AQUIFER INTERNAL MEDICINE END OF CASE EXAM
Questions 1-250 with Correct Answers & Rationales
Latest 2025/2026 Update | 100% Verified | A+ Graded
Question 1
A 31-year-old male with previously diagnosed hypertension comes in for a follow-up
visit. He currently takes 10 mg of amlodipine daily, 40 mg of enalapril daily, and 100 mg
of atenolol daily. His pulse is 65 beats/minute. His blood pressure is 190/100 mmHg in
his right arm and 188/ mmHg in his left leg. He reports adherence to all of his
medications. His basic metabolic profile reveals: Sodium 139, Potassium 3, Chloride 103,
Bicarbonate 21, BUN 10, Creatinine 1, Glucose 87. Which of the following is the most
likely cause for the man's hypertension?
A. Aortic coarctation
B. Essential hypertension
C. Pheochromocytoma
D. Primary hyperaldosteronism
E. Renal artery stenosis
Correct Answer: D. Primary hyperaldosteronism
Rationale: The patient has hypertension resistant to three antihypertensive medications
(amlodipine, enalapril, atenolol) with hypokalemia (potassium 3). Primary
hyperaldosteronism is suggested by hypertension with hypokalemia, and it is a common
cause of resistant hypertension.
Question 2
A 63-year-old male comes for a new-patient visit. He has a past medical history of a
myocardial infarction (MI) and hyperlipidemia one year ago. He ran out of his previous
medications several weeks ago and cannot remember what they were. He is
asymptomatic with a normal physical exam except for a blood pressure of 165/92
mmHg. His labs show a hemoglobin A1c of 5.4%, an elevated LDL, and normal
,electrolytes and renal function. In addition to a statin and daily aspirin, what other
medication would be the best to start him on?
A. Amlodipine
B. Diltiazem
C. Hydrochlorothiazide
D. Lisinopril
E. Metoprolol
Correct Answer: E. Metoprolol
Rationale: Beta-blockers like metoprolol are first-line agents for hypertension in patients
with coronary artery disease and prior MI. They reduce myocardial oxygen demand and
improve survival post-MI.
Question 3
A 42-year-old female comes to the clinic for a follow-up of newly diagnosed type 2
diabetes mellitus. She is asymptomatic with a normal physical exam. Her blood pressure
is 142/ mmHg, consistent with previous home measurements. Results show 1+ protein
on her urinalysis and a normal basic metabolic panel. What is the most appropriate
treatment for this patient?
A. Amlodipine
B. Hydrochlorothiazide
C. Lisinopril
D. Metoprolol
E. No further treatment
Correct Answer: C. Lisinopril
Rationale: ACE inhibitors (like lisinopril) are the preferred antihypertensive in patients with
diabetes and proteinuria, as they reduce intraglomerular pressure and slow progression of
diabetic nephropathy.
Question 4
Mr. Sands is a 63-year-old male with a 25-year history of hypertension and type 2
,diabetes mellitus who presents for a follow-up of his blood pressure. Given his long-
standing history of poor blood pressure control, you evaluate him for end-organ effects
of long-standing hypertension. Which of the following findings would be most specific
for possible end-organ damage from hypertension?
A. Decreased monofilament sensation on bilateral feet
B. Left basilar crackles on lung exam
C. Left leg edema
D. Paralysis of upper and lower face on right side
E. Point of maximum impulse (PMI) of the heart palpated 6 cm lateral to the mid-
clavicular line
Correct Answer: E. Point of maximum impulse (PMI) of the heart palpated 6 cm
lateral to the mid-clavicular line
Rationale: A laterally displaced PMI indicates left ventricular hypertrophy, a specific end-
organ effect of chronic hypertension. This reflects cardiac remodeling from chronic
pressure overload.
Question 5
A 53-year-old male comes in for his yearly checkup. He has no past medical history and
takes no medications. He rushes in five minutes after his appointment time because his
bus ran late, and he had to run one block to get to the office. He is sweaty and still
breathing heavy. His blood pressure taken by the medical assistant is 157/85 mmHg in
his right arm. What is the most appropriate next step?
A. Diagnose hypertension and start lisinopril
B. Diagnose hypertension and start hydrochlorothiazide
C. Recheck blood pressure at end of appointment
D. Send for echocardiogram
E. Start aspirin daily
Correct Answer: C. Recheck blood pressure at end of appointment
Rationale: Blood pressure should be rechecked after the patient has rested, as acute
exertion can transiently elevate blood pressure. A diagnosis of hypertension requires
elevated readings on multiple occasions.
, Question 6
A 33-year-old previously healthy female is admitted to the hospital with pneumonia.
Two weeks prior, she developed fever and myalgias and was diagnosed with influenza.
Five days ago, she developed a productive cough, fever, and chills. Today, temperature
is 38.9°C, pulse 110, respiratory rate 22, BP 90/68, and oxygen saturation 89% on room
air. Respiratory exam reveals crackles at the lung bases bilaterally. WBC is 3,400/mm³.
Chest X-ray shows multilobular cavitating alveolar infiltrates. Which organism is the
most likely cause?
A. Adenovirus
B. Legionella pneumophila
C. Mycoplasma pneumoniae
D. Pseudomonas aeruginosa
E. Staphylococcus aureus
Correct Answer: E. Staphylococcus aureus
Rationale: S. aureus pneumonia is a complication of influenza and presents with cavitating
infiltrates, multilobar involvement, and leukopenia. The patient's recent influenza infection
makes S. aureus the most likely pathogen.
Question 7
A 78-year-old male has been admitted after a severe stroke. On day five of
hospitalization, he develops fever, productive cough, pleuritic chest pain, and shortness
of breath. Pulmonary exam reveals bronchial breath sounds, dullness to percussion,
increased tactile vocal fremitus, and whispered pectoriloquy in the right-lower lung
fields. There are no adventitious sounds. What is the most likely diagnosis?
A. COPD exacerbation
B. Congestive heart failure exacerbation
C. Pleural effusion
D. Pneumonia
E. Pulmonary embolism
Correct Answer: D. Pneumonia
Questions 1-250 with Correct Answers & Rationales
Latest 2025/2026 Update | 100% Verified | A+ Graded
Question 1
A 31-year-old male with previously diagnosed hypertension comes in for a follow-up
visit. He currently takes 10 mg of amlodipine daily, 40 mg of enalapril daily, and 100 mg
of atenolol daily. His pulse is 65 beats/minute. His blood pressure is 190/100 mmHg in
his right arm and 188/ mmHg in his left leg. He reports adherence to all of his
medications. His basic metabolic profile reveals: Sodium 139, Potassium 3, Chloride 103,
Bicarbonate 21, BUN 10, Creatinine 1, Glucose 87. Which of the following is the most
likely cause for the man's hypertension?
A. Aortic coarctation
B. Essential hypertension
C. Pheochromocytoma
D. Primary hyperaldosteronism
E. Renal artery stenosis
Correct Answer: D. Primary hyperaldosteronism
Rationale: The patient has hypertension resistant to three antihypertensive medications
(amlodipine, enalapril, atenolol) with hypokalemia (potassium 3). Primary
hyperaldosteronism is suggested by hypertension with hypokalemia, and it is a common
cause of resistant hypertension.
Question 2
A 63-year-old male comes for a new-patient visit. He has a past medical history of a
myocardial infarction (MI) and hyperlipidemia one year ago. He ran out of his previous
medications several weeks ago and cannot remember what they were. He is
asymptomatic with a normal physical exam except for a blood pressure of 165/92
mmHg. His labs show a hemoglobin A1c of 5.4%, an elevated LDL, and normal
,electrolytes and renal function. In addition to a statin and daily aspirin, what other
medication would be the best to start him on?
A. Amlodipine
B. Diltiazem
C. Hydrochlorothiazide
D. Lisinopril
E. Metoprolol
Correct Answer: E. Metoprolol
Rationale: Beta-blockers like metoprolol are first-line agents for hypertension in patients
with coronary artery disease and prior MI. They reduce myocardial oxygen demand and
improve survival post-MI.
Question 3
A 42-year-old female comes to the clinic for a follow-up of newly diagnosed type 2
diabetes mellitus. She is asymptomatic with a normal physical exam. Her blood pressure
is 142/ mmHg, consistent with previous home measurements. Results show 1+ protein
on her urinalysis and a normal basic metabolic panel. What is the most appropriate
treatment for this patient?
A. Amlodipine
B. Hydrochlorothiazide
C. Lisinopril
D. Metoprolol
E. No further treatment
Correct Answer: C. Lisinopril
Rationale: ACE inhibitors (like lisinopril) are the preferred antihypertensive in patients with
diabetes and proteinuria, as they reduce intraglomerular pressure and slow progression of
diabetic nephropathy.
Question 4
Mr. Sands is a 63-year-old male with a 25-year history of hypertension and type 2
,diabetes mellitus who presents for a follow-up of his blood pressure. Given his long-
standing history of poor blood pressure control, you evaluate him for end-organ effects
of long-standing hypertension. Which of the following findings would be most specific
for possible end-organ damage from hypertension?
A. Decreased monofilament sensation on bilateral feet
B. Left basilar crackles on lung exam
C. Left leg edema
D. Paralysis of upper and lower face on right side
E. Point of maximum impulse (PMI) of the heart palpated 6 cm lateral to the mid-
clavicular line
Correct Answer: E. Point of maximum impulse (PMI) of the heart palpated 6 cm
lateral to the mid-clavicular line
Rationale: A laterally displaced PMI indicates left ventricular hypertrophy, a specific end-
organ effect of chronic hypertension. This reflects cardiac remodeling from chronic
pressure overload.
Question 5
A 53-year-old male comes in for his yearly checkup. He has no past medical history and
takes no medications. He rushes in five minutes after his appointment time because his
bus ran late, and he had to run one block to get to the office. He is sweaty and still
breathing heavy. His blood pressure taken by the medical assistant is 157/85 mmHg in
his right arm. What is the most appropriate next step?
A. Diagnose hypertension and start lisinopril
B. Diagnose hypertension and start hydrochlorothiazide
C. Recheck blood pressure at end of appointment
D. Send for echocardiogram
E. Start aspirin daily
Correct Answer: C. Recheck blood pressure at end of appointment
Rationale: Blood pressure should be rechecked after the patient has rested, as acute
exertion can transiently elevate blood pressure. A diagnosis of hypertension requires
elevated readings on multiple occasions.
, Question 6
A 33-year-old previously healthy female is admitted to the hospital with pneumonia.
Two weeks prior, she developed fever and myalgias and was diagnosed with influenza.
Five days ago, she developed a productive cough, fever, and chills. Today, temperature
is 38.9°C, pulse 110, respiratory rate 22, BP 90/68, and oxygen saturation 89% on room
air. Respiratory exam reveals crackles at the lung bases bilaterally. WBC is 3,400/mm³.
Chest X-ray shows multilobular cavitating alveolar infiltrates. Which organism is the
most likely cause?
A. Adenovirus
B. Legionella pneumophila
C. Mycoplasma pneumoniae
D. Pseudomonas aeruginosa
E. Staphylococcus aureus
Correct Answer: E. Staphylococcus aureus
Rationale: S. aureus pneumonia is a complication of influenza and presents with cavitating
infiltrates, multilobar involvement, and leukopenia. The patient's recent influenza infection
makes S. aureus the most likely pathogen.
Question 7
A 78-year-old male has been admitted after a severe stroke. On day five of
hospitalization, he develops fever, productive cough, pleuritic chest pain, and shortness
of breath. Pulmonary exam reveals bronchial breath sounds, dullness to percussion,
increased tactile vocal fremitus, and whispered pectoriloquy in the right-lower lung
fields. There are no adventitious sounds. What is the most likely diagnosis?
A. COPD exacerbation
B. Congestive heart failure exacerbation
C. Pleural effusion
D. Pneumonia
E. Pulmonary embolism
Correct Answer: D. Pneumonia
