Internal Medicine

Match each clinical presentation to its most likely cause of secondary hypertension.

A 42-year-old man is brought to the emergency department due to progressive fatigue, easy bruising, and bleeding gums for the past week. His temperature is 37.8°C (100.0°F), blood pressure is 110/70 mm Hg, and pulse is 98/min. Physical examination shows diffuse petechiae over the extremities and oozing from the gingiva.

Laboratory studies show:

A peripheral blood smear reveals numerous atypical promyelocytes with folded nuclei and multiple needle-like intracytoplasmic inclusions (Auer rods).

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

Match each clinical vignette describing an adverse pharmacologic event to the most accurate underlying pharmacokinetic or pharmacodynamic mechanism of drug interaction.

A 42-year-old woman is brought to the emergency department due to severe agitation, palpitations, and confusion. Her family reports she has a history of Graves disease but stopped taking her prescribed medications three months ago. On presentation, her temperature is 39.4°C (102.9°F), blood pressure is 160/70 mm Hg, and pulse is 145/min and irregular. Physical examination reveals a diffuse, nontender goiter, bilateral proptosis, a fine resting tremor, and a hyperdynamic precordium. ECG demonstrates atrial fibrillation with a rapid ventricular response. She is diagnosed with thyroid storm based on clinical criteria.

Arrange the following management steps in the correct chronological sequence for this patient, from the initial acute intervention to definitive long-term therapy.

A 52-year-old man was admitted to the hospital 3 days ago for acute pyelonephritis. At the time of admission, he presented with a temperature of $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), left-sided costovertebral angle tenderness, and leukocytosis. He was empirically started on intravenous piperacillin-tazobactam. Currently, he has been afebrile for 24 hours, his flank pain has largely resolved, and he is eating a regular diet without nausea. The urine culture obtained on admission has grown $>100,000\text{ CFU/mL}$ of *Escherichia coli*. Antimicrobial susceptibility testing indicates the isolate is susceptible to trimethoprim-sulfamethoxazole, levofloxacin, ceftriaxone, and piperacillin-tazobactam. Which of the following is the most appropriate next step in the management of this patient's infection?

A $24$-year-old woman comes to the clinic reporting progressive fatigue and generalized weakness that has worsened over the past three months. She notes that her menstrual cycles are regular but feature heavy bleeding, frequently lasting up to $8$ days with the passage of large clots. She takes no daily medications and has no chronic medical conditions. Vital signs show a blood pressure of $112/68$ mm Hg and a heart rate of $102$/min. Physical examination is notable for pale conjunctivae and a regular tachycardia without murmurs.

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

Paramedics rush a $55$-year-old female to the resuscitation bay due to sudden-onset severe dyspnea and a home blood pressure reading that exceeded her monitor's maximum limit. She has a four-year history of diffuse cutaneous systemic sclerosis and mild asthma. Ten days ago, an urgent care physician prescribed a course of high-dose oral prednisone for a suspected asthma exacerbation.

Upon arrival, her temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $225/120\text{ mm Hg}$, pulse is $112/\text{min}$, and respiratory rate is $28/\text{min}$. Oxygen saturation is $88\%$ on room air. Physical examination reveals diffuse skin thickening over her extremities, chest, and face. Jugular venous distension is present, and auscultation reveals bilateral basilar lung crackles. Cardiac examination shows a regular tachycardia with a prominent $S_4$ gallop.

Laboratory results:
- Hemoglobin: $8.4\text{ g/dL}$ (baseline $12.1\text{ g/dL}$)
- Platelets: $78,000/\text{mm}^3$
- Creatinine: $3.4\text{ mg/dL}$ (baseline $0.8\text{ mg/dL}$)
- Peripheral blood smear: 3 to 4 schistocytes per high-power field

Arterial blood gas (room air):
- pH: $7.32$
- $PaCO_2$: $30\text{ mm Hg}$
- $HCO_3^-$: $15\text{ mEq/L}$

Thyroid function tests reveal a TSH of $2.2\text{ \mu U/mL}$ and a free T4 of $0.6\text{ ng/dL}$ (normal: $0.8-1.8\text{ ng/dL}$). A sputum culture obtained three days ago during a routine pulmonology visit has just resulted, showing heavy growth of penicillin-sensitive *Streptococcus pneumoniae*.

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

Review the brief patient descriptions below. Match each clinical scenario with its most likely hematologic diagnosis.

A 68-year-old man presents to his primary care physician reporting progressive fatigue, generalized weakness, and a persistent "tingling" sensation in both of his feet that began four months ago. He has a history of type 2 diabetes mellitus, which is currently managed with metformin. His vital signs are within normal limits. Physical examination demonstrates pale conjunctivae, a smooth and erythematous tongue, and decreased vibratory sensation in the bilateral lower extremities. Laboratory analysis reveals a hemoglobin of 9.6 g/dL, a mean corpuscular volume of 115 fL, a white blood cell count of 4,500/mm³, and a platelet count of 140,000/mm³. Which of the following is the most appropriate next step in the diagnostic workup for this patient?

On the oncology ward, nurses urgently call for a physician to evaluate a 48-year-old male patient. He was admitted 48 hours earlier to begin R-CHOP therapy for stage IV diffuse large B-cell lymphoma. Over the last several hours, he has developed profound leg weakness, palpitations, and decreased urine output. Vital signs show a heart rate of 115/min and blood pressure of 105/65 mm Hg. Examination reveals diminished deep tendon reflexes and generalized lethargy.

Stat laboratory testing reveals:

A 12-lead electrocardiogram demonstrates tall, tented T waves with loss of P waves and a widened QRS complex.

Which of the following is the most appropriate initial intervention for this patient?

Match each sexually transmitted pathogen with its characteristic primary clinical presentation.

Match each clinical presentation of a vector-borne or zoonotic illness with its most appropriate first-line antimicrobial regimen.

Evaluate the following distinct clinical vignettes detailing patients with specific environmental or occupational exposures. Match each patient's presentation with the most likely causative zoonotic pathogen.

Match each clinical presentation to the most likely associated rheumatologic condition.

A primary care physician is reviewing the charts of four outpatients who presented with acute infectious or inflammatory symptoms. Match each patient's clinical presentation with the most appropriate, guideline-concordant initial management strategy to optimize antimicrobial stewardship and patient outcomes.

A $35$-year-old man comes to the clinic with a rash on his right thigh. He first noticed it $3$ days ago, and it has been expanding. He returned from a camping trip in Massachusetts one week ago. He feels well otherwise and denies fever, joint pain, or headaches. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $120/80$ mmHg, and pulse is $76$/min. Physical examination shows a $10$-cm erythematous annular plaque with central clearing on the right thigh. Which of the following is the most appropriate next step in management?

A 58-year-old man with a history of osteoarthritis and poorly controlled type 2 diabetes presents to the emergency department with a severely swollen, red, and intensely painful right knee. The symptoms began abruptly 18 hours ago. He reports subjective chills and has a temperature of 38.9°C (102.0°F). On physical examination, the right knee demonstrates a large effusion and is very warm to the touch; passive range of motion is severely restricted due to excruciating pain. Arrange the following steps in the most appropriate chronological sequence for evaluating and managing this patient's suspected acute septic arthritis.

A 28-year-old man presents to the clinic reporting a painless mass in his right neck that has been enlarging over the past 8 weeks. He also reports drenching night sweats and a 6-kg (13.2-lb) weight loss over the past 3 months. Physical examination reveals a 4.5-cm, firm, rubbery, non-tender lymph node in the right anterior cervical chain. There is no palpable hepatosplenomegaly. Routine laboratory tests, including a complete blood count and comprehensive metabolic panel, are within normal limits. A chest radiograph demonstrates mediastinal widening. The physician highly suspects a diagnosis of Hodgkin lymphoma.

Arrange the following steps in the most appropriate chronological sequence for the definitive diagnosis, staging, and initial management of this patient.

A $28$-year-old male is seen at the university health clinic for right knee pain and swelling that began $3$ days ago. He also reports a mild burning sensation when urinating and bilateral eye redness. Four weeks ago, he experienced an episode of severe, watery diarrhea that resolved without medical intervention after several days. His temperature is $37.3^\circ\text{C}$ ($99.1^\circ\text{F}$), blood pressure is $122/78\text{ mmHg}$, and pulse is $84/\text{min}$. Physical examination reveals a warm, swollen, and tender right knee with a palpable effusion. There is exquisite tenderness upon palpation of the left posterior heel at the calcaneal insertion. The conjunctivae are injected bilaterally. Arthrocentesis of the right knee yields synovial fluid with a leukocyte count of $22,000/\text{mm}^3$ and no organisms on Gram stain. Which of the following is the most appropriate next step in management for this patient?

A 29-year-old woman with a 5-year history of systemic lupus erythematosus (SLE), previously well-controlled on hydroxychloroquine, presents with new-onset bilateral lower extremity edema, new hypertension (150/92 mm Hg), and an elevated serum creatinine of 1.4 mg/dL. Assuming no contraindications or delays in procedural availability, arrange the following steps in the most appropriate chronological sequence for the standard evaluation and management of this patient's new clinical presentation.