Aquifer Internal Medicine End of Case Questions With Complete Solutions

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. Hydrochlorothiazide E. Ramipril 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 peritonitis, but absence of it does not affect the probability of peritonitis 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 B. Call a surgical consult C. Order a bowel regimen D. Place a nasogastric tube for decompression E. Start IV steroids correct 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 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 test for occult blood correct answer: The answer is A. From IM 12.