Internal Medicine

A 38-year-old woman is referred to the endocrinology clinic due to progressive weight gain, facial plethora, and easy bruising over the past eight months. Physical examination reveals prominent supraclavicular fat pads, violaceous abdominal striae, and proximal muscle weakness. Her blood pressure is $155/95$ mm Hg. Suspecting Cushing syndrome, the physician decides to initiate a comprehensive diagnostic evaluation. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for this patient.

A primary care physician evaluates a 45-year-old woman who noticed an expanding area of redness on her right shin that began 48 hours ago. The affected region is tender to the touch, and she reports feeling mildly fatigued but denies chills, nausea, or recent trauma. Medical history is notable only for mild allergic rhinitis, for which she takes over-the-counter cetirizine. Her temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), blood pressure is $122/78 \text{ mmHg}$, pulse is $84/\text{min}$, and respiratory rate is $14/\text{min}$. Physical examination reveals a $10 \times 6 \text{ cm}$ erythematous, warm, and swollen plaque on the anterior right lower leg. The margins are indistinct. There is no palpable fluctuance, purulent exudate, or ulceration. Tender right inguinal lymphadenopathy is present. Which of the following is the most appropriate initial pharmacotherapy for this patient?

Match each cardiovascular medication to its most characteristic adverse effect.

Match each patient's specific clinical presentation with the most likely corresponding gastrointestinal histologic finding observed on biopsy.

A $42$-year-old male construction worker comes to the primary care clinic for evaluation of profound fatigue, a $9$-kg ($20$-lb) weight gain, and diminished libido progressing over the last nine months. He has a history of chronic, severe lumbar radiculopathy following a workplace injury four years ago. His daily medications include extended-release oxycodone, duloxetine, and ibuprofen. Vital signs show a blood pressure of $118/76$ mmHg and a heart rate of $58$/min. Physical examination reveals a flat affect, dry skin, and a delayed relaxation phase of the Achilles tendon reflexes. Visual field testing is entirely normal. A comprehensive metabolic panel is unremarkable. Neuroimaging of the sella turcica with gadolinium reveals no masses or structural lesions.

Relevant laboratory results are as follows:

Which of the following is the most likely mechanism underlying this patient's endocrine laboratory abnormalities?

Match each clinical presentation of renal disease with the most likely corresponding glomerular pathology.

A $32$-year-old female nurse presents to the clinic reporting a $6$-week history of persistent jitteriness, heat intolerance, and difficulty sleeping. She also reports a $4\text{-kg}$ ($8.8\text{-lb}$) weight loss during this period despite a normal appetite. The patient has no significant past medical history. She mentions feeling significant stress recently due to her upcoming wedding. Her temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $138/78\text{ mm Hg}$, and pulse is $115/\text{min}$. On physical examination, she appears anxious and diaphoretic. A fine resting tremor is observed in her outstretched hands. The thyroid gland is nonpalpable and non-tender. There is no cervical lymphadenopathy, proptosis, or pretibial myxedema. Laboratory studies are obtained and reveal the following:

Which of the following is the most likely diagnosis?

A 22-year-old man with sickle cell disease comes to the urgent care center due to a 3-day history of productive cough, fever, and severe, sharp chest pain. He also reports increasing difficulty breathing over the last 24 hours. The patient takes folic acid and hydroxyurea daily. His temperature is 38.8°C (101.8°F), blood pressure is 114/72 mm Hg, pulse is 122/min, and respirations are 28/min. Pulse oximetry shows an oxygen saturation of 89% on room air. Physical examination reveals scleral icterus. Lung auscultation demonstrates decreased breath sounds and crackles in the right lower lung field.

Laboratory test results are as follows:

Arterial blood gas analysis on room air reveals:

A chest radiograph displays a new opacity in the right lower lobe. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old man is evaluated in the emergency department for a 3-day history of high fever, productive cough, and progressive shortness of breath. His medical history includes type 2 diabetes mellitus and hypertension. He does not smoke. His temperature is 38.9°C (102°F), blood pressure is 90/55 mm Hg, pulse is 122/min, and respirations are 28/min. Pulse oximetry shows 88% on room air. Physical examination reveals a patient in severe respiratory distress with diminished breath sounds and coarse crackles over the right lower lung field.

Laboratory results:
Sodium: 140 mEq/L
Potassium: 4.6 mEq/L
Chloride: 102 mEq/L
Bicarbonate: 14 mEq/L
Blood urea nitrogen: 38 mg/dL
Serum creatinine: 1.6 mg/dL
Lactate: 6.1 mmol/L

Arterial blood gas on room air:
pH: 7.18
PaCO2: 38 mm Hg
PaO2: 58 mm Hg

Which of the following accurately describes this patient's acid-base disorders?

A $42$-year-old man is evaluated in the emergency department for a $3$-week history of progressively worsening right upper quadrant abdominal pain, high fevers, and a dry cough. He immigrated from a rural region of Central America $12$ years ago and returned there to visit relatives for a month, arriving back in the United States two months ago. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $110/70$ mm Hg, pulse is $112$/min, and respirations are $24$/min. Physical examination reveals scleral icterus and significant point tenderness over the right lower rib cage. Dullness to percussion is noted at the right lung base.

Arterial blood gas analysis on room air shows:

Additional laboratory studies show:

An abdominal ultrasound demonstrates a solitary, $8$-cm, hypoechoic lesion in the right hepatic lobe. To rule out a pyogenic source, an ultrasound-guided aspiration is performed, yielding a thick, odorless, dark-brown fluid. Gram stain shows abundant leukocytes but no organisms.

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

A $42$-year-old man presents with episodic severe headaches, diaphoresis, and palpitations. His blood pressure is $185/110$ mmHg and heart rate is $112$/min during an episode. A $24$-hour urine fractionated metanephrines test is markedly elevated. A non-contrast CT scan of the abdomen reveals a $4.5$-cm right adrenal mass. He is diagnosed with a pheochromocytoma and is scheduled for surgical resection in $3$ weeks. Arrange the following steps in the correct chronological sequence for the optimal preoperative and operative management of this patient.

A 28-year-old woman, gravida 1, para 0, at 28 weeks gestation is brought to the emergency department due to the sudden onset of severe shortness of breath, orthopnea, and a cough productive of pink, frothy sputum. She recently immigrated to the United States and has had limited prenatal care. Over the past month, she noticed progressive fatigue and palpitations, which she attributed to normal pregnancy. Temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $110/70\text{ mm Hg}$, heart rate is $142\text{/min}$ and irregularly irregular, and respiratory rate is $32\text{/min}$. Pulse oximetry is $86\%$ on room air. Jugular venous distension is prominent. Lung auscultation reveals diffuse bilateral crackles and prolonged expiratory wheezes. Cardiac auscultation demonstrates a loud S1, an early diastolic sound, and a low-pitched, mid-diastolic rumble best heard at the cardiac apex. Arterial blood gas analysis on room air reveals:

$\text{pH}$: $7.30$
$\text{pCO}_2$: $55\text{ mm Hg}$
$\text{pO}_2$: $55\text{ mm Hg}$
$\text{HCO}_3^-$: $26\text{ mEq/L}$

In addition to noninvasive positive pressure ventilation, which of the following is the most appropriate next step in pharmacologic management for this patient?

A $31$-year-old woman comes to the outpatient clinic due to profound fatigue, generalized weakness, and amenorrhea for the past six months. Ten months ago, she delivered a healthy neonate via vaginal delivery. Her delivery was complicated by severe postpartum hemorrhage requiring a massive transfusion protocol and a brief intensive care unit stay. Since the delivery, she has been unable to produce breast milk. Her current blood pressure is $94/58$ mm Hg, and her pulse is $58$/min. Physical examination shows delayed relaxation of deep tendon reflexes and loss of pubic hair.

Laboratory results are as follows:
Serum sodium: $133$ mEq/L
Serum potassium: $4.2$ mEq/L
Thyroid-stimulating hormone (TSH): $1.1$ $\mu$ U/mL (Normal: $0.4$–$4.0$ $\mu$ U/mL)
Free thyroxine (T4): $0.5$ ng/dL (Normal: $0.9$–$1.7$ ng/dL)

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

A 65-year-old man suddenly collapses while walking in the hospital hallway. A physician is the first to arrive and finds the patient unresponsive, with no normal breathing and no palpable carotid pulse. The physician immediately calls for help and requests a resuscitation cart. Arrange the following subsequent steps in the most appropriate chronological sequence for managing this patient's cardiac arrest, assuming the underlying rhythm is ventricular fibrillation.

Match each patient's clinical vignette with the most likely corresponding coagulation profile and mixing study result.

Match the following hereditary gastrointestinal polyposis and cancer syndromes with their defining genetic, clinical, or phenotypic characteristics.

A clinician is reviewing laboratory results for four different patients being evaluated for mineral and bone disorders. Match each laboratory profile with its most likely underlying pathophysiologic diagnosis.

A 38-year-old woman is evaluated in the emergency department for severe, progressive muscle weakness over the past two days. She reports feeling so weak today that she had difficulty standing up from a chair. Her medical history is significant for a 2-year history of dry eyes and dry mouth, for which she uses artificial tears and saliva substitutes. She takes no other medications. Her temperature is 37.0°C (98.6°F), blood pressure is 110/70 mmHg, pulse is 88/min, and respirations are 18/min. Physical examination reveals dry oral mucosa and 4/5 motor strength in the proximal muscles of the upper and lower extremities. Sensation and deep tendon reflexes are intact.

Based on these findings, which of the following is most likely to be found on further evaluation of this patient?

A $65$-year-old man with a $15$-year history of structuring Crohn's disease, chronic obstructive pulmonary disease (COPD), and heart failure with preserved ejection fraction is currently hospitalized. He was admitted two days ago with colicky abdominal pain, obstipation, and bilious vomiting due to a mechanical small bowel obstruction. Initial management included bowel rest, intravenous fluids, and nasogastric decompression.

Over the past four hours, the patient reports a sudden transition from intermittent colicky pain to severe, unremitting diffuse abdominal pain. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $88/54\text{ mm Hg}$, heart rate is $128/\text{min}$, and respiratory rate is $28/\text{min}$. Physical examination reveals a rigid, silent abdomen with exquisite diffuse rebound tenderness and involuntary guarding.

Blood cultures drawn upon admission are currently growing *Escherichia coli* that is susceptible to ceftriaxone, ciprofloxacin, and metronidazole, but resistant to ampicillin.

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

Match each clinical vignette describing a patient with a normal anion gap metabolic acidosis to the most likely corresponding serum and urine laboratory profile.