Internal Medicine

A 19-year-old college student is admitted to the hospital with a two-day history of fever, severe headache, photophobia, and neck stiffness. On physical examination, the patient is alert but uncomfortable. Temperature is 38.6°C (101.5°F), blood pressure is 118/76 mm Hg, and pulse is 98/min. Nuchal rigidity is present. A lumbar puncture is performed, and empiric intravenous ceftriaxone and vancomycin are initiated. Cerebrospinal fluid (CSF) analysis reveals a leukocyte count of 140/mm³ with 92% lymphocytes, a glucose level of 65 mg/dL (serum glucose 90 mg/dL), and a protein level of 40 mg/dL. Gram stain reveals no organisms. A multiplex polymerase chain reaction (PCR) assay of the CSF is positive for enterovirus and negative for all common bacterial pathogens. Which of the following is the most appropriate next step in this patient's pharmacologic management?

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. Her temperature is $37.8^\circ\text{C}$, blood pressure is $142/88 \text{ mmHg}$, and pulse is $108/\text{min}$. Physical examination reveals scleral icterus and scattered petechiae on the lower extremities. Neurological examination shows mild disorientation but no focal motor deficits.

Laboratory studies show:

Arrange the following clinical steps in the most appropriate sequential order for the evidence-based diagnosis and management of this patient.

Following a deceased-donor renal allograft transplantation eight months ago, a 58-year-old woman is admitted to the hospital due to a three-week history of productive cough, night sweats, and new-onset left-sided hemiparesis. Her immunosuppressive regimen includes tacrolimus, mycophenolate mofetil, and prednisone. Routine post-transplant antimicrobial prophylaxis was discontinued two months ago. Vital signs show a temperature of 38.2°C (100.8°F). Neurological examination reveals 3/5 strength in the left upper and lower extremities. A chest radiograph demonstrates a large cavitary lesion in the right upper lobe. Subsequent magnetic resonance imaging of the brain reveals a 2.5-cm ring-enhancing lesion in the right frontal lobe with surrounding vasogenic edema. Bronchoscopy with bronchoalveolar lavage is performed, and cytological analysis reveals branching, filamentous, Gram-positive rods that stain weakly positive with a modified acid-fast stain. Which of the following is the most appropriate initial targeted pharmacotherapy for this patient's underlying infection?

Match each clinical presentation of a chemotherapy-induced adverse effect to the specific antineoplastic agent responsible for the toxicity.

Match each patient's clinical presentation with the autoantibody or immunologic marker most strongly associated with their underlying disease process.

On the third day of hospitalization, a $34$-year-old woman is re-evaluated during morning rounds. She was initially admitted for severe right flank pain, dysuria, nausea, and a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$). She was empirically started on intravenous ceftriaxone for acute pyelonephritis. Today, the patient reports significant improvement in her symptoms and has tolerated a regular diet since yesterday evening. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $118/76\text{ mm Hg}$, and pulse is $78/\text{min}$. Right costovertebral angle tenderness is no longer present. Blood cultures obtained at admission have shown no growth. Urine culture results are now available and demonstrate $>10^5\text{ CFU/mL}$ of *Escherichia coli*. The organism is susceptible to ciprofloxacin, ceftriaxone, and meropenem; it is resistant to ampicillin and trimethoprim-sulfamethoxazole. Based on the patient's current clinical status and laboratory findings, which of the following is the most appropriate next step in management?

A 68-year-old man with a history of end-stage renal disease is brought to the emergency department due to profound generalized weakness. He missed his last two hemodialysis appointments due to transportation issues. His pulse is 55/min and blood pressure is 112/68 mm Hg. An electrocardiogram is obtained and displays peaked T waves along with a widened QRS complex. A basic metabolic panel reveals a serum potassium concentration of 7.8 mEq/L. Arrange the following therapeutic interventions in the correct chronological sequence for managing this patient's acute presentation, starting with the most immediate required step and ending with definitive treatment.

A 43-year-old woman is brought to the emergency department due to a 3-day history of escalating, throbbing headaches, blurred vision, and severe shortness of breath. The patient has a known 4-year history of diffuse cutaneous systemic sclerosis. Three weeks ago, she received a high-dose oral prednisone taper for an exacerbation of joint pain and severe skin tightness.

Upon arrival, her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $230/125 \text{ mmHg}$, heart rate is $115/\text{min}$, and respiratory rate is $26/\text{min}$ with an oxygen saturation of $91\%$ on room air. Physical examination reveals extensive skin thickening over the face, trunk, and proximal upper extremities. Fundoscopic examination demonstrates bilateral flame-shaped hemorrhages and papilledema. Chest auscultation reveals bibasilar crackles.

Laboratory studies are as follows:

Peripheral blood smear shows 4 to 6 schistocytes per high-power field.

Arterial blood gas on room air:
pH: $7.32$
$\text{PaCO}_2$: $30 \text{ mmHg}$
$\text{PaO}_2$: $60 \text{ mmHg}$
Bicarbonate: $15 \text{ mEq/L}$

Urinalysis reveals $1+$ proteinuria with no red blood cell casts. A recent outpatient sputum culture grew only normal respiratory flora.

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

A 28-year-old man presents to the clinic for evaluation of a painless lump on the left side of his neck that has been progressively enlarging for the past two months. He reports experiencing drenching night sweats and a 5-kg (11-lb) unintentional weight loss over the same period. His temperature is 38.2°C (100.8°F), blood pressure is 120/78 mm Hg, and pulse is 88/min. Physical examination reveals a 4-cm, firm, rubbery, and non-tender lymph node in the left supraclavicular region. There is no other palpable lymphadenopathy, and the liver and spleen are not enlarged on abdominal palpation. A complete blood count is within normal limits. Based on the clinical presentation, there is a high suspicion for Hodgkin lymphoma.

Arrange the following management steps in the most appropriate chronological sequence for the comprehensive evaluation and treatment of this patient.

A 32-year-old woman comes to the ambulatory care center reporting profound fatigue and achiness in her wrists and hands over the past 3 months. She also notes a facial rash that becomes more prominent after spending time outdoors in the sun. On physical examination, there is a fixed erythema over the malar eminences and the bridge of the nose; the nasolabial folds are unaffected. Examination of the oral cavity reveals two painless ulcerations on the hard palate. A dipstick urinalysis in the clinic shows 2+ proteinuria and hematuria. Which of the following is the most appropriate initial laboratory test to evaluate this patient's condition?

An inpatient physician is preparing discharge orders for a 55-year-old male patient. The patient was admitted 72 hours ago for community-acquired pneumonia and was empirically started on intravenous ceftriaxone and azithromycin. His cough and shortness of breath have significantly improved. He has been afebrile for the past 24 hours, his vital signs are currently within normal limits, and he is tolerating an oral diet. Blood and sputum cultures obtained on admission have both grown *Streptococcus pneumoniae*. Antimicrobial susceptibility testing reveals the organism is susceptible to penicillin, amoxicillin, ceftriaxone, levofloxacin, and linezolid. He has no known drug allergies. Which of the following is the most appropriate next step in pharmacotherapy to complete this patient's treatment course?

Match each clinical presentation of pneumonia with the most likely causative pathogen based on classic epidemiological risk factors and clinical findings.

A 68-year-old woman is brought to the emergency department by her daughter due to progressive confusion, fever, and a severe headache over the past 24 hours. The patient has a history of rheumatoid arthritis treated with methotrexate and infliximab. Temperature is 39.1°C (102.4°F), blood pressure is 105/65 mm Hg, pulse is 115/min, and respirations are 20/min. Neurologic examination reveals a lethargic patient who only opens her eyes to painful stimuli. There is marked nuchal rigidity. Papilledema is absent, and there are no focal motor deficits. The physician suspects bacterial meningitis. Arrange the following management steps in the most appropriate chronological order for this patient.

Idiopathic inflammatory myopathies are characterized by distinct myositis-specific autoantibodies that strongly predict clinical phenotypes, organ involvement, and prognosis. Match each myositis-specific autoantibody with its most characteristic clinical phenotype or primary disease association.

A 68-year-old man comes to the clinic reporting a 2-month history of worsening fatigue, shortness of breath when walking up stairs, and a "tingling" sensation in his toes. He has a history of hypothyroidism, chronic obstructive pulmonary disease (COPD), and major depressive disorder. His medications include levothyroxine, inhaled tiotropium, and sertraline.

Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate $98\text{/min}$, blood pressure $130/80\text{ mm Hg}$, respiratory rate $16\text{/min}$, and oxygen saturation $96\%$ on room air. Physical examination reveals pale conjunctivae and a smooth, glossy, red tongue. Neurologic examination demonstrates diminished vibratory sensation in the bilateral lower extremities and a broad-based gait. Lungs are clear to auscultation bilaterally.

Laboratory evaluation shows:
Hemoglobin: $7.4\text{ g/dL}$
Mean corpuscular volume (MCV): $116\text{ fL}$
Thyroid-stimulating hormone (TSH): $2.8\text{ \mu U/mL}$ (normal: $0.5 - 5.0\text{ \mu U/mL}$)

An arterial blood gas analysis on room air shows a pH of $7.40$ and $\text{PaCO}_2$ of $40\text{ mm Hg}$.

Which of the following is the most likely diagnosis explaining this patient's current presentation?

A 64-year-old man is brought to the emergency department by his spouse due to worsening confusion, a severe global headache, and a high fever over the last 24 hours. His temperature is 39.4°C (102.9°F), blood pressure is 128/82 mmHg, and heart rate is 114/min. Physical examination shows a lethargic patient who only opens his eyes to painful stimuli. Marked resistance to passive neck flexion is present. Funduscopic examination reveals bilateral blurring of the optic disc margins with absent venous pulsations. Arrange the following steps in the most appropriate chronological order for managing this patient's condition.

A 74-year-old woman presents to the emergency department with a 2-day history of right-sided throbbing headache, scalp tenderness, and jaw pain while chewing. This morning, she experienced a temporary episode of complete vision loss in her right eye that lasted for 10 minutes before resolving. Laboratory testing shows an erythrocyte sedimentation rate (ESR) of 85 mm/h. Arrange the following steps in the correct chronological order for the most appropriate evaluation and management of this patient.

A 32-year-old man is brought to the emergency department by his partner due to a 24-hour history of severe headache, high fever, and progressive lethargy. His medical history is significant for HIV infection, but he has not taken antiretroviral therapy for the past year. His temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $110/70\text{ mm Hg}$, and heart rate is $115\text{/min}$. Physical examination reveals nuchal rigidity and confusion. Funduscopic examination demonstrates bilateral papilledema. The physician suspects acute bacterial meningitis. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for this patient's acute management.

A 24-year-old woman presents to the outpatient clinic with a 2-day history of burning with urination and increased urinary frequency. She reports no fever, chills, back pain, or vaginal discharge. She is sexually active with one male partner and uses condoms inconsistently. Her last menstrual period was 2 weeks ago. Vital signs are temperature 37.0°C (98.6°F), blood pressure 110/70 mmHg, pulse 78/min, and respirations 14/min. Physical examination reveals mild suprapubic tenderness but no costovertebral angle tenderness. A urine pregnancy test is negative. Urinalysis is positive for leukocyte esterase and nitrites. Which of the following is the most appropriate pharmacotherapy for this patient?

A medical team is reviewing the chart of an inpatient being treated for a severe right-sided soft tissue infection. The patient, who has a history of well-controlled type 2 diabetes mellitus, presented two days ago with rigors, marked localized erythema, and a temperature of 39.0 C (102.2 F). Upon admission, blood cultures were drawn, and empiric intravenous vancomycin and piperacillin-tazobactam were initiated. Today, the patient is clinically stable and afebrile. The microbiology laboratory reports that both sets of admission blood cultures are growing Staphylococcus aureus. Susceptibility testing indicates the isolate is sensitive to oxacillin, cefazolin, and clindamycin, but resistant to penicillin and ampicillin. Which of the following is the most appropriate next step in the pharmacologic management of this patient?