Internal Medicine

A 65-year-old man is brought to the emergency department due to severe, sudden-onset shortness of breath that awakened him from sleep. The patient has a history of essential hypertension, hyperlipidemia, type 2 diabetes mellitus, and a 35-pack-year history of smoking. Current medications include amlodipine, metformin, and atorvastatin.

Temperature is 37.1°C (98.8°F), blood pressure is 210/115 mmHg, heart rate is 115/min, and respiratory rate is 28/min. Pulse oximetry is 88% on room air.

Physical examination reveals an anxious, diaphoretic man in severe respiratory distress, utilizing accessory muscles of respiration. Lung auscultation reveals a prolonged expiratory phase with diffuse bilateral wheezing and scattered crackles in the lower lung fields. Cardiac examination shows a tachycardic, regular rhythm with a prominent S4 gallop and no murmurs. There is 1+ bilateral pitting edema of the lower extremities.

Chest radiograph demonstrates bilateral perihilar alveolar opacities, indistinct pulmonary vascular margins, and cephalization of the pulmonary veins. There is no focal lobar consolidation.

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

A $71$-year-old woman is evaluated in the surgical step-down unit for a sudden onset of shortness of breath and a nonproductive cough. She is currently on postoperative day $3$ following an uncomplicated right total knee arthroplasty. Her medical history is significant for coronary artery disease, heart failure with preserved ejection fraction, and a $40$-pack-year smoking history with known chronic obstructive pulmonary disease. Her temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $168/96\text{ mmHg}$, pulse is $108/\text{min}$, and respirations are $26/\text{min}$. Oxygen saturation is $89\%$ on room air. Physical examination reveals distended neck veins with a jugular venous pressure of $11\text{ cm H}_2\text{O}$. Chest auscultation demonstrates a prolonged expiratory phase with diffuse bilateral wheezes and scattered bibasilar crackles. Cardiac examination reveals a regular tachycardia with a distinct S4 gallop and no murmurs. Her lower extremities show bilateral $2+$ pitting edema, which is unchanged from her preoperative baseline. Which of the following is the most appropriate next step in management?

Following a transurethral resection of the prostate four weeks ago, a 65-year-old man presents to the emergency department reporting two weeks of worsening fatigue, night sweats, and shortness of breath with mild exertion. He has no other significant past medical history and takes no daily medications. Vital signs show a temperature of 38.4°C (101.1°F), heart rate of 98/min, and blood pressure of 118/72 mm Hg. Cardiac auscultation reveals a new grade 3/6 holosystolic murmur at the apex radiating to the left axilla. Dermatologic examination shows dark red, linear lesions in the nail beds of both hands. Laboratory evaluation reveals a leukocyte count of 14,500/mm³. A transesophageal echocardiogram demonstrates a 1.4-cm mobile vegetation on the mitral valve with moderate regurgitation. Gram stain of blood cultures drawn at admission shows gram-positive cocci in pairs and short chains. Subsequent speciation confirms *Enterococcus faecalis*. The susceptibility report indicates the organism is susceptible to ampicillin, vancomycin, and daptomycin, but testing demonstrates high-level resistance to gentamicin. Which of the following is the most appropriate definitive intravenous pharmacotherapy for this patient?

A gastroenterology team is evaluating several adult patients presenting with elevated liver function tests and suspected chronic liver disease. Match each clinical diagnosis with its most specific characteristic serologic marker or initial diagnostic laboratory finding.

Emergency medical services transport a 64-year-old male to the trauma bay following multiple episodes of massive, bright red rectal bleeding at his residence. He is somnolent and profoundly diaphoretic. Initial vital signs reveal a temperature of 36.8°C (98.2°F), heart rate of 134/min, respiratory rate of 24/min, and blood pressure of 76/42 mm Hg. Collateral history from his partner indicates he takes daily high-dose naproxen for lumbar osteoarthritis. The abdomen is soft and non-tender without organomegaly. Digital rectal examination demonstrates a vault full of fresh blood and clots. Two large-bore peripheral intravenous catheters have just been inserted. Arrange the following subsequent management steps in the most appropriate chronological order for evaluating and treating this hemodynamically unstable patient.

A $65$-year-old man is evaluated in the intensive care unit on day $3$ of admission for septic shock secondary to severe community-acquired pneumonia. He has a past medical history of severe chronic obstructive pulmonary disease and heart failure with preserved ejection fraction. He was intubated on the day of admission and remains mechanically ventilated.

Current vital signs include a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $105/65\text{ mm Hg}$ on vasopressors, and heart rate of $98\text{/min}$.

Physical examination reveals diminished breath sounds bilaterally with prolonged expiration and scattered expiratory wheezing. Jugular venous pressure is normal, and there are no pulmonary crackles or peripheral edema.

Blood and sputum cultures obtained on admission have finalized, growing *Streptococcus pneumoniae* susceptible to penicillin and ceftriaxone. He is currently receiving continuous intravenous norepinephrine, vancomycin, and piperacillin-tazobactam.

An arterial blood gas analysis is obtained on the current ventilator settings:
pH: $7.22$
$\text{PaCO}_2$: $35\text{ mm Hg}$
$\text{PaO}_2$: $82\text{ mm Hg}$
$\text{HCO}_3^-$: $14\text{ mEq/L}$

Based on the current clinical data, which of the following actions are appropriate in the ongoing management of this patient? (Select all that apply)

A 48-year-old woman is admitted to the hospital with a 2-day history of fever, chills, and progressive right lower extremity swelling and redness. Her past medical history is unremarkable. On admission, her temperature is 38.6°C (101.5°F), blood pressure is 110/70 mmHg, and pulse is 108/min. Physical examination reveals a $10 \times 8$ cm area of well-demarcated erythema, warmth, and exquisite tenderness over the right calf. Two sets of peripheral blood cultures are obtained, and the patient is started on empiric intravenous vancomycin and piperacillin-tazobactam.

By hospital day 3, her temperature has normalized, and the erythema has significantly receded. The admission blood cultures grow *Staphylococcus aureus* in all four bottles. Antimicrobial susceptibility testing reveals the following:

A subsequent transthoracic echocardiogram shows no valvular vegetations. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A male patient, aged $55$, arrives at the acute care clinic complaining of worsening shortness of breath and chest discomfort over the past two days. He recently recovered from a severe viral respiratory infection. He describes the chest pain as sharp and states that it lessens significantly when he sits up and leans forward. Within the last two hours, he has felt increasingly dizzy. Vital signs show a temperature of $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), a blood pressure of $88/72$ mm Hg, a heart rate of $118$/min, and a respiratory rate of $22$/min. Physical examination reveals prominent distention of the neck veins and heart sounds that are noticeably faint on auscultation. An exaggerated drop in systolic blood pressure during inspiration is observed. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 45-year-old man comes to the clinic reporting a 4-month history of progressive fatigue, cold intolerance, and decreased libido. He says he feels sluggish and lacks the energy to perform his job as an accountant. His medical history is unremarkable, and he takes no medications. Vital signs show a blood pressure of 105/70 mm Hg and a heart rate of 56/min. Physical examination reveals delayed relaxation of the deep tendon reflexes and somewhat soft, small testes. Laboratory studies show:

Serum thyroid-stimulating hormone (TSH): 1.6 $\mu$ U/mL (Normal: 0.4–4.0 $\mu$ U/mL)
Serum free thyroxine (T4): 0.6 ng/dL (Normal: 0.9–1.7 ng/dL)

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

Match the following specific cardiovascular physical examination findings with their most likely underlying structural or pathophysiological etiology.

Match each clinical presentation of a central nervous system infection (or related exposure) to the most appropriate targeted antimicrobial therapy or prophylaxis regimen.

A team of internal medicine residents is reviewing the post-infarction clinical course of several patients admitted to the cardiac intensive care unit. Match each described clinical presentation with the most likely underlying mechanical or structural complication of acute myocardial infarction.

Match each patient's clinical presentation with the most likely corresponding auscultatory finding and its characteristic response to dynamic maneuvers.

Paramedics arrive at the emergency department with an $80$-year-old male who developed sudden, severe shortness of breath one hour ago while watching television. The patient has a medical history significant for poorly controlled hypertension, type 2 diabetes mellitus, and a $45$-pack-year history of smoking. Upon arrival, he is in acute respiratory distress, utilizing accessory muscles to breathe, and cannot speak more than a few words at a time. Vital signs include a blood pressure of $225/115 \text{ mm Hg}$, a heart rate of $115/\text{min}$, and a respiratory rate of $30/\text{min}$. Oxygen saturation is $86\%$ on ambient air. Physical examination shows profound diaphoresis. Pulmonary auscultation reveals prominent expiratory wheezing diffusely, along with fine crackles at both lung bases. Cardiovascular examination is notable for a rapid, regular rhythm and a distinct fourth heart sound (S4). Evaluation of the neck shows flat jugular veins, and there is no peripheral edema. Which of the following is the most appropriate initial pharmacologic therapy for this patient?

A 62-year-old woman with a history of chronic obstructive pulmonary disease (COPD) presents to the emergency department complaining of progressive shortness of breath over the past three days. She reports an increased frequency of cough and a change in her sputum from clear to thick and yellow-green. She denies chest pain, orthopnea, or paroxysmal nocturnal dyspnea. Her daily medications include a long-acting muscarinic antagonist and a short-acting beta-agonist as needed. Vital signs are temperature $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure $135/85\text{ mmHg}$, heart rate $108\text{/min}$, and respiratory rate $26\text{/min}$. Oxygen saturation is $86\%$ on room air.

Physical examination reveals a patient in moderate respiratory distress, using accessory muscles of respiration. Auscultation demonstrates a prolonged expiratory phase and diffuse end-expiratory wheezing bilaterally. Cardiac examination shows a rapid, regular rhythm with no murmurs, gallops, or jugular venous distention. There is no peripheral edema.

Chest radiograph shows hyperinflated lung fields with flattened diaphragms, but no focal consolidations or pleural effusions.

Arterial blood gas on room air reveals:
pH: $7.28$
$\text{PaCO}_2$: $66\text{ mmHg}$
$\text{PaO}_2$: $54\text{ mmHg}$
$\text{HCO}_3^-$: $30\text{ mEq/L}$

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

Complaints of a racing heart, persistent heat intolerance, and frequent loose stools have brought a 31-year-old medical assistant to the clinic. She reports unintentionally losing $4$ kg ($8.8$ lb) over the past month. She denies any neck pain, dysphagia, or recent viral illnesses. Her past medical history is unremarkable, and she denies taking any prescribed medications or over-the-counter supplements. Vital signs show a blood pressure of $138/78$ mm Hg and a regular pulse of $112$/min. Physical examination reveals an anxious-appearing woman with a fine, symmetric resting tremor in her outstretched fingers. The neck is supple, and the thyroid gland is not palpable. No proptosis or localized pretibial edema is noted.

Laboratory studies yield the following results:
- Thyroid-stimulating hormone (TSH): $0.02$ $\mu$ U/mL (Normal: $0.4-4.2$ $\mu$ U/mL)
- Free T4: $3.4$ ng/dL (Normal: $0.8-1.8$ ng/dL)
- Free T3: $6.2$ pg/mL (Normal: $2.3-4.2$ pg/mL)

A 24-hour radioactive iodine uptake scan demonstrates an uptake of $1\%$ (Normal: $15\%-30\%$).

Which of the following laboratory findings is most likely present in this patient?

A 55-year-old man with a history of decompensated alcohol-related cirrhosis is brought to the emergency department after vomiting a large amount of bright red blood. On arrival, his blood pressure is 85/50 mmHg, and his heart rate is 122/min. He appears pale and lethargic but is maintaining his airway.

Arrange the following management steps in the most appropriate chronological sequence for this patient's acute condition.

A 54-year-old man arrives at the emergency department due to the sudden onset of left-sided chest pain and shortness of breath that began $2$ hours ago. The chest pain worsens with deep inspiration. Over the past $6$ months, he has experienced worsening fatigue, frequent headaches, and intense generalized pruritus that is particularly severe after taking hot showers. He also describes a burning sensation in his palms and soles. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $142/88\text{ mm Hg}$, pulse is $112\text{/min}$, and respirations are $24\text{/min}$. Pulse oximetry shows an oxygen saturation of $90\%$ on room air. Physical examination reveals a plethoric face and engorged retinal veins. The spleen is palpated $4\text{ cm}$ below the left costal margin. The lungs are clear to auscultation bilaterally. The right calf is visibly swollen, erythematous, and tender to palpation.

Laboratory studies reveal:
Hemoglobin: $19.2\text{ g/dL}$
Hematocrit: $59\%$
Leukocyte count: $15,200\text{ /mm}^3$
Platelet count: $620,000\text{ /mm}^3$

Arterial blood gas analysis (room air):
pH: $7.51$
PaCO $_2$: $29\text{ mm Hg}$
PaO $_2$: $60\text{ mm Hg}$

Which of the following is the most appropriate initial step in the management of this patient's acute presentation?

A 70-year-old woman is currently hospitalized on the general medical ward for a deep vein thrombosis of the left lower extremity, which is being treated with a direct oral anticoagulant. On hospital day 3, she reports a sudden increase in shortness of breath, a "tight" chest, and a productive cough with greenish sputum that started yesterday. Her past medical history includes severe emphysema and hypertension. She appears anxious and is utilizing her scalene muscles for respiration. Her temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), pulse is $108/\text{min}$, respirations are $26/\text{min}$, and blood pressure is $142/88 \text{ mm Hg}$. Oxygen saturation is $86\%$ on room air. Physical examination is notable for a prolonged expiratory phase and prominent diffuse polyphonic rhonchi. Jugular veins are not distended. A bedside echocardiogram shows a normal left ventricular ejection fraction and normal right ventricular size. An arterial blood gas analysis reveals a pH of $7.27$, $PaCO_2$ of $65 \text{ mm Hg}$, $PaO_2$ of $52 \text{ mm Hg}$, and $HCO_3^-$ of $29 \text{ mEq/L}$.

Which of the following are the most appropriate immediate steps in the management of this patient's respiratory status? (Select all that apply)

Evaluate the following four adult patients who have presented to the emergency department with acute cardiopulmonary distress. Match each patient's clinical presentation to the single most appropriate initial pharmacological or procedural treatment strategy.