Internal Medicine

A 71-year-old man comes to the clinic due to the sudden onset of extensive bruising over his trunk and arms over the past two weeks. He also reports painful swelling in his right knee that began yesterday after bumping it against a table. He has a history of hypertension and osteoarthritis. He has never had abnormal bleeding before, including during a cholecystectomy 10 years ago. Current medications include lisinopril and acetaminophen. Vital signs are within normal limits. Physical examination reveals large, coalescing ecchymoses over the abdomen and proximal extremities. The right knee is warm, swollen, and tender. Laboratory studies show:

A 1:1 mixing study with normal plasma is performed, and the aPTT remains prolonged at 72 seconds. Which of the following is the most appropriate next step in the management of this patient's bleeding?

Secondary hypertension should be suspected in patients presenting with resistant hypertension, severe blood pressure elevations, or specific clinical manifestations. Match each patient vignette with the most appropriate initial diagnostic screening test to evaluate the underlying etiology.

A 45-year-old woman presents to the clinic with a 3-month history of bilateral wrist and metacarpophalangeal joint pain, accompanied by 2 hours of morning stiffness. Physical examination reveals symmetric synovitis of the hands and wrists. Arrange the following clinical steps in the most appropriate chronological order for the diagnosis and longitudinal pharmacologic management of this patient, assuming she experiences inadequate treatment responses at each subsequent stage.

A 28-year-old man comes to the clinic because of a 5-day history of right knee pain and swelling. He reports that the knee feels stiff and is difficult to bend. He also notes a gritty sensation in both eyes and mild burning upon urination for the past two days. One month ago, he had an episode of severe diarrhea with abdominal cramping that resolved without treatment after a week. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $122/78\text{ mm Hg}$, and pulse is $84/\text{min}$. Physical examination shows a swollen, warm, and tender right knee with a moderate effusion. Conjunctival injection is present bilaterally. Arthrocentesis of the right knee yields synovial fluid with a leukocyte count of $18,000/\text{mm}^3$ and no crystals. Gram stain of the fluid is negative. Which of the following is the most appropriate next step in the management of this patient's joint condition?

Match each patient's clinical scenario regarding malaria prevention or treatment with the most appropriate targeted pharmacotherapy.

A 68-year-old woman is brought to the emergency department by her family due to a severe headache, fever, and confusion that started earlier today. On examination, her temperature is 39.2°C (102.6°F), blood pressure is 110/70 mm Hg, and heart rate is 115/min. She exhibits nuchal rigidity and a new-onset right-sided facial droop with right arm weakness. Arrange the following steps in the most appropriate chronological sequence for the immediate management of this patient.

During multidisciplinary rounds in the surgical intensive care unit, the team evaluates the antimicrobial regimen for a 54-year-old man. The patient underwent an exploratory laparotomy 8 days ago for a perforated viscus. On his fifth postoperative day, he developed a temperature of 38.9°C (102.0°F) and tachycardia. His right internal jugular central venous catheter, which had been placed preoperatively, was removed, and blood cultures were drawn from peripheral veins and the catheter before removal. Empiric therapy with intravenous vancomycin and cefepime was initiated. Today, the microbiology laboratory reports that two out of two blood culture sets are growing Staphylococcus aureus. The susceptibility panel indicates resistance to penicillin and ampicillin, but susceptibility to oxacillin, cefazolin, vancomycin, and daptomycin. The patient has no known drug allergies. His current temperature is 37.2°C (99.0°F), blood pressure is 128/82 mmHg, and pulse is 82/min. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

During a hospital observation, an 82-year-old male with a history of moderate chronic obstructive pulmonary disease and diet-controlled hypertension is receiving a blood transfusion. He was admitted earlier today for severe fatigue and was found to have a hemoglobin level of $6.2 \text{ g/dL}$ due to suspected chronic gastrointestinal blood loss. While receiving his second unit of packed red blood cells, he suddenly develops worsening shortness of breath and a dry cough. His blood pressure is $168/94 \text{ mmHg}$, pulse is $112/\text{min}$, and respiratory rate is $26/\text{min}$. Oxygen saturation is $88\%$ on room air. Physical examination reveals distended neck veins and bilateral crackles at the lung bases. There is no fever, rash, or wheezing. Which of the following is the most appropriate next step in management?

During clinical rounds, the infectious disease service evaluates a 68-year-old male admitted with a two-week history of nocturnal sweats, generalized malaise, and a newly detected holosystolic murmur at the cardiac apex. Transesophageal echocardiography reveals a 1.4-cm mobile vegetation on the mitral valve along with moderate mitral regurgitation. The laboratory notifies the team that all four sets of blood cultures drawn upon admission are growing Enterococcus faecalis. The isolate demonstrates susceptibility to ampicillin, vancomycin, and daptomycin, but exhibits high-level resistance to gentamicin. Renal function is within normal limits. Which of the following is the most appropriate intravenous antibiotic regimen for this patient?

An evaluation is requested for a $65$-year-old man in the intensive care unit who developed right calf swelling and tenderness this morning. $6$ days ago, he underwent an exploratory laparotomy with a small bowel resection for acute mesenteric ischemia. His postoperative course has been complicated by severe acute kidney injury secondary to prolonged intraoperative hypotension, though he remains nonoliguric. Since admission, he has been receiving subcutaneous unfractionated heparin for deep venous thrombosis prophylaxis.

His temperature is $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), blood pressure is $135/85$ mm Hg, pulse is $98$/min, and respirations are $16$/min. Physical examination reveals pitting edema and tenderness over the right calf. The laparotomy incision is clean, dry, and intact.

Laboratory results today:
Hemoglobin: $11.2$ g/dL
Platelet count: $85,000/\text{mm}^3$ (preoperative: $250,000/\text{mm}^3$)
Leukocyte count: $9,500/\text{mm}^3$
Blood urea nitrogen: $48$ mg/dL
Serum creatinine: $3.4$ mg/dL

A compression ultrasonography of the right lower extremity confirms a new deep venous thrombosis in the popliteal vein. Which of the following is the most appropriate next step in the management of this patient?

A 64-year-old man is brought to the emergency department due to a 2-day history of progressively worsening shortness of breath and coughing up blood-tinged sputum. His past medical history is significant for chronic rhinosinusitis that has been poorly responsive to multiple courses of antibiotics, and migrating joint pains for the past 6 months. His temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $155/95\text{ mmHg}$, pulse is $108/\text{min}$, and respiratory rate is $26/\text{min}$. Oxygen saturation is 88% on room air. Physical examination reveals a mild collapse of the nasal bridge. Lung auscultation reveals diffuse bilateral crackles. Heart sounds are normal with no murmurs, gallops, or jugular venous distention. There is trace bilateral lower extremity edema. Laboratory results show:

Hemoglobin: $9.2\text{ g/dL}$
Leukocyte count: $14,000/\text{mm}^3$
Platelet count: $410,000/\text{mm}^3$
Blood urea nitrogen: $42\text{ mg/dL}$
Serum creatinine: $2.8\text{ mg/dL}$ (baseline $1.0\text{ mg/dL}$ 6 months ago)
Urinalysis: 2+ protein, large blood, 20-30 red blood cells/hpf, presence of red blood cell casts.

A portable chest radiograph shows bilateral, patchy, diffuse alveolar infiltrates. An electrocardiogram shows normal sinus rhythm. Which of the following is the most appropriate initial step in the management of this patient's acute condition?

Match the following classic peripheral blood smear findings with their most likely associated hematologic disorder.

A $38$-year-old woman is brought to the emergency department due to a $4$-day history of worsening fatigue, spontaneous bruising, and continuous oozing of blood from her gums. Her temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), blood pressure is $110/65 \text{ mm Hg}$, and pulse is $112/\text{min}$. Physical examination shows scattered petechiae and large ecchymoses over her extremities.

Laboratory studies reveal the following:

A peripheral blood smear demonstrates pancytopenia and atypical promyelocytes with abundant primary granules and multiple rod-like intracytoplasmic inclusions bundled together.

Arrange the following steps in the most appropriate chronological order for the diagnosis and management of this patient's condition:

Zoonotic and vector-borne infections can present with diverse, overlapping systemic symptoms. Their management heavily depends on the specific pathogen, disease stage, and patient comorbidities. Based on the clinical features provided, which antimicrobial regimen is the most appropriate next step in management for each patient? Match each clinical scenario with its optimal targeted pharmacotherapy.

Autoantibodies serve as crucial diagnostic markers in evaluating systemic autoimmune conditions. Match each specific clinical manifestation profile with the autoantibody most characteristically associated with the underlying disease.

Match each patient's clinical scenario with the most appropriate antimicrobial management strategy, reflecting current infectious disease and antimicrobial stewardship guidelines.

A 42-year-old man presents to the emergency department with a 4-week history of a persistent productive cough, subjective low-grade fevers, drenching night sweats, and an unintentional 5-kg (11-lb) weight loss. He immigrated to the United States from Southeast Asia five years ago. His vital signs are temperature 38.1°C (100.6°F), blood pressure 118/76 mmHg, heart rate 92/min, and respiratory rate 18/min. A portable chest radiograph performed in the emergency department demonstrates a 3-cm cavitary lesion in the apical segment of the right upper lobe. The patient is currently resting in a standard emergency department examination room with the door closed.

Arrange the following interventions in the most appropriate chronological sequence for the comprehensive management of this patient.

For each of the following patients, select the most appropriate targeted antimicrobial therapy based on current clinical guidelines and stewardship principles.

A 67-year-old female presents to an outpatient clinic complaining of progressively worsening shortness of breath over the last three days. She has a medical history of essential hypertension, hyperlipidemia, and a 45-pack-year smoking history. She reports increased chest tightness and wheezing but notes her daily cough remains productive of only minimal, clear sputum. She denies any fever, chills, orthopnea, or paroxysmal nocturnal dyspnea. Her medications include amlodipine, atorvastatin, and an albuterol inhaler. The temperature is 37.0°C (98.6°F), blood pressure is 154/90 mm Hg, pulse is 95/min, and respiratory rate is 22/min. Pulse oximetry reveals an oxygen saturation of 91% on room air. The jugular venous pressure is estimated at 5 cm H2O. Chest auscultation reveals a prolonged expiratory phase with widespread, high-pitched polyphonic wheezing bilaterally. No crackles or cardiac murmurs are heard. There is trace, chronic non-pitting edema of the lower extremities. Which of the following is the most appropriate next step in management?

A 24-year-old female undergoes comprehensive coagulation testing for a lifelong history of mucocutaneous bleeding and menorrhagia. Her hematologist suspects a variant of von Willebrand disease (vWD) and orders a full diagnostic panel, including vWF antigen (vWF:Ag), vWF ristocetin cofactor activity (vWF:RCo), Factor VIII activity, ristocetin-induced platelet aggregation (RIPA), and multimer analysis. Match the specific laboratory profiles below with their exact underlying molecular pathophysiology.