Family Medicine Aquifer Exam Questions Solved
100% Correct
Venous Doppler has the best sensitivity and specificity for diagnosing a DVT.
D-dimer is best used when there is a low pre-test probability of a DVT. If it is negative
then it is fairly certain that there is not a DVT. A positive test does not diagnose a DVT
(poor specificity) but indicates the need for further testing. MRI and CT angiography are
very expensive, carry risks with contrast, and do not add to the care unless an invasive
intervention is being contemplated. - ANSWER A 65-year-old truck driver presents to
your office complaining of right calf pain and swelling. He has recently returned from a
four-day cross-country trip after which he had onset of his current symptoms. The
patient reports that the week prior to his four-day trip, he was mostly in bed recovering
from a bout of the flu. His PMH is significant for DM type 2 and COPD. He has a 25-
pack-year smoking history. He denies having any chest pain or SOB. His physical
exam shows 2+ pitting edema of his right leg. When measuring the circumference of
his right leg, you note that it is 14 cm compared to the left, which has a circumference
of 10 cm. What is the most appropriate next step in diagnosis?
A. D-dimer
B. MRI
C. Lower extremity Doppler
D. CT angiography
*A*
This is the case where the pretest probability of a DVT is low, so that a negative D-dimer
would save further testing. If the D-dimer is positive then the next step would be the lower
extremity Doppler. CT and MRI are expensive and do not add anything to diagnostic
accuracy in the majority of cases. - ANSWER A 45-year-old female presents to your office
complaining of left calf pain and swelling. She reports first noticing the pain after her yoga
class earlier in the week. She denies having any chest pain or shortness of breath. She
has no significant PMH. Her physical exam is significant for tenderness to palpation over
the left calf. No edema or redness is present. The
,circumference of her left calf is 10 cm and the circumference of her right calf is 9
cm. What is the most appropriate next step in diagnosis?
A. D-dimer
B. MRI
C. Lower extremity Doppler
D. CT angiography
*C*
In light of the fever with redness and tenderness of the exam, the extra swelling is most
likely due to cellulitis. There is no added benefit of treating with heparin and no
particular reason to rule out a DVT with the Doppler or D-dimer. - ANSWER A 65-year-
old truck driver presents to your office complaining of right calf redness and swelling. He
reports that he has had these symptoms off and on for some time but noticed that the
redness and swelling on the right has worsened over the past few days and he also
noticed fevers and chills. His PMH is significant for DM Type 2, COPD, and heart
failure. He has a 25-pack-year smoking history. His physical exam shows a temperature
of 101.1, 2+ pitting edema of his calves bilaterally, and dry, flaking skin over both
calves. His right foot shows interdigital maceration and he has redness, warmth, and
tenderness just inferior to the knee. When measuring the circumference of his right leg,
you note that it is 12 cm compared to the left, which has a circumference of 10 cm.
What is the most appropriate next step in this patient's care?
A. Initiate treatment with Low molecular weight heparin.
B. Order a lower extremity Doppler.
C. Initiate treatment with antibiotics.
D. Check a D-dimer.
*C* - ANSWER A 56-year-old Spanish-speaking male presents to your office for a six-
month follow-up visit for DM Type 2 diagnosed at his previous visit with a HbA1C of
7.0%. At that visit, you discussed dietary modification including eliminating
carbohydrates like rice from his diet. You also emphasized the importance of exercise
and recommended he join a gym. On repeat testing of HbA1C today, you find that his
HbA1C has increased to 7.5%. What might you do differently when counseling the
patient at this visit?
A. Suggest he get a personal trainer.
B. Recommend he follow a more strict dietary protocol including elimination of meat
from his diet.
,C. Find out from the patient whether barriers exist to his adherence to your
previous suggestions.
D. Tell him you are disappointed that he was not able to adhere to your previous
recommendations.
Obesity is an important cause of mortality and morbidity. Knee pain is common in obese
patients and losing weight can be helpful. Steroid injections generally help in
osteoarthritis when there is joint inflammation, and this patient does not have signs of
an effusion. There is no indication at this point for knee replacement surgery or opioids.
Opioid pain medications are generally only indicated for severe acute pain and in this
case his pain is likely to be chronic. - ANSWER A 55-year-old man presents to your
office complaining of pain and stiffness in his knees. He used to play basketball three
times a week with his friends but stopped about seven months ago because he was
finding it difficult to keep up. His PMH is significant for hypertension, hyperlipidemia, and
obesity. His BMI is 32. On exam, he is afebrile. There is no erythema or effusion of his
knee joints but there is crepitus on movement of each joint. His range of motion of the
knees is full. His x-rays show narrowed joint spaces and subchondral calcification. What
is the most appropriate initial counseling for this patient?
A. Instruct him to see an orthopedist for steroid injections.
B. Refer him for knee replacement surgery.
C. Develop a weight loss plan with the patient.
D. Prescribe opioids for pain relief.
The correct answers are A, B, D, F, G, H, I, K. - ANSWER Which of the following is
in your differential diagnosis for palpitations in this 50-year-old woman? Select all
that apply.
A. Dysrhythmia
B. Valvular heart disease
C. Hypothyroidism
D. Hyperthyroidism (or over-replacement)
E. Cushing's disease
F. Anxiety / panic disorder
G. Coronary heart disease (CHD)
H. Vasomotor symptoms of climacteric
I. Anemia
J. Pulmonary embolus
K. Prescription or illicit drug use
, *mitral valve prolapse*, the most common structural heart abnormality presenting
with palpitations. - ANSWER midsystolic click with a holosystolic murmur
*hypertrophic obstructive cardiomyopathy* that may be associated with atrial fibrillation
as a cause of palpitations. - ANSWER systolic murmur at the left sternal border that
increases with Valsalva maneuver
*aortic stenosis* that can cause palpitations and dizziness. - ANSWER A harsh
crescendo-decrescendo that radiates into the carotid arteries
atrial fibrillation - ANSWER dysarrhythmia associated with CHF
*Pleuritic* -- worsened by respiration and may be exacerbated when lying down.
Causes of pleuritic chest pain include pulmonary embolism, pneumothorax, viral
or idiopathic pleurisy, pneumonia, and pleuropericarditis.
*Pulsating*.
*Positional* -- could be pericarditis, which typically improves with sitting up and leaning
forward; pleuritic chest pain, which may be exacerbated when lying down; or
musculoskeletal pain, which body position or movement may exacerbate.
Reproduced by *Palpation* -- musculoskeletal pain.
Stabbing pain also decreases the likelihood of ACS - ANSWER Pain Characteristics
That Decrease the Likelihood of ACS (4 Ps)
*E* This patient's lack of exercise and sedentary job are risk factors.
Age becomes a risk factor over age 55 for women and 45 for men.
The family history becomes a risk factor if a first degree relative has CHD male <55 and
female <65.
Rheumatoid arthritis is not a risk factor, and the patient is not obese. - ANSWER A 52-year-
old woman with a history of diabetes and rheumatoid arthritis presents for her annual
examination. She works in an office 10 hours a day, and rarely gets exercise. Her BMI is 23
and her blood pressure is 152/85. Her previous visit two months ago showed blood
pressure of 148/82. Her father had a history of diabetes and her maternal grandmother
died of rheumatic heart disease at the age of 42. She admits to marijuana
100% Correct
Venous Doppler has the best sensitivity and specificity for diagnosing a DVT.
D-dimer is best used when there is a low pre-test probability of a DVT. If it is negative
then it is fairly certain that there is not a DVT. A positive test does not diagnose a DVT
(poor specificity) but indicates the need for further testing. MRI and CT angiography are
very expensive, carry risks with contrast, and do not add to the care unless an invasive
intervention is being contemplated. - ANSWER A 65-year-old truck driver presents to
your office complaining of right calf pain and swelling. He has recently returned from a
four-day cross-country trip after which he had onset of his current symptoms. The
patient reports that the week prior to his four-day trip, he was mostly in bed recovering
from a bout of the flu. His PMH is significant for DM type 2 and COPD. He has a 25-
pack-year smoking history. He denies having any chest pain or SOB. His physical
exam shows 2+ pitting edema of his right leg. When measuring the circumference of
his right leg, you note that it is 14 cm compared to the left, which has a circumference
of 10 cm. What is the most appropriate next step in diagnosis?
A. D-dimer
B. MRI
C. Lower extremity Doppler
D. CT angiography
*A*
This is the case where the pretest probability of a DVT is low, so that a negative D-dimer
would save further testing. If the D-dimer is positive then the next step would be the lower
extremity Doppler. CT and MRI are expensive and do not add anything to diagnostic
accuracy in the majority of cases. - ANSWER A 45-year-old female presents to your office
complaining of left calf pain and swelling. She reports first noticing the pain after her yoga
class earlier in the week. She denies having any chest pain or shortness of breath. She
has no significant PMH. Her physical exam is significant for tenderness to palpation over
the left calf. No edema or redness is present. The
,circumference of her left calf is 10 cm and the circumference of her right calf is 9
cm. What is the most appropriate next step in diagnosis?
A. D-dimer
B. MRI
C. Lower extremity Doppler
D. CT angiography
*C*
In light of the fever with redness and tenderness of the exam, the extra swelling is most
likely due to cellulitis. There is no added benefit of treating with heparin and no
particular reason to rule out a DVT with the Doppler or D-dimer. - ANSWER A 65-year-
old truck driver presents to your office complaining of right calf redness and swelling. He
reports that he has had these symptoms off and on for some time but noticed that the
redness and swelling on the right has worsened over the past few days and he also
noticed fevers and chills. His PMH is significant for DM Type 2, COPD, and heart
failure. He has a 25-pack-year smoking history. His physical exam shows a temperature
of 101.1, 2+ pitting edema of his calves bilaterally, and dry, flaking skin over both
calves. His right foot shows interdigital maceration and he has redness, warmth, and
tenderness just inferior to the knee. When measuring the circumference of his right leg,
you note that it is 12 cm compared to the left, which has a circumference of 10 cm.
What is the most appropriate next step in this patient's care?
A. Initiate treatment with Low molecular weight heparin.
B. Order a lower extremity Doppler.
C. Initiate treatment with antibiotics.
D. Check a D-dimer.
*C* - ANSWER A 56-year-old Spanish-speaking male presents to your office for a six-
month follow-up visit for DM Type 2 diagnosed at his previous visit with a HbA1C of
7.0%. At that visit, you discussed dietary modification including eliminating
carbohydrates like rice from his diet. You also emphasized the importance of exercise
and recommended he join a gym. On repeat testing of HbA1C today, you find that his
HbA1C has increased to 7.5%. What might you do differently when counseling the
patient at this visit?
A. Suggest he get a personal trainer.
B. Recommend he follow a more strict dietary protocol including elimination of meat
from his diet.
,C. Find out from the patient whether barriers exist to his adherence to your
previous suggestions.
D. Tell him you are disappointed that he was not able to adhere to your previous
recommendations.
Obesity is an important cause of mortality and morbidity. Knee pain is common in obese
patients and losing weight can be helpful. Steroid injections generally help in
osteoarthritis when there is joint inflammation, and this patient does not have signs of
an effusion. There is no indication at this point for knee replacement surgery or opioids.
Opioid pain medications are generally only indicated for severe acute pain and in this
case his pain is likely to be chronic. - ANSWER A 55-year-old man presents to your
office complaining of pain and stiffness in his knees. He used to play basketball three
times a week with his friends but stopped about seven months ago because he was
finding it difficult to keep up. His PMH is significant for hypertension, hyperlipidemia, and
obesity. His BMI is 32. On exam, he is afebrile. There is no erythema or effusion of his
knee joints but there is crepitus on movement of each joint. His range of motion of the
knees is full. His x-rays show narrowed joint spaces and subchondral calcification. What
is the most appropriate initial counseling for this patient?
A. Instruct him to see an orthopedist for steroid injections.
B. Refer him for knee replacement surgery.
C. Develop a weight loss plan with the patient.
D. Prescribe opioids for pain relief.
The correct answers are A, B, D, F, G, H, I, K. - ANSWER Which of the following is
in your differential diagnosis for palpitations in this 50-year-old woman? Select all
that apply.
A. Dysrhythmia
B. Valvular heart disease
C. Hypothyroidism
D. Hyperthyroidism (or over-replacement)
E. Cushing's disease
F. Anxiety / panic disorder
G. Coronary heart disease (CHD)
H. Vasomotor symptoms of climacteric
I. Anemia
J. Pulmonary embolus
K. Prescription or illicit drug use
, *mitral valve prolapse*, the most common structural heart abnormality presenting
with palpitations. - ANSWER midsystolic click with a holosystolic murmur
*hypertrophic obstructive cardiomyopathy* that may be associated with atrial fibrillation
as a cause of palpitations. - ANSWER systolic murmur at the left sternal border that
increases with Valsalva maneuver
*aortic stenosis* that can cause palpitations and dizziness. - ANSWER A harsh
crescendo-decrescendo that radiates into the carotid arteries
atrial fibrillation - ANSWER dysarrhythmia associated with CHF
*Pleuritic* -- worsened by respiration and may be exacerbated when lying down.
Causes of pleuritic chest pain include pulmonary embolism, pneumothorax, viral
or idiopathic pleurisy, pneumonia, and pleuropericarditis.
*Pulsating*.
*Positional* -- could be pericarditis, which typically improves with sitting up and leaning
forward; pleuritic chest pain, which may be exacerbated when lying down; or
musculoskeletal pain, which body position or movement may exacerbate.
Reproduced by *Palpation* -- musculoskeletal pain.
Stabbing pain also decreases the likelihood of ACS - ANSWER Pain Characteristics
That Decrease the Likelihood of ACS (4 Ps)
*E* This patient's lack of exercise and sedentary job are risk factors.
Age becomes a risk factor over age 55 for women and 45 for men.
The family history becomes a risk factor if a first degree relative has CHD male <55 and
female <65.
Rheumatoid arthritis is not a risk factor, and the patient is not obese. - ANSWER A 52-year-
old woman with a history of diabetes and rheumatoid arthritis presents for her annual
examination. She works in an office 10 hours a day, and rarely gets exercise. Her BMI is 23
and her blood pressure is 152/85. Her previous visit two months ago showed blood
pressure of 148/82. Her father had a history of diabetes and her maternal grandmother
died of rheumatic heart disease at the age of 42. She admits to marijuana
