AQUIFER FAMILY MEDICINE END OF CASE EXAM QUESTIONS 2023-2024 ACTUAL EXAM 170 QUESTIONS
AND CORRECT DETAILED ANSWERS
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 - (answer) The 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 - (answer) The 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.
,AQUIFER FAMILY MEDICINE END OF CASE EXAM QUESTIONS 2023-2024 ACTUAL EXAM 170 QUESTIONS
AND CORRECT DETAILED ANSWERS
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 - (answer) The 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 - (answer) The 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 - (answer) The answer is D. From IM 04.
,AQUIFER FAMILY MEDICINE END OF CASE EXAM QUESTIONS 2023-2024 ACTUAL EXAM 170 QUESTIONS
AND CORRECT DETAILED ANSWERS
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
D. Presence of rebound tenderness strongly suggests peritonitis
E. Presence of rebound tenderness strongly suggests peritoniti - (answer) The answer is C. From IM 12.
A 39-year-old male with no significant past medical history presents to the hospital with lower
abdominal pain for the past two days. His initial vitals are notable where his temperature is 38.5 C (101.3
F), pulse is 112 beats/minute, and blood pressure is 103/68 mmHg. He reports that his last bowel
movement was two days ago, and he recalls passing flatus earlier today. Your physical exam reveals
hypoactive bowel sounds, and a diffusely tender abdomen, most tender in the right-lower quadrant. His
abdominal muscles are tense, and do not relax with distraction techniques. A computed tomography
(CT) scan of the abdomen and pelvis confirms your suspected diagnosis. You order broad-spectrum
intravenous (IV) antibiotics. What is the best next step in management?
A. Call a gastrointestinal (GI) consult for colonoscopy
B. Call a surgical consult
C. Order a bowel regimen
D. Place a nasogastric tube for decompression
E. Start - (answer) The answer is B. From IM 12.
A 68-year-old male with a history of peptic ulcer disease, diabetes mellitus, and hypertension is
admitted to the hospital with a 24-hour history of abdominal pain and three episodes of loose stool.
Initial vital signs reveal temperature is 38.9 C (102.02 F), pulse is 102 beats/minute, respiratory rate is 16
breaths/minute, blood pressure is 132/78 mmHg, and oxygen saturation is 98% on room air. White blood
, AQUIFER FAMILY MEDICINE END OF CASE EXAM QUESTIONS 2023-2024 ACTUAL EXAM 170 QUESTIONS
AND CORRECT DETAILED ANSWERS
count (WBC) is 13,100 cells/μl. He has tenderness to palpation of the left lower quadrant of his
abdomen, with guarding but no rigidity. Renal function is normal. Computerized tomography (CT) scan of
the abdomen and pelvis shows sigmoid diverticulitis without any sign of abscess or perforation. In
addition to ordering intravenous (IV) antibiotics, IV fluid, and pain medication, what is the next best step
in management?
A. Blood cultures
B. Colorectal surgery consult
C. High-fiber diet
D. Stool culture
E. Stool te - (answer) The answer is A. From IM 12.
A 51-year-old male is admitted to the hospital for acute, uncomplicated diverticulitis. Medical history is
significant for asthma, gastroesophageal reflux disease (GERD), and hypertension. He is treated with
intravenous ciprofloxacin and metronidazole, intravenous fluids, and pain medication. After two days, his
pain is improved and he is tolerating food. Which of the following discharge plans is most appropriate for
him?
A. Continue oral antibiotics for 21 days
B. Prescribe subcutaneous enoxaparin for 28 days
C. Refer to gastroenterology for a colonoscopy
D. Refer to a nutritionist to initiate a gluten-free diet
E. Refer to surgery for resection of the affected bowel - (answer) The answer is C. From IM 12.
A 63-year-old female with a past history of hypertension, chronic obstructive pulmonary disease (COPD),
type 2 diabetes mellitus, and hyperlipidemia is admitted to the hospital with Clostridium difficile (C.
difficile) colitis. Of the following options, which is the best choice for deep vein thrombosis (DVT)
prophylaxis for her?
A. Ambulation
B. Aspirin, 81 mg by mouth (PO) daily
AND CORRECT DETAILED ANSWERS
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 - (answer) The 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 - (answer) The 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.
,AQUIFER FAMILY MEDICINE END OF CASE EXAM QUESTIONS 2023-2024 ACTUAL EXAM 170 QUESTIONS
AND CORRECT DETAILED ANSWERS
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 - (answer) The 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 - (answer) The 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 - (answer) The answer is D. From IM 04.
,AQUIFER FAMILY MEDICINE END OF CASE EXAM QUESTIONS 2023-2024 ACTUAL EXAM 170 QUESTIONS
AND CORRECT DETAILED ANSWERS
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
D. Presence of rebound tenderness strongly suggests peritonitis
E. Presence of rebound tenderness strongly suggests peritoniti - (answer) The answer is C. From IM 12.
A 39-year-old male with no significant past medical history presents to the hospital with lower
abdominal pain for the past two days. His initial vitals are notable where his temperature is 38.5 C (101.3
F), pulse is 112 beats/minute, and blood pressure is 103/68 mmHg. He reports that his last bowel
movement was two days ago, and he recalls passing flatus earlier today. Your physical exam reveals
hypoactive bowel sounds, and a diffusely tender abdomen, most tender in the right-lower quadrant. His
abdominal muscles are tense, and do not relax with distraction techniques. A computed tomography
(CT) scan of the abdomen and pelvis confirms your suspected diagnosis. You order broad-spectrum
intravenous (IV) antibiotics. What is the best next step in management?
A. Call a gastrointestinal (GI) consult for colonoscopy
B. Call a surgical consult
C. Order a bowel regimen
D. Place a nasogastric tube for decompression
E. Start - (answer) The answer is B. From IM 12.
A 68-year-old male with a history of peptic ulcer disease, diabetes mellitus, and hypertension is
admitted to the hospital with a 24-hour history of abdominal pain and three episodes of loose stool.
Initial vital signs reveal temperature is 38.9 C (102.02 F), pulse is 102 beats/minute, respiratory rate is 16
breaths/minute, blood pressure is 132/78 mmHg, and oxygen saturation is 98% on room air. White blood
, AQUIFER FAMILY MEDICINE END OF CASE EXAM QUESTIONS 2023-2024 ACTUAL EXAM 170 QUESTIONS
AND CORRECT DETAILED ANSWERS
count (WBC) is 13,100 cells/μl. He has tenderness to palpation of the left lower quadrant of his
abdomen, with guarding but no rigidity. Renal function is normal. Computerized tomography (CT) scan of
the abdomen and pelvis shows sigmoid diverticulitis without any sign of abscess or perforation. In
addition to ordering intravenous (IV) antibiotics, IV fluid, and pain medication, what is the next best step
in management?
A. Blood cultures
B. Colorectal surgery consult
C. High-fiber diet
D. Stool culture
E. Stool te - (answer) The answer is A. From IM 12.
A 51-year-old male is admitted to the hospital for acute, uncomplicated diverticulitis. Medical history is
significant for asthma, gastroesophageal reflux disease (GERD), and hypertension. He is treated with
intravenous ciprofloxacin and metronidazole, intravenous fluids, and pain medication. After two days, his
pain is improved and he is tolerating food. Which of the following discharge plans is most appropriate for
him?
A. Continue oral antibiotics for 21 days
B. Prescribe subcutaneous enoxaparin for 28 days
C. Refer to gastroenterology for a colonoscopy
D. Refer to a nutritionist to initiate a gluten-free diet
E. Refer to surgery for resection of the affected bowel - (answer) The answer is C. From IM 12.
A 63-year-old female with a past history of hypertension, chronic obstructive pulmonary disease (COPD),
type 2 diabetes mellitus, and hyperlipidemia is admitted to the hospital with Clostridium difficile (C.
difficile) colitis. Of the following options, which is the best choice for deep vein thrombosis (DVT)
prophylaxis for her?
A. Ambulation
B. Aspirin, 81 mg by mouth (PO) daily
