Internal Medicine

A 45-year-old man presents to the emergency department with a 4-week history of productive cough, hemoptysis, drenching night sweats, and a $6\text{-kg}$ ($13\text{-lb}$) weight loss. He recently emigrated from a region highly endemic for tuberculosis. His temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $120/78\text{ mm Hg}$, and pulse is $92/\text{min}$. A chest radiograph reveals a $3\text{-cm}$ cavitary lesion in the right upper lobe. Arrange the following management steps in the most appropriate chronological sequence.

A 72-year-old man is brought to the emergency department due to the sudden onset of severe shortness of breath and a cough productive of pink, frothy sputum that began $1$ hour ago. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$, mild chronic obstructive pulmonary disease (COPD), and poorly controlled hypertension. His current medications include lisinopril, metoprolol succinate, aspirin, and a tiotropium inhaler. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $220/120$ mmHg, pulse is $115$/min, and respirations are $32$/min. Pulse oximetry shows $84\%$ on room air. The patient is alert, oriented, and speaks in short, gasping phrases. Physical examination reveals use of accessory muscles of respiration. Auscultation of the lungs reveals diffuse, high-pitched expiratory wheezes bilaterally with no audible crackles. Cardiovascular examination reveals a regular tachycardia with a prominent $S_4$ gallop. There is no jugular venous distention or lower extremity edema. An arterial blood gas analysis on room air shows:

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

A 45-year-old man is evaluated for treatment-resistant hypertension. His current medications include amlodipine, olmesartan, and hydrochlorothiazide. His blood pressure is 165/100 mmHg. Laboratory studies reveal a serum potassium level of 3.1 mEq/L and a serum sodium level of 144 mEq/L. The physician suspects primary aldosteronism and appropriately transitions the patient's antihypertensive regimen to non-interfering medications (e.g., verapamil, doxazosin) for accurate biochemical testing. Arrange the following steps in the correct sequential order for the comprehensive diagnostic workup and pre-surgical evaluation of this patient, from initial screening to final functional lateralization.

Match each brief clinical presentation of chronic diarrhea to its most likely underlying etiology or pathogenesis.

A 74-year-old woman is admitted to the hospital with a 4-week history of progressively worsening exertional dyspnea, increased abdominal girth, and bilateral lower extremity swelling. She has a history of chronic obstructive pulmonary disease (COPD), essential hypertension, and obesity ($BMI$ 36 kg/m $^2$). Her current medications include amlodipine, lisinopril, and a tiotropium inhaler. Blood pressure is 155/92 mm Hg, pulse is 92/min, and respirations are 20/min. Pulse oximetry is 94% on room air. Jugular venous pressure is estimated at 12 cm $H_2O$ and shows a prominent v wave. Lung auscultation reveals distant breath sounds with prolonged expiration and scattered end-expiratory wheezes. Cardiac examination shows a regular rhythm, a right-sided S3 gallop, and a 3/6 holosystolic murmur at the left lower sternal border that increases with inspiration. The abdomen is distended with shifting dullness, and there is 3+ pitting edema of the lower extremities extending to the thighs.

Laboratory testing reveals the following:
Brain natriuretic peptide (BNP): 650 pg/mL
Thyroid-stimulating hormone (TSH): 1.2 $\mu U/mL$ (normal: 0.4-4.0 $\mu U/mL$)
Free thyroxine (T4): 0.7 ng/dL (normal: 0.9-1.7 ng/dL)
Arterial blood gas (room air): pH 7.32, $pCO_2$ 55 mm Hg, $HCO_3^-$ 28 mEq/L

An echocardiogram shows a normal-sized left ventricle with an ejection fraction of 65%. The left atrium is severely enlarged (volume index 48 mL/m $^2$). The right ventricle is dilated and hypokinetic. Estimated pulmonary artery systolic pressure is 70 mm Hg. Tissue Doppler imaging of the mitral annulus shows an $E/e'$ ratio of 18 (normal $< 8$).

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

A patient presents to the emergency department with a $3$-day history of worsening dyspnea and increased production of purulent, yellow sputum. The patient is $72$ years of age and has documented heart failure with preserved ejection fraction, as well as advanced chronic obstructive pulmonary disease (COPD). His home medications consist of umeclidinium, fluticasone, and lisinopril.

Upon evaluation, he is using accessory muscles to breathe. Vital signs show a temperature of $37.2^\circ$ C ($99.0^\circ$ F), a blood pressure of $145/90$ mm Hg, a heart rate of $112$/min, and a respiratory rate of $26$/min. Pulse oximetry displays $88\%$ on ambient air. Physical examination reveals jugular venous distention up to $8$ cm above the sternal angle. Auscultation of the lungs demonstrates a prolonged expiratory phase with diffuse wheezing and scattered basilar crackles. The patient has trace bilateral pitting edema in the lower extremities.

A Gram stain of the sputum demonstrates numerous polymorphonuclear leukocytes and Gram-positive diplococci.

An arterial blood gas analysis obtained on room air indicates:

A chest radiograph displays hyperinflation and flattened hemidiaphragms but lacks focal consolidations or pleural effusions.

Which of the following represents the most appropriate initial management for this patient?

A 71-year-old woman who resides in a skilled nursing facility is currently receiving care in the intensive care unit for septic shock. She initially presented 48 hours ago with a temperature of 39.2°C (102.6°F), lethargy, and severe hypotension. A chronically encrusted indwelling urinary catheter was identified as the suspected source and immediately removed. Due to her frequent healthcare exposure and risk for multidrug-resistant organisms, empiric antimicrobial therapy was initiated with meropenem and linezolid. She has improved significantly over the past two days, and vasopressor support has been successfully discontinued. Current vital signs are temperature 37.1°C (98.8°F), blood pressure 122/78 mm Hg, pulse 84/min, and respirations 16/min. Finalized results from both blood and urine cultures isolate Proteus mirabilis. Susceptibility testing reveals the organism is resistant to tetracycline but fully susceptible to ampicillin, ceftriaxone, cefepime, piperacillin-tazobactam, and meropenem. Which of the following is the most appropriate pharmacological intervention at this time?

A 62-year-old woman is brought to the emergency department by her family due to a three-day history of productive cough, fever, and progressively worsening shortness of breath. Her past medical history is significant for type 2 diabetes mellitus and essential hypertension. Upon arrival, she appears lethargic and is in marked respiratory distress. Vital signs show a temperature of $38.9^\circ\text{C}$ ($102^\circ\text{F}$), blood pressure of $86/52$ mm Hg, pulse of $124$/min, and respirations of $28$/min. Pulse oximetry indicates an oxygen saturation of $87\%$ on room air. Physical examination demonstrates prominent use of accessory muscles of respiration and coarse crackles over the right lower lung field. Cardiac examination reveals tachycardia with a regular rhythm and no murmurs.

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

A 62-year-old man is recovering in the intensive care unit on day 3 of an admission for acute hypoxemic respiratory failure secondary to severe community-acquired pneumonia. Upon admission, he required endotracheal intubation and mechanical ventilation. Empiric therapy was initiated with intravenous vancomycin and cefepime. Today, his clinical condition has markedly improved; he is afebrile, his oxygenation has stabilized, and he is being evaluated for extubation. Sputum cultures obtained via endotracheal aspirate on admission are now growing Streptococcus pneumoniae. Susceptibility testing demonstrates that the organism is highly sensitive to penicillin, ceftriaxone, and levofloxacin, but resistant to macrolides. Blood cultures from admission have shown no growth. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 35-year-old woman presents to the emergency department with profound weakness in her legs that began earlier today. She reports difficulty standing from a seated position. Her medical history is significant for Sjögren syndrome and recurrent nephrolithiasis. She denies recent diarrhea, vomiting, or changes in her medications. Her temperature is 37.0°C (98.6°F), blood pressure is 110/70 mm Hg, pulse is 88/min, and respiratory rate is 16/min with shallow breaths. Physical examination reveals 2/5 motor strength in the bilateral lower extremities and diminished deep tendon reflexes.

Laboratory results are as follows:

Arterial blood gas on room air:

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

A 67-year-old male with a 45-pack-year smoking history is evaluated in the intensive care unit for progressive dyspnea, marked bilateral lower extremity edema, and elevated jugular venous pressure. Echocardiography demonstrates a dilated right ventricle with severe tricuspid regurgitation, but a normal left ventricular ejection fraction. He is diagnosed with severe cor pulmonale secondary to advanced chronic obstructive pulmonary disease (COPD). Arrange the following pathophysiological mechanisms in the correct chronological sequence that led to this patient's current cardiovascular state, starting with the primary respiratory insult.

Select the most appropriate first-line antimicrobial therapy for each of the following patient presentations.

A 2nd-year internal medicine resident is preparing a presentation on inherited and acquired renal tubular disorders. Match each of the following tubulopathies with its primary pathophysiological defect or defining molecular characteristic.

A $44$-year-old woman is evaluated in the outpatient clinic due to profound fatigue, generalized muscle cramps, and a $6$-kg ($13.2$-lb) weight gain over the past several months. She reports feeling constantly sluggish and relies on multiple blankets at night despite living in a warm environment. Her medical history is significant for a nonfunctioning pituitary macroadenoma treated with transsphenoidal resection and subsequent adjuvant radiotherapy three years ago. Her blood pressure is $105/65$ mmHg and pulse is $54$/min. Physical examination demonstrates a puffy face and delayed relaxation of the deep tendon reflexes.

Before initiating targeted pharmacotherapy for her thyroid abnormalities, which of the following is the most appropriate next step in management?

Match each clinical presentation of a patient with a suspected hereditary gastrointestinal syndrome to the most accurate diagnosis.

A 24-year-old man with a known history of sickle cell anemia presents to the emergency department reporting acute-onset chest pain, shortness of breath, and a productive cough. His symptoms began 12 hours ago and have progressively worsened. His temperature is $38.6^\circ C$ ($101.5^\circ F$), blood pressure is 110/70 mm Hg, pulse is 118/min, and respiratory rate is 28/min. Oxygen saturation is 88% on room air. Physical examination reveals dullness to percussion and decreased breath sounds over the right lower lung field.

Laboratory evaluation shows:
Hemoglobin: 7.0 g/dL
Leukocyte count: $18,000/mm^3$
Platelet count: $450,000/mm^3$
Reticulocyte count: 14%

Arterial blood gas on room air:
$pH$: 7.48
$PaO_2$: 55 mm Hg
$PaCO_2$: 30 mm Hg

Chest radiograph demonstrates a new right lower lobe consolidation.

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

An $82$-year-old woman arrives at the emergency department accompanied by her daughter. She reports a $3$-day history of progressively worsening, colicky abdominal pain accompanied by multiple episodes of dark green vomiting. The patient mentions she has not passed gas or had a bowel movement for the past $48$ hours. Her past medical history includes hypertension, diet-controlled type 2 diabetes mellitus, and osteoarthritis. Ten years ago, she experienced recurrent episodes of severe postprandial right upper quadrant pain but elected not to undergo surgical intervention. She has never had abdominal or pelvic surgery.

Her temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $112/68\text{ mm Hg}$, pulse is $105/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals dry oral mucosa. The abdomen is markedly distended and tympanic to percussion. Auscultation reveals high-pitched, tinkling bowel sounds. There is mild, diffuse abdominal tenderness but no rigidity, guarding, or rebound tenderness. Laboratory studies show a leukocyte count of $11,200/\text{mm}^3$.

A plain radiograph of the abdomen reveals prominently dilated loops of small bowel with multiple air-fluid levels. Additionally, a branching radiolucency is visible overlying the central liver shadow, and a $3.0\text{ cm}$ opaque calcified density is noted in the right lower quadrant.

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

A $65$-year-old male is evaluated in the cardiac intensive care unit for undifferentiated shock. A pulmonary artery catheter is placed to obtain precise hemodynamic measurements. Match the following cardiac conditions with their most characteristic right heart catheterization hemodynamic profile.

Match the following clinical and laboratory descriptions with the most likely underlying hematologic disorder.

A 28-year-old man is brought to the trauma bay after a high-speed motorcycle collision. He is in severe respiratory distress. His blood pressure is 82/50 mm Hg, heart rate is 135/min, and oxygen saturation is 84% on room air. Physical examination reveals tracheal deviation to the left, distended neck veins, and absent breath sounds over the right hemithorax. The patient is receiving high-flow supplemental oxygen. Arrange the following management steps in the most appropriate chronological sequence for this patient's condition.