Internal Medicine

An $82$-year-old woman is evaluated in the progressive care unit due to sudden-onset difficulty breathing. She was admitted yesterday for a lower gastrointestinal bleed secondary to diverticulosis. Her medical history is significant for hypertension and heart failure with preserved ejection fraction. Two hours ago, her hemoglobin was noted to be $6.4 \text{ g/dL}$, and a transfusion of two units of packed red blood cells was initiated. She is currently receiving the second unit. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $172/92 \text{ mmHg}$, heart rate is $112/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows $87\%$ on ambient air. Physical examination reveals distended jugular veins and bounding peripheral pulses. Auscultation of the lungs demonstrates bibasilar crackles extending to the mid-lung fields. A new S3 gallop is appreciated on cardiac auscultation. Which of the following is the most appropriate next step in the management of this patient's respiratory distress?

Match the following specific clinical presentations of infectious diseases with their most appropriate first-line targeted antimicrobial therapy.

A 52-year-old man presents to the emergency department with a 24-hour history of generalized, colicky abdominal pain, intractable nausea, and multiple episodes of bilious emesis. He states he has not had a bowel movement or passed flatus for the past day. His medical history is significant for an open appendectomy 15 years ago. His temperature is $37.1^{\circ} \text{C}$ ($98.8^{\circ} \text{F}$), blood pressure is $135/82 \text{ mmHg}$, heart rate is $88/\text{min}$, and respiratory rate is $16/\text{min}$. Physical examination reveals a markedly distended abdomen with high-pitched, hyperactive bowel sounds. The abdomen is mildly tender to palpation diffusely, but there is no guarding, rigidity, or rebound tenderness. Laboratory studies show a leukocyte count of $8,500/\text{mm}^3$. An upright abdominal radiograph demonstrates multiple dilated loops of small bowel with prominent air-fluid levels and a paucity of air in the colon. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old man comes to the clinic due to progressive fatigue, generalized weakness, and decreased libido over the past 4 months. He has also noticed a loss of body hair and occasional morning headaches. His medical history is significant for type 2 diabetes mellitus and hyperlipidemia. Over the past month, his basal insulin dose was reduced due to recurrent episodes of fasting hypoglycemia. Vital signs show a temperature of 36.8°C (98.2°F), blood pressure of 102/64 mm Hg, and pulse of 58/min. Physical examination reveals pale, cool skin and a delayed relaxation phase of the deep tendon reflexes. Visual field testing by confrontation reveals decreased peripheral vision bilaterally.

Laboratory results are as follows:

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

Match each clinical presentation of an opportunistic infection in a patient with advanced HIV to the most appropriate initial targeted pharmacotherapy.

An occupational health screening includes spirometry for a 42-year-old male construction worker who reports slowly progressive exertional breathlessness over the past year. He denies chronic cough, sputum production, or wheezing. The patient has a 10-year history of daily lower back stiffness that is worst upon waking and improves after a few hours of physical labor. He does not smoke and has no history of cardiovascular disease. Vital signs are within normal limits. Physical examination reveals a stooped posture and a significantly reduced range of motion of the lumbar spine. Chest expansion during deep inspiration is markedly limited to 1.5 cm (normal is greater than 5 cm). Cardiac auscultation is normal, and breath sounds are clear bilaterally. Pulmonary function testing demonstrates a forced vital capacity (FVC) of 65% of predicted, a forced expiratory volume in 1 second (FEV1) of 70% of predicted, and an FEV1/FVC ratio of 86%. Diffusing capacity of the lung for carbon monoxide (DLCO) is normal. Which of the following is the most likely primary cause of this patient's respiratory symptoms?

Match each patient's clinical presentation and initial diagnostic findings with the most accurate underlying pathophysiologic mechanism or defining etiology.

A 19-year-old woman presents to the emergency department reporting persistent ringing in her ears, nausea, and feeling short of breath for the past 6 hours. She recently had an argument with her family and subsequently ingested an entire bottle of an over-the-counter analgesic. Vital signs include a temperature of 38.1°C (100.6°F), blood pressure of 116/74 mm Hg, pulse of 115/min, and respiratory rate of 28/min. She appears agitated and is taking deep, rapid breaths.

Initial laboratory testing reveals:

Arterial blood gas (room air):

Which of the following is the most accurate description of the acid-base abnormality in this patient?

A 72-year-old woman is brought to the emergency department by ambulance after being found unresponsive in her home. According to her family, she has a history of hypothyroidism but stopped taking her medications a year ago. On arrival, she is unarousable. Vital signs show a temperature of $34.2^\circ\text{C}$ ($93.6^\circ\text{F}$), a heart rate of $46/\text{min}$, a blood pressure of $85/50\text{ mm Hg}$, and a respiratory rate of $6/\text{min}$ with shallow breathing. Her oxygen saturation is $82\%$ on room air. Physical examination reveals periorbital puffiness, generalized non-pitting edema, and cold, dry skin. Arrange the following steps in the most appropriate chronological sequence for the acute evaluation and management of this patient.

A $55$-year-old woman is evaluated in the emergency department for a fever that started earlier today. She is currently undergoing systemic chemotherapy for diffuse large B-cell lymphoma; her most recent treatment cycle was $8$ days ago. The patient reports associated chills and generalized weakness. Temperature is $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), blood pressure is $98/60\text{ mmHg}$, heart rate is $112/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals a chronically ill-appearing woman. Her indwelling central venous port site appears clean, with no erythema, induration, or purulent discharge. The lungs are clear to auscultation, and the remainder of the examination is unremarkable.

Laboratory studies show:
- Hemoglobin: $9.2\text{ g/dL}$
- Platelets: $85,000/\mu\text{L}$
- Leukocytes: $600/\mu\text{L}$
- Absolute neutrophil count: $150/\mu\text{L}$

Blood and urine cultures are obtained. Which of the following is the most appropriate next step in management?

Following a transfer from a long-term care facility, an 82-year-old female patient is evaluated in the hospital for a two-day history of progressive somnolence. Her medical history is significant for advanced Alzheimer dementia and chronic urinary retention requiring an indwelling urethral catheter. Upon presentation, her blood pressure is $112/64\text{ mmHg}$, heart rate is $96/\text{min}$, and temperature is $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$). Physical examination reveals dry oral mucosa, diminished skin turgor, and no costovertebral angle tenderness. The patient is lethargic but arouses to voice. Laboratory evaluation reveals a serum sodium concentration of $159\text{ mEq/L}$ and a blood urea nitrogen level of $45\text{ mg/dL}$. A urinalysis demonstrates cloudy, malodorous urine with positive leukocyte esterase, positive nitrites, and $45\text{ WBCs/hpf}$. A urine culture is submitted, and she is started on intravenous fluid resuscitation.

By the third day of hospitalization, her serum sodium has corrected to $142\text{ mEq/L}$, and her mental status has returned to her baseline of being pleasantly confused but conversational. She remains hemodynamically stable and afebrile. The admission urine culture now reports $>10^5\text{ CFU/mL}$ of *Escherichia coli* that is susceptible to all tested antimicrobial agents. Which of the following is the most appropriate next step in the management of this patient's urinary findings?

A 45-year-old man presents to the gastroenterology clinic for chronic, watery diarrhea and recurrent abdominal pain. Over the past year, he has been treated for peptic ulcer disease with a high-dose proton pump inhibitor, but his symptoms have persisted and worsened. Upper gastrointestinal endoscopy reveals thickened gastric folds and multiple ulcerations in the stomach, distal duodenum, and proximal jejunum. A diagnosis of Zollinger-Ellison syndrome (gastrinoma) is suspected. Arrange the following steps in the most appropriate diagnostic and therapeutic sequence for this patient.

A hospital's blood bank and transfusion medicine service is reviewing recent adverse events. Match each patient's clinical presentation following a blood product transfusion with the most likely underlying pathophysiologic mechanism.

A 27-year-old man with a 4-year history of ileocolonic Crohn disease presents to the emergency department with a 2-day history of progressive, colicky abdominal pain, nausea, and bilious vomiting. He reports that his baseline bowel habit is 3 loose stools daily, but he has not passed stool or flatus for the past 24 hours. He admits to being nonadherent to his prescribed infliximab therapy for the last 6 months.

His temperature is 38.3°C (100.9°F), blood pressure is 112/68 mm Hg, pulse is 115/min, and respiratory rate is 22/min. Physical examination shows a distended abdomen with hypoactive bowel sounds. There is significant tenderness in the right lower quadrant with localized involuntary guarding and rebound tenderness.

Laboratory results are as follows:
Leukocyte count: 16,500/mm³
Hemoglobin: 12.1 g/dL
Platelet count: 450,000/mm³
Serum sodium: 136 mEq/L
Serum potassium: 3.2 mEq/L
Serum chloride: 102 mEq/L
Serum bicarbonate: 15 mEq/L
Blood urea nitrogen: 38 mg/dL
Serum creatinine: 1.3 mg/dL

Arterial blood gas (room air):
$pH$: 7.32
$pCO_2$: 30 mm Hg
$pO_2$: 92 mm Hg
Lactate: 4.5 mmol/L (Normal: 0.5-1.5 mmol/L)

An upright abdominal radiograph shows multiple dilated loops of small bowel with air-fluid levels and a paucity of gas in the colon.

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

Match each esophageal disorder with its most characteristic diagnostic imaging or endoscopic finding.

A $62$-year-old man with a history of alcohol-associated cirrhosis is brought to the emergency department by his daughter due to increasing confusion and sleepiness over the past two days. She reports that he has also had a productive cough with yellowish sputum and intermittent chills for the last three days. His medical history includes chronic obstructive pulmonary disease (COPD) and diet-controlled type 2 diabetes mellitus. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $105/65\text{ mmHg}$, pulse is $108/\text{min}$, and respirations are $24/\text{min}$. Pulse oximetry shows $92\%$ on room air. Physical examination reveals scleral icterus and spider angiomas. His breath has a sweet, musty odor. Auscultation of the lungs reveals crackles and bronchial breath sounds in the right lower lung field. Abdominal examination shows distension with shifting dullness but no tenderness or rigidity. Neurological examination reveals lethargy, disorientation to time and place, and a distinct flapping tremor when his arms are extended with wrists dorsiflexed. Laboratory studies show a leukocyte count of $14,500/\text{mm}^3$, hemoglobin of $11.2\text{ g/dL}$, and a platelet count of $85,000/\text{mm}^3$. Comprehensive metabolic panel is notable for a blood urea nitrogen of $22\text{ mg/dL}$, creatinine of $1.0\text{ mg/dL}$, and normal electrolytes. Arterial blood gas on room air shows a pH of $7.48$, pCO $_2$ of $30\text{ mmHg}$, and pO $_2$ of $68\text{ mmHg}$. Diagnostic paracentesis yields ascitic fluid with an absolute neutrophil count of $120/\text{mm}^3$ and negative Gram stain. A chest radiograph demonstrates a right lower lobe infiltrate. In addition to initiating lactulose therapy for his hepatic encephalopathy, which of the following is the most appropriate next step in management?

A 72-year-old man is evaluated on postoperative day 3 following a right total hip arthroplasty for a femoral neck fracture. He reports progressive abdominal distention, nausea, and an inability to pass flatus or stool for the past 48 hours. His medical history includes hypertension and benign prostatic hyperplasia. Current medications include lisinopril, tamsulosin, and intravenous morphine for pain control. Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $130/80\text{ mm Hg}$, pulse of $92\text{/min}$, and respiratory rate of $16\text{/min}$. Abdominal examination reveals massive, tympanitic distension with diminished bowel sounds; there is no guarding or rebound tenderness. Laboratory studies show a serum potassium of $3.1\text{ mEq/L}$ and magnesium of $1.3\text{ mg/dL}$. A CT scan of the abdomen confirms diffuse dilation of the colon with a cecal diameter of $10.5\text{ cm}$ and no evidence of mechanical obstruction or perforation. The patient is diagnosed with acute colonic pseudo-obstruction (Ogilvie syndrome).

Arrange the following management interventions in the correct standard sequential order for this condition, progressing from the most appropriate initial action to the final therapeutic option for refractory disease.

A 28-year-old woman with a history of systemic lupus erythematosus presents to the clinic with new-onset bilateral lower extremity edema. Her blood pressure is 150/92 mm Hg. Laboratory studies show a serum creatinine of 1.5 mg/dL (baseline 0.8 mg/dL), positive anti-dsDNA antibodies, and decreased C3 and C4 levels. Urinalysis reveals 3+ protein, 15-20 red blood cells/hpf, and the presence of red blood cell casts.

Arrange the following steps in the standard chronological sequence for the definitive diagnostic evaluation and long-term pharmacologic management of this patient's renal disease.

A 64-year-old man with a 15-year history of type 2 diabetes mellitus is evaluated in the outpatient clinic for a chronic ulcer on the plantar surface of his right great toe. Over the past 3 days, he has noted new-onset redness and mild pain surrounding the ulcer. He has not had fever, chills, or other systemic symptoms. He has no recent hospitalizations and has not received any antibiotics in the past year. Vital signs are temperature 37.0°C (98.6°F), blood pressure 135/85 mm Hg, heart rate 78/min, and respirations 14/min. Physical examination reveals a 1.5-cm, shallow ulcer on the plantar aspect of the right great toe. There is a 1-cm rim of blanching erythema surrounding the ulcer margins. There is no purulent drainage, fluctuance, or crepitus. The ulcer base does not probe to bone, and pedal pulses are palpable bilaterally. A superficial swab culture of the ulcer base obtained by a visiting home nurse 3 days ago shows heavy growth of methicillin-susceptible Staphylococcus aureus (MSSA) and Pseudomonas aeruginosa. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

An urgent bedside evaluation is requested for a $71$-year-old man in the intensive care unit who developed abrupt, severe shortness of breath and altered mental status. He was admitted $5$ days ago after sustaining a comminuted left femoral shaft fracture in a motor vehicle collision, for which he underwent open reduction and internal fixation. Today, he became suddenly agitated and then poorly responsive.

Physical examination shows profound diaphoresis and mottling of the lower extremities. The jugular venous pulsation is visible at the angle of the mandible while sitting at $45^\circ$. Auscultation of the lungs reveals clear breath sounds bilaterally. Cardiac examination shows a tachycardic, regular rhythm with a prominent parasternal heave and a right-sided S3 gallop.

A 12-lead ECG demonstrates sinus tachycardia with new T-wave inversions in leads V1-V4 and a complete right bundle branch block.

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