Internal Medicine

Match each clinical and laboratory profile of a patient presenting with secondary hypertension to the most likely underlying pathophysiologic diagnosis.

Match each patient's clinical and high-resolution manometry (HRM) presentation with the most accurate underlying pathophysiologic mechanism.

A 48-year-old man comes to the clinic reporting progressive fatigue, muscle weakness, and decreased libido over the past 6 months. He has gained 4 kg (8.8 lb) during this period. The patient has a history of a traumatic brain injury sustained in a motor vehicle collision one year ago, which required a prolonged hospital stay. His vital signs are temperature 36.4°C (97.5°F), blood pressure 105/65 mmHg, and pulse 56/min. Physical examination shows loss of axillary and pubic hair, and delayed relaxation of deep tendon reflexes. Laboratory results are as follows:

Serum sodium: 132 mEq/L
Serum potassium: 4.0 mEq/L
Thyroid-stimulating hormone (TSH): 1.1 µU/mL (Normal: 0.4–4.0 µU/mL)
Free thyroxine (T4): 0.5 ng/dL (Normal: 0.7–1.9 ng/dL)

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

A 45-year-old man who recently emigrated from an area highly endemic for tuberculosis presents to the emergency department with a 4-week history of productive cough, blood-tinged sputum, drenching night sweats, and unintentional weight loss. Vital signs show a temperature of 38.3°C (100.9°F). A chest radiograph reveals a large cavitary lesion in the apical segment of the right upper lobe. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 62-year-old woman with a history of cirrhosis secondary to metabolic dysfunction-associated steatohepatitis presents to the hospital complaining of generalized abdominal pain and lethargy for the past two days. Her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $102/60 \text{ mm Hg}$, and pulse is $92/\text{min}$. Physical examination shows a noticeably distended abdomen that is diffusely tender to palpation, accompanied by a positive fluid wave test. A diagnostic paracentesis is promptly performed. The ascitic fluid analysis demonstrates an absolute neutrophil count of $450 / \text{mm}^3$. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A $74$-year-old woman is evaluated in the preoperative clinic $5$ days before a scheduled right total knee arthroplasty. She has a history of severe osteoarthritis and chronic urge incontinence, which has been stable on a scheduled voiding regimen. The patient reports no new symptoms and specifically denies dysuria, urinary frequency, suprapubic discomfort, or flank pain. Her current medications include acetaminophen and cholecalciferol. Vital signs are within normal limits, including a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$). Physical examination shows severe right knee crepitus and limited range of motion. There is no costovertebral angle or suprapubic tenderness. Preoperative laboratory results are as follows:

Leukocyte count: $7,800/\mu\text{L}$
Hemoglobin: $12.4$ g/dL
Platelets: $210,000/\mu\text{L}$

Urinalysis:
Color: Yellow
Appearance: Cloudy
Specific gravity: $1.018$
pH: $7.5$
Leukocyte esterase: Positive
Nitrites: Positive
WBC: $30$/hpf
Bacteria: Many

A urine culture grows $>10^5$ CFU/mL of *Proteus mirabilis* that is susceptible to cefazolin, ceftriaxone, and ciprofloxacin. Which of the following is the most appropriate management of this patient's urinary findings prior to surgery?

During a routine health maintenance examination, laboratory testing is performed on a 58-year-old man with a long-standing history of type 2 diabetes mellitus and essential hypertension. The patient reports feeling entirely well and denies any recent illness, changes in urine output, or gastrointestinal symptoms. His current medication regimen consists of metformin, lisinopril, amlodipine, and rosuvastatin. Vital signs show a blood pressure of 134/82 mm Hg and a heart rate of 72/min. There is no peripheral edema on examination. The basic metabolic panel and urinalysis results are as follows:

Serum sodium: $138$ mEq/L
Serum potassium: $5.8$ mEq/L
Serum chloride: $110$ mEq/L
Serum bicarbonate: $18$ mEq/L
Blood urea nitrogen: $26$ mg/dL
Serum creatinine: $1.7$ mg/dL
Fasting glucose: $148$ mg/dL
Urine pH: $5.2$

Which of the following is the most likely primary mechanism for this patient's laboratory abnormalities?

A $64$-year-old man is evaluated on postoperative day $3$ following an uncomplicated partial colectomy for a diverticular stricture. He reports the abrupt onset of excruciating pain, swelling, and redness in his right knee that woke him from sleep. His temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $135/85\text{ mm Hg}$, and heart rate is $98\text{/min}$. Physical examination reveals a markedly swollen, warm, and erythematous right knee. Any range of motion elicits severe pain. Laboratory studies show a serum creatinine of $2.4\text{ mg/dL}$ (baseline $2.2\text{ mg/dL}$) and a serum uric acid level of $5.5\text{ mg/dL}$. Arthrocentesis is performed, yielding cloudy yellow fluid with a leukocyte count of $35,000/\mu\text{L}$ ($85\%$ neutrophils). Polarized light microscopy demonstrates numerous needle-shaped, negatively birefringent crystals. Gram stain shows no organisms. Which of the following is the most appropriate next step in management for this patient's joint symptoms?

A $68$-year-old man with a history of metastatic prostate cancer is brought to the emergency department by his family due to a $2$-day history of progressively worsening mid-back pain. This morning, he developed weakness in both legs and has been unable to void his bladder for the past $10$ hours. His temperature is $37.1^\circ \text{C}$ ($98.8^\circ \text{F}$), blood pressure is $142/88$ \text{mmHg}, and pulse is $92$/\text{min}. Neurologic examination reveals $3/5$ motor strength in the bilateral lower extremities, diminished deep tendon reflexes at the knees and ankles, and decreased sensation to pinprick below the level of the umbilicus. Anal sphincter tone is decreased. Bladder ultrasound reveals $600$ \text{mL} of retained urine.

Based on the clinical presentation, arrange the following steps in the most appropriate chronological order for the acute management and diagnostic workup of this patient.

An unresponsive 26-year-old woman is admitted to the intensive care unit after being found lethargic in her apartment by a roommate. The roommate notes that the patient has a history of type 1 diabetes mellitus and has been suffering from a severe gastrointestinal illness with copious vomiting for the past four days. The patient stopped all insulin therapy during this time because she could not tolerate oral intake. At presentation, her blood pressure is 92/58 mm Hg, pulse is 122/min, and respiratory rate is 28/min. Physical examination reveals deep, rapid breathing and profoundly dry mucous membranes.

Initial laboratory evaluation reveals the following:
Serum sodium: 142 mEq/L
Serum potassium: 3.2 mEq/L
Serum chloride: 96 mEq/L
Serum bicarbonate: 16 mEq/L
Blood urea nitrogen: 52 mg/dL
Serum creatinine: 1.8 mg/dL
Plasma glucose: 610 mg/dL

Arterial blood gas analysis on room air:
pH: 7.32
pCO2: 32 mm Hg
pO2: 98 mm Hg

Based on these findings, which of the following best describes this patient's acid-base status?

Match each patient's clinical presentation and hypothalamic-pituitary-adrenal (HPA) axis laboratory profile to the most likely underlying pathophysiologic mechanism.

A 42-year-old man is admitted to the hospital with a 24-hour history of severe, unrelenting epigastric pain that radiates directly to his mid-back. The pain is accompanied by continuous nausea and several episodes of nonbilious emesis. He admits to consuming a large amount of alcohol over the past weekend. His temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $112/68\text{ mmHg}$, and pulse is $110/\text{min}$. Physical examination reveals marked tenderness to deep palpation in the epigastric region, with decreased bowel sounds but no rigidity or rebound tenderness. Laboratory evaluation shows a leukocyte count of $14,500/\text{mm}^3$, aspartate aminotransferase of $45\text{ U/L}$, alanine aminotransferase of $38\text{ U/L}$, alkaline phosphatase of $90\text{ U/L}$, total bilirubin of $1.0\text{ mg/dL}$, and serum lipase of $2,800\text{ U/L}$ (normal: $10-140\text{ U/L}$). An ultrasound of the right upper quadrant demonstrates an enlarged, hypoechoic pancreas but no evidence of gallstones, sludge, or biliary ductal dilation. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's gastrointestinal presentation with the most appropriate antimicrobial management strategy.

A rheumatology clinic is updating its patient safety protocols to ensure appropriate baseline screening and long-term monitoring for patients on immunomodulatory therapies. Match each pharmacologic agent commonly used in the management of rheumatologic diseases to its most characteristic severe adverse effect.

A 28-year-old woman with a history of Sjögren syndrome is evaluated in the clinic for progressive muscle weakness over the past week. She reports no vomiting, diarrhea, or recent illnesses. Her vital signs are within normal limits. Physical examination reveals 3/5 strength in the proximal muscles of her lower extremities. Laboratory studies show:

Serum:
Na $^+$: 139 mEq/L
K $^+$: 2.8 mEq/L
Cl $^-$: 114 mEq/L
HCO $_3^-$: 14 mEq/L

Arterial blood gas (room air):
pH: 7.28
pCO $_2$: 32 mm Hg

Urine:
Na $^+$: 62 mEq/L
K $^+$: 30 mEq/L
Cl $^-$: 55 mEq/L
pH: 6.0

What is the calculated urine anion gap for this patient in mEq/L?

A 48-year-old male presents to the emergency department after vomiting a large amount of coffee-ground material. He reports feeling lightheaded, dizzy, and fatigued over the past several hours. His blood pressure is 88/55 mm Hg and his heart rate is 118/min. Physical examination shows pale conjunctivae and mild epigastric tenderness. He has a significant history of daily ibuprofen use for chronic lower back pain. Arrange the following management steps in the most appropriate chronological order for this patient.

Identify the most specific diagnostic marker or laboratory finding for the following patients presenting with classic hepatobiliary manifestations.

Match each clinical exposure scenario with the most appropriate targeted post-exposure management or prophylaxis protocol.

A $68$-year-old man is evaluated in the hospital for a new-onset fever. He was admitted $5$ days ago for an acute exacerbation of chronic obstructive pulmonary disease, which has significantly improved with intravenous corticosteroids and bronchodilators. A Foley catheter was placed on admission for strict fluid monitoring but was removed $48$ hours later. Yesterday, he developed a fever of $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), dysuria, and suprapubic tenderness. Urinalysis revealed $50$ leukocytes per high-power field and positive leukocyte esterase. He was empirically started on intravenous piperacillin-tazobactam and vancomycin. Today, the patient's fever has resolved, his urinary symptoms are improving, and he is tolerating an oral diet. Blood cultures drawn concurrently have no growth to date. Cardiac examination reveals a regular rate and rhythm with no murmurs. Urine culture from yesterday grows $>100,000$ CFU/mL of *Enterococcus faecalis*. Susceptibility testing demonstrates that the isolate is susceptible to ampicillin, vancomycin, and linezolid.

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

A 44-year-old man visits the urgent care clinic complaining of a 3-day history of progressive left lower quadrant abdominal pain. He reports mild nausea but has not vomited. His last bowel movement was yesterday and was normal in consistency. He has no significant past medical history and takes no medications. His temperature is $37.3^\circ\text{C}$ ($99.1^\circ\text{F}$), blood pressure is $124/78\text{ mmHg}$, and pulse is $82/\text{min}$. Physical examination reveals focal tenderness to palpation in the left lower quadrant without rigidity, guarding, or rebound tenderness. Laboratory studies show a leukocyte count of $9,800/\text{mm}^3$. A CT scan of the abdomen and pelvis with intravenous contrast demonstrates wall thickening of the sigmoid colon with adjacent pericolonic fat stranding. There is no evidence of an abscess, stricture, fistula, or free intraperitoneal air. He is able to tolerate oral fluids without difficulty. Which of the following is the most appropriate next step in management?