Internal Medicine

The intensive care team is evaluating a 64-year-old male who was intubated overnight for progressive hypoxemic and hypercapnic respiratory failure. The patient was admitted to the hospital 48 hours ago for community-acquired pneumonia. His medical history is significant for severe chronic obstructive pulmonary disease (COPD) and hypertension. He is currently sedated and receiving mechanical ventilation.

Current medications include intravenous vancomycin, cefepime, azithromycin, and continuous infusions of propofol and fentanyl.

Current ventilator settings (Volume Assist-Control):

Arterial blood gas (on current settings):

Serum chemistry shows a lactate level of 4.2 mmol/L. Sputum cultures collected at the time of admission are now growing moderate *Streptococcus pneumoniae* that is susceptible to ceftriaxone, levofloxacin, and penicillin.

Physical examination reveals coarse breath sounds bilaterally with a prolonged expiratory phase. Cardiovascular examination reveals regular rate and rhythm with no murmurs. Jugular venous pressure is estimated at 6 cm H $_2$ O (normal < 8 cm H $_2$ O). There is no lower extremity edema.

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

A 69-year-old man presents to the emergency department complaining of progressively worsening shortness of breath over the past 2 days. His medical history is significant for chronic obstructive pulmonary disease, essential hypertension, and a myocardial infarction 5 years ago. The patient reports a cough productive of clear sputum and states he has been sleeping in his recliner chair because lying flat makes him feel as though he is suffocating. His temperature is 37.0 C (98.6 F), blood pressure is 168/96 mmHg, pulse is 108/min, and respiratory rate is 24/min. Oxygen saturation is 90% on room air. On physical examination, the patient is in moderate respiratory distress and is using accessory muscles of respiration. Lung auscultation demonstrates bilateral end-expiratory wheezes and prominent crackles in the lower two-thirds of both lung fields. Cardiac auscultation reveals a regular tachycardia with a distinct third heart sound (S3). The jugular venous pressure is 12 cm H2O. Which of the following findings is most likely to be present on this patient's chest radiograph?

A 62-year-old man is brought to the emergency department after falling from a 10-foot ladder while cleaning his gutters. He states he was lying on the ground for approximately 12 hours before a neighbor found him. He complains of severe, sharp pain in his right lower chest that significantly worsens when he takes a deep breath. His temperature is 36.8°C (98.2°F), blood pressure is 115/75 mmHg, pulse is 112/min, and respiratory rate is 16/min with shallow breaths. Physical examination reveals bruising and marked point tenderness over the right 7th and 8th ribs. Decreased breath sounds are noted at the right lung base.

Laboratory results are as follows:

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

A 58-year-old man presents to the emergency department with sudden-onset, severe "tearing" chest pain that radiates to his back. His blood pressure is 210/115 mm Hg in his right arm and 175/90 mm Hg in his left arm. His heart rate is 112/min. Physical examination reveals a diastolic decrescendo murmur at the right sternal border. An electrocardiogram shows sinus tachycardia, and a portable chest x-ray reveals a widened mediastinum. The physician suspects an acute aortic dissection.

Arrange the following steps in the most appropriate chronological sequence for the management of this patient.

A 68-year-old man with a history of metastatic prostate cancer is brought to the emergency department due to progressively worsening mid-thoracic back pain, bilateral lower extremity weakness, and new-onset urinary incontinence over the past 48 hours. Neurologic examination reveals $3/5$ motor strength in the lower extremities, hyperreflexia at the knees, and decreased pinprick sensation below the T10 dermatome. Arrange the following management steps in the most appropriate chronological sequence for evaluating and treating this patient's oncologic emergency.

A $74$-year-old woman is brought to the emergency department from a skilled nursing facility due to progressive confusion, shortness of breath, and decreased urine output over the last $48$ hours. She has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of $30\%$, severe chronic obstructive pulmonary disease (COPD), and stage III chronic kidney disease. Her temperature is $36.8^\circ C$ ($98.2^\circ F$), blood pressure is $82/54$ mm Hg, pulse is $118$/min, and respirations are $28$/min. Pulse oximetry shows $85\%$ on room air. Physical examination reveals a lethargic patient in moderate respiratory distress. The jugular venous pressure is estimated at $14$ cm $H_2O$. Chest auscultation reveals bilateral basilar crackles and diffuse expiratory wheezes with a prolonged expiratory phase. Cardiac auscultation reveals a regular tachycardia and a prominent third heart sound (S3). The extremities are cool and mottled, with 2+ bilateral pitting edema extending to the knees. Laboratory studies show a leukocyte count of $11,200$/mm $^3$, a blood urea nitrogen of $48$ mg/dL, and a serum creatinine of $2.3$ mg/dL (baseline $1.4$ mg/dL). An arterial blood gas on room air reveals a pH of $7.22$, $PaCO_2$ of $60$ mm Hg, $PaO_2$ of $50$ mm Hg, and $HCO_3^-$ of $24$ mEq/L. Which of the following is the most appropriate initial management for this patient?

A 68-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. He has a history of severe chronic obstructive pulmonary disease and primary hypothyroidism. His current medications include an albuterol inhaler as needed and daily levothyroxine. Temperature is 37.7°C (99.9°F), pulse is 105/min, respirations are 24/min, and blood pressure is 140/90 mm Hg. Pulse oximetry shows 89% on room air. Examination shows a prolonged expiratory phase with diffuse expiratory wheezing. Jugular venous pressure is normal, and there is no lower extremity edema. Laboratory studies show a leukocyte count of 9,000/mm³ and a thyroid-stimulating hormone level of 2.5 µU/mL (normal: 0.4–4.0 µU/mL). Arterial blood gas analysis on room air shows a pH of 7.36, PaCO₂ of 52 mm Hg, and HCO₃⁻ of 29 mEq/L. A chest radiograph reveals hyperinflation without focal consolidation or pulmonary vascular congestion. In addition to supplemental oxygen and inhaled short-acting bronchodilators, which of the following is the most appropriate next step in management?

A 54-year-old man is brought to the emergency department by his wife due to worsening confusion and lethargy over the past 48 hours. He has a history of decompensated alcoholic cirrhosis and was recently discharged after treatment for a variceal bleed. His home medications include nadolol, spironolactone, furosemide, and lactulose. The wife reports he has been having 2 to 3 soft bowel movements daily. Temperature is 38.1°C (100.6°F), blood pressure is 105/65 mmHg, pulse is 98/min, and respirations are 18/min. Physical examination reveals scleral icterus and spider angiomas. The abdomen is distended with a positive fluid wave and shifting dullness. There is diffuse, mild abdominal tenderness to palpation without rebound or guarding. Neurologic examination demonstrates asterixis and disorientation to time and place. Laboratory studies show a leukocyte count of 11,500/mm³, a sodium level of 131 mEq/L, and a bicarbonate level of 18 mEq/L. Which of the following is the most appropriate next step in management?

Match each patient presentation describing a suspected tick-borne illness with the most appropriate targeted antimicrobial therapy.

A 73-year-old woman is brought to the emergency department due to a 4-day history of progressively worsening shortness of breath and an increase in the volume and purulence of her sputum. Her medical history includes severe chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy with a left ventricular ejection fraction of 35%.

Vital signs are temperature 38.1°C (100.6°F), blood pressure 146/88 mmHg, pulse 112/min, and respirations 28/min. Pulse oximetry shows 87% on room air.

Physical examination shows a patient in respiratory distress using accessory muscles. Jugular venous pressure is estimated at 7 cm H2O. Chest auscultation reveals a prolonged expiratory phase with diffuse polyphonic wheezing. There is no lower extremity edema.

Laboratory studies show:
Leukocyte count: 14,200/mm³
B-type natriuretic peptide: 85 pg/mL

Arterial blood gas (room air):
pH: 7.26
PaCO2: 68 mmHg
PaO2: 50 mmHg
HCO3-: 30 mEq/L

A sputum Gram stain reveals numerous polymorphonuclear leukocytes and gram-negative coccobacilli. She is promptly started on noninvasive positive-pressure ventilation, nebulized ipratropium-albuterol, and intravenous methylprednisolone.

Which of the following is the most appropriate additional pharmacologic intervention for this patient?

Match each clinical and serological laboratory profile to the most appropriate hepatobiliary diagnosis.

A $52$-year-old woman is evaluated in the clinic due to new-onset palpitations, resting tremor, and heat intolerance over the past four weeks. She also reports a $3$-kg ($6.6$-lb) unintentional weight loss despite maintaining a normal appetite. Her past medical history is unremarkable, and she takes no medications. Vital signs show a temperature of $37.1^\circ$ C ($98.8^\circ$ F), blood pressure of $135/75$ mmHg, and heart rate of $112$/min. Physical examination reveals warm, moist skin, a fine resting tremor in the outstretched hands, and a diffusely enlarged thyroid gland without discrete nodules. Cardiovascular examination confirms a regular tachycardia. No exophthalmos or pretibial myxedema is noted.

Initial laboratory studies show:

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

A $54$-year-old man is evaluated in the hospital on his third day of admission for community-acquired pneumonia. He was initially started on empiric therapy with intravenous ceftriaxone and oral azithromycin. His cough and shortness of breath have significantly improved, and he has been afebrile for the past $24$ hours. He is currently tolerating a regular diet. Sputum cultures collected on admission grew *Streptococcus pneumoniae*. Susceptibility testing reveals that the isolate is susceptible to penicillin, amoxicillin, ceftriaxone, levofloxacin, and vancomycin, and resistant to azithromycin. He has no known drug allergies. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), pulse $76/\text{min}$, respirations $14/\text{min}$, and blood pressure $124/78\text{ mmHg}$. Pulse oximetry is $97\%$ on room air. The patient is being prepared for discharge. Which of the following is the most appropriate antimicrobial regimen to prescribe for this patient upon discharge?

A 68-year-old man with a history of hypertension and type 2 diabetes mellitus presents to the emergency department with palpitations, fatigue, and mild shortness of breath that began 3 days ago. His blood pressure is 125/80 mm Hg, heart rate is 142/min and irregularly irregular, and respiratory rate is 18/min. An electrocardiogram confirms atrial fibrillation with rapid ventricular response. The physician decides to pursue an early rhythm control strategy to alleviate his persistent symptoms.

Arrange the following management steps in the most appropriate chronological sequence for this patient:

A medical team is reviewing arterial blood gas and basic metabolic panel results for several patients in the intensive care and step-down units. Match each patient's clinical presentation with their most likely primary acid-base disturbance.

An emergency medical services team brings a $76$-year-old female resident of a skilled nursing facility to the hospital because of severe respiratory distress that awakened her from sleep. The patient is unable to speak in full sentences and is actively coughing up pink, frothy sputum. Her past medical history is notable for systemic hypertension, osteoarthritis, and a $30$-pack-year history of smoking (quit $15$ years ago). Two weeks ago, she was prescribed daily naproxen for worsening knee pain.

Upon arrival, her temperature is $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$), blood pressure is $192/108\text{ mmHg}$, heart rate is $118/\text{min}$, and respiratory rate is $30/\text{min}$. Oxygen saturation is $84\%$ on room air.

Physical examination displays prominent use of accessory respiratory muscles. The internal jugular vein is visibly distended while the patient is sitting upright. Chest auscultation reveals diffuse expiratory wheezes and coarse crackles extending halfway up both lung fields. Cardiac examination is significant for a rapid, regular rhythm with a distinct low-frequency sound heard just after $S_2$.

An electrocardiogram shows sinus tachycardia with left ventricular hypertrophy but no acute ischemic changes.

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

A $72$-year-old woman is evaluated in the hospital for sudden-onset shortness of breath and right-sided pleuritic chest pain. She was admitted $3$ days ago for an elective left total hip arthroplasty. Her past medical history is significant for ischemic cardiomyopathy (baseline left ventricular ejection fraction $45\%$), mild chronic obstructive pulmonary disease, and a pituitary macroadenoma treated with transsphenoidal resection $5$ years ago resulting in panhypopituitarism. Her current medications include aspirin, lisinopril, metoprolol succinate, tiotropium, hydrocortisone, and levothyroxine.

Temperature is $37.6^\circ C$ ($99.7^\circ F$), pulse is $118/min$, blood pressure is $132/84$ mm Hg, and respirations are $26/min$. Pulse oximetry shows $88\%$ on room air. Physical examination reveals clear lungs to auscultation bilaterally. The jugular venous pressure is $9$ cm $H_2O$. The right calf is swollen, erythematous, and tender to palpation.

Laboratory results are as follows:
Leukocyte count: $9,500/mm^3$
Thyroid-stimulating hormone (TSH): $1.1 \mu U/mL$ (Normal: $0.4-4.0 \mu U/mL$)
Free thyroxine (T4): $0.6 ng/dL$ (Normal: $0.9-1.7 ng/dL$)

Arterial blood gas on room air:
pH: $7.50$
$PaCO_2$: $28$ mm Hg
$PaO_2$: $56$ mm Hg
$HCO_3^-$: $22 mEq/L$

An electrocardiogram shows sinus tachycardia with a prominent S wave in lead I, a Q wave in lead III, and an inverted T wave in lead III.

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

Match the following structural heart pathologies with their characteristic auscultatory findings and their specific responses to physiological maneuvers.

A $58$-year-old woman is mechanically ventilated in the intensive care unit for acute respiratory distress syndrome (ARDS) secondary to severe pneumonia. She has shown significant clinical improvement over the past $48$ hours. Arrange the following steps in the standard, evidence-based sequential order for assessing readiness and executing liberation from mechanical ventilation.

A 74-year-old man is hospitalized for symptomatic anemia secondary to newly diagnosed myelodysplastic syndrome. His medical history includes chronic obstructive pulmonary disease (COPD) and essential hypertension. His pre-transfusion hemoglobin is 6.1 g/dL.

A transfusion of two units of packed red blood cells is ordered. Thirty minutes into the transfusion of the second unit, the patient reports acute-onset shortness of breath and a dry cough. A urine culture sent on admission for mild dysuria has just resulted, showing >100,000 CFU/mL of *Escherichia coli* that is susceptible to nitrofurantoin and cephalexin, but resistant to ciprofloxacin.

Temperature is 37.1°C (98.8°F), blood pressure is 185/95 mm Hg, pulse is 112/min, and respirations are 28/min. Pulse oximetry shows an oxygen saturation of 85% on room air. Physical examination reveals prominent jugular venous distention. Cardiac examination shows regular tachycardia with a loud S3 gallop. Pulmonary examination reveals bilateral crackles extending halfway up the lung fields, with scattered expiratory wheezes.

Arterial blood gas analysis on room air shows:

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