Internal Medicine

Evaluate the following complex clinical presentations of patients with underlying autoimmune or rheumatic conditions. Pair each patient's specific complication with the most accurate diagnostic term.

A 74-year-old woman is brought to the emergency department reporting a new, severe right-sided headache, scalp tenderness, and a sudden visual field defect in her right eye. She also notes pain in her jaw when chewing food. Arrange the following medical steps in the most appropriate chronological sequence for the standard management of this patient's condition.

Match each patient's clinical presentation and laboratory findings to the most appropriate initial therapeutic intervention.

Match each clinical presentation of acute poisoning or overdose to the most appropriate initial specific antidote or pharmacologic therapy.

Match each healthcare worker's specific post-exposure scenario with the most appropriate Hepatitis B virus (HBV) management protocol according to current CDC guidelines.

A 68-year-old man with a history of metastatic prostate cancer is brought to the emergency department due to progressively worsening lower back pain and new-onset weakness in both legs over the past 24 hours. He also reports urinary retention since this morning. Neurological examination reveals bilateral lower extremity weakness, hyperreflexia, and decreased sensation below the T10 dermatome. Arrange the following management steps in the most appropriate chronological sequence for this patient.

Match each patient's clinical presentation and unique host factors with the most appropriate empiric or targeted pharmacotherapy.

An established clinic patient, a 42-year-old female with known limited cutaneous systemic sclerosis, presents to discuss worsening symptoms in her hands. She describes increasingly frequent and painful episodes where her fingers turn white, then blue, upon exposure to mild temperature drops. The episodes are now significantly limiting her daily activities. Arrange the following management steps in the correct chronological order of therapeutic escalation, starting from initial baseline management and progressing to interventions for critical, medically refractory ischemia.

A 62-year-old woman with a 10-year history of diffuse cutaneous systemic sclerosis presents to the emergency department with acute-onset shortness of breath and profound fatigue over the last 48 hours. Her medical history includes Raynaud phenomenon, gastroesophageal reflux disease, and mild interstitial lung disease. Her baseline medications include mycophenolate mofetil, omeprazole, and nifedipine. Three weeks ago, she was evaluated by an outside provider for worsening polyarticular joint pain and was started on oral prednisone $60\text{ mg}$ daily.

On physical examination, her temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $225/115\text{ mmHg}$, heart rate is $110/\text{min}$, and respiratory rate is $26/\text{min}$. Pulse oximetry is $92\%$ on room air. Jugular venous distention is present. Pulmonary auscultation reveals bilateral basilar crackles.

Laboratory results are as follows:

Arterial blood gas on room air:

A peripheral blood smear demonstrates 3 to 5 schistocytes per high-power field. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old woman with a known history of systemic lupus erythematosus (SLE) presents to the clinic with bilateral lower extremity edema and new-onset hypertension (blood pressure 152/94 mmHg). A preliminary urine dipstick in the clinic shows 3+ protein. She is suspected of having lupus nephritis. Arrange the following steps in the appropriate clinical sequence for the diagnostic evaluation and long-term pharmacological management of this patient's renal condition, from first to last.

Match the following clinical scenarios with their most likely primary acid-base disturbance.

An 82-year-old female resident of a skilled nursing facility presents for a routine wellness examination. The nursing staff reports that her urine has appeared cloudy and foul-smelling over the past three days. However, the patient denies any dysuria, urinary frequency, urinary urgency, flank pain, or changes in her cognitive baseline. Her temperature is 37.0°C (98.6°F), blood pressure is 128/78 mm Hg, and pulse is 72/min. Physical examination reveals a soft, non-tender abdomen without suprapubic or costovertebral angle tenderness. A clean-catch urinalysis reveals positive leukocyte esterase, positive nitrites, and 45 leukocytes/hpf. Which of the following is the most appropriate next step in management?

A 71-year-old woman is brought to the emergency department by her daughter due to a 3-day history of progressively worsening headache, dizziness, and blurry vision. The patient also reports having a severe nosebleed this morning that lasted for 30 minutes. Over the past 6 months, she has experienced significant fatigue and a 5-kg (11-lb) weight loss. She has no prior medical conditions and takes no medications. Vital signs are temperature 37.1°C (98.8°F), blood pressure 130/80 mm Hg, pulse 92/min, and respirations 16/min. Physical examination reveals conjunctival pallor and painless, rubbery cervical lymphadenopathy. Funduscopic examination demonstrates bilateral dilated, tortuous retinal veins with scattered flame-shaped hemorrhages. Laboratory studies show:

Hemoglobin: 8.2 g/dL
Platelets: 135,000/mm³
Leukocytes: 6,800/mm³
Blood urea nitrogen: 18 mg/dL
Serum creatinine: 1.0 mg/dL
Total protein: 11.2 g/dL
Albumin: 3.4 g/dL

Serum protein electrophoresis reveals a sharp localized band in the gamma region. Immunofixation electrophoresis confirms this is a monoclonal IgM kappa protein. Which of the following is the most appropriate next step in management for this patient?

A $61$-year-old man comes to the clinic for evaluation of frequent headaches, dizziness, and generalized pruritus that severely worsens after he takes a warm shower. He has a history of mild chronic obstructive pulmonary disease (COPD) and a $35$-pack-year smoking history. Vital signs show a blood pressure of $148/92\text{ mm Hg}$, pulse of $82/\text{min}$, and respiratory rate of $14/\text{min}$. Pulse oximetry is $96\%$ on room air. Physical examination reveals a ruddy facial complexion and a palpable spleen tip $3\text{ cm}$ below the left costal margin. Laboratory studies reveal the following:

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

Following a week-long camping excursion in Rhode Island, a 34-year-old woman presents to an urgent care clinic with a 4-day history of sudden-onset high fever, profound fatigue, severe headache, and diffuse muscle pain. She has no significant past medical history and takes no medications. Her temperature is 38.9°C (102°F), blood pressure is 112/72 mmHg, and pulse is 98/min. Physical examination reveals no skin rashes, eschars, lymphadenopathy, or joint swelling. Sclerae are anicteric. Laboratory evaluation shows:

A peripheral blood smear is examined and reveals no intraerythrocytic inclusions. Which of the following is the most appropriate next step in management?

A 24-year-old man presents to the clinic with a 2-month history of profound fatigue, intermittent fevers, and drenching night sweats. Physical examination reveals a 4-cm, painless, rubbery right supraclavicular lymph node. A preliminary CT scan of the neck and chest confirms the presence of an isolated 4.2-cm right supraclavicular lymph node without significant mediastinal or axillary lymphadenopathy. Laboratory studies show a normal complete blood count, but the erythrocyte sedimentation rate is elevated at 65 mm/hr.

Arrange the following steps in the most appropriate sequential order for the definitive diagnosis, staging, and management of this patient's most likely condition.

During a wellness evaluation, a 42-year-old woman reports a recent onset of episodic, severe muscle weakness. Over the past month, she has experienced profound difficulty rising from a chair and climbing stairs. She also notes a two-year history of a "sandy" sensation in her eyes requiring daily artificial tears, as well as multiple new dental caries despite good oral hygiene. She takes no medications and denies diarrhea or diuretic use. Vital signs are within normal limits. Physical examination reveals an erythematous, dry oral mucosa and $3/5$ muscle strength in the bilateral lower extremities with diminished deep tendon reflexes.

Initial laboratory studies reveal the following:

Which of the following diagnostic tests is most likely to confirm the underlying systemic etiology of this patient's presentation?

An 78-year-old man is evaluated for sudden-onset shortness of breath. He was admitted to the hospital earlier today for symptomatic anemia secondary to chronic gastrointestinal blood loss. His medical history is significant for ischemic heart disease, hypertension, and chronic obstructive pulmonary disease. Two hours ago, a transfusion of packed red blood cells was initiated. Current vital signs include a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $172/96 \text{ mmHg}$, pulse of $114/\text{min}$, and respiratory rate of $28/\text{min}$. Pulse oximetry shows an oxygen saturation of $85\%$ on room air. Physical examination reveals visibly distended neck veins. Lung auscultation demonstrates bilateral bibasilar crackles extending to the mid-lung fields, as well as scattered expiratory wheezes. Cardiac auscultation reveals a regular rhythm with an audible S3 gallop. The transfusion is immediately stopped and supplemental oxygen is provided. Which of the following is the most appropriate next step in management?

A 32-year-old man presents to the outpatient clinic with a 4-day history of nasal congestion, rhinorrhea, and a bothersome dry cough. He states the cough occasionally keeps him awake at night. He reports feeling mildly fatigued but has had no fever, chills, or shortness of breath. The patient has no significant past medical history and takes no daily medications. Vital signs are temperature 37.0 °C (98.6 °F), blood pressure 122/78 mmHg, pulse 76/min, and respiratory rate 14/min. Physical examination reveals erythematous nasal mucosa and a clear posterior pharynx. Auscultation of the lungs reveals clear breath sounds bilaterally with no wheezes, rhonchi, or crackles. Which of the following is the most appropriate next step in management?

During morning rounds in the surgical intensive care unit, a physician reviews the microbiological data for a patient recovering from an emergency laparotomy. The patient, a 67-year-old female, underwent surgery six days prior for perforated diverticulitis. At that time, she presented in septic shock and was resuscitated with intravenous fluids, vasopressors, and empiric broad-spectrum coverage utilizing vancomycin and piperacillin-tazobactam. Her clinical status has steadily improved; she was extubated on postoperative day 3 and is currently hemodynamically stable without vasoactive medications. Current vital signs show a temperature of 37.8°C (100.0°F). The electronic medical record flags a new critical result: blood cultures drawn 48 hours ago demonstrate growth of *Enterobacter cloacae*. The laboratory reports the isolate is susceptible to ceftriaxone, ceftazidime, cefepime, piperacillin-tazobactam, and meropenem. It shows resistance to ampicillin and first-generation cephalosporins. Based on these findings, which of the following is the most appropriate modification to her pharmacotherapy?