Internal Medicine

A 63-year-old man with a history of metastatic non-small cell lung cancer is brought to the emergency department by his family. Over the past week, he has experienced progressively worsening, severe mid-thoracic back pain that is exacerbated by coughing. This morning, he was unable to stand due to profound weakness in his legs and reports that he has not been able to urinate for the past $12$ hours. On physical examination, his temperature is $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$), blood pressure is $142/88\text{ mmHg}$, and heart rate is $98/\text{min}$. Neurologic examination reveals $2/5$ motor strength in bilateral lower extremities, hyperactive patellar reflexes, positive Babinski signs bilaterally, and diminished sensation to pinprick below the level of the umbilicus. A post-void residual volume measured by bladder ultrasound is $750\text{ mL}$. Suspecting malignant epidural spinal cord compression, arrange the following management steps in the most appropriate sequential order.

Match each atypical clinical presentation of a complex hematologic or coagulopathic disorder to the most appropriate and highly specific targeted management strategy.

A 34-year-old woman presents to the outpatient department due to left-sided chest pain and shortness of breath for the past 3 days. The chest pain is sharp and noticeably worsens when she takes a deep breath or coughs. She also reports feeling persistently fatigued and sad for the past month. Her medical history is significant for systemic lupus erythematosus (SLE) and bipolar disorder. Her current daily medications include hydroxychloroquine, prednisone 5 mg, and quetiapine. Her temperature is 37.8°C (100.0°F), blood pressure is 120/78 mmHg, and heart rate is 88/min. Cardiopulmonary examination reveals a pleural friction rub on the left side, with no murmurs, gallops, or jugular venous distention. A chest radiograph demonstrates a small left-sided pleural effusion without any pulmonary infiltrates. An electrocardiogram is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's clinical presentation and laboratory findings of hyponatremia with the most appropriate targeted initial therapeutic intervention.

A 68-year-old man with a history of atrial fibrillation is brought to the emergency department after vomiting large amounts of bright red blood. He takes warfarin daily. On presentation, he appears pale and lethargic. His temperature is 37.1°C (98.8°F), blood pressure is 88/56 mm Hg, and heart rate is 118/min. Physical examination reveals delayed capillary refill and cool extremities. Laboratory studies show a hemoglobin of 8.2 g/dL and an International Normalized Ratio (INR) of 8.4. Intravenous fluid resuscitation with normal saline is initiated. Which of the following is the most appropriate next step in management?

Match the following common outpatient clinical presentations to their most appropriate first-line oral pharmacological therapy.

Evaluate the following clinical presentations of immunocompromised patients with opportunistic infections. Match each clinical scenario with the most appropriate initial targeted pharmacotherapy.

A 55-year-old man with poorly controlled type 2 diabetes mellitus is evaluated in the hospital on day 4 of admission for a severe diabetic foot infection. He initially presented with a deep, purulent ulcer on the plantar aspect of his right foot surrounded by extensive cellulitis. On admission, empiric therapy was initiated with intravenous vancomycin and piperacillin-tazobactam, and he subsequently underwent surgical debridement of necrotic tissue. Today, his temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $128/78\text{ mm Hg}$, and pulse is $78\text{/min}$. The wound appears clean with developing granulation tissue. Deep tissue cultures obtained during surgery yield heavy growth of Staphylococcus aureus. Antimicrobial susceptibility testing demonstrates resistance to penicillin and susceptibility to oxacillin, cefazolin, and vancomycin. Which of the following is the most appropriate next step in pharmacotherapy?

Match the following complex nephrologic and acid-base clinical presentations with their most appropriate specific therapeutic interventions.

An emergency department evaluation is requested for a $42$-year-old man who reports severe, diffuse abdominal pain that consistently begins $30\text{ minutes}$ after meals over the past $4\text{ weeks}$. He also reports a $6\text{-kg}$ ($13\text{-lb}$) weight loss during this period, diffuse muscle aches, and intermittent fevers. Two days ago, the patient developed difficulty lifting his right foot while walking. His temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$) and blood pressure is $168/98\text{ mmHg}$. Physical examination shows a mottled, purplish, net-like rash on the lower extremities. Neurologic examination demonstrates $2/5$ motor strength in right foot dorsiflexion and decreased pinprick sensation over the right lateral calf.

Laboratory studies are as follows:

Urinalysis reveals $1+$ protein, $0-2$ red blood cells/hpf, and no cellular casts.

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

Match each clinical presentation of systemic vasculitis with the most likely specific diagnosis.

A $55$-year-old man is brought to the emergency department by his wife due to confusion, high fever, and a severe headache that started $12$ hours ago. His medical history is significant for a deceased-donor renal transplant $2$ years ago, for which he takes tacrolimus and mycophenolate mofetil. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $105/65\text{ mm Hg}$, pulse is $115\text{/min}$, and respirations are $22\text{/min}$. On physical examination, the patient is lethargic but arousable. He has pronounced nuchal rigidity. Neurologic examination reveals left-sided pronator drift and a sluggish left pupillary reflex. Fundoscopy shows bilateral blurring of the optic discs. Arrange the following management steps in the most appropriate chronological order for this patient.

A 68-year-old man arrives at the emergency department reporting two days of progressively worsening dyspnea and an inability to lie flat without severe respiratory distress. He has a past medical history of chronic obstructive pulmonary disease (COPD), diet-controlled type 2 diabetes mellitus, and hypertension. Current medications include inhaled tiotropium and oral amlodipine. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $174/96\ \text{mm Hg}$, pulse is $116/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry indicates an oxygen saturation of $87\%$ on room air. Physical examination reveals a patient in moderate respiratory distress using accessory muscles. Jugular venous pressure is elevated to $11\ \text{cm H}_2\text{O}$ above the sternal angle. Pulmonary auscultation reveals a prolonged expiratory phase with diffuse bilateral wheezing and scattered crackles at the lung bases. Cardiac examination shows tachycardia with a regular rhythm and an audible S3 gallop. There is $2+$ pitting edema in the lower extremities bilaterally.

Laboratory results are as follows:
Leukocyte count: $8,200/\text{mm}^3$
Thyroid-stimulating hormone (TSH): $0.2\ \mu\text{IU}/\text{mL}$ (Normal: $0.4\text{-}4.0$)
Free T4: $1.2\ \text{ng}/\text{dL}$ (Normal: $0.9\text{-}1.7$)
N-terminal pro-B-type natriuretic peptide (NT-proBNP): $2,800\ \text{pg}/\text{mL}$

Arterial blood gas analysis on room air reveals:
pH: $7.25$
$\text{PaCO}_2$: $64\ \text{mm Hg}$
$\text{PaO}_2$: $55\ \text{mm Hg}$
$\text{HCO}_3^-$: $27\ \text{mEq}/\text{L}$

A portable chest radiograph displays cardiomegaly, bilateral pleural effusions, prominent upper lobe pulmonary vessels, and hyperinflated lung fields. Which of the following is the most appropriate next step in the management of this patient?

An emergency medical services team brings a 58-year-old male to the emergency department following a new-onset generalized tonic-clonic seizure. His wife reports that he had been complaining of a progressively worsening headache, severe neck stiffness, and subjective fevers for the past 48 hours. His temperature is 39.4°C (102.9°F), blood pressure is 112/68 mmHg, and pulse is 118/min. On physical examination, the patient is obtunded and grimaces upon neck flexion. Funduscopic examination shows no papilledema, but a detailed neurologic exam reveals a new right-sided pronator drift.

Arrange the following interventions in the most appropriate chronological sequence for this patient's management.

A 62-year-old man is evaluated on postoperative day 3 following an uncomplicated laparoscopic inguinal hernia repair. He reports the acute onset of severe pain, swelling, and redness in his right first metatarsophalangeal joint that began overnight. The patient has a history of hypertension and hyperlipidemia. His temperature is 37.8°C (100.0°F), blood pressure is 135/85 mmHg, and pulse is 88/min. Physical examination reveals an exquisitely tender, warm, and erythematous right big toe. Synovial fluid analysis of the affected joint reveals a leukocyte count of 22,000/mm³ and the presence of needle-shaped, negatively birefringent crystals. Gram stain shows no organisms. Which of the following is the most appropriate next step in management?

A $72$-year-old man is evaluated on postoperative day $1$ following an elective total hip arthroplasty due to severe osteoarthritis. Prior to surgery, his hemoglobin was $11.2 \text{ g/dL}$. Postoperatively, his hemoglobin dropped to $6.8 \text{ g/dL}$, and a transfusion of $2$ units of packed red blood cells was ordered. One hour into the transfusion of the second unit, he reports severe shortness of breath and a new-onset dry cough. His medical history is significant for hypertension, type $2$ diabetes mellitus, and coronary artery disease.

Vital signs are:
- Temperature: $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$)
- Blood pressure: $175/95 \text{ mmHg}$
- Heart rate: $112/\text{min}$
- Respiratory rate: $28/\text{min}$
- SpO $_2$: $88\%$ on room air

Physical examination reveals elevated jugular venous pressure to $9 \text{ cm H}_2\text{O}$. Cardiac auscultation reveals a regular tachycardia with a new $S_3$ gallop. Pulmonary examination reveals bibasilar crackles extending midway up the lung fields. There is no rash or stridor.

Laboratory studies obtained one hour prior to the transfusion:

Arterial blood gas (room air, during acute event):
- pH: $7.48$
- pCO $_2$: $30 \text{ mmHg}$
- pO $_2$: $55 \text{ mmHg}$

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

A 58-year-old man presents to the outpatient clinic with a 2-day history of steady left lower quadrant abdominal pain. The pain is associated with mild nausea and a decreased appetite. He denies vomiting, hematochezia, or melena. He has a history of essential hypertension treated with amlodipine. He underwent a screening colonoscopy three years ago, which revealed scattered diverticula but no polyps or malignancy. Vital signs are temperature 37.6°C (99.7°F), blood pressure 132/82 mmHg, heart rate 84/min, and respiratory rate 16/min. The abdomen is soft and non-distended. There is focal tenderness to deep palpation in the left lower quadrant, but no guarding or rebound tenderness is appreciated. Complete blood count shows a leukocyte count of 11,200/mm³. A CT scan of the abdomen and pelvis with contrast reveals focal thickening of the sigmoid colon wall and adjacent pericolic fat stranding. There are no fluid collections, abscesses, pneumatosis, or free intraperitoneal air. Which of the following is the most appropriate next step in management?

A 26-year-old woman with a 3-year history of systemic lupus erythematosus (SLE) presents to the clinic with 2 weeks of worsening bilateral lower extremity edema and newly frothy urine. Her current medications include hydroxychloroquine and low-dose prednisone. Vital signs show a blood pressure of 152/94 mm Hg. Physical examination reveals 2+ pitting edema up to the mid-calves. You suspect new-onset lupus nephritis. Arrange the following steps in the standard sequential order for the diagnostic evaluation and subsequent therapeutic management of this patient.

A 74-year-old woman is evaluated in the emergency department for a 3-day history of progressively worsening shortness of breath and increased sputum production. She has a medical history of chronic obstructive pulmonary disease (COPD), heart failure with preserved ejection fraction, and type 2 diabetes mellitus. Her current medications include lisinopril, amlodipine, metformin, and a daily tiotropium inhaler. She has a 40-pack-year smoking history. Her temperature is 37.3 °C (99.1 °F), blood pressure is 138/86 mm Hg, pulse is 92/min, and respirations are 24/min. Pulse oximetry shows an oxygen saturation of 89% on room air. The patient is sitting upright and using accessory muscles of respiration. The jugular venous pressure is 6 cm H2O. Chest auscultation reveals a prolonged expiratory phase with diffuse expiratory wheezing bilaterally. Cardiac examination shows a regular rate and rhythm with a normal S1 and S2; there are no murmurs or gallops. There is no peripheral edema. Laboratory studies show:

Leukocyte count: 9,500/mm³
Serum $Na^+$: 139 mEq/L
Serum $K^+$: 4.1 mEq/L
Serum $Cl^-$: 96 mEq/L
Serum $HCO_3^-$: 33 mEq/L
BUN: 18 mg/dL
Creatinine: 0.9 mg/dL
Thyroid-stimulating hormone (TSH): 0.15 µU/mL (Normal: 0.4–4.0 µU/mL)
Free thyroxine (T4): 1.1 ng/dL (Normal: 0.9–2.4 ng/dL)

An arterial blood gas on room air shows:
pH: 7.35
$PaCO_2$: 60 mm Hg
$PaO_2$: 58 mm Hg

A chest radiograph shows hyperinflated lungs and flattened diaphragms, with no focal consolidation, pleural effusion, or pulmonary vascular congestion. Which of the following is the most appropriate next step in management of this patient's current condition?

A 48-year-old man is brought to the emergency department by his wife due to a 2-week history of worsening shortness of breath, fever, and coughing up blood-tinged sputum. He has a past medical history of chronic rhinosinusitis refractory to antibiotics, recurrent epistaxis, and bilateral knee pain over the past year. His only medication is ibuprofen as needed.

His temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $155/95\text{ mm Hg}$, pulse is $112/\text{min}$, and respirations are $26/\text{min}$. Oxygen saturation is $89\%$ on room air.

Physical examination shows ulceration of the nasal septum and a saddle nose deformity. Lung auscultation reveals bilateral fine crackles. Heart sounds are normal. There is no peripheral edema.

Laboratory results are as follows:

Urinalysis shows 3+ protein and large blood; microscopy reveals 25-50 RBCs/hpf and occasional red blood cell casts.

An arterial blood gas on room air shows:
pH: $7.28$
PaO $_2$: $58\text{ mm Hg}$
PaCO $_2$: $25\text{ mm Hg}$
HCO $_3^-$: $11\text{ mEq/L}$

A chest X-ray shows multiple bilateral nodular opacities, several of which are cavitating.

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