Internal Medicine

During a cardiovascular clinical skills workshop, a group of medical students is reviewing the hemodynamic effects of various physical examination maneuvers on structural heart lesions. Match each described pathophysiological hemodynamic change (left) with the appropriate clinical scenario consisting of a bedside maneuver and its corresponding underlying cardiac pathology (right).

A $58$-year-old man is evaluated in the hospital on the third day of his admission for community-acquired pneumonia. His symptoms at presentation included fever, productive cough, and pleuritic chest pain. A chest radiograph on admission showed a left lower lobe consolidation. He was empirically started on intravenous ceftriaxone and azithromycin. Today, the patient reports significant improvement in his symptoms. He has been afebrile for the past $24$ hours. Current vital signs show a heart rate of $78$/min, blood pressure of $128/82$ mmHg, and respiratory rate of $16$/min. His oxygen saturation is $96\%$ on room air. Sputum culture obtained on admission has grown *Streptococcus pneumoniae*. Antimicrobial susceptibility testing demonstrates that the isolate is sensitive to penicillin, amoxicillin, ceftriaxone, and levofloxacin. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old woman comes to the urgent care clinic complaining of progressively worsening dyspnea over the last 48 hours. She mentions that her usual morning cough has become more frequent and is now producing a larger amount of thick, yellowish-green mucus. Her medical history is significant for severe chronic obstructive pulmonary disease (COPD) and hypertension. Vital signs include a temperature of 37.3°C (99.1°F), heart rate of 94/min, respiratory rate of 24/min, and blood pressure of 142/88 mmHg. Oxygen saturation is 89% on room air. Physical examination demonstrates a prolonged expiratory phase with diffuse bilateral wheezing. There is no jugular venous distention and no lower extremity edema. A chest radiograph reveals hyperinflated lungs and flattened diaphragms, but no focal opacities. Which of the following treatments are indicated for this patient right now? (Select all that apply)

A 64-year-old man is brought to the emergency department due to massive hemoptysis. Over the past $2$ hours, he has expectorated approximately $700\text{ mL}$ of bright red blood. He has a medical history significant for cavitary pulmonary tuberculosis treated $15$ years ago, which left residual scarring in his right upper lobe. On presentation, the patient is lethargic, in severe respiratory distress, and coughing weakly with ongoing blood expectoration. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $88/54\text{ mm Hg}$, pulse is $132/\text{min}$, and respiratory rate is $32/\text{min}$. Oxygen saturation is $80\%$ on room air. Auscultation reveals prominent coarse gurgling sounds over the right hemithorax, with diminished but clear breath sounds on the left. Intravenous access is established.

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

A 66-year-old man is admitted to the intensive care unit after sustaining right-sided rib fractures in a motor vehicle collision. He has a history of severe chronic obstructive pulmonary disease (COPD). On hospital day 2, he develops increasing respiratory distress and is intubated for mechanical ventilation. He is deeply sedated with a continuous propofol infusion and paralyzed with rocuronium.

Ten minutes after intubation, the ventilator's high-pressure alarm sounds. His blood pressure precipitously drops from 145/88 mm Hg to 72/40 mm Hg, and his heart rate increases to 132/min. Oxygen saturation is 93% on a fraction of inspired oxygen ($FiO_2$) of 1.0.

An arterial blood gas reveals:
- pH: 7.18
- $PaCO_2$: 74 mm Hg
- $PaO_2$: 68 mm Hg
- $HCO_3^-$: 27 mEq/L

Bedside evaluation of ventilator mechanics reveals a peak airway pressure of 68 cm $H_2O$ and a plateau airway pressure of 22 cm $H_2O$ (measured during an end-inspiratory breath hold).

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

A 58-year-old man is brought to the emergency department for sudden, excruciating chest pain radiating to his interscapular region. He appears diaphoretic and in severe distress. Blood pressure is 210/110 mm Hg in the right arm and 170/95 mm Hg in the left arm. Heart rate is 118/min. A new early diastolic decrescendo murmur is heard at the right upper sternal border. Neurologic examination reveals no focal deficits. Electrocardiogram shows sinus tachycardia and left ventricular hypertrophy without acute ischemic changes. Chest radiograph demonstrates a widened mediastinum. Arrange the following next steps in the management of this patient in the most appropriate chronological order.

A 76-year-old male presents to the emergency department reporting five days of progressively worsening shortness of breath, increased volume of yellow sputum, and new swelling in both of his legs. His medical history includes severe chronic obstructive pulmonary disease and a myocardial infarction six years ago.

Vital signs show a temperature of 37.2°C (99.0°F), blood pressure of 135/85 mmHg, pulse of 112/min, and respirations of 26/min. Oxygen saturation is 88% on room air. Physical examination reveals a barrel-shaped chest and use of accessory muscles. The jugular venous pressure is visibly elevated to 11 cm $H_2O$. Cardiac auscultation shows distant heart sounds and a regular tachycardia without murmurs or gallops. Lung auscultation reveals prolonged expiration with diffuse expiratory wheezes, but no crackles are present. Bilateral 2+ pitting edema is noted up to the knees.

A chest radiograph demonstrates hyperinflated lungs, flattened diaphragms, and prominent central pulmonary arteries without alveolar infiltrates or pleural effusions. An electrocardiogram shows sinus tachycardia, right axis deviation, and right ventricular hypertrophy.

Assuming a diagnosis of acute decompensated heart failure due to his cardiac history and volume overload status, the treating physician administers a dose of intravenous furosemide. Sixty minutes later, the patient becomes acutely confused. Repeat vital signs show a blood pressure of 72/45 mmHg and a pulse of 128/min.

Which of the following is the most likely primary mechanism for this patient's acute clinical deterioration?

A 62-year-old woman is evaluated in the surgical intensive care unit for sudden-onset severe shortness of breath. She underwent an open abdominal hysterectomy 4 days ago. Her temperature is 37.6°C (99.7°F), blood pressure is 78/52 mm Hg, pulse is 128/min, and respirations are 32/min. Pulse oximetry shows 85% on room air. Physical examination reveals prominent jugular venous distention. The lungs are clear to auscultation bilaterally. Cardiac examination shows a regular, rapid rhythm with a loud pulmonic component of the second heart sound ($P_2$). An electrocardiogram shows sinus tachycardia with new T-wave inversions in leads V1 through V4. Arterial blood gas analysis on room air shows a pH of 7.22, a $PaCO_2$ of 32 mm Hg, a $PaO_2$ of 54 mm Hg, and an $HCO_3^-$ of 13 mEq/L. Which of the following is the most appropriate next step in management?

A 71-year-old woman is evaluated in the intensive care unit on the second day of her admission for community-acquired pneumonia that progressed to septic shock. She was intubated and placed on mechanical ventilation upon arrival. The patient is currently receiving an intravenous infusion of norepinephrine and is deeply sedated, triggering no spontaneous breaths.

Blood and sputum cultures obtained at admission have grown *Streptococcus pneumoniae* susceptible to penicillin and ceftriaxone. Her current empiric antimicrobial regimen consists of intravenous piperacillin-tazobactam and vancomycin. Her temperature is 38.4°C (101.1°F), blood pressure is 92/58 mm Hg, and heart rate is 112/min.

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

Match each distinct arterial pulse or blood pressure finding with its most characteristic underlying cardiovascular pathology.

A 38-year-old man comes to the clinic reporting a three-month history of intermittent, burning epigastric pain that is frequently relieved by eating. He has no history of nonsteroidal anti-inflammatory drug (NSAID) use and no alarm symptoms such as weight loss, dysphagia, or melena. Physical examination is unremarkable. Arrange the following steps in the most appropriate chronological order for the diagnosis and management of this patient's most likely condition.

A 49-year-old female is evaluated in the emergency department for a sudden onset of severe upper abdominal pain that shoots directly into her back. The pain began approximately 5 hours ago, shortly after she consumed a heavy meal, and has been accompanied by two episodes of non-bilious vomiting. Her past medical history is notable for well-controlled type 2 diabetes mellitus and primary hypothyroidism, managed with daily metformin and levothyroxine.

Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), pulse of $108/\text{min}$, blood pressure of $130/80\text{ mm Hg}$, and respiratory rate of $16/\text{min}$. Physical examination is significant for pronounced epigastric tenderness to palpation, with no guarding, rigidity, or rebound tenderness.

Laboratory evaluation reveals the following:

A right upper quadrant abdominal ultrasound reveals gallstones within the gallbladder but a normal-caliber common bile duct without any pericholecystic fluid.

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

Paramedics transport an $82$-year-old male resident of an assisted living facility to the acute care bay after he was found severely short of breath and lethargic. His medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of $30\%$, severe chronic obstructive pulmonary disease (COPD), and stage $3$ chronic kidney disease. Vital signs reveal a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $84/52\text{ mm Hg}$, pulse of $110/\text{min}$ and irregularly irregular, and respiratory rate of $32/\text{min}$. Pulse oximetry is $80\%$ on room air. Physical examination reveals a somnolent patient using accessory muscles of respiration. Jugular venous distention is prominent up to the angle of the mandible. Auscultation of the lungs reveals diffuse bilateral expiratory wheezing with no focal consolidation. Cardiac examination demonstrates a prominent $S_3$ gallop and a $2/6$ holosystolic murmur at the apex. Point-of-care arterial blood gas analysis on room air reveals:

$\text{pH}$: $7.16$
$\text{pCO}_2$: $74\text{ mm Hg}$
$\text{pO}_2$: $48\text{ mm Hg}$
$\text{HCO}_3^-$: $25\text{ mEq/L}$

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

A $73$-year-old man is brought to the emergency department by his daughter due to a $3$-day history of progressively worsening shortness of breath and a severe, productive cough. The daughter reports that his sputum, which is usually scant and clear, has become thick, abundant, and yellowish-green. He has a $45$-pack-year smoking history and was diagnosed with severe chronic obstructive pulmonary disease (COPD) $5$ years ago. His medical history is otherwise notable for hypertension. He has no history of heart failure or recent hospitalizations.

Vital signs are temperature $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure $142/86\text{ mm Hg}$, pulse $112/\text{min}$, and respirations $28/\text{min}$. Pulse oximetry is $86\%$ on room air.

On physical examination, the patient is alert but in moderate respiratory distress, using accessory muscles of respiration. Lung auscultation reveals a prolonged expiratory phase with diffuse expiratory wheezes bilaterally. Heart sounds are normal with no murmurs or gallops. Jugular venous pressure is normal, and there is no peripheral edema.

A chest radiograph demonstrates hyperinflated lungs with flattened hemidiaphragms, without focal infiltrates or signs of pulmonary vascular congestion.

Arterial blood gas analysis on room air reveals:

Which of the following interventions are appropriate in the acute management of this patient? (Select all that apply)

A 54-year-old woman is evaluated in the intensive care unit for worsening respiratory distress. She was admitted 48 hours ago for a severe right lower lobe community-acquired pneumonia and was started on intravenous ceftriaxone and azithromycin. Blood and sputum cultures drawn on admission are now growing *Streptococcus pneumoniae* susceptible to penicillin.

Current vital signs are:
Temperature: 38.9°C (102.0°F)
Pulse: 124/min
Blood pressure: 82/50 mmHg
Respirations: 32/min
SpO2: 87% on a high-flow nasal cannula (FiO2 60%)

Over the past 4 hours, she has received 3 L of intravenous normal saline without improvement in her blood pressure. Physical examination reveals cool, mottled extremities. Jugular venous pressure is 5 cm H2O. Pulmonary auscultation reveals diffuse bilateral crackles, a change from the isolated right-sided crackles noted on admission. A bedside chest radiograph demonstrates new, diffuse bilateral alveolar opacities in addition to the right lower lobe consolidation.

Laboratory results:
Leukocytes: 18,500/mm³
Serum sodium: 138 mEq/L
Serum potassium: 4.8 mEq/L
Serum chloride: 101 mEq/L
Serum bicarbonate: 13 mEq/L
Blood urea nitrogen: 34 mg/dL
Serum creatinine: 2.2 mg/dL
Serum lactate: 6.5 mmol/L

Arterial blood gas (on HFNC 60%):
pH: 7.20
PaCO2: 35 mmHg
PaO2: 55 mmHg

Which of the following statements regarding this patient's condition and management are correct? (Select all that apply)

During a routine outpatient follow-up, a 69-year-old retired carpenter complains of gradually increasing swelling in both ankles over the past month. He has a 45-pack-year smoking history and severe chronic obstructive pulmonary disease. The patient states his chronic daily cough and baseline exertional shortness of breath have not worsened. He denies waking up gasping for air at night and sleeps comfortably on a single pillow. He is afebrile. Vital signs show a blood pressure of 118/76 mm Hg, a pulse of 84/min, and a respiratory rate of 18/min. Pulse oximetry reveals an oxygen saturation of 87% on room air. Physical examination demonstrates an elevated jugular venous pressure, a prominent right ventricular heave, and 2+ bilateral pitting edema up to the shins. Auscultation of the lungs reveals distant breath sounds with prolonged expiration but no crackles. A basic metabolic panel reveals a serum bicarbonate of 32 mEq/L. Which of the following management steps is most likely to improve this patient's long-term survival?

A 42-year-old woman presents to the clinic with progressively worsening exertional dyspnea and fatigue over the past 6 months. She has no significant past medical history and takes no medications. Physical examination reveals a prominent jugular venous a-wave, a loud pulmonic component of the second heart sound (P2), a right ventricular heave, and trace bilateral pedal edema. Her lungs are clear to auscultation. Pulmonary function testing demonstrates normal spirometry with an isolated reduction in the diffusing capacity of the lungs for carbon monoxide (DLCO). Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for evaluating and managing this patient's condition.

A $74$-year-old woman is brought to the emergency department via ambulance with acute, severe respiratory distress that awoke her from sleep $30$ minutes ago. She is profoundly diaphoretic, anxious, and sitting bolt upright on the stretcher. Her blood pressure is $240/130$ mm Hg, heart rate is $128$/min, and respiratory rate is $38$/min. Oxygen saturation is $82\%$ on room air. Physical examination reveals a hyperdynamic precordium and diffuse, coarse crackles auscultated throughout all lung fields bilaterally. There is no significant lower extremity edema. Arrange the following therapeutic interventions in the most appropriate chronological sequence for the optimal acute management of this patient's condition.

A 55-year-old man is evaluated in the intensive care unit on his fourth day of mechanical ventilation for acute respiratory distress syndrome secondary to severe pneumonia. Over the past 48 hours, his clinical status has markedly improved. His fraction of inspired oxygen (FiO2) requirement has decreased to 35%, his positive end-expiratory pressure (PEEP) is at a minimal setting, and he no longer requires vasopressor support. The critical care team decides to initiate the protocol to liberate him from the ventilator. Arrange the following steps in the standard sequential order for evaluating and performing ventilator liberation.

An emergency department physician evaluates a 67-year-old man due to four days of escalating dyspnea and nocturnal coughing. The patient reports having to sleep upright in a recliner to avoid respiratory distress. His medical background includes type 2 diabetes, essential hypertension, and osteoarthritis. He recently began taking over-the-counter ibuprofen around the clock for severe knee pain. He smoked one pack of cigarettes daily for 35 years but ceased a decade ago. Temperature is 37.0°C (98.6°F), blood pressure is 158/92 mm Hg, pulse is 112/min, and respirations are 22/min. Pulse oximetry is 92% on room air. Physical examination reveals an anxious patient utilizing accessory respiratory muscles. Jugular venous pressure is elevated at 11 cm H2O. Chest auscultation demonstrates bibasilar dullness to percussion and widespread expiratory wheezes. Cardiac evaluation shows a regular rhythm with a normal S1 and S2, accompanied by a low-frequency sound occurring shortly after S2. Moderate pitting edema is present up to the mid-shins bilaterally. Which of the following is the most appropriate initial pharmacotherapy for this patient?