Internal Medicine

A 34-year-old man comes to the urgent care clinic in early June because he found a tick attached to his left groin. He recently returned from a 3-day camping trip in the woods of Connecticut. The tick is still firmly attached to his skin and appears visibly engorged. He has no rash, fever, or joint pain. The patient asks the physician to safely manage the tick and prevent any potential diseases.

Arrange the following management steps in the most appropriate chronological order.

Hepatitis B virus (HBV) serologic testing is crucial for determining a patient's exact infectious status and immunity. Different combinations of surface and core antigens, along with their respective antibodies, reflect specific phases of the disease. Match each HBV serologic profile below to its most accurate clinical interpretation.

A 26-year-old individual is brought to the emergency department experiencing a severe exacerbation of asthma. Upon arrival, the patient exhibits significant work of breathing, use of accessory muscles, and bilateral widespread wheezing. Despite initial treatments, the patient's condition progressively worsens over several hours, showing signs of impending respiratory failure. Arrange the following therapeutic interventions in the correct chronological sequence according to standard step-up management, from the immediate initial therapy to the final rescue intervention.

A $71$-year-old male is evaluated in the emergency department due to severe shortness of breath that has progressively worsened over the last two days. The patient reports that his breathing becomes especially difficult when he lies flat in bed, requiring him to sleep in a recliner chair. His medical history includes hypertension and a $45$-pack-year smoking history. He currently takes amlodipine. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $172/98$ mmHg, pulse is $112$/min, and respirations are $28$/min. Pulse oximetry shows $89\%$ on room air. Physical examination reveals an anxious patient in mild respiratory distress. Auscultation of the lungs demonstrates diffuse, bilateral expiratory wheezes and a prolonged expiratory phase. Cardiac auscultation reveals a regular tachycardia; an extra, low-pitched heart sound is heard shortly after the second heart sound at the cardiac apex. The apical impulse is displaced laterally. There is trace bilateral pitting edema of the lower extremities. Bedside chest radiography shows an enlarged cardiac silhouette, prominent pulmonary vasculature, and prominent septal lines. Which of the following is the most likely primary underlying mechanism for this patient's acute respiratory symptoms?

A 54-year-old woman is brought to the emergency department due to the sudden onset of severe, tearing chest pain that radiates to her upper back. The pain began 45 minutes ago while she was lifting heavy furniture. She has a history of poorly controlled hypertension and tobacco use. Her blood pressure is 210/115 mm Hg in the right arm and 175/95 mm Hg in the left arm. Her pulse is 114/min and regular. Physical examination reveals a new decrescendo diastolic murmur heard best at the right upper sternal border. Electrocardiography shows sinus tachycardia with left ventricular hypertrophy, but no acute ischemic changes. Initial portable chest radiography demonstrates a widened mediastinum. Arrange the following management steps in the most appropriate chronological order.

A 62-year-old woman is evaluated in the intensive care unit on postoperative day 6 following an exploratory laparotomy for a perforated appendix. She remains intubated and mechanically ventilated. Yesterday, she developed a temperature of $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), increased purulent endotracheal secretions, and an increased oxygen requirement. A chest radiograph showed a new right lower lobe consolidation. Empiric intravenous vancomycin and piperacillin-tazobactam were initiated after obtaining blood and bronchoalveolar lavage (BAL) cultures.

Today, her temperature is $37.5^\circ\text{C}$ ($99.5^\circ\text{F}$). Blood pressure is $118/72$ mm Hg and pulse is $88$/min.

The BAL culture from yesterday is now growing $>10^5$ CFU/mL of *Haemophilus influenzae*. Susceptibility testing indicates the organism is sensitive to ceftriaxone, levofloxacin, and piperacillin-tazobactam. Blood cultures show no growth.

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

A 54-year-old female is brought to the emergency department by her husband due to progressive lethargy and confusion over the past $24$ hours. Her husband reports she has had severe, large-volume, watery diarrhea for the last $5$ days. She has not urinated since yesterday. Vital signs include a temperature of $37.2^\circ$ C ($99.0^\circ$ F), blood pressure of $82/50$ mm Hg, heart rate of $132$/min, and respiratory rate of $26$/min. Physical examination reveals delayed capillary refill, dry mucous membranes, and cold extremities.

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

While working in the urgent care clinic, a physician evaluates a $32$-year-old female patient complaining of a racing heartbeat that started abruptly while she was reading a book. She reports no chest discomfort, dyspnea, or lightheadedness. Her blood pressure is $122/78$ mmHg, and her radial pulse is rapid and weak. A $12$-lead electrocardiogram is obtained and displays a perfectly regular tachycardia at $175$ beats per minute with narrow QRS complexes and no discernible P waves.

Assuming she remains hemodynamically stable but the arrhythmia does not resolve with initial interventions, arrange the following management steps in the standard chronological sequence for this condition, concluding with definitive long-term therapy.

A 32-year-old woman comes to the urgent care clinic 8 hours after sustaining a bite to her right hand from a neighbor's cat. The incident occurred while she was attempting to feed the animal. Immediately after the bite, she washed the hand with soap and warm water. Her past medical history is unremarkable, and she takes no daily medications. She received a tetanus, diphtheria, and pertussis (Tdap) booster vaccination 2 years ago. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, and pulse is 74/min. Physical examination of the right hand reveals three deep puncture wounds on the dorsal surface. There is surrounding erythema extending approximately 1 cm from the wounds, accompanied by mild localized edema and tenderness to palpation. There is no active bleeding or purulent discharge. Sensation and active range of motion are intact, although movement exacerbates the pain. The wounds are copiously irrigated. Which of the following is the most appropriate pharmacotherapy for this patient?

A $68$-year-old woman with a history of heart failure with preserved ejection fraction (HFpEF) and hypertension is brought to the emergency department by her daughter due to $4$ days of profound, watery diarrhea and generalized weakness. She reports having up to $10$ to $12$ bowel movements a day since returning from a cruise.

Vital signs are as follows:
- Temperature: $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$)
- Heart rate: $122/\text{min}$
- Blood pressure: $82/50$ mmHg
- Respiratory rate: $26/\text{min}$
- Oxygen saturation: $96\%$ on room air

Physical examination reveals a lethargic patient. Her mucous membranes are extremely dry, and capillary refill time is $4$ seconds. Jugular venous pressure is undetectable. Lungs are clear to auscultation bilaterally. Cardiac examination reveals regular tachycardia with no murmurs, rubs, or gallops. The abdomen is soft, non-distended, and has hyperactive bowel sounds with mild, diffuse tenderness to deep palpation. There is no guarding or rebound tenderness.

Laboratory results are as follows:

Arterial blood gas (on room air):
- pH: $7.25$
- $pCO_2$: $26$ mmHg
- $pO_2$: $92$ mmHg

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

While staffing the cardiac intensive care unit, a physician assumes care of a $66$-year-old male admitted directly from the prehospital setting. Paramedics were called after the patient experienced the sudden onset of crushing retrosternal chest pain and diaphoresis while resting at home. A prehospital $12$-lead electrocardiogram demonstrated marked ST-segment elevations in leads II, III, and aVF, with reciprocal depressions in leads I and aVL. Upon arrival, the patient appears ashen and complains of persistent chest discomfort and profound lightheadedness. Vital signs are temperature $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure $82/50\text{ mm Hg}$, heart rate $54\text{/min}$ (sinus rhythm), and respiratory rate $16\text{/min}$. Pulse oximetry is $96\%$ on ambient air. Physical examination reveals elevated jugular venous pressure with prominent x and y descents. The lung fields are completely clear to auscultation bilaterally. Cardiac auscultation reveals a regular rhythm with no murmurs, though a right-sided S4 is audible. Point-of-care laboratory testing shows an arterial pH of $7.32$, $\text{pCO}_2$ of $36\text{ mm Hg}$, and a serum lactate of $3.8\text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient?

Match the following clinical scenarios with their most likely characteristic finding on microscopic urinalysis.

A $64$-year-old man with a history of type $2$ diabetes mellitus and hypertension is hospitalized due to a $5$-day history of high fever, right upper quadrant abdominal pain, and profound fatigue. On admission, his temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $105/65\text{ mmHg}$, and pulse is $112/\text{min}$. Physical examination is notable for hepatomegaly and localized tenderness over the right upper quadrant. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ with a left shift, and an alkaline phosphatase level of $450\text{ U/L}$. Contrast-enhanced abdominal CT reveals a $7\text{-cm}$ multiloculated fluid collection in the right hepatic lobe. A chest radiograph demonstrates a small, right-sided pleural effusion without infiltrates.

The patient undergoes successful CT-guided percutaneous drain placement for the hepatic collection, and empiric intravenous piperacillin-tazobactam and vancomycin are initiated. Three days later, he is hemodynamically stable and his fever has resolved. The right-sided pleural effusion is unchanged, and he has no respiratory distress. Abscess fluid and blood cultures both grow *Streptococcus intermedius*. Susceptibility testing shows the organism is susceptible to penicillin, ceftriaxone, and cefepime, but resistant to clindamycin.

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

A 62-year-old man is hospitalized for severe, unremitting lower back pain and fever. His temperature is 38.8°C (101.8°F), blood pressure is 130/80 mm Hg, and pulse is 98/min. Physical examination reveals focal tenderness to palpation over the L4 and L5 spinous processes. Magnetic resonance imaging of the lumbar spine confirms L4-L5 vertebral osteomyelitis. Blood cultures are drawn, and the patient is empirically started on intravenous vancomycin and ceftriaxone. On day 3 of hospitalization, he is clinically stable and afebrile. Final blood culture results return positive for Staphylococcus aureus. Susceptibility testing shows resistance to penicillin, and susceptibility to oxacillin, cefazolin, vancomycin, and daptomycin. Which of the following is the most appropriate next step in antibiotic therapy?

A 27-year-old woman is brought to the emergency department by her roommate due to severe, progressively worsening shortness of breath over the past 2 days. She has a history of severe persistent asthma and has been using her albuterol inhaler every 2 hours at home without relief. On arrival, the patient appears lethargic and speaks only in single words. Her temperature is 37.1°C (98.8°F), blood pressure is 112/68 mmHg, heart rate is 132/min, and respiratory rate is 34/min. Pulse oximetry shows an oxygen saturation of 88% on room air.

Physical examination demonstrates marked use of accessory muscles of respiration. Auscultation of the lungs reveals poor air movement bilaterally with very faint expiratory wheezing.

An arterial blood gas analysis on room air shows:

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

A $59$-year-old male with a history of alcohol-associated cirrhosis is evaluated in the hospital. Three days ago, he was admitted with a temperature of $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), diffuse abdominal tenderness, and lethargy. Diagnostic paracentesis on admission yielded ascitic fluid with a neutrophil count of $550/\mu\text{L}$. Given his recent hospitalization for pneumonia one month ago, he was empirically started on intravenous meropenem along with intravenous albumin.

Today, the patient is alert and fully oriented. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $112/70\text{ mmHg}$, and pulse is $82/\text{min}$. The abdomen is distended with shifting dullness but is no longer tender to palpation.

Laboratory studies today show:

The ascitic fluid culture from admission now grows *Escherichia coli*. Susceptibility testing demonstrates that the organism is resistant to ampicillin, but susceptible to ceftriaxone, cefotaxime, piperacillin-tazobactam, and meropenem.

Based on the patient's clinical improvement and laboratory data, which of the following is the most appropriate next step in management?

A 58-year-old man with a history of right-sided cavitary pulmonary tuberculosis is brought to the emergency department after coughing up approximately 800 mL of bright red blood over the last 12 hours. Upon arrival, he is coughing continuously and expectorating large volumes of blood. He appears pale and is in severe respiratory distress. His blood pressure is 90/60 mmHg, heart rate is 122/min, and respiratory rate is 28/min. Oxygen saturation is 85% on room air. Auscultation reveals coarse crackles predominantly over the right upper lung field. Arrange the following interventions in the most appropriate sequential order for the acute management of this patient's life-threatening condition.

Match each patient's clinical vignette and laboratory profile to the most accurate underlying pathophysiologic mechanism describing their calcium and bone metabolism disorder.

A 68-year-old man is brought to the emergency department by emergency medical services due to severe, progressively worsening shortness of breath that began 4 hours ago. He has a history of essential hypertension, type 2 diabetes mellitus, and a 40-pack-year smoking history. He has not seen a physician in three years and does not take any medications currently. Upon arrival, the patient is agitated, diaphoretic, and unable to speak in full sentences. He is sitting upright and leaning forward. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $215/115\text{ mmHg}$, heart rate of $122/\text{min}$, and respiratory rate of $32/\text{min}$. Oxygen saturation is $85\%$ on room air. Jugular venous pulsation is visible $10\text{ cm}$ above the sternal angle. Pulmonary auscultation reveals prolonged expiration with diffuse, loud, bilateral wheezing; no crackles are heard. Cardiac auscultation reveals a regular tachycardia and an extra low-frequency diastolic heart sound heard immediately after S2. The point of maximal impulse is displaced laterally. Bedside electrocardiogram demonstrates sinus tachycardia with voltage criteria for left ventricular hypertrophy. Which of the following is the most appropriate initial pharmacotherapy for this patient?

A $45$-year-old man is brought to the emergency department by emergency medical services after a witnessed generalized tonic-clonic seizure on the street. Bystanders report the seizure lasted approximately $3$ minutes. The patient has a known history of severe alcohol use disorder and was found unresponsive outside a liquor store. On arrival, he is lethargic and arousable only to painful stimuli. His temperature is $36.8^\circ C$ ($98.2^\circ F$), blood pressure is $112/72$ mm Hg, heart rate is $108$/min, and respiratory rate is $10$/min. Pulse oximetry shows $92\%$ on room air.

Laboratory studies show:

Arterial blood gas on room air:

Which of the following best explains this patient's acid-base findings?