Aquifer Internal Medicine End of Case
Questions With Correct 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 - CORRECT 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 - CORRECT 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. 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 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
| | | | | | | | | | |
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 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 |
D. Presence of rebound tenderness strongly suggests peritonitis
| | | | | | |
E. Presence of rebound tenderness strongly suggests peritoniti - CORRECT
| | | | | | | | | |
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
| | | | | | |
Questions With Correct 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 - CORRECT 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 - CORRECT 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. 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 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
| | | | | | | | | | |
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 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 |
D. Presence of rebound tenderness strongly suggests peritonitis
| | | | | | |
E. Presence of rebound tenderness strongly suggests peritoniti - CORRECT
| | | | | | | | | |
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
| | | | | | |
