Internal Medicine

Match each clinical presentation of infective endocarditis with the most appropriate targeted antimicrobial regimen based on current consensus guidelines.

A $45$-year-old man is hospitalized for community-acquired pneumonia. Ten minutes after starting his first dose of intravenous ceftriaxone, he develops sudden-onset diffuse urticaria, shortness of breath, and throat tightness. His temperature is $37.2^{\circ}\text{C}$ ($99.0^{\circ}\text{F}$), blood pressure is $82/50\text{ mm Hg}$, pulse is $124/\text{min}$, and respiratory rate is $26/\text{min}$. Oxygen saturation is $90\%$ on room air. Examination reveals diffuse expiratory wheezing and facial angioedema. Arrange the following steps in the most appropriate chronological order for the acute management of this patient's condition.

A $44$-year-old woman is evaluated for a $6$-month history of progressive weight gain, new-onset facial hair growth, and easy bruising. Her blood pressure is $160/100$ mmHg. Physical examination reveals a rounded face, dorsocervical fat pad, prominent proximal muscle weakness, and wide, violaceous abdominal striae.

Arrange the following diagnostic steps in the most appropriate sequential order to establish the diagnosis and definitively localize the source of this patient's condition, assuming each successive biochemical test points toward a pituitary origin but initial anatomic imaging remains equivocal.

A $35$-year-old woman is brought to the emergency department by her husband due to progressive confusion and lethargy that began yesterday. Over the past week, she has complained of profound fatigue, intermittent nausea, and a low-grade fever. She has no significant past medical history and takes no medications. On physical examination, her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $130/80\text{ mmHg}$, pulse is $105/\text{min}$, and respirations are $16/\text{min}$. She is mildly disoriented to time and place. Examination of her skin reveals diffuse petechiae and purpura over her bilateral lower extremities. Laboratory studies show:

Hemoglobin: $7.8\text{ g/dL}$
Platelet count: $22,000/\text{mm}^3$
Leukocyte count: $7,200/\text{mm}^3$
Blood urea nitrogen: $35\text{ mg/dL}$
Serum creatinine: $2.4\text{ mg/dL}$
Total bilirubin: $3.2\text{ mg/dL}$
Indirect bilirubin: $2.6\text{ mg/dL}$
Lactate dehydrogenase (LDH): $950\text{ U/L}$
Direct antiglobulin (Coombs) test: Negative
Prothrombin time (PT): $12\text{ seconds}$
Activated partial thromboplastin time (aPTT): $30\text{ seconds}$

A peripheral blood smear reveals numerous schistocytes.

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

A $42$-year-old man presents to the clinic for follow-up of hypertension. His blood pressure remains poorly controlled at $165/100$ mmHg despite adherence to maximum doses of amlodipine, lisinopril, and chlorthalidone. Laboratory results reveal a serum potassium level of $3.1$ mEq/L. The physician suspects secondary hypertension due to primary hyperaldosteronism.

Arrange the following diagnostic steps in the correct sequential order to evaluate and localize this patient's suspected condition.

A 74-year-old man is brought to the emergency department by his daughter due to severe pain and swelling in his right knee that began 18 hours ago. He cannot bear weight on the affected leg. His medical history is significant for primary hyperparathyroidism, osteoarthritis, and stage 3 chronic kidney disease. His temperature is 38.0°C (100.4°F), blood pressure is 142/88 mmHg, and pulse is 96/min. Physical examination reveals a swollen, warm, and erythematous right knee with a palpable effusion. Range of motion is severely limited by pain. Arthrocentesis yields 25 mL of cloudy yellow synovial fluid. Laboratory analysis of the fluid reveals a leukocyte count of 32,000/mm³ with 82% neutrophils. Polarized light microscopy of the fluid demonstrates rhomboid-shaped, weakly positively birefringent crystals. Gram stain of the synovial fluid shows no organisms. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old man presents to the primary care office for evaluation of profound sluggishness and persistent constipation over the last five months. He mentions that he needs to wear a heavy sweater even when indoors because he constantly feels chilled. His medical background is significant for surgical removal of a large benign pituitary mass three years prior. On physical examination, his heart rate is 58/min, and there is a noticeable delay in the relaxation phase of his Achilles reflexes. Laboratory testing reveals the following:

Which of the following best describes the underlying mechanism for this patient's current condition?

Match each clinical presentation of an infectious disease to its most appropriate, targeted first-line pharmacotherapy.

Match each clinical presentation of a sexually transmitted infection to its most appropriate definitive antimicrobial management strategy based on current guidelines.

A patient in the surgical intensive care unit develops oliguria on the second day following an elective partial colectomy. Over the past 8 hours, the urinary catheter has drained only 150 mL of highly concentrated urine. The patient has been receiving maintenance intravenous fluids at a conservative rate due to a known history of heart failure with preserved ejection fraction.

Vital signs show a temperature of 37.2°C (99.0°F), heart rate of 105/min, and blood pressure of 102/65 mmHg. Physical examination reveals dry oral mucosa and flat jugular veins.

Laboratory studies are obtained:

Based on the provided laboratory values, calculate the patient's fractional excretion of sodium (FENa). (Enter your answer as a percentage.)

A $78$-year-old man is brought to the emergency department from a skilled nursing facility due to a $2$-day history of progressively worsening confusion, profound lethargy, and severe constipation. His past medical history is significant for advanced prostate cancer with known bone metastases, benign prostatic hyperplasia, and the presence of a chronic indwelling urethral catheter.

Upon arrival, his temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $136/84\text{ mm Hg}$, pulse is $76/\text{min}$, and respirations are $14/\text{min}$. He is difficult to arouse but oriented to person when awakened. Physical examination reveals markedly dry mucous membranes and poor skin turgor. His abdomen is soft and non-tender, and there is no costovertebral angle or suprapubic tenderness.

Laboratory evaluation shows:
- Leukocyte count: $8,200/\text{mm}^3$
- Hemoglobin: $10.4\text{ g/dL}$
- Serum creatinine: $1.8\text{ mg/dL}$ (baseline $1.0\text{ mg/dL}$)
- Blood urea nitrogen: $42\text{ mg/dL}$
- Serum calcium: $13.8\text{ mg/dL}$
- Serum albumin: $3.5\text{ g/dL}$

Urinalysis reveals cloudy urine with positive leukocyte esterase, positive nitrites, and $45-50\text{ white blood cells/hpf}$.

The patient is admitted and aggressively treated with intravenous normal saline and calcitonin, resulting in a rapid improvement in his mental status over the next $24$ hours. However, a urine culture obtained at the time of admission now grows $>10^5\text{ CFU/mL}$ of *Escherichia coli*. The isolate is resistant to ciprofloxacin but susceptible to ceftriaxone, cefepime, and meropenem.

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

A 74-year-old man is evaluated on the inpatient medical ward due to the sudden onset of severe shortness of breath and a dry cough. He was admitted $2\text{ days}$ ago for symptomatic anemia secondary to newly diagnosed myelodysplastic syndrome. His past medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$, type 2 diabetes mellitus, and a 40-pack-year smoking history. The patient is currently $45\text{ minutes}$ into a transfusion of his second unit of packed red blood cells (PRBCs). His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), heart rate is $118/\text{min}$, respiratory rate is $28/\text{min}$, and blood pressure is $172/96\text{ mmHg}$. Pulse oximetry shows an oxygen saturation of $85\%$ on room air. The patient is in acute respiratory distress and is using accessory muscles of respiration. Jugular venous pulsation is visible at $13\text{ cm H}_2\text{O}$. Lung auscultation reveals bilateral crackles halfway up the posterior lung fields and scattered expiratory wheezes. Cardiac examination reveals a regular tachycardia with a prominent $S_3$ gallop. There is no skin rash or urticaria. Arterial blood gas on room air shows a pH of $7.28$, $\text{PaCO}_2$ of $58\text{ mmHg}$, and $\text{HCO}_3^-$ of $26\text{ mEq/L}$. Which of the following is the most appropriate next step in the management of this patient?

A 45-year-old woman comes to the clinic for evaluation of a neck lump she noticed in the mirror while swallowing. She reports feeling generally well but mentions having occasional palpitations and a slight increase in the frequency of her bowel movements over the past few months. Her weight has been stable. Vital signs are temperature 37.1°C (98.8°F), blood pressure 128/78 mmHg, and pulse 96/min. Physical examination reveals a 1.6-cm, smooth, firm, and mobile nodule in the left lobe of the thyroid gland. No cervical lymphadenopathy is appreciated. A thyroid ultrasound confirms the presence of a 1.6-cm solid, hypoechoic nodule with regular margins in the left lobe, and no suspicious lymph nodes. Laboratory testing shows a serum thyroid-stimulating hormone (TSH) level of 0.05 µU/mL (normal: 0.4–4.0 µU/mL). Which of the following is the most appropriate next step in the management of this patient?

A $59$-year-old woman with a history of squamous cell carcinoma of the lung is admitted to the hospital with worsening lethargy, abdominal pain, and confusion over the past $3$ days. Her vital signs show a blood pressure of $102/64$ mmHg and a heart rate of $110$/min. Physical examination reveals dry mucous membranes and delayed capillary refill. Laboratory testing reveals a severely elevated serum calcium level of $15.2$ mg/dL. The decision is made to initiate acute medical management for severe hypercalcemia.

Arrange the following interventions in the correct chronological order of their required administration and physiological onset of action, starting with the most immediate first-line resuscitative step and ending with the therapy that provides delayed but sustained long-term control.

A $42$-year-old man comes to the clinic reporting progressive fatigue, weakness, and a $6$-kg ($13.2$-lb) weight loss over the past $4$ months. He feels constantly cold and reports a significant decrease in libido. His medical history is notable for a traumatic brain injury sustained in a motor vehicle collision $18$ months ago, which required a prolonged intensive care unit stay. Vital signs show a blood pressure of $98/62 \text{ mm Hg}$ while supine and $82/50 \text{ mm Hg}$ while standing. His heart rate is $64\text{/min}$. On physical examination, the patient appears lethargic. His skin is pale with no areas of hyperpigmentation. The thyroid gland is not palpable. Testicular volume is decreased bilaterally. Laboratory results are as follows:

Sodium: $130 \text{ mEq/L}$
Potassium: $4.1 \text{ mEq/L}$
Thyroid-stimulating hormone (TSH): $1.4 \text{ \mu U/mL}$ (Normal: $0.4-4.0 \text{ \mu U/mL}$)
Free T4: $0.5 \text{ ng/dL}$ (Normal: $0.9-1.7 \text{ ng/dL}$)

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

Evaluation for hospital discharge is being performed for a $67$-year-old male recovering from community-acquired pneumonia. Upon initial admission $3$ days ago, he presented with a temperature of $39.1^\circ C$ ($102.4^\circ F$), productive cough, and right lower lobe consolidation on chest radiography. Empiric treatment was initiated with intravenous ceftriaxone and azithromycin. Currently, he has been afebrile for $28$ hours, his respiratory rate is $16$/min, and oxygen saturation is $96\%$ on room air. He is ambulating well and tolerating a regular diet. Blood cultures obtained at admission have finalized, growing *Streptococcus pneumoniae*. Antimicrobial susceptibility testing indicates the isolate is susceptible to penicillin (MIC $\leq 0.03 \mu$ g/mL), amoxicillin, ceftriaxone, levofloxacin, and linezolid. Based on these findings, which of the following is the most appropriate antimicrobial strategy for discharge?

A 34-year-old woman presents to an outpatient rheumatology clinic with a four-month history of symmetric pain, swelling, and pronounced morning stiffness in her wrists and metacarpophalangeal joints. Serologic testing demonstrates high titers of anti-cyclic citrullinated peptide (anti-CCP) antibodies, and imaging confirms early periarticular osteopenia. She is diagnosed with active, moderate-to-severe rheumatoid arthritis. Assuming this patient experiences an inadequate clinical response or refractory disease progression at each stage of standard management over the next decade, arrange the following therapeutic interventions in the most appropriate chronological order of step-up therapy.

Match each clinical presentation of hypercalcemia to its most likely underlying pathophysiologic mechanism.

A 32-year-old woman is brought to the emergency department by her husband due to progressive lethargy and confusion. She has a history of Crohn disease and has been experiencing frequent, voluminous, watery diarrhea for the past four days. Two days ago, she was prescribed oral hydrocodone-acetaminophen for an acute musculoskeletal back injury. Her husband reports she has been taking the pain medication more frequently than prescribed. Temperature is 37.1°C (98.8°F), blood pressure is 92/60 mm Hg, pulse is 112/min, and respirations are 8/min. Physical examination shows dry mucous membranes, decreased skin turgor, and pinpoint pupils. The patient is somnolent but arousable. Laboratory studies are obtained:

Based on these findings, which of the following best describes this patient's acid-base disorder?

A $61$-year-old woman with a known history of advanced HIV (recent CD4 count $85/\text{mm}^3$) arrives at the emergency department accompanied by her daughter. She has a $2$-day history of progressively severe generalized headache, subjective fevers, and profound lethargy. Upon arrival, her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $110/65\text{ mmHg}$, pulse is $112/\text{min}$, and respirations are $18/\text{min}$. On physical examination, she is difficult to arouse and oriented only to person. Neck flexion produces involuntary hip and knee flexion. Neurologic evaluation reveals that the right pupil is $4\text{ mm}$ and sluggishly reactive, while the left is $2\text{ mm}$ and briskly reactive. Arrange the following diagnostic and therapeutic steps in the optimal chronological sequence for this patient's initial management.