Family Medicine Aquifer Cases

Family Medicine Aquifer Cases You are seeing a 55-year-old female with a past medical history of hypertension, diabetes, and gout. She has no complaints today and is here to manage her chronic conditions. She is taking her medications, which include lisinopril 10 mg daily, metformin 500 mg twice daily, and allopurinol 100 mg daily. She is trying to focus on her diet in an effort to lose weight. She smokes a pack of cigarettes every day, and she is worried that quitting will make her gain weight and worsen her diabetes. Her family history is positive for a recent myocardial infarction in her father at age 78. Her vitals today include a blood pressure of 128/78 mmHg, pulse of 78 beats/minute, respirations of 14/minute and a BMI of 32 kg/m2. Her general exam is unremarkable today. Which of the following is not a risk factor for coronary artery disease in this patient? A. Hypertension B. Her family history C. Smoking D. Diabetes E. Obesity Correct Ans - B 56-year old male with a past medical history of hypertension and type 2 diabetes mellitus presents with progressive dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and dependent edema over the prior 4 days. His social history is notable for a 30 pack-year tobacco history and occasional marijuana use. His family history is positive for bypass surgery in his mother at the age of 62. On exam, his vitals include a blood pressure of 166/86 mmHg, pulse of 98 beats/minute, respirations of 21/minute and a BMI of 32 kg/m^2. He appears mildly dyspneic. His neck reveals an elevated jugular venous pulse, his chest exam reveals bilateral crackles in the lower lung fields, and his cardiovascular exam reveals mild tachycardia, a regular rhythm, and no murmurs. His abdominal exam is unremarkable, and he has 2+ edema in his legs midway to his knees. An EKG reveals sinus tachycardia with a left axis deviation and Q waves in leads II, III, and AVF. A BNP is measured and is found to be 510 pg/ml. Which of the following is the most likely cause of this patient's heart failure? A. Atrial fibrillation B. Non-ischemic cardiomyopathy C. Valvular disease D. Pulmonary embolism E. Ischemic cardiomyopathy Correct Ans - E A 56-year-old male presents for care at the ED complaining of dry cough for the past three days. He notes that this problem started a few days after his family's annual fish fry and barbecue and has been worsening since. He has no known past medical history but mentions that he has not seen a doctor in years. He notes that the cough is worse at night often waking him from sleep. He is unable to lie flat on his back and has started using three to four pillows to sleep comfortably. He also reports increased swelling in his legs that worsens throughout the day. He denies having any chest pain or palpitations and also does not believe he has had any sick contacts. He does not know his family history since he was adopted as a child. He has not had any fevers, sweats, or chills. On exam, you observe a tachypneic, obese man in mild distress. On chest auscultation, he has an S3, bilateral crackles at the lung bases, and 2+ pitting edema in the lower legs bilaterally. What diagnostic test would you perform first? A. Exercise stress test B. Pharmacologic stress test C. Echocardiogram D. Electrocardiogram E. Cardiac catheterization Correct Ans - D You are seeing a 63-year-old male with hypertension, diabetes, and a history of an NSTEMI two years ago. His most recent echocardiogram reveals mild hypokinesis of the inferior wall of the left ventricle and a LV ejection fraction of 40%. Shortly after his MI, he was treated for symptoms of congestive heart failure, but he has not has any such symptoms since then. His exercise tolerance is excellent. Today his physical exam is completely unremarkable. The correct pairing of NYHA functional class and ACCF/AHA Stage of CHF is which of the following for this man? A. NYHA II / Stage C B. NYHA I / Stage A C. NYHA I / Stage B D. NYHA I / Stage C E. NYHA II / Stage B Correct Ans - D You are seeing a 72-year-old female with a recent diagnosis of diastolic heart failure (HFpEF) with an ejection fraction of 60% on a recent echo. She was given a diuretic in the ER last week and told to follow up with you. She complains of mild new dyspnea on exertion, orthopnea and lower extremity edema. On exam, her vitals include a blood pressure of 142/86 mmHg, pulse of 84 beats/minute, respirations of 16/minute and oxygen saturation of 98% on room air. Pulmonary exam reveals mild bibasilar crackles, cardiac exam reveals a regular rate and rhythm with no murmurs, and her extremities have 1+ edema to the lower shins. Of the following, which would be the most appropriate choice of medication for this patient? A. Amlodipine B. Digoxin C. Metoprolol succinate D. Hydrochlorothiazide E. Spironolactone Correct Ans - C A 4-year-old boy who recently emigrated from eastern Europe presents with his mother to your general pediatrics clinic. His mother reports that he has a chronic nonproductive cough during the day and night, mild wheezing for one month and failure to gain weight (his weight has dropped from the 50th to the 10th percentile for his age). His mother denies any high fevers, rhinorrhea, or night sweats. Which of the following are the next best diagnostic tests? A. Chest x-ray and tuberculin skin test B. CT of nasal sinuses C. Spirometry, before and after bronchodilator therapy D. Chest x-ray and methacholine challenge E. None needed, patient likely has habitual cough Correct Ans - A An 11-year old boy presents to clinic with wheezing. Mom states that in the past he has used inhaled albuterol and it has helped with wheezing and shortness of breath. On further history you find out that the patient experiences shortness of breath three times a week and is awakened at night by these symptoms once a week.