Internal Medicine

A 24-year-old woman is seen in the ambulatory care center for evaluation of easy bruising and frequent nosebleeds. She reports that her epistaxis occurs spontaneously and often requires up to 20 minutes of direct compression to resolve. Furthermore, she has experienced exceptionally heavy menstrual bleeding since menarche, frequently bleeding through super-absorbent tampons every 2 hours during the heaviest days of her cycle. Last month, a dental extraction was complicated by continuous mucosal oozing that persisted for 48 hours. She has no other medical conditions and does not take any prescription or over-the-counter medications. Her vital signs are within normal limits. Physical examination reveals several small ecchymoses on her bilateral lower extremities, but no petechiae, hemarthroses, or hepatosplenomegaly are noted. The physician suspects an underlying inherited bleeding diathesis.

Arrange the following steps in the diagnostic and management algorithm for this patient in the correct chronological sequence, from initial screening to therapeutic planning.

A 42-year-old woman is newly diagnosed with seropositive rheumatoid arthritis. She presents with symmetric polyarthritis involving the metacarpophalangeal and proximal interphalangeal joints, morning stiffness lasting 3 hours, and early marginal erosions on hand radiography. Assuming she experiences an initial inadequate clinical response to each successive pharmacological intervention, but eventually achieves and maintains deep remission, arrange the following management steps in the standard evidence-based sequence according to current treatment guidelines.

Match each patient's clinical presentation with the most appropriate specific therapeutic intervention.

A 41-year-old woman recently diagnosed with limited cutaneous systemic sclerosis seeks care for progressively worsening color changes and throbbing pain in her fingers upon cold exposure. Over several years, her symptoms progressively escalate despite compliance with each prescribed treatment regimen, eventually leading to severe digital ischemia and impending gangrene. Arrange the following therapies for secondary Raynaud phenomenon in the standard stepwise order of clinical escalation, from initial baseline management to interventions for medically refractory, limb-threatening disease.

For each patient presentation describing a new diagnosis of primary hypertension with specific comorbidities, select the most appropriate preferred initial antihypertensive medication class.

During a scheduled wellness examination, a 72-year-old male mentions to his physician that his daily neighborhood walks have become increasingly difficult over the last three months due to profound fatigue. He has no prior history of cardiopulmonary disease and denies melena, hematochezia, changes in bowel habits, or abdominal pain. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure 135/82 mm Hg, pulse 86/min, and respirations 14/min. Physical examination demonstrates noticeable conjunctival pallor. The abdomen is soft and non-tender without hepatosplenomegaly.

Laboratory evaluation reveals the following:

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

A $68$-year-old man is admitted to the general medical floor with a $4$-day history of fever, chills, and a cough productive of rust-colored sputum. His past medical history is significant only for benign prostatic hyperplasia. He has not had any recent hospitalizations, does not reside in a nursing facility, and has not received any antibiotics in the past year. Vital signs on presentation include a temperature of $38.8^{\circ}\text{C}$ ($101.8^{\circ}\text{F}$), blood pressure of $115/76\text{ mm Hg}$, pulse of $102/\text{min}$, and respiratory rate of $24/\text{min}$. Oxygen saturation is $94\%$ on $2\text{ L/min}$ via nasal cannula. Chest radiography demonstrates a dense consolidation in the left lower lobe. The admitting physician empirically prescribes intravenous piperacillin-tazobactam and vancomycin. A high-quality sputum Gram stain demonstrates many polymorphonuclear leukocytes and abundant Gram-positive diplococci. Which of the following is the most appropriate modification to this patient's antimicrobial regimen?

An athletic 24-year-old male construction worker presents with an 8-month history of insidious-onset lower back pain and severe morning stiffness. He reports that the stiffness often lasts for over an hour after awakening but gradually improves as he engages in physical labor throughout the day. His symptoms frequently awaken him in the second half of the night. He denies any radiating leg pain, numbness, or bowel/bladder dysfunction. Physical examination reveals a restricted range of motion in the lumbar spine, as evidenced by a modified Schober test expansion of only $3\text{ cm}$ (normal $>5\text{ cm}$). Neurologic examination of the lower extremities is unremarkable.

Assuming the patient's initial imaging studies do not yield a definitive diagnosis and his symptoms remain unacceptably high despite initial interventions, arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for establishing the diagnosis and managing this patient according to standard rheumatologic guidelines.

A 27-year-old woman is brought to the emergency department due to a 2-day history of progressively worsening shortness of breath, fever, and coughing up blood-tinged sputum. She has a history of systemic lupus erythematosus (SLE) complicated by class IV lupus nephritis, for which she takes mycophenolate mofetil and low-dose prednisone. Her temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $105/65\text{ mmHg}$, pulse is $124/\text{min}$, and respirations are $28/\text{min}$. Oxygen saturation is $86\%$ on room air. Physical examination reveals a pale, fatigued woman in moderate respiratory distress. Auscultation of the lungs reveals diffuse bilateral crackles. There is no jugular venous distension. Cardiac examination shows a regular tachycardia with no murmurs, rubs, or gallops. Trace bilateral pedal edema is present.

Chest radiograph reveals new diffuse, bilateral patchy alveolar infiltrates. An emergency bedside echocardiogram demonstrates a left ventricular ejection fraction of $60\%$ with normal right ventricular function and no significant valvular abnormalities.

Which of the following diagnostic findings would most likely be seen on further evaluation of this patient?

Match each patient's clinical presentation with the most appropriate initial pharmacological intervention.

A 54-year-old man is brought to the emergency department by his partner due to a 24-hour history of severe headache, high fever, and worsening confusion. He has a history of advanced HIV infection and has been non-adherent to his antiretroviral therapy. His temperature is 39.4°C (102.9°F), blood pressure is 105/65 mmHg, and heart rate is 118/min. He is lethargic and oriented only to person. Physical examination is notable for marked resistance to passive neck flexion. Fundoscopic evaluation reveals blurring of the optic disc margins bilaterally. Arrange the following diagnostic and therapeutic interventions in the most appropriate chronological order for the immediate management of this patient.

For each of the following classic clinical presentations of infectious diseases, select the most appropriate first-line targeted antimicrobial therapy.

Match each clinical presentation of infective endocarditis or severe bacteremia to its most appropriate targeted antimicrobial regimen.

A 42-year-old woman with a 3-year history of diffuse cutaneous systemic sclerosis comes to the emergency department due to a severe headache and blurred vision that began 24 hours ago. Her temperature is 37.0°C (98.6°F), blood pressure is 218/116 mm Hg, and pulse is 92/min. Physical examination shows tight, thickened skin over the face, trunk, and extremities. Laboratory studies show a serum creatinine of 2.9 mg/dL (baseline 0.9 mg/dL) and a hemoglobin of 10.2 g/dL. A peripheral blood smear reveals numerous schistocytes. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old man comes to the emergency department complaining of progressive shortness of breath and an increasingly productive cough over the last 3 days. He notes his sputum has changed from clear to thick and yellowish-green. His medical history is significant for chronic obstructive pulmonary disease (COPD) and a 45-pack-year smoking history. Temperature is 37.6°C (99.7°F), blood pressure is 138/86 mmHg, pulse is 92/min, and respiratory rate is 22/min. Oxygen saturation is 89% on room air. Physical examination reveals a barrel-shaped chest with diffuse bilateral expiratory wheezing and a prolonged expiratory phase. Jugular venous pressure is normal, and there is no lower extremity edema. A bedside chest radiograph demonstrates hyperinflated lungs with flattened diaphragms, but no focal consolidations, pleural effusions, or cardiomegaly. Which of the following is the most appropriate next step in management?

A $54$-year-old man undergoing induction chemotherapy for acute myeloid leukemia presents to the emergency department with a new-onset fever of $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$) and chills. He has an indwelling central venous catheter. His blood pressure is $105/65 \text{ mm Hg}$, heart rate is $112/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals no obvious source of infection, and the catheter site appears clean without erythema or fluctuance. Laboratory studies demonstrate an absolute neutrophil count of $200/\mu\text{L}$. Arrange the following management steps in the most appropriate chronological sequence for this patient.

As part of an introductory hematopathology module, a medical trainee is asked to correlate microscopic cellular abnormalities with their corresponding disease states. Match each classic peripheral blood smear description with the diagnosis it most strongly suggests.

A $35$-year-old man presents to the emergency department with a $3$-day history of increasing fatigue, spontaneous gum bleeding, and a diffuse petechial rash. He has no significant past medical history and takes no medications. Vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), heart rate $105/\text{min}$, blood pressure $110/70\text{ mmHg}$, and respiratory rate $18/\text{min}$. Physical examination reveals pale conjunctivae, continuous oozing from the gingival margins, diffuse petechiae on the lower extremities, and large ecchymoses on the trunk. There is no hepatosplenomegaly or lymphadenopathy.

Laboratory results are as follows:

A peripheral blood smear reveals numerous large, atypical mononuclear cells with abundant cytoplasm containing multiple primary granules and prominent needle-like cytoplasmic inclusions.

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

A 53-year-old woman is brought to the emergency department by her husband due to a severe headache, blurred vision, and progressive confusion over the past 24 hours. Her past medical history is significant for diffuse cutaneous systemic sclerosis diagnosed three years ago. Two weeks ago, she was started on oral prednisone for worsening joint pain and skin tightness. Her temperature is 37.1°C (98.8°F), blood pressure is 225/115 mmHg, and pulse is 102/min. Physical examination shows thickened, tight skin over her face, forearms, and chest. Neurological examination reveals a confused patient but is negative for focal motor or sensory deficits. Fundoscopy demonstrates bilateral flame-shaped hemorrhages and papilledema. Laboratory studies show:

A peripheral blood smear demonstrates 3-5 schistocytes per high-power field. Her baseline creatinine one month ago was 0.8 mg/dL. Which of the following is the most appropriate next step in the pharmacologic management of this patient's condition?

A physician is evaluating a hospitalized patient with chronic kidney disease who has developed anuria and profound muscle weakness over the past twelve hours. An electrocardiogram demonstrates prolonged PR intervals, widened QRS complexes, and tall, peaked T waves. A point-of-care basic metabolic panel reveals a serum potassium level of $7.4$ mEq/L. Arrange the following therapeutic interventions in the most appropriate chronological order of administration for this patient's acute management.