AQUIFER FAMILY MEDICINE END OF CASE EXAM
QUESTIONS ACTUAL EXAM 170 QUESTIONS AND
WELL DETAILED ANSWERS WITH RATIONALES||
NEWEST 2025/2026
A 52-year-old female presents with one month of progressive dyspnea on exertion, a
productive cough of clear sputum, bilateral leg swelling, and orthopnea. She has had no
chest pain or fevers. She has a history of poorly controlled hypertension and 30-pack-
years of smoking. Before beginning her physical exam, you determine that her pre-
exam probability of heart failure is moderate. On exam, you find a jugular venous pulse
and pressure (JVP) of 12 cm with positive hepatojugular reflux, regular heart rate,
normal S1 and S2 with S3 gallop, 3/6 systolic crescendo-decrescendo murmur at the
right upper sternal border, crackles at both lung bases. Which of the following physical
examination findings most increases your post-exam probability of congestive heart
failure?
A. Bibasilar crackles
B. Hepatojugular reflux
C. Increased jugular venous pressure
D. Systolic murmur in the aortic area
E. Third heart sound -CORRECT ANSWER The CORRECT ANSWER is E. From IM
04.
,A 68-year-old male with hypertension and non-ischemic cardiomyopathy is admitted to
the hospital with an acute exacerbation of his congestive heart failure (CHF). An
echocardiogram (ECG) one month ago showed left-ventricular hypertrophy and a left-
ventricular ejection fracture (LVEF) of 60%. He takes ramipril and chlorthalidone at
home, and these are continued. His pulse is 85 beats/minutes, blood pressure is 134/88
mmHg, and oxygen saturation is 95% on two liters of oxygen by nasal cannula. His
exam is notable for jugular venous pulse and pressure (JVP) of 12, bilateral leg edema,
and crackles at his lung bases. What will be the next step in management of this man?
A. Add furosemide intravenously
B. Add metoprolol orally
C. Add valsartan
D. Increase dose of chlorthalidone
E. Increase dose of ramipril -CORRECT ANSWER The CORRECT ANSWER is A.
From IM 04.
A 56-year-old female with non-ischemic cardiomyopathy and hypertension presents to
the office for a routine followup. Her last hospitalization for a congestive heart failure
(CHF) exacerbation was two years ago. Currently, she has no shortness of breath,
orthopnea, leg edema, or chest pain. She has been following a low-salt diet and does
not drink alcohol. Her medications are carvedilol and a baby aspirin. Her home blood
pressure measurements have ranged from 140-150/80-90 mmHg. Her exam is notable
for a blood pressure of 150/90 mmHg. Her pulse is 60 beats/minute with normal S1 and
,S2 with no murmurs or gallops, and she has a normal respiratory rate. Her jugular
venous pulse and pressure (JVP) is normal and her lungs are clear. Her point of
maximal impulse (PMI) is laterally displaced. What medication should you add that can
also improve her mortality from heart failure?
A. Amlodipine
B. Digoxin
C. Furosemide
D. Hyd -CORRECT ANSWER The CORRECT ANSWER is E. From IM 04.
Which of the following physical examination findings is most consistent with right-sided
heart failure?
A. Abdominojugular reflux
B. Bibasilar crackles
C. Pitting pedal edema
D. Sustained apical impulse
E. Systolic murmur at right upper sternal border -CORRECT ANSWER The CORRECT
ANSWER is A. From IM 04.
A 68-year-old female is admitted to the hospital because of increasing dyspnea and
orthopnea over the past two weeks. Her medical history is significant for ischemic
cardiomyopathy with an ejection fraction of 40% and low back pain for one month. She
, reports no chest pain, palpitations, fever, and cough. She has been adherent to a low-
sodium diet. She does not use alcohol or tobacco. Daily medications are carvedilol,
lisinopril, amlodipine, atorvastatin, aspirin, and ibuprofen. Which medication would most
likely cause her worsening symptoms?
A. Amlodipine
B. Atorvastatin
C. Carvedilol
D. Ibuprofen
E. Lisinopril -CORRECT ANSWER The CORRECT ANSWER is D. From IM 04.
A 24-year-old female presents to the emergency department with 18 hours of lower
abdominal pain, nausea, vomiting, and diarrhea. She is afebrile and has normal vital
signs except for tachycardia with a pulse at 105 beats/minute. Her abdomen is soft and
non-distended with hypoactive bowel sounds. There is rebound tenderness in the left-
lower quadrant. The abdominal exam finding of rebound tenderness has +LR = 2 and -
LR = 0.4 for peritonitis. What is the best interpretation of this finding?
A. Absence of rebound tenderness strongly argues against peritonitis
B. Absence of rebound tenderness strongly argues against peritonitis, but presence of it
does not affect the probability of peritonitis
C. Neither the presence nor the absence of rebound tenderness is very helpful in
diagnosing peritonitis
QUESTIONS ACTUAL EXAM 170 QUESTIONS AND
WELL DETAILED ANSWERS WITH RATIONALES||
NEWEST 2025/2026
A 52-year-old female presents with one month of progressive dyspnea on exertion, a
productive cough of clear sputum, bilateral leg swelling, and orthopnea. She has had no
chest pain or fevers. She has a history of poorly controlled hypertension and 30-pack-
years of smoking. Before beginning her physical exam, you determine that her pre-
exam probability of heart failure is moderate. On exam, you find a jugular venous pulse
and pressure (JVP) of 12 cm with positive hepatojugular reflux, regular heart rate,
normal S1 and S2 with S3 gallop, 3/6 systolic crescendo-decrescendo murmur at the
right upper sternal border, crackles at both lung bases. Which of the following physical
examination findings most increases your post-exam probability of congestive heart
failure?
A. Bibasilar crackles
B. Hepatojugular reflux
C. Increased jugular venous pressure
D. Systolic murmur in the aortic area
E. Third heart sound -CORRECT ANSWER The CORRECT ANSWER is E. From IM
04.
,A 68-year-old male with hypertension and non-ischemic cardiomyopathy is admitted to
the hospital with an acute exacerbation of his congestive heart failure (CHF). An
echocardiogram (ECG) one month ago showed left-ventricular hypertrophy and a left-
ventricular ejection fracture (LVEF) of 60%. He takes ramipril and chlorthalidone at
home, and these are continued. His pulse is 85 beats/minutes, blood pressure is 134/88
mmHg, and oxygen saturation is 95% on two liters of oxygen by nasal cannula. His
exam is notable for jugular venous pulse and pressure (JVP) of 12, bilateral leg edema,
and crackles at his lung bases. What will be the next step in management of this man?
A. Add furosemide intravenously
B. Add metoprolol orally
C. Add valsartan
D. Increase dose of chlorthalidone
E. Increase dose of ramipril -CORRECT ANSWER The CORRECT ANSWER is A.
From IM 04.
A 56-year-old female with non-ischemic cardiomyopathy and hypertension presents to
the office for a routine followup. Her last hospitalization for a congestive heart failure
(CHF) exacerbation was two years ago. Currently, she has no shortness of breath,
orthopnea, leg edema, or chest pain. She has been following a low-salt diet and does
not drink alcohol. Her medications are carvedilol and a baby aspirin. Her home blood
pressure measurements have ranged from 140-150/80-90 mmHg. Her exam is notable
for a blood pressure of 150/90 mmHg. Her pulse is 60 beats/minute with normal S1 and
,S2 with no murmurs or gallops, and she has a normal respiratory rate. Her jugular
venous pulse and pressure (JVP) is normal and her lungs are clear. Her point of
maximal impulse (PMI) is laterally displaced. What medication should you add that can
also improve her mortality from heart failure?
A. Amlodipine
B. Digoxin
C. Furosemide
D. Hyd -CORRECT ANSWER The CORRECT ANSWER is E. From IM 04.
Which of the following physical examination findings is most consistent with right-sided
heart failure?
A. Abdominojugular reflux
B. Bibasilar crackles
C. Pitting pedal edema
D. Sustained apical impulse
E. Systolic murmur at right upper sternal border -CORRECT ANSWER The CORRECT
ANSWER is A. From IM 04.
A 68-year-old female is admitted to the hospital because of increasing dyspnea and
orthopnea over the past two weeks. Her medical history is significant for ischemic
cardiomyopathy with an ejection fraction of 40% and low back pain for one month. She
, reports no chest pain, palpitations, fever, and cough. She has been adherent to a low-
sodium diet. She does not use alcohol or tobacco. Daily medications are carvedilol,
lisinopril, amlodipine, atorvastatin, aspirin, and ibuprofen. Which medication would most
likely cause her worsening symptoms?
A. Amlodipine
B. Atorvastatin
C. Carvedilol
D. Ibuprofen
E. Lisinopril -CORRECT ANSWER The CORRECT ANSWER is D. From IM 04.
A 24-year-old female presents to the emergency department with 18 hours of lower
abdominal pain, nausea, vomiting, and diarrhea. She is afebrile and has normal vital
signs except for tachycardia with a pulse at 105 beats/minute. Her abdomen is soft and
non-distended with hypoactive bowel sounds. There is rebound tenderness in the left-
lower quadrant. The abdominal exam finding of rebound tenderness has +LR = 2 and -
LR = 0.4 for peritonitis. What is the best interpretation of this finding?
A. Absence of rebound tenderness strongly argues against peritonitis
B. Absence of rebound tenderness strongly argues against peritonitis, but presence of it
does not affect the probability of peritonitis
C. Neither the presence nor the absence of rebound tenderness is very helpful in
diagnosing peritonitis
