Internal Medicine

A 61-year-old woman presents to the emergency department after a minor motor vehicle collision. She reports mild right-sided chest wall pain. She has a 35-pack-year smoking history. Vital signs are temperature 37.0°C (98.6°F), blood pressure 130/82 mm Hg, pulse 88/min, and respiratory rate 16/min. Physical examination reveals focal tenderness over the right anterior ribs but normal breath sounds bilaterally. A chest radiograph shows no rib fractures but incidentally reveals a $15\text{ mm}$ well-circumscribed, non-calcified nodule in the periphery of the left upper lobe. She is discharged home with adequate pain control and follows up in the pulmonary clinic the next week. Arrange the following subsequent steps in the most appropriate chronological sequence for the evaluation and management of this patient's pulmonary nodule.

A 54-year-old man is evaluated in the intensive care unit 48 hours after being admitted for severe community-acquired pneumonia and septic shock. Initial sputum and blood cultures grew *Streptococcus pneumoniae* that is susceptible to ceftriaxone, and he has been receiving this targeted intravenous therapy since admission. Over the last 6 hours, his oxygen requirements have dramatically increased, culminating in endotracheal intubation and mechanical ventilation.

His temperature is 38.2°C (100.8°F), blood pressure is 105/65 mmHg (on a low-dose norepinephrine infusion), and heart rate is 118/min. The ventilator is set to a respiratory rate of 24/min. Pulse oximetry shows an oxygen saturation of 88% on a fraction of inspired oxygen ($FiO_2$) of 0.80 and a positive end-expiratory pressure (PEEP) of 10 cm $H_2O$.

Physical examination reveals diffuse bilateral crackles. Jugular venous pressure is estimated at 6 cm $H_2O$. Heart sounds are normal with no murmurs or gallops. A new portable chest radiograph demonstrates diffuse, dense bilateral alveolar opacities. A bedside echocardiogram shows a normal left ventricular ejection fraction (60%) with no regional wall motion abnormalities or significant valvular disease.

Arterial blood gas analysis on the current ventilator settings reveals:
pH: 7.22
$pCO_2$: 42 mmHg
$pO_2$: 55 mmHg
$HCO_3^-$: 16 mEq/L

Serum lactate is 4.5 mmol/L.

Based on the clinical presentation and laboratory data, which of the following statements regarding the most appropriate management of this patient are correct? (Select all that apply)

A 29-year-old woman at 28 weeks gestation presents to the emergency department with acute-onset right-sided pleuritic chest pain and shortness of breath. Her heart rate is 110/min, respiratory rate is 24/min, blood pressure is 112/68 mm Hg, and oxygen saturation is 96% on room air. Physical examination reveals normal heart sounds, clear lungs bilaterally, and no lower extremity edema. A portable chest radiograph is unremarkable. The clinical suspicion for pulmonary embolism is high. Arrange the following diagnostic modalities in the most appropriate sequential order for evaluating this patient, from the FIRST indicated step to the LAST resort if preceding tests are non-diagnostic.

A $73$-year-old woman is brought to the emergency department at 3:00 AM due to the sudden onset of severe shortness of breath. She reports waking up from sleep feeling as though she were suffocating. Her medical history is significant for hypertension, coronary artery disease, and a $40$-pack-year smoking history for which she takes a daily fluticasone-salmeterol inhaler. She has not had any recent fever, chills, or changes in sputum production.

On arrival, the patient is diaphoretic, anxious, and speaking in short, two-word phrases. She is sitting upright on the edge of the stretcher.

Vital signs are:
- Temperature: $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$)
- Blood pressure: $175/100\text{ mmHg}$
- Pulse: $118/\text{min}$ and regular
- Respirations: $28/\text{min}$
- SpO $_2$: $84\%$ on room air

Physical examination reveals jugular venous distention up to $9\text{ cm H}_2\text{O}$. Cardiac auscultation reveals a regular tachycardia with a prominent S3 gallop, and the point of maximal impulse is displaced lateral to the midclavicular line. Pulmonary auscultation demonstrates diffuse, bilateral expiratory wheezing and fine inspiratory crackles at the lung bases. There is bilateral trace pitting edema of the lower extremities.

Arterial blood gas analysis on room air reveals:
- $\text{pH}$: $7.26$
- $\text{PaCO}_2$: $58\text{ mmHg}$
- $\text{PaO}_2$: $52\text{ mmHg}$
- $\text{HCO}_3^-$: $25\text{ mEq/L}$

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

A 62-year-old man presents to the emergency department complaining of severe, sudden-onset tearing chest pain that radiates to his back. His blood pressure is 196/112 mm Hg in the right arm and 188/108 mm Hg in the left arm. His heart rate is 114/min. On physical examination, a decrescendo diastolic murmur is heard at the right upper sternal border. An electrocardiogram shows sinus tachycardia with no ischemic changes. A chest radiograph reveals a widened mediastinum. Arrange the following management steps in the most appropriate sequential order for this patient, from initial stabilization to definitive treatment.

A $68$-year-old man is evaluated in the intensive care unit due to difficulty weaning from mechanical ventilation. He was intubated $5$ days ago for acute hypercapnic respiratory failure secondary to a severe chronic obstructive pulmonary disease exacerbation. Initial treatment included bronchodilators, systemic glucocorticoids, empiric antibiotics, and aggressive diuresis with intravenous furosemide due to concurrent right ventricular failure and severe peripheral edema.

Over the last $24$ hours, his clinical status has improved. His chest radiograph shows clear lung fields, and he has minimal endotracheal secretions. A spontaneous breathing trial was attempted but was aborted after $15$ minutes due to rapid shallow breathing and a respiratory rate of $32$/min. Current vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate $88$/min, and blood pressure $132/82\text{ mm Hg}$.

Laboratory studies show:

Arterial blood gas on pressure support ventilation (FiO $_2$ $30\%$, PEEP $5\text{ cm H}_2\text{O}$, pressure support $8\text{ cm H}_2\text{O}$) reveals:

Which of the following is the most appropriate next step in management to facilitate ventilator weaning in this patient?

A 38-year-old man presents to the emergency department with a 2-day history of progressively worsening shortness of breath, chest tightness, and a nonproductive cough. He has a history of severe persistent asthma but has not used his maintenance inhalers for the past three weeks.

Vital signs are temperature 37.1°C (98.8°F), heart rate 132/min, respiratory rate 34/min, and blood pressure 135/85 mmHg. Oxygen saturation is 87% on room air.

On physical examination, the patient is visibly fatigued, diaphoretic, and sitting in a tripod position. There is prominent use of the sternocleidomastoid and intercostal muscles. Pulmonary auscultation reveals markedly diminished breath sounds bilaterally with only faint expiratory wheezing.

Arterial blood gas analysis on room air shows:
- pH: 7.34
- $PaCO_2$: 46 mmHg
- $PaO_2$: 56 mmHg
- $HCO_3^-$: 24 mEq/L

Chest radiograph demonstrates hyperinflated lung fields with flattened diaphragms but no focal consolidations or pleural effusions.

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

Emergency medical services bring a 49-year-old male with decompensated cirrhosis to the trauma bay following an episode of voluminous hematemesis at home. He appears lethargic and pale. Initial vital signs reveal a heart rate of 128/min and a blood pressure of 82/48 mmHg. Arrange the following interventions in the most appropriate sequential order for managing this patient's condition.

An ambulance transports a 70-year-old man to the emergency department for severe dyspnea and a persistent cough that have progressively worsened over the last 72 hours. He notes waking up multiple times at night feeling as though he is suffocating, and he has developed new-onset swelling in his lower legs. His past medical history includes a 45-pack-year smoking habit and chronic obstructive pulmonary disease (COPD), which is managed with a daily tiotropium inhaler. He also has poorly controlled hypertension and has not seen a physician in over five years. He denies having a fever, and his cough yields only a small amount of clear, frothy sputum.

Upon arrival, his temperature is $37.2^\circ\text{C}$, blood pressure is $172/98\text{ mm Hg}$, heart rate is $112\text{/min}$, and respiratory rate is $26\text{/min}$. Pulse oximetry on room air indicates an oxygen saturation of $88\%$.

Physical examination shows a patient in moderate respiratory distress using accessory muscles of respiration. The jugular venous pulse is distended and visible $10\text{ cm}$ above the sternal angle. Auscultation of the lungs reveals a prolonged expiratory phase with widespread, diffuse expiratory wheezing; no crackles are heard. Cardiac auscultation demonstrates tachycardia with a regular rhythm. A distinct, low-frequency extra heart sound is heard in diastole just after the second heart sound, localized to the fifth intercostal space at the midclavicular line. Pitting edema (2+) is present bilaterally extending to the mid-calves.

Arterial blood gas analysis obtained on room air demonstrates:
- pH: $7.30$
- PaCO $_2$: $54\text{ mm Hg}$
- PaO $_2$: $55\text{ mm Hg}$

A chest radiograph displays hyperinflation of the lungs, enlarged central pulmonary arteries, and prominent peribronchial cuffing without focal infiltrates or pleural effusions.

Which of the following is the most appropriate initial pharmacologic intervention for this patient's acute presentation?

A $42$-year-old woman is evaluated in the intensive care unit for worsening hypoxemia. She was admitted $2$ days ago for severe acute pancreatitis. Over the last $12$ hours, she developed progressive respiratory distress requiring endotracheal intubation and mechanical ventilation. Her temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $110/70$ mm Hg, and pulse is $115$/min. Pulse oximetry shows an oxygen saturation of $89\%$. The patient is sedated and paralyzed.

Current mechanical ventilator settings and arterial blood gas analysis are as follows:

Peak airway pressure is $45$ cm $\text{H}_2\text{O}$, and plateau airway pressure is $36$ cm $\text{H}_2\text{O}$. A portable chest radiograph reveals bilateral diffuse alveolar opacities without pleural effusions or cardiomegaly. Echocardiography shows a normal left ventricular ejection fraction.

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

A $42$-year-old man is admitted to the intensive care unit with severe acute pancreatitis. On his third day of hospitalization, he develops rapidly progressive dyspnea and hypoxemia. His temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $115/75\text{ mmHg}$, pulse is $112/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows an oxygen saturation of $85\%$ despite receiving oxygen via a non-rebreather mask. Physical examination reveals diffuse bilateral crackles without wheezing, jugular venous distention, or lower extremity edema. A portable chest radiograph displays bilateral alveolar opacities. An echocardiogram shows a normal left ventricular ejection fraction and no valvular abnormalities. The patient is subsequently endotracheally intubated for acute respiratory distress syndrome (ARDS). Which of the following is the most appropriate next step in the management of this patient's respiratory failure?

Match each classic arterial pulse abnormality with the underlying cardiovascular condition it most strongly suggests.

A $68$-year-old man with severe chronic obstructive pulmonary disease is admitted to the intensive care unit for an acute exacerbation requiring invasive mechanical ventilation. On the second day of admission, the ventilator alarm suddenly indicates high peak airway pressures. The patient becomes acutely unstable with a heart rate of $145$/min, blood pressure of $70/38$ mm Hg, and oxygen saturation dropping to $81\%$. Physical examination reveals tracheal deviation to the left, distended neck veins, and absent breath sounds over the right hemithorax. Arrange the following interventions in the most appropriate chronological order for managing this patient's acute decompensation.

During bedside rounds in the cardiovascular intensive care unit, an attending physician asks the clinical team to evaluate the central venous pressure waveforms and jugular venous pulsations of several patients. Match each detailed clinical description of a jugular venous pulse abnormality with the underlying structural, valvular, or electrical pathology that best explains its pathophysiology.

A 58-year-old man with a history of treated pulmonary tuberculosis presents to the emergency department after expectorating approximately 600 mL of bright red blood over the past two hours. He is in severe respiratory distress, tachypneic, and diaphoretic. His oxygen saturation is 84% on room air. A portable chest radiograph reveals a large cavitary lesion in the right upper lobe with surrounding new alveolar opacities, consistent with the source of bleeding. Arrange the following management steps for this patient's massive hemoptysis in the most appropriate sequential order, from the initial life-saving intervention to the definitive therapy of last resort.

A 62-year-old man with a 40-pack-year smoking history and type 2 diabetes mellitus presents with reproducible, severe cramping pain in his right calf after walking two blocks. The pain reliably resolves with 5 minutes of rest. He has no rest pain, ulceration, or gangrene. Examination reveals diminished pedal pulses on the right. His ankle-brachial index (ABI) is 0.65 in the right leg and 1.05 in the left leg. Assuming his symptoms remain persistently lifestyle-limiting despite strict patient compliance with each preceding intervention, arrange the following management steps in the correct guideline-directed sequential order.

A 75-year-old man is admitted to the progressive care unit with worsening shortness of breath, increased sputum purulence, and subjective fever over the past $3$ days. His medical history includes severe chronic obstructive pulmonary disease (FEV $_1$ $35\%$ of predicted) and ischemic cardiomyopathy (left ventricular ejection fraction $30\%$).

Vital signs are temperature $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure $135/85$ mm Hg, pulse $112$/min, and respirations $26$/min. Pulse oximetry shows $86\%$ on room air. Physical examination reveals a barrel-shaped chest, prolonged expiratory phase with diffuse wheezing, and coarse rhonchi at the right lung base. Jugular venous pressure is $7$ cm H $_2$ O. There is no lower extremity edema. A chest radiograph demonstrates hyperinflated lungs, flattened diaphragms, and a new patchy right lower lobe infiltrate.

Arterial blood gas analysis on room air reveals:

Sputum Gram stain reveals numerous polymorphonuclear leukocytes and Gram-negative diplococci. The patient is started on noninvasive positive pressure ventilation and intravenous methylprednisolone.

Which of the following additional therapies are indicated for this patient? (Select all that apply)

A 27-year-old woman visits her primary care clinic reporting six months of frequent, bulky, and foul-smelling bowel movements associated with abdominal bloating and profound fatigue. Over this timeframe, she has experienced an unintentional weight loss of 3.5 kg (7.7 lb). Her medical history is significant for type 1 diabetes mellitus. Vital signs are stable. Physical examination reveals conjunctival pallor but no abdominal tenderness. Laboratory results show a hemoglobin of 10.2 g/dL and a mean corpuscular volume of 74 fL. Suspecting a specific autoimmune enteropathy, the physician decides to initiate a diagnostic workup. Which of the following is the most appropriate initial step in the evaluation of this patient?

During morning rounds in the step-down unit, the medical team evaluates a patient who was admitted three days prior for severe, refractory peripheral edema, abdominal fullness, and exertional dyspnea. The patient, a $55$-year-old individual, has not responded to high-dose intravenous torsemide. Medical history is notable for classical Hodgkin lymphoma in her twenties, which was treated with multi-agent chemotherapy and mantle field radiation, as well as moderate chronic obstructive pulmonary disease.

Vital signs show a blood pressure of $112/74\text{ mm Hg}$, pulse of $92/\text{min}$, and respiratory rate of $18/\text{min}$. Oxygen saturation is $96\%$ on room air. Physical examination demonstrates marked jugular venous distention that paradoxically rises when the patient takes a deep breath. A sharp, high-frequency sound is heard along the left sternal border occurring approximately $0.10\text{ seconds}$ after the second heart sound. The liver edge is palpable $4\text{ cm}$ below the right costal margin. Lungs are clear to auscultation without wheezing.

The team decides to perform simultaneous right and left heart catheterization to clarify the hemodynamic profile. Which of the following findings is most expected in this patient?

Paramedics rush a 55-year-old male to the resuscitation bay following the acute onset of crushing substernal chest discomfort that began while he was doing yard work. En route, emergency medical personnel administered chewable aspirin and one dose of sublingual nitroglycerin. Upon arrival, the patient appears ashen and confused. Vital signs reveal a blood pressure of 78/48 mmHg, heart rate of 112/min, and respiratory rate of 18/min. Physical examination demonstrates pronounced jugular venous distention. Pulmonary auscultation reveals clear breath sounds bilaterally without crackles or wheezes. Cardiac auscultation shows a regular, rapid rhythm with no murmurs, rubs, or gallops. A 12-lead electrocardiogram demonstrates 3-mm ST-segment elevations in leads II, III, and aVF. Which of the following is the most appropriate next step in the management of this patient's current hemodynamic state?