Internal Medicine

A 35-year-old man presents to the emergency department in mid-July with a 4-day history of high fever, severe headache, myalgias, and profound fatigue. He recently returned from a week-long camping trip in the Ozark Mountains of Arkansas. He does not recall any specific insect bites. His temperature is 39.1°C (102.4°F), pulse is 112/min, blood pressure is 118/76 mmHg, and respirations are 18/min. Physical examination reveals a non-toxic appearing man with no skin rashes, nuchal rigidity, or palpable lymphadenopathy. Laboratory studies reveal:

Leukocyte count: 2,400/mm³
Platelet count: 85,000/mm³
Aspartate aminotransferase (AST): 135 U/L
Alanine aminotransferase (ALT): 142 U/L

A peripheral blood smear demonstrates basophilic, intracytoplasmic inclusions within monocytes. Which of the following is the most appropriate pharmacotherapy for this patient?

A 64-year-old man is brought to the emergency department due to sudden-onset, severe, "tearing" chest pain that radiates to his back between the shoulder blades. His blood pressure is 210/115 mm Hg in the right arm and 170/95 mm Hg in the left arm. His pulse is 115/min. Physical examination reveals an early diastolic decrescendo murmur at the right upper sternal border. Electrocardiogram shows sinus tachycardia and voltage criteria for left ventricular hypertrophy without acute ischemic changes. Chest x-ray reveals a widened mediastinum. A presumptive diagnosis of acute aortic dissection is made. Arrange the following steps in the most appropriate clinical sequence for managing this patient.

Match each clinical presentation requiring targeted or empiric antimicrobial therapy with the most appropriate guideline-concordant oral antibiotic regimen.

A 34-year-old woman comes to the clinic due to a 6-month history of worsening fatigue, constipation, and a 6-kg (13.2-lb) weight gain. She also reports that her menstrual periods, previously regular, have ceased entirely for the past 5 months. Recently, she noticed a spontaneous, bilateral milky nipple discharge. Her medical history is unremarkable, and she takes no medications. Vital signs are within normal limits except for a heart rate of 54/min. Physical examination reveals delayed relaxation of the deep tendon reflexes. Confrontational visual field testing demonstrates a loss of peripheral vision bilaterally. Laboratory evaluation shows:

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

Match each clinical presentation following an acute ST-segment elevation myocardial infarction with the most likely underlying structural or inflammatory complication.

A 22-year-old male college student is brought to the emergency department by his roommate due to a 24-hour history of severe headache, high fever, and progressive confusion. His temperature is 39.4°C (102.9°F), blood pressure is 110/65 mm Hg, pulse is 118/min, and respirations are 22/min. Physical examination reveals marked nuchal rigidity and a positive Brudzinski sign. Funduscopic examination demonstrates blurring of the optic disc margins bilaterally. Which of the following represents the most appropriate chronological sequence of management steps for this patient?

During morning rounds in the intensive care unit, a physician evaluates a $68$-year-old woman who is receiving mechanical ventilation. She was admitted two days ago and intubated for acute hypercapnic respiratory failure triggered by a severe exacerbation of chronic obstructive pulmonary disease (COPD).

She has a $45$-pack-year smoking history and uses home oxygen therapy.

Current vital signs are temperature $37.1^\circ \text{C}$ ($98.8^\circ \text{F}$), blood pressure $118/76\text{ mm Hg}$, and pulse $84\text{/min}$.

On physical examination, the patient is sedated but breathes synchronously with the ventilator. Auscultation reveals prolonged expiration and diminished breath sounds globally, without crackles or wheezes. Jugular venous pressure is $5\text{ cm H}_2\text{O}$. There is no peripheral edema. Sputum cultures obtained at admission have grown normal respiratory flora.

The mechanical ventilator is set to volume control mode with a tidal volume of $400\text{ mL}$, respiratory rate of $16\text{/min}$, $\text{FiO}_2$ of $0.30$, and positive end-expiratory pressure (PEEP) of $5\text{ cm H}_2\text{O}$.

An arterial blood gas analysis is performed on these settings:
pH: $7.52$
$\text{PaCO}_2$: $43\text{ mm Hg}$
$\text{PaO}_2$: $82\text{ mm Hg}$
$\text{HCO}_3^-$: $34\text{ mEq/L}$

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

A 64-year-old retired teacher with a history of chronic hepatitis C viral infection and cirrhosis is brought to the emergency department after vomiting a large amount of bright red blood at home. Her husband reports she has been increasingly fatigued over the last week but had no prior episodes of bleeding. Upon arrival, the patient is lethargic but arousable. Vitals show a temperature of 36.8°C (98.2°F), pulse of 132/min, and blood pressure of 82/48 mm Hg. Physical examination reveals scleral icterus, palmar erythema, and a distended abdomen with a positive fluid wave. Capillary refill is delayed. Arrange the following interventions in the most appropriate chronological sequence for managing this patient's acute presentation.

A 54-year-old woman is evaluated in the oncology clinic for a new-onset fever. She is currently receiving induction chemotherapy for acute myeloid leukemia. Yesterday, her temperature was normal, but today she reports a sudden onset of chills and a temperature of 38.8°C (101.8°F). She has no cough, dyspnea, dysuria, abdominal pain, or diarrhea. Vital signs show a blood pressure of 115/75 mm Hg, a pulse of 105/min, and respirations of 16/min. Physical examination reveals a right internal jugular central venous catheter with no surrounding erythema, induration, or purulent drainage. Cardiopulmonary, abdominal, and skin examinations are otherwise unremarkable. Laboratory studies show:

Hemoglobin: 9.2 g/dL
Platelets: 45,000/mm³
Leukocytes: 800/mm³
Neutrophils: 10%
Lymphocytes: 80%
Monocytes: 10%

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

A 39-year-old woman is evaluated for a 1-year history of progressive central obesity, facial plethora, and new-onset hypertension. She also reports menstrual irregularities and easy bruising. Physical examination reveals violaceous striae on her abdomen and prominent proximal muscle weakness in her lower extremities. She does not use any prescription, over-the-counter, or topical medications. Suspecting an endogenous hypercortisolism disorder, her physician decides to initiate a comprehensive diagnostic workup. Arrange the following diagnostic modalities in the correct sequential order for the evaluation of this patient's condition, starting from the initial screening to the definitive localization of the source.

A $69$-year-old man comes to the clinic with progressively worsening lower extremity edema, fatigue, and exertional dyspnea over the last three months. He has a $50$-pack-year smoking history and was diagnosed with severe chronic obstructive pulmonary disease (COPD) four years ago. He is compliant with his long-acting muscarinic antagonist and beta-agonist inhalers. Vital signs show a blood pressure of $132/84\text{ mmHg}$, pulse of $88\text{/min}$, and respirations of $18\text{/min}$. Oxygen saturation is $91\%$ on room air. Physical examination shows a barrel-shaped chest with decreased breath sounds bilaterally. The jugular venous pressure is elevated at $12\text{ cm H}_2\text{O}$. Heart sounds are distant, but a regular rhythm is appreciated. Abdominal examination shows hepatomegaly. There is $2+$ pitting edema extending to the knees bilaterally. The physician is trying to determine if the patient has developed concurrent left ventricular failure or if his symptoms are solely due to cor pulmonale from his severe COPD. Which of the following findings on further evaluation would most strongly indicate the presence of concurrent left-sided heart failure rather than isolated cor pulmonale?

Paramedics transport a $58$-year-old male to the emergency department following the acute onset of unrelenting retrosternal chest pressure and profound diaphoresis that began $90$ minutes ago. On evaluation, his blood pressure is $82/52$ mmHg and his pulse is $52$/min. His respiratory rate is $16$/min and oxygen saturation is $96\%$ on room air. Physical examination demonstrates visibly distended neck veins while the patient is sitting at a $45^\circ$ angle. Auscultation reveals clear lung fields bilaterally without crackles or wheezing. Cardiac examination demonstrates a regular, slow rhythm without murmurs, rubs, or gallops. A 12-lead electrocardiogram obtained by triage staff demonstrates $3$-mm convex ST-segment elevations in leads II, III, and aVF, with reciprocal ST-segment depressions in leads I and aVL. In addition to antiplatelet therapy and preparation for immediate revascularization, which of the following is the most appropriate initial intervention to stabilize this patient's hemodynamics?

A 62-year-old woman is evaluated in the hospital on hospital day 3. She was initially admitted with fever, chills, severe right flank pain, and dysuria. On admission, her temperature was 39.1°C (102.4°F), heart rate was 112/min, and blood pressure was 105/65 mmHg. Physical examination revealed pronounced right costovertebral angle tenderness. Laboratory studies showed a leukocyte count of 16,500/mm³. Due to a history of an extended-spectrum beta-lactamase (ESBL)-producing *Escherichia coli* urinary tract infection two years ago, she was empirically started on intravenous meropenem. Today, her temperature is 37.1°C (98.8°F), her flank pain has significantly improved, and she is tolerating a regular diet. Blood and urine cultures obtained on admission both grow *Escherichia coli*. Susceptibility testing indicates the isolate is resistant to ampicillin, but susceptible to ceftriaxone, trimethoprim-sulfamethoxazole, ciprofloxacin, and meropenem. Which of the following is the most appropriate next step in management?

Evaluate the following clinical scenarios involving patients with altered thyroid function. Match each patient's presentation with the most accurate diagnosis.

A $58$-year-old male patient is recovering in the cardiac intensive care unit following an anterior wall myocardial infarction. On hospital day $2$, the telemetry alarms sound. The nurse finds the patient unresponsive and apneic, with no palpable carotid pulse. The bedside cardiac monitor displays a regular, wide-complex tachycardia at a rate of $210/\text{min}$. Arrange the following resuscitation interventions in the most appropriate chronological sequence from first to last according to standard adult advanced cardiovascular life support (ACLS) algorithms.

A 48-year-old man comes to the clinic reporting a 6-month history of worsening fatigue, generalized joint pain, and decreased libido. His joint pain is most prominent in the second and third metacarpophalangeal joints of both hands. He has no significant past medical history and takes no medications. Vital signs are within normal limits. Physical examination reveals hepatomegaly and bilateral testicular atrophy. Skin examination shows a diffuse, slate-gray hyperpigmentation that is most pronounced in sun-exposed areas. Laboratory studies show the following:

Fasting blood glucose: $135 \text{ mg/dL}$
Thyroid-stimulating hormone (TSH): $1.4 \text{ mIU/L}$ (normal: $0.4–4.0 \text{ mIU/L}$)
Free thyroxine (T4): $0.6 \text{ ng/dL}$ (normal: $0.9–1.7 \text{ ng/dL}$)
Total testosterone: $140 \text{ ng/dL}$ (normal: $300–1,000 \text{ ng/dL}$)
Luteinizing hormone (LH): $2.1 \text{ mIU/mL}$ (normal: $1.8–8.6 \text{ mIU/mL}$)

Which of the following is the most likely mechanism underlying this patient's thyroid laboratory abnormalities?

Match the following classic electrocardiographic (ECG) findings with their most likely underlying cardiac structural pathology, inflammatory condition, or electrophysiological syndrome.

A $22$-year-old tall, thin man is brought to the emergency department by emergency medical services after a high-speed motorcycle collision. He is in severe respiratory distress and appears cyanotic. His blood pressure is $80/50$ mm Hg, heart rate is $135$/min, and oxygen saturation is $84\%$ on a non-rebreather mask. Physical examination reveals obvious tracheal deviation to the left, significantly distended neck veins, and completely absent breath sounds over the right hemithorax. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological order for managing this patient's life-threatening condition.

Match each patient vignette describing clinical features of Cushing syndrome to their most likely corresponding diagnostic laboratory profile.

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