Internal Medicine

Nurses urgently call the physician to evaluate a 62-year-old woman in the step-down unit due to progressive somnolence and respiratory distress. She was admitted 48 hours ago for community-acquired pneumonia and is currently receiving intravenous ceftriaxone and azithromycin. Temperature is 38.6°C (101.5°F), blood pressure is 85/54 mm Hg, pulse is 122/min, and respirations are 30/min. Pulse oximetry shows 89% on a 6 L/min simple face mask. Physical examination reveals a lethargic patient who only briefly opens her eyes to painful stimuli. She has marked intercostal retractions and diminished breath sounds with crackles at the right lung base.

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

A 65-year-old man is admitted to the cardiac intensive care unit following a myocardial infarction. While he is resting in bed, the telemetry monitor suddenly alarms, showing a wide-complex tachycardia at a rate of 180/min. The nurse rushes into the room and finds the patient completely unresponsive. Arrange the following critical next steps in the correct chronological sequence according to standard Advanced Cardiovascular Life Support (ACLS) protocols.

A 24-year-old man with a history of type 1 diabetes mellitus is evaluated in the intensive care unit. He was admitted 12 hours ago for the management of diabetic ketoacidosis. Initial therapy included a continuous intravenous regular insulin infusion and aggressive volume resuscitation with a total of 6 liters of 0.9% sodium chloride. He is now alert and reports feeling much better. Vital signs are temperature 37.0°C (98.6°F), blood pressure 118/76 mm Hg, heart rate 88/min, and respiratory rate 20/min.

Laboratory results are as follows:
Serum sodium: 142 mEq/L
Serum potassium: 4.1 mEq/L
Serum chloride: 112 mEq/L
Serum bicarbonate: 10 mEq/L
Blood glucose: 190 mg/dL

Arterial blood gas on room air:
pH: 7.26
PaCO2: 23 mm Hg
PaO2: 95 mm Hg

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

A 65-year-old man is brought to the emergency department by ambulance due to the sudden onset of severe, "tearing" chest pain radiating to his interscapular region that began $1$ hour ago. He also reports progressive, severe shortness of breath over the past $30$ minutes. His medical history is significant for hypertension, hyperlipidemia, and a $40$-pack-year smoking history.

Vital signs are:
Blood pressure: $84/40$ mmHg in the right arm and $62/35$ mmHg in the left arm
Heart rate: $128$/min
Respiratory rate: $28$/min
SpO2: $85\%$ on room air

Physical examination reveals a diaphoretic, agitated patient in severe respiratory distress. Jugular venous distension is present at $12$ cm $H_2O$. Cardiac auscultation reveals tachycardia and a high-pitched, blowing, early diastolic murmur best heard at the right second intercostal space. Lung auscultation reveals diffuse bilateral crackles and prominent expiratory wheezes. The right radial pulse is bounding, while the left radial pulse is absent.

ECG shows sinus tachycardia and left ventricular hypertrophy with a strain pattern, but no ST-segment elevations.

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

Match the following Hepatitis B viral (HBV) serologic test profiles with their most accurate clinical interpretation. Assume all positive or negative results are definitive.

A $64$-year-old man is brought to the emergency department via ambulance due to the sudden onset of severe, "tearing" anterior chest pain that radiates to his back. He has a history of long-standing, poorly controlled hypertension. On arrival, he appears diaphoretic and in severe distress. Blood pressure is $210/110$ mmHg in the right arm and $170/90$ mmHg in the left arm. Heart rate is $112$/min. Physical examination reveals an early diastolic decrescendo murmur auscultated at the right upper sternal border. Neurological examination is unremarkable. Electrocardiogram shows left ventricular hypertrophy without acute ischemic changes. Arrange the following management steps in the most appropriate sequential order for this patient.

During morning rounds, a physician evaluates a patient hospitalized for the treatment of high-grade Burkitt lymphoma. The patient received his first cycle of cytotoxic chemotherapy 24 hours ago. He now complains of severe muscle cramps, perioral numbness, and progressive nausea.

Vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $108/65 \text{ mm Hg}$, pulse $115/\text{min}$, and respirations $18/\text{min}$. Physical examination reveals hyperactive deep tendon reflexes and a positive Chvostek sign.

Laboratory evaluation reveals the following:
* Sodium: $137 \text{ mEq/L}$
* Potassium: $7.3 \text{ mEq/L}$
* Bicarbonate: $18 \text{ mEq/L}$
* Blood urea nitrogen: $52 \text{ mg/dL}$
* Creatinine: $3.1 \text{ mg/dL}$ (baseline $0.9 \text{ mg/dL}$)
* Calcium: $6.2 \text{ mg/dL}$
* Phosphorus: $9.1 \text{ mg/dL}$
* Uric acid: $16.4 \text{ mg/dL}$

A 12-lead electrocardiogram demonstrates peaked T waves and widening of the QRS complex. Which of the following is the most appropriate initial intervention?

Paramedics arrive at the emergency department with a 58-year-old male executive who experienced an abrupt onset of excruciating, sharp pain between his shoulder blades while in a board meeting. His medical history is significant for tobacco use and noncompliance with antihypertensive medications. Vital signs reveal a blood pressure of $215/118\text{ mm Hg}$, a heart rate of $118\text{/min}$, and a respiratory rate of $22\text{/min}$. Cardiac auscultation reveals a regular rhythm with a new early diastolic murmur at the right sternal border. An immediate bedside electrocardiogram shows left ventricular hypertrophy without acute ischemic changes. Given the high clinical suspicion for an acute vascular emergency, arrange the following management steps in the most appropriate chronological sequence from first to last.

A 68-year-old man is evaluated on hospital day 3 for management of community-acquired pneumonia. He was admitted with a 3-day history of productive cough, fever, and shortness of breath. On admission, chest radiography revealed a left lower lobe infiltrate. He was started on empiric intravenous ceftriaxone and intravenous azithromycin. Today, his cough and shortness of breath have significantly improved. He is tolerating a regular diet well. His temperature is $37.1^{\circ}\text{C}$ ($98.8^{\circ}\text{F}$), blood pressure is $128/82\text{ mm Hg}$, pulse is $78/\text{min}$, and respiratory rate is $16/\text{min}$. Oxygen saturation is $96\%$ on ambient air. A sputum culture obtained on admission grew *Streptococcus pneumoniae*. Antimicrobial susceptibility testing demonstrates that the isolate is susceptible to penicillin, amoxicillin, ceftriaxone, and levofloxacin, but resistant to azithromycin. Which of the following is the most appropriate next step in antimicrobial therapy?

A 68-year-old man is admitted to the medical ward following a 4-day history of worsening diarrhea and generalized weakness. He states he has been unable to keep fluids down. His past medical history is significant for hypertension and osteoarthritis. His temperature is 37.0°C (98.6°F), blood pressure is 98/60 mm Hg, and pulse is 108/min. Jugular venous pressure is decreased, and skin turgor is poor. A Foley catheter is placed, yielding a small amount of concentrated urine.

Laboratory evaluation reveals the following:

What is this patient's fractional excretion of sodium?

A 68-year-old man with a known history of severe chronic obstructive pulmonary disease (COPD) comes to the emergency department reporting a 3-day history of progressively worsening shortness of breath. He also notes a significant increase in the amount of sputum he produces daily, and he reports the sputum has changed from clear to dark yellow. His last COPD exacerbation was 2 years ago, and he has not been hospitalized recently. Vital signs show a temperature of 37.4°C (99.3°F), blood pressure of 135/85 mmHg, heart rate of 98/min, and respiratory rate of 22/min. Oxygen saturation is 89% on room air. Physical examination reveals a prolonged expiratory phase with diffuse bilateral wheezing. There is no jugular venous distension, and trace bilateral lower extremity edema is present, which the patient states is his baseline. Which of the following are appropriate initial pharmacological interventions for this patient? (Select all that apply)

A 38-year-old woman presents to the emergency department with a 3-day history of spontaneous mucosal bleeding, easy bruising, and extreme fatigue. Laboratory studies reveal a leukocyte count of 45,000/mm³, hemoglobin of 7.9 g/dL, and platelet count of 18,000/mm³. Coagulation panel shows a prolonged prothrombin time, prolonged activated partial thromboplastin time, elevated D-dimer, and profoundly decreased fibrinogen levels. Acute promyelocytic leukemia (APL) is highly suspected based on the presentation of pancytopenia with disseminated intravascular coagulation (DIC).

Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for the management of this patient.

A 68-year-old man is brought to the emergency department due to a syncopal episode at home. Over the past 3 days, he has experienced progressively worsening shortness of breath and a dry cough. His medical history is significant for severe chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and a recent diagnosis of prostate cancer. His current medications include inhaled tiotropium, inhaled albuterol as needed, and metformin.

On arrival, his temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $82/50\text{ mm Hg}$, pulse is $122/\text{min}$, and respirations are $28/\text{min}$. Pulse oximetry shows $84\%$ on room air.

Physical examination reveals significant jugular venous distention to the angle of the jaw. Cardiac auscultation demonstrates a loud second heart sound ($P_2$) at the left upper sternal border and a holosystolic murmur at the left lower sternal border that increases in intensity with inspiration. Lung auscultation reveals faint, bilateral end-expiratory wheezes without crackles. The right calf is visibly swollen and tender to palpation.

A bedside echocardiogram demonstrates a severely dilated, hypokinetic right ventricle with bowing of the interventricular septum into the left ventricle.

Arterial blood gas analysis on room air reveals:
pH: $7.29$
$\text{PaCO}_2$: $32\text{ mm Hg}$
$\text{PaO}_2$: $52\text{ mm Hg}$
$\text{HCO}_3^-$: $15\text{ mEq/L}$

Serum lactic acid is $5.4\text{ mmol/L}$.

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

A 27-year-old woman comes to the clinic reporting a 4-month history of rapidly increasing facial and body hair. She also mentions that her voice has deepened recently and her menstrual periods, previously regular, have stopped completely over the same timeframe. She has no significant past medical history and takes no medications. Her blood pressure is 118/76 mm Hg, pulse is 72/min, and BMI is 23 kg/m². Physical examination reveals coarse, dark hair over the upper lip, chin, chest, and lower abdomen. Temporal hair thinning is noted. Pelvic examination demonstrates significant clitoromegaly. Which of the following is the most appropriate next step in the evaluation of this patient?

A $55$-year-old woman is evaluated in the emergency department for severe shortness of breath that has worsened over the past $2$ days. She has a history of asthma and hypertension. Her home medications include inhaled budesonide-formoterol and oral amlodipine. Over the last $12$ hours, she has been using her albuterol rescue inhaler every hour with minimal relief.

On initial presentation, she is in acute respiratory distress, using accessory muscles of respiration. Lung auscultation reveals diffuse expiratory wheezing. She has $1+$ bilateral lower extremity pitting edema, which she states is her baseline. Initial treatment is initiated with oxygen, continuous nebulized albuterol and ipratropium, intravenous methylprednisolone, and intravenous magnesium sulfate.

Four hours later, the patient reports that her breathing is significantly easier. Her work of breathing has decreased, and wheezing is now faint and only audible at the lung bases. However, she now reports new-onset palpitations and hand tremors.

Current vital signs:
Temperature: $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$)
Blood pressure: $122/78\text{ mm Hg}$
Heart rate: $118/\text{min}$
Respiratory rate: $16/\text{min}$
SpO2: $96\%$ on room air

Laboratory evaluation reveals:
Serum sodium: $140\text{ mEq/L}$
Serum potassium: $3.6\text{ mEq/L}$
Serum chloride: $104\text{ mEq/L}$
Serum bicarbonate: $15\text{ mEq/L}$
Serum lactate: $4.8\text{ mmol/L}$ (Normal: $0.5$-$1.0\text{ mmol/L}$)

Arterial blood gas (room air):
pH: $7.32$
PaCO2: $30\text{ mm Hg}$
PaO2: $84\text{ mm Hg}$

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

During morning rounds, the medical team evaluates a 42-year-old female patient admitted overnight for obstipation and diffuse abdominal discomfort. Her past medical history is significant for Crohn's disease, for which she underwent an ileocecal resection five years ago. Initial emergency department radiographs revealed multiple dilated loops of small bowel with air-fluid levels and a paucity of colonic gas. She was made strictly nothing-by-mouth, and a nasogastric tube was placed for decompression.

Upon bedside reassessment, the patient appears toxic and reports that her abdominal pain has sharply increased, transitioning from intermittent cramping to a severe, continuous ache.

Current vital signs are:
Temperature: $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$)
Heart rate: $122/\text{min}$
Blood pressure: $96/58\text{ mm Hg}$
Respiratory rate: $24/\text{min}$

Physical examination reveals a rigid abdomen with involuntary guarding and diffuse rebound tenderness. Bowel sounds are absent.

Laboratory analysis shows:
Leukocyte count: $18,500/\text{mm}^3$
Serum lactate: $4.2\text{ mmol/L}$
Serum bicarbonate: $15\text{ mEq/L}$

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

Match each clinical presentation of a localized skin and soft tissue infection with the most appropriate empiric oral antimicrobial therapy.

Match each of the following urinalysis sediment findings with the most likely underlying renal etiology or clinical condition.

A 67-year-old retired factory worker is evaluated in the outpatient clinic due to progressive bilateral lower extremity swelling, abdominal fullness, and exertional breathlessness over the past 3 months. He has a 45-pack-year smoking history and a five-year history of severe chronic obstructive pulmonary disease (COPD). His current daily medications include an inhaled corticosteroid, a long-acting muscarinic antagonist, and a long-acting beta-agonist. Today, his blood pressure is 128/78 mmHg, pulse is 88/min, and oxygen saturation is 87% on room air. Physical examination reveals a barrel-shaped chest. Jugular venous distension is prominent at 11 cm H2O. Lung fields are hyperresonant to percussion with globally diminished breath sounds but no crackles. Cardiac auscultation reveals a palpable right ventricular heave and a distinctly loud pulmonic component of the second heart sound (P2), with no apical murmurs or left-sided gallops. Abdominal palpation demonstrates hepatomegaly and a positive hepatojugular reflux. A recent transthoracic echocardiogram confirms severe right ventricular dilation and right ventricular hypertrophy, alongside a normal left ventricular ejection fraction of 62%. Which of the following interventions is most likely to prolong this patient's survival?

Match each clinical presentation with the most likely underlying cardiovascular diagnosis.