Internal Medicine

A $64$-year-old man comes to the clinic with a $3$-week history of worsening joint pain, morning stiffness lasting over an hour, and low-grade fevers. He also reports sharp, left-sided chest pain that worsens with deep inspiration and coughing. His medical history includes heart failure with reduced ejection fraction, hypertension, and bipolar disorder. Five months ago, he was hospitalized for a heart failure exacerbation, and his medical regimen was adjusted. Current medications include carvedilol, spironolactone, hydralazine, isosorbide dinitrate, and lithium. Temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, and heart rate is $78/\text{min}$. Physical examination reveals a pleural friction rub at the left lung base. There is symmetric swelling, warmth, and tenderness of the proximal interphalangeal joints and wrists bilaterally. Laboratory testing shows normal C3 and C4 complement levels, and a positive antinuclear antibody (ANA) titer of $1:640$ with a homogeneous pattern. Anti-double-stranded DNA (anti-dsDNA) antibodies are negative. Which of the following is the most appropriate next step in management?

Match each clinical exposure scenario with the most appropriate post-exposure prophylaxis or initial preventive management strategy.

A 35-year-old woman presents to the emergency department with a sudden onset of severe epistaxis, diffuse petechiae, and profound fatigue. Her initial complete blood count reveals a leukocyte count of 24,000/mm³, hemoglobin of 7.8 g/dL, and a platelet count of 15,000/mm³. Based on the acuity and bleeding diathesis, there is a high clinical suspicion for acute promyelocytic leukemia (APL). Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for the optimal management of this patient.

A 42-year-old woman comes to the physician for evaluation of a lump in her neck that she noticed two weeks ago. She has no neck pain, hoarseness, or difficulty swallowing. Over the past two months, she has experienced unintentional weight loss, frequent palpitations, and increased sweating. Vital signs show a heart rate of 110/min and a blood pressure of 135/85 mm Hg. Physical examination reveals warm, moist skin and a fine tremor of the outstretched hands. Palpation of the anterior neck demonstrates a 3-cm, firm, non-tender, mobile mass in the right lobe of the thyroid gland. A targeted bedside neck ultrasound confirms a 3.2-cm solid, hypoechoic nodule with regular margins and no microcalcifications. Laboratory testing reveals:

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

An 82-year-old male resident of a skilled nursing facility is brought to the outpatient clinic for a routine follow-up appointment. His medical history is significant for benign prostatic hyperplasia, type 2 diabetes mellitus, and vascular dementia. The patient relies on a chronic indwelling urinary catheter due to refractory urinary retention. His caregiver reports that he has been at his baseline mental and physical status, eating well, and participating in daily activities without issue. The patient denies any fever, chills, flank pain, or suprapubic discomfort. Vital signs are temperature 37.1°C (98.8°F), blood pressure 130/80 mmHg, pulse 78/min, and respiratory rate 14/min. Physical examination reveals a soft, non-tender abdomen and no costovertebral angle tenderness. As part of a recent facility protocol, a routine urinalysis was performed yesterday which showed 50 white blood cells per high-power field, positive leukocyte esterase, and positive nitrites. Today, the urine culture results return showing >10^5 CFU/mL of multidrug-resistant Pseudomonas aeruginosa. Which of the following is the most appropriate next step in management?

A 45-year-old man presents to the emergency department with epistaxis, bleeding gums, and easy bruising for the past three days. A complete blood count reveals a hemoglobin of $8.2 \text{ g/dL}$, a leukocyte count of $28,000/\mu L$, and a platelet count of $18,000/\mu L$. Coagulation studies demonstrate a prolonged prothrombin time (PT), prolonged activated partial thromboplastin time (aPTT), profoundly low fibrinogen, and elevated D-dimer. A peripheral blood smear shows atypical cells with abundant cytoplasm, heavy azurophilic granulation, and bundles of Auer rods.

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

An 82-year-old woman is evaluated in her long-term care facility for a 1-day history of acute confusion and agitation. She has a history of advanced Alzheimer dementia, hypertension, and osteoarthritis. According to the nursing staff, she has been combative during morning care and is disoriented to place, which represents a significant change from her baseline behavior. She has not exhibited any cough, vomiting, or diarrhea. Vital signs are temperature 37.1°C (98.8°F), blood pressure 138/86 mm Hg, pulse 82/min, and respirations 14/min. Physical examination shows dry mucous membranes and decreased skin turgor. Cardiopulmonary examination is unremarkable. The abdomen is soft and non-tender; there is no suprapubic or costovertebral angle tenderness.

Laboratory results:
Serum sodium: 149 mEq/L
Blood urea nitrogen: 38 mg/dL
Serum creatinine: 1.3 mg/dL (baseline: 0.9 mg/dL)

Urinalysis:
Color: Cloudy yellow
Leukocyte esterase: Positive
Nitrites: Positive
White blood cells: 25/hpf
Bacteria: Numerous

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

A 55-year-old man who has been mechanically ventilated for 5 days in the intensive care unit develops a new fever of $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), increased purulent endotracheal secretions, and worsening oxygenation requiring an increase in fraction of inspired oxygen ($FiO_2$) from $0.40$ to $0.60$. Physical examination reveals coarse crackles in the right lower lung field. Laboratory studies show a leukocyte count of $16,000/\text{mm}^3$. A portable chest radiograph reveals a new right lower lobe consolidation. The patient is hemodynamically stable. The clinical team suspects ventilator-associated pneumonia (VAP). Arrange the following management steps in the most appropriate sequential order for this patient.

A 29-year-old woman is evaluated for a four-month history of worsening fatigue, unquenchable thirst, and passing large volumes of pale urine, including waking 4 to 5 times a night to urinate. She also reports clear, bilateral nipple discharge and has not had a menstrual period for six months. Her menstrual cycles were previously regular. She takes no medications and has no history of head trauma or recent pregnancy. Vital signs are within normal limits. Physical examination reveals a visual field defect in the bilateral temporal peripheries. Deep tendon reflexes exhibit a delayed relaxation phase.

Laboratory studies show:
Serum sodium: 147 mEq/L
Serum prolactin: 78 ng/mL (Normal: 4–23)
Thyroid-stimulating hormone (TSH): 1.2 $\mu$ U/mL (Normal: 0.5–5.0)
Free thyroxine (T4): 0.5 ng/dL (Normal: 0.9–1.7)
Urine osmolality: 140 mOsm/kg H $_2$ O

Which of the following mechanisms best explains this patient's clinical and laboratory findings?

A 68-year-old man presents to the outpatient clinic reporting a three-week history of worsening swelling in his lower extremities and an uncomfortable sensation of abdominal fullness. He has a 45-pack-year smoking history and was diagnosed with severe chronic obstructive pulmonary disease (COPD) five years ago, for which he takes inhaled bronchodilators and corticosteroids. Vital signs show a blood pressure of 118/76 mmHg, a heart rate of 88/min, and an oxygen saturation of 89% on room air. Physical examination reveals prominent jugular venous distention and a palpable parasternal heave. Auscultation of the chest demonstrates distant breath sounds with a prolonged expiratory phase, but no crackles are heard. A holosystolic murmur is auscultated at the lower left sternal border that increases in intensity with inspiration. Tender hepatomegaly is noted on abdominal palpation. Which of the following pathophysiologic mechanisms is the most direct cause of this patient's cardiovascular findings?

A 42-year-old man presents to the emergency department with sharp, pleuritic chest pain and worsening dyspnea 10 days after a presumed viral upper respiratory infection. While in the emergency department, he suddenly becomes lightheaded. His blood pressure drops to 85/50 mm Hg, and his pulse increases to 115/min. Physical examination reveals distended jugular veins and distant, muffled heart sounds. Bedside echocardiography confirms a large pericardial effusion. Arrange the following pathophysiological events in the chronological order they occur during the development of this patient's acute hemodynamic compromise.

A 54-year-old man with a history of treated pulmonary tuberculosis is brought to the emergency department after coughing up approximately 800 mL of bright red blood over the last 2 hours. On arrival, he is in severe respiratory distress and is coughing continuously. He is lethargic and confused. Blood pressure is 90/60 mm Hg, pulse is 125/min, and respirations are 32/min. Pulse oximetry shows 84% on room air. Auscultation reveals coarse crackles and diminished breath sounds over the right upper and middle lung fields, with clear breath sounds on the left. A chest radiograph demonstrates a right upper lobe cavitary lesion with new surrounding consolidation. Arrange the following management steps in the correct sequential order from first to last.

Match each jugular venous pulse (JVP) waveform abnormality with the cardiac pathology it most specifically represents.

A 22-year-old man is brought to the emergency department after a motor vehicle collision. He is in severe respiratory distress. Vital signs show a blood pressure of 82/50 mm Hg, pulse of 135/min, and oxygen saturation of 84% on room air. Examination shows distended neck veins, tracheal deviation to the left, and absent breath sounds over the right hemithorax. Arrange the following management steps in the most appropriate chronological order.

A 24-year-old woman presents to the clinic with a 3-day history of frequent, watery, nonbloody diarrhea, accompanied by mild diffuse abdominal cramping and nausea. She has not experienced fever, chills, or vomiting. She recently returned from a 2-day weekend camping trip in a nearby state park. She has no significant past medical history and takes no medications. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, and pulse is 82/min. Physical examination shows normal skin turgor and moist mucous membranes. The abdomen is soft and nontender with hyperactive bowel sounds. Which of the following is the most appropriate next step in the management of this patient?

A male patient, aged $42$, presents to a gastroenterology practice for a follow-up evaluation. He complains of a persistent sensation of abdominal fullness and an inability to finish normal-sized meals, which began three weeks ago. He also notes experiencing intermittent waves of nausea without vomiting. The patient was hospitalized eight weeks prior for a severe episode of acute pancreatitis secondary to heavy alcohol consumption, which was managed with supportive care. His vital signs are currently within normal limits, and he is afebrile. Physical examination is notable for a palpable, non-tender fullness in the epigastric region. Laboratory test results show a normal leukocyte count, normal serum lipase, and normal liver function panels. A contrast-enhanced abdominal computed tomography scan demonstrates a $9$ cm unilocular, well-circumscribed, thin-walled fluid collection located in the lesser sac, tightly abutting the posterior wall of the stomach. There is no solid debris or free air within the collection. Based on these clinical and radiographic findings, which of the following is the most appropriate next step in management?

Match each clinical presentation of an oncologic emergency with the most appropriate next step in management.

Match each clinical presentation of an immunocompromised patient with HIV to the most appropriate initial targeted antimicrobial regimen.

A 71-year-old man is brought to the emergency department by emergency medical services due to severe shortness of breath and altered mental status. His past medical history is significant for severe chronic obstructive pulmonary disease (COPD), cor pulmonale, and hypertension. Home medications include inhaled tiotropium, oral furosemide, and lisinopril. His wife reports he has experienced a productive cough with green sputum and a fever for the past three days.

Vital signs include a temperature of 38.5°C (101.3°F), blood pressure of 82/50 mm Hg, heart rate of 118/min, and respiratory rate of 28/min. Oxygen saturation is 84% on room air. On physical examination, he is somnolent but arousable. Jugular venous distention is present. Lung auscultation reveals bilateral diffuse wheezes and coarse rhonchi.

Laboratory results are as follows:

Based on the laboratory results, which of the following best describes this patient's primary acid-base disturbances?

A $41$-year-old woman is brought to the emergency department by her husband due to severe dizziness, intractable vomiting, and confusion that started earlier today. Two weeks ago, the patient was diagnosed with primary hypothyroidism after presenting with profound fatigue, muscle aches, and unintended weight loss. At that time, her thyroid-stimulating hormone level was $18.5$ mU/L (Normal: $0.4-4.0$ mU/L) and free thyroxine was $0.5$ ng/dL (Normal: $0.8-1.8$ ng/dL). She was prescribed levothyroxine $100$ $\mu$ g daily, which she has been taking as directed. The patient's medical history is significant for vitiligo. She does not take any other medications.

On physical examination, temperature is $37.6^\circ$ C ($99.7^\circ$ F), blood pressure is $78/48$ mmHg, heart rate is $118$/min, and respiratory rate is $20$/min. The patient appears lethargic. Skin examination reveals depigmented patches on her hands and face, as well as noticeable hyperpigmentation of the palmar creases and oral mucosa.

Which of the following best explains the mechanism of this patient's acute clinical deterioration?