Internal Medicine

Emergency medical services bring a 68-year-old male to the resuscitation bay due to acute-onset, unremitting respiratory distress. The patient's spouse reports that he was seated on the couch watching television when he suddenly began gasping for air and clutching his chest. Three days prior, he complained of 'terrible heartburn' but refused to seek medical care. His past medical history is significant for diet-controlled type 2 diabetes mellitus. On arrival, he is profoundly diaphoretic, cyanotic, and confused. Vital signs include a blood pressure of $82/56\text{ mmHg}$, heart rate of $128\text{/min}$, and respiratory rate of $30\text{/min}$. Pulse oximetry reads $84\%$ on high-flow oxygen. Physical examination reveals an elevated jugular venous pressure of $11\text{ cm H}_2\text{O}$. Cardiac auscultation is notable for a loud, blowing grade 4/6 holosystolic murmur heard best at the apex with radiation to the left axilla. Pulmonary examination reveals coarse crackles extending up to the apices bilaterally. An emergent 12-lead electrocardiogram demonstrates deep Q waves and T-wave inversions in leads II, III, and aVF. Which of the following is the most appropriate next step in the management of this patient?

A $72$-year-old man is evaluated in the intensive care unit for persistently abnormal thyroid function tests. He was admitted one week ago for severe sepsis secondary to a perforated diverticulum and underwent emergent exploratory laparotomy and bowel resection. His postoperative course has been complicated by acute kidney injury and respiratory failure requiring mechanical ventilation, though his clinical status is now slowly improving. He has no prior history of thyroid disorders. Current medications include broad-spectrum antibiotics, prophylactic heparin, and pantoprazole. Vital signs show temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $110/70$ mmHg, and heart rate $88$/min. Physical examination reveals a healing abdominal incision and no palpable thyroid enlargement.

Laboratory studies show:
TSH: $0.2$ $\mu$ U/mL (Reference: $0.4 - 4.0$ $\mu$ U/mL)
Free T4: $0.7$ ng/dL (Reference: $0.9 - 1.7$ ng/dL)
Total T3: $40$ ng/dL (Reference: $80 - 200$ ng/dL)

Which of the following is the most appropriate management of this patient's thyroid laboratory abnormalities?

A 42-year-old man is evaluated in the clinic for a two-year history of severe, burning epigastric pain and chronic, high-volume watery diarrhea. He reports having had two episodes of melena over the past year. His current medications include high-dose omeprazole, which provides only transient and partial relief of his symptoms. An esophagogastroduodenoscopy is performed, revealing prominently thickened gastric folds and multiple deep ulcerations extending past the duodenal bulb into the distal duodenum and proximal jejunum. The physician suspects a specific neuroendocrine tumor is responsible for this clinical presentation. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for evaluating and treating this patient's suspected condition.

A 52-year-old woman is evaluated in the emergency department for altered mental status and profound weakness. For the past week, she has experienced a worsening cough productive of rust-colored sputum, right-sided chest pain, and high fevers. Her husband notes she became progressively confused this morning.

Temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), pulse is $128/\text{min}$, respirations are $26/\text{min}$, and blood pressure is $82/50\text{ mm Hg}$. Pulse oximetry shows $88\%$ on $4\text{ L/min}$ via nasal cannula. Physical examination reveals a lethargic patient who only opens her eyes to painful stimuli. Auscultation demonstrates bronchial breath sounds and crackles over the right lower lung field. Jugular venous pressure is $5\text{ cm H}_2\text{O}$.

Laboratory and arterial blood gas (ABG) studies are obtained:

A rapid chest radiograph shows a dense consolidation in the right lower lobe. Intravenous fluids and appropriate narrow-spectrum antibiotics based on the local antibiogram for community-acquired pneumonia are immediately prescribed.

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

A 27-year-old female with a history of type 1 diabetes mellitus and asthma is evaluated in the emergency department for a three-day history of worsening cough, fever, and shortness of breath. She has been unable to eat and has missed several doses of her basal insulin. On physical examination, her temperature is $38.5^{\circ}\text{C}$ ($101.3^{\circ}\text{F}$), blood pressure is 105/65 mmHg, pulse is 118/min, and respirations are 32/min. The patient appears lethargic and is using accessory muscles for respiration.

Laboratory studies reveal the following:

Arterial blood gas analysis on room air:

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

A $68$-year-old man is evaluated in the hospital on the $3$ rd day of admission for sepsis secondary to a complicated urinary tract infection. He initially presented to the emergency department with fever, severe chills, and left-sided flank pain. His medical history includes benign prostatic hyperplasia and type 2 diabetes mellitus. On admission, his blood pressure was $88/56$ mm Hg and his heart rate was $112$/min. He received aggressive intravenous fluid resuscitation and was started on empiric intravenous vancomycin and cefepime.

Currently, the patient is clinically stable. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $126/82$ mm Hg, and pulse is $78$/min. He reports that his flank pain has significantly improved.

Blood and urine cultures obtained on admission both grow $>100,000$ CFU/mL of *Enterococcus faecalis*. Antimicrobial susceptibility testing results are as follows:

Ampicillin: Susceptible
Vancomycin: Susceptible
Linezolid: Susceptible
Daptomycin: Susceptible
Ciprofloxacin: Resistant

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

Match each classic electrocardiogram (ECG) finding with its most likely associated cardiovascular condition or electrolyte disturbance.

A $70$-year-old man is brought to the emergency department due to sudden-onset severe shortness of breath, generalized weakness, and confusion that developed over the past $4$ hours. His medical history is significant for an inferior ST-elevation myocardial infarction $5$ days ago (for which he presented late and was managed medically), severe chronic obstructive pulmonary disease (COPD), bipolar I disorder, and chronic kidney disease.

On presentation, the patient is lethargic and oriented only to person. Temperature is $35.8^{\circ}\text{C}$ ($96.4^{\circ}\text{F}$), blood pressure is $82/52\text{ mmHg}$, heart rate is $118\text{/min}$, and respiratory rate is $28\text{/min}$. Oxygen saturation is $85\%$ on room air. Physical examination reveals distended neck veins up to the angle of the mandible while sitting at a $45$-degree angle. Chest auscultation demonstrates bilateral crackles extending to the mid-lung fields and diffuse expiratory wheezes. Cardiac auscultation reveals tachycardia with a new, harsh, holosystolic murmur heard best at the apex with radiation to the axilla. His extremities are cool and clammy with $2+$ bilateral pitting edema.

Laboratory studies show:
Leukocyte count: $12,500\text{/mm}^3$
Serum sodium: $131\text{ mEq/L}$
Serum potassium: $4.9\text{ mEq/L}$
Serum chloride: $96\text{ mEq/L}$
Serum bicarbonate: $14\text{ mEq/L}$
Blood urea nitrogen: $55\text{ mg/dL}$
Serum creatinine: $2.6\text{ mg/dL}$ (baseline $1.3\text{ mg/dL}$)
Serum lactate: $6.2\text{ mmol/L}$

Arterial blood gas on room air:
pH: $7.26$
$\text{PaCO}_2$: $29\text{ mmHg}$
$\text{PaO}_2$: $54\text{ mmHg}$

A sputum culture collected three days ago at his primary care clinic for a mild chronic cough has grown *Streptococcus pneumoniae*, which is fully susceptible to amoxicillin. His family mentions he has been profoundly depressed over the past three weeks and urgently requests he be started on fluoxetine.

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

A $69$-year-old man presents to the clinic complaining of a persistent dry cough, progressive shortness of breath on exertion, and worsening fatigue over the last two months. He also notes new-onset anxiety and difficulty sleeping due to his respiratory distress. His past medical history is significant for ischemic cardiomyopathy with a reduced ejection fraction and recurrent symptomatic sustained ventricular tachycardia, for which he takes amiodarone, lisinopril, carvedilol, escitalopram, and rivaroxaban. He has a $10$-pack-year smoking history but quit $15$ years ago. Vital signs include a blood pressure of $112/68\text{ mmHg}$, a heart rate of $64/\text{min}$, a respiratory rate of $22/\text{min}$, and an oxygen saturation of $91\%$ on ambient air. Physical examination reveals fine, late-inspiratory crackles at both lung bases. The jugular venous pressure is $6\text{ cm H}_2\text{O}$. There is no lower extremity edema. Laboratory studies show a leukocyte count of $8,200/\text{mm}^3$, a serum thyroid-stimulating hormone (TSH) level of $8.5\text{ \mu U/mL}$ (normal: $0.4-4.0\text{ \mu U/mL}$), and a free thyroxine (T4) level of $0.6\text{ ng/dL}$ (normal: $0.8-1.8\text{ ng/dL}$). His B-type natriuretic peptide (BNP) level is $145\text{ pg/mL}$ (similar to a baseline of $150\text{ pg/mL}$ three months ago). An electrocardiogram demonstrates normal sinus rhythm with a QTc interval of $475\text{ ms}$. High-resolution computed tomography of the chest reveals peripheral, bilateral ground-glass opacities with associated septal thickening. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old female is admitted to the hospital from an assisted living facility due to five days of severe, voluminous watery diarrhea. On presentation, she is lethargic with dry mucous membranes and delayed capillary refill. Her blood pressure is 88/54 mm Hg and her heart rate is 115/min. Laboratory studies are obtained:

Assuming a normal anion gap of 12 mEq/L and a normal serum bicarbonate of 24 mEq/L, what is this patient's delta-delta ratio ($\frac{\Delta AG}{\Delta HCO_3^-}$)?

A $78$-year-old man develops massive abdominal distension three days after undergoing an uncomplicated right total hip arthroplasty. He reports diffuse abdominal discomfort but no severe pain, nausea, or vomiting. He has not passed flatus or had a bowel movement since the surgery. Current medications include lisinopril, tamsulosin, and intravenous morphine for postoperative pain control. Physical examination reveals a markedly distended, tympanic abdomen with high-pitched bowel sounds but no rigidity, guarding, or rebound tenderness. A portable plain radiograph of the abdomen demonstrates marked dilation of the colon extending to the splenic flexure, with a maximal cecal diameter of $10.5$ cm. Arrange the following steps in the standard, chronological order for the evaluation and progressive management of this patient's condition.

A 55-year-old woman is evaluated in the emergency department due to a 4-day history of progressively worsening shortness of breath. She reports that her baseline chronic morning cough has increased in frequency and is now producing thick, yellow sputum. She has a 35-pack-year smoking history. Her temperature is $37.5^\circ\text{C}$ ($99.5^\circ\text{F}$), blood pressure is $132/82\text{ mm Hg}$, pulse is $96/\text{min}$, and respiratory rate is $22/\text{min}$. Pulse oximetry on room air is $92\%$. Physical examination reveals a prolonged expiratory phase with diffuse bilateral expiratory wheezing. Jugular venous pressure is $6\text{ cm H}_2\text{O}$. There is no peripheral edema. Chest radiograph shows hyperinflated lung fields with flattened diaphragms but no focal consolidation or pulmonary edema. Arterial blood gas analysis on room air reveals:

$\text{pH}$: $7.37$
$\text{pCO}_2$: $50\text{ mm Hg}$
$\text{pO}_2$: $66\text{ mm Hg}$
$\text{HCO}_3^-$: $28\text{ mEq/L}$

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

A 55-year-old male is brought to the emergency department by his partner due to severe headache, fever, and progressive confusion over the past 24 hours. He has a known history of HIV infection and his most recent CD4 count was 150/mm³. Vital signs show a temperature of 39.0°C (102.2°F), blood pressure of 110/70 mm Hg, and heart rate of 112/min. On physical examination, marked nuchal rigidity is present. Neurological evaluation reveals a sluggishly reactive right pupil and a new mild left-sided hemiparesis. A diagnosis of bacterial meningitis is strongly suspected.

Arrange the following diagnostic and therapeutic interventions in the most appropriate chronological sequence for this patient's management.

A series of critically ill patients presenting with hypotension and tachycardia undergo pulmonary artery catheterization for hemodynamic monitoring in the intensive care unit. Match each specific hemodynamic profile obtained (Profiles 1 through 4) with the most likely underlying cardiovascular or cardiopulmonary pathology.

(Reference ranges: Right atrial [RA] pressure 2-8 mmHg; Pulmonary artery [PA] pressure 15-30/4-12 mmHg; Pulmonary capillary wedge pressure [PCWP] 6-12 mmHg; Cardiac index [CI] 2.5-4.0 L/min/m²).

Emergency medical services bring a 58-year-old male to the acute care bay complaining of relentless, diffuse abdominal pain that started two days ago. The patient reports having vomited bilious material several times and notes a complete inability to pass stool or flatus since the pain began. His surgical history is significant for an open appendectomy a decade ago. Vital signs show a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), a heart rate of $122/\text{min}$, and a blood pressure of $86/54\text{ mmHg}$. Abdominal examination demonstrates marked distension, tympany to percussion, and exquisite diffuse tenderness accompanied by board-like rigidity and rebound tenderness. Laboratory evaluation is notable for a leukocyte count of $19,500/\text{mm}^3$ and a serum lactate level of $4.8\text{ mmol/L}$. Venous blood gas reveals a pH of $7.28$ and a bicarbonate concentration of $14\text{ mEq/L}$. Which of the following is the most appropriate next step in management?

A 28-year-old woman is brought to the emergency department due to a 2-day history of worsening, diffuse abdominal pain and recurrent vomiting of greenish material. She reports that her pain was initially crampy and intermittent but has become constant and severe over the past 6 hours. She has not had a bowel movement or passed flatus since the symptoms began. Her medical history is significant for stricturing ileal Crohn's disease, for which she was previously treated with infliximab, but she discontinued all medications a year ago. Her temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), pulse is $124/\text{min}$, blood pressure is $88/54 \text{ mmHg}$, and respirations are $22/\text{min}$. Physical examination reveals a distended, tympanitic abdomen with absent bowel sounds. There is diffuse tenderness with marked guarding and rebound tenderness in the right lower quadrant. Laboratory studies show a leukocyte count of $21,000/\text{mm}^3$ with $15\%$ bands, and a serum lactate level of $4.8 \text{ mmol/L}$. An abdominal CT scan with intravenous contrast demonstrates markedly dilated loops of small intestine with a distinct transition point in the terminal ileum. There is circumferential thickening of the terminal ileum, pneumatosis intestinalis, and moderate free fluid in the pelvis. Which of the following is the most appropriate next step in management?

Paramedics arrive at the emergency department with a lethargic 65-year-old man in severe respiratory distress. His wife reports that his breathing has grown progressively labored over the last two days, accompanied by a persistent cough. His medical background is significant for ischemic cardiomyopathy (ejection fraction $35\%$), severe chronic obstructive pulmonary disease (COPD), and hypothyroidism. Home medications include lisinopril, metoprolol, tiotropium, and levothyroxine.

Vital signs upon arrival show a temperature of $37.2^\circ \text{C}$ ($99.0^\circ \text{F}$), blood pressure of $145/88 \text{ mm Hg}$, heart rate of $118\text{/min}$, and respiratory rate of $28\text{/min}$. Oxygen saturation is $84\%$ on ambient air.

On physical examination, the patient is somnolent but awakens when his name is called loudly. His jugular venous pressure is normal at $7 \text{ cm H}_2\text{O}$. Auscultation of the lungs reveals diminished air entry globally, a notably prolonged expiratory phase, and diffuse expiratory wheezing. No crackles or rales are heard. Cardiac auscultation demonstrates tachycardia with a regular rhythm and no $S_3$ gallop. The lower extremities are free of edema.

Initial laboratory results are as follows:

Chest radiograph reveals hyperinflated lungs with flattened hemidiaphragms; there are no focal consolidations, pleural effusions, or pulmonary vascular congestion.

Noninvasive positive pressure ventilation (NIPPV) is initiated, and the patient's respiratory effort improves slightly.

Which of the following represents the most accurate diagnostic assessment and most appropriate next step in pharmacologic management?

A $62$-year-old retired mechanic comes to the outpatient clinic with a $3$-day history of progressively worsening dyspnea. He states that his daily morning cough has become more frequent and is now producing thick, dark yellow sputum in significantly greater amounts than usual. His medical history is significant for chronic obstructive pulmonary disease and hypertension. He previously smoked $2$ packs of cigarettes daily for $20$ years before quitting $5$ years ago. His temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), pulse is $98/\text{min}$, respirations are $22/\text{min}$, and blood pressure is $135/85\text{ mmHg}$. Pulse oximetry shows $93\%$ on ambient air. Pulmonary auscultation demonstrates a prolonged expiratory phase with diffuse bilateral wheezing. Cardiovascular examination is unremarkable with no jugular venous distention. There is no peripheral edema. Which of the following therapeutic interventions are indicated for this patient? (Select all that apply)

A 58-year-old woman presents to the clinic complaining of progressive fatigue, generalized weakness, and a tingling sensation in her lower extremities that has steadily worsened over the past four months. Her past medical history is significant for vitiligo and Hashimoto thyroiditis, for which she takes daily levothyroxine. Vital signs are temperature 36.8°C (98.2°F), blood pressure 118/76 mmHg, heart rate 82/min, and respiratory rate 14/min. Physical examination reveals pale conjunctivae, a smooth and beefy-red tongue, and decreased vibratory sensation in both feet.

Laboratory results are as follows:

A peripheral blood smear demonstrates macro-ovalocytes and several neutrophils with six or more lobes.

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

A 76-year-old woman is evaluated in the clinic prior to an elective right total knee arthroplasty scheduled for the following week. She has a history of osteoarthritis and well-controlled essential hypertension. She reports no new symptoms and specifically denies dysuria, urinary frequency, urgency, suprapubic pain, fever, or chills. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $128/78\text{ mm Hg}$, and pulse is $76/\text{min}$. Physical examination of the abdomen and costovertebral angles is unremarkable. As part of her preoperative evaluation, a urinalysis is obtained which shows $15$ white blood cells/hpf and is positive for leukocyte esterase and nitrites. A subsequent urine culture grows $>10^5\text{ CFU/mL}$ of Escherichia coli that is susceptible to ceftriaxone, ciprofloxacin, trimethoprim-sulfamethoxazole, and nitrofurantoin. Which of the following is the most appropriate management regarding these laboratory findings?