air, chest discomfort, or recent travel. Vital signs are within normal limits, with a blood pressure of 126/80 mm Hg. Physical examination reveals 2+ pitting edema over the bilateral medial malleoli. The overlying skin is intact, with no erythema, warmth, or tenderness. Jugular venous pressure is 6 cm H2O. Lungs are clear to auscultation bilaterally, and cardiac auscultation reveals a regular rate and rhythm with no extra heart sounds. Which of the following is the most appropriate next step in the management of this patient?

A 45-year-old man is brought to the emergency department by his wife due to a 24-hour history of high fever, severe headache, and progressively worsening confusion. On physical examination, his temperature is 39.2°C (102.6°F), blood pressure is 130/80 mm Hg, and heart rate is 110/min. He has marked nuchal rigidity. Neurologic examination reveals a lethargic patient who only opens his eyes to painful stimuli. He demonstrates mild left-sided hemiparesis. Arrange the following steps in the most appropriate chronological sequence for the initial management of this patient.

A 62-year-old man presents to the clinic with a three-week history of a nonproductive cough and progressively worsening shortness of breath. He reports that his breathing becomes particularly difficult when he lies down to sleep at night, forcing him to prop himself up with three pillows. His medical history includes hypertension, osteoarthritis of the knees, and a 25-pack-year smoking history. Three weeks ago, he was evaluated for worsening knee pain and elevated blood pressure, at which time naproxen and amlodipine were added to his daily regimen. Temperature is 37.0°C (98.6°F), blood pressure is 152/92 mm Hg, pulse is 92/min, and respirations are 20/min. BMI is 31 kg/m². Lung auscultation reveals diffuse expiratory wheezing with no crackles. Cardiac examination shows a regular rhythm with normal S1 and S2; a faint, low-frequency sound is heard just after S2 at the cardiac apex. Trace bilateral pitting edema is present at the ankles. Which of the following is the most likely pathophysiologic mechanism underlying this patient's current respiratory symptoms?

Match the following pathophysiological states or clinical conditions with their most characteristic electrocardiogram (ECG) finding.

A 69-year-old woman is brought to the emergency department due to severe shortness of breath that awakened her from sleep 2 hours ago. She has a history of hypertension, type 2 diabetes mellitus, and a 40-pack-year smoking history. Her current medications include amlodipine and metformin. Her temperature is 36.8°C (98.2°F), blood pressure is 172/98 mm Hg, pulse is 115/min, and respirations are 26/min. Pulse oximetry is 89% on room air. Physical examination reveals elevated jugular venous pressure. Lung auscultation demonstrates bilateral basilar crackles and diffuse expiratory wheezing. Cardiac auscultation reveals a regular tachycardia with a prominent S3 gallop. There is 1+ bilateral lower extremity pitting edema. Which of the following diagnostic findings is most likely to be present in this patient?

A $64$-year-old man is brought to the emergency department by 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. His blood pressure is $210/115\text{ mmHg}$ in the right arm and $170/95\text{ mmHg}$ in the left arm. His heart rate is $115\text{/min}$. A portable chest radiograph reveals a widened mediastinum. An acute aortic dissection is highly suspected. Arrange the following next steps in the most appropriate chronological sequence for the initial management of this patient.

Match each of the following specific cardiomyopathies with its most characteristic echocardiographic finding.

A 71-year-old retired teacher with a 45-pack-year smoking history is brought to the emergency department at 2:00 AM by his spouse due to sudden, severe respiratory distress. The patient states he was awakened from sleep by a feeling of suffocation. His medical history includes essential hypertension and moderate chronic obstructive pulmonary disease, for which he uses a daily long-acting muscarinic antagonist. Vital signs show a temperature of 36.8°C (98.2°F), blood pressure of 182/105 mm Hg, heart rate of 115/min, and respiratory rate of 28/min. Pulse oximetry is 87% on room air. Physical examination reveals a patient in obvious distress, using accessory muscles of respiration. The jugular venous pressure is estimated at 11 cm H2O, and sustained manual compression of the mid-abdomen results in a persistent 4 cm elevation of the jugular venous column. Pulmonary auscultation reveals widespread, high-pitched expiratory wheezes without any audible crackles. Cardiac examination is notable for a regular tachycardia and a low-frequency sound occurring shortly after the second heart sound, best heard over the fifth intercostal space at the midclavicular line. A portable chest radiograph displays hyperlucent lung fields with flattened diaphragms, accompanied by vascular redistribution to the upper lung zones and distinct bronchial wall thickening. Based on the clinical presentation, which of the following sets of hemodynamic findings is most likely present in this patient?

A $64$-year-old male construction worker presents to the emergency department for escalating breathlessness and a productive cough over the past three days. He notes that his baseline morning cough has worsened, and he is now producing thick, yellow-green sputum. His past medical history is significant for severe chronic obstructive pulmonary disease (COPD) and essential hypertension. He is currently compliant with a daily tiotropium inhaler. Vital signs demonstrate a temperature of $37.5^\circ\text{C}$ ($99.5^\circ\text{F}$), blood pressure of $132/84$ mmHg, heart rate of $94$/min, and respiratory rate of $24$/min. Pulse oximetry shows an oxygen saturation of $91\%$ on room air. Chest auscultation reveals prominent bilateral expiratory wheezing with a prolonged expiratory phase. There are no crackles. The jugular venous pressure is normal, and there is no lower extremity edema. Which of the following is the most appropriate pharmacological management for this patient?

A 32-year-old man with a history of intravenous drug use is admitted to the intensive care unit with a 4-day history of high fever, chills, and pleuritic chest pain. On physical examination, his temperature is 39.2°C (102.6°F), blood pressure is 110/65 mmHg, pulse is 112/min, and respirations are 22/min. Cardiovascular examination reveals a 3/6 holosystolic murmur best heard at the left lower sternal border that increases in intensity with inspiration. The lungs are clear to auscultation bilaterally. Empiric therapy with intravenous vancomycin and cefepime is initiated after blood cultures are drawn.

On hospital day 3, the patient develops acute respiratory distress. His oxygen saturation drops to 86% on room air. A chest radiograph reveals multiple bilateral nodular opacities with central cavitation. Echocardiography shows a 1.5-cm, highly mobile vegetation on the tricuspid valve with moderate tricuspid regurgitation. The left ventricular ejection fraction is 60%. All four blood culture bottles return positive for methicillin-susceptible Staphylococcus aureus (MSSA).

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

An urgent care clinic evaluates a $74$-year-old male who reports four days of worsening shortness of breath and a persistent dry cough. He notes that lying flat in bed induces a feeling of suffocation, forcing him to sleep in a recliner for the past two nights. His medical history is notable for a myocardial infarction three years ago, essential hypertension, hyperlipidemia, and a $45$-pack-year smoking history. Current medications include aspirin, lisinopril, and atorvastatin. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $158/92\text{ mm Hg}$, pulse of $112\text{/min}$, and respiratory rate of $24\text{/min}$. Pulse oximetry is $89\%$ on room air. The patient appears anxious and is using accessory muscles of respiration. Examination of the neck shows distention of the jugular veins when seated at a $45^\circ$ angle. Pulmonary auscultation reveals diffuse expiratory wheezing and bibasilar crackles. Cardiac auscultation reveals a regular tachycardia with a low-pitched extra heart sound heard shortly after $\text{S}_2$. There is $1+$ pitting edema of the lower extremities bilaterally. Which of the following is the most appropriate initial pharmacological intervention for this patient?

Match each clinical presentation of a myocardial infarction complication with its most characteristic hemodynamic finding on right heart catheterization.