Internal Medicine

A 71-year-old man comes to the clinic reporting progressive dyspnea on exertion, fatigue, and bilateral leg swelling for the past 4 months. He has a 45-pack-year smoking history and was previously told he has "smoker's lung." His medical history is significant for hypertension and a gunshot wound to the right thigh 30 years ago. His blood pressure is $162/52$ mm Hg, and his pulse is $104$/min. Physical examination shows an elevated jugular venous pressure of $10$ cm $H_2O$. The carotid upstrokes are brisk, and the apical impulse is hyperdynamic and laterally displaced. Auscultation reveals a $2/6$ systolic flow murmur at the left upper sternal border. Lung fields have faint bibasilar crackles. Examination of the right thigh reveals a well-healed scar with a palpable thrill and a continuous murmur auscultated over the area. Which of the following hemodynamic profiles is most likely present in this patient?

A 62-year-old man is evaluated in the intensive care unit on day 2 of admission. He was admitted for septic shock secondary to a perforated gastric ulcer and underwent an emergent exploratory laparotomy. Postoperatively, he developed severe hypoxemia and bilateral pulmonary infiltrates consistent with acute respiratory distress syndrome (ARDS). He remains intubated and mechanically ventilated.

Current ventilator settings are as follows:

Current vital signs include a temperature of 38.2°C (100.8°F), heart rate of 118/min, and blood pressure of 92/58 mm Hg while receiving a norepinephrine infusion. Pulse oximetry shows an oxygen saturation of 91%.

Arterial blood gas and serum chemistry results are as follows:

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

While rounding in the surgical recovery unit, a physician is urgently called to the bedside of a $58$-year-old male who just experienced a sudden cardiovascular collapse. The patient underwent an extensive small bowel resection for acute mesenteric ischemia $5$ days prior. The nurse reports that the patient acutely developed severe breathlessness and profound diaphoresis while being repositioned in bed.

Vital signs are temperature $38.0^{\circ}\text{C}$ ($100.4^{\circ}\text{F}$), blood pressure $76/40$ mm Hg, heart rate $136$/min, and respirations $34$/min. Pulse oximetry displays $82\%$ on room air.

On physical examination, the patient is obtunded with cool, mottled extremities. There is marked jugular venous distension. Lung auscultation is clear bilaterally. Cardiac auscultation reveals a prominent parasternal heave, a loud P2, and a right-sided S3 gallop. The abdominal incision is intact with mild surrounding erythema but no fluctuance or purulent drainage.

Arterial blood gas reveals:
pH: $7.21$
PaCO $_2$: $29$ mm Hg
PaO $_2$: $52$ mm Hg
HCO $_3^-$: $11$ mEq/L

A portable bedside echocardiogram is immediately performed, demonstrating a severely enlarged right ventricle with free-wall hypokinesis and apical sparing, along with leftward bowing of the interventricular septum. Left ventricular systolic function is preserved.

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

A 65-year-old retired factory worker presents to an urgent care center complaining of severe shortness of breath and a persistent cough that has progressively worsened over the past 3 days. He has a 35-pack-year smoking history and was diagnosed with essential hypertension a decade ago. The patient reports that he has been sleeping in a recliner because lying flat in bed causes a sudden choking sensation. His temperature is 37.1°C (98.8°F), blood pressure is 172/96 mm Hg, heart rate is 112/min, and respiratory rate is 26/min. Oxygen saturation is 88% on ambient air. Physical examination reveals markedly distended jugular veins when the patient is seated upright. Lung auscultation demonstrates diffuse expiratory wheezes and fine crackles at both lung bases. Cardiac auscultation reveals a regular, rapid rhythm with a distinct low-frequency sound occurring just after S2. Which of the following is the most appropriate initial pharmacologic therapy for this patient's acute symptoms?

A 52-year-old man is evaluated in the intensive care unit for worsening hypoxemia. He was admitted 48 hours ago with severe right lower lobe pneumonia and was intubated yesterday due to progressive respiratory failure. He is currently receiving continuous intravenous norepinephrine. His temperature is 38.2°C (100.8°F), blood pressure is 94/58 mm Hg, pulse is 112/min, and respirations are 28/min. A bedside echocardiogram shows normal left ventricular systolic function with an estimated ejection fraction of 60%. A portable chest radiograph reveals new diffuse bilateral alveolar opacities. He is deeply sedated and receiving volume-cycled assist-control ventilation.

Current ventilator settings and arterial blood gas (ABG) results are as follows:

The measured plateau pressure is 35 cm $H_2O$. The patient's predicted body weight is calculated to be 65 kg (143 lb).

ABG on current settings:
pH: 7.26
$PaCO_2$: 58 mm Hg
$PaO_2$: 55 mm Hg
$HCO_3^-$: 25 mEq/L

Which of the following are the most appropriate next steps in the management of this patient's respiratory status? (Select all that apply)

A 68-year-old man is hospitalized for community-acquired pneumonia and treated with intravenous ceftriaxone and azithromycin. On day 5 of his admission, he develops new-onset frequent, watery diarrhea, mild diffuse abdominal pain, and a temperature of 38.2°C (100.8°F). His vital signs are otherwise stable, and physical examination reveals mild lower abdominal tenderness without rebound or guarding. The medical team suspects an infectious complication related to his recent pharmacotherapy. Arrange the following management steps in the most appropriate chronological sequence for addressing this new complication.

During the cardiovascular physical examination, distinct abnormalities in the arterial pulse contour and amplitude can provide critical clues to the underlying structural or hemodynamic pathology. Match each abnormal arterial pulse description to the cardiac condition it most classically represents.

An inpatient medical team is evaluating a 62-year-old man with a known history of decompensated alcohol-associated cirrhosis who developed worsening confusion and lethargy over the past 24 hours. He has a past medical history of chronic obstructive pulmonary disease. His wife, who is his legally appointed healthcare proxy, is at the bedside; his estranged son is also present and frequently interrupts the care team to demand interventions. Vital signs are within normal limits. Physical examination reveals scleral icterus, a moderately distended abdomen with shifting dullness, and a coarse, flapping tremor of the hands when the wrists are extended. Laboratory evaluation demonstrates an elevated serum ammonia level, a normal thyroid-stimulating hormone level with a slightly decreased free T4, and a urinalysis showing $>10^5$ colony-forming units/mL of Escherichia coli without leukocyte esterase or nitrites. The patient denies dysuria or urinary frequency. An arterial blood gas reveals a normal partial pressure of carbon dioxide. The son demands that the team immediately insert a feeding tube to provide nutrition. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old woman presents to the emergency department with sudden-onset, severe, tearing chest pain radiating to her upper back. Her blood pressure is 195/110 mm Hg and heart rate is 112/min. A bedside chest radiograph shows a widened mediastinum. The physician suspects an acute aortic dissection. Arrange the following steps in the most appropriate sequential order for the evaluation and management of this patient.

A 62-year-old man is brought to the emergency department complaining of sudden-onset, severe, 'tearing' chest pain that radiates to between his shoulder blades. His blood pressure is 210/115 mm Hg in the right arm and 170/95 mm Hg in the left arm. His heart rate is 112/min. A chest x-ray reveals a widened mediastinum. The clinical suspicion for an acute aortic dissection is very high. Arrange the following steps in the most appropriate sequential order for the acute management of this patient.

A 54-year-old man is admitted to the intensive care unit with severe bilateral pneumonia and subsequently develops acute respiratory distress syndrome (ARDS). The clinical team decides to initiate invasive mechanical ventilation due to worsening hypoxemia and respiratory fatigue. Arrange the following steps in the standard sequential order for the management of severe ARDS, proceeding from the initial ventilator setup to advanced therapies.

Match each systemic disease or infectious etiology with its most characteristic cardiovascular manifestation or pathophysiologic consequence.

A $72$-year-old retired mechanic is evaluated on the medical ward on hospital day $5$. He originally presented with worsening shortness of breath, three-pillow orthopnea, and marked lower extremity swelling. Medical history is notable for ischemic cardiomyopathy with a left ventricular ejection fraction of $25\%$, hypertension, and a $40$-pack-year smoking history. Over the past four days, he has received intravenous bumetanide, resulting in a net negative fluid balance of $6$ liters and significant improvement in his respiratory symptoms. His oxygen saturation is now $96\%$ on room air. A chest radiograph obtained this morning shows a persistent, moderate, right-sided pleural effusion, which is slightly smaller than it was on admission. To evaluate the persistent fluid, a diagnostic thoracentesis is performed.

Simultaneous laboratory studies reveal the following:

The upper limit of normal for serum LDH is $250 \text{ U/L}$. Pleural fluid analysis also shows a leukocyte count of $210/\text{mm}^3$ ($85\%$ lymphocytes), a glucose level of $95 \text{ mg/dL}$, and a pH of $7.46$.

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

A $45$-year-old man is receiving mechanical ventilation in the intensive care unit for acute respiratory distress syndrome (ARDS). The ventilator alarm suddenly sounds for high peak airway pressures. The patient's blood pressure drops abruptly from $110/70$ mm Hg to $70/40$ mm Hg, and his oxygen saturation falls to $82\%$. Physical examination reveals absent breath sounds on the right side, hyperresonance to percussion, and the trachea is deviated to the left. Arrange the following interventions in the most appropriate chronological order to manage this acute life-threatening event.

An emergency medical team brings a 67-year-old male to the acute care unit due to sudden-onset respiratory distress that awakened him from sleep. The patient has a medical history significant for long-standing essential hypertension, diet-controlled type 2 diabetes mellitus, and a 40-pack-year history of cigarette smoking. On physical examination, his blood pressure is $165/92 \text{ mmHg}$, pulse is $112/\text{min}$, and respiratory rate is $26/\text{min}$ with an oxygen saturation of $88\%$ on room air. Jugular venous distention is prominent when sitting at a 45-degree angle. Cardiac auscultation reveals a regular tachycardia with a distinct $S_3$ gallop. Lung auscultation demonstrates bilateral basilar crackles along with scattered expiratory wheezes. Laboratory studies show:

Leukocyte count: $8,200/\text{mm}^3$
Arterial blood gas (room air):
$\text{pH}$: $7.34$
$p\text{CO}_2$: $48 \text{ mmHg}$
$\text{HCO}_3^-$: $25 \text{ mEq/L}$

Thyroid panel:
$\text{TSH}$: $1.2 \text{ } \mu\text{U/mL}$ (Normal: $0.4-4.0 \text{ } \mu\text{U/mL}$)
Free $T_4$: $0.7 \text{ ng/dL}$ (Normal: $0.9-1.7 \text{ ng/dL}$)

Which of the following is the most appropriate initial pharmacological therapy for this patient's respiratory distress?

An emergency medical services team brings a $28$-year-old male to the trauma bay following a high-speed motor vehicle collision. The patient was the unrestrained driver and struck his chest forcefully against the steering wheel. He is diaphoretic, agitated, and confused. Upon arrival, his temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure is $75/40\text{ mm Hg}$, pulse is $135/\text{min}$, and respiratory rate is $26/\text{min}$. Pulse oximetry indicates an oxygen saturation of $94\%$ on a non-rebreather mask. Physical examination reveals pronounced engorgement of the jugular veins and a noticeable contusion over the central sternum. Lung fields are clear to auscultation bilaterally. Cardiac auscultation reveals distant, muffled heart sounds. An arterial blood gas analysis demonstrates a pH of $7.28$, PaCO $_2$ of $32\text{ mm Hg}$, and HCO $_3^-$ of $15\text{ mEq/L}$, with an elevated serum lactate level. Which of the following is the most appropriate next step in the management of this patient?

Brought to the emergency department via ambulance, a 68-year-old individual presents with acute-onset, severe dyspnea and loud wheezing that rapidly worsened over the past 2 hours. The patient has a history of hypertension, a 50-pack-year smoking history, and a remote anterior myocardial infarction. On arrival, the patient is diaphoretic, unable to speak in full sentences, and actively using accessory respiratory muscles. Vital signs show a blood pressure of 192/110 mmHg, a heart rate of 124/min, a respiratory rate of 32/min, and an oxygen saturation of 82% on room air. Physical examination is notable for a prolonged expiratory phase and diffuse bilateral polyphonic wheezes; no crackles are auscultated. Jugular venous pressure is evaluated at 15 cm H2O. Cardiac auscultation reveals a regular tachycardia and a prominent S3 gallop. A portable chest radiograph demonstrates hyperinflated lung fields, a widened vascular pedicle, and peribronchial cuffing, without lobar consolidation. Bedside lung ultrasound reveals diffuse bilateral B-lines. Which of the following is the most appropriate initial pharmacological therapy for this patient?

A 72-year-old woman is brought to the emergency department by her daughter due to severe, worsening shortness of breath and a persistent cough for the past 48 hours. The patient reports that her breathing is significantly worse when she attempts to lie flat in bed, forcing her to sleep in a recliner last night. Her medical history includes type 2 diabetes mellitus, essential hypertension, severe obesity (BMI $43\text{ kg/m}^2$), and a 35-pack-year history of cigarette smoking. Home medications include metformin, lisinopril, and an as-needed albuterol inhaler.

Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $182/104\text{ mm Hg}$, heart rate of $115/\text{min}$, and respiratory rate of $28/\text{min}$. Pulse oximetry on ambient air is 88%.

On physical examination, the patient is speaking in short phrases and using accessory muscles of respiration. Jugular venous distention cannot be accurately assessed due to her body habitus. Pulmonary auscultation reveals a prolonged expiratory phase with diffuse, high-pitched polyphonic wheezing bilaterally, along with dullness to percussion at the lung bases. Cardiac auscultation reveals a rapid, regular rhythm; an extra low-frequency sound is heard just after S2 at the cardiac apex. The lower extremities show 2+ bilateral pitting edema.

Laboratory evaluation reveals the following:

Arterial blood gas analysis on ambient air:

Chest radiography reveals prominent upper lobe pulmonary vasculature and indistinct vascular margins, but no lobar consolidation or pneumothorax is seen.

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

Match each specific clinical condition with its most characteristic classic electrocardiogram (ECG) finding.

An outpatient pulmonary clinic evaluates a 69-year-old man for progressively worsening fatigue and bilateral ankle swelling over the last two months. He has a known diagnosis of chronic obstructive pulmonary disease (COPD). The patient reports no recent increase in cough or changes in sputum character. His current daily medications are inhaled tiotropium and formoterol.

Vital signs are:
Blood pressure: 130/82 mmHg
Heart rate: 88/min
Respiratory rate: 18/min
Oxygen saturation: 87% on room air

Physical examination reveals distension of the jugular veins to 8 cm above the sternal angle and 2+ pitting edema in the lower extremities bilaterally. Cardiac auscultation identifies a loud pulmonic component of the second heart sound ($P_2$) with no murmurs. Pulmonary auscultation reveals globally diminished breath sounds without adventitious sounds.

Laboratory and diagnostic data on room air:

Which of the following interventions is most likely to improve this patient's long-term survival?