Internal Medicine

A 38-year-old woman is evaluated in the outpatient clinic for a 6-month history of profound fatigue, progressive generalized weakness, dry skin, and constipation. She also reports frequent lightheadedness, particularly when standing up quickly. The patient has not menstruated for the past 5 months, although she previously had regular cycles. Her last pregnancy was 4 years ago and was uncomplicated. She takes no medications and does not use illicit drugs. Her body mass index is $22 \text{ kg/m}^2$. Vital signs show a blood pressure of $92/58 \text{ mm Hg}$ while supine that drops to $80/50 \text{ mm Hg}$ upon standing. Her heart rate is $58/\text{min}$. Physical examination reveals pale, dry skin and sparse axillary and pubic hair. The relaxation phase of the ankle reflexes is significantly delayed.

Laboratory studies show:
Hemoglobin: $11.2 \text{ g/dL}$
Sodium: $132 \text{ mEq/L}$
Potassium: $4.1 \text{ mEq/L}$
Thyroid-stimulating hormone (TSH): $0.15 \text{ \mu U/mL}$ (normal: $0.4 - 4.0 \text{ \mu U/mL}$)
Free thyroxine (T4): $0.3 \text{ ng/dL}$ (normal: $0.9 - 2.4 \text{ ng/dL}$)

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

Match each infectious exposure scenario with the most appropriate guideline-directed post-exposure prophylaxis or preemptive pharmacotherapy.

A 38-year-old woman is evaluated in the outpatient clinic for progressive weight gain, proximal muscle weakness, and new-onset facial hair growth over the past 8 months. She takes no prescription or over-the-counter medications. Her temperature is 37.0°C (98.6°F), blood pressure is 158/98 mm Hg, pulse is 82/min, and BMI is 34 kg/m². Physical examination reveals facial plethora, a prominent dorsocervical fat pad, and wide, violaceous striae on the lower abdomen. Basic metabolic panel shows a serum potassium of 3.2 mEq/L and a fasting blood glucose of 145 mg/dL. The physician strongly suspects endogenous Cushing syndrome. Arrange the following diagnostic steps in the correct chronological sequence required to accurately diagnose and localize the etiology of this patient's condition.

A $54$-year-old woman with a history of type $2$ diabetes mellitus is evaluated in the hospital on day $3$ of admission for a liver abscess. She originally presented to the emergency department with a $4$-day history of right upper quadrant abdominal pain, high fever, and chills. At that time, an abdominal ultrasound revealed a $6\text{ cm}$ fluid collection in the right hepatic lobe. She underwent successful image-guided percutaneous drain placement and was empirically started on intravenous vancomycin, piperacillin-tazobactam, and metronidazole. Today, the patient reports significant improvement in her abdominal pain. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $124/78\text{ mm Hg}$, and pulse is $76/\text{min}$. The percutaneous drain has minimal purulent output. Both blood cultures and the initial abscess aspirate cultures (aerobic and anaerobic) are now growing pure *Klebsiella pneumoniae*. Susceptibility testing demonstrates the isolate is sensitive to ceftriaxone, cefepime, ciprofloxacin, and piperacillin-tazobactam, and is resistant to ampicillin. Which of the following is the most appropriate next step in pharmacotherapy?

A 58-year-old man with a history of alcohol-associated cirrhosis and refractory ascites is evaluated on hospital day 2. He initially presented with progressive confusion, fever, and diffuse abdominal discomfort. Upon admission, his temperature was $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure was $102/65\text{ mmHg}$, and heart rate was $105/\text{min}$. Physical examination demonstrated a tense, distended abdomen with shifting dullness and diffuse tenderness, but no guarding or rigidity.

Initial laboratory results from admission:

Diagnostic paracentesis performed in the emergency department yielded cloudy fluid with a leukocyte count of $850/\text{mm}^3$ ($85\%$ neutrophils). Total protein in the ascitic fluid was $0.8\text{ g/dL}$. Ascitic fluid cultures were sent, and the patient was empirically started on intravenous ceftriaxone.

Today, his temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $98/62\text{ mmHg}$, and pulse is $92/\text{min}$. He appears less confused. Urine output over the last 24 hours has been $600\text{ mL}$.

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

A 68-year-old man is admitted to the hospital with a 3-week history of low-grade fever, fatigue, and progressive dyspnea on exertion. His medical history is significant for hypertension, type 2 diabetes mellitus, and stage 4 chronic kidney disease with a baseline serum creatinine of 2.8 mg/dL. His temperature is 38.2°C (100.8°F), blood pressure is 132/78 mmHg, and heart rate is 96/min. Physical examination reveals a new grade 3/6 holosystolic murmur heard best at the cardiac apex and radiating to the axilla. Small, dark red linear streaks are noted under the nail beds of both hands. A transesophageal echocardiogram demonstrates a 1.2-cm mobile vegetation on the posterior leaflet of the mitral valve with moderate mitral regurgitation. Three sets of blood cultures drawn 12 hours apart all grow *Enterococcus faecalis*. Antimicrobial susceptibility testing shows the isolate is susceptible to ampicillin, vancomycin, daptomycin, linezolid, and high-level gentamicin. Which of the following is the most appropriate definitive intravenous pharmacotherapy for this patient?

A 42-year-old woman with a 3-year history of limited cutaneous systemic sclerosis is evaluated in the clinic for progressively worsening episodic finger pain. She describes her fingers turning sharply demarcated white, then blue, and finally red upon exposure to cold temperatures. Recent episodes have become more frequent, lasting up to 30 minutes, and are starting to interfere with her work as a graphic designer. Arrange the following management steps for this patient's vasomotor symptoms in the standard sequential order of escalation, starting with the initial fundamental intervention and ending with advanced salvage therapy for refractory disease.

A 28-year-old man is brought to the emergency department with a 3-day history of high fevers, severe fatigue, and a new rash. He has a history of intravenous drug use. His temperature is 39.5°C (103.1°F), blood pressure is 108/60 mm Hg, pulse is 115/min, and respiratory rate is 18/min. Physical examination reveals a loud holosystolic murmur at the left lower sternal border that becomes louder with inspiration. Small, tender, erythematous nodules are present on the palmar surface of his fingertips. The patient appears acutely ill and toxic. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for this patient.

Match each patient's clinical presentation and diagnostic findings with the most appropriate targeted antimicrobial regimen.

A 45-year-old woman is evaluated in the rheumatology clinic and newly diagnosed with highly active, seropositive rheumatoid arthritis (RA). Baseline radiographs reveal early marginal erosions in the metacarpophalangeal joints. Arrange the following clinical steps in the most appropriate chronological order for her long-term management, assuming she exhibits an inadequate response to each successive pharmacological intervention.

Emergency medical responders bring a 42-year-old female teacher to the emergency department after she was found profoundly disoriented in her classroom. Her husband reports she has experienced worsening fatigue, diffuse headaches, and nausea over the past three days. She has no significant past medical history and takes no medications. On arrival, her temperature is 38.2°C (100.8°F), blood pressure is 145/90 mmHg, pulse is 112/min, and respirations are 18/min. Physical examination is notable for lethargy, mild scleral icterus, and widespread nonblanching purple pinpoint spots over her lower extremities.

Laboratory studies reveal the following:

A peripheral blood smear demonstrates numerous fragmented red blood cells. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old man with a history of intravenous drug use is brought to the emergency department due to severe lower back pain and an inability to move his legs since this morning. For the past week, he has had worsening back pain and subjective fevers. Today, he also noticed he has been unable to urinate. His temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $110/70\text{ mm Hg}$, and pulse is $112/\text{min}$. Physical examination reveals exquisite point tenderness over the L3-L4 spinous processes. Neurologic examination shows $1/5$ strength in bilateral lower extremities, decreased sensation below the umbilicus, and absent patellar and Achilles reflexes. Bedside ultrasound reveals $800\text{ mL}$ of retained urine.

Arrange the following steps in the most appropriate chronological order for the optimal management of this patient's condition.

A 68-year-old man with a history of type 2 diabetes mellitus is brought to the emergency department by his family due to a severe headache, fever, and progressive confusion over the past 24 hours. On physical examination, his temperature is 39.2°C (102.6°F), blood pressure is 112/72 mmHg, heart rate is 115/min, and respiratory rate is 18/min. He is lethargic, opens his eyes to pain, and is oriented only to his name. Marked nuchal rigidity is present. There are no focal motor deficits, but fundoscopic examination is limited due to patient noncompliance. Place the following management steps in the most appropriate sequential order.

During a routine primary care appointment, a $71$-year-old woman reports experiencing a severe, right-sided headache for the past two weeks. She describes her scalp as being highly sensitive, noting that it hurts simply to brush her hair. Over the last $48$ hours, she has also developed a deep, cramping pain in her jaw that exclusively occurs when she is eating meals. Earlier this morning, she experienced a frightening episode where the vision in her right eye completely went dark for five minutes before spontaneously returning to normal. Her temperature is $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$). Physical examination demonstrates a prominent, thickened right temporal artery that is tender to palpation and lacks a palpable pulse. Point-of-care laboratory testing reveals an erythrocyte sedimentation rate of $105\text{ mm/h}$.

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

A 62-year-old man presents to the emergency department with a 5-day history of progressively worsening shortness of breath, orthopnea, and lower extremity swelling. He has a 30-pack-year smoking history but quit 5 years ago. He also has a 10-year history of erosive rheumatoid arthritis. His joint symptoms were poorly controlled with methotrexate alone, so etanercept was added 4 months ago, resulting in significant improvement in his joint pain. His other medical conditions include mild depression, for which he takes fluoxetine. Temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $154/92 \text{ mm Hg}$, pulse is $108 \text{ min}^{-1}$, and respirations are $24 \text{ min}^{-1}$. Pulse oximetry on room air shows an oxygen saturation of $91\%$. Physical examination reveals jugular venous distention. Lung auscultation demonstrates bilateral bibasilar crackles and scattered expiratory wheezes. Cardiac examination reveals tachycardia with a prominent S3 gallop. There is $2+$ bilateral pitting edema of the lower extremities. Joint examination shows no active synovitis. Laboratory studies show:

Brain natriuretic peptide: $850 \text{ pg/mL}$

Arterial blood gas on room air:
$\text{pH}: 7.49$
$\text{PaCO}_2: 28 \text{ mm Hg}$
$\text{PaO}_2: 64 \text{ mm Hg}$
$\text{HCO}_3^-: 21 \text{ mEq/L}$

Chest radiography reveals cardiomegaly, bilateral alveolar infiltrates, and small bilateral pleural effusions.

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

An emergency medical services team brings a $72$-year-old man to the acute care clinic due to a three-day history of escalating dyspnea and lower extremity swelling. He reports coughing up clear sputum and finds it difficult to lie flat at night. His past medical history includes chronic obstructive pulmonary disease (COPD), diet-controlled hypertension, and osteoarthritis. Current medications include inhaled tiotropium and as-needed albuterol.

His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $156/92\text{ mm Hg}$, pulse is $108/\text{min}$, and respirations are $26/\text{min}$. Pulse oximetry shows $87\%$ on room air. Physical examination reveals jugular venous distention up to $9\text{ cm H}_2\text{O}$. Lung auscultation demonstrates bibasilar crackles extending to the mid-lung fields and prolonged expiration with scattered wheezes. Cardiac examination shows a regular, rapid rhythm with an audible S $_3$ gallop. There is $2+$ pitting edema in both lower extremities.

Laboratory results are as follows:

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

A 38-year-old man comes to the emergency department due to persistent high fever, drenching sweats, and dark-colored urine. Five days ago, he was evaluated at an urgent care clinic for an expanding, target-shaped erythematous rash on his right calf and a mild headache. The symptoms began a week after a hiking trip in Rhode Island. He was diagnosed with early localized Lyme disease and prescribed oral doxycycline.

Despite adherence to the medication, the rash has faded but his fevers have worsened. Over the past 48 hours, he developed profound fatigue and noticed his eyes appearing yellow. Vital signs show a temperature of 39.4°C (102.9°F), blood pressure of 112/70 mmHg, and heart rate of 115/min. Physical examination is notable for mild scleral icterus. The abdomen is soft, with a spleen tip palpable below the left costal margin.

Laboratory evaluation shows:
- Hemoglobin: 8.6 g/dL
- Platelet count: 88,000/mm³
- Total bilirubin: 3.5 mg/dL
- Direct bilirubin: 0.5 mg/dL
- Lactate dehydrogenase: 720 U/L

A peripheral blood smear reveals intraerythrocytic pleomorphic ring forms. Which of the following is the most appropriate modification to this patient's antimicrobial regimen?

During morning rounds, a 64-year-old woman is evaluated on her third hospital day for management of acute pyelonephritis. She initially presented to the emergency department with a temperature of 38.9°C (102.0°F), right-sided flank pain, and persistent emesis. Blood and urine cultures were drawn, and empiric intravenous piperacillin-tazobactam was initiated.

Today, the patient reports feeling much better. Her flank pain has nearly resolved, and she is eating a regular diet without nausea. She has been afebrile for the past 24 hours. Current vital signs are temperature 37.1°C (98.8°F), heart rate 78/min, and blood pressure 118/76 mm Hg.

The admission blood and urine cultures are now finalizing, both demonstrating heavy growth of *Escherichia coli*. The isolate susceptibility report is as follows:

The patient has no known drug allergies. Her serum creatinine is $0.8$ mg/dL.

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

A 31-year-old man presents to the emergency department with a 5-week history of productive cough, low-grade fever, drenching night sweats, and a $5$-kg ($11$-lb) weight loss. He emigrated from an area with high tuberculosis prevalence three years ago and currently resides in a crowded apartment. His temperature is $38.4^\circ$ C ($101.1^\circ$ F), blood pressure is $118/76$ mm Hg, pulse is $92$/min, and respirations are $20$/min. Oxygen saturation is $96\%$ on room air. Pulmonary examination reveals bronchial breath sounds and crackles in the right upper lung field. A chest radiograph demonstrates a cavitary infiltrate in the right upper lobe.

Arrange the following interventions in the most appropriate chronological order for the management of this patient.

A 32-year-old man is brought to the emergency department due to a 3-day history of progressively worsening, severe right upper quadrant abdominal pain and abdominal swelling. Over the past year, he has experienced significant fatigue and several episodes where his urine appeared abnormally dark, particularly upon waking in the morning. His temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $112/68 \text{ mm Hg}$, and pulse is $108/\text{min}$. Physical examination reveals scleral icterus, mildly labored breathing, and a markedly distended abdomen with shifting dullness. There is severe tenderness to palpation in the right upper quadrant. The liver edge is palpable $4 \text{ cm}$ below the right costal margin.

Laboratory results are as follows:

Abdominal duplex ultrasonography shows a prominently enlarged liver with moderate ascites and absent color flow signal within the hepatic veins.

Which of the following therapies directly targets the primary etiology of this patient's current condition?