Internal Medicine

Match each clinical exposure scenario with the most appropriate post-exposure prophylaxis or next step in management.

A 38-year-old man with a history of hereditary hemorrhagic telangiectasia and pulmonary arteriovenous malformations presents with a 10-day history of progressively worsening headache and low-grade fevers. He is hemodynamically stable. He is alert and fully oriented. Neurologic examination reveals a mild right-hand pronator drift but no papilledema or signs of meningeal irritation. An MRI of the brain with contrast reveals a $2.5$-cm ring-enhancing lesion in the left frontal lobe with moderate surrounding vasogenic edema but no midline shift. Arrange the following management steps in the most appropriate chronological order.

Match the following classic infectious disease clinical presentations with their most appropriate first-line antimicrobial therapy.

Match each clinical exposure scenario with the most appropriate post-exposure prophylaxis (PEP) regimen.

An outpatient physician evaluates a young adult with a known systemic autoimmune disorder who presents complaining of profound generalized muscle weakness over the last week. The patient, who has a well-documented history of severe dry eyes, dry mouth, and positive anti-Ro/SSA antibodies, reports that she has been unable to climb the stairs in her home due to bilateral leg heaviness. She takes no medications other than artificial tears and has had no recent diarrhea, vomiting, or changes in diet. Her blood pressure is $112/72\ \text{mmHg}$, and pulse is $84\text{/min}$. Physical examination reveals symmetric proximal muscle weakness in the upper and lower extremities with diminished deep tendon reflexes.

Laboratory studies reveal the following:
Serum sodium: $140\ \text{mEq/L}$
Serum potassium: $2.1\ \text{mEq/L}$
Serum chloride: $114\ \text{mEq/L}$
Serum bicarbonate: $14\ \text{mEq/L}$
Blood urea nitrogen: $14\ \text{mg/dL}$
Serum creatinine: $0.9\ \text{mg/dL}$
Urine pH: $6.8$

Which of the following best describes the underlying pathophysiology of this patient's laboratory abnormalities?

A 54-year-old female patient is seen during morning rounds on the inpatient medical ward following 48 hours of treatment. She was initially admitted for a high fever, productive cough, and right-sided pleuritic chest discomfort. At the time of admission, a chest radiograph demonstrated a dense consolidation in the right lower lobe, prompting empiric therapy with intravenous ceftriaxone and oral azithromycin. Her past medical history is notable for chronic obstructive pulmonary disease.

This morning, the patient reports significant symptomatic improvement and is tolerating an oral diet. Vital signs demonstrate a temperature of 37.1°C (98.8°F), blood pressure of 124/80 mmHg, heart rate of 76/min, and a respiratory rate of 16/min with an oxygen saturation of 98% on room air. Pulmonary auscultation reveals decreased breath sounds at the right lung base but no wheezing or rhonchi.

The hospital laboratory reports that the sputum culture collected upon admission has grown *Streptococcus pneumoniae*. The antimicrobial susceptibility profile is as follows:

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

A 76-year-old woman is evaluated in the clinic for a routine wellness visit. She resides in an assisted living facility and has no acute complaints. Her medical history is notable for hypertension, osteoarthritis, and well-controlled type 2 diabetes mellitus. Vital signs are within normal limits. She specifically denies dysuria, urinary frequency, urgency, or suprapubic pain. A screening urinalysis obtained by the facility staff prior to the visit reveals trace leukocyte esterase, positive nitrites, and 15-20 white blood cells/hpf. A subsequent urine culture grows $>10^5$ CFU/mL of *Escherichia coli*. Which of the following is the most appropriate next step in management?

A 41-year-old woman is evaluated in the emergency department for a 2-day history of severe epistaxis, easy bruising, and profound fatigue. Laboratory studies reveal a hemoglobin of $7.8 \text{ g/dL}$, a leukocyte count of $1,200/\mu\text{L}$, and a platelet count of $18,000/\mu\text{L}$. Coagulation studies show a prolonged prothrombin time, a prolonged activated partial thromboplastin time, a significantly elevated D-dimer, and a fibrinogen level of $85 \text{ mg/dL}$ (normal: $150-400 \text{ mg/dL}$). The patient is suspected to have acute promyelocytic leukemia (APL). Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for managing this patient.

Match each clinical presentation with the most likely rheumatologic diagnosis.

A 48-year-old man is hospitalized with a 1-week history of fever and severe lower back pain. He has a history of injection drug use. Temperature is 38.6°C (101.5°F), blood pressure is 120/75 mm Hg, and pulse is 98/min. Physical examination shows point tenderness over the lower lumbar spine. Neurologic examination is unremarkable. Magnetic resonance imaging of the spine reveals L3-L4 vertebral osteomyelitis and a small epidural abscess without cord compression. Empiric therapy with intravenous vancomycin and piperacillin-tazobactam is initiated. Two days later, blood cultures drawn at admission grow methicillin-susceptible Staphylococcus aureus (MSSA). The isolate is susceptible to oxacillin, cefazolin, and vancomycin. The patient's clinical status is stable. Which of the following is the most appropriate next step in pharmacotherapy?

A $65$-year-old man is brought to the emergency department by his daughter due to a $24$-hour history of severe headache, fever, and progressive confusion. His temperature is $39.2^{\circ}\text{C}$ ($102.6^{\circ}\text{F}$), blood pressure is $118/76 \text{ mmHg}$, pulse is $112/\text{min}$, and respiratory rate is $18/\text{min}$. On physical examination, the patient is lethargic and oriented only to his name. He resists passive neck flexion. Pupils are equal and reactive to light, and there are no focal motor deficits. A purpuric rash is not present. Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for this patient's management.

An infectious diseases consultation is requested for a 72-year-old man due to persistent fevers. He was admitted to the hospital 4 days ago with a 3-week history of malaise, low-grade fevers, and chills. These symptoms began approximately one month after he underwent a cystoscopy for benign prostatic hyperplasia. His medical history is notable for hypertension, type 2 diabetes mellitus, and stage 3 chronic kidney disease.

On physical examination, his temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $138/82\text{ mmHg}$, and pulse is $92\text{/min}$. Cardiac auscultation reveals a new grade $2/6$ diastolic decrescendo murmur heard best at the right upper sternal border. Examination of the hands shows small, linear, dark red streaks in the nail beds.

A transesophageal echocardiogram demonstrates a $1.2\text{-cm}$ mobile vegetation on the aortic valve with moderate aortic regurgitation. Four sets of blood cultures drawn upon admission are all positive for *Enterococcus faecalis*.

Antimicrobial susceptibility testing of the isolate shows the following:

Current laboratory results reveal a leukocyte count of $14,200/\text{mm}^3$ and a serum creatinine of $1.9\text{ mg/dL}$ (baseline $1.8\text{ mg/dL}$).

Which of the following is the most appropriate definitive intravenous antimicrobial regimen for this patient?

A 65-year-old man is brought to the emergency department by his wife due to fever, severe headache, and progressive confusion for the past 12 hours. His temperature is 39.2°C (102.6°F), blood pressure is 110/70 mmHg, and pulse is 115/min. Physical examination reveals nuchal rigidity, lethargy, and a new-onset left-sided pronator drift. Suspecting acute bacterial meningitis, arrange the following management steps in the most appropriate chronological order.

An intensive care unit team is evaluating a 68-year-old man who was admitted four days ago for septic shock complicated by acute respiratory failure. The patient initially presented with a perforated diverticulum and underwent an emergency exploratory laparotomy. He is currently mechanically ventilated and receiving continuous intravenous norepinephrine. His medical history includes hypertension and benign prostatic hyperplasia.

Current vital signs are temperature 37.6°C (99.7°F), pulse 98/min, blood pressure 102/64 mmHg, and oxygen saturation 96% on a fraction of inspired oxygen of 0.40. Physical examination reveals a sedated patient with a healing midline abdominal incision.

Arterial blood gas analysis on current ventilator settings reveals:
- $pH$: 7.32
- $pCO_2$: 35 mmHg
- $pO_2$: 82 mmHg
- $HCO_3^-$: 18 mEq/L

Due to persistent vasopressor requirements, an endocrine evaluation is obtained, which shows:
- Thyroid-stimulating hormone (TSH): 0.2 $\mu$ U/mL (Normal: 0.4–4.0 $\mu$ U/mL)
- Free thyroxine (T4): 0.6 ng/dL (Normal: 0.9–1.7 ng/dL)
- Total triiodothyronine (T3): 40 ng/dL (Normal: 80–200 ng/dL)

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

A 68-year-old man is brought to the emergency department by his daughter due to a 24-hour history of fever, severe headache, and worsening confusion. He has a medical history of type 2 diabetes mellitus and hypertension. His temperature is 39.4°C (102.9°F), blood pressure is 105/65 mm Hg, pulse is 118/min, and respirations are 22/min. On physical examination, the patient is lethargic and oriented only to person. He has marked nuchal rigidity. Neurologic examination reveals a newly developed left-sided facial droop and left arm weakness. Funduscopic examination is limited due to poor patient cooperation.

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

A 24-year-old man presents to the clinic for a routine wellness examination and sexual health screening. He reports having multiple male sexual partners and inconsistent condom use. He currently feels well and has no acute symptoms. The physician decides to screen him for human immunodeficiency virus (HIV). Assuming the patient has an acute HIV-1 infection, arrange the following laboratory evaluation steps in the correct chronological sequence according to the standard diagnostic algorithm.

A $48$-year-old man presents to the oncology unit with a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$) and rigors. He is currently on day $10$ of induction chemotherapy for acute myeloid leukemia (AML). Vital signs are pulse $118\text{ /min}$, blood pressure $95/60\text{ mmHg}$, and respirations $22\text{ /min}$. He has an indwelling central venous catheter with no surrounding erythema or purulence. Laboratory studies demonstrate a hemoglobin of $8.5\text{ g/dL}$, platelets of $45,000/\mu\text{L}$, and an absolute neutrophil count (ANC) of $100/\mu\text{L}$.

Arrange the following management steps in the optimal chronological sequence for this patient according to standard oncologic guidelines.

A 28-year-old man is found unresponsive in his bedroom by his roommate. Emergency medical services are called and he is brought to the hospital. He has a known past medical history of type 1 diabetes mellitus and major depressive disorder. On arrival, his temperature is 37.0°C (98.6°F), blood pressure is 105/65 mm Hg, pulse is 112/min, and respiratory rate is 12/min. Oxygen saturation is 92% on room air. Physical examination reveals a lethargic patient who only groans in response to sternal rub. His mucous membranes are notably dry. Pupillary examination reveals 2 mm pupils bilaterally that are sluggish to react to light.

Laboratory results are obtained:

Which of the following best describes this patient's acid-base status?

During morning rounds, a 30-year-old nulligravid patient is evaluated for discharge planning. She was admitted to the general medical ward 48 hours ago for acute pyelonephritis and was started on empiric intravenous ceftriaxone. She has shown rapid clinical improvement; she is now afebrile, her right-sided costovertebral angle tenderness has completely resolved, and she is eating a regular diet without nausea. The urine culture collected at admission grew $>100,000$ CFU/mL of *Escherichia coli*. The susceptibility report is as follows:

Based on principles of antimicrobial stewardship, which of the following is the most appropriate next step in pharmacological management?

A 34-year-old previously healthy man presents to the outpatient clinic complaining of a painful swelling on his right posterior thigh that began 3 days ago. He has no significant past medical history and takes no medications. His temperature is 37.0°C (98.6°F), blood pressure is 122/78 mmHg, pulse is 76/min, and respiratory rate is 14/min. Physical examination reveals a 2.5-cm, exquisitely tender, fluctuant, erythematous nodule. There is less than 1 cm of surrounding erythema and no regional lymphadenopathy. A point-of-care ultrasound confirms a localized fluid collection with no deep tissue tracking. The physician performs an uncomplicated bedside incision and drainage, yielding approximately 10 mL of opaque, yellow purulent material. Which of the following is the most appropriate next step in the management of this patient?