Internal Medicine

Match the following synovial fluid analysis findings to their most likely corresponding joint disorder.

A 67-year-old man presents to the emergency department with a 2-day history of severe, progressively worsening shortness of breath. He reports coughing up frothy, clear sputum and states he had to sleep sitting in a recliner last night due to a feeling of suffocation when lying flat. His medical history includes long-standing hypertension, type 2 diabetes mellitus, and a 45-pack-year smoking history. He takes amlodipine and metformin.

Temperature is 37.0°C (98.6°F), blood pressure is 185/105 mmHg, pulse is 112/min, and respirations are 28/min. Pulse oximetry is 86% on room air. The patient is using accessory muscles of respiration. Jugular venous distension is present up to the angle of the mandible while the patient is sitting at a 45-degree angle. Lung auscultation reveals diffuse, bilateral end-expiratory wheezes and scattered crackles at the lung bases. Cardiac examination shows a regular rhythm, tachycardia, and a distinct S4 gallop. Bilateral 2+ pitting edema is noted in the lower extremities.

Laboratory studies show:
Leukocyte count: 9,200/mm³
Procalcitonin: $0.03$ ng/mL (normal: $< 0.15$ ng/mL)
Arterial blood gas (room air): pH $7.28$, PaCO $_2$ $55$ mmHg, PaO $_2$ $52$ mmHg, HCO $_3^-$ $25$ mEq/L

Chest radiograph shows cardiomegaly, peribronchial cuffing, enlarged pulmonary veins, and prominent interlobular septal lines without focal opacities.

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

A 64-year-old woman is brought to the emergency department by her husband due to rapidly progressive confusion and a severe headache over the past 14 hours. She has a history of a deceased-donor renal transplant performed three years ago and is currently maintained on a regimen of tacrolimus, mycophenolate mofetil, and low-dose prednisone. On arrival, her temperature is 39.4°C (102.9°F), blood pressure is 98/60 mmHg, heart rate is 118/min, and respiratory rate is 24/min. Physical examination demonstrates marked nuchal rigidity. She is lethargic, oriented only to person, and withdraws appropriately from painful stimuli. Pupils are equal and reactive to light.

Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for the immediate management of this patient.

A 32-year-old man comes to the outpatient clinic reporting a 5-month history of worsening fatigue, cold intolerance, generalized weakness, and decreased libido. He struggles to concentrate at work and frequently takes naps during the day. Eight months ago, he was involved in a high-speed motor vehicle collision that resulted in a severe traumatic brain injury. His hospital course was complicated by increased intracranial pressure requiring a 3-week stay in the intensive care unit. He currently takes no medications. Vital signs show a blood pressure of $105/65$ mm Hg and a pulse of $58$/min. Physical examination reveals a slow, deliberate speech pattern and delayed relaxation phase of the deep tendon reflexes. Visual fields are full to confrontation. Laboratory results are as follows:

Which of the following is the most likely underlying mechanism for this patient's current condition?

In the evaluation of patients with suspected idiopathic inflammatory myopathies, specific autoantibody profiles offer critical prognostic information regarding disease progression, expected complications, and treatment response. Match each myositis-specific autoantibody to its most characteristic clinical phenotype.

An antimicrobial stewardship team is auditing the appropriateness of targeted therapies for various complex infections. Match each specific patient scenario and pathogen profile below with its single most appropriate targeted treatment strategy based on current clinical guidelines.

Match each clinical scenario describing a medication-induced renal, electrolyte, or acid-base abnormality to the corresponding causative pharmacological agent.

A 72-year-old woman presents to the emergency department with a 2-day history of right-sided temporal headache, jaw pain with chewing, and scalp tenderness. This morning, she experienced a 10-minute episode of painless visual loss in her right eye that has since resolved. Her temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $130/80\text{ mmHg}$, and pulse is $84/\text{min}$. Physical examination reveals a prominent, tender right temporal artery with diminished pulsation. Laboratory studies show an erythrocyte sedimentation rate (ESR) of $105\text{ mm/h}$. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 19-year-old male college student is brought to the emergency department by paramedics after experiencing a generalized tonic-clonic seizure that lasted 2 minutes. His roommate reports that the patient had complained of a severe headache, nausea, and high fever for the past 12 hours. His temperature is $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$), blood pressure is $98/60$ mmHg, and heart rate is $124$/min. On physical examination, the patient is lethargic, postictal, and mildly confused. Pronounced nuchal rigidity is present. A non-blanching petechial rash is observed on his bilateral lower extremities.

Arrange the following next steps in management in the most appropriate chronological order for this patient.

An internal medicine team is evaluating a $67$-year-old male who presented to the emergency department with a $5$-day history of progressively worsening shortness of breath, orthopnea, and lower extremity swelling. His medical history includes seropositive rheumatoid arthritis, for which infliximab was added to his methotrexate regimen $4$ months ago due to refractory joint pain. He also has a $35$-pack-year smoking history. On physical examination, his temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $112/74\text{ mm Hg}$, heart rate is $110\text{ /min}$, and respiratory rate is $24\text{ /min}$. Pulse oximetry shows $91\%$ on ambient air. Jugular venous distention is prominent at $45$ degrees. Chest auscultation reveals bilateral basilar crackles and a prominent third heart sound (S3). There is $2+$ bilateral pitting edema extending to the knees. Joint examination shows no active synovitis, warmth, or effusions. Which of the following is the most appropriate next step in the pharmacologic management of this patient's current condition?

A 32-year-old man is admitted to the hospital with a 1-week history of fever, chills, and profound fatigue. He has a history of intravenous drug use and was treated for a skin abscess two months ago. His temperature is 38.8°C (101.8°F), blood pressure is 110/70 mm Hg, and pulse is 108/min. Physical examination reveals a new grade 3/6 holosystolic murmur best heard at the cardiac apex. Transesophageal echocardiography demonstrates a 1.2-cm mobile vegetation on the mitral valve. Three sets of blood cultures obtained on admission grow *Enterococcus faecalis* that is susceptible to ampicillin, vancomycin, gentamicin, and linezolid. The patient is initiated on continuous intravenous ampicillin and every-8-hour intravenous gentamicin. Over the next 48 hours, his clinical symptoms improve and his temperature decreases to 37.9°C (100.2°F). However, laboratory studies show his serum creatinine has increased from 0.8 mg/dL on admission to 2.5 mg/dL, and his urine output has been 350 mL over the past 24 hours. Which of the following is the most appropriate modification to this patient's antimicrobial regimen?

A 22-year-old man presents to the emergency department with a 2-day history of worsening nausea, diffuse abdominal pain, and profound fatigue. He has been excessively thirsty and urinating frequently. He has no significant past medical history. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $98/60\text{ mmHg}$, heart rate is $118/\text{min}$, and respiratory rate is $24/\text{min}$ with deep, rapid breaths. Mucous membranes are dry. The abdomen is diffusely tender but soft without rebound. Point-of-care testing reveals a capillary blood glucose of $480\text{ mg/dL}$ and large blood ketones. An arterial blood gas shows a pH of $7.18$. The patient is diagnosed with an acute endocrine emergency.

Arrange the following management steps in the most appropriate algorithmic sequence for the acute stabilization and definitive therapy of this patient.

During morning rounds, a $58$-year-old male inpatient is evaluated on postoperative day $7$ following an open partial gastrectomy for gastric adenocarcinoma. The patient reports new-onset severe right calf pain and swelling that began earlier this morning, along with mild shortness of breath. His medications include pantoprazole and subcutaneous unfractionated heparin, which was started postoperatively for venous thromboembolism prophylaxis. Temperature is $37.8^\circ \text{C}$ ($100.0^\circ \text{F}$), blood pressure is $135/85 \text{ mmHg}$, pulse is $105/\text{min}$, and respirations are $18/\text{min}$. Pulse oximetry shows $96\%$ on room air. Physical examination reveals a swollen, erythematous, and tender right calf. Lungs are clear to auscultation bilaterally.

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

A male patient, aged $48$, presents to an ambulatory care facility reporting a $6$-week history of a persistent cough and episodes of blood-tinged sputum. Over this same period, he has experienced recurrent nosebleeds, intermittent low-grade fevers, and profound fatigue. His medical history includes major depressive disorder, for which he has been taking citalopram for the last $3$ years. He does not smoke or use illicit drugs.

Vital signs show a temperature of $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), blood pressure of $152/96\text{ mm Hg}$, heart rate of $88/\text{min}$, and respiratory rate of $16/\text{min}$.

Examination of the nasal cavity reveals mucosal ulcerations and adherent crusts. Auscultation of the lungs demonstrates scattered crackles in the right middle lung field.

Laboratory studies reveal:
Hemoglobin: $10.2\text{ g/dL}$
Leukocyte count: $11,500/\text{mm}^3$
Blood urea nitrogen: $34\text{ mg/dL}$
Serum creatinine: $2.2\text{ mg/dL}$ (was $0.8\text{ mg/dL}$ during a routine checkup $8$ months ago)
Urinalysis: $2+$ protein, large blood, $>50\text{ red blood cells/hpf}$, and several red blood cell casts.

A radiograph of the chest demonstrates a $3.5\text{-cm}$ cavitary lesion in the right middle lobe with thick walls.

Based on the most likely diagnosis, which of the following is the most appropriate next step in evaluation or management?

A 32-year-old woman with a history of systemic lupus erythematosus and recurrent kidney stones is evaluated in the clinic for progressive, generalized muscle weakness over the past two weeks. She reports difficulty climbing stairs and rising from a seated position. She denies diarrhea, vomiting, fever, or recent illnesses. Her vital signs are within normal limits. Physical examination reveals symmetric proximal muscle weakness in the bilateral lower extremities with diminished deep tendon reflexes.

Laboratory evaluation shows the following:

Serum chemistry:
Sodium: 140 mEq/L
Potassium: 2.6 mEq/L
Chloride: 114 mEq/L
Bicarbonate: 14 mEq/L
Blood urea nitrogen: 16 mg/dL
Creatinine: 0.9 mg/dL

Arterial blood gas (room air):
pH: 7.26
pCO2: 29 mm Hg
pO2: 96 mm Hg

Urinalysis reveals a pH of 6.8 with no protein or blood.

Based on the provided laboratory data, which of the following statements is most accurate regarding this patient's current acid-base physiological state?

Match each clinical vignette describing a systemic fungal infection with the most appropriate first-line pharmacotherapy.

Emergency medical services transport a $65$-year-old man from a long-term care facility to the hospital due to acute-onset confusion, fever, and severe abdominal pain. His past medical history is significant for alcohol-associated cirrhosis with refractory ascites, which is managed with high-dose furosemide and spironolactone. Upon arrival, his temperature is $39.2^\circ$ C ($102.6^\circ$ F), blood pressure is $80/50$ mm Hg, heart rate is $122$/min, and respiratory rate is $28$/min. Abdominal examination reveals severe distension, diffuse tenderness, and involuntary guarding. Laboratory results are as follows:

Based on the clinical presentation and laboratory results, which of the following sets of acid-base disorders is present in this patient?

Match each characteristic physical examination or radiographic hand finding to the most likely underlying rheumatologic or musculoskeletal condition.

A 54-year-old man with a history of severe alcohol use disorder is admitted to the intensive care unit with acute necrotizing pancreatitis. Over the past 72 hours, he has experienced intractable vomiting and an inability to tolerate any oral intake. On physical examination, the patient is lethargic. Mucous membranes are extremely dry, and skin turgor is poor. Vital signs show a blood pressure of 88/50 mmHg, a pulse of 118/min, and a respiratory rate of 22/min.

Laboratory studies reveal the following:

The physician evaluates the patient's acid-base status. Assuming a baseline normal anion gap of 12 mEq/L and a normal serum bicarbonate of 24 mEq/L, what is the patient's calculated delta ratio ($\Delta\text{AG}/\Delta\text{HCO}_3^-$) after appropriately correcting the anion gap for his hypoalbuminemia?

A $45$-year-old woman is brought to the emergency department by her husband due to a severe, throbbing headache, blurred vision, and worsening shortness of breath over the past $48$ hours. She was diagnosed with diffuse cutaneous systemic sclerosis $3$ years ago. Her home medications include mycophenolate mofetil. She recently visited an urgent care clinic for dysuria, and a urine culture sent at that time grew $>100,000$ CFU/mL of *Escherichia coli* susceptible to amoxicillin, nitrofurantoin, and ceftriaxone. She has not yet started antibiotic therapy.

Today, her temperature is $37.1^\circ C$ ($98.8^\circ F$), blood pressure is $225/125$ mmHg, pulse is $110$/min, and respirations are $26$/min. Oxygen saturation is $93\%$ on room air. Physical examination reveals taut, thickened skin over the face, chest, and upper extremities. Funduscopic examination demonstrates bilateral papilledema and flame-shaped hemorrhages. Lung auscultation reveals fine bibasilar crackles.

Laboratory results are as follows:

Arterial blood gas on room air:
pH: $7.32$
pCO₂: $30$ mmHg
pO₂: $72$ mmHg
HCO₃⁻: $15$ mEq/L

Peripheral blood smear shows numerous schistocytes.

Which of the following is the most appropriate initial step in the management of this patient's condition?