AQUIFER INTERNAL MEDICINE END OF CASE
EXAM
Questions 1-200 with Correct Answers & Rationales
Latest 2025/2026 Update | 100% Verified | A+ Graded
Question 1
A 21-year-old college student presents with one day of fever, headache,
and neck stiffness. Retinal and neurological examinations are normal.
Ceftriaxone is given, and a lumbar puncture is performed. CSF shows:
cloudy fluid, WBC 2,400 with 85% PMNs, protein 250 mg/dL, glucose 32
mg/dL. Gram stain shows Gram-negative diplococci. Which finding in the
CSF is most specific for bacterial infection?
A. Cloudy fluid
B. High CSF protein
C. Low CSF glucose (hypoglycorrhachia)
D. Pleocytosis with neutrophil predominance
E. Positive Gram stain
Correct Answer: E. Positive Gram stain
Rationale: While cloudy fluid, elevated protein, low glucose, and neutrophil
predominance are all suggestive of bacterial meningitis, the Gram stain
directly identifies the causative organism. Gram-negative diplococci are
specific for Neisseria meningitidis. From IM 24.
,Question 2
A 52-year-old female with hypertension, diabetes, and obesity presents for
routine follow-up. She is asymptomatic and on lisinopril, aspirin,
simvastatin, and metformin. Pulse 76, BP 128/72, BMI 32. She is due for an
annual foot examination. Which of the following is the most appropriate
component of the foot exam?
A. Assessment of Achilles tendon thickness
B. Assessment of femoral pulses
C. Assessment of patellar reflex
D. Inspection between toes for evidence of skin breakdown
E. Use of monofilament to assess temperature sensation
Correct Answer: D. Inspection between toes for evidence of skin
breakdown
Rationale: In diabetic patients, annual foot exams should include inspection
for skin breakdown, especially between the toes where moisture and friction
can lead to ulceration. This helps prevent diabetic foot complications. From
IM 08.
Question 3
A 58-year-old female with chronic kidney disease stage III secondary to
type II diabetes presents to establish care. BP 154/86, BMI 30, HbA1C 9.8%,
urine protein/creatinine ratio 1.5. She takes long-acting insulin. In addition
to tighter glucose management, which treatment is best for diabetic
nephropathy?
A. Lisinopril
B. Pentoxifylline
C. Protein restriction
D. Simvastatin
E. Spironolactone
,Correct Answer: A. Lisinopril
Rationale: ACE inhibitors (like lisinopril) are first-line for diabetic nephropathy
as they reduce intraglomerular pressure and proteinuria, slowing progression
of kidney disease. From IM 23.
Question 4
A 39-year-old male with no significant PMH presents with lower abdominal
pain for two days. Temperature 38.5°C, pulse 112, BP 103/68. Last bowel
movement two days ago, passing flatus. Exam reveals hypoactive bowel
sounds and diffuse tenderness most notable in the right-lower quadrant.
What is the most likely diagnosis?
A. Acute appendicitis
B. Diverticulitis
C. Gastroenteritis
D. Bowel obstruction
E. Ruptured ovarian cyst
Correct Answer: A. Acute appendicitis
Rationale: The presentation of right-lower quadrant tenderness, fever,
tachycardia, and hypoactive bowel sounds with obstipation is classic for acute
appendicitis. From IM 12.
Question 5
A 68-year-old male with history of peptic ulcer disease, diabetes, and
hypertension is admitted with 24-hour history of abdominal pain and three
episodes of loose stool. Temperature 38.9°C, pulse 102, WBC 13,100.
Tenderness to palpation in the left lower quadrant. What is the most likely
diagnosis?
, A. Acute diverticulitis
B. Acute pancreatitis
C. Ischemic colitis
D. Perforated ulcer
E. Gastroenteritis
Correct Answer: A. Acute diverticulitis
Rationale: Left lower quadrant pain with fever and leukocytosis in an older
patient is classic for acute diverticulitis. From IM 12.
Question 6
A 51-year-old male is admitted for acute uncomplicated diverticulitis. He is
treated with IV ciprofloxacin, metronidazole, IV fluids, and pain medication.
After two days, pain improves and he tolerates food. Which discharge plan
is most appropriate?
A. Discharge with oral antibiotics for 7-10 days
B. Discharge with no further antibiotics
C. Discharge with oral antibiotics for 21 days
D. Discharge with subcutaneous enoxaparin
E. Continue IV antibiotics as outpatient
Correct Answer: A. Discharge with oral antibiotics for 7-10 days
Rationale: For uncomplicated diverticulitis, patients can be transitioned to
oral antibiotics upon clinical improvement and tolerance of oral intake. From
IM 12.
Question 7
A 50-year-old male presents with progressive bilateral knee and ankle pain.
EXAM
Questions 1-200 with Correct Answers & Rationales
Latest 2025/2026 Update | 100% Verified | A+ Graded
Question 1
A 21-year-old college student presents with one day of fever, headache,
and neck stiffness. Retinal and neurological examinations are normal.
Ceftriaxone is given, and a lumbar puncture is performed. CSF shows:
cloudy fluid, WBC 2,400 with 85% PMNs, protein 250 mg/dL, glucose 32
mg/dL. Gram stain shows Gram-negative diplococci. Which finding in the
CSF is most specific for bacterial infection?
A. Cloudy fluid
B. High CSF protein
C. Low CSF glucose (hypoglycorrhachia)
D. Pleocytosis with neutrophil predominance
E. Positive Gram stain
Correct Answer: E. Positive Gram stain
Rationale: While cloudy fluid, elevated protein, low glucose, and neutrophil
predominance are all suggestive of bacterial meningitis, the Gram stain
directly identifies the causative organism. Gram-negative diplococci are
specific for Neisseria meningitidis. From IM 24.
,Question 2
A 52-year-old female with hypertension, diabetes, and obesity presents for
routine follow-up. She is asymptomatic and on lisinopril, aspirin,
simvastatin, and metformin. Pulse 76, BP 128/72, BMI 32. She is due for an
annual foot examination. Which of the following is the most appropriate
component of the foot exam?
A. Assessment of Achilles tendon thickness
B. Assessment of femoral pulses
C. Assessment of patellar reflex
D. Inspection between toes for evidence of skin breakdown
E. Use of monofilament to assess temperature sensation
Correct Answer: D. Inspection between toes for evidence of skin
breakdown
Rationale: In diabetic patients, annual foot exams should include inspection
for skin breakdown, especially between the toes where moisture and friction
can lead to ulceration. This helps prevent diabetic foot complications. From
IM 08.
Question 3
A 58-year-old female with chronic kidney disease stage III secondary to
type II diabetes presents to establish care. BP 154/86, BMI 30, HbA1C 9.8%,
urine protein/creatinine ratio 1.5. She takes long-acting insulin. In addition
to tighter glucose management, which treatment is best for diabetic
nephropathy?
A. Lisinopril
B. Pentoxifylline
C. Protein restriction
D. Simvastatin
E. Spironolactone
,Correct Answer: A. Lisinopril
Rationale: ACE inhibitors (like lisinopril) are first-line for diabetic nephropathy
as they reduce intraglomerular pressure and proteinuria, slowing progression
of kidney disease. From IM 23.
Question 4
A 39-year-old male with no significant PMH presents with lower abdominal
pain for two days. Temperature 38.5°C, pulse 112, BP 103/68. Last bowel
movement two days ago, passing flatus. Exam reveals hypoactive bowel
sounds and diffuse tenderness most notable in the right-lower quadrant.
What is the most likely diagnosis?
A. Acute appendicitis
B. Diverticulitis
C. Gastroenteritis
D. Bowel obstruction
E. Ruptured ovarian cyst
Correct Answer: A. Acute appendicitis
Rationale: The presentation of right-lower quadrant tenderness, fever,
tachycardia, and hypoactive bowel sounds with obstipation is classic for acute
appendicitis. From IM 12.
Question 5
A 68-year-old male with history of peptic ulcer disease, diabetes, and
hypertension is admitted with 24-hour history of abdominal pain and three
episodes of loose stool. Temperature 38.9°C, pulse 102, WBC 13,100.
Tenderness to palpation in the left lower quadrant. What is the most likely
diagnosis?
, A. Acute diverticulitis
B. Acute pancreatitis
C. Ischemic colitis
D. Perforated ulcer
E. Gastroenteritis
Correct Answer: A. Acute diverticulitis
Rationale: Left lower quadrant pain with fever and leukocytosis in an older
patient is classic for acute diverticulitis. From IM 12.
Question 6
A 51-year-old male is admitted for acute uncomplicated diverticulitis. He is
treated with IV ciprofloxacin, metronidazole, IV fluids, and pain medication.
After two days, pain improves and he tolerates food. Which discharge plan
is most appropriate?
A. Discharge with oral antibiotics for 7-10 days
B. Discharge with no further antibiotics
C. Discharge with oral antibiotics for 21 days
D. Discharge with subcutaneous enoxaparin
E. Continue IV antibiotics as outpatient
Correct Answer: A. Discharge with oral antibiotics for 7-10 days
Rationale: For uncomplicated diverticulitis, patients can be transitioned to
oral antibiotics upon clinical improvement and tolerance of oral intake. From
IM 12.
Question 7
A 50-year-old male presents with progressive bilateral knee and ankle pain.
