Internal Medicine

A $68$-year-old man with a history of severe chronic obstructive pulmonary disease (COPD) and chronic cor pulmonale is brought to the emergency department due to profound weakness and increasing shortness of breath over the past $2$ days. His wife reports that he has had $5$ to $6$ large-volume watery stools daily for the past $4$ days. He is alert and oriented but in visible respiratory distress, utilizing accessory muscles of respiration.

Vital signs:
- Temperature: $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$)
- Blood pressure: $105/65\text{ mm Hg}$
- Heart rate: $112/\text{min}$
- Respiratory rate: $28/\text{min}$
- Oxygen saturation: $89\%$ on room air

Physical examination reveals a jugular venous pressure of $5\text{ cm}$ above the sternal angle. Pulmonary auscultation demonstrates prolonged expiration and diffuse bilateral wheezing, but no crackles are appreciated. Cardiac examination shows a normal $S_1$ and $S_2$ with a loud $P_2$.

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

A $62$-year-old male with a history of pulmonary tuberculosis treated $15$ years ago is brought to the emergency department for massive hemoptysis. He reports coughing up approximately $800\text{ mL}$ of bright red blood over the past two hours. He is visibly anxious, diaphoretic, and in respiratory distress. Vital signs are temperature $37.1^\circ\text{C}$, blood pressure $88/54\text{ mmHg}$, heart rate $126/\text{min}$, respiratory rate $30/\text{min}$, and oxygen saturation $85\%$ on room air. Auscultation reveals loud, coarse crackles and diminished breath sounds isolated to the right lung fields; the left lung fields are clear. A chest radiograph from two months ago documented a large, thick-walled cavitary lesion in the right upper lobe. Arrange the following management steps in the most appropriate chronological sequence for this patient.

Match each acute cardiovascular clinical presentation with its most characteristic pulmonary artery catheterization (hemodynamic) profile.

A 68-year-old woman is evaluated in the hospital on day 3 of admission for acute cholangitis. She initially presented with fever, right upper quadrant pain, and jaundice. She was started on empiric intravenous piperacillin-tazobactam and successfully underwent endoscopic retrograde cholangiopancreatography with biliary stone extraction.

Currently, she is afebrile and her abdominal pain has entirely resolved. Blood and bile cultures obtained on admission both grow *Klebsiella pneumoniae*. The antimicrobial susceptibility report is as follows:

Which of the following is the most appropriate next step in the patient's pharmacotherapy?

A 71-year-old man is evaluated in the emergency department for a 3-day history of progressively worsening shortness of breath, increased cough, and a change in sputum color from clear to yellow-green. He has a 45-pack-year smoking history and severe chronic obstructive pulmonary disease (COPD). Temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), heart rate is $105/\text{min}$, respiratory rate is $24/\text{min}$, and blood pressure is $135/85\text{ mmHg}$. Pulse oximetry shows an $SpO_2$ of $88\%$ on room air.

Physical examination shows a patient sitting forward and using accessory muscles of respiration. Jugular venous pulsation is visible at $10\text{ cm H}_2\text{O}$. Chest examination reveals a barrel-shaped chest, hyperresonance to percussion, and diffuse expiratory wheezing with a prolonged expiratory phase. Cardiac examination reveals distant heart sounds with a prominent $P_2$, but no $S_3$ gallop. There is $2+$ bilateral pitting edema of the lower extremities.

Arterial blood gas on room air shows:
pH: $7.30$
$pCO_2$: $62\text{ mmHg}$
$pO_2$: $55\text{ mmHg}$
$HCO_3^-$: $30\text{ mEq/L}$

Chest radiograph demonstrates hyperinflated lung fields, flattened diaphragms, enlarged central pulmonary arteries, and a narrow cardiac silhouette, with no focal consolidations or pleural effusions.

Based on the clinical presentation and diagnostic findings, which of the following are the most appropriate immediate interventions for this patient? (Select all that apply)

A 68-year-old man comes to the emergency department due to a 2-day history of worsening shortness of breath, cough, and increased production of thick, yellow sputum. He has a 40-pack-year smoking history and was diagnosed with chronic obstructive pulmonary disease (COPD) 5 years ago. His temperature is 37.4°C (99.3°F), blood pressure is 140/88 mm Hg, pulse is 95/min, and respiratory rate is 24/min. Pulse oximetry shows an oxygen saturation of 86% on room air. Physical examination reveals a barrel-shaped chest, diffuse bilateral wheezing, and a prolonged expiratory phase. There is no jugular venous distention, crackles, or lower extremity edema. Which of the following are appropriate initial management steps for this patient? (Select all that apply)

During morning rounds, the care team reviews the chart of a 71-year-old woman who is currently receiving inpatient treatment for acute ascending cholangitis. She was admitted three days ago with a temperature of 39.2°C (102.6°F), severe right upper quadrant pain, and scleral icterus. On the day of admission, blood cultures were drawn, and she was started on empiric intravenous piperacillin-tazobactam. The following day, she underwent an urgent endoscopic retrograde cholangiopancreatography (ERCP), during which a 12-mm common bile duct stone was successfully extracted, restoring normal biliary flow. Today, the patient reports feeling significantly better and is tolerating a liquid diet. Her vital signs are a temperature of 37.0°C (98.6°F), blood pressure of 122/76 mm Hg, and pulse of 78/min. Laboratory studies show her leukocyte count has normalized to 7,500/mm³. The microbiology laboratory reports that the admission blood cultures are positive for *Escherichia coli*. The susceptibility panel confirms the isolate is resistant to ampicillin but highly susceptible to ceftriaxone, ciprofloxacin, and piperacillin-tazobactam. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 64-year-old man presents to his primary care physician complaining of a two-week history of progressively worsening shortness of breath. Initially, he only felt breathless when walking up an incline, but now he experiences it while walking on level ground. He also reports a new, dry cough that occurs mainly at night, which has prompted him to sleep in a recliner chair for the past three nights. His medical history includes essential hypertension and a 35-pack-year smoking history. His temperature is 37.0°C (98.6°F), blood pressure is 158/92 mm Hg, pulse is 88/min, and respiratory rate is 20/min. Physical examination reveals distention of the jugular veins while the patient is sitting at a 45-degree angle. Auscultation of the lungs demonstrates fine crackles at both lung bases that do not clear with coughing. Cardiac examination reveals a regular rate and rhythm with an extra, low-frequency heart sound occurring shortly after S2. Trace pitting edema is noted in both ankles.

Which of the following is the most likely underlying mechanism for this patient's clinical presentation?

A medical student is reviewing small bowel biopsy pathology reports for several patients presenting with chronic diarrhea, weight loss, and signs of malabsorption. Match each clinical diagnosis with its hallmark histologic finding on small intestinal biopsy.

A $41$-year-old woman with a history of cystic fibrosis presents to the emergency department after coughing up large volumes of bright red blood. She estimates expectorating over $600$ mL of blood since this morning. On arrival, she is in severe respiratory distress, coughing persistently, and unable to speak in full sentences.

Vital signs:
Temperature: $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$)
Blood pressure: $100/60$ mmHg
Heart rate: $118$/min
Respiratory rate: $30$/min
Oxygen saturation: $86\%$ on room air

A bedside chest radiograph demonstrates extensive bronchiectasis, predominantly in the right upper and middle lobes, with new dense alveolar opacities in the left lower lobe.

Arrange the following interventions in the correct sequential order of management, from the immediate life-saving stabilization step to the definitive last-resort therapy.

A 74-year-old man presents to the emergency department at 3:00 AM with sudden-onset, severe shortness of breath and wheezing. He has a 45-pack-year smoking history, essential hypertension, and diet-controlled type 2 diabetes mellitus. He reports waking up gasping for air and states that his cough produces frothy sputum. Current medications include amlodipine and metformin. His temperature is 37.0°C (98.6°F), blood pressure is 210/115 mm Hg, pulse is 112/min, and respirations are 28/min. Pulse oximetry shows 88% on room air. Physical examination reveals use of accessory muscles of respiration. Lung auscultation demonstrates diffuse, bilateral end-expiratory wheezes with a prolonged expiratory phase. Cardiac examination reveals a sustained but non-displaced apical impulse and a prominent fourth heart sound (S4). Jugular venous pressure is estimated at 10 cm H2O. There is no lower extremity edema. A chest radiograph reveals peribronchial cuffing, indistinct pulmonary vascular margins, and a normal cardiothoracic ratio. An electrocardiogram demonstrates normal sinus rhythm with voltage criteria for left ventricular hypertrophy. Which of the following pathophysiologic mechanisms is the primary driver of this patient's current respiratory distress?

A 28-year-old woman presents to an urgent care center with a two-day history of progressive shortness of breath, chest tightness, and a dry cough. Her symptoms began shortly after she adopted a cat. She was diagnosed with asthma in childhood but has not required daily medications for the past five years. Over the last 48 hours, she has used her short-acting albuterol inhaler up to six times daily with minimal relief. Her temperature is 37.1°C (98.8°F), blood pressure is 122/78 mmHg, pulse is 112/min, and respiratory rate is 24/min. Pulse oximetry shows an oxygen saturation of 93% on room air. Physical examination reveals a prolonged expiratory phase with diffuse bilateral wheezing. There is no jugular venous distention, and heart sounds are normal without murmurs or gallops. Which of the following is the most appropriate next step in pharmacologic management?

A $74$-year-old woman is brought to the emergency department by her daughter due to sudden, severe abdominal pain that started $2$ hours ago. The patient reports the pain is constant, diffuse, and poorly localized. She has a history of type 2 diabetes mellitus, hypertension, and a previous transient ischemic attack. She was diagnosed with atrial fibrillation one year ago but stopped taking her prescribed apixaban three months ago due to financial constraints. Her temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), pulse is $112/\text{min}$ and irregularly irregular, blood pressure is $142/88 \text{ mm Hg}$, and respirations are $20/\text{min}$. Physical examination shows a patient in significant distress, writhing on the stretcher. However, abdominal palpation elicits only mild, diffuse tenderness without rigidity, guarding, or rebound tenderness. Bowel sounds are hypoactive. Stool is negative for occult blood. Laboratory studies show a leukocyte count of $16,500/\text{mm}^3$ and a serum lactate of $4.2 \text{ mmol/L}$.

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

A $19$-year-old male college student presents to the student health clinic complaining of a severely painful throat, subjective fevers, and profound exhaustion that has progressively worsened over the past $7$ days. He notes that he has been too tired to attend his classes. He has no chronic medical conditions and takes no daily medications. Vital signs show a temperature of $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure of $115/72\text{ mm Hg}$, pulse of $92/\text{min}$, and respirations of $14/\text{min}$. Physical examination demonstrates marked bilateral posterior cervical lymphadenopathy, erythematous tonsils with grayish-white exudates, and mild splenomegaly. A point-of-care heterophile antibody test yields a positive result. Which of the following is the most appropriate management for this patient?

A $60$-year-old woman is brought to the emergency department by her husband due to progressive confusion, profound fatigue, and generalized weakness over the past week. Two weeks ago, she had a mild upper respiratory infection. Her husband notes she has been complaining of intermittent headaches and peripheral vision loss for the last three months. Her temperature is $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$), blood pressure is $82/50\text{ mm Hg}$, pulse is $54/\text{min}$, and respirations are $16/\text{min}$. Physical examination shows a lethargic woman with dry, pale skin and delayed relaxation of deep tendon reflexes. Mild bilateral non-pitting lower extremity edema is present. Lung auscultation reveals decreased breath sounds at the bases but no crackles or wheezes.

Laboratory evaluation shows:

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

A 62-year-old man is evaluated in the hospital on hospital day 3. He was initially admitted for fever, chills, and a warm, swollen right calf. On admission, his temperature was 39.1 C (102.4 F), blood pressure was 105/65 mm Hg, and pulse was 110/min. He was started on empiric intravenous vancomycin and piperacillin-tazobactam. Today, his temperature is 37.4 C (99.3 F), blood pressure is 120/75 mm Hg, and pulse is 82/min. The erythema on his right calf has significantly decreased. Blood cultures drawn on admission are positive for Staphylococcus aureus in 2 of 2 bottles. Susceptibility testing shows the isolate is resistant to penicillin but susceptible to oxacillin, cefazolin, and vancomycin. The patient has no history of medication allergies. Which of the following is the most appropriate next step in management?

Match each classic clinical presentation of an infectious disease with its most appropriate first-line pharmacotherapy.

Match each patient's clinical presentation with the most likely corresponding urinalysis sediment finding.

Match each classic physical examination finding to the endocrine condition with which it is most commonly associated.

Match each highly specific clinical scenario to the most appropriate guideline-directed pharmacotherapy, taking into account patient-specific contraindications.