1
AQUIFER INTERNAL MEDICINE END
OF CASE QUESTIONS WITH
SOLUTIONS 2026
A 77-year-old female is brought to the office by her daughter with complaints of
fatigue, poor appetite, and forgetfulness that have been getting progressively
worse over the past three months. Conversing with the patient is difficult, as she
only provides one-word answers to your questions; her daughter provides most
of the history. The patient has had weight loss and constipation for which she has
been taking glycerin suppositories. She has had more difficulty bathing and
decreased motivation to practice good hygiene. She lives alone, but her daughter
is nearby and has been visiting her with increasing frequency over the past
month. On physical examination, she is afebrile. Her pulse is 120 beats/minute.
Her blood pressure is 140/90 mmHg. She appears frail and disheveled. A mini-
mental state examination (MMSE) is performed, and her score is 7. What would
be the next best step in management?
A. No further lab testi - correct-answer - The answer is C. From IM 18.
, 2
You are asked to evaluate a 75-year-old female with a history of coronary artery
disease and hypertension who presents with forgetfulness and difficulty caring for
herself. She is accompanied by her son who has noticed a progressive functional
decline in his mother over at least the past year. She has been increasingly
forgetful, including several incidents wherein she would leave water for tea
boiling for hours. In the past two months, he has taken over the management of
her bills, as she had missed several payments. She is able to ambulate without
assistance. Two days ago, her neighbors found her wandering around the
neighborhood in the middle of the night. When they tried to redirect her, she
became agitated, yelling that strangers were trying to rob her. She calmed down
when her son arrived to the scene. She states that she does not feel depressed.
Her vital signs are normal. Her physical exam was unremarkable an - correct-
answer - The answer is A. From IM 18.
A 56-year-old female is being evaluated in the hospital for anemia. She was
admitted five days ago with a myocardial infarction. She underwent stent
, 3
placement and was doing well until last night when she developed lower
abdominal cramping and started passing blood clots in her stools. Her medical
history is significant for type II diabetes mellitus, hypertension, hypothyroidism,
and rheumatoid arthritis. On physical examination, she appears to be in mild
distress. Her pulse is 100 beats/minute and blood pressure is 110/54 mmHg.
Abdominal exam reveals tenderness in bilateral lower quadrants with no guarding
or rigidity. The remainder of her exam is normal. A complete blood count (CBC)
obtained today is shown. White blood count (WBC): 5 cells x103/μL
Hemoglobin (Hgb): 8 g/dLHematocrit (Hct): 24% Mean corpuscular volume (MCV):
84 μm3
Red blood cell distribution width (RDW): 12 Platelets: 280,000 /mm3A complete
blood cou - correct-answer - The answer is A. From IM 19.
A 22-year-old male comes to your office with fatigue and shortness of breath on
exertion. On exam, you notice conjunctival pallor. You obtain a hemogram, which
shows the following: Hemoglobin: 10 g/dL Hematocrit: 29%
Mean corpuscular volume (MCV): 74 μm3 Red blood cell distribution width
(RDW): 14% What is the most likely diagnosis?
, 4
A. Beta thalassemia
B. Hemolytic anemia
C. Hypothyroidism
D. Iron deficiency anemia
E. Sideroblastic anemia - correct-answer - The answer is A. From IM 19.
An 84-year-old female comes to the clinic with concern for fatigue for the past six
months. Otherwise, a review of systems is negative. On physical examination, her
vital signs show pulse is 99 beats/minute, blood pressure is 122/76 mmHg,
oxygen saturation is 98% on room air. She appears slightly pale, but is otherwise
comfortable. Cardiovascular and pulmonary examination is otherwise normal. Her
complete blood count (CBC) is as follows:
White blood cell (WBC): 3.2 cells x 103/μL
Hemoglobin: 7.5 g/dL
Hematocrit (Hct): 22%
Mean corpuscular volume (MCV): 84 μm3
Red blood cell distribution width (RDW): 20 fLPlatelet (Plt): 128,000 mm3
AQUIFER INTERNAL MEDICINE END
OF CASE QUESTIONS WITH
SOLUTIONS 2026
A 77-year-old female is brought to the office by her daughter with complaints of
fatigue, poor appetite, and forgetfulness that have been getting progressively
worse over the past three months. Conversing with the patient is difficult, as she
only provides one-word answers to your questions; her daughter provides most
of the history. The patient has had weight loss and constipation for which she has
been taking glycerin suppositories. She has had more difficulty bathing and
decreased motivation to practice good hygiene. She lives alone, but her daughter
is nearby and has been visiting her with increasing frequency over the past
month. On physical examination, she is afebrile. Her pulse is 120 beats/minute.
Her blood pressure is 140/90 mmHg. She appears frail and disheveled. A mini-
mental state examination (MMSE) is performed, and her score is 7. What would
be the next best step in management?
A. No further lab testi - correct-answer - The answer is C. From IM 18.
, 2
You are asked to evaluate a 75-year-old female with a history of coronary artery
disease and hypertension who presents with forgetfulness and difficulty caring for
herself. She is accompanied by her son who has noticed a progressive functional
decline in his mother over at least the past year. She has been increasingly
forgetful, including several incidents wherein she would leave water for tea
boiling for hours. In the past two months, he has taken over the management of
her bills, as she had missed several payments. She is able to ambulate without
assistance. Two days ago, her neighbors found her wandering around the
neighborhood in the middle of the night. When they tried to redirect her, she
became agitated, yelling that strangers were trying to rob her. She calmed down
when her son arrived to the scene. She states that she does not feel depressed.
Her vital signs are normal. Her physical exam was unremarkable an - correct-
answer - The answer is A. From IM 18.
A 56-year-old female is being evaluated in the hospital for anemia. She was
admitted five days ago with a myocardial infarction. She underwent stent
, 3
placement and was doing well until last night when she developed lower
abdominal cramping and started passing blood clots in her stools. Her medical
history is significant for type II diabetes mellitus, hypertension, hypothyroidism,
and rheumatoid arthritis. On physical examination, she appears to be in mild
distress. Her pulse is 100 beats/minute and blood pressure is 110/54 mmHg.
Abdominal exam reveals tenderness in bilateral lower quadrants with no guarding
or rigidity. The remainder of her exam is normal. A complete blood count (CBC)
obtained today is shown. White blood count (WBC): 5 cells x103/μL
Hemoglobin (Hgb): 8 g/dLHematocrit (Hct): 24% Mean corpuscular volume (MCV):
84 μm3
Red blood cell distribution width (RDW): 12 Platelets: 280,000 /mm3A complete
blood cou - correct-answer - The answer is A. From IM 19.
A 22-year-old male comes to your office with fatigue and shortness of breath on
exertion. On exam, you notice conjunctival pallor. You obtain a hemogram, which
shows the following: Hemoglobin: 10 g/dL Hematocrit: 29%
Mean corpuscular volume (MCV): 74 μm3 Red blood cell distribution width
(RDW): 14% What is the most likely diagnosis?
, 4
A. Beta thalassemia
B. Hemolytic anemia
C. Hypothyroidism
D. Iron deficiency anemia
E. Sideroblastic anemia - correct-answer - The answer is A. From IM 19.
An 84-year-old female comes to the clinic with concern for fatigue for the past six
months. Otherwise, a review of systems is negative. On physical examination, her
vital signs show pulse is 99 beats/minute, blood pressure is 122/76 mmHg,
oxygen saturation is 98% on room air. She appears slightly pale, but is otherwise
comfortable. Cardiovascular and pulmonary examination is otherwise normal. Her
complete blood count (CBC) is as follows:
White blood cell (WBC): 3.2 cells x 103/μL
Hemoglobin: 7.5 g/dL
Hematocrit (Hct): 22%
Mean corpuscular volume (MCV): 84 μm3
Red blood cell distribution width (RDW): 20 fLPlatelet (Plt): 128,000 mm3
