Internal Medicine

A $28$-year-old primigravida at $32$ weeks gestation presents to the emergency department reporting acute-onset fatigue, shortness of breath, and dark urine for the past $24$ hours. $3$ days ago, she was diagnosed with an uncomplicated urinary tract infection and prescribed nitrofurantoin. Her prenatal course has otherwise been unremarkable.

Temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $110/70$ mmHg, pulse is $112$/min, and respirations are $20$/min. Physical examination reveals conjunctival pallor and mild scleral icterus. The uterine fundus is consistent with gestational age. Continuous fetal heart rate monitoring demonstrates a baseline of $165$/min, minimal variability, and occasional variable decelerations.

Laboratory studies show:

A peripheral blood smear stained with Wright-Giemsa is obtained (see image) and reveals scattered erythrocytes with irregular, semi-circular marginal defects.

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

A group of patients presents to the emergency department with signs and symptoms of lower respiratory tract infection. Based on the unique clinical features described for each patient, match the clinical presentation with the most likely causative pathogen.

Match each clinical presentation to the most appropriate initial therapeutic intervention.

Match each patient's clinical presentation following a toxic ingestion or medication overdose to the most appropriate initial specific pharmacologic antidote or therapy.

Match the following classic peripheral blood smear findings with their most likely associated hematologic diagnosis.

Match the following rheumatologic autoantibodies with their most characteristic clinical phenotypes and prognostic associations.

A hospital rapid response team is called to the bedside of a 58-year-old female inpatient due to acute right leg pain and swelling. The patient was admitted six days ago for an acute non-ST-segment elevation myocardial infarction and has been receiving a continuous intravenous infusion of unfractionated heparin since admission. Her other medications include aspirin, atorvastatin, and metoprolol. Temperature is 37.1°C (98.8°F), blood pressure is 135/85 mmHg, pulse is 92/min, and respirations are 16/min. Physical examination of the right lower extremity reveals significant edema from the calf to the mid-thigh with localized tenderness, but peripheral pulses remain palpable. Laboratory results on admission showed a platelet count of 260,000/mm³. Today's laboratory studies reveal a hemoglobin of 13.1 g/dL, leukocyte count of 8,200/mm³, and a platelet count of 65,000/mm³. A stat lower extremity compression ultrasonography confirms a new, occlusive deep venous thrombosis in the right femoral vein. Which of the following is the most appropriate next step in the management of this patient?

A 54-year-old man is brought to the emergency department by his husband due to severe headache, high fever, and new-onset confusion that began 24 hours ago. His medical history is notable for a deceased-donor renal allograft three years ago, and he currently takes tacrolimus and mycophenolate mofetil. This morning, he developed right-sided weakness and difficulty speaking. His temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $112/68\text{ mmHg}$, pulse is $118/\text{min}$, and respiratory rate is $20/\text{min}$. Physical examination reveals marked nuchal rigidity, expressive aphasia, and a mild right-sided hemiparesis. Arrange the following interventions in the most appropriate sequential order for the acute management of this patient.

Match each patient's clinical presentation with the most characteristic diagnostic or pathologic finding associated with their underlying condition.

A medical resident is evaluating a 72-year-old man in the preoperative clinic prior to a scheduled open abdominal aortic aneurysm repair. The patient has a history of stroke, insulin-dependent diabetes mellitus, and chronic kidney disease. He is sedentary and unable to climb a flight of stairs due to lower extremity claudication. The attending physician asks the resident to outline the standardized stepwise approach for perioperative cardiovascular risk assessment according to the current clinical guidelines.

Arrange the following steps of the perioperative cardiovascular evaluation algorithm in their correct sequential order, from the absolute initial consideration to final preoperative decision-making.

A 62-year-old man is admitted to the hospital with a 2-day history of fever, chills, and severe right flank pain. He has a history of benign prostatic hyperplasia and recurrent urinary tract infections. His temperature is $39.1^{\circ}\text{C}$ ($102.4^{\circ}\text{F}$), blood pressure is $92/60\text{ mmHg}$, heart rate is $118/\text{min}$, and respiratory rate is $20/\text{min}$. Physical examination reveals marked right costovertebral angle tenderness.

Laboratory studies show a leukocyte count of $16,500/\text{mm}^3$. Intravenous fluids are administered, and he is started empirically on intravenous vancomycin and piperacillin-tazobactam.

On hospital day 3, the patient's clinical status has significantly improved. He is afebrile with a blood pressure of $118/76\text{ mmHg}$. Blood and urine cultures obtained on admission both grow *Enterobacter cloacae*.

The antimicrobial susceptibility report for the *Enterobacter cloacae* isolate is as follows:

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

A 35-year-old woman is evaluated for a 1-year history of her fingers turning white, then blue, and finally red when she takes food out of the freezer. She has also noticed some tightness in the skin of her hands. The patient is diagnosed with secondary Raynaud phenomenon.

Arrange the following interventions in the standard step-wise order of therapy, from the initial recommendation to the final escalation for severe, tissue-threatening disease.

The nursing staff urgently requests an evaluation of a $64$-year-old man in the pulmonary step-down unit due to decreasing responsiveness. The patient was admitted $36$ hours ago for a severe exacerbation of chronic obstructive pulmonary disease (COPD). His initial treatment included intravenous methylprednisolone, nebulized ipratropium-albuterol, oral doxycycline, and supplemental oxygen. Over the past $12$ hours, his oxygen delivery was escalated to a non-rebreather mask by the cross-cover team due to perceived hypoxemia. His other medical history includes systemic hypertension, diet-controlled type 2 diabetes, and osteoarthritis.

Vital signs are:
Temperature: $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$)
Blood pressure: $142/86 \text{ mm Hg}$
Heart rate: $108/\text{min}$
Respiratory rate: $8/\text{min}$
Pulse oximetry: $99\%$ on the non-rebreather mask

On physical examination, the patient is lethargic but opens his eyes and follows simple commands when spoken to loudly. Noticeable asterixis is present on bilateral wrist extension. The jugular venous pressure is visually estimated at $5 \text{ cm H}_2\text{O}$. Auscultation of the chest reveals a markedly prolonged expiratory phase with faint, diffuse wheezing, but no crackles. The cardiac rhythm is regular. Trace bilateral pedal edema is noted.

Relevant morning laboratory panels show:
Leukocytes: $8,200/\text{mm}^3$
Sodium: $138 \text{ mEq/L}$
Potassium: $4.3 \text{ mEq/L}$
Chloride: $94 \text{ mEq/L}$
Bicarbonate: $36 \text{ mEq/L}$
Thyroid-stimulating hormone (TSH): $0.1 \mu\text{U/mL}$ (Normal: $0.4-4.0 \mu\text{U/mL}$)
Free thyroxine (T4): $1.2 \text{ ng/dL}$ (Normal: $0.9-1.7 \text{ ng/dL}$)

An arterial blood gas analysis drawn on his current oxygen support demonstrates:
pH: $7.20$
$PaCO_2$: $95 \text{ mm Hg}$
$PaO_2$: $148 \text{ mm Hg}$

Based on these clinical and laboratory findings, which of the following is the most appropriate next step in management?

A 45-year-old woman is newly diagnosed with seropositive rheumatoid arthritis involving her metacarpophalangeal and proximal interphalangeal joints. According to standard clinical guidelines, arrange the following therapeutic interventions in the correct chronological sequence of escalation, starting from the initial medical management to the treatment of advanced, medically refractory disease.

An emergency department physician is evaluating a college student brought in by roommates for a severe headache, high fever, and altered mental status. On physical examination, the patient is lethargic, has pronounced nuchal rigidity, and exhibits a new right-sided hemiparesis. Acute bacterial meningitis is highly suspected. Arrange the following interventions in the most appropriate sequential order for the immediate management of this patient.

A public health clinic evaluates four patients presenting with different types of genital lesions. Match each patient's clinical presentation (left) with the most appropriate first-line pharmacotherapy (right) according to current infectious disease guidelines.

Match each patient's clinical presentation of an oncologic or hematologic emergency with the most appropriate immediate medical intervention.

An internal medicine physician is urgently called to evaluate a 54-year-old male admitted overnight for observation. The nursing staff reports that the patient has developed new-onset confusion, a severe holocephalic headache, and photophobia over the last 4 hours. Vital signs show a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), pulse of $112/\text{min}$, and blood pressure of $138/82\text{ mmHg}$. Neurologic examination demonstrates a Glasgow Coma Scale score of 11, prominent resistance to passive neck flexion, and bilateral papilledema. No other focal neurologic deficits are present.

Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for this patient's management.

A 65-year-old man presents to the clinic with a 4-month history of progressive fatigue, shortness of breath on exertion, and frothy urine. Physical examination reveals periorbital purpura, an enlarged tongue with lateral indentations, and 2+ pitting edema of the lower extremities. Jugular venous distention is present. Echocardiography demonstrates thickened left and right ventricular walls with a sparkling, granular appearance and an ejection fraction of 55%. Urinalysis shows 4+ proteinuria, and a 24-hour urine collection confirms 5.2 g of protein. Suspecting an underlying hematologic disorder, the physician plans a diagnostic and therapeutic workup.

Arrange the following steps in the most appropriate chronological sequence for the definitive diagnosis and management of this patient's condition.

During morning rounds, a physician evaluates a patient admitted two days ago for a severe lower respiratory tract infection. The patient, a 52-year-old non-smoker, initially presented with a high fever, productive cough, and lobar consolidation on chest radiography. At admission, he was empirically started on intravenous ceftriaxone and oral azithromycin. Today, he is completely afebrile, his respiratory rate is 16/min, his oxygen saturation is 97% on ambient air, and he is eager to go home. The microbiology laboratory reports that the admission sputum culture is growing *Streptococcus pneumoniae*. Susceptibility testing indicates the isolate is susceptible to penicillin, amoxicillin, ceftriaxone, levofloxacin, and vancomycin. Blood cultures remain sterile. The physician is writing discharge orders to complete a total 5-day course of therapy. Which of the following is the most appropriate oral antibiotic regimen for discharge?