Aquifer Internal Medicine End of Case
Questions and answers Newest RATED A+
A 52-year-old female presents with one month of progressive dyspnea on exertion, a productive
II! II! II! II! II! II! II! II! II! II! II! II! II!
cough of clear sputum, bilateral leg swelling, and orthopnea. She has had no chest pain or fevers.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
She has a history of poorly controlled hypertension and 30-pack-years of smoking. Before
II! II! II! II! II! II! II! II! II! II! II! II! II!
beginning her physical exam, you determine that her pre-exam probability of heart failure is
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
moderate. On exam, you find a jugular venous pulse and pressure (JVP) of 12 cm with positive
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
hepatojugular reflux, regular heart rate, normal S1 and S2 with S3 gallop, 3/6 systolic crescendo-
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
decrescendo murmur at the right upper sternal border, crackles at both lung bases. Which of the II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
following physical examination findings most increases your post-exam probability of congestive
II! II! II! II! II! II! II! II! II! II! II!
heart failure?
II! II!
A. Bibasilar crackles
II! II!
B. Hepatojugular reflux
II! II!
C. Increased jugular venous pressure
II! II! II! II!
D. Systolic murmur in the aortic area
II! II! II! II! II! II!
E. Third heart sound - Correct Answers The answer is E. From IM 04.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! A 68-year-old male with hypertension and non-ischemic cardiomyopathy is admitted to the
II! II! II! II! II! II! II! II! II! II! II!
II! hospital with an acute exacerbation of his congestive heart failure (CHF). An echocardiogram
II! II! II! II! II! II! II! II! II! II! II! II!
II! (ECG) one month ago showed left-ventricular hypertrophy and a left-ventricular ejection fracture
II! II! II! II! II! II! II! II! II! II! II!
II! (LVEF) of 60%. He takes ramipril and chlorthalidone at home, and these are continued. His pulse is
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! 85 beats/minutes, blood pressure is 134/88 mmHg, and oxygen saturation is 95% on two liters of
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! oxygen by nasal cannula. His exam is notable for jugular venous pulse and pressure (JVP) of 12,
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! bilateral leg edema, and crackles at his lung bases. What will be the next step in management of
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! this man? II!
A. Add furosemide intravenously
II! II! II!
B. Add metoprolol orally
II! II! II!
,C. Add valsartan
II! II!
D. Increase dose of chlorthalidone
II! II! II! II!
E. Increase dose of ramipril - Correct Answers The answer is A. From IM 04.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
A 56-year-old female with non-ischemic cardiomyopathy and hypertension presents to the office
II! II! II! II! II! II! II! II! II! II! II! II!
for a routine followup. Her last hospitalization for a congestive heart failure (CHF) exacerbation
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
was two years ago. Currently, she has no shortness of breath, orthopnea, leg edema, or chest
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
pain. She has been following a low-salt diet and does not drink alcohol. Her medications are
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
carvedilol and a baby aspirin. Her home blood pressure measurements have ranged from 140-
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
150/80-90 mmHg. Her exam is notable for a blood pressure of 150/90 mmHg. Her pulse is 60 II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
beats/minute with normal S1 and S2 with no murmurs or gallops, and she has a normal
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
respiratory rate. Her jugular venous pulse and pressure (JVP) is normal and her lungs are clear.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
Her point of maximal impulse (PMI) is laterally displaced. What medication should you add that
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
can also improve her mortality from heart failure?
II! II! II! II! II! II! II! II!
A. Amlodipine
II!
B. Digoxin
II!
C. Furosemide
II!
D. Hyd - Correct Answers The answer is E. From IM 04.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! Which of the following physical examination findings is most consistent with right-sided heart
II! II! II! II! II! II! II! II! II! II! II! II!
II! failure?
A. Abdominojugular reflux
II! II!
B. Bibasilar crackles
II! II!
C. Pitting pedal edema
II! II! II!
D. Sustained apical impulse
II! II! II!
E. Systolic murmur at right upper sternal border - Correct Answers The answer is A. From IM 04.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
,II! A 68-year-old female is admitted to the hospital because of increasing dyspnea and orthopnea
II! II! II! II! II! II! II! II! II! II! II! II! II!
II! over the past two weeks. Her medical history is significant for ischemic cardiomyopathy with an
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! ejection fraction of 40% and low back pain for one month. She reports no chest pain, palpitations,
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! fever, and cough. She has been adherent to a low-sodium diet. She does not use alcohol or
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! tobacco. Daily medications are carvedilol, lisinopril, amlodipine, atorvastatin, aspirin, and
II! II! II! II! II! II! II! II! II!
II! ibuprofen. Which medication would most likely cause her worsening symptoms?
II! II! II! II! II! II! II! II! II!
A. Amlodipine
II!
B. Atorvastatin
II!
C. Carvedilol
II!
D. Ibuprofen
II!
E. Lisinopril - Correct Answers The answer is D. From IM 04.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! A 24-year-old female presents to the emergency department with 18 hours of lower abdominal
II! II! II! II! II! II! II! II! II! II! II! II! II!
II! pain, nausea, vomiting, and diarrhea. She is afebrile and has normal vital signs except for
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! tachycardia with a pulse at 105 beats/minute. Her abdomen is soft and non-distended with
II! II! II! II! II! II! II! II! II! II! II! II! II!
II! hypoactive bowel sounds. There is rebound tenderness in the left-lower quadrant. The
II! II! II! II! II! II! II! II! II! II! II!
II! abdominal exam finding of rebound tenderness has +LR = 2 and -LR = 0.4 for peritonitis. What is
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! the best interpretation of this finding?
II! II! II! II! II!
A. Absence of rebound tenderness strongly argues against peritonitis
II! II! II! II! II! II! II! II!
B. Absence of rebound tenderness strongly argues against peritonitis, but presence of it does not
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
affect the probability of peritonitis
II! II! II! II! II!
C. Neither the presence nor the absence of rebound tenderness is very helpful in diagnosing
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
peritonitis
II!
D. Presence of rebound tenderness strongly suggests peritonitis
II! II! II! II! II! II! II!
E. Presence of rebound tenderness strongly suggests peritoniti - Correct Answers The answer is
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
C. From IM 12.
II! II! II! II!
, II! A 39-year-old male with no significant past medical history presents to the hospital with lower
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! abdominal pain for the past two days. His initial vitals are notable where his temperature is 38.5 C
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! (101.3 F), pulse is 112 beats/minute, and blood pressure is 103/68 mmHg. He reports that his last
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! bowel movement was two days ago, and he recalls passing flatus earlier today. Your physical
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! exam reveals hypoactive bowel sounds, and a diffusely tender abdomen, most tender in the
II! II! II! II! II! II! II! II! II! II! II! II! II!
II! right-lower quadrant. His abdominal muscles are tense, and do not relax with distraction II! II! II! II! II! II! II! II! II! II! II! II!
II! techniques. A computed tomography (CT) scan of the abdomen and pelvis confirms your II! II! II! II! II! II! II! II! II! II! II! II!
II! suspected diagnosis. You order broad-spectrum intravenous (IV) antibiotics. What is the best next
II! II! II! II! II! II! II! II! II! II! II! II!
II! step in management?
II! II!
A. Call a gastrointestinal (GI) consult for colonoscopy
II! II! II! II! II! II! II!
B. Call a surgical consult
II! II! II! II!
C. Order a bowel regimen
II! II! II! II!
D. Place a nasogastric tube for decompression
II! II! II! II! II! II!
E. Start - Correct Answers The answer is B. From IM 12.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! A 68-year-old male with a history of peptic ulcer disease, diabetes mellitus, and hypertension is
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! admitted to the hospital with a 24-hour history of abdominal pain and three episodes of loose
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! stool. Initial vital signs reveal temperature is 38.9 C (102.02 F), pulse is 102 beats/minute,
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! respiratory rate is 16 breaths/minute, blood pressure is 132/78 mmHg, and oxygen saturation is
II! II! II! II! II! II! II! II! II! II! II! II! II!
II! 98% on room air. White blood count (WBC) is 13,100 cells/μl. He has tenderness to palpation of
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! the left lower quadrant of his abdomen, with guarding but no rigidity. Renal function is normal.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! Computerized tomography (CT) scan of the abdomen and pelvis shows sigmoid diverticulitis II! II! II! II! II! II! II! II! II! II! II!
II! without any sign of abscess or perforation. In addition to ordering intravenous (IV) antibiotics, IV
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! fluid, and pain medication, what is the next best step in management?
II! II! II! II! II! II! II! II! II! II! II!
A. Blood cultures
II! II!
B. Colorectal surgery consult
II! II! II!
C. High-fiber diet
II! II!
D. Stool culture
II! II!
E. Stool te - Correct Answers The answer is A. From IM 12.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
Questions and answers Newest RATED A+
A 52-year-old female presents with one month of progressive dyspnea on exertion, a productive
II! II! II! II! II! II! II! II! II! II! II! II! II!
cough of clear sputum, bilateral leg swelling, and orthopnea. She has had no chest pain or fevers.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
She has a history of poorly controlled hypertension and 30-pack-years of smoking. Before
II! II! II! II! II! II! II! II! II! II! II! II! II!
beginning her physical exam, you determine that her pre-exam probability of heart failure is
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
moderate. On exam, you find a jugular venous pulse and pressure (JVP) of 12 cm with positive
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
hepatojugular reflux, regular heart rate, normal S1 and S2 with S3 gallop, 3/6 systolic crescendo-
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
decrescendo murmur at the right upper sternal border, crackles at both lung bases. Which of the II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
following physical examination findings most increases your post-exam probability of congestive
II! II! II! II! II! II! II! II! II! II! II!
heart failure?
II! II!
A. Bibasilar crackles
II! II!
B. Hepatojugular reflux
II! II!
C. Increased jugular venous pressure
II! II! II! II!
D. Systolic murmur in the aortic area
II! II! II! II! II! II!
E. Third heart sound - Correct Answers The answer is E. From IM 04.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! A 68-year-old male with hypertension and non-ischemic cardiomyopathy is admitted to the
II! II! II! II! II! II! II! II! II! II! II!
II! hospital with an acute exacerbation of his congestive heart failure (CHF). An echocardiogram
II! II! II! II! II! II! II! II! II! II! II! II!
II! (ECG) one month ago showed left-ventricular hypertrophy and a left-ventricular ejection fracture
II! II! II! II! II! II! II! II! II! II! II!
II! (LVEF) of 60%. He takes ramipril and chlorthalidone at home, and these are continued. His pulse is
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! 85 beats/minutes, blood pressure is 134/88 mmHg, and oxygen saturation is 95% on two liters of
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! oxygen by nasal cannula. His exam is notable for jugular venous pulse and pressure (JVP) of 12,
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! bilateral leg edema, and crackles at his lung bases. What will be the next step in management of
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! this man? II!
A. Add furosemide intravenously
II! II! II!
B. Add metoprolol orally
II! II! II!
,C. Add valsartan
II! II!
D. Increase dose of chlorthalidone
II! II! II! II!
E. Increase dose of ramipril - Correct Answers The answer is A. From IM 04.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
A 56-year-old female with non-ischemic cardiomyopathy and hypertension presents to the office
II! II! II! II! II! II! II! II! II! II! II! II!
for a routine followup. Her last hospitalization for a congestive heart failure (CHF) exacerbation
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
was two years ago. Currently, she has no shortness of breath, orthopnea, leg edema, or chest
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
pain. She has been following a low-salt diet and does not drink alcohol. Her medications are
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
carvedilol and a baby aspirin. Her home blood pressure measurements have ranged from 140-
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
150/80-90 mmHg. Her exam is notable for a blood pressure of 150/90 mmHg. Her pulse is 60 II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
beats/minute with normal S1 and S2 with no murmurs or gallops, and she has a normal
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
respiratory rate. Her jugular venous pulse and pressure (JVP) is normal and her lungs are clear.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
Her point of maximal impulse (PMI) is laterally displaced. What medication should you add that
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
can also improve her mortality from heart failure?
II! II! II! II! II! II! II! II!
A. Amlodipine
II!
B. Digoxin
II!
C. Furosemide
II!
D. Hyd - Correct Answers The answer is E. From IM 04.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! Which of the following physical examination findings is most consistent with right-sided heart
II! II! II! II! II! II! II! II! II! II! II! II!
II! failure?
A. Abdominojugular reflux
II! II!
B. Bibasilar crackles
II! II!
C. Pitting pedal edema
II! II! II!
D. Sustained apical impulse
II! II! II!
E. Systolic murmur at right upper sternal border - Correct Answers The answer is A. From IM 04.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
,II! A 68-year-old female is admitted to the hospital because of increasing dyspnea and orthopnea
II! II! II! II! II! II! II! II! II! II! II! II! II!
II! over the past two weeks. Her medical history is significant for ischemic cardiomyopathy with an
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! ejection fraction of 40% and low back pain for one month. She reports no chest pain, palpitations,
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! fever, and cough. She has been adherent to a low-sodium diet. She does not use alcohol or
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! tobacco. Daily medications are carvedilol, lisinopril, amlodipine, atorvastatin, aspirin, and
II! II! II! II! II! II! II! II! II!
II! ibuprofen. Which medication would most likely cause her worsening symptoms?
II! II! II! II! II! II! II! II! II!
A. Amlodipine
II!
B. Atorvastatin
II!
C. Carvedilol
II!
D. Ibuprofen
II!
E. Lisinopril - Correct Answers The answer is D. From IM 04.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! A 24-year-old female presents to the emergency department with 18 hours of lower abdominal
II! II! II! II! II! II! II! II! II! II! II! II! II!
II! pain, nausea, vomiting, and diarrhea. She is afebrile and has normal vital signs except for
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! tachycardia with a pulse at 105 beats/minute. Her abdomen is soft and non-distended with
II! II! II! II! II! II! II! II! II! II! II! II! II!
II! hypoactive bowel sounds. There is rebound tenderness in the left-lower quadrant. The
II! II! II! II! II! II! II! II! II! II! II!
II! abdominal exam finding of rebound tenderness has +LR = 2 and -LR = 0.4 for peritonitis. What is
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! the best interpretation of this finding?
II! II! II! II! II!
A. Absence of rebound tenderness strongly argues against peritonitis
II! II! II! II! II! II! II! II!
B. Absence of rebound tenderness strongly argues against peritonitis, but presence of it does not
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
affect the probability of peritonitis
II! II! II! II! II!
C. Neither the presence nor the absence of rebound tenderness is very helpful in diagnosing
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
peritonitis
II!
D. Presence of rebound tenderness strongly suggests peritonitis
II! II! II! II! II! II! II!
E. Presence of rebound tenderness strongly suggests peritoniti - Correct Answers The answer is
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
C. From IM 12.
II! II! II! II!
, II! A 39-year-old male with no significant past medical history presents to the hospital with lower
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! abdominal pain for the past two days. His initial vitals are notable where his temperature is 38.5 C
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! (101.3 F), pulse is 112 beats/minute, and blood pressure is 103/68 mmHg. He reports that his last
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! bowel movement was two days ago, and he recalls passing flatus earlier today. Your physical
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! exam reveals hypoactive bowel sounds, and a diffusely tender abdomen, most tender in the
II! II! II! II! II! II! II! II! II! II! II! II! II!
II! right-lower quadrant. His abdominal muscles are tense, and do not relax with distraction II! II! II! II! II! II! II! II! II! II! II! II!
II! techniques. A computed tomography (CT) scan of the abdomen and pelvis confirms your II! II! II! II! II! II! II! II! II! II! II! II!
II! suspected diagnosis. You order broad-spectrum intravenous (IV) antibiotics. What is the best next
II! II! II! II! II! II! II! II! II! II! II! II!
II! step in management?
II! II!
A. Call a gastrointestinal (GI) consult for colonoscopy
II! II! II! II! II! II! II!
B. Call a surgical consult
II! II! II! II!
C. Order a bowel regimen
II! II! II! II!
D. Place a nasogastric tube for decompression
II! II! II! II! II! II!
E. Start - Correct Answers The answer is B. From IM 12.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! A 68-year-old male with a history of peptic ulcer disease, diabetes mellitus, and hypertension is
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! admitted to the hospital with a 24-hour history of abdominal pain and three episodes of loose
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! stool. Initial vital signs reveal temperature is 38.9 C (102.02 F), pulse is 102 beats/minute,
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! respiratory rate is 16 breaths/minute, blood pressure is 132/78 mmHg, and oxygen saturation is
II! II! II! II! II! II! II! II! II! II! II! II! II!
II! 98% on room air. White blood count (WBC) is 13,100 cells/μl. He has tenderness to palpation of
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! the left lower quadrant of his abdomen, with guarding but no rigidity. Renal function is normal.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! Computerized tomography (CT) scan of the abdomen and pelvis shows sigmoid diverticulitis II! II! II! II! II! II! II! II! II! II! II!
II! without any sign of abscess or perforation. In addition to ordering intravenous (IV) antibiotics, IV
II! II! II! II! II! II! II! II! II! II! II! II! II! II!
II! fluid, and pain medication, what is the next best step in management?
II! II! II! II! II! II! II! II! II! II! II!
A. Blood cultures
II! II!
B. Colorectal surgery consult
II! II! II!
C. High-fiber diet
II! II!
D. Stool culture
II! II!
E. Stool te - Correct Answers The answer is A. From IM 12.
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!
