Internal Medicine

A $52$-year-old man requires reassessment in the intensive care unit on hospital day $4$. He was initially admitted for severe acute gallstone pancreatitis, presenting with intractable epigastric pain and a serum lipase level of $3,800\text{ U/L}$. Initial imaging via right upper quadrant ultrasound confirmed cholelithiasis but no choledocholithiasis. He has been managed with aggressive intravenous crystalloids and parenteral analgesia. Today, he reports persistent, though stable, abdominal discomfort. His temperature is $38.5^\circ\text{C}$ ($101.3^\circ\text{F}$), pulse is $110/\text{min}$, and blood pressure is $122/78\text{ mm Hg}$. Physical examination reveals a distended abdomen that is diffusely tender, with hypoactive bowel sounds.

Laboratory results are as follows:

An abdominal CT scan with intravenous contrast reveals diffuse pancreatic enlargement. There is non-enhancement affecting approximately $40\%$ of the pancreatic parenchyma, alongside a large volume of peripancreatic fluid. No intramural or retroperitoneal gas is visualized. Routine blood, urine, and sputum cultures drawn $12$ hours prior are currently negative.

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

An intensivist is reviewing the microbiological data for a 48-year-old male patient on mechanical ventilation. The patient was admitted to the intensive care unit 8 days ago following a motor vehicle collision that resulted in severe head trauma. Three days ago, he developed a new fever of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), thick endotracheal secretions, and worsening hypoxemia. A chest radiograph at that time revealed a new left lower lobe consolidation. He was empirically started on intravenous vancomycin, cefepime, and tobramycin for suspected ventilator-associated pneumonia (VAP).

Today, the patient is clinically improved. His temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), and his oxygen requirements have decreased. The endotracheal aspirate culture obtained prior to antibiotic initiation now shows:

- Heavy growth of *Pseudomonas aeruginosa*
- Moderate growth of *Candida albicans*
- No *Staphylococcus aureus* isolated

Antimicrobial susceptibility testing for the *Pseudomonas aeruginosa* isolate demonstrates susceptibility to cefepime, meropenem, piperacillin-tazobactam, and tobramycin. Blood cultures drawn at the time of the fever have remained sterile.

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

The following vignettes describe patients presenting with various glomerular diseases. Match each patient's clinical presentation with the most characteristic renal biopsy finding (immunofluorescence or electron microscopy) associated with their underlying condition.

A 42-year-old man comes to the clinic for a follow-up visit. Three weeks ago, he presented to the emergency department with a 1-week history of right upper quadrant pain, fever, and weight loss. He had recently returned from a 2-month trip to rural Mexico. At that time, a CT scan of the abdomen revealed a 6-cm, solitary, well-defined cystic lesion in the right hepatic lobe. Serologic testing was positive for a protozoal infection, and he was successfully treated with a 10-day course of oral metronidazole. His symptoms have now completely resolved, and a repeat ultrasound shows the lesion has decreased to 3 cm. His vital signs today are temperature 37.0°C (98.6°F), blood pressure 122/78 mmHg, and pulse 74/min. Physical examination reveals a soft, non-tender abdomen with normoactive bowel sounds. Laboratory studies show a leukocyte count of 7,200/mm³. He reports no current fever, abdominal pain, or changes in bowel habits. He currently works as a food prep worker at a local restaurant. Which of the following is the most appropriate next step in management?

A hospital's infection control committee is reviewing occupational exposure protocols. As part of a case-based training module for incoming residents, several distinct Hepatitis B serological profiles are presented to assess proficiency in post-exposure evaluation. Match each specific clinical interpretation with its corresponding Hepatitis B serological profile.

A 23-year-old man with sickle cell disease (HbSS) arrives at the emergency department accompanied by his roommate, reporting severe chest pain, a productive cough, and rapidly worsening shortness of breath over the past day. He was evaluated two days prior for a mild vaso-occlusive crisis and discharged with oral analgesics. Vital signs show a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure of $110/70\text{ mmHg}$, pulse of $122/\text{min}$, and respiratory rate of $28/\text{min}$. Pulse oximetry reveals an oxygen saturation of $85\%$ on room air. Examination shows scleral icterus and decreased breath sounds with dullness to percussion over the left lower lung field.

A chest radiograph demonstrates a new, dense left lower lobe consolidation. Immediate interventions including intravenous fluids, supplemental oxygen, and pain management are initiated.

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

A 28-year-old female presents to the clinic complaining of profound fatigue, a constant feeling of cold, and an inability to breastfeed her newborn infant. These symptoms have progressively worsened over the four months since she gave birth. Her delivery was complicated by severe uterine atony resulting in massive postpartum hemorrhage, which required an emergency peripartum hysterectomy and multiple blood transfusions. On physical examination, she appears pale and lethargic. Her blood pressure is 90/60 mm Hg and her pulse is 62/min. Which of the following thyroid function test profiles is most consistent with this patient's current condition?

A 68-year-old man is brought to the emergency department due to profound lethargy and significantly decreased urine output for the past 2 days. The patient reports having 5 to 6 episodes of large-volume watery diarrhea daily for the last 4 days. His medical history is significant for hypertension, benign prostatic hyperplasia, and type 2 diabetes mellitus. His current medications include lisinopril, metformin, and tamsulosin.

On physical examination, his blood pressure is 92/60 mm Hg, heart rate is 112/min, and respiratory rate is 16/min. The patient's oral mucosa is extremely dry, skin turgor is poor, and jugular venous pressure is flat.

Laboratory results are as follows:

Based on these findings, what is the calculated fractional excretion of sodium (FeNa) for this patient, expressed as a percentage?

A $34$-year-old man comes to the clinic for a routine health maintenance examination. He feels well and has no specific complaints. He has no history of nephrolithiasis, bone pain, fractures, or peptic ulcer disease. His family history is notable for asymptomatic hypercalcemia in his mother, which has never required treatment. He takes no medications. Vital signs are within normal limits. Physical examination reveals a healthy-appearing man with an unremarkable neck exam and normal deep tendon reflexes.

Laboratory results are as follows:

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

A 45-year-old woman is evaluated in the emergency department for 4 days of severe, voluminous watery diarrhea. She reports significant weakness and lightheadedness when standing. Her medical history is unremarkable, and she takes no medications. Vital signs show a temperature of 37.2°C (99°F), blood pressure of 96/60 mm Hg, heart rate of 114/min, and respiratory rate of 22/min. Physical examination shows dry mucous membranes and decreased skin turgor.

Laboratory studies show the following:

Arterial blood gas (room air):

Which of the following best describes this patient's current acid-base status?

A $62$-year-old man with a $40$-pack-year smoking history presents to the emergency department with a two-week history of progressive facial swelling, dull headache, and worsening shortness of breath. Physical examination reveals plethora of the face, engorged neck veins that do not collapse with inspiration, and dilated superficial veins over the upper anterior chest wall. His blood pressure is $135/85 \text{ mm Hg}$, heart rate is $98/\text{min}$, respiratory rate is $18/\text{min}$, and oxygen saturation is $94\%$ on room air. He is alert and oriented with no signs of stridor, respiratory distress, or airway compromise. Arrange the following steps in the most appropriate clinical sequence for evaluating and managing this patient's condition.

Match each patient's clinical presentation with the most likely corresponding peripheral blood smear finding.

Match each characteristic clinical, serologic, or histologic finding with the most appropriate hepatobiliary disorder.

A 64-year-old man presents to the emergency department with a 2-week history of progressive shortness of breath, a nonproductive cough, and facial fullness. He has a 45-pack-year smoking history. His temperature is 37.1°C (98.8°F), blood pressure is 138/85 mmHg, pulse is 102/min, and respirations are 22/min. Pulse oximetry is 94% on room air. Physical examination reveals prominent swelling and erythema of the face and neck. The jugular veins are distended, and dilated superficial veins are visible over the anterior chest. Pulmonary auscultation reveals decreased breath sounds at the right lung base but no wheezing or crackles. Cardiac examination shows normal heart sounds with no murmurs or gallops.

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

Match each patient's clinical presentation of toxic ingestion or poisoning with the most appropriate specific pharmacological antidote or treatment.

A 64-year-old man is evaluated on the medical ward on hospital day 3. He was initially admitted for a two-day history of productive cough, right-sided pleuritic chest pain, and fever. At the time of admission, his temperature was 38.9°C (102.0°F), and a chest radiograph revealed a right lower lobe consolidation. He was started on empiric intravenous ceftriaxone and azithromycin.

Today, the patient reports feeling much better and asks when he can be discharged. He is tolerating his meals without difficulty.

Vital signs are:
Temperature: 37.2°C (99.0°F)
Blood pressure: 128/82 mm Hg
Pulse: 84/min
Respirations: 16/min
Oxygen saturation: 96% on room air

Physical examination reveals diminished crackles at the right lung base, which are significantly improved compared to admission.

A sputum culture obtained on admission has grown Streptococcus pneumoniae. Susceptibility testing results are as follows:
Penicillin: Susceptible
Amoxicillin: Susceptible
Ceftriaxone: Susceptible
Levofloxacin: Susceptible
Azithromycin: Resistant

Which of the following is the most appropriate modification to this patient's antimicrobial therapy?

A 58-year-old female is admitted to the progressive care unit with worsening confusion, severe fatigue, abdominal pain, and polyuria over the past two weeks. She has a history of breast cancer treated with mastectomy and localized radiation five years ago. Vital signs show a blood pressure of 98/60 mm Hg and a heart rate of 110/min. Physical examination demonstrates dry mucous membranes and diminished skin turgor. Laboratory analysis reveals a serum calcium level of 14.8 mg/dL (normal: 8.4-10.2 mg/dL), a low parathyroid hormone level, and elevated parathyroid hormone-related peptide (PTHrP).

Arrange the following management steps in the most appropriate sequential order for this patient's acute severe hypercalcemia, from the immediate initial intervention to definitive long-term management.

Match each classic clinical presentation of secondary hypertension to its most likely underlying etiology.

A 35-year-old woman is evaluated in the outpatient clinic due to a 4-month history of profound fatigue, a 6-kg (13-lb) weight loss, and generalized weakness. She also reports feeling lightheaded when standing up quickly. She has not had a menstrual period since giving birth 18 months ago. Her delivery was complicated by severe postpartum hemorrhage requiring intensive care admission and multiple blood transfusions. She was unable to breastfeed her infant. She occasionally has a mild, nonproductive cough but no fever or chills. She does not use tobacco.

Her temperature is 37.2°C (99.0°F), blood pressure is 92/58 mm Hg sitting and 78/48 mm Hg standing, pulse is 102/min, and respirations are 16/min. Physical examination shows pale skin with no abnormal hyperpigmentation, and notably sparse axillary and pubic hair. Lung fields are clear to auscultation, and there is no jugular venous distention or peripheral edema.

Laboratory studies show the following:

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

A 65-year-old man with a history of stage 4 chronic kidney disease and heart failure with reduced ejection fraction is brought to the emergency department due to profound muscle weakness and palpitations. His home medications include lisinopril, spironolactone, and carvedilol. Vital signs show a blood pressure of $110/70 \text{ mmHg}$ and a heart rate of $52/\text{min}$. An electrocardiogram reveals sinus bradycardia with peaked T waves and widened QRS complexes. Laboratory studies demonstrate a serum potassium level of $7.6 \text{ mEq/L}$ and a serum creatinine of $3.4 \text{ mg/dL}$ (baseline $2.2 \text{ mg/dL}$). Arrange the following pharmacological interventions in the most appropriate chronological order for this patient's acute management.