Internal Medicine

A 42-year-old woman is newly diagnosed with limited cutaneous systemic sclerosis. She is highly anxious about the potential progression of her Raynaud phenomenon, which currently manifests as mild, infrequent vasospastic episodes triggered by cold exposure. During her clinic visit, she asks about the long-term management strategy for this condition if her symptoms worsen over time. You outline a stepwise therapeutic escalation pathway. Arrange the following management steps in the correct chronological order of therapeutic escalation, from the initial foundational intervention to the final rescue treatment for medically refractory, critical digital ischemia.

Review the following clinical presentations of patients with severe malabsorption or those receiving long-term parenteral nutrition. Match each clinical vignette to the specific underlying trace mineral deficiency it describes.

A 45-year-old woman presents to the clinic reporting pain and swelling in her wrists and the knuckles of both hands for the past 3 months. She mentions that her joints feel extremely stiff when she wakes up, typically taking about two hours to loosen up. Physical examination reveals tender, boggy swelling of the bilateral metacarpophalangeal and proximal interphalangeal joints. Initial laboratory testing is notable for an elevated erythrocyte sedimentation rate and a positive rheumatoid factor. Which of the following is the most appropriate initial disease-modifying pharmacotherapy for this patient?

A 68-year-old male is currently receiving care in the intensive care unit for acute respiratory distress syndrome secondary to severe acute pancreatitis. He has been mechanically ventilated for the past 11 days. Over the last 48 hours, his oxygen requirements have increased, and he has developed copious purulent endotracheal secretions. His temperature is 38.8°C (101.8°F), blood pressure is 110/65 mm Hg, and pulse is 112/min. Physical examination reveals coarse crackles in the right lung base. A portable chest radiograph demonstrates a new right lower lobe consolidation. Endotracheal aspirate and blood cultures are obtained, and the patient is empirically started on intravenous vancomycin, meropenem, and tobramycin.

Two days later, the patient's clinical status has improved, and he is afebrile. Blood cultures show no growth. The endotracheal aspirate culture yields heavy growth of *Enterobacter cloacae*. The antimicrobial susceptibility report is as follows:

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

A 42-year-old woman is brought to the emergency department by her husband due to a 24-hour history of severe headache, high fever, and worsening confusion. Her medical history is significant for a recent kidney transplant, for which she takes immunosuppressive medications. Her temperature is 39.2°C (102.6°F). Physical examination demonstrates marked nuchal rigidity and a new left lower extremity weakness. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for managing this patient.

A 24-year-old man is diagnosed with active ankylosing spondylitis characterized by progressive inflammatory back pain, elevated inflammatory markers, and severe morning stiffness. Arrange the following therapeutic interventions in the standard chronological sequence for escalating disease management, from initial first-line therapy to end-stage treatment.

A clinic evaluates a 55-year-old male who developed sudden, severe right knee swelling and pain 48 hours ago. He denies any recent trauma, falls, or prior joint issues. His current temperature is 38.2°C (100.8°F). Examination reveals a visibly enlarged, erythematous right knee that is exquisitely tender to palpation. Range of motion is severely limited by pain. Which of the following is the most appropriate initial step in the evaluation of this patient?

A 64-year-old woman is brought to the emergency department by her son due to worsening confusion, nausea, and ringing in her ears for the past 24 hours. She has a history of chronic obstructive pulmonary disease (COPD), hypertension, and osteoarthritis, for which she frequently takes over-the-counter analgesics. She also underwent transsphenoidal resection of a pituitary macroadenoma 5 years ago.

Vital signs: Temperature 37.1°C (98.8°F), blood pressure 110/70 mmHg, heart rate 112/min, respiratory rate 28/min.

Physical examination reveals dry mucous membranes and lethargy. Lung auscultation reveals clear breath sounds bilaterally. There is no jugular venous distention.

Laboratory results:
Sodium: 141 mEq/L
Potassium: 3.9 mEq/L
Chloride: 105 mEq/L
Bicarbonate: 14 mEq/L
Blood urea nitrogen: 38 mg/dL
Creatinine: 1.8 mg/dL
Thyroid-stimulating hormone (TSH): 1.1 µU/mL (normal: 0.4–4.0 µU/mL)
Free T4: 0.5 ng/dL (normal: 0.9–1.7 ng/dL)

Arterial blood gas on room air:
pH: 7.42
$PaCO_2$: 22 mmHg
$PaO_2$: 96 mmHg

A urine culture sent 3 days ago from an outpatient clinic visit for mild dysuria has returned positive for $>100,000$ CFU/mL of *Escherichia coli*, which is susceptible to cephalexin and nitrofurantoin, but resistant to fluoroquinolones.

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

A $19$-year-old male of Mediterranean descent is admitted to the hospital with newly diagnosed Burkitt lymphoma. He has a massive abdominal tumor burden. Baseline laboratory studies reveal a serum uric acid level of $14.2 \text{ mg/dL}$ and a serum creatinine of $1.9 \text{ mg/dL}$. To mitigate the risk of tumor lysis syndrome, he receives aggressive intravenous hydration and a dose of rasburicase. Forty-eight hours later, the patient acutely develops shortness of breath, fatigue, and bluish discoloration of his lips and fingertips. Vital signs are: temperature $37.1^\circ \text{C}$, heart rate $128$ /min, blood pressure $105/65$ mmHg, and respiratory rate $28$ /min. Pulse oximetry shows an oxygen saturation of $84\%$ on room air, which does not improve following the administration of $100\%$ oxygen via a non-rebreather mask. Arterial blood gas on $100\%$ oxygen shows a PaO $_2$ of $410$ mmHg. Blood drawn from the patient's vein appears chocolate-brown. Laboratory studies show a rapid decline in hemoglobin from $14.5 \text{ g/dL}$ to $8.2 \text{ g/dL}$. A peripheral blood smear reveals numerous bite cells and Heinz bodies. Which of the following is the most appropriate next step in the management of this patient's acute respiratory compromise?

Match each patient scenario describing the initiation of a specific targeted biologic or immunomodulatory therapy with the most appropriate infectious disease screening or prophylactic management step.

Match each advanced biologic or targeted synthetic disease-modifying antirheumatic drug (DMARD) with its most characteristic severe adverse effect or specific clinical contraindication.

A 68-year-old man is evaluated in the hospital on day 4 of admission for persistent low-grade fevers and fatigue. He originally presented with a 2-week history of generalized weakness, night sweats, and shortness of breath. His medical history is significant for hypertension and osteoarthritis. On examination today, temperature is 37.8°C (100.0°F), blood pressure is 128/76 mmHg, and pulse is 88/min. Cardiac auscultation reveals a new grade 3/6 holosystolic murmur heard best at the cardiac apex. Laboratory studies show a leukocyte count of 12,400/mm³ and serum creatinine of 1.4 mg/dL (baseline 0.9 mg/dL). Blood cultures drawn at admission have grown *Enterococcus faecalis* in 4 out of 4 bottles. Susceptibility testing demonstrates the isolate is susceptible to ampicillin, vancomycin, and linezolid, and lacks high-level aminoglycoside resistance. A transesophageal echocardiogram shows a 1.2-cm mobile vegetation on the mitral valve. The patient is currently receiving empiric therapy with intravenous vancomycin and cefepime. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

Match each clinical scenario describing a medication-specific toxicity, mechanism, or required screening protocol to the appropriate disease-modifying medication used in rheumatologic conditions.

A $74$-year-old man is admitted to the hospital with a four-week history of low-grade fevers, progressive fatigue, and an unintentional weight loss of $4\text{ kg}$ ($8.8\text{ lbs}$). His medical history is significant for ischemic cardiomyopathy, type 2 diabetes mellitus, and a surgical aortic valve replacement with a bioprosthetic valve three years ago. His temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $122/76\text{ mmHg}$, and pulse is $92/\text{min}$. Physical examination reveals a grade 3/6 diastolic murmur at the right upper sternal border. Inspection of the hands reveals small, painless, erythematous macules on the palms. A transesophageal echocardiogram shows an oscillating $1.1\text{ cm}$ mass on the bioprosthetic aortic valve. Three sets of blood cultures grow gram-positive cocci in pairs and short chains that are catalase-negative and capable of growing in $6.5\%$ sodium chloride broth. Susceptibility testing indicates that the organism is susceptible to ampicillin, vancomycin, and daptomycin, but it exhibits high-level resistance to gentamicin and streptomycin. His serum creatinine is $1.9\text{ mg/dL}$. Which of the following is the most appropriate targeted intravenous antibiotic regimen for this patient?

Pair each patient's key clinical findings with the most appropriate rheumatologic or vasculitic diagnosis.

During morning rounds on the general medical floor, a resident evaluates a newly admitted patient who presented overnight with chronic cough, progressive fatigue, and hemoptysis. The patient recently emigrated from a country with a high incidence of endemic respiratory pathogens. Vital signs reveal a temperature of $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$). Review of a portable chest radiograph obtained in the emergency department demonstrates a prominent cavitary opacity in the right upper lobe with surrounding consolidation. The clinical team strongly suspects active pulmonary tuberculosis.

Arrange the following clinical and infection control interventions in the most appropriate chronological sequence for this patient.

A 24-year-old primigravid woman at 26 weeks gestation is evaluated during a routine prenatal visit. She has no fatigue, dyspnea, or palpitations. Her pregnancy has been uncomplicated. She takes a daily prenatal multivitamin. Blood pressure is 112/70 mm Hg and pulse is 78/min. Physical examination shows a gravid uterus consistent with gestational age and no peripheral edema.

Laboratory results are as follows:

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

Review the following clinical presentations of patients who develop complications during or shortly after receiving blood product transfusions. Match each patient's clinical scenario with the primary pathophysiologic mechanism responsible for their reaction.

Match each patient's clinical presentation with the most likely causative pneumonia pathogen.

A 62-year-old woman is evaluated on postoperative day 6 following a right total knee arthroplasty. Since the surgery, she has been receiving subcutaneous unfractionated heparin for deep vein thrombosis prophylaxis. Today, she reports new-onset left calf pain and swelling.

Vital signs are within normal limits. Physical examination reveals left calf tenderness, erythema, and 2+ pitting edema up to the knee.

Laboratory studies on admission:
Hemoglobin: 13.2 g/dL
Leukocyte count: 8,500/mm³
Platelet count: 260,000/mm³

Laboratory studies today:
Hemoglobin: 12.8 g/dL
Leukocyte count: 9,200/mm³
Platelet count: 110,000/mm³

A duplex ultrasonography of the left lower extremity demonstrates a noncompressible popliteal vein. Which of the following is the most appropriate next step in management?