AQUIFER FAMILY MEDICINE ANSWERS AND
QUESTIONS SET A+
Mr. Brown is a 42-year-old male accountant with a significant past medical history of
obesity who presents to his primary care physician after one week of lower back pain.
After moving into a new home three days ago, he woke up the next morning with
bilateral lower back pain without any radiation. He denies any recent trauma, fever,
chills, numbness, tingling, or incontinence. He has not had any urinary frequency or
dysuria. He takes no medications and has no significant past medical history.
Which additional findings in his history or physical exam would make the diagnosis of
lumbosacral sprain/strain more likely?
A.) Abnormal gait
B.) Increased pain with coughing
C.) Loss of ankle jerk
D.) Point tenderness on spinous processes
E.) Spasm of paraspinous muscles - ✔✔E.) Spasm of paraspinous muscles
✔✔Mr. Giovanni is a 37-year-old male who drives a delivery truck. He presents to your
clinic after acute onset of severe lower back pain that began after lifting a large package
while at work. When you enter the room, you find him standing, unable to sit
comfortably.
On physical exam, he has limited lumbar flexion, reduced to 45 degrees, positive
straight leg test at 45 degrees on the left, normal gait, but difficulty with heel walk. He
has 4/5 strength on the left with ankle plantar flexion. Strength is preserved on the right.
Which additional physical exam finding would be consistent with this man's level of disc
herniation?
A. 2/5 strength on hip flexion
B. Decreased range of motion on lumbar extension
C. Decreased rectal tone
D. Hypoactive ankle tendon reflex
E. Positive Stoop test - ✔✔D.) Hypoactive ankle tendon reflex
✔✔Mr. Roberts is a 78-year-old male with a significant past medical history of chronic
kidney disease stage II, coronary artery disease, and hypertension who presents lumbar
back pain. He has also been feeling general malaise and chills over the past few days.
,On review of symptoms he reports having some difficulty urinating with hesitancy and
pain on urination.
Currently, his chronic conditions are well managed with metoprolol, lisinopril, and
aspirin. He has never smoked. Vital signs: temperature is 38 C (100.4 F), blood
pressure is 135/75 mmHg, pulse is 76 beats/minute, and respiratory rate is 15
breaths/minute.
Given this history, which of the following physical exam maneuvers would be the most
helpful in making the diagnosis?
A. Abdominal palpation
B. Auscultation for an abdominal bruit
C. Digital rectal exam
D. Pinprick sensation of the legs
E. Straight leg test - ✔✔C. Digital rectal exam
✔✔Working at your clinic, you receive a call from a patient of yours, Mr. Smith, a 45-
year-old male who was seen three days ago complaining of lower back pain. At that
time he had no history of trauma, pain that improved while lying down and no neurologic
deficits. He works as a truck driver. He was treated conservatively along with
pharmacologic intervention with NSAIDs and muscle relaxants.
He calls your office now due to only minimal improvement. And although his symptoms
have not changed, he is frustrated with the slow progress, needs to get back to work as
soon as possible, and is concerned this might be "something serious."
Which of the following is the most appropriate next step in management?
A. Ask him to double the dosage of his muscle relaxants
B. Obtain a plain film x-ray
C. Order an MRI
D. Reassure him and schedule a follow-up appointment in a few days
E. Schedule him for an appointment immediately - ✔✔D. Reassure him and schedule a
follow-up appointment in a few days
✔✔Ms. Vasquez is a 38-year-old female with a past medical history of sarcoidosis and
recently completed a six-month steroid taper. She presents to her primary care
physician after two weeks of lower lumbar back pain. She does not recall any trauma
but began to feel a sharp pain after bending over to pick up laundry. The pain radiates
bilaterally into her anterior abdomen. She has found no relief with over the counter
NSAIDs. On physical exam, she has point tenderness along her vertebrae in the L1-L2
region. There are no neurologic deficits and reflexes are intact.
Which of the following is the most appropriate next step in management?
A. Order a plain x-ray
B. Order complete blood count (CBC)
C. Reassess in four weeks
D. Recommend conservative management
E. Refer to spine specialist - ✔✔A. Order a plain x-ray
✔✔You are seeing one of your regular patients, a 65-year-old female, for a follow-up
appointment for intractable knee pain from osteoarthritis. The knee pain has not
, responded to ibuprofen or acetaminophen. She has a past medical history that also
includes obesity, diabetes, hypertension, and depression. Her current medications
include aspirin, HCTZ, metformin, and duloxetine. You are considering prescribing
tramadol. She has never taken any kind of opioid medication in the past.
Which of the following potential problems should you inquire about when adding
tramadol?
A. Hypercoagulability
B. Hypotension
C. Rash
D. Recent hyperglycemia
E. Seizures - ✔✔E. Seizures
✔✔A 59-year-old patient comes to the local ER with a swollen, tender knee that started
yesterday. He returned home two days ago from a five-day hike on the Appalachian
Trail. He reports no recent or previous injury to the knee and any history of previous
inflammatory joint disease. Vital signs: temperature is 36.5 C (97.7 F), pulse is 80
beats/minute, blood pressure is 139/75 mmHg, and respiratory rate is 22
breaths/minute. His lower extremities are marked with abrasions in various stages of
healing. He holds the knee in full extension. The knee is swollen, reddened, and tender,
and it feels warm. Which of the following is the most appropriate next step?
A. Knee aspiration
B. Magnetic resonance imaging (MRI) of the knee
C. Prescription for colchicine
D. Prescription for full-dose acetaminophen
E. X-ray of the knee, including sunrise and standing films - ✔✔A. Knee aspiration
✔✔You are seeing a 19-year-old female who suffered a knee injury playing soccer one
day ago. The injury involved a sudden deceleration in which she planted her right foot in
front of her while running, whereupon another athlete fell against her shin. She felt a
pop and sudden pain. She had to be helped off the field and her knee swelled
immediately. Today, she reports that she has considerable right knee pain with bearing
weight and that her knee feels unstable at times. Her past medical history is
unremarkable, and she takes no medications. On exam, her vital signs are perfectly
normal. You conduct a knee exam.
Which of the following exam maneuvers is most likely to be abnormal in this patient?
A. Lachman test
B. Laxity to valgus stress
C. Laxity to varus stress
D. McMurray test
E. Posterior drawer test - ✔✔A. Lachman test
✔✔A 51-year-old female comes to you with acute pain and swelling of the knee. Joint
fluid analysis confirms the diagnosis of acute gout. She has a past medical history of
atrial fibrillation, hypothyroidism, hypertension, and prior treatment for H. pylori infection.
Her current medications include losartan, warfarin, levothyroxine, and omeprazole. She
QUESTIONS SET A+
Mr. Brown is a 42-year-old male accountant with a significant past medical history of
obesity who presents to his primary care physician after one week of lower back pain.
After moving into a new home three days ago, he woke up the next morning with
bilateral lower back pain without any radiation. He denies any recent trauma, fever,
chills, numbness, tingling, or incontinence. He has not had any urinary frequency or
dysuria. He takes no medications and has no significant past medical history.
Which additional findings in his history or physical exam would make the diagnosis of
lumbosacral sprain/strain more likely?
A.) Abnormal gait
B.) Increased pain with coughing
C.) Loss of ankle jerk
D.) Point tenderness on spinous processes
E.) Spasm of paraspinous muscles - ✔✔E.) Spasm of paraspinous muscles
✔✔Mr. Giovanni is a 37-year-old male who drives a delivery truck. He presents to your
clinic after acute onset of severe lower back pain that began after lifting a large package
while at work. When you enter the room, you find him standing, unable to sit
comfortably.
On physical exam, he has limited lumbar flexion, reduced to 45 degrees, positive
straight leg test at 45 degrees on the left, normal gait, but difficulty with heel walk. He
has 4/5 strength on the left with ankle plantar flexion. Strength is preserved on the right.
Which additional physical exam finding would be consistent with this man's level of disc
herniation?
A. 2/5 strength on hip flexion
B. Decreased range of motion on lumbar extension
C. Decreased rectal tone
D. Hypoactive ankle tendon reflex
E. Positive Stoop test - ✔✔D.) Hypoactive ankle tendon reflex
✔✔Mr. Roberts is a 78-year-old male with a significant past medical history of chronic
kidney disease stage II, coronary artery disease, and hypertension who presents lumbar
back pain. He has also been feeling general malaise and chills over the past few days.
,On review of symptoms he reports having some difficulty urinating with hesitancy and
pain on urination.
Currently, his chronic conditions are well managed with metoprolol, lisinopril, and
aspirin. He has never smoked. Vital signs: temperature is 38 C (100.4 F), blood
pressure is 135/75 mmHg, pulse is 76 beats/minute, and respiratory rate is 15
breaths/minute.
Given this history, which of the following physical exam maneuvers would be the most
helpful in making the diagnosis?
A. Abdominal palpation
B. Auscultation for an abdominal bruit
C. Digital rectal exam
D. Pinprick sensation of the legs
E. Straight leg test - ✔✔C. Digital rectal exam
✔✔Working at your clinic, you receive a call from a patient of yours, Mr. Smith, a 45-
year-old male who was seen three days ago complaining of lower back pain. At that
time he had no history of trauma, pain that improved while lying down and no neurologic
deficits. He works as a truck driver. He was treated conservatively along with
pharmacologic intervention with NSAIDs and muscle relaxants.
He calls your office now due to only minimal improvement. And although his symptoms
have not changed, he is frustrated with the slow progress, needs to get back to work as
soon as possible, and is concerned this might be "something serious."
Which of the following is the most appropriate next step in management?
A. Ask him to double the dosage of his muscle relaxants
B. Obtain a plain film x-ray
C. Order an MRI
D. Reassure him and schedule a follow-up appointment in a few days
E. Schedule him for an appointment immediately - ✔✔D. Reassure him and schedule a
follow-up appointment in a few days
✔✔Ms. Vasquez is a 38-year-old female with a past medical history of sarcoidosis and
recently completed a six-month steroid taper. She presents to her primary care
physician after two weeks of lower lumbar back pain. She does not recall any trauma
but began to feel a sharp pain after bending over to pick up laundry. The pain radiates
bilaterally into her anterior abdomen. She has found no relief with over the counter
NSAIDs. On physical exam, she has point tenderness along her vertebrae in the L1-L2
region. There are no neurologic deficits and reflexes are intact.
Which of the following is the most appropriate next step in management?
A. Order a plain x-ray
B. Order complete blood count (CBC)
C. Reassess in four weeks
D. Recommend conservative management
E. Refer to spine specialist - ✔✔A. Order a plain x-ray
✔✔You are seeing one of your regular patients, a 65-year-old female, for a follow-up
appointment for intractable knee pain from osteoarthritis. The knee pain has not
, responded to ibuprofen or acetaminophen. She has a past medical history that also
includes obesity, diabetes, hypertension, and depression. Her current medications
include aspirin, HCTZ, metformin, and duloxetine. You are considering prescribing
tramadol. She has never taken any kind of opioid medication in the past.
Which of the following potential problems should you inquire about when adding
tramadol?
A. Hypercoagulability
B. Hypotension
C. Rash
D. Recent hyperglycemia
E. Seizures - ✔✔E. Seizures
✔✔A 59-year-old patient comes to the local ER with a swollen, tender knee that started
yesterday. He returned home two days ago from a five-day hike on the Appalachian
Trail. He reports no recent or previous injury to the knee and any history of previous
inflammatory joint disease. Vital signs: temperature is 36.5 C (97.7 F), pulse is 80
beats/minute, blood pressure is 139/75 mmHg, and respiratory rate is 22
breaths/minute. His lower extremities are marked with abrasions in various stages of
healing. He holds the knee in full extension. The knee is swollen, reddened, and tender,
and it feels warm. Which of the following is the most appropriate next step?
A. Knee aspiration
B. Magnetic resonance imaging (MRI) of the knee
C. Prescription for colchicine
D. Prescription for full-dose acetaminophen
E. X-ray of the knee, including sunrise and standing films - ✔✔A. Knee aspiration
✔✔You are seeing a 19-year-old female who suffered a knee injury playing soccer one
day ago. The injury involved a sudden deceleration in which she planted her right foot in
front of her while running, whereupon another athlete fell against her shin. She felt a
pop and sudden pain. She had to be helped off the field and her knee swelled
immediately. Today, she reports that she has considerable right knee pain with bearing
weight and that her knee feels unstable at times. Her past medical history is
unremarkable, and she takes no medications. On exam, her vital signs are perfectly
normal. You conduct a knee exam.
Which of the following exam maneuvers is most likely to be abnormal in this patient?
A. Lachman test
B. Laxity to valgus stress
C. Laxity to varus stress
D. McMurray test
E. Posterior drawer test - ✔✔A. Lachman test
✔✔A 51-year-old female comes to you with acute pain and swelling of the knee. Joint
fluid analysis confirms the diagnosis of acute gout. She has a past medical history of
atrial fibrillation, hypothyroidism, hypertension, and prior treatment for H. pylori infection.
Her current medications include losartan, warfarin, levothyroxine, and omeprazole. She
