Internal Medicine

A series of patients present to the cardiac intensive care unit with profound hypotension and cardiogenic shock 3 to 5 days following an acute ST-segment elevation myocardial infarction. Pulmonary artery catheterization (right heart catheterization) is performed for each patient to guide hemodynamic management. Match each post-myocardial infarction complication with its most characteristic hemodynamic profile.

A $60$-year-old male is transported to the emergency department by ambulance following an abrupt onset of severe dyspnea that started $2$ hours ago. He has a known medical history of essential hypertension and mitral valve prolapse. He reports no recent febrile illness, chills, or changes in sputum. His temperature is $37.0^\circ$ C ($98.6^\circ$ F), blood pressure is $165/95$ mmHg, heart rate is $118$/min, respiratory rate is $28$/min, and oxygen saturation is $85\%$ on room air. He is visibly distressed and using accessory muscles of respiration. Jugular venous distention is noted at $8$ cm H $_2$ O. Lung auscultation reveals diffuse bilateral crackles extending up to the apices, accompanied by prominent expiratory wheezing. Cardiac auscultation demonstrates a regular tachycardia with a normal S $1$ and a harsh holosystolic murmur heard best at the apex that radiates to the axilla.

Laboratory results are as follows:
- Leukocyte count: $8,500$/mm $^3$
- Thyroid-stimulating hormone (TSH): $0.1$ $\mu$ U/mL (Normal: $0.4-4.0$ $\mu$ U/mL)
- Free thyroxine (T4): $1.2$ ng/dL (Normal: $0.8-1.8$ ng/dL)
- Arterial blood gas (room air): pH $7.28$, pCO $_2$ $55$ mmHg, pO $_2$ $50$ mmHg, HCO $_3^-$ $25$ mEq/L

Chest radiography reveals bilateral alveolar opacities with a normal-sized cardiac silhouette.

Which of the following is the most appropriate initial pharmacologic intervention for this patient's underlying condition?

An emergency department physician is evaluating a 70-year-old female who complains of worsening shortness of breath over the past three days. The patient states she has been waking up in the middle of the night gasping for air and has had to sleep in a recliner chair. Her medical history includes hypertension, type 2 diabetes mellitus, and coronary artery disease. Vital signs show a blood pressure of 158/92 mm Hg, heart rate of 110/min, and respiratory rate of 24/min. Physical examination reveals elevated jugular venous pressure, an S3 heart sound, and bilateral crackles at the lung bases. Trace pitting edema is noted in the lower extremities. Which of the following is the most appropriate initial pharmacologic intervention for this patient?

An emergency medical response team brings a 65-year-old man to the resuscitation bay due to the sudden onset of severe shortness of breath. The patient has a known history of type 2 diabetes mellitus and a 35-pack-year history of cigarette smoking. He reports that his breathing difficulties awoke him from sleep approximately two hours ago. Upon further questioning, his wife mentions that he complained of deep, aching chest discomfort three days ago, which he attributed to indigestion and for which he refused to seek medical care. Vital signs are temperature 37.1°C (98.8°F), blood pressure 82/54 mmHg, heart rate 128/min and regular, and respiratory rate 32/min. Oxygen saturation is 83% on ambient air. Physical examination reveals an ashen, diaphoretic patient in severe respiratory distress using accessory muscles of respiration. Lung auscultation demonstrates diffuse, high-pitched expiratory wheezes throughout all lung fields with scattered dependent crackles. Cardiac auscultation reveals a hyperdynamic precordium and a grade 4/6 harsh holosystolic murmur heard best at the cardiac apex with radiation to the left axilla. Jugular venous pressure is estimated at 6 cm H2O. Electrocardiogram demonstrates normal sinus rhythm with pathologic Q waves and T-wave inversions in leads II, III, and aVF. Chest radiography shows bilateral perihilar alveolar opacities with prominent pulmonary vascular congestion, but a normal cardiac silhouette. Which of the following is the most appropriate next step in the management of this patient?

A 45-year-old man with a history of intravenous drug use presents to the hospital with a 5-day history of severe chills, fatigue, and high fevers. On physical examination, his temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), heart rate is 112/min, and blood pressure is 118/76 mm Hg. Cardiac auscultation reveals a newly documented holosystolic murmur prominent at the lower left sternal border. Cutaneous examination demonstrates painful, violaceous nodules on the pads of his fingers. Suspecting acute infective endocarditis, arrange the following clinical management steps in the correct chronological sequence according to standard guidelines.

Emergency medical services transport a 61-year-old male to the resuscitation bay following the acute onset of heavy, retrosternal chest pressure, diaphoresis, and severe shortness of breath. The symptoms began approximately 90 minutes ago. His medical history includes type 2 diabetes mellitus and a 45-pack-year smoking history.

On arrival, his temperature is $37.4^{\circ}\text{C}$ ($99.3^{\circ}\text{F}$), blood pressure is $82/50$ mmHg, heart rate is $108$/min, and respiratory rate is $26$/min. Pulse oximetry is $91\%$ on room air.

Physical examination reveals prominent jugular venous distention with a positive Kussmaul sign. Chest auscultation yields faint, bilateral expiratory wheezes, but no crackles. Cardiac auscultation reveals a regular tachycardia, a right-sided $S_4$ gallop, and no murmurs.

A 12-lead electrocardiogram displays $3$-mm ST-segment elevations in leads II, III, and aVF, with reciprocal ST-segment depressions in leads I and aVL. Right-sided ECG leads show a $2$-mm ST-segment elevation in lead $V_4R$.

An arterial blood gas analysis on room air reveals:

The patient is immediately administered chewable aspirin and intravenous heparin.

Which of the following is the most appropriate initial step to address this patient's hemodynamic status prior to definitive reperfusion therapy?

A $64$-year-old man comes to the clinic due to three days of worsening shortness of breath and a productive cough. He has a $40$-pack-year smoking history and was diagnosed with chronic obstructive pulmonary disease (COPD) five years ago. He currently uses a daily tiotropium inhaler and an albuterol inhaler as needed. Over the past three days, he has needed to use his albuterol inhaler every two hours with minimal relief. He also reports that his sputum has increased in volume and changed in color from clear to dark yellow. His temperature is $37.5^\circ\text{C}$ ($99.5^\circ\text{F}$), blood pressure is $130/82\text{ mmHg}$, pulse is $94/\text{min}$, and respiratory rate is $22/\text{min}$. Pulse oximetry is $93\%$ on room air. Physical examination reveals an increased anteroposterior chest diameter. Lung auscultation shows prolonged expiration with diffuse expiratory wheezing bilaterally. Cardiac examination shows a regular rate and rhythm with no murmurs, gallops, or jugular venous distention. There is no lower extremity edema. Arterial blood gas analysis on room air shows:

pH: $7.38$
$\text{pCO}_2$: $48\text{ mmHg}$
$\text{pO}_2$: $68\text{ mmHg}$
$\text{HCO}_3^-$: $27\text{ mEq/L}$

The patient is administered nebulized ipratropium-albuterol and oral prednisone. Which of the following is the most appropriate additional pharmacotherapy for this patient?

A $68$-year-old man presents to the emergency department with worsening shortness of breath and nocturnal awakenings over the past $5$ days. He reports needing to sleep in a reclining chair to breathe comfortably and frequently wakes up gasping for air. The patient has a history of hypertension, type 2 diabetes mellitus, and a $40$-pack-year smoking history. He has tried using an over-the-counter bronchodilator inhaler without relief. Vital signs show a blood pressure of $165/95 \text{ mm Hg}$, pulse of $105\text{/min}$, and respirations of $22\text{/min}$. Pulse oximetry is $91\%$ on room air. On physical examination, the body mass index is $32 \text{ kg/m}^2$. The jugular venous pulse is visible $5 \text{ cm}$ above the sternal angle while seated at a $45^\circ$ angle. Lung auscultation reveals prolonged expiration, diffuse bilateral wheezes, and dullness to percussion at the lung bases. Cardiac examination reveals a regular tachycardia with a prominent early diastolic extra heart sound at the apex. Trace bilateral pitting edema is present at the ankles. Which of the following pathophysiologic processes best explains the primary cause of this patient's respiratory findings?

A 72-year-old woman comes to the outpatient clinic due to a 4-day history of progressively worsening shortness of breath. She also reports waking up multiple times at night feeling a sensation of suffocation, which is only relieved by sitting upright for several minutes. Her medical history includes long-standing hypertension, type 2 diabetes mellitus, and a 35-pack-year smoking history. Current medications include lisinopril, amlodipine, and metformin. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 162/94 mm Hg, pulse of 102/min, and respiratory rate of 22/min. Pulse oximetry is 92% on room air. Examination reveals elevated jugular venous pressure and pitting edema of the lower extremities up to the knees. Which of the following additional physical examination findings is most likely to be present in this patient?

A $68$-year-old man is evaluated for progressive shortness of breath, fatigue, and bilateral lower extremity swelling over the past $6$ months. He also reports numbness and tingling in both hands, for which he underwent bilateral carpal tunnel release surgery last year. Blood pressure is $110/70 \text{ mmHg}$, and pulse is $85 \text{ /min}$. Physical examination reveals elevated jugular venous pressure with prominent x and y descents, clear lungs, and $2+$ pitting edema in the lower extremities. An electrocardiogram shows low voltage in the limb leads. A transthoracic echocardiogram demonstrates severe left ventricular concentric thickening, a granular "sparkling" appearance of the myocardium, biatrial enlargement, and a preserved left ventricular ejection fraction of $60\%$. A diagnosis of cardiac amyloidosis is suspected.

Arrange the following diagnostic and management steps in the most appropriate chronological sequence for evaluating and treating this patient's condition.

Following admission to the intensive care unit $24$ hours ago for status asthmaticus, a 26-year-old woman is evaluated due to new-onset tachypnea. Her initial treatment included continuous albuterol nebulization, intravenous methylprednisolone, and supplemental oxygen. Over the past day, her peak expiratory flow rate has improved significantly from 35% to 70% of her baseline. Auscultation currently demonstrates clear breath sounds bilaterally with minimal end-expiratory wheezing.

Despite this objective improvement in her airway resistance, she reports feeling profoundly anxious and her respiratory rate has climbed to 32/min.

Which of the following is the most likely underlying mechanism for this patient's current clinical deterioration?

An 82-year-old woman is brought to the emergency department at 3:00 AM by her daughter due to sudden, severe difficulty breathing. The patient reports waking up feeling as if she were smothering and has been coughing up pink, frothy sputum. Her medical history includes long-standing hypertension, diet-controlled type 2 diabetes mellitus, and a 45-pack-year smoking history, though she quit 5 years ago. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $185/105\text{ mm Hg}$, pulse is $112/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows an oxygen saturation of $85\%$ on room air. The patient is sitting upright and using accessory muscles of respiration. Examination of the neck reveals jugular venous distention $10\text{ cm}$ above the sternal angle. Pulmonary auscultation reveals widespread, high-pitched expiratory wheezes and scattered fine crackles in the bilateral lower lung zones. Cardiac auscultation reveals a regular rhythm, tachycardia, and a prominent S3 gallop. Bilateral $2+$ pitting edema is noted up to the mid-calves. Arterial blood gas analysis on room air shows:

$\text{pH}: 7.28$
$\text{PaCO}_2: 56\text{ mm Hg}$
$\text{PaO}_2: 52\text{ mm Hg}$
$\text{HCO}_3^-: 25\text{ mEq/L}$

Which of the following is the most appropriate initial pharmacologic therapy for this patient's condition?

An obtunded 68-year-old man is brought to the emergency department by paramedics following a two-day history of worsening shortness of breath, productive cough, and fever. His medical history is significant for severe chronic obstructive pulmonary disease (COPD) requiring 2 L/min home oxygen, and cor pulmonale. His temperature is 38.6°C (101.5°F), pulse is 112/min, blood pressure is 90/60 mm Hg, and respirations are 26/min. Physical examination reveals a somnolent patient utilizing accessory muscles of respiration. Auscultation of the lungs reveals diffuse expiratory wheezing and coarse crackles in the right lower lobe.

Laboratory results from a routine outpatient clinic visit one month ago, when the patient was at his clinical baseline, showed:

Current laboratory results obtained upon arrival are as follows:

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

A $72$-year-old woman is brought to the emergency department by her daughter due to a $3$-day history of progressively worsening shortness of breath. The patient reports that she has been unable to sleep in her bed for the past two nights, opting to sleep in a recliner chair instead. Her medical history is significant for hypertension, type 2 diabetes mellitus, and a $45$-pack-year smoking history. She was diagnosed with chronic obstructive pulmonary disease (COPD) five years ago. Current medications include amlodipine, metformin, and an albuterol inhaler as needed. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $168/94\text{ mmHg}$, heart rate is $115/\text{min}$, respiratory rate is $26/\text{min}$, and oxygen saturation is $85\%$ on room air. She appears in respiratory distress and is using accessory muscles of respiration. Jugular venous pressure is estimated at $12\text{ cm H}_2\text{O}$. Lung auscultation reveals bilateral basilar dullness to percussion, diffuse fine crackles extending to the mid-lung fields, and scattered expiratory wheezes. Cardiac examination shows a regular rhythm, tachycardia, and a prominent $S_3$ gallop. There is $3+$ pitting edema of the bilateral lower extremities extending to the mid-calves. Which of the following is the most appropriate next step in management for this patient?

An ambulance brings a $32$-year-old woman to the emergency department due to severe agitation, palpitations, and confusion. She has a history of Graves disease but reports stopping her medications $3$ months ago. Her temperature is $39.6^{\circ}\text{C}$ ($103.3^{\circ}\text{F}$), blood pressure is $150/70\text{ mmHg}$, and heart rate is $148\text{/min}$ and irregular. Physical examination reveals a diffuse goiter, bilateral proptosis, diaphoresis, and a fine resting tremor. An electrocardiogram shows atrial fibrillation with a rapid ventricular response. A clinical diagnosis of thyroid storm is established.

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

An occupational therapist in her late fifties is brought to the emergency department by her partner due to sudden-onset high fever, profound weakness, and bleeding gums over the last $48\text{ hours}$. She has a documented history of severe, erosive rheumatoid arthritis that has been clinically silent for the past two years on a maintenance regimen of azathioprine and low-dose prednisone. She also takes sertraline for generalized anxiety disorder.

Three weeks ago, she experienced a severely painful, swollen, and erythematous right first toe. Arthrocentesis yielded fluid containing negatively birefringent, needle-shaped crystals. Following resolution of the acute episode, her rheumatologist initiated a daily prophylactic medication to prevent future articular attacks.

Upon arrival today, her temperature is $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), pulse is $118\text{/min}$, and blood pressure is $100/60\text{ mmHg}$. Physical examination reveals marked mucosal pallor, diffuse lower extremity petechiae, and continuous oozing from the gingival margins.

Laboratory findings:
Leukocytes: $750/\text{mm}^3$
Hemoglobin: $6.8\text{ g/dL}$
Platelets: $14,000/\text{mm}^3$
Thyroid-stimulating hormone: $3.9\text{ \mu U/mL}$ (Normal: $0.4-4.2\text{ \mu U/mL}$)
Free thyroxine (T4): $1.2\text{ ng/dL}$ (Normal: $0.8-2.8\text{ ng/dL}$)

Which of the following mechanisms is the most likely primary cause of this patient's current hematologic crisis?

A fundamental aspect of diagnosing renal pathology involves interpreting urine microscopy. Match each of the following clinical renal conditions with its characteristic, classic urinalysis sediment finding.

A variety of patients present to the clinic and emergency department seeking care after high-risk infectious exposures. Match each clinical exposure scenario to the most appropriate post-exposure prophylaxis or preventive intervention.

Match each clinical presentation to the most appropriate and specific diagnostic autoantibody test.

A 68-year-old man with a history of metastatic prostate cancer is brought to the emergency department by his wife due to a 2-day history of progressively worsening lower back pain and new-onset difficulty walking. This morning, he also experienced an episode of urinary incontinence. Vital signs are within normal limits. Neurologic examination shows 3/5 strength in both lower extremities, diminished pinprick sensation below the T10 dermatome, and bilateral Babinski signs. Anal sphincter tone is markedly decreased. Arrange the following management steps in the most appropriate chronological order for this patient.