Internal Medicine

A 52-year-old man with a history of alcohol-associated cirrhosis is brought to the emergency department after vomiting a large volume of bright red blood. His blood pressure is 88/50 mmHg and pulse is 124/min. Arrange the following steps for the management of this patient in the most appropriate chronological order, from first to last.

Match each clinical and laboratory presentation to the most likely hematologic diagnosis.

A healthcare clinic evaluates several patients for hepatitis B virus (HBV) exposure and immunity. Match each patient's hepatitis B serologic panel to the most accurate clinical interpretation.

A $78$-year-old woman is brought to the emergency department by her daughter due to $3$ days of worsening, diffuse abdominal pain accompanied by nausea and voluminous bilious vomiting. She has not had a bowel movement or passed flatus for the past $48$ hours. Her medical history is significant for diet-controlled type 2 diabetes mellitus, essential hypertension, and recurrent episodic right upper quadrant abdominal pain for which she has previously declined surgery.

Temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $105/65\text{ mm Hg}$, pulse is $112/\text{min}$, respiratory rate is $18/\text{min}$, and oxygen saturation is $96\%$ on room air. The abdomen is significantly distended and tympanic to percussion. It is diffusely tender to palpation without guarding or rebound tenderness. High-pitched, tinkling bowel sounds are auscultated.

Laboratory studies show:
Leukocyte count: $11,000/\text{mm}^3$
Serum creatinine: $1.6\text{ mg/dL}$ (baseline $0.9\text{ mg/dL}$)
Aspartate aminotransferase: $35\text{ U/L}$
Alanine aminotransferase: $40\text{ U/L}$
Alkaline phosphatase: $110\text{ U/L}$
Total bilirubin: $1.0\text{ mg/dL}$

A computed tomography (CT) scan of the abdomen without contrast reveals markedly dilated loops of small bowel with a transition point in the distal ileum, where a $3\text{ cm}$ calcified mass is impacted. There are also tubular radiolucencies in the right upper quadrant conforming to the central biliary tree.

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

Match each clinical presentation with the most appropriate antimicrobial stewardship intervention based on current clinical guidelines.

A 54-year-old man with a history of alcohol-associated cirrhosis is brought to the emergency department by his family after vomiting a large amount of bright red blood. Upon arrival, he appears pale and lethargic but is adequately protecting his airway. His temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure is $85/55$ mmHg, and pulse is 120/min. Physical examination reveals shifting dullness, spider angiomas, and palmar erythema. Arrange the following steps in the optimal chronological sequence for the management of this patient's condition, from most immediate to subsequent.

A 64-year-old woman is brought to the emergency department by her family due to profound weakness and confusion. She has had 5 days of severe, voluminous watery diarrhea. Her medical history includes type 2 diabetes mellitus and hypertension. On examination, blood pressure is 82/50 mm Hg, heart rate is 118/min, and respiratory rate is 24/min. She has dry mucous membranes, flat neck veins, and delayed capillary refill.

Laboratory studies show:
Serum $Na^+$: 140 mEq/L
Serum $K^+$: 3.2 mEq/L
Serum $Cl^-$: 112 mEq/L
Serum $HCO_3^-$: 8 mEq/L
Blood urea nitrogen: 54 mg/dL
Serum creatinine: 2.8 mg/dL (baseline 0.9 mg/dL)
Serum lactate: 5.2 mmol/L (Normal: 0.5-1.0 mmol/L)
Serum albumin: 4.0 g/dL

Assuming a reference anion gap of 12 mEq/L and a normal serum bicarbonate of 24 mEq/L, what is this patient's calculated delta ratio (also known as the $\Delta/\Delta$ ratio)?

A 62-year-old woman is evaluated in the hospital on hospital day 2. She was admitted with right upper quadrant abdominal pain, fever, and jaundice, and was diagnosed with acute ascending cholangitis. She underwent an urgent endoscopic retrograde cholangiopancreatography (ERCP) with successful biliary stone extraction and stent placement. On admission, blood cultures were drawn, and she was started on empiric intravenous piperacillin-tazobactam. Today, her temperature is 37.1°C (98.8°F), blood pressure is 122/78 mm Hg, and pulse is 78/min. She reports significant improvement in her abdominal pain. The admission blood cultures are now growing *Escherichia coli*. The antimicrobial susceptibility report is as follows:

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

A rapid response is called for a patient who is deteriorating in the intensive care unit. The 28-year-old woman was intubated 15 minutes ago for refractory status asthmaticus. She is deeply sedated and chemically paralyzed. Mechanical ventilation is running in volume-assist control mode with a tidal volume of 450 mL (approximately 6 mL/kg ideal body weight), a respiratory rate of 18/min, an inspiratory flow rate of 40 L/min, and a positive end-expiratory pressure (PEEP) of 5 cm H2O. Upon arrival, the high-pressure alarm is sounding continuously. Vital signs show a blood pressure of 72/40 mm Hg (down from 115/75 mm Hg post-intubation), a heart rate of 138/min, and an oxygen saturation of 93% on a fraction of inspired oxygen of 1.0. Physical examination reveals distended jugular veins and a midline trachea. Auscultation demonstrates symmetrically distant breath sounds with faint, prolonged expiratory wheezes bilaterally. Arterial blood gas analysis indicates a pH of 7.21, PaCO2 of 72 mm Hg, and PaO2 of 150 mm Hg. Review of the real-time ventilator waveforms shows that the expiratory flow curve is abruptly interrupted by the next inspiratory breath before reaching the zero baseline. Which of the following is the most appropriate immediate next step in management?

A 35-year-old woman presents to the clinic for evaluation of generalized muscle weakness and fatigue over the past several weeks. She also reports a recent history of passing two kidney stones. Her past medical history is significant for Sjögren syndrome, for which she uses artificial tears and saliva substitutes. Vital signs are within normal limits. Laboratory evaluation reveals the following:

Urinalysis:
- pH: 6.5
- Specific gravity: 1.015
- Protein: Negative
- Blood: Negative
- Glucose: Negative

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

An intensive care unit team is managing a 68-year-old man who was admitted 5 days ago for severe pneumococcal pneumonia complicated by acute respiratory distress syndrome and septic shock. He remains mechanically ventilated. Sedation was discontinued yesterday in an attempt to perform a spontaneous breathing trial, but the patient remains largely unresponsive. His wife mentions that over the past year he has been more fatigued than usual and has gained 4.5 kg (10 lb). His temperature is 36.5°C (97.7°F), blood pressure is 105/65 mmHg on low-dose vasopressin, and heart rate is 82/min. Physical examination shows no focal neurologic deficits, but relaxation of deep tendon reflexes is slightly delayed. To evaluate for potential endocrine causes of his depressed mental status, a thyroid panel is obtained:

Thyroid-stimulating hormone (TSH): 0.2 µU/mL (Normal: 0.5-5.0 µU/mL)
Free thyroxine (T4): 0.6 ng/dL (Normal: 0.9-1.7 ng/dL)
Total triiodothyronine (T3): 42 ng/dL (Normal: 80-200 ng/dL)

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

Match each clinical presentation of acute renal dysfunction with the most characteristic finding expected on microscopic urinalysis.

An evaluation is requested for a 53-year-old woman who presents to the clinic reporting a three-week history of progressively worsening shortness of breath and new-onset lower extremity swelling. She reports waking up frequently during the night gasping for air. The patient has a 12-year history of seropositive rheumatoid arthritis that has been stable for the past two years on a regimen of methotrexate and infliximab. She also takes naproxen as needed for joint pain. Her temperature is 37.0°C (98.6°F), blood pressure is 138/85 mmHg, pulse is 96/min, and respiratory rate is 22/min. Pulse oximetry shows 94% on room air. Physical examination reveals jugular venous distention at 9 cm $H_2O$. Lung auscultation demonstrates bibasilar fine crackles. Cardiac examination shows a regular rate and rhythm with a prominent S3 gallop. The abdomen is soft, and there is 2+ pitting edema of the lower extremities bilaterally. Joint examination shows ulnar deviation of the metacarpophalangeal joints but no acute synovitis or effusions. Laboratory studies reveal a hemoglobin of 11.2 g/dL, a normal comprehensive metabolic panel, a thyroid-stimulating hormone (TSH) level of 1.2 $\mu$ U/mL (normal: 0.5-5.0 $\mu$ U/mL), and a slightly decreased total $T_4$ level. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation and high-resolution manometry (HRM) profile with the most likely esophageal motility disorder diagnosis based on the Chicago Classification.

A $32$-year-old woman is brought to the emergency department by her husband due to severe confusion, agitation, and repeated vomiting over the past $12$ hours. She had an uncomplicated spontaneous vaginal delivery $3$ days ago. Her past medical history is notable for Graves disease, for which she discontinued her antithyroid medications during the third trimester. Her temperature is $39.8^\circ\text{C}$ ($103.6^\circ\text{F}$), blood pressure is $165/75\text{ mmHg}$, pulse is $152/\text{min}$ and irregular, and respirations are $28/\text{min}$. Physical examination reveals a staring gaze, diaphoresis, marked fine tremor, and a diffusely enlarged, non-tender thyroid gland. An electrocardiogram shows atrial fibrillation with a rapid ventricular response. A clinical diagnosis of thyroid storm is made, and the patient is admitted to the intensive care unit.

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

A 74-year-old woman presents to the emergency department with a 3-day history of severe right-sided headache and jaw pain while chewing. She reports that 2 hours ago, she experienced sudden, painless vision loss in her right eye. Physical examination reveals a tender, nonpulsatile right temporal artery. Laboratory studies show an erythrocyte sedimentation rate of $110$ mm/h. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for the management of this patient's condition, from immediate (first) to long-term (last).

Match each clinical presentation of hypercalcemia and its associated laboratory profile with the most likely underlying pathophysiologic mechanism.

A 36-year-old woman comes to the clinic for evaluation of a neck mass. She noticed a lump on the right side of her neck 3 weeks ago while applying lotion. She feels occasionally warm and has had mild palpitations recently, but she attributes these symptoms to stress at work. Her menstrual cycles are regular. Vital signs show a heart rate of $98/\text{min}$ and blood pressure of $128/78\text{ mmHg}$. Physical examination reveals a firm, mobile, $2.4\text{-cm}$ nodule in the right lobe of the thyroid gland. No cervical lymphadenopathy is appreciated.

Laboratory studies reveal the following:

Ultrasound of the neck shows a $2.4\text{-cm}$ solid, hypoechoic nodule in the right lobe with smooth margins and no microcalcifications.

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

A $62$-year-old man comes to the emergency department complaining of severe, worsening lower back pain for the past $3$ weeks. The pain is constant, wakes him up at night, and is not relieved by rest or over-the-counter analgesics. He reports feeling warm at times but denies any leg weakness, numbness, or loss of bowel and bladder control. His medical history is significant for type 2 diabetes mellitus and end-stage renal disease, for which he receives hemodialysis via a right internal jugular venous catheter. Temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), blood pressure is $135/85 \text{ mm Hg}$, and pulse is $88/\text{min}$. Physical examination reveals exquisite tenderness to percussion over the L3 and L4 spinous processes. Neurologic examination of the lower extremities shows $5/5$ strength, normal sensation to pinprick and light touch, and $2+$ deep tendon reflexes symmetrically. Anal sphincter tone is normal. Laboratory studies show a leukocyte count of $9,500/\text{mm}^3$, an erythrocyte sedimentation rate of $88 \text{ mm/hr}$, and a C-reactive protein of $65 \text{ mg/L}$. Two sets of blood cultures are drawn. Magnetic resonance imaging of the lumbar spine reveals increased fluid signal in the L3-L4 intervertebral disc space with adjacent vertebral body marrow edema, consistent with pyogenic spondylodiscitis. There is no evidence of an epidural abscess or spinal cord compression. Which of the following is the most appropriate next step in the management of this patient?

A 37-year-old woman presents to the clinic with an 8-month history of progressive shortness of breath. She reports initially feeling winded only during heavy exertion, but her dyspnea now occurs when walking short distances on flat ground. Last week, she experienced a syncopal episode while climbing stairs. She has no significant past medical history, takes no medications, and has never smoked. Vital signs show temperature 37.0°C (98.6°F), blood pressure 110/72 mm Hg, pulse 94/min, and respirations 18/min. Oxygen saturation is 96% on room air. Physical examination reveals clear breath sounds bilaterally. Cardiovascular examination is notable for a palpable left parasternal heave and a prominently accentuated pulmonic component of the second heart sound (P2). Jugular venous pressure is estimated at 9 cm H2O. There is trace bilateral lower extremity edema.

Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's condition, starting from the initial evaluation step to the final confirmatory assessment.