Internal Medicine

A physician is evaluating the antimicrobial regimen of a patient on the medical floor. The patient, a 58-year-old male, was admitted three days prior for management of severe shortness of breath and a productive cough. At the time of admission, imaging confirmed a left lower lobe consolidation, prompting the initiation of empiric intravenous ceftriaxone and azithromycin. Currently, the patient is clinically stable, breathing comfortably on ambient air, and tolerating his regular diet. He has not had a fever for over 24 hours. Laboratory data today reveals that the initial blood cultures are sterile. However, the admission sputum culture has finalized, demonstrating heavy growth of *Streptococcus pneumoniae*. Susceptibility profiling indicates the isolate is sensitive to penicillin, amoxicillin, levofloxacin, ceftriaxone, and vancomycin. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 28-year-old woman comes to the clinic for evaluation of chronic fatigue, poor sleep, and diffuse muscle aches over the past 4 months. She describes the pain as "aching all over" and notes that she often wakes up feeling unrefreshed. She has no history of joint swelling, facial rashes, oral ulcers, or fever. Her medical history is notable for atypical depression, for which she currently takes phenelzine. Physical examination reveals normal range of motion in all joints with no effusions, erythema, or synovitis. However, there is symmetric point tenderness to palpation over the neck, shoulders, and greater trochanters.

Because she was worried about having systemic lupus erythematosus (SLE), she recently obtained laboratory tests at an independent clinic. The results are as follows:

Based on the patient's clinical presentation and laboratory findings, which of the following is the most appropriate next step in management?

An otherwise healthy 45-year-old man presents to the primary care clinic for evaluation of an expanding red rash on his right lower extremity. He first noticed the redness 48 hours ago, and it has since become increasingly tender and warm. His medical history is notable only for recurrent tinea pedis, for which he sporadically uses an over-the-counter antifungal cream. His temperature is 37.2°C (99.0°F), pulse is 78/min, respirations are 14/min, and blood pressure is 126/82 mm Hg. Physical examination of the right lower leg demonstrates a poorly demarcated, erythematous, edematous, and warm plaque extending from the lateral ankle to the mid-calf. There are no fluctuant nodules, purulent exudates, or overlying ulcers. Bilateral pedal pulses are palpable and symmetric. Which of the following is the most appropriate empiric pharmacotherapy for this patient?

A 35-year-old woman is evaluated in the clinic for progressive fatigue, cold intolerance, and a 5-kg (11-lb) weight gain over the past 4 months. She also reports that she has not had a menstrual period for the last 6 months, despite having previously regular 28-day cycles. She is not taking any medications. Her temperature is 36.4°C (97.5°F), blood pressure is 100/60 mm Hg, and pulse is 58/min. Physical examination reveals dry skin and a delayed relaxation phase of the deep tendon reflexes. A urine pregnancy test is negative.

Laboratory results are as follows:
Thyroid-stimulating hormone (TSH): $1.8$ mU/L (Reference: $0.5 - 5.0$ mU/L)
Free thyroxine (T4): $0.4$ ng/dL (Reference: $0.9 - 1.7$ ng/dL)

Which of the following is the most likely diagnosis?

Match each clinical presentation of a common infectious disease with the most appropriate first-line pharmacotherapy.

A 67-year-old man is brought to the emergency department by his family due to a 1-day history of high fever, severe headache, and worsening confusion. His medical history is significant for hypertension and type 2 diabetes mellitus. His temperature is 39.4°C (102.9°F), blood pressure is 145/85 mm Hg, and pulse is 115/min. He is lethargic, mumbling incomprehensibly, and unable to follow complex commands. Neurologic examination shows a right-sided facial droop and right upper extremity weakness. Nuchal rigidity is present. Arrange the following steps in the most appropriate chronological sequence for the management of this patient.

A 36-year-old woman comes to the outpatient clinic reporting a 4-month history of profound fatigue, a 5-kg (11-lb) weight gain, and persistent constipation. She also mentions that her menstrual periods have stopped completely for the past 3 months. She has no prior medical conditions and takes no daily medications.

Her temperature is 36.6°C (97.8°F), blood pressure is 102/64 mmHg, and pulse is 54/min. Physical examination reveals dry, cool skin and a delayed relaxation phase of the deep tendon reflexes. The thyroid gland is nonpalpable and non-tender. During cranial nerve evaluation, the patient has difficulty seeing fingers presented in the lateral aspects of her visual fields bilaterally.

Initial laboratory testing reveals the following:
TSH: 2.1 $\mu$ U/mL (Normal: 0.5-5.0 $\mu$ U/mL)
Free $T_4$: 0.4 ng/dL (Normal: 0.9-1.7 ng/dL)

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

A 62-year-old woman comes to the clinic for a routine follow-up. She has a 10-year history of rheumatoid arthritis that has been poorly controlled due to medication nonadherence. She reports feeling increasingly tired over the past several months but denies black stools, blood in her urine, or heavy menses. Vital signs are within normal limits. Physical examination reveals swelling and tenderness in the metacarpophalangeal joints of both hands. Laboratory studies show the following:

Which of the following best describes the primary pathophysiology of this patient's hematologic findings?

A 26-year-old woman presents to the physician to discuss recent laboratory results. She specifically requested an antinuclear antibody (ANA) screening after reading a health blog about autoimmune disorders, despite having no physical complaints. She explicitly denies any history of joint stiffness, photosensitive skin rashes, oral ulcers, profound fatigue, or weight changes. Her past medical history is unremarkable. Vital signs and a comprehensive physical examination are entirely within normal limits. The laboratory report reveals a positive ANA at a titer of $1:40$ in a speckled pattern. The patient is highly distressed and wants to know her treatment options for systemic lupus erythematosus. Which of the following is the most appropriate next step in management?

For each of the following outpatient clinical scenarios, select the most appropriate initial targeted pharmacotherapy.

A 45-year-old woman presents to the clinic with a 3-month history of symmetric pain, swelling, and morning stiffness in her metacarpophalangeal and proximal interphalangeal joints lasting up to 2 hours daily. Physical examination reveals active synovitis in multiple small joints of the hands. Laboratory evaluation is strongly positive for rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies. The patient is diagnosed with moderate-to-severe rheumatoid arthritis. Arrange the following steps in the most appropriate chronological sequence for the standard diagnostic workup and long-term pharmacologic management of this patient, according to current clinical guidelines.

A 45-year-old man is evaluated in the intensive care unit on day 8 of hospitalization. He was admitted after a motor vehicle collision that caused a severe traumatic brain injury and bilateral pulmonary contusions, requiring immediate intubation and mechanical ventilation. Over the past 24 hours, the nursing staff has noted an increase in the volume of thick, yellowish endotracheal secretions. The patient remains sedated. His temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $128/78\text{ mmHg}$, heart rate is $86/\text{min}$, and respiratory rate is $16/\text{min}$. Physical examination reveals coarse rhonchi over both lung fields. Laboratory studies show a leukocyte count of $8,500/\text{mm}^3$. A portable chest radiograph demonstrates stable, resolving bilateral opacities with no new focal consolidations compared to imaging from three days prior. An endotracheal aspirate culture obtained yesterday grows $>10^5\text{ CFU/mL}$ of Pseudomonas aeruginosa. Which of the following is the most appropriate next step in the management of this patient?

Rheumatology consultation is requested for a 74-year-old man who developed sudden, excruciating pain and swelling in his right knee overnight. The patient is currently recovering on the surgical ward on postoperative day 4 following an open cholecystectomy for acute cholecystitis. His medical background is significant for long-standing hypertension, diet-controlled type 2 diabetes, and stage 3b chronic kidney disease. He is receiving prophylactic subcutaneous enoxaparin. Temperature is 37.9°C (100.2°F). The right knee is markedly erythematous, warm to the touch, and held in slight flexion; any attempted movement elicits severe distress. Laboratory evaluation reveals a serum creatinine of 2.3 mg/dL. An ultrasound-guided diagnostic arthrocentesis yields 35,000 leukocytes/mm³ (85% neutrophils). Microscopic examination under polarized light demonstrates multiple rhomboid-shaped crystals with weak positive birefringence. Gram stain of the synovial fluid is negative for microorganisms. Which of the following is the most appropriate next step in management?

Match each clinical presentation of a suspected blood transfusion complication with its most likely diagnosis.

A 58-year-old man with a history of end-stage renal disease presents to the emergency department with profound muscle weakness. He missed his last two scheduled hemodialysis appointments due to transportation issues. His blood pressure is 110/70 mmHg, and his pulse is 52/min. An electrocardiogram (ECG) reveals peaked T waves, a prolonged PR interval, and widened QRS complexes. Laboratory testing shows a serum potassium level of 7.6 mEq/L. Arrange the following therapeutic interventions in the most appropriate chronological order for this patient's acute management.

Match each clinical vignette describing a systemic or opportunistic infection with the most appropriate primary therapeutic management.

Match each clinical presentation with the most appropriate first-line targeted antimicrobial therapy.

Match each clinical presentation of a hypertensive emergency to the most appropriate initial targeted pharmacologic intervention. Assume all patients require immediate medical management.

A 68-year-old man with a history of advanced prostate cancer presents to the emergency department with a 3-day history of progressively worsening mid-back pain and new-onset bilateral leg weakness. Earlier today, he developed urinary incontinence. Neurologic examination reveals 3/5 motor strength in both lower extremities, hyperreflexia at the knees and ankles, and decreased sensation to pinprick below the T10 dermatome level. Suspecting an oncologic emergency, arrange the following clinical interventions in the most appropriate chronological sequence for managing this patient.

A 72-year-old man is brought to the emergency department by emergency medical services due to severe, progressively worsening shortness of breath that began abruptly $4\text{ hours}$ ago. Over the past week, he has noticed increased swelling in his lower legs and difficulty sleeping flat. He has a history of essential hypertension, type 2 diabetes mellitus, and a 50-pack-year smoking history. Current medications include metformin, sitagliptin, and amlodipine. On arrival, he is visibly distressed, diaphoretic, and using accessory muscles of respiration. Temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), pulse is $118/\text{min}$, blood pressure is $178/102\text{ mm Hg}$, and respirations are $28/\text{min}$. Pulse oximetry shows an oxygen saturation of $88\%$ on room air. Physical examination reveals jugular venous distention to the angle of the mandible while the patient is sitting upright. Lung auscultation reveals prolonged expiration, diffuse expiratory wheezes, and fine crackles at both lung bases. Cardiac auscultation reveals a regular tachycardia and an S3 gallop. Bilateral 2+ pitting edema is present up to the mid-calves.

Laboratory studies show:
Leukocyte count: $8,400/\text{mm}^3$
Serum sodium: $136\text{ mEq/L}$
Serum potassium: $4.1\text{ mEq/L}$
Serum bicarbonate: $16\text{ mEq/L}$
Blood urea nitrogen: $32\text{ mg/dL}$
Serum creatinine: $1.4\text{ mg/dL}$
Serum lactate: $4.0\text{ mmol/L}$
Thyroid-stimulating hormone (TSH): $1.8\ \mu\text{U/mL}$ (Normal: $0.4 - 4.0\ \mu\text{U/mL}$)
Free thyroxine (T4): $0.6\text{ ng/dL}$ (Normal: $0.9 - 1.7\text{ ng/dL}$)

Arterial blood gas on room air:
pH: $7.34$
pCO2: $30\text{ mm Hg}$
pO2: $58\text{ mm Hg}$

A chest radiograph shows cardiomegaly, bilateral perihilar opacities, and fluid in the horizontal fissure. Gram stain of the frothy sputum shows rare polymorphonuclear leukocytes and abundant normal respiratory flora without predominant organisms.

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