Internal Medicine

A 62-year-old woman with a body mass index of 34 kg/m² presents to the clinic with chronic, progressive bilateral knee pain. She notes the pain worsens with weight-bearing activities, such as walking up stairs, and is relieved by rest. She experiences morning stiffness in her knees lasting approximately 15 minutes. Physical examination reveals bony enlargement, crepitus, and a limited range of motion in both knees, without significant warmth or large effusions. Radiographs demonstrate asymmetric joint space narrowing, subchondral sclerosis, and prominent osteophyte formation. Arrange the following management steps for this patient's condition in the most appropriate sequential order, progressing from initial conservative measures to definitive advanced interventions.

Match each clinical presentation of a genital ulcer disease with its most appropriate first-line pharmacotherapy.

Match each clinical presentation of infective endocarditis with the most appropriate targeted diagnostic evaluation or therapeutic intervention.

A 21-year-old woman with type 1 diabetes mellitus is brought to the emergency department due to lethargy, abdominal pain, and vomiting. She stopped taking her insulin two days ago because she was unable to eat. Her blood pressure is $88/55 \text{ mm Hg}$, heart rate is $132\text{/min}$, and respiratory rate is $26\text{/min}$ with deep, sighing breaths. Mucous membranes are markedly dry. Laboratory studies reveal:

Arrange the following targeted management steps in the most appropriate chronological sequence according to standard diabetic ketoacidosis (DKA) protocols.

During a weekend shift at the acute care clinic, a $69$-year-old male with a history of castration-resistant prostate cancer is evaluated for escalating mid-thoracic back pain over the past three days. He describes a new sensation of heaviness in both legs that has progressively impaired his ability to walk unassisted. Additionally, he reports an episode of involuntary urinary dribbling earlier this morning. Current medications include leuprolide and denosumab. Vital signs are temperature $37.1^{\circ}\text{C}$ ($98.8^{\circ}\text{F}$), blood pressure $142/86 \text{ mm Hg}$, pulse $88/\text{min}$, and respiratory rate $14/\text{min}$. Physical examination reveals exquisite tenderness to percussion over the $T10$ spinous process. Neurologic evaluation demonstrates $3/5$ muscle strength in bilateral lower extremities, symmetrically hyperactive patellar reflexes, and diminished pinprick sensation below the umbilicus. Digital rectal examination reveals decreased anal sphincter tone. Which of the following is the most appropriate initial step in the management of this patient?

A 62-year-old man is evaluated in the hospital on hospital day 3. He was initially admitted for high fever and rigors. His past medical history is significant for end-stage renal disease requiring hemodialysis via a right internal jugular tunneled catheter. Upon admission, peripheral and catheter-drawn blood cultures were obtained, and he was started on empiric antimicrobial therapy with intravenous vancomycin and piperacillin-tazobactam. Today, his temperature is 37.2°C (99.0°F), blood pressure is 128/76 mmHg, and heart rate is 82/min. The admission blood cultures are now positive for Staphylococcus aureus in 4 out of 4 bottles. Susceptibility testing reveals the isolate is resistant to penicillin, but susceptible to oxacillin, cefazolin, and vancomycin. A review of the patient's medical record indicates a documented allergy to amoxicillin, which the patient describes as a 'flat, red skin rash' that occurred several days into a treatment course 10 years ago, without associated pruritus, facial swelling, or difficulty breathing. Which of the following is the most appropriate modification to his current pharmacotherapy?

A $45$-year-old man is brought to the emergency department by his sister due to altered mental status. She states that he has a history of alcohol use disorder and was found confused in his apartment with an empty bottle of antifreeze nearby. Laboratory studies show:

Based on these laboratory results, what is this patient's calculated osmolar gap? (Provide the exact numerical value)

A 45-year-old woman is evaluated in the intensive care unit on the second day of induction chemotherapy for newly diagnosed high-grade Burkitt lymphoma. Over the past 8 hours, her urine output has significantly decreased. She reports mild nausea and generalized weakness. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, and pulse is $88/\text{min}$. A stat laboratory panel shows the following results:

An electrocardiogram (ECG) reveals tall, peaked T waves with a shortened QT interval. Which of the following is the most appropriate next step in the management of this patient?

A 74-year-old man is evaluated in the surgical telemetry unit on postoperative day 4 following an open cholecystectomy and common bile duct exploration. The nursing staff requested a review because his urine output has decreased to $250 \text{ mL}$ over the last 24 hours, and he has become increasingly confused and short of breath. His medical history includes hypertension, type 2 diabetes mellitus, and a 40-pack-year smoking history. Temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $155/92 \text{ mm Hg}$, pulse is $112/\text{min}$, and respirations are $26/\text{min}$. Oxygen saturation is $88\%$ on room air. Physical examination shows jugular venous distention $10 \text{ cm}$ above the sternal angle. Auscultation of the lungs reveals bilateral basilar crackles. The abdomen is soft and non-tender, with intact surgical staples and no erythema. Bilateral $2+$ pitting edema is present in the lower extremities.

Laboratory studies show:
Serum sodium: $134 \text{ mEq/L}$
Serum potassium: $5.2 \text{ mEq/L}$
Serum chloride: $98 \text{ mEq/L}$
Serum bicarbonate: $14 \text{ mEq/L}$
Blood urea nitrogen: $68 \text{ mg/dL}$
Serum creatinine: $3.1 \text{ mg/dL}$ (baseline $1.1 \text{ mg/dL}$)

Arterial blood gas (room air):
pH: $7.24$
PaCO2: $42 \text{ mm Hg}$
PaO2: $58 \text{ mm Hg}$

Which of the following is the most accurate characterization of this patient's acid-base status and the most appropriate next step in management?

A 62-year-old man is evaluated in the intensive care unit on day 4 of an admission for severe urosepsis. He initially required mechanical ventilation and vasopressor support but is now hemodynamically stable and was extubated yesterday. He has a history of hypertension and benign prostatic hyperplasia. His medications include amlodipine, tamsulosin, and intravenous antibiotics. He has no history of thyroid disease. His temperature is 37.2°C (99.0°F), blood pressure is 118/76 mm Hg, and pulse is 82/min. Physical examination reveals clear lungs and a normal-sized, non-tender thyroid gland.

Laboratory studies show:

Which of the following is the most likely mechanism responsible for this patient's thyroid laboratory findings?

Match each clinical presentation of an adverse drug effect with the most likely responsible antineoplastic or targeted therapy agent.

Emergency medical services bring a 68-year-old man to the hospital after his daughter found him lethargic and struggling to breathe. For the past 48 hours, he has experienced a fever and a worsening productive cough. His medical history is significant for severe chronic obstructive pulmonary disease (COPD), hypertension, and type 2 diabetes mellitus. His daily medications include tiotropium, lisinopril, and empagliflozin.

Vital signs are:
Temperature: 38.2°C (100.8°F)
Blood pressure: 110/65 mm Hg
Pulse: 118/min
Respirations: 26/min
Oxygen saturation: 86% on room air

Physical examination reveals a somnolent but arousable patient. Lung auscultation demonstrates diffuse wheezing and right lower lobe crackles with a prolonged expiratory phase.

Laboratory results are as follows:

Arterial blood gas analysis on room air reveals:

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

A 34-year-old woman comes to the clinic for an annual health maintenance evaluation. She mentions feeling a bit fatigued lately but otherwise feels well. She has no history of neck radiation, surgery, or significant medical conditions. Her vital signs are within normal limits. Physical examination reveals a normal-sized thyroid gland without palpable nodules.

Laboratory studies are obtained with the following results:

Thyroid-stimulating hormone (TSH): $6.8 \text{ \mu U/mL}$ (Normal: $0.5 - 5.0 \text{ \mu U/mL}$)
Free thyroxine (T4): $1.4 \text{ ng/dL}$ (Normal: $0.9 - 1.7 \text{ ng/dL}$)

Which of the following is the most likely diagnosis?

A 72-year-old man is brought to the emergency department by his daughter due to severe shortness of breath and an inability to lie flat in bed for the past $3$ days. He also reports a persistent nonproductive cough. His medical history is significant for chronic obstructive pulmonary disease (COPD), hypertension, stage 3 chronic kidney disease, and a nonfunctioning pituitary macroadenoma that was surgically resected $5$ years ago. His current medications include a daily tiotropium inhaler and amlodipine.

His temperature is $37.1^\circ$ C ($98.8^\circ$ F), blood pressure is $165/95$ mm Hg, pulse is $102$/min, and respiratory rate is $24$/min. Pulse oximetry shows $88\%$ on room air. Physical examination reveals an elevated jugular venous pressure of $10$ cm H $_2$ O. Lung auscultation demonstrates bilateral crackles in the lower lung fields and a prolonged expiratory phase with scattered wheezes. Cardiac examination reveals a regular tachycardia and a prominent S $_3$ gallop. There is $2+$ pitting edema in the bilateral lower extremities.

A chest radiograph displays cardiomegaly, bilateral pleural effusions, and prominent interstitial markings without focal consolidation. Which of the following is the most appropriate next step in management for this patient?

A 64-year-old woman is evaluated in the clinic following routine laboratory testing that revealed hypercalcemia. She has no symptoms of fatigue, abdominal pain, bone pain, or cognitive changes. Her medical history is significant for essential hypertension and osteopenia. Her medications include chlorthalidone and cholecalciferol. Blood pressure is 132/82 mm Hg, and pulse is 72/min. Physical examination is unremarkable.

Laboratory results are as follows:

The calculated calcium-to-creatinine clearance ratio is $0.006$.

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

An evaluation is requested for a 48-year-old male who is admitted to the intensive care unit with a 4-day history of coughing up blood-tinged sputum, progressive dyspnea, and passing dark red urine. Over the past six months, he has been treated three times for therapy-resistant maxillary sinusitis and chronic otitis media. Vital signs show a temperature of $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure of $165/95\text{ mm Hg}$, heart rate of $110/\text{min}$, and respiratory rate of $26/\text{min}$. Oxygen saturation is $89\%$ on room air. Physical examination reveals ulceration of the nasal septum and bilateral coarse crackles in the lung fields. Laboratory results are as follows:

Urinalysis demonstrates $3+$ blood, $1+$ protein, $30-40$ dysmorphic red blood cells per high-power field, and occasional red blood cell casts. Chest radiography reveals diffuse bilateral alveolar opacities.

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

A $62$-year-old man is hospitalized for the treatment of an acute right-sided pulmonary embolism. He is initially started on a continuous intravenous unfractionated heparin infusion. On hospital day 6, his platelet count is noted to have decreased from a baseline of $240,000/mm^3$ on admission to $90,000/mm^3$. Concurrently, he reports new-onset left leg pain and swelling. Venous duplex ultrasonography reveals a new acute deep venous thrombosis in the left femoral vein. Heparin-induced thrombocytopenia is suspected. The heparin infusion is immediately discontinued, and intravenous argatroban is initiated. A serotonin release assay later returns positive, confirming the diagnosis. Four days later, the patient's leg swelling has significantly improved, and his respiratory status remains stable. His current platelet count is $115,000/mm^3$. The patient is eager to transition to an oral anticoagulant and be discharged. Which of the following is the most appropriate next step in the management of this patient's anticoagulation?

A $34$-year-old woman presents to the clinic for evaluation of a skin rash. She noticed the rash on her right posterior thigh $4$ days ago, and it has steadily increased in size. She recently returned from a camping trip in Maine. The patient reports mild fatigue and muscle aches but denies fever, joint swelling, or shortness of breath. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $120/78\text{ mm Hg}$, and pulse is $76\text{/min}$. Physical examination reveals a $10\text{-cm}$, annular, erythematous plaque with a central area of clearing on the right posterior thigh. The remainder of the examination is unremarkable. Which of the following is the most appropriate next step in management?

An occupational health clinic evaluates a $31$-year-old hospital pharmacist for a two-month history of irritability, frequent palpitations, and heat intolerance. She reports poor sleep and an unintentional $4\text{-kg}$ ($8.8\text{-lb}$) weight loss during this period. The patient has no significant past medical history and takes no prescribed medications, although she admits to taking various over-the-counter "energy supplements" to help with long shifts. Her vital signs show a pulse of $112\text{/min}$ and a blood pressure of $138/82\text{ mm Hg}$. Physical examination reveals a fine tremor of the outstretched hands and hyperactive deep tendon reflexes. The eyes show no proptosis, lid lag, or periorbital edema. The thyroid gland is not palpable, and there is no cervical lymphadenopathy or anterior neck tenderness.

Laboratory evaluation shows:
Thyroid-stimulating hormone (TSH): $<0.01\text{ }\mu\text{U/mL}$ (normal: $0.4$-$4.0\text{ }\mu\text{U/mL}$)
Free T4: $2.9\text{ ng/dL}$ (normal: $0.8$-$1.8\text{ ng/dL}$)
Free T3: $6.2\text{ pg/mL}$ (normal: $2.3$-$4.2\text{ pg/mL}$)

A subsequent $24$-hour radioactive iodine uptake scan reveals $<1\%$ uptake (normal: $10\%$-$30\%$).

Which of the following is the most appropriate next step in the diagnostic workup?

During morning rounds in the intensive care unit, the medical team evaluates a patient with septic shock secondary to a perforated viscus. The patient's arterial blood gas and basic metabolic panel are drawn to assess his acid-base status. The laboratory results reveal a severe primary metabolic acidosis with a serum bicarbonate level of $14 \text{ mEq/L}$ and a significantly elevated serum lactate. To determine if a superimposed respiratory acid-base disorder is present, the physician calculates the expected respiratory response. Assuming appropriate respiratory compensation, which of the following is the expected partial pressure of carbon dioxide ($PaCO_2$) in this patient?