General Internal Medicine

A 67-year-old woman is brought to the emergency department by her daughter due to increasing confusion, rapid breathing, and generalized weakness that started yesterday. The daughter notes that the patient has been complaining of a "constant buzzing" in her ears for the past 24 hours. The patient has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of 35%, type 2 diabetes mellitus, and severe bilateral knee osteoarthritis. Her current medications include metoprolol, lisinopril, empagliflozin, and several over-the-counter analgesics that she has been taking frequently due to a recent pain flare.

Vital signs are:
Temperature: 38.3°C (100.9°F)
Heart rate: 118/min
Respiratory rate: 32/min
Blood pressure: 105/65 mm Hg
Oxygen saturation: 97% on room air

Physical examination reveals a disoriented patient taking deep, rapid breaths. Chest auscultation demonstrates scattered bilateral basilar crackles. Cardiac examination shows a regular, rapid rhythm with no murmurs, gallops, or jugular venous distention. Trace bilateral pedal edema is present.

Laboratory results:
Serum sodium: 142 mEq/L
Serum potassium: 3.4 mEq/L
Serum chloride: 100 mEq/L
Serum bicarbonate: 14 mEq/L
Blood urea nitrogen: 32 mg/dL
Serum creatinine: 1.6 mg/dL (baseline 1.1 mg/dL)

Arterial blood gas on room air:
pH: 7.46
PaCO2: 20 mm Hg
PaO2: 88 mm Hg

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

Paramedics bring an 81-year-old female to the acute care unit from her assisted living facility. Staff members called for help after noticing she was acting confused and breathing rapidly since she woke up. Her medical history is notable for severe osteoarthritis, hypertension, and diet-controlled type 2 diabetes mellitus. According to the facility's notes, she had been complaining of a constant "ringing" sound in her ears for the past 48 hours and self-administering extra over-the-counter analgesics for knee pain.

On arrival, her temperature is 37.1°C (98.8°F), blood pressure is 135/85 mm Hg, pulse is 112/min, and respirations are 28/min. Oxygen saturation is 96% on ambient air.

The patient appears mildly lethargic and is oriented only to person. Her mucous membranes are notably dry. Auscultation of the chest reveals a rapid, regular heart rate with no murmurs, and breath sounds are clear in all lung fields. The abdomen is non-tender. Trace pitting edema is noted at the ankles.

Laboratory evaluation demonstrates:
Sodium: 142 mEq/L
Potassium: 3.9 mEq/L
Chloride: 102 mEq/L
Bicarbonate: 14 mEq/L
Blood urea nitrogen: 24 mg/dL
Creatinine: 1.2 mg/dL
Glucose: 105 mg/dL

Arterial blood gas analysis on ambient air reveals:
pH: 7.42
pCO2: 20 mm Hg
pO2: 92 mm Hg

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

A 38-year-old woman comes to the clinic due to a 3-month history of worsening fatigue, generalized weakness, and a 4.5-kg (10-lb) weight gain despite a decreased appetite. She also reports feeling constantly cold and having increasingly irregular menstrual cycles. Her temperature is 36.1°C (97.0°F), blood pressure is 100/65 mm Hg, and pulse is 54/min. Physical examination shows dry skin and delayed relaxation of the deep tendon reflexes. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 0.1 $\mu$ U/mL (normal: 0.5-5.0 $\mu$ U/mL) and a free thyroxine (T4) level of 0.4 ng/dL (normal: 0.9-1.7 ng/dL). Which of the following is the most likely cause of this patient's findings?

A $24$-year-old woman with type $1$ diabetes mellitus presents to the emergency department with abdominal pain, nausea, and Kussmaul respirations. She is diagnosed with diabetic ketoacidosis. Her initial laboratory results demonstrate a serum glucose of $600$ mg/dL and a serum potassium of $5.8$ mEq/L. She is tachycardic and hypotensive.

Arrange the following interventions in the correct chronological order as her treatment progresses over the next several hours.

A 66-year-old man is brought to the emergency department by his wife due to severe, progressively worsening shortness of breath over the past 24 hours. He has a history of essential hypertension, type 2 diabetes mellitus, and a 45-pack-year smoking history. The patient reports a dry, hacking cough. His wife notes that he has been sleeping in his recliner for the past two nights because he feels like he is "smothering" when lying flat in bed.

Temperature is 37.0°C (98.6°F), blood pressure is 175/100 mm Hg, pulse is 112/min, and respirations are 26/min. Oxygen saturation is 89% on room air. The patient is diaphoretic, sitting upright, and using accessory muscles of respiration. Jugular venous pressure is estimated at 10 cm H2O. Pulmonary auscultation reveals a prolonged expiratory phase with diffuse, loud, bilateral expiratory wheezes; no crackles are appreciated. Cardiac auscultation reveals a regular tachycardia with a prominent S4 gallop. Trace bilateral pitting edema is present at the ankles.

Laboratory results are as follows:
Sodium: 138 mEq/L
Potassium: 4.2 mEq/L
Chloride: 104 mEq/L
Bicarbonate: 16 mEq/L
Blood urea nitrogen: 30 mg/dL
Serum creatinine: 1.6 mg/dL
Lactate: 4.1 mmol/L
Thyroid-stimulating hormone: 2.5 µU/mL (normal: 0.5-5.0 µU/mL)
Free T4: 0.6 ng/dL (normal: 0.9-2.4 ng/dL)

An arterial blood gas on room air reveals:
pH: 7.30
pCO2: 33 mm Hg
pO2: 64 mm Hg

A chest radiograph demonstrates cardiomegaly, peribronchial cuffing, and prominent upper lobe vessels, with no focal consolidations.

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

A 54-year-old man with a history of alcohol use disorder and liver cirrhosis is brought to the emergency department vomiting bright red blood. His blood pressure is 85/55 mm Hg, and his pulse is 122/min. Arrange the following management steps in the most appropriate sequential order.

A 72-year-old man is brought to the emergency department by his son due to worsening shortness of breath, increased cough, and progressive lethargy over the past 48 hours. The son notes that the patient's baseline morning cough has been producing thick, yellowish sputum since yesterday. The patient has a history of severe chronic obstructive pulmonary disease (COPD) and hypertension. His temperature is 38.1°C (100.6°F), blood pressure is 134/82 mm Hg, pulse is 108/min, and respirations are 26/min. Pulse oximetry shows 88% on room air. Physical examination reveals an increased anteroposterior chest diameter. Lung auscultation demonstrates bilateral diffuse wheezing and a prolonged expiratory phase. There are no crackles, jugular venous distension, or lower extremity edema.

Laboratory testing shows:
Leukocyte count: 12,500/mm³
Thyroid-stimulating hormone (TSH): 2.5 µU/mL (normal: 0.5-5.0)
Free thyroxine (T4): 1.2 ng/dL (normal: 0.9-1.7)

Arterial blood gas on room air:
pH: 7.28
PaCO₂: 65 mm Hg
PaO₂: 55 mm Hg

Which of the following is the most appropriate initial pharmacological management?

An internal medicine rapid response team is activated for a $68$-year-old hospitalized male who developed profound lower extremity weakness and lethargy. The patient was admitted two days ago for a diabetic foot infection and is receiving intravenous piperacillin-tazobactam. His home medications, including lisinopril and spironolactone for heart failure with reduced ejection fraction, were continued on admission. Over the past $12$ hours, his urine output has dropped significantly to $150$ mL. Vital signs demonstrate a heart rate of $42$/min and a blood pressure of $98/60$ mmHg. A point-of-care basic metabolic panel reveals a serum potassium of $7.8$ mEq/L and a serum creatinine of $3.2$ mg/dL (baseline $1.4$ mg/dL). A stat $12$-lead electrocardiogram demonstrates widened QRS complexes, absent P waves, and peaked T waves.

Arrange the following management steps in the most appropriate chronological sequence for this patient's acute presentation, from the most immediate intervention to subsequent actions.

Match each patient presenting with severe hypertension and distinct clinical features to the most appropriate initial targeted pharmacologic intervention.

An emergency medical services team transports a $68$-year-old retired teacher to the emergency department due to rapidly progressive breathlessness that awoke her from sleep. She has a medical history significant for a myocardial infarction three years ago and moderate chronic obstructive pulmonary disease, for which she uses an as-needed albuterol inhaler. Over the past $12$ hours, her inhaler has provided no relief. Her home medications include aspirin, metoprolol, and lisinopril.

On arrival, her temperature is $37.0^\circ \text{C}$ ($98.6^\circ \text{F}$), blood pressure is $178/104 \text{ mm Hg}$, pulse is $112/\text{min}$, and respiratory rate is $28/\text{min}$. Oxygen saturation is $86\%$ on room air. The patient appears highly anxious and is sitting upright on the stretcher. Physical examination reveals distended jugular veins when sitting at a $45^\circ$ angle. Pulmonary auscultation reveals diffuse expiratory wheezing with a prolonged expiratory phase, as well as bilateral bibasilar crackles. Cardiac examination demonstrates a regular tachycardia with a prominent early diastolic extra heart sound.

Arterial blood gas analysis on room air shows:
- pH: $7.28$
- $\text{PaCO}_2$: $56 \text{ mm Hg}$
- $\text{PaO}_2$: $54 \text{ mm Hg}$
- $\text{HCO}_3^-$: $25 \text{ mEq/L}$

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

Match each patient's preoperative medication profile with the most appropriate perioperative management strategy for that specific medication.

Review the following clinical presentations of patients with severe malabsorption or those receiving long-term parenteral nutrition. Match each clinical vignette to the specific underlying trace mineral deficiency it describes.

A 64-year-old woman is brought to the emergency department by her son due to worsening confusion, nausea, and ringing in her ears for the past 24 hours. She has a history of chronic obstructive pulmonary disease (COPD), hypertension, and osteoarthritis, for which she frequently takes over-the-counter analgesics. She also underwent transsphenoidal resection of a pituitary macroadenoma 5 years ago.

Vital signs: Temperature 37.1°C (98.8°F), blood pressure 110/70 mmHg, heart rate 112/min, respiratory rate 28/min.

Physical examination reveals dry mucous membranes and lethargy. Lung auscultation reveals clear breath sounds bilaterally. There is no jugular venous distention.

Laboratory results:
Sodium: 141 mEq/L
Potassium: 3.9 mEq/L
Chloride: 105 mEq/L
Bicarbonate: 14 mEq/L
Blood urea nitrogen: 38 mg/dL
Creatinine: 1.8 mg/dL
Thyroid-stimulating hormone (TSH): 1.1 µU/mL (normal: 0.4–4.0 µU/mL)
Free T4: 0.5 ng/dL (normal: 0.9–1.7 ng/dL)

Arterial blood gas on room air:
pH: 7.42
$PaCO_2$: 22 mmHg
$PaO_2$: 96 mmHg

A urine culture sent 3 days ago from an outpatient clinic visit for mild dysuria has returned positive for $>100,000$ CFU/mL of *Escherichia coli*, which is susceptible to cephalexin and nitrofurantoin, but resistant to fluoroquinolones.

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

A 68-year-old man is evaluated in the hospital on day 4 of admission for persistent low-grade fevers and fatigue. He originally presented with a 2-week history of generalized weakness, night sweats, and shortness of breath. His medical history is significant for hypertension and osteoarthritis. On examination today, temperature is 37.8°C (100.0°F), blood pressure is 128/76 mmHg, and pulse is 88/min. Cardiac auscultation reveals a new grade 3/6 holosystolic murmur heard best at the cardiac apex. Laboratory studies show a leukocyte count of 12,400/mm³ and serum creatinine of 1.4 mg/dL (baseline 0.9 mg/dL). Blood cultures drawn at admission have grown *Enterococcus faecalis* in 4 out of 4 bottles. Susceptibility testing demonstrates the isolate is susceptible to ampicillin, vancomycin, and linezolid, and lacks high-level aminoglycoside resistance. A transesophageal echocardiogram shows a 1.2-cm mobile vegetation on the mitral valve. The patient is currently receiving empiric therapy with intravenous vancomycin and cefepime. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

Match each clinical presentation to the most appropriate initial therapeutic intervention.

Match each patient's clinical presentation following a toxic ingestion or medication overdose to the most appropriate initial specific pharmacologic antidote or therapy.

A medical resident is evaluating a 72-year-old man in the preoperative clinic prior to a scheduled open abdominal aortic aneurysm repair. The patient has a history of stroke, insulin-dependent diabetes mellitus, and chronic kidney disease. He is sedentary and unable to climb a flight of stairs due to lower extremity claudication. The attending physician asks the resident to outline the standardized stepwise approach for perioperative cardiovascular risk assessment according to the current clinical guidelines.

Arrange the following steps of the perioperative cardiovascular evaluation algorithm in their correct sequential order, from the absolute initial consideration to final preoperative decision-making.

The nursing staff urgently requests an evaluation of a $64$-year-old man in the pulmonary step-down unit due to decreasing responsiveness. The patient was admitted $36$ hours ago for a severe exacerbation of chronic obstructive pulmonary disease (COPD). His initial treatment included intravenous methylprednisolone, nebulized ipratropium-albuterol, oral doxycycline, and supplemental oxygen. Over the past $12$ hours, his oxygen delivery was escalated to a non-rebreather mask by the cross-cover team due to perceived hypoxemia. His other medical history includes systemic hypertension, diet-controlled type 2 diabetes, and osteoarthritis.

Vital signs are:
Temperature: $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$)
Blood pressure: $142/86 \text{ mm Hg}$
Heart rate: $108/\text{min}$
Respiratory rate: $8/\text{min}$
Pulse oximetry: $99\%$ on the non-rebreather mask

On physical examination, the patient is lethargic but opens his eyes and follows simple commands when spoken to loudly. Noticeable asterixis is present on bilateral wrist extension. The jugular venous pressure is visually estimated at $5 \text{ cm H}_2\text{O}$. Auscultation of the chest reveals a markedly prolonged expiratory phase with faint, diffuse wheezing, but no crackles. The cardiac rhythm is regular. Trace bilateral pedal edema is noted.

Relevant morning laboratory panels show:
Leukocytes: $8,200/\text{mm}^3$
Sodium: $138 \text{ mEq/L}$
Potassium: $4.3 \text{ mEq/L}$
Chloride: $94 \text{ mEq/L}$
Bicarbonate: $36 \text{ mEq/L}$
Thyroid-stimulating hormone (TSH): $0.1 \mu\text{U/mL}$ (Normal: $0.4-4.0 \mu\text{U/mL}$)
Free thyroxine (T4): $1.2 \text{ ng/dL}$ (Normal: $0.9-1.7 \text{ ng/dL}$)

An arterial blood gas analysis drawn on his current oxygen support demonstrates:
pH: $7.20$
$PaCO_2$: $95 \text{ mm Hg}$
$PaO_2$: $148 \text{ mm Hg}$

Based on these clinical and laboratory findings, which of the following is the most appropriate next step in management?

An internal medicine physician is urgently called to evaluate a 54-year-old male admitted overnight for observation. The nursing staff reports that the patient has developed new-onset confusion, a severe holocephalic headache, and photophobia over the last 4 hours. Vital signs show a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), pulse of $112/\text{min}$, and blood pressure of $138/82\text{ mmHg}$. Neurologic examination demonstrates a Glasgow Coma Scale score of 11, prominent resistance to passive neck flexion, and bilateral papilledema. No other focal neurologic deficits are present.

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

A $60$-year-old woman is brought to the emergency department by her husband due to progressive confusion, profound fatigue, and generalized weakness over the past week. Two weeks ago, she had a mild upper respiratory infection. Her husband notes she has been complaining of intermittent headaches and peripheral vision loss for the last three months. Her temperature is $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$), blood pressure is $82/50\text{ mm Hg}$, pulse is $54/\text{min}$, and respirations are $16/\text{min}$. Physical examination shows a lethargic woman with dry, pale skin and delayed relaxation of deep tendon reflexes. Mild bilateral non-pitting lower extremity edema is present. Lung auscultation reveals decreased breath sounds at the bases but no crackles or wheezes.

Laboratory evaluation shows:

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