Internal Medicine

A 34-year-old man presents to the emergency department with a 4-day history of progressively worsening right upper quadrant abdominal pain and abdominal swelling. Over the past several months, he has experienced profound fatigue and noticed that his first morning urine is often dark, gradually clearing up as the day progresses. He takes no medications and has no significant past medical history. Temperature is 37.2°C (99.0°F), blood pressure is 118/76 mm Hg, and pulse is 98/min. Physical examination shows scleral icterus and a distended abdomen with shifting dullness. The liver edge is markedly tender and palpable 4 cm below the right costal margin.

Doppler ultrasonography of the abdomen reveals the absence of blood flow in the hepatic veins. Which of the following is the most appropriate next step in diagnosing the underlying cause of this patient's condition?

During a visit to the student health clinic, a 20-year-old male describes a sudden onset of severe throat pain and subjective fever over the past 24 hours. He reports no cough or rhinorrhea. Vital signs reveal a temperature of 38.3°C (101.0°F). Physical examination demonstrates bilateral tonsillar erythema with purulent exudates and tender anterior cervical lymph nodes. A rapid antigen detection test for Group A Streptococcus is positive. Which of the following is the most appropriate antimicrobial regimen for this patient?

An elderly man is evaluated on the surgical ward on postoperative day 3 following an elective sigmoid resection for diverticular disease. His medical history is significant for ischemic cardiomyopathy and stage 3a chronic kidney disease. Overnight, he developed acute, intense pain and marked swelling in his right knee. His temperature is 38.3°C (101.0°F), blood pressure is 132/82 mmHg, and pulse is 98/min. Physical examination of the right knee reveals significant erythema, warmth, and a large effusion. Passive range of motion is severely restricted by pain. Mild bilateral pitting edema is present at the ankles, which the patient states is his baseline. Arthrocentesis is performed, yielding synovial fluid with a leukocyte count of 35,000/μL (85% neutrophils). Microscopic analysis under polarized light reveals rhomboid-shaped crystals exhibiting weak positive birefringence. Gram stain of the fluid shows no organisms. Which of the following is the most appropriate next step in management?

Match each type 2 diabetes mellitus medication to its most characteristic adverse effect or clinical contraindication.

Match each clinical scenario involving a potential infectious exposure with the most appropriate post-exposure prophylaxis (PEP) or management strategy.

A $42$-year-old woman is evaluated in the clinic due to progressive fatigue, constant chilling, and a $6$-kg ($13.2$-lb) weight gain over the past $6$ months. She also reports worsening shortness of breath when climbing stairs, frequent morning headaches, and a tendency to bump into objects on her sides. She has not had a menstrual period in $8$ months. Her medical history is unremarkable, and she takes no medications. Vital signs show a temperature of $36.1^\circ$ C ($97.0^\circ$ F), blood pressure of $88/58$ mmHg, pulse of $54$/min, and respiratory rate of $14$/min. Physical examination reveals a lethargic, pale woman with a delayed relaxation phase of the deep tendon reflexes. Visual field testing reveals bitemporal hemianopsia. She has non-pitting edema of the bilateral lower extremities. The lungs are clear to auscultation.

Laboratory studies reveal:
Sodium: $131$ mEq/L
Potassium: $4.1$ mEq/L
Creatinine: $0.8$ mg/dL
Thyroid-stimulating hormone (TSH): $1.1$ $\mu$ U/mL (Normal: $0.4$–$4.0$ $\mu$ U/mL)
Free thyroxine (T4): $0.4$ ng/dL (Normal: $0.9$–$2.4$ ng/dL)

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

Match each classic infectious disease clinical presentation with its most appropriate first-line antimicrobial therapy.

Match each clinical presentation with the most likely rheumatologic diagnosis.

During a routine follow-up for chronic hepatitis B infection, a 45-year-old male construction worker reports a 6-week history of intermittent fevers, severe muscle aches, and an unintentional $6$ kg ($13$ lb) weight loss. He also describes a new, crampy abdominal pain that predictably begins 30 to 45 minutes after every meal. Yesterday, he stumbled while walking and noticed difficulty lifting his right foot. His hepatitis B is currently untreated.

Vital signs show a temperature of $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure of $168/102$ mmHg, and heart rate of $98$/min. Neurologic examination reveals 2/5 strength in right ankle dorsiflexion and decreased pinprick sensation over the dorsum of the right foot. Skin examination demonstrates a violaceous, net-like pattern over both lower extremities.

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

A 70-year-old male with long-standing diabetic nephropathy arrives at the emergency department reporting profound generalized weakness and progressive palpitations that started earlier today. He missed his last two nephrology appointments and recently began taking an angiotensin-receptor blocker for uncontrolled hypertension. His heart rate is 55/min and blood pressure is 110/60 mmHg. An electrocardiogram is immediately obtained and demonstrates absent P waves, widening of the QRS complexes, and tall, symmetric, peaked T waves. Laboratory testing shows a serum potassium level of $7.4$ mEq/L.

Arrange the following therapeutic interventions in the most appropriate chronological sequence for the acute stabilization and management of this patient.

An emergency medicine physician evaluates a 45-year-old immigrant male who complains of a 6-week history of productive cough, intermittent hemoptysis, drenching night sweats, and unintentional weight loss. The triage nurse notes a temperature of 38.2°C (100.8°F). The patient hands the physician a chest radiograph taken earlier today at an urgent care center, which reveals a prominent cavitary lesion in the right upper lobe. Arrange the following management steps in the most appropriate chronological order for this patient.

A 42-year-old man presents to the clinic with a 2-day history of a progressively spreading red, swollen, and tender area on his right lower extremity. He recalls scratching a mosquito bite in the same location a few days prior. He has no significant past medical history and takes no medications. Vital signs are temperature 37.3°C (99.1°F), blood pressure 124/76 mmHg, pulse 82/min, and respirations 14/min. Physical examination reveals a 10-cm area of diffuse erythema, warmth, and induration on the right shin. The borders of the erythema are indistinct. There is no palpable fluctuance, purulent drainage, ulceration, or crepitus. Peripheral pulses and distal sensation are intact. Which of the following is the most appropriate empiric pharmacotherapy for this patient?

A 26-year-old woman comes to the clinic reporting a 3-day history of a burning sensation with urination and increased urinary frequency. She has no fever, chills, flank pain, nausea, or vaginal discharge. Her temperature is $37.1^\circ C$ ($98.8^\circ F$), blood pressure is $118/76$ mm Hg, and pulse is $74$/min. Physical examination reveals mild suprapubic tenderness but no costovertebral angle tenderness. A urine dipstick test is positive for nitrites and leukocyte esterase. A urine pregnancy test is negative. Which of the following is the most appropriate empiric pharmacotherapy for this patient?

A 65-year-old man is hospitalized for symptomatic anemia and is receiving a transfusion of packed red blood cells. Thirty minutes into the transfusion, he develops severe chills, flank pain, and shortness of breath. His temperature is 39.1°C (102.4°F), blood pressure is 85/50 mm Hg, and heart rate is 115/min. The urine in his Foley catheter tubing suddenly appears dark red. An acute hemolytic transfusion reaction is suspected.

Arrange the following management steps in the most appropriate, evidence-based sequential order for this patient.

A 24-year-old primigravida at $18$ weeks gestation presents to the obstetric clinic with a painless, indurated ulcer on her right labium majus that appeared one week ago. She has bilateral inguinal lymphadenopathy. Rapid plasma reagin (RPR) testing is reactive at a titer of $1:32$, and fluorescent treponemal antibody absorption (FTA-ABS) testing is positive. The patient reports a well-documented history of anaphylaxis to amoxicillin in childhood, characterized by severe wheezing, facial swelling, and hypotension requiring epinephrine. She is otherwise healthy and takes a daily prenatal vitamin. Vital signs are within normal limits, and fetal heart tones are $145$/min.

Arrange the following interventions in the most appropriate chronological sequence for the management of this patient's infectious disease.

A 20-year-old college student presents to the emergency department with a 12-hour history of severe headache, fever, and neck stiffness. Her temperature is 39.2°C (102.6°F), blood pressure is 110/70 mm Hg, and pulse is 112/min. She is fully alert and oriented. Neurologic examination reveals a positive Brudzinski sign. There are no focal neurologic deficits, and fundoscopic examination shows no evidence of papilledema. She has no history of immunocompromise and no significant past medical history. What is the most appropriate chronological sequence for the following management steps?

A 62-year-old woman is evaluated in the emergency department for progressive dyspnea, a dry cough, and profound fatigue over the past $4$ months, which have acutely worsened over the last week. She also reports significant morning stiffness in her hands and wrists lasting up to $3$ hours, along with intermittent joint swelling for the past $6$ months. Her temperature is $37.4^\circ$ C ($99.3^\circ$ F), blood pressure is $142/88$ mmHg, pulse is $96$/min, respiratory rate is $22$/min, and oxygen saturation is $92\%$ on room air. Examination shows bilateral boggy swelling and tenderness of the metacarpophalangeal and proximal interphalangeal joints. Lung auscultation reveals fine crackles at both lung bases. There is no jugular venous distention, $S_3$ gallop, or peripheral edema.

Laboratory studies show:
Thyroid-stimulating hormone (TSH): $1.2$ $\mu$ U/mL (Normal: $0.4-4.0$ $\mu$ U/mL)
Free thyroxine (T4): $0.6$ ng/dL (Normal: $0.9-1.7$ ng/dL)

An arterial blood gas on room air shows $pH = 7.48$, $PaCO_2 = 30$ mmHg, $PaO_2 = 65$ mmHg, and $HCO_3^- = 22$ mEq/L.
Chest radiograph shows diffuse, fine reticular opacities predominantly in the lower lung zones without cardiomegaly or pleural effusions.

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

A 72-year-old woman is evaluated on hospital day 3. She was initially admitted for progressively worsening shortness of breath and bilateral lower extremity swelling. Her medical history is significant for chronic obstructive pulmonary disease, type 2 diabetes mellitus, and essential hypertension. On admission, she was afebrile, with a blood pressure of $152/88$ mmHg, heart rate of $88$/min, and respiratory rate of $20$/min. Physical examination revealed jugular venous distention, bibasilar crackles, and scattered expiratory wheezing. An indwelling urinary catheter was placed to strictly monitor fluid output, and intravenous furosemide was initiated. Over the last $72$ hours, she has had excellent diuresis resulting in a $4.5$-kg ($9.9$-lb) weight loss, and her dyspnea has completely resolved. She currently breathes comfortably on room air. A urine culture sent on admission due to a cloudy appearance now grows $>100,000$ CFU/mL of *Escherichia coli*. The patient reports no suprapubic pain, flank pain, or dysuria. Her current temperature is $37.0^\circ$ C ($98.6^\circ$ F). Which of the following is the most appropriate next step in management?

Match each clinical presentation of acute poisoning or overdose with the most appropriate targeted antidote or therapeutic intervention.

A 58-year-old man is evaluated on hospital day 6 for new-onset right lower extremity swelling and pain. He was admitted 6 days ago for a severe exacerbation of chronic obstructive pulmonary disease and has been receiving intravenous corticosteroids, bronchodilators, and subcutaneous unfractionated heparin for deep vein thrombosis prophylaxis. His respiratory status has significantly improved, but today he reports worsening right calf pain. Vital signs are temperature 37.2°C (99.0°F), blood pressure 130/80 mmHg, pulse 92/min, and respirations 16/min. Physical examination shows a swollen, erythematous, and tender right calf. Laboratory studies from today show a hemoglobin of 13.2 g/dL, leukocyte count of 8,500/mm³, and platelet count of 90,000/mm³. His platelet count on admission was 240,000/mm³. A lower extremity venous duplex ultrasound reveals a noncompressible right popliteal vein. Which of the following is the most appropriate next step in management?