Internal Medicine

A primary care physician is evaluating several patients in an outpatient clinic. Match each patient's clinical presentation with the most appropriate initial management step.

A $64$-year-old man comes to the office complaining of a progressive, dry cough and worsening shortness of breath upon exertion for the past $4$ months. He has a $12$-year history of seropositive rheumatoid arthritis, currently treated with weekly methotrexate and daily folic acid. He also takes over-the-counter ibuprofen for occasional joint pain. He has a $25$-pack-year smoking history but quit $5$ years ago. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $128/82\text{ mm Hg}$, pulse of $84\text{/min}$, and respiratory rate of $18\text{/min}$. Pulse oximetry is $94\%$ on ambient air. Physical examination shows bilateral ulnar deviation and metacarpophalangeal joint subluxation. Lung auscultation reveals fine, end-inspiratory crackles prominently at both lung bases. There is no wheezing. Cardiovascular examination shows a regular rate and rhythm with no murmurs, gallops, or jugular venous distention. There is no lower extremity edema. Laboratory studies reveal an erythrocyte sedimentation rate of $45\text{ mm/h}$ and a normal complete blood count. A plain chest radiograph obtained in the clinic shows bilateral, fine reticular opacities at the lung bases.

Which of the following is the most appropriate next step in the management of this patient's respiratory symptoms?

A 52-year-old man is evaluated in the hospital on day 3 of admission for severe right lower extremity cellulitis and fever. On presentation to the emergency department, his temperature was $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$) and his blood pressure was $92/58\text{ mmHg}$. Blood cultures were drawn, and he was empirically started on intravenous vancomycin and piperacillin-tazobactam along with fluid resuscitation. Today, his temperature is $37.3^\circ\text{C}$ ($99.1^\circ\text{F}$), his blood pressure is $124/78\text{ mmHg}$, and the erythema and induration of his right leg have significantly decreased. The admission blood cultures are now growing *Staphylococcus aureus* in both sets. Susceptibility testing demonstrates that the organism is resistant to penicillin, but susceptible to oxacillin, cefazolin, and vancomycin. Which of the following is the most appropriate next step in this patient's pharmacotherapy?

During an urgent clinic visit, a 68-year-old male reports a one-week history of progressively worsening shortness of breath, lightheadedness, and profound fatigue. The patient was diagnosed with extensive-stage small cell lung cancer three months ago and recently completed his second cycle of chemotherapy. His medical history also includes severe chronic obstructive pulmonary disease.

Vital signs reveal a temperature of 37.1°C (98.8°F), pulse of 116/min, respirations of 24/min, and blood pressure of 105/85 mmHg. Oxygen saturation is 93% on room air. Physical examination demonstrates elevated jugular venous pressure. Heart sounds are distant and difficult to auscultate. Lung examination reveals faint scattered wheezes bilaterally. Blood pressure testing reveals a decrease in systolic pressure of 18 mmHg during normal inspiration. Recent laboratory studies are unremarkable, with a normal leukocyte count and a serum sodium level of 132 mEq/L.

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

A 58-year-old female presents to an urgent care facility reporting progressively worsening shortness of breath over the last three days. She notes that she must prop herself up on multiple pillows at night to sleep comfortably. Her medical history includes long-standing type 2 diabetes mellitus, hypertension, and a 20-pack-year smoking history. Vital signs show a blood pressure of 162/94 mmHg, heart rate of 98/min, respiratory rate of 24/min, and oxygen saturation of 92% on ambient air. Physical examination reveals prominent jugular venous pulsations and fine bibasilar crackles on lung auscultation. Trace bilateral pedal edema is also present. Which of the following is the most appropriate initial pharmacological management for this patient's acute symptoms?

A 31-year-old woman visits the ambulatory clinic complaining of severe fatigue, low-grade fevers, and generalized joint achiness that has gradually worsened over the past two months. She recently started a landscaping business and notes that spending hours in the sun causes a bright, flat red rash to appear across her nose and cheeks. On physical examination, her temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$). A confluent, erythematous rash is visible over the malar eminences, notably sparing the nasolabial folds. She has mild synovial thickening and tenderness in the wrists and proximal interphalangeal joints bilaterally. Which of the following laboratory findings is most specific for this patient's likely diagnosis?

A 72-year-old woman is evaluated in the hospital for progressive lethargy and confusion over the past 24 hours. She was admitted 4 days ago for an acute exacerbation of chronic obstructive pulmonary disease (COPD). On admission, she was started on intravenous methylprednisolone, nebulized ipratropium-albuterol, and empiric piperacillin-tazobactam. She was also continued on her home dose of furosemide for a history of ischemic cardiomyopathy with a left ventricular ejection fraction of 35%. Her other home medications include lisinopril and levothyroxine.

Her temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $100/60\text{ mm Hg}$, pulse is $110\text{/min}$, and respirations are $22\text{/min}$. Physical examination shows dry mucous membranes. The jugular venous pressure is $4 \text{ cm H}_2\text{O}$. Lung auscultation reveals distant breath sounds with faint expiratory wheezes and fine bibasilar crackles. Cardiac examination shows a regular tachycardia with no murmurs or gallops.

Laboratory studies show:
Sodium: $136 \text{ mEq/L}$
Potassium: $2.8 \text{ mEq/L}$
Chloride: $92 \text{ mEq/L}$
Bicarbonate: $36 \text{ mEq/L}$
Blood urea nitrogen: $52 \text{ mg/dL}$
Creatinine: $2.3 \text{ mg/dL}$ (baseline $1.1 \text{ mg/dL}$)
Thyroid-stimulating hormone (TSH): $0.1 \mu\text{U/mL}$ (normal: $0.4–4.0 \mu\text{U/mL}$)
Free T4: $1.0 \text{ ng/dL}$ (normal: $0.9–1.7 \text{ ng/dL}$)

Arterial blood gas on $2 \text{ L/min}$ oxygen by nasal cannula shows:
pH: $7.54$
PaCO₂: $48 \text{ mm Hg}$
PaO₂: $68 \text{ mm Hg}$

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

A 65-year-old woman is hospitalized for a deep vein thrombosis and treated with an unfractionated heparin infusion. On day $6$ of hospitalization, her platelet count falls from $240,000/\text{mm}^3$ on admission to $75,000/\text{mm}^3$. Physical examination reveals a new, painful, swollen, and pulseless right foot. Her 4T score is calculated to be $7$, indicating a high probability of heparin-induced thrombocytopenia (HIT) complicated by arterial thrombosis. Arrange the following management steps in the correct chronological sequence for this patient.

A 59-year-old woman is evaluated in the hospital on day 3 of admission for acute cholangitis. She initially presented with fever, right upper quadrant pain, and jaundice. She underwent an uncomplicated endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction on the day of admission and was started on empiric piperacillin-tazobactam and vancomycin. She is currently afebrile and her hemodynamics are stable.

Blood cultures drawn on admission are now positive for *Klebsiella aerogenes*. Antimicrobial susceptibility testing is reported as follows:

Which of the following is the most appropriate definitive pharmacotherapy for this patient?

A 24-year-old woman presents to the university health clinic reporting two days of severe burning upon urination and a sensation of needing to urinate frequently. She denies any fever, chills, flank pain, nausea, or vaginal discharge. Her medical history is unremarkable, and she takes no daily medications other than an oral contraceptive pill. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 118/76 mmHg, and a heart rate of 78/min. Physical examination reveals mild suprapubic tenderness but no costovertebral angle tenderness. A clean-catch urinalysis is positive for leukocyte esterase and nitrites, with >50 white blood cells per high-power field. A urine culture is pending. Which of the following is the most appropriate empiric pharmacotherapy for this patient?

Evaluate the following clinical scenarios of patients diagnosed with infective endocarditis. Pair each patient profile with the most appropriate definitive antimicrobial regimen based on current treatment guidelines.

A $28$-year-old woman is admitted to the hospital for a $2$-week history of high, daily spiking fevers up to $39.8^\circ\text{C}$ ($103.6^\circ\text{F}$), severe pharyngitis, and polyarthralgia in her wrists and knees. During the fever spikes, she develops a transient, salmon-colored macular rash on her trunk and extremities. Initial laboratory studies on admission showed:

She is treated with high-dose nonsteroidal anti-inflammatory drugs. On day $4$ of hospitalization, she rapidly becomes lethargic and hypotensive. Physical examination now reveals marked hepatosplenomegaly. Repeat laboratory studies show:

Which of the following is most likely to be found on further evaluation of this patient's current condition?

A $64$-year-old man is evaluated in the intensive care unit for a persistent fever. He was admitted $8$ days ago for a severe exacerbation of chronic obstructive pulmonary disease and required endotracheal intubation on the second day of admission. Four days ago, he developed a new fever, worsening oxygenation, and thick endotracheal secretions. Blood and lower respiratory tract cultures were obtained, and empiric therapy with intravenous piperacillin-tazobactam and vancomycin was initiated. Today, his temperature is $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), blood pressure is $112/68\text{ mm Hg}$, pulse is $102/\text{min}$, and leukocyte count is $16,500/\text{mm}^3$. Blood cultures have remained sterile. The endotracheal aspirate culture grows \textit{Enterobacter cloacae}. Antimicrobial susceptibility testing shows the isolate is susceptible to ceftriaxone, ceftazidime, cefepime, piperacillin-tazobactam, and meropenem, but resistant to ampicillin and cefazolin. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

Match the following characteristic peripheral blood smear descriptions to the most likely underlying hematologic diagnosis.

Match each clinical scenario of severe or life-threatening bleeding to the most appropriate specific pharmacological reversal agent.

Match each biologic disease-modifying antirheumatic drug (bDMARD) with its specific mechanism of action and the most characteristic clinical caveat or adverse effect associated with its use.

A 74-year-old man is admitted to the intensive care unit with septic shock secondary to a severe complicated urinary tract infection. He has a history of neurogenic bladder managed with clean intermittent catheterization. On admission, his temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $82/50\text{ mmHg}$, and heart rate is $118/\text{min}$. He receives aggressive fluid resuscitation and is started on empiric intravenous piperacillin-tazobactam and vancomycin. By hospital day 3, his condition has significantly improved; he is afebrile, hemodynamically stable off vasopressors, and transferred to the general medical floor. Blood cultures and a urine culture obtained on admission both yield *Enterococcus faecalis*. Susceptibility testing indicates the organism is sensitive to ampicillin, vancomycin, linezolid, and daptomycin, but intrinsically resistant to cephalosporins. Which of the following is the most appropriate next step in pharmacotherapy?

A 54-year-old man develops severe pain, redness, and swelling of his right big toe on postoperative day 3 following an uncomplicated laparoscopic cholecystectomy. He cannot bear weight on the affected foot. His temperature is 37.6°C (99.7°F), blood pressure is 135/85 mm Hg, and pulse is 88/min. Examination shows an exquisitely tender, erythematous, and swollen right first metatarsophalangeal joint. Synovial fluid analysis reveals a leukocyte count of 22,000/mm³ and numerous negatively birefringent, needle-shaped crystals. Which of the following is the most appropriate next step in management?

A 58-year-old female patient visits the outpatient clinic to discuss a two-month history of progressively worsening shortness of breath. Initially, she noticed breathlessness only when climbing stairs, but she now experiences it after walking short distances on level ground. The patient's medical background is notable for limited cutaneous systemic sclerosis, characterized by diffuse calcinosis cutis, severe esophageal dysmotility, and tightening of the skin over her fingers. She also has a history of primary hypothyroidism and severe digital vasospasm triggered by cold exposure.

Her daily medications include amlodipine, omeprazole, levothyroxine, and sildenafil.

Vital signs are as follows:
- Temperature: $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$)
- Blood pressure: $126/78\text{ mm Hg}$
- Heart rate: $94/\text{min}$
- Respiratory rate: $22/\text{min}$
- Pulse oximetry: $94\%$ on room air

Physical examination reveals clear lung fields bilaterally with no crackles or wheezes. Cardiovascular assessment demonstrates a prominent parasternal impulse and a markedly accentuated pulmonic component of the second heart sound. Examination of the lower extremities shows mild bilateral pitting edema.

Recent laboratory and diagnostic results:

An electrocardiogram reveals right axis deviation and signs of right ventricular hypertrophy. A chest radiograph demonstrates prominent central pulmonary arteries with rapid peripheral tapering and completely clear lung parenchyma. A transthoracic echocardiogram obtained yesterday estimates a right ventricular systolic pressure of $55\text{ mm Hg}$ with normal left ventricular ejection fraction.

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

An otherwise healthy 45-year-old woman receives treatment in the inpatient ward for an acute complicated urinary tract infection with associated bacteremia. At the time of admission two days ago, she presented with fever, chills, and costovertebral angle tenderness, prompting the initiation of empiric intravenous piperacillin-tazobactam. Today, she has been afebrile for the past 24 hours, her flank pain has nearly resolved, and she is tolerating a regular diet. Final culture results from both blood and urine demonstrate growth of *Escherichia coli*. The susceptibility report indicates resistance to ampicillin, but susceptibility to ceftriaxone, trimethoprim-sulfamethoxazole, levofloxacin, and piperacillin-tazobactam. Based on the culture results and the patient's clinical improvement, what is the most appropriate next step in management?