Internal Medicine

A $74$-year-old woman presents to the emergency department with a severe, unilateral right-sided headache and jaw pain when chewing. She also reports a transient episode of complete vision loss in her right eye that resolved after $10$ minutes. Laboratory studies show an erythrocyte sedimentation rate of $88\text{ mm/h}$ and a C-reactive protein of $45\text{ mg/L}$. Arrange the following management steps in the most appropriate sequential order for this patient.

An elderly woman is brought to the emergency department by her daughter after developing a sudden high fever, an intense headache, and confusion over the last 12 hours. The patient is a 72-year-old with a history of hypertension. Vital signs reveal a temperature of 39.4°C (102.9°F) and a heart rate of 112/min. Physical examination demonstrates marked nuchal rigidity and a Glasgow Coma Scale score of 12. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 58-year-old man is evaluated in the emergency department for a 2-day history of severe headache, fever, and progressive lethargy. His wife reports that he became disoriented this morning. His temperature is 39.2°C (102.6°F), blood pressure is 110/70 mmHg, heart rate is 115/min, and respiratory rate is 18/min. The patient is stuporous but grimaces to painful stimuli. Neurologic examination reveals marked nuchal rigidity and a new right-sided pronator drift.

Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for the management of this patient.

A 72-year-old man with a history of chronic obstructive pulmonary disease and a mechanical mitral valve replacement is brought to the emergency department due to 5 days of fever, progressive dyspnea, and a cough producing frothy sputum. Temperature is 38.6°C (101.5°F), blood pressure is 105/60 mm Hg, pulse is 115/min, and respirations are 28/min. Oxygen saturation is 86% on room air. Lung auscultation reveals diffuse bilateral crackles. Cardiovascular examination reveals a new, loud holosystolic murmur at the apex radiating to the axilla. Chest radiograph shows cardiomegaly and bilateral perihilar alveolar opacities.

Laboratory studies on admission:
Leukocyte count: $18,500/\text{mm}^3$
Serum creatinine: $1.2\ \text{mg/dL}$
Thyroid-stimulating hormone (TSH): $0.15\ \mu\text{U/mL}$ (Normal: $0.4-4.0\ \mu\text{U/mL}$)
Free T4: $0.8\ \text{ng/dL}$ (Normal: $0.9-2.4\ \text{ng/dL}$)

The patient is intubated for acute respiratory failure. Blood cultures are drawn, and he is empirically started on intravenous vancomycin, cefepime, and furosemide. Transesophageal echocardiography demonstrates severe mitral regurgitation and a $12\text{-mm}$ mobile vegetation on the mechanical mitral valve.

On day 3, four out of four blood culture bottles grow *Enterococcus faecalis*. The isolate is susceptible to ampicillin, vancomycin, and high-level gentamicin. Repeat laboratory studies show a serum creatinine of $2.9\ \text{mg/dL}$ and a blood urea nitrogen of $52\ \text{mg/dL}$.

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

A $45$-year-old man with recently diagnosed Burkitt lymphoma is evaluated in the hospital on the second day of his induction chemotherapy regimen. He reports new-onset nausea, generalized weakness, and severe muscle cramps. Over the past $12$ hours, his urine output has decreased to approximately $200$ mL. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $118/76$ mmHg, pulse is $114$/min, and respirations are $18$/min. Physical examination reveals muscle fasciculations and diffuse weakness. Laboratory studies show the following:

An electrocardiogram is obtained and demonstrates peaked T waves, flattened P waves, and a widened QRS complex. Which of the following is the most appropriate initial step in the management of this patient?

Review the clinical vignettes describing five different patients presenting with hematologic abnormalities. Based on the provided clinical presentations and laboratory profiles, which peripheral blood smear finding best matches each patient?

A 68-year-old man is brought to the emergency department by his daughter due to worsening confusion, profound fatigue, and severe lower back pain over the past two weeks. He has a history of hypertension. Temperature is 37.1°C (98.8°F), blood pressure is 110/70 mmHg, pulse is 112/min, and respiratory rate is 16/min. Physical examination reveals dry mucous membranes and point tenderness over the L3 and L4 vertebrae. Neurologic examination shows no focal deficits, but the patient is lethargic and oriented only to name.

Laboratory studies show:
- Hemoglobin: 8.9 g/dL
- Platelet count: 140,000/mm³
- Leukocyte count: 4,500/mm³
- Serum calcium: 13.8 mg/dL
- Serum creatinine: 2.8 mg/dL (baseline 0.9 mg/dL)
- Blood urea nitrogen: 56 mg/dL
- Total protein: 10.2 g/dL
- Albumin: 3.1 g/dL

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

A $55$-year-old woman with a history of diffuse large B-cell lymphoma presents to the emergency department with chills and a fever. She received her last cycle of R-CHOP chemotherapy $8$ days ago. Her temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, and heart rate is $105/\text{min}$. Physical examination reveals a central venous port in the right upper chest with no surrounding erythema. Her absolute neutrophil count is pending but is suspected to be severely low.

Arrange the following steps in the correct chronological order for the optimal initial and subsequent management of this patient's condition.

Targeted biologic and synthetic disease-modifying antirheumatic drugs (DMARDs) have revolutionized the management of rheumatologic conditions, but they carry risks for unique and severe adverse effects. Match each clinical vignette describing a therapy-related complication with the specific medication class most likely responsible.

A 38-year-old woman is brought to the emergency department by her husband due to a 2-day history of progressive, ascending muscle weakness and difficulty breathing. She also reports palpitations. She has a 5-year history of severe dry eyes, a persistent sensation of "cotton mouth," and recurrent bilateral parotid gland swelling. Her only daily medication is artificial tears.

Physical examination reveals a respiratory rate of 28/min, heart rate of 115/min, and blood pressure of 110/70 mmHg. She is using accessory muscles of respiration. Neurologic examination shows 2/5 motor strength in her proximal lower and upper extremities, and globally diminished deep tendon reflexes.

Laboratory studies show:
Sodium: 140 mEq/L
Potassium: 1.8 mEq/L
Chloride: 118 mEq/L
Bicarbonate: 10 mEq/L

Arterial blood gas on room air:
pH: 7.22
$PaCO_2$: 38 mmHg
$PaO_2$: 85 mmHg

Endocrine studies obtained due to her profound weakness show a TSH of 0.2 $\mu U/mL$ (Normal: 0.4-4.0) and Free T4 of 0.6 ng/dL (Normal: 0.8-1.8).

Urinalysis shows a pH of 6.5 and 15 WBC/hpf. A urine culture obtained at an urgent care clinic two days ago is now resulting, showing >100,000 CFU/mL of *Escherichia coli* that is sensitive to nitrofurantoin, cephalexin, and trimethoprim-sulfamethoxazole.

Which of the following is the most accurate interpretation of this patient's current condition and the most appropriate initial management step?

Review the following clinical vignettes describing patients who are experiencing complications related to underlying malignancies. Match each patient's clinical presentation with the primary pathophysiologic mechanism responsible for their symptoms.

During a routine wellness check, a 68-year-old retired carpenter describes gradually worsening right knee discomfort over the past two years. He notes the pain is most pronounced after an afternoon of gardening and improves when he sits in his recliner. He denies any systemic symptoms such as fever, fatigue, or unintended weight loss. Morning joint stiffness is minimal, rarely exceeding 15 minutes. Physical assessment of the right knee demonstrates palpable crepitus during active range of motion and prominent bony hypertrophy, but lacks joint effusion, significant warmth, or overlying erythema. A recent complete blood count and inflammatory marker panel were within normal limits. Which of the following pathophysiologic processes best explains this patient's current clinical presentation?

A 52-year-old man is evaluated in the clinic for resistant hypertension. Despite adherence to a regimen of amlodipine, lisinopril, and chlorthalidone at maximum tolerated doses, his blood pressure remains poorly controlled at 168/102 mm Hg. He reports occasional muscle weakness but is otherwise asymptomatic. Laboratory studies reveal a serum potassium level of 3.1 mEq/L and a serum sodium level of 144 mEq/L. The physician suspects a secondary cause for his resistant hypertension. Arrange the following diagnostic steps in the most appropriate chronological order to definitively evaluate and subtype this patient's condition.

A 74-year-old male patient with known metastatic prostate carcinoma is evaluated in the emergency department for severe mid-thoracic back pain that has been escalating over the past week. During the last 24 hours, he has noted profound weakness in both of his legs and an inability to void urine. Vital signs are within normal limits. Neurologic evaluation demonstrates a motor strength of $2/5$ in bilateral lower extremities, hyperactive patellar reflexes, positive Babinski signs bilaterally, and diminished pain sensation below the umbilicus.

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

A 24-year-old woman, gravida 2 para 1, at 18 weeks gestation, presents to the clinic with a diffuse maculopapular rash that includes her palms and soles. She also reports generalized malaise and a low-grade fever over the past week. Her medical history is notable for a severe anaphylactic reaction (hypotension, wheezing, and angioedema) to amoxicillin prescribed for a respiratory infection two years ago. Laboratory evaluation reveals a rapid plasma reagin (RPR) titer of 1:64 and a reactive fluorescent treponemal antibody absorption (FTA-ABS) test. Arrange the following management steps in the most appropriate chronological order for this patient.

A 45-year-old female patient presents to a primary care office complaining of unexpected weight gain, weakness in her thighs, and frequent bruising over the past six months. On examination, she has a plethoric face, prominent supraclavicular fat pads, and violaceous striae across her abdomen. Vital signs show a blood pressure of 155/95 mm Hg. Arrange the following diagnostic steps in the most appropriate chronological order to properly evaluate this presentation.

During a routine clinic visit, a 62-year-old male veteran complains of severe, widespread itching that reliably occurs within minutes of stepping out of a warm shower. He also reports recent onset of headaches and a sensation of fullness in his head. Physical examination reveals a ruddy facial complexion and a palpable spleen edge extending $3$ cm below the left costal margin. Laboratory studies reveal:

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

A 22-year-old man is admitted to the hospital for initiation of induction chemotherapy for recently diagnosed Burkitt lymphoma. His medical history is significant for an episode of acute jaundice, fatigue, and dark urine two years ago after taking primaquine for malaria prophylaxis; the episode spontaneously resolved upon discontinuation of the medication. The patient currently feels well and reports no symptoms. His temperature is 37.1°C (98.8°F), blood pressure is 120/78 mm Hg, and pulse is 82/min. Physical examination reveals prominent cervical and axillary lymphadenopathy but is otherwise unremarkable.

The patient is started on aggressive intravenous normal saline hydration. Which of the following is the most appropriate next step in the management of this patient's hyperuricemia?

Match each specific autoantibody profile with its most strongly associated rheumatologic condition.

A 34-year-old woman is brought to the emergency department by her husband due to progressive confusion and severe fatigue over the past 48 hours. She also complains of a new-onset rash on her lower extremities. She has no significant past medical history and takes no medications. Temperature is 38.1°C (100.6°F), blood pressure is 142/85 mm Hg, pulse is 110/min, and respiratory rate is 18/min. Physical examination reveals mild scleral icterus and pale conjunctivae. There are numerous pinpoint, non-blanching red macules over both lower extremities. Neurological examination is notable for mild disorientation to time and place, but no focal motor or sensory deficits are present.

Laboratory results are as follows:

A peripheral blood smear demonstrates numerous fragmented red blood cells.

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