Internal Medicine

A 59-year-old male is evaluated in the emergency department for a sudden onset of severe, tearing chest pain that radiates to his interscapular region. The symptoms began 30 minutes prior to arrival. His past medical history includes essential hypertension and tobacco use. On evaluation, he appears extremely uncomfortable and diaphoretic. His blood pressure is 220/115 mm Hg in the right upper extremity and 175/90 mm Hg in the left upper extremity. His heart rate is 114/min. Auscultation reveals a high-pitched, early diastolic decrescendo murmur heard best at the right second intercostal space. An electrocardiogram shows sinus tachycardia and voltage criteria for left ventricular hypertrophy. A portable chest radiograph displays a widened mediastinum. Arrange the following next steps in the optimal chronological sequence for managing this patient's condition.

Match each of the following distinct electrocardiographic (ECG) findings with its most likely underlying pathophysiologic or structural etiology.

A $71$-year-old man is admitted to the progressive care unit due to a three-day history of progressively worsening breathlessness, a cough productive of yellowish sputum, and a sensation of a "racing heart." He has a history of essential hypertension and has smoked a pack of cigarettes daily for the past $45$ years. His current medications include amlodipine and a daily multivitamin. On arrival, his temperature is $37.3^\circ\text{C}$ ($99.1^\circ\text{F}$), blood pressure is $132/84\text{ mmHg}$, heart rate is $128\text{/min}$ and irregularly irregular, and respiratory rate is $26\text{/min}$. Pulse oximetry shows an oxygen saturation of $89\%$ on ambient air. Physical examination reveals an increased anteroposterior chest diameter and diffuse, high-pitched expiratory wheezing across all lung fields. There is no jugular venous distension, and his lower extremities show no edema. Thyroid function tests drawn on admission reveal a thyroid-stimulating hormone (TSH) of $0.2\ \mu\text{U/mL}$ (normal: $0.4-4.0\ \mu\text{U/mL}$) and a free T4 of $0.8\text{ ng/dL}$ (normal: $0.9-1.7\text{ ng/dL}$). A 12-lead electrocardiogram demonstrates an irregularly irregular rhythm with narrow QRS complexes and three distinct P-wave morphologies preceding the QRS complexes in lead II. Which of the following is the most appropriate next step in the management of this patient's cardiac finding?

A 68-year-old man presents to the clinic for evaluation of progressive shortness of breath, fatigue, and right-sided abdominal discomfort that has worsened over the past three weeks. One month ago, he underwent uncomplicated placement of a dual-chamber transvenous pacemaker for symptomatic third-degree atrioventricular block. His medical history includes severe chronic obstructive pulmonary disease, for which he uses a daily inhaled long-acting muscarinic antagonist and an inhaled corticosteroid-long-acting beta-agonist combination.

Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $115/70\text{ mm Hg}$, and a paced pulse of $72\text{/min}$. Oxygen saturation is $94\%$ on room air.

Physical examination reveals distended neck veins while sitting at a $45^\circ$ angle, with a jugular venous pressure of $15\text{ cm H}_2\text{O}$ and a prominent, rapid positive wave occurring during ventricular systole. Pulmonary auscultation demonstrates a prolonged expiratory phase with scattered bilateral wheezes. Cardiac examination reveals a regular rate and a grade $3/6$ blowing holosystolic murmur at the left lower sternal border that becomes louder during inspiration. The liver is enlarged and exhibits a palpable systolic pulsation. There is $2+$ pitting edema in both lower extremities up to the knees. Laboratory studies show a normal leukocyte count and a serum creatinine of $1.1\text{ mg/dL}$.

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

Pair each frequently prescribed cardiovascular medication with its most characteristic adverse effect profile.

A 65-year-old male with a history of treated pulmonary tuberculosis is brought to the emergency department after coughing up copious amounts of bright red blood. The patient estimates he has expectorated approximately 600 mL of blood over the past 8 hours. On arrival, he is in severe respiratory distress and continues to actively cough up fresh blood. Blood pressure is 98/60 mmHg, heart rate is 120/min, and oxygen saturation is 86% on room air. A bedside chest radiograph reveals a large cavitary lesion in the right upper lobe with new adjacent opacities. Arrange the following interventions in the most appropriate sequential order for the ongoing management of this patient's life-threatening condition.

A 25-year-old male is transported to the trauma bay via emergency medical services following a high-speed motorcycle crash. He is in acute respiratory distress and appears cyanotic. His blood pressure is 70/40 mm Hg, heart rate is 145/min, and respiratory rate is 38/min. Physical examination shows markedly decreased breath sounds over the left hemithorax, hyperresonance to percussion on the left, and distended neck veins. The trachea is deviated to the right. Arrange the following management steps in the most appropriate chronological sequence for this patient.

Match each cardiovascular pathology with its most characteristic hemodynamic and echocardiographic diagnostic profile.

Emergency medical services bring an $81$-year-old woman to the hospital after she awoke gasping for air. Her daughter reports that the patient has been sleeping in a recliner for the past week due to a persistent nighttime cough and an inability to lie flat. Past medical history includes long-standing hypertension, diet-controlled type 2 diabetes mellitus, and a $40$-pack-year smoking history, though she quit a decade ago. A recent outpatient laboratory report from two days ago shows a thyroid-stimulating hormone (TSH) level of $1.2\ \mu\text{U/mL}$ (normal: $0.4\text{-}4.0\ \mu\text{U/mL}$) and a free thyroxine (T4) level of $0.5\ \text{ng/dL}$ (normal: $0.9\text{-}1.7\ \text{ng/dL}$). Upon arrival, the patient is visibly anxious, using accessory muscles of respiration, and unable to speak in full sentences. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $182/105\ \text{mm Hg}$, pulse of $115\ \text{beats/min}$, and respirations of $28\ \text{breaths/min}$. Pulse oximetry reveals an oxygen saturation of $86\%$ on ambient air. Physical examination demonstrates distended jugular veins when sitting upright. Auscultation of the chest reveals diffuse bilateral crackles extending to the apices, accompanied by scattered expiratory wheezes. Cardiac auscultation reveals a regular tachycardia with a prominent extra heart sound occurring just after $S_2$. The lower extremities show $2+$ bilateral pitting edema to the knees. Arterial blood gas analysis on room air demonstrates a pH of $7.48$, a $p\text{CO}_2$ of $31\ \text{mm Hg}$, and a $p\text{O}_2$ of $54\ \text{mm Hg}$. Which of the following is the most appropriate initial step in the management of this patient?

A 68-year-old woman with a history of nonvalvular atrial fibrillation presents to the emergency department with sudden-onset, severe right leg pain that began 2 hours ago. She admits to missing several doses of her prescribed oral anticoagulant over the past week. On examination, the right leg is cold, pale, and exquisitely painful to palpation. The right femoral pulse is palpable, but the right popliteal and pedal pulses are absent by Doppler ultrasound. Motor function and light touch sensation in the right foot are fully intact. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A $45$-year-old man is evaluated in the intensive care unit for persistent hypoxemia. He was admitted $2$ days ago for severe acute pancreatitis and was intubated yesterday due to acute respiratory distress syndrome (ARDS). He is a former smoker. His ideal body weight is $70$ kg ($154$ lb). He is sedated and mechanically ventilated in volume-assist control mode.

Current ventilator settings are as follows:

Vital signs are temperature $38.4^\circ$ C ($101.1^\circ$ F), blood pressure $112/72$ mm Hg, and pulse $108$/min. Central venous pressure is $8$ mm Hg. Auscultation of the lungs reveals diffuse bilateral crackles. A chest radiograph demonstrates diffuse, bilateral alveolar opacities without cardiomegaly.

Laboratory studies show:

Arterial blood gas analysis on the current ventilator settings reveals:

Ventilator mechanics reveal a peak airway pressure of $36$ cm H₂O and a plateau airway pressure of $21$ cm H₂O.

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

A $68$-year-old man comes to the emergency department due to four days of progressively worsening dyspnea, frequent coughing, and increased production of thick, yellowish sputum. His medical history includes a $45$-pack-year smoking habit and a pituitary microadenoma discovered incidentally on a brain MRI last year. He does not experience orthopnea or lower extremity swelling. On arrival, his temperature is $37.3^\circ\text{C}$ ($99.1^\circ\text{F}$), blood pressure is $146/90 \text{ mm Hg}$, heart rate is $108/\text{min}$, and respiratory rate is $26/\text{min}$. Pulse oximetry shows an oxygen saturation of $88\%$ on room air. Chest examination reveals a barrel-shaped chest, hyperresonance to percussion, and a prolonged expiratory phase with diffuse bilateral wheezes. Neck veins are flat, and cardiac auscultation shows no gallops or murmurs. The extremities have no edema. Laboratory results are as follows:

Leukocyte count: $10,800/\text{mm}^3$
Thyroid-stimulating hormone (TSH): $1.4 \mu\text{U/mL}$ (normal: $0.4-4.0 \mu\text{U/mL}$)
Free T4: $0.6 \text{ ng/dL}$ (normal: $0.9-1.7 \text{ ng/dL}$)

Arterial blood gas on room air:
pH: $7.27$
PaCO $_2$: $66 \text{ mm Hg}$
PaO $_2$: $52 \text{ mm Hg}$
HCO $_3^-$: $30 \text{ mEq/L}$

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

A $62$-year-old man comes to the physician due to a rapidly enlarging mass on the left side of his neck. Over the past month, he has also experienced drenching night sweats, profound fatigue, and a $5$ kg ($11$ lb) weight loss. Vital signs are within normal limits. Physical examination shows a $5$ cm, firm, non-tender, and rubbery lymph node in the left anterior cervical chain. The remainder of the examination, including abdominal palpation, is unremarkable. Initial laboratory studies show an elevated serum lactate dehydrogenase (LDH) concentration.

Arrange the following diagnostic and management steps in the most appropriate chronological order for this patient.

Match each clinical presentation of hypokalemic metabolic alkalosis with its corresponding underlying pathophysiologic mechanism.

A 64-year-old woman presents to her primary care physician reporting five days of profuse, watery diarrhea. She experiences 6 to 8 loose bowel movements daily along with mild abdominal cramping. She denies fever, nausea, vomiting, or hematochezia. Medical history is significant for a sinus infection treated with a course of amoxicillin-clavulanate three weeks ago. Vital signs are within normal limits. Abdominal examination reveals mild, diffuse tenderness to deep palpation without guarding or rebound. Stool testing confirms the presence of Clostridioides difficile toxin. Which of the following is the most appropriate next step in management?

A 24-year-old woman presents to the clinic with a 3-month history of profound fatigue, symmetric arthralgias in her hands and wrists, and an erythematous rash over her cheeks that worsens after sun exposure. Physical examination reveals synovitis in the metacarpophalangeal joints bilaterally and a malar rash sparing the nasolabial folds. Arrange the following steps in the most appropriate chronological sequence for her diagnostic evaluation and longitudinal management.

Which specific glomerular disease diagnosis best corresponds to each of the following patient clinical scenarios?

A 56-year-old man is brought to the emergency department by his family due to worsening confusion and diffuse abdominal pain over the past $48$ hours. He has also experienced nausea and has not had a bowel movement for two days. His medical history is significant for decompensated cirrhosis secondary to chronic hepatitis C infection. He takes furosemide, spironolactone, and nadolol. His temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), pulse is $102/\text{min}$, blood pressure is $105/65\text{ mm Hg}$, and respirations are $18/\text{min}$. Physical examination shows scleral icterus and a distended abdomen with shifting dullness. There is diffuse, mild abdominal tenderness without rebound or guarding. Bowel sounds are hypoactive. Bilateral asterixis is present. Laboratory studies show:

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

A $65$-year-old man is hospitalized for symptomatic anemia and is receiving a transfusion of packed red blood cells. Thirty minutes into the transfusion, he develops acute-onset chills, severe flank pain, and shortness of breath. His temperature is 39.2°C (102.5°F), blood pressure is 85/50 mm Hg, and pulse is 120/min. The nurse notes that the urine in his Foley catheter bag has suddenly turned dark red. Arrange the following steps in the most appropriate chronological order for the acute management of this patient.

Match each characteristic clinical presentation with the most likely corresponding gastrointestinal or pancreatic neuroendocrine tumor.