Internal Medicine

An outpatient clinic evaluates a $65$-year-old male with a known history of severe emphysema. Over the last $48$ hours, he has experienced progressive dyspnea, increased cough frequency, and a new onset of purulent green sputum. He is afebrile. His respiratory rate is $24/\text{min}$ and oxygen saturation is $90\%$ on room air. Auscultation reveals a significantly prolonged expiratory phase with diffuse expiratory wheezes. Cardiovascular examination demonstrates no jugular venous distension and no peripheral edema. Chest radiography displays flattened diaphragms and hyperlucent lung fields without infiltrates or effusions. Which of the following interventions are indicated for the initial management of this patient's acute exacerbation? (Select all that apply)

A 74-year-old woman is admitted to the intensive care unit with profound dyspnea, altered mental status, and hypotension. She has a history of severe chronic obstructive pulmonary disease (COPD). For the past three days, she has experienced a worsening productive cough and subjective fevers.

Upon arrival, she is lethargic and easily arousable but confused. Vital signs are temperature $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure $82/50 \text{ mmHg}$, pulse $124/\text{min}$, and respirations $28/\text{min}$. Oxygen saturation is $84\%$ on her baseline home oxygen requirement of $2 \text{ L/min}$ via nasal cannula.

Physical examination reveals dry mucous membranes, delayed capillary refill, and diffuse expiratory wheezes with right lower lobe crackles.

Based on these findings, which of the following best characterizes this patient's acid-base status?

A $32$-year-old woman with no significant past medical history presents with a $6$-month history of progressive exertional dyspnea, atypical chest pain, and near-syncope during exercise. Vital signs are within normal limits. Physical examination reveals a prominent 'a' wave in the jugular venous pulse, a loud pulmonic component of the second heart sound ($P_2$), and a right ventricular heave. Lungs are clear to auscultation. An electrocardiogram demonstrates right axis deviation and right ventricular hypertrophy.

Arrange the following diagnostic steps in the most appropriate chronological order according to current guidelines for the evaluation of this patient's suspected condition.

A $72$-year-old man is evaluated in the surgical intensive care unit for worsening shortness of breath, altered mental status, and hypotension. He was admitted $4$ days ago for an emergency exploratory laparotomy due to a perforated gastric ulcer. His medical history includes heart failure with preserved ejection fraction and severe chronic obstructive pulmonary disease. Temperature is $38.9^\circ \text{C}$ ($102.0^\circ \text{F}$), blood pressure is $80/48 \text{ mm Hg}$, pulse is $128/\text{min}$, and respirations are $28/\text{min}$. Oxygen saturation is $88\%$ on room air. Physical examination reveals a lethargic patient with warm, well-perfused extremities. Lung auscultation reveals coarse crackles and bronchial breath sounds over the right lower lung field. Cardiac examination shows tachycardia with a regular rhythm and no murmurs. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ and a serum lactate of $4.2 \text{ mmol/L}$. Arterial blood gas analysis on room air reveals:

pH: $7.25$
$\text{PaCO}_2$: $28 \text{ mm Hg}$
$\text{PaO}_2$: $56 \text{ mm Hg}$
$\text{HCO}_3^-$: $12 \text{ mEq/L}$

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

A $42$-year-old man is evaluated in the gastroenterology clinic for a $6$-month history of chronic, watery diarrhea and recurrent epigastric pain. His symptoms have persisted despite taking high-dose omeprazole twice daily. Esophagogastroduodenoscopy reveals thickened gastric folds and multiple $1$- to $2$-cm ulcers in the stomach, duodenal bulb, and descending duodenum. Rapid urease test for Helicobacter pylori is negative. The physician suspects a neuroendocrine tumor. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for this patient's suspected condition.

A 61-year-old male with a history of moderate chronic obstructive pulmonary disease is evaluated in the intensive care unit for worsening hypoxemia. He was admitted two days ago with severe community-acquired pneumonia and was intubated yesterday due to progressive respiratory failure. Sputum cultures from admission grew *Streptococcus pneumoniae* sensitive to penicillin, and he is currently receiving intravenous aqueous penicillin G.

His temperature is 38.3°C (100.9°F), blood pressure is 112/68 mmHg, and heart rate is 108/min. Physical examination reveals diffuse bilateral crackles. A chest radiograph demonstrates new, diffuse bilateral alveolar opacities.

He is receiving mechanical ventilation in volume assist-control mode with the following settings:
- Tidal volume: 550 mL (approximately 8 mL/kg of predicted body weight)
- Respiratory rate: 14/min
- FiO₂: 0.70
- Positive end-expiratory pressure (PEEP): 5 cm H₂O

Arterial blood gas analysis on these settings reveals:
- pH: 7.18
- PaCO₂: 38 mmHg
- PaO₂: 52 mmHg
- HCO₃⁻: 14 mEq/L

Ventilator mechanics show a peak inspiratory pressure of 45 cm H₂O and a plateau pressure of 34 cm H₂O.

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

A 58-year-old man is evaluated in the emergency department for sudden-onset, severe "tearing" chest pain that radiates to his interscapular region. He is markedly anxious and diaphoretic. His blood pressure is $218/115\text{ mmHg}$ in the right arm and $182/95\text{ mmHg}$ in the left arm. His heart rate is $114\text{/min}$. Physical examination reveals a new prominent early diastolic decrescendo murmur at the right upper sternal border. An electrocardiogram reveals sinus tachycardia and voltage criteria for left ventricular hypertrophy. Bedside chest radiography demonstrates a widened mediastinum. Arrange the following interventions in the most appropriate sequential order for the acute management of this patient.

A $22$-year-old tall, thin man is brought to the emergency department by emergency medical services with sudden-onset severe right-sided chest pain and profound shortness of breath. He is in severe respiratory distress. His blood pressure is $78/48$ mmHg, heart rate is $135$ /min, and oxygen saturation is $85\%$ on high-flow oxygen. Physical examination reveals absent breath sounds over the right hemithorax, hyperresonance to percussion on the right, and the trachea is visibly deviated to the left. The patient has markedly distended neck veins. Arrange the following management steps in the most appropriate chronological order.

A physician is evaluating a 62-year-old man on the medical ward due to acute-onset severe shortness of breath. The patient was admitted 24 hours ago for community-acquired pneumonia and was started on targeted antimicrobial therapy with ceftriaxone and azithromycin. In the emergency department, his initial blood pressure was 88/58 mm Hg, for which he received a total of 4 liters of normal saline. His blood pressure subsequently normalized. His past medical history includes chronic obstructive pulmonary disease (COPD), hypertension, and hypothyroidism. Currently, he reports worsening dyspnea and difficulty breathing while lying flat. His temperature is 37.1 C (98.8 F), blood pressure is 158/92 mm Hg, pulse is 112/min, and respirations are 26/min. Pulse oximetry is 86% on room air. Physical examination shows distended neck veins up to 10 cm above the sternal angle. Cardiac auscultation reveals a regular tachycardia with a prominent third heart sound (S3). Lung examination demonstrates bilateral crackles extending to the mid-lung fields, alongside the previously noted right lower lobe bronchial breath sounds. There is mild bilateral lower extremity pitting edema. Arterial blood gas analysis on room air shows $pH = 7.32$, $pCO_2 = 52\text{ mm Hg}$, and $pO_2 = 56\text{ mm Hg}$. Which of the following is the most appropriate next step in management for this patient's acute respiratory decline?

Match the following clinical scenarios of patients presenting with acute circulatory collapse to their most likely corresponding invasive hemodynamic profile (pulmonary capillary wedge pressure [PCWP], cardiac output [CO], systemic vascular resistance [SVR], and right atrial pressure [RAP]).

A $48$-year-old man is brought to the emergency department after expectorating approximately $600\text{ mL}$ of bright red blood over the past two hours. He has a history of cavitary pulmonary tuberculosis that was fully treated $10$ years ago. On arrival, he is in moderate respiratory distress and continues to cough up large volumes of blood. Vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $105/65\text{ mmHg}$, pulse $118/\text{min}$, and respirations $28/\text{min}$. Pulse oximetry shows an oxygen saturation of $88\%$ on room air. Pulmonary auscultation reveals coarse crackles and gurgling sounds over the right mid-to-upper lung fields, while breath sounds on the left are completely clear. Arrange the following management steps in the most appropriate sequential order for this patient.

A 27-year-old primigravida at 28 weeks gestation is brought to the emergency department with sudden-onset severe dyspnea and a cough producing frothy sputum. Over the past month, she experienced progressive fatigue and exertional dyspnea, which she assumed were normal changes of pregnancy. She recently emigrated from Southeast Asia and has had limited medical care. She is terrified and tearfully states, 'Please don't do any surgery, I refuse a C-section no matter what happens.'

Temperature is 36.8°C (98.2°F), blood pressure is 108/64 mm Hg, and pulse is 138/min and irregularly irregular. Respirations are 32/min. Pulse oximetry is 86% on room air. Physical examination reveals bibasilar crackles extending to the mid-lung fields and widespread expiratory wheezing. Cardiac auscultation in the left lateral decubitus position reveals a loud first heart sound, a high-pitched early diastolic sound, and a low-pitched diastolic rumble at the apex. An electrocardiogram demonstrates narrow QRS complexes with absent P waves and varying R-R intervals. Arterial blood gas on room air shows a pH of 7.28, $\text{PaCO}_2$ of 55 mm Hg, and $\text{PaO}_2$ of 58 mm Hg. Continuous fetal heart rate monitoring demonstrates a baseline of 160/min with minimal variability and recurrent late decelerations.

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

A 78-year-old man is admitted to the medical ward for the treatment of a urinary tract infection. Due to initial hypotension in the emergency department, he received 4 liters of intravenous normal saline over the first 12 hours of admission. He subsequently develops severe dyspnea, orthopnea, and a cough producing pink-tinged sputum. His respiratory rate is 32/min, heart rate is 114/min, and oxygen saturation drops to 85% on room air. Physical examination reveals an S3 gallop, elevated jugular venous pressure, and diffuse bilateral pulmonary crackles accompanied by expiratory wheezing. The patient has a known medical history of mild chronic obstructive pulmonary disease. Which of the following are appropriate immediate steps in the management of this patient's respiratory decompensation? (Select all that apply)

A 66-year-old man is evaluated in the emergency department for severe shortness of breath and a cough productive of yellow sputum over the past three days. He has a history of chronic obstructive pulmonary disease (COPD) and heart failure with preserved ejection fraction. His home medications include inhaled tiotropium, inhaled fluticasone-salmeterol, and oral amlodipine. His temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $132/82\text{ mmHg}$, pulse is $112/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows $88\%$ on room air. The patient is alert but using accessory muscles of respiration. Auscultation reveals a prolonged expiratory phase with diffuse bilateral wheezing. Jugular venous pressure is estimated at $6\text{ cm H}_2\text{O}$. Trace bilateral pedal edema is present. A chest radiograph demonstrates hyperinflation and flattened diaphragms without focal consolidation or pulmonary vascular congestion.

Laboratory studies show:
- Leukocyte count: $14,500/\text{mm}^3$
- Serum sodium: $140\text{ mEq/L}$
- Serum chloride: $104\text{ mEq/L}$
- Serum bicarbonate: $14\text{ mEq/L}$
- Serum creatinine: $2.1\text{ mg/dL}$ (baseline $1.0\text{ mg/dL}$)
- Serum lactate: $4.5\text{ mmol/L}$

Arterial blood gas analysis on room air reveals:
- pH: $7.21$
- pCO $_2$: $35\text{ mmHg}$
- pO $_2$: $56\text{ mmHg}$

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

A 48-year-old man is evaluated on his second day of hospitalization for acute pancreatitis. He initially presented with severe epigastric pain radiating to the back, and laboratory studies on admission showed a serum lipase level of $2,400\text{ U/L}$. The patient has a history of heavy alcohol consumption. He has been receiving aggressive intravenous fluid resuscitation and pain management.

Currently, the patient reports some improvement in his abdominal pain. His temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $122/78\text{ mmHg}$, pulse is $105\text{/min}$, and respirations are $18\text{/min}$. Physical examination reveals a distended abdomen with epigastric tenderness, but no guarding or rebound tenderness. Laboratory studies show a leukocyte count of $15,500\text{/mm}^3$. A contrast-enhanced CT scan of the abdomen demonstrates diffuse pancreatic enlargement with peripancreatic fluid collections and uniform enhancement of the pancreatic parenchyma. There is no evidence of gas within the fluid collections.

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

A $65$-year-old man is brought to the emergency department by ambulance due to severe, heavy chest pressure, diaphoresis, and worsening shortness of breath that began $90$ minutes ago. His medical history is significant for chronic obstructive pulmonary disease (COPD), hyperlipidemia, and hypothyroidism. His home medications include a statin, an inhaled fluticasone-salmeterol diskus, and oral levothyroxine.

Upon arrival, his temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $86/52\text{ mm Hg}$, pulse is $108/\text{min}$, and respirations are $24/\text{min}$. Pulse oximetry is $92\%$ on room air.

Physical examination reveals prominent jugular venous distention while the patient is sitting at a $45^\circ$ angle. Lung auscultation shows prolonged expiration with mild, scattered wheezes bilaterally, but the lungs are clear of crackles. Cardiac examination reveals tachycardia with a regular rhythm; no murmurs or gallops are appreciated. The liver edge is palpable $4\text{ cm}$ below the right costal margin.

Laboratory testing shows:
- Troponin I: $2.4\text{ ng/mL}$ (Normal $<0.04\text{ ng/mL}$)
- TSH: $5.5\text{ \mu U/mL}$ (Normal $0.4 - 4.0\text{ \mu U/mL}$)
- Free T4: $1.1\text{ ng/dL}$ (Normal $0.8 - 1.8\text{ ng/dL}$)

Arterial blood gas on room air reveals a pH of $7.36$, $\text{pCO}_2$ of $48\text{ mm Hg}$, and $\text{pO}_2$ of $65\text{ mm Hg}$.

A $12$-lead electrocardiogram demonstrates $3\text{-mm}$ ST-segment elevations in leads II, III, and aVF, with reciprocal ST-segment depressions in leads I and aVL.

The patient is given chewable aspirin and an intravenous fluid bolus. Which of the following interventions is most strongly contraindicated in the immediate management of this patient's condition?

Match each of the following clinical presentations of cardiovascular disease with its most characteristic combination of jugular venous pulse (JVP) and arterial pulse contour findings.

Match each classic esophageal disorder with its most characteristic clinical or diagnostic finding.

Paramedics transport a 74-year-old female to the emergency department because she awoke suddenly with a sensation of suffocating. Her medical history is notable for hypertension, diet-controlled type 2 diabetes mellitus, and a 40-pack-year smoking history. Current medications include daily amlodipine and metoprolol succinate. Upon arrival, she appears in acute distress, sitting upright and using accessory muscles of respiration. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $182/105\text{ mm Hg}$, pulse $114/\text{min}$, and respirations $28/\text{min}$. Pulse oximetry is $88\%$ on room air.

Physical examination reveals marked jugular venous distention to $11\text{ cm H}_2\text{O}$. Lung auscultation demonstrates diffuse expiratory wheezing and coarse crackles extending halfway up both posterior lung fields. Cardiac auscultation is limited by breath sounds but reveals a regular tachycardia and a low-frequency diastolic sound heard best at the cardiac apex.

Arterial blood gas analysis on room air reveals the following:

Chest radiography displays an enlarged cardiac silhouette, prominent interstitial markings, and bilateral pleural effusions.

What is the most appropriate initial pharmacologic therapy for this patient?

A 62-year-old woman is evaluated in the emergency department due to progressively worsening shortness of breath and an increased volume of purulent sputum over the past three days. She has a 45-pack-year smoking history and a known diagnosis of advanced chronic obstructive pulmonary disease. Upon arrival, she is awake and alert but in moderate respiratory distress, speaking in short phrases and utilizing accessory muscles of respiration. Her temperature is 37.3°C (99.1°F), blood pressure is 142/86 mm Hg, pulse is 112/min, and respiratory rate is 26/min. Oxygen saturation is 87% on room air. Physical examination shows a barrel-shaped chest, hyperresonance to percussion, and diffusely diminished breath sounds with a prolonged expiratory phase and scattered expiratory wheezes. Cardiac examination reveals distant heart sounds with no murmurs, gallops, or jugular venous distention. There is no lower extremity edema.

Arterial blood gas analysis on room air reveals the following:

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