Internal Medicine

Correlate the following clinical patient profiles with their most likely underlying systemic rheumatologic diagnosis and associated extra-articular complication.

Correlate the following patient presentations with their most characteristic histopathologic finding on renal biopsy.

A $42$-year-old woman is brought to the emergency department by her husband due to progressive confusion, lethargy, and a low-grade fever over the past $24$ hours. She has no significant past medical history. Her temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $142/88$ mmHg, and pulse is $105$/min. Physical examination reveals petechiae on her lower extremities and scleral icterus. Neurologic examination shows a lethargic patient who is oriented only to person.

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

A critical care team evaluates a $64$-year-old woman in the surgical intensive care unit. She was admitted $6$ days ago following an exploratory laparotomy for a perforated duodenal ulcer. Her past medical history is notable for hypertension and mild chronic obstructive pulmonary disease. She remains intubated and mechanically ventilated. Over the past $72$ hours, she has been afebrile and hemodynamically stable without vasopressor support. A nasogastric tube set to low continuous wall suction has drained approximately $1.5\text{ L}$ of greenish fluid daily.

The respiratory therapist initiates a spontaneous breathing trial (SBT) using pressure support ventilation. Thirty minutes into the trial, the patient exhibits a weak respiratory effort with a tidal volume of $250\text{ mL}$. Capnography shows a gradually rising end-tidal carbon dioxide, and the SBT is aborted.

Current laboratory evaluation reveals:

Arterial blood gas (drawn while breathing comfortably on pressure support ventilation just prior to the SBT):
* pH: $7.52$
* PaCO $_2$: $49\text{ mm Hg}$
* PaO $_2$: $85\text{ mm Hg}$

Urine chloride is $8\text{ mEq/L}$.

Which of the following is the most appropriate management to improve her likelihood of successful extubation?

Emergency medical services bring a somnolent $71$-year-old male to the emergency department following three days of escalating dyspnea and increased purulent sputum production. His family reports that he has been excessively sleepy since this morning.

His medical history is significant for severe chronic obstructive pulmonary disease (COPD), ischemic cardiomyopathy with a left ventricular ejection fraction of $40\%$, and hypothyroidism. Home medications include lisinopril, metoprolol succinate, tiotropium, and levothyroxine.

On arrival, his temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $138/82\text{ mm Hg}$, pulse is $108/\text{min}$, and respiratory rate is $26/\text{min}$. Pulse oximetry reveals an oxygen saturation of $86\%$ on ambient air.

Physical examination shows an obtunded patient who arouses only to painful stimuli. The jugular veins are flat when the patient is positioned at $45^\circ$. Cardiac auscultation demonstrates a tachycardic, regular rhythm without murmurs, rubs, or gallops. Lung auscultation reveals a markedly prolonged expiratory phase with diffuse bilateral wheezing, but no crackles are appreciated. The lower extremities show no pitting edema.

Initial laboratory and diagnostic studies reveal the following:

Leukocyte count: $14,500/\text{\mu L}$

Arterial blood gas (ambient air):
pH: $7.24$
PaCO $_2$: $72\text{ mm Hg}$
PaO $_2$: $52\text{ mm Hg}$
HCO $_3^-$: $30\text{ mEq/L}$

Thyroid-stimulating hormone (TSH): $0.2\text{ mIU/L}$ (Reference: $0.5 - 5.0\text{ mIU/L}$)
Free T4: $0.7\text{ ng/dL}$ (Reference: $0.9 - 1.7\text{ ng/dL}$)

A portable chest radiograph displays hyperinflated lung fields and flattened hemidiaphragms, with no focal consolidations, pleural effusions, or pulmonary venous congestion. A sputum Gram stain demonstrates numerous polymorphonuclear leukocytes and Gram-negative coccobacilli.

Which of the following is the most appropriate initial management for this patient's current condition?

A critical care physician is reviewing the mechanical ventilator settings of a $55$-year-old woman in the intensive care unit. She was admitted $2$ days ago for severe community-acquired pneumonia and required endotracheal intubation $12$ hours ago due to progressive hypoxemic respiratory failure. Her current temperature is $37.8^{\circ}C$ ($100^{\circ}F$), blood pressure is $112/74$ mm Hg, and pulse is $98$/min. She is heavily sedated and paralyzed. Chest radiography shows bilateral, diffuse alveolar opacities without cardiomegaly or pleural effusions. Echocardiography performed yesterday demonstrated a normal left ventricular ejection fraction. Current ventilator settings in volume assist-control mode are:

Fraction of inspired oxygen ($FiO_2$): $0.80$
Tidal volume: $8$ mL/kg of predicted body weight
Respiratory rate: $14$/min
Positive end-expiratory pressure (PEEP): $5$ $cm H_2O$

Arterial blood gas analysis reveals:
pH: $7.32$
$PaCO_2$: $50$ mm Hg
$PaO_2$: $54$ mm Hg

Which of the following interventions are indicated for the management of this patient's respiratory failure? (Select all that apply)

A $72$-year-old man is evaluated in the intensive care unit on postoperative day $5$. He was initially admitted for septic shock secondary to a perforated gastric ulcer and underwent an emergent exploratory laparotomy. His current medications include broad-spectrum intravenous antibiotics, pantoprazole, and prophylactic subcutaneous heparin. He has no prior history of endocrine disorders. The patient remains intubated and sedated. Routine morning laboratory studies display the following results:

Thyroid-stimulating hormone (TSH): $0.15$ $\mu$ U/mL (normal: $0.4$-$4.0$ $\mu$ U/mL)
Free thyroxine (T4): $0.7$ ng/dL (normal: $0.9$-$1.7$ ng/dL)
Total triiodothyronine (T3): $45$ ng/dL (normal: $80$-$200$ ng/dL)

Which of the following is the most appropriate next step in management regarding his thyroid function?

A 58-year-old man presents to the emergency department with acute-onset, crushing substernal chest pain radiating to his left jaw that began 45 minutes ago. He is diaphoretic and appears distressed. Vital signs show a blood pressure of 145/90 mm Hg and a heart rate of 92/min. Arrange the following steps in the most appropriate chronological order for the initial diagnosis and definitive management of this patient's condition.

A 61-year-old man visits an outpatient clinic due to a three-week history of progressively worsening fatigue, a persistent nighttime cough, and swelling in both ankles. He has not seen a healthcare provider in several years. The patient notes that he recently started sleeping in a recliner chair because lying flat in bed makes him feel as though he is suffocating. His medical history is notable for long-standing, untreated hypertension. Vital signs show a temperature of 37.0°C (98.6°F), pulse of 96/min, respirations of 18/min, and blood pressure of 168/94 mmHg. Examination reveals 2+ pitting edema up to the mid-calves bilaterally. Cardiac auscultation demonstrates a low-frequency extra heart sound occurring shortly after S2. Pulmonary auscultation reveals fine crackles at both lung bases. Which of the following is the most appropriate initial medication to alleviate this patient's acute symptoms?

Match the following classic physical examination findings (heart murmurs and sounds) with their most likely underlying valvular pathology.

During a hospital night shift, a physician assesses a newly admitted patient reporting worsening breathlessness and the inability to sleep lying flat. The patient's medical background includes coronary artery stenting three years ago and a lengthy history of cigarette smoking. Bedside evaluation demonstrates elevated jugular venous pressure, a prominent S3 gallop, and bilateral basilar crackles. Oxygen saturation is 90% on ambient air. Which of the following is the most appropriate initial pharmacological intervention for this patient?

A $24$-year-old male is being evaluated in the cardiology clinic after experiencing an episode of syncope while playing basketball. He has a family history of a sudden, unexplained death in a maternal uncle at age $35$. The evaluation of syncope often hinges on recognizing specific electrocardiographic (ECG) patterns associated with an increased risk of sudden cardiac death. Match each of the following classic ECG findings with its most likely clinical diagnosis.

Match the following antihypertensive medications with their characteristic mechanism of adverse effect or specific clinical contraindication.

A 68-year-old man comes to the clinic due to a three-week history of progressively worsening swelling in his legs and an uncomfortable sensation of abdominal fullness. He also notes increased shortness of breath when walking up a flight of stairs. His medical history is significant for a 45-pack-year smoking habit and chronic bronchitis. His current medications include inhaled tiotropium and as-needed albuterol.

Vital signs show a blood pressure of 128/78 mm Hg, a heart rate of 88/min, a respiratory rate of 18/min, and an oxygen saturation of 87% on room air.

Physical examination reveals an elevated jugular venous pressure of 12 cm H2O. Auscultation of the lungs demonstrates scattered expiratory wheezing but no crackles. Cardiac examination shows a parasternal heave and a loud pulmonic component of the second heart sound. The abdomen is distended with a palpable, tender liver edge. Bilateral pitting edema is present up to the knees.

An echocardiogram demonstrates right ventricular hypertrophy and dilation, with an estimated pulmonary artery systolic pressure of 55 mm Hg. The left ventricular ejection fraction is 60%, and there are no left-sided valvular abnormalities.

Which of the following interventions is most likely to prolong this patient's survival?

A 74-year-old man is evaluated in the outpatient clinic due to a two-month history of progressively worsening exertional dyspnea and a persistent, dry cough. He has a known history of ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$, moderate chronic obstructive pulmonary disease, and recurrent symptomatic ventricular tachycardia. His current daily medications include aspirin, metoprolol succinate, lisinopril, empagliflozin, inhaled tiotropium, and amiodarone, which was initiated eight months ago for arrhythmia control. His temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $128/78\text{ mm Hg}$, pulse is $64/\text{min}$, and respiratory rate is $22/\text{min}$. Pulse oximetry shows an oxygen saturation of $91\%$ on room air. Jugular venous pressure is measured at $6\text{ cm H}_2\text{O}$. Cardiopulmonary examination reveals regular heart sounds with no murmurs, gallops, or rubs. Auscultation of the lungs reveals fine, bilateral inspiratory crackles most prominent at the bases, without any wheezing. There is no lower extremity edema. Laboratory studies show a white blood cell count of $8,500/\mu\text{L}$ and a B-type natriuretic peptide level of $145\text{ pg/mL}$. A high-resolution computed tomography scan of the chest demonstrates diffuse, bilateral ground-glass opacities and thickened interlobular septa. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old male is brought to the emergency department due to acute, severe dyspnea and lightheadedness that began one hour ago. The patient has a history of a "heart murmur" diagnosed in childhood and "asthma." He reports developing a mild upper respiratory tract infection three days ago. Over the past 24 hours, he has been using his albuterol metered-dose inhaler every 1 to 2 hours for perceived wheezing and chest tightness. Despite this, his breathing progressively worsened, culminating in a near-syncopal episode just prior to arrival.

Vital signs include a temperature of 37.2°C (99.0°F), blood pressure of 82/50 mm Hg, heart rate of 138/min, and a respiratory rate of 28/min. Pulse oximetry shows an oxygen saturation of 87% on room air.

Physical examination reveals a diaphoretic, pale patient in severe respiratory distress, utilizing accessory muscles of respiration. The jugular venous pressure is estimated at 9 cm $H_2O$. Palpation of the carotid arteries reveals brisk, bifid upstrokes. Lung auscultation demonstrates diffuse bilateral expiratory wheezes and basilar crackles. Cardiac auscultation reveals a regular tachycardia and a grade 4/6 harsh, crescendo-decrescendo systolic murmur heard best at the left lower sternal border that radiates to the apex but not to the carotids.

An electrocardiogram shows sinus tachycardia, left axis deviation, marked voltage criteria for left ventricular hypertrophy, and deep, narrow Q waves in leads I, aVL, V5, and V6. A portable chest radiograph demonstrates bilateral interstitial infiltrates, prominent pulmonary vasculature, and a normal cardiac silhouette.

Which of the following is the most appropriate initial management for this patient's current condition?

A 24-year-old man presents to the clinic with acute, sharp chest pain that started yesterday. The pain worsens when he takes a deep breath or lies supine, but significantly improves when he sits up and leans forward. He reports having had a mild upper respiratory tract infection one week ago. His temperature is 37.4°C (99.3°F), blood pressure is 120/78 mmHg, and pulse is 88/min. Cardiac auscultation reveals a scratchy, high-pitched extra sound at the left lower sternal border that is heard during both systole and diastole. An electrocardiogram demonstrates diffuse concave ST-segment elevations and PR-segment depressions in most leads. Which of the following is the most appropriate initial treatment for this patient's condition?

A 64-year-old man arrives at the emergency department reporting the abrupt onset of severe, tearing chest pain that radiates between his shoulder blades. His blood pressure is 210/120 mmHg in the right arm and 180/100 mmHg in the left arm, with a heart rate of 118/min. Physical examination reveals a new diastolic decrescendo murmur at the right upper sternal border. An acute aortic dissection is highly suspected. Arrange the following steps in the most appropriate clinical sequence for the evaluation and management of this patient.

Match each physical examination finding and dynamic auscultation response with its most likely underlying structural or valvular pathophysiology.

Match the following classic arterial pulse abnormalities with their most likely underlying cardiovascular pathology.